NUR 2755 \/ NUR2755 Exam 2 (Latest 2024 \/ 2025): Multidimensional Care IV \/ MDC 4 – Rasmussen<\/p>\n\n\n\n
NUR 2755 Multidimensional Care IV
MDC4 Exam 2
Which assessment is important for the nurse to evaluate whether the
treatment of a client with anaphylactic shock has been effective?
a. Pulse rate
b. Orientation
c. Blood pressure
d. Oxygen saturation
Correct Answer:
d. Oxygen saturation
Burn client is brought into the emergency department with the following
burns: half of the front torso, entire left arm, front of the left leg. The nurse
should record the total body surface area burn as?
A. 27%
B. 35%
C. 20%
D. 40%
Correct Answer:
A. 27%<\/p>\n\n\n\n
Nurse is planning care for an adult client who sustained severe burn injuries.
Which
interventions should the nurse include in the plan of care? SATA
A. limit visitors in the clients 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 2 or 3 times a day and progress in length each time
E. apply compression dressings before the graft heals to prevent scar
formation
Correct Answer:
A. limit visitors in the clients room when immunosuppressed
C. offer high calorie, high protein foods or supplemental feeding
Nurse is caring for a client in shock. The nurse understands the client
sympathetic nervous system is still correctly attempting to compensate
when the following is assessed?
A. Client has decreased peripheral pulses
B. Client has an increase thirst
C. Client has decreased heart rate
D. Client has an increased respiratory rate
E. Client has widening pulse pressure
Correct Answer:
D. Client has an increased respiratory rate
E. Client has widening pulse pressure<\/p>\n\n\n\n
Client is treated in the emergency department for shock of unknown
etiology. The first action by the nurse is which of the following?
A. Administer oxygen
B. Attach a cardiac monitor
C. Obtain a blood pressure
D. Check level of consciousness
Correct Answer:
A. Administer oxygen
Client has been diagnosed with pulmonary embolism. Which diagnostics and
treatments does the nurse anticipate will be ordered? SATA
A. D dimer
B. Thrombolytics
C. Atropine
D. Nitroglycerin
E. CT angiogram
Correct Answer:
A. D dimer
B. Thrombolytics
E. CT angiogram<\/p>\n\n\n\n
interventions- A client with a pulmonary embolism may have which of the following interventions
Embolectomy
Heparin drug therapy<\/p>\n\n\n\n
for- An older adult client arrives in the emergency department after falling off a roof. The
nurse observes “sucking inward” of the loose chest area during inspiration and a “puffing
out” of the same area during expiration. Arterial blood gas results show severe
hypoxemia and hypercarbia. Which procedure does the nurse prepare for?
Endotracheal intubation<\/p>\n\n\n\n
appropriate- A nurse in a burn treatment center is caring for a client admitted with severe burns to
both lower extremities and is scheduled for an escharotomy. The client’s spouse asks the
nurse what the procedure entails. Whish nursing statement is appropriate
Large, surgical incision will be made in the hardened dermal layer to improve
circulation<\/p>\n\n\n\n
teaching- A nurse is caring for a client who has burn injuries to his trunk. The nurse is explaining
what to expect from the prescribed hydrotherapy. Which of the following statements by
the client indicates an understanding of the teaching
I will be on a special shower table to enhance wound inspection and
debridement<\/p>\n\n\n\n
Dosage- Calculate the mean arterial pressure in mmHg for a client with a blood pressure of 84\/46
mmHg
59 mmHg<\/p>\n\n\n\n
pneumothorax- Which if the following interventions is not appropriate for a client diagnosed with a
pneumothorax
Apply wet to dry dressing on wound<\/p>\n\n\n\n
complication- A client in the intensive care unit was recovering from moderate burns and smoke
inhalation. His condition was improving, and plans were made to transfer him to a step-
down unit. On the morning of the transfer, the client began to experience elevated
temperatures and shortness of breath. Urine output decreased to 10ml\/hr. labs were
drawn and indicated elevated WBC, GFR, creatinine, and liver enzymes. The client is
experiencing which medical complication
Multiple organ dysfunction syndrome<\/p>\n\n\n\n
provider- A nurse is assessing a client who sustained superficial partial thickness and deep partial
thickness burns 38 hours ago. Which finding should the nurse report to the provider
ABG pH 7.31, PaCO2 37 mmHg, HCO3 31 mEq\/L<\/p>\n\n\n\n
following- A nurse is caring for a client who has sustained burns over 37% of total body surface
area. The client’s voice has become hoarse, a brassy cough has developed, and the client
is drooling. The nurse should identify these findings as indications that the client has
which of the following
Inhalation injury<\/p>\n\n\n\n
first- A nurse is assisting the provider in caring for a client who has developed a tension
pneumothorax. Which actions should be performed first
Prepare for large bore needle thoracostomy<\/p>\n\n\n\n
characteristics- When assessing a client who has suffered a burn injury, the nurse classifies the burn as a
full thickness burn based on observing which characteristics
Charred skin with milky area<\/p>\n\n\n\n
resuscitation- A client with 55% total body surface area burns arrives in the emergency department.
