EXAM 3 PRACTICE QUESTIONS: MED SURG 3 QUESTIONS AND CORRECT ANSWERS

EXAM 3 PRACTICE QUESTIONS: MED
SURG 3 QUESTIONS AND CORRECT
ANSWERS
AA2nurseA2isA2monitoringA2aA2clientA2forA2signsA2andA2symptomsA2relatedA2toA2superiorA2v
enaA2cavaA2syndrome.A2WhichA2ofA2theA2followingA2isA2anA2earlyA2signA2ofA2thisA2oncologi
calA2emergency?

A.A2cyanosis
B.A2armA2edema
C.A2periorbitalA2edema
D.A2mentalA2statusA2changesA2-A2Ans--C.A2periorbitalA2edema

Rationale:A2SuperiorA2venaA2cavaA2syndromeA2occursA2whenA2theA2superiorA2venaA2cava
A2isA2compressedA2orA2obstructedA2byA2tumorA2growth.A2EarlyA2signsA2andA2symptomsA2g
enerallyA2occurringA2theA2morningA2andA2includeA2edemaA2ofA2theA2face,A2especiallyA2aro
undA2theA2eyes.A2TheA2clientA2complainsA2tightnessA2aroundA2theA2neck.A2AsA2theA2compr
essionA2worsensA2theA2clientA2experiencesA2edemaA2ofA2theA2arms.A2MentalA2statusA2cha
ngesA2andA2cyanosisA2areA2lateA2signs.

TheA2burnedA2clientA2onA2admissionA2isA2droolingA2andA2havingA2difficultyA2swallowing.A2
WhatA2isA2theA2nurse'sA2bestA2firstA2action?

A.A2AssessA2levelA2ofA2consciousnessA2andA2pupillaryA2reactions.
B.A2AskA2theA2clientA2atA2whatA2timeA2foodA2orA2liquidA2wasA2lastA2consumed.
C.A2AuscultateA2breathA2soundsA2overA2theA2tracheaA2andA2mainstemA2bronchi.
D.A2MeasureA2abdominalA2girthA2andA2auscultateA2bowelA2soundsA2inA2allA2fourA2quadrant
s.A2-A2Ans--
C.A2AuscultateA2breathA2soundsA2overA2theA2tracheaA2andA2mainstemA2bronchi.

AA2burnA2clientA2whoA2isA2droolingA2andA2havingA2difficultyA2swallowingA2isA2likelyA2experie
ncingA2airwayA2issues.A2TheA2client'sA2airwayA2andA2respiratoryA2systemA2needsA2toA2beA2
assessedA2immediatelyA2andA2anA2artificialA2airwayA2andA2mechanicalA2ventilationA2mayA2
needA2toA2beA2estimatedA2beforeA2theA2airwayA2becomesA2tooA2edematous.

WhenA2assessingA2aA2patientA2whoA2spilledA2hotA2oilA2onA2theA2rightA2legA2andA2foot,A2theA
2nurseA2notesA2dry,A2pale,A2andA2hardA2skin.A2TheA2patientA2statesA2thatA2theA2burnA2isA2n
otA2painful.A2WhatA2termA2wouldA2theA2nurseA2useA2toA2documentA2theA2burnA2depth?

a.A2First-degreeA2skinA2destruction
b.A2Full-thicknessA2skinA2destruction
c.A2DeepA2partial-thicknessA2skinA2destruction

,d.A2SuperficialA2partial-thicknessA2skinA2destructionA2-A2Ans--b.A2Full-
thicknessA2skinA2destruction

-WithA2full-
thicknessA2skinA2destruction,A2theA2appearanceA2isA2paleA2andA2dryA2orA2leathery,A2andA2t
heA2areaA2isA2painlessA2becauseA2ofA2theA2associatedA2nerveA2destruction.A2
-Erythema,A2swelling,A2andA2blistersA2pointA2toA2aA2deepA2partial-thicknessA2burn.A2
-WithA2superficialA2partial-
thicknessA2burns,A2theA2areaA2isA2red,A2butA2noA2blistersA2areA2present.A2
-First-degreeA2burnsA2exhibitA2erythema,A2blanching,A2andA2pain.

OnA2admissionA2toA2theA2burnA2unit,A2aA2patientA2withA2anA2approximateA225%A2totalA2bod
yA2surfaceA2areaA2(TBSA)A2burnA2hasA2theA2followingA2initialA2laboratoryA2results:A2HctA25
8%,A2HgbA218.2A2mg/dLA2(172A2g/L),A2serumA2K+A24.9A2mEq/LA2(4.8A2mmol/
L),A2andA2serumA2Na+A2135A2mEq/LA2(135A2mmol/
L).A2WhichA2ofA2theA2followingA2prescribedA2actionsA2shouldA2beA2theA2nurse'sA2priority?

a.A2MonitoringA2urineA2outputA2everyA24A2hours.
b.A2ContinuingA2toA2monitorA2theA2laboratoryA2results.
c.A2IncreasingA2theA2rateA2ofA2theA2orderedA2IVA2solution.
d.A2TypingA2andA2crossmatchingA2forA2aA2bloodA2transfusion.A2-A2Ans--
c.A2IncreasingA2theA2rateA2ofA2theA2orderedA2IVA2solution.

