NUR 102- Final Exam Questions with Answers 2023 /2024 Updates Tested and Verified, Exams of Nursing

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NUR 102- Final Exam

The nurse is screening children for scoliosis. What nursing assessment finding is indicative of scoliosis?

Correct response:

•

lateral curvature of the spine

Which term refers to a grating or crackling sound or sensation?

Correct response:

• Crepitus

Which elements of assessment of a traumatic musculoskeletal injury should be included when a client is

evaluated. Select all that apply.

Correct response:

•

All should be included.

A nurse is assessing a client who is experiencing peripheral neurovascular dysfunction. What assessment findings

are most consistent with this diagnosis?

Correct response:

•

Absence of feeling, capillary refill of 4 to 5 seconds, and cool skin

The human body has 206 bones, which are classified into four categories. Which types of bones are the femur

and ulna?

Correct response:

• long bones

Which term refers to moving away from midline?

Correct response:

• Abduction

A client is recovering from a fractured hip. The nurse would suggest that the client increase intake of which of

the following to facilitate calcium absorption from food and supplements?

Correct response:

•

Vitamin D

Which body movement involves moving toward the midline?

Correct response:

Adduction

The nurse is reporting on the results of client blood work to the oncoming nurse. Upon reviewing the data, it is

noted that the client has an elevated uric acid level. Which inflammatory process would the nurse screen for on

shift rounds?

Correct response:

Gout

A patient comes to the clinic and informs the nurse of numbness, tingling, and a burning sensation in the arm

from the elbow down to the fingers. What type of symptom would this be documented as?

Correct response:

•

Paresthesia

Which of the following diagnostic studies are done to relieve joint pain due to effusion?

Correct response:

• Arthrocentesis

The primary functions of cartilage are to reduce friction between articular surfaces, absorb shocks, and reduce

stress on joint surfaces. Where in the human body is cartilage found?

Correct response:

•

All options are correct.

During the physical assessment of a client with a musculoskeletal disorder, which techniques would enable the

nurse to determine the client’s ability to exhibit fine motor skills?

Correct response:

•

asking the client to grasp objects

A client tells the health care provider about shoulder pain that is present even without any strenuous

movement. The health care provider identifies a sac filled with synovial fluid. What condition will the nurse

educate the client about?

Correct response:

• bursitis

The nurse is caring for a client who experienced a crushing injury of the lower extremities. Which of the

following symptoms is essential to be reported to the physician?

Correct response:

•

Pulselessness

Which is an indicator of neurovascular compromise?

Correct response:

•

Capillary refill of more than 3 seconds

A patient has had a stroke and is unable to move the right upper and lower extremity. During assessment the

nurse picks up the arm and it is limp and without tone. How would the nurse document this finding?

Correct response:

•

Flaccidity

A nurse practitioner assesses a patient's movement in his left hand after a cast is removed. The nurse asks the

patient to turn his wrist so the palm of his hand is facing up. This movement is known as:

Correct response:

•

Supination.

A client experiences a musculoskeletal injury that involves the structure that connects a muscle to the bone. The

nurse understands that this injury involves which structure?

Correct response:

• Tendon

A patient is scheduled for a procedure that will allow the physician to visualize the knee joint in order to

diagnose the patient’s pain. What procedure will the nurse prepare the patient for?

Correct response:

•

Arthroscopy

Which hormone inhibits bone reabsorption and increases calcium deposit in the bone?

Correct response:

• Calcitonin

A nurse is caring for a client with an undiagnosed bone disease. When instructing on the normal process to

maintain bone tissue, which process transforms osteoblasts into mature bone cells?

Correct response:

•

Ossification

and calcification

An instructor is describing the process of bone development. Which of the following would the instructor

describe as being responsible for the process of ossification?

Correct response:

• Osteoblasts

The nurse is assessing the client following orthopedic surgery for a deep vein thrombosis. When performing this

assessment, the nurse is most correct to perform which movement?

•

Correct response:

Dorsiflexion

A client is seen in the emergency room for a knee injury that happened during a basketball game.

