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Exam 3 : NUR20 9 / NUR 20 9 (New 2024/
2025 Update) Medical Surgical Nursing II
| Questions and Verified Answers| 100%
Correct| A Grade – Fortis
QUESTION
A nurse obtains a health history from a patient who has a 35-pack year smoking history. The patient reports hoarseness and tightness in the throat and difficulty swallowing. Which question is important for the nurse to ask?- Answer: "how much alcohol do you drink in an average week"
QUESTION
Which action should the nurse take first when a patient develops epistaxis- Answer: apply squeezing pressure to the nostrils for 10 minutes
QUESTION
patient in ent clinic, what is priority assessment Answer: sore throat, muffled voice
QUESTION
patient has the flu, what is most important to communicate with the hcp?- Answer: Crackles in lungs
QUESTION
patient has acute sinusitis, what interventions to include Answer: decongestants to relive swelling taking a hot shower will increase drainage and decrease pain saline spray can be made at home sit in an upright position
QUESTION
The nurse discusses management of upper respiratory infections (URIs) with a patient who has acute sinusitis, Which statement needs additional teaching? Answer: "I can use nasal decongestant spray until the congestion is gone"
QUESTION
The nurse plans to teach a patient how to manage allergic rhinitis. Which information should the nurse include in the teaching plan? Answer: Identifying and avoiding environmental triggers are the best way to prevent symptoms
QUESTION
A 26-year old is being evaluated for vomiting and abdominal pain. Which question from the nurse will be most useful in determining the cause of patient's symptoms Answer: "can you tell me more about the pain?"
QUESTION
A patient preparing to undergo a colon resection for cancer of the colon asks about the elevated carcinoembryonic antigen (CEA) test result. The nurse explains that the test is used to Answer: monitor the tumor status after surgery.
QUESTION
patient with nissen fundoplication for hernia four hours ago findings con- cern Answer: absent breath sounds
QUESTION
The patient with pulmonary embolism symptoms Answer: Elevate head of bed in semi-fowler's position
QUESTION
Obese patient has right lower lobe pneumonia., which position? Answer: Left side lateral
QUESTION
The nurse assesses vital signs for a patient admitted 2 days ago with gram-negative sepsis; temp 101.2, BP 90/56mmHg, pulse 92, and respirations
- Which action should the nurse take next? Answer: Obtain oxygen saturation using pulse oximetry
QUESTION
While caring for a patient who has been admitted with a pulmonary em- bolism, the nurse notes a change in the patient's oxygen saturation from 94% to 88%. Which action should the nurse take? Answer: Increase prescribed o2 rate
QUESTION
Patient has respiratory failure with 6breath/min, what do we do? Answer: Endotra- cheal intubation and positive pressure ventilation
QUESTION
which finding by the nurse most specifically indicates that a patient is not able to effectively clear the airway? Answer: weak cough
The nurse is assessing a patient with abdominal pain. How will the nurse document ecchymosis around the area of the umbilicus? Answer: Positive Cullen's sign?
QUESTION
Which item should the nurse offer to the patient who is to restart oral intake after being NPO due to nausea and vomiting? Answer: Dish of lemon gelatin
QUESTION
A patient who has GERD is experiencing increasing discomfort. Which patient statement to the nurse indicates the additional teaching about GERD is needed? Answer: "I eat small meals and have a snack at bedtime"
QUESTION
A 58 year old woman who was recently diagnosed with esophageal cancer tells the nurse, "I do not feel ready to die yet" Which response from the nurse is most appropriate? Answer: "Having this new diagnosis must be very hard for you"
QUESTION
After bariatric surgery, a patient who is being discharged tells the nurse, "I prefer to be independent. I am not interested in any support groups." Which response by the nurse is best? Answer: "Tell me what types of resources you think you might use after this surgery."
QUESTION
A 40-year old obese woman woman reports that she wants to lose weight. Which question should the nurse ask first? Answer: "what factors led to your obesity?"
QUESTION
After an unimmunized person is exposed to hepatitis B through a nee- dle-stick injury which actions will the nurse plan to take? SATA Answer: Administer hep b vaccine test for antibodies of hep b give hep b immune globulin
QUESTION
Which finding indicates to the nurse that the administered nifedipine (procardia) was effective for a patient who has idiopathic pulmonary arterial hypertension (IPAH) Answer: Patient reports a decrease in exertional dyspnea
QUESTION
The nurse is caring for a patient with idiopathic pulmonary hypertension (IPAH). Which assessment information requires the most immediate action by the nurse
A patient appears somnolent
QUESTION
The nurse has just auscultated coarse crackles bilaterally on a patient and was unsuccessful in coughing up secretions, what action should the nurse take? Answer: Put on sterile gloves and use a sterile catheter to suction
QUESTION
The nurse cares for a client with acute respiratory distress syndrome (ARDS) Which finding indicates that the client is experiencing a complication from ARDS Answer: Urine output of 20ml dark amber urine in the past 8 hours
QUESTION
During change of shift report on a medical unit, the nurse learns that a client who was admitted with aspiration pneumonia has become increasingly agitated. Which action should the nurse take first? Answer: Use pulse oximetry to check the oxygen saturation
QUESTION
Which nursing interventions included in the care of a mechanically vented patient with acute respiratory failure can the rn delegate to the lpn/lvn working in the ICU Answer:
insert an indwelling catheter
QUESTION
The healthcare provider orders narcan 0.3 mg iv stat for respiratory de- pression. Narcan is provided as 0.4mg/ml. The nurse will administer ml. Round to the nearest tenth Answer:
QUESTION
The healthcare provider temazepam 30 mg p.o. at bedtime prn. Available is 15mg tablets. How many to give Answer: 2
QUESTION
The physician orders a continuous heparin infusion at 1300 units/hour. The heparin is provided as 25,000 units 500ml D5W. The nurse will set the pump for the rate of ml/hr Answer: 26
QUESTION
The physician orders morphine 5 mg/hr continuous IV infusion. The mor- phine is supplied as 125mg in 250 ml D5W. The nurse will set the infusion at ml/hr Answer: 10
QUESTION
A patient admitted for bariatric surgery, which can the nurse delegate to unlicensed assistive personnel Answer: Assist with IV insertion by holding adipose tissue out of the way
