AH3 exam3

The nurse in the emergency department is caring for a group of clients who have experienced poisoning. Which of the following actions by the nurse would be appropriate?

- Preparing a client who ingested an excessive dose of aspirin for hemodialysis (A client who has ingested an excessive dose of aspirin (salicylic acid) may develop severe acidosis. Hemodialysis can help to correct this imbalance.)

The nurse in the emergency department is caring for a client with a wound from a human bite on the hand 12 hours ago. Which of the following prescriptions should the nurse clarify?

- Rabies immune globulin - Sterile dressing

The nurse is caring for a client who was involved in a workplace accident and has a penetrating wound of the chest that led to acute respiratory failure. Which of the following goals of treatment should the care team prioritize when planning this client's care?

- Restoration of adequate gas exchange

The nurse in the emergency department is assessing clients who arrived by ambulance following a bridge collapse. The nurse must recognize that

- Subcutaneous emphysema (rice crispy/bubble wrap) may indicate laryngeal tracheal disruption

The nurse administered NPH insulin to an assigned client at 0700. Which of the following times should the nurse expect the insulin to begin peaking?

- 1100 (NPH insulin peaks between 4 and 12 hours after administration so the nurse should expect the NPH to begin peaking around 1100)

The nurse in the emergency department is receiving a client who is arriving by ambulance after a traumatic accident. The paramedic reports that the client has asymmetric chest wall movement. The nurse demonstrates a correct understanding of this report by taking which of the following actions?

- Palpate the thorax for crepitus/ flail chest

The nurse is assessing a client with a blunt force chest trauma after hitting the handlebars of a bicycle. The nurse suspects the client has a flail chest. Which of the following findings should the nurse expect with a flail chest?

- Paradoxical breathing/ The fractured rib sections pull inward on inspiration and outward on expiration

The nurse is caring for a client who fell at home and is diagnosed with right hip fracture. Which of the following would be most important for the nurse to assess?

- Pedal pulses and capillary refill (neurovascular assessment)

You are planning care for a homeless client who gets admitted with mild hypothermia. What intervention would be most appropriate for rewarming the client?

- Place the client in a warm room with warm blankets

The nurse in the emergency department receives a client who has choked on a piece of food and is unconscious. Abdominal thrusts and suctioning have failed to remove the foreign object, and the physician has determined intubation is impossible due to the obstruction. The nurse should emergently prepare for which of the following procedures?

- Prepare patient for tracheostomy

The nurse in the emergency department is triaging clients. The nurse should first attend to which of the following clients?

- An 18-year-old female client who has severe pelvic and abdominal pain that began 10 hours ago

A nurse is caring for a client with heat stroke. Which actions by the nurse is appropriate to lower client's core temperature? Select all that apply:

- Applying an ice pack to the client's groin and axilla - positioning a large fan so it's blowing on client - covering the client with wet sheets

The nurse in the emergency department has received a 5-year-old client who has flu-like symptoms and an erythematous lesion on the flank that is 8 cm in diameter. It is important for the nurse to ask the client's parent if the child has recently been around which of the following?

- Ask if they have been in wooded area (The child is exhibiting classic manifestations of the early stages of Lyme disease. Lyme disease is caused by a tick bite, and ticks are prevalent in wooded areas.)

The nurse in the emergency department is caring for a client who has a closed lower extremity fracture that has just been realigned and splinted by the physician. Which of the following actions should the nurse take first?

- Check both feet for warmth and color

The nurse has taught a client with diabetes mellitus, type 1 (DM-1) about exercise and glucose control. Which of the following actions by the client would indicate the need for further teaching?

- Client increases daily exercises when ketones are present in the urine (When the client is ketonic, exercise may result in an increase in blood glucose level. Type 1 diabetic clients should be taught to avoid exercise when blood glucose levels exceed 250 mg/dL and have ketosis in urine.)

The nurse is providing care for a client who survived near drowning. Which of the following interventions should be a priority for the nurse to take?

- Correcting hypoxia

The nurse is providing discharge teaching for the parent of an 18-month-old toddler who was brought into the emergency department (ED) after being found face down in the bathtub by the parent. The toddler fully recovered and is ready for discharge. Which of the following information should the nurse include during discharge teaching?

