Elsevier EAQ

Which client condition would the triage nurse provide care for first?

Chest pain with diaphoresis

Under which emergency severity index (ESI) level would the nurse triage the client who incurred multiple traumas after a bus crash and whose vital function is threatened?

ESI- 2

Which statement about radiological dispersal devices (RDDs) made by the nursing student indicates effective learning?

Ionizing radiation released by an RDD may cause immediate serious illness to people nearby

Which nursing intervention would be the priority for an older client with depression who is prescribed a tricyclic antidepressant?

REquest that the health care provider change the medication

Which action by a client with asthma indicates that the client teaching about use of a peak flow meter has been effective?

Uses a quick relief inhaled medication when peak flow is in yellow zone

According to the disaster triage tag system, which client has been correctly tagged?

b- open fracture at elbow- Yellow

Which personal protective equipment would the nurse use when giving a bath to a client with acquired immunodeficiency syndrome (AIDS), pneumonia, and AIDS wasting syndrome with fecal incontinence? Select all that apply. One, some, or all responses may be correct.

-Goggles -Surgical Mask -Gown -Gloves

In which order would the nurse follow disaster management steps after a group of clients injured during a wildfire are admitted to an emergency unit?

1. Designing a plan to structure the response and assess risk 2. Attempting to limit a disaster's impact on human health 3. Actual implementing of the disaster plan 4. Focusing actions on stabilizing the community 5. Evaluating the response effort to prepare for the future

Which problem would the nurse rank as high priority when planning care for a group of clients? Select all that apply.

1.Complaints of chest pain following ambulation in the hallway 2.Decreased levels of consciousness after an automobile accident 3.Respiratory depression after narcotic pain medication administration

Once a client admitted with shock secondary to severe gastrointestinal (GI) bleeding is stabilized, which action would the nurse take?

Take a blood sample for laboratory test

Which potential life-threatening conditions would be considered during the primary survey for a client admitted after a fire accident? Select all that apply. One, some, or all responses may be correct.

-Shock -Inhalation injury -Direct cardiac injury

Using the Five-Level Emergency Severity Index (ESI), which client would the triage nurse designate as needing to receive prioritized care when triaging clients in the emergency department?

A school-age client with asthma presenting with dyspnea

Which action by nursing staff during a facility fire drill requires correction?

Use an ABC extinguisher to put out a small trash can fire before evacuation

Based on laboratory values, which client's needs would the nurse address first?

Client B: A1C%: 6.8Fasting plasma glucose level (mg/dL): 130Two-hour plasma glucose level (mg/dL): 200

Based on the data in the table, which client who arrived at the hospital after a large-scale disaster is appropriately tagged according to the disaster triage tag system?

Client C = Black= 90% of body with full thickness burns

Which intervention would the nurse perform while caring for a preschooler with lead poisoning? Select all that apply. One, some, or all responses may be correct.

Prevent further lead exposure Identify the sources of lead in the environment ADminister chelation therapy

In which order based on priority would the nurse perform interventions for a severely traumatized client with difficulty breathing because of debris in the mouth, external hemorrhaging, symptoms of severe hypoglycemia, and bruises on the skin?

1. Remove the debris from the mouth (Airway) 2.Apply pressure bandages to the bleeding areas 3. Administer intravenous glucose 4. apply bandage on the bruises

A client enters the emergency department reporting shortness of breath and epigastric distress. Which would be the triage nurse's first intervention?

Provide the client with oxygen

The emergency department nurse would provide immediate care based on priority to the client with which condition?

Repeated tonic-clonic seizures

Which intervention would the nurse include when teaching a client about self-care after mastectomy to prevent infection and lymphedema? Select all that apply.One, some, or all responses may be correct.Which client would the nurse see first after receiving reports on four clients who are postnephrostomy tube placement?

The client with cloudy urine in drainage bag

Which beliefs or situations are barriers to effective delegation by the registered nurse (RN)? Select all that apply.One, some, or all responses may be correct.

