Foundations

When taking the patient’s blood pressure below, what is the most important thing to remember? Your 95-year-old patient is 6 feet tall and weighs 390 pounds. He presented to the emergency department from a nursing home with SOB, chest tightness and pain and a pulse ox of 85%. He was placed on 6 liters oxygen via nasal cannula that brought his pulse ox up to 100%. The patient’s past medical history includes a pack a day smoker for at least 60+years. He quit smoking 20 years ago. He has a history of renal failure. He has an AV fistula in his right upper arm. He tells you he also has hypertension and diabetes. Chest x-ray reveals a small patchy right basilar consolidation that may be due to aspiration.

Your 85 y/o patent's heart rate is 188. The implications for your patient are as follows

Ms. Jackson is admitted to the ED via ambulance with chest pain. On your initial assessment of the patient the VS are: Temp 99.2 F, Pulse 114, RR 24, BP 78/62. Sats 90% . You note significant jugular venous distention at 60 degrees. You would expect that: (select all that apply)

When assessing pedal pulses in a patient with Congestive Heart Failure (CHF) and an albumin level of 2.0 you would expect to find:

Your pt’s absolute neutrophil count (ANC) is less than 0.5. You would place your pt in:

Jack Sparrow's VS are: 101.6 120 18 80/60 98 % RA 8/10. Without more information, there are three probable causes for the heart rate. What are they?

Your patient has been diagnosed with TB and also MRSA in his wound. The personal protective equipment that the nurse should have to care for this patient is:

Your pt says he used to sleep flat, but now uses 3 pillows to help him sleep through the night. You focus your assessment on his:

You check your pt’s VS and lab values on admission and find his H and H is 6 and 18. His K is 3. 7. His albumin is 3.5. His VS are 97.8 88 14 130/52 sats 97% on 3l NC and pain is 1/10. You should:

A nurse is beginning to conduct a health history for a patient with respiratory problems. He notes that the patient is having respiratory distress. What would the nurse do next?

Your pt is a 65 y/o male who walked into the ER a few minutes ago. He is speaking a language other than English and does not seem to speak nor understand English. VS are 98.6 100 28 100/70 88 %. His eyes are open wide and he is sitting upright at 90 degree angle in bed. You listen quickly to the chest and hear wheezing across all lung fields. His AP to lateral is 1:2, no clubbing noted. You hear a slight diastolic murmur. You will continue to focus your immediate assessment and interventions on the pt's:

Our pt has been stable through the night. This morning the aide, whom you trust, stops you to say the pt. Has the following VS: 98.6 - 98 - 18 - 82/60 96 % on room air - Pain 2/10. The aide also says the lab called to tell you his potassium is 3.8, and glucose is 100. You go back to see the pt. You would: (Select all that apply)

Mrs. Stewart, 77 years old, was admitted after fainting in her home. The physician ordered orthostatic blood pressures. You would:

Select all that apply (1 to 4 answers ): Patent safety before leaving a room includes:

Your pt is on narcotic for pain. You take your pt's respiratory rate and count 9 per minute. This is reason to call for assistance stat.

S1 is closure of the mitral and tricuspid valves and indicates

Your pt. has C Diff. You know the bacteria:

Select all that apply: Crackles are:

Your nursing assistant has taken VS on Mr. Acid, Mr. Black, Mr. Cage, and Mrs. Dingbald. She hands you the list of VS as soon as you get out of report. Which pt. Would you go in to see first?

Your patient has a hemoglobin value of 5g/dl. His pulse ox is 96%. You know your patient:

Our pt has returned from the operating room 8 hours ago. You have activity orders to get her oob tonight. Her husband tells you she has back pain and asks you to raise the head of the bed. (hob) She also asks you to raise the hob because it will make her back feel better. You raise the head of the bed to relieve her pain and get her ready to get oob. She complains of feeling dizzy. Your very next intervention would be to:

Your patient is confused. Her VS are 98.6 100 20 120/80 92% on room air. Her labs are: Glucose-58 Na 132 K 3.4 creatinne 0.8 albumin 2.0 Which one of these values needs immediate attention?

A simple face mask must at minimum be set with a liter flow per minute of:

Your pt. Has a temperature of 104 F. His H and H is 14 and 40. He starts to complain of chest pain. This could be a result of:

A stenotic valve would produce:

Mr. Copper’s potassium is 6.5 mEq/l.

Mr. Hemmings has just returned to your floor after having some tests done in the x-ray department. He was in a motor vehicle accident and is just being admitted to your floor from the emergency room. It is 4:30 am. You are the nurse working nights. The 4 am labs return. They are the first set drawn on your pt. Mr. Hemmings’ H and H are 5 and 15 respectively. You:

The pt. Is complaining of dyspnea after returning to your unit following a laparoscopic appendectomy. What should the nurse do first?

You are surprised to detect an elevated temperature (1020 F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. The first thing you do is:

A nurse is providing postural drainage for a patient with cystic fibrosis. In which position should the nurse place the patient to drain the right lung?

Mr. Jake is admitted to your unit on your shift. His heart rate on admission was 70. Four hours later his HR is 63. You:

You are walking down the street in January. The temperature is minus 7. You see a child in his pajamas, huddled near a house with an open front door, but a closed storm door. An ambulance is going by. You flag them down as you run to the child. He is unconscious, not breathing and pulseless. The ambulance driver says he has 20 years experience and tells you not to do CPR because the child is dead. You:

Your pt's sats are 92 on 4 L nasal cannula. He needs to go to the bathroom (BR). The extension tubing does not reach. You:

You assess an apical-radial pulse on a patient. The pulse deficit is 16 beats/min. What does this indicate?

A pt. Has a HDL reading of 95 and an LDL value of 65. You:

The Center for Disease Control’s recommended sequence for removing soiled personal protective equipment is evidenced based and should never be changed based on the situation and the nurse’s judgment.

Your little brother is trying out for football in early August. It is now 3 pm. The temperature is 96 degrees outside. There is no shade on the field. You stop to pick him up on your way home and find him irritable, confused, and walking away. He tells you he was cut from the soccer team. He is flushed, but not sweating. You suspect:

Mrs. Davis was recently diagnosed with a cold, C Diff and the flu. (Not the swine H1N1 flu.) She is placed in droplet isolation and contact isolation. You teach your patient that from now on she can expect that hospital personnel will now be using PPE that consists of:

nurse caring for patients in a critical care unit knows that providing good oral hygiene is an essential part of nursing care. What are some of the benefits of providing this care? Select all that apply.

TIME 11:00 AM Mrs. Smith is admitted to the ED . The pt is a 88 year old female presenting to the ED with complaints of chest pain. The chest pain team is in the room with her.The following labs come up on the desk printer; the computer is down. Na 140 K 2.9 Cl 100 Bicarb 24 BUN 15 Creat 1.2 Glucose 120 You are in the middle of giving another stable pt. A bath when the aide comes and gives you the lab slip with the Mrs. Smith’s values recorded. You know the chest pain team does not have access to these results. Select your one best response. A B C or D

Your pt is a 74 y/o man with a hx of an MI 7 years ago, and asthma. He is in the ED. He was in relative good health until he slipped on ice and fractured his humorous. He smokes one pack per day. He says he has had a bad cold for 3 weeks. You hear Broncho Vesicular breath sounds in LLL . At 4 pm the pts VS are: 98.6 84 18 156/84 92 on RA Pain 0/10 At 6 pm his VS are: 98.9 88 26 160/88 88% on RA Pain 5/10 You hear BV breath sounds in LLL and a few wheezing anteriorly on left.

At 6:01 you should: (Select all that apply, possibly 1 answer through all)