1.

Below, what systolic BP level is perfusion to the vital organs compromised in a usually
normotensive client?
a. 100 mm Hg
c. 80 mm Hg
b. 110 mm Hg
d. 40

2. Blood levels of angiotensin and renin are ↑ during shock. What clinical findings would the nurse
assess for because of these blood levels?

a. peripheral vasoconstriction

b. peripheral vasodilation

c. ↑ RR

d. ↓ RR

3. What is the best parameter for adequate fluid replacement in a client who is in shock?

a. systolic BP above 100 mmhg

b. systolic BO above 90 mmhg

c. urine output of 30 cc/hr

d. urine output of 20 cc/hr

4. A fluid challenge is begun w/ Mr. Hagalpok. Which assessment will give the best indication of client
response to treatment?

a. CVP readings and hourly urine outpurs

b. BP and apical heart checks

c. lung sounds and ABG’s

d. electrolytes, BUN, Creatine

5. Vasopressin is a potent vasoconstrictor and is the drug of choice for GI bleeding because of its rapid
effect to stop bleeding. Since fluid retention may be expected after its administration, the nurse should
also assess for a

a. distended bladder

b. distended brain

c. distended abdomen
d. distended Rectum

6. During emergency and periods of shock, the rapid adjustments made by the body are associated with
increased activity of the:

a. tyroid gland

b. adrenal gland

c. thymus gland

d. pancreatic gland

7. Tito Pablo has a BP of 80/40 after a blood transfusion. In an effort to support renal perfusion, the
nurse administers Dopamine at 2 mcg/kg/min as ordered. The most relevant outcome indicating
effectiveness of this medication for this client is

a. a decrease in BP

b. an increase in urine output

c. an increase in LOC

d. a decrease in core temperature

8. When a client is experiencing hypovolemic shock with decreased tissue perfusion, the nurse
recognizes that the body initially attempts to compensate by:

a. maintaining peripheral vasoconstriction

b. producing less ADH

c. producing more RBC’s

d. decreasing mineralcorticoid production

9. When caring for a client with Disseminated Intravascular Coagulation (DIC) following shock, it is
important for the nurse to

a. avoid IM injections

b. maintaining peripheral vasoconstriction

c. take temperature via rectal route

d. apply sequential compression stockings

10. Which of the ff. laboratory findings support the diagnosis of Disseminated Intravascular Coagulation
(DIC)?

a. Elevated factor assays (II, V and VII)

b. Elevated RBC’s. WBC’s, platelets

c. Increased platelet count

d. Prolonged Prothrombin time and PTT

11. During the progressive stage of shock, anaerobic metabolism occurs. The nurse must be aware that
initially this causes:

a. Metabolic acidosis

b. Respiratory acidosis

c. Metabolic alkalosis

d. Respiratory alkalosis

12. Which of the ff. indicates Sympathetic Nervous system compensation during shock?

a. hypotension

b. diarrhea

c. urinary frequency

d. dilatation of pupil

13. The physician estimates that Tito Pablo has lost about 15-20% of blood volume. An assessment
finding the nurse should expect this client to exhibit is:

a. a distention of neck veins

b. an output of 50ml urine/hr

c. an apical heart rate of 142 bpm

d. a BP of 150/90

14. Mr. Garlit Isip BP is 100/60 and the physical assessment suggests massive internal hemorrhage.
Based on the info., the nurse should assess the client for an early sign of decreased arterial pressure,
such as:
a. warm flushed skin

b. increased pulse pressure

c. confusion and lethargy

d. reduced peripheral pulses

15. Mr. G.I who is in hypovolemic shock has a hematocrit value of 25%. The nurse should anticipate that
the physician will order:

a. Lactated Ringer’s solution

b. Blood replacement

c. Serum albumin

d. High molecular Plasma expanders

16. Adrenergic drugs, such as epinephrine are given during shock for what primary reason?

a. to ↑ cardiac output by ↑ rate and strength of myocardial activity

c. to prevent spasm and constriction of peripheral vessels

b. to ↑ tone and motility of GIT

d. to prevent cardiac dysrhythmias

17. Following Irreversible shock, a client develops deficiency of ADH. Normally secretion of ADH causes:

a. serum osmolality to increase

c. GFR to decrease

b. urine concentration to decrease

d. Tubular reabsorption of water to increase

18. The nurse suspects a client is in Cardiogenic shock. The nurse understands that this type of shock is:

a. an irreversible phenomenon

c. usually a fleeting reaction to tissue injury

b. a failure of the circulatory pump

d. generally caused by decreased blood volume

Uray Camille Anne, a 68 y/o female was admitted in the hospital after suffering from severe respiratory
distress which he reported came in suddenly, upon assessment, the nurse notes the ff: (+) intercostals
retractions, (+) clubbing of fingers, presence of crackles bilaterally upon auscultation and an O2 sat. Of
88%. The initial admitting diagnosis is ARDS.

