CC HESI ELSEVIER

A carpenter with full-thickness burns of the entire right arm confides, "I'll never be able to use my arm again and I'll be scarred forever." Which initial response by the nurse is best?

"I know you're worried, but it is too early to tell how much scarring will occur."

A registered nurse teaches a new orienting nurse about interventions to be followed for a client with burns due to inhalation injury. Which statement made by the new orienting nurse indicates the new nurse needs more orientation?

"I should check pulses distal to burns."

An adolescent girl who has sustained superficial partial-thickness burns of the face because of excessive exposure to the sun exclaims, "Prom night is only 4 weeks away. I'll never be healed!" What is the nurse's best response?

"Recovery will take about 3 weeks."

healthcare provider prescribes oral aluminum-magnesium hydroxide and intravenous ranitidine for a client with traumatic burns and crush injuries. The client asks how these medications work. What is the nurse's best response?

"They limit acidity in the gastrointestinal tract."

A male client who sustained a head injury is admitted to the hospital. The client is able to open his eyes to pain stimulus and to localize the pain, but the verbal response is found to be confused. What would be the score of the client based on the Glasgow coma scale. Record your answer as a whole number.

11

A nurse is working with a cardiologist for a client needing temporary pacing. Which methods are examples that the cardiologist with the assistance of the nurse might use?

Epicardial pacing Transcutaneous pacing Transvenous pacing

A client with multiple injuries due to an accident is admitted into the emergency department. Which is the priority nursing intervention in this situation?

Establishing a patent airway in the client

A nurse is caring for a client with first degree atrioventricular (AV) block. Which information will the nurse consider when planning care?

Every P wave is conducted to the ventricles.

The nurse in the intensive care unit is monitoring a client who had an aortic valve replacement. What can a slowing pulse rate during the early postoperative period after open heart surgery indicate?

Heart block

A nurse is evaluating a client's fluid loss resulting from extensive burns. Which laboratory result will the nurse check?

Hematocrit (Hct)

A client is admitted to the hospital with a diagnosis of peptic ulcer. Which most common complication should the nurse assess for in this client?

Hemorrhage

A nurse is caring for a client who is scheduled to have a pigskin graft applied to a burned area. Which type of graft will the nurse provide information about to the client?

Heterograft

The nurse is caring for a client 4 days after the client was admitted to the hospital with burns on the trunk and arms. The nurse collaborates with the dietician to develop a dietary plan for the following day. Which plan will the nurse follow?

High caloric intake, liberal potassium intake, and 3 g protein/kg/day

While performing a secondary emergency assessment survey, the nurse uses the mnemonic AMPLE to determine the client's condition after a natural disaster. Which type of assessment is performed in this scenario?

History and head-to-toe assessment

The nurse is evaluating the condition of a client with burns of the upper body. Which finding will alert the nurse of a potential respiratory obstruction?

Hoarse quality to the voice

What is the most important information the nurse and the rapid response team must keep in mind when caring for a client who just had a cardiac arrest?

How long the client was anoxic

A nurse is caring for a client with an endotracheal tube. what is the most effective way for the nurse to loosen respiratory secretions? Increase oral fluid intake

Humidify the prescribed oxygen

A client is experiencing kidney failure. Which is the most serious complication for which the nurse must monitor a client with kidney failure?

Hyperkalemia

During the first 48 hours after a client has sustained a thermal injury, which conditions should the nurse assess for?

Hyperkalemia and hyponatremia

The nurse is caring for a client with a spinal cord injury. Which assessment findings alert the nurse that the client is developing autonomic hyperreflexia (autonomic dysreflexia)?

Hypertension and bradycardia

A client is admitted to the cardiac care unit with an anterior lateral myocardial infarction. The healthcare provider prescribes 500 mL of D 5W with 50 mg of nitroglycerin to be administered intravenously to relieve pain. The nurse should assess for which mostcommon side effect of this medication?

Hypotension

The nurse is categorizing victims of hypothermia as having mild, moderate, and severe hypothermia. Which assessment findings will help the nurse identify the clients with moderate hypothermia? Select all that apply.

Hypovolemia Respiratory acidosis

The nurse is caring for a client with wound dressings to the burns on 55% of the body. The dressing changes are very painful, and the client rates them 7/10 on the pain scale. The client has morphine 2 mg to be administered by mouth every 2 hours as needed. When planning the client's care, when does the nurse decide to administer the medication?

60 minutes before the dressing change

The nurse is performing a rewarming procedure on a client with severe hypothermia by administering warmed intravenous fluids. The nurse carefully monitors the client's core temperature while performing this procedure. What is the lowest temperature at which the nurse will stop the rewarming?g

91.4° F (33°C)

A client with a fracture is found to have compartment syndrome. Which interventions will be contraindicated? Select all that apply.

Applying cold compresses Elevating the extremity above heart level

Which activity is performed first when a client is bitten by a brown recluse spider?

Applying cold compresses over the site

A client who survived a lightning strike is admitted to the emergency unit. Which interventions could be beneficial for this client's condition? Select all that apply.

Applying spinal immobilization technique Stabilization of airway, breathing, and circulation

A nurse is caring for a client with compartment syndrome. Which nursing actions are appropriate?

Asisting with splitting the cast Assessing urine output Evaluating the pain on a scales

Which nursing interventions are beneficial in the event of fire in the hospital?

Asking ambulatory clients to help push wheelchair clients out of danger Maintaining injured clients' respiratory status manually until removed from the fire area

Which action should be the nurse's first priority for a client with major burns?

Assessing airway patency

What is the priority nursing action for a scorpion bite?

Assessing the client's vital signs

A nurse is caring for a client with a spinal cord injury during the immediate postinjury period. Which is the priority focus of nursing care during this immediate phase?

Avoiding flexion or hyperextension of the spine

A client is brought to the emergency department with deep partial-thickness burns on the face and full-thickness burns on the neck, entire anterior chest, and one arm. To assess for heat inhalation, the nurse first should observe for which finding?

Nasal discharge containing carbon particles

A client has a diagnosis of partial-thickness burns. While planning care, the nurse recalls that the client's burn is different than full-thickness burns. Which information did the nurse recall?

Partial-thickness burns are often painful, reddened, and have blisters

What is the priority nursing intervention for a client injured by lightning?

