CHAPTER 72 prepU
After inserting an oropharyngeal airway, which of the following indicates that the airway is properly positioned?
Flange is at the client's lips. Rationale: An oropharyngeal airway is properly positioned when the distal end is in the hypopharynx and the flange is approximately at the client's lips. Air moving through the airway may or may not indicate proper placement. An oropharyngeal airway is inserted so that the tongue is displaced anteriorly.
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 Rationale: Types of shock include cardiogenic, neurogenic, anaphylactic, and septic. Of these, the most common cause is hypovolemia.
The nurse is caring for a client in the ED following a sexual assault. The client is hysterical and crying. The client states, "I know I'm pregnant now, maybe I have HIV. Why did this happen to me?" Which is the best response by the nurse?
"Let's talk about this. Do you want me to call a support person?" Rationale: The client should be reassured that anxiety is natural and asked whether a support person may be called. The goals of management are to provide support, reduce the client's emotional trauma, and gather available evidence for possible legal proceedings. Throughout the client's stay in the ED, the client's privacy and sensitivity must be respected. The client may exhibit a wide range of emotional reactions, such as hysteria, stoicism, or feelings of being overwhelmed. Support and caring are crucial.
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. Rationale: Decompression sickness, also known as "the bends," occurs in patients who have engaged in diving (lake/ocean diving), high-altitude flying, or flying in commercial aircraft within 24 hours after diving. Signs and symptoms include joint or extremity pain, numbness, hypesthesia, and loss of range of motion. A patent airway and adequate ventilation are established before all other interventions, as described previously, and 100% oxygen is administered throughout treatment and transport.
The nurse is caring for a client with diabetes who requires a peripheral intravenous (PIV) line for antibiotic administration and to treat dehydration. The nurse must avoid inserting which type of PIV?
Foot Rationale: PIV lines should rarely be used in the foot for various reasons. They limit the client's ability to ambulate and tend to occlude easily. These types of IVs should never be used in clients with diabetes due to the risk that the client has neuropathy and cannot feel injury caused by the IV catheter. IV lines in the forearm and hands are acceptable and are commonly used sites. These sites would be safe to use for a client with diabetes. The upper arm is a site of choice for the insertion of a peripherally inserted central line (PICC) not a PIV line. Although, this site would not be an option for a PIV line, it would be safe for use in a client with diabetes if warranted
The nurse is caring for a victim of a sexual assault. The client is fearful and experiencing flashbacks. The nurse recognizes that the client is experiencing which phase of the psychological reaction to rape?
Heightened anxiety phase Rationale: During the heightened anxiety phase, the client demonstrates anxiety, hyperalertness, and psychosomatic reactions, in addition to fear and flashbacks. The acute disorganization phase is characterized by shock, disbelief, guilt, humiliation, and anger. The denial phase is characterized by an unwillingness to talk. The reorganization phase occurs when the incident is put into perspective. Some clients never fully recover from rape trauma.
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 Rationale: Early in shock, heart rate increases. Inadequate tissue perfusion causes pale, cool, clammy skin (not pale, warm, dry skin). In the early stages of shock, the client's heart rate will become elevated above normal. In early shock the client's blood pressure will remain normal, but as shock progresses the mechanisms that regulate blood pressure will not be able to compensate.
The nurse is caring for a client suffering from carbon monoxide poisoning. The nurse will expect the client to exhibit which manifestation?
Intoxication Rationale: A client suffering from carbon monoxide poisoning appears intoxicated (from cerebral hypoxia). Other signs and symptoms include headache, muscular weakness, palpitation, dizziness, and mental confusion. The skin coloring in the client with carbon monoxide poisoning can range from pink to cherry red to cyanotic and pale and is not a reliable diagnostic sign.