Diagnostic tests reveal torn cords of fibrous connective tissue that connect muscles to bones. What type of

tear has this client sustained?

Correct response:

• Tendon

A client is scheduled to undergo an electromyography. When performed, what will this test evaluate?

Correct response:

•

Muscle weakness

The nurse is caring for a client who had a surgical amputation of the left leg related to complication from

diabetes. The client asks the nurse, “If my leg is really gone, then why am I having such bad pain?” What is the

best response by the nurse?

Correct response:

• “It is called phantom pain and may come and go.”

A patient is scheduled for hip replacement surgery in a month. Which statement made by the client

demonstrates understanding for the preoperative instructions?

Correct response:

•

“I

will stop taking my aspirin prior to my surgery.”

A client is in Buck's traction after fracturing his right hip. The nurse should include which action in the care plan?

Correct response:

•

Maintaining correct body alignment

The nurse is assigned to care for a client who has had an open reduction and internal fixation of a fractured

right femur 2 days ago. The nurse is listening to the client’s lungs and, when moving the gown, observes

petechial hemorrhages on the skin of the chest. What is the first action by the nurse?

Correct response:

•

Call the physician to inform them of the findings.

The nurse is assigned to care for a client who has had a total knee arthroplasty yesterday. What type of

pharmacologic therapy does the nurse anticipate administering to this client to prevent complications related to

the surgery?

Correct response:

•

Anticoagulation therapy

A nurse is caring for a client who has a leg cast. The nurse observes that the client uses a pencil to scratch the

skin under the edge of the cast. How should the nurse respond to this observation?

Correct response:

• Encourage the client to avoid scratching, and obtain a prescription for an antihistamine if severe

itching persists.

A client diagnosed with a right ulnar fracture asks why the cast needs to go all the way up the arm. What is

the best response by the nurse?

Correct response:

• “The joint above the fracture and below the fracture must be immobilized.”

The nurse is caring for a client with an external fixator that requires pin care twice a day. The nurse observes that

there is a new purulent drainage around one of the pins. What intervention should the nurse anticipate doing?

Correct response:

•

Obtaining a culture

A client is reporting pain following orthopedic surgery. Which intervention will help relieve pain?

Correct response:

•

Elevate

the affected extremity and use cold applications.

A client is brought to the emergency department by a softball team member who states the client and another

player ran into each other, and the client is having severe pain in the right shoulder. What symptoms of a

fractured clavicle does the nurse recognize?

Correct response:

•

Right shoulder slopes downward and droops inward.

Which orthopedic surgery is done to correct and align a fracture after surgical dissection and exposure of the

fracture?

Correct response:

• Open reduction

A client has severe osteoarthritis in the left hip and is having surgery to replace both articular surfaces of the hip.

What type of surgical procedure will the nurse prepare the client for?

Correct response:

•

Total arthroplasty

•

The nurse is caring for a patient who had a total hip replacement. What lethal postoperative complication should

the nurse closely monitor for?

Correct response:

•

Pulmonary embolism

A nurse is reviewing a client's activities of daily living prior to discharge from total hip replacement. The nurse

should identify what activity as posing a potential risk for hip dislocation?

Correct response:

•

Bending down to put on socks

A client with a fractured femur is in balanced suspension traction. The client needs to be repositioned toward

the head of the bed. During repositioning, what should the nurse do?

Correct response:

•

Maintain consistent traction tension while repositioning.

The nursing care plan for a client in traction specifies regular assessments for venous thromboembolism (VTE).

When assessing a client's lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)?

Correct response:

•

Increased warmth of the calf

A patient in pelvic traction needs circulatory status assessed. How should the nurse assess for a positive Homans’

sign?

Correct response:

• Have the patient extend each leg and dorsiflex each foot to determine if pain or tenderness is present

in the lower leg.

The nurse is caring for a client who had an amputation of the left leg above the knee. What position can the

nurse place the client in several times per day to promote stump extension and prevent contractures?

Correct response:

•

Prone

A nurse is caring for a patient who is postoperative day 1 right hip replacement. How should the nurse position

the patient?

Correct response:

•

Keep the client's hips in abduction at all times.

