NUR 250 - Excelsior University| NUR250 Module 4 | Complete Questions and Answers latest fall 2025/26.

NUR 250 - Excelsior University| NUR250 Module 4 | Complete Questions and Answers latest fall 2025/26. Module 4 questions 1. The director mentions the initial notification the ED will receive from an external source. Which of the following information should the nurse expect that the ED will learn when they receive the initial notification about the incident? Select all that apply. A Type of incident B Estimated number of casualties C Type of injuries to expect D Estimated time to activate the phone tree E The plan for traffic control F The plan for rescheduling elective surgeries 2. The director discusses the placement of clients from the mass casualty in hospital areas based on the colors of their triage tags. Match the color of the tag with the client on whom the triage nurse will place the tag. Drag the options on the left to their match on the right (or match pairs by first selecting the option on the left and then selecting its match on the right). Client who has burns and a spinal cord injury Red tag Client who has deep lacerations and fractures Yellow tag Client who has agonal respirations Black tag Client who has superficial lacerations and a sprain Green tagModule 4 questions 3. A nurse is participating in the daily intensive care unit (ICU) rounds using the ABCDEF tool to assess a critically ill client. Which of the following actions should the nurse take during the rounds? Select all that apply. A Report the client's current status, including changes in physical and mental functioning over the previous 24 hours. B Discuss the client's response to medications used to treat pain, agitation, and delirium. C Provide an update on the client's nutritional status and intake. D Conduct a spontaneous awakening trial by stopping sedatives and narcotics as prescribed. E Increase the dose of sedatives if the client shows signs of agitation during the weaning process from the ventilator. 4. Which of the following clients is at the highest risk for developing delirium in the ICU? A 35-year-old client who is postoperative after an axillofemoral bypass graft B 78-year-old client who is being treated for pneumonia with possible sepsis C 55-year-old client who is postoperative following catheter ablation for supraventricular tachycardia D 65-year-old client who has myocardial infarction and is postoperative following stent placement 5. The ED nurse is triaging five clients. Match the client situations with the appropriate triage level. Drag the options on the left to the corresponding category on the right (or select the option on the left and then the corresponding category on the right). Level 1—Resuscitation Client has systolic BP 56. Level 2—High risk Client requires oxygen at 6 L/min. Level 3—Two resources needed Client requires IV fluids and chest x-ray. Level 4—One resource neededModule 4 questions Client requires an ECG. Level 5—No resources needed Client requires admission assessment. 6. A nurse is performing the primary survey of a trauma client in the emergency department. Place the following steps of the ABCDE assessment in the correct order that the nurse should perform them. Drag the options on the left to the corresponding category on the right (or click the option on the left and then the corresponding category on the right). 1 Assess mouth, larynx, pharynx, trachea, bronchi, and bronchioles for potential obstruction or aspiration. 2 Assess for respiratory distress, rate, oxygen saturation, and chest movement. 3 Assess heart function and blood vessels for signs of cardiac arrest or hemorrhage.  4 Assess neurological status using the AVPU scale. 5 Assess for injuries and preserve any evidence such as clothing or weapons. 7. Which of the following is the primary reason that a client who has experienced a sexual assault may choose not to report the assault? A Fear of stigma B Unable to prove that assault happened C Concern for retribution D Being unsure that the assault was a crimeModule 4 questions 8. A nurse is performing a physical assessment on a client who has presented to the emergency department. Which of the following key points should the nurse include to evaluate the client's circulatory or cardiac status? Select all that apply. A Assess perfusion in hands and feet. B Compare blood pressure readings while the client is lying and standing. C Observe for jugular venous pressure (JVP). D Check carotid pulse for amplitude and contour. E Listen to heart sounds. Case Study Part 1 The nurse is assessing Jennifer, a 20-year-old woman who was admitted to the emergency department at 1300 hours. Jennifer’s ABCDE assessment and x-ray revealed a complete fracture in her right tibia and fibula, which she states she “got when she fell.” Jennifer reports no previous health problems. She states she is single and living with several women in an apartment nearby. Jennifer is accompanied by an individual who Jennifer refers to as “her uncle.” Jennifer’s fracture has been splinted and stabilized, and she is waiting to be admitted to the medical surgical unit for surgery tomorrow. Jennifer’s vital signs are stable: temperature of 96° F; apical pulse is 74/min and regular; respirations are 18/min and regular; blood pressure is 126/72 mm Hg; pain is 7/10. Following evaluation by the trauma team, morphine sulfate 5 mg IV was administered for pain at 1330. 