Final Review

A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first

Auscultate for wheezing

Before undergoing a colon resection for cancer of the colon, a patient has an elevated carcinoembryonic antigen (CEA) test. The nurse explains that the test is used to

monitor the tumor status after surgery

A nurse is caring for a client who has increased ICP, which of the following interventions should the nurse take?

elevate the head of bed

If a client is admitted to the hospital for treatment of atrial fibrillation complains of dyspnea and chest pain, the nurse would suspect

pulmonary emboli

While obtaining a nursing history from a 55-year-old patient scheduled for a colonoscopy, the nurse would be most concerned about

recent blood in the stool

The nurse explains to the client that in addition to approximating the bone fragments, traction also

reduces muscle spasm

A nurse is caring for a client 4 hr following evacuation of subdural hematoma. Which of the following assessments is the nurses priority?

respiratory status

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increases intracranial pressure (ICP)

restlessness

A nurse is participating in a disaster simulation in which a toxic substance is released into a crowded stadium. Multiple clients are transferred to the facility. Which of the following activities would be the lowest priority for the nurse

transferring a client to the discharge location

A patient with deep partial-thickness and full-thickness burns of the face and chest has the wounds treated with the open method. The nurse identifies the expected patient outcome of the absense of wound infection. An appropriate nursing action to help the patient meet this outcome is to

wear gowns, caps, masks, and gloves, during all care of the patient

A patient newly diagnosed with Crohns disease asks the nurse what to expect in the future. The best response by the nurse is

"you need to know there is a probability of lifelong unpredictable periods of remission and recurrences"

A nurse in the emergency room is caring for a client who has burns on the front and back of both of his legs and arms. Using the rule of nines, the nurse should document burns to which percentage of the client's total body surface area (TBSA)

54 percent

A nurse is preforming triage for a group of clients following a mass casualty incident (MCI) which of the following clients should the nurse plan to care for first.

A client experiencing a tension pneumothorax

A nurse is to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. Which of the following clients should the nurse tag to be the priority for care.

A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site.

A nurse is assessing four clients for fluid balance. The nurse should identify that which of the following clients is exhibiting manifestations of dehydration

A client who has temperature of 39C

Two days after an accident in which a client sustained multiple injuries, including fractures, the client becomes confused and dyspneic and has a fever of 103.4. The nurse assesses the client has developed

A fat embolism

A nurse is caring for a client who has an epidural hematoma. Which of the following manifestations should the nurse expect?

A lucid period followed by an immediate loss of conciousness

A nurse is caring for a client who has lung cancer and is scheduled for a lobectomy. The nurse should prepare the client to expect which of the following after the procedure

Chest tube

A charge nurse is discussing disaster response with nursing staff. Which of the following statements indicated an understanding of the hospital incident command system (HICS)

HICS identifies facility responsibilities and channels of reporting

A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching

If I could lose about 50 pounds, I might stop having so many apneic episodes

A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hours following a burn injury

Lactated ringers

A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?

Large incisions will be made in the eschar to improve circulation

A patient develops sinus bradycardia at a rate of 32 beats/ min, has a bp of 80/36 and is complaining of feeling faint. Which should the nurse take first

Obtain and apply the transcutaneous pacemaker

In analyzing a patient's electrocardiographic (ECG) rhythm strip, the nurse uses the knowledge that the time of the conduction of an impulse through the Purkinje fibers is represented by the

PR interval

A nurse is reviewing the laboratory values of a patient with respiratory acidosis. Which of the findings should the nurse expect.

PaCO2 50mmhg

A nurse is caring for a client who has had a spinal cord injury at the level of the T-9 T-10 vertebrae. When planning care the nurse should anticipate which of the following types of disability.

Paraplegia

A nurse is caring for a patient with a peripheral access device who is experiencing pain, redness, and swelling at the site. After removing the device what action will the nurse take to relieve the pain

Place warm compress at the site

An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client

Plantar flexion of the legs

A nurse is caring for a client who had a right sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take

Remind the client to look for food on the left side of the tray

A nurse is discussing emergency response with a newly licensed nurse. The nurse should identify which of the following as a triage officer during the time of a disaster?

nurses and other medical emergency personnel

A nurse assesses a patient's peripheral IV site and notices edema and tenderness above the site. What action will the nurse take next?