19. Which of the ff. statements regarding ARDS is / are TRUE?

1. Occurs in the presence of LSCHF

2. Associated with a very poor prognosis; cause of death is Respiratory Arrest

3. The pathologic changes result in increased lung compliance leading to over distention of the alveoli

4. Has a characteristic feature of hypoxemia refractory to O2 supplementation

a. all of the above

b. 2,3

c. 2,4

d. 1,2

e. 3,

20. Ms. Uray was given Milrinone (Primacor), this drug is used to:

a. reduces pulmonary edema by ↑ reabsorption of plasma filtrates

b. promotes surfactant production

c. reverses pulmonary arterial vasoconstriction

d. paralyzes the muscles of respiration for PEEP therapy

21. Ms. Uray was started on PEEP therapy, which of the following is true about PEEP?

1. Causes unnatural breathing pattern

2. Feels strange to the patient

3. May ↑ anxiety

4. May depress Cardiac output from high levels of PEEP

a. NOTA

b. all of the above

c. 1,2

d. 1,3
e. 1,4

22. While on PEEP therapy, Ms. Uray struggled to control her own respiration and eventually lead to
“fighting the respirator.” As such, she was given Atracurium Besylate. Which of the ff. is true of this
drug?

1. It is a sedative agent that ↓ patient’s anxiety and allows the ventilator to provide full support of
ventilation

2. It is a depolarizing muscle relaxant that prevents Acetylcholine from binding to receptors in muscle
end plate

3. It is a neuromuscular blocking agent that results in temporary paralysis of voluntary and involuntary
muscles

4. It is a general anesthetic agent that promotes relaxation of muscles, resulting in improved ventilation

a. NOTA

b. all of the above

c. 1,2

d. 1,3

e. 1,4

23. Which of the ff. nursing considerations regarding PEEP therapy is/ are TRUE?

1. Paralytic agents should be used for the shortest possible and never w/ sedatives

2. A lower FiO2 may be required during PEEP

3. Sedation may be required to ↓ patient’s O2 consumption

4. Causes an ↑ in Inspiratory Reserve volume

a. NOTA

b. all of the above

c. 1,2

d. 2, 3

e. 1,4

24. The nurse would suspect ARDS in a client diagnosed with Hypovolemic Shock secondary to multiple
traumaswhen the client exhibits which of the ff.?
a. PaO2 of 62mmHg after 2 H of O2 therapy at 10LPM/ face mask

b. Increased breath sounds with increased chest expansion

c. PaCO2 of 65mmHg withPaO2 of 85 mmHg

d. Greenish tenacious secretion

25. Nursing care of a client with ARDS would include:

a. Preparing patient for possible lobectomy

b. O2 therapy at 4-5 LPM/NC

c. Chest tube Thoracotomy

d. Beta blockers to control tremors

Umbo, 25 years old, comes to the ER with acute asthmatic attack. RR is 48 cpm and he appears to be in
acute respiratory distress.

26. Which of the following nursing actions should be initiated first?

a. Administer bronchodilator by nebulizer

b. Promote emotional support

c. Administer oxygen at 6 LPM

d. Suction the patient every 30 minutes

27. Aminophylline was ordered for acute asthmatic attack. The mother is asking for the drug’s
indication. The nurseis correct if she says:

a. Suppress cough

b. Prevent thickening of secretions

c. Promote expectoration

d. Relax smooth muscles of the bronchial airway

28. You will give health instructions to Marikit, a case of bronchial asthma. The health instruction will
include the following EXCEPT:

a. avoid pollution like smoking

b. avoid pollens, dust and seafood’s

c. practice respiratory isolation

d. avoid emotional stress and extreme temperature

Luna Kristel Cabantog, a staff nurse in the emergency department of Sebastien Town Medical Center,
possesses a good background on the management of patients with problems related to airway and
breathing.

29. As a nurse, Luna is always alerted to monitor status asthmaticus patients who will likely and initially
manifest symptoms of:

a. metabolic acidosis

b. metabolic alkalosis

c. respiratory acidosis

d. respiratory alkalosis

30. Luna has triaged 4 clients. Which client should be given priority treatment?

a. Dao, 40, with sinus tachycardia and complains of nausea, vomiting and diarrhea

b. Lei, 28, stung by a wasp and exhibiting stridor

c. Mei Zuo, with an impaled knife in the abdomen

d. Ximen, 32, with an obvious fracture of the right femur and complains of severe pain

31. Few minutes later, another client is admitted to the ER with a knife protruding from his chest wall.
The nurse’s immediate action is to:

a. Assess breath and heart sounds

c. Remove the knife and dress the wound

b. Obtain history and notify law enforcement

d. Administer pain medication and oxygen32. Mary Angeline, another staff nurse in the ER, asks Luna
about most common source of upper-airway obstruction? Luna is correct if she answers:

a. fluids

b. the tongue

c. food

d. swelling
33. A client with new onset of Atrial Fibrillation is receiving Warfarin (Coumadin) to help prevent
thromboembolic.The Warfarin dosage will reach therapeutic levels when the International Normalized
Ration (INR) falls withinwhich range?

