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NUR 2755 FINAL EXAM| 2025 - 2026|75 ACTUAL EXAM
QUESTIONS AND CORRECT ANSWERS|A+ GRADE
1) When caring for a patient who has septic shock, which assessment finding is most important for the nurse to report to the care provider? (a) BP 92/ (b) Skin cool and clammy- means progression (c) Apical pulse 118 beats/min (d) Arterial oxygen saturation 91% 2) Calculate the mean arterial pressure (MAP) in mmHg for a patient with a blood pressure of 84/46mmHg. (Record answer to the nearest whole number) MAP = SBP + 2 (DBP)/ 3 84+2(46)/3= 3) 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? (a) A low respiratory rate (b) Diminished breath sounds (c) The presence of a barrel chest-copd (d) A sucking sound at the site of injury-open chest 4) The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding? (a) Slow deep respirations (b) Rapid deep respiration (c) Paradoxical respirations (d) Pain, especially with inspiration 5) A client with a chest injury has suffered a flail chest. The nurse assesses the client for which most distinctive sign of flail chest? (a) Cyanosis (b) Hypotension (c) Paradoxical chest movement-hall mark (d) Dyspnea, especially on exhalation 6) A client has been admitted with chest trauma after a motor vehicle crash
and has undergone subsequent intubation. The nurse checks the client when the high- pressure alarm on the ventilator sounds and notes that the client has an absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition? (a) Right pneumothorax (b) Pulmonary embolism (c) Displaced endotracheal tube (d) Acute respiratory distress syndrome 7) A burn patient is brought into the emergency department with the following burns: half of the front torso(9), entire left arm (9), front of left le (9)g. The nurse should record the TBSA burns as. (a) 27% TBSA (b) 35% TBSA (c) 20%TBSA (d) 40% TBSA 8) The client, who is one-day postoperative following chest surgery is having difficulty breathing, has bilateral rales, and is confused and restless. Which intervention should the nurse implement first? (a) Assess the client pulse oximeter reading (b) Notify the rapid response team (c) Place the client in the Trendelenburg position (d) Check the client’s surgical dressing 9) The intensive care unit (ICU) nurse is caring for a client on a ventilator who is exhibiting respiratory distress. The ventilator alarms are going off. Which interventions should the nurse implement first? (a) Notify the respiratory therapist immediately (b) Ventilate with a manual resuscitation bag (c) Check the ventilator to resolve the problem-first step (d) Auscultate the client’s lung sound 10) The client in the intensive care unit is on a ventilator. Which interventions should the nurse implement? (select all that apply) (a) Ensure there is manual resuscitation bag at the bedside (b) Monitor the client’s pulse oximeter reading every shift (c) Assess the client’s respiratory status every 2 hours (d) Check the ventilatory setting every 4 hours (e) Collaborate with the respiratory therapist 11) Which actions are essential for the nurse caring for a mechanically ventilated to prevent ventilator-acquired pneumonia (VAP) (Select all
formationx 16) When assessing a patient who is severely bleeding and at risk for hypovolemic shock, the nurse anticipates which of the following? (a) Slow, labored breathing (b) Hot flushed skin (c) Edematous extremities (d) Weak, thready pulse 17) A nurse is assessing a client who sustained superficial partial- thickness and deep partial-thickness burn 38 hours ago. Which finding should the nurse report to the provider? (a) Edema in the burned extremities - expected (b) Severe pain at the burn sites - expected (c) Urine output of 65ml/hr. over 2 hours (d) ABG pH 7.31, CO 2 37, HCO 3 31 18) When assessing a patient who has suffered a burn injury, the nurse classifies the burn as a deep partial-thickness burn based on the observation of which characteristics? (a) Painful, reddened skin (b) Charred skin with milky-white areas- wshite is key and it is dry (c) Erythema and blisters (d) Erythema, pain, and swelling 19) The nurse is developing a care plan for a patient in the acute phase of a burn injury. Which of the following would be the priority nursing diagnosis for this patient? (a) Risk for falls r/t contracture of burned extremities (b) Risk for infection r/t slow healing graft donor site (c) Risk for denial r/t inability to participate in dressing change x (d) Risk for ineffective coping r/t inability to look at burn woundsx 20) 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. Which nursing statement is appropriate? (a) Large surgical incisions will be made in the hardened dermal layer to improve circulation (b) This procedure involves placing the client into a shower and removing the dead tissue (c) A piece of healthy skin will be removed from an unburned area and
