prep U questions for acute 2 final exam

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? "Are any of the victims expected to have electrical burns?" "Are the burns associated with chemicals used in the plant?"

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

A client undergoes a total hip replacement. Which statement made by the client indicates to the nurse that the client requires further teaching? "I need to remember not to cross my legs. It's such a habit." "The occupational therapist is showing me how to use a sock puller to help me get dressed." "I'll need to keep several pillows between my legs at night." "I don't know if I'll be able to get off that low toilet seat at home by myself."

"I don't know if I'll be able to get off that low toilet seat at home by myself."

A home care nurse visits a client diagnosed with atrial fibrillation who is ordered warfarin. The nurse teaches the client about warfarin therapy. Which statement by the client indicates the need for further teaching? "I'll use an electric razor to shave." "I'll eat four servings of fresh, dark green vegetables every day." "I'll report unexplained or severe bruising to my doctor right away." "I'll watch my gums for bleeding when I brush my teeth."

"I'll eat four servings of fresh, dark green vegetables every day"

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? "It shows the time it takes the AV node impulse to depolarize the ventricles and travel through the SA node." "It shows the time it takes the AV node impulse to depolarize the atria and travel through the SA node." "It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node." "It shows the time it takes the AV node impulse to depolarize the septum and travel through the Purkinje fibers."

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

A client with a mechanical valve replacement asks the nurse, "Why do I have to take antibiotics before getting my teeth cleaned?" What is the nurse's best response? "Antibiotics will prevent vegetative growth on your valves." "You are at risk of developing an infection in your heart."

"You are at risk of developing an infection in your heart."

After performing an ECG on an adult client, the nurse reports that the PR interval reflects normal sinus rhythm. What is the PR interval for a normal sinus rhythm? 0.15 and 0.3 seconds. 0.25 and 0.4 seconds. 0.12 and 0.2 seconds. 0.05 and 0.1 seconds.

0.12 and 0.2 seconds

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?

180 g/day

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? 2,400 mL 4,800 mL 3,600 mL 1,200 mL

2,400 mL

A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned? 36% 45% 27% 18%

27%

A client who had a prosthetic valve replacement was taking warfarin to reduce the risk of postoperative thrombosis. The client visited the nurse at a clinic once a week. What INR level would alert the nurse to notify the health care provider? 2.6 3.8 3.4 3.0

3.8

The nurse receives an order to administer a colloidal solution for a patient experiencing hypovolemic shock. What common colloidal solution will the nurse most likely administer? 6% hetastarch 5% albumin 6% dextran Blood products

5% albumin

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? A urinary output of 10 mL/hr A urinary output of 30 mL/hr A urinary output of 80 mL/hr A urinary output of 100 mL/hr

A urinary output of 30 mL/hr

The nurse is providing care for a client with pulmonary edema. Which assessment method should the nurse prioritize to monitor the respiratory status of this individual? Pulse oximetry Skin color assessment Arterial blood gas (ABG) analysis Lung sounds

ABG analysis

The nurse caring for a 2-year-old near-drowning victim monitors for what possible complication? Atelectasis Metabolic alkalosis Acute respiratory distress syndrome Respiratory acidosis

ARDS

Which of the following is the most common hematologic condition affecting elderly patients

Anemia

Which would the nurse stress as a periodic lifelong necessity for a client managing infective endocarditis? Exercise regimen Potassium replacement Antihypertensive medication Antibiotic therapy

Antibiotic therapy

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? Removal of clothing Application of ice

Application of Ice

The nurse is auscultating the heart sounds of a patient with mitral stenosis. The pulse rhythm is weak and irregular. What rhythm does the nurse expect to see on the electrocardiogram (ECG)? Sinus dysrhythmia First-degree atrioventricular block Ventricular tachycardia Atrial fibrillation

Atrial Fibrillation

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? Atrial depolarization Early ventricular repolarization Ventricular depolarization Ventricular repolarization

Atrial depolarization

The nurse recognizes that which laboratory test is a key diagnostic indicator of heart failure? Brain natriuretic peptide (BNP) Blood urea nitrogen (BUN) Complete blood count (CBC) Creatinine

BNP (brain natriutetic peptide )

A client with aortic stenosis is reluctant to have valve replacement surgery. A nurse is present when the health care provider talks to the client about a treatment that is less invasive than surgery which will likely relieve some of the client's symptoms. What treatment option has been discussed? Antibiotic therapy Placement of an autograft valve Placement of a xenograft valve Balloon percutaneous valvuloplasty

Balloon percutaneous valvuloplasty

During preshock, the compensatory stage of shock, the body, through sympathetic nervous system stimulation, will release catecholamines to shunt blood from one organ to another. Which of the following organs will always be protected? Kidneys Lungs Liver Brain

Brain

A client reports feeling tired, cold, and short of breath at times. Assessment reveals tachycardia and reduced energy. What would the nurse expect the physician to order?

