Purdue Global NU144 Medical-Surgical Nursing II

Question 1

Purdue Global NU144 Medical-Surgical Nursing II. As an ICU nurse, you are responsible for the admission of a client with elevated intracranial pressure (ICP). What is the best positioning for this client to optimize cerebral perfusion and reduce ICP?

• Supine position with the head of the bed flat
• High Fowler’s position with the head of the bed elevated at 90 degrees
• Trendelenburg position with the feet elevated higher than the head
• Semi-Fowler’s position with the head of the bed elevated at 30 degrees

Question 2

A client is admitted with an exacerbation of multiple sclerosis. A student nurse asks if suction equipment should be in the client’s room. What is the best response from the experienced nurse?

• “Yes, we should have suction available in case of respiratory distress.”
• “No, suction is not necessary for a client with multiple sclerosis.”
• “Suction equipment is only required for clients with infectious diseases.”
• “I’m not sure; let’s consult the healthcare provider for their recommendation.”

Question 3

The nurse is planning the care of a client with a T1 spinal cord injury. The nurse has identified the nursing diagnosis of risk for impaired skin integrity. How can the nurse best address this risk?

• Change the client’s position at least every 2 hours
• Provide a high fat diet
• Provide range of motion to the extremities every hour
• Assisting the client to cough and deep breath every hour

Question 4

A child on the school playground has landed awkwardly on their head, and 911 has been called. While waiting for the ambulance to arrive, what should be the nurse’s priority action?

• Instruct the child to remain still and avoid any movement.
• Gather the child’s personal information for documentation.
• Stand up the child and move inside the building.
• Inform the school staff about the situation and evacuation.

Question 5

A client is admitted to the emergency department after a head injury. The healthcare team uses the Glasgow Coma Scale (GCS) to assess the client’s neurological status. The client’s GCS score is 6. What does this score indicate about the client’s neurological status?

• Severe brain injury with a high likelihood of a poor outcome.
• Moderate brain injury with potential for neurological recovery.
• Mild brain injury with minimal risk of complications.
• Normal neurological status without any signs of brain injury.

Question 6

A client with a head injury has become increasingly agitated, and the nurse has identified a risk for injury. What is the nurse’s best intervention for preventing injury?

• Restrain the client as prescribed
• Administer opioids PRN as prescribed
• Arrange for friends and family members to sit with the client
• Pad the side rails of the client’s bed

Question 7

The nurse is caring for a client with increased intracranial pressure (ICP). The client has a nursing diagnosis of “ineffective cerebral tissue perfusion.” What would be an expected outcome that the nurse would document after providing interventions for this diagnosis?

• Copes with sensory deprivation
• Registers normal body temperature
• Pays attention to grooming and appearance
• Obeys commands with appropriate motor responses

Question 8

The nurse is preparing a client for magnetic resonance imaging (MRI). Which action should the nurse prioritize?

• Withholding stimulants 24 to 48 hours prior to exam
• Removing all metal-containing objects
• Instructing the client to void prior to the MRI
• Initiating an IV line for administration of contrast

Question 9

A client has been brought to the Emergency Department (ED) after experiencing a loss of consciousness (LOC) due to blunt force trauma. What is the nurse’s primary assessment when evaluating the client’s LOC?

• Assessment of vital signs, including heart rate and blood pressure
• Assessing the client’s orientation to time, place, and person
• Conducting a neurological assessment, including the Glasgow Coma Scale (GCS) Purdue Global NU144 Medical-Surgical Nursing II
• Reviewing the client’s medical history and previous head injuries

Question 10

The nurse is caring for a client with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the client may be experiencing increased brain compression causing brain stem damage?

• Hyperthermia
• Tachycardia
• Hypotension
• Tachypnea

Question 11

A client is admitted to the ICU with suspected bacterial meningitis. What expected assessment finding should the nurse anticipate?

• Clear sensorium and decreased cognitive function
• A positive Brudzinski sign during the physical examination
• An abnormal and pain-free range of motion in the neck
• Change in vital signs, excluding temperature

Question 12

A 73-year-old man comes to the clinic complaining of weakness and loss of sensation in his feet and legs. Assessment of the client shows decreased reflexes bilaterally. Why would it be a challenge to diagnose peripheral neuropathy in this client?

• Older adults are often vague historians
• The elderly have fewer peripheral nerves than younger adults
• Many older adults are hesitant to admit that their body is changing
• Many symptoms can be the result of the normal aging process

Question 13

A client is recovering from hip replacement surgery performed approximately 24 hours ago and is complaining of a headache that the client rates at 8 on a 10-point pain scale. What nursing action is most appropriate?

