Question

The nurse is caring for a patient in the acute care setting with a spinal cord injury (SCI) at the level of C-3. What is the main cause of complications or death related to this level of injury?

Answer 1

Correct Answers:

Respiratory compromise

Rationale :

🔷 An injury at the C3 spinal cord level affects the phrenic nerve, which innervates the diaphragm, the primary muscle of respiration.

🔷 Paralysis of the diaphragm leads to respiratory failure, making mechanical ventilation necessary.

🔷 Respiratory complications like hypoventilation, atelectasis, or pneumonia are the leading causes of death in high cervical injuries.

🔷 These clients require aggressive pulmonary care and often long-term ventilator support.

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Answer 2

Correct Answers:

Assess daily for redness. swelling or exudate at insertion site weekly

Rationale :

🔶 A tunneled central line like a Hickman catheter increases the risk of local and systemic infections.

🔶 The insertion site should be inspected daily for signs such as redness, swelling, and drainage, which indicate infection.

🔶 Early detection of infection is crucial to prevent sepsis, especially in immunocompromised clients like those undergoing cancer treatment.

🔶 Clients should be educated to report fever, chills, or unusual drainage promptly.

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Answer 3

Correct Answers:

13.7

Rationale :

✍️ Convert weight:

🟠 ⇨ 121 lbs × 0.45 = 54.5 kg

Dose required: 1 mg/kg × 54.5 kg = 54.5 mg
Drug concentration: 40 mg / 10 mL = 4 mg/mL

🔴 ↠ Volume = 54.5 mg ÷ 4 mg/mL

= 13.625 mL (rounding off)

👉= 13.7 mL

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Answer 4

Correct Answers:

Generalized edema
Epistaxis

Rationale :

Generalized Edema

💠 ALL often leads to bone marrow suppression, causing low albumin levels, which results in fluid shifts and edema.

💠 It also impairs immune and clotting functions, predisposing to fluid imbalance and edematous states.

Epistaxis

💠 Clients with ALL have low platelet counts (thrombocytopenia), making them prone to spontaneous bleeding, including nosebleeds.

💠 Epistaxis is an early sign of hematologic compromise in leukemia.

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Answer 5

Correct Answers:

Use of intravenous substances

Rationale :

🔺 Infective endocarditis is strongly associated with IV drug use, which introduces bacteria directly into the bloodstream.

🔺 These pathogens can colonize damaged heart valves, especially on the right side of the heart (tricuspid valve).

🔺 The use of non-sterile needles leads to bacteremia and vegetation formation on valves.

🔺 Endocarditis can lead to valve destruction, embolism, and sepsis.

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Answer 6

Correct Answers:

Assess the respiratory status hourly and as needed
Ensure that a manual resuscitation bag is at the bedside
Collaborate frequently with the respiratory therapist

Rationale :

🟠 Assess the respiratory status hourly and as needed

🔷 Clients on mechanical ventilation require frequent respiratory assessments to detect early signs of deterioration such as increased secretions, changes in oxygen saturation, or altered breath sounds.

🔷 Monitoring should include breath sounds, respiratory rate, airway patency, and ventilator synchrony.

🔷 This helps identify complications like ventilator-associated pneumonia, barotrauma, or accidental extubation quickly.

🔴 Ensure that a manual resuscitation bag is at the bedside

🔷 A manual resuscitation bag (Ambu bag) must be immediately accessible to provide emergency ventilation if the machine fails or the patient needs to be disconnected.

🔷 It is a standard emergency precaution in ICU protocols for ventilated patients.

🔷 This ensures continuous oxygen delivery during power outages, equipment failure, or transport.

🟢 Collaborate frequently with the respiratory therapist

🔷 Respiratory therapists play a vital role in managing ventilator settings and ensuring optimal gas exchange.

🔷 Frequent collaboration allows for timely adjustment of ventilator parameters based on the patient’s respiratory effort and ABG values.

🔷 It ensures safe, patient-centered care, especially for weaning protocols and secretion management.

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Answer 7

Correct Answers:

A heart murmur

Rationale :

⬖ Mitral valve stenosis causes turbulent blood flow from the left atrium to the left ventricle, producing a diastolic murmur.

⬖ The murmur is low-pitched and often heard at the apex using the bell of the stethoscope.

⬖ The narrowing increases left atrial pressure, leading to atrial enlargement and pulmonary symptoms.

⬖ It’s common in clients with history of rheumatic fever.

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Answer 8

Correct Answers:

The earlier the age of sexual activity and the more partners, the greater the risk

Rationale :

🟡 Human papillomavirus (HPV) is the leading cause of cervical cancer, and early sexual activity increases exposure.

🟡 Having multiple sexual partners increases the risk of persistent HPV infection, the primary etiological agent.

🟡 HPV types 16 and 18 are linked to 70% of cervical cancer cases.

🟡 Vaccination and routine screening are preventive strategies.

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Answer 9

Correct Answers:

PH of 7.21 (normal 7.35-7.45)

Rationale :

✴ A pH of 7.21 indicates acidosis, often due to tissue hypoxia and lactic acid accumulation in hemorrhagic shock.

✴ Acidosis impairs myocardial contractility, reducing perfusion and causing multi-organ failure.

