Questionsand Answers (Multiple Choices)
1. A nurse is caring for a client who has sustained burns over 37% of total body surface area. The client’s voice has become hoarse, a brassy cough has developed, and the client is drooling. The nurse should identify these findings as indications that the client has which of the following?
a. Pulmonary edema
b. Bacterial pneumonia
c. Inhalation injury
d. Carbon monoxide poisoning (vasodilation will cause a cherry red appearance, treatment is high flow oxygen to pt.)
2. A client in the intensive care unit (ICU) was recovering from moderate burns and smoke inhalation. His condition was improving, and plans were made to transfer him to a step-down unit. On the morning of the transfer, the client began to experience elevated temperatures and shortness of breath. Urine output decreased to 10ml/hr. Labs were drawn and indicated elevated white blood cells (WBC), glomerular filtration rate (GFR) creatinine, and liver enzymes. This client is experiencing which medical complication?
a. Disseminated Intravascular coagulation (DIC)
b. Acute respiratory failure (ARF)
c. Multiple organ dysfunction syndrome (MODS)
d. Acute kidney injury (AKI)
3. A nurse is educating a new nurse on the different types of shock. The new nurse asked to identify which client is not experiencing distributive shock?
a. A client with septic-induced hypotension refractory to adequate fluid resuscitation b. A client with extensive spinal cord injury at T4 and a heart rate of 40 beats per minute
c. A client with an extreme type of allergic reaction to penicillin and stridor
d. A client with a tension pneumothorax and cardiovascular compression
4. A nurse is managing several IV medications to maintain the blood pressure of a client in hypovolemic shock. Which medication places the client at risk for a hypertensive reaction requiring the nurse to assess the blood pressure at least every 15 minutes?
c. sodium nitroprusside
5. A nurse is caring for a client who is in hypovolemic shock related to hemorrhage. The nurse prepares intravenous (IV) tubing to infuse with which IV solution in preparation for a blood transfusion?
a. 3% Sodium chloride solution
b. Total parenteral nutrition
c. Normal Saline solution (Blood can only be administered with NS)
d. Lactated Ringer’s solution
6. A nurse is caring for a client who suffered a third-degree burn to his hands after a house fire. He presented with an airway injury secondary to smoke inhalation and has been intubated. The client is currently on the incubator with 100% FiO2. Based on this
information, which of the following would be a sign or symptom of acute respiratory distress syndrome (ARDS)?
a. Respiratory rate 14 breaths/minute
b. Arterial Blood Gas results show PaO2 50mmHg
c. Fatigue and weakness
d. Urine output 580 mL last shift
7. The nurse is developing a care plan for a client in the acute phase of a burn injury. Which of the following would be the priority nurse diagnosis for this client?
a. Risk for falls r/t contracture of burned extremities
b. Risk for infection related to slow healing graft donor site
c. Risk for denial r/t inability to participate in dressing changes
d. Risk for ineffective coping r/t inability to look at burn wounds
8. When assessing a client who has suffered a burn injury. The nurse classifies the burn as a superficial partial-thickness burn based on observing which characteristics?
a. A. Painful, reddened skin
b. Charred skin with milky-white areas-another and it is dry-check (this is for deep partial-thickness)
c. Erythema and blisters (superficial)
d. Erythema, pain, and swelling -the answer will be B if it says full-thickness burn 9. A client is receiving warfarin after pulmonary embolism (PE). The nurse evaluates the lab results and notifies the physician that the client’s warfarin level is therapeutic when which of the following numbers is reported?
a. International normalized ratio (INR) 1:1
b. Partial thromboplastin time (PTT) 24 seconds
c. International normalized ratio (INR) 2.8 (expected level 2.0 to 3.0)
d. Prothrombin time (PT) 14 seconds
10. A nurse is reviewing the health records of clients. Which client is at least at risk for developing acute respiratory distress syndrome (ARDS)?
