Nur217T exam#4 ATI test

A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first? A. Clean and dress the wound. B. Administer pain medication. C. Administer a tetanus booster. D. Administer IV fluids.

D. Administer IV fluids. Rationale: Using the airway, breathing, circulation framework, the priority action the nurse should take is to initiate fluid resuscitation to maintain blood volume and preserve cardiac output. The nurse can utilize large bore peripheral IV cannulas. However, in extensive burns a central line should be inserted to allow for rapid infusion of fluids.

A nurse enters a client's room and finds him unresponsive. After notifying the rapid response team, which of the following actions should the nurse take first? A. Attach defibrillator pads to the client. B. Check for a carotid pulse. C. Begin chest compressions. D. Deliver two breaths.

B. Check for a carotid pulse. Rationale: The first action the nurse should take when using the nursing process is to assess the client. The nurse should check the client's circulatory status by palpating the carotid pulse for 5 to 10 seconds first before initiating further interventions.

A nurse in an emergency department is caring for a client who is bleeding profusely from a deep laceration on his left lower forearm. After observing standard precautions, which of the following actions should the nurse perform first? A. Apply a tourniquet just below the elbow. B. Apply direct pressure over the wound. C. Clean the wound. D. Elevate the limb and apply ice.

B. Apply direct pressure over the wound. Rationale: The greatest risk to the client is injury from hemorrhage. Therefore, the first action the nurse should take is to apply firm pressure with a thick, dry dressing material directly over the wound to stop bleeding.

A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider? A. Urinary output 25 mL/hr B. Difficulty swallowing C. Heart rate 122/min D. Pain of 6 on a scale of 0 to 10

B. Difficulty swallowing Rationale: Using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding is difficulty swallowing as this is can be an indication that the client's airway is obstructed.

A nurse in an emergency room is caring a the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take? A. Insert an indwelling urinary catheter. B. Inspect the mouth for signs of inhalation injuries. C. Administer intravenous pain medication. D. Draw blood for a complete blood cell (CBC) count.

B. Inspect the mouth for signs of inhalation injuries. Rationale: Since the client sustained burns to the chest and face, there is a possibility that flames and smoke from the client's burning clothes could have caused an inhalation injury. The nurse should inspect the mouth and throat for soot and swelling. Using the airway, breathing, circulation (ABC) priority-setting framework, is the priority concern at this time.

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 factors is the nurse's priority when assessing the severity of the client's burns? A. Age of the client B. Associated medical history C. Location of the burn D. Cause of the burn

C. Location of the burn Rationale: When using the urgent vs. nonurgent approach to client care, the nurse determines the priority is to assess the location of the burns that can lead to respiratory distress.

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 client's care, the nurse should identify which of the following risks as the priority for assessment and intervention? A. Airway obstruction B. Infection C. Fluid imbalance D. Paralytic ileus

A. Airway obstruction Rationale: When using the airway, breathing, circulation approach to client care, the nurse determines that the priority risk is airway obstruction. Burns of the head, neck, and chest often involve damage to the pulmonary tree due to heat as well as smoke and soot inhalation. This can result in severe respiratory difficulty. Nursing measures to maintain a patent airway should take priority in this client's care.

A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care? A. Airway protection B. Decreasing intracranial pressure C. Stabilizing cardiac arrhythmias D. Preventing musculoskeletal disability

A. Airway protection Rationale: When assessing and treating a client who has trauma, a systematic approach is taken during the primary survey. It begins with the assessment and interventions necessary to ensure a patent airway.

A nurse is caring for client whose throat culture is positive for group A streptococcus 24 hr after a rapid strep test (RST) was negative. Which of the following actions is the nurse's priority? A. Notify the client to return to the clinic for initiation of antibiotic therapy. B. Ask the client to identify friends and family who have been in close contact. C. Reinforce teaching about gargling with warm saline several times daily. D. Instruct the client to take antipyretics as directed for elevated temperature.

A. Notify the client to return to the clinic for initiation of antibiotic therapy. Rationale: An RST can produce a false negative result. A throat culture that is positive for streptococcus indicates a bacterial infection that is often associated with enlarged red tonsils, exudate, nasal discharge, and local lymph node involvement. A streptococcal infection can lead to serious complications, including glomerulonephritis, rheumatic fever, and endocarditis, so it is imperative and the highest priority for the nurse to start the client on antibiotic therapy to prevent complications.

A nurse is caring for a client who has infective endocarditis. Which of the following manifestations is the priority for the nurse to monitor for? A. Anorexia B. Dyspnea C. Fever D. Malaise

B. Dyspnea Rationale: When using the airway, breathing, circulation (ABC) approach to client care, the nurse determines the priority manifestation to monitor for is dyspnea. Dyspnea can be an indication of left-sided heart failure, or a pulmonary infarction due to embolization.

A nurse is assessing a client following the application of an aquathermia pad. Which of the following is the first indication to the nurse that the client is experiencing a superficial burn injury to the application site? A. Blistering B. Erythema C. Eschar D. Absence of pain

B. Erythema Rationale: Erythema is an indication that the client has experienced a superficial burn with damage limited to the epidermis. Other manifestations include edema, pain, and increased sensitivity to heat.

A nurse in an emergency department is caring for a client who has 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? A. Initiate fluid resuscitation. B. Medicate for pain. C. Insert an indwelling urinary catheter. D. Maintain the airway.

D. Maintain the airway. Rationale: The client is at risk for respiratory obstruction.Using the airway, breathing, circulation approach to client care is the first action the nurse should take to ensure that the client has a patent airway.

A nurse is assessing a client who has a cast in place for a fractured tibia. Which of the following actions should the nurse take first? A. Checking capillary refill B. Discussing cast care C. Managing pain D. Performing range of motion

A. Checking capillary refill Rationale: The priority action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to check the client's capillary refill. Musculoskeletal injuries can cause changes in the neurovascular system, usually distal to the injury. Capillary refill provides data about the client's circulation.

A nurse in the emergency department is assessing a newly admitted client who has facial trauma. Which of the following assessments is the nurse's priority? A. Soft-tissue edema B. Facial asymmetry C. Active bleeding D. Altered respirations

D. Altered respirations Rationale: When using the airway, breathing, circulation approach to client care, the nurse determines that the priority is to assess the client's respirations, because edema from the client's injuries could cause airway obstruction. The nurse should assess the client's airway for stridor, shortness of breath, and dyspnea.