MDC4
A 28 year old female is admitted for an elective surgical procedure. which information is most
important to report to the anesthesiologists before surgery - ANS-The client's statement that her
last menstrual period was 6 weeks previously
A 30-year-old female client sustained deep partial thickness burns on the foot and back of the
fight and left leg front of right arm and anterior trunk at 2000 while starting a bonfire. the client
weighs 63kg using the parkland formula calculate the first 8 hours pt arrived to the er at 2300 -
ANS-1474
A 56 year old client comes to the triage area with left sided chest pain diaphoresis and
dizziness. with an O2 of 88% of room air what is the priority nursing action - ANS-administer O2
via nasal cannula
A client arrives in the emergency department with an ischemic stroke because the healthcare
team is considering administering a tissue plasminogen activator administration the nurse
should preform which of the following first? - ANS-Identify the time of onset of the stroke
A client has accidentally received twice the normal dose of medication that was administered on
the previous shift. what should the nurse who discovered the error do next. - ANS-Assess the
client and note any changes in condition
A client has experienced a PE. a nurse assesses for which commonly reported symptom? -
ANS-Sudden onset of dyspnea
A client is on intravenous heparin to treat a pulmonary embolism. The client reports bleeding
gums and PTT was 120 seconds - ANS-Stop the heparin and notify the healthcare provider
A client is receiving warfarin after PE, the nurse evaluates the lab results and notifies the
physician that the client's warfarin level is therapeutic which of the following results is reported?
- ANS-INR 2.8
A client is to be discharged for same day surgery 7 hours after his inguinal hernia repair. which
nursing observation indicates this client is ready to be discharged SATA - ANS-the client voids
500ml of urine
the client has active bowel sounds
the client walks in the halway unassisted
the client o2 is 96% on room air
A client receives fluid resuscitation per the parkland formula after a severe burn and continues
to have urine output ranging from 20-25ml/hr. After the health care provider checks the client,
which order does the nurse question? - ANS-Administer furosemide 40mg iv push
A client who experienced a near drowing accident in a local pool now is awake and breathing
spontaneously is admitted for observation. which assesment will be most important during the
observation period - ANS-Auscultate breath sounds
A client who is conscious after a fall from a ladder is transported to the emergency department
by emergency medical personnel. which of the following does the nurse include in the
secondary survey - ANS-Complete a comprehensive assessment
, A client with a chest injury has suffered a flail chest. a nurse assesses the client for which most
distinctive sign of a flail chest - ANS-paradoxical chest movement
A client with a head injury regains consciousness after several days. When the client first
awakes what should the nurse say to the client - ANS-You are in the hospital. You were in an
accident and unconscious
A client with a serious head injury with increased ICP is to be discharged to a rehabilitation
facility. Which outcome of rehabilitation would be appropriate for the client? the client will -
ANS-Actively participate in the rehabilitation process as appropriate
A client with hypotension and an elevated temperature after working outside on a hot day is
treated in the emergency department. The nurse determines that discharge teaching has been
effective when the client makes which statement? - ANS-I should drink electrolyte sports drinks
when working outside in the hot weather
A client's blood pressure reading is 104/50. after determining the MAP the nurse understands
that the client is at risk for which of the following complications - ANS-decreased cardiac output
A medication order stated lactated ringers 1000 ml IV to infuse over the next 8 hours what is the
infusion rate - ANS-125
A nurse assesses a client for changes in LOC using GCS. the client opens his eyes when
spoken to. Withdrawals his extremities when pain is applied and verbalizes baseball when
referring to the bathroom. Which of the following GCS score should the nurse document -
ANS-E3+M4+V3=10
A nurse assesses a client with a long history of seizure disorder. Which manifestation does the
nurse understand is a typical reaction to long-term phenytoin sodium therapy? - ANS-Excessive
growth of gum tissue
A nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse is
interpreted as a normal finding at the surgical site? - ANS-Serous drainage
A nurse in an emergency department is caring for a client who had a seizure and became
unresponsive after stating she had a sudden sever headache and vomiting. The client's vitals
are as follows which of the following neurologic disorders should the nurse suspect -
ANS-Hemorrhagic stroke
A nurse in an emergency department is caring for a unconscious client with a penetrating
trauma from a gunshot and a sucking chest wound. the client has a blood pressure of 90/61 a
weak pulse rate of 117 and o2 of 80% on room air. Which action should the nurse take first in
the primary survey - ANS-provide bag valve mask ventilation
A nurse in field triaging clients after an industrial accident. which client condition would the
nurse triage with a red tag? - ANS-Multiple fractures ribs and SOB
A nurse in the emergency department is completing an assessment on a client who is in shock
which finding should the nurse expect SATA - ANS-Respiratory rate of 41
weak thready pulse
A nurse is assessing a client's lab values before surgery which result should the nurse report to
the provider SATA - ANS-creatinine 2.9
blood glucose 236
WBC 17,762
A 28 year old female is admitted for an elective surgical procedure. which information is most
important to report to the anesthesiologists before surgery - ANS-The client's statement that her
last menstrual period was 6 weeks previously
A 30-year-old female client sustained deep partial thickness burns on the foot and back of the
fight and left leg front of right arm and anterior trunk at 2000 while starting a bonfire. the client
weighs 63kg using the parkland formula calculate the first 8 hours pt arrived to the er at 2300 -
ANS-1474
A 56 year old client comes to the triage area with left sided chest pain diaphoresis and
dizziness. with an O2 of 88% of room air what is the priority nursing action - ANS-administer O2
via nasal cannula
A client arrives in the emergency department with an ischemic stroke because the healthcare
team is considering administering a tissue plasminogen activator administration the nurse
should preform which of the following first? - ANS-Identify the time of onset of the stroke
A client has accidentally received twice the normal dose of medication that was administered on
the previous shift. what should the nurse who discovered the error do next. - ANS-Assess the
client and note any changes in condition
A client has experienced a PE. a nurse assesses for which commonly reported symptom? -
ANS-Sudden onset of dyspnea
A client is on intravenous heparin to treat a pulmonary embolism. The client reports bleeding
gums and PTT was 120 seconds - ANS-Stop the heparin and notify the healthcare provider
A client is receiving warfarin after PE, the nurse evaluates the lab results and notifies the
physician that the client's warfarin level is therapeutic which of the following results is reported?
