Orange Book - Critical Care

the nurse has received a prescription to transfuse a client with a unit of packed RBCs. before explaining the procedure to the client, the nurse should ask which initial question? a. "have you ever had a transfusion before?" b. "why do you think that you need the transfusion?" c. "have you ever gone into shock for any reason in the past?" d. "do you know the complications and risks of a transfusion?"

a. "have you ever had a transfusion before?" asking the client about personal experience with transfusion therapy provides a good starting point for client teaching about this procedure. questioning about previous history of shock and knowledge of complications and risks of transfusion is not helpful because it may elicit a fearful response from the client. although determining whether the client knows the reason for the transfusion is important, it is not a appropriate statement in terms of eliciting information from the client regarding an understanding of the need for the transfusion. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Blood Administration Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Safety Strategy(ies): Strategic Words, Therapeutic Communication Techniques

the nurse has discontinued a unit of blood that was infusing into a client because the client experienced a transfusion reaction. after documenting the incident appropriately, the nurse sends the blood bag and tubing to which department? a. blood bank b. infection control c. risk management d. environmental services

a. blood bank the nurse returns the blood transfusion bag containing any remaining blood to the blood bank. this allows the blood bank to complete any follow-up testing procedures needed once a transfusion reaction has been documented. the other options identify incorrect departments.

the nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. the nurse takes which actions in order to prevent a complication of the blood transfusion as it related to deterioration of blood cells? select all that apply a. checks the expiration date b. inspects for presence of clots c. checks the blood group and type d. checks the blood ID number e. hangs the blood within the specified time frame per agency policy

a. checks the expiration date e. hangs the blood within the specified time frame per agency policy the nurse notes that the expiration date on the unit of blood to ensure that the blood is fresh. blood cells begin to deteriorate over time, so safe storage usually is limited to 35 days. careful notation of the expiration date by the nurse is an essential part of the verification process before hanging a unit of blood. the nurse also needs to hang the blood within the specified time frame after receiving it from the blood bank per agency policy to ensure that the blood being transfused is fresh. the blood bank keeps the blood regulated at a specific temperature, and therefore it must be infused within a specified time frame once received on the unit. the nurse also notes the blood ID (unit) number, blood group and type, and client's name, but this is not specifically RT the degradation of blood cells. the nurse also inspects the unit for leaks, abnormal color, clots, bubbles, and returns the unit to the blood bank if clots are noted. again, this is not RT the degradation of blood cells over time. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Blood Administration Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Safety Strategy(ies): Subject

a client begins to experience drainage of small amounts of bright red blood from the trach tube 24 hours after supraglottic laryngectomy. which is the best nursing action? a. notify the PHCP b. increase the frequency of suctioning c. add moisture to the O2 delivery system d. document the character and amount of drainage

a. notify the PHCP immediately after laryngectomy, a small amount of bleeding occurs from the trach that resolves within the first few hours. otherwise, bleeding that is bright red may be a sign of impending rupture of a vessel. the bleeding in this instance represents a potential threat to life, and the PHCP is notified to further evaluate the client and suture or repair the source of the bleeding. the other options do not address the urgency of the problem. failure to notify PHCP places the client at risk. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Respiratory: Upper Airway Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Clotting Strategy(ies): Strategic Words

which should the nurse do when setting up an arterial line? a. tighten all tubing connections b. use macro-drip IV tubing c. level the transducer to the ventricle d. raise the height of the NS infusion to prevent backup

a. tighten all tubing connections because the arterial vasculature is a high-pressure system, all tubing connections must be tight to avoid blood loss from loose connections. high-pressure tubing with a transducer is used (not macro-drip tubing). the transducer should be level to the atrium, not the ventricle. raising the height of the infusion is not sufficient to prevent backflow. Client Needs: Safe and Effective Care Environment Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Subject

the nurse is caring for a client who overdosed on ASA 24 hours ago. the nurse should expect to note which findings associated with an anticipated acid-base disturbance? a. disorientation and dyspnea b. drowsiness, HA, tachypnea c. tachypnea, dizziness, paresthesias d. decreased RR and depth, cardiac irregularities

b. drowsiness, HA, tachypnea the client who ingests a large amount of ASA is at risk for developing metabolic acidosis 24 hours later. if metabolic acidosis occurs, the client is likely to exhibit drowsiness, headache, and tachypnea. in the very early hours following aspirin overdose, the client may exhibit respiratory alkalosis as a compensatory mechanism. however, by 24 hours post overdose, the compensatory mechanism fails, and the client reverts to metabolic acidosis. the client with metabolic alkalosis (option 4) is likely to experience cardiac irregularities and a compensatory decreased RR and depth. options 1 and 3 indicate respiratory acidosis and alkalosis, respectively. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Poisoning Integrated Process: Nursing Process/Assessment Priority Concepts: Acid-Base Balance, Clinical Judgment Strategy(ies): Subject

the nurse should report which assessment finding to the PHCP before initiating thrombolytic therapy in a client with PE? a. adventitious breath sounds b. temp of 99.4 F (37.4 C) orally c. BP of 198/110 d. RR of 28 breaths/min

c. BP of 198/110 thrombolytic therapy is contraindicated in a number of preexisting conditions in which there is a risk of uncontrolled bleeding, similar to the case in anticoagulant therapy. thrombolytic therapy also is contraindicated in severe uncontrolled HTN because of the risk of cerebral hemorrhage. therefore, the nurse would report the results of the BP to the PHCP before initiating therapy. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Clotting Strategy(ies): Subject

the nurse is reviewing the medical record of a client transferred to the medical unit from the critical care unit. the nurse notes that the client received intra-aortic balloon pump (IABP) therapy while in the critical care unit. the nurse suspects that the client received this therapy for which condition? a. HF b. pulmonary edema c. cardiogenic shock d. aortic insufficiency

c. cardiogenic shock IABP therapy is most often used in treatment of cardiogenic shock and is most effective if instituted early in the course of treatment. use of IABP therapy is contraindicated in clients with aortic insufficiency and thoracic and abdominal aneurysms. this therapy is not used in the treatment of CHF or pulmonary edema. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Integrated Process: Nursing Process/Analysis Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Comparable or Alike Options

the nurse overhears a PHCP that a client diagnosed with DIC requires a transfusion. which blood product should the nurse anticipate that the PHCP will write a prescription for? a. albumin b. platelets c. cryoprecipitate d. packed RBCs

c. cryoprecipitate cryoprecipitate is useful in treating bleeding from hemophilia or DIC because it is rich in clotting factors. albumin may be used as a plasma expander in hypovolemia with or without shock. platelets are used when the client's platelet count is low. packed RBCs replace erythrocytes, not fibrinogen. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Blood Administration Health Problem: Adult Health: Hematological: Bleeding/Clotting Disorders Integrated Process: Nursing Process/Planning Priority Concepts: Clotting, Collaboration Strategy(ies): Subject

a client is brought to the ED having experienced blood loss related to an arterial laceration. which blood component should the nurse expect the PHCP to prescribe? a. platelets b. granulocytes c. fresh-frozen plasma d. packed RBCs

c. fresh-frozen plasma fresh-frozen plasma is often for volume expansion as a result of fluid and blood loss. it is rich in clotting factors and can be thawed quickly and transfused quickly. platelets are used to treat thrombocytopenia and platelet dysfunction. granulocytes may be used to treat a client with sepsis or a neutropenic client with an infection that is unresponsive to antibiotics. packed RBCs are a blood product used to replace erythrocytes. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Blood Administration Integrated Process: Nursing Process/Planning Priority Concepts: Clinical Judgment, Fluid and Electrolyte Balance Strategy(ies): Subject

the client has developed a-fib, with a ventricular rate of 150 BPM. the nurse should assess the client for which associated s/s? a. flat neck veins b. N/V c. hypotension and dizziness d. HTN and HA

c. hypotension and dizziness the client with uncontrolled a-fib with a ventricular rate > 100 BPM is at risk for low CO becayse of loss of atrial kick. the nurse assesses the client for palpitations, chest pain/discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, SOB, and distended neck veins. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Cardiovascular: Dysrhythmias Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Subject

a client who has just suffered a large flail chest is experiencing severe pain and dyspnea. the client's CVP is rising, and the arterial BP is falling. which condition should the nurse interpret that the client is experiencing? a. fat embolism b. mediastinal shift c. mediastinal flutter d. hypovolemic shock

c. mediastinal flutter the client with severe flail chest will have significant paradoxical chest movement. this causes the mediastinal structures to swing back and forth with respiration. this movement can affect hemodynamics. specifically, the client's CVP rises, the filling of the R side of the heart is impaired, and the arterial BP falls. this is referred to as mediastinal flutter. the client with fat embolism experiences chest pain and dyspnea, but this condition occurs as a complication of a bone fracture. mediastinal shift is a condition in which the structures of the mediastinum shift or move to the opposite side of the chest cavity; this may be caused by a pleural effusion or tension pneumothorax. in hypovolemic shock, the BP falls and the pulse rises; this occurs following hemorrhage. Client Needs: Physiological Integrity Cognitive Ability: Synthesizing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Respiratory: Chest Injuries Integrated Process: Nursing Process/Assessment Priority Concepts: Gas Exchange, Perfusion Strategy(ies): Subject