A client in the emergency department is being treated for a wrist fracture. The client asks why a splint is being

applied instead of a cast. What is the best response by the nurse?

Correct response:

“A splint is applied when more swelling is expected at the site of injury.”

A nurse is caring for a client who is recovering in the hospital following orthopedic surgery. The nurse is

performing frequent assessments for signs and symptoms of infection in the knowledge that the client faces a

high risk of what infectious complication?

Correct response:

•

Osteomyelitis

A client had a total left hip arthroplasty. What clinical manifestation would indicate to the nurse that the

prosthesis is dislocated?

Correct response:

•

The left leg is internally rotated.

Reduction of a fracture refers to

Correct response:

•

Bringing bone fragments into proper alignment

The surgical nurse is admitting a client from postanesthetic recovery following the client's below-the-knee

amputation. The nurse recognizes the client's high risk for postoperative hemorrhage and should keep

what equipment at the bedside?

Correct response:

• A tourniquet

A client who has undergone a lower limb amputation is preparing to be discharged home. What outcome is

necessary prior to discharge?

Correct response:

•

Client

can demonstrate safe use of assistive devices.

Which term refers to the failure of fragments of a fractured bone to heal together?

Correct response:

• Nonunion

In a client with a dislocation, the nurse should initially perform neurovascular assessments a minimum of every

15 minutes until stable. Which complication does the assessments help the nurse to monitor in the client?

Correct response:

•

Compartment syndrome

•

A client reports pain in the right knee, stating, “My knee got twisted when I was going down the stairs.” The

client was diagnosed with an injury to the ligaments and tendons of the right knee. Which terminology,

documented by the nurse, best reflects the injury?

Correct response:

Sprain

When providing discharge teaching to a client with a fractured toe, the nurse should include which instruction?

Correct response:

• Apply ice to the fracture site.

After a car accident, a client is admitted to an acute care facility with multiple traumatic injuries, including

a fractured pelvis. For 24 to 48 hours after the accident, the nurse must monitor the client closely for which

potential complication of a fractured pelvis?

Correct response:

• Fat embolism

When is it advisable for the nurse to apply heat to a sprain or a contusion?

Correct response:

• After 2 days

The nurse is assisting with an examination of a client suspected of having carpal tunnel syndrome. The

physician has the patient flex the wrist for 30 seconds and percusses the median nerve. The client complains of

pain and numbness when this is done. What does the nurse know this positive sign is documented as?

Correct response:

• Phalen’s sign

Which is a hallmark sign of compartment syndrome?

Correct response:

• Pain

A patient sustains a fracture of the arm. When does the nurse anticipate pendulum exercise should begin?

Correct response:

•

As soon as tolerated, after a reasonable period of immobilization

A nurse is assigned to support a patient while a cast is being applied to treat a greenstick fracture. The nurse

documents that this fracture is classified as what type of fracture?

Correct response:

•

Incomplete

The nurse is monitoring a patient who sustained an open fracture of the left hip. What type of shock should the

nurse be aware can occur with this type of injury?

Correct response:

• Hypovolemic

A client was climbing a ladder, slipped on a rung, and fell on the right side of the chest. X-ray studies reveal three

rib fractures, and the client reports pain with inspiration. What is the anticipated treatment for this client?

Correct response:

•

Coughing and deep breathing with pillow splinting

A client is diagnosed with a first-degree strain of the left ankle related to running 5 miles daily. How would the

nurse differentiate the first-degree strain from other strains and sprains?

Correct response:

• The client has some edema of the lef t ankle with muscle spasms but is able to walk without

assistive devices.

The femur fracture that commonly leads to avascular necrosis or nonunion because of an abundant supply of

blood vessels in the area is a fracture of the:

Correct response:

• Femoral neck.

Pulselessness, a very late sign of compartment syndrome, may signify

Correct response:

• Lack of distal tissue perfusion

A client is transported to the emergency department for a femur fracture following a motor vehicle crash. What

action by the nurse is the highest priority?

Correct response:

•

Assess vital signs and level of consciousness.

