NUR2755 / NUR 2755 Final Exam (Latest ):
Multidimensional Care IV / MDC 4
paradoxical chest movement - What is a classic sign of a flail chest?
Paradoxical chest movement
Cyanosis
Hypotension
Pain with exhalation
False - a disconnection is a low alarm - A disconnected ET tube from a ventilatory will
sound a high alarm on the vent
True
False
Elevate the head of the bed 30 degrees
mouth care q 2 hours*
suction prn* - To prevent a patient from getting VAP the nurse should include what in
her patient's care?
Perform mouth care q 12 hours
Suction q 1-2 hours around the clock
Elevate the head of the bed 30 degrees
Keep the patient on their left side
Pulmonary emboli - A post op patient complains of sudden SOB and pleuritis chest
pain. What is the most likely cause?
Pneumothorax
Pulmonary emboli
Heart attack
Congestive heart failure
False - Stupor is a sign of respiratory distress
True
False
27%
,half of the front torso (9%) + entire R arm (9%) + back of R leg (9%) - Calculate the
TBSA: Burn to half of the front torso, entire right arm, back of right leg
Head flat with legs elevated - A patient is showing early signs of shock. How should the
patient be positioned?
Head flat with legs elevated
Elevate HOB 30 degrees
Prone
Side-lying
Apical heart rate 50 - What finding is a sign of shock after a spinal cord injury?
Stabbing pain in the extremities
Apical heart rate 50
Inspiratory crackles
Elevated WBC count
True - One of the biggest risks of neurogenic shock is severe bradycardia
True
False
DIC is caused by abnormal clotting involving fibrinogen - Which statement is true
regarding DIC?
DIC is caused by abnormal clotting involving fibrinogen
Patients with DIC will be on lifelong hepatin
DIC is caused by a vitamin K deficiency
DIC is a genetic disorder
False! They need a warm room w/ warm fluids - The nurse should always lower the
temperature of the room for a patient with neurogenic shock
True
False
A patient who just extubated themselves - Which patient should be seen first?
An intubated patient with a flail chest
A patient with rib fractures asking for pain meds
A patient who just extubated themselves
A patient with a fracture and weak distal pulses
D-dimer - Which lab would the nurse anticipate for a patient with a pulmonary emboli?
, Sed rate
Urinalysis
CBC
D-dimer
True - A vena cava filter is one of the preventions used for patients with pulmonary
emboli to prevent further PEs
True
False
0.9% NS - Which IV fluid is the best choice for a patient in hypovolemic shock?
0.45% Sodium Chloride
0.9% NS
Dextrose 10%
Lactated Ringers
False - A patient with a tension pneumothorax and cardiovascular compression is at risk
for distributive shock
True
False
Increased MAP without change to vascular tone - Norepinephrine is often used for
patients in distributive shock due to its ability to cause
Increased MAP by increasing vascular tone
Decreased MAP by decreasing vascular volume
Decreased MAP from capillary leak
Increased MAP without change to vascular tone
*1,000 mL/hr*
Use Parkland Formula:
4mL x TBSA% x kg
4mL x 55% x (160/2.2) = 16,000 divided by 2 = 8,000 mL in the first 8 hours...8,000mL/8
hr = 1,000mL/hr - TBSA 55%, Wt 160 lbs, what is the initial IV rate if the client arrived
immediately after the injurt?
1000 mL/hr
800 mL/hr
750 mL/hr
1200 mL/hr
Multidimensional Care IV / MDC 4
paradoxical chest movement - What is a classic sign of a flail chest?
Paradoxical chest movement
Cyanosis
Hypotension
Pain with exhalation
False - a disconnection is a low alarm - A disconnected ET tube from a ventilatory will
sound a high alarm on the vent
True
False
Elevate the head of the bed 30 degrees
mouth care q 2 hours*
suction prn* - To prevent a patient from getting VAP the nurse should include what in
her patient's care?
Perform mouth care q 12 hours
Suction q 1-2 hours around the clock
Elevate the head of the bed 30 degrees
Keep the patient on their left side
Pulmonary emboli - A post op patient complains of sudden SOB and pleuritis chest
pain. What is the most likely cause?
Pneumothorax
Pulmonary emboli
Heart attack
Congestive heart failure
False - Stupor is a sign of respiratory distress
True
False
27%
,half of the front torso (9%) + entire R arm (9%) + back of R leg (9%) - Calculate the
TBSA: Burn to half of the front torso, entire right arm, back of right leg
Head flat with legs elevated - A patient is showing early signs of shock. How should the
patient be positioned?
Head flat with legs elevated
Elevate HOB 30 degrees
Prone
Side-lying
Apical heart rate 50 - What finding is a sign of shock after a spinal cord injury?
Stabbing pain in the extremities
Apical heart rate 50
Inspiratory crackles
Elevated WBC count
True - One of the biggest risks of neurogenic shock is severe bradycardia
True
False
DIC is caused by abnormal clotting involving fibrinogen - Which statement is true
regarding DIC?
DIC is caused by abnormal clotting involving fibrinogen
Patients with DIC will be on lifelong hepatin
DIC is caused by a vitamin K deficiency
DIC is a genetic disorder
False! They need a warm room w/ warm fluids - The nurse should always lower the
temperature of the room for a patient with neurogenic shock
True
False
A patient who just extubated themselves - Which patient should be seen first?
An intubated patient with a flail chest
A patient with rib fractures asking for pain meds
A patient who just extubated themselves
A patient with a fracture and weak distal pulses
D-dimer - Which lab would the nurse anticipate for a patient with a pulmonary emboli?
, Sed rate
Urinalysis
CBC
D-dimer
True - A vena cava filter is one of the preventions used for patients with pulmonary
emboli to prevent further PEs
True
False
0.9% NS - Which IV fluid is the best choice for a patient in hypovolemic shock?
0.45% Sodium Chloride
0.9% NS
Dextrose 10%
Lactated Ringers
False - A patient with a tension pneumothorax and cardiovascular compression is at risk
for distributive shock
True
False
Increased MAP without change to vascular tone - Norepinephrine is often used for
patients in distributive shock due to its ability to cause
Increased MAP by increasing vascular tone
Decreased MAP by decreasing vascular volume
Decreased MAP from capillary leak
Increased MAP without change to vascular tone
*1,000 mL/hr*
Use Parkland Formula:
4mL x TBSA% x kg
4mL x 55% x (160/2.2) = 16,000 divided by 2 = 8,000 mL in the first 8 hours...8,000mL/8
hr = 1,000mL/hr - TBSA 55%, Wt 160 lbs, what is the initial IV rate if the client arrived
immediately after the injurt?
1000 mL/hr
800 mL/hr
750 mL/hr
1200 mL/hr
