Final
Which nursing action prevents cross contamination when the patient's full-thickness burn wounds to the face are exposed? Use sterile gloves when removing old dressings Wear gown, gloves, cap, mask during all care of patient Administer IV antibiotics to prevent bacterial colonization of wounds Turn the room temperature up to at least 70 degrees Farenheit during dressing changes
Wear gown, gloves, cap, mask during all care of patient
A patient who is on the progressive care unit develops atrial flutter, rate 150 with associated dyspnea and chest pain. Which action that is included in the dysrhythmia protocol should nurse do first? A. Obtain a 12-lead ECG B. Notify the HCP of the change in rhythm C. Give supplemental O2 at 2-3 L/min via nasal cannula D. Assess the patients VS including O2
C. Give supplemental O2 at 2-3 L/min via nasal cannula
An adult client with a burn injury just arrived at the ED. Place the nursing interventions in the care of this client in order of priority. A. OBTAIN BLOOD AND URINE CULTURES B. GIVE VANCOMYCIN BY V INFUSION C. START NOREPINEPHRINE 0.5 MCG/MIN D. INFUSE NORMAL SALINE 2000ML OVER 30 MINUTES E. ADMINISTER OXYGEN TO KEEP O2 SATURATION ABOVE 95%
E,D,C,A,B
A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take first? Notify the health care provider. Monitor the pulses every 2 hours. Elevate both legs above heart level with pillows. Encourage the patient to flex and extend the toes on both feet.
Notify the health care provider.
A client is admitted to the emergency room with a respiratory of 7 breaths/min. Arterial blood gas reveal the following values. Which is an appropriate analysis of the ABGs?pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Saturation 80% Bicarbonate 26 mEq/L Metabolic alkalosis Metabolic acidosis Respiratory alkalosis Respiratory Acidosis
Respiratory Acidosis
When planning care for a client in the emergency department, prioritize which interventions are needed in the myocardial infarction (MI)? 1. morphine sulfate 2. oxygen 3. nitroglycerin 4. aspirin
2,4,3,1
When the nurse is screening patients for possible peripheral arterial disease indicate where the posterior tibial artery will be palpated A. 1 B. 2 C. 3 D. 4
3
During the change of shift report the nurse learns that a patient with a head injury has decorticate posturing to noxious stimulation. Which positioning shown in the accompanying figure will the nurse expect to observe A. 1 B. 2 C. 3 D. 4
A. 1- hands to the core
The nurse notes that a patient's endotracheal tube, which was at the 22-cm lip mark, is now at the 24-cm mark and the patient is anxious, restless and tachycardia. Which action should the nurse take next? A. Auscultate breath sounds bilaterally B. Calm the patient C. Bag the patient at FiO2 of 100% D. Call a rapid response
A. Auscultate breath sounds bilaterally
Admission vital signs for a patient who has a brain injury are blood pressure of 128/68 mm hg, pulse of 110 beats/min, and of respirations 26 breaths/min. which set of vital signs, if taken I hour later will be of most concern to the nurse? A. Blood pressure 154/68, pulse 56, respirations 12 B. Blood pressure 134/72, pulse 90, respirations 32 C. Blood pressure 148/78, pulse 112, respirations 28 D. Blood pressure 110/70, pulse 120, respirations 30
A. Blood pressure 154/68, pulse 56, respirations 12
A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease the risk for ventilator associated pneumonia. Which action will the nurse include in the plan of care A. Elevate head of bed to 30 to 45 degrees. B. Suction the endotracheal tube every 2 to 4 hours. C. Limit the use of positive end-expiratory pressure. D. Give enteral feedings at no more than 10 mL/hr.
A. Elevate head of bed to 30 to 45 degrees.
A client whose cardiac rhythm was normal sinus rhythm suddenly exhibits the following rhythm on the monitor. What immediate action should the nurse take? A. notify the HCP B. continue to monitor
A. notify the HCP
A nurse is caring for a client after a colon resection for stage 3 cancer three hours ago. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock? A. Increase in the HR from 88 to 110/min B. Decrease in the urinary output from 50 ml to 30 ml per hour C. Decrease in the respiratory rate from 20 to 16/min D. Increase in the temperature from 99.5 F to 101.6 F
A. Increase in the HR from 88 to 110/min
A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action A. Insert a feeding tube and initiate enteral feedings. B. Infuse total parenteral nutrition via a central catheter. C. Encourage an oral intake of at least 5000 kcal per day. D. Administer multiple vitamins and minerals in the IV solution.
