When caring for a patient experiencing a tonic clonic seizure, the most appropriate nursing intervention is:
  • Sputum with streaks of bloodNOT: increased salivation
  • Morphine Duramorph, oxygen, nitrates, Aceticsalicylic acid, bayer buffered aspirin
  • Protecting the patient's head and extremities from contact with surrounding objects
  • Lipase and amylase
Which of the following antidiabetic medication is contraindicated 48 hours after receiving contrast dye
  • Wheat bread
  • Metformin
  • Rifampin
  • Potassium 2.5 mEq/L
What information is vital for you to know prior to administering an ordered dose of digoxin
  • Heart rate
  • Canned meats
  • Metformin
  • Wheat bread
You're reviewing the menu list of a patient on Warfran what food should they not eat?
  • Spinach
  • Rifampin
  • Increase shortness of breath
  • Laryngeal strider
At 0500, you know your patient to be diaphoretic, clammy, and their hands are shaking. The patient's blood sugar is currentlyWhich of the following is the most appropriate intervention
  • Have the patient drink 120 ML's of orange juice
  • Refused to sign for the waste
  • Sputum with streaks of bloodNOT: increased salivation
  • Educate the spouse on oxygen use as a medical device in the hospital
You are taking care of a patient who is admitted for left flank pain with a kidney stone of 1.5 cm. He asks you about the procedure what would be the most therapeutic response?
  • Educate the spouse on oxygen use as a medical device in the hospital
  • The hospitals language interpreter
  • Due to the size of the kidney stone it is an appropriate treatment?NOT:Print reading materials about the subject and give it to the patient
  • Assess the patient Not: start CPR
Your patient fell and hit his head on the bed rail during a physical therapy session. Upon initial assessment you observe a blood pressure of 90/45, heart rate of 28, and a constricted pupil. The patient is lying in a supine position. What should be your first response?
  • KCI 40 mEq IV push STAT
  • Honor the patient's wishes
  • And washing with soap and water is mandatory because alcohol based hand sanitizers do not kill C-diff
  • Call a rapid response
One of the signs of left sided heart failure is:
  • Heparin infusion per pharmacy protocol
  • Increase shortness of breath
  • Pulmonary edemaNOT: pedal edema
  • Pulmonary embolism?NOT: tuberculosis
Didn't nurse ask you about the typical signs and symptoms of myocardial infarction
  • Apply sterile saline soap towels over the extruding site
  • Women could have pain in their arm, neck, back or jaw
  • Call a rapid response
  • 4ml
The Glasgow, scale ranges from:
  • Rifampin
  • 3 to 15
  • V-Tach
  • Change in LOC
You're a king for a patient who is postop after surgical removal of fibroids. She hears a pop sound after coughing in her surgical wound has dehisced
  • Sputum with streaks of bloodNOT: increased salivation
  • Due to the size of the kidney stone it is an appropriate treatment?NOT:Print reading materials about the subject and give it to the patient
  • 4ml
  • Apply sterile saline soap towels over the extruding site
What is the first sign of increased intracranial pressure?
  • Heart rate
  • Change in LOC
  • Metformin
  • Rifampin
You were caring for a patient who is 18 hours postop after a right BKA a. They report sudden chest pain pulse ox at 86%. The patient may be experiencing:
  • Canned meats
  • Pulmonary embolism
  • Pulmonary edemaNOT: pedal edema
  • Perform a bladder scan
The doctor ordered Lasix 40 mg IV push, 100mg/10 mL
  • Women could have pain in their arm, neck, back or jaw
  • And washing with soap and water is mandatory because alcohol based hand sanitizers do not kill C-diff
  • 4ml
  • Rifampin
Your patient was admitted with severe dehydration. Which of the following orders would you question
  • Perform a bladder scan
  • Compress the drain, then plug the bulb to establish suction
  • KCI 40 mEq IV push STAT
  • Saturday at 3 PM
When assessing a patient, you notice crepitus on the right upper shoulder. You notify the physician and anticipate which diagnosis?
  • Perform a bladder scan
  • Lipase and amylase
  • Potassium 2.5 mEq/L
  • Subcutaneous emphysema
Heart rate
  • Sinus rhythm with PAC
  • V-Tach
  • 80
  • Narcan
You're preparing your patient for discharge need to provide dietary education related to his diagnosis what should you instruct the patient to avoid?
  • Increase shortness of breath
  • Canned meats
  • Saturday at 3 PM
  • Spinach
The patient has a morphine PCA post operatively. On rounding you notice respirations at eight per minute O2 saturation of 82%. What medication would be given in the situation?
  • Saturday at 3 PM
  • NOT: ammonia
  • Narcan
  • Wheat bread
You're providing discharge instructions to a CHF patient.
  • Refused to sign for the waste
  • Acetylsalicylic acid ( Bauer buffered aspirin)
  • Protonix is given as G.I. prophylaxis to prevent stress ulcers
  • Increase shortness of breath
You're caring for a 12 hour postoperative parathyroidectomy patient. Which assessment finding would indicate an emergency?
