Ncsbn NCLEX Lesson 8-H Medical Emergencies
The nurse in the emergency department is caring for a pregnant client at 32-weeks gestation with suspected placental abruption. Which order from the health care provider should the nurse implement first? Administer 100% oxygen via nonrebreather mask Start a normal saline IV infusion at 150 mL per hour Type and crossmatch for 2 units of packed RBCs Initiate continuous fetal heart rate monitoring
1 Abruptio placentae, or placental abruption, means the premature detachment of the placenta, wholly or partially, from the uterine wall. Immediate birth, i.e., delivery, is the treatment of choice if the fetus is near term or the bleeding is moderate to severe or the life of the mother or fetus is in jeopardy. In this scenario, the nurse should use the Airway-Breathing-Circulation (A-B-C) approach to prioritize the ordered interventions. The nurse should first administer the oxygen to prevent hypoxia in the fetus. Then the nurse should implement the other interventions.
The client is a 16-year-old with full-thickness burns involving 20% total body surface area. After the initial 24 hours of treatment to replace fluids, which factor is used to determine if the client's fluid needs are being met? 1. Hourly urine output 2. Parkland formula for fluids 3. Daily hematocrit results 4. Daily weight measurements
1 Burn victims are at risk for deficient fluid volume. The Parkland formula for fluid replacement is used during the initial fluid resuscitation for burn victims. Thereafter, hourly urine output is used to guide fluid management. The desired urine output is 30-50 mL/hour for most adults and older children. Fluid replacement formulas (like Parkland) depend on the client's weight on admission and daily weights are more commonly used to determine if caloric intake is enough to meet increased metabolic needs. Hematocrit (and hemoglobin) can be used to help identify blood loss and RBC destruction, but they are is not used to determine fluid replacement needs.
The nurse is caring for a client who is experiencing an acute gout attack. Which action should the nurse implement? 1.Administer indomethacin. 2.Monitor liver enzymes. 3. Restrict sodium intake. 4. Provide a high-protein diet.
1 Gout is a disease where uric acid crystals form and accumulate in joints and other tissues. During an acute gout attack, the client experiences pain and inflammation in the joints. The nurse should administer a non-steroidal anti-inflammatory medication such as indomethacin to help decrease pain and inflammation. Restricting sodium would not benefit the client and providing a high-protein diet may make the situation worse. There is no need to monitor liver enzymes with an acute gout attack.
A client with a known large abdominal aortic aneurysm develops a sudden change in level of consciousness and tachycardia. The client's blood pressure is 72/48 mm Hg. What should the nurse do first? 1. Activate the hospital's emergency response team. 2. Conduct a complete head-to-toe physical assessment. 3. Obtain a 12-lead electrocardiogram. 4. Page the client's health care provider.
1 The client is exhibiting signs and symptoms of an abdominal aortic aneurysm (AAA) rupture. The nurse's first action should be to activate the hospital's emergency response team, as this client needs immediate advanced care. The nurse is anticipating the need for rapid action and surgical intervention to avoid the death of the client. While notifying the client's health care provider and obtaining a 12-lead electrocardiogram (ECG) may be needed, activating the emergency response team should be done first. Similarly, the nurse does not have time complete a head-to-toe physical assessment before activating the emergency response team.
A client is admitted to the ER with chest pain. He has been in the ER for five hours and is being admitted to your unit for observation. From the options below, what is the most IMPORTANT information the nurse needs to know about this client at this time? Troponin result and when the next troponin level is due to be collected Diet status Last consumption of caffeine Glucose level results and when the next glucose level is due to be collected
1 The key words in this question are "chest pain" and "been in the ER for five hours." The patient should have already had one troponin level drawn, since it starts to elevate 2-4 hours after injury and he has been in the ER for five hours. Therefore, it is essential for you to know what the level is and when the next level is due. If the patient's chest pain is caused by a myocardial event, the troponin levels will trend upward.
A client presents with a burn that is pale and waxy with large flat blisters. The client asks the nurse about the severity of the burn. How should the nurse respond to this question? The wound is a deep partial-thickness burn The wound is similar to a sunburn The wound is a superficial burn The wound is a full-thickness burn
1 The wound described is a deep partial-thickness burn. Deep partial-thickness wounds will take more than three weeks to heal. A superficial burn or sunburn is bright red and moist, and might appear glistening with blister formation. The healing time for this type of wound is within 21 days. A full thickness burn involves all layers of the skin and may extend into the underlying tissue. These burns take many weeks to heal. Stating that wound healing is individualized does not answer the patient's question about the severity of the burn.
The nurse is developing a plan of care for an older adult client who will be undergoing a total hip arthroplasty. To improve the client's postoperative recovery, which interventions should the nurse include? Select all that apply. 1. Application of sequential compression device 2. The use of assistive devices for ambulation 3. Preoperative pain control with naproxen 4. Administration of subcutaneous warfarin 5. Instruction on plantar and dorsiflexion exercises
1, 2 ,5 Due to the client's age and the surgical procedure, the client is at risk for a venous thromboembolism. The nurse should include the use of sequential compression devices to decrease venous stasis along with providing instruction on plantar and dorsiflexion exercises. Warfarin is administered orally; it does not come in an injectable form. The client will most likely need assistive devices initially for safe ambulation postoperatively. Preoperatively, the nurse should not use naproxen to control pain because it is a nonsteroidal anti-inflammatory drug (NSAID) and can increase the risk of bleeding during surgery.
