MDC 4 Exam 2 Rasmussen
A patient comes to the ED having diminished breath sounds on his left lung and asymmetrical chest
expansion when asked to breathe. The nurse feels the patient's trachea has deviated to the right side of
the throat. What is the patient suffering from? - (correct Answer) - Pneumothorax
A provider tells the nurse that a patient is having a simple pneumothorax. What treatment might be
prescribed for the patient? - (correct Answer) - Chest Tube
A provider tells the nurse that a patient is having a tension pneumothorax. What could the nurse
anticipate about how this will be treated? - (correct Answer) - With a needle decompression
thoracotomy
A nurse sees a patient coming into the trauma bay with paradoxical chest movement. What might the
patient be having? - (correct Answer) - Flail Chest
A provider tells the ED nurse that the patient has a flail chest. What does the nurse anticipate will
happen next for the patient? - (correct Answer) - Intubation and mechanical ventilation
What is an early manifestation of hypovolemic shock? - (correct Answer) - Decreased urine output
A nurse is caring for a patient who is critically ill and has a fever, low BP and yellowish mucus coming
from the nose. What type of shock is occurring with this patient? - (correct Answer) - Septic Shock
What is the main nursing issues revolving around rib fractures? - (correct Answer) - Pain! Puncturing
vasculature or organs.
What can the nurse teach the patient who has had a rib fracture to decrease pain? - (correct Answer) -
Splint when coughing
A nurse is caring for a patient with ARDS in the ICU. What manifestations might she see? - (correct
Answer) - Low oxygen levels that do not get better with 100% oxygen applied, bilateral pulmonary
edema that is not cardiac related, broken glass lung appearance on the X-ray.
A client ate peanuts and has an allergy to peanuts and tree nuts. What manifestations might the nurse
see upon client arrival related to anaphylactic shock? - (correct Answer) - Stridor and angioedema
A client is having anaphylactic shock due to a bee sting. What medication should be given to treat this? -
(correct Answer) - Epinephrine
A nurse is caring for a patient with ARDS. What treatment orders might the nurse see from the provider
for the patient? - (correct Answer) - Place them prone and on PEEP
What are complications of PEEP? - (correct Answer) - Pneumothorax
Low BP
, What is ventilator associated pneumonia? - (correct Answer) - Infection from being on the ventilator for
a long time
A nurse is learning about ARDS. What are the causes of ARDS? - (correct Answer) - Sepsis, Infection,
burns, near drowning, trauma, shock.
A client with a bone infection is getting information on ensuring his infection does not progress into
sepsis or septic shock. What might be some risk factors of the conditions? - (correct Answer) - Infection
risks, chancer, chemo, immunocompromised states, immunosuppressants, HIV
A nurse will be preparing to care for a newly intubated patient. What are some things she must prepare
and remember while caring for the patient? - (correct Answer) - Place ambu bag at bedside, suction PRN,
switch tube once a shift, assess respiratory status every 2 hrs, oral and mouth care every 2 hrs, wash
hands, expect orders for PPI or H2RB,
A patient is suspected to have a PE while in the ED. What might be some manifestations of this
occurring? - (correct Answer) - Low o2 saturation, low BP, sudden severe SOB, chest pain, LOC changes,
petechiae, lung edema , ascites.
A client was recently just extubated and now is showing signs of stridor and low oxygen levels. What
might of occurred and who should be called? - (correct Answer) - Irritation fo the throat form the tube.
Call RRT
What are clinical manifestations of hypovolemic shock? - (correct Answer) - weak and thready pulse,
decreased BP, increased HR, altered LOC, shallow and fast respiration, long capillary refill, decreased
H/H, low urine output.
A client has fluid volume excess due to heart failure. What are some of the important cardiac findings for
this condition? - (correct Answer) - Bounding pulse, JVD, central venous pressure is high, wedge pressure
is high
What must the nurse do immediately when a patient presents with an inhalation injury? - (correct
Answer) - Intubate to assume an airway, assess respiratory status.
A burn patient presents to the ED. What are some of the signs they may present with leading to an
inhalation injury? - (correct Answer) - SOB, soot around nose, singed facial hairs, drooling, not
swallowing, black membranes.
What things could cause an elevated wedge pressure? - (correct Answer) - FVE, left ventricular failure
What are the components of DIC? - (correct Answer) - Inappropriate clotting that uses up all the clotting
factors and bleeding due to not having enough clotting factors bath the same time.
