MED SURG 3 EXAM 3
MED SURG 3 EXAM 3
PRACTICE QUESTIONS
ACTUAL EXAM STUDY GUIDE.
GRADED A+. WITH QUESTIONS
AND 100% VERIFIED
ANSWERS. LATEST UPDATE
A nurse is monitoring a client for signs and symptoms related to superior vena
cava syndrome. Which of the following is an early sign of this oncological
emergency?
A. cyanosis
B. arm edema
C. periorbital edema
D. mental status changes - Ans✔✔-C. periorbital edema
Rationale: Superior vena cava syndrome occurs when the superior vena cava is
compressed or obstructed by tumor growth. Early signs and symptoms
generally occurring the morning and include edema of the face, especially
around the eyes. The client complains tightness around the neck. As the
,MED SURG 3 EXAM 3
compression worsens the client experiences edema of the arms. Mental status
changes and cyanosis are late signs.
The burned client on admission is drooling and having difficulty swallowing.
What is the nurse's best first action?
A. Assess level of consciousness and pupillary reactions.
B. Ask the client at what time food or liquid was last consumed.
C. Auscultate breath sounds over the trachea and mainstem bronchi.
D. Measure abdominal girth and auscultate bowel sounds in all four quadrants.
- Ans✔✔-C. Auscultate breath sounds over the trachea and mainstem bronchi.
A burn client who is drooling and having difficulty swallowing is likely
experiencing airway issues. The client's airway and respiratory system needs to
be assessed immediately and an artificial airway and mechanical ventilation
may need to be estimated before the airway becomes too edematous.
When assessing a patient who spilled hot oil on the right leg and foot, the
nurse notes dry, pale, and hard skin. The patient states that the burn is not
painful. What term would the nurse use to document the burn depth?
a. First-degree skin destruction
b. Full-thickness skin destruction
c. Deep partial-thickness skin destruction
d. Superficial partial-thickness skin destruction - Ans✔✔-b. Full-thickness skin
destruction
,MED SURG 3 EXAM 3
-With full-thickness skin destruction, the appearance is pale and dry or
leathery, and the area is painless because of the associated nerve destruction.
-Erythema, swelling, and blisters point to a deep partial-thickness burn.
-With superficial partial-thickness burns, the area is red, but no blisters are
present.
-First-degree burns exhibit erythema, blanching, and pain.
On admission to the burn unit, a patient with an approximate 25% total body
surface area (TBSA) burn has the following initial laboratory results: Hct 58%,
Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+
135 mEq/L (135 mmol/L). Which of the following prescribed actions should be
the nurse's priority?
a. Monitoring urine output every 4 hours.
b. Continuing to monitor the laboratory results.
c. Increasing the rate of the ordered IV solution.
d. Typing and crossmatching for a blood transfusion. - Ans✔✔-c. Increasing the
rate of the ordered IV solution.
The patient's laboratory results show hemoconcentration, which may lead to a
decrease in blood flow to the microcirculation unless fluid intake is increased.
Because the hematocrit and hemoglobin are elevated, a transfusion is
inappropriate, although transfusions may be needed after the emergent phase
once the patient's fluid balance has been restored. On admission to a burn
unit, the urine output would be monitored more often than every 4 hours
(likely every1 hour).
, MED SURG 3 EXAM 3
A patient is admitted to the burn unit with burns to the head, face, and hands.
Initially, wheezes are heard, but an hour later, the lung sounds are decreased
and no wheezes are audible. What is the best action for the nurse to take?
a. Encourage the patient to cough and auscultate the lungs again.
b. Notify the health care provider and prepare for endotracheal intubation.
c. Document the results and continue to monitor the patient's respiratory rate.
d. Reposition the patient in high-Fowler's position and reassess breath sounds.
- Ans✔✔-b. Notify the health care provider and prepare for endotracheal
intubation.
The patient's history and clinical manifestations suggest airway edema, and the
health care provider should be notified immediately so that intubation can be
done rapidly. Placing the patient in a more upright position or having the
patient cough will not address the problem of airway edema.
During the emergent phase of burn care, which assessment will be most useful
in determining whether the patient is receiving adequate fluid infusion?
a. Check skin turgor.
c. Assess mucous membranes.
b. Monitor daily weight.
d. Measure hourly urine output. - Ans✔✔-d. Measure hourly urine output.
When fluid intake is adequate, the urine output will be at least 0.5 to 1
mL/kg/hr. The patient's weight is not useful in this situation because of the
effects of third spacing and evaporative fluid loss. Mucous membrane
MED SURG 3 EXAM 3
PRACTICE QUESTIONS
ACTUAL EXAM STUDY GUIDE.
