Medical - Surgical Evaluation Exam

Name: _____________________ Year/Section: ________________ Date: ________________________ Score: ________________________

Page |

Note: Please encircle the answer that corresponds to the question asked. Strictly NO ERASURE allowed. 1. Manang Tinay is scheduled to have a descending colostomy. Shes very anxious and has many questions regarding the surgical procedure, care of stoma, and lifestyle changes. It would be most appropriate for the nurse to make a referral to which member of the health care team? a. Social worker b. registered dietician c. occupational therapist d. enterostomal nurse therapist

2. A client undergone ileostomy, when should the drainage appliance be applied to the stoma? a. In the operating room. b. When the client is able to begin self-care procedures. 3. Mang Tonyo who has severe burns is receiving H2 receptor antagonist therapy. The nurse Incharge knows the purpose of this therapy is to: a. Enhance gas exchange b. Prevent stress ulcer c. Facilitate protein synthesis. d. Block prostaglandin synthesis c. 24 hours later, when edema has subsided. d. After the ileostomy begin to function.

4. The nurse is preparing to discharge a patient with chronic low back pain. Which statement by the patient indicates that additional teaching is necessary? a. I will avoid exercise because the pain gets worse. b. I will use heat or ice to help control the pain. c. I will not wear high-heeled shoes at home or work. d. I will purchase a firm mattress to replace my old one. 5. A patient with a spinal cord injury (SCI) complains about a severe throbbing headache that suddenly started a short time ago. Assessment of the patient reveals increased blood pressure (168/94) and decreased heartrate (48/minute), diaphoresis, and flushing of the face and neck. What action should you take first? a. Administer the ordered acetaminophen (Tylenol). b. Check the Foley tubing for kinks or obstruction. c. Adjust the temperature in the patients room. d. Notify the physician about the change in status.
BSN IV

6. Which patient should you, as charge nurse, assign to a new graduate RN who is orienting to the neurologic unit? a. A 28-year-old newly admitted patient with spinal cord injury b. A 67-year-old patient with stroke 3 days ago and left-sided weakness c. An 85-year-old dementia patient to be transferred to long-term care today d. A 54-year-old patient with Parkinsons who needs assistance with bathing 7. A patient with a spinal cord injury at level C3-4 is being cared for in the Emergency Department. What is the priority assessment? a. Determine the level at which the patient has intact sensation. b. Assess the level at which the patient has retained mobility. c. Check blood pressure and pulse for signs of spinal shock. d. Monitor respiratory effort and oxygen saturation level. 8. You are pulled from the ED to the neurologic floor. Which action should you delegate to the nursing assistant when providing nursing care for a patient with SCI? a. Assess patients respiratory status every 4 hours. b. Take patients vital signs and record every 4 hours. c. Monitor nutritional status including calorie counts. d. Have patient turn, cough, and deep breathe every 3 hours. 9. You are helping the patient with an SCI to establish a bladder-retraining program. What strategies may stimulate the patient to void? (Choose all that apply). a. Stroke the patients inner thigh. b. Pull on the patients pubic hair. c. Initiate intermittent straight catheterization. d. Pour warm water over the perineum. e. Tap the bladder to stimulate detrusor muscle. 10. A client is hospitalized with a diagnosis of chronic renal failure. An arteriovenous fistula was created in his left arm for hemodialysis. When preparing the client for discharge, the nurse should reinforce which dietary instruction? A. Be sure to eat meat at every meal. B. Monitor your fruit intake and eat plenty of bananas. C. Restrict your salt intake. D. Drink plenty of fluids.
Page |

BSN IV

11. You are preparing a nursing care plan for the patient with SCI including the nursing diagnoses

Impaired Physical Mobility and Self-Care Deficit. The patient tells you, I dont know why were Page | 3 doing all this. My lifes over. What additional nursing diagnosis takes priority based on this statement? a. Risk for Injury related to altered mobility b. Imbalanced Nutrition, Less Than Body Requirements c. Impaired Adjustment to Spinal Cord Injury d. Poor Body Image related to immobilization 12. Which patient should be assigned to the traveling nurse, new to neurologic nursing care, who has been on the neurologic unit for 1 week? a. A 34-year-old patient newly diagnosed with multiple sclerosis (MS) b. A 68-year-old patient with chronic amyotrophic lateral sclerosis (ALS) c. A 56-year-old patient with Guillain-Barre syndrome (GBS) in respiratory distress d. A 25-year-old patient admitted with CA level spinal cord injury (SCI) 13. What is the most common complication of a myocardial infarction? a. Cardiogenic shock b. Heart failure c. Arrhythmias d. Pericarditis

