PN3 Exam 2

PN3 Exam 2 1. A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center? a. Level I-located within remote areas and provides advanced life support with resource capabilities b.Level II- located within community hospitals and provides care to most injured clients c. Level III- located in rural communities and provides only basic care to clients d. Level IV-located in large teaching hospitals and provides a full continuum of trauma care for all clients 2. 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 3. An emergency department charge nurse notes and increase in sick calls and bickering among the staff after a week with multiple trauma incidents. What action should 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 4. 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? (SATA) 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 5. A nurse is triaging clients in the emergency department. Which client would the nurse classify as “non-urgent?” a. A client with chest pain and diaphoresis b. A client with chest trauma and absent breath sounds c. A client with a runny nose and cough d. A client with temperature of 104F (40C) and difficulty breathing 6. A client presents to the Emergency Department with 30% total body surface area (TBSA) burns. The client weighs 176lbs. Use the Parkland Formula (4ml) to calculate the hourly rate for the first 8 hours. a. 600ml/hr. b. 1200ml/hr. c. 1760ml/hr. d. 2670ml/hr. 7. A client is being evaluated in the emergency department following burn injury at home. The client has second- and third-degree burns to bilateral posterior arms, posterior chest and back, and back of head, bilateral back legs. Using the rule of nines, the nurse would calculate this client’s burn as being: a. 36% b. 45% c. 54% d.49.5 8. A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide psychosocial support? a. Assign assistive personnel to keep his room neat and clean b. Rotate nursing staff so he can have varied interactions c. Utilize therapeutic technique d. Keep family members aware of his condition 9. A nurse is providing care for a 22-year-old female who received burns to much of head and anterior neck. As the nurse, you understand that Mary should be positioned in which of the following positions to prevent contractures of the head and neck? a. Hyperextension with no pillow b. Flexion and promoting side-to-side movement of the head c. Hyperextension with neck brace d. Flexion and supine 10. The nurse is in the emergency department is using a triage system because this system ranks clients by: a. Severity of illness or injury b. Body systems involved c. Name d. Age 11. Emergent interventions for a client with burns to the face and trunk/arms may include which of the following? (SATA) a. Inserting an indwelling urinary catheter b. Intubating the client c. Oral medications for pain management d.Starting an intravenous solution of Ringer’s lactate e. Range of motion exercise to avoid contractures to extremities 12. A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client’s care. The nurse should identify which of the following risks as the priority for assessment and intervention? a. Airway obstruction b. Infection c. Fluid imbalance d. Paralytic ileus 13. The emergency department nurse is preparing to triage victims of an internal event. Which of the following would be considered an internal event? a. Bus crash in front of the hospital b. Train crash 5 miles away c. Fire in the hospital d. Explosion in a nearby oil station 14. In the event of a mass casualty situation the best triage nurse is: a. The recently graduated registered nurse (RN) b. The licensed vocational nurse (LVN) with 5 years; experience c. The RN with the most experience and best assessment skills d. The recently graduated LVN 15. A client sustains burns to the anterior torso involving only the chest, anterior bilateral right and left legs and anterior right arm after a gas explosion. Using the rule of nines, what is the total body surface area (TBSA) % of burns? a. 36% b. 45% c. 40.5% d.31.5% 16. When caring for a client with severe burns, the nurse can expect to administer pain medication via which route? a. Intramuscular (IM) b.Intravenous (IV) c. Oral d. Subcutaneous 17. A client has sustained a 50% TBSA burns to torso and extremities in a house fire. The main weighs 154Lbs (70kg). Using the Parkland formula, how much fluid would this client be given in the first 24 hours? a. 12,000ml b.14,000ml c. 26,000ml d. 16,000ml 18. A client is receiving a large amount of fluids using the Parkland Formula following burns of 50% TBSA. the nurse knows that signs of fluid overload includes? (SATA) a. Formation of dependent edema b. Presence of lung crackles on auscultation c. Decreased skin turgor d.Engorged neck veins e. Loud, brassy cough 19. The nurse is aware that which phase begins 36 to 48 hours after a burn injury, when the fluid shift resolves and lasts until the wound closure is complete? a. Resuscitation phase b.Acute phase c. Chronic phase d. Rehabilitation phase 20. 