The nurse believes delegation is too time-consuming. The nurse lacks confidence in the delegatee's abilities. The nurse overburdens the delegatee with too many tasks.

Which intervention would be in the plan of care of a client with kidney dysfunction who is about to undergo renal testing using a contrast medium? Select all that apply. One, some, or all responses may be correct.

-Assessing the client for a history of cirrhosis -Asking the client about shellfish allergies -Evaluating the cleints hydration status by checking BP and RR

Which client would be triaged under emergency severity index (ESI)-1 based on stability in vital function and life threat?

Client A = Cardiac arrest due to severe respiratory depression

Which client would the nurse categorize in an emergent level based on condition according to the 3-tiered triage system?

Client A. Respiratory Distress

Which clinical manifestations would the nurse monitor for in a toddler during the latency period after a suspected ingestion of a poisonous plant? Select all that apply. One, some, or all responses may be correct.

Fever Seizures Bleeding

A client with Laënnec cirrhosis has a Sengstaken-Blakemore tube in place. The client becomes increasingly confused and tries to climb out of bed. The client's breath becomes fetid. Which is the nursing priority?

Implement fall precautions and/or prevention measures

Which intervention would be the priority for the nurse to incorporate into the plan of care for the client status post mastectomy and breast augmentation receiving anthracycline chemotherapy?

Instructing the client to report a chronic cough and shortness of breath

When providing care for a client during the first few hours after admission to the burn unit with full-thickness burns of the trunk and head, which goal is the nurse's priority during the emergent phase of this injury?

Managing fluid loss

Which assessment finding during the administration of intravenous penicillin would prompt the nurse to stop the infusion? Select all that apply. One, some, or all responses may be correct.

-Hives -Itching -Skin rash -SOB

Which conditions of clients who have been exposed to cold temperatures in a snowstorm put them at a high risk of sustaining cold injuries? Select all that apply. One, some, or all responses may be correct.

-Hypoglycemia -Opiod medication use -A heavy smoker for years

Which nursing action is most important for a client with urinary retention related to benign prostatic hyperplasia who has a secondary diagnosis of delirium related to urosepsis and a prescription for the insertion of an indwelling urinary retention catheter?

Determine whether any unsafe behavior pattern exist

When interviewing and assessing a 17-year-old client, which finding alerts the nurse to explore substance abuse with the adolescent? Select all that apply

Failing grades Blood spots on clothing Absenteeism from school Long-sleeved shirts in warm weather

Which clinical manifestations would the nurse monitor for in a toddler 3 days after ingesting a poisonous substance? Select all that apply. One, some, or all responses may be correct. Lethargy Jaundice Renal failure Hypoglycemia Productive cough

Lethargy Jaundice Hypoglycemia

Which interventions would the nurse include in the plan of care for a client with depression who is at risk for self-directed violence? Select all that apply. One, some, or all responses may be correct.

Make rounds q15 min Assign a room

Which antenatal precaution would be taken to minimize the risk of medication-induced teratogenesis? Select all that apply. One, some, or all responses may be correct.

Preventing conception Discontinuing teratogenic medications during pregnancy if possible Avoiding the use of nonessential medications during pregnancy Discussing pregnancy termination if the medication that causes teratogenicity cannot be withheld Educating the client about the risks associated with teratogenic medication

Which effect of diazepam administered to a client with status epilepticus would the nurse anticipate in addition to decreasing central neuronal activity?

Relaxing of peripheral muscles

Which parental activities would the nurse recognize as placing a preschooler at risk for bodily harm? Select all that apply. One, some, or all responses may be correct. The parent supervises the child swimming from the kitchen. The parents leave medications within reach of the child. A parent tricks the child into eating a vitamin by saying, "This is candy.

The parent supervises the child swimming from the kitchen. The parents leave medications within reach of the child. A parent tricks the child into eating a vitamin by saying, "This is candy.