14. With which of the following disorders is jugular vein distention most prominent? a. Abdominal aortic aneurysm b. Heart failure c. Myocardial infarction d. Pneumothorax

15. What position should the nurse place the head of the bed in to obtain the most accurate reading of jugular vein distention? a. High-fowlers b. Raised 10 degrees c. Raised 30 degrees d. Supine position

16. Which of the following parameters should be checked before administering digoxin? a. Apical pulse b. Blood pressure c. Radial pulse d. Respiratory rate

17. Toxicity from which of the following medications may cause a client to see a green halo around lights? a. Digoxin b. Furosemide c. Metoprolol d. Enalapril

18. Which ofthe following symptoms is most commonly associated with left-sided heart failure? a. Crackles b. Arrhythmias
BSN IV

c. Hepatic engorgement

19. In which of the following disorders would the nurse expect to assess sacral edema in bedridden Page | 4 client? a. DM b. Pulmonary emboli c. Renal failure d. Right-sided heart failure

d. Hypotension

20. Which of the following symptoms might a client with right-sided heart failure exhibit? a. Adequate urine output b. Polyuria c. Oliguria d. Polydipsia

21. Which of the following classes of medications maximizes cardiac performance in clients with heat failure by increasing ventricular contractility? a. Beta-adrenergic blockers b. Calcium channel blockers c. Diuretics d. Inotropic agents

22. Stimulation of the sympathetic nervous system produces which of the following responses? a. Bradycardia b. Tachycardia c. Hypotension d. Decreased myocardial contractility

23. You are supervising a senior nursing student who is caring for a patient with a right hemisphere stroke. Which action by the student nurse requires that you intervene? a. The student instructs the patient to sit up straight, resulting in the patients puzzled expression. b. The student moves the patients tray to the right side of her over-bed tray. c. The student assists the patient with passive range-of-motion (ROM) exercises. d. The student combs the left side of the patients hair when the patient combs only the right side. 24. When caring for a client with esophageal varices, the nurse knows that bleeding in this disorder usually stems from: a. esophageal perforation b. pulmonary hypertension c. portal hypertension d. peptic ulcers

25. A 49-yer-old client was admitted for surgical repair of a Colles fracture. An external fixator was placed during surgery. The surgeon explains that this method of repair: a. has very low complication rate b. maintains reduction and overall hand function c. is less bothersome than a cast d. is best for older people

BSN IV

26. You have just admitted a patient with bacterial meningitis to the medical-surgical unit. The

patient complains of a severe headache with photophobia and has a temperature of 102.60 F orally. Page | 5 Which collaborative intervention must be accomplished first? a. Administer codeine 15 mg orally for the patients headache. b. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection. c. Give acetaminophen (Tylenol) 650 mg orally to reduce the fever. d. Give furosemide (Lasix) 40 mg IV to decrease intracranial pressure. 27. You are mentoring a student nurse in the intensive care unit (ICU) while caring for a patient with meningococcal meningitis. Which action by the student requires that you intervene immediately? a. The student enters the room without putting on a mask and gown. b. The student instructs the family that visits are restricted to 10 minutes. c. The student gives the patient a warm blanket when he says he feels cold. d. The student checks the patients pupil response to light every 30 minutes. 28. The nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society (ACS) guidelines, the nurse should recommend that the women: a. perform breast self-examination annually b. have a mammogram annually c. have a hormonal receptor assay annually d. have a physician conduct a clinical evaluation every 2 years 29. While working in the ICU, you are assigned to care for a patient with a seizure disorder. Which of these nursing actions will you implement first if the patient has a seizure? a. Place the patient on a non-rebreather mask will the oxygen at 15 L/minute. b. Administer lorazepam (Ativan) 1 mg IV. c. Turn the patient to the side and protect airway. d. Assess level of consciousness during and immediately after the seizure. 30. A patient recently started on phenytoin (Dilantin) to control simple complex seizures is seen in the outpatient clinic. Which information obtained during his chart review and assessment will be of greatest concern? a. The gums appear enlarged and inflamed. b. The white blood cell count is 2300/mm3. c. Patient occasionally forgets to take the phenytoin until after lunch. d. Patient wants to renew his drivers license in the next month.
BSN IV

