N480 FINAL EXAM SHOCK AND BURNS UPDATED
ACTUAL QUESTIONS AND CORRECT ANSWERS
Question:
a pt has been admitted in anaphylactic shock due to an unknown allergen. the nurse
understands that the decrease in the pt's cardiac output is the result of which
mechanism?
a. increased alveolar ventilation
b. peripheral vasodilation
c. increased venous return
d. decreased myocardial contractility
Answer:
b. peripheral vasodilation
Question:
using the "rule of nines" calculate the percent of injury in an adult who was injured as
follows: the pt sustained partial and full thickness burns to half of his arm anteriorly,
his entire leg, and his perineum.
a. 28%
b. 16%
c. 45.5%
d. 23.5%
Answer:
d. 23.5%
Question:
the nurse is concerned about a deteriorating pt. which signs of cardiogenic shock does
the nurse expect? (SATA)
a. bounding pedal pulse
b. BP 86/42
c. cool and moist skin
d. HR 126 bpm
e. urine output 20 mL/hr
Answer:
b. BP 86/42
c. cool and moist skin
d. HR 126 bpm
e. urine output 20 mL/hr
, Question:
a pt with massive trauma and possible SCI is admitted to the ER, which assessment
finding by the nurse will help confirm a diagnosis of neurogenic shock?
a. cool clammy extremities
b. inspiratory crackles
c. HR 39 bpm
d. temp 101.2
Answer:
c. HR 39 bpm
Question:
a pt is admitted to the burn unit with burns to the upper body and head after a garage
fire. initially, wheezes are heard, but an hour later, the lung sounds are decreased and
no wheezes are audible. what is the best action for the nurse to take?
a. encourage the pt to cough and auscultate the lungs again
b. notify the HCP and prepare for endotracheal intubation
c. reposition the pt in high fowler's and reassess breath sounds
d. document the results and continue to monitor the pt's RR
Answer:
b. notify the HCP and prepare for endotracheal intubation
Question:
a pt is admitted with a brain and SCI secondary to an
MVC. the nurse is monitoring the pt for signs of neurogenic shock. clinical findings in
neurogenic shock are related to which pathophysiologic process?
a. focal injury to cerebral hemisphere
b. loss of SNS innervation
c. PNS stimulation
d. injury to the hypothalamus
Answer:
b. loss of SNS innervation
Question:
a nurse is caring for a pt admitted to the ER with extensive partial and full thickness
burns of the head, neck, and chest. while planning the pt's care, the nurse should be
aware that initially, the pt is at greatest risk for which of the following?
a. infection
b. airway obstruction
c. fluid imbalance
d. paralytic ileus
Answer:
b. airway obstruction
ACTUAL QUESTIONS AND CORRECT ANSWERS
Question:
a pt has been admitted in anaphylactic shock due to an unknown allergen. the nurse
understands that the decrease in the pt's cardiac output is the result of which
mechanism?
a. increased alveolar ventilation
b. peripheral vasodilation
c. increased venous return
d. decreased myocardial contractility
Answer:
b. peripheral vasodilation
Question:
using the "rule of nines" calculate the percent of injury in an adult who was injured as
follows: the pt sustained partial and full thickness burns to half of his arm anteriorly,
his entire leg, and his perineum.
a. 28%
b. 16%
c. 45.5%
d. 23.5%
Answer:
d. 23.5%
Question:
the nurse is concerned about a deteriorating pt. which signs of cardiogenic shock does
the nurse expect? (SATA)
a. bounding pedal pulse
b. BP 86/42
c. cool and moist skin
d. HR 126 bpm
e. urine output 20 mL/hr
Answer:
b. BP 86/42
c. cool and moist skin
d. HR 126 bpm
e. urine output 20 mL/hr
, Question:
a pt with massive trauma and possible SCI is admitted to the ER, which assessment
finding by the nurse will help confirm a diagnosis of neurogenic shock?
a. cool clammy extremities
b. inspiratory crackles
c. HR 39 bpm
d. temp 101.2
Answer:
c. HR 39 bpm
Question:
a pt is admitted to the burn unit with burns to the upper body and head after a garage
fire. initially, wheezes are heard, but an hour later, the lung sounds are decreased and
no wheezes are audible. what is the best action for the nurse to take?
a. encourage the pt to cough and auscultate the lungs again
b. notify the HCP and prepare for endotracheal intubation
c. reposition the pt in high fowler's and reassess breath sounds
d. document the results and continue to monitor the pt's RR
Answer:
b. notify the HCP and prepare for endotracheal intubation
Question:
a pt is admitted with a brain and SCI secondary to an
MVC. the nurse is monitoring the pt for signs of neurogenic shock. clinical findings in
neurogenic shock are related to which pathophysiologic process?
a. focal injury to cerebral hemisphere
b. loss of SNS innervation
c. PNS stimulation
d. injury to the hypothalamus
Answer:
b. loss of SNS innervation
Question:
a nurse is caring for a pt admitted to the ER with extensive partial and full thickness
burns of the head, neck, and chest. while planning the pt's care, the nurse should be
aware that initially, the pt is at greatest risk for which of the following?
a. infection
b. airway obstruction
c. fluid imbalance
d. paralytic ileus
Answer:
b. airway obstruction
