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When caring for a patient who has septic shock, which assessment
finding is most important for the nurse to report to the care
provider?
(a) BP 92/56
(b) Skin cool and clammy- means progression
(c) Apical pulse 118 beats/min
(d) Arterial oxygen saturation 91%
Calculate the mean arterial pressure (MAP) in mmHg for a patient
with a blood pressure of 84/46mmHg. (Record answer to the nearest
whole number)
MAP = SBP + 2 (DBP)/
3
84+2(46)/3=59
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) A low respiratory
rate (b) Diminished
NUR 2755 PRACTICE EXAM Questions And
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breath sounds
(c) The presence of a barrel chest-copd
(d) A sucking sound at the site of injury-open chest
The 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 respiration
(c) Paradoxical respirations
(d) Pain, especially with inspiration
A 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-hall mark
(d) Dyspnea, especially on exhalation
A client has been admitted with chest trauma after a motor vehicle
crash and has undergone subsequent intubation. The nurse checks the
client when the high- pressure alarm on the ventilator sounds and
notes that the client has an absence of breath sounds in the right
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upper lobe of the lung. The nurse immediately assesses for other signs
of which condition?
(a) Right pneumothorax
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(b) Pulmonary embolism
(c) Displaced endotracheal tube
(d) Acute respiratory distress syndrome
A burn patient is brought into the emergency department with the
following burns: half of the front torso(9), entire left arm (9), front of
left le (9)g. The nurse should record the TBSA burns as.
(a) 27% TBSA
(b) 35% TBSA
(c) 20%TBSA
(d) 40% TBSA
A client is admitted to the emergency department with a full-thickness
burn to the right arm. Upon assessment, the arm is edematous, fingers
are mottled, and radial pulse is now absent. The client states that the
pain is 8 on a scale of 1 to 10. The nurse should:
(a) Administer morphine sulfate IV push for the severe pain
(b) Call the healthcare provider (HCP) to report the loss of the radial pulse
(c) Continue to assess the arm every hour for any additional changes
(d) Instruct the client to exercise the fingers and wrist
The client, who is one-day postoperative following chest surgery is
having difficulty breathing, has bilateral rales, and is confused and
restless. Which intervention should the nurse implement first?
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