• Administer the prescribed analgesic and reassess pain in 30–60 minutes
• Encourage the client to ambulate to relieve tension
• Instruct the client to perform neck stretches
• Elevate the client’s legs above heart level

Question 13

A client is recovering from hip replacement surgery performed approximately 24 hours ago and is complaining of a headache that the client rates at 8 on a 10-point pain scale. What nursing action is most appropriate?

• Administer the prescribed analgesic and reassess pain in 30–60 minutes
• Encourage the client to ambulate to relieve tension
• Instruct the client to perform neck stretches
• Elevate the client’s legs above heart level

Question 14

The provider orders Heparin to be given every 8 hours subcutaneously. The order reads 2 mg/kg, and the patient weighs 174 pounds. How much would you administer for one dose?

• 158 mg
• 156 mg
• 157 mg
• 160 mg

Question 15

A nurse administers an IV infusion at 3 mL/min. What is the infusion rate in mL/hr?

• 150 ml/hr
• 180 ml/hr
• 160 ml/hr
• 220 ml/hr

Question 16

The nurse is preparing to assess a client with neurologic dysfunction. What does accurate and appropriate assessment require? Select all that apply.

• The ability to select basic medications for the neurologic dysfunction
• Understanding of the tests used to diagnose neurological disorders
• Knowledge of nursing interventions related to assessment of neurologic patients
• Knowledge of the anatomy of the nervous system
• The ability to interpret the results of diagnostic tests
• knowledge of the anatomy of the integumentary system

Question 18

Case Study Information: A 34-year-old woman presents to the clinic with ongoing fatigue, joint pain, and intermittent low-grade fevers for the past several months. She reports morning stiffness lasting more than an hour and describes episodes of facial redness that worsen with sun exposure. The client also notes hair thinning, unintentional weight loss, and occasional numbness in her fingers when exposed to cold temperatures. Assessment findings include swollen, tender joints in the hands and wrists, pale nail beds, and a faint erythematous rash across the cheeks and bridge of the nose. Laboratory results reveal anemia, elevated inflammatory markers, and the presence of autoantibodies. NOTE: All of this information will be pertinent to the following questions. Please analyze the information so that you can identify one (1) Suspected Condition, two (2) Priority Actions, and two (2) Parameters to Monitor.

What is most likely the patient’s condition? (Select 1)

• Osteoarthritis
• Fibromyalgia
• Systemic lupus erythematosus
• Hypothyroidism

Question 19

Case Study Information: A 34-year-old woman presents to the clinic with ongoing fatigue, joint pain, and intermittent low-grade fevers for the past several months. She reports morning stiffness lasting more than an hour and describes episodes of facial redness that worsen with sun exposure. The client also notes hair thinning, unintentional weight loss, and occasional numbness in her fingers when exposed to cold temperatures. Assessment findings include swollen, tender joints in the hands and wrists, pale nail beds, and a faint erythematous rash across the cheeks and bridge of the nose. Laboratory results reveal anemia, elevated inflammatory markers, and the presence of autoantibodies. NOTE: All of this information will be pertinent to the following questions. Please analyze the information so that you can identify one (1) Suspected Condition, two (2) Priority Actions, and two (2) Parameters to Monitor.

What are two priority interventions? (Select 2)

• Educate the client to avoid sun exposure and use sunscreen
• Monitor renal function and urine output regularly
• Encourage high-impact exercise to reduce joint stiffness
• Apply heat continuously to inflamed joints
• Discontinue all immunosuppressive medications once symptoms improve
• Increase dietary sodium to prevent hypotension

Question 20

Case Study Information: A 34-year-old woman presents to the clinic with ongoing fatigue, joint pain, and intermittent low-grade fevers for the past several months. She reports morning stiffness lasting more than an hour and describes episodes of facial redness that worsen with sun exposure. The client also notes hair thinning, unintentional weight loss, and occasional numbness in her fingers when exposed to cold temperatures. Assessment findings include swollen, tender joints in the hands and wrists, pale nail beds, and a faint erythematous rash across the cheeks and bridge of the nose. Laboratory results reveal anemia, elevated inflammatory markers, and the presence of autoantibodies. NOTE: All of this information will be pertinent to the following questions.

Identify two parameters to monitor right now? (Select 2)

• Urine output and urine protein levels
• Serum creatinine and BUN
• Blood glucose levels
• Peak expiratory flow rate Purdue Global NU144 Medical-Surgical Nursing II
• Serum calcium levels
• Bowel sounds