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You are to obtain informed consent for a Spanish-speaking patient scheduled for surgery. You do not speak Spanish and are having difficulty communicating with your patient. Which of the following resources would be most appropriate to utilize in order to obtain consent?
The hospitals language interpreter
You’re reviewing the discharge medication list of a patient diagnosed with gastric ulcer. Which of the following medication should you question?
Acetylsalicylic acid ( Bauer buffered aspirin)
When taking care of a patient with pancreatitis, which of the following lab should be reviewed?
Lipase and amylase
You’re caring for a 12 hour postoperative parathyroidectomy patient. Which assessment finding would indicate an emergency?
Laryngeal strider
Which of the following actions would be considered a violation of Hyppa?
Looking through the chart of a coworker admitted to your unit
You are taking care of a patient who is admitted for left flank pain with a kidney stone of 1.5 cm. He asks you about the procedure what would be the most therapeutic response?
Due to the size of the kidney stone it is an appropriate treatment? NOT:Print reading materials about the subject and give it to the patient
The nurse is taking care of a patient who is terminally ill and has a DNR on file. Their patient has a sudden cardiac arrest and family wants CPR initiated. How should you respond?
Honor the patient’s wishes
Your patient began deteriorating rapidly after complaining of shortness of breath. And ABG was drawn and the results are pH? HCO3 – 23. These values indicate the patient is experiencing:
Your inserting a urinary catheter into a male patient. As you inflate a balloon, the patient complains of discomfort what is the best action?
Aspirate the fluid, advance the catheter farther, then re-inflate the balloon
When assessing a patient, you notice crepitus on the right upper shoulder. You notify the physician and anticipate which diagnosis?
Subcutaneous emphysema
You are providing patient education to a patient prior to administering IV Protonix…. When there is no history of GERD
Protonix is given as G.I. prophylaxis to prevent stress ulcers
The patient has a morphine PCA post operatively. On rounding you notice respirations at eight per minute O2 saturation of 82%. What medication would be given in the situation?
Narcan
You were caring for a patient who is 18 hours postop after a right BKA a. They report sudden chest pain pulse ox at 86%. The patient may be experiencing:
Pulmonary embolism
Cardiac strip
Unable to determine
At 0500, you know your patient to be diaphoretic, clammy, and their hands are shaking. The patient’s blood sugar is currently 60. Which of the following is the most appropriate intervention
Have the patient drink 120 ML’s of orange juice
Which of the following food items would you question in the menu of your patient who is diagnosed with celiac disease?
Wheat bread
A postoperative laparoscopic appendectomy patient is receiving morphine PCA for pain findings with alert you to the potential of a narcotic overdose?
A respiratory rate of 8 breaths per minute
Your patient was admitted with severe dehydration. Which of the following orders would you question
KCI 40 mEq IV push STAT
What is the first sign of increased intracranial pressure?
Change in LOC
A patient suddenly complains of new onset of chest pain. The doctor is suspecting a possible?… What is most likely to be ordered?
Morphine Duramorph, oxygen, nitrates, Aceticsalicylic acid, bayer buffered aspirin
The Glasgow, scale ranges from:
3 to 15
You deserve the nurse aid removing her gloves and immediately using alcohol hand sanitizer in a room with a patient who has C-Diff. What education should you provide to the nurse aide
And washing with soap and water is mandatory because alcohol based hand sanitizers do not kill C-diff
Heart rate
80
Which of the following assessment findings should you report immediately to the physician for a patient who just had a bronchoscopy and biopsy?
Sputum with streaks of blood NOT: increased salivation
Your patient was just returned from surgery with a Jackson-Pratt JP drain in place which of the following is the best nursing action?
Compress the drain, then plug the bulb to establish suction
Patient is admitted for shortness of breath. Do you notice the spouse adjusting the oxygen on the wall and she states “she always takes care of my husband” what would be an appropriate response?
Educate the spouse on oxygen use as a medical device in the hospital
Deposition has ordered for your patience to begin a 24 hour urine collection. Your patient voids for the first time two hours after the orders received. What should be done with this urine sample?
Discarded, then begin the 24 hour collection
Which of the following lab values would you expect to see in a patient diagnosed with?….
Lipase – 196
You were caring for a patient admitted with abdominal pain. Your patient has a bowel movement and you know dark tarry stool what would be the diagnosis?
Upper G.I. bleed
Your COPD patient is complaining of wheezing and increased shortness of breath
Assess your patient for a change in condition
What information is vital for you to know prior to administering an ordered dose of digoxin
Heart rate
Your patient has been diagnosed with a hemorrhagic CVA
Heparin infusion per pharmacy protocol
A 56-year-old man has an acute onset of shortness of breath, chest pain, apprehension, rapid pulse, cough with bloody sputum, diaphoresis, and syncope. The symptoms are indicative of:
Pulmonary embolism? NOT: tuberculosis
You’re reviewing the menu list of a patient on Warfran what food should they not eat?
Spinach
Which of the following issues should be reported up the chain of command
A coworker arriving to work under the influence of alcohol
You’re providing discharge instructions to a CHF patient.
Increase shortness of breath
cardiac rhythm
V-Tach
Which of the following electrolyte value should be Addressed immediately by the nurse
Potassium 2.5 mEq/L
Which of the following medication may cause urine discoloration
Rifampin
Calculate the 12 hour intake for a patient that has received the following during your shift: normal saline 750 ML, 24 ounces of sprite, Levaquin 50 ML, 650 ML urine in Foley catheter
1520
When caring for a patient experiencing a tonic clonic seizure, the most appropriate nursing intervention is:
Protecting the patient’s head and extremities from contact with surrounding objects
You went to the room of a 58-year-old female. You find that the patient’s cardiac monitor shows asystolye, what should be your first action?
Assess the patient Not: start CPR
Didn’t nurse ask you about the typical signs and symptoms of myocardial infarction
Women could have pain in their arm, neck, back or jaw
While performing the narcotic count at the end of the shift, my coworker admits to something, coworker to sign for the ways that you did not witness
Refused to sign for the waste
Cardiac strip
Sinus rhythm with PAC
You’re preparing your patient for discharge need to provide dietary education related to his diagnosis what should you instruct the patient to avoid?
Canned meats
Your patient complains of not being able to urinate since 0500. It is now 1900. What should be your next step?
Perform a bladder scan
The doctor ordered Lasix 40 mg IV push, 100mg/10 mL
4ml
After a patient completes dialysis, you should anticipate seeing an improvement in which of the following lab values?
NOT: ammonia
Your patient fell and hit his head on the bed rail during a physical therapy session. Upon initial assessment you observe a blood pressure of 90/45, heart rate of 28, and a constricted pupil. The patient is lying in a supine position. What should be your first response?
Call a rapid response
Which of the following antidiabetic medication is contraindicated 48 hours after receiving contrast dye
Metformin
You’re a king for a patient who is postop after surgical removal of fibroids. She hears a pop sound after coughing in her surgical wound has dehisced
Apply sterile saline soap towels over the extruding site
One of the signs of left sided heart failure is:
Pulmonary edema NOT: pedal edema
Your patient had a TB skin test done on Thursday at 2:45 PM
Saturday at 3 PM
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