The nurse is working the triage area of the emergency room department. The nurse will determine in which order the clients will be seen. (Drag and drop the items into the correct order.) -1. An irritable infant with a fever, petechiae and nuchal rigidity -2. An ambulatory, dazed 25-year-old male with a bandaged head wound -3. A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity -4. A 50-year-old female with moderate abdominal pain and occasional vomiting Submit(1 attempt remaining)
1, 2,4.3 An irritable infant with fever and petechiae should be further assessed for other meningeal signs. The patient with the head wound needs additional history and assessment for intracranial pressure. The patient with moderate abdominal pain is uncomfortable, but not unstable at this point. For the ankle injury, medical evaluation can be delayed 24-48 hours if necessary.
A 28-year-old is transferred to the emergency department (ED) via ambulance with a traumatic head injury. The client is awake and reports having a headache and some amnesia. What are the priority nursing interventions for this client? (Select all that apply.) Assess the wound for presence of drainage or bruising on the head Assess vital signs and neurological function Assess the airway Prepare for CT imaging of the head Position this client in high Fowler's position
1,2,3,4, Remember primary emergency trauma assessment using "A, B, C, D and E". The ED nurse will assess airway, breathing, circulation, and disability/neurological function on a person who has experienced a traumatic head injury. The nurse will also examine the client for the presence of any bruising or drainage, particularly of the ears and nose. A supine position is best; the head of the bed may be elevated slightly if not contraindicated. A CT scan is required if the client presents with an abnormal mental status, clinical signs of skull fracture, history of vomiting, or headache.
The home health nurse is discussing safety concerns with a client who has osteoporosis. Which interventions should the nurse recommend to the client? Select all that apply. 1. Request a referral for physical therapy. 2. Increase intake of dairy products. 3. Enroll in a smoking cessation program. 4. Go for a jog or run several times a week.
1,2,3,5 Clients with osteoporosis have fragile bones and are at risk for fractures. The nurse should encourage coordination with physical therapy to increase muscle strength, balance and decrease the likelihood of a fall. The nurse would also provide assistive devices if the client requires them. Not all clients with osteoporosis will need an assistive device. Due to the impact on joints that occurs with running, the nurse should not recommend jogging or running to a client with osteoporosis. Low-impact activities such as walking would be better. Since smoking decreases tissue perfusion in general and impacts bone development, the client should stop smoking. Dairy products are high in calcium and will help with strengthening bones.
The home health nurse is discussing safety concerns with a client who has osteoporosis. Which interventions should the nurse recommend to the client? Select all that apply. 1. Request a referral for physical therapy. 2. Increase intake of dairy products. 3. Enroll in a smoking cessation program. 4. Go for a jog or run several times a week. 5. Provide assistive devices, if needed.
1,2,3,5 Clients with osteoporosis have fragile bones and are at risk for fractures. The nurse should encourage coordination with physical therapy to increase muscle strength, balance and decrease the likelihood of a fall. The nurse would also provide assistive devices if the client requires them. Not all clients with osteoporosis will need an assistive device. Due to the impact on joints that occurs with running, the nurse should not recommend jogging or running to a client with osteoporosis. Low-impact activities such as walking would be better. Since smoking decreases tissue perfusion in general and impacts bone development, the client should stop smoking. Dairy products are high in calcium and will help with strengthening bones.
The office nurse is discussing how to prevent an acute gouty attack with a client who has gout. Which actions should the nurse recommend to the client? Select all that apply. 1. Limit the consumption of alcohol. 2. Make sure to drink at least 2,000 mL of water daily. 3. Take the prescribed prednisone regularly. 4. Limit the intake of shellfish and red meats. 5. Implement stress reduction techniques.
1,2,4,5 Gout is a disease where uric acid crystals form and accumulate in joints and other tissues. Gout attacks may be brought on by excessive alcohol intake, increased stress and a diet high in purine. Clients should be encouraged to have a low-purine diet by limiting red meats and shellfish, along with drinking alcohol in moderation. The client should be encouraged to drink at least 2,000 mL of water daily to maintain hydration and prevent the buildup of uric acid. Stress management can decrease the likelihood of triggering an acute attack. Prednisone is used during an acute attack, but it does not prevent an attack from occurring.
The nurse is admitting a 73-year-old client who has a fractured right hip. Which interventions should the nurse include in the client's plan of care? Select all that apply. 1. Place the client on continuous pulse oximetry. 2. Reposition the client every hour to prevent skin breakdown. 3. Palpate the client's bilateral pedal pulses every four hours. 4. Ask about the client's pain level with every set of vital signs. 5. Perform daily circulation, motion and sensation checks on the client's right leg.
1,3,4 The client with a hip fracture is at risk for impaired perfusion to the affected extremity. Monitoring bilateral pedal pulses allows the nurse to compare the pulse strength in the injured site with that in the non-injured site. A decrease in the injured leg could signal a decrease in circulation that would require immediate intervention. A fat embolism is also a risk with a hip fracture and continuous pulse oximetry would allow the nurse to identify hypoxia quickly which could be associated with a fat embolism. Clients with a hip fracture usually experience great pain and assessing pain with each set of vital signs is key to effective pain management. Circulation, motion and sensation checks should be completed at least every four hours, not daily. Repositioning the client every hour is unnecessary and will only increase the client's pain level even more.
The nurse in a well-baby clinic is speaking with the mother of a 3-week-old newborn. Which statement by the mother should be of highest concern to the nurse? 1. "No matter how hard I try, I don't feel any love for my baby." 2. "I have not been doing my Kegel exercises as much as I should." 3. "I have not been able to empty my breasts completely with each feeding." 4. "I think my baby is not gaining as much weight as it should."
