Periodical 2 Medical Surgical Nursing LectureCheck for Understanding (C.I. Lincoln T.
Sumaylo)
Total points93/100
Medical Surgical Lecture – Session 11, 12, 13, 14,15,16,17 &18.
Multiple Choice Questions Sessions 11-13
42 of 45 points
Dr. Hugo has prescribed sulfonylureas for Rebecca in the management of diabetes mellitus type
2. As a nurse, youknow that the primary purpose of sulfonylureas, such as long-acting glyburide
(Micronase), is to:*
1/1
A. Induce hypoglycemia by decreasing insulin sensitivity.
B. Improve insulin sensitivity and decrease hyperglycemia.
C. Stimulate the beta cells of the pancreas to secrete insulin.
D. Decrease insulin sensitivity by enhancing glucose uptake.
Your patient has a GI tract that is functioning, but has the inability to swallow foods. Which is
the preferred method offeeding for your patient?*
0/1
A. TPN
B. PPN
C. NG feeding
D. Oral liquid supplement
Correct answer
B. PPN
When a client is in diabetic ketoacidosis, the insulin that would be administered is:*
1/1
A. Human NPH insulin
B. Human regular insulin
C. Insulin lispro injection
D. Insulin glargine injection
When teaching a client about pancreatic function, the nurse understands that pancreatic lipase
performs whichfunction?*
1/1
A. Transport fatty acids into the brush border
B. Breaks down fat into fatty acids and glycerol
C. Triggers cholecystokinin to contract the gallbladder
D. Breaks down protein into dipeptides and amino acid
Oxygen 3L/min by nasal cannula is prescribed for Joey who is admitted to the hospital for chest
pain. The nurseinstitutes safety precautions in the room because oxygen:*
1/1
A. Supports combustion
B. Converts to an alternate form of matter
C. Has unstable properties
D. Is inflammable
The nurse is caring for a female client with active upper GI bleeding. What is the appropriate diet
for this client duringthe first 24 hours after admission?*
1/1
A. Nothing by mouth
B. Regular diet
C. Clear liquids
D. Skim milk
During the admission of a client with diabetic ketoacidosis, Nurse Kendra will anticipate the
physician ordering which ofthe following types of intravenous solution if the client cannot take
fluids orally?*
1/1
A. Lactated Ringer’s solution
B. 0.9 normal saline solution
C. 5% dextrose in water (D5W)
D. 0.45% normal saline solution
Patient admitted to ER has profuse bright-red hematemesis. During initial care of the patient, the
nurse's first priority is to:*
1/1
A. perform a nursing assessment of patient's status
B. establish 2 IV sites
C. obtain a thorough health history
D. perform a gastric lavage with cool tap water in prep for endoscopic exam
The client’s blood gases reflect diabetic acidosis. The nurse should expect:*
1/1
A. Increased pH
B. Decreased PO2
C. Increased PCO2
D. Decreased HCO3
A patient with chronic alcohol abuse is admitted with liver failure. You closely monitor the
patient’s blood pressurebecause of which change that is associated with the liver failure?*
1/1
A. Hypoalbuminemia
B. Increased capillary permeability
C. Abnormal peripheral vasodilation
D. Excess renin release of the kidney
A male client with a history of cirrhosis and alcoholism is admitted with severe dyspnea resulted
to ascites. Thenurse should be aware that the ascites is most likely the result of increased.*
1/1
A. Pressure in the portal vein
B. Production of serum albumin
C. Secretion of bile salt
D. Interstitial osmotic pressure
Which of the following chronic complications is associated with diabetes?*
1/1
A. Dizziness, dyspnea on exertion, and coronary artery disease
B. Retinopathy, neuropathy, and coronary artery disease
C. Leg ulcers, cerebral ischemic events, and pulmonary infarcts
D. Fatigue, nausea, vomiting, muscle weakness, and cardiac arrhythmias
Which of the following if stated by the nurse is correct about Hyperglycemic Hyperosmolar
Nonketotic Syndrome?*
A. This syndrome occurs mainly in people with Type I Diabetes
B. It has a higher mortality rate than Diabetic Ketoacidosis
C. The client with HHNS is in a state of over hydration
D. This condition develops very rapidly
A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a
bleeding duodenal ulcer. Theclient develops a sudden, sharp pain in the mid epigastric area along
with a rigid, board-like abdomen. These clinicalmanifestations most likely indicate which of the
following?*
1/1
A. The esophagus has become inflamed
B. Additional ulcers have developed
C. An intestinal obstruction has developed
D. The ulcers have perforated
Blood sugar is well controlled when Hemoglobin A1C is:*
1/1
A. Below 5.7%
B. Between 12%-15%
C. Less than 180 mg/dL
D. Between 90 and 130 mg/dL
What assessment finding of a patient with acute pancreatitis would indicate a bluish
discoloration around theumbilicus?*
1/1
A. Grey-Turner’s sign
B. Homan’s sign
C. Rovsing’s sign
D. Cullen’s sign
A clinical manifestation of acute pancreatitis is epigastric pain. Your nursing intervention to
facilitate relief of painwould place the patient in a:*
1/1
A. Knee chest position
B. Semi-Fowler’s position
C. Recumbent position
D. Low -Fowlers position
A 52-year-old man was referred to the clinic due to increased abdominal girth. He is diagnosed
with ascites by thepresence of a fluid thrill and shifting dullness on percussion. After
administering diuretic therapy, which nursing actionwould be most effective in ensuring safe
