1. The rule of nines helps to determine:
1. Depth of burn injury.
2. Infection in the patient.
3. Number of organs involved.
4. Total body surface area burned.
2. On a patient's arterial blood gas (ABG) the nurse notes a decrease in the
carbon dioxide level. What is most likely causing this to occur?
1. Hyperventilation
2. Loss of fluid volume
3. Apnea
4. Hypoventilation
3. A patient experiencing hypercapnia can lead to which of the
following complications?
1. Decreased carbonic acid in the blood
2. Decreased respirations and heart rate
3. Respiratory acidosis
4. A rise in the serum pH
4. Your patient is a 10-year-old girl with a diagnosis of pneumonia. On arrival to
the room the child is stating that it is difficult to breathe, she states “I feel like I
can't get any air.” You note subcostal and intercostal retractions on your exam.
You document that she is experiencing:
1. Orthostatic hypertension
2. Orthopnea
3. Tachycardia
Dyspnea
4.
5. A patient has a traumatic injury to the chest wall and lungs following a fall.
The patient is now experiencing respiratory failure. What would the nurse
expect to see in the labs?
1. Elevated sodium levels on the comprehensive metabolic panel
2. Increased hematocrit on the CBC
3. Elevated PaCO2 on the ABG
4. Elevated blood glucose levels
6. A 50-year-old male presents to the ED with hypoxemia, hypotension and
tracheal deviation to the left. The pulmonologist upon examination and review of
tests reports that the air pressure in the pleural cavity exceeds barometric
pressure in the atmosphere. What does the nurse suspect the patient is
experiencing?
1. Open pneumothorax
2. Trauma to the chest wall
3. Right side pleural effusion
4. Tension pneumothorax
7. A nurse is caring for a client who has emphysema. Which of the following
findings should the nurse expect to assess in this client? (Select all that
apply)
1. Dyspnea
2. Anemia
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