Tiêu đề RECALLS 3 - NP2 - SC ✅

4 | Page 43. Oxytocin drip was started to induce labor. Which assessment findings should cause the nurse to IMMEDIATELY discontinue the oxytocin infusion? (Select all that apply) I. Fatigue and drowsiness II. Early decelerations of the fetal heart rate. III. Uterine hyperstimulation IV. Late decelerations of the fetal heart rate A. III and IV B. II and III C. I and III D. I and II 44. Simultaneous with the oxytocin drip (left arm) is the prescribed intravenous (IV) lidocaine (Xylocaine). Nurse Aurora should dilute the concentrated solution of lidocaine (right arm) with which solution? A. 5 percent Dextrose in water B. Normal saline 0.99 percent C. Normal saline 0.45 percent. D. Lactated Ringer's 45. Take home medications given to Patient Lily includes digitalis therapy which was given to patient since she was pregnant. Which of the following would the nurse anticipate with patient's drug therapy? A. Switching to a more potent drug. B. Continuation of the same dosage. C. Need for change in medication. D. Addition of diuretic to the regimen. Situation: The indication of tracheostomy in children has changed substantially in the last two decades. Nurse Robert is taking care of Patient Irma, an eight year old female child, who was admitted to the Pediatric Ward due to pneumonia. The child is hooked to a tracheostomy tube. Nurse Robert is quite anxious in taking care of this patient being her first day of duty in the Pediatric Ward. 46. When preparing the patient for suctioning, what is the FIRST step? A. Perform hand hygiene B. Gather equipment C. Assess lung sounds, heart rate and rhythm D. Check physician's order and patient care plan 47. Patient Irma will be placed in which of the following position? Select all that apply. 1. Fowler 2. Semi-Fowler 3. Supine 4. Sim A. 1, 2 & 3 B. 2 only C. 1 & 2 D. 1 only 48. Usually the common indication (s) for the tracheostomy in Patient Irma's condition is which of the following? (Select all that apply.) 1. Prolonged intubation. 2. Sepsis 3. Hypoventilation associated with neurologic disorders. 4. Severe Sleep Obstructive Apnea Syndrome (SOAS) A. 2 only B. 1 & 2 C. 1, 2, 3 & 4 D. 1 only. 49. The PRIORITY nursing objective when caring a patient with a tracheostomy is ______. A. To increase tissue oxygenation B. To provide patent airway C. To decrease tissue oxygenation D. To improve ventilation 50. The TOP nursing expected outcome when performing suctioning is ______. A. Lessened amount of secretions leading to decreased frequency of suctioning. B. Secretions removed without complication. C. Tube-fed patient does not aspirate feeding. D. Prevention of occurrence of hypoxemia and bradycardia. Situation: Sonny, 11 years old, is admitted due to bronchitis. Upon admission, he manifested the following signs and symptoms: cough, production of mucus (sputum), yellowish in color, fatigue, shortness of breath, slight fever and chills and chest discomfort. The physician orders 4L/min oxygenation. 51. The first standard step in oxygen therapy that the nurse should do is _______. A. assess client's condition B. gather all the equipment and supplies C. prepare the client for the oxygen treatment D. check the chart for ordered flow rate and oxygen delivery method 52. In planning for Sonny's oxygen therapy, the nurse should consider which of the following, EXCEPT _____. A. need for a humidifier. B. length of tubing C. determine the age of Excel. D. manner of administering oxygen, continuous or intermittent. 53. Which of the following is the PRIORITY action of the nurse for Sonny who in on oxygen therapy? A. Check the flow. B. Connect the flow meter to the pipe in oxygen outlet. C. Turn on the oxygen. D. Attach the humidifier and connecting tubing to the oxygen delivery device. 54. What PRIORITY precautionary measure should be done by the nurse during the oxygen therapy? A. Humidifier's water should be checked regularly. B. No Smoking sign. C. Oxygen tank should have belt. D. Limit visitors. 55. One evening, Sonny complained of dyspnea despite continuous oxygen therapy. What should be the FIRST action of the nurse? A. Reassess the client. B. Give PRN medication. C. Assess the patency of the tubing. D. Refer client to the physician. Situation: The senior nurse Reese, is planning to revisit and implement a change in the management system for the Obstetric Unit. This would be a pilot unit as planned by the administration. Many problems have occurred one of which is the present documentation system, and the charge nurse determines that a change is required. 56. What should be the INITIAL STEP in the process of change for the senior nurse. A. set goals and priorities regarding the change process. B. Plan strategies to implement the change. C. Identify potential solutions and strategies for the change. D. Identify the inefficiency that needs improvement or correction. 57. Nurse Reese is preparing the patient assignment for the day and needs to assign patients to a midwife and nursing assistant. Which patient should the nurse assign to the midwife because of patient needs that cannot be met by the nursing assistant? A patient requiring _______. A. dressing change of post caesarian surgery B. collecting of urine specimen for urinalysis testing. C. performing range-of-motion exercises twice a day D. taking of vital signs measurement every hours 58. Because of the scarcity of nurses in the hospital settings, different service delivery models were proposed. Which situation represents the primary nursing care delivery model? A. The nursing aide is assigned to make beds and other errands while the nurse is to give medications B. The nurse develops a plan of care for patients and collaborates with other team members. C. The nurse performs all tasks needed by the individual patient to optimize health. D. The nurse provides care to 4 patients while the nursing aide is to care for 2 patients. 59. One of the post-caesarian patients has a private duty nurse and is responsible for providing holistic care to her patient