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NSG 430 Term Final – Practice Questions & Full Answer Key., Exams of Nursing

Texas State UniversityNursing

NSG 430 Term Final – Practice Questions & Full Answer Key.

Typology: Exams

2024/2025

Available from 07/02/2025

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NSG 430 Term Final – Practice
Questions & Full Answer Key.
WHICH LIVER TRANSPLANT PATIENT BEING CARED FOR IN THE ICU IS EXHIBITING SIGNS OF
ACUTE REJECTION?
SELECT ONE:
A. PATIENT WITH DARK URINE AND JAUNDICE
B. PATIENT WITH POSTOPERATIVE PAIN 6/10
C. PATIENT WITH TEMP OF 99.0° F AND THIRST
D. PATIENT WITH A CVP OF 6 MM HG - <<<ANSWERS >>>A. PATIENT WITH DARK
URINE AND JAUNDICE
THE NURSE ADMITS A 35-YEAR-OLD PATIENT TO THE EMERGENCY DEPARTMENT
FOLLOWING A 3-DAY HISTORY OF NAUSEA AND VOMITING. VITAL SIGNS ASSESSED BY THE
NURSE INCLUDE A BP OF 70/50 MM HG, HR 145 BEATS/MIN, RR 36 BREATHS/MIN, AND
SPO2 OF 92% ON ROOM AIR. THE NURSE RECOGNIZES WHICH CLASSIFICATION OF SHOCK?
SELECT ONE:
A. OBSTRUCTIVE
B. ANAPHYLACTIC
C. CARDIOGENIC
D. HYPOVOLEMIC - <<<ANSWERS >>>D. HYPOVOLEMIC
ARTERIAL BLOOD GAS ALTERATIONS IN PNEUMONIA INCLUDE WHICH OF THE
FOLLOWING?
SELECT ONE:
A. HYPOXEMIA AND METABOLIC ACIDOSIS
B. HYPOXEMIA AND RESPIRATORY ALKALOSIS
C. NORMAL OXYGEN AND RESPIRATORY ACIDOSIS
D. NORMAL VALUES - <<<ANSWERS >>>B. HYPOXEMIA AND RESPIRATORY ALKALOSIS
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Download NSG 430 Term Final – Practice Questions & Full Answer Key. and more Exams Nursing in PDF only on Docsity!

NSG 430 Term Final – Practice

Questions & Full Answer Key.

WHICH LIVER TRANSPLANT PATIENT BEING CARED FOR IN THE ICU IS EXHIBITING SIGNS OF

ACUTE REJECTION?

SELECT ONE:

A. PATIENT WITH DARK URINE AND JAUNDICE

B. PATIENT WITH POSTOPERATIVE PAIN 6/

C. PATIENT WITH TEMP OF 99.0° F AND THIRST

D. PATIENT WITH A CVP OF 6 MM HG - <<>>A. PATIENT WITH DARK

URINE AND JAUNDICE

THE NURSE ADMITS A 35-YEAR-OLD PATIENT TO THE EMERGENCY DEPARTMENT

FOLLOWING A 3-DAY HISTORY OF NAUSEA AND VOMITING. VITAL SIGNS ASSESSED BY THE

NURSE INCLUDE A BP OF 70/50 MM HG, HR 145 BEATS/MIN, RR 36 BREATHS/MIN, AND

SPO2 OF 92% ON ROOM AIR. THE NURSE RECOGNIZES WHICH CLASSIFICATION OF SHOCK?

SELECT ONE:

A. OBSTRUCTIVE

B. ANAPHYLACTIC

C. CARDIOGENIC

D. HYPOVOLEMIC - <<>>D. HYPOVOLEMIC

ARTERIAL BLOOD GAS ALTERATIONS IN PNEUMONIA INCLUDE WHICH OF THE

FOLLOWING?

SELECT ONE:

A. HYPOXEMIA AND METABOLIC ACIDOSIS

B. HYPOXEMIA AND RESPIRATORY ALKALOSIS

C. NORMAL OXYGEN AND RESPIRATORY ACIDOSIS

D. NORMAL VALUES - <<>>B. HYPOXEMIA AND RESPIRATORY ALKALOSIS

WHICH INTERVENTION IS MOST IMPORTANT IN ASSESSING FLUID BALANCE IN THE

PATIENT WITH AKI?

