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MDC 4 Exam 2 Rasmussen with correct answers
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MDC 4 Exam 2 Rasmussen with correct answers
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MDC4
Exam
2
Rasmussen
with
correct
answers
A
patient
comes
to
the
ED
having
diminished
breath
sounds
on
his
left
lung
and
asymmetrical
chest
expansion
when
asked
to
breathe.
The
nurse
feels
the
patient's
trachea
has
deviated
to
the
right
side
of
the
throat.
What
is
the
patient
suffering
from?
-
answer-Pneumothorax
A
provider
tells
the
nurse
that
a
patient
is
having
a
simple
pneumothorax.
What
treatment
might
be
prescribed
for
the
patient?
-
answer-Chest
Tube
A
provider
tells
the
nurse
that
a
patient
is
having
a
tension
pneumothorax.
What
could
the
nurse
anticipate
about
how
this
will
be
treated?
-
answer-With
a
needle
decompression
thoracotomy
A
nurse
sees
a
patient
coming
into
the
trauma
bay
with
paradoxical
chest
movement.
What
might
the
patient
be
having?
-
answer-Flail
Chest
A
provider
tells
the
ED
nurse
that
the
patient
has
a
flail
chest.
What
does
the
nurse
anticipate
will
happen
next
for
the
patient?
-
answer-Intubation
and
mechanical
ventilation
What
is
an
early
manifestation
of
hypovolemic
shock?
-
answer-Decreased
urine
output
A
nurse
is
caring
for
a
patient
who
is
critically
ill
and
has
a
fever,
low
BP
and
yellowish
mucus
coming
from
the
nose.
What
type
of
shock
is
occurring
with
this
patient?
-
answer-Septic
Shock
What
is
the
main
nursing
issues
revolving
around
rib
fractures?
-
answer-Pain!
Puncturing
vasculature
or
organs.
What
can
the
nurse
teach
the
patient
who
has
had
a
rib
fracture
to
decrease
pain?
-
answer-Splint
when
coughing
A
nurse
is
caring
for
a
patient
with
ARDS
in
the
ICU.
What
manifestations
might
she
see?
-
answer-Low
oxygen
levels
that
do
not
get
better
with
100%
oxygen
applied,
bilateral
pulmonary
edema
that
is
not
cardiac
related,
broken
glass
lung
appearance
on
the
X-ray.
A
client
ate
peanuts
and
has
an
allergy
to
peanuts
and
tree
nuts.
What
manifestations
might
the
nurse
see
upon
client
arrival
related
to
anaphylactic
shock?
-
answer-Stridor
and
angioedema
A
client
is
having
anaphylactic
shock
due
to
a
bee
sting.
What
medication
should
be
given
to
treat
this?
-
answer-Epinephrine A
nurse
is
caring
for
a
patient
with
ARDS.
What
treatment
orders
might
the
nurse
see
from
the
provider
for
the
patient?
-
answer-Place
them
prone
and
on
PEEP
What
are
complications
of
PEEP?
-
answer-Pneumothorax
Low
BP
What
is
ventilator
associated
pneumonia?
-
answer-Infection
from
being
on
the
ventilator
for
a
long
time
A
nurse
is
learning
about
ARDS.
What
are
the
causes
of
ARDS?
-
answer-Sepsis,
Infection,
burns,
near
drowning,
trauma,
shock.
A
client
with
a
bone
infection
is
getting
information
on
ensuring
his
infection
does
not
progress
into
sepsis
or
septic
shock.
What
might
be
some
risk
factors
of
the
conditions?
-
answer-Infection
risks,
chancer,
chemo,
immunocompromised
states,
immunosuppressants,
HIV
A
nurse
will
be
preparing
to
care
for
a
newly
intubated
patient.
What
are
some
things
she
must
prepare
and
remember
while
caring
for
the
patient?
-
answer-Place
ambu
bag
at
bedside,
suction
PRN,
switch
tube
once
a
shift,
assess
respiratory
status
every
2
hrs,
oral
and
mouth
care
every
2
hrs,
wash
hands,
expect
orders
for
PPI
or
H2RB,
A
patient
is
suspected
to
have
a
PE
while
in
the
ED.
What
might
be
some
manifestations
of
this
occurring?
-
answer-Low
o2
saturation,
low
BP,
sudden
severe
SOB,
chest
pain,
LOC
changes,
petechiae,
lung
edema
,
ascites.
A
client
was
recently
just
extubated
and
now
is
showing
signs
of
stridor
and
low
oxygen
levels.
What
might
of
occurred
and
who
should
be
called?
-
answer-Irritation
fo
the
throat
form
the
tube.
Call
RRT
What
are
clinical
manifestations
of
hypovolemic
shock?
-
answer-weak
and
thready
pulse,
decreased
BP,
increased
HR,
altered
LOC,
shallow
and
fast
respiration,
long
capillary
refill,
decreased
H/H,
low
urine
output.
A
client
has
fluid
volume
excess
due
to
heart
failure.
What
are
some
of
the
important
cardiac
findings
for
this
condition?
-
answer-Bounding
pulse,
JVD,
central
venous
pressure
is
high,
wedge
pressure
is
high
What
must
the
nurse
do
immediately
when
a
patient
presents
with
an
inhalation
injury?
-
answer-Intubate
to
assume
an
airway,
assess
respiratory
status.
A
burn
patient
presents
to
the
ED.
What
are
some
of
the
signs
they
may
present
with
leading
to
an
inhalation
injury?
-
answer-SOB,
soot
around
nose,
singed
facial
hairs,
drooling,
not
swallowing,
black
membranes.
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