Rasmussen College: NUR 2790/N3 exam 2 practice questions_ LATEST,100% CORRECT

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Rasmussen College: NUR 2790/N3 exam 2 practice questions_ LATEST ▪ A hospital responds to a local mass casualty event. Which action should the nurse supervisor take to prevent staff post-traumatic... stress disorder during a mass casualty event? a. Provide water and healthy snacks for energy throughout the event. b. Schedule 16-hour shifts to allow for greater rest between shifts. c. Encourage counseling upon deactivation of the emergency response plan. d. Assign staff to different roles and units within the medical facility. ▪ A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at a nurse when dinner is served late. How should the nurse respond? a. Do you need something for pain right now? b. Please stop yelling. I brought dinner as soon as I could. c. I suggest that you get control of yourself. d. You seem upset. I have time to talk if you’d like. ▪ A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag? a. Dislocated right hip and an open fracture of the right lower leg b. Large contusion to the forehead and a bloody nose c. Closed fracture of the right clavicle and arm numbness d. Multiple fractured ribs and shortness of breath ▪ An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event? a. Ask ED staff to discharge clients from the medical-surgical units in order to make room for critically injured victims. b. Call additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in. c. Inform the incident commander at the mass casualty scene about how many victims may be handled by the ED. d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims. ▪ The hospital administration arranges for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation? a. You are free to express your feelings; whatever is said here stays here. b. Lets evaluate what went wrong and develop policies for future incidents. c. This session is only for nursing and medical staff, not for ancillary personnel. d. Lets pass around the written policy compliance form for everyone. ▪ A nurse is caring for a client whose wife died in a recent mass casualty accident. The client says, I cant believe that my wife is gone and I am left to raise my children all by myself. How should the nurse respond? a. Please accept my sympathies for your loss. b. I can call the hospital chaplain if you wish. c. You sound anxious about being a single parent. d. At least your children still have you in their lives. ▪ A nurse cares for clients during a community-wide disaster drill. Once of the clients asks, Why are the individuals with black tags not receiving any care? How should the nurse respond? a. To do the greatest good for the greatest number of people, it is necessary to sacrifice some. b. Not everyone will survive a disaster, so it is best to identify those people early and move on. c. In a disaster, extensive resources are not used for one person at the expense of many others. d. With black tags, volunteers can identify those who are dying and can give them comfort care. ▪ A nurse wants to become part of a Disaster Medical Assistance Team (DMAT) but is concerned about maintaining licensure in several different states. Which statement best addresses these concerns? a. Deployed DMAT providers are federal employees, so their licenses are good in all 50 states. b. The government has a program for quick licensure activation wherever you are deployed. c. During a time of crisis, licensure issues would not be the governments priority concern. d. If you are deployed, you will be issued a temporary license in the state in which you are working. ▪ After a hospitals emergency department (ED) has efficiently triaged, treated, and transferred clients from a community disaster to appropriate units, the hospital incident command officer wants to stand down from the emergency plan. Which question should the nursing supervisor ask at this time? a. Are you sure no more victims are coming into the ED? b. Do all areas of the hospital have the supplies and personnel they need? c. Have all ED staff had the chance to eat and rest recently? d. Does the Chief Medical Officer agree this disaster is under control? ▪ A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention should the nurse complete first? a. Provide a calm location for the family to cope and discuss needs. b. Call the hospital chaplain to stay with the family and pray for the deceased. c. Do not allow visiting of the victims until the bodies are prepared. d. Provide privacy for law enforcement to interview the family. ▪ An emergency department charge nurse notes an increase in sick calls and bickering among the staff after a week with multiple trauma incidents. Which action should the nurse take? a. Organize a pizza party for each shift. b. Remind the staff of the facilitys sick-leave policy. c. Arrange for critical incident stress debriefing. d. Talk individually with staff members. ▪ A hospital prepares to receive large numbers of casualties from a community disaster. Which clients should the nurse identify as appropriate for discharge or transfer to another facility? (Select all that apply.) a. Older adult in the medical decision unit for evaluation of chest pain b. Client who had open reduction and internal fixation of a femur fracture 3 days ago c. Client admitted last night with community-acquired pneumonia d. Infant who has a fever of unknown origin e. Client on the medical unit for wound care ▪ A client presents to the emergency department after prolonged exposure to the cold. The client is difficult to arouse and speech is incoherent. Which action should the nurse take first? a. Reposition the client into a prone position. b. Administer warmed intravenous fluids to the client. c. Wrap the clients extremities in warm blankets. ▪ An emergency department nurse cares for a middle-aged mountain climber who is confused and exhibits bizarre behaviors. After administering oxygen, which priority intervention should the nurse implement? a. Administer dexamethasone (Decadron). b. Complete a minimental state examination. c. Prepare the client for computed tomography of the brain. d. Request a psychiatric consult. ▪ An emergency department nurse assesses a client admitted after a lightning strike. Which assessment should the nurse complete first? a. Electrocardiogram (ECG) b. Wound inspection c. Creatinine kinase d. Computed tomography of head ▪ A nurse teaches a community health class about water safety. Which statement by a participant indicates that additional teaching is needed? a. I can go swimming all by myself because I am a certified lifeguard. b. I cannot leave my toddler alone in the bathtub for even a minute. c. I will appoint one adult to supervise the pool at all times during a party. d. I will make sure that there is a phone near my pool in case of an emergency. ▪ A provider prescribes a rewarming bath for a client who presents with partial-thickness frostbite. Which action should the nurse take prior to starting this treatment? a. Administer intravenous morphine. b. Wrap the limb with a compression dressing. c. Massage the frostbitten areas. d. Assess the limb for compartment syndrome. ▪ While on a camping trip, a nurse cares for an adult client who had a drowning incident in a lake and is experiencing agonal breathing with a palpable pulse. Which action should the nurse take first? a. Deliver rescue breaths. b. Wrap the client in dry blankets. c. Assess for signs of bleeding. d. Check for a carotid pulse. ▪ A provider prescribes diazepam (Valium) to a client who was bitten by a black widow spider. The client asks, What is this medication for? How should the nurse respond? a. This medication is an antivenom for this type of bite. b. It will relieve your muscle rigidity and spasms. c. It prevents respiratory difficulty from excessive secretions. d. This medication will prevent respiratory failure. ▪ An emergency department nurse plans care for a client who is admitted with heat stroke. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Administer oxygen via mask or nasal cannula. b. Administer ibuprofen, an antipyretic medication. c. Apply cooling techniques until core body temperature is less than 101 F. d. Infuse 0.9% sodium chloride via a large-bore intravenous cannula. e. Obtain baseline serum electrolytes and cardiac enzymes. ▪ An emergency room nurse is triaging victims of a multi-casualty event. Which client should receive care first? a. A 30-year-old distraught mother holding her crying child b. A 65-year-old conscious male with a head laceration c. A 26-year-old male who has pale, cool, clammy skin d. A 48-year-old with a simple fracture of the lower leg ▪ A nurse is triaging clients in the emergency department (ED). Which client should the nurse prioritize to receive care first? a. A 22-year-old with a painful and swollen right wrist b. A 45-year-old reporting chest pain and diaphoresis c. A 60-year-old reporting difficulty swallowing and nausea d. An 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101 F ▪ A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center? a. Level I Located within remote areas and provides advanced life support within resource capabilities b. Level II Located within community hospitals and provides care to most injured clients c. Level III Located in rural communities and provides only basic care to clients d. Level IV Located in large teaching hospitals and provides a full continuum of trauma care for all clients ▪ Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action should the nurse take first? a. Assess that the client is breathing adequately. b. Insert a large-bore intravenous line. c. Place the client on a cardiac monitor. d. Assess for the best neurologic response. ▪ An emergency department (ED) case manager is consulted for a client who is homeless. Which intervention should the case manager provide? a. Communicate client needs and restrictions to support staff. b. Prescribe low-cost antibiotics to treat community-acquired infection. c. Provide referrals to subsidized community-based health clinics. d. Offer counseling for substance abuse and mental health disorders. ▪ A nurse is triaging clients in the emergency department. Which client should the nurse classify as nonurgent? a. A 44-year-old with chest pain and diaphoresis b. A 50-year-old with chest trauma and absent breath sounds c. A 62-year-old with a simple fracture of the left arm d. A 79-year-old with a temperature of 104 F ▪ An emergency department (ED) nurse is preparing to transfer a client to the trauma intensive care unit. Which information should the nurse include in the nurse-to-nurse hand-off report? (Select all that apply.) a. Mechanism of injury b. Diagnostic test results c. Immunizations d. List of home medications e. Isolation precautions ▪ The complex care provided during an emergency requires interdisciplinary collaboration. Which interdisciplinary team members are paired with the correct responsibilities? (Select all that apply.) a. Psychiatric crisis nurse Interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis b. Forensic nurse examiner Performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources c. Triage nurse Provides basic life support interventions such as oxygen, basic wound care, splinting, spinal immobilization, and monitoring of vital signs d. Emergency medical technician Obtains client histories, collects evidence, and offers counseling and followup care for victims of rape, child abuse, and domestic violence e. Paramedic Provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration ▪ A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next? a. Begin the prescribed infusion via the new access. b. Ensure an x-ray is completed to confirm placement. c. Check medication calculations with a second RN. d. Make sure the solution is appropriate for a central line. ▪ A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first? a. Amount of pressure in fluid container b. Date of catheter tubing change c. Percent of heparin in infusion container d. Presence of an ulnar pulse ▪ A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention? a. The initial site dressing is 3 days old. b. The PICC was inserted 4 weeks ago. c. A securement device is absent. d. Upper extremity swelling is noted. ▪ A nurse assesses a client's peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next? a. Apply cold compresses to the IV site. b. Elevate the extremity on a pillow. c. Flush the catheter with normal saline. d. Stop the infusion of intravenous fluids. ▪ While assessing a client's peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding? a. "Grade 3 phlebitis at IV site" b. "Infection at IV site" c. "Thrombosed area at IV site" d. "Infiltration at IV site" ▪ A nurse responds to an IV pump alarm related to increased pressure. Which action should the nurse take first? a. Check for kinking of the catheter. b. Flush the catheter with a thrombolytic enzyme. c. Get a new infusion pump. d. Remove the IV catheter. ▪ A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action should the nurse take to protect the client's skin during this procedure? a. Lower the extremity below the level of the heart. b. Apply warm compresses to the extremity. c. Tap the skin lightly and avoid slapping. d. Place a washcloth between the skin and tourniquet. ▪ A nurse delegates care to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene for a client who has a vascular access device? a. "Provide a bed bath instead of letting the client take a shower." b. "Use sterile technique when changing the dressing." c. "Disconnect the intravenous fluid tubing prior to the client's bath." d. "Use a plastic bag to cover the extremity with the device." ▪ A nurse teaches a client who is prescribed a central vascular access device. Which statement should the nurse include in this client's teaching? a. "You will need to wear a sling on your arm while the device is in place." b. "There is no risk of infection because sterile technique will be used during insertion." c. "Ask all providers to vigorously clean the connections prior to accessing the device." d. "You will not be able to take a bath with this vascular access device." ▪ A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, which action should the nurse take to relieve pain? a. Administer topical lidocaine to the site. b. Place warm compresses on the site. c. Administer prescribed oral pain medication. d. Massage the site with scented oils. ▪ When assessing a client's peripheral IV site, the nurse notices edema and tenderness above the site. What action does the nurse take first? Stop the infusion of IV fluids. 1. ED nurse assesses a rape victim. Who to collaborate with? Forensic nurse examiner. Can offer counseling, collect evidence, and follow up. 6. A client who has experienced a burn is in the emergent phase of treatment that usually occurs during which of the following periods? 