ARDS
client is ventilated with acute respiratory distress syndrome following infection of COVID-19.
Which of the following are priority actions by the nurse? Select all that apply.
A. Placing the client supine
B. Elevating the HOB
C. Frequent oral care
D. Clear liquid diet
E. Flutter valve as needed
B. Elevating the HOB
C. Frequent oral care
The client is admitted with full-thickness and partial-thickness burns to more than 30% of the body. The nurse is concerned with the client’s nutritional status. Which intervention should the nurse implement?
A. Encourage the client’s family to bring favorite foods.
B. Provide a low-fat, low-cholesterol diet for the client.
C. Monitor the client’s weight weekly in the same clothes.
C. Make a referral to the hospital social worker.
A. Encourage the client’s family to bring favorite foods.
he client is diagnosed with a closed head injury and is in a coma. The nurse writes the client problem as “high risk for immobility complications.” Which
intervention would be included in the plan of care?
A. Explain all procedures to the client before performing them.
B. Perform active range-of-motion (ROM) exercises every 4 hours.
C. Turn the client every shift and massage bony prominences.
D. Position the client with the head of the bed elevated at intervals
D. Position the client with the head of the bed elevated at intervals
After successfully losing 1 lb weekly for several months, a patient at the clinic has not lost any weight for the last month. The nurse should first?
A. review the diet and exercise guidelines with the patient.
B. instruct the patient to weigh and record weights weekly.
C. ask the patient whether there have been any changes in exercise or diet patterns.
D. discuss the possibility that the patient has reached a temporary weight loss plateau.
C. ask the patient whether there have been any changes in exercise or diet patterns.
The nurse is teaching a client with hypertrophic cardiomyopathy about physical activities. Which
activity should the nurse advise the client to avoid?
a) Regular exercise
b) Contact sports
c) Deep breathing exercises
d) Swimming
b) Contact sports
A nurse is caring for a client diagnosed with acute respiratory distress syndrome that is being weaned from mechanical ventilation. What sign may indicate the development of dysfunctional ventilatory weaning response in the client?
A) Improving ABG values
B) Increased blood pressure
C) Maintained O2 saturation
D) Decreased respiratory rate
B) Increased blood pressure
The nurse is caring for a client with burns. What is the priority nursing intervention during the
emergent phase of burn injury management?
a) Administering analgesics
b) Initiating fluid resuscitation
c) Applying antibiotic ointment
d) Performing debridemen
b) Initiating fluid resuscitation
A patient arrives at the E.R. with suspected head trauma from an MVA. Which of the
following assessment findings is the highest priority?
a. GCS score of 6
b. 10/10 pain reported in neck
c. 1.5 cm laceration on forehead
d. Pupils sluggish to light
a. GCS score of 6
A 42-year-old female client with a body mass index (BMI) of 35 is scheduled for bariatric surgery. Which of the following nursing interventions is the highest priority in the preoperative care of this client?
A) Providing education about dietary modifications postoperatively.
B) Encouraging the client to begin an exercise regimen immediately.
C) Assessing for obstructive sleep apnea (OSA) and implementing appropriate interventions.
D) Administering medications to assist with weight loss.
C) Assessing for obstructive sleep apnea (OSA) and implementing appropriate interventions.
A nurse is taking care of a patient with severe Dilated Cardiomyopathy that just had a heart transplant surgery, which signs and symptoms should the nurse assess, that can indicate transplant rejection? Select all that apply
a. Hypotension
b. Fatigue
c. Hypertension
d. Increased weight
e. Tachycardia
a. Hypotension
b. Fatigue
d. Increased weight
he nurse is caring for a client with suspected acute respiratory distress syndrome (ARDS). Which symptom of ARDS should the nurse anticipate appearing within 24 to 48 hours following the initial insult?
a. ABG’s varying from normal limits
b. Fluid imbalance
c. Shortness of breath
d. Productive cough with sputum
c. Shortness of breath
A patient who has burns on bilateral arms, legs and chest has become agitated 8 hours after
being admitted to the hospital. Which action should the nurse take first?
a. Stay at the bedside and reassure the patient
b. Assess orientation and level of consciousness
c. Administer the ordered IV morphine sulfate
d. Assess lung sounds and pulse oximetry
d. Assess lung sounds and pulse oximetry
A nurse is caring for a patient with a traumatic brain injury who is exhibiting signs of increased intracranial pressure. Which intervention should the nurse implement first?
A. Administer pain medication
B. Elevate the head of the bed to 30 degrees
C. Encourage deep breathing exercises
D. Administer an osmotic diuret
B. Elevate the head of the bed to 30 degrees
What BMI is considered in the Obese category?
a. 18
b. 23
c. 27
d. 33
D. 33
A nurse is caring for a patient diagnosed with dilated cardiomyopathy. Which
assessment finding would the nurse prioritize?
A. Decreased peripheral edema
B. Increased urine output
C. Irregular heart rhythm
D, Decreased respiratory rate
C. Irregular heart rhythm
The nurse is caring for a client diagnosed with ARDS. Which finding would the nurse anticipate in the arterial blood gas (ABG) analysis?
A) Respiratory alkalosis
B) Metabolic acidosis
C) Respiratory acidosis
D) Metabolic alkalosis
C) Respiratory acidosis
When treating an acute burn, the nurse expects to infuse which fluids?
A: Cold NS
B: Warm LR
C: Warm NS
D: Cold LR
B: Warm LR
A client was treated in the ED for a concussion sustained during football practice.
The nursing student is teaching the family about signs to report to the primary
health care provider if observed at home. The student nurse determines the
family needs further teaching if they report to call about which of the following?
a. Difficulty speaking
b. Vomiting
c. Minor headache
d. One-sided weakness
c. Minor headache
What ethnic population has the highest prevalence of obesity?
a. Hispanic
b. Non-Hispanic Black
c. Non-Hispanic Caucasian
d. Non-Hispanic Asian
b. Non-Hispanic Black
The nurse is working with a patient diagnosed with the initial stages of dilate cardiomyopathy
(DCM). Which goal is appropriate for the ongoing treatment and support of the patient?
a. To eliminate exercise from the lifestyle
b. To begin a medication regimen of beta blockers
c. Implement low sodium dietary modifications
d. Prepare for implantable cardioverter defibrillator
c. Implement low sodium dietary modifications
A 45-year-old female client is admitted to the intensive care unit (ICU) with acute respiratory distress syndrome (ARDS) following a severe chest injury sustained in a motor vehicle accident. The client is receiving mechanical ventilation with
positive end-expiratory pressure (PEEP). The nurse should prioritize which action for this client?
A) Administering intravenous furosemide to reduce pulmonary edema.
B) Providing chest physiotherapy every 4 hours to mobilize secretions.
C) Monitoring arterial blood gases (ABGs) to assess oxygenation status.
D) Initiating continuous enteral feedings to meet nutritional needs
C) Monitoring arterial blood gases (ABGs) to assess oxygenation status.
A 65 kg 45 year old patient presents to the emergency department with burns to the front
and back of his left leg, the back of his torso, the back of his left arm and the back of his
head. How many mL of fluid to you anticipate administering to him in the first 8 hours?
A. 6,213 mL
B. 5,915 mL
C. 11,830 mL
D. 7,544 ml
B. 5,915 mL, B. 18 + 18 + 4.5 + 5 = 45.5 —> 45.5 X 4 X 65 = 11,830 —> 11,830/2 = 5,915
The home health nurse is working with a family of a 10-year -old child who suffered a moderate
traumatic brain injury (TBI). Which information should the nurse provide to the parents to help them
understand the changes that may occur due to this injury? (select all that apply)
A. Requires less sleep
B. No interest in favorite toys
C. Increased lethargy
D. Increased appetite
E. Less communicative
B. No interest in favorite toys
C. Increased lethargy
What are the three most common comorbidities exacerbated by obesity? (select all that
apply)
a) Diabetes mellitus
b) Chronic kidney disease
c) Hypertension
d) Liver Cirrhosis
e) Hyperlipidemia
a) Diabetes mellitus
c) Hypertension
e) Hyperlipidemia
A 50-year-old male client is admitted to the hospital with a diagnosis of dilated
cardiomyopathy. The nurse understands that which of the following medications is
most commonly prescribed to manage symptoms and improve cardiac function in
this client?
A) Spironolactone
B) Lisinopril
C) Digoxin
D) Metoprolol
D) Metoprolol