a - IS the selected answer: The nurse is providing postprocedure care to a client who had a
cardiac catheterization. The client begins to manifest signs and symptoms associated with
embolization. Whichaction should the nurse take?
a. Notify the primary healthcare provider immediately
b. Apply a warm, moist compress to the incision site
c. Increase the intravenous fluid rate by 20 mL/hr
d. Monitor vital signs more frequently
b - IS the selected answer: A nurse observes a window washer falling 25 feet (7.6 m) to the
ground. The nurse rushes to the scene and determines that the person is in cardiopulmonary
arrest. What should thenurse do first?
a. Feel for a pulse
b. Begin chest compressions
c. Leave to call for assistance
d. Perform the abdominal thrust maneuver
d - IS the selected answer: A client reports left-sided chest pain after playing racquetball. The
client ishospitalized and diagnosed with left pneumothorax. When assessing the client's left
chest area, the nurse expects to identify which finding?
,a. Dull sound on percussion
b. Vocal fremitus on palpation
c. Rales with rhonchi on auscultation
d. Absence of breath sounds on auscultation
c - IS the selected answer: A client is admitted to the hospital with partial- and full-thickness
burns of thechest and face sustained while trying to extinguish a brush fire. Which is the nurse's
priority concern?
a. Loss of skin integrity caused by the burns
b. Potential infection as a result of the burn injury
c. Inadequate gas exchange caused by smoke inhalation
d. Decreased fluid volume because of the depth of the burns
b - IS the selected answer: During the first 48 hours after a client has sustained a thermal injury,
whichconditions should the nurse assess for?
a. Hypokalemia and hyponatremia
b. Hyperkalemia and hyponatremia
c. Hypokalemia and hypernatremia
,d. Hyperkalemia and hypernatremia
a - IS the selected answer: A nurse is assessing a client's ECG reading. The client's atrial and
ventricularheart rates are equal at 88 beats per min. The PR interval is 0.14 seconds, and the
QRS width is 0.10 seconds. Rhythm is regular with normal P waves and QRS complexes. How
will the nurse interpret thisrhythm?
a. Normal sinus rhythm
b. Sinus tachycardia
c. Sinus bradycardia
d. Sinus arrhythmia
b - IS the selected answer: The nurse is caring for a client with a diagnosis of necrotizing
fasciitis. Whichis the priority concern of the nurse when caring for this client?
a. Fluid volume
b. Skin integrity
c. Physical mobility
d. Urinary elimination
c - IS the selected answer: A client who had extensive pelvic surgery 24 hours ago becomes
cyanotic, isgasping for breath, and reports right-sided chest pain. What should the nurse do
first?
a. Obtain vital signs
, b. Initiate a cardiac arrest code
c. Administer oxygen using a face mask
d. Encourage the use of an incentive spirometer
c - IS the selected answer: A nurse is caring for a client with severe burns. The nurse determines
that thisclient is at risk for hypovolemic shock. Which physiologic finding supports the nurse's
conclusion?
a. Decreased rate of glomerular filtration
b. Excessive blood loss through the burned tissues
c. Plasma proteins moving out of the intravascular compartment
d. Sodium retention occurring as a result of the aldosterone mechanism
a - IS the selected answer: The nurse is caring for a client with burns and reviews the client's
laboratory results: blood urea nitrogen (BUN), 30 mg/dL (10.2 mmol/L); creatinine, 2.4 mg/dL
(184 mcmol/L); serum potassium, 6.3 mEq/L (6.3 mmol/L); pH, 7.1; Po 2, 90 mm Hg; and
hemoglobin (Hgb), 7.4 g/dL (74mmol/L). Which condition does the nurse suspect the client has
based upon these findings?
a. Azotemia
b. Hypokalemia
c. Metabolic alkalosis
d. Respiratory alkalosis
cardiac catheterization. The client begins to manifest signs and symptoms associated with
embolization. Whichaction should the nurse take?
a. Notify the primary healthcare provider immediately
b. Apply a warm, moist compress to the incision site
c. Increase the intravenous fluid rate by 20 mL/hr
d. Monitor vital signs more frequently
b - IS the selected answer: A nurse observes a window washer falling 25 feet (7.6 m) to the
ground. The nurse rushes to the scene and determines that the person is in cardiopulmonary
arrest. What should thenurse do first?
a. Feel for a pulse
b. Begin chest compressions
c. Leave to call for assistance
d. Perform the abdominal thrust maneuver
d - IS the selected answer: A client reports left-sided chest pain after playing racquetball. The
client ishospitalized and diagnosed with left pneumothorax. When assessing the client's left
chest area, the nurse expects to identify which finding?
,a. Dull sound on percussion
b. Vocal fremitus on palpation
c. Rales with rhonchi on auscultation
d. Absence of breath sounds on auscultation
c - IS the selected answer: A client is admitted to the hospital with partial- and full-thickness
burns of thechest and face sustained while trying to extinguish a brush fire. Which is the nurse's
priority concern?
a. Loss of skin integrity caused by the burns
b. Potential infection as a result of the burn injury
c. Inadequate gas exchange caused by smoke inhalation
d. Decreased fluid volume because of the depth of the burns
b - IS the selected answer: During the first 48 hours after a client has sustained a thermal injury,
whichconditions should the nurse assess for?
a. Hypokalemia and hyponatremia
b. Hyperkalemia and hyponatremia
c. Hypokalemia and hypernatremia
,d. Hyperkalemia and hypernatremia
a - IS the selected answer: A nurse is assessing a client's ECG reading. The client's atrial and
ventricularheart rates are equal at 88 beats per min. The PR interval is 0.14 seconds, and the
QRS width is 0.10 seconds. Rhythm is regular with normal P waves and QRS complexes. How
will the nurse interpret thisrhythm?
a. Normal sinus rhythm
b. Sinus tachycardia
c. Sinus bradycardia
d. Sinus arrhythmia
b - IS the selected answer: The nurse is caring for a client with a diagnosis of necrotizing
fasciitis. Whichis the priority concern of the nurse when caring for this client?
a. Fluid volume
b. Skin integrity
c. Physical mobility
d. Urinary elimination
c - IS the selected answer: A client who had extensive pelvic surgery 24 hours ago becomes
cyanotic, isgasping for breath, and reports right-sided chest pain. What should the nurse do
first?
a. Obtain vital signs
, b. Initiate a cardiac arrest code
c. Administer oxygen using a face mask
d. Encourage the use of an incentive spirometer
c - IS the selected answer: A nurse is caring for a client with severe burns. The nurse determines
that thisclient is at risk for hypovolemic shock. Which physiologic finding supports the nurse's
conclusion?
a. Decreased rate of glomerular filtration
b. Excessive blood loss through the burned tissues
c. Plasma proteins moving out of the intravascular compartment
d. Sodium retention occurring as a result of the aldosterone mechanism
a - IS the selected answer: The nurse is caring for a client with burns and reviews the client's
laboratory results: blood urea nitrogen (BUN), 30 mg/dL (10.2 mmol/L); creatinine, 2.4 mg/dL
(184 mcmol/L); serum potassium, 6.3 mEq/L (6.3 mmol/L); pH, 7.1; Po 2, 90 mm Hg; and
hemoglobin (Hgb), 7.4 g/dL (74mmol/L). Which condition does the nurse suspect the client has
based upon these findings?
a. Azotemia
b. Hypokalemia
c. Metabolic alkalosis
d. Respiratory alkalosis
