Med Surge 3 Finals PDF

1.A patient with a head injury opens his eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. How would the nurse record the patient's Glasgow Coma Scale score? a. 9 b.11 C.13 d. 15 2. A patient is admitt...

1.A patient with a head injury opens his eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. How would the nurse record the patient's Glasgow Coma Scale score? a. 9 b.11 C.13 d. 15 2. A patient is admitted after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. Which laboratory value would the nurse expect to note to support this diagnosis? a. Decreased fibrinogen degradation products b. Decreased D-dimer concentrations c. Decreased platelet counts d. Increased serum glucose levels 3.Which action would the nurse implement when caring for a patient who has an acute exacerbation of polycythemia vera? a. Place the patient on bed rest. b. Administer blood products. c. Avoid use of aspirin products. d. Monitor hydration status. 4.A patient with submassive pulmonary embolism has been prescribed warfarin in addition to a heparin infusion. The patient asks the nurse why he has to be on two medications. The nurse's response is based on which rationale? a. The oral and injection forms work synergistically. b. The combination of heparin and an oral anticoagulant results in fewer adverse effects than heparin used alone. c. The warfarin is used to reach an adequate level of anticoagulation when heparin alone is unable to do so. d. Heparin is used to start anticoagulation so as to allow time for the blood levels of warfarin to reach adequate levels. 5.A Patient is brought to the emergency department after a house fire ….. A lid cigarette and the couch ignited. What is the nurse's first priority ? a. Clean the wounds and remove blisters. b. Assess the airway and provide 100% oxygen. C. Place the urinary drainage catheter and assess for myoglobin. d. Place a central intravenous assess and provide antibiotics. 6. Rejection that occurs within hours after transplantation and results in immediate graft failure is referred to as what type of rejection? a. Acute b. Intermediate c. Chronic d. Hyperacute 7.A patient involved in a house fire is brought by ambulance to the emergency department. The patient is breathing spontaneously but appears agitated and does not respond appropriately to questions. The nurse knows the patient has inhaled carbon monoxide and probably has carbon monoxide (CO) poisoning. What action should the Nurse next? a. Ask the practitioner to order a STAT chest radiograph. b. Apply a pulse oximeter to one of his unburned fingers. c. Call the local hyperbaric chamber to check on its availability. d. Administer 100% high-flow oxygen via a nonrebreathing mask. 8.A patient is receiving heparin therapy as part of the treatment for a pulmonary embolism. The nurse monitors the results of which laboratory test to check the drug's effectiveness? a. Bleeding times b. Activated partial thromboplastin time (aPTT) c. Prothrombin time/international normalized ratio (PT/INR) d. Vitamin K levels 9. Using the Parkland formula for fluid resuscitation 9. Using the Parkland formula for fluid resuscitation and your knowledge of injury calculations using the "rule of nines," calculate the estimated fluid requirements during the first 8 hours for a 75-kg patient with full-thickness burns to the anterior chest, perineum, and entire right leg. a. 2775 mL b. 5550 mL c. 8325 mL d. 11,100 mL Rational To calculate the fluid requirements during the first 8 hours for a 75-kg patient with full-thickness burns using the Parkland formula, we need to follow these steps: Parkland Formula: \text{Fluid requirement} = 4 \times \text{Body weight (kg)} \times \text{% TBSA burned} After calculating the total fluid volume, we will divide it into two phases: ​ 50% of the fluid is given in the first 8 hours. ​ 50% of the fluid is given over the next 16 hours. Step 1: Calculate the % TBSA burned (using the Rule of Nines) The Rule of Nines helps estimate the percentage of total body surface area (TBSA) that is burned: ​ Anterior chest: 18% (for the front of the torso) ​ Perineum: 1% (entire perineum) ​ Right leg: 18% (an entire leg) So the total % TBSA burned is: 18% (anterior chest)+1% (perineum)+18% (right leg)=37%18%(anterior chest)+1%(perineum)+18%(right leg)=37% Step 2: Calculate the total fluid requirement using the Parkland formula Now, apply the formula: \text{Fluid requirement} = 4 \times \text{Body weight} \times \text{% TBSA burned} For a 75-kg patient with 37% TBSA burned: Fluid requirement=4×75×37 Fluid requirement=4×75×37 Fluid requirement=4×75×37=11,100 mLFluid requirement=4×75×37=11,100mL Step 3: Calculate the fluid required during the first 8 hours Since half of the total fluid is given during the first 8 hours, we divide the total by 2: Fluid for first 8 hours=11,100 mL2=5,550 mLFluid for first 8 hours=211,100mL​=5,550mL Final Answer: The estimated fluid requirement during the first 8 hours is 5,550 mL. So the correct answer is: b. 5550 mL. 10.Using the "rule of nines," calculate the percent of injury in an adult who was injured as follows: the patient sustained partial and full-thickness burns to half of his left arm, his entire left leg, and his perineum. A.28% b.23.5% C.45.5% D.16% RATIONAL To calculate the percent of injury in an adult using the Rule of Nines, we need to estimate the Total Body Surface Area (TBSA) burned based on the affected areas. Here's the breakdown: Rule of Nines for an Adult: ​ Head and neck: 9% ​ Each arm: 9% ​ Each leg: 18% ​ Front of the torso (anterior chest): 18% ​ Back of the torso (posterior chest): 18% ​ Perineum: 1% Now, let’s break down the injury: ​ Half of the left arm: The entire arm is 9%, so half of the left arm is 4.5%. ​ Entire left leg: This is 18% (for one full leg). ​ Perineum: This is 1% (for the perineal region). Total Percent of Injury: ​ Half of the left arm = 4.5% ​ Entire left leg = 18% ​ Perineum = 1% Total injury percentage=4.5%+18%+1%=23.5%Total injury percentage=4.5%+18%+1%=23.5% Final Answer: The percentage of injury is 23.5%. So the correct answer is: b. 23.5%. 