RELIAS MEDICAL SURGICAL TELEMETRY EXAM TEST BANK COMPLETE QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+

RELIAS MEDICAL SURGICAL TELEMETRY EXAM TEST BANK COMPLETE QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+ Is what is the earliest sign indicating increased intracranial pressure(ICP)? - ANSWER Level of consciousness What patient population is the pneumococcal vaccine PPSV23 indicated for? - ANSWER Adults aged 65 years and older Your patient takes 5 mg of warfarin(coumadin) day and reports having black cored stool today. What do you most likely suspect? - ANSWER Gastrointestinal bleeding 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 A patient presents with a heart rate of 45 bpm and is experiencing dizziness. What is the most appropriate initial nursing intervention? - ANSWER C) Assess the patient's blood pressure RATIONALE:: Assessing blood pressure is essential to determine the hemodynamic stability of the patient before further interventions. When monitoring a patient's telemetry, what does a wide QRS complex indicate? - ANSWER C) A bundle branch block or ventricular rhythm RATIONALE:: A wide QRS complex can indicate a bundle branch block or a ventricular rhythm, which could be life-threatening. Which of the following is a common complication associated with telemetry monitoring? - ANSWER B) Skin irritation from electrode placement RATIONALE:: Skin irritation can occur due to prolonged electrode placement, leading to discomfort or skin breakdown. A telemetry technician notices that a patient's heart rate suddenly increases from 70 bpm to 150 bpm. What should be the technician's first action? - ANSWER C) Notify the nurse immediately RATIONALE:: Immediate notification of the nurse is essential to assess the potential cause of the tachycardia and intervene as necessary. In telemetry monitoring, what does ST segment elevation typically indicate? - ANSWER C) Myocardial injury RATIONALE:: ST segment elevation is often associated with myocardial injury, indicating a possible acute coronary event. A patient is being monitored for potential arrhythmias. Which finding would most likely indicate a need for immediate intervention? - ANSWER B) Ventricular tachycardia RATIONALE:: Ventricular tachycardia is a serious arrhythmia that requires prompt intervention to prevent further complications. What is the best position for a patient experiencing shortness of breath and tachycardia? - ANSWER C) High Fowler's position RATIONALE:: High Fowler's position facilitates better lung expansion and improves oxygenation in patients experiencing respiratory distress. If a telemetry monitor displays a flat line, what should the nurse do first? - ANSWER B) Check the patient's leads and connections RATIONALE:: The first step is to check the connections to ensure the monitor is functioning correctly before assuming the patient has no pulse. A patient has a history of atrial fibrillation. What medication is commonly prescribed to prevent complications? - ANSWER C) Anticoagulants RATIONALE:: Anticoagulants are often prescribed to prevent thromboembolic complications associated with atrial fibrillation. In telemetry monitoring, what does a sinus rhythm with a PR interval of 0.24 seconds suggest? - ANSWER C) First-degree AV block RATIONALE:: A PR interval greater than 0.20 seconds indicates a first-degree AV block, which may require monitoring. A patient in telemetry is experiencing palpitations. What is the first action the nurse should take? - ANSWER C) Assess the patient's vital signs RATIONALE:: Assessing vital signs helps determine the patient's hemodynamic status and guides further interventions. What is the primary purpose of telemetry monitoring in a medical-surgical unit? - ANSWER B) To continuously monitor cardiac rhythms RATIONALE:: The main purpose of telemetry is to continuously monitor cardiac rhythms for early detection of arrhythmias. 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. Which adaptive equipment would be most appropriate to use for a severely contracted patient who is unable to bear weight when transferring from bed to chair - ANSWER Patient Lift example hoyer What lab values are expected to be in a patient with end stage renal disease on hemodialysis - ANSWER BUN 32, CREATNINE 8.32 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? You're? - ANSWER Hold wayfaring (coumadin) for the next 48 hours Your new admission presents with a cough, unintentional weight loss, frequent knot sweats, and bloody sputum. What type of isolation precautions should you initiate, if any? - ANSWER Airborne precautions Upon entering your patient's room you note that they are having a seizure. What is your 1st action? - ANSWER Position the patient on their side to maintain the airway You find your coworker looking through your patient's medical record.. She States how is Mr. Smith doing? He is my best friend's dad. We are so worried about him. What is the best course of action? - ANSWER Tell her you cannot give her information and report her actions to your manager. Your male patient complaints of discomfort while inflating the balloon during insertion of a endwelling urinary catheter. What would be the most appropriate action? - ANSWER Deflate the balloon, advance the catheter further, then reinflate the balloon. Your patient takes regular insulin and NPH twice A-day for glucose control. What times should the patient be taught to be alert for signs of hypoglycemia? - ANSWER Is late afternoon and early morning What is a proton pump inhibitor, such as pantoprazole (protonix) used for? - ANSWER Reduce gastric acid secretion Your patient has a non productive cough and presence of secretions in his tracheostomy. Prior to sectioning the patient, what should you do 1st? - ANSWER Hyperoxygenate patient dietary teaching for a patient with chronic renal failure should include choices that are: - ANSWER Low potassium, low protein, moderate fat Which of the following nursing diagnosis is most important for a patient with chronic obstructive pulmonary disease(COPD) - ANSWER Impaired gas exchange 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. You have a patient going for dialysis. There are medications include Lisinopril(prinivil), ondansetron (zofran), famotidine(pepcid) and atorvastatin(lipitor). Which medication would you possibly hold and seek clarification? - ANSWER LISINOPRIL(PRINIVIL) What is the best indication of an acute neurological problem? - ANSWER Change in level of consciousness Your patient is admitted with diverticulitis. What type of diet do you expect to be ordered for the patient? - ANSWER Clear liquids Which tool should you use to assess pain in your 80 year old patient with severe dementia? - ANSWER ? Your post op patient has a Jackson - Pratt drain in place. how do you ensure effective drain function? - ANSWER Compress the drain, then plug the bulb to establish suction.