Performing cardiopulmonary resuscitation

A client who was in a traffic accident is choking. The nurse suspects that the client may have a spinal cord injury. Which procedure may benefit the client?

Performing jaw-thrust maneuver

A nurse is caring for a client with severe burns. The nurse determines that this client is at risk for hypovolemic shock. Which physiologic finding supports the nurse's conclusion?

Plasma proteins moving out of the intravascular compartment

What is an appropriate nursing intervention for a neonate with respiratory distress syndrome (RDS)?

Position the infant to promote respiratory efforts

A nurse is caring for a client during the emergent phase of a severe burn injury. Which parenteral intervention prescribed by the healthcare provider should the nurse question?

Potassium

Which serum laboratory values in a client with urinary problems may indicate the risk of developing muscle weakness and cardiac arrhythmias?

Potassium of 7.02 mEq/L (7.02 mmol/L)

During a party, an individual reports intense chest pain and begins to perspire profusely. Which nursing action is priority when the client is brought to the emergency department?

Prepare the client for continuous ECG monitoring.

While providing palliative care, the nurse finds symptoms of dyspnea. What will be the priority nursing intervention in this situation?

Providing prescribed oxygen by nasal cannula

A nurse is caring for a client after cardiac surgery. Which signs will cause the nurse to suspect cardiac tamponade? Select all that apply.

Pulsus paradoxus Muffled heart sounds Jugular vein distention

Two days after a myocardial infarction, a client has a temperature of 100.2° F (37.9° C). What should the nurse do first?

Record the temperature reading and continue to monitor it.

A client is brought to the emergency department after an automobile collision. The client's blood pressure is 100/60 mm Hg, and the physical assessment suggests a ruptured spleen. For which early clinical indicator of decreased arterial pressure should the nurse assess the client?

Reduced peripheral pulses

A client is admitted to the hospital after sustaining serious burns that involve a large surface of the skin. The nurse is caring for the client during the emergent phase after the injury. Which nursing objective is the priority during this phase?

Restoring fluid volume

A client's burn wounds are scheduled to be debrided mechanically. Which equipment will the nurse prepare?

Scissors and forceps

The nurse notes that the client's ECG rhythm strips show more P waves than QRS complexes. When there are PR intervals, they are all consistent. How should the nurse interpret this strip?

Second degree AV block Mobitz II

Which clinical indicator is the nurse most likely to identify when completing a history and physical assessment of a client with complete heart block?

Syncope

A nurse is notified that the latest potassium level for a client in acute kidney injury is 6.2 mEq (6.2 mmol/L). Which action should the nurse take first?

Take vital signs and notify the primary healthcare provider.

What should the nurse consider when providing care to a client in the acute phase of treatment for a full-thickness burn?

The risk of septicemia and its potential complications from treatment

A client is to receive conscious sedation during a cardiac catheterization. Which route of administration should the nurse explain will be used to deliver the conscious sedation?

Through an intravenous catheter

Why is the Glasgow Coma Scale used by the nurse while performing an assessment in a traumatized client?

To assess level of consciousness

A client with tongue occlusion has loss of gag reflex and alterations in level of consciousness. The blood gas test shows oxygen saturation as 40mm Hg and carbon dioxide saturation as 75 mm Hg. Which type of support provides immediate relief to the client?

Tracheotomy

What steps should the nurse take for managing an adolescent that sustained drug poisoning?

Turn the head of the client to the side. Empty the mouth to clean the residue of the drug. Call local poison control center before any intervention.

A nurse is evaluating a client's response to fluid replacement therapy. Which clinical finding indicates successful replacement?

Urinary output of 30 mL in an hour

A client is receiving intravenous mannitol after sustaining a critical head injury. What assessment will the nurse perform that is specific to the safe administration of the medication?

Urine output hourly

While reviewing the medical reports in an acute care setting, the nurse finds that the client is at risk for kidney damage and requests the healthcare provider to increase the intravenous fluid rate as a priority nursing intervention. Which finding supports the nurse's conclusion?

Urine output is 25 mL per hr

A nurse is caring for a client with full-thickness burns of the anterior trunk and thigh. The nurse is monitoring fluid balance during the first 2 to 3 days after the burn. Which area is most important for the nurse to assess for fluid balance in this client?

Urine output qhr

A client with bleeding esophageal varices is to be treated via infusion of medication through an intravenous line. Which medication should the nurse anticipate will be prescribed?

Vasopressin

A nurse is planning care to prevent deformities and contractures in a client with burns. When will the nurse begin range-of-motion (ROM) exercises?

When vital signs are stable

A client with a head injury is admitted to the hospital. Which assessment finding alerts the nurse to increasing intracranial pressure?

Widening pulse pressure

Which color of cerebrospinal fluid (CSF) may indicate subarachnoid hemorrhage in the client?

Yellow

he nurse is caring for four clients in an emergency department. Which client is treated first according to a three-tiered triage system? active hemorrhage renal colic sever abd pian strain sprain

active hemorrhage

A client falls from a two-story building and is taken to the hospital unconscious. Which finding identified during the initial nursing assessment should be of most concern to the nurse?

bleeding of ear

The nurse is working with a group of clients in a community health center. Which client should the nurse consider at highest risk for developing pneumonia?

c.. 67 YO rr 38

What is a common metabolic cause of hypothermia?

hypoglycemia

A client with 35% of total body surface area burned in a fire is now 48 hours postburn. The nurse concludes that the client is moving from the emergent to the acute phase of burn management. Which finding supports the nurse's conclusion?

hypokalemia

The nurse is using a three tier triage system to treat four clients who sustained injuries after a bus accident. Which condition is triaged as urgent among these client conditions?

multiple fx

Twelve hours after a subtotal gastrectomy, a nurse identifies large amounts of bloody drainage from the client's nasogastric (NG) tube. Which action should the nurse take?

obtain VS

What are the potential life-threatening conditions that should be considered during the primary survey for a client admitted after a fire accident? Select all that apply.

shock Inhalation injury Direct cardiac injury

The nurse is caring for clients who are admitted with injuries due to a bus accident. Which conditions of the clients are prioritized under the emergent classification? Select all that apply.

shock airway obstruction

The nurse is caring for a client two days after the client was admitted with burn injury. When performing the respiratory assessment, the nurse observes for which type of sputum?

sooty

A client presents to the emergency department with symptoms of acute myocardial infarction (MI). Which results will the nurse expect to find upon assessment?

troponin increase

An adult client is receiving lactated Ringer (LR) solution for burns to the genitalia. Which percentage will the nurse calculate for total body surface area (TBSA) burned?

