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MED/SURG FINAL ACTUAL QUESTIONS AND CORRECT ANSWERS
The nurse is assessing a patient for heart failure. Which findings would indicate decreased cardiac output and a potential for fluid overload from heart failure? - answer Orthopnea, peripheral edema, crackles A patient comes to the ER with chest pain. A nurse review the following lab results (elevated CPK, CK-MB, tropinin). What does the nurse do first? - answer Prepare the patient go go immediately to cardiac catheterization What would be included in the collaborative management of a patient's pulmonary status following coronary artery bypass graft (CABG) surgery? - answer Mobilizing the patient as soon as possible to prevent atelectasis and venous stasis. What should the nurse prepare to administer to a patient with sustained supraventricular tachycardia (SVT)? - answer Adenosine A patient is admitted with chest discomfort and a possible myocardial infarction. What would be a contraindication to administration of fibrinolytic medications to the patient? The patient had: - answer A stroke within the past month A patient is experiencing reduced after load. The nurse realizes that a cause of reduced after load is: - answer Vasodilator medications
The electrocardiogram of a patient receiving tPA for a myocardial infarction shows that the ST segment has returned to baseline. How should the nurse interpret this finding? - answer The blocked artery has been reperfused. Which of the following will the nurse not include in the plan kf care for a patient with atrial fibrillation? - answer Prepare the patient for unsynchronized defibrillation to assist in controlling heart rate. A nurse is assessing a patient diagnosed with an anterior-lateral myocardial infarction. The nurse adds a nursing diagnosis to the patient's plan of care of decreased cardiac output when which finding is noted on assessment? - answer Crackles auscultated in bilateral lung bases A patient has had a recent myocardial infarction involving the left ventricle. Which assessment finding is expected? - answer decreased cardiac output Following cardiac repercussion treatments, a patient develops the following: hematuria, hypotension, tachycardia, a drop in hemoglobin, hematocrit, and a drop in oxygen saturation. What is most likely the cause for these symptoms? - answer Over-anticoagulation A patient with heart failure has a decreasing cardiac output. The nurse will expect compensatory mechanisms to be activated in order to: - answer Maintain perfusion to vital organs The healthcare provider is preparing to insert a swan into a patient. The nurse realizes this monitoring device is used for all of the following except: - answer Continuously monitoring the blood pressure
A patient's cardiac catheterization has shown an 80% blockage of the right coronary artery (RCA). While waiting for bypass surgery, what is essential to have on hand? - answer an external pacemaker A patient with sepsis is in the ICU, and has a PA catheter. The mixed venous oxygen saturation (SvO2) is 86%. The patient's SaO2 is 92%, and temperature is 96.2 F. Which is the nurse's primary intervention? - answer Apply warm blankets to the patient because they are not extracting enough oxygen at the tissue level to avoid anaerobic metabolism and subsequent acidemia. Nursing interventions for the patient with sinus tachycardia include which of the following? - answer Remove or treat the underlying cause, such as fever, pain, or anxiety. A nurse is monitoring a patient undergoing exercise electrocardiography (stress test). Which assessment finding necessitates that the test be stopped? - answer The patient's electrocardiogram (ECG) indicates significant ST segment depression. The nurse is caring for the patient with acute pain associated with a myocardial infarction (MI). What is the goal or purpose of collaborative management for this patient? - answer Eliminate discomfort by providing pain relief modalities, decrease myocardial oxygen demand, and increase myocardial oxygen supply. A patient arrives in the emergency department for chest pain, light-headedness, and shortness of breath (SOB). The cardiac monitor shows sinus rhythm with the presence of multifocal PVCs. Which order would the nurse question? - answer Atropine 0.5 mg IV
What is the most appropriate position for a patient in pulmonary edema with a blood pressure of 194/92? - answer Sitting upright with legs dependent A patient is experiencing sinus bradycardia with hypotension and dizziness. Which of the following listed drugs should the nurse prepare to administer. - answer Atropine A patient undergoes emergency CABG surgery after failed thrombolysis and a percutaneous coronary intervention (PCI) in which coronary artery dissection occurred. Prior to surgery, the patient was alert and able to give verbal consent. Mediastinal and pleural chest tubes are present with moderate drainage. Moderate oozing is also present at the sternotomy and saphenous vein graft incisions and at the right groin sheath site. The patient has a PA catheter, an NG tube, and a urinary catheter in place. Frequent assessments by the nurse for this patient should include which of the following? - answer Hourly groin palpation and neurovascular checks of the leg used for PCI A patient with a PA (Swan) catheter has an SVO2 of 90%. The nurse should assess the patient for: - answer hypothermia What should the nurse monitor in response to a change in SVO2 readings? - answer hemoglobin A patient with sepsis is in the ICU, and has a PA catheter. The mixed venous oxygen saturation (SvO2) is 86%. The patient's SaO2 is 92%, and temperature is 96.2 F. Which is the nurse's primary intervention? - answer Apply warm blankets to the patient because they are not extracting enough oxygen at the tissue level to avoid anaerobic metabolism and subsequent acidemia.
