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Med Surg 3 Exam 3
Questions and Answers
1. A nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome.Which of the following is an early sign of this oncologicalemergency? A. cyanosis B. arm edema C. periorbital edema D. mental status changes ANS : C. periorbital edema Rationale: Superior vena cava syndrome occurs when the superior vena cava is compressed or obstructed by tumor growth. Early signs and symptoms generally occurring the morning and include edema of the face, especially around the eyes. The client complains tightness around the neck. As the compression worsens the client experiences edema of the arms. Mental status changes and cyanosis are latesigns. 2. The burned client on admission is drooling and having difficulty swallowing.What is the nurse's best first action?
A. Assess level of consciousness and pupillary reactions. B. Ask the client at what time food or liquid was last consumed. C. Auscultate breath sounds over the trachea and mainstem bronchi. D. Measure abdominal girth and auscultate bowel sounds in all four quad-rants. ANS : C. Auscultate breath sounds over the trachea and mainstem bronchi. A burn client who is drooling and having difficulty swallowing is likely experiencingairway issues. The client's airway and respiratory system needs to be assessed immediately and an artificial airway and mechanical ventilation may need to be estimated before the airway becomes too edematous.
3. When assessing a patient who spilled hot oil on the right leg and foot, thenurse notes dry, pale, and hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth? a. First-degree skin destruction b. Full-thickness skin destruction c. Deep partial-thickness skin destruction d. Superficial partial-thickness skin destruction ANS : B. Full-thickness skin destruc-tion
- With full-thickness skin destruction, the appearance is pale and dry or leathery, and
a. Encourage the patient to cough and auscultate the lungs again. b. Notify the health care provider and prepare for endotracheal intubation. c. Document the results and continue to monitor the patient's respiratory rate. d. Reposition the patient in high-Fowler's position and reassess breath sounds. ANS : B. Notify the health care provider and prepare for endotracheal intubation. The patient's history and clinical manifestations suggest airway edema, and the health care provider should be notified immediately so that intubation can be donerapidly. Placing the patient in a more upright position or having the patient cough willnot address the problem of airway edema.
6. During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion?
a. Check skin turgor. c. Assess mucous membranes. b. Monitor daily weight. d. Measure hourly urine output. ANS : D. Measure hourly urine output. When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hr. The patient's weight is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgoralso may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion.
7. A patient has just been admitted with a 40% total body surface area (TBSA)burn injury. To maintain adequate nutrition, the nurse should plan to take which action? a. Administer vitamins and minerals intravenously. b. Insert a feeding tube and initiate enteral feedings. c. Infuse total parenteral nutrition via a central catheter. d. Encourage an oral intake of at least 5000 kcal per day. ANS : B. Insert a feeding tubeand initiate enteral feedings. Enteral feedings can usually be started during the emergent phase at low rates andincreased over 24 to 48 hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet nutritional needs and may havea paralytic ileus that prevents adequate nutrient absorption. Vitamins and mineralsmay be administered during the emergent phase, but these will not assist in meetingthe patient's caloric needs. Parenteral
- When removing contaminated dressings and washing the dirty wound, use non-sterile, disposable gloves.
- The room temperature should be kept at approximately 85° F for patients with openburn wounds to prevent shivering.
- Systemic antibiotics are not well absorbed into deep burns because of the lack ofcirculation. 9. A nurse is caring for a patient who has burns of the ears, head, neck, andright arm and hand. The nurse should place the patient in which position? a. Place the right arm and hand flexed in a position of comfort. b. Elevate the right arm and hand on pillows and extend the fingers. c. Assist the patient to a supine position with a small pillow under the head. d. Position the patient in a side-lying position with rolled towel under theneck. ANS : B. Elevate the right arm and hand on pillows and extend the fingers.
- The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be com-fortable for the patient).
- The patient with burns of the ears should NOT use a pillow for the head becausethis will put pressure on the ears, and the pillow may stick to the ears.
- Patients with neck burns should not use a pillow or rolled towel because the headshould be maintained in an extended position in order to avoid contractures. 10. A patient with burns covering 40% total body surface area (TBSA) is in theacute phase of burn treatment. Which snack would be best for the nurse to offer to this patient?
a. Bananas c. Vanilla milkshake b. Orange gelatin d. Whole grain bagel ANS : C. Vanilla milkshake A patient with a burn injury needs high-protein and high-calorie food intake, and the milkshake is the highest in these nutrients.
11. A patient has just arrived in the emergency department after an electricalburn from exposure to a high-voltage current. What is the priority nursing assessment? a. Oral temperature c. Extremity movement
13. A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital.Which action should the nurse take first? a. Stay at the bedside and reassure the patient. b. Administer the ordered morphine sulfate IV. c. Assess orientation and level of consciousness. d. Use pulse oximetry to check oxygen saturation. ANS : D. Use pulse oximetry tocheck oxygen saturation. *priority is still O2, even though O2 may be normal if carbon monoxide poisoning,still assess! LOC and orientation also important, but breathing still priority! 14. A patient arrives in the emergency department with facial and chest burnscaused by a house fire. Which action should the nurse take first?
a. Auscultate the patient's lung sounds. b. Determine the extent and depth of the burns. c. Give the prescribed hydromorphone (Dilaudid). d. Infuse the prescribed lactated Ringer's solution. ANS : A. Auscultate the patient'slung sounds. A patient with facial and chest burns is at risk for inhalation injury and assessment of airway and breathing is the priority. The other actions will be completed after airwaymanagement is assured.
