HA Quiz 2

When the fetal head begins to crown during an emergency precipitous birth, how should the nurse respond? 1 Pressing firmly on the fundus 2 Applying gentle perineal pressure 3 Encouraging the client to push 4 Telling the client to take prolonged deep breaths

2 Applying gentle perineal pressure

A client is diagnosed with emphysema. What long-term problem should the nurse monitor in this client? 1 Localized tissue necrosis 2 Carbon dioxide retention 3 Increased respiratory rate 4 Saturated hemoglobin molecules

2 Carbon dioxide retention Loss of alveolar surface area causes retention of carbon dioxide, which, after exhausting the available bicarbonate ions functioning as buffers, will cause a lower pH (respiratory acidosis). Tissue necrosis results from localized tissue anoxia and will not cause the systemic response of respiratory acidosis. An increased respiratory rate may lead to respiratory alkalosis. Normal oxygen saturation of hemoglobin is 95% to 100%, so this is not a sign of acidosis.

A registered nurse is examining the medical reports of different clients. Which client may need immediate assessment? 1 A client who is scheduled for a bronchoscopy 2 A client who is scheduled for a thoracentesis 3 A client with pleural effusion and decreased breath sounds 4 A client with acute asthma and 85% oxygen saturation

4 A client with acute asthma and 85% oxygen saturation

A person on the beach sustains a deep partial-thickness burn because of a severe sunburn. What is the best first-aid measure the nurse can instruct the person to apply before seeking healthcare? Cool, moist towels Dry, sterile dressings Analgesic sunburn spray Vitamin A and D ointment

Cool, moist towels

The nurse is assessing the victims of a disaster brought in to the emergency department for signs of hypothermia. Which statements made by the nurse indicate accurate awareness about the conditions associated with hypothermia? Select all that apply. 1 "Shivering is the body's first attempt to conserve heat." 2 "Wet clothing increases evaporative heat loss twice as much as normal." 3 "Hypothermia can often be misdiagnosed as it mimics other disorders." 4 "Near drowning increases evaporative heat loss to 25 times greater than normal." 5 "Older adults are less prone to hypothermia due to medications that alter body defenses."

"Hypothermia can often be misdiagnosed as it mimics other disorders." "Near drowning increases evaporative heat loss to 25 times greater than normal." Hypothermia mimics cerebral or metabolic disturbances causing ataxia, confusion, and withdrawal, so the client may be misdiagnosed. Immersion in cold water, such as near drowning, increases evaporative heat loss to 25 times greater than normal. Peripheral vasoconstriction is the body's first attempt to conserve heat. As cold temperatures persist, shivering and movement are the body's only mechanisms for producing heat. Wet clothing increases evaporative heat loss to five times greater than normal. Older adults are more prone to hypothermia because of decreased body fat, diminished energy reserves, decreased basal metabolic rate, decreased shivering response, decreased sensory perception, chronic medical conditions, and medications that alter body defenses.

A client is admitted to the emergency department with dyspnea, a productive cough, and fever. The healthcare provider suspects pneumonia and writes prescriptions. Place the nursing actions in the order they should be performed.

1.Elevate the head of the bed. 2. Insert a catheter to establish venous access. 3. Obtain a sputum culture. 4. Administer the prescribed intravenous piggyback antibiotic. 5. Review the results of the sensitivity test.

There are five clients in the emergency unit. Which client requires immediate treatment? Select all that apply. 1 A client with skin rash 2 A client with unstable vital signs 3 A client with severe abdominal pain 4 A client with chest pain with diaphoresis 5 A client with multiple complex soft tissue injuries

2 A client with unstable vital signs 3 A client with severe abdominal pain 4 A client with chest pain with diaphoresis A client with unstable vital signs requires immediate treatment. A client with severe abdominal pain could be experiencing aneurysm or ectopic pregnancy that is rupturing and should be treated immediately. A client with chest pain and diaphoresis may have cardiac arrest and should be treated immediately. A client with skin rash can wait for several hours if needed without any fear of deterioration. A client with multiple complex soft tissue injuries does not need immediate treatment since the injuries are not likely to be life threatening.

