RELIAS MEDICAL SURGICAL TELEMETRY EXAM 2024 TEST BANK COMPLETE 180 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY
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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 when his 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 - ...ANSWER...Have the patient drink 120 ML's of orange juice
- ...ANSWER...Ventricular tachycardia
- ...ANSWER...Normal sinus rhythm
Which of the following food items would you question in the menu of your patient who is diagnosed with celiac disease? - ...ANSWER...Wheat bread
A postoperative laparoscopic appendectomy patient is receiving morphine PCA for pain findings with alert you to the potential of a narcotic overdose? - ...ANSWER...A respiratory rate of 8 breaths per minute
- ...ANSWER...Paced rhythm
Your patient was admitted with severe dehydration. Which of the following orders would you question - ...ANSWER...KCI 40 mEq IV push STAT
What is the first sign of increased intracranial pressure? - ...ANSWER...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? - ...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 - ...ANSWER...A coworker arriving to work under the influence of alcohol
You're providing discharge instructions to a CHF patient. - ...ANSWER...Increase shortness of breath
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...1520
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 - ...ANSWER...Refused to sign for the waste
Cardiac strip - ...ANSWER...Sinus rhythm with PAC
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 1900. What should be your next step? -
...ANSWER...Perform a bladder scan
The doctor ordered Lasix 40 mg IV push, 100mg/10 mL - ...ANSWER...4ml
After a patient completes dialysis, you should anticipate seeing an improvement in which of the following lab values? - ...ANSWER...NOT: ammonia
Your patient fell and hit his head on the bed rail during a physical therapy session. Upon initial assessment you observe a blood pressure of 90/45, heart rate of 28, and a constricted pupil. The patient is lying in a supine position. What should be your first response? - ...ANSWER...Call a rapid response
Which of the following antidiabetic medication is contraindicated 48 hours after receiving contrast dye - ...ANSWER...Metformin
You're a king for a patient who is postop after surgical removal of fibroids. She hears a pop sound after coughing in her surgical wound has dehisced - ...ANSWER...Apply sterile saline soap towels over the extruding site
One of the signs of left sided heart failure is: -
...ANSWER...Pulmonary edema
NOT: pedal edema
Your patient had a TB skin test done on Thursday at 2:45 PM - ...ANSWER...Saturday at 3 PM
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 8.32
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. [Show Less]