Med-Surg II Exam 4 – Fortis Medical-Surgical
Nursing Review Complete Solution Guide
Progressive Care & Critical Care Priorities
Q1: Which patient in the progressive care unit would the nurse be most
concerned about?
A1: A patient prescribed tPA or IV heparin who has the opportunity to bleed (high risk
for hemorrhage).
Q2: Which patient on ventilator weaning requires priority monitoring?
A2: The patient who has recently been extubated but shows decreased urinary
output (indicates potential renal compromise/hypovolemia).
Q3: Intervention for a patient with subarachnoid hemorrhage and elevated ICP?
A3:
• Check for JVD (jugular venous distension)
• Assess for fluid overload (if increased JVD present)
• Notify provider immediately
Q4: How to manage a patient "fighting" or breathing over the ventilator?
A4: Verbally coach them (coordinate breathing efforts with vent settings).
, Q5: Management of ICU elderly patient with new-onset confusion progressing toward
delirium during transfer?
A5: Report findings to the receiving nurse and continue transfer (do not delay safe
handoff).
Q6: Intervention for thick respiratory secretions?
A6: Increase fluid intake (hydration thins secretions).
Multi-System & Hematological Emergencies
Q7: A septic/pneumonia patient developing multiorgan failure is at risk for which
complication?
A7: DIC (Disseminated Intravascular Coagulation).
Q8: Major concerns when a patient receives vasopressor therapy?
A8:
• Vasopressin is a potent vasoconstrictor → decreases coronary artery
perfusion
• Monitor for chest pain (immediate concern/risk of myocardial ischemia).
Nursing Review Complete Solution Guide
Progressive Care & Critical Care Priorities
Q1: Which patient in the progressive care unit would the nurse be most
concerned about?
A1: A patient prescribed tPA or IV heparin who has the opportunity to bleed (high risk
for hemorrhage).
Q2: Which patient on ventilator weaning requires priority monitoring?
A2: The patient who has recently been extubated but shows decreased urinary
output (indicates potential renal compromise/hypovolemia).
Q3: Intervention for a patient with subarachnoid hemorrhage and elevated ICP?
A3:
• Check for JVD (jugular venous distension)
• Assess for fluid overload (if increased JVD present)
• Notify provider immediately
Q4: How to manage a patient "fighting" or breathing over the ventilator?
A4: Verbally coach them (coordinate breathing efforts with vent settings).
, Q5: Management of ICU elderly patient with new-onset confusion progressing toward
delirium during transfer?
A5: Report findings to the receiving nurse and continue transfer (do not delay safe
handoff).
Q6: Intervention for thick respiratory secretions?
A6: Increase fluid intake (hydration thins secretions).
Multi-System & Hematological Emergencies
Q7: A septic/pneumonia patient developing multiorgan failure is at risk for which
complication?
A7: DIC (Disseminated Intravascular Coagulation).
Q8: Major concerns when a patient receives vasopressor therapy?
A8:
• Vasopressin is a potent vasoconstrictor → decreases coronary artery
perfusion
• Monitor for chest pain (immediate concern/risk of myocardial ischemia).
