MS2 ATI prep

A nurse is caring for a male client who has peripheral vascular disease (PVD), is taking dietary supplements, and has a new prescription for warfarin. The nurse should instruct the client to stop which of the following supplements prior to starting the warfarin? ( SATA) a. Saw palmetto b. Flaxseed oil c. Glucosamine d. Black cohosh e. Ginkgo biloba

- Saw palmetto - Glucosamine - Ginkgo biloba

A nurse is planning a staff education session regarding biological weapons of mass destruction. Which of the following should he plan to include in the session? (SATA) a. Sarin b. Smallpox c. Anthrax d. Hydrogen cyanide e. Botulism

- Smallpox - Anthrax - Botulism

A college health nurse interprets the peak expiratory flow rate for a student who has asthma and finds that the student is in the yellow zone of his asthma action plan. The nurse should base her actions on which of the following information? (SATA) a. The nurse should obtain a second expiratory flow rate b. The student needs to go to the hospital c. The students asthma is not well controlled d. The students peak flow is 50% to 80% of his beat peak flow e. The student should use his quick relief inhaler

- The nurse should obtain a second expiratory flow rate - The students asthma is not well controlled - The students peak flow is 50% to 80%of his beat peak flow - The student should use his quick relief inhaler

A nurse is admitting a client who has acute heart failure following myocardial infarction. The nurse recognizes that which of the following prescriptions by the provider requires clarification? a. Morphine sulfate 2 mg IV bolus every 2 hours PRN pain b. Laboratory testing serum potassium upon admission c. 0.9% normal saline IV at 50 ml / hour continuous d. Bumetanide 1 mg IV bolus every 12 hours

0.9% normal saline IV at 50 ml / hour continuous

A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a MVA. Identify the sequence of actions the nurse should take. 1. Perform GCS assessment 2. Establish IV access 3. Open the airway using jaw-thrust maneuver 4. Determine effectiveness of ventilator efforts 5. Remove clothing for a thorough assessment

3,4,2,1,5

A nurse is performing triage for a group of clients following a mass casualty incident (MCI). Which of the following clients should the nurse plan to care for first? a. A client experiencing a tension pneumothorax b. A client who has a closed upper extremity fracture c. A client who has full-thickness burns over 80% of his body d. A client who has agonal respirations

A client experiencing a tension pneumothorax

A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. Which of the following clients should the nurse tag to be the priority for care? a. A client who has severe head injuries, respiratory rate 6/min, and is unresponsive b. A client who has a simple fracture of the femur, multiple scratches on both legs, and is crying hysterically c. A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site d. A female who is pregnant at 20 weeks of gestation, has multiple cuts and abrasions, and is walking around

A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site

A nurse in the emergency department is triaging clients following a mass casualty event. The nurse should identify which of the following clients as emergent? a. A client who has a punctured femoral artery b. A client who has multiple fractures c. A client who has a red rash over his abdomen d. A client who reports severe flank pain radiating to the groin

A client who has a punctured femoral artery

A nurse is triaging clients following a mass casualty event. Which of the following clients should the nurse assess first? a. A client who has a splinted open fracture of a left medial malleolus b. A client who has a massive head injury and is experiencing seizures c. A client who has severe respiratory stridor and a deviated trachea d. A client who has a small partial-thickness burn of the left calf

A client who has severe respiratory stridor and a deviated trachea

A nurse is assisting with triaging clients following an explosion. Which of the following clients should the nurse identify as the highest priority? a. An unconscious adult client who has a large head wound with gray matter exposed; absent respirations b. A conscious adult client who has second-degree burns on both lower legs; respiratory rate is > 30/min c. An unconscious 6-month-old infant with no respirations; no visible injuries d. A conscious adult client wearing a medic-alert diabetic bracelet; client reports feeling clammy and shaky.

A conscious adult client who has second-degree burns on both lower legs; respiratory rate is > 30/min

A nurse is caring for a client Who develops a pulmonary embolism. Which of the following interventions should the nurse implement first? a. Give morphine IV b. Administer oxygen therapy c. Start an IV infusion of lactated ringers d. Initiate cardiac monitoring

Administer oxygen therapy

A nurse is caring for a client who develops an airway obstruction from a foreign body but remains conscious. Which of the following actions should the nurse take first? a. Insert an oral airway. b. Administer the abdominal thrust maneuver. c. Turn the client to the side. d. Perform a blind finger sweep.

