UTA. AON4581 Exam 3.

Question 2

UTA. AON4581 Exam 3. A nurse is teaching a client with a partial-thickness wound how to wear the elastic pressure garment. How often should the nurse instruct the client to wear this garment?

• 4 to 6 hours a day for 6 months
• Continuously
• During waking hours for 2 to 3 months after the injury
• Only at night while sleeping for a year after the injury

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Question 3

The nurse assesses a 72-kg client six hours after a thermal burn covering 50% of the client’s total body surface area. Of the findings listed below, which is the most important to communicate to the health care provider?

• Blood pressure is 94/50 per arterial line
• Serous exudate is leaking from the burns
• Urine output is 20 mL for the past 2 hours
• Cardiac monitor shows a pulse rate of 104

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Question 4

The nurse is assessing the client with a circumferential burn to the left upper extremity. The nurse anticipates the performance of an escharotomy with which of the following assessment findings?

• Limited range of motion
• Loss of distal pulses
• Increased capillary refill
• Increased sensitivity to pain in the area

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Question 5

A 72-kg client with 60% severe thermal burns has crystalloid fluid replacement ordered using the American Burn Association (ABA) formula. The nurse will initially set the IV pump at ___ mL/hr for the first 8 hours.

• 1080
• 2667
• 4320
• 540

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Question 6

A nurse is caring for a client with 25% full-thickness burns on the arms, face, neck and shoulders. The client’s voice is hoarse and has a brassy cough. These findings indicate that the client most likely has

• carbon monoxide poisoning
• inhalation injury
• pulmonary edema
• pneumonia

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Question 7

The severity of each burn injury is determined by which of these factors?

• Depth of the burn, weight of the client
• Depth of the burn, presence of inhalation injury
• Gender of the client, duration of the burn
• Amount of surface area of the body that is burned, gender of the client UTA. AON4581 Exam 3.

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Question 8

A client is brought to the emergency department with partial-thickness and full-thickness burns on the anterior surface of both arms and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned?

• 30%
• 36%
• 18%
• 27%

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Question 9

A client in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the client’s laboratory studies, the nurse will expect the results to indicate what?

• Hyperkalemia, hyponatremia, and metabolic acidosis
• Hypokalemia, hypernatremia, and hypoalbuminemia
• Hyperkalemia, hypernatremia, and hyperalbuminemia
• Hyperkalemia, hyponatremia, and metabolic alkalosis UTA. AON4581 Exam 3.

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Question 10

Twenty hours after undergoing kidney transplantation, a client develops a hyperacute rejection. To correct this problem, the nurse should prepare the client for

• bone marrow transplant
• immediate dialysis to prevent damage to the new kidney
• high-dose intravenous cyclosporine therapy
• removal of the transplanted kidney

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Question 11

A client in neurogenic shock secondary to a spinal cord injury continues to have a mean arterial pressure (MAP) of 50 mmHg. To assess for the onset of acute kidney injury, what laboratory findings should be reviewed?

• Creatinine level, blood urea nitrogen (BUN) level, and urine specific gravity
• Urine specific gravity, albumin level, and alkaline phosphatase level
• Serum albumin level, alkaline phosphatase level, and blood urea nitrogen level
• Alkaline phosphatase level, creatinine level, and blood urea nitrogen level

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Question 12

A client who has acute glomerulonephritis is hospitalized with acute kidney injury (AKI) and hyperkalemia. Which information will the nurse obtain to evaluate the effectiveness of the prescribed calcium gluconate IV?

• Calcium level
• Cardiac rhythm UTA. AON4581 Exam 3.
• Urine output
• Phosphate level

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Question 13

A client with severe heart failure develops elevated blood urea nitrogen (BUN) and creatinine levels. The nurse will plan care to meet the goal of

• preventing hypertension
• delaying nephrotoxin substances
• maintaining adequate cardiac output
• reducing fluid volume

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Question 14

When a client is in the diuretic phase of acute kidney injury, the nurse must monitor for which serum electrolyte imbalances?

• Hypokalemia and hyponatremia
• Hyperkalemia and hypernatremia
• Hyperkalemia and hyponatremia
• Hypokalemia and hypernatremia

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Question 15

Which condition most likely caused pre-renal acute kidney injury? UTA. AON4581 Exam 3.

