Med Surg 3 (2024/2025) FINAL EXAM
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES || ALREADY
GRADED A+ <LATEST VERSION>
The nurse in the intensive care unit (ICU) is caring for a patient diagnosed with
acute respiratory distress syndrome (ARDS). Vital signs prior to endotracheal
intubation: HR 108 bpm, RR 32 bpm, BP 88/58 mm Hg, and oxygen saturation
82%. The patient is intubated and placed on mechanical ventilation with positive
pressure ventilation. Which assessment finding indicates a further decrease of
cardiac output secondary to positive pressure ventilation? - ANSWER ✔ Urine
output 25mL/hr
Rationale:Decreased cardiac output is supported by a decrease of urine output.
Expected urine output is at least 30 mL/hr. This patient's urine output is decreased;
therefore, this finding supports the diagnosis of decreased cardiac output.
A patient admitted with smoke inhalation injuries develops signs and symptoms of
acute respiratory distress syndrome (ARDS). Which health-care provider
prescription does the nurse anticipate for this patient? - ANSWER ✔ Mechanical
ventilation
Rationale: With ARDS, it is rarely possible to maintain adequate tissue
oxygenation with oxygen therapy alone. With mechanical ventilation, the FiO2
(fraction of inspired oxygen-the percentage of oxygen administered) is set at the
lowest possible level to maintain a PaO2 higher than 60 mm Hg and oxygen
saturation of approximately 90%. It is important to remember that mechanical
,ventilation does not cure ARDS; it simply supports respiratory function while the
underlying problem is identified and treated.
The nurse caring for a patient recovering from an abdominal hysterectomy
suspects the patient is experiencing a pulmonary embolism. Which clinical
manifestation supports the nurse's suspicion? - ANSWER ✔ Dyspnea and
shortness of breath
Rationale: Manifestations of a pulmonary embolism include dyspnea, shortness of
breath, pleuritic chest pain, anxiety, apprehension, cough, tachycardia, tachypnea,
crackles, and a low-grade fever.
The nurse is concerned that a patient admitted for a total hip replacement is at risk
for thrombus formation and pulmonary embolism. Which assessment finding
supports the nurse's concern? - ANSWER ✔ Body mass index (BMI) 35.8
Rationale: Risk factors for the development of thrombus formation that could lead
to a pulmonary embolism include obesity, orthopedic surgery, myocardial
infarction, heart failure, and advancing age. The BMI of 35.8 falls into the category
of obese, which would increase the patient's risk of developing a thrombus and
possible pulmonary embolism.
The nurse is providing discharge instructions to an older adult patient who is
going home after having a total knee replacement. Which will the nurse include in
the discharge teaching to decrease the patient's risk for developing a thrombosis or
pulmonary embolism? - ANSWER ✔ Use compression stockings
Rationale: A patient being discharged after having orthopedic surgery is at
increased risk for pulmonary embolism. The nurse should instruct the patient to
continue with leg exercises and use compression stockings to reduce the risk of
deep vein thrombosis formation.
A patient diagnosed with a pulmonary embolism has a reduction in arterial oxygen
saturation level and dyspnea. Which is the priority nursing diagnosis for this
patient? - ANSWER ✔ Impaired Gas Exchange
Rationale: A reduction in arterial oxygen saturation level and dyspnea indicate the
patient is experiencing impaired gas exchange. This would be the priority for the
patient at this time.
, The nurse is planning care for a patient with a pulmonary embolism. Which
intervention would assist with the patient's decrease in cardiac output? - ANSWER
✔ Monitor pulmonary arterial pressures
Rationale: The patient with a pulmonary embolism and decreased cardiac output is
at risk for developing right heart failure. The nurse should monitor pulmonary
arterial pressures.
The nurse has instructed a patient recovering from a pulmonary embolism on
long-term anticoagulant therapy. Which patient statement indicates that instruction
has been effective? - ANSWER ✔ "I need to use a soft toothbrush and an electric
razor, and avoid injuries."
Rationale: Instruction on anticoagulant therapy should include the need to avoid
injury, use a soft toothbrush, and use an electric razor.
The nurse is preparing to discharge a patient recovering from a pulmonary
embolism. Which topics are appropriate for the nurse to include in the teaching
session? - ANSWER ✔ Anticoagulant administration schedule
Rationale: The nurse should instruct the patient in symptoms of bleeding or
recurrence of a pulmonary embolism and the schedule for anticoagulation
administration.
