Final Exam NSG430
The nurse is caring for a patient with an arterial monitoring system. The nurse asses the
patient's noninvasive cuff blood pressure to be 70/40 mm Hg. The arterial blood
pressure measurement via an intra-arterial catheter in the same arm is assessed by the
nurse to be 108/70 mm Hg. What is the best action by the nurse?
Select one:
a. Frequent oropharyngeal suctioning
b. Side to side position changes
c. Range-of-motion to extremities
d. Frequent neurological assessments - Answers -d. Frequent neurological
assessments
The nurse is caring for a burn-injured patient who weighs 154 pounds, and the burn
injury covers 40% of his body surface area. The nurse calculates the fluid needs for the
first 24 hours after a burn injury using a standard fluid resuscitation formula of 4
mL/kg/% burn of intravenous (IV) fluid for the first 24 hours. The nurse plans to
administer what amount of fluid in the first 24 hours?
Select one:
a. 14000 ml
b. 2800 ml
c. 7000 ml
d. 11200 ml - Answers -a. 14000 ml
For patients with major burns, when should you start enteral feedings?
Select one:
a. A few hours after the injury has occurred
b. Not until bowel sounds have returned
c. After the emergent phase of the injury
d. 2 to 3 days after the injury - Answers -c. After the emergent phase of the injury
After receiving the handoff report from the day shift charge nurse, which patient should
the evening charge nurse assess first?
Select one:
a. Patient with meningitis complaining of photophobia
b. A patient with bacterial meningitis on droplet precautions
c. Mechanically ventilated patient with a GCS of 6
d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of
104°F - Answers -d. A patient with an intracranial pressure ICP of 20 mm Hg and an
oral temperature of 104°F
, The charge nurse assigns patients based on their acuity and the level of experience of
the critical care nurses on duty. This is an example of implementation of:
Select one:
a. Healthy work environment
b. National patient safety goals
c. SBAR communication
d. Synergy model - Answers -d. Synergy model
While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage
from the patient's left naris. What is the best nursing action?
Select one:
a. Insert bilateral cotton nasal packing.
b. Have the patient blow the nose until clear.
c. Place a nasal drip pad under the nose.
d. Suction the left nares until the drainage clears. - Answers -c. Place a nasal drip pad
under the nose.
The nurse is caring for a patient who was hit on the head with a hammer. The patient
was unconscious at the scene briefly but is now conscious upon arrival at the
emergency department with a GCS score of 15. One hour later, the nurse assesses a
GCS score of 3. What is the priority nursing action?
Select one:
a. stimulate the patient hourly.
b. Notify the provider immediately.
c. Elevate the head of the bed.
d. Continue to monitor the patient. - Answers -b. Notify the provider immediately.
The nurse is caring for a patient who has a diminished level of consciousness and who
is mechanically ventilated. While performing endotracheal suctioning, the patient's
hands clench and pull into the chest. What is the best interpretation by the nurse?
Select one:
a. The patient is exhibiting purposeful movement.
b. The patient is exhibiting flexion posturing.
c. The patient is exhibiting extension posturing.
d. The patient is exhibiting decorticate posturing. - Answers -d. The patient is exhibiting
decorticate posturing.
(9) Which of the following would be seen in a patient with myxedema coma?
Select one:
a. Decreased reflexes
b. Hyperthermia
c. Tachycardia
d. Hyperventilation - Answers -a. Decreased reflexes
The nurse is caring for a patient with an arterial monitoring system. The nurse asses the
patient's noninvasive cuff blood pressure to be 70/40 mm Hg. The arterial blood
pressure measurement via an intra-arterial catheter in the same arm is assessed by the
nurse to be 108/70 mm Hg. What is the best action by the nurse?
Select one:
a. Frequent oropharyngeal suctioning
b. Side to side position changes
c. Range-of-motion to extremities
d. Frequent neurological assessments - Answers -d. Frequent neurological
assessments
The nurse is caring for a burn-injured patient who weighs 154 pounds, and the burn
injury covers 40% of his body surface area. The nurse calculates the fluid needs for the
first 24 hours after a burn injury using a standard fluid resuscitation formula of 4
mL/kg/% burn of intravenous (IV) fluid for the first 24 hours. The nurse plans to
administer what amount of fluid in the first 24 hours?
Select one:
a. 14000 ml
b. 2800 ml
c. 7000 ml
d. 11200 ml - Answers -a. 14000 ml
For patients with major burns, when should you start enteral feedings?
Select one:
a. A few hours after the injury has occurred
b. Not until bowel sounds have returned
c. After the emergent phase of the injury
d. 2 to 3 days after the injury - Answers -c. After the emergent phase of the injury
After receiving the handoff report from the day shift charge nurse, which patient should
the evening charge nurse assess first?
Select one:
a. Patient with meningitis complaining of photophobia
b. A patient with bacterial meningitis on droplet precautions
c. Mechanically ventilated patient with a GCS of 6
d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of
104°F - Answers -d. A patient with an intracranial pressure ICP of 20 mm Hg and an
oral temperature of 104°F
, The charge nurse assigns patients based on their acuity and the level of experience of
the critical care nurses on duty. This is an example of implementation of:
Select one:
a. Healthy work environment
b. National patient safety goals
c. SBAR communication
d. Synergy model - Answers -d. Synergy model
While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage
from the patient's left naris. What is the best nursing action?
Select one:
a. Insert bilateral cotton nasal packing.
b. Have the patient blow the nose until clear.
c. Place a nasal drip pad under the nose.
d. Suction the left nares until the drainage clears. - Answers -c. Place a nasal drip pad
under the nose.
The nurse is caring for a patient who was hit on the head with a hammer. The patient
was unconscious at the scene briefly but is now conscious upon arrival at the
emergency department with a GCS score of 15. One hour later, the nurse assesses a
GCS score of 3. What is the priority nursing action?
Select one:
a. stimulate the patient hourly.
b. Notify the provider immediately.
c. Elevate the head of the bed.
d. Continue to monitor the patient. - Answers -b. Notify the provider immediately.
The nurse is caring for a patient who has a diminished level of consciousness and who
is mechanically ventilated. While performing endotracheal suctioning, the patient's
hands clench and pull into the chest. What is the best interpretation by the nurse?
Select one:
a. The patient is exhibiting purposeful movement.
b. The patient is exhibiting flexion posturing.
c. The patient is exhibiting extension posturing.
d. The patient is exhibiting decorticate posturing. - Answers -d. The patient is exhibiting
decorticate posturing.
(9) Which of the following would be seen in a patient with myxedema coma?
Select one:
a. Decreased reflexes
b. Hyperthermia
c. Tachycardia
d. Hyperventilation - Answers -a. Decreased reflexes
