NUR 2755 45 which assessment finding is most important for the
nurse to report to the care provider 2022
1) 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%
2) 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
3) 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 breath sounds
(c) The presence of a barrel chest-copd
(d) A sucking sound at the site of injury-open chest
4) 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
5) 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
6) 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 upper lobe of the lung. The nurse immediately
assesses for other signs of which condition?
(a) Right pneumothorax
,NUR 2755 45 which assessment finding is most important for the
nurse to report to the care provider 2022
(b) Pulmonary embolism
(c) Displaced endotracheal tube
(d) Acute respiratory distress syndrome
7) 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
8) 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?
(a) Assess the client pulse oximeter reading
(b) Notify the rapid response team
(c) Place the client in the Trendelenburg position
(d) Check the client’s surgical dressing
9) The intensive care unit (ICU) nurse is caring for a client on a ventilator who
is exhibiting respiratory distress. The ventilator alarms are going off. Which
interventions should the nurse implement first?
(a) Notify the respiratory therapist immediately
(b) Ventilate with a manual resuscitation bag
(c) Check the ventilator to resolve the problem-first step
(d) Auscultate the client’s lung sound
10) The client in the intensive care unit is on a ventilator. Which interventions
should the nurse implement? (select all that apply)
(a) Ensure there is manual resuscitation bag at the bedside
(b) Monitor the client’s pulse oximeter reading every
shift (c) Assess the client’s respiratory status every 2
hours (d) Check the ventilatory setting every 4 hours
(e) Collaborate with the respiratory therapist
11) Which actions are essential for the nurse caring for a mechanically ventilated
to prevent ventilator-acquired pneumonia (VAP) (Select all that apply)?
(a) Keep the HOB elevated at least 30 degrees
(b) Perform oral care every 12 hours
(c) Prevent aspiration
(d) Suction every 1-2 hours around the clock
(e) Turn and reposition the patient every 2
hours (f) Prevent pressure ulcers around the
mouth
12) A patient in respiratory failure is diagnosed with a flail chest. After the patient is
, NUR 2755 45 which assessment finding is most important for the
nurse to report to the care provider 2022
intubated, which treatment does the nurse expect to be implemented?
nurse to report to the care provider 2022
1) 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%
2) 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
3) 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 breath sounds
(c) The presence of a barrel chest-copd
(d) A sucking sound at the site of injury-open chest
4) 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
5) 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
6) 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 upper lobe of the lung. The nurse immediately
assesses for other signs of which condition?
(a) Right pneumothorax
,NUR 2755 45 which assessment finding is most important for the
nurse to report to the care provider 2022
(b) Pulmonary embolism
(c) Displaced endotracheal tube
(d) Acute respiratory distress syndrome
7) 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
8) 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?
(a) Assess the client pulse oximeter reading
(b) Notify the rapid response team
(c) Place the client in the Trendelenburg position
(d) Check the client’s surgical dressing
9) The intensive care unit (ICU) nurse is caring for a client on a ventilator who
is exhibiting respiratory distress. The ventilator alarms are going off. Which
interventions should the nurse implement first?
(a) Notify the respiratory therapist immediately
(b) Ventilate with a manual resuscitation bag
(c) Check the ventilator to resolve the problem-first step
(d) Auscultate the client’s lung sound
10) The client in the intensive care unit is on a ventilator. Which interventions
should the nurse implement? (select all that apply)
(a) Ensure there is manual resuscitation bag at the bedside
(b) Monitor the client’s pulse oximeter reading every
shift (c) Assess the client’s respiratory status every 2
hours (d) Check the ventilatory setting every 4 hours
(e) Collaborate with the respiratory therapist
11) Which actions are essential for the nurse caring for a mechanically ventilated
to prevent ventilator-acquired pneumonia (VAP) (Select all that apply)?
(a) Keep the HOB elevated at least 30 degrees
(b) Perform oral care every 12 hours
(c) Prevent aspiration
(d) Suction every 1-2 hours around the clock
(e) Turn and reposition the patient every 2
hours (f) Prevent pressure ulcers around the
mouth
12) A patient in respiratory failure is diagnosed with a flail chest. After the patient is
, NUR 2755 45 which assessment finding is most important for the
nurse to report to the care provider 2022
intubated, which treatment does the nurse expect to be implemented?