care?*
1/1
A. Measuring serum potassium for hyperkalemia
B. Assessing the client for hypovolemia
C. Measuring the client’s weight daily
D. Documenting precise intake and output.
A nurse performs a physical assessment on a client with type 2 DM. Findings include a fasting
blood glucose of120mg/dl, temperature of 101, pulse of 88, respirations of 22, and a BP of
140/84. Which finding would be of most concern of the nurse?*
1/1
A. Pulse
B. BP
C. Respiration
D. Temperature
Which diagnostic tests would be used first to evaluate a client with upper GI bleeding?*
1/1
A. Upper GI series
B. Arteriography
C. Endoscopy
D. Hemoglobin level and hematocrit
A patient has severe abdominal compartment syndrome and will undergo surgical
decompression. The nurse willexpect to administer which drugs before this surgery to help
reduce unstable cardiac dysrhythmias? Select all that apply*
2/2
A. Furosemide
B. Vasopressin
C. Sodium Bicarbonate
D. Epinephrine
E. Mannitol
The patient is at risk for developing intra-abdominal hypertension (IAH) after surgery to correct
abdominal trauma. Inwhich way will the nurse measure the progress of this complication?*
1/1
A. Monitoring the amount of respiratory distress exhibited by the patient
B. Monitoring the amount of gastrointestinal tube drainage
C. Measurement of abdominal distention
D. Monitoring transurethral bladder pressure
The nurse should assess for an important early indicator of acute pancreatitis, which is a
prolonged and elevatedlevel of:*
1/1
A. Serum calcium
B. Serum lipase
C. Serum bilirubin
D. Serum amylase
Pancreatitis is commonly characterized by:*
1/1
A. Edema and inflammation
B. Pleural effusion
C. Sepsis
D. Disseminated intravascular coagulation
A 24-year-old man undergoes a laparotomy after a gunshot wound to the abdomen. The patient
has multiple injuriesincluding significant liver laceration, colon injuries, multiple small bowels
and an injury to the intrahepatic vena cava. Thepatient receives 34 units of packed red blood
cells, 15 liters of crystalloid, 11 units of FFP, and 12 packs of platelets. Thepatient’s abdomen is
packed close and he is taken to the intensive care unit for further resuscitation. Which of
thefollowing is sequela of abdominal compartment syndrome?*
0/1
A. Decreased systemic vascular resistance
B. Increased intracranial pressure
C. Decreased plasma renin and aldosterone
D. Decreased peak airway pressure
Correct answer
B. Increased intracranial pressure
A major symptom of pancreatitis that brings the patient to medical care is:*
1/1
A. Severe abdominal pain
B. Fever
C. Jaundice
D. Mental agitation
Which diagnostic test is best to evaluate liver enlargement and ascites?*
1/1
A. Ultrasound
B. X-ray
C. CT Scan
D. Nuclear medicine
A nurse is caring for a client admitted to the ER with DKA. In the acute phase the priority
nursing action is to prepare to:*
A. Administer regular insulin intravenously
B. Administer 5% dextrose intravenously
C. Correct the acidosis
D. Apply an electrocardiogram monitor
Thrombus formation is a danger for all postoperative clients. The nurse should act independently
to prevent thiscomplication by:*
1/1
A. Encouraging adequate fluids
B. Performing active -assistive leg exercise
C. Massaging gently the legs with lotion
D. Applying elastic stocking
Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the
liver: Which laboratorytest indicates liver cirrhosis?*
1/1
A. Decreased red blood cell count
B. Decreased serum acid phosphatase
C. Elevated white blood cell count
D. Elevated serum aminotransferase
Develop a teaching care plan for Angie who is about to undergo a liver biopsy. Which of the
following points do youinclude?*
0/1
A. “You’ll need to lie on your stomach during the test.”
B. “You’ll need to lie on your right side after the test.”
C. “During the biopsy you’ll be asked to exhale deeply and hold it.”
D. “The biopsy is performed under general anesthesia.”
Correct answer
A. “You’ll need to lie on your stomach during the test.”
A client with suspected gastric cancer undergoes an endoscopy of the stomach. Which of the
following assessmentsmade after the procedure would indicate the development of a potential
complication?*
1/1
A. The client displays signs of sedation
B. The client demonstrates lack of appetite
C. The client complaints of a sore throat
D. The client experiences a sudden increase in temperature
Kevin has a history of peptic ulcer disease and vomits coffee-ground emesis. What does this
indicate?*
1/1
A. His gastric bleeding occurred 2 hours earlier
B. He has fresh, active upper GI bleeding
C. He needs transfusion of packed RBC
D. He needs immediate saline gastric lavage
Which of the following methods of insulin administration would be used in the initial treatment
of hyperglycemia in aclient with diabetic ketoacidosis?*
1/1
A. Subcutaneous
B. Intramuscular
C. IV bolus only
D. IV bolus, followed by continuous infusion
The principal goals of therapy for older patients who have poor glycemic control are:*
1/1
A. Enhancing quality of life.
B. Decreasing the chance of complications.
C. Improving self-care through education.
D. All of the above.
When a client is first admitted with hyperglycemic hyperosmolar nonketotic syndrome (HHNS),
the nurse’s priority is toprovide:*
1/1
A. Oxygen
B. Carbohydrates
C. Fluid replacement
D. Dietary instruction
A client is in DKA, secondary to infection. As the condition progresses, which of the following
symptoms might thenurse see?*
1/1
A. Kussmaul’s respirations and a fruity odor on the breath
B. Shallow respirations and severe abdominal pain
C. Decreased respirations and increased urine output
D. Cheyne-stokes respirations and foul-smelling urine
You’re caring for Betty with liver cirrhosis. Which of the following assessment findings leads
you to suspect hepaticencephalopathy in her?*
1/1
A. Asterixis
B. Chvostek sign
C. Trousseau’s sign
D. Hepatojugular reflex
The student nurse is teaching the family of a patient with liver failure. You instruct them to limit
which foods in thepatient’s diet?*
1/1
A. Meats and beans
B. Butter and gravies
C. Potatoes and pasta
D. Cakes and pastries
Which adaptations should the nurse caring for a client with diabetic ketoacidosis expect the
