• ATI 265 Test 3 Mock Exam (Answered) Complete Solution.

• ATI 265 Test 3 Mock Exam (Answered) Complete Solution. Answers And Rationale At The Bottom Multiple Choice Identify the choice that best completes the statement or answers the question. 1. An emergency room nurse assesses a patient who was rescued from a home fire. The patient suddenly develops a loud, brassy cough. What action would the nurse take first? a. Apply oxygen and continuous pulse oximetry. b. Provide small quantities of ice chips and sips of water. c. Request a prescription for an antitussive medication. d. Ask the respiratory therapist to provide humidified air. 2. A nurse prepares to administer intravenous cimetidine to a patient who has a new burn injury. The patient asks, “Why am I taking this medication?” How would the nurse respond? a. “Tagamet stimulates intestinal movement so you can eat more.” b. “It improves fluid retention, which helps prevent hypovolemic shock.” c. “It helps prevent stomach ulcers, which are common after burns.” d. “Tagamet protects the kidney from damage caused by dehydration.” 3. A nurse cares for a patient with a burn injury who presents with drooling and difficulty swallowing. What action would the nurse take first? a. Assess the level of consciousness and pupillary reactions. b. Administer 100% FIO2 via non rebreather mask. c. Auscultate breath sounds over the trachea and bronchi. d. Measure abdominal girth and auscultate bowel sounds. 4. A nurse assesses a patient who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. What action would the nurse take next? a. Administer furosemide. b. Perform chest physiotherapy. c. Document and reassess in an hour. d. Place the patient in an upright position. 5. A nurse cares for a patient who has burn injuries. The patient’s wife asks, “When will his high risk for infection decrease?” How would the nurse respond? a. “When the antibiotic therapy is complete.” b. “As soon as his albumin levels return to normal.” c. “Once we complete the fluid resuscitation process.” d. “When all of his burn wounds have closed.” 6. A nurse administers topical gentamicin sulfate to a patient’s burn injury. Which laboratory value would the nurse monitor while the patient is prescribed this therapy? a. Creatinine b. SED rate c. Sodium d. Magnesium 7. A nurse cares for a patient with burn injuries. Which intervention would the nurse implement to appropriately reduce the patient’s pain? a. Administer the prescribed intravenous morphine sulfate. b. Apply ice to skin around the burn wound for 20 minutes. c. Administer prescribed intramuscular ketorolac d. Decrease tactile stimulation near the burn injuries. 8. A nurse cares for a patient with burn injuries from a house fire. The patient is not consistently oriented and reports a headache. What action would the nurse take? a. Increase the patient’s oxygen and obtain blood gases. b. Draw blood for a carboxyhemoglobin level. c. Increase the patient’s intravenous fluid rate. d. Perform a thorough Mini-Mental State Examination. 9. A nurse uses the rule of nines to assess a patient with burn injuries to the entire back region and left arm. How would the nurse document the percentage of the patient’s body that sustained burns? a. 9% b. 18% c. 27% d. 36% 10. A nurse assesses a patient admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding would alert the nurse to a potential complication? a. Partial pressure of arterial oxygen (PaO2) of 80 mm Hg b. Urine output of 20 mL/hr c. Productive cough with white pulmonary secretions d. Core temperature of 100.6° F (38° C) 11. A nurse reviews the following data in the chart of a patient with burn injuries: Admission Notes Wound Assessment 36-year-old female with bilateral leg burns NKDA Health history of asthma and seasonal allergies Bilateral leg burns present with a white and leatherlike appearance. No blisters or bleeding present. Patient rates pain 2/10 on a scale of 0 to 10. Based on the data provided, how would the nurse categorize this patient’s injuries? a. Partial-thickness deep b. Partial-thickness superficial c. Full thickness d. Superficial 12. After assessing an older adult patient with a burn wound, the nurse documents the findings as follows: Vital Signs Laboratory Results Wound Assessment Heart rate: 110 beats/min Red blood cell count: Left chest burn wound, Blood pressure: 112/68 mm Hg 5,000,000/(5 × 1012/L) 3 × 2.5 × 0.5 cm, Respiratory rate: 20 White blood cell count: wound bed pale, breaths/min 10,000/mm3 (10 × surrounding tissues Oxygen saturation: 94% 109/L) with edema present Pain: 3/10 Platelet count: 200,000/mm3 (200 × 109/L) Based on the documented data, what action would the nurse take next? a. Assess the patient’s skin for signs of adequate perfusion. b. Calculate intake and output ratio for the last 24 hours. c. Prepare to obtain blood and wound cultures. d. Place the patient in an isolation room. 13. A nurse is caring for a patient after surgery. The patient’s respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since the patient was last assessed 4 hours ago. What action by the nurse is best? a. Ask if the patient needs pain medication. b. Assess the patient’s tissue perfusion further. c. Document the findings in the patient’s chart. d. Increase the rate of the patient’s IV infusion. 