FINAL COMPLEX

The adult client was burned as a result of an explosion, the burn initially affected the clients entire face and the upper half of the anterior torso and there were circumferential burns to the lower half of both arms. the clients clothes caught on fire and the client ran causing subsequent burn injuries to the posterior surface of the head and upper half of the posterior torso.

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Which prescribed intervention will the nurse implement first for a patient in the emergency department who is experiencing status epilepticus

Administer lorazepam (Ativan) 4 mg IV.

A patient physician has ordered a liver panel in response to the patients development of jaundice. when reviewing the results of this laboratory testing the nurse should expect to review what blood tests

Alanine aminotransferase (ALT) Gamma-glutamyl transferase (GGT) Aspartate aminotransferase (AST)

A client with trauma to the chest develops a tension pneumothorax. After needle thoracostomy is performed the nurse would expect

An increase in blood pressure

A nurse is assisting with caloric testing of the oculovestibular reflect of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements towards the left followed by a rapid nystagmus towards the right. the nurse understands that this indicates the client has

An intact brain stem

What is the first step to stop a hemorrhage associated with an amputated extremity

Apply tourniquet

a nurse is participating in the emengey care of a patient who has just developed variceal bleeding. what intervention should the nurse anticipate

IV administration of octreotide (sandostatin)

A patient is brought by friends to the ED after being

Immobilize the patient on a backboard

A patient is diagnosed with a small subdural hematoma with a history of a trip and fall in which he hit his head on the sink two days ago. He is waiting for an inpatient bed. the nursing shift reports indicates that he did not sleep last night and has been very anxious as the nurse begins an assessment, he vomits and states he couldn't sleep because young children kept coming into his room during the night. What is a likely cause of these signs and symptoms?

Increased intracranial pressure

A patietn with aids has dark purplish brown lesions on the mucus membranes of the mouth. As the nurse you know these lesions correlate with what type of opportunistic disease

Kaposi's sarcoma

the Monro Kellie hypotheses explains the compensatory relationship among the structures in the skull that play a role with intracranial pressure. Which of the following are not compensatory mechanisms performed by the body to decrease intracranial pressure naturally

Leaking proteins into the brain barrier vasodilation of cerebral vessels

While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions? A Autonomic dysreflexia B Hemorrhagic shock C Neurogenic shock D Pulmonary embolism

Neurogenic shock

Which medication below used to treat SLE decreases inflammation quickly, is not for long term usage and can lead to weight gain, susceptibility to infection , diabetes and osteoporosis.

Prednisone

A 6-year-old child is seen in the urgent care unit for a history of seizures at home. he begins to have seizures in the urgent care unit that last more than 5 minutes. IV access has not been successful. the nurse caring for this child is knowledgeable that either of these medication may be given to stop the child's seizure

Rectal diazepam and Buccal midazolam

Which of the following would lead the nurse to suspect that a client with a fracture of the right femur may be developing a fat embolus

acute respiratory distress syndrome

A client with pancreatitis may exhibit cullen sign of physical examination. which of the following best describes cullen sign

blush discoloration of the peri-umbilical area

the nurse is reviewing the orders written for a client admitted to the hospital with acute pancreatitis. which physician order should the nurse questions

consent for laparoscopic cholecystectomy

A young male patient has been brought to the emergency department with a knife wound to the abdomen. when the patient's hands are removed from the area of the wound to facilitate assessment, the patients intestine protrudes from the wound. How should the nurse respond to the development

cover the protruding viscera with saline soaked, sterile gauze

Which of the following findings on initial assessment is a late manifestation of a tension pneumothorax

cyanosis

a nurse is caring for a client following his first hemodialyisis treatment. the client reports a headache, nausea, and restlessness, the nurse should identify these findings as manifestations of

dialysis disequilbrium

When caring for a patient with systemic sclerosis, the nurse knows it is important to instruct the patient related to

performing mouth excursion yawning exercises maintain joint function and preserving muscle strength strategies for good dental hygiene and mouth care protecting the extremities from hot and cold temperature

A patient complaines of a fever and sternal chest pain that is worse when lying down. for this patient the emergency nurse suspects

pericarditis

how will the nurse assess for flank tenderness in a 30 year old female patient with suspected rhabdomyolysis

strike a flat hand covering the CVA

You respond to a call for help from the ED waiting room. there is an elderly patient lying on the floor.