1%

Four near-drowning victims are admitted to the emergency department. Which victim does the nurse determine to be at greatest risk for hypovolemia?v

50-year-old rescued from the ocean

After an earthquake in the city, four clients were admitted to the emergency department. Based on this data, which clients should the nurse have triaged into emergency severity index level 1 (ESI-1)?

B- high resource intensity; staff at bedside continuosuly

A nurse in the emergency department is assigned a recently admitted client. The nurse reviews the client's progress notes, obtains the vital signs, and performs a physical assessment. Which intervention should the nurse anticipate the primary healthcare provider will prescribe initially? bp 92/50

IV fluids

When changing the dressings on deep partial-thickness burns on a client's hand, the nurse should use which type of gauze and which technique?

Non-cotton-backed; placing a hand roll with fingers slightly flexed

A burn client is receiving the open method for wound treatment. Which information will the nurse explain to the client?

Personal protective equipment will be worn by staff.

A client has a compound fracture of the femur. The nurse should assess the client for the typical signs and symptoms of a fat embolus. In comparison to thromboembolism, which unique clinical indicator can help the nurse identify a fat embolus?

Pinpoint red spots on the chest

The nursing student is learning about submersion injuries. Which component of sea water does the nurse know to be responsible for making it hypertonic compared to body fluids?

SALT

A client with a history of cardiac dysrhythmias is admitted to the hospital with dehydration. What does the nurse add to the client's plan of care?

Small, frequent intake of juices, broth, or milk

A client who sustained a burn injury involving 36% of the body surface area is receiving hydrotherapy. Which is the best nursing intervention when providing wound care?

Use a consistent approach to care and encourage participation

The registered nurse is caring for a client with burns who is being treated with collagenase and polysporin powder therapy. Which action should the nurse take?

Use collagenase with polysporin powder on partial-thickness wounds with eschar.

The nurse is caring for the victims of a natural disaster who are all hypothermic. Which interventions does the nurse employ when using spontaneous rewarming? Select all that apply.

Using radiant lights Moving the client to a warm and dry place

The registered nurse delegates the task of feeding a 90-year-old client suffering from dysphagia to the unlicensed assistive personnel (UAP) who has previously performed this task. The client died of choking and aspiration after being fed by the UAP. Which right of delegation was violated for this client?

circumstance

A person on the beach sustains a deep partial-thickness burn because of a severe sunburn. What is the best first-aid measure the nurse can instruct the person to apply before seeking healthcare?

cool, moist towels

Which clinical manifestation can a client experience during a fat embolism syndrome (FES)?

dyspnea

A nurse is caring for a client who recently had a kidney transplant. Which priorityassessment finding requires follow up by the nurse?

fever

The nurse is providing postprocedure care to a client who had a cardiac catheterization. The client begins to manifest signs and symptoms associated with embolization. Which action should the nurse take?

Notify the primary healthcare provider immediately

The nurse is assessing a client 12 hours after the client sustained a deep partial-thickness burn on the forearm. What characteristics should the nurse expect to identify when assessing the injured tissue?

Painful and reddish-white

A nurse determines that a client in the acute phase of burns has eaten only a small portion of each meal. What should the nurse assess for in this client?

Prolonged wound healing

A client is admitted to the hospital with a diagnosis of deep vein thrombosis, and intravenous (IV) heparin sodium is prescribed. If the client experiences excessive bleeding, what should the nurse be prepared to administer?

Protamine sulfate

During resuscitation of a critically injured client in a bomb blast, the nurse finds the client is breathing spontaneously. Which nursing intervention would the nurse perform in this situation?

Providing non-rebreather mask

A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. Which are the priority nursing assessments?

Quality of respirations and presence of pulses

The nurse manager has delegated tasks to a registered nurse (RN) and unlicensed assistive personnel (UAP) who are paired to provide care for a client with substance abuse. Which hospital care setting uses this model to deliver care to the clients?

Rehabilitative care

The nurse is assessing clients who have sustained submersion injuries. Which are most likely to be the nurse's assessment findings? Select all that apply.

Ronchi Cough with pink-frothy sputum

The nurse notices that the client's cardiac rhythm has become irregular; QRS complexes are missing after some of the P waves. The nurse also notes that the PR intervals become progressively longer until a P wave stands without a QRS; then the PR interval is normal with the next beat and starts the cycle again with each successive PR interval getting longer until there is a missing QRS. The nurse notifies the primary healthcare provider. Which rhythm does the nurse share with the provider?

Second degree AV block Mobitz I (Wenckebach)

Which electrolyte concentration has the potential to precipitate dysrhythmias and cardiac arrest in a client? Serum sodium of 139 mEq/L (139 mmol/L) Serum chloride of 100 mEq/L (100 mmol/L) Serum calcium of 10.2 mg/dL (2.55 mmol/L) Serum potassium of 7.2 mEq/L (7.2 mmol/L)

Serum potassium of 7.2 mEq/L (7.2 mmol/L)

A nurse is caring for a client who had a skin graft applied over a full-thickness burn on the chest. Which observation of the donor site during the first 24 hours after surgery should the nurse report to the primary healthcare provider immediately?

Small amount of yellowish green oozing

An adolescent is admitted to the burn unit with partial-thickness burns of both arms and the chest. What information about burns should guide the nurse's plan of care?

Spontaneous epithelial regeneration occurs within several weeks

The first responders rescue and bring submersion victims of a natural disaster to the emergency department. Which is an appropriate intervention for treating clients with submersion injuries?

Stabilize or immobilize cervical spine in all near-drowning victims

A nurse is caring for a client who had a traumatic brain injury with increased intracranial pressure. Which healthcare provider prescription should the nurse question?

Teach isometric exercises

The nurse is caring for some clients with chronic anemia who are on blood transfusion therapy. The nurse notices that one of the clients requires immediate treatment. Which client is the nurse addressing in this situation? Client with itching Client with flushing Client with pruritus Client with wheezing

Client with wheezing

Which clients belong to class I according to the disaster triage tag system?

Clients who need emergency treatment

A nurse is caring for a client who has had multiple myocardial infarctions and has now developed cardiogenic shock. Which clinical manifestation supports this diagnosis?

