The Call Light Chronicles
A 75-year-old patient is admitted for evaluation of dizziness and frequent falls. During the assessment, the nurse notes an unsteady gait, a BP of 88/56 mmHg, and a heart rate of 102 bpm.
What is the nurse’s priority action?
A 72-year-old patient with heart failure is admitted for shortness of breath. The nurse notes bilateral lower extremity edema, jugular vein distension, and crackles in the lungs. Which action should the nurse prioritize?
(a) Administer diuretics as ordered.
(b) Monitor vital signs every hour.
(c) Provide oxygen therapy immediately.
(d) Reassess the patient’s fluid intake and output.
(a) Administer diuretics as ordered.
A nurse is caring for a patient who is non-verbal and has advanced dementia. The patient’s family requests that no life-saving interventions be used if the patient experiences a cardiac arrest. What should the nurse do in this situation?
Document the conversation in the EMR and contact the healthcare provider to receive an order for DNR.
A patient recovering from surgery is in moderate pain and is requesting oral medication. The nurse finds the patient’s pain level to be 5/10. What is the best action for the nurse to take?
(a) Administer pain medication as prescribed.
(b) Encourage the patient to take deep breaths and relax.
(c) Offer an additional dose of medication beyond the prescription.
(d) Reassess the pain in 30 minutes.
(a) Administer pain medication as prescribed.
A 45-year-old patient is admitted with severe vomiting for three days. Lab values include pH 7.50, PaCO2 40 mmHg, and HCO3 32 mEq/L. The ABG results indicate the patient is experiencing ________________________.
Metabolic Alkalosis
A 34-year-old woman presents with acute shortness of breath and a history of asthma. The nurse notes wheezing on auscultation and oxygen saturation of 88%. What should the nurse prioritize in the management of this patient?
(a) Administer albuterol via nebulizer.
(b) Obtain an arterial blood gas (ABG) sample.
(c) Initiate non-invasive ventilation.
(d) Request a chest X-ray to assess for pneumonia.
(a) Administer albuterol via nebulizer.
A nurse is preparing a patient for a total knee replacement surgery. The nurse needs to ensure the patient understands the procedure and recovery process. Which topic should the nurse prioritize in preoperative teaching?
(a) Postoperative pain management and expectations.
(b) Exercise restrictions during the postoperative period.
(c) The possibility of needing physical therapy after surgery.
(d) The need for a blood transfusion during surgery.
(a) Postoperative pain management and expectations.
A patient with chronic kidney disease is receiving dialysis and expresses a desire to discontinue treatment. The family is strongly against discontinuing dialysis, stating that the patient will die without it. What should the nurse do in this situation?
(a) Encourage the patient to continue treatment despite their wishes.
(b) Discuss the patient’s wishes with the family in a family meeting.
(c) Notify the healthcare provider about the conflict between patient and family.
(d) Honor the family’s wishes and continue dialysis without the patient’s consent.
(b) Discuss the patient’s wishes with the family in a family meeting.
A 62-year-old patient is being prepared for surgery and expresses fear about the postoperative pain. The nurse needs to provide education regarding pain management options. What is the best approach to address the patient’s concerns about pain?
(a) Discuss both pharmacologic and non-pharmacologic pain management strategies.
(b) Reassure the patient that there will be no pain after surgery.
(c) Offer the patient an analgesic to take immediately before surgery.
(d) Provide a detailed explanation of the risks associated with opioid use.
(a) Discuss both pharmacologic and non-pharmacologic pain management strategies.
A 25-year-old patient presents with dizziness and muscle weakness. Labs reveal potassium of 2.9 mEq/L. Match the potential cause to the electrolyte disturbance.
(a) Potassium 2.9 mEq/L - Excessive diuretic use
(b) Potassium 2.9 mEq/L - Renal failure
(c) Potassium 2.9 mEq/L - Increased dietary intake
(d) Potassium 2.9 mEq/L - Dehydration
(a) Potassium 2.9 mEq/L - Excessive diuretic use
A 50-year-old patient is preparing for a major abdominal surgery. The patient expresses anxiety about the procedure. Which intervention is most appropriate to help reduce the patient's anxiety?
(a) Explain the steps of the surgery in detail.
(b) Offer reassurance that the surgery will be successful.
(c) Allow the patient to ask questions and provide clear, honest answers.
(d) Provide a sedative to calm the patient before the surgery.
(c) Allow the patient to ask questions and provide clear, honest answers.
A 54-year-old patient is admitted with an acute stroke. The nurse notes that the patient has a drooping right eyelid and is unable to smile on the right side of the face. Which of the following should the nurse monitor for immediately after the stroke?
(a) Impaired swallowing and airway protection.
(b) Increased intracranial pressure.
(c) Blurred vision and changes in mental status.
(d) The presence of aphasia or dysphasia.
(a) Impaired swallowing and airway protection.
A 25-year-old patient has been diagnosed with a life-threatening illness. The nurse is aware that the patient's family is insisting on keeping the diagnosis a secret from the patient. What is the nurse’s ethical obligation in this situation?
(a) Keep the diagnosis confidential as requested by the family.
(b) Encourage the family to tell the patient the truth about their condition.
(c) Respect the patient’s right to know about their diagnosis and inform them.
(d) Wait until the family agrees to tell the patient before disclosing the diagnosis.
(c) Respect the patient’s right to know about their diagnosis and inform them.