client to exhibit? Select all that apply:*
2/2
A. Sweating
B. Low PCO2
C. Retinopathy
D. Acetone breath
E. Elevated serum bicarbonate
You promote hemodynamic stability in a patient with upper GI bleeding by:*
1/1
A. Encouraging oral fluid intake.
B. Monitoring central venous pressure
C. Monitoring laboratory test results and vital signs
D. Giving blood, electrolyte and fluid replacement
A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the ER. Which
finding would a nurse expectto note as confirming this diagnosis?*
1/1
A. Elevated blood glucose level and a low plasma bicarbonate
B. Decreased urine output
C. Increased respirations and an increase in pH
D. Comatose state
For Rico who has chronic pancreatitis, which nursing intervention would be most helpful?*
1/1
A. Allowing liberalized fluid intake
B. Counseling to stop alcohol consumption
C. Encouraging daily exercise
D. Modifying dietary protein
A male client with extreme weakness, pallor, weak peripheral pulses, and disorientation is
admitted to the emergencydepartment. His wife reports that he has been “spitting up blood.” A
Mallory-Weiss tear is suspected, and the nurse beginstaking a client history from the client’s
wife. The question by the nurse that demonstrates her understanding of Mallory-Weiss tearing
is:*
1/1
A. “Tell me about your husband’s alcohol usage.”
B. Has your husband recently fallen or injured his chest?”
C. “Is your husband being treated with tuberculosis?”
D. “Describe spices and condiments your husband uses on food.”
You’re caring for Lewis, a 67 year-old patient with liver cirrhosis who developed ascites and
requires paracentesis.Relief of which symptom indicated that the paracentesis was effective?*
1/1
A. Pruritus
B. Dyspnea
C. Jaundice
D. Peripheral neuropathy
Multiple Choice Questions Sessions 14-16
26 of 28 points
The most common early sign of kidney disease is:*
1/1
A. Sodium retention
B. Elevated BUN level
C. Development of metabolic acidosis
D. Inability to dilute or concentrate urine
You have a patient that is receiving peritoneal dialysis. What should you do when you notice the
return fluid is slowlydraining?*
0/1
A. Check for kinks in the outflow tubing
B. Raise the drainage bag above the level of the abdomen
C. Place the patient in a reverse Trendelenburg position
D. Ask the patient to cough
Correct answer
A. Check for kinks in the outflow tubing
A client arrives in the emergency department with an ischemic stroke and receives tissue
plasminogen activator (t-PA)administration. Which is the priority nursing assessment?*
1/1
A. Complete physical and history.
B. Upcoming surgical procedures.
C. Time of onset of current stroke.
D. Current medications.
Which action should take the highest priority when caring for a client with hemiparesis caused
by a cerebrovascularaccident (CVA)?*
1/1
A. Apply antiembolism stockings
B. Place the client on the affected side
C. Use hand rolls or pillows for support
D. Perform passive range-of-motion (ROM) exercises
A major sensitive indicator of kidney disease is:*
1/1
A. BUN level.
B. Creatinine clearance level.
C. Serum potassium level.
D. Uric acid level.
The degree of neurologic damage that occurs with an ischemic stroke depends on the:*
1/1
A. Location of the lesion.
B. Size of the area of inadequate perfusion.
C. Amount of collateral blood flow.
D. Combination of the above factors.
In chronic renal failure (end-stage renal disease), decreased glomerular filtration leads to:*
1/1
A. Increased pH.
B. Decreased creatinine clearance.
C. Increased BUN.
D. All of the above.
What change indicates recovery in a patient with nephrotic syndrome?*
1/1
A. Disappearance of protein from the urine
B. Decrease in blood pressure to normal
C. Increase in serum lipid levels
D. Gain in body weight
Your patient with chronic renal failure reports pruritus. Which instruction should you include in
this patient’s teachingplan?*
1/1
A. Rub the skin vigorously with a towel
B. Take frequent baths
C. Apply alcohol-based emollients to the skin
D. Keep fingernails short and clean
Which sign indicated the second phase of acute renal failure?*
···/1
A. Daily doubling of urine output (4 to 5 L/day)
B. Urine output less than 400 ml/day
C. Urine output less than 100 ml/day
D. Stabilization of renal function
No correct answers
The most common cause of cerebrovascular accident is:*
1/1
A. Arteriosclerosis
B. Embolism
C. Hypertensive changes
D. Vasospasm
Your patient is complaining of muscle cramps while undergoing hemodialysis. Which
intervention is effective in relievingmuscle cramps?*
1/1
A. Increase the rate of dialysis
B. Infuse normal saline solution
C. Administer a 5% dextrose solution
D. Encourage active ROM exercises
What is a priority nursing assessment in the first 24 hours after admission of the client with a
thrombotic stroke?*
1/1
A. Echocardiogram
B. Cholesterol level
C. Pupil size and papillary response
D. Vowel sounds
A 70 year-old client with a diagnosis of left-sided cerebrovascular accident is admitted to the
facility. To prevent thedevelopment of diffuse osteoporosis, which of the following objectives is
most appropriate?*
1/1
A. Maintaining vitamin levels
B. Promoting weight-bearing exercises
C. Promoting range-of-motion (ROM) exercises
D. Maintaining protein levels
In chronic renal failure (end-stage renal disease), decreased glomerular filtration leads to:*
1/1
A. Increased pH.
B. Decreased creatinine clearance.
C. Increased BUN.
D. All of the above.
Decreased levels of erythropoietin, a substance normally secreted by the kidneys, leads to which
serious complicationof chronic renal failure?*
1/1
A. Anemia.
B. Acidosis.
C. Hyperkalemia.
D. Pericarditis.
Which sign indicated the second phase of acute renal failure?*
1/1
A. Daily doubling of urine output (4 to 5 L/day)
B. Urine output less than 400 ml/day
C. Urine output less than 100 ml/day
D. Stabilization of renal function
A 78-year old client is admitted to the emergency department with numbness and weakness of
the left arm and slurredspeech. Which nursing intervention is priority?*
1/1
A. Notify the speech pathologist for an emergency consult.
B. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
C. Discuss the precipitating factors that caused the symptoms.
D. Schedule for A STAT computer tomography (CT) scan of the head.
Which cause of hypertension is the most common in acute renal failure?*
1/1
A. Pulmonary edema
B. Hypervolemia
C. Hypovolemia
D. Anemia
During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to
control the client’s:*
1/1
A. Respirations
B. Temperature
C. Pulse
D. Blood pressure
Significant nursing assessment data relevant to renal function should include information about:*