A young client is being treated for a femoral fracture suffered in a snowboarding accident. The nurse's

most recent assessment reveals that the client is uncharacteristically confused. What diagnostic test should

be performed on this client?

Correct response:

•

Arterial blood gases

•

A client has returned to the postsurgical unit from the PACU after an above-the-knee amputation of the right leg.

Results of the nurse's initial postsurgical assessment were unremarkable but the client has called out. The nurse

enters the room and observes copious quantities of blood at the surgical site. What should be the nurse's initial

action?

Correct response:

•

Apply

a tourniquet.

A client arrives at the orthopedic clinic and informs the nurse that he thinks he has another stress fracture of the

right foot. The physician orders an x-ray with negative results. What does the nurse understand that these

negative results can mean?

Correct response:

• The stress fracture may not be seen on x-ray for a few weeks.

A patient has suffered a femoral shaft fracture in an industrial accident. What is an immediate nursing concern

for this patient?

Correct response:

• Hypovolemic shock

When the client who has experienced trauma to an extremity reports severe burning pain, vasomotor changes,

and muscles spasms in the injured extremity, the nurse recognizes that the client is likely demonstrating signs of

Correct response:

• complex regional pain syndrome.

The nurse assesses subtle personality changes, restlessness, irritability, and confusion in a client who has

sustained a fracture. The nurse suspects which complication?

Correct response:

•

Fat

embolism syndrome

A client has delayed bone healing in a fractured right humerus. What should the nurse prepare the client for that

promotes bone growth?

Correct response:

•

Electrical stimulation

The primary nursing intervention that will control swelling while treating a musculoskeletal injury is:

Correct response:

Elevate the affected area.

A client's rheumatoid arthritis (RA) has failed to respond appreciably to first-line treatments and the primary

provider has added prednisone to the client's drug regimen. What principle will guide this aspect of the client's

treatment?

Correct response:

•

The drug should be used for as short a time as possible.

Which medication directly inhibits osteoclasts, thereby reducing bone loss and increasing BMD?

Correct response:

•

Calcitonin

(Miacalcin)

A client has Paget’s disease. An appropriate nursing diagnosis for this client is:

Correct response:

•

Risk

for falls

Which of the following was formerly called a bunion?

Correct response:

• Hallux valgus

A patient is diagnosed with osteogenic sarcoma. What laboratory studies should the nurse monitor for the

presence of elevation?

Correct response:

•

Alkaline phosphatase

A nurse is providing care for a client who has osteomalacia. What major goal should guide the choice of medical

and nursing interventions?

Correct response:

• Maintenance of adequate levels of activated vitamin D

When an infection is bloodborne, the manifestations include which symptom?

Correct response:

• Chills

A client presents to the emergency department with fever, chills, restlessness, and limited movement of a

fractured jaw. What complication should the nurse interpret as the findings?

Correct response:

•

Osteomyelitis

A client with rheumatoid arthritis has infiltration of the lacrimal and salivary glands with lymphocytes as a result

of the disease. What does the nurse understand that this clinical manifestation is?

Correct response:

•

Sicca syndrome

Localized rapid bone turnover, most commonly affecting the skull, femur, tibia, pelvic bones, and vertebrae, is

characterized by which bone disorder?

Correct response:

•

Paget disease

Which drug is not used in the treatment of rheumatoid arthritis?

Correct response:

• allopurinol

A client with diabetes is attending a class on the prevention of associated diseases. What action should the client

perform to reduce the risk of osteomyelitis?

Correct response:

•

Perform meticulous foot care.

A client is prescribed a disease-modifying antirheumatic drug that is successful in the treatment of rheumatoid

arthritis but has side effects, including retinal eye changes. What medication will the nurse anticipate

educating the client about?

Correct response:

•

hydroxychloroquine

A client is informed that he has a benign bone tumor but that this type of tumor that may become malignant.

The nurse knows that this is characteristic of which type of tumor?

Correct response:

• Osteoclastoma

A client with systemic lupus erythematosus (SLE) is preparing for discharge. The nurse knows that the client has

understood health education when the client makes what statement?

Correct response:

• “I'll make sure to monitor my body temperature on a regular basis.”

