Ms Mbol 21

Medical-Surgical Nursing 3: MBOL BATCH 2021 4/14/21, 8:51 PM
Medical-Surgical Nursing 3
Due No due date Points 100 Questions 100
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Submitted Apr 14 at 8:51pm
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Question 1 1 / 1 pts
During CPR to an adult victim, it is appropriate that a rescuer palpates

what particular artery?
brachial
radial
popliteal
carotid
https://feu.instructure.com/courses/67584/quizzes/584835 Page 1 of 63
The ratio of compression and breathing for adult CPR:
15 compression : 2 breathing
30 compression :1 breathing
It is always appropriate to consider and treat victims as suspected

spinal cord injury if the incident is a vehicular accident.
True, only if the victim is unconscious
True, the victim might possibly be having spinal fracture even though he
is
False, if the victim should not be able to walk
All are correct
We always consider trauma victims to have a possible spinal

cord injury so we protect the spine/ backbone.
One of the victim showed manifestation of severe bleeding that could

possibly lead to hypovolemic shock. Which of the following action
should a first aider do?
Elevate the leg of the victim
All options are correct
Ensure adequate supply of O2
Maintain normal temperature
This a disaster zone wherein first aid is limited to airway and

hemorrhage control so as to stabilize the victim condition:
Hot Zone
Warm Zone
Cold Zone
All options are correct
Hot Zone, the zone where the actual disaster happens. We need
to limit our activity because the scene is unsafe.
Incorrect Question 6 0 / 1 pts
Which of the following patient casualty handling procedure is best

applied that will help you avoid smoke suffocation from a burning train.
Pack strap carry
Fireman's carry
Fireman's drag
Carry by extremities
In case of fire, the oxygen is confined on the ground. To avoid

suffocation, and to be able to get enough oxygen, rescuers
should drag the victim on the ground to keep them low.
It occurs when the heart stops beating and breathing ceases abruptly or
unexpectedly:
Respiratory Arrest
Ventricular fibrillation
Cardiac standstill
Cardiac Arrest
Which of the following is not a characteristic of a full thickness burn?
Dry pale, white leathery skin
Broken skin, fat is exposed
None of the options are correct
Painful feeling
Full thickness burn or 3rd degree burn is not painfull because

the epidermis is already damage. Pain receptor is absent.
You conduct voice triage:
To tag as Black, victims who did not respond
To separate the victims who are able to walk on their own
To separate the victims who can at least respond to your questions
To separate the loud victims from the rest of the group so others can get
rest
Voice triage is asking all those who can walk to leave the
disaster site and go to a safer place for possible treatment. In
this case sorting of those walking wounded (less priority) is
being done.
A portable automated device that helps to produce cardiac contraction

attached to the chest of the victim during cardiac arrest is called:
ECG
Electronic Defibrillator
ECT
Automated External Defibrillator
Incorrect
Which of the following emergency rescue procedure is appropriate in

evacuating a victim utilizing the narrow door of the train?
Hammock carry
Bearer's alongside
Pack strap carry
Fireman's drag
Bearer's alongside is the best technique used to evacuate

victims in a narrow spaces because it utilize a technique
"Clipping" patient towards the body of the rescuers. This helps
facilitate evacuation of victim with ease even though the space is
narrow.
During a disaster one male victim sustained an injury with penetrating

trauma on his head and loss of consciousness. The triage officer
classify the victim under
Critical
Deceased
Urgent
All of the options
Unconscious victim is considered deceased and is

triage/categorize as black.
Which of the following statement describes a victim that needs urgent

attention?
Broken Skull
Pregnant, ruptured bag of H2O
Agitated, blabbering incoherent words
Chest pain, difficulty of breathing
The principle is still Airway, breathing and circulation. Our

foremost goal is to aid the victim to breath.
This is an area in the emergency department of a hospital where new

victims are sent after triage and decontamination procedure is
performed:
Hot zone
Warm Zone
Clean Zone
Cold zone
the area in the hospital where victims are sent following

decontamination. Ex. ER
According to American Heart Association, victim of a traumatic incident

which manifests symptoms of negative breath, and absence of pulse
needs immediate CPR. Which of the following is true about CPR?
All of the options
Airway is opened after 30 chest compressions
Push hard and fast or give high quality compression
Begin with external chest compression before giving rescue breaths
All the 3 choices pertains to the principle of giving CPR

according to AHA
During CPR to an infant, it is appropriate that a rescuer palpates what

particular artery?
brachial
carotid
popliteal
radial
Which of the following is not an appropriate action of an emergency

