Tiêu đề RECALLS 5 - NP4 - SC ✅

3 | Page C. Osmosis D. Ultrafiltration TOPIC: LEADERSHIP AND MANAGEMENT – PRIORITIZATION AND DELEGATION (PALMER) Situation - Ms. Kath is the charge nurse on a 36-bed unit that admits clients with gastrointestinal disorders and gastrointestinal surgery. The unit is staffed with four RNs, and two Nursing Assistants. 26. Ms. Kathy is making assignments. Which client should be assigned to the graduate nurse who has been on the unit for 1 month?  A. The client diagnosed with lower esophageal dysfunction who is complaining of pyrosis. B. The client who had an endoscopy this morning and has absent bowel sounds. C. The client with gastroesophageal reflux disease who has bilateral wheezing. D. The client who is 1 day post-op open cholecystectomy and refuses to breathe. 27. The client is admitted to the medical unit with a diagnosis of acute diverticulitis.Which order should Ms. Kath clarify with the healthcare provider?  A. Insert a nasogastric tube. B. Start IV D5W at 125 mL/hr. C. Schedule the client for a sigmoidoscopy. D. Place the client on bed rest with bathroom privileges 28. Ms. Kathy observes the nursing assistant turning the client who has just had a liver biopsy to the supine position. Which action should Ms. Kath implement first?  A. Tell the UAP to keep the client on bed rest for 2 hours. B. Praise the UAP for placing the client in the supine position. C. Instruct the UAP to place the client on the right side. D. Complete an incident report on the UAP’s behavior 29. One of the primary nurses, Nurse Abby, tells Ms. Kath that she stuck herself in the finger with a “used” needle and cleaned the site with soap and water. Which intervention shouldMs. Kath implement first?  A. Notify the infection control nurse. B. Complete an adverse occurrence report. C. Request post-exposure prophylaxis. D. Check the hepatitis status of the client. 30. Which nursing task is most appropriate for Ms. Kathy to delegate to the Nursing Assistant?  A. Bathe the client with liver failure who has a Sengstaken-Blakemore tube inflated. B. Teach the client with an open cholecystectomy to splint the incision when coughing. C. Assist the client with pruritus to the bathroom for a shower and a.m. care. D. Tell the UAP to assist the nurse performing a paracentesis on the client with liver failure. TOPIC: NURSING ETHICS - BIOETHICAL PRINCIPLES IN NURSING (PALMER)   Situation: Ethical considerations in nursing encompass a broad range of principles and practices that guide nurses in providing compassionate, respectful, and safe patient care. 31. You have just taken a report for your shift and you are doing your initial assessment of your patients. One of your patients asks you if an error has been made in her medication. You know that an incident report was filed yesterday after a nurse inadvertently missed a scheduled dose of the patient's antibiotic. Which of the following principles would apply if you give an accurate response?  A. Veracity B. Confidentiality C. Respect D. Justice 32. A medical nurse has obtained a new patient's health history and completed the admission assessment. The nurse has followed this by documenting the results and creating a care plan for the patient. Which of the following is the most important rationale for documenting the patient's care?  A. It provides continuity of care. B. It creates a teaching log for the family. C. It verifies appropriate staffing levels. D. It keeps the patient fully informed. 33.  The care team has deemed the occasional use of restraints necessary in the care of a patient with Alzheimer's disease. What ethical violation is most often posed when using restraints in a long-term care setting?  A. It limits the patient's personal safety. B. It exacerbates the patient's disease process. C. It threatens the patient's autonomy. D. It is not normally legal. 34. A patient has been diagnosed with small-cell lung cancer. He has met with the oncologist and is now weighing the relative risks and benefits of chemotherapy and radiotherapy as his treatment. This patient is demonstrating which ethical principle in making his decision? A. Beneficence B. Confidentiality C. Autonomy D. Justice 35. The physician has recommended an amniocentesis for an 18-year-old primiparous woman. The patient is 34 weeks gestation and does not want this procedure. The physician is insistent that the patient have the procedure. The physician arranges for the amniocentesis to be performed. The nurse should recognize that the physician is in violation of what ethical principle?  