31. After receiving a change-of-shift report at 7:00 AM, which of these patients will you assess first?

a. A 23-year-old with a migraine headache who is complaining of severe nausea associated with Page | 6 retching b. A 45-year-old who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching c. A 59-year-old with Parkinsons disease who will need a swallowing assessment before breakfast d. A 63-year-old with multiple sclerosis who has an oral temperature of 101.80 F and flank pain 32. Ottorrhea and rhinorrhea are most commonly seen with which type of skull fracture? a. basilar b. temporal c. occipital d. parietal

33. A male client should be taught about testicular examinations: a. when sexual activity starts b. after age 60 c. after age 40 d. before age 20

34. Before weaning a client from a ventilator, which assessment parameter is most important for the nurse to review? a. fluid intake for the last 24 hours b. baseline arterial blood gas (abg) levels c. prior outcomes of weaning d. electrocardiogram (ecg) results

35. You are caring for a patient with a recurrent glioblastoma who is receiving dexamethasone (Decadron) 4 mg IV every 6 hours to relieve symptoms of right arm weakness and headache. Which assessment information concerns you the most? a. The patient does not recognize family members. b. The blood glucose level is 234 mg/dL. c. The patient complains of a continued headache. d. The daily weight has increased 1 kg. 36. A 70-year-old alcoholic patient with acute lethargy, confusion, and incontinence is admitted to the hospital ED. His wife tells you that he fell down the stairs about a month ago, but he didnt have a scratch afterward. She feels that he has become gradually less active and sleepier over the last 10 days or so. Which of the following collaborative interventions will you implement first? a. Place on the hospital alcohol withdrawal protocol. b. Transfer to radiology for a CT scan. c. Insert a retention catheter to straight drainage. d. Give phenytoin (Dilantin) 100 mg PO. 37. Which of these patients in the neurologic ICU will be best to assign to an RN who has floated from the medical unit?
BSN IV

a. A 26-year-old patient with a basilar skull structure who has clear drainage coming out of the nose

b. A 42-year-old patient admitted several hours ago with a headache and diagnosed with a ruptured Page | 7 berry aneurysm. c. A 46-year-old patient who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due d. A 65-year-old patient with a astrocytoma who has just returned to the unit after having a craniotomy 38. The burned client newly arrived from an accident scene is prescribed to receive 4 mg of morphine sulfate by IV push. What is the most important reason to administer the opioid analgesic to this client by the intravenous route? a. The medication will be effective more quickly than if given intramuscularly. b. It is less likely to interfere with the clients breathing and oxygenation. c. The danger of an overdose during fluid remobilization is reduced. d. The client delayed gastric emptying. 39. Which vitamin deficiency is most likely to be a long-term consequence of a full-thickness burn injury? a. Vitamin A b. Vitamin B c. Vitamin C d. Vitamin D

40. Which client factors should alert the nurse to potential increased complications with a burn injury? a. The client is a 26-year-old male. b. The client has had a burn injury in the past. c. The burned areas include the hands and perineum. d. The burn took place in an open field and ignited the clients clothing. 41. The burned client is ordered to receive intravenous cimetidine, an H 2 histamine blocking agent, during the emergent phase. When the clients family asks why this drug is being given, what is the nurses best response? a. To increase the urine output and prevent kidney damage. b. To stimulate intestinal movement and prevent abdominal bloating. c. To decrease hydrochloric acid production in the stomach and prevent ulcers. d. To inhibit loss of fluid from the circulatory system and prevent hypovolemic shock. 42. At what point after a burn injury should the nurse be most alert for the complication of hypokalemia?
BSN IV