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) Rationale: Prothrombin time (PTT) is assessed in the blood work to identify coagulopathy or presence of chemically induced anticoagulation. This client is receiving heparin, an intravenous medication that helps to prevent the formation of clots; therefore, the PTT must be monitored regularly to ensure the medication remains within the therapeutic range. The client's white blood cell (WBC) reflects a count of this blood component to detect elevation of these cells, which is related to increased physiological stress. Typically this stress is infection, but it can also increase when there is trauma. Lactate would be drawn with the blood work to determine acidosis and need for continued resuscitation. Arterial blood gas (ABG) is evaluated to determine pH for the presence of acidosis, the base deficit for resuscitation evaluation, and ventilation parameters (PaCO2, PaO2).
A nurse is providing in-service education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step?
Supporting the client's emotional status Explanation: The teaching session is successful when staff members focus first on supporting the client's emotional status. Next, staff members should gain consent to perform the pelvic examination, perform the examination, and collect evidence, such as semen if present.
The intensive care unit nurse is assessing a client who is going to require a peripheral intravenous (PIV) line for fluids. The nurse should consider what information in the client's health history when deciding the site for the PIV?
The client has had a mastectomy on the right side Rationale: Contraindications to the placement of a PIV line in any specific placement (right vs. left side) will include history of mastectomy, arterial-venous shunt placement, peripherally inserted central catheter (PICC) line placement, thrombus, trauma, and other device placements, such as splints and casts. The nurse will only have the option to start the PIV on a site in the client's left arm if the client has had a ride-sided mastectomy. A history of hypertension does not preclude the client from having a PIV inserted in any specific location. Although fluid requirements are monitored more strictly with clients who are on a fluid volume restriction, this does not influence the placement of the PIV. The nurse should always be aware of the risks of a PIV for a client with a falls history. The tubing can be a tripping hazard, therefore, the client with a falls history who requires a PIV should be closely monitored but this does not preclude the client from having a PIV inserted.
A patient is brought to the ED by a friend, who states that a tree fell on the patient's leg and crushed it while they were cutting firewood. What priority actions should the nurse perform? (Select all that apply.)
-Apply a clean dressing to protect the wound -elevating the site to limit the accumulation of fluid in the interstitial spaces -splinting the wound in a position of rest to prevent motion Rationale: Major soft tissue injuries are dressed and splinted promptly to control bleeding and pain. If an extremity is injured, it is elevated to relieve swelling and pressure.
A client presents to the ED after an unsuccessful suicide attempt. The client is diagnosed with an acetaminophen overdose. The nurse anticipates the administration of which medication?
N-acetylcysteine Rationale: Treatment of acetaminophen overdose includes administration of N-acetylcysteine. Flumazenil is administered in the treatment of nonbarbiturate sedative overdoses. Naloxone is administered in the treatment of narcotic overdoses. Diazepam may be administered to treat uncontrolled hyperactivity in the client with a hallucinogen overdose.
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 hypotension. Rationale: Bleeding is a volume-loss problem, which causes a drop in blood pressure. As the bleeding persists and the body's ability to compensate declines, orthostatic hypotension becomes evident. A prolonged PTT and a history of warfarin usage are causes of bleeding but aren't evidence of bleeding. As bleeding persists and the client's level of consciousness declines, breathing will become more shallow and breath sounds will diminish; however, this is a late and unreliable manifestation of bleeding.
A patient with frostbite to both lower extremities from exposure to the elements is preparing to have rewarming of the extremities. What intervention should the nurse provide prior to the procedure?
Administer an analgesic as ordered. Explanation: During rewarming, an analgesic for pain is administered as prescribed, because the rewarming process may be very painful. To avoid further mechanical injury, the body part is not handled. Massage is contraindicated.
The nurse is caring for a patient in the ED who is breathing but unconscious. In order to avoid an upper airway obstruction, the nurse is inserting an oropharyngeal airway. How would the nurse insert the airway?
Upside down and then rotated 180 degrees Rationale: The nurse should insert the oropharyngeal airway with the tip facing up toward the roof of the mouth until it passes the uvula and then rotate the tip 180 degrees so that the tip is pointed down toward the pharynx. This displaces the tongue anteriorly, and the patient then breathes through and around the airway.
Permanent brain injury or death will occur within which time frame secondary to hypoxia?
