Page 1 of 46
,Question 1
A nurse suspects that a patient receiving IVF has an air embolism. What is their priority action?
Correct Answer
- clamp the tubing
- turn patient on left side in trendelenburg to trap the air in the RA
- oxygenate
Question 1
The nurses calculating fluid resuscitation for young adult male who was burned in a bloody accident at 1200 and is
seen in the ER at 1400. The HCP determines that the client has burn over 30% of his body, mainly over his arms and
chest. Using the Parkland formula for fluid resuscitation, the client is to receive 7000 mL of fluid in 24 hours. Which
goal should the nurse establish for this clients plan of care?
Correct Answer
By 2000, the client will have received 3500 mL of fluid
Question 2
Adult female with a history of chronic adrenal insufficiency is admitted to the ICU for adrenal crisis. Which
intervention should the nurse implement first?
Correct Answer
Give IV hydrocortisone
Page 2 of 46
,Question 3
The nurse administers a thrombolytic agent to a client who is experiencing angina and ECG changes are indicative of
an acute MI. Which assessment best indicates that the medication has has the desired effect?
Correct Answer
Client reports cessation of angina
Question 4
A client arrives in the ER via ambulance with injuries that resulted from being hit by a bus. Vital signs on admission
are: BP 126/78, HR 100 bpm, RR 28, temperature 99F. Bloody drainage is noted at the clients left ear canal. What
should the nurse do to assess for possible basilar skull fracture and cerebral spinal fluid leak?
Correct Answer
Gently dab blood from the ear with a sterile gauze and observe for Halo
Question 5
A female client who is 4 hours post-laportomy, has rapidly increasing abdominal distention, with elevated pulse and
RR. Her skin is cool and pale, but there is no change in her BP. What intervention should the nurse implement
immediately?
Correct Answer
Notify the HCP of the clients status
Page 3 of 46
, Question 6
A client admitted to the ICU after a colon resection with the formation of the loop colostomy. The nurse determines
that the clients abdominal dressing is clean and dry. Vital signs are: HR: 130, temperature: 100, BP: 88/65, and urine
output of 10 mL/hr. What interventions should the nurse implement?
Correct Answer
Give a 500 mL IV fluid bolus challenge
Question 7
A client is admitted with syncopal episodes related to a third degree heart block. After the placement of a
transcutaneous pacemaker, the nurse observes several episodes the pacemaker failure to sense. What action should
the nurse take?
Correct Answer
Increase the sensitivity
Question 8
A client arrives in the ER complaining of pain. What description of pain should prompt the nurse to suspect it
originated in the myocardium?
Correct Answer
Produces chest heaviness with left arm pain
Page 4 of 46