NUR 322 - exam 4 practice questions - ATI, prepU, etc

Question the client about alcohol and illicit drug use.

A 28-year-old client presents to the emergency department, stating severe restlessness and anxiety. Upon assessment, the client's heart rate is 118 bpm and regular, the client's pupils are dilated, and the client appears excitable. Which action should the nurse take next?

Joint stabilization Stimulation of bone healing Defect filling

A bone graft may be used for which of the following reasons? Select all that apply.

Immerse the child's legs in cool water.

A child tips a pot of boiling water onto his bare legs. The mother should:

inherent rhythmicity of cardiac muscle tissue.

A client asks the nurse what causes the heart to be an effective pump. The nurse informs the client that this is due to the:

Subluxation

A client comes to the emergency department and it is found that the client's radial head is partially dislocated. What is this partially dislocated radial head documented as?

Infection

A client experienced an open fracture to the left femur during a horse-riding accident. For which complication is this client at highest risk?

crepitus.

A client has a fractured femur and is being seen in the emergency department. The nurse assessing the area notices there is a grating sound that is suspected to be bone ends moving over one another. This sound is called:

escharotomy

A client has a third-degree burn on the leg. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to the leg. What procedure would be done to relieve pressure on the affected area?

27%

A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned?

Lactated Ringer's solution

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first?

deep tissue cooling

A client has received significant electrical burns in a workplace accident. What occurrence makes it difficult to assess internal burn damage in electrical burns?

Diagnose the dysrhythmia.

A client is admitted to the cardiac care unit for an electrophysiology (EP) study. What goal should guide the planning and execution of the client's care?

"I'll make sure to keep my ankle elevated as much as possible."

A client is being discharged from the Emergency Department after being diagnosed with a sprained ankle. Which client statement indicates the client understands the discharge teaching?

Fluid resuscitation

A client is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client

contusion

A client is brought to the emergency department after being struck with a baseball bat on the upper arm while diving for a pitched ball. Diagnostic tests reveal that the humerus is not broken but that the client has suffered another type of injury. What type of injury would the physician likely diagnose?

36%

A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned?

sinus bradycardia

A client is diagnosed with an arrhythmia at a rate slower than 60 beats/minute with a regular interval between 0.12 and 0.20 seconds. What type of arrhythmia does the client have?

Left hip arthroplasty

A client is seen in the orthopedic clinic for complaints of severe pain in the left hip. After a series of diagnostic tests, the client is diagnosed with severe degenerative joint disease of the left hip and suggested to have the hip reconstructed. What procedure will the nurse schedule the client for?

Assess vital signs and level of consciousness.

A client is transported to the emergency department for a femur fracture following a motor vehicle crash. What action by the nurse is the highest priority?

"Spike" on the rhythm strip

A client is unconscious on arrival to the emergency department. The nurse in the emergency department identifies that the client has a permanent pacemaker due to which characteristic?

atrial flutter disorder

A client presents to the emergency department via ambulance with a heart rate of 210 beats/minute and a sawtooth waveform pattern per cardiac monitor. The nurse is most correct to alert the medical team of the presence of a client with which disorder?

27

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?

The early appearance of the burn injury may change.

A client receiving emergency treatment for severe burns has just been assessed to establish the burn depth. Why is a nurse asked to reassess the burn depth after 72 hours?

Apply warm compresses over the areas

A client recovering from burn injuries over both forearms reports itching of the wounds. Which action will the nurse take to enhance the client's comfort?

Sprain

A client reports pain in the right knee, stating, "My knee got twisted when I was going down the stairs." The client was diagnosed with an injury to the ligaments and tendons of the right knee. Which terminology, documented by the nurse, best reflects the injury?

covering the area with a sterile dressing if the fracture is open immobilizing the affected site splinting the injured limb

A client sustains an open fracture of the left arm after an accident. What does emergency management of this fracture involve? Select all that apply.

inflammatory

A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury?

dislocation

A client who has fallen and injured a hip cannot place weight on the leg and is in significant pain. After radiographs indicate intact but malpositioned bones, what would the physician diagnose?

Risk for Impaired Gas Exchange

A client who has sustained burns to the anterior chest and upper extremities is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary?

Changing the client's position within prescribed limits.