The nurse is caring for a client who is displaying increased agitation and anger that is not responding to de-escalatory techniques. Which interventions would the nurse perform next to maintain client and staff safety? Select all that apply. One, some, or all responses may be correct.

-Apply restraints. -Place in seclusion. -Administer medication.

Which strategies will promote safety and quality of client care on the unit? Select all that apply. One, some, or all responses may be correct.

-Communicate with clarity and precision when designing multidisciplinary plans of care. -Create a safety huddle so all health care professionals are aware of the clinical objectives. -Conduct communication simulations to increase knowledge about expertise of other health care disciplines.

Which action is the nurse's responsibility when administering prescribed opioid analgesics? Select all that apply. One, some, or all responses may be correct.

-Count the clients respiration -Document the intensity of the clients pain -Verify the number of doses in the locked cabinet before administering the prescribed dose

Which statement by the nursing student indicates a need for further teaching about disaster management on how to cope effectively after a disaster event? Select all that apply. One, some, or all responses may be correct.

-I will work for 15 hours per day -I will walk about my feeling with my family

Which personal protective equipment would the nurse use when giving a bath to a client with acquired immunodeficiency syndrome (AIDS), pneumonia, and AIDS wasting syndrome with fecal incontinence? Select all that apply. One, some, or all responses may be correct.

-Sexual Dysfunction -Insomnia and restlessness -Urinary Frequency

Which statements would the nurse include in teaching about the Hospital Incident Command Systems (HICS)? Select all that apply. One, some, or all responses may be correct.

-Specific job action sheets are distributed to all HICS personnel. -The emergency operations center or command center is established by HICS personnel. -All internal requests and communication with field teams should be coordinated through the emergency operations center.

Which client activity warrants the highest priority for education about health promotion to prevent head and neck cancer? Select all that apply. One, some, or all responses may be correct.

1. Chews Tobacco 2. Multiple sex partners 3. History of alcohol abuse for 5 years

In which order would the nurse perform the following interventions for a client with injuries from a motor vehicle accident?

1. Control external bleeding 2. Elevating the injured limb 3. Apply ice packs 4. Monitor for temperature elevation

After completing education on accidental poisoning in the home for the parent of a toddler, which parent statements would concern the nurse? Select all that apply.One, some, or all responses may be correct

A. My cosmetics are in my purse B. I only keep children's chewable vitamins on the counter D. I make sure all of m medications are stored in a bottle with childproof cap

A woman who misused illicit substances during pregnancy gave birth to a neonate who experiences withdrawal. Which nursing intervention would be beneficial to the neonate? Select all that apply. One, some, or all responses may be correct.

Administering neonatal doses of the dependent substance Monitoring the neonate closely Educating the mother about the risks to the neonate

Which criteria would the nurse assess before discharging a pediatric client who had received moderate sedation? Select all that apply. One, some, or all responses may be correct. Assess gag reflexes.

Assess gag reflexes. Ensure pain and ambulation are at a base level. Ensure an adult is present with the child and can remain with them for at least two half-lives of the anesthetic medication.

Which action would the nurse take when a client arrives for an influenza vaccination and reports a low-grade fever with a cough?

Check the temperature and current history.

Which client would be given immediate care based on priority?

Client D: Chemical Burns; Degeneration of exposed tissues, respiratory distress

Which type of fracture does the client admitted to the emergency department after a bomb blast who is given a yellow tag most likely have?

Compound fracture

Which action would the nurse take to decrease the risk of ventilator-associated pneumonia (VAP) for a client receiving mechanical ventilation?

Elevate the head of the bed to at least 30 degress.

Which initial action would the nurse take in light of the information elicited during the assessment interview?

Encourage the client to express feelings concerning the accident and wife's death

The nurse admits a client with severe preeclampsia to the high-risk prenatal unit. Which is the next nursing intervention after the vital signs have been obtained?

Establishing an IV lines

Which condition would the nurse keep in mind while performing a rewarming procedure for a client with severe hypothermia?