SELECT ONE:

A. INTAKE AND OUTPUT

B. ESTIMATED GFR

C. SERUM CREATININE

D. DAILY WEIGHT - <<>>A. INTAKE AND OUTPUT

THE NURSE IS PREPARING TO ADMIT A PATIENT FROM THE ED WHO HAS SUSTAINED A

COMPLETE SPINAL CORD LESION AT THE C5 LEVEL. WHEN PLANNING THE PATIENT'S CARE,

WHICH NURSING INTERVENTION IS MOST IMPORTANT?

SELECT ONE:

A. GIVE SMALL, FREQUENT FEEDINGS.

B. ASSIST WITH PASSIVE RANGE-OF-MOTION.

C. APPLY WARMING DEVICES AS NEEDED.

D. PERFORM HOURLY INCENTIVE SPIROMETRY. - <<>>D. PERFORM

HOURLY INCENTIVE SPIROMETRY.

THE GREATEST RISK OF GI BLEEDING IS:

SELECT ONE:

A. INFECTION

B. HYPOVOLEMIA

C. ANEMIA

D. INCREASED CARDIAC OUTPUT - <<>>B. HYPOVOLEMIA

A PATIENT SUDDENLY BECOMES UNRESPONSIVE AS YOU'RE SPEAKING TO HIM AND

DEVELOPS GENERALIZED TONIC-CLONIC SEIZURES. YOUR PRIORITY IS TO:

SELECT ONE:

A. NOTIFY THE PRIMARY CARE PROVIDER IMMEDIATELY.

B. ADMINISTER INTRAVENOUS DIAZEPAM.

C. RANGE-OF-MOTION TO EXTREMITIES

D. FREQUENT NEUROLOGICAL ASSESSMENTS - <<>>D. FREQUENT

NEUROLOGICAL ASSESSMENTS

THE NURSE IS CARING FOR A BURN-INJURED PATIENT WHO WEIGHS 154 POUNDS, AND

THE BURN INJURY COVERS 40% OF HIS BODY SURFACE AREA. THE NURSE CALCULATES THE

FLUID NEEDS FOR THE FIRST 24 HOURS AFTER A BURN INJURY USING A STANDARD FLUID

RESUSCITATION FORMULA OF 4 ML/KG/% BURN OF INTRAVENOUS (IV) FLUID FOR THE

FIRST 24 HOURS. THE NURSE PLANS TO ADMINISTER WHAT AMOUNT OF FLUID IN THE

FIRST 24 HOURS?

SELECT ONE:

A. 14000 ML

B. 2800 ML

C. 7000 ML

D. 11200 ML - <<>>A. 14000 ML

FOR PATIENTS WITH MAJOR BURNS, WHEN SHOULD YOU START ENTERAL FEEDINGS?

SELECT ONE:

A. A FEW HOURS AFTER THE INJURY HAS OCCURRED

B. NOT UNTIL BOWEL SOUNDS HAVE RETURNED

C. AFTER THE EMERGENT PHASE OF THE INJURY

D. 2 TO 3 DAYS AFTER THE INJURY - <<>>C. AFTER THE EMERGENT PHASE

OF THE INJURY

AFTER RECEIVING THE HANDOFF REPORT FROM THE DAY SHIFT CHARGE NURSE, WHICH

PATIENT SHOULD THE EVENING CHARGE NURSE ASSESS FIRST?

