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Nurs 547 Med Surg Proctored Exam(Examplify)
Total Questions : 48
Showing 10 questions, Sign in for moreA patient with End-stage renal disease (ESRD) has returned to the unit following hemodialysis treatment. What is the nurse's priority assessment when the patient first returns to the unit?
The critical care nurse is planning care for a patient with 25% burn injuries. Which of the following does the nurse recognize as complications for this patient that need to be considered in the plan of care? Directions for drag and drop: Click your answer choice from the possible answers box on the left and drag to the Selected Answers box on the right.
Explanation
A. Impaired mobility: Burn injuries, especially involving joints or large surface areas, can lead to contractures, pain, and decreased range of motion. Immobility increases the risk of muscle atrophy and joint stiffness, making early mobility and physical therapy essential in the plan of care.
B. Delayed wound healing: Extensive burns compromise skin integrity and the body’s immune and regenerative processes. Factors such as fluid loss, infection risk, and nutritional deficiencies can slow epithelialization, so strategies to promote optimal wound healing must be included in care planning.
C. Hypothermia: Large burn areas disrupt the skin’s thermoregulatory function, leading to excessive heat loss. Patients are at high risk for hypothermia, which can exacerbate metabolic demand, impair immune function, and complicate fluid and electrolyte management, making temperature monitoring and maintenance critical.
D. Respiratory distress: Burns, especially those involving the chest, face, or inhalation injuries, can cause airway edema, carbon monoxide exposure, or inhalation of toxic fumes. Early recognition and management of respiratory compromise, including supplemental oxygen or intubation if necessary, are vital to prevent life-threatening complications.
E. Infection: Loss of the protective skin barrier and immunosuppression due to burn shock increases susceptibility to bacterial colonization and sepsis. Infection is a leading cause of morbidity and mortality in burn patients, requiring strict aseptic techniques, wound care, and surveillance.
F. Vomiting: While vomiting may occur in some patients due to pain, medications, or stress, it is not a direct or common complication of burn injuries. It is considered a secondary concern and does not generally drive the initial plan of care for burn management.
The nurse is providing care to a patient with a 10% TBSA burn injury. Which of the following is a priority intervention for preventing infection?
The nurse is providing health promotion teaching to a patient who is at risk for developing end-stage renal disease (ESRD). Which of the following does the nurse include when discussing primary prevention of ESRD?
The trauma nurse is caring for a patient who was ejected from a motor vehicle. Which of the following alerts the nurse to the manifestations of hemorrhagic shock? Directions for drag and drop: Click your answer choice from the possible answers box on the left and drag to the Selected Answers box on the right.
Explanation
A. Tachycardia: Tachycardia is an early compensatory response to hemorrhagic shock. As blood volume decreases, the body increases heart rate to maintain cardiac output and perfusion to vital organs. Persistent tachycardia in the trauma patient signals ongoing hypovolemia and inadequate tissue perfusion.
B. Bradycardia: Bradycardia is not typical in hemorrhagic shock; it may occur in late-stage shock due to severe hypoxia or increased intracranial pressure, but it is not a primary indicator of acute blood loss or hypovolemia.
C. Numbness in the extremities: Numbness is not a direct manifestation of hemorrhagic shock. While peripheral hypoperfusion can cause coolness or pallor, sensory deficits are not a hallmark of acute blood loss.
D. Warm extremities: Warm extremities are usually associated with early sepsis or distributive shock, not hemorrhagic shock. In hypovolemic shock, peripheral vasoconstriction leads to cool, clammy extremities.
E. Hypotension: Hypotension is a classic sign of worsening hemorrhagic shock. As blood volume decreases, systemic perfusion drops, and blood pressure falls, indicating decompensation and the need for immediate intervention.
F. Hyperreactive reflexes: Hyperactive reflexes are not associated with hemorrhagic shock; they are more related to neurological disorders or metabolic disturbances, not acute hypovolemia.
G. Cool extremities: Cool, clammy skin reflects peripheral vasoconstriction as the body attempts to preserve core perfusion. It is a key physical manifestation of hypovolemic shock and indicates inadequate tissue perfusion.
H. Hypertension: Hypertension is not typical in hemorrhagic shock; it may occasionally occur transiently due to pain or anxiety, but sustained high blood pressure is not a manifestation of significant blood loss.
The critical care nurse is planning patient care at the beginning of their shift (0730). Which of the following patient's should the nurse see first?
