Acute 2 Final
The nurse is providing teaching to a client with an implanted cardiac device. Which client statement indicates that teaching has been effective?
"I will not place my cell phone in my chest pocket."
A complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify?
Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
On auscultation, which finding suggests a right pneumothorax?
Absence of breath sounds in the right thorax
A client is transported to the emergency department for a femur fracture following a motor vehicle crash. What action by the nurse is the highest priority?
Assess vital signs and level of consciousness.
A client in endstage renal disease is prescribed epoetin alfa and oral iron supplements monthly. Before administering the next dose of epoetin alfa and oral iron supplement, what is the priority action taken by the nurse?
Assesses the hemoglobin level
A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern?
BUN: 28 mg/dL (Normal is 7-18)
A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's:
Blood pressure
Which of the following is a common complication of an electrical burn injury?
Cardiac dysrhythmias
An x-ray demonstrates a fracture in which a bone has splintered into several pieces. Which type of fracture is this?
Comminuted
The nurse obtains a blood pressure of 120/78 mm Hg from a patient in hypovolemic shock. Since the blood pressure is within normal range for this patient, what stage of shock does the nurse realize this patient is experiencing?
Compensatory stage
A client is admitted to the emergency room after being hit by a car while riding a bicycle. The client sustained a fracture of the left femur, and the bone is protruding through the skin. What type of fracture does the nurse recognize requires emergency intervention?
Compound
A client is brought to the emergency department after being involved in a motor vehicle collision. Which of the following would lead the nurse to suspect internal bleeding?
Delayed capillary refill
The nurse is observing the monitor of a patient with a first degree atrioventricular (AV) block. What is the nurse aware characterizes this block?
Delayed conduction, producing a prolonged PR interval
The nurse working in the emergency department places a client in anaphylactic shock on a cardiac monitor and sees the cardiac rhythm shown. Which dysrythmia should the nurse document?
ventricular tachycardia
The licensed practical nurse is coassigned with a registered nurse in the care of a client admitted to the cardiac unit with chest pain. The licensed practical nurse is assessing the accuracy of the cardiac monitor, which notes a heart rate of 34 beats/minute. The client appears anxious and states not feeling well. The licensed practical nurse confirms the monitor reading. When consulting with the registered nurse, which of the following is anticipated?
The registered nurse administering atropine sulfate intravenously
What is a common source of airway obstruction in an unconscious client?
The tongue
After receiving chemotherapy for lung cancer, a client's platelet count falls to 98,000/mm3. What term should the nurse use to describe this low platelet count?
Thrombocytopenia
A nurse is doing a physical examination of a child with sickle cell anemia. When the child asks why the nurse auscultates the lungs and heart, what would be best the response by the nurse?
To detect the abnormal sounds suggestive of acute chest syndrome and heart failure
After surgery to treat a hip fracture, a client returns from the postanesthesia care unit to the medical-surgical unit. Postoperatively, how should the nurse position the client?
With the leg on the affected side abducted
A nurse cares for clients with hematological disorders and notes that women are diagnosed with hemochromatosis at a much lower rate than men. What is the primary reason for this?
Women lose iron through menstrual cycles
The nurse is working with a client with a new onset of atrial fibrillation during a three month follow up visit. The healthcare provider is planning a cardioversion, and the client asks the nurse why there is a wait for the treatment. What is the best response by the nurse?
Your atrial chambers may contain blood clots now, so you must take an anticoagulant for a few weeks before the cardioversion."
The nurse is monitoring the patient in shock. The patient begins bleeding from previous venipuncture sites, in the indwelling catheter, and rectum, and the nurse observes multiple areas of ecchymosis. What does the nurse suspect has developed in this patient
Disseminated intravascular coagulation (DIC)
Which of the following disorders results in widespread hemorrhage and microthrombosis with ischemia?
Disseminated intravascular coagulation (DIC)
Which of the following disorders results in widespread hemorrhage andmicrothrombosis with ischemia?
Disseminated intravascular coagulation (DIC)
The nurse caring for a client, who has been treated for a hip fracture, instructs the client not to cross their legs and to have someone assist with tying their shoes. Which additional instruction should the nurse provide to client?
Do not flex the hip more than 90 degrees.
The nurse is assessing a client admitted with cardiogenic shock. What medication will the nurse titrate to improve blood flow to vital organs?