a. A client following coronary artery bypass graft surgery
b. A client who experienced a near-drowning incident in freshwater
c. A client who is experiencing acute pancreatitis and vomiting
d. A client who has hemoglobin of 10.1mg/dl post 1-unit PRBC
11. After receiving reports of four clients, the nurse determines the order of care of the clients. Based on the report, the nurse will prioritize the clients to see which one first?
a. A newborn Mottling of extremities
b. A 72-year-old with dry skin with tenting
c. A 35-year-old athlete with bradycardia
d. A healthy 18-year-old with rapid shallow respirations
12. A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which statement indicates the nurse’s correct understanding of DIC?
a. “DIC is controllable with lifelong heparin usage.”
b. “DIC is a genetic disorder characterized by an elevated factor VIII count.”
c. “DIC is caused by abnormal coagulation involving fibrinogen” and presents with simultaneous abnormal clotting and bleeding
d. “DIC is a genetic disorder involving a vitamin K deficiency”
13. A nurse is assisting the provider in caring for a client who has developed a tension pneumothorax. Which actions should be performed first?
a. Assess the client’s pain
b. Prepare Large-bore needle thoracostomy (tension pneumothorax)
c. Administer lorazepam
d. Prepare for chest tube insertion (pneumothorax)
14. A nurse is planning care for a client who has severe acute respiratory distress syndrome (ARDS) which actions should the nurse include?
a. Aggressive fluid therapy and diuretics
b. Administer antiviral and antibiotics for every cause of ARDS
c. Assess lung daily and suction hourly to maintain airway-lungs should be assessed hourly
d. Maintain intubation and mechanical ventilator support
15. A certified burn nurse is introducing a new nurse to the burn unit. The nurse is educating the new nurse on the degrees of the staging of burns which of the following provides the correct description of a wound to the correct level of injury (MATCHING)
a. Superficial reddened skin disqualification heals quickly without intervention
b. Superficial partial-thickness pink moist blanching and some blistering is involved
c. Deep partial-thickness – epidermal and dermal layer is destroyed development of eschar
d. Full Thickness – blisters typically do not form, deep dermal injury may need grafting
16. A postoperative client reports a sudden onset of shortness of breath and pleuritic chest pain. Assessment findings include diaphoresis. Hypotension, crackles in the left lower lobe, and pulse oximetry of 85%. What does the nurse suspect have occurred with this client?
c. Pulmonary embolism
d. Flail Chest
17. A client has been diagnosed with a pulmonary embolism. Which diagnostics and treatments do the nurse anticipate will be ordered? (Select all that apply.)
d. Computed tomography angiogram (CTA)
e. Chest tube insertion
18. A nurse is reviewing the health records of clients. Which client is at the greatest risk for developing acute respiratory distress syndrome (ARDS) and Multiple Organ Dysfunction Syndrome (MODS)?
a. A client who experienced neurogenic shock
b. A client following anaphylactic shock
c. A client who is experiencing septic shock
19. Which intervention will the nurse include in the plan of care for a client who has cardiogenic shock?
a. Avoid elevating the head of the bed
b. Assess hemoglobin and hematocrit levels every 6 hours
c. Check heart rate every 2 hours
d. Auscultate breath sounds frequently
20. A 30-year-old female patient sustained deep partial-thickness burns on the front of the right leg, front of the right arm, and anterior trunk at 2100 while starting a bonfire. The patient weighs 65kg. Using the Parkland Burn formula (4mL) to calculate the flow rate during the FIRST 8 hours (mL/hr) after the burn if the patient arrived at the ER at 2200? Answer: 4ml*65*TBSA (4.5+9+18) = 8190/2 = 4095/7 = 585ml/hr ✓
a. 585 ml/hr ✓
b. 512 ml/hr
c. 669 ml/hr
d. 256 ml/hr
21. A client with respiratory failure is diagnosed with a flail chest. After the client is intubated, which ventilator settings does the nurse expect to be included in the plan of care?
