MDC4 Final Exam | Multidimensional Care IV | Nursing Exam Study Guide
The emergency nurse is admitting a client experiencing a Cool, clammy skin
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?
A client who is in shock is receiving dopamine in addition The drug dose should be tapered down once vital signs improve.
to IV fluids. What principle should inform the nurse's care
planning during the administration of a vasoactive drug?
The nurse is caring for a client in intensive care unit Frequent monitoring of vital signs, monitoring the central line site, and providing
whose condition is deteriorating. The nurse receives accurate drug titration
orders to initiate an infusion of dopamine. Which
assessments and interventions should the nurse
prioritize?
The nurse is caring for a client admitted with cardiogenic It promotes coping and slows catecholamine release.
shock. The client is experiencing chest pain and there is It dilates the blood vessels.
an order for the administration of morphine. In addition to
pain control, what is the main rationale for administering
morphine to this client? SATA
An 11-year-old client has been brought to the emergency Establishing a patent airway and beginning cardiopulmonary resuscitation (CPR)
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?
A client is responding poorly to interventions aimed at Communicate clearly and frequently with the client's family.
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?
The nurse is caring for a boy who has muscular Maximizing the client's level of function
dystrophy. When planning assistance with the client's
ADLs, what goal should the nurse prioritize?
A client is being treated in the ICU for neurogenic shock Blood urea nitrogen (BUN) level
secondary to a spinal cord injury. Despite aggressive Urine specific gravity
interventions, the client's mean arterial pressure (MAP) Creatinine level
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.
An immunocompromised 65-year-old client has Remove invasive devices as soon as they are no longer needed.
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?
A nurse is caring for a client in shock. The nurse The client has decreased peripheral pulses
understands the client's Sympathetic nervous system The client has an increasing thirst
(SNS) is still correctly attempting to compensate when The client has a decreased heart rate
the following is assessed? (SATA)
The paramedics bring a client who has suffered a sexual Respect the client's privacy during assessment
assault to the ED. What is important for the sexual
assault nurse examiner to do when assessing a sexual
assault victim?
A client is brought to the emergency room (ER) in an Clearly document level of consciousness (LOC) and health status on the client's
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?
, MDC4 Final Exam | Multidimensional Care IV | Nursing Exam Study Guide
A client is brought by friends to the ED after being Immobilize the client on a backboard
involved in a motor vehicle accident. The client sustained
blunt trauma to the abdomen. What nursing action would
be most appropriate for this client?
A client with a fractured femur presenting to the ED Hemorrhage
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?
A homeless person is admitted the ED during a blizzard, Addressing the client's hypothermia
and is unable to feel the feet and lower legs. Core
temperature is noted at 33.2°C (91.8°F). The client is
intoxicated with alcohol at the time of admission and is
visibly malnourished. What is the triage nurse's priority in
the care of this client?
The ED nurse is planning the care of a client who has Encouraging the client to gain a sense of control over his or her life
been admitted following a sexual assault. The nurse
knows that all of the nursing interventions are aimed at
what goal?
A workplace explosion has left a 40-year-old client with Black
full thickness burns over 75% of the body. Despite these
injuries, the client is conscious. How would this person
be triaged?
A client who has been exposed to anthrax is being Assessment of respiratory status
treated in the local hospital. The nurse should prioritize
what health assessments?
A nurse takes a shift report and will be caring for a client Standard precautions
who has been exposed to anthrax by inhalation. What
precautions does the nurse know must be put in place
when providing care for this client?
A client has been brought to the ED after suffering Await orders following the urologist's assessment.
genitourinary trauma in an assault. Initial assessment
reveals that the client's bladder is distended. What is the
nurse's most appropriate action?
After radiation exposure, a client has been assessed and A latent phase
determined to be a possible survivor. Following the
resolution of the client's initial symptoms, should the care
team anticipate what event?
A nurse who is a member of the local disaster response Victims are thrown by the pressure wave.
team is learning about blast injuries. The nurse should
plan for what event that occurs in the tertiary phase of
the blast injury?
A client is admitted to the ED with an apparent overdose Administer naloxone hydrochloride (Narcan).
of IV heroin. After stabilizing the client's cardiopulmonary
status, should the nurse prepare to perform what
intervention?
The nurse is preparing health education for a patient "Take antihypertensive medication as ordered."
being discharged after a hemorrhagic stroke. Which
statement is appropriate to include?
A patient with a traumatic brain injury is prescribed anti- Triggers, side effects, adherence, and serum drug levels
seizure medications. What should the nurse monitor for?
A patient with TBI is at risk for developing diabetes Monitor urine output and specific gravity
insipidus. What is the nurse's priority intervention?
