Unit 3 Med-Surg

The nurse is talking to a critical patient's family about hypovolemic shock. Which statements made by the significant other indicates understanding? Select all that apply. 1. "Hypovolemic shock can occur from severe blood loss or fluids." 2. "Vomiting is the most common cause of hypovolemic shock." 3. "If dehydration is treated quickly, shock can be prevented." 4. "If he had taken antibiotics, shock would not have occurred." 5. "I should have taken him to the hospital when he first became confused."

1. "Hypovolemic shock can occur from severe blood loss or fluids." 3. "If dehydration is treated quickly, shock can be prevented." 5. "I should have taken him to the hospital when he first became confused."

A nurse is teaching about malignant hyperthermia. Which statement indicates a need for further teaching? 1. "It is characterized by loss of muscular tension related to a decrease in intracellular calcium ion concentration." 2. "It is characterized by skeletal muscle rigidity, tachycardia, and hypercarbia." 3. "It is a hypermetabolic state that can be caused by exposure to a gas anesthetic." 4. "It is a genetic disorder."

1. "It is characterized by loss of muscular tension related to a decrease in intracellular calcium ion concentration."

A nurse is teaching about the process of obtaining informed consent before a surgery. Which statement indicates a need for further teaching? 1. "The informed consent given by a patient who cannot physically sign, but is able to make his or her own care decisions, needs to be witnessed by three people." 2. "Informed consent should generally be obtained in the presence of the patient and one witness." 3. "Informed consent of the patient is important if there is any need for blood product." 4. "Informed consent is mandatory even at the risk of death."

1. "The informed consent given by a patient who cannot physically sign, but is able to make his or her own care decisions, needs to be witnessed by three people."

An infant is scheduled to undergo surgery. Up until when before the surgery can the infant be given breast milk? 1. 4 hours prior to surgery 2. 6 hours prior to surgery 3. 2 hours prior to surgery 4. 8 hours prior to surgery

1. 4 hours prior to surgery

Which steps need to be taken when performing a neurological assessment on a patient in surgery? Select all that apply. 1. Assessing the patient's cognition and ability to understand commands 2. Assessing the movement, strength, and sensation of the extremities 3. Assessing the patient's breathing for rate, depth, rhythm, and adventitious breath sounds 4. Assessing peripheral pulses, color, skin turgor, capillary refill, temperature, and edema 5. Assessing for the presence of preoperative delirium or confusion

1. Assessing the patient's cognition and ability to understand commands 2. Assessing the movement, strength, and sensation of the extremities 5. Assessing for the presence of preoperative delirium or confusion

Which steps need to be taken when performing a respiratory assessment on a patient in surgery? Select all that apply. 1. Assessing the patient's oxygen saturation level 2. Assessing the movement, strength, and sensation of the extremities 3. Assessing the patient's breathing for rate, depth, rhythm, and adventitious breath sounds 4. Assessing peripheral pulses, color, skin turgor, capillary refill, temperature, and edema 5. Assessing the patient's airways and maintaining intubation

1. Assessing the patient's oxygen saturation level 3. Assessing the patient's breathing for rate, depth, rhythm, and adventitious breath sounds 5. Assessing the patient's airways and maintaining intubation

The nurse is caring for a patient with obstructive shock and an increased afterload. Which assessment is priority to determine the cause? 1. Auscultation of the heart valves 2. Auscultation of the lung sounds 3. Evaluation of the electrocardiogram (ECG) 4. Auscultation of the heart tones

1. Auscultation of the heart valves

The nurse is treating a patient who received burns over 40% of his lower body in a flash fire incident 2 hours ago. Which orders are the highest priority in the first 30 minutes? Select all that apply. 1. Blood cultures 2. Vasopressors 3. Broad-spectrum antibiotics 4. Central venous pressure (CVP) 5. ScvO2

1. Blood cultures 3. Broad-spectrum antibiotics

The nurse is caring for a patient with a decreased level of consciousness who does not seem to be awakening after surgery. Which should be assessed when the patient is suspected to be at risk of postsurgical neurological complications? 1. Blood glucose levels 2. Serum calcium levels 3. Serum creatinine levels 4. Blood hemoglobin levels