nurse pertaining to a care of a 2nd degree burn patient?
Treat the patient for shock if necessary
None of the options
Administer pain reliever by injection as ordered by a physician
Cover the burn area with a sterile dressing or a clean sheet
The triage system designed specifically for pediatrics that compliments

the START system is called
JUMPSTEP
JUMPSTART
STEPBACK
STEPSTART
JUMPSTART Triage system is a triage system intended for

children below 8 years old.
In utilizing the spine board, which of the following injured body parts is
best protected and immobilized?
Head, neck and lower limbs
None of the options
Thoracic vertebra, sacrum, coccyx
Legs, shoulder blades
During VA or fall, or any trauma accident, we consider patient as

having a spinal cord injury.We utilize the spine board to align the
backbones and prevent further injury.
The ideal and easiest way to conduct emergency rescue among

children is to use which among these techniques?
Carry by extremities
Logrolling
Pack strap carry
Fireman's carry
For children and those who are not heavy, we utilize the carry by
extremities technique because it requires less weight bearing on
the part of the rescuers and easy movement.
What is the depth of compression for an adult during CPR?
2 inches
1/2 inch
1 ½ inch
1 inch
It includes recognition of respiratory arrest or cardiac arrest, access to

EMS system and application of basic CPR.
AED
BLS
EMS
CPR
The critical time that may result to possible brain damage is within:
1-3 minutes
4-6 minutes
6-8 minutes
above 10 minutes
A specific zone in the disaster area that first aider commence

decontamination of victims is located in the:
Hot zone
None of the options
Warm zone
Cold zone
Warm zone – this is where decontamination happens. The area

is less threatening than hot zone.
It is the management of Foreign Body Airway obstruction to an infant:
Chest thrust
Back slapping and chest thrust
Heimlich Maneuver
Back slapping technique
Nurse Angelo should expect a client with hypothyroidism to report

which health concerns?
Increased appetite and weight loss
Puffiness of the face and hands
Nervousness and tremors
Thyroid gland swelling
Hypothyroidism (myxedema) causes facial puffiness, extremity

edema, and weight gain. Signs and symptoms of
hyperthyroidism (Graves' disease) include an increased
appetite, weight loss, nervousness, tremors, and thyroid gland
enlargement (goiter).
The nurse caring for a client with a history of experiencing the Somogyi
effect would monitor the client's blood sugar level between
10 AM and 3 PM.
5 PM and 12 AM.
2 AM and 3 AM.
12 PM and 6 PM.
Nocturnal rebound hyperglycemia (Somogyi phenomenon)

should be investigated by monitoring blood glucose levels
between 2 and 4 AM and again at 7 AM.
When assessing a client's neck dressing the first day after

thyroidectomy, the nurse would
remove the dressing with each inspection.
avoid using gloves to best detect moisture.
ensure that the dressing is very tight.
include the back of the neck and shoulders.
The nurse should examine the back of the neck and shoulders
for bleeding because blood tends to drain posteriorly.
Nurse Christina is developing a teaching plan for a male client

diagnosed with diabetes insipidus. The nurse should include
information about which hormone lacking in clients with diabetes
insipidus?
luteinizing hormone (LH).
follicle-stimulating hormone (FSH).
thyroid-stimulating hormone (TSH).
antidiuretic hormone (ADH).
ADH is the hormone clients with diabetes insipidus lack. The

client's TSH, FSH, and LH levels won't be affected.
When a client asks if he can use the disposable insulin syringe more
than once, the nurse's most appropriate reply would be
"No; insulin from the previous dose will alter the next dose."
"No; the equipment is designed for single use only."
"Yes; make sure to cap the needle to prevent infection."
"Yes; make sure the needle is straight and sharp."
Although the equipment is designed for single use, many clients

use the syringes until the needle is dull. If the needle is capped
securely and not brought into contact with any object other than
the client's skin, the narrow gauge of the needle and the
bacteriostatic qualities of the insulin would allow multiple use of
one syringe.
For many years, physiologists regarded the pituitary gland as the