Administer the abdominal thrust maneuver.

A nurse is caring for a child who has asthma and a prescription for montelukast granules. Which of the following instructions should the nurse provide to the client's parent when administering the medication? a. Give the medication in the morning daily b. Administer the medication 2 hours before exercise c. Give the medication at the onset of wheezing d. Administer the granules mixed with 20 oz of water

Administer the medication 2 hours before exercise

A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurses highest priority? a. Initiating oxygen therapy b. Providing immediate rest for the client c. Positioning the client in high Fowler's d. Administering a nebulized beta adrenergic

Administering a nebulized beta adrenergic

A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? a. Nausea b. Dysphasia c. Agitation d. Hypotension

Agitation

A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care? a. Airway protection b. Decreasing intracranial pressure c. Stabilizing cardiac arrhythmias d. Preventing musculoskeletal disability

Airway protection

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? a. Soft-tissue edema b. Facial asymmetry c. Active bleeding d. Altered respirations

Altered respirations

A nurse is the triage officer in the emergency department when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first? a. A conscious adult client who reports shortness of breath, RR of 24/min, and cap refill of < 2 seconds b. An unconscious adult client who has a sucking chest wound, RR of 38/min, and cap refill of < 2 seconds c. A conscious adult client who has a dislocated right shoulder, RR of 18/min, and cap refill of < 2 seconds d. An unconscious adult client who has no respirations, cap refill is < 2 seconds, and paramedics have already tried to reposition airway without results

An unconscious adult client who has a sucking chest wound, RR of 38/min, and cap refill of < 2 seconds

A nurse is working with an emergency response team in caring for a group of people who may have been exposed to anthrax while doing farm work, but are not exhibiting manifestation of illness. Which of the following is the appropriate action for the nurse to take? a. Place the clients in isolation. b. Initiate client decontamination. c. Administer antibiotic therapy. d. Treat clients with an antitoxin.

Administer antibiotic therapy.

A nurse in the emergency department is caring for a client who has pulmonary edema, reports dyspnea, and appears anxious. The client blood pressure is 108/79 and his apical pulse is 112. Which of the following interventions is the nurses priority? a. Administer high-flow oxygen at 5L/min by face mask to the client b. Place the client in high Fowler's c. Position with legs dependent d. Give the client sublingual nitroglycerin e. Reassure the client

Administer high-flow oxygen at 5L/min by facemask to the client

A nurse is teaching a client's family about lighting strike prevention following a lightning injury to the client. Which of the following information should the nurse include the teaching? a. Avoid using a corded landline telephone b. Move out of the open area by standing by a tree c. Lie down on the ground d. Seek safety in an isolated shed.

Avoid using a corded landline telephone

A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition? a. Anorexia b. Weight gain c. Breathlessness d. Distended abdomen

Breathlessness

A nurse is caring for a client who was exposed to anthrax. Which of the following antibiotics should the nurse plan to administer? a. Ciprofloxacin b. Fluconazole c. Tobramycin d. Vancomycin

Ciprofloxacin

A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority? a. Defibrillation b. Airway management c. Epinephrine administration d. Amiodarone administration

Defibrillation

A nurse is providing discharge instructions to a client who has asthma and a new prescription for montelukast. The nurse should instruct the client to report which of the following adverse effects to the provider? a. Blurred vision b. Palpitations c. Constipation d. Depression

Depression

A nurse is providing discharge teaching for a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include? a. Take aspirin if headaches develop b. Eat foods that contain plenty of potassium c. Expect some sweating in the hands and feet d. Take the medication at bedtime

Eat foods that contain plenty of potassium

A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect? a. Dependent rubor b. Edema c. Hair loss d. Thick, deformed toenails

Edema

A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions? a. Defibrillation b. Elective cardioversion c. CPR d. Radiofrequency catheter ablation

Elective cardioversion

A nurse working in an emergency room is caring for a client who has third degree frostbite to both lower extremities. The nurse should plan to take which of the following actions? a. Immerse the legs in cool water b. Elevate the legs. c. Massage the legs d. Apply dry heat to the legs.

Elevate the legs.