1. Blood glucose levels

The nurse is intervening to prevent and treat venous thromboembolism (VTE) in the postoperative patient. Which interventions are most supportive? Select all that apply. 1. Compression stockings 2. Increase fluids 3. Intermittent pneumatic compression boots 4. Anticoagulation therapy 5. Ambulation

1. Compression stockings 3. Intermittent pneumatic compression boots 4. Anticoagulation therapy 5. Ambulation

The nurse identifies that a patient in cardiogenic shock has poor contractility. What medication should the nurse request when completing a Situation, Background, Assessment, Recommendation (SBAR) communication to the provider? 1. Dobutamine 2. Nitroglycerin 3. Phenylephrine 4. Vasopressin

1. Dobutamine

The nurse is caring for a critical patient with severe hypotension that is not responding to IV fluid resuscitation. Which medications will cause vasoconstriction and should improve the patient's blood pressure? Select all that apply. 1. Dopamine 2. Epinephrine 3. Norepinephrine 4. Nitroglycerin 5. Vasopressin

1. Dopamine 2. Epinephrine 3. Norepinephrine 5. Vasopressin

The health-care provider is administering spinal anesthesia to a patient before surgery. Which assessment change is most concerning? 1. Heart rate of 52 beats per minute 2. Blood pressure of 135/78 mm Hg 3. SvO2 of 65% 4. Central venous pressure (CVP) of 8 cm H2O

1. Heart rate of 52 beats per minute

The nurse is assessing a patient at risk for shock. Vital signs are: temperature 97.8ᵒF (36.5ᵒC), HR 87 beats per minute, respirations 16 breaths, blood pressure 110/75, oxygen saturation 95%. Which stage of shock does this reflect? 1. Initial stage 2. Refractory stage 3. Progressive stage 4. Compensatory stage

1. Initial stage

A patient is about to have surgery. The nurse learns that the patient is taking corticosteroids for a chronic medical condition. The nurse anticipates that it will impact surgery in what way(s)? Select all that apply. 1. It may increase the healing time. 2. It may alter response to muscle relaxants. 3. It may increase the risk of hemorrhage. 4. It may affect tolerance of anesthesia. 5. It may mask signs of infection.

1. It may increase the healing time. 3. It may increase the risk of hemorrhage. 5. It may mask signs of infection.

The nurse administers the first dose of IV ampicillin. Ten minutes later, the patient calls the nurse and says, "I feel funny." The nurse observes the rash below. What should be the nurse's next actions? Select all that apply. 1. Obtain a full set of vital signs. 2. Stop the antibiotic infusion. 3. Notify the provider. 4. Place the patient on oxygen at 4 L/min per nasal cannula. 5. Auscultate the lungs

1. Obtain a full set of vital signs. 2. Stop the antibiotic infusion. 3. Notify the provider. 5. Auscultate the lungs

The nurse is caring for a patient in the postanesthesia care unit (PACU) who has not voided since surgery despite having over 2 liters of fluid infused. What action should the nurse take next? 1. Perform a bladder scan. 2. Insert a Foley catheter. 3. Notify the provider. 4. Obtain blood pressure.

1. Perform a bladder scan.

While treating a patient, the nurse finds that the patient has extensive shunting of blood away from nonessential organs. The patient shows symptoms of lethargy and has severe metabolic acidosis. Which stage of shock is the patient experiencing? 1. Progressive 2. Compensatory 3. Initial 4. Refractory

1. Progressive

The nurse recognized that postoperatively the patient is at risk for bleeding, fluid loss, electrolytes imbalance, renal function, and clotting abnormalities. Which laboratory results indicate a possible problem? Select all that apply. 1. Prothrombin time (PT) 15 seconds 2. Creatinine 2.0 mg/dL 3. Glucose 87 mg/dL 4. Potassium 3.7 mEq/L 5. White blood cells 13.6 10ᶟ/mmᶟ