the post-op client receives a dose of naloxone hydrochloride for respiratory depression shortly after transfer to the nursing unit from the PACU. after administration of the medication, the nurse should assess the client for which change? a. pupillary changes b. scattered lung wheezes c. sudden increase in pain d. sudden episodes of vomiting

c. sudden increase in pain naloxone hydrochloride is an antidote to opioids, and it also may be given to post-op patients to treat respiratory depression. when given to post-op patients to treat respiratory depression, it may reverse the effects of analgesics. therefore, the nurse must assess the client for a sudden increase in the level of post-op pain. the remaining options are unrelated to the administration of naloxone. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Gas Exchange Strategy(ies): Subject

a client is brought to the ED immediately after a smoke inhalation injury. the nurse initially prepares the client for which treatment? a. pain medication b. ETT intubation c. O2 via NC d. 100% humidified O2 by face mask

d. 100% humidified O2 by face mask with a smoke inhalation injury, the client is immediately treated with 100% humidified O2 delivered by face mask. this method provides a greater concentration of O2 than O2 delivered via NC. ETT intubation is needed if the client exhibits respiratory stridor, which indicates airway obstruction. pain medication may be needed but would not be the initial intervention. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Respiratory: Upper Airway Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Gas Exchange Strategy(ies): ABCs-Airway, Breathing, Circulation, Strategic Words

a PAC is inserted into a client during cardiac surgery. the nurse is monitoring the RA pressure (RAP). which finding requires immediate nursing intervention? a. 4 mmHg b. 6 mmHg c. 8 mmHg d. 12 mmHg

d. 12 mmHg the normal RAP is 1-8 mmHg; therefore, (a), (b), and (c) are all within normal range. an elevated RAP can be indicative of RV failure. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Emergency Situations/ Management Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Subject, Strategic Words

a client in v-fib is about to be defibrillated. to convert this rhythm effectively, the monophasic defibrillator machine should be set at which energy level (in joules, J) for the first delivery? a. 50 J b. 120 J c. 200 J d. 360 J

d. 360 J the energy level used for all defibrillation attempts with a monophasic defibrillator is 360 J. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Basic Life Support/CPR/ Cardiac Arrest Health Problem: Adult Health: Cardiovascular: Dysrhythmias Integrated Process: Nursing Process/Implementation Priority Concepts: Perfusion, Safety Strategy(ies): Subject

fetal distress is occurring with a laboring client. as the nurse prepares the client for a cesarean birth, what is the most important nursing action? a. slow the IV flow rate b. continue the oxytocin drip if infusing c. place the client in a high Fowler's position d. administer O2, 8-10 L/min via face mask

d. administer O2, 8-10 L/min via face mask O2 is administered, 8-10 L/min, via face mask to optimize oxygenation of the circulating blood. (a) is incorrect, because the IV infusion should be increased (per PHCP prescription) to increase the maternal blood volume. (b) is incorrect, because oxytocin stimulation of the uterus is discontinued if fetal heart rate patterns change for any reason. (c) is incorrect because the client is placed in the lateral position with her legs raised to increase maternal blood volume and improve fetal perfusion. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Maternity: Fetal Distress/Demise Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): ABCs-Airway, Breathing, Circulation, Strategic Words

the nurse has just received a unit of packed RBCs from the blood bank for transfusion to an assigned client. the nurse is careful to select tubing especially made for blood products, knowing that this tubing is manufactured with which item? a. tinted tubing b. injection port in the tubing c. micro-drip d. in-line filter

d. in-line filter the tubing used for blood admin has an in-line filter. the filter helps to ensure that any particles larger than the size of the filter are caught inn the filter and are not infused into the client. tinted tubing is incorrect because blood does not need to be protected from light. an injection port I the tubing is unnecessary because medication should not be added to blood. the tubing should be macro-drip, not micro-drip, to allow blood to flow freely through the drip chamber. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Blood Administration Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Safety Strategy(ies): Subject

a child undergoes surgical removal of a brain tumor. during the post-op period, the nurse notes that the child is restless, the HR is elevated, and the BP has decreased significantly from the baseline value. the nurse suspects that the child is in shock. which is the most appropriate nursing action? a. place the child in a supine position b. place the child in Trendelenburg's position c. increase the flow rate of the IV fluids d. notify the PHCP

d. notify the PHCP In the event of shock, the PHCP is notified immediately before the nurse changes the child's position or increases intravenous fluids. After craniotomy, a child is never placed in the supine or Trendelenburg's position because it increases intracranial pressure (ICP) and the risk of bleeding. The head of the bed should be elevated. Increasing intravenous fluids can cause an increase in ICP. Client Needs: Physiological Integrity Cognitive Ability: Synthesizing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Pediatric-Specific: Cancers Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Intracranial Regulation Strategy(ies): Strategic Words, Subject

the nurse is caring for a client who sustained multiple fractures in a MVC 12 hours earlier. the client now exhibits severe dyspnea, tachycardia, and mental confusion, and the nurse suspects fat embolism. which is the initial nursing action? a. reassess the VS b. palpate bilateral peripheral pulses c. perform a neuro assessment d. position the client in a Fowler's position

d. position the client in a Fowler's position clients with fractures are at risk for fat embolism. with suspected fat embolism, the nurse would position the client in a sitting (Fowler's) position to relieve dyspnea. supp O2 is indicated to reduce the s/s of hypoxia. the PHCP needs to be notified. VS will need to be taken, but this action may delay initial and required interventions. peripheral pulse assessment is not a priority action. a neuro assessment needs to be performed, but this would not be the initial nursing action. Client Needs: Physiological Integrity Cognitive Ability: Synthesizing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Musculoskeletal: Skeletal Injury Integrated Process: Nursing Process/Implementation Priority Concepts: Gas Exchange, Perfusion Strategy(ies): Data in the Question, Strategic Words

the nurse is picking up a unit of packed RBCs at the hospital blood bank. after putting the pen down, the nurse glances at the clock, which reads 1300. the nurse calculates that the transfusion must be started by which time? a. 1330 b. 1400 c. 1430 d. 1500

a. 1330 blood must be hung asap (within 30 min) after it is obtained from the blood bank. after that time, the blood temperature will be higher than 50 F (10 C), and the blood could be unsafe for use. if blood will not be used within 30 minutes, it should be returned to the blood bank. for this reason, the remaining options are incorrect. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Blood Administration Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Safety Strategy(ies): Subject

the nurse walking in a downtown business area witnesses a worker fall from a ladder. the nurse rushes to the victim who is unresponsive. a layperson is attempting to perform resuscitative measures. the nurse should intervene if which action by the layperson is noted? a. use of the head tilt-chin lift b. checking the scene for safety c. use of the jaw thrust maneuver d. moving the client away from a busy traffic road

a. use of the head tilt-chin lift whenever a neck injury is suspected, the jaw thrust maneuver should be used during BLS to open the airway. the head tilt-chin lift produces hyperextension of the neck and could cause complications if a neck injury is present. the scene should be checked for safety, and the client should be moved away from a busy traffic road in order to ensure safety. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Basic Life Support/CPR/ Cardiac Arrest Health Problem: Adult Health: Neurological: Head Injury/Trauma Integrated Process: Nursing Process/Implementation Priority Concepts: Gas Exchange, Safety Strategy(ies): Comparable or Alike Options, Subject

the nurse determines that a client is having a transfusion reaction. after the nurse stops the transfusion, which action should be taken next? a. remove the IV line b. run a solution of 5% dextrose in water c. run NS at a keep-vein-open rate d. obtain a culture of the tip of the catheter device removed from the client

c. run NS at a keep-vein-open rate if the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses NS at a keep-vein-open rate pending further PCHP prescriptions. this maintains a patent IV access line and aids in maintaining the client's IV volume. the nurse would not remove the IV line because the there would be no IV access route. obtaining a culture of the tip of the catheter device removed from the client is incorrect. first, the catheter should not be removed. second, cultures are performed when infection, not transfusion reaction, is suspected. NS is the solution of choice over solutions containing dextrose because saline does not cause RBC to clump. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Blood Administration Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Safety Strategy(ies): Strategic Words

to perform defibrillation, the defibrillator pads should be placed in which areas of the client's chest? a. behind the right and left shoulders in the scapular area b. 1 inch below the sternum and 4 inches to the left of the sternum c. 1 inch below the umbilicus and 2 inches to the right of the left nipple d. to the right of the sternum just below the clavicle and to the left side, just below and to the left of the pectoral muscle

d. to the right of the sternum just below the clavicle and to the left side, just below and to the left of the pectoral muscle the anterior-apex placement works well for defibrillation and cardioversion, as well as for monitoring an ECG. in this placement, the anterior pad is placed on the right, below the clavicle. the other is applied to the left side of the client, just below and to the left of the pectoral muscle. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Basic Life Support/CPR/ Cardiac Arrest Health Problem: Adult Health: Cardiovascular: Dysrhythmias Integrated Process: Nursing Process/Implementation Priority Concepts: Gas Exchange, Perfusion Strategy(ies): Subject

