TIA Medical-Surgical Nursing 3

Question 1

A patient with type 1 diabetes is found unconscious with a blood glucose of 38 mg/dL. What is the priority intervention?

Accepted Answer

Administer IV dextrose 50% (D50W)

Answer

Administer subcutaneous insulin

Answer

Give 15 g of oral carbohydrate

Answer

Notify the physician and wait for orders

Question 2

A patient with a spinal cord injury at T4 develops sudden hypertension, pounding headache, and diaphoresis above the level of injury. The nurse recognizes this as:

Accepted Answer

Autonomic dysreflexia

Answer

Neurogenic shock

Answer

Orthostatic hypotension

Answer

Hypertensive urgency from anxiety

Question 3

A nurse assesses a patient's chest tube drainage system and notices continuous bubbling in the water-seal chamber. This indicates:

Accepted Answer

An air leak in the system or patient's lung

Answer

Normal function of the drainage system

Answer

The tube needs to be clamped immediately

Answer

Adequate chest tube suction

Question 4

A patient taking warfarin has an INR of 5.8 and no active bleeding. What is the priority nursing action?

Accepted Answer

Hold the next warfarin dose and notify the provider

Answer

Administer vitamin K IV push immediately

Answer

Give fresh frozen plasma (FFP)

Answer

Continue current dose and recheck in 24 hours

Question 5

Which assessment finding in a patient with acute appendicitis indicates perforation has occurred?

Accepted Answer

Sudden relief of pain followed by diffuse abdominal rigidity

Answer

Rebound tenderness at McBurney's point

Answer

Low-grade fever and nausea

Answer

Right lower quadrant pain on palpation

Question 6

A nurse is teaching a patient about signs of infection at a surgical wound. Which finding should be reported to the provider?

Accepted Answer

Purulent drainage with increasing redness

Answer

Mild swelling on postoperative day 1

Answer

Thin, pink serosanguineous drainage

Answer

Wound edges that are approximated