grafted over the burned area (d) Surgical incisions will be made into the deep tissue, possibly to the bone, to permit better circulation 21) A nurse is caring for a client who has sustained burns over 37% of total body surface area. The client 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? (a) Pulmonary edema (b) Bacterial pneumonia (c) Inhalation injury (d) Carbon monoxide poisoning 22) 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: (a) Administer morphine sulfate IV push for the severe pain (b) Call the healthcare provider (HCP) to report the loss of the radial pulse (c) Continue to assess the arm every hour for any additional changes (d) Instruct the client to exercise the fingers and wrist
(b) DIC is a genetic disorder characterized by an elevated factor VIII count (c) DIC is a caused by abnormal coagulation involving fibrinogen (d) DIC is a genetic disorder involving vitamin K deficiency 29) During change of shift report, the nurse learns that a patient 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? (a) Decreased bowel sounds (b) Apical pulse 110 beats/min (c) Pale, cool and dry extremities (d) New onset of confusion and agitation 30) A patient with septic shock has a urine output of 20 ml/hr for the past 3 hours. The pulse rate is 120, and the central venous pressure and pulmonary artery wedge pressure are low. Which of these orders by the health care provider will the nurse question? (a) Give furosemide (b) Increased normal saline infusion (c) Administer hydrocortisone (d) Prepare to give broad spectrum antibiotic 31) A 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? (a) WBC count of 10,000 per ml (b) The patient has a deep partial-thickness burn wound (c) The patient has a sulfa allergy listed on the chart – potential for cross allergy (d) The patient has a full-thickness burn wound 32) A patient with shock of unknown etiology whose hemodynamic monitoring indicates a BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure has the following collaborative interventions prescribed. Which intervention will the nurse question? (a) Infuse normal saline at 250ml/hr (b) Keep head of bed elevated to 30 degrees (c) Give nitroprusside unless systolic BP is less than 90 mmHg (d) Administer dobutamine to keep systolic BP greater than 90 mmHg 33) Which assessment is important for the nurse to make to evaluate whether the treatment of a patient with anaphylactic shock has been effective? (a) Pulse rate (b) Orientation (c) Blood pressure
(d) Oxygen saturation 34) A patient with neurogenic shock has just arrived in the emergency department after a driving accident. He has a cervical collar in place. Which of the following actions should the nurse take? (select all that apply) (a) Prepare to administer atropine IV (b) Obtained baseline body temperature (c) Prepare for intubation and mechanical ventilation (d) Administer large volumes of lactated Ringer’s solution (e) Assist the patient into a semi fowler’s position 35) When the charge nurse is evaluating the skills of a new RN, which action by the new RN indicates a need for more education in the care of patients with shock? (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) Decreasing the room temperature to 68 degrees for a patient with neurogenic shock (d) Increasing the nitroprusside infusion rate for a patient with a high SVR 36) The patient with neurogenic shock is receiving a phenylephrine infusion through a left forearm IV. Which assessment information obtained by the nurse indicates a need for immediate action? (a) The patient’s IV infusion site is cool and pale (b) The patient has warm dry skin on the extremities (c) The patient has an apical pulse rate of 58 beats/min (d) The patient’s urine output has never been 28 ml over the last hour 37) Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? (a) Avoid elevating head of bed (b) Check temperature every 2 hours (c) Monitor breath sounds frequently (d) Assess skin for flushing and itching 38) A patient is treated in the emergency department (ED) 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) Obtained the blood pressure (d) Check of the level of consciousness
