Exam 19: Reflecting on Your Transition

A patient weighed 200 lb 6 months ago. He now weighs 160 lb. He has not been trying to lose weight. Based on the defining characteristics of nutrition, less than body requirements, the nurse's best response would be:

A graduate RN on the telemetry unit is on the way to the nurse's station to chart and suddenly hears from a patient's room, "Help! Nurse!" This is not the nurse's assigned patient. Others also hear this cry for help and quickly run in with the crash cart while the graduate RN looks on. In planning care for this patient, the beginning RN must realize the importance of identifying and (select all that apply):

It is 0800 and the nurse just received report. Which patient situation demands the nurse's immediate attention? The patient:

A 43-year-old patient is scheduled for a laparoscopic cholecystectomy. A nurse has a plan to teach the preoperative patient how to splint his abdomen with a pillow and cough and deep breathe, so the patient can avoid fluid accumulation in the lungs postoperatively. When the nurse enters the room, it becomes evident that the patient is blind. What critical thinking skill would you recommend a scenario like this requires?

The nurse enters the room of a sleeping patient to administer the 0200 dose of antibiotic that has been ordered every 6 hours. Which action would most effectively maintain a therapeutic blood level of this medication?

As a graduate nurse, which statement strongly suggests future success in the current nursing practice environment?

The nurse asks a hospitalized patient to sign the operative consent. The patient tells the nurse, "I do not really understand what is involved in the surgery." The nurse should:

The nurse is to take a meal tray to a patient the nurse knows nothing about. Before leaving the tray with the patient, which is the most critical safety factor the nurse should determine?

A patient who had recent abdominal surgery is becoming increasingly agitated and confused. He has pulled out his IV and his nasogastric tube. His skin is pale and clammy, heart rate 120 bpm, BP 130/60. The physician has been called. What nursing action is most important at this time?

What could a nurse say who believed that a nursing student has a duty to understand pertinent clinical information to make sound clinical judgments?

A toddler is brought to the well-child community clinic by her grandmother. The health history reveals recurrent nausea, vomiting, and diarrhea. Her physical exam reveals a negligible gain in height and weight, lethargy, and a delay in achieving milestones. As a result of the child's delays, multiple disciplines would likely be involved in caring for the child. Which of the following represents the most effective role the nurse would play in caring for the child?

The patient reports intense pain and rates it 10/10. He is talking and laughing on the telephone but interrupts his conversion to request pain medication. The nurse would make a decision about the administration of medication based on which indicator of pain?

Which of the following is an example of an anxiety-causing situation below that is potentially caused by a role transition from LPN/LVN to RN?

A nurse is assigned to care for an elderly, confused patient. The patient's son is sitting at the bedside and is watching a loud television program. The nurse needs to complete the respiratory and cardiac assessment and vital signs. What would be the best approach to this situation?

A nurse notices that the respiratory therapist assigned to his unit frequently forgets to raise the bed rails after completing treatments. The nurse's best action is to:

If a patient refuses a medication or is undergoing a diagnostic test that results in a missed dose of medication, the nurse will document the omission on the medication administration record and:

Which comments by the graduate RN are examples of interventions that will lead to a successful transition into professional nursing? (Select all that apply.)

Which patient is at greatest risk for injury and requires the nurse's immediate attention? The patient who had a(n):