19,20,23,24,25
26,27,28,29,30
100
A 31-year-old patient has returned to the postsurgical unit following a hysterectomy. The patient's care plan addresses the risk of hemorrhage. How should the nurse best monitor the patient's postoperative blood loss?
Have the patient void and have bowel movements using a bed pan only.
Count and inspect each perineal pad that the patient uses.
Swab the patient's perineum for the presence of blood at least once per shift.Leave the patient's perineum open to air to facilitate inspection.
Count and inspect each perineal pad that the patient uses.
100
Ms. Alvarez, 56 years old, admitted with cirrhosis and ascites. On low-sodium diet and spironolactone. You have the following data:
Which interpretation is correct and what is the next best action?
Condition improving; continue current plan
Condition worsening; anticipate paracentesis order
Condition stable; monitor for infectionCondition worsening; increase potassium intake
Condition worsening; anticipate paracentesis order
200
The nurse is caring for a child with a gastrointestinal disorder and measuring intake and output. The nurse determines that the child is adequately hydrated when they note which finding(s)? Select all that apply.
fontanels (fontanelles) with normal tension
adequate skin turgor
some oral intake
pink and moist mucous membranes
loose stools
fontanels (fontanelles) with normal tension
adequate skin turgor
pink and moist mucous membranes
200
Mr. Thompson, 48 years old, admitted with severe epigastric pain and nausea. Diagnosed with acute pancreatitis. NPO, receiving IV fluids and pain management. You have the following data:
Which interpretation is correct and what action is anticipated?
Condition improving; anticipate advancing diet to clear liquids
Condition worsening; monitor for hypocalcemia and decreased perfusion
Condition stable; continue current plan
Condition worsening; prepare for insulin administration
Condition improving; anticipate advancing diet to clear liquids
300
The nurse is teaching the parents of a 6-month-old infant with gastroesophageal reflux. What will the nurse include in the teaching? Select all that apply.
Hold the infant upright for 30 minutes after feeding.
Avoid placing the infant in a car seat after feeding.
Thicken feedings as directed.
Monitor the infant's weight gain.
Provide less feedings.
Give larger feedings.
Hold the infant upright for 30 minutes after feeding.
Avoid placing the infant in a car seat after feeding.
Thicken feedings as directed.
Monitor the infant's weight gain.
300
BOW TIE
PATIENT DATA Fred (he/him) is a 67-year-old with a history of alcohol use disorder and cirrhosis admitted to the medical surgical unit. He is oriented to person only. He also has mild HTN and GERD. Fred is on oxygen 2L per NC and becomes dyspneic with effort. He is drowsy and dozing off, although is irritable when awakened or when answering questions. He has ascites and the nurse notes mild jaundice and asterixis. Admission weight is 64.5 kg, height is 6'1". VS: 36.8, 85, 22, 142/72, 92%, abdominal girth 100cm. Labs: BUN 22, Creatinine 1.4, Glucose 70, Ammonia 94, Albumin 2.9.
28. What condition is the patient most likely experiencing?
Esophageal varices
Hepatic encephalopathy
Acute alcohol intoxication
29. What are the TWO actions to take?
Administer lactulose
Ensure safe environment
Administer acetaminophen
Administer IV furosemide
Raise HOB to 90 degrees
Request order for sedative
30. What are the TWO parameters to monitor?
Blood pressure
Vitamin D level
Intracranial pressure
Serum creatinine
Neurologic status
Serum ammonia
Condition: Hepatic encephalopathy
Two Actions: Administer lactulose and ensure safe environment
Monitor: Neurological status and serum ammonia
400
A patient Assigned Male at Birth (AMAB) presents to the clinic for an annual check-up. The nurse notices that the patient wrote on a form that she identifies as female and uses the pronouns she/her. What are the nurse's priorities? Select all that apply.
Introducing self using name and pronouns
Entering the patient's name, gender, and pronouns in her health care record
Ignoring mistakes made regarding the patient's pronouns so as not to embarrass her
Explaining to the patient why other health care providers may make mistakes even though the correct information is in the chart
Introducing self using name and pronouns
Entering the patient's name, gender, and pronouns in her health care record
500
The nurse is providing care to a patient with gross ascites who is maintaining a position of comfort in the high semi-Fowler’s position. What is the nurse’s priority assessment of this patient?
Respiratory assessment related to increased thoracic pressure
Urinary output related to increased sodium retention
Peripheral vascular assessment related to immobility
Skin assessment related to increase in bile salts
Respiratory assessment related to increased thoracic pressure