✴ The early post-trauma phase is marked by hypovolemia and acid-base disturbances.

✴ Acidosis, not just hypothermia or tachycardia, directly contributes to early trauma mortality.

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Answer 10

Correct Answers:

respiratory alkalosis

Rationale :

✳️ A pH > 7.45 and PaCO₂ < 35 mmHg indicate respiratory alkalosis due to hyperventilation.

✳️ The HCO₃⁻ is normal, confirming the cause is respiratory, not metabolic.

✳️ This often occurs in anxiety, early sepsis, or pain, which increases respiratory rate and reduces CO2 levels.

✳️ Signs include dizziness, paresthesia, and lightheadedness due to cerebral vasoconstriction.

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RN ATI MedSurg~300 Final Exam

No.

1 :
The nurse is caring for a patient in the acute care setting with a spinal cord injury (SCI) at the level of C-3. What is the main cause of complications or death related to this level of injury?

2 :
The nurse is preparing discharge teaching for a client newly diagnosed with cancer who just had a tunneled IV catheter (Hickman) placed. The nurse would include which information in the teaching plan regarding signs and symptoms of infection?

3 :
A patient is ordered 1 mg/kg of furosemide IV push. The patient weighs 121 lbs. The medication is supplied at 40 mg/10 mL. How many mL should the nurse administer? (round to the nearest tenth)

4 :
Which initial assessment findings would the nurse expect in a client diagnosed with acute lymphocytic leukemia (ALL)? (SELECT ALL THAT APPLY)

5 :
The nurse is caring for a client with infectious endocarditis. Which information obtained from the health history could have contributed to the development of the disease's progress?

6 :
The client Is in the intensive care unit on a ventilator. Which intervention(s) should the nurse implement? (SELECT ALL THAT APPLY)

7 :
A nurse is assessing a client who has mitral valve stenosis. Which of the following findings should the nurse accept?

8 :
A client in the gynecology clinic asks the nurse, "What are the risk factors for developing cervical cancer?" Which statement by the nurse is the best response?

10 :
The client's arterial blood gases reveal the following results: pH 7.51, PaO2 80 mmHg, PaCO₂ 28 mmHg, HCO3-24 mEq/L, and O2 saturation 92%. The nurse interprets this blood gas result as.

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RN ATI MedSurg~300 Final Exam

No.

1 : The nurse is caring for a patient in the acute care setting with a spinal cord injury (SCI) at the level of C-3. What is the main cause of complications or death related to this level of injury?

2 : The nurse is preparing discharge teaching for a client newly diagnosed with cancer who just had a tunneled IV catheter (Hickman) placed. The nurse would include which information in the teaching plan regarding signs and symptoms of infection?

3 : A patient is ordered 1 mg/kg of furosemide IV push. The patient weighs 121 lbs. The medication is supplied at 40 mg/10 mL. How many mL should the nurse administer? (round to the nearest tenth)

4 : Which initial assessment findings would the nurse expect in a client diagnosed with acute lymphocytic leukemia (ALL)? (SELECT ALL THAT APPLY)

5 : The nurse is caring for a client with infectious endocarditis. Which information obtained from the health history could have contributed to the development of the disease's progress?

6 : The client Is in the intensive care unit on a ventilator. Which intervention(s) should the nurse implement? (SELECT ALL THAT APPLY)

7 : A nurse is assessing a client who has mitral valve stenosis. Which of the following findings should the nurse accept?

8 : A client in the gynecology clinic asks the nurse, "What are the risk factors for developing cervical cancer?" Which statement by the nurse is the best response?

10 : The client's arterial blood gases reveal the following results: pH 7.51, PaO2 80 mmHg, PaCO₂ 28 mmHg, HCO3-24 mEq/L, and O2 saturation 92%. The nurse interprets this blood gas result as.

1 :
The nurse is caring for a patient in the acute care setting with a spinal cord injury (SCI) at the level of C-3. What is the main cause of complications or death related to this level of injury?

2 :
The nurse is preparing discharge teaching for a client newly diagnosed with cancer who just had a tunneled IV catheter (Hickman) placed. The nurse would include which information in the teaching plan regarding signs and symptoms of infection?

3 :
A patient is ordered 1 mg/kg of furosemide IV push. The patient weighs 121 lbs. The medication is supplied at 40 mg/10 mL. How many mL should the nurse administer? (round to the nearest tenth)

4 :
Which initial assessment findings would the nurse expect in a client diagnosed with acute lymphocytic leukemia (ALL)? (SELECT ALL THAT APPLY)

5 :
The nurse is caring for a client with infectious endocarditis. Which information obtained from the health history could have contributed to the development of the disease's progress?

6 :
The client Is in the intensive care unit on a ventilator. Which intervention(s) should the nurse implement? (SELECT ALL THAT APPLY)

7 :
A nurse is assessing a client who has mitral valve stenosis. Which of the following findings should the nurse accept?

8 :
A client in the gynecology clinic asks the nurse, "What are the risk factors for developing cervical cancer?" Which statement by the nurse is the best response?

10 :
The client's arterial blood gases reveal the following results: pH 7.51, PaO2 80 mmHg, PaCO₂ 28 mmHg, HCO3-24 mEq/L, and O2 saturation 92%. The nurse interprets this blood gas result as.