• Heart failure
• Aminoglycoside toxicity
• Ureterolithiasis
• Glomerulonephritis

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Question 16

You are caring for a client who has suffered a severe crush injury yesterday and now has decreasing urine output. The urine is now a dark cola color. You suspect the client is developing acute kidney injury as a direct result of

• embolus in a renal artery
• bilirubinemia
• myoglobinuria
• acute glomerulonephritis

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Question 17

Which of the following assessment findings or results will the nurse plan to obtain in order to determine the effectiveness of the prescribed calcium carbonate for a client with chronic kidney disease?

• Creatinine clearance
• Blood pressure
• Phosphate level
• Neurologic status

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Question 18

A client with chronic kidney disease is completing an exchange during peritoneal dialysis. The nurse observes that the peritoneal fluid is draining slowly and that the client’s abdomen is increasing in girth. What is the nurse’s most appropriate action?

• Advance the catheter 2 to 4 cm further into the peritoneal cavity
• Flush the catheter with 50 mL of additional dialysate
• Aspirate from the catheter using a 60 mL syringe UTA. AON4581 Exam 3.
• Reposition the client to facilitate drainage

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Question 19

Which of the following are complications the nurse should monitor for during dialysis?

• Hypertension, muscle cramping, and nausea
• Muscle cramping, dysrhythmias, and hypotension
• Dysrhythmias, hypertension, and a change in the LOC
• Hyperphosphatemia, a change in the LOC, and dysrhythmias

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Question 20

A 55-year-old male client is admitted with a diagnosis of acute hepatitis B with fever. Which of the following orders should the nurse question?

• Acetaminophen 1 g IM Q 4 hrs for fever
• Low protein diet
• Bed rest
• Encourage fluid intake as tolerated

Question 21

Which of the following clients are at risk for hepatitis D?

• Clients with hepatitis C
• Clients with hepatitis B ✓
• Clients with hepatitis E
• Clients with non viral hepatitis

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Question 22

A client who has advanced cirrhosis is receiving lactulose. Which finding by the nurse indicates that the medication is effective?

• The client denies nausea or anorexia
• The client has at least one stool daily UTA. AON4581 Exam 3.
• The client’s bilirubin level decreases
• The client is alert and oriented ✓

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Question 23

When assessing a client with portal hypertension, the nurse should be alert for life threatening indications of

• hemorrhage from duodenal diverticulitis
• hemorrhage from esophageal varices ✓
• small bowel obstruction
• liver abscess

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Question 24

Which of the following drugs is administered to promote hemostasis and control active bleeding in esophageal varices?

• Propranolol
• Neomycin sulfate
• Lactulose
• Vasopressin ✓

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Question 25

A client with cirrhosis has an episode of bleeding esophageal varices that is controlled with administration of vasopressin and endoscopic sclerotherapy. To detect possible complications of the bleeding episode, it is most important for the nurse to monitor serum

• bilirubin levels
• ammonia levels ✓
• creatinine levels
• potassium levels

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Question 26

A client admitted with a head injury has admission vital signs of temperature 98.6 F (37 C), blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken several hours after admission, will be of the most concern to the nurse?

• Blood pressure 148/78, pulse 112, respirations 28
• Blood pressure 110/70, pulse 120, respirations 30 UTA. AON4581 Exam 3.
• Blood pressure 130/72, pulse 90, respirations 32
• Blood pressure 156/60, pulse 58, respirations 12 ✓

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Question 27

A client with a head injury has an arterial blood pressure of 108/54 mmHg and an intracranial pressure of 15 mmHg. Which action by the nurse is appropriate?

• Check the client’s pupillary response to light
• Document and continue to monitor the parameters ✓
• Decrease the client’s IV infusion rate
• Notify the health care provider about the assessments

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Question 28

The physician prescribes intravenous mannitol for a client with a head injury. The nurse monitors the client for which expected therapeutic outcome of this drug?

• Decreased cerebral metabolism
• Decreased cerebral edema ✓
• Decreased seizure activity
• Decreased urinary output

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Question 29

The nurse notes that a client with a head injury and periorbital ecchymosis has clear nasal drainage. Which nursing action is most appropriate upon this finding?

