Critical Care
A client is receiving thrombolytic therapy by continuous infusion. The client suddenly becomes extremely anxious and complains of itching. The nurse hears stridor, and on examination of the client, notes generalized urticaria and hypotension. Which should be the priority action of the nurse?
1. Administer oxygen and protamine sulfate. 2.Stop the infusion, and notify the registered nurse. 3.Cut the infusion rate in half, and sit the client up in bed. 4.Administer diphenhydramine and continue the infusion. Answer: 2 Rationale:The client is experiencing an anaphylactic reaction to thrombolytic therapy. The infusion should be stopped; the registered nurse notified; and the client treated with epinephrine, antihistamines, and corticosteroids as prescribed.
The nurse is caring for a client who had a tracheostomy tube inserted 1 week ago. The client begins to cough vigorously, and accidental decannulation of the tracheostomy tube occurs. Which action should be the nurse's immediate response?
1. Call a code. 2. Call an anesthesiologist. 3. Call a respiratory therapist. 4. Replace the tracheostomy tube. Answer: 4
A postpartum client has lost 700 mL of blood. The vital signs indicate hypovolemia and the uterus remains atonic in spite of treatment. The nurse assisting in caring for the client understands what is necessary in this situation and prepares the client for which treatment?
1. Fundal massage 2. A blood transfusion 3. Emergency surgery 4. An infusion of oxytocin Answer: 3 Rationale: Options 1, 2, and 4 identify interventions to reverse uterine atony. When uterine atony cannot be reversed, surgery is required.
A client presents to the emergency department with upper gastrointestinal (GI) bleeding and is in moderate distress. Which nursing action should be the priority for this client?
1.Determine vital signs. 2.Complete abdominal physical examination. 3.Thoroughly investigate the precipitating events. 4.Insert a nasogastric tube and conduct a Hematest of the emesis. Answer: 1 Rationale:The determination of vital signs indicates whether the client is in shock from blood loss and provides a baseline blood pressure and pulse by which to monitor the progress of treatment.
The nurse determines that a student in a basic cardiac life support (BCLS) course correctly performs cardiopulmonary resuscitation (CPR) on an infant when the nurse observes which rate of chest compressions delivered to the infant mannequin?
100 beats per minute Rationale: In an infant, the rate of chest compressions is at least 100 per minute. All other options are incorrect rates of compression based on current recommendations.
A family of a spinal cord-injured client rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic, with a flushed face and neck, and complains of a severe headache. The pulse is 40 beats per minute, and the blood pressure is 230/100 mm Hg. The nurse acts quickly, knowing that the client is experiencing which condition?
1. Spinal shock 2.Pulmonary embolism 3.Autonomic dysreflexia 4.Malignant hyperthermia Answer: 3 Rationale:The client with spinal cord injury above the level of T7 is at risk for autonomic dysreflexia. It is characterized by severe, throbbing headache; flushing of the face and neck; bradycardia; and sudden, severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea, and sweating. It is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury.
Signs and symptoms of an air embolus
confusion, pallor, lightheadedness, tachycardia, tachypnea, hypotension, anxiety, and unresponsiveness.
Signs and symptoms of shock
low blood pressure; rapid, weak pulse; increased thirst; cold, clammy skin; and restlessness.
Dimercaprol
Antidote for arsenic, mercury, lead, and gold poisoning Note that dimercaprol is prepared with peanut oil, and hence should be avoided by clients with known or suspected peanut allergy.
Extravasation
refers to the tissue injury that occurs from leakage of medication into surrounding skin and subcutaneous tissue; it can also cause tissue necrosis.
manifestations of hyperglycemia
unresponsiveness. Polyuria, polydipsia, and polyphagia
The nurse is checking the date of an intravenous (IV) insertion in a client. The insertion date on the dressing is 2/9 (February 9). The nurse calculates that the site should be changed on which date?
1. 2/12 2. 2/14 3. 2/15 4. 2/16 Answer: 1 Rationale:The IV site should be changed very 72 to 96 hours based on the Center for Disease Control guidelines.
A mother of a 9-year-old child calls the emergency department and tells the nurse that her child received a minor burn on the hand after accidentally touching a grill during a family cookout. The mother asks the nurse for advice on how to treat the burn. Which action should the nurse tell the mother to immediately perform?
