Medical-Surgical RN A Prophecy Relias

You notice your patient who recently had a stroke is coughing intermittently during meals. What is the MOST likely cause of this?

He could be aspirating.

Which of the following is MOST important in preventing a catheter associated urinary tract infection (CAUTI)?

Using sterile technique when inserting the catheter

Your patient is currently under 1:1 observation for suicide precautions. He states he needs to have a bowel movement and would like some privacy to use the bathroom. What is the MOST appropriate response?

"I must be within an arms' length view of you at all times for your safety, including while using the bathroom."

Your patient, who has soft wrist restraints for safety (non-violent), is working with the occupational therapist at the bedside. The nursing assistant enters and says, "The patient is not allowed to have his restraints untied." How do you respond?

"Restraints can be temporarily off while directly working with staff. Let me know when the therapy session is finished and I will re-apply them."

The patient has diltiazem HCl (Cardizem CD) ordered and is requesting the capsule be mixed into her morning yogurt. How should you respond?

"Sorry, it is a slow-release medication that cannot be opened or crushed."

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?

"You have the right to refuse the blood transfusion. I will inform the provider of your decision."

Digoxin (Lanoxin) 125 mcg is equivalent to how many mg?

0.125mg

When would sucralfate (Carafate) 4 times daily be scheduled for?

1 hour before meals and at bedtime

1.2 milligrams is equal to how many micrograms?

1200 mcg

Insulin lispro (Humalog) is orders via sliding scale a.c. for your patient with diabetes. When is the best time to administer insulin lispro (Humalog)?

15 min before the meal arrives

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?

167 mL/hr

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?

18 mL/hr

The provider orders Heparin 4 units/kg SQ. Your patient weighs 176 pounds. How many units should you administer?

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?

72 hours

A female patient requests a female nurse to provide care for her based on her religious beliefs. What is the MOST appropriate action to take?

Accommodate her request if possible.

What is a proton pump inhibitor, such as pantoprazole (Protonix) used for?

Acid Reduction

Your patient may have tuberculosis TB) and is placed in airborne precautions. What test would you expect to be ordered?

Acid-fast bacilli sputum

A patient has recently been diagnosed with terminal cancer. Her responses are caustic and abrasive. What is the BEST way to respond?

Acknowledge her feelings, understanding this is expected in the grieving process.

What patient population is the pneumococcal vaccine, PPSV23 indicated for?

Adults aged 65 years and older

Your new admission presents with a cough, unintentional weight loss, frequent night sweats, and bloody sputum. What type of isolation precautions should you initiate, if any?

Airborne precautions

Your patient was admitted for a hypertensive crisis and has a history of HTN, Parkinson's disease, depression, and alcohol use. On his second hospitalized day, you notice he is more anxious and restless than his baseline. What would be your FIRST nursing intervention?

Ask the patient when his last drink of alcohol was.

Central Telemetry calls and tells you your patient is experiencing bradycardia. What is the first thing you should do after entering the room?

Assess the patient and take vital signs.

Black and tarry colored stools are CLASSIC symptoms of what condition?

Bleeding gastric ulcer

Your patient had a transurethral resection of the prostate (TURP) 24 hours ago. What signs require further intervention?

Bright red urine

Your 80-year-old patient is being discharged home post CVA. She lives alone, yet still requires assistance with ADLs. What referral is MOST appropriate to ensure her needs are met?

Case Manager

What is the BEST indication of an acute neurological problem?

Change in level of consciousness

If your patient with a known history of diabetes is displaying symptoms of diaphoresis, cool skin, lethargy, and shakiness. What is your first action?

Check the patient's blood glucose level.

What is clubbing of the fingers MOST likely associated with?

Chronic oxygen deficiency

You receive a provider's order that is not consistent with evidence-based practice. What is your FIRST step?

Clarify the order with the provider.

Your post-op patient has a Jackson-Pratt (JP) drain in place. How do you ensure effective drain function?

Compress the drain, then plug the bulb to establish suction

Your new patient understands very limited English. How should you communicate with them when completing the admission assessment?

Use the organization's interpreter services.

Your patient starts to complain of difficulty breathing while laying down, and states that he has been coughing up pink sputum. While performing your assessment, you notice jugular vein distention and coarse crackles in both lungs on auscultation. What diagnosis do you suspect?

