Proctor Study N480 ALL 94 Complete
Solutions
Proctor Study N480 ALL 94 Complete
Solutions
1. A nurse in a burn treatment center is caring for a client who is admitted with severe
burns to both lower extremities and is pending an escharotomy. The client's spouse
asks the nurse what the procedure entails. Which of the following nursing statements is
appropriate?
a. "large incisions will be made in the eschar to improve circulation"
b. " I can call the doctor back here if you want me to"
c. "a piece of skin will be removed and grafted over the burned area"
d. "dead tissue will be surgically removed" - ANSWER-a. "large incisions will be made in
the eschar to improve circulation"
2. A nurse is monitoring the fluid replacement of a client who has sustained burns.
Which of the following fluids is used in the first 24 hours following a burn injury?
a. 5% dextrose in water
b. 5% dextrose in normal saline
c. normal saline
d. lactated ringers - ANSWER-d. lactated ringers
3. A nurse is caring for a client who has full-thickness burns all over 75% of his body.
Which of the following methods is appropriate to accurately monitor the cardiovascular
system?
a. auscultate cuff blood pressure
b. palpate pulse pressure
c. obtain a central venous pressure
d. monitor the pulmonary artery pressure - ANSWER-c. obtain a central venous
pressure
4. A nurse is assessing the depth and extent of a client who has severe burns to the
face, neck, and upper extremities. Which of the following factors is the first priority when
assessing the severity of the burn?
a. Age of the client
b. Associated medical history
c. Location of the burn
d. Cause of the burn - ANSWER-d. Cause of the burn
5. A client arrives at the emergency dept following an explosion at the chemical plant.
He has deep partial and full-thickness chemical burns over more than 25 % of his body
surface area. What is the nurse's priority intervention?
a. Initiate fluid resuscitation
b. Medication for pain
,Proctor Study N480 ALL 94 Complete
Solutions
c. Administer antibiotics
d. Maintain a patent airway - ANSWER-d. Maintain a patent airway
6. A nurse is caring for a client who came the emergency dept reporting chest pain. The
provider suspects a myocardial infarction. While waiting for the laboratory to report the
client's troponin levels, the client asks what this blood test will show. The nurse should
explain that troponin is
a. An enzyme that indicates damage to brain, heart, and skeletal muscle tissues
b. A protein whose levels reflect the risk for coronary artery disease
c. A heart muscle protein that appears in the bloodstream when there is damage to the
heart
d. A protein that helps transport oxygen throughout the body - ANSWER-c. A heart
muscle protein that appears in the bloodstream when there is damage to the heart
7. A nurse is assessing a client who has disseminated intravascular coagulation (DIC).
Which of the following should the nurse expect in the findings?
a. Excessive thrombosis and bleeding
b. Progressive increase in platelet production
c. Immediate sodium and fluid retention
d. Increased clotting factors - ANSWER-d. Increased clotting factors
8. A nurse is about to administer warfarin (Coumadin) to a client who has atrial
fibrillation. When the client asks what his medication will do, which of the following is an
appropriate nursing response?
a. It helps convert atrial fibrillation to sinus rhythm
b. Is dissolves clots in the bloodstream
c. It slows the response of the ventricles to the fast atrial impulses
d. It prevents strokes in clients who have atrial fibrillation - ANSWER-d. It prevents
strokes in clients who have atrial fibrillation
9. A nurse in a cardiac care unit is caring for a client with acute heart failure. Which of
the following findings should the nurse expect?
a. Decreased brain natriuretic peptide (BNP)
b. Elevated central venous pressure (CVP)
c. Decreased pulmonary pressure
d. Increases urinary output - ANSWER-b. Elevated central venous pressure (CVP)
10. A client comes into the ED reporting nausea and vomiting that worsens when lying
down and without relief from antacids. The provider suspects acute pancreatitis. Which
of the following lab test results should the nurse expect to see if the client has acute
pancreatitis?
