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c - CORRECT ANSWERS While receiving a blood transfusion, the client suddenly shouts, "I
feel like someone is lowering a heavy weight on my chest. I feel like I'm going to die!" Which
actions are priority?
a. Administer nitroglycerin and aspirin
b. Slow the rate and monitor the vital signs
c. Stop the transfusion and administer normal saline through new IV tubing
d. Ask the client to further describe the feeling and rate the pain
d - CORRECT ANSWERS A client who was hospitalized with partial- and full-thickness burns
over 30% of the total body surface area is to be discharged. The client asks the nurse, "How
will my spouse be able to care for me at home?" How should the nurse interpret this
statement?
a. Readiness to discuss the client's deformities
b. Indication of a change in family relations
c. Need for more time to think about the future
d. Beginning realization of implications for the future
b - CORRECT ANSWERS A nurse is assessing a client with a cast to the extremity. Which
assessment finding is the priority?
,a. Warmth
b. Numbness
c. Skin desquamation
d. Generalized discomfort
b - CORRECT ANSWERS Which color of cerebrospinal fluid (CSF) may indicate subarachnoid
hemorrhage in the client?
a. Hazy
b. Yellow
c. Brown
d. Colorless
c - CORRECT ANSWERS A client arrives in the emergency department with multiple crushing
wounds of the chest, abdomen, and legs. Which are the priority nursing assessments?
a. Level of consciousness and pupil size
b. Characteristics of pain and blood pressure
c. Quality of respirations and presence of pulses
d. Observation of abdominal contusions and other wounds
,b - CORRECT daANSWERS da daWhich dacolor datag dawill dabe dagiven daby dathe datriage danurse
dato daa daclient daassigned dato daclass daIV, daduring daa damass dacasualty dasituation?
a. daRed
da
b. daBlack
da
c. daGreen
da
d. daYellow
a da- da daCORRECT daANSWERS da daA daclient dawho dasustained daa daburn dainjury dainvolving
da36% daof dathe dabody dasurface daarea dais dareceiving dahydrotherapy. daWhich dais dathe dabest
danursing daintervention dawhen daproviding dawound dacare?
a. daUse daa daconsistent daapproach dato dacare daand daencourage daparticipation.
da
b. daPrepare daequipment dawhile dadoing dathe daprocedure daand daexplain dathe datreatment
dato dathe daclient.
da
c. daRinse dathe daburn daarea dawith da105° daF da(40.6° daC) dawater dato daprevent daloss daof
dabody datemperature.
da
d. daArrange dafor daa dachange daof dastaff daevery da4 dato da5 dadays daand dahave dathe daclient
daselect dathe datime dafor dathe daprocedure dato dabe dadone.
b da- da daCORRECT daANSWERS da daWhich daclinical damanifestation dacan daa daclient
daexperience daduring daa dafat daembolism dasyndrome da(FES)?
a. daNausea
da
b. daDyspnea
da
, c. daOrthopnea
da
d. daParesthesia
b da- da daCORRECT daANSWERS da daA daclient dawas daadmitted dawith dafull-thickness daburns da2
daweeks daago. daSince daadmission, dathe daclient dahas dalost daan daaverage daof da1 dalb da(0.5
dakg) daof daweight daeach daday. daWhich daaction dawill dathe danurse damost dalikely datake
dabased daupon dathe daadjusted dadietary daplan?
a. daProvide dalow-sodium damilk.
da
b. daProvide dahigh-protein dadrinks.
da
c. daProvide dafoods dathat daare dalow dain dapotassium.
da
d. daProvide da10% damore dacalories dain dathe daform daof dafats.
d da- da daCORRECT daANSWERS da daA daburn davictim dahas dawaxy dawhite daareas dainterspersed
dawith dapink daand dared daareas daon dathe daanterior datrunk daand daall daof daboth daarms.
daThe danurse dacalculates dathe dapercentage daof datotal dabody dasurface daarea da(TBSA).
daWhich dapercentage dawill dathe danurse dareport?
a. da20
da
b. da25
da
c. da30
da
d. da36
d da- da daCORRECT daANSWERS da daA danurse daplaces daa daclient dawith dasevere daburns daon daa
dacirculating daair dabed. daWhich dagoal dais dathe danurse datrying dato daachieve?