RELIAS MEDICAL SURGICAL-TELEMETRY EXAMS , Exams of Nursing

Download RELIAS MEDICAL SURGICAL-TELEMETRY EXAMS and more Exams Nursing in PDF only on Docsity! RELIAS MEDICAL SURGICAL-TELEMETRY EXAMS WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED RATIONALES ANSWERS LATEST UPDATE 2024 ALREADY GRADED A+ 100 % GUARANTEED PASS!!! Which of the following food items would you question in the menu of your patient who is diagnosed with celiac disease? Wheat bread A postoperative laparoscopic appendectomy patient is receiving morphine PCA for pain findings with alert you to the potential of a narcotic overdose? A respiratory rate of 8 breaths per minute Paced rhythm Your patient was admitted with severe dehydration. Which of the following orders would you question KCI 40 mEq IV push STAT What is the first sign of increased intracranial pressure? Change in LOC A patient suddenly complains of new onset of chest pain. The doctor is suspecting a possible?... What is most likely to be ordered? Morphine Duramorph, oxygen, nitrates, Aceticsalicylic acid, bayer buffered aspirin The Glasgow, scale ranges from: 3 to 15 You deserve the nurse aid removing her gloves and immediately using alcohol hand sanitizer in a room with a patient who has C-Diff. What education should you provide to the nurse aide And washing with soap and water is mandatory because alcohol based hand sanitizers do not kill C-diff Heart rate 80 Which of the following assessment findings should you report immediately to the physician for a patient who just had a bronchoscopy and biopsy? Sputum with streaks of blood NOT: increased salivation Your patient was just returned from surgery with a Jackson-Pratt JP drain in place which of the following is the best nursing action? Compress the drain, then plug the bulb to establish suction Patient is admitted for shortness of breath. Do you notice the spouse adjusting the oxygen on the wall and she states "she always takes care of my husband" what would be an appropriate response? Educate the spouse on oxygen use as a medical device in the hospital Deposition has ordered for your patience to begin a 24 hour urine collection. Your patient voids for the first time two hours after the orders received. What should be done with this urine sample? Discarded, then begin the 24 hour collection Which of the following lab values would you expect to see in a patient diagnosed with?.... Lipase - 196 You were caring for a patient admitted with abdominal pain. Your patient has a bowel movement and you know dark tarry stool what would be the diagnosis? Upper G.I. bleed Your COPD patient is complaining of wheezing and increased shortness of breath Assess your patient for a change in condition What information is vital for you to know prior to administering an ordered dose of digoxin Heart rate Your patient has been diagnosed with a hemorrhagic CVA Heparin infusion per pharmacy protocol A 56-year-old man has an acute onset of shortness of breath, chest pain, apprehension, rapid pulse, cough with bloody sputum, diaphoresis, and syncope. The symptoms are indicative of: Pulmonary embolism? NOT: tuberculosis You're reviewing the menu list of a patient on Warfran what food should they not eat? Spinach Which of the following issues should be reported up the chain of command A coworker arriving to work under the influence of alcohol You're providing discharge instructions to a CHF patient. Increase shortness of breath cardiac rhythm Due to the size of the kidney stone it is an appropriate treatment? NOT:Print reading materials about the subject and give it to the patient The nurse is taking care of a patient who is terminally ill and has a DNR on file. Their patient has a sudden cardiac arrest and family wants CPR initiated. How should you respond? Honor the patient's wishes Not normal sinus rhythm into a flutter Correct answer is ventricular fibrillation Your patient began deteriorating rapidly after complaining of shortness of breath. And ABG was drawn and the results are pH? HCO3 - 23. These values indicate the patient is experiencing: Your inserting a urinary catheter into a male patient. As you inflate a balloon, the patient complains of discomfort what is the best action? Aspirate the fluid, advance the catheter farther, then re-inflate the balloon When assessing a patient, you notice crepitus on the right upper shoulder. You notify the physician and anticipate which diagnosis? Subcutaneous emphysema You are providing patient education to a patient prior to administering IV Protonix.... When there is no history of GERD Protonix is given as G.I. prophylaxis to prevent stress ulcers Normal sinus with VTach The patient has a morphine PCA post operatively. On rounding you notice respirations at eight per minute O2 saturation of 82%. What medication would be given in the situation? Narcan You were caring for a patient who is 18 hours postop after a right BKA a. They report sudden chest pain pulse ox at 86%. The patient may be experiencing: Pulmonary embolism Cardiac strip Unable to determine At 0500, you know your patient to be diaphoretic, clammy, and their hands are shaking. The patient's blood sugar is currently 60. Which of the following is the most appropriate intervention Have the patient drink 120 ML's of orange juice Ventricular tachycardia Normal sinus rhythm 1.2 milligrams is equal to how many micrograms? 1200 mcg What lab values are expected to be in a patient with end stage renal disease on hemodialysis BUN 32, CREATNINE 8.32 Brainpower Read More dietary teaching for a patient with chronic renal failure should include choices that are: Low potassium, low protein, moderate fat Your post-op patient has a Jackson-Pratt (JP) drain in place. How do you ensure effective drain function? 