RELIAS MEDICAL SURGICAL TELEMETRY EXAM 2024 TEST BANK COMPLETE 180
QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous
pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine
now. What action is best for the nurse to take? - (ANSWER)After clearing the tube with 30 ml of air,
check the pH of fluid withdrawn from the tube.
Which adaptive equipment would be most appropriate to use for a severely contracted patient who is
unable to bear weight when transferring from bed to chair - (ANSWER)Patient Lift example hoyer
What lab values are expected to be in a patient with end stage renal disease on hemodialysis -
(ANSWER)BUN 32, CREATNINE 8.32
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? You're? - (ANSWER)Hold wayfaring (coumadin) for the next 48
hours
Your new admission presents with a cough, unintentional weight loss, frequent knot sweats, and bloody
sputum. What type of isolation precautions should you initiate, if any? - (ANSWER)Airborne precautions
Upon entering your patient's room you note that they are having a seizure. What is your 1st action? -
(ANSWER)Position the patient on their side to maintain the airway
You find your coworker looking through your patient's medical record.. She States how is Mr. Smith
doing? He is my best friend's dad. We are so worried about him. What is the best course of action? -
(ANSWER)Tell her you cannot give her information and report her actions to your manager.
Your male patient complaints of discomfort while inflating the balloon during insertion of a endwelling
urinary catheter. What would be the most appropriate action? - (ANSWER)Deflate the balloon, advance
the catheter further, then reinflate the balloon.
Your patient takes regular insulin and NPH twice A-day for glucose control. What times should the
patient be taught to be alert for signs of hypoglycemia? - (ANSWER)Is late afternoon and early morning
,What is a proton pump inhibitor, such as pantoprazole (protonix) used for? - (ANSWER)Reduce gastric
acid secretion
Your patient has a non productive cough and presence of secretions in his tracheostomy. Prior to
sectioning the patient, what should you do 1st? - (ANSWER)Hyperoxygenate patient
dietary teaching for a patient with chronic renal failure should include choices that are: - (ANSWER)Low
potassium, low protein, moderate fat
Which of the following nursing diagnosis is most important for a patient with chronic obstructive
pulmonary disease(COPD) - (ANSWER)Impaired gas exchange
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.
You have a patient going for dialysis. There are medications include Lisinopril(prinivil), ondansetron
(zofran), famotidine(pepcid) and atorvastatin(lipitor). Which medication would you possibly hold and
seek clarification? - (ANSWER)LISINOPRIL(PRINIVIL)
What is the best indication of an acute neurological problem? - (ANSWER)Change in level of
consciousness
Your patient is admitted with diverticulitis. What type of diet do you expect to be ordered for the
patient? - (ANSWER)Clear liquids
Which tool should you use to assess pain in your 80 year old patient with severe dementia? - (ANSWER)?
Your post op patient has a Jackson - Pratt drain in place. how do you ensure effective drain function? -
(ANSWER)Compress the drain, then plug the bulb to establish suction.
,Is 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
Your patient with a known history of diabetes is displaying symptoms of diaphoresis, Cool skin, lethargy,
And shakiness. What is your 1st action? - (ANSWER)Check the patient's blood glucose level
a patient on warfarin(Coumadin/jantoven) has an INR of 6. Which medication would you anticipate
administering? - (ANSWER)Vitamin K
While in a supine position your patient States" I'm tired and cannot catch my breath". Physical
assessment reveals juggler vein distention and a 3rd heart sound(S3). These symptoms are indicative of
what condition? - (ANSWER)Heart failure
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/minute And 02 sat is 84%. Which mode of oxygen
delivery would most likely reverse the symptoms? - (ANSWER)Non rebreather mask
Your patient continues to pull at their iv 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 and order for soft mitts As they are the least restrictive..
What is an early symptom that a patient is developing a complication of heart failure? - (ANSWER)Edema
in the legs and feet
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 under staffed. Which is the most appropriate action? -
(ANSWER)Report to the post surgical unit
What type of personal protective equipment(Ppe) Is applied prior to entering a room for a patient with
with C diff? - (ANSWER)Gown and gloves
When would sucralfate(Carafate) 4 times daily be scheduled for? - (ANSWER)1 hour before meals and at
bedtime
, Your new patient was admitted with Blunt force trauma to the abdomen Following a motor vehicle
accident. 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
What is clubbing of the fingers most likely associated with? - (ANSWER)Chronic oxygen deficiency
Is 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
Is 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.
You're patient Recently had a G Tube Placed and interminent enteral Feedings have been initiated. What
symptoms may indicate intolerance to the feedings? - (ANSWER)Vomiting and diarrhea
You are caring for a patient post lobotomy With a chest tube in place for drainage. What is a priority in
caring for this patient? - (ANSWER)Encourage the patient to cough and deep breathe.
Your new patient understands very limited English. How should you communicate with them when
completing the admission assessment? - (ANSWER)Use the organizations interpreter services
You are ordered to give Digoxin(lanoxin). Your patience vital signs are BP 130/75, temp 97.9F, HR 52, RR
16, o2 sat 100% on room air. What should you do next? - (ANSWER)HOLD DIGOXIN AND CALL PROVIDER
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 the provider to ensure the medical
record reflects her wishes
What are the most common causes of acute onset pancreatitis? - (ANSWER)Alcoholism and gallstones
QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous
pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine
now. What action is best for the nurse to take? - (ANSWER)After clearing the tube with 30 ml of air,
check the pH of fluid withdrawn from the tube.
