NUR445 Exam 4 UPDATED ACTUAL
Exam Questions and CORRECT Answers
A nurse is assisting with triaging clients following an explosion. Which of the following clients
should the nurse identify as the highest priority? - CORRECT ANSWER -A conscious
adult client who has second-degree burns on both lower legs; respiratory rate is > 30/min
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? - CORRECT ANSWER -"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? - CORRECT ANSWER -Blood pressure 92/50
mm Hg
A nurse is caring for a client who experienced an open, right femur fracture following a motor-
vehicle crash. - CORRECT ANSWER -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 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? -
CORRECT ANSWER -Smallpox
Which of the following are potential signs or symptoms of internal bleeding caused by a brown
recluse spider bite? - CORRECT ANSWER -Internal bleeding caused by a brown recluse
spider bite can manifest as abdominal pain, black or tarry stools, bloody or dark urine, and chest
pain with shortness of breath. Skin rash and itching, headache and dizziness, joint pain and
,swelling, numbness and tingling, and fever and chills are not typically associated with internal
bleeding from a spider bite.
A nurse is preparing a response protocol for botulism as a bioterrorism agent. The nurse should
prepare the protocol based on which of the following information? (Select all that apply.) -
CORRECT ANSWER -Botulism can produce paralysis within 12 to 72 hr following
exposure is correct. Botulism is a neurotoxin that can cause flaccid paralysis within hours of
exposure. Notify the Centers for Disease Control and Prevention (CDC) when more than three
cases are confirmed is incorrect. Due to the threat of a botulism outbreak, the CDC should be
notified if even a single case is suspected. Botulism is acquired through direct contact with an
infected person is incorrect. Botulism is primarily acquired through ingestion of a contaminated
food source. Vomiting and diarrhea are expected findings following exposure is correct.
Vomiting and diarrhea are expected findings following ingestion of botulism. Botulism is a toxin
found in castor beans is incorrect. Ricin, rather than botulism, is a toxin found in castor beans.
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? - CORRECT
ANSWER -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?
- CORRECT ANSWER -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? - CORRECT ANSWER -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? - CORRECT ANSWER -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? - CORRECT
ANSWER -"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? - CORRECT ANSWER -
54%
Which of the following are potential indications for spinal immobilization in clients? -
CORRECT ANSWER -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? - CORRECT
ANSWER -A client experiencing a tension pneumothorax
When should a client with rib fractures use the incentive spirometer? - CORRECT
ANSWER -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? - CORRECT
ANSWER -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? -
CORRECT ANSWER -Lactated Ringer's
Exam Questions and CORRECT Answers
A nurse is assisting with triaging clients following an explosion. Which of the following clients
should the nurse identify as the highest priority? - CORRECT ANSWER -A conscious
adult client who has second-degree burns on both lower legs; respiratory rate is > 30/min
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? - CORRECT ANSWER -"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? - CORRECT ANSWER -Blood pressure 92/50
mm Hg
A nurse is caring for a client who experienced an open, right femur fracture following a motor-
vehicle crash. - CORRECT ANSWER -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 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? -
CORRECT ANSWER -Smallpox
Which of the following are potential signs or symptoms of internal bleeding caused by a brown
recluse spider bite? - CORRECT ANSWER -Internal bleeding caused by a brown recluse
spider bite can manifest as abdominal pain, black or tarry stools, bloody or dark urine, and chest
pain with shortness of breath. Skin rash and itching, headache and dizziness, joint pain and
,swelling, numbness and tingling, and fever and chills are not typically associated with internal
bleeding from a spider bite.
A nurse is preparing a response protocol for botulism as a bioterrorism agent. The nurse should
prepare the protocol based on which of the following information? (Select all that apply.) -
CORRECT ANSWER -Botulism can produce paralysis within 12 to 72 hr following
exposure is correct. Botulism is a neurotoxin that can cause flaccid paralysis within hours of
exposure. Notify the Centers for Disease Control and Prevention (CDC) when more than three
cases are confirmed is incorrect. Due to the threat of a botulism outbreak, the CDC should be
notified if even a single case is suspected. Botulism is acquired through direct contact with an
infected person is incorrect. Botulism is primarily acquired through ingestion of a contaminated
food source. Vomiting and diarrhea are expected findings following exposure is correct.
Vomiting and diarrhea are expected findings following ingestion of botulism. Botulism is a toxin
found in castor beans is incorrect. Ricin, rather than botulism, is a toxin found in castor beans.
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? - CORRECT
ANSWER -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?
- CORRECT ANSWER -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? - CORRECT ANSWER -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? - CORRECT ANSWER -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? - CORRECT
ANSWER -"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? - CORRECT ANSWER -
54%
Which of the following are potential indications for spinal immobilization in clients? -
CORRECT ANSWER -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? - CORRECT
ANSWER -A client experiencing a tension pneumothorax
When should a client with rib fractures use the incentive spirometer? - CORRECT
ANSWER -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? - CORRECT
ANSWER -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? -
CORRECT ANSWER -Lactated Ringer's