SELECT ONE:

A. PATIENT WITH MENINGITIS COMPLAINING OF PHOTOPHOBIA

B. A PATIENT WITH BACTERIAL MENINGITIS ON DROPLET PRECAUTIONS

C. MECHANICALLY VENTILATED PATIENT WITH A GCS OF 6

D. A PATIENT WITH AN INTRACRANIAL PRESSURE ICP OF 20 MM HG AND AN ORAL

TEMPERATURE OF 104°F - <<>>D. A PATIENT WITH AN INTRACRANIAL

PRESSURE ICP OF 20 MM HG AND AN ORAL TEMPERATURE OF 104°F

THE CHARGE NURSE ASSIGNS PATIENTS BASED ON THEIR ACUITY AND THE LEVEL OF

EXPERIENCE OF THE CRITICAL CARE NURSES ON DUTY. THIS IS AN EXAMPLE OF

IMPLEMENTATION OF:

SELECT ONE:

A. HEALTHY WORK ENVIRONMENT

B. NATIONAL PATIENT SAFETY GOALS

C. SBAR COMMUNICATION

D. SYNERGY MODEL - <<>>D. SYNERGY MODEL

WHILE CARING FOR A PATIENT WITH A BASILAR SKULL FRACTURE, THE NURSE ASSESSES

CLEAR DRAINAGE FROM THE PATIENT'S LEFT NARIS. WHAT IS THE BEST NURSING ACTION?

SELECT ONE:

A. INSERT BILATERAL COTTON NASAL PACKING.

B. HAVE THE PATIENT BLOW THE NOSE UNTIL CLEAR.

C. PLACE A NASAL DRIP PAD UNDER THE NOSE.

D. SUCTION THE LEFT NARES UNTIL THE DRAINAGE CLEARS. - <<>>C.

PLACE A NASAL DRIP PAD UNDER THE NOSE.

THE NURSE IS CARING FOR A PATIENT WHO WAS HIT ON THE HEAD WITH A HAMMER.

THE PATIENT WAS UNCONSCIOUS AT THE SCENE BRIEFLY BUT IS NOW CONSCIOUS UPON

ARRIVAL AT THE EMERGENCY DEPARTMENT WITH A GCS SCORE OF 15. ONE HOUR LATER,

THE NURSE ASSESSES A GCS SCORE OF 3. WHAT IS THE PRIORITY NURSING ACTION?

SELECT ONE:

A. STIMULATE THE PATIENT HOURLY.

B. NOTIFY THE PROVIDER IMMEDIATELY.

C. ELEVATE THE HEAD OF THE BED.

D. CONTINUE TO MONITOR THE PATIENT. - <<>>B. NOTIFY THE PROVIDER

IMMEDIATELY.

TO GLUCOSE MONITORING, WHICH OF THE FOLLOWING ELECTROLYTES REQUIRES CLOSE

MONITORING?

SELECT ONE:

A. CHLORIDE

B. SODIUM

C. POTASSIUM

D. CALCIUM - <<>>C. POTASSIUM

DIABETIC KETOACIDOSIS, THE LABORATORY RESULTS ARE SIMILAR TO THOSE OF

HYPEROSMOLAR HYPERGLYCEMIC SYNDROME, WITH THREE MAJOR EXCEPTIONS. WHAT

DIFFERENCES WOULD YOU EXPECT TO SEE IN PATIENTS WITH DIABETIC KETOACIDOSIS?

SELECT ONE:

A. LOWER SERUM GLUCOSE, LOWER OSMOLALITY, AND NO KETOSIS

B. HIGHER SERUM GLUCOSE, HIGHER OSMOLALITY, AND NO KETOSIS

C. LOWER SERUM GLUCOSE, LOWER OSMOLALITY, AND HIGHER KETOSIS

D. HIGHER SERUM GLUCOSE, HIGHER OSMOLALITY, AND HIGHER KETOSIS -

<<>>B. HIGHER SERUM GLUCOSE, HIGHER OSMOLALITY, AND NO KETOSIS

A PATIENT PRESENTS TO THE EMERGENCY DEPARTMENT WITH THE FOLLOWING CLINICAL

SIGNS: PULSE: 132 BEATS/MIN, BLOOD PRESSURE: 88/50 MM HG, RESPIRATORY RATE: 32

BREATHS/MIN, BLOOD SUGAR OF 60, FATIGUE, DIZZINESS AND DARKENING OF SKIN.

THESE SIGNS ARE CONSISTENT WITH WHICH DISORDER?

SELECT ONE:

A. SYNDROME OF INAPPROPRIATE SECRETION OF ANTIDIURETIC HORMONE (SIADH)

B. THYROID STORM

C. MYXEDEMA COMA

D. ADRENAL CRISIS - <<>>B. THYROID STORM

WHICH OF THE FOLLOWING PATIENTS IS AT THE HIGHEST RISK FOR HYPEROSMOLAR

HYPERGLYCEMIC SYNDROME?