a. 1 to 2

c. 2 to 3

b. 1.5 to 2.5

d. 2.5 to 3.5

34. A 38-year-old client comes to the emergency department complaining that her heart “suddenly
began to race. “After attaching her to the cardiac monitor, the nurse observes atrial tachycardia. Which
of the following rhythm strip characteristics indicate this arrhythmia?

a. Atrial greater than the ventricular rate, saw tooth P waves

b. Irregular rhythm, indiscernible atrial rate, absent P waves

c. Regular atrial and ventricular rhythms, rate of 123 beats/minute

d. Regular atrial and ventricular rhythms, P wave hidden in the T wave, rate of 210 beats/minute

35. A 23-year-old client develops Cardiac Tamponade when the car he was driving hits a telephone pole;
he wasn’t wearing a seat belt. The nurse helps the physician perform pericardiocentesis. Which of the
following outcomes would indicate that Pericardiocentesis has been effective?

a. Neck vein distention

c. Increased BP

b. Pulsus paradoxus

d. Muffled heart sounds

36. During change-of-shift report, the nurse is told that a patient has been admitted with dehydration
and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the

nurse to report to the health care provider?

a. New onset of confusion

b. Decreased bowel sounds

c. Heart rate 112 beats/min

d. Pale, cool, and dry extremities

37. A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED)
with cool, clammy skin; tachycardia; and hypotension. Which intervention ordered by the health care

provider should the nurse implement first?

a. Insert two large-bore IV catheters.

b. Provide O2 at 100% per non-rebreather mask.

c. Draw blood to type and crossmatch for transfusions.

d. Initiate continuous electrocardiogram (ECG) monitoring.

38. A patient who has neurogenic shock is receiving a phenylephrine infusion through a right forearm IV.

Which assessment finding obtained by the nurse indicates a need for immediate action?

a. The patient's heart rate is 58 beats/min.

b. The patient's extremities are warm and dry.

c. The patient's IV infusion site is cool and pale.

d. The patient's urine output is 28 mL over the past hour.

39. The following interventions are ordered by the health care provider for a patient who has respiratory

distress and syncope after eating strawberries. Which will the nurse complete first?

a. Give epinephrine.

b. Administer diphenhydramine.

c. Start continuous ECG monitoring.

d. Draw blood for complete blood count (CBC)

40.Which finding about a patient who is receiving vasopressin to treat septic shock indicates an
immediate need for the nurse to report the finding to the health care provider?

a. The patient's urine output is 18 mL/hr.

b. The patient is complaining of chest pain.

c. The patient's peripheral pulses are weak.

d. The patient's heart rate is 110 beats/minute.

41. After change-of-shift report in the progressive care unit, who should the nurse care for first?

a. Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases

b. Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics

c. Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/minute

d. Patient admitted with anaphylaxis 3 hours ago who now has clear lung sounds and a blood pressure

of 108/58 mm Hg

42. Which assessment information is most important for the nurse to obtain when evaluating whether

treatment of a patient with anaphylactic shock has been effective?

a. Heart rate

b. Orientation

c. Blood pressure

d. Oxygen saturation

43. Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the

patient may be developing multiple organ dysfunction syndrome (MODS)?

a. The patient's serum creatinine level is elevated.

b. The patient complains of intermittent chest pressure.

c. The patient's extremities are cool and pulses are weak.

d. The patient has bilateral crackles throughout lung fields.

44. A patient with septic shock has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32

breaths/min, temperature of 104°F, and blood glucose of 246 mg/dL. Which intervention ordered by the

health care provider should the nurse implement first?

a. Give normal saline IV at 500 mL/hr.

b. Give acetaminophen (Tylenol) 650 mg rectally.

c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL.

d. Start norepinephrine to keep systolic blood pressure above 90 mm Hg.

45. When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients

experiencing shock, which action by the new RN indicates a need for more education?

a. Placing the pulse oximeter on the ear for a patient with septic shock

b. Keeping the head of the bed flat for a patient with hypovolemic shock

c. Maintaining a cool room temperature for a patient with neurogenic shock

d. Increasing the nitroprusside infusion rate for a patient with a very high SVR

46. The nurse is caring for a patient who has septic shock. Which assessment finding is most important
for the nurse to report to the health care provider?

a. Skin cool and clammy

b. Heart rate of 118 beats/min

c. Blood pressure of 92/56 mm Hg

d. O2 saturation of 93% on room air

47. A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first
action

by the nurse should be to

a. obtain the blood pressure.

b. check the level of orientation.

c. administer supplemental oxygen.

d. obtain a 12-lead electrocardiogram.

