New Question Set
1. 1.ID: 14
The triage nurse is assessing a victim of a stab wound. According to the paramedics, the victim was
stabbed by a male attacker. The knife blade is 6 inches (7.2 cm) in length and 1 inch (2.5 cm) in width.
The "point of entry" of the stab wound is two inches above ...
new question set 1 1id 20120683614 the triage nurse is assessing a victim of a stab wound according to the paramedics
the victim was stabbed by a male attacker the knife blade is 6 inches 72
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New Question Set
1. 1.ID: 20120683614
The triage nurse is assessing a victim of a stab wound. According to the paramedics, the victim was
stabbed by a male attacker. The knife blade is 6 inches (7.2 cm) in length and 1 inch (2.5 cm) in width.
The "point of entry" of the stab wound is two inches above and left of the victim's xiphoid process.
Which vital organ(s) are at an increased risk of being in the direct path of injury? (Select all that apply.)
A. Heart. Correct
A. Lungs. Correct
A. Stomach.
A. Intestines.
A. Diaphragm. Correct
Stab wounds are low velocity wounds that the path of injury to the underlying organs is determined by the direction
of the path of the impaled knife and the length and width of the blade. The gender of the attacker is important to
know because females tend to stab in a downward direction (trajectory) and males tend to stab in an upward
direction (trajectory).
Awarded 0.99 points out of 0.99 possible points.
2. 2.ID: 20120683612
A client reports to the nurse feeling achy and weak, being tired and coughing all the time, frequent
headaches and experiencing night sweats. The client's assessment is significant for crackles scattered
throughout the lungs, dependent peripheral edema +3/+4, S3 and S4 heart sounds, temperature of
102.4° F(39.1° C), heart rate of 110 beats/minute, respirations of 20 breaths/minute, and blood pressure
of 105/60 mmHg with a mean arterial pressure of (75). Which diagnostic procedure should the nurse
prepare to do first?
A. Metabolic panel with electrolytes.
A. Complete blood count.
A. Liver function test.
A. Blood culture. Correct
The client is demonstrating clinical signs and symptoms of infective endocarditis. The key in treating infective
endocarditis is identifying the causative infectious agent and treat with the appropriate antibiotics. Blood cultures
should identify which bacteria is the offending bacteria causing the endocarditis. What distinguishes infective
endocarditis from the other conditions listed is the presence of the heart failure symptoms of edema, and S 3 and
S4 heart sounds.
Awarded 1.0 points out of 1.0 possible points.
3. 3.ID: 20120683610
According to the paramedic's report, the victim of a motor vehicle collision was sitting in the passenger
seat on the left side of the vehicle. The vehicle was stopped at a traffic light when the vehicle was hit
on the left side by another vehicle traveling at speeds exceeding 60 mph (97 kmh). The client reports
slight tenderness and achiness on (L) side of thorax and body. The significant assessment findings
include: weak and thready pulse; diffuse abdominal pain, tenderness and guarding present upon
palpation; skin is diaphoretic and extremities cool to touch, capillary refill +4 in extremities, and
bruising is present in the (L) flank area and progresses towards the abdomen. Vital signs are
temperature- 97.2° F (36.2° C), pulse- 110 beats/minute, respirations- 22 breaths/minute, blood
pressure 84/46 mmHg, MAP- (57), and pulse oximetry 90% on 2 lpm O2 via nasal cannula.
,Which potential injuries should the triage nurse assess? (Select all that apply.)
A. Flailed ribs.
A. Fractured liver. Correct
A. Ruptured spleen. Correct
A. Cardiac tamponade.
A. Tension pneumothorax.
The assessment priorities are based on the report of the mechanism of injury which indicated that the majority of
point of impact from the motor vehicle collision was on the client's left side of the body. Along with the physical
assessment and vital signs findings the client is displaying signs and symptoms indicating blunt trauma to the liver
and the spleen.
Awarded 1.0 points out of 1.0 possible points.
4. 4.ID: 20120683608
The nurse is analyzing an arterial blood gas (ABG) of a client who is mechanicallly ventilated. The
ABG results are pH- 7.52; paCO2- 30 mmHg; HCO3- 28 mEq/liter. How should the nurse interpret this
blood gas?
A. Respiratory acidosis.
A. Respiratory alkalosis. Correct
A. Metabolic acidosis.
A. Metabolic alkalosis.
The normal arterial blood gas (ABG) levels are pH: 7.35-7.45; paCO2: 35-45 mmHg; HCO3: 22-26 mEq/liter. In
respiratory alkalosis, the pH and HCO3 is increased and the CO2 is decreased.
Awarded 1.0 points out of 1.0 possible points.
5. 5.ID: 20120683606
The nurse is analyzing an arterial blood gas of a client who is mechanical ventilated. The ABG results
are pH- 7.42; paCO 2- 50 mmHg; HCO 3- 30mEq/liter. How should the nurse interpret this blood gas?
A. Fully compensated respiratory acidosis. Correct
A. Fully compensated respiratory alkalosis.
A. Fully compensated metabolic acidosis.
A. Fully compensated metabolic alkalosis.
The normal arterial blood gas (ABG) levels are pH: 7.35-7.45; paCO2: 35-45 mmHg; HCO3: 22-26 mEq/liter. In fully
compensated respiratory acidosis the pH is within normal limits because compensation has occurred. In
compensation, the opposite of the disorder compensates to bring the pH to normal range. In this case, the HCO 3 is
elevated to compensate for the paCO2.
Awarded 1.0 points out of 1.0 possible points.
6. 6.ID: 20120683604
The nurse is caring for a client in the intensive care unit (ICU) with type 1 diabetes mellitus who has a
blood glucose level of 600 mg/dL (33.3 mmol/L). Which clinical manifestation is most important for
the nurse to report to the healthcare provider if the blood sugar continues to rise?
A. Change in level of consciousness. Correct
A. Increase in urinary output.
A. Onset of Kussmaul respirations.
A. Decrease in serum potassium level.
As blood sugar rises (norm 70 to 110 mg/dl or 3.9-6.1 mmol/L SI), a client with hyperglycemia becomes dehydrated
due to excessive urine output that causes a drop in blood volume and cerebral hypoperfusion. A change in the client's
, level of consciousness should be reported to the healthcare provider immediately.
Awarded 1.0 points out of 1.0 possible points.
7. 7.ID: 20120683602
The nurse is caring for a client in the critical care unit who has a pituitary tumor and subsequent
diabetes insipidus (DI). Which finding indicates the need to place the client on seizure precautions?
A. Sodium 155 mEq/L or mmol/L. Correct
A. Arterial pH 7.42.
A. Calcium 9.5 mEq/L (4.75 mmol/L)
A. Potassium 4.9 mEq/L or mmol/L.
Clients with diabetes insipidus (DI) experience increased urinary output due to decreased antidiuretic hormone (ADH),
which may cause dehydration and high serum sodium levels (norm 136 to 145 mEq/L or 136 to 145 mmol/L (SI units).
Hypernatremia places the client at risk for seizures.
Awarded 1.0 points out of 1.0 possible points.
8. 8.ID: 20120683600
A client with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is admitted to the
intensive care unit with a serum sodium level of 112 mEq/L or mmol/L. Which protocol prescription
should the nurse implement first?
A. Obtain serum sodium levels every 4 hours. Correct
A. Provide oral sodium chloride supplements.
A. Monitor fluid restriction and document hourly intake and output.
A. Initiate normal saline IV at 100 mL/hour.
A client diagnosed with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) can experience sodium
levels that are dangerously below the norm range of 136 to 145 mEq/L or 136 to 145 mmol/L (SI units). The first
action is to evaluate the client's serum sodium levels to determine fluid and electrolyte correction with isotonic saline
based on the client's status of hypotonic hyponatremia.
Awarded 1.0 points out of 1.0 possible points.
9. 9.ID: 20120682498
The nurse is caring for a client in the critical care unit who has type 2 diabetes mellitus and is admitted
with hyperglycemic hyperosmolar syndrome (HHS). The health care provider prescribes an insulin drip
of 0.1 unit/kg per hour based on a current blood glucose level of 670 mg/dL (35.3 mmol/L) . Which
intervention should the nurse perform during this infusion?
A. Obtain blood glucose levels hourly. Correct
A. Give potassium chloride 40 mEq per secondary infusion.
A. Infuse Dextrose 5% with 0.45% NaCl (D 5 1/2 NS).
A. Initiate a 2,000 calorie diabetic diet.
Administering an insulin drip for a client with hyperglycemic hyperosmolar syndrome (HHS) should cause blood
glucose levels to drop 50 to 70 mg/dL per hour. The nurse should perform hourly blood glucose monitoring to
evaluate the effectiveness of the insulin drip.
Awarded 1.0 points out of 1.0 possible points.
10.10.ID: 20120682496
The nurse is caring for a client who is demonstrating signs of impending death. The family is
experiencing emotional distress as the client's condition declines. Which information should the nurse
provide the family to facilitate the process?
A. Encourage the family to give the client permission to die. Correct
A. Revoke the "do not resuscitate" advanced directive.
A. Send the family to an area to seek spiritual comfort.
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