1. Prothrombin time (PT) 15 seconds 2. Creatinine 2.0 mg/dL 5. White blood cells 13.6 10ᶟ/mmᶟ

The nurse is discharging a patient to home. What criteria must be met? Select all that apply. 1. Skin is intact, surgical site is clean and dry. 2. No adverse reactions to medications 3. Vital signs below preoperative values 4. Voiding 5. Passing stool

1. Skin is intact, surgical site is clean and dry. 2. No adverse reactions to medications 4. Voiding

The nurse in the emergency department is caring for a newly admitted patient. Analyze the information and determine which statement is correct. Past medical history: HTN, type 2 diabetes Admitting diagnosis: Left great toe necrosis, confusion, dehydration Labs: WBC 16,000; Glucose 354; Hct 56% Orders: 0.9% NaCl @ 500 mL/hr; O2 to keep sat >94% Vitals 0945; 1000; 1015; 1030 HR 120; 118; 116; 116 BP 76/52; 80/55; 82/56; 85/60 RR 24; 24; 22; 22 O2 sat 87%; 91%; 92%; 92% O2 del RA; 100% NRM Temp 100.4°F 1. The patient's condition is improving from the medical interventions provided. 2. The patient is in the compensatory stage of shock. 3. Additional intervention with fluids and medications is not needed. 4. Wound culture and IV antibiotics are the priority medical interventions.

1. The patient's condition is improving from the medical interventions provided.

A patient recently had mediastinal chest tubes removed after surgery and is experiencing obstructive shock from cardiac tamponade. Which assessment changes would the nurse observe? 1. Weak peripheral pulses 2. Increased urine output 3. Increased bowel sounds 4. Valvular click

1. Weak peripheral pulses

The nurse is caring for a postoperative patient with symptoms of malignant hyperthermia. Which actions should the nurse take? Select all that apply. 1. "Cover the patient with blanket." 2. "Administer dantrolene to the patient." 3. "Perform nasogastric saline lavage on the patient." 4. "Perform cold body cavity lavage on the patient." 5. "Administer cool normal saline to the patient."

2. "Administer dantrolene to the patient." 5. "Administer cool normal saline to the patient."

The trauma nurse is preparing to care for a patient who has been involved in a motor vehicle accident and has massive blood loss. Which items should the nurse have prepared in the room before the patient arrives? Select all that apply. 1. IV start kits with 20-gauge needles 2. Bags of 0.9% NaCl on blood tubing 3. Central venous catheter insertion kit 4. High-flow oxygen delivery devices 5. Intubation equipment

2. Bags of 0.9% NaCl on blood tubing 3. Central venous catheter insertion kit 4. High-flow oxygen delivery devices 5. Intubation equipment

The nurse is mentoring a new graduate nurse and discussing oxygen delivery. What should the nurse say to the new graduate is assessed through the evaluation of cardiac output and arterial oxygen content? Select all that apply. 1. Hemoglobin 2. Cardiac output 3. Vascular dilation 4. Venous oxygen content 5. Arterial oxygen content

2. Cardiac output 4. Venous oxygen content 5. Arterial oxygen content

The nurse is caring for a patient in cardiogenic shock after a cardiac arrest. The patient is placed on an intra-aortic balloon pump (IABP). The chest x-ray shows that the tip of the catheter is just below the aortic arch, about 2 cm from the left subclavian artery. What action should the nurse take? 1. Have the chest x-ray repeated for better visualization. 2. Confirm that the catheter is secured in that location. 3. Call the provider to adjust the catheter placement. 4. Confirm the waveform demonstrates accurate placement.

2. Confirm that the catheter is secured in that location.

While caring for a patient with burns and excessive loss of fluids, the nurse is concerned that the patient is in the compensatory stage of shock. Which assessment findings has caused the nurse to think this? Select all that apply. 1. Anuria 2. Cool, pale skin 3. Lethargy 4. Weak pulse 5. Hypotension

2. Cool, pale skin 4. Weak pulse

Which is true regarding time-out during a surgical procedure? 1. It starts on the patient's discharge from the health-care facility. 2. It occurs in the operating room and is used to identify the correct patient, correct procedure, and correct surgical site. 3. It is the duty of the preoperative or circulating nurse to mark the surgical site using a permanent marker. 4. It is essential to confirm the patient's complete name along with email identification.

