Ati med surg exam n300 exam day
Total Questions : 54
Showing 25 questions, Sign in for moreThe healthcare provider has prescribed intravenous (IV) lorazepam for the patient in status epilepticus. During administration, which is the priority assessment by the nurse?
Explanation
A. While drug dependence can be a concern with long-term use, it is not the immediate priority in an emergency setting where the goal is to stabilize the patient in status epilepticus.
B. Cardiac rhythm monitoring is important when administering certain medications, but lorazepam primarily affects the central nervous system and respiratory system, making oxygen saturation monitoring more critical.
C. Pulse oximetry is the priority assessment as IV lorazepam can depress the respiratory system, leading to hypoxia. Monitoring oxygen saturation helps ensure the patient maintains adequate respiratory function during administration.
D. Assessing pain is important in patient care, but it is not the priority in managing a patient in status epilepticus, where stabilization is essential.
A patient admits to intravenous (IV) drug use and presents with red and severely painful right eye, floaters, photophobia and decreased visual acuity. The nurse explains to the patient and family that the plan of care will be as follows:
Explanation
A. Surgery to remove the eye is not the immediate course of action and is only considered in severe cases where infection cannot be managed.
B. Referral for a drug rehabilitation program is beneficial for the patient's long-term health but is not the priority in this case where there is an active eye infection.
C. Admission for IV and intravitreal antibiotics is necessary to treat a possible severe eye infection, which can be sight-threatening, especially in immunocompromised patients, such as those with a history of IV drug use.
D. An outpatient follow-up with an eye specialist may be part of ongoing care but does not address the acute need for immediate antibiotic therapy to prevent further complications.
A patient is admitted to the Emergency Department (ED). The nurse documents "postictal upon transfer" as evidenced by which observation?
Explanation
A. Abnormal sensory sensations such as tingling may be associated with the aura phase of a seizure but are not typically observed postictally.
B. Yellowing of the skin is usually indicative of jaundice, unrelated to seizure activity or the postictal state.
C. Itching of the eyes is unrelated to seizure activity and would not typically be documented in the context of postictal observations.
D. The postictal state is characterized by drowsiness, confusion, and other altered mental statuses that follow a seizure. This period can vary in duration depending on the patient and seizure type.
The Emergency Department nurse is expecting a patient with a spinal cord transection at C1. Which of the following assessments take priority upon the patient's arrival? (SELECT ALL THAT APPLY)
Explanation
A. Blood pressure monitoring is essential, as spinal cord injuries at high levels can cause disruptions in autonomic regulation, leading to significant blood pressure fluctuations.
B. Bladder function is impacted by spinal cord injuries; however, it is not the initial priority in an emergency setting when life-threatening complications must be managed first.
C. Heart rate is critical as high spinal cord injuries can impact cardiac function by affecting autonomic control, potentially leading to bradycardia.
D. Reflexes are often assessed in cases of spinal injury, but they are not the immediate priority when stabilizing the patient upon arrival.
E. Respirations are a priority, as a C1 spinal cord injury can compromise respiratory function, necessitating immediate assessment to ensure adequate oxygenation and airway management.
The nurse is caring for a patient with a spinal cord injury who has a flaccid or atonic bladder. The nurse would provide discharge education to the patient and family regarding which bladder management technique?
Explanation
A. Scheduled voiding is less effective in patients with a flaccid bladder because there is no voluntary control of bladder function.
B. Intermittent catheterization is the preferred management technique for a flaccid or atonic bladder, allowing the bladder to empty at regular intervals and reducing the risk of infection associated with continuous catheters.
C. An indwelling catheter is usually avoided for long-term use due to a higher risk of infection.
D. An external catheter is generally not effective for flaccid or atonic bladder management in spinal cord injuries as it doesn’t actively empty the bladder.
The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for the patient with an acute head injury. Which action(s) should the nurse take to achieve this goal? (SELECT ALL THAT APPLY)
Explanation
A. Coughing can increase ICP by increasing intrathoracic pressure and should be minimized in patients with head injuries.