A. Any voiding disorders.
B. The patient’s occupation.
C. The presence of hypertension or diabetes.
D. All of the above
A patient with diabetes has had many renal calculi over the past 20 years and now has chronic
renal failure. Whichsubstance must be reduced in this patient’s diet?*
1/1
A. Carbohydrates
B. Fats
C. Protein
D. Vitamin C
Frequent PVCs are noted on the cardiac monitor of a patient with end-stage renal disease. The
priority intervention is:*
1/1
A. Call the doctor immediately
B. Give the patient IV lidocaine (Xylocaine)
C. Prepare to defibrillate the patient
D. Check the patient’s latest potassium level
Dietary intervention for renal deterioration includes limiting the intake of:*
1/1
A. Fluid
B. Protein
C. Sodium and potassium
D. All of the above
Polystyrene sulfonate (Kayexalate) is used in renal failure to:*
1/1
A. Correct acidosis
B. Reduce serum phosphate levels
C. Exchange potassium for sodium
D. Prevent constipation from sorbitol use
What is the appropriate infusion time for the dialysate in your 38 year-old patient with chronic
renal failure?*
1/1
A. 15 minutes
B. 30 minutes
C. 1 hour
D. 2 to 3 hours
What is the most important nursing diagnosis for a patient in end-stage renal disease?*
1/1
A. Risk for injury
B. Fluid volume excess
C. Altered nutrition: less than body requirements
D. Activity intolerance
The majority of strokes have what type of origin?*
1/1
A. Cardiogenic emboli.
B. Cryptogenic.
C. Large artery thrombotic.
D. Small artery thrombotic.
Mr. Mendoza who has suffered a cerebrovascular accident (CVA) is too weak to move on his
own. To help the clientavoid pressure ulcers, Nurse Celia should:*
1/1
A. Reduce the client's fluid intake.
B. Encourage the client to use a footboard.
C. Perform passive range-of-motion (ROM) exercises.
D. Turn him frequently.
Multiple Choice Questions Sessions 17-18
25 of 27 points
Following the initial care of a client with asthma and impending anaphylaxis from
hypersensitivity to a drug, the nurseshould take which of the following steps next?
0/1
Administer beta-adrenergic blockers
Administer bronchodilators
Obtain serum electrolyte levels
Have the client lie flat in the bed
Correct answer
Administer bronchodilators
Emergency treatment for a client with impending anaphylaxis secondary to hypersensitivity to a
drug should includewhich of the following actions first?
1/1
Administering oxygen
Inserting an I.V. catheter
Obtaining a complete blood count (CBC)
Taking vital signs
A client comes into the ER after hitting his head in an MVA. He’s alert and oriented. Which of
the following nursinginterventions should be done first?
0/1
Assess full ROM to determine extent of injuries
Immobilize the client’s head and neck
Call for an immediate chest x-ray
Open the airway with the head-tilt chin-lift maneuver
Correct answer
Immobilize the client’s head and neck
A 20-year-old client who fell approximately 30’ is unresponsive and breathless. A cervical spine
injury is suspected.How should the first-responder open the client’s airway for rescue breathing?
1/1
By performing a jaw-thrust maneuver
By inserting a nasopharyngeal airway
By inserting a oropharyngeal airway
By performing the head-tilt, chin-lift maneuver
You are preparing a nursing care plan for the patient with SCI including the nursing diagnosis
Impaired PhysicalMobility and Self-Care Deficit. The patient tells you, “I don’t know why we’re
doing all this. My life’s over.” What additionalnursing diagnosis takes priority based on this
statement?
1/1
Risk for Injury related to altered mobility
Imbalanced Nutrition, Less Than Body Requirements
Impaired Adjustment to Spinal Cord Injury
Poor Body Image related to immobilization
An anxious 24-year-old college student complains of tingling sensations, palpitations, and chest
tightness. Deep, rapidbreathing and carpal spasms are noted. What priority nursing action should
you take?
1/1
Have the student breathes into a paper bag.
Notify the physician immediately.
Obtain an order for an anxiolytic medication.
Administer supplemental oxygen.
A patient with a spinal cord injury (SCI) complains about a severe throbbing headache that
suddenly started a shorttime ago. Assessment of the patient reveals increased blood pressure
(168/94) and decreased heart rate (48/minute),diaphoresis, and flushing of the face and neck.
What action should you take first?
1/1
Administer the ordered acetaminophen (Tylenol).
Check the Foley tubing for kinks or obstruction.
Adjust the temperature in the patient’s room.
Notify the physician about the change in status.
An anxious female client complains of chest tightness, tingling sensations, and palpitations.
Deep, rapid breathing, andcarpal spasms are noted. Which of the following priority action should
the nurse do first?
1/1
Provide oxygen therapy.
Notify the physician immediately.
Administer anxiolytic medication as ordered.
Have the client breathe into a brown paper bag.
You are helping the patient with an SCI to establish a bladder-retraining program. What
strategies may stimulate thepatient to void? (Choose all that apply).
3/3
Stroke the patient’s inner thigh.
Pull on the patient’s pubic hair.
Initiate intermittent straight catheterization.
Pour warm water over the perineum.
Tap the bladder to stimulate detrusor muscle.
A client with a C6 spinal injury would most likely have which of the following symptoms?
1/1
Aphasia
Hemiparesis
Paraplegia
Tetraplegia
The nurse is planning care for the client in neurogenic shock. Which of the following actions
would be least helpful inminimizing the effects of vasodilation below the level of the injury?
1/1
Monitoring vital signs before and during position changes
Using vasopressor medications as prescribed
Moving the client quickly as one unit
Applying Teds or compression stockings
Nurse Ejay is assigned to a telephone triage. A client called who was stung by a honeybee and is
asking for help. Theclient reports of pain and localized swelling but has no respiratory distress or
other symptoms of anaphylactic shock. Whatis the appropriate initial action that the nurse should
direct the client to perform?
1/1
Removing the stinger by scraping it.
Applying a cold compress.
Taking an oral antihistamine.
Calling the 911.
A 65-year-old patient arrived at the triage area with complaints of diaphoresis, dizziness, and
left-sided chest pain. Thispatient should be prioritized into which category?
1/1
Non-urgent.
Urgent.
Emergent.
High urgent.
A client arrived at the emergency department after suffering multiple physical injuries including
a fractured pelvis from avehicular accident. Upon assessment, the client is incoherent, pale, and
diaphoretic. With vital signs as follows:temperature of 97°F (36.11° C), blood pressure of 60/40
mm Hg, heart rate of 143 beats/minute, and a respiratory rate of30 breaths/minute. The client is
mostly suffering from which of the following shock?
