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1.Hematemesis- - Contact HCP if blood is visible in body fluids such as
hematemesis. - ANSWER A patient with acute anterior wall MI 1 week ago is given
low-dose aspirin. The medication is related to which problem and HCP should be
notified?
2. Elevated blood urea nitrogen (BUN) - ANSWER For a patient with SLE
exacerbation what is the most important to report which assessment finding?
3. Rate of pain on a scale from 0-10. - ANSWER Before selecting a medication to
administer, which action should the nurse implement in the post-op patient who
reports incisional pain and has 2 PRN analgesia available in MAR?
4. Keep patient NPO- Patient should be kept NPO until procedure is successfully
completed. The patient should not take anything by mouth. - ANSWER Patient had
bariatric surgery 2 months ago who developed post-op strictures who is
experiencing nausea and vomiting and anorexia who is admitted for fluid
resuscitation. Which intervention should the nurse implement?
5. Vital sign changes and ECGs- Priority parameters are vital sign changes related
to hypovolemia and ECG changes due to serum electrolyte loss, which can be life
threatening. - ANSWER Acute Kidney Injury due to aminoglycoside antibiotic
moved from oliguric phase to the diuretic phase. Which parameters are most
important to monitor?
, 6. Nuts, chocolate, dark greens, and spinach. - ANSWER Patient has a calcium
oxalate renal stone. Which food are you going to teach the patient to avoid?
7. Pancreatitis- complications include pancreatitis that may manifest with upper
left quadrant or mid-epigastric pain which radiates to the back and accompanied
by nausea, vomiting, and fever. - ANSWER A patient had a cholecystectomy 2 days
ago, the patient is febrile, abdominal pain radiating to the back and has had 3
episodes of vomiting in the last 8 hours. The patient is exhibiting symptoms for
which condition?
8. Uncompensated Metabolic Alkalosis - ANSWER Patient has a bowel obstruction
and ABGs read ph- 7.50 PaCO2-42 and HCO3-33. How would you define this acid
base balance?
9.Neutrophil count- The patient is experiencing infection, so a nurse should review
the neutrophil count before contacting the HCP. - ANSWER While caring for a
client with full thickness burns covering 40% of the body, the nurse observes
purulent drainage from the wounds. Before reporting the finding, what is the best
lab value to evaluate?
10. Demonstrate the use of visual scanning during meals to the client and family. -
ANSWER An older woman who experienced a cerebrovascular accident (CVA) has
difficulty with visual perception and she only eats half of the food on her meal
tray. Her family expresses concern about her nutritional status. How should the
nurse respond to the family's concern?
11. High Fowler's Position- High fowlers helps to decrease venous return, which
decreases fluid volume in the heart that results in decreased cardiac workload. -
ANSWER Best position for respiratory distress?