Exam final

A nurse is preparing to administer transfusion of RBC's to a client who has heart failure. For which of the following manifestations should the nurse monitor to prevent fluid volume overload?

Dyspnea JVD Confusion

A nurse is collecting a medication history from a client that is scheduled to have a cardiac catheterization. Which of the following medications taken by the client interacts with contrast material in places to client at risk for acute kidney injury?

Metformin

A nurse is caring for a client with full thickness burns over 75% of the body. The nurse should use which of the following methods to monitor the cardiovascular system?

Monitor the pulmonary artery pressure

When developing the plan of care for an older adult client with acute kidney injury, the nurse understands that it is essential to consider which factor in the client's history?

Recent use of antibiotics

The nurse is assessing a client during hemodialysis. Which finding should the nurse report to the health care provider immediately?

Redness at insertion site

A nurse is caring for a client experiencing a traumatic brain injury. The nurse understands that which action is a priority when managing the risks of increased intracranial pressure?

Reduce environmental stimuli during care

A nurse is caring for a client with a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure? .

Restlessness

The nurse is caring for a client with coronary artery disease (CAD). Which long term outcome is most important for the nurse to consider?

Risk factor modification

A nurse is preparing to administer 50mg by intermittent IV bolus to a client with a seizure disorder. Which of the following actions should the nurse take?

Slow the injection if the medication crystallizes.

The nurse is caring for a client whose vital signs are monitored using invasive hemodynamic monitoring. Which action is most important for the nurse to implement to decrease the risk of infection?

Strict hand washing

A nurse is developing a plan of care for a client Who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support?

Talk with the client during wound care.

A nurse is teaching the family of a client who is receiving treatment for spinal cord injury with a halo fixation device. Which of the following statements should a nurse make?

The purpose of this device is to immobilize the cervical spine

Which statement by the client is most important for the nurse to communicate to the physical therapist when planning discharge care for a client who is recovering from an acute myocardial infarction?

"I used to be active when I was younger, but now I just get so weak."

A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/ml. How many ml should the nurse administer per dose?

0.2

A client comes to the emergency department (ED) with diaphoresis, nausea, and shoulder pain. What assessment data should the nurse obtain first?

12-lead ECG

Best indicator of GFR is

24-hour urine for creatinine clearance.

A nurse is caring for a patient post craniotomy for a subdural hematoma evacuation with an external ventricular drain (EVD) and Intracranial Pressure (ICP) monitoring. The patient's current blood pressure is 130/78 and ICP is 17. What is the CPP? (round to the nearest whole number)

78

A client with a diagnosis of heart failure has a hemodynamic monitor in place. Which central venous pressure reading would the nurse expect to see in this client?

8 mm Hg

A nurse in an emergency Department is preparing to administer alteplase to a client with an acute ischemic stroke. which of the following actions should the nurse plan to take?

Assess for signs and symptoms of bleeding during and after receiving the medication closely monitor the patient's vital signs Monitor patient neurologic status for improvement or for potential deterioration

The nurse is caring for a client being monitored by arterial pressure monitoring. The nurse notes a systolic pressure of 164 mmHg. What action should the nurse take first?

Assess the client.

A nurse in the emergency room is assessing a client brought in following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next?

Assess the cranial nerves.

*A nurse is caring for a client receiving rtPA. In planning care, the nurse knows that during the administration of this treatment, a neurological assessment should be conducted how frequently?

q15 for the first 2 hours

The most common manifestation of complications of meningitis is Increase ICP. Intervention is

reduce stimulus

a rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take?

Establish a plan of care with the client that sets attainable goals.

The nurse in the trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

Evaluate chest expansion

When assessing a female client for risk factors of coronary artery disease (CAD), the nurse should communicate which finding to the healthcare provider?

Family history of diabetes

Intervention for stroke:

Glucose check

A nurse is caring for a client who had a stroke involving a right cerebral hemisphere. The nurse should monitor for which of the following findings?

Poor impulse control

A nurse is caring for a client with ICP who is not responding to treatment. Pertinent assessment data is the image (you will get an image). What information takes precedence when communicating the client's status to the healthcare provider?

