Client Care
The nurse assists in administering first aid to a client who has been bitten by a snake on the right leg. The nurse should take which action?
Ensure that the victim is lying down, and remove restrictive items.
During the emergent phase of a client with severe burns the nurse expects to perform which action?
Insert a Foley catheter.
A child is admitted to the burn unit with partial- and full-thickness burns over 35% of the body. The nurse assisting in caring for the child develops the plan of care. Which nursing intervention is the priority?
Inserting a Foley catheter
A client is admitted to the emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially?
Maintain a patent airway.
The client brought to the emergency department is experiencing an anaphylactic reaction from eating shellfish. The nurse should implement which immediate action?
Maintaining a patent airway
The nurse is assisting in preparing to administer acetylcysteine to a client with an overdose of acetaminophen. How should the nurse administer the medication?
Mix the medication in a flavored ice drink, and allow the client to drink the medication through a straw.
The nurse is monitoring a client receiving a blood transfusion for circulatory overload. The nurse understands that which is a clinical indication of circulatory overload?
Moist, productive cough
A client who is receiving total parenteral nutrition (TPN) complains of a headache. The nurse notes that the client has an increased blood pressure and a bounding pulse. The nurse reports the findings, knowing that these signs/symptoms are indicative of which complication of this therapy?
Fluid overload
A client presents to the urgent care center with a chemical burn of the right eye. The priority for the nurse is to prepare the client for which nursing intervention?
Flushing the right eye with copious amounts of sterile solution
The nurse is caring for a client with heart failure. The client suddenly becomes anxious and restless, has a sudden onset of breathlessness, and becomes cyanotic. The nurse suspects pulmonary edema and immediately places the client in which best position?
High-Fowler's
A 4-year-old child has been brought to the emergency department after the grandparents found him with an open bottle of chewable, orange-flavored 81-mg aspirin tablets. In order to determine whether the child is experiencing a toxic effect, which question should the nurse ask the child?
"Do you hear a sound like a bell ringing in your ears?"
Several clients arrive simultaneously at the emergency department after sustaining burn injuries in a house fire. Which client will require the closest observation for signs of respiratory distress?
A client who has singed nasal hairs and worsening hoarseness
The nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which finding?
A decrease in oozing from puncture sites and gums
The nurse is doing a routine assessment of a client's peripheral intravenous (IV) site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which has probably occurred?
Infiltration
The nurse is performing a vaginal check of a pregnant client in labor. The nurse notes that the umbilical cord is protruding from the vagina. Which action should the nurse immediately perform?
Exert upward pressure against the presenting part with gloved fingers.
The nurse is working in the primary care office and is conducting an interview with the parents of a child. The parents of the child state that they would like some syrup of ipecac for use at home in case of an accidental poisoning. The nurse provides which appropriate instruction specific to the use of this medication?
"Ipecac syrup is not for home use and is administered only under medical supervision."
A client has had extensive surgery on the gastrointestinal tract and has been started on total parenteral nutrition (TPN). The client tells the nurse, "I think I'm going crazy. I feel like I'm starving, and yet that bag is supposed to be feeding me." Which is the best response from the nurse?
"That is because the empty stomach sends signals to the brain to stimulate hunger."
The primary health care provider prescribes one unit of packed red blood cells to infuse over 4 hours. One unit of blood contains 250 mL, and the drop factor is 10 gtt/1 mL. Although an infusion pump will be used, the registered nurse asks the licensed practical nurse (LPN) to assist with monitoring the flow rate during the infusion. The LPN monitors the flow rate, knowing that how many gtt/min should infuse? Fill in the blank and round answer to the nearest whole number.
10
The nurse determines that a student in a basic cardiac life support (BCLS) course correctly performs cardiopulmonary resuscitation (CPR) on an infant when the nurse observes which rate of chest compressions delivered to the infant mannequin?
100 times per minute
A client is brought to the emergency department following a smoke inhalation injury. The initial nursing action is to prepare the client to receive which treatment?
100% humidified oxygen by face mask
A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. Which prescription should the nurse anticipate for the client?
100% oxygen via a tight-fitting non-rebreather face mask
The client arrives at the emergency department after a burn injury that occurred in their home basement and an inhalation injury is suspected. Which should the nurse anticipate as being prescribed for the client?
100% oxygen via a tight-fitting, nonrebreather face mask
A client is going to be transfused with a unit of packed red blood cells (PRBCs). The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started?
15 minutes
The nurse is reinforcing instructions regarding cardiopulmonary resuscitation (CPR) to a group of nursing students. The nurse tells the group that when performing chest compressions on adults, the sternum should be depressed to at least which depth?
2 inches
The nurse is checking the date of an intravenous (IV) insertion in a client. The insertion date on the dressing is 2/9 (February 9). The nurse calculates that the site should be changed on which date?
2/12
The nurse employed in the emergency department receives a telephone call from the emergency alert system informing the department that a child who ingested a bottle of acetaminophen is en route to the emergency department. The nurse prepares the room for the arrival of the child and checks the medication supply to determine whether which medication that is the antidote is available?
Acetylcysteine
The nurse suspects that the client has a pulmonary embolism. Which is the most important nursing action?
Administer oxygen by face mask, as prescribed.
The nurse receives a telephone call from a neighbor who states that her child was found sitting on the floor near the kitchen sink playing with several bottles of cleaning fluids. The bottles of cleaning fluid were opened and spilled on the child and the floor, and the mother suspects that the child may have consumed some of the cleaning fluid. Which action should the nurse tell the mother to do immediately?