Dopamine
What is the reason for chest tubes after thoracic surgery?
Draining secretions, air, and blood from the thoracic cavity is necessary.
A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia?
Dyspnea and wheezing
A client with anemia has been admitted to the medicalsurgical unit. Which assessment findings are characteristic of iron deficiency anemia?
Dyspnea, tachycardia, and pallor
A person suffers leg burns from spilled charcoal lighter fluid. A family member extinguishes the flames. While waiting for an ambulance, what should the burned person do?
Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel.
A client has a medical diagnosis of an advanced first degree atrioventricular block and is symptomatic. What initial treatment will the nurse be prepared to complete?
administer an IV bolus of atropine
A client comes to the emergency department with a suspected airway obstruction. The emergency department team prepares to manage the client as if he has a complete airway obstruction based on which of the following?
High-pitched noise on inhalation
When assessing a client with partial thickness burns over 60% of the body, which finding should the nurse report immediately?
Hoarseness of the voice
A nurse is completing her annual cardiopulmonary resuscitation training. The class instructor tells her that a client has fallen off a ladder and is lying on his back; he is unconscious and isn't breathing. What maneuver should the nurse use to open his airway?
Jaw-thrust
A client undergoes open reduction with internal fixation to treat an intertrochanteric fracture of the right hip. The nurse should include which intervention in the postoperative care plan?
Keeping a pillow between the client's legs at all times
A client has partial thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first
Lactated Ringer's solution
The nurse understands that during the emergent/resuscitative phase of burn injury, hemoconcentration is due to which of the following?
Liquid blood component is lost into extravascular space
Which medication reverses severe respiratory depression and coma?
Naloxone
Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues?
Natural
Following an earthquake, a client who was rescued from a collapsed building is seen in the emergency department. He has blunt trauma to the thorax and abdomen. The nursing observation that most suggests the client is bleeding is:
Orthostatic hypertension
A client diagnosed with systemic lupus erythematosus comes to the emergency department with severe back pain. The client is taking prednisone daily and reported feeling pain after manually opening the garage door. What adverse effect of longterm corticosteroid therapy is most likely responsible for the pain?
Osteoporosis
The nurse has received a client into care who was admitted with a heroin overdose. The client has a 5-year history of illicit substance use with cocaine, heroine and oxycodone. The client develops a sudden onset of wheezing, restlessness and a cough that produces a frothy, pink sputum. The nurse suspects the client has most likely developed which complication of opioid overdose?
Pulmonary edema
Following a burn injury, the nurse determines which area is the priority for nursing assessment?
Pulmonary system
Which ECG waveform characterizes conduction of an electrical impulse through the left ventricle?
QRS complex
The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS?
Rapid onset of severe dyspnea
A client is brought to the emergency department with suspected genitourinary injury. The nurse prepares the client for insertion of an indwelling urinary catheter for bladder decompression and urine output monitoring. The nurse reviews the client's medical record to ensure that which of the following has been completed?
Renal perfusion
A nurse is establishing a patient's airway. Which action would the nurse perform first?
Repositioning the patient's head
A client at the clinic has just been diagnosed with iron deficiency anemia. What would you recommend the client consume to promote the absorption of iron?
Rich sources of vitamin C
A client who has sustained burns to the anterior chest and upper extremities is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary?
Risk for Impaired Gas Exchange
A patient is brought to the emergency department following an overdose of a selective serotonin reuptake inhibitor (SSRI). While assessing the patient, the nurse suspects that the patient may be developing serotonin syndrome based on which of the following?
Seizures
What assessment findings of the leg are consistent with a fracture of the femoral neck?
Shortened, adducted, and externally rotated
A client is to have an amputation. The client is acutely ill and diagnosed with a gangrenous limb and related fever, disorientation, and electrolyte imbalances. Which of the following would be most important for the nurse to monitor in this client?
Signs of sepsis
The nurse is caring for a patient with pleurisy. What symptoms does the nurse recognize are significant for this patient's diagnosis?
Stabbing pain during respiratory movement
A patient with sickle cell disease comes to the emergency department and reports severe pain in the back, right hip, and right arm. What intervention is important for the nurse to provide?
Start an intravenous line with dextrose 5% in 0.25 normal saline
A nurse admits a new client with acute respiratory failure. What are the clinical findings of a client with acute respiratory failure?