The client should be monitored for a after drop during rewarming.

Which intervention promotes safe movement of objects to protect the back? Use handles or grips on the object.

Use handles or grips on the object.

Which action would the nurse take first for a client with dyspnea and unilateral absence of breath sounds on auscultation?

Prepare for needle thoracostomy

Which nursing action is correct when the state department of health recommends administering tetanus vaccine to pregnant women who have not received it previously?

administering the vaccine to pregnant women at any gestational age

Among clients with sleep disturbances after surviving a large-scale disaster, which client is most likely contraindicated for further evaluation using the Impact of Event Scale-Revised (IES-R)?

Client A= 50 years old= Alzheimer's disease

The client with which change in vital signs measurements would be treated first to ensure safety?

Client B. = Vital are RR: 17--> 10 HR: 72-->120 bpm

A pregnant client is admitted with abdominal pain and heavy vaginal bleeding. Which is the immediate nursing action?

Establishing IV access

Which action would the nurse implement for a client who has overdosed on barbiturates? Select all that apply. One, some, or all responses may be correct.

1.Maintain Airway 2. Give activated charcoal 3. Give intravenous fluids

Which assessment finding supports the diagnosis of neuroleptic malignant syndrome (NMS) in a client with schizophrenia being treated with haloperidol? Select all that apply. One, some, or all responses may be correct.

1.Rigidity 2. Sweating 3.Temperature 105.8°F (41°C)

The nurse educator is presenting to a group of nurses about the use of de-escalatory techniques. Which actions would the nurse include in the presentation? Select all that apply. One, some, or all responses may be correct.

-Identify client needs -Determine stressors and triggers -Refrain from arguing with the client

The nurse is assessing a client with a history of aggression and inappropriate anger issues. Which findings indicate the client is escalating and requires immediate intervention to prevent harm to others? Select all that apply. One, some, or all responses may be correct.

-Mumbling to oneself -Pacing back and forth -Maintaining strong eye contact

Which adverse effect would prompt the nurse administering a course of aminoglycoside treatment to a client with Klebsiella infection to hold treatment and contact the health care provider? Select all that apply. One, some, or all responses may be correct.

-Vertigo -Tinnitus -Dizziness -Persistent HA

Which statement made by the nurse regarding the prevention of human immunodeficiency virus (HIV) transmission by health care workers is correct? Select all that apply. One, some, or all responses may be correct.

1. "If I perform exposure-prone procedures, I should know my HIV antibody status." 2. "I should identify exposure-prone procedures by institutions where they are performed." 3. "If I have exudative lesions or weeping dermatitis, I should not perform direct client care or handle client care equipment."

Which client condition would the triage nurse classify as needing immediate care? Select all that apply. One, some, or all responses may be correct.

1. ACtive hemorrhage 2. Substernal chest pain

In which order would the nurse provide care based on client condition and the 5-level triage system?

1. Cardiac arrest 2. Chest pain to ischemia 3. Hip Fracture 4. Minor burns

Which statements by the nurse while teaching students about viable pregnancy relate to preterm labor? Select all that apply. One, some, or all responses may be correct

2 The treatment for preterm labor includes bed rest and hydration. 3 Preterm labor before the 20th week is indicative of a nonviable fetus.

The nurse has 100 units regular insulin in 100-mL normal saline for infusion. There is a prescription to calculate the infusion rate based on the client's glucose levels using the formula: Glucose mg/dL ÷ 100 = units/h. The client's glucose level is 350 mg/dL. The insulin will need to infuse at how many milliliters per hour? Record your answer using one decimal place.

3.5

The health care provider has prescribed an intravenous piggyback (IVPB) of 1200 mg vancomycin, which must be added to 50 mL of 5% dextrose in water (D W). The nurse has a solution contains 1 gram of vancomycin per 3 mL. How much antibiotic solution will be added to the 50 mL of D W? Record your answer using one decimal place. m

3.6

Which action is contraindicated in the care of a client prescribed chlorpromazine for schizophrenia who experiences involuntary choreoathetotic movements of the tongue and face ?