Call the area poison control center.
A 4-year-old child sustains a fall at home injuring the right arm and is brought to the emergency department by the mother. The nurse should perform which emergency actions in the care of the child? Select all that apply.
Elevate the right arm. Check the neurovascular status of the right extremity. Determine the level of pain using a pediatric pain assessment tool.
A postpartum client has lost 700 mL of blood. The vital signs indicate hypovolemia and the uterus remains atonic in spite of treatment. The nurse assisting in caring for the client understands what is necessary in this situation and prepares the client for which treatment?
Emergency surgery
The nursing student is asked to describe the correct steps for performing adult cardiopulmonary resuscitation (CPR). Arrange the steps of adult CPR in the order of priority. All options must be used.
Determine unconsciousness by shaking the client and asking, "Are you OK?" Perform chest compressions. Open the client's airway. Initiate breathing.
A client presents to the emergency department with upper gastrointestinal (GI) bleeding and is in moderate distress. Which nursing action should be the priority for this client?
Determine vital signs.
A child is hospitalized with a diagnosis of lead poisoning. The nurse caring for the child should prepare to assist in administering which medication?
Dimercaprol
The nurse is assisting in monitoring the condition of a client after pericardiocentesis for cardiac tamponade. Which observation indicates that the procedure was unsuccessful?
Distant and muffled heart sounds
A client has been on total parenteral nutrition for 8 weeks. The primary health care provider prescribes that the total parenteral nutrition be weaned down by 50 mL/hr/day until discontinued. The client asks the nurse, "Why doesn't the doctor just stop the parenteral nutrition instead of dragging it on for 3 days?" The nursing response should be to explain that the primary health care provider is concerned about which phenomenon?
Rebound hypoglycemia
The nurse is assisting in caring for a client admitted to the emergency department with diabetic ketoacidosis. The nurse anticipates that the primary health care provider will prescribe which type of insulin for intravenous administration to treat this disorder?
Regular
A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client?
Remain with the client until the anxiety decreases.
The nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. Which is the most appropriate action?
Remove the IV.
The nurse employed in the emergency department is preparing to administer syrup of ipecac to a 7-month-old child. The nurse prepares 5 mL of the syrup and administers one half glass of water following administration of the ipecac syrup. Which response should the nurse expect?
Vomiting
The nurse checks the peripheral intravenous (IV) site dressing and notes that it is damp and that the tape is loose. Which is the first action by the nurse?
Check that the tubing is securely attached.
The nurse is monitoring a client who is receiving a unit of packed red blood cells. Within an hour after the initiation of a transfusion, the nurse finds the client to be restless, with reports of chills and back pain. The nurse notes that there is dark urine in the Foley catheter drainage bag. The nurse interprets that the client is experiencing which reaction?
Acute hemolytic
An assessment of a woman at 32 weeks of gestation indicates moderate fetal distress. Which intervention is the nurse's priority?
Administer oxygen with a face mask at 7 to 10 L/min.
Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action?
Administer oxygen, 8 to 10 L/minute, via face mask.
A client in the postpartum unit complains of sudden, sharp chest pain. The client is tachycardic and the respiratory rate is increased, and the primary health care provider diagnoses a pulmonary embolism. Which interventions apply to the care of this client? Select all that apply.
Administer oxygen. Monitor the blood pressure. Prepare to administer morphine sulfate. Prepare to start an intravenous (IV) line.
The nurse notes that a client who is attached to a cardiac monitor suddenly develops atrial fibrillation at a rate of 130 beats per minute. The nurse immediately notifies the registered nurse and prepares the client for which initial intervention?
Administration of a calcium channel blocker
A client who has been receiving total parenteral nutrition by way of a central venous access device complains of chest pain and dyspnea. The nurse quickly assesses the client's vital signs and notes that the pulse rate has increased and that the blood pressure has dropped. The nurse determines that the client is most likely experiencing which sign?
Air embolism
A child is brought to the emergency room and the mother reports that the child accidentally swallowed paint thinner after mistaking it for water. The nurse should perform which action first?
Check the circulation, airway, and breathing status of the child.
The nurse who is assisting in caring for a client with a tracheostomy tube notes heavy bleeding from the stoma. The nurse also notes that the tracheostomy tube pulsates with the client's heartbeat. The nurse immediately performs which action?
Applies pressure to the artery at the stoma site
To use an external cardiac defibrillator on a client, which action should be performed to check the cardiac rhythm?
Applying the adhesive patch electrodes to the skin and moving away from the client
A client requiring upcoming surgery is extremely anxious about the need for a possible blood transfusion and is concerned about the risk of infection from contaminated blood. The nurse suggests that the client consider which as an effective method to minimize this risk?
Arrange an autologous blood donation before the planned surgery.
A client is admitted to the emergency department with a diagnosis of acute myocardial infarction (MI). Which prescriptions should the nurse anticipate implementing? Select all that apply.
Aspirin Oxygen Morphine Nitroglycerin
A client with myasthenia gravis is receiving pyridostigmine. The nurse monitors for signs and symptoms of cholinergic crisis caused by overdose of the medication. The nurse checks the medication supply to ensure that which medication is available for administration if a cholinergic crisis occurs?