3 to 5 minutes Rationale: If the airway is completely obstructed, permanent brain injury or death will occur within 3 to 5 minutes secondary to hypoxia. Air movement is absent in the presence of complete airway obstruction. Oxygen saturation of the blood decreases rapidly because obstruction of the airway prevents air from entering the lungs. Oxygen deficit occurs in the brain, resulting in unconsciousness, with death following rapidly. The other time frames are incorrect.
Medical and nursing interventions for patients who present with multiple injuries follow a sequence of treatment priorities. Which of the following is the first priority of care?
Establish an airway. Rationale: The immediate intervention is to always manage the airway and breathing first; controlling hemorrhage is the second priority, followed by preventing and treating hypovolemic shock.
A client comes to the emergency department after experiencing a wound. Inspection reveals an opening in the skin with distinct edges and whose depth is greater than the length of the wound. The nurse documents this as which type of wound?
Stab Rationale: A stab wound is an incision of the skin with well-defined edges and is typically deeper than long. It is usually caused by a sharp instrument. A laceration is a tear in the skin with irregular edges and vein bridging. An avulsion is manifested as a tearing away of tissue from the supporting structures. A patterned wound takes on the outline of the object causing the wound.
The nurse is caring for a client who is being prepared for the placement of a central intravenous line. The nurse recognizes this client requires this type of intravenous access for which reason?
The client requires total parenteral nutrition Rationale: For a patient who requires total parenteral nutrition (TPN), a central intravenous line is required due to the length of time the client will require the infusion as well as the nature of the solution itself. A large vein is required to safely infuse TPN. For this reason, a central line is needed. A peripheral intravenous line is safe to used when IV access is required under six days. Beyond this time, either a new peripheral IV will need to be inserted. If it is known in advance that IV treatment will last beyond six days, the client's health care provider will order the placement of a central intravenous line. Intravenous antibiotics can be administered peripherally unless the course is longer than six days. D5W is an intravenous solution that can be administered either peripherally or centrally. The nature of this IV solution would not determine which type of IV access the client requires.
Which of the following statements would most lead a nurse to suspect that a patient is experiencing food poisoning?
"My brother got sick like me after eating the same food." Rationale: The statement about the patient's brother also being sick after eating the same food suggests food poisoning. Feeling sick to the stomach for 3 to 4 days could indicate various problems, not just food poisoning. Food tasting or looking fine does not really indicate anything definitive about the patient's condition. Most foods causing bacterial poisoning do not have unusual odor or taste. A pain in the left groin area is more suggestive of appendicitis, not food poisoning.
A nurse is providing care to the family of a client who was brought to the emergency department and suddenly died. Which of the following would be appropriate for the nurse to do? Select all that apply.
-Ask the family if they would like to view the body -provide a private place for the family to be together -Allow the family to express their emotions freely Rationale: When providing care to a family experiencing the sudden death of a member, the nurse would take the relatives to a private place where they can be together to grieve. In addition, the nurse would encourage the family to view the body if they wish and allow members to support each other and express their emotions freely. Euphemisms such as "passing on" or "going to a better place" should be avoided. Sedation is avoided because it may mask or delay the grieving process, which is necessary to achieve emotional equilibrium and prevent prolonged depression
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. Rationale: Direct, firm pressure is applied over the bleeding area or the involved artery at a site that is proximal to the wound (Fig. 72-3). Most bleeding can be stopped or at least controlled by application of direct pressure. Otherwise, unchecked arterial bleeding results in death. A firm pressure dressing is applied, and the injured part is elevated to stop venous and capillary bleeding, if possible. If the injured area is an extremity, the extremity is immobilized to control blood loss. A tourniquet is applied to an extremity only as a last resort when the external hemorrhage cannot be controlled in any other way and immediate surgery is not feasible.
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 Rationale: Continuous electrocardiograph (ECG) monitoring is performed during the rewarming process because cold-induced myocardial irritability leads to conduction disturbances, especially ventricular fibrillation. A urinary catheter should be inserted to monitor urinary output; however, ECG monitoring is the priority. There is no indication for endotracheal intubation. Inotropic medications are contraindicated because they can stimulate the heart and increase the risk for fatal dysrhythmias, such as ventricular fibrillation.
