NUR242 / NUR 242 Exam 3 Medical-Surgical Nursing Concepts 100% Guarantee passing score of 90% or higher

NUR242 / NUR 242 Exam 3 ss ss ss ss ss ss ss




Medical-Surgical Nursing Concepts ss ss




100% Guarantee passing score of 90% or higher
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Consist of 50 Questions with Answers
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1. The nurse recognizes that a patient with sleep apnea may benefit from which
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intervention(s)? (Select all that apply.) ss ss ss ss




A. Weight loss ss




B. Nasal mask to deliver BiPAP ss ss ss ss




C. A change in sleeping position
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D. Medication to increase daytime sleepiness ss ss ss ss




E. Position-fixing device that prevents tongue subluxation: ss ss ss ss ss ss




: ANSWER A, B, C, E
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All interventions listed are viable interventions that can be of benefit to patients
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who have sleep apnea. Patients should work with their providers of care to
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ss determine the severity of their sleep apnea and which specific interventions
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ss would be of most importance to them. Encouraging daytime sleepiness is the
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ss opposite of the effect needed for this patient.
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,2. Based on the patient's diagnosis, which clinical manifestations would
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ss the s s nurse expect to see when assessing this patient? (Select all that
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ss apply.)


A. Bradycardia
B. Shortness of breath ss ss




C. Use of accessory muscles ss ss ss




D. Sitting in a forward posture ss ss ss ss




E. Barrel chest appearance: ss ss ss




: ANSWER B, C, D, E
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The patient with COPD often has a barrel chest appearance, is short of
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ss breath, and may use accessory muscles when breathing. These patients
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ss tend to move slowly and are slightly stooped. Usually they sit with a forward-
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bending posture.With severe dyspnea, they exhibit activity intolerance and
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ss activities such as bathing and grooming are avoided.
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3. When the patient arrives to the unit, she is assessed and is in acute
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respira- tory distress. Her respirations are labored and her respiratory
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ss rate is 34. She states that she had a peak flow meter measurement of
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"Red Zone" on the way and is severely short of air. Her oxygen saturation
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is 82% on O2 at 2 L via nasal
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Based on these findings, what should the nurse do next?:
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,: ANSWER The Rapid Response Team should be notified immediately. All of
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these assessment findings indicate acute respiratory distress. The peak flow
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meter is in the RED Zone. The oxygen saturation should be at least 90% on
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ss 2 L per NC.
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4. While the Rapid Response Team is at the bedside, the patient's
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ss healthcare
provider arrives. The provider writes several orders.
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Which order is most important for the nurse to implement immediately?
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A. Transfer to ICU ss ss




B. Increase O2 to 3 L per nasal cannula ss ss ss ss ss ss ss




C. ABGs 30 minutes after oxygen is increased
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D. Methylprednisolone sodium succinate (Solu-Medrol) 40 mg IVP: ss ss ss ss ss ss ss




: ANSWER B
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All of the provider's orders are very important, but based on the patient's
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ss severe shortness of breath, the first thing that should be done is to
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ss increase her oxygen. Once her oxygen is increased, the nurse should note
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the time and remember to call for stat ABGs in 30 minutes. The patient
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should then be transferred to the ICU as soon as possible. Once the
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ss patient arrives in the ICU, they can administer the one-time dose of Solu-
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Medrol.


5. The nurse immediately checks on the patient and finds that she
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, ss appears
anxious and her vital signs are as ss ss ss ss ss ss




ss follows: ØBlood pressure: 128/84 mm ss ss ss ss




ss Hg
ØHeart rate: 114 (sinus tachycardia) ss ss ss ss




ss ØRespiratory rate: 24, labored and ss ss ss ss




ss restless ØTemperature: 99.4° F (axillary)
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ØO2 saturation: 91% on 40% O2 via trach collar
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Which of these findings are cause for concern?:
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: ANSWER **The BP is within normal range and only slightly elevated. **The
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ss temperature is only slightly elevated. **Her heart rate is elevated; the nurse
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ss should check the patient's medications to see if she is on a bronchodilator
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ss or other medication that could cause her heart rate to increase. The priority
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ss concern is the RESTLESSNESS with increased respiratory rate and the
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ss decreased oxygen saturation despite the 40% oxygen setting.
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6. A patient with a history of chronic obstructive pulmonary disease is
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ss admit- ted with shortness of breath.Which nursing intervention is most
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ss appropriate?


A. Do not administer oxygen. ss ss ss




B. Administer oxygen via Venturi mask. ss ss ss ss




C. Use nasal cannula to administer high flow oxygen.
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D. Administer oxygen at 6L per simple face mask.: ss ss ss ss ss ss ss ss




: ANSWER B
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