Atropine sulfate
A family of a spinal cord-injured client rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic, with a flushed face and neck, and complains of a severe headache. The pulse is 40 beats per minute, and the blood pressure is 230/100 mm Hg. The nurse acts quickly, knowing that the client is experiencing which condition?
Autonomic dysreflexia
The nurse notes that the 4-hour postpartum client has cool, clammy skin and that she is restless and excessively thirsty. The nurse immediately notifies the registered nurse and then performs which action?
Checks the vital signs
A woman in active labor has contractions every 2 to 3 minutes that last for 45 seconds. The fetal heart rate between contractions is 100 beats per minute. On the basis of these findings which is the priority nursing action?
Notify the registered nurse (RN) immediately.
The nurse has administered a dose of salmeterol to a client. Following administration, the client develops a generalized rash and urticaria and the eyelids begin to swell. Which action should the nurse take?
Notify the registered nurse immediately.
A client has been receiving parenteral nutrition at 125 mL/hr for 5 days. On data collection, the LPN notes bilateral crackles and 2+ pedal edema and that the client has gained 3 pounds in 5 days. Which would be appropriate as the initial nursing action?
Notify the registered nurse of the findings.
Following surgical removal of a brain tumor, the primary health care provider writes a prescription to maintain the child in a semi-Fowler's position. In the postoperative period, the nurse is monitoring the child and notes that the child is restless, the pulse rate is elevated, and the blood pressure has dropped significantly from the baseline value. The nurse suspects that the child is in shock. Which nursing action would be appropriate?
Notify the registered nurse.
The nurse is assisting in caring for a victim of a burn injury during the emergent/resuscitative phase. On data collection of the client, the nurse notes that the urine output has decreased and the blood pressure is dropping. The nurse should perform which immediate action?
Notify the registered nurse.
The nurse is checking the insertion site of a peripheral intravenous (IV) catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is likely the result of which?
Phlebitis of the vein
A client rings the call light and complains of pain at the site of an intravenous (IV) infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which actions in the care of this client? Select all that apply.
Remove the IV catheter at that site. Apply warm moist packs to the site. Notify the primary health care provider (PHCP). Document the occurrence, actions taken, and the client's response.
The nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. Based on these findings, the nurse plans to take which initial nursing action?
Remove the IV.
The nurse is caring for a client who had a tracheostomy tube inserted 1 week ago. The client begins to cough vigorously, and accidental decannulation of the tracheostomy tube occurs. Which action should be the nurse's immediate response?
Replace the tracheostomy tube.
The nurse caring for a client at home arrives to find the client in the bedroom, unconscious and with a pill bottle of the selective serotonin reuptake inhibitor, sertraline on the bed. Which assessment has priority?
Respirations
A client who experienced ventricular fibrillation has just been defibrillated. Following the defibrillation, which action should the nurse take immediately?
Resume cardiopulmonary resuscitation (CPR).
A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which area?
The blood bank
The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100° F (37.7° C) orally. The nurse reports the finding to the registered nurse (RN) and anticipates that which action will take place?
The blood will be held, and the primary health care provider (PHCP) will be notified.
The nurse is caring for a client in labor. The nurse notes the presence of fetal bradycardia on the fetal monitor and suspects that the umbilical cord is compressed. The nurse should immediately place the client in which position?
With the hips elevated
The nurse discusses emergency nursing measures that are implemented at the site of an injury with a nursing student. Which initial action does the nurse tell the student to perform in the event of carbon monoxide poisoning?
Carry the client to fresh air.
The nurse is assisting with caring for a client who is receiving a unit of packed red blood cells (PRBCs). The nurse should tell the client that it is most important to report which sign(s) immediately?
Chills, itching, or rash
The nurse is assigned to assist with caring for a client who is at risk for eclampsia. If the client progresses from preeclampsia to eclampsia, the nurse should take which action first?
Clear and maintain an open airway.
A mother of a 9-year-old child calls the emergency department and tells the nurse that her child received a minor burn on the hand after accidentally touching a grill during a family cookout. The mother asks the nurse for advice on how to treat the burn. Which action should the nurse tell the mother to immediately perform?
Place the child's hand under cool running water.
The nurse is preparing for the intershift report when a nurse's aide pulls an emergency call light in a client's room. On answering the light, the nurse finds a client experiencing tachycardia and tachypnea. The client's blood pressure is 88/60 mm Hg. Which action should the nurse take first?
Place the client in modified Trendelenburg's position.
Skin breakdown occurs on a client's hand at the site of an intravenous catheter that had medication infusing. The nurse determines that which adverse effect occurred? Refer to figure.
Extravasation
One unit of packed red blood cells is infusing into a client over a 4-hour period. The unit of blood contains 250 mL. The drop factor is 15 drops (gtt) per 1 mL. The nurse determines that the flow rate should be set at how many drops per minute? Fill in the blank and round answer to the nearest whole number.
16 gtt
A depressed client is found unconscious on the floor in the dayroom of a psychiatric nursing unit. The nurse finds several empty bottles of a prescribed tricyclic antidepressant lying near the client. What is the immediate action of the nurse?
Call a rapid response.
The nurse is caring for a client on a cardiac monitor who is alone in a room at the end of the hall. The client has a short burst of ventricular tachycardia (VT), followed by ventricular fibrillation (VF). The client suddenly loses consciousness. Which intervention should the nurse do first?
Call for help and initiate cardiopulmonary resuscitation (CPR).