a. Mechanical ventilation with positive end-expiratory pressure (PEEP)
b. Synchronized intermittent mechanical ventilator (SIMV) with low breathing frequency (f)
c. Positive pressure ventilation with elevated peak inspiratory pressure (PIP)
d. Bi-level positive airway pressure (Bi-PAP) with a low fraction of inspired oxygen (FiO2)
22. Which of the following interventions is not appropriate for a client diagnosed with a pneumothorax?
a. Apply wet to dry dressing on wound/leave the chest tube side open to air
b. Monitor respiratory and circulatory function
c. Assess for tracheal deviation
d. Provide analgesics
e. Administer ordered medications
23. The nurse is caring for a ventilated client. Which intervention is appropriate for this client?
a. Ensure there is a manual resuscitation bag at the bedside
b. Monitor the client’s pulse oximeter reading every shift
c. Turn alarm volumes down to allow the client to rest
d. Assess the client’s respiratory status every 8 hours
e. Assess the client’s respiratory status every 2 hours
f. Check the ventilatory setting every 4 hours
g. Collaborate with the respiratory therapist
24. A client with 55% total body surface area burn (TBSA) arrives in the emergency department. The client weighs 160 pounds. Using the Parkland Burn Formula (Consensus formal), calculate the hourly flow rate (mL/hr) of Lactated rangers during the first 8 hours of fluid resuscitation (mL/hr). (Round answer to the nearest whole number. Do not use a trailing zero). Formula (4mlxTBSAxweight in Kg)/2/8
a. 4ml/kg*55*72.7kg = 15994/2 = 7997ml/8hr = 1000ml/hr ✓
25. The nurse recognizes indications of respiratory distress including all the following except
26. A nurse is caring for a client who has burn injuries to his trunk. The nurse explained what to expect from the prescribed hydrotherapy. Which of the following statements by the client indicates an understanding of the teaching?
a. “I will be on a special shower table to enhance wound inspection and debridement
b. “The nurse will use a wire-bristled brush to remove loose skin”
c. “The nurse will use scissors to open small blisters”
d. “The water temperature will be hot to improve blood flow and healing”
27. A client with a chest injury has suffered a flail chest. The nurse assesses the client for which most distinctive sign of flail chest?
a. Cyanosis (tension pneumothorax)
c. Paradoxical chest movement
d. Dyspnea, especially on exhalation
28. A nurse is caring for a client who is in the progressive stage of shock. Which finding should the nurse expect?
a. Blood pressures change from 129/78 (95) to 89/45 (60)
b. Blood pressures change from 95/55 (68) to 90/52 (65)
c. Blood pressures change from 100/50 (67) to 90/45 (60)
d. Blood pressure reading is undetectable
29. A client with a shock of unknown etiology whose hemodynamic monitoring indicates a blood pressure of 95/54 mm Hg, pulse 64 beats/minute, and an elevated pulmonary artery wedge pressure have the following collaborative interventions prescribed. Which intervention will the nurse question?
a. Keep the head of the bed elevated to 30 degrees
b. Infuse normal saline at 250 ml/hr
c. Administer dobutamine to keep systolic BP>90 mm Hg
d. Give nitroprusside unless systolic BP<90 mm Hg
30. A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following actions should the nurse take?
a. Apply a vest restraint if self-extubating is attempted
b. Monitor daily ventilator settings
c. Document tube placement in centimeters at the angle of the jaw
d. Assess breath sounds every 4hours. (Every 2-4hours)
31. A client was admitted to the burn unit more than two weeks ago. The care plan for this client requires assistance from the nurse to perform daily ROM exercises and help with mobility. The client tells the nurse he is no longer going to participate due to the pain it always causes. Which of the following should the nurse do next?
a. Give the client his ordered PRN dose of intravenous hydromorphone 4mg with his scheduled PO oxycodone 10 mg 30 minutes before treatment to allow for pain-free therapy
b. Remind the client that contractures hurt worse and to let the nurse know when he is ready
c. Acknowledge the client’s concerns regarding pain and discuss how to promote his exercise plan in a way to have less pain but also allow a therapeutic level of treatment.
d. Call the doctor to report noncompliance with treatment.
