Multidimensional_Care_Iv_Mdc_4 Final Exam (Exam Questions With 100% Correct & Verified Answers)

Question 1 The nurse is working on a medical-surgical unit when a fire breaks out in the stairwell near the nurse’s station. Which of the following correctly describes the nurse’s first action? A. Rescue anyone in immediate danger of the fire B. Activate the emergency response system C. Close the door to the stairwell D. Extinguish the fire Question 2 The emergency room nurse is educating a new nurse on the traditional triage system. The new nurse shows a correct understanding of the system when which of the following statements is made? A. “This system is based on the severity of illness or injury.” B. “This system is based on which body systems are involved.” C. “This system is based on placing client names in alphabetical order.” D. “This system is based on the client’s age, prioritizing the youngest first.” Question 3 The nurse is orienting a new nurse to the pediatric intensive care unit and discussing the care of a client recovering from drowning. Which statement by the new nurse accurately demonstrates an understanding of this condition? A. “Drowning results in the collapse of alveoli and pulmonary edema.” B. “Drowning causes an increased amount of surfactant in the lungs, which decreases airway pressure.”C. “Since the client has recovered, we should not need to monitor for any complications.”D. “It is okay to leave children unattended in a bathtub as long as it’s only for a minute or two.” Question 4 On a hot, humid day, a client arrives in the Emergency Department (ED) presenting with confusion, lethargy, and the following vital signs: temperature 104.1 degrees F, pulse 132 beats/min, respirations 26 breaths/min, and blood pressure 106/66 mmHg. What is the most appropriate intervention for this client? A. Encourage the client to drink cool water or sports drinks B. Start an intravenous line and infuse 0.9% saline solution C. Administer acetaminophen 650 mg orally D. Encourage rest and reassess in 15 minutes Question 5 The nurse has instructed the family of a client with a stroke who has homonymous hemianopiaabout measures to help the client overcome the deficit. The nurse determines understanding of the education when which correct statement is made? A. “Necessary objects should be placed in the impaired visual field.” B. “We should discourage the client from the use of eyeglasses.” C. “We should approach the client from the impaired field of vision.” D. “We should remind the client to turn the head to scan the lost visual field.” Question 6 The client has returned to the surgery unit from the post-anesthesia unit (PACU). The client’s respirationsare rapid and shallow, the pulse is 120 beats/minute, and the blood pressure is 88/52 mmHg. The client’s level of consciousness is declining. What should the nurse do first? A. Call the PACU B. Call the healthcare provider (HCP) C. Call the respiratory therapist D. Call the rapid response team (RRT)/ medical emergency team Question 7 A client who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. Which of the following does the nurse include during the primary survey of the client? A. Administer oxygen via nasal cannel B. Complete a comprehensive assessment C. Ask about chronic medical conditions D. Place a cardiac monitor on the client Question 8 A nurse is assessing a client for changes in the level of consciousness using the Glasgow Coma Scale (GCS). The client opens his eyes when spoken to, withdraws his extremities when pain is applied, and verbalizes “baseball” when referring to the “bathroom.” Which of the following GCS scores should the nurse document? A. E2 + M5 + V3 = 10 B. E4 + M6 + V5 = 15 C. E2 + M4 + V2 = 8 D. E3 + M4 + V3 = 10Question 9 A nurse prepares to administer intravenous pantoprazole to a client who has a new burn injury. The client asks, “Why am I taking this medication?” How would the nurse respond? A. “Pantoprazole stimulates intestinal movement so you can eat more.” B. “It improves fluid retention, which helps prevent hypovolemic shock.” C. “It helps prevent stomach ulcers, which are common after burns.” D. “Pantoprazole protects the kidney from damage caused by dehydration.” Question 10 A client is on intravenous heparin to treat pulmonary embolism. The client reports bleeding gums, and the most recent partial thromboplastin time (PTT) was 120 seconds. What action should the nurse take? A. Decrease the heparin rate, and document the PTT B. Increase the heparin rate, and document the PTT C. Document the findings in the electronic health record D. Stop the heparin, and notify the health care provider (HCP) Question 11 Which of the following events would the hospital’s disaster plan be activated? A. Fight