Acute A NUR2203 Flashcards
The nurse is caring for patient three days post myocardial infarction and reviesing the vital signs, blood results, and physical assessment. Which information is most important for the nurse to report to the cardiac team?
Select one:
a.
Hyperglycaemia
b.
Peripheral oedema and crackles in lungs
c.
PR-interval on ECG
d.
Q waves on ECG
Peripheral oedema and crackles in lungs
In the post anaesthetic care unit (PACU) a patients vital signs are blood pressure 116/72, pulse 74, respirations 12, and oxygen saturations 90%. The patient is sleepy but easily rousable. Which action should the nurse take first?
Select one:
a.
Increase the rate of post-operative intravenous fluids
b.
Encourage the patient to take deep breaths
c.
Encourage the patient to press the patient controlled analgesia (PCA)
d.
Prepare the patient for transfer back to the surgical ward
Encourage the patient to take deep breaths
You are caring for a patient with a suspected myocardial infarction (MI). Which of the following nursing interventions would you prioritise first in delivering care to this patient?
Select one:
a.
Infuse intravenous fluids at a rate of 150 mL per hour
b.
Begin thrombolytic therapy
c.
Place the patient on continuous cardiac monitoring
d.
Administer oxygen at a rate of 6 L per minute by nasal cannula
Place the patient on continuous cardiac monitoring
Heparin is ordered for a patient with a nonST-segment-elevation myocardial infarction (NSTEMI). What is the purpose of the heparin?
Select one:
a.
Heparin dissolves clots that are blocking blood flow in the coronary arteries
b.
Heparin enhances platelet aggregation
c.
Heparin decreases coronary artery plaque size
d.
Heparin prevents the development of new clots in the coronary arteries
d.
Heparin prevents the development of new clots in the coronary arteries
What laboratory finding is the primary diagnostic indicator for pancreatitis?
Select one:
a.
Elevates aspartate aminotransferase (AST)
b.
Elevated blood urea nitrogen (BUN)
c.
Elevated serum lipase
d.
Elevated serum potassium (K+)
Elevated serum lipase
The nurse assesses a patient who had abdominal surgery 2 days ago. Which information about the patient is most important to communicate to the surgical team?
Select one:
a.
The patient’s temperature is 37.7C
b.
The right calf is swollen, warm, and painful
c.
The patient complains of abdominal pain at level 6 (0 to 10 scale) when mobilising
d.
The 24-hour oral intake is 600 mL greater than the total output
The right calf is swollen, warm, and painful
Which statement by a patient scheduled for surgery is most important to report to the treating surgical team?
Select one:
a.
I get nausea and vomiting after after having anaesthetic
b.
I get knee pain whenever I walk or jog
c.
I have a strong family of breast cancer
d.
I had a heart attack last year
I had a heart attack last year
A 78 year old patient with a fractured left femur has Buck’s (skeletal) traction in place while waiting for surgery. To assess for pressure areas on the patients back and sacral area the nurse should:
Select one:
a.
Loosen the traction and help the patient turn onto the unaffected side
b.
Turn the patient partially to each side with the assistance of another nurse
c.
Have the patient lift their buttocks by bending the right leg
d.
Place a pillow between the patients legs and turn gently side to side
Have the patient lift their buttocks by bending the right leg
The nurse will suspect that the patient with stable angina is experiencing a side effect of the prescribed beta-adrenergic blocking agent, metoprolol, if the:
Select one:
a.
Blood pressure is 90/54 mm Hg
b.
Patient complains about feeling anxious
c.
Patient is restless and agitated
d.
Cardiac monitor shows a heart rate of 68 beats per minute
Blood pressure is 90/54 mm Hg
A 32 -year -old patient who has had an open reduction and internal fixation (ORIF) of the left lower leg continues to complain of severe pain in the leg after 15 minutes after receiving the prescribed intravenous morphine. Pulses are faintly palpable and the foot is cool. Which action should the nurse take next?
Select one:
a.
Notify the treating orthopaedic team
b.
Assess the incision for redness
c.
Reposition the left leg on pillows
d.
Check the patients blood pressure
Notify the treating orthopaedic team
When developing a teaching plan for a 61-year-old man with the following risk factors for coronary artery disease (CAD), the nurse should focus on the:
Select one:
a.
High blood pressure and cholesterol
b.
Increased risk associated with patient’s gender
c.
Increased risk of cardiovascular disease as people age
d.
Family history of cardiac disease
High blood pressure and cholesterol
A male patient with cholelithiasis has a gallstone lodged in the common bile duct and an elevated serum bilirubin. When assessing this patient, the nurse expects to note:
Select one:
a.
Yellow skin and sclera
b.
Black, tarry stools
c.
Light amber urine
d.
Perioral pallor
Yellow skin and sclera
Which nursing intervention will the nurse take in order to evaluate the effectiveness of Bucks (skeletal) traction for a 62-year-old patient who has a right fractured neck of femur?
Select one:
a.
Ask about the level of hip pain
b.
Assess for hip contractures
c.
Monitor for hip dislocation
d.
Check peripheral pulses
Ask about the level of hip pain
A patient is transferred from the post anaesthetic care unit (PACU) back to the surgical ward. Which action by the nurse on the ward should be performed first?
Select one:
a.
Assess the patients pain
b.
Read the postoperative orders
c.
Orientate the patient to the ward
d.
Take the patients vital signs
Take the patients vital signs
Which action most effectively demonstrates that a new staff member understands the role of the scrub nurse?
Select one:
a.
Remains gloved while performing activities in the sterile field
b.
Labels all pathology specimens to send to the lab
c.
Assists in preparing the operating room for the patient
d.
Administers intra-operative anaesthetics ordered by the anaesthetist
Remains gloved while performing activities in the sterile field