32. A client begins to show signs of shock. How should the client be positioned?
a. In a prone position
b. Supine with legs elevated
c. Lithotomy position
d. High fowler’s position
33. A burn patient is brought into the emergency department with the following burns: half of the front torso, entire left arm, and front of both legs. The nurse should record the TBSA burns as (9+9+18) = 36
a. 20% TBSA
b. 40% TBSA
c. 36% TBSA
d. 27% TBSA
34. An older adult arrives in the emergency department after falling off a roof. The nurse observes sucking inward of the loose chest area during inspiration and outward movement of the same area during expiration. Arterial blood gas results show severe hypoxemia and hypercarbia. Which procedures does the nurse prepare for?
a. Chest tube insertion
b. Endotracheal intubation
c. Needle thoracotomy
35. Which of these findings is the best indicator that the fluid resuscitation for a client with hypovolemic shock has been successful?
a. Hemoglobin is normal 14mg/dl
b. Urine output is 60 mL over the last hour- If there is this option in the answers then it is the right answer
c. The client has a urine output of 15ml/hr
d. The lactate level decreases from 4mm/l to 1.9mmol/L
e. Pulmonary artery edge pressure (PAWP) is normal 8-10mmhg
f. Mean arterial pressure (MAP) is 65 mm Hg
36. A nurse is assessing the fluid status of a client being treated for a burn during the emergent phase. Which of the following is an indicator of adequate fluid resuscitation?
a. Blood pressure 90/60 mmHg
b. Pulse 115 bpm
c. Client confusion
d. Urine output at least 30 mL/hr
37. When the charge nurse is evaluating the skills of a new RN, which action by the new RN indicates a need for further education in the care of patients with shock?
a. Keeping the head of the bed flat for a client with hypovolemic shock
b. Decreasing the room temperature to 68 degrees F for a client with neurogenic shock
c. Placing the pulse oximeter on the ear for a patient with septic shock d. Increase the IV fluid rate to maintain an adequate mean arterial pressure.
38. A client was treated in the emergency department (ED) for the shock of unknown etiology. The first action by the nurse is which of the following?
a. Administer oxygen.
b. Attach a cardiac monitor.
c. Obtain the blood pressure.
d. Check the level of consciousness
39. A client is being treated for distributive shock with iv norepinephrine. The nurse experts on the drug to have which affect the client’s mean arterial pressure (MAP)
a. Increased MAP by increasing intravascular volume
b. Decreased MAP from widespread capillary leak
c. Increased MAP with no change in intravascular volume
d. Increased MAP and increased myocardial contractility
e. Decreased MAP by decreasing intravascular volume
40. A client presents with the following vital signs BP 90/60, temp 38.3 ‘C (101 ‘F), HR 116, RR 24. The client has a post-op abdominal incision that is warm and red. Which type of shock is this client experiencing?
a. Hypovolemia shock
b. Septic shock
c. Anaphylactic shock
d. Neurogenic shock
41. A nurse is caring for a client in shock. Does the nurse understand the client’s sympathetic nervous system (SNS) is still correctly attempting to compensate when the following is assessed?
a. The client has decreased peripheral pulse
b. The client has a decreased heart rate
c. The client has an increased appetite
d. The client has an increasing thirst
e. The client has an increased respiratory rate
f. The client has a widening pulse pressure
42. The client with neurogenic shock is receiving a phenylephrine infusion through a left forearm IV. Which assessment information obtained by the nurse indicates a need for immediate action?