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 suffered from? a. Cardiac arrest b. Hemorrhagic stroke c. Carbon monoxide poisoning d. Cyanide poisoning 21. A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)? a. Assess the client for sedation needs b. Get family permission for restraints c. Provide frequent oral care per protocol d. Use nonverbal pain assessment tools 22. A client has sustained circumferential full thickness burns to the left arm. The nurse knows that the fluid buildup under the burns and the eschar can lead to compression of the arterial circulation of the extremity. To restore the blood flow to the extremity which intervention will be necessary? a. Diuretics b.Escharotomy c. Elevate the affected arm higher than the heart d. Compression garment to the left arm 23. A nurse who is caring for a client who has a deep vein thrombosis and is prescribed continuous IV infusion at 1,200 units/hr. Available is heparin 25000 units in 250 mL D5W. The nurse should set the IV pump to deliver how many ml/hr? 24 mL/hr. 24. Mr. M. is admitted to the hospital with a GI bleed and his physician orders a blood transfusion of packed red blood cells. Order: 1-unit PRBCs (400 ml) IV to infuse over 4 hours. Drop factor: 15gtt/ml. What is the infusion rate in gtt/min? 25 gtt/min 25. A client is on mechanical ventilation and the client’s spouse wonders why ranitidine (Zantac) is needed since the client “only has lung problems.” what response by the nurse is best? a. “It will increase the motility of the gastrointestinal tract” b. “It will keep the GI tract functioning normally” c. “It will prepare the GI tract for enteral feedings” d.“It will prevent ulcers from the stress of mechanical ventilation” 26. A client is admitted to the ICU with a flail chest and placed on mechanical ventilation. The nurse should monitor for which of the following? a. Tuberculosis because the client will have prolonged close contact with other individuals b. Chest tube placement because the lung has collapsed c. Pneumonia because the client is a high risk for acquiring infection d. Cor pulmonale because the chest wall is unstable 27. The nurse is caring for a client that has been in a car accident. The nurse notices the client’s chest are movements are paradoxical (inward movement of the thorax wit inspiration with outward movement of the thorax with expiration). The nurse knows this condition is: a. Tension pneumothorax b. Pulmonary embolism c. Flail chest d. Hemothorax 28. The client has been intubated due to acute respiratory distress syndrome. Following a chest x-ray for ET tube placement, the tube was readjusted. The client’s abdomen is distended. In order to decompress the abdomen, the intervention necessary will be a. Place the client on his side b. Administer pantoprazole (Protonix) 40 mg IV c. Push on the abdomen d.Insert a nasogastric tube to decompress the stomach 29. A nurse in the intensive care unit is providing teaching for a client prior to removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching? a. “Rest in a side-lying position after the tube is removed” b. “Use the incentive spirometer every 4 hours after the tube is removed” c. “Avoid speaking for long periods” d. “A nurse will monitor your vital signs every 15 minutes in the first hour after the tube is removed” 30. The client sustained a blunt chest trauma and has a life-threatening tension pneumothorax. Initial management of a tension pneumothorax. Initial management of a tension pneumothorax is an immediate: a. Needle thoracostomy b. Place the client in high fowler’s position c. Surgery to drain the blood from the pleural space d. Chest x-ray to determine the extent of the pneumothorax 31. Which of the following interventions are for a client diagnosed with pneumothorax? (SATA) a. Apply wet to dry dressing on wound b. Monitor respiratory and circulatory function c. Assess for tracheal deviation d. Provide analgesics e. Insertion of a chest tube 32. The nurse is preparing for which intervention when she gets the code (crash) cart, airway equipment box, calls for the appropriate personnel and sets up suction? a. Embolectomy b. Chest tube placement c. Intubation d. Thoracostomy 33. A client has just been intubated following cardiac arrest. The nurse knows that in order to ensure the endotracheal tube (ET) has been placed properly is to: (SATA) a. Observe for symmetrical chest movement b. Assess breath sounds bilaterally c. Auscultate apical pulse for 1 full minute d.Verify placement by checking end-tidal carbon dioxide levels e. Assess for sounds over the gastric area 34. A nurse is completing discharge teaching with a client who has a permanent pacemaker. Which of the following statements by the client is correct? a. “I don't have to check my pulse anymore since I have a pacemaker” b.“I will wear a medical bracelet and carry the pacemaker identification card” c. “I don't have to tell airport security about my pacemaker” d. “I will start ROM exercises with my arms immediately” 35. A client with pulmonary embolism will have which of the following interventions? (SATA) a. Continuous monitoring of pulse ox b. Surgical chest tube placement c. Apply oxygen therapy d.Administration of anticoagulants and thrombolytic therapy e. Refrain from massaging/compressing leg muscles 36. A client is diagnosed with superior ventricular tachycardia; the nurse should prepare to administer which of the following medications? a. Procainamide b. Amiodarone c. Verapamil d.Adenosine 37. A one day post operative client is experiencing a sudden onset of chest pain, SOB, and hemoptysis. Based on history and presenting symptoms, which condition does the nurse expect? a. STEMI b. GI bleed c. Musculoskeletal pain d.Pulmonary Embolism 38. The nurse knows this drug will minimize the growth of existing clots and prevent the development of additional clots in the client with pulmonary embolism: a. Alteplase b. Levophed c. Heparin d. Surfactant 39. A 56-year-old female presents to the emergency department complaining of lightheadedness and chest palpitations, HR is 100, BP 70/40 the cardiac monitoring shows the following. What is the appropriate treatment? a. Cardiovert b. Defibrillate c. Administer lidocaine IV d. Administer Nitro IV 40. A client complains of fluttering in his chest, the nurse applies the cardiac monitor and correctly identifies the following rhythm as: a. Atrial fibrillation b.Atrial flutter c. Normal sinus rhythm d. Sinus tachycardia 41. A client is unresponsive and has no pulse, the nurse notes the electrocardiogram tracing shows continuous larger and bizarre QRS complexes measured greater