NUR 445 EXAM 4 COMPLETE EXAM QUESTIONS WITH VERIFIED ANSWERS
ALREADY GRADED A+ | ARIZONA COLLEGE OF NURSING
A nurse is assisting with triaging clients following an explosion. Which of the following clients
should the nurse identify as the highest priority?
A conscious adult client who has second-degree burns on both lower legs; respiratory rate is >
30/min
A nurse is reviewing treatment protocols for clients exposed to bioterrorism agents. For which of
the following agents should the nurse plan to administer a vaccine following exposure?
Smallpox
A charge nurse is discussing the phases of community response to disaster with nursing staff.
Which of the following statements indicates an understanding of the heroic phase of disaster
response?
"Personnel are willing to work in dangerous conditions to provide assistance."
A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the
following findings is the nurse's priority?
Blood pressure 92/50 mm Hg
A nurse is preparing to administer ciprofloxacin to a client. The nurse should identify that the
medication is treatment for exposure to which of the following agents?
Anthrax
A nurse is caring for a client who experienced an open, right femur fracture following a motor-
vehicle crash.
The nurse should identify that the client is most likely experiencing compartment syndrome.
Compartment syndrome occurs following a fracture due to increased edema of the extremity or
restriction by a cast or splint. It is identified by the five Ps: pain, pallor, pulselessness,
paresthesia, and paralysis. Compartment syndrome is a medical emergency. The nurse's priorities
are to loosen the dressing to the splint and assess the client's peripheral pulses. A pulse volume
recorder may be necessary to detect the peripheral pulses. The nurse should frequently monitor
the client's neurovascular function to detect any changes that may indicate further progression of
compartment syndrome. The nurse should also monitor and treat the client's pain using
prescribed opioids.
A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should
identify which of the following is the priority finding to report to the provider?
Difficulty swallowing
A nurse in an emergency department is caring for a client who has a sucking chest wound
resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of
118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?
Administer oxygen via nasal cannula.
, A community health nurse is teaching a group of community members about natural disasters.
Which of the following information about natural disasters should the nurse include in the
teaching?
They are geological or meteorological occurrences.
A nurse is among the first responders to a mass-casualty incident and does not know what type
of personal protective equipment (PPE) is needed. Which of the following actions should the
nurse take?
Choose the highest level of protection equipment available.
A public health nurse is teaching a group of nurses about smallpox. Which of the following
statements by one of the nurses indicates understanding of the teaching?
"Unlike chickenpox, the vesicles of smallpox are more abundant on the face."
A nurse is admitting a client who sustained severe burn injuries. The nurse refers to the rule of
nines to determine the total body surface area of the burn injury. What percentage of body
surface area should the nurse estimate the client has burned?
54%
Which of the following are potential indications for spinal immobilization in clients?
Spinal immobilization is indicated in clients with suspected spinal cord injury and loss of
consciousness as these conditions may be associated with spinal injury. Simple fractures of
extremities, acute myocardial infarction, asthma exacerbation, severe allergic reactions, and
acute appendicitis do not require spinal immobilization unless there is suspicion of associated
spinal injury.
A nurse is performing triage for a group of clients following a mass casualty incident (MCI).
Which of the following clients should the nurse plan to care for first?
A client experiencing a tension pneumothorax
When should a client with rib fractures use the incentive spirometer?
Every 1 hour while awake
A burn patient with 20% total body surface area (TBSA) burn is receiving fluid resuscitation.
The Parkland formula is being used to calculate the fluid replacement. The formula recommends
administering 4 mL of lactated Ringer's solution per kilogram of body weight for the first 24
hours, with half of the total volume given in the first 8 hours. The patient weighs 70 kg. How
much lactated Ringer's solution should the patient receive in the first 8 hours?
1400 mL
CORRECT
Correct! According to the Parkland formula, the patient should receive half of the total volume in
the first 8 hours. Therefore, the patient should receive 1400 mL of lactated Ringer's solution in
the first 8 hours (70 kg x 20 mL/kg = 1400 mL).
