Copy of MDC 4 Final Blueprint, (Answered) Complete
Solution
The student got an 82% with the answers that are selected~
1. Which of the following describes the process of initial surveillance of
victims injury severity when administering first aid in an emergency
situation?
a. The Good Samaritan law
b. an emergency interview
c. Triage p. 151 A key process in any multi-casualty or mass casualty response is effective triage to
rapidly sort ill or injured patients into priority categories based on their acuity and survival potential.
d. taking vital signs
2. The nurse reminds a group of certified nursing assistants (CNA) that for a
client with an elevated temperature, the quickest and simplest technique to
reduce a temperature is which of the following?
a. Apply cool wash cloth to forehead
b. bathe in tepid water
c. remove clothing and bed linen- dumb but I think this is the right
answer… watched another review that said this exactly- BR
Removing the patient's clothing and bed linen covering the patient is a quick, simple, and usually effective way to reduce
temperature. The application of ice packs may result in excessive cooling and result in shivering, which acts to increase
metabolic rate. Bathing in tepid water is effective but requires more time and interaction than simply removing clothing and
bed linens. Chilled drinks will not adequately reduce the total body temperature.
d. give chilled drinks- don’t want to give them drinks cuz they could
aspirate
3. Which time of the day should the nurse encourage a client with Parkinson's
disease to schedule the most demanding physical activities to minimize the
effects of hypokinesia?
a. early in the morning when the clients energy
level is high b. to coincide with the peak action of
drug therapy
c. immediately after a rest period
d. When family members will be available
4. A client with multiple sclerosis(MS) is receiving baclofen. The nurse
determines that the drug is effective with which of the following outcomes
a. Induces sleep
b. stimulates the clients
appetite c. relieve
muscular spasticity
d. reduces the urine bacterial count
5. the nurse is caring for several clients on the Burn Unit who have sustained
extensive tissue damage. The nurse should monitor for which electrolyte
imbalance that is typical associated with initial third spacing fluid shift?
a. Hypercalcemia
b. Hypernatremia
c. Hyperkalemia p. 485 --- hyperkalemia, hyponatremia, metabolic acidosis, hypovolemia
d. Hypokalemia
6. When taking a client's vital signs on the first postoperative day, the
unlicensed assistive Personnel reports to the nurse that the oral
,temperature is 100 degrees. After encouraging the clients use the incentive
spirometer, the nurse should delegate which activity to the UAP?
a. Apply a ice caps the clients forehead
b. bathe the client with cool water
, c. place a hyperthermia blanket on the client's bed I think the idea of the
hypothermia blanket is to prevent shock-RM but what are the
indications of shock? I remember Fitz saying something about once
they are below 102 to stop the cooling or else it’ll drop too far down.
She might have said that in clinical though -BR so a slight increase
in temperature can indicate risk for sepsis, right?-RM I mean it could
but even if it did I think antibiotics would be done and then the blanket
later if the temp kept climbing
d. continue to monitor the clients temperature- I think this one is
correct… it’s not a fever? I can’t find much in the postop chapter on
this; a UAP woudlnt “monitor” that requires judgement af
7. the nurse is assessing a client with multiple traumas who is at risk for
developing acute respiratory distress syndrome(ARDS). the nurse assesses
for which earliest sign of acute respiratory distress syndrome?
a. Bilateral wheezing
b. inspiratory
crackles c. retractions pg 627????Doesn’t mention increased RR just increased
intercostal
work load… let me look
d. increased respiratory rate
I found this rationale - The earliest detectable sign of ARDS is an
increased respiratory rate, which can begin from 1-96 hours after the
initial injury to the body. This is followed by increasing dyspnea., air
hunger, retractions of accessory muscles, and cyanosis. Breath sounds
may be clear or consist of fine
inspiratory crackles or diffuse coarse
8. a client has a jackson-pratt drainage tube in place the first day after
surgical repair of a ruptured diverticula. The client asks the nurse the
purpose of the drains. What is the nurses best response? The drainage tube
is used to prevent”:
a. infection in the peritoneal cavity- Okay so fitz week 4 lecture 1hr 56
minutes in mentions it removes fluid to lower chances of infection
b. Bleeding into the peritoneal cavity--- pretty sure it’s this one, I don’t
think drains prevent infection they just pull blood out, page 278 briefly
talks about them being put in if the surgeon expects more than a
minimal amount of drainage
c. Pressure on the bladder
d. Pressure on the gallbladder
9. Wasn’t this question ^^^^ It was what drain removed through gravity
options were woundvac, jp drain, penrose, and another I put penrose.