A. Insert a feeding tube and initiate enteral feedings.
A nurse caring for a client with heart disease observes tented T waves on the cardiac monitor. Upon checking laboratory values, which value would be of most concern to the nurse? A. K 6.2 B. Sodium 148 mEq/L C. Calcium level 10 mEq/L D. Magnesium level of 1.0 mEq/L
A. K 6.2
A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which fluids in the first 24 hours following a burn injury? A. Lactated Ringers B. Dextrose 5% in 0.9% sodium chloride C. Dextrose 5% in waterD. 0.9% in sodium chloride
A. Lactated Ringers
Computed tomography (CT) of a patient's head reveals that a hemorrhagic stroke. What is the priority nursing intervention in the emergency department? A. Maintenance of the patient's airway. B. Positioning to promote cerebral perfusion. C. Control of fluid and electrolyte imbalances. D. Administration of tissue plasminogen activator (tPA)
A. Maintenance of the patient's airway.
What is a nursing priority in the care of a patient with a diagnosis of hypothyroidism? A. Patient teaching related to levothyroxine B. Closely monitoring the patient's intake and output C. Providing a dark, low stimulation environment D. Patient teaching related to radioactive iodine therapy
A. Patient teaching related to levothyroxine
A client presents to the emergency department after a fall thereby striking the head. The client has a Glasgow Coma Score of 12, which is decreased for this client, and has projectile vomiting. What is the priority intervention for this client? A. Positioning the client to prevent aspiration B. Establishing IV access C. Preparing for thrombolytic administration D. Calling the stroke team
A. Positioning the client to prevent aspiration
A patient has been brought to the ED with a sudden onset of a severe headache that is different from any other headache previously experienced. When considering the possibility of a stroke, which type of stroke should the nurse suspect is most likely occurring? A. Subarachnoid hemorrhage B. Thrombotic stroke C. Embolic stroke D. Transient ischemic attack
A. Subarachnoid hemorrhage
The nurse is conducting an assessment on a patient with angina pectoris who takes nitroglycerin for chest pain at home. During the assess, the patient reports an episode of chest pain. Which priority question should the nurse ask? A. Tell me where your pain is located B. Do you have medication allergies? C. Do you carry nitroglycerin with you? D. Do you feel like vomiting?
A. Tell me where your pain is located
Which laboratory findings are consistent with acute coronary syndrome? A. Troponin 3.2 ng/mL B. Lipoprotein-a 18 mg/dl C. Triglycerides 400 mg/dl D. C-reactive protein 13 mg/dl
A. Troponin 3.2 ng/mL
The patient takes insulin every morning with sliding scale coverage. The standing insulin order every morning before breakfast is NPH 20 units and regular insulin as per sliding scale coverage before meals and at bedtime as follows (see below)Just enter a numerical value. Do not hit spacebar, just enter numerical answer What is the sum total units of insulin the patient will receive for a finger stick of 275 mg/dl before breakfast?
ANS: 24 Units
The patient comes to the ED with severe, prolonged angina that is not immediately reversible. The nurse knows if the patient once had angina related to a stable atherosclerotic plaque and the plaque ruptures, there may be occlusion of a coronary vessel and this type of pain. How will the nurse document this situation related to pathophysiology, presentation, diagnosis, prognosis, and interventions for this disorder? A Unstable angina B Acute coronary syndrome (ACS) C ST-segment-elevation myocardial infarction (STEMI)D Non-ST-segment-elevation myocardial infarction (NSTEMI)
B Acute coronary syndrome (ACS)
A patient with respiratory failure is receiving mechanical ventilation with peak end expiratory pressure (PEEP) of 12 cm H2O. Which information indicates that a negative physiological effect of PEEP is occurring? A. Heart rate 68 bpm B. B/P 98/58 mmHg C. Temperature 99 F D. Sa02 96%
B. B/P 98/58 mmHg
A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced? A. The patient's PaO2 is 50 mm Hg and the SaO2 is 88% B. The patient has subcutaneous emphysema on the upper thorax. C. The patient has bronchial breath sounds in both the lung fields D. The patient has a first-degree atrioventricular heart block with a rate of 58.
