ATI 265 Test 3 Mock Exam (Answered) Complete Solution.
Answers And Rationale At The Bottom
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. An emergency room nurse assesses a patient who was rescued from a home fire. The patient
suddenly develops a loud, brassy cough. What action would the nurse take first?
a.
Apply oxygen and continuous pulse oximetry.
b.
Provide small quantities of ice chips and sips of water.
c.
Request a prescription for an antitussive medication.
d.
Ask the respiratory therapist to provide humidified air.
2. A nurse prepares to administer intravenous cimetidine to a patient who has a new burn injury. The
patient asks, “Why am I taking this medication?” How would the nurse respond?
a.
“Tagamet stimulates intestinal movement so you can eat more.”
b.
“It improves fluid retention, which helps prevent hypovolemic shock.”
c.
“It helps prevent stomach ulcers, which are common after burns.”
d.
“Tagamet protects the kidney from damage caused by dehydration.”
3. A nurse cares for a patient with a burn injury who presents with drooling and difficulty swallowing.
What action would the nurse take first?
a.
Assess the level of consciousness and pupillary reactions.
b.
Administer 100% FIO2 via non rebreather mask.
c.
Auscultate breath sounds over the trachea and bronchi.
d.
Measure abdominal girth and auscultate bowel sounds.
4. A nurse assesses a patient who has burn injuries and notes crackles in bilateral lung bases, a
respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. What
action would the nurse take next?
a.
Administer furosemide.
b.
Perform chest physiotherapy.
c.
Document and reassess in an hour.
d.
Place the patient in an upright position.
5. A nurse cares for a patient who has burn injuries. The patient’s wife asks, “When will his high risk
for infection decrease?” How would the nurse respond?
a.
“When the antibiotic therapy is complete.”
b.
“As soon as his albumin levels return to normal.”
c.
“Once we complete the fluid resuscitation process.”
d.
“When all of his burn wounds have closed.”
6. A nurse administers topical gentamicin sulfate to a patient’s burn injury. Which laboratory value
would the nurse monitor while the patient is prescribed this therapy?
a.
Creatinine
b.
SED rate
c.
Sodium
d.
Magnesium
7. A nurse cares for a patient with burn injuries. Which intervention would the nurse implement to
appropriately reduce the patient’s pain?
,a.
Administer the prescribed intravenous morphine sulfate.
b.
Apply ice to skin around the burn wound for 20 minutes.
c.
Administer prescribed intramuscular ketorolac
, d.
Decrease tactile stimulation near the burn injuries.
8. A nurse cares for a patient with burn injuries from a house fire. The patient is not consistently
oriented and reports a headache. What action would the nurse take?
a.
Increase the patient’s oxygen and obtain blood gases.
b.
Draw blood for a carboxyhemoglobin level.
c.
Increase the patient’s intravenous fluid rate.
d.
Perform a thorough Mini-Mental State Examination.
9. A nurse uses the rule of nines to assess a patient with burn injuries to the entire back region and left
arm. How would the nurse document the percentage of the patient’s body that sustained burns?
a. 9%
b. 18%
c. 27%
d. 36%
10. A nurse assesses a patient admitted with deep partial-thickness and full-thickness burns on the face,
arms, and chest. Which assessment finding would alert the nurse to a potential complication?
a.
Partial pressure of arterial oxygen (PaO2) of 80 mm Hg
b.
Urine output of 20 mL/hr
c.
Productive cough with white pulmonary secretions
d.
Core temperature of 100.6° F (38° C)
11. A nurse reviews the following data in the chart of a patient with burn injuries:
Admission Notes Wound Assessment
36-year-old female with bilateral leg burns Bilateral leg burns present with a
NKDA white and leatherlike appearance. No
Health history of asthma and seasonal allergies blisters or bleeding present. Patient
rates pain 2/10 on a scale of 0 to 10.
Based on the data provided, how would the nurse categorize this patient’s injuries?
a.
Partial-thickness deep
b.
Partial-thickness superficial
c.
Full thickness
d.
Superficial
12. After assessing an older adult patient with a burn wound, the nurse documents the findings as
follows:
Vital Signs Laboratory Results Wound Assessment
Heart rate: 110 beats/min Red blood cell count: Left chest burn wound,
Blood pressure: 112/68 mm Hg 5,000,000/(5 × 10 /L) 3 × 2.5 × 0.5 cm,
12
Respiratory rate: 20 White blood cell count: wound bed pale,
breaths/min 10,000/mm3 (10 × surrounding tissues
Oxygen saturation: 94% 10 /L)
9
with edema present
Pain: 3/10 Platelet count:
200,000/mm3 (200 ×
109/L)
Based on the documented data, what action would the nurse take next?
a.
Assess the patient’s skin for signs of adequate perfusion.
b.
Calculate intake and output ratio for the last 24 hours.
c.
Prepare to obtain blood and wound cultures.
d.
Place the patient in an isolation room.