The client weighs 160 #. Using the parkland burn formula calculate the hourly rate of
lactate ringer during the first 8 hours of fluid resuscitation
1000<\/p>\n\n\n\n
embolism- A nurse is caring for a group of clients. Which client is at most risk for a pulmonary
embolism
A long distance truck driver<\/p>\n\n\n\n
first- After receiving report of four client, the nurse determines the order of care of the
clients. Based on report, the nurse will prioritize the clients to see which one first
Healthy 18 year old with rapid shallow respirations<\/p>\n\n\n\n
reported- A client is receiving warfarin after pulmonary embolism. The nurse evaluates the lab
results and notifies the physician that the clients warfarin level is therapeutic when
which of the following numbers is reported
INR 2.8<\/p>\n\n\n\n
first- A nurse is assessing four clients. Which of the following clients should the nurse assess
first
A client that has self extubated his endotracheal tube<\/p>\n\n\n\n
client- A client who has an endotracheal tube is being considered for a tracheostomy. Which of
the following criteria would support the placement of a tracheostomy in this client
Client is unable to maintain airway when extubated<\/p>\n\n\n\n
syndrome- The nurse is caring for a client who suffered a third degree burn to his hands after a
house fire. He presented with an airway injury secondary to smoke inhalation and has
been intubated. The client is surrently on the ventilator with 100% FiO2. Based on the
information, which of the following would be a sign or symptom of acute respiratory
distress syndrome
Arterial blood gas results show PaO2 50 mmhg<\/p>\n\n\n\n
pneumonia- Which actions are essential for the nurse caring for a mechanically ventilated client to
prevent ventricular acquired pneumonia
b. Perform oral care every 12 hours
c. Prevent aspiration
d. Suction every 1-2 hours around the clock<\/p>\n\n\n\n
following- The pathophysiology of acute respiratory distress syndrome is characterized by which of
the following
Refractory hypoxemia<\/p>\n\n\n\n
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provider- During change of shift report, the nurse learns that a client has been admitted with
dehydration and hypotension after having vomiting and diarrhea for 3 days. Which
finding is most important for the nurse to report to the health care provider
New onset of confusion and agitation<\/p>\n\n\n\n
shock- When the charge nurse is evaluating the skills of a new RN, which action by the new RN
indicated a need for further education in the care of clients with shock
Decreasing the room temperature to 68 F for a patient with neurogenic shock<\/p>\n\n\n\n
syndrome- A nurse is reviewing the health records of clients. Which client is at least risk for
developing acute respiratory distress syndrome
A client who has hemoglobin of 10.1 mg\/dl post 1 unit PRBC<\/p>\n\n\n\n
dosage- . The provider ordered dopamine 20mcg\/kg\/min IV infusion. The bag is labeled dopamine
100mg\/50ml. the client weighs 88 #. What is the infusion rate in ml\/hr
24ml\/hr<\/p>\n\n\n\n
following- A client is admitted to the emergency department with a full thickness burn to the right
arm. Upon assessment, the arm is edematous, fingers are mottled, and radial pulse is now absent. The client states that the pain is 8 on a scale of 1 to 10. The nurse should
perform which of the following?
