Exam 2 Evolve Questions

The camp nurse is providing snakebite prevention tips. Which statement by a camper indicates a need for additional education?

"A dead snake is a safe snake." A newly dead or decapitated snake can still inflict a bite for 20 to 60 minutes after death because of persistence of the bite reflex. Statements suggesting that snakes are most active on warm nights, should be transported in sealed containers, and do not make good pets are all true statements and indicate a correct understanding of snakebite prevention.

As a direct result of overcrowding in emergency department (ED) environments, for whom must the emergency department nurse expect to provide care?

"Boarding" or holding inpatient clients ED overcrowding has become a widespread problem, with frequent boarding or holding of admitted clients in the ED because of lack of beds in the hospital. The ED nurse must be adept at providing safe and competent care to clients who are awaiting bed placement. The focus then becomes one of ongoing care (scheduled medications, testing) instead of one-time orders. Although a variety of age groups and cultures; clients with a broad spectrum of illness, issues, and injuries; and uninsured/underinsured clients are seen in the ED, this is not a result of overcrowding.

The nurse is reviewing the record of a client admitted to the nursing unit and notes that the client has a history of Laënnec's cirrhosis. Which question related to the client's history would be most important to ask?

"Do you abuse alcohol?" Rationale: Laënnec's cirrhosis results from long-term alcohol abuse; therefore, the question inquiring about alcohol abuse is most appropriate. Cardiac cirrhosis most commonly is caused by long-term right-sided heart failure. Exposure to hepatotoxins, chemicals, or infections or a metabolic disorder can cause postnecrotic cirrhosis. Biliary cirrhosis results from a decrease in bile flow and is most commonly caused by long-term obstruction of bile ducts.

A client with viral hepatitis is having difficulty coping with the disorder. Which question by the nurse is the most appropriate in identifying the client's coping problem?

"Have you enjoyed having visitors?"

The health care provider has determined that a client has contracted hepatitis A based on flulike symptoms and jaundice. Which statement made by the client supports this medical diagnosis?

"I ate shellfish about 2 weeks ago at a local restaurant."

A sexually active young adult client has developed viral hepatitis. Which client statement indicates the need for further teaching?

"I can go back to work right away." Rationale: To prevent transmission of hepatitis, vaccination of the partner is advised. In addition, a condom is advised during sexual intercourse. Alcohol should be avoided because it is detoxified in the liver and may interfere with recovery. Rest is especially important until laboratory studies show that liver function has returned to normal. The client's activity is increased gradually, and the client should not return to work right away.

A home care nurse visits a client who was recently diagnosed with cirrhosis. The nurse provides home care management instructions to the client. Which client statement indicates a need for further instruction?

"I will take acetaminophen if I get a headache."

The nurse is performing an assessment on a client with suspected acute pancreatitis. Which complaint made by the client supports the diagnosis?

"I've been experiencing constant, severe abdominal pain that is unrelieved by vomiting."

Which client should the emergency department triage nurse classify as emergent?

A client with crushing substernal pain who is short of breath

The nurse is caring for a client with altered protein metabolism as a result of liver dysfunction. Which finding should the nurse expect to note when reviewing the client's laboratory results?

Increased ammonia level Rationale During deamination of proteins in the liver, the amino group splits from the carbon-containing compound, which results in formation of ammonia and a carbon residue. The liver then converts the toxic ammonia substance into urea, which can be excreted by the kidneys. Clients with liver dysfunction may have high serum ammonia levels as a result.

A client who had been hospitalized with pancreatitis is being discharged with home health services. The client is severely weakened after this illness. Which nursing intervention is the highest priority in conserving the client's strength?

Limiting the client's activities to one floor of the home

The nurse is caring for a client with common bile duct obstruction. The nurse should anticipate that the health care provider (HCP) will prescribe which diet for this client?

Low fat Rationale Blockage of the common bile duct impedes the flow of bile from the gallbladder to the duodenum. Bile acids or bile salts are produced by the liver to emulsify or break down fats. The diets listed in the remaining options are incorrect.

A client with acute pancreatitis is experiencing severe pain from the disorder. The nurse determines that education about positioning to reduce pain was effective if the client avoids which action?

Lying flat Rationale: The pain of pancreatitis is aggravated by lying supine or walking. This is because the pancreas is located retroperitoneally, and the edema and inflammation will intensify the irritation of the posterior peritoneal wall with these positions or movements. Positions such as sitting up, leaning forward, and flexing the legs (especially the left leg) will alleviate some of the pain associated with pancreatitis. The fetal position (with the legs drawn up to the chest) may decrease the abdominal pain of pancreatitis.

A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding?

Malaise Rationale: Hepatitis causes gastrointestinal symptoms such as anorexia, nausea, right upper quadrant discomfort, and weight loss. Fatigue and malaise are common. Stools will be light- or clay-colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile ducts.

The nurse expects that which client will be discharged to the home environment first

Middle-aged thin adult who has had a laparoscopic cholecystectomy

When providing discharge teaching to a client with cirrhosis, it is essential for the nurse to emphasize avoidance of which of these?

Nonsteroidal anti-inflammatory drugs (NSAIDs) Clients who have cirrhosis should not take NSAIDs because they may predispose to bleeding. The client with cirrhosis is prone to bleeding; vitamin K can decrease bleeding, so it is not necessary to restrict this in the diet. Potassium-sparing diuretics are used to reduce ascites. Nonabsorbable antibiotics are used to decrease ammonia levels.

Which set of assessment findings indicates to the nurse that a client may have acute pancreatitis?

Presence of jaundice, pain worsening when lying supine

A client with liver dysfunction has low serum levels of fibrinogen and a prolonged prothrombin time (PT). Based on these findings, which actions should the nurse plan to promote client safety? Select all that apply.

Provide the client with a soft toothbrush. Instruct the client to use an electric razor. Monitor all secretions for frank or occult blood.

A client has developed acute pancreatitis after also developing gallstones. Which is the highest priority instruction for this client to avoid further attacks of pancreatitis?

See your health care provider immediately when experiencing symptoms of a gallbladder attack.

The community health nurse is working with disaster relief after a tornado. The nurse assists in finding safe housing for survivors, providing support to families, organizing counseling, and securing physical care when needed. Which level of prevention does the nurse exercise?

Tertiary level of prevention

A nurse is working at a day camp for church leaders when a sudden severe thunderstorm occurs. Several adults participating in outdoor activities appear to have been hit by lightning. The nurse arrives on scene and finds four injured people. One person appears to be unconscious, one has ferning marks and burns on his skin, and the other two are sitting up against the wall of a building and reporting severe weakness of their lower extremities. 1. What risk factors did these people have for lightning injury?

The campers were participating in outdoor activities and had little shelter from the impending storm. Some may have been wet from water activities or in or around water, which would increase the flashover effect lightning had on that person.

Pancreatin is prescribed for a client with postgastrectomy syndrome. Which assessment finding would indicate a therapeutic effect of this medication?

The stool is less fatty and decreases in frequency.

After receiving change-of-shift report on these clients, which client does the nurse plan to assess first?

Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min

The nurse is coordinating care for a client who was bitten by a black widow spider. Which nursing action is assigned to the LPN/LVN?

a. Administering tetanus toxoid vaccine intramuscularly Administration of medication is within the scope of practice and education level of an LPN/LVN. Physical assessment and ongoing monitoring for complications, as well as client education and planning for discharge, are all actions that require broader education and scope of practice and should be done by an RN.

The nurse has a suggestion for improving response in the next mass casualty event. Which channel does the nurse use to introduce this idea?

a. The Administrative Review (The goal of the Administrative Review is to discern what went right and what went wrong during activation and implementation of the emergency preparedness plan. In this way, changes can be made.)

The nurse is assessing a client's alcohol intake to determine whether it is the underlying cause of the client's attacks of pancreatitis. Which question does the nurse ask to elicit this information?

tell me more about your alcohol intake

The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first?

A young woman who appears dazed and confused and is shivering The young woman is demonstrating classic signs of shock, possibly from a closed head injury. Initial management of a client displaying signs of shock includes management of airway, breathing, and circulation. Initial treatment includes keeping the client warm. Oxygenation and intravenous fluids will be needed immediately to stabilize and maintain tissue perfusion. A first responder would be unlikely to be able to release a foot trapped under wreckage without help. The teenager is already applying pressure to the arm and is more likely to be able to maintain self-care until help arrives. Assisting a client with search and rescue would only be feasible once help arrives. Therefore, the nurse should attend to the client with the priority needs and the greatest potential of survival.

An occupational health nurse is teaching a safety class to city employees who work outdoors year round. What does the nurse teach are risk factors for developing frostbite? Select all that apply.

A. Excessive fatigue B. Prior episodes of frostbite C. Diabetes or other peripheral vascular disease D. Dehydration E. Smoking All of these factors predispose a person to frostbite except for wearing polyester socks.

A client seen in the ambulatory care clinic has ascites and slight jaundice. The nurse should assess the client for a history of chronic use of which medication?

Acetaminophen

A client is experiencing an attack of acute pancreatitis. Which nursing intervention is the highest priority for this client?

Administer opioid analgesic medication

The nurse has taught the client with chronic pancreatitis about risk factor modification to reduce the incidence of recurrences. The nurse determines that teaching was effective if the client states that it will be necessary to control which factor?

Alcohol intake

Which client does the charge nurse assign to an experienced LPN/LVN working on the adult medical unit?