the nurse is providing care for a client with new onset of a-fib. the nurse anticipates which prescriptions from the PHCP? select all that apply. a. O2 therapy b. an echo c. an IV does of metoprolol d. 1 dose of atropine to promote slowing of the rate e. a bolus of IV heparin followed by a continuous infusion

a. O2 therapy b. an echo c. an IV does of metoprolol e. a bolus of IV heparin followed by a continuous infusion in a-fib, the ventricles often beat with a rapid rate in response to the numerous atrial impulses. heart dilation and blood pooling in the atria can lead to thrombus formation, which increases the risk for stroke or other embolic events; therefore, heparin is indicated. the rapid and irregular ventricular rate decreases ventricular filling and reduces CO, further impairing the heart's perfusion ability. therefore, O2 and metoprolol (to slow the ventricular response) are appropriate. an echo will help to assess heart valve function because mitral valve disease can lead to a-fib. atropine will increase the heart rate further. Client Needs: Physiological Integrity Cognitive Ability: Synthesizing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Cardiovascular: Dysrhythmias Integrated Process: Nursing Process/Planning Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Subject

a client in the postpartum unit complains of sudden, sharp chest pain. the client is tachycardic, and the RR is increased. the PHCP diagnoses a PE. which actions should the nurse plan to take? select all that apply. a. administer O2 b. assess the BP c. start an IV line d. prepare to administer warfarin sodium e. prepare to administer morphine sulfate f. place the client on bed rest in a supine position

a. administer O2 b. assess the BP c. start an IV line e. prepare to administer morphine sulfate if PE is suspected, O2 is administered to decrease hypoxia. the client also is kept on bed rest, with the HOB elevated to reduce dyspnea. morphine sulfate may be prescribed for the client to reduce pain and apprehension. an IV line also will be required, and VS must be monitored. heparin therapy (not warfarin sodium) is administered. Client Needs: Physiological Integrity Cognitive Ability: Synthesizing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Respiratory: Pulmonary Embolism Integrated Process: Nursing Process/Planning Priority Concepts: Clotting, Perfusion Strategy(ies): ABCs-Airway, Breathing, Circulation

a new nursing graduate is caring for a client who is attached to a cardiac monitor. while assisting the client with bathing, the nurse observes the sudden development of v-tach, but the client remains A&O and has a pulse. which interventions would the nurse take? select all that apply. a. administer O2 b. defibrillate the client c. obtain ECG d. contact the PHCP e. assess circulation, airway, and breathing f. initiate CPR

a. administer O2 c. obtain ECG d. contact the PHCP e. assess circulation, airway, and breathing with v-tach, in a stable client, the nurse assesses circulation, airway, and breathing; administers O2; and confirms the rhythm via a 12-lead ECG. the PHCP is contacted, and antidysrhythmics may be prescribed. with pulseless v-tach, the PHCP or a specially trained nurse must immediately defibrillate the client or initiate CPR followed by defibrillation asap. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Cardiovascular: Dysrhythmias Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Subject

a client is admitted to the hospital with a diagnosis of neurogenic shock after a traumatic MVC. which manifestation best characterizes this diagnosis? a. bradycardia b. hyperthermia c. hypoglycemia d. increased CO

a. bradycardia neurogenic shock can occur after a spinal cord injury. usually the body attempts to compensate massive vasodilation by becoming tachycardic to increase the amount of blood flow and O2 delivered to the tissues; however, in neurogenic shock, the SNS is disrupted, so the PSNS takes over, resulting in bradycardia. this insufficient pumping of the heart leads to decreased CO. hypoglycemia is not an indicator of neurogenic shock. hypothermia develops because of vasodilation and the inability to control body temp through vasoconstriction.

acetylcysteine is prescribed for a client in the hospital ED after diagnosis of acetaminophen OD. the nurse prepares to administer the medication using which procedure? a. diluting the medication in cola and administering it to the client orally b. calling the RT to administer via inhaler c. obtaining a 1-mL syringe to administer the small dose via subQ route d. obtaining an appropriate size syringe and need for IM injection in the ventrogluteal muscle

a. diluting the medication in cola and administering it to the client orally acetylcysteine can be given orally or by NGT to treat acetaminophen OD. it is administered by inhalation for use as a mucolytic. before administration of the medication as an antidote, the nurse would ensure that the client's stomach is empty through emesis for gastric lavage. the solution is diluted in cola, water, or juice to make the solution more palatable. it is not administered via nebulizer, subQ, or IM for the client experiencing acetaminophen OD. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Emergency Situations/ Management Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Safety Strategy(ies): Subject

an ED nurse is caring for a child with suspected acute epiglottitis. which nursing interventions apply in the care of this child? select all that apply. a. ensure a patent airway b. obtain a throat culture c. maintain the child in a supine position d. obtain a pediatric-size trach tray e. prepare the child for a chest radiographic study f. place the child on an O2 sat monitor

a. ensure a patent airway d. obtain a pediatric-size trach tray e. prepare the child for a chest radiographic study f. place the child on an O2 sat monitor acute epiglottitis is a serious obstructive inflammatory process that requires immediate intervention. the nurse immediately ensures a patent airway. to reduce respiratory distress, the child should sit upright. examining the throat with a tongue depressor or attempting to obtain a throat culture is contraindicated because it could precipitate further obstruction. a CBC is obtained, and the child is placed on an O2 sat monitor. lateral neck and chest radiographic films are obtained to determine the degree of obstruction, if present. a pediatric-size trach tray should be readily available, and intubation may be necessary if respiratory distress is severe. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Gas Exchange Strategy(ies): ABCs-Airway, Breathing, Circulation

a client with depression receiving phenelzine sulfate suddenly complains of a severe HA and neck stiffness and soreness and then begins to vomit. the nurse takes the client's BP and notes that it is 210/102. on the basis of the findings, the nurse should obtain which medication from the emergency drawer of the medication cart? a. phentolamine b. protamine sulfate c. calcium gluconate d. phenobarbital sodium

a. phentolamine the antidote for HTN crisis is phentolamine. HTN crisis may be manifested by HTN, occipital HA radiating frontally, neck stiffness and soreness, N/V, sweating, fever/chills, clammy skin, dilated pupils, and palpitations. tachycardia or bradycardia and constricting chest pain also may be present. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Safety Strategy(ies): Subject

the nurse has a prescription to administer acetylcysteine to a client admitted to the ED with acetaminophen OD. before giving this medication, what is the nurse's best action? a. administer the full-strength solution b. empty the stomach by emesis or lavage c. check that the antidote is readily available d. ensure that the client knows how to use a nebulizer

b. empty the stomach by emesis or lavage acetylcysteine can be given orally or by NGT to treat acetaminophen OD, or it may be given by inhalation for use as a mucolytic. before giving the medication as an antidote to acetaminophen, the nurse ensures that the client's stomach is empty through emesis or gastric lavage. the solution is diluted in cola, water, or juice to make it more palatable. it is then administered orally or by NGT. acetylcysteine is the antidote to acetaminophen. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Safety Strategy(ies): Subject

the nurse is assessing a client hospitalized with acute pericarditis. the nurse monitors the client for cardiac tamponade, knowing that which signs are associated with this complication of pericarditis? select all that apply. a. bradycardia b. pulsus paradoxus c. distant heart sounds d. falling BP e. distended jugular veins

b. pulsus paradoxus c. distant heart sounds d. falling BP e. distended jugular veins assessment findings with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention, and a falling BP, accompanied by pulses paradoxus (a drop in inspiratory BP by more than 10 mmHg). Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Cardiovascular: Inflammation and Structural Heart Disorders Integrated Process: Nursing Process/Assessment Priority Concepts: Gas Exchange, Perfusion Strategy(ies): Subject

a client with MI is developing cardiogenic shock. because of the risk of myocardial ischemia, what condition should the nurse carefully assess the client for? a. bradycardia b. ventricular dysrhythmias c. rising DBP d. falling CVP

b. ventricular dysrhythmias classic signs of cardiogenic shock as they relate to myocardial ischemia include low BP and tachycardia. the CVP would rise as the backward effects of the severe LV failure became apparent. dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Cardiovascular: Myocardial Infarction Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Subject

the nurse is performing an assessment on a client admitted to the nursing unit who has sustained an extensive burn injury involving 45% of TBSA. when planning for fluid resuscitation, the nurse should consider that fluid shifting to the interstitial spaces is greatest during which time period? a. immediately after the injury b. within 12 hours after the injury c. between 18-24 hours after the injury d. between 42-72 hours after the injury

c. between 18-24 hours after the injury the maximum amount of edema in a client with a burn injury is seen between 18-24 hours after the injury. with adequate fluid resuscitation, the transmembrane potential is restored to normal within 24-36 hours after the burn. the remaining options are incorrect. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Integumentary: Burns Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Tissue Integrity Strategy(ies): Subject

which clinical manifestations of a tension pneumothorax should be of immediate concern to the nurse? select all that apply. a. bradypnea b. flattened neck veins c. decreased CO d. hyper-resonance to percussion e. tracheal deviation to the opposite side