The nurse is providing care to several patients on a medical-surgical unit. Which
patient is at highest risk for a nonthrombotic pulmonary embolism? - ANSWER ✔
The patient who is postoperative from a femur fracture repair.
Rationale: he other patients may be at risk for pulmonary embolism; however, they
are incorrect choices for the most common cause of nonthrombotic pulmonary
emboli.
A nurse caring for a patient with a pulmonary embolism expects to find which
diagnostic result? - ANSWER ✔ Tachycardia and nonspecific T-wave changes on
EKG
Rationale: With pulmonary embolism, tachycardia and nonspecific T-wave
changes occur on EKG.
, The nurse is planning care for a newly admitted patient diagnosed with pulmonary
embolism. The nurse anticipates the patient will need anticoagulant therapy. What
is true regarding this therapy for the treatment of this condition? - ANSWER ✔
Heparin and warfarin (Coumadin) are usually initiated at the same time.
Rationale: Heparin and warfarin are usually initiated at the same time for the
treatment of pulmonary embolus.
The nurse working with a student nurse is providing care for a patient requiring
mechanical ventilation. The student nurse asks the meaning of assist control.
Which response by the nurse is the most appropriate? - ANSWER ✔ "Assist
control is a means of delivering ventilation that delivers a preset volume and/or
pressure each time the patient begins an inspiration."
Rationale: Assist control allows the patient to begin inspiration, but the ventilator
provides a preset pressure or volume to boost the patient's tidal volume.
The nurse working in the intensive care unit is assigned a patient requiring
mechanical ventilation. When responding to the ventilator alarm, the nurse sees a
high-pressure alarm. Which nursing action is the priority - ANSWER ✔ Assessing
the patient
Rationale: In most instances, depending on facility policy, if a patient requires
mechanical ventilation, he is placed on cardiorespiratory monitors with continuous
oxygen saturation monitoring. The nurse would assess heart rate and oxygen
saturation, and examine the patient for any signs of distress.
A patient receiving treatment for acute respiratory distress syndrome (ARDS) is
demonstrating anxiety and fear of having to stay on the ventilator indefinitely.
Which interventions by the nurse are appropriate? Select all that apply. -
ANSWER ✔ Instruct that intubation and ventilation are temporary measures.
Encourage family visits and participation in care.
Remain with the patient as much as possible.
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES || ALREADY
GRADED A+ <LATEST VERSION>
The nurse in the intensive care unit (ICU) is caring for a patient diagnosed with
acute respiratory distress syndrome (ARDS). Vital signs prior to endotracheal
intubation: HR 108 bpm, RR 32 bpm, BP 88/58 mm Hg, and oxygen saturation
82%. The patient is intubated and placed on mechanical ventilation with positive
pressure ventilation. Which assessment finding indicates a further decrease of
cardiac output secondary to positive pressure ventilation? - ANSWER ✔ Urine
output 25mL/hr
Rationale:Decreased cardiac output is supported by a decrease of urine output.
Expected urine output is at least 30 mL/hr. This patient's urine output is decreased;
therefore, this finding supports the diagnosis of decreased cardiac output.
A patient admitted with smoke inhalation injuries develops signs and symptoms of
acute respiratory distress syndrome (ARDS). Which health-care provider
prescription does the nurse anticipate for this patient? - ANSWER ✔ Mechanical
ventilation
Rationale: With ARDS, it is rarely possible to maintain adequate tissue
oxygenation with oxygen therapy alone. With mechanical ventilation, the FiO2
(fraction of inspired oxygen-the percentage of oxygen administered) is set at the
lowest possible level to maintain a PaO2 higher than 60 mm Hg and oxygen
saturation of approximately 90%. It is important to remember that mechanical
,ventilation does not cure ARDS; it simply supports respiratory function while the
underlying problem is identified and treated.
The nurse caring for a patient recovering from an abdominal hysterectomy
suspects the patient is experiencing a pulmonary embolism. Which clinical
manifestation supports the nurse's suspicion? - ANSWER ✔ Dyspnea and
shortness of breath
Rationale: Manifestations of a pulmonary embolism include dyspnea, shortness of
breath, pleuritic chest pain, anxiety, apprehension, cough, tachycardia, tachypnea,
crackles, and a low-grade fever.
The nurse is concerned that a patient admitted for a total hip replacement is at risk
for thrombus formation and pulmonary embolism. Which assessment finding
supports the nurse's concern? - ANSWER ✔ Body mass index (BMI) 35.8
Rationale: Risk factors for the development of thrombus formation that could lead
to a pulmonary embolism include obesity, orthopedic surgery, myocardial
infarction, heart failure, and advancing age. The BMI of 35.8 falls into the category
of obese, which would increase the patient's risk of developing a thrombus and
possible pulmonary embolism.
