Medical-Surgical RN A Prophecy Relias Exam 2022 (Answered 100% Correct)

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1.2 milligrams is equal to how many micrograms? - ANSWER 1200 mcg Your post-op patient has a Jackson-Pratt (JP) drain in place. How do you ensure effective drain function? - ANSWER Compress the dra... in, 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 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, 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. What is a proton pump inhibitor, such as pantoprazole (Protonix) used for? - ANSWER 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? - ANSWER Patient lift (e.g., Hoyer) Which tool should you use to assess pain in you 80-year-old patient with severe dementia? - 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? - 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? - 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. - 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 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 when his last drink of alcohol was. What is the BEST indication of an acute neurological problem? - ANSWER Change in level of consciousness While in a supine position your patient states, "I'm tired and cannot catch my breath." Physical assessment reveals jugular vein distention and a third heart sound (S3). These symptoms are indicative of what condition? - ANSWER Heart failure 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. 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 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? - 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? - ANSWER Encourage the patient to cough and deep breathe. What patient population is the pneumococcal vaccine, PPSV23 indicated for? - ANSWER 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? - ANSWER 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? - ANSWER 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? - ANSWER "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? - ANSWER 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? - ANSWER Clarify the order with the provider. When would sucralfate (Carafate) 4 times daily be scheduled for? - ANSWER 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? - ANSWER 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? - ANSWER risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, paliperidone, lurasidone, chlorpromazine, fluphenazine, haloperidol, perphenazine Your 80-year-old patient is being discharged home post CVA. She lives alone, yet still requires assistance with ADLs. What referral is MOST appropriate to ensure her needs are met? - ANSWER Case Manager Central Telemetry calls and tells you your patient is experiencing bradycardia. What is the first thing you should do after entering the room? - ANSWER Assess the patient and take vital signs. Your patient is currently under 1:1 observation for suicide precautions. He states he needs to have a bowel movement and would like some privacy to use the bathroom. What is the MOST appropriate response? - ANSWER "I must be within an arms' length view of you at all times for your safety, including while using the bathroom." A female patient requests a female nurse to provide care for her based on her religious beliefs. What is the MOST appropriate action to take? - ANSWER Accommodate her request if possible. 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? - 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)? - ANSWER 15 min before the meal arrives Which of the following would be used as part of the preop procedure to prevent infection? - 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? - ANSWER Delirium What is the proper technique when suctioning a tracheostomy? - 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? - 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? - ANSWER 167 mL/hr 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? - 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? - 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? - 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? - 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? - 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? - ANSWER Phenazopyridine (Pyridium) Your patient is taking digoxin (Lanoxin) and has a potassium level of 3.0. How might this affect the patient? - 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? - 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? - 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? - 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? - ANSWER 320 units What diagnostic finding would support a diagnosis of deep vein thrombosis? - 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? - ANSWER Urinalysis with cultures, CBC A patient has recently been diagnosed with terminal cancer. Her responses are caustic and abrasive. What is the BEST way to respond? - ANSWER Acknowledge her feelings, understanding this is expected in the grieving process. You notice your patient who recently had a stroke is coughing intermittently during meals. What is the MOST likely cause of this? - ANSWER He could be aspirating. A patient with acute diverticulitis is MOST likely to complain of abdominal pain with what quadrant? - ANSWER Left lower quadrant Which of the following is MOST important in preventing a catheter associated urinary tract infection (CAUTI)? - ANSWER Using sterile technique when inserting the catheter The provider orders a Heparin infusion of 900 units/hr. Your IV medication on hand has 25,000 units of Heparin in 500 mL of D5W. How many mL/hr will you infuse? - ANSWER 18 mL/hr Your patient has developed a productive cough and fever. The provider is suspecting influenza. Which actions should you take FIRST? - ANSWER Initiate droplet precautions What medication would you anticipate to be ordered for a patient who has a LDL > 200 mg/dL? - ANSWER Statin Fifteen minutes after starting a blood transfusion, the patient complains of lower back pain, shortness of breath, and chills. What is your FIRST action? - ANSWER Stop the tranfusion. Your patient had a transurethral resection of the prostate (TURP) 24 hours ago. What signs require further intervention? - ANSWER Bright red urine What condition (not medication related) might cause an elevation in the patients PT/INR level? - ANSWER Liver disease Your patient admitted for small bowel obstruction has been vomiting for the last 3 days. What electrolyte imbalance would you expect to be associated with this patient? - ANSWER Hypokalemia Digoxin (Lanoxin) 125 mcg is equivalent to how many mg? - ANSWER 0.125mg As you are walking down the hallway you overhear your colleague discussing her personal family issues with a patient. What would be the MOST appropriate response? - ANSWER Remind her later of her responsibility for establishing and maintaining professional boundaries with patients. Your patient, who has soft wrist restraints for safety (non-violent), is working with the occupational therapist at the bedside. The nursing assistant enters and says, "The patient is not allowed to have his restraints untied." How do you respond? - ANSWER "Restraints can be temporarily off while directly working with staff. Let me know when the therapy session is finished and I will re-apply them." Your patient suddenly develops signs and symptoms of shortness of breath, restlessness, tachypnea, hemoptysis, and decreased oxygen saturations despite being on 2L/min of O2 by nasal cannula. What do you expect is happening? - ANSWER Pulmonary embolism The dosage of which drug must be tapered down slowly to prevent acute adrenal insufficiency? - ANSWER Prednisone Your patient with CHF states, "I can still eat the same food, I just have to weight myself everyday." Based on this statement, which nursing diagnosis would be appropriate? - ANSWER Knowledge Deficit patient arrives on unit. you do an assessment and notice lice in her hair. what is your first action? - ANSWER Secure a private room [Show More]

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