A client is brought to the emergency department by ambulance. The client is seriously ill and unconscious. No family or friends are present. Which of the following would be most appropriate to do?
Document the client's condition and absence of friends or family for obtaining consent to treatment. Rationale: Consent is needed to examine and treat a client unless he or she is unconscious or in critical condition and unable to make decisions. In this situation, the client is unconscious and no friends or family are around to provide consent to treatment. The nurse should document this fact and provide care. Checking the client's record and asking the ambulance team for information would waste valuable time. Explaining to the client that care will be provided is appropriate even though the client is unconscious, but documentation is essential
The nurse is conducting a secondary survey on a client in the ED. Which action is completed during the secondary survey?
Diagnostic and laboratory testing Rationale: Diagnostic and laboratory testing is completed during the secondary survey, along with a complete health history, a head-to-toe assessment, insertion or application of monitoring devices, splinting of suspected fractures, cleansing, closure, and dressing of wounds, and performance of other necessary interventions based on the client's condition. The other interventions are completed during the primary survey.
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 Rationale: If a neck or spine injury is suspected, the jaw-thrust maneuver should be used to open the client's airway. To perform this maneuver, the nurse should position herself at the client's head and rest her thumbs on his lower jaw, near the corners of his mouth. She should then grasp the angles of his lower jaw with her fingers and lift the jaw forward. The head tilt-chin lift maneuver is used to open the airway when a neck or spine injury isn't suspected. To perform this maneuver the nurse places two fingers on the chin and lifts while pushing down on the forehead with the other hand. The abdominal thrust is used to relieve severe or complete airway obstruction caused by a foreign body. The Seldinger maneuver is a method of percutaneous introduction of a catheter into a vessel.
A patient with intra-abdominal injuries is brought to the emergency department. Which of the following would most likely alert the nurse to suspect internal bleeding secondary to a ruptured spleen?
Pain in the left shoulder Rationale: Pain in the left shoulder is common in a patient with bleeding from a ruptured spleen. Pain in the right shoulder is consistent with a laceration of the liver. The spleen is located in the left upper quadrant, not the right. Rebound tenderness and abdominal distention are generalized signs suggesting intraperitoneal injury. Although these generalized signs may accompany a ruptured spleen, they are less specific than pain in the left shoulder.
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 Rationale: When performing abdominal thrusts, the nurse would place the thumb side of one fist against the client's abdomen in the midline slightly above the umbilicus and well below the xiphoid process, grasping the fist with the other hand. Then the nurse would press the fist into the client's abdomen with a quick inward and upward thrust such that each new thrust should be a separate and distinct maneuver. The unconscious client is positioned on the back. The client who is conscious should be standing or sitting.
A nurse is providing care to a client in the emergency department and walks into the hallway to get equipment. All of a sudden, gunshots are heard. Which of the following would be the nurse's priority?
Protecting himself or herself Rationale: If gunfire occurs in the emergency department, self-protection is the priority. Security officers and police must gain control of the situation first and then care is provided to the injured.
The nurse has commenced a transfusion of fresh frozen plasma (FFP) and notes the client is exhibiting symptoms of a transfusion reaction. After the nurse stops the transfusion, what is the next required action?
Run a normal saline line to keep the vein open Rationale: If the nurse suspects a transfusion reaction, the transfusion must be stopped immediately and the nurse's next action is to ensure the normal saline line is running at a rate that permits administration of IV fluids or medications that are required to treat the reaction. The nurse should ensure IV access is maintained. The "to keep vein open" (TKVO) rate allows the nurse to keep the IV client without the potential to cause fluid volume overload. It would be unsafe for the nurse to remove the peripheral IV because continued access is required for urgent IV administration of medications or fluids to treat the reaction. Obtaining a blood culture at the IV site would be necessary if an infection was suspected. This is not required for a transfusion reaction. Normal saline is the solution of choice when transfusing blood products because there is a risk for incompatibility with all other IV solutions.
