RELIAS MEDICAL SURGICAL TELEMETRY EXAM 2025 TEST BANK COMPLETE 100
QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) |ALREADY GRADED A+
The provider orders a Heparin infusion of 900 units/hr. Your IV medication on hand has
25,000 units of Heparin in 500 mL of D5W. How many mL/hr will you infuse? - ANSWER - 18
mL/hr
The provider orders and IV infusion of D5W 1000 mL to infuse over the next 6 hours. How
many mls per hour should the IV pump be set to? - ANSWER - 167 mL/hr
The provider orders Heparin 4 units/kg SQ. Your patient weighs 176 pounds. How many
units should you administer? - ANSWER - 320 units
To reduce the risk of infection and phlebitis in an adult patient with a peripheral IV, what is
the MINIMUM duration the catheter should remain in place before ROUTINE replacement?
- ANSWER - 72 hours
Two days after surgery, your 72-year-old patient is showing signs of agitation and
confusion, which is not his baseline. The severity fluctuates throughout the day. His
medications include hydromorphone (Dilaudid), amlodipine (Norvasc), alprazolam
(Xanax), and carbidopa-levodopa (Sinemet). What condition do you MOST likely suspect? -
ANSWER - Delirium
Upon entering your patient's room, you note that they are having a seizure. What is your
FIRST action? - ANSWER - Position the patient on their side to maintain the airway.
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? -
ANSWER - Non-rebreather mask
What condition (not medication related) might cause an elevation in the patients PT/INR
level? - ANSWER - Liver disease
What diagnostic finding would support a diagnosis of deep vein thrombosis? - ANSWER -
Positive D-dimer
,What is a proton pump inhibitor, such as pantoprazole (Protonix) used for? - ANSWER -
Acid Reduction
What is an early symptom that the patient is developing a complication of heart failure? -
ANSWER - Edema in the legs and feet
What is clubbing of the fingers MOST likely associated with? - ANSWER - Chronic oxygen
deficiency
What is the BEST indication of an acute neurological problem? - ANSWER - Change in level
of consciousness
What is the EARLIEST sign indicating increased intracranial pressure (ICP)? - ANSWER -
Level of consciousness
What is the proper technique when suctioning a tracheostomy? - ANSWER - Suction in a
circular motion while the catheter is being pulled out.
What medication would you anticipate to be ordered for a patient who has a LDL > 200
mg/dL? - ANSWER - Statin
What patient population is the pneumococcal vaccine, PPSV23 indicated for? - ANSWER -
Adults aged 65 years and older
What type of personal protective equipment (PPE) is applied prior to entering a room for a
patient 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
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? -
ANSWER - Patient lift (e.g., Hoyer)
Which of the following is MOST important in preventing a catheter associated urinary tract
infection (CAUTI)? - ANSWER - Using sterile technique when inserting the catheter
Which of the following nursing diagnoses is MOST important for a patient with chronic
obstructive pulmonary disease (COPD)? - ANSWER - Impaired gas exchange
Which of the following would be used as part of the preop procedure to prevent infection? -
ANSWER - Prophylactic antibiotics
, Which tool should you use to assess pain in you 80-year-old patient with severe dementia?
- ANSWER - PAINAD scale
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? - ANSWER - Heart failure
You are assigned a new admission and note a Braden score of 11 after completing your
assessment. Which interventions would be MOST appropriate based on your assessment?
- ANSWER - Turn q 2hours, request nutrition consult, request low airloss mattress.
You are caring for a combative 85-year-old male with a history of dementia, CHF, UTI, and
anemia. The family states he appears to be more confused than his baseline. What tests
do you expect the provider to order? - ANSWER - Urinalysis with cultures, CBC
You are caring for a patient post lobectomy with a chest tube in place for drainage. What is
a priority in care for this patient? ANSWER - Encourage the patient to cough and deep
breathe. -
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? - ANSWER - Obtain
capillary blood glucose level.
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 are preparing to hang 1 unit PRBC's to administer to your patient. The patient states, "I
don't take blood products." What is the MOST appropriate response? - ANSWER - "You
have the right to refuse the blood transfusion. I will inform the provider of your decision."
