Copy of MDC 4 Final Blueprint, (Answered) Complete Solution

Copy of MDC 4 Final Blueprint, (Answered) Complete Solution The student got an 82% with the answers that are selected~ 1. Which 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 p. 151 A key process in any multi-casualty or mass casualty response is effective triage to rapidly sort ill or injured patients into priority categories based on their acuity and survival potential. d. taking vital signs 2. The nurse reminds a group of certified nursing assistants (CNA) that for a client with an elevated temperature, the quickest and simplest technique to reduce a temperature is which of the following? a. Apply cool wash cloth to forehead b. bathe in tepid water c. remove clothing and bed linen- dumb but I think this is the right answer… watched another review that said this exactly- BR Removing the patient's clothing and bed linen covering the patient is a quick, simple, and usually effective way to reduce temperature. The application of ice packs may result in excessive cooling and result in shivering, which acts to increase metabolic rate. Bathing in tepid water is effective but requires more time and interaction than simply removing clothing and bed linens. Chilled drinks will not adequately reduce the total body temperature. d. give chilled drinks- don’t want to give them drinks cuz they could aspirate 3. Which time of the 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 clients 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 4. 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 clients appetite c. relieve muscular spasticity d. reduces the urine bacterial count 5. the 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 typical associated with initial third spacing fluid shift? a. Hypercalcemia b. Hypernatremia c. Hyperkalemia p. 485 --- hyperkalemia, hyponatremia, metabolic acidosis, hypovolemia d. Hypokalemia 6. When taking a client's vital signs on the first postoperative day, the unlicensed assistive Personnel reports to the nurse that the oral temperature is 100 degrees. After encouraging the clients use the incentive spirometer, the nurse should delegate which activity to the UAP? a. Apply a ice caps the clients forehead b. bathe the client with cool water c. place a hyperthermia blanket on the client's bed I think the idea of the hypothermia blanket is to prevent shock-RM but what are the indications of shock? I remember Fitz saying something about once they are below 102 to stop the cooling or else it’ll drop too far down. She might have said that in clinical though -BR so a slight increase in temperature can indicate risk for sepsis, right?-RM I mean it could but even if it did I think antibiotics would be done and then the blanket later if the temp kept climbing d. continue to monitor the clients temperature- I think this one is correct… it’s not a fever? I can’t find much in the postop chapter on this; a UAP woudlnt “monitor” that requires judgement af 7. the nurse is assessing a client with multiple traumas who is at risk for developing acute respiratory distress syndrome(ARDS). the nurse assesses for which earliest sign of acute respiratory distress syndrome? a. Bilateral wheezing b. inspiratory crackles c. work load… let me look d. increased respiratory rate I found this rationale - The earliest detectable sign of ARDS is an increased respiratory rate, which can begin from 1-96 hours after the initial injury to the body. This is followed by increasing dyspnea., air hunger, retractions of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine 8. a client has a jackson-pratt drainage tube in place the first day after surgical repair of a ruptured diverticula. The client asks the nurse the purpose of the drains. What is the nurses best response? The drainage tube is used to prevent”: a. infection in the peritoneal cavity- Okay so fitz week 4 lecture 1hr 56 minutes in mentions it removes fluid to lower chances of infection b. Bleeding into the peritoneal cavity--- pretty sure it’s this one, I don’t think drains prevent infection they just pull blood out, page 278 briefly talks about them being put in if the surgeon expects more than a minimal amount of drainage c. Pressure on the bladder d. Pressure on the gallbladder 9. Wasn’t this question ^^^^ It was what drain removed through gravity options were woundvac, jp drain, penrose, and another I put penrose. 10. 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 facilities sick leave policy c. Arrange for critical incident stress debriefing d. Talk individually with staff members 11. The nurse is assessing a client for decorticate 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 12. A client with a serious head injury with increased intracranial pressure is to be discharged to a rehabilitation facility. Which outcome of rehab 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. 13. Which findings will the nurse observe in the client in the ictal phase of generalized tonic-clonic seizure? a. Jerking in one extremity that spreads gradually to adjacent areas b. Vacant staring and abruptly ceasing all activity c. Facial grimaces, patting motions, and lip-smacking d. Loss of consciousness, body stiffening, and violent muscle contractions 14. The nurse is aware that the treatment for frostbite includes the following: (SATA) Vigorously rubbing the hands in fingers to reestablish circulation Immersion of hands and feet in warm water Tightly wrapping hands in mitten-like dressings to retain warmth Administering opioids to reduce pain Elevating the affected limbs- pg 144 15. A nurse is caring for several clients at risk for shock. Which laboratory values requires the nurse to communicate with the healthcare provider? a. Creatinine: 0.9 mg/dL b. Lactate: 54 mg/dL c. Sodium: 145 mEq/L d. White Blood cell count: 11,000/mm3 16. A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3, blood glucose level 198 mg/dL, and temperature 96.2f. What action by the nurse takes priority? a. Document the findings in the client's chart b. Give the client warmed blankets for comfort c. Notify the health care provider immediately d. Prepare to administer insulin per sliding scale 17. During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control which of the following in the client? a. Pulse b. Respirations c. Blood pressure d. Temperature 18. A medication order for a client that weights 80 kg states, infuses dobutamine 250 mg mL D5W at 4 mcg/kg/min. The infusion pump must be set to mL/hr? (whole number) 19 19. A client has undergone preadmission laboratory studies, including a CBC, coagulation studies, and electrolytes and creatinine levels. Which of the following laboratory results should be reported to the surgeon’s office by the nurse knowing that it could cause the surgery to be postponed? a. Sodium 141 b. Hemoglobin 8.0 c. Platelets, 210,000 d. Serum creatinine 0.8 20. 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 dependence on the drug develops over time b. Status epilepticus may develop c. A hypoglycemic reaction develops d. Heart block is likely to develop 21. 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 cause d. If you are deployed, you will be issued a temporary license in the state in which you are working. 22. The client has returned to the surgery unit from the post anesthesia unit (PACU). The client’s respirations are rapid and shallow, the pulse is 120 bpm, and the BP is 88/52. 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 therapists d. Call the rapid response team (RRT)/medical emergency team 23. 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? (SATA) a. The client voids 500 mL of urine b. The client has active bowel sounds c. The client’s pain is not controlled d. The client walks in the hallway unassisted e. The client 02 saturation is 90% on room air 24. The nurse is assessing a client in the postictal phase of generalized tonic-clonic seizure. The nurse should determine if the client has which of the following assessment findings?