CBC

The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema? Low-pitched rhonchi during expiration Crackles in the lung bases Sibilant wheezes Pleural friction rub

Crackles in the lung bases

The nurse is monitoring the patient in shock. The patient begins bleeding from previous venipuncture sites, in the indwelling catheter, and rectum, and the nurse observes multiple areas of ecchymosis. What does the nurse suspect has developed in this patient? Septicemia Stress ulcer Disseminated intravascular coagulation (DIC) Stevens-Johnson syndrome from the administration of antibiotics

Disseminated Intravascular Coagulation (DIC)

Which diagnostic study is usually performed to confirm the diagnosis of heart failure?

Echocardiogram

The spouse of a client who was struck by lightning asks the nurse why the areas involved seems so small but the damage is extensive. Which is the best explanation from the nurse? Lightning is higher in voltage than electricity. Moisture intensifies the damage inflicted. The skin is a good conductor of electricity. Electrical burns usually follow an internal path.

Electrical burns usually follow an internal path

Which intervention does a nurse implement for clients with empyema? Place suspected clients together Encourage breathing exercises Institute droplet precautions Do not allow visitors with respiratory infections

Encourage breathing exercises

Stress ulcers occur frequently in acutely ill patient. Which of the following medications would be used to prevent ulcer formation? Select all that apply. Lansoprazole Famotidine (Pepcid) Nizatidine Desmopressin Furosemide

Famotidine (Pepcid) Nizatidine Lansoprazole

A patient sustained an open fracture of the femur 24 hours ago. While assessing the patient, the nurse observes the patient is having difficulty breathing, and oxygen saturation decreases to 88% from a previous 99%. What does the nurse understand is likely occurring with this patient? Pneumonia Cardiac tamponade Fat emboli Spontaneous pneumothorax

Fat emboli

A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates? ARDS Pneumothorax Tension pneumothorax Flail chest

Flail chest

A client with endocarditis is being discharged home. What statement indicates effectiveness of client teaching about preventing recurrence of the infection?

I will ask for antibiotics whenever I have dental work done."

A patient who has accidentally ingested toilet bowel cleaner is brought to the emergency department. Which action would NOT be appropriate for the nurse to implement? Gastric lavage Induced vomiting Activated charcoal Dilution with milk

Induce vomiting

The client with a lower respiratory airway infection is presenting with the following symptoms: fever, chills, dry hacking cough, and wheezing. Which nursing diagnosis best supports the assessment by the nurse? Impaired gas exchange Ineffective airway clearance

Ineffective airway clearance

A client experienced an open fracture to the left femur during a horse-riding accident. For which complication is this client at highest risk? Depression Malunion Infection Complex regional pain syndrome

Infection

Which nursing diagnosis takes highest priority for a client with a compound fracture? Infection related to effects of trauma Imbalanced nutrition: Less than body requirements related to immobility Activity intolerance related to weight-bearing limitations Impaired physical mobility related to trauma

Infection related to the effects of trauma

A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first? Perform nasopharyngeal suctioning. Administer a heparin bolus and begin an infusion at 500 units/hour. Initiate oxygen therapy. Administer analgesics as ordered.

Initiate oxygen therapy.

Which of the following is the effect of protein catabolism in a client with severe burns? It compromises dexterity and mobility. It maximizes the risk of impaired ventilation. It compromises wound healing and immunocompetence. It maximizes the risk of sodium retention and hypotension.

It compromises wound healing and immunocompetence.

The staff educator is teaching a class in arrhythmias. What statement is correct for defibrillation? It is used to eliminate ventricular arrhythmias. It is a scheduled procedure 1 to 10 days in advance. The client is sedated before the procedure. It uses less electrical energy than cardioversion.