Administer diphendrymine

Which nursing intervention is priority when caring for a client with schizophrenia who begins to have difficulty breathing and whose eyes begin to roll up after receiving the first dose of chlorpromazine?

Administer intravenous benztropine

Which medication would the nurse anticipate developing a teaching plan for when a client reports becoming panicked and having an irrational fear of talking in public?

Alprazolam

Which feeling would the nurse be trying to prevent in other clients when setting limits on a client diagnosed with bipolar disorder, manic episode, who has a superior, authoritative, and condescending manner?

Anger

An ultrasound scan of a baby shows the proximal tubule in the kidney is not well developed. Which medication treatment in the mother during pregnancy would the nurse identify as a potential cause for this condition?

Angiotensin-converting enzyme inhibitors

Which action by the client indicates the need for further instruction on insulin administration?

Aspirate before administering the does

A client's infusion of vesicant intravenous solution through a short peripheral catheter leaks into their extravascular tissue. After stopping the infusion and disconnecting the administration set, which action would the nurse take next?

Aspirate the medication from a short peripheral catheter

Which intervention is most important for maintaining the safety of a restrained client?

Assess every 15 minute

A 500-mL bag of 5% Dextrose and 0.45% Sodium Chloride injection USP (D5 in ½ NS) is hung at 1:00 AM and is to infuse at 45 mL/h for a child receiving fluid replacement. At 6:00 AM the nurse notes there is 125 mL left in the bag. The nurse concludes which item is correct regarding the amount left in the bag?

Is more than the child should have received

Which medication can cause hemolytic anemia?

Methyldopa

Which action would the nurse take when preparing to discharge a 3-day-old newborn whose birth weight was 3800 grams and who currently weighs 3344 grams?

Notify the health care provider

A pregnant client is prescribed heparin to prevent the risk of thromboembolism. Which is a possible adverse effect of this medication when used during pregnancy? Select all that apply. One, some, or all responses may be correct.

Osteoporosis Increased risk of serious bleeding Compression fractures of the spine

Which primary intervention would the nurse perform on a diabetic client who survives a fire, but has a head injury, tachycardia, and pale and ashen-colored skin? Select all that apply. One, some, or all responses may be correct.

Placing the client in a cool environment Managing and maintaining airway-breathing-circulation Administering cool IV fluids

Which activities would the nurse perform to meet the client's safety and security needs based on Maslow's hierarchy of needs? Select all that apply. One, some, or all responses may be correct.

Positioning the bed in a low position and keeping the side rails up Monitoring vital signs, such as blood pressure to decrease the risk of falls Observing a client who has suicidal tendencies to prevent adverse incidents

Which of these clinical manifestations would the nurse report to the healthcare provider immediately in a client with preeclampsia?

Severe Headache

Which would the nurse include when teaching clients about the potentially serious consequences of using diuretics during pregnancy? Select all that apply. One, some, or all responses may be correct.

Severe hypovolemia Reduced placental perfusion

Which statement by a student indicates teaching about the administration of total parenteral nutrition (TPN) via a central venous access device/catheter was effective?

TPN is typically administered continuously, not intermittently.

Which uses of automated tracking systems with infrared and radiofrequency technology (RFT) would the nurse list for emergency departments during disaster treatment? Select all that apply

To track clients triage priority upon arrival To track interaction of clients with caregiver To portray the overall census and acuity of client

Which abnormal laboratory value can lithium cause?

White blood cells

Which nursing intervention would be implemented routinely in the immediate recovery period after a client has a vacuum aspiration abortion?

encourage the client to take the prescribed antibiotic medication

Which triage tag and client condition pair would the triage nurse assign?

major injuries with yellow tag

List suicidal behaviors in priority order, from highest risk to lowest risk

o Attempts at suicide o Suicidal gestures o Threats of suicide o Suicidal ideation ·

Which parental statement indicates to the nurse that additional teaching about accident prevention for toddlers is needed?

