ADVANCED MED SURGE EXAM 3
1. The nurse is caring for an adult client who was recently admitted with a head injury following a
motor vehicle crash. One hour ago, the client's vital signs (VS) were temperature (T): 98.6° F;
pulse (P): 110; respirations (R): 26; blood pressure (BP): 128/68 mm Hg. Which of the following
findings is a priority for the nurse to follow up?
a. P: 56; R: 14; BP: 166/52 mm Hg.
2. The nurse is caring for a client who sustained a closed head injury, is receiving mechanical
ventilation, and is at risk for developing increased intracranial pressure (ICP). Which of the
following actions should the nurse take when caring for this client?
a. Log roll the client during turning and repositioning.
3. The newly hired nurse is caring for a client who was admitted 12 hours ago with a traumatic
brain injury (TBI), is intubated, and is at risk for developing increased intracranial pressure (ICP).
Which interventions from the box below should the nurse include in the client's plan of care?
a. Avoid clustering client care activities.
b. Maintain the head in a flexed position.
c. Provide a quiet environment by limiting visitors.
d. Have the client cough and deep breathe every hour.
e. Hyper oxygenate the client before and after suctioning.
f. Avoid maintaining hips in a flexed position.
i. 1, 3, 5, 6.
4. The nurse working in the intensive care unit (ICU) is assessing a client who sustained a basilar
skull fracture 24 hours ago. It is most important to follow up with the primary health care
provider (PHCP)
a. if the client becomes irritable and restless.
5. The nurse is assessing a client who has experienced a mild traumatic brain injury (TBI). Which
findings from the box below are consistent with this diagnosis?
a. Dizziness and gait problems.
b. A widened pulse pressures.
c. Increased sensitivity to light or noise.
d. A Glasgow Coma Scale (GCS) score of 9. 5
e. Dilated pupils that are not reactive to light.
f. Amnesia about the events around the time of injury.
i. 1, 3, 6
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, ADVANCED MED SURGE EXAM 3
6. The nurse is providing discharge instructions to the parents of a 15-year-old female who
sustained a concussion while playing field back Which of the following statements by a parent
indicates a need for further teaching?
a. "We should avoid giving any acetaminophen to treat headaches.
7. The nurse is assessing clients for the risk of sustaining a traumatic brain injury (TBI). Which of
the following clients should the nurse identify as being at greatest risk?
a. 75-year-old who lives alone and has macular degeneration.
8. The nurse is providing discharge instructions to the partner of a client who sustained a mild
head injury as a result of a motor vehicle crash. Which of the following statements by a partner
indicates a need for farther teaching?
a. "It is expected that my partner will have drainage from the nose for
the next few days."
9. The nurse is caring for a client who is postoperative following a craniotomy and has developed
syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following actions should
the purse take?
a. Remove salt packets from the client's meal tray.
10. The nurse is caring for the following assigned clients. Which client should the nurse see first?
a. The client who has bacterial meningitis and has become lethargic.
11. The nurse is caring for a client who has meningitis. It is a priority for the nurse to follow up
a. if has a change in blood pressure (BP) from 132/75 to 160/56 mm
Hg.
12. The nurse is admitting a client who is diagnosed with bacterial meningitis. Which of the
following actions should the nurse take first?
a. Determine who the client has been in contact with.
13. The nurse is caring for a newly admitted client who sustained a spinal cord injury (SCI) at the
level of T5 and has the following assessment findings:
a. A decreased level of consciousness (LOC).
b. Garbled speech.
c. BP 82/44 mm Hg.
d. P 56.
e. Sa0, 88%.
Which of the following actions should the nurse take immediately?
i. Raise the head of bed (HOB) to a sitting position.
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1. The nurse is caring for an adult client who was recently admitted with a head injury following a
motor vehicle crash. One hour ago, the client's vital signs (VS) were temperature (T): 98.6° F;
pulse (P): 110; respirations (R): 26; blood pressure (BP): 128/68 mm Hg. Which of the following
findings is a priority for the nurse to follow up?
a. P: 56; R: 14; BP: 166/52 mm Hg.
2. The nurse is caring for a client who sustained a closed head injury, is receiving mechanical
ventilation, and is at risk for developing increased intracranial pressure (ICP). Which of the
following actions should the nurse take when caring for this client?
a. Log roll the client during turning and repositioning.
3. The newly hired nurse is caring for a client who was admitted 12 hours ago with a traumatic
brain injury (TBI), is intubated, and is at risk for developing increased intracranial pressure (ICP).
Which interventions from the box below should the nurse include in the client's plan of care?
a. Avoid clustering client care activities.
b. Maintain the head in a flexed position.
c. Provide a quiet environment by limiting visitors.
d. Have the client cough and deep breathe every hour.
e. Hyper oxygenate the client before and after suctioning.
f. Avoid maintaining hips in a flexed position.
i. 1, 3, 5, 6.
4. The nurse working in the intensive care unit (ICU) is assessing a client who sustained a basilar
skull fracture 24 hours ago. It is most important to follow up with the primary health care
provider (PHCP)
a. if the client becomes irritable and restless.
5. The nurse is assessing a client who has experienced a mild traumatic brain injury (TBI). Which
findings from the box below are consistent with this diagnosis?
a. Dizziness and gait problems.
b. A widened pulse pressures.
c. Increased sensitivity to light or noise.
d. A Glasgow Coma Scale (GCS) score of 9. 5
e. Dilated pupils that are not reactive to light.
f. Amnesia about the events around the time of injury.
i. 1, 3, 6
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, ADVANCED MED SURGE EXAM 3
6. The nurse is providing discharge instructions to the parents of a 15-year-old female who
sustained a concussion while playing field back Which of the following statements by a parent
indicates a need for further teaching?
a. "We should avoid giving any acetaminophen to treat headaches.
7. The nurse is assessing clients for the risk of sustaining a traumatic brain injury (TBI). Which of
the following clients should the nurse identify as being at greatest risk?
a. 75-year-old who lives alone and has macular degeneration.
8. The nurse is providing discharge instructions to the partner of a client who sustained a mild
head injury as a result of a motor vehicle crash. Which of the following statements by a partner
indicates a need for farther teaching?
a. "It is expected that my partner will have drainage from the nose for
the next few days."
9. The nurse is caring for a client who is postoperative following a craniotomy and has developed
syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following actions should
the purse take?
a. Remove salt packets from the client's meal tray.
10. The nurse is caring for the following assigned clients. Which client should the nurse see first?
a. The client who has bacterial meningitis and has become lethargic.
11. The nurse is caring for a client who has meningitis. It is a priority for the nurse to follow up
a. if has a change in blood pressure (BP) from 132/75 to 160/56 mm
Hg.
12. The nurse is admitting a client who is diagnosed with bacterial meningitis. Which of the
following actions should the nurse take first?
a. Determine who the client has been in contact with.
13. The nurse is caring for a newly admitted client who sustained a spinal cord injury (SCI) at the
level of T5 and has the following assessment findings:
a. A decreased level of consciousness (LOC).
b. Garbled speech.
c. BP 82/44 mm Hg.
d. P 56.
e. Sa0, 88%.
Which of the following actions should the nurse take immediately?
i. Raise the head of bed (HOB) to a sitting position.
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