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    Exam Review

    1. An immunocompromised older adult has developed a urinary tract infection and the care team recognizes the need to prevent an exacerbation of the patient's infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the patient's risk of septic shock?
      A)Apply an antibiotic ointment to the patient's mucous membranes, as ordered.
      B)Perform passive range-of-motion exercises unless contraindicated
      C)Initiate total parenteral nutrition (TPN)
      D)Remove invasive devices as soon as they are no longer needed
    2. A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care?
      A)Airway protection
      B)Decreasing intracranial pressure
      C)Stabilizing cardiac arrhythmias
      D)Preventing musculoskeletal disability
    3. A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)(SATA)
      A)Increased hematocrit.
      B)Increased temperature.
      C)Increased heart rate.
      D)Increased blood pressure.
      E)Increased respiratory rate.
    4. A nursing home patient is brought to the ED with complaints of fever and generalized weakness. Skin is warm, dry and flushed. The patient is mildly agitated - an abnormal situation for this patient. Vital signs are HR 110/min, respirations 26/min, and temperature 101.8° F (28.8° C). A Foley catheter is draining cloudy yellow urine. You suspect this patient to have which of the following?
      A)A urinary tract infection
      B)Hyperdynamic sepsis
      C)Hypodynamic sepsis
      D)Toxic shock syndrome
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    Exam Review

    1. A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion?
      A)Confusion
      B)Blood pressure 84/50 mm Hg
      C)Anuria
      D)Petechiae
    2. The healthcare provider is caring for a patient with a diagnosis of hemorrhagic pancreatitis. The patient's central venous pressure (CVP) reading is 2, blood pressure is 90/50 mmHg, lung sounds are clear, and jugular veins are flat. Which of these actions is most appropriate for the nurse to take?
      A)Slow the IV infusion rate
      B)Administer dopamine
      C)No interventions are needed at this time
      D)Increase the IV infusion rate
    3. To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform?
      A)Palpate for abdominal tenderness.
      B)Auscultate bowel sounds.
      C)Check stools for occult blood.
      D)Ask the patient about nausea.
    4. A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?
      A)Age of the client
      B)Associated medical history
      C)Location of the burn
      D)Cause of the burn
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    Exam Review

    1. A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?
      A)Heart rate 160 beats/min.
      B)Cyanotic skin.
      C)Blood pressure 115/74.
      D)Hypoglycemia.
    2. A nurse in an emergency room is caring for the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
      A)Insert an indwelling urinary catheter.
      B)Inspect the mouth for signs of inhalation injuries.
      C)Administer intravenous pain medication.
      D)Draw blood for a complete blood cell (CBC) count.
    3. Which client would be most at risk for developing disseminated intravascular coagulation (DIC)?
      A)A 35 year old pregnant client with placenta previa
      B)A 42 year old client with a pulmonary embolus
      C)A 60 year old client receiving hemodialysis 3 days a week
      D)A 78 year old client with septicemia
    4. A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?
      A)Airway obstruction
      B)Infection
      C)Fluid imbalance
      D)Paralytic ileus
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    Exam Review

    1. A patient who has been involved in a motor-vehicle crash is admitted to the ED with cool, clammy skin, tachycardia, and hypotension. All of these orders are written. Which one will the nurse act on first?
      A)Insert two 14-gauge IV catheters.
      B)Administer oxygen at 100% per non-rebreather mask.
      C)Place the patient on continuous cardiac monitor.
      D)Draw blood to type and crossmatch for transfusions.
    2. A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?
      A)Flattened neck veins.
      B)Bradycardia.
      C)Sudden lethargy.
      D)Muffled heart sounds.
    3. Administering Dopamine (Inotropin) at 2 mcg/kg/minute results in:
      A)decreased renal perfusion.
      B)decreased reabsorption of sodium and water.
      C)increased renal perfusion.
      D)increased reabsorption of sodium and water.
    4. Ampicillin 350 mg IM daily is ordered for your patient. After reconstitution with 3.5 ml of sterile water, the vial of Ampicillin contains a total of 500 mg/ml. How many milliliters will your patient receive per day?
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    Exam Review

    1. An adult weighing 194 lb is brought to the Emergency Department after sustaining a thermal injury. Burns are partial and full thickness over 38% of the body surface area. According to the Parkland formula using 4 mL, what would this client's fluid requirements be for the first 24 hours after injury?
      A)3,344 mL
      B)13,376 mL
      C)6,688 mL
      D)18,796 mL
    2. The physician orders furosemide 67 mg IV push STAT for edema. Your vial of furosemide contains 40 mg in 4 ml. How many milliliters will you administer?
    3. A nurse in the ICU is planning the care of a patient who is being treated for shock. Which of the following statements best describes the pathophysiology of this patient's health problem?
      A)Blood is shunted from vital organs to peripheral areas of the body.
      B)Cells lack an adequate blood supply and are deprived of oxygen and nutrients.
      C)Circulating blood volume is decreased with a resulting change in the osmotic pressure gradient.
      D)Hemorrhage occurs as a result of trauma, depriving vital organs of adequate perfusion.
    4. A patient is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the physician will perform which of the following actions?
      A)Insert an oropharyngeal airway.
      B)Perform the jaw thrust maneuver.
      C)Perform endotracheal intubation.
      D)Perform a cricothyroidotomy.
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