2. It occurs in the operating room and is used to identify the correct patient, correct procedure, and correct surgical site.

The nurse observes that a patient is in the late stage of septic shock. Which assessment supports the nurse's conclusion? 1. Temperature of 101.2ᵒF (38.4ᵒC) 2. Lethargy and coma 3. Bounding pulse 4. Warm, flushed skin

2. Lethargy and coma

Which surgical procedure can be performed in an outpatient surgical postanesthesia care unit (PACU)? 1. Craniotomy 2. Mastectomy 3. Open reduction 4. Exploratory laparotomy

2. Mastectomy

Which physical assessment findings will the nurse report during hand-off when the patient is in the compensatory shock stage? Past medical history: HTN, type 2 diabetes Admitting diagnosis: Left great toe necrosis, confusion, dehydration Labs: WBC 16,000; Glucose 354; Hct 56% Orders: 0.9% NaCl @ 500 mL/hr; O2 to keep sat >94% Vitals 0945; 1000; 1015; 1030 HR 102; 109; 114 irregular; 118 irregular BP 105/67; 101/63; 96/65; 92/65 RR 18; 20; 20; 24 O2 sat 92%; 91%; 92%; 90% O2 del RA; 2L NC; 2L NC; 100% NRM Temp 1001.2°F; 101.5; 101.0; 101.0 1. Bradypnea 2. Oliguria 3. Hypertension 4. Decreased cardiac output

2. Oliguria

The nurse received hand-off report on each of these four patients. Which patient is demonstrating signs of anaphylactic shock? Patient A- Warm, dry, and flushed skin Patient B- Wheezing, stridor, cyanosis Patient C- Chest pain, shortness of breath Patient D- Diaphoresis, nausea, vomiting 1. Patient A 2. Patient B 3. Patient C 4. Patient D

2. Patient B

The nurse is caring for an unconscious patient in the postanesthesia care unit (PACU). The provider has added an order for a patient-controlled analgesia (PCA) pump for pain medication delivery. What action should the nurse take? 1. Connect and begin the PCA. 2. Wait for the PCA to be started once the patient is awake. 3. Contact the provider and question the order. 4. Deliver the medication IV push instead.

2. Wait for the PCA to be started once the patient is awake.

A nurse is teaching about the genitourinary assessments that need to be performed before surgery. Which statement indicates a need for further teaching? 1. "The nurse should document the need for or use of any devices for urinary elimination." 2. "The nurse should have the patient void before entering the operating suite." 3. "A nurse should discourage a patient to discuss any concerns about urination postoperatively as the patient may feel nervous." 4. "The nurse should document any perineal abnormalities on the chart."

3. "A nurse should discourage a patient to discuss any concerns about urination postoperatively as the patient may feel nervous."

The nurse is caring for a patient in the postanesthesia care unit (PACU) whose body temperature is 95.7ᵒF (35.4°C). What action should the nurse take next? 1. Provide warm IV solution. 2. Administer an antipyretic. 3. Apply warm blankets. 4. Administer antibiotics.

3. Apply warm blankets.

Which step followed by a nurse while caring for a patient in the perioperative phase can prevent aspiration during intubation and extubation? 1. Checking heart rate, blood pressure, temperature, and oxygen saturation level 2. Conducting a physical examination of the patient 3. Confirming the last oral intake of the patient 4. Confirming that appropriate skin preparation and bowel preparation has been carried out

3. Confirming the last oral intake of the patient

Which postanesthesia care unit (PACU) setting is suitable to perform lung lobectomy? 1. Procedure unit 2. ICU 3. Inpatient PACU 4. Outpatient PACU

