ACUTE CARE NURSING/// FINAL REAL
EXAM ///190 QUESTI0NS AND CORRECT
ANSWERS 2024-2025 LATEST//GRADED
A+
1. When vasoactive medications are administered, the nurse must monitor vital signs at least how
often? - answer-15 min When vasoactive medications are administered, the nurse must monitor
vitals frequently (at least every 15 minutes until stable, or more often is indicated).
2. A patient arrives at the ED via ambulance following a motor cycle accident. The paramedics state the
patient was found unconscious at the scene of the accident, but briefly regained consciousness
during transport to the hospital. Upon initial assessment, the patient's GCS score is 7. The nurse
anticipates which of the following? - answer-immediate craniotomy. The patient is experiencing an
epidural hematoma. An epidural hematoma is considered an extreme emergency; marked
neurologic deficit or even respiratory arrest can occur within minutes. Treatment consists of making
openings through the skull (burr holes) to decrease ICP emergently, remove the clot, and control the
bleeding. A craniotomy may be required to remove the clot and control the bleeding. Epidural
hematomas are often characterized by a brief loss of consciousness followed by a lucid interval in
which the patient is awake and conversant. During this lucid interval, compensation for the
expanding hematoma takes place by rapid absorption of CSF and decreased intravascular volume,
both of which help to maintain the ICP within normal limits. When these mechanisms can no longer
compensate, even a small increase in the volume of the blood clot produces a marked elevation in
ICP. The patient then becomes increasingly restless, agitated, and confused as the condition
progresses to coma.
3. Cardiogenic shock is most commonly seen in which patient population? - answer-myocardial
infarction Cardiogenic shock is seen most often in patient with myocardial infarction.
4. A nurse is participating in the emergency care of a patient who has just developed variceal bleeding.
What intervention should the nurse anticipate? - answer-IV administration of octreotide (Sandostatin).
Octreotide (Sandostatin)—a synthetic analog of the hormone somatostatin—is effective in decreasing
bleeding from esophageal varices, and lacks the vasoconstrictive effects of vasopressin. Because of this
safety and efficacy profile, octreotide is considered the preferred treatment regimen for immediate
control of variceal bleeding. Vitamin K and albumin are not administered and heparin would exacerbate,
not alleviate, bleeding.
,5. The nurse is caring for a client in the irreversible stage of shock. The nurse is explaining to the client's
family the poor prognosis. Which would the nurse be most accurate to explain as the rationale for
imminent death? - answer-Multiple organ failure. In the irreversible stage of shock, significant cells
and organs are damaged. The client's condition reaches a "point of no return" despite treatment
efforts.
Death occurs from multiple system failure as the kidneys, heart, lungs, liver, and brain cease to function.
6. The nurse is caring for a patient diagnosed with unstable angina receiving IV heparin. The patient is
placed on bleeding precautions. Bleeding precautions include which of the following measures? -
answer-Avoiding continuous BP monitoring.The patient receiving heparin is placed on bleeding
precautions, which can include: applying pressure to the site of any needle punctures for a longer
time than usual, avoiding intramuscular injections, avoiding tissue injury and bruising from trauma or
constrictive devices (e.g. continuous use of an automatic BP cuff). SQ injections are permitted; a soft
toothbrush should be used, and the patient may use nail clippers, but with caution.
7. An elderly woman found with a head injury on the floor of her home is subsequently admitted to the
neurologic ICU. What is the best rationale for the following physician orders: elevate the HOB, keep
the head in neutral alignment with no neck flexion or head rotation, avoid sharp hip flexion? -
answer-To avoid impeding venous outflow. Any activity or position that impedes venous outflow
from the head may contribute to increased volume inside the skull and possibly increase ICP.
Cerebral arterial pressure will be affected by the balance between oxygen and carbon dioxide.
Flexion contractures are not a priority at this time. Stomach contents could still be aspirated in this
position.
8. Which type of shock occurs from an antigen-antibody response? - answer-Anaphylactic. During
anaphylactic shock, an antigen-antibody reaction provokes mast cells to release potent vasoactive
substances, such as histamine or bradykinin, causing widespread vasodilation and capillary
permeability. Septic shock is a circulatory state resulting from overwhelming infection causing
relative hypovolemia. Neurogenic shock results from loss of sympathetic tone causing relative
hypovolemia. Cardiogenic shock results from impairment or failure of the myocardium.
9. The nurse is preparing to provide care for a patient diagnosed with myasthenia gravis. The nurse
should know that the signs and symptoms of the disease are the result of what? - answer-A lower
motor neuron lesion. Myasthenia gravis is characterized by a weakness of muscles, especially in the
face and throat, caused by a lower neuron lesion at the myoneural junction. It is not a genetic
disorder. A combined upper and lower neuron lesion generally occurs as a result of spinal injuries. A
lesion involving cranial nerves and their axons in the spinal cord would cause decreased conduction
of impulses at an upper motor neuron.