"master gland" of the body because it appeared to control the activity of
endocrine glands throughout the body. We now know that in fact the
hypothalamus of the brain controls the pituitary through the action of:
Thyroxine
Neurotransmitters
Stimulating hormones
Releasing hormones
A male client with type 1 diabetes mellitus has a highly elevated

glycosylated hemoglobin (Hb) test result. In discussing the result with
the client, nurse Jushley would be most accurate in stating:
"Your insulin regimen needs to be altered significantly."
"It tells us about your sugar control for the last 3 months."
"It looks like you aren't following the prescribed diabetic diet."
"The test needs to be repeated following a 12-hour fast."
The glycosylated Hb test provides an objective measure of

glycemic control over a 3-month period. The test helps identify
trends or practices that impair glycemic control, and it doesn't
require a fasting period before blood is drawn. The nurse can't
conclude that the result occurs from poor dietary management
or inadequate insulin coverage.
Early this morning, a female client had a subtotal thyroidectomy. During

evening rounds, nurse Tina assesses the client, who now has nausea,
a temperature of 105° F (40.5° C), tachycardia, and extreme
restlessness. What is the most likely cause of these signs?
Tetany
Thyroid crisis
Hypoglycemia
Diabetic ketoacidosis
Thyroid crisis usually occurs in the first 12 hours after

thyroidectomy and causes exaggerated signs of
hyperthyroidism, such as high fever, tachycardia, and extreme
restlessness. Diabetic ketoacidosis is more likely to produce
polyuria, polydipsia, and polyphagia; hypoglycemia, to produce
weakness, tremors, profuse perspiration, and hunger. Tetany
typically causes uncontrollable muscle spasms, stridor,
cyanosis, and possibly asphyxia.
Which hormone(s) does the posterior pituitary release?
ADH and oxytocin
FSH and LH
Growth hormone
ACTH
The nurse would remind a client that the preparation for thyroid surgery
might take as long as
1 week.
1 or 2 days.
6 months or longer.
2 to 3 months.
Adequate preoperative preparation may take as long as 2 to 3

months, although the final period of preparation for thyroid
surgery is more intense and lasts about 10 days.
When caring for a male client with diabetes insipidus, nurse Ronwald
expects to administer:
10% dextrose.
regular insulin.
furosemide (Lasix).
vasopressin (Pitressin Synthetic).
Because diabetes insipidus results from decreased antidiuretic

hormone (vasopressin) production, the nurse should expect to
administer synthetic vasopressin for hormone replacement
therapy. Furosemide, a diuretic, is contraindicated because a
client with diabetes insipidus experiences polyuria. Insulin and
dextrose are used to treat diabetes mellitus and its
complications, not diabetes insipidus.
It measures oxygen consumption at the lowest cellular activity.
Basal metabolic rate
Thyroid scan
Fine needle biopsy
Reflex testing
It is a condition of parathyroid hormone deficiency characterized by

hypocalcemia, hyperphosphotemia, and neuromuscular
hyperexcitability.
hypothyroidism
hypoparathyroidism
hyperparathyroidism
hyperthyroidism
Nurse Kristine is providing dietary instructions to a male client with

hypoglycemia. To control hypoglycemic episodes, the nurse should
recommend:
Consuming a low-carbohydrate, high-protein diet and avoiding fasting.
Increasing saturated fat intake and fasting in the afternoon.
Increasing intake of vitamins B and D and taking iron supplements.
Eating a candy bar if light-headedness occurs.
To control hypoglycemic episodes, the nurse should instruct the

client to consume a low-carbohydrate, high-protein diet, avoid
fasting, and avoid simple sugars. Increasing saturated fat intake
and increasing vitamin supplementation wouldn't help control
hypoglycemia.
The nurse should most closely observe a client receiving NPH insulin at
7 AM for manifestations of an insulin reaction at
2 PM.
9 AM.
7:30 AM.
8 PM.
The peak action for intermediate-acting NPH is 4 to 10 hours

after administration.
A female client with hypothyroidism (myxedema) is receiving

levothyroxine (Synthroid), 25 mcg P.O. daily. Which finding should
nurse Ces recognize as an adverse drug effect?
Blurred vision
Tachycardia
Dysuria
Leg cramps
Levothyroxine, a synthetic thyroid hormone, is given to a client

with hypothyroidism to simulate the effects of thyroxine. Adverse
effects of this agent include tachycardia. The other options aren't
associated with levothyroxine.
In making emergency equipment available at the bedside of a client

who has undergone subtotal thyroidectomy, the nurse would include
a defibrillator.
an intra-aortic balloon pump.
a tracheostomy set.
an electrocardiogram (ECG) monitor.
The nurse should assemble the equipment at the bedside before

the client returns from surgery. The equipment includes a blood
pressure cuff and stethoscope, additional pillows, oxygen,
suction equipment, intubation supplies, and tracheostomy set.
Nurse Jonathan is assigned to care for a postoperative male client who

