NUR 224 FINAL EXAM QUESTIONS & ANSWERS
Patient with DIC, bp 82/40, temp 102, severe back pain, which order implement first -
Answers - Infuse NS
Patients with neutropenia, assess first? - Answers - Fever 100.8
AAA repair, coolness of extremities and bloated feeling, priority - Answers - Check
pulses
Which patient is most important to refer to dietician - Answers - Weight gain and loss,
Debridement for Infected surgical wound, Rheumatoid arthritis who takes prednisone
Patient with deep partial thickness burns of face and chest, wounds treated with open
method, which action would be included - Answers - Wear gown, gloves, mask
Which action will be included for patient with burns of ears, neck, right arm, right hand -
Answers - Elevate arm and hand on pillow and extend fingers
Patient with circumferential burns of both arms, decreased radial pulse, strength, and
numbness in fingers, which action - Answers - Notify provider
Renetidine prescribed for patient with extensive burn 5 days ago, evaluate effectiveness
of med - Answers - Stools for occult blood
Patient who has burns on the back and chest has becoming agitated and restless -
Answers - Check O2
Patient with extensive electric burn, which intervention should be implemented first -
Answers - Cardiac monitor
What traumatic event is classified as penetrating trauma mechanism injury - Answers -
Gunshot, Stab wound to neck
Which of the following will be performed during primary survey - Answers - Removal of
wet clothing, Initiating IV fluids, Endotracheal intubation, Needle decompression
Client injured in stabbing incident, bp 80/60, hr 130, rr 35, bleeding from stabbing
wound site, client is lethargic, most appropriate level trauma center - Answers - Level I
Nurse needs to triage clients, client with which complain would be non-urgent -
Answers - Left arm fracture
Nurse assigned role is triage nurse after explosion at local factory, priority of nurse -
Answers - Performs rapid assessment
,Industrial explosion, brought to ER for injuries, which is a red tag - Answers - Rib
fractures and SOB
Priority for nursing supervisor during mass casualty - Answers - Directing nurses to
care for clients already in hospital so staff in ER can care for patients
Explosion, patient is diaphoretic, HR 125, chest pain - Answers - Red tag
ED expecting large amount after bridge has collapsed, priority for ED leadership -
Answers - ED may receive many unexpected victims
Bus is hit by a train, which intervention performed immediately for red tag - Answers -
Intubating cyanotic patient in respiratory distress, Initiating IV access, Pacemaker for
HR 46
46. Triage nurse assessing patient in ED following mass caulaty incident, which
question is appropriate to determine traige category - Answers - Can you wiggle toes,
Difficulty breathing, What day is it, Abdominal or back pain
Mass casualty, yellow tag - Answers - Partial thickness burns covering both legs, Neck
injury numbness both legs, Small piece shrapnel in both eyes, Bruising and pain in right
lower abdomen
Assessment finding to patient with flail chest - Answers - Left area goes in during
inhalation and out during exhalation
Dyspnea, tracheal deviation, and O2 86% - Answers - Tension pneumothorax
V tach - Answers - Debrillate
Discharge included in plan for client with ICD - Answers - Avoid magnetic fields
Third degree AV block with HR of 40, nursing diagnosis priority - Answers - Decreased
cardiac output
Third degree heart block to telemetry unit, wide QRS, HR 35, physcial assessment
important to include - Answers - Confusion
Unstable vtach receiving amnidirone IV, HR from 68-50, asymptomatic, priority -
Answers - Slow infusion
Administered adenisone, therapeutic - Answers - Brief period of asystole
Client with MI having frequent PVC, which med - Answers - Lidocaine
, Which dysrhythmia with frequent PVC - Answers - V tach
Patient with chronic afib, which drug to prevent systemic emboli - Answers - Heparin
Which client is most at risk for afib - Answers - CABG
Sinus brady with hypotension and dizziness - Answers - Atropine
EKG PR measures 0.14 - Answers - Document finding
P wave - Answers - Atrial depolarization
Teaching for client at risk for sepsis secondary to supress immune response - Answers
- Take temp daily, Wash dishes with hot sudsy water, Wash toothbrush in bleach
Nurse correlates which manifestations of hypovolemic shock - Answers - Elevated HR,
Elevated DBP
Admitted to inpatient is ordered to receive PRB to correct surgical blood loss, how will it
assist in recovery - Answers - Improve ability of blood to carry o2
Patient suspected of internal bleeding, hypovolemic shock is expected - Answers -
Increase HR
Client MI, which hemodynamic in cardiogenic shock - Answers - Decreased CO,
decreased MAP
GI ulcer, NPO, tube on low suction, monitor for what shock - Answers - Hypovolemic
Acidosis from hypovolemic shock, which fluid - Answers - LR
Client in hypovolemic placed on dopamine, which parameter as desired use - Answers
- Increased CO
Which manifestation will nurse monitor when caring for a client with distributive shock
from anaphylactic event - Answers - Decrease BP and edema
Septic shock, develop tachycardia, increase 20 in SBP, which pathophysiological factor
of hypodynamic shock are responsible for these manifestations - Answers -
Inflammatory reaction circulating endotoxins
Which patient is at risk for developing septic shock - Answers - Cancer being treated
with chemo
Community acquired pneumonia, which blood cell and differential at risk for septic
shock - Answers - WBC 2,000 neutrophil 400
