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NUR 417
NUR 417 Exam 3 Guide | Care of Adult II |
Questions & Answers| Grade A | 100%
Correct | (NEW 2025/ 2026)
1. During the primary assessment of a patient with multiple trauma,
the nurse observes that the patient's right pedal pulses are absent
and the leg is swollen.
The nurse's first action should be to
a. initiate isotonic fluid infusion through two large-bore IV lines.
b. send blood to the lab for a complete blood count (CBC).
c. finish the airway, breathing, circulation, disability survey.
d. assess further for a cause of the decreased circulation.: A
Rationale: The assessment data indicate that the patient may have arterial
trauma and hemorrhage. When a possibly life-threatening injury is found
during the primary survey, the nurse should immediately start
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interventions before proceeding with the survey. Although a CBC is
indicated, administration of IV fluids should be started first. Completion of
the primary survey and further assessment should be completed after the
IV fluids are initiated.
After the return of spontaneous circulation following the
resuscitation of a patient who had a cardiac arrest, therapeutic
hypothermia is ordered. Which action will the nurse include in the
plan of care?
a. Initiate cooling per protocol.
b. Avoid the use of sedative drugs.
c. Check mental status every 15 minutes.
d. Rewarm if temperature is below 91° F (32.8° C).: ANS: A
When therapeutic hypothermia is used postresuscitation, external cooling
devices or cold normal saline infusions are used to rapidly lower body
temperature to 89.6° F to 93.2° F (32° C to 34° C). Because hypothermia
will decrease brain activity, assessing mental status every 15 minutes is
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not done at this stage. Sedative drugs are given during therapeutic
hypothermia. DIF: Cognitive Level: Apply (application)
Which interventions will the nurse plan for a comatose patient who
is to begin therapeutic hypothermia (select all that apply)?
a. Assist with endotracheal intubation.
b. Insert an indwelling urinary catheter.
c. Begin continuous cardiac monitoring.
d. Obtain an order to restrain the patient.
e. Prepare to give sympathomimetic drugs.: ANS: A, B, C
Cooling can produce dysrhythmias, so the patient's heart rhythm should be
continuously monitored and dysrhythmias treated if necessary. Bladder
catheterization and endotracheal intubation are needed during cooling.
Sympathomimetic drugs tend to stimulate the heart and increase the risk
for fatal dysrhythmias such as ventricular fibrillation. Patients receiving
therapeutic hypothermia are comatose or do not follow commands so
restraints are not indicated.
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DIF: Cognitive Level: Apply (application)
one match for drowning
A 22-yr-old patient who experienced a drowning accident in a local
pool, but now is awake and breathing spontaneously, is admitted
for observation. Which assessment will be most important for the
nurse to take during the observation period?
a. Auscultate heart sounds.
c. Auscultate breath sounds.
b. Palpate peripheral pulses.
d. Check mental orientation: ANS: C
Because pulmonary edema is a common complication after drowning, the
nurse should assess the breath sounds frequently. The other information
also will be obtained by the nurse, but it is not as pertinent to the patient's
admission diagnosis.
DIF: Cognitive Level: Analyze (analysis)
triage base on complaints
NUR 417
NUR 417
NUR 417 Exam 3 Guide | Care of Adult II |
Questions & Answers| Grade A | 100%
Correct | (NEW 2025/ 2026)
1. During the primary assessment of a patient with multiple trauma,
the nurse observes that the patient's right pedal pulses are absent
and the leg is swollen.
The nurse's first action should be to
a. initiate isotonic fluid infusion through two large-bore IV lines.
b. send blood to the lab for a complete blood count (CBC).
c. finish the airway, breathing, circulation, disability survey.
d. assess further for a cause of the decreased circulation.: A
Rationale: The assessment data indicate that the patient may have arterial
trauma and hemorrhage. When a possibly life-threatening injury is found
during the primary survey, the nurse should immediately start
NUR 417
, 2
NUR 417
interventions before proceeding with the survey. Although a CBC is
indicated, administration of IV fluids should be started first. Completion of
the primary survey and further assessment should be completed after the
IV fluids are initiated.
After the return of spontaneous circulation following the
resuscitation of a patient who had a cardiac arrest, therapeutic
hypothermia is ordered. Which action will the nurse include in the
plan of care?
a. Initiate cooling per protocol.
b. Avoid the use of sedative drugs.
c. Check mental status every 15 minutes.
d. Rewarm if temperature is below 91° F (32.8° C).: ANS: A
When therapeutic hypothermia is used postresuscitation, external cooling
devices or cold normal saline infusions are used to rapidly lower body
temperature to 89.6° F to 93.2° F (32° C to 34° C). Because hypothermia
will decrease brain activity, assessing mental status every 15 minutes is
NUR 417
, 3
NUR 417
not done at this stage. Sedative drugs are given during therapeutic
hypothermia. DIF: Cognitive Level: Apply (application)
Which interventions will the nurse plan for a comatose patient who
is to begin therapeutic hypothermia (select all that apply)?
a. Assist with endotracheal intubation.
b. Insert an indwelling urinary catheter.
c. Begin continuous cardiac monitoring.
d. Obtain an order to restrain the patient.
e. Prepare to give sympathomimetic drugs.: ANS: A, B, C
Cooling can produce dysrhythmias, so the patient's heart rhythm should be
continuously monitored and dysrhythmias treated if necessary. Bladder
catheterization and endotracheal intubation are needed during cooling.
Sympathomimetic drugs tend to stimulate the heart and increase the risk
for fatal dysrhythmias such as ventricular fibrillation. Patients receiving
therapeutic hypothermia are comatose or do not follow commands so
restraints are not indicated.
NUR 417
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NUR 417
DIF: Cognitive Level: Apply (application)
one match for drowning
A 22-yr-old patient who experienced a drowning accident in a local
pool, but now is awake and breathing spontaneously, is admitted
for observation. Which assessment will be most important for the
nurse to take during the observation period?
a. Auscultate heart sounds.
c. Auscultate breath sounds.
b. Palpate peripheral pulses.
d. Check mental orientation: ANS: C
Because pulmonary edema is a common complication after drowning, the
nurse should assess the breath sounds frequently. The other information
also will be obtained by the nurse, but it is not as pertinent to the patient's
admission diagnosis.
DIF: Cognitive Level: Analyze (analysis)
triage base on complaints
NUR 417
