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1. A client who has experienced trauma is admitted to the B) let me contact the
intensive care unit (ICU). The nurse's initial assessment health care provider to an-
findings include a Glasgow Coma Scale score of (3), swer your questions.
pupils fixed and dilated with an absence of corneal re-
flex, blood pressure of 80/30 mmHg, core temperature
of 95.7°F (35.4° C). The client's spouse asks the nurse
when the client will wake up. How should the nurse
respond?
A) "Your spouse's condition indicates irreversible dam-
age."
B) "Let me contact the health care provider to answer
your questions."
C) "Each person is different and we need to wait and
see what happens."
D) "I need to initiate the volume expanders and warm-
ing blanket to stimulate a response."
2. The nurse is caring for a client who is recently ex- A) Call a rapid response
tubated in the post anesthesia care unit (PACU). The team for emergency air-
client has humidified oxygen per mask and suddenly way management
develops stridor and respiratory difficulty. Which ac-
tion should the nurse implement?
A) Call a rapid response team for emergency airway
management.
B) Encourage the client to take deep breaths, cough,
and expectorate.
C) Increase the flow rate of the humidified oxygen.
D) Suction the client's mouth and oropharynx thor-
oughly.
3. An older client is admitted to the intensive care unit A) Push button when pain
after a small bowel resection. The postoperative pre- is first experienced instead
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scriptions include a patient-controlled analgesia (PCA) of waiting until pain is un-
device with morphine titrated per protocol. Which in- bareable
formation should the nurse provide the client about
the use of the PCA?
A) Push button when pain is first experienced instead
of waiting until pain is unbearable.
B) Family members or visitors can press the button
when the client grimaces in pain.
C) Press the button every 15 minutes even when pain
is not present.
D) Delay pressing the button until the pain level is 8 on
a scale of 1 to 10.
4. The nurse is analyzing an arterial blood gas (ABG) of a B) Respiratory alkalosis
client who is mechanically ventilated. The ABG results
are pH- 7.52; paCO2- 30 mmHg; HCO3- 28 mEq/liter.
How should the nurse interpret this blood gas?
A) Respiratory acidosis.
B) Respiratory alkalosis.
C) Metabolic acidosis.
D) Metabolic alkalosis.
5. According to the paramedic's report, the victim of B) Fractured liver
a motor vehicle collision was sitting in the passen- C) Ruptured spleen
ger seat on the left side of the vehicle. The vehicle
was stopped at a traffic light when the vehicle was
hit on the left side by another vehicle traveling at
speeds exceeding 60 mph (97 kmh). The client reports
slight tenderness and achiness on (L) side of thorax
and body. The significant assessment findings include:
weak and thready pulse; diffuse abdominal pain, ten-
derness and guarding present upon palpation; skin
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is diaphoretic and extremities cool to touch, capillary
refill +4 in extremities, and bruising is present in the (L)
flank area and progresses towards the abdomen. Vital
signs are temperature- 97.2° F (36.2° C), pulse- 110
beats/minute, respirations- 22 breaths/minute, blood
pressure 84/46 mmHg, MAP- (57), and pulse oximetry
90% on 2 lpm O2 via nasal cannula.Which potential
injuries should the triage nurse assess? (Select all that
apply.)
A) Flailed ribs.
B) Fractured liver.
C) Ruptured spleen.
D) Cardiac tamponade.
E) Tension pneumothorax
6. A client reports to the nurse feeling achy and D) Blood culture
weak, being tired and coughing all the time, fre-
quent headaches and experiencing night sweats. The
client's assessment is significant for crackles scattered
throughout the lungs, dependent peripheral edema
+3/+4, S3 and S4 heart sounds, temperature of 102.4°
F(39.1° C), heart rate of 110 beats/minute, respirations
of 20 breaths/minute, and blood pressure of 105/60
mmHg with a mean arterial pressure of (75). Which
diagnostic procedure should the nurse prepare to do
first?
A) Metabolic panel with electrolytes.
B) Complete blood count.
C) Liver function test.
D) Blood culture.
7.