a. Decreased WBC
b. Increased serum amylase
c. Decreased serum lipase
, Proctor Study N480 ALL 94 Complete
Solutions
d. Increased serum calcium - ANSWER-b. Increased serum amylase
11. A nurse in the ICU is caring for a client who has acute respiratory distress syndrome
(ARDS) and is receiving mechanical via an endotracheal tube. The provider plans to
extubate her within the next 24 hour. Which of the following is an important criterion for
extubating the client?
a. Ability to cough effectively
b. Adequate tidal volume without manually assisted breaths
c. No indication of infection
d. No need for supplemental oxygen - ANSWER-b. Adequate tidal volume without
manually assisted breaths
12. A nurse is caring for a client following a CT scan with dye who suffered from an
anaphylactic reaction. Which of the following conditions requires a priority nursing
response?
a. urticaria
b. stridor
c. tachypnea
d. angioedema - ANSWER-b. stridor
13. A nurse is caring for a female client who came in to the ED reporting SOB and pain
in the lung area. Her heart rate is 110/min, resp. rate 40/min, and blood pressure 140/80
m8juiimHg. Her arterial blood gases are: pH 7.5, PaCO2 29 mmHg, PaO2 60 mm Hg,
HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority intervention?
a. Prepare for mechanical ventilation
b. Administer oxygen via face mask
c. Prepare to administer a sedative
d. Monitor for pulmonary embolism - ANSWER-b. Administer oxygen via face mask
14. A nurse is monitoring a client who has just had a thoracentesis to remove pleural
fluid. Which of the following clinical manifestations indicate a complication that requires
notifying the provider immediately?
a. Serosanguineous drainage from the puncture site
b. Discomfort at the puncture site
c. Increased heart rate
d. Decreased temperature - ANSWER-c. Increased heart rate
15. A group of college students was attending a weekend football rally when one of the
students stumbled and fell into the bonfire. Although several friends quickly intervened,
the client sustained partial-thickness burns to both lower legs, chest, and both forearms.
Which of the following is priority nursing action when the client is brought to the ED?
a. cover the burned area with sterile gauze
b. inspect mouth for signs of inhalation
c. administer intravenous pain medication
Solutions
Proctor Study N480 ALL 94 Complete
Solutions
1. A nurse in a burn treatment center is caring for a client who is admitted with severe
burns to both lower extremities and is pending an escharotomy. The client's spouse
asks the nurse what the procedure entails. Which of the following nursing statements is
appropriate?
a. "large incisions will be made in the eschar to improve circulation"
b. " I can call the doctor back here if you want me to"
c. "a piece of skin will be removed and grafted over the burned area"
d. "dead tissue will be surgically removed" - ANSWER-a. "large incisions will be made in
the eschar to improve circulation"
2. A nurse is monitoring the fluid replacement of a client who has sustained burns.
Which of the following fluids is used in the first 24 hours following a burn injury?
a. 5% dextrose in water
b. 5% dextrose in normal saline
c. normal saline
d. lactated ringers - ANSWER-d. lactated ringers
3. A nurse is caring for a client who has full-thickness burns all over 75% of his body.
Which of the following methods is appropriate to accurately monitor the cardiovascular
system?
a. auscultate cuff blood pressure
b. palpate pulse pressure
c. obtain a central venous pressure
d. monitor the pulmonary artery pressure - ANSWER-c. obtain a central venous
pressure
4. A nurse is assessing the depth and extent of a client who has severe burns to the
face, neck, and upper extremities. Which of the following factors is the first priority when
assessing the severity of the burn?
a. Age of the client
b. Associated medical history
c. Location of the burn
d. Cause of the burn - ANSWER-d. Cause of the burn
5. A client arrives at the emergency dept following an explosion at the chemical plant.
He has deep partial and full-thickness chemical burns over more than 25 % of his body
surface area. What is the nurse's priority intervention?