Stop the infusion of intravenous fluids

A nurse is caring for a client who has a suspected diagnosis of cystic fibrosis. Which of the following diagnostic tests will confirm

Sweat chloride test

A patient has just undergone a spinal fusion and a laminectomy and has returned from the operating room. Which assessments are done in the first 24 hours. SATA

Take vital signs every 4 hours assess for fever and hypotension, perform neuro assessment every four hours paying attention to movement and sensation, monitor intake and output to assess for urinary retention, Assess for clear fluid on or around the dressing, assess for and immediately report sudden onset of headache

A nurse is assessing a client who has a score of 6 on the glasgow coma scale. The nurse should expect which of the following outcomes based on this score

The client needs total nursing care

A nurse is receiving transfer report for a client who has a head injury. The client has a glasgow coma scale of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

The client opens his eyes when spoken to

A 53-year-old woman collapses while gardening. She is unresponsive, is not breathing, and does not have a pulse. A neighbor, who is an emergency medical technician, rushes to her with an AED. When the AED arrives what is the first step for using it.

Turn it on

When needing to estimate the ventricular rate quickly for a patient with a regular heart rhythm using an ECG strip, the nurse will

Use the 3-second markers to count the QRS complexes in 6 seconds and multiply by 10

A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but over 100. The nurse determines that the client is experiencing:

Ventricular tachycardia

A nurse is caring for a client who is one day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the clients three chamber drainage systems, the nurse notes there is no bubbling in the suction control chamber? Which of the following actions should the nurse take

Verify that the suction regulator is on and check the tubing for leaks

A nurse is auscultating breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds

Wheezes

A nurse in the emergency department is caring for a client who has an epidural hematoma following a motor vehicle crash. Which of the following is an expected finding for this client

alternating periods of alertness and unconsciousness

In caring for a client with peritonitis from inflamed diverticuli, the nurse should assign priority to assessing

bowel sounds

A nurse is caring for a client with a spinal cord injury who has neurogenic shock. Which of the following should the nurse recognize as an expected finding?

bradycardia

A nurse is caring for a client who had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first

check the oximeter

A nurse is educating community members about how to prepare for a disaster, which of the following supplies should the nurse instruct the clients to include in a disaster preparedness kit? SATA

clean clothing, personal identification, matches, prescription medications

A nurse is caring for a client who has a three chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in water seal chamber with client inspiration

continue to monitor

A nurse is assessing a client who is 1 day postoperative following a lobectomy and has a chest tube drainage system in place. Which of the following findings by the nurse indicates a need for intervention

development of subcutaneous emphysema

The initial process of bone healing ocurring at the fracture site in the first 72 hours is

formation of hematoma

A nurse reviews the following data in the chart of a patient with burn injuries. ADMISSIONS NOTES: 36-year-old female with bilateral leg burns. No known allergies. Health history of asthma and seasonal allergies Patient reports pain of 2/10 on a scale of 0 to 10. WOUND ASSESSMENT: bilateral leg burns present with a white and leatherlike appearance. No blisters or bleeding present. Based on the data provided how would you categorize this patients' injuries

full thickness

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications SATA

hypotension, absence of bowel sounds, weak gag reflux, difficulty breathing

A nurse would explain to a client that when a major burn occurs, the body's initial systemic responses include

increased capillary permeability, decreased cardiac output, and oliguria

A nurse is caring for a client who had a stroke involving the left cerebral hemisphere. The nurse should monitor for which of the following findings

intellectual impairment

A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following is the nurse's priority when assessing the severity of the clients burns

location of the burns

A nurse in the emergency department is caring for a client who has a deep-partial and full-thickness burns to his chest abdomen and upper arms. What is the nurse's priority intervention for this client during the resuscitation of phase of injury

maintain the airway

A client with Crohns disease is recovering from a fourth bowel resection and is being dismissed. The nurse determines that teaching goals have been met when the client indicates that s/he will watch for manifestations of

malabsorption syndrome

In caring for a client with Crohns disease and a nursing diagnosis of imbalanced nutrition: less than body requirements related to diarrhea, the nurse would plan to observe for

manifestations of anemia

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?