- ANS-INR 2.8
A client is to be discharged for same day surgery 7 hours after his inguinal hernia repair. which
nursing observation indicates this client is ready to be discharged SATA - ANS-the client voids
500ml of urine
the client has active bowel sounds
the client walks in the halway unassisted
the client o2 is 96% on room air
A client receives fluid resuscitation per the parkland formula after a severe burn and continues
to have urine output ranging from 20-25ml/hr. After the health care provider checks the client,
which order does the nurse question? - ANS-Administer furosemide 40mg iv push
A client who experienced a near drowing accident in a local pool now is awake and breathing
spontaneously is admitted for observation. which assesment will be most important during the
observation period - ANS-Auscultate breath sounds
A client who is conscious after a fall from a ladder is transported to the emergency department
by emergency medical personnel. which of the following does the nurse include in the
secondary survey - ANS-Complete a comprehensive assessment
, A client with a chest injury has suffered a flail chest. a nurse assesses the client for which most
distinctive sign of a flail chest - ANS-paradoxical chest movement
A client with a head injury regains consciousness after several days. When the client first
awakes what should the nurse say to the client - ANS-You are in the hospital. You were in an
accident and unconscious
A client with a serious head injury with increased ICP is to be discharged to a rehabilitation
facility. Which outcome of rehabilitation would be appropriate for the client? the client will -
ANS-Actively participate in the rehabilitation process as appropriate
A client with hypotension and an elevated temperature after working outside on a hot day is
treated in the emergency department. The nurse determines that discharge teaching has been
effective when the client makes which statement? - ANS-I should drink electrolyte sports drinks
when working outside in the hot weather
A client's blood pressure reading is 104/50. after determining the MAP the nurse understands
that the client is at risk for which of the following complications - ANS-decreased cardiac output
A medication order stated lactated ringers 1000 ml IV to infuse over the next 8 hours what is the
infusion rate - ANS-125
A nurse assesses a client for changes in LOC using GCS. the client opens his eyes when
spoken to. Withdrawals his extremities when pain is applied and verbalizes baseball when
referring to the bathroom. Which of the following GCS score should the nurse document -
ANS-E3+M4+V3=10
A nurse assesses a client with a long history of seizure disorder. Which manifestation does the
nurse understand is a typical reaction to long-term phenytoin sodium therapy? - ANS-Excessive
growth of gum tissue
A nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse is
interpreted as a normal finding at the surgical site? - ANS-Serous drainage
A nurse in an emergency department is caring for a client who had a seizure and became
unresponsive after stating she had a sudden sever headache and vomiting. The client's vitals
are as follows which of the following neurologic disorders should the nurse suspect -
ANS-Hemorrhagic stroke
A nurse in an emergency department is caring for a unconscious client with a penetrating
trauma from a gunshot and a sucking chest wound. the client has a blood pressure of 90/61 a
weak pulse rate of 117 and o2 of 80% on room air. Which action should the nurse take first in
the primary survey - ANS-provide bag valve mask ventilation
A nurse in field triaging clients after an industrial accident. which client condition would the
nurse triage with a red tag? - ANS-Multiple fractures ribs and SOB
A nurse in the emergency department is completing an assessment on a client who is in shock
which finding should the nurse expect SATA - ANS-Respiratory rate of 41
weak thready pulse
A nurse is assessing a client's lab values before surgery which result should the nurse report to
the provider SATA - ANS-creatinine 2.9
blood glucose 236
WBC 17,762
