Tiêu đề RECALLS 8 - NP3 - SC ✅

C. Repaglinide D. Regular insulin 13. One of your clients is having a sinus bradycardia, with a heart rate of 45 beats per minute and blood pressure of 82/60 mm Hg, reports dizziness. Which intervention would you anticipate will be prescribed? A. Administer digoxin. B. Defibrillate the client. C. Continue to monitor the client. D. Prepare for transcutaneous pacing. 14. You are watching the cardiac monitor and notices that a client’s rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 beats per minute. The nurse determines that the client is experiencing which dysrhythmia? A. Sinus tachycardia B. Ventricular Fibrillation C. Ventricular tachycardia D. Premature ventricular contractions 15. You are assisting to defibrillate a client in ventricular fibrillation. Which intervention is your priority after placing the pads on the client’s chest and before discharging the device? A. Ensure that the client has been intubated. B. Set the defibrillator to “synchronize” mode. C. Administer an amiodarone bolus. D. Confirm the cardiac rhythm 16. You noticed that your client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would you anticipate when auscultating the client’s breath sounds? A. Stridor B. Crackles C. Scattered rhonchi D. Diminished breath sound 17. You are assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable. How would you interpret the client’s neurovascular status? A. The neurovascular status is expected because of increased blood flow through the leg. B. The neurovascular status is moderately impaired, and the surgeon needs to be called. C. The neurovascular status is slightly deteriorating and needs to be monitored for another hour. D. The neurovascular status shows adequate arterial flow, but venous complications are arising. 18. A client has frequent bursts of ventricular tachycardia on the cardiac monitor. Which factor is your highest priority with regard to this dysrhythmia? A. It can develop into ventricular fibrillation at any time. B. It is almost impossible to convert to a normal rhythm. C. It is uncomfortable for the client, giving a sense of impending doom. D. It produces a high cardiac output with cerebral and myocardial ischemia 19. Your client with ventricular fibrillation is about to be defibrillated. Which energy level (in joules, J) would you set on the monophasic defibrillator machine for the first delivery? A. 50 J B. 120 J C. 200 J D. 360 J 20. You are caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an intravenous (IV) infusion at a rate of 150 mL/hr, unchanged for the last 10 hours. The client’s urine output for the last 3 hours has been 90, 50, and 28 mL (28 mL is most recent). The client’s blood urea nitrogen level is 35 mg/dL (12.6 mmol/L), and the serum creatinine level is 1.8 mg/dL (159 mcmol/L), measured this morning. Which nursing action is your priority? A. Check the serum albumin level. B. Check the urine specific gravity. C. Continue to monitor urine output. D. Call the primary health care provider. 21. A client is wearing a continuous cardiac monitor, which begins to sound its alarm. You notice that there are no electrocardiographic complexes on the screen. Which is the priority nursing action? A. Call a code. B. Check the client’s status. C. Call the primary health care provider. D. Document the lack of complexes. 22. You are evaluating a client’s response to cardioversion. Which assessment would be the priority? A. Blood pressure B. Airway patency C. Oxygen flow rate D. Level of consciousness Situation: You are on shift, responsible for managing the care of several patients with various respiratory conditions. 23. A 12-year-old child with asthma is being treated for a severe asthma attack in the emergency room. What symptom should you specifically watch for, as it would signal a worsening of the child's condition? A. Warm, dry skin B. Decreased wheezing C. Pulse rate of 90 beats per minute D. Respirations of 18 breaths per minute 24. An 8-year-old child undergoing home treatment for right lower lobe pneumonia calls the clinic with their parent, who reports that the child is experiencing discomfort on the right side and that ibuprofen is not providing relief. What guidance should you offer to the parent? A. Increase the dose of ibuprofen. B. Increase the frequency of ibuprofen. C. Encourage the child to lie on the left side. D. Encourage the child to lie on the right side. 25. A new parent is worried about sudden infant death syndrome (SIDS) and asks the nurse for guidance on the safest sleep position for their newborn. What position should you recommend for placing the infant? A. Side or prone B. Back or prone C. Stomach with the face turned D. Back rather than on the stomach 26. You are discussing the immunization schedule with the parent of a child with cystic fibrosis. What information should you, as the nurse, provide to the parent regarding the child's vaccinations? A. “The immunization schedule will need to be altered.” B. “The child should not receive any hepatitis vaccines.” C. “The child will receive all of the immunizations except for the polio series.” D. “The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination.” 27. You are an emergency department nurse evaluating a child diagnosed with epiglottitis. What signs should you watch for to determine if the child may be experiencing an airway obstruction? A. The child exhibits nasal flaring and bradycardia. B. The child is leaning forward, with the chin thrust out. C. The child has a low-grade fever and complains of a sore throat. D. The child is leaning backward, supporting self with the hands and arms. 28. A child with croup is being treated with a cool mist vaporizer in their hospital room. The child is visibly distressed, crying persistently, and attempting to leave the area. What should you do to address the child's discomfort and ensure their safety? A. Tell the parent that the child must stay in the tent. B. Place a toy in the tent to make the child feel more comfortable. C. Call the pediatrician and obtain a prescription for a mild sedative. D. Let the parent hold the child and direct the cool mist over the child’s face. 29. You reviews the tuberculin skin test (TST) results for a 3-year-old child and notes an induration area measuring 10 mm. How should you interpret these results? A. Positive B. Negative 2 | Page