has diabetes mellitus. During the assessment interview, the client
reports that he's impotent and says he's concerned about its effect on
his marriage. In planning this client's care, the most appropriate
intervention would be to:
Provide time for privacy.
Encourage the client to ask questions about personal sexuality.
Suggest referral to a sex counselor or other appropriate professional.
Provide support for the spouse or significant other.
The nurse should refer this client to a sex counselor or other

professional. Making appropriate referrals is a valid part of
planning the client's care. The nurse doesn't normally provide
sex counseling.
An agitated, confused female client arrives in the emergency

department. Her history includes type 1 diabetes mellitus, hypertension,
and angina pectoris. Assessment reveals pallor, diaphoresis, headache,
and intense hunger. A stat blood glucose sample measures 42 mg/dl,
and the client is treated for an acute hypoglycemic reaction. After
recovery, nurse Phillip teaches the client to treat hypoglycemia by
ingesting:
25 to 30 g of a simple carbohydrate.
To reverse hypoglycemia, the American Diabetes Association

recommends ingesting 10 to 15 g of a simple carbohydrate,
such as three to five pieces of hard candy, two to three packets
of sugar (4 to 6 tsp), or 4 oz of fruit juice. If necessary, this
treatment can be repeated in 15 minutes. Ingesting only 2 to 5 g
of a simple carbohydrate may not raise the blood glucose level
sufficiently. Ingesting more than 15 g may raise it above normal,
causing hyperglycemia.
Drugs such as alcohol and caffeine cause the production of voluminous

amounts of dilute urine because they interfere with the secretion of
ADH in the:
Cerebelum
Kidney
Cerebrum
Hypothalamus
A female client has a serum calcium level of 7.2 mg/dl. During the
physical examination, nurse Noah expects to assess:
Hegar's sign
Homans' sign.
Trousseau's sign.
Goodell's sign.
This client's serum calcium level indicates hypocalcemia, an

electrolyte imbalance that causes Trousseau's sign (carpopedal
spasm induced by inflating the blood pressure cuff above
systolic pressure). Homans' sign (pain on dorsiflexion of the foot)
indicates deep vein thrombosis. Hegar's sign (softening of the
uterine isthmus) and Goodell's sign (cervical softening) are
probable signs of pregnancy.
Ralph, who weighs 210 lb (95 kg) and has been diagnosed with
hyperglycemia tells the nurse that her husband sleeps in another room
because her snoring keeps him awake. The nurse notices that she has
large hands and a hoarse voice. Which of the following would the nurse
suspect as a possible cause of the client's hyperglycemia?
Hypothyroidism
Acromegaly
Type 1 diabetes mellitus
Deficient growth hormone
Acromegaly, which is caused by a pituitary tumor that releases

excessive growth hormone, is associated with hyperglycemia,
hypertension, diaphoresis, peripheral neuropathy, and joint pain.
Enlarged hands and feet are related to lateral bone growth,
which is seen in adults with this disorder. The accompanying soft
tissue swelling causes hoarseness and often sleep apnea. Type
1 diabetes is usually seen in children, and newly diagnosed
persons are usually very ill and thin. Hypothyroidism isn't
associated with hyperglycemia, nor is growth hormone
deficiency.
A male client is admitted for treatment of the syndrome of inappropriate

antidiuretic hormone (SIADH). Which nursing intervention is
appropriate?
Infusing I.V. fluids rapidly as ordered
Administering glucose-containing I.V. fluids as ordered
Encouraging increased oral intake
Restricting fluids
To reduce water retention in a client with the SIADH, the nurse

should restrict fluids. Administering fluids by any route would
further increase the client's already heightened fluid load.
During preoperative teaching for a female client who will undergo

subtotal thyroidectomy, the nurse should include which statement?
"The head of your bed must remain flat for 24 hours after surgery."
"You must avoid hyperextending your neck after surgery."
"You won't be able to swallow for the first day or two."
"You should avoid deep breathing and coughing after surgery."
To prevent undue pressure on the surgical incision after subtotal

thyroidectomy, the nurse should advise the client to avoid
hyperextending the neck. The client may elevate the head of the
bed as desired and should perform deep breathing and
coughing to help prevent pneumonia. Subtotal thyroidectomy
doesn't affect swallowing.
The drug ibuprofen (tradename: Advil, Motrin) reduces inflammation,

fever, and pain by inhibiting the release of:
Neurotransmitters
Prostaglandins
Cortisol
Antidiuretic hormones
The physician orders intravenous fluid replacement therapy with

