A.H. Exam 1 - Practice HESI Questions
The nurse expects that a client with mitral stenosis would demonstrate symptoms associated with congestion in the: a. Aorta b. Right Atrium c. Superior Vena Cava d. Pulmonary circulation
D Rationale: Blood not going through mitral valve means backflow to lungs.
Which is the most important instrument used as a diagnostic and monitoring tool for determining the severity of a shock state? a. Arterial line b. Indwelling urinary catheter c. Electrocardiogram (ECG) monitor d. Pulmonary artery catheter
D Rationale: Gives us volumes and pressures.
When analyzing the rhythm of a patient's electrocardiogram (ECG), the nurse will need to investigate further upon finding a(n): a. Isoelectric ST segment b. PR interval of 0.18 seconds c. Heart rate of 98 d. QRS interval of 0.14 seconds
D Rationale: QRS should be 0.6-0.12
Which interventions will the nurse plan for a comatose patient who is to begin therapeutic hypothermia? (Select all that apply.) a. Assist with endotracheal intubation. b. Insert an indwelling urinary catheter. c. Begin continuous cardiac monitoring. d. Obtain an order to restrain the patient. e. Prepare to give sympathomimetic drugs.
A, B, C
The nurse is caring for a patient whose ABG results reveal the following: pH 7.56, PaCO2 32, HCO3 42, PaO2 90. Which condition will the nurse expect to see in the patient's chart as the underlying cause of these results? a. Gastroenteritis with severe nausea and vomiting b. Widespread tissue ischemia caused by cardiogenic shock c. Respiratory failure caused by pneumonia with pleural effusions d. Hyperventilation after a panic attack
A Rationale: Pt has metabolic alkalosis due to loss of acids and electrolytes.
A patient arrives in the emergency department several hours after taking "25 to 30" acetaminophen (Tylenol) tablets. Which action will the nurse implement? a. Give N-acetylcysteine. b. Discuss the use of chelation therapy. c. Start oxygen using a non-rebreather mask. d. Have the patient drink large amounts of water.
A
A triage nurse in the emergency department assesses a patient who reports 7/10 abdominal pain and states, "I had a temperature of 103.9°F (39.9°C) at home." The nurse's first action would be to: a. assess the patient's current vital signs. b. give acetaminophen (Tylenol) per agency protocol. c. ask the patient to provide a clean-catch urine for urinalysis. d. tell the patient that it will be 1 to 2 hours before seeing a health care provider.
A
After the return of spontaneous circulation (ROSC) following the resuscitation of a patient who had a cardiac arrest, targeted temperature management (TTM) therapeutic hypothermia is ordered. Which action will the nurse include in the plan of care? a. Initiate cooling per protocol. b. Avoid the use of sedative drugs. c. Check mental status every 15 minutes. d. Rewarm if temperature is below 91°F (32.8°C).
A
An asthmatic client is being discharged with a prescription for cromolyn. The nurse determines that teaching is effective when the client states: a. "I should use my inhaler no more than one hour before I exercise. b. "I should use my inhaler whenever I feel an asthma attack coming on." c. "I should stop taking steroids if I need a dose of my inhaler." d. "I should avoid gargling and rinsing my mouth after using my inhaler."
A
An unresponsive older adult is admitted to the emergency department during a summer heat wave. The patient's core temperature is 105.4°F (40.8°C), blood pressure (BP) is 88/50 mm Hg, and pulse is 112 beats/min. The nurse will plan to: a. apply wet sheets and a fan to the patient. b. provide O2 at 2 L/min with a nasal cannula. c. start lactated Ringer's solution at 1000 mL/hr. d. give acetaminophen (Tylenol) rectal suppository.
