Tiêu đề RECALLS 13 - NP4 - SC ✅

D. Quadriceps setting 15. Nurse Em is aware that a complication the client with paraplegia may experience is formation of urinary calculi. The factor that contributes to this condition is: A. High fluid intake B. Increases loss of calcium for the skeletal system. C. Inadequate kidney functioning. D. Increased calcium intake. 16-20. Situation. A 63-year-old male arrives at the Out-Patient Department complaining of numbness and tingling sensation of the lower extremities and pain in the legs upon exercising. The nurse suspects the client may have Peripheral Arterial Disease (PAD). 16. The nurse asks the client the following questions. Which of the questions would determine the risk factors of PAD? 1. “Do you smoke cigarettes?” 2. “Are you diabetic?” 3. “Are you hypertensive?” 4. “Do you exercise?” 5. “Do you drink alcohol?” A. 2, 3, & 4 B. 1, 2, 3, 4, & 5 C. 1, 4, & 5 D. 1, 2, & 3 17. The client asks the nurse what the doctor meant when he heard him say that the client has intermittent claudication. The nurses’ BEST response is, Intermittent claudication is_______ A. Pain that can occur in the body with exercise B. Pain in the leg when exercising C. Pain in the leg that occurs when at rest D. A tingling feeling of sensation in the hands 18. The nurse writes a nursing diagnosis of Ineffective Tissue Perfusion for the client. Which of the following interventions is MOST appropriate for this nursing diagnosis? A. Keep his legs in dependent position B. Elevate his legs C. Take hot bath D. Limit his daily activities. 19. The nurse writes another nursing diagnosis of Risk for Impaired Skin Integrity related to decreased peripheral circulation. Which of the following interventions is MOST appropriate for the nurse to instruct the client? A. Monitor the extremities for color, motion and sensation, and pulses. B. Maintain an appropriate level of activity to promote circulation. C. Avoid risk factors that may increase problems with Peripheral Arterial Disease. D. Protect the legs from injury because the tissues are fragile. 20. Which of the following outcomes indicate that there is increased arterial blood supply to the extremity of the client with peripheral arterial disease? A. Reduced sensation to touch B. Reduced muscle pain C. Increased rubor D. Decreased hair on the extremity 21-25. Situation. Nurse Rose is a newly registered nurse. She is assigned to the surgical unit of X hospital. She is aware of the legal responsibilities when performing patient care. The following are situations she encountered in the surgical unit with legal significance. 21. A patient is scheduled for abdominal surgery. Which of the following statements is a responsibility of Nurse Rose in obtaining a consent form? 1. Ensure that the consent form has been signed and is attached to the chart of the patient before the operation. 2. Witness the signing of the consent before the operation is performed. 3. Provide a detailed description of the operation before asking the patient to sign the consent form 4. Answer questions that the patient may ask before the patient signs the consent form. A. 3 & 4 B. 1, 2 & 3 C. 1, 2 & 4 D. 1 & 3 22. Which of the following health care professionals is legally responsible for obtaining informed consent for an invasive procedure? The ____ A. Surgeon B. Nurse Supervisor of the unit C. Medical director D. Registered nurse on duty 23. Nurse Rose documents her observation on a patient for abdominal surgery. Which of the following statements is legally appropriate notation? A. “The charge nurse spoke with the patient about the surgery” B. “The surgeon committed an error in the medication dose to be given” C. “Patient says he will sue the surgeon and the hospital if the operation turns out to be a failure.” D. “Patient says he feels sharp and stabbing pain in the abdominal area.” 24. The attending physician writes an order of Do Not Resuscitate (DNR) on a patient who is seriously ill. Which of the following is a responsibility of Nurse Rose? Nurse Rose should ________ 1) Carry out the order in the event the patient experiences sudden need for CPR 2) Determine if there is a living will on the medical record of the patient 3) Consult the policies and procedures of the Institution if she feels such DNR order is contrary to the patient’s or family’s wishes. 4) Refer to the Ethics Committee of the Institution the DNR order to determine appropriateness of the order. A. 2 & 3 B. 1 & 3 C. 3 & 4 D. 1 & 2 25. The physician orders a dose of medication to be given to a patient before undergoing surgery. Nurse Rose is aware that the dose is too high for the patient. She tries to locate the physician to check the order but the physician is not available. Which of the following is the MOST appropriate action Nurse Rose will take to ensure the safety of the patient? A. Notify the nurse supervisor immediately B. Administer half of the dose of the medication ordered. C. Administer the medication as ordered. D. Withhold the medication. 26-30. Situation. The charge nurse in the Emergency Department calls for a crisis meeting to review principles in mass casualty to enhance preparedness and improve emergency quality care. 26. Which of the following statements is NOT TRUE about emergency preparedness? A. Hospitals should have an emergency preparedness plan that is tested through drills or actual participation. B. Generally, hospital employees participate seriously in emergency drills. C. Emergency preparedness training and drills are standard functions of emergency departments of hospitals. D. Drills must involve the participation and collaboration of the community. 27. The charge nurse explains that mass casualty incidents are due to events such as the following EXCEPT: A. Earthquakes B. Severe weather phenomena. C. Lightning strikes. D. Transportation disasters. 28. The charge nurse reiterates the importance of using a disaster triage tag system. Clients that have been “green-tagged” are those ________. A. With injuries of closed fracture, sprains, contusions and abrasions. B. Who are expected to die or are dead already. 2 | Page