ATI 265 Test 3 Mock Exam (Answered) Complete Solution.
Answers And Rationale At The Bottom
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. An emergency room nurse assesses a patient who was rescued from a home fire. The patient
suddenly develops a loud, brassy cough. What action would the nurse take first?
a.
Apply oxygen and continuous pulse oximetry.
b.
Provide small quantities of ice chips and sips of water.
c.
Request a prescription for an antitussive medication.
d.
Ask the respiratory therapist to provide humidified air.
2. A nurse prepares to administer intravenous cimetidine to a patient who has a new burn injury. The
patient asks, “Why am I taking this medication?” How would the nurse respond?
a.
“Tagamet stimulates intestinal movement so you can eat more.”
b.
“It improves fluid retention, which helps prevent hypovolemic shock.”
c.
“It helps prevent stomach ulcers, which are common after burns.”
d.
“Tagamet protects the kidney from damage caused by dehydration.”
3. A nurse cares for a patient with a burn injury who presents with drooling and difficulty swallowing.
What action would the nurse take first?
a.
Assess the level of consciousness and pupillary reactions.
b.
Administer 100% FIO2 via non rebreather mask.
c.
Auscultate breath sounds over the trachea and bronchi.
d.
Measure abdominal girth and auscultate bowel sounds.
4. A nurse assesses a patient who has burn injuries and notes crackles in bilateral lung bases, a
respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. What
action would the nurse take next?
a.
Administer furosemide.
b.
Perform chest physiotherapy.
c.
Document and reassess in an hour.
d.
Place the patient in an upright position.
5. A nurse cares for a patient who has burn injuries. The patient’s wife asks, “When will his high risk
for infection decrease?” How would the nurse respond?
a.
“When the antibiotic therapy is complete.”
b.
“As soon as his albumin levels return to normal.”
c.
“Once we complete the fluid resuscitation process.”
d.
“When all of his burn wounds have closed.”
6. A nurse administers topical gentamicin sulfate to a patient’s burn injury. Which laboratory value
would the nurse monitor while the patient is prescribed this therapy?
a.
Creatinine
b.
SED rate
c.
Sodium
d.
Magnesium
7. A nurse cares for a patient with burn injuries. Which intervention would the nurse implement to
appropriately reduce the patient’s pain?
,a.
Administer the prescribed intravenous morphine sulfate.
b.
Apply ice to skin around the burn wound for 20 minutes.
c.
Administer prescribed intramuscular ketorolac
, d.
Decrease tactile stimulation near the burn injuries.
8. A nurse cares for a patient with burn injuries from a house fire. The patient is not consistently
oriented and reports a headache. What action would the nurse take?
a.
Increase the patient’s oxygen and obtain blood gases.
b.
Draw blood for a carboxyhemoglobin level.
c.
Increase the patient’s intravenous fluid rate.
d.
Perform a thorough Mini-Mental State Examination.
9. A nurse uses the rule of nines to assess a patient with burn injuries to the entire back region and left
arm. How would the nurse document the percentage of the patient’s body that sustained burns?
a. 9%
b. 18%
c. 27%
d. 36%
10. A nurse assesses a patient admitted with deep partial-thickness and full-thickness burns on the face,
arms, and chest. Which assessment finding would alert the nurse to a potential complication?
a.
Partial pressure of arterial oxygen (PaO2) of 80 mm Hg
b.
Urine output of 20 mL/hr
c.
Productive cough with white pulmonary secretions
d.
Core temperature of 100.6° F (38° C)
11. A nurse reviews the following data in the chart of a patient with burn injuries:
Admission Notes Wound Assessment
36-year-old female with bilateral leg burns Bilateral leg burns present with a
NKDA white and leatherlike appearance. No
Health history of asthma and seasonal allergies blisters or bleeding present. Patient
rates pain 2/10 on a scale of 0 to 10.
Based on the data provided, how would the nurse categorize this patient’s injuries?
a.
Partial-thickness deep
b.
Partial-thickness superficial
c.
Full thickness
d.
Superficial
12. After assessing an older adult patient with a burn wound, the nurse documents the findings as
follows:
Vital Signs Laboratory Results Wound Assessment
Heart rate: 110 beats/min Red blood cell count: Left chest burn wound,
Blood pressure: 112/68 mm Hg 5,000,000/(5 × 10 /L) 3 × 2.5 × 0.5 cm,
12
Respiratory rate: 20 White blood cell count: wound bed pale,
breaths/min 10,000/mm3 (10 × surrounding tissues
Oxygen saturation: 94% 10 /L)
9
with edema present
Pain: 3/10 Platelet count:
200,000/mm3 (200 ×
109/L)
Based on the documented data, what action would the nurse take next?
a.
Assess the patient’s skin for signs of adequate perfusion.
b.
Calculate intake and output ratio for the last 24 hours.
c.
Prepare to obtain blood and wound cultures.
d.
Place the patient in an isolation room.