A client has chronic obstructive pulmonary disease (COPD). To decrease the risk of CO2 intoxication (CO2 narcosis), what should the nurse do? 1 Initiate pulmonary hygiene to clear air passages of trapped mucus 2 Instruct to deep breathe slowly with inhalation longer than exhalation 3 Encourage continuous rapid panting to promote respiratory exchange 4 Administer oxygen at a low concentration to maintain respiratory drive

4 Administer oxygen at a low concentration to maintain respiratory drive With chronically high levels of carbon dioxide it is believed that decreased oxygen levels become the stimulus to breathe; high oxygen administration negates this mechanism. Initiating pulmonary hygiene to clear air passages of trapped mucus is an appropriate intervention, but is not directly related to CO2 intoxication (CO2 narcosis). Encouraging continuous rapid panting to promote respiratory exchange will not bring oxygen into the alveoli for exchange; nor will it adequately remove carbon dioxide because it will increase bronchiolar obstruction. Inhalation should be of regular depth, and expiration should be prolonged to prevent carbon dioxide trapping (air trapping).

A client is experiencing kidney failure. Which is the most serious complication for which the nurse must monitor a client with kidney failure? 1 Anemia 2 Weight loss 3 Uremic frost 4 Hyperkalemia

4 Hyperkalemia Decreased glomerular filtration leads to hyperkalemia, which may cause lethal dysrhythmias such as cardiac arrest. Anemia may occur but is not the most serious complication and should be treated in relation to the client's clinical manifestation; erythropoietin and iron supplements usually are used. Weight loss alone is not life threatening. Uremic frost, a layer of urea crystals on the skin, causes itching but it is not the most serious complication.

A newborn with respiratory distress syndrome (RDS) is receiving continuous positive airway pressure (CPAP) therapy by way of an endotracheal tube. The nurse determines that the infant's breath sounds on the right side are diminished and that the point of maximum impulse (PMI) of the heartbeat is in the left axillary line. What is the interpretation of these assessment data and the appropriate nursing action? 1 Inspiratory pressure on the ventilator is probably too low and should be increased for adequate ventilation. 2 Infants with RDS often have some degree of atelectasis, and there should be no change in treatment. 3 The endotracheal tube has slipped into the left main stem bronchus and should be pulled back to ventilate both lungs. 4 The infant may have a pneumothorax, and the health care provider should be called so that corrective therapy can be started immediately.

4 The infant may have a pneumothorax, and the health care provider should be called so that corrective therapy can be started immediately.

Which client would have the highest risk of pneumonia? 1. 16 y/o w/ poor nutritional status, vax in last 3 months 2. 28 y/o tobacco, vax 2 yrs ago 3. 45 y/o alcoholic, vax 1 yr ago 4. 67 y/o chronic lung disease, vax >5yrs ago

4. 67 y/o chronic lung disease, vax >5yrs ago

While preparing the client for a diagnostic procedure, the nurse positions the client upright with elbows on an overbed table and the feet supported. The nurse also instructs the client not to talk or cough during the procedure. Which diagnostic test is the client undergoing? 1 Lung biopsy 2 Thoracentesis 3 Mediastinoscopy 4 Ventilation-perfusion scan

A thoracentesis is performed to obtain a specimen of pleural fluid for diagnosis. The client should be positioned upright with elbows on an overbed table with the feet supported. The client should not talk or cough during the procedure because the inserted needle may cause trauma. A lung biopsy or mediastinoscopy may not require the client to be seated upright. No special precautions are needed after performing ventilation-perfusion scan because the gas and isotope transmits radioactivity for only a brief interval.

The nurse notes asystole on the cardiac monitor. Which action should the nurse take immediately? Defibrillate Assess the client's pulse Initiate advanced cardiac life support Check another lead to confirm asystole

Assess the client's pulse Pulse should be immediately assessed because a lead or electrode coming off may mimic this dysrhythmia. Asystole is characterized by complete cessation of electrical activity. A flat baseline is seen, without any evidence of P, QRS, or T waveforms. A pulse is absent, and there is no cardiac output; cardiac arrest has occurred. Once confirmed, Basic Life Support (BLS) and Advanced Cardiovascular Life Support (ACLS) protocols are initiated for asystole. Defibrillation is part of the ACLS protocol for ventricular fibrillation.

