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RELIAS MEDICAL SURGICAL TELEMETRY TEST BANK 2024-2025 /RELIAS MEDICAL SURGICAL TELEMETRY TEST BANK 2024-2025 /RELIAS MEDICAL SURGICAL TELEMETRY TEST BANK 2024-2025 /RELIAS MEDICAL SURGICAL TELEMETRY TEST BANK 2024-2025
Typology: Exams
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Your inserting a urinary catheter into a male patient. As you inflate a balloon, the patient complains of discomfort what is the best action? - ...ANSWER...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? - ...ANSWER...Subcutaneous emphysema 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? - ...ANSWER...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? - ...ANSWER...Ask the patient whenhis last drink of alcohol was. You are providing patient education to a patient prior to administering IV Protonix.... When there is no history of GERD -
...ANSWER...Protonix is given as G.I. prophylaxis to prevent stress ulcers 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? - ...ANSWER...Narcan Your patient is 4 hours post open appendectomy and has not voided yet. You note his lower abdomen is distended. What should you do NEXT? - ...ANSWER...Perform a bladder scan A patient with peritonitis presents with tachycardia, hypotension, and dehydration. What other assessment finding would you anticipate as part of your physical assessment? - ...ANSWER...Severe abdominal pain or rebound tenderness What is the EARLIEST sign indicating increased intracranial pressure (ICP)? - ...ANSWER...Level of consciousness In addition to pain, pallor, and pulselessness, a neurovascular assessment also includes checking for: - ...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? - ...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? - ...ANSWER...Hold digoxin (Lanoxin) and call the provider
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: - ...ANSWER...Pulmonary embolism Cardiac strip - ...ANSWER...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
A patient suddenly complains of new onset of chest pain. The doctor is suspecting a possible?... What is most likely to be ordered? - ...ANSWER...Morphine Duramorph, oxygen, nitrates, Aceticsalicylic acid, bayer buffered aspirin The Glasgow, scale ranges from: - ...ANSWER... 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 - ...ANSWER...And washing with soap and water is mandatory because alcohol based hand sanitizers do not kill C-diff Heart rate - ...ANSWER... 80 Which of the following assessment findings should you report immediately to the physician for a patient who just had a bronchoscopy and biopsy? - ...ANSWER...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? - ...ANSWER...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? - ...ANSWER...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? - ...ANSWER...Discarded, then begin the 24 hour collection Which of the following lab values would you expect to see in a patient diagnosed with?.... - ...ANSWER...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? - ...ANSWER...Upper G.I. bleed Your COPD patient is complaining of wheezing and increased shortness of breath - ...ANSWER...Assess your patient for a change in condition What information is vital for you to know prior to administering an ordered dose of digoxin - ...ANSWER...Heart rate Your patient has been diagnosed with a hemorrhagic CVA - ...ANSWER...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: - ...ANSWER...Pulmonary embolism? NOT: tuberculosis You're reviewing the menu list of a patient on Warfran what food should they not eat? - ...ANSWER...Spinach Which of the following issues should be reported up the chain of command
cardiac rhythm - ...ANSWER...V-Tach Which of the following electrolyte value should be Addressed immediately by the nurse - ...ANSWER...Potassium 2.5 mEq/L Which of the following medication may cause urine discoloration - ...ANSWER...Rifampin Calculate the 12 hour intake for a patient that has received the following during your shift: normal saline 750 ML, 24 ounces of sprite, Levaquin 50 ML, 650 ML urine in Foley catheter - ...ANSWER... When caring for a patient experiencing a tonic clonic seizure, the most appropriate nursing intervention is: - ...ANSWER...Protecting the patient's head and extremities from contact with surrounding objects You went to the room of a 58 - year-old female. You find that the patient's cardiac monitor shows asystolye, what should be your first action? - ...ANSWER...Assess the patient Not: start CPR Didn't nurse ask you about the typical signs and symptoms of myocardial infarction - ...ANSWER...Women could have pain in their arm, neck, back or jaw While performing the narcotic count at the end of the shift, my coworker admits to something, coworker to sign for the ways that you did not witness
You're preparing your patient for discharge need to provide dietary education related to his diagnosis what should you instruct the patient to avoid? - ...ANSWER...Canned meats Your patient complains of not being able to urinate since 0500. It is now
1.2 milligrams is equal to how many micrograms? - ...ANSWER...1200 mcg What lab values are expected to be in a patient with end stage renal disease on hemodialysis - ...ANSWER...BUN 32, CREATNINE 8. dietary teaching for a patient with chronic renal failure should include choices that are: - ...ANSWER...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? - ...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? - ...ANSWER...Deflate the balloon, advance the catheter further, then reinflate the balloon What are the most common causes of acute onset pancreatitis? - ...ANSWER...Alcoholism and gallstones What medication is contraindicated In a patient with A hemorrhagic CVA? - ...ANSWER...heparin Your patient appears dusky colored and you cannot palpate a pulse. What is the 1st thing you should do? - ...ANSWER...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? - ...ANSWER...hyperglycemia