Ans: A 32-year-old who needs a nasogastric tube inserted for gastric acid analysis Nasogastric tube insertion is included in LPN/LVN education and is an appropriate task for an experienced LPN/LVN.Assessment and client teaching would be done by an RN. IV hypnotic medications would be administered by an RN.

What is a common gastrointestinal problem that older adults experience more frequently as they age?

Ans: Decreased hydrochloric acid levels In older adults, decreased hydrochloric acid levels (hypochlorhydria) results from atrophy of the gastric mucosa.A decrease in lipase production results from calcification of pancreatic vessels. A decrease in the number and size of hepatic cells leads to decreased liver weight and mass. Peristalsis decreases, and nerve impulses are dulled.

A 12-year-old boy comes to the emergency department (ED) after being bitten by a scorpion. Which action does the nurse perform first?

Assess the client's vital signs. The first priority is vital sign assessment and continuous monitoring for several hours. This is done in the hospital ED or critical care unit to enable rapid intervention if symptoms progress. A tetanus shot and ice pack are not the immediate priority. Calling the poison control center is a secondary priority.

A client comes into the emergency department (ED) clutching the chest. Which core competency for ED nurses is the first one used in this situation?

Assessment Similar to any nurse in practice, the foundation of the emergency nurse's skill base is assessment. The nurse must be able to discern normal from abnormal rapidly and accurately, and must interpret assessment findings according to acuity and age. Communication, priority setting, and technical and procedural skills are not the first competencies to be used in this situation.

A client with viral hepatitis states, "I am so yellow." What is the most appropriate nursing action?

Assist the client in expressing feelings.

A Penrose drain is in place on the first postoperative day in a client who has undergone a cholecystectomy procedure. Serosanguineous drainage is noted on the dressing covering the drain. Which nursing intervention is most appropriate?

Change the dressing. Rationale: Serosanguinous drainage with a small amount of bile is expected from the Penrose drain for the first 24 hours. Drainage then decreases, and the drain is usually removed within 48 hours. A sterile dressing covers the site and should be changed if wet to prevent infection and skin excoriation. Although the nurse would continue to monitor the drainage, the most appropriate intervention is to change the dressing. The HCP does not need to be notified

A client has undergone the Whipple procedure (radical pancreaticoduodenectomy) for pancreatic cancer. Which precautionary measures does the nurse implement to prevent potential complications? (Select all that apply.)

Check blood glucose often. Check bowel sounds and stools. Monitor mental status

Emergency Medical Services arrives at the scene of an automobile crash. On primary assessment, the driver is found to be unresponsive, not breathing, and bleeding profusely. What is the first resuscitation intervention to be performed?

Clear the airway. Even minutes without an adequate oxygen supply in humans can lead to cerebral injury, and can progress to anoxic brain death. The airway should be cleared of any secretions or debris with a suction catheter or manually, if necessary. Applying pressure to wounds and placing a cervical collar are important, but neither is the priority. Commencing with artificial respiration is important, but the airway must be cleared first.

The RN has just received the change-of-shift report for the medical unit. Which client should the RN see first?

Client with portal-systemic encephalopathy (PSE) who has become increasingly difficult to arouse A change in the level of consciousness (LOC) of the client with PSE is the greatest concern; actions to improve the client's LOC should be rapidly implemented. Although uncomfortable, a headache in the client with ascites is not likely related to liver disease and does not pose an immediate threat or complication. A hemoglobin of 10.9 g/dL and thrombocytopenia are expected findings in a client with cirrhosis and do not pose an immediate threat. Elevated ALT and AST levels are expected for the client with hepatitis A and do not indicate a risk for severe complications.

The nurse is caring for clients in the outpatient clinic. Which of these phone calls should the nurse return first?

Client with severe ascites who has a temperature of 101.4° F (38° C) The client with ascites and an elevated temperature may have spontaneous bacterial peritonitis; the nurse should call this client first. Itching is anticipated with jaundice, this client may be called last. Weight gain with cirrhosis is not uncommon owing to low albumin levels. Cirrhosis may cause mild right upper quadrant pain; this client should be called after the client with severe ascites.

The nurse is providing reminders to a Red Cross class about safety procedures to prevent drowning or submersion. In which situation does this present the greatest risk?

College students going to a fraternity party at a boat house College parties often include alcohol or other mood-altering substances. A reminder may be needed to avoid alcoholic beverages when swimming or boating, or while in proximity to water. Because the couple swimming in the local lake is using the "buddy system," this situation is does not present the greatest risk. Lifeguards and protective equipment most likely will be in place at a community pool. Because adults will be present at the quarry, this situation does not present the greatest risk.

The nurse should incorporate which in the dietary plan to ensure optimal nutrition for the client during the acute phase of hepatitis? Select all that apply.

Consume multiple small meals throughout the day. Allow client to select foods most appealing. Eliminate fatty foods from the meal trays until nausea subsides

When providing dietary teaching to a client with hepatitis, what practice does the nurse recommend?

Consuming increased carbohydrates and moderate protein To repair the liver, the client should have a high-carbohydrate and moderate-protein diet; fats may cause dyspepsia. The client with hepatitis feels full easily and should have four to six small meals daily. Fluids are restricted with ascites caused by cirrhosis; not all clients with hepatitis progress to cirrhosis. Complete abstention from alcohol is necessary until the liver enzymes return to normal.

The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the health care provider (HCP)?

Dark red drainage Rationale: For the first 12 hours after gastric surgery, the nasogastric tube drainage may be dark brown to dark red. Later, the drainage should change to a light yellowish-brown color. The presence of bile may cause a green tinge. The HCP should be notified if dark red drainage, a sign of hemorrhage, is noted 24 hours postoperatively.

The emergency department manager has created a task force to decrease the rate of adverse incidents in patients who have increased safety needs during their stay in the department. At their meeting, each person discussed a specific safety need and actions that can be taken to reduce that risk. 2. What specific procedures can the unit implement to decrease medication errors?

Decrease interruptions while obtaining and dispensing medications, ensure using two methods of identification before giving medications, always ask about allergies before giving any medication, and use standard policy for identifying unconscious people or those who do not have identification.

The nurse is caring for a client with pancreatitis. Which finding should the nurse expect to note when reviewing the client's laboratory results?

Elevated level of amylase Rationale: The serum level of amylase, an enzyme produced by the pancreas, increases with pancreatitis. Amylase normally is responsible for carbohydrate digestion. Pepsin is produced by the stomach and is used in protein digestion. Lactase and enterokinase are enzymes produced by the small intestine; lactase splits lactose into galactose and fructose, and enterokinase activates trypsin.

The nurse is caring for a client with acute pancreatitis. Which finding should the nurse expect to note when reviewing the laboratory results?

Elevated serum lipase level

A client with chronic pancreatitis needs information on dietary modification to manage the health problem. Which item in the diet should the nurse teach the client to limit?

Fat

A client is admitted to the emergency department after reporting being raped. Who is the best team member for the admitting nurse to locate to provide care for this client?

Forensic nurse examiner The forensic nurse examiner is trained to recognize evidence of abuse and to intervene on the client's behalf. Although the physician or health care provider, the psychiatric crisis nurse, and the police officer may be involved at some point in the care of this particular client, they are not the best individuals to collaborate with at this time. It is important to remember that not all rapes are required to be reported to the police.

The nurse is reviewing the health care provider's prescriptions written for a client admitted to the hospital with acute pancreatitis. Which prescription requires follow-up by the nurse?

Full liquid diet Rationale The client with acute pancreatitis is placed on NPO (nothing by mouth) status to decrease the activity of the pancreas, which occurs with oral intake. Pain management for acute pancreatitis typically begins with the administration of opioids by patient-controlled analgesia. Medications such as morphine or hydromorphone are typically used. Nasogastric tube insertion is done to provide suction of secretions and administer medications as necessary.

While on the school playground, a child is stung by a bee, resulting in redness and swelling. The school nurse is nearby when it happens. What does the nurse do first?

Gently scrape out the stinger with a credit card. The preferred method is to remove the stinger by gently scraping or brushing it off with the edge of a knife blade, credit card, or needle. However, it is important to realize that the method used to remove the stinger is not as relevant as the speed of removal. Applying an ice pack would be the second course of action that should be taken; removal of the stinger is more important. An epinephrine pen would be administered for known allergies or for a severe allergic reaction, not for localized redness and swelling. Keeping the bee is not an important element in the treatment of this emergency; bumble bees and wasps can re-sting, but honey bees can sting only once and die after injecting their victim with their stingers.

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply.

Gray-blue color at the flank Abdominal guarding and tenderness Left upper quadrant pain with radiation to the back Rationale: Grayish-blue discoloration at the flank is known as Grey-Turner's sign and occurs as a result of pancreatic enzyme leakage to cutaneous tissue from the peritoneal cavity. The client may demonstrate abdominal guarding and may complain of tenderness with palpation. The pain associated with acute pancreatitis is often sudden in onset and is located in the epigastric region or left upper quadrant with radiation to the back. The other options are incorrect.

Which intervention is important for the nurse to include in the plan of care for a client who is to undergo paracentesis later today?

Have the client void before the procedure is performed. Voiding before the procedure prevents bladder injury. The drainage color and amount will be recorded after the procedure. Liver enzymes are expected to be elevated; this is the purpose of the procedure. The health care provider performing the procedure should discuss the intervention and potential complications with the client and obtain informed consent.

