AHT II Review
Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter? a. Notify the health care provider. b. Offer reassurance to the patient. c. Auscultate the patient's breath sounds. d. Give the prescribed PRN morphine sulfate IV.
C. Auscultate the patient's breath sounds.
Which action can the RN who is caring for a critically ill patient with multiple IV lines and medications delegate to a LVN/LPN? a. Flush a saline lock with normal saline b. Verify blood products prior to administration c. Remove the patient's central venous catheter d. Titrate the flow rate of vasoactive IV medications
a. Flush a saline lock with normal saline
The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse take next? a. Monitor ionized calcium level. b. Give oral calcium citrate tablets. c. Check parathyroid hormone level. d. Administer vitamin D supplements.
a. Monitor ionized calcium level
A patient with renal failure who arrives for outpatient hemodialysis is unresponsive to questions and has decreased DTR. Family members report that the patient has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. Which action should the nurse take first? a. Notify the patient's HCP b. Obtain an order to draw a potassium level c. Review the last magnesium level on the patient's chart Teach the patient about magnesium-containing antacids
a. Notify the patient's HCP
Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." Which assessment should the nurse complete immediately? a. Presence of the Chvostek's sign b. Abnormal serum potassium level c. Decreased thyroid hormone level d. Bleeding on the patient's dressing
a. Presence of the Chvostek's sign The Chvostek sign is a clinical finding associated with hypocalcemia, or low levels of calcium in the blood. This clinical sign refers to a twitch of the facial muscles that occurs when gently tapping an individual's cheek, in front of the ear
A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the HCP? a. The patient is experiencing laryngeal stridor. b. The patient complains of generalized fatigue. c. The patient's bowels have not moved for 4 days d. The patient has numbness and tingling of the lips
a. The patient is experiencing laryngeal stridor.
A patient comes to the clinic complaining of frequent, watery stools for the past 2 days. Which action should the nurse take first? a. Obtain the baseline weight. b. Check the patient's blood pressure. c. Draw blood for serum electrolyte levels. d. Ask about extremity numbness or tingling.
b. Check the patient's blood pressure.
A patient who has a transverse colectomy for diverticulosis 18hrs ago has nasogastric suction. The patient complains of anxiety and incisional pain. The patient's respiratory rate is 32 breaths/min, and the ABGs indicate respiratory alkalosis. Which action should the nurse take first? a. Check to make sure the nasogastric tube is patent. b. Give the patient the PRN IV morphine sulfate 4mg. c. Notify the HCP about the ABG results. d. Teach the patient how to take slow, deep breaths when anxious.
b. Give the patient the PRN IV morphine sulfate 4mg.
A patient admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse? a. Arterial blood pH is 7.32 b. Serum calcium is 18mg/dL c. Serum potassium is 5.1 mEq/L d. Arterial oxygen saturation is 91%
b. Serum calcium is 18mg/dL Normal range: 8.4-10.6
When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the HCP immediately? a. The bibasilar breath sounds are decreased b. The patellar and triceps reflexes are absent c. The patient has been sleeping most of the day d. The patient reports feeling "sick to my stomach"
b. The patellar and triceps reflexes are absent
A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse? a. The patient's radial pulse is 105 beats/minute. b. There are crackles audible throughout both lung fields. c. There is sediment and blood in the patient's urine. d. The blood pressure increases from 120/80 to 142/94.
b. There are crackles audible throughout both lung fields.
A nurse is assessing a newly admitted patient with chronic HF who forgot to take prescribed medications and seems confused. The patient has peripheral edema and shortness of breath. Which assessment should the nurse complete first? a. Skin turgor b. Heart sounds c. Mental status d. Capillary refill
c. Mental status
After receiving change-of-shift report, which patient should the nurse assess first? a. Patient w/ serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping b. Patient with serum sodium level of 145 mEq/L who has a dry mouth & is asking for a glass of water c. Patient w/ serum magnesium level of 1.1 mEq/L who has tremors & hyperactive DTR d. Patient w/ serum phosphorous level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates
c. Patient w/ serum magnesium level of 1.1 mEq/L who has tremors & hyperactive DTR Normal range: 1.3-2.1