NUR 242 MED SURG EXAM 3 LATEST ACTUAL
EXAM 180 QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES|ALREADY GRADED
A
A pt's health history states that they are on corticosteroids. The PACU nurse that this
increases the risk of what? - wound dehiscence
After a procedure, what should the nurse assess immediately? - ABC's
Make sure airway is clear, note respiration depth, listen to lung sounds
After a procedure, a pt's vitals signs are the following:
BP: 90/50
RR: 26
HR: 110
O2: 88%
What is this a potential sign of?
A.Infection
B. Heavy blood loss
C. These vitals are to be expected after a procedure - B
Normal RBC Lab Values - Women: 4.2 to 5.4 million/uL
Men: 4.7 to 6.1 million/uL
Children: 4.6 to 4.8 million/uL
A pt presents with muscle weakness, trouble walking, and a beefy red tongue. Based on
these symptoms, what might we conclude the patient will be diagnosed with? - B-12
Deficiency
What signs and symptoms might you suspect a patient exhibit if they were iron
deficient? Select all that apply.
a. weakness
b. palor
c. tachypnea
d. fatigue
e. beefy red tongue - Answer:
A, B, and D
,When caring for a patient with Sickle Cell Anemia, what are some nursing interventions
you'll need to implement? - - Avoid extreme temperatures
- Keep room warm
- Encourage fluid intake
-Encourage ROM
- Pain management
Match the following infections with the precaution type
A pt is receiving a blood transfusion and breaks out in hives. What is the nurses first
step? - Immediately stop the the transfusion and start normal saline
How often should the nurse monitor patient's vital signs when they are receive a blood
transfusion? - Vital sings must be checked after 15 minutes, 30 minutes, and one hour
followed by every hour after.
Patricia is an RN working at a rehabilitation center and witnesses a nurse aid struggling
to lift and reposition an elderly, bed ridden patient. She explains to the nurse aide that
there is a No Lift Policy in place in the establishment. What does this policy entail? - The
concept of a no-lift policy is a pledge from administrators that proper equipment,
adequately maintained and in sufficient numbers, will be available to care providers to
reduce the risks associated with manual patient handling
Immobility effects multiple body systems. What are some interventions that you can
implement to decrease these effects? Select all that apply.
A. Utilizing waffle mattress to reduce the need for repositioning
B. Teds/SCDs
C. Rubbing reddened areas
D. Limiting fluid intake
E. ROM exercises - Answer: B and E
Rational:
-A is incorrect because regardless of implemented mattress, positioning should be
every 2 hours
-C is incorrect. You should not rub at reddened areas. This increases the risk for skin
break.
, -D is incorrect. You should encourage proper hydration to promote well hydrated and
healthy skin.
True or False: Nurses should do skin assessments once a week. - False
Rational: Nurses should do full skin assessments a minimum of once per shift.
A pt goes to the ER for swelling and pain in her right calf. The PT states that it occurred
after she accidentally cut herself. Based on her symptoms, what skin condition might
the nurse suspect the patient has? - Cellulitis.
Cellulitis is inflammation of the skin and subq tissue.
Pt A is admitted from a nursing home with a stage 3 pressure ulcer. When creating his
plan of care, who else would be involved besides the primary care physician? - Wound
care nurse, Dietician, Physical therapist. OT can also be included, however they deal
more with fine motor skills.
An 85 year old woman is admitted to the hospital. When doing the initial assessment,
what are some factors that you know put her at risk for pressure injuries? - -if the pt is
immobile
-if the pt is incontinent
-if the pt has comorbidities such as diabetes or PVD
-if the pt is malnourished or dehydrated
-if the pt suffers from decreased sensory perception
The nurse notices a localized red area that is nonblanchable on the the patient's coccyx.
What stage pressure injury is this recognized as? - Stage 1
Stage 1 pressure injury means the skin is intact with a localized area of nonblanchable
erythema (fancy word for redness).
A pt asks you why what he eats has anything to do with wound healing. What is your
response? - Successful healing of pressure injuries depends on adequate intake of
calories protein, vitamins, minerals and water.
After receiving shift report, the night nurse looks at the lab values for a patient with
cellulitis. What abnormal lab values might you see? - -WBC - elevated
-Creatinine- elevated
-Bicarbonate- low
-Albumin- low
-Calcium- low
What pain rating scale might you use for a child or a nonverbal patient? - Wong Baker-
Faces Scale
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