1. Apply an ice pack to the child's hand. 2. Apply a tepid compress to the child's hand. 3. Place the child's hand under cool running water. 4. Apply a sterile bandage tightly over the burn area to prevent swelling. Answer: 3 Rationale: Most minor burns can be handled at home by the parents. For minor burns, exposure to cool running water is the best treatment. This stops the burning process and helps alleviate pain. Ice is contraindicated because it may add more damage to already injured skin. Option 4 is an incorrect measure. In addition, the mother may not have a sterile dressing available.
The nurse is monitoring a client receiving a blood transfusion for circulatory overload. The nurse understands that which is a clinical indication of circulatory overload?
1. Fatigue 2. Flat neck veins 3. Moist, productive cough 4. Decreasing blood pressure Answer: 3 Rationale: Chest or lumbar pain, cyanosis, dyspnea, moist productive cough, crackles in the lung bases, distended neck veins, and an increase in blood pressure are clinical indications of circulatory overload caused by excessive infusion amounts or too rapid an infusion rate. All other options are incorrect.
A client is brought to the emergency department following a smoke inhalation injury. The initial nursing action is to prepare the client to receive which treatment?
1. Pain medication 2. Endotracheal intubation 3. Oxygen via nasal cannula 4. 100% humidified oxygen by face mask Answer: 4 Rationale: If the client sustains a smoke inhalation injury, the client is treated immediately with 100% humidified oxygen delivered by face mask. Oxygen via nasal cannula will not provide adequate oxygenation.
The nurse caring for a client at home arrives to find the client in the bedroom, unconscious and with a pill bottle of the selective serotonin reuptake inhibitor, sertraline on the bed. Which assessment has priority?
1. Pulse 2. Respirations 3. Blood pressure 4. Urinary output Answer: 2 Rationale: In a suspected poisoning, the nurse should check the respiratory status and the pulse. Blood pressure would be checked after these parameters were determined. Urinary output is also important but not the priority at this time.
The nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. Which is the most appropriate action?
1. Remove the IV. 2. Check for a blood return. 3. Apply a warm compress. 4. Measure the area of infiltration. Answer: 1 Rationale: Blanching, coolness, and edema of the IV site are signs of infiltration. Because infiltration can be damaging to the surrounding tissue, the most appropriate action is to remove the IV to prevent any further damage.
The nurse employed in the emergency department is preparing to administer syrup of ipecac to a 7-month-old child. The nurse prepares 5 mL of the syrup and administers one half glass of water following administration of the ipecac syrup. Which response should the nurse expect?
1. Vomiting 2. Diarrhea 3. Elevated blood pressure 4. Increased level of consciousness Answer: Vomiting Rationale: Syrup of ipecac is a medication that may be prescribed for the induction of emesis. It is indicated following ingestion of some poisons. It is contraindicated following ingestion of strong acids or bases and for clients who are comatose, delirious, or experiencing convulsions. It is not recommended for home use but may be prescribed in a hospital setting under supervision. The dose for children younger than 1 year of age is 5 to 10 mL followed by one half to one glass of water.
One unit of packed red blood cells is infusing into a client over a 4-hour period. The unit of blood contains 250 mL. The drop factor is 15 drops (gtt) per 1 mL. The nurse determines that the flow rate should be set at how many drops per minute? Fill in the blank and round answer to the nearest whole number.
16 gtt/min
Electrical cardioversion
cardioverting (restoring normal sinus rhythm) the electrical activity of the heart by placing pads or paddles onto the chest and literally "electrically shocking" the heart. Is an option for atrial fibrillation if the client is clinically unstable or if the client has not responded to chemical cardioversion after a 6-week period of anticoagulant therapy. Anticoagulant therapy, for example, with a continuous heparin infusion, is indicated to prevent development of thrombus formation in the atria but is not the priority over rate control.
Infiltration
is seepage of the intravenous fluid out of the vein and into the surrounding interstitial spaces. It is a form of tissue injury, but the injury is not to the extent that occurs with extravasation.
Defibrillation
the use of electrical shock to restore the heart's normal rhythm. Is indicated when a client is in pulseless ventricular tachycardia or ventricular fibrillation.