Call the healthcare provider to report the loss of the radial pulse<\/p>\n\n\n\n
DIC- A nurse is teaching a client who has septic shock about the development of
disseminated intravascular coagulation. Which statement indicates the nurses correct
understanding of DIC
DIC is caused by abnormal coagulation involving fibrinogen<\/p>\n\n\n\n
positioned- A client begins to show signs of shock. How should the client be positioned?
Flat with legs elevated<\/p>\n\n\n\n
client- The nurse is caring for a ventilated client. Which intervention is appropriate for this
client
Ensure there is a manual resuscitation bag at the bedside<\/p>\n\n\n\n
shock- Which intervention will the nurse include in the plan of care for a client who has
cardiogenic shock?
Monitor breath sounds frequently<\/p>\n\n\n\n
pressure- A client is being treated for distributive shock with IV norepinephrine. The nurse expects
the drug to have which effect on the clients mean arterial pressure
Increased MAP with no change in vascular volume<\/p>\n\n\n\n
syndrome- A nurse is reviewing the health records of clients. Which client is at greatest risk for
developing acute respiratory distress syndrome and multiple organ dysfunction
syndrome
A client who experienced anaphylactic shock<\/p>\n\n\n\n
effective- A client is being treated for hypovolemic shock. As the nurse reassesses the client, which
finding indicates the interventions are effective
Serum lactate and serum potassium level are declining<\/p>\n\n\n\n
resuscitation- A nurse is assessing the fluid status of a client being treated for a burn during the
emergent phase. Which of the following is an indicator of adequate fluid resuscitation
Urine output at least 30 ml\/hr<\/p>\n\n\n\n
implemented- A client in respiratory failure is diagnosed with a flail chest. After the client is intubated,
which treatment does the nurse expect to be implemented
Positive end expiratory pressure (PEEP)<\/p>\n\n\n\n
administer- A nurse is caring for a client with arterial blood gas results pH 7.21, PaCO2 60 mmhg,
PaO2 42 mmHg, HCO3 22mEq\/L. which medication should the nurse prepare to
administer
Bronchodilator<\/p>\n\n\n\n
provider- When caring for a client who has early sepsis, which change in status is most important
for the nurse to report to the health care provider
Altered mental status<\/p>\n\n\n\n
provider- Which information about a client receiving dobutamine to treat septic shock is most
important for the nurse to communicate to health care provider?
Client is complaining of chest pain<\/p>\n\n\n\n
question- A client with septic shock has a urine output of 20ml\/hr for the past 3 hours. The pulse
rate is 120 beats\/min, and the venous pressure and pulmonary artery wedge pressure
are low. Which of these orders by the health care provider will the nurse question
Give furosemide<\/p>\n\n\n\n
first-The client, who is 2 days postoperative following a pneumonectomy, has an apical pulse
rate of 128 beats\/min and a blood pressure of 80\/50 mmhg. Which intervention should
the nurse implement first
Increase the clients IV rate as ordered<\/p>\n\n\n\n
expect- A nurse is assessing a client who has fluid volume overload from cardiogenic shock.
Which manifestation of cardiogenic shock should the nurse expect
Heart rate 121 beats\/min<\/p>\n\n\n\n
following- When assessing a client who is severely bleeding and at risk for hypovolemic shock, the
nurse anticipates which of the following
Weak, thready pulse<\/p>\n\n\n\n
client- The nurse is developing a care plan for a client in the acute phase of a burn injury. Which
of the following would be the priority nursing diagnosis for this client
Risk for infection related to slow healing graft donor site<\/p>\n\n\n\n
shock- A nurse is educating a new nurse on the different types of shock. The new nurse is asked
to identify which client is not experiencing distributive shock
Client with tension pneumothorax and cardiovascular compression<\/p>\n\n\n\n
action- Client with neurogenic shock is receiving phenylephrine infusion through a left forearm
IV. Which assessment information obtained by the nurse indicates a need for immediate
action?