9. Which of the following pulse sites should the nurse assess now?Module 4 questions Right pedal pulse 10. Which of the following should the nurse do next? A Repeat vital signs. B Provide handoff report to unit nurse. C Obtain urine for analysis. D Perform secondary survey. Case Study Part 2 At 1430 Jennifer was moved to a private room to complete the secondary survey. The survey revealed skin abrasions on her wrists and multiple wounds in various stages of healing on her back, arms, and buttocks. Jennifer appears very thin for her height and seems afraid to respond to specific questions about her living and eating situation. Also noted was a tattoo on her upper left arm picturing a doubleheaded dragon. Jennifer reported having had previous abortions. The nurse questions Jennifer about her pain, and Jennifer reports it at 7 out of 10. Jennifer seems frightened and asks, “What is going to happen to me next?” An additional dose of morphine sulfate 5 mg is administered. Case Study Part 3 The nurse has recognized that Jennifer is most likely being trafficked. Legally the nurse is required to obtain Jennifer’s consent in order to intervene. The nurseModule 4 questions discusses their concerns with Jennifer, and Jennifer affirms their suspicions regarding Jennifer’s trafficking situation. The nurse offers to help, and Jennifer readily consents. Social services are consulted, and the National Human Trafficking Hotline is called for further assistance. At 1430, the nurse proceeds to implement standard measures for clients who have fractures. Jennifer reported pain at 10 out of 10, no paresthesia, poikilothermic, no paralysis. Pedal pulse was difficult to feel, and the foot was swollen. The nurse reported the findings to the provider. 11. Using SBAR, which of the following assessments will the nurse report to the provider? A Jennifer may be developing compartment syndrome. B Jennifer may need another dose of pain medicine. C Jennifer’s wrappings are too loose. D Jennifer may need a different splint. 12. A nurse is caring for multiple clients in the emergency department following a factory fire. Which of the following actions should the nurse take during the primary survey of clients who have sustained burn injuries? Select all that apply. A Assess for evidence of burns around the mouth and nose. B Determine the percentage of total body surface area affected by burns. C Initiate intravenous fluid resuscitation for clients with burns greater than 15% of TBSA. D Recommend mechanical ventilation for clients who exhibit continuous coughing. E Monitor oxygen saturation and provide supplemental oxygen for readings less than 95%.Module 4 questions 13. A nurse is actively triaging clients at the scene of a mass casualty incident. Match the following client scenarios with the appropriate triage tag colors based on the SALT triage system. Drag the options on the left to the corresponding category on the right (or click the option on the left and then the corresponding category on the right). Black Tag Client found unresponsive with no signs of breathing after initial positioning. Red Tag Client exhibiting signs of shock with rapid, shallow breathing and weak, thready pulse, but responsive to painful stimuli. Yellow Tag Client unable to walk without assistance due to a suspected fracture in the lower leg, but with stable vital signs and no respiratory distress. Green Tag Client walking wounded, with a sprained ankle and minor abrasions, fully alert and oriented. 14. A nurse is caring for a client who has a fracture who was admitted to the hospital following an earthquake. The nurse suggests that the provider prescribes 5 mg of morphine sulphate IV for pain instead of the 10 mg IV. This is an example of which of the following strategies? A Substitute B Adapt C Conserve D Reallocate 15. A client’s blood pressure is 95/65 mm Hg. The ICP is 18 mm Hg. What is the client’s CPP? MAP- S + 2(D)/3 95+ 2(65)/3= 95+ 130/3= 225/3=75 MAP-ICP=CPP 75-18= 57 The client is at risk of decreased cerebral perfusion because the CPP is less than 60 mm Hg. 16. For which of the following reasons should enteral nutrition be started within 24 to 48 hr of admission in high nutritional risk clients?Module 4 questions A Prevent bacterial translocation B Decrease client’s hunger C Increase oxidative stress D Improve level of consciousness Case Study Part 2 Edward was connected to telemetry in the ED, and their vital signs were BP 189/94, HR 91, RR 16, Temp 37.2º C (99º F), O2 sat 93%, pain 6/10 (headache). They also had general weakness and increasing dizziness when lying down. GCS 13. Edward was taken emergently to CT scan. 17. Which