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    Exam Review

    1. Why is it important for the nurse caring for a patient experiencing a stroke to establish the onset of the stroke before administering tissue plasminogen activator?
      A)The activator is not recommended if the stroke onset is less than 3 hours.
      B)The activator is recommended for transient ischemic attacks
      C)The activator is recommended for patients with increased ICP.
      D)The activator is not recommended if the stroke onset is greater than 3 hours.
    2. Which finding(s) would the nurse expect to assess on a patient with a diagnosis of diabetic ketoacidosis (DKA) recently admitted to the emergency department? (Select all that apply)(SATA)
      A)Deep, rapid breathing
      B)Decreased urine output
      C)Elevated blood glucose level
      D)Increase in pH
      E)Acetone breath
    3. A 25-year-old male is brought to the Emergency Department via EMS after being involved in a motor vehicle collision with fire entrapment. The patient is conscious and in visible pain. You, a student nurse, are assigned to assist with his initial assessment and care. Exhibits Calculate the fluid requirements using the Parkland formula. What is the total fluid needed in the first 24 hours?
    4. The nurse is caring for a patient who sustained rib fractures with dropping Sa02 and BP. The nurse assesses that breath sounds are absent throughout the left lung fields. The nurse notifies the physician and anticipates which order?
      A)Endotracheal intubation and mechanical ventilation.
      B)Chest x-ray study to determine the etiology of the symptoms.
      C)Needle thoracostomy and chest tube insertion.
      D)Administration of lactated Ringer's solution (1 L) wide open.
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    Exam Review

    1. Which of the following lab values would be most important to monitor during the fluid resuscitation phase? (Select All that Apply.)(SATA)
      A)Blood glucose
      B)Potassium
      C)Lactate
      D)Troponin
      E)Hematocrit
    2. What are some ethical dilemma warning signs? (Select All that Apply.)(SATA)
      A)Confusion about facts
      B)Hesitancy about the correct set of actions
      C)Deviation from customary practice
      D)Emotionally charged
      E)Significant change in patient's condition
      F)Need for secrecy regarding proposed actions
    3. The nurse understands that the most common reasons for initiating dialysis in acute kidney injury include which of the following? (Select all that apply)(SATA)
      A)Hypokalemia
      B)Volume overload
      C)Uremia
      D)Hyperkalemia
      E)Acidosis
    4. The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department (ED) with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action?
      A)Stimulate the patient hourly
      B)Notify the primary care provider immediately
      C)Elevate the head of the bed
      D)Continue to monitor the patient
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    Exam Review

    1. A nurse caring for a patient with neurological impairment often must use painful stimuli to pressure. She neither slaps the patient nor pinches the nipple to elicit a response to pain. In this scenario, the nurse is exemplifying the ethical principle of
      A)veracity
      B)autonomy
      C)fidelity
      D)nonmaleficence.
    2. The nurse caring for a patient on a ventilator knows the amount of effort needed to maintain a given level of ventilation is called what?
      A)Resistance.
      B)Compliance
      C)Tidal volume.
      D)Work of breathing.
    3. Which patient being cared for in the emergency department does the nurse identify as most at risk for developing hypovolemic shock?
      A)A patient with a 2-day history of nausea, vomiting and diarrhea
      B)A patient with a temperature of 102° F and a general dermal rash.
      C)A patient with slight rectal bleeding from inflamed hemorrhoids
      D)A patient admitted with abdominal pain and an elevated white blood cell count
    4. A patient receives a vaccine and, days later, their plasma cells begin producing large quantities of antibodies that neutralize the antigen. Which type of immune defense is demonstrated?
      A)Innate immunity
      B)Autoimmune response
      C)Humoral immunity
      D)Cell-mediated immunity
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    Exam Review

    1. As the nurse cares for a patient who has delirium, what characteristics are expected in the hypoactive delirium state?
      A)Agitation
      B)Restlessness
      C)Hitting
      D)Withdrawal
    2. The nurse understands that the rapid response teams (RRTS) have been implemented to function how? (Select all that apply)(SATA)
      A)Ensure interventions are available quickly when patient conditions become unstable.
      B)Provide a unit based resource team to intervene as needed.
      C)Be available Monday-Friday to assess patients outside the critical care unit.
      D)Address changes in a patient's clinical condition before a cardiac and/or respiratory arrest occurs.
      E)Improve recognition of and response to deterioration in patients.
    3. You are a nurse working in an outpatient clinic. A 22-year-old female arrives after spending the entire day at the beach without sun protection. She complains of red, painful skin on her shoulders and upper back Which of the following best describes a first-degree burn?
      A)involves subcutaneous tissue with white or charred skin
      B)involves epidermis and dermis, appears moist with blister
      C)involves all layers of skin and may be painless due to nerve damage
      D)involves only the epidermis and appears red and painful without blister
    4. What does the nurse state as the most common intrarenal cause of acute kidney injury?
      A)Exposure to nephrotoxic substances,
      B)Prolonged ischemia.
      C)Acute tubular necrosis (ATN).
      D)Hypotension for several hours.
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    Exam Review

    1. Which of the following is NOT typically considered an indication for Percutaneous Coronary Intervention (PCI)?
      A)Acute stroke
      B)Chronic stable angina unresponsive to medical therapy
      C)Multi-vessel coronary artery disease in a patient with heart failure
      D)High-risk unstable angina
    2. The RN is to calculate gtt/min to transfuse one unit (300 ml) of Packed Red Blood Cells (PRBC) over two hours using blood tubing that has a drop factor of 10. How many gtts/min will be infused?
      A)20
      B)35
      C)25
      D)30
    3. Which common postoperative dysrhythmia should the nurse monitor for in a patient who has undergone open chest surgery for coronary artery bypass grafting?
      A)Second degree heart block
      B)Atrial fibrillation or flutter
      C)Premature junctional contractions
      D)Ventricular ectopy
    4. The patient in the progressive care unit following arteriovenous fistula implantation in his left upper arm, and is due to have blood drawn with his next set of vital signs and assessment. When the nurse assesses the patient, what should he/she do?
      A)Draw the blood for all labs from the left arm.
      B)Auscultate the left arm for a bruit and palpate for a thrill
      C)Take the blood pressure from the left arm every 4 hours.
      D)Start a new intravenous line in the left lower arm
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    Exam Review

    1. Your patient with facial burns from a house fire is being assessed in the Emergency Department. He begins to develop hoarseness, stridor, and difficulty speaking. What is the priority nursing action?
      A)Monitor vital signs every 15 minutes
      B)Place the patient in high Fowler's position
      C)Notify the physician and prepare for intubation
      D)Administer high-flow oxygen via non-rebreather mask
    2. Select the correct antibody with its function.(Select all that apply)(SATA)
      A)IgD
      B)IgA
      C)IgM
      D)IgG
      E)IgE
    3. A 38-year-old male is brought into the Emergency Department by ambulance after a car explosion while working in his garage. He was trapped under the hood momentarily and pulled out by a neighbor. He is unconscious, and full-thickness burns are visible on his anterior torso, both arms, and part of his face. Based on the assessment and wound appearance, what type of burn is this?
      A)First-degree
      B)Third-degree (full thickness)
      C)Second-degree (partial thickness)
      D)Fourth-degree (extends to muscle/bone)
    4. The nurse caring for a patient with acute respiratory distress syndrome (ARDS) would expect to observe which of the following symptoms?
      A)Increased lung compliance with increased FiO2 administration
      B)Respiratory acidosis associated with hyperventilation.
      C)Elevated alveolar surfactant levels
      D)Decreasing PaO2 levels despite increased FiO2 administration.
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