The nurse is preparing an infusion of Norepinephrine for a patient in severe septic shock. Why is this medication being used for the patient? - answer It reverses hypotension when fluid resuscitation was unsuccessful Early goal-directed therapy for management of severe sepsis or septic shock involves maximizing cardiac preload, afterload, and contractility to balance oxygen delivery to tissues with demand. During the first 6 hours of resuscitation for sepsis-induced hypoperfusion, which of the following pairs of parameters represents desired target values? - answer CVP: 12 mmHg; MAP: 67 mmHg Which finding indicates that re-hydration is complete and hypovolemic shock has been successfully treated in a non-intubated patient? - answer CVP = 8 mmHg A patient in hypovolemic shock would be expected to have a high SVR because: - answer They have released catecholamines, which stimulate the alpha receptors in blood vessels, thereby "shrinking" the vessels to fit around the existing blood volume The nurse is caring for a patient who was brought into the emergency department after being struck by lightning. This patient's injuries will most likely be to which body areas? - answer Heart and bones A nurse caring for a patient with a spinal cord injury experiencing hypotension and bradycardia, will plan to administer all of the following collaborative interventions EXCEPT: - answer Apresoline A patient rescued from a small house fire is brought to the emergency department. There is no burn injury to the skin, however laboratory results show an elevated carbon monoxide (CO)
level. Which intervention would the nurse expect to implement? - answer Give 100% oxygen by mask A patient is experiencing acute respiratory distress after eating an item of a known food allergy. The nurse will implement all of the following interventions when providing emergency care to this patient EXCEPT: - answer Prepare to administer antithrombolytic agents as prescribed A patient with cardiomyopathy is demonstrating signs of cardiogenic shock. The nurse realizes that this type of shock is due to: - answer Reduced cardiac output The nurse delegates care for a patient with leukemia to a licensed practical nurse (LPN). Which instruction is the most important for the RN to provide to the LPN? - answer Wash hands frequently The nurse is evaluating a patient for the presence of systemic inflammatory response syndrome (SIRS). Which assessment data indicates the presence of SIRS? - answer Temperature 38.4 C, respiratory rate 23, pulse rate 98, and PaCO2 30 What intervention will the nurse implement to prevent injury in the patient with bone cancer? - answer Using a lift sheet when repositioning the patient The nurse is preparing medications for a patient being treated for cardiogenic shock. The nurse might administer all of the following medications EXCEPT: - answer Epinephrine
With which pathophysiologic changes does the nurse correlate the acidosis associated with hypovolemic shock? - answer Lactic acid production resulting from decreased oxygen delivery to the tissues and increased anaerobic metabolism A nurse is evaluating a patient with sepsis for the development of disseminated intravascular coagulation (DIC). What is a sign that the patient may have developed this condition? - answer melena stool What will the nurse do when administering antibiotics to a patient with sepsis? - answer Antibiotics should be administered after blood cultures are obtained Which finding indicates that fluid resuscitation has been successful for a patient with a burn injury? - answer Urine output equal to or greater than 50 mL/hr Which assessment finding indicates that an infusion of intravenous Epinephrine 4 mcg/min is effective in the treatment of a patient with anaphylactic shock? - answer Reduced wheezing A patient being successfully treated for breast cancer with chemotherapy presents to the ED with severe fatigue. The nurse will assess for all of the following problems EXCEPT: - answer spinal shock A patient is receiving Norepinephrine 30 mcg/min for treatment of refractory shock. Which assessment finding suggests the patient is experiencing peripheral vasoconstriction from the medication? - answer drop in axillary body temp
Of the following, which is the most appropriate nursing intervention for the patient in cardiogenic shock who is receiving Nitroprusside? - answer Assess BP Q The nurse has reviewed plans for wound and scar management for the rehabilitation phase following an extensive burn with a patient and explains about complications that can occur including all of the following EXCEPT: - answer osteomyelitis A patient is experiencing an anaphylactic reaction to a medication. The nurse is concerned that the patient will develop distributive shock because: - answer The release of histamine causes vasodilation with plasma leakage A patient is admitted to your unit after a motor vehicle crash. He is suspected of having internal bleeding. Of the following clinical manifestations, which would you NOT expect to find if this patient was in the progressive stage of shock? - answer metabolic alkalosis Which laboratory finding should cause the nurse to suspect that a patient is developing hypovolemic shock? - answer Metabolic acidosis validated by arterial blood gases. The nurse is caring for a patient recovering from a spinal cord injury sustained during a motor vehicle crash. In addition to hypotension and bradycardia, what assessment finding indicates that the patient is developing neurogenic shock? - answer warm, dry skin A patient has arrived by ambulance at the emergency department after a cervical spinal cord injury. Which assessment is a priority for the nurse to perform at this time? - answer Airway and respiratory rate and rhythm
When discussing hemorrhagic shock with a nursing class, which statement by a student indicates to the nurse educator that additional teaching is required? - answer Loss of blood into the pelvis or thighs is nothing to be concerned about Which of the following would be LEAST helpful in conveying comfort to a trauma patient? - answer Giving all details to get full cooperation When performing a quick assessment to identify life-threatening problems in a trauma patient, the nurse would include which assessments under the D-Disability section? - answer Ability to respond to verbal or painful stimuli A patient who suffered a spinal cord injury at level T3 several months ago develops a flushed face and blurred vision. On taking vital signs, the nurse notes the blood pressure to be 184/ mmHg. Which is the nurse's first action? - answer Palpating the area over the bladder for distention A patient was hit in the forehead by a fast-pitched softball 4 hours earlier in the day. Which clinical manifestations alert the nurse to the possibility of increased intracranial pressure? - answer Papilledema A nurse notes that a patient with a traumatic brain injury is having a rapid decline in level of consciousness. If the nurse suspects cerebral herniation, the most appropriate intervention would be to: - answer Briefly hyperventilate the patient