48. A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28.
The pulmonary artery wedge pressure (PAWP) is increased, and cardiac output is low. The nurse will

anticipate an order for which medication?

a. 5% albumin infusion

b. furosemide (Lasix) IV

c. epinephrine (Adrenalin) drip

d. hydrocortisone (Solu-Cortef)
49. The emergency department (ED) nurse receives report that a seriously injured patient involved in a

motor vehicle crash is being transported to the facility with an estimated arrival in 5 minutes. In

preparation for the patient's arrival, the nurse will obtain

a. a dopamine infusion.

b. a hypothermia blanket.

c. lactated Ringer's solution.

d. two 16-gauge IV catheters.

50. Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic

shock has been effective?

a. Hemoglobin is within normal limits.

b. Urine output is 65 mL over the past hour.

c. Central venous pressure (CVP) is normal.

d. Mean arterial pressure (MAP) is 72 mm Hg.

51. Which intervention will the nurse include in the plan of care for a patient who has cardiogenic
shock?

a. Check temperature every 2 hours.

b. Monitor breath sounds frequently.

c. Maintain patient in supine position.

d. Assess skin for flushing and itching.

52. Norepinephrine has been prescribed for a patient who was admitted with dehydration and
hypotension. Which patient data indicate that the nurse should consult with the health care provider
before starting the norepinephrine?

a. The patient is receiving low dose dopamine.

b. The patient's central venous pressure is 3 mm Hg.

c. The patient is in sinus tachycardia at 120 beats/min.

d. The patient has had no urine output since being admitted.

53. A nurse is assessing a patient who is receiving a nitroprusside infusion to treat cardiogenic shock.
Which finding indicates that the drug is effective?

a. No new heart murmurs

b. Decreased troponin level

c. Warm, pink, and dry skin

d. Blood pressure of 92/40 mm Hg

54. A 78-kg patient with septic shock has a pulse rate of 120 beats/min with low central venous pressure

and pulmonary artery wedge pressure. Urine output has been 30 mL/hr for the past 3 hours. Which

order by the health care provider should the nurse question?

a. Administer furosemide (Lasix) 40 mg IV.

b. Increase normal saline infusion to 250 mL/hr.

c. Give hydrocortisone (Solu-Cortef) 100 mg IV.

d. Titrate norepinephrine to keep systolic blood pressure (BP) above 90 mm Hg.

55. A nurse is caring for a patient whose hemodynamic monitoring indicates a blood pressure of 92/54
mmHg, a pulse of 64 beats/min, and an elevated pulmonary artery wedge pressure (PAWP). Which

intervention ordered by the health care provider should the nurse question?

a. Elevate head of bed to 30 degrees.

b. Infuse normal saline at 250 mL/hr.

c. Hold nitroprusside if systolic BP is less than 90 mm Hg.

d. Titrate dobutamine to keep systolic BP is greater than 90 mm Hg.

56. A patient with massive trauma and possible spinal cord injury is admitted to the emergency
department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic
shock?

a. Inspiratory crackles

b. Heart rate 45 beats/min

c. Cool, clammy extremities

d. Temperature 101.2°F (38.4°C)

57. An older patient with cardiogenic shock is cool and clammy. Hemodynamic monitoring indicates a
high systemic vascular resistance (SVR). Which intervention should the nurse anticipate?

a. Increase the rate for the dopamine infusion.

b. Decrease the rate for the nitroglycerin infusion.

c. Increase the rate for the sodium nitroprusside infusion.

d. Decrease the rate for the 5% dextrose in normal saline (D5/.9 NS) infusion.

58. After receiving 2 L of normal saline, the central venous pressure for a patient who has septic shock is
10 mmHg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate an order for

a. furosemide.

b. nitroglycerin.

c. norepinephrine.

d. sodium nitroprusside.

59. To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic

inflammatory response syndrome (SIRS), which assessment will the nurse perform?

a. Auscultate bowel sounds.

b. Ask the patient about nausea.

c. Check stools for occult blood.

d. Palpate for abdominal tenderness

BURNS

1. Using the rule of nines, which of the ff. is the best estimate of total body surface area burned?

a. 18%

c. 22%

b. 31%

d. 40%
2. Upon admission to the ER, the nurse noted that the burn area is edematous, with large amount of
fluid exudates noted. Urine output is 30 ml/hr, BP 90/60, Pulse 110. A primary nursing diagnosis during
the initial 48-72 hours following the burn is:

a) Body image disturbance r/t disfiguring burns on both legs

b) High risk for infection r/t skin breakdown

c) Potential for ineffective airway clearance r/t smoke inhalation

d) Fluid volume deficit r/t increased capillary permeability

3. While assessing Mrs. Abad, the nurse notes areas that are not painful, grayish white in color and

leathery in appearance. The nurse documents that these burns are:

a) Superficial burns

b) Superficial partial thickness burns

c) Deep partial thickness burns

d) Full thickness burns

4. The nurse determines that Mrs. Abad has 2nd and 3rd degree burns. Which of the ff. would be

characteristics of a fresh 2nd degree burn?