a. Initiate fluid resuscitation
b. Medication for pain
,Proctor Study N480 ALL 94 Complete
Solutions
c. Administer antibiotics
d. Maintain a patent airway - ANSWER-d. Maintain a patent airway
6. A nurse is caring for a client who came the emergency dept reporting chest pain. The
provider suspects a myocardial infarction. While waiting for the laboratory to report the
client's troponin levels, the client asks what this blood test will show. The nurse should
explain that troponin is
a. An enzyme that indicates damage to brain, heart, and skeletal muscle tissues
b. A protein whose levels reflect the risk for coronary artery disease
c. A heart muscle protein that appears in the bloodstream when there is damage to the
heart
d. A protein that helps transport oxygen throughout the body - ANSWER-c. A heart
muscle protein that appears in the bloodstream when there is damage to the heart
7. A nurse is assessing a client who has disseminated intravascular coagulation (DIC).
Which of the following should the nurse expect in the findings?
a. Excessive thrombosis and bleeding
b. Progressive increase in platelet production
c. Immediate sodium and fluid retention
d. Increased clotting factors - ANSWER-d. Increased clotting factors
8. A nurse is about to administer warfarin (Coumadin) to a client who has atrial
fibrillation. When the client asks what his medication will do, which of the following is an
appropriate nursing response?
a. It helps convert atrial fibrillation to sinus rhythm
b. Is dissolves clots in the bloodstream
c. It slows the response of the ventricles to the fast atrial impulses
d. It prevents strokes in clients who have atrial fibrillation - ANSWER-d. It prevents
strokes in clients who have atrial fibrillation
9. A nurse in a cardiac care unit is caring for a client with acute heart failure. Which of
the following findings should the nurse expect?
a. Decreased brain natriuretic peptide (BNP)
b. Elevated central venous pressure (CVP)
c. Decreased pulmonary pressure
d. Increases urinary output - ANSWER-b. Elevated central venous pressure (CVP)
10. A client comes into the ED reporting nausea and vomiting that worsens when lying
down and without relief from antacids. The provider suspects acute pancreatitis. Which
of the following lab test results should the nurse expect to see if the client has acute
pancreatitis?
a. Decreased WBC
b. Increased serum amylase
c. Decreased serum lipase
, Proctor Study N480 ALL 94 Complete
Solutions
d. Increased serum calcium - ANSWER-b. Increased serum amylase
11. A nurse in the ICU is caring for a client who has acute respiratory distress syndrome
(ARDS) and is receiving mechanical via an endotracheal tube. The provider plans to
extubate her within the next 24 hour. Which of the following is an important criterion for
extubating the client?
a. Ability to cough effectively
b. Adequate tidal volume without manually assisted breaths
c. No indication of infection
d. No need for supplemental oxygen - ANSWER-b. Adequate tidal volume without
manually assisted breaths
12. A nurse is caring for a client following a CT scan with dye who suffered from an
anaphylactic reaction. Which of the following conditions requires a priority nursing
response?
a. urticaria
b. stridor
c. tachypnea
d. angioedema - ANSWER-b. stridor
13. A nurse is caring for a female client who came in to the ED reporting SOB and pain
in the lung area. Her heart rate is 110/min, resp. rate 40/min, and blood pressure 140/80
m8juiimHg. Her arterial blood gases are: pH 7.5, PaCO2 29 mmHg, PaO2 60 mm Hg,
HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority intervention?
a. Prepare for mechanical ventilation
b. Administer oxygen via face mask
c. Prepare to administer a sedative
d. Monitor for pulmonary embolism - ANSWER-b. Administer oxygen via face mask
14. A nurse is monitoring a client who has just had a thoracentesis to remove pleural
fluid. Which of the following clinical manifestations indicate a complication that requires
notifying the provider immediately?
a. Serosanguineous drainage from the puncture site
b. Discomfort at the puncture site
c. Increased heart rate
d. Decreased temperature - ANSWER-c. Increased heart rate
15. A group of college students was attending a weekend football rally when one of the
students stumbled and fell into the bonfire. Although several friends quickly intervened,
the client sustained partial-thickness burns to both lower legs, chest, and both forearms.
Which of the following is priority nursing action when the client is brought to the ED?
a. cover the burned area with sterile gauze
b. inspect mouth for signs of inhalation
c. administer intravenous pain medication