potassium chloride to be added for a child with severe gastroenteritis.
Before adding the potassium chloride to the intravenous fluid, which of
the following assessments would be most important?
Ability to void.
Passage of stool today.
Baseline electrocardiogram.
Serum calcium level.
A Full Thickness burn is describe as:
Thick, dry in appearance, pearly gray or charred black color and

painless
Moist, shiny in appearance, pearly gray or charred black color and is

painful when exposed to air
Reddened skin, with edema but no blistering, burn blanches under

pressure
Moist, shiny in appearance, salmon pink to red color, and is painful

when exposed to air
Which of the following clinical manifestations does the nurse find in the
client who has systemic adverse effects from long-term corticosteroid
therapy?
Low sodium.
Hyperkalemia.
High serum albumin.
Weight gain.
A client presents to the emergency room with diabetic ketoacidosis. The

nurse would identify which of the following nursing diagnoses as a
priority problem?
Imbalanced Nutrition: Less than Body Requirements.
Deficient Fluid Volume.
Impaired Health Maintenance.
Disturbed Sleep Pattern.
To prevent complications related to fluid and electrolytes imbalance, the

nurse should collaborate well to other health teams. Who among the
following members of the health team should the nurse talk to when
asking for the result of the ABG result?
Respiratory therapist
Medical technologist
Pulmonologist
Head nurse
When an individual is burned there is massive cell destruction resulting

in a disruption of the normal homeostasis of the body. The nurse
anticipates that the client will be susceptible to which of the following in
the early phase of burn care?
Hyponatremia.
Hypernatremia.
Hyperkalemia.
Metabolic alkalosis.
The sudden onset of which of the following signs or symptoms indicates

a potentially serious complication for the client receiving an intravenous
infusion?
Noisy respirations.
Moist skin.
Pupillary constriction
Halitosis.
Which of the following describes the movement of Potassium during

Acidosis to patient who received Blood transfusion?
Intracellular Potassium moves out into the extracellular compartment in

exchange for Hydrogen ion which will enter the cells
Potassium concentration remains the same
Hydrogen ion is added with potassium in the presence of an enzyme
Extracellular Potassium becomes excreted and intracellular Potassium

moves out, causing Hypokalemia
A client who has ulcerative colitis has persistent diarrhea. He is thin and
has lost 12 pounds since the exacerbation of his ulcerative colitis. The
nurse should anticipate that the physician will order which of the
following treatment approaches to help the client meet his nutritional
needs?
Provide six small meals a day
Initiate continuous enteral feedings
Implement total parenteral nutrition
Encourage a high-calorie, high-protein diet
Which of the following solutions would the nurse administer for this
patient with Hypernatremia?
0.3 NSS
D5 LR
Plain NSS
D5W
The client is supposed to receive 500 mL of 5% dextrose on 0.45%

normal saline (D5/0.45 NS) with 20 mEq of potassium chloride (KCl)
over the next 6 hours. The infusion set administers 10 gm/mL. To what
flow rate should the nurse adjust the intravenous flow?
14 gm/minute.
25 gm/minute.
18 gm/minute.
21 gm/minute.
Which of the following is a risk factor for hypovolemic shock?
Gram-negative bacteria
Hemorrhage
Vasodilatation
Antigen-antibody reaction
Which of line following is the best indicator for determining whether a

client with Addison's disease is receiving the correct amount of
glucocorticoid replacement?
Thirst.
Skin turgor.
Daily weight.
Temperature.
The nurse administers mannitol (Osmitrol) to the client with increased

ICP and closely monitors
pupil dilation.
muscle relaxation.
widening of the pulse pressure.
intake and output.
A patient who undergo hemodialysis has a distinct characteristic of

pulse which is:
increased pulse
thready pulse
pulse with bruit
weak pulse
After monitoring the clients in the ICU, you noticed significant changes
indicating that they are improving. The following are indicators of
adequate fluid balance you have observe on these clients EXCEPT
one.
Urine output of 30 -50 cc per hour in an adult
Systolic Blood Pressure of < 90 – 100
Heart rate of < 110 per minute in adults
Absence of ileus and nausea
The nurse initiates the client's first hemodialysis treatment. The client
develops a headache, confusion, and nausea. These symptoms
indicate which of the following potential complications?
Peritonitis.
Air embolism.
Disequilibrium syndrome.
Myocardial infarction.
A 65 y/o woman is brought to the hospital after vomiting excessively at

home. After checking pt.’s ABG levels, the doctor diagnoses severe
dehydration. Using ABG guide, which acid-base imbalance would you
expect to patient to have?
Metabolic acidosis
Respiratory acidosis
Respiratory alkalosis
Metabolic alkalosis
If the client's serum potassium continues to rise in acute renal failure,

