PN3 EXAM 2 GUIDE

PN3 EXAM 2 GUIDE 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 44-year old with chest pain and diaphoresis b. A 50-year old with chest trauma and absent breath sounds c. A 62-year old with a simple fracture of the left arm d. A 79 year old with a temperature of 104F (40C) 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 the right and left arms, back and both posterior legs. Using the rule of nines, the nurse would calculate this client’s burn as being: a. 36% b. 45% c. 54% d. 72% 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 emotional support? a. Assign assistive personnel to keep his room neat and clean b. Rotate nursing staff so he can have varied interactions c. Talk with the client during wound care d. Keep family members aware of his condition 9. You are providing care to Mary 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 bst assessment skills d. The recently graduated LVN 15. A client who ignited a rubbish pile with gasoline-sustained burns to his anterior torso, bilateral anterior legs and right anterior arm. 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 154ibs (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 this phase in burn injury began at admission, however it is technically defined when there has been wound closure? 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. Escharectomy 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 25,000 units in 500 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 (40 ml) IV to infuse over 4 hours. Drop factor: 15gtt/ml. What is the infusion rate in gtt/min? a. 25 gtt/min b. 41 gtt/min c. 43 gtt/min d. 52 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 flair 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 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 inorder 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. Check apical pulse for 1 full minute d. Verify with chest x-ray e. Assess for extended neck veins 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 call my doctor about prolonged hiccups” c. “I don't have to tell airport security about my pacemaker” d. “I will wear a sling for the first 24 hours, then start ROM exercise with left arm” 35. A client with pulmonary embolism will have which of the following interventions? (SATA) a. IVC (inferior vena cava filter) b. Embolectomy c. Chest tube placement d. Heparin drug therapy e. Thoracotomy 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. PE 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