Rasmussen College: NUR 2790 N3- Exam 2-Test questions from chapters 8, 10, 26, 32, 34,100% CORRECT

Rasmussen College: NUR 2790 N3- Exam 2-Test questions from chapters 8, 10, 26, 32, 34 1. An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event? Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims. 2. The hospital administration arranges for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation? You are free to express your feelings; whatever is said here stays here. 3. A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? (SATA.) A 35-year-old female with severe chest pain: red tag A 60-year-old male with an open fracture with distal pulses: yellow tag 4. A hospital prepares for a mass casualty event. Which functions are correctly paired with the personnel role? (Select allthat apply.) Hospital incident commander Assumes overall leadership for implementing the emergency plan Triage officer Rapidly evaluates each client to determine priorities for treatment 5. The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client? Wash your hands upon entering the patient’s room. 6. The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by auto-contamination? Change gloves between wound care on different parts of client’s body. 7. A nurse cares for a client who has facial burns. The client asks, Will I ever look the same? How should the nurse respond? You won’t look exactly the same but cosmetic surgery will help. 8. The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury? It’s normal to feel some depression 9. A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, “Why am I taking this medication?” How should the nurse respond? It helps prevent stomach ulcers, which are common after burns 10. A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The clients urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question? Administer Furosemide (Lasix) 40mg IV push 11. A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately? Serum potassium 6.5 12. A nurse cares for a client who has burn injuries. The client’s wife asks, when will his high risk for infection decrease? How should the nurse respond? When all of his burns have closed 13. A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the clients pain? Administer the prescribed IV morphine sulfate 14. A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take? Gather appropriate equipment and prepare for an emergency airway 15. A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the clients body that sustained burns? 27% 16. A nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication? Urine output of 20mL/hr 17. A nurse reviews the following data in the chart of a client with burn injuries: Admission Note: 36- year-old female with bilateral leg burns NKDA-Health history of asthma and seasonal allergies. Wound Assessment: Bilateral leg burns present with a white and leather-like appearance. No blisters or bleeding present. Client rates pain 2/10 on a scale of 0- 10. Based on the data provided, how should the nurse categorize this clients injuries? Full Thick-ness 18. A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (SATA) Administer analgesics, prevent wound infection, provide fluid replacement 19. A nurse cares for a client with burn injuries who is experiencing anxiety and pain. Which non- pharmacologic comfort measures should the nurse implement? (SATA) music as a distraction tactile stimulation increasing client control 20. A nurse plans care for a client with burn injuries. Which interventions should the nurse implement to prevent infection in the client? (SATA) Ask all family members and visitors to perform hand hygiene before touching client carefully monitor burn wounds when providing each dressing change using aseptic technique and wear gloves when performing wound care 21. An emergency room nurse cares for a client admitted with a 50% burn injury at 10:00 this morning. The client weighs 90 kg. Using the Parkland formula, calculate the rate at which the nurse should infuse intravenous fluid resuscitation when started at noon. (Record your answer using a whole number.) 1500mL/hr. Parkland formula: 4 mL/ 90 / 50% BSA = 18,000 mL first 24 hours post burn. Half- first 8 hours after injury, 2nd half during the next 16 hours. This client was burned at 10:00 AM, and fluid was not started until noon. Therefore, 9000 mL must be infused over the next 6 hours at a rate of 1500 mL/hr to meet the criteria of receiving half the calculated dose during the first 8 post burn hours. 22. An emergency room nurse implements fluid replacement for a client with severe burn injuries. The provider prescribes a liter of 0.9% normal saline to infuse over 1 hour and 30 minutes via gravity tubing with a drip factor of 30 drops/mL. At what rate should the nurse administer the infusion? (Record your answer using a whole number and rounding to the nearest drop.) 333 drops/min 1000 mL divided by 90 minutes, then multiplied by 30 drops, equals 333 drops/min. 23. A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood Pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority? Notify Rapid Response Team 24. A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the client’s oxygen saturation has not significantly improved. What response by the nurse is best? Blood clot interferes with perfusion in lungs 25. A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred? Platelet count: 82,000/L 26. An intubated client’s oxygen saturation has dropped to 88%. What action by the nurse takes priority? Listen to Client’s lung sounds 27. A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)? Provide frequent oral care per protocol 28. A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate? Assess cause of agitation 29. A client is on mechanical ventilation and the clients spouse wonders why ranitidine (Zantac) is needed since the client only has lung problems. What response by the nurse is best? It’ll prevent ulcers from the stress of mechanical ventilation 30. A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority? Ensure patent airway 31. A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication? Large chef salads and muffin 32. A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management? Strict vegetarian 33. A student nurse asks for an explanation of refractory hypoxemia. What answer by the nurse instructor is best? It is hypoxemia that persists even with 100% oxygen administration. 34. A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (SATA). Client with a new spinal cord injury on a rotating bed Older client who is 1-day post hip replacement surgery Young obese client with a fractured femur 35. The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator- associated pneumonia. What actions are included in this practice? (Select all that apply.) Adherence to proper hand hygiene administering anti-ulcer medication elevating the head of the bed providing oral care per protocol 36. A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this Client? (Select all that apply.) Allow visitors at the client’s bedside. Ensure the client can communicate if awake. Provide back and hand massages when turning. Turn the client every 2 hours or more. 37. A nurse assesses a client’s EKG tracing and observes that not all QRS complexes are preceded by a P wave. How should the nurse interpret this observation? Ventricular and atrial depolarizations are initiated from different sites. 38. A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition? Speech alterations 39. A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this clients medication administration record to prevent a common complication of this condition? Warfarin (Coumadin) 40. A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next? Level of consciousness 41. A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the client’s electrocardiogram. Which action should the nurse take next? Assess vital signs and level of consciousness. 42. A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client? Ensure that everyone is clear of contact with the client and the bed. 43. The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, why do you want to know if I use cocaine? How should the nurse respond? Clients who use cocaine are at risk for fatal dysrhythmias. 44. A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP related to this procedure? Clean the skin and clip hairs if needed. 45. A nurse assesses a client’s electrocardiogram (ECG) and observes the reading shown below: How should the nurse document this clients ECG strip? Sinus rhythm with premature ventricular contractions (PVCs) 46. A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below: Which action should the nurse take first? Assess airway, breathing, and level of consciousness. 47. The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below: After calling for assistance and a defibrillator, which action should the nurse take next? Initiate cardiopulmonary resuscitation (CPR). 48. A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.) Decrease in cardiac output Increase in blood pressure Decrease in urine output 49. An emergency room nurse assesses a client who has been raped. With which health care team member should the nurse collaborate when planning this client’s care? Forensic nurse examiner 50. The emergency department team is performing cardiopulmonary resuscitation on a client when the clients spouse arrives at the emergency department. Which action should the nurse take first? Ask the spouse if he wishes to be present during the resuscitation. 51. An emergency department nurse is caring for a client who has died from a suspected homicide. Which action should the nurse take? Communicate the client’s death to the family in a simple and concrete manner. 52. An emergency department nurse is caring for a client who is homeless. Which action should the nurse take to gain the clients trust? Listen to the clients concerns and needs.