Possible development of Cushing Triad

The nurse is caring for a client requiring hemodynamic monitoring to evaluate cardiac output. The nurse understands that which factors are involved in cardiac output? [select apply]

Preload Afterload Heart rate Contractility Stroke volume FOR THE XAM THE OPTIONS WERE: RESPIRATION, BP, Heart rate, Cardiac output

The nurse is caring for a newly admitted client diagnosed with acute kidney injury. The nurse understands that the acute kidney injury is most likely related to a history of which condition?

Sepsis

The nurse anticipates that a client with which type of shock would be most likely to develop systemic inflammatory response syndrome (SIRS)?

Septic shock

A nurse is monitoring an older adult client with a myocardial infarction for the development of an acute kidney injury. Which of the following findings should the nurse identify as indicating an increased risk of acute kidney injury (AKI)?

Serum creatinine 1.8 mg/dL

A nurse in the intensive care unit (ICU) is caring for a client with a cerebral perfusion pressure (CPP) of 40 mmHg following a head injury. The nurse understands that the client may be experiencing which condition?

Severe brain hypoxia OR Intracranial hemorrhage. IDK cant find

A patient presents to the ED with a slurred speech and right sided weakness. Which action must the nurse perform first upon patient's arrival?

Transport patient to CT

Brain death:

apnea

Complications of Icp:

inadequate cerebral perfusion

The nurse is caring for a client with hypovolemic shock. The family member asks why the fluids are being warmed. What is the best response by the nurse?

"to prevent complications from hypothermia"

A nurse is preparing to administer Phenytoin 50 mg by intermittent bolus to a client who has seizure disorder. Which of the following action should the nurse take?

-Administer the medication over 1 minute

in the emergency department is caring for a client who has extensive partial and full thickness burn of the head neck and chest while planning the client's care the nurse should identify which of the following risk as a priority for assessment and intervention

-Airway obstructions

1. a nurse in an emergency dept. is preparing to care for a patient who being brought in with multiple system trauma following a motor vehicle crash which of the following should the nurse identify as a priority focus of care

-Airway protection

The nurse is assessing jugular venous pressure. In what order should the nurse proceed with the steps in the process? [place the steps in the correct order beginning with the first step] 3.place head of bed between 30-45 degrees. 2. Have client turn head slightly to the left. 6. Shine a pen light across the neck, assess for jugular venous distension at end of exhalation. 5.observe the highest point of pulsation in the internal jugular vein at end exhalation. 4. Measure the vertical distance between the pulsation and the angle of louis. 1. Add 5 cm to the measurement.

3.place head of bed between 30-45 degrees. 2. Have client turn head slightly to the left. 6. Shine a pen light across the neck, assess for jugular venous distension at end of exhalation. 5.observe the highest point of pulsation in the internal jugular vein at end exhalation. 4. Measure the vertical distance between the pulsation and the angle of louis. 1. Add 5 cm to the measurement.

A nurse is preparing to start an IV infusion of lactated ringers for a client that sustained a burn injury. The client is prescribed 5,200 mL of fluid over the first 24 hours. Using the Parkland method of fluid resuscitation, how many ml/hr should the nurse set the pump to infuse for the first 8 hr?

325

A nurse is admitting a client that sustained severe burn injuries. The nurse refers to the rule of nines to determine the total body surface area of the burn injury. What percentage of the body surface area should the nurse estimate the client has burned? [both legs front and back, back]

54%

A nurse is performing triage for a group of clients following a mass casualty incident. Which of the clients should the nurse plan to care for first?

A client experiencing a tension pneumothorax.

A nurse in the emergency Department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? SATA

Absence of bowel sounds weakened gag reflex hypotension

A nurse on the intensive care unit is caring for a client with severe traumatic brain injury and a cerebral perfusion pressure 59 mm Hg. which of the following actions should the most take?

Adjust the client's head of the bed

A nurse in the emergency Department is caring for clients with a 30% burn injury to the lower extremities. which of the following interventions should the nurse perform first?

Administer IV fluids

Primary survey:

Airway

A nurse in the ER is triaging clients following a mass casuality event. The nurse should identify which of the following clients as emergent? A) A client that reports severe flank pain radiating to the groin B) A client who has a punctured femoral artery C) A client with multiple fracture D) A client with a red rash over his abdomen

B) A client who has a punctured femoral artery

3 finding of the Cushing triad late sign of ICP.