A client has had extensive surgery on the gastrointestinal tract and has been started on total parenteral nutrition (TPN). The client tells the nurse, "I think I'm going crazy. I feel like I'm starving, and yet that bag is supposed to be feeding me." Which is the best response from the nurse?
1. "Don't worry. Many others in your situation say the same thing." 2. "That is unusual. I wonder if the solution is being mixed correctly?" 3. "That is because the empty stomach sends signals to the brain to stimulate hunger." 4. "Maybe you should ask your primary health care provider about that; I've never heard of that before." Answer: 3 Rationale: The stomach does send signals to the brain when it is empty to stimulate hunger. The client should be told that this is normal. Some clients also experience food cravings for the same reason. Options 1 and 4 will block the communication process. Option 2 will produce fear in the client.
Fluid overload
causes increased intravascular volume, which increases the blood pressure and the pulse rate as the heart tries to pump the extra fluid volume. Fluid overload also causes neck vein distention and the shifting of fluid into the alveoli, resulting in lung crackles. Complications should be reported to the registered nurse and/or the primary health care provider immediately.
A child is admitted to the burn unit with partial- and full-thickness burns over 35% of the body. The nurse assisting in caring for the child develops the plan of care. Which nursing intervention is the priority?
1. Inserting a Foley catheter 2.Inserting a nasogastric tube 3.Restricting intravenous (IV) fluids 4.Sedating the child with morphine sulfate Answer: 1 Rationale:A Foley catheter is inserted into the child's bladder so that urine output can be accurately measured hourly.
The nurse employed in the emergency department receives a telephone call from the emergency alert system informing the department that a child who ingested a bottle of acetaminophen is en route to the emergency department. The nurse prepares the room for the arrival of the child and checks the medication supply to determine whether which medication that is the antidote is available?
1. Pancreatin 2. Phytonadione 3. Acetylcysteine 4. Protamine sulfate Answer: 3 Rationale: Acetylcysteine is the antidote for acetaminophen. Phytonadione is the antidote for warfarin sodium. Protamine sulfate is the antidote for heparin. Pancreatin is a pancreatic enzyme replacement or supplement.
A client who has been receiving total parenteral nutrition by way of a central venous access device complains of chest pain and dyspnea. The nurse quickly assesses the client's vital signs and notes that the pulse rate has increased and that the blood pressure has dropped. The nurse determines that the client is most likely experiencing which sign?
1. Sepsis 2.Air embolism 3.Fluid overload 4.Fluid imbalance Answer: 2 Rationale:The signs and symptoms of air embolism include chest pain, dyspnea, hypoxia, anxiety, tachycardia, and hypotension. The nurse also should hear a loud churning sound over the pericardium on auscultation of the chest.
The nurse is assisting in monitoring the condition of a client after pericardiocentesis for cardiac tamponade. Which observation indicates that the procedure was unsuccessful?
1. Clear breath sounds 2.Client expressions of relief 3.Clearly audible heart sounds 4.Distant and muffled heart sounds Answer: 4. Rationale:Following pericardiocentesis, the client usually expresses immediate relief. Heart sounds are no longer muffled or distant. Clear breath sounds and clearly audible heart sounds are positive signs.
A client who sustained an inhalation injury arrives in the emergency department. On data collection, the nurse notes that the client is very confused and combative. The nurse determines that the client is experiencing which problem?
1. Fear 2. Pain 3. Hypoxia 4. Anxiety Answer: 3 Rationale: After a burn injury, clients are normally alert. If a client becomes confused or combative, hypoxia may be the cause. Hypoxia occurs after inhalation injury and may occur after an electrical injury.
A client rings the call light and complains of pain at the site of an intravenous (IV) infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which actions in the care of this client? Select all that apply.
1. Remove the IV catheter at that site. 2. Apply warm moist packs to the site. 3. Notify the primary health care provider (PHCP). 4. Start a new IV line in a proximal portion of the same vein. 5. Document the occurrence, actions taken, and the client's response. Answer: 1, 2, 3, 5 Rationale: Phlebitis is an inflammation of the vein that can occur from mechanical or chemical (medication) trauma or from a local infection and can cause the development of a clot (thrombophlebitis). The nurse should remove the IV at the phlebitic site and apply warm moist compresses to the area to speed resolution of the inflammation. Because phlebitis has occurred, the nurse also notifies the PHCP about the IV complication. The nurse should restart the IV in a vein other than the one that has developed phlebitis. Finally, the nurse documents the occurrence, actions taken, and the client's response.