A patient was bitten by a tick 3 months ago and is now having muscle aches as well as joint pain and swelling. The patient is having difficulty with self care and requires assistance with activities of daily living (ADLs). What stage of Lyme disease does the nurse recognize the patient is in?
Stage III Rationale: Lyme disease has three stages. Stage I presents with a classic "bull's-eye" rash (i.e., erythema migrans) and flulike signs and symptoms that may include chills, fever, myalgia, fatigue, and headache. If antibiotics are not administered, stage II Lyme disease may present within 4 to 10 weeks following the tick bite and may manifest with joint pain, memory loss, poor motor coordination, and meningitis. Stage III can begin anywhere from weeks to more than a year after the bite and has serious long-term chronic sequelae, including arthritis, neuropathy, myalgia, and myocarditis.
A client presents to the ED with serious health problems that are not immediately life threatening. The nurse will correctly triage the client into which category?
Urgent Rationale: Clients triaged as urgent have serious health problems that are not immediately life threatening. They must be seen within 1 hour. The emergent category is for clients who have the highest priority conditions that are life-threatening and they must be seen immediately. Nonurgent is for clients who have episodic illness that can be addressed within 24 hours without increased morbidity. Clients in the less urgent category must be reassessed at least every 60 minutes and do not have serious health problems.
The nurse is caring for an intensive care unit client who has died with family members at the bedside. The death was sudden and unexpected resulting from a car accident that took place three days ago. The family is upset and the client's partner, crying loudly, yells, "How did this happen? We were just about to celebrate his birthday. He can't be gone!" The family member continues to cry inconsolably. How should the nurse respond?
"We did everything we could possibly do to try to save his life." Rationale: In order to help the family cope with the sudden death of their loved one, it is helpful for the nurse to explain that the care team employed all medical interventions possible to try to save the client's life. With the support of other members of the health care team, the nurse can take the time to explain what life saving treatments were rendered. The nurse should avoid giving sedation to family members; this may mask or delay the grieving process, which is necessary to achieve emotional equilibrium and to prevent prolonged depression. It is important that the nurse avoid using euphemisms such as "passed on." Instead the nurse should show the family that he or she cares by touching, and offering coffee, water, and the services of a chaplain. The nurse should encourage the family to express emotion including events leading up to the event that led to the client's death. The nurse should not challenge initial feelings of anger or denial.
Nursing students are reviewing the categories of intra-abdominal injuries. The students demonstrate understanding of the information when they identify which of the following as examples of penetrating trauma? Select all that apply.
-Gunshot wound -Knife-stab wound Rationale: Examples of penetrating trauma include gunshot wounds and stab wounds. Motor vehicle crashes, falls, and being struck with a baseball bat are examples of blunt trauma.
A female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing interventions should be provided? (Select all that apply.)
-assess and document any bruises and lacerations -record a history of the event, using the patient's own words -Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police Rationale: A history is obtained only if the patient has not already talked to a police officer, social worker, or crisis intervention worker. The patient should not be asked to repeat the history. Any history of the event that is obtained should be recorded in the patient's own words. The patient is asked whether he or she has bathed, douched, brushed his or her teeth, changed clothes, urinated, or defecated since the attack, because these actions may alter interpretation of subsequent findings. Each item of clothing is placed in a separate paper bag. The bags are labeled and given to appropriate law enforcement authorities. The patient is examined (from head to toe) for injuries, especially injuries to the head, neck, breasts, thighs, back, and buttocks. The exam focuses on external evidence of trauma (bruises, contusions, lacerations, stab wounds).
A client presents to the ED following a motor vehicle collision. The client is suspected of having internal hemorrhage. The nurse assesses the client for signs and symptoms of shock. Which are signs and symptoms of shock? Select all that apply.
-cool, most skin -Decreasing blood pressure -Increased heart rate -Delayed capillary refill Rationale: Signs and symptoms of shock include cool, moist skin (resulting from poor peripheral perfusion), decreasing blood pressure, increasing heart rate, delayed capillary refill, and decreasing urine volume.
