N480 - Final Exam UPDATED QUESTIONS
AND CORRECT ANSWERS
A pt has been admitted in anaphylactic shock due to an unknown allergen. The nurse understands that
the decrease in the pt's cardiac output is the result of which mechanism?
A. Increased alveolar ventilation
B. Peripheral vasodilation
C. Increased venous return
D. Decreased myocardial contractility - correct answer b. Peripheral vasodilation
Using the "rule of nines" calculate the percent of injury in an adult who was injured as follows: the pt
sustained partial and full thickness burns to half of his arm anteriorly, his entire leg, and his perineum.
A. 28%
B. 16%
C. 45.5%
D. 23.5% - correct answer d. 23.5%
The nurse is concerned about a deteriorating pt. Which signs of cardiogenic shock does the nurse
expect? (sata)
A. Bounding pedal pulse
B. Bp 86/42
C. Cool and moist skin
D. Hr 126 bpm
E. Urine output 20 ml/hr - correct answer b. Bp 86/42
C. Cool and moist skin
D. Hr 126 bpm
E. Urine output 20 ml/hr
A pt with massive trauma and possible sci is admitted to the er, which assessment finding by the nurse
will help confirm a diagnosis of neurogenic shock?
A. Cool clammy extremities
B. Inspiratory crackles
, C. Hr 39 bpm
D. Temp 101.2 - correct answer c. Hr 39 bpm
A pt is admitted to the burn unit with burns to the upper body and head after a garage fire. Initially,
wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What
is the best action for the nurse to take?
A. Encourage the pt to cough and auscultate the lungs again
B. Notify the hcp and prepare for endotracheal intubation
C. Reposition the pt in high fowler's and reassess breath sounds
D. Document the results and continue to monitor the pt's rr - correct answer b. Notify the hcp
and prepare for endotracheal intubation
A pt is admitted with a brain and sci secondary to an mvc. The nurse is monitoring the pt for signs of
neurogenic shock. Clinical findings in neurogenic shock are related to which pathophysiologic
process?
A. Focal injury to cerebral hemisphere
B. Loss of sns innervation
C. Pns stimulation
D. Injury to the hypothalamus - correct answer b. Loss of sns innervation
A nurse is caring for a pt admitted to the er with extensive partial and full thickness burns of the head,
neck, and chest. While planning the pt's care, the nurse should be aware that initially, the pt is at
greatest risk for which of the following?
A. Infection
B. Airway obstruction
C. Fluid imbalance
D. Paralytic ileus - correct answer b. Airway obstruction
When assessing a pt's full thickness burn injury during the emergent phase, what would the nurse
expect to find?
A. Massive edema at the injury site
B. Red fluid filled vesicles
C. Leathery dry hard skin
AND CORRECT ANSWERS
A pt has been admitted in anaphylactic shock due to an unknown allergen. The nurse understands that
the decrease in the pt's cardiac output is the result of which mechanism?
A. Increased alveolar ventilation
B. Peripheral vasodilation
C. Increased venous return
D. Decreased myocardial contractility - correct answer b. Peripheral vasodilation
Using the "rule of nines" calculate the percent of injury in an adult who was injured as follows: the pt
sustained partial and full thickness burns to half of his arm anteriorly, his entire leg, and his perineum.
A. 28%
B. 16%
C. 45.5%
D. 23.5% - correct answer d. 23.5%
The nurse is concerned about a deteriorating pt. Which signs of cardiogenic shock does the nurse
expect? (sata)
A. Bounding pedal pulse
B. Bp 86/42
C. Cool and moist skin
D. Hr 126 bpm
E. Urine output 20 ml/hr - correct answer b. Bp 86/42
C. Cool and moist skin
D. Hr 126 bpm
E. Urine output 20 ml/hr
A pt with massive trauma and possible sci is admitted to the er, which assessment finding by the nurse
will help confirm a diagnosis of neurogenic shock?
A. Cool clammy extremities
B. Inspiratory crackles
, C. Hr 39 bpm
D. Temp 101.2 - correct answer c. Hr 39 bpm
A pt is admitted to the burn unit with burns to the upper body and head after a garage fire. Initially,
wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What
is the best action for the nurse to take?
A. Encourage the pt to cough and auscultate the lungs again
B. Notify the hcp and prepare for endotracheal intubation
C. Reposition the pt in high fowler's and reassess breath sounds
D. Document the results and continue to monitor the pt's rr - correct answer b. Notify the hcp
and prepare for endotracheal intubation
A pt is admitted with a brain and sci secondary to an mvc. The nurse is monitoring the pt for signs of
neurogenic shock. Clinical findings in neurogenic shock are related to which pathophysiologic
process?
A. Focal injury to cerebral hemisphere
B. Loss of sns innervation
C. Pns stimulation
D. Injury to the hypothalamus - correct answer b. Loss of sns innervation
A nurse is caring for a pt admitted to the er with extensive partial and full thickness burns of the head,
neck, and chest. While planning the pt's care, the nurse should be aware that initially, the pt is at
greatest risk for which of the following?
A. Infection
B. Airway obstruction
C. Fluid imbalance
D. Paralytic ileus - correct answer b. Airway obstruction
When assessing a pt's full thickness burn injury during the emergent phase, what would the nurse
expect to find?
A. Massive edema at the injury site
B. Red fluid filled vesicles
C. Leathery dry hard skin