A. Veracity B. Beneficence C. Nonmaleficence D. Autonomy TOPIC: LEADERSHIP AND MANAGEMENT - DELEGATION (PALMER) Situation - Mr. Andrew is the head nurse on the 10-bed Neurological Intensive Care Unit and 20-bed Neurological Step-Down unit. He supervises 15 nurses in the ICU, along with 30 nurses and 15 Nursing Assistants.  36. Elizabeth, who is the day staff nurse, and the nursing assistant are caring for a client with a right-sided cerebrovascular accident (CVA) with hemi-paralysis. Which action by the UAP requires Elizabeth to intervene?  A. The UAP places the call light on the client’s left side. B. The UAP assists the client to eat the breakfast meal. C. The UAP uses the draw sheet to move the client up in bed. D. The UAP places a small pillow under the client’s left shoulder. 37. Klarisse is caring for the following clients on the Neurological Intensive Care unit.Which client should Courtney assess first?  A. The client with a C-6 SCI who is complaining of dyspnea and has crackles in the lungs. B. The client with Guillain-Barré syndrome who is complaining of ascending paralysis. C. The client with traumatic brain injury who has a Glasgow Coma Scale score of 6. D. The client was diagnosed with a cerebrovascular accident (CVA) who has expressive aphasia 38. Mr. Andrew is making shift assignments. Which client should be assigned to the most experienced nurse?  A. The client diagnosed with bacterial meningitis who is experiencing photophobia. B. The client with an L-4 SCI who has spastic muscle spasms of the lower extremities. C. The client diagnosed with Parkinson’s who has a mask-like face and has pill rolling. D. The client has amyotrophic lateral sclerosis (ALS) who is having respiratory distress. 39. Jessie is assigned to care for a client who had a C-6 SCI 2 years ago and is admitted for Stage IV pressure ulcers in the coccyx area. The client is complaining of a severe headache and B/P is 190/110. Which intervention should Jessie implement first? 
4 | Page A. Insert a urinary catheter into the client. B. Complete a neurological assessment. C. Put the client in the Trendelenburg position. D. Palpate the client’s bladder. 40. The nurse is caring for clients in a Neurological Intensive Care unit. Which client should be assessed first?  A. The client with increased intracranial pressure whose Glasgow Coma Scale went from 11 to 14. B. The client was diagnosed with a C-6 SCI who has bradycardia, hypotension, and hyperreflexia. C. The client with a brain stem herniation whose big toe moves toward the top surface of the foot and the other toes fan out after the sole of the foot has been firmly stroked. 4. D. The client was diagnosed with West Nile virus who has a temperature of 101.2°F and generalized body aches. TOPIC: EMERGENCY NURSING - HEAT STROKE, CHOKING, and OTHER COMMON EMERGENCY SITUATIONS   Situation: Emergency Nursing 41. The nursing educator is reviewing the signs and symptoms of heat stroke with a group of nurses. The educator should describe what sign or symptom?  A. Hypertension with a wide pulse pressure B. Anhidrosis C. Copious diuresis D. Cheyne Stokes Respiration 42. A triage nurse is talking to a patient when the patient begins choking on his lunch. The patient is coughing forcefully. What should the nurse do?  A. Stand him up and perform the abdominal thrust maneuver from behind. B. Lay him down, straddle him, and perform the abdominal thrust maneuver. C. Leave him to get assistance. D. Stay with him and encourage him, but not intervene at this time. 43. A male patient with multiple injuries is brought to the ED by ambulance. He has had his airway stabilized and is breathing on his own. The ED nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding?  