a – ANS) – The nurse is providing postprocedure care to a client who had a cardiac
catheterization. The client begins to manifest signs and symptoms associated with
embolization. Which action should the nurse take?
a. Notify the primary healthcare provider immediately
b. Apply a warm, moist compress to the incision site
c. Increase the intravenous fluid rate by 20 mL\/hr
d. Monitor vital signs more frequently
b – ANS) – A nurse observes a window washer falling 25 feet (7.6 m) to the ground. The
nurse rushes to the scene and determines that the person is in cardiopulmonary arrest.
What should the nurse do first?
a. Feel for a pulse
b. Begin chest compressions
c. Leave to call for assistance
d. Perform the abdominal thrust maneuver
d – ANS) – A client reports left-sided chest pain after playing racquetball. The client is
hospitalized and diagnosed with left pneumothorax. When assessing the client’s left
chest area, the nurse expects to identify which finding?
a. Dull sound on percussion
b. Vocal fremitus on palpation
c. Rales with rhonchi on auscultation
d. Absence of breath sounds on auscultation
c – ANS) – A client is admitted to the hospital with partial- and full-thickness burns of the
chest and face sustained while trying to extinguish a brush fire. Which is the nurse’s
priority concern?
a. Loss of skin integrity caused by the burns
b. Potential infection as a result of the burn injury
c. Inadequate gas exchange caused by smoke inhalation
d. Decreased fluid volume because of the depth of the burns
b – ANS) – During the first 48 hours after a client has sustained a thermal injury, which
conditions should the nurse assess for?
a. Hypokalemia and hyponatremia
b. Hyperkalemia and hyponatremia
c. Hypokalemia and hypernatremia
d. Hyperkalemia and hypernatremia
a – ANS) – A nurse is assessing a client’s ECG reading. The client’s atrial and ventricular
heart rates are equal at 88 beats per min. The PR interval is 0.14 seconds, and the
QRS width is 0.10 seconds. Rhythm is regular with normal P waves and QRS
complexes. How will the nurse interpret this rhythm?
a. Normal sinus rhythm
b. Sinus tachycardia
c. Sinus bradycardia
d. Sinus arrhythmia
b – ANS) – The nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which
is the priority concern of the nurse when caring for this client?
a. Fluid volume
b. Skin integrity
c. Physical mobility
d. Urinary elimination
c – ANS) – A client who had extensive pelvic surgery 24 hours ago becomes cyanotic, is
gasping for breath, and reports right-sided chest pain. What should the nurse do first?
a. Obtain vital signs
b. Initiate a cardiac arrest code
c. Administer oxygen using a face mask
d. Encourage the use of an incentive spirometer
c – ANS) – A nurse is caring for a client with severe burns. The nurse determines that
this client is at risk for hypovolemic shock. Which physiologic finding supports the
nurse’s conclusion?
a. Decreased rate of glomerular filtration
b. Excessive blood loss through the burned tissues
c. Plasma proteins moving out of the intravascular compartment
d. Sodium retention occurring as a result of the aldosterone mechanism
a – ANS) – The nurse is caring for a client with burns and reviews the client’s laboratory
results: blood urea nitrogen (BUN), 30 mg\/dL (10.2 mmol\/L); creatinine, 2.4 mg\/dL (184
mcmol\/L); serum potassium, 6.3 mEq\/L (6.3 mmol\/L); pH, 7.1; Po 2, 90 mm Hg; and
hemoglobin (Hgb), 7.4 g\/dL (74 mmol\/L). Which condition does the nurse suspect the
client has based upon these findings?
a. Azotemia
b. Hypokalemia
c. Metabolic alkalosis
d. Respiratory alkalosis
d – ANS) – A nurse is caring for a client who experienced serious burns in a fire. Which
relationship between a client’s burned body surface area and fluid loss should the nurse
consider when evaluating fluid loss in a client with burns?
a. Equal
b. Unrelated
c. Inversely related
d. Directly proportional
c – ANS) – A burn client is receiving the open method for wound treatment. Which
information will the nurse explain to the client?
a. Bathing will not be permitted.
b. Dressings will be changed daily.
c. Personal protective equipment will be worn by staff.
d. Room temperature will be kept below 72\u00b0 F (22.2\u00b0 C).
a – ANS) – A client presents to the emergency department with weakness and dizziness.
The blood pressure is 90\/60 mm Hg, pulse is 92 and weak, and body weight reflects a
3-pound (1.4 kilogram) loss in two days. The weather has been hot. Which condition
should the nurse conclude is the priority for this client?
a. Deficient fluid volume
b. Impaired skin integrity
c. Inadequate nutritional intake
d. Decreased participation in activities
b – ANS) – A client is admitted with severe burns. The nurse is caring for the client 36
hours after the client’s admission and identifies the client’s potassium level of 6.0 mEq\/L
(6.0 mmol\/L). Which drink will the nurse recommend be included in the client’s diet?
a. Milk
b. Tea
c. Orange juice
d. Tomato juice
a – ANS) – A woman comes to the office of her healthcare provider reporting shortness
of breath and epigastric distress that is not relieved by antacids. To which question
would a woman experiencing a myocardial infarction respond differently than a man?
a. “Do you have chest pain?”
b. “Are you feeling anxious?”
c. “Do you have any palpitations?”
d. “Are you feeling short of breath?”
b – ANS) – During a vertex vaginal birth the nurse notes meconium-stained amniotic
fluid. What is the priority nursing intervention for the newborn?
a. Stimulating crying<\/p>\n","protected":false},"excerpt":{"rendered":"
a – ANS) – The nurse is providing postprocedure care to a client who had a cardiaccatheterization. The client begins to manifest signs and symptoms associated withembolization. Which action should the nurse take?a. Notify the primary healthcare provider immediatelyb. Apply a warm, moist compress to the incision sitec. Increase the intravenous fluid rate by 20 […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[25],"tags":[],"class_list":["post-120094","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/120094","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=120094"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/120094\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=120094"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=120094"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=120094"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}