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

B. Elevate the leg and recheck the pulse C. Call the physician immediately D. Assist the patient to ambulate 48. A client with peripheral vascular disease is being discharged. Which modifiable risk factor is most important for Rafael to address? A. Orthostatic hypotension B. Age C. Smoking D. Hypoglycemia 49. Rafael is caring for a client 6 hours postpartum and wants to prevent thrombophlebitis. What is the best nursing action? A. Encourage early ambulation and increased fluid intake B. Restrict bathroom privileges and elevate legs C. Administer anticoagulants to all postpartum clients D. Initiate breastfeeding as soon as possible 50. Ms. H. is admitted to the coronary care unit to rule out a myocardial infarction. She tells the nurse she is sure it is just angina and cannot understand what the difference is between angina and infarct pain. Which response is most appropriate for the nurse to make? A. Anginal pain usually only lasts 3–5 minutes B. Anginal pain produces clenching of the fists over the chest while acute MI pain does not C. Anginal pain requires morphine for relief D. Anginal pain radiates to the left arm while acute MI pain does not Situation: Kiera has felt constipated and bloated for quite a while now. Two days ago, she was complaining of moderate cramping in her abdomen. Upon assessment, she is febrile with two episodes of vomiting before arriving to the emergency department. Nurse Eliza suspects that she has diverticulitis. The following questions apply. 51. Nurse Eliza is aware that, most commonly, the location of diverticulitis is found in which area of the abdomen? A. Right upper quadrant B. Right lower quadrant C. Left upper quadrant D. Left lower quadrant 52. Nurse Eliza differentiates diverticulitis from diverticulosis. She in incorrect when she states which of the following statement to describe the disorders? A. Diverticulosis develops as a result of high intake of fiber and fast colonic transit time B. Diverticulitis develops when one or more diverticula is inflamed C. Diverticulosis forms when the mucosal layers of the colon herniate through the muscular wall 53. Which of the following dietary recommendation can Nurse Eliza provide Kiera to manage her condition? A. Fluid intake of 2 liters a day B. Foods low in fiber C. High fat diet D. Regular diet 54. The diagnostic procedure of choice to confirm diverticulitis and reveal any perforation or abscess is done through? A. Abdominal CT scan with contrast B. Abdominal X-ray C. CBC with elevated WBC count D. Prescence of frank blood in the stool 55. A few hours later, Kiera reports sdden severe abdominal pain that radiates to the back and shoulder, upon assessment the abdomen appears rigid and board like with absent bowel sounds. Kiera has a weak and thready pulse and nauseated. Which of the following priority intervention should nurse eliza perform immediately? A. Administer fleet enema as ordered B. Insert an NG tube C. Notify the Physician D. Administer Psyllium as ordered Situation: Critically ill patients with prolonged pressure due to immobility poses great risk for pressure injury. As an ICU nurse. Nurse Llyana initiates intervention to prevent the occurences of these injuries. 56. In order to assess for risk for pressure injury. Nurse llyana can perform all of the following nursing actions, except. (-) A. Evaluate the level of mobility B. Assess the neurovascular status C. Determine the presence of incontinence D. Evaluate the use of skin care products 57. The most common site or area susceptible to pressure injuries are. A. Scapula and elbows B. Sacrum and heels C. Occiput and ears D. All of the above 58. Nurse Llyana stages the pressure injury of one of the patients who was admitted to the ICU with existing community acquired pressure injury. She is aware that partial thickness skin loss with exposed epidermis is considered as A. Stage 1 pressure injury B. Stage 2 pressure injury C. Stage 3 pressure injury D. Stage 4 pressure injury 59. To minize moisture on the skin, the most inappropriate measure for Nurse Llyana to apply would be? (-) A. Wash soiled skin with mild soap and water B. Lubricate the skin with a bland lotion C. Put absorbent pads in the skin D. Apply drying agents and powders 60. Which nursing intervention is most crucial for the prevention of pressure injuries A. Frequent position changes B. Elevate the head of bed to more than 30 degrees C. Eliminate protein from the diet D. Ignore skin folds when performing hygiene measures Situation: Elmer has been diagnosed with ESRD and si set to go undergo hemodialysis while awaiting for availability of functioning kidney transplant. Nurse Mocha assist him during his stay in the Hospital 61. Nurse Moca knows that the most sensitive indicator of renal function is A. Blood urea nitrogen B. Serum Creatinine C. Glomerular Filtration Rate D. ABG 62. Nurse Mocha interprets the Arterial Blood Gas of the patient. Result shows a ph 7.28 HCo3 10 and Paco2 55 A. Respiratory Acidosis B. Respiratory Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis 63. Nephrologist require strict monitoring of intake and output among patients with renal disorders. Nurse Mocha can effectively assess for fluid status by doing all of the following except.? A. Assess skin turgor and presence of edema B. Assess patient’s food preferences C. Weight the patient daily D. Check for neck distention 64. Elmer is scheduled for surgical AVF creation on his right forearm. Nurse Mocha will interpret the following as abnormal when it comes to the vascular access for dialysis except. A. Distal Pain of the right extremity B. Poor capillary refill C. Numbness and Tingling D. Presence of a thrill and bruit 65. Nurse Mocha understands that all but one are inappropriate intervention when it comes to the patient with an arteriovenous fistula? A. Check the BP in the right and left extremities B. Perform blood culture and sensitivity on two sites C. Insert a large bore access in the right arm for blood transfusion D. Place an arm precaution sign on the bedside. Situation: Patients approaching the end of life experience can benefit from palliative care. As a nurse, Nurse Regine is knowledge about palliative and end of life principles of care and the ability to recoignize the unique response of each 4 | Page