When assisting in the identification process required before a blood transfusion, which action will the nurse take when it is noted that all of the necessary information is correct, except for the client's name?
Call the blood bank about the discrepancy.
A mother calls a neighborhood nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. Which action should the nurse instruct the mother to take first?
Call the poison control center.
A mother of a 6-year-old child calls the nurse who lives in the neighborhood and tells the nurse that her child accidentally rubbed waterproof sunscreen in his eyes. Which action should the nurse tell the mother to immediately perform?
Call the poison control center.
The nurse in the newborn nursery receives a telephone call to prepare for the admission of a neonate born at 43 weeks' gestation with Apgar scores of 1 and 4. When planning for the admission of this infant, which is the nurse's highest priority?
Connecting the resuscitation bag to the oxygen outlet
An emergency department nurse prepares to collect data from a pregnant woman. The woman tells the nurse that she felt a large gush of fluid on the way to the hospital. The nurse checks the fetal heart rate (FHR) and notes that it is 90 beats per minute. On physical examination, the nurse notes that the umbilical cord is protruding from the vagina. Which is the initial nursing action?
Wrap the cord loosely in a sterile normal saline saturated towel.
A client who sustained an inhalation injury arrives in the emergency department. On data collection, the nurse notes that the client is very confused and combative. The nurse determines that the client is experiencing which problem?
Hypoxia
The nurse is assisting in the preparation of a client for a blood transfusion. Which item is the most important for the completion of the identification process?
Identification bracelet
vThe nurse is assigned to care for a client who has experienced uterine rupture. The nurse plans care knowing that which is the priority concern in caring for the client?
Impaired gas exchange
A client receiving intravenous (IV) fluid therapy complains of burning and a feeling of tightness at the IV insertion site. On data collection, the nurse detects coolness and swelling at the site and notes that the IV rate has slowed. The nurse determines that which has occurred?
Infiltration
The nurse is assisting in admitting a client to the emergency department with suspected carbon monoxide poisoning. The nurse understands that which sign/symptom is least reliable for determining the oxygenation status of this client?
Skin color
A client is receiving thrombolytic therapy by continuous infusion. The client suddenly becomes extremely anxious and complains of itching. The nurse hears stridor, and on examination of the client, notes generalized urticaria and hypotension. Which should be the priority action of the nurse?
Stop the infusion, and notify the registered nurse.
The nurse is assisting in caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide level reveals a level of 45%. Based on this level, the nurse should anticipate which sign in the client?
Tachycardia
The nurse is conducting a teaching session on basic life support (BLS) for nursing students. Which statement made by a nursing student indicates a need for further teaching?
"I will remember the algorithm airway, breathing, and compressions to guide my actions when providing BLS."
The nurse arrives at the scene of a code and begins to assist in performing cardiopulmonary resuscitation (CPR) on an adult client. The nurse knows that interruptions in performing chest compressions should be limited to less than how many seconds?
10
When performing cardiopulmonary resuscitation (CPR), the nurse should deliver how many breaths per minute to an adult client?
10
The nurse is providing cardiopulmonary resuscitation (CPR) to an adult cardiac arrest victim. Which is the proper compression-to-ventilation ratio for one-person CPR?
30:2
An adult client is admitted to the emergency department following a burn injury. The burn initially affected the client's upper half of the anterior torso, and there were circumferential burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the entire face (anterior half of the head) and the upper half of the posterior torso. Using the rule of nines, which percentage would characterize the burn injury? Refer to the figure.<
31.5%
A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which intravenous (IV) solution will most likely be prescribed for this client?
5% dextrose in lactated Ringer's solution
The nurse is monitoring a client with a diagnosis of gastric ulcer. Which finding would indicate perforation of the ulcer?
A rigid, boardlike abdomen
The nurse is assisting in admitting a child who arrived from the emergency department after treatment for acetaminophen overdose. The nurse reviews the child's record and expects to note that the child received which for the acetaminophen overdose?
Acetylcysteine
The nurse is caring for a client who is a victim of a major burn injury. Which are the names of the primary phases of burn care assessment? Select all that apply.
Acute Resuscitative 6.Rehabilitative
The nurse witnesses a person starting to choke in the hospital cafeteria. Before performing abdominal thrusts, which action should the nurse perform?
Ask the client, "Are you choking?"
A client receiving a blood transfusion begins to exhibit flushing, stridor, and a drop in blood pressure. The nurse should obtain which medication from the emergency cart to have ready for use as prescribed?
Epinephrine
A client with a major burn is admitted to the emergency department. In priority order, which actions should the nurse take? Arrange the actions in the order that they should be used. All options must be used.
Establish airway. Initiate fluid therapy. Insert Foley catheter. Insert a nasogastric tube.
The nurse observes the following rhythm on the cardiac monitor. Which action should the nurse take first? Refer to the figure.
Evaluate the client for hypotension and assess mental status.
The nurse has been assigned to the care of four adult clients who are receiving continuous intravenous (IV) infusions. The nurse planning the work assignment for the shift makes a notation to check the IV sites of these clients at which time interval?
Every hour
The nurse is caring for a client with a permanent pacemaker. The nurse knows that which three primary problems can occur when cardiac pacemakers malfunction? Select all that apply.
Failure to sense Failure to capture 4.Failure to pace or fire
The nurse is assigned to care for a client receiving total parenteral nutrition via the subclavian vein. The nurse should identify which intervention in the plan of care for the client as the priority?