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

Client with wheezing Wheezing indicates anaphylactic and allergic reactions in the client who is on blood transfusion therapy. Therefore the client with wheezing should be treated first. Itching, flushing, and pruritus indicate a mild allergic reaction. Clients with itching, flushing, and pruritus can be treated after treating the client with wheezing symptoms.

The nurse is providing emergency care to a client suffering from heat stroke. What should be the order of nursing interventions in this scenario? Remove the client from the hot environment. Ensure a patent airway. Remove the client's clothing. Pour or spray cold water on the client's body and scalp. Place ice in cloth or bags and position the packs on the client's scalp. Fan the client with newspapers or whatever is available.

Ensure a patent airway. Remove the client from the hot environment. Remove the client's clothing. Pour or spray cold water on the client's body and scalp. Fan the client with newspapers or whatever is available. Place ice in cloth or bags and position the packs on the client's scalp.

After a bronchoscopy because of suspected cancer of the lung, a client develops pleural effusion. What should the nurse conclude is the most likely cause of the pleural effusion? Excessive fluid intake Inadequate chest expansion Extension of cancerous lesions Irritation from the bronchoscopy

Extension of cancerous lesions Cancerous lesions in the pleural space increase the osmotic pressure, causing a shift of fluid to that space. Excessive fluid intake is usually balanced by increased urine output. Inadequate chest expansion results from pleural effusion and is not the cause of it. A bronchoscopy does not involve the pleural space.

While a multiparous client is in active labor, her membranes rupture spontaneously. The nurse notes a loop of umbilical cord protruding from her vagina. What is the priority nursing action at this time? Monitoring the fetal heart rate Covering the cord with a saline dressing Pushing the cord back into the vaginal vault Holding the presenting part away from the cord

Holding the presenting part away from the cord Holding the presenting part away from the cord must be done immediately to maintain cord circulation and prevent the fetus from becoming anoxic. The priority is maintaining cord circulation; although monitoring is important, it does not alter the emergency. Keeping the cord moist is secondary; keeping pressure off the cord is the priority. The cord should not be touched, because this increases pressure on the cord, further reducing oxygen flow to the fetus.

The nurse in the postanesthesia care unit is caring for a client who had a left-sided pneumonectomy. Which goal is priority? 1 Replace blood loss 2 Maintain ventilatory exchange 3 Maintain closed chest drainage 4 Replace supplemental oxygenation

Maintain ventilatory exchange Oxygen and carbon dioxide exchange is essential for life and is the priority. Blood replacement is not the priority. Closed chest drainage is unnecessary with a left-sided pneumonectomy because there is no lung to reinflate. Supplemental oxygenation is not the priority.STUDY TIP: Laughter is a great stress reliever. Watching a short program that makes you laugh, reading something funny, or sharing humor with friends helps decrease stress.

Which nursing interventions are important when caring for clients receiving IV digoxin? Select all that apply. Monitor the heart rate closely Check the blood levels of digoxin Administer the dose over 1 minute Monitor the serum potassium level Give the drug with other infusing medications

Monitor the heart rate closely Check the blood levels of digoxin Monitor the serum potassium level Bradycardia or other dysrhythmias may occur; therefore, the heart rate and rhythm should be monitored. ECG monitoring should be continuous. The digoxin level is checked before administration to avoid toxicity. A low serum potassium level when digoxin is administered can contribute to toxicity. Digoxin should be given over a 5-minute period through a Y-tube or three-way stopcock. There are many syringe, Y-site, and additive incompatibilities; the manufacturer recommends that digoxin not be administered with other drugs.

What are the priority nursing interventions for a client with neutropenia in an emergency department? Select all that apply. 1 Monitor for rashes and pruritus. 2 Prepare an appropriate diet plan. 3 Obtain blood cultures immediately. 4 Teach hygiene measures to be followed. 5 Administer antibiotic STAT as prescribed.