the nurse should be prepared for which of the following emergency
situations?
Hemorrhage.
Pulmonary edema.
Cardiac arrest.
Circulatory collapse.
The nurse should be especially alert for signs and symptoms of digitalis
toxicity if serum levels indicate that the client has a
low sodium level.
low potassium level.
high calcium level.
high glucose level.
Infusion of a hypertonic solution is given intravascularly to a patient

during an operation due to multiple stab wound. This solution moves
towards the interstitial cells through the process of:
diffusion
osmosis
The nurse is teaching the relative of a patient who just had a kidney
transplant about intake and output monitoring. You will be worried if the
patient’s relative stated that:
“I do not know how much his vomitus was this morning.”
“I will drain the foley catheter every hour and record it.”
“I will make sure he uses measuring cup every time he takes in fluid.”
“He moved her bowel this morning twice!”
The client with Cushing's disease needs to modify dietary intake to

control symptoms. In addition to increasing protein, which strategy
would be most appropriate?
Reduce fat to 10%.
Increase calories.
Restrict potassium.
Restrict sodium.
A child is to receive intravenous fluids at a rate of 95 mL/hour. The

tubing for the infusion delivers 10 drops/mL. At which of the following
rates would the nurse infuse the solution?
10 drops/minute
20 drops/minute
14 drops/minute
16 drops/minute
In the oliguric phase of acute renal failure, the nurse should anticipate
the development of which of the following complications?
Metabolic alkalosis.
Hypokalemia.
Pulmonary edema.
Hypotension.
A nurse prepared an audiotaped exchange with another nurse of

information about a patient. Which action did the nurse complete?
Consultation
Record
Referral
Report
Reports are oral, written, or audiotaped exchanges of

information among caregivers. A patient's record or chart is a
confidential, permanent legal document consisting of information
relevant to his or her health care. Consultations are another form
of discussion in which one professional caregiver gives formal
advice about the care of a patient to another caregiver. Nurses
document referrals.
A client is receiving parenteral nutrition (PN) complains of shortness of

breath and shoulder pain. A nurse notes that the client has an
increased pulse rate. The nurse determines that client is experiencing
which complication of PN therapy?
Pneumothorax
Air embolism
Hypervolemia
Hyperglycemia
Pneumothorax might happen during a parenteral therapy due to

inexact catheter placement. In order to prevent this, the nurse
obtains a chest x-ray after insertion of the catheter to ensure
proper catheter placement.
A postpartum patient is to receive 1500 ml of LR over the next 8 hours.

Compute for ml/hr:
187.5 ml/hr
46.67 ml/hr
158.7 ml/hr
47.66 ml/hr
Incorrect
What classifies a drug as a high alert medication?
It's ability to look and sound-like another drug
It's difficult spelling
It's expensive cost
It's narrow therapeutic index
A client is brought to the emergency department having experienced

blood loss due to a deep puncture wound. A 3 unit fresh-frozen plasma
(FFP) is ordered. The nurse determines that the reason behind this
order is to:
Increase hemoglobin, hematocrit, and neutrophil levels
Treat thrombocytopenia
Treat platelet dysfunction
Provide clotting factors and volume expansion
A patient is to receive heparin at 1000 units/hr. The concentration is

Heparin 25,000 units in 250 ml 0.9% NSS. How many ml /hr should the
IV pump be set?
10 ml/hr
15 ml/hr
25 ml/hr
11 ml/hr
A client is receiving a first-time blood transfusion of packed RBC. How

long should the nurse stay and monitor the client to ensure a
transfusion reaction will not happen?
60 minutes
15 minutes
45 minutes
30 minutes
Usually, a transfusion reaction occurs within the 15 minutes of a

transfusion.
Nurse Andrea is changing the central line dressing of a client receiving

parenteral nutrition (PN) and notes that there are redness and drainage
at the insertion site. The nurse will next assess which of the following?
Expiration date
Client's temperature
Time of last dressing change
Allergy
Redness at the catheter insertion site is a possible sign of

infection. The nurse would next assess for other signs of
infection. Of the options given, the temperature is the next item
to assess.
A nurse is preparing to hang the initial bag of the parenteral nutrition

