AH3 FINAL PRACTICE QUESTIONS & ANSWERS
A nurse in an emergency room is caring a the client who sustained partial-thickness
burns to both lower legs, chest, face, and both forearms. Which of the following is the
priority action the nurse should take?
A. Insert an indwelling urinary catheter.
B. Inspect the mouth for signs of inhalation injuries.
C. Administer intravenous pain medication.
D. Draw blood for a complete blood cell (CBC) count. - Answers :Inspect the mouth for
signs of inhalation injuries.
Since the client sustained burns to the chest and face, there is a possibility that flames
and smoke from the client's burning clothes could have caused an inhalation injury. The
nurse should inspect the mouth and throat for soot and swelling. Using the airway,
breathing, circulation (ABC) priority-setting framework, is the priority concern at this
time.
A nurse is monitoring the fluid replacement of a client who has sustained burns. The
nurse should administer which of the following fluids in the first 24 hr following a burn
injury?
A. Dextrose 5% in water
B. Dextrose 5% in 0.9% sodium chloride
C. 0.9% sodium chloride
D. LR - Answers :LR.
Lactated Ringer's is used in the first 24 hr following a burn injury because it is a
crystalloid solution whose composition and osmolality most closely resembles plasma.
A nurse is caring for a client who returns to the nursing unit from the recovery room after
a sigmoid colon resection for adenocarcinoma. The client had an episode of
intraoperative bleeding. Which finding indicates to the nurse that the client may be
developing hypovolemic shock?
A. Decrease in the respiratory rate from 20 to 16/min.
B. Decrease in the urinary output from 50 mL to 30 mL per hour.
C. Increase in the temperature from 37.5° C (99.5° F) to 38.6° C (101.5° F)
D. Increase in the heart rate from 88 to 110/min. - Answers :Increase in the heart rate
from 88 to 110/min.
Hypovolemic shock is a condition in which the heart is unable to supply enough blood to
the body because of blood loss or inadequate blood volume. In an effort to compensate
for this, the heart rate increases steadily. In the first stage of shock (compensatory), the
,heart rate is > 100/min. As shock progresses, the heart rate continues to accelerate to
more than 150/min. In the final (irreversible or refractory) stage, the heart rate becomes
very erratic and may develop asystole.
A nurse is caring for a client who is at risk for shock. Which of the following findings is
the earliest indicator that this complication is developing?
A. Hypotension.
B. Anuria.
C. Narrowing pulse pressure
D. Decreased LOC - Answers :Narrowing pulse pressure
Pulse pressure is the difference between the systolic and diastolic blood pressures. In
the initial stage of shock there is a slight increase in the diastolic blood pressure, which
narrows the pulse pressure.
A nurse is caring for a client who is experiencing anaphylactic shock in response to the
administration of penicillin. Which of the following medications should the nurse
administer first?
A. Dobutamine.
B. Methylprednisolone.
C. Furosemide.
D. Epinephrine. - Answers :Epinephrine.
A nurse in the emergency department is caring for a client who has extensive partial
and full-thickness burns of the head, neck, and chest. While planning the client's care,
the nurse should identify which of the following risks as the priority for assessment and
intervention?
A. Airway obstruction.
B. Infection.
C. Fluid imbalance.
D. Paralytic Ileus. - Answers :Airway obstruction.
When using the airway, breathing, circulation approach to client care, the nurse
determines that the priority risk is airway obstruction. Burns of the head, neck, and
chest often involve damage to the pulmonary tree due to heat as well as smoke and
soot inhalation. This can result in severe respiratory difficulty. Nursing measures to
maintain a patent airway should take priority in this client's care.
The priority action the nurse should take when using the airway, breathing, circulation
approach to client care is to administer epinephrine, a bronchodilator and vasopressor
used for allergic reactions to reverse severe manifestations of anaphylactic shock.
, A nurse is caring for a client who who has had a stroke involving the right hemisphere.
Which of the following alterations in function should the nurse expect?
A. Difficulty reading.
B. Inability to recognize family members.
C. Right hemiparesis.
D. Aphasia. - Answers :Inability to recognize family members.
The right hemisphere is involved with visual and spatial awareness. A client who is
unable to recognize faces would have involvement with the right hemisphere.
A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous
hemianopsia when eating. Which of the following actions should the nurse take?
A. Provide a nonskid mat to alleviate plate movement.
B. Encourage the client to use his right hand when feeding himself.
C. Remind the client to look for food on the left side of the tray.
D. Encourage the use of the wide grip utensils. - Answers :Remind the client to look for
food on the left side of the tray.
The nurse's action to remind the client to look for food on the left side of the tray will
train the client to scan the tray by moving his head and eyes, which will help to resolve
the problem of homonymous hemianopsia.
A nursing is caring for a client who has aphasia following a stroke. A family member
asks the nurse how she should communicate with the client. Which of the following
responses by the nurse is appropriate?
A. "Incorporate nonverbal cues in the conversation."
B. "Ask multiple choice questions as part of the conversation."
C. "Use a higher-pitched tone of voice when speaking."
D. "Use simple, child-like statements when speaking." - Answers :Incorporate nonverbal
cues in the conversation.
Nonverbal cues enhance the client's ability to comprehend and use language.
A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured
cerebral aneurysm. Which of the following manifestations should the nurse expect?
A. Gradual onset of several hours
B. Manifestations preceded by a severe headache.
C. Maintains consciousness.
D. History of neurologic deficits lasting less than 1 hr. - Answers :Manifestations
preceded by a severe headache.
