Tiêu đề RECALLS 7 - NP3 - SC ✅

C. Watch out for increased urine output. D. Closely monitor the blood pressure for hypotension 13. The nurse asked the student nurse about the clinical manifestations of a patient with diabetes insipidus. The student nurse would be correct if she states the following, except: A. Flat neck veins B. Altered LOC C. Skin tenting D. Crackles on both lungs 14. A fluid deprivation test was ordered by the physician and the patient was deprived of fluid for 10 hours. The patient still excretes large volumes of urine and weight loss. What would warrant the nurse’s attention and prompt for an immediate termination of the test? A. The urine specific gravity gradually increases. B. The urine output decreases. C. The patient’s blood pressure is below the baseline, and continuously decreases. D. 3% of the body weight is lost. 15. DI happens due to a decreased production of ADH. On the other hand, SIADH has an overproduction of ADH leading to hypertension, weight gain, crackles, as well as edema. What nursing interventions are appropriate for a nursing diagnosis of fluid volume excess, except? A. Accurately replace fluid loss. B. Restrict fluid intake. C. Administer furosemide as prescribed. D. Assess lung sounds for crackles. Situation: Evelyn, a retired Barangay Health Worker, came to the OPD for her check-up for her diabetes mellitus. She had been diabetic since she was 37 years old. She has been taking her maintenance medications which she sometimes does not comply with. 16. There are metabolic abnormalities in the development of type 2 Diabetes. Which of the following is NOT included in these abnormalities? A. Inappropriate production of the liver B. Increased ability of the pancreas to produce insulin C. Insulin resistance D. Altered production of hormones by adipose tissues 17. Ms. Evelyn was admitted to the hospital for further check-up. Which of the following diagnostic tests do you expect to be ordered by the diabetologist as an indicator that the patient is compliant to her prescribed diet? A. Oral glucose tolerance test B. Glycosylated hemoglobin level C. Finger glucose findings for one day D. Fasting blood glucose level 18. While Nurse Eric was completing her assessment, she discovered the following findings. Which of the following should she refer immediately to the physician? A. Tingling sensation of the hands and feet B. Changes in the peripheral vision C. Beginning ulceration of the left big toe D. Fruity odor breath 19. Nurse Eric, the nurse in charge of patient Evelyn, informed her physician that her serum glucose level is 38mmol/L and quite unresponsive to verbal questioning. The nurse suspects that she is starting to develop Diabetes Ketoacidosis (DKA). Which of the following manifestations is UNIQUE to this condition? A. Shallow slow respirations B. Increased serum potassium C. Rapid deep respirations D. Decreased serum albumin 20. Nurse Eric’s counseling role includes lifestyle changes as well as pharmacologic regimen. Evelyn’s family were interested to know information regarding insulin. She differentiated an intermediate acting insulin from that of short-acting which is _________. A. Regular onset is 2 hrs. Peak is 3 1⁄2 hr., duration -7 hrs., administered 20-30 min. before meal B. Regular onset is 2-4 hr., peak is 4-12 hr., duration is 8 hr., administered 20-30 min. after meal C. Regular, onset is 1 1⁄2 hr, peak is 3-4 hrs, duration is 6 hrs. administered 20-30 min after meal D. Regular onset is 1⁄2 - 1hr, peak is 2-3 hr., 4-6hr duration administered 20-30 min. before meal Situation: Nurse April is managing patients with cardiac dysrhythmias and conduction problems. 21. Nurse April interprets the rhythm strip of a patient who underwent electrocardiogram. Which of the following waves represent ventricular depolarization? A. P wave B. QRS complex C. T wave D. ST segment 22. Nurse April reads the ECG rhythm of a patient as having torsades de pointes. Which of the following medications must she expect to be ordered immediately? A. Magnesium B. Atropine C. Sodium bicarbonate D. Vasopressin 23. Which of the following ECG rhythms warrant immediate defibrillation? A. Ventricular tachycardia B. Ventricular fibrillation C. Asystole D. Atrial fibrillation Situation: Client suffering from cardiovascular disorders. 24. Which of the following nursing interventions is most appropriate in the care of a patient who has venous insufficiency? A. Elevating the legs B. Increasing the fluid intake C. Limiting the activity level D. Massaging the extremities 25. A client's medical record states a history of intermittent claudication. In collecting data about this symptom, the nurse would ask the client about which symptom? A. Chest pain that is dull and feels like heartburn B. Leg pain that is sharp and occurs with exercise C. Chest pain that is sudden and occurs with exertion D. Leg pain that is achy and gets worse as the day progresses Situation: Nurse Karen is assigned to care of clients with respiratory disorders. 26. The client is scheduled for a bronchoscopy. Which of the following is not necessary to be done by the nurse when preparing the client for the procedure? A. Secure written consent. B. Ask for allergy to seafoods or iodine. C. Maintain NPO for 6 to 8 hours. D. Instruct client to remove dentures or bridges. 27. The nurse is teaching the client how to manage a nosebleed. Which of the following instructions would be appropriate to give to the client? A. "Tilt your head backward' and pinch your nose." B. "Lie down at and place an ice compress over the bridge of your nose." C. "Blow your nose gently with your neck flexed." D. "Sit down, lean forward, and pinch the soft portion of your nose." 28. Which of the following is the primary reason to teach pursed-lip breathing to clients with emphysema? A. To promote oxygen intake. B. To strengthen the diaphragm. C. To strengthen intercostal muscles. D. To promote carbon dioxide elimination. 29. Which of the following diets would be most appropriate for a client with COPD? A. Low fat, low cholesterol diet. B. Bland, soft diet. C. Low sodium diet. D. High calorie, high protein diet. 2 | Page

