Advanced med surg 3 Flashcards
Which interventions will the nurse include in the plan of the care for a patient
who has cardiogenic shock?
a. Avoid elevating head of bed
b. Check temperature every 2 hours
c. Monitor breath sounds frequently
d. Assess skin for flushing and itching
c. Monitor breath sounds frequently
. Which assessment is most important for the nurse to make in order to evaluate
whether treatment of a patient with anaphylactic shock has been effective?
a. Pulse rate
b. Orientation
c. Blood pressure
d. Oxygen saturation
d. Oxygen saturation
When caring for the patient who has septic shock, which assessment finding is
most important for the nurse to report to the health care provider? (TB ch.67 Q.17)
a. BP 92/56 mm Hg
b. Skin cool and clammy
c. apical pulse 118 beats/min
d. Arterial oxygen saturation 91%
b. Skin cool and clammy
During change-of-shift report, the nurse learns that a patient has been admitted
with dehydration and hypotension after having vomiting and diarrhea for 3 days.
Which findings is most important for the nurse to report to the HCP?
a. Decreased bowel sounds
b. Apical pulse 110 beats/min
c. Pale, cool, and dry extremities
d. New onset of confusion and agitation
d. New onset of confusion and agitation
A patient is admitted to the burn unit with burns the upper body and head after a
garage fire. Initially, wheezes are heard, but an hour later, the lung sounds are
decreased ad no wheezes are audible. What is the best action for the nurse to take?
a. encourage the patient to cough and auscultate the lungs again
b. Notify the HCP and prepare for endotracheal intubation
c. Document the results and continue to monitor the patient’s resp. rate
d. Reposition pt in high-Fowler’s position and reassess breath sounds
b. Notify the HCP and prepare for endotracheal intubation
During the emergent phase of burn care, which nursing action will be most
useful in determining whether the patient is receiving adequate fluid infusion?
a. Check skin turgor
b. Monitor daily weight
c. Assess mucous membranes
d. Measures hourly urine output
d. Measures hourly urine output
After receiving change-of-shift report, which of these patients should the nurse
assess first?
a.A patient with smoke inhalation who has wheezes and altered mental
status
b. A patient with full-thickness leg burns who has a dressing change scheduled
c. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale)
pain.
d. A patient with 40% total body surface area (TBSA) burns who is receiving IV
fluids at 500 mL/hr
a. A patient with smoke inhalation who has wheezes and altered mental
status
The RN observes all of the following actions begin taken by a staff nurse who has floated to the unit. Which action requires that the RN intervene?
a.The nurse uses latex gloves when applying antibacterial cream to a burn
wound
b. The float nurse obtains burn cultures when the patient has a temp of 101* F
c. The float nurse administers PRN fentanyl (Sublimaze) IV to a pt 5 minutes
before a dressing change
d. The float nurse calls the health care provider for an insulin order when a
nondiabetic pt has an elevated serum glucose.
a. The nurse uses latex gloves when applying antibacterial cream to a burn
wound
A client with cervical neck fracture is admitted to the intensive care unit. Which
findings would the nurse recognize as indicative of spinal shock?
A. Spastically, neuromuscular irritability, hyperreflexia
B. Flaccidity and lack of sensation below the level of spinal cord lesion.
C. Automatic dysreflexia with neurogenic bladder symptoms
D. Muscular spasticity and loss of motor reflexes in all parts of the body below the
level of spinal cord lesion.
B. Flaccidity and lack of sensation below the level of spinal cord lesion.
A client with T6 spinal cord injury is being discharged. The PT is concerned
about autonomic dysreflexia. S/S include the following:
A. Dialited pupils
B. Sudden vomiting and diarrhea
C. drop in BP and pulse
D. Diaphoresis above the level of the lesion
D. Diaphoresis above the level of the lesion
A woman has been recently diagnosed with systemic lupus and shares with the
nurse, I want to get pregnant, but I don’t know how I will tolerate pregnancy because
I have lupus. Which response is best?
A. Most women find that they feel better when they are pregnant
B. How long have you been in remission?
C. Women with lupus frequently have slightly longer gestation
D. Its best to become pregnant within the first 6 months of diagnosis
B. How long have you been in remission?
When teaching a client about the expected outcomes after intravenous
administration of furosemide, the nurse would include which outcome?
A. Increased blood pressure
B. Increased urine output
C. Decreased pain
D. Decreased PVCs
B. Increased urine output
Epoetin alfa (Epogen) is prescribed for a client diagnosed with chronic renal
failure. The client asks the nurse about the purpose of the medication. The
appropriate response would be which of the following?
A. It is used to lower your blood pressure
B. It is used to treat anemia
C. It will help to increase the potassium levels in your body
D. It is an anticonvulsant medication given to all clients after dialysis to prevent
seizure activity.
B. It is used to treat anemia
A client with and ECG reading showing sinus bradycardia has a blood pressure of
47/28 mmhg. Which drugs does the nurse expect the physician to order for this client?
A. Lidocaine (Xylocaine)
B. Atropine sulfate
C. Isoproterenol hydrochloride (Isuprel)
D. Epinephrine
B. Atropine sulfate
Chemical cardioversion is prescribed for the client with atrial fibrillation. The
nurse who is assisting in preparing the client would expect that which medication
specific for chemical cardioversion will be needed?
A. Nitroglycerin
B Nifedipine (Procardia)
C. Lidocaine (Xylocaine)
D. Amiodarone (Cordarone)
D. Amiodarone (Cordarone)