45. The client receiving blood transfusion begins to wheeze on respiration, itch and observes that his skin becomes flushed with hives. The nurse recognizes these signs as characteristic of what type of reaction? A. Bacterial B. Hemolytic C. Allergic D. Systemic 46-50. Situation. Nurse Olan works the day shift in the female medical unit. Nurse Olan is aware that when caring for clients, the nursing process can be an effective tool for communication. 46. Nurse Olan understands that the MOST important aspect of communication is to_____ A. Observe the facial expressions of your patients. B. Clarify the statements made. C. Listen to what is being said. D. Restate the words you hear from the client. 47. Which of the following activities will Olan consider to validate effectiveness of a nurse-client communication? A. Assessment of the physician. B. Feedback from the client. C. Adaptation of the client to physiologic changes. D. Conference with the members of the health team. 48. Nurse Olan formulates nursing diagnoses for her clients. She knows that a nursing diagnosis represents the: A. Prepared plan of care. B. Actual nursing interventions carried out. C. Nursing judgments about the health of her patients. D. Actual or potential health problems of her patients. 49. Nurse Olan collects data and begins to develop a trust relationship with her clients. This activity is what aspect of the nursing process? A. Evaluation B. Implementation C. Planning D. Assessment 50. Nurse Olan understands that the nursing process is a scientific method and a proven form for: A. Problem solving B. Health education C. Oral communication D. Cost containment 51-55. Situation. The nurse assists in the care of female clients. Jaira is a 35 year old woman with hyponatremia. According to the client she is taking diuretic medications. 51. Which of the following statements is TRUE about hyponatremia? A. Hyponatremia from diuretic use may produce small quantities of urine. B. Hyponatremia occurs because of excess fluid volume diluting the potassium. C. A serum sodium level determined above 135 mEq/L indicates hyponatremia. D. Hyponatremia from diuretic use may produce large quantities of urine. 52. In assessing the client, the nurse should focus on which part of the following? The ______: A. Spiritual state of the client B. Physical signs and symptoms C. Diagnostic to be done on the client D. Mental status of the client Ratio: Hyponatremia could cause seizures. 53. The nurse writes a nursing diagnosis. Which of the following is appropriate? A. Disturbed thought processes B. Decreased cardiac output C. Activity intolerance D. Ineffective breathing pattern 54. The client has a serum sodium level of 115 mEq/L. a priority nursing intervention is for the nurse to: A. Give frequent oral care B. Take precautions for occurrence of seizures C. Monitor cardiac rhythm D. Take the vital signs every two hours 55. The nurse is much aware that a client receiving D5W at 100 ml/hr. is MOST at risk for developing which of the following conditions? A. Hyponatremia B. Fluid volume excess C. Hypernatremia D. Fluid volume deficit 56-60. Situation. Nurse Frances assists in the care of female patients with coronary artery disease (CAD). She schedules time to educate these groups of women about CAD. 56. A correct statement about CAD in women is that _____: A. Hormone Replacement Therapy is recommended for prevention of coronary artery disease. B. Women develop CAD earlier than men. C. The genetic component for CAD is weak. D. The rate of women having CAD is steadily rising while it is declining in men. 57. Research indicates that a woman with CAD needs to exercise to decrease the risk of having CAD. Which of the following exercises is recommended? A. Light to moderate exercise for 30 minutes 5x a week. B. Light exercises (walking) 20 minutes 3x a week. C. Aggressive exercise for 30 minutes 3x a week D. Moderate exercise for 20 minutes 5x a week. 58. Nurse Frances gives information about blood pressure in women. Which of the following statements is correct? A. Hypertension doesn’t affect CAD risk as women age. B. Low blood pressure is twice as common as oral contraceptive users. C. Twenty percent of women have hypertension before menopause. D. Weight, age, and oral contraceptive use affect blood pressure. 59. Nurse Frances explains that stress can be managed by which of the following: A. An individual has low and constant stress B. An individual has high stress level and low control C. An individual has high control and low stress level D. Stress is controlled over short periods. 60. Nurse Frances explains that stress can be managed by which of the following: A. Socializing with other patients with similar disease B. Taking in prescribed medications to relieve you of stress. C. Finding spiritual meaning in what you are experiencing D. Reflecting on your condition and accepting it. 61-65. Situation. The nurse assists in the care of a female client, 45 years old admitted for severe pain related to cancer. 61. In relieving pain related to cancer, which of the following nursing actions is MOST appropriate? A. Keep the room well-lighted so that the nurse can assess the client thoroughly. B. Allow the client to stay in one position to prevent the occurrence of pain. C. Apply heat or cold in the areas that are painful as prescribed by the physician. D. Place a hand bedroll behind the client’s back. 62. The client has a tunneled epidural catheter to control pain. The catheter site should be assessed every shift by the nurse on duty. Which of the following signs indicate catheter migration or tissue trauma? A. Bright red bleeding under the dressing. B. Catheter insertion site is red, swollen with purulent discharges. C. Bright red bleeding and fluid collecting under the dressing with loss of pain control. D. Bright red bleeding and fluid collecting under the dressing. 63. If catheter becomes disconnected from the tubing, the nurse should use which of the following solutions to clean the tubing or connectors: 4 | Page