MED SURG III - FINAL EXAM #1
Question 1
The nurse is assisting in caring for a client with multiple organ dysfunction syndrome (MODS). The nurse understands that which intervention is most important in the care of clients with this syndrome?
Treatment of the infection
Maintaining tissue oxygenation
Prevention and early identification
Prevention and early identification
Question 2
Which of the following are risk factors for septic shock? Select all that apply
Malnutrition, Immunosuppression
Alcoholism, Hepatitis
Liver Disease, diabetes
Kidney Disease, Diabetes
Infections
Question 3
Which of the following are risk factors for cardiogenic shock? Select all that apply
Tension Pneumothorax
Multiple Surgeries
Valvular Dysfunction, Ventricular Septal Rupture
MI, Cardiomyopathies
Kidney Disease
Question 4
Which of the following are risk factors for hypovolemic shock? Select all that apply
Diuretics, Nasogastric Suction, Nausea/Vomiting
Tension Pneumothorax
GI Ulcers, Hemorrhaging, Hemophilia
Liver Disease
Pulmonary Hypertension
Question 5
Which of the following are true statements regarding MODS? Select all that apply
Occurs in acutely ill patients, most commonly in sepsis
The respiratory system is usually the first to fail
The cardiovascular system is usually the first to fail
Can lead to formation of microemboli, increased bleeding
Symptoms include dyspnea, hypotension, hyperglycemia, altered mental status
Question 6
A patient presents in the ED with the following:
- Pulmonary Congestion
- Pain
- Fatigue
- Tachycardia
- Hypotension
Which type of shock does the nurse suspect the patient is suffering from?
Septic
Neurogenic
Anaphylactic
Cardiogenic
Question 7
What is the PRIORITY treatment of hypovolemic shock?
Crystalloid Therapy (0.9% NS, LR)
Colloid Therapy (0.9% NS, LR)
Vasopressors
Oxygen Therapy
Question 8
What is the PRIORITY treatment of cardiogenic shock
Oxygen & Pharmacological Therapy
Fluid Therapy
Oxygenation
Circulation
Question 9
A patient presents in the ED with the following:
- Hypotension
- Tachycardia
- Temperature of 102.3
- WBC count of 13,000
Which type of shock does the nurse suspect the patient is suffering from?
Neurogenic
Septic
Hypovolemic
Cardiogenic
Question 10
Which of the following medications are often used to treat cardiogenic shock? Select all that apply
Dobutamine
Nitroglycerin
Dopamine
ACE Inhibitors
Question 11
Which of the following are true about Antivenin Administration? Select all that apply
Most effective if given within 4 hours, but not no more than 12 hours
Before administering and every 15 minutes after administration the circumference of the affected part is measured
Total dose is given within 4-6 hours.
There is no limit to the number of vials that can be given
Total dose should be given within 4-6 hours
Most effective if given within 4 hours, but no more than 6 hours
Question 12
A clients family member asks the nurse why DIC occurs. Which statement by the nurse correctly explains the cause?
It is caused by abnormal activation of the clotting pathway, causing excessive amounts of tiny clots to from inside organs
It is a complication of an autoimmune disease, that attacks the body's own cells
It occurs when the immune system attacks platelets and causes massive bleeding
It is caused when hemolytic processes destroy erythrocytes
Question 13
Cerebral Edema peaks at which time point after intracranial surgery?
48 hours
24 hours
12 hours
72 hours
Question 14
You’re precepting a new nurse. You ask the new nurse to list the purpose of why a patient with cardiogenic shock may benefit from an intra-aortic balloon pump. What responses below indicate the new nurse understands the purpose of an intra-aortic balloon pump? Select all that apply:
“This device increases the cardiac afterload, which will increase cardiac output.”
“This device will help increase blood flow to the coronary arteries.”
“The balloon pump will help remove extra fluid from the heart and lungs.”
“The balloon pump will help increase cardiac output.”
Question 15
The nurse is planning to provide education about prevention in the community YMCA due to the increase in numbers of SCIs. What predominant risk factors does the nurse determine should be addressed? (Select all that apply.)