The emergency department manager has created a task force to decrease the rate of adverse incidents in patients who have increased safety needs during their stay in the department. At their meeting, each person discussed a specific safety need and actions that can be taken to reduce that risk. 1. What populations are at highest risk of safety compromise while in the ED?

Highest risk populations include older adults, confused patients, patients who were given pain medication or sedation, patients impaired by drug or alcohol use, those who are unconscious, and those with no identification. In addition any condition that can cause dizziness and fainting or lying in the same position can cause a safety risk. Invasive procedures can increase the patient's risk for infection.

A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition?

Increase intake of fluids, including juices. Rationale: A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition?Rationale: Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a low-fat diet, as fat may be tolerated poorly because of decreased bile production. Small, frequent meals are preferable and may even prevent nausea. Frequently, appetite is better in the morning, so it is easier to eat a good breakfast. An adequate fluid intake of 2500 to 3000 mL/day that includes nutritional juices is also important.

The nurse is performing an assessment on a client with acute pancreatitis who was admitted to the hospital. Which assessment question would most specifically elicit information regarding the pain that is associated with acute pancreatitis?

"Does the pain in your stomach radiate to your back?" Rationale: The pain that is associated with acute pancreatitis is often severe, is located in the epigastric region, and radiates to the back. The remaining options are incorrect because they are not specific for the pain experienced by the client with pancreatitis.

The elementary school nurse is teaching children how to prevent injuries from cold exposure in the winter. Which student statement demonstrates that the teaching has been effective?

"Dressing in layers is important." Layering is important in preventing cold injuries. In a cold environment, lightweight and synthetic fabric clothing is best. Drinking plenty of fluids and frequent rest are important in preventing heat injuries. Cotton socks will get wet (from perspiration) and will conduct cold temperatures; wearing cotton fabric in cold environments is not advisable.

A client has been discharged to home after being hospitalized with an acute episode of pancreatitis. The client, who is an alcoholic, is unwilling to participate in Alcoholics Anonymous (AA), and the client's spouse expresses frustration to the home health nurse regarding the client's refusal. What is the nurse's best response?

"I'll get you some information on the support group Al-Anon.

The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs further information if the client makes which statement?

"I'm glad I don't have to lie still for this procedure." Rationale: The client does have to lie still for ERCP, which takes about 1 hour to perform. The client also has to sign a consent form. Intravenous sedation is given to relax the client, and an anesthetic spray is used to help keep the client from gagging as the endoscope is passed.

A client with viral hepatitis is discussing with the nurse the need to avoid alcohol and states, "I'm not sure I can avoid alcohol." What is the most appropriate nursing response?

"I'm not sure that I understand. Would you please explain?"

Which statement by a client with cirrhosis indicates that further instruction is needed about the disease?

"My liver is scarred, but the cells can regenerate themselves and repair the damage." Although cells and tissues will attempt to regenerate, this will result in permanent scarring and irreparable damage. Cirrhosis is a chronic condition that leaves scars on the liver. Permanent scars form in response to attempts by the cells to regenerate and create problems in blood circulation moving through the liver. Liver scarring will create problems with blood clotting, cholesterol levels, and blood pressure, as well as with the metabolism of drugs and toxins.

A 16-year-old high school athlete recently suffered heat exhaustion. The school nurse is instructing the student on how to prevent a recurrence of this situation. Which student statement demonstrates that the nurse's teaching has been effective?

"Taking frequent rests is important when in a hot environment." Frequent rest periods will decrease the risk of heat exhaustion. Exercising during times of peak sun exposure (midday) will increase the risk of heat exhaustion. Limiting the types of fluids and times consumed will also increase the risk of heat exhaustion; fluids need to be consumed throughout the exercising session. Dark clothing attracts heat; light clothes are more effective in deflecting heat to prevent heat exhaustion.

The nurse is teaching a class of park ranger trainees about prioritizing care for clients who have received snakebites. Which ranger's statement demonstrates a need for further teaching?

"You should first place a tourniquet above the bite." If transportation and treatment are delayed, a 2- to 4-cm constricting band may be applied proximal to an extremity wound to slow venom circulation via lymphatic flow. It should not be used as a tourniquet, however; this could worsen local tissue necrosis by retaining venom in the tissues. Alcohol or stimulants such as caffeinated beverages should not be offered because they may speed up the absorption of venom. Affected extremities should be kept below the level of the heart. The first priority is to move the victim to a safe area away from the snake and to encourage rest to decrease venom circulation.

a client comes to the emergency department after being bitten 5 hours ago by a rattlesnake. As the nurse administers Crotalidae Polyvalent Immune Fab [Ovine] (CroFab), the client asks how long he will need to receive the medication. How does the nurse respond?

"You will be given this antivenin over a period of 18 hours." CroFab should be given to clients as soon as possible, with optimal timing within 6 hours of the bite. Once the symptoms are under control, two vials of CroFab are administered every 6 hours for a total of 18 hours of administration.

The nurse is caring for a client diagnosed with cirrhosis of the liver with portal hypertension. The client vomited 500 mL bright red emesis and states that he is feeling lightheaded. In which priority order should the nurse perform these interventions? Arrange the actions in the order they should be performed. All options must be used.

1. Apply oxygen. 2.Ensure that 2 large-bore intravenous lines are present with an isotonic solution infusing. 3. Check the client's blood pressure. 4. Ask the client if he is taking any nonsteroidal antiinflammatory medications. Rationale: The client has an upper gastrointestinal (GI) bleed. Upper GI bleeding is an emergency because it can lead to hypovolemic shock. The first intervention of those listed should be to apply oxygen in an attempt to maximize the amount of oxygen being delivered by the decreased number of red blood cells due to the bleeding. The next action should be to ensure that 2 large-bore intravenous (IV) lines are present, and begin replacement of the intravascular fluid volume with an isotonic IV fluid. The nurse should then check the blood pressure. These are all actions to stabilize and assess the client's current condition. The last intervention is to ask the client about nonsteroidal antiinflammatory medications. Although it is important to identify the cause of the bleeding and obtain a complete history of events leading up to the bleeding episode, this needs to be deferred until emergency care is initiated.

Clients who have been admitted to the emergency department (ED) are assessed by the ED triage nurse for an oncoming shift. Which client is most appropriately assigned to an LPN/LVN?

A 24-year-old with heat exhaustion, receiving an IV of normal saline, with normal chemistry laboratory results and a temperature of 37° C Because the client who has heat exhaustion is stable and is already receiving appropriate treatment, it is appropriate to assign an LPN/LVN to care for this client. The data for the client reporting right forearm swelling indicate a risk for hemodynamic instability and the need for ongoing assessment and intervention by an RN. The data for the client who was hiking and the client stung by an unknown insect indicate a risk for respiratory instability, and also require ongoing assessment and intervention by an RN.

The emergency department nurse is assigned to five clients waiting for orders to be implemented. Which client does the nurse assess first?

A 60-year-old waiting for transport to the operating room for an emergency appendectomy Rationale: The 60-year old client is scheduled for an emergent surgery and needs to be assessed to be transported. The other clients are stable at this time or have less life-threatening health problems.

Which client is at greatest risk for heat exhaustion?

A 78-year-old gardener Older adults and the homeless are particularly at risk for heat-related illnesses because of decreased body fluid volume and/or overexposure to the sun. The young construction worker is at risk, but is not the one at highest risk; he or she will have a "thirst" response and will keep hydrated as needed. The police officer in his or her 30s is a young adult who is probably in an acceptable state of fitness, and should have a healthy knowledge of how to keep hydrated. The swimming instructor in his or her 40s can "cool off" by getting into the pool (or other body of water).

The nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the nurse attend to first?

A child who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!" Priority nursing care in disaster situations needs to be delivered to the living and not the dead. The child who is bleeding badly is the priority. The bleeding could be from an arterial vessel; if the bleeding is not stopped, the child is at risk for shock and death. The pregnant client is the next priority, but the absence of fetal movement may or may not be indicative of fetal demise. The young child is with a family member and is safe at this time. The older victim will need comfort measures; there is no information indicating she is physically hurt.

The nurse in charge of a nursing unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Select the clients who can be safely discharged. Select all that apply.

A client experiencing sinus rhythm A client receiving oral anticoagulants A client with chronic atrial fibrillation

The nurse in charge of a nursing unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply.

A client with a Holter monitor A client receiving oral antibiotics A client experiencing sinus rhythm

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client?

A client with chest pain who states that he just ate pizza that was made with a very spicy sauce In an emergency department, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits, or who have sustained chemical splashes to the eyes, are classified as emergent and are the number-1 priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as a number-2 priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are a number-3 priority.

A nurse is working at a day camp for church leaders when a sudden severe thunderstorm occurs. Several adults participating in outdoor activities appear to have been hit by lightning. The nurse arrives on scene and finds four injured people. One person appears to be unconscious, one has ferning marks and burns on his skin, and the other two are sitting up against the wall of a building and reporting severe weakness of their lower extremities. 3. What potential complication does the nurse plan to address in the immediate rescue period?

A potential complication the nurse must consider is the possibility of spinal cord injury, especially if one of the victims was thrown by the strike. The individuals reporting lower extremity weakness are also at risk for this complication.

The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first?

A victim experiencing airway obstruction Client needs related to maintaining a patent airway are always the priority. Therefore, the nurse would attend to the victim experiencing airway obstruction first. Care to the other victims follows.

The nurse is the first responder at the scene of a 6-car crash on a highway. Which victim should the nurse attend to first?

