PN3 EXAM 2 QUESTIONS AND ANSWERS

PN3 EXAM 2 QUESTIONS AND ANSWERS 1. A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center? a. Level I-located within remote areas and provides advanced life support with resource capabilities b. Level II- located within community hospitals and provides care to most injured clients c. Level III- located in rural communities and provides only basic care to clients d. Level IV-located in large teaching hospitals and provides a full continuum of trauma care for all clients 2. A nurse is field-triaging clients after an industrial accident. Which client condition would the nurse triage with a red tag? a. Dislocated right hip and open fracture b. Large contusion to the forehead and bloody nose c. Closed fracture of the right clavicle and arm numbness d. Multiple fractured ribs and shortness of breath 3. An emergency department charge nurse notes and increase in sick calls and bickering among the staff after a week with multiple trauma incidents. What action should the nurse take? a. Organize a pizza party for each shift b. Remind the staff of the facility’s sick-leave policy c. Arrange for critical incident stress debriefing d. Talk individually with staff members 4. The nurse is concerned about developing post-traumatic stress disorder after working for several years in the emergency department. Which of the following should the nurse do to ensure this disorder does not manifest? (SATA) a. Eat well-balanced meals b. Drink water c. Take breaks when needed d. Do not work more than 12 hours per day e. Ingest at least one alcoholic drink every evening 5. A nurse is triaging clients in the emergency department. Which client would the nurse classify as “non-urgent?” a. A 44-year old with chest pain and diaphoresis b. A 50-year old with chest trauma and absent breath sounds c. A 62-year old with a simple fracture of the left arm d. A 79 year old with a temperature of 104F (40C) 6. A client presents to the Emergency Department with 30% total body surface area (TBSA) burns. The client weighs 176lbs. Use the Parkland Formula (4ml) to calculate the hourly rate for the first 8 hours. a. 600ml/hr b. 1200ml/hr c. 1760ml/hr d. 2670ml/hr 7. A client is being evaluated in the emergency department following burn injury at home. The client has second- and third-degree burns to the right and left arms, back and both posterior legs. Using the rule of nines, the nurse would calculate this client’s burn as being: a. 36% b. 45% c. 54% d. 72% 8. A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support? a. Assign assistive personnel to keep his room neat and clean b. Rotate nursing staff so he can have varied interactions c. Talk with the client during wound care d. Keep family members aware of his condition 9. You are providing care to Mary a 22-year old female who received burns to much of head and anterior neck. As the nurse, you understand that Mary should be positioned in which of the following positions to prevent contractures of the head and neck? a. Hyperextension with no pillow b. Flexion and promoting side-to-side movement of the head c. Hyperextension with neck brace d. Flexion and supine 10. The nurse is in the emergency department is using a triage system because this system ranks clients by: a. Severity of illness or injury b. Body systems involved c. Name d. Age 11. Emergent interventions for a client with burns to the face and trunk/arms may include which of the following? (SATA) a. Inserting an indwelling urinary catheter b. Intubating the client c. Oral medications for pain management d. Starting an intravenous solution of Ringer’s lactate e. Range of motion exercise to avoid contractures to extremities 12. A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client’s care. The nurse should identify which of the following risks as the priority for assessment and intervention? a. Airway obstruction b. Infection c. Fluid imbalance d. Paralytic ileus 13. The emergency department nurse is preparing to triage victims of an internal event. Which of the following would be considered an internal event? a. Bus crash in front of the hospital b. Train crash 5 miles away c. Fire in the hospital d. Explosion in a nearby oil station 14. In the event of a mass casualty situation the best triage nurse is: a. The recently graduated registered nurse (RN) b. The licensed vocational nurse (LVN) with 5 years; experience c. The RN with the most experience and bst assessment skills d. The recently graduated LVN 15. A client who ignited a rubbish pile with gasoline-sustained burns to his anterior torso, bilateral anterior legs and right anterior arm. Using the rule of nines, what is the total body surface area (TBSA) % of burns? a. 36% b. 45% c. 40.5% d. 31.5% 16. When caring for a client with severe burns, the nurse can expect to administer pain medication via which route? a. Intramuscular (IM) b. Intravenous (IV) c. Oral d. Subcutaneous 17. A client has sustained a 50% TBSA burns to torso and extremities in a house fire. The main weighs 154ibs (70kg). Using the Parkland formula, how much fluid would this client be given in the first 24 hours? a. 12,000ml b. 14,000ml c. 26,000ml d. 16,000ml 18. A client is receiving a large amount of fluids using the Parkland Formula following burns of 50% TBSA. the nurse knows that signs of fluid overload includes? (SATA) a. Formation of dependent edema b. Presence of lung crackles on auscultation c. Decreased skin turgor d. Engorged neck veins e. Loud, brassy cough 19. The nurse is aware that this phase in burn injury began at admission, however it is technically defined when there has been wound closure? a. Resuscitation phase b. Acute phase c. Chronic phase d. Rehabilitation phase 20. An elderly man was found unresponsive in his home and unable to give a history of any contributing events. The nurse recognizes the man’s skin color of “cherry red” as a sign that he has suffered from? a. Cardiac arrest b. Hemorrhagic stroke c. Carbon monoxide poisoning d. Cyanide poisoning 21. A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)? a. Assess the client for sedation needs b. Get family permission for restraints c. Provide frequent oral care per protocol d. Use nonverbal pain assessment tools 22. A client has sustained circumferential full thickness burns to the left arm. The nurse knows that the fluid buildup under the burns and the eschar can lead to compression of the arterial circulation of the extremity. To restore the blood flow to the extremity which intervention will be necessary? a. Diuretics b. Escharectomy c. Elevate the affected arm higher than the heart d. Compression garment to the left arm 23. A nurse who is caring for a client who has a deep vein thrombosis and is prescribed continuous IV infusion at 1,200 units/hr. Available is heparin 25,000 units in 500 mL D5W. The nurse should set the IV pump to deliver how many ml/hr? 24. Mr. M. is admitted to the hospital with a GI bleed and his physician orders a blood transfusion of packed red blood cells. Order: 1 unit PRBCs (40 ml) IV to infuse over 4 hours. Drop factor: 15gtt/ml. What is the infusion rate in gtt/min? a. 25 gtt/min b. 41 gtt/min c. 43 gtt/min d. 52 gtt/min 25. A client is on mechanical ventilation and the client’s spouse wonders why ranitidine (Zantac) is needed since the client “only has lung problems.” what response by the nurse is best? a. “It will increase the motility of the gastrointestinal tract” b. “It will keep the GI tract functioning normally” c. “It will prepare the GI tract for enteral feedings” d. “It will prevent ulcers from the stress of mechanical ventilation” 26. A client is admitted to the ICU with a flair chest and placed on mechanical ventilation. The nurse should monitor for which of the following? a. Tuberculosis because the client will have prolonged close contact with other individuals b. Chest tube placement because the lung has collapsed c. Pneumonia because the client is a high risk for acquiring infection d. Cor pulmonale because the chest wall is unstable 27. The nurse is caring for a client that