A nurse receives shift report on a patient with renal failure who has received sodium polystyrene. The nurse reviews the patient's chart to evaluate the effectiveness of the medication. Which laboratory result would indicate to the nurse that the medication has been effective?
The patient is a 74-year-old female who presented to the emergency department with abdominal pain, diarrhea, fatigue, vomiting, and pallor
Hypertension for 10 years, controlled with lisinopril 10 mg daily
Type 2 diabetes mellitus for 15 years, on metformin 500 mg twice daily
General: Appears pale, fatigued, and mildly confused
Vital Signs: Temperature 37.9°C, HR 108 bpm, BP 92/58 mmHg, RR 24/min, O₂ saturation 95% on room air
Abdominal: Diffuse tenderness, mild distention, hyperactive bowel sounds, no guarding or rebound tenderness
Skin: Cool, clammy, poor turgor
CBC: WBC 14,800/mm³, Hgb 9.8 g/dL, Hct 30%
Electrolytes: Na⁺ 132 mEq/L, K⁺ 3.0 mEq/L, Cl⁻ 98 mEq/L, CO₂ 18 mEq/L
Stool sample: Positive for Clostridioides difficile toxin
After reviewing the patient's chart, which medications should the nurse administer?
Explanation
A. Acetaminophen: The patient may be experiencing discomfort or mild pain from abdominal cramping and systemic illness. Acetaminophen is appropriate for pain and fever management in elderly patients with hypotension and renal considerations, as it avoids the gastrointestinal and renal risks associated with NSAIDs.
B. Metronidazole: The stool test is positive for Clostridioides difficile toxin, confirming C. difficile infection. Metronidazole is an appropriate first-line antibiotic for mild to moderate C. difficile colitis, targeting the underlying bacterial cause and helping prevent further systemic complications.
C. Furosemide: The patient is hypotensive (BP 92/58 mmHg) and shows signs of dehydration and poor perfusion. Administering a diuretic like furosemide would worsen hypovolemia and could precipitate shock, so it is contraindicated.
D. Ondansetron: The patient is experiencing vomiting, which can worsen dehydration and electrolyte imbalances. Administering ondansetron can control nausea and vomiting, improving oral intake tolerance and aiding in overall fluid and electrolyte management.
E. Potassium chloride: Laboratory results reveal hypokalemia (K⁺ 3.0 mEq/L), which is clinically significant and can lead to cardiac arrhythmias, especially in a patient with fatigue and hypotension. Administering potassium chloride corrects the deficiency and helps stabilize cardiac and neuromuscular function.
The nurse is caring for a male client who reports blood in their stool and has a Hgb 5.6 g/dL (reference range 13.5-18 g/dL), Hct 16.8% (reference range 40-50%), and a WBC 3,400/mm3 (reference range 4500-11,000/mm3). The provider orders 2 units of packed red blood cells (PRBC). While monitoring the patient 10 minutes after starting the blood transfusion, the patient reports a sudden onset of chills, back pain, and appears anxious. What is the nurse's first action?
A patient with chronic renal failure requiring dialysis has missed the last two (2) dialysis sessions. Which of the following indicates that the patient is experiencing fluid volume overload? Directions: Drag and drop your choices from the Possible Answers in the left box to the Selected Answers box on the right to indicate your selected answers More than one choice may be selected
Explanation
A. 3+ edema bilateral lower extremities: Significant peripheral edema indicates fluid accumulation in the interstitial spaces. In patients with chronic renal failure who miss dialysis, excess fluid is not removed by the kidneys or dialysis, leading to dependent edema, which is a hallmark of fluid volume overload.
B. Crackles auscultated bilateral lower lobes: Pulmonary crackles are caused by fluid accumulation in the alveoli, reflecting pulmonary congestion. This is a classic sign of fluid volume overload and may progress to pulmonary edema if not addressed promptly.
C. Serum sodium level 130 mEq/L (reference range 135-145 mEq/L): Hyponatremia can occur in chronic renal failure but is not a direct indicator of fluid overload. Low sodium may reflect dilutional changes, but edema, JVD, and hypertension are more reliable clinical markers of excess fluid.
D. Blood pressure is 188/98 mmHg: Hypertension results from increased intravascular volume and elevated systemic vascular resistance. In patients missing dialysis, fluid retention contributes to elevated blood pressure, which is a major sign of fluid volume overload.
E. Jugular vein distention (JVD): Elevated central venous pressure due to fluid retention causes visible distention of the jugular veins. JVD is a key clinical indicator of fluid overload and correlates with increased intravascular volume and right-sided heart strain.
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