A nurse is caring for a client with osteomyelitis. What complication should the nurse consider that the client is

at risk to develop?

Correct response:

Bone abscess formation

A nurse is providing an educational class to a group of older adults at a community senior center. In an effort

to prevent osteoporosis, the nurse should encourage participants to ensure that they consume the

recommended intake of what nutrients? Select all that apply.

Correct response:

- Calcium - Vitamin D

Which of the following is the first-line medication that would be used to treat and prevent osteoporosis?

Correct response:

• Bisphosphonates

A high school student who was injured in a football game presents with knee pain with internal rotation of the

foot. Which interventions are appropriate nursing actions? Select all that apply.

Correct response:

• Elevate the affected leg.
• Apply ice packs to the affected knee.
• Apply a knee brace or wrap the affected knee.

A client asks the nurse why the cast on his fractured left tibia extendcs on to his foot and over his knee?

Correct response:

• It is important to immobilize the bone fragments and keep them aligned. In order to do so that the

joint above the fracture and below the fracture must be immobilized

A client has a fractured jaw sustained in an automobile accident and has had the fracture surgically reduced

and immobilized with a wire loop. What should the nurse ensure is present at the client's bedside in case of

vomiting?

Correct response:

• Wire cutters

In fixation, the surgeoun inserts metal pins into the bone or bones from outside the skin

surface then attaches a compression device to the pins

Correct response:

• External

, death of bones tissues, occurs when there is diminished or absent blood

supply Correct response:

Avascular necrosis

•

•

A client is experiencing symptoms that are suspected to be related to systemic lupus erythematosus. What

cutaneous symptom occurs in about 50% of clients affected by this disease?

Correct response:

Butterfly-shaped rash on the face over the bridge of the nose and cheeks

During the stage of bone healing a certain structural formation occurs in which the bone fragments are joined by

fibrous tissue, cartilage and immature fiber bone. This formation is called?

Correct response:

• Callus

Which stage of a pressure sore is exhibited by deeply ulcerated tissue, exposing muscle and bone?

Correct response:

• IV

The nurse is performing a skin assessment on a client that is admitted to the hospital and observes an area

over the left heel that is reddened but intact. How would the nurse stage this pressure sore?

Correct response:

• Stage I

A nurse is explaining the importance of sunlight on the skin to a woman with decreased mobility who

rarely leaves her house. The nurse would emphasize that ultraviolet light helps to synthesize what vitamin?

Correct response:

• D

Which is the principal hardening ingredient of the hair and nails?

Correct response:

• Keratin

Which diagnostic test would be used if a malignancy is suspected?

Correct response:

• Biopsy

A gerontologic nurse is teaching a group of nursing students about integumentary changes that occur in older

adults. How should these students best integrate these changes into care planning?

Correct response:

•

By protecting older adults against shearing injuries

•

A client has been prescribed an antibiotic to treat a bacterial skin infection. What should the nurse inform the

client is most important to do when taking the medication?

Correct response:

Be sure to complete the prescription even if the infection appears to resolve.

A patient with a history of chronic respiratory illness exhibits nail clubbing. The nurse interprets this finding as

indicating which of the following?

Correct response:

• Hypoxia

Which of the following actions helps the nurse to determine the quality of the skin turgor?

Correct response:

•

Grasping the skin

An African American is admitted to the medical unit with liver disease. To correctly assess this client for jaundice,

on what body area should the nurse look for yellow discoloration?

Correct response:

• Sclerae

A nurse is doing a shift assessment on a group of clients after first taking report. An elderly client is having

her second dose of IV antibiotics for a diagnosis of pneumonia. The nurse notices a new rash on the client's

chest. The nurse should ask what priority question regarding the presence of a reddened rash?

Correct response:

• “Are you allergic to any foods or medication?”

The nurse assesses a patient with silvery-white, thick scales on the scalp, elbows, and hand that bleed when

picked off. What does the nurse suspect that this patient may have?

Correct response:

• Psoriasis

A nurse is preparing a patient with a history of allergies for diagnostic testing. Which of the following would the

nurse anticipate as being most likely?

