Medsurge Adult Health II final Questions With Complete
Solutions
. Burns caused by flame, flash, scald, or contact with a hot
object are examples of which type of burn injury? Correct
Answer Thermal
. Nursing priorities such as assisting the patient to resume a
functional role in society and rehabilitating following functional
and cosmetic surgeries are seen in which phase of burn care?
Correct Answer Rehabilitation phase
. Priorities of care such as removing the patient from the source
of the burn and stopping the burning process are seen in which
phase of burn care? Correct Answer (Prehospital phase)
Your book indicates that this role may also extend into the
emergent phase!
. The pathophysiology of burn shock begins with the concept of
Correct Answer (increased capillary permeability).
Fluid leaves the vascular system creating RELATIVE
HYPOVOLEMIA (and hypovolemic shock)
1. A patient who has been involved in a motor vehicle crash is
admitted to the emergency room with cool, clammy skin,
tachycardia, and hypotension. Which of the following
interventions should the nurse implement first?
A. Place the patient on continuous cardiac monitor
B. Draw blood to type and crossmatch for transfusions
C. Insert two 14-guage IV catheters
,D. Administer oxygen @ 100% per non-rebreather mask
Correct Answer D
The first priority in the initial management of shock is
maintenance of the airway and ventilation. Cardiac monitoring,
insertion of IV catheters, and obtaining blood for transfusions
also should be rapidly accomplished, but only after actions to
maximize oxygen delivery have been implemented.
1. A patient with septic shock has a BP of 70/46 mm Hg, pulse
136, respirations 32, and blood glucose of 246. Which of these
prescribed interventions will the nurse implement first?
A. Give normal saline IV @ 500 ml / hr
B. Infuse drotrocogin alpha (Xigris) 24 mcg / kg
C. Start insulin drip to maintain blood glucose between 110 and
130 mg / dL
D. Titrate norepinephrine (Levophed) to keep MAP @ 70 mm
Hg Correct Answer A
Because of the low systemic vascular resistance (SVR)
associated with septic shock, fluid resuscitation is the initial
therapy. The other actions also are appropriate and should be
initiated quickly as well.
1. A patient with shock of unknown etiology whose
hemodynamic monitoring reveals BP 92/54, pulse 64, and an
elevated pulmonary artery wedge pressure (PAWP) has the
following collaborative interventions prescribed. Which
intervention will the nurse question?
A. Infuse normal saline @ 250 ml / hr
,B. Keep HOB elevated to 30 degrees
C. Give nitroprusside (Nipride) unless systolic BP < 90
D. Titrate dobutamine (Dobutrex) to keep systolic BP > 90
Correct Answer A
The patient's elevated pulmonary artery wedge pressure
indicates volume excess. A normal saline infusion at 250 mL/hr
will exacerbate this. The other actions are appropriate for the
patient.
1. When caring for a patient who has septic shock, which
assessment finding is most important for the nurse to report to
the health care provider?
A. BP 92/56 mm Hg
B. Skin cool & clammy
C. Apical pulse 118 beats / min
D. Arterial oxygen saturation 91% Correct Answer B
Since patients in the early stage of septic shock have warm and
dry skin, the patient's cool and clammy skin indicates that shock
is progressing. The other information also will be reported, but
does not indicate deterioration of the patient's status.
1. When the nurse is assessing a patient who is receiving
nitroprusside (Nipride) infusion to treat cardiogenic shock,
which finding indicates that the medication is effective?
A. No heart murmur is audible
B. Skin is warm, pink, and dry
C. Troponin level is decreased
D. Blood pressure is 90/40 mm Hg Correct Answer B
, Warm, pink, and dry skin indicates that perfusion to tissues is
improved. Since nitroprusside is a vasodilator, the blood
pressure may be low even if the medication is effective.
Absence of a heart murmur and a decrease in troponin level are
not indicators of improvement in shock.
1. Which assessment information is most important for the nurse
to make in order to evaluate whether treatment for the patient
with anaphylactic shock has been effective?
A. Pulse rate
B. Orientation
C. Blood pressure
D. Oxygen saturation Correct Answer D
Because the airway edema that is associated with anaphylaxis
can affect airway and breathing, the oxygen saturation is the
most critical assessment. Improvements in the other assessments
also will be expected with effective treatment of anaphylactic
shock.
1. Which information obtained by the nurse when caring for a
patient who has cardiogenic shock is an indication that the
patient may be developing multiple organ dysfunction syndrome
(MODS)?