1/1
Cardiogenic.
Distributive.
Hypovolemic.
Obstructive.
A patient who is in hypovolemic shock has the following clinical signs: Heart rate 120
beats/minute, blood pressure80/55 mmHg and urine output 20ml/hr. After administering an IV
fluid bolus, which of these signs if noted by thehealthcare provider is the best indication of
improved perfusion?
1/1
Heart rate drops to 100 beats/minute.
Right atrial pressure increases.
Urine output increases to 30mL/hour.
Systolic blood pressure increases to 85 mmHg.
You are pulled from the ED to the neurologic floor. Which action should you delegate to the
nursing assistant whenproviding nursing care for a patient with SCI?
1/1
Assess patient’s respiratory status every 4 hours.
Take patient’s vital signs and record every 4 hours.
Monitor nutritional status including calorie counts.
Have patient turn, cough, and deep breathe every 3 hours.
A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40,
pulse 34, dry skin, andflaccid paralysis of the lower extremities. Which of the following
conditions would most likely be suspected?
1/1
Autonomic dysreflexia
Hypervolemia
Neurogenic shock
Sepsis
After falling 20’, a 36-year-old man sustains a C6 fracture with spinal cord transaction. Which
other findings should thenurse expect?
1/1
Quadriplegia and loss of respiratory function
Loss of bowel and bladder control
Paraplegia with intercostal muscle loss
Quadriplegia with gross arm movement and diaphragmic breathing
Anaphylactic shock is associated with which type of hypersensitivity?
1/1
Type I hypersensitivity
Type II hypersensitivity
Type III hypersensitivity
Type IV hypersensitivity
The nurse is planning care for the client in spinal shock. Which of the following actions would
be least helpful inminimizing the effects of?
1/1
Using vasopressor medications as prescribed
Applying Teds or compression stockings.
Moving the client quickly as one unit
Monitoring vital signs before and during position changes
The nurse is caring for a client admitted with spinal cord injury. The nurse minimizes the risk of
compounding the injurymost effectively by:
1/1
Logrolling the client on a soft mattress
Keeping the client on a stretcher
Logrolling the client on a firm mattress
Placing the client on a Stryker frame
Nurse Kelly, a triage nurse encountered a client who complaints of mid-sternal chest pain,
dizziness, and diaphoresis.Which of the following nursing action should take priority?
1/1
Complete history taking.
Put the client on ECG monitoring.
Notify the physician.
Administer oxygen therapy via nasal cannula.
The nurse is evaluating neurological signs of the male client in neurogenic shock following
spinal cord injury. Which ofthe following observations by the nurse indicates that neurogenic
shock persists?
1/1
Positive reflexes.
Hyperreflexia.
Inability to elicit a Babinski’s reflex.
Reflex emptying of the bladder.
A patient with a spinal cord injury is recovering from neurogenic shock. The nurse realizes that
the patient should notdevelop a full bladder because what emergency condition can occur if it is
not corrected quickly?
1/1
Autonomic dysreflexia
Autonomic crisis
Autonomic shutdown
Autonomic failure
A patient with a spinal cord injury at level C3-4 is being cared for in the ED. What is the priority
assessment?
1/1
Determine the level at which the patient has intact sensation.
Assess the level at which the patient has retained mobility.
Check blood pressure and pulse for signs of spinal shock.
Monitor respiratory effort and oxygen saturation level.
Periodical 2 Medical Surgical Nursing RLECheck for Understanding
Medical Surgical RLE- Session 10, 11, 13, 14, 16 & 17
The respondent's email (japa.bucad.coc@phinmaed.com) was recorded on submission of this
form.
STUDENT ID NUMBER*
02-1920-01348
ACTIVE MOBILE NUMBER*
09057220561
SECTION*
C-03
LAST NAME, FIRST NAME (EX: VELASQUEZ, REGINE)*
BUCAD, JAQUELYN P.
Multiple Choice Questions (Sessions 10-11)
A patient with a diagnosis of esophageal varices has undergone endoscopy to gauge the
progression of this complication of liver disease. Following the completion of this diagnostic
test, what nursing intervention should nurse perform?
A) Keep patient NPO until the results of test are known.
B) Keep patient NPO until the patient’s gag reflex returns.
C) Administer analgesia until post-procedure tenderness is relieved.
D) Give the patient a cold beverage to promote swallowing ability.
During treatment of a patient with a Minnesota balloon tamponade for bleeding esophageal
varices, which nursing action will be included in the plan of care?
A. Encourage the patient to cough and deep breathe.
B. Insert the tube and verify its position q4hr.
C. Monitor the patient for shortness of breath.
D. Deflate the gastric balloon q8-12hr.
Before initiating the blood transfusion, you obtain the patient's baseline vital signs, which are:
heart rate100, blood pressure 115/72, respiratory rate 18, and temperature 100.8'F. Your next
action is to:
A. Administer the blood transfusion as ordered.
B. Hold the blood transfusion and reassess vital signs in 1 hour.
C. Notify the physician before starting the transfusion.
D. Administer 200 mL of the blood and then reassess the patient's vital signs.
A patient started receiving their first unit of blood at 10:00AM. It is now 10:10AM and the
patient is reporting itching,chills, and a headache. In addition, the patient's temperature is now
99.8'F from 98'F. Your next nursing actionis:
A. Stop the transfusion
B. Notify the physician
C. Decrease the rate of the transfusion
D. Reassure the patient that this is normal and will resolve in 30 minutes.
You promote hemodynamic stability in a patient with upper GI bleeding by:
A. Encouraging oral fluid intake.
B. Monitoring central venous pressure.
C. Monitoring laboratory test results and vital signs.
D. Giving blood, electrolyte and fluid replacement.
Before starting a blood transfusion the nurse will perform a verification process with
__________. This will include?
A. any available personnel; physician's order, patient's identification, blood bank's information, expiration
date of blood
B. licensed personnel only (another RN); physician's order, patient's identification, blood bank's
information, patient's blood type and donor's type along with Rh factor, expiration date, assess the bag of
blood for damage or abnormal substances
C. blood bank; patient's identification, blood bank's information, patient's blood type and donor's type
alongwithRhfactor, expiration date, bag of blood for damage or abnormal substances
D. licensed personnel only (another RN); blood compatibility, physician order, expiration date
Which condition is NOT a known cause of cirrhosis?