(PN) solution via the central line of a malnourished client. The nurse
ensures the availability of which medical equipment before hanging the
solution?
Dressing tray
Nebulizer
Infusion Pump
Glucometer
Nurse Paolo has received a blood unit from the blood bank and has re-
checked the blood bag properly with Nurse Edward. Prior the facilitation
of the blood transfusion, nurse Paolo priority check which of the
following?
Intake and output
NPO standing order
Skin turgor
Vital signs
The nurse must assess the vital signs before and 15 minutes
after the procedure so that any changes during the transfusion
may indicate a transfusion reaction is happening.
To verify the age of blood cells in a blood, the nurse will check which of
the following?
Blood group
Blood identification number
Blood type
Blood expiration date
The safe storage of blood usually takes 35 days. Examining the

expiration date is an important responsibility of a nurse prior
hanging the blood.
A nurse is caring a client who disconnected the tubing of the parenteral

nutrition from the central line catheter. A nurse suspects an occurrence
of an air embolism. Which of the following is an appropriate position for
the client in this kind of situation?
On the left side, with the head higher than the feet
On the right side, with head higher than the feet
On the left side, with the head lower than the feet
On the right side, with head lower than the feet
Air embolism happens because of the entry of air into the

catheter system. If it occurs, the client should be placed in a left-
side-lying position with the head lower than the feet. This
position will lessen the effect of the air traveling as a bolus to the
lungs by trapping it on the right side of the heart.
If too much or the wrong kind of insulin is given, what could be the
dangerous outcome?
Blood glucose levels will drop putting the person at risk for a coma
Blood will not clot putting the person at risk for bleeding
Blood pressure will rise putting the person at risk for a stroke
Blood pressure will drop putting the person at risk for fainting
Which nursing intervention takes highest priority when caring for a

newly admitted client who's receiving blood transfusion?
Informing the client that the transfusion usually takes 4 to 6 hours
Documenting blood administration in the client chart
Warming the blood prior transfusion
Instructing the client to report any itching, chest pain, or dyspnea
This will help the nurse take immediate action in case a reaction
happens during a transfusion.
Which of these is the order of events a nurse should follow when

applying personal protective equipment (PPE)?
Mask, eye protection, hand washing, gloves, and gown
Hand washing, gloves, gown, eye protection, and mask
Gown, mask, eye protection, hand washing, and gloves
Hand washing, gown, mask, eye protection, and gloves
When applying PPE, the nurse should always follow the order
of: hand washing, gown, mask, eye protection, and gloves. This
should preferably take place outside of the patient's room. The
reverse order is always followed when removing PPE.
Nurse Spencer is caring for anorexic client who is having total

parenteral nutrition solution for the first time. Which of the following
assessments requires the most immediate attention?
Fasting blood sugar of 98 mg/dl
Dry sticky mouth
Blood glucose of 210 mg/dl
Temperature of 100F
Total parenteral nutrition formula contains dextrose range from

5% to 70%. A blood glucose level of 210 mg/dl is considered
high.
A nurse is caring for a group of clients on a medical-surgical nursing

unit. The nurse recognizes that which of the following clients would be
the least likely candidate for parenteral nutrition?
A 55-year-old with persistent nausea and vomiting from chemotherapy
A 44-year-old client with ulcerative colitis
A 25-year-old client with a Hirschsprung's Disease
A 59-year-old client who had an appendectomy
Which of the following statements about FOCUS is incorrect?
Focus is sometimes a significant change in patient status or behavior or

a significant event in the patient's therapy
Focus is sometimes a current patient concern or behavior
Uses the nursing process and the more positive concept of patient
needs
Focus can be a medical diagnosis
Focus charting is used to describe a perspective of a patient. It

is a method that health professionals used to organize the
records of a patient's health information. This type of charting
can be described as a systematic approach to recording or
documenting a patient's health status and the required nursing
action needed. The aim of focus charting is to bring back the
focal point of the nursing care to the patient and his or her
worries, instead of focusing on a list of problems and medical
diagnosis. This type of care incorporates various aspects of
patient care processes.
A patient with heart failure has dobutamine ordered at 10 mcg/kg/min.

The patient's working weight is 100 kg. The concentration is 250 mg
Dobutamine in 500 ml D5W. What is the ml/hr?
8.25 ml/hr
121.21 ml/hr
122 ml/hr
5 ml/hr
Nurse Rick is administering a 2 unit packed RBC's on a client with a low

hemoglobin. The nurse will prepare which of the following in order to
transfuse the blood?
Polyvol Pro Burette Set
Microfusion set
Tubing with an in-line filter
Photofusion set
Which situation best indicates that the nurse has a good understanding
regarding auditing and monitoring of patients' health records?
The nurse knows that reimbursement is based on the diagnosis-related