Obtain blood cultures immediately. Administer antibiotic STAT as prescribed. Identifying the causative agent for neutropenia is important for starting treatment. Therefore the priority nursing intervention is to obtain blood cultures immediately and administer antibiotic STAT as prescribed to the client. The nurse can monitor for rashes and pruritus after administering the medication. The nurse can prepare a diet plan and teach hygiene measures after stabilizing the client.Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

A client with internal bleeding is in the intensive care unit (ICU) for observation. At the change of shift an alarm sounds, indicating a decrease in blood pressure. What is the initial nursing action? Perform an assessment of the client before resuming the change-of-shift report. Continue the change-of-shift report and include the decrease in blood pressure. Lower the diastolic pressure limits on the monitor during the change-of-shift report. Turn off the alarm temporarily and alert the oncoming nurse to the decrease in blood pressure.

Perform an assessment of the client before resuming the change-of-shift report.

A nurse is determining whether or not a client's atrial rhythm is regular when reviewing the ECG rhythm strip. Which consistency of spacing will the nurse use to determine regularity? 1 P wave and the QRS complex 2 QRS complexes 3 QRS widths 4 P waves

4 P waves The P wave represents atrial contraction. Regularity is assessed by using electronic or physical calipers, or a piece of paper and pencil. To determine atrial regularity, identify the P wave and place one caliper point on the peak of the P wave. Locate the next P wave and place the second caliper point on its peak. The second point is left stationary, and the calipers are flipped over. If the first caliper point lands exactly on the next P wave, the atrial rhythm is perfectly regular. If the point lands one small box or less away from the next P wave, the rhythm is essentially regular. If the point lands more than one small box away, the rhythm is considered irregular. The same process can be performed with a simple piece of paper. Place the paper parallel and below the rhythm line, make a hatch mark below the first and second P waves, and then move the paper over to determine if the distance between the second and third P waves is equal to the first and second. When an atrial rhythm is perfectly regular, each P wave is an equal distance from the next P wave. This process is also used to assess ventricular regularity, except that the caliper points are placed on the peak of two consecutive R waves. QRS intervals can lengthen in response to new bundle branch blocks or with ventricular dysrhythmias.

The nurse is preparing to educate a group of clients about health promotion to prevent head and neck cancer. Which clients are of highest priority for education? Select all that apply. A client who chews tobacco A client who has multiple sex partners A client who uses condoms when having sex A client with a history of alcohol abuse for 5 years A client who brushes with a soft bristle toothbrush

A client who chews tobacco A client who has multiple sex partners A client with a history of alcohol abuse for 5 years Tobacco, alcohol, and human papilloma virus (HPV) are the major causes of neck cancer. The nurse should counsel the client who chews tobacco and educate regarding the importance of oral hygiene. The nurse should advise the client to stop chewing tobacco to reduce the risk of head and neck cancer. The nurse should educate the client with multiple sex partners about protecting against human papilloma virus (HPV), which is a risk factor for cancer. The nurse should place a high priority on health promotion in a client with a history of alcohol abuse for 5 years because it is one of the major risk factors for head and neck cancer. The client should use condoms when having sex with potentially infectious partners to prevent HPV infections that can lead to head and neck cancer. A client should maintain proper oral hygiene by brushing his or her teeth regularly with a soft bristle brush and flossing.

A nurse is caring for a client in postoperative recovery who just had a central venous catheter inserted. The client begins to complain of chest pain. Upon further assessment, the nurse notes that the client has decreased breath sounds on the affected side. Which action should the nurse do first? Administer oxygen as prescribed. Notify the healthcare provider. Assist with insertion of chest tube. Continue to assess client's respiratory status.

Administer oxygen as prescribed. The client most likely is experiencing a pneumothorax, which is a collection of air in the pleural space. This can be caused during the insertion of a central venous catheter. During insertion, the pleural covering of the lung can be punctured by the introducer on insertion of a direct subclavian approach. Signs and symptoms of a pneumothorax include chest pain, dyspnea, apprehension, cyanosis, decreased breath sounds on the affected side, and abnormal chest x-ray findings. The nurse should first think about the "ABC's" (airway, breathing, circulation) and therefore should administer oxygen as prescribed, then notify the healthcare provider, continue to assess the client's respiratory status, and then assist with chest tube insertion if indicated.