A. Obesity
B. Alcohol consumption
C. Blockage of the bile duct
D. Hepatitis C
E. All are known causes of cirrhosis
A patient with severe cirrhosis has an episode of bleeding esophageal varices. To detect possible
complications of the bleeding episode, it is most important for the nurse to monitor
A. Prothrombin time.
B. Bilirubin levels.
C. Ammonia levels.
D. Potassium levels.
What solution or solutions below are compatible with red blood cells?
A. Normal Saline
B. Dextrose Solutions
C. Any medications with normal saline
D. No solutions are compatible with blood
Why are transfusions given?
A. To increase the amount of blood
B. To increase the blood's ability to carry oxygen
C. To decrease the risk of bleeding
D. All of the above
A patient with esophageal varices is being cared for in the ICU. The varices have begun to bleed
and thepatientisatrisk for hypovolemia. The patient has Ringer’s lactate at 150 cc/hr infusing.
What else might the nurse expect to have ordered to maintain volume for this patient?
A) Arterial line
B) Diuretics
C) Foley catheter
D) Volume expanders
A patient is receiving 1 unit of packed red blood cells. The unit of blood will be done at 12:00
noon. Thepatientisscheduled to have IV antibiotics at 10:00AM. As the nurse you will:
A. Stop the blood transfusion and administer the IV antibiotic, and when the antibiotic is done resume the
blood transfusion.
B. Administer the IV antibiotic via secondary tubing into the blood transfusion’s y-tubing.
C. Hold the antibiotic until the blood transfusion is done.
D. Administer the IV antibiotic as scheduled in a second IV access site.
You're discussing to new nurse graduates about esophageal varices in patients with cirrhosis.
You ask thegraduatestolist activities that should be avoided by a patient with this condition.
Which activities listed are correct: Select all that apply
A. Excessive coughing
B. Sleeping on the back
C. Drinking juice
D. Alcohol consumption
E. Straining during a bowel movement
F. Vomiting
What blood type is known as the “universal recipient”?
A. Type A
B. Type B
C. Type AB
D. Type O
Correct answer
C. Type AB
Mr. J has a seven-year history of hepatic cirrhosis. He was brought to the emergency room
because he began vomiting large amounts of dark-red blood. An Esophageal Balloon Tamponade
tube was inserted to tamponade the bleeding esophageal varices. While the balloon tamponade is
in place, the nurse caring for Mr. J. gives the highest priority to:
A. Assessing his stools for occult blood.
B. Evaluating capillary refill in extremities.
C. Auscultating breath sounds.
D. Performing frequent mouth care.
A patient with a diagnosis of cirrhosis has developed variceal bleeding and will imminently
undergo variceal banding.What psychosocial nursing diagnosis should the nurse most likely
prioritize during this phase of the patient’s treatment?
A) Decisional Conflict
B) Deficient Knowledge
C) Death Anxiety
D) Disturbed Thought Processes
A nurse is preparing to care for a female client with esophageal varices who has just has a
Sengstaken-Blakemore Tube Inserted. The nurse gathers supplies, knowing that which of the
following items must be kept at the bedside at all times?
A. An obturator
B. Kelly clamp
C. An irrigation set
D. A pair of scissors
Correct answer
D. A pair of scissors
Before a blood transfusion you educate the patient to immediately report which of the following
signs and symptoms during the blood transfusion that could represent a transfusion reaction:
(Select all that apply).
A. Sweating
B. Chills
C. Hives
D. Tinnitus
E. Headache
F. Back pain
G. Pruritus
H. Paresthesia
I. Shortness of Breath
J. Nausea
Correct answer
A. Sweating
B. Chills
C. Hives
E. Headache
F. Back pain
G. Pruritus
I. Shortness of Breath
Your patient needs 1 unit of packed red blood cells. You've completed all the prep and the blood
bank notifies the patient's unit of blood is ready. You send for the blood and the transporter
arrives with the unit at 1200. Youknowthatyou must start transfusing the blood within
_________.
A. 5 minutes
B. 15 minutes
C. 30 minutes
D. 1 hour
What blood type is known as the “universal donor”?
A. Type A
B. Type B
C. Type AB
D. Type O
Multiple Choice Questions Sessions 13&14
The client newly diagnosed with chronic renal failure recently has begun hemodialysis. Knowing
that the client is at risk for disequilibrium syndrome, the nurse assesses the client during dialysis
for:
A. Hypertension, tachycardia, and fever
B. Headache, deteriorating level of consciousness, and twitching.
C. Restlessness, irritability, and generalized weakness
D. Hypotension, bradycardia, and hypothermia
Mrs. Johansson, who had undergone surgery in the post-anesthesia care unit (PACU), is difficult
to arouse two hours following surgery. Nurse Florence in the PACU has been administering
Morphine Sulfateintravenously to the client for complaints of post-surgical pain. The client’s
respiratory rate is 7per minute and demonstrates shallow breathing. The patient does not respond
to any stimuli! The nurse assesses the ABCs(remember Airway, Breathing, Circulation!) and
obtains ABGs STAT! Measurement of arterial bloodgasshowspH 7.10, PaCO2 70 mm Hg and
HCO3 24 mEq/L. What does this mean?
A. Respiratory acidosis, uncompensated
B. Respiratory acidosis, uncompensated
C. Metabolic, uncompensated
D. Metabolic acidosis, partially,compensated
Indications for ABG : SATA
A. Idiopathic SOB
B. COPD
C. Any respiratory condition
D. Pneumonia
E. Interstitial lung disease
The nurse is preparing to care for a client receiving peritoneal dialysis. Which of the following
would be included in the nursing plan of care to prevent the major complication associated with
peritoneal dialysis?
