Name: Score:
20 Multiple choice questions
,Term 1 of 20
POST
after admitting ms jones the nurse calls the provider. What data would the nurse include in the
SBAR communications? SATA
-Clonus 1+
-coarse crackles in lungs
-Severe headache
-RUQ pain
Rationale: Crackles in lungs, headache, clonus, and RUQ pain are all signs of worsening
preeclampsia and need to be shared with the provider and incorporated into the medical
plan of care. The nurse can independently address the patient being scared. The patient is
not having a heart attack but is having RUQ pain.
-productive cough
-restlessness
- neck vein distension
Rationale: A productive cough, neck vein distention, and restlessness are signs of
pulmonary edema and potential for right-sided heart failure. Urine output is an assessment
of renal status. Vomiting and RUQ pain are symptoms that may be associated with liver
involvement but not respiratory status.
-seizure precaustions
-reduced stimulation
-bed rest
-dim light
Rationale: The environment needs to be quiet, darkened, and relaxing. Seizure precautions
are necessary for the potential development of eclampsia. The changing light intensity from
a television can aggravate central nervous system irritability. Having frequent visitors
doesn't create a relaxing environment for the patient.
-bring suction to bedside
-pad side rails
-have O2 available
, Rationale: The side rails are padded for safety. Oxygen and suction equipment are at the
bedside to support the patient and to remove excessive secretions and prevent aspiration,
if needed. Restraints and inserting a tongue depressor may cause injury to the seizing
patient.
Definition 2 of 20
apply firm pressure to puncture sites for 2 minutes
Rationale: Low platelet count increases the potential for bleeding and bruising. Firm pressure for
2 minutes will promote clotting and decrease bruising at puncture sites. A blood transfusion is not
needed based on this isolated laboratory result. Vitamin K is the antidote for warfarin (Coumadin);
it will not treat thrombocytopenia. Steroids are not appropriate in this situation.
POST
ms jones is complaining of nausea and RUQ pain. Which set of labs would the nurse expect
the provider to order based on her symptoms?
POST
a review of ms jones lab results reveals thrombocytopenia. Based on this info which of the
following nursing actions is important while caring for this pt?
POST
Monitoring ms jones liver enzymes, chem panel, and coagulation studies will assist the
nurse to determine if the pts condition is progressing to what?
POST
ms jones presents with chest tightness and coarse crackles. What additional assessment
parameter would the nurse evaluate to determine her pulmonary/ resp status? SATA
20 Multiple choice questions
,Term 1 of 20
POST
after admitting ms jones the nurse calls the provider. What data would the nurse include in the
SBAR communications? SATA
-Clonus 1+
-coarse crackles in lungs
-Severe headache
-RUQ pain
Rationale: Crackles in lungs, headache, clonus, and RUQ pain are all signs of worsening
preeclampsia and need to be shared with the provider and incorporated into the medical
plan of care. The nurse can independently address the patient being scared. The patient is
not having a heart attack but is having RUQ pain.
-productive cough
-restlessness
- neck vein distension
Rationale: A productive cough, neck vein distention, and restlessness are signs of
pulmonary edema and potential for right-sided heart failure. Urine output is an assessment
of renal status. Vomiting and RUQ pain are symptoms that may be associated with liver
involvement but not respiratory status.
-seizure precaustions
-reduced stimulation
-bed rest
-dim light
Rationale: The environment needs to be quiet, darkened, and relaxing. Seizure precautions
are necessary for the potential development of eclampsia. The changing light intensity from
a television can aggravate central nervous system irritability. Having frequent visitors
doesn't create a relaxing environment for the patient.
-bring suction to bedside
-pad side rails
-have O2 available
, Rationale: The side rails are padded for safety. Oxygen and suction equipment are at the
bedside to support the patient and to remove excessive secretions and prevent aspiration,
if needed. Restraints and inserting a tongue depressor may cause injury to the seizing
patient.
Definition 2 of 20
apply firm pressure to puncture sites for 2 minutes
Rationale: Low platelet count increases the potential for bleeding and bruising. Firm pressure for
2 minutes will promote clotting and decrease bruising at puncture sites. A blood transfusion is not
needed based on this isolated laboratory result. Vitamin K is the antidote for warfarin (Coumadin);
it will not treat thrombocytopenia. Steroids are not appropriate in this situation.
POST
ms jones is complaining of nausea and RUQ pain. Which set of labs would the nurse expect
the provider to order based on her symptoms?
POST
a review of ms jones lab results reveals thrombocytopenia. Based on this info which of the
following nursing actions is important while caring for this pt?
POST
Monitoring ms jones liver enzymes, chem panel, and coagulation studies will assist the
nurse to determine if the pts condition is progressing to what?
POST
ms jones presents with chest tightness and coarse crackles. What additional assessment
parameter would the nurse evaluate to determine her pulmonary/ resp status? SATA
