Final Exam Review 202310

The nurse is caring for a client who is POD0 of a total abdominal hysterectomy and bilateral salpingoophorectomy (TAH-BSO). When performing an assessment, the nurse notices scant output in the urinary catheter after 2 hours, and the surgical drain with ~80mL of nearly-serous serosanguineous fluid.  The client complains of flank pain. The nurse recognizes that which complication may be present? 

• Fluid overload

• Pancreatic leak

• Urine leak

• Expected finding

Upon initial admission, a client was thought to have an incomplete spinal cord injury. After a few days, it was confirmed that the clients SCI resulted in a complete cord injury. What is the reason for this?

• Too much time spent immobile in the ED stretcher

• Infarction and necrosis of the cord caused by edema and hemorrhage

• Mechanical transection of the cord at the time of injury

• Inadequate assessments completed by the interdisciplinary staff

The nurse is receiving shift report. Based on the report, who should the nurse see first? 

• POD5 pneumonectomy client awaiting discharge teaching 

• POD1 wedge resection client with 600mL sanguineous drainage in the chest tube 

• Pre-bronchoscopy client scheduled for pickup in 30 minutes 

• Post-admission day (PAD) 2 client with pneumonia with coarse crackles to the left lung

The nurse is caring for a client who has an enlarged prostate detected by digital rectal examination (DRE) and an elevated prostate specific antigen (PSA) level. Which of the following procedures should the nurse anticipate being ordered for the client?

• Cystoscopy

• Uroflowmetry

• MRI

• Transrectal US

A client is admitted with an incomplete spinal cord lesion in their cervical spine. They are found to have greater weakness in their upper extremeties than in their lower. Which of the following cord syndromes does the client likely have?

• Central cord syndrome

• Anterior cord syndrome

• Posterior cord syndrome

• Cauda equina and conus medullaris syndrome

The nurse is caring for a client who arrived four hours ago following a R lobectomy. Which assessment finding cues the nurse to take immediate action? 

• Ordered to gravity, but there is no float visible in the suction meter 

• Chest tube with 50ml serosanguineous output 

• Pain limiting deep breathing and coughing exercises 

• Irregular apical heart beat with no prior cardiac history

You are an emergency room nurse. You read the chart - the client came in because they noticed their left hand turning purple. What are your priority assessments? (SATA, 2 correct) 

• CWMS

• Peripheral pulses

• Pedal edema

• Elevation pallor

You are an emergency room nurse. You read the chart - the client came in because they noticed their left hand turning purple. You assess CWMS and peripheral pulses and not the clients radial pulse is absent and they have lost sensation in their fingers. (SATA, 2 correct)

• Immediately notify the primary healthcare provider 

• Notify the provider if/when things get worse 

• Heparin infusion 

• Pantoprazole infusion 

• Amputation

The nurse listening to a client recount the events surrounding their spinal cord injury several months ago. “I was told that when I was injured, bone fragments tore into my spinal cord! Can you believe that?” The nurse recognizes that the client is describing which of the following: 

• Spinal shock

• Hyperflexion

• Primary injury

• Secondary injury

• Immediate injury

The emergency room nurse is receiving a client with a new injury to the C3 vertebra. The nurse prepares for which priority intervention? 

• Pain management

• Mechanical ventilation

• Involvement of the interdisciplinary team

• Application of an abdominal binder

• Assess swallowing difficulty and consult SLP