Med Surg 3 Exam 3.

MED SURG 3 EXAM 3. 1. A nurse should anticipate giving a client with a tempoparol parietal fracture which of the following meds to reduce ICP? Mannitol 2. If a clients paCO2 level rises, what happens to the cerebral blood flow? Dilates 3. An expected outcome of mannitol or furosemide administration in clients with increased ICP is? Increase urine output 4. A client diagnosed with DI has an order to receive vasopressin intranasally. Which of the following assessments indicates to a nurse that the treat is effective? Urinating 3-4 hours 5. A client with a serum sodium of 115 has a decreased LOC and is complaining of a headache. A nurse knows that the client is at risk for cerebral edema caused by? Shif t of fluid into intracellular space 6. A client is admitted to the nuerological ICU following a MVA which resulted in a closed head injury. Which of the following is an appropriate short term goal for this client? Icp shouldn’t increase 15 7. A client is brought to ER immediately after a head trauma that resulted in a fracture to the temporal bone. What clinical manifestation is considered a neurological emergency? Change in LOC 8. The family of a client with a severe head injury states that they do not understand why the client is being put into a drug induced (barbiturate) coma when brain damage may be present. Whats the nurses best response? This med is used to decrease the activity of the brain so more damage doesn’t occur 9. During assessment of a client with a head injury, a nurse notes that the arms, wrists, and fingers are flexed, and the arms are adducted. The nurse notes? Decorticate 10. The nurse is caring for a client postop who had a craniotomy. The nurse is preparing meperidine (Demerol) 100 mg when the client complains of pain of 7. The medication available on the unit is meperidine 20mg/ml. at this time, the nurse should administer? 0.5 mL and another RN to witness the waste 11. Four victims of an automobile accident are brought by ambulance to the ER. The nurse determines that the victim who has the highest priority for treatment is? Sucking chest wound 12. A client with a spinal cord injury at C3-4 is being cared for in the ER. What is the priority assessment? Monitor resp effort and oxygen saturation level 13. The nurse on the rehab unit is caring for the following clients. Which client should the nurse assess first after receiving the change of shift report? C6 spinal cord who is complaining of dyspnea and has crackles in his lungs 14. Bowel and bladder function are impaired after a complete spinal cord injury. Which of the following statements about what occurs immediately after the injury is true? NG tube usually inserted to decompress the stomach 15. A nurse is caring for a client who has had a complete cervical spine injury for many years. The client tells the nurse he has an extreme headache. The nurse assesses a blood pressure of 190/100. Which of the following interventions should be performed first? Look for kinked foley catheter and bowel impaction 16. A client with a cervical neck fracture at the c5 level is admitted to the ICU following initial treatment in the ER. During initial assessment of the client, the nurse recognizes the presence of spinal shock upon finding? Flaccid paralysis and lack of sensation below the level of injury 17. A client diagnosed with C4 cervical spine injury is treated for respiratory insufficiency. Which of these manifestations would indicate that the clients condition is worsening? SELECT ALL THAT APPLY. Reduce chest excursion pco2 of 55 and poor cough effort 18. A client is admitted with a spinal cord injury and high dose methylprednisone therapy is initiated. Which of these lab results would require immediate follow up by the nurse? Wbc of 20,000 19. The nurse expects syndrome when a client with spinal cord trauma has loss of motor function and temperature sensation below the level of the lesion while light touch, position, and vibration remain intact? Anterior cord 20. A nurse is caring for a client who is receiving chemotherapy. which intervention is most important for the nurse to implement to prevent complications from tumor lysis syndrome during chemotherapy? Ensure that the client has fluid intake of 3-5 L day 21. The nurse on the oncology unit notes a calcium level of 13. Which of the following should the nurse plan to include when caring for this client? Increase hydration and increase mobility 22. A nurse is caring for a client who has cancer and has gained 2 pounds in 24 hours. Which lab result suggest the possibility of SIADH? Serum sodium of 120 23. The nurse documents the following assessment for a 78 year old client admitted with SVC syndrome secondary to lung cancer. Nurses progress notes client awake and alert sitting in chair at bedside for past 3 hours. Complains of back pain 3/10. Responds appropriately to commands. Bilateral crackles at base cleared with cough, bilateral pedal edema 1+ bilaterally. Periorbital edema noted. Client states I cannot remove my wedding ring it is stuck on my hand. Which of the following problems are consistent with the diagnosis of SVC syndrome? SELECT ALL THAT APPLY. Periorbital swelling and ring stuck on the left hand 24. The nurse notes that a client on the oncology unit has a sodium of 120 potassium of 4.8 calcium of 9.1 and has gained 2 pounds in the past day. The client has an IV infusion of 0.9 NS at 75 ml/hr. in completing SBAR report to the physician, which of the following is most appropriately recorded in the recommendations section of the SBAR form? Change infusion iv line to saline lock 25. A nurse on the oncology unit is caring for a client who has developed SIADH. The nurse notes that the serum sodium level is 125. Which of the following interventions should the nurse anticipate to include when caring for this client? Administer fluid restriction of 1800 ml day 26. A nurse on the oncology unit is caring for a client who is receiving chemotherapy treatment. Which of the following are early signs that the client is developing tumor lysis syndrome? SELECT ALL THAT APPLY. Diarrhea muscle cramps and nausea and vomiting 27. A nurse on the oncology unit is caring for a client who is receiving treatment for small cell lung cancer. Which of the following is an early sign that the client is developing SVC syndrome? Facial edema 28. A nurse is caring for a client who has been admitted with severe sepsis. Which of the following signs would lead to nurse to suspect that DIC may be occurring? Occult blood in stool and oozing blood from intervenous site 29. Which of the following lab values should the nurse expect in a client with DIC? Plt 70,000, increase FDP, ptt, pt 30. Fresh frozen plasma is given to the client with DIC to? Replace the clotting factor 31. A transfusion of fresh frozen plasma is administered to a client with DIC. Which of the following outcomes indicates to the nurse that this treatment is effective? Bleeding from iv site stops 32. A nurse writes nursing diagnosis in planning care for a client who has DIC. Which of the following nursing diagnosis should be listed at the priority? Altered tissue perfusion related to abnormal clotting and microemboli 33. A family member reports bright red blood leaking at the venipuncture site of a client with severe anemia and peripheral cyanosis. In which order should the nurse perform the following actions? Assess for other sites of bleeding, take vital signs, notify the HCP, document 34. Which of these lab results would be most important for the nurse to assess in a client who has been diagnosed with HIT? low platelets 35. Which of these assessments found client diagnosed with HIT requires immediate nursing interventions? ST segment elevation 36. The nurse counsels a client with ITP that if medication therapy is not effective. The surgical procedure is most likely to be used in the treatment is? Splenectomy 37. A client with multiple trauma is brought to the ER. The nurse initiates two peripheral IV sies and begins fluid resuscitation with?Normal saline 38. A client admitted to med surg unit has an order to receive packed red blood cells to correct a moderate surgical blood loss. The client asks how this treatment will assist in the recovery. What is the nurses best response? Improve the ability of the blood to carry oxygen 39. A nurse in the ER assesses a client who was injured in a driving accident 2 hours earlier. A ct scan reveals a fracture of the C4 cervical vertebra. The client is breathing independently but has no movement or muscle tone from below the area of injury. The nurse understands that the client? Has Spinal shock 40. The patient is receiving a transfusion of packed red blood cells, which of these clinical manifestations would alert the nurse to the development of transfusion related acute lung injury (trail)? Pink frothy sputum