Tiêu đề RECALLS 6 - NP3 - SC ✅

B. Apply a mask to the client C. Gown and mask the client D. Use a full isolation transport team 14. During assessment, Fiona notes a pulsating mass in a client’s periumbilical area. Which action is most appropriate? A. Palpate the mass for size and tenderness B. Auscultate the mass for a bruit C. Measure its length with a tape measure D. Percuss the abdomen 15. A post-operative client suddenly becomes profoundly short of breath and gray in color. Which earlier assessment finding would have been the first sign of deterioration? A. Temperature 100.4°F (38°C) B. Respiratory rate of 26/min C. Heart rate of 110 bpm D. Blood pressure of 120/70 mmHg Situation: Nurse Lara is assigned to the gastrointestinal surgical ward. She is caring for patients undergoing diagnostic procedures and recovering from abdominal surgeries. Her responsibilities include providing pre- and post-operative teaching, preventing complications, and ensuring patients follow dietary modifications. 16. Lara is preparing a patient for a barium swallow and gastroduodenoscopy. Which instruction should she give? A. “You’ll need to eat a low-residue diet the day before and be NPO for 6–12 hours before the test.” B. “You’ll be NPO for 24 hours after the test to ensure you can tolerate food.” C. “You’ll have a nasogastric tube for 24 hours after the test for drainage.” D. “You’ll be placed under general anesthesia and recover in the OR.” Answer: A Ratio: Patients are placed on a low-residue diet the night before and NPO 6–12 hours before procedures like barium swallow and gastroduodenoscopy. (Source: Smeltzer & Bare, Medical-Surgical Nursing (10th ed.), p. 108) 17. A client recovering from gastrectomy asks Lara how to prevent dumping syndrome. Which advice is most appropriate? A. “You should eat 5–6 small meals a day indefinitely.” B. “Limit fluids during meals and for 1 hour afterward.” C. “Increase your carbohydrate and salt intake.” D. “Increase activity for 1 hour after meals to help digestion.” Answer: B Ratio: Limiting fluids during and after meals reduces rapid gastric emptying, which triggers dumping syndrome. (Source: Smeltzer & Bare, Medical-Surgical Nursing (10th ed.), p. 112) 18. In the recovery room, a patient who underwent gastric resection complains of nausea. What is Lara’s priority action? A. Check the patency of the nasogastric tube B. Administer an antiemetic as ordered C. Place the patient in semi-Fowler’s position D. Provide a narcotic analgesic for pain Answer: A Ratio: Nausea after gastric surgery can indicate NG tube obstruction, which must be corrected before giving medications. (Source: Smeltzer & Bare, Medical-Surgical Nursing (10th ed.), p. 112) 19. Which diagnostic test confirms pyloric stenosis? A. Flat plate of the abdomen B. Colonoscopy C. Electrolyte levels D. Upper GI series Answer: D Ratio: An upper GI series will reveal delayed gastric emptying and a narrowed pyloric channel. (Source: Smeltzer & Bare, Medical-Surgical Nursing (10th ed.), p. 109) 20. A client with a duodenal ulcer is admitted. Which symptom does Lara expect to find? A. Recent weight loss B. Worsening indigestion after meals C. Awakening at night with epigastric pain D. Frequent episodes of vomiting Situation: Nurse Ramon is caring for patients with renal and urologic conditions. His role includes monitoring fluid balance, preventing complications of altered renal function, and teaching clients about dietary and medication adherence. 21. A client with altered renal function is being managed at home. Which assessment provides the most accurate indicator of fluid balance? A. Measuring intake and output B. Assessing mucous membrane moisture C. Checking skin turgor D. Monitoring daily weight 22. A client with chronic kidney disease is prescribed a low-sodium diet. Which food selection shows the client understands the instructions? A. Canned vegetable soup B. Fresh apple slices C. Processed cheese D. Pickled cucumbers 23. Ramon is caring for a client with a new arteriovenous (AV) fistula for hemodialysis. Which nursing action is appropriate? A. Draw blood samples from the fistula arm B. Apply a blood pressure cuff to the fistula arm C. Assess for a bruit and thrill over the fistula daily D. Use the arm for routine IV infusions 24. A patient with renal calculi is encouraged to increase fluid intake. What is the goal of this intervention? A. Dilute urine and reduce stone formation B. Flush out electrolytes C. Decrease protein metabolism D. Promote blood pressure control 25. A client with end-stage renal disease reports itchy, dry skin. Which nursing measure is most appropriate? A. Restrict fluids further B. Bathe the client twice daily using hot water C. Apply emollient lotion after bathing D. Avoid all forms of soap Situation: Nurse Andrea is assigned to the endocrine unit where she cares for patients with hormonal disorders. She provides pre-operative and post-operative teaching, monitors for complications, and offers lifestyle counseling for patients with chronic endocrine conditions. 26. Andrea is caring for a client diagnosed with hypopituitarism. Which assessment finding should she expect? A. Increased blood pressure B. Truncal obesity C. Increased cardiac output D. Hyperactivity and increased energy levels 27. A client recovering from a hypophysectomy reports clear nasal drainage. What is Andrea’s initial action? A. Notify the surgeon immediately B. Encourage the client to blow their nose C. Test the drainage for glucose D. Place the client in Trendelenburg position 28. After a hypophysectomy, Andrea teaches the client to monitor for which possible complication? A. Cushing’s disease B. Grave’s disease C. Diabetes mellitus D. Hypopituitarism 29. A client with diabetes insipidus is prescribed vasopressin (Pitressin). What is the purpose of this medication? A. Stimulate pancreatic insulin production B. Slow glucose absorption in the intestines C. Increase reabsorption of water in the renal tubules D. Increase blood pressure 2 | Page