It is used to eliminate ventricular arrhythmias

A large volume of intravenous fluids is being administered to an elderly client who experienced hypovolemic shock following diarrhea. The nurse is evaluating the client's response to treatment and notes the following as a sign of an adverse reaction: Vesicular breath sounds Jugular venous distention Decreased pulse rate to 110 beats/minute Positive increase in the fluid balance ratio

Jugular venous distention

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? Normal saline solution with 20 mEq of potassium per 1,000 ml Lactated Ringer's solution Dextrose 5% in water (D5W) Albumin

Lactated Ringer's solution

Which positioning strategy should be used for the client diagnosed with hypovolemic shock?

Modified Trendelenburg

The nurse determines that a patient in shock is experiencing a decrease in stroke volume when what clinical manifestation is observed?

Narrowed pulse pressure

A client with a diagnosis of pernicious anemia comes to the clinic and reports numbness and tingling in the arms and legs. What do these symptoms indicate? Severity of the disease Neurologic involvement

Neurologic Involvement

In the treatment of shock, which of the following vasoactive drugs result in reduced preload and afterload, reducing oxygen demand of the heart? Nitroprusside Dopamine Epinephrine Methoxamine

Nitroprusside

To evaluate a client's atrial depolarization, the nurse observes which part of the electrocardiogram waveform? PR interval QRS complex T wave P wave SUBMIT ANSWER

P wave

A client with a recent history of atrial fibrillation has been prescribed warfarin. What action will the nurse take to confirm safe dosing? Assess the client's apical pulse. Review the client's international normalized ratio (INR). Assess the client's radial pulse. Review the client's most recent warfarin blood levels.

Review the client's INR

The client is admitted with full-thickness burns to the forearm. Which is the most accurate interpretation made by the nurse? Ligaments, tendons, muscles, and bone are not involved. Skin grafting will be necessary. The wound will take up to 3 weeks to heal. Pain management will be a challenge.

Skin grafting will be necessary

When a client is in the compensatory stage of shock, which symptom occurs? Respiratory acidosis Bradycardia Urine output of 45 mL/hr Tachycardia

Tachycardia

An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior?

The client has experienced extensive full-thickness burns

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? The client's heart rate is rapid and regular. The client's breathing is unlabored, and skin is clammy. The client's urinary output is 0.5 to 1 mL/kg/hour. The client is alert and conscious.

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

After receiving chemotherapy for lung cancer, a client's platelet count falls to 98,000/mm3. What term should the nurse use to describe this low platelet count? Anemia Thrombocytopenia Neutropenia Leukopenia

Thrombocytopenia

A nurse is doing a physical examination of a child with sickle cell anemia. When the child asks why the nurse auscultates the lungs and heart, what would be best the response by the nurse? To detect the evidence of infection such as fever and tachycardia To detect the abnormal sounds suggestive of acute chest syndrome and heart failure To detect the evidence of dehydration that might have triggered a sickle cell crisis To detect the motor strength and stroke-related signs and symptoms

To detect the abnormal sounds suggestive of acute chest syndrome and heart failure

Which nursing intervention should the nurse perform when a client with valvular disorder of the heart has a heart rate less than 60 beats/min before administering beta-blockers?

Withhold the drug and inform the primary health care provider.

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? Asystole Atrial flutter Premature ventricular contraction Ventricular fibrillation

atrial flutter

A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's: hemoglobin level. temperature. blood pressure. heart rate.

blood pressure

During preshock, the compensatory stage of shock, the body, through sympathetic nervous system stimulation, will release catecholamines to shunt blood from one organ to another. Which of the following organs will always be protected?

brain

Which is a symptom of hemochromatosis? Inflammation of the tongue Weight gain Inflammation of the mouth Bronzing of the skin

bronzing of the skin

An important nursing assessment, post fracture, is to evaluate neurovascular status. Therefore, the nurse should check for: Shortening and deformity. Swelling and discoloration. Crepitus. Capillary refill.

capillary refill

The nurse is admitting a client to a telemetry unit with an atrial dysrhythmia. What symptoms will the nurse further evaluate? chest pain hypocarbia hypertension leg pain

chest pain

A client sustains a fractured right humerus in an automobile accident. The arm is edematous, the client states not being able to move or feel the fingers, and the nurse does not feel a pulse. What condition should the nurse be concerned about that requires emergency measures? Dislocation Muscle spasms Compartment syndrome Subluxation

compartment syndrome

A patient with end-stage kidney disease (ESKD) has developed anemia. What laboratory finding does the nurse understand to be significant in this stage of anemia? Potassium level of 5.2 mEq/L Magnesium level of 2.5 mg/dL Calcium level of 9.4 mg/dL Creatinine level of 6 mg/100 mL