Monitoring the insertion site for signs of infection
The nurse is assisting in caring for a client who is receiving morphine sulfate by continuous intravenous infusion. The nurse ensures that which medication is readily available if a morphine overdose occurs?
Nalmefene
A woman arrives at the emergency department complaining of abdominal pain of 4 on a scale of 1 to 10. She states that she thinks she is about 10 weeks pregnant. Her vital signs are pulse, 86 beats per minute; respirations,16 breaths per minute; and blood pressure,112/78 mm Hg. Which signs/symptoms should the nurse report to the primary health care provider immediately? Select all that apply.
Pulse, 112 beats per minute Pain rating of 8 on a scale of 1 to 10 5. States "I feel like I am about to faint."
The client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client's vital signs, what are the nurse's actions in order of priority? Arrange the actions in the order that they should be performed. All options must be used.
Raise the head of the bed. Loosen tight clothing on the client. Check for bladder distention. Prepare to administer an antihypertensive medication as prescribed. Document the occurrence, treatment, and response.f50
The nurse is assisting to administer acetylcysteine to a client admitted with acetaminophen overdose. Before this medication is given, the nurse ensures which factor is in place?
The stomach is empty from emesis or lavage.
The nurse notes that an 8-year-old child is choking. As the nurse rushes to aid the conscious and alert child, the nurse plans to place the hands between which landmarks to remove the foreign body?
The umbilicus and xiphoid process
The nurse notes redness, warmth, and a yellowish drainage at the insertion site of a central venous catheter in a client receiving parenteral nutrition. These findings indicate which potential complication?
There may be an infection at the central catheter site, which can lead to septicemia.
A client with suspected opioid overdose has received a dose of nalmefene. The client subsequently becomes restless, starts to vomit, and complains of abdominal cramping. The blood pressure increases from 110/72 to 160/86 mm Hg. The nurse provides emotional support and reassurance while administering care to the client, knowing which statement is true?
These are signs of opioid withdrawal.
A primary health care provider prescribes an intravenous fat emulsion solution for a client who will be receiving parenteral nutrition (PN). The nurse should explain to the client the administration of the fat emulsion solution is for which reason?
To provide essential fatty acids and additional calories
The nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The client suddenly complains of chest pain and dyspnea. The nurse should initially check which item?
Vital signs
The nurse has a prescription to give ear drops to a 2-year-old child. To administer the drops, the nurse should pull the pinna of the ear in which direction?
Downward and backward
The licensed practical nurse is assisting the registered nurse (RN) in the care of a child who is receiving a blood transfusion and notifies the RN if the child displays which signs/symptoms of fluid overload? Select all that apply.
Dry cough 5. Distended neck veins
A client who has undergone a cardiac catheterization using the right femoral approach is returned to the nursing unit. Thirty minutes later the client complains of numbness and tingling of the right foot. The pedal pulse is weak, and the foot is pale. The nurse notifies the registered nurse because these symptoms are consistent with which problem?
Femoral artery thrombus or hematoma
The nurse is monitoring a client at risk for placental abruption. Which findings are indicative of this complication? Select all that apply.
Fetal distress Dark red vaginal bleeding
The nurse should use which best method to open the airway of a victim who has a suspected neck injury?
Jaw thrust maneuver
A client with complaints of mild shortness of breath and weakness comes to the medical clinic. The nurse reviews the client's chart and immediately contacts the primary health care provider about which life-threatening finding? Refer to chart.
Potassium level
One unit of packed red blood cells has been prescribed for a client postoperatively because the client's hemoglobin level is low. The primary health care provider prescribes diphenhydramine to be administered before the administration of the transfusion. Why is this medication being given?
Prevent a rash and pruritus
The nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. What is the most appropriate action?
Pull back on the tube and wait until the respiratory distress subsides.
The nurse assisting in caring for a client hospitalized with acute pericarditis is monitoring the client for signs of cardiac tamponade. The nurse determines that which finding is unrelated to possible cardiac tamponade?
Pulse rate of 58 beats per minute
A client rings the call bell and complains of pain at the site of an intravenous (IV) infusion. The licensed practical nurse (LPN) inspects the site and determines that the client has developed phlebitis. The LPN should plan to avoid which action in the care of this client?
Prepare to start a new line in a proximal portion of the same vein.
The nurse employed in the pediatric unit working on the 11:00 pm to 7:00 am shift finds an infant unresponsive and without respiration or a pulse. The nurse plans to deliver chest compressions at which rate?
100 times per minute
A registered nurse has just hung a 250-mL bag of packed red blood cells (PRBCs) on a client. The licensed practical nurse assisting in caring for the client plans to remain with the client for at least how many minutes following the start of the infusion?
15 minutes
A client sustains a burn injury to the anterior right and left legs and perineal area. According to the rule of nines, the nurse should determine that this injury constitutes which body percentage?
19%
A hospitalized client with coronary artery disease complains of substernal chest pain. After checking the client's heart rate and blood pressure, the nurse administers nitroglycerin, 0.4 mg sublingually. After 5 minutes, the client states, "My chest still hurts." If the vital signs have remained stable, which action should the nurse perform?
Administer another nitroglycerin tablet.
A lethargic, yet easily aroused 6-year-old child is brought to the emergency department with a diagnosis of an overdose with diazepam. During the initial data collection, the nurse determines that the child's blood pressure and respirations are below normal for his age. The Glasgow Coma Scale is performed and reveals a score of 10. Based on this information the nurse determines that which problem should have the highest priority?