A client comes in to the ED experiencing DIC. What treatment might the provider order for this
condition? - (correct Answer) - Clotting factors, blood, plasma, platelets, heparin or other anticoagulant
What could happen if DIC is not treated? - (correct Answer) - Refractory shock, septic shock, excessive
blood loss
A client is scheduled to go in for an escharotomy. What does this procedure entail? - (correct Answer) -
A patient comes to the ED having diminished breath sounds on his left lung and asymmetrical chest
expansion when asked to breathe. The nurse feels the patient's trachea has deviated to the right side of
the throat. What is the patient suffering from? - (correct Answer) - Pneumothorax
A provider tells the nurse that a patient is having a simple pneumothorax. What treatment might be
prescribed for the patient? - (correct Answer) - Chest Tube
A provider tells the nurse that a patient is having a tension pneumothorax. What could the nurse
anticipate about how this will be treated? - (correct Answer) - With a needle decompression
thoracotomy
A nurse sees a patient coming into the trauma bay with paradoxical chest movement. What might the
patient be having? - (correct Answer) - Flail Chest
A provider tells the ED nurse that the patient has a flail chest. What does the nurse anticipate will
happen next for the patient? - (correct Answer) - Intubation and mechanical ventilation
What is an early manifestation of hypovolemic shock? - (correct Answer) - Decreased urine output
A nurse is caring for a patient who is critically ill and has a fever, low BP and yellowish mucus coming
from the nose. What type of shock is occurring with this patient? - (correct Answer) - Septic Shock
What is the main nursing issues revolving around rib fractures? - (correct Answer) - Pain! Puncturing
vasculature or organs.
What can the nurse teach the patient who has had a rib fracture to decrease pain? - (correct Answer) -
Splint when coughing
A nurse is caring for a patient with ARDS in the ICU. What manifestations might she see? - (correct
Answer) - Low oxygen levels that do not get better with 100% oxygen applied, bilateral pulmonary
edema that is not cardiac related, broken glass lung appearance on the X-ray.
A client ate peanuts and has an allergy to peanuts and tree nuts. What manifestations might the nurse
see upon client arrival related to anaphylactic shock? - (correct Answer) - Stridor and angioedema
A client is having anaphylactic shock due to a bee sting. What medication should be given to treat this? -
(correct Answer) - Epinephrine
A nurse is caring for a patient with ARDS. What treatment orders might the nurse see from the provider
for the patient? - (correct Answer) - Place them prone and on PEEP
What are complications of PEEP? - (correct Answer) - Pneumothorax
Low BP
, What is ventilator associated pneumonia? - (correct Answer) - Infection from being on the ventilator for
a long time
A nurse is learning about ARDS. What are the causes of ARDS? - (correct Answer) - Sepsis, Infection,
burns, near drowning, trauma, shock.
A client with a bone infection is getting information on ensuring his infection does not progress into
sepsis or septic shock. What might be some risk factors of the conditions? - (correct Answer) - Infection
risks, chancer, chemo, immunocompromised states, immunosuppressants, HIV
A nurse will be preparing to care for a newly intubated patient. What are some things she must prepare
and remember while caring for the patient? - (correct Answer) - Place ambu bag at bedside, suction PRN,
switch tube once a shift, assess respiratory status every 2 hrs, oral and mouth care every 2 hrs, wash
hands, expect orders for PPI or H2RB,
A patient is suspected to have a PE while in the ED. What might be some manifestations of this
occurring? - (correct Answer) - Low o2 saturation, low BP, sudden severe SOB, chest pain, LOC changes,
petechiae, lung edema , ascites.
A client was recently just extubated and now is showing signs of stridor and low oxygen levels. What
might of occurred and who should be called? - (correct Answer) - Irritation fo the throat form the tube.
Call RRT
What are clinical manifestations of hypovolemic shock? - (correct Answer) - weak and thready pulse,
decreased BP, increased HR, altered LOC, shallow and fast respiration, long capillary refill, decreased
H/H, low urine output.
A client has fluid volume excess due to heart failure. What are some of the important cardiac findings for
this condition? - (correct Answer) - Bounding pulse, JVD, central venous pressure is high, wedge pressure
is high
What must the nurse do immediately when a patient presents with an inhalation injury? - (correct
Answer) - Intubate to assume an airway, assess respiratory status.
A burn patient presents to the ED. What are some of the signs they may present with leading to an
inhalation injury? - (correct Answer) - SOB, soot around nose, singed facial hairs, drooling, not
swallowing, black membranes.
What things could cause an elevated wedge pressure? - (correct Answer) - FVE, left ventricular failure
What are the components of DIC? - (correct Answer) - Inappropriate clotting that uses up all the clotting
factors and bleeding due to not having enough clotting factors bath the same time.
A client comes in to the ED experiencing DIC. What treatment might the provider order for this
condition? - (correct Answer) - Clotting factors, blood, plasma, platelets, heparin or other anticoagulant
What could happen if DIC is not treated? - (correct Answer) - Refractory shock, septic shock, excessive
blood loss
A client is scheduled to go in for an escharotomy. What does this procedure entail? - (correct Answer) -