11. The nurse is caring for a patient with extensive burns. Which intervention should be included in the nursing management plan to prevent cross-contamination and decrease the risk of infection in the burn-injured patient? a. Gloves are the only personal protective equipment worn when changing dressings that are in direct contact with body fluids. b. Family members only have to wear a gown when visiting a patient because masks will increase anxiety in the patient. c. Changing gloves and handwashing should be done when moving from area to area on the same patient. d. Sharing of equipment between patients in the same room does not show evidence of cross-contamination. 12.A patient was admitted following an aspiration event on the medical-surgical floor. The patient is receiving 40% oxygen via a simple facemask. The patient has become increasingly agitated and confused. The patient's oxygen saturation has dropped from 92% to 84%. The nurse notifies the practitioner about the change in the patient's condition. What interventions should the nurse anticipate? a. Intubation and mechanical ventilation b. Change in antibiotics orders c. Suction and reposition the patient d. Orders for a sedative 13. A patient has been admitted with anaphylactic shock due to an unknown allergen. The nurse understands that the decrease in the patient's cardiac output is the result of which mechanism? a. Peripheral vasodilation b. Increased venous return c. Increased alveolar ventilation d. Decreased myocardial contractility 14. A client is being discharged on anticoagulant therapy for a low-risk stable pulmonary embolism. Which anticoagulant enhances the activity of antithrombin Ill and does require activated partial thromboplastin time (aPTT) or activated clotting time (ACT) monitoring? a. Heparin b. Enoxaparin c. Bivalirudin d. Argatroban 15. A patient with coronary artery disease (CAD) is admitted with chest pain. The patient is suddenly awakened with severe chest pain. Three nitroglycerin sublingual tablets are administered 5 minutes apart without relief. A 12-lead electrocardiograph (ECG) reveals nonspecific ST segment elevation. The nurse suspects the patient may have which disorder? a. Silent ischemia b. Stable angina c. Unstable angina d. Prinzmetal angina 16.Which statement best describes the effects of positive-pressure ventilation on cardiac output? a. Positive-pressure ventilation increases intrathoracic pressure, which increases venous return and cardiac output. b. Positive-pressure ventilation decreases venous return, which increases preload and cardiac output. c. Positive-pressure ventilation increases venous return, which decreases preload and cardiac output. d. Positive-pressure ventilation increases intrathoracic pressure, which decreases venous return and cardiac output. 17.What is the primary mechanism in the development of tumor lysis syndrome? a. Destruction of platelets by lymphocytic antibodies b. Destruction of malignant cells through radiation or chemotherapy c. Formation of heparin antibodies d. Damage to the endothelium This is the primary mechanism in tumor lysis syndrome because the rapid breakdown of malignant cells releases their intracellular contents, leading to the metabolic abnormalities characteristic of TLS. 18. The patient is admitted with an acute inferior myocardial infarction (MI). A 12-lead electrocardiogram (ECG) is done to validate the area of infarction. Which finding on the ECG is most conclusive for infarction? a. Inverted T waves b. Tall, peaked T waves c. ST segment depression d. Pathologic Q waves 19. Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness? a. Coordinate the transfer of the patient to the operating room. b. Provide discharge instructions about monitoring neurological status. c. Arrange to admit the patient to the neurologic unit for observation. d. Transport the patient to radiology for magnetic resonance imaging (MRI). 20. Admission vital signs for a patient who has a brain injury are blood pressure of 128/68 mm Hg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse? a. Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12 breaths/min b. Blood pressure 134/72 mm Hg, pulse 90 beats/min, respirations 32 breaths/min c. Blood pressure 148/78 mm Hg, pulse 112 beats/min, respirations 28 breaths/min d. Blood pressure 110/70 mm Hg, pulse 120 beats/min, respirations 30 breaths/min 21.A patient has been newly diagnosed with stable angina. He tells the nurse he knows a lot about his diagnosis already because his father had the same diagnosis 15 years ago.The nurse asks him to state what he already knows about angina. Which response indicates the need for additional education? a. He should stop smoking. b. He can no longer drink colas or coffee. c. He can no longer get a strong back massage. d. He should take stool softeners to prevent straining. 22. A patient with known penicillin allergies developed anaphylactic shock after ampicillin was given in error. Which medication would the nurse administer? a. Methylprednisolone b. Gentamicin c. Atropine d. Epinephrine 23.A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature me 102° (38.9°C), and severe back pain. Which prescribed action will the nurse implement first? a. Administer morphine sulfate 4 mg IV. b. Give acetaminophen (Tylenol) 650 mg. c. Infuse normal saline 500 mL over 30 minutes. d. Schedule complete blood count and coagulation studies. 24.The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by assistive personnel (AP), if observed by the nurse, would require an intervention? a. The AP flushes the toilet twice after emptying the patient's bedpan. b. The AP stands by the patient's bed for 30 minutes talking with the patient. c. The AP places the patient's bedding in a laundry bag in a container in the hallway. d. The AP gives the patient non alcohol-containing mouthwash to use for oral care. 25. During the change-of-shift report, the nurse learns about the following four patients. Which patient would the nurse assess first? a. A patient who has compensated cirrhosis and reports anorexia b. A patient with chronic pancreatitis who has gnawing abdominal pain c. A patient with cirrhosis and ascites who has a temperature of 102°F (38.8°C) d. A patient recovering from a laparoscopic cholecystectomy who has shoulder pain The fever in the patient with cirrhosis and ascites could indicate spontaneous bacterial peritonitis, a life-threatening infection that requires immediate attention. Therefore, this patient should be the first one assessed. 