1 establish unresponsiveness 2 call for help and activate the code team 3 perform the chin lift or jaw thrust maneuver 4 initiate CPR 5 instruct a nursing assestant to het the crash cart

Which of these oncological emergencies would be considered an infiltrate of emergency?

Cardiac tamponade

The nurse recognizes the presence of Cushing's triad in the patient with a. Increased pulse, irregular respiration, increased BP b. decreased pulse, irregular respiration, increased pulse pressure c. increased pulse, decreased respiration, increased pulse pressure d. decreased pulse, increased respiration, decreased systolic BP

Decreased pulse, irregular respiration, widened pulse pressure

A trauma cleitn with multiple open wounds is brought to the emergency department in cardiac arrest. which action should the nurse take prior to providing advanced cardiac slife support

Don personal protective equipment

A patient who received a bone marrow transplant for treatment of leukemia develops a skin rash 10 days after the transplant. the nurse recognizes this reaction as an indication that the

Donor T cells are attacking the patients skin cells

A client was brought to the emergency department after suffering a closed head injury and laceration around the face due to a hit-run accident. the client is unconscious and has a minimal responses to noxious stimuli which of the following assessment findings if observed after a few hours should be reported to the physician immediately

Drainage of a clear fluid from the clients nose

Which patient should the nurse priories as needing emergent treatment assuming no other injuries present except the ones outlined below

A patient with a blunt chest trauma with some difficulty breathing

A week after kidney transplantation, the client develops a temperature of 101 F the blood pressure is elevated and the kidney is tender. The X-ray indicates that the kidney is enlarged. Based on these assessment findings, the nurse would suspect which of the following complications

Acute rejection

A client with a head injury has an intracranial pressure monior in place. The nurse is monitoring the cerebral perfusion pressure which interventions would the nurse employ while monitoring the clients CPP

Administer vasoactive drugs as ordered

In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey

Brief neurologic assessment

on average less than _____ of patients who receive CPR survive to leave the hospital

10%

therapeutic hypothermia is initiated for a patient with return of spontaneous circulation after cardiac arrest. the nurse should expect to maintain the hypothermic state for how long after the resuscitation

12-24 hours

A patient with SLE is experiencing a complication called Lupus nephritis. What are some signs and symptoms that correlate with this complication of SLE

48 hour urinary output of 720 ml increased BUN proteinuria edema in the upper and lower extremities

After teaching a patient on immunosuppressant therapy after a kidney transplant about the posttransplant drug regimen, the nurse determines that additional teaching is needed when the patient says

After a couple years, it is likely that I will be able to stop taking the calcineurin inhibitor

A 15 year old has been brought to the emergency department by his friends after serving his brachial artery while trying to scale a fance. In order to stop this patents bleeding, the nurse should

Apply direct pressure to the wound

Each chemotherapeutic agent has a specific nadir. What is important to do when giving combination therapy?

Avoid giving agents with the same nadirs and toxicities at the same time

A trauma patient in the emergency department is showing signs of acute renal failure that the care team suspects are due to myoglobinuria. the ED nurse should recognize that these problems are most closely associated with what type of injury

Crush injury

MI are caused by thrombotic events

FALSE

Wolff-Parkinson-White Syndrome

Most common type of ventriuclar pre-excitation sydnrome. Abnormal fast accessory conduction pathway from atria to venricle bypasses the rate-slowing AV node causing a delta wave and widening QRS with shortened PR interval. Could lead to a reentrant circuit and suprvaventicular tachy.

An intubated patient is being transferred to the ICU after a motor vehicle crash. He received aggressive fluid resuscitation. results of an FAST exam in the emergency department were negative. Assessment at this time reveals marked abdominal distention, oliguria, and significant tachycardia with hypotension. Investigating the most likely etiology the nurse would expect to obtain

Renal ultrasound

A nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a 3rd-degree circumferential arm burn. the nurse understands that the anticipated outcome of the escharotomy is

Return of distal pulses

A nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decebrate posturing. On assessment of the child the nurse would expect to note which of the following if this type of posturing was present

Rigid extension and pronation of the arms and legs

which of the following EKG changes are abnormal findings that indicate ischemia found on 12 lead EKG

ST segment elevation t wave inversion ST segment depression

A 78 year old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priotity.