A. Change the catheter site dressing daily
B. Maintain strict aseptic technique
C. Add heparin to the dialysate solution
D. Monitor the client's level of consciousness
Correct answer
A. Change the catheter site dressing daily
The nurse is assisting a client on a low-potassium diet to select food items from the menu. Which
Of the following food items, if selected by the client, would indicate an understanding of this
dietary restriction?
A. Strawberries
B. Cantaloupe
C. Spinach
D. Lima beans
The nursing responsibilities after obtaining the sample include: SATA
A. Ensuring direct & proper transport to the lab with the appropriate labels
B. Documenting the procedure in the patient's chart
C. Monitoring the patient for complications.
D. Reassess puncture site at least every 5-10 minutes for 30 minutes for bleeding, bruising,
changeincolor,loss of pulse, color changes in hand
The client with chronic renal failure returns to the nursing unit following a hemodialysis
treatment. On assessment, the nurse notes that the client’s temperature is 100.2. Which of the
following is the most appropriate nursing action?
A. Continue to monitor vital signs
B. Encourage fluids
C. Monitor the site of the shunt for infection
D. Notify the physician
Factors that can cause false ABG results: SATA
A. Mixture of venous and arterial blood during puncturing
B. Air bubbles
C. Insufficient mixing with heparin (causing clotting)
D. Delayed analysis of non-cooled sample
E. hemolysis of blood cells
A client with chronic renal failure has completed a hemodialysis treatment. The nurse would use
which of the following standard indicators to evaluate the client’s status after dialysis?
A. BUN and creatinine levels
B. VS and weight
C. VS and BUN
D. Potassium level and weight
Correct answer
D. Potassium level and weight
A client newly diagnosed with renal failure is receiving peritoneal dialysis. During the infusion
of the dialysate the client complains of abdominal pain. Which action by the nurse is most
appropriate?
A. Decrease the amount to be infused
B. Explain that the pain will subside after the first few exchanges
C. Slow the infusion
D. Stop the dialysis
A cigarette vendor was brought to the emergency department of a hospital after she fell into the
ground and hurt her left leg. She is noted to be tachycardic and tachypneic. Painkillers were
carried out tolessenherpain. Suddenly, she started complaining that she is still in pain and now
experiencing muscle cramps, tingling,and paraesthesia. Measurement of arterial blood gas
reveals pH 7.6, PaO2 120 mmHg, PaCO2 31mmHg, andHCO3 25 mmol/L. What does this
mean?
A. Respiratory acidosis, uncompensated
B. Respiratory acidosis, compensated
C. Metabolic, uncompensated
D. Metabolic acidosis, partially,compensated
Correct answer
B. Respiratory acidosis, compensated
A nurse is assessing the patency of an arteriovenous fistula in the left arm of a client who is
receiving hemodialysis for the treatment of chronic renal failure. Which finding indicates that the
fistula is patent?
A. Absence of bruit on auscultation of the fistula.
B. Capillary refill time less than 3 seconds in the nail beds of the fingers on the left hand.
C. Presence of a radial pulse in the left wrist
D. Palpation of a thrill over the fistula
What does an ABG measure? SATA
A. PaO2
B. PaCO2
C. Oxygen saturation
D. Blood pH
E. Base excess
E. Blood sugar
F. Complete blood count
The nurse is performing an assessment on a client who has returned from the dialysis unit
following hemodialysis. The client is complaining of a headache and nausea and is extremely
restless. Which Of the following is the most appropriate nursing action?
A. Elevate the head of the bed
B. Medicate the client for nausea
C. Notify the physician
D. Monitor the client
In a patient undergoing surgery, it was vital to aspirate the contents of the upper gastrointestinal
tract. After the operation, the following values were acquired from an arterial blood sample:
pH7.55, PCO252mmHg and HCO3- 40 mmol/l. What is the underlying disorder?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
Carl, an elementary student, was rushed to the hospital due to vomiting and a decreased level of
consciousness. The patient displays slow and deep (Kussmaul breathing), and he is lethargic and
irritable in response to stimulation. He appears to be dehydrated—his eyes are sunken and
mucous membranes dry—and he has a two week history of polydipsia, polyuria, and weight loss.
Measurement of arterial blood gas shows pH 7.0, PaO2 90 mm Hg, PaCO2 23 mm Hg, and
HCO3 12 mmol/L; other results are Na+126 mmol/L,K+ 5 mmol/L, and Cl- 95 mmol/L. What is
your assessment?
A. Respiratory acidosis, uncompensated
B. Respiratory acidosis, compensated
C. Metabolic, uncompensated
D. Metabolic acidosis, partially compensated
Ricky’s grandmother is suffering from persistent vomiting for two days now. She appears to be
lethargic and weak and has myalgia. She is noted to have dry mucus membranes and her
capillary refill takes >4 seconds.She is diagnosed as having gastroenteritis and dehydration.
Measurement of arterial blood gas showspH7.5,PaO2 85 mm Hg, PaCO2 40 mm Hg, and HCO3
34 mmol/L. What acid-base disorder is shown?
A. Respiratory acidosis, uncompensated
B. Respiratory acidosis, compensated
C. Metabolic alkalosis, uncompensated
D. Metabolic acidosis, partially,compensated
George Kent is a 54 year old widower with a history of chronic obstructive pulmonary disease
andis rushed to the emergency department with increasing shortness of breath, pyrexia, and a
productive cough with yellow-green sputum. He has difficulty in communicating because of his
inability to completeasentence.One of his sons, Jacob, says he has been unwell for three days.
Upon examination, crackles and wheezes can be heard in the lower lobes; he has a tachycardia
and a bounding pulse. Measurement of arterial blood gas shows pH 7.3, PaCO2 68 mm Hg,
HCO3 28 mmol/L, and PaO2 60 mm Hg. How would you interpret this?
A. Respiratory acidosis, uncompensated
B. Respiratory acidosis, Partially compensated
C. Metabolic, uncompensated
D. Metabolic acidosis, partially,compensated
A client receiving hemodialysis treatment arrives at the hospital with a blood pressure of
200/100, a heart rate of 110, and a respiratory rate of 36. Oxygen saturation on room air is 89%.
He complains of shortness of breath,and +2 pedal edema is noted. His last hemodialysis
treatment was yesterday. Which of the following interventions should be done first?