,10. A patient was admitted to the hospital with the following lab values: hemoglobin 5 g/dL, abnormally
shaped erythrocytes, leukocyte count 2000/mm3 with hypersegmented neutrophils and a platelet
count of 48,000/mm3. The platelets appear abnormally large. A bone marrow biopsy was competed
and revealed hyperplasia. Based on this information, the nurse determines that patient most likely
has which of the following diagnoses? - answer-Folic acid deficiency. Anemia caused by a deficiency
of folic acid cause bone marrow and peripheral blood changes. The erythrocytes that are produced
are abnormally large and are called megaloblastic red cells. Other cells derived from the myeloid
stem cell are also abnormal. A bone marrow analysis reveals hyperplasia (abnormal increase in the
number of cells). Pancytopenia (a decrease in all myeloid stem cell-derived cells) can develop. In
advanced stages of disease, the hemoglobin value may be as low as 4 to 5 g/dL, the leukocyte count
2,000 to 3,000/mm3, and the platelet count less than 50,000/mm3. Cells that are released into the
circulation are often abnormally shaped. The neutrophils are hypersegmented. The platelets may be
abnormally large. The erythrocytes are abnormally shaped.
11. The nurse is administering a medication to the client with a positive inotropic effect. Which action of
the medication does the nurse anticipate? - answer-a) Increase the force of myocardial contraction.
The nurse realizes that when administering a medication with a positive inotropic effect, the
medication increases the force of heart muscle contraction. The heart rate increases not decreases.
The central nervous system is not depressed nor is there a dilation of the bronchial tree.
12. A nurse is caring for a patient who has been admitted for the treatment of advanced cirrhosis. What
assessment should the nurse prioritize in this patient's plan of care? - answer-d) Assessment for
variceal bleeding. Esophageal varices are a major cause of mortality in patients with uncompensated
cirrhosis. Consequently, this should be a focus of the nurse's assessments and should be prioritized
over the other listed assessments, even though each should be performed.
13. An 80-year-old male client who has been informed by his physician that he has arteriosclerosis is
confused by what this means. The nurse explains that arteriosclerosis is a: - answer-c) Expected part
of the aging process. Arteriosclerosis is loss of elasticity or hardening of the arteries that
accompanies the aging process. While arteriosclerosis is a contributing factor to vascular occlusive
disease, it is a term that refers to a loss of elasticity or hardening of the arteries that accompanies
the aging process.
Atherosclerosis is a condition in which the lumen of arteries fill with fatty deposits called plaque.
Hyperlipidemia, or high levels of blood fat, triggers atherosclerotic changes.
14. A patient complains of pain in the right knee, stating, "My knee got twisted when I was going down
the stairs." The patient was diagnosed with an injury to the ligaments and tendons of the right knee.
Which terminology, documented by the nurse, best reflects the injury? - answer-b) Sprain. A sprain is
an injury to the ligaments and tendons surrounding a joint, usually caused by a wrenching or twisting
, motion. Dislocation refers to the separation of joint surfaces. Subluxation refers to partial separation
or dislocation of joint surfaces. Strain refers to a muscle pull or tear.
15. The nurse caring for an older adult with a diagnosis of leukemia would encourage the client to use an
electric razor. Why? - answer-d) Trauma and micro abrasions may contribute to anemia. In a client
with leukemia who is at risk for hemorrhage, the nurse handles the client gently when assisting and
encourages the client to use electric razors. Trauma and microabrasions from razors may contribute
to anemia from bleeding. Fragile tissues and altered clotting mechanisms may result in hemorrhage
even after minor trauma. Therefore, the nurse inspects the skin for signs of bruising and petechiae
and reports melena, hematuria, or epistaxis (nosebleeds). The risks for spontaneous and
uncontrolled bleeding or infection from microorganisms are not addressed by the use of electric
razors.
16. When caring for a client with hepatitis B, the nurse should monitor closely for the development of
which finding associated with a decrease in hepatic function? - answer-c) Irritability and drowsiness.
Although all the options are associated with hepatitis B, the onset of irritability and drowsiness
suggests a decrease in hepatic function. To detect signs and symptoms of disease progression, the
nurse should observe for disorientation, behavioral changes, and a decreasing level of consciousness
and should monitor the results of liver function tests, including the blood ammonia level. If hepatic
function is decreased, the nurse should take safety precautions.
17. Tom Benson, a 42-year-old electrical lineman, suffered significant burns in a workplace accident.
During his airlift to a regional burn unit, you assess his wounds taking care to find and mark his
entrance and exit wounds. What occurrence makes it difficult to assess internal burn damage in
electrical burns? - answer-a) Deep tissue cooling. Because deep tissues cool more slowly than those
at the surface, it is difficult initially to determine the extent of internal damage.
18. A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient
complains of a severe throbbing headache. What should the nurse do first? - answer-d) Check the
patient's indwelling urinary catheter for kinks to ensure patency.. A severe throbbing headache is a
common symptom of autonomic dysreflexia, which occurs after injuries to the spinal cord above T6.
The syndrome is usually brought on by sympathetic stimulation, such as bowel and bladder
distention. Lowering the HOB can increase ICP. Before administering analgesia, the nurse should
check the patient's catheter, record vital signs, and perform an abdominal assessment. A severe
throbbing headache is a dangerous symptom in this patient and is not expected.
19. The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is
essential when caring for a client in spinal shock with injury in the lower thoracic region? - answer-d)
Pulse and blood pressure. Spinal shock is a loss of sympathetic reflex activity below the level of the