c. decreased CO d. hyper-resonance to percussion e. tracheal deviation to the opposite side tension pneumothorax is the rapid accumulation of air in the pleural space. this causes extremely high intraplerual pressures, resulting in tension on the heart and great vessels. this can cause decreased CO (tachycardia, hypotension), hyper-resonance on percussion, and a tracheal shift away from the affected side. bradypnea and flattened neck veins are incorrect because the client would have tachypnea and distended neck veins. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Respiratory: Pneumothorax Integrated Process: Nursing Process/Assessment Priority Concepts: Gas Exchange, Perfusion Strategy(ies): Strategic Words, Subject

the nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. there are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 BPM. the nurse determines that the client is experiencing which dysrhythmia? a. sinus tachycardia b. v-fib c. v-tach d. PVCs

c. v-tach v-tach is characterized by the absence of P waves, wide QRS complexes (longer than 0.12 seconds), and typically a rate between 140-180 impulses/min. the rhythm is regular. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Cardiovascular: Dysrhythmias Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Data in the Question, Subject

the nurse has a prescription to administer packed RBCs to client who does not currently have an IV line inserted. when obtaining supplies to start the blood infusion, the nurse should select an angiocatheter of at least which size? a. 19 gauge b. 21 gauge c. 24 gauge d. 26 gauge

a. 19 gauge blood components are usually administered with at least a 19-gauge needle, cannula, or catheter. larger sizes (18-16) may be preferred if rapid transfusions are given. smaller needles can be used for platelets, albumin, and clotting factor replacement. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Blood Administration Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Safety Strategy(ies): Subject

the nurse is planning care for a client being admitted to the nursing unit who attempted suicide. which priority nursing intervention should the nurse include in the plan of care? a. 1:1 suicide precautions b. suicide precautions with 30-min checks c. checking the whereabouts of the client q15min d. asking the client to report suicidal thoughts immediately

a. 1:1 suicide precautions 1:1 suicide precautions are required for a client who has attempted suicide. options (b) and (c) may be appropriate, but not at the present time, considering the situation. option (d) also may be an appropriate nursing intervention, but the priority is identified in the correct option. the best intervention is constant supervision so that the nurse may intervene as needed if the client attempts to harm herself/himself. Client Needs: Safe and Effective Care Environment Cognitive Ability: Applying Content Area: Complex Care: Emergency Situations/ Management Health Problem: Mental Health: Suicide Integrated Process: Nursing Process/Implementation Priority Concepts: Caregiving, Safety Strategy(ies): Strategic Words

the nurse is caring for a client with CKD on CRRT without the use of a hemodialysis machine. the nurse determines that which parameter is most important in ensuring success of this treatment? a. MAP b. systolic BP c. diastolic BP d. CVP

a. MAP CRRT provides continuous ultrafiltration of extracellular fluid and clearance of urinary toxins over a period of 8-24 hours; it is used primarily for clients with AKI or critically ill clients with CKD who cannot tolerate hemodialysis. water, electrolytes, and other solutes are removed as the client's blood passes through a hemofilter. if CRRT does not require a hemodialysis machine, the client's MAP needs to be maintained above 60 mmHg, and arterial and venous access sites are necessary. the SBP, DBP, and CVP may be monitored but each of these measures a component of the cardiovascular status rather than the complete cardiac cycle. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Renal and Urinary: Chronic Kidney Disease Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment Strategy(ies): Strategic Words, Umbrella Option

the nurse is caring for a client hospitalized for HF exacerbation ad suspects the client may be entering a state of shock. the nurse knows that which intervention is the priority for this client? a. admin of digoxin b. admin of whole blood c. admin of IV fluids d. admin of packed RBCs

a. admin of digoxin the client in this question is likely experiencing cardiogenic chock secondary to HF exacerbation. it is important to note that if the shock state is cardiogenic in nature, the infusion of volume-expanding fluids may result in pulmonary edema; therefore, restoration of cardiac function is the priority for this type of shock. cardiotonic medications (digoxin, dopamine, norepinephrine) may be administered to increased cardiac contractility and induce vasoconstriction. whole blood, IV fluids, and packed RBCs are volume-expanding fluids and may further complicate the client's clinical status; therefore, they should be avoided. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Shock Health Problem: Adult Health: Cardiovascular: Shock Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Comparable or Alike Options, Strategic Words, Subject

a client develops an anaphylactic reaction after receiving morphine. the nurse should plan to institute which actions? select all that apply. a. administer O2 b. quickly assess the client's respiratory status c. document event, interventions, and response d. leave client briefly and contact PHCP e. keep client supine regardless of BP reading f. start IV infusion of D5W and admin a 500mL bolus

a. administer O2 b. quickly assess the client's respiratory status c. document event, interventions, and response an anaphylactic reaction requires immediate action, starting with quickly assessing the client's respiratory status. although the PCHP and the RRT must be notified immediately, the nurse must stay with the client. O2 is administered and an IV of NS is started and infused per PHCP prescription. documentation of the event, actions taken, and client outcomes need to be performed. the HOB should be elevated if the client's BP is normal. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Immune: Hypersensitivity Reactions and Allergy Integrated Process: Nursing Process/Planning Priority Concepts: Clinical Judgment, Immunity Strategy(ies): Subject

a client with CKD being hemodialyzed suddenly becomes SOB and complains of chest pain. the client is tachycardic, pale, and anxious, and the nurse suspects air embolism. what are the priority nursing actions? select all that apply. a. administer O2 to the client b. continue dialysis at a slower rate after checking the lines for air c. notify the PHCP and RRT d. stop dialysis, and turn the client on the left side with head lower than feet e. bolus the client with 500 mL of NS to break up the air embolus

a. administer O2 to the client c. notify the PHCP and RRT d. stop dialysis, and turn the client on the left side with head lower than feet if the client experiences air embolus during hemodialysis, the nurse should terminate dialysis immediately, position the client so the air embolus is in the R side of the heart, notify the PHCP and RRT, and administer O2 as needed. slowing the dialysis treatment or giving an IV bolus will not correct the air embolism or prevent complications. Client Needs: Physiological Integrity Cognitive Ability: Synthesizing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Renal and Urinary: Chronic Kidney Disease Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Gas Exchange Strategy(ies): Strategic Words

the nurse in a medical unit is caring for a client with HF. the client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. the nurse immediately asks another nurse to contact the PHCP and prepares to implement which priority interventions? select all that apply. a. administering O2 b. inserting a foley catheter c. administering furosemide d. administering morphine sulfate IV e. transporting the client to the coronary care unit f. placing the client in low-Fowler's side-lying position

a. administering O2 b. inserting a foley catheter c. administering furosemide d. administering morphine sulfate IV pulmonary edema is a life-threatening event that can result from severe HF. in pulmonary edema, the LV fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. O2 is always prescribed, and the client is placed in a high-Fowler's position to ease the work of breathing. furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. a foley catheter is inserted to measure output accurately. IV administered morphine sulfate reduces venous return (preload), decreases anxiety, and also reduces the work of breathing. transporting the client to the coronary care unit is not a priority intervention. in fact, this may not be necessary at all if the client's response to treatment is successful. Client Needs: Physiological Integrity Cognitive Ability: Synthesizing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Cardiovascular: Pulmonary Edema Integrated Process: Nursing Process/Implementation Priority Concepts: Gas Exchange, Perfusion Strategy(ies): ABCs-Airway, Breathing, Circulation, Strategic Words

a unit of platelets was just received from the blood bank for transfusion to an assigned client. the nurse should select tubing with which feature for the transfusion? a. an in-line filter b. at least 3 Y-ports c. self-sealing valves d. tinted to protect the blood from light

a. an in-line filter the tubing used for platelet administration has an in-line filter. this helps ensure that any particles larger than the size of the filter are caught in the filter and are not infused into the client. self-sealing valves and Y-ports are unnecessary. these features may be used to administer medication. no medication is infused through the IV line that the blood is infusing through. if the client needed medications as a result of a complication while receiving blood or for another reason, it would need to be administered via a different IV site and line. platelets do not need to be protected from light. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Blood Administration Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Safety Strategy(ies): Subject

the client sustains a contusion of the eyeball following a traumatic injury with a blunt object. which intervention should be initiated immediately? a. apply ice to the affected eye b. irrigate the eye with cool water c. notify the PHCP d. accompany the client to the ED

a. apply ice to the affected eye treatment for a contusion begins at the time of injury. ice is applied immediately. the client then should be seen by a PHCP and receive a thorough eye exam to rule out the presence of other eye injuries. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Eye: Inflammation/Infections/Injuries Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Tissue Integrity Strategy(ies): Strategic Words

the nurse should evaluate that defibrillation of a client was most successful if which observation was made? a. arousable, sinus rhythm, BP 116/72 b. nonarousable, sinus rhythm, BP 88/60 c. arousable, marked bradycardia, BP 86/54 d. nonarousable, SV tachycardia, BP 122/60

a. arousable, sinus rhythm, BP 116/72 after defibrillation, the client requires continuous monitoring of ECG rhythm, hemodynamic status, and neurological status. respiratory and metabolic acidosis develop during v-fib because of lack of respiration and CO. these can cause cerebral and cardiopulmonary complications. arousable status, adequate BP, and a sinus rhythm indicate successful response to defibrillation. Client Needs: Physiological Integrity Cognitive Ability: Evaluating Content Area: Complex Care: Basic Life Support/CPR/ Cardiac Arrest Health Problem: Adult Health: Cardiovascular: Dysrhythmias Integrated Process: Nursing Process/Evaluation Priority Concepts: Evidence, Perfusion Strategy(ies): Strategic Words