Which adaptive equipment would be most appropriate to use for a severely contracted patient who is
unable to bear weight when transferring from bed to chair - (ANSWER)Patient Lift example hoyer
What lab values are expected to be in a patient with end stage renal disease on hemodialysis -
(ANSWER)BUN 32, CREATNINE 8.32
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? You're? - (ANSWER)Hold wayfaring (coumadin) for the next 48
hours
Your new admission presents with a cough, unintentional weight loss, frequent knot sweats, and bloody
sputum. What type of isolation precautions should you initiate, if any? - (ANSWER)Airborne precautions
Upon entering your patient's room you note that they are having a seizure. What is your 1st action? -
(ANSWER)Position the patient on their side to maintain the airway
You find your coworker looking through your patient's medical record.. She States how is Mr. Smith
doing? He is my best friend's dad. We are so worried about him. What is the best course of action? -
(ANSWER)Tell her you cannot give her information and report her actions to your manager.
Your male patient complaints of discomfort while inflating the balloon during insertion of a endwelling
urinary catheter. What would be the most appropriate action? - (ANSWER)Deflate the balloon, advance
the catheter further, then reinflate the balloon.
Your patient takes regular insulin and NPH twice A-day for glucose control. What times should the
patient be taught to be alert for signs of hypoglycemia? - (ANSWER)Is late afternoon and early morning
,What is a proton pump inhibitor, such as pantoprazole (protonix) used for? - (ANSWER)Reduce gastric
acid secretion
Your patient has a non productive cough and presence of secretions in his tracheostomy. Prior to
sectioning the patient, what should you do 1st? - (ANSWER)Hyperoxygenate patient
dietary teaching for a patient with chronic renal failure should include choices that are: - (ANSWER)Low
potassium, low protein, moderate fat
Which of the following nursing diagnosis is most important for a patient with chronic obstructive
pulmonary disease(COPD) - (ANSWER)Impaired gas exchange
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.
You have a patient going for dialysis. There are medications include Lisinopril(prinivil), ondansetron
(zofran), famotidine(pepcid) and atorvastatin(lipitor). Which medication would you possibly hold and
seek clarification? - (ANSWER)LISINOPRIL(PRINIVIL)
What is the best indication of an acute neurological problem? - (ANSWER)Change in level of
consciousness
Your patient is admitted with diverticulitis. What type of diet do you expect to be ordered for the
patient? - (ANSWER)Clear liquids
Which tool should you use to assess pain in your 80 year old patient with severe dementia? - (ANSWER)?
Your post op patient has a Jackson - Pratt drain in place. how do you ensure effective drain function? -
(ANSWER)Compress the drain, then plug the bulb to establish suction.
,Is 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
Your patient with a known history of diabetes is displaying symptoms of diaphoresis, Cool skin, lethargy,
And shakiness. What is your 1st action? - (ANSWER)Check the patient's blood glucose level
a patient on warfarin(Coumadin/jantoven) has an INR of 6. Which medication would you anticipate
administering? - (ANSWER)Vitamin K
While in a supine position your patient States" I'm tired and cannot catch my breath". Physical
assessment reveals juggler vein distention and a 3rd heart sound(S3). These symptoms are indicative of
what condition? - (ANSWER)Heart failure
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/minute And 02 sat is 84%. Which mode of oxygen
delivery would most likely reverse the symptoms? - (ANSWER)Non rebreather mask
Your patient continues to pull at their iv 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 and order for soft mitts As they are the least restrictive..
What is an early symptom that a patient is developing a complication of heart failure? - (ANSWER)Edema
in the legs and feet
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 under staffed. Which is the most appropriate action? -
(ANSWER)Report to the post surgical unit
What type of personal protective equipment(Ppe) Is applied prior to entering a room for a patient with
with C diff? - (ANSWER)Gown and gloves
When would sucralfate(Carafate) 4 times daily be scheduled for? - (ANSWER)1 hour before meals and at
bedtime
, Your new patient was admitted with Blunt force trauma to the abdomen Following a motor vehicle
accident. 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
What is clubbing of the fingers most likely associated with? - (ANSWER)Chronic oxygen deficiency
Is 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
Is 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.
You're patient Recently had a G Tube Placed and interminent enteral Feedings have been initiated. What
symptoms may indicate intolerance to the feedings? - (ANSWER)Vomiting and diarrhea
You are caring for a patient post lobotomy With a chest tube in place for drainage. What is a priority in
caring for this patient? - (ANSWER)Encourage the patient to cough and deep breathe.
Your new patient understands very limited English. How should you communicate with them when
completing the admission assessment? - (ANSWER)Use the organizations interpreter services
You are ordered to give Digoxin(lanoxin). Your patience vital signs are BP 130/75, temp 97.9F, HR 52, RR
16, o2 sat 100% on room air. What should you do next? - (ANSWER)HOLD DIGOXIN AND CALL PROVIDER
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 the provider to ensure the medical
record reflects her wishes
What are the most common causes of acute onset pancreatitis? - (ANSWER)Alcoholism and gallstones