24 to 48 hours 7. A client is beginning the initial treatment of a major burn in the emergency room. Which of the following interventions would NOT be completed? Giving oral medications for pain management 8. The formula used to calculate the volume of IV fluid required for fluid resuscitation of a client receiving care in the first 24 hours after a burn is 2 to 4 mL of lactated Ringer's solution x weight(KG) x burn % Parkland Formula 9. A client is being evaluated in the emergency department following a burn injury at home. The client has second and third degree burns to the right and left arms, back, and both posterior legs. Using the rule of nines, the nurse would calculate the client's burn as being: 54% 10. The nurse is assessing a client diagnosed with second and third degree burns. Which of the following assessment signs would NOT need to be reported by the nurse? Urine output of 30 mL in the first hour 11. The nurse is initiating care for a client diagnosed with burns to the chest, back, neck, and face. For this client, which of the following nursing diagnoses would receive the highest priority? Ineffective airway clearance 12. A client is recovering from a skin graft to her right arm. Which of following nursing interventions would not be indicated for this client? Encourage exercise of the right arm 13. A client diagnosed with major burn is being prescribed medication for pain. The nurse realized that the drug of choice for this client will be? morphine sulfate 14. The goals of management during the emergent period after a burn include which of the following? (Select all that apply) -Airway management -Aseptic Technique -Emotional Support -Fluid Replacement -Pain Management 15. An individual's sleeve catches on fire while cooking. He runs through the kitchen and out the back door. Which of the following interventions should the family perform? (select all that apply) -Remove any loose debris -Remove jewelry -Use water hose to cool the burn -Cover the burned areas with a clean dry material 16. The nurse is determining if a client who sustained a burn should be referred to a burn unit for care. Which of the following types of burn injuries should be referred to this type of care area? (select all that apply) -Burn of the face -Burn to the genitalia -Burn to a fractured limb -Burn caused by chemicals 17. The nurse is preparing to provide wound care to a client newly diagnosed with a burn. Which of the following are goals of this initial wound care? (select all that apply) -Cleanse the skin -Prevent further skin destruction -Provide comfort -Prevent Infection 18. The nurse in the emergency department is using a triage system because this system ranks clients by: Severity of illness or injury 19. In the event of a mass casualty situation, the best triage nurse is: The RN with the most experience and best assessment skills 20. The nurse, triaging victims of a mass casualty incident, will focus attention on the victims who are color coded as: RED 21. The emergency room nurse is utilizing a triage approach for a mass casualty incident that is different from traditional triage. The difference between these two triage approaches is that: mass casualty is most likely to survive first, traditional is most critical first 22. The emergency department nurse is preparing to triage victims of an internal event. Which of the following would be considered an internal event? Fire in the hospital 23. The nurse is a member of the emergency preparedness committee, and she learns that anthrax is a bio-terrorism threat that could infect and kill large numbers of people. Because of this, the organization should have which of the following on stock to treat anthrax? IV or Oral ciprofloxacin 24. Victims of a chemical spill are brought to the hospital for treatment. The nurse learns that 50 victims will be arriving within the hour. When preparing for these victims, the nurse should ensure that which of the following is available? A large area to decontaminate the victims 25. The nurse is preparing to assess a client who was a victim of a blast injury. Prior to assessing the client, which are the mechanisms of a blast injury that the nurse will review? -Primary -Secondary -Tertiary -Quaternary 26. The nurse believes a client is experiencing a reaction to a traumatic event when which of the following is assessed? -Client is not responding verbally to assessment questions -Client complains of dizziness -Client complains of nausea -Client asks for medication for a headache 27. The nurse is concerned about developing post-traumatic stress disorder after working for several years in the ED. Which of the following should the nurse do to ensure this disorder does not manifest? -Eat a well-balanced diet -Drink Water -Limit Caffeine -Limit Sugar Intake -Exercise at least 4 times a week for 30 minutes 28. The nurse determines that a client's cardiac output is normal. Which of the following values would be considered normal? 6 L/min 4-8 L/min is normal 29. The nurse is caring for a client who is experiencing an increase in cardiac contractility. Which of the following will decrease contractility and reduce myocardial oxygen demand for this client? Administer beta-blocker as prescribed 30. A client is prescribed a vasoactive IV medication to maintain a normal blood pressure. Which of the following is not a vasoactive medication? Amiodarone 31. A client is diagnosed with increased ICP. Which of the following interventions can be used to reduce this pressure? Administer Mannitol 32. A client who has an endotracheal tube is being considered for a tracheostomy. Which of the following criteria would support the placement of a trach in this client? Client is unable to maintain airway when extubated 33. A client who is being mechanically ventilated has positive and expiratory pressure set at 20 cm of water. Which of the following should the nurse assess in this client? Pneumothorax 34. The nurse, planning care for a client who is mechanically ventilated, would plan to administer medication to prevent the onset of which of the following complications? stress ulcers 35. A client has been participating in weaning from the ventilator for several days. Which of the following should be done to assist this client to regain strength? Provide full ventilatory support during overnight hours. 36. Which of the following nursing interventions would be appropriate for a client who has has an endotracheal tube removed? Provide oral care immediately after extubation 37. A client's pulmonary artery wedge pressure is 1mmHg. Which of the following health problems can cause this low pressure? (Select all that apply) -Dehydration -Hemorrhage -Hypovalemia 38. Which of the following interventions would be appropriate for a client who is being mechanically ventilated? (select all that apply) -Secure artificial airway -Auscultate lungs every 4 hours as needed -Monitor endotracheal tube cuff pressure once per shift -Provide alternative form of communication -Monitor arterial blood gas analysis results and adjust ventilator as needed 39. A client is diagnosed with fractured ribs. Which of the following should the nurse instruct this patient? Splint the rib cage when deep breathing and coughing 40. A client is prescribed a diuretic for treatment of pulmonary hypertension. Which of the following should the nurse instruct the client regarding this medication? 41. This medication reduces the amount of water in the body 42. The nurse is assessing a client experiencing manifestations of cor pulmonale. Which of the following will the nurse most likely assess in this client? Hoarseness 43. The nurse, planning care for a client diagnosed with a pneumothorax, Identifies which type of pneumothorax? (select all that apply) -Spontaneous -traumatic -tension -latrogenic 44. Which of these instructions are for a client diagnosed with a pneumothorax? (select all that apply) -Remove air from the pleural space -Correct acid-base imbalances -Minimize damage -Re-expand the lung 45. A client is experiencing an alteration in heart rate. The nurse realizes the client is experiencing a disorder of which part of the heart? Sinoatrial node 46. A client is suspected of having cardiac damage. The nurse realized that which of the following diagnostic tests is most commonly used to help diagnose this client's possible cardiac damage or disease? 