NSG 460 6TH PRACTICE EXAM QUESTIONS AND ANSWERS ALREADY GRADED A+
The physician has ordered a solumedrol infusion for a pt with a spinal cord injury. Solumedrol has been
shown to be effective in:
A. decreasing cerebral edema
B. preventing stress ulcers
C. decreasing spinal injury spasticity
D. improving motor and sensory functioning - answer-D. improving motor and sensory functioning
Solumedrol is given within the first 8 hours of injury
A pt with a T6 injury 3 months ago develops facial flushing and a BP of 210/106. After elevating the HOB,
which is the most appropriate nursing action?
A. increase IV fluids
B. assess for a distended bladder
C. apply oxygen at 4L/min
D. notify the physician - answer-B. assess for a distended bladder
When the pt is in neurogenic shock, the nurse will assess for:
A. mental confusion and tachycardia
B. bradycardia and hypotension
C. unilateral pupil dilation and hypotension
D. hypertension and tachypnea - answer-B. bradycardia and hypotension
Which of the following is descriptive of a concussion?
A. venous blood collects in the subdural space
B. petechial hemorrhages cause intermittent amnesia
C. a lesion develops opposite the site of trauma
D. it is a transient neuronal dysfunction - answer-D. it is a transient neuronal dysfunction
,Autonomic dysreflexia is an emergency because:
A. severe vasoconstriction occurs
B. hypoxia results from regurgitation
C. spasticity produces joint deformity
D. airway spasm occurs - answer-A. severe vasoconstriction occurs
Your client is transported to the ED after sustaining head, back and chest injuries when he fell 25 ft from
a tree. The primary survey has been completed. His BP drops to 80/40, HR is 56, RR is 20. BBS are equal
and clear. SaO2 is 99%. This data is most consistent with:
A. neurogenic shock
B. tension pneumothorax
C. hypovolemic shock
D. closed head injury - answer-A. neurogenic shock
A client who sustained a spinal cord injury at the T2 level should be assessed for signs of autonomic
dysrefelxia because:
A. the injury results in loss of the reflex arc
B. there has been a partial transaction of the cord
C. there is a flaccid paralysis of the lower extremities
D. the injury is above the 6th thoracic vertebrae - answer-D. the injury is above he 6th thoracic
vertebrae
A client is admitted to the hospital 24 hrs ago after sustaining blunt trauma. For which early clinical
manifestation of acute respiratory distress syndrome (ARDS) should the nurse monitor for?
A. crackles throughout lung fields
B. increase in respiratory rate from 18 to 24 breaths/min
C. "white-out" appearance of lungs on chest radiograph
D. cyanosis and pallor - answer-B. increase in respiratory rate from 18 to 24 breaths/min
The nurse is caring for a client who required tube insertion for a pneumothorax. The nurse is aware that
the best test to assess for pneumothorax resolution is:
,A. ABG
B. pulse ox
C. CXR
D. breath sounds - answer-C. CXR
An adult arrives in the ED after being assaulted with a baseball bat. He is intubated and becoming
progressively more difficult to ventilate. Suddenly he becomes unresponsive and pulseless. What is the
priority intervention?
A. defibrillation
B. transporting pt for angioplasty
C. relieving the tension pneumothorax
D. correcting the internal bleed - answer-C. relieving the tension pneumothorax
Mr. T is admitted to the SICU following an MVC. The initial drainage from a right chest tube inserted in
the ED is 400cc. The following hour the chest tube drains 300cc of blood. Which the most appropriate
action by the nurse?
A. elevate the HOB
B. notify the physician
C. continue to monitor VS
D. "milk" the chest tube - answer-B. notify the physician
>200cc/hr should be reported
Your trauma pt has a spinal cord transection at the T-1 level. The primary nursing concern is:
A. renal status
B. skin integrity
C. GI function
D. cardiovascular status - answer-D. cardiovascular status
(Autonomic dysreflexia)
, A pt arrives in the ER. He is tachycardia and hypotensive. He says: "I have a knife in my chest and I have
Beck's triad: muffled heart sounds, JVD and hypotension. I think I have cardiac tamponade. Do you think
that's true?"
A. True
B. False - answer-A. True
54 hours after sustaining deep partial thickness burns to both lower extremities and his abdomen, the
pt's urine output has increased from 1000cc to 2300cc in 24 hrs. His labs are: Na 137, K 4.4, HCT 38%.
These finding suggest:
A. beginning of the interstitial to plasma fluid shift
B. circulatory overload
C. early coagulopathy
D. early renal failure secondary to volume depletion - answer-A. beginning of the interstitial to plasma
fluid shift
When admitting the trauma pt with a diagnosis of pelvic fracture to the ICU, the nurse's initial concerns
will focus on:
A. peripheral perfusion
B. respiratory management
C. hemorrhage control
D. mental status change - answer-C. hemorrhage control
A pt with a major burn receives TPN. The primary reason for this is:
A. to insure adequate calories and protein/cholesterol
B. to prevent GI obstruction
C. to correct fluid and electrolyte imbalance
D. to provide supplemental vitamins and minerals - answer-A. to insure adequate calories and
protein/cholesterol
A 72 yo female pedestrian hit by a car is admitted to the ER with bilateral fetal fractures. The priority
nursing concern is:
The physician has ordered a solumedrol infusion for a pt with a spinal cord injury. Solumedrol has been
shown to be effective in:
A. decreasing cerebral edema
B. preventing stress ulcers
C. decreasing spinal injury spasticity
D. improving motor and sensory functioning - answer-D. improving motor and sensory functioning
Solumedrol is given within the first 8 hours of injury
A pt with a T6 injury 3 months ago develops facial flushing and a BP of 210/106. After elevating the HOB,
which is the most appropriate nursing action?
