Exam 4: NUR209/ NUR 209 (New 2024/ 2025 Update) Medical Surgical Nursing II | Q&A, Exams of Nursing

Download Exam 4: NUR209/ NUR 209 (New 2024/ 2025 Update) Medical Surgical Nursing II | Q&A and more Exams Nursing in PDF only on Docsity! Exam 4: NUR209/ NUR 209 (New 2024/ 2025 Update) Medical Surgical Nursing II | Questions and Verified Answers| 100% Correct| A Grade – Fortis QUESTION Admission vital signs for a brain-injured patient are blood pressure 128/68, pulse 110, and respirations 26. Which set of vital signs, if taken 1 hour after admission, will be of most concern to the nurse? Answer: Blood pressure 154/68, pulse 56, respirations 12 QUESTION An unconscious patient is admitted to the ed with a head injury. The pa- tient's spouse and teenage children stay at pt's side and ask many questions about the treatment Answer: Allow the family to stay with the patient and briefly explain all procedures to them QUESTION A 20-year old make patient is admitted with a head injury after a collision while playing football, after noting the patient has developed clear nasal drainage, which action should the nurse take? Answer: Check drainage for glucose content QUESTION A patient who has suspected epidural hematoma is admitted to the emer- gency department. Which action will the nurse expect to take? Answer: Prepare the patient for craniotomy QUESTION The public health nurse is planning a program to decrease the incidence of meningitis in teenagers and young adults. Which action is most likely to be effective? Answer: Encourage immunization for adolescent and college freshmen QUESTION Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness (LOC). Which nursing diagnosis do they determine has the highest priority for the patient Answer: Risk for aspiration QUESTION The home health nurse caring for an 81 year old Answer: provide support to the spouse caregiver A patient is admitted to the emergency department for shock of unknown etiology. what first? Answer: Administer oxygen QUESTION The nurse is caring for a patient with subarachnoid hemorrhage who is intubated Answer: Increased jugular venous distension QUESTION after change of shift report on a ventilator wearing unit, which patient should nurse see first Answer: Patient who was successfully weaned and extubated 4 hours ago and has had no urine output for 6 hours QUESTION after change of shift report, which patient should the progressive care nurse assess first Answer: Patient who is receiving IV heparin for venous thromboem- bolism and has partial thromboplastin time of 98 seconds QUESTION A 60-year old patient has open reduction and internal fixation for an open, displaced tibial fracture, what should the nurse identify as the priority patient problem? Answer: Risk for infection QUESTION After being hospitalized for 3 days with a right femur fracture, a 32-year-old patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" Which action should the nurse take first? Answer: Administer the prescribed PRN oxygen at 4 L/min. QUESTION Which information should the nurse include when teaching a patient with acute low back pain? SATA Answer: expect symptoms of acute low back pain to improve avoid twisting activities and twisting of back prolonged use ibuprophin or tylenol QUESTION Which action should the nurse include in the plan of care for a patient with metastatic bone cancer of the left femur SATA Answer: monitor serum calcium explain the use of sustained-release opioids support the left leg when repositioning the patient Assist family and patient as they discuss the prognosis QUESTION Which action should the nurse take first when a patient is seen in an outpatient clinic with neck pain? Answer: Asking about numbness or tingling of the hands and arms QUESTION A nurse who works on the orthopedic unit just received change of shift report. Which patient should the nurse assess first? Answer: Patient who has not voided 8 hours after a laminectomy QUESTION A patient has had surgical reduction of an open fracture of the right radius. Which assessment findings should the nurse immediately report to provider? Answer: Temperature of 101.4 QUESTION A patient who's employment requires frequent lifting has a history if chronic back pain. After the nurse has taught the patient about correct body mechanics, which patient statement indicates teaching has been effective? Answer: " I will begin doing exercises to strengthen and support my back" QUESTION A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical is in place. Which actions should the nurse take? Answer: Prepare to administer atropine IV Obtain baseline body temperature Provide high-flow o2 100% by nonrebreather mask Prepare for emergent intubation and mechanical ventilation QUESTION After reviewing the information in the accompanying figure for a patient with pneumonia and sepsis, which information is most important to report to the health care provider? Answer: Platelet count and presence of petechiae QUESTION Which finding about a patient who is receiving vasopressin (Pitressin) to treat septic shock is most important for the nurse to communicate to the health care provider? Answer: The patient reports diffuse chest pressure QUESTION A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia and hypoten- sion. Which intervention ordered by the health care provider should the nurse implement first? Answer: Provide oxygen at 100% per non-rebreather mask QUESTION Which assessment information is most important for the nurse to obtain to evaluate whether treatment of a patient with anaphylactic shock has been effective? Answer: Oxygen saturation QUESTION A patient with massive trauma and possible spinal cord injury is admitted to the emergency room. Which assessment finding by the nurse will help confirm a diagnosis of neurologic shock Answer: heart rate 45 beats/minute QUESTION patient in ed, first action Answer: check oxygen QUESTION Which information obtained by the nurse about a patient with a lumbar vertebral compression fracture requires an immediate report to the health care provider? Answer: Patient has been incontinent of urine and stool QUESTION Which finding in a patient with a Colles' fracture of the left wrist is most important to communicate to the health care provider? Answer: Capillary refill to the fingers is prolonged. QUESTION Which action will the urgent care nurse take when caring for a patient who has possible knee meniscus injury? Answer: Apply a knee immobilizer to affected leg QUESTION A patient is admitted to the ed with a left femur fracture. Which assessment by the nurse is most important to report to the health care provider? Answer: Slow cap refill to the left foot