45. A hospital administrator has implemented a change in the method of assigning nurses to client care units. A group of registered nurses is resistant to the change, and the nursing administrator anticipates that the nurses will not facilitate the process of change. Which approach is best for the administrator to take initially in dealing with the resistance? A. Cancel the implementation of the change. B. Implement the change first on a trial basis. C. Delay implementing the change for a few weeks. D. Encourage the nurses to verbalize feelings regarding the change. Situation: Various clients will undergo different post op positioning from various procedures. 46. After Pneumonectomy, a client is positioned: A. Right side lying B. Affected side C. Left side lying D. Unaffected side 47. While after Lobectomy, the client is positioned: A. Right side lying B. Affected side C. Left side lying D. Unaffected side 48. After Liver Biopsy, The client is positioned: A. Right side lying B. Supine C. Left side lying D. Semi Fowlers Situation: A nurse is teaching a group of healthcare workers the proper technique for handwashing in a clinical setting. 49. What is the first step of the handwashing process to ensure proper hygiene and minimize the spread of infections? A. Apply soap to hands B. Wet hands with water C. Scrub the hands for 20 seconds D. Rinse hands with clean water 50. According to WHO guidelines, how long is the recommended duration for the entire procedure of handwashing? A. 20 – 30 secs B. 30 – 60 secs C. 40 – 60 secs D. 15 – 20 secs Situation: You are the ICU nurse handling high-risk cardiovascular patients and post-surgical cases. Prompt recognition of life-threatening signs is critical. 51. A nurse assessing a client who reports persistent lower back pain and a sensation of “beating” in the abdomen. Upon palpation, the nurse notes a pulsating mass in the abdomen. Which of the following is the nurse’s priority action? A. Notify the health care provider B. Apply deep pressure to assess the mass C. Measure abdominal girth D. Reassure the client and continue monitoring 52. A client with left-sided heart failure is admitted with dyspnea and orthopnea. What additional sign is the nurse most likely to find? A. Hepatomegaly B. Crackles in lung bases C. Dependent edema D. Jugular vein distention 53. A patient receiving nitroglycerin IV for chest pain develops a BP of 70/30 mmHg. What is the nurse’s priority action? A. Stop the infusion immediately B. Elevate the foot of the bed C. Notify the provider and reduce the dose D. Administer IV fluids rapidly 54. A client with pericardial effusion suddenly becomes dyspneic and restless. The nurse notes BP 80/50 mmHg, muffled heart sounds, and jugular vein distention. Which nursing action takes priority? A. Elevate the head of the bed to 90 degrees B. Administer high-flow oxygen via non-rebreather mask C. Prepare for emergency pericardiocentesis D. Initiate a rapid IV fluid bolus 55. A client recently discharged after mitral valve replacement returns to the clinic with complaints of fatigue. Which finding is most concerning? A. INR of 2.3 B. Irregular pulse C. Fever and chills D. Mild fatigue Situation: You are preparing patients for discharge and monitoring for high-risk cardiac medication effects. 56. Which client is most at risk for developing digoxin toxicity? A. A client with hyperkalemia B. A client taking a loop diuretic C. A client with low BUN D. A client with a high-potassium diet 57. A client is being discharged after heart surgery. Which statement signals need for further teaching? A. “I will avoid heavy lifting.” B. “I can resume sex when I can climb two flights of stairs.” C. “I’ll take my medications only if I feel chest pain.” D. “I’ll walk daily as tolerated.” 58. A client on IV heparin infusion for atrial fibrillation has an aPTT of 110 seconds. What is the nurse’s best action? A. Stop the infusion B. Slow the infusion and reassess in 2 hours C. Continue as ordered and monitor for bleeding D. Document the result and recheck in the morning 59. Which discharge instruction is most appropriate for a patient with an abdominal aortic aneurysm (AAA) repair? A. “Resume weightlifting in 1 week to regain strength.” B. “Call the provider for back or abdominal pain.” C. “Check blood pressure once a month.” D. “Take your blood pressure only when you feel dizzy.” 60. The nurse is monitoring a client who received IV furosemide. Which finding requires immediate follow-up? A. Serum potassium 2.9 mEq/L B. Mild decrease in BP after ambulation C. Urine output 200 mL after 2 hours D. Complaint of mild muscle cramp Situation: You are the nurse caring for clients with respiratory conditions and trauma. Quick recognition of abnormal signs and proper patient education is key. 61. The nurse is teaching a client with asthma about proper inhaler use. Which statement indicates correct technique? A. “I inhale before pressing the inhaler.” B. “I hold my breath after inhaling the medication.” C. “I exhale immediately after using it.” D. “I don’t need to shake the canister.” 62. The nurse is caring for a client with chest trauma after a road traffic accident. Which finding requires immediate action? A. Paradoxical chest movement B. Chest pain when coughing C. Decreased breath sounds on one side D. Rib tenderness on palpation 63. Which client condition warrants placing them in High Fowler’s position? A. Post-lumbar puncture B. Hypovolemic shock C. Acute respiratory distress D. Severe dizziness 64. A nurse is monitoring a client with asthma. Which finding is most concerning? A. Use of accessory muscles B. Audible wheezing C. Sudden absence of wheezing D. Reports of chest tightness Situation: You are caring for clients with respiratory disorders requiring immediate assessment and intervention. 4 | Page