Tiêu đề RECALLS 11- NP3 - SC ✅

2 | Page 10. When the nurse checked the water sealed drainage, she observed that the water level does not fluctuate simultaneously with the client’s breathing. The nurse interprets this observation as: A. An abnormal occurrence suggestion problem with the system’s patency B. Normal but may require water to be added to the suction control chamber C. Emergent requiring immediate reporting to the physician D. Expected with the client’s current condition Situation: A woman who underwent hysterectomy 2 days ago is under your care. 11. Which nursing observations would MOST likely predispose the client to develop venous thrombosis in the lower extremity? A. Drinking coffee at least 3 to 5 cups in a day B. Refusing to get out of bed C. Taking soft diet only D. Requesting for analgesics frequently 12. The patient was prescribed to have antiembolism stockings. The nurse assess the patient knows its purpose when she states 1. It promotes venous return 2. It strengthen muscle tone 3. It prevents pooling of blood in the extremities A. 1 & 2 B. 1 & 3 C. 2 & 3 D. 1, 2 & 3 13. The nurse assesses the client for Homan’s sign. Which of the following is the CORRECT instruction of the nurse? A. Have the client push each foot hard against the mattress B. Tell the client to sit on bed and point to her toes C. Ask the client to contract her tight musclesma D. Instruct the client to extent her legs and flex each foot toward the head 14. Which client’s response suggest a positive Homan’s sign? A. Inability of the client to bend her knees B. Sudden numbness while extending the foot C. Tingling sensation throughout the affected leg D. Sharp, immediate calf pain in the legs 15. Based on the findings, the client has been diagnosed with thrombophlebitis. Which of the following nursing action must be AVOIDED? A. Elevating the client’s leg B. Massaging the affected leg C. Applying ice compress to the affected leg D. Ambulating at least twice each shift Situation: After a head injury, Samantha, 36 years old begun to manifest signs and symptoms of Diabetes Insipidus. 16. The nurse in charge understands that Diabetes Insipidus (DI) is caused by an ADH deficiency resulting to which problem in metabolism?. A. Protein B. Water C. Carbohydrates D. Fat 17. The nurse caring for Samantha would expect to find which characteristic assessment findings? 1. Excessive thirst 2. Polyuria 3. Hyperglycemia 4. Glycosuria A. 1 and 3 B. 2 and 3 C. 1 and 2 D. 3 and 4 18. Which nursing action is critical in monitoring Samantha’s condition? A. Measuring intake and output B. Assessing vital signs C. Monitoring sleeping pattern D. Analyzing blood glucose 19. The physician orders “weigh daily”. When instructing the nursing aide to weigh the client, what essential instruction is MOST important to obtain an accurate data? A. Weight the client on the same scale time of the day wearing the similar amount of clothing B. Ask the client to state her weight before the disorder manifested C. Instruct the client to weigh before breakfast daily D. Have the client remove her footwear 20. The client was prescribed with intranasal Lypressin (Diapid) 2 spray 4x a day and as needed. Which is the CORRECT way to administer the spray? A. Siting in an upright position, insert the spray into the nostril then inhale while compressing the container B. Shaking the spray vigorously before inhaling in both nostrils C. Tilting the head to the side, and inhale the spray 2 times D. Inhaling with each spray 2 times Situation: A 45 year old female was admitted because of acute pancreatitis. Nurse Michelle was assigned to take care of the client. 21. While nurse Michelle was making her rounds before endorsement to the next shift, her client asks her which would be a comfortable position to assume. The nurse would recommend the following positions EXCEPT: A. Flexing the left leg B. Leaning forward C. Lying in supine position D. Sitting up 22. There has been an increasing rate of acute pancreatitis in the Philippines. She is aware that the most common cause of acute pancreatitis is? A. Alcohol Use B. Trauma C. Infections D. Gallstones 23. Nurse Michelle is aware that the treatment of acute pancreatitis consist of pain relief and “putting the pancreas to rest”. This is BEST accomplished by which of the following? A. Serving clear liquid diet B. Following a frequent but small feeding C. Feeding by nasogastric tube D. Parenteral nutrition administration as prescribed 24. The client has a standing order of Meperidine HCL (Demerol) 100mg intramuscularly (IM) every 4 hours. At 8am, nurse Michelle administered Demerol as prescribed. At 10am, the client asked for the next dose. The nurse verified the intensity of pain and the client said, it is not so painful. I just don’t want to feel any sort of pain”. What would be the MOST appropriate action of the nurse? A. Apply warm compress over the painful area B. Inject the prescribed dose and the other half at 12 noon C. Change patient’s position and implement diversional activity D. Administer the full dose of Demerol now. 25. When the client said, “it is not so painful”. What is the client trying to describe? A. Unrelieved pain B. Location of pain C. Pain tolerance