Burns exam
A nurse in a clinic is caring for a client who has a prescription for digoxin. Which of the following statements indicates the client is experiencing digoxin toxicity? "I am gaining weight." "I am constipated." "My vision seems yellow." "My tongue is red and beefy."
"My vision seems yellow."
A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification? Morphine sulfate 2 mg IV bolus every 2 hr PRN pain Laboratory testing of serum potassium upon admission 0.9% normal saline IV at 50 mL/hr continuous Bumetanide 1 mg V bolus every 12 hr
0.9% normal saline IV at 50 mL/hr continuous
A nurse in an emergency department is caring for a client who has diabetic ketoacidosis (DKA) and a blood glucose level of 925 mg/dL. The nurse should anticipate which of the following prescriptions from the provider? Glucocorticoid medications Dextrose 5% in 0.45% sodium chloride Oral hypoglycemic medications 0.9% sodium chloride IV bolus
0.9% sodium chloride IV bolus
A nurse is caring for a client who has sepsis and a prescription for vancomycin 1 g in 250 ml dextrose 5% every 2 hr by IV intermittent bolus. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a training zero)
125
A nurse is reviewing a client's prescription for 1,000 mL of 5% dextrose in water IV to infuse over 8 hr. At 1400, the nurse observes that there is 500 mL of solution remaining in the client's current IV bag. At what time should the nurse administer the next bag of IV solution? 1500 1600 1700 1800
1600
A nurse is preparing to administer 0.45% sodium chloride (NaCl) 2000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
250
A nurse is admitting a client who has sustained severe burn injuries in a grease fire. The nurse shades in a diagram indicating the burned surface areas. Using the Rule of Nines, the nurse should estimate that the client has burned what percentage of body surface area? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
45
A nurse is admitting a client who sustained severe burn injuries. The nurse refers to the rule of nines to determine the total body surface area of the burn injury. What percentage of body surface area should the nurse estimate the client has burned? (FRONT AND BACK OF BOTH LEGS, BACK OF TORSO/NECK
54 - wrong
A nurse is preparing to start an IV infusion of lactated Ringer's for a client who sustained a burn injury. The client is prescribed 5,200 mL of fluid over the first 24 hr. How many mL/hr should the nurse set the pump to infuse for the first 8 hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
650
A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect? Malignant hypertension Acetone odor to breath Cheyne-Stokes breathing Blood glucose level below 40
Acetone odor to breath
A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110, respiratory rate 40 and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29, HCO3 20 and O2 86%. Which of the following is the priority nursing intervention? Prepare for mechanical ventilation Administer oxygen via face mask. Prepare to administer a sedative. Assess for indications of pulmonary embolism.
Administer oxygen via face mask.
A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg. a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take? Raise the foot of the bed to a 90° angle. Remove the dressing to inspect the wound. Prepare to insert a central line. Administer oxygen via nasal cannula.
Administer oxygen via nasal cannula.
A nurse in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and thrown from the vehicle. When assessing the client, the nurse observes clear fluid draining from the client's nose. Which of the following interventions should the nurse take? Obtain a culture of the specimen using sterile swabs Allow the drainage to drip onto a sterile gauze pad. Suction the nose gently with a bulb syringe Insert sterile packing into the nares.
Allow the drainage to drip onto a sterile gauze pad.
A nurse in the emergency department is caring for a client who has an epidural hematoma following a motor-vehicle crash. Which of the following is an expected finding for this client? Narrowing pulse pressure Drainage of clear fluid from the ears Alternating periods of alertness and unconsciousness Extensive bruising in the mastoid area
Alternating periods of alertness and unconsciousness
A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia? Epinephrine Magnesium Atropine Sodium bicarbonate
Atropine
A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG? First-degree AV block Atrial fibrillation Sinus bradycardia Sinus tachycardia
Atrial fibrillation
A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion? Confusion Blood pressure 84/50 mm Hg Anuria Petechiae
Confusion
A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration? Continue to monitor the client. Immediately notify the provider. Reposition the client toward the left side. Clamp the chest tube near the water seal.
Continue to monitor the client.
A nurse is caring for a client who has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication? Continuous bubbling in the water-seal chamber Occasional bubbling in the water-seal chamber Constant bubbling in the suction-control chamber Fluctuations in the fluid level in the water-seal chamber
Continuous bubbling in the water-seal chamber
A nurse is caring for a client whe has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.) Confusion Bradycardia Hypotension Nonreactive dilated pupils Slurred speech
Hypotension Nonreactive dilated pupils
A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? Decreased level of consciousness Tachypnea Bilateral weakness of extremities Hypotension
Decreased level of consciousness
A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make? Fluid overload Left ventricular failure Intracardiac shunt Hypovolemia
Hypovolemia
A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take? Teach controlled coughing and deep breathing Provide a brightly lit environment. Elevate the head of the bed. Encourage a minimum intake of 2000 ml (67.6 oz) of clear fluids per day
Elevate the head of the bed.