26.Patient who is being treated with chemotherapy and radiation for stage IV lung cancer tells the nurse about intense new-onset back pain. Which action would the nurse take first? a. Give the patient the prescribed PRN opioid. b. Assess for sensation and strength in the legs. C.Notify the health care provider about the symptoms. d. Teach the patient how to use relaxation to reduce pain. Rationale: Given that the patient is undergoing treatment for stage IV lung cancer, new-onset intense back pain raises the concern for possible spinal cord compression (SCC), which can occur in cancer patients, especially with lung cancer that has metastasized. Spinal cord compression can lead to neurological deficits, including sensory and motor changes in the legs (such as weakness, numbness, or paralysis). The first priority is to assess the patient for any signs of neurological involvement (e.g., loss of sensation, weakness, or bowel and bladder dysfunction), as spinal cord compression requires urgent intervention to prevent permanent neurological damage. 27. Which action would the nurse include in the plan of care for a patient who has thalassemia major? A.Administer blood component therapy as needed. b. Teach the patient to use iron supplements. c. Avoid the use of intramuscular injections. d. Notify health care providers of hemoglobin 11 g/dL. Rationale: Thalassemia major (also known as Cooley's anemia) is a severe form of thalassemia, a genetic blood disorder characterized by abnormal hemoglobin production. Patients with thalassemia major typically require regular blood transfusions to maintain adequate hemoglobin levels and prevent complications such as anemia, organ damage, and growth retardation. These transfusions provide the patient with the healthy red blood cells they lack. 28.The nurse is caring for a patient who was just admitted with septic shock. The nurse knows that certain interventions should be completed within 3 hours of time of presentation. Which intervention would be a priority for the nurse to implement upon receipt of a practitioner's order? a. Administer fresh frozen plasma b. Obtain a serum lactate level c. Administer epinephrine d. Measure central venous pressure Rationale: In the management of septic shock, the Sepsis-3 guidelines recommend several critical interventions within the first 3 hours of presentation, which are part of the initial "Sepsis Bundle." These include: 1.​ Obtaining a serum lactate level: This is done to assess the degree of tissue hypoxia and organ dysfunction. Elevated lactate levels are often a marker of severe sepsis or septic shock and indicate impaired tissue perfusion. 2.​ Blood cultures (if not already done) to identify the causative organism(s). 3.​ Administering broad-spectrum antibiotics as soon as possible, ideally within the first hour. 4.​ Administering intravenous fluids to improve perfusion, typically 30 mL/kg of crystalloid for initial resuscitation. 29.During a health education session, a participant asked about the hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with this virus? a. Following proper hand-washing techniques b. Avoiding chemicals that are toxic to the liver c. Wearing a condom during sexual contact d. Limiting alcohol intake 30.The nurse is caring for a patient after a liver transplant. Which finding would be of most concern to the nurse? a. Serum glucose 153 mg/dL b. Low aspartate aminotransferase (AST) and alanine aminotransferase (ALT) c. Elevated prothrombin time and INR d.Decreased blood urea nitrogen and creatinine Rationale: After a liver transplant, the liver's ability to produce clotting factors may be impaired, especially in the early post-operative period. An elevated prothrombin time (PT) and international normalized ratio (INR) are indicators of impaired liver function or a deficiency in clotting factors, which the liver produces. These lab values suggest the patient is at increased risk for bleeding. 31. A patient Admitted with a severe head injury. The nurse knows that critically patients are at risk for gastrointestinal hemorrhage due to stress related mucosal disease. The nurse would monitor the patient for which signs and symptoms? A.Metabolic acidosis and hypovolemia b. Decreasing hemoglobin and hematocrit c. Hyperkalemia and hypernatremia d. Hematemesis and melena Patients with severe head injury are at risk for developing stress-related mucosal disease (SRMD), which can lead to gastrointestinal hemorrhage. This is often a consequence of gastric mucosal injury resulting from the physiological stress response, including increased gastric acid secretion and impaired mucosal protection. The signs and symptoms of gastrointestinal hemorrhage include: ​ Hematemesis: Vomiting of blood, which may appear as bright red or "coffee-ground" material, indicating active or recent bleeding from the upper gastrointestinal tract. ​ Melena: Black, tarry stools, which is indicative of digested blood coming from the upper gastrointestinal tract, typically due to bleeding from the stomach or duodenum. 32. Which statement regarding the difference between stable and unstable angina is accurate? a. Stable angina responds predictably well to nitrates. b. Stable angina is not precipitated by activity. c. Stable angina has a low correlation to coronary artery disease (CAD). d. Stable angina is a result of coronary artery spasm. 33. The nurse is caring for a patient with acute liver failure. The patient has elevated ammonia levels. Which medication would the nurse expect the provider to order for this patient? a. Octreotide b. Vitamin K c. Lactulose d. Lorazepam Rationale: In acute liver failure, the liver's ability to detoxify the body is severely impaired, leading to the accumulation of toxins like ammonia in the bloodstream. Elevated ammonia levels are particularly concerning because they can lead to hepatic encephalopathy, a condition characterized by confusion, altered level of consciousness, and possibly coma. Lactulose is a non-absorbable disaccharide that works by reducing the absorption of ammonia in the gut. It acidifies the colon and traps ammonia in the form of ammonium ions, which are then excreted in the stool. This helps lower blood ammonia levels and prevent or treat hepatic encephalopathy. 