Altered respiratory status
A client undergoing a computed tomography (CT) scan develops chest pain, wheezing, and stridor after injection of contrast media. Which type of shock is this client most likely exhibiting?
Anaphylactic
The nurse on a telemetry unit checks a client's chart and notes that the potassium level is 6.3 mEq/L. Based on this laboratory result, which signs/symptoms should the nurse anticipate? Select all that apply.
Anxiety Electrocardiogram (ECG) changes
An automatic external defibrillator (AED) is available to treat a client who goes into cardiac arrest. The nurse uses this equipment to determine cardiac rhythm by doing which?
Applying the adhesive patch electrodes to the skin and moving away from the client
A toddler ingested drain cleaner found under the sink. The frantic mother calls poison control and asks what she should do because the child has started vomiting blood. What is the nurse's immediate response?
Ask the mother if the child is breathing on his own.
The nurse is caring for a client with liver disease. Laboratory studies are performed, and the client's serum calcium level is 13 mg/dL. The nurse checks to see that which medication is available in the stock medication supply area on the clinical nursing unit that may be needed to treat this calcium imbalance?
Calcitonin
The nurse is visiting an older client whose family has gone out for the day. During the visit, the client experiences chest pain that is unrelieved by nitroglycerin given by the nurse. Which action by the nurse would be appropriate at this time?
Call for an ambulance to transport the client to the emergency department.
A client has experienced pulmonary embolism. The nurse should assess for which symptom that is most commonly reported?
Chest pain that occurs suddenly
A client with a peripheral intravenous (IV) site calls the nurse to the room and tells the nurse, "The IV is not running right." Which findings would indicate an infiltrated IV? Select all that apply.
Cool to touch Swelling at the site May not have a blood return
Intravenous (IV) fluids have been infusing at 100 mL/hour via a central line catheter in the right internal jugular for approximately 24 hours to increase urine output and maintain the client's blood pressure. Upon entering the client's room, the nurse notes that the client is breathing rapidly and coughing. For which additional signs of a complication should the nurse assess based on the previously known data?
Crackles in the lungs
A client with a Sengstaken-Blakemore tube in place to treat esophageal varices suddenly becomes restless, the heart rate and blood pressure increase, and the client's pulse oximetry reading is decreasing. The nurse calls for the registered nurse and plans to take which immediate nursing action?
Cut the tube, and pull it out.
The nurse is caring for a client with a multilumen catheter and is monitoring for signs of an air embolism. Which signs and symptoms would be noted in this complication? Select all that apply.
Cyanosis Chest pain Coughing A churning "windmill" sound heard over the right ventricle on auscultation
An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription?
Delivery of the fetus
The nurse enters a client's room to check the client who began receiving a blood transfusion 45 minutes earlier. The client is flushed and dyspneic. The nurse listens to the client's lung sounds and notes the presence of crackles in the lung bases. The nurse determines that this client is most likely experiencing which complication of blood transfusion therapy?
Fluid (circulatory) overload
The nurse administering medications to a client notes a prescription to give a subcutaneous dose of heparin sodium. The nurse should perform which action to give this medication safely?
Give the injection using a 25- to 27-gauge, ½-inch needle.
A client suffered smoke inhalation and burns to the anterior trunk during a house fire. The nurse reviews the plan of care and notes that the client has an airway problem. Which findings support an airway problem? Select all that apply.
Hoarse voice Guttural respiratory sounds
An adult client is admitted to the emergency department with acute extensive partial thickness burns to the lower extremities. The nurse anticipates the primary health care provider will initially prescribe which medications and route for pain control? Select all that apply.
Hydromorphone intravenouslyb Morphine sulfate intravenously
During the emergent phase after a major burn injury, which abnormalities should the nurse expect to note?
Increased hematocrit and increased potassium
A client wishes to donate blood for a family member and asks the nurse about the procedure for identifying compatibility. The nurse tells the client that which test will be done to test compatibility?
Indirect Coombs
A comatose client received therapeutic hypothermia after a cardiac arrest. The nurse anticipates which primary complications associated with this treatment? Select all that apply.
Infection 2.Bleeding Metabolic and electrolyte disturbances
A 50-year-old client with a history of cardiac disease has been admitted to the intensive care unit (ICU) with a diagnosis of acute alcohol withdrawal. Which initial client data should the nurse expect to find? Select all that apply.
Insomnia Diaphoresis 4.Tachycardia Increased serum total bilirubin
A client in the clinical unit who is allergic to shellfish unknowingly ate a dish brought by a friend that had shellfish as an ingredient. The client quickly develops anaphylaxis. The nurse should focus on which intervention first until additional help arrives?
Maintaining a patent airway
A client is admitted to the emergency department with a diagnosis of drug-induced anxiety related to over ingestion of his prescribed antipsychotic medication. Which important piece of information should the nurse obtain initially?
Name of the ingested medication and the amount ingested
The nurse is collecting data on a client who sustained circumferential burns of both legs. The nurse should check which first?
Peripheral pulses
The nurse is caring for a client in the critical care unit. The nurse is reviewing the Critical Care Family Needs Inventory. The nurse knows that the most important issues of family members of critically ill clients include which factors? Select all that apply.
Receiving assurance 2.Receiving information 3.Having support available 4.Remaining near the client
An emergency department nurse is assigned to assist in caring for a client who has suffered a head injury following a motor vehicle crash. The nurse understands that the initial data collection should focus on which sign/symptom?