BRADYCARDIA bradypnea Hypertension

The nurse is caring for a client with acute kidney injury. The nurse should anticipate which abnormal assessment finding?

BUN/creatinine ration 25.1

When providing care for an older adult who has undergone cardiac catheterization and angiography, which action is most important for the nurse to implement?

Bedrest with the head-of-bed elevation no higher than 30 degrees

A nurse is caring for a client with acute kidney injury (AKI). The nurse understands which of the following etiologies contributes to post-renal AKI? SATA

Benign Prostate hyperplasia Prostate cancer renal calculi.

The nurse is evaluating a client who is being treated for shock. Which findings indicates an improvement in the client's condition? [select all that apply]

Blood pressure 120/70 Bun of 12 mg/dL

The nurse is caring for a client admitted with sepsis. Which assessment finding indicates to the nurse that the client has progressed to the stage of progressive shock?

Blood pressure of 80/66

A nurse is caring for a unresponsive, critically ill client in the medical ICU. The client's power of attorney decides to discontinue life sustaining therapies of the client in accordance with the client's advance directive. The nurse understands this action is defined as which of the following: A) Do not rescuscitate B) Euthanasia C) To withhold or withdrawn certain treatments D) Physician Assisted Suicide

C) To withhold or withdrawn certain treatments

The nurse is caring for a client in hypovolemic shock. The nurse should anticipate which central venous pressure (CVP) reading for this client?

CVP reading of 1 mmHg

A nurse caring for a client following a CVAand observes the client experiencing severe dysphagia. The nurse notifies the provider. Which of the following nutritional therapies will likely be prescribed? A) Initiation of total parenteral nutrition B) NPO and dysphagia subsides C) Soft residue diet D) Supplements via nasogastric tube

D) Supplements via nasogastric tube

A nurse is receiving a transfer report for clients with a head injury. The client has a Glasgow coma scale score of 3 for eye opening. 5 for best verbal response. And 5 for best motor response. Which of the following is an appropriate conclusion based on this data? A. The client can follow simple motor commands. B. The client is unable to make vocal sound. C. The client is unconscious. D. The client opens his eyes when spoken to.

D. The client opens his eyes when spoken to.

The nurse is teaching a client about the clinical manifestations of increased fluid retention secondary to heart disease. Which clinical manifestation(s) require the client to contact the healthcare provider? [select all that apply]

Decrease in urine output. Bilateral pitting pedal edema. Noticeable shortness of breath.

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Decreased LOC

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurism. Which of the following manifestations should the nurse expect?

Manifestations preceding by severe headache

A nurse is caring for a client in a intensive care unit who sustained a traumatic brain injury following a motor vehicle accident. The client has increased intracranial pressure. When positioning the client, which action has the highest priority?

Keep the head in alignment to prevent blockage if cerebral spinal fluid flow.

When planning care for a client with a history of coronary artery disease, which assessment finding(s) would the nurse be most concerned about? [select all that apply]

Last dose of nitroglycerin tablet Location of new onset pain Quality of pain

A nurse is assessing a client brought to the emergency room with burn injuries. Which of the following findings should the nurse identify partial-thickness (deep second-degree burn)?

Leathery, waxy

*A nurse is caring for a client with increased intercranial pressure who is not responding to treatment. Pertinent assessment data is noted in the image below. What information takes precedence When communicating the clients that is to the health care provider?

Look up

A client is being discharged from the hospital following placement of a biventricular pacemaker. When planning this client's discharge in which order will the nurse prioritize teaching action? [order] Assess knowledge of causes treatment, and care related to heart failure Identify misconceptions regarding care Evaluate the client's ability to describe treatment options Educate about disease progression, dietary modifications, and community resources Ask the client to explain the recommended follow up treatment

Look up

A home health nurse is caring for a client who is quadriplegic following a spinal cord injury and who is adjusting to the home environment. Which of the following client statement indicate the client is adapting? a. "I have all the equipment to take a shower, but I prefer a bed bath, because it is easier." b. "I am using the modified feeding utensils at every meal. I still spill but I am getting better." c. "My wife tries to get me to go to the grocery store, but I don't like to go out much." d. "My greatest pleasure each day is having a few beers every day."

b. "I am using the modified feeding utensils at every meal. I still spill but I am getting better."

