CMSRN - Medical-Surgical Nursing Medical-Surgical Nursing 1 — Questions and Answers
Question 1: A patient with a traumatic brain injury has a Glasgow Coma Scale score of 8 and begins exhibiting Cushing's triad. Which set of vital signs best represents this triad?
- Hypotension, tachycardia, and irregular respirations
- Hypertension, bradycardia, and irregular respirations (Correct answer)
- Hypertension, tachycardia, and shallow respirations
- Hypotension, bradycardia, and deep rapid respirations
Correct answer: Hypertension, bradycardia, and irregular respirations
Cushing's triad is a late sign of increased intracranial pressure consisting of hypertension (widened pulse pressure), bradycardia, and irregular respirations (often Cheyne-Stokes). It signals impending brainstem herniation and requires immediate intervention.
Question 2: A patient is admitted with an acute exacerbation of COPD and an arterial blood gas showing pH 7.28, PaCO2 62 mmHg, HCO3 26 mEq/L, and PaO2 54 mmHg. How should the nurse interpret these results?
- Metabolic acidosis, uncompensated
- Respiratory alkalosis, partially compensated
- Respiratory acidosis, uncompensated (Correct answer)
- Metabolic alkalosis, compensated
Correct answer: Respiratory acidosis, uncompensated
The low pH indicates acidosis; the elevated PaCO2 identifies the cause as respiratory (CO2 retention from hypoventilation). The HCO3 is normal, meaning the kidneys have not yet compensated, making this uncompensated respiratory acidosis.
Question 3: A nurse is caring for a postoperative patient who suddenly develops a PaO2 of 58 mmHg, dyspnea, pleuritic chest pain, and hemoptysis 3 days after a total hip replacement. What is the priority nursing action?
- Administer prescribed bronchodilators via nebulizer
- Place the patient in Trendelenburg position and notify the physician
- Administer supplemental oxygen and notify the physician immediately (Correct answer)
- Obtain a sputum specimen for culture and sensitivity
Correct answer: Administer supplemental oxygen and notify the physician immediately
The clinical picture — pleuritic chest pain, hemoptysis, hypoxemia, and dyspnea following orthopedic surgery — strongly suggests pulmonary embolism. The priority is to maintain oxygenation with supplemental oxygen while immediately notifying the physician for further management including imaging and anticoagulation.
Question 4: A patient with type 1 diabetes is found unresponsive with a blood glucose of 28 mg/dL. The patient has no IV access and is unable to swallow. Which intervention should the nurse perform first?
- Administer 25 g of 50% dextrose (D50) orally dissolved in water
- Administer 1 mg of glucagon intramuscularly (Correct answer)
- Initiate a peripheral IV line and infuse D5W at 125 mL/hr
- Apply a glucose gel to the buccal mucosa
Correct answer: Administer 1 mg of glucagon intramuscularly
When a patient is unresponsive and has no IV access, intramuscular glucagon is the correct route of administration for severe hypoglycemia. Glucagon stimulates hepatic glycogenolysis to rapidly raise blood glucose. Oral glucose and buccal gel are contraindicated in an unresponsive patient due to aspiration risk.
Question 5: A patient with acute pancreatitis is prescribed morphine for pain management. The nurse understands that which laboratory value should be monitored most closely due to this drug's pharmacological effect?
- Serum amylase and lipase levels (Correct answer)
- Serum calcium and magnesium levels
- International Normalized Ratio (INR)
- Blood urea nitrogen and creatinine levels
Correct answer: Serum amylase and lipase levels
Opioids, including morphine, can cause spasm of the sphincter of Oddi, potentially worsening pancreatitis by impeding pancreatic enzyme drainage. Monitoring serum amylase and lipase tracks whether pancreatic inflammation is improving or worsening during treatment.
Question 6: A patient recovering from a myocardial infarction develops a new holosystolic murmur at the left sternal border with signs of acute heart failure on day 3 post-MI. Which complication does the nurse suspect?
- Pericarditis with pericardial friction rub
- Ventricular septal rupture (Correct answer)
- Aortic stenosis exacerbation
- Mitral valve prolapse
Correct answer: Ventricular septal rupture
Ventricular septal rupture is a serious mechanical complication of MI that typically occurs 3–7 days post-infarction. Necrosis of the interventricular septum causes a left-to-right shunt, producing a new holosystolic murmur and rapid hemodynamic deterioration with signs of heart failure.
CMSRN - Medical-Surgical Nursing Medical-Surgical Nursing 1
A patient with a traumatic brain injury has a Glasgow Coma Scale score of 8 and begins exhibiting Cushing's triad.
Which set of vital signs best represents this triad?