34. Which statement describes the assist-control mode of ventilation? a. It delivers gas at preset volume, at a set rate, and in response to the patient's inspiratory efforts. b.It delivers gas at a preset volume, allowing the patient to breathe spontaneously at his or her own volume. c. It applies positive pressure during both ventilator breaths and spontaneous breaths. d. It delivers gas at preset rate and tidal volume regardless of the patient's inspiratory efforts. Rationale: In assist-control (AC) mode of ventilation, the ventilator provides a preset tidal volume (the amount of air delivered with each breath) at a set rate. Additionally, if the patient initiates a breath, the ventilator will assist by delivering the same preset tidal volume. This means that the patient can trigger additional breaths, but they will receive the full set tidal volume with each breath, whether initiated by the ventilator or the patient. 35. Which topical antimicrobial agent is commonly used as a broad-spectrum and fights against gram-positive and -negative bacteria? a.Pure silver b. Bacitracin c. Mafenide acetate cream d. Silver sulfadiazine 36. A patient has been admitted with neurologic disorder. With which disorder should the nurse be the most vigilant for the development of neurogenic shock? A.Ischemic stroke B. Spinal cord injury C.Guillain-Barré syndrome d. Brain tumor Rationale: Neurogenic shock is a type of shock that occurs due to the loss of sympathetic tone, typically following a spinal cord injury (SCI), particularly when the injury is at or above the T6 level. This results in vasodilation, hypotension, and a decrease in heart rate due to the disruption of the sympathetic nervous system’s ability to maintain vascular tone and regulate the heart. 37. A patient is admitted with a brain and spinal cord injury secondary to a motor vehicle crash. The nurse is monitoring the patient for signs of neurogenic shock. Clinical findings in neurogenic shock are related to which pathophysiologic process? a. Loss of sympathetic nervous system innervation b. Parasympathetic nervous system stimulation C. Injury to the hypothalamus d. Focal injury to cerebral hemispheres Rationale: Neurogenic shock occurs when there is damage to the spinal cord (particularly at or above T6), leading to loss of sympathetic nervous system (SNS) innervation. This results in the following pathophysiologic changes: 1.​ Vasodilation: The SNS normally helps maintain vascular tone by constricting blood vessels. When the sympathetic control is lost due to spinal cord injury, there is widespread vasodilation, leading to hypotension. 2.​ Bradycardia: The SNS also normally increases heart rate in response to stress or low blood pressure. With the loss of SNS function, there is often bradycardia (slow heart rate), which contributes to the hypotension.  3.​ Impaired thermoregulation: Because the SNS controls blood vessel constriction in the skin, the patient may also experience impaired temperature regulation and can become hypothermic. 38. A patient is admitted with symptoms of a low-grade fever, joint pain, tachycardia, hepatomegaly, photophobia, and an inability to follow commands. The patient is becoming more agitated and complaining of pain. The parent says the patient has had similar symptoms when they were living in the northeast states. The nurse suspects that the patient has which disorder? A.Idiopathic thrombocytopenic purpura b. Heparin-induced thrombocytopenia c. Sickle cell anemia D.Disseminated intravascular coagulation 39. A nurse has entered the room of a client with long term cirrhosis and found the client on the floor. The client reports feeling faint and falling when transferring to the commode. The client's vital signs are within reference ranges and the nurse observes no apparent injuries. What is the nurse's most appropriate action? A.Remove the client's commode and supply a bedpan. b. Complete an incident report and submit it to the unit supervisor. c. Have the client assessed by the primary provider due to the risk of internal bleeding. d. Perform a focused abdominal assessment in order to rule out injury. 40.A patient was admitted with acute liver failure. The patient is lethargic,slurred speech, has marked asterixis.what is the earliest stage of hepatic encephalopathy that finding may be seen? a. Stage 1 b. Stage 2 C.Stage 3 d. Stage 4 41. A nurse on a solid organ transplant unit is planning the care of a client who will soon be admitted upon immediate recovery following liver transplantation. What aspect of nursing care is the nurse's priority? a. Implementation of infection-control measures b. Close monitoring of skin integrity and color c. Frequent assessment of the client's psychosocial status d. Administration of antiretroviral medications 42. A nurse is caring for a client with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the client's cognition and behavior. What is the nurse's most appropriate response? a. Ensure that the client's sodium intake does not exceed recommended levels. b. Report this finding to the primary provider due to the possibility of hepatic encephalopathy. c. Inform the primary provider that the client should be assessed for alcoholic hepatitis. d. Implement interventions aimed at ensuring a calm and therapeutic care environment. 43. A patient's ICP is 34 mm Hg, and his cerebral perfusion pressure is 65 mm Hg. Given that the provider has left appropriate orders, which action should the nurse take next? a. No action is required. b. Administer mannitol 1 to 2 g/kg IV. c. Place the patient supine and flat in bed. d. Suction the patient. 44. A nurse is caring for a patient in shock with elevated lactate levels. Which order should the nurse question in the management of this patient? a. Start an insulin drip for blood sugar greater than 180 mg/dL. b. Administer sodium bicarbonate to keep arterial pH greater than 7.5. c. Start a norepinephrine drip to keep mean arterial blood pressure greater d. Administer crystalloid fluids. 