1. The postpartum period is a time of great adjustment and change for the new parent. The nurse's role should focus on supportive care and monitoring for postpartum complications such as postpartum depression (PPD). Up to 20% of new mothers experience PPD. Symptoms of PPD include intense sadness lasting longer than two weeks, severe and labile mood swings, feelings of fear, anxiety or anger and worries about being an incompetent parent or not loving the child. Although all of the mother's statements should be followed-up by the nurse, the mother's statement about trying but not being able to feel love for their child should be of highest concern. Correct!
An off-duty nurse arrives at a park and is told by a bystander that a child is choking and needs assistance. The bystander has already called 911. The nurse observes an approximately 8-year-old child with cyanosis and an inability to breathe who remains conscious and standing. What should the nurse do next? 1. Stand behind the child and administer abdominal thrusts. 2. Check the child's carotid pulse. 3. Instruct the child to lay down and begin CPR. 4. Deliver two rescue breaths.
1. For a conscious choking victim, according to basic life support (BLS) guidelines by the American Heart Association (AHA), the next action by the nurse should be to perform abdominal thrusts (i.e., the Heimlich Maneuver) to attempt to clear the airway obstruction. Attempting to deliver rescue breaths or checking the carotid pulse of a conscious choking victim would not be indicated. If the child were to become unconscious, then chest compressions should be initiated.
The nurse is caring for a group of adult clients on a neurological unit in an acute care hospital. Which client should the nurse see first? 1. A client admitted with hepatic encephalopathy who has an elevated ammonia level 2. A client admitted several hours ago with a subdural hematoma due to an unwitnessed fall at home 3. A client admitted with a transient ischemic attack, who has a bubble study echocardiogram ordered 4. A client admitted two days ago with an ischemic stroke who has a blood pressure of 158/64
2 After an unwitnessed fall, the nurse must consider the possibility of head injury. Due to the elevated risk for worsening bleeding and increased intracranial pressure because of the fall and pre-existing head injury, the client with a subdural hematoma should be seen first. A blood pressure of 158/64 in a client with an ischemic stroke would not represent an urgent situation, and an elevated ammonia level would not be unexpected for a client with hepatic encephalopathy. While the results of an echocardiogram with a bubble study would be relevant to the care of client with a transient ischemic attack (TIA), this client is not showing signs of a worsening condition requiring urgent assessment.
The nurse is assessing a client with a stage II skin ulcer. Which of these approaches should be most effective to promote healing? 1. Cover the wound with a dry dressing 2. Apply a hydrocolloid or foam dressing 3. Use hydrogen peroxide soaks 4. Leave the area open to dry
2 In prior years an accepted treatment was the use of a transparent cover. However, evidence-based nursing outcomes now recommends the use of the foam (DuoDerm) dressings to keep the wound somewhat moist. One could eliminate the two options that have the word "dry" in them. This is called the elimination of "similar - dissimilar" options. Hydrogen peroxide should not be used full strength on any type of wound because it is destructive to the cells.
The nurse is talking with a client during a home health visit. The client states, "my right arm and right leg are beginning to feel heavy." The nurse notices the client is having trouble speaking and has stopped moving the right side of their face. What action the nurse should take first? 1. Take the client's vital signs. 2. Call 911. 3. Document the onset of symptoms in the medical record. 4. Ask the client if they have a headache.
2 The client is exhibiting signs of an acute stroke. A stroke is caused by a disruption in the normal blood supply to the brain. A stroke is a medical emergency. The nurse in the home health setting should call 911 first. While waiting for emergency medical help to arrive, the nurse should gather additional data by obtaining vital signs and evaluating the client's neurological status. The data should be recorded in the medical record.
An adult client who has been experiencing a seizure for approximately 15 minutes is brought to the emergency department by private vehicle. Which intervention should the nurse implement first? 1. Administer levetiracetam intravenously. 2. Administer lorazepam intravenously. 3. Obtain a STAT 12-lead electrocardiogram. 4. Obtain a STAT electroencephalogram.
2 This client is experiencing status epilepticus and is in immediate need of medication to stop the seizure. Of the provided options, the highest priority would be to administer the intravenous (IV) lorazepam to stop the seizure. While levetiracetam, an anticonvulsant, may be indicated for the client, lorazepam, a benzodiazepine, would be administered first in an attempt to stop the seizure quickly. An electroencephalogram (EEG) is an important test when evaluating for seizures, but it would not be highest priority at this time. A 12-lead electrocardiogram (ECG) may be part of a more general diagnostic work-up for many clients, but it would be a lower priority than stopping the seizures.
A 4-year-old child is admitted with burns on the legs and lower abdomen. During the assessment of the child's hydration status, which finding indicates a less-than-adequate fluid replacement therapy? 1. Decreased heart rate and respiratory rate 2. Increased hematocrit and decrease in the urine volume 3. Decreased white blood cell count 4. A fall in the hematocrit and decrease in blood urea nitrogen (BUN)
2 Very aggressive fluid replacement is indicated in children who have been burned, because hypovolemia may quickly lead to shock. A rising hematocrit indicates a decrease in total blood volume, which is a finding consistent with dehydration. Because there is a fluid volume deficit, the kidneys will conserve water and urine output will decrease. The nurse should expect an increase in white blood cells due to tissue damage. With dehydration, both heart and respiratory rates will increase. BUN will increase due to both dehydration and the burns.
The nurse observes an unlicensed assistive person (UAP) providing care to a client who had a total hip arthroplasty 24 hours ago. Which action by the UAP would require the nurse to intervene immediately? 1. Reminding the client not to cross their legs. 2. Standing by the client's non-operative side during ambulation. 3. Placing non-slip foot wear on the client prior to ambulation. 4. Placing a raised toilet seat in the client's bathroom.
