Exam 5 NUR211 practice questions

A young client is brought from the emergency department (ED) to the psychiatric unit. ED staff report that the client is not answering questions and has been sitting in the same position in the wheelchair for 45 minutes. When the client's arm was extended to draw blood, the client did not move their arm back to a natural position. The client's sibling reports finding the client this way yesterday and could not get them to move on their own. Which nursing intervention(s) does the nurse prioritize for the client's first 24 hours on the unit? Select all that apply. a) Ask the client to describe their stressors. b) Monitor body positions to prevent injury. c) Offer the client nutritional shakes every 3 hours. d) Encourage the client to talk about their feelings. e) Assist the client to the bathroom every 2 hours. f) Protect the client from intrusions by other clients.

b, c, e, f

The nurse finds a child who is not breathing. The nurse has someone activate the emergency medical system and then does what first?

Start chest compressions.

Thirty people are injured in a train derailment. Which client should be transported to the hospital first?

25-year-old with a sucking chest wound

A triage nurse in the emergency department admits a male client with second-degree burns on the anterior and posterior portions of both legs. Based on the Rule of Nines, what percentage of the body is burned? Record your answer using a whole number.

36

A client has been involved in a shooting and is brought to the emergency department with profuse bleeding from the abdomen. Place each intervention in order of priority. All options must be used.

Assess all vital signs, including oxygen saturation. Infuse intravenous fluids to prevent shock. Assess the chest for evidence of other injuries. Control the pain from the gunshot wound. Maintain NPO in anticipation of surgery.

A local chemical plant has had an environmental leak requiring the mass evacuation of its employees and neighbors in the surrounding area. The emergency room nurse is in the triage area when the first client is brought to the hospital. What should the nurse do first?

Determine what decontamination measures took place in the field before approaching the client.

An 8-month-old infant is brought to the emergency department (ED) following a fall from his high chair. The child is awake, alert, and crying. Which nursing intervention would be most appropriate for the nurse?

Discharge to home with instructions to the parents for head injury

The infant with hemophilia A experiences bleeding at the elbow and is seen in the emergency department. Which nursing intervention would be most appropriate to minimize bleeding in the affected area?

Elevate the elbow above the level of the heart.

The parents of a 2-year-old bring their child to the emergency department because the child ingested approximately 15 acetaminophen tablets 30 minutes ago. Place the following nursing actions in the order the nurse should perform them, from most important to least important.

Establish an airway. Assess vital signs. Administer activated charcoal. Administer N-acetylcysteine.

A 4-month-old infant has been carried into the emergency department after falling off the parents' bed and hitting the head on the floor. What should the nurse do first?

Move the family to an area where an assessment can be completed and call for a physician.

A client is being treated in the emergency department for a leg wound and has been impatient about the wait. The nurse explains how the triage process works and the importance of being assessed. The client tells the nurse, "I am not waiting around here any longer. My leg is fine." What is the best response by the nurse?

Notify the healthcare provider of the client's intent to leave.

There has been a car collision involving four vehicles. The nearest emergency department is 30 minutes away. Which client should be transported by helicopter rather than an ambulance to the nearest hospital?

a middle-age female with cold, clammy skin and a heart rate of 120 bpm who is unconscious

An airplane crash results in mass casualties. The nurse is directing personnel to tag all clients. Which information should be placed on the tag? Select all that apply. a) triage priority b) identifying information when possible (such as name and age) c) medications and treatments administered d) presence of jewelry e) next of kin

a, b, c

A nurse working in the triage area of an emergency department sees several pediatric clients arrive simultaneously. Which client should be treated first?

a 2-year-old child with stridorous breath sounds, sitting up and drooling

In a disaster situation in the emergency department, the nurse is assessing a client who is critically ill, with a high likelihood of mortality. Which triage level would be appropriate?