Sudden onset of lung impairment in a client who had normal lung function
A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following?
Superficial
An older adult client who is a vegetarian has a hemoglobin of 10.2 gm/dL, vitamin B12 of 68 pg/mL (normal: 200 to 900 pg/mL), and MCV of 110 cubic micrometers. After interpreting the data, what instruction should the nurse give to the client?
Supplement the diet with vitamin B12.
A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation?
The client's urinary output is 0.5 to 1 mL/kg/hour.
The nurse is obtaining physician orders which include a pulse pressure. The nurse is correct to report which of the following?
The difference between the systolic and diastolic pressure
A client's family member asks the nurse why disseminated intravascular coagulation (DIC) occurs. Which statement by the nurse correctly explains the cause of DIC?
"DIC is caused by abnormal activation of the clotting pathway, causing excessive amounts of tiny clots to form inside organs."
A client with megaloblastic anemia reports mouth and tongue soreness. What instruction will the nurse give the client regarding eating while managing the client's symptoms?
"Eat small amounts of bland, soft foods frequently."
When vasoactive medications are administered, the nurse must monitor vital signs at least how often?
15 minutes
A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first?
Administer oxygen by nasal cannula as ordered.
Which nursing intervention must a nurse perform when administering prescribed vasopressors to a client with a cardiac dysrhythmia?
Monitor vital signs and cardiac rhythm
A nursing instructor is evaluating a student caring for a neutropenic client. The instructor concludes that the nursing student demonstrates accurate knowledge of neutropenia based on which intervention?
Monitoring the client's temperature and reviewing the client's complete blood count (CBC) with differential
A client with a diagnosis of pernicious anemia comes to the clinic and reports numbness and tingling in the arms and legs. What do these symptoms indicate?
Neurologic involvement
The nurse is caring for a client with known myocardial ischemia. The client will be getting up to ambulate for the first time in three days after being on bedrest since admission to the intensive care unit. Which medication should the nurse administer before the client ambulates?
Nitroglycerin
When evaluating a patient's symptoms that are consistent with a diagnosis of leukemia, the nurse is aware that all leukemias have which common feature?
Unregulated accumulation of white cells in the bone marrow, which replace normal marrow elements
A nurse on a hematology/oncology floor is caring for a client with aplastic anemia. Which would not be included in the client's discharge instructions?
Use a disposable razor when shaving.
Which medication is the antidote to warfarin?
Vitamin K
An 85-year-old client is admitted to the ED. Heat stroke is suspected. The client's core temperature is 106.2°F (41.2°C), blood pressure (BP) 90/60 mm Hg, and pulse 102 bpm. The nurse understands that the primary treatment measure for the client will include
mmersion of the client in a cold-water bath.
Arterial blood gas analysis would reveal which value related to acute respiratory failure?
pH 7.28
A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder?
pH 7.28, PaO2 50 mm Hg
A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as
pleural effusion.
A family member brings a patient to the emergency department. The family member states, "I think he overdosed on heroin." Which of the following would the nurse expect to assess?
Pinpoint pupils
When preparing to perform abdominal thrusts on a client with an airway obstruction, which of the following would be most appropriate?
Positioning the hands in the midline slightly above the umbilicus
The nurse knows that inflammatory response following a burn is proportional to the extent of injury. Which factor presents the greatest impact on the ability to modify the magnitude and duration of the inflammatory response in a client with a burn?
Preexisting conditions
A healthy adult client is seeing a health care provider for an annual physical examination. While the nurse is taking the client's vital signs, the client states, "Occasionally, my heart skips a beat." The nurse believes that the client is experiencing what condition?
Premature atrial complex
The nurse observes an electrocardiogram (ECG) tracing on a cardiac monitor with a pattern in lead II as well as a bizarre, abnormal shape to the QRS complex. The nurse has likely observed which ventricular dysrhythmia?
Premature ventricular contraction
A nurse is caring for a client who underwent a total hip replacement. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis?
Prevent internal rotation of the affected leg.
You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure?
Progressive loss of lung function associated with chronic disease
The nurse in an intensive care unit is caring for a client who requires blood work to assess for changes in blood coagulation due to heparin therapy. Which test should the nurse expect to see prescribed for this value to be assessed?