2 When assisting the client during ambulation following a total hip arthroplasty, the UAP should stand on the operative side (i.e., the side of the surgery) to help provide support to the client because that is the client's weaker side. The other actions are appropriate for this client and do not require intervention by the nurse.
The off-duty nurse witnesses a motor vehicle accident and is concerned that the driver of the automobile may be injured. What should the nurse do first? 1. Check the driver's respiratory rate. 2. Consider scene safety to prevent further injury. 3. Check the driver's pulse. 4. Minimize movement of the driver's cervical spine.
2 When attempting to render aid after a motor vehicle collision, it is critically important that the responder first consider scene safety. Responders should assess the scene for risks to safety to prevent further injury to themselves, the victim and other motorists on the road. Minimizing the movement of the driver's cervical spine, checking the driver's pulse and checking the driver's respiratory rate may all be indicated in the scenario, but scene safety should be considered first.
The nurse enters the client's room and finds the client, who was previously alert, lethargic and slow to respond. Prioritize the nursing actions by dragging and dropping the options below. -1. Call the rapid response team and report the client's situation; request immediate assistance -2.Attempt to elicit a response by physically shaking the client and loudly stating "open your eyes and talk to me." -3. Remain with the client; send another staff member to get the list of medications and the chart -4. Complete a quick neurological assessment: orientation, pupil response, ability to follow commands
2, 4, 1, 3 When a client exhibits an acute change in condition, such as a reduced level of consciousness, it is an emergency situation and requires immediate intervention. First, the client's status must be determined through quick focused assessment. Most facilities have a rapid response team to assist the staff nurse so this asset should be mobilized next. Because the client should not be left alone, the nurse should call for help and ask a colleague to bring the list of medications along with the client's chart before the rapid response team arrives.
The nurse in the urgent care center is caring for a 20-year-old client who sustained a sprained ankle while playing sports. Which instructions should the nurse give the client to prevent a future sprain injury? Select all that apply. 1. Take ibuprofen 30 minutes before starting any sports activity. 2. Warm up for several minutes before starting the activity. 3. Encourage stretching before and after any sports activity. 4. Use appropriate protective equipment with the activity. 5. Wear snug, well-fitting shoes that go up to the ankle.
2,3,4,5 A sprain occurs when there is a sudden, abnormal movement around the joint that can lead to stretching and/or tearing of the ligaments attached to the joint. Stretching before and after exercising increases the ligaments pliability and decreases the risk for injury. Gradually warming up prior to engaging in physical activity provides the muscles with increased circulation and loosens up joints; both will decrease the risk for strains or sprains. Wearing proper fitting shoes enhances stability and wearing appropriate protective gear provides protection and decreases the likelihood of sprains. Taking ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), to decrease inflammation would be appropriate after a musculoskeletal injury, but will not help to prevent one.
The nurse in the prenatal clinic is developing a plan of care for a client with preeclampsia. Which interventions should the nurse include? Select all that apply. 1. Maintain complete bedrest 2. Limit sodium intake 3. Self-monitor blood pressure daily 4. Count and record fetal movement daily 5. Avoid all sexual activity 6. Use acetaminophen for headache
2,3,4,6 Preeclampsia is defined as an elevated BP (≥140/90 mm Hg) after the 20th week of pregnancy on more than one occasion, and proteinuria. Recommended interventions include accurate, regular monitoring of BP and education on when to report readings to the health care provider, fetal movement counts and lowering or limiting sodium intake to avoid fluid retention. Headaches are common with preeclampsia and using acetaminophen for pain management would be appropriate. Maintaining complete bedrest or abstaining from all sexual activity is no longer recommended or indicated at this time.
A client presents to the emergency department with a prolonged asthma attack that did not resolve after the client used a metered-dosed inhaler at home. Which medication should the nurse plan to administer first for this client? 1. Intravenous azithromycin 2. Nebulized albuterol 3. Oral prednisone 4. Fluticasone inhaler
2. The nurse would anticipate that nebulized albuterol would be given first in this situation to address the acute asthma attack through bronchodilation. While oral prednisone may be used in the treatment of this client, it would be given after administration of an inhaled B2-adrenergic agonist like albuterol. There is no information provided that would indicate antibiotic therapy is needed for the client. A fluticasone inhaler may be part of long-term asthma management for this client, but is not recommended as a rescue treatment for acute asthma attacks.
The nurse is caring for a client with osteoporosis who has been prescribed alendronate. When providing care, which intervention would be a priority? 1. Monitor the client's serum calcium levels. 2. Administer the alendronate 30 to 60 minutes before the client eats. 3. Notify the health care provider if the client reports jaw pain. 4. Encourage the client to increase their intake of vitamin D.
3 Alendronate is a bisphosphonate that helps slow down bone resorption, decreasing osteoporosis. Osteonecrosis of the jaw is a rare, adverse reaction to alendronate, and jaw pain can be a symptom of this. Therefore, notifying the health care provider of the jaw pain is the priority. The other interventions are also correct for a client with osteoporosis, but are not as important as reporting the potential adverse drug effect.
The off-duty nurse is helping to administer first aid following a mass casualty incident in the community. Emergency medical personnel at the scene have started to triage victims, using a common, color-tagging system. Which tag color usually indicates the highest priority for a victim to receive care? 1. Yellow 2. Black 3. Red 4. Green
3 In a mass casualty incident (MCI), first responders often use a color-tagging system to facilitate rapid triage of victims. Generally speaking, a green tag would indicate minor injuries, a yellow tag would indicate more significant but not expected to be life-threatening injuries, a red tag would indicate life-threatening injuries, and a black tag would identify a victim who has died, is near death or has the lowest chance for survival. Victims assigned a red tag are the highest priority for care and transport to the nearest hospital.
