NSG 223 MEDSURG II FINAL EXAM 2025
ACTUAL EXAM QUESTIONS AND
DETAILED CORRECT ANSWERS | A+
GRADE
A patient recovering from a CVA asks the purpose of the
Warfarin (Coumadin). What is the best response by the
nurse regarding the purpose of coumadin ? Correct
Answer Prevents the formation of new clots
A patient who has sustained a hemorrhagic stroke is
placed on a protocol of 60 mg of calcium channel blocker
(nimodipine) every 4 hours. The patient's pulse is 82
beats/min before the administration of the prescribed
dose. Which action should the nurse implement? Correct
Answer Give a full dose as prescribed without further
assessment
During the acute CVA phase, a risk for falls related to
paralysis is present Which intervention best protects the pt
from injury? Correct Answer Keep side rails up, according
to agency policy
Which assessment indicates that a patient with a CVA is in
transition to the rehab Phase? Correct Answer No further
neurologic deficit are observed
,Which assessment would indicate the resolution of spinal
shock? Correct Answer Spastic involuntary movements in
affected limbs
During a neurologic assessment, a nurse asks a patient to
dorsiflex the foot against the resistance of the nurse's
hand. The patient is unable to perform the action. Where
does this assessment confirm that cord damage has
occurred? Correct Answer L5
A patient is receiving methylprednisolone. What purpose
should the nurse explain this drug has in treating a patient
with an SCI? Correct Answer Reduces spinal cord cellular
damage
What should a nurse include in a pts plan of care when
considering interventions for the outcome of prevention of
contractures in a pt with an SCI? Correct Answer Apply
Splints to the limbs
A home health nurse encourages the family of a patient
with an SCI to use the assisted cough technique. What
does this technique require the caregiver to do? Correct
Answer Apply pressure to diaphragm as the patient
coughs
A patient comes into the clinic complaining of a runny
nose and facial pain. What should the nurse's initial
assessment include Correct Answer Assessment for nasal
drainage and sinus tenderness
,What should patient education for a patient being nose
drops for the first time include? Correct Answer Tipping
the head back and holding the dropper over the nostril and
then telling the patient to keep her head back for a few
mins.
What intervention should a nurse implement when
providing tracheostomy care? Correct Answer Use a
sterile solution of normal saline or other solution to wash
the inner cannula and then rinse with sterile water.
What is the importance of the nurse closely monitoring
bilateral breath sounds and chest movement after a
thoracentesis? Correct Answer The lung may have been
punctured during the procedure
A home health nurse who is caring for an 88-year-old
patient with severe hypertension in addition to a
respiratory problem notices several drugs on the bedside
table. Which medication should the nurse suggest the
patient avoid? Correct Answer Decongestant
A patient complains of morning headaches, a feeling of
fullness in her head, and a pain similar to that of a
toothache under her eye. What should the nurse
recognize that these symptoms indicate? Correct Answer
Sinusitis
Which is the best candidate for a tonsillectomy? Correct
Answer 23 Y-O patient with a peritonsillar abscess
, What are the most common causes of laryngitis? Correct
Answer Resp infection and voice strain
A patient who had a laryngectomy 3 months earlier returns
to the physician's office with the complaint of increasing
dyspnea. Which common post-laryngectomy complication
should the nurse recognize this complaint as indicating?
Correct Answer Tracheal stenosis
What should a nurse prepare when assessing paradoxical
movement in a patient with a flail chest who has significant
dyspnea? Correct Answer intubation
Which intervention would be inappropriate for decreasing
the risk of further emboli in a patient with a PE? Correct
Answer Placing pillow under the knees to elevate limbs
A young patient with acquired immunodeficiency
syndrome (AIDS) reports debilitating night sweats. Why
should the home health nurse suggest that the patient visit
the clinic? Correct Answer TB screening
A nurse is assigned to care for a patient with the diagnosis
of centriacinar (centrilobar) emphysema. What is a
characteristic of this type of emphysema? Correct Answer
Enlarged and broken down bronchioles with intact alveoli
A patient with cystic fibrosis (CF) furiously refuses any
more manual chest physiotherapeutic treatment. Which
alternative is appropriate for the nurse to suggest? Correct
Answer Flutter mucus device
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