SELECT ONE:

A. AN 18-YEAR-OLD COLLEGE STUDENT WITH TYPE 2 DIABETES WHO WAS DIAGNOSED

WITH THE FLU

B. AN 83-YEAR-OLD, LONG-TERM CARE RESIDENT WITH TYPE 1 DIABETES AND NEW ONSET

ALZHEIMER'S DISEASE.

C. A 75-YEAR-OLD MAN WITH TYPE 2 DIABETES AND CORONARY ARTERY DISEASE WHO

HAS RECENTLY STARTED ON INSULIN INJECTIONS

D. A 45-YEAR-OLD WOMAN WITH TYPE 1 DIABETES WHO FORGETS TO TAKE HER INSULIN

IN THE MORNING - <<>>B. AN 83-YEAR-OLD, LONG-TERM CARE RESIDENT

WITH TYPE 1 DIABETES AND NEW ONSET ALZHEIMER'S DISEASE.

THE NURSE ASSESSES A PATIENT WITH A SKULL FRACTURE TO HAVE A GLASGOW COMA

SCALE SCORE OF 3. ADDITIONAL VITAL SIGNS ASSESSED BY THE NURSE INCLUDE BLOOD

PRESSURE 100/70 MM HG, HEART RATE 55 BEATS/MIN, RESPIRATORY RATE 10

BREATHS/MIN, OXYGEN SATURATION (SPO2) 94% ON OXYGEN AT 3 L PER NASAL

CANNULA. WHAT IS THE PRIORITY NURSING ACTION?

SELECT ONE:

A. INCREASE SUPPLEMENTAL OXYGEN DELIVERY.

B. MONITOR THE PATIENT'S AIRWAY PATENCY.

C. ELEVATE THE HEAD OF THE PATIENT'S BED.

D. SUPPORT BONY PROMINENCES WITH PADDING. - <<>>B. MONITOR

THE PATIENT'S AIRWAY PATENCY.

WHICH OF THE FOLLOWING STATEMENTS IS TRUE ABOUT THE MEDICAL MANAGEMENT

OF DIABETIC KETOACIDOSIS?

SELECT ALL THAT APPLY

SELECT ONE OR MORE:

A. SODIUM BICARBONATE IS USED TO CORRECT SEVERE ACIDOSIS.

B. BLOOD GLUCOSE LEVELS ARE USED TO GUIDE INSULIN ADMINISTRATION.

C. THE DEGREE OF ACIDOSIS IS ASSESSED THROUGH CONTINUOUS PULSE OXIMETRY.

AN INDIVIDUAL WITH TYPE 2 DIABETES WHO TAKES GLIPIZIDE HAS BEGUN A FORMAL

EXERCISE PROGRAM AT A LOCAL GYM. WHILE EXERCISING ON THE TREADMILL, THE

INDIVIDUAL BECOMES PALE, DIAPHORETIC, SHAKY, AND HAS A HEADACHE. THE

INDIVIDUAL FEELS AS THOUGH SHE IS GOING TO PASS OUT. WHAT IS THE INDIVIDUAL'S

PRIORITY ACTION?

SELECT ONE:

A. DRINK ADDITIONAL WATER TO PREVENT DEHYDRATION

B. EAT AN APPLE

C. TAKE ANOTHER DOSE OF THE GLIPIZIDE

D. GO TO THE FIRST-AID STATION TO HAVE GLUCOSE CHECKED - <<>>B.

EAT AN APPLE

AN ELDERLY FEMALE PATIENT HAS PRESENTED TO THE EMERGENCY DEPARTMENT WITH

ALTERED MENTAL STATUS, HYPOTHERMIA, AND CLINICAL SIGNS OF HEART FAILURE.

MYXEDEMA IS SUSPECTED. WHICH OF THE FOLLOWING LABORATORY FINDINGS SUPPORT

THIS DIAGNOSIS?

