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ATI MEDSURG 2 NUR 265/ DETAILED ANSWER KEY NEURO-SHOCK & BURNS PRACTICE
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ATI MEDSURG 2 NUR 265/ DETAILED ANSWER KEY NEURO-SHOCK & BURNS PRACTICE
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NUR 120: ADVANCED MEDSURG FINAL FOR LUCKY STUDENTSATI MEDSURG 2 NUR 265/ DETAILED ANSWER KEY NEURO-SHOC
& BURNS PRACTICE
I. The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a
patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP
is observed?
a. UAP splint the patient’s chest during
coughing.
b. UAP assist the patient to
ambulate to the bathroom.
c. UAP help the patient to a bedside chair for
meals.
d. UAP lower the head of the patient’s
bed to 15 degrees.
ANS: D
Positioning the patient with the head of the bed lowered will decrease ventilation. The other
actions are appropriate for a patient with pneumonia.
DIF: Cognitive Level: Apply (application) REF: 527
OBJ: Special Questions: Delegation TOP: Nursing Process:
Implementation MSC: NCLEX: Safe and Effective Care Environment
, NUR 120: ADVANCED MEDSURG FINAL FOR LUCKY STUDENTS
II. A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an
oxygen saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to
get out of bed. Which nursing diagnosis should the nurse assign as the highest priority?
a. Hyperthermia related to infectious illness
b. Impaired transfer ability related to
weakness
c. Ineffective airway clearance related
to thick secretions
d. Impaired gas exchange related to
respiratory congestion
ANS: D
All these nursing diagnoses are appropriate for the patient, but the patient’s oxygen saturation
indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved.
DIF: Cognitive Level: Apply (application) REF: 527
OBJ: Special Questions: Prioritization TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integr
III. A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing.
The nurse finds a heart rate of 142 beats/minute, blood pressure of 100/60 mmHg, and
respirations of 42 breaths/minute. Which action should the nurse take first?
a. Administer anticoagulant drug therapy.
b. Notify the patient’s health care provider.
c. Prepare patient for a spiral computed
tomography (CT).
d. Elevate the head of the bed to a semi-
Fowler’s position.
, NUR 120: ADVANCED MEDSURG FINAL FOR LUCKY STUDENTS
ANS: D
The patient has symptoms consistent with a pulmonary embolism (PE). Elevating the head of the
bed will improve ventilation and gas exchange. The other actions can be accomplished after the
head is elevated (and oxygen is started). A spiral CT may be ordered by the health care provider
to identify PE. Anticoagulants may be ordered after confirmation of the diagnosis of PE.
DIF: Cognitive Level: Apply (application) REF: 553
OBJ: Special Questions: Prioritization TOP: Nursing Process:
Implementation MSC: NCLEX: Physiological Integrity
IV. The nurse receives change-of-shift report on the following four patients. Which patient should the nurse asses
first?
a. A 23-year-old patient with cystic fibrosis
who has pulmonary function testing
scheduled
b. A 46-year-old patient on bed rest who is
complaining of sudden onset of shortness
of breath
c. A 77-year-old patient with tuberculosis
(TB) who has four antitubercular
medications due in 15 minutes
d. A 35-year-old patient who was
admitted the previous day with
pneumonia and has a temperature of
100.2° F (37.8° C)
, NUR 120: ADVANCED MEDSURG FINAL FOR LUCKY STUDENTS
ANS: B
Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden
onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism and requires
immediate assessment and action such
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