(c) Chest tube placement (d) Heparin drug therapy (e) Thoracotomy 44) A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse except? (a) Hemoglobin 10 g/dL (b) Sodium 143 mEq/L - normal (c) Albumin 2.9g/dL (d) Potassium 4.0 mEq/dL - normal 45) A nurse is caring for a client who is receiving mechanical via an endotracheal tube. Which of the following actions should the nurse take? (a) Apply a vest restraint if self-extubation is attempted (b) Monitor daily ventilator settings (c) Document tube placement in centimeters at the angle of the jaw (d) Assess breath sounds every 2 hours 46) A client arrived at the burn unit more than two weeks ago. The care plan for this client requires assistance by the nurse to perform daily ROM exercises and help with mobility. The client tells the nurse he is no longer going to participate due to the pain it always causes. Which of the following should the nurse do next? (a) Call the doctor to report noncompliance with treatment
(b) Remind the client that contractures hurt worse and to let you know when he is ready (c) Give him his ordered PRN dose of IV hydromorphone 4mgs with his scheduled PO oxycodone 10mgs 30 minutes prior to treatment to allow for pain free therapy. (d) Acknowledge the client’s concerns regarding pain, and discuss how to promote his exercise plan in a way to have less pain but also allow a therapeutic level of treatment 47) A client has been diagnosed with a pulmonary embolism. Which diagnostics and treatments does the nurse anticipate will be ordered? (Select all that apply.) (a) D-Dimer (b) Thrombolytics (c) Atropine - for bp (d) Nitroglycerin for chest pain (e) CT Angiogram (CTA) 48) A client in the intensive care unit (ICU) 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 10 mL/hr. Labs were drawn and indicated elevated WBCs. GFR creatinine and lever enzymes. This client is experiencing which disease process? (a) Acute respiratory failure (ARF) (b) Acute kidney injury (AKI) (c) Disseminated intravascular coagulation (DIC) (d) Multiple organ dysfunction syndrome (MODS). 49) After receiving report of four clients the nurse determines the order of care of the clients. Based on report, the nurse will prioritize the clients to see which one first? (a) Mottling of extremities in a newborn-can bed normal (b) Dry skin with tenting in a 72 - year-old-dehydration (c) Bradycardia in a 35 - year-old athlete - normalx (d) Rapid shallow respirations in a healthy 18 - year-old- 50) A 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? (a) Norepinephrine (Levophed) (b) Sodium nitroprusside (Nipride)
(a) Client is unable to maintain airway when extubated (b) Client has been on the ventilator for 24 hours (c) Client has been diagnosed diabetes x (d) Client is coughing and bucking the endotracheal tube. 56) A client is being treated for hypovolemic shock. As the nurse reassesses the client. Which finding indicates the interventions are effective? (a) Oxygen saturations remains unchanged (b) Core body temperature has increased to 99 degrees F (c) The client incorrectly states the month and year (d) Serum lactate and serum potassium levels are declining 57) Client presents with the following vital signs: B/P 90/60, temp 38.3C (101F), HR 116, RR 24. The client has a post-op abdominal incision that is warm and red. Which type of shock is this client in? (a) Hypovolemic shock (b) Septic Shock (c) Anaphylactic shock (d) Neurogenic shock 58) A nurse is assessing the provider in caring for a client who has developed a tension pneumothorax. Which actions should be performed first? (a) Assess the client’s pain (b) Large-bone needle thoracostomy (c) Administer lorazepam (d) Prepare for chest tube insertion. 59) A client is being treated for distribute shock with IV vasopressin. The nurse expects the drug to have which effect on the client’s mean arterial pressure (MAP)? (a) Increased MAP with no change in vascular volume (b) Increased MAP by increasing vascular volume (c) Decreased MAP from widespread capillary leak (d) Decreased MAP from decreasing vascular volume 60) A client with 55% total body surface area burns (TBSA) arrives in the emergency department. The client weighs 160 pounds. Using the Parkland Burn Formula (Consensus formula), calculate the hourly flow rate (mL/hr) of Lactated Ringers during the first 8 hours of fluid resuscitation (mL/hr). (Round answer to the nearest whole number. Do not use a trailing zero.) 160lbs /2.2 =72.7272 kg 4 ML X 55 X 72.727272 =16000ml
