RELIAS MEDICAL SURGICAL TELEMETRY EXAM 2024 TEST BANK CMPLETE QUESTIONS AND WELL EXPLAINED ANSWERS

RELIAS MEDICAL SURGICAL TELEMETRY EXAM 2024 TEST BANK CMPLETE QUESTIONS AND WELL EXPLAINED ANSWERS "Advance care plans provide direction to healthcare professionals when a person is not in a position to make and/or communicate their own healthcare choices." Choose a potential barrier in ACP for patients who have received an HSCT? A. Lack of reassurance from the program B. Difficulty understanding procedures of documentations C. Lack of co-operation from the patient's family members D. Provider discomfort discussing end-of-life issues - AnswerD. Provider discomfort discussing end-of-life issues Explanation: Advance care planning is a process that allows people to make plans when they are unable to express their own healthcare preferences. Because of the elevated mortality risk associated with HSCT, advance care planning (ACP) is difficult. As a result, in ACP, provider anxiety addressing end-of-life problems is seen as an obstacle. Sophia has undergone an HSCT treatment for lymphoma. She barely knows there will be a re-immunization after HSCT. After six months, during one of her hospital visits, she inquired about the particulars about revaccination to the nurse. What would be the likely response of the nurse? A. Re-immunization is not required if the body doesn't develop an infections B. Immunization shall start after 24 months since transplant C. Re-immunization was administrated along with the HSCT treatment D. Re-immunization begins approximately after 12 months since transplant - AnswerD. Re-immunization begins approximately after 11 months since transplant Explanation: Patients diagnosed with blood-related cancers as a leukemia, lymphoma, and multiple myeloma often undergo HSCT treatment. Patients normally lose some or all of their immunities against infectious diseases that they already had or were vaccinated against during care. Revaccination or reimmunization is getting new immunizations after the HSCT treatment since many of the childhood diseases patients were vaccinated against years ago could come again at this stage of compromised immunity. Jeni got an HSCT transplant. She had been put on a cyclophosphamide-based conditioning regime. What are the possible side effects that she would experience within the first two weeks after the transplant? A. Appetite Loss B. Delirium C. Lymphedema D. Pleural effusion - AnswerD. Pleural effusion Explanation: Pleural effusion is the accumulation of excess fluid between the layers of the pleura outside the lungs, also known as "water on the lungs." Pleura are thin membranes that lubricate and facilitate breathing by lining the lungs and the inside of the chest cavity. Cyclophosphamide-containing conditioning regimens increase the risk of pleural effusion in the immediate post-transplant period. Rosy is undergoing a second transplant has a history of nausea from chemotherapy. Which kind of nausea is most likely to strike her now? A. Anticipatory nausea B. Acute nausea C. Delayed nausea D. Acute and Delayed nausea - AnswerA. Anticipatory nausea Explanation: Anticipatory nausea is a conditioned reaction that arises from a previous encounter with nausea and vomiting during chemotherapy and begins prior to administration. Anticipatory nausea and vomiting is a conditioned reaction that occurs in the days prior to scheduled chemotherapy when vomiting has been difficult to manage in previous cycles. It's linked to higher anxiety, more serious post-chem 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? - Answer Acid 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? - Answer Stat 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? - Answer Obtain 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? - Answer Vomiting 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? - Answer Hyperoxygenate 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? - Answer Bleeding 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