A
Following an earthquake, patients are triaged by emergency medical personnel and transported to the emergency department. Which patient would the nurse assess first? a. A patient with a red tag b. A patient with a green tag c. A patient with a black tag d. A patient with a yellow tag
A
If the client who was admitted for myocardial infarction (MI) develops cardiogenic shock, which characteristic sign should the nurse expect to observe? a. Oliguria b. Bradycardia c. Elevated blood pressure d. Fever
A
The nurse knows that a 75-year-old client with severe hypertension will experience increased workload of the heart due to which of the following? a. Increased afterload b. Increased cardiac output c. Overload of the heart d. Increased preload
A
The nurse observes a patient going into another patient's room without permission, which upsets the other patient. When responding to the wandering patient's behavior, the nurse should initially: a. Help the patient to the correct room b. Place the patient in restraints temporarily c. Determine the motivation for the patient's behavior d. Share the observation about the patient with the health team
A
The nurse should anticipate that which of the following conditions can place a client at risk for ARDS? a. Septic shock b. COPD c. Asthma d. Heart failure
A
When planning the response to the potential use of smallpox as a biological weapon, the emergency department nurse manager will need to obtain adequate quantities of: a. vaccine b. atropine c. antibiotics d. whole blood
A
Which action would the nurse take first when caring for a patient with a tick bite? a. Use tweezers to remove any remaining ticks. b. Check the vital signs, including temperature. c. Give doxycycline (Vibramycin) 100 mg orally. d. Obtain information about recent outdoor activities.
A
Which class of medications protects the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation? a. Beta-adrenergic blockers b. Calcium channel clockers c. Opioids d. Nitrates
A
After an anterior-wall myocardial infarction (MI), which problem is indicated by auscultation of crackles in the lungs? a. Left-sided heart failure b. Pulmonic valve malfunction c. Right-sided heart failure d. Tricuspid valve malfunction
A Rationale: Crackles suggest backflow of blood into the lungs.
An unresponsive patient is admitted to the emergency department after falling through the ice while ice skating. Which assessment would the nurse obtain first? a. Pulse b. Heart rhythm c. Breath sounds d. Body temperature
A Rationale: Do CAB (rather than ABC) if pt is unresponsive.
Which of the following complications is associated with mechanical ventilation? a. Gastrointestinal hemorrhage b. Immunosuppression c. Increased cardiac output d. Pulmonary emboli
A Rationale: Due to developing stress ulcers.
The nurse is caring for a patient who is admitted to the hospital with diabetic ketoacidosis. Which assessment finding indicates an attempt made by the patient's body to correct the pH? a. The patient's respirations are very deep and rapid b. The patient's urine is dark and concentrated c. The patient's skin is pale, cool, and diaphoretic d. The patient is sleepy and difficult to arouse
A Rationale: Kussmaul's respirations are a hallmark sign of DKA
Which action would the nurse take first for a patient in the emergency department with multiple bee stings to the hands? a. Remove the patient's rings. b. Apply ice packs to both hands. c. Apply calamine lotion to itching areas. d. Give diphenhydramine (Benadryl) 50 mg PO.
A Rationale: Want them removed before swelling develops.
In early return of a spontaneous circulation (ROSC) regarding a patient, the physician orders therapeutic hypothermia. Which of the following are true statements? (Select all that apply) a. Hypothermia decreases mortality rates and improves neurologic outcomes. b. It is important to monitor the patient's cardiac rhythm during hypothermia treatment. c. Hypothermia is implemented for about 24 hours after ROSC . d. A physician will usually administer a sedative with hypothermia treatment. e. The goal core temperature is 89.6 to 93.2 degrees F.
A, B, C, D, E
Which of the following are true about patient falls? (select all that apply) a. May be caused by a stroke or MI b. Fractures are most common result with patients over the age of 65 c. May cause a c-spine fracture d. Normally associated with cholesterol medication administration e. Occur mostly at home with loose rugs
A, B, C, E
Emergency medications for cardiac arrest are: (select all the apply) a. Epinephrine b. Dobutamine c. Amiodarone d. Magnesium hydroxide
A, C
A nurse is assessing a client with heart failure. The nurse should assess the client based on which compensatory mechanisms that are activated in the presence of heart failure? Select all that apply: a. Ventricular hypertrophy b. Parasympathetic nervous stimulation c. Renin-angiotensin-aldosterone system d. Jugular venous distention e. Sympathetic nervous stimulation
A, C, E
What are the appropriate nursing interventions for the patient with delirium in the ICU? (select all that apply) a. Use clocks and calendars to maintain orientation. b. Encourage round-the-clock presence of caregivers at the bedside. c. Sedate the patient with appropriate drugs to protect the patient from harmful behaviors d. Silence all alarms, reduce overhead paging, and avoid conversations around the patient. e. Identify physiologic factors that may be contributing to the patient's confusion and irritability.