- Do not leave your child unattended in the bathtub

A nurse in the ED is caring for a patient who has Ethylene glycol poisoning (antifreeze). The healthcare provider tells nurse to prepare for activated charcoal administration. What information should the nurse explain to client?

- I will inset a tube through one of your nares that will go into your stomach and absorb the poison

The nurse and a nursing colleague are caring for a client in the emergency department who has frostbite on the feet. The nurse should intervene if the colleague is observed taking which of the following actions?

- Immersing the client's feet in a circulating water bath with a temperature of 120 degrees F Rewarming of areas affected by frostbite is accomplished by immersion in circulating water that is temperature-controlled between 98.6 and 104 degrees Fahrenheit. One hundred twenty degrees is too hot and could cause further tissue damage, so the nurse should intervene if the coworker places the client's feet in a bath of that temperature.

The charge nurse in the emergency department is observing nursing colleagues care for clients who have suffered various traumatic injuries. The charge nurse must intervene if a nursing colleague is observed doing which of the following?

- Inserting an indwelling catheter for a client who has blood in the urinary meatus A nurse should not insert an indwelling catheter for a client with blood present in the urinary meatus because bleeding is a sign of tissue trauma and placement of a catheter might cause further trauma. The nurse should instead make the physician aware of the finding.

The nurse is planning an education conference about administering insulin to clients with diabetes mellitus. Which of the following information should the nurse include in the conference?

- Insulin pens are great alternative with clients with poor vision The nurse should include that insulin pens are a great alternative for client's with poor vision because the client can hear the clicks of the pen as the dose is selected.

The nurse in the emergency department is working to stabilize an unconscious client who has just arrived via ambulance and is suspected to have internal bleeding following a trauma. The nurse anticipates that which of the following would most likely be used for aggressive fluid resuscitation?

- Lactated Ringers

The nurse receives an unconscious client with a c collar applied that arrived by ambulance after an automobile accident. What action is appropriate for the nurse to take while attempting to stabilize the client?

- Lift the lower jaw forward while the client is supine

The nurse in the emergency department is triaging clients who have arrived following a mass casualty incident. The nurse should consider which of the following factors when triaging clients? Select all that apply.

- Nearness to death - Level of resources required

The nurse in the emergency department is caring for a client who has hyperthermia. The client's family member asks why the nurse is placing a urinary catheter. It is appropriate for the nurse to explain that placement of a urinary catheter in the client helps the nurse?

- The catheter is being placed because it helps to monitors for signs of kidney damage

The nurse in the emergency department is stabilizing an unconscious client who was in a car accident. A family member asks why the nurse is inserting a nasogastric tube. The nurse should explain that the purpose is to do which of the following?

- The nasogastric tube prevents stomach fluid from building up and entering the lungs

The nurse in the emergency department is assessing a client who arrived by ambulance following a traumatic injury at a construction site. Which of the following assessment findings should be a priority for the nurse to address?

- Trachea to the left of the midline

Triaging a set of clients who just arrived in the ER, multi car crash, which of the following clients is priority?

- Traumatic amputation in and out of conscious

The nurse in the emergency department attended a staff training about family and intimate partner violence. Which of the following statements by the nurse would indicate a correct understanding of the training?

- ask client if they feel safe at home

The nurse in the emergency department is caring for a client who received gastric lavage for treatment of nonsteroidal anti-inflammatory drug overdose. Which of the following actions by the nurse would be appropriate for monitoring the client for complications from the procedure?

- auscultate the lungs Aspiration is a potential complication of gastric lavage because fluid instilled in the stomach during the procedure can come up the esophagus and enter the trachea and lungs. Signs of aspiration include adventitious lung sounds, so the nurse demonstrates an understanding of potential complications of gastric lavage by auscultating the client's lungs.

55. The nurse provided teaching for a client who is scheduled to have a laparoscopic cholecystectomy. Which of the following statements by the client would indicate a correct understanding of the teaching?

- can shower 24 to 48 hours after the procedure

The nurse is assessing an assigned client with a left fractured femur for complications. Which of the following findings would require immediate action by the nurse?

- cyanosis, decreased PaO2.