Cold, clammy skin

A client is admitted with head trauma after a fall. The client is being prepared for a supratentorial craniotomy with burr holes, and an intravenous infusion of mannitol is instituted. The nurse concludes that this medication primarily is given to do what?

Decrease fluid in the brain

What should a nurse assess after applying a body jacket brace to a client with severe spine injuries following a car accident? Select all that apply.

Development of cast syndrome Abdomen for decreased bowel sounds Areas of pressure over the bony prominences

A client with third-degree burns asks a nurse, "Why do I need a temporary pigskin graft?" What is the nurse's best response?

"It promotes rapid healing of the wound."

A person sustains severe burns of the arms and is waiting for emergency services to arrive. A nurse bystander responds to the scene. Another bystander is getting ready to apply butter to the burns, stating that it will provide soothing relief. Which response by the nurse is best?

"Let's cover up the victim with one of those tablecloths instead."

The nurse is caring for a client with a body surface burn injury of 55%. Which information will the nurse consider when planning care for this client?

Is prone to poor healing because of a hypermetabolic state

An older adult client is brought to the hospital by a family member because of deep partial-thickness burns on the arms and hands. The client protests being hospitalized and asks, "Why can't I just go home and have my spouse care for me?" What is the best response by the nurse?

"You may heal more slowly because of your age, and you may need the special care and equipment available in the hospital."

The nurse is performing peritoneal lavage on a client who is hypothermic, as a surface rewarming measure. What is the highest temperature up to which the fluid can be heated?

113° F (45°C)

An adult client sustains partial- and full-thickness burns of the left thigh and left arm. Using the Lund-Browder chart, the nurse calculates the percentage of total body surface area burned. Which percentage will the nurse record?

16.5%

A client is admitted for treatment of partial- and full-thickness burns of the entire right lower extremity and the anterior portion of the right upper extremity. The nurse performs an immediate appraisal, using the rule of nines. Which percentage of body surface area burned will the nurse record?

22.5%

The victims of a large scale near-drowning incident are brought to the emergency department. What is the minimum length of time all such victims should be kept under observation in the hospital?

23 hours

A client is admitted with posttraumatic brain injury and multiple fractures. The client's eyes remain closed, and there is no evidence of verbalization or movement when the nurse changes the client's position. What score on the Glasgow Coma Scale (GCS) should the nurse document?

3

There are five clients in the emergency unit. Which client requires immediate treatment? Select all that apply.

A client with unstable vital signs A client with severe abdominal pain A client with chest pain with diaphoresis

A registered nurse is explaining healthcare settings and services to a nursing student. Which scenario mentioned by the registered nurse is considered secondary acute care?

A nurse prepares a client who has suffered from repeated cerebral attacks for a CT scan.

A client has undergone nasal hypophysectomy surgery. During post-operative care, which finding indicates cerebrospinal leakage?

A yellow edge around nasal discharge

The nurse is assessing four clients in the emergency department. Which client requires least priority according to the Glasgow Coma Scale?

Client D: higher the score the better they are

Who should be triaged first a chest pain b displaced or multiple fx's c renal colic d strains and sprains

A. CHEST PAIN

The nurse is caring for the victims of a hurricane. Which client should be triaged first?

A. SEVERE resp. distress

The nurse is reviewing the medical reports of four clients who survived an earthquake. Which client does the nurse assess first to prevent an emergency threat?

Active hemorrhage

The nurse is performing triage based on tier levels for a group of clients who were impacted by a tornado. Which client conditions should receive higher priority? Select all that apply. Active hemorrhage Respiratory distress Chest pain with diaphoresis Stroke skin rash Displaced or multiple fractures

Active hemorrhage Respiratory distress Stroke

A client's extensive burns are being treated with silver nitrate 0.5% dressings. A week after treatment is begun, the nurse identifies that the client's sodium level is 135 mEq/L (135 mmol/L) and the potassium level is 3.0 mEq/L (3.0 mmol/L). The nurse notifies the primary healthcare provider. Which prescription should the nurse be prepared to administer?

Add potassium chloride (KCl) to the existing intravenous (IV) lactated Ringer solution.

A client who had extensive pelvic surgery 24 hours ago becomes cyanotic, is gasping for breath, and reports right-sided chest pain. What should the nurse do first?

Administer oxygen using a face mask

Which nursing action is most important to promote the nutritional status of a client during the acute phase of treatment after extensive burns?

Administer the prescribed intravenous fluid with the added vitamin C.

A client with a recent history of sinusitis develops meningitis and demonstrates a positive Brudzinski sign. What is the priority nursing care?

Administering prescribed antibiotics

An emergency management team is removing foreign bodies and performing cricothyroidotomy on a client post burn injury. Which emergency assessment has been performed on this client?

Airway

The nurse is caring for a client with injuries from a bomb blast. Which emergency assessments are performed by the nurse in a primary survey?

Airway Breathing Circulation Identify deformities

The nursing student is comparing the causative agents of hyperthermia and hypothermia. Which causative agent is common to both conditions?

Alcohol

A client is admitted to the cardiac care unit with a myocardial infarction. The cardiac monitor reveals several runs of ventricular tachycardia. The nurse anticipates that the client will be receiving a prescription for which drug?

Amiodarone

A client who had a myocardial infarction is in the coronary care unit on a cardiac monitor. The nurse observes runs of ventricular tachycardia on the screen. What medication should the nurse prepare to administer?

Amiodarone

A client rescued from a burning building has partial- and full-thickness burns over 40% of the body. Which initial physiologic change will the nurse expect?

An increase in serum potassium

A client is considered to be in septic shock when what changes are assessed in the client's labwork?

An increased serum lactate level

what rewarming method is appropriate specifically for a client suffering from severe hypothermia?

Application of heated humidified oxygen

A nurse is assessing the ECG rhythm strip. The nurse checks the P wave. Which function of the heart is the nurse assessing?

Atrial depolarization

While a pacemaker catheter is being inserted, the client's heart rate drops to 38 beats/min. What medication should the nurse expect the healthcare provider to prescribe?

Atropine sulfate

A client is admitted to the hospital with a diagnosis of heart failure and acute pulmonary edema. The healthcare provider prescribes furosemide 40 mg intravenous (IV) stat to be repeated in 1 hour. What nursing action will best evaluate the effectiveness of the furosemide in managing the client's condition?