Correct response:

• Patch testing

The nurse is caring for a client in the long-term care facility that was living in their home with a family member

caring for them. The family member states that they had a difficult time getting the client to eat or drink and he

developed a “bed sore.” The nurse observes a serous drainage covering the dressing and a 2 × 2 cm crater that is

0.5 cm deep. What stage does the nurse document this pressure sore as?

•

Correct response:

Stage III

A nurse is working with a client who has a diagnosis of Cushing syndrome. When completing a physical

assessment, the nurse should specifically observe for what integumentary manifestation?

Correct response:

• Hirsutism

Which of the following pigments influences hair color?

Correct response:

• Melanin

Which of the following causes odor in perspiration?

Correct response:

•

Bacteria on the skin

A client has an elevated temperature. The nurse is applying a cool compress to his forehead. This is an example

of which of the following types of heat loss?

Correct response:

• Conduction

During a routine checkup, a nurse observes the client’s skin to be tight and shiny. Which of the following is the

correct indication of this sign?

Correct response:

• Fluid retention

Which of the following conditions is the cause of thickening of the nail?

Correct response:

•

Fungal infection

Which medication classification is prescribed when allergy is a factor causing the skin disorder?

Correct response:

•

Antihistamines

Plantar warts may be treated with which of the following modalities?

Correct response:

•

•

Electrodesiccation

The nurse is administering a medication to a client who is suffering from pain related to partial thickness burns.

The medication will interrupt the sensation and transmission of pain stimuli. What type of receptors will this

medication block?

Correct response:

• Nociceptors

The nurse is assessing a client in the clinic and observes a fine skin rash over the arms and trunk. What

question is a priority that the nurse asks related to the rash?

Correct response:

•

“What medication are you taking?”

Which term describes a fungal infection of the scalp?

Correct response:

• Tinea capitis

The nurse teaches the client who demonstrates herpes zoster (shingles) that

Correct response:

•

the infection results from reactivation of the chickenpox virus.

A patient is complaining of severe itching that intensifies at night. The nurse decides to assess the skin using a

magnifying glass and penlight to look for the “itch mite.” What skin condition does the nurse anticipate finding?

Correct response:

• Scabies

The nurse is assessing a patient for psoriatic lesions after treatment with a nonsteroidal cream. What type of

lesion does the nurse know is characteristic of psoriasis?

Correct response:

•

Red, raised patch covered with silver scales

Development of malignant melanoma is associated with which risk factor?

Correct response:

• History of severe sunburn

What advice should the nurse give a client with a furuncle to prevent the spread of the infection?

Correct response:

•

Never pick or squeeze a furuncle.

A nurse is planning the care of a client with herpes zoster. What medication, if given within the first 24 hours of

the initial eruption, can arrest herpes zoster?

Correct response:

• Acyclovir

A patient has developed a boil on the face and the nurse observes the patient squeezing the boil. What does the

nurse understand is a potential severe complication of this manipulation?

Correct response:

•

Brain abscess

Dermatophytes (also called tinea) are parasitic fungi that invade the skin, scalp, and nails. How is a diagnosis

made for this condition? Select all that apply.

Correct response:

• visual examination
• Wood's light

The initial treatment of rosacea includes which of the following?

Correct response:

• Antibiotics

Which of the following is a dermatophyte infection of the fingernails or toes?

Correct response:

• Onychomycosis

Treatment of melanoma includes which of the following?

Correct response:

• Radical excision

A young college student recently had her tongue and lip pierced. She has developed a superinfection of

candidiasis from the antibacterial mouthwash. Which of the following would be the correct recommendation for

her?

Correct response:

•

Use an antifungal mouthwash or salt water.

While assessing a client with onychocryptosis, which of the following is evident if the tissue is infected?

Correct response:

•

Purulent drainage and an odor

When caring for the client with a new tattoo, which nursing diagnosis is of highest priority?

Correct response:

•

Risk for Infection

A client with a burn injury is in acute stress. Which of the following complications is prone to develop in

this client?

Correct response:

•

Gastric ulcers

Which zone consists of the area where the injury is most severe and deepest?