The nurse has provided dietary education to a client with gallbladder disease. The nurse should reinforce teaching if the client chose which of the following food choices for a meal?

- fried chicken - green beans - cooked carrots

The nurse is caring for a client with chest trauma after a fall. The nurse should assess for which of the following complications of chest trauma? Select all that apply.

- hypovolemia - cardiac failure - hypoxemia

The nurse in the emergency department is caring for a client with severe hypothermia. It is important for the nurse to monitor the client's

- nurse must monitor cardiac telemetry

The nurse in the emergency room is caring for a client whose serum blood sugar is 821 mg/dL. The nurse should expect the health care provider to prescribe which of the following insulins for intravenous infusion?

- regular insulin because it is the only insulin that is given

Nurse in ED caring for pt with moderate hypothermia. What complications should be monitored for?

- stroke

A nurse is doing triage at a disaster cite of a work place explosion. A conscious 40 year old client has an open leg fracture and minor bruising. What color tag should be applied to this client?

- yellow

The nurse in the emergency department has just received a client who might have been exposed to anthrax. The client is afraid and says, "I know there is no treatment for anthrax exposure." Which of the following would be a correct response by the nurse?

- you can be effectively treated with antibiotic therapy

The nurse is caring for a child with a severe allergic reaction who has a prescription for diphenhydramine 1.25 mg/kg, IV times one. The nurse has 50 mg/mL available. The client ways 79.2 lbs. How many mL should the nurse administer to the client? Do not round your answer. Enter numeric value only.

0.9

The nurse is preparing an education conference about agents of terrorism. Which of the following information should the nurse include in the conference? Select all that apply.

-An explosive accident can result in blast, crush, or penetrating injuries -Atropine can be used to treat nerve agent poisoning - Radioactive dispersal devices include a combination of explosives and radioactive material

The nurse is caring for a client who had a submersion injury and is being treated with mannitol for cerebral edema. The prescription is for 0.5 g/kg as 25% solution, once over 30 min and the client weighs 143 lbs. The nurse has a 25% solution available. How many grams should the nurse administer to the client? Do not round your answer. Enter numeric value only.

32.5g

The nurse is caring for a client who was exposed to inhalation anthrax and is to receive prescribed ciprofloxacin 400 mg, every 12 hours, IV for 60 days. The nurse has 400 mg/200 mL in D5W to be infused over 2 hours. How many mL per hour should the nurse administer? Do not round your answer. Enter numeric value only.

100

A nurse is participating in the planning of a hospitals emergency operations plan. The nurse is aware of the potential for ethical dilemmas during a disaster or other emergency. Ethical dilemmas in these contexts are best addressed by which of the following actions? A) Having an ethical framework in place prior to an emergency B) Allowing staff to provide care anonymously during an emergency C) Assuring staff that they are not legally accountable for care provided during an emergency D) Teaching staff that principles of ethics do not apply in an emergency situation

A

A nurse is caring for a group of clients in the ED. Which of the following interventions will the nurse implement? Select all that apply: a. Administer antibiotics with a puncture wound from a cat b. Tweezers to remove a tick c. Administer rabies from human bite d. Administer rabies post exposure venously e. Needle or fingernail to remove bee sting

a. Administer antibiotics with a puncture wound from a cat b. Tweezers to remove a tick e. Needle or fingernail to remove bee sting

. The nurse is preparing to administer an oral antidiabetic medication that stimulates release of insulin from pancreatic islets which in turn enhances cellular sensitivity to insulin. Which of the following types of oral medication should the nurse be administering? a. Biguanides b. Meglitinides c. Thiazolidinediones d. sulfonylureas

a. Biguanides

The nurse in the emergency department is asked by another nurse about tetanus prophylaxis for clients with unknown vaccination status. The nurse should confirm for the colleague that tetanus prophylaxis is indicated for clients with which of the following? Select all that apply. a. Human bite wound b. Severe frost bite c. Hyperthermia d. Lacerations sustained while gardening e. Dog bite

a. Human bite wound b. Severe frost bite d. Lacerations sustained while gardening e. Dog bite

The nurse in the emergency department has received training about ways to protect oneself from potential violence from clients. Which of the following actions by the nurse would indicate a correct understanding of the training? Select all that apply.