A nurse in a Cardiac Care Unit is caring for a client with acute right sided heart failure. Which of the following findings should the nurse expect? a. Decreased brain natriuretic peptide b. Elevated central venous pressure c. Increased pulmonary artery wedge pressure d. Decreased specific gravity

Elevated central venous pressure

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? a. Dobutamine b. Methylprednisolone c. Furosemide d. Epinephrine

Epinephrine

The nurse in 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? a. Evaluate chest expansion. b. Check pupillary response to light c. Assess the capillary refill d. Check client's response to questions about place and time.

Evaluate chest expansion.

A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following actions is appropriate? a. Withholding the medication if the heart rate is above 100/minute b. Instructing the client to eat foods that are low in potassium c. Measuring apical pulse rate for 30 seconds before administration d. Evaluating the client for nausea, vomiting, and anorexia

Evaluating the client for nausea, vomiting, and anorexia

A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instruction should the nurse include in the teaching? a. Exercise at least three times per week. b. Take diuretics early in the morning and before bedtime. c. Notify the provider of a weight gain of 0.5 kg (1 lb) in a week d. Take naproxen for generalized discomfort

Exercise at least three times per week.

A nurse is teaching a client who has asthma how to use a metered dose inhaler. The nurse identifies the sequence of steps the client should follow. Move the steps into the box on the right, placing them in the selected order performance. a. Inhale deeply and then exhale completely b. Place lips firmly around mouthpiece c. Breathe in deeply over 2-3 seconds while pushing down on the canister d. Hold breath for 10 seconds e. Exhale slowly through pursed lips f. Wait 60 seconds between each puff

Inhale deeply and then exhale completely > Place lips firmly around mouthpiece > Breathe in deeply over 2-3 seconds while pushing down on the canister > Hold breath for 10 seconds > Exhale slowly through pursed lips > Wait 60 seconds between each puff

A nurse working in an emergency department is caring for a client who has been exposed to sarin gas following a bioterrorism attack. Which of the following interventions should the nurse plan to take? a. Vigorously rub the skin following a decontamination shower. b. Initiate seizure precautions. c. Provide respiratory support with a plastic oral airway. d. Prepare to administer amyl nitrate

Initiate seizure precautions.

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan? a. Restrict the clients food intake to less than 2 L/day b. Provide the client with a low protein diet c. Have the client use the early morning hours for exercise and activity d. Instruct the client to use pursed lip breathing

Instruct the client to use pursed lip breathing

A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client? a. Cryoprecipitates b. Platelets c. Albumin d. Packed RBCs

Packed RBCs

A nurse is triaging victims of a multiple motor-vehicle crash. The nurse assesses a client trapped under a car who is apneic and has a weak pulse at 120/min. After repositioning his upper airway, the client remains apneic. Which of the following actions should the nurse take? a. Start CPR b. Place a red tag on the client's upper body and obtain immediate help from other personnel. c. Place a black tag on the client's upper body and attempt to help the next client in need. d. Reposition the client's upper airway a second time before assessing his respirations

Place a black tag on the client's upper body and attempt to help the next client in need.

A nurse is triaging clients injured during a tornado. The nurse assesses a client who has an open fracture of his arm. Which of the following actions should the nurse take? a. Place a yellow tag on the client's upper body. b. Place a red tag on the client's upper body. c. Perform a rapid head-to-toe assessment. d. Have the client's wife drive him to the hospital

Place a yellow tag on the client's upper body.

A is nurse assisting with field triage following a motor-vehicle crash involving a bus with multiple victims. The nurse assesses a child who has an open fracture of the femur. Which of the following actions should the nurse take? a. Locate the child's parents to obtain consent for treatment. b. Place a yellow triage tag on the child c. Notify the emergency department of the child's imminent arrival. d. Perform a complete head-to-toe assessment.