A client who is receiving total parenteral nutrition (TPN) complains of a headache. The nurse notes that the client has an increased blood pressure and a bounding pulse. The nurse reports the findings, knowing that these signs/symptoms are indicative of which complication of this therapy?
1. Sepsis 2.Air embolism 3.Fluid overload 4.Hyperglycemia Answer 3 Due to: The client's signs and symptoms are consistent with fluid overload. The increased intravascular volume increases the blood pressure, whereas the pulse rate increases as the heart tries to pump the extra fluid volume.
phlebitis
is an inflammation of the vein that can occur from mechanical or chemical (medication) trauma or from a local infection. Phlebitis can cause the development of a clot (thrombophlebitis).
pericardiocentesis
surgical puncture to aspirate fluid from the sac surrounding the heart
The nurse is assisting in preparing to administer acetylcysteine to a client with an overdose of acetaminophen. How should the nurse administer the medication?
1. Administer the medication subcutaneously in the deltoid muscle. 2. Administer the medication by the intramuscular route in the gluteal muscle. 3. Administer the medication by the intramuscular route, mixed in 10 mL of normal saline. 4. Mix the medication in a flavored ice drink, and allow the client to drink the medication through a straw. Answer: 4 Rationale:Because acetylcysteine has a pervasive odor of rotten eggs, it must be disguised in a flavored ice drink. It is consumed preferably through a straw to minimize contact with the mouth. It is not administered by the intramuscular or subcutaneous route.
The nurse notes that a client who is attached to a cardiac monitor suddenly develops atrial fibrillation at a rate of 130 beats per minute. The nurse immediately notifies the registered nurse and prepares the client for which initial intervention?
1. Defibrillation 2. Electrical cardioversion 3. Heparin infusion therapy 4. Administration of a calcium channel blocker Answer: 4. Rationale: The initial treatment goal when atrial fibrillation suddenly occurs is to control the rate of impulses with the administration of a calcium channel blocker or a beta blocker.
The nurse is assigned to care for a client who has experienced uterine rupture. The nurse plans care knowing that which is the priority concern in caring for the client?
1. Fear 2. Grieving 3. Acute pain 4. Impaired gas exchange Answer: 4 Rationale: The priority should always deal with airway. Although options 1, 2, and 3 are also appropriate concerns for this client, they are not the priority and assume a lesser priority than impaired gas exchange.
The nurse assisting in caring for a client with a myocardial infarction is monitoring for cardiogenic shock. The nurse should monitor for which peripheral vascular symptoms?
1. Flushed, dry skin with bounding pedal pulses 2. Warm, moist skin with irregular pedal pulses 3. Cool, dry skin with alternating weak and strong pedal pulses 4. Cool, clammy skin with either weak or thready pedal pulses Answer: 4 Rationale: Classic signs of cardiogenic shock include increased pulse (weak and thready); decreased blood pressure; decreased urine output; signs of cerebral ischemia (confusion, agitation); and cool, clammy skin.
The nurse who is assisting in caring for a client with a tracheostomy tube notes heavy bleeding from the stoma. The nurse also notes that the tracheostomy tube pulsates with the client's heartbeat. The nurse immediately performs which action?
1. Transports the client to surgery 2. Administers supplemental oxygen 3. Initiates an intravenous (IV) line 4. Applies pressure to the artery at the stoma site Answer: 4 Rationale: Heavy bleeding from a tracheostomy site is a life-threatening complication. Direct pressure is applied to the innominate artery at the stoma site. The client is then prepared for immediate surgical repair. An IV line will need to be initiated, but this is not the immediate action.
The primary health care provider prescribes one unit of packed red blood cells to infuse over 4 hours. One unit of blood contains 250 mL, and the drop factor is 10 gtt/1 mL. Although an infusion pump will be used, the registered nurse asks the licensed practical nurse (LPN) to assist with monitoring the flow rate during the infusion. The LPN monitors the flow rate, knowing that how many gtt/min should infuse? Fill in the blank and round answer to the nearest whole number.