A victim experiencing dyspnea The client experiencing dyspnea is the priority. Needs related to maintaining a patent airway are always the priority. The victims experiencing confusion, tachycardia, and intense pain would be assessed following stabilization of the client with an airway problem.

When caring for a client with portal hypertension, the nurse assesses for which potential complications? (Select all that apply.)

A. Esophageal varices D. Ascites E. Hemorrhoids Portal hypertension results from increased resistance to or obstruction (blockage) of the flow of blood through the portal vein and its branches. The blood meets resistance to flow and seeks collateral (alternative) venous channels around the high-pressure area. Veins become dilated in the esophagus (esophageal varices), rectum (hemorrhoids), and abdomen (ascites due to excessive abdominal [peritoneal] fluid). Hematuria may indicate insufficient production of clotting factors in the liver and decreased absorption of vitamin K. Fever indicates an inflammatory process.

When caring for a client with Laennec's cirrhosis, which of these does the nurse expect to find on assessment? (Select all that apply.)

A. Prolonged partial thromboplastin time B. Icterus of skin C. Swollen abdomen The liver produces clotting factors; when it is damaged, prolonged coagulation times and bleeding may result. Icterus, or jaundice, results from cirrhosis. The client with cirrhosis may develop ascites, or fluid in the abdominal cavity. Elevated magnesium is not related to cirrhosis. The client with cirrhosis may develop hypocalcemia and/or hypokalemia. Currant jelly stool is consistent with intussusception, a type of bowel obstruction. Cirrhosis is consistent with elevations of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase; amylase is typically elevated in pancreatitis.

The nurse who is caring for a client with a diagnosis of cirrhosis is monitoring the client for signs of portal hypertension. Which finding should the nurse interpret as a sign or symptom of portal hypertension?

Abdominal distention Rationale: With portal hypertension, proteins shift from the blood vessels via the larger pores of the sinusoids (capillaries) into the lymph space. When the lymphatic system is unable to carry off the excess proteins and water, they leak through the liver capsule into the peritoneal cavity. This is called ascites, and abdominal distention would be the consequence. Increased portal pressure can lead to findings associated with right-sided heart failure, such as distended jugular veins. Thrombocytopenia, leukopenia, and anemia are caused by the splenomegaly that results from backup of blood from the portal vein into the spleen (portal hypertension).

The nurse is developing a teaching plan for a client with viral hepatitis. The nurse should plan to include which information in the teaching session?

Activity should be limited to prevent fatigue.

When assessing a client for hepatic cancer, the nurse anticipates finding an elevation in which laboratory test result?

Alpha-fetoprotein Fetal hemoglobin (alpha-fetoprotein) is abnormal in adults; it is a tumor marker indicative of cancers. Although anemia may be present, elevated hemoglobin and hematocrit are not diagnostic of hepatic cancer. White blood cells (leukocytes) are not used to specifically diagnose cancers. Serum albumin levels may be low in liver cancer and in malnutrition.

the RN working at a long-term-care facility places priority on providing interventions for which resident?

An 80-year-old man with congestive heart failure who is outdoors for some "fresh air" when the temperature is 95° F Evidence has shown that older adults (especially those over the age of 80) are more likely to die in the year following non-exertional heat stroke. This is especially true in those with cardiac and cancer diagnoses. The resident who is outside when it is 94° F needs to be removed from this environment. Although the 65-year-old paraplegic man has valid concerns, they are not the nurse's highest priority in the group. The 76-year-old woman with a total hip replacement needs to be handled carefully and safely during a new activity, but the resident who is at risk for heat stroke has greater importance for intervention. Although the 82-year-old woman with dementia has a valid request, she is not the nurse's highest priority in this scenario.

While working in the outpatient procedure unit, the RN is assigned to these clients. Which client does the nurse assess first?

Ans: A 51-year-old who recently had an endoscopic retrograde cholangiopancreatography (ERCP) ERCP requires conscious sedation, so the client needs immediate assessment of respiratory and cardiovascular status. The endoscopic procedure and nursing care for a client having an ERCP are similar to those for the EGD procedure, except that the endoscope is advanced farther into the duodenum and into the biliary tractA 54-year old client being discharged after a colonoscopy, a 58-year old client who is going to have a gastric acid test, and a 60-year old client with questions about an endoscopic ultrasound examination are not at risk for depressed respiratory status.

The nurse is assessing an alert client who had abdominal surgery yesterday. What method provides the most accurate data about resumption of peristalsis in the client?

Ans: Asking the client whether he or she has passed flatus (gas) within the previous 12 to 24 hours. (p. 17) The best and most reliable method for assessing the return of peristalsis following abdominal surgery is the client's report of passing flatus within the past 8 hours or stool within the past 12 hours.Although auscultation and counting the number of sounds was once a method of assessing for bowel activity, it is no longer considered the most effective method. Observing the abdomen is one method of examining a client's abdomen, but it is not a reliable way to assess for resumption of activity after surgery.

A client had a routine sigmoidoscopy with a tissue biopsy. What postprocedure complication would the nurse report to the health care provider?

Ans: Excessive bleeding Excessive or heavy bleeding is a possible complication following a sigmoidoscopy. It must be reported immediately to the health care provider.Nausea, vomiting, and severe rectal pain are not common complications of sigmoidoscopy. Gas and flatulence are expected assessment findings post-sigmoidoscopy (p. 36)

The nurse practitioner is performing an abdominal assessment on a newly admitted client. In which order should the nurse proceed with assessment technique?

Ans: Inspection, auscultation, percussion, palpation The assessment technique proceeds as inspection, auscultation, percussion, palpation. This sequence is different from that used for other body systems. It is used so that palpation and percussion do not increase intestinal activity and bowel sounds. Nurse generalists may perform inspection, auscultation, and light palpation; percussion and deep palpation may be done by advanced practice nurses.Inspection must be the first assessment technique. Options beginning with auscultation, palpation, or percussion are incorrect.

The nurse is assessing a client who comes to the emergency department with acute abdominal pain. The nurse notes a bulging, pulsating mass when inspecting the abdomen. Which action by the nurse is correct?

Ans: Notify the provider about this finding immediately. The nurse needs to immediately notify the health care provider because a bulging, pulsating mass may indicate an abdominal aortic aneurysm requiring emergency actions.Palpating the abdomen or even touching the abdomen with a stethoscope may cause this to rupture, which would be a life-threatening emergency. Because this is a potential life-threatening situation, questioning the client about stool habits is not appropriate.

A client arrives at the emergency department with acute abdominal pain in the left lower quadrant. In which order does the nurse examine and assess the client's abdomen? (left lower quadrant (LLQ), left upper quadrant (LUQ), right lower quadrant (RLQ), and right upper quadrant (RUQ))?

Ans: RUQ, LUQ, RLQ, LLQ The LLQ would be the last area assessed for this client. Abdominal examination usually begins at the client's right side and proceeds in a systematic fashion: RUQ, LUQ, RLQ, LLQ. However, if the client is experiencing pain in a specific quadrant, that area should be assessed last in the examination sequence. This action prevents the client from tensing abdominal muscles because of the pain, which would make the examination difficult.The options that do not assess the quadrant where the pain presents last are incorrect.

Which factors place a client at risk for gastrointestinal (GI) problems? Select all that apply. Eating a high-fiber diet Smoking a half-pack of cigarettes per day Socioeconomic status Some herbal preparations Use of nonsteroidal anti-inflammatory drugs (NSAIDs)

Ans: Smoking a half-pack of cigarettes per day Socioeconomic status Some herbal preparations Use of nonsteroidal anti-inflammatory drugs (NSAIDs) Smoking or any tobacco use places a client in a higher-risk category for GI problems. Socioeconomic status can also influence the risk for GI problems; clients may not be able to afford to seek care or treatment and may put off seeking help. Some herbal preparations contribute to GI problems, such as Ayurvedic herbs, which can affect appetite, absorption, and elimination. NSAIDs can predispose clients to peptic ulcer disease or GI bleeding.High-fiber diets are generally believed to be healthy for most clients.

The nurse is directing the care of a newly admitted client who is severely hypothermic. What does the nurse advise the rapid assessment team to do first?

Apply electrocardiographic monitor leads to monitor cardiac activity. People who are hypothermic are at risk for lethal cardiac dysrhythmias and need continual monitoring until rewarming is successful. Samples for laboratory testing and IV access should be implemented rapidly, and a nasogastric tube should be inserted soon after admission, but monitoring for potentially fatal dysrhythmias should be initiated first.

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence?

Ask the client to extend the arms. Rationale: Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. Asterixis is the most common and reliable sign that hepatic encephalopathy is developing.

The nurse asks a client with liver disease to raise the arms to shoulder level and dorsiflex the hands. A few moments later, the hand begins to flap upward and downward. How does the nurse correctly document this in the medical record?

Asterixis Liver flap or asterixis is related to increased serum ammonia levels—the dorsiflexed hands begin to flap upward and downward when outstretched for a few moments. Babinski's sign is positive when, as the sole of the foot is stroked, the great toe points up and the toes fan out. Hyperreflexia refers to deep tendon reflexes that are overactive. Kehr's sign is reflected by increased abdominal pain, exaggerated by deep breathing, and referred to the right shoulder.

The nurse is performing discharge teaching for a client with chronic pancreatitis. Which information should the nurse include?

Avoid caffeine because it may aggravate symptoms.

