NUR 2755 Multidimensional Care IV
MDC IV – Exam 2
What would the nurse expect to find in a patient with a pneumothorax?
- Decreased heart rates
- Diminished breath sounds
- Decreased respiratory rate
- A sucking sound at the site of injury
Correct Answer:
diminished breath sounds
What is a classic sign of a flail chest?
- Paradoxical chest movement
- Cyanosis
- Hypotension
- Pain with exhalation
Correct Answer:
paradoxical chest movement
A disconnected ET tube from a ventilatory will sound a high alarm on the vent
- True
- False
Correct Answer:
False - a disconnection is a low alarm 1 / 3
To prevent a patient from getting VAP the nurse should include what in her patient's care?
- Perform mouth care q 12 hours
- Suction q 1-2 hours around the clock
- Elevate the head of the bed 30 degrees
- Keep the patient on their left side
Correct Answer:
Elevate the head of the bed 30 degrees
mouth care q 2 hours* suction prn*
A post op patient complains of sudden SOB and pleuritis chest pain. What is the most likely cause?
- Pneumothorax
- Pulmonary emboli
- Heart attack
- Congestive heart failure
Correct Answer:
Pulmonary emboli
Stupor is a sign of respiratory distress
- True
- False
Correct Answer:
False
- / 3
Calculate the TBSA: Burn to half of the front torso, entire right arm, back of
right leg
Correct Answer:
27% half of the front torso (9%) + entire R arm (9%) + back of R leg (9%)
A patient is showing early signs of shock. How should the patient be positioned?
- Head flat with legs elevated
- Elevate HOB 30 degrees
- Prone
- Side-lying
Correct Answer:
Head flat with legs elevated
What finding is a sign of shock after a spinal cord injury?
- Stabbing pain in the extremities
- Apical heart rate 50
- Inspiratory crackles
- Elevated WBC count
Correct Answer:
Apical heart rate 50
One of the biggest risks of neurogenic shock is severe bradycardia
- True
- False
Correct Answer:
True
- / 3