45. The nurse is caring for a patient with acute liver failure. The provider asks the nurse to assess the patient for asterixis. How should the nurse assess this symptom? a. Inflate a blood pressure cuff on the patient's arm. b. Have the patient bring the knees to the chest. C.Have the patient extend the arms and dorsiflex the wrists. d. Dorsiflex the patient's foot. 46. A client survived a massive myocardial infarction (MI) and is advised to have an ICD implanted. What dysrhythmia is most frequently associated with sudden cardiac death after an MI? a. Premature ventricular contractions b. Ventricular tachycardia c. Third degree heart block d. Asystole Rationale: Ventricular tachycardia (VT) is the most common dysrhythmia associated with sudden cardiac death (SCD) after a myocardial infarction (MI). It can lead to ventricular fibrillation (VF), which causes the heart to quiver instead of contracting normally, leading to cardiac arrest. VT and VF are life-threatening arrhythmias that can occur in the setting of ischemic heart disease or after an MI due to the damage to the heart's electrical conduction system. 47. A patient is admitted after being burned while lighting the barbecue. The injuries appear moist and red with some blister formation and the patient states they are very painful. What kind of burn would the nurse document in the patient's record? a. Superficial, first-degree burn b. Partial-thickness, second-degree burn c.Deep dermal partial-thickness, second-degree burn d. Full-thickness, third-degree burn 48. A patient is admitted after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. The nurse knows that DIC is known to occur in patients with retained placental fragments. What is the pathophysiologic consequence of DIC? a. Hypersensitivity response to an antigen b. Excessive thrombosis and fibrinolysis c. Profound vasodilatation d. Loss of intravascular volume 49.The nurse reviews the laboratory results of a patient who is receiving chemotherapy Thich laboratory result is most important to report to the health care prom Suịp a. Hematocrit 30% b. Platelets 95,000/pL c. Hemoglobin 10 g/L d. White blood cells (WBC) 1700/uL 50.nurse is caring for a patient in cardiogenic shock. The nurse recognizes that the patient's signs and symptoms are the result of what problem? a. Inability of the heart to pump blood forward b. Loss of circulating volume and subsequent decreased venous return c. Disruption of the conduction system when reentry phenomenon occurs d. Suppression of the sympathetic nervous system 51. The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient. Which action can the nurse delegate to assistive personnel (AP)? a. Verify the patient identification (ID) according to hospital policy. b. Obtain the patient's temperature and blood pressure before the transfusion. c. Double-check the product numbers on the PRBCs with the patient ID band. d. Monitor the patient for shortness of breath or chest pain during the transfusion. 52. A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. What medication would the nurse expect the provider to order for this patient a. Histamines (H2) antagonists b. Vasopressin c. Heparin d. Antacids 53. A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. The nurse knows that varices are caused by which pathophysiologic mechanism? a. Portal hypertension resulting in diversion of blood from a high-pressure area to a low-pressure area b. Superficial mucosal erosions because of increased stress levels c. Loss of protective mechanisms resulting in the breakdown the mucosal resistance d. Inflammation and ulceration secondary to nonsteroidal anti-inflammatory 54. A patient with a history of alcoholism is admitted with esophageal bleeding. Which finding would be an indication for the administration of blood in this patient? A.Hemoglobin less than 7 g/dL B.Hematocrit less than 30% C.Altered level of consciousness D.D-dimer greater than 250 ng/mL 55. A patient is brought to the emergency department after a house fire. The patient sustained an inhalation injury. The nurse is aware that this injury predisposes the patient to the development of what complication? A.Tension pneumothorax B.Adult respiratory distress syndrome (ARDS) C.Asthma D.Lung cancer 56. A patient has been admitted with tumor lysis syndrome (TLS). Which intervention would be incorporated into the plan of care to prevent the metabolic imbalances associated with this disorder? A.Give sodium polystyrene sulfonate for hypokalemia. B.Keep urine pH below 7.0. C.Restrict all oral fluids. D.Restrict foods containing potassium. Rationale: Tumor lysis syndrome (TLS) occurs when a large number of tumor cells are rapidly destroyed, releasing their intracellular contents into the bloodstream. This can lead to several metabolic imbalances, including hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia. The goal in managing TLS is to prevent or correct these imbalances. 57. What ventilator mode has the preset positive pressure used to augment the patient's inspiratory effort and can be used as a weaning mode? a. Positive end-expiratory pressure (PEEP) b. Continuous positive airway pressure (CPAP) c. Pressure control ventilation (PCV) d. Pressure support ventilation (PSV) 58. A patient with leukemia is considering whether to have hematopoietic stem cell transplantation (HSCT). Which information would the nurse include in the patient's teaching plan? A.Donor bone marrow is transplanted through a sternal or hip incision. B.Protective isolation is required for several weeks after the stem cell transplant. C.The transplant procedure takes place in a sterile operating room to decrease the risk for infection. D. Transplant of the donated cells can be very painful because of the nerves in the tissue lining the bone. 59. A patient who has been anticoagulated with warfarin has been admitted for gastrointestinal bleeding.The history and physical examination indicated that the patient has been taking too much warfarin. The nurse will anticipate that the patient will receive which antidote? A.Vitamin E b. Vitamin K C.Protamine sulfate D.Potassium chloride 60. Which action would the nurse in the emergency department take first for a patient with cirrhosis who arrives vomiting blood? a. Insert a large-gauge IV catheter. b. Draw blood for coagulation studies. c. Check blood pressure and heart rate. d. Place the patient in the supine position. 