Prothrombin time (PTT)
The nurse witnesses a client experiencing ventricular fibrillation. What is the nurse's priority action?
defibrillation
A client has pernicious anemia and has been receiving treatment for several years. Which symptom may be confused with another condition in older adults?
dementia
A client who has injured a hip in a fall cannot place weight on the leg and is in significant pain. After radiographs indicate intact yet malpositioned bones, what repair would the physician perform?
joint manipulation and immobilization
Which nursing intervention is appropriate for a client with a closed-reduction extremity fracture?
Encourage participation in ADLs
A patient brought to the ED by the rescue squad after getting off a plane at the airport is complaining of severe joint pain, numbness, and an inability to move the arms. The patient was on a diving vacation and went for a last dive this morning before flying home. What is a priority action by the nurse?
Ensure a patent airway and that the patient is receiving 100% oxygen.
The nurse observes the laboratory studies for a client in the hospital with fatigue, feeling cold all of the time, and hemoglobin of 8.6 g/dL and a hematocrit of 28%. What finding would be an indicator of irondeficiency anemia?
Erythrocytes that are microcytic and hypochromic
The nurse caring for a 2-year-old near-drowning victim monitors for what possible complication?
Acute respiratory distress syndrome
A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia?
A client with a nasogastric tube
A homeless client presents to the ED. Upon assessment, the client is experiencing hypothermia. The nurse will plan to complete which priority intervention during the rewarming process?
Attach a cardiac monitor
The nurse is providing discharge instructions to a client after a permanent pacemaker insertion. Which safety precaution will the nurse communicate to the client?
Avoid undergoing magnetic resonance imaging (MRI).
A high school football player is brought to the emergency department after collapsing at practice in extremely hot and humid weather. Which of the following would lead the nurse to suspect that the client is experiencing heat stroke?
Delirium
Which of the following measures can be used to cool a burn?
Application of cool water
Which is a symptom of hemochromatosis (excess iron)?
Bronzing of the skin
Which of the following neuroendocrine changes occur within the first 24 hours of a serious burn?
Hyperglycemia
The nurse is collecting data for a client who has been diagnosed with irondeficiency anemia. What subjective findings does the nurse recognize as symptoms related to this type of anemia?
"I have difficulty breathing when walking 30 feet."
The nurse is caring for a client who is being discharged after insertion of a permanent pacemaker. Which question by the client indicates a need for clarification?
"I should ask for a handheld device search when I go through airport security.
Permanent brain injury or death will occur within which time frame secondary to hypoxia?
3 to 5 minutes
A client is brought to the emergency department with partial thickness and full thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned?
36%
An emergency department nurse is evaluating a client with partial thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned?
36%
A client is admitted to the emergency department reporting chest pain and shortness of breath. The nurse notes an irregular rhythm on the bedside electrocardiograph monitor. The nurse counts 9 RR intervals on the client's 6 second rhythm tracing. The nurse correctly identifies the client's heart rate as
90 bpm.
A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily?
Intubate the client and control breathing with mechanical ventilation
The nurse observes a coworker who always seems to be eating a cup of ice. The nurse encourages the coworker to have an examination and diagnostic workup with the health care provider. What type of anemia is the nurse concerned the coworker may have?
Iron deficiency anemia
A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene?
Irrigate the wounds with water.
A client is unconscious on arrival to the emergency department. The nurse in the emergency department identifies that the client has a permanent pacemaker due to which characteristic?
"Spike" on the rhythm strip
The client asks the nurse to explain what is meant by a ventricular bigeminy cardiac rhythm. What is the best response by the nurse?
"The rhythm has a normal beat, then a premature beat pattern."
The nursing student asks the nurse how to tell the difference between ventricular tachycardia and ventricular fibrillation on an electrocardiogram strip. What is the best response?
"Ventricular fibrillation is irregular with undulating waves and no QRS complex. Ventricular tachycardia is usually regular and fast, with wide QRS complexes."
After performing an ECG on an adult client, the nurse reports that the PR interval reflects normal sinus rhythm. What is the PR interval for a normal sinus rhythm?
0.12 and 0.2 seconds.
The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement?
A urinary output of 30 mL/hr
The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that this client is at increased risk for which of the following?
Acute respiratory distress syndrome
The nurse is working on a telemetry unit, caring for a client who develops dizziness and a second degree heart block, Mobitz Type 1. What will be the initial nursing intervention?
