Tulloch

Ramona Stukes, 69 yr-old, third day post-op cholecystectomy. Non-significant past medical history. No known allergies (NKA). Vital signs -Temp 98.6, BP 114/62, P 100, RR 20, SaO2 94%. Neuro WNL, alert, and cooperative. Skin warm and dry, daily dressing changes, T-tube without drainage. NG tube to low suction possibly D/C'd today after Dr. Levine rounds. Today's incentive spirometry Tidal Volume is 1250ml, improvement over yesterday's 900ml. NPO with small amount of ice chips only. Today...

A patient's blood glucose is 36 mg/dL. Which of the following signs and symptoms are associated with this level of blood glucose? (Select all that apply.) - >>>>Confusion, Diaphoresis, Headache, Weakness 2A 23-year-old patient is diagnosed with type 2 diabetes mellitus. Which of the following statements, by the patient, indicates an understanding of this diagnosis? - >>>>Weight loss could eliminate the need for me to take medications. A patient is receiving insulin...

Tachypnea, fever, malaise, and use of accessory muscles - >>>>Expected assessment findings of a patient with pneumonia may include which of the following? A. Tachypnea B. Fever C. Malaise D. Enuresis E. Use of accessory muscles raise the head of the bed - >>>>A patient in semi Fowler's position is having difficulty breathing. What is the priority action of the nurse? A. raise the head of the bed. B. call respiratory therapy C. conduct a pain assessment D. aus...

Which characteristics are associated with anxiety? Select all that apply - >>>>-A feeling that is unavoidable and life. -A vague feeling of apprehension. -A reaction to internal or external stimuli. Which of the following best defines normal anxiety? - >>>>Dread that is appropriate to the situation in intensity and duration. Which physiological response describes an individual preparing to defend himself or herself against a perceive stressor? - >>>>Fig...

The patient asks the nurse "What type of disease is schizophrenia?" Which statement is the nurse's best response? - >>>>Schizophrenia is a syndrome with many different types and symptoms What is the average age of peak onset of symptoms of schizophrenia? - >>>>Men 15-25 years Women 25-35 years Schizophrenia is characterized by both positive and negative symptoms. which of the follow is an example of a positive symptom? - >>>>Auditory hallucinations D...

The patient is being admitted to an inpatient psychiatric unit after an overdose in a suicide attempt. The patient is now medically stable. Which intervention should the RN recognize as the priority action? - >>>>Place the patient on safety precautions During a report from the ED, the RN is told the patient is of Asian descent. What will the RN recognize while caring for this patient? - >>>>Patients of Asian descent may not need as high a dose of medications as other...

During assessment the pediatric patient reports good control of asthma symptoms with no interference in daily activities and one incidence of nighttime cough in the past month. The patient uses a rescue inhaler occasionally during the week for asthma exacerbations. The patient would be classified as having which of the following levels of asthma severity? - >>>>Mild intermittent A nurse is explaining the pathophysiology of asthma and asthma exacerbation to a group of nursing st...

A nurse is caring for a cognitively impaired nonverbal patient on a med-surg unit. In what ways should the nurse assess the patient's pain? (Select all that apply) - >>>>a. A pain estimate made by a family member c. Nonverbal pain assessment tool e. The behavioral pain scale What should the nurse document regarding a patient's pain? - >>>>The date and time of your assessment; the assessment tool used; pain indicators that are present; the patient's behavior, pos...

A patient is scheduled to receive digoxin 0.25 mg per intravenous injection once digoxin therapy resumes. The digoxin vial is labeled 0.5 mg/2 mL. Which of the following is the best procedure for administering digoxin via intravenous injection? - >>>>Inject 1 mL over 5 minutes A patient is receiving potassium chloride 20 mEq in 250 mL of normal saline to infuse over 90 minutes. Calculate the setting for the infusion pump in mL/hr. (Round to the nearest tenth.)___________________...

Which nursing actions demonstrate an understanding of the components required when conducting the objective portion of a neurologic assessment? (Select all that apply.) - >>>>a. Evaluate cranial nerve XI function by asking the patient to shrug the shoulders d. Test for tactile discrimination using a door key Rationale: A complete neurologic examination consists of evaluating the following five areas: mental status, cranial nerves, motor and cerebellar systems, sensory system, a...