GRADED A+. WITH QUESTIONS
AND 100% VERIFIED
ANSWERS. LATEST UPDATE
A nurse is monitoring a client for signs and symptoms related to superior vena
cava syndrome. Which of the following is an early sign of this oncological
emergency?
A. cyanosis
B. arm edema
C. periorbital edema
D. mental status changes - Ans✔✔-C. periorbital edema
Rationale: Superior vena cava syndrome occurs when the superior vena cava is
compressed or obstructed by tumor growth. Early signs and symptoms
generally occurring the morning and include edema of the face, especially
around the eyes. The client complains tightness around the neck. As the
,MED SURG 3 EXAM 3
compression worsens the client experiences edema of the arms. Mental status
changes and cyanosis are late signs.
The burned client on admission is drooling and having difficulty swallowing.
What is the nurse's best first action?
A. Assess level of consciousness and pupillary reactions.
B. Ask the client at what time food or liquid was last consumed.
C. Auscultate breath sounds over the trachea and mainstem bronchi.
D. Measure abdominal girth and auscultate bowel sounds in all four quadrants.
- Ans✔✔-C. Auscultate breath sounds over the trachea and mainstem bronchi.
A burn client who is drooling and having difficulty swallowing is likely
experiencing airway issues. The client's airway and respiratory system needs to
be assessed immediately and an artificial airway and mechanical ventilation
may need to be estimated before the airway becomes too edematous.
When assessing a patient who spilled hot oil on the right leg and foot, the
nurse notes dry, pale, and hard skin. The patient states that the burn is not
painful. What term would the nurse use to document the burn depth?
a. First-degree skin destruction
b. Full-thickness skin destruction
c. Deep partial-thickness skin destruction
d. Superficial partial-thickness skin destruction - Ans✔✔-b. Full-thickness skin
destruction
,MED SURG 3 EXAM 3
-With full-thickness skin destruction, the appearance is pale and dry or
leathery, and the area is painless because of the associated nerve destruction.
-Erythema, swelling, and blisters point to a deep partial-thickness burn.
-With superficial partial-thickness burns, the area is red, but no blisters are
present.
-First-degree burns exhibit erythema, blanching, and pain.
On admission to the burn unit, a patient with an approximate 25% total body
surface area (TBSA) burn has the following initial laboratory results: Hct 58%,
Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+
135 mEq/L (135 mmol/L). Which of the following prescribed actions should be
the nurse's priority?
a. Monitoring urine output every 4 hours.
b. Continuing to monitor the laboratory results.
c. Increasing the rate of the ordered IV solution.
d. Typing and crossmatching for a blood transfusion. - Ans✔✔-c. Increasing the
rate of the ordered IV solution.
The patient's laboratory results show hemoconcentration, which may lead to a
decrease in blood flow to the microcirculation unless fluid intake is increased.
Because the hematocrit and hemoglobin are elevated, a transfusion is
inappropriate, although transfusions may be needed after the emergent phase
once the patient's fluid balance has been restored. On admission to a burn
unit, the urine output would be monitored more often than every 4 hours
(likely every1 hour).
, MED SURG 3 EXAM 3
A patient is admitted to the burn unit with burns to the head, face, and hands.
Initially, wheezes are heard, but an hour later, the lung sounds are decreased
and no wheezes are audible. What is the best action for the nurse to take?
a. Encourage the patient to cough and auscultate the lungs again.
b. Notify the health care provider and prepare for endotracheal intubation.
c. Document the results and continue to monitor the patient's respiratory rate.
d. Reposition the patient in high-Fowler's position and reassess breath sounds.
- Ans✔✔-b. Notify the health care provider and prepare for endotracheal
intubation.
The patient's history and clinical manifestations suggest airway edema, and the
health care provider should be notified immediately so that intubation can be
done rapidly. Placing the patient in a more upright position or having the
patient cough will not address the problem of airway edema.
During the emergent phase of burn care, which assessment will be most useful
in determining whether the patient is receiving adequate fluid infusion?
a. Check skin turgor.
c. Assess mucous membranes.
b. Monitor daily weight.
d. Measure hourly urine output. - Ans✔✔-d. Measure hourly urine output.
When fluid intake is adequate, the urine output will be at least 0.5 to 1
mL/kg/hr. The patient's weight is not useful in this situation because of the
effects of third spacing and evaporative fluid loss. Mucous membrane
