Acute Care Final Practice
Questions with Accurate
Answers
A 21-year-old patient who is in the rehabilitation phase after having deep partial-thickness face and neck
burns has a nursing diagnosis of disturbed body image. Which action by the patient indicates that the
problem is resolving?
a. Stating that the scarring will only be temporary.
b. Avoiding using a pillow to prevent neck contractures.
c. Asking about how to use make-up to cover up the scars.
d. Expressing sadness and anger about the scar appearance. correct answer Answer: C
Rationale: The willingness to use strategies to enhance appearance is an indication that the disturbed
body image is resolving. Expressing feelings about the scars indicates a willingness to discuss
appearance, but not resolution of the problem. Because deep partial-thickness burns leave permanent
scars, a statement that the scars are temporary indicates denial rather than resolution of the problem.
Avoiding using a pillow will help prevent contractures, but it does not address the problem of disturbed
body image.
A 70 kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using
the Parkland formula, calculate the volume of lactated Ringers solution that the nursing staff will
administer during the first 24 hours. correct answer ANS: 8400 mL
Rationale: The Parkland formula states that patients should receive 4 mL X kg X %TBSA burned during
the first 24 hours.
A client diagnosed with widespread lung cancer asks the nurse why he must be careful to avoid crowds
and people who are ill. What is the nurse's best response?
A. "With lung cancer, you are more likely to develop pneumonia and could pass this on to other people
who are already ill."
,B. "When lung cancer is in the bones, it becomes a bone marrow malignancy, which stops producing
immune system cells."
C. "The large amount of mucus produced by the cancer cells is a good breeding ground for bacteria and
other microorganisms."
D. "When lung cancer is in the bones, it can prevent production of immune system cells, making you less
resistant to infection." correct answer Answer: C
Rationale: Tumor cells that enter the bone marrow reduce the production of healthy white blood cells
(WBCs), which are needed for normal immune function. Therefore clients who have cancer, especially
leukemia, are at an increased risk for infection. Other people are not at risk for becoming infected as a
result of contact with a person who has lung cancer. Lung cancer that has spread to the bone is still lung
cancer; it is not a bone marrow malignancy. It is true that the person with lung cancer may produce
more mucus, which can harbor microorganisms, but this is not the main reason why the client should
avoid crowds and people who are ill.
A client has an arm cast and reports that it feels really tight and the fingers are puffy. What is the nurse's
best response?
a. "Elevate your arm on two pillows and apply ice to the cast."
b. "Continue to take ibuprofen (Motrin) until the swelling subsides."
c. "It is normal for a new cast to feel a little tight for the first few days."
d. "Please come to the clinic today to have your arm checked by the health care provider." correct
answer Answer: D
Rationale: Puffy fingers and a feeling of tightness from the cast may indicate the development of
compartment syndrome. The client should come to the clinic that day to be evaluated by the provider
because delay of treatment can cause permanent damage to the extremity. Ice and Motrin are
acceptable actions, but checking the cast is the priority because it ensures client safety. The nurse
should not just reassure the client that this is normal.
A client is diagnosed as having a bowel tumor. The nurse should monitor the client for which
complications of this type of tumor? Select all that apply.
a. Flatulence
,b. Peritonitis (inflammation of the abdominal lining)
Hemorrhage
c. Fistula formation (abnormal connection of 2 parts of the body that are not supposed to be connected.
d. Usually due to surgery, inflammation, infection, or injury.)
e. Bowel perforation
f. Lactose intolerance correct answer Answer: B, C, D, E
Rationale: not provided
A client who has sustained a crush injury to the right lower leg reports numbness and tingling of the
affected extremity. The skin of the right leg appears pale. Which is the nurse's first intervention?
a. Assess pedal pulses.
b. Apply oxygen by nasal cannula.
c. Increase the IV flow rate.
d. Document the finding. correct answer Answer: A
Rationale: The symptoms represent early warning of acute compartment syndrome. In acute
compartment syndrome, sensory deficits such as paresthesias precede changes in vascular or motor
signs. If the nurse finds a decrease in pedal pulses, the health care provider should be notified as soon as
possible.
A client with acute hepatitis is prescribed lactulose. The nurse knows this medication will:
A. Prevent the absorption of ammonia from the bowel.
B. Prevent hypoglycemia.
C. Remove bilirubin from the blood.
D. Mobilize iron stores from the liver correct answer Answer: A
, Rationale: Lactulose helps prevent the absorption of ammonia from the bowel because it will cause
frequent bowel movements, which facilitates the removal of ammonia from the intestines.
A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse
assess for as the expected therapeutic response?
a. Decreased intraocular pressure
b. Increased heart rate
c. Short period of asystole
d. Hypertensive crisis correct answer Answer: C
Rationale: Clients usually respond to adenosine with a short period of asystole, bradycardia,
hypotension, dyspnea, and chest pain. Adenosine has no conclusive impact on intraocular pressure.
A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the
possibility of a serious complication from this condition?
a. Sinus tachycardia
b. Speech alterations
c. Fatigue
d. Dyspnea with activity correct answer Answer: B
Rationale: Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events
includes changes in mentation, speech, sensory function, and motor function. Clients with atrial
fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients
with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the
rhythm disturbance.
