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Question 1 of 10
1. Question
An older adult male patient is admitted to the medical/surgical unit with a history of myasthenia gravis. Which of the tests that follow should the nurse expect to see ordered? Choose all that apply
Correct
Know about Diagnostic tests; Potential for complications of diagnostic tests/treatments/procedures.
Incorrect
Know about Diagnostic tests; Potential for complications of diagnostic tests/treatments/procedures.
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Question 2 of 10
2. Question
The presence of hepatitis B surface antigens and hepatitis B antibodies reveals the laboratory values of an adult male patient. Which of the following laboratory outcomes should the nurse expect to see as well? Select all that is applicable.
Correct
Know about Laboratory values.
-Hepatitis B surface antigen (HBsAg): A protein on the surface of the hepatitis B virus that can be detected at high serum levels during acute or chronic infection of the hepatitis B virus. The existence of HBsAg suggests the individual is infectious. Normally, the body produces
As part of the normal immune response to infection, antibodies to HBsAg. HBsAg is the antigen used to make the vaccine for hepatitis B.-Hepatitis B surface antibody (anti-HBs): The presence of anti-HBs is generally understood to indicate recovery and immunity from infection with the hepatitis B virus. Anti-HBs also develop in an individual, Who has been vaccinated successfully against hepatitis B.
Incorrect
Know about Laboratory values.
-Hepatitis B surface antigen (HBsAg): A protein on the surface of the hepatitis B virus that can be detected at high serum levels during acute or chronic infection of the hepatitis B virus. The existence of HBsAg suggests the individual is infectious. Normally, the body produces
As part of the normal immune response to infection, antibodies to HBsAg. HBsAg is the antigen used to make the vaccine for hepatitis B.-Hepatitis B surface antibody (anti-HBs): The presence of anti-HBs is generally understood to indicate recovery and immunity from infection with the hepatitis B virus. Anti-HBs also develop in an individual, Who has been vaccinated successfully against hepatitis B.
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Question 3 of 10
3. Question
A patient who needs mechanical ventilation is cared for by an IC nurse. Which of the following measures should be taken by the nurse to help prevent ventilator-associated pneumonia (VAP)? Select all that is applicable.
Correct
The following practices that are evidence-based nurse-led are recommended to reduce the risk of VAP: reduce exposure to mechanical ventilation, provide excellent oral care and subglottic suction, promote early mobility, and advocate for adequate staffing of nurses and a healthy work environment.
Incorrect
The following practices that are evidence-based nurse-led are recommended to reduce the risk of VAP: reduce exposure to mechanical ventilation, provide excellent oral care and subglottic suction, promote early mobility, and advocate for adequate staffing of nurses and a healthy work environment.
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Question 4 of 10
4. Question
The nurse takes care of a patient undergoing blood transfusion therapy. Which clinical manifestations should alert a hemolytictic to the nurse? Reaction to the transfusion? Select all that is applicable.
Correct
Blood type or Rh hemolytic transfusion reactions are caused by Incompatibility. When blood containing antigens distinct from the patient’s own antigens is infused, antigen-antibody complexes are formed in the blood of the patient. These complexes destroy the transfused cells in the patient’s blood vessel walls and organs and start inflammatory responses. The reaction may involve fever and chills or, with disseminated intravascular coagulation and circulatory collapse, may be life-threatening. Headache, tachycardia, apprehension, a sense of impending doom, chest pain, low-back pain, tachypnea, hypotension, and hemoglobinuria are other manifestations. The onset may be immediate or may not occur until subsequent units have been transfused. Distended neck veins are characteristics of circulatory overload.
Incorrect
Blood type or Rh hemolytic transfusion reactions are caused by Incompatibility. When blood containing antigens distinct from the patient’s own antigens is infused, antigen-antibody complexes are formed in the blood of the patient. These complexes destroy the transfused cells in the patient’s blood vessel walls and organs and start inflammatory responses. The reaction may involve fever and chills or, with disseminated intravascular coagulation and circulatory collapse, may be life-threatening. Headache, tachycardia, apprehension, a sense of impending doom, chest pain, low-back pain, tachypnea, hypotension, and hemoglobinuria are other manifestations. The onset may be immediate or may not occur until subsequent units have been transfused. Distended neck veins are characteristics of circulatory overload.
