Relias Medical Surgical Telemetry Exam Test Bank, Exams of Nursing

Download Relias Medical Surgical Telemetry Exam Test Bank and more Exams Nursing in PDF only on Docsity! 1 RELIAS MEDICAL SURGICAL TELEMETRY EXAM TEST BANK COMPLETE QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES |GET IT 100% RIGHT| (VERIFIED ANSWERS) |ALREADY GRADED A+ 1.2 milligrams is equal to how many micrograms? - correct answer 1200 mcg Your post-op patient has a Jackson-Pratt (JP) drain in place. How do you ensure effective drain function? - correct answer Compress the drain, then plug the bulb to establish suction Your male patient complains of discomfort while inflating the balloon during insertion of an indwelling urinary catheter. What would be the MOST appropriate action? - correct answer Deflate the balloon, advance the catheter further, then reinflate the balloon Your patient has symptomatic anemia but is refusing a blood transfusion for religious reason. What is an appropriate response? - correct answer Respect his wishes and notify the provider Your patient is admitted with diverticulitis. What type of diet do you expect to be ordered for the patient? - correct answer broth, jello, soft fruit no skin, You were hired to work the medical unit and when you arrive at work the charge nurse has assigned you to the post-surgical unit since they are understaffed. Which is the MOST appropriate action? - correct answer Report to the post- surgical unit. What is a proton pump inhibitor, such as pantoprazole (Protonix) used for? - correct answer Acid Reduction 2 Which adaptive equipment would be MOST appropriate to use for a severely contracted patient who is unable to bear weight when transferring from the bed to the chair? - correct answer Patient lift (e.g., Hoyer) Which tool should you use to assess pain in you 80-year-old patient with severe dementia? - correct answer PAINAD scale Your patient is admitted from the ED with failure to thrive and advanced dementia. You note he is extremely underweight, appears unbathed for some time, and has a stage 4 pressure injury to his coccyx. You were told in report that he lives at home with family members. What should you do? - correct answer Notify the charge nurse and social worker of your concerns. Your 85-year-old patient with atrial fibrillation fell at home 3 days ago. You notice she has been having several episodes of acute confusion since being admitted to your unit. What is the MOST important order you should anticipate from the provider? - correct answer Stat CT of head Your patient has a temp of 102.3 F, HR 122, and has had 15 mL of urine from the indwelling urinary catheter in the last 2 hours. What is your patient MOST likely experiencing. - correct answer Sepsis What type of personal protective equipment (PPE) is applied prior to entering a room for a patient with C. diff? - correct answer Gown and gloves Your patient continues to pull at their IV site located in their left forearm despite verbal reminders and increased observation. The nursing assistant recommends 5 In addition to pain, pallor, and pulselessness, a neurovascular assessment also includes checking for: - correct answer Paresthesia and paralysis You received a report on a patient that sustained a right hemisphere CVA 48 hours ago. What do you expect the patient to exhibit? - correct answer Left sided weakness of the leg, arm, and face. You are ordered to give digoxin (Lanoxin). Your patients vital signs are: BP 130/70, Temp 97.9F, HR 52, RR 16, O2 Sat 100% on room air. What should you do NEXT? - correct answer Hold digoxin (Lanoxin) and call the provider Upon entry to your patient's room, you find her sitting in High Fowler's position and complaining of shortness of breath. Her respiratory rate is 34 breaths/min and O2 sat is 84%. Which mode of oxygen delivery would MOST likely reverse these symptoms? - correct answer Non-rebreather mask Your patient is on contact precautions for active MRSA. What proper PPE should you use before entering the room? - correct answer Gown and gloves Your patient recently had a G-tube placed and intermittent enteral feedings have been initiated. What symptoms may indicate intolerance to the feedings? - correct answer Vomiting and diarrhea Upon entering your patient's room, you note that they are having a seizure. What is your FIRST action? - correct answer Position the patient on their side to maintain the airway. 6 Your 18-year-old female patient was admitted with dehydration secondary to anorexia nervosa. During your assessment you note she has a flat affect and says, "I just want to die. I'm tired of my life." What should be your FIRST intervention? - correct answer Stay with the patient and ask fi she has a plan to carry out this wish. Your patient has a non-productive cough and presence of secretions in his tracheostomy. Prior to suctioning the patient, what should you do FIRST? - correct answer Hyperoxygenate patient. Your patient takes 5 mg of warfarn (Coumadin/Jantoven) daily and reports having black colored stool today. What do you most likely suspect? - correct answer Gastrointestinal bleeding Your new patient was admitted with blunt force trauma to the abdomen following a motor vehicle accident (MVA). A NG tube is in place for decompression; however, you note during the assessment that the stomach is rigid and hard during palpation. What condition do you suspect? - correct answer Hemorrhage Which of the following nursing diagnoses is MOST important for a patient with chronic obstructive pulmonary disease (COPD)? - correct answer Impaired gas exchange You have a patient going for dialysis. Their medications include lisinopril (Prinivil), ondansetron (Zofran), famotidine (Pepcid), and atorvastatin (Lipitor). Which medication would you possibly hold and seek clarification? - correct answer famotidine (Pepcid) 7 What