Your patient has symptomatic anemia but is refusing a blood transfusion for religious reason. What is an appropriate response? - ...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? - ...ANSWER...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? - ...ANSWER...Report to the post-surgical unit. You are to obtain informed consent for a Spanish-speaking patient scheduled for surgery. You do not speak Spanish and are having difficulty communicating with your patient. Which of the following resources would be most appropriate to utilize in order to obtain consent? - ...ANSWER...The hospitals language interpreter You're reviewing the discharge medication list of a patient diagnosed with gastric ulcer. Which of the following medication should you question? - ...ANSWER...Acetylsalicylic acid ( Bauer buffered aspirin) When taking care of a patient with pancreatitis, which of the following lab should be reviewed? - ...ANSWER...Lipase and amylase You're caring for a 12 hour postoperative parathyroidectomy patient. Which assessment finding would indicate an emergency? - ...ANSWER...Laryngeal strider
Which of the following actions would be considered a violation of Hyppa? - ...ANSWER...Looking through the chart of a coworker admitted to your unit
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? - ...ANSWER...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? - ...ANSWER...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. - ...ANSWER...Sepsis What type of personal protective equipment (PPE) is applied prior to entering a room for a patient with C. diff? - ...ANSWER...Gown and gloves What is the BEST indication of an acute neurological problem?
pH? HCO3 - 23. These values indicate the patient is experiencing: - ...ANSWER... Your new admission presents with a cough, unintentional weight loss, frequent night sweats, and bloody sputum. What type of isolation precautions should you initiate, if any? - ...ANSWER...Airborne precautions Patients with diabetes are at high risk for complications from damage to what body areas? - ...ANSWER...Nerve and kidney damage If your patient with a known history of diabetes is displaying symptoms of diaphoresis, cool skin, lethargy, and shakiness. What is your first action? - ...ANSWER...Check the patient's blood glucose level. 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? - ...ANSWER...Discuss code status with the patient and follow up with provider to ensure the medical record reflects her wishes. Your coworker posted photos on social media from a birthday party they had for her in the unit breakroom. What should be your NEXT course of action? - ...ANSWER...No action is necessary because no PHI was displayed. Your new patient understands very limited English. How should you communicate with them when completing the admission assessment? - ...ANSWER...Use the organization's interpreter services.
You are caring for a patient with a history of diabetes mellitus. You walk into the room and find the patient lethargic and diaphoretic. What is your first action? - ...ANSWER...Obtain capillary blood glucose level. 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? - ...ANSWER...Non-rebreather mask Your patient is on contact precautions for active MRSA. What proper PPE should you use before entering the room? - ...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? - ...ANSWER...Vomiting and diarrhea Upon entering your patient's room, you note that they are having a seizure. What is your FIRST action? - ...ANSWER...Position the patient on their side to maintain the airway. 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? - ...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? - ...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? - ...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? - ...ANSWER...Hemorrhage Which of the following nursing diagnoses is MOST important for a patient with chronic obstructive pulmonary disease (COPD)? - ...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? - ...ANSWER...famotidine (Pepcid) What is an early symptom that the patient is developing a complication of heart failure? - ...ANSWER...Edema in the legs and feet Black and tarry colored stools are CLASSIC symptoms of what condition? - ...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? - ...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? - ...ANSWER...Paracentesis What is clubbing of the fingers MOST likely associated with? - ...ANSWER...Chronic oxygen deficiency A patient on warfarin (Coumadin/Jantoven) has an INR of 6. Which medication would you anticipate administering? - ...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?
The patient has diltiazem HCl (Cardizem CD) ordered and is requesting the capsule be mixed into her morning yogurt. How should you respond? - ...ANSWER..."Sorry, it is a slow-release medication that cannot be opened or crushed." 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 - ...ANSWER..Patient Lift example hoyer What lab values are expected to be in a patient with end stage renal disease on hemodialysis - ...ANSWER..BUN 32, CREATNINE 8. 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? - ...ANSWER..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? - ...ANSWER..Airborne precautions Upon entering your patient's room you note that they are having a seizure. What is your 1st action? - ...ANSWER..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? - ...ANSWER..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? - ...ANSWER..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? - ...ANSWER..Is late afternoon and early morning What is a proton pump inhibitor, such as pantoprazole (protonix) used for?