An older client with heat exhaustion is being cooled with cool water spray and fanning. What assessment indicates to the nurse that the client needs hospitalization?

B The client's mucous membranes are dry and sticky. Heat exhaustion is usually treatable with a cool water spray and fanning. However, if the client does not respond to these interventions, heat stroke can occur with severe dehydration. Dry and sticky membranes are present in clients with severe dehydration.

After receiving a change-of-shift report, the client with which condition should be assessed by the emergency department (ED) nurse first?

Bee sting on the jawline with an inability to swallow The client who was stung by a bee is showing potential signs of respiratory compromise and needs immediate assessment and intervention. The client with a spider bite should be assessed rapidly, but is not at immediate risk for life-threatening complications. The client with the dog bite should be assessed rapidly and may need a regimen of rabies protection to be initiated, but this is not an immediate need. The client with severe muscle cramps should be assessed soon, but is probably the lowest priority in this group of clients.

The nurse is caring for a client with a low thrombin level as a result of liver dysfunction. Based on this finding it is most important for the nurse to monitor the client for signs and symptoms of which potential complication?

Bleeding Rationale: Thrombin is produced by the liver and is necessary for normal clotting. The client who has an insufficient level of this substance is at risk for bleeding. Therefore, the client should be monitored for evidence of blood loss, such as visual cues and vital sign changes.

It is essential that the nurse monitor the client returning from hepatic artery embolization for hepatic cancer for which potential complication?

Bleeding When monitoring a client post hepatic artery embolization, an arterial approach is taken; therefore, prompt detection of hemorrhage is the priority. Discomfort may be present, but the priority is to assess for hemorrhage. The nurse must assess for signs of shock, not polyuria. Embolization does not suppress the bone marrow; if chemotherapy or immune modulators are used, the nurse then assesses for bone marrow suppression.

A client with a gunshot wound is admitted to the emergency department (ED). Which minimum Standard Precaution activity does the nurse require for staff safety?

Blood and body fluid precautions The ED nurse uses Standard Precautions at all times when there is the potential for contamination by blood or other body fluids. Screening of the client with a metal detector, appointing a security guard, and use of a PAPR, although beneficial, are not minimum Standard Precautions.

The nurse from a medical unit is called to assist with care for clients coming into the hospital emergency department during an external disaster. Using principles of triage during a disaster, the nurse should attend to the client with which problem first?

Bright red bleeding from a neck wound The client with arterial bleeding from a neck wound is in immediate need of treatment to save the client's life. This client is classified as such and would wear a color tag of red from the triage process. The client with a penetrating abdominal injury would be tagged yellow and classified as "delayed," requiring intervention within 30 to 60 minutes. A green or "minimal" designation would be given to the client with a fractured tibia, who requires intervention but who can provide self-care if needed. A designation of expectant is applied to the client with massive head or other injuries and minimal chance of survival; the corresponding color code is black in the triage process. Such clients receive supportive care and pain management but are given definitive treatment last.

The nurse is giving instructions to a client with cholecystitis about food to exclude from the diet. Which food item identified by the client indicates that the educational session was successful?

Brown gravy Rationale: The client with cholecystitis should decrease overall intake of dietary fat. Foods that should be avoided include sausage, gravies, fatty meats, fried foods, products made with cream, and desserts. Appropriate food choices include fruits and vegetables, fish, and poultry without skin.

A client with acute cholecystitis is admitted to the medical-surgical unit. Which nursing activity associated with the client's care will be best for the nurse to delegate to unlicensed assistive personnel (UAP)?

Obtaining the admission weight, height, and vital signs

A client has been placed on enzyme replacement for treatment of chronic pancreatitis. In teaching the client about this therapy, the nurse advises the client not to mix enzyme preparations with foods containing which element?

Protein

A client on a climbing expedition reports a headache and nausea. The client rests 1 day at the current altitude and then climbs further the following day. The third day, other members of the climbing team note that the client has developed gross motor coordination difficulties. What action by the team nurse takes priority?

C. Having the client descend to a lower altitude The client needs to be at a lower altitude first before other interventions are used. Treating the client at a high altitude will not resolve the clinical manifestations of altitude illness.

A trauma client has been brought to the emergency department after a motor vehicle crash. The client has severe injuries. What action does the nurse perform first?

C. Stabilize the cervical spine and assess the airway. Establishing an airway is always the priority in a client with major trauma. The other interventions are done after the airway is established and patent.

When assessing a client with hepatitis B, the nurse anticipates which assessment findings? (Select all that apply.)

C. Tea-colored urine D. Right upper quadrant tenderness E. Itching The urine may be brown, tea-, or cola-colored in clients with hepatitis. Inflammation of the liver may cause right upper quadrant pain. Deposits of bilirubin on the skin, secondary to high bilirubin levels, and jaundice irritate the skin and cause itching. Hepatitis B virus, not the influenza virus, causes hepatitis B, which is spread by blood and body fluids. The stool in hepatitis may be tan or clay-colored.

The nurse in the hospital emergency department is notified by emergency medical services that several victims who survived a plane crash will be transported to the hospital. Victims are suffering from cold exposure because the plane plummeted and was submerged in a local river. What is the initial action of the nurse?

Call the nursing supervisor to activate the agency disaster plan. In an external disaster, many people may be brought to the emergency department for treatment. The initial nursing action must be to activate the disaster plan. Although options 2, 3, and 4 may be additional measures that the nurse would take, the initial action would be to activate the disaster plan.

On a hot summer day, an older adult is found by a neighbor lying on the floor, agitated and confused. After calling 911, the neighbor places ice bags on the client's groin area and armpits. Upon arrival at the hospital, which action does the emergency department (ED) nurse perform first?

Check the client's airway, continuing oxygen by mask. Once in a clinical setting, the nurse monitors and supports the client's airway, breathing, and circulatory status. High-concentration oxygen therapy, IV lines with 0.9% saline solution, and a urinary catheter are also indicated. Nothing should be given by mouth to this client upon admission. Vital signs should be monitored, but they are not the immediate priority in this scenario. Use of a cooling blanket is not the first priority, especially if ice bags are already in place.

The nursing team consists of an RN, an LPN/LVN, and a nursing assistant. Which client should be assigned to the RN?

Client with end-stage cirrhosis who needs teaching about a low-sodium diet The RN is responsible for client teaching; therefore, the client with end-stage cirrhosis should be assigned to the RN. Assisting a client with toileting and recording stool number and amount can be accomplished by nonprofessional staff. The LPN/LVN can provide dressing changes. Ancillary staff can perform venipuncture.

A client who was awaiting liver transplantation is excluded from the procedure after the presence of which condition is discovered?

Colon cancer with metastasis to the liver Transplantation is performed for hepatitis and primary (not secondary) liver cancers. Hypertension is a controllable factor and would not preclude the client from a liver transplant. Encephalopathy is a consequence of advanced liver disease, consistent with the condition of a client awaiting transplantation; it can be treated with lactulose and nonabsorbable antibiotics. Ascites and resulting shortness of breath are also consequences of advanced liver disease, consistent with the client awaiting transplantation; they can be managed with diuretics and paracentesis.

the provider is planning to discharge a client home. The nurse suspects domestic violence as the cause of injury, although the client denies this. What is the best course of action for the nurse to take?

Consult with Social Services. If discharge home is not deemed safe, the client may be admitted to the hospital until resources can be organized to provide a safe environment. Social workers or case managers are consulted to investigate resource needs and plan accordingly. Calling the police is not an appropriate response. Letting the client go home could place the client in danger. The client may not have a safe place to go.

A client from a local care facility has sustained a cardiac arrest in the emergency department (ED), and resuscitation was unsuccessful. The client's family wishes to view the body. What steps should the ED nurse take?

Cover the client with a sheet, leaving the face exposed. Not all clients presenting to the ED survive to discharge. The client's family has the right to view the body prior to removal to the morgue or funeral home. Dimming the lights in the room and covering the body with a sheet or blanket should be done prior to the family viewing. Leaving the head exposed allows the family to see the client and to comprehend that the death has occurred. IV lines and indwelling tubes may need to be left in place unless their removal has been authorized. The family should be escorted to the room by hospital personnel; however, this is not always exclusively done by a chaplain or social worker. The nurse must exhibit compassion and empathy; however, using terms such as "died" and "dead" create less confusion than "in a better place."

A client with cirrhosis is beginning to show signs of hepatic encephalopathy. The nurse should plan a dietary consultation to limit the amount of which ingredient in the client's diet?

Protein

In caring for a client who has undergone paracentesis, which changes in the client's status should be promptly reported to the provider?

Decreased blood pressure, increased heart rate Decreased blood pressure and increased heart rate are indicative of shock. Increased blood pressure, increased respiratory rate, increased apical pulse, pallor, tachypnea, and diaphoresis are all indicative of anxiety on the client's part.

The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate?

Document the findings. Rationale: Following cholecystectomy, drainage from the T-tube is initially bloody and then turns a greenish-brown color. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 mL/day. The nurse would document the output.

The nurse is caring for a hospitalized client with pancreatitis. Which findings should the nurse look for and expect to note when reviewing the laboratory results? Select all that apply.

Elevated lipase level Elevated trypsin level Elevated amylase level Rationale: Lipase, trypsin, and amylase are produced in the pancreas and aid in the digestion of fats, starches, and proteins, respectively. Lactase is produced in the small intestine and aids in splitting neutral fats into glycerol and fatty acids. Sucrase is produced in the small intestine and converts sucrose into glucose and fructose.

