[Document title]
Relias Med-Surg Clinical Assessment Relias
Medical-Surgical Telemetry Prophecy RN A Exam
Questions and Answers | 100% Pass Guaranteed |
Graded A+ |
A nurse is preparing to administer a transfusion of RBCs to a client who has heart
failure. For which of the following manifestations should the nurse monitor to
prevent fluid volume overload? (Select all that apply.)
A. Dyspnea
B. Gastrointestinal bloating
C. Jugular vein distention
D. Confusion
E. Hypotension - ANSWER -A. Dyspnea
C. Jugular vein distention
D. Confusion
Dyspnea is a clinical manifestation of fluid volume overload. Jugular vein
distention is a clinical manifestation of fluid volume overload. Confusion is a
clinical manifestation of fluid volume overload.
A nurse is caring for a client who has a spinal cord injury and suspects the client is
developing autonomic dysreflexia. Which of the following actions should the
nurse take first?
pg. 1
,[Document title]
A. Check the client for a fecal impaction.
B. Examine the client for areas of skin breakdown.
C. Check the client's bladder for distention.
D. Place the client in a sitting position. - ANSWER -D. Place the client in a sitting
position.
The nurse should use the least invasive intervention first. Therefore, the nurse
should place the client in a sitting position to decrease the manifestation of
hypertension.
The nurse might have to check the client for fecal impaction, which can precipitate
autonomic dysreflexia. However, the nurse should use a less invasive intervention
first. The nurse might have to examine the client's skin for areas of skin
breakdown or pressure, which can trigger autonomic dysreflexia. However, the
nurse should use a less invasive intervention first. The nurse might have to check
the client for bladder distention, which can precipitate autonomic dysreflexia.
However, the nurse should use a less invasive intervention first.
A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for
clients who have surgical incisions. Which of the following factors should the
nurse include in the teaching? (Select all that apply.)
A. Poor nutritional state
B. Altered mental status
C. Obesity
D. Pain medication administration
E. Wound infection - ANSWER -A. Poor nutritional state
pg. 2
, [Document title]
C. Obesity
E. Wound infection
A nurse is caring for a client who has an endotracheal tube and is receiving
mechanical ventilation. Which of the following interventions should the nurse take
to reduce the risk for ventilator-associated pneumonia?
A. Position the head of the client's bed in the flat position.
B. Turn the client every 4 hr.
C. Rinse the client's mouth with an antimicrobial solution every 4 hr.
D. Perform hand hygiene prior to suctioning the client's endotracheal tube. -
ANSWER -C. Rinse the client's mouth with an antimicrobial solution every 4 hr.
The nurse should brush the client's teeth every 8 hr and rinse the client's mouth
with an antimicrobial rinse every 2 hr to reduce the growth of bacteria.
The nurse should elevate the head of the client's bed 30° to reduce the risk for
aspiration and pneumonia. The nurse should turn the client every 2 hr to promote
lung expansion and reduce the risk for pneumonia. The nurse should perform
hand hygiene prior to suctioning the client's endotracheal tube to reduce the risk
of introducing bacteria.
A nurse is providing instruction to a new nurse about caring for clients who are
receiving diuretic therapy to treat heart failure. The nurse should explain that
which of the following medications puts clients at risk for both hyperkalemia and
hyponatremia?
A. Furosemide
pg. 3
Relias Med-Surg Clinical Assessment Relias
Medical-Surgical Telemetry Prophecy RN A Exam
Questions and Answers | 100% Pass Guaranteed |
Graded A+ |
A nurse is preparing to administer a transfusion of RBCs to a client who has heart
failure. For which of the following manifestations should the nurse monitor to
prevent fluid volume overload? (Select all that apply.)
A. Dyspnea
B. Gastrointestinal bloating
C. Jugular vein distention
D. Confusion
E. Hypotension - ANSWER -A. Dyspnea
C. Jugular vein distention
D. Confusion
Dyspnea is a clinical manifestation of fluid volume overload. Jugular vein
distention is a clinical manifestation of fluid volume overload. Confusion is a
clinical manifestation of fluid volume overload.
A nurse is caring for a client who has a spinal cord injury and suspects the client is
developing autonomic dysreflexia. Which of the following actions should the
nurse take first?
pg. 1
,[Document title]
A. Check the client for a fecal impaction.
B. Examine the client for areas of skin breakdown.
C. Check the client's bladder for distention.
D. Place the client in a sitting position. - ANSWER -D. Place the client in a sitting
position.
The nurse should use the least invasive intervention first. Therefore, the nurse
should place the client in a sitting position to decrease the manifestation of
hypertension.
The nurse might have to check the client for fecal impaction, which can precipitate
autonomic dysreflexia. However, the nurse should use a less invasive intervention
first. The nurse might have to examine the client's skin for areas of skin
breakdown or pressure, which can trigger autonomic dysreflexia. However, the
nurse should use a less invasive intervention first. The nurse might have to check
the client for bladder distention, which can precipitate autonomic dysreflexia.
However, the nurse should use a less invasive intervention first.
A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for
clients who have surgical incisions. Which of the following factors should the
nurse include in the teaching? (Select all that apply.)
A. Poor nutritional state
B. Altered mental status
C. Obesity
D. Pain medication administration
E. Wound infection - ANSWER -A. Poor nutritional state
pg. 2
, [Document title]
C. Obesity
E. Wound infection
A nurse is caring for a client who has an endotracheal tube and is receiving
mechanical ventilation. Which of the following interventions should the nurse take
to reduce the risk for ventilator-associated pneumonia?
A. Position the head of the client's bed in the flat position.
B. Turn the client every 4 hr.
C. Rinse the client's mouth with an antimicrobial solution every 4 hr.
D. Perform hand hygiene prior to suctioning the client's endotracheal tube. -
ANSWER -C. Rinse the client's mouth with an antimicrobial solution every 4 hr.
The nurse should brush the client's teeth every 8 hr and rinse the client's mouth
with an antimicrobial rinse every 2 hr to reduce the growth of bacteria.
The nurse should elevate the head of the client's bed 30° to reduce the risk for
aspiration and pneumonia. The nurse should turn the client every 2 hr to promote
lung expansion and reduce the risk for pneumonia. The nurse should perform
hand hygiene prior to suctioning the client's endotracheal tube to reduce the risk
of introducing bacteria.
A nurse is providing instruction to a new nurse about caring for clients who are
receiving diuretic therapy to treat heart failure. The nurse should explain that
which of the following medications puts clients at risk for both hyperkalemia and
hyponatremia?
A. Furosemide
pg. 3
