NSG 460 Exam 6 Practice Questions And
All Correct Answers.
The physician has ordered a solumedrol infusion for a pt with a spinal cord injury. Solumedrol
has been shown to be effective in:
A. decreasing cerebral edema
B. preventing stress ulcers
C. decreasing spinal injury spasticity
D. improving motor and sensory functioning - Answer D. improving motor and sensory
functioning
Solumedrol is given within the first 8 hours of injury
A pt with a T6 injury 3 months ago develops facial flushing and a BP of 210/106. After elevating
the HOB, which is the most appropriate nursing action?
A. increase IV fluids
B. assess for a distended bladder
C. apply oxygen at 4L/min
D. notify the physician - Answer B. assess for a distended bladder
When the pt is in neurogenic shock, the nurse will assess for:
A. mental confusion and tachycardia
B. bradycardia and hypotension
C. unilateral pupil dilation and hypotension
D. hypertension and tachypnea - Answer B. bradycardia and hypotension
Which of the following is descriptive of a concussion?
A. venous blood collects in the subdural space
B. petechial hemorrhages cause intermittent amnesia
C. a lesion develops opposite the site of trauma
D. it is a transient neuronal dysfunction - Answer D. it is a transient neuronal dysfunction
,C. spasticity produces joint deformity
D. airway spasm occurs - Answer A. severe vasoconstriction occurs
Your client is transported to the ED after sustaining head, back and chest injuries when he fell
25 ft from a tree. The primary survey has been completed. His BP drops to 80/40, HR is 56, RR is
20. BBS are equal and clear. SaO2 is 99%. This data is most consistent with:
A. neurogenic shock
B. tension pneumothorax
C. hypovolemic shock
D. closed head injury - Answer A. neurogenic shock
A client who sustained a spinal cord injury at the T2 level should be assessed for signs of
autonomic dysrefelxia because:
A. the injury results in loss of the reflex arc
B. there has been a partial transaction of the cord
C. there is a flaccid paralysis of the lower extremities
D. the injury is above the 6th thoracic vertebrae - Answer D. the injury is above he 6th thoracic
vertebrae
A client is admitted to the hospital 24 hrs ago after sustaining blunt trauma. For which early
clinical manifestation of acute respiratory distress syndrome (ARDS) should the nurse monitor
for?
A. crackles throughout lung fields
B. increase in respiratory rate from 18 to 24 breaths/min
C. "white-out" appearance of lungs on chest radiograph
D. cyanosis and pallor - Answer B. increase in respiratory rate from 18 to 24 breaths/min
The nurse is caring for a client who required tube insertion for a pneumothorax. The nurse is
aware that the best test to assess for pneumothorax resolution is:
A. ABG
B. pulse ox
C. CXR
D. breath sounds - Answer C. CXR
,B. transporting pt for angioplasty
C. relieving the tension pneumothorax
D. correcting the internal bleed - Answer C. relieving the tension pneumothorax
Mr. T is admitted to the SICU following an MVC. The initial drainage from a right chest tube
inserted in the ED is 400cc. The following hour the chest tube drains 300cc of blood. Which the
most appropriate action by the nurse?
A. elevate the HOB
B. notify the physician
C. continue to monitor VS
D. "milk" the chest tube - Answer B. notify the physician
>200cc/hr should be reported
Your trauma pt has a spinal cord transection at the T-1 level. The primary nursing concern is:
A. renal status
B. skin integrity
C. GI function
D. cardiovascular status - Answer D. cardiovascular status
(Autonomic dysreflexia)
A pt arrives in the ER. He is tachycardia and hypotensive. He says: "I have a knife in my chest and
I have Beck's triad: muffled heart sounds, JVD and hypotension. I think I have cardiac
tamponade. Do you think that's true?"
A. True
B. False - Answer A. True
54 hours after sustaining deep partial thickness burns to both lower extremities and his
abdomen, the pt's urine output has increased from 1000cc to 2300cc in 24 hrs. His labs are: Na
137, K 4.4, HCT 38%. These finding suggest:
A. beginning of the interstitial to plasma fluid shift
B. circulatory overload
, When admitting the trauma pt with a diagnosis of pelvic fracture to the ICU, the nurse's initial
concerns will focus on:
A. peripheral perfusion
B. respiratory management
C. hemorrhage control
D. mental status change - Answer C. hemorrhage control
A pt with a major burn receives TPN. The primary reason for this is:
A. to insure adequate calories and protein/cholesterol
B. to prevent GI obstruction
C. to correct fluid and electrolyte imbalance
D. to provide supplemental vitamins and minerals - Answer A. to insure adequate calories and
protein/cholesterol
A 72 yo female pedestrian hit by a car is admitted to the ER with bilateral fetal fractures. The
priority nursing concern is:
A. shock
B. infection
C. fat embolism
D. pain - Answer A. shock
A severely burned client is ordered albumin on the second day of hospitalization. The nurse
understands that the rationale for giving albumin is:
A. provides protein to increase serum osmotic pressure
B. provides fluid to prevent dehydration
C. replace clotting factors and prevent bleeding
D. replace hemolyzed RBCs and reduce anemia - Answer A. provides protein to increase serum
osmotic pressure
A 44 yo male is admitted to a burn unit with 2nd and 3rd degree burns on 60% of his body. After
12 hrs, his urine output is 24cc/hr and his ABG is: pH 7.31, PaO2 96 (2L NC), PaCO2 36, HCO 18.
The nurse concludes that:
A. he is in renal failure and metabolic acidosis
All Correct Answers.
The physician has ordered a solumedrol infusion for a pt with a spinal cord injury. Solumedrol
has been shown to be effective in:
A. decreasing cerebral edema
B. preventing stress ulcers
C. decreasing spinal injury spasticity
D. improving motor and sensory functioning - Answer D. improving motor and sensory
functioning
Solumedrol is given within the first 8 hours of injury
A pt with a T6 injury 3 months ago develops facial flushing and a BP of 210/106. After elevating
the HOB, which is the most appropriate nursing action?
A. increase IV fluids
B. assess for a distended bladder
C. apply oxygen at 4L/min
D. notify the physician - Answer B. assess for a distended bladder
When the pt is in neurogenic shock, the nurse will assess for:
A. mental confusion and tachycardia
B. bradycardia and hypotension
C. unilateral pupil dilation and hypotension
D. hypertension and tachypnea - Answer B. bradycardia and hypotension
Which of the following is descriptive of a concussion?
A. venous blood collects in the subdural space
B. petechial hemorrhages cause intermittent amnesia
C. a lesion develops opposite the site of trauma
D. it is a transient neuronal dysfunction - Answer D. it is a transient neuronal dysfunction
,C. spasticity produces joint deformity
D. airway spasm occurs - Answer A. severe vasoconstriction occurs
Your client is transported to the ED after sustaining head, back and chest injuries when he fell
25 ft from a tree. The primary survey has been completed. His BP drops to 80/40, HR is 56, RR is
20. BBS are equal and clear. SaO2 is 99%. This data is most consistent with:
A. neurogenic shock
B. tension pneumothorax
C. hypovolemic shock
D. closed head injury - Answer A. neurogenic shock
A client who sustained a spinal cord injury at the T2 level should be assessed for signs of
autonomic dysrefelxia because:
A. the injury results in loss of the reflex arc
B. there has been a partial transaction of the cord
C. there is a flaccid paralysis of the lower extremities
D. the injury is above the 6th thoracic vertebrae - Answer D. the injury is above he 6th thoracic
vertebrae
A client is admitted to the hospital 24 hrs ago after sustaining blunt trauma. For which early
clinical manifestation of acute respiratory distress syndrome (ARDS) should the nurse monitor
for?
A. crackles throughout lung fields
B. increase in respiratory rate from 18 to 24 breaths/min
C. "white-out" appearance of lungs on chest radiograph
D. cyanosis and pallor - Answer B. increase in respiratory rate from 18 to 24 breaths/min
The nurse is caring for a client who required tube insertion for a pneumothorax. The nurse is
aware that the best test to assess for pneumothorax resolution is:
A. ABG
B. pulse ox
C. CXR
D. breath sounds - Answer C. CXR
,B. transporting pt for angioplasty
C. relieving the tension pneumothorax
D. correcting the internal bleed - Answer C. relieving the tension pneumothorax
Mr. T is admitted to the SICU following an MVC. The initial drainage from a right chest tube
inserted in the ED is 400cc. The following hour the chest tube drains 300cc of blood. Which the
most appropriate action by the nurse?
A. elevate the HOB
B. notify the physician
C. continue to monitor VS
D. "milk" the chest tube - Answer B. notify the physician
>200cc/hr should be reported
Your trauma pt has a spinal cord transection at the T-1 level. The primary nursing concern is:
A. renal status
B. skin integrity
C. GI function
D. cardiovascular status - Answer D. cardiovascular status
(Autonomic dysreflexia)
A pt arrives in the ER. He is tachycardia and hypotensive. He says: "I have a knife in my chest and
I have Beck's triad: muffled heart sounds, JVD and hypotension. I think I have cardiac
tamponade. Do you think that's true?"
A. True
B. False - Answer A. True
54 hours after sustaining deep partial thickness burns to both lower extremities and his
abdomen, the pt's urine output has increased from 1000cc to 2300cc in 24 hrs. His labs are: Na
137, K 4.4, HCT 38%. These finding suggest:
A. beginning of the interstitial to plasma fluid shift
B. circulatory overload
, When admitting the trauma pt with a diagnosis of pelvic fracture to the ICU, the nurse's initial
concerns will focus on:
A. peripheral perfusion
B. respiratory management
C. hemorrhage control
D. mental status change - Answer C. hemorrhage control
A pt with a major burn receives TPN. The primary reason for this is:
A. to insure adequate calories and protein/cholesterol
B. to prevent GI obstruction
C. to correct fluid and electrolyte imbalance
D. to provide supplemental vitamins and minerals - Answer A. to insure adequate calories and
protein/cholesterol
A 72 yo female pedestrian hit by a car is admitted to the ER with bilateral fetal fractures. The
priority nursing concern is:
A. shock
B. infection
C. fat embolism
D. pain - Answer A. shock
A severely burned client is ordered albumin on the second day of hospitalization. The nurse
understands that the rationale for giving albumin is:
A. provides protein to increase serum osmotic pressure
B. provides fluid to prevent dehydration
C. replace clotting factors and prevent bleeding
D. replace hemolyzed RBCs and reduce anemia - Answer A. provides protein to increase serum
osmotic pressure
A 44 yo male is admitted to a burn unit with 2nd and 3rd degree burns on 60% of his body. After
12 hrs, his urine output is 24cc/hr and his ABG is: pH 7.31, PaO2 96 (2L NC), PaCO2 36, HCO 18.
The nurse concludes that:
A. he is in renal failure and metabolic acidosis
