Medical_Surgical_RN_A_Prophecy_Relias__Exam_2022_latest_update.pdf

Your patient is admitted with diverticulitis. What type of diet do you expect to be ordered for the patient? - answerbroth, 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? - answerReport to the post-surgical unit. What is a proton pump inhibitor, such as pantoprazole (Protonix) used for? - answerAcid 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? - answerPatient lift (e.g., Hoyer) Which tool should you use to assess pain in you 80-year-old patient with severe dementia? - answerPAINAD 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? - answerNotify 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? - answerStat 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. - answerSepsis What type of personal protective equipment (PPE) is applied prior to entering a room for a patient with C. diff? - answerGown 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? - answerRequest 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? - answerAsk the patient when his last drink of alcohol was. What is the BEST indication of an acute neurological problem? - answerChange 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? - answerHeart 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? - answerAirborne precautions Patients with diabetes are at high risk for complications from damage to what body areas? - answerNerve 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? - answerCheck 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? - answerDiscuss 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? - answerNo 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? - answerUse 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? - answerObtain 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? - answerPerform 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? - answerSevere abdominal pain or rebound tenderness What is the EARLIEST sign indicating increased intracranial pressure (ICP)? - answerLevel of consciousness In addition to pain, pallor, and pulselessness, a neurovascular assessment also includes checking for: - answerParesthesia 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? - answerLeft 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? - answerHold 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? - answerNon-rebreather mask Your patient is on contact precautions for active MRSA. What proper PPE should you use before entering the room? - answerGown 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? - answerVomiting and diarrhea