Auscultate breath sounds

A nurse is caring for a client who sustained a transection of the spinal cord with no other injuries. The nurse continually monitors this client for which medical emergency?

Autonomic hyperreflexia

The nurse is planning to triage clients according to emergency severity index (ESI). Which client should be triaged under ESI-1 based on threat to life and stability of vital functions? A: chest pain resulting from ischemia B: Cardiac arrest simple laceration hip fx

B: Cardiac arrest

Which noninvasive assessment and management skills certification would the nurse be required to use for airway maintenance and cardiopulmonary resuscitation (CPR)?

BLS

The nurse observes a window washer fall 25 feet (7.6 m) to the ground, rushes to the scene, and determines that the person is in cardiopulmonary arrest. What should the nurse do first?

Begin chest compressions

A client who was hospitalized with partial- and full-thickness burns over 30% of the total body surface area is to be discharged. The client asks the nurse, "How will my spouse be able to care for me at home?" How should the nurse interpret this statement?

Beginning realization of implications for the future

A client is admitted to the hospital due to electrical burns. Which assessment findings does the nurse anticipate? Select all that apply.

Burn odor Leathery skin Cardiac arrest

A nurse reviews the assessment findings of four different clients with burns. Which client most likely has chemical burns?

C. paralysis

A client's cells are deprived of oxygen during a cardiac arrest. What medication should the nurse be prepared to administer?

Calcium gluconate

A hospitalized client puts the call light on and reports a sudden onset of chest pain that feels like a pressure or weight on the chest. The client also states, "I feel nauseated and very weak." Which action should the nurse take?

Call the rapid response team.

A client with anorexia nervosa is admitted to the critical care unit following a period of prolonged starvation. What signs or symptoms indicate to the nurse that the client may have hypokalemia?

Cardiac dysrhythmias Muscle weakness

The nurse is caring for four victims of a lightning strike in an emergency department. Which client requires immediate treatment?

Cardiopulmonary Arrest

A client is admitted after incurring electrical burns to both hands while playing golf during a lightning storm. The nurse is assessing the entrance and exit wounds. Which information should the nurse consider about electrical burns?

Causes severe nervous tissue destruction along a path of least resistance

A severely burned client has been hospitalized for 3 days and is now in the acute phase. Until now recovery has been uneventful, but the client begins to exhibit extreme restlessness. What does the nurse conclude the client is most likely developing?

Cerebral hypoxia

Two days after a severely burned client is admitted to the hospital, the client begins to exhibit restlessness. Which condition does the nurse determine the client is most likely developing?

Cerebral hypoxia

The nurse observes a client collapse while walking down the hallway and establishes unresponsiveness. What should the nurse do first?v

Check for a carotid pulse

A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first?

Check for a pulse

What is the role of a Licensed Practical Nurse (LPN) while caring for the client with a cast or traction? Select all that apply.

Checking color, temperature, capillary refill, and pulses distal to the cast Monitoring skin integrity around the cast Marking circumference of any drainage on the cast

What would be the priority nursing intervention in a client with electric burns?

Checking the airway, breathing and circulation

The nurse is reviewing the diagnostic reports of four clients with complications of fracture. Which client may be treated with a fasciotomy?

Compartment Syndrome

A nurse is caring for a client who has a disturbed body image as a result of a burn injury. Which is an important initial nursing intervention for this client?

Conveying a positive attitude toward the client

The nurse is teaching first aid to a group of community members. A participant asks what first aid should be administered, after calling 911, to a person who suffers extensive burns. Which response by the nurse is best?

Cover the burned areas with a bed sheet; this provides protection.

A client is admitted to the intensive care unit with pulmonary edema. Which clinical finding does the nurse expect when performing the admission assessment?

Crackles at bases of the lungs

While assessing a client the nurse observes abnormal rigidity with pronation of the arms. Which condition should the nurse record in the assessment findings?

Decerebration

While caring for a client who sustained a severe head injury in a motor vehicle accident, the nurse observes that the client is constantly passing urine and is dehydrated. What does the nurse suspect as the cause for the client's condition?

Decreased secretion of antidiuretic hormone

An adolescent child is in the terminal stage of cancer. The parents ask how they will know when death is imminent. The nurse discusses the physical manifestations with the parents. What are the signs and symptoms of approaching death? Select all that apply.

Decreased thirst Weak pulse Difficulty swallowing Loss of bladder control

A worker is involved in an explosion of a steam pipe and receives a scalding burn to the chest and arms. The burned areas are painful, mottled red, weeping, and edematous. Which classification should the nurse use to describe these burns?

Deep partial-thickness

A client presents to the emergency department with weakness and dizziness. The blood pressure is 90/60 mm Hg, pulse is 92 and weak, and body weight reflects a 3-pound (1.4 kilogram) loss in two days. The weather has been hot. Which condition should the nurse conclude is the priority for this client?

Deficient fluid volume

A nurse is caring for a client who experienced serious burns in a fire. Which relationship between a client's burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns?

Directly proportional

The nurse is reassessing level of consciousness and mental status in a client who survived a fire. Which type of emergency assessment of the trauma client is the nurse performing

Disability

The nurse is assessing a client with a laryngeal trauma. This client presents with hemoptysis, aphonia, hoarseness, dyspnea, and subcutaneous emphysema. Which condition of the client stands first in the priority list?

Dyspnea

The nurse is caring for a client who is experiencing cardiogenic shock. Which assessment findings support this diagnosis? Select all that apply.

Dyspnea Diaphoresis Tachycardia

Which type of burn/injury may cause a client to have a cervical spine injury? Electrical burns Chemical burns Inhalation injury Cold thermal injury

Electrical burns

A client who has been experiencing chest pain and vomiting for several hours is admitted to the hospital with a diagnosis of myocardial infarction. The client is transferred immediately to the cardiac intensive care unit. The client's potassium level is below the expected range. Considering this laboratory result, what should the nurse monitor the client's electrocardiogram (ECG) for?

Elevated U and flattened T waves

A nurse is caring for a client who has a burn in the emergent stage. Which assessment is the highest priority?

Extent of burn

After reviewing the laboratory reports of a client with a severe joint injury, the nurse suspects fat embolism syndrome (FES). Which findings support the nurse's suspicion? Select all that apply.