of the following clinically significant cues does the nurse need to further investigate? Select all that apply. A Pain B Elevated blood pressure C O2 saturation D Weakness and dizziness E GCS F CT scan resultsModule 4 questions 18. A nurse is assessing a client following a traumatic brain injury. Which of the following findings could indicate an increase in intracranial pressure? Select all that apply. A New onset of confusion B  GCS score change from 8 to 9 C Photophobia D Headache E Pain level change from 6 to 8 19. A nurse is caring for a client who has increased intracranial pressure, is on mechanical ventilation and is receiving propofol. The nurse should monitor the client for which of the following potential adverse effects? A Dry eyes B Hypokalemia  C Hypotension  D Edema 20. A nurse is caring for a client who has a traumatic brain injury and a ventriculostomy. Which of the following is the purpose of the ventriculostomy? A Measures CSF output from the brain ventricles B Monitors intracranial pressure C Drains venous blood from the cranium D Provides sedation directly into the brainModule 4 questions 21. Which of the following are risk factors or comorbidities for an SAH? Select all that apply. A Diabetes mellitus B Traumatic brain injury C Being older than 40 D Smoking E Hypertension Case Study Part 3 Edward returned from getting a CT scan. They have become increasingly drowsy and will only open their eyes to pain. Their speech is slurred and incomprehensible. Edward withdraws to painful stimuli. Their pupils are unequal. They are placed back on telemetry. Their vital signs are now BP 158/81, HR 72, RR 13, Temp 37.5º C (99.5º F), O2 sat 88%. Their GCS has changed from 13 to 8. Their CT scan shows a subarachnoid hemorrhage. 22. Which of the following is the new priority for Edward after they return from getting a CT scan? A Airway protection B Pain control C Blood pressure control D Siderails up x 2 23. Sort the following tasks into tasks that would be included in the role of the nurse caring for a client who has a neurologic injury and tasks that are outside the nurse’s role.Module 4 questions Drag the options on the left to the corresponding category on the right (or select the option on the left and then the corresponding category on the right). Within the role of the nurse Providing client education Monitoring vital signs Providing frequent assessments Administering medications Outside the role of the nurse Inserting a ventriculostomy Removing a subarachnoid bolt 24. Which of the following is a common cause of traumatic brain injuries? A Rupture of an aneurysm B Penetrating trauma C Alcohol use disorder D Frequent migraines 25. The nurse is caring for a client who had a moderate traumatic brain injury. Which of the following statements indicates the client requires further teaching? A “I can participate on my church’s golf team.” B “I can participate on the croquet team of retired players.” C “I can throw darts when my buddies come over on the weekends.” D “I can participate on my community soccer team during the summer season.” 26. The nurse and client discuss some physical, cognitive, and emotional changes the client experiences after a traumatic injury. Which of the following changes does the nurse recognize as emotional changes? Select all that apply. A Anxiety B IrritabilityModule 4 questions C Decreased concentration D Loss of memory E Frustration 27. Match the GCS with the correct TBI severity. Drag the options on the left to the corresponding category on the right (or select the option on the left and then the corresponding category on the right). Mild TBI Glasgow Coma Score (GCS) 13 to 15 Moderate TBI Glasgow Coma Score (GCS) 9 to 12 Severe TBI Glasgow Coma Score (GCS) < 9 28. A nurse is caring for a client who is receiving IV mannitol. The nurse should monitor which of the following laboratory results for this client? A WBC count B Glucose C Uric acid level D Blood Urea Nitrogen (BUN) 29. Which of the following processes does not occur with HHS? A Ketoacidosis B Osmotic diuresis C Hyperglycemia DModule 4 questions Glycosuria 30. Which of the following complications is specific to HHS? A Thromboembolic disease B Hypovolemia C Metabolic alkalosis D Hyperglycemia 31. A nurse is caring for a client in the emergency department who has diabetic ketoacidosis (DKA). Which of the following findings should the nurse expect? A Swelling of the conjunctiva and pink sclera B Chest pain and a productive cough C Tachycardia and hypotension D Profuse sweating and pallor 32. A nurse is providing the client with education on how to avoid a future episode of HHS. What should the education include? Select all that apply. A Information on diabetes treatment B Recognizing manifestations of HHS C Monitoring blood glucose regularlyModule 4 questions D Insulin administration at mealtime E Client responsibility for educating their family 33. A nurse is caring for a client on the critical care unit who has been diagnosed with Diabetic Ketoacidosis (DKA). Which of the following interventions should be included in the client’s care? Select all that apply. A Assess for manifestations of hypokalemia. B Obtain blood glucose levels daily. C Monitor for cardiac dysrhythmias. D Monitor vital signs frequently. E Educate the client and family. 