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? Deflate the balloon, advance the catheter further, then reinflate the balloon What are the most common causes of acute onset pancreatitis? Alcoholism and gallstones What medication is contraindicated In a patient with A hemorrhagic CVA? heparin Your patient appears dusky colored and you cannot palpate a pulse. What is the 1st thing you should do? Initiate a code per facility protocol and begin CPR A patient with diabetes who is receiving peritoneal dialysis Is at risk for which of the following? hyperglycemia Your patient has symptomatic anemia but is refusing a blood transfusion for religious reason. What is an appropriate response? 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? broth, jello, soft fruit no skin, clear liquids 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? Report to the post-surgical unit. What is a proton pump inhibitor, such as pantoprazole (Protonix) used for? Acid Reduction 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? Patient lift (e.g., Hoyer) Which tool should you use to assess pain in you 80-year-old patient with severe dementia? PAINAD scale 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? Hold wayfaring (coumadin) for the next 48 hours Stat CT of head 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? Notify the charge nurse and social worker of your concerns. 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. Sepsis What type of personal protective equipment (PPE) is applied prior to entering a room for a patient with C. diff? 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 using soft mitt restraints on the patient. What is your recommendation? Request an order for soft mitts as they are the least restrictive Your patient was admitted for a hypertensive crisis and has a history of HTN, Parkinson's disease, depression, and alcohol use. On his second hospitalized day, you notice he is more anxious and restless than his baseline. What would be your FIRST nursing intervention? Ask the patient when his last drink of alcohol was. What is the BEST indication of an acute neurological problem? Change in level of consciousness Hemorrhage Which of the following nursing diagnoses is MOST important for a patient with chronic obstructive pulmonary disease (COPD)? 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? famotidine (Pepcid) What is an early symptom that the patient is developing a complication of heart failure? Edema in the legs and feet Black and tarry colored stools are CLASSIC symptoms of what condition? 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? 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? Paracentesis What is clubbing of the fingers MOST likely associated with? Chronic oxygen deficiency A patient on warfarin (Coumadin/Jantoven) has an INR of 6. Which medication would you anticipate administering? 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? 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? Encourage the patient to cough and deep breathe. What patient population is the pneumococcal vaccine, PPSV23 indicated for? Adults aged 65 years and older Your patient with stave IV terminal lung cancer continues to experience increasing pain as each day passes. What would you anticipate the provider ordering for this patient? Palliative care consult The provider gives you a telephone order to explain a surgical procedure to your patient and obtain surgical consent. How should you respond? Inform the provider that explaining the procedure is outside the nurse's scope of practice. The patient has diltiazem HCl (Cardizem CD) ordered and is requesting the capsule be mixed into her morning yogurt. How should you respond? "Sorry, it is a slow-release medication that cannot be opened or crushed." Your 72-year-old male patient is admitted for colon cancer related complications and has a history of CHF, stroke, and a recent knee replacement. Based on your patient's risk assessment, you determine he is at risk for venous thromboembolism (VTE). What is an appropriate VTE prophylaxis order for this patient? Enoxaparin (Lovenox) once daily and intermittent pneumatic compressions (IPC) You receive a provider's order that is not consistent with evidence-based practice. What is your FIRST step? Clarify the order with the provider. When would sucralfate (Carafate) 4 times daily be scheduled for? 1 hour before meals and at bedtime Your patient's morning labs revealed a hemoglobin level of 6.3 and hematocrit of 18. What blood product do you expect to administer? PRBCs Your 68-year-old patient is a Type 1 diabetic with a history of schizophrenia and exhibits signs and symptoms of tardive dyskinesia. What long-term medication is associated with signs and symptoms of tardive dyskinesia? chlorpromazine Which adaptive equipment would be most appropriate to use for a severely contracted patient who is unable to bear weight when transferring from bed to chair Patient Lift example hoyer What lab values are expected to be in a patient with end stage renal disease on hemodialysis BUN 32, CREATNINE 8.32 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? You're? Hold wayfaring (coumadin) for the next 48 hours Your new admission presents with a cough, unintentional weight loss, frequent knot sweats, and bloody sputum. What type of isolation precautions should you initiate, if any? Airborne precautions Upon entering your patient's room you note that they are having a seizure. What is your 1st action? Position the patient on their side to maintain the airway You find your coworker looking through your patient's medical record.. She States how is Mr. Smith doing? He is my best friend's dad. We are so worried about him. What is the best course of action? Tell her you cannot give her information and report her actions to your manager. Your male patient complaints of discomfort while inflating the balloon during insertion of a endwelling urinary catheter. What would be the most appropriate action? Deflate the balloon, advance the catheter further, then reinflate the balloon. Your patient takes regular insulin and NPH twice A-day for glucose control. What times should the patient be taught to be alert for signs of hypoglycemia? Is late