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Exam 3: NSG 233 Med-Surg III Questions with verified Answers| Latest 2024/2025– Herzing
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Exam 3: NSG 233 Med-Surg III Questions with verified Answers| Latest 2024/2025– Herzing
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Exam 3: NSG 233 Med-Surg III Questionswith verified Answers – Herzing
What assessment finding should the nurse document in the EMR for a
client experiencing autonomic dysreflexia after a spinal cord injury?
Severe hypertension
Diaphoresis
Flushing above the lesion
The nurse performs a prescribed neurological check at the beginning of
the shift on a client who was admitted to the hospital with a
subarachnoid brain attack (stroke). The client's Glasgow coma scale is 9.
What information is most important for the nurse to determine?
The client's previous GCS score
As the nurse is turning a client with a chest tube, the tube becomes
dislodged from the pleural space. What action should the nurse take
first? Have the client exhale forcefully and tape three sides of a
sterile gauze over the insertion site
A client is recieving CPR. After asystole is confirmed in two leads and
sending for the trancutaneous pacemaker, which IV med should be
administered? Epinephrine
,The nurse plans to administer a low dose prescription for dopamine
(Intropin) to a client who is in septic shock. What physiological
parameter should the nurse use to evaluate the therapeutic response?
Urinary output
The nurse assess a male client postoperately who has an arterial line in
the raidal artery. Assessment findings include pallet, parastesia, and
slow capillary refill in the clients right hand fingers. What action should
the nurse take? Notify HCP
A male client is admitted to the cardiac intensive unit with chest pain
that began twelve hours ago. The nurse recognizes increased ventricular
ectopic. Based on this what action is important for the nurse to
implement? Initiate the unit's antiarrythmic protocol if
symptomatic
The nurse is assessing a client who was admitted 24 hours ago to the
critical care unit after a motercycle accident. Which finding requires
intervention by the nurse to reduce the risk for complications related to
increased ICP? Change of PaCo2 to 55mmHg following ventilator
setting adjustment
Pneumonectomy Chest Tube After a pneumonectomy, the operated
side should be dependent so that fluid in the pleural space remains
below the level of the bronchial stump and the other lung can fully
expand
, AAA- Tests The most important diagnostic indication of an
abdominal aortic aneurysm is a pulsatile mass in the middle and upper
abdomen. Most clinically significant aortic aneurysms are palpable
during routine physical examination; however, the sensitivity depends
upon the size of the aneurysm, abdominal girth of the patient (i.e.,
more difficult to find in the patient with obesity), and the skill of the
examiner. A systolic bruit may be heard over the mass. Duplex
ultrasonography or CTA is used to determine the size, length, and
location of the aneurysm. When the aneurysm is small, ultrasonography
is conducted at 6-month intervals until the aneurysm reaches a size so
that surgery to prevent rupture is of more benefit than the possible
complications of a surgical procedure. Some aneurysms remain stable
over many years of monitoring.
AAA- Post Op The patient who has had an endovascular repair must
lie supine for 6 hours; the head of the bed may be elevated up to 45
degrees after two hours. The patient needs to use a bedpan or urinal
while on bed rest. Vital signs and Doppler assessment of peripheral
pulses are performed initially every 15 minutes and then at
progressively longer intervals if the patient's status remains stable. The
access site (usually the femoral artery) is assessed when vital signs and
pulses are monitored. The nurse assesses for bleeding, pulsation,
swelling, pain, and hematoma formation. Skin changes of the lower
extremity, lumbar area, or buttocks that might indicate signs of
embolization, such as extremely tender, irregularly shaped, cyanotic
areas, as well as any changes in vital signs, pulse quality, bleeding,
swelling, pain, or hematoma, are immediately reported to the primary
provider.
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