A, C, E
A client with acute respiratory distress syndrome (ARDS) has fine crackles at lung bases and the respirations are shallow at a rate of 28 breaths per minute. The client is restless and anxious. In addition to monitoring the arterial blood gas results, the nurse should do which of the following? Select all that apply. a. Monitor serum creatinine and BUN levels b. Administer a sedative c. Keep the head of the bed flat d. Administer humidified oxygen e. Auscultate the lungs
A, D, E
Effective interventions to decrease absorption or increase elimination of an ingested poison include which of the following? (Select all that apply) a. Hemodialysis b. Milk dilution c. Eye irrigation d. Gastric lavage e. Activated charcoal
A, D, E
When assessing an older patient admitted to the emergency department with a broken arm and facial bruises, the nurse observes several additional bruises in various stages of healing. Which statement would the nurse make first? a. "You should not go home." b. "Do you feel safe at home?" c. "Would you like to see a social worker?" d. "I need to report my concerns to the police."
B
Which action is the first priority of care for a client exhibiting signs and symptoms of coronary artery disease? a. Decrease anxiety b. Enhance myocardial oxygenation c. Administer sublingual nitroglycerin d. Educate the client about his symptoms
B
A nurse is preparing a client for cardiac catheterization. Which assessments are most important prior to the procedure? a. Weight and height b. Allergies and kidney function tests c. Apical heart rate and peripheral pulses d. Cardiac rhythm
B
A patient has a core temperature of 90 degrees F (32.2 degrees C). The most appropriate rewarming technique would be: a. Passive rewarming with warm blankets b. Active internal rewarming using warmed IV fluids c. Passive rewarming using air-filled warming blankets d. Active external rewarming by submersing in a warm bath
B
A patient with blunt abdominal trauma from a motor vehicle collision reports increasing abdominal pain. The nurse will plan to prepare the patient for: a. peritoneal lavage. b. focused-abdominal sonography. c. nasogastric (NG) tube placement. d. magnetic resonance imaging (MRI).
B
An ice skater does not follow the rules of the rink and skates on the ice during the cleaning procedure. As the large Zamboni machine crosses the ice, the skater collapses. What is the most likely cause? a. Hydrocarbon exposure b. Carbon monoxide toxicity c. Cyanide inhalation d. Nitrogen narcosis
B
During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient has an unobstructed airway. Which priority action would the nurse take next? a. Palpate extremities for bilateral pulses. b. Observe the patient's respiratory effort. c. Check the patient's level of consciousness. d. Examine the patient for any external bleeding.
B
During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next? a. Palpate extremities for bilateral pulses. b. Observe the patient's respiratory effort. c. Check the patient's level of consciousness. d. Examine the patient for any external bleeding.
B
Family members are in the patient's room when the patient has a cardiac arrest, and the staff start resuscitation measures. Which action would the nurse perform next? a. Keep the family in the room and assign a staff member to explain the care given and answer questions. b. Ask the family members whether they would prefer to remain in the patient's room or wait outside the room. c. Ask the family to wait outside the patient's room with a designated staff member to provide emotional support. d. Tell the family members that patients are comforted by having family members present during resuscitation efforts.
B
Gastric lavage and activated charcoal are ordered for an unconscious patient who is in the emergency department after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action would the nurse perform first? a. Insert a large bore orogastric tube. b. Assist with intubation of the patient. c. Prepare a 60-mL syringe with saline. d. Give first dose of activated charcoal.
B
If a cerebral spinal fluid leak is suspected, the nurse should test nasal drainage for the presence of: a. Nitrites b. Glucose c. Ketones d. Potassium
B
The nurse is initiating an intravenous infusion of Lactated Ringer's (LR) for a client in shock recognizes that the purpose of LR for the client is to: a. Provide dextrose and nutrients to prevent cellular death. b. Increase fluid volume and urinary output. c. Draw water from the cells into the blood vessels. d. Replace electrolytes of sodium, potassium, calcium, and magnesium for cardiac stabilization.