afternoon and early morning What is a proton pump inhibitor, such as pantoprazole (protonix) used for? Reduce gastric acid secretion Your patient has a non productive cough and presence of secretions in his tracheostomy. Prior to sectioning the patient, what should you do 1st? Hyperoxygenate patient dietary teaching for a patient with chronic renal failure should include choices that are: Low potassium, low protein, moderate fat Which of the following nursing diagnosis is most important for a patient with chronic obstructive pulmonary disease(COPD) Impaired gas exchange 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? Notify the charge nurse and social worker of your concerns. You are ordered to give Digoxin(lanoxin). Your patience vital signs are BP 130/75, temp 97.9F, HR 52, RR 16, o2 sat 100% on room air. What should you do next? HOLD DIGOXIN AND CALL PROVIDER Your patient tells you I hope I don't die, but if I do I don't want to be brought back. You notice on her chart and wrist band that she is a full code. What would be the most appropriate action? Discuss code status with the patient and follow up with the provider to ensure the medical record reflects her wishes What are the most common causes of acute onset pancreatitis? Alcoholism and gallstones Your 18 year old female patient was admitted with dehydration secondary to anorexia nervosa. During your assessment you note she has a flat effect and says" I just want to die, I'm tired of my life ". What should be your 1st intervention? Stay with the patient and ask if she has a plan to carry out this wish A patient with diabetes who is receiving peritoneal dialysis Is at risk for which of the following? ? To reduce the risk of infection and phlebotomy in an adult patient with a peripherL IV, What is the minimum duration the catheter should remain in place before routine replacement. 72 hours Your patient was admitted for a hypertensive crisis and has a history of HTN. Parkinson disease, depression and alcohol use. On his 2nd hospitalized day, you notice he is more anxious and restless than his baseline. What would be your 1st nursing intervention? Ask the patient when his last drink of alcohol was Black and tarry Colored stools are classic symptoms of what condition? Bleeding gastric ulcer In addition to pain, pallor, and pulselssness, a neurovascular assessment Also includes checking for Parasthesia and paralysis After scrolling through your social media, you notice a coworker posted a photo with a patient from your unit. What is the most appropriate action to take? Report the situation to the hospital compliance officer. Your patient's morning labs revealed a hemoglobin level of 6.3 and hematocrit of 18. What blood product do you expect to administer? PRBCs What medication is contraindicated In a patient with A hemorrhagic CVA? Heparin Your patient appears dusky colored and you cannot palpate a pulse. What is the 1st thing you should do? Initiate a code per facility protocol and begin CPR Your 68 year old patient is a is a Type one diabetic with a history of schizophrenia And exhibit signs and symptoms of tardiness dyskinesia. Is what long term medication is associated with signs and symptoms of tardive dyskinesia? Chlorpromazine(thorazine) You received a report on a patient that sustained a right hemisphere CVA 48 hours ago. What do you expect the patient to exhibit? Lift sided weakness of the leg, arm, and face and face You have 4 patients who have high priority needs. One needs to go to surgery, 1 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 1st? The patient with chest pain Your coworker posted photos on social media from a birthday party they had for her in the unit break room. What should be your next course of action? No action is necessary because no PHI was displayed. Is your patient with stage IV Terminal lung cancer continues to experience increasing pain as each day passes. What would you anticipate the provider ordering for this patient? Palliative care consult Your 72 Year old male patient is admitted for colon cancer Related complications and has a history of CHF, stroke and a recent Knee replacement.Based on your patient's risk assessment,You determine he is at risk for Venous thromboembolism (VTE) What is an appropriate VTE prophylaxis prophylaxis order for this patient? Enoxaparin(Lovenox) once daily and intermittent pneumatic compressions(IPC) 1.2 Milligrams is equal to how many micrograms 1200 mcg Your patient is on contact precautions for active MRSA. What proper PPE should you use before entering the room? Gown and gloves You are caring for a patient with history of diabetes mellitus. You walk into the room and find the patient lethargic and diaphoretic. What is your 1st action? Obtain capillary blood glucose level Your patient has symptomatic anemia but is refusing a blood transfusion for religious reasons. What is an appropriate response? Respect his wishes and notify the provider Your patient has a temp of 102.3 F, HR 122, and has had 15ml of urine from the indwelling urinary catheter in the last 2 hours. What is your patient most likely experiencing? ? Patients with diabetes are at a high risk for complications for damage in what body areas? Nerve and kidney damage Your patient is 4 hours post open appendectomy Anne has not voided yet. You note his lower abdomen is distended. What should you do next? Perform a bladder scan You receive a provider's order that is not consistent with evidence based practice.What is your 1st step? Clarify the order with the provider Is what is the earliest sign indicating increased intracranial pressure(ICP)? Level of consciousness What patient population is the pneumococcal vaccine PPSV23 indicated for? Adults aged 65 years and older Your patient takes 5 mg of warfarin(coumadin) day and reports having black cored stool today. What do you most likely suspect? Gastrointestinal bleeding Failed to capture question Failed to capture answer Failed to capture question Failed to capture answer