1. A nurse is caring for a client who had a stroke involving a left cerebral hemisphere 3 weeks ago. Which of the following goal should the nurse include in the rehabilitation program? a. Improve left-sided motor function b. Establish ability to communicate c. Learn to control impulsive behavior d. Compensate for loss of depth perception

b. Establish ability to communicate

A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident. which of the following parameters should the nurse use first in order to assess the client's pain level? a. Scheduled treatments and client illness b. Behavioral indicators and effect c. A self-report pain rating scale d. Pulse and blood pressure findings

c. A self-report pain rating scale

A nurse is assessing a client who has a spinal cord injury. Which of the following actions should the nurse take to monitor C4 function? a. Apply resistance while the client flexes his arms b. Ask the client to grasp an object and form a fist c. Apply downward pressure while the client shrugs his shoulders upward d. Apply resistance while the client lifts his legs from the bed

c. Apply downward pressure while the client shrugs his shoulders upward

While instructing a patient on what occurs with a myocardial infarction, the nurse plans to explain which process? a. Coronary artery spasm. b Decreased blood flow (ischemia). c. Death of cardiac muscle from lack of oxygen (tissue necrosis). d. Sporadic decrease in oxygen to the heart (transient oxygen imbalance).

c. Death of cardiac muscle from lack of oxygen (tissue necrosis).

A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hour following a burn injury? a. 0.9% sodium chloride b. Dextrose 5% in 0.9% sodium chloride c. Lactated Ringers d. Dextrose 5% in water

c. Lactated Ringers

A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluids resuscitation therapy the nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?

-Heart rate

assessing client who has a traumatic head injury, to determine motor response which of the following client's responses to painful stimuli is expected

-Pushed the painful stimuli away

A nurse is caring for a client with a mild traumatic brain injury. Which of the following manifestations should the nurse immediately report to the health care provider?

A change in the Glasgow coma scale score from 13 to 11

A nurse is triaging clients following a mass casualty event. Which of the following clients should the nurse assess first?

A client with a severe respiratory stridor and a deviated trachea.

. A nurse is reviewing information with a client about the risk factors associated with heart failure. What information does the nurse provide to the client?

A heart attack can increase the risk of developing heart failure. ,,,,,,look for this cause they change the wording

A nurse in the emergency department is assessing a newly admitted client who has facial trauma. Which of the following assessments is the nurse's priority?

Altered Respirations

A nurse is teaching the family of a Hispanic client with an acute kidney injury from diabetes mellitus about the systemic effects of dialysis. What would the nurse include in the plan of care to promote family-centered care?

Ask what cultural needs are important to the client and the family.

Which action should the nurse take to prevent complications in a client with arterial pressure monitoring?

Assess extremity every 2 hours

A nurse caring for a client in the first 24 hours following a stroke. Which of the following assessments should the nurse prioritize?

Assessing pupil size and pupillary response

. A nurse is caring for a client with burns to face, ears, and eyelids. Which of the following is the priority finding to report to the provider? A. Urinary output 25mL/hr B. Difficulty swallowing C. HR 122 beats/min D. Lip edema

B. Difficulty swallowing

A question about factory explosion what will you do?

Check if patient is conscious(airway)

A clinic nurse is assessing a client with a history of a myocardial infarction for an annual health visit. What assessment data would the nurse follow up on in regards to the possibility of heart failure?

Client states they get short of breath walking to their mailbox.

A client with shock has been upgraded to critically ill. What information should be discussed with the family? [select all that apply]

Client's wishes Cultural preferences Presence of a living will Usual coping strategies Life sustaining therapies

A nurse is caring for a client following a motor vehicle accident-causing traumatic brain injury. Which of the following clinical manifestation would meet the diagnostic criteria guidelines for the clinical diagnosis of brain death? SATA

Coma Apnea Absence of brain stem reflexes

A nurse is caring for a client who has intercranial pressure reading of 40. What assessment should the nurse recognize as a late sign of ICP? Select all that apply:

Confusion Non-reactive dilated pupils slurred speech

a client with thermal bun injury with a TBSA burned of 70%. Which of the ff. action by the nurse indicate an understanding of the nutritional needs of a burn patient?

