NUR2755 / NUR 2755 Multidimensional Care IV Exam 2
1. Nurse is caring for a client experiencing hypovolemic shock. Which of the following
interventions would not be appropriate for this client?
A. Monitor intravenous fluid replacement
B. Monitor vital signs
C. Monitor hemoglobin and hematocrit levels
D. Assist to a sitting position
2. The emergency department nurse is assessing a client who has sustained a blunt injury to
the chest wall. Which finding would indicate the presence of pneumothorax in this client?
A. Low respiratory rate
B. Diminished breath sounds
C. Presence of barrel chest
D. Sucking sound at the site of injury
3. Nurse is assessing the respiratory status of a client who has suffered a fractured rib. The
nurse should expect to note which finding?
A. Slow deep respirations
B. Rapid deep respirations
C. Paradoxical respirations
D. Pain, especially with inspiration
,4. Nurse is caring for a client who is in hypovolemic shock related to hemorrhage. The
nurse prepares IV tubing to infuse with which IV solution in preparation for a blood
transfusion?
A. 0.45% sodium chloride/
B. Lactated ringer's solution
C. Dextrose 10% in water
D. 0.9% sodium chloride
5. Client presents with the following vital signs: blood pressure 90/60 mm hg, temperature
38.3C (101F), heart rate 116 beats/min, respiratory 24 breaths/min. the client has a post-
op abdominal incision that is warm and red. Which type of shock is this client in?
A. Hypovolemic shock
B. Septic shock
C. Anaphylactic shock
D. Neurogenic shock
6. Nurse is caring for a client being treated with mechanical ventilation. The ventilator
sounds a low pressure alarm. The nurse immediately assess for other signs of which
condition?
A. Right pneumothorax
B. Pulmonary embolism
C. Disconnected endotracheal tube
D. Acute respiratory distress syndrome
, 7. Client with a chest injury has suffered a flail chest. The nurse assesses the client for
which most distinctive sign of flail chest?
A. Cyanosis
B. Hypotension
C. Paradoxical chest movement
D. Dyspnea, especially on exhalation
8. Nurse is planning care for a client who has severe acute respiratory distress syndrome
(ARDS). Which actions should the nurse include?
A. Aggressive fluid therapy and diuretics
B. Administer antiviral and antibiotics for every cause of ARDS X
C. Assess lungs daily and hourly suction to maintain airway
D. Maintain intubation and mechanical ventilator support.
9. Which of these findings is the best indicator that the fluid resuscitation for a client with
hypovolemic shock has been successful?
A. Hemoglobin is within normal limits
B. Urine output is 60 ml over the last hour
C. Pulmonary artery wedge pressure is normal
D. Mean arterial pressure is 65 mm hg
10. Nurse is caring for a client who is in the progressive stage of shock. Which finding
should the nurse expect?
A. Blood pressure change from 129/78 (95) mm hg to 89/45 (60) mm hg
B. Blood pressure change from 95/55 (65) to 90/52 (65)
1. Nurse is caring for a client experiencing hypovolemic shock. Which of the following
interventions would not be appropriate for this client?
A. Monitor intravenous fluid replacement
B. Monitor vital signs
C. Monitor hemoglobin and hematocrit levels
D. Assist to a sitting position
2. The emergency department nurse is assessing a client who has sustained a blunt injury to
the chest wall. Which finding would indicate the presence of pneumothorax in this client?
A. Low respiratory rate
B. Diminished breath sounds
C. Presence of barrel chest
D. Sucking sound at the site of injury
3. Nurse is assessing the respiratory status of a client who has suffered a fractured rib. The
nurse should expect to note which finding?
A. Slow deep respirations
B. Rapid deep respirations
C. Paradoxical respirations
D. Pain, especially with inspiration
,4. Nurse is caring for a client who is in hypovolemic shock related to hemorrhage. The
nurse prepares IV tubing to infuse with which IV solution in preparation for a blood
transfusion?
A. 0.45% sodium chloride/
B. Lactated ringer's solution
C. Dextrose 10% in water
D. 0.9% sodium chloride
5. Client presents with the following vital signs: blood pressure 90/60 mm hg, temperature
38.3C (101F), heart rate 116 beats/min, respiratory 24 breaths/min. the client has a post-
op abdominal incision that is warm and red. Which type of shock is this client in?
A. Hypovolemic shock
B. Septic shock
C. Anaphylactic shock
D. Neurogenic shock
6. Nurse is caring for a client being treated with mechanical ventilation. The ventilator
sounds a low pressure alarm. The nurse immediately assess for other signs of which
condition?
A. Right pneumothorax
B. Pulmonary embolism
C. Disconnected endotracheal tube
D. Acute respiratory distress syndrome
, 7. Client with a chest injury has suffered a flail chest. The nurse assesses the client for
which most distinctive sign of flail chest?
A. Cyanosis
B. Hypotension
C. Paradoxical chest movement
D. Dyspnea, especially on exhalation
8. Nurse is planning care for a client who has severe acute respiratory distress syndrome
(ARDS). Which actions should the nurse include?
A. Aggressive fluid therapy and diuretics
B. Administer antiviral and antibiotics for every cause of ARDS X
C. Assess lungs daily and hourly suction to maintain airway
D. Maintain intubation and mechanical ventilator support.
9. Which of these findings is the best indicator that the fluid resuscitation for a client with
hypovolemic shock has been successful?
A. Hemoglobin is within normal limits
B. Urine output is 60 ml over the last hour
C. Pulmonary artery wedge pressure is normal
D. Mean arterial pressure is 65 mm hg
10. Nurse is caring for a client who is in the progressive stage of shock. Which finding
should the nurse expect?
A. Blood pressure change from 129/78 (95) mm hg to 89/45 (60) mm hg
B. Blood pressure change from 95/55 (65) to 90/52 (65)
