Prophecy medical surgical-telemetry 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
ANSWER Sinus tachycardia You are taking care of a patient who is admitted for left flank pain with a kidney stone of 1.5 cm. He asks you about the procedure what would be the most therapeutic response? ANSWER 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? ANSWER Honor the patient's wishes
ANSWER 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: ANSWER
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 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
ANSWER 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? ANSWER 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: 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