You have 4 patients who have high priority needs. One needs to go to surgery, one needs
STAT lab draws from a PICC line, another has chest pain rated 8/10, and another needs
toileting. Which patient should you tend to FIRST? - ANSWER - The patient with chest pain
You have a patient going for dialysis. Their medications include lisinopril (Prinivil),
ondansetron (Zofran), famotidine (Pepcid), and atorvastatin (Lipitor). Which medication
would you possibly hold and seek clarification? - ANSWER - famotidine (Pepcid)
You just left your patient's room with her husband at bedside. You then receive a phone
call from someone states that she is your patient's mother and demands updates about
QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) |ALREADY GRADED A+
The provider orders a Heparin infusion of 900 units/hr. Your IV medication on hand has
25,000 units of Heparin in 500 mL of D5W. How many mL/hr will you infuse? - ANSWER - 18
mL/hr
The provider orders and IV infusion of D5W 1000 mL to infuse over the next 6 hours. How
many mls per hour should the IV pump be set to? - ANSWER - 167 mL/hr
The provider orders Heparin 4 units/kg SQ. Your patient weighs 176 pounds. How many
units should you administer? - ANSWER - 320 units
To reduce the risk of infection and phlebitis in an adult patient with a peripheral IV, what is
the MINIMUM duration the catheter should remain in place before ROUTINE replacement?
- ANSWER - 72 hours
Two days after surgery, your 72-year-old patient is showing signs of agitation and
confusion, which is not his baseline. The severity fluctuates throughout the day. His
medications include hydromorphone (Dilaudid), amlodipine (Norvasc), alprazolam
(Xanax), and carbidopa-levodopa (Sinemet). What condition do you MOST likely suspect? -
ANSWER - Delirium
Upon entering your patient's room, you note that they are having a seizure. What is your
FIRST action? - ANSWER - Position the patient on their side to maintain the airway.
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? -
ANSWER - Non-rebreather mask
What condition (not medication related) might cause an elevation in the patients PT/INR
level? - ANSWER - Liver disease
What diagnostic finding would support a diagnosis of deep vein thrombosis? - ANSWER -
Positive D-dimer
,What is a proton pump inhibitor, such as pantoprazole (Protonix) used for? - ANSWER -
Acid Reduction
What is an early symptom that the patient is developing a complication of heart failure? -
ANSWER - Edema in the legs and feet
What is clubbing of the fingers MOST likely associated with? - ANSWER - Chronic oxygen
deficiency
What is the BEST indication of an acute neurological problem? - ANSWER - Change in level
of consciousness
What is the EARLIEST sign indicating increased intracranial pressure (ICP)? - ANSWER -
Level of consciousness
What is the proper technique when suctioning a tracheostomy? - ANSWER - Suction in a
circular motion while the catheter is being pulled out.
What medication would you anticipate to be ordered for a patient who has a LDL > 200
mg/dL? - ANSWER - Statin
What patient population is the pneumococcal vaccine, PPSV23 indicated for? - ANSWER -
Adults aged 65 years and older
What type of personal protective equipment (PPE) is applied prior to entering a room for a
patient 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
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? -
ANSWER - Patient lift (e.g., Hoyer)
Which of the following is MOST important in preventing a catheter associated urinary tract
infection (CAUTI)? - ANSWER - Using sterile technique when inserting the catheter
Which of the following nursing diagnoses is MOST important for a patient with chronic
obstructive pulmonary disease (COPD)? - ANSWER - Impaired gas exchange
Which of the following would be used as part of the preop procedure to prevent infection? -
ANSWER - Prophylactic antibiotics
, Which tool should you use to assess pain in you 80-year-old patient with severe dementia?
- ANSWER - PAINAD scale
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? - ANSWER - Heart failure
You are assigned a new admission and note a Braden score of 11 after completing your
assessment. Which interventions would be MOST appropriate based on your assessment?
- ANSWER - Turn q 2hours, request nutrition consult, request low airloss mattress.
You are caring for a combative 85-year-old male with a history of dementia, CHF, UTI, and
anemia. The family states he appears to be more confused than his baseline. What tests
do you expect the provider to order? - ANSWER - Urinalysis with cultures, CBC
You are caring for a patient post lobectomy with a chest tube in place for drainage. What is
a priority in care for this patient? ANSWER - Encourage the patient to cough and deep
breathe. -
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? - ANSWER - Obtain
capillary blood glucose level.
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 are preparing to hang 1 unit PRBC's to administer to your patient. The patient states, "I
don't take blood products." What is the MOST appropriate response? - ANSWER - "You
have the right to refuse the blood transfusion. I will inform the provider of your decision."
You have 4 patients who have high priority needs. One needs to go to surgery, one needs
STAT lab draws from a PICC line, another has chest pain rated 8/10, and another needs
toileting. Which patient should you tend to FIRST? - ANSWER - The patient with chest pain
You have a patient going for dialysis. Their medications include lisinopril (Prinivil),
ondansetron (Zofran), famotidine (Pepcid), and atorvastatin (Lipitor). Which medication
would you possibly hold and seek clarification? - ANSWER - famotidine (Pepcid)
You just left your patient's room with her husband at bedside. You then receive a phone
call from someone states that she is your patient's mother and demands updates about
