1. A nurse in a burn treatment center is caring for a client who is admitted with
severe burns to both lower extremities and is pending an escharotomy. The
client’s spouse asks the nurse what the procedure entails. Which of the following
nursing statements is appropriate?
a. “large incisions will be made in the eschar to improve circulation”
b. “ I can call the doctor back here if you want me to”
c. “a piece of skin will be removed and grafted over the burned area”
d. “dead tissue will be surgically removed”
2. A nurse is monitoring the fluid replacement of a client who has sustained
burns. Which of the following fluids is used in the first 24 hours following a burn
injury?
a. 5% dextrose in water
b. 5% dextrose in normal saline
c. normal saline
d. lactated ringers
3. A nurse is caring for a client who has full-thickness burns all over 75% of
his body. Which of the following methods is appropriate to accurately monitor
the cardiovascular system?
a. auscultate cuff blood pressure
b. palpate pulse pressure
c. obtain a central venous pressure
d. monitor the pulmonary artery pressure
4. A nurse is assessing the depth and extent of a client who has severe burns to
the face, neck, and upper extremities. Which of the following factors is the first
priority when assessing the severity of the burn?
a. Age of the client
b. Associated medical history
c. Location of the burn
d. Cause of the burn
5. A client arrives at the emergency dept following an explosion at the chemical
plant. He has deep partial and full-thickness chemical burns over more than 25
% of his body surface area. What is the nurse’s priority intervention?
a. Initiate fluid resuscitation
b. Medication for pain
c. Administer antibiotics
d. Maintain a patent airway
,6. A nurse is caring for a client who came the emergency dept reporting chest
pain. The provider suspects a myocardial infarction. While waiting for the
laboratory to report the client’s troponin levels, the client asks what this blood
test will show.
The nurse should explain that troponin is
a. An enzyme that indicates damage to brain, heart, and skeletal
muscle tissues
b. A protein whose levels reflect the risk for coronary artery disease
c. A heart muscle protein that appears in the bloodstream when there
is damage to the heart
d. A protein that helps transport oxygen throughout the body
7. A nurse is assessing a client who has disseminated intravascular
coagulation (DIC). Which of the following should the nurse expect in the
findings?
a. Excessive thrombosis and bleeding
b. Progressive increase in platelet production
c. Immediate sodium and fluid retention
d. Increased clotting factors
8. A nurse is about to administer warfarin (Coumadin) to a client who has
atrial fibrillation. When the client asks what his medication will do, which of
the following is an appropriate nursing response?
a. It helps convert atrial fibrillation to sinus rhythm
b. Is dissolves clots in the bloodstream
c. It slows the response of the ventricles to the fast atrial impulses
d. It prevents strokes in clients who have atrial fibrillation
9. A nurse in a cardiac care unit is caring for a client with acute heart failure.
Which of the following findings should the nurse expect?
a. Decreased brian natriuretic peptide (BNP)
b. Elevated central venous pressure (CVP)
c. Decreased pulmonary pressure
d. Increases urinary output
10. A client comes into the ED reporting nausea and vomiting that worsens when
lying down and without relief from antacids. The provider suspects acute
pancreatitis. Which of the following lab test results should the nurse expect to
see if the client has acute pancreatitis?
a. Decreased WBC
b. Increased serum amylase
c. Decreased serum lipase
, d. Increased serum calcium
11. A nurse in the ICU is caring for a client who has acute respiratory distress
syndrome (ARDS) and is receiving mechanical via an endotracheal tube. The
provider plans to exubate her within the next 24 hour. Which of the following
is an important criterion for exubating the client?
a. Ability to cough effectively
b. Adequate tidal volume without manually assisted breaths
c. No indication of infection
d. No need for supplemental oxygen
12. A nurse is caring for a client following a CT scan with dye who suffered from
an anaphylactic reaction. Which of the following conditions requires a priority
nursing response?
a. urticaria
b. stridor
c. tachypnea
d. angioedema
13. A nurse is caring for a female client who came in to the ED reporting SOB
and pain in the lung area. Her heart rate is 110/min, resp. rate 40/min, and
blood pressure 140/80 mmHg. Her arterial blood gases are: pH 7.5, PaCO2 29
mmHg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the
following is the priority intervention?
a. Prepare for mechanical ventilation
b. Administer oxygen via face mask
c. Prepare to administer a sedative
d. Monitor for pulmonary embolism
14. A nurse is monitoring a client who has just had a thoracentesis to remove
pleural fluid. Which of the following clinical manifestations indicate a complication
that requires notifying the provider immediately?
a. Serosanguineous drainage from the puncture site
b. Discomfort at the puncture site
c. Increased heart rate
d. Decreased temperature
15. A group of college students was attending a weekend football rally when one
of the students stumbled and fell into the bonfire. Although several friends quickly
intervened, the client sustained partial-thickness burns to both lower legs, chest,
and both forearms. Which of the following is priority nursing action when the
client is brought to the ED?
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