Scheule for a stat CT scan of the head

A client was a C4 spinal injury would most likely have which of the following symptoms

Tetraplegia

A clients presents in the emergency department after falling from a roof. A fracture of the femoral neck suspected. Which of these assessments best supports this diagnosis

The affected extremity is shortened, adducted and extremely rotated

Four years after seroconversion, an HIV-infected patient has a CD4+ cell count of 800/µl and a low viral load. The nurse teaches the patient that a. the patient is at risk for development of opportunistic infections because of CD4+ cell destruction. b. the patient is in a clinical and biologic latent period, during which very few viruses are being replicated. c. anti-HIV antibodies produced by B cells enter CD4+ cells infected with HIV to stop replication of viruses in the cells. d. the body currently is able to produce an adequate number of CD4+ cells to replace those destroyed by viral activity.

The body currently is able to produce an adequate number of CD4+ cells to replace those destroyed by viral activity

A client with a subdural hematoma becomes restless with confused, with dilation of the ipsilateral pupil. the physician orders mannitol for which of the following reasons

To promote osmotic diuresis to decrease ICP

following kidney transplant cyclosporine is prescribed for a client. which laboratory results would indicate an adverse effect from the use of the medication

elevated BUN level

The nurse suspects the presence of an arterial epidural hematoma in the patient who experiences a. failure to regain consciousness following a head injury b. a rapid deterioration of neurologic function within 24 to 48 hours following a head injury c. nonspecific, nonlocalizing progression of alteration in LOC occurring over weeks or months d. unconsciousness at the time of a head injury with a brief period of consciousness followed by a decrease in LOC

unconsciousness at the time of a head injury with a brief period of consciousness followed by a decrease in LOC

The major preventable cause of death in the trauma patient is:

uncontrolled hemorrhage

non-invasive techniques that nurses can encourage patients to do to interrupt tachyarrhythmias

vagal maneuves, valsalva maneuver

A client with MI is going in to cardiogenic shock the nurse should carefully assess

ventricular dysthymias

First few hours up to days after and Acute MI

ventricular septum rupture reperfusion injury acute mitral regurgitation PCI occlusion

The nurse prepares to give a bath and change the linens for a client with cutaneous Kaposi sarcoma lesions. the lesions are open and draining a scant amount of serous fluid. Which of the following would the nurse incorporate into the plan during bathing of this client.

wearing a gown and glocves

which of the laboratory results would be expected in a client with peritonitis?

white blood cell count above 15000

nurses caring for a patient receiving an initial dose of chemotherapy to treat a rapidly growing metastatic colon cancer. And the nurses are where those patients at risk for tumor lysis syndrome and will monitor the patient closely for which abnormality associated with this oncologic emergency

Hypocalcemia

which of these disorders is common cause for acute kidney injury

Hypovolemia sepsis azotemia nephrotic agents

During the first 24 hours after thrombolytic therapy for ischemic stroke the primary goal is to contol the clients

blood pressure

the emergency nurse initiates the prescribed treatment for a patient with a dissecting aortic aneurysm. which condition indicates that this intervention is having the desired effect

blood pressure is controlled

Serious adverse effects of adenosine

bradycardia, bronchospasms and ventricular standstill

A client develops atrial fibrillation with a ventricular rate of 140 bpm and signs of decreased cardiac output what should the nurse administer first

metoprolol (Lopressor)

A client is diagnosed with an acute MI and is receiving tissue plasminogen activator alteplase what is a priority nursing intervention

monitor for signs of bleeding

The nurse is assessing the motor function of an unconscious client. the nurse would plan to use which of the following to test the clients peripheral response to pain

nail bed pressure

The nurse should anticipate administering all of the following medical treatments to a client with increased intracranial pressure due to brain hemorrhage except

nitroglycerin

the nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. the client begins to complain of increased abdominal pain and begins to vomit. on assessment, the nurse notes that the abdomen is distended, and bowel sounds are Dimiches. which is appropriate nursing intervention

notify the Phyician

A nurse has conducted teaching with a client in an arm cast about signs and symptoms of compartment syndrome. The nurse determines that the client understand the information if the client states that he or she should report which of the following early symptoms of compartment syndrome.

numbness and tingling in the fingers

A patient is complaining of chest pain. on the bedside monitor you observe a pronounce T wave the most important nursing intervention

obtain a 12 lead EKG administer Nitroglycerin sublingual collect cardiac enzymes administer morphine place patient on oxygen

a nurse is assessing a client who had a craniotome and has developed SIADH which of the following manifestations should the nurse anticipate

oliguria

The nurse is caring for a patient who has a head injury, which finding when reported to the health care provider should the nurse expect will result in new prescribed interventions

pale yellow urine output of 1200 mL over the past 2 hours.