a low priority

A nurse is caring for a client with a complete T5 spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above T5, and a blood pressure of 174/100 mm Hg. The client reports a severe, pounding headache. Which nursing interventions are appropriate for this client? Select all that apply. a) Elevate the head of the bed 90 degrees. b) Loosen constrictive clothing. c) Use a fan to reduce diaphoresis. d) Assess for bladder distention and bowel impaction. e) Administer antihypertensive medication as ordered. f) Administer morphine as ordered.

a, b, d, e

The unlicensed assistive personnel (UAP) reports to the nurse that a client is "feeling short of breath." The client's blood pressure was 124/78 mm Hg 2 hours ago with a heart rate of 82 bpm; the UAP reports that blood pressure is now 84/44 mm Hg with a heart rate of 54 bpm, and the client stated, "I just don't feel good." What action(s) should the nurse take? Select all that apply. a)Confirm the client's vital signs and complete a quick assessment. b) Inform the charge nurse of the change in condition and initiate the hospital's rapid/emergency response team. c) Make a quick check on other assigned clients before spending the time required to take care of this client. d) Place the client in the semi-Fowler position. e) Stay with the client, and reassure them. f) Call the health care provider (HCP), and report the situation using SBAR format.

a, b, d, e, f

A client is admitted to the emergency department with a broken humerus after a motor vehicle collision. Significant assessment findings include respiratory rate 28 breaths/min and arterial blood gas (ABG) readings of pH 7.51, PaCO2 30 mm Hg (3.99 kPa), HCO3 23 mEq/L (23 mmol/L), and PaO2 90 mm Hg (11.97 kPa). Which nursing action would be a priority?

Offer reassurance, and treat the client's pain.

What nursing interventions are appropriate for a client experiencing status epilepticus? Select all that apply. a) protect the client from harm b) insert a padded tongue blade in the mouth c) assess for hypoglycemia d) administer lorazepam per healthcare providers prescription e) place in prone position f) remain with client and give verbal reassurance

a, c, d, f

The nurse manager in the emergency department (ED) conducts an in-service for the nursing staff about screening clients for suicide. One of the nurses states, "Questioning adolescents about suicide will only increase their thinking about self-harm, and they wouldn't admit it to me anyhow." How should the nurse manager respond? Select all that apply. a) "Suicide is a leading cause of death in adolescents." b) "We'll limit the assessment to adolescents with psychiatric diagnoses." c) "It's a myth that talking about suicide leads to suicide attempts." d) "If you think the adolescent isn't telling you the truth, you can question the parents." e) "Adolescents will disclose suicidal thoughts when asked directly."

a, c, e

A nurse is working in a long-term care facility when a fire erupts in the kitchen. The fire alarm is sounded and the building is to be evacuated. The nurse is thinking about legal responsibilities and duties during the fire emergency. Which statements indicate the nurse understands the nursing legal responsibilities during this fire emergency? Select all that apply. a) "The kitchen staff is liable for any injuries." b) "The nurse can be negligent for failure to evacuate residents safely if a facility elevator is used." c) "A family of a resident can bring criminal charges to the facility for the loss of life during an emergency." d) "A bariatric resident can determine that a civil crime was committed if the facility staff cannot evacuate the resident safely during an emergency." e) "The facility can be charged with negligence for failure to have a working plan in place during a fire emergency."

b, c, d, f

A client arrives at the emergency department with deep partial-thickness and full-thickness burns over 15% of his body. At admission, the client's vital signs are: blood pressure 100/50 mm Hg, heart rate 130 beats/minute, and respiratory rate 26 breaths/minute. Which nursing interventions are appropriate for this client? Select all that apply. a) cleaning the burns with hydrogen peroxide b) covering the burns with saline-soaked towels c) starting an I.V. infusion of lactated Ringer's solution d) placing ice directly on the burn areas e) administering 6 mg of morphine I.V. f) administering tetanus prophylaxis as ordered

c, e, f

A nurse implements a healthcare facility's disaster plan. Which action should be performed first?

identify a command center at which activities are coordinated.

A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of:

respiratory alkalosis.

The nurse is performing triage in the emergency department. Which client should be seen first?

the client with burns to the chest and neck with singed nasal hair