EXAM QUESTIONS AND ANSWERS|GRADED A+|
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A patient with severe burns has crystalloid fluid replacement ordered using the
Parkland formula. The initial volume of fluid to be given in the first 24 hrs. Is
30,000 mL. The initial rate of administration is 1875, L/hr. After the first 8
hours, what rate should the nurse infuse the IV fluids? - Answer 938 mL/hr.
Which nursing action is a priority for a patient who has suffered a burn injury
while working on an electrical power line? - Answer Stabilize the cervical spine
The nurse is caring for a patient who has a right-sided chest tube after a right
lower lobectomy. Which nursing action can the nurse delegate to the unlicensed
assistive personnel (UAP)? - Answer document the amount of drainage every 8
hours.
A patient who has had chest pain for several hours is admitted with a diagnosis
of rule out acute myocardial infarction (AMI). Which laboratory test is most
specific for the nurse to monitor in determining whether the patient has had an
AMI? - Answer Cardiac-specific troponin
A patient arrives in the emergency department with facial and chest burns
caused by a house fire. Which actions should the nurse take first? - Answer
Auscultate for breath sounds
,Which electrocardiographic (ECG) change by a patient with chest pain is most
important for the nurse to report rapidly to the health care provider? - Answer
St-segment elevation
Which assessment finding in a patient admitted with acute decompensated heart
failure) ADHF) requires the most immediate action by the nurse? - Answer O2
saturation of 88%
After receiving change -of-shift report on a heart failure unit, which patient
should the nurse assess first? - Answer Patient who is taking digoxin and has a
potassium level of 3.1 mEq/L.
A patient with supraventricular tachycardia who is alert and has a blood
pressure of 110/66 mmHg is being prepared for cardioversion. Which action
should the nurse take? - Answer Give a sedative before cardioversion is
implemented.
Which laboratory result for a patient with multifocal premature ventricular
contractions (PVCs) is most important for the nurse to communicate to the
health care provider? - Answer Serum potassium of 2.9 mEq/L.
A 70-year-old female client is being treated for diverticulitis. The nurse explains
that there are several complications associates with this disease. The nurse
informs the patient that diverticulitis is most common cause of what
complication? - Answer Lower gastrointestinal bleeding
A young adult patient is hospitalized with massive abdominal trauma from a
motor vehicle crash the patient asks the nurse about the purpose of receiving
,famotidine (Pepcid). What should the nurse explain about the action of the
medication? - Answer "It inhibits development of stress ulcers."
A 72-yr-old male patient with dehydration caused by an exacerbation of
ulcerative colitis is receiving 5% dextrose in normal saline at 125 mL/hour.
Which assessment finding by the nurse is most important to report to the health
care provider? - Answer Crackles are heard halfway up the posterior chest.
After change-of-shift report, which should the nurse assess first? - Answer A
30-yr-old female patient with a femoral hernia who has abdominal pain and
vomiting.
Which action should the nurse in the emergency department take first for a new
patient who is vomiting blood? - Answer Check blood pressure and heart rate
A 62-yr-old female patient has been hospitalized for 4 days with acute kidney
injury (AKI) caused by dehydration. Which information will be most important
for the nurse to report to the health care provider? - Answer Urine output over
ran 8 hr. period of 2500 mL.
Which laboratory value reported by the unlicensed assistive personnel (UAP)
indicates an urgent need for the nurse to assess the patient? - Answer Noon
blood glucose of 52 mg/dL.
After change-of-shift report, which patient will the nurse assess first? - Answer
A 60-yr-old patient with hyperosmolar hyperglycemic syndrome who has poor
and dry oral mucosa
, A patient with a history of Addison's disease was unable to fill their prescription
for Prednisone. The patient complains of abdominal pain, fatigue and poor skin
turgor. The patient is hypotensive with an elevated potassium level 5.3, sodium
of 118 and glucose of 65. Which medication would the nurse anticipate
administering? - Answer IV solu-cortef
Family members of a patient who has a traumatic brain injury ask the nurse
about the purpose of the ventriculostomy system being use for intracranial
pressure monitoring. Which response by the nurse is best for the situation? -
Answer Correct Answer: The ventriculostomy monitoring system helps check
for changes in cerebral perfusion pressure. Answered (given the points) The
monitoring system helps show whether blood flow to the brain is adequate.
Admission vital signs for a patient who has a brain injury are Bp 128/68
mmHm, Pulse 110 bpm, RR 26 bpm. Which se of vital signs, if taken 1-hour
taken would most concern the nurse? - Answer Bp 154/68 mm Hg, Pulse 56
bpm, RR 12 bpm.
After receiving change-of-shift report on the following four patients, which
patient should the nurse see first? - Answer A 60-yr-old patient with right-sided
weakness who has an infusion of tPA prescribed.
To prevent autonomic dysreflexia, which nursing action should the home health
nurse include in the plan of care for a patient who has paraplegia at the T4
level? - Answer Assist to plan a prescribed bowel program.
Which hemodynamic parameter best reflects the effectiveness of drugs the
nurse gives to reduce a patient's left ventricular afterload? - Answer Systemic
vascular resistance (SVR).