You have a patient going for dialysis. There are medications include Lisinopril(prinivil), ondansetron (zofran), famotidine(pepcid) and atorvastatin(lipitor). Which medication would you possibly hold and seek clarification? - ...ANSWER..LISINOPRIL(PRINIVIL) What is the best indication of an acute neurological problem? - ...ANSWER..Change in level of consciousness Your patient is admitted with diverticulitis. What type of diet do you expect to be ordered for the patient? - ...ANSWER..Clear liquids Which tool should you use to assess pain in your 80 year old patient with severe dementia? - ...ANSWER..? Your post op patient has a Jackson - Pratt drain in place. how do you ensure effective drain function? - ...ANSWER..Compress the drain, then plug the bulb to establish suction. Is a patient with peritonitis Presents with tachycardia, hypotension , and dehydration. What other assessment finding would you anticipate as part of your physical assessment? - ...ANSWER..Severe abdominal pain or rebound tenderness Your patient with a known history of diabetes is displaying symptoms of diaphoresis, Cool skin, lethargy, And shakiness. What is your 1st action? - ...ANSWER..Check the patient's blood glucose level a patient on warfarin(Coumadin/jantoven) has an INR of 6. Which medication would you anticipate administering? - ...ANSWER..Vitamin K While in a supine position your patient States" I'm tired and cannot catch my breath". Physical assessment reveals juggler
vein distention and a 3rd heart sound(S3). These symptoms are indicative of what condition? - ...ANSWER..Heart failure 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/minute And 02 sat is 84%. Which mode of oxygen delivery would most likely reverse the symptoms? - ...ANSWER..Non rebreather mask Your patient continues to pull at their iv 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? - ...ANSWER..Request and order for soft mitts As they are the least restrictive.. What is an early symptom that a patient is developing a complication of heart failure? - ...ANSWER..Edema in the legs and feet 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 under staffed. Which is the most appropriate action? - ...ANSWER..Report to the post surgical unit What type of personal protective equipment(Ppe) Is applied prior to entering a room for a patient with with C diff? - ...ANSWER..Gown and gloves When would sucralfate(Carafate) 4 times daily be scheduled for? - ...ANSWER..1 hour before meals and at bedtime Your new patient was admitted with Blunt force trauma to the abdomen Following a motor vehicle accident. 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. - ...ANSWER..Hemorrhage What is clubbing of the fingers most likely associated with? - ...ANSWER..Chronic oxygen deficiency Is 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? - ...ANSWER..Paracentesis Is the provider gives you a telephone order to explain a surgical procedure to your patient and obtain surgical consent. How should you respond? - ...ANSWER..Inform the provider that explaining the procedure is outside the nurse's scope of practice. You're patient Recently had a G Tube Placed and interminent enteral Feedings have been initiated. What symptoms may indicate intolerance to the feedings?
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?
In addition to pain, pallor, and pulselssness, a neurovascular assessment Also includes checking for - ...ANSWER..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? - ...ANSWER..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? - ...ANSWER..PRBCs What medication is contraindicated In a patient with A hemorrhagic CVA? - ...ANSWER..Heparin Your patient appears dusky colored and you cannot palpate a pulse. What is the 1st thing you should do? - ...ANSWER..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? - ...ANSWER..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? - ...ANSWER..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? - ...ANSWER..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? - ...ANSWER..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? - ...ANSWER..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? - ...ANSWER..Enoxaparin(Lovenox) once daily and intermittent pneumatic compressions(IPC) 1.2 Milligrams is equal to how many micrograms - ...ANSWER..1200 mcg Your patient is on contact precautions for active MRSA. What proper PPE should you use before entering the room? - ...ANSWER..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? - ...ANSWER..Obtain capillary blood glucose level Your patient has symptomatic anemia but is refusing a blood transfusion for religious reasons. What is an appropriate response? - ...ANSWER..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? - ...ANSWER..? Patients with diabetes are at a high risk for complications for damage in what body areas? - ...ANSWER..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? - ...ANSWER..Perform a bladder scan You receive a provider's order that is not consistent with evidence based practice.What is your 1st step? - ...ANSWER..Clarify the order with the provider Is what is the earliest sign indicating increased intracranial pressure(ICP)? - ...ANSWER..Level of consciousness What patient population is the pneumococcal vaccine PPSV23 indicated for?