manifestations preceded by a severe headache

What is a key feature of large bowel obstruction

minimal or no vomiting

A nurse is planning care for a client who has a halo fixation device, which of the following actions should the nurse include in the plan of care

monitor for the presence of purulent drainage from the pin sites

A nurse is assessing a client with a suspected diagnosis of multiple sclerosis. Which assessment findings will the nurse expect? SATA

muscle spasticity, fatigue, diplopia, dysarthia

A nurse is caring for a client following a total laryngectomy. Which of the following is the priority observation in the clients care

need for suctioning

A 26-year-old patient is diagnosed with Crohn's disease after having frequent diarrhea and a weight loss of 10 pounds (4.5 kg) over 2 months The nurse will plan to teach the patient about

oral corticosteroids

a client with inflammatory bowel disease takes sulfasalazine for management of manifestations. To counteract a side effect of this drug the nurse would encourage the client to increase the intake of

peas and beans

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first

place the client in a high fowlers position

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk of experiencing autonomic dysreflexia?

the client's bladder becomes distended

A nurse is working with limited staff because of a severe storm in the area. The facility incident commander has initiated disaster protocols. Which of the following actions should the nurse take.

Focus on providing care that prevents life-threatening emergencies

A patient presents to the emergency department after prolonged exposure to the cold. The patient is difficult to arouse, and speech is incoherent. What action would the nurse take first

Administer warmed intravenous fluids to the patient.

A nurse in an urgent care center is caring for a client who is having acute asthma exacerbation. Which of the following actions is the nurses highest priority

Administering a nebulized beta-adrenergic

A nurse in the emergency department is caring for a client who has extensive partial and full thickness burns of the head, neck, and chest. While planning the clients care the nurse should identify which of the following risks as the priority for assessment and intervention

Airway obstruction

A patient in the emergency department has several broken ribs. What care measure will best promote comfort.

Allowing the patient to choose the position of comfort in the bed

A nurse is the triage officer in the emergency department when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first

An unconscious adult client who has a sucking chest wound, respirations of 38/min, and a capillary refill of <2 seconds

During change of shift report the nurse learns that a patient with a large myocardial infarction has been having frequent PVC's. When monitoring the patient for the effects of PVCs the nurse will check the patients

Apical heart rate

A nurse is caring for a patient with ARDS on mechanical ventilation and finds the patient agitated and thrashing about. What action by the nurse is most appropriate to do first

Assess the cause of the agitation

A nurse responds to an IV pump alarm related to increased pressure. What action will the nurse take first?

Assess the infusion system starting at the insertion site

A nurse is teaching a client's family about lightning strike prevention following a lightening injury to the client. Which of the following information should the nurse include in the teaching

Avoid using a corded landline telephone

A nurse is caring for a patient who has just had central venous access line inserted. What action will the nurse take next?

Ensure that an x-ray is completed to confirm placement

Which laboratory finding does the nurse anticipate to note for a female client with an exacerbation of ulcerative colitis

Erythrocyte sedimentation rate (ESR) 55mm/hr

The local hospital, health department, and university together planned and implemented a mock casualty drill, with the university's theater and nursing students playing the injured victims. After the drill, which of the following would the nursing students most likely complete?

Evaluate the drill and offer recommendations for more effectiveness in the future

A nurse is caring for a client who has hypertension and develops epistaxis. Which of the following actions should the nurse take SATA

apply pressure to the nares, place ice on bridge of clients nose, move to high fowlers.

A client is admitted with appendicitis and is awaiting surgery. The client states, "now instead of pain in just one spot, the pain is kind of all over my abdomen" Which action by the nurse takes priority

assess the clients abdomen

A patient has a chest tube drainage system that is 3 days old. Upon assessment, the nurse notes that the patients face is puffy, the eyelids are swollen, and the chest appears bloated. What action by the nurse takes priority.

assess the patient's oxygen saturation