A patient with a post-operative hip replacement is experiencing moderate pain. The nurse administers an opioid analgesic as prescribed. The patient is also reporting nausea and dizziness. What is the priority nursing action after the administration of the analgesic?
(a) Monitor the patient for signs of opioid overdose.
(b) Assess the patient’s pain level again in 15 minutes.
(c) Document the pain level and wait for the prescribed interval.
(d) Administer an antiemetic to prevent nausea and vomiting.
(d) Administer an antiemetic to prevent nausea and vomiting.
A 65-year-old patient is admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) and presents with a pH of 7.32, PaCO2 60 mmHg, and HCO3 28 mEq/L. What is the likely cause of the patient's acid-base imbalance?
Respiratory acidosis with partial compensation.
A 32-year-old male patient is admitted with a suspected pulmonary embolism. The nurse observes a sudden onset of shortness of breath and chest pain. What should be the nurse’s first priority when assessing this patient?
(a) Administer oxygen therapy and assess vital signs.
(b) Contact the healthcare provider immediately for further orders.
(c) Check for signs of deep vein thrombosis.
(d) Obtain an ECG to evaluate heart function.
(a) Administer oxygen therapy and assess vital signs.
A 75-year-old patient is receiving IV fluids at a rate of 100 mL/hr after undergoing surgery. The nurse notices that the patient has gained 4 kg over the past 24 hours. What is the most likely explanation for this weight gain?
(a) Fluid retention related to surgery and IV fluids.
(b) Increased dietary intake.
(c) Postoperative muscle mass gain.
(d) A change in the patient’s metabolic rate.
(a) Fluid retention related to surgery and IV fluids.
A 40-year-old patient who is pregnant with twins refuses a blood transfusion due to religious beliefs after a complicated delivery. What should the nurse do in this situation?
(a) Respect the patient’s wishes and do not administer the transfusion.
(b) Encourage the patient to accept the transfusion to save her life.
(c) Obtain a court order to provide the blood transfusion.
(d) Notify the healthcare provider and allow them to discuss the matter with the patient.
(a) Respect the patient’s wishes and do not administer the transfusion.
A 70-year-old patient recovering from a hip replacement is complaining of moderate pain. The patient is currently receiving oral analgesics. What is the most appropriate approach for managing this patient’s pain?
(a) Increase the dosage of the oral analgesic.
(b) Administer a higher-dose IV opioid for more immediate relief.
(c) Provide a non-pharmacologic intervention such as relaxation techniques.
(d) Administer the prescribed analgesic and reassess pain in 30 minutes.
(d) Administer the prescribed analgesic and reassess pain in 30 minutes.
A patient with chronic asthma presents with a history of wheezing and difficulty breathing. The nurse notes a respiratory rate of 30 breaths per minute, a pH of 7.48, and PaCO2 of 30 mmHg. What is the likely acid-base imbalance the patient is experiencing?
Respiratory alkalosis
A 60-year-old patient is scheduled for a scheduled cholecystectomy. The nurse is preparing the patient for surgery and needs to educate them about postoperative care. What is the most important education topic for this patient?
(a) The importance of deep breathing and coughing exercises.
(b) Avoiding any physical activity for at least 4 weeks post-surgery.
(c) The need to keep the surgical site dry for 48 hours.
(d) The importance of avoiding food for 12 hours after surgery.
(a) The importance of deep breathing and coughing exercises.
A 45-year-old patient with chronic alcoholism is admitted with symptoms of confusion and tremors. Lab results reveal a serum magnesium level of 0.9 mg/dL. What is the most appropriate intervention for this patient?
(a) Administer magnesium sulfate as ordered.
(b) Initiate fluid resuscitation with normal saline.
(c) Begin a glucose infusion to treat hypoglycemia.
(d) Administer a benzodiazepine to manage withdrawal symptoms.
(a) Administer magnesium sulfate as ordered.
A 50-year-old patient who is undergoing chemotherapy asks the nurse whether they should continue treatment despite severe side effects. What is the nurse’s role in this situation?
(a) Encourage the patient to continue treatment because the potential for remission exists.
(b) Discuss the benefits and side effects of treatment with the patient to allow them to make an informed decision.
(c) Advise the patient to discontinue treatment and seek palliative care.
(d) Provide information on alternative treatment options, including herbal remedies.
(b) Discuss the benefits and side effects of treatment with the patient to allow them to make an informed decision.
A 45-year-old patient who was prescribed opioid pain medication following a recent surgery is being monitored postoperatively. The nurse enters the room and finds the patient unresponsive, with slow, irregular breathing. The nurse also observes that the patient’s lips are slightly cyanotic. Which of the following is the most likely explanation for the patient’s condition?
(a) The patient is experiencing an allergic reaction to the medication.
(b) The patient is having a panic attack due to pain.
(c) The patient is likely experiencing an opioid overdose.
(d) The patient is showing typical symptoms of postoperative delirium.
(c) The patient is likely experiencing an opioid overdose.
A 28-year-old patient is experiencing excessive vomiting and diarrhea after a stomach virus. The nurse’s assessment reveals dry mucous membranes, low blood pressure, and increased heart rate. Which of the following interventions is most important to correct the patient’s fluid imbalance?
(a) Administer IV fluids with sodium chloride.
(b) Encourage oral fluid intake with electrolytes.
(c) Provide antidiarrheal medications.
(d) Initiate IV antibiotics to prevent infection.
(a) Administer IV fluids with sodium chloride.