between two local street gangs B. School bus involved in an accidentC. Explosion at a chemical factory D. Three-car collision on the highway Question 12 A client who is receiving fluid resuscitation per the Parkland formula after a serious burn continues to have urine output ranging from 20-25mL/hour. After the health care provider checks the client, which order does the nurse question? A. Increase IV fluids by 100 mL/hr B. Administer furosemide 40 mg IV push C. Continue to monitor urine output hourly D. Draw blood for serum electrolytes stat cv Question 13 The nurse is caring for a client suspected of having a heatstroke. Which findings are consistent with this diagnosis? (Select all that apply.) A. Tachypnea B. Tachycardia C. Dysrhythmias D. Hallucinations E. Decreased urinary output Question 14 A client with a chest injury has suffered a flail chest. A nurse assesses the client for which most distinctive sign of a flail chest? A. CyanosisB. Hypotension C. Paradoxical chest movement D. Dyspnea, especially on exhalation Question 15 A nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse would expect to note which of the following? A. Slow deep respirations B. Rapid deep respirations C. Paradoxical respirations D. Pain with management Question 16 The nurse is assessing a victim in the emergency department that was involved in a motor vehicle accident. After asssessing the. Which of the following primary survey assessments would the nurse assess first? A. Disability B. Breathing C. Exposure D. Circulation Question 17 The nurse has given instructions to the client with Parkinson’s disease about maintaining mobility. The nurse determines that the client understands the directions when the client performs which of the following interventions?A. The client sits in a soft, deep chair B. The exercises in the evening to combat fatigue C. The client rocks back and forth to start movement with bradykinesia D. The client buys clothes with many buttons to maintain finger dexterity Question 18 The nurse is assessing a client in the postictal phase of a generalized tonic-clonic seizure. The nurse should determine if the client has which of the following assessment findings? A. Drowsiness B. Inability to move C. Paresthesia D. Hypotension Question 19 An elderly man was found unresponsive in his home and unable to give a history of any contributing events. The nurse recognizes the man’s skin color of “cherry red” as a sign that he has been involved in which of the following scenarios? A. Cardiac arrest B. Hemorrhagic stroke C. Carbon monoxide poisoning D. Cyanide poisoning Question 20 A nurse is triaging clients in the emergency department. Which client would the nurse classify as “Urgent?”A. A 44-year-old with chest pain and diaphoresis B. A 50-year-old with chest trauma and absent breath sounds C. A 62-year-old with a simple fracture of the left arm D. A 79-year-old with a temperature of 104 degrees F (40 degrees C) Question 21 A triage officer is discussing mass casualty triage during a tabletop disaster drill. Which statement should indicate the staff member requires further teaching? A. “Clients in the emergent category should be treated first.” B. “Clients in the expected category should receive comfort measures only.” C. “Clients in the nonurgent category would include closed fracture injuries.” D. “Clients in the urgent category would include shock and airway obstruction.” Question 22 A client with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). The nurse determines that discharge teaching has been effective when the client makes which statement? A. “I will take salt tablets when I work outdoors in the summer.” B. “I should take acetaminophen if I start to feel too warm.” C. “I should drink electrolyte sports drinks when working outside in hot weather.” D. “I will move to a cool environment if I notice that I am feeling confused.” Question 23At which time of day should the nurse encourage a client with Parkinson’s disease to schedule the most demanding physical activities to minimize the effects of hypokinesia? A. Early in the morning, when the client’s energy level is high B. To coincide with the peak action of drug therapy C. Immediately after a rest period D. When family members will be available Question 24 A nurse in the emergency department is completing an assessment on a client who is in shock. Which findings should the nurse expect? (Select all that apply.) A. Heart rate 63/min B. Blood pressure 89/41 mmHg C. Respiratory rate 41/min D. Urine output 120mL/hr E. Weak, thready pulse Question 25 A nurse is caring for a client after surgery. The client’s respiratory rate has increased from 12 to 18 breaths/min, and the pulse rate increased from 86 to 98 beats/min