TheA2patient'sA2laboratoryA2resultsA2showA2hemoconcentration,A2whichA2mayA2leadA2toA2a
A2decreaseA2inA2bloodA2flowA2toA2theA2microcirculationA2unlessA2fluidA2intakeA2isA2increase
d.A2BecauseA2theA2hematocritA2andA2hemoglobinA2areA2elevated,A2aA2transfusionA2isA2ina
ppropriate,A2althoughA2transfusionsA2mayA2beA2neededA2afterA2theA2emergentA2phaseA2on
ceA2theA2patient'sA2fluidA2balanceA2hasA2beenA2restored.A2OnA2admissionA2toA2aA2burnA2un
it,A2theA2urineA2outputA2wouldA2beA2monitoredA2moreA2oftenA2thanA2everyA24A2hoursA2(likel
yA2every1A2hour).

AA2patientA2isA2admittedA2toA2theA2burnA2unitA2withA2burnsA2toA2theA2head,A2face,A2andA2ha
nds.A2Initially,A2wheezesA2areA2heard,A2butA2anA2hourA2later,A2theA2lungA2soundsA2areA2de
creasedA2andA2noA2wheezesA2areA2audible.A2WhatA2isA2theA2bestA2actionA2forA2theA2nurseA
2toA2take?


a.A2EncourageA2theA2patientA2toA2coughA2andA2auscultateA2theA2lungsA2again.
b.A2NotifyA2theA2healthA2careA2providerA2andA2prepareA2forA2endotrachealA2intubation.
c.A2DocumentA2theA2resultsA2andA2continueA2toA2monitorA2theA2patient'sA2respiratoryA2rate.
d.A2RepositionA2theA2patientA2inA2high-
Fowler'sA2positionA2andA2reassessA2breathA2sounds.A2-A2Ans--
b.A2NotifyA2theA2healthA2careA2providerA2andA2prepareA2forA2endotrachealA2intubation.

TheA2patient'sA2historyA2andA2clinicalA2manifestationsA2suggestA2airwayA2edema,A2andA2th
eA2healthA2careA2providerA2shouldA2beA2notifiedA2immediatelyA2soA2thatA2intubationA2canA2

, beA2doneA2rapidly.A2PlacingA2theA2patientA2inA2aA2moreA2uprightA2positionA2orA2havingA2the
A2patientA2coughA2willA2notA2addressA2theA2problemA2ofA2airwayA2edema.


DuringA2theA2emergentA2phaseA2ofA2burnA2care,A2whichA2assessmentA2willA2beA2mostA2us
efulA2inA2determiningA2whetherA2theA2patientA2isA2receivingA2adequateA2fluidA2infusion?

a.A2CheckA2skinA2turgor.
c.A2AssessA2mucousA2membranes.
b.A2MonitorA2dailyA2weight.
d.A2MeasureA2hourlyA2urineA2output.A2-A2Ans--d.A2MeasureA2hourlyA2urineA2output.

WhenA2fluidA2intakeA2isA2adequate,A2theA2urineA2outputA2willA2beA2atA2leastA20.5A2toA21A2mL
/kg/
hr.A2TheA2patient'sA2weightA2isA2notA2usefulA2inA2thisA2situationA2becauseA2ofA2theA2effectsA
2ofA2thirdA2spacingA2andA2evaporativeA2fluidA2loss.A2MucousA2membraneA2assessmentA2a
ndA2skinA2turgorA2alsoA2mayA2beA2used,A2butA2theyA2areA2notA2asA2adequateA2inA2determin
ingA2thatA2fluidA2infusionsA2areA2maintainingA2adequateA2perfusion.

AA2patientA2hasA2justA2beenA2admittedA2withA2aA240%A2totalA2bodyA2surfaceA2areaA2(TBSA
)A2burnA2injury.A2ToA2maintainA2adequateA2nutrition,A2theA2nurseA2shouldA2planA2toA2takeA2
whichA2action?

a.A2AdministerA2vitaminsA2andA2mineralsA2intravenously.
b.A2InsertA2aA2feedingA2tubeA2andA2initiateA2enteralA2feedings.
c.A2InfuseA2totalA2parenteralA2nutritionA2viaA2aA2centralA2catheter.
d.A2EncourageA2anA2oralA2intakeA2ofA2atA2leastA25000A2kcalA2perA2day.A2-A2Ans--
b.A2InsertA2aA2feedingA2tubeA2andA2initiateA2enteralA2feedings.

EnteralA2feedingsA2canA2usuallyA2beA2startedA2duringA2theA2emergentA2phaseA2atA2lowA2ra
tesA2andA2increasedA2overA224A2toA248A2hoursA2toA2theA2goalA2rate.A2DuringA2theA2emerge
ntA2phase,A2theA2patientA2willA2beA2unableA2toA2eatA2enoughA2caloriesA2toA2meetA2nutrition
alA2needsA2andA2mayA2haveA2aA2paralyticA2ileusA2thatA2preventsA2adequateA2nutrientA2abs
orption.A2VitaminsA2andA2mineralsA2mayA2beA2administeredA2duringA2theA2emergentA2pha
se,A2butA2theseA2willA2notA2assistA2inA2meetingA2theA2patient'sA2caloricA2needs.A2Parenteral
A2nutritionA2increasesA2theA2infectionA2risk,A2doesA2notA2helpA2preserveA2gastrointestinalA2f
unction,A2andA2isA2notA2routinelyA2usedA2inA2burnA2patientsA2unlessA2theA2gastrointestinalA
2tractA2isA2notA2availableA2forA2use.


WhileA2theA2patient'sA2full-
thicknessA2burnA2woundsA2toA2theA2faceA2areA2exposed,A2whatA2nursingA2actionA2prevents
A2crossA2contamination?


a.A2UseA2sterileA2glovesA2whenA2removingA2dressings.
b.A2WearA2gown,A2cap,A2mask,A2andA2glovesA2duringA2care.
c.A2KeepA2theA2roomA2temperatureA2atA270°A2FA2(20°A2C)A2atA2allA2times.