NSG 460 Exam 6 Practice Questions |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
exam with correct answers |||\\\ |||\\\ |||\\\
The physician has ordered a solumedrol infusion for a pt with a spinal cord injury. Solumedrol
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
has been shown to be effective in:
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A. decreasing cerebral edema
|||\\\ |||\\\ |||\\\
B. preventing stress ulcers
|||\\\ |||\\\ |||\\\
C. decreasing spinal injury spasticity
|||\\\ |||\\\ |||\\\ |||\\\
D. improving motor and sensory functioning - correct answer✔✔D. improving motor and
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
sensory functioning |||\\\
Solumedrol is given within the first 8 hours of injury |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A pt with a T6 injury 3 months ago develops facial flushing and a BP of 210/106. After elevating
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
the HOB, which is the most appropriate nursing action?
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A. increase IV fluids
|||\\\ |||\\\ |||\\\
B. assess for a distended bladder
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\
C. apply oxygen at 4L/min
|||\\\ |||\\\ |||\\\ |||\\\
D. notify the physician - correct answer✔✔B. assess for a distended bladder
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
When the pt is in neurogenic shock, the nurse will assess for:
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A. mental confusion and tachycardia
|||\\\ |||\\\ |||\\\ |||\\\
B. bradycardia and hypotension
|||\\\ |||\\\ |||\\\
C. unilateral pupil dilation and hypotension
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\
D. hypertension and tachypnea - correct answer✔✔B. bradycardia and hypotension
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
,Which of the following is descriptive of a concussion? |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A. venous blood collects in the subdural space
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
B. petechial hemorrhages cause intermittent amnesia
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\
C. a lesion develops opposite the site of trauma
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
D. it is a transient neuronal dysfunction - correct answer✔✔D. it is a transient neuronal
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
dysfunction
Autonomic dysreflexia is an emergency because: |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A. severe vasoconstriction occurs
|||\\\ |||\\\ |||\\\
B. hypoxia results from regurgitation
|||\\\ |||\\\ |||\\\ |||\\\
C. spasticity produces joint deformity
|||\\\ |||\\\ |||\\\ |||\\\
D. airway spasm occurs - correct answer✔✔A. severe vasoconstriction occurs
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Your client is transported to the ED after sustaining head, back and chest injuries when he fell
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
25 ft from a tree. The primary survey has been completed. His BP drops to 80/40, HR is 56, RR
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
is 20. BBS are equal and clear. SaO2 is 99%. This data is most consistent with:
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A. neurogenic shock
|||\\\ |||\\\
B. tension pneumothorax
|||\\\ |||\\\
C. hypovolemic shock
|||\\\ |||\\\
D. closed head injury - correct answer✔✔A. neurogenic shock
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A client who sustained a spinal cord injury at the T2 level should be assessed for signs of
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
autonomic dysrefelxia because: |||\\\ |||\\\
A. the injury results in loss of the reflex arc
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
B. there has been a partial transaction of the cord
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
C. there is a flaccid paralysis of the lower extremities
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
D. the injury is above the 6th thoracic vertebrae - correct answer✔✔D. the injury is above he
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
6th thoracic vertebrae |||\\\ |||\\\
,A client is admitted to the hospital 24 hrs ago after sustaining blunt trauma. For which early
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
clinical manifestation of acute respiratory distress syndrome (ARDS) should the nurse monitor
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
for?
A. crackles throughout lung fields
|||\\\ |||\\\ |||\\\ |||\\\
B. increase in respiratory rate from 18 to 24 breaths/min
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
C. "white-out" appearance of lungs on chest radiograph
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
D. cyanosis and pallor - correct answer✔✔B. increase in respiratory rate from 18 to 24
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
breaths/min
The nurse is caring for a client who required tube insertion for a pneumothorax. The nurse is
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
aware that the best test to assess for pneumothorax resolution is:
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A. ABG |||\\\
B. pulse ox |||\\\ |||\\\
C. CXR |||\\\
D. breath sounds - correct answer✔✔C. CXR
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
An adult arrives in the ED after being assaulted with a baseball bat. He is intubated and
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
becoming progressively more difficult to ventilate. Suddenly he becomes unresponsive and |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
pulseless. What is the priority intervention? |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A. defibrillation |||\\\
B. transporting pt for angioplasty
|||\\\ |||\\\ |||\\\ |||\\\
C. relieving the tension pneumothorax
|||\\\ |||\\\ |||\\\ |||\\\
D. correcting the internal bleed - correct answer✔✔C. relieving the tension pneumothorax
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Mr. T is admitted to the SICU following an MVC. The initial drainage from a right chest tube
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
inserted in the ED is 400cc. The following hour the chest tube drains 300cc of blood. Which the
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
most appropriate action by the nurse?