Place a yellow triage tag on the child

A nurse is caring for a client who is brought into the emergency department immediately following a snake bite to his forearm. The client suspects. The snake to be venomous. Which of the following interventions should the nurse take? a. Apply an ice pack to the site of the bite b. Apply a tourniquet just above the elbow c. Administer a corticosteroid d. Place the extremity in a dependent position

Place the extremity in a dependent position

A nurse is reviewing the lab data on a client who has a new prescription for heparin for treatment of pulmonary embolism. Which of the following data should the nurse report to the provider? a. Hematocrit 45% b. PTT 65 seconds c. WBC 8000/mm3 d. Platelets 74,000/mm3

Platelets 74,000/mm3

A nurse is caring for a client who receives furosemide to treat heart failure. Which of the following laboratory values should the nurse monitor for this client due to this medication? a. Potassium b. Albumin c. Cortisol d. Bicarbonate

Potassium

A client is planning to perform nasotracheal suction for a client who has a COPD and an artificial airway. Which of the following actions should the nurse take? a. Perform suctioning for up to four passes b. Apply suction to the catheter when advancing it into the trachea c. Preoxygenate the client with 100% oxygen for up to 3 min d. Limit each suction pass to 25 seconds

Preoxygenate the client with 100% oxygen for up to 3 min

A nurse is admitting a client who is having exacerbation of his asthma. When reviewing the provider's orders, the nurse recognizes that clarification is needed for which of the following medications? a. Propranolol b. Theophylline c. Montelukast d. Prednisone

Propranolol

A nurse is creating a plan of care for a client who is in the late stage of inhalation anthrax. Which of the following is appropriate to include in the plan of care? a. Provide respiratory support. b. Place the client in droplet isolation. c. Administer antihypertensive medications. d. Monitor ascites.

Provide respiratory support.

A nurse is caring for a client who has heart failure and is receiving IV furosemide. The nurse should monitor the client for which of the following electrolyte imbalances? a. Hypernatremia b. Hyperuricemia c. Hypercalcemia d. Hyperchloremia

Hyperuricemia

A nurse is caring for a client who has heart failure and a new prescription for Furosemide. For which of the following adverse effects should the nurse monitor? a. Hypervolemia b. Hypertension c. Hypokalemia d. Hypoglycemia

Hypokalemia

A nurse is providing discharge instructions for a client who has congestive heart failure. Which of the following client statements indicates to the nurse that the teaching was effective? a. I will read a food labels and limit my sodium to 4 grams per day b. I should use naproxen to manage discomfort c. I plan to slow down if I'm tired the day after exercising d. I will take my diuretic before sleep and drink fluids during the day

I plan to slow down if I'm tired the day after exercising

A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following statements by the client indicates an adverse effect of the medication? a. I can walk a mile a day. b. I've had a back ache for several days. c. I'm urinating more frequently. d. I'm nauseated and have no appetite

I'm nauseated and have no appetite

A nurse is teaching a group of clients about emergency care for a snake bite. Which of the following information should the nurse include in the teaching? a. Raise the affected extremity above the level of the heart b. Immobilize the affected extremity with a splint c. Apply ice to the bite area d. Apply a torniquet to the affected extremity

Immobilize the affected extremity with a splint

A nurse is preparing to administer a 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? (SATA) a. Dyspnea b. Gastrointestinal bloating c. Jugular vein distention d. Confusion e. Hypotension

- Dyspnea - Jugular vein distention - Confusion

A nurse is providing discharge teaching to a client who has asthma and new prescriptions for cromolyn and albuterol, both by nebulizer. Which of the following statements by the client indicates an understanding of the teaching? a. "I will use both medications immediately after exercising." b. "If my breathing begins to feel tight, I will use the cromolyn immediately." c. "I will be sure to take the albuterol before taking the cromolyn." d. "I will administer the medications 10 minutes apart."

"I will be sure to take the albuterol before taking the cromolyn."

A nurse is discussing community responses to disaster with nursing staff. Which of the following statements indicates an understanding of the heroic phase? a. "Personnel are willing to work in dangerous conditions to provide assistance." b. "Survivors come together and share stories of survival." c. "Responders experience exhaustion due to extended relief efforts." d. "Normalcy begins to return to the community."

"Personnel are willing to work in dangerous conditions to provide assistance."

A community health nurse is providing a community education program about disaster preparedness. Which of the following should the nurse recommend that clients include in their family's disaster readiness supply kit or "go bag"? (SATA) a. Pencil and paper b. Whistle c. Antibiotics d. Copies of insurance cards e. Household bleach

- Pencil and paper - Whistle - Copies of insurance cards - Household bleach

A nurse is providing staff education about smallpox as a bioterrorism threat. Which of the following statements indicates an understanding of this agent? (SATA) a. "Smallpox is transmitted person to person." b. "Infection is characterized by severe respiratory distress." c. "Smallpox vaccination ensures lifelong immunity." d. "Naturally occurring smallpox has been eradicated from the world." e. "Smallpox is often confused with varicella."