The emergency nurse is admitting a client experiencing a Cool, clammy skin
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?
A client who is in shock is receiving dopamine in addition The drug dose should be tapered down once vital signs improve.
to IV fluids. What principle should inform the nurse's care
planning during the administration of a vasoactive drug?
The nurse is caring for a client in intensive care unit Frequent monitoring of vital signs, monitoring the central line site, and providing
whose condition is deteriorating. The nurse receives accurate drug titration
orders to initiate an infusion of dopamine. Which
assessments and interventions should the nurse
prioritize?
The nurse is caring for a client admitted with cardiogenic It promotes coping and slows catecholamine release.
shock. The client is experiencing chest pain and there is It dilates the blood vessels.
an order for the administration of morphine. In addition to
pain control, what is the main rationale for administering
morphine to this client? SATA
An 11-year-old client has been brought to the emergency Establishing a patent airway and beginning cardiopulmonary resuscitation (CPR)
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?
A client is responding poorly to interventions aimed at Communicate clearly and frequently with the client's family.
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?
The nurse is caring for a boy who has muscular Maximizing the client's level of function
dystrophy. When planning assistance with the client's
ADLs, what goal should the nurse prioritize?
A client is being treated in the ICU for neurogenic shock Blood urea nitrogen (BUN) level
secondary to a spinal cord injury. Despite aggressive Urine specific gravity
interventions, the client's mean arterial pressure (MAP) Creatinine level
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.
An immunocompromised 65-year-old client has Remove invasive devices as soon as they are no longer needed.
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?
A nurse is caring for a client in shock. The nurse The client has decreased peripheral pulses
understands the client's Sympathetic nervous system The client has an increasing thirst
(SNS) is still correctly attempting to compensate when The client has a decreased heart rate
the following is assessed? (SATA)
The paramedics bring a client who has suffered a sexual Respect the client's privacy during assessment
assault to the ED. What is important for the sexual
assault nurse examiner to do when assessing a sexual
assault victim?
A client is brought to the emergency room (ER) in an Clearly document level of consciousness (LOC) and health status on the client's
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?
, MDC4 Final Exam | Multidimensional Care IV | Nursing Exam Study Guide
A client is brought by friends to the ED after being Immobilize the client on a backboard
involved in a motor vehicle accident. The client sustained
blunt trauma to the abdomen. What nursing action would
be most appropriate for this client?
A client with a fractured femur presenting to the ED Hemorrhage
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?
A homeless person is admitted the ED during a blizzard, Addressing the client's hypothermia
and is unable to feel the feet and lower legs. Core
temperature is noted at 33.2°C (91.8°F). The client is
intoxicated with alcohol at the time of admission and is
visibly malnourished. What is the triage nurse's priority in
the care of this client?
The ED nurse is planning the care of a client who has Encouraging the client to gain a sense of control over his or her life
been admitted following a sexual assault. The nurse
knows that all of the nursing interventions are aimed at
what goal?
A workplace explosion has left a 40-year-old client with Black
full thickness burns over 75% of the body. Despite these
injuries, the client is conscious. How would this person
be triaged?
A client who has been exposed to anthrax is being Assessment of respiratory status
treated in the local hospital. The nurse should prioritize
what health assessments?
A nurse takes a shift report and will be caring for a client Standard precautions
who has been exposed to anthrax by inhalation. What
precautions does the nurse know must be put in place
when providing care for this client?
A client has been brought to the ED after suffering Await orders following the urologist's assessment.
genitourinary trauma in an assault. Initial assessment
reveals that the client's bladder is distended. What is the
nurse's most appropriate action?
After radiation exposure, a client has been assessed and A latent phase
determined to be a possible survivor. Following the
resolution of the client's initial symptoms, should the care
team anticipate what event?
A nurse who is a member of the local disaster response Victims are thrown by the pressure wave.
team is learning about blast injuries. The nurse should
plan for what event that occurs in the tertiary phase of
the blast injury?
A client is admitted to the ED with an apparent overdose Administer naloxone hydrochloride (Narcan).
of IV heroin. After stabilizing the client's cardiopulmonary
status, should the nurse prepare to perform what
intervention?
The nurse is preparing health education for a patient "Take antihypertensive medication as ordered."
being discharged after a hemorrhagic stroke. Which
statement is appropriate to include?
A patient with a traumatic brain injury is prescribed anti- Triggers, side effects, adherence, and serum drug levels
seizure medications. What should the nurse monitor for?
A patient with TBI is at risk for developing diabetes Monitor urine output and specific gravity
insipidus. What is the nurse's priority intervention?