B. Elevating the head of the bed to 30-45 degrees promotes venous drainage from the head, reducing ICP.
C. Active stimulation can increase ICP and is generally avoided in patients with acute head injuries.
D. Serial neurologic assessments help monitor any changes in the patient’s condition and ICP, allowing for timely intervention.
E. Sustained ICP levels between 30-40 mmHg are significantly elevated and require immediate communication with the healthcare provider, as they are above the normal range and could lead to further complications.
The emergency department nurse is caring for a patient who has had a chemical splash in both eyes. What is the priority nursing action?
Explanation
A. Anesthetic eye drops can help with pain, but irrigation is the priority to prevent further damage.
B. A visual acuity exam is part of the assessment but should be performed after initial irrigation to prevent further damage.
C. Determining the pH of the chemical splash can guide further treatment but is secondary to immediate irrigation to dilute and remove the chemical.
D. Irrigating both eyes with normal saline is the priority action to dilute and flush out the chemical, reducing the risk of further injury.
The nurse is educating on the placement of a ventriculostomy (intraventricular catheter) to the patient diagnosed with a brain injury and their family. The nurse states, "The ventriculostomy is placed:
Explanation
A. EEG is a monitoring tool for brain activity, but it is not a prerequisite for ventriculostomy placement.
B. While the procedure is carefully managed to reduce infection risk, ventriculostomy does have an infection risk due to its invasive nature.
C. Ventriculostomy is not inserted via the femoral artery; it is placed directly in the brain’s ventricles.
D. A ventriculostomy is used to monitor ICP and allows for the drainage of cerebrospinal fluid, which helps in managing elevated ICP in patients with brain injuries.
The patient who is diagnosed with a seizure disorder is prescribed a ketogenic diet. The nurse knows that the patient understands the teaching when they state, "My diet will include:
Explanation
A. A ketogenic diet does not focus on high sodium or high sugar, as high sugar intake would increase carbohydrate levels.
B. A ketogenic diet is high in fat rather than low in fat.
C. High carbohydrates are avoided in a ketogenic diet, as the goal is to limit carbohydrates to promote ketone production.
D. The ketogenic diet consists of high fat and low carbohydrates, which helps to manage seizure activity by altering the brain's energy source to ketones rather than glucose.
A nurse is caring for a patient who is diagnosed with diabetes and a new prescription for 14 units of regular insulin and 28 units of NPH insulin subcutaneously at breakfast daily. What is the total number of units of insulin that the nurse should prepare in the insulin syringe? (round to the nearest whole number)
Explanation
A. 28 units only accounts for the NPH insulin dosage and does not include the regular insulin dosage.
B. Adding 14 units of regular insulin and 28 units of NPH insulin results in a total of 42 units, the correct dose to prepare in the syringe.
C. 14 units only accounts for the regular insulin dosage and does not include the NPH insulin dosage.
D. 32 units is not the correct total dose; it underestimates the combined dosage.
The nurse is caring for a patient with mitral valve disease. At which anatomic landmark will the nurse hear a heart murmur the loudest?
Explanation
A. The fifth intercostal space at the left midclavicular line is the location of the mitral valve, where murmurs associated with mitral valve disease are best auscultated.
B. The fourth intercostal space at the right sternal border is the location for assessing the tricuspid valve, not the mitral valve.
C. The third intercostal space at the left midclavicular line is not associated with loudest auscultation of the mitral valve murmur.
D. The second intercostal space at the right sternal border is where the aortic valve sounds are best heard.
The nurse is caring for a patient diagnosed with epilepsy who is prescribed antiepileptic medications. The nurse would identify the need for further teaching when the patient states:
Explanation
A. Discussing over-the-counter drugs with the healthcare provider is essential, as they can interact with antiepileptic medications.
B. Discontinuing antiepileptic medications abruptly can lead to rebound seizures and is unsafe, so this statement is correct.
C. Doubling up on doses can lead to toxicity and adverse effects; missed doses should not be made up by doubling the next dose. This response indicates the need for further teaching.