Correct response:

• Coagulation

Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues?

Correct response:

• Natural

Which of the following is a disadvantage of surgical debridement?

Correct response:

•

Bleeding

Skin grafts are necessary for which of the following burns?

Correct response:

•

Full-thickness

Following a serious thermal burn, which complication will the nurse take action to prevent first?

Correct response:

• Hypovolemia

An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both

legs. Based on the rule of nines, what is the percentage of the body burned?

Correct response:

•

36%

When the area of burn is irregular in shape and is scattered over multiple areas of the body, which is the best

method for the nurse to obtain a quick assessment of the total body surface area of the burn?

Correct response:

•

Use client’s palm size

Following a burn, the nurse understands that the focused management of which burn zone is of greatest

concern?

Correct response:

• Zone of stasis

An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns.

The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the

best interpretation of this behavior?

Correct response:

•

The client has experienced extensive full-thickness burns.

After being exposed to smoke and flames from a house fire, which assessment finding is most important in

determining care of the client?

Correct response:

•

Presence of soot around nasal passages

A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the

hospital. Which is the most important question for the nurse to ask prior to the arrival of victims?

Correct response:

• “Are the burns associated with chemicals used in the plant?”

Which is the primary reason for placing a client in a horizontal position while smothering flames are present?

Correct response:

•

To

keep fire and smoke from airway

Initial first aid rendered at the scene of a fire includes preventing further injury through heat exposure. Which

intervention could contribute to tissue hypoxia and necrosis and therefore should be avoided?

Correct response:

• Application of ice

Which is the primary nursing intervention in the care of a client with burns exceeding 20% of total body surface

area?

Correct response:

Fluid resuscitation

Which of the following would indicate the need to increase fluids beyond what is recommended for fluid

resuscitation?

Correct response:

•

Myoglobin in the urine

What are the expected findings in the fluid remobilization phase (acute phase, diuresis) that the nurse should

monitor for? Select all that apply.

Correct response:

• Hemodilution
• Increased urinary output
• Sodium deficit

A client who was severely burned begins to exhibit symptoms of renal failure during treatment. What physiologic

process can cause acute renal failure?

Correct response:

• hemoconcentration

A client has been burned significantly in a workplace accident. Which conditions create the need

for immediate intensive care by specifically trained personnel? Select all that apply.

Correct response:

• Fluid loss
• Fluid shift
• Hypotension

The nursing student is preparing to care for an ICU client with shock. The instructor asks the student to name the

different categories of shock. Which of the following is a category of shock?

Correct response:

•

Distributive

The nurse is caring for a client in shock who is deteriorating. The nurse is infusing IV fluids and giving

medications as ordered. What type of medications is the nurse most likely giving to this client?

Correct response:

•

Adrenergic drugs

The nurse is caring for a client with shock. The nurse is concerned about hypoxemia and metabolic acidosis

with the client. What finding should the nurse analyze for evidence of hypoxemia and metabolic acidosis in a

client with shock?

Correct response:

•

•

Arterial blood gas (ABG) findings

The nurse is assessing a 6-year-old child in the emergency department (ED) who was brought in by the mother.

The child was stung by a bee and is allergic to bee venom. The child is now having trouble breathing, and is

vasodilated, hypotensive, and has broken out in hives. What does the nurse suspect is wrong with this child?

Correct response:

•

The child is having an allergic reaction and going into anaphylactic shock.

The nurse is caring for a client in the compensation stage of shock. The nurse knows that one of the body’s

mechanisms of compensation in this stage of shock is the renin-angiotensin-aldosterone system. What does this

system do?

Correct response:

•

Restores blood pressure

A client presents to the ED in shock. At what point in shock does the nurse know that metabolic acidosis is

going to occur?

Correct response:

• Decompensation

A nurse is evaluating a mechanically ventilated client in the intensive care unit to identify improvement in the

client’s condition. Which outcome does the nurse note as the result of inadequate compensatory mechanisms?

Correct response:

• organ damage

A client is in a driving accident creating a spinal cord injury. The nurse caring for a client realizes that the client is

at risk for which type of shock?