A. The patient's serum creatinine level is elevated
B. The patient complains of intermittent chest pain
C. The patient has crackles throughout both lung fields
D. The patient's extremities are cool and pulses are weak
Correct Answer A
The elevated serum creatinine level indicates that the patient has
renal failure as well as heart failure. The crackles, chest
Solutions
. Burns caused by flame, flash, scald, or contact with a hot
object are examples of which type of burn injury? Correct
Answer Thermal
. Nursing priorities such as assisting the patient to resume a
functional role in society and rehabilitating following functional
and cosmetic surgeries are seen in which phase of burn care?
Correct Answer Rehabilitation phase
. Priorities of care such as removing the patient from the source
of the burn and stopping the burning process are seen in which
phase of burn care? Correct Answer (Prehospital phase)
Your book indicates that this role may also extend into the
emergent phase!
. The pathophysiology of burn shock begins with the concept of
Correct Answer (increased capillary permeability).
Fluid leaves the vascular system creating RELATIVE
HYPOVOLEMIA (and hypovolemic shock)
1. A patient who has been involved in a motor vehicle crash is
admitted to the emergency room with cool, clammy skin,
tachycardia, and hypotension. Which of the following
interventions should the nurse implement first?
A. Place the patient on continuous cardiac monitor
B. Draw blood to type and crossmatch for transfusions
C. Insert two 14-guage IV catheters
,D. Administer oxygen @ 100% per non-rebreather mask
Correct Answer D
The first priority in the initial management of shock is
maintenance of the airway and ventilation. Cardiac monitoring,
insertion of IV catheters, and obtaining blood for transfusions
also should be rapidly accomplished, but only after actions to
maximize oxygen delivery have been implemented.
1. A patient with septic shock has a BP of 70/46 mm Hg, pulse
136, respirations 32, and blood glucose of 246. Which of these
prescribed interventions will the nurse implement first?
A. Give normal saline IV @ 500 ml / hr
B. Infuse drotrocogin alpha (Xigris) 24 mcg / kg
C. Start insulin drip to maintain blood glucose between 110 and
130 mg / dL
D. Titrate norepinephrine (Levophed) to keep MAP @ 70 mm
Hg Correct Answer A
Because of the low systemic vascular resistance (SVR)
associated with septic shock, fluid resuscitation is the initial
therapy. The other actions also are appropriate and should be
initiated quickly as well.
1. A patient with shock of unknown etiology whose
hemodynamic monitoring reveals BP 92/54, pulse 64, and an
elevated pulmonary artery wedge pressure (PAWP) has the
following collaborative interventions prescribed. Which
intervention will the nurse question?
A. Infuse normal saline @ 250 ml / hr
,B. Keep HOB elevated to 30 degrees
C. Give nitroprusside (Nipride) unless systolic BP < 90
D. Titrate dobutamine (Dobutrex) to keep systolic BP > 90
Correct Answer A
The patient's elevated pulmonary artery wedge pressure
indicates volume excess. A normal saline infusion at 250 mL/hr
will exacerbate this. The other actions are appropriate for the
patient.
1. When caring for a patient who has septic shock, which
assessment finding is most important for the nurse to report to
the health care provider?
A. BP 92/56 mm Hg
B. Skin cool & clammy
C. Apical pulse 118 beats / min
D. Arterial oxygen saturation 91% Correct Answer B
Since patients in the early stage of septic shock have warm and
dry skin, the patient's cool and clammy skin indicates that shock
is progressing. The other information also will be reported, but
does not indicate deterioration of the patient's status.
1. When the nurse is assessing a patient who is receiving
nitroprusside (Nipride) infusion to treat cardiogenic shock,
which finding indicates that the medication is effective?
A. No heart murmur is audible
B. Skin is warm, pink, and dry
C. Troponin level is decreased
D. Blood pressure is 90/40 mm Hg Correct Answer B
, Warm, pink, and dry skin indicates that perfusion to tissues is
improved. Since nitroprusside is a vasodilator, the blood
pressure may be low even if the medication is effective.
Absence of a heart murmur and a decrease in troponin level are
not indicators of improvement in shock.
1. Which assessment information is most important for the nurse
to make in order to evaluate whether treatment for the patient
with anaphylactic shock has been effective?
A. Pulse rate
B. Orientation
C. Blood pressure
D. Oxygen saturation Correct Answer D
Because the airway edema that is associated with anaphylaxis
can affect airway and breathing, the oxygen saturation is the
most critical assessment. Improvements in the other assessments
also will be expected with effective treatment of anaphylactic
shock.
1. Which information obtained by the nurse when caring for a
patient who has cardiogenic shock is an indication that the
patient may be developing multiple organ dysfunction syndrome
(MODS)?
A. The patient's serum creatinine level is elevated
B. The patient complains of intermittent chest pain
C. The patient has crackles throughout both lung fields
D. The patient's extremities are cool and pulses are weak
Correct Answer A
The elevated serum creatinine level indicates that the patient has
renal failure as well as heart failure. The crackles, chest