Consult HCP and Dietician to increase enternal tube feedings

Caridogenic shock: SATA

Cool clammy skin Weak or thready pulses tachypnea tachycardia dyspnea

10. The nurse is evaluating a client who is being treated for shock. When evaluating a client being treated for shock, what finding indicated an improvement in the client's condition?

Creatine 2.6mg/dL

A client is to receive spironolactone to manage heart failure. Which finding, if present, should the nurse report to the healthcare provider before administering the medication?

Creatinine level of 2.7 mg/dL

The charge nurse is assigning care of a client with continuous renal replacement therapy (CRRT). Which stage member should be assigned to care for this client?

Critical Care RN

The nurse is assessing the health history of a 61-year old client admitted with a diagnosis of acute myocardial infarction (AMI) secondary to coronary artery disease (CAD). Which factors contributes to the client's condition? [select all that apply]

Eats a fast food lunch 5 days a week. Blood pressure averages 150/90 mmHg. Family history of coronary artery disease. ...THIS QUESTION THE OPTIONS WERE CHANGED: LDL 160, EATS A FAST FOOD 5 DAYS A WEEKS, QUIT SMOKING 30 YRS AGO.. Don't chose the red on..

The nurse is monitoring a client on hemodialysis. The nurse understands that which lab value has the highest potential to be abnormal and cause complications as a result of fluid imbalance?

Electrolytes

A nurse is planning care for a female client who has T4 spinal cord injury and is at risk for a UTI which of the following actions should the nurse include in the plan of care.

Encourage fluid intake in between meals

A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of Penicillin. Which of the following medications should the nurse administer first?

Epinephrine

A nurse is interviewing a client who has acute Pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history?

Gall stones

The nurse is rounding on clients at the beginning of the shift. Which observation requires immediate action when caring for a client with a percutaneous catheter for dialysis?

Gauze dressing over insertion site

Which information should the nurse communicate immediately to the health care provider after assessing the client admitted with a cervical spine injury?

Heart rate of 45 with a BP of 90/60

A nurse in the emergency room is caring for a client meeting "brain attack" criteria. The client presents with a headache, nausea, vomiting, and seizures. The nurse understands these clinical manifestations are most closely associated with which type of stroke?

Hemorrhagic stroke

A nurse is evaluating a central venous pressure of a client who has sustained multiple traumas. Which of the following interpretations of low CVP pressure should the nurse make?

Hypovolemia

The nurse is caring for a client with shock who is receiving dobutamine. To evaluate the effectiveness of dobutamine, the nurse should assess for what outcome?

Increased heart rate

When caring for a client with pleural chest tube following a coronary artery bypass graft, what assessment finding would require further assessment/

Increased output

The nurse is caring for a client diagnosed with kidney failure who is undergoing hemodialysis. The nurse is aware the client is at risk for complications. Which complications should the nurse be aware of when caring for this client? [select all that apply]

Infection Hypertension Hypervolemia

Evidence base questions how will you talk to a patient family ?

Informing the family about all necessary treatment options

a nurse in an emergency is caring for a client who sustain a partial thickness burn to both lower legs, chest and face and both forearms. Which of the following is the priority action the nurse should take?

Inspect the mouth for sign of inhalation injuries

The charge nurse is evaluating a new nurse's ability to manage a client after cardiac surgery. In what order of priority should the nurse perform these actions? [rank in order of priority the actions the new nurse should perform] A. Monitor and trend output from chest tubes and urine output B. Monitor hemoglobin and hematocrit C. Provide pain relief D. Assess wounds and provide incisional care E.Provides emotional support the client and family

Look yo

The nurse understands that the care of a client following a cardiac catheterization should include which action(s)? [select all that applies]

Maintain head of bed elevation no higher than 30 degrees Observe the insertion site for bleeding Monitor intake and output .........THIS one the options was change: put patient in high fowler not good

A nurse is caring for a client who is experiencing Cushing triad following a subdural hematoma. Which of the following medication should the nurse plan to administer?

Mannitol 25%

The nurse is caring for a client with an arteriovenous (AV) fistula. Upon assessment, the nurse is unable to auscultate a bruit. What action should the nurse take first?

Notify the provider

there was a question about (MI) Miaocadial infraction which order the nurse would espect:

OXYGEN Nitroglycerin Morphine cardiac enzyme.