since the client was last assessed 4 hours ago. What is the nurse’s best action? A. Ask if the client needs pain medication B. Assess the client’s tissue perfusion C. Document the findings in the client’s chart D. Increase the rate of the client’s IV infusion Question 26Which clinical manifestations should the nurse be the most concerned with while monitoring a post-operative client ? A. Increased level of consciousness B. A pulse of 86 beats/min C. Blood pressure of 128/80 mmHg D. Hyperactive bowel sounds in all four quadrants Question 27 A nurse wants to become part of a Disaster Medical Assistance Team (DMAT) but is concerned about maintaining licensure in several states. Which statement best addresses these concerns? A. “Deployed DMAT providers are federal employees, so their licenses are good in all 50 states.” B. “The government has a program for quick licensure activation wherever you are deployed.” C. “During a time of crisis, licensure issues would not be the government’s priority concern.” D. “If you are deployed, you will be issued a temporary license in the state in which you are working.” Question 28 A nurse is caring for several clients on the burn unit who have sustained extensive tissue damage. The nurse should monitor for which electrolyte imbalance that is typically associated with the initial third spacing fluid shift? A. Hypercalcemia B. Hypernatremia C. Hyperkalemia D. Hypokalemia Question 29Which of the following describes the process of initial surveillance of victims’ injury severity when administering first aid in an emergency situation? A. The Good Samaritan Law B. An emergency interview C. Triage D. Taking vital signs Question 30 A client with multiple sclerosis (MS) is receiving baclofen. The nurse determines that the drug is effective with which of the following outcomes? A. Induces sleep B. Stimulates the client’s appetite C. Relieves muscular spasticity D. Reduces the urine bacterial count Question 31 A medication order states, infuse 0.9% normal saline (NS) solution 500 mL IV over 6 hours. The drop factor of the manual IV tubing available is 15 gtt/mL. The nurse should set the flow rate to deliver how many gtt/min? (Record answer as a whole number. Do not use a trailing zero.) 21 Question 32 A client has accidentally received twice the normal dose of medication that was administered on the previous shift. What should the nurse who discovers the error do next?A. Call the person who made the error and request that an incident report be completed B. Assess the client, and note any changes in condition C. Call the healthcare provider (HCP) to obtain a prescription for additional intravenous fluids to dilute the drug D. Administer a drug antidote per standing prescription Question 33 A client with a serious head injury with increased intracranial pressure is to be discharged to a rehabilitation facility. Which outcome of rehabilitation would be appropriate for the client? The client will A. Exhibit no further episodes of short-term memory loss B. Be able to return to his construction job in 3 weeks C. Actively participate in the rehabilitation process as appropriate D. Be emotionally stable and display preinjury personality traits Question 34 A medication order for a client that weighs 95 kg states, infuse dobutamine 250 mg IV in 250 mL D5W at 3 mcg/kg/min. the infusion pump must be set to _________ mL/hr. (Record answer as a whole number. Do not use a trailing zero.) 17 Question 35 A client with a head injury regains consciousness after several days. When the client first awakes, what should the nurse say to the client?A. “I will get your family.” B. “Can you tell me what you remember?” C. “I will bet you are a little confused right now.” D. “You are in the hospital. You were in an accident and unconscious.” Question 36 A client is receiving warfarin after pulmonary embolism (PE). The nurse evaluates the lab results and notifies the physician that the client’s warfarin level is therapeutic when which of the following results is reported? A. International normalized ratio (INR) 2.8 B. Partial thromboplastin time (PTT) 24 seconds C. International normalized ratio (INR) 1.1 D. Prothrombin Time (PT) 14 seconds Question 37 A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client’s vital signs are as follows: blood pressure of 197/111 mmHg, pulse of 81/min, and respirations of 26/min. which of the following neurologic disorders should the nurse suspect? A. Hemorrhagic stroke B. Transient ischemic attack (TIA) C. Thrombotic stroke D. Embolic strokeQuestion 38 An emergency department charge nurse notes an increase in sick calls and bickering among the staff after a week with multiple trauma incidents. What action would the nurse take? A. Organize a