MDC4 Final Exam Questions with 100%
Correct Answers
The emergency nurse is admitting a client experiencing a GI bleed who is believed to be
in the compensatory stage of shock. What assessment finding would be most consistent
with the early stage of compensation?
Cool, clammy skin
A client who is in shock is receiving dopamine in addition to IV fluids. What principle
should inform the nurse's care planning during the administration of a vasoactive
drug?
The drug dose should be tapered down once vital signs improve.
The nurse is caring for a client in intensive care unit whose condition is deteriorating.
The nurse receives orders to initiate an infusion of dopamine. Which assessments and
interventions should the nurse prioritize?
Frequent monitoring of vital signs, monitoring the central line site, and providing accurate
drug titration
The nurse is caring for a client admitted with cardiogenic shock. The client is
experiencing chest pain and there is an order for the administration of morphine. In
addition to pain control, what is the main rationale for administering morphine to this
client? SATA
It promotes coping and slows catecholamine release.
It dilates the blood vessels.
An 11-year-old client has been brought to the emergency department by their parent,
who reports that the client may be having a "really bad allergic reaction to peanuts"
,after trading lunches with a peer. The triage nurse's rapid assessment reveals the
presence of respiratory and cardiac arrest. Which interventions should the nurse
prioritize?
Establishing a patent airway and beginning cardiopulmonary resuscitation (CPR)
A client is responding poorly to interventions aimed at treating shock and appears to be
transitioning to the irreversible stage of shock. What action should the intensive care
nurse include during this phase of the client's care?
Communicate clearly and frequently with the client's family.
The nurse is caring for a boy who has muscular dystrophy. When planning assistance
with the client's ADLs, what goal should the nurse prioritize?
Maximizing the client's level of function
A client is being treated in the ICU for neurogenic shock secondary to a spinal cord
injury. Despite aggressive interventions, the client's mean arterial pressure (MAP) has
fallen to 55 mm Hg. The nurse should assess for the onset of acute kidney injury by
referring to what laboratory findings? Select all that apply.
Blood urea nitrogen (BUN) level
Urine specific gravity
Creatinine level
An immunocompromised 65-year-old client has developed a urinary tract infection, and
the care team recognizes the need to prevent an exacerbation of the client's infection
that could result in urosepsis and septic shock. Which action should the nurse perform
to reduce the client's risk of septic shock?
Remove invasive devices as soon as they are no longer needed.
, A nurse is caring for a client in shock. The nurse understands the client's Sympathetic
nervous system (SNS) is still correctly attempting to compensate when the following is
assessed? (SATA)
The client has decreased peripheral pulses
The client has an increasing thirst
The client has a decreased heart rate
The paramedics bring a client who has suffered a sexual assault to the ED. What is
important for the sexual assault nurse examiner to do when assessing a sexual assault
victim?
Respect the client's privacy during assessment
A client is brought to the emergency room (ER) in an unconscious state and emergency
surgery is needed. No family members are present, and the client does not have
identification. What action by the nurse is the priority regarding consent for treatment?
Clearly document level of consciousness (LOC) and health status on the client's
A client is brought by friends to the ED after being involved in a motor vehicle accident.
The client sustained blunt trauma to the abdomen. What nursing action would be most
appropriate for this client?
Immobilize the client on a backboard
A client with a fractured femur presenting to the ED exhibits cool, moist skin, increased
heart rate, and falling BP. The care team should consider the possibility of what
complication of the client's injuries?
Hemorrhage
Correct Answers
The emergency nurse is admitting a client experiencing a GI bleed who is believed to be
in the compensatory stage of shock. What assessment finding would be most consistent
with the early stage of compensation?
Cool, clammy skin
A client who is in shock is receiving dopamine in addition to IV fluids. What principle
should inform the nurse's care planning during the administration of a vasoactive
drug?
The drug dose should be tapered down once vital signs improve.
The nurse is caring for a client in intensive care unit whose condition is deteriorating.
The nurse receives orders to initiate an infusion of dopamine. Which assessments and
interventions should the nurse prioritize?
Frequent monitoring of vital signs, monitoring the central line site, and providing accurate
drug titration
The nurse is caring for a client admitted with cardiogenic shock. The client is
experiencing chest pain and there is an order for the administration of morphine. In
addition to pain control, what is the main rationale for administering morphine to this
client? SATA
It promotes coping and slows catecholamine release.
It dilates the blood vessels.
An 11-year-old client has been brought to the emergency department by their parent,
who reports that the client may be having a "really bad allergic reaction to peanuts"
,after trading lunches with a peer. The triage nurse's rapid assessment reveals the
presence of respiratory and cardiac arrest. Which interventions should the nurse
prioritize?
Establishing a patent airway and beginning cardiopulmonary resuscitation (CPR)
A client is responding poorly to interventions aimed at treating shock and appears to be
transitioning to the irreversible stage of shock. What action should the intensive care
nurse include during this phase of the client's care?
Communicate clearly and frequently with the client's family.
The nurse is caring for a boy who has muscular dystrophy. When planning assistance
with the client's ADLs, what goal should the nurse prioritize?
Maximizing the client's level of function
A client is being treated in the ICU for neurogenic shock secondary to a spinal cord
injury. Despite aggressive interventions, the client's mean arterial pressure (MAP) has
fallen to 55 mm Hg. The nurse should assess for the onset of acute kidney injury by
referring to what laboratory findings? Select all that apply.
Blood urea nitrogen (BUN) level
Urine specific gravity
Creatinine level
An immunocompromised 65-year-old client has developed a urinary tract infection, and
the care team recognizes the need to prevent an exacerbation of the client's infection
that could result in urosepsis and septic shock. Which action should the nurse perform
to reduce the client's risk of septic shock?
Remove invasive devices as soon as they are no longer needed.
, A nurse is caring for a client in shock. The nurse understands the client's Sympathetic
nervous system (SNS) is still correctly attempting to compensate when the following is
assessed? (SATA)
The client has decreased peripheral pulses
The client has an increasing thirst
The client has a decreased heart rate
The paramedics bring a client who has suffered a sexual assault to the ED. What is
important for the sexual assault nurse examiner to do when assessing a sexual assault
victim?
Respect the client's privacy during assessment
A client is brought to the emergency room (ER) in an unconscious state and emergency
surgery is needed. No family members are present, and the client does not have
identification. What action by the nurse is the priority regarding consent for treatment?
Clearly document level of consciousness (LOC) and health status on the client's
A client is brought by friends to the ED after being involved in a motor vehicle accident.
The client sustained blunt trauma to the abdomen. What nursing action would be most
appropriate for this client?
Immobilize the client on a backboard
A client with a fractured femur presenting to the ED exhibits cool, moist skin, increased
heart rate, and falling BP. The care team should consider the possibility of what
complication of the client's injuries?
Hemorrhage