creatinine level of 6 mg/100 mL

A client with lung cancer develops pleural effusion. During chest auscultation, which breath sound should the nurse expect to hear? Rhonchi Crackles Wheezes Decreased breath sounds

decreased breath sounds

During assessment of a client admitted for cardiomyopathy, the nurse notes the following symptoms: dyspnea on exertion, fatigue, fluid retention, and nausea. The initial appropriate nursing diagnosis is which of the following? Disturbed sensory perception Autonomic dysreflexia Ineffective airway clearance Decreased cardiac output

decreased cardiac output

What is the reason for chest tubes after thoracic surgery? Draining secretions, air, and blood from the thoracic cavity is necessary. Chest tubes allow air into the pleural space. Chest tubes indicate when the lungs have re-expanded by ceasing to bubble. Draining secretions and blood while allowing air to remain in the thoracic cavity is necessary.

draining secretions, air, and blood from the thoracic cavity is necessary

A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient?

dyspnea

The nurse is assessing a client with mitral regurgitation. The nurse expects to note what finding in this client? Dry cough, wheezing, and hemoptysis Dizziness, syncope, and palpitations Orthopnea, angina, and pulmonary edema Dyspnea, fatigue, and weakness

dyspnea, fatigue, and weakness

A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron deficiency anemia? Nausea, vomiting, and anorexia Itching, rash, and jaundice Dyspnea, tachycardia, and pallor Nights sweats, weight loss, and diarrhea

dyspnea, tachycardia, and pallor

A nurse is preparing to assist with a gastric lavage for a client who has ingested an unknown poison and is obtunded. To ensure that the tube reaches the stomach, the nurse would measure the distance from the bridge of the nose to which of the following? Ear lobe and then to the xiphoid process Chin and then to the xiphoid process Chin and then to the umbilicus Ear lobe and then to the umbilicus

ear lobe and then to the xiphoid process

A client has been having cardiac symptoms for several months and is seeing a cardiologist for diagnostics to determine the cause. How will the client's ejection fraction be measured? electrocardiogram cardiac ultrasound cardiac catheterization echocardiogram

echocardiogram

A patient is admitted with suspected cardiomyopathy. What diagnostic test will the nurse need to teach the client about for identification of this disease? phonocardiogram cardiac catheterization echocardiogram serial enzyme studies

echocardiogram

The nurse is caring for a client in the intensive care unit and while reviewing the client's history, the nurse notes the client had a King laryngeal tube inserted to begin ventilation. The nurse recognizes this intervention was required for which reason? Laryngeal edema prevented placement of an endotracheal tube. The client was hemorrhaging into the neck. Emergency response personnel performed this intervention outside the hospital. The client's airway is oversized requiring a specialized endotracheal tube.

emergency response personnel performed this intervention outside the hospital

Which general nursing measure is used for a client with a fracture reduction? Examine the abdomen for enlarged liver or spleen Promote intake of omega-3 fatty acids Assist with intake of immune-enhancing tube feeding formulas Encourage participation in ADLs

encourage participation in ADLs

The occupational nurse is completing routine assessments on the employees at a company. What might be revealed by a chest radiograph for a client with occupational lung diseases? Hemorrhage Fibrotic changes in lungs Lung contusion Damage to surrounding tissues

fibrotic changes in lungs

A client is diagnosed with rheumatic endocarditis. What bacterium is the nurse aware causes this inflammatory response? Pseudomonas aeruginosa Group A, beta-hemolytic streptococcus Staphylococcus aureus Serratia marcescens

group a beta-hemolytic streptococcus

A client comes to the emergency department with a suspected airway obstruction. The emergency department team prepares to manage the client as if he has a complete airway obstruction based on which of the following? Wheezing between coughs Refusal to lie flat Forceful coughing High-pitched noise on inhalation

high-pitched noise on inhalation

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? Hoarseness of the voice Complaints of intense thirst Urine output of 70 ml the first hour Moderate to severe pain

hoarseness of the voice

Which of the following neuroendocrine changes occur within the first 24 hours of a serious burn? Hypoglycemia Polyuria Sodium loss Hyperglycemia

hyperglycemia

The nurse monitors a client for side effects associated with furosemide, which is newly prescribed for the treatment of heart failure. Complete the following sentence by choosing from the lists of options. Due to the client's high risk for developing ___________ as a result of the prescribed medication, the nurse focuses on monitoring the client for ____________. blank one options: hypokalemia hyperuricemia hyponatremia blank two options: ventricular arrhythmia joint swelling nausea

hypokalemia, ventricular arrhythmia

A nurse is caring for a client who has arrived at the emergency department in shock. The nurse intervenes based on the knowledge that which of the following is the most common cause of shock? Anaphylaxis Sepsis Cardiac dysfunction Hypovolemia

hypovolemia

What is the major clinical use of dobutamine? treat hypertension. increase cardiac output. treat hypotension. prevent sinus bradycardia.

