Founcations Of Nursing- Clinical
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- 1.Your are working with a nurse at Med-Surg floor. The nurse just received a report from E.R. about a patient who will be transferred to your floor. You asked your nurse to tell you a little bit about the patient. She replied: He is a 74 years old male, came with mild shortness of breathe (SOB). He is alert, awake, with +3 edema in the ankles bilaterally. His vital signs in ER are: BP 156/34, pulse, 92, Temp, 98.1 F, respiration 28, SpO2 93% at nasal cannula 3 L/min. Based on these information, which of the following is most likely the medical diagnosis of this patient? What is your best guess?
- A.
Sepsis
- B.
Congestive Heart Failure (CHF)
- C.
Altered level of consciousness
- D.
CVA
- 2.While you're waiting for ER staff to bring the patient to your floor, you decide to look up his laboratory work. You find the following:Na: 129, K: 5.9, BUN: 15, Cr. 1.1, Hb: 14.1, WBC: 9.2. Which of these laboratory results is/are abnormal?
- A.
Na, K, and BUN
- B.
Na, K, and Hb
- C.
Na, K, Hb, and WBC
- D.
Na and K only
- 3.Your patient will be coming soon from ER, describe how are you going to prepare his room (in terms of bed, bed making, equipments...)
- 4.Your patient is in your floor now. You and the ER nurse assisted the patient in moving from the gurney to his bed. Now its time for quick physical assessment. Your patient looks stable now, What is the first system you should assess?
- A.
Respiratory
- B.
Cardiovascular
- C.
Neurological
- D.
GI
- 5.You greeted your patient, introduced yourself, and ask the patient to tell you his name, date of birth, today's date, and which hospital he is at now. Your patient answered all these question correctly and was smiling. His level of consciousness is:
- A.
Alert, awake, oriented, and cheerful
- B.
Confused
- C.
Withdrawal
- D.
Comatose
- 6.You thanked your patient for the information. Now your are going to tell him briefly about the routine in the floor. Which of the following information should be mentioned?
- A.
We will take your vital signs once a day
- B.
You should not expect to have enough sleep here
- C.
If you need anything you can use the calling bell to call for me
- D.
Your family can bring you the food that you like
- 7.As part of your assessment, you next obtained the vital signs, which were:BP 163/45, Temp 99.1, HR 81, SpO2 95%, Respiration 23, pain 0/10. Based on these readings, the patient is having:
- A.
Hypotension and hyperthemia
- B.
Hypertension and tachycardia
- C.
Hypertension and tachypnea
- D.
Hypertension and desaturation
- 8.
![While you were doing your assessment, you noticed several bruises in the patient's skin. You also noticed this (see the picture) in his left upper chest. Which of the following medication has caused the bruises? - ProProfs]( "While you were doing your assessment, you noticed several bruises in the patient's skin. You also noticed this (see the picture) in his left upper chest. Which of the following medication has caused the bruises?")
While you were doing your assessment, you noticed several bruises in the patient's skin. You also noticed this (see the picture) in his left upper chest. Which of the following medication has caused the bruises?- A.
Lasix
- B.
Nitroglycerin
- C.
Coreg
- D.
Coumadin
- 9.What is the name of the device in the picture above?
- 10.You informed the physician about the bruises. He said "we need to check his coagulation." Which of the following is coagulation test?
- A.
CBC
- B.
PTT, PT, INR
- C.
Blood culture
- D.
BMP
- 11.Based on the information from ER and chest x-ray, when you auscultate the patient's lungs with the patient in high Fowler's position, you expect to hear:
- A.
Regular breathing sounds
- B.
Crackles, which indicate presence of fluid
- C.
Wheezing, which indicates airway narrowing
- D.
Diminished breathing sounds all over the chest
- 12.When you assess the apical pulse, which of the following will be most likely finding?
- A.
Regular tachycardia
- B.
Irregular tachcardia
- C.
Normal heart rate and rhythm
- D.
Irregular heart rate and rhythm
- 13.During your assessment, you find a pink IV catheter in the right arm. What is the gauge of this pink IV?
- A.
18
- B.
20
- C.
22
- D.
24
- 14.You saw that the IV is connected to an infusing pump. The pump screen reads 50. How many mL of IV fluid is being infused for this patient every 4 hours?
- A.
50
- B.
100
- C.
150
- D.
200
- 15.As you continued your assessment, you found that patient's hands and feet swollen with fluid under the skin, what do we call this condition?
- A.
Dehydration
- B.
Edema
- C.
Internal bleeding
- D.
Inflammation
- 16.So far, what is the best nursing diagnosis?
- A.
Pain
- B.
Decreased cardiac output
- C.
Impaired gas exchange
- D.
Impaired skin integrity
- 17.A phlebotomist came from the lab and took a blood sample for coagulation. He called you after 30 minutes to informed you with critical results: PT= 58. You are going to informed the physician of this result, what you expect the physician to order?
- A.
Continue coumadin as ordered
- B.
No order, just observe the patient
- C.
Stop coumadin and give vitamin K
- D.
Transfuse 2 units of blood
- 18.Based on your assessment, you found that the patient is at risk for fall RT edema, antiHTN medication, connected IV.. which of the following should be done next:
- A.
Have a green band around the patient's hand
- B.
Raised 4 side rails
- C.
Encourage the patient to call you for help
- D.
Have a family member sit with patient all the time
- 19.Thirty minutes later, your patient called your and told you that his SOB became worse. You checked his respiration and O2 sat and found: RR 31, O2 sat 88%. The patient is currently on nasal cannual. You informed the respiratory therapist and now both of you need to decide to replace the nasal cannula, which of the following oxygen modalities would you choose?
- A.
Room air
- B.
Keep the nasal cannula and increase the oxygen flow to 15 liters
- C.
Non-rebreathing mask, which gives oxygen up to 100%
- D.
Oxymizer
- 20.It is time to give your patient his anti-hypertension medication. The patient is taking norvasc and coreg. His current blood pressure is 155/49. The patient asked you about the difference between the two "blood pressure" medicine, what would you say?
- A.
There is no difference, but you need both because your BP is pretty high
- B.
One is very expensive and other one is cheap
- C.
They both lower the high BP, but have two different mechanism
- D.
I really do not know, you can ask your doctor
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