Answer: 10gtt/min Rationale: The prescribed 250 mL is to be infused over 4 hours. Follow the formula, and multiply 250 mL by 10 (gtt factor). Then divide the result by 240 minutes (4 hours × 60 minutes). The infusion is to run at 10.4 or 10 gtt/min.
A client requiring upcoming surgery is extremely anxious about the need for a possible blood transfusion and is concerned about the risk of infection from contaminated blood. The nurse suggests that the client consider which as an effective method to minimize this risk?
Arrange an autologous blood donation before the planned surgery. Rationale: Donating autologous blood to be reinfused as needed during or after surgery minimizes the risk of cross-infection from contaminated blood. The next most effective way is to ask a family member to donate blood before surgery. Blood banks do not provide extra screening on request. Preoperative iron supplements are helpful for iron deficiency anemia but are not helpful in affecting the possibility of infection.
The nurse is monitoring a client who is receiving a unit of packed red blood cells. Within an hour after the initiation of a transfusion, the nurse finds the client to be restless, with reports of chills and back pain. The nurse notes that there is dark urine in the Foley catheter drainage bag. The nurse interprets that the client is experiencing which reaction?
1. Allergic 2. Hyperkalemic 3. Acute hemolytic 4. Delayed hemolytic Answer: 3 Rationale:The client is experiencing an acute hemolytic reaction to the transfusion. The nurse in this instance would immediately stop the infusion and notify the primary health care provider. A delayed hemolytic reaction typically occurs from 2 to 14 days after transfusion. A hyperkalemic reaction occurs when blood is transfused that has been stored for too long, resulting in red blood cell hemolysis. The client experiencing a hyperkalemic reaction would exhibit nausea, muscle weakness or paresthesias, apprehension, bradycardia, electrocardiogram (ECG) changes, and possibly cardiac arrest. An allergic reaction is characterized by flushing, nausea and vomiting, respiratory stridor, hypotension, and other signs of anaphylaxis.
A client who experienced ventricular fibrillation has just been defibrillated. Following the defibrillation, which action should the nurse take immediately?
1. Increase the intravenous flow rate. 2. Check the client's neurological status. 3. Take the client's blood pressure and pulse. 4. Resume cardiopulmonary resuscitation (CPR). Answer: 4 Rationale: Following defibrillation, the nurse immediately resumes CPR for 2 minutes. Even if a normal rhythm has been restored, the heart pump needs to be reprimed to provide improved cerebral blood flow to improve neurological outcome.
During the emergent phase of a client with severe burns the nurse expects to perform which action?
1. Insert a Foley catheter. 2. Apply a pressure garment to the burn area. 3. Prepare the client for a scheduled skin graft. 4. Administer a prescribed dose of oral codeine. Answer: 1 Rationale: In the emergent phase of severe burns, a Foley catheter is inserted to monitor hourly urine output and provide data to determine whether fluid resuscitation is adequate. The minimum acceptable urine flow for an adult is 30 mL/hr. The other options would not be implemented in the emergent phase.
A child is hospitalized with a diagnosis of lead poisoning. The nurse caring for the child should prepare to assist in administering which medication?
1. Dimercaprol 2.Syrup of ipecac 3.Activated charcoal 4.Sodium bicarbonate Answer: 1 Rationale: Dimercaprol is a chelating agent that is administered to remove lead from the circulating blood and from some tissues and organs for excretion in the urine. Sodium bicarbonate may be used in salicylate poisoning. Syrup of ipecac is used in the hospital setting in poisonings to induce vomiting. Activated charcoal is used to decrease absorption in certain poisoning situations.
A 4-year-old child has been brought to the emergency department after the grandparents found him with an open bottle of chewable, orange-flavored 81-mg aspirin tablets. In order to determine whether the child is experiencing a toxic effect, which question should the nurse ask the child?
1. Do you have trouble seeing my penlight?" 2. "Do you smell something rotten in the air?" 3. "Do you feel like you have bugs under your skin?" 4. "Do you hear a sound like a bell ringing in your ears?" Answer: 4 Rationale: Ringing in the ears is a common sign of salicylate toxicity, and it is appropriate to ask a 4-year-old whether they hear an unusual sound. Unusual skin sensations, trouble seeing, and unusual odors are not indicative of salicylate toxicity.
The nurse is assisting in admitting a client to the emergency department with suspected carbon monoxide poisoning. The nurse understands that which sign/symptom is least reliable for determining the oxygenation status of this client?