than 0.12, this rhythm is identified as: a. Premature ventricular complexes (PVCs) b. Ventricular fibrillation c. Ventricular tachycardia d. Atrial tachycardia 42. A nurse is performing cardiopulmonary resuscitation (CPR) for an adult client who is unresponsive. The nurse should evaluate the client's circulation by palpating which of the following pulses? a. Radial b.Carotid c. Popliteal d. Apical 43. The nurse is caring for a client who is experiencing an increase in cardiac contractility, which of the following will decrease cardiac contractility and reduce myocardial oxygen? a. Administer pramcit as prescribed b. Administer digoxin as prescribed c. Administer beta-blockers as prescribed d. Administer potassium chloride as prescribe 44. The nurse caring for a client with severe burns, realizes that the clients care will progress through specific periods of treatment EXCEPT: a. Acute b. Resuscitation c. Rehabilitation d.Stabilization 45. The nurse is initiating care for a client diagnosed with burns to chest, back, neck, and face. For this client which following diagnosis would receive the highest priority? a. Disturbed body image b. Impaired skin integrity c. Ineffective airway clearance d. Risk for infection 46. A client presents to the ED C/O light-headedness and chest palpitations. HR is 90-120, BP 70/40. Cardiac monitor shows the following rhythm. a. Unsynchronized defibrillation b. Administer IV atropine c. High-quality chest compressions d.Synchronized cardioversion 47. The client presents to the ED with high pitched stridor, dyspnea, and cyanosis. The nurse is preparing for which ventilation after receiving the crash cart and airway management? a. Prepare the client for a surgical thoracotomy (needle decompression) b. Prepare the client for a surgical embolectomy c. Assist the health care provider with chest tube placement d.Assist the health care provider with endotracheal intubation 48. The nurse is preparing to discharge the client from the burn unit. Which of the following needs are the nurse's top priority to address before the client's discharge? SATA a. Development of a teaching plan b. Send employer work release paperwork with medical information attached c. Client and family teaching (home care) d. Send the clients medical records to law enforcement for investigation e. Rehabilitation referral 49. The nurse is caring for a client with burns to the face, neck, and bilateral upper arms prior to arrival the the ED. Which of the following interventions would the nurse do first? a. Assess for airway obstruction b. Administer IV isolated crystalloids according to the resuscitation Parkland formula c. Administer oral acetaminophen for pain management d.Assess for airway patency and apply oxygen per order 50. A nurse is interpreting the ECG rhythm strip of a client who has bradycardia. Which of the following cardiac components should the nurse identify as the role of the P wave? a. Atrial depolarization b. Early ventricular repolarization c. Slow repolarization of the ventricular Purkinje fibers d. Ventricular depolarization 51. A nurse is caring for a client with a pulmonary embolism. Upon assessment, the pulse oximeter is 86% on room air, respiratory rate is 32/minute, and the client is anxious. Which of the following is the nurses top priority? a. Assess for airway patency and apply oxygen per order b. Notify the HCP c. Reassess the client in one hour d. Document the assessment findings 52. A client complains of heart palpitations in the chest region. The nurse applies the cardiac monitor, revealing disorganized atrial impulses at 250/min and a ventricular heart rate of 90-120 BPM. The nurse identifies the following as which rhythm. a. Atrial flutter b. Normal sinus c. Sinus tachycardia d.Atrial fibrillation 53. A client with severe burns will progress through which phase of burn injury 24-48 hours after the injury until diuresis has occurred? a. Resuscitation phase b. Chronic phase c. Acute phase d. Recovery phase 54. A client is admitted with superficial burns to the shoulders from sunburn. Which of the following clinical manifestations should the nurse expect? a. Black, brown, yellow, white, and red wounds with hard necrotic tissue b. Red and white wounds with mild pain upon palpitation c. Painful pink to red wounds with blisters noted d.Painful pink to red wounds with mild edema, no blisters noted 55. The nurse is caring for a mechanically ventilated client and knows that older adults are at highest risk for weaning failure. What age-related changes contributes to failure with weaning off a ventilator? SATA a. Inability to cooperate b.Less lung elasticity c. Decreased muscle strength d. Poor vision and hearing e. Chest and wall stiffness 56. A client was admitted with a pneumothorax. Which of the following interventions would the nurse implement first? a. Assess for tracheal deviation b.Assess for respiratory and circulatory function c. Administer oral analgesics d. Apply a wet dressing to the wound 57. Which one of the following is the nurse's priority when evacuating clients for a fire in the hospital? a. Disconnect oxygen from the clients b. Utilize ambulatory clients to close doors, disconnect oxygen, and turn off lights c. Rescue and remove any clients or staff in immediate danger of the fire or smoke d. Disconnect life support machines attached to clients 58. The nurse is caring for a client who is experiencing upper abdominal pain. The ECG tracing interprets heart rate 80 bpm, QRS <0.10, PR-interval 0.16 seconds. This rhythm is identified as which of the following? a. Sinus Bradycardia b. Sinus tachycardia c. Normal sinus d. Sinus arrythmia 59. A client with decrease cardiac output from SVT exhibits which of the following clinical manifestations? a. Chest discomfort b. Hypotension c. Hypertension d.Palpitations e. Warm, dry skin