B
The nurse observes a multi-vehicle collision where several people are seriously injured. When a nurse stops at the scene of this accident, the nurse is: a. Given legal immunity by the Good Samaritan Law b. Held responsible for the care provided at the scene c. Meeting the legal trust that accompanies a nursing license d. Immune from prosecution because contract does not exist
B
The priority intervention for a patient with suspected tension pneumothorax is: a. Endotracheal intubation b. Needle thoracentesis c. Two large-bore IV needles d. Covering the wound w/ occlusive dressing
B
Which symptom is one of the earliest signs of cardiogenic shock? a. Cyanosis b. Decreased urine output c. Prescence of S4 d. Altered LOC
D
Which of the following statements is true about human bites? a. Human bites have a decreased risk for cellulitis b. Human bites have the highest rate of infection of all bite injuries c. A patient who has been bitten by another person should receive antibiotics if signs of infection are present d. Human bites rarely cause deep tissue injury
B
While caring for a client who has sustained a myocardial infarction (MI), the nurse notes eight premature ventricular contractions (PVCs) in 1 minute on the cardiac monitor. The client is receiving an I.V. infusion of 5% dextrose in water (D5W) and oxygen at 2 L/minute. The nurse's first course of action should be to: a. Increase the I.V. infusion rate b. Notify the physician promptly c. Increase the oxygen concentration d. Administer a prescribed analgesic
B
The nurse interprets which of the following as an early sign of ARDS in a client at risk? a. Elevated carbon dioxide level. b. Hypoxia not responsive to oxygen therapy. c. Metabolic acidosis. d. Severe, unexplained electrolyte imbalance.
B Rationale: A hallmark sign of ARDS is refractory hypoxemia.
A client is involved in a motor vehicle accident. Upon admission to the emergency department, the client's heart rate was 130 bpm, with shallow respirations of 32 breaths/min, and a blood pressure of 90/60 mmHg. The breath sounds were diminished on the right side, and paradoxical chest-wall movement appears on the right side. A chest X-ray reveals a right pneumothorax with multiple rib fractures. What diagnosis would the nurse anticipate for this client? a. Tension pneumothorax b. Flail chest c. Ruptured diaphragm d. Massive hemothorax
B Rationale: A hallmark sign of flail chest is paradoxical breathing.
Your otherwise healthy post-operative abdominal hysterectomy patient is noted to have a RR of 8/min. while sleeping. An ABG reveals the following: pH 7.31, pCO2 55, pO2 60. Nursing actions for this patient include all of the following except: a. Placement of 02 @ 3L/min. by nasal cannula as per prn order b. Administer narcotic pain medication per prn order c. Stimulate patient and ask patient to take deep breaths d. Notify physician
B Rationale: Don't want to further decrease respiratory status.
A client with ARDS is showing signs of increased dyspnea. The nurse reviews a report of blood gas values that recently arrived, shown below. - pH 7.48 - PaCO2 25 - HCO3 22 - PaO2 95 Which finding should the nurse report to the HCP? a. pH b. PaCO2 c. HCO3 d. PaO2
B Rationale: High pH and low PaCO2 means respiratory alkalosis due to hyperventilation.
A client's rhythm strip shows a regular rhythm with atrial and ventricular rates of 70 beats/minute, a PR interval of 0.24, and a QRS duration of 0.08 second. The nurse interprets this rhythm as: a. Normal sinus rhythm (NSR) b. NSR with 1-degree atrioventricular (AV) block c. Sinus arrhythmia d. Accelerated junctional rhythm
B Rationale: PR interval should be 0.12-0.20 and QRS should be 0.6-0.12
A client with a fat embolism continues to be hypoxic following therapy with positive end-expiratory pressure (PEEP). What is the priority intervention to reduce oxygen demand? a. Administer diuretics b. Administer neuromuscular blockers c. Put the head of the bed flat d. Use bronchodilators
B Rationale: Pt doesn't move therefore decreasing oxygen demand.