a. The client’s IV infusion site is cool and pale
b. The client has warm, dry skin on the extremities
c. The client has an epical pulse rate of 58 beats/min
d. The client’s urine output has been 28 mL over the test hour
43. A client with neurogenic shock has just arrived in the emergency department after a diving accident. He has a cervical collar in place. Which of the following actions should the nurse take? SATA
a. Prepare to administer atropine IV
b. Administer large volumes of lactated ringers’ solution
c. Obtain baseline body temperature
d. Assist the client into a semi-fowlers position
e. Prepare for intubation and mechanical ventilation
44. A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect?
a. Hemoglobin 10 g/dL
b. Sodium 143 mEq/L
c. Albumin 2.9 g/dL (this will help pull some of the fluid back into the vascular system)
d. Potassium 4.0 mEq/dL
45. The nurse is assessing the respiratory status of a client who has suffered an uncomplicated fractured rib. The nurse should expect to note which findings? a. Slow deep respirations
b. Tracheal deviation
c. Reduced depth of breathing
d. Rapid deep respiration
e. Paradoxical respirations
f. Pain, especially with inspiration
46. Which information about a client receiving dobutamine/vasopressin to treat septic shock is most important for the nurse to communicate to the health care provider?
a. The client’s heart rate is 108 beats/min
b. The client is complaining of chest pain
c. The client’s peripheral pulses are weak
d. The client’s urine output is 15 mL/hr
47. A nurse is caring for a client with arterial blood gas (ABG) results in pH 7.21, pCO2 60, paO2 42. HCO3 22. Which medication should the nurse prepare to administer first? a. Antiemetic
48. A client is being treated for hypovolemic shock. As the nurse reassesses the client, which finding indicates the interventions are effective?
a. Oxygen saturations remain uncharged
b. Core body temperature has increased to 99 degrees F
c. The client incorrectly states the month and year
d. Serum lactate and serum potassium levels are declining
49. When assessing a client who is severely bleeding and at risk for hypovolemic shock, the nurse anticipates which of the following?
a. Shallow, deep respiration
b. Hot, flushed skin
c. Warm extremities
d. Increased blood pressure
e. Slow, labored breathing
f. Strong bounding pulse
g. Edematous extremities
h. Weak, thready pulse
i. Cool, clammy skin
50. The intensive care unit (ICU) nurse is caring for a client on a ventilator who is exhibiting respiratory distress. The ventilator alarms are going off. Which interventions should the nurse implement first? -quillet
a. Auscultate the breath sounds
b. Notify the respiratory therapist immediately
c. Ventilate with a manual resuscitation bag (pic)
d. Silence the ventilator alarm
e. Check the ventilator to resolve the problem (old doc) Monitor ventilator second 51. The nurse is caring for a client with mechanical ventilation. The ventilator sounds like a high-pressure alarm. The nurse immediately assesses for other signs of which condition?
a. Disconnected endotracheal tube (this could be low pressure)
b. Mucous plug (look for obstructions in the airway or kinks, cough)
c. Cuff leak in the endotracheal tube (low pressure)
d. Loose circuit equipment failure (low pressure)
52. A client presented to the ED after receiving second and third-degree burns from a kitchen grease spill. The tops of both thighs the groin area and the lower abdomen were the areas of injury. About three hours after the injury the client begins to decompensate and is
being prepared for intubation. Regarding the charge in client status. Which explanation by the nurse is correct when educating the clients family
a. Fluids shift in the body immediately cause an increased cardiac output and increased tissue perfusion which can negatively affect the healing process
b. The client is complaining of severe pain and will be intubated to safely give pain medications and sedatives
c. The client is experiencing paralytic ileus and requires intubation to prevent further damage
d. Even a burn as little as 25% of the body can cause a systemic response requiring emergency management
53. During change of shift report, the nurse learn that a client has been admitted with dehydration and hypotension after having vomiting and diarrhea for 3 days. Which finding is most important for the nurse to report the health care provider?
a. Radial pulse 110 beats/min
b. Cool, pale extremities
c. Worsening confusion and agitation
d. Hypoactive bowel sound
e. Diminished breath sound
g. Apical pulse 110 beat/min
h. Pale, cool, and dry extremities
I. New onset of confusion and agitation
54. A nurse is assessing a client who sustained superficial partial-thickness and deep partial-thickness burns 38 hours ago. Which finding should the nurse report to the providers?