a. absence of pain and pressure sense

b. large thick blisters

c. white or dark, dry, leathery appearance

d. visible thrombosed small vessels

5. When the nurse is completing an assessment of a burned client, 2nd degree burns would appear as

a) Full thickness with extension to underlying muscle and bone

b) Partial thickness with erythema and often edema but no vesicles

c) Partial thickness with involvement of epidermis and dermis, showing edema and vesicles

d) Full thickness with dry, waxy or leathery appearance without vesicles

6. Burns classified as full thickness extend to involve destruction of the;

a. Hair follicle

b. Upper dermis

c. Epidermal layer

d. Subcutaneous layer

7. Because of the location of Mrs. Abad’s burns, what is the nurse’s primary concern?

a. debride and dressed the wound

b. frequently observed for hoarseness, dyspnea and stridor

c. initiate and administer antibiotics

d. obtain a thorough history of events leading to the accident

8. A narcotic IV was ordered to control Mrs. Abad’s pain. Why was the IV route selected?

a. Burn cause excruciating pain, requiring immediate relief

b. Circulatory blood volume is reduced, delaying absorption from SQ and muscle tissues

c. Cardiac function is enhanced by immediate action of the drug

d. Metabolism of the drug would be delayed because of decreased insulin production

9. A major goal during the 1at 48 hours is to prevent hypovolemic shock. Which of the ff. would not be a

useful guide to fluid restitution during this period?

a. elevated Hematocrit

b. urine output of 30 cc/hr

c. change in sensorium

d. estimated fluid loss throughout burn area

10. What is the primary aim of all burn wound care?

a. To debride the wound of dead tissue and eschar

b. To limit fluid loss through the skin

c. To prevent growth of microorganisms

d. To decrease formation of distinguishing scars

11. Contractures are among the most serious long complications of burn. Because of the location if

these burn, which of the ff. would most likely cause Mrs. Abad to have contractures?

a. Change the location of the bed or the TV set or both, daily

b. Encourage her to chew gum and blow up balloons

c. Avoid using a pillow or place the head in a position of hyperextension

d. Help her assume a position of comfort

12. When teaching Mrs. Abad first aid for minor burns, a nurse should instruct her to

a) Cover the burned area with cotton gauze

b) Apply ice directly to the burned area

c) Coat the burned area lightly with petroleum jelly

d) Immerse the burned area in cool water

13. Mrs. Abad tells the ER nurse that when she realized her clothes were on fire, she ran into her house

to telephone for help. It would have been best for her to;

a) Fall to the ground and roll

b) Take off his clothing immediately y

c) Stand still and call for help

d) Spray his clothing immediately

14. The nurse assesses the client for fluid shifting. Fluid shifts that occur during the emergent phase of a

burn injury are cause by a fluid moving;

a) From the vascular to the interstitial space

b) From the extracellular to the intracellular space

c) From the intracellular to the extracellular space

d) From the interstitial to the vascular space

15. Sulfadiazine is prescribed to be applied to the site of injury. Which side effect should the nurse be

monitoring for?

A) Skin discoloration

B) Hardened eschar

C) Increased neutrophils

D) Urine sulfa crystals

16. The nurse documents which of the following in the plan of care as the appropriate method in

applying Silver Sulfadiazine to the burn areas?

a. apply dressings soaked with saline solution over the medication

b. apply 1 inch film directly to the burn sites

c. apply 1/16 inch film directly to the burn sites

d. apply ½ inch film directly to the burn sites

17. Mrs. Abad developed wound sepsis and Mafenide acetate 10% (sulfamylon) is ordered BID. While

applying the Sulfamylon to the wound, it is important for the nurse to prepare the client for expected

responses to the topical application, which include

a) Severe burning pain for a few minutes following application

b) Possible severe metabolic alkalosis with continued use

c) Black discoloration of everything that comes in contact with this drug

d) Chilling due to evaporation of solution from the moisten dressing.

18. Skin closure with heterograft will be performed on Mrs. Abad and she asks the nurse about the

meaning of heterograft. A heterograft is skin form;

a) Another species

b) A cadaver

c) The burned client

d) A skin bank
19. In the oliguric phase of burns, what is the most appropriate nursing diagnosis?

a. Fluid volume deficit

b. Activity intolerance

c. Ineffective breathing pattern

d. Fluid volume excess

20. The nurse would explain to Mrs. Abad that when a major burn occurs, the body’s initial systemic

responses include

a. elevated pulse rate, decreased cardiac output, and polyuria.

b. production of epinephrine, vasodilation, and increased cardiac output

.c. plasma leakage into surrounding tissue, decreased hematocrit, and oliguria.

d. increased capillary permeability, decreased cardiac output, and oliguria.

21. When a client sustains deep partial thickness burns because of a severe sunburn, the best 1st aid

measure to use is:

a. cool moist towels

b. dry sterile dressings

c. analgesic sunburn spray

d. Vit. A and D ointment

22. The nurse is applying silver sulfadiazine (Silvadene) to a patient with severe burns to arms and legs.

Which side effect should the nurse be monitoring for?

a. Skin discoloration

b. Hardened eschar

c. transient leukopenia

d. Urine sulfa crystals

23. The nurse caring for a burn client would monitor the client’s stools for occult blood as assessment

for development of

a. stress ulcers.

b. intestinal ileus.

c. gastric irritation related to smoke.

d. bleeding due to bowel distention.