61. When assessing an intubated patient, the nurse notes normal breath sounds on the right side of the chest and absent breath sounds on the left side of the chest. What problem should the nurse suspect? a. Right mainstem intubation b. Left pneumothorax c. Right hemothorax d. Gastric intubation Rationale: In the scenario described, normal breath sounds on the right side and absent breath sounds on the left side are indicative of a right mainstem intubation. This occurs when the endotracheal tube (ETT) is accidentally inserted too far into the right mainstem bronchus, causing ventilation to be delivered predominantly to the right lung, while the left lung does not receive air, resulting in absent breath sounds on the left side. 62. A patient has been admitted with hypovolemic shock due to traumatic blood loss. Which nursing measure can best facilitate the administration of large volumes of fluid? a. Inserting a large-diameter peripheral intravenous catheter b. Positioning the patient in the Trendelenburg position c. Encouraging the patient to drink at least 240 mL of fluid each hour. d. Administering intravenous fluids under pressure with a pressure bag. 63. A client who has undergone liver transplantation is ready to be discharged home. Which outcome of health education should the nurse prioritize? a. The client will obtain measurement of drainage from the T-tube. b. The client will exercise three times a week. c. The client will take immunosuppressive agents as required. d. The client will monitor for signs of liver dysfunction. 64. A patient was admitted to the critical care unit with acute respiratory failure. The patient has been on a ventilator for 3 days and is being considered for weaning. Which criteria would indicate that the patient is not tolerating weaning and therefore postpone weaning? a.A decrease in heart rate from 92 to 80 beats/min b. An Sp02 of 92% c. An increase in respiratory rate from 22 to 38 breaths/min d. Spontaneous tidal volumes of 300 to 350 mL Rationale: When a patient is being considered for weaning from a ventilator, it is essential to monitor several indicators of their ability to breathe independently. A significant increase in respiratory rate is one of the most important signs that the patient is not tolerating weaning and may not be ready to be extubated. A respiratory rate increase from 22 to 38 breaths per minute is indicative of respiratory distress or an inability to maintain adequate ventilation on their own. 65. A patient with acute lung failure has been on a ventilator for 3 days and is being considered for weaning. The ventilator high-pressure limit alarm keeps alarming. What would cause this problem? a. A leak in the patient's endotracheal (ET) tube cuff b. A kink in the ventilator tubing C.The patient is disconnected from the ventilator d. A faulty oxygen filter Rationale: The high-pressure limit alarm on a ventilator sounds when the pressure in the ventilator circuit exceeds a set threshold. This can happen for several reasons, but a kink in the ventilator tubing is a common cause. A kink can obstruct the flow of air, increasing resistance and causing the ventilator to exceed its high-pressure limit. This will trigger the alarm to prevent potential harm to the patient, such as barotrauma (lung injury due to excessive pressure). A leak in the patient's endotracheal (ET) tube cuff: A leak in the ET tube cuff would typically cause low pressure or low tidal volume alarms (depending on the ventilator settings), not a high-pressure limit alarm. This is because air would escape through the cuff rather than build up pressure. 66. A patient with chronic obstructive pulmonary disease (COPD) requires intubation. After the provider intubates the patient, the nurse auscultates for breath sounds. Breath sounds are questionable in this patient. Which action would best quickly assist in determining correct endotracheal tube placement in this patient? a. Stat chest radiographic examination b. End-tidal CO, monitor c. Ventilation-perfusion (V/Q) scan d. Pulmonary artery catheter insertion 67. When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, how would the nurse report the response? a. Flexion withdrawal b. Localization of pain c. Decorticate posturing d. Decerebrate posturing 68. After evacuation of an epidural hematoma, a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse requires urgent communication with the health care provider? a. Pulse of 102 beats/min b. Temperature of 101.6°F c. Intracranial pressure of 15 mm Hg d. Mean arterial pressure of 90 mm Hg 69. What two medications are commonly prescribed at discharge for a patient who had a coronary artery stent placed? a. Aspirin and clopidogrel b. Aspirin and abciximab c. Clopidogrel and eptifibatide d. Tirofiban and ticagrelor Rationale: After a coronary artery stent placement (particularly drug-eluting stents or bare-metal stents), patients are typically prescribed dual antiplatelet therapy (DAPT) to prevent stent thrombosis and reduce the risk of a heart attack or other cardiovascular events. The two most commonly used medications for DAPT are: ​ Aspirin: An antiplatelet drug that irreversibly inhibits cyclooxygenase-1 (COX-1), preventing platelet aggregation and reducing the risk of clot formation. ​ Clopidogrel: A P2Y12 receptor inhibitor that prevents platelet activation and aggregation. It is typically prescribed along with aspirin to provide additional protection against thrombosis. 70.A patient has had a kidney transplant. The nurse knows that monitoring of which parameter would have the highest priority? a. Fluid volume b. Electrolytes c. Complete blood count d. Temperature 71. A group of nurses have attended an in-service on the prevention of occupationally acquired diseases that affect health care providers. What action has the greatest potential to reduce a nurse's risk of acquiring hepatitis C in the workplace? a. Disposing of sharps appropriately and not recapping needles b. Performing meticulous hand hygiene at the appropriate moments in care c. Adhering to the recommended schedule of immunizations d. Wearing an N95 mask when providing care for clients on airborne precautions Explanation: Hepatitis C is primarily transmitted through exposure to infected blood, which is a significant risk for healthcare workers who handle needles and other sharp instruments. The most effective preventive measure for nurses to reduce the risk of acquiring hepatitis C is the proper disposal of sharps and ensuring that needles are not recapped, as this can prevent accidental needle-stick injuries, which are a primary route of transmission for the virus. 