B. The patient has subcutaneous emphysema on the upper thorax.
The nurse notes the presence of this cardiac rhythm on the monitor of a patient. The nurse quickly assesses the client, knowing that this rhythm is experiencing which dysrhythmia? A. Sinus tachycardia B. Ventricular tachycardia C. Premature ventricular contractions
B. Ventricular tachycardia
A nurse is caring for a patient with acute coronary syndrome (ACS) and atrial fibrillation who takes metoprolol. Which monitoring is a priority when administering the medication? A. ST segment B. Heart rate C. Troponin D. Myoglobin
B. Heart rate
The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective? A. Signs of dyspnea B. Increase in Blood Pressure C. Distended neck veins D. Muffled cardiac sounds
B. Increase in Blood Pressure
The patient received aspart insulin 15 units subcutaneously at 0830 for a blood glucose level of 253 mg/dL. The nurse plans to ensure that the patient has what available upon administration of the insulin? Breakfast tray 15 gram snack Glass of water Intravenous fluids
Breakfast tray
The unlicensed assistive personnel (UAP) reported to the nurse that the patient's blood glucose is 690 mg/dl and the patient is hard to arouse. When the nurse assesses the urine , there are no ketones present . What collaborative care should the nurse expect for this patient? A. Initiate intravenous fluids to correct dehydration B. Administer a different antibiotic C. Administer insulin aspart D. Routine insulin therapy and exercise
C. Administer insulin aspart
A 19-yr-old student comes to the student health center at the end of the semester complaining that, "My heart is skipping beats." An electrocardiogram (ECG) shows occasional unifocal premature ventricular contractions (PVCs). What action should the nurse take next? A. Insert an IV catheter for emergency use. B. Start supplemental O2 at 2 to 3 L/min via nasal cannula. C. Ask the patient about current stress level and caffeine use. D. Have the patient taken to the nearest emergency department (ED).
C. Ask the patient about current stress level and caffeine use.
A client is wearing a continuous cardiac monitor which begins to sound its alarm. The nurse notes no electrocardiographic complexes on the monitor, which is the priority nursing intervention? A. Call a code. B. Call the health care provider. C. Assess the client's status and lead placement. D. Press the recorder button on the electrocardiogram console.
C. Assess the client's status and lead placement.
A patient with type 2 diabetes has a urinary tract infection (UTI). The unlicensed assistive personnel (UAP) reported to the nurse that the patient's blood glucose is 642 mg/dL and the patient is hard to arouse. When the nurse assesses the urine, there are no ketones present. What collaborative care should the nurse expect for this patient? A. Routine insulin therapy and exercise B. Administer a different antibiotic for the UTI C. Cardiac monitoring to detect potassium changes D. Administer intravenous (IV) fluids rapidly to correct dehydration
C. Cardiac monitoring to detect potassium changes
A client with a diagnosis of diabetic ketoacidosis (DKA) has an initial blood glucose level 950 mg/dl is started on a continuous intravenous (IV) infusion of short acting insulin along with IV hydration with normal saline. The serum glucose level is now decreased to 240 mg/dl. What should the nurse prepare next to administer to the patient? A. An ampule of 50% dextrose B. NPH insulin subcutaneously C. IV fluids containing dextrose D. Phenytoin for the prevention of seizures
C. IV fluids containing dextrose
On admission to the burn unit, a patient with an approximate 25% total body surface (TBSA) area burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L) . Which of the following prescribed actions should be the nurse's priority? A. Monitor Urine Output B. Continue to monitor the lab results C. Increase the rate of the ordered IV solution D. Type and crossmatch for a blood transfusion
C. Increase the rate of the ordered IV solution
The nurse is assessing a client diagnosed with pericarditis for manifestations of cardiac tamponade. Which findings indicate the presence of cardiac tamponade? A. Heart rate 68 bpm B. Wheezing on auscultation C. Increased Central Venous Pressure D. Decreased CVP
C. Increased Central Venous Pressure
A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling. Which nursing intervention will be included in the plan of care? A. Encourage coughing and deep breathing. B. Position the patient with knees and hips flexed. C. Keep the head of the bed elevated to 30 degrees. D. Cluster nursing interventions to provide rest periods.
C. Keep the head of the bed elevated to 30 degrees.
A nurse in an emergency department is caring for a client who has deep-partial and full-thickness burns to his chest, abdomen and upper arms. What is the nurse's priority intervention for this client during the resuscitation of phase of injury? A. Medicate for pain B. Insert an indwelling urinary catheter C. Maintaining the airway D. Initiate fluid resuscitation
C. Maintaining the airway
The nurse is assessing the patient 90 minutes after insertion of a chest tube to the right chest wall. On assessment the nurse notes the following <image> what immediate action should the nurse take? **PIC ONLY SHOWS ABC** A. Do nothing, drainage color is as expected B. Change the CDU C. Notify the provider
C. Notify the provider
The nurse assesses vital signs for a patient admitted 2 days ago with gram negative sepsis, temperature of 101.2 degree F, blood pressure of 90/56 mm Hg, pulse of 92 beats/min and respirations of 34 breaths/min. Which action should the nurse take next? A. Give the scheduled IV antibiotic. B. Give the PRN acetaminophen (Tylenol). C. Obtain oxygen saturation using pulse oximetry. D. Notify the health care provider of the patient's vital signs.