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A. elevate the HOB |||\\\ |||\\\ |||\\\
, B. notify the physician
|||\\\ |||\\\ |||\\\
C. continue to monitor VS
|||\\\ |||\\\ |||\\\ |||\\\
D. "milk" the chest tube - correct answer✔✔B. notify the physician
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
>200cc/hr should be reported |||\\\ |||\\\ |||\\\
Your trauma pt has a spinal cord transection at the T-1 level. The primary nursing concern is:
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A. renal status |||\\\ |||\\\
B. skin integrity |||\\\ |||\\\
C. GI function |||\\\ |||\\\
D. cardiovascular status - correct answer✔✔D. cardiovascular status
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
(Autonomic dysreflexia) |||\\\
A pt arrives in the ER. He is tachycardia and hypotensive. He says: "I have a knife in my chest
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
and I have Beck's triad: muffled heart sounds, JVD and hypotension. I think I have cardiac
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
tamponade. Do you think that's true?" |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A. True |||\\\
B. False - correct answer✔✔A. True
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
54 hours after sustaining deep partial thickness burns to both lower extremities and his
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
abdomen, the pt's urine output has increased from 1000cc to 2300cc in 24 hrs. His labs are: Na |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
137, K 4.4, HCT 38%. These finding suggest:
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A. beginning of the interstitial to plasma fluid shift
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
B. circulatory overload
|||\\\ |||\\\
C. early coagulopathy
|||\\\ |||\\\
D. early renal failure secondary to volume depletion - correct answer✔✔A. beginning of the
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
interstitial to plasma fluid shift |||\\\ |||\\\ |||\\\ |||\\\
exam with correct answers |||\\\ |||\\\ |||\\\
The physician has ordered a solumedrol infusion for a pt with a spinal cord injury. Solumedrol
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
has been shown to be effective in:
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A. decreasing cerebral edema
|||\\\ |||\\\ |||\\\
B. preventing stress ulcers
|||\\\ |||\\\ |||\\\
C. decreasing spinal injury spasticity
|||\\\ |||\\\ |||\\\ |||\\\
D. improving motor and sensory functioning - correct answer✔✔D. improving motor and
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
sensory functioning |||\\\
Solumedrol is given within the first 8 hours of injury |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A pt with a T6 injury 3 months ago develops facial flushing and a BP of 210/106. After elevating
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
the HOB, which is the most appropriate nursing action?
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A. increase IV fluids
|||\\\ |||\\\ |||\\\
B. assess for a distended bladder
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\
C. apply oxygen at 4L/min
|||\\\ |||\\\ |||\\\ |||\\\
D. notify the physician - correct answer✔✔B. assess for a distended bladder
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
When the pt is in neurogenic shock, the nurse will assess for:
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A. mental confusion and tachycardia
|||\\\ |||\\\ |||\\\ |||\\\
B. bradycardia and hypotension
|||\\\ |||\\\ |||\\\
C. unilateral pupil dilation and hypotension
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\
D. hypertension and tachypnea - correct answer✔✔B. bradycardia and hypotension
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
,Which of the following is descriptive of a concussion? |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A. venous blood collects in the subdural space
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
B. petechial hemorrhages cause intermittent amnesia
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\
C. a lesion develops opposite the site of trauma
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
D. it is a transient neuronal dysfunction - correct answer✔✔D. it is a transient neuronal
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
dysfunction
Autonomic dysreflexia is an emergency because: |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A. severe vasoconstriction occurs
|||\\\ |||\\\ |||\\\
B. hypoxia results from regurgitation
|||\\\ |||\\\ |||\\\ |||\\\
C. spasticity produces joint deformity
|||\\\ |||\\\ |||\\\ |||\\\
D. airway spasm occurs - correct answer✔✔A. severe vasoconstriction occurs
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Your client is transported to the ED after sustaining head, back and chest injuries when he fell
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
25 ft from a tree. The primary survey has been completed. His BP drops to 80/40, HR is 56, RR
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
is 20. BBS are equal and clear. SaO2 is 99%. This data is most consistent with:
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A. neurogenic shock
|||\\\ |||\\\
B. tension pneumothorax
|||\\\ |||\\\
C. hypovolemic shock
|||\\\ |||\\\
D. closed head injury - correct answer✔✔A. neurogenic shock
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A client who sustained a spinal cord injury at the T2 level should be assessed for signs of
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
autonomic dysrefelxia because: |||\\\ |||\\\
A. the injury results in loss of the reflex arc
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
B. there has been a partial transaction of the cord
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
C. there is a flaccid paralysis of the lower extremities
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
D. the injury is above the 6th thoracic vertebrae - correct answer✔✔D. the injury is above he
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
6th thoracic vertebrae |||\\\ |||\\\
,A client is admitted to the hospital 24 hrs ago after sustaining blunt trauma. For which early
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
clinical manifestation of acute respiratory distress syndrome (ARDS) should the nurse monitor
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
for?