A client who is undergoing skeletal traction reports pressure on bony areas. Which action would be most appropriate to provide comfort for the client?

Gastric ulcers

A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client?

Fasciotomy

A client with a fracture develops compartment syndrome that requires surgical intervention. What treatment will the nurse would most likely prepare the client for?

Explain that the sensation being felt is normal and will not burn the client.

A client with a fractured ankle is having a fiberglass cast applied. The client starts yelling, "My leg is burning, take it off." What action by the nurse is most appropriate?

Cut a cast window.

A client with a fractured distal left radius reports discomfort at the cast site, with pain specifically in the upper forearm. What would the nurse expect the physician to do?

physical therapy

A client with a right leg fracture is returning to the orthopedist to have the cast removed. What would the physician prescribe as further treatment?

"The small box will transmit the heart rhythm to the central monitor all the time."

A client with a second-degree atrioventricular heart block, Type II is admitted to the coronary care unit. How will the nurse explain the need to monitor the client's electrocardiogram (ECG) strip to the spouse?

pain management.

A client with a superficial partial-thickness solar burn (sunburn) of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be:

Provide feedback on the client's strengths and available resources.

A client with a traumatic amputation of the right lower leg is refusing to look at the leg. Which action by the nurse is most appropriate?

Elective electrical cardioversion

A client with an atrial dysrhythmia has come to the clinic for a follow-up appointment and to talk with the health care provider about options to stop this dysrhythmia. What procedure could be used to treat this client?

The medication increases the force of the myocardial contraction.

A client with heart failure asks the nurse how dobutamine affects the body's circulation. What is the nurse's best response?

Apply lotions and take warm baths or soaks.

A client's cast is removed. The client is worried because the skin appears mottled and is covered with a yellowish crust. What advice should the nurse give the client to address the skin problem?

no immediate treatment.

A client's electrocardiogram reveals an irregular rhythm of 75 bpm with a normal QRS and P wave. The nurse who is caring for the client should anticipate:

Better molding to the client

A group of students are reviewing information about cast composition in preparation for a discussion on the advantages and disadvantages of each. The students demonstrate understanding of the topic when they cite which of the following as an advantage of a plaster cast?

"Are the burns associated with chemicals used in the plant?"

A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims?

Document the findings and continue to monitor the client

A nurse evaluates a client with a temporary pacemaker. The client's ECG tracing shows each P wave followed by the pacing spike. What is the nurse's best response?

"I need to take a cardiopulmonary resuscitation (CPR) class now that I have an ICD."

A nurse has provided discharge instructions to a client who received an implantable cardioverter defibrillator (ICD). Which statement, made by the client, indicates the need for further teaching?

Replace lost fluids and electrolytes.

A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to:

Clients with recurrent life-threatening tachydysrhythmias

A nurse is caring for a client who has been admitted to have a cardioverter defibrillator implanted. The nurse knows that implanted cardioverter defibrillators are used in which clients?

Fluttering/heart skipping

A nurse is caring for a client who has premature ventricular contractions. What sign would the nurse assess in this client?

Assist with a gradual introduction of activity.

A nurse is caring for a client who has sustained ligament and a meniscal injury to the knee. Which action would be most appropriate to allow the client to progress without causing further injury?

Assess the pin insertion site every 8 hours.

A nurse is caring for a client who is in skeletal traction. To prevent the complication of skin breakdown in a client with skeletal traction, what action should be included in the plan of care?

Risk for Impaired Skin Integrity

A nurse is planning the care of a client who will require a prolonged course of skeletal traction. When planning this client's care, the nurse should prioritize interventions related to what risk nursing diagnosis?

Disturbed Body Image

A nurse is planning the care of a client with osteomyelitis that resulted from a diabetic foot ulcer. The client requires a transmetatarsal amputation. When planning the client's postoperative care, which of the following nursing diagnoses should the nurse most likely include in the plan of care?

The client's complete blood count readings reflect a reduced hematocrit.

A nurse is preparing a care plan for a client burned over 36% of his body 2 days ago. Which clinical manifestation indicates that the client has progressed into the intermediate phase of burn care?

Reporting signs of impaired circulation

A nurse is providing discharge education to a client who is going home with a cast on his leg. What topic should the nurse emphasize in the teaching session?