a client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. the nurse suggests to the client to take which actions to reduce the risk of possible transfusion reactions? select all that apply. a. ask a family member to donate blood ahead of time b. give an autologous blood donation before the surgery c. take iron supplements before surgery to boost Hgb levels d. request that any donated blood be screened twice by the blood bank e. take adequate amounts of vitamin C several days prior to the surgery date

a. ask a family member to donate blood ahead of time b. give an autologous blood donation before the surgery a donation of the client's own blood before a scheduled procedure is autologous. donating autologous blood to be reinfused as needed during or after surgery reduces the risk of disease transmission and potential transfusion complications. the next most effective way is to ask a family member to donate blood before surgery. blood banks do not provide extra screening on request. preoperative iron supplements are helpful for iron deficiency anemia but are not helpful in replacing blood lost during the surgery. vitamin C enhances iron absorption but also is not helpful in replacing blood lost during surgery. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Blood Administration Integrated Process: Nursing Process/Implementation Priority Concepts: Anxiety, Safety Strategy(ies): Subject

a client presents to the ED with upper GI bleeding and is in moderate distress. in planning care, what is the priority nursing action for this client? a. assessment of VS b. completion of abdominal exam c. insertion of the prescribed NGT d. thorough investigation of precipitating events

a. assessment of VS the priority nursing action is to assess the VS. this would provide information about the amount of blood loss that has occurred and provide a baseline by which to monitor the progress of treatment. the client may be unable to provide subjective data until the immediate physical needs are met. although an abdominal examination and an assessment of the precipitating events may be necessary, these actions are not the priority. insertion of a NGT is not the priority and will require a PHCP's prescription; in addition, the VS should be checked before performing this procedure. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Gastrointestinal: Upper GI Disorders Integrated Process: Nursing Process/Implementation Priority Concepts: Care Coordination, Clinical Judgment Strategy(ies): Strategic Words

during the early post-op period, a client who has undergone a cataract extraction complains of nausea and severe eye pain over the operative site. what should be the initial nursing action? a. call the surgeon b. reassure the client that this is normal c. turn the client onto her/his operative side d. administer the prescribed pain medication and antiemetic

a. call the surgeon severe pain or pain accompanied by nausea following a cataract extraction is an indicator of increased IOP and should be reported to the surgeon immediately. options (a), (b), and (c) are inappropriate actions. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Eye: Cataracts Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Pain Strategy(ies): Strategic Words

the nurse is assisting in monitoring a client who is receiving a trasfusion of packed RBCs. before leaving the room, the nurse tells the client to immediately report which symptoms of a transfusion reaction? select all that apply. a. chills b. fatigue c. sleepiness d. chest pain e. lower back pain f. difficulty breathing

a. chills d. chest pain e. lower back pain f. difficulty breathing the nurse should instruct the client to immediately report signs of a transfusion reaction, which can include chest pain, lower back pain, chills, itching, rash, or difficulty breathing. these signs of transfusion reaction would require the nurse to stop the transfusion. fatigue and sleepiness are unrelated to transfusion reaction. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Blood Administration Integrated Process: Nursing Process/Implementation Priority Concepts: Client Education, Safety Strategy(ies): Comparable or Alike Options, Strategic Words, Subject

the community health nurse is providing a teaching session to firefighters in a small community regarding care of a burn victim at the scene of injury. the nurse instructs the firefighters that in the event of a tar burn, which is the immediate action? a. cooling the injury with water b. removing all clothing immediately c. removing the tar from the burn injury d. leaving any clothing that is saturated with tar in place

a. cooling the injury with water scald burns and tar or asphalt burns are treated by immediate cooling with saline solution or water, if available, or immediate removal of saturated clothing. clothing that is burned into the skin is not removed because increased tissue damage and bleeding may result. no attempt tis made to remove tar from the skin at the scene. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Integumentary: Burns Integrated Process: Teaching and Learning Priority Concepts: Clinical Judgment, Tissue Integrity Strategy(ies): Strategic Words, Subject

the nurse is monitoring a client who required a Sengstaken-Blakemore tube because other measures for treating bleeding esophageal varices were unsuccessful. the client complains of severe pain of abrupt onset. which nursing action is most appropriate? a. cut the tube b. reposition the client c. assess the lumens of the tubes d. administer the prescribed analgesics

a. cut the tube spontaneous rupture of the gastric balloon, upward migration of the tube, and occlusion of the airway are possible complications associated with a Sengstaken-Blakemore tube. esophageal rupture also may occur and is characterized by the abrupt onset of severe pain. in the event of any of these life-threatening emergencies, the tube is cut and removed. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Emergency Situations/ Management Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Pain Strategy(ies): Strategic Words

the nurse is caring for a client experiencing acute lower GI bleeding. in developing the plan of care, which priority problem should the nurse assign to this client? a. deficient fluid volume RT acute blood loss b. risk for aspiration RT acute bleeding in the GI tract c. risk for infection RT acute disease process and medications d. imbalanced nutrition, less than body requirements, RT lack of nutrients and increased metabolism

a. deficient fluid volume RT acute blood loss the priority problem for the client with acute GI bleeding among these options is deficient fluid volume RT acute blood less. this state can result in decreased CO and hypovolemic shock. although nutrition is a problem, fluid volume deficit is more of a priority. the client is at risk for aspiration and infection, but these are not actual problems at this point in time. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Gastrointestinal: Lower GI Disorders Integrated Process: Nursing Process/Analysis Priority Concepts: Fluid and Electrolyte Balance Strategy(ies): Strategic Words

a client has experienced high BP and crackles in the lungs during previous blood transfusions. the client asks the nurse whether it is safe to receive another transfusion. the nurse explains that which medication most likely will be prescribed before the transfusion is begun? a. furosemide b. acetaminophen c. diphenhydramine d. acetylsalicylic acid

a. furosemide fluid overload is one of the potential complications of a blood transfusion and is characterized by a variety of signs, including high blood pressure, fluid in the lungs manifesting as crackles, and distended jugular veins. this type of transfusion reaction is prevented by pretreating the client with a diuretic such as furosemide. acetaminophen and aspirin are analgesics, which can also be used for analgesia. these medications may reduce fever as well but do not treat fluid overload. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Blood Administration Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Safety Strategy(ies): Comparable or Alike Options, Strategic Words

while changing the tapes on a newly inserted trach tube, the client coughs and the tube is dislodged. which is the initial nursing action? a. grasp the retention sutures to spread the opening b. call the PHCP to reinsert the tube c. call the RT to reinsert the trach d. cover the trach site with a sterile dressing to prevent infection

a. grasp the retention sutures to spread the opening if the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures and spread the opening. if agency policy permits, the nurse then attempts to replace the tube immediately. calling ancillary services or the PHCP will delay treatment in this emergency situation. covering the trach site will block the airway. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Respiratory: Upper Airway Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Gas Exchange Strategy(ies): Comparable or Alike Options, Strategic Words

to perform CPR, the nurse should use the jaw thrust maneuver without the head tilt to open the airway in which situation? a. if neck trauma is suspected b. in all situations requiring CPR c. if the client has a history of seizures d. if the client has a history of HAs

a. if neck trauma is suspected the jaw thrust without the head tilt maneuver is used when head or neck trauma is suspected. this maneuver opens the airway while maintaining proper head and neck alignment, reducing the risk of further damage to the neck. options (b), (c), and (d) are incorrect. in addition, it is unlikely that the nurse would be able to obtain data about the client's history. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Basic Life Support/CPR/ Cardiac Arrest Integrated Process: Nursing Process/Implementation Priority Concepts: Gas Exchange, Safety Strategy(ies): Closed-ended Word

a woman was working in her garden. she accidentally sprayed insecticide into her right eye. she calls the ED, frantic and screaming for help. the nurse should instruct the woman to take which immediate action? a. irrigate the eyes with water b. come to the ED c. call the PHCP d. irrigate the eyes with diluted hydrogen peroxide

a. irrigate the eyes with water in this type of accident, the client is instructed to irrigate the eyes immediately with running water for at least 20 minutes, or until the emergency medical services personnel arrive. in the ED, the cleansing agent of choice is usually NS. Calling the PHCP and going to the ED delays necessary intervention. hydrogen peroxide is never placed in the eyes. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Eye: Inflammation/Infections/Injuries Integrated Process: Nursing Process/Implementation Priority Concepts: Client Education, Tissue Integrity Strategy(ies): Strategic Words

a client has had radical neck dissection and begins to hemorrhage at the incision site. the nurse should take which actions in this situation? select all that apply. a. monitor VS b. monitor the client's airway c. apply manual pressure over the site d. lower HOB to a flat position e. call the PHCP immediately