The nurse is providing discharge instructions to an older adult patient who is
going home after having a total knee replacement. Which will the nurse include in
the discharge teaching to decrease the patient's risk for developing a thrombosis or
pulmonary embolism? - ANSWER ✔ Use compression stockings
Rationale: A patient being discharged after having orthopedic surgery is at
increased risk for pulmonary embolism. The nurse should instruct the patient to
continue with leg exercises and use compression stockings to reduce the risk of
deep vein thrombosis formation.
A patient diagnosed with a pulmonary embolism has a reduction in arterial oxygen
saturation level and dyspnea. Which is the priority nursing diagnosis for this
patient? - ANSWER ✔ Impaired Gas Exchange
Rationale: A reduction in arterial oxygen saturation level and dyspnea indicate the
patient is experiencing impaired gas exchange. This would be the priority for the
patient at this time.
, The nurse is planning care for a patient with a pulmonary embolism. Which
intervention would assist with the patient's decrease in cardiac output? - ANSWER
✔ Monitor pulmonary arterial pressures
Rationale: The patient with a pulmonary embolism and decreased cardiac output is
at risk for developing right heart failure. The nurse should monitor pulmonary
arterial pressures.
The nurse has instructed a patient recovering from a pulmonary embolism on
long-term anticoagulant therapy. Which patient statement indicates that instruction
has been effective? - ANSWER ✔ "I need to use a soft toothbrush and an electric
razor, and avoid injuries."
Rationale: Instruction on anticoagulant therapy should include the need to avoid
injury, use a soft toothbrush, and use an electric razor.
The nurse is preparing to discharge a patient recovering from a pulmonary
embolism. Which topics are appropriate for the nurse to include in the teaching
session? - ANSWER ✔ Anticoagulant administration schedule
Rationale: The nurse should instruct the patient in symptoms of bleeding or
recurrence of a pulmonary embolism and the schedule for anticoagulation
administration.
The nurse is providing care to several patients on a medical-surgical unit. Which
patient is at highest risk for a nonthrombotic pulmonary embolism? - ANSWER ✔
The patient who is postoperative from a femur fracture repair.
Rationale: he other patients may be at risk for pulmonary embolism; however, they
are incorrect choices for the most common cause of nonthrombotic pulmonary
emboli.
A nurse caring for a patient with a pulmonary embolism expects to find which
diagnostic result? - ANSWER ✔ Tachycardia and nonspecific T-wave changes on
EKG
Rationale: With pulmonary embolism, tachycardia and nonspecific T-wave
changes occur on EKG.
, The nurse is planning care for a newly admitted patient diagnosed with pulmonary
embolism. The nurse anticipates the patient will need anticoagulant therapy. What
is true regarding this therapy for the treatment of this condition? - ANSWER ✔
Heparin and warfarin (Coumadin) are usually initiated at the same time.
Rationale: Heparin and warfarin are usually initiated at the same time for the
treatment of pulmonary embolus.
The nurse working with a student nurse is providing care for a patient requiring
mechanical ventilation. The student nurse asks the meaning of assist control.
Which response by the nurse is the most appropriate? - ANSWER ✔ "Assist
control is a means of delivering ventilation that delivers a preset volume and/or
pressure each time the patient begins an inspiration."
Rationale: Assist control allows the patient to begin inspiration, but the ventilator
provides a preset pressure or volume to boost the patient's tidal volume.
The nurse working in the intensive care unit is assigned a patient requiring
mechanical ventilation. When responding to the ventilator alarm, the nurse sees a
high-pressure alarm. Which nursing action is the priority - ANSWER ✔ Assessing
the patient
Rationale: In most instances, depending on facility policy, if a patient requires
mechanical ventilation, he is placed on cardiorespiratory monitors with continuous
oxygen saturation monitoring. The nurse would assess heart rate and oxygen
saturation, and examine the patient for any signs of distress.
A patient receiving treatment for acute respiratory distress syndrome (ARDS) is
demonstrating anxiety and fear of having to stay on the ventilator indefinitely.
Which interventions by the nurse are appropriate? Select all that apply. -
ANSWER ✔ Instruct that intubation and ventilation are temporary measures.
Encourage family visits and participation in care.
Remain with the patient as much as possible.