is an early symptom that the patient is developing a complication of heart failure? - correct answer Edema in the legs and feet Black and tarry colored stools are CLASSIC symptoms of what condition? - correct answer Bleeding gastric ulcer You have 4 patients who have high priority needs. One needs to go to surgery, one needs STAT lab draws from a PICC line, another has chest pain rated 8/10, and another needs toileting. Which patient should you tend to FIRST? - correct answer The patient with chest pain Your patient with Hepatitis C exhibits signs of jaundice and a distended abdomen. What procedure would you anticipate being performed by the provider at the bedside for this patient? - correct answer Paracentesis What is clubbing of the fingers MOST likely associated with? - correct answer Chronic oxygen deficiency A patient on warfarin (Coumadin/Jantoven) has an INR of 6. Which medication would you anticipate administering? - correct answer Vitamin K To reduce the risk of infection and phlebitis in an adult patient with a peripheral IV, what is the MINIMUM duration the catheter should remain in place before ROUTINE replacement? - correct answer 72 hours You are caring for a patient post lobectomy with a chest tube in place for drainage. What is a priority in care for this patient? - correct answer Encourage the patient to cough and deep breathe. 10 Your patient is a 40-year-old female with a recent history of hair loss, extremely dry skin, a nd a 20-point weight loss in the last 3 weeks. She also exhibits occasional episodes of tremors in her upper extremities. What condition do these symptoms MOST likely indicate? - correct answer Hyperthyroidism Insulin lispro (Humalog) is orders via sliding scale a.c. for your patient with diabetes. When is the best time to administer insulin lispro (Humalog)? - correct answer 15 min before the meal arrives Which of the following would be used as part of the preop procedure to prevent infection? - correct answer Prophylactic antibiotics Two days after surgery, your 72-year-old patient is showing signs of agitation and confusion, which is not his baseline. The severity fluctuates throughout the day. His medications include hydromorphone (Dilaudid), amlodipine (Norvasc), alprazolam (Xanax), and carbidopa-levodopa (Sinemet). What condition do you MOST likely suspect? - correct answer Delirium What is the proper technique when suctioning a tracheostomy? - correct answer Suction in a circular motion while the catheter is being pulled out. Your new patient admitted for cholecystitis expresses she has a history of anxiety disorder. She is feeling panicked and does not think she can handle staying in the hospital for her surgery. What action is MOST appropriate for you to take? - correct answer Sit calmly next to her and offer her compassion and a sense of security. The provider orders and IV infusion of D5W 1000 mL to infuse over the next 6 hours. How many mLs per hour should the IV pump be set to? - correct answer 167 mL/hr 11 You are assigned a new admission and note a Braden score of 11 after completing your assessment. Which interventions would be MOST appropriate based on your assessment? - correct answer Turn q 2hours, request nutrition consult, request low airloss mattress. Your patient may have tuberculosis TB) and is placed in airborne precautions. What test would you expect to be ordered? - correct answer Acid-fast bacilli sputum Your patient starts to complain of difficulty breathing while laying down, and states that he has been coughing up pink sputum. While performing your assessment, you notice jugular vein distention and coarse crackles in both lungs on auscultation. What diagnosis do you suspect? - correct answer Congestive heart failure You received a patient post op transurethral resection of the prostate (TURP). Which of the following symptoms would cause you the MOST concern? - correct answer Hemorrhage and hypotension Your patient with C. diff (Clostridioides difficile) has a family member about to leave the room. What education about performing hand hygiene should you give? - correct answer Hand hygiene with soap and water Your patient has a diagnosis of urinary tract infection (UTI) and is currently taking medication that has recently made her urine reddish-orange. Which of the following medications would cause this side effect? - correct answer Phenazopyridine (Pyridium) 12 Your patient is taking digoxin (Lanoxin) and has a potassium level of 3.0. How might this affect the patient? - correct answer Increase risk of digoxin toxicity You are preparing to hang 1 unit PRBC's to administer to your patient. The patient states, "I don't take blood products." What is the MOST appropriate response? - correct answer "You have the right to refuse the blood transfusion. I will inform the provider of your decision." An older adult patient arrives on the unit looking emaciated, disheveled, and with soiled clothes. The patient claims that his daughter cares for him at home. What would you suspect? - correct answer Neglect You just left your patient's room with her husband at bedside. You then receive a phone call from someone states that she is your patient's mother and demands updates about your patient. What should you do NEXT? - correct answer Verify your patient's consent to release information to her mother. The provider orders Heparin 4 units/kg SQ. Your patient weighs 176 pounds. How many units should you administer? - correct answer 320 units What diagnostic finding would support a diagnosis of deep vein thrombosis? - correct answer Positive D-dimer You are caring for a combative 85-year-old male with a history of dementia, CHF, UTI, and anemia. The family states he appears to be more confused than his baseline. What tests do you expect the provider to order? - correct answer Urinalysis with cultures, CBC