Which nursing action is most important to promote the nutritional status of a client during the acute phase of treatment after extensive burns? 1 Provide a diet high in sodium. 2 Limit caloric intake to decrease the work of the body. 3 Reduce protein intake to avoid overtaxing the kidneys. 4 Administer the prescribed intravenous fluid with the added vitamin C.

Administer the prescribed intravenous fluid with the added vitamin C. Vitamin C is essential for wound healing. It provides a component of intercellular ground substance that develops into collagen and is necessary to build supportive tissue. To prevent excessive fluid retention, which will increase the cardiovascular workload, sodium intake should be regulated. Decreasing calories will promote catabolism of body tissue; caloric need is increased. Protein intake should be increased to help repair damaged tissue.

While auscultating a client's lung, a nurse hears these sounds. What type of sound does the nurse document on the client's assessment report? Rhonchi Wheezes Coarse crackles Pleural friction rubs

Coarse crackles Coarse crackles are series of long-duration, discontinuous, low-pitched sounds associated with pulmonary edema or pneumonia with severe congestion. They sound like air is blowing through a straw underwater and are caused by air passing through airways intermittently occluded by mucus, unstable bronchial walls, or folds of mucosa. Rhonchi are continuous rumbling, snoring, or rattling sounds that occur due to obstruction of large airways with secretions. Wheezes are continuous high-pitched squeaking or musical sounds that result from rapid vibration of bronchial walls. Pleural friction rubs are creaking or grating sounds caused by roughened, inflamed pleural surfaces rubbing together. They are associated with pleurisy, pneumonia, or a pulmonary infarct.

The nurse is caring for a client with a spinal cord injury. Which assessment findings alert the nurse that the client is developing autonomic hyperreflexia (autonomic dysreflexia)? 1 Hypertension and bradycardia 2 Flaccid paralysis and numbness 3 Absence of sweating and pyrexia 4 Escalating tachycardia and shock

Hypertension and bradycardia Hypertension and bradycardia occur as a result of exaggerated autonomic responses. If autonomic hyperreflexia is identified, immediate intervention is necessary to prevent serious complications. Paralysis is related to transection, not autonomic hyperreflexia; the client will have no sensation below the injury. Profuse diaphoresis occurs above the level of injury. Bradycardia occurs.

A client with bronchial pneumonia is having difficulty maintaining airway clearance because of retained secretions. To decrease the amount of secretions retained, what should the nurse do? 1 Administer continuous oxygen 2 Increase fluid intake to at least 2 L a day 3 Place the client in a high-Fowler position 4 Instruct the client to gargle deep in the throat using warmed normal saline

Increase fluid intake to at least 2 L a day Increased fluid intake helps to liquefy respiratory secretions, which promotes expectoration. Oxygen may dry the mucous membranes, which may thicken secretions; oxygen should be administered only when necessary. Placing the client in a high-Fowler position promotes retention of secretions; supine, prone, and Trendelenburg positions promote removal of secretions via gravity. Retained secretions are in the bronchi and trachea; gargling lubricates only the oropharynx.STUDY TIP: The old standbys of enough sleep and adequate nutritional intake also help keep excessive stress at bay. Although nursing students learn about the body's energy needs in anatomy and physiology classes, somehow they tend to forget that glucose is necessary for brain cells to work. Skipping breakfast or lunch or surviving on junk food puts the brain at a disadvantage.

Which statement effectively describes the steps to be taken by healthcare personnel when responding to healthcare facility fires? 1 Oxygen should be continued for clients. 2 The nurse should not attempt to contain the fire. 3 The respiratory status of clients on life support should be maintained manually. 4 Bedridden clients should be removed from the fire area only by stretchers or wheelchairs.

The respiratory status of clients on life support should be maintained manually. For clients on life support, the nurse should maintain their respiratory status manually until they are removed from the fire area. The nurse should discontinue oxygen for all clients who can breathe without it. After everyone is out of danger, the nurse can seek to contain the fire by closing doors and windows and using an ABC extinguisher, if possible. Bedridden clients can be moved from the fire area in bed, by stretcher, or in a wheelchair. If required, however, one or two staff members can move these clients on blankets or carry them.