You are treating a patient with heat stroke. Place the following nursing intervention in order that you would initiate. a. Place in front of fan b. Remove patient's clothing c. Place wet sheets over patient d. Administer cool IV fluids or gavage with cold water e. Immerse in a cool water bath
B, C, A, E, D
The hemodynamic changes the nurse expects to find after successful initiation of intraaortic balloon pump therapy in a patient with cardiogenic shock include: (select all that apply) a. Decreased SV b. Decreased SVR c. Decreased PAWP d. Increased diastolic BP e. Decreased myocardial oxygen consumption
B, C, D, E
The emergency department nurse is starting therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/VN)? (Select all that apply.) a. Continuously monitor heart rhythm. b. Give acetaminophen (Tylenol) 650 mg. c. Assess neurologic status every 2 hours. d. Place cooling blankets above and below patient. e. Attach rectal temperature probe to cooling blanket control panel.
B, D, E
A 2-year-old child is being monitored after cardiac surgery. Which sign represents a decreased in cardiac output? a. Hypertension b. Increased urine output c. Weak peripheral pulses d. Capillary refill less than 2 seconds
C
A 22-yr-old patient admitted for observation after a drowning accident in a local pool is awake and breathing spontaneously. Which assessment will be most important for the nurse to perform during the observation period? a. Auscultate heart sounds. b. Palpate peripheral pulses. c. Auscultate breath sounds. d. Assess mental orientation.
C
A client has been intubated and placed on a ventilator with positive end-expiratory pressure (PEEP). What is the primary purpose of PEEP? a. Provide more oxygen and less carbon dioxide to the client. b. Open up bronchioles and allow more oxygen to the lungs. c. Open up the collapsed alveoli and help keep them open. d. Add pressure to the lung tissue and improve gas exchange.
C
A client has returned to the medical-surgical unit after a cardiac catheterization. What is the PRIORITY post-procedure nursing assessment for this client? a. Assess the patient's pain level. b. Observe neurologic function every 15 minutes. c. Palpate the site for a possible hematoma. d. Monitor skin warmth and turgor.
C
A client who is being evaluated for myocardial infarction (MI) asks the nurse which diagnostic tool is most commonly used to determine the location of myocardial damage. Which of the following would be the best response by the nurse? a. Cardiac catheterization b. Cardiac enzyme C Electrocardiogram (ECG) d. Echocardiogram
C
A client with a pulmonary embolism has been placed on oxygen therapy. The nurse is reviewing lab work and determines that the therapy is effective when the lab work shows which value? a. PaCO2 greater than 40 mmHg b. PaCOz less than 40 mmHg c. PaO2 greater than 60 mmHg d. PaO2 less than 60 mmHg
C
A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water-seal chest tube drainage system. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation? a. An obstruction is present in the chest tube. b. The client is developing subcutaneous emphysema. c. The chest tube system is functioning properly. d. There is a leak in the chest tube system.
C
A client's arterial blood gas (ABG) results are: pH: 7.16, PaCO2; 80 mm Hg, HCO3 -: 24 mEq/L, SaO2, 81%. Based on these values, this client is showing signs of: a. Metabolic acidosis. b. Metabolic alkalosis. c. Respiratory acidosis. d. Respiratory alkalosis.
C
A client's electrocardiogram (ECG) is showing ST elevation in Leads V2, V3 and V4. Which artery is most likely to be occluded? a. Circumflex artery b. Internal mammary artery c. Left anterior descending artery d. Right coronary artery
C
A client, suspected of having a pulmonary embolism, asks the nurse how a definitive diagnosis is determined. Which test would definitively diagnosis a pulmonary embolism? a. ABG analysis b. Chest X-ray c. Pulmonary angiogram d. Ventilation-perfusion scan
C
A patient comes to the ED in respiratory distress and the nurse identifies the presence of wheezing breath sounds. The nurse understands that wheezing breath sounds occur when: a. Fluid in the lungs b. Sitting in the orthopneic position c. Air moves through narrowed airways d. Pleural surfaces rub against each other
C
A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey, the nurse would: a. obtain laboratory tests. b. auscultate bowel sounds. c. obtain a Glasgow Coma Scale score. d. ask about chronic medical conditions.
C
A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department. The nurse determines that discharge teaching has been effective when the patient makes which statement? a. "I'll take salt tablets when I work outdoors in the summer." b. "I should take two acetaminophens if I start to feel too warm." c. "I need to drink extra fluids when working outside in hot weather." d. "I'll move to a cool environment if I notice that I'm feeling confused."