Clients IV infusion site is cool and pale<\/p>\n\n\n\n
effective- Which assessment is important for the nurse to evaluate whether the treatment of a
client with anaphylactic shock has been effective
Oxygen saturation<\/p>\n\n\n\n
except- Nurse recognizes indication of respiratory distress includes all the following except
stridors<\/p>\n\n\n\n
question- Client with shock of unknown etiology whose hemodynamic monitoring indicates a
blood pressure of 92\/54 mm hg, pulse 64 beats\/min, and an elevated pulmonary artery
wedge pressure has the following collaborative interventions prescribed. Which
intervention will the nurse question?
Infuse saline at 250 ml\/hr<\/p>\n\n\n\n
cream- Client has been prescribed silver sulfadiazine for a burn injury. Which of the following
findings would give the nurse reason to question the order for this topical burn cream
Client has a sulfa allergy listed on the char]<\/p>\n\n\n\n
injury- Certified burn nurse is introducing a new nurse to the burn unit. The nurse is educating
the new nurse on the degree staging of burns. Which of the following provides the
correct description of a wound to the correct level of injury
Superficial thickness: reddened skin, desquamation, heals quickly without
intervention
b. Superficial partial thickness: pink, moist, blanching, some blistering is involved
c. Deep partial thickness: blisters typically do not form, deep dermal injury, may
need grafting
d. Full thickness: epidermal and dermal layers are destroyed, development of
eschar<\/p>\n\n\n\n
client- Nurse is caring for a client experiencing hypovolemic shock. Which of the following
interventions would not be appropriate for this client
d. Assist to a sitting position<\/p>\n\n\n\n
client- 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
b. Diminished breath sounds<\/p>\n\n\n\n
finding- Nurse is assessing the respiratory status of a client who has suffered a fractured rib. The
nurse should expect to note which finding
Pain, especially with inspiration<\/p>\n\n\n\n
transfusion- Nurse is caring for a client who is in hypovolemic shock related to hemorrhage. The
nurse prepares IV tubing to infuse with which IV solution in preparation for a blood
transfusion
d. 0.9% sodium chloride<\/p>\n\n\n\n
in- Client presents with the following vital signs: blood pressure 90\/60 mm hg, temperature
38.3C (101F), heart rate 116 beats\/min, respiratory 24 breaths\/min. the client has a
post-op abdominal incision that is warm and red. Which type of shock is this client in
Septic shock<\/p>\n\n\n\n
condition- Nurse is caring for a client being treated with mechanical ventilation. The ventilator
sounds a low pressure alarm. The nurse immediately assess for other signs of which
condition
Disconnected endotracheal tube<\/p>\n\n\n\n
chest- Client with a chest injury has suffered a flail chest. The nurse assesses the client for
which most distinctive sign of flail chest
Paradoxical chest movement<\/p>\n\n\n\n
include- Nurse is planning care for a client who has severe acute respiratory distress syndrome
(ARDS). Which actions should the nurse include
Assess lungs daily and hourly suction to maintain airway
Maintain intubation and mechanical ventilator support
Consider dietician and enternal nutrition<\/p>\n\n\n\n
successful- Which of these findings is the best indicator that the fluid resuscitation for a client with
hypovolemic shock has been successful
Mean arterial pressure is 65 mm hg<\/p>\n\n\n\n
expect- Nurse is caring for a client who is in the progressive stage of shock. Which finding should
the nurse expect
Blood pressure change from 129\/78 (95) mm hg to 89\/45 (60) mm hg<\/p>\n\n\n\n
expect- Nurse is evaluating the lab values of a client who is in the resuscitation phase following a
major burn. Which of the following lab findings should the nurse expect
Sodium 143<\/p>\n\n\n\n
care- Nurse is planning care for an adult client who sustained severe burn injuries. Which
interventions should the nurse include in the plan of care
-limit visitors in the clients room when immunosuppressed
-offer high calorie, high protein foods or supplemental feeding<\/p>\n\n\n\n
assessed- nurse is caring for a client in shock. The nurse understands the client’s sympathetic
nervous system is still correctly attempting to compensate when the following is
assessed
d. Client has an increased respiratory rate
e. Client has widening pulse pressure<\/p>\n\n\n\n