The client's urinary output is 0.5 to 1 mL/kg/hour.

A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation?

Epidermis and a portion of deeper dermis.

A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the:

Assess the client and monitor leads.

A nurse provides evening care for a client wearing a continuous telemetry monitor. While the nurse is giving the client a back rub, the client 's monitor alarm sounds and the nurse notes a flat line on the bedside monitor system. What is the nurse's first response?

T wave P wave P-R interval

A nursing instructor is reviewing the parts of an EKG strip with a group of students. One student asks about the names of all the EKG cardiac complex parts. Which of the following items are considered a part of the cardiac complex on an EKG strip? Choose all that apply

call 911 immediately

A patient calls the cardiac clinic you are working at and reports that they have taken 3 sublingual doses of Nitroglycerin as prescribed for chest pain, but the chest pain is not relieved. What do you educate the patient to do next?

Superficial

A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following?

full-thickness

A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following?

- if scheduled for a surgical procedure, notify MD you are taking medication and stop 5-7 days prior to procedure - notify MD immediately if you develop bruising, problems urinating or fever

A patient is receiving treatment for stable coronary artery disease. The doctor prescribes the patient Plavix. What important information will you include in the patient's teaching? Select-all-that-apply:*

stable angina

A patient reports during a routine check-up that he is experiencing chest pain and shortness of breath while performing activities. He states the pain goes away when he rests. This is known as:

ST segment elevation

A patient reports having crushing chest pain that radiates to the jaw. You administer sublingual nitroglycerin and obtain a 12 lead EKG. Which of the following EKG findings confirms your suspicion of a possible myocardial infraction?

check glucose regularly because this medication can mask the typical signs/symptoms of hypoglycemia

A patient who has diabetes will be started on Metoprolol for medical management of coronary artery disease. Which of the following will you include in your discharge teaching about this medication?

Warfarin

A patient with hypertension has a newly diagnosed atrial fibrillation. What medication does the nurse anticipate administering to prevent the complication of atrial thrombi?

Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel

A person suffers leg burns from spilled charcoal lighter fluid. A family member extinguishes the flames. While waiting for an ambulance, what should the burned person do?

2,400 mL

A sample consensus formula for fluid replacement recommends that a balanced salt solution be administered in the first 24 hours of a chemical burn in the range of 2 mL/kg/% of burn, with 50% of the total given in the first 8 hours postburn. A 176-lb (80-kg) man with a 30% burn should receive a minimum of how much fluid replacement in the first 8 hours?

Maintaining traction continuously to ensure its effectiveness.

After a traumatic back injury, a client requires skeletal traction. Which intervention takes priority?

Decreased cardiac output and decreased systolic and diastolic blood pressure

After evaluating a client for hypertension, a health care provider orders atenolol, 50 mg P.O. daily. Which therapeutic effect should atenolol have in treating hypertension?

Avascular necrosis may develop at the site if it is not promptly resolved.

An emergency department client is diagnosed with a hip dislocation. The client's family is relieved that the client has not suffered a hip fracture, but the nurse explains that this is still considered to be a medical emergency. What is the rationale for the nurse's statement?

18%

An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned?

Administer prescribed analgesics around-the-clock.

An older adult client slipped on an area rug at home and fractured the left hip. The client is unable to have surgery immediately and is having severe pain. What interventions should the nurse provide for the patient to minimize energy loss in response to pain?

depressed.

An x-ray demonstrates a fracture in which the fragments of bone are driven inward. This type of fracture is referred to as

Distal radius

Colles fracture occurs in which area?

circulatory status.

During the acute phase of a burn, a nurse should assess:

A urine output consistently above 40 ml/hour

In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client?

Application of ice

Initial first aid rendered at the scene of a fire includes preventing further injury through heat exposure. Which intervention could contribute to tissue hypoxia and necrosis and therefore should be avoided?

"The rhythm has a normal beat, then a premature beat pattern."

The client asks the nurse to explain what is meant by a ventricular bigeminy cardiac rhythm. What is the best response by the nurse?

A fasciotomy

The client displays manifestations of compartment syndrome. What treatment will the nurse expect the client to be scheduled for?

Physiologic cast syndrome

The client presents with nausea and vomiting, sluggish bowel sounds, and abdominal distention. How does the nurse interpret these findings?