A nurse in an emergency room is caring a the client who sustained partial-thickness
burns to both lower legs, chest, face, and both forearms. Which of the following is the
priority action the nurse should take?
A. Insert an indwelling urinary catheter.
B. Inspect the mouth for signs of inhalation injuries.
C. Administer intravenous pain medication.
D. Draw blood for a complete blood cell (CBC) count. - Answers :Inspect the mouth for
signs of inhalation injuries.
Since the client sustained burns to the chest and face, there is a possibility that flames
and smoke from the client's burning clothes could have caused an inhalation injury. The
nurse should inspect the mouth and throat for soot and swelling. Using the airway,
breathing, circulation (ABC) priority-setting framework, is the priority concern at this
time.
A nurse is monitoring the fluid replacement of a client who has sustained burns. The
nurse should administer which of the following fluids in the first 24 hr following a burn
injury?
A. Dextrose 5% in water
B. Dextrose 5% in 0.9% sodium chloride
C. 0.9% sodium chloride
D. LR - Answers :LR.
Lactated Ringer's is used in the first 24 hr following a burn injury because it is a
crystalloid solution whose composition and osmolality most closely resembles plasma.
A nurse is caring for a client who returns to the nursing unit from the recovery room after
a sigmoid colon resection for adenocarcinoma. The client had an episode of
intraoperative bleeding. Which finding indicates to the nurse that the client may be
developing hypovolemic shock?
A. Decrease in the respiratory rate from 20 to 16/min.
B. Decrease in the urinary output from 50 mL to 30 mL per hour.
C. Increase in the temperature from 37.5° C (99.5° F) to 38.6° C (101.5° F)
D. Increase in the heart rate from 88 to 110/min. - Answers :Increase in the heart rate
from 88 to 110/min.
Hypovolemic shock is a condition in which the heart is unable to supply enough blood to
the body because of blood loss or inadequate blood volume. In an effort to compensate
for this, the heart rate increases steadily. In the first stage of shock (compensatory), the
,heart rate is > 100/min. As shock progresses, the heart rate continues to accelerate to
more than 150/min. In the final (irreversible or refractory) stage, the heart rate becomes
very erratic and may develop asystole.
A nurse is caring for a client who is at risk for shock. Which of the following findings is
the earliest indicator that this complication is developing?
A. Hypotension.
B. Anuria.
C. Narrowing pulse pressure
D. Decreased LOC - Answers :Narrowing pulse pressure
Pulse pressure is the difference between the systolic and diastolic blood pressures. In
the initial stage of shock there is a slight increase in the diastolic blood pressure, which
narrows the pulse pressure.
A nurse is caring for a client who is experiencing anaphylactic shock in response to the
administration of penicillin. Which of the following medications should the nurse
administer first?
A. Dobutamine.
B. Methylprednisolone.
C. Furosemide.
D. Epinephrine. - Answers :Epinephrine.
A nurse in the emergency department is caring for a client who has extensive partial
and full-thickness burns of the head, neck, and chest. While planning the client's care,
the nurse should identify which of the following risks as the priority for assessment and
intervention?
A. Airway obstruction.
B. Infection.
C. Fluid imbalance.
D. Paralytic Ileus. - Answers :Airway obstruction.
When using the airway, breathing, circulation approach to client care, the nurse
determines that the priority risk is airway obstruction. Burns of the head, neck, and
chest often involve damage to the pulmonary tree due to heat as well as smoke and
soot inhalation. This can result in severe respiratory difficulty. Nursing measures to
maintain a patent airway should take priority in this client's care.
The priority action the nurse should take when using the airway, breathing, circulation
approach to client care is to administer epinephrine, a bronchodilator and vasopressor
used for allergic reactions to reverse severe manifestations of anaphylactic shock.
, A nurse is caring for a client who who has had a stroke involving the right hemisphere.
Which of the following alterations in function should the nurse expect?
A. Difficulty reading.
B. Inability to recognize family members.
C. Right hemiparesis.
D. Aphasia. - Answers :Inability to recognize family members.
The right hemisphere is involved with visual and spatial awareness. A client who is
unable to recognize faces would have involvement with the right hemisphere.
A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous
hemianopsia when eating. Which of the following actions should the nurse take?
A. Provide a nonskid mat to alleviate plate movement.
B. Encourage the client to use his right hand when feeding himself.
C. Remind the client to look for food on the left side of the tray.
D. Encourage the use of the wide grip utensils. - Answers :Remind the client to look for
food on the left side of the tray.
The nurse's action to remind the client to look for food on the left side of the tray will
train the client to scan the tray by moving his head and eyes, which will help to resolve
the problem of homonymous hemianopsia.
A nursing is caring for a client who has aphasia following a stroke. A family member
asks the nurse how she should communicate with the client. Which of the following
responses by the nurse is appropriate?
A. "Incorporate nonverbal cues in the conversation."
B. "Ask multiple choice questions as part of the conversation."
C. "Use a higher-pitched tone of voice when speaking."
D. "Use simple, child-like statements when speaking." - Answers :Incorporate nonverbal
cues in the conversation.
Nonverbal cues enhance the client's ability to comprehend and use language.
A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured
cerebral aneurysm. Which of the following manifestations should the nurse expect?
A. Gradual onset of several hours
B. Manifestations preceded by a severe headache.
C. Maintains consciousness.
D. History of neurologic deficits lasting less than 1 hr. - Answers :Manifestations
preceded by a severe headache.
