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

An unconscious patient with severe hypoglycemia cannot take oral glucose — IV dextrose (D50W) must be administered immediately.

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

Autonomic dysreflexia is a hypertensive emergency in spinal cord injury above T6, triggered by a noxious stimulus below the injury level.

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

Continuous bubbling in the water-seal chamber indicates an air leak either in the patient's lung or in the drainage system connections.

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

For supratherapeutic INR without bleeding, the warfarin dose is held and the provider is notified to adjust dosing.

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

A sudden brief relief of pain followed by diffuse, board-like rigidity suggests the appendix has ruptured and peritonitis is developing.

TIA - Assessment Technologies Institute Practice Test

TIA - Assessment Technologies Institute Practice Test

TIA Medical-Surgical Nursing 3