Adult Health 2 Exam | Revision Guide

Adult Health 2 Exam | Revision Guide Have the patient void immediately before the procedure begins. - ansWhich of the following are appropriate interventions for a patient who is scheduled to have a paracentesis? (select all that apply) The cobalamin injections will prevent me from becoming anemic. - ansCobalamin injections have been prescribed for a patient with chronic atrophic gastritis. The nurse determines that teaching regarding the injections has been effective when the patient states: Check the patient's BP - ansDuring hemodialysis, a 69-year-old patient complains of lightheadedness, dizziness, and nausea. Which action should the nurse take first? Persistent cough Fatigue Night sweats - ansA nurse is providing information to a group of patients at a local community center about tuberculosis. Which of the following clinical symptoms should be included in the teaching? (select all that apply) Help the patient use a pillow to splint while coughing. - ansWhich nursing intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days ago is appropriate for the nurse to delegate to the unlicensed assistive personnel? My legs cramp whenever I walk more than a block. - ansWhile working in the outpatient clinic, the nurse notes that a patient has a history of intermittent claudication. Which statement by the patient would support this information? Diffuse crackles in the lungs - ansWhich finding would alert the nurse that complications of influenza are occurring in the patient? "Tell me more about what you are thinking regarding dialysis." - ansA 74-year-old patient, progressing to stage 5 chronic kidney disease, asks the nurse "do you think I should go on dialysis?" The BEST initial response from the nurse would be? Whipple's Procedure (Pancreaticoduodenectomy) - ansA patient will be given insulin and have frequent blood glucose monitoring (BGM) for the rest of their life following which of the following surgical procedures? "I can use my topical nasal decongestant spray until the congestion is all gone." - ansThe nurse discusses management of upper respiratory infections (URIs) with a patient who has acute sinusitis. Which statement by the patient indicated that the patient needs more education? Patient's peritoneal fluid return appears cloudy - ansA female patient with chronic kidney disease is receiving peritoneal dialysis. Which information should the nurse report IMMEDIATELY? Alcohol Caffeine Corticosteroids NSAIDs - ansThe student nurse studying stomach disorders learns that the risk factors for acute gastritis include which of the following? (select all that apply) Position patients with altered levels of consciousness with the head of the bed raised 30 degrees. - ansWhich nursing action is important to protect susceptible patients in the hospital from aspiration pneumonia? Teach the patient how to self-cath - ansPatient with paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. Which action should be included in the plan of care? Tachypnea Tachycardia I will stop what I am doing and sit down before I put the nitroglycerin under my tongue. I will leave on my nitroglycerin patch regardless of taking any sublingual nitroglycerin. - ansIn preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that teaching has been effective? (select all that apply) Discontinue the heparin & flush the IV lines with normal saline. - ansA patient who has been receiving heparin infusion & Coumadin for a DVT is diagnosed with heparin induced thrombocytopenia when her platelet count drops to 110,000/uL. Which action should the nurse include in the plan of care? Pinch lower portion of the nose for 10-15 minutes. Place the patient in a sitting position. Keep patient quiet. - ansActions a nurse should take when a patient develops a nosebleed Na 154 mEq/L (154 mmol/L) - ansAn older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately? Limit intake of colas, coffee, tea Limit sodium intake Drink 300 mL of water daily - ansThe nurse is preparing a renal calculi patient for discharge—which statements indicate the patient has proper understanding? Gradually decreasing LOC. - ansThe nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has an NG tube to low suction, & is NPO. Which assessment finding would be priority for the nurse to report to the health care provider? You will need to be NPO for 8 hours before the procedure. You will be kept NPO after the procedure until your gag reflex returns. - ansMr. J is scheduled for an EGD. Which of the following statements will the nurse include in the teaching plan? (select all that apply) Bilirubin levels - ansThe nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the lab results for what? Place the client in a private room on contact isolation. - ansWhich action will the nurse include in the plan of care for a 42-year-old patient who is being admitted with C-diff? Monitor IV sites for redness, swelling, or tenderness. - ansWhich action can an RN caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? Put on sterile gloves and use a sterile catheter to suction patient - ansPatient has a trach with rhonchi heard bilaterally and is unsuccessful in coughing up secretions - what should you do? The patient is experiencing difficulty breathing with a laryngeal stridor. - ansA patient has a serum Ca level of 7.0 mEq/L. Which assessment finding is most important to report to the health care provider? Monitor for skin breakdown Consult enterostomal therapy Assess patient for psychological stressors - ansIleal conduit (urinary drainage) patient planning: Place a sign on the door directing visitors to the nurse's station. A 46-year-old patient who has a deep vein thrombosis and is complaining of sudden onset shortness of breath - ansAfter the nurse has received a change-of-shift report about the following patients, which patient should be assessed first? Apply SCDs whenever the patient is in bed. - ansWhich actions would the nurse delegate to the unlicensed assistive personnel who is providing care for a patient who is at risk for a venous thromboembolism? "I may find that NSAIDs and anti-depressant medications may help me feel better physically." - ansWhich of the following statements, if made by the patient newly diagnosed with chronic fatigue syndrome, indicates that correct understanding has occurred? A fistula is much less likely to clot - ansA patient will need vascular access for hemodialysis—which statement by the nurse accurately describes a fistula over a graft? Right lateral position - ansThe position of choice for a patient who had just had a liver biopsy that helps to decrease the risk of complication is: New onset of SOB (shortness of breath). - ansWhich assessment finding for a patient who has been admitted with a right calf venous thromboembolism requires IMMEDIATE action by the nurse? Promote early joint mobility and increased knee flexion - ansFollowing a knee arthroplasty, a patient has CPM (continuous passive movement) machine for the affected joint. The nurse explains to the patient that this device is used to: Check BP before starting dialysis - ansA patient has arrived for a scheduled hemodialysis session. The nursing action MOST appropriate for the RN to delegate to a dialysis tech is?