a. Immediately following the injury b. During the fluid shift

c. During fluid remobilization d. During the late acute phase

Page |

43. What clinical manifestation should alert the nurse to possible carbon monoxide poisoning in a client who experienced a burn injury during a house fire? a. Pulse oximetry reading of 80% b. Expiratory stridor and nasal flaring c. Cherry red color to the mucous membranes d. Presence of carbonaceous particles in the sputum 44. What clinical manifestation indicates that an escharotomy is needed on a circumferential extremity burn? a. The burn is full thickness rather than partial thickness. b. The client is unable to fully pronate and supinate the extremity. c. Capillary refill is slow in the digits and the distal pulse is absent. d. The client cannot distinguish the sensation of sharp versus dull in the extremity. 45. What additional laboratory test should be performed on any African American (or any other race coming from a tropical and sub-tropical country like Philippines) client who sustains a serious burn injury? a. Total protein b. Tissue type antigens c. Prostate specific antigen d. Hemoglobin S electrophoresis

46. Which type of fluid should the nurse expect to prepare and administer as fluid resuscitation during the emergent phase of burn recovery? a. Colloids b. Crystalloids the nurses best first action? a. Administer oxygen. b. Loosen the dressing. c. Notify the emergency team. d. Document the observation as the only action 48. The client who experienced an inhalation injury 6 hours ago has been wheezing. When the client is assessed, wheezes are no longer heard. What is the nurses best action? A. Raise the head of the bed. B. Notify the emergency team. C. Loosen the dressings on the chest.
BSN IV

c. Fresh-frozen plasma d. Packed red blood cells

47. The client with a dressing covering the neck is experiencing some respiratory difficulty. What is

D. Document the findings as the only action. is the nurses best action? A. Notify the emergency team. B. Document the finding as an action.

49. Ten hours after the client with 50% burns is admitted, her blood glucose level is 90 mg/dL. What Page | 9

C. Ask the client if anyone in her family has diabetes mellitus. D. Slow the intravenous infusion of dextrose 5% in Ringers lactate. 50. On admission to the emergency department the burned clients blood pressure is 90/60, with an apical pulse rate of 122. These findings are an expected result of what thermal injury related response? a. Fluid shift b. Intense pain c. Hemorrhage d. Carbon monoxide poisoning

BSN IV

Medical - Surgical Evaluation Exam Answer Key

1. Answer: D - An enterostomal nurse therapist is a registered nurse who has received advance education in an accredited program to care for clients with stomas. The enterostomal nurse therapist can assist with selection of an appropriate stoma site, teach about stoma care, and provide emotional support. 2. Answer: A - The stoma drainage bag is applied in the operating room. Drainage from the ileostomy contains secretions that are rich in digestive enzymes and highly irritating to the skin. Protection of the skin from the effects of these enzymes is begun at once. Skin exposed to these enzymes even for a short time becomes reddened, painful, and excoriated. 3. Answer: B - Curlings ulcer occurs as a generalized stress response in burn patients. This results in a decreased production of mucus and increased secretion of gastric acid. The best treatment for this prophylactic use of antacids and H2 receptor blockers 4. Answer: A Exercises are used to strengthen the back, relieve pressure on compressed nerves and protect the back from re-injury. Ice, heat, and firm mattresses are appropriate interventions for back pain. People with chronic back pain should avoid wearing high-heeled shoes at all times. 5. Answer: B These signs and symptoms are characteristic of autonomic dysreflexia, a neurologic emergency that must be promptly treated to prevent a hypertensive stroke. The cause of this syndrome is noxious stimuli, most often a distended bladder or constipation, so checking for poor catheter drainage, bladder distention, or fecal impaction is the first action that should be taken. Adjusting the room temperature may be helpful, since too cool a temperature in the room may contribute to the problem. Tylenol will not decrease the autonomic dysreflexia that is causing the patients headache. Notification of the physician may be necessary if nursing actions do not resolve symptoms. 6. Answer: B The new graduate RN who is oriented to the unit should be assigned stable, noncomplex patients, such as the patient with stroke. The patient with Parkinsons disease needs assistance with bathing, which is best delegated to the nursing assistant. The patient being transferred to the nursing home and the newly admitted SCI should be assigned to experienced nurses.