as- Burn client is brought into the emergency department with the following burns: half of
the front torso, entire left arm, front of the left leg. The nurse should record the total
body surface area burn as
27%<\/p>\n\n\n\n
following- Client is treated in the emergency department for shock of unknown etiology. The first
action by the nurse is which of the following
Administer oxygen<\/p>\n\n\n\n
ordered- Client has been diagnosed with pulmonary embolism. Which diagnostics and treatments
does the nurse anticipate will be ordered
a. D dimer
b. Thrombolytics
CT angiogram<\/p>\n\n\n\n
minutes- Nurse is managing several IV medications to maintain the blood pressure of a client in
hypovolemic shock. Which medication places the client at risk for a hypertensive
reaction, requiring the nurse to assess the blood pressure at least every 15 minutes
Sodium nitroprusside<\/p>\n\n\n\n
take- Nurse is caring for a client who is receiving mechanical ventilation via an endotracheal
tube. Which of the following actions should the nurse take?
Assess breath sounds every 4 hours<\/p>\n\n\n\n
first- Client who is one day post-op following chest surgery, is having difficulty breathing, has
bilateral rales, and is confused and restless. Which intervention should the nurse
implement firs
Notify the rapid response team<\/p>\n\n\n\n
client- Postop client 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% on room air. What does the nurse suspect has occurred with this
client
Pulmonary embolism<\/p>\n\n\n\n
family- Client presented to the ED after receiving second and third degree burns from a kitchen
grease spill. The tops of both thighs, the groin area, and lower abdomen were the areas
of injury. About 3 hours after the injury, the client begins to decompensate and is being
prepped for intubation. Regarding the change in client status, which explanation by the
nurse is correct when educating the clients family
Even a burn as little as 25% of the body can cause a systemic response,
requiring emergency management<\/p>\n\n\n\n
shock- Client with a possible spinal cord injury is admitted to the emergency department.
Which finding by the nurse will help confirm a diagnosis of neurogenic shock
Apical heart rate 48 beat\/min<\/p>\n\n\n\n
next- Client arrived at the burn unit more than 2 weeks ago. The care plan for this client
requires assistance by the nurse to perform daily range of motion exercises and help
with mobility. The client tells the nurse he will no longer participate due to the pain it
always causes. Which of the following should the nurse do next
Acknowledge the clients concerns regarding pain and discuss how to promote
his exercise plan in a way to have less pain but also allow therapeutic level of
treatment<\/p>\n\n\n\n
first- Intensive care unit nurse is caring for a client. The ventilator alarms are sounding. Which
interventions should the nurse implement first
Auscultate the client’s lung sounds<\/p>\n\n\n\n
anticipate- Nurse is caring for a client who is in the nonprogressive compensatory stage of
hypovolemic shock. Which finding should the nurse anticipate
decrease in mean arterial pressure MAP by 20 points form baseline<\/p>\n\n\n\n
take- client with neurogenic shock has just arrived in the emergency department after a diving
accident. Ha has a cervical collar in place. Which of the following actions should the
nurse take
b. Obtain baseline body temperature
c. Prepare for intubation and mechanical ventilation
e. Assist the client into semi fowlers position<\/p>\n","protected":false},"excerpt":{"rendered":"
NUR 2755 \/ NUR2755 Exam 2 (Latest 2024 \/ 2025): Multidimensional Care IV \/ MDC 4 – Rasmussen NUR 2755 Multidimensional Care IVMDC4 Exam 2Which assessment is important for the nurse to evaluate whether thetreatment of a client with anaphylactic shock has been effective?a. Pulse rateb. Orientationc. Blood pressured. Oxygen saturationCorrect Answer:d. Oxygen saturationBurn client […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","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-131406","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/131406","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=131406"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/131406\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=131406"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=131406"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=131406"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}