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Question 5 of 10
5. Question
The nurse assesses a pregnant patient with a diagnosis of abruptio placentae. Which manifestations should the nurse expect to notice of this condition?
Correct
The separation of a normally implanted placenta before the fetus is born is placental abruption, also referred to as abruptio placentae. It occurs when the maternal side of the placenta has bleeding and hematoma formation.
Incorrect
The separation of a normally implanted placenta before the fetus is born is placental abruption, also referred to as abruptio placentae. It occurs when the maternal side of the placenta has bleeding and hematoma formation.
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Question 6 of 10
6. Question
When a patient is prescribed tranylcypromine, what food items should the nurse instruct the client to avoid? Select all that is applicable.
Correct
The monoamine oxidase inhibitor (MAOI) used to treat depression is tranylcypromine. Due to the risk of a hypertensive crisis associated with the use of this medication, foods containing tyramine must be avoided.
Incorrect
The monoamine oxidase inhibitor (MAOI) used to treat depression is tranylcypromine. Due to the risk of a hypertensive crisis associated with the use of this medication, foods containing tyramine must be avoided.
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Question 7 of 10
7. Question
For analysis, the nurse sends an arterial blood gas (ABG) specimen to the laboratory. What should the nurse include in the laboratory requisition information? Select all that is applicable.
Correct
Usually, an ABG requirement includes information about the date and time the specimen was drawn, the temperature of the patient, whether the specimen was drawn in room air or using additional oxygen, and the settings of the ventilator if the patient is on a mechanical ventilator.
Incorrect
Usually, an ABG requirement includes information about the date and time the specimen was drawn, the temperature of the patient, whether the specimen was drawn in room air or using additional oxygen, and the settings of the ventilator if the patient is on a mechanical ventilator.
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Question 8 of 10
8. Question
The nurse provides a preoperative patient who will be receiving relaxation therapy with information. With regard to this type of therapy, what effects should the nurse teach the patient to expect? Select all that is applicable.
Correct
The state of generalized decreased physiological, and/or behavioral, cognitive, arousal is relaxation. Relaxation elongates the muscle fibers, decreases the brain’s neural impulses, and therefore decreases the brain and other systems’ activity.
Incorrect
The state of generalized decreased physiological, and/or behavioral, cognitive, arousal is relaxation. Relaxation elongates the muscle fibers, decreases the brain’s neural impulses, and therefore decreases the brain and other systems’ activity.
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Question 9 of 10
9. Question
A patient has developed atrial fibrillation resulting in a rate of 150 ventricular per minute beats. What effects of this cardiac event should the nurse evaluate the patient for? Select all that is applicable.
Correct
An uncontrolled atrial fibrillation patient with a ventricular rate of more than 100 beats per minute is at risk of low cardiac output caused by atrial kick loss. The patient should be assessed by the nurse for palpitations, chest pain, or pain, hypotension, pulse deficit, weakness, fatigue, dizziness, syncope, shortness of breath, and neck veins that are distended.
Incorrect
An uncontrolled atrial fibrillation patient with a ventricular rate of more than 100 beats per minute is at risk of low cardiac output caused by atrial kick loss. The patient should be assessed by the nurse for palpitations, chest pain, or pain, hypotension, pulse deficit, weakness, fatigue, dizziness, syncope, shortness of breath, and neck veins that are distended.
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Question 10 of 10
10. Question
After receiving a renal transplant, the home care nurse gives a follow-up visit to a patient. What evaluation data support the possible existence of acute rejection of graft? Select all that is applicable.
Correct
Acute rejection generally occurs within the first 3 months after transplantation, although it may occur after transplantation for up to 2 years. Fever, hypertension, malaise, and graft tenderness are shown by the patient. Treatment with corticosteroids, and possibly also with monoclonal antibodies and anti-lymphocytic agents, begins immediately. Symptoms associated with acute graft rejection are not present in any of the other options.
Incorrect
Acute rejection generally occurs within the first 3 months after transplantation, although it may occur after transplantation for up to 2 years. Fever, hypertension, malaise, and graft tenderness are shown by the patient. Treatment with corticosteroids, and possibly also with monoclonal antibodies and anti-lymphocytic agents, begins immediately. Symptoms associated with acute graft rejection are not present in any of the other options.