- "Smallpox is transmitted person to person." - "Naturally occurring smallpox has been eradicated from the world." - "Smallpox is often confused with varicella."

A nurse in the emergency department is preparing to care for a client who received multiple injuries during a fight. The nurse should plan to base his primary survey on which of the following? (SATA) a. Airway b. Cervical spine c. Disability d. Exposure e. Urinary output

- Airway - Disability - Exposure - Cervical Spine

A nurse is planning care for a client who has quadriplegia. Which of the following actions should the nurse take to prevent a pulmonary embolism? (SATA) a. Assess legs for redness b. Apply elastic compression stockings c. Perform passive range of motion exercises d. Place pillows under the client's knees when in bed massage the calves every shift

- Assess legs for redness - Apply elastic compression stockings - Perform passive range of motion exercises

A nurse is preparing a response protocol for botulism as a bioterrorism agent. The nurse should prepare the protocol based on which of the following information? (SATA) a. Botulism can produce paralysis within 12 to 72 hr following exposure. b. Notify the Centers for Disease Control and Prevention (CDC) when more than three cases are confirmed. c. Botulism is acquired through direct contact with an infected person. d. Vomiting and diarrhea are expected findings following exposure. e. Botulism is a toxin found in castor beans.

- Botulism can produce paralysis within 12 to 72 hr following exposure. - Vomiting and diarrhea are expected findings following exposure.

A nurse is caring for a client following exposure to inhalational anthrax due to bioterrorism. Which of the following medications should the nurse expect as a common medication to treat anthrax? (SATA) a. Ciprofloxacin b. Doxycycline c. Amoxicillin d. Penicillin G e. Cefotaxime

- Ciprofloxacin - Doxycycline - Amoxicillin

A nurse is caring for a school-age child who has mild persistent asthma. Which of the following is an expected finding? (SATA) a. Symptoms are continuous throughout the day b. Daytime symptoms occur more than twice a week c. Nighttime symptoms occur approximately twice a month d. Minor limitations occur with normal activity e. Peak expiratory flow is greater than or equal to 80% of the predicted value

- Daytime symptoms occur more than twice a week - Minor limitations occur with normal activity - Peak expiratory flow is greater than or equal to 80% of the predicted value

A nurse is caring for a child who is experiencing status asthmaticus. Which of the following interventions is the priority for the nurse to take? a. Administer a short-acting beta-2 agonist b. Obtain a peak flow reading c. Administer an inhaled glucocorticoid d. Determine the cause of the acute exacerbation

Administer a short-acting beta-2 agonist

A nurse in an emergency department is caring for a client who is bleeding profusely from a deep laceration on his left lower forearm. After observing standard precautions, which of the following actions should the nurse perform first? a. Apply a tourniquet just below the elbow. b. Apply direct pressure over the wound. c. Clean the wound. d. Elevate the limb and apply ice.

Apply direct pressure over the wound.

A nurse in an emergency department is caring for a client who has deep laceration on her left lower forearm and is bleeding heavily from the wound. Which of the following interventions should the nurse perform first? a. Apply a torniquet just above the wound b. Apply pressure directly to the wound c. Start two large-bore IV catheters d. Place the client in a modified Trendelenburg

Apply pressure directly to the wound

A nurse is dining at a restaurant when a woman begins to scream that her husband is choking. Which of the following should the nurse do first? a. Instruct the wife to call 911 b. Ask the victim if he can speak c. Use the jaw-thrust maneuver d. Administer an abdominal thrust

Ask the victim if he can speak

A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. the client reports difficulty breathing. Which of the following actions is the nurses priority? a. Increase the oxygen flow to 3 b. Assess the client's respiratory status c. Call emergency services for the client d. Have the client cough and expectorate secretions

Assess the client's respiratory status

A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia? a. Epinephrine b. Magnesium c. Atropine d. Sodium bicarbonate

Atropine

A nurse is caring for a client who reports that he has a headache and vertigo after turning on his furnace for the first time this season. The nurse should suspect which of the following conditions? a. Carbon monoxide poisoning b. Heat stroke c. Hypersensitivity reaction d. Oxygen toxicity