a. monitor VS b. monitor the client's airway c. apply manual pressure over the site e. call the PHCP immediately if the client begins to hemorrhage from the surgical site after radical neck dissection, the nurse elevates the HOB to maintain airway patency and prevent aspiration. the nurse applies pressure over the bleeding site and calls the surgeon immediately. the nurse also monitors the client's airway and VS. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Cancer: Laryngeal and Lung Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Gas Exchange Strategy(ies): ABCs-Airway, Breathing, Circulation, Subject

the nurse is caring for a client immediately after removal of the ETT. the nurse should report which sign immediately if experienced by the client? a. stridor b. occasional pink-tinged sputum c. RR of 24 breaths/min d. a few basilar lung crackles on the right

a. stridor Following removal of the endotracheal tube the nurse monitors the client for respiratory distress. The nurse reports stridor to the primary health care provider (PHCP) immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction. Although the findings identified in the remaining options require monitoring, they do not require immediate notification of the PHCP. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Respiratory: Upper Airway Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Gas Exchange Strategy(ies): Strategic Words

the nurse is initiating 1-rescuer CPR on an adult client. the nurse should place the hands in which position to begin chest compressions? a. on the lower half of the sternum b. on the upper half of the sternum c. on the lower third of the sternum d. on the upper third of the sternum

a. on the lower half of the sternum chest locations are found by placing the hands on the lower half of the sternum. to locate this area, find the notch where the rib margin meets the sternum, and place the middle finger on this notch and the index finger next to it. next, place the heel of the opposite hand on the lower half of the sternum, close to the index finger. remove the first hand, place it on top of the hand on the sternum, and begin chest compressions. chest compressions will not be as effective with the hand placements described in the remaining options. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Basic Life Support/CPR/ Cardiac Arrest Health Problem: Adult Health: Cardiovascular: Dysrhythmias Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Subject

the nurse caring for a client with a chest tube turns the client to the side, and the chest tube accidentally disconnects from the water seal chamber. which initial action should the nurse take? a. place the tube in a bottle of sterile water b. replace the chest tube system immediately c. call the PHCP d. place a sterile dressing over the disconnection site

a. place the tube in a bottle of sterile water if the chest drainage system is disconnected, the and of the tube is placed in a bottle of sterile water held below the level of the chest. the PHCP may need to be notified, but this is not the initial action. the system is replaced if it breaks or cracks or if the collection chamber is full. placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Gas Exchange Strategy(ies): Strategic Words

a client experienced an open pneumothorax (sucking wound), which has been covered with an occlusive dressing. the client begins to experience severe dyspnea, and the BP begins to fall. the nurse should first perform which action? a. remove the dressing b. reinforce the dressing c. call the PHCP d. measure O2 sat by oximetry

a. remove the dressing placement of a dressing over a chest wound could convert an open pneumothorax to a closed (tension) pneumothorax. this may result in a sudden decline in respiratory status, mediastinal shift with twisting of the great vessels, and circulatory compromise. if clinical changes occur, the nurse should remove the dressing immediately allowing air to escape. therefore, reinforcing the dressing is an incorrect action. the nurse would measure O2 sat and would call the PHCP, but these would not be the first actions in this situation. Client Needs: Physiological Integrity Cognitive Ability: Synthesizing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Respiratory: Pneumothorax Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Gas Exchange Strategy(ies): Strategic Words

a client receiving a transfusion of packed RBCs begins to vomit. the client's BP is 90/50 from a baseline of 125/78. the client's temperature is 100.8 F (38.2 C) orally from a baseline of 99.2 F (37.3 C) orally. the nurse determines that the client may be experiencing which complication of a blood transfusion? a. septicemia b. hyperkalemia c. circulatory overload d. delayed transfusion reaction

a. septicemia septicemia occurs with the transfusion of blood contaminated with microorganisms. signs include chills, fever, V/D, hypotension, and development of shock. hyperkalemia causes weakness, paresthesias, abdominal cramps, D, and dysrhythmias. circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and HTN. a delayed transfusion reaction can occur days to years after a transfusion. signs include fever, mild jaundice, and decreased Hct level. Client Needs: Physiological Integrity Cognitive Ability: Synthesizing Content Area: Complex Care: Blood Administration Integrated Process: Nursing Process/Analysis Priority Concepts: Clinical Judgment, Infection Strategy(ies): Subject

a client had a 1000 mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. the nurse making rounds at 1545 finds that the client is complaining of a pounding HA and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. the IV bag has 400 mL remaining. the nurse should take which action first? a. slow the IV infusion b. sit the client up in bed c. remove the IV catheter d. call the PHCP

a. slow the IV infusion the client's symptoms are compatible with circulatory overload. this may be verified by noting that 600 mL has infused in the course of 45 minutes. the first action of the nurse is to slow the infusion. other actions may follow in rapid sequence. the nurse may elevate the HOB to aid the client's breathing, if necessary. the nurse also notifies the PHCP. the IV catheter is not removed; it may be needed for the administration of medications to resolve the complication. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Intravenous Therapy Integrated Process: Nursing Process/Implementation Priority Concepts: Fluid and Electrolyte Balance, Perfusion Strategy(ies): Strategic Words

a client is receiving thrombolytic therapy with a continuous infusion of alteplase suddenly becomes extremely anxious and reports itching. the nurse hears stridor and notes generalized urticaria and hypotension. which interventions are a priority? select all that apply. a. stop the infusion b. raise the HOB c. administer protamin sulfate d. administer diphenhydramine e. call for the RRT

a. stop the infusion d. administer diphenhydramine e. call for the RRT the client is experiencing an anaphylactic reaction. therefore, the priority action is to stop the infusion and notify the RRT. the client may be treated with antihistamines (diphenhydramine). raising the HOB would not be helpful, as that may exacerbate the hypotension. protamine sulfate is the antidote for heparin, so it is not useful for a client receiving alteplase. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Shock Health Problem: Adult Health: Cardiovascular: Shock Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Gas Exchange Strategy(ies): Strategic Words

the nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. just before beginning the transfusion, the nurse should assess which priority item? a. vital signs b. skin color c. urine output d. latest Hct level

a. vital signs a change in VS during the transfusion from baseline may indicate that a transfusion reaction is occurring. this is why the nurse assesses VS before the procedure and again after the first 15 min and thereafter per agency policy. the other options do not identify assessments that are a priority just before beginning a transfusion. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Blood Administration Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Safety Strategy(ies): ABCs-Airway, Breathing, Circulation, Strategic Words

a client has a prescription to receive a unit of packed RBCs. the nurse should obtain which IV solution from the IV storage area to hang with the blood product at the client's bedside? a. LR b. 0.9% sodium chloride c. 5% dextrose in 0.9% sodium chloride d. 5% dextrose in 0.45% sodium chloride

b. 0.9% sodium chloride 0.9% sodium chloride (normal saline) is a standard isotonic solution used to precede and follow infusion of blood products. dextrose is not used because it could result in clumping and subsequent hemolysis of RBCs. LR is not the solution of choice with this procedure. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Blood Administration Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Safety Strategy(ies): Comparable or Alike Options

a client is admitted to the hospital 24 hours following an ASA overdose. the nurse assesses this client for which s/s indicating acid-base disturbance that could occur in the client? a. bradypnea, dizziness, paresthesias b. HA, N/V/D c. bradycardia, listlessness, hyperactivity d. restlessness, confusion, positive Troussaeu's sign

b. HA, N/V/D the client who ingests a large amount of aspirin (ASA) is at risk for developing metabolic acidosis 24 hours after the poisoning. if metabolic acidosis occurs, the client may exhibit hyperpnea with Kussmaul's respirations, HA, N/V/D, fruity-smelling breath because of improper fat metabolism, CNS depression, twitching, convulsions, and hyperkalemia. shortly after ASA overdose, the client may exhibit respiratory alkalosis as a compensatory mechanism. by 24 hours post overdose, however, the compensatory mechanism fails, and the client reverts to metabolic acidosis. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Poisoning Integrated Process: Nursing Process/Assessment Priority Concepts: Acid-Base Balance, Clinical Judgment Strategy(ies): Subject

the nurse is teaching CPR to a group of community members. the nurse tells the group that when chest compressions are performed on infants, the sternum should be depressed how far? a. at least 2 inches b. about 1.5 inches c. at lease one half the depth of the chest d. deep enough to make a finger impression

b. about 1.5 inches according to the AHA's 2015 guidelines, when CPR is performed on infants, the sternum should be depressed at least 1/3 the depth of chest, which is about 1.5 inches. the remaining options are incorrect. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Basic Life Support/CPR/ Cardiac Arrest Health Problem: Adult Health: Cardiovascular: Dysrhythmias Integrated Process: Teaching and Learning Priority Concepts: Client Education, Perfusion Strategy(ies): Subject

the nurse is performing CPR on a client who has had a cardiac arrest. an AED is available to treat the client. which activity will allow the nurse to assess the client's cardiac rhythm? a. hold the defibrillator paddles firmly against the chest b. apply adhesive patch electrodes to the chest and move away from the client c. connect standard ECG electrodes to a transtelephonic monitoring device d. apply standard ECG monitoring leads to the client, and observe the rhythm

