• A nurse is assessing a patient in postoperative recovery. The patient
complains of the followingsymptoms. Which of the following is abnormal and
should be reported immediately?
• Emesis that is red
• Complaint of feeling cold
• Nausea
• Complaint of pain
• A patient's neurological status deteriorates over hours, and a craniotomy is
performed to evacuate a hematoma. Which nursing intervention is indicated to help
decrease the threat ofincreased intracranial pressure?
• Elevate the head of the bed 30 degrees
• Cluster nursing interventions to provide uninterrupted periods of rest
• Teach the patient to cough and deep breathe to prevent the necessity for
suctioning
• Teach the patient to hold his breath and bear down while repositioning in bed.
• A patient presents to the emergency room with complaints of bilateral lower
extremity loss of sensation that started in the feet but has now progressed to the
knees and hips. The nurse interprets these symptoms to indicate an immediate
workup for which of the following diseases?
• Myasthenia gravis
,• Cerebrovascular accident
• The charge nurse is obtaining the patient’s signature on a surgical consent
form. The patient states, I didn’t really understand what my surgeon explained, but
I trust him completely, “whichresponse by the charge nurse is correct?
• I need to contact your surgeon so your questions can be answered
• I can answer any questions that you might have regarding your surgery.
• As long as you are comfortable, then you may sign the consent form.
• Maybe you should call your surgeon to be sure it is okay to sign the consent.
• A patient has a head injury and is presenting with signs and symptoms of
increased intracranialpressure. Which nursing intervention would be helpful in
reducing this pressure?
• Place the neck in a neutral position to promote venous drainage
• Suction hourly to stimulate the cough reflex
• Add extra blankets to keep the patient warm.
• Turn the patient frequently to prevent skin impairment
• A patient has recently suffered a stroke with left-sided weakness. The nurse
assesses for dysphagia, especially with thin liquids. Which nursing intervention is
most helpful in assistingthis patient to swallow safely?
• The patient should avoid all liquids.
• Instructing to tuck the chin when swallowing
• Give sips of water with each bite
• Turn head to the left.
• A patient has a comminuted fracture of T6-T7, resulting in paraplegia. The
nurse educates thepatient on preventing autonomic dysreflexia. Which of the
following is the priority intervention in this medical emergency?
, • Scheduled bladder and bowel training
• Choosing foods to prevent nausea
• Avoiding food allergies
• Preventing electrolyte imbalances
• The nurse develops a care plan for a patient recovering from surgery. What
nursinginterventions will the nurse include to minimize the effects of venous
stasis?
• Pillows under the knee in a position of comfort
• Sitting with feet flat on the floor
• Early ambulation
• Gentle leg massage
• The patient has an order for 0.45% sodium chloride 1 liter to infuse over 15
hours.At what ratein mL/hr would the nurse set the infusion pump? (Round to the
nearest whole number, do not use a trailing zero.) 67mL/hr
• A patient with multiple sclerosis (MS) is receiving baclofen. The nurse
determines that thedrug is effective when it causes which action?
• Induces sleep
• Stimulates the patient’s appetite
• Relieves muscular spasticity
• Reduces the urine bacterial count
• Sudden chest pain combined with dyspnea, cyanosis, and tachycardia are
symptomsassociated with which of the following complications of surgery?
• Hypovolemic shock
• Dehiscence
• Atelectasis
• Pulmonary embolus
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