12-lead electrocardiogram 47. The nurse is analyzing a client's ECG tracing. Which of the following complexes is NOT normally seen on an ECG tracing? The U wave 48. A client is unresponsive and has no pulse. The nurse notes that the ECG tracing shows continuous large and bizarre QRS complexes measured greater than 0.12 each. This rhythm is identified as Ventricular Tachycardia 49. An elderly client is demonstrating a change in heart rate that occurs with respiration. When planning care for the client, the nurse knows that treatment may include: pacemaker insertion 50. A clients ECG tracing shows a sawtooth pattern with F waves. The nurse realized this client is demonstrating? atrial flutter 51. Which of the following should the nurse instruct a client who has been diagnosed with an arrhythmia? How to take his own pulse 52. A client is diagnosed with supraventricular tachycardia. The nurse should prepare to administer which of the following meds? Adenosine 53. A client is recovering from insertion of a pacemaker to pace the activity of the ventricles. At which point on the ECG tracing will the nurse assess pacer spikes? Before the QRS 54. A client with a heart rate of 40 who is experiencing shortness of breath and nausea is diagnosed with second degree av-block, type II. Which of the following will be included int his clients treatment? (select all that apply) -Administer atropine sulfate -Insert external pacemaker 55. A client's ECG rhythm strip is a straight line. Which of the following should the nurse do to help the client? (Select all that apply) -assess for loose leads -assess for power to the monitor -assess the strop for possible fine ventricular fibrillation -begin cardiopulmonary resuscitation once verified the client has no pulse 56. The nurse is assessing a client who is diagnosed with pulse-less electrical activity. Which of the following will the nurse include in this assessment? (select all that apply) -hypovalemia -hypoxia -hypothermia -tamponade -thrombosis 57. Which of the following should be implemented to ensure the safe use of a defibrillator? (select all that apply) -do not place over monitoring electrodes -do not place over an implanted pacemaker 58. An emergency room nurse assesses a client who has been raped. Which health care team member should the nurse collaborate when planning this clients care? forensic nurse examiner 59. The ED team is performing cardiopulmonary resuscitation on a client when the clients spouse arrives at the ED. What action should the nurse take first? Ask the spouse if he wishes to be present during resuscitation 60. An ER nurse is triaging victims of a multi casualty event. Which client should receive care first? a 26-year old male who has pale, cool, clammy extremities 61. While triaging clients in a crowded ED, a nurse assesses a client who presents with symptoms of TB. Which action should the nurse take first? Transfer the client to a negative pressure room 62. A nurse triaging client in the ED. Which client should the nurse prioritize to receive care first? a 45-year old reporting chest pain and diaphoresis 63. A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center? Level II, located within a community hospital and provides care to most injured clients 64. Emergency medical technicians arrive at the ED with an unresponsive client who has an oxygen mask in place. Which action should the nurse take first? Assess that the client is breathing adequately 65. A trauma center with multiple open wounds is brought to the ED in cardiac arrest. Which action should the nurse take prior to providing advance cardiac life support? Don personal protective equipment 66. A nurse is triaging clients in the ED. Which client should be considered urgent but not emergent? a 75-year old female with a cough and a temp of 102 67. An ED nurse is caring for a client who has died from a suspected homicide. Which action should the nurse take? Communicate the clients death to the family in a simple and concrete manner 68. An ED nurse case manage is consulted for a client who is homeless. Which intervention should the case manager provide? Provide referrals to subsidized community-based health clinics 69. An ED nurse is caring for a client who is homeless. Which action should the nurse take to gain the clients trust? Listen to the clients concerns and needs 70. A nurse is triaging clients in the ED. Which client should the nurse classify as nonurgent? A 62-year old with a simple fracture of the left arm 71. A nurse is caring for clients in a busy ED. Which actions should the nurse take to ensure client and staff safety? (Select all the Apply) -Use two identifiers before each intervention and before medication administration -Attempt De-escalation strategies for clients who demonstrate aggressive behaviors. -Search the belongings of clients with altered mental status to gain essential medical information 72. AN Ed nurse is preparing to transfer a client to the trauma ICU. Which info should the nurse include in the nurse-to-nurse hand off report? (select all that apply) -mechanisms of injury -diagnostic test results -Isolation precautions 73. An ER nurse is caring for a trauma client. What interventions should the nurse perform during the primary survey? (select all that apply) -Needle decompression -Initiating IV fluids -Endotracheal intubation -Removing wet clothing 74. A nurse prepared to discharge an older adult client home from the ED. Which actions should the nurse take to prevent future ED visits? (select all that apply) -Screen for depression and suicide -Complete a functional assessment 75. A hospital responds to a local mass casualty event. Which action should the nurse supervisor take to prevent staff post-traumatic stress disorder during a mass casualty event? Provide water and healthy snacks for energy throughout the event 76. A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at a nurse when dinner is served late. How should the nurse respond? you seem upset. I have time to talk if you'd like. 77. A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag? Multiple fractured ribs and shortness of breath 78. An ED charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during this event? Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims. 79. The hospital administration arranges for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation? You are free to express your feelings; whatever is said here stays here 80. A nurse is caring for a client whose wife died in a recent mass casualty accident. The client says, I can't believe my wife is gone and I am left to raise my children all by myself. How should the nurse respond? You sound anxious about being a single parent 81. A nurse cares for clients during a community-wide disaster drill. One of the clients asks, Why are the individuals with black tags not receiving any care? How should the nurse respond? 84. 85.A client diagnosed with a-fib will most likely be placed on which two long term medications Cardizem and anticoagulant 86.A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? (Select all that apply.) A 35-year-old female with severe chest pain: red tag A 60-year-old male with an open fracture with distal pulses: yellow tag 1. An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event? Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims. 2. The hospital administration arranges for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation? You are free to express your feelings; whatever is said here stays here. 3. A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? (SATA.) A 35-year-old female with severe chest pain: red tag A 60-year-old male with an open fracture with distal pulses: yellow tag 4. A hospital prepares for a mass casualty event. Which functions are correctly paired with the personnel role? (Select allthat apply.) Hospital incident commander Assumes overall leadership for implementing the emergency plan Triage officer Rapidly evaluates each client to determine priorities for treatment 5. The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client? Wash your hands upon entering the patient’s room. 6. The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by auto-contamination? Change gloves between wound care on different parts of client’s body. 7. A nurse cares for a client who has facial burns. The client asks, Will I ever look the same? How should the nurse respond? You won’t look exactly the same but cosmetic surgery will help. 8. The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury? It’s normal to feel some depression 9. A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, “Why am I taking this medication?” How should the nurse respond? It helps prevent stomach ulcers, which are common after burns 10. A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The clients urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question? Administer Furosemide (Lasix) 40mg IV push 11. A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately? Serum potassium 6.5 12. A nurse cares for a client who has burn injuries. The client’s wife asks, when will his high risk for infection decrease? How should the nurse respond? When all of his burns have closed 13. A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the clients pain? Administer the prescribed IV morphine sulfate 14. A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take? Gather appropriate equipment and prepare for an emergency airway 15. A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the clients body that sustained burns? 