Administer an IV bolus of atropine.
The nurse is caring for a client in the ED with frostbite to the left hand. During the rewarming process of the hand, the nurse should perform which action?
Administer analgesic medications as ordered.
The nurse is providing care for a client who is experiencing alcohol withdrawal. The client reports, "I cannot fall or stay asleep." The nurse observes that the client is agitated, having difficulty falling asleep and crying uncontrollably, with confused speech and a tachycardic pulse. Which intervention should the nurse implement first?
Administer lorazepam as ordered by the health care provider
The nurse is preparing to administer warfarin to a client with a mechanical valve replacement. The client's international normalized ratio is 2.7. What action will the nurse take?
Administer the medication as ordered
A client is hospitalized 3 days prior to a total hip arthroplasty and reports a high level of pain with ambulation. The client has been taking warfarin at home, which is now discontinued. To prevent the formation of blood clots, which action should the nurse take?
Administer the prescribed enoxaparin (Lovenox).
A client with sickle cell crisis is admitted to the hospital in severe pain. While caring for the client during the crisis, which is the priority nursing intervention?
Administering and evaluating the effectiveness of opioid analgesics
Which of the following medication classifications is more likely to be expected when the nurse is caring for a client with atrial fibrillation?
Anticoagulant
When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are located in the carotid sinus. Which other area should the nurse mention as a site of arterial baroreceptors?
Aorta
A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use the intraaortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which condition is a contraindication for IABP use?
Aortic insufficiency
The nurse received a patient from a motor vehicle accident who is hemorrhaging from a femoral wound. What is the initial nursing action for the control of the hemorrhage?
Apply firm pressure over the involved area or artery.
The nurse is planning care for a client with severe fatigue secondary to anemia. What concept will the nurse use as the basis for planning interventions?
Assisting in prioritizing activities.
A client's electrocardiogram (ECG) tracing reveals a atrial rate between 250 and 400, with saw toothed P waves. The nurse correctly identifies this dysrhythmia as
Atrial flutter
A nurse is caring for a client who's experiencing sinus bradycardia with a pulse rate of 40 beats/minute. The client's blood pressure is 80/50 mm Hg and the client reports dizziness. Which medication does the nurse anticipate administering to treat bradycardia?
Atropine
A client was climbing a ladder, slipped on a rung, and fell on the right side of the chest. X-ray studies reveal three rib fractures, and the client reports pain with inspiration. What is the anticipated treatment for this client?
Coughing and deep breathing with pillow splinting
After evaluating a client for hypertension, a health care provider orders atenolol, 50 mg P.O. daily. Which therapeutic effect should atenolol have in treating hypertension?
Decreased cardiac output and decreased systolic and diastolic blood pressure
A patient with chronic renal failure is examined by the health care provider for anemia. Which laboratory results will the nurse monitor?
Decreased level of erythropoietin
A nurse is inspecting the area of contusion and notes numerous areas of bruising. How would the nurse document this finding?
Ecchymosis
A client with an atrial dysrhythmia has come to the clinic for a follow up appointment and to talk with the health care provider about options to stop this dysrhythmia. What procedure could be used to treat this client?
Elective electrical cardioversion
The nurse is assessing a patient who has been admitted with possible ARDS. Which finding would be evidence for a diagnosis of cardiogenic pulmonary edema rather than ARDS?
Elevated B-type natriuretic peptide (BNP) levels
You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia?
Encourage increased fluid intake
The nurse in the emergency department receives a patient who sustained a severe burn injury. What is the priority action by the nurse in this situation?
Establish a patent airway.
After a car accident, a client is admitted to an acute care facility with multiple traumatic injuries, including a fractured pelvis. For 24 to 48 hours after the accident, the nurse must monitor the client closely for which potential complication of a fractured pelvis?
Fat embolism
The nurse is caring for a client who has premature ventricular contractions. What sign or symptom is observed in this client?
Fluttering
Which term refers to a break in the continuity of a bone?
Fracture
When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?
Hypercapnia, hypoventilation, and hypoxemia
The nurse is caring for a client who has sustained severe burns to 50% of the body. The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury cause massive cell destruction. What should the nurse report if it occurs immediately after burn injury?
Hyperkalemia
The nurse identifies which of the following as a potential cause of premature ventricular complexes (PVCs)?