Fat cells in the urine PaO 2 value of 58 mm Hg (7.73 kPa) Hematocrit value of 30% (0.30)

A client with dehydration suddenly becomes diaphoretic, clammy, and pale. The client's blood pressure falls to 50/30 mm Hg. In which position will the nurse place the client?

Feet elevated with head at 20-degree angle

What is the priority nursing intervention for a client bitten by a snake?

Immobilizing the effected extremity using a splint

A client is admitted to the hospital with partial- and full-thickness burns of the chest and face sustained while trying to extinguish a brush fire. Which is the nurse's priorityconcern?

Inadequate gas exchange caused by smoke inhalation

A client with a coronary occlusion is experiencing chest pain and distress. What is the primary reason that the nurse should administer oxygen to this client?

Increase oxygen concentration to heart cells

A client with the diagnosis of myocardial infarction is admitted to the intensive care unit, and a pulmonary artery catheter is inserted for hemodynamic monitoring. Therapy is administered to maintain the pulmonary artery wedge pressure at 16 to 20 mm Hg to optimize stroke volume. The client's pulmonary artery wedge pressure increases to 24 mm Hg. What does the nurse consider as the most likely reason for this change?

Increased intravascular volume

A nurse is performing external cardiac compression. Which action should the nurse take?

Interlock the fingers with the heel of one hand on the sternum and the heel of the other on top of it.

A client is admitted to the hospital with a head injury sustained while playing soccer. For which early sign of increased intracranial pressure should the nurse monitor this client?

Lethargy

A nurse is caring for a client during the first few hours after admission to the burn unit with full-thickness burns of the trunk and head. Which nursing goal is the priority during the emergent phase of a burn injury?

Managing fluid loss

he nurse is caring for rescued flood victims in the emergency department. Which drugs are used to treat cerebral edema or decrease free water in clients with submersion injuries?

Mannitol (Osmitrol) Furosemide (Lasix)

The nurse is caring for a client who is receiving treatment via intrathecal therapy. The client reports a headache and neck stiffness. Upon assessment, the nurse finds that the client's body temperature is 103 °F. Which condition should the nurse suspect in the client?

Meningitis

A nurse assesses a client who is experiencing profound (late) hypovolemic shock. When monitoring the client's arterial blood gas results, which response does the nurse expect

Metabolic acidosis

A client arrives in the emergency department with epigastric pain and prolonged vomiting. Assessment findings include rapid and shallow respirations, dry and flushed skin, weakness, and lethargy. Which is the primary nursing concern?

Metabolic alkalosis

The nurse is interpreting the client's rhythm strip and finds that the P and QRS waves are consistent, with a P wave preceding every QRS complex. The PR interval is 0.26 seconds long. The rate is 64 beats per minute. How should the nurse interpret this rhythm?

Sinus rhythm with first degree AV block

The nurse is caring for a client who is on a cardiac rhythm monitor. The nurse notes that the client's P waves are of normal configuration and that each P wave is followed by a QRS complex. All intervals are normal as well, but the client's heart rate is 112 beats per min. How will the nurse interpret this rhythm?

Sinus tachycardia

A client is admitted to the burn unit with partial-thickness burns over 30% of the body surface area. Twenty-four hours later, the client, who has an intravenous (IV) line of 5% dextrose in saline running, has tremors, twitching, and signs of disorientation. During the past hour the urinary output was 110 mL. What should the nurse do next?

Slow the IV rate and notify the healthcare provider.

A nurse is assessing a client during the first 24 hours after a burn injury. Which sign indicates to the nurse that fluid replacement therapy is adequate?

Slowing of a previously rapid pulse

Which is the most difficult problem for the nurse to manage when meeting the needs of an extensively burned client 3 days after admission?

Sterile wound care to prevent infection including cleaning and debridement.

A client who is on long-term corticosteroid therapy following an adrenalectomy is admitted to the surgical intensive care unit after being involved in a motor vehicle crash. What is the nurse's most important concern related to the client's history?

Steroid therapy will need to be increased to avert a life-threatening crisis.

The nurse finds the respiratory rate is 8 breaths per minute in a client who is on intravenous morphine sulfate. What should the nurse do immediately in this situation?

Stop administering the medication.

A nurse is administering a histamine H 2 antagonist to a client who has extensive burns. The nurse explains to the client that this drug is given prophylactically during the first few weeks after extensive burns. What complication of burns will it prevent?

Stress ulcer

In addition to atrial fibrillation, which cardiac dysrhythmia exhibited by a client does the nurse determine may be converted to sinus rhythm by cardioversion?

Supraventricular tachycardia

The nurse is performing a rewarming procedure in a client with severe hypothermia. What should the nurse keep in mind while performing this procedure?

The client should be monitored for after drop during rewarming.

A nurse is caring for a client who sustained a partial-thickness burn to the lower leg accounting for 5% of the total body surface area 1 day ago. Which primary short-term outcome established by the nurse and client will be added to the care plan?

The client's pain will remain at 2 or less on a scale of 0 to 10.

A client presenting to the emergency department with chest pain and dizziness is found to be having a myocardial infarction and subsequently suffers cardiac arrest. The healthcare team is able to successfully resuscitate the client. Lab work shows that the client now is acidotic. How does the nurse interpret the cause of the acidosis?

The decreased tissue perfusion caused lactic acid production.

A client has a diagnosis of superficial partial-thickness burns. The client asks what layers of skin are involved with this type of burn. Which response by the nurse is most appropriate?

The epidermis is damaged.

A client has sustained a spinal cord injury at the T2 level. The nurse assesses for signs of autonomic hyperreflexia (autonomic dysreflexia). What is the rationale for the nurse's assessment?

The injury is above the sixth thoracic vertebra.

Which information should the nurse include in a teaching plan for a client whose burns are being treated with the exposure (open) method?

ascetic technique

The nurse notes asystole on the cardiac monitor. Which action should the nurse take immediately?

assess pulse

During the postoperative period after surgery for a kidney transplant, the client's creatinine level is 3.1 mg/dL (260 mcmol/L). What should the nurse do first in response to this laboratory result?

Assess for decreased urine output.

The nursing student is learning about the common causes of hypothermia. Which statements made by the nursing student demonstrate adequate knowledge about the etiology of hypothermia? Select all that apply.