Congestive heart failure

Your male patient complains of discomfort while inflating the balloon during insertion of an indwelling urinary catheter. What would be the MOST appropriate action?

Deflate the balloon, advance the catheter further, then reinflate the balloon

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?

Delirium

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?

Discuss code status with the patient and follow up with provider to ensure the medical record reflects her wishes.

Your patient with C. diff (Clostridioides difficile) has a family member about to leave the room. What education about performing hand hygiene should you give?

Hand hygiene with soap and water

What is an early symptom that the patient is developing a complication of heart failure?

Edema in the legs and feet

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?

Encourage the patient to cough and deep breathe.

Your 72-year-old male patient is admitted for colon cancer related complications and has a history of CHF, stroke, and a recent knee replacement. Based on your patient's risk assessment, you determine he is at risk for venous thromboembolism (VTE). What is an appropriate VTE prophylaxis order for this patient?

Enoxaparin (Lovenox) once daily and intermittent pneumatic compressions (IPC)

Your patient takes 5 mg of warfarn (Coumadin/Jantoven) daily and reports having black colored stool today. What do you most likely suspect?

Gastrointestinal bleeding

What type of personal protective equipment (PPE) is applied prior to entering a room for a patient with C. diff?

Gown and gloves

Your patient is on contact precautions for active MRSA. What proper PPE should you use before entering the room?

Gown and gloves

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?

Heart failure

Your new patient was admitted with blunt force trauma to the abdomen following a motor vehicle accident (MVA). 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?

Hemorrhage

You received a patient post op transurethral resection of the prostate (TURP). Which of the following symptoms would cause you the MOST concern?

Hemorrhage and hypotension

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?

Hold digoxin (Lanoxin) and call the provider

Your patient has a non-productive cough and presence of secretions in his tracheostomy. Prior to suctioning the patient, what should you do FIRST?

Hyperoxygenate patient.

Your patient is a 40-year-old female with a recent history of hair loss, extremely dry skin, a nd a 20-point weight loss in the last 3 weeks. She also exhibits occasional episodes of tremors in her upper extremities. What condition do these symptoms MOST likely indicate?

Hyperthyroidism

Your patient admitted for small bowel obstruction has been vomiting for the last 3 days. What electrolyte imbalance would you expect to be associated with this patient?

Hypokalemia

Which of the following nursing diagnoses is MOST important for a patient with chronic obstructive pulmonary disease (COPD)?

Impaired gas exchange

Your patient is taking digoxin (Lanoxin) and has a potassium level of 3.0. How might this affect the patient?

Increase risk of digoxin toxicity

The provider gives you a telephone order to explain a surgical procedure to your patient and obtain surgical consent. How should you respond?

Inform the provider that explaining the procedure is outside the nurse's scope of practice.

Your patient has developed a productive cough and fever. The provider is suspecting influenza. Which actions should you take FIRST?

Initiate droplet precautions

Patient presents dusky pallor and pulseless. First action

Initiate facility code procedure

Your patient with CHF states, "I can still eat the same food, I just have to weight myself everyday." Based on this statement, which nursing diagnosis would be appropriate?

Knowledge Deficit

A patient with acute diverticulitis is MOST likely to complain of abdominal pain with what quadrant?

Left lower quadrant

You received a report on a patient that sustained a right hemisphere CVA 48 hours ago. What do you expect the patient to exhibit?

Left sided weakness of the leg, arm, and face.

What is the EARLIEST sign indicating increased intracranial pressure (ICP)?

Level of consciousness

What condition (not medication related) might cause an elevation in the patients PT/INR level?

Liver disease

An older adult patient arrives on the unit looking emaciated, disheveled, and with soiled clothes. The patient claims that his daughter cares for him at home. What would you suspect?

Neglect

Patients with diabetes are at high risk for complications from damage to what body areas?

Nerve and kidney damage

Your coworker posted photos on social media from a birthday party they had for her in the unit breakroom. What should be your NEXT course of action?

No action is necessary because no PHI was displayed.

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?

Non-rebreather mask

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?

Notify the charge nurse and social worker of your concerns.

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?

Obtain capillary blood glucose level.

Which tool should you use to assess pain in you 80-year-old patient with severe dementia?