Nursing students are reviewing information about anaphylactic reactions and their possible causes. The students demonstrate understanding of this information when they identify which of the following as a common cause? Select all that apply
-insect stings -medications -latex -eggs -shellfish Rationale: Common causes of anaphylactic reactions include insect stings, medications (e.g., penicillin, iodinated-contrast materials), latex, insect stings, eggs, peanuts, and shellfish. Green vegetables typically are not associated with anaphylaxis.
The nurse is preparing to transfer a client from the ICU to a medical unit in the hospital. To ensure consistent communication regarding the client's care needs to the receiving unit, in what sequence of steps should the nurse organize the report?
-obtain the client's health record -state the client's admission date and current diagnosis -provide a brief statement of current concerns -give the client's pertinent medical history -provide the most recent vital signs and assessment findings -give recommendations for what needs to be done done for the client
The nurse in the hospital emergency department is assessing a patient who fell while intoxicated with alcohol. The nurse is using the Clinical Institute Withdrawal Assessment-Alcohol (CIWA-A) scale to assess the patient's need for a benzodiazepine medication. In order to assess for auditory disturbances, which question should the nurse ask the patient?
Are you hearing anything that is disturbing you? Explanation: The Clinical Institute Withdrawal Assessment-Alcohol (CIWA-A) scale is used in the assessment of alcohol withdrawal. The patient's score on this scale helps determine the level of intervention that is required to support safe, withdrawal from alcohol. Assessing for auditory disturbances is one subsection on the scale. In order to effectively assess for this symptom, the nurse should ask the patient if they are hearing anything that is disturbing. By asking the patient if they are experiencing any numbness or burning would help to assess for tactile disturbances. By asking the patient if the light is bothering their eyes would support the assessment for visual disturbances. Asking the patient if it feels like there is a tight band around their head would help determine if the patient has a headache or fullness of the head. These are all symptom items that are measured by this scale.
A client has a gaping wound on his forearm that is bleeding profusely. Applying pressure to which pressure point would be most helpful?
Brachial Explanation: The pressure point at the brachial artery would be most appropriate because this site is proximal to the bleeding site. The femoral pressure point would be useful for bleeding in the lower extremities. The radial pressure point would be appropriate for bleeding in the wrist and hands. The subclavian pressure point would be used for bleeding in the upper anterior chest area.
The health care team in an intensive care unit have experienced a critical incident in which a young client died unexpectedly and the client's father physically attacked the senior physician treating the client. The client's father was arrested and escorted from the intensive care unit by police, against his will and in handcuffs. A critical incident stress management (CISM) staff meeting held 3 days after the incident took place. What would be the purpose for that meeting?
Debriefing Rationale: After serious events, critical incident stress management (CISM) is necessary to critique individual and group performance and to facilitate healthy coping. Optimally, this may consist of three steps: defusing, debriefing, and follow-up. Debriefing typically occurs 1 to 10 days after the critical incident. Debriefing sessions follow a format similar to the initial defusing session; however, during these sessions, participating staff are encouraged to discuss their feelings about the incident and are reassured that their negative reactions and feelings are normal and that their negative feelings will diminish over time. Defusing occurs immediately after the critical incident. During this session, affected staff are encouraged to discuss their feelings about the incident and are given contact information so that they may talk to someone if they have disturbing symptoms (e.g., sleeplessness, excessive worry). Follow-up may occur after the debriefing session is completed for those participants who have persistent negative symptoms and may consist of continued individual or group counseling and therapy. Counseling or group therapy would typically occur outside the context of the stress-inducing environment. Individuals may require private counseling versus group counseling.
The nurse has come on shift to find that a client newly admitted to the ICU is confused and persistently trying to get out of bed despite being comforted and re-oriented by the nurse. The client begins to pull on the peripheral intravenous line in the hand and speaking in non-sensical terms. The client's history indicates a sudden onset of neurological symptoms after developing a bacterial infection. The nurse anticipates providing care for which health problem?
