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NU 456 Exam 3
6 P's of Compartment Syndrome - . . ANSWER ✓✓ Pain
Paresthesias
Pallor
Pressure
Paralysis
Pulselessness
A nurse in a provider's office is assessing a client who has a
severe sunburn. Which of the following classifications should the
nurse use to document this burn?
a. superficial thickness
b. superficial partial thickness
c. deep partial thickness
d. full thickness - . . ANSWER ✓✓ a. superficial thickness
A nurse in the critical care unit is completing an admission
assessment of a client who has a GSW to the head. Which of the
following assessment findings are indicative of increased ICP?
Select all that apply
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a. headache
b. dilated pupils
c. tachycardia
d. decorticate posturing
e. hypotension - . . ANSWER ✓✓ a. headache
b. dilated pupils
d. decorticate posturing
A nurse in the emergency department is assessing a client who
has sustained multiple rib fractures and has flail chest. Which of
the following findings should the nurse expect? Select all that
apply
a. bradycardia
b. cyanosis
c. hypotension
d. dyspnea
e. paradoxical breathing movement - . . ANSWER ✓✓ b. cyanosis
c. hypotension
d. dyspnea
e. paradoxical breathing movement
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A nurse in the ER is assessing a client who was in a MVA.
Findings include absent breath sounds in the left lower lobe,
dyspnea, BP 118/68, HR 124, RR 38, T 101.4F, and O2 92% on RA.
Which of the following actions should the nurse take first?
a. obtain chest x-ray
b. prepare for chest tube insertion
c. administer oxygen via high-flow mask
d. initiate IV access - . . ANSWER ✓✓ c. administer oxygen via
high flow mask
A nurse is assessing a client following a GSW to the chest. For
which of the following findings should the nurse monitor to
detect a pneumothorax? Select all that apply
a. tachypnea
b. tracheal deviation
c. bradycardia
d. decreased accessory muscle use
e. pleuritic pain - . . ANSWER ✓✓ a. tachypnea
b. tracheal deviation
e. pleuritic pain
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A nurse is assessing a client who has a chest tube and drainage
system in place. Which of the following are expected findings?
Select all that apply
a. continuous bubbling in the water and seal chamber
b. gentle constant bubbling in the suction control chamber
c. rise and fall of the level of water seal chamber with inspire
and expire
d. exposed sutures without dressing
e. drainage system upright at chest level - . . ANSWER ✓✓ b.
gentle constant bubbling in the suction control chamber
c. rise and fall of the level of water seal chamber with inspire
and expire
A nurse is assessing a client who has a history of asthma. Which
of the following findings should the nurse identify as a risk factor
for asthma?
a. sex
b. environmental allergies
c. alcohol use
d. history of diabetes - . . ANSWER ✓✓ b. environmental
allergies
NU 456 Exam 3
6 P's of Compartment Syndrome - . . ANSWER ✓✓ Pain
Paresthesias
Pallor
Pressure
Paralysis
Pulselessness
A nurse in a provider's office is assessing a client who has a
severe sunburn. Which of the following classifications should the
nurse use to document this burn?
a. superficial thickness
b. superficial partial thickness
c. deep partial thickness
d. full thickness - . . ANSWER ✓✓ a. superficial thickness
A nurse in the critical care unit is completing an admission
assessment of a client who has a GSW to the head. Which of the
following assessment findings are indicative of increased ICP?
Select all that apply
,2|Page
a. headache
b. dilated pupils
c. tachycardia
d. decorticate posturing
e. hypotension - . . ANSWER ✓✓ a. headache
b. dilated pupils
d. decorticate posturing
A nurse in the emergency department is assessing a client who
has sustained multiple rib fractures and has flail chest. Which of
the following findings should the nurse expect? Select all that
apply
a. bradycardia
b. cyanosis
c. hypotension
d. dyspnea
e. paradoxical breathing movement - . . ANSWER ✓✓ b. cyanosis
c. hypotension
d. dyspnea
e. paradoxical breathing movement
,3|Page
A nurse in the ER is assessing a client who was in a MVA.
Findings include absent breath sounds in the left lower lobe,
dyspnea, BP 118/68, HR 124, RR 38, T 101.4F, and O2 92% on RA.
Which of the following actions should the nurse take first?
a. obtain chest x-ray
b. prepare for chest tube insertion
c. administer oxygen via high-flow mask
d. initiate IV access - . . ANSWER ✓✓ c. administer oxygen via
high flow mask
A nurse is assessing a client following a GSW to the chest. For
which of the following findings should the nurse monitor to
detect a pneumothorax? Select all that apply
a. tachypnea
b. tracheal deviation
c. bradycardia
d. decreased accessory muscle use
e. pleuritic pain - . . ANSWER ✓✓ a. tachypnea
b. tracheal deviation
e. pleuritic pain
, 4|Page
A nurse is assessing a client who has a chest tube and drainage
system in place. Which of the following are expected findings?
Select all that apply
a. continuous bubbling in the water and seal chamber
b. gentle constant bubbling in the suction control chamber
c. rise and fall of the level of water seal chamber with inspire
and expire
d. exposed sutures without dressing
e. drainage system upright at chest level - . . ANSWER ✓✓ b.
gentle constant bubbling in the suction control chamber
c. rise and fall of the level of water seal chamber with inspire
and expire
A nurse is assessing a client who has a history of asthma. Which
of the following findings should the nurse identify as a risk factor
for asthma?
a. sex
b. environmental allergies
c. alcohol use
d. history of diabetes - . . ANSWER ✓✓ b. environmental
allergies
