NSG 233 Med Surg 3 Exam 3

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NSG 233 Med Surg 3 Exam 3 2023 Questions and Answers (Verified Answers) 1.A nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which of the following is an early sign of this oncological emergency?A.cyanosis B.arm edema C.periorbital edema

D.mental status changes ANS : C. periorbital edema

Rationale: Superior vena cava syndrome occurs when the superior vena

cava is compressed or obstructed by tumor growth. Early signs and symptoms generally occurring the morning and include edema of the face, especially around the eyes. The client complains tightness around the neck. As the compression worsens the client experiences edema of the arms. Mental status changes and cyanosis are late signs.

2.The burned client on admission is drooling and having difficulty swallowing. What is the nurse's best first action? 1 / 4

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A.Assess level of consciousness and pupillary reactions.B.Ask the client at what time food or liquid was last consumed.C.Auscultate breath sounds over the trachea and mainstem bronchi.D.Measure abdominal girth and auscultate bowel sounds in all four

quad- rants. ANS : C. Auscultate breath sounds over the trachea and

mainstem bronchi.A burn client who is drooling and having difficulty swallowing is likely experiencing airway issues. The client's airway and respiratory system needs to be assessed immediately and an artificial airway and mechanical ventilation may need to be estimated before the airway becomes too edematous.

3.When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes dry, pale, and hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth?a.First-degree skin destruction b.Full-thickness skin destruction c.Deep partial-thickness skin destruction

d.Superficial partial-thickness skin destruction ANS : B. Full-thickness

skin destruc- tion -With full-thickness skin destruction, the appearance is pale and dry or leathery, and 2 / 4

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the area is painless because of the associated nerve destruction.-Erythema, swelling, and blisters point to a deep partial-thickness burn.-With superficial partial-thickness burns, the area is red, but no blisters are present.-First-degree burns exhibit erythema, blanching, and pain.

4.On admission to the burn unit, a patient with an approximate 25% total

body surface area (TBSA) burn has the following initial laboratory results:

Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which of the following prescribed actions should be the nurse's priority?a.Monitoring urine output every 4 hours.b.Continuing to monitor the laboratory results.c.Increasing the rate of the ordered IV solution.

d.Typing and crossmatching for a blood transfusion. ANS : C. Increasing

the rate of the ordered IV solution.The patient's laboratory results show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Because the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase once the patient's fluid balance has been restored. On admission to a burn unit, the urine output would be monitored more often than every 4 hours (likely every1 hour).

5.A patient is admitted to the burn unit with burns to the head, face, and 3 / 4

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hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take?a.Encourage the patient to cough and auscultate the lungs again.b.Notify the health care provider and prepare for endotracheal intubation.c.Document the results and continue to monitor the patient's respiratory rate.d.Reposition the patient in high-Fowler's position and reassess breath

sounds. ANS : B. Notify the health care provider and prepare for

endotracheal intubation.The patient's history and clinical manifestations suggest airway edema, and the health care provider should be notified immediately so that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema.

6.During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion?

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