16000/2 = 8000ml/8 hrs = 1000ml/hr 61) A nurse is caring for a client in shock. The nurse understands the client’s sympathetic nervous system (SNS) is still correctly attempting to compensate when the following is assessed? (SATA ) (a) The client has decreased peripheral pulses (b) The client has an increasing thirst (c) The client has a decreased heart rate (d) The client has an increasing respiratory rate (e) The client has a widening pulse pressure 62) A nurse is caring for a client who is in the progressive stage of shock. Which finding should the nurse expect? (a) Blood pressures change from 129/78 (95) to 89/45 (60) (goes from normal to less than 90/65) (b) Blood pressures change from 95/55 (68) to 90/52 (65) (c) Blood pressures change from 100/50 (67) to 90/45 (60) (d) Blood pressure reading is undetectable 63) Which of the following interventions is not appropriate for a client diagnosed with a pneumothorax? (a) Apply wet to dry dressing on wound (b) Monitor respiratory and circulatory function x (c) Assess for tracheal deviationx
(c) Corticosteroi d (d) Bronchodilator 70) 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 currently on the ventilator with 100% FIO2. Based on this information, which of the following would be a sign or symptom of acute respiratory distress syndrome (ARDS)? (a) Respiratory rate 14 (12- 20 normal) (b) ABG results show PaO 50 (c) Fatigue and weakness (d) Urine output 580 mL last shift 71) A client is receiving warfarin after pulmonary embolism (PE). The nurse evaluates the lab results and notifies the physician that the client’s Coumadin level is therapeutic when which of the following numbers is reported? (a) International normalized ratio (INR) 2.8 (2- 3 is therapeutic) (b) Partial thromboplastin time (PTT) 24 seconds (c) International normalized ratio (INR) 1. (d) Prothrombin time (PT) 14 seconds 72) A nurse is reviewing the health records of clients. Which client is at least risk for developing acute respiratory distress syndrome (ARDS)? (a) A client who experienced a near-drowning incident in freshwater x (b) A client following coronary artery bypass graft surgery x (c) A client who has a hemoglobin of 10.1 mg/dL post 1 - unit PRBC (d) A client who is experiencing acute pancreatitis and vomitingx 73) A 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 three hours after the injury, the client begins to decompensate and is being prepped for intubation. Regarding the change in the client's status, which explanation by the nurse is correct when educating the client's family? (a) Even a burn as little as 25% of the body can cause a systemic response, requiring emergency management" (b) The client is complaining of serve pain and will be intubated to safety given pain medication and seductive (c) The client is experiencing a paralytic ileum and requires intubation to prevent further damage (d) Fluid shift in the body immediately cause an increased cardiac output and increased tissue profusion which can negatively affect the healing
process **74) A nurse is caring for a client who is in the non-progressive (compensatory) stage of hypervolemic shock. Which finding should the nurse anticipate? ***** (a) Multi-organ Dysfunction Syndrome and seizures (b) Increase thirst reflex and moderate vasoconstriction (c) pH 7.5 and potassium level of 3.0 mEq/L – hypokalemia occurs (d) Decrease in MAP by 20 points from baseline 75) A nurse is reviewing the health records of clients. Which client is at greatest risk for developing Acute Respiratory Distress Syndrome (ARDS) and Multiple Organ Dysfunction Syndrome (MODS)? (a) A client who experienced neurogenic shock (b) A client following anaphylactic shock (c) A client who is experiencing septic shock (d) A client who is experiencing obstructive shock