a. Performing activities when cna is also in the room b. Position self between pt. and room door c. Making self-aware of rooms that can be locked

The nurse working in the emergency department is caring for a female client who has a spiral fracture to the right arm and ecchymosis to the right eye. The client's spouse states the client fell at home and the nurse notes the client has multiple ED visits in the last 6 months for other injuries. Which of the following actions would be most appropriate for the nurse to take? Select all that apply. a. Prove information to client about a safe house b. Report findings of abuse to charge nurse c. Attempt to interview client alone d. Ask spouse if he caused the injuries e. Call police to arrest spouse

a. Prove information to client about a safe house b. Report findings of abuse to charge nurse c. Attempt to interview client alone

The nurse in the emergency department is assessing the vaccination status of a client who has a penetrating injury sustained while working with farming equipment. It would be a priority for the nurse to assess whether the client is vaccinated against which of the following? a. Tetanus b. hepatitis A c. herpes zoster d. polio

a. Tetanus

The nurse in the emergency department is providing discharge teaching for a client who arrived with hypothermia. The nurse should include in the teaching that which of the following increases the risk for hypothermia? a. alcohol b. prednisone c. caffeine d. aspirin

a. alcohol

The nurse is planning an education conference about contractility of the heart. Which of the following medications should the nurse include when discussing positive inotropes that improve contractility. Select all that apply. a. epinephrine b. isoproterenol c. dopamine d. diltiazem e. metoprolol

a. epinephrine b. isoproterenol c. dopamine

The nurse is planning an education conference about insulin for clients with diabetes mellitus. Which of the following medications should the nurse include when discussing rapid-acting insulin? Select all that apply. a. lispro b. aspart c. regular d. glulisine e. detemir

a. lispro b. aspart d. glulisine

The nurse is caring for a client who is critically ill and at risk for stress ulcers. Which of the following prescribed medications should the nurse expect from the healthcare provider as prophylactic therapy? Select all that apply. a. misoprostol b. Ranitidine c. famotidine d. cimetidine e. pantoprazole

a. misoprostol e. pantoprazole

The nurse is assessing a client who sustained a blunt injury to the chest wall. Which of the following findings would indicate to the nurse that the client has a pneumothorax? a. A low respiratory rate b. Diminished breath sounds c. The presence of a barrel chest d. A sucking sound at the site of injury

b. Diminished breath sounds

The nurse in the emergency department is caring for a client who arrived by ambulance unconscious and hypotensive following a fall from a second-story balcony. It would be appropriate for the nurse to take which of the following actions? Select all that apply. a. Insert two 22 GAUGE b. Inspect posterior surfaces while log rolling holding head c. IV pain medications d. Packed RBC O- on standby e. Ventilate with 100% oxygen via non-rebreather mask.

b. Inspect posterior surfaces while log rolling holding head d. Packed RBC O- on standby e. Ventilate with 100% oxygen via non-rebreather mask.

The nurse is providing triage at a disaster site of a workplace explosion. A 40-year-old client is burned over 65% of the body; the burns are second- and third-degree burns, but the client is conscious. The nurse should tag the client with which of the following triage colors? a. green b. blue c. yellow d. red

b. blue

The nurse is caring for a client who has signs and symptoms of pulmonary congestion and reports feelings of anxiety. Which of the following prescriptions should the nurse expect from the health care provider? Select all that apply. a. albuterol b. furosemide c. Ceftriaxone d. lorazepam e. diltiazem

b. furosemide d. lorazepam The nurse should expect a diuretic like furosemide and an anti-anxiety medication like lorazepam. Albuterol is a bronchodilator used for relief of bronchospasms not congestion. Ceftriaxone is an antibiotic and diltiazem is a calcium channel blocker.

The nurse is caring for a client on the critical care unit who reports severe sleep disturbance. The nurse should call the health care provider and request a prescription for which of the following to help the client sleep? a. Olanzapine b. risperidone c. temazepam d. diphenhydramine

c. temazepam

The nurse is caring for a client who is alert and having an acute asthma attack. Which of the following prescribed medications should the nurse plan to administer? Select all that apply. a. Fentanyl b. dobutamine c. norepinephrine d. albuterol e. methylprednisolone

d. albuterol e. methylprednisolone