Respiratory status
An adolescent is admitted to the pediatric intensive care unit after suffering a seizure at school. She is alert on admission and tells the nurse that she has asthma and takes theophylline every day. She has a heart rate of 116 beats per minute with some shortness of breath. She also is complaining of nausea and vomiting. Which should the nurse suspect as the reason for the complaints that were gathered during the data collection process?
The child might have a toxic theophylline level.
The nurse assists in developing a plan of care for a client admitted to the hospital with an acute myocardial infarction (MI). Which is the priority problem during the acute phase?
The client's pain
The nurse collecting data on a client during the second stage of labor notes a slowing of the fetal heart rate (FHR) with a loss of variability and determines that these are indicators of possible complications. Which priority interventions should the nurse perform?
Turn client to her side and administer oxygen by mask at 8 to 10 L/min.
The nurse is assisting with caring for a client with abruptio placentae. While caring for the client, the nurse notes that the client begins to develop signs of shock. The nurse should take which action first?
Turn the client onto her side.
A licensed practical nurse (LPN) is a certified basic life support (BLS) instructor. The LPN is conducting a BLS recertification class and is discussing automated external defibrillation. A member of the class asks the LPN to identify the correct location for the placement of conductive gel pads to treat ventricular fibrillation. The LPN tells the class that the conductive gel pads are placed in which location on the client's chest?
Under the right clavicle and to the left of the precordium
An emergency department nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area. The client sustained the burn from a home fire that occurred in the basement. Which data would indicate that the client sustained a respiratory injury as a result of the burn?
Use of accessory muscles for breathing
The nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to check which item?
Vital signs
The nurse assisting in caring for a client with a myocardial infarction is monitoring for cardiogenic shock. The nurse should monitor for which peripheral vascular symptoms?
Cool, clammy skin with either weak or thready pedal pulses
The nurse is caring for a client who has just been admitted to the nursing unit after receiving flame burns to the face and chest. The nurse notes a hoarse cough, and the client is expectorating sputum with black flecks. The client suddenly becomes restless and his color is becoming dusky. Based on this data, which interpretation should the nurse make?
The burn has probably caused laryngeal edema, which has occluded the airway.
The nurse evaluates the client following treatment for carbon monoxide poisoning. The nurse should document that the treatment has been successful if which result is obtained?
The carboxyhemoglobin levels are less than 5%.
A client who is receiving a blood transfusion pushes the call light for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. How should the nurse correctly interpret these findings?
Transfusion reaction
The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to attach the distal end of the IV tubing to a needleless device, the tubing drops and hits the top of the medication cart. Which is the appropriate action by the nurse?
Change the IV tubing.
The nurse is caring for a cardiac client who has recently displayed this monitored rhythm. Which actions by the nurse are most appropriate? Refer to figure. Select all that apply.
Check all telemetry leads. 2.Check blood pressure (BP). Obtain stat electrocardiogram (ECG). Assess client's level of consciousness (LOC).
The nurse enters a client's room and finds the client slumped down in the chair. Breathing is shallow and a pulse is present. Based on this data, the nurse determines that which action is the priority?
Check the vital signs and level of consciousness.
The nurse is assigned to care for a client being admitted to the mental health unit following a suicide attempt. The client attempted the suicide by lacerating both wrists. Which is the initial nursing action upon admission of the client?
Check the wound sites.
A primary health care provider prescribes a parenteral nutrition solution to start at 50 mL/hr by infusion pump via an established subclavian central line. After 2 hours of initiating the parenteral nutrition infusion, the client suddenly complains of difficulty in breathing and chest pain. Which action would the nurse prepare to do first?
Clamp the parenteral nutrition infusion.
When a client progresses from preeclampsia to eclampsia, which is the nurse's first action?
Clear and maintain an open airway.
A client is scheduled for insertion of a peripherally inserted central catheter (PICC), and the nurse explains the advantages of this catheter. Which statement by the client indicates a lack of understanding about this type of catheter?
It is specifically designed for short-term use.
The nurse is caring for a client who had a small bowel resection the previous day and has continuous gastric suction attached to the nasogastric tube. Which intravenous solution should the nurse anticipate to be prescribed for the client?
Lactated Ringer's solution
A client newly admitted to the labor unit reports to the nurse that she felt a large gush of fluid before arriving at the hospital. The nurse checks the client and notes that the umbilical cord is protruding from the vagina. Which action should the nurse take first?
Place the client in the Trendelenburg position.
A client receiving total parenteral nutrition (TPN) is demonstrating signs and symptoms of an air embolism. Which action should the nurse take first?
Place the client on the left side with the head lowered.
A client who is receiving antineoplastic medication by the intravenous (IV) route complains of pain at the insertion site of the IV. The nurse inspects the site and finds the area is swollen and reddened. The nurse further observes that the solution is no longer infusing. The nurse immediately takes which priority nursing action?
Notifies the registered nurse (RN)
The nurse is caring for a client who has bilateral vocal cord paralysis. The client begins to experience severe dyspnea; the nurse listens to the client's breath sounds and hears this sound. (Refer to audio.) Which intervention should the nurse take immediately?
Notify the registered nurse.
The nurse discovers an unresponsive, breathing newborn infant. To assess circulatory status, the nurse should palpate which arterial pulse area?