A. crackles throughout lung fields
|||\\\ |||\\\ |||\\\ |||\\\
B. increase in respiratory rate from 18 to 24 breaths/min
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
C. "white-out" appearance of lungs on chest radiograph
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
D. cyanosis and pallor - correct answer✔✔B. increase in respiratory rate from 18 to 24
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
breaths/min
The nurse is caring for a client who required tube insertion for a pneumothorax. The nurse is
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
aware that the best test to assess for pneumothorax resolution is:
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A. ABG |||\\\
B. pulse ox |||\\\ |||\\\
C. CXR |||\\\
D. breath sounds - correct answer✔✔C. CXR
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
An adult arrives in the ED after being assaulted with a baseball bat. He is intubated and
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
becoming progressively more difficult to ventilate. Suddenly he becomes unresponsive and |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
pulseless. What is the priority intervention? |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A. defibrillation |||\\\
B. transporting pt for angioplasty
|||\\\ |||\\\ |||\\\ |||\\\
C. relieving the tension pneumothorax
|||\\\ |||\\\ |||\\\ |||\\\
D. correcting the internal bleed - correct answer✔✔C. relieving the tension pneumothorax
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Mr. T is admitted to the SICU following an MVC. The initial drainage from a right chest tube
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
inserted in the ED is 400cc. The following hour the chest tube drains 300cc of blood. Which the
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
most appropriate action by the nurse?
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A. elevate the HOB |||\\\ |||\\\ |||\\\
, B. notify the physician
|||\\\ |||\\\ |||\\\
C. continue to monitor VS
|||\\\ |||\\\ |||\\\ |||\\\
D. "milk" the chest tube - correct answer✔✔B. notify the physician
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
>200cc/hr should be reported |||\\\ |||\\\ |||\\\
Your trauma pt has a spinal cord transection at the T-1 level. The primary nursing concern is:
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A. renal status |||\\\ |||\\\
B. skin integrity |||\\\ |||\\\
C. GI function |||\\\ |||\\\
D. cardiovascular status - correct answer✔✔D. cardiovascular status
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
(Autonomic dysreflexia) |||\\\
A pt arrives in the ER. He is tachycardia and hypotensive. He says: "I have a knife in my chest
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
and I have Beck's triad: muffled heart sounds, JVD and hypotension. I think I have cardiac
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
tamponade. Do you think that's true?" |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A. True |||\\\
B. False - correct answer✔✔A. True
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
54 hours after sustaining deep partial thickness burns to both lower extremities and his
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
abdomen, the pt's urine output has increased from 1000cc to 2300cc in 24 hrs. His labs are: Na |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
137, K 4.4, HCT 38%. These finding suggest:
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A. beginning of the interstitial to plasma fluid shift
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
B. circulatory overload
|||\\\ |||\\\
C. early coagulopathy
|||\\\ |||\\\
D. early renal failure secondary to volume depletion - correct answer✔✔A. beginning of the
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
interstitial to plasma fluid shift |||\\\ |||\\\ |||\\\ |||\\\