15. A patient with extensive electrical burn injuries is admitted to the emer- gency department.Which prescribed intervention should the nurse implementfirst? a. Assess pain level. c. Check potassium level. b. Place on heart monitor. d. Assess oral temperature. ANS : B. Place on heart monitor. After an electrical burn, the patient is at risk for life-threatening dysrhythmias andshould be placed on a heart monitor. 16. Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA), the nurse assesses the patient. The patient weighs 92 kg(202.4 lb). Which information would be a priority to communicate to the healthcare provider?
- BP during the emergent phase should be greater than 90 mm Hg systolic and thepulse rate should be less than 120 beats/min. 17. A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patient's skin color is bright red. Which action should the nurse take first? a. Insert two large-bore IV lines. b. Check the patient's orientation. c. Assess for singed nasal hair and dark oral mucous membranes. d. Place the patient on 100% O2using a nonrebreather mask. ANS : D. Place thepatient on 100% O2using a nonrebreather mask. The patient's history and skin color suggest carbon monoxide poisoning, which should be treated by rapidly starting O2 at 100%. The other actions can be takenafter the action to correct gas exchange. 18. The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require immedi-ate intervention by the charge nurse? a. The new nurse uses clean gloves when applying antibacterial cream to aburn wound. b. The new nurse obtains burn cultures when the patient has a temperature of95.2° F (35.1° C). c. The new nurse gives PRN fentanyl (Sublimaze) IV to a patient 5 minutesbefore a dressing change.
d. The new nurse calls the health care provider when a nondiabetic patient's serum glucose is elevated. ANS : A. The new nurse uses clean gloves when applyingantibacterial cream to a burn wound. *Sterile gloves should be worn when applying medications or dressings to a burn.
- Hypothermia is an indicator of possible sepsis, and cultures are appropriate.
- Nondiabetic patients may require insulin because stress and high calorie intakemay lead to temporary hyperglycemia.
- Fentanyl peaks 5 minutes after IV administration and should be used just beforeand during dressing changes for pain management. 19. Which nursing action is a priority for a patient who has suffered a burninjury while working on an electrical power line? a. Inspect the contact burns.
d. tissue plasminogen activator (tPA). ANS : C. oral low-dose aspirin therapy. The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent a stroke.
22. A patient with a stroke experiences facial drooping on the right side andright-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided tendon reflexes d. Difficulty comprehending instructions ANS : D. Difficulty comprehending instruc-tions
Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke.
23. A patient admitted with possible stroke has been aphasic for 3 hours, andhis current blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question? a. Keep head of bed elevated at least 30 degrees. b. Infuse normal saline intravenously at 75 mL/hr. c. Start a labetalol drip to keep BP less than 140/90 mm Hg. d. Administer tissue plasminogen activator (tPA) intravenously per protocol.- ANS : C. Start a labetalol drip to keep BP less than 140/90 mm Hg. *Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if systolic pressure is greater than 220 mm Hg.
- Fluid intake should be 1500 to 2000 mL/day to maintain cerebral blood flow.
- The head of the bed should be elevated to at least 30 degrees unless the patienthas symptoms of poor tissue perfusion.
- tPA may be administered if the patient meets the other criteria for tPA use. (within3 hour window to start?) 24. A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a historyof several transient ischemic
a. ask questions that the patient can answer with "yes" or "no." b. develop a list of words that the patient can read and practice reciting. c. have the patient practice her facial and tongue exercises with a mirror. d. prevent embarrassing the patient by answering for her if she does notrespond. ANS : A. ask questions that the patient can answer with "yes" or "no."
26. For a patient who had a right hemisphere stroke, the nurse anticipatesplanning interventions to manage a. impaired physical mobility related to right-sided hemiplegia. b. risk for injury related to denial of deficits and impulsiveness. c. impaired verbal communication related to speech-language deficits. d. ineffective coping related to depression and distress about disability. ANS : B. riskfor injury related to denial of deficits and impulsiveness. The patient with right-sided brain damage typically denies any deficits and has poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability. 27. When caring for a patient with a new right-sided homonymous hemianop- sia resulting from a stroke, which intervention should the nurse include in theplan of care? a. Apply an eye patch to the right eye. b. Approach the patient from the right side.
c. Place needed objects on the patient's left side. d. Teach the patient that the left visual deficit will resolve. ANS : C. Place neededobjects on the patient's left side. During the acute period, the nurse should place objects on the patient's unaffected side. Because there is a visual defect in the right half of each eye, an eye patch is notappropriate. The patient should be approached from the left side. The visual deficit may not resolve, although the patient can learn to compensate for the defect.
28. left-handed patient with left-sided hemiplegia has difficulty feeding him-self. Which intervention should the nurse include in the plan of care? a. Provide a wide variety of food choices. b. Provide oral care before and after meals. c. Assist the patient to eat with the right hand.
