MDC IV EXAM 2 COMPREHENSIVE QUESTIONS
AND SOLUTIONS
◉ B. Initiate intravenous fluid resuscitation.
Answer: A 37-year-old male is admitted with a severely abscessed
tooth, BP 90/42, HR 136, RR 28, Spo2 90% on room air, temperature
38.7º C. The nurse suspects that the patient has developed sepsis.
What is the priority nursing intervention?
A. Insert an indwelling urinary catheter.
B. Initiate intravenous fluid resuscitation.
C. Obtain a complete chemistry for laboratory analysis.
D. Administer prescribed antibiotics prior to blood cultures.
◉ B. Increased heart rate
Answer: When assessing a patient for shock, the nurse knows that
which symptom is the earliest manifestation of shock?
A. Anuria
B. Increased heart rate
C. A decrease in respiratory rate and depth
D. A change in both systolic and diastolic blood pressure
,◉ D. Bleeding, oozing from IV sites
Answer: Which clinical manifestations does the nurse recognize that
indicates worsening in the condition of a patient in the refractory
phase of shock?
A. Warm, flushed skin
B. Urine output of 20 mL/hr
C. Increasing respiratory rate
D. Bleeding, oozing from IV sites
◉ *Diminished breath sounds*
▪ also asymmetry
paradoxical chest movement = flail chest (when pt inhales the good
side goes out and the bad side goes in, like a see saw)*
fever = sepsis
decrease urinary output = a good measure of perfusion/kidneys
(ideally 30 mL/hr; formula = 0.5/kg/hr)
Answer: Clinical manifestation of a Pneumothorax include
, Fever
Paradoxical chest movement
Diminished breath sounds
Decrease urinary output
◉ ET tube...patient needs to be intubated
Answer: Treatment for flail chest
◉ pain! teach them to splint when coughing and use pain meds
rib fractures can lead to hypovolemic shock!
Answer: Uncomplicated rib fracture - most common symptom
◉ Tension Pneumothorax
- first thing you do is a needle thoracotomy (aka needle
decompression) then chest tube
Answer: Tracheal deviation is a clinical manifestation of:
Rib fracture
Tension Pneumothorax
ARDS
AND SOLUTIONS
◉ B. Initiate intravenous fluid resuscitation.
Answer: A 37-year-old male is admitted with a severely abscessed
tooth, BP 90/42, HR 136, RR 28, Spo2 90% on room air, temperature
38.7º C. The nurse suspects that the patient has developed sepsis.
What is the priority nursing intervention?
A. Insert an indwelling urinary catheter.
B. Initiate intravenous fluid resuscitation.
C. Obtain a complete chemistry for laboratory analysis.
D. Administer prescribed antibiotics prior to blood cultures.
◉ B. Increased heart rate
Answer: When assessing a patient for shock, the nurse knows that
which symptom is the earliest manifestation of shock?
A. Anuria
B. Increased heart rate
C. A decrease in respiratory rate and depth
D. A change in both systolic and diastolic blood pressure
,◉ D. Bleeding, oozing from IV sites
Answer: Which clinical manifestations does the nurse recognize that
indicates worsening in the condition of a patient in the refractory
phase of shock?
A. Warm, flushed skin
B. Urine output of 20 mL/hr
C. Increasing respiratory rate
D. Bleeding, oozing from IV sites
◉ *Diminished breath sounds*
▪ also asymmetry
paradoxical chest movement = flail chest (when pt inhales the good
side goes out and the bad side goes in, like a see saw)*
fever = sepsis
decrease urinary output = a good measure of perfusion/kidneys
(ideally 30 mL/hr; formula = 0.5/kg/hr)
Answer: Clinical manifestation of a Pneumothorax include
, Fever
Paradoxical chest movement
Diminished breath sounds
Decrease urinary output
◉ ET tube...patient needs to be intubated
Answer: Treatment for flail chest
◉ pain! teach them to splint when coughing and use pain meds
rib fractures can lead to hypovolemic shock!
Answer: Uncomplicated rib fracture - most common symptom
◉ Tension Pneumothorax
- first thing you do is a needle thoracotomy (aka needle
decompression) then chest tube
Answer: Tracheal deviation is a clinical manifestation of:
Rib fracture
Tension Pneumothorax
ARDS
