When examining a patient who is paralyzed below the T4 level, the medical-surgical nurse expects to find:
flaccidity of the upper extremities.
hyperreflexia and spasticity of the upper extremities.
impaired diaphragmatic function requiring ventilator support.
independent use of upper extremities and efficient cough.
For a patient with Crohn’s disease, the medical-surgical nurse recommends a diet that is:
high in fiber, and low in protein and calories.
high in potassium.
low in fiber, and high in protein and calories.
low in potassium.
Which action best describes a sentinel event alert?
Documenting the breakdown in communication during a shift report.
Indicating that a community or institution is unsafe.
Recording the harm done when a medication error occurs.
Signaling the need for immediate investigation and response.
Which statement by a patient with diabetes mellitus indicates an understanding of the medication insulin glargine (Lantus)?
“Lantus causes weight loss.”
“Lantus is used only at night.”
“The duration of Lantus is six hours.”
“There is no peak time for Lantus.”
During an assessment of a patient who sustained a head injury 24 hours ago, the medical-surgical nurse notes the development of slurred speech and disorientation to time and place. The nurse’s initial action is to:
continue the hourly neurologic assessments.
inform the neurosurgeon of the patient’s status.
prepare the patient for emergency surgery.
recheck the patient’s neurologic status in 15 minutes.
A patient who received spinal anesthesia four hours ago during surgery is transferred to the surgical unit and, after one and a half hours, now reports severe incisional pain. The patient’s blood pressure is 170/90 mm Hg, pulse is 108 beats/min, temperature is 99oF (37.2oC), and respirations are 30 breaths/min. The patient’s skin is pale, and the surgical dressing is dry and intact. The most appropriate nursing intervention is to:
medicate the patient for pain.
place the patient in a high Fowler position and administer oxygen.
place the patient in a reverse Trendelenburg position and open the IV line.
report the findings to the provider.
Which physiological response is often associated with surgery-related stress?
Bronchial constriction.
Decreased cortisol levels.
Peripheral vasodilation.
Sodium and water retention.
The main goal of treatment for acute glomerulonephritis is to:
encourage activity.
encourage high protein intake.
maintain fluid balance.
teach intermittent urinary catheterization.
A patient recently had a cardiac catheterization via right-radial approach. The patient has a compression device in place. The patient complains of numbness and pain in the right hand. The cardiac-vascular nurse notes a diminished pulse, with a cool and cyanotic hand. The nurse:
calls the physician.
performs an Allen’s test.
reduces the pressure on the puncture site.
uses the Doppler to assess for pulse signals.
A patient with negative troponins and stress test results reports recurring chest pain that is similar to the patient’s pain on admission. According to the American Nurses Association’s cardiovascular nursing scope and standards of practice, the cardiac-vascular nurse’s next action is to:
activate the cardiac catheterization team.
administer analgesics.
obtain a 12-lead electrocardiogram.
promote relaxation and monitor the response.
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