Page |

10

BSN IV

7. Answer: D The first priority for the patient with an SCI is assessing respiratory patterns and ensuring an adequate airway. The patient with a high cervical injury is at risk for respiratory compromise because the spinal nerves (C3 5) innervate the phrenic nerve, which controls the diaphragm. The other assessments are also necessary, but not as high priority. 8. Answer: B The nursing assistants training and education include taking and recording patients vital signs. The nursing assistant may assist with turning and repositioning the patient and may remind the patient to cough and deep breathe but does not teach the patient how to perform these actions. Assessing and monitoring patients require additional education and are appropriate to the scope of practice for professional nurses. 9. Answer: S A, B, D & E- All of the strategies, except straight catheterization, may stimulate voiding in patients with SCI. Intermittent bladder catheterization can be used to empty the patients bladder, but it will not stimulate voiding. 10. Answer: C - In a client with chronic renal failure, unrestricted intake of sodium, protein, potassium, and fluids may lead to a dangerous accumulation of electrolytes and protein metabolic products, such as amino acids and ammonia. Therefore, the client must limit his intake of sodium, meat (high in Protein), bananas (high in potassium), and fluid because the kidneys cant secrete adequate urine. 11. Answer: C The patients statement indicates impairment of adjustment to the limitations of the injury and indicates the need for additional counseling, teaching, and support. The other three nursing diagnoses may be appropriate to the patient with SCI, but they are not related to the patients statement. 12. Answer: B The traveling is relatively new to neurologic nursing and should be assigned patients whose conditions are stable and not complex. The newly diagnosed patient will need to be transferred to the ICU. The patient with C4 SCI is at risk for respiratory arrest. All three of these patients should be assigned to nurses experienced in neurologic nursing care. 13. Answer: c. Arrhythmias Arrhythmias, caused by oxygen deprivation to the myocardium, are the most common complication of an MI. cardiogenic shock, another complication of MI, is defined as the end stage of left ventricular dysfunction. The condition occurs in approximately 15% of clients with MI. Because the pumping function of the heart is compromised by an MI, heart failure is the second most common complication. Pericarditis most commonly results from a bacterial of viral infection but may occur after MI.
Page |

11

BSN IV

14. Answer: B. Heart failure. Elevated venous pressure, exhibited as jugular vein distention, indicates a failure of the heart to pump. Jugular vein distention isnt a symptom of abdominal aortic aneurysm or pneumothorax. An MI, if severe enough, can progress to heart failure; however, in and of itself, an MI doesnt cause jugular vein distention. 15. Answer: C. Raised 30 degrees. Jugular venous pressure is measured with a centimeter ruler to obtain the vertical distance between the sternal angle and the point of highest pulsation with the head of the bed inclined between 15 and 30 degrees. Inclined pressure cant be seen when the client is supine or when the head of the bed is raised 10 degrees because the point that marks the pressure level is above the jaw (therefore, not visible). In high Fowlers position, the veins would be barely discernible above the clavicle. 16. Answer: A. Apical pulse. An apical pulse is essential or accurately assessing the clients heart rate before administering digoxin. The apical pulse is the most accurate point in the body. Blood pressure is usually only affected if the heart rate is too low, in which case the nurse would withhold digoxin. The radial pulse can be affected by cardiac and vascular disease and therefore, wont always accurately depict the heart rate. Digoxin has no effect on respiratory function. 17. Answer: A. Digoxin. One of the most common signs of digoxin toxicity is the visual disturbance known as the green halo sign. The One of the most common signs of digoxin toxicity is the visual disturbance known as the green halo sign. The other medications arent associated with such an effect. 18. Answer: A. Crackles. Crackles in the lungs are a classic sign of left-sided heart failure. These sounds are caused by fluid backing up into the pulmonary system. Arrhythmias can be associated with both right and left-sided heart failure. Leftsided heart failure causes hypertension secondary to an increased workload on the system. 19. Answer: D. Right-sided heart failure. The most accurate area on the body to assed dependent edema in a bedridden client is the sacral area. Sacral, or dependent, edema is secondary to rightsided heart failure. Diabetes mellitus, pulmonary emboli, and renal disease arent directly linked to sacral edema. 20. Answer: C. Oliguria. Inadequate deactivation of aldosterone by the liver after right-sided heart failure leads to fluid retention, which causes oliguria. Adequate urine output, polyuria, and polydipsia arent associated with right-sided heart failure.
Page |