A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse
should administer which of the following fluids in the first 24 hr. following a burn injury?
ALREADY GRADED A+ | ARIZONA COLLEGE OF NURSING
A nurse is assisting with triaging clients following an explosion. Which of the following clients
should the nurse identify as the highest priority?
A conscious adult client who has second-degree burns on both lower legs; respiratory rate is >
30/min
A nurse is reviewing treatment protocols for clients exposed to bioterrorism agents. For which of
the following agents should the nurse plan to administer a vaccine following exposure?
Smallpox
A charge nurse is discussing the phases of community response to disaster with nursing staff.
Which of the following statements indicates an understanding of the heroic phase of disaster
response?
"Personnel are willing to work in dangerous conditions to provide assistance."
A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the
following findings is the nurse's priority?
Blood pressure 92/50 mm Hg
A nurse is preparing to administer ciprofloxacin to a client. The nurse should identify that the
medication is treatment for exposure to which of the following agents?
Anthrax
A nurse is caring for a client who experienced an open, right femur fracture following a motor-
vehicle crash.
The nurse should identify that the client is most likely experiencing compartment syndrome.
Compartment syndrome occurs following a fracture due to increased edema of the extremity or
restriction by a cast or splint. It is identified by the five Ps: pain, pallor, pulselessness,
paresthesia, and paralysis. Compartment syndrome is a medical emergency. The nurse's priorities
are to loosen the dressing to the splint and assess the client's peripheral pulses. A pulse volume
recorder may be necessary to detect the peripheral pulses. The nurse should frequently monitor
the client's neurovascular function to detect any changes that may indicate further progression of
compartment syndrome. The nurse should also monitor and treat the client's pain using
prescribed opioids.
A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should
identify which of the following is the priority finding to report to the provider?
Difficulty swallowing
A nurse in an emergency department is caring for a client who has a sucking chest wound
resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of
118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?
Administer oxygen via nasal cannula.
, A community health nurse is teaching a group of community members about natural disasters.
Which of the following information about natural disasters should the nurse include in the
teaching?
They are geological or meteorological occurrences.
A nurse is among the first responders to a mass-casualty incident and does not know what type
of personal protective equipment (PPE) is needed. Which of the following actions should the
nurse take?
Choose the highest level of protection equipment available.
A public health nurse is teaching a group of nurses about smallpox. Which of the following
statements by one of the nurses indicates understanding of the teaching?
"Unlike chickenpox, the vesicles of smallpox are more abundant on the face."
A nurse is admitting a client who sustained severe burn injuries. The nurse refers to the rule of
nines to determine the total body surface area of the burn injury. What percentage of body
surface area should the nurse estimate the client has burned?
54%
Which of the following are potential indications for spinal immobilization in clients?
Spinal immobilization is indicated in clients with suspected spinal cord injury and loss of
consciousness as these conditions may be associated with spinal injury. Simple fractures of
extremities, acute myocardial infarction, asthma exacerbation, severe allergic reactions, and
acute appendicitis do not require spinal immobilization unless there is suspicion of associated
spinal injury.
A nurse is performing triage for a group of clients following a mass casualty incident (MCI).
Which of the following clients should the nurse plan to care for first?
A client experiencing a tension pneumothorax
When should a client with rib fractures use the incentive spirometer?
Every 1 hour while awake
A burn patient with 20% total body surface area (TBSA) burn is receiving fluid resuscitation.
The Parkland formula is being used to calculate the fluid replacement. The formula recommends
administering 4 mL of lactated Ringer's solution per kilogram of body weight for the first 24
hours, with half of the total volume given in the first 8 hours. The patient weighs 70 kg. How
much lactated Ringer's solution should the patient receive in the first 8 hours?
1400 mL
CORRECT
Correct! According to the Parkland formula, the patient should receive half of the total volume in
the first 8 hours. Therefore, the patient should receive 1400 mL of lactated Ringer's solution in
the first 8 hours (70 kg x 20 mL/kg = 1400 mL).
A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse
should administer which of the following fluids in the first 24 hr. following a burn injury?
