Tiêu đề RECALLS 6 - NP3 - SC ✅

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