SELECT ONE:

A. ELEVATED THYROID-STIMULATING HORMONE

B. ELEVATED CORTISOL LEVELS

C. ELEVATED T3 AND T

D. ELEVATED ADRENOCORTICOTROPIC HORMONE - <<>>A. ELEVATED

THYROID-STIMULATING HORMONE

THE NURSE IS CARING FOR A PATIENT WHO UNDERWENT PITUITARY SURGERY 12 HOURS

AGO. THE NURSE WILL GIVE PRIORITY TO MONITORING THE PATIENT CAREFULLY FOR

WHICH OF THE FOLLOWING?

SELECT ONE:

A. INFECTION

B. DIABETES INSIPIDUS

C. VOLUME OVERLOAD

D. CONGESTIVE HEART FAILURE - <<>>B. DIABETES INSIPIDUS

WHICH OF THE FOLLOWING INTERVENTIONS IS A STRATEGY TO PREVENT FAT EMBOLISM

SYNDROME?

SELECT ONE:

A. ADMINISTER LIPID-LOWERING STATIN MEDICATIONS.

B. INTUBATE THE PATIENT EARLY AFTER THE INJURY TO PROVIDE MECHANICAL

VENTILATION.

C. PROVIDE PROPHYLAXIS WITH LOW-MOLECULAR WEIGHT HEPARIN.

D. STABILIZE EXTREMITY FRACTURES EARLY. - <<>>D. STABILIZE

EXTREMITY FRACTURES EARLY.

A 36-YEAR-OLD DRIVER WAS PULLED FROM A CAR AFTER IT COLLIDED WITH A TREE AND

THE GAS TANK EXPLODED. WHAT ASSESSMENT DATA SUGGEST THE PATIENT SUFFERED

TISSUE DAMAGE CONSISTENT WITH A BLAST INJURY?

SELECT ONE:

A. BLOOD PRESSURE 82/60 MM HG, HEART RATE 122 BEATS/MIN, RESPIRATORY RATE 28

BREATHS/MIN

B. RESPONSIVE ONLY TO PAINFUL STIMULI

C. IRREGULAR HEART RATE AND RHYTHM

D. CRACKLES (RALES) ON AUSCULTATION OF BILATERAL LUNG FIELDS - <<<ANSWERS

>>>D. CRACKLES (RALES) ON AUSCULTATION OF BILATERAL LUNG FIELDS

WHICH OF THE FOLLOWING STATEMENTS ARE TRUE REGARDING FLUID RESUSCITATION

DURING THE CARE OF A TRAUMA PATIENT?

SELECT ALL THAT APPLY

SELECT ONE OR MORE:

A. ONLY FULLY CROSSMATCHED BLOOD PRODUCTS ARE ADMINISTERED

B. LACTATED RINGER'S IS RECOMMENDED FOR RAPID CRYSTALLOID INFUSION.

C. IV FLUIDS MAY NEED TO BE WARMED TO PREVENT HYPOTHERMIA.

SELECT ONE:

A. LEVEL IV

B. LEVEL II

C. LEVEL III

D. LEVEL 1 - <<>>D. LEVEL 1

WHICH OF THE FOLLOWING INTERVENTIONS WOULD NOT BE APPROPRIATE FOR A

PATIENT WHO IS ADMITTED WITH A SUSPECTED BASILAR SKULL FRACTURE?

SELECT ONE:

A. PLACEMENT OF AN ORAL AIRWAY

B. INSERTION OF A NASOTRACHEAL TUBE

C. INSERTION OF AN INDWELLING URINARY CATHETER

D. ENDOTRACHEAL INTUBATION - <<>>B. INSERTION OF A

NASOTRACHEAL TUBE

THE NURSE IS CARING FOR A PATIENT ADMITTED WITH NEW ONSET OF SLURRED SPEECH,

FACIAL DROOP, AND LEFT-SIDED WEAKNESS 8 HOURS AGO. DIAGNOSTIC COMPUTED

TOMOGRAPHY SCAN RULES OUT THE PRESENCE OF AN INTRACRANIAL BLEED. WHICH

ACTIONS ARE MOST IMPORTANT TO INCLUDE IN THE PATIENT'S PLAN OF CARE?