A. increase IV fluids
B. assess for a distended bladder
C. apply oxygen at 4L/min
D. notify the physician - answer-B. assess for a distended bladder
When the pt is in neurogenic shock, the nurse will assess for:
A. mental confusion and tachycardia
B. bradycardia and hypotension
C. unilateral pupil dilation and hypotension
D. hypertension and tachypnea - answer-B. bradycardia and hypotension
Which of the following is descriptive of a concussion?
A. venous blood collects in the subdural space
B. petechial hemorrhages cause intermittent amnesia
C. a lesion develops opposite the site of trauma
D. it is a transient neuronal dysfunction - answer-D. it is a transient neuronal dysfunction
,Autonomic dysreflexia is an emergency because:
A. severe vasoconstriction occurs
B. hypoxia results from regurgitation
C. spasticity produces joint deformity
D. airway spasm occurs - answer-A. severe vasoconstriction occurs
Your client is transported to the ED after sustaining head, back and chest injuries when he fell 25 ft from
a tree. The primary survey has been completed. His BP drops to 80/40, HR is 56, RR is 20. BBS are equal
and clear. SaO2 is 99%. This data is most consistent with:
A. neurogenic shock
B. tension pneumothorax
C. hypovolemic shock
D. closed head injury - answer-A. neurogenic shock
A client who sustained a spinal cord injury at the T2 level should be assessed for signs of autonomic
dysrefelxia because:
A. the injury results in loss of the reflex arc
B. there has been a partial transaction of the cord
C. there is a flaccid paralysis of the lower extremities
D. the injury is above the 6th thoracic vertebrae - answer-D. the injury is above he 6th thoracic
vertebrae
A client is admitted to the hospital 24 hrs ago after sustaining blunt trauma. For which early clinical
manifestation of acute respiratory distress syndrome (ARDS) should the nurse monitor for?
A. crackles throughout lung fields
B. increase in respiratory rate from 18 to 24 breaths/min
C. "white-out" appearance of lungs on chest radiograph
D. cyanosis and pallor - answer-B. increase in respiratory rate from 18 to 24 breaths/min
The nurse is caring for a client who required tube insertion for a pneumothorax. The nurse is aware that
the best test to assess for pneumothorax resolution is:
,A. ABG
B. pulse ox
C. CXR
D. breath sounds - answer-C. CXR
An adult arrives in the ED after being assaulted with a baseball bat. He is intubated and becoming
progressively more difficult to ventilate. Suddenly he becomes unresponsive and pulseless. What is the
priority intervention?
A. defibrillation
B. transporting pt for angioplasty
C. relieving the tension pneumothorax
D. correcting the internal bleed - answer-C. relieving the tension pneumothorax
Mr. T is admitted to the SICU following an MVC. The initial drainage from a right chest tube inserted in
the ED is 400cc. The following hour the chest tube drains 300cc of blood. Which the most appropriate
action by the nurse?
A. elevate the HOB
B. notify the physician
C. continue to monitor VS
D. "milk" the chest tube - answer-B. notify the physician
>200cc/hr should be reported
Your trauma pt has a spinal cord transection at the T-1 level. The primary nursing concern is:
A. renal status
B. skin integrity
C. GI function
D. cardiovascular status - answer-D. cardiovascular status
(Autonomic dysreflexia)
, A pt arrives in the ER. He is tachycardia and hypotensive. He says: "I have a knife in my chest and I have
Beck's triad: muffled heart sounds, JVD and hypotension. I think I have cardiac tamponade. Do you think
that's true?"
A. True
B. False - answer-A. True
54 hours after sustaining deep partial thickness burns to both lower extremities and his abdomen, the
pt's urine output has increased from 1000cc to 2300cc in 24 hrs. His labs are: Na 137, K 4.4, HCT 38%.
These finding suggest:
A. beginning of the interstitial to plasma fluid shift
B. circulatory overload
C. early coagulopathy
D. early renal failure secondary to volume depletion - answer-A. beginning of the interstitial to plasma
fluid shift
When admitting the trauma pt with a diagnosis of pelvic fracture to the ICU, the nurse's initial concerns
will focus on:
A. peripheral perfusion
B. respiratory management
C. hemorrhage control
D. mental status change - answer-C. hemorrhage control
A pt with a major burn receives TPN. The primary reason for this is:
A. to insure adequate calories and protein/cholesterol
B. to prevent GI obstruction
C. to correct fluid and electrolyte imbalance
D. to provide supplemental vitamins and minerals - answer-A. to insure adequate calories and
protein/cholesterol
A 72 yo female pedestrian hit by a car is admitted to the ER with bilateral fetal fractures. The priority
nursing concern is:
