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NUR 213 Final Questions With Complete Solutions
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NUR 213 Final Questions With Complete Solutions
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NUR 213 Final Questions With Complete Solutions. A finding indicating to the nurse that a 22-year-old patient with
respiratory distress is in acute respiratory failure includes a
a. shallow breathing pattern.
b. partial pressure of arterial oxygen (PaO2) of 45 mm Hg.
c. partial pressure of carbon dioxide in arterial gas (PaCO2) of
34 mm Hg.
d. respiratory rate of 32/min. Correct Answers B
Rationale: The PaO2 indicates severe hypoxemia and that the
nurse should take immediate action to correct this problem.
Shallow breathing, rapid respiratory rate, and low PaCO2 can be
caused by other factors, such as anxiety or pain.
8. The wounded victim is unable to walk, respiratory rate is
absent but when airway is repositioned breathing is noted. The
wounded victim is assigned what tag color?
A. Green
B. Red
C. Yellow
D. Black Correct Answers B: Red
A 30 year old female patient has deep partial thickness burns on
the front and back of the right and left leg, front of right arm,
and anterior trunk. The patient weighs 63 kg. Use the Parkland
Burn Formula: What is the flow rate during the FIRST 8 hours
(mL/hr) based on the total you calculated?
,A. 921 mL/hr
B. 938 mL/hr
C. 158 mL/hr
D. 789 mL/hr Correct Answers A: 921 mL/hr
First calculate the total amount of fluid needed with the formula:
Total Amount of LR = 4 mL x BSA % x pt's weight in kg. The
pt's weight 63 kg. BSA percentage: 58.5%...Front and back of
right and left leg (36%), front of right arm (4.5%), anterior trunk
(18%) which equals 58.5%. ......4 x 58.5 x 63 = 14,742
mL......Remember during the FIRST 8 hours 1/2 of the solution
is infused, which will be 14,742 divided by 2 = 7371
mL......Hourly Rate: 7371 divide by 8 equals 921 mL/hr
A 40-year-old patient is diagnosed with end-stage liver disease.
The patient began drinking alcohol heavily at 17 years of age.
Which statement indicates to the nurse that the patient has
alcoholic cirrhosis?
A) "I seem to be sweating profusely all the time."
B) "I've had a lot of abdominal pain and swelling."
C) "I've been experiencing crushing chest pain."
D) "I've had a low-grade fever for several weeks now." Correct
Answers B) "I've had a lot of abdominal pain and swelling."
Rationale: Alcoholic cirrhosis causes metabolic changes in the
liver. It results in fluid buildup and pain in the abdomen caused
by the shunting of blood around the liver and bleeding in the
gastrointestinal tract. Pruritus, not profuse sweating, is a
manifestation of alcoholic cirrhosis and occurs because of severe
jaundice and bile salt deposits on the skin. Crushing chest pain
,and low-grade fever are not manifestations of alcoholic
cirrhosis.
A 58 year old female patient has superficial partial-thickness
burns to the anterior head and neck, front and back of the left
arm, front of the right arm, posterior trunk, front and back of the
right leg, and back of the left leg. Using the Rule of Nines,
calculate the total body surface area percentage that is burned?
A. 63%
B. 81%
C. 72%
D. 54% Correct Answers A.
Anterior head and neck (4.5%), front and back of the left arm
(9%), front of the right arm (4.5%), posterior trunk (18%), front
and back of the right leg (18%), back of the left leg (9%) which
equals 63%.
A catastrophic disaster has occurred 5 miles from the hospital
you are working in. The hospital's disaster plan is activated and
the wounded are brought to the hospital. You're helping triage
the survivors. One of the wounded is able to walk around and
has minor lacerations on the arms, hands, chest, and legs. You
would place what color tag on this survivor?
A. Red
B. Yellow
C. Green
D. Black Correct Answers C
, Green tags are for patients who have MINOR injuries. If the
patient can walk around they are tagged as green. Sometimes
they are referred to as the "walking wounded".
A client admitted to the hospital with a diagnosis of cirrhosis has
massive ascites and difficulty breathing. The nurse performs
which intervention as a priority measure to assist the client with
breathing?
A) Repositions the client from side to side every 2 hours
B) Elevates the head of the bed to 60 degrees
C) Auscultates the lung fields every 4 hours
D) Encourages deep breathing exercises every 2 hours Correct
Answers B) Elevates the head of the bed to 60 degrees
Rationale: Elevating the head of the bed enlists gravity as an aid
in relieving pressure on the diaphragm. The other options are
general measures in the care of a client with ascites, but the
primary measure is the one that relieves diaphragmatic pressure.
A client has an AV fistula in the right upper arm for
hemodialysis treatments. When planning care for this client,
which measure should the nurse implement to promote client
safety?
A) Take blood pressures only on the right side to ensure
accuracy
B) Use the fistula for all venipunctures and IV infusions
C) Ensure that small clamps are attached to the fistula dressing
at all times
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