34.A nurse working in the critical care unit is educating new nurses about the causes of DI. Sort each option by whether the nurse should discuss it as a cause of central DI or nephrogenic DI. Drag the options on the left to the corresponding category on the right (or click the option on the left and then the corresponding category on the right). Central DI Traumatic brain injury Neurosurgery Nephrogenic DI Lithium Hypercalcemia Renal disease 35. A nurse is caring for a client on a critical care unit diagnosed with Diabetes Insipidus (DI) after neurosurgery. Which of the following interventions should be included in the client’s care? Select all that apply. A Check for neurological changes like agitation or restlessness. B Assist client with communication challenges express their thirst needs.Module 4 questions C Monitor for dehydration. D Administer prescribed glucocorticoids. E Limit fluid intake to prevent water intoxication. 36. A nurse is reviewing laboratory results for a client in a critical care unit. Which of the following findings does the nurse recognize as manifestations of DI? Select all that apply. A Increased serum osmolality B Decreased urine osmolality C Decreased urinary sodium D Hyponatremia E Hypernatremia 37. A nurse is caring for a client on a critical care unit diagnosed with Diabetes Insipidus (DI) after neurosurgery. Which of the following interventions should be included in the client’s care? Select all that apply. A Check for neurological changes like agitation or restlessness. B Assist client with communication challenges to express their thirst needs.Module 4 questions C Monitor for dehydration. D Administer prescribed glucocorticoids. E Limit fluid intake to prevent water intoxication. 38. Which of the following are indications for the use of desmopressin in the management of DI? Select all that apply. A Increase absorption of sodium. B Replace fluid lost through urine output. C Stimulate vasopressin receptors. D Decrease urine output. E Decrease ADH secretion by the pituitary gland. 39. A nurse is reviewing the history of a client who is in the intensive care unit. Which of the following conditions does the nurse recognize as associated with an increased risk of SIADH? Select all that apply. A Throat cancer B Pneumonia C HypothyroidismModule 4 questions D Deep vein thrombosis E Hypertension 40. A nurse is monitoring a client who is at high risk for developing hyponatremia associated with SIADH. Which of the following manifestations indicate to the nurse that the client has developed hyponatremia? Select all that apply. A Headaches B Muscle cramps C Confusion D Increased urine output E Dry mucous membranes 41. A nurse in the critical care unit is caring for clients who have endocrine dysfunctions. Sort the clinical findings by whether they are characteristics of DI or SIADH. Drag the options on the left to the corresponding category on the right (or select the option on the left and then the corresponding category on the right). DI Increased urinary output Hypernatremia Increased thirstModule 4 questions Irritability SIADH Decreased urinary output Hyponatremia Muscle cramps Tremors 42. A nurse is planning care for clients who have recently been admitted to the critical care unit. Which of the following prescribed medications indicate that the nurse should plan to closely monitor the clients for manifestations of SIADH? Select all that apply. A Carbamazepine B SSRI C Vincristine D Desmopressin E Furosemide 43. The nurse caring for Alex recognized manifestations of fluid overload. Which of the following additional findings led the charge nurse, Jamie, to suspect manifestations consistent with SIADH? Select all that apply. A Oxygen saturation B Sodium level low C Urine output decreasedModule 4 questions D Mental status E Headache 44. A nurse is caring for a client who is receiving chemotherapy for lung cancer and who has a sodium level of 122. The client reports they are too tired and weak to get out of bed, and the nurse notes decreased urine output over the last 24 hr. Which of the following should the nurse assess first? A Fluid intake B Capillary refill C Mental status D Specific gravity 45.Match the clinical manifestations and risk factors in the right column with the correct description or association related to thyroid storm in the left column. Cardiac manifestations due to overstimulation of the metabolic system Tachyarrhythmias Indicators of severe hypermetabolic state High fever and sweating Inadequate oxygen from ineffective cardio-respiratory function Neurological changes (e.g., delirium, seizures) Causes of thyroid storm Precipitating factors (e.g., stopping hyperthyroid medication, surgery) Laboratory findings in thyroid storm Elevated free T3 and free T4 levels