A client has moles with irregular edges that vary in color located on her hands. The nurse knows that this could be associated with what type of skin cancer? Basal cell carcinoma (BCC) Squamous cell carcinoma Melanoma Actinic keratosis
3Melanoma appears as lesions with irregular edges and can be black, brown, gray or white in color.
A client is brought to the emergency department after falling 10 feet off a roof. The client is drowsy and reports back pain and difficulty moving the lower extremities. Which additional nursing assessment is an indication the client may be experiencing neurogenic shock? Poor skin turgor Dry, warm to the touch skin Increase in blood pressure Decrease in blood pressure Submit(1 attempt remaining) Help|Terms & Trademarks © 2020 NCSBN. All rights reserved.
4 A decrease in blood pressure is an additional finding that indicates neurogenic shock. The other findings listed in the example do not occur in a client experiencing shock.
The nurse on a postpartum nursing unit is receiving report about a client who had a normal spontaneous vaginal delivery the night before. The client has been passing golf ball-sized clots on her peri-pad for the last few hours. The client's most recent blood pressure is 88/56 mm Hg, and her heart rate is 118 bpm. The nurse enters the client's room and notices blood oozing from her intravenous insertion site. Which action should the nurse take first? 1. Palpate and massage the client's uterus. 2. Perform peri-care and change the client's peri-pad. 3. Encourage breastfeeding to promote uterine contractions. 4. Notify the client's health care provider.
4 After a normal spontaneous vaginal delivery (NSVD), it is normal for a client to have vaginal bleeding on their peri-pad. Postpartum hemorrhage (PPH) is defined as blood loss greater than or equal to 500 mL after birth. If a patient is saturating more than one peri-pad in an hour or passing several large clots, the patient could be experiencing PPH. This is an obstetric emergency. Signs and symptoms of PPH include dizziness, hypotension, tachycardia, large clots passed vaginally and heavy bleeding on the peri-pad. PPH can progress to a life-threatening condition called disseminated intravascular coagulation (DIC). This can occur after an injury or childbirth. Proteins in the blood that form blood clots travel to the injury site to help stop bleeding. If these proteins become abnormally overactive throughout the body, DIC can ensue. Small blood clots form in blood vessels throughout the body, and can clog the vessels and cut off the normal blood supply to the organs. Signs and symptoms of DIC include severe bleeding, oozing from puncture sites, hypotension, tachycardia, dizziness and hypoxia. The nurse should suspect DIC and should notify the primary health care provider (HCP) immediately. Nursing measures to monitor and control normal postpartum uterine bleeding can include uterine massage, breastfeeding and peri-care. The client in this scenario may be experiencing a medical emergency (e.g., DIC), therefore the nurse should first notify the HCP.
The home health care nurse is caring for a client who has epilepsy. While the nurse is providing care, the client has a seizure. Which intervention would be most appropriate to prevent an injury to the client? 1. Asking the client to state where they are 2. Loosening clothing around the waist 3. Placing a pillow under the client's head 4. Lowering the client to the ground
4 Epilepsy is a disorder that involves two or more unprovoked seizures. A seizure is an abnormal discharge of electrical activity in the brain which can cause alterations in motor function, sensation, consciousness, behavior and autonomic function. During a seizure, clients may suddenly lose consciousness and fall to the ground, increasing their risk of breaking a bone or suffering a head injury. The most appropriate intervention at this time is to prevent further injury by lowering the client to the ground and placing them in the recovery position to prevent aspiration. Clothing should be loosened around the neck, not the waist, to ensure a patent airway. Once the client is more awake, the nurse can reoriented them to their surroundings.
The nurse is caring for a client with a medical history of peripheral artery disease, hypertension and smoking. The client reports severe pain in the right lower leg that started very suddenly and did not get better after receiving an analgesic. What action should the nurse take first? 1. Notify the health care provider. 2. Offer the client an ice pack for the pain. 3. Administer an additional dose of the analgesic. 4. Check the client's pedal pulse.
4 Peripheral artery disease (PAD) refers to excessive plaque buildup in the arterial walls. Excessive plaque buildup, due to atherosclerosis, can have an impact on perfusion to limbs. The client is exhibiting symptoms of an acute arterial occlusion. This occlusion usually causes severe pain, loss of pulses and skin color changes. The nurse should follow the nursing process and first perform an assessment, i.e., check the pulse in the affected extremity. Based on the findings (e.g., an absent pulse), the nurse should notify the health care provider right away because this would signal a medical, possibly surgical, emergency. Ice would be contraindicated as that would further reduce tissue perfusion to the leg.
The RN is working in a clinic where a client presents with a painful, blistering rash on the hip. The health care provider diagnoses shingles (herpes zoster). What is the priority nursing diagnosis? Risk for impaired skin integrity related to skin lesions Risk for infection related to skin lesions Knowledge deficit related to disease process Pain related to nerve root inflammation and skin lesions
4 Shingles is a reactivation of the herpes zoster virus responsible for chickenpox. It is characterized by a vesicular rash in a unilateral dermatomal distribution. The first symptom of shingles is usually pain, tingling, or burning before the blisters form. The pain and burning may be severe, and can lead to long-term residual pain, known as postherpetic neuralgia. Early appropriate treatment with an antiviral medication such as acyclovir can reduce these long-term complications, as well as the duration and severity of the initial symptoms. Pain is the priority nursing diagnosis. It is important that the client keeps the sores clean and avoids contact with people who haven't gotten the herpes zoster vaccine or who haven't had chickenpox, as well as people with weakened immune systems, until the rash crusts over and heals.