Young age
Male gender
Older adult
Substance abuse
Low-income community
Question 16
Which medication is a calcium channel blocker typically used to treat atrial fibrillation & atrial flutter?
Atropine
Adenosine
Digoxin
Verapamil
Question 17
The nurse is assigned to care for clients with SCI on a rehabilitation unit. Which signs does the nurse recognize as clinical manifestations of autonomic dysreflexia? Select all that apply.
Nasal congestion
Diaphoresis
Fever
Tachycardia
Hypertension
Question 18
A client is treated for increased ICP. It is important for the client to avoid hypothermia because
Hypothermia can cause death
Shivering and hypothermia can increase ICP
Hypothermia is indicative of severe meningitis
Hypothermia is indicative of malaria
Question 19
The nurse is caring for a client with a ventriculostomy. Which assessment finding demonstrates effectiveness of the ventriculostomy?
MAP is equal to ICP
Pupils are fixed and dilated
Increased ICP is 12 mm Hg
CPP is 21 mm Hg
Question 20
The nurse is caring for a client with increased intracranial pressure as a result of a head injury. The nurse would note which trend in vital signs if the intracranial pressure is rising?
Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure
Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure
Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure
Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure
Question 21
The nurse is planning the care of a patient with a TBI in the neurosurgical ICU. In developing the plan of care, what interventions should be a priority? (Select all that apply.)
Making nursing assessments
Setting priorities for nursing interventions
Anticipating needs and complications
Initiating rehabilitation
Ensuring that the patient regains full brain function
Question 22
Semi-Fowler position is maintained for at least which timeframe following completion of an intermittent tube feeding?
2 hours
1 hour
30 minutes
90 minutes
Question 23
The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated?
Ensuring that humidified oxygen is always introduced through the tube
Routinely deflating the cuff
Checking the cuff pressure every 6 to 8 hours
Deflating the cuff before removing the tube
Question 24
A patient with late-stage cirrhosis develops portal hypertension. Which of the following options below are complications that can develop from this condition? Select all that apply:
Increase albumin levels
Ascites
Splenomegaly
Fluid volume deficient
Esophageal varices
Question 25
The client with a continent urinary diversion is being discharged. Which discharge instructions should the nurse include in the teaching?
Have the client demonstrate catheterizing the stoma.
Instruct the client on how to pouch the stoma.
Explain the use of a bedside drainage bag at night.
Tell the client to call the HCP if the temperature is 99°F or less.
Question 26
The nurse is caring for a client who is mechanically ventilated and is monitoring for complications of mechanical ventilation. Which assessment finding, if noted by the nurse, indicates the need for follow-up?
Muscle weakness in the arms and legs
A temperature of 98.6° F (37° C), decreased from 99.0° F (37.2° C)
A blood pressure of 90/60 mm Hg, decreased from 112/78 mm Hg
A heart rate of 80 beats/minute, decreased from 85 beats/minute
Question 27
A patient with severe chronic liver dysfunction comes to the clinic with bleeding of the gums and blood in the stool. What vitamin deficiency does the nurse suspect the patient may be experiencing?
Riboflavin deficiency
Folic acid deficiency
Vitamin A deficiency
Vitamin K deficiency
Question 28
When caring for a client with advanced cirrhosis and hepatic encephalopathy, which assessment finding should the nurse report immediately?
Anorexia for more than 3 days
Constipation for more than 2 days
Change in the client's handwriting and/or cognitive performance
Weight loss of 2 pounds in 3 days
Question 29
A client with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade is used temporarily to control hemorrhage and stabilize the client. In planning care, the nurse gives the highest priority to which goal?
Relieving the client's anxiety
Maintaining the airway
Maintaining fluid volume
Controlling bleeding
Question 30
Which medication is used to decrease portal pressure, halting bleeding of esophageal varices?
Vasopressin
Spironolactone
Cimetidine
Nitroglycerin
Question 31
What intervention does the nurse anticipate providing for the patient with ascites that will help correct the decrease in effective arterial blood volume that leads to sodium retention?
