Tiêu đề RECALLS 8 (NP3) - STUDENT COPY ✅

C. “Receiving intravenous fluids will prevent or treat fluid imbalance.” D. “Early ambulation and the use of blood thinners will prevent pulmonary embolism.” 26. When preparing a nursing care plan for a client scheduled for surgery, which activity should be included for the day of the procedure? A. Avoid performing oral hygiene and using mouthwash. B. Confirm that the client has fasted for the past 24 hours. C. Ensure the client void before going into surgery. D. Report any slight increases in blood pressure or pulse immediately. 27. During preoperative teaching about using an incentive spirometer, which instruction should the nurse include for the client? A. Inhale as rapidly as possible. B. Maintain a loose seal between the lips and the mouthpiece. C. After taking the deepest breath, hold it for 15 seconds and then exhale. D. The best results are obtained when sitting up or with the head of the bed elevated 45 to 90 degrees. 28. A client has had preadmission testing and blood drawn for various laboratory studies. Which laboratory result should the nurse report to the surgeon’s office, as it could potentially cause the surgery to be postponed? A. Hemoglobin, 8.0 g/dL (80 mmol/L) B. Sodium, 145 mEq/L (145 mmol/L) C. Serum creatinine, 0.8 mg/dL (70.6 mcmol/L) D. Platelets, 210,000 cells/mm3 (210 × 109/L) 29. The nurse is reviewing a surgeon’s prescription sheet that states the client must be nothing by mouth (NPO) after midnight. Which medication should the nurse clarify with the surgeon to determine if it should be given to the client and not withheld? A. Prednisone B. Ferrous sulfate C. Cyclobenzaprine D. Conjugated estrogen Situation: Mrs. Thompson, a 55-year-old patient, has recently undergone a colostomy due to colon cancer. She is being discharged from the hospital and will need to manage her ostomy and stoma care at home. The nurse is providing instructions and support to ensure she can perform these tasks effectively. 30. The nurse is evaluating a client with bladder cancer who has undergone a cystectomy and has a ureterostomy. Which statement made by the client suggests they need additional instruction on urinary stoma care? A. “I replace my pouch once a week.” B. “I change the appliance in the morning.” C. “I empty the urinary collection bag when it is two-thirds full.” D. “I make sure to direct the water away from my stoma while showering.” 31. The nurse is caring for a client with ulcerative colitis who has had a transverse colostomy. Which observation should prompt the nurse to immediately notify the surgeon? A. Stoma is beefy red and shiny. B. Stoma has a purple discoloration. C. Skin excoriation is noted around the stoma. D. Semiformed stool is noted in the ostomy pouch. 32. The staff nurse is observing a new graduate nurse performing care for an indwelling urinary catheter on an uncircumcised client. Which action by the new graduate nurse suggests that additional teaching is needed? A. Cleans the catheter from proximal to distal with soap and water. B. Keeps the urinary collection bag positioned below the level of the bladder. C. Removes a loose catheter anchor and attaches a new anchor on the lower leg. D. Uses the nondominant hand to retract the foreskin, cleanse the urethral meatus with soap and water, and then returns the foreskin to its normal position. 33. The nurse is getting ready to irrigate a client's sigmoid colostomy. Which intervention should the nurse plan to perform for this procedure? A. Instill 500 to 1000 mL of lukewarm tap water through the stoma. B. Advise the client to hold their breath if cramping occurs during the instillation of the solution. C. Hang the irrigation solution so that the bottom of the bag is 18 inches above the client's torso. D. Insert the irrigation tube with a small amount of force and a twisting motion into the stoma, and then unclamp the tubing to allow the solution to flow. 34. The nurse is inserting an indwelling urinary catheter and begins to inflate the balloon when the client complains of pain. What should the nurse do next? A. Continue inflating the balloon. B. Deflate the balloon, slightly withdraw the catheter, and attempt to reinflate the balloon. C. Deflate the balloon, completely withdraw the catheter, and end the procedure to notify the primary health care provider. D. Stop inflating the balloon, allow the saline solution to drain into the syringe, and advance the catheter further before reinflating the balloon. Situation: Mr. Johnson, a 68-year-old man with a history of chronic venous insufficiency and peripheral artery disease, is admitted to the hospital for evaluation and management of his leg ulcers. He has been experiencing worsening symptoms in both legs and is now presenting with new signs. 35. Which of the following client is at highest risk for developing a DVT? A. 25-year-old male, smoker with hypertension B. 67-year-old overweight female recovering from a hip replacement (1st day post-op) C. 22-year-old female with history of raynaud’s disease D. 72-year-old male with a history of arthritis and bypass surgery 36. A male client visits the ambulatory clinic reporting pain in the right leg when he tries to perform his walking exercises 3x a week. Upon examination, the right foot is dusky and purplish while it is dangling from the stretcher. The right dorsalis pedis is palpable but diminished, and he states his foot “tingles on occasion”. The nurse has him lie supine on the stretcher with the foot of the stretcher elevated for about 10 minutes, after which his foot shows pallor. The nurse concludes that the manifestations are consistent with? A. Varicose veins B. Thrombophlebitis C. Raynaud’s disease D. Arterial insufficiency 37. The home care nurse notes that a client with intermittent claudication of the left leg has developed tissue breakdown of the left foot. Nurse Sheena explains to the client that the plan of care should include which of the following activity levels at this time? A. Increased exercise to stimulate blood flow B. Bed rest to minimize tissue oxygen demand C. Active ROM exercises to maintain joint flexibility D. Walking in comfortable light slippers to minimize impact or fragile tissue 38. The nurse evaluates the teaching for a client with raynaud’s disease is effective when the client make which of the following statements? A. I will decrease my smoking to six cigarettes per day B. I will try to learn to relax, but I can’t promise anything C. I will wear gloves in cool weather and socks to bed at night D. I will try to eat a healthier diet. 39. A client is receiving a continuous intravenous infusion of heparin sodium for deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) is 65 seconds. What action should the nurse anticipate? A. Discontinue the heparin infusion. B. Increase the rate of the heparin infusion. C. Decrease the rate of the heparin infusion. D. Leave the rate of the heparin infusion as is. 3 | Page