A nurse needs to administer cardiopulmonary resuscitation to a 5-year-old child. In order to be effective, the nurse should take which action as a single rescuer? Assess the brachial pulses bilaterally Initiate compression-only CPR and compress the chest at least 1.5 inches Compress the chest at a rate of about 90 times per minute Use a ratio of two breaths to 30 compressions
4 The American Heart Association recommends 30 compressions and two breaths. The compression rate is at least 100 beats per minute. Compression-only CPR is recommended for lay persons. Compressions should be one-third to one-half of the chest depth in children. Health care professionals should assess the carotid pulse on children; the brachial pulse is assessed in infants.
A postoperative client following a thyroidectomy suddenly develops difficulty breathing, stridor and an increase in swelling of the anterior neck area. What should the nurse do first? 1. Check the client's blood pressure and heart rate. 2. Place a heart monitor on the client and observe for dysrhythmias. 3. Ask the charge nurse to come see the client immediately. 4. Activate the hospital's emergency or rapid response system.
4 The client is demonstrating clinical manifestations of an airway obstruction related to bleeding and/or swelling following the thyroidectomy. This is a life-threatening, medical emergency and the nurse's first action should be to activate the hospital's emergency or rapid response system. It is possible that the client will need an emergency surgical airway intervention, such as a tracheostomy, to maintain a patent airway.
The nurse is caring for a client who suddenly develops slurred speech and a facial droop. What diagnostic test would the nurse expect to be performed first? 1. Chest X-ray 2. Arterial blood gas 3. Echocardiogram 4. Computerized tomography scan
4 The client's symptoms are indicative of an acute stroke. The nurse would anticipate that a non-contrast computerized tomography (CT) of the head will be done first because time is of the essence with an acute stroke. The other tests may or may not be indicated for this client.
The nurse is performing the initial assessment of a client with asthma at the beginning of the shift. The client has oxygen running at 2 liters per minute per nasal cannula. Which assessment finding would the nurse be most concerned about? Crackles at the base of the lungs on auscultation Pulse oximetry reading of 89% Excessive thirst with a dry cracked tongue Rapid shallow respirations with intermittent wheezes
4 The most common symptoms of asthma include tightness in the chest, labored breathing, coughing and wheezing. Rapid and shallow respirations associated with labored breathing indicate the client is losing the strength required to breathe. The intermittent wheezes indicate increased narrowing of the small airways and a worsening condition. This client requires prompt and aggressive respiratory intervention to avoid respiratory failure, including bronchodilators (such as nebulized albuterol), increased oxygen supplementation to maintain a SpO2 of at least 92%, and anti-inflammatory medications (such as IV corticosteroids). The increased mucus in the airways stimulates coughing and can cause coarse crackles; the anti-inflammatory medication and bronchodilator will make breathing and mucus removal easier
The nurse in a long-term care facility is caring for an 89-year-old client with atrial fibrillation and a history of multiple falls. The client's medications include amiodarone, atorvastatin, baby aspirin and metoprolol. Which new finding should be of greatest concern to the nurse? 1. Bibasilar crackles 2. Heart rate of 106 3. SpO2 of 89% on room air 4. Right-sided facial droop
4 The most concerning finding would be the development of a right-sided facial droop. The client with atrial fibrillation is at increased risk of stroke, and this client's listed medications do not include an anticoagulant, typically prescribed to prevent a stroke. Given the finding of frequent falls, it is possible that the client is not on a stronger anticoagulant, such as warfarin, due to an increased risk of intracranial hemorrhage after a fall. A SpO2 of 89% on room air, a heart rate of 106 and crackles on auscultation are all concerning findings, but the possibility of a stroke should be of the greatest concern to the nurse. Incorrect
The nurse is reviewing vital signs documented in the electronic health record for a group of clients. Based on this data, which client should the nurse see first? 1. A client diagnosed with mitral valve insufficiency who has a blood pressure of 152/88. 2. A client diagnosed with atrial fibrillation who has a heart rate of 110 beats per minute. 3. A client diagnosed with infective endocarditis who has a temperature of 101.8°F (39°C). 4. A client diagnosed with heart failure who has a SpO2 of 82%
4 The nurse should see the client with heart failure and a SpO2 of 82% first. The client with heart failure could be experiencing life-threatening pulmonary edema, and the SpO2 of 82% indicates dangerously low oxygenation.An elevated temperature in a client with infective endocarditis is a clinically significant but not unexpected finding. A heart rate of 110 beats per minute in a client with atrial fibrillation is concerning, but it does not reflect the same life-threatening clinical finding as the low SpO2 in the client with heart failure. While elevated and of concern, a blood pressure of 152/88 is not as high of a priority for the nurse to address as a dangerously low oxygen level.
A child is brought to the emergency department with suspected ingestion of a toxic substance. Place the following nursing actions in priority order by dragging and dropping the options. -1. Obtain a history of the ingestion -2. Start an IV infusion -3. Reverse or eliminate the toxic substance -4. Stabilize the child
4, 2,1,3 The first priority is to assess the ABCs. Provide supplemental oxygen (and ventilator support, if needed). Next, an IV infusion is started using a large bore needle; this will allow for blood to be drawn for a toxicology screen as well as IV therapy. Then, a history of the ingestion is needed to guide the provider in planning care. Once the substance is identified, or there is a high index of suspicion, then treatment to reverse or eliminate the toxic substance is begun.
