Medical-Surgical RN A Prophecy Relias Exam With 100% Verified Answers (2024/2025)

1.2 milligrams is equal to how many micrograms? - ANSWER-1200 mcg Your post-op patient has a Jackson-Pratt (JP) drain in place. How do you ensure effective drain function? - ANSWER-Compress the drain, then plug the bulb to establish suction Your male patient complains of discomfort while inflating the balloon during insertion of an indwelling urinary catheter. What would be the MOST appropriate action? - ANSWER-Deflate the balloon, advance the catheter further, then reinflate the balloon Your patient has symptomatic anemia but is refusing a blood transfusion for religious reason. What is an appropriate response? - ANSWER-Respect his wishes and notify the provider Your patient is admitted with diverticulitis. What type of diet do you expect to be ordered for the patient? - ANSWER-broth, jello, soft fruit no skin, 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? - ANSWER-Report to the post-surgical unit. What is a proton pump inhibitor, such as pantoprazole (Protonix) used for? - ANSWERAcid Reduction 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 tool should you use to assess pain in you 80-year-old patient with severe dementia? - ANSWER-PAINAD scale 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? - ANSWER-Notify the charge nurse and social worker of your concerns. 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? - ANSWERStat CT of head 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. - ANSWER-Sepsis What type of personal protective equipment (PPE) is applied prior to entering a room for a patient with C. diff? - ANSWER-Gown and gloves 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? - ANSWER-Request an order for soft mitts as they are the least restrictive 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? - ANSWER-Ask the patient when his last drink of alcohol was. What is the BEST indication of an acute neurological problem? - ANSWER-Change in level of consciousness 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 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? - ANSWER-Airborne precautions Patients with diabetes are at high risk for complications from damage to what body areas? - ANSWER-Nerve and kidney damage If your patient with a known history of diabetes is displaying symptoms of diaphoresis, cool skin, lethargy, and shakiness. What is your first action? - ANSWER-Check the patient's blood glucose level. 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? - ANSWER-Discuss code status with the patient and follow up with provider to ensure the medical record reflects her wishes. 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? - ANSWER-No action is necessary because no PHI was displayed. Your new patient understands very limited English. How should you communicate with them when completing the admission assessment? - ANSWER-Use the organization's interpreter services. 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? - ANSWERObtain capillary blood glucose level. 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? - ANSWER-Perform a bladder scan A patient with peritonitis presents with tachycardia, hypotension, and dehydration. What other assessment finding would you anticipate as part of your physical assessment? - ANSWER-Severe abdominal pain or rebound tenderness What is the EARLIEST sign indicating increased intracranial pressure (ICP)? - ANSWER-Level of consciousness In addition to pain, pallor, and pulselessness, a neurovascular assessment also includes checking for: - ANSWER-Paresthesia and paralysis You received a report on a patient that sustained a right hemisphere CVA 48 hours ago. What do you expect the patient to exhibit? - ANSWER-Left sided weakness of the leg, arm, and face. 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 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 Your patient is on contact precautions for active MRSA. What proper PPE should you use before entering the room? - ANSWER-Gown and gloves Your patient recently had a G-tube placed and intermittent enteral feedings have been initiated. What symptoms may indicate intolerance to the feedings? - ANSWERVomiting and diarrhea 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. 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? - ANSWER-Stay with the patient and ask fi she has a plan to carry out this wish. Your patient has a non-productive cough and presence of secretions in his tracheostomy. Prior to suctioning the patient, what should you do FIRST? - ANSWERHyperoxygenate patient. Your patient takes 5 mg of warfarn (Coumadin/Jantoven) daily and reports having black colored stool today. What do you most likely suspect? - ANSWER-Gastrointestinal bleeding 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? - ANSWER-Hemorrhage Which of the following nursing diagnoses is MOST important for a patient with chronic obstructive pulmonary disease (COPD)? - ANSWER-Impaired gas exchange 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) What is an early symptom that the patient is developing a complication of heart failure? - ANSWER-Edema in the legs and feet Black and tarry colored stools are CLASSIC symptoms of what condition? - ANSWERBleeding gastric ulcer 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 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? - ANSWER-Paracentesis What is clubbing of the fingers MOST likely associated with? - ANSWER-Chronic oxygen deficiency A patient on warfarin (Coumadin/Jantoven) has an INR of 6. Which medication would you anticipate administering? - ANSWER-Vitamin K 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 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. What patient population is the pneumococcal vaccine, PPSV23 indicated for? - ANSWER-Adults aged 65 years and older 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? - ANSWER-Palliative care consult The provider gives you a telephone order to explain a surgical procedure to your patient and obtain surgical consent. How should you respond? - ANSWER-Inform the provider that explaining the procedure is outside the nurse's scope of practice. The patient has diltiazem HCl (Cardizem CD) ordered and is requesting the capsule be mixed into her morning yogurt. How should you respond? - ANSWER-"Sorry, it is a slow-release medication that cannot be opened or crushed." 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? - ANSWER-Enoxaparin (Lovenox) once daily and intermittent pneumatic compressions (IPC) You receive a provider's order that is not consistent with evidence-based practice. What is your FIRST step? - ANSWER-Clarify the order with the provider. When would sucralfate (Carafate) 4 times daily be scheduled for? - ANSWER-1 hour before meals and at bedtime Your patient's morning labs revealed a hemoglobin level of 6.3 and hematocrit of 18. What blood product do you expect to administer? - ANSWER-PRBCs 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? - ANSWER-risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, paliperidone, lurasidone, chlorpromazine, fluphenazine, haloperidol, perphenazine