The nurse suspects that a client may have acute pancreatitis as evidenced by which group of laboratory results?

Elevated lipase, elevated white blood cell count, elevated glucose

The nurse is reviewing the results of serum laboratory studies for a client admitted for suspected hepatitis. Which laboratory finding is most associated with hepatitis, requiring the nurse to contact the health care provider?

Elevated serum bilirubin level Rationale: Laboratory indicators of hepatitis include elevated liver enzymes, serum bilirubin level, and ESR. However, ESR is a nonspecific test that indicates the presence of inflammation somewhere in the body. The hemoglobin concentration is unrelated to this diagnosis. An elevated BUN level may indicate renal dysfunction

Which activity by the nurse will best relieve symptoms associated with ascites?

Elevating the head of the bed The enlarged abdomen of ascites limits respiratory excursion; Fowler's position will increase excursion and reduce shortness of breath. The client may need oxygen, but first the nurse should raise the head of the bed to improve respiratory excursion and oxygenation. Monitoring will detect anticipated decreased serum albumin levels associated with cirrhosis and hepatic failure but does not relieve the symptoms of ascites. Administering IV fluids will contribute to fluid volume excess and fluid shifts into the peritoneal cavity, worsening ascites.

A client with cirrhosis complicated by ascites is admitted to the hospital. The client reports a 10-lb weight gain over the past 1½ weeks. The client has edema of the feet and ankles, and his abdomen is distended, taut, and shiny with striae. Which client problem is most appropriate at this time?

Excessive body fluid volume Rationale The client with weight gain who also has cirrhosis complicated by ascites most often is retaining fluid. This is especially true when the client has not demonstrated an appreciable increase in food intake or when the weight gain is massive in relation to the time frame given. Therefore, excessive body fluid volume is the most appropriate problem. No data are given to support difficulty with breathing, although in some clients upward pressure on the diaphragm from ascites does impair respiration. Risk for skin breakdown assumes a lower priority because it is a risk rather than an actual problem. There are no data in the question that indicate that the client is having difficulty with sleep.

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply.

Fever Complaints of indigestion Pain in the upper right quadrant after a fatty meal Rationale: During an acute episode of cholecystitis, the client may complain of severe right upper quadrant pain that radiates to the right scapula or shoulder or experience epigastric pain after a fatty or high-volume meal. Fever and signs of dehydration would also be expected, as well as complaints of indigestion, belching, flatulence, nausea, and vomiting. Options 4 and 6 are incorrect because they are inconsistent with the anatomical location of the gallbladder. Option 2 (Cullen's sign) is associated with pancreatitis

The nurse is caring for a client who was admitted after a diving accident with prolonged submersion in a lake. Which task is appropriate to delegate to an experienced nursing assistant?

Helping maintain cervical spine stability during transfer to a stretcher Transferring and positioning clients is included in nursing assistant education and scope of practice. An experienced nursing assistant would be able to help with maintenance of cervical spine stability while under the supervision of licensed nursing staff. Nursing activities such as making assessments, arranging for client transfers, and communicating laboratory results to the health care provider require broader education and scope of practice and should be done by an RN. The actual drawing of ABGs is usually done by a respiratory therapist.

The nurse has been caring for a client who required a Sengstaken-Blakemore tube because other treatment measures for esophageal varices were unsuccessful. The health care provider (HCP) arrives on the nursing unit and deflates the esophageal balloon. Which assessment finding by the nurse is the most important and should be reported to the HCP immediately?

Hematemesis Rationale: A Sengstaken-Blakemore tube may be inserted in a client with a diagnosis of cirrhosis with bleeding esophageal varices. It has both an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated, the client may begin to bleed again from the esophageal varices, manifested as vomiting of blood (hematemesis). The remaining options are unrelated to deflating the esophageal balloon.

The nurse is assigned to care for a client with a Sengstaken-Blakemore tube. Which laboratory result is most focused on evaluating the effectiveness of this tube?

Hemoglobin Rationale: A Sengstaken-Blakemore tube may be used in a client with a diagnosis of cirrhosis with ruptured esophageal varices if other treatment measures are unsuccessful. The tube has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The gastric balloon holds the tube in the correct position and prevents migration of the esophageal balloon, which could harm the client. Evaluation of the client's hemoglobin level trends will determine if the tube is effective. Sodium, creatinine, and ammonia levels are not related to monitoring for blood loss.

The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which assessment data would alert the nurse to this occurrence?

Inability to pass flatus

Which diagnostic results lead the nurse to suspect that a client may have gallbladder disease?

Increased white blood cell (WBC) count, visualization of calcified gallstones, edema of the gallbladder wall

A 2-year-old child falls into the community swimming pool and does not resurface. A lifeguard dives in to save the child. What does the lifeguard do first after the rescue?

Initiates rescue breathing on the child Airway clearance and ventilatory support measures should be initiated as soon as possible. This child did not suffer long exposure to cold water, so hypothermia is not a risk. No attempt should be made to remove water from the lungs unless an obstruction is present. Spinal cord injury should always be considered in a water-related emergency; however, it is not likely in this scenario. Establishing an airway and beginning rescue breathing is the first priority.

The nurse is teaching the client with viral hepatitis about the stages of the disease. The nurse should explain to the client that the second stage of this disease is characterized by which specific assessment findings? Select all that apply.

Jaundice Clay-colored stools Elevated bilirubin levels Dark or tea-colored urine Rationale: There are 3 stages associated with viral hepatitis. The first (preicteric) stage includes flulike symptoms only. The second (icteric) stage includes the appearance of jaundice and associated symptoms such as elevated bilirubin levels, dark or tea-colored urine, and clay-colored stools. The third (posticteric) stage occurs when the jaundice decreases and the colors of the urine and stool return to normal.

A client is scheduled to undergo a liver transplantation. Which nursing intervention is most likely to prevent the complications of bile leakage and abscess formation?

Keeping the T-tube in a dependent position Keeping the T-tube in a dependent position and secured to the client is likely to prevent bile leakage, abscess formation, and hepatic thrombosis. Preventing hypotension will help to prevent the complication of acute kidney injury. Administering antibiotic vaccinations will help to prevent infection. Administering immune-suppressant drugs will help to prevent graft rejection.

When caring for a client with hepatic encephalopathy, in which situation does the nurse question the use of neomycin (Mycifradin)?

Kidney failure The aminoglycoside drugs, which include neomycin, are nephrotoxic and ototoxic, and should not be taken by the client with hepatic encephalopathy. Cirrhosis and hepatic failure cause both ascites and encephalopathy; no contraindication for neomycin is known. Fetor hepaticus causes an ammonia smell to the breath when serum ammonia levels are elevated; neomycin is used to decrease serum ammonia levels. The client may be NPO for a few hours before paracentesis, but may take neomycin when the procedure is complete, or with less than 30 mL of water, depending on hospital policy.

An air medical helicopter arrives on the scene of a high-speed motorcycle collision with a train. The client was not wearing a helmet and is very confused, with a Glasgow Coma Scale score of 13. There is an apparent partial amputation of both hands. Vital signs are stable and the airway is secure. Which level of trauma center would be the most appropriate destination for this client?

Level I The American College of Surgeons defines a Level I trauma center as a regional resource facility capable of "providing leadership and total care for every aspect of injury, from prevention through rehabilitation." A Level II trauma center may not be able to meet the resource needs of clients who require very complex injury management, such as those in need of advanced surgical care. The primary focus of a Level III trauma center is injury stabilization and client transfer. In a Level IV trauma center, clients are stabilized to the best degree possible before transfer, with the use of available personnel. Resources, including the consistent availability of a physician, may be extremely limited.

The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply.

Maintain NPO (nothing by mouth) status. Encourage coughing and deep breathing. Give hydromorphone intravenously for pain. Rationale: The client with acute pancreatitis normally is placed on NPO status to rest the pancreas and suppress gastrointestinal secretions, so adequate intravenous hydration is necessary. Because abdominal pain is a prominent symptom of pancreatitis, pain medications such as morphine or hydromorphone are prescribed. Meperidine is avoided, as it may cause seizures. Some clients experience lessened pain by assuming positions that flex the trunk, with the knees drawn up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may help to ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore, measures such as turning, coughing, and deep breathing are instituted.

A hospitalized client with liver disease has a dietary protein restriction. The nurse encourages intake of which source of complete proteins to maximize the availability of essential amino acids?

Meats

What teaching does the home health nurse give the family of a client with hepatitis C to prevent the spread of the infection?

Members of the household must not share toothbrushes. Toothbrushes, razors, towels, and items that may spread blood and body fluids should not be shared. The client should not consume alcohol, but abstention will not prevent spread of the virus. The client may share a bathroom if he or she is continent. To prevent hepatitis A when traveling to foreign countries, bottled water should be consumed and ice made from tap water should be avoided.

When providing community education, the nurse emphasizes that which group should receive immunization for hepatitis B?

Men who prefer sex with men Men who prefer sex with men are at increased risk for hepatitis B, which is spread by the exchange of blood and body fluids during sexual activity. Consuming raw or undercooked shellfish may cause hepatitis A, not hepatitis B. Travel to third-world countries exposes the traveler to contaminated water and risk for hepatitis A; hepatitis B is not of concern, unless the client is exposed to blood and body fluids during travel. Clients who have liver disease should receive the vaccine, but men who have sex with men are at higher risk for contracting hepatitis B.