pizza party for each shift B. Remind the staff of the facility’s sick-leave policy C. Arrange for critical incident stress debriefing D. Talk individually with staff members Question 39 The spouse of a 67-year-old male client with early-stage Alzheimer's Disease (AD) tells the nurse, “I am exhausted from worrying all the time. I don’t know what to do.” Which actions are best for the nurse to take next? (Select all that apply.) A. Suggest that a long-term care facility be considered B. Offer ideas for ways to distract or redirect the client C. Teach the spouse about adult day care as a possible respite D. Suggest that the spouse consult with the physician for antianxiety drugs E. Ask the spouse what she knows and has considered about dementia care options Question 40 Which findings will the nurse observe in the client in the ictal phase of a generalized tonic clonic seizure? A. Jerking in one extremity that spreads gradually to adjacent areas B. Vacant staringand abruptly ceasing all activity C. Facial grimaces, patting motions, and lip-smacking D. Loss of consciousness, body stiffening, and violent muscle contractions Question 41 A nurse is caring for five clients. For which client’s would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.) A. Older adult with chronic atrial fibrillation B. Client who had a reaction to contrast dye yesterday C. Older client who is 1-day post-hip replacement surgery D. Client with a new deep vein thrombosis E. Young obese client with a fractured femur F. Middle-aged man with an exacerbation of asthma Question 42 A nurse is planning care for an adult who has sustained burn injuries. Which interventions should the nurse include in the plan of care? (Select all that apply.) A. Administer pain medications 30 minutes after dressing changes B. Monitor for constipation with morphine medication orders C. Wash hands before and after dressing changes D. Take prescribed antibiotics until the client states they are feeling better E. Contact primary health care provider for purulent drainage or feverF. Administer Tetanus vaccination (if not given in the last 10 years) Question 43 The nurse assesses the frostbite on a client’s hands and feet to be third-degree frostbite because the skin has which of the following assessment findings? A. Reddened and has hard white plaques B. Waxy and has blisters filled with milky fluid C. Reddened and has blisters filled with milky fluid D. Waxy non-blanchable areas with blood-filled blisters. Question 44 A nurse in an emergency department is caring for a client with a penetrating trauma from a gunshot and a sucking chest wound. The client has a blood pressure of 101/61 mmHg, a weak pulse rate of 117/min, a respiratory rate of 39/min, and a pulse oximeter reading of 90% on room air. Which action should the nurse take first in the primary survey? A. Place the client in Trendelenburg position B. Remove the dressing to inspect the wound C. Prepare to insert a central line D. Administer oxygen via nonrebreather mask per order Question 45 When preparing for a surgical procedure, which of the following factors will influence how the nurse will position the client? (Select all that apply.) A. The weight, age, and size of the client B. The anesthetic delivery techniqueC. The client’s ethnicity D. Pain on movement in the conscious client E. The surgical site location Question 46 The nurse is caring for an elderly client who has suffered from a myocardial infarction. The nurse identifies the need for vigilant monitoring against which form of shock in this client? A. Septic shock B. Obstructive shock C. Cardiogenic shock D. Hypovolemic shock Question 47 When preparing to teach a client about phenytoin sodium therapy, the nurse should urge the client not to stop the drug suddenly due to which of the following concerns? A. Physical dependency on the drug develops over time B. Status epilepticus may develop C. A hypoglycemic reaction develops D. Heart block is likely to develop Question 48 A nurse caring for a client notes the following assessments: white blood cell counts 3800/mm3, blood glucose level 198 mg/dL (11 mmol/L), and temperature 96.2 F (35.6 C). What action by the nurse takes priority? A. Document the findings in the client’s chartB. Give the client warmed blankets for comfort C. Notify the health care provider immediately D. Prepare to administer insulin per sliding scale Question 49 The nurse is working in the triage area of an emergency department (ED), and the following four clients approach the triage desk at the same time. Client 1 is an ambulatory, dazed 25-year-old man with a bandaged head wound; client 2 is an irritable infant with a fever, petechiae, and nuchal rigidity; client 3 is a 35-year-old jogger with