3. Inpatient PACU

The nurse in the emergency department is caring for a newly admitted patient. Analyze the information and determine which statement is correct. Past medical history: HTN, type 2 diabetes Admitting diagnosis: Left great toe necrosis, confusion, dehydration Labs: WBC 16,000; Glucose 354; Hct 56% Orders: 0.9% NaCl @ 500 mL/hr; O2 to keep sat >94% Vitals 0945; 1000; 1015; 1030 HR 102; 109; 114 irregular; 118 irregular BP 105/67; 101/63; 96/65; 92/65 RR 18; 20; 20; 24 O2 sat 92%; 91%; 92%; 90% O2 del RA; 2L NC; 2L NC; 100% NRM Temp 1001.2°F; 101.5; 101.0; 101.0 1. The patient's condition is improving from the medical interventions provided. 2. The patient is in the compensatory stage of shock. 3. Rapid intervention with fluids and medications is needed. 4. Wound culture and IV antibiotics are the priority medical interventions.

3. Rapid intervention with fluids and medications is needed.

The nurse is caring for an older adult patient admitted a week ago with pneumonia and a urinary tract infection. Blood cultures were positive upon admission and the patient has been unstable since admission. The nurse notes that the serum creatinine and liver enzymes are increasing. What conclusions can be made? 1. The infection is worsening and has spread to other organs. 2. The patient's condition has stabilized. 3. The patient is developing complications from the sepsis. 4. Treatments are effective.

3. The patient is developing complications from the sepsis.

The nurse is calculating the shift intake for an unstable patient who is in septic shock. What is the final intake total? Enter the numeral only. Oral intake 50 mL IV intake 200 mL/hour X 12 hours; 500 mL; 100 mL; 500 mL; 100 mL

3650

The nurse is caring for a postoperative patient after a ruptured spleen was removed. Which assessment change is most concerning? 1. An increased blood pressure and widening pulse pressure 2. A bulb drain in the lower abdomen with 50 mL serous fluid 3. Jugular venous distention with the head of the bed at a 45-degree angle 4. A central venous pressure (CVP) of 1 cm H2O and urine output of 25 mL per hour

4. A central venous pressure (CVP) of 1 cm H2O and urine output of 25 mL per hour

After reviewing the data of a patient who is scheduled for surgery, the nurse suspects a risk of hemorrhage. Which medication in the prescription may lead to this condition? 1. Sotalol 2. Valsartan 3. Phenytoin 4. Dexamethasone

4. Dexamethasone

The nurse is admitting a patient with severe diarrhea related to Clostridium difficile colitis. Which type of shock is the patient at the greatest risk for? 1. Obstructive shock 2. Distributive shock 3. Cardiogenic shock 4. Hypovolemic shock

4. Hypovolemic shock

The nurse identifies that a patient is showing signs of cardiogenic shock. Which oxygen device should be applied? 1. Nasal cannula 2. Simple mask 3. Venturi mask 4. Nonrebreather mask

4. Nonrebreather mask

Which perioperative action can help to avoid complications in a patient taking antiarrhythmic medications? 1. Assessing for hyperglycemia 2. Obtaining baseline coagulation studies (PT, INR, aPTT) 3. Assessing for infection 4. Obtaining baseline electrocardiogram and vital signs

4. Obtaining baseline electrocardiogram and vital signs

Which preoperative medication may reduce the risk of vomiting in the patient? 1. Diazepam 2. Glycopyrrolate 3. Vancomycin HCl 4. Ondansetron HCl

4. Ondansetron HCl

Which laboratory finding is most likely to indicate that the patient is at risk of postoperative bleeding? 1. RBC count 2. WBC count 3. Hemoglobin 4. Prothrombin time

4. Prothrombin time

Arrange the order of progression of septic shock. 1. Late septic shock 2. Sepsis 3. Multiorgan dysfunction syndrome 4. Infection 5. Systemic inflammatory response 6. Early septic shock

Infection Systemic inflammatory response Sepsis Early septic shock Late septic shock Multiorgan dysfunction syndrome