Patient with DIC, bp 82/40, temp 102, severe back pain, which order implement first -
Answers - Infuse NS
Patients with neutropenia, assess first? - Answers - Fever 100.8
AAA repair, coolness of extremities and bloated feeling, priority - Answers - Check
pulses
Which patient is most important to refer to dietician - Answers - Weight gain and loss,
Debridement for Infected surgical wound, Rheumatoid arthritis who takes prednisone
Patient with deep partial thickness burns of face and chest, wounds treated with open
method, which action would be included - Answers - Wear gown, gloves, mask
Which action will be included for patient with burns of ears, neck, right arm, right hand -
Answers - Elevate arm and hand on pillow and extend fingers
Patient with circumferential burns of both arms, decreased radial pulse, strength, and
numbness in fingers, which action - Answers - Notify provider
Renetidine prescribed for patient with extensive burn 5 days ago, evaluate effectiveness
of med - Answers - Stools for occult blood
Patient who has burns on the back and chest has becoming agitated and restless -
Answers - Check O2
Patient with extensive electric burn, which intervention should be implemented first -
Answers - Cardiac monitor
What traumatic event is classified as penetrating trauma mechanism injury - Answers -
Gunshot, Stab wound to neck
Which of the following will be performed during primary survey - Answers - Removal of
wet clothing, Initiating IV fluids, Endotracheal intubation, Needle decompression
Client injured in stabbing incident, bp 80/60, hr 130, rr 35, bleeding from stabbing
wound site, client is lethargic, most appropriate level trauma center - Answers - Level I
Nurse needs to triage clients, client with which complain would be non-urgent -
Answers - Left arm fracture
Nurse assigned role is triage nurse after explosion at local factory, priority of nurse -
Answers - Performs rapid assessment
,Industrial explosion, brought to ER for injuries, which is a red tag - Answers - Rib
fractures and SOB
Priority for nursing supervisor during mass casualty - Answers - Directing nurses to
care for clients already in hospital so staff in ER can care for patients
Explosion, patient is diaphoretic, HR 125, chest pain - Answers - Red tag
ED expecting large amount after bridge has collapsed, priority for ED leadership -
Answers - ED may receive many unexpected victims
Bus is hit by a train, which intervention performed immediately for red tag - Answers -
Intubating cyanotic patient in respiratory distress, Initiating IV access, Pacemaker for
HR 46
46. Triage nurse assessing patient in ED following mass caulaty incident, which
question is appropriate to determine traige category - Answers - Can you wiggle toes,
Difficulty breathing, What day is it, Abdominal or back pain
Mass casualty, yellow tag - Answers - Partial thickness burns covering both legs, Neck
injury numbness both legs, Small piece shrapnel in both eyes, Bruising and pain in right
lower abdomen
Assessment finding to patient with flail chest - Answers - Left area goes in during
inhalation and out during exhalation
Dyspnea, tracheal deviation, and O2 86% - Answers - Tension pneumothorax
V tach - Answers - Debrillate
Discharge included in plan for client with ICD - Answers - Avoid magnetic fields
Third degree AV block with HR of 40, nursing diagnosis priority - Answers - Decreased
cardiac output
Third degree heart block to telemetry unit, wide QRS, HR 35, physcial assessment
important to include - Answers - Confusion
Unstable vtach receiving amnidirone IV, HR from 68-50, asymptomatic, priority -
Answers - Slow infusion
Administered adenisone, therapeutic - Answers - Brief period of asystole
Client with MI having frequent PVC, which med - Answers - Lidocaine
, Which dysrhythmia with frequent PVC - Answers - V tach
Patient with chronic afib, which drug to prevent systemic emboli - Answers - Heparin
Which client is most at risk for afib - Answers - CABG
Sinus brady with hypotension and dizziness - Answers - Atropine
EKG PR measures 0.14 - Answers - Document finding
P wave - Answers - Atrial depolarization
Teaching for client at risk for sepsis secondary to supress immune response - Answers
- Take temp daily, Wash dishes with hot sudsy water, Wash toothbrush in bleach
Nurse correlates which manifestations of hypovolemic shock - Answers - Elevated HR,
Elevated DBP
Admitted to inpatient is ordered to receive PRB to correct surgical blood loss, how will it
assist in recovery - Answers - Improve ability of blood to carry o2
Patient suspected of internal bleeding, hypovolemic shock is expected - Answers -
Increase HR
Client MI, which hemodynamic in cardiogenic shock - Answers - Decreased CO,
decreased MAP
GI ulcer, NPO, tube on low suction, monitor for what shock - Answers - Hypovolemic
Acidosis from hypovolemic shock, which fluid - Answers - LR
Client in hypovolemic placed on dopamine, which parameter as desired use - Answers
- Increased CO
Which manifestation will nurse monitor when caring for a client with distributive shock
from anaphylactic event - Answers - Decrease BP and edema
Septic shock, develop tachycardia, increase 20 in SBP, which pathophysiological factor
of hypodynamic shock are responsible for these manifestations - Answers -
Inflammatory reaction circulating endotoxins
Which patient is at risk for developing septic shock - Answers - Cancer being treated
with chemo
Community acquired pneumonia, which blood cell and differential at risk for septic
shock - Answers - WBC 2,000 neutrophil 400