• Check the nasal drainage for glucose ✓
• Obtain a specimen of the fluid for culture and sensitivity UTA. AON4581 Exam 3.
• Perform a halo test
• Instruct the client to blow his nose and check the nares for inflammation

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Question 30

The most reliable prognostic factor in the rehabilitation potential of head injured clients is

• the depth and duration of unresponsiveness and altered LOC ✓
• recognizing and treating complications early
• the skill and competency of the nursing and medical staff
• the size of the subdural hematoma

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Question 31

Which of the following assessment findings would indicate an increasing intracranial pressure (ICP) in a client with head trauma?

• Stiff neck, bradycardia, narrowing pulse pressure
• Narrow pulse pressure, bradycardia, irregular respirations
• Bradycardia, irregular breathing, widening pulse pressure ✓
• Narrowing pulse pressure, bradycardia, irregular heart rate

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Question 32

When assessing a client with a spinal cord injury, the nurse notes areflexia below the level of injury. What should the nurse suspect?

• Spinal shock ✓
• Autonomic dysreflexia
• Neurogenic shock
• Epidural hematoma

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Question 33

A client with spinal cord injury is ready to be discharged home. What are the potential complications that should be monitored for in this client?

• Autonomic dysreflexia and orthostatic hypotension ✓
• Salt-wasting syndrome and autonomic dysreflexia
• Deep vein thrombosis and increased intracranial pressure
• Orthostatic hypertension and deep vein thrombosis

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Question 34

Your client is at home in northern Texas during the month of August. The average daytime temperature is 103 degrees F. What advice should you give your client with a T4 spinal cord injury in this situation?

• Dress lightly during the day and stay in an air conditioned environment ✓
• Drink at least 3000 mL of cold liquids daily in hot weather
• Dress lightly during the heat of the day and stay on the screened porch UTA. AON4581 Exam 3.
• Sit outside for a limited time (one hour) in the morning only

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Question 35

A client with a history of a T2 spinal cord injury tells the nurse, “I feel awful today. My head is throbbing and I feel sick to my stomach.” Which action should the nurse take first?

• Assess for a fecal impaction
• Notify the health care provider
• Check the blood pressure ✓
• Give the prescribed antiemetic

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Question 36

A client has a spinal cord injury (SCI) following a motor vehicle crash. The nurse recognizes that the pathophysiology of secondary SCI includes

• initial infarction of the white matter of the cord
• necrotic destruction of the cord from hemorrhage and edema ✓
• release of epinephrine leading to massive vasodilation of spinal cord vessels
• mechanical transection of the cord

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Question 37

A patient with a T4 spinal cord injury develops the following assessment findings:

• BP 76/42 mm Hg
• HR 48 beats/min
• Warm, dry skin

The nurse recognizes these findings are primarily caused by:

• Massive intravascular fluid loss causing decreased preload
• Loss of sympathetic vascular tone resulting in unopposed parasympathetic stimulation ✓
• Impaired myocardial contractility resulting in decreased cardiac output
• Systemic inflammatory mediator release causing widespread capillary leak

Question 38

A trauma client is admitted with tracheal deviation to the left side of the chest and neck. His respirations are 30 breaths/minute, heart rate is 120, and BP is 90/60. Based on your nursing knowledge of chest trauma, you would suspect

• right-sided tension pneumothorax ✓
• flail chest with sternal involvement
• fractured ribs with splinting of the chest wall
• left-sided tension pneumothorax

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Question 39

The nurse is assessing an adult client following a motor vehicle accident and observes that the client has an increased use of accessory muscles and is reporting chest pain and shortness of breath. The nurse should recognize the possibility of what condition?

• Aspiration
• Cardiac tamponade
• Pneumothorax ✓
• Splenic laceration

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Question 40

Which client should the nurse prioritize as needing emergent treatment assuming no other injuries are present except the ones outlined below?

• A client with a sore neck who was immobilized in the field on a backboard with a cervical collar
• A client with a blunt chest trauma with some difficulty breathing ✓ UTA. AON4581 Exam 3.
• A client with confusion
• A client with a possible fractured tibia with adequate pedal pulses

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Question 41

A male client with multiple injuries is brought to the ED by ambulance. His airway is stabilized and he is breathing on his own. The ED nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding?

• Rapid pulse and prolonged capillary refill ✓
• Increasing urinary output
• Sudden diaphoresis
• Increased BP with narrowed pulse pressure

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Question 42

A patient with cardiogenic shock has the following hemodynamic values:

• CVP: 8 mm Hg
• Cardiac Index: 1.8 L/min/m²

Which prescribed medication would best improve cardiac output and tissue perfusion?