C. Obtain oxygen saturation using pulse oximetry.
A patient who is complaining of a racing heart and feeling anxious comes to the emergency department. The nurse places the patient on a heart monitor and obtains the following electrocardiographic (ECG) tracing. A. Prepare to perform electrical cardioversion B. Have the patient perform the Valsalva maneuver. C. Obtain the patient's vital signs including O2 saturation. D. Prepare to give a -blocker medication to slow the heart rate.
C. Obtain the patient's vital signs including O2 saturation.
A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first? A. Assess oral temperature B. Check Potassium level C. Place on cardiac monitor D. Assess for pain at contact points
C. Place on cardiac monitor
After reviewing the information shown in the accompanying figure for a patient with pneumonia and sepsis, which data is most important to report to the provider? A. Temperature and IV site appearance B. Oxygen sat & breath sounds C. Platelet count and presence of petechiae D. Blood pressure, pulse rate and RR
C. Platelet count and presence of petechiae
A patient with diabetes shows no symptoms of angina but holter monitoring reveals changes in electrocardiography (ECG). The nurse suspects what condition? A. Microvascular angina B. Prinzmetal's angina C. Silent ischemia D. Angina decubitus
C. Silent ischemia
The nurse notes premature ventricular contractions (PVCs) while suctioning a patient's endotracheal tube. Which action by the nurse is a priority? A. Decrease the suction pressure to 80 mm Hg B. Document the dysrhythmia in the patients chart C. Stop and ventilate the patient with 100% oxygen D. Give antidysrhythmic medications per protocol
C. Stop and ventilate the patient with 100% oxygen
The blood enters on the left side of the heart through the ___________ and enters the left atrium, it then passes through the ______ to enter the left ventricle. A. pulmonary artery, aortic valve B. pulmonary vein, tricuspid valve C. pulmonary vein, bicuspid valve D. pulmonary artery, mitral valve
C. pulmonary vein, bicuspid valve
The nurse is caring for a patient on a telemetry unit who has a regular heart rhythm and rate of 60 beats/min; a P wave precedes each QRS complex, and the PR interval is 0.20 second. Additional vital signs are: Blood pressure 118/68mm Hg, respiratory rate 16 breaths/min, and temperature 98.8F All of these medications are available on the medication record. A) Administer atropine. B) Administer digoxin. C) Administer clonidine. D) Continue to monitor.
D) Continue to monitor.
A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines, the nurse should document burns to which percentage of the client's TBSA? A. 9% B. 18% C. 36% D. 54%
D. 54%
A patient experiences an open pneumothorax secondary to a gunshot wound. What is an important nursing intervention when caring for this patient? A. Administering morphine sulfate B. Application of an occlusive dressing C. Place on unaffected side D. Applying a 3-sided sterile dressing
D. Applying a 3-sided sterile dressing
A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first? A. Determine the extent and depth of the burns B. Infuse the prescribed lactated ringers solution C. Give the prescribed hydromorphone D. Auscultate breath sounds
D. Auscultate breath sounds
A nurse is caring for a patient who is experiencing anaphylactic stock in response to the administration of penicillin. Which medication should the nurse administer first? A. Methylprednisolone B. Furosemide C. dobutamine D. Epinephrine
D. Epinephrine
A client received trauma to the chest that caused severe impairment of the primary pacemaker cells of the heart. Which of the following areas received the greatest damage? A. Ventricles B. Bundle of his C. Atrioventricular (AV) node D. Sinoatrial (SA) node
D. Sinoatrial (SA) node
A patient with prior cardiac history is brought to the ED with an acute myocardial infarction. On arrival, the client is started on tissue plasminogen activator. What assessment finding indicates complication of therapy? A. Decreased urine output B. Anorexia C. Amber color urine D. Tarry stools
D. Tarry stools
A nurse is assessing a client who had a craniotomy and has developed syndrome of inappropriate antidiuretic hormone (SIADH). Which manifestation should the nurse anticipate? A. Urine output > 30 ml/hour B. Increased thirst C. Na 155 mEq/L D. Urine Output < 20 ML/HOUR
D. URINE OUTPUT < 20 ML/HOUR
A nurse assesses a patient who has aortic regurgitation. In which location in the illustration shown below would the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation? A. LOC A B. LOC B C. LOC C D. LOC D
LOCATION A
Which type of dysrhythmia is associated with a fever? Ventricular fibrillation Atrial fibrillation Sinus bradycardia Sinus tachycardia
Sinus tachycardia
Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line? Stabilize the cervical spine Check the blood pressure Assess alertness and orientation Inspect the contact burns
Stabilize the cervical spine
Which nurse would be assigned to care for a client who is intubated with septic shock due to a methicillin-resistant staphylococcus aureus (MRSA) infection. The LPN/LVN who has 20 years of experience The new RN who recently finished orienting and is working independently with moderately complex clients The RN who will also be caring for a client who had coronary artery bypass graft (CABG) surgery 12 hours ago The RN with 2 years of experience in intensive care unit (ICU)
The RN with 2 years of experience in intensive care unit (ICU)
A patient arrives in the ED with facial and chest burns caused by a house fire. Which action should the nurse take first? a. Auscultate the patient's lung sounds. b. Determine the extent and depth of the burns. c. Infuse the ordered lactated Ringer's solution d. Administer the ordered hydromorphone (Dilaudid).