"You will eventually be able to withstand full weight-bearing after the amputation."

The client scheduled for a Syme amputation is concerned about the ability to eventually stand on the amputated extremity. How should the nurse best respond to the client's concern?

Bigeminy

The licensed practical nurse is monitoring the waveform pattern on the cardiac monitor of the client admitted following a myocardial infarction. The nurse notes that every other beat includes a premature ventricular contraction (PVC). The nurse notes which of the following in the permanent record?

decreased catabolism.

The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories. The nurse recognizes this intervention is to promote

normal sinus rhythm.

The nurse analyzes a 6-second electrocardiogram (ECG) tracing. The P waves and QRS complexes are regular. The PR interval is 0.18 seconds long, and the QRS complexes are 0.08 seconds long. The heart rate is calculated at 70 bpm. The nurse correctly identifies this rhythm as

During ventricular depolarization

The nurse and student nurse are observing a cardioversion procedure. The nurse is correct to tell the student that electrical current will be initiated at which time?

Atrial depolarization

The nurse cares for a client with a dysrhythmia and understands that the P wave on an electrocardiogram (ECG) represents which phase of the cardiac cycle?

HR urine output

The nurse cares for a client with extensive burn injuries. Which parameter(s) would the nurse evaluate to determine if the client is receiving adequate fluid resuscitation? Select all that apply.

Music therapy may provide reality orientation, distraction, and sensory stimulation.

The nurse determines which statement reflects current research regarding the utilization of nonpharmacological measures in the management of burn pain?

Pacer rate

The nurse is assessing vital signs in a patient with a permanent pacemaker. What should the nurse document about the pacemaker?

hyperkalemia

The nurse is caring for a client who has sustained severe burns to 50% of the body. The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury cause massive cell destruction. What should the nurse report if it occurs immediately after burn injury?

"You will need to cancel this activity; you must restrict arm movement above your head for 2 weeks."

The nurse is caring for a client who is being discharged after insertion of a permanent pacemaker. The client, an avid tennis player, is scheduled to play in a tournament in 1 week. What is the best advice the nurse can give related to this activity?

Alerting the healthcare provider of the third-degree heart block

The nurse is caring for a client who is displaying a third-degree AV block on the EKG monitor. What is the priority nursing intervention for the client?

Claw-like deformity of the right hand without ability to extend fingers

The nurse is caring for a client who was involved in an automobile accident and sustained multiple trauma. The client has a Volkmann's contracture to the right hand. What objective data does the nurse document related to this finding?

Elective cardioversion

The nurse is caring for a client with atrial fibrillation. What procedure would be recommended if drug therapies did not control the arrhythmia?

Fat emboli syndrome

The nurse is caring for a patient postoperatively following orthopedic surgery. The nurse assesses an oxygen saturation of 89%, confusion, and a rash on the upper torso. What does the nurse suspect is occurring with this patient?

Pulmonary embolism

The nurse is caring for a patient who had a total hip replacement. What lethal postoperative complication should the nurse closely monitor for?

20 to 25 lbs

The nurse is defibrillating a patient in ventricular fibrillation with paddles on a monophasic defibrillator. How much paddle pressure should the nurse apply when defibrillating?

Within 30 minutes, then every 1 to 2 hours

The nurse is helping to set up Buck's traction on an orthopedic client. How often should the nurse assess circulation to the affected leg?

An automatic external defibrillator

The nurse is in the mall and observes a client slump to the floor. The nurse assesses the client and notes no pulse. The nurse calls for assistance to others in the mall and requests which piece of equipment?

A urinary output of 30 mL/hr

The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement?

Avoid undergoing magnetic resonance imaging (MRI).

The nurse is providing discharge instructions to a client after a permanent pacemaker insertion. Which safety precaution will the nurse communicate to the client?

Your family and friends may want to take a CPR class.

The nurse is proving discharge instructions for a client with a new arrhythmia. Which statement should the nurse include?

Sinoatrial (SA) node, atrioventricular (AV) node, bundle of His, right and left bundle branches, and the Purkinje fibers

The nurse is teaching a beginning EKG class to staff nurses. As the nurse begins to discuss the parts of the EKG complex, one of the students asks what the normal order of conduction through the heart is. What order does the nurse describe?