Administration of diuretic therapy
Assisting with a therapeutic paracentesis
Infusing platelets
Infusing albumin
Question 32
The nurse is educating a patient who has been treated for hepatic encephalopathy about dietary restrictions to prevent ammonia accumulation. What should the nurse include in the teaching?
Decrease the amount of fats in the diet
Increase the amount of potassium in the diet
Decrease the amount of protein in the diet
Increase the amount of magnesium in the diet
Question 33
While providing mouth care to a patient with late-stage cirrhosis, you note a pungent, sweet, musty smell to the breath. This is known as:
Metallic Hepatico
Fetor Hepaticus
Hepaticoacidosis
Asterixis
Question 34
The nursing management of a patient with an artificial airway includes
maintaining the ET tube cuff pressure at 30 cm H20
routine suctioning of the tube at least every 2 hours
observing for cardiac dysrhythmias during suctioning
preventing tube dislodgment by limiting mouth care to lubrication of the lips
Question 35
A patient is recovering from a pneumothorax and has a chest tube present. Which of the following is an appropriate finding when assessing the chest tube drainage system?
Intermittent bubbling may be noted in the water seal chamber.
200 cc of drainage per hour is expected during recovery of a pneumothorax.
The chest tube is positioned at the patient's chest level to facilitate drainage.
All of these options are appropriate findings.
Question 36
While helping a patient with a chest tube reposition in the bed, the chest tube becomes dislodged. What is your immediate nursing intervention?
Stay with the patient and monitor their vital signs while another nurse notifies the physician.
Place a sterile dressing over the site and tape it on three sides and notify the physician.
Attempt to re-insert the tube.
Keep the site open to air and notify the physician.
Question 37
A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect?
Serous
Bloody
Serosanguineous
Bloody, with frequent small clots
Question 38
A patient with bleeding esophageal varices has had pharmacologic therapy with octreotide and endoscopic therapy with esophageal varices banding, but the patient has continued to have bleeding. What procedure that will lower portal pressure does the nurse prepare the patient for?
Transjugular intrahepatic portosystemic shunting (TIPS)
Administration of vasopressin
Sclerotherapy
Balloon tamponade
Question 39
The nurse is caring for a client who is mechanically ventilated, and the high-pressure ventilator alarm is sounding. The nurse understands that which complications may cause this alarm? Select all that apply.
Water or a kink in the tubing
Biting on the endotracheal tube
Increased secretions in the airway
Disconnection or leak in the system
The client ceasing spontaneous breathing
Question 40
A patient with late-stage cirrhosis develops portal hypertension. Which of the following options below are complications that can develop from this condition? Select all that apply:
Increase albumin levels
Ascites
Splenomegaly
Fluid volume deficient
Esophageal varices
Question 41
While caring for a patient with Pneumocystis pneumonia, the nurse assesses flat, purplish lesions on the back and trunk. What does the nurse suspect these lesions indicate?
Molluscum contagiosum
Tuberculosis of the skin
Kaposi sarcoma
Seborrheic dermatitis
Question 42
A patient has experienced full-thickness burns to the face and neck. As the nurse it is priority to:
Assess the airway
Prevent hypothermia
Prevent Infection
Assess BP
Question 43
Which complication is common for victims of electrical burns?
Hypovolemic Shock
Cardiac Dysrhythmias
Inhalation Injury
Infection
Question 44
After a subtotal gastrectomy, care of the client’s nasogastric tube and drainage system should include which of the following nursing interventions?
Reposition the tube if it is not draining well
Monitor the client for N/V, and abdominal distention
Irrigate the tube with 30 mL of sterile water
Turn the machine to high suction if the drainage is sluggish on low suction
Question 45
The nurse is caring for a patient who sustained a full-thickness burn to the arm after being scalded with boiling water. How did the nurse determine that the patient’s burns are full-thickness burns?
Classification by the appearance of blisters
Identification by the destruction of the dermis and epidermis
Not associated with edema formation
Usually very painful because of exposed nerve endings