ACM POST TEST

A patient/client is admitted to the hospital with a head injury resulting from an automobile accident. On admission the patient/client's vital signs are temperature 98.6 F, blood pressure 126/68, pulse 110, and respirations 26. One hour after admission the nurse notes the presence of the Cushing's triad when the patient's/client's vital signs are:

-BLOOD PRESSURE 148/78 -PULSE 112 RESPIRATIONS 28

A patient/client has been brought to the emergency department with multiple traumas after a motor vehicle accident. After the nurse stabilizes the patient, which of the following would the nurse perform? Select all that apply.

-DRAW BLOOD FOR A TYPE AND CROSSMATCH -PERFORM A RAPID PHYSICAL ASSESSMENT -SPLINT FRACTURES -CHECKS IV FOR PATENCY

Which patient/client would the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined below?

A PATIENT/CLIENT WITH A BLUNT CHEST TRAUMA & SOME DIFFICULTY BREATHING

During the early emergent phase of burns, the nurse understands that analgesics should be given intravenously because.

ABSORPTION OF ORAL OR IM DRUGS IS DIMINSHED BECAUSE OF IMPAIRED CIRCULATION

A nurse in the telemetry unit observes a rhythm of an irregular heart rate of 120 bpm. Based on an interpretation of the rhythm, what is the priority action of the nurse?

ASSESS THE PATIENT'S CAROTID PULSE AND LEVEL OF CONSCIOUSNESS

A patient/client who underwent a lobectomy and has a water-seal chest drainage system is breathing with a little more effort and at a faster rate than 1 hour ago. The client's pulse is also increased. The nurse should.

CHECK THE TUBING TO ENSURE THAT THE CLIENT IS NOT LYING ON IT OR KINKING IT

The male patient/client with a c-6 spinal cord injury (SCI) tells the home health nurse he has had a severe pounding headache for the last 2 hours. Which intervention should the home health nurse implement?

DETERMINE WHEN THE PATIENT/CLIENT LAST URINATED.

The community health nurse is designing programs to reduce kidney problems and kidney injury among the general public. In order to do so, the nurse targets health promotion and compliance with therapy for which conditions?

DIABETES MELLITUS AND HYPERTENSION

A patient is admitted for a poisonous snake bite. The nurse observes that the patient has hematuria, hemoptysis, petechiae, and excessive bruising. These critical observations indicate to the nurse that the patient may be experiencing which hemorrhagic complication associated with snakebites?

DISSEMINATED INTRAVASCULAR COAGULATION

20. Which test is the best tool for diagnosing heart failure?

ECHOCARDIOGAPHY

A patient is admitted for emergency surgery after an accident. In addition, the patient has a pustular rash related to secondary syphilis. What instructions does the nurse give to the unlicensed assistive personnel (UAP)?

GLOVES SHOULD BE WORN AT ALL TIMES WHEN TOUCHING THE PATIENT

An older adult patient/client has been admitted to your unit with a gastrointestinal ulcer. The patient/client is NPO and has a nasogastric tube in place connected to low suction. What form of shock should you monitor this patient/client for?

HYPOVOLEMIC SHOCK

How is neomycin sulfate (Mycifradin) used to treat patients with cirrhosis?

IT DESTROYS THE NORMAL FLORA IN THE BOWEL

A nurse is teaching a patient about preventing HIV infection through sexual contact. Which statement made by the patient indicates effective teaching?

MUTUALLY MONOGAMOUS SEX WITH A NON-INFECTED PARTNER WILL BEST PREVENT HIV INFECTION

The nursing student is assisting in the care of a patient on mechanical ventilator. Which action by the student contributes to the prevention of ventilator assisted pneumonia?

PERFORMS ORAL CARE EVERY 2 HOURS

A nurse is caring for a female patient/client who sustained a closed head injury 8 days ago in motor vehicle accident. Which signs/symptoms would alert the nurse to a complication of the head injury?

THE PATIENT/CLIENT COMPLAINS OF EXTREME THIRST AND HAS AN INCREASED URINE OUTPUT

What is the rationale for administering tissue plasminogen activator (t-PA) within 4.5 hours of thrombotic stroke?

TO CAUSE FIBRINOLYSIS OF THE CLOT

A patient/client with end stage renal disease is scheduled for the first hemodialysis treatment. The patient/client asks the nurse what common complications may occur from the treatment. What would be the nurse's best reply? Select all that apply.

· HYPOTENSION · MUSCLE CRAMPS · D&E · HEADACHES & NAUSEA

The new registered nurse is giving a blood transfusion to a patient. Which statement by the new nurse indicates the need for action by the supervising nurse. Select all that apply.

· I WILL BE SURE TO COMPLETE THE RED BLOOD CELL TRANSFUSIONS WITHIN 6 HOURS OF REMOVAL FROM REFRIGERATION · I WILL USE LACTATED RINGERS' SOLUTION TO DILUTE THE BLOOD · I WILL MONITOR VITAL SIGNS EVERY SHIFT AFTER THE INFUSION IS COMPLETE

The patient/client with myocardial infarction has undergone electrocardiography (ECG). What changes in the ECG tracing would the nurse expect to see in this patient/client?

· ST SEGMENT ELEVATION · T WAVE INVERSION · ABNORMAL Q WAVE