Hypokalemia
A nurse is caring for a client who has arrived at the emergency department in shock. The nurse intervenes based on the knowledge that which of the following is the most common cause of shock?
Hypovolemia
The nurse assesses a client with a heart rate of 120 beats per minute. What are the known causes of sinus tachycardia?
Hypovolemia
The nurse receives a client following a serious thermal burn. Which complication will the nurse take action to prevent first?
Hypovolemia
The nurse is monitoring a patient who sustained a fracture of the left hip. The nurse should be aware that which kind of shock can be a complication of this type of injury?
Hypovolemic
A client with severe anemia reports symptoms of tachycardia, palpitations, exertional dyspnea, cool extremities, and dizziness with ambulation. Laboratory test results reveal low hemoglobin and hematocrit levels. Based on the assessment data, which nursing diagnoses is most appropriate for this client?
Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit
A client has been in a motor vehicle collision. Radiographs indicate a fractured humerus; the client is awaiting the casting of the upper extremity and admission to the orthopedic unit. What is the primary treatment for musculoskeletal trauma?
Immobiliazation
A nurse provides nutritional information for a patient diagnosed with an irondeficiency anemia. What education should the nurse provide?
Increase the intake of green, leafy vegetables.
A client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later, the nurse identifies which finding as an early sign of shock?
Increasing heart rate
The client with a lower respiratory airway infection is presenting with the following symptoms: fever, chills, dry hacking cough, and wheezing. Which nursing diagnosis best supports the assessment by the nurse?
Ineffective airway clearance
A client experienced an open fracture to the left femur during a horse-riding accident. For which complication is this client at highest risk
Infection
Which nursing diagnosis takes highest priority for a client with a compound fracture?
Infection related to effects of trauma
A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury?
Inflammatory
A nurse is providing an in-service program for fellow emergency nurses about hypothermia and rewarming methods used. The nurse determines that the presentation was successful when the group identifies which of the following as a passive active rewarming method?
Over the bed heaters
To evaluate a client's atrial depolarization, the nurse observes which part of the electrocardiogram waveform?
P wave
The nurse is assessing vital signs in a patient with a permanent pacemaker. What should the nurse document about the pacemaker?
Pacer rate
A nurse is caring for a client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?
Pallor, tachycardia, and a sore tongue
When a client is in the compensatory stage of shock, which symptom occurs?
Tachycardia
The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation?
Tension pneumothorax
A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition?
The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher.
When providing care to a client who has experienced multiple trauma, which of the following would be most important for the nurse to keep in mind?'
The client is assumed to have a spinal cord injury until proven otherwise.
A client receiving emergency treatment for severe burns has just been assessed to establish the burn depth. Why is a nurse asked to reassess the burn depth after 72 hours?
The early appearance of the burn injury may change.
A client with heart failure asks the nurse how dobutamine affects the body's circulation. What is the nurse's best response?
The medication increases the force of the myocardial contraction.
A client has been diagnosed with atrial fibrillation and has been prescribed warfarin therapy. What should the nurse prioritize when providing health education to the client?
The need to have regular blood levels drawn
A patient is taking prednisone 60 mg per day for the treatment of an acute exacerbation of Crohn's disease. The patient has developed lymphopenia with a lymphocyte count of less than 1,500 mm3. What should the nurse monitor the client for?
The onset of a bacterial infection
As the first priority of care, a patient with a burn injury will initially need
a patent airway established.
Which technique does a nurse suggest to a patient with pleurisy for splinting the chest wall?
Turn onto the affected side.
A patient with hypertension has a newly diagnosed atrial fibrillation. What medication does the nurse anticipate administering to prevent the complication of atrial thrombi?
Warfarin
The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories. The nurse recognizes this intervention is to promote
decreased catabolism.
A client with frequent premature ventricular contractions is prescribed amiodarone. The nurse will withhold the medication until the completion of which diagnostic test?
pulmonary function
A client is diagnosed with an arrhythmia at a rate slower than 60 beats/minute with a regular interval between 0.12 and 0.20 seconds. What type of arrhythmia does the client have?
sinus bradycardia
The nurse cares for a client with superficial partial thickness burn injuries to the lower extremities. The client is ordered IV morphine for pain. The nurse understands narcotics are given via IV during the initial management of pain because
tissue edema may interfere with drug absorption via other routes.