a. Edema in the burned extremities
b. Severe pain at the burn sites
c. Urine output of 65 mL/hr. over 2 hours
d. ABG pH 7.31, CO2 37, HCO3 31
55. A client has been prescribed silver sulfadiazine for a burn injury. Which of the following findings would give the nurse reason to question the order for this topical burn cream?
a. WBC count to 10.000 per mL
b. The client has a deep partial-thickness burn wound
c. The client has a sulfa allergy listed on the chart
d. The client has a full-thickness burn wound
56. A nurse is caring for a client experiencing a hypovolemic shock. Which of the following interventions would not be appropriate?
a. Monitor intravenous fluid replacement
b. Monitor vital signs
c. Monitor hemoglobin and hematocrit levels
d. Assist to a sitting position
57. A client with septic shock has had a urine output of 20 mL/hr for the past 3 hours. The pulse rate is 120, and the central venous pressure and pulmonary artery wedges pressure are low. Which of these orders by the health care provider will the nurse question?
a. Give furosemide
b. Administer hydrocortisone
c. Prepare to give broad-spectrum antibiotic (Review note)
d. Increase normal saline infusion
58. The pathophysiology of acute respiratory distress syndrome is characterized by one of the following?
a. Absent pulmonary infiltrates (pic)
b. Increased pulmonary compliance
d. non-cardiac pulmonary edema
e. Bilateral pulmonary edema-non-cardiac-related.
f. Refractory hypoxemia
59. The nurse is caring for a client with an electrical burn. The client has entrance wounds on the hands and exit wounds on the feet. What information is the most important to include when planning care?
a. Everything between the entry and exit wounds can be damaged
b. Electrical burns increase the risk of developing future cancers
c. The client may have memory and cognitive issue postburn
d. The respiratory system requires close monitoring for signs and swelling (electrical burn can affect the heart, watch for increased potassium)
60. When caring for a client who has early sepsis. Which change in status is most important for the nurse to report to the health care provider?
a. Arterial oxygen saturation 93%
b. Altered mental status
c. Apical pulse 112 beats/min
d. BP 100/56 mmHg
61. A nurse is planning care for an adult client who sustained severe burn injuries. Which interventions should the nurse include in the plan of care? (Select all that apply.)
a. Limit visitors in the client’s room when immunosuppressed
b. Encourage raw foods to improve exposure to natural flora
c. Offer high-calorie, high protein foods or supplemental feeding
d. Ambulate two or three times a day and progress in length each time
e. Apply compression dressings before the graft heals to prevent scar formation
62. The provider ordered dopamine 15mcg/kg/minute intravenous (IV) infusion. The bag is labeled dopamine 100mg/50ml. The client weighs 180 lbs. what is the infusion rate in ml/hr? (Record answer to the nearest whole number. Do not use a trailing zero)
63. A client is admitted to the emergency department with a full thickness burn to the right arm. Upon assessment, the arm is edematous, fingers are mottled, and radial pulse is now absent. The client states that the pain is 8 on a scale of 1 to 10. The nurse should:
a. Administer morphine sulfate Iv push for the severe pain
b. Call the healthcare provider (HCP) to report the loss of the radial pulse
c. Continue to assess the arm every hour for an additional change
d. Instruct the client to exercise the fingers and wrist.
