MDC IV Exam 2 Nur 2775 –
Questions with Answers
B. Evaluate airway and circulation. - -The nurse is caring for a patient who is
admitted to the ED with burns to the lower legs and hands. During the initial
management, what is the priority nursing care?
A. Assess and treat pain.
B. Evaluate airway and circulation.
C. Place two IV catheters and initiate fluid resuscitation.
D. Use the rule of nines to estimate percent of body surface area burned.
-B. Notify the physician immediately. - -It has been 12 hours since a patient
has been admitted for burns to the face and neck with associated inhalation
injuries. The patient had been wheezing audibly and the wheezing has now
stopped. What nursing action is appropriate?
A. Check the patient's Spo2 level.
B. Notify the physician immediately.
C. Re-assess breathing in 1 hour.
D. Document improvement in patient's condition.
-D. Possible allergic reaction to silver sulfadiazine (Silvadene) - -A patient
has been receiving dressing changes with silver sulfadiazine (Silvadene) for
burn injuries over both lower arms. The nurse notices that the patient's white
blood cell count has dropped significantly over the past 4 days. How does the
nurse interpret this finding?
A. Electrolyte imbalance
B. Infection is improving
C. Impending kidney disease
D. Possible allergic reaction to silver sulfadiazine (Silvadene)
-A. 24-year-old male admitted with blunt chest trauma and aspiration - -
Which patient is at greatest risk of developing acute respiratory distress
syndrome (ARDS)?
A. 24-year-old male admitted with blunt chest trauma and aspiration
B. 56-year-old male with a history of alcohol abuse and chronic pancreatitis
C. 72-year-old male post heart valve surgery receiving 1 unit of packed red
blood cells
D. 82-year-old female on antibiotics for pneumonia
, -B. "I should eat more green leafy vegetables like spinach." - -A patient is
being discharged to home on warfarin (Coumadin) therapy to manage an
acute pulmonary embolism. Which patient response indicates a need for
further teaching by the nurse?
A. "I should limit my alcohol consumption."
B. "I should eat more green leafy vegetables like spinach."
C. "I should take the medication at the same time every day."
D. "I should make a doctor's appointment for weekly blood draws."
-D. Opioid analgesic overdose - -A patient in acute respiratory failure is
classified as having ventilatory failure. The nurse understands that which
finding is a potential cause of ventilatory failure?
A. Pulmonary edema
B. Hypovolemic shock
C. Pulmonary embolus
D. Opioid analgesic overdose
-B. Initiate intravenous fluid resuscitation. - -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 - -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 - -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
Questions with Answers
B. Evaluate airway and circulation. - -The nurse is caring for a patient who is
admitted to the ED with burns to the lower legs and hands. During the initial
management, what is the priority nursing care?
A. Assess and treat pain.
B. Evaluate airway and circulation.
C. Place two IV catheters and initiate fluid resuscitation.
D. Use the rule of nines to estimate percent of body surface area burned.
-B. Notify the physician immediately. - -It has been 12 hours since a patient
has been admitted for burns to the face and neck with associated inhalation
injuries. The patient had been wheezing audibly and the wheezing has now
stopped. What nursing action is appropriate?
A. Check the patient's Spo2 level.
B. Notify the physician immediately.
C. Re-assess breathing in 1 hour.
D. Document improvement in patient's condition.
-D. Possible allergic reaction to silver sulfadiazine (Silvadene) - -A patient
has been receiving dressing changes with silver sulfadiazine (Silvadene) for
burn injuries over both lower arms. The nurse notices that the patient's white
blood cell count has dropped significantly over the past 4 days. How does the
nurse interpret this finding?
A. Electrolyte imbalance
B. Infection is improving
C. Impending kidney disease
D. Possible allergic reaction to silver sulfadiazine (Silvadene)
-A. 24-year-old male admitted with blunt chest trauma and aspiration - -
Which patient is at greatest risk of developing acute respiratory distress
syndrome (ARDS)?
A. 24-year-old male admitted with blunt chest trauma and aspiration
B. 56-year-old male with a history of alcohol abuse and chronic pancreatitis
C. 72-year-old male post heart valve surgery receiving 1 unit of packed red
blood cells
D. 82-year-old female on antibiotics for pneumonia
, -B. "I should eat more green leafy vegetables like spinach." - -A patient is
being discharged to home on warfarin (Coumadin) therapy to manage an
acute pulmonary embolism. Which patient response indicates a need for
further teaching by the nurse?
A. "I should limit my alcohol consumption."
B. "I should eat more green leafy vegetables like spinach."
C. "I should take the medication at the same time every day."
D. "I should make a doctor's appointment for weekly blood draws."
-D. Opioid analgesic overdose - -A patient in acute respiratory failure is
classified as having ventilatory failure. The nurse understands that which
finding is a potential cause of ventilatory failure?
A. Pulmonary edema
B. Hypovolemic shock
C. Pulmonary embolus
D. Opioid analgesic overdose
-B. Initiate intravenous fluid resuscitation. - -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 - -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 - -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
