NSG 460 Exam 6 Practice Questions
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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT ANSWER-A. neurogenic shock
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 - CORRECT 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 - CORRECT ANSWER-B. assess for a distended bladder
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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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:
A. shock
B. infection
C. fat embolism
D. pain - CORRECT ANSWER-A. shock
, A severely burned client is ordered albumin on the second day of hospitalization. The
nurse understands that the rationale for giving albumin is:
A. provides protein to increase serum osmotic pressure
B. provides fluid to prevent dehydration
C. replace clotting factors and prevent bleeding
D. replace hemolyzed RBCs and reduce anemia - CORRECT ANSWER-A. provides
protein to increase serum osmotic pressure
A 44 yo male is admitted to a burn unit with 2nd and 3rd degree burns on 60% of his
body. After 12 hrs, his urine output is 24cc/hr and his ABG is: pH 7.31, PaO2 96 (2L
NC), PaCO2 36, HCO 18. The nurse concludes that:
A. he is in renal failure and metabolic acidosis
B. he is hypoxic from renal failure
C. he is in respiratory acidosis from CO2 retention secondary to renal failure
D. he is in early CHF from overhydration - CORRECT ANSWER-A. he is in renal failure
and metabolic acidosis
A pt is admitted with a ruptured spleen following an ATV accident, he is being prepared
for surgery and the nurse suspects he is in the compensatory stage of shock. This
assessment is based upon what findings?
A. HR 120, BP 110/86
B. anxious, bibasilar crackles
C. HR 140, urine output < 30cc/hr
D. difficult to arouse, BP 80/60 - CORRECT ANSWER-A. HR 120, BP 110/86
An immobilized multi-system trauma pt begins to vomit. The nurse's first action is:
A. assess breath sounds
B. obtain VS
C. turn the pt maintaining spine precautions
D. suction the pt - CORRECT ANSWER-C. turn the pt maintaining spine precautions
A 30 yo female arrives in the ED after a MVC. Unresponsive at the scene she arrives
intubated. Her VS are HR 100, BP 140/90, RR 16 (assisted). The change is VS are
more likely a result of:
A. early hypovolemic shock
B. increased ICP
C. neurogenic shock
D. pain - CORRECT ANSWER-B. increased ICP
The following bus accident victims are brought to the ED. Which should be assessed
first?
A. a 30 yo with a HR of 128
B. a 65 yo with a GCS of 14
C. a 54 yo with an irregular heartbeat
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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT ANSWER-A. neurogenic shock
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 - CORRECT 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 - CORRECT ANSWER-B. assess for a distended bladder
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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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:
A. shock
B. infection
C. fat embolism
D. pain - CORRECT ANSWER-A. shock
, A severely burned client is ordered albumin on the second day of hospitalization. The
nurse understands that the rationale for giving albumin is:
A. provides protein to increase serum osmotic pressure
B. provides fluid to prevent dehydration
C. replace clotting factors and prevent bleeding
D. replace hemolyzed RBCs and reduce anemia - CORRECT ANSWER-A. provides
protein to increase serum osmotic pressure
A 44 yo male is admitted to a burn unit with 2nd and 3rd degree burns on 60% of his
body. After 12 hrs, his urine output is 24cc/hr and his ABG is: pH 7.31, PaO2 96 (2L
NC), PaCO2 36, HCO 18. The nurse concludes that:
A. he is in renal failure and metabolic acidosis
B. he is hypoxic from renal failure
C. he is in respiratory acidosis from CO2 retention secondary to renal failure
D. he is in early CHF from overhydration - CORRECT ANSWER-A. he is in renal failure
and metabolic acidosis
A pt is admitted with a ruptured spleen following an ATV accident, he is being prepared
for surgery and the nurse suspects he is in the compensatory stage of shock. This
assessment is based upon what findings?
A. HR 120, BP 110/86
B. anxious, bibasilar crackles
C. HR 140, urine output < 30cc/hr
D. difficult to arouse, BP 80/60 - CORRECT ANSWER-A. HR 120, BP 110/86
An immobilized multi-system trauma pt begins to vomit. The nurse's first action is:
A. assess breath sounds
B. obtain VS
C. turn the pt maintaining spine precautions
D. suction the pt - CORRECT ANSWER-C. turn the pt maintaining spine precautions
A 30 yo female arrives in the ED after a MVC. Unresponsive at the scene she arrives
intubated. Her VS are HR 100, BP 140/90, RR 16 (assisted). The change is VS are
more likely a result of:
A. early hypovolemic shock
B. increased ICP
C. neurogenic shock
D. pain - CORRECT ANSWER-B. increased ICP
The following bus accident victims are brought to the ED. Which should be assessed
first?
A. a 30 yo with a HR of 128
B. a 65 yo with a GCS of 14
C. a 54 yo with an irregular heartbeat