C
A trauma victim was designated a red status 20 minutes ago related to an amputated arm and massive bleeding. A tourniquet was applied and two liters of normal saline administered. On a secondary assessment, you find the patient alert and oriented times three, speaking in full sentences without confusion and has a capillary refill time (CRT) less than 2 seconds. It is appropriate to: a. Assign the patient a triage status of black related to massive bleeding b. Keep the patient in the red triage status c. Downgrade the patient's triage status to yellow d. Downgrade the patient's triage status to green
C
Captopril (Capoten), an angiotensin-converting enzyme (ACE) inhibitor, may be administered to a client with heart failure because it acts as a: a. Vasopressor b. Volume expander c. Vasodilator d. Potassium-sparing diuretic.
C
The nurse is reviewing the patient's laboratory results. Which result must be communicated to the physician immediately? a. Serum chloride 85 b. Serum sodium 134 c. Serum potassium 6.8 d. Serum magnesium 2.3
C
The nurse monitors the patient with positive pressure mechanical ventilation for: a. Paralytic ileus because pressure on the abdominal contents affects bowel motility. b. Diuresis and sodium depletion because of increased release of atrial natriuretic peptide. c. Signs of cardiovascular insufficiency because pressure in the chest impedes venous return. d. Respiratory acidosis in a patient with COPD because of alveolar hyperventilation and increased PaO2 levels.
C
To establish hemodynamic monitoring for a patient, the nurse zeros the: a. Cardiac output monitoring system to the level of the left ventricle b. Pressure monitoring system to the level of the catheter tip located in the patient. c. Pressure monitoring system to the level of the atrium, identified as the phlebostatic axis d. Pressure monitoring system to the level of the atrium, identified as the midclavicular line.
C
Ventricular Tachycardia is displayed on the cardiac monitor of a client admitted to the telemetry unit. Which should the nurse do first? a. Prepare for immediate cardioversion. b. Begin cardiopulmonary resuscitation (CPR). c. Check for a pulse. d. Prepare for immediate defibrillation.
C
What is the most common complication of a myocardial infarction (MI)? a. Cardiogenic shock b. Heart failure c. Arrhythmias d. Pericarditis
C
Your 36-year-old trauma patient has been diagnosed with a severe liver laceration. Initial vital signs are BP 82/palpation, pulse 126/min, and respirations 34/min. His level of consciousness is "confused." As the ED nurse, you anticipate that volume replacement will include: a. 0.3% NS b. LR c. NS and blood products d. 3% NS
C
A client how has undergone a mitral valve replacement experiences persistent bleeding from the surgical incision during the early postoperative period. Which of the following pharmaceutical agents should the nurse be prepared to administer to this client? a. Vitamin C b. Protamine Sulfate c. Quinidine Sulfate d. Warfarin Sodium
C Rationale: Protamine sulfate is the antidote to heparin.
A patient, with the diagnosis of pneumonia, is transferred from the emergency department to a medical unit at 1630. The patient arrives on a stretcher in the low-Fowler's position. The physician writes the following orders: chest x-ray, sputum for culture and sensitivity, oxygen via nasal cannula at 2 liters per minute, bed rest, regular diet, and ciprofloxacin (Cipro) 400 mg IVPB every 12 hours. In what order should the nurse perform the following activities? a. Administer Cipro b. Order regular diet c. Place in high-Fowler's position d. Obtain vital signs e. Begin oxygen via nasal cannula at 2L/min f. Obtain sputum for culture and sensitivity
C, E, D, F, A, B Rationale: Least invasive options first. ALWAYS get a culture before administering antibiotics.
A 19-yr-old young adult patient is brought to the emergency department with multiple lacerations and tissue avulsion of the left hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. The nurse will anticipate giving: a. tetanus immunoglobulin (TIG) only. b. TIG and tetanus-diphtheria toxoid (Td). c. tetanus-diphtheria toxoid and pertussis vaccine (Tdap) only. d. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap).