12

BSN IV

21. Answer: D. Inotropic agents. Inotropic agents are administered to increase the force of the hearts contractions, thereby increasing ventricular contractility and ultimately increasing cardiac output. Beta-adrenergic blockers and calcium channel blockers decrease the heart rate and ultimately decrease the workload of the heart. Diuretics are administered to decrease the overall vascular volume, also decreasing the workload of the heart. 22. Answer: B. Tachycardia. Stimulation of the sympathetic nervous system causes tachycardia and increased contractility. The other symptoms listed are related to the parasympathetic nervous system, which is responsible for slowing the heart rate. 23. Answer: A Patients with right cerebral hemisphere stroke often present with neglect syndrome. They lean to the left and when asked, respond that they believe they are sitting up straight. They often neglect the left side of their bodies and ignore food on the left side of their food trays. The nurse would need to remind the student of this phenomenon and discuss the appropriate interventions. 24. Answer: C - Increased pressure within the portal veins causes them to bulge, leading to rupture and bleeding into the lower esophagus. Bleeding associated with esophageal varices doesnt stem from esophageal perforation, pulmonary hypertension, or peptic ulcers. 25. Answer: B - Complex intra-articular fractures are repaired with external fixators because they have a better long-term outcome than those treated with casting. This is especially true in a young client. The incidence of complications, such as pin tract infections and neuritis, is 20% to 60%. Clients must be taught how to do pin care and assess for development of neurovascular complications. 26. Answer: B Untreated bacterial meningitis has mortality are approaching 100%, so rapid antibiotic treatment is essential. The other interventions will help reduce CNS stimulation and irritation, and should be implemented as soon as possible. 27. Answer: A Meningococcal meningitis is spread through contact with respiratory secretions so use of a mask and gown is required to prevent spread of the infection to staff members or other patients. The other actions may not be appropriate but they do not require intervention as rapidly. The presence of a family member at the bedside may decrease patient confusion and agitation. Patients with hyperthermia frequently complain of feeling chilled, but warming the patient is not an appropriate intervention. Checking the pupil response to light is appropriate, but it is not needed every 30 minutes and is uncomfortable for a patient with photophobia.
Page |

13

BSN IV

28. Answer: B - According to the ACS guidelines, Women older than age 40 should perform breast self examination monthly (not annually). The hormonal receptor assay is done on a known breast tumor to determine whether the tumor is estrogen- or progesterone-dependent. 29. Answer: C The priority action during a generalized tonic-clonic seizure is to protect the airway. Administration of lorazepam should be the next action, since it will act rapidly to control the seizure. Although oxygen may be useful during the postictal phase, the hypoxemia during tonic-clonic seizures is caused by apnea. Checking the level of consciousness is not appropriate during the seizure, because generalized tonic-clonic seizures are associated with a loss of consciousness. 30. Answer: B Leukopenia is a serious adverse effect of phenytoin and would require discontinuation of the medication. The other data indicate a need for further assessment and/or patient teaching, but will not require a change in medical treatment for the seizures. 31. Answer: D Urinary tract infections are a frequent complication in patient with multiple sclerosis because of the effect on bladder function. The elevated temperature and decreased breath sounds suggest that this patient may have pyelonephritis. The physician should be notified immediately so that antibiotic therapy can be started quickly. The other patients should be assessed soon, but do not have needs as urgent and this patient. 32. Answer: A - Ottorrhea and rhinorrhea are classic signs of basilar skull fracture. Injury to the dura commonly occurs with this fracture, resulting in cerebrospinal fluid (CSF) leaking through the ears and nose. Any fluid suspected of being CSF should be checked for glucose or have a halo test done. 33. Answer: D - Testicular cancer commonly occurs in men between ages 20 and 30. A male client should be taught how to perform testicular self-examination before age 20, preferably when he enters his teens. 34. Answer: B - Before weaning a client from mechanical ventilation, its most important to have a baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the clients record, and the nurse can refer to them before the weaning process begins.
Page |