The nurse is creating a plan of care for a client with cirrhosis and ascites. Which nursing actions should be included in the care plan for this client? Select all that apply.

Monitor daily weight. Measure abdominal girth. Monitor respiratory status. Assist the client with care as needed. Rationale: Ascites is a problem because as more fluid is retained, it pushes up on the diaphragm, thereby impairing the client's breathing patterns. The client should be placed in a semi Fowler's position with the arms supported on a pillow to allow for free diaphragm movement. The correct options identify appropriate nursing interventions to be included in the plan of care for the client with ascites.

A client with viral hepatitis has no appetite, and food makes the client nauseated. Which nursing intervention is appropriate?

Monitor for fluid and electrolyte imbalance. Rationale: If nausea occurs and persists, the client will need to be assessed for fluid and electrolyte imbalance. It is important to explain to the client that most calories should be eaten in the morning hours because nausea is most common in the afternoon and evening. Clients should select a diet high in calories because energy is required for healing. Protein increases the workload on the liver. Changes in bilirubin interfere with fat absorption, so low-fat diets are better tolerated.

A client is admitted to the emergency department after being in a motor vehicle crash. The client was wearing a seat belt and the airbag deployed. There are no apparent injuries besides an abrasion from the shoulder harness across the clavicle and anterior chest. First vital signs are BP 110/70, HR 98, R 18, SaO2 98% on room air. The client's Glasgow Coma Scale score is 15. What does the nurse do next?

Monitors the client Blunt trauma results from impact forces. The energy transmitted from a blunt trauma mechanism, particularly the rapid acceleration-deceleration forces involved in high-speed crashes or falls from a great height, produce injury by tearing, shearing, and compressing anatomic structures. Injury may not be evident right away. A seat belt abrasion across the chest should alert the nurse to monitor closely for signs of potential internal injuries. Allowing the client to leave is not the best course of action because complications could still occur. No evidence in this scenario suggests that the client was drinking. There is no indication from the scenario that surgical intervention is required.

The nurse is caring for a client with acute pancreatitis. Which medications should the nurse expect to be prescribed for treatment of this problem? Select all that apply.

Morphine Dicyclomine Pantoprazole Acetazolamide Rationale: Medications used to treat acute pancreatitis include pain medications such as morphine, antispasmodics such as dicyclomine, proton pump inhibitors such as pantoprazole, and acetazolamide to decrease the volume and bicarbonate concentration of pancreatic secretions. Insulin is used in chronic pancreatitis to treat diabetes mellitus or hyperglycemia if needed, and pancreatic enzyme products are used for replacement of pancreatic enzymes.

While at a soccer match, a player drops to the ground with heat exhaustion and a diminished level of consciousness. What does the team nurse do first?

Move the player to the shade. Treat the client by immediately stopping physical activity, moving him or her to a cool place, and using cooling measures. Salt tablets can cause stomach irritation, nausea, and vomiting; the victim should not have anything by mouth until able to swallow. Placing ice in lymphatic areas is important, but is not the first intervention. Providing fluids is also important, but is not the first intervention because the victim should not have anything by mouth until able to swallow.

A client with a history of esophageal varices has just been admitted to the emergency department after vomiting a large quantity of blood. Which action does the nurse take first?

Obtain pulse and blood pressure. The nurse should assess vital signs to detect hypovolemic shock caused by hemorrhage. Obtaining charts, assessing bowel sounds, and pain assessment can be delayed until the client has stabilized. Assessment for adequate perfusion is the highest priority at this time.

A female client visiting the student health clinic for the first time states, "I think that I am allergic to bee stings." What does the nurse do with this data initially?

Obtains a prescription for an epinephrine emergency kit for the client It is a nursing responsibility to teach clients who are allergic to bee stings to carry an epinephrine emergency kit with them at all times. Sending the client to another care provider could be dangerous if the client suffers a bee sting in the interim. Although the client may not be allergic to bee stings, the fact that this allergy is stated by the client makes it something that the nurse needs to follow up on at this visit, rather than suggest the client follow up after talking to her family. Obtaining an allergy ID bracelet is an important precaution for the client to take, but is not the most critical initial intervention in this scenario.

A client with cirrhosis has ascites and excess fluid volume. Which assessment findings does the nurse anticipate to note as a result of increased abdominal pressure? Select all that apply.

Orthopnea and dyspnea Petechiae and ecchymosis Inguinal or umbilical hernia Abdominal distention and tenderness Rationale: Excess fluid volume, related to the accumulation of fluid in the peritoneal cavity and dependent areas of the body, can occur in the client with cirrhosis. Ascites can cause physical problems because of the overdistended abdomen and resultant pressure on internal organs and vessels. These problems include respiratory difficulty, petechiae and ecchymosis, development of hernias, and abdominal distention and tenderness. Poor body posture and balance are unrelated to increased abdominal pressure.

A golfer who is caught in a thunderstorm is struck by lightning. A fellow golfer, who is a nurse, runs to the victim's aid. What does the nurse do initially?

Palpate to check for the presence of a pulse. The most lethal initial effect of the massive current discharge of lightning on the cardiopulmonary system is asystole. The nurse should palpate for a pulse and begin cardiopulmonary resuscitation, if necessary. Dressing of the wound should be done only if the victim is stable. Victims of lightning strike are not electrically charged, so the rescuer is in no danger from physical contact.

The nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which nursing action is focused on the consequence of low albumin levels?

Palpating for peripheral edema

The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client?

Pasta with sauce Rationale: Cirrhosis is a chronic, progressive disease of the liver characterized by diffuse degeneration and destruction of hepatocytes. The serum ammonia level assesses the ability of the liver to deaminate protein byproducts. Normal reference interval is 10 to 80 mcg/dL (6 to 47 mcmol/L). Most of the ammonia in the body is found in the GI tract. Protein provided by the diet is transported to the liver by the portal vein. The liver breaks down protein, which results in the formation of ammonia. Foods high in protein should be avoided since the client's ammonia level is elevated above the normal range; therefore, pasta with sauce would be the best selection

The nurse is assessing a client with liver disease for signs and symptoms of low albumin. Which sign or symptom should the nurse expect to note?

Peripheral edema Rationale: Albumin is responsible for maintaining the osmolality of the blood. When the albumin level is low, osmotic pressure is decreased, which in turn can lead to peripheral edema. Weight loss is not a sign or symptom for hypoalbuminemia. Capillary refill of 5 seconds is a delayed filling time but is not associated with decreased albumin levels. Clotting factors produced by the liver (not albumin) are responsible for coagulation, and lack of clotting factors can result in bleeding from old puncture sites. The total protein level may decrease if the albumin level is low.

The RN is caring for a client with end-stage liver disease that has resulted in ascites. Which action does the RN delegate to unlicensed assistive personnel (UAP)?

Placing the client in a semi-Fowler's position Positioning the client in a semi-Fowler's position is included within UAP education and scope of practice, although the RN will need to supervise the UAP in providing care and will evaluate the effect of the semi-Fowler's position on client comfort and breathing. Assessment of skin integrity and abdominal distention, obtaining blood from a central line, and evaluation of laboratory results should be done by the RN.

The nurse is caring for a client with cirrhosis. As part of dietary teaching to minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the material if the client states to increase intake of which food?

Pork Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in the vitamin. Other good sources include peanuts, asparagus, and whole-grain and enriched cereals.

Which problem for a client with cirrhosis takes priority?

Potential for injury related to hemorrhage Potential for injury related to hemorrhage is the priority client problem because this complication could be life-threatening. Insufficient knowledge, discomfort, and inadequate nutrition are not priorities because these issues are not immediately life-threatening.

The nurse is monitoring a client with cirrhosis of the liver for signs of hepatic encephalopathy. Which assessment finding would the nurse note as an early sign of hepatic encephalopathy?

Presence of asterixis Rationale: Asterixis is a flapping tremor of the hand that is an early sign of hepatic encephalopathy. The exact cause of this disorder is not known, but abnormal ammonia metabolism may be implicated. Increased serum ammonia levels are thought to interfere with normal cerebral metabolism. Tremors and drowsiness also would be noted.

The nurse administers lactulose (Evalose) to a client with cirrhosis for which purpose?

Promotes gastrointestinal (GI) excretion of ammonia Lactulose reduces serum ammonia levels by excreting ammonia through the GI tract. Lactase is the enzyme that digests dairy products. The mechanism of action of lactulose is not to reduce portal pressure. Lactulose does not affect bleeding.

The emergency department manager has created a task force to decrease the rate of adverse incidents in patients who have increased safety needs during their stay in the department. At their meeting, each person discussed a specific safety need and actions that can be taken to reduce that risk. 4. How can the staff reduce hazard risks for patients who are confused (either as a chronic condition or as the result of medication side effects) or who have delirium?

Reorient the patient as needed, provide a calm, quiet environment and have family or familiar person sit at the bedside; if no family is available, provide a sitter. Use the smallest dose of medication needed to control symptoms, reassure the patient that he or she is safe, allow the patient to sit in a chair as tolerated, provide food and fluids if allowed, keep the patient warm, and meet other needs that might lead to patient trying to get up. Keep the siderails up and the call light in reach.

A health care worker believes that he may have been exposed to hepatitis A. Which intervention is the highest priority to prevent him from developing the disease?

Requesting an injection of immunoglobulin The administration of immunoglobulin, antibodies to hepatitis A, may prevent development of the disease. The vaccine for hepatitis A will take several weeks to stimulate the development of antibodies; passive immunity in the form of immunoglobulin is needed. Implementing a needleless system and getting the three-part vaccine may prevent the development of hepatitis B, not hepatitis A.

