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Nursing Care in Medical-Surgical Scenarios Quiz

#1

Which condition is a potential complication of immobility in bedridden patients?

Pneumonia
Explanation

Stagnation of respiratory secretions can lead to pneumonia.

#2

Which nursing intervention is appropriate for a patient with impaired skin integrity?

Implementing a turning schedule and using pressure-relieving devices
Explanation

Prevention of pressure ulcers through proper positioning and support.

#3

Which nursing intervention is appropriate for a patient experiencing chest pain?

Assessing vital signs and contacting the healthcare provider
Explanation

Immediate assessment to identify potential cardiac issues.

#4

What is the priority nursing action for a patient with acute respiratory distress?

Administering oxygen therapy
Explanation

Ensuring adequate oxygenation to support respiratory function.

#5

Which laboratory result requires immediate action for a patient on warfarin therapy?

INR of 5.0
Explanation

Indicates increased risk of bleeding, necessitating adjustment of anticoagulation therapy.

#6

What is the priority nursing action for a patient admitted with diabetic ketoacidosis?

Administering regular insulin via IV infusion
Explanation

To lower blood glucose levels and address metabolic acidosis.

#7

Which action is essential when caring for a patient with a chest tube drainage system?

Keeping the drainage system below the level of the chest
Explanation

Prevents backflow of fluid and air into the chest cavity.

#8

Which assessment finding requires immediate intervention for a patient receiving continuous enteral feeding?

Residual volume greater than 100 mL
Explanation

Indicates inadequate digestion or absorption, risking aspiration.

#9

Which action is essential for the nurse when caring for a patient with a suspected spinal cord injury?

Immobilizing the head and neck
Explanation

Prevents further damage to the spinal cord and nerves.

#10

Which assessment finding indicates a potential complication in a patient with a nasogastric tube?

Abdominal distension and absent bowel sounds
Explanation

Signs of gastrointestinal dysfunction or obstruction.

#11

Which nursing action is appropriate when caring for a patient with a newly inserted urinary catheter?

Ensuring the catheter bag is kept above the level of the bladder
Explanation

Prevents backflow of urine and reduces risk of infection.

#12

What is the priority nursing intervention for a patient at risk for aspiration?

Elevating the head of the bed to at least 30 degrees during and after meals
Explanation

Reduces risk of aspiration by promoting proper swallowing and digestion.

#13

What is the priority nursing intervention for a patient experiencing a seizure?

Ensuring a patent airway and protecting the patient from injury
Explanation

Safety measures to prevent harm during seizure activity.

#14

Which assessment finding requires immediate intervention in a patient with a nasogastric tube?

Abdominal distension and absent bowel sounds
Explanation

Indicative of potential bowel obstruction or other complications.

#15

What is the priority nursing intervention for a patient with a central venous catheter experiencing signs of infection?

Obtaining cultures from the catheter and initiating antibiotic therapy as ordered
Explanation

Early identification and treatment of infection to prevent systemic complications.

#16

Which intervention is essential to prevent ventilator-associated pneumonia in a mechanically ventilated patient?

Maintaining the head of the bed at 30 to 45 degrees
Explanation

Reduces risk of aspiration and improves lung expansion.

#17

What is the priority nursing intervention for a patient experiencing anaphylaxis?

Administering epinephrine
Explanation

Counteracts severe allergic reactions to prevent further complications.

#18

What is the priority nursing intervention for a patient experiencing a hypertensive crisis?

Administering IV antihypertensive medication as ordered
Explanation

To rapidly lower blood pressure and prevent end-organ damage.

#19

What is the priority nursing intervention for a patient experiencing a hypertensive emergency?

Administering IV vasodilators as ordered
Explanation

To rapidly reduce blood pressure and prevent complications.

#20

What is the priority nursing intervention for a patient experiencing a hemorrhagic stroke?

Monitoring neurologic status closely
Explanation

Early detection of neurological deterioration is crucial for timely intervention.

#21

What is the priority nursing intervention for a patient with hypovolemic shock?

Administering IV fluids rapidly
Explanation

To restore circulating volume and improve tissue perfusion.

#22

What is the priority nursing intervention for a patient with septic shock?

Administering IV antibiotics
Explanation

To combat the underlying infection and prevent systemic complications.

#23

Which assessment finding requires immediate intervention for a patient receiving intravenous (IV) therapy?

Formation of a blood clot in the IV tubing
Explanation

Can obstruct flow and increase risk of embolism or infection.

#24

What is the priority nursing action for a patient admitted with a suspected stroke?

Assessing and maintaining airway, breathing, and circulation
Explanation

Immediate assessment to prevent further neurological compromise.

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