72. Which pathophysiologic event contributes to renal failure associated with tumor lysis syndrome? a. Hypocalcemia b. Elevated white blood cell count c. Metabolic acidosis d. Crystallization of uric acid in the renal tubules 73. The patient is 72 hours postoperative for a coronary artery bypass graft (CABG). The patient's vital signs include temperature 103° F, heart rate 112, respiratory rate 22, blood pressure 134/78 mm Hg, and 02 saturation 94% on 3L nasal cannula. The nurse suspects that the patient has developed what problem? a. Infection and notifies the physician immediately b. Infection, which is common postoperatively, and monitors the patient's condition c. Cardiac tamponade and notifies the physician immediately d. Delirium caused by the elevated temperature 74. When caring for a patient who has cirrhosis, which nursing action could the registered nurse (RN) delegate to assistive personnel (AP)? a.Assessing the patient for jaundice b. Providing oral hygiene after a meal c. Palpating the abdomen for distention d. Teaching the patient the prescribed diet 75. Answer is B. Neutropenia 76. After change-of-shift report on the oncology unit, which patient would the nurse assess first? a. Patient who has a platelet count of 102,000/uL after chemotherapy. b. Patient who has xerostomia after receiving head and neck radiation. c. Patient who is neutropenic and has a temperature of 100.5°F (38.1°C). d. Patient who is worried about getting the prescribed long-acting opioid on time. 77. Which statement by a patient who is being discharged from the emergency department (ED) after a concussion indicates a need for intervention by the nurse? a. "I will return if I feel dizzy or nauseated." b. "I am going to drive home and go right to bed." C."I do not even remember being in an accident today." d. "I can take acetaminophen (Tylenol) for my headache." 78. Less than 24 hours ago a patient sustained full -thickness burns to his face, chest and bilateral upper arms, in a house fire. He also sustained an inhalation injury. The patient was intubated and ventilated and is now showing signs of increasing agitation and rising peak airway pressures. The nurse suspects the patient's change in condition is due to which problem? a. Uncontrolled pain b. Hypovolemia c. Worsening hypoxemia d. Decreased pulmonary compliance 79. A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action would the nurse take first? a.Document the BP and ICP in the patient's record. b. Report the BP and ICP to the health care provider. c. Elevate the head of the patient's bed to 60 degrees. d. Continue to monitor the patient's vital signs and ICP. 80. What is the rationale for administering a fibrinolytic agent to a patient experiencing acute ST-elevation myocardial infarction (STEMI)? a. Dilation of the blocked coronary artery b. Anticoagulation to prevent formation of new emboli c. Dissolution of atherosclerotic plaque at the site of blockage d. Restoration of blood flow via lysis of the thrombus 81. The nurse has administered prescribed IV mannitol to an unconscious patient. Which parameter would the nurse monitor to determine the medication's effectiveness? a. Blood pressure b. Oxygen saturation c. Intracranial pressure d. Hemoglobin and hematocrit 82. A nurse is caring for a patient in septic shock due to urinary sepsis. Which pathophysiologic mechanism results in septic shock? a. Bacterial toxins lead to vasodilation. b. White blood cells are released to fight invading bacteria. C.Microorganisms invade organs such as the kidneys and heart. D. Decreased red blood cell production and fluid loss. 83.A patient with a history of chronic alcoholism was admitted with acute decompensated cirrhosis. What intervention would the nurse include in the patient's plan of care? a.Monitor the patient for hypovolemic shock from plasma volume depletion. b. Observe the patient for hypoglycemia and hypercalcemia. c.Initiate enteral feedings after the nasogastric tube is placed. d. Place the patient on a fluid restriction to avoid the fluid sequestration. In acute decompensated cirrhosis, especially in patients with a history of chronic alcoholism, the liver's ability to manage fluids and produce proteins (such as albumin) is compromised. This can lead to fluid shifts that result in plasma volume depletion. Although the patient may also experience fluid retention due to ascites and edema, there is often a relative hypovolemia caused by the leakage of fluid from the intravascular space into the peritoneal cavity (ascites) or other extravascular areas. Key interventions: ​ Monitoring for hypovolemic shock is important because the patient may show signs of low circulating volume, such as low blood pressure, tachycardia, and decreased urine output. ​ Fluid balance and careful monitoring of the patient's hemodynamics are crucial in the management of acute decompensated cirrhosis. 84. What is the preferred initial treatment of an acute myocardial infarction? a. Fibrinolytic therapy b.Percutaneous coronary intervention (PCI) c. Coronary artery bypass surgery (CABG) d. Implanted Cardioverter defibrillator (ICD) The preferred initial treatment for acute myocardial infarction (MI), particularly ST-elevation myocardial infarction (STEMI), is Percutaneous Coronary Intervention (PCI), also known as angioplasty with or without stent placement. ​ PCI is the most effective way to restore coronary blood flow and minimize myocardial damage if performed within 90 minutes of patient presentation to a medical facility. ​ It is the gold standard for STEMI patients when timely access to PCI is available. 