24 . When caring for a severely burned client, the nurse notes that the client’s urine is dark brown. The

nurse would

a. titrate systolic blood pressure to 110 mm Hg.

b. ensure that intravenous (IV) fluid is maintained at the prescribed rate.

c. insert a new urinary catheter.

d. notify the physician immediately.

25. The nurse would assess that the client at highest risk for burns sustained from clothing ignition

during meal preparation is

a. an 18-month-old toddler.

b. a 5-year-old child.

c. a 15-year-old teenager.

d. a 75-year-old adult.

26. The nurse would explain to a client that when a major burn occurs, the body’s initial systemic

responses include

a. elevated pulse rate, decreased cardiac output, and polyuria.

b. production of epinephrine, vasodilation, and increased cardiac output.

c. plasma leakage into surrounding tissue, decreased hematocrit, and oliguria.

d. increased capillary permeability, decreased cardiac output, and oliguria

27. The nurse would assess that the client with a “major burn” is

a. a 60-year-old with a 25% burn.

b. a 32-year-old with a 14 % burn.

c. an 18-year-old with an 18% burn.

d. a 10-year-old with a 15% burn.

28. The nurse would stress to the ancillary staff that the most important means of preventing the spread

of infection in the burn unit is

a. restricting visitors with respiratory tract infections.

b. using clean gowns, gloves, and masks.

c. strict hand-washing.

d. prophylactic antibiotics.

29. A client has a circumferential third-degree burn on the upper left arm. The nursing assessments for

this client would be modified by

a. monitoring blood pressure in the left arm.

b. evaluating left hand strength.

c. assessing capillary refill in the left hand.

d. measuring left forearm circumference.

30.When admitting a client who has sustained a burn injury, the nurse would inoculate against tetanus if

the client has

a. third-degree burns.

b. been inoculated in the last 6 years.

c. open wounds with copious debris embedded.

d. second-degree burns with broken blisters.

RENAL

1. After the physician orders a culture and sensitivity test, why would the nurse instruct the patient to

obtain a clean-catch midstream urine specimen?

A. the urinary tract normally harbors some microorganisms

B. microorganisms on the patient's external genitalia may contaminate the specimen

C. the nurse does not want to catheterize the patient

D. a midstream specimen obtains the largest number of microorganisms in the lower tract

2. The nurse monitors for significant changes by focusing on which of the following laboratory tests in a

patient whose renal function is deteriorating?

A. increase in BUN

B. decrease in serum creatinine levels

C. increase in urine creatinine clearance

D. decrease in serum potassium levels

3. The patient is complaining of dribbling, urgency, and inability to get to the bathroom before urinating

starts. The nurse suspects which of the following?

A. urinary tract infection

B. renal calculi

C. acute renal failure

D. urinary incontinence

4. The nurse knows the patient understands how to do Kegel exercises when the patient states...

A. I should pretend like I am starting and stopping my urine stream

B. I should do exercises three times a week

C. I can only do the Kegel exercises when I am lying down

D. this will help me prevent urinary retention

5. Clinical manifestations and assessment findings that supports a diagnosis of acute pyelonephritis

include...

A. urinary stress incontinence and abdominal pain

B. flank pain, fever, and dysuria

C. burning on urination and inflamed urinary meatus

D. acute, sharp, intermittent pain and anuria

6. A 65-year-old man is hospitalized for bladder cancer. He is scheduled for ileal loop surgery to create a

urostomy. Which information is most important for the nurse to include in a teaching plan for this

patient when learning to change his urostomy appliance?

A. change the appliance before going to bed

B. cut the wafer 1/2 inch larger than the stoma

C. cleanse the peristomal skin with soap and water

D. use firm pressure to attach the wafer to the skin

7. Which nursing intervention best prevents urinary infections in a person who has an ilea conduit?

A. allowing the bag to fill completely

B. attaching a larger bag at night

C. restricting fluids to less than 1000 ml daily

D. changing the appliance every 8 hours

8. A 74-year-old man has just returned to the nursing unit after a transurethral resection. He has a

three-way foley catheter for continuous bladder irrigation connected to straight drainage. Immediately

after surgery, the nurse would expect his urine to be...

A. Clear

B. light yellow

C. pink or dark red

D. bright red
9. An elderly patient has just returned to the nursing care unit following a transurethral resection. He

has a three-way indwelling catheter with continuous bladder irrigation. He tells the nurse he has to void.

The most appropriate nursing action is to...

A. allow him to void around the catheter

B. irrigate the catheter

C. notify the physician

D. remove the catheter

10. The nurse is teaching a patient with an L-3 spinal cord injury regarding a bladder training regimen.

Which of the following instructions should be included in the bladder training process?