Carbon monoxide poisoning

A nurse is performing cardiopulmonary resuscitation (CPR) for an adult client who is unresponsive. The nurse should evaluate the client's circulation by palpating which of the following pulses? a. Radial b. Popliteal c. Carotid d. Apical

Carotid

The nurse is caring for a client who has heart failure and a history of asthma. The nurse reviews the provider's orders and recognizes that clarification is needed for which of the following medications? a. Carvedilol b. Fluticasone c. Captopril d. Isosorbide dinitrate

Carvedilol

A nurse enters a client's room and finds him unresponsive. After notifying the rapid response team, which of the following actions should the nurse take first? a. Attach defibrillator pads to the clients b. Check for a carotid pulse c. Begin chest compressions d. Deliver two breaths

Check for a carotid pulse

A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first? a. Check the client's vital signs b. Request a dietitian consult c. Suggest that the client rest before eating the meal d. Request an order for an antiemetic

Check the client's vital signs

A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following should be the nurse's priority intervention? a. Insert an IV line. b. Count the respiratory rate. c. Administer oxygen. d. Prepare equipment for intubation.

Count the respiratory rate.

A nurse is caring for a client who is taking digoxin for heart failure and develops indications of severe digoxin toxicity. Which of the following medication should the nurse prepare to administer? a. Fab antibody fragments b. Flumazenil c. Acetylcysteine d. Naloxone

Fab antibody fragments

A nurse is caring for a client who suspects recent exposure to inhalation anthrax. Which of the following of the following finding indicate possible exposure? a. Flu-like symptoms b. Sloughing of skin c. Vesicles on the skin d. Respiratory failure

Flu-like symptoms

A nurse is caring for an older adult who has left sided heart failure. Which of the following assessment findings should the nurse expect? a. Frothy sputum b. Dependent edema c. Nocturnal edema nocturnal polyuria d. Jugular distention

Frothy sputum

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? a. Jugular venous distention b. Abdominal distention c. Dependent edema d. Hacking cough

Hacking cough

A school nurse receives a call that some children and teachers report being exposed to an undetermined noxious gas odor presenting in the classrooms and are experiencing dizziness. Which of the following actions should the nurse take? a. Have students evacuated from the school and establish a triage area in the school parking lot. b. Move individuals who are reporting symptoms to one of the affected classrooms and create a triage area inside the room. c. Arrange for client transportation to the nearest emergency department and tell the group triage will occur there. d. Transport all children and school personnel to the nearest medical facility using school

Have students evacuated from the school and establish a triage area in the school parking lot.

A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering? a. Furosemide b. Dexamethasone c. Heparin d. Atropine

Heparin

A nurse is collaborating on care for a client who has COPD. Which of the following tasks should the nurse recommend be referred to an occupational therapist for assistance? a. Instructing how to measure oxygen saturations b. Instructing how to use kitchen tools to prepare a meal c. Instruction how to plan a diet based on individual caloric needs d. Instructing how to perform pursed-lip breathing

Instructing how to use kitchen tools to prepare a meal

A nurse is assessing a client who has heart failure and is prescribed furosemide. Which of the following findings is an adverse effect of this medication? a. Weight gain b. Increased blood pressure c. Hypoglycemia d. Leg cramps

Leg cramps

A nurse is reviewing the guidelines for reporting nationally notifiable infectious diseases. Which of the following diseases should the nurse plan to report to the Centers for Disease Control and Prevention (CDC)? a. Lyme disease b. Cytomegalovirus c. Streptococcus pharyngitis d. Toxoplasmosis

Lyme disease

A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion? a. Sudden lethargy. b. Muffled heart sounds. c. Flattened neck veins. d. Bradycardia

Muffled heart sounds.

A nurse is discussing emergency response with a newly licensed nurse. The nurse should identify which of the following is a triage officer during the time of a disaster? a. Members of the Federal Emergency Management Agency (FEMA) b. Responding law enforcement officers c. Representatives from the American Red Cross d. Nurses and other emergency medical personnel

Nurses and other emergency medical personnel

A nurse in an emergency department is assessing a client who was bitten on the left leg by a poisonous snake. The client has placed elastic bandages snuggly above and below the bite marks and is in no apparent distress. Which of the following actions should the nurse take? a. Discharge the client. b. Obtain a prescription for the appropriate anti-venom. c. Remove both of the elastic bandages from the leg d. Obtain a prescription for pain medication

Obtain a prescription for the appropriate anti-venom.