D. Taking medications exactly as prescribed is necessary to maintain therapeutic levels and manage seizure control effectively.
The nurse is performing the morning assessment on a patient. The patient suddenly screams loudly and begins to have a generalized tonic/clonic type seizure. What is the priority nursing intervention?
Explanation
A. Soft restraints are not recommended during a seizure and can cause harm to the patient.
B. Placing anything in the mouth during a seizure can lead to injury or airway obstruction and is contraindicated.
C. Turning the patient on their side helps to maintain an open airway and prevent aspiration; staying with the patient ensures ongoing monitoring.
D. Leaving the patient alone to seek help is unsafe, as it leaves the patient unmonitored during the seizure.
The nurse suspects autonomic dysreflexia in the patient with a spinal cord injury at the level of C-7. After checking vital signs what are the priority nursing interventions?
Explanation
A. Elevating the head of the bed, loosening clothing, and checking for urinary catheter obstruction are key steps to lower blood pressure and relieve triggers of autonomic dysreflexia, a potentially life-threatening condition.
B. A cool compress may provide comfort but does not directly address the primary triggers or symptoms of autonomic dysreflexia.
C. Semi-Fowler's position is insufficient compared to a full 90-degree sitting position, which helps reduce blood pressure.
D. IV access and oxygen may be required if symptoms do not resolve, but immediate actions focus on relieving the cause of dysreflexia.
The nurse is assessing a patient with a cochlear implant and notices that there is drainage, swelling, and tenderness behind the ear with the implant. What is the priority nursing intervention?
Explanation
A. A hearing test does not address the infection symptoms and would not be the priority.
B. Obtaining a culture of the drainage is necessary to identify any infection and guide appropriate antibiotic treatment.
C. Removing a foreign body may not be relevant and could worsen infection symptoms if not necessary.
D. A CT scan may be needed if further complications are suspected, but it is not the priority for infection symptoms.
The nurse is assessing a patient with a cochlear implant and notices that there is drainage, swelling, and tenderness behind the ear with the implant. What is the priority nursing intervention?
Explanation
A. A hearing test does not address the infection symptoms and would not be the priority.
B. Obtaining a culture of the drainage is necessary to identify any infection and guide appropriate antibiotic treatment.
C. Removing a foreign body may not be relevant and could worsen infection symptoms if not necessary.
D. A CT scan may be needed if further complications are suspected, but it is not the priority for infection symptoms.
The provider has prescribed timolol ophthalmic drops for the patient diagnosed with glaucoma. The nurse should assess the patient for which of the following side effects?
Explanation
A. Timolol is a beta-blocker that can be absorbed systemically, leading to side effects such as bradycardia and hypotension, which require monitoring.
B. Tachycardia and dry cough are not common side effects of timolol; dry cough is more associated with ACE inhibitors.
C. Scleral injection and tearing are not common side effects and are not expected with timolol use.
D. Changes in eye pigmentation are more commonly seen with prostaglandin analogs, not with beta-blockers like timolol.
The nurse is caring for a patient who will be discharged with a prescription for lisinopril. What discharge teaching should be provided related to this medication?
Explanation
A. While taking some medications with food or milk can help with absorption, this is not a specific requirement for lisinopril.
B. Lisinopril, an ACE inhibitor, can lead to elevated potassium levels. Periodic monitoring of potassium levels is essential to prevent hyperkalemia, a potentially dangerous side effect.
C. Increasing intake of green vegetables is generally healthy but does not directly impact lisinopril's effects.
D. Many salt substitutes contain potassium, which could elevate potassium levels further when taken with ACE inhibitors like lisinopril, posing a risk for hyperkalemia.
The nurse teaches a patient diagnosed with Bell's Palsy about the use of an eye patch to prevent which eye complication?
Explanation
A. Conjunctivitis (pink eye) is not a typical complication of Bell's Palsy.
B. Retinal detachment is unrelated to the incomplete eye closure seen in Bell’s Palsy.
C. Bell's Palsy often results in incomplete eye closure, which can lead to drying and irritation of the cornea, increasing the risk for corneal abrasions. An eye patch protects the cornea by helping the eye stay moist and protected from injury.