A. drink 1200-1500 ml of water per day

B. drink adequate fluids until 10 pm at night

C. tighten the abdominal muscles to void

D. pour cool water on the perineum

11. Mr. Cy underwent major surgery yesterday. He is on strict intake and output. Calculate his intake

and output for eight-hour period. Intake: IV-D5LR at 125 ml/hr, PO-1 ounce ice chips, NGirrigant-NS 15

ml q 2 hr; Output: Foley urine output 850 ml, NG tube- 200 ml

A. I=170 ml; O=1050 ml

B. I=1090 ml; O=1050 ml

C. I=141 ml; O=1000 ml

D. I=1000 ml; O=990 ml

12. An adult is scheduled for an intravenous pyelogram. Before sending her to have the test the nurse

should...

A. ask if she is allergic to barium

B. ask if she is allergic to shellfish

C. give her a full of glass water

D. instruct her not to urinate until after the test

13. An adult patient who has had an abdominal perineal resection asks the nurse when he can expect his

bowel function to return. The nurse explains that the earliest that normal bowel function can be

expected to return post-op is..

A. six hours

B. 12 hours

C. 3 days

D. 1 week

14. Type of Cytoclysis that is for frequent intermittent irrigations or continuous irrigation without

disrupting the sterile alignment of the catheter and drainage system through use of a three-way

catheter

A. open bladder irrigation system

B. manual bladder irrigation system

C. closed bladder irrigation system

D. continuous intermittent bladder irrigation system

15. An adult woman had a cystectomy with ileal conduit for a diagnosis of bladder cancer. During the

first 48 hours post-op which symptoms should be reported to the physician?

A. absence of urinary output over a period of 1-2 hours

B. swelling of the abdominal stoma

C. pain along the incision site

D. absent bowel sounds

16. The nurse is teaching an adult who had a cystectomy and ileal conduit. Which statement made by

the patient indicates a need for further instruction?

A. "Now that I've had the surgery, I'll have to be careful that I don't get frequent urinary tract infections

B. "My stoma is 1 1/2 inches in size now, but I understand it will get smaller. Therefore, I need to

measure it again in several weeks"

C. "I'm glad that once I get home and am better regulated, I will only have to wear an appliance at night"
D. "I certainly don't want my stoma to close up so I will gently dilate it with my finger once a week"

17. A 24-hour urine specimen is ordered for an adult patient. The nurse goes to the patient at 8:00AM to

start the specimen collection. The nurse instructs the patient to...

A. empty her bladder and save the specimen. Collect all urine until 8:00 AM tomorrow

B. drink large amounts of fluid during the test. Collect all urine for the next 24 hours

C. empty her bladder and discard the specimen. Collect all urine for 24 hours including that voided at

8:00 AM tomorrow

D. note the time when she next voids and collect urine for 24 hours from that time. Notify the nurse

when the collection is completed

18. The nurse is caring for a woman who had a vaginal hysterectomy 2 days ago. The indwelling catheter

has been removed. The nurse has performed a catheterization for residual urine. Which finding indicates

the patient does not have a problem? The urine volume obtained was...

A. 30 ml

B. 150 ml

C. 300 ml

D. 500 ml

19. For which procedure would the nurse use aseptic technique, and which would require the nurse to

use sterile technique?

A. aseptic technique for changing the patient's linen and sterile technique for placing central line

B. aseptic technique for urinary catheterization in the hospital and sterile technique for cleaning surgical

wound

C. aseptic technique for spinal tap and sterile technique for surgery

D. aseptic technique for food preparation and sterile technique for starting an IV line
20. A female patient is to have a urine culture collected. The nurse instructs the patient on the

procedure for collecting a clean catch urine specimen by telling the patient to...

A. separate the labia, clean from the front to back with three wipes impregnated with cleaning solution,

and then start to void in the toilet. Stop, and finally continue to void into the sterile container

B. retract the foreskin, cleanse with three cleansing sponges, and start to void. stop, and finally continue

to void into the sterile container

C. separate the labia, clean from back to front with the three wipes impregnated with the cleaning

solution, and then start to void in the toilet. Stop, and finally continue to void in the sterile container

D. retract the foreskin, clean with soap and water, and then start to void. Stop, and finally continue to

void in the sterile container

21. The nurse is to collect a urine culture specimen from a catheterized patient. Which one of the

following statements describes the nurse's actions for this procedure?

A. with a sterile syringe, the nurse aspirates 50 ml of urine from the silicone catheter tubing

B. with a sterile syringe, the nurse aspirates 1-3 ml from the distal end of the catheter after cleaning the

sampling port with alcohol

C. with a sterile syringe, the nurse aspirates 1-3 ml from the distal end of the catheter after first cleaning

the sampling port with soap and water

D. the nurse disconnects the catheter from the tubing and allow small volume of urine to drain into a

sterile container

22. The nurse is ordered to perform a urinary catheterization for post-void residual volume on a patient

with urinary incontinence. Several minutes after the patient voids, the nurse obtains a residual urine of

30 ml. The nurse interprets this residual volume of urine to be ...

