RN Physiological Adaptation 3

Question 1

A patient presents with absent breath sounds on the left, tracheal deviation to the right, and severe respiratory distress. The nurse should prepare for:

Accepted Answer

Emergency needle decompression for tension pneumothorax

Answer

Thoracentesis for pleural effusion

Answer

Oxygen therapy via nasal cannula

Answer

Incentive spirometry

Question 2

Which finding in a burn patient indicates adequate fluid resuscitation during the first 24 hours?

Accepted Answer

Urine output of 0.5–1 mL/kg/hour

Answer

Urine output of 0.1 mL/kg/hour

Answer

Serum sodium of 155 mEq/L

Answer

Heart rate of 130 bpm

Question 3

A patient on mechanical ventilation has a sudden decrease in oxygen saturation and increasing peak airway pressures. The nurse's first action should be:

Accepted Answer

Disconnect from the ventilator and manually ventilate with a bag-valve mask

Answer

Increase the FiO2 on the ventilator

Answer

Call the physician

Answer

Suction the patient

Question 4

A patient with Addison's disease is admitted with hypotension, hyponatremia, and hyperkalemia during a stressful illness. The nurse anticipates:

Accepted Answer

Administration of IV hydrocortisone

Answer

Administration of aldosterone antagonists

Answer

Fluid restriction

Answer

Insulin and glucose infusion

Question 5

Which lab value is the most sensitive early indicator of acute pancreatitis?

Accepted Answer

Elevated serum lipase

Answer

Elevated serum amylase

Answer

Elevated ALT

Answer

Elevated bilirubin

Question 6

A patient with deep partial-thickness burns to 30% TBSA is at highest risk for which complication in the first 24–48 hours?

Accepted Answer

Hypovolemic shock

Answer

Infection and sepsis

Answer

Pulmonary embolism

Answer

Hypertensive crisis