Which assessment finding indicates that lactulose is effective in decreasing the ammonia level in the client with hepatic encephalopathy

passage of two or three soft stools daily

A nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. which of the following is an early sign of this oncological emergency

periorbital edema

a client with acute renal failure has a potassium of 6.0 the nurse would give which of the following as a priority action

place the client on cardiac monitoring

the client with cirrhosis is beginning to show signs of hepatic encephalopathy. the nurse would plan a dietary consult to limit the amount of which ingredient in the clients diet

protein

A patient receiving radiation to the chest area reports shortness of breath, fever and cough. the nurses identifies that the patient is showing signs of what complication

radiation pneumonitis

a nurse is caring for a hospitalized female client with a diagnosis of ischemic colitis. which findings if noted on assessment of the client would the nurse report to the physician

reboundtenderness

A nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. which of the following would indicate the procedure was unsuccessful?

rising central venous pressure

A female client has clear fluid leaking from the nose following a basilar skull fracture. the nurse assess that this is cerebrospinal fluid if the fluid

separates into concentric rings and tests positive for glucose

A nurse is reviewing the lab report of a client and identify a potassium level of 6.8 which of the following mediations should the nurse administer

sodium polystyrene

a client is receiving thrombolytic therapy with a continuous infusion of streptase. the client becomes anxious and complains of itching

stop the infusion and call the physician

A 25 year-old female is about to deliver a baby. the patient is HIV positive and has been taking antiviral therapy during pregnancy. What steps can be taken to help prevent transmitting the virus to the baby after birth

substitute formula for breast feeding

the patient is brought to the ED with an anterior ST elevation MI STEMI you are assessing him for possible administration of fibrinolytics. an absolute contraindication is

symptoms began 36 hours before arrival

What condition is transmitted through wound contamination, causes painful tonic spasms or seizures and be be prevented by immunizations

tetanus

The client with acquired immunodeficiency syndrome and pneumocystis carinii infection has been receiving pentam. the client develop a temperature of 101F the nurse does further monitoring of the client., know that the sign most likely indicates

that the result of another infection cause by leukopenia effects f the medication

The female client who has been receiving therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. the nurse interprets that the client may be experienceing

the development of vesicovaginal fistula

The client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the clients' vital signs, place the nurse actions in order of priority

1 raise the head of bed 2loosen tight clothing 3 check for bladder distention 4 contact the physician 5administer antihypertensive medication 6documentation

When assessing the laboratory results of the client with bladder caner and bone metastasis, the nurse notes a calcium level of 12And our recognizes consistent with which oncological emergency

Hypercalcemia

A client arrives at the emergency department who suffered multiple injuries from a head-on car collision. which of the following assessments should take the highest priority to perform

A Deviated trachea

The nurse is caring for a client following radical neck dissection and creation of a tracheostomy performed for laryngeal cancer and is providing discharge instructions to the client. which statement by the client indicates a need for further instruction

I need to use an air conditioner to provide cool air to assist in breathing

As part of chemotherapy education of nurse tells a female client about the risk for bleeding and self-care during the period of the greatest bone marrow suppression or the nadir. The nurse understands that further teaching is needed. Again, those keywords, further teaching is needed when the client states.

I'm going to take aspirin for my headache as soon as I get home

Plasmapheresis can be used to treat autoimmune diseases such as

ITP Glomerulonephritis Rheumatoid arthritis Goodpasture Syndrome Myasthenia gravis SLE TTP Gulllian-barre syndrome

Which is the most common HIV related neurological complication

Toxoplasmosis

The nurse is caring for a ventilated client with increased intracranial pressure following a motor vechine accident. the nurse monitors the PaCO2 to ensure it remains between 30-35mmHg. Which of the following is an expected outsome at this range of PaCO2

Vasoconstriction of cerebral blood vessels Decreased cerebral blood flow Decreased intracranial pressure

