MedSurg II Exam 2
A client diagnosed with acute pancreatitis 5 days ago is experiencing respiratory distress. The nurse should report which of the following to the health care provider? a) Arterial oxygen level of 46 mm Hg. b) Respirations of 12. c) Lack of adventitious lung sounds. d) Oxygen saturation of 96% on room air.
a
A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis? a) Impaired physical mobility b) Ineffective breathing pattern c) Disturbed sensory perception (tactile) d) Dressing or grooming self-care deficit
b
When caring for a client with acute pancreatitis, the nurse should use which comfort measure? a) Administering an analgesic once per shift, as ordered, to prevent drug addiction b) Positioning the client on the side with the knees flexed c) Encouraging frequent visits from family and friends d) Administering frequent oral feedings
b
What laboratory finding fits with a medical diagnosis of cardiogenic shock? a) Decreased liver enzymes b) Increased white blood cells c) Decreased red blood cells, hemoglobin, and hematocrit d) Increased blood urea nitrogen (BUN) and serum creatinine levels
d
Which hematologic problem most significantly increases the risks associated with pulmonary artery (PA) catheter insertion? a) Leukocytosis b) Hypovolemia c) Hemolytic anemia d) Thrombocytopenia
d
A 78-kg patient with septic shock has a urine output of 30 mL/hr for the past 3 hours. The pulse rate is 120/minute and the central venous pressure and pulmonary artery wedge pressure are low. Which order by the health care provider will the nurse question? a) Give PRN furosemide (Lasix) 40 mg IV. b) Increase normal saline infusion to 250 mL/hr. c) Administer hydrocortisone (Solu-Cortef) 100 mg IV. d) Titrate norepinephrine (Levophed) to keep systolic BP >90 mm Hg.
a
A client with quadriplegia is in spinal shock. What finding should the nurse expect? a) Absence of reflexes along with flaccid extremities b) Positive Babinski's reflex along with spastic extremities c) Hyperreflexia along with spastic extremities d) Spasticity of all four extremities
a
A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a) administer oxygen. b) obtain a 12-lead electrocardiogram (ECG). c) obtain the blood pressure. d) check the level of consciousness.
a
When caring for a patient in acute septic shock, what should the nurse anticipate? a) Infusing large amounts of IV fluids b) Administering osmotic and/or loop diuretics c) Administering IV diphenhydramine (Benadryl) d) Assisting with insertion of a ventricular assist device (VAD)
a
Which assessment finding obtained by the nurse when caring for a patient with a right radial arterial line indicates a need for the nurse to take immediate action? a) The right hand is cooler than the left hand. b) The mean arterial pressure (MAP) is 77 mm Hg. c) The system is delivering 3 mL of flush solution per hour. d) The flush bag and tubing were last changed 3 days previously.
a
A client with acute pancreatitis has a blood pressure of 88/40, heart rate of 128 beats per minute, respirations of 28 per minute, and Grey Turner's sign. What action should the nurse perform first? a) Assess the urine output. b) Place an intravenous line. c) Position on the left side. d) Insert a nasogastric tube.
b
The nurse would recognize which clinical manifestation as suggestive of sepsis? a) Sudden diuresis unrelated to drug therapy b) Hyperglycemia in the absence of diabetes c) Respiratory rate of seven breaths per minute d) Bradycardia with sudden increase in blood pressure
b
When caring for a critically ill patient who is being mechanically ventilated, the nurse will astutely monitor for which clinical manifestation of multiple organ dysfunction syndrome (MODS)? a) Increased serum albumin b) Decreased respiratory compliance c) Increased gastrointestinal (GI) motility d) Decreased blood urea nitrogen (BUN)/creatinine ratio
b
The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider? a) Blood pressure (BP) 92/56 mm Hg b) Skin cool and clammy c) Oxygen saturation 92% d) Heart rate 118 beats/minute
b
Which hemodynamic parameter is most appropriate for the nurse to monitor to determine the effectiveness of medications given to a patient to reduce left ventricular afterload? a) Mean arterial pressure (MAP) b) Systemic vascular resistance (SVR) c) Pulmonary vascular resistance (PVR) d) Right ventricular pressure (RVP)
b
Which finding will the nurse assess in a client diagnosed with peritonitis? a) Abdominal wall rigidity b) Absence of bowel sounds c) Positive Cullen's sign d) Battle's sign
a
Which of the following goals is most important for a client with acute pancreatitis? a) The client reports minimal abdominal pain. b) The client regains a normal pattern for bowel movements. c) The client limits alcohol intake to two to three drinks per week. d) The client maintains normal liver function.
a
A nurse is caring for an elderly male client who complains that he can't pass urine. A bladder scan reveals 600 ml of urine present in the bladder. The nurse attempts to place the indwelling catheter the physician ordered, but resistance prevents him from placing it. A serum prostate-specific antigen (PSA) test indicates a level of 29 g/L. The physician places an indwelling catheter and the urine specimen returns positive for nitrites, leukocytes, and bacteriuria. Which conditions should the nurse suspect? Select all that apply. a) Prostate problems b) Urinary tract infection (UTI) c) Acute renal failure d) Vitamin K deficiency e) Liver failure
a, b
A nurse is caring for a client with a complete T5 spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above T5, and a blood pressure of 162/96 mm Hg. The client reports a severe, pounding headache. Which nursing interventions are appropriate for this client? Select all that apply. a) Elevating the head of the bed 90 degrees b) Loosening constrictive clothing c) Using a fan to reduce diaphoresis d) Assessing for bladder distention and bowel impaction e) Administering antihypertensive medication f) Placing the client in a supine position with legs elevated
a, b, d, e
A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is: a) elevated liver enzymes and low serum protein level. b) subnormal serum glucose and elevated serum ammonia levels. c) subnormal clotting factors and platelet count. d) elevated blood urea nitrogen and creatinine levels and hyperglycemia.
b
While family members are visiting, a patient has a respiratory arrest and is being resuscitated. Which action by the nurse is best? a) Tell the family members that watching the resuscitation will be very stressful. b) Ask family members if they wish to remain in the room during the resuscitation. c) Take the family members quickly out of the patient room and remain with them. d) Assign a staff member to wait with family members just outside the patient room.
b
A client has a C7 spinal cord injury. Which of the following would be the most important nursing intervention during the acute stage of the injury? a) Turning and repositioning every 2 hours. b) Maintaining proper alignment. c) Maintaining a patent airway. d) Monitoring vital signs.
c
An older patient with cardiogenic shock is cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate doing next? a) Increase the rate for the dopamine (Intropin) infusion. b) Decrease the rate for the nitroglycerin (Tridil) infusion. c) Increase the rate for the sodium nitroprusside (Nipride) infusion. d) Decrease the rate for the 5% dextrose in normal saline (D5 /.9 NS) infusion.
c
The nurse is assessing a client who is in the early stages of cirrhosis of the liver. Which focused assessment is appropriate? a) Peripheral edema. b) Ascites. c) Anorexia. d)Jaundice.
c
The nurse is caring for a patient who has an intraaortic balloon pump in place. Which action should be included in the plan of care? a) Position the patient supine at all times. b) Avoid the use of anticoagulant medications. c) Measure the patient's urinary output every hour. d) Provide passive range of motion for all extremities.
c