SELECT ALL THAT APPLY

SELECT ONE OR MORE:

A. MAKE FREQUENT NEUROLOGICAL ASSESSMENTS.

B. MAINTAIN CO2 LEVEL AT 35-45 MM HG.

C. PREPARE FOR THROMBOLYTIC ADMINISTRATION.

D. MAINTAIN MAP GREATER THAN 130 MM HG. - <<>>D. MAINTAIN MAP

GREATER THAN 130 MM HG.

A PATIENT WITH A HEAD INJURY HAS AN INTRACRANIAL PRESSURE (ICP) OF 18 MM HG.

THE BLOOD PRESSURE IS 144/90 MM HG, AND MEAN ARTERIAL PRESSURE (MAP) IS 90

MM HG. WHAT IS THE CEREBRAL PERFUSION PRESSURE (CPP)?

SELECT ONE:

A. 90 MM HG

B. 72 MM HG

C. 126 MM HG

D. 54 MM HG - <<>>A. 90 MM HG

THE NURSE ADMITS A PATIENT TO THE EMERGENCY DEPARTMENT (ED) WITH A

SUSPECTED CERVICAL SPINE INJURY. WHAT IS THE PRIORITY NURSING ACTION?

SELECT ONE:

A. REMOVE CERVICAL COLLAR UPON ARRIVAL TO THE ED.

B. PREPARE FOR IMMEDIATE ENDOTRACHEAL INTUBATION.

C. KEEP THE NECK IN THE HYPEREXTENDED POSITION.

D. MAINTAIN PROPER HEAD AND NECK ALIGNMENT. - <<>>D. MAINTAIN

PROPER HEAD AND NECK ALIGNMENT.

WHILE CARING FOR A PATIENT WITH A TRAUMATIC BRAIN INJURY, THE NURSE ASSESSES

AN ICP OF 20 MM HG AND A CPP OF 55 MM HG. WHAT IS THE BEST INTERPRETATION BY

THE NURSE?

SELECT ONE:

A. ICP IS HIGH; CPP IS LOW.

B. BOTH PRESSURES ARE LOW.

C. BOTH PRESSURES ARE HIGH.

D. ICP IS HIGH; CPP IS NORMAL. - <<>>A. ICP IS HIGH; CPP IS LOW.

THE NURSE IS CARING FOR A PATIENT ADMITTED TO THE EMERGENCY DEPARTMENT IN

STATUS EPILEPTICUS. VITAL SIGNS ASSESSED BY THE NURSE INCLUDE BLOOD PRESSURE

160/100 MM HG, HEART RATE 145 BEATS/MIN, RESPIRATORY RATE 36 BREATHS/MIN,

OXYGEN SATURATION (SPO2) 96% ON 100% SUPPLEMENTAL OXYGEN BY NON-

REBREATHER MASK. AN IV HAS BEEN ESTABLISHED AND THE PATIENT HAS BEEN GIVEN

LORAZEPAM, BUT THE SEIZURES CONTINUE. WHAT IS THE NEXT NURSING PRIORITY?

SELECT ONE:

A. OBTAIN STAT PORTABLE CHEST X-RAY.

THE PHYSICIAN HAS ORDERED NITROGLYCERIN FOR A PATIENT WITH CHEST PAIN AT A

RATE OF 10 MCG/MIN. THE PHARMACY PROVIDES NITROGLYCERIN 25 MG IN 250 ML OF

D5W. THE NURSE WILL SET THE INFUSION PUMP @ A RATE OF _______ ML/HR. -

<<>>0.1ML/HR

DURING THE TREATMENT AND MANAGEMENT OF THE TRAUMA PATIENT, MAINTAINING

TISSUE PERFUSION, OXYGENATION, AND NUTRITIONAL SUPPORT ARE STRATEGIES TO

PREVENT

SELECT ONE:

A. MULTISYSTEM ORGAN DYSFUNCTION.

B. WOUND INFECTION

C. DISSEMINATED INTRAVASCULAR COAGULATION.

D. SEPTIC SHOCK. - <<>>A. MULTISYSTEM ORGAN DYSFUNCTION.

THE NURSE HAS ADMITTED A PATIENT TO THE ED FOLLOWING A FALL FROM A FIRST-

FLOOR HOTEL BALCONY. THE PATIENT SMELLS OF ALCOHOL AND BEGINS TO VOMIT IN

THE ED. WHICH OF THE FOLLOWING INTERVENTIONS IS MOST APPROPRIATE?