A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention
by the nurse?
a. Mid-sternal chest pain
Questions with Accurate
Answers
A 21-year-old patient who is in the rehabilitation phase after having deep partial-thickness face and neck
burns has a nursing diagnosis of disturbed body image. Which action by the patient indicates that the
problem is resolving?
a. Stating that the scarring will only be temporary.
b. Avoiding using a pillow to prevent neck contractures.
c. Asking about how to use make-up to cover up the scars.
d. Expressing sadness and anger about the scar appearance. correct answer Answer: C
Rationale: The willingness to use strategies to enhance appearance is an indication that the disturbed
body image is resolving. Expressing feelings about the scars indicates a willingness to discuss
appearance, but not resolution of the problem. Because deep partial-thickness burns leave permanent
scars, a statement that the scars are temporary indicates denial rather than resolution of the problem.
Avoiding using a pillow will help prevent contractures, but it does not address the problem of disturbed
body image.
A 70 kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using
the Parkland formula, calculate the volume of lactated Ringers solution that the nursing staff will
administer during the first 24 hours. correct answer ANS: 8400 mL
Rationale: The Parkland formula states that patients should receive 4 mL X kg X %TBSA burned during
the first 24 hours.
A client diagnosed with widespread lung cancer asks the nurse why he must be careful to avoid crowds
and people who are ill. What is the nurse's best response?
A. "With lung cancer, you are more likely to develop pneumonia and could pass this on to other people
who are already ill."
,B. "When lung cancer is in the bones, it becomes a bone marrow malignancy, which stops producing
immune system cells."
C. "The large amount of mucus produced by the cancer cells is a good breeding ground for bacteria and
other microorganisms."
D. "When lung cancer is in the bones, it can prevent production of immune system cells, making you less
resistant to infection." correct answer Answer: C
Rationale: Tumor cells that enter the bone marrow reduce the production of healthy white blood cells
(WBCs), which are needed for normal immune function. Therefore clients who have cancer, especially
leukemia, are at an increased risk for infection. Other people are not at risk for becoming infected as a
result of contact with a person who has lung cancer. Lung cancer that has spread to the bone is still lung
cancer; it is not a bone marrow malignancy. It is true that the person with lung cancer may produce
more mucus, which can harbor microorganisms, but this is not the main reason why the client should
avoid crowds and people who are ill.
A client has an arm cast and reports that it feels really tight and the fingers are puffy. What is the nurse's
best response?
a. "Elevate your arm on two pillows and apply ice to the cast."
b. "Continue to take ibuprofen (Motrin) until the swelling subsides."
c. "It is normal for a new cast to feel a little tight for the first few days."
d. "Please come to the clinic today to have your arm checked by the health care provider." correct
answer Answer: D
Rationale: Puffy fingers and a feeling of tightness from the cast may indicate the development of
compartment syndrome. The client should come to the clinic that day to be evaluated by the provider
because delay of treatment can cause permanent damage to the extremity. Ice and Motrin are
acceptable actions, but checking the cast is the priority because it ensures client safety. The nurse
should not just reassure the client that this is normal.
A client is diagnosed as having a bowel tumor. The nurse should monitor the client for which
complications of this type of tumor? Select all that apply.
a. Flatulence
,b. Peritonitis (inflammation of the abdominal lining)
Hemorrhage
c. Fistula formation (abnormal connection of 2 parts of the body that are not supposed to be connected.
d. Usually due to surgery, inflammation, infection, or injury.)
e. Bowel perforation
f. Lactose intolerance correct answer Answer: B, C, D, E
Rationale: not provided
A client who has sustained a crush injury to the right lower leg reports numbness and tingling of the
affected extremity. The skin of the right leg appears pale. Which is the nurse's first intervention?
a. Assess pedal pulses.
b. Apply oxygen by nasal cannula.
c. Increase the IV flow rate.
d. Document the finding. correct answer Answer: A
Rationale: The symptoms represent early warning of acute compartment syndrome. In acute
compartment syndrome, sensory deficits such as paresthesias precede changes in vascular or motor
signs. If the nurse finds a decrease in pedal pulses, the health care provider should be notified as soon as
possible.
A client with acute hepatitis is prescribed lactulose. The nurse knows this medication will:
A. Prevent the absorption of ammonia from the bowel.
B. Prevent hypoglycemia.
C. Remove bilirubin from the blood.
D. Mobilize iron stores from the liver correct answer Answer: A
, Rationale: Lactulose helps prevent the absorption of ammonia from the bowel because it will cause
frequent bowel movements, which facilitates the removal of ammonia from the intestines.
A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse
assess for as the expected therapeutic response?
a. Decreased intraocular pressure
b. Increased heart rate
c. Short period of asystole
d. Hypertensive crisis correct answer Answer: C
Rationale: Clients usually respond to adenosine with a short period of asystole, bradycardia,
hypotension, dyspnea, and chest pain. Adenosine has no conclusive impact on intraocular pressure.
A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the
possibility of a serious complication from this condition?
a. Sinus tachycardia
b. Speech alterations
c. Fatigue
d. Dyspnea with activity correct answer Answer: B
Rationale: Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events
includes changes in mentation, speech, sensory function, and motor function. Clients with atrial
fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients
with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the
rhythm disturbance.
A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention
by the nurse?
a. Mid-sternal chest pain
