Exam 1 - NUR2755 / NUR 2755 (Latest 2022 / 2023): Multidimensional Care IV / MDC 4 - Rasmussen

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When caring for a patient who has septic shock, which assessment finding is most important for the nurse to report to the care provider? (a) BP 92/56 (b) Skin cool and clammy- means progression (c... ) Apical pulse 118 beats/min (d) Arterial oxygen saturation 91% 2) Calculate the mean arterial pressure (MAP) in mmHg for a patient with a blood pressure of 84/46mmHg. (Record answer to the nearest whole number) MAP = SBP + 2 (DBP)/ 3 84+2(46)/3=59 3) The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding would indicate the presence of pneumothorax in this client? (a) A low respiratory rate (b) Diminished breath sounds (c) The presence of a barrel chest-copd (d) A sucking sound at the site of injury-open chest 4) The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding? (a) Slow deep respirations (b) Rapid deep respiration (c) Paradoxical respirations (d) Pain, especially with inspiration 5) A client with a chest injury has suffered a flail chest. The nurse assesses the client for which most distinctive sign of flail chest? (a) Cyanosis (b) Hypotension (c) Paradoxical chest movement-hall mark (d) Dyspnea, especially on exhalation 6) A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the highpressure alarm on the ventilator sounds and notes that the client has an absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition? (a) Right pneumothorax (b) Pulmonary embolism (c) Displaced endotracheal tube (d) Acute respiratory distress syndrome 7) A burn patient is brought into the emergency department with the following burns: half of the front torso(9), entire left arm (9), front of left le (9)g. The nurse should record the TBSA burns as. (a) 27% TBSA (b) 35% TBSA (c) 20%TBSA (d) 40% TBSA 8) The client, who is one-day postoperative following chest surgery is having difficulty breathing, has bilateral rales, and is confused and restless. Which intervention should the nurse implement first? (a) Assess the client pulse oximeter reading (b) Notify the rapid response team (c) Place the client in the Trendelenburg position (d) Check the client’s surgical dressing 9) The intensive care unit (ICU) nurse is caring for a client on a ventilator who is exhibiting respiratory distress. The ventilator alarms are going off. Which interventions should the nurse implement first? (a) Notify the respiratory therapist immediately (b) Ventilate with a manual resuscitation bag (c) Check the ventilator to resolve the problem-first step (d) Auscultate the client’s lung sound 10) The client in the intensive care unit is on a ventilator. Which interventions should the nurse implement? (select all that apply) (a) Ensure there is manual resuscitation bag at the bedside (b) Monitor the client’s pulse oximeter reading every shift (c) Assess the client’s respiratory status every 2 hours (d) Check the ventilatory setting every 4 hours (e) Collaborate with the respiratory therapist 11) Which actions are essential for the nurse caring for a mechanically ventilated to prevent ventilator-acquired pneumonia (VAP) (Select all that apply)? (a) Keep the HOB elevated at least 30 degrees (b) Perform oral care every 12 hours (c) Prevent aspiration (d) Suction every 1-2 hours around the clock (e) Turn and reposition the patient every 2 hours (f) Prevent pressure ulcers around the mouth 12) A patient in respiratory failure is diagnosed with a flail chest. After the patient is intubated, which treatment does the nurse expect to be implemented? (a) Positive end-expiratory pressure (PEEP) (b) Synchronized intermittent mechanical ventilator (SSIMV) (c) Bi-level positive airway pressure (Bi-PAP) (d) Peak inspiratory pressure (PIP) 13) An older adult patient arrives in the emergency department after falling off a roof. The nurse observes “sucking inward” of the loose chest during inspiration and a “puffing out” of the same area during expiration. Arterial blood gas (ABG) results show severe hypoxemia and hypercarbia. Which procedure does the nurse prepare for? (a) Chest tube insertion (b) Endotracheal intubation (c) Needle thoracotomy (d) Tracheostomy 14) A postoperative patient reports a sudden onset of shortness of breath and pleuritic chest pain. Assessment findings include diaphoresis, hypotension, crackles in the left lower lobe, and pulse oximetry of 85%. What does the nurse suspect has occurred with this patient? (a) Atelectasis (b) Pneumothorax (c) Pulmonary embolism (d) Flail chest 15) A nurse is planning care for an adult client who sustained severe burn injuries. Which interventions should the nurse include in the plan of care? (select all that apply) (a) Limit visitors in the client’s room when immunosuppressed (b) Encourage raw foods to improve exposure to natural flora (c) Offer high-calorie, high protein foods or supplemental feeding (d) Ambulate two or three times a day and progress in length each time (e) Apply compression dressing before the graft heals to prevent scar formationx 16) When assessing a patient who is severely bleeding and at risk for hypovolemic shock, the nurse anticipates which of the following? (a) Slow, labored breathing (b) Hot flushed skin (c) Edematous extremities (d) Weak, thready pulse 17) A nurse is assessing a client who sustained superficial partial-thickness and deep partial-thickness burn 38 hours ago. Which finding should the nurse report to the provider? (a) Edema in the burned extremities -expected (b) Severe pain at the burn sites -expected [Show More]

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