1. An emergency room nurse is assessing a pt who was rescued from a home fire. The pt suddenly
develops a loud brassy cough. What action would the nurse take first?
- Apply oxygen and continuous pulse ox
2. A Nurse prepared to administer IV Cimetidine to a pt who has a new burn injury. The pt asks,
why am I taking this medication? How would you respond?
- It helps prevent stomach ulcers, which are common after burns
3. A nurse cares for a pt with burn injury who presents with drooling and difÏculty swallowing.
What action would the nurse take first?
- Auscultate breath sounds over the trachea and bronchi
4. A nurse assess a pt who has burn injuries and notes crackles in bilateral lung bases, a RR of 40,
and a productive cough with blood- tinged sputum. What action would the nurse take next?
- Place the pt in an upright position
5. A nurse cares for a pt who has burn injuries. The pts wife asks, “when will his high risk for
infection decrease?” How would the nurse respond?
- When all of his burn wounds have closed
6. A nurse gives a topical gentamicin to a pt burn injury. Which lab value would the nurse monitor
while the pt is prescribed this therapy?
- Creatinine (due to gent being a kidney killer)
7. A nurse cares for a pt with burn injuries. Which intervention would the nurse implement to
appropriately reduce the pts pain?
-Administer IV morphine **also give 20 min before a procedure
8. A pt has a TBI. The nurse assesses the following: pulse change from 82 to 60, pulse pressure
increase from 26 to 40, and irregular respirations. What action by the nurse takes priority?
-Call the rapid response team ** Cushing Triad
9. A nurse uses the rule of 9 to assess a pt with burn injuries to the entire back region and left arm.
How would the nurse document the % of the pts body that sustained burned?
-27% (back is 18% and the whole arm is 9%)
10. A nurse assess a pt with deep partial-thickness and full-thickness burns on the face, arms, and
chest. Which assessment finding would alert the nurse to potential complications?
- Urine output of 20mL/hr
11. After assessing the following documented data, what action would the nurse take next?
HR: 110 BP: 112/68. RR:20 O2: 94%. Pain: 3/10
RBC: 5,000,000
WBC: 10,000
Platelets: 200,000
Wound bed is pale, and surrounding tissues have edema present.
, - Prepare to obtain a blood and wound culture
12. Which pt would the nurse assess first?
- TBI with BP change of 122/74 to 140/68
- Burn pt with oxygen sat of 93%
- C6 SCI pt with a pulse change of 100 to 78
- A pt admitted with sepsis has urine output of 40mL/hr for the last 2 hours
13. A nurse caring for a pt with the following assessment:
WBC: 3800 Blood Glucose: 198 Temp: 96.2
What action by the nurse takes priority?
-Notify PCP immediately (late stage of septic shock)
14. A pt arrives in the ED after being in a MVC with fatalities. The pt has a wound to the leg that i
bleeding profusely. What action by the nurse takes priority?
- Ensure the pt has a patent airway
15. A pt receiving norepinephrine for shock. What assessment finding best indicates a therapeutic
effect from this drug?
-Alert and oriented, answering questions
16. An ER nurse is assessing a pt with a mild TBI, what signs and symptoms does the nurse recognize
as consistent? SATA
- Sensitivity to light and sound
-Reports “foggy feeling”
- Unconscious for 2 hours after injury
- Elevated temp
- Amnesia
17. A pt with Myasthenia Gravis is prescribed pyridostigmine. Which of the following statements
should be included in the medications teaching plan of care? SATA
- Do not eat a full meal for 45min after taking the drug
-Seek immediate care if you develop trouble swallowing
- Take this drug on an empty stomach for best absorption
- The dose may change frequently depending of symptoms
- Your urine may turn a reddish-orange color while on this drug
18. Which of the following clinical manifestations would the nurse suspect in the development of all
shocks? SATA
develops a loud brassy cough. What action would the nurse take first?
- Apply oxygen and continuous pulse ox
2. A Nurse prepared to administer IV Cimetidine to a pt who has a new burn injury. The pt asks,
why am I taking this medication? How would you respond?
- It helps prevent stomach ulcers, which are common after burns
3. A nurse cares for a pt with burn injury who presents with drooling and difÏculty swallowing.
What action would the nurse take first?
- Auscultate breath sounds over the trachea and bronchi
4. A nurse assess a pt who has burn injuries and notes crackles in bilateral lung bases, a RR of 40,
and a productive cough with blood- tinged sputum. What action would the nurse take next?
- Place the pt in an upright position
5. A nurse cares for a pt who has burn injuries. The pts wife asks, “when will his high risk for
infection decrease?” How would the nurse respond?
- When all of his burn wounds have closed
6. A nurse gives a topical gentamicin to a pt burn injury. Which lab value would the nurse monitor
while the pt is prescribed this therapy?
- Creatinine (due to gent being a kidney killer)
7. A nurse cares for a pt with burn injuries. Which intervention would the nurse implement to
appropriately reduce the pts pain?
-Administer IV morphine **also give 20 min before a procedure
8. A pt has a TBI. The nurse assesses the following: pulse change from 82 to 60, pulse pressure
increase from 26 to 40, and irregular respirations. What action by the nurse takes priority?
-Call the rapid response team ** Cushing Triad
9. A nurse uses the rule of 9 to assess a pt with burn injuries to the entire back region and left arm.
How would the nurse document the % of the pts body that sustained burned?
-27% (back is 18% and the whole arm is 9%)
10. A nurse assess a pt with deep partial-thickness and full-thickness burns on the face, arms, and
chest. Which assessment finding would alert the nurse to potential complications?
- Urine output of 20mL/hr
11. After assessing the following documented data, what action would the nurse take next?
HR: 110 BP: 112/68. RR:20 O2: 94%. Pain: 3/10
RBC: 5,000,000
WBC: 10,000
Platelets: 200,000
Wound bed is pale, and surrounding tissues have edema present.
, - Prepare to obtain a blood and wound culture
12. Which pt would the nurse assess first?
- TBI with BP change of 122/74 to 140/68
- Burn pt with oxygen sat of 93%
- C6 SCI pt with a pulse change of 100 to 78
- A pt admitted with sepsis has urine output of 40mL/hr for the last 2 hours
13. A nurse caring for a pt with the following assessment:
WBC: 3800 Blood Glucose: 198 Temp: 96.2
What action by the nurse takes priority?
-Notify PCP immediately (late stage of septic shock)
14. A pt arrives in the ED after being in a MVC with fatalities. The pt has a wound to the leg that i
bleeding profusely. What action by the nurse takes priority?
- Ensure the pt has a patent airway
15. A pt receiving norepinephrine for shock. What assessment finding best indicates a therapeutic
effect from this drug?
-Alert and oriented, answering questions
16. An ER nurse is assessing a pt with a mild TBI, what signs and symptoms does the nurse recognize
as consistent? SATA
- Sensitivity to light and sound
-Reports “foggy feeling”
- Unconscious for 2 hours after injury
- Elevated temp
- Amnesia
17. A pt with Myasthenia Gravis is prescribed pyridostigmine. Which of the following statements
should be included in the medications teaching plan of care? SATA
- Do not eat a full meal for 45min after taking the drug
-Seek immediate care if you develop trouble swallowing
- Take this drug on an empty stomach for best absorption
- The dose may change frequently depending of symptoms
- Your urine may turn a reddish-orange color while on this drug
18. Which of the following clinical manifestations would the nurse suspect in the development of all
shocks? SATA