27% 16. A nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication? Urine output of 20mL/hr 17. A nurse reviews the following data in the chart of a client with burn injuries: Admission Note: 36-year-old female with bilateral leg burns NKDA-Health history of asthma and seasonal allergies. Wound Assessment: Bilateral leg burns present with a white and leather-like appearance. No blisters or bleeding present. Client rates pain 2/10 on a scale of 0- 10. Based on the data provided, how should the nurse categorize this clients injuries? Full Thick-ness 18. A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (SATA) Administer analgesics, prevent wound infection, provide fluid replacement 19. A nurse cares for a client with burn injuries who is experiencing anxiety and pain. Which non-pharmacologic comfort measures should the nurse implement? (SATA) music as a distraction tactile stimulation increasing client control 20. A nurse plans care for a client with burn injuries. Which interventions should the nurse implement to prevent infection in the client? (SATA) Ask all family members and visitors to perform hand hygiene before touching client carefully monitor burn wounds when providing each dressing change using aseptic technique and wear gloves when performing wound care 21. An emergency room nurse cares for a client admitted with a 50% burn injury at 10:00 this morning. The client weighs 90 kg. Using the Parkland formula, calculate the rate at which the nurse should infuse intravenous fluid resuscitation when started at noon. (Record your answer using a whole number.) 1500mL/hr. Parkland formula: 4 mL/ 90 / 50% BSA = 18,000 mL first 24 hours post burn. Half- first 8 hours after injury, 2nd half during the next 16 hours. This client was burned at 10:00 AM, and fluid was not started until noon. Therefore, 9000 mL must be infused over the next 6 hours at a rate of 1500 mL/hr to meet the criteria of receiving half the calculated dose during the first 8 post burn hours. 22. An emergency room nurse implements fluid replacement for a client with severe burn injuries. The provider prescribes a liter of 0.9% normal saline to infuse over 1 hour and 30 minutes via gravity tubing with a drip factor of 30 drops/mL. At what rate should the nurse administer the infusion? (Record your answer using a whole number and rounding to the nearest drop.) 333 drops/min 1000 mL divided by 90 minutes, then multiplied by 30 drops, equals 333 drops/min. 23. A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood Pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority? Notify Rapid Response Team 24. A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the client’s oxygen saturation has not significantly improved. What response by the nurse is best? Blood clot interferes with perfusion in lungs 25. A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred? Platelet count: 82,000/L 26. An intubated client’s oxygen saturation has dropped to 88%. What action by the nurse takes priority? Listen to Client’s lung sounds 27. A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)? Provide frequent oral care per protocol 28. A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate? Assess cause of agitation 29. A client is on mechanical ventilation and the clients spouse wonders why ranitidine (Zantac) is needed since the client only has lung problems. What response by the nurse is best? It’ll prevent ulcers from the stress of mechanical ventilation 30. A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority? Ensure patent airway 31. A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication? Large chef salads and muffin 32. A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management? Strict vegetarian 33. A student nurse asks for an explanation of refractory hypoxemia. What answer by the nurse instructor is best? It is hypoxemia that persists even with 100% oxygen administration. 34. A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (SATA). Client with a new spinal cord injury on a rotating bed Older client who is 1-day post hip replacement surgery Young obese client with a fractured femur 35. The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.) Adherence to proper hand hygiene administering anti-ulcer medication elevating the head of the bed providing oral care per protocol 36. A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this Client? (Select all that apply.) Allow visitors at the client’s bedside. Ensure the client can communicate if awake. Provide back and hand massages when turning. Turn the client every 2 hours or more. 37. A nurse assesses a client’s EKG tracing and observes that not all QRS complexes are preceded by a P wave. How should the nurse interpret this observation? Ventricular and atrial depolarizations are initiated from different sites. 38. A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition? Speech alterations 39. A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this clients medication administration record to prevent a common complication of this condition? Warfarin (Coumadin) 40. A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next? Level of consciousness 41. A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the client’s electrocardiogram. Which action should the nurse take next? Assess vital signs and level of consciousness. 42. A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client? Ensure that everyone is clear of contact with the client and the bed. 43. The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, why do you want to know if I use cocaine? How should the nurse respond? Clients who use cocaine are at risk for fatal dysrhythmias. 44. A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP related to this procedure? Clean the skin and clip hairs if needed. 45. A nurse assesses a client’s electrocardiogram (ECG) and observes the reading shown below: How should the nurse document this clients ECG strip? Sinus rhythm with premature ventricular contractions (PVCs) 46. A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below: Which action should the nurse take first? Assess airway, breathing, and level of consciousness. 47. The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below: After calling for assistance and a defibrillator, which action should the nurse take next? Initiate cardiopulmonary resuscitation (CPR). 48. A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.) Decrease in cardiac output Increase in blood pressure Decrease in urine output 49. An emergency room nurse assesses a client who has been raped. With which health care team member should the nurse collaborate when planning this client’s care? Forensic nurse examiner 50. The emergency department team is performing cardiopulmonary resuscitation on a client when the clients spouse arrives at the emergency department. Which action should the nurse take first? Ask the spouse if he wishes to be present during the resuscitation. 51. An emergency department nurse is caring for a client who has died from a suspected homicide. Which action should the nurse take? Communicate the client’s death to the family in a simple and concrete manner. 