1. Skin color 2. Palpitations 3. Muscular weakness 4. Complaints of a headache Answer: 1 Rationale: Skin color is the least reliable sign for determining the oxygenation status of the client with carbon monoxide poisoning. Skin color may vary and range from pink to cherry red, or pale to cyanotic. Other signs that result from the lack of oxygen include dizziness, headache, muscular weakness, palpitations, and mental confusion, which can progress rapidly to coma.
A client receiving intravenous (IV) fluid therapy complains of burning and a feeling of tightness at the IV insertion site. On data collection, the nurse detects coolness and swelling at the site and notes that the IV rate has slowed. The nurse determines that which has occurred?
1. Infection 2.Phlebitis 3.Infiltration 4.Thrombosis Answer: 3 Rationale:An infiltrated IV line is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness, and swelling at the IV site result when IV fluid is deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of IV solution will slow down or stop. The corrective action is to remove the catheter and start a new IV line at another site. Infection, phlebitis, and thrombosis are likely to be accompanied by warmth at the site, not coolness.
The nurse is assisting in caring for a victim of a burn injury during the emergent/resuscitative phase. On data collection of the client, the nurse notes that the urine output has decreased and the blood pressure is dropping. The nurse should perform which immediate action?
1. Notify the registered nurse. 2. Check the client in 30 minutes. 3. Increase the intravenous (IV) flow rate. 4. Cover the client with a warm blanket. Answer: 1 Rationale: The nurse notifies the registered nurse, who will then notify the primary health care provider immediately if the burn client exhibits a decreased urine output or blood pressure or an increased pulse rate. Because of the rapid fluid shifts that occur in burn shock, fluid deficit must be detected early so that distributive shock does not occur. The nurse does not increase an IV rate without a specific prescription to do so. Checking the client in 30 minutes will delay necessary interventions to prevent the development of distributive shock. A warm environment is maintained, but this is not the immediate action.
Following surgical removal of a brain tumor, the primary health care provider writes a prescription to maintain the child in a semi-Fowler's position. In the postoperative period, the nurse is monitoring the child and notes that the child is restless, the pulse rate is elevated, and the blood pressure has dropped significantly from the baseline value. The nurse suspects that the child is in shock. Which nursing action would be appropriate?
1. Notify the registered nurse. 2. Elevate the head of the bed. 3. Increase intravenous (IV) fluids. 4. Place the child in Trendelenburg's position. Answer: 1 Rationale: The child is never placed in the Trendelenburg's position because it increases intracranial pressure (ICP) and the risk of bleeding. In the event of shock, the registered nurse is notified, who immediately notifies the primary health care provider. Elevating the heads of the bed may worsen the shock state. Increasing IV fluids can cause an increase in ICP and should not be done without a primary health care provider's prescription.
The nurse is caring for a client in labor. The nurse notes the presence of fetal bradycardia on the fetal monitor and suspects that the umbilical cord is compressed. The nurse should immediately place the client in which position?
1. Upright 2. High-Fowler's 3. Semi-Fowler's 4. With the hips elevated Answer: 4 Rationale: When cord compression is suspected, the woman is immediately repositioned. The client may be turned from side to side or the hips elevated to shift the fetal presenting part toward her diaphragm, thus relieving cord compression. A hand-and-knees position may also reduce compression on the cord that is entrapped behind the fetus. Several position changes may be required before the fetal pattern improves or resolves
A client with myasthenia gravis is receiving pyridostigmine. The nurse monitors for signs and symptoms of cholinergic crisis caused by overdose of the medication. The nurse checks the medication supply to ensure that which medication is available for administration if a cholinergic crisis occurs?
1. Vitamin K 2. Acetylcysteine 3. Atropine sulfate 4. Protamine sulfate Answer: 3 Rationale: The antidote for cholinergic crisis is atropine sulfate. Vitamin K is the antidote for warfarin. Protamine sulfate is the antidote for heparin, and acetylcysteine is the antidote for acetaminophen.
An emergency department nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area. The client sustained the burn from a home fire that occurred in the basement. Which data would indicate that the client sustained a respiratory injury as a result of the burn?
