NUR 417 MED SURG FINAL EXAM WITH
CORRECT ANSWERS
TPN is running out what do you do: - CORRECT ANSWER- Run
dextrose 10%
Check blood sugar every 4-6 hours
Q: Esophageal varicies , hepatic portal hypertension and cirrhosis -
CORRECT ANSWER- Pushing to poop
Q: Frostbite - CORRECT ANSWER- elevate limb
A patient with cardiogenic shock has the following vital signs: BP 102/50,
pulse 128, RR 28. The pulmonary artery wedge pressure (PAWP) is
increased and cardiac output is low. The nurse will anticipate and order
for which medication? - CORRECT ANSWER- Furosemide IV
To prevent autonomic dysreflexia, which nursing action should the home
health nurse include in the plan of care for a patient who
has paraplegia at the T4 level? - CORRECT ANSWER- Assist to
plan a prescribed bowel program.
The nurse is admitting a patient who has a neck fracture at the C6 level
to the intensive care unit. Which finding on the nursing
assessment is congruent with neurogenic shock? - CORRECT
ANSWER- Hypotension and warm extremities
What should the nurse explain to the patient who has a T2 spinal cord
transection injury? - CORRECT ANSWER- Function of both arms
should be maintained.
, What should the nurse include in a rehabilitation plan as an appropriate
goal for a 30-yr-old patient with a C6 spinal cord injury? - CORRECT
ANSWER- Propel a manual wheelchair on a flat surface.
A patient with paraplegia resulting from a T9 spinal cord injury has a
neurogenic reflexic bladder. Which action should the nurse
include in the plan of care? - CORRECT ANSWER- Instruct the
patient how to self-catheterize.
A 20-yr-old patient who sustained a T2 spinal cord injury 10 days ago
tells the nurse, "I want to be transferred to a hospital where
the nurses know what they are doing." Which action should the nurse
appropriately take? - CORRECT ANSWER- Ask the patient to
provide input for the plan of care.
A 38-yr-old patient who has had a spinal cord injury returned home
following a stay in a rehabilitation facility. The home care
nurse notes the spouse is performing many of the activities that the
patient had been managing unassisted during rehabilitation.
What should the nurse identify as the most appropriate action at this
phase of rehabilitation? - CORRECT ANSWER- Develop a plan to
increase the patient's independence in consultation with the
patient and the spouse.
Which action should the nurse recognize has the highest priority for a
patient who was admitted 16 hours earlier with a C5 spinal
cord injury? - CORRECT ANSWER- Assessment of respiratory rate
and effort
A patient who had a C7 spinal cord injury 1 week ago has a weak cough
effort and crackles. What initial intervention should the
nurse perform? - CORRECT ANSWER- Push upward on the
epigastric area as the patient coughs.
A patient with a history of T3 spinal cord injury is admitted with dermal
ulcers. The patient tells the nurse, "I have a pounding
headache and I feel sick to my stomach." Which action should the nurse
take first? - CORRECT ANSWER- Assess the blood pressure (BP).
CORRECT ANSWERS
TPN is running out what do you do: - CORRECT ANSWER- Run
dextrose 10%
Check blood sugar every 4-6 hours
Q: Esophageal varicies , hepatic portal hypertension and cirrhosis -
CORRECT ANSWER- Pushing to poop
Q: Frostbite - CORRECT ANSWER- elevate limb
A patient with cardiogenic shock has the following vital signs: BP 102/50,
pulse 128, RR 28. The pulmonary artery wedge pressure (PAWP) is
increased and cardiac output is low. The nurse will anticipate and order
for which medication? - CORRECT ANSWER- Furosemide IV
To prevent autonomic dysreflexia, which nursing action should the home
health nurse include in the plan of care for a patient who
has paraplegia at the T4 level? - CORRECT ANSWER- Assist to
plan a prescribed bowel program.
The nurse is admitting a patient who has a neck fracture at the C6 level
to the intensive care unit. Which finding on the nursing
assessment is congruent with neurogenic shock? - CORRECT
ANSWER- Hypotension and warm extremities
What should the nurse explain to the patient who has a T2 spinal cord
transection injury? - CORRECT ANSWER- Function of both arms
should be maintained.
, What should the nurse include in a rehabilitation plan as an appropriate
goal for a 30-yr-old patient with a C6 spinal cord injury? - CORRECT
ANSWER- Propel a manual wheelchair on a flat surface.
A patient with paraplegia resulting from a T9 spinal cord injury has a
neurogenic reflexic bladder. Which action should the nurse
include in the plan of care? - CORRECT ANSWER- Instruct the
patient how to self-catheterize.
A 20-yr-old patient who sustained a T2 spinal cord injury 10 days ago
tells the nurse, "I want to be transferred to a hospital where
the nurses know what they are doing." Which action should the nurse
appropriately take? - CORRECT ANSWER- Ask the patient to
provide input for the plan of care.
A 38-yr-old patient who has had a spinal cord injury returned home
following a stay in a rehabilitation facility. The home care
nurse notes the spouse is performing many of the activities that the
patient had been managing unassisted during rehabilitation.
What should the nurse identify as the most appropriate action at this
phase of rehabilitation? - CORRECT ANSWER- Develop a plan to
increase the patient's independence in consultation with the
patient and the spouse.
Which action should the nurse recognize has the highest priority for a
patient who was admitted 16 hours earlier with a C5 spinal
cord injury? - CORRECT ANSWER- Assessment of respiratory rate
and effort
A patient who had a C7 spinal cord injury 1 week ago has a weak cough
effort and crackles. What initial intervention should the
nurse perform? - CORRECT ANSWER- Push upward on the
epigastric area as the patient coughs.
A patient with a history of T3 spinal cord injury is admitted with dermal
ulcers. The patient tells the nurse, "I have a pounding
headache and I feel sick to my stomach." Which action should the nurse
take first? - CORRECT ANSWER- Assess the blood pressure (BP).