The nurse is providing education to a patient about group B streptococcus (GBS) during a prenatal visit. This education session would include which statement from the following choices? - >>>>Between 35 and 37 weeks' gestation, GBS screening is done to detect this bacteria. What are the possible complications that a newborn can acquire from the mother with a positive GBS status during the birthing process? - >>>>Pneumonia, sepsis, meningitis. The nurse is carrying o...

Symptoms of alcohol withdrawal begin within what time period after the cessation or marked reduction of alcohol intake by the chronic alcohol drinker? A. 120 minutes B. 1 week C. 3 days D. 12 hours - >>>>D What term refers to the collection of symptoms that are associated with untreated alcohol withdrawal? A. korsakoff syndrome B. cardiac myopathy C. delirium tremens D. wernicke's encephalopathy - >>>>C Which clinical manifestations confirm that a patient is ...

Which symptoms are consistent with a diagnosis of bipolar disorder? - >>>>Mania Depression Which characteristics are associated with the manic phase of bipolar disorder? - >>>>Distractibility Flight of ideas High-risk behaviors Grandiosity The term lability is used to define what type of mood-associated behavior? - >>>>Rapid shifts between emotional extremes Which symptom of mania places a patient with bipolar disorder at greatest risk for injury? - ...

The nurse wants to document an assessment of the amount of pain a patient is experiencing. Which of the following methods will provide the most accurate information regarding the level of a patient's pain? a) Assess the patient's nonverbal indicators of pain. b) Use a numeric pain scale and have the patient rate their pain. c) Ask open-ended questions about the patient's pain. d) Have the patient indicate if the pain is high or low. - >>>>b) Use a numeric pain scale and hav...

When taking a patient's health history, which of the following does the nurse identify as risk factors for having a stroke? (select all that apply) a. diabetes mellitus b. recent weight loss c. smoking d. hypertension e. asthma - >>>>d. hypertension c. smoking a .diabetes mellitus The nurse has an order to complete neurochecks every four hours. Which assessments would the nurse include in the neurological examination? - >>>>memory, level of consciousness, sen...

PRE which of the entries on a pts medical record are evidence of the diagnosis of severe preeclampsia. SATA - >>>>-Scotomata -Epigastric pain -Oliguria - 3 lb weight gain in 1 week -blood pressure 182/116 PRE which of the following need to be implemented when a pt with severe preeclampsia is admitted to the hospital. SATA - >>>>-seizure precaustions -reduced stimulation -bed rest -dim light PRE what are the Priorities of care if a pregnant woman experiences ...

the nurse knows that vernon watkins is at most risk for developing which of the following complications following a pulmonary embolism? - >>>>cardiogenic shock what initial objective and subjective data in mr. watkins case should lead the nurse to suspect a pulmonary embolism - >>>>reluctance to ambulate pain in leg Watkins ABG results were.... how does nurse interpret results - >>>>respiratory alkalosis with mild hypoxemia purpose of d-dimer - >>...

The nurse is reviewing the patient's laboratory results. Which lab test most accurately represents current nutritional status? - >>>>Prealbumin The nurse is completing an admission assessment on a patient admitted for impaired skin integrity. Which questions would be appropriate for the nurse to ask the patient? - >>>>-Have you noticed any swelling on your feet, ankles, or fingers? -Do some areas of your skin seem warmer or colder than others? -Have you used pads o...

the nurse has an order to check the post void residual urine. how would the nurse carry out this order? - >>>>measure the amount of urine using a bladder scanner the nurse is caring for a pt who is unable to urinate voluntarily since a gunshot injury. pt data associated with which intervention will provide info regarding the pt's kidney function? - >>>>daily serum creatinine levels what info presented to a pt concerning a bladder scan will assist in addressing anxie...

Which of the entries on a patient's medical record are evidence of the diagnosis of severe preeclampsia? (Select all that apply.) a) Oliguria b) Blood pressure 182/116 mmHg c) 3 lb (1.4 kg) weight gain in 1 week d) Epigastric pain e) Negative urine ketones f) Scotomata - >>>>a) Oliguria b) Blood pressure 182/116 mmHg c) 3 lb (1.4 kg) weight gain in 1 week d) Epigastric pain f) Scotomata All of these findings, except negative ketones, support the diagnosis. The urine find...