Ventricular fibrillation

The nurse is working on a monitored unit assessing the cardiac monitor rhythms. Which waveform pattern needs attention first?

Administer an IV bolus of atropine.

The nurse is working on a telemetry unit, caring for a client who develops dizziness and a second-degree heart block, Mobitz Type 1. What will be the initial nursing intervention?

0.24 seconds

The nurse knows that what PR interval presents a first-degree heart block?

Roll the client in a blanket.

The nurse participates in a health fair about fire safety. When clothes catch fire, which intervention helps to minimize the risk of further injury to an affected person at a scene of a fire?

Contact the primary care provider and prepare for an escharotomy.

The nurse provides care for a client with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the client is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. What is the nurse's best response based on the clinical findings?

Hypovolemia

The nurse receives a client following a serious thermal burn. Which complication will the nurse take action to prevent first?

Skin turgor Hourly urine output DW

The nurse recognizes that which of the following provide clues about fluid volume status? Select all that apply.

Dry a wet fiberglass cast thoroughly to avoid skin problems

The nurse teaching the client with a cast about home care includes which instruction?

Acidosis Hypovolemia Hypoxia Hypothermia

The nurse understands that asystole can be caused by several conditions. Select all that apply.

"The only difference is the heart rate."

The nursing student asks the nurse to describe the difference between sinus rhythm and sinus bradycardia on the electrocardiogram strip. What is the nurse's best reply?

Balanced traction allows for greater client movement and independence than other forms of traction.

The orthopedic surgeon has prescribed balanced skeletal traction for a client. What advantage is conferred by balanced traction?

180 g/day

To meet early nutritional demands for protein, a 198-lb (90-kg) burned patient will need to ingest a minimum of how much protein every 24 hours?

"It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node."

Two nursing students are reading EKG strips. One of the students asks the instructor what the P-R interval represents. The correct response should be which of the following?

Compare the client's palm with the size of the burn wound

What quick assessment technique should the nurse use to assess the percentage of burn injury?

Hoarseness of the voice

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?

QRS complex

Which ECG waveform characterizes conduction of an electrical impulse through the left ventricle?

Assisting in early ambulation.

Which action would be most important postoperatively for a client who has had a knee or hip replacement?

Splint

Which device is designed specifically to initially support and immobilize a body part in a desired position until swelling subsides?

Atrial flutter

Which dysrhythmia has an atrial rate between 250 and 400, with saw-toothed P waves?

Local malignancy

Which factor inhibits fracture healing?

Roll the client in a blanket

Which intervention helps to minimize the risk of further injury to an affected person at the scene of a fire?

To keep fire and smoke from airway

Which is the primary reason for placing a client in a horizontal position while smothering flames are present?

Infection related to effects of trauma

Which nursing diagnosis takes highest priority for a client with a compound fracture?

Monitor vital signs and cardiac rhythm

Which nursing intervention must a nurse perform when administering prescribed vasopressors to a client with a cardiac dysrhythmia?

Contusion

Which of the following is a term used to describe a soft tissue injury produced by a blunt force?

Lactated Ringer's (LR)

Which of the following is the preferred IV fluid for burn resuscitation?

Hypotension Tachycardia Anxiety

Which of the following is to be expected soon after a major burn? Select all that apply.

Application of cool water

Which of the following measures can be used to cool a burn?

Heterotopic ossification

Which of the following musculoskeletal injuries is manifested by acromioclavicular joint pain?

Avoid sources of electrical interference

Which postimplantation instruction must a nurse provide to a client with a permanent pacemaker?

Skeletal traction is never interrupted

Which principle applies to the client in traction?

The surgeon inserts metal pins into the bone or bones from outside the skin surface and then attaches a compression device to the pins.

Which statement describes external fixation?

Deep partial-thickness

Which type of burn injury involves destruction of the epidermis and upper layers of the dermis as well as injury to the deeper portions of the dermis?

Full-thickness

Which type of burn injury requires skin grafting?

Incomplete

Which type of fracture involves a break through only part of the cross-section of the bone?

"the brachial artery is most commonly used for this procedure"

You're providing education to a patient who will be undergoing a heart catheterization. Which statement by the patient requires you to re-educate the patient about this procedure?