Correct response:

•

Neurogenic

A client presents to the community health office experiencing rapidly increasing symptoms of anaphylactic

shock. Which nursing action would be completed first?

Correct response:

• Administer an epinephrine injection as ordered by the health care provider.

The nurse is reviewing diagnostic lab work of a client developing shock. Which laboratory result does the nurse

note as a key in determining the type of shock?

Correct response:

•

WBC:

42,000/mm

3

A nurse educator is teaching students the types of shock and associated causes. Which combination of shock

type and causative factors are correct? Select all that apply.

Correct response:

Hypovolemic shock; blood loss

• Cardiogenic shock; myocardial infarction
• Anaphylactic shock; nuts
• Septic shock; infection

The nurse is caring for a critically ill client. Which of the following is the nurse correct to identify as a positive

effect of catecholamine release during the compensation stage of shock?

Correct response:

•

Increase in arterial oxygenation

The nurse is caring for a client diagnosed with shock. During report, the nurse reports the results of which

assessments that signal early signs of the decompensation stage? Select all that apply.

Correct response:

• Vital signs
• Skin color
• Urine output
• Peripheral pulses

The nurse is obtaining physician orders which include a pulse pressure. The nurse is most correct to report which

of the following?

Correct response:

•

The

difference between the systolic and diastolic pressure

The nurse is administering a medication to the client with a positive inotropic effect. Which action of the

medication does the nurse anticipate?

Correct response:

• Increase the force of myocardial contraction

The nurse is caring for the client with massive blood loss from a gunshot wound. With little time to spare, which

blood type is infused?

Correct response:

• Type O-

The nurse in the ED is caring for a client recently admitted with a likely myocardial infarction. The nurse

understands that the client's heart is pumping an inadequate supply of oxygen to the tissues. For what health

problem should the nurse assess?

Correct response:

•

Dysrhythmias

A nurse caring for a client after epidural anesthesia observes that the client is beginning to present with dry skin

and bradycardia with hypotension. What type of shock is the nurse assessing?

Correct response:

• neurogenic

The nurse is caring for a client who is receiving large volumes of crystalloid fluid to treat hypovolemic shock. In

light of this intervention, for what sign or symptom should the nurse monitor?

Correct response:

• Hypothermia

Which stage of shock encompasses mechanical ventilation, altered level of consciousness, and profound

acidosis?

Correct response:

• Irreversible

A nurse is developing a care plan for a client recovering from a serious thermal burn. After maintaining

respirations, the nurse knows that the most important immediate goal of therapy is:

Correct response:

•

maintaining

the client's fluid, electrolyte, and acid-base balance.

The nurse is administering an analgesic to a patient with major burns. What is the recommended route for

administration for this patient?

Correct response:

• Intravenous

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the

nurse plan to administer first?

Correct response:

•

Lactated

Ringer's solution

Which complication is common for victims of electrical burns?

Correct response:

• Cardiac dysrhythmia

A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns.

Which of the following assessments would indicate the success of the fluid resuscitation?

•

Correct response:

The client’s urinary output is 0.5 to 1 mL/kg/hour.

In assessing a scar, you notice an overgrowth of tissue. It is best described as a

Correct response:

• Keloid

The nurse observes a client’s fingernails have a concave shape. What laboratory studies should the nurse

review?

Correct response:

•

Hemoglobin and hematocrit

Which of the following is a fight or flight hormone?

Correct response:

• epinephrine

Which of the following causes the most severe form of metabolic stress?

Correct response:

•

extensive burns

Respiratory stress leads to which of the following physiological processes?

Correct response:

• lower oxygen and higher carbon dioxide in the blood.

Selenium, zinc, and copper been shown to be helpful in patients with which of the following?

Correct response:

• severe burns.

A patient has an unstable condition with acute respiratory distress and is on a mechanical ventilator. Which of

the following nutrients are recommended?

Correct response:

• omega-3 fatty acids

A patient has burns over 65% of his total body surface area. His metabolic rate would be expected to be

approximately what proportion of the normal rate?

Correct response:

•