A. Elevate the foot of the bed
B. Administer oxygen
C. Prepare the client for hemodialysis.
D. Restrict the client’s fluids
Dialysis allows for the exchange of particles across a semipermeable membrane by which of the
following actions?
A. Osmosis and diffusion
B. Passage of fluid toward a solution with a lower solute concentration
C. Passage of solute particles toward a solution with a higher concentration.
D. Allowing the passage of blood cells and protein molecules through it.
Which of the following clients is at greatest risk for developing acute renal failure?
A. A client with diabetes who has a heart catheterization
B. A pregnant woman who has a fractured femur
C. A dialysis client who gets influenza
D. A teenager who has an appendectomy
Multiple Choice Questions Sessions 15,16,17
Nurse Layla asks the patient to say “ah”…the uvula will move up and she also asks the patient to
swallow. She noticed that the patient can do it with ease and has no hoarseness when talking,
which cranial nerve is tested?SATA:
A. Glossopharyngeal nerve
B. Vagus nerve
C. Trigeminal nerve
D. Optic nerve
E. Accessory nerve
Olfactory nerve is:
A. Purely sensory
B. Mainly motor
C. Both A and B
D. None of the above
What possible sequence of responses is assessed in the eye component?
A. Spontaneous, None, To Pain, To Sound
B. To Pressure, None, To Spoken Word, Spontaneous
C. Spontaneous, Not Testable, To Pain, To Sound
D. Spontaneous, To Sound, To Pressure, None
In EEG, it is sometimes recommended that the patient be deprived of sleep the night before the
procedure.
A. True
B. False
The night before the procedure the patient should be instructed to wash hair and avoid applying
the following:
A. Conditioners
B. Hair Creams
C. Gel
D. All of the above
Anti-seizure agents, tranquilizers, stimulants, and depressants should be given 24 to 48 hours
before an EEG.
True
False
Correct answer
False
EEG standard procedure takes about:
A. 20-30 minute
B. 30-40 minutes
C. 45-60 minutes
D. 60 – 90 minutes
Which of the following represents the acronym for EEG?
A. Encephalogram.
B. Electric energy graph.
C. Encephalitic emotion graphing.
D. Egoenergy galvoscope.
Cranial nerve which has maximum branch in the body is:
A. Vagus nerve
B. Facial nerve
C. Trigeminal nerve
D. Glossopharynheal
The Components of “FOUR” Assessments are:
A. Eye response, Motor response, Brainstem reflexes, Respiration
B. Eye response, Motor response, Brainstem reflexes, Reflexes
C. Eye response, Motor response, Verbal, Motor
D. Eye response, Motor response, Verbal, Reflexes
When assessing a patient, what is the reason for the CHECK step in the assessment?
A. To identify factors that may interfere with the assessment
B. To look at the previous Glasgow Coma Scale assessment on the patient’s chart
C. To listen for sounds from the patient
D. None of the above
The three components of the Glasgow Coma Scale are?
A. Eyes, Motor, Pain
B. Eyes, Verbal, Motor
C. Motor, Memory
D. All of the above
When assessing cranial nerve XII in a client who has experienced a stroke, which task should the
nurse ask the client to perform?
A. Focus on a distant object
B. Stand with eyes closed
C. Turn the head to one side
D. Stick out the tongue
The patient should be instructed not to eat 8 hours prior to the procedure.
True
False
Correct answer
False
If when you approach the patient they are awake and looking at you, how would you record this
on theGlasgowComa Scale?
A. None
B. Orientated
C. Obeying commands
D. Spontaneous eye opening
A patient came into the ER who had fallen through a plate glass door. As you approach the
patient you observe that his eyes are extremely swollen and unable to open them. How would
you record the eye component of the scale?
A. No Response
B. None
C. To pain
D. Eyes Not testable (NT)
EEG is one form of treatment for patient with Tumor.
A. True
B. False
Nurse Gord provided adequate lighting and asked the client to read from a reading material held
at a distance of 36 cm, which cranial nerve is tested during this assessment?
A. Vagus nerve
B. Accessory muscle
C. Optic nerve
D. Occulomotor nerve
Nurse Zhask asks the client to smile, raise the eyebrows, frown, and puff out cheeks, close eyes
tightly. Which cranial nerve is tested?
A. Accessory nerve
B. Trigeminal nerve
C. Vagus nerve
D. Facial nerve
Sedation is required in EEG procedure.
True
False
In each component of the Glasgow Coma Scale the ‘Best Response’ is,
A. No response
B. A normal response
C. Spontaneous
D. All of the above
Correct answer
B. A normal response
EEG is useful for diagnosing and evaluating the following except:
A. Seizure disorders
B. Coma
C. Organic brain syndrome
D. None of the above
When assessing a patient, you should:
A. Observe, Move, Feel, Rate
B. Look, Feel, Rate, Stimulate
C. Check, Observe, Stimulate, Rate
D. None of the above
As part of preparation, explain to the patient events that will occur during the procedure will be
the following: SATA (Select All That Apply).
A. Patients will be asked to relax in a reclining chair or lie on a bed, and electrodes will be attached to the
scalp.
B. Assure the patient that the electrodes will not cause electrical shocks.
C. If needle electrodes are used, the patient will feel pricking sensations when they are inserted.
D. Before the recording procedure starts, the patient is instructed to relax with the eyes
closedandremainstill.
Is responsible for inferior and medial eye movement
A. Trochlear nerve
B. Trigeminal nerve
C. Optic nerve
D. Vagus nerve
Asking the client to shrug shoulders against resistance from your hands and turn head to side
against resistance from your hand, which cranial nerve does nurse Borg try to assess?
A. Accessory nerve
B. Trigeminal
C. Vagus
D. Facial
Which of the following cranial nerves is tested when you ask the client to identify a common
smell
A. Abducens nerve
B. Olfactory nerve
C. Trigeminal nerve
D. Hypoglossal nerve
Which of the following are the correct combinations for each of the three components of the
GlasgowComaScale?
A. Eyes 4 Verbal 5 Motor 6
B. Eyes 5 Verbal 4 Motor 6
C. Eyes 4 Verbal 5 Motor 5
D. None of the above