  • Canned meats
  • Saturday at 3 PM
  • Laryngeal strider
  • KCI 40 mEq IV push STAT
A patient suddenly complains of new onset of chest pain. The doctor is suspecting a possible?... What is most likely to be ordered?
  • A respiratory rate of 8 breaths per minute
  • Morphine Duramorph, oxygen, nitrates, Aceticsalicylic acid, bayer buffered aspirin
  • Compress the drain, then plug the bulb to establish suction
  • Aspirate the fluid, advance the catheter farther, then re-inflate the balloon
Your patient has been diagnosed with a hemorrhagic CVA
  • KCI 40 mEq IV push STAT
  • Saturday at 3 PM
  • Heparin infusion per pharmacy protocol
  • Perform a bladder scan
A postoperative laparoscopic appendectomy patient is receiving morphine PCA for pain findings with alert you to the potential of a narcotic overdose?
  • A respiratory rate of 8 breaths per minute
  • Assess your patient for a change in condition
  • Discarded, then begin the 24 hour collection
  • Aspirate the fluid, advance the catheter farther, then re-inflate the balloon
You are to obtain informed consent for a Spanish-speaking patient scheduled for surgery. You do not speak Spanish and are having difficulty communicating with your patient. Which of the following resources would be most appropriate to utilize in order to obtain consent?
  • Protonix is given as G.I. prophylaxis to prevent stress ulcers
  • The hospitals language interpreter
  • Acetylsalicylic acid ( Bauer buffered aspirin)
  • Due to the size of the kidney stone it is an appropriate treatment?NOT:Print reading materials about the subject and give it to the patient
You were caring for a patient admitted with abdominal pain. Your patient has a bowel movement and you know dark tarry stool what would be the diagnosis?
  • Canned meats
  • Upper G.I. bleed
  • Wheat bread
  • Perform a bladder scan
Your COPD patient is complaining of wheezing and increased shortness of breath
  • Heparin infusion per pharmacy protocol
  • Assess the patient Not: start CPR
  • Assess your patient for a change in condition
  • Compress the drain, then plug the bulb to establish suction
Your patient was just returned from surgery with a Jackson-Pratt JP drain in place which of the following is the best nursing action?
  • Protecting the patient's head and extremities from contact with surrounding objects
  • Assess the patient Not: start CPR
  • Compress the drain, then plug the bulb to establish suction
  • Educate the spouse on oxygen use as a medical device in the hospital
A 56-year-old man has an acute onset of shortness of breath, chest pain, apprehension, rapid pulse, cough with bloody sputum, diaphoresis, and syncope. The symptoms are indicative of:
  • Pulmonary embolism?NOT: tuberculosis
  • A respiratory rate of 8 breaths per minute
  • Pulmonary edemaNOT: pedal edema
  • Have the patient drink 120 ML's of orange juice
Deposition has ordered for your patience to begin a 24 hour urine collection. Your patient voids for the first time two hours after the orders received. What should be done with this urine sample?
  • Compress the drain, then plug the bulb to establish suction
  • Have the patient drink 120 ML's of orange juice
  • A respiratory rate of 8 breaths per minute
  • Discarded, then begin the 24 hour collection
Your inserting a urinary catheter into a male patient. As you inflate a balloon, the patient complains of discomfort what is the best action?
  • Aspirate the fluid, advance the catheter farther, then re-inflate the balloon
  • Due to the size of the kidney stone it is an appropriate treatment?NOT:Print reading materials about the subject and give it to the patient
  • Compress the drain, then plug the bulb to establish suction
  • Educate the spouse on oxygen use as a medical device in the hospital
You're reviewing the discharge medication list of a patient diagnosed with gastric ulcer. Which of the following medication should you question?
  • Acetylsalicylic acid ( Bauer buffered aspirin)
  • Protonix is given as G.I. prophylaxis to prevent stress ulcers
  • A respiratory rate of 8 breaths per minute
  • Spinach
Which of the following food items would you question in the menu of your patient who is diagnosed with celiac disease?
  • Wheat bread
  • Sputum with streaks of bloodNOT: increased salivation
  • Metformin
  • Potassium 2.5 mEq/L
You deserve the nurse aid removing her gloves and immediately using alcohol hand sanitizer in a room with a patient who has C-Diff. What education should you provide to the nurse aide
  • Call a rapid response
  • Apply sterile saline soap towels over the extruding site
  • And washing with soap and water is mandatory because alcohol based hand sanitizers do not kill C-diff
  • Assess the patient Not: start CPR
Your patient had a TB skin test done on Thursday at 2:45 PM
  • KCI 40 mEq IV push STAT
  • Lipase and amylase
  • Laryngeal strider
  • Saturday at 3 PM
Which of the following electrolyte value should be Addressed immediately by the nurse
  • Wheat bread
  • Lipase - 196
  • Sputum with streaks of bloodNOT: increased salivation
  • Potassium 2.5 mEq/L
While performing the narcotic count at the end of the shift, my coworker admits to something, coworker to sign for the ways that you did not witness
  • Increase shortness of breath
  • Acetylsalicylic acid ( Bauer buffered aspirin)
  • Canned meats
  • Refused to sign for the waste
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