"I'll keep medications in a kitchen cabinet."

Place these nursing assessment questions in the appropriate order to best ensure safety for a client with suicidal ideations.

"Are you thinking about hurting yourself?" "Have you decided on a plan to harm yourself?" " What is your plan for killing yourself?" "How would you get what you need to end your life?"

A nurse provides instructions to a client who has glaucoma. Which statement made by the client after receiving the nurse's instructions indicates that the nurse needs to intervene? Select all that apply.

"I can lift objects that weigh more than 10 lb (4.5 kg)." "I should keep my head in a dependent position."

When a client has difficulty swallowing after a stroke, which action by the nurse would be most important in preventing pneumonia?

Having suction available during meals

The nurse manager is educating a group of nurses regarding older adults and the risk for suicide. Which factors would be included in this presentation? Select all that apply. One, some, or all responses may be correct.

- Loss of Independence -Chronic health conditions -Access to many medication

The nursing staff used seclusion for a client due to behavior that placed other clients and staff at risk for harm. Which intervention would the nurse perform first when reintegrating the client into the unit?

Discuss behavior that necessitated seclusion

Which question would the nurse ask before administering an adrenergic agonist to a client with increased intraocular pressure?

Do you take antidepressants

Which consideration would be included in the plan for deactivating the emergency plan after treating the major casualties? Select all that apply.

- Providing adequate rest periods to nurses -Washing, packing, and resterilizing the instruments trays -Reordering depleted supplies after the termination of the pplan

Which nursing assessment would performed by a nurse before administering intravenous (IV) infusion of potassium chloride (KCl) 40 mEq in 100 mL of 5% dextrose and water to be infused over 2 hours? Select all that apply. One, some, or all responses may be

- Urinary output -Last serum potassium level -Patency of the IV access

A client had a rubella infection (German measles) during the fourth month of pregnancy. At the time of the infant's birth, the nurse places the newborn in the isolation nursery. Which type of infection control precautions would the nurse institute?

Droplet

The nurse prepares a teaching plan for a client prescribed clomiphene citrate to treat anovulatory cycles. Which finding would the nurse instruct the client to report to the health care provider immediately?

Missed period

A few hours after being admitted to the hospital with a diagnosis of inevitable abortion, a client at 16 weeks' gestation begins to experience a bearing-down sensation and suddenly expels the products of conception in the bed. Which would be the nurse's immediate action?

Monitor and measure vaginal bleeding

When the nurse is caring for a client who had an open cholecystectomy, which assessment finding most indicates the need for action by the nurse?

Decreased breath sounds at lung base

Which statement by a staff member after an educational session on the use of adenosine for supraventricular tachycardia indicates that the teaching has been effective?

"We will need a crash cart available at the client's bedside."

When the registered nurse (RN) assigns the unlicensed assistive personnel (UAP) to obtain and record routine vital signs on all clients on the unit, what should the RN be sure to do? Select all that apply.One, some, or all responses may be correct.

-Validate willingness to accept the delegated task. -Convey unique client requirements, characteristics, or concerns. -State the exact task, how it is to be accomplished, and expected outcomes. -Specify concerns or emergency conditions that warrant prompt reporting.

Which initial nursing intervention is the most appropriate for a client who survived a fire in the hospital and is found to have neck trauma, dyspnea, gasping breathing, and is unable to speak? Select all that apply. One, some, or all responses may be correct.

-Performing Jaw-Thrust maneuver -Preparing to assist in performing endeotracheal intubation

Which client would benefit from the administration of prophylactic antibiotics? Select all that apply. One, some, or all responses may be correct.

-Pre-op hip replacement -COngenital bicuspid aortic valve -Current chemotherapy tx

Which conditions are triaged using the three-tier system as life-threatening conditions among a group of clients injured in a tornado? Select all that apply.