increase cardiac output

A client with sickle cell anemia has a normal blood smear. low hematocrit. high hematocrit. normal hematocrit.

low hematocrit

A client has experienced hypovolemic shock and is being treated with 2 liters of lactated Ringer's solution. It is now most important for the nurse to assess Bowel sounds Skin perfusion Lung sounds Mental status

lung sounds

A nurse is providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate? Providing an analgesic for pain Placing sterile cotton between the toes after rewarming Massaging the feet Restricting ambulation

massaging the feet

Following a motor vehicle collision, a client is admitted to the emergency department with a blood pressure of 88/46, pulse of 54 beats/min with a regular rhythm, and respirations of 20 breaths/min with clear lung sounds. The client's skin is dry and warm. The nurse assesses the client to be in which type of shock? Neurogenic Anaphylactic Cardiogenic Septic

neurogenic

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 first-degree atrioventricular block. sinus tachycardia. junctional tachycardia. normal sinus rhythm.

normal sinus rhythm

The school nurse is providing care to a child with a sore throat. With any sign of throat infection, the nurse stresses which of the following? Warm, salt water gargling Administering antiseptic lozenges Obtaining a throat culture Fluid increase to 2500cc

obtaining a throat culture

When a client has increased difficulty breathing when lying flat, the nurse records that the client is demonstrating hyperpnea. orthopnea. paroxysmal nocturnal dyspnea. dyspnea upon exertion.

orthopnea

A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder? pH 7.28, PaO2 50 mm Hg pH 7.46, PaO2 80 mm Hg pH 7.35, PaCO2 48 mm Hg pH 7.36, PaCO2 32 mm Hg

pH 7.28, PaO2 50 mm Hg

Following a burn injury, the nurse determines which area is the priority for nursing assessment? Pain Nutrition Pulmonary system Cardiovascular system

pulmonary system

Morphine sulfate has which of the following effects on the body? No effect on preload or afterload Reduces preload Increases preload Increases afterload

reduces preload

The client exhibits a blood pressure of 110/68 mm Hg, pulse rate of 112 beats/min, temperature of 102°F with skin warm and flushed. Respirations are 30 breaths/min. The nurse assesses the client may be exhibiting the early stage of which shock? Septic Cardiogenic Anaphylactic Neurogenic

septic

Which term refers to an injury to ligaments and other soft tissues surrounding a joint? Strain Sprain Subluxation Dislocation

sprain

The nurse is caring for a patient with pleurisy. What symptoms does the nurse recognize are significant for this patient's diagnosis? Dullness or flatness on percussion over areas of collected fluid Dyspnea and coughing Fever and chills Stabbing pain during respiratory movement

stabbing pain during respiratory movement

The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation? Cardiac tamponade Tension pneumothorax Pulmonary contusion Flail chest

tension pneumothorax

A client present to the ED following a work-related injury to the left hand. The client has an avulsion of the left ring finger. Which correctly describes an avulsion? Skin tear with irregular edges and vein bridging Denuded skin Incision of the skin with well-defined edges, usually long rather than deep Tissue tearing away from supporting structures

tissue tearing away from the supportive structures

The nurse working in the emergency department places a client in anaphylactic shock on a cardiac monitor and sees the cardiac rhythm shown. Which dysrythmia should the nurse document? atrial fibrillation ventricular tachycardia junctional rhythm ventricular asystole sinus rhythm

v tach

The nurse working in the emergency department places a client in anaphylactic shock on a cardiac monitor and sees the cardiac rhythm shown. Which dysrythmia should the nurse document?

ventricular tachycardia

During preparation for bowel surgery, a client receives an antibiotic to reduce intestinal bacteria. The nurse knows that hypoprothrombinemia may occur as a result of antibiotic therapy interfering with synthesis of which vitamin? Vitamin D Vitamin E Vitamin A Vitamin K

vitamin K

Which medication is the antidote to warfarin? Clopidogrel Aspirin Vitamin K Protamine sulfate

vitamin K