Delirium Rationale: Delirium is a confused state that has a sudden onset and can last hours to days or weeks; it is characterized by hyperactivity and has the potential to be reversible. The client who quickly becomes confused and agitated while attempting to pull out IV lines and get out of bed is experiencing delirium. The nurse caring for this client should anticipate the need to provide close monitoring to prevent injury. Although clients can experience a high level of stress with both pain and anxiety, which often accompany one another, these problems do not cause confusion and disorientation. Nursing interventions would be aimed at reducing pain and anxiety with the use of medications and other non-pharmacological interventions that enhance client comfort. Although fever can accompany delirium, it does not produce confusion and disorientation on its own.
A nurse is preparing to assist with a gastric lavage for a client who has ingested an unknown poison and is obtunded. To ensure that the tube reaches the stomach, the nurse would measure the distance from the bridge of the nose to which of the following?
Ear lobe and then to the xiphoid process
A patient arrives at the emergency department after sustaining a gunshot wound to the abdomen. When assessing the patient, the nurse pays particular attention to which of the following?
Liver Rationale: Penetrating abdominal injuries, such as from a gunshot wound, are serious and result in a high incidence of injury to hollow and solid organs. Although any organs can be injured, the liver is the most frequently injured solid organ. The small bowel is a frequently injured hollow organ. Thus, of the options shown, the nurse would assess the liver area most closely.
A nurse is providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate?
Massaging the feet Rationale: For a client with frostbite, massaging the affected body part is contraindicated. Analgesia is given for pain during the rewarming process because it can be very painful. Ambulation would be restricted. Once rewarmed, sterile gauze or cotton is placed between the affected toes to prevent maceration.
Which medication reverses severe respiratory depression and coma?
Naloxone hydrochloride Rationale: Naloxone hydrochloride, a narcotic antagonist, reverses respiratory depression and coma. Diazepam is a benzodiazepine. Flumazenil is a benzodiazepine antagonist. N-acetylcysteine is used for acetaminophen toxicity.
A client is admitted to the ED after a near-drowning accident. The client is diagnosed with saltwater aspiration. The nurse will observe the client for several hours to monitor for symptoms of
Pulmonary Edema Explanation: Resultant pathophysiologic changes and pulmonary injury depend on the type of fluid (fresh or salt water) and the volume aspirated. Freshwater aspiration results in a loss of surfactant and therefore an inability to expand the lungs. Saltwater aspiration leads to pulmonary edema from the osmotic effects of the salt within the lungs. If a person survives submersion, acute respiratory distress syndrome, resulting in hypoxia, hypercarbia, and respiratory or metabolic acidosis, can occur. The client would experience hypernatremia. Hypothermia and head injury may be associated with near drowning but would
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 Rationale: The nurse should suspect the client has developed pulmonary edema, which is frequently seen in clients who abuse/overdose on narcotics. Many drugs — ranging from illegal drugs such as heroin and cocaine to aspirin — are known to cause noncardiogenic pulmonary edema. Pneumonia is not the likely cause given the sudden onset of respiratory symptoms accompanied but coughing up the pink frothy sputum. The client's history of illicit substance use and now overdose on these drugs should lead the nurse to suspect pulmonary edema is the cause of the sudden onset of these symptoms over congestive heart failure, in which clients have a more gradual onset of respiratory issues. Although a panic attack can manifest in shortness or breath and restlessness, the client would not be wheezing or producing blood tinged sputum with a cough. Panic attacks do, however, have a sudden onset and can cause the client chest pain and a sense of doom.
What is a common source of airway obstruction in an unconscious client?
The tongue Rationale: In an unconscious client, the muscles controlling the tongue commonly relax, causing the tongue to obstruct the airway. When this situation occurs, the nurse should use the head-tilt, chin-lift maneuver to cause the tongue to fall back into place. If she suspects the client has a neck injury she must perform the jaw-thrust maneuver.
The nurse educator is providing orientation to a group of nurses newly hired to an intensive care unit. The group of nurses are correct in stating which is the most common type of shock managed in critical care?
hypovolemic Rationale: The underlying cause of shock (hypovolemic, cardiogenic, neurogenic, anaphylactic, or septic) must be determined. Of these, hypovolemia is the most common cause.