D
A 34-year-old female with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/minute, nasal flaring, and use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath sounds. Based on these findings, which action should the nurse take to initiate care of the client? a. Initiate oxygen therapy and reassess the client in 10 minutes. b. Draw blood for an arterial blood gas analysis and send the client for a chest X-ray. c. Encourage the client to relax and breathe slowly through the mouth. d. Administer bronchodilators.
D
A client with angina pectoris has an electrocardiogram (ECG) performed during an episode of chest pain. Which change on the ECG indicated myocardial ischemia? a. Increased QRS duration b. Shortened PR interval c. Pathological Q-wave formation d. T-wave inversion
D
A client's chest tube is to be removed by the physician. Which of the following items should the nurse have ready to be placed directly over the wound when the chest tube is removed? a. Butterfly dressing b. Montgomery strap c. Fine-mesh gauze dressing d. Petroleum gauze dressing
D
A patient arrives in the emergency department after topical exposure to powdered lime at work. Which action would the nurse take first? a. Obtain the patient's vital signs. b. Obtain a baseline complete blood count. c. Decontaminate the patient by showering with water. d. Brush off any visible powder on the skin and clothing.
D
A patient who has deep human bite wounds on the left hand is being treated in the urgent care center. Which action would the nurse implement? a. Assist the provider with suturing the bite wounds. b. Prepare to administer rabies immune globulin (BayRab). c. Keep the wounds dry until the provider can assess them. d. Teach the patient the reason for prophylactic antibiotics.
D
During the primary survey of a patient with severe leg trauma, the nurse assesses that the patient's left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next? a. Send blood to the lab for a complete blood count. b. Assess further for a cause of the decreased circulation. c. Finish the airway, breathing, circulation, disability survey. d. Start normal saline fluid infusion with a large-bore IV line.
D
The emergency department triage nurse is assessing 4 victims involved in a motor vehicle collision. Which patient has the highest priority for treatment? a. A patient with no pedal pulses b. A patient with an open femur fracture c. A patient with bleeding facial lacerations d. A patient with paradoxical chest movement
D
The nurse is caring for a patient who was brought to the ED after overdosing on narcotic pain medication. The patient was found unresponsive with no respirations. Arterial blood gasses were drawn shortly after the patient's arrival to the hospital. Which results will the nurse expect to see? а. pH 7.56, PaС02 32, НСО3 32, Pa02 90 b. pH 7.35, PaCO2 45, НСО3 26, Pa02 70 c. pH 7.45, PaC02 38, HCO3 28, Pa02 80 d. pH 7.27, PaCO2 58, hCO3 24, Pa02 60
D
What is the primary reason for administering morphine to a client with a myocardial infarction? a. To sedate the client b. To decrease the client's pain c. To decrease the client's anxiety d. To decrease oxygen demand on the client's heart
D
When rewarming a patient who arrived in the emergency department with a temperature of 87°F (30.6°C), which finding indicates that the nurse would discontinue active rewarming? a. The patient begins to shiver. b. The BP decreases to 86/42 mm Hg. c. The patient develops atrial fibrillation. d. The core temperature is 94°F (34.4°C).
D
Which client would be considered to be at the highest risk for respiratory failure? a. A client with breast cancer b. A client with cervical sprains c. A client with a fractured hip A client with Guillain-Barre syndrome
D
Which of the following finding would suggest pneumothorax in a trauma victim? a. Pronounced crackles b. Inspiratory wheezing c. Dullness on percussion d. Absent breath sounds.
D
Which of the following nursing diagnoses would be a priority for a client with ARDS? a. Teaching cigarette-smoking cessation. b. Maintaining adequate serum potassium levels. c. Monitoring clients for signs of hypercapnia. Replacing fluids adequately during hypovolemic states.
D
Which of the following nursing interventions would promote effective airway clearance in a client with acute respiratory distress? a. Administering oxygen every 2 hours. b. Turning the client every 4 hours. c. Administering sedatives to promote rest. d. Suctioning if cough is ineffective.
D
Which one of the following assessments would be most appropriate for determining the correct placement of an endotracheal tube in a mechanically ventilated client? a. Assessing the client's skin color. b. Monitoring the respiratory rate. c. Verifying the amount of cuff inflation. d. Auscultating breath sounds bilaterally.
D