The nurse in an urgent care clinic is teaching a client who is being discharged with a new cast due to a radius fracture. Which statement indicates that the client correctly understands how to care for the cast? 1. "I should be able to fit three fingers between the cast and my skin." 2. "I will avoid using ice the first 24 hours that my cast is on." 3. "A moderate amount of daily drainage from my cast is expected." 4. "I will notify my health care provider if my hand becomes pale."
4. Clients being discharged with a cast on their arm should be instructed to elevate their arm above the level of the heart, to apply ice to their cast to help decrease swelling and to monitor for signs and symptoms of decreased perfusion. A pale hand can signal a decrease in perfusion and the client should report this to their health care provider. The client with a cast should not expect drainage and any drainage should be reported. The nurse should explain that the gap between the cast and skin should not be greater than one finger width.
The nurse is teaching a client with systemic lupus erythematosus about methotrexate. Which statement by the client indicates an understanding of the medication? 1. "I should not use contraception that contains estrogen." 2. "Lab work won't be necessary while I take this medication." 3. "I will not take any vitamin that contains folic acid." 4. "I will avoid interacting with people in large crowds."
4. Methotrexate is an immunosuppressant medication that is used to treat systemic lupus erythematosus (SLE). Due to immunosuppression, clients taking methotrexate should avoid large crowds of people to prevent becoming ill. Methotrexate should be taken with folic acid to decrease gastrointestinal and hepatic toxicity. Clients who are taking this medication should have a complete blood count test done regularly to monitor for decreased white blood cells and platelets, which can indicate bone marrow suppression. Methotrexate is teratogenic, therefore, pregnancy should be avoided while taking this medication. Oral contraceptives that contain estrogen are not contraindicated with this medication or disease.
The nurse just returned from a conference and is walking to baggage claim in the airport. The nurse sees a man clutch his chest and fall to the ground. He does not respond when the nurse tries to speak with him. Indicate how the nurse should respond by placing the following actions in the correct order.Instructions: Click and hold the reorder icon to drag and drop the steps into the correct order. -1. Start chest compression -2. Attempt to deliver rescue breaths -3. Locate and activate the Automated External Defibrillator (AED) -4. Check pulse -5. Activate the Emergency Response System (911) -6. Open the client's airway
5, 3, 4. 1. 6,2 The American Heart Association (AHA) recommends that chest compressions be initiated before attempting ventilations when performing cardiopulmonary resuscitation (CPR). While no published human or animal evidence demonstrates that starting CPR with 30 compressions rather than two ventilations leads to improved outcomes, it is clear that blood flow depends on chest compressions. Therefore, minimize delays and interruptions of chest compressions during the resuscitation. Moreover, the nurse can start chest compressions immediately. Positioning the client's head and achieving a seal for mouth-to-mouth rescue breathing takes time. Incorrect
when a patient has an injury to an extremity and do what
remove clothing from the uninjured side first
pulmonary edema is swelling of
respiratory tract caused by trapped excess fluid
petit mal siezure is a brief loss of consciousness during which the patient may
stare or may lose balance and fall
what is an interruption of the blood supply to the brain
stroke
angina pectoris is pain when coronary arteries are unable to supply
the heart with sufficient oxygen and blood to the heart
what is a blood clot formed on the wall of a vessel
thrombus
what is congenital heart condition that allows blood to shunt between the right and left ventricles
ventricular septal defect
what is the primary method of detection for a pulmonary embolism
CTA
psychological shock
mental trauma
ACS indicates what
myocardial ischemia
pooling of blood in the peripheral vessels can be from
neurogenic shock
what is a epistaxis
nose bleed
grand mal seizure, the patient should be placed how
on side
An adult client arrives at the clinic after being stung by a bee. The nurse notes that the client is having difficulty breathing, is audibly wheezing and has swollen lips. What is the nurse's highest priority? Obtain an arterial blood gas. Administer epinephrine. Administer a bronchodilator. Obtain a home medication list.
The client's condition indicates the high likelihood of a life-threatening anaphylactic reaction to a bee sting, with an obstructed airway due to bronchoconstriction and a high potential for hypoxemia. While obtaining a home medication list and obtaining arterial blood gases may be part of the care provided to the client, the highest priority is to administer epinephrine. Epinephrine is a critical drug in the treatment of anaphylaxis. Relieving the vasoconstriction effects on bronchial muscles with epinephrine could be life-saving in this situation. A bronchodilator may also be prescribed, but not before epinephrine has been administered.
what does ACS stand for
acute coronary syndrome
blood pools in the extremities when the torso is elevated may cause
anoxia
respiratory arrest is caused by
apnea due to failure of lungs to function correctly
pallor and weakness, drop in blood pressure, increased pulse, and cyanosis are all symptoms of
shock
what is the sensation that the room is spinning and whirling
vertigo
what do you get patient to do if they have a nosebleed
keep head level, breathe through mouth, squeeze against nasal septum for 10 mins
anoxia is
lack of oxygen
A toddler is diagnosed with atopic dermatitis. What information is important for the nurse to share with the parents about caring for their child? Keep the child away from other children for the duration of the rash Dress the child warmly to avoid chilling when in or outdoors Wrap the child's hand in mittens or socks to prevent scratching Clean the affected areas with tepid water and antibacterial soap
3 A toddler with atopic dermatitis needs to have fingernails cut short and covered so the child will not be able to scratch the skin lesions. With scratching, there is often the possibility of developing a secondary infection of the lesions. Atopic dermatitis is a pruritic noncontagious disease of unknown origin with common findings of itching, xerosis (dry skin) and lichenification (thickening of the skin and an increase in skin markings). Heat makes the rash itch more.