How does the home care nurse best modify the client's home environment to manage side effects of lactulose (Evalose)?

Requests a bedside commode for the client Lactulose therapy increases the frequency of stools, so a bedside commode should be made available to the client, especially if he or she has difficulty reaching the toilet. Small frequent meals and elevating the head of the bed will not have any effect on the side effects of lactulose. Although lactulose produces excessive stools and could potentially result in loss of potassium, it is inappropriate for the nurse to suggest that the client take potassium supplements.

The nurse assists a health care provider in performing a liver biopsy. After the procedure, the nurse should place the client in which position?

Right side Rationale: To splint and provide pressure at the puncture site, the client is kept on the right side for a minimum of 2 hours after a liver biopsy. Therefore, the remaining positions are incorrect.

The nurse is attempting to position a client having an acute attack of pancreatitis in the most comfortable position possible. In which position does the nurse place this client?

Side-lying position, with knees drawn up to the chest

The nurse in charge of a nursing unit is asked to select those hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply.

The client who 24 hours earlier gave birth to her second child by caesarean delivery The 48-hour postoperative client who has undergone an ileostomy because of ulcerative colitis The 2-day postoperative client who has undergone total knee replacement and is ambulating with a walker The 3-day postoperative client who has undergone coronary artery bypass grafting and is ready for rehabilitation

Following paracentesis, during which 2500 mL of fluid was removed, which assessment finding is most important to communicate to the heath care provider?

The client's heart rate is 122 beats/min. Rapid removal of fluid may cause symptoms of shock; tachycardia, especially when associated with hypotension, should be reported to the provider. A small amount of serous fluid may leak; the dressing should be reinforced. Platelets will be checked before the procedure; these are slightly low, but this is not a cause for concern. An albumin level of 2.8 mg/dL is an expected finding for a client with cirrhosis; it is not life threatening. Awarded 1.0 points out of 1.0 possible points.

Lactulose is prescribed for a hospitalized client with a diagnosis of hepatic encephalopathy. Which assessment finding indicates that the client is responding to this medication therapy as anticipated?

The fecal pH is acidic. Rationale: Lactulose is an osmotic laxative used to decrease ammonia levels, which are elevated in hepatic encephalopathy. The desired effect is 2 or 3 soft stools per day with an acid fecal pH. Lactulose creates an acid environment in the bowel, resulting in a fall of the colon's pH from 7 to 5. This causes ammonia to leave the circulatory system and move into the colon for excretion. Diarrhea may indicate excessive administration of the medication. Vomiting and ability to tolerate a full diet do not determine that a desired effect has occurred.

A nurse is working at a day camp for church leaders when a sudden severe thunderstorm occurs. Several adults participating in outdoor activities appear to have been hit by lightning. The nurse arrives on scene and finds four injured people. One person appears to be unconscious, one has ferning marks and burns on his skin, and the other two are sitting up against the wall of a building and reporting severe weakness of their lower extremities. 2. Which person should the nurse assess first, and what is the priority of care of this patient?

The nurse should assess the unconscious patient first. The most lethal effect of lightning is on the cardiopulmonary system and can manifest as cardiopulmonary arrest. If needed, the nurse needs to provide cardiopulmonary resuscitation to this individual.

A client is admitted to the hospital with a diagnosis of acute pancreatitis. Which would the nurse expect the client to report about the pain?

The pain usually increases after vomiting. Rationale Pain with acute pancreatitis usually increases after vomiting because of an increase in intraductal pressure caused by retching, which leads to further obstruction of the outflow of pancreatic secretions. The pain is a steady and intense epigastric pain that radiates to the client's back and flank. The pain may lessen when the client sits up or bends forward. Eating exacerbates the pain by stimulating the secretion of enzymes.

A client diagnosed with acalculous cholecystitis asks the nurse how the gallbladder inflammation developed when there is no history of gallstones. What is the nurse's best response?

This type of gallbladder inflammation is associated with hypovolemia."

The nurse is caring for a client recently diagnosed with type 1 diabetes mellitus who has had an episode of acute pancreatitis. The client asks the nurse how he developed diabetes when the disease does not run in the family. What is the nurse's best response?

Type 1 diabetes can occur when the pancreas is destroyed by disease."

A nurse is working at a day camp for church leaders when a sudden severe thunderstorm occurs. Several adults participating in outdoor activities appear to have been hit by lightning. The nurse arrives on scene and finds four injured people. One person appears to be unconscious, one has ferning marks and burns on his skin, and the other two are sitting up against the wall of a building and reporting severe weakness of their lower extremities. 4. What direction should the nurse give the large crowd of campers and camp staff?

Unless someone is actively helping in the rescue effort, the nurse should direct the crowd indoors to prevent further injuries. Someone should call 911 for prompt evacuation of all injured people to a hospital for further assessment and care. If available, dry sterile dressings can be applied to any obvious burns.

The nurse is obtaining a health history for a client with chronic pancreatitis. The health history is most likely to include which as a most common causative factor in this client's disorder?

Use of alcohol Rationale: Chronic pancreatitis occurs most often in alcoholics. Abstinence from alcohol is important to prevent the client from developing chronic pancreatitis. Clients usually experience malabsorption with weight loss. Chemical exposure is associated with cancer of the pancreas. Pain will not be relieved with food or antacids.

The nurse is preparing to instruct a client with chronic pancreatitis who is to begin taking pancrelipase (Cotazym). Which instruction does the nurse include when teaching the client about this medication?

Wipe your lips after taking pancrelipase

There has been an explosion at a local refinery. Numerous serious and life-threatening injuries have occurred. The following clients arrive from the scene by private vehicle. Which client is considered a priority for treatment?

Woman bleeding heavily The woman critically injured with trauma or an active hemorrhage is prioritized as emergent. The emergent triage category implies that a condition exists that poses an immediate threat to life or limb and should be treated immediately. Although the child with an open fracture of the arm, the man with a contusion of the head, and the teenager with a closed fracture of the leg are urgent, they are not emergent and can wait for a short time.

client has just been diagnosed with pancreatic cancer. The client's upset spouse tells the nurse that they have recently moved to the area, have no close relatives, and are not yet affiliated with a church. What is the nurse's best response?

Would you like me to contact the hospital chaplain for you?

The emergency department manager has created a task force to decrease the rate of adverse incidents in patients who have increased safety needs during their stay in the department. At their meeting, each person discussed a specific safety need and actions that can be taken to reduce that risk. 3. What actions can be delegated to unlicensed personnel in the following areas: medication administration, skin protection, and fall risk?

a. Medication administration: none b. Skin protection: Institute turning schedule, keep linens dry and wrinkle free, keep incontinent patients clean and dry, offer trips to the bathroom frequently for those who can walk, and ensure that the patient is not lying on supplies or other items. c. Fall risk: Sit with the patient, reorient the patient, ensure that the call light is within reach, ensure that side rails are up, and ask about personal needs (e.g., bathroom, water as allowed).

How does the high school nurse react directly after a random shooting at a high school?

b. Assesses his or her own individual feelings (One must be able to support oneself before supporting others.)

In an emergency situation, how is the incident of an overturned school bus categorized?

b. May be a mass casualty (A mass casualty event overwhelms local medical capabilities. It may require the collaboration of multiple agencies and health care facilities to handle the crisis. Depending on the community, available resources, and the quantity and severity of those injured, this may be a mass casualty.)

Which essential item is added to a personal readiness supplies "go bag"?

b. Potable water (The go bag should contain 1 gallon of potable water per person per day.)

After successful treatment of clients involved in a mass casualty incident, the incident commander deactivates the emergency response plan. Which of these activities is most important for the emergency department (ED) charge nurse to initiate at this time?

b. Take inventory, and re-stock the ED with supplies and equipment. (The priority is re-stock the ED to return to normal operation.)

The client comes to the emergency department covered with coagulated blood and a white powder. The client is hysterical and fears that it is anthrax. What does the nurse do first?

c. Takes the client to the decontamination room (Decontamination should precede triage. Only the most basic life-sustaining interventions should be performed before or during decontamination. The coagulated blood indicates that the major active bleeding has likely subsided.)

After losing her home to a hurricane several years ago, the client says, "I get very nervous during a thunderstorm and want to hide under the bed." What is the nurse's best response?

d. "What do you do when you feel this way?" (Check to see whether the thought is causing maladaptive behavior, and then assess whether it is normal or abnormal.)

The emergency department charge nurse is making client assignments and delegating care after a mass casualty event. Care for which of these clients could be delegated to a nursing assistant?

d. A client who is unconscious and has massive aortic bleeding from the chest (This client is unlikely to survive owing to massive thoracic bleeding and would be "black-tagged" and assigned to a nursing assistant.)

During a mass casualty, which injury receives care first?

d. Sucking chest wound (This casualty is a red tag, or emergent, because it can be quickly resolved until further help can be given.)

During a mass casualty, staff roles are defined. If the triage officer is incapacitated, who is the best choice for replacement?

d. Triage nurse (When physician resources are limited, an experienced nurse may assume this role. Whoever can best meet the needs of the clients is the best choice.)

The nurse suspects that which client is at highest risk for developing gallstones?

obese female on hormone replacement therapy

The nurse is teaching a client with gallbladder disease about diet modification. Which meal does the nurse suggest to the client?

turkey sandwich on wheat bread