Situation: Annaliza, a senior nurse, is reviewing her knowledge regarding delegation and task management. 46. Annaliza, a nurse in a busy Philippine hospital is delegating tasks to a team of nurses and nursing assistants. Which task should she delegate to a nursing assistant? A. Administering intravenous medications B. Performing a comprehensive physical assessment C. Assisting a patient with daily activities and basic care D. Developing a care plan for a complex patient 47. The head nurse is reviewing the delegation process with a new nurse in a hospital in the Philippines. Which of the following principles should the nurse use to ensure effective delegation? A. Delegate tasks that require the nurse’s unique skills to unlicensed personnel B. Ensure that the delegatee has the necessary competence and training for the task C. Delegate all tasks to ensure that the workload is evenly distributed D. Only delegate tasks that are easy and can be done quickly 48. Nurse Annaliza is dealing with a situation where a nursing assistant is frequently late for their shift. What is the most appropriate action for the nurse manager to take? A. Ignore the lateness if it does not affect patient care B. Discuss the issue with the nursing assistant privately and address the pattern of lateness C. Reprimand the nursing assistant publicly to set an example D. Reassign the nursing assistant to a different shift without discussing the issue 49. Nurse Annaliza is preparing to delegate a complex wound dressing change. Which aspect of delegation is critical for ensuring that the task is performed safely? A. Verifying that the task is within the scope of practice for the delegatee B. Delegating the task without providing instructions C. Only providing verbal instructions without written guidelines D. Assuming that the delegatee knows how to perform the task without supervision 50. A nurse manager in the Philippines needs to prioritize tasks for a busy unit. Which of the following tasks should the nurse manager prioritize? A. Completing paperwork for routine audits B. Addressing a sudden change in a patient's condition C. Organizing a staff social event D. Conducting a review of patient satisfaction surveys Situation: A patient arrives at the emergency department accompanied by her son, who reports that about 30 minutes ago, his mother suddenly developed numbness and weakness in her left arm, along with slurred speech, while watching television. She has no history of head trauma. 51. The patient reports numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority? A. Prepare to administer recombinant tissue plasminogen activator (rt-PA). B. Discuss the precipitating factors that caused the symptoms. C. Schedule for a STAT computed tomography (CT) scan of the head. D. Notify the speech pathologist for an emergency consult. 52. The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestation would the nurse document? A. Hemiparesis of the client’s left arm and apraxia. B. Paralysis of the right side of the body and ataxia. C. Homonymous hemianopsia and diplopia. D. Impulsive behavior and hostility toward family. 53. The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care? A. Observe the client swallowing for possible aspiration. B. Position the client in a semi-Fowler’s position when sleeping. C. Place a suction setup at the client’s bedside during meals. D. Refer the client to an occupational therapist for evaluation. 54. The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? A. Aspirin B. Timolol C. Heparin D. Streptokinase 55. The resident in a long-term care facility fell during the previous shift and has a laceration in the occipital area that has been closed with steristrips. Which signs/symptoms would warrant transferring the resident to the emergency department? A. A 4-cm area of bright red drainage on the dressing. B. A weak pulse, shallow respirations, and cool pale skin. C. Pupils that are equal, react to light, and accommodate. D. Complaints of a headache that resolves with medication. 56. A client with a stroke is unable to speak but can understand spoken language. Which condition best describes this client’s speech difficulty? A. Receptive aphasia B. Expressive aphasia C. Global aphasia D. Wernicke’s aphasia 57. A patient is given a hairbrush but uses it to brush their teeth instead. This incorrect use of an object demonstrates which condition? A. Ataxia B. Apraxia C. Aphasia D. Agnosia 58. The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority? A. Assess neurological status. B. Monitor pulse, respiration, and blood pressure. C. Initiate an intravenous access. D. Maintain an adequate airway 59. A patient admitted to the CCU was rushed to the hospital following a myocardial infarction. The patient has a history of hemorrhagic stroke. Which medication order would the nurse question? A. Alteplase (tPA) 15 mg IV bolus, then infusion as per protocol B. Oxygen at 2 L/min via nasal cannula C. Metoprolol 25 mg PO twice daily D. Morphine sulfate 2 mg IV every 2 hours PRN for chest pain Situation: Head injury is trauma to the scalp, skull, or brain from blunt or penetrating forces. It can be open (with fracture/penetration) or closed (without fracture), ranging from mild concussion to severe brain injury, and may lead to complications like increased intracranial pressure, cerebral edema, or secondary injury from hypoxia or hypotension. 60. The client is diagnosed with a closed head injury and is in a coma. The nurse writes the client problem as “high risk for immobility complications.” Which intervention would be included in the plan of care? A. Position the client with the head of the bed elevated at intervals. B. Perform active range-of-motion (ROM) exercises every four (4) hours. C. Turn the client every shift and massage bony prominences. D. Explain all procedures to the client before performing them. 61. An unconscious client with multiple injuries to the head and neck arrives in the emergency department. What should the nurse do first? A. Determine the identity of the client. B. Stop bleeding from open wounds. C. Check for a neck fracture. 4 | Page