An adult client in the waiting room of an outpatient clinic is found to have become unresponsive. Their carotid pulse cannot be palpated. Emergency medical services have been requested by calling 911. What should the nurse do next? 1. Use a jaw-thrust maneuver to open the client's airway. 2. Wait for the emergency medical services technicians to arrive. 3. Begin chest compressions. 4. Deliver two rescue breaths.
3 According to basic life support (BLS) guidelines by the American Heart Association (AHA), chest compressions are the next step in initiating cardiopulmonary resuscitation (CPR) for an unresponsive client in whom a carotid pulse cannot be palpated. After the initial round of 30 chest compressions, the nurse should open the client's airway with a head tilt-chin lift maneuver (or a jaw-thrust maneuver if spinal cord injury is suspected) and deliver two breaths. It would not be appropriate to wait to start CPR until emergency medical services technicians arrive because immediate action is needed.
The nurse enters the room of an adult client in cardiac arrest with cardiopulmonary resuscitation already in progress. The client's bedside telemetry monitor shows ventricular fibrillation. What should the nurse do next? 1. Quickly leave the room and notify the client's next-of-kin. 2. Prepare to administer two rescue breaths. 3. Assist with preparing the client for defibrillation. 4. Assist with the insertion of a large-bore IV catheter.
3 Ventricular fibrillation (V-Fib) is a life-threatening dysrhythmia that requires immediate defibrillation to attempt to restore a viable cardiac rhythm. V-Fib will cause death within minutes due to the complete lack of cardiac output and tissue perfusion. The other actions should be implemented after defibrillation has been performed or attempted.
The nurse is participating in a disaster simulation that involves a school bus accident. The nurse is assigned to care for the following four clients in a rural hospital's emergency department. Which client should the nurse see first? The client with a third degree burn to the arm The client with multiple facial abrasions The client with a penetrating abdominal wound The client with an open humerus fracture
3. Part of a nurse's role is being a part of disaster management and assisting in client care throughout all aspects of health care delivery. To better prepare nurses for disaster situations, simulation is a method used to evaluate preparedness. The nurse needs to be able to respond to disasters in the community and keep clients safe. Answering this specific scenario requires the application of survival potential priority setting frameworks. A client with a penetrating abdominal wound should be seen first because a penetrating injury usually causes internal injuries, such as bleeding, which can quickly lead to death.
An off-duty nurse witnesses a person collapse in a grocery store, and the individual is now unresponsive. Multiple bystanders are present. What should the nurse do first? 1. Deliver two rescue breaths. 2. Begin chest compressions. 3. Check for a carotid pulse and instruct a bystander to call 911. 4. Run to get the store's automated external defibrillator.
3. The off-duty nurse's first action when encountering this unresponsive individual who just collapsed should be to check for a pulse and to ensure the activation of 911 emergency response. While chest compressions may very well be needed, the nurse should first check for a carotid pulse. If a carotid pulse cannot be palpated in this unresponsive individual, cardiopulmonary resuscitation (CPR) chest compressions should be initiated. An automated external defibrillator (AED) should be incorporated into the response once it is available. However, the nurse should stay with the victim, begin CPR and assign the task of obtaining the AED to someone else at the scene.
what are some examples of symptoms of diaphoretic patient
pale, cool, clammy skin
what two things should you do for a patient with abdominal pain
place pillow under head and support under the knee
astma is difficulty breathing by
bronchospasm
what does cpr stand for
cardiopulmonary resuscitation
apnea is a
cessation of breathing
syncope is
fainting
According to basic life support (BLS) guidelines by the American Heart Association (AHA), chest compressions are the next step in initiating cardiopulmonary resuscitation (CPR) for an unresponsive client in whom a carotid pulse cannot be palpated. After the initial round of 30 chest compressions, the nurse should open the client's airway with a head tilt-chin lift maneuver (or a jaw-thrust maneuver if spinal cord injury is suspected) and deliver two breaths. It would not be appropriate to wait to start CPR until emergency medical services technicians arrive because immediate action is needed.The nurse just returned from a trip and is walking through the airport. The nurse sees a man clutch his chest and fall to the ground. He does not respond when the nurse tries to speak with him. Indicate how the nurse should respond by placing the following actions in the correct order.Instructions: Click and hold the reorder icon to drag and drop the steps into the correct order.
-1. Activate the Emergency Response System (911) -2. Instruct a bystander to get the AED -3. Check for a pulse -4. Start chest compressions -5. Open the client's airway -6. Attempt to deliver rescue breaths
patient that is experiencing syncopes needs to be placed how and why
dorsal recumbent and feet elevated to get blood flow to the brain
what should you provide a patient with that is nauseated and vomiting
emesis basin
pleural effusion is
fluid in the pleural space of the lung
embolus is a
free floating clot
stridor is
harsh sound on inspiration
myocardial ischemia is an insufficient blood supply to the
heart muscle results from coronary artery disease
a patient who is diaphoretic is one who is
in a cold sweat
diabetes mellitus is an
inability to metabolize blood glucose
symptoms of impending diabetic coma include
increased urination, sweet breath, extreme thirst
pneumonia is
inflammation of the lungs
neurogenic shock is
injury to nervous system
shaking, nervousness, dizziness, cold and clammy skin, blurred vision, and slurred speech are all early symptoms to a
insulin reaction
pulmonary embolism is a blood clot that travels though the vascular system and lodgnes in one of the pulmonary vessels, which causes what
interrupting blood flow to the heart
first duty if a patient is having a seizure
keep patient safe as possible from falling
hypovolemic shock is caused from
large amount of blood loss
septic shock is from a
massive infection
cardiogenic shock
results from cardiac failure
