SOLUTIONS
. The nurse, in collaboration with the patient's family, is
assigning priorities related to the care of the patient. The nurse
explains that when setting priorities it is important to look at the
urgency of specific problems. What provides the best framework
for prioritizing patient problems?
A) Availability of hospital resources
B) Family member statements
C) Maslow's hierarchy of needs
D) Nursing skill Correct Answers C
1. A client has had a recent myocardial infarction involving the
left ventricle. Which assessment finding is expected?
a.
Faint S1 and S2 sounds on auscultation
b.
Decreased cardiac output
c.
Increased blood pressure
d.
Increased strength of peripheral pulses Correct Answers B
1. A large number of victims arrive at the ER after a bus is hit by
a train. Which interventions will be performed immediately for
red-tagged victims? (Select all that apply.)
a.
Splinting a closed tibial fracture
b.
Intubating a cyanotic client in respiratory distress
,c.
Initiating IV fluids for a client with a blood pressure of 96/60
mm Hg and pulse of 144 betas/min
d.
Catheterizing a client who cannot void
e.
Inserting a pacemaker for a client with a heart rate of 44
beats/min
f.
Performing postmortem care for a client who has just died
g.
Removing glass that is embedded in a client's arm Correct
Answers BCE
1. A patient is brought to the Emergency Department from the
site of a chemical fire. The paramedics report that the patient has
a burn that involves the epidermis, dermis, and the muscle and
bone of the right arm. When you assess the patient he verbalizes
no pain in the right arm and the skin appears charred. Based
upon these assessment findings, what is the depth of the burn on
the patient's right arm?
A) Superficial partial-thickness
B) Deep partial-thickness
C) Full partial-thickness
D) Full-thickness Correct Answers D
1. A patient with mitral stenosis exhibits symptoms of a
dysrhythmia. Based on the pathophysiology of this disease
process, the nurse would expect the patient to exhibit what heart
rhythm?
A) Normal sinus rhythm
,B) Supraventricular tachycardia
C) Atrial fibrillation
D) Electromechanical dissociation Correct Answers C
1. An understanding of the pathophysiologic rationale behind
shock is something every nurse needs to have. Which of the
following statements best describes the pathophysiology for
shock?
A) Blood is shunted from vital organs to peripheral areas of the
body.
B) Cells lack an adequate blood supply and are deprived of
oxygen and nutrients.
C) Circulating blood volume is decreased.
D) Hemorrhage occurs as a result of trauma. Correct Answers B
1. The emergency department nurse assesses for which clinical
manifestation in the client suspected to be in the nonprogressive
stage of shock?
a.
Decreased heart rate and decreased urinary output
b.
Increased heart rate and decreased urinary output
c.
Increased pulse pressure and increased heart rate
d.
Decreased pulse pressure and decreased heart rate Correct
Answers B
1. The emergency department nurse assesses for which clinical
manifestation in the client suspected to be in the nonprogressive
stage of shock?
, a.
Decreased heart rate and decreased urinary output
b.
Increased heart rate and decreased urinary output
c.
Increased pulse pressure and increased heart rate
d.
Decreased pulse pressure and decreased heart rate Correct
Answers B
1. The nurse correlates which clinical manifestations with the
early stages of hypovolemic shock? (Select all that apply.)
a.
Elevated heart rate
b.
Elevated systolic blood pressure
c.
Elevated diastolic blood pressure
d.
Decreased respiratory rate
e.
Decreased pulse rate
f.
Decreased body temperature Correct Answers AC
1. The nurse correlates which clinical manifestations with the
early stages of hypovolemic shock? (Select all that apply.)
a.
Elevated heart rate
b.
Elevated systolic blood pressure