To maintain the airway and promote respiratory function, the best position for the nurse to place the unconscious patient in the Post Anesthesia Care Unit (PACU) is:
A. Supine
B. Lateral
C. Trendelenberg
D. Fowler's
The nurse teaches a patient recovering from a total hip replacement that it is important to avoid:
A. Putting a pillow between the legs while sleeping
B. Sitting with the legs crossed
C. Abduction exercises of the affected leg
D. Bearing weight exercises on the affected leg for 6 weeks
The patient did not sleep well last night and is anxious about having a bronchoscopy later this morning. The priority nursing intervention would be to:
A. Reassure and encourage expression of feelings
B. Administer the premedication a little earlier
C. Keep the patient occupied until the procedure
D. Explain the purpose of the bronchoscopy
An elderly patient is admitted to the hospital with swollen ankles. The best way to limit edema of the feet is for the nurse to:
A. Restrict fluids
B. Apply bandages
C. Elevate the legs
D. Do passive range of motion exercises (ROM)
A patient requires tracheal suctioning through the nose. Which of the following nursing action would be incorrect?
A. Lubricating the catheter with sterile water
B. Applying suction while withdrawing the catheter from the nose
C. Applying suction for a minimum of 30 seconds
D. Rotating the catheter while withdrawing it
A patient is admitted to a hospital with acute renal failure. The patient wakes up complaining of abdominal pain. On assessment, the nurse observes edema to the patient's ankles and distended neck veins. The patient is dyspneic with a blood pressure of 200/96 mmHg. The proper nursing diagnosis for this patient is:
A. Deficient fluid volume related to disease process
B. Excess fluid volume related to decreased glomerular filtration rate
C. Knowledge deficit related to proper medication regimen
D. Acute pain related to renal edema
The administration of which of the following types of parenteral fluids would result in a lowering of the osmotic pressure and cause the fluid to move into the cells?
A. Hypotonic
B. Isotonic
C. Hypertonic
D. Colloid
The patient is receiving piperacillin (Pipril) I.V. Which of the following should the nurse consider when administering the medication to the patient?
A. Assess for Stevens-Johnson Syndrome
B. Be alert for the possibility of hypersensitivity
C. Watch for signs of increasing severity of infection
D. Instruct patient to increase the intake of protein-rich foods
A nurse is making rounds taking vital signs. Which of the following vital signs is abnormal?
A. 11 year old male ?90 b.p.m, 22 resp/min. , 100/70 mm Hg
B. 13 year old female ?105 b.p.m., 22 resp/min., 105/60 mm Hg
C. 5 year old male- 102 b.p.m, 24 resp/min., 90/65 mm Hg
D. 6 year old female- 100 b.p.m., 26 resp/min., 90/70mm Hg
You are the nurse providing post-operative care for a 9 year old boy who is 6 hours post- tonsillectomy. He is sleeping, but on routine observation you notice that his pulse has increased, he seems to be restless and trying to swallow frequently. Your immediate action would be:
A. Apply an ice collar to reduce discomfort
B. Allow child to keep sleeping and record observations
C. Wake him and offer some ice chips to suck
D. Check inside his mouth for any signs of bleeding and notify the physician