10.An emergency department charge nurse notes an increase in sick calls and
bickering among the staff after a week with multiple trauma incidents. What
action would the nurse take?
a. Organize a pizza party for each shift
b. Remind the staff of the facilities sick leave
policy c. Arrange for critical incident stress
debriefing
d. Talk individually with staff members
11.The nurse is assessing a client for decorticate posturing. What should the
Solution
The student got an 82% with the answers that are selected~
1. Which of the following describes the process of initial surveillance of
victims injury severity when administering first aid in an emergency
situation?
a. The Good Samaritan law
b. an emergency interview
c. Triage p. 151 A key process in any multi-casualty or mass casualty response is effective triage to
rapidly sort ill or injured patients into priority categories based on their acuity and survival potential.
d. taking vital signs
2. The nurse reminds a group of certified nursing assistants (CNA) that for a
client with an elevated temperature, the quickest and simplest technique to
reduce a temperature is which of the following?
a. Apply cool wash cloth to forehead
b. bathe in tepid water
c. remove clothing and bed linen- dumb but I think this is the right
answer… watched another review that said this exactly- BR
Removing the patient's clothing and bed linen covering the patient is a quick, simple, and usually effective way to reduce
temperature. The application of ice packs may result in excessive cooling and result in shivering, which acts to increase
metabolic rate. Bathing in tepid water is effective but requires more time and interaction than simply removing clothing and
bed linens. Chilled drinks will not adequately reduce the total body temperature.
d. give chilled drinks- don’t want to give them drinks cuz they could
aspirate
3. Which time of the day should the nurse encourage a client with Parkinson's
disease to schedule the most demanding physical activities to minimize the
effects of hypokinesia?
a. early in the morning when the clients energy
level is high b. to coincide with the peak action of
drug therapy
c. immediately after a rest period
d. When family members will be available
4. A client with multiple sclerosis(MS) is receiving baclofen. The nurse
determines that the drug is effective with which of the following outcomes
a. Induces sleep
b. stimulates the clients
appetite c. relieve
muscular spasticity
d. reduces the urine bacterial count
5. the nurse is caring for several clients on the Burn Unit who have sustained
extensive tissue damage. The nurse should monitor for which electrolyte
imbalance that is typical associated with initial third spacing fluid shift?
a. Hypercalcemia
b. Hypernatremia
c. Hyperkalemia p. 485 --- hyperkalemia, hyponatremia, metabolic acidosis, hypovolemia
d. Hypokalemia
6. When taking a client's vital signs on the first postoperative day, the
unlicensed assistive Personnel reports to the nurse that the oral
,temperature is 100 degrees. After encouraging the clients use the incentive
spirometer, the nurse should delegate which activity to the UAP?
a. Apply a ice caps the clients forehead
b. bathe the client with cool water
, c. place a hyperthermia blanket on the client's bed I think the idea of the
hypothermia blanket is to prevent shock-RM but what are the
indications of shock? I remember Fitz saying something about once
they are below 102 to stop the cooling or else it’ll drop too far down.
She might have said that in clinical though -BR so a slight increase
in temperature can indicate risk for sepsis, right?-RM I mean it could
but even if it did I think antibiotics would be done and then the blanket
later if the temp kept climbing
d. continue to monitor the clients temperature- I think this one is
correct… it’s not a fever? I can’t find much in the postop chapter on
this; a UAP woudlnt “monitor” that requires judgement af
7. the nurse is assessing a client with multiple traumas who is at risk for
developing acute respiratory distress syndrome(ARDS). the nurse assesses
for which earliest sign of acute respiratory distress syndrome?
a. Bilateral wheezing
b. inspiratory
crackles c. retractions pg 627????Doesn’t mention increased RR just increased
intercostal
work load… let me look
d. increased respiratory rate
I found this rationale - The earliest detectable sign of ARDS is an
increased respiratory rate, which can begin from 1-96 hours after the
initial injury to the body. This is followed by increasing dyspnea., air
hunger, retractions of accessory muscles, and cyanosis. Breath sounds
may be clear or consist of fine
inspiratory crackles or diffuse coarse
8. a client has a jackson-pratt drainage tube in place the first day after
surgical repair of a ruptured diverticula. The client asks the nurse the
purpose of the drains. What is the nurses best response? The drainage tube
is used to prevent”:
a. infection in the peritoneal cavity- Okay so fitz week 4 lecture 1hr 56
minutes in mentions it removes fluid to lower chances of infection
b. Bleeding into the peritoneal cavity--- pretty sure it’s this one, I don’t
think drains prevent infection they just pull blood out, page 278 briefly
talks about them being put in if the surgeon expects more than a
minimal amount of drainage
c. Pressure on the bladder
d. Pressure on the gallbladder
9. Wasn’t this question ^^^^ It was what drain removed through gravity
options were woundvac, jp drain, penrose, and another I put penrose.
10.An emergency department charge nurse notes an increase in sick calls and
bickering among the staff after a week with multiple trauma incidents. What
action would the nurse take?
a. Organize a pizza party for each shift
b. Remind the staff of the facilities sick leave
policy c. Arrange for critical incident stress
debriefing
d. Talk individually with staff members
11.The nurse is assessing a client for decorticate posturing. What should the