groups documented in patients' records.
The nurse determines the degree to which standards of care are met by
reviewing patients' health records.
The nurse realized that care not documented in patients' health records
still qualifies as care provided.
The nurse compares data in patients' records to determine whether a

new treatment had better outcomes than the standard treatment.
A nurse is monitoring the status of a client's fat emulsion (lipid) infusion

and notes that the infusion is 2 hours delay. The nurse should do which
of the following actions?
Adjust the infusion rate to full blast until the solution is back on time
Increase the infusion rate to catch up over the next few hours
Adjust the infusion rate to catch up over the next hours
Make sure the infusion rate is infusing at the ordered rate
How would you classify pills as waste?
Pathological waste
Pharmaceutical waste
Infectious waste
Genotoxic waste
These include: expired or unused pharmaceutical products;

spilled or contaminated pharmaceutical products; surplus drugs,
vaccines or sera; and discarded items used in handling
pharmaceutical, for example bottles, gloves, masks, tubes.
Why are specific medications classified as "high alert" medications?
Only RNs are allowed to administer these medications.
Medications always cause certain adverse side effects.
States require that these medications be on high alert list.
Potential for patient harm is higher with these medications.
Medications on the high alert list of medications have been

identified as such because of their potentially toxic nature and
their need for special care when prescribing, dispensing and
administering.
After providing care, a nurse charts in the patient's record. Which entry
should the nurse document?
Drank adequate amounts of water
Appears restless when sitting in the chair
Skin pale and cool
Apparently is asleep with eyes closed
A factual record contains descriptive, objective information about

what a nurse sees, hears, feels, and smells. An objective
description is the result of direct observation and measurement.
For example, BP 80/50, patient diaphoretic, heart rate 102 and
regular." Avoid vague terms such as appears, seems, or
apparently because these words suggest that you are stating an
opinion, do not accurately communicate facts, and do not inform
another caregiver of details regarding behaviors exhibited by the
patient. Use of exact measurements establishes accuracy. For
example, a description such as "intake, 360 ml of water" is more
accurate than "Patient drank an adequate amount of fluid."
Quiz Score: 94 out of 100

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Medical-Surgical Nursing 3: MBOL BATCH 2021 4/14/21, 8:51 PM

Take the Quiz Again

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Score for this attempt: 94 out of 100

During CPR to an adult victim, it is appropriate that a rescuer palpates

The ratio of compression and breathing for adult CPR:

It is always appropriate to consider and treat victims as suspected

True, only if the victim is unconscious

False, if the victim should not be able to walk

All are correct

We always consider trauma victims to have a possible spinal

One of the victim showed manifestation of severe bleeding that could

Elevate the leg of the victim

All options are correct

Ensure adequate supply of O2

Maintain normal temperature

This a disaster zone wherein first aid is limited to airway and

All options are correct

Incorrect Question 6 0 / 1 pts

Which of the following patient casualty handling procedure is best

Pack strap carry

In case of fire, the oxygen is confined on the ground. To avoid

Which of the following is not a characteristic of a full thickness burn?

Dry pale, white leathery skin

Broken skin, fat is exposed

None of the options are correct

Full thickness burn or 3rd degree burn is not painfull because

Incorrect Question 9 0 / 1 pts

You conduct voice triage:

To tag as Black, victims who did not respond

To separate the victims who are able to walk on their own

To separate the victims who can at least respond to your questions

A portable automated device that helps to produce cardiac contraction

Automated External Defibrillator

Which of the following emergency rescue procedure is appropriate in

Pack strap carry

Bearer's alongside is the best technique used to evacuate

During a disaster one male victim sustained an injury with penetrating

All of the options

Unconscious victim is considered deceased and is

Which of the following statement describes a victim that needs urgent

Pregnant, ruptured bag of H2O

Agitated, blabbering incoherent words

Chest pain, difficulty of breathing

The principle is still Airway, breathing and circulation. Our

This is an area in the emergency department of a hospital where new

the area in the hospital where victims are sent following

According to American Heart Association, victim of a traumatic incident

All of the options

Airway is opened after 30 chest compressions

Push hard and fast or give high quality compression

Begin with external chest compression before giving rescue breaths

All the 3 choices pertains to the principle of giving CPR

During CPR to an infant, it is appropriate that a rescuer palpates what

Which of the following is not an appropriate action of an emergency

Treat the patient for shock if necessary

None of the options

Administer pain reliever by injection as ordered by a physician

Cover the burn area with a sterile dressing or a clean sheet

The triage system designed specifically for pediatrics that compliments

JUMPSTART Triage system is a triage system intended for

Head, neck and lower limbs

None of the options