• Furosemide
• Metoprolol
• Nitroglycerin
• Dobutamine ✓

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Question 43

The emergency department nurse is caring for a patient with an acute gastrointestinal bleed. The nurse suspects the patient is in the compensatory stage of shock. Which assessment finding best supports this conclusion?

• Blood pressure requiring norepinephrine infusion, ventricular tachycardia, anuria, and severe metabolic acidosis
• Blood pressure 110/70 mm Hg, heart rate 82 beats/min, warm, flushed skin, and bounding peripheral pulses ✓
• Blood pressure 118/74 mm Hg, heart rate 124 beats/min, respiratory rate 30 breaths/min, urine output 0.6 mL/kg/hr, and cool, clammy skin
• Blood pressure 86/48 mm Hg, heart rate 142 beats/min, urine output 0.3 mL/kg/hr, lethargy, and mottled skin

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Question 44

A client who is in shock is receiving norepinephrine in addition to IV fluids. What principle should influence the nurse’s care planning during the administration of a vasoactive drug?

• The client should have arterial blood gases drawn every 10 minutes during treatment
• The drug should be discontinued immediately after blood pressure increases
• The infusion rate should be titrated according to client’s subjective sensation of adequate perfusion
• The drug dose should be tapered down once vital signs improve ✓

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Question 45

A critical care nurse is aware of similarities and differences between the treatments for different types of shock. What intervention is used in all types of shock?

• Aggressive antibiotic therapy
• Administration of hypertonic IV fluids
• Early provision of nutritional support ✓
• Aggressive hypoglycemic control

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Question 46

Which of the following types of shock is associated with bradycardia, vasodilation and hypotension?

• Hypovolemic shock
• Neurogenic shock ✓
• Cardiogenic shock UTA. AON4581 Exam 3.
• Septic shock

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Question 47

A patient develops anaphylactic shock after receiving IV ceftriaxone. After administering epinephrine, which assessment finding best indicates the medication is having its intended effect?

• Resolution of urticaria
• Decreased itching
• Decreased anxiety
• Resolution of stridor with improved air movement ✓

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Question 48

A patient with hemorrhagic shock has:

• Hemoglobin 6.5 g/dL
• MAP 62 mm Hg
• Lactate 5.4 mmol/L

After receiving packed red blood cells, which assessment finding best indicates that tissue oxygenation has improved?

• Hemoglobin increases to 8.0 g/dL
• Heart rate decreases to 104 beats/min
• Lactate decreases to 2.8 mmol/L ✓
• Blood pressure increases to 104/62 mm Hg

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Question 49

A trauma patient has received 2 liters of lactated Ringer’s solution. Current assessment findings include:

• BP 82/48 mm Hg
• HR 132 beats/min
• Hemoglobin 6.9 g/dL

The provider prescribes packed red blood cells. What is the primary goal of administering this blood product?

• Correct thrombocytopenia
• Reverse metabolic acidosis
• Expand intravascular volume
• Increase oxygen-carrying capacity and improve tissue oxygen delivery ✓

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Question 50

A patient with septic shock is receiving aggressive treatment. Twelve hours later the nurse notes increasing oxygen requirements, bilateral crackles, and new diffuse pulmonary infiltrates on the chest x-ray. Serum creatinine remains within the normal range. Which interpretation by the nurse is most appropriate?

• The patient is improving because renal function has not yet declined
• These findings are unrelated to septic shock and require evaluation for a separate disease process
• These findings may represent the earliest manifestation of multiple organ dysfunction syndrome (MODS) ✓
• Acute kidney injury must occur before pulmonary complications develop in MODS

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Question 51

A patient with septic shock develops the following laboratory and assessment findings:

• Platelet count: 42,000/mm³
• Elevated D-dimer
• Prolonged PT and aPTT
• Oozing from IV insertion sites

Which pathophysiologic process best explains these findings?

• Autoimmune destruction of circulating platelets causes spontaneous bleeding
• Widespread activation of coagulation consumes platelets and clotting factors, resulting in both thrombosis and bleeding ✓
• Excessive fibrinolysis prevents clot formation despite normal coagulation
• Impaired hepatic synthesis of clotting factors results in isolated coagulopathy