-Stroke -Active hemorrhage -Respiratory distress -Chest pain with diaphoresis

The nurse teaches an older adult client with kyphosis about self-care measures. Which statement by the client indicates effective learning?

I should sit in a supportive armchair

While reviewing the laboratory reports on a client with bipolar disorder, the nurse finds the client's lithium levels are 1.2 mEq/L (1.2 mmol/L). Which nursing intervention would be most appropriate in this client?

continue administering the drug

A client with congestive heart failure is receiving intravenous digoxin therapy. The registered nurse identifies which item on the client's care plan is appropriate for a licensed practical nurse (LPN) to perform? Select all that apply.

-Help the client ambulate when required -Monitor the client vital every 30 minutes -Administer adequate oral fluids to the client

arrange the steps involved in applying a surgical in the correct order

1.Find the top edge of the mask. 2.Hold the mask by its two strings or loops. 3.Secure the two top ties at the back of the head, with the ties above the ears. 4.Tie the two lower ties snugly around the neck with the mask well around the chin. 5.Gently pinch the upper metal band around the bridge of the nose.

A child with plumbism is prescribed edetate calcium disodium (calcium EDTA). Which assessment would be the most appropriate for the nurse to conduct before administering EDTA?

Checking for protein in the urine

Hypertension develops in a school-age child with acute glomerulonephritis. Which medication would the nurse anticipate providing teaching for?

Furosemide

Which action would the nurse use to minimize confrontation and the need for seclusion in a client with a conduct disorder?

Employing low expresses emotion

Which client would the nurse classify as requiring immediate care based on condition and stability?

1. Overdoes with bradypnea 2. Cardiac arrest 3. Chest pain due to ischemia 4. Hip Fracture ANswer Client B= Cardiac Arrest

Which is the priority nursing action immediately after the insertion of a subclavian central venous access catheter for a client who is to begin total parenteral nutrition (TPN)?

Auscultate the lung to evaluate breath sounds

Which intervention regarding preventing future infections are taught to a sexually active female client with a urinary tract infection? Select all that apply. One, some, or all responses may be correct.

Increase fluid intake Clean Perineum wiping front to back Empty the bladder before and after sex

Which client is contraindicated to receive contrast media

The client administered a dose of metformin this morning with a sip of water

Which condition in a client with carbon monoxide poisoning would be given priority nursing care?

Cardiopulmonary instability

Which client condition would the triage nurse classify as the lowest priority of care? Select all that apply. One, some, or all responses may be correct.

a. Cystitis b. Cold Symptoms

Which client would the triage nurse classify as requiring the least priority of care?

client D, foreign body aspiration/pneumonia

Which response would be given by a nurse caring for a client receiving corticosteroid therapy who states, "I have difficulty controlling my temper, which is so unlike me, and I don't know why this is happening."?

Inquire about mood swings

Which statements made by a natural disaster victim indicates the need for further teaching about the precautions to be taken to prevent infections? Select all that apply. One, some, or all responses may be correct.

"I will avoid ultraviolet pens." "I will avoid using toilet liners." "I will avoid using a camp stove to boil water."

Which information would the nurse provide a client beginning treatment with haloperidol to prevent injury?

Change position slowly

Which nursing action is the priority to include in a disaster plan for the radioactive dust and smoke that can cause illness from a radiological dispersal device?

Covering the nose

Which adverse effect of warfarin will the nurse identify as a reason for a client with a partial occlusion of the left common carotid artery to seek medical consultation? Select all that apply. One, some, or all responses may be correct.

- Hematuria -Hemoptysis -Vomiting coffee-ground emesis

Which statement by a client with rheumatoid arthritis prescribed ibuprofen 800 mg by mouth three times a day indicates that the nurse's education about the medication's side effects was effective? Select all that apply. One, some, or all responses may be correct.