A. Absence of bruising at contusion sites B. Rapid pulse and decreased capillary refill C. Increased BP with narrowed pulse pressure D. Sudden diaphoresis 44. A patient is brought to the ER in an unconscious state. The physician notes that the patient is in need of emergency surgery. No family members are present, and the patient does not have identification. What action by the nurse is most important regarding consent for treatment? A. Ask the social worker to come and sign the consent. B. Contact the police to obtain the patient's identity. C. Obtain a court order to treat the patient. D. Clearly document LOC and health status on the patient's chart. 45. A patient is brought by friends to the ED after being involved in a motor vehicle accident. The patient sustained blunt trauma to the abdomen. What nursing action would be most appropriate for this patient? A. Ambulate the patient to expel flatus. B. Place the patient in a high Fowler's position. C. Immobilize the patient on a backboard. D. Place the patient in a left lateral position. TOPIC: EMERGENCY NURSING - DIFFERENT TYPES OF SHOCK Situation: Shock  46. The nurse is caring for a client diagnosed with septic shock. Which assessment data warrant immediate intervention by the nurse?  A. Vital signs T 38*C, P 104, R 26, and BP 102/60. B. A white blood cell count of 18,000/mm. C. A urinary output of 90 mL in the last four (4) hours. D. The client complains of being thirsty. 47. The client is diagnosed with neurogenic shock. Which signs/symptoms should the nurse assess in this client?  A. Cool, moist skin. B. Bradycardia. C. Wheezing. D. Decreased bowel sounds. 48. The client has recently experienced a myocardial infarction. Which action by the nurse helps prevent cardiogenic shock?  A. Monitor the client’s telemetry. B. Turn the client every two (2) hours. C. Administer oxygen via nasal cannula. D. Place the client in the Trendelenburg position 49. The elderly female client with vertebral fractures who has been self-medicating with ibuprofen, a nonsteroidal anti- inflammatory drug (NSAID), presents to the ED complaining of abdominal pain, is pale and clammy, and has a P of 110 and a BP of 92/60. Which type of shock should the nurse suspect?  A. Cardiogenic shock. B. Hypovolemic shock. C. Neurogenic shock. D. Septic shock. 50. The client is admitted into the emergency department with diaphoresis, pale clammy skin, and BP of 90/70. Which intervention should the nurse implement first?  A. Start an IV with an 18-gauge catheter. B. Administer dopamine intravenous infusion. C. Obtain arterial blood gases (ABGs). D. Insert an indwelling urinary catheter TOPIC: PHARMACOLOGY NURSING - MEDS FOR ANGINA/M.I Situation: Medication for a patient with angina/myocardial infarction   51. The nurse is teaching the client diagnosed with angina about sublingual nitroglycerin (NTG). Which statement indicates the client needs more medication teaching?  A. “I will always carry my nitroglycerin in a dark-colored bottle.” B. “If I have chest pain, I will put a tablet underneath my tongue.” C. “If my pain is not relieved with one tablet, I will get medical help.” D. “I should expect to get a headache after taking my nitroglycerin. 52. The nurse is preparing to administer an nitroglycerin (NTG) transdermal patch to the client diagnosed with a myocardial infarction (MI). Which intervention should the nurse implement?  A. Question applying the patch if the client’s blood pressure is less than 110/70. B. Use non sterile gloves when applying the transdermal patch. C. Date and time the transdermal patch prior to applying to the client's skin. D. Place the transdermal patch on the site where the old patch was removed 53. The client diagnosed with angina who is prescribed nitroglycerin (NTG) tells the nurse, “I don’t understand why I can’t take my sildenafil. I need to take it so that I can make love to my wife.” Which statement is the nurse’s best response?  A. “If you take the medications together, they may cause you to have very low blood pressure.” B. “You are worried your wife will be concerned if you cannot make love.” C. “If you wait at least 8 hours after taking your nitroglycerin, you can take your sildenafil.” D. “You should get clarification with your HCP about taking sildenafil.” 54. The client being discharged after sustaining an acute MI is prescribed lisinopril. Which instruction should the nurse include when teaching about this medication?  A. Instruct the client to monitor the blood pressure weekly.