Extract:

Question 1 of 5

The nurse caring for a client with severe sepsis suspects the client may be developing disseminated intravascular coagulation (DIC). Which of the following signs and symptoms would support the diagnosis of DIC?

A. sudden onset of chest pain and copious sputumB. foul smelling concentrated urineC. oozing blood from iv sites & previous venipuncture sitesD. reddened, inflamed central line catheter site

Correct Answer: C

Rationale: Oozing blood from IV sites is a classic sign of DIC due to excessive clotting followed by bleeding.

Question 2 of 5

Which of the following would the nurse understand is correct when implementing a primary assessment for clients suffering major trauma? The primary assessment:

A. includes the head-to-toe anterior and posterior assessment.B. priorities are continuing and ongoing but treatment will be deferred if the clients unstablesC. is focused on airway maintenance and ventilation effectiveness.D. focuses on the ABCDs of the client to identify life threatening problems

Correct Answer: D

Rationale: The primary assessment is focused on identifying life-threatening problems using the ABCDs (Airway, Breathing, Circulation, Disability).

Question 3 of 5

The nurse cannot auscultate bowel sounds during the assessment of a client who has had a repair of an abdominal aortic aneurysm four days ago. The client is complaining of severe abdominal pain and the abdomen is distended. What action should the nurse take at this time?

A. Continue to monitor the client as a paralytic ileus is possibleB. Administer the PRN stool softener to the clientC. Obtain an order to insert a nasogastric tube set to low suctionD. Report the assessment findings to the surgeon

Correct Answer: D

Rationale: Absent bowel sounds, severe pain, and distension suggest bowel ischemia, requiring immediate surgical evaluation.

Question 4 of 5

What action priority in preventing anaphylactic shock?

A. Removal of the educating patient to carry an EpipenB. Assess and document for previous allergies and drug reactions prior to medication administrationC. Administer diphenhydramine and solumedrol IV and solumedrol IV at the first sign of allergic symptomsD. Application of red allergy bracelet patient's upper extremity

Correct Answer: B

Rationale: Identifying and documenting allergies before administering medications or treatments helps prevent exposure to known allergens, reducing the risk of anaphylaxis.

Question 5 of 5

The nurse is testing the function of cranial nerve XI (Spinal accessory nerve). Which finding would the nurse expect if the nerve is intact?

A. Follows an object with eyes without nystagmus or strabismusB. Moves the tongue out midline without tremors or deviationC. Moves the head and shoulders against resistance with equal strengthD. Demonstrates full range of the neck

Correct Answer: C

Rationale: Cranial nerve XI controls the sternocleidomastoid and trapezius muscles, enabling head turning and shoulder shrugging against resistance.