14

BSN IV

35. Answer: A The inability to recognize a family member is a new neurologic deficit for this patient, and indicates a possible increase in intracranial pressure (ICP). This change should be communicated to the physician immediately so that treatment can be initiated. The continued headache also indicates that the ICP may be elevated, but it is not a new problem. The glucose elevation and weight gain are common adverse effects of dexamethasone that may require treatment, but they are not emergencies. 36. Answer: B The patients history and assessment data indicate that he may have a chronic subdural hematoma. The priority goal is to obtain a rapid diagnosis and send the patient to surgery to have the hematoma evacuated. The other interventions also should be implemented as soon as possible, but the initial nursing activities should be directed toward treatment of any intracranial lesion. 37. Answer: C This patient is the most stable of the patients listed. An RN from the medical unit would be familiar with administration of IV antibiotics. The other patients require assessments and care from RNs more experienced in caring for patients with neurologic diagnoses. 38. Answer: C - Although providing some pain relief has a high priority, and giving the drug by the IV route instead of IM, SC, or orally does increase the rate of effect, the most important reason is to prevent an overdose from accumulation of drug in the interstitial space during the fluid shift of the emergent phase. When edema is present, cumulative doses are rapidly absorbed when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics. 39. Answer: D - Skin exposed to sunlight activates vitamin D. Partial-thickness burns reduce the activation of vitamin D. Activation of vitamin D is lost completely in full thickness burns. 40. Answer: C - Burns of the perineum increase the risk for sepsis. Burns of the hands require special attention to ensure the best functional outcome. 41. Answer: C - Ulcerative gastrointestinal disease may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and decreased mucosal barrier. Cimetidine inhibits the production and release of hydrochloric acid. 42. Answer: C - Hypokalemia is most likely to occur during the fluid remobilization period as a result of dilution, potassium movement back into the cells, and increased potassium excreted into the urine with the greatly increased urine output.
Page |

15

BSN IV

43. Answer: C - The saturation of hemoglobin molecules with carbon monoxide and the subsequent vasodilation induces a cherry red color of the mucous membranes in these clients. The other manifestations are associated with inhalation injury, but not specifically carbon monoxide poisoning. 44. Answer: C - Circumferential eschar can act as a tourniquet when edema forms from the fluid shift, increasing tissue pressure and preventing blood flow to the distal extremities and increasing the risk for tissue necrosis. This problem is an emergency and, without intervention, can lead to loss of the distal limb. This problem can be reduced or corrected with an escharotomy. 45. Answer: D - Sickle cell disease and sickle cell trait are more common among African Americans (or any other race coming from a tropical and sub-tropical country like Philippines). Although clients with sickle cell disease usually know their status, the client with sickle cell trait may not. The fluid, circulatory, and respiratory alterations that occur in the emergent phase of a burn injury could result in decreased tissue perfusion that is sufficient to cause sickling of cells, even in a person who only has the trait. Determining the clients sickle cell status by checking the percentage of hemoglobin S is essential for any African American client who has a burn injury. 46. Answer: B - Although not universally true, most fluid resuscitation for burn injuries starts with crystalloid solutions, such as normal saline and Ringers lactate. The burn client rarely requires blood during the emergent phase unless the burn is complicated by another injury that involved hemorrhage. Colloids and plasma are not generally used during the fluid shift phase because these large particles pass through the leaky capillaries into the interstitial fluid, where they increase the osmotic pressure. Increased osmotic pressure in the interstitial fluid can worsen the capillary leak syndrome and make maintaining the circulating fluid volume even more difficult. 47. Answer: B - Respiratory difficulty can arise from external pressure. The first action in this situation would be to loosen the dressing and then reassess the clients respiratory status. 48. Answer: B - Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective movement of air. When this occurs, wheezing is no longer heard and neither are breath sounds. The client requires the establishment of an emergency airway and the swelling usually precludes intubation.
Page |

16

BSN IV

49. Answer: B - Neural and hormonal compensation to the stress of the burn injury in the emergent phase increases liver glucose production and release. An acute rise in the blood glucose level is an expected client response and is helpful in the generation of energy needed for the increased metabolism that accompanies this trauma. 50. Answer: A - Intense pain and carbon monoxide poisoning increase blood pressure. Hemorrhage is unusual in a burn injury. The physiologic effect of histamine release in injured tissues is a loss of vascular volume to the interstitial space, with a resulting decrease in blood pressure.
Page |

17

BSN IV