Title RECALLS 9 - NP4 - SC ✅

activity, has a heart rate of 110 bpm, and has generalized edema. Which of the following actions would be most appropriate for this patient? A. Administer high-flow oxygen B. Encourage the client to rest more C. Continue to monitor the client’s heart rhythm D. Compare the client’s admission weight with the client’s current weight 43. You are caring for patient Whitebeard immediately following an insertion of a permanent pacemaker via his right subclavian vein. As a skilled nurse, you know that the action that can best prevent pacemaker lead dislodgement is: A. inspecting the incision site dressing for bleeding and the incision for approximation B. limiting the client’s right arm activity and preventing the client reaching above shoulder level C. assisting the client with getting out of bed and ambulating with a walker D. ordering a stat chest x-ray following return from the implant procedure 44. You are increasing activity for patient Bon with an admitting diagnosis of acute coronary syndrome. Which of the following symptoms experienced by patient Bon best supports the nursing diagnosis of activity intolerance? A. Pulse rate increased by 15 beats per minute during activity B. Blood pressure (BP) 130/86 mm Hg before activity; BP 108/66 mm Hg during activity C. Increased dyspnea and diaphoresis relieved when sitting in a chair D. A mean arterial pressure (MAP) of 80 following activity 45. Cobra is a patient who suffered an inferior septal wall myocardial infarction. Which of the following complications would you suspect in Cobra when you note on your assessment a jugular venous distention and ascites? A. Left-sided heart failure B. Pulmonic valve malfunction C. Right-sided heart failure D. Ruptured septum SITUATION: You are an emergency nurse tasked to work with patients with medical emergencies. You utilize your knowledge to help these patients. 46. A patient’s wife is allowed to be present during resuscitation efforts for a patient in the ICU. Which of the following statements made by you would be the most correct and appropriate? A. “You can hold your loved one’s hand; sometimes a recovering person remembers that touch.” B. “Another staff member will be with you; I will show you where you can stand near your husband.” C. “Because the resuscitation team needs to work quickly, you need to stay out of their way and not \ interfere.” D. “If the resuscitation efforts fail, the health-care provider will ask you if you want to terminate resuscitation efforts.” 47. An apartment fire broke out near the hospital. The injured victims are sent to the emergency department of the hospital. Five families of the injured patients arrived in the ED subsequently to inquire about the health status of their family members. Which of the following is your best action? A. Take the families to the triage area so they can be with their loved ones B. Ask the families to wait in the waiting area until information is available C. Ensure that there is a designated area for family staffed by available social workers or clergy D. Direct families to a lounge where a receptionist will be keeping families informed 48. Patient Aokiji is a male client that presented themself in the emergency department after vomiting a “large” amount of bright red blood. Which of the following actions should you implement first? A. Start an intravenous line with an 18-gauge needle. B. Have the UAP take the client’s vital signs. C. Ask the client to provide a stool specimen for blood. D. Send the client to radiology for an abdominal CT scan. 49. You are working as a triage nurse in a large trauma center. The center has been notified of an explosion in a nearby major chemical manufacturing plant. Which of the following actions should you implement first when the injured patients arrive at the emergency department? A. Triage the clients and send them to the appropriate areas. B. Thoroughly wash the clients with soap and water and then rinse. C. Remove the clients’ clothing and have them shower. D. Assume the clients have been decontaminated at the plant. 50. You are attending a seminar on codes. After the session, you recall that which of the following interventions is the most important for you to implement when participating in a code? A. Elevate the arm after administering medication. B. Maintain sterile technique throughout the code. C. Treat the client’s signs/symptoms; do not treat the monitor. D. Provide accurate documentation of what happened during the code. Situation - Ms. Hange is the charge nurse of a medical unit. She is responsible for the management and supervision of the unit. 51. Ms. Hange observes that one of the female staff nurses is not performing her duties very well. Which of the following strategies will she implement to assist the staff nurse? A. Discuss with the staff nurse her performance and ways she can improve. B. Allow the staff nurse to select own assignment. C. Assign the staff nurse several clients with various illnesses. D. Ask the staff nurse to work as an assistant charge nurse. 52. Ms. Hange notes one of the male staff nurse is frequently absent and his absence has adversely affected the quality of care given to the clients unit. Which of the following would be the BEST approach? A. Talk with the staff nurse regarding the concern and remind him of the standards of the agency. B. Write the staff nurse a memorandum regarding his absence. C. Inform the staff nurse that his absence will be a ground for termination. D. Record the absence of the staff nurse in a log book. 53. Ms. Hange assigns a new staff nurse to administer the medications of a client. Which detail of the client’s drug therapy is the staff nurse legally responsible to document? The ________. A. Peak concentration time of the drug. B. Safe ranges of the drug. C. Client’s socio-economic status. D. Client’s reaction to the drug. 54. Ms. Hange decides what is best for a recovering client and acts on the decision without consulting the client. Ms. Hange is applying a moral principle which is ______________. A. Paternalism B. Beneficence C. Fidelity D. Autonomy Situation - The nurse cares for a female client who is terminally ill and is experiencing pain. The nurse prepares a care plan for the client. The overall goal for the client is ________. 55. The client will: A. Achieve control of pain and discomfort. B. Receive adequate cerebral oxygenation and perfusion. C. Be free from infection. D. Receive life sustaining food and liquids. 56. The nurse is aware of the document that expresses a client’s wish for life sustaining treatment in the event of terminal illness or permanent unconsciousness. This document is the ______; A. No-code order B. Durable power of attorney C. Living will D. Last will and testament 4 | Page