NUR 2755 MDC 4 EXAM 2 LATEST -

pg. 1

NUR 2755 MDC 4 EXAM 2 LATEST -

ACTUAL EXAMS (FORMS A, B C& D)

RASMUSSEN/ MULTIDIMENSIONAL CARE

IV EXAM 2 NUR 2755 LATEST EXAMS (4

VERSIONS) GRADED A+ RASMUSSEN

MDC 4 EXAM 2 FORM A

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

• This procedure involves placing the client into a shower and removing the dead

tissue

• A piece of healthy skin will be removed from an unburned area and grafter over

the burned area

• Surgical incisions will be made into the deep tissue, possibly to the bone, to

permit better circulation A A nurse is caring for a group of clients. Which client is at most risk for a pulmonary embolism?

• Client who has a body mass index of 24
• An active postmenopausal female
• A long distance truck driver-
• A client who consumes alcohol

C 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?

• Newborn with mottling of extremities
• 72 year old with dry skin with tenting 1 / 4

pg. 2

• 35 year old athlete with bradycardia-
• Healthy 18 year old with rapid shallow respirations

D 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
• PTT 24 seconds
• INR 1.1
• PT 14 seconds

A A nurse is assessing four clients. Which of the following clients should the nurse assess first?

• A client who has 2 rib fracture in 8/10 pain requestion pain meds
• An intubated client with a flail chest awaiting surgical fixation
• A client that has self extubated his endotracheal tube
• A client with a compound fracture and weak distal pulses

C . 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
• Client has been on the ventilator for 24 hours
• Client has been diagnosed with diabetes
• Client is coughing and bucking the endotracheal tube

A A client with a pulmonary embolism may have which of the following interventions?

• IVC filter- catches blood clot and stops from moving to heart and lungs
• Embolectomy- surgical removal of emboli
• Chest tube placement
• Heparin drug therapy- anticoagulant e. Thoracotomy

A,B,D 2 / 4

pg. 3 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?

• Chest tube insertion X
• Endotracheal intubation- protect airway
• Needle thoracotomy
• Tracheostomy

B 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
• The water temperature will be hot to improve blood flow and healing X
• The nurse will use a wire brush to remove loose skin
• The nurse will use scissors to open small blisters

A Which if the following interventions is not appropriate for a client diagnosed with a pneumothorax?

• Apply wet to dry dressing on wound b. Monitor respiratory and circulatory

function

• Assess for tracheal deviation
• Provide analgesics

A 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? a . Acute respiratory failure

• Acute kidney injury
• Disseminated intravascular coagulation
• Multiple organ dysfunction syndrome 3 / 4

pg. 4 D 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?

• Edema in the burned extremities
• Severe pain at the burn site
• Urine output of 65ml/hr over 2 hours d. ABG pH 7.31, PaCO2 37 mmHg, HCO3

31 mEq/L D 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?

• Pulmonary edema
• Bacterial pneumonia
• Inhalation injury
• Carbon monoxide poisoning

C A nurse is assisting the provider in caring for a client who has developed a tension pneumothorax. Which actions should be performed first?

• Assess the clients pain
• Prepare for large bore needle thoracotomy
• Administer lorazepam
• Prepare for chest tube insertion

B 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?

• Painful, reddened skin
• Charred skin with milky areas
• Erythema and blisters
• Erythema, pain, and swelling

B

• / 4