b. apply adhesive patch electrodes to the chest and move away from the client the nurse or rescuer puts 2 adhesive patch electrodes on the client's chest in the usual defibrillator positions. the nurse stops CPR and requests that anyone near the client move away and not touch the client. the defibrillator then analyzes the rhythm, which may take up to 30 seconds. the machine then indicates whether defibrillation is necessary. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Basic Life Support/CPR/ Cardiac Arrest Health Problem: Adult Health: Cardiovascular: Dysrhythmias Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Comparable or Alike Options, Subject

the police arrive at the ED with a client who has lacerated both wrists. which is the initial nursing action? a. administer an antianxiety agent b. assess and treat the wound sites c. secure and record a detailed history d. encourage and assist the client to ventilate feelings

b. assess and treat the wound sites the initial nursing action is to assess and treat the self-inflicted injuries. injuries from lacerated wrists can lead to a life-threatening situation. other interventions, such as options (a), (c), and (d), may follow after the client has been treated medically. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Emergency Situations/ Management Health Problem: Mental Health: Suicide Integrated Process: Nursing Process/Implementation Priority Concepts: Caregiving, Safety Strategy(ies): Maslow's Hierarchy of Needs Theory, Strategic Words

a client is brought to the ED with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. the nurse should implement which nursing actions for this client? select all that apply. a. restrict fluids b. assess for airway patency c. administer O2 as prescribed d. place a cooling blanket on the client e. elevate extremities if no fractures are present f. prepare to give oral pain medication as prescribed

b. assess for airway patency c. administer O2 as prescribed e. elevate extremities if no fractures are present the primary goal for a burn injury is to maintain a patent airway, administer IV fluids to prevent hypovolemic shock, and preserve vital organ functioning. therefore, the priority actions are to assess for airway patency and maintain a patent airway. the nurse then prepares to administer O2. O2 is necessary to perfuse vital tissues and organs. an IV line should be obtained and fluid resuscitation started. the extremities are elevated to assist in preventing shock and decrease fluid moving to the extremities, especially in the burn-injured upper extremities. the client is kept warm, because the loss of skin integrity causes heat loss. the client is placed on NPO status because of the altered GI function that occurs as a result of a burn injury. Client Needs: Physiological Integrity Cognitive Ability: Synthesizing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Integumentary: Burns Integrated Process: Nursing Process/Analysis Priority Concepts: Clinical Judgment, Tissue Integrity Strategy(ies): Subject

in order by priority, place the nursing actions that should be taken for a pediatric client in the event of poison ingestion. all options must be used. a. administer the antidote prescribed b. assess the ABCs c. begin CPR if necessary d. empty mouth of pills, if present, or flush skin or body part exposed e. identify the poison by asking parents or witnesses to the ingestion

b. assess the ABCs c. begin CPR if necessary d. empty mouth of pills, if present, or flush skin or body part exposed e. identify the poison by asking parents or witnesses to the ingestion a. administer the antidote prescribed in the event of a poisoning, the nurse treats the child first, not the poison. the ABCs - airway, breathing, and circulation - and VS are assessed. CPR is initiated immediately if necessary. exposure to the poison is terminated next, such as emptying the mouth of pills or other materials or flushing the skin or other body area. then the poison is identified by questioning the parents or witnesses of the event to determine the appropriate treatment. the nurse administers the antidote or takes other measures as prescribed by the PHCP, such as administering activated charcoal. the nurse documents the occurrence, assessment findings, poison ingested, treatment measures, and the child's response. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Poisoning Health Problem: Pediatric-Specific: Poisoning Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): ABCs-Airway, Breathing, Circulation, Strategic Words

the nurse is told by a PHCP that a client in hypovolemic shock will require plasma expansion. the nurse should prepare which supplies for transfusion? a. bag of platelets with filtered tubing b. bottle of albumin with vented tubing c. cryoprecipitate bag with vented tubing d. infusion pump and bag of packed RBCs

b. bottle of albumin with vented tubing albumin may be used as a plasma expander. albumin is supplied in a bottle, and vented tubing is required for transfusion. platelets are used when the client's platelet count is too low. cryoprecipitate is useful in treating bleeding from hemophilia or DIC because it is rich in clotting factors. cryoprecipitate is usually supplied in bags, so vented tubing is not required. packed RBCs replace erythrocytes and are not a plasma expander. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Blood Administration Integrated Process: Nursing Process/Planning Priority Concepts: Clinical Judgment, Fluid and Electrolyte Balance Strategy(ies): Subject

the nurse has completed 5 cycles of compressions after beginning CPR on a hospitalized adult client who experienced unmonitored cardiac arrest. what should the nurse plan to do next? a. prepare epinephrine b. charge the defibrillator c. check the client's heart rhythm d. pause CPR for 20 seconds and reassess

b. charge the defibrillator for witnessed adult cardiac arrest when a defibrillator is immediately available, it is reasonable that the defibrillator be used asap. for adults with unmonitored cardiac arrest or for whom the defibrillator is not immediately available, it is reasonable that CPR be initiated while the defibrillator equipment is being retrieved and applied, and that defibrillation, if indicated be attempted as soon as the device is ready for use. after completing 5 cycles of compressions and ventilations, the nurse should reassess the client by checking the heart rhythm. defibrillation may be warranted depending on the assessed rhythm. epinephrine may be prepared depending on the rhythm, but this would be prescribed by a PHCP. chest compressions should not be interrupted for more than 10 seconds. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Basic Life Support/CPR/ Cardiac Arrest Health Problem: Adult Health: Cardiovascular: Dysrhythmias Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Strategic Words

a client with MI suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. which finding would the nurse anticipate when auscultating the client's breath sounds? a. stridor b. crackles c. scattered rhonchi d. diminished breath sounds

b. crackles pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinges sputum. auscultation of the lungs reveals crackles. rhonchi and diminished breath sounds are not associated with pulmonary edema. stridor is a crowing sound associated with laryngospasm or edema of the upper airway. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Cardiovascular: Pulmonary Edema Integrated Process: Nursing Process/Assessment Priority Concepts: Gas Exchange, Perfusion Strategy(ies): Subject

the nurse is monitoring a client with a head injury for s/s of IICP. the nurse would note which trend in VS if the ICP is rising? a. increasing temp, increasing HR, increasing RR, decreasing BP b. increasing temp, decreasing HR, decreasing RR, increasing BP c. decreasing temp, decreasing HR, increasing RR, decreasing BP d. decreasing temp, increasing HR, decreasing RR, increasing BP

b. increasing temp, decreasing HR, decreasing RR, increasing BP a change in VS may be a late sign of IICP. trends include increasing temp and BP and decreasing HR and RR. respiratory irregularities also may occur. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Neurological: Head Injury/Trauma Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Intracranial Regulation Strategy(ies): Subject

the nurse is assigned the care of a client who experienced an MI and is being monitored by cardiac telemetry. the nurse notes the sudden onset of coarse v-fib on the monitor. the nurse should immediately take which action? a. take the client's BP b. initiate CPR c. place a nitroglycerin tablet under the client's tongue d. continue to monitor the client for 1 minute and then contact the PHCP

b. initiate CPR the goals of treatment are to terminate VF promptly and to convert it to an organized rhythm. the PHCP or an advanced cardiac life support-qualified nurse must immediately defibrillate the client. if a defibrillator is not readily available, CPR must be initiated until the defibrillator arrives. the remaining options are incorrect; these are not immediate actions and would delay life-saving treatment. Client Needs: Physiological Integrity Cognitive Ability: Synthesizing Content Area: Complex Care: Basic Life Support/CPR/ Cardiac Arrest Health Problem: Adult Health: Cardiovascular: Dysrhythmias Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): ABCs-Airway, Breathing, Circulation, Strategic Words

a client arrives in the ED with a penetrating eye injury from wood chips that occurred while cutting wood. the nurse assesses the eye and notes a piece of wood protruding from the eye. what is the initial nursing action? a. apply an eye patch b. perform visual acuity tests c. irrigate the eye with sterile saline d. remove the piece of wood using a sterile eye clamp

b. perform visual acuity tests if the eye injury is the result of a penetrating object, the object may be noted protruding from the eye. this object must never be removed except by the ophthalmologist, because it may be holding ocular structures in place. application of an eye patch or irrigation of the eye may disrupt the foreign body and cause further tearing of the cornea. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Eye: Inflammation/Infections/Injuries Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Tissue Integrity Strategy(ies): Strategic Words

following infusion of a unit of packed RBCs, the client has developed new onset of tachycardia, bounding pulses, crackles, and wheezes. which action should the nurse implement first? a. maintain bed rest with legs elevated b. place client in high-Fowler's c. increase rate of infusion of IV fluids d. consult with PHCP regarding initiation of O2 therapy

b. place client in high-Fowler's new onset tachycardia, bounding pulses, and crackles and wheezes post-transfusion is evidence of fluid overload, a complication associated with blood transfusions. placing the client in high-Fowler's (upright) position will facilitate breathing. measures that increase blood return to the heart, such as leg elevation and administration of IV fluids, should be avoided at this time. in addition, administration of fluids cannot be initiated without a prescription. consulting with the PHCP regarding administration of O2 may be necessary, but positional changes take a short amount of time to do and should be initiated first. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Blood Administration Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): ABCs-Airway, Breathing, Circulation, Strategic Words

the nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. the nurse notes the presence of the umbilical cord protruding from the vagina. what is the first nursing action with this finding? a. gently push the cord into the vagina b. place the client in Trendelenburg's position c. find the closest telephone and page the PHCP stat d. call the delivery room to notify the staff that the client will be transported immediately

b. place the client in Trendelenburg's position when cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. the client should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. the nurse should push the call light to summon help, and other staff members should call the PHCP and notify the delivery room. if the cord is protruding from the vagina, no attempt should be made to replace it because to do so could traumatize it and reduce blood flow further. also as a first action, the examiner should place a gloved hand into the vagina and hold the presenting part off the umbilical cord. O2 8-10 L/min by face mask is administered to the client to increase fetal oxygenation. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Maternity: Prolapsed Umbilical Cord Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Strategic Words

a client arrives in the ED following an automobile crash. the client's forehead hit the steering wheel, and a hyphema is diagnosed. the nurse should place the client in which position? a. flat in bed b. semi-Fowler's position c. lateral on the affected side d. lateral on the unaffected side

b. semi-Fowler's position a hyphema is the presence of blood in the anterior chamber. hyphema is produced when a force is sufficient to break the integrity of the blood vessels in the eye and can be caused by direct injury, such as a penetrating injury from a BB or pellet, or indirectly, such as from striking the forehead on a steering wheel during an accident. the client is treated by bed rest in a semi-Fowler's position to assist gravity in keeping the hyphema away from the optical center of the cornea. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Eye: Inflammation/Infections/Injuries Integrated Process: Nursing Process/Implementation Priority Concepts: Safety, Tissue Integrity Strategy(ies): Subject

a client at risk for shock secondary to pneumonia develops restlessness and is agitated and confused. urinary output has decreased and the BP is 92/68. the nurse minimally suspects which stage of shock based on this data? a. stage 1 b. stage 2 c. stage 3 d. stage 4

b. stage 2 shock is categorized by 4 stages. stage 1 is characterized by restlessness, increased HR, cool and pale skin, and agitation. stage 2 is characterized by CO <4-6 L/min, systolic BP <100. stage 3 is characterized by edema, excessively low BP, dysrhythmias, and weak and thready pulses. stage 4 is characterized as unresponsiveness to vasopressors, profound hypotension, slowed HR, and multiple organ failure (most often, the client will not survive). Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Shock Health Problem: Adult Health: Cardiovascular: Shock Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Data in the Question

the nurse notes that a 14-year-old child is choking but is awake and alert at this time. the nurse rushes to perform the abdominal thrust maneuver. the child becomes unconscious. what procedure should the nurse perform next? a. perform a finger sweep b. start chest compressions c. attempt rescue breathing d. ask the parent what happened

b. start chest compressions to perform the abdominal thrust maneuver for a conscious child, the rescuer stands or kneels behind the child and places the arms directly under the child's axillae and then around the child. the thumb side of 1 fist is placed against the child's abdomen in the midline slightly above the umbilicus and well below the tip of the xiphoid process. the xiphoid process and ribs are avoided to prevent damage to internal organs. the fist is grasped with the other hand, and upward thrusts are delivered. if the child becomes unconscious, the nurse should start CPR, first beginning compressions. performing a blind finger sweep is not recommended. if the object can be visualized and is retrievable, it is acceptable to attempt to remove the object. rescue breathing is not appropriate at this time but may be necessary later. it will be necessary at some point to determine what happened, but this would not be the nurse's next action. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Basic Life Support/CPR/ Cardiac Arrest Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Gas Exchange Strategy(ies): Strategic Words, Subject

an adult client has been unsuccessfully defibrillated for v-fib, and CPR is resumed. the nurse confirms that CPR is being administered effectively by noting which action? a. the ratio of compressions to ventilations is 30:2 b. the carotid pulse is palpable with each compression c. respirations are given at a rate of 10 breaths/min d. the chest compressions are given at a depth of 1.5-2 inches

b. the carotid pulse is palpable with each compression with effective compressions, carotid pulsations should be present. at its best, CPR produces only 30% of the normal CO, so correct technique is vital. assessment of the carotid pulse during CPR is the most accurate way to assess the effectiveness of CPR. correct procedure for CPR in an adult includes a compression-to-ventilation ratio of 30:2. with adults, compressions are performed at a depth of at least 2 inches. the 30:2 compression-to-ventilation ratio yields an effective rate of 10 breaths/min. Client Needs: Physiological Integrity Cognitive Ability: Evaluating Content Area: Complex Care: Basic Life Support/CPR/ Cardiac Arrest Health Problem: Adult Health: Cardiovascular: Dysrhythmias Integrated Process: Nursing Process/Evaluation Priority Concepts: Evidence, Perfusion Strategy(ies): Strategic Words

a client is admitted to the hospital with a diagnosis of DKA. the initial blood glucose level is 950 mg/dL, a continuous IV infusion of short-acting insulin is initiated, along with IV rehydration with NS. the serum glucose is now decreased to 240 mg/dL. the nurse would next prepare to administer which medication? a. an ampule of 50% dextrose b. NPH insulin subQ c. IV fluids containing dextrose d. phenytoin for the prevention of seizures

c. IV fluids containing dextrose emergency management of DKA focuses on correcting fluid and electrolyte imbalances and normalizing the serum glucose level. if the corrections occur too quickly, serious consequences, including hypoglycemia and cerebral edema, can occur. during management of DKA, when the blood glucose level falls to 250, or until the client recovers from ketosis, administer IV fluids containing dextrose. 50% dextrose is used to treat hypoglycemia. NPH insulin is not used to treat DKA. phenytoin is not a usual treatment measure for DKA. Client Needs: Physiological Integrity Cognitive Ability: Synthesizing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Endocrine: Diabetes Mellitus Integrated Process: Nursing Process/Planning Priority Concepts: Clinical Judgment, Glucose Regulation Strategy(ies): Strategic Words, Subject

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. muffled heart sounds b. client reports dyspnea c. a rise in BP d. JVD

c. a rise in BP following pericardiocentesis, the client usually expresses immediate relief. heart sounds are no longer muffled or distant and BP increases. distended neck veins are a sign of increased venous pressure, which occurs with cardiac tamponade. Client Needs: Physiological Integrity Cognitive Ability: Evaluating Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Cardiovascular: Cardiac Tamponade Integrated Process: Nursing Process/Evaluation Priority Concepts: Evidence, Perfusion Strategy(ies): Strategic Words, Subject

in order of priority, how should the nurse perform abdominal thrusts on an unconscious child? arrange the actions in the order that they should be performed. a. open the airway b. attempt ventilation c. assess unconsciousness d. perform abdominal thrusts e. look in the mouth and remove the object blocking the airway, if seen

c. assess unconsciousness a. open the airway e. look in the mouth and remove the object blocking the airway, if seen b. attempt ventilation d. perform abdominal thrusts for PHCPs such as the nurse, the sequence for removing a FBAO in an adult is as follows. after determining unconsciousness, the airway is opened and the rescuer looks into the mouth of the victim and removes the object blocking the airway, if it is seen. next, the PHCP attempts to ventilate this victim. if unsuccessful, the victim's head is repositioned and ventilation is reattempted. 5 abdominal thrusts are then delivered. the sequence is repeated until successful. Client Needs: Physiological Integrity Cognitive Ability: Synthesizing Content Area: Complex Care: Basic Life Support/CPR/ Cardiac Arrest Integrated Process: Nursing Process/Implementation Priority Concepts: Gas Exchange, Safety Strategy(ies): ABCs-Airway, Breathing, Circulation, Strategic Words, Subject

the nursing instructor teaches a group of students about CPR. the instructor asks a student to identify the most appropriate location at which to assess the pulse of an infant younger than 1 year of age. which response would indicate that the student understands the appropriate assessment procedure? a. radial artery b. carotid artery c. brachial artery d. popliteal artery

c. brachial artery to assess a pulse in an infant < 1 year, the pulse is checked at the brachial or femoral artery. the infant's relatively short, fat neck makes palpation of the carotid artery difficult.the popliteal and radial pulses are also difficult to palpate in an infant. Client Needs: Physiological Integrity Cognitive Ability: Evaluating Content Area: Complex Care: Basic Life Support/CPR/ Cardiac Arrest Health Problem: Adult Health: Cardiovascular: Dysrhythmias Integrated Process: Teaching and Learning Priority Concepts: Development, Perfusion Strategy(ies): Strategic Words, Subject

the nurse enters a client's room to assess the client, who began receiving a blood transfusion 45 minutes earlier, and notes that the client is flushed and dyspneic. on assessment, the nurse auscultates the presence of crackles in the lung bases. the nurse determines that this client most likely is experiencing which complication of blood transfusion therapy? a. bacteremia b. hypovolemia c. circulatory overload d. transfusion reaction

c. circulatory overload circulatory overload is caused by the infusion of blood at a rate too rapid for the client to tolerate. with circulatory overload, crackles are present in addition to dyspnea. an allergic reaction, which is one type of blood transfusion reaction, would produce symptoms such as flushing, dyspnea, itching, and a generalized rash. hypovolemia is not likely a complication of a blood transfusion. with bacteremia, the