"Administration of blood causes hypothermia." Administration of neuromuscular blocking agents causes hypothermia."

A woman comes to the office of her healthcare provider reporting shortness of breath and epigastric distress that is not relieved by antacids. To which question would a woman experiencing a myocardial infarction respond differently than a man?

"Do you have chest pain?"

A person sustains deep partial-thickness burns while working on a boat in a town marina and seeks advice from the nurse in the first aid station. The nurse encourages the client to seek medical attention but the client refuses. Which instruction will the nurse provide to the person?

"Go see a primary healthcare provider if urinary output decreases."

The nurse is assessing the victims of a disaster brought in to the emergency department for signs of hypothermia. Which statements made by the nurse indicate accurate awareness about the conditions associated with hypothermia? Select all that apply.

"Hypothermia can often be misdiagnosed as it mimics other disorders." "Near drowning increases evaporative heat loss to 25 times greater than norma

he victims of a natural disaster are brought to the emergency department and found to be suffering from hypothermia. What is most likely to be the core body temperature of the hypothermic victim in whom shivering is diminished or absent?

82.4° F (28°C)

The nurse is caring for the victims of a natural disaster who are suffering from hypothermia. Which is most likely to be the core body temperature of the client with moderate hypothermia?

89.6° F (32°C)

A client is burned on the anterior part of both legs, from the knees to the feet. The nurse uses the rule of nines to assess the percentage of total body surface area (TBSA) burned. Which percentage should the nurse document in the client's hospital record?

9%

The nurse is caring for a client with bomb blast injuries. Which are priority emergency assessments that need to be performed? Select all that apply. Airway Breathing Circulation Give comfort measures Facilitate family presence Exposure or environmental control

A B C Exposure Primary survey

The nurse is assessing the client with subdural hematoma after a fall. The client was admitted for observation with a normal neurologic assessment on admission. Upon entering the room the nurse finds the client exhibiting seizure activity. Which is the first action the nurse should take?

Assess the client's airway.

A 14-year-old adolescent is severely injured in a motor vehicle collision. There are multiple fractures, contusions, and muscle spasms, causing the teenager to refuse to move. How can the nurse best support the adolescent and encourage movement?

Encouraging decision-making regarding care

A client who has partial-thickness burns on the chest, abdomen, and right side arrives in the emergency department. Which action will the nurse take first?

Evaluate whether the client has inhaled smoke.

A client is admitted with 50% of the body surface area burned. The nurse caring for the client 48 hours after admission reviews the client's laboratory results: urine specific gravity, 1.015; urine output, 50 mL/hr; hematocrit, 42 (0.42 volume fraction); albumin, 3.6 g/dL (36 g/L); and pulmonary arterial wedge pressure, 10 mm Hg. Which conclusion will the nurse draw based upon the laboratory results?

Fluid therapy is successful.

A client is admitted to the emergency unit after a fire. The nurse initiates continuous cardiac monitoring and maintains oxygen saturation and end-tidal carbon dioxide. Which type of emergency assessment is being performed?

Focused adjuncts

The nurse is watching the technician obtain a 12-lead ECG. In which area should the nurse make sure the technician places the V 1 lead?

Fourth intercostal space right sternal border

nurse is obtaining an admission history for a client who is scheduled for surgery to repair a ruptured abdominal aneurysm. Which type of shock should the nurse monitor for in this client?

Hypovolemic

A client is recovering from a myocardial infarction. Which action should the nurse take before developing the client's teaching plan?

Identify the learning needs of the client.

After an acute episode of upper gastrointestinal (GI) bleeding, a client vomits undigested medications and reports severe epigastric and abdominal pain. The client has absent bowel sounds, rigid abdomen, a pulse rate of 134, and shallow respirations of 32 per minute. The primary healthcare provider has been contacted. What should be the nurse's next priority?

Keep the client nothing by mouth (NPO)

A client had a craniotomy for excision of a brain tumor. After surgery, the nurse monitors the client for increased intracranial pressure. Which clinical finding supports an increase in intracranial pressure?

Lowered level of consciousness

Findings on a client's cardiac monitor indicate a need for an intravenous infusion that contains potassium for a client with hypokalemia. The nurse concludes that what finding on the monitor indicated a need for potassium replacement?

Lowering of the T wave

What is the priority nursing intervention for a client during the immediate postoperative period?

Maintain airway #1

A nurse reviews the laboratory test results of a client with emphysema who is recovering from a myocardial infarction. The nurse obtains the client's vital signs and performs a physical assessment. Which prescribed medication should the nurse consider the priority at this time?

Metoprolol

Twelve hours after sustaining full-thickness burns to the chest and thighs a client who is on nothing-by-mouth status (NPO) is reporting severe thirst. The client's urinary output has been 60 mL/hr for the past 10 hours. No bowel sounds are heard. What should the nurse do?

Moisten the client's lips with a wet 4 × 4 gauze.

After an anterior fossa craniotomy, a client is placed on controlled mechanical ventilation. To ensure adequate cerebral blood flow, which action should the nurse take?

Monitor serum carbon dioxide levels routinely.

A client with a gunshot wound has severe hemiplegia associated with abnormal body posturing and fixed and dilated pupils. What is the nursing priority in this condition?

Monitoring respiratory rate

The nurse is performing a primary assessment on a client who fell down the stairs. Which priority nursing action benefits the client? Monitoring the client for hemorrhage Anticipating for rapid blood component administration Inserting 16-gauge at the antecubital area for intravenous line Infusing warm intravenous fluids at a rate of 8 drops per minute

Monitoring the client for hemorrhage

A client with a cardiac dysrhythmia is receiving digoxin and verapamil. Because of the combined effect of these two medications, what adverse effect does the nurse anticipate?

Myocardial depression

lient is admitted to the hospital with deep partial-thickness burns to both hands and forearms after an accident. How should the nurse apply the prescribed antimicrobial medication?

Place the medication directly on the burn wound in a thin layer using sterile gloves.

What is the immediate nursing intervention for a client experiencing autonomic dysreflexia?

Placing the client in a sitting position

A client is postoperative from open heart surgery. What should the nurse do to decrease or control the sensory and cognitive disturbances?

Plan for maximum periods of rest

During a fire, a large group of people suffocate due to smoke inhalation and are immediately admitted to the emergency unit. The assessment findings in these clients reveal absent breath sounds. Which nursing interventions are appropriate in this situation? Select all that apply.