A nurse is assessing a client following the application of an aquathermia pad. Which of the following is the first indication to the nurse that the client is experiencing a superficial burn injury to the application site? Blistering Erythema Eschar Absence of pain
Erythema
A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. His blood urea nitrogen (BUN) is 32mg creatinine 1.1mg / d * L and hematocrit 50%. Which of the following nursing interventions is appropriate? Collect a urine specimen for culture and sensitivity, Continue routine care because the results are within the expected reference range Decrease the IV Nuid infusion rate and limit oral fluid intake. Evaluate urine for amount and for specific gravity
Evaluate urine for amount and for specific gravity
A nurse remains with a client to observe for any adverse reactions after initiating a transfusion of packed RBCs. The client becomes apprehensive and tachycardic, reporting headache and low back pain. The nurse should recognize that these findings indicate which of the following transfusion reactions? Febrile Hemolytic Allergic Bacterial
Hemolytic
A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect? Metabolic alkalosis Hypervolemia Hyperkalemia Low hemoglobin
Hyperkalemia
A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock? Increased heart rate Widening pulse pressure Increased deep tendon reflexes Pulse oximetry 96%
Increased heart rate
a nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing? Hypotension Anuria Increased respiratory rate Decreased level of consciousness
Increased respiratory rate
A nurse is performing a neurological assessment for a client who has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III? Instruct the client to look up and down without moving his head. Observe the client's ability to smile and frown. Have the client stand with eyes closed and touch his nose. Ask the client to shrug his shoulders against passive resistance.
Instruct the client to look up and down without moving his head.
A nurse is caring for a client who has full-thickness burns over 75% of his body. The nurse should use which of the following methods to monitor the cardiovascular system? Auscultate cuff blood pressure. Palpate pulse pressure. Obtain a central venous pressure. Monitor the pulmonary artery pressure.
Monitor the pulmonary artery pressure.
A nurse is assessing a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply.) Muscle distortion Pain behind the ear Hearing loss Facial twitching Impaired taste
Muscle distortion Pain behind the ear Hearing loss Facial twitching Impaired taste
A nurse in an emergency department is assessing a client who is having a suspected acute myocardial infarction (MI). Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI (Select all that apply.) Orthopnea Headache Nausea Tachycardia Diaphoresis
Nausea Tachycardia Diaphoresis
A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.) Establish IV access. Remove clothing for a thorough assessment. Determine effectiveness of ventilator efforts. Perform a Glasgow Coma Scale assessment. Open the airway using a jaw-thrust maneuver.
Open the airway using a jaw-thrust maneuver. Determine effectiveness of ventilator efforts. Establish IV access. Perform a Glasgow Coma Scale assessment. Remove clothing for a thorough assessment.
A nurse is caring for a client who has acute kidney Injury (AKI). Which of the following arterial blood gas values would the nurse expect this client to have? pH 7,49, HCO3 24, PaCo2 30 pH 7.49, HCO 30, PaCo2 20 PH7.26, HCO3 24 PaCO, 46 PH 7.26, HCO, 14, PaCO2 30
PH 7.26, HCO, 14, PaCO2 30
An acute care nurse receives a shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client? Extension of the arms Pronation of the hands Plantar flexion of the legs External rotation of the lower extremities
Plantar flexion of the legs
A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following interventions should the nurse include in the plan? Apply restraints Administer opioids. Darken the room. Reduce Stimuli
Reduce stimuli.
A nurse is caring for a client who has a serum potassium level of 5.5mEq / L The provider prescribes polystyrene sulfonate. If this medication is effective, the nurse should expect which of the following changes on the client's ECG? Reduction of T-wave amplitude Shortening of P-wave duration Widening of the QRS complex Restoration of QRS complex amplitude
Reduction of T-wave amplitude
A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the emergency department confused, flushed, and with an acetone odor on the breath. Diabetic ketoacidosis is suspected. The nurse should anticipate using which of the following types of insulin to treat this client?
Regular Insulin
A client is admitted to the emergency room with a respiratory rate of 7 / m * in Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68, Base excess-2, PacO2 78 Saturation 80%, Bicarbonate 26 Respiratory acidosis Metabolic acidosis Metabolic alkalosis Respiratory alkalosis
Respiratory acidosis
A nurse is reviewing the laboratory report of a client and identifies a serum potassium level of 6.8mEq / L Which of the following medications should the nurse plan to administer? Lactulose Sevelamer Sodium polystyrene Darbepoetin alfa
Sodium polystyrene
A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first? Test the drainage for glucose. Suction the nostril. Notify the physician. Ask the client to blow his nose.
Test the drainage for glucose.
A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score? The client needs total nursing care. The client is alert and oriented. The client is in a deep coma Indicates stable neurologic status
The client needs total nursing care.
A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data? The client can follow simple motor commands. The client is unable to make vocal sound The client is unconscious. The client opens his eyes when spoken to
The client opens his eyes when spoken to
A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client? Troponin is an enzyme that indicates damage to brain, heart, and skeletal muscle tissues. Troponin is a lipid whose levels reflect the risk for coronary artery disease. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. Troponin is a protein that helps transport oxygen throughout the body
Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart.
A nurse is preparing to infuse a 250-ml unit of packed RBCs over 2 hr. The drop factor of the manual IV tubing is 15 gtts/mL. The nurse should adjust the flow rate to deliver how many drops per minute? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
31
A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply) Hypotension Polyuria Hyperthermia Absence of bowel sounds Weakened gag reflex
Hypotension Absence of bowel sounds Weakened gag reflex
A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take? Obtain a cardiology consult. Suction the client less frequently. Administer an antidysrhythmic medication. Perform pre-oxygenation prior to suctioning.
Perform pre-oxygenation prior to suctioning.
A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of Increased intracranial pressure (ICP)? Tachycardia Amnesia Hypotension Restlessness
Restlessness
A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see? pH below 7.35 HCO3 above 26mEo / L PaCO2 below 70 mm Hg PaCO2 above 45 mm Hg
pH below 7.35
