ATI MEDSURG 2 NUR 265/ ER/SHOCK/ DISASTER DETAILED ANSWER KEY NEURO -SHOCK & BURNS PRACTICE EXAM 2024 -2026 An occupational health nurse is instructing workers at an industrial facility in emergency procedures in the event of a traumatic amputation. Which of the following guidelines should the nurse include for emergency ca re? (Select all that apply.) Wrap the part in dry sterile gauze. Place the severed end of the part into crushed ice. Put the severed part in a dry, waterproof plastic bag. Elevate the extremity . Prevent contact of the severed part with water . - CORRECT A NSWER✔
✔Wrap the part in dry sterile gauze. Put the severed part in a dry, waterproof plastic bag. Elevate the extremity. Prevent contact of the severed part with water. A nurse is caring for a client who has hypovolemic shock. Which of the following shoul d the nurse recognize as an expected finding? hypertension flushing of the skin oliguria bradypnea - CORRECT ANSWER ✔✔ oliguria A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be deve loping hypovolemic shock? * Decrease in the respiratory rate from 20 to 16/min. *Decrease in the urinary output from 50 mL to 30 mL per hour. *Increase in the temperature from 37.5° C (99.5° F) to 38.6° C (101.5° F). *Increase in the heart rate from 88 to 110/min. - CORRECT ANSWER ✔
✔increase hr from 88 to 110 A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect? Mottled skin Blood pressure 115/68 mmHg Heart rate 160/min Metabolic acidosis - CORRECT ANSWER ✔✔ BP 115/68 mmHg A nurse is caring for a client who is taking aspirin for arthritis. The nurse should identify which of the following findings as an adverse effect of this medication? tinnitus clay colored stools nystagmus respi ratory depression - CORRECT ANSWER ✔✔ tinnitus A nurse in the emergency department is preparing to care for a client who received multiple injuries during a fight. The nurse should plan to base his primary survey on which of the following? (Select all that apply.)
✔Wrap the part in dry sterile gauze. Put the severed part in a dry, waterproof plastic bag. Elevate the extremity. Prevent contact of the severed part with water. A nurse is caring for a client who has hypovolemic shock. Which of the following shoul d the nurse recognize as an expected finding? hypertension flushing of the skin oliguria bradypnea - CORRECT ANSWER ✔✔ oliguria A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be deve loping hypovolemic shock? * Decrease in the respiratory rate from 20 to 16/min. *Decrease in the urinary output from 50 mL to 30 mL per hour. *Increase in the temperature from 37.5° C (99.5° F) to 38.6° C (101.5° F). *Increase in the heart rate from 88 to 110/min. - CORRECT ANSWER ✔
✔increase hr from 88 to 110 A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect? Mottled skin Blood pressure 115/68 mmHg Heart rate 160/min Metabolic acidosis - CORRECT ANSWER ✔✔ BP 115/68 mmHg A nurse is caring for a client who is taking aspirin for arthritis. The nurse should identify which of the following findings as an adverse effect of this medication? tinnitus clay colored stools nystagmus respi ratory depression - CORRECT ANSWER ✔✔ tinnitus A nurse in the emergency department is preparing to care for a client who received multiple injuries during a fight. The nurse should plan to base his primary survey on which of the following? (Select all that apply.)