a twisted ankle who has a pedal pulse and no deformity.; and client 4 is a 50-year-old woman with moderate abdominal pain and occasional vomiting. What is the order in which the nurse should assess these clients? A. 4,3,2,1 B. 2,1,3,4 C. 3,2,1,4 D. 2,1,4,3 Question 50 The client with a spinal cord injury is prone to experiencing autonomic dysreflexia. Which immediate interventions should the nurse implement first? A. Reposition the client a safe sitting positon B. Check the urinary catheter tubing C. Examine the skin for any injuries D. Check for any fecial impectionQuestion 51 A nurse is assessing a client’s laboratory values before surgery. Which results should the nurse report to the provider? (Select all that apply.) A. Potassium 3.9 mEq/L B. Sodium 146 mEq/L C. Creatinine 2.9 mg/dL D. Blood glucose 236 mg/dL E. WBC 17,762/mm3 F. Urinalysis negative ketones Question 52 A 28-year-old female is admitted for an elective surgical procedure. Which information obtained by the nurse during the preoperative assessment is most important to report to the anesthesiologist before surgery? A. The client’s lack of knowledge about post-operative pain control measures B. The client’s statement that her last menstrual period was 6 weeks previously C. The client’s history of a post-operative infection following a prior cholecystectomy D. The client’s concern that she will be unable to care for her children postoperativelyQuestion 53 A student nurse is caring for a client who suffered massive blood loss after trauma. How does the student nurse correlate the blood loss with the client’s mean arterial pressure (MAP)? A. It causes vasoconstriction and increase MAP B. Lower blood volume lowers MAP C. There is no direct correlation to MAPD. It raises cardiac output and MAP Question 54 Which of the following drainage systems works with gravity to prevent the collection of drainage in a surgical incision? A. Penrose drain B. Jackson-Pratt drain C. Hemovac D. Negative pressure wound vac Question 55 A nurse is caring for a client who experienced a spinal cord injury with recent increased drowsiness upon assessment. Based on this presentation, which of the following should the nurse clarify with the provider? A. Pantoprazole B. Intrathecal baclofen (ITB) therapy C. Enoxaparin D. Morphine sulfate Question 56 The nurse assesses a client with drainage from the nose following a basilar skull fracture. Which evaluation by the nurse helps positively identify the drainage as cerebrospinal fluid? A. The fluid is clear and tests negative for glucose B. The fluid is grossly bloody in appearance and has a pH of 6 C. The fluid clumps together on the dressing and has a pH of 7D. The fluid separates into concentric rings and tests positive for glucose Question 57 Which client has the greatest risk for latex allergies? A. A woman who is admitted for her first surgery B. A man who has an allergy to avocados and bananas C. A man with well-controlled type 2 diabetes D. A woman who is having laser surgery Question 58 What is the priority nursing intervention in the postictal phase of a seizure? A. Reorient the client to time, person, and place B. Determine the client’s level of sleepiness C. Assess the client’s breathing pattern D. Position the client comfortably Question 59 A nurse is reviewing the health records of six clients. Which of the following clients are at risk for developing acute respiratory distress syndrome? (Select all that apply.) A. A client who experience a pulmonary contusion B. A client with non-cardiac assoicateed pulmonary edema C. A client with seasonal allergies and a dry cough D. A client with decreased pulmonary compliance E. A client with viral pneumonia from COVID-19Question 60 The experienced nurse is teaching a new nurse about hospital emergency plans and personal emergency preparedness. Which statement by the new nurse indicates a need for further teaching? A. “I need to assemble a personal readiness go-bag.” B. “I need to have plans for child and eldercare.” C. “I need to know where I am expected to report.” D. “I should have enough supplies to last me 1-2 days.” Question 61 A client has experienced a pulmonary embolism. A nurse assesses for which most commonly reported symptom? A. Hot, flushed feeling B. Sudden chills and fever C. Chest pain that occurs suddenly D. Dyspnea when deep breaths are taken Question 62 A nurse assesses a client’s surgical incision for signs of infection. Which finding by the nurse is interpreted as a normal finding at the surgical site? A. Red, hard skin B. Serous drainage C. Purulent drainage D. Warm, tender skin Question 63The nurse is teaching the client with myasthenia gravis about preventing myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by which