1. Fear and anxiety 2. Complaints of pain 3. Clear breath sounds 4. Use of accessory muscles for breathing Answer: 4 Rationale: Clinical indicators in a burn client that would indicate respiratory injury include the presence of facial burns, the presence of soot around the mouth or nose, and singed nasal hairs. Signs of respiratory difficulty include changes in respiratory rate and the use of accessory muscles for breathing.
A client in the postpartum unit complains of sudden, sharp chest pain. The client is tachycardic and the respiratory rate is increased, and the primary health care provider diagnoses a pulmonary embolism. Which interventions apply to the care of this client? Select all that apply.
1. Administer oxygen. 2.Monitor the blood pressure. 3.Prepare to administer morphine sulfate. 4.Prepare to start an intravenous (IV) line. 5.prepare to administer warfarin sodium. 6.Place the client on bed rest in a supine position. Answer: 1, 2, 3, 4 Rationale:If pulmonary embolism is suspected, oxygen is administered to decrease hypoxia. The client also is kept on bed rest, with the head of the bed slightly elevated, not supine, to reduce dyspnea. Morphine sulfate may be prescribed for the client to reduce pain and apprehension. An IV line also will be required, and vital signs must be monitored. Heparin therapy (not warfarin sodium) is administered.
The emergency department nurse is caring for a child brought to the emergency department following the ingestion of approximately one half bottle of acetylsalicylic acid (aspirin) 10 minutes before arrival. Which should the nurse anticipate as the likely initial treatment?
1. Dialysis 2. The administration of vitamin K 3. The administration of activated charcoal 4. The administration of sodium bicarbonate Answer: 3 Rationale:Initial treatment of salicylate overdose includes administration of activated charcoal to decrease absorption of the aspirin. Intravenous (IV) fluids and inducing emesis may be prescribed to enhance excretion but would not be the initial treatment. Dialysis is used in extreme cases if the child is unresponsive to therapy. Vitamin K is the antidote for warfarin overdose.
The nurse is performing a vaginal check of a pregnant client in labor. The nurse notes that the umbilical cord is protruding from the vagina. Which action should the nurse immediately perform?
1. Administer oxygen to the client. 2.Transport the client to the delivery room. 3.Place an external fetal monitor on the client. 4.Exert upward pressure against the presenting part with gloved fingers. Answer: 4 Rationale:If the umbilical cord is protruding from the vagina, no attempt should be made to replace it because to do so could traumatize it and further reduce blood flow. The nurse should place a gloved hand into the vagina toward the cervix and exert upward pressure against the presenting part to relieve compression of the cord. The nurse also should wrap the cord loosely in a sterile towel saturated with warm, sterile normal saline solution. Oxygen, 8 to 10 L/minute by face mask, is administered to the mother to increase fetal oxygenation, and the client is prepared for immediate delivery. However, the immediate action is to relieve pressure on the cord. The client would already have an external fetal monitor in place.
The nurse receives a telephone call from a neighbor who states that her child was found sitting on the floor near the kitchen sink playing with several bottles of cleaning fluids. The bottles of cleaning fluid were opened and spilled on the child and the floor, and the mother suspects that the child may have consumed some of the cleaning fluid. Which action should the nurse tell the mother to do immediately?
1. Call the area poison control center. 2. Call the primary health care provider. 3. Call the pharmacy to purchase syrup of ipecac for administration. 4. Call an ambulance to bring the child to the emergency department. Answer: 1 Rationale: The area poison control center should be called if an unknown toxic agent has been ingested or if it is necessary to identify an antidote for a known toxic agent.
The nurse is preparing for the intershift report when a nurse's aide pulls an emergency call light in a client's room. On answering the light, the nurse finds a client experiencing tachycardia and tachypnea. The client's blood pressure is 88/60 mm Hg. Which action should the nurse take first?
1. Check the hourly urine output. 2. Check the client's pulse oximetry. 3. Check the intravenous (IV) site for infiltration. 4. Place the client in modified Trendelenburg's position. Answer: 4 Rationale: The client is exhibiting signs of shock and requires emergency intervention. Placing the client in the modified Trendelenburg's position increases blood return from the legs, which increases venous return and subsequently the blood pressure. The nurse can then verify the client's blood volume status by assessing the urine output and ensuring that the IV is infusing without complications. The nurse should also check the client's pulse oximetry and notify the registered nurse.