30. Andrea is teaching dietary management to a client with Addison’s disease. Which advice is appropriate? A. Eat a high-protein, high-calcium, low-calorie diet B. Avoid salt in all meals C. Increase carbohydrate intake and limit potassium-rich foods D. Consume foods rich in sodium and moderate carbohydrates Situation: Nurse Maricel is assigned to the neurology unit. She cares for clients recovering from head injuries, strokes, and spinal cord injuries. She must monitor for complications, ensure proper positioning, and teach families how to assist with daily care. 31. Maricel is transferring a client with a possible spinal injury from a stretcher to a bed. Which technique is best? A. Move the client segmentally in small parts B. Logroll the client with assistance C. Use a draw sheet and lift from behind the shoulders D. Sit the client up and transfer slowly 32. A stroke patient with right-sided hemiparesis needs to transfer from bed to wheelchair. Which is the safest approach? A. Place the wheelchair parallel to the bed on the weaker side B. Position the wheelchair 45° to the bed on the stronger side C. Ask the patient to wrap arms around the nurse’s neck D. Place the wheelchair far from the bed 33. A client with a spinal cord injury needs to be repositioned in bed. Which action will Maricel take? A. One nurse lifts the patient by the arms B. Two nurses use a draw sheet to lift the client C. One nurse rolls the patient toward the stronger side D. Ask the client to scoot up the bed 34. While caring for a patient with a head injury, which sign should Maricel report immediately? A. Complaints of mild headache B. Low-grade fever C. Mild photophobia D. Increasing drowsiness and difficulty arousing 35. A patient recovering from a stroke has mild dysphagia. Which nursing intervention is most appropriate? A. Place the patient in an upright position when eating B. Offer a clear liquid diet C. Tilt the patient’s head back while swallowing D. Provide dry finger foods like crackers Situation: Nurse Isabel is assigned to the oncology unit. She cares for patients receiving chemotherapy, radiation therapy, and palliative care. Her responsibilities include monitoring for complications, ensuring adherence to treatment protocols, and providing emotional and ethical support to patients and families. 36. A patient undergoing chemotherapy develops painful mouth ulcers. What is Isabel’s most appropriate intervention? A. Encourage frequent use of alcohol-based mouthwash B. Provide soft, bland foods and perform saline rinses C. Advise the patient to brush vigorously with a firm-bristled toothbrush D. Recommend citrus juices to promote healing 37. A cancer patient tells Isabel that a lawyer will be coming to prepare a living will and asks if she can be a witness. How should Isabel respond? A. Agree to serve as a witness to help the patient B. Refuse and avoid discussing the matter further C. Explain that nurses caring for the patient cannot serve as witnesses D. Call the attending physician to resolve the issue 38. Which of the following should Isabel include in discharge teaching for a patient who has undergone external radiation therapy? A. Apply lotion daily to the radiation site B. Avoid exposing the treated skin to direct sunlight C. Use heating pads on the treated area for comfort D. Scrub the area daily with strong soap 39. A patient with terminal cancer expresses a desire to stop aggressive treatment. Which ethical principle supports Isabel’s decision to honor the patient’s request? A. Justice B. Autonomy C. Beneficence D. Nonmaleficence 40. Isabel observes that a patient receiving chemotherapy has a temperature of 38.5°C (101.3°F). What should she do first? A. Administer acetaminophen as ordered B. Notify the physician immediately C. Encourage the patient to increase oral fluids D. Recheck the temperature in one hour Situation: Nurse Leo is assigned to a post-operative surgical ward. He is responsible for closely monitoring patients' vital signs, ensuring medications are administered correctly, and maintaining safe care practices. He must also be aware of legal and ethical implications of negligence or malpractice in nursing practice. 41. A nurse overhears a physician tell a patient derogatory remarks about the nursing staff. Which legal violation applies to the physician’s actions? A. Libel B. Slander C. Assault D. Negligence 42. Leo notices a patient’s condition deteriorates over several hours, but he does not act on the changes. The patient later requires emergency surgery. This inaction is considered: A. Tort B. Misdemeanor C. Common law D. Statutory law 43. A post-operative patient complains of severe pain despite receiving narcotics. Leo suspects the assigned LPN may be diverting narcotics. What should he do first? A. Avoid assigning the LPN to patients receiving narcotics B. Review the medication records and report the situation to the nurse supervisor C. Ask the physician to increase the narcotic dosage D. Confront the LPN directly 44. A patient is scheduled for surgery but the consent form is unsigned. What is the best action for Leo to take? A. Obtain the patient’s signature immediately B. Inform the physician that the consent is missing C. Allow the surgery because it is implied consent D. Have a family member sign the consent form 45. During the night shift, Leo discovers that a patient wants to leave the hospital against medical advice (AMA). Which statement about the AMA form is correct? A. It confirms the patient’s control over care B. It is used during readmission C. It releases the physician and hospital from liability for the patient’s health status D. It documents the patient’s refusal to pay Situation: Nurse Rafael is working in a cardiovascular step-down unit. He is caring for clients who have undergone vascular surgeries and those with chronic cardiovascular conditions. His responsibilities include assessing for complications, preventing thromboembolic events, and providing patient education about lifestyle modifications and medications. 46. Rafael is administering a fluid challenge to a client in hypovolemic shock. Which assessment finding shows the client is responding favorably? A. Urine output increases from 25 mL/hr to 40 mL/hr B. Systolic BP increases from 80 mmHg to 90 mmHg C. Central venous pressure (CVP) increases from 5 cm H2O to 7 cm H2O D. PaO2 increases to 90% saturation 47. Four hours after an aortic-femoral bypass graft, Rafael cannot palpate pulses in the operative leg, and the patient reports pain. What should he do first? A. Massage the leg and apply warm towels 3 | Page