- I need to report any dark tarry stools -I will need to stop taking this medication before any scheduled surgery

The nurse reviews the serum laboratory values of a client. The nurse suspects hypofunctioning of the adrenal gland based on which results? Select all that apply. One, some, or all responses may be correct.

- Increased Calcium -Decreased Cortisol -Decreased Sodium

The nurse is providing discharge instructions for a client receiving unsealed radioactive isotope. Which actions made by the client indicate an understanding of the instructions provided? Select all that apply. One, some, or all responses may be correct.

-Avoids contact with pregnant women -Takes laxatives 3 days after tx -Washes clothes separately from others

Which long-term care facility staff member statements indicate correct understanding of a disaster response plan for staff and residents? Select all that apply.

-We have to implement annual drills -The plan must include an evacuation plan

Which ophthalmic conditions can cause a client to have photophobia? Select all that apply. One, some, or all responses may be correct.

1. Chalazion 2. Trachoma 3. Keratoconjuntivitis sicca

Which nursing action would be the priority when providing care for a trauma client with a penetrating wound after the completion of the secondary survey?

1. Documenting the clients care 2. Administering tetanus prophylaxis to the client

In which order, from the most to the least urgent, would the nurse triage clients based on their conditions?

1. Overdoes and bradypnea 2. multiple traumas 3. Gynecological disorder 4. Simple laceration 5. Minor Burns

Which intervention would be a priority for the nurse to implement topromote client safety directly after esophagogastroduodenoscopy (EGD)? Select all that apply. One, some, or all responses may be correct.

1. Positioning to prevent aspiration 2. Monitoring for signs of perforation

In which order would the nurse implement the steps for cooling a client with heatstroke who has a a body temperature of 104°F (40°C) so that breathing and circulation are not impaired?

1. Remove Clients clothing 2. Palce Ice packs on the clients neck 3. immerse the client in cold water 4. Fan the client rapidly to aid in cooling by evaporation

Which statement made by a new nurse would indicate to the nurse mentor that additional teaching is needed regarding emergency treatment procedures for the local complication of intravenous therapy involving thrombosis? Select all that apply. One, some, or all responses may be correct. "I should lower the extremity of the client." "I should apply warm compresses to stabilize the clot." "I should apply cold compresses to decrease the blood flow." "I should use low-dose thrombolytic agent that can lyse the clot." "I should stop the infusion but keep the short peripheral catheter in pla

1. Should lower the extremity of the client 2. I should apply warm compress to stabilize the clot 3. I should stop the infusion but keep the short peripheral catheter in place

A client is to receive an antibiotic by intravenous piggyback (IVPB). The antibiotic is available in 50 mL of solution to infuse in 20 minutes. The drop factor of the IV set is 15 gtt/mL. The nurse will set the piggyback to flow at how many drops per minute? Record your answer using a whole number.

38

Which intervention would be the priority for the nurse to implement when providing care to a child brought to the emergency department with partial and full thickness burns of the lower extremities?

4.Starting an intravenous (IV) line with a large-bore catheter

When performing a rewarming procedure with warmed intravenous fluids for a client with severe hypothermia, which core temperature is lowest temperature in which the nurse would stop rewarming the client?

91.4

Which action would the nurse use when administering the allergen to a client who experiences severe anaphylactic reactions to insect venom when beginning allergen therapy?

Rotating the sites for each injection

Which nursing interventions would help ensure safe administration of antiepileptics to children? Select all that apply. One, some, or all responses may be correct.

Use a graduated device to deliver an oral dose Avoid carbonated beverages while taking valproic acid. Encourage the wearing of a medical alert bracelet. Maintain a record of symptoms of seizures before, during, and after treatment with antiepileptics.

A client who takes antipsychotic medications complains of painful muscle spasms. The nurse suspects that the client may have pseudoparkinsonism. Which medications are indicated to counter this condition? Select all that apply. One, some, or all responses may be correct.

a. Benztropine b. Trihexyphenidyl