Brachial
The nurse in the emergency department is listening to the breath sounds of a client with respiratory distress and hears this sound. (Refer to audio.) The nurse determines that this finding is characteristic of which disorder?
Bronchitis
An adult client presents to the emergency department (ED) with complaints of substernal chest pain and is taken directly to a stretcher in the department. Which priority intervention should the nurse undertake?
Obtain an electrocardiogram (ECG).
A toddler is rushed to the emergency department by her father, who states that he found the child sitting on the floor with an empty bottle of vitamins. He is not sure how many vitamins were in the bottle. The child is responsive but crying. What is the nurse's immediate action?
Assess the child and take the vital signs.
The nurse is assisting in monitoring a client who is receiving a transfusion of packed red blood cells. Before leaving the room, the nurse tells the client that it is important to immediately report which sign if it occurs?
Backache
The nurse is monitoring a child who is receiving calcium disodium edetate for the treatment of lead poisoning. The nurse reviews the laboratory results of the child during treatment with this medication and is particularly concerned with monitoring which laboratory test result?
Blood urea nitrogen
The nurse is suctioning an endotracheal tube (ET) for an intensive care unit client who is being mechanically ventilated. Five minutes after suctioning, which primary outcomes should tell the nurse that the suctioning has been successful? Select all that apply.
Clear lung sounds 2.Increase in O2 saturation Heart rate on monitor within normal limits
The nurse determines that which client is most likely to be a candidate for cardioversion?
Client with unstable rapid atrial fibrillation
A client has sustained full-thickness circumferential burns of the trunk. Which should be the priority concern of the nurse?
Client's ability to adequately ventilate
The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the primary health care provider's prescriptions and should question which prescription?
Obtain equipment for a manual pelvic examination.
The nurse is initiating cardiopulmonary resuscitation on an adult client. The nurse should place the hands in which position to begin chest compressions?
On the lower half of the sternum
An automatic external defibrillator (AED) interprets that the rhythm of a pulseless client is ventricular fibrillation. The nurse takes which action next?
Orders personnel away from the client, charges the machine, and depresses the discharge buttons
A client who weighs 50 kg has arrived in the emergency department complaining of severe chest pain. The telemetry monitor shows an evolving anterior myocardial infarction (MI). The nurse anticipates that the primary health care provider will initially prescribe which treatments? Select all that apply.
Oxygen 2 L, per nasal cannula 2.Chewable aspirin 324 mg, oral 3.Nitroglycerin 0.4 mg, sublingual Morphine sulfate 4 mg, intravenously
A licensed practical nurse (LPN) assisting a registered nurse in the cardiac care unit (CCU) prepares to admit a client with a diagnosis of myocardial infarction (MI). The LPN should be certain to have which item(s) readily available on the unit when the client arrives by stretcher?
Oxygen cannula and flowmeter
The nurse is assisting in caring for a client who is receiving a dose of nalmefene intravenously to treat opioid overdose. The nurse plans to have which supplies available as supportive equipment in case it is needed?
Resuscitation equipment
The nurse is caring for a client who was admitted to the maternity unit at 8:00 am with contractions occurring every 2 minutes, lasting 1½ minutes, and who is dilated 4 cm with a cervical effacement of 60%. At 10:30 am, the contractions cease. The client reports chest pain and manifests signs and symptoms of shock. The nurse quickly plans care, suspecting which complication?
Ruptured uterus
A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 15:00. The nurse, making rounds at 15:45, finds that the client is complaining of a pounding headache, is dyspneic with chills, is apprehensive, and has an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action?
Shut off the infusion.
A client uses the call system to notify the nurse to say that "the IV hurts and my left hand is swollen." The nurse assesses the site and determines infiltration has occurred. In order of priority, which actions should the nurse take? Arrange the actions in the order they should be performed. All options must be used.
Stop the infusion. Remove the intravenous catheter. Apply a compress to the site. Notify the registered nurse to start a new IV on the right extremity.
The critical care nurse is caring for a client with a subclavian central line catheter. The nurse knows that a specific central-line bundle was developed to reduce the client's risk for developing a catheter-related bloodstream infection (CLABSI). The interventions include which essential actions? Select all that apply.
Strict hand washing Optimal catheter site selection 5.Strict sterile technique with maximal barrier precautions during placement
A nursing student is assisting the clinic nurse with the administration of immunizations in the well-baby clinic. The student is asked to administer a measles, mumps, and rubella (MMR) vaccine to a child and prepares to administer the vaccine in which way?
Subcutaneously in the upper arm
The nurse is caring for a new postoperative client and is monitoring the client for signs of shock. The nurse monitors for which signs of this postoperative complication?
Tachycardia, cold skin, and hypotension
The emergency department nurse is caring for a child brought to the emergency department following the ingestion of approximately one half bottle of acetylsalicylic acid (aspirin) 10 minutes before arrival. Which should the nurse anticipate as the likely initial treatment?
The administration of activated charcoal
The nurse has been instructed to remove an intravenous (IV) line. The nurse removes the catheter by withdrawing the catheter while applying pressure to the site with which item?
The nurse has been instructed to remove an intravenous (IV) line. The nurse removes the catheter by withdrawing the catheter while applying pressure to the site with which item?
The nurse is assisting with caring for a client who is receiving intravenous fluids and who has sustained full-thickness burn injuries of the back and legs. The nurse understands that which would provide the most reliable indicator for determining the adequacy of the fluid resuscitation?
Urine output