64. A nurse is assessing a client who has fluid volume overload from cardiogenic shock. Which manifestation of cardiogenic shock should the nurse expect?
a. Heart Rate 121 BMP
b. Blood pressure
c. Respiratory Rate 12 bpm
d. Temperature 103.1F
65. A client with a possible spinal cord injury is admitted to the emergency department (ED). Which finding by the nurse will help confirm a diagnosis of neurogenic shock?
a. Apical heart 48 beats/min
b. Inspiratory crackles
c. Stabbing pain in the extremities
d. Skin is warm and dry
66. A client with pulmonary embolism may have which of the following interventions? (Select all that apply).
a. Inferior vena cave (IVC) filter
c. Chest tube placement
d. Heparin drug therapy
e. Administer oxygen
f. Thrombolytic therapy
67. Which actions are essential for the nurse caring for a mechanically ventilated patient to prevent ventilator-acquired pneumonia (VAP)? (Select all that apply).
a. Prevent aspiration
b. Implement pressure ulcer prophylaxis for oral care
c. Turn and reposition the client every 4 hours (every 2 hrs)
d. Provide oral care every day and suction just the mouth (mouth care every 2hr, disinfectant every 12hrs)
e. Keep the patient in a supine position
f. good hand hygiene
g. Keep HOB elevated 30 degrees
68. A nurse is caring for a client who is in the non-progressive (compensatory) stage of hypovolemic shock. Which finding should the nurse anticipate?
a. Decreased in mean arterial pressure (MAP) by 20 points from baseline b. Severe tissue hypoxia with necrosis
c. Decreased urine output and increased heart rate
d. Hypoxia of vital organs
69. A nurse is caring for a group of clients. Which client is at most risk for pulmonary embolism?
a. A client who has a body mass index (BMI) of 24
b. An active postmenopausal female
c. A client who consumes alcohol
d. A long-distance truck driver
70. The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding would indicate the presence of an in this client?
a. The presence of a clubbing finger
b. A sucking sound at the site of injury
c. Poor chest movement on the affected side
d. Diminished cough effort
71. Which assessment is important for the nurse to evaluate to determine if the treatment of a patient with anaphylactic shock has been effective?
a. Pulse rate
b. Blood pressure
c. Oxygen saturation
72. The client, who is one-day postoperative following chest surgery is having difficulty breathing, has bilateral rales, and is confused and restless. Which interventions should the nurse implement first?
a. Assess the client’s pulse oximeter reading
b. Notify the Rapid Response Team
c. Place the client in the Trendelenburg position
d. Check the client’s surgical dressing
73. A nurse is assessing four clients. Which of the following clients should the nurse assess first?
a. A client who has two rib fractures in 8/10 pain requesting pain meds
b. An intubated client with a flail chest awaiting surgical fixation (medical emergency)
c. A client with a compound fracture and weak distal pulses
d. A client that has self-extubated his endotracheal ET tube (pic)
74. A client who has an endotracheal tube is being considered for a tracheostomy. Which of the following criteria would support the placement of a tracheostomy in this client?
a. Client is unable to maintain airway when extubated
b. Client has been on the ventilator for 24 hours)
c. Client has been diagnosed with diabetes
d. Client is coughing and bucking the endotracheal tube.
75. The client who is two days postoperative following a pneumonectomy has an apical pulse (AP) rate of 128 beats per minute and blood pressure (BP) of 80/50 mmHg. Which intervention should the nurse implement first?
a. Document and continue to monitor
b. Raise the client’s head in bed 45 degrees
c. Prepare to increase intravenous fluid, as ordered
d. Perform STAT arterial blood gas (ABGs) as ordered
76. The surgical incision of the hardened dermal layer of the skin is an
77. All must be done within an hour for a client with septic shock except
a. Draw lactic acid level
b. Administer acetaminophen
c. Administer antibiotics
d. Draw blood cultures
78. Which of the following indicates that the fluid resuscitation for a client with hypovolemic shock has been successful?
a. Decreased pulmonary artery wedge pressure (PAWP)
b. Normal time perfusion
c. Urine output is 20mL over the last hour
d. Capillary refill of 4 seconds in the distal extremities
79. The nurse recognizes that indications of adult respiratory distress syndrome (ARDS). Include which of the following (Select all that apply)
a. Unstable angina
c. Pulmonary edema
d. Refractory hypoxemia
e. Cognition changes
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