NUR 2755 Multidimensional Care IV

MDC 4 Exam 2

1. The patient is a 54-year-old male with history of COPD, who was rushed to the 

emergency department with increasing shortness of breath, pyrexia, and a 

productive cough with yellow-green sputum. Measurement of arterial blood gas 

shows pH 7.3, PaCO2 68 mmHg, HCO3 28 mmol/L, and PaO2 60 mmHg. How 

would you interpret this?

- Respiratory acidosis, partially compensated

2. Silver sulfadiazine (Silvadene, Thermazene)

- Watch for allergic reaction causing a drop in white blood cell count.

- Do not use if reaction to sulfonamide has occurred.

- Use on deep partial-thickness or full-thickness wounds.

- Monitor wounds for infection

3. A client with a 3-day history of nausea and vomiting presents to the emergency 

department. The client is hypoventilating and has a respiratory rate of 10 

breaths/min. Arterial blood gases are drawn and the nurse reviews the results, 

expecting to note which of the following?

- An increased pH with an increased HCO3

4. A nurse is caring for a client with diabetic ketoacidosis and documents that the 

client is experiencing Kussmaul respirations. Based on this documentation, which 

of the following did the nurse observe?

- Respirations that are labored and increased in depth and rate

5. A nurse is caring for a client who has a tracheostomy and is receiving 

mechanical ventilation. When the low-pressure alarm on the ventilator sounds, it 

indicates which of the following to the nurse?

- Decreased lung compliance

6. A nurse on a medical-surgical unit is caring for a client who is postoperative 

following a hip replacement surgery. The client reports feeling apprehensive and 

restless. Which of the following findings should the nurse recognize as an 

indication of pulmonary embolism?

- Sudden onset of dyspnea

7. A client comes to the emergency department in severe respiratory distress 

following left-sided blunt chest trauma. The nurse notes absent breath sounds on 

the client's left side and a tracheal shift to the right. For which of the following 

procedures should the nurse prepare the client?

- Chest tube insertion

8. A nurse is caring for a client who is experiencing acute opioid toxicity. Which of 

the following actions should the nurse identify as the priority?

- Ensure an adequate airway

9. A nurse is caring for a client who has chronic obstructive pulmonary disease 

(COPD) and is experiencing shortness of breath. Which of the following actions 

should the nurse perform first?

- Place the client in an upright position

10.A nurse is assessing a client who has pharyngitis. Which of the following findings 

is the nurse's priority to report to the provider?

- Inspiratory stridor