A nurse is working with an interdisciplinary disaster committee to develop a community wide emergency response plan in the event of a non biological or chemical incident. The nurse should include which of the following agencies to be notified immediately after calling 911? a. Office of Emergency Management (OEM) b. Federal Emergency Management Agency (FEMA) c. American Red Cross (ARC) d. U.S. Department of Homeland Security (DHS)

Office of Emergency Management (OEM)

A nurse witnesses a motor vehicle crash and finds a client who is not breathing. The nurse suspects the client has a cervical vertebrae fracture. Which of the following actions should the nurse take first? a. Place the client in a rigid cervical collar. b. Open the client's airway using the jaw-thrust maneuver. c. Evaluate the client for other injuries. d. Complete a neurological check on the client.

Open the client's airway using the jaw-thrust maneuver.

A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis? a. Oral mucosa b. Conjunctivae c. Earlobes d. Soles of the feet

Oral mucosa

A nurse is providing teaching to a client who has asthma and a new prescription for inhaled beclomethasone. Which of the following instructions should the nurse provide? a. Check the pulse after medication administration b. Take the medication with meals c. Rinse the mouth after administration d. Limit caffeine intake

Rinse the mouth after administration

A nurse is caring for a client involved in a suspected bioterrorism event involving exposure to cutaneous anthrax. Which of the following manifestations should the nurse anticipate? a. Respiratory distress b. Flu-like symptoms c. Skin lesions with pruritus d. Bloody diarrhea

Skin lesions with pruritus

A nurse is reviewing treatment protocols for clients exposed to bioterrorism agents. For which of the following agents should the nurse plan to administer a vaccine following exposure? a. Anthrax b. Botulism c. Plague d. Smallpox

Smallpox

A charge nurse is conducting an in-service about smallpox with a group of nurses. Which of the following statements should the nurse include in the teaching? a. Healthcare workers should receive a yearly vaccination for smallpox b. Smallpox lesions appear similar those of the varicella zoster virus c. Smallpox is a current epidemic in third-world countries d. Smallpox is infectious prior to the development of the maculopapular rash

Smallpox lesions appear similar those of the varicella zoster virus

A nurse is providing instruction to a new nurse about caring for clients who are receiving diuretic therapy to treat heart failure. The nurse should explain that which of the following medications puts the clients at risk for both hyperkalemia and hyponatremia? a. Furosemide b. Hydrochlorothiazide c. Metrolazone d. Spironolactone

Spironolactone

The nurse enters an adult patient's room and finds him unresponsive. After determining that the client is not breathing and does not have a pulse, which of the following actions should the nurse take first? a. Summon the code team b. Begin chest compressions c. Administer rescue breathing d. Open the client's airway

Summon the code team

A nurse is providing discharge instructions to a client who has asthma and is about to start taking theophylline. The nurse should tell the client that this medication might cause which of the following adverse effects? a. Drowsiness b. Constipation c. Oliguria d. Tachycardia

Tachycardia

A nurse in a long term care facility is assisting a client with eating during meal time and recognizes another client indicating he is choking. Which of the following situations requires immediate intervention by the nurse? a. The client has a high-pitched stridor b. The client is able to whisper c. The client is coughing only d. The client is not making any sounds

The client is not making any sounds

A nurse is teaching a client who has a new diagnosis of venous insufficiency. Which of the following instruction should the nurse include? a. Apply ice packs to your legs. b. Use elastic stockings. c. Remain on bed rest. d. Place your legs in a dependent position while in bed.

Use elastic stockings.

A nurse is providing discharge teaching to a client who has asthma and a new prescription for fluticasone/salmeterol. For which of the following adverse effects should the nurse instruct the client to report to the provider? a. Sedation b. Increased appetite c. White coating in the mouth d. Dry oral mucous membrane

White coating in the mouth

A nurse is caring for a client who is postoperative following an intermaxillary fixation as a result of multiple facial fractures. Which of the following types of equipment should the nurse plan to have at the client's bedside? a. Wire cutters b. NG tube c. Urinary catheter tray d. IV infusion pump

Wire cutters