Preparing to intubate Preparing for needle thoracostomy and chest tube insertion

A client was admitted with full-thickness burns 2 weeks ago. Since admission, the client has lost an average of 1 lb (0.5 kg) of weight each day. Which action will the nurse mostlikely take based upon the adjusted dietary plan?

Provide high-protein drinks.

The nurse is assessing a client with multiple injuries due to a severe motor vehicle accident. Which nursing intervention should the nurse perform first?

Providing bag-valve-mask ventilation

An older adult who is in acute care has a risk of skin breakdown. Which interventions are beneficial to the client? Select all that apply.

Providing meticulous skin care Reducing shear forces and friction Avoiding pressure with proper positioning

The nurse is caring for a client who is diagnosed with diabetes insipidus and is on intranasal desmopressin acetate (DDAVP). The client develops an upper respiratory tract infection during a hospital stay. Which alteration does the nurse anticipate in the client's prescription?

Reduced DDAVP dose via subcutaneous route

A client with burns caused by flames is hospitalized. Which specific emergency burn management would be appropriate for this client?

Removing all metal objects

The nurse is assessing a client with burns over 15% of the body. Which priority nursing action should be taken to ensure a complete assessment?

Removing the clothes of the client

What should the nurse monitor for when caring for a postoperative client who presents with 180 mL of urine in the urinary drainage bag from the past 8 hours?

Renal failure

While reviewing the laboratory results of a client in an acute care setting, the nurse finds urine output of 250 mL in 24 hours, blood osmolality of 310 milliosmoles per kg, and a systolic blood pressure of 90 mm Hg. What is the priority nursing intervention in this situation?

Request an increase in the intravenous fluid rate from the healthcare provider.w

The nurse is assessing four clients in the hospital. Which client should the nurse categorize in an emergent level according to the three-tiered triage system? Resp distress cold must. fx sprain/strain

Resp distress

The nurse is caring for a client with chronic pain who is on opioid treatment. The client has constipation, nausea, vomiting, level 3 sedation, respiratory rate of 8 breaths per minute, and pruritus. Which conditions of the client should the nurse consider as highest priority?

Respiratory rate Sedation

The nurse is caring for four clients admitted at the same time under mass casualty conditions. Based on this data, which client should be given the highest priority for treatment? a. massive head trauma b. open fx w distal pulse c. shock d. strain/contusion

SHOCK

A client sustains a crushing injury to the lower left leg, and a below-the-knee amputation is performed. For which common clinical manifestations of a pulmonary embolus should the nurse assess this client?

Sharp chest pain Acute onset of dyspnea

A nurse on the Code Blue/Arrest team responds to a code that is called for a client with hyperkalemia who is experiencing cardiac standstill. What would an appropriate immediate treatment plan include?

Sodium bicarbonate Sodium bicarbonate decreases the potassium level. It works by increasing the movement of potassium from the blood into the cells. The body stores potassium inside the cells, with only a small amount in the bloodstream. Electrical defibrillation should not be applied indiscriminately to the client in asystole. This is not only fruitless but also detrimental, eliminating any possibility of recovering a rhythm. Furosemide is a diuretic commonly used for heart failure. There is no indication for anticoagulation therapy.

A nursing student compares the pathophysiology of submersion injury in victims of freshwater drowning and victims of saltwater drowning. Which statement made by the nursing student indicates effective learning?

The osmotic gradient caused by the aspirated fluid causes fluid imbalances in case of submersion in both types of water."

A nurse is assessing the adequacy of a client's intravenous fluid replacement therapy during the first 2 to 3 days after sustaining full-thickness burns to the trunk and right thigh. What assessment will provide the nurse with the most significant data?

U O q hr

A client is admitted to the hospital with severe burns. Which client response should the nurse anticipate during the acute phase of burn recovery?

Unstable vital signs

A nurse is caring for a client who had a pneumonectomy. Which is the priority nursing assessment?

Ventilatory exchange

Four clients who sustained head injuries are presented below. Which client has the least score on the Glasgow coma scale?

client C. open eyes to pain, norm flexion, in.verbal response

The nurse is assessing the vital signs of four clients and comparing them with their previous vital signs measurements. Which client should be treated first to ensure safety?

client w RR that go from 17-10 in 15 min

The nurse is caring for the victims of a snowstorm who have been exposed to cold temperatures. Which clients are at a high risk of sustaining cold injuries? Select all that apply.

client who is hypoglycemic A client who is on opioid medication A client who has been a heavy smoker for years

An older adult client is admitted to the hospital with a diagnosis of chronic kidney disease. The nurse reviews the client's medical record. Which clinical finding is a priority to be communicated to the primary healthcare provider? Potasssium 6.0 na= 135 bp 150/100

potassium

A client who is prescribed diuretic therapy develops metabolic alkalosis. To which intervention should the nurse give priority as the healthcare team corrects the alkalosis?

preventing falls

While caring for a client receiving hydrocortisone therapy, the nurse anticipates a dose adjustment in the client's prescription. Which observation in the client supports this anticipation?

sudden wt gain

The nurse is assessing a client with hemorrhagic stroke due to a motor bike accident. Which condition of the client requires immediate attention? Glasgow Coma score of 10 Body temperature of 81.2°F Oxygen saturation of 90 percent Presence of carotid pulse with blood pressure of 80 mm Hg

temp....

A client is admitted with multiple trauma after a bus crash. The nurse finds that the stability of the client's vital function is threatened. Under which emergency severity index (ESI) level should the nurse triage this client's condition?

ESI-2

A nurse is assessing a client with a cast to the extremity. Which assessment finding is the priority?

Numbness

A client is admitted to the hospital for a surgical resection of the lower left lobe of the lung. After surgery the client has a chest tube to a closed chest drainage system. What should the nurse do to determine if the chest tube is patent?

Observe for fluctuations of the fluid in the water-seal chamber

While caring for a client receiving blood transfusion care, the nurse notices that the client is having an acute hemolytic reaction. What is the priority nursing intervention in this situation?

Stop the blood transfusion immediately.

The nurse is caring for a client who was just admitted to the hospital with the diagnosis of head trauma. Which clinical indicators should the nurse consider as evidence of increasing intracranial pressure?

Vomiting irritability decreased LOC