Exam 3 Review

Exam 3 Review: Practice your

test taking techniques!

by Ginny Bayes

Multiple Choice

A patient admitted with a diffuse axonal injury has a systemic blood pressure of 136/52 mm Hg, irregular respirations and an intracranial pressure (ICP) reading of 26 mm Hg. Which action should the nurse take first?

• Document the BP and ICP in the patient’s record.

• Report the BP and ICP to the health care provider.

• Asses pupillary response.

• Assess for abnormal posturing in response to painful stimuli

Multiple Choice

The nurse is caring for a patient who has a head injury. Which finding, when reported to the health care provider, should the nurse expect will result in new prescribed interventions?

• Pale yellow urine output of 1200 mL over the past 2 hours.

• Ventriculostomy drained 40 mL of fluid in the past 2 hours.

• Intracranial pressure spikes to 18 mm Hg when patient is turned.

• The patient appears to have retrograde amnesia.

Multiple Choice

Esomeprazole is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the medication? 

• Bowel sounds

• Stool frequency

• Stool occult blood

• Abdominal distention

Multiple Choice

A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What action should the nurse take?

• Encourage the patient to cough and deep breath and auscultate the lungs again.

• Notify the health care provider and prepare for endotracheal intubation.

• Document the results and continue to monitor the patient’s respiratory status.

• Reposition the patient in high-Fowler’s position and reassess breath sounds.

Multiple Select

Which collaborative and nursing actions should the nurse include in the plan of care for a patient who experienced a T2 spinal cord transection with the presence of spinal shock 24 hours ago?

(Select FOUR that apply)

• Urinary catheter care

• Nasogastric tube feeding

• Early initiation of a bowel management program

• Administration of H2 receptor blockers

• Maintenance of a warm room temperature

Multiple Choice

A patient with a history of T3 spinal cord injury is admitted with dermal ulcers. The patient tells the nurse, “I have a pounding headache and I feel sick to my stomach.” Which action should the nurse take first?

• Assess for a fecal impaction

• Administer the prescribed antiemetic

• Notify the healthcare provider

• Check the patient's blood pressure

Multiple Choice

A patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care?

• Restrict daily dietary protein intake.

• Place protective foam dressings on the patient's sacrum and coccyx.

• Perform passive range of motion on all extremities twice daily.

• Place the patient on a pressure-relief mattress.

Multiple Choice

During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first?

• A 58-yr-old patient who has chronic cirrhosis and reports anorexia and scleral icterus 

• A 40-yr-old patient with chronic pancreatitis who has gnawing epigastric abdominal pain

• A 55-yr-old patient with cirrhosis and ascites who has an oral temperature of 101.5° F 

• A 36-yr-old patient recovering from a laparoscopic cholecystectomy who has severe right shoulder pain

Multiple Choice

A pedestrian who was hit by a car is admitted to the emergency department with possible right lower leg fractures. What initial action should the nurse take?

• Elevate the right leg

• Splint the lower leg

• Verify tetanus immunization

• Assess pedal pulses