NUR 1055 multi-dimensional-care-mdc4-exam-2-study-questions and answers updated 2022

1) When caring for a patient who has septic shock, which assessment finding is most important for the nurse to report to the care provider? (a) BP 92/56 (b) Skin cool and clammy (c) Apical pulse 118 beats/min (d) Arterial oxygen saturation 91% 2) Calculate the mean arterial pressure (MAP) in mmHg for a patient with a blood pressure of 84/46mmHg. (Record answer to the nearest whole number) 59 3) The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding would indicate the presence of 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 injury 4) The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding? (a) Slow deep respirations (b) Rapid deep respiration (c) Paradoxical respirations (d) Pain, especially with inspiration 5) A client with a chest injury has suffered a flail chest. The nurse assesses the client for which most distinctive sign of flail chest? (a) Cyanosis (b) Hypotension (c) Paradoxical chest movement (d) Dyspnea, especially on exhalation 6) A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the highpressure alarm on the ventilator sounds and notes that the client has an absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition? (a) Right pneumothorax (b) Pulmonary embolism (c) Displaced endotracheal tube (d) Acute respiratory distress syndrome 7) A burn patient is brought into the emergency department with the following burns: half of the front torso, entire left arm, front of left leg. The nurse should record the TBSA burns as. (a) 27% TBSA (b) 35% TBSA (c) 20%TBSA (d) 40% TBSA 8) The client, who is one-day postoperative following chest surgery is having difficulty breathing, has bilateral rales, and is confused and restless. Which intervention should the nurse implement first? (a) Assess the client pulse oximeter reading (b) Notify the rapid response team (c) Place the client in the Trendelenburg position (d) Check the client’s surgical dressing 9) The intensive care unit (ICU) nurse is caring for a client on a ventilator who is exhibiting respiratory distress. The ventilator alarms are going off. Which interventions should the nurse implement first? (a) Notify the respiratory therapist immediately (b) Ventilate with a manual resuscitation bag (c) Check the ventilator to resolve the problem (d) Auscultate the client’s lung sound 10) The client in the intensive care unit is on a ventilator. Which interventions should the nurse implement? (select all that apply) (a) Ensure there is manual resuscitation bag at the bedside (b) Monitor the client’s pulse oximeter reading every shif (c) Assess the client’s respiratory status every 2 hours (d) Check the ventilatory setting every 4 hours (e) Collaborate with the respiratory therapist