SELECT ONE:

A. PREPARE TO SUCTION THE OROPHARYNX WHILE MAINTAINING CERVICAL SPINE

IMMOBILIZATION.

B. SEND A SPECIMEN OF THE EMESIS TO THE LABORATORY FOR ANALYSIS OF BLOOD

ALCOHOL CONTENT.

C. INSERT AN ORAL AIRWAY TO PREVENT ASPIRATION AND TO PROTECT THE AIRWAY.

D. OFFER THE PATIENT AN EMESIS BASIN SO THAT YOU CAN MEASURE THE AMOUNT OF

EMESIS. - <<>>A. PREPARE TO SUCTION THE OROPHARYNX WHILE

MAINTAINING CERVICAL SPINE IMMOBILIZATION.

A 24-YEAR-OLD UNRESTRAINED DRIVER WHO SUSTAINED MULTIPLE TRAUMATIC INJURIES

FROM A MOTOR VEHICLE CRASH HAS A BLOOD PRESSURE OF 80/60 MM HG AT THE

SCENE. THE PRIMARY SURVEY OF THIS PATIENT UPON ARRIVAL TO THE ED

SELECT ONE:

A. INVOLVES TURNING THE PATIENT FROM SIDE TO SIDE TO GET A LOOK AT HIS BACK.

B. INCLUDES A CERVICAL SPINE X-RAY STUDY TO DETERMINE THE PRESENCE OF A

FRACTURE.

C. IS DONE QUICKLY IN THE FIRST FEW MINUTES TO GET A BASELINE ASSESSMENT AND

ESTABLISH PRIORITIES.

D. IS A METHODICAL HEAD-TO-TOE ASSESSMENT IDENTIFYING INJURIES AND TREATMENT

PRIORITIES. - <<>>C. IS DONE QUICKLY IN THE FIRST FEW MINUTES TO

GET A BASELINE ASSESSMENT AND ESTABLISH PRIORITIES.

THE NURSE IS CARING FOR PATIENT WHO HAS BEEN STRUCK BY LIGHTNING. BECAUSE OF

THE NATURE OF THE INJURY, THE NURSE ASSESSES THE PATIENT FOR WHICH OF THE

FOLLOWING?

SELECT ONE:

A. INFECTION

B. CENTRAL NERVOUS SYSTEM DEFICITS

C. CONTRACTURES

D. STRESS ULCERS - <<>>B. CENTRAL NERVOUS SYSTEM DEFICITS

A 63-YEAR-OLD PATIENT IS ADMITTED WITH NEW-ONSET FEVER; FLULIKE SYMPTOMS;

BLISTERS OVER THE ARMS, CHEST, AND NECK; AND RED, PAINFUL ORAL MUCOUS

MEMBRANES. THE PATIENT SHOULD BE FURTHER EVALUATED FOR WHICH POSSIBLE NON-

BURN-INJURED SKIN DISORDER?

SELECT ONE:

A. NECROTIZING SOFT TISSUE INFECTION

B. GRAFT-VERSUS-HOST DISEASE

C. STAPHYLOCOCCAL SCALDED SKIN SYNDROME

D. TOXIC EPIDERMAL NECROLYSIS - <<>>D. TOXIC EPIDERMAL

NECROLYSIS

WHEN PARAMEDICS NOTICE SINGED HAIRS IN THE NOSE OF A BURN PATIENT, IT IS

RECOMMENDED THAT THE PATIENT BE INTUBATED. WHAT IS THE REASONING FOR THE

IMMEDIATE INTUBATION?