After the insertion of a mediastinal chest tube. Which action is most important for the nurse to implement?

Observe the color and consistency of fluid in the drainage system.

The nurse is preparing a client for placement of a catheter for arterial pressure monitoring. What is the best way for the nurse to assess ulnar circulation prior to catheter insertion?

Occlude the radial artery.

A nurse is caring for a client who has had a spinal cord injury at the level of T2/T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disabilities?

Paraplegia

The nurse is caring for a client with cardiogenic shock. Which clinical manifestation indicates the client has progressed to multiple organ dysfunction syndrome (MODS)?

Petechia

1. A nurse is caring for a client who is a quadriplegic for spinal cord injury and reports having a severe headache. The nurse obtains the blood pressure reading of: 210/108, and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take?

Place the client in high Fowler's position

A nurse is caring for a client who has a central venous catheter and suddenly develops chest pain, dyspnea, dizziness and tachycardia. The nurse suspects air embolism and clamps the catheter immediately. What other actions should the nurse take?

Place the client on his left side in Trendelenburg position

is assessing a client who is brought to the emergency room with burnt injury which of the following findings should the nurse identify as a deep partial thickness burn

The burn area is red in color with eschar present

A nurse is assessing a client brought to the ER room with burn injuries. Which of the ff findins should the nurse identify as a partiual thickness?

The burned area is very painful, edematous, and has fluid filled vesicles that are red and shiny

A nurse is setting goals for a client who has AIDS and is at the end of life. Which of the following are realistic goals?

The client will receive medication to minimize episodes of breakthrough pain

A nurse is planning care for a client who has a T4 spinal cord injury which of the following client findings should the nurse Identify as an indication the client is at risk for experiencing autonomic dysreflexia

The client's bladder becomes distended

The nurse should explain to a client that while undergoing a pulmonary artery catheter insertion, that the client will be placed in which position?

Trendelenburg

. A client with diabetes mellitus is scheduled for an cholecystectomy. Which information is important to obtain before the procedure to prevent acute kidney injury? [select all that apply]

Urinary output Use of NSAIDS Use of diuretics Mean arterial pressure Trough levels of aminoglycosides

A nurse is developing a plan of care to prevent skin breakdown for client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate?

Use pillows to keep heels off the bed surface minimize skin exposure to moisture.

1. A nurse in the burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for escharotomy. The clients spouse asks the nurse what the procedure entails. Which of the following statements is appropriate? a. "Large incisions will be made in the eschar to provide circulation. " b. "Dead tissue will be non-surgically removed." c. "A piece of healthy skin will be removed from an unburned area and grafted over the burned area." d. "this procedure involves placing the client into a shower and removing the dead tissue."

a. "Large incisions will be made in the eschar to provide circulation. "

A nurse in emergency Department is caring for a client with deep lacerations to the left lower extremity and has pulsatile bleeding from the wound. Which of the following interventions should the nurse perform first? a. Apply a tourniquet above the wound site b. Initiate two large-bore IV catheters c. Place client in reverse Trendelenburg position d. Assess the distal pulses

a. Apply a tourniquet above the wound site

Which interventions should the nurse include in the plan of care for a client with traumatic brain injury TBI? SATA. a. Head of bed elevated to only 30 degrees b. Avoid flexing the client's hips and knees c. Aggressive pulmonary hygiene every hour post-surgery d. Administer anti-emetics as needed for nausea and vomiting e. Implement seizure precautions

a. Head of bed elevated to only 30 degrees e. Implement seizure precautions

A nurse is caring for a client experiencing a traumatic brain injury. The nurse understands that which action is a priority when managing the risks of increased intracranial pressure. a. Plan care such that the care is bundled and completed over multiple short sessions. b. Arrange care such that only one procedure is completed in a single episode of care c. Ensure the head of the bed remains at 45 degrees during care d. Reduce environmental stimuli during care

c. Ensure the head of the bed remains at 45 degrees during care

Communicable diseases, disasters, and bio terrorism: triage following a mass casualty.

client with wood penetration to head (red tag)

A nurse is planning care for a newly admitted client who has skeletal traction for a fractured femur which of the following interventions should the nurse include in the plan

monitor pedal pulse every hour