14. The nurse gets the hand-off report on four patients. Which patient would the nurse assess first? a. Patient with a blood pressure change of 128/74 to 110/88 mm Hg b. Patient with oxygen saturation unchanged at 94% c. Patient with a pulse change of 100 to 88 beats/min d. Patient with urine output of 40 mL/hr for the last 2 hours 15. A nurse caring for a patient notes the following assessments: white blood cell count 3800/mm3 (3.8 × 109/L), blood glucose level 198 mg/dL (11 mmol/L), and temperature 96.2° F (35.6° C). What action by the nurse takes priority? a. Document the findings in the patient’s chart. b. Give the patient warmed blankets for comfort. c. Notify the health care provider immediately. d. Prepare to administer insulin per sliding scale. 16. A nurse works at a community center for older adults. What self-management measure can the nurse teach the patients to prevent shock? a. Do not get dehydrated in warm weather. b. Drink fluids on a regular schedule. c. Seek attention for any lacerations. d. Take medications as prescribed. 17. A patient arrives in the emergency department after being in a car crash with fatalities. The patient has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority? a. Apply direct pressure to the bleeding. b. Ensure that the patient has a patent airway. c. Obtain consent for emergency surgery. d. Start two large-bore IV catheters. 18. A patient is receiving norepinephrine (Levophed) for shock. What assessment finding best indicates a therapeutic effect from this drug? a. Alert and oriented, answering questions b. Patient denial of chest pain or chest pressure c. IV site without redness or swelling d. Urine output of 30 mL/hr for 2 hours 19. A patient in shock is apprehensive and slightly confused. What action by the nurse is best? a. Offer to remain with the patient for a while. b. Prepare to administer antianxiety medication. c. Raise all four side rails on the patient’s bed. d. Tell the patient that everything possible is being done. 20. A patient in shock has been started on dopamine. What assessment finding requires the nurse to communicate with the provider immediately? a. Blood pressure of 98/68 mm Hg b. Pedal pulses 1+/4+ bilaterally c. Report of chest heaviness d. Urine output of 32 mL/hr 21. A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question would the nurse ask? a. “Do you live in a crowded residence?” b. “When was your last tetanus vaccination?” c. “Have you had any viral infections recently?” d. “Have you traveled out of the country in the last month?” 22. A nurse assesses a patient with a spinal cord injury at level T5. The patient’s blood pressure is 184/95 mm Hg, and the patient presents with a flushed face and blurred vision. What action would the nurse take first? a. Initiate oxygen via a nasal cannula. b. Place the patient in a supine position. c. Palpate the bladder for distention. d. Administer a prescribed beta-blocker. 23. An emergency room nurse initiates care for a patient with a cervical spinal cord injury who arrives via emergency medical services. What action would the nurse take first? a. Assess level of consciousness. b. Obtain vital signs. c. Administer oxygen therapy. d. Evaluate respiratory status. 24. A nurse is caring for a patient with paraplegia who is scheduled to participate in a rehabilitation program. The patient states, “I do not understand the need for rehabilitation; the paralysis will not go away and it will not get better.” How would the nurse respond? a. “If you don’t want to participate in the rehabilitation program, I’ll let the provider know.” b. “Rehabilitation programs have helped many patients with your injury. You should give it a chance.” c. “The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability.” d. “When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first.” 25. A nurse assesses a patient with a neurologic disorder. Which assessment finding would the nurse identify as a late manifestation of amyotrophic lateral sclerosis (ALS)? a. Dysarthria b. Dysphagia c. Muscle weakness d. Impairment of respiratory muscles 26. A nurse cares for a patient with a spinal cord injury. With which interdisciplinary team member would the nurse consult to assist the patient with activities of daily living? a. Social worker b. Physical therapist c. Occupational therapist d. Case manager