PAINAD scale

Your patient's morning labs revealed a hemoglobin level of 6.3 and hematocrit of 18. What blood product do you expect to administer?

PRBCs

Your patient with stave IV terminal lung cancer continues to experience increasing pain as each day passes. What would you anticipate the provider ordering for this patient?

Palliative care consult

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?

Paracentesis

In addition to pain, pallor, and pulselessness, a neurovascular assessment also includes checking for:

Paresthesia and paralysis

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?

Patient lift (e.g., Hoyer)

Your patient is 4 hours post open appendectomy and has not voided yet. You note his lower abdomen is distended. What should you do NEXT?

Perform a bladder scan

Your patient has a diagnosis of urinary tract infection (UTI) and is currently taking medication that has recently made her urine reddish-orange. Which of the following medications would cause this side effect?

Phenazopyridine (Pyridium)

Upon entering your patient's room, you note that they are having a seizure. What is your FIRST action?

Position the patient on their side to maintain the airway.

What diagnostic finding would support a diagnosis of deep vein thrombosis?

Positive D-dimer

The dosage of which drug must be tapered down slowly to prevent acute adrenal insufficiency?

Prednisone

Which of the following would be used as part of the preop procedure to prevent infection?

Prophylactic antibiotics

Your patient suddenly develops signs and symptoms of shortness of breath, restlessness, tachypnea, hemoptysis, and decreased oxygen saturations despite being on 2L/min of O2 by nasal cannula. What do you expect is happening?

Pulmonary embolism

As you are walking down the hallway you overhear your colleague discussing her personal family issues with a patient. What would be the MOST appropriate response?

Remind her later of her responsibility for establishing and maintaining professional boundaries with patients.

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 understaffed. Which is the MOST appropriate action?

Report to the post-surgical unit.

Your patient continues to pull at their IV site 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?

Request an order for soft mitts as they are the least restrictive

Your patient has symptomatic anemia but is refusing a blood transfusion for religious reason. What is an appropriate response?

Respect his wishes and notify the provider

patient arrives on unit. you do an assessment and notice lice in her hair. what is your first action?

Secure a private room

Your patient has a temp of 102.3 F, HR 122, and has had 15 mL of urine from the indwelling urinary catheter in the last 2 hours. What is your patient MOST likely experiencing.

Sepsis

A patient with peritonitis presents with tachycardia, hypotension, and dehydration. What other assessment finding would you anticipate as part of your physical assessment?

Severe abdominal pain or rebound tenderness

Your new patient admitted for cholecystitis expresses she has a history of anxiety disorder. She is feeling panicked and does not think she can handle staying in the hospital for her surgery. What action is MOST appropriate for you to take?

Sit calmly next to her and offer her compassion and a sense of security.

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?

Stat CT of head

What medication would you anticipate to be ordered for a patient who has a LDL > 200 mg/dL?

Statin

Your 18-year-old female patient was admitted with dehydration secondary to anorexia nervosa. During your assessment you note she has a flat affect and says, "I just want to die. I'm tired of my life." What should be your FIRST intervention?

Stay with the patient and ask fi she has a plan to carry out this wish.

Fifteen minutes after starting a blood transfusion, the patient complains of lower back pain, shortness of breath, and chills. What is your FIRST action?

Stop the tranfusion.

What is the proper technique when suctioning a tracheostomy?

Suction in a circular motion while the catheter is being pulled out.

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?

The patient with chest pain

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?

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?

Urinalysis with cultures, CBC

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 your patient. What should you do NEXT?

Verify your patient's consent to release information to her mother.

A patient on warfarin (Coumadin/Jantoven) has an INR of 6. Which medication would you anticipate administering?

Vitamin K

Your patient recently had a G-tube placed and intermittent enteral feedings have been initiated. What symptoms may indicate intolerance to the feedings?

Vomiting and diarrhea

Your patient is admitted with diverticulitis. What type of diet do you expect to be ordered for the patient?

broth, jello, soft fruit no skin,

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?

famotidine (Pepcid)

Your 68-year-old patient is a Type 1 diabetic with a history of schizophrenia and exhibits signs and symptoms of tardive dyskinesia. What long-term medication is associated with signs and symptoms of tardive dyskinesia?

risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, paliperidone, lurasidone, chlorpromazine, fluphenazine, haloperidol, perphenazine