85. A nurse is providing care to a patient on fibrinolytic therapy. Which statements from the patient warrants further assessment and intervention by the nurse? A."My back is killing me!" b."There is blood on my toothbrush!" C."Look at the bruise on my arm where you stuck me earlier!" d. "My arm has dry blood where my IV is!" Fibrinolytic therapy is used to break down clots in patients with acute myocardial infarction (MI) or pulmonary embolism (PE), but it carries the risk of bleeding complications. The statement "My back is killing me!" is of particular concern because: ​ Back pain could be indicative of a retroperitoneal hemorrhage (bleeding behind the peritoneum), a serious and potentially life-threatening complication of fibrinolytic therapy. This condition can occur if there is bleeding from a blood vessel in the retroperitoneal space, often associated with the femoral artery puncture site during PCI or catheterization. The blood can pool in the retroperitoneum, causing severe back pain. 86. Which nursing intervention is a priority for a patient with gastrointestinal hemorrhage from esophageal varices? a. Positioning the patient in a high-Fowler position b. Ensuring the patient has a patent airway c.Irrigating the nasogastric tube with iced saline d.Maintaining venous access so that fluids and blood can be administered 87. A 26-yr-old patient who was admitted with viral hepatitis has severe anorexia and fatigue, and is homeless. Which goal has the highest priority in the plan of care? a. Increase activity level. b. Maintain adequate nutrition. c. Establish a stable place of residence. d. Identify source of hepatitis exposure. 88. After the emergency department nurse has received a status report on the following patients with head injuries, which patient would the nurse assess first? a. A 20-yr-old patient whose cranial x-ray shows a linear skull fracture b. A 30-yr-old patient who lost consciousness for 10 seconds after a fall c. A 40-yr-old patient who has an initial Glasgow Coma Scale score of 13 d. A 50-yr-old patient whose right pupil is 10 mm, unresponsive to light. 89.The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient's nose. Which admission order would the nurse question? a. Keep the head of the bed elevated. b. b.Insert nasogastric tube to low suction. c. Turn patients side to side every 2 hours. d. Apply cold packs intermittently to face. 90. A nurse is discussing the concept of ALL the different types of shock with a new graduate nurse. Which statement indicates the new graduate nurse understood the information? a. "Shock is a physiologic state resulting in hypotension and tachycardia." b. "Shock is an acute, widespread process of inadequate tissue perfusion." C."Shock is a degenerative condition leading to organ failure and death." d. "Shock is a condition occurring with hypovolemia that results in hypotension." Multiple Response Identify one or more choices that best complete the statement or answer the question. 91. The nurse is caring for a patient who has had a recent heart transplant. Which signs and symptoms would alert the nurse that the patient is rejecting the transplant? (Select all that apply) a. Shortness of breath b. Tolerance of exercise C.Sudden onset of edema d.Decreased weight e. Pulmonary crackles 92. A patient has been admitted with acute liver failure. Which interventions would the nurse expect as part of the interprofessional collaborative management plan? (Select all that apply, one, some, or all.) a. Benzodiazepines for agitation b. Pulse oximetry and serial arterial blood gas measurements c. Insulin drip for hyperglycemia and hyperkalemia d. Monitoring electrolyte blood levels e. Assessing for signs of neurologic deficits 93.A client with end-stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the client's fluid volume excess? Select all that apply a.Administering diuretics b.Administering calcium channel blockers C.Implementing fluid restrictions D.Implementing a 1500 kcal/day restriction e. Monitoring daily weights 94. A patient has been admitted with tumor lysis syndrome (TLS). Which laboratory findings would the nurse expect to note to support this diagnosis? (Select all that apply) a. Increased calcium b. Decreased potassium c. Dysrhythmias d.Elevated blood urea nitrogen (BUN) e. Elevated creatine 95. Which interventions minimize the complications associated with suctioning an artificial airway? (Select all that apply) a. Hyperoxygenate the patient prior to the start of the procedure b. Hyperoxygenate the patient after each pass of the suction catheter C.Limit the duration of each suction pass to 20 seconds d. Instill 5 to 10 mL of normal saline to facilitate secretion removal e. Use intermittent suction to avoid damaging tracheal tissue 96. A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply. a. Immunization b. Use of standard precautions c. Consumption of a vitamin-rich diet d. Annual vitamin K injections e. Annual vitamin B12 injections 97.The nurse is caring for a patient on a mechanical ventilator that is set on 91. assist-control mode. Which statements accurately describe this function? (Select all that apply.) a.The ventilator delivers a set tidal volume. b.The ventilator delivers a set number of breaths even if the patient's rate falls. c. The ventilator automatically cuts off if the patient is breathing independently. d. The ventilator delivers more oxygen at the end of an inspiration. e. The ventilator helps prevent respiratory alkalosis. 98. Which disorders or conditions are potential causes of acute liver failure/cirrhosis? (Select all that apply) a. Alcoholism b. Hepatitis A, B, C, D, E c. Digoxin toxicity d. Chronic biliary obstruction and cholangitis e. Metabolic syndrome 99. A patient is being admitted with septic shock. The nurse appreciates that the key to treatment is finding the cause of the infection. Which cultures would the nurse obtain before initiating antibiotic therapy? (Select all that apply) a. Blood cultures b. Wound cultures c. Urine cultures d. Sputum cultures e. Complete blood count (CBC) with differential 100. The nurse at the clinic is interviewing a 54-yr-old woman who is 5 feet, 3 inches tall and weighs 125 1b (57 kg). The patient has not seen a health care provider for 20 years. With all everything She walks 5 miles most days and has a glass of wine 2 or 3 times a week. Which will the nurse plan to include in patient teaching about cancer screening and decrease cancer risk? (Select all that apply.) a. Pap testing b. Tobacco use c. Sunscreen use d. Mammography e, Colorectal screening