a. Auscultate the patient's lung sounds.
The standard policy on the cardiac unit states, "Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg." Which patient should the nurse call the health care provider about? a. postoperative patient with a BP of 116/42 mm Hg. b. newly admitted patient with a BP of 150/87 mm Hg c. patient with left ventricular failure who has a BP of 110/70 mm Hg. d. patient with a myocardial infarction who has a BP of 140/86 mm Hg.
a. postoperative patient with a BP of 116/42 mm Hg.
A patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 78%. The patient is increasingly lethargic. Which intervention will the nurse anticipate? a. Administration of 100% O2 by non-rebreather mask b. Endotracheal intubation and positive pressure ventilation c. Insertion of a mini-tracheostomy with frequent suctioningd. Initiation of continuous positive pressure ventilation (CPAP)
b. Endotracheal intubation and positive pressure ventilation
The nurse is teaching a client with a new pacemaker. What teaching will the nurse include? Do not lean over electrical or gasoline motors you may bathe, taking only showers avoid sudden, jerky movements for several weeks take pulse for 20 seconds each day and record avoid the use of microwave ovens be sure to know the rate at which your pacemaker is set
be sure to know the rate at which your pacemaker is set avoid sudden, jerky movements for several weeks Do not lean over electrical or gasoline motors
The nurse notes premature ventricular while suctioning a client's endotracheal tube. Which intervention by the nurse is a priority? a. Decrease the suction pressure to 80 mm Hg. b. Document the dysrhythmia in the patient's chart. c. Stop and ventilate the patient with 100% oxygen. d. Give antidysrhythmic medications per protocol.
c. Stop and ventilate the patient with 100% oxygen
Eight hours after thermal burn covering 50% of a patient's total body surface area, the nurse assesses the patient. The patient weighs 92 kg (202.4lb). Which info would be priority to communicate to the provider? a. Blood pressure is 95/48 per arterial line. b. Serous exudate is leaking from the burns c. Cardiac monitor shows a pulse rate of 108 d. Urine output is 20 mL per hour for the past 2 hours.
d. Urine output is 20 mL per hour for the past 2 hours.
The nurse responds to a ventilator alarm and finds the patient holding the endotracheal tube. Which priority action should the nurse take? a. Activate the rapid response team b. Provide reassurance to the patient. c. Call the health care provider to reinsert the tube. d. Manually ventilate the patient with 100% oxygen.
d. Manually ventilate the patient with 100% oxygen.
A patient who was found unconscious in a burning house is brought to the ED by ambulance. The nurse notes that the patient's skin color is bright red. Which action should the nurse take? a. Insert two large-bore IV lines. b. Check the patient's orientation c. Assess for singed nasal hair and dark oral mucous membranes. d. Place the patient on 100% oxygen using a non-rebreather mask.
d. Place the patient on 100% oxygen using a non-rebreather mask.
Which prescribed drug is best for the nurse to give before scheduled wound debridement on a patient with partial-thickness burns? a. ketorolac b. lorazepam (Ativan) c. gabapentin (Neurontin) d. hydromorphone (Dilaudid)
d. hydromorphone (Dilaudid)
The nurse care for a client who experienced a myocardial infarction notes the sudden onset of this rhythm on the monitor. What immediate action should the nurse take? Refer to illustration. A. administer one nitroglycerin tablet sublingual B. continue to monitor every 30 minutes C. initiate CPR D. record blood pressure
initiate CPR