A. adequate bladder emptying

B. inadequate bladder emptying

C. decreased urethral pressure

D. increased urethral pressure

23. A post-op patient is unable to void and is ordered to have an indwelling catheter inserted

immediately. The nurse performing the catheterization is extremely concerned with

A. teaching the patient deep breathing techniques to decrease post-op pain, pre-procedure

B. maintaining strict aseptic technique

C. medicating the patient for pain, before the procedure

D. teaching the patient, the signs and symptoms of urinary tract infection

24. The nurse assessing a patient with an indwelling catheter and finds the catheter is not draining and

the patient's bladder is distended. The nurse should immediately plan to...

A. notify the physician

B. assess catheter tubing for kinks and position so downhill flow is initiated

C. change the catheter

D. aspirate urine for culture

25. A three-day post-op patient for a ureterosigmoidostomy is complaining of cramping in lower

extremities and occasional dizziness. The nurse should give highest priority to...

A. assessing for electrolyte imbalance

B. assessing for cardiac dysrhythmias

C. observing the patient's response to surgery

D. verifying the temperature of the patient's lower extremities

26. Following a prostatectomy, the patient has a three-way, indwelling catheter for continuous bladder

irrigation. During evening shift, 2400 ml of irritant was instilled. At the end of the shift, the drainage bag

was drained of 2900 ml of fluid. The nurse calculates the urine output to be...

A. 5300 ml

B. 2900ml

C. 240 ml

D. 500 ml
27. The nurse who is caring for a patient with an ileal conduit should plan to teach the patient about...

A. decreasing the patient's sexual encounters

B. adhering to catheterization schedules

C. decreasing fluid intake to avoid embarrassing situations

D. decreasing fluid intake to manage the urinary diversion

28. A patient's foley catheter is to be discontinued in the AM. After explaining the procedure, the next

thing the nurse should do before removing the catheter is...

A. deflate the balloon

B. gently remove the catheter

C. place a towel under buttocks

D. empty the urine from the bag

29. A priority nursing intervention following removal of an indwelling catheter is...

A. Ambulation

B. restrict fluid

C. force fluids

D. pain management

30. Which record of urinary output is minimally acceptable, but would alert the nurse to problems?

A. less than 30 ml/hr

B. less than 60 ml/hr

C. less than 90 ml/hr

D. less than 120 ml/hr

31. How much urine can the bladder normally hold?

A. 100 ml

B. 200 ml

C. 1000 ml
D. 500 ml

32. The doctor orders a clean, voided specimen. What does the nurse instruct the patient to do when

obtaining this specimen?

A. collect the first urine voided

B. collect urine during midstream voiding

C. sterilize the meatus as much as possible

D. void completely into a clean urine cup

33. In planning care, the nurse is aware that the greatest risk of urinary catheterization is...

A. bladder irritation

B. meatal swelling

C. bladder puncture

D. urinary tract infection

34. The nurse assesses the renal patient's mental status. If there is a problem, what condition is most

likely to be assessed?

A. Aggression

B. Delirium

C. Confusion

D. intense anger

35. This is a type of Urinary Diversion that often involve creation of a pouch inside the body from part of

the intestines to hold urine – there are two types: those that have stoma brought out of the abdomen

and those in which a neobladder is made.

A. continent urinary diversion

B. incontinent urinary diversion

C. nephrostomy

D. bladder catheterization
36. Why should the nurse plan to address malnutrition for client with renal failure?

A. Anemia causes increased absorption of water-soluble vitamins

B. The client requires increased carbohydrate intake

C. Increased anabolism occurs in renal failure

D. Anemia often causes anorexia, nausea, and vomiting

37. Nursing interventions for client diagnosed with renal calculi would include

A. Decreasing fluid intake to less than 1000 ml/day

B. Encouraging the client to ambulate as much as possible

C. Medicating the client with intravenous Demerol as needed as prescribed

D. Applying cold compresses to the flank area

38. Clinical manifestations and assessment findings that support a diagnosis of acute pyelonephritis

include

A. Urinary stress incontinence and abdominal pain

B. Flank pain, fever, and dysuria

C. Burning on urination and inflamed urinary meatus

D. Acute, sharp, intermittent pain and anuria

39. A 20-year-old renal transplantation client has expressed frustration about feeling alone in the

hospital room. “I wish I could be out in the waiting room visiting with my friends.” Which of the

following responses would be most appropriate by the nurse?

A. Allow client to go to the waiting room for 10 minutes only

B. Allow client’s friends to come into the room for a short visit

C. Allow client to verbalize feeling of isolation

D. Discuss activities that client can do to combat isolation

40. A client who is in acute renal failure develops pulmonary edema. Nursing interventions for this client

include all of the following except

A. Administering oxygen

B. Encouraging coughing and deep breathing

C. Placing the client in semi-fowler’s position

D. Replacing fluid lost