D. A chalazion is a small eyelid bump caused by blocked oil glands, not associated with Bell’s Palsy.
The nurse is caring for a patient diagnosed with a brain injury to the cerebellum. Which nursing intervention is priority?
Explanation
A. Reorienting confused patients is important but is not directly related to cerebellar injury.
B. While turning every 2 hours is important to prevent pressure injuries, it does not address the specific fall risk associated with cerebellar damage.
C. The cerebellum is responsible for balance and coordination, so injuries in this area increase the risk of falls. Ensuring the bed alarm is on provides immediate alerts if the patient attempts to get out of bed, helping to prevent falls.
D. Varying the schedule to prevent boredom is not a priority in the care of patients with cerebellar injury.
A 24-year-old patient who is an intravenous drug user asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). The nurse informs the patient that the risk of developing the human immunodeficiency virus (HIV) infection from drug use can be reduced by:
Explanation
A. Avoiding sexual intercourse under the influence of drugs reduces certain risks but does not address the specific risk of needle transmission.
B. Asking others to be tested for HIV may be unrealistic and does not prevent HIV transmission through shared equipment.
C. Participating in a needle exchange program reduces the risk of HIV transmission by providing sterile needles, lowering the likelihood of infection from shared or contaminated needles.
D. Cleaning needles with betadine is not effective for HIV prevention; only sterile, unused needles should be used.
The nurse is preparing to turn the patient who sustained a spinal cord injury. How should the nurse proceed?
Explanation
A. Using a draw sheet may cause twisting, which can compromise spinal alignment.
B. Asking the patient to assist may risk further spinal injury.
C. Turning hips and shoulders separately risks disrupting spinal alignment, making this an unsafe approach.
D. Log rolling is the safest way to turn a patient with a spinal cord injury, maintaining spinal alignment and preventing further injury. It requires one person to stabilize the head while others turn the body as a single unit.
The nurse is caring for a patient who suffered a spinal cord injury (SCI) who has had halo traction placed for spinal immobilization. What emergency equipment should the nurse have at the bedside? (SELECT ALL THAT APPLY)
Explanation
A. Padded tongue blades are not appropriate for seizure management and are not necessary in this context.
B. Soft wrist restraints are not required in this scenario unless otherwise indicated.
C. An Ambu bag and oxygen are crucial for respiratory support, especially if the patient has compromised breathing due to spinal cord injury.
D. Wrenches should be readily available to quickly remove halo traction in case of an emergency, such as if the patient's airway needs to be accessed.
E. An oral suction tube (Yankauer) is important for managing oral secretions, which can be challenging for patients with limited mobility.
The nurse teaching a patient who is diagnosed with human immunodeficiency virus (HIV), would include which information regarding an activity that has the highest potential to spread the disease to relatives or friends in a household?
Explanation
A. Sharing eating utensils does not transmit HIV, as the virus is not spread through saliva.
B. Sharing razors is a high-risk activity for transmitting HIV because it can involve direct blood-to-blood contact if the razor causes cuts.
C. HIV transmission through kissing is highly unlikely due to low levels of the virus in saliva.
D. HIV cannot be spread through shared toilets, as the virus does not survive on surfaces and is not spread through casual contact.
Which situation should be reported to the nursing supervisor as an exposure for the nurse caring for a patient diagnosed with acquired immunodeficiency syndrome (AIDS)? The nurse
Explanation
A. Touching a patient’s shoulder does not pose a risk of HIV transmission, as it is not spread through casual skin contact.
B. While recapping needles is discouraged due to the risk of needlestick injury, it is not an exposure unless an actual needlestick occurs.
C. Not wearing a mask is typically not necessary in all interactions with HIV/AIDS patients unless there is an active infection requiring airborne precautions.
D. Exposure of bodily fluids to mucous membranes (such as the eyes) is a significant occupational exposure risk and should be reported. This requires immediate response and evaluation for potential infection.
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