Situation: Mr. James Carter, a 65-year-old man, has been admitted to the emergency department with symptoms of palpitations, dizziness, and shortness of breath. He has a history of hypertension and coronary artery disease. An ECG reveals atrial fibrillation (AF) with a rapid ventricular response. 40. A patient experiencing a myocardial infarction is showing signs of cardiogenic shock. Which condition should the nurse expect and keep an eye on to identify cardiogenic shock? A. Pulsus paradoxus B. Ventricular dysrhythmias C. Increasing diastolic blood pressure D. Decreasing central venous pressure 41. A patient with atrial fibrillation who is on regular warfarin sodium therapy has a prothrombin time (PT) of 35 seconds. Based on these lab results, what prescription should the nurse expect? A. Administering a dose of heparin sodium B. Withholding the next dose of warfarin C. Increasing the next dose of warfarin D. Continuing with the next dose of warfarin 42. The nurse is observing the cardiac monitor and notices a sudden change in the client's rhythm. The rhythm shows no P waves, wide QRS complexes, and a regular ventricular rate exceeding 140 beats per minute. The nurse identifies the client as experiencing which dysrhythmia? A. Sinus tachycardia B. Ventricular fibrillation C. Ventricular tachycardia D. Premature ventricular contractions 43. A patient is wearing a continuous cardiac monitor that starts alarming, and no electrocardiographic complexes are visible on the screen. What should the nurse's priority action be? A. Call a code. B. Check the client’s status. C. Call the primary health care provider. D. Document the lack of complexes. 44. A patient’s cardiac rhythm suddenly changes on the monitor, showing no P waves and fibrillatory waves before each QRS complex. How should the nurse interpret this rhythm? A. Atrial fibrillation B. Sinus tachycardia C. Ventricular fibrillation D. Ventricular tachycardia NO #45 Situation: A 55-year-old female patient is admitted to the hospital with symptoms of weight loss, frequent palpitations, and fatigue. She has a history of hyperthyroidism and is being evaluated for possible complications. During her admission, she also reports bone pain, muscle weakness, and increased thirst. Upon assessment, the nurse notes that the patient has a history of hyperparathyroidism, which is characterized by elevated calcium levels. The patient is currently taking alendronate to manage her condition. 46. The nurse is conducting an assessment on a client being admitted for a diagnostic workup for primary hyperparathyroidism. Which of the following complaints would be characteristic of this disorder? A) Polyuria B) Headache C) Bone pain D) Nervousness E) Weight gain A. A,C B. B,D C. B,C D. D,E 47. The nurse is instructing a client on how to manage hyperparathyroidism at home. Which statement by the client suggests that further education is needed? A. “I should limit my fluid intake to less than 1 liter per day.” B. “I should use my treadmill or go for walks every day.” C. “I should follow a diet that is moderate in calcium and high in fiber.” D. “My alendronate helps prevent calcium from being released from my bones.” 48. A client has just been admitted to the nursing unit after a thyroidectomy. Which assessment should be the priority for this client? A. Hoarseness B. Hypocalcemia C. Audible stridor D. Edema at the surgical site 49. The nurse is providing instructions to a client taking levothyroxine. The nurse should advise the client to take the medication in which manner? A. With food B. At lunchtime C. On an empty stomach D. At bedtime with a snack 50. The client with hyperparathyroidism is taking alendronate. Which of the following statements demonstrate the client’s understanding of how to properly take this medication? Select all that apply. A. “I should take this medication with food.” B. “I should take this medication at bedtime.” C. “I should remain upright for at least 30 minutes after taking this medication.” D. “I should take this medication first thing in the morning on an empty stomach.” E. “I can choose a time to take this medication that suits my schedule as long as I take it at the same time each day.” A. B,C B. A,C,E C. A,D,E D. C,D 51. You are caring for a patient admitted with a diagnosis of acute kidney injury. Upon reviewing your patient’s laboratory reports, you noted that the patient’s magnesium levels are high. You should prioritize assessment for which of the following health problems? A. Diminished deep tendon reflexes B. Tachycardia C. Twitches D. Seizures 52. Which of the following ECG Changes can be seen in a patient with Hypokalemia? A. Wide QRS complex B. Tall peaked T waves C. Flat P waves D. Prominent U wave 53. The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? A. Weight loss and dry skin B. Flat neck and hand veins C. An increase in blood pressure and increased respirations D. Weakness and decreased central venous pressure (CVP) 54. The nurse is reading a physician’s progress notes in the client’s record and reads that the physician has documented “insensible fluid loss of approximately 500 mL daily.” The nurse plans to monitor the client, knowing that insensible fluid loss occurs through which type of excretion? A. Urinary output B. Wound drainage C. Integumentary output D. The gastrointestinal tract 55. A patient took 8 ounces of apple juice, 6 ounces of coffee, and 6 ounces of water. What is the calculated intake of the client? A. 400 ml B. 500 ml C. 600 ml D. 700 ml 56. What acid-base imbalance may occur if a patient undergoes gastric lavage or is experiencing prolonged vomiting? A. Respiratory acidosis B. Respiratory alkalosis 4 | Page