SELECT ONE:

A. BLOOD UREA NITROGEN.

B. DAILY WEIGHT

C. HOURLY INTAKE AND URINE OUTPUT

D. SERUM POTASSIUM - <<>>C. HOURLY INTAKE AND URINE OUTPUT

AN AUTOGRAFT IS USED TO OPTIMALLY TREAT A PARTIAL- OR FULL-THICKNESS WOUND

THAT

SELECT ALL THAT APPLY

SELECT ONE OR MORE:

A. IS INFECTED.

B. INVOLVES A JOINT.

C. REQUIRES LESS THAN 2 WEEKS FOR HEALING.

D. INVOLVES THE FACE, HANDS, OR FEET. - <<>>B. INVOLVES A JOINT.

C. REQUIRES LESS THAN 2 WEEKS FOR HEALING.

D. INVOLVES THE FACE, HANDS, OR FEET.

THE NURSE IS CARING FOR A PATIENT WHO HAS CIRCUMFERENTIAL FULL-THICKNESS

BURNS OF HIS FOREARM. A PRIORITY IN THE PLAN OF CARE IS

SELECT ONE:

A. TO KEEP THE EXTREMITY IN A DEPENDENT POSITION.

B. TO PREPARE FOR AN ESCHAROTOMY AS A PROPHYLACTIC MEASURE.

C. ACTIVE OR PASSIVE RANGE-OF-MOTION EXERCISES EVERY HOUR.

D. TO SPLINT THE FOREARM. - <<>>C. ACTIVE OR PASSIVE RANGE-OF-

MOTION EXERCISES EVERY HOUR.

TISSUE DAMAGE FROM BURN INJURY ACTIVATES AN INFLAMMATORY RESPONSE THAT

INCREASES THE PATIENT'S RISK FOR

SELECT ONE:

A. ACUTE RESPIRATORY DISTRESS SYNDROME.

B. ACUTE KIDNEY INJURY.

C. INFECTION

D. STRESS ULCERS - <<>>C. INFECTION

A PATIENT WITH A 60% BURN IN THE ACUTE PHASE OF TREATMENT DEVELOPS A TENSE

ABDOMEN, DECREASING URINE OUTPUT, HYPERCAPNIA, AND HYPOXEMIA. BASED ON

THIS ASSESSMENT, THE NURSE ANTICIPATES INTERVENTIONS TO EVALUATE AND TREAT

THE PATIENT FOR

SELECT ONE:

A. ACUTE KIDNEY INJURY.

B. DISSEMINATED INTRAVASCULAR COAGULATION DISORDER.

C. ACUTE RESPIRATORY DISTRESS SYNDROME.

D. INTRA-ABDOMINAL HYPERTENSION. - <<>>D. INTRA-ABDOMINAL

HYPERTENSION.

THE NURSE IS PLANNING CARE TO MEET THE PATIENT'S PAIN MANAGEMENT NEEDS

RELATED TO BURN TREATMENT. THE PATIENT IS ALERT, ORIENTED, AND FOLLOWS

COMMANDS. THE PAIN IS WORSE DURING THE DAY, WHEN VARIOUS TREATMENTS ARE

SCHEDULED. WHICH STATEMENT TO THE PROVIDER BEST INDICATES THE NURSE'S

KNOWLEDGE OF PAIN MANAGEMENT FOR THIS PATIENT?

SELECT ONE:

A. "THE PATIENT'S PAIN IS OFTEN UNRELIEVED. I SUGGEST THAT WE ALSO ADD

BENZODIAZEPINES TO THE OPIOIDS AROUND THE CLOCK."

B. "THE PATIENT'S PAIN IS OFTEN UNRELIEVED. IT WOULD BE BEST IF WE CAN SCHEDULE

THE OPIOIDS AROUND THE CLOCK."

C. "THE PATIENT'S PAIN VARIES DEPENDING ON THE TREATMENT GIVEN. CAN WE TRY

PATIENT-CONTROLLED ANALGESIA TO SEE IF THAT HELPS THE PATIENT BETTER?"

D. "CAN WE ASK THE MUSIC THERAPIST TO COME BY EACH MORNING TO SEE IF THAT

WILL HELP THE PATIENT'S PAIN?" - <<>>C. "THE PATIENT'S PAIN VARIES

DEPENDING ON THE TREATMENT GIVEN. CAN WE TRY PATIENT-CONTROLLED ANALGESIA

TO SEE IF THAT HELPS THE PATIENT BETTER?"