The nurse is evaluating that status of a client who had a craniotomy 3 days ago. the nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits

a positive Brudzinski's sign

paitient monitor shows bradycardia, no palpable pulse CPR continues IV access is established

administer epinephrine

Pulmonary edema priority intervention

administer oxygen insert urinary catheter administer furosemide administer morphine

A patient is admitted to the hospital with acute rejection of a kidney transplant. the nurse will anticipate

administration of immunosuppressant medications

the nurse is reviewing the record of a client with a dx of cirrhosis and notes that there is documentation fo the presence of asterixis

ask patient to extend the arms

A nurse is caring for a patient who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this patients plan of care

assessment for variceal bleeding

The family of a client with a spinal cord injury rush to the nursing station, saying that the client needs immediate help on entering the room the nurse notes that the client is diaphoretic with a flushed face and neck and complains of severe headache. the HR is 40 beats/min and the BP is 230/110 mmHg. the nurse acts quickly suspecting that the client is experiencing

autonomic dysreflexia

increased pulse increased respiratory rate decreased BP

cardiogenic shock

an 84 year old female is admitted the the ED after her neighbor reported that they had not seen her for several days. EMS found her at home unable to get off the floor after a fall. while reviewing the patients initial laboratory values which results should the nurse report immediately to the provider

elevated CPK and myoglobin

a nurse is planning care for a client who has new diagnosis of diabetes insipidus. which of the following interventions should the nurse include in the plan of care

encourage fluid intake check urine specific gravity

You are providing nursing care for a patient with ARF who has a nursing diagnosis of fluid volume excess related to compromised regulatory mechanisms. which action should you delegate to the experienced nursing assistant?

ensure the patients urinal is within reach remind patient to save all urine for intake and output record weigh patient every morning using standing scale monitor and record vital signs every 4 hours

A patient is undergoing plasmapheresis for treatment of SLE. the nurse explains that plasmapheresis is used in her treatment to

exchange her plasma that contains antinuclear antibodies with a substitute fluid

a 64 year old male is scheduled for an ERCP related to end stage liver failure and portal hypertension what potential adverse effect should the nurse be vigilant for

hemorrage

possible causes of cardiac arrest include all of the following except: hypoxia, hypokalemia, tension pneumorthorax

hypervolemia

in acute rapid atrial fibrillation when is it advised to use electrical manament

in patient with Wolff -Parkinson white syndrome

a nurse is caring for a client with cirrhosis of the liver who has developed esophageal varices. the nurse understands that the best explanation for development of esophageal varices is

increased portal pressure causes some of the blood that normally circulates through the liver to be shunted to the esophageal vessels increasing that pressure and causing varicosities

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. the nurse assessment reveals a blood pressure of 90/50mmhg a pulse rate of 100 beats/min and urine output of 20ml over the past hour. the nurse reports the findings to the physician and antipastes which of the following orders to be prescribed

increasing the amount of IV lactated ringers administered per hour

The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists

instability to elicit a Babinski reflex

the nurse is reviewing the lab results in a cleitn with cirrhosis and notes that the ammonia level is elevated. which medication does the nurse anticipate to be prescribed for this patient

lactulose

The client who is HIV seropositive has been taking zalcitabine as a component of treatment. the nurse plans to monitor which of the following most closely while the client is taking this medication

liver function studies

a client with carcinoma of the kidney develops syndrome of SIADH as a complication of cancer. The nurse anticipates that which of the following may be prescribed

medication that is antagonist to ADH decreased oral sodium intake chemotherapy radiation

Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best? a. "This type of monitoring system is complex and it is managed by skilled staff." b. "The monitoring system helps show whether blood flow to the brain is adequate." c. "The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure." d. "This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage."

the monitoring system helps show whether blood flow to the brain is adequate

What is the main purpose of initiation targeted temperature management in patients who are post cardiac arrest

to halt progression of reperfusion injury in comatose patients post ROSC

A client with a subdural comes restless and confused with dilation of the ipsilateral pupil. the physician orders a mannitol for which of the following reasonings

to promote osmotic diuretics to decrease ICP

Magnesium deficiency

torsade's de Pointes

A female client who was found unconscious at home is brought to the hospital by a rescue squad to the ICU the nurse checks the client oculocephalic response by

turning the clients head suddenly while holding the eyelids open