of the following? A. Eating large, well-balanced meals B. Doing muscle-strengthening exercises C. Doing all chores early in the day while less fatigued D. Taking medication on time to maintain therapeutic blood levels Question 64 A nurse is developing a care plan for a client who has had a thrombotic stroke. What is the priority nursing assessment in the first 24 hours after admission of this client? A. Cholesterol level B. Pupil size and pupillary response C. Bowel sounds D. Echocardiogram Question 65 A client arrives in the emergency department with an ischemic stroke. Because the healthcare team is considering administering tissue plasminogen activator (t-PA), the nurse should perform which of the following first? A. Ask what medications the client is taking B. Complete history and health assessment C. Identify the time of onset of the stroke D. Determine if the client is scheduled for any surgical procedures Question 66Following a stroke, a client has dysphagia and left-sided facial paralysis. Which feeding technique will be most helpful this time? A. Encourage sipping diluted liquid meal supplements from a straw B. Position the client with the bed at a 30-degree angle C. Offer solid foods from the unaffected side of the mouth D. Feed the client a soft diet from a spoon into the left side of the mouth Question 67 The nurse is assessing a client for decerebrate posturing. What should the nurse assess the client for? A. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers B. Back hunched over and rigid flexion of all four extremities with supination of arms and plantar flexion of feet C. Supination of arms and dorsiflexion of the feet D. Back arched and rigid extension of all four extremities Question 69 A nurse is evaluating the status of a post-operative day 3 client with a craniotomy. Which of the following clinical manifestations would indicate that the client is developing a post-operative complication of meningitis? (Select all that apply.) A. A positive Kernig and Brudzinki sign B. Photophobia C. Fever and chills D. A Glasgow Comma scale of 15 E. Severe unrelenting headache Question 70A client who experienced a near-drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period? A. Auscultate heart sounds B. Palpate peripheral pulses C. Auscultate breath sounds D. Check pupil reaction to light Question 71 A 56-year-old client comes to the triage area with left-sided chest pain, diaphoresis, and dizziness, with an oxygen saturation of 88% on room air. What is the priority action? A. Place the client on continuous electrocardiographic monitoring B. Notify the Emergency Department (ED) physician C. Administer oxygen via nasal cannula D. Establish intravenous (IV) access Question 72 A client is to be discharged from same-day surgery 7 hours after his inguinal hernia repair. Which nursing observation indicates this client is ready to be discharged? (Select all that apply.) A. The client voids 500 mL of urine B. The client has active bowel sounds C. The client’s pain is not controlledD. The client walks in the hallway unassisted E. The client’s O2 saturation is 96% on room air Question 73 The nurse is aware that the treatment for frostbite includes which of the following? (Select all that apply.) A. Vigorously rubbing the hands and fingers to reestablish circulation B. Immersion of hands and feet in hot water C. Loose wrapping of hands in mitten-like dressings to retain warmth D. Administering opioids to reduce pain E. Elevating the affected limbs F. Pad between fingers or toes to prevent blister rupture Question 74 The nurse is caring for the client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated? A. Loosening restrictive clothing B. Restraining the client’s limbs C. Removing the pillow and raising padded side rails D. Positioning the client to the side, if possible, with the head flexed forward Question 75 Which situation would be carrying an EpiPen be of the most benefit to a client?A. A history of hay fever from environmental allergies B. Allergy to poison ivy and grass C. No history of having allergic reactions D. Previous anaphylaxis allergic reaction to a wasp sting Question 76 A medication order states, lactated Ringers 1,000 mL IV to infuse over the next 8 hours. What is the infusion rate in mL/hr.? (Record answer as a whole number. Do not use a trailing zero.) 125 Question 77 A nurse assesses a client with a long history of seizure disorder. Which manifestation does the nurse understand as a typical reaction to long-term phenytoin sodium therapy? A. Weight gain B. Insomnia C. Excessive growth of gum tissue D. Deteriorating eyesight Question 78 A nurse is assessing a child at the scene of a school bus crash. This child has facial lacerations and audible stridor. The nurse should assign the child to which of the following triage categories? A. Emergent (red) B. Expectant (black) C. Urgent (yellow) D. Nonurgent (green)Question 79 During a power outage in summer, more individuals with heat-related conditions are seen in the local emergency departments. Which of the following is a risk factor for heat-related emergencies? A. Use of calcium channel blockers B. Middle-aged adults C. Heart disease D. Renal disease Question 80 A nurse is field triaging clients after an industrial accident. Which client condition would the nurse triage with a red tag? A. Dislocated right hip and open fracture B. Large contusion to the forehead and bloody nose C. Closed fracture of the right clavicle and arm numbness D. Multiple fractured ribs and shortness of breath Question 81 An emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client? A. A low respiratory rate B. Diminished breath sounds C. The presence of a barrel chest D. A sucking sound at the site of injuryQuestion 82 The client will have an electroencephalogram (EEG) in the morning. The nurse should instruct the client to have which foods/fluids for breakfast? A. No food or fluids B. Only coffee or tea if needed C. A full breakfast as desired without coffee, tea, or energy drinks D. A liquid breakfast of fruit juice, oatmeal, or smoothie Question 83 The client scheduled for surgery is confused and shows signs of dementia. There is no advance directive on file designating a power of attorney for healthcare. The nurse should ask which person to sign the consent for the client? A. Minister or pastor B. Nursing supervisor C. Attorney D. Spouse Question 84 An unresponsive 79-year-old is admitted to the emergency department (ED) during a summer heatwave for hypovolemic shock caused from dehydration. The client’s core temperature is 105.4 F (40.8 C), blood pressure (BP) 88/50 mmHg, pulse 112 beats/min, pulse oximeter is 95% on room air. Which of the following interventions would the nurse implement first? A. Insert a rectal temperature probe B. Administer Oxygen by nasal cannulaC. Start an intravenous access line D. Administer intravenous fluids as ordered Question 85 A 30-year-old female client sustained deep partial-thickness burns on the front and back of the right and left leg, front of right arm, and anterior trunk at 2000 while starting a bonfire. The client weighs 63 kgs. Use the Parkland Burn Formula to calculate the flow rate during the FIRST 8hrs (mL/hr.) after the burn if the client arrived in the ER at 2300. (Round to a whole number.) 14742/2, 1474 Question 86 The client is admitted to the hospital with a diagnosis of Guillain-Barre Syndrome. During the nursing admission interview, the nurse inquires if the client has a history of which of the following? A. Seizures or trauma to the brain B. Meningitis during the last five years C. Back injury or trauma to the spinal cord D. Respiratory or gastrointestinal infection during the previous month Question 87 When taking a client’s vital signs on the first post-operative day, the unlicensed assistive personnel (UAP) reports to the nurse that the oral temperature is 100 degrees F (37.8 degrees C). After encouraging the client to use the incentive spirometer, the nurse should delegate which activity to the UAP? A. Apply ice cap to the client’s forehead B. Bathe the client with cool waterC. Place the hyperthermia blanket on the client’s bed D. Continue to monitor the client’s temperature Question 88 After receiving a report on four clients, the nurse determines the order of care of the clients. Based on the report, the nurse will prioritize the clients to see which one first? A. A 4 year-old with a skin rash and sore throat B. A 72 year-old with chest pain and diaphoresis Question 89 An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. What action would the nurse take first? A. Apply oxygen and continuous pulse oximetry B. Provide small quantities of ice chips and sips of water C. Request a prescription for an antitussive medication D. Ask the respiratory therapist to provide humidified air Question 90 The nurse reminds a group of Certified Nursing Assistants (CNAs) that for a client with an elevated temperature, the quickest and simplest technique to reduce the temperature is which of the following? A. Apply wet washcloths to the forehead B. Bathe in tepid water C. Remove clothing and bed linenD. Give chilled drinks Question 91 The client recovering from a head injury is arousable and participating in care. Which of the following demonstrates effective client teaching on the prevention of increased intracranial pressure? A. Blowing their nose after sneezing B. Straining during a bowel movement C. Coughing vigorously D. Maintain an elevated head of bed to 30 degrees Question 92 The nurse is concerned about developing post-traumatic stress disorder after working for several years in the emergency department. Which of the following should the nurse do to ensure this disorder does not manifest? (Select all that apply.) A. Eat well-balanced meals B. Drink water C. Take breaks when needed D. Do not work more than 12 hours per day E. Ingest at least one alcoholic drink every evening F. Do not debrief after an incident Question 93 A client arrives at the emergency department following a motor vehicle collision. The client is not awake and is being bagged with a bag-valve-mask by paramedics. The client has sustained obvious injuries to the head and face and an open right femur fracture that is bleeding profusely. What will the nurse do first?A. Splint the right lower extremity B. Apply direct pressure to the leg C. Assess for a patent airway D. Start two large-bore IVs Question 94 Which of the following would be classified as an external disaster? A. A fire started in the emergency department B. A city-wide power outage C. Massive flooding D. A bomb threat to administration Question 95 A nurse on a medical-surgical unit is caring for a group of clients. The nurse should notify the rapid response team for which of the following clients? A. Client who has a pressure injury on the left heel whose blood glucose is 298 mg/dL B. Client who has blood on a pressure dressing in the femoral area following a cardiac catheterization C. Client with a central line whose lactic acid level is 6 mmol/L after 2 liters of 0.9% normal saline given in 1 hour D. Client in hospice care who has dark red coloration of left toes and palpable pedal pulse by Doppler Question 96 The low-pressure alarm sounds on a ventilator. After assessing the client and the ventilator, the nurse takes what action next? A. Reposition the client into a supine positionB. Checks the client’s vital signs C. Starts to ventilate the client manually D. Starts cardiopulmonary resuscitation Question 97 The nurse is evaluating preadmission laboratory studies. Which of the following laboratory results should be reported to the surgeon’s office? A. Sodium, 141 mEq/L B. Hemoglobin, 14.8 g/dL C. Platelets, 150,000/mm3 D. Serum creatinine,0.8 mg/dL Question 98 A client’s blood pressure reading is 104/50 mmHg. After determining the mean arterial pressure, the nurse understands the patient is at risk for which of the following complications?A. Increase in organ perfusion B. Decrease in cardiac output C. Rebound hypertension D. Increased stroke volume Question 99 The nurse has completed discharge instructions for the client with an application of a halo device. The nurse determines that the client needs further clarification of the instructions if the client states that they will do which of the following? A. Use a straw for drinkingB. Drive only during the daytime C. Use caution because the device alters balance D. Wash the skin daily under the lamb’s wool liner of the vest Question 100 A client presents to the emergency room with burns to the front of both legs and the front torso (chest and abdomen) after a firework went off when he was nearby. Estimate the percentage of body surface area burned using the rule of nines. 36 Question 101 The nurse is working on medical surgical unit when a fire breaks out in this stairwell near the nurse’s station. After rescuing anyone in immediate dsnage. What is the nurse’s next action? a. Alert the unit’s floor management b. Activate the emergency response system c. Close the door to the stairwell d. Extinguish the fire 102. The nurse is assessing a client for decerebrase posturing. What should the nurse assess the client for? A. Internal rotation and adduction of areas with flexion of the works. B. Progressive thickening of the palmar fasclo C. Abnormal flexion or exetersion of the upper extremitiesD. A dors flexction of the great toe and faming of the other toes 103. The nurse is caring a horspilzed client with frostbite. Which interventions are appropriate for this client? ( select all that apply) A. Massage the area to establish circulation B. Immersion of hands and feet in warm water C. Swirl the affected area in warm water, not touching the sides D. Administer intravenous opioids to reduce pain E. Administer ibuprofen to decrease thromboxane production Questions 104 A nurse is assessing the motor function an older adult client. The nurse would plan to use which of the following to test the client’s peripheral response to plan? a. Rubbing and twisting knuckles on the sternal bone b. Application of pressure on the nail base c. Pressure on the orbital-rim in the middle of the eyebrow d. Squeezing of the sternociedomastoid muscle