52. An emergency department nurse is caring for a client who is homeless. Which action should the nurse take to gain the clients trust? Listen to the clients concerns and needs. A nurse is planning care for a client who has extensive burn injuries and is immunocompromised. Which of the following precautions should the nurse include in the plan of care to prevent a Pseudomonas aeruginosa infection? Avoid placing plants or flowers in the client's room. A nurse is providing discharge instructions to a client who has a partial-thickness burn on the hand. Which of the following instructions should the nurse include? Wrap fingers with individual dressings. A nurse in an emergency department is caring for a client who has full-thickness burns over 20% of their total body surface area. After ensuring a patent airway and administering oxygen, which of the following items should the nurse prepare to administer first? IV fluids The weather center has just issued a hurricane warning. What type of disaster warning does the nurse anticipate will be activated? External disaster An emergency nurse is performing disaster triage following the crash of a 737 jetliner. Which patient does the nurse assign a black tag? 42-year-old with full-thickness burns to torso and extremities An ED nurse informs the charge nurse that he can't sleep or eat after providing care for school shooting victims last week. What is the appropriate charge nurse response? "The occupational nurse can help you explore critical incident stress debriefing options." the nurse is preparing to triage clients at the scene of an airplane crash. which of these clients will the nurse identify as emergent? middle-aged man with third-degree burns over 90% of his body a nurse needs to discharge two medical-surgical clients to make room for two victims of a tornado. which of these clients could be discharged from the unit now? select all that apply. (B) 57-year-old who had bowel resection for cancer 2 days ago (C) 44-year-old who has received 3 days of IV antibiotics for pneumonia Which of the following will the nurse most likely assess in a client diagnosed with a second- degree burn? Pain and blisters 1. A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center? 1. Level I-located within remote areas and provides advanced life support with resource capabilities 2. Level II- located within community hospitals and provides care to most injured clients 3. Level III- located in rural communities and provides only basic care to clients 4. Level IV-located in large teaching hospitals and provides a full continuum of trauma care for all clients 2. A nurse is field-triaging clients after an industrial accident. Which client condition would the nurse triage with a red tag? a. b. c. d. Dislocated right hip and open fracture Large contusion to the forehead and bloody nose Closed fracture of the right clavicle and arm numbness Multiple fractured ribs and shortness of breath 3. An emergency department charge nurse notes and increase in sick calls and bickering among the staff after a week with multiple trauma incidents. What action should the nurse take? 1. Organize a pizza party for each shift 2. Remind the staff of the facility’s sick-leave policy 3. Arrange for critical incident stress debriefing 4. Talk individually with staff members 4. The nurse is concerned about developing post-traumatic stress disorder after working for several years in the emergency department. Which of the following should the nurse do to ensure this disorder does not manifest? (SATA) 1. Eat well-balanced meals 2. Drink water 3. Take breaks when needed 4. Do not work more than 12 hours per day 5. Ingest at least one alcoholic drink every evening 5. A nurse is triaging clients in the emergency department. Which client would the nurse classify as “non-urgent?” 1. A 44-year old with chest pain and diaphoresis 2. A 50-year old with chest trauma and absent breath sounds 3. A 62-year old with a simple fracture of the left arm 4. A 79 year old with a temperature of 104F (40C) 6. A client presents to the Emergency Department with 30% total body surface area (TBSA) burns. The client weighs 176lbs. Use the Parkland Formula (4ml) to calculate the hourly rate for the first 8 hours. a. 600ml/hr b. 1200ml/hr c. 1760ml/hr d. 2670ml/hr 7. A client is being evaluated in the emergency department following burn injury at home. The client has second- and third-degree burns to the right and left arms, back and both posterior legs. Using the rule of nines, the nurse would calculate this client’s burn as being: a. 36% b. 45% c. 54% d. 72% 8. A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support? 1. Assign assistive personnel to keep his room neat and clean 2. Rotate nursing staff so he can have varied interactions 3. Talk with the client during wound care 4. Keep family members aware of his condition 9. You are providing care to Mary a 22-year old female who received burns to much of head and anterior neck. As the nurse, you understand that Mary should be positioned in which of the following positions to prevent contractures of the head and neck? a. Hyperextension with no pillow b. Flexion and promoting side-to-side movement of the head c. Hyperextension with neck brace d. Flexion and supine 10. The nurse is in the emergency department is using a triage system because this system ranks clients by: 1. Severity of illness or injury 2. Body systems involved 3. Name 4. Age 11. Emergent interventions for a client with burns to the face and trunk/arms may include which of the following? (SATA) 1. Inserting an indwelling urinary catheter 2. Intubating the client 3. Oral medications for pain management 4. Starting an intravenous solution of Ringer’s lactate 5. Range of motion exercise to avoid contractures to extremities 12. A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client’s care. The nurse should identify which of the following risks as the priority for assessment and intervention? 1. Airway obstruction 2. Infection 3. Fluid imbalance 4. Paralytic ileus 13. The emergency department nurse is preparing to triage victims of an internal event. Which of the following would be considered an internal event? 1. Bus crash in front of the hospital 2. Train crash 5 miles away 3. Fire in the hospital 4. Explosion in a nearby oil station 14. In the event of a mass casualty situation the best triage nurse is: 1. The recently graduated registered nurse (RN) 2. The licensed vocational nurse (LVN) with 5 years; experience 3. The RN with the most experience and bst assessment skills 4. The recently graduated LVN 15. A client who ignited a rubbish pile with gasoline-sustained burns to his anterior torso, bilateral anterior legs and right anterior arm. Using the rule of nines, what is the total body surface area (TBSA) % of burns? a. 36% b. 45% c. 40.5% d. 31.5% 16. When caring for a client with severe burns, the nurse can expect to administer pain medication via which route? 1. Intramuscular (IM) 2. Intravenous (IV) 3. Oral 4. Subcutaneous 17. A client has sustained a 50% TBSA burns to torso and extremities in a house fire. The main weighs 154ibs (70kg). Using the Parkland formula, how much fluid would this client be given in the first 24 hours? a. 12,000ml b. 14,000ml c. 26,000ml d. 16,000ml 18. A client is receiving a large amount of fluids using the Parkland Formula following burns of 50% TBSA. the nurse knows that signs of fluid overload includes? (SATA) 1. Formation of dependent edema 2. Presence of lung crackles on auscultation 3. Decreased skin turgor 4. Engorged neck veins 5. Loud, brassy cough 19. The nurse is aware that this phase in burn injury began at admission, however it is technically defined when there has been wound closure? 1. Resuscitation phase 2. Acute phase 3. Chronic phase 4. Rehabilitation phase 20. An elderly man was found unresponsive in his home and unable to give a history of any contributing events. The nurse recognizes the man’s skin color of “cherry red” as a sign that he has suffered from? 1. Cardiac arrest 2. Hemorrhagic stroke 3. Carbon monoxide poisoning 4. Cyanide poisoning 21. A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Assess the client for sedation needs 2. Get family permission for restraints 3. Provide frequent oral care per protocol 4. Use nonverbal pain assessment tools 22. A client has sustained circumferential full thickness burns to the left arm. The nurse knows that the fluid buildup under the burns and the eschar can lead to compression of the arterial circulation of the extremity. To restore the blood flow to the extremity which intervention will be necessary? 1. Diuretics 2. Escharectomy 3. Elevate the affected arm higher than the heart 4. Compression garment to the left arm 23. A nurse who is caring for a client who has a deep vein thrombosis and is prescribed continuous IV infusion at 1,200 units/hr. Available is heparin 25,000 units in 500 mL D5W. The nurse should set the IV pump to deliver how many 24 ml/hr 24. Mr. M. is admitted to the hospital with a GI bleed and his physician orders a blood transfusion of packed red blood cells. Order: 1 unit PRBCs (40 ml) IV to infuse over 4 hours. Drop factor: 15gtt/ml. What is the infusion rate in gtt/min? 1. 25 gtt/min 2. 41 gtt/min 3. 43 gtt/min 4. 52 gtt/min 25. A client is on mechanical ventilation and the client’s spouse wonders why ranitidine (Zantac) is needed since the client “only has lung problems.” what response by the nurse is best? 1. “It will increase the motility of the gastrointestinal tract” 2. “It will keep the GI tract functioning normally” 3. “It will prepare the GI tract for enteral feedings” 4. “It will prevent ulcers from the stress of mechanical ventilation” 26. A client is admitted to the ICU with a flair chest and placed on mechanical ventilation. The nurse should monitor for which of the following? 1. Tuberculosis because the client will have prolonged close contact with other individuals 2. Chest tube placement because the lung has collapsed 3. Pneumonia because the client is a high risk for acquiring infection 4. Cor pulmonale because the chest wall is unstable 27. The nurse is caring for a client that has been in a car accident. The nurse notices the client’s chest are movements are paradoxical (inward movement of the thorax wit inspiration with outward movement of the thorax with expiration). The nurse knows this condition is: 1. Tension pneumothorax 2. Pulmonary embolism 3. Flail chest 4. Hemothorax 28. The client has been intubated due to Acute Respiratory Distress Syndrome. Following a chest x-ray for ET tube placement, the tube was readjusted. The client’s abdomen is distended. In order to decompress the abdomen the intervention necessary will be: 1. Place the client on his side 2. Administer pantoprazole (Protonix) 40 mg IV 3. Push on the abdomen 4. Insert a nasogastric tube 29. A nurse in the intensive care unit is providing teaching for a client prior to removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching? 1. “Rest in a side-lying position after the tube is removed” 2. “Use the incentive spirometer every 4 hours after the tube is removed” 3. “Avoid speaking for long periods” 4. “A nurse will monitor your vital signs every 15 minutes in the first hour after the tube is removed” 30. The client sustained a blunt chest trauma and has a life threatening tension pneumothorax. Initial management of a tension pneumothorax. Initial management of a tension pneumothorax is an immediate: 1. Needle thoracostomy 2. Place the client in high fowler’s position 3. Surgery to drain the blood from the pleural space 4. Chest x-ray to determine the extent of the pneumothorax 31. Which of the following interventions are for a client diagnosed with pneumothorax? (SATA) 1. Apply wet to dry dressing on wound 2. Monitor respiratory and circulatory function 3. Assess for tracheal deviation 4. Provide analgesics 5. Insertion of a chest tube 32. The nurse is preparing for which intervention when she gets the code (crash) cart, airway equipment box, calls for the appropriate personnel and sets up suction? 1. Embolectomy 2. Chest tube placement 3. Intubation 4. Thoracostomy 33. A client has just been intubated following cardiac arrest. The nurse knows that inorder to ensure the endotracheal tube (ET) has been placed properly is to: (SATA) 1. Observe for symmetrical chest movement 2. Assess breath sounds bilaterally 3. Check apical pulse for 1 full minute 4. Verify with chest x-ray 5. Assess for extended neck veins 34. A nurse is completing discharge teaching with a client who has a permanent pacemaker. Which of the following statements by the client is correct? 1. “I don't have to check my pulse anymore since I have a pacemaker” 2. “I will call my doctor about prolonged hiccups” 3. “I don't have to tell airport security about my pacemaker” 4. “I will wear a sling for the first 24 hours, then start ROM exercise with left arm” 35. A client with pulmonary embolism will have which of the following interventions? (SATA) 1. IVC (inferior vena cava filter) 2. Embolectomy 3. Chest tube placement 4. Heparin drug therapy 5. Thoracotomy 36. A client is diagnosed with superior ventricular tachycardia, the nurse should prepare to administer which of the following medications? a. Procainamide b. Amiodarone c. Verapamil d. Adenosine 37. A one day post operative client is experiencing a sudden onset of chest pain, SOB, and hemoptysis. Based on history and presenting symptoms, which condition does the nurse expect? 1. STEMI 2. GI bleed 3. Musculoskeletal pain 4. PE 38. The nurse knows this drug will minimize the growth of existing clots and prevent the development of additional clots in the client with pulmonary embolism: a. Alteplase b. Levophed c. Heparin d. Surfactant 39. A 56 year old female presents to the emergency department complaining of lightheadedness and chest palpitations, HR is 100, BP 70/40 the cardiac monitoring shows the following. What is the appropriate treatment? 1. Cardiovert 2. Defibrillate 3. Administer lidocaine IV 4. Administer Nitro IV 40. A client complains of fluttering in his chest, the nurse applies the cardiac monitor and correctly identifies the following rhythm as: 1. Atrial fibrillation 2. Atrial flutter 3. Normal sinus rhythm 4. Sinus tachycardia 41. A client is unresponsive and has no pulse, the nurse notes the electrocardiogram tracing shows continuous larger and bizarre QRS complexes measured greater than 0.12, this rhythm is identified as: 1. Premature ventricular complexes (PVCs) 2. Ventricular fibrillation 3. Ventricular tachycardia 4. Atrial tachycardia 42. A nurse is performing cardiopulmonary resuscitation (CPR) for an adult client who is unresponsive. The nurse should evaluate the client's circulation by palpating which of the following pulses? a. Radial b. Carotid c. Popliteal d. Apical 43. The nurse is caring for a client who is experiencing an increase in cardiac contractility, which of the following will decrease cardiac contractility and reduce myocardial oxygen? 1. Administer pramcit as prescribed 2. Administer digoxin as prescribed 3. Administer beta-blockers as prescribed 4. Administer potassium chloride as prescribe 44. The nurse caring for a client with severe burns, realizes that the clients care will progress through specific periods of treatment EXCEPT: a. Acute b. Resuscitation c. Rehabilitation d. Stabilization 45. The nurse is initiating care for a client diagnosed with burns to chest, back, neck, and face. For this client which following diagnosis would receive the highest priority? 1. Disturbed body image 2. Impaired skin integrity 3. Ineffective airway clearance 4. Risk for infection A client with fluid volume excess will exhibit which of the following signs and symptoms Hypotension Critically ill clients are in a hypermetabolic state. Which intervention will address this issue Parental nutrition Mr. M is admitted to the hospital with a GI bleed and his physician orders a blood transfusion of red packed blood cells order is 1 unit iv to infuse over 4 hrs drop factor 10ggt/ml what is the infusion rate gtt/min 22gtt/min Which one of the following medication may be given to treat a client who is hypertensive and hemodynamically unstable Norepinephrine ANIA the fluid status of a client being treated for a burn during the emergent phase which of the following is the best indicator of adequate fluid resuscitation Urine output of 30 ml/hr When caring for a client with severe burns the nurse can expect to administer pain med via which route IV The icu nurse is CF of a client on a ventilator when the low-pressure alarm goes off the nurses next step is to assess for which of the following Look for a disconnected ventilator tubing or leak Which of the following rhythm will require immediate application of an external pacemaker A sinus bradycardia with blood pressure of 70/30 Strip When caring for a client with a head injury the nurse suspects ICP when the VS indicate Cushing's triad. Which vitals did the nurse observe Widening pulse pressure bradycardia and irregular respiration's Emergent intervention to a client with burn injuries to the face and trunk may include which of the following select all that apply Inserting an indwelling urinary catheter Intubating the client Starting an IV solution of ringer’s lactates When caring for a critically ill client the nurse anticipates giving prophylactic meds to prevent which of the following complications Stress ulcer WCFC with respiratory disease the nurse notices sp02 drops down to 85% when ambulating in the hallway which of the following is the best plan for the nurse Provide supplemental 02 when the client walks and assess for improvement Respiratory distress caused by a wide spread inflammatory response damage to the alveoli and will require intubation is called Acute respiratory distress syndrome (ARDS) A client has been diagnosed with a pulmonary embolism which diagnostics and treatment will the nurse anticipate will be ordered. Select all that apply D-dimer Thrombolytics CT angiogram A nurse is assessing a client with DVT during the assessment the nurse will also assess for which of the following side effects or complication of a DVT Pulmonary embolism Following a motor vehicle collision, a client is diagnosed with a flail chest the nurse will anticipate which intervention. Select all that apply Endotracheal intubation Surgical stabilization of flail segment Administration of humidified 02 Postoperative complications after pacemaker insertion will include which of the following. Select all that apply Pneumothorax Myocardial damage Hematoma at insertion Arrhythmias A client who is being mechanically ventilated has positive end expiratory pressure (peep) set at 20cm of water which of the following should the nurse assess for in this client Pneumothorax A client is being evaluated in the ED following an explosion the client has 2nd and 3rd degree burns to the posterior trunk, arms legs using the rule of 9 the nurse would calculate this clients burns as being 72% During an assessment of a client on a cardiac monitor the nurse observes a change in the client's rhythm identify this rhythm and their appropriate treat strip Ventricular fibrillation Defibrillator A client presents to the ED with 60% total body surface burns the client weighs 176lbs using the parkland formula 4ml to calculate the hourly drip rate for the 1st 8hrs 1200ml/hr 4x80x60=19200/8=1200 A nurse is completing discharge teaching to a client who has a permanent pacemaker in the which of the following statements by the client is correct I will call my dr about prolonged hiccups Mrs. G is admitted to the critical care unit with and an acute MI her physician orders a lidocaine drip via infusion pump order is lidocaine 1 g in 250ml D5W iv to infuse at 4mg/min what is the infusion rate in ml per/min 1ml/min ANIC for client who was admitted 24hrs ago with deep partial thickness and full thickness burns over 40% of his body which of the following are expected findings in this client. Select all that apply Edema Hyperkalemia Hyponatremia Increased hct levels Which lab value is most important to monitor for a client who is receiving heparin for the treatment for pulmonary embolism activated partial thromboplastin time (aptt) Which of the following interventions are used for the client diagnosed with pneumothorax. Select all that apply Monitor respiratory and circulatory function Assess for tracheal deviation Provide analgesic Insertion of a chest tube The nurse is aware that wet sterile dressing maybe applied to which burns An adult with 18% tbsa total body surface area burn Which of the following intervention would be appropriate for a client who just had an endotracheal tube removed Provide oral care immediately after extubation A client who has an endotracheal tube is being considered for a tracheostomy which of the following criteria would support the placement of a tracheostomy in this client Client is unable to maintain airway when extubated A client with a history of copd is diagnosed with pneumonia the nurse applies 2/L nasal cannula as prescribed when the nurse leaves the room a family member increases the flow rate to 15L/min. which complication may occur Apnea A 1 day post op client is experiencing a sudden onset of chest pain sob hemoptysis based on history and presenting symptoms which condition does the nurse suspect Pulmonary embolism A child presents to the ED with a thermo burn to the arm and leg which assessment by the nurse requires immediate action A coughing wheezing A client with a history of dysrhythmias is placed on a cardiac monitor the following rhythm is observed the nurse correctly documents it as which rhythm strip Atrial flutter Which of the following signs and symptoms of client would indicate that a client may have active TB. Select all that apply. Weight loss Hemoptysis Night sweats Which of the following will a nurse most likely diagnose with a second degree partial thickness burn Pain and blisters In order to reduce afterload in a patient with HTN and HF the nurse will administer which IV meds Nitroprusside A client is complaining of dizziness and near syncope the nurse finds the following VS bp 86/40 hr rr 12 cardiac monitor shows this rhythm the nurse anticipates giving which of the following meds strip Atropine The nurse suspects the client has left sided HF when which of the following are assessed a jvd pedal edema elevated central venous pressure Shortness of breath, rails & frothy sputum A client with copd is complaining of severe sob and a productive cough an ABG shows PH- 7.27 PAC02 53 HC03 24 pa02 60 Uncompensated respiratory acidosis A client accidentally touched a live wire and was electrocuted he has full thickness burns to his right hand which intervention is the highest priority Place client on cardiac monitor Care of the client with chemical burns include which of the following intervention Brush off dry chemical from clothing then irrigate contaminated skin A practitioner has just intubated a client who is in respiratory arrest he arrest he assess breath sounds for tube replacement and can only hear breath sounds over the right lung what is the most probable reason for this The endotracheal tube is in the main right stem bronchus The following rhythm is identified on the clients cardiac monitor what is the 1st action the nurse will take Check the client and check the leads A client in the critical care has an arterial line the client is aware that an advantage to having an arterial line includes which of the following Allows ability to provide continuous b/p monitoring A client is admitted to the intensive care unit with flail chest and placed on mechanical ventilator the nurse should monitor for which of the following Pneumonia because the client is a high risk for acquiring an infection A client is being weaned from the vent which setting will give partial support continue to giving ventilation and allow spontaneous breathing AC SIMV CPAP Prevention of a thromboembolism includes which of the following interventions Application of pneumatic compression device Potential consequences of burns may include which of the following. Select all that apply Contractures Hypertropic scaring Newly healed area can be hypersentitive to cold heat and touch A client presents with a glucose of 700 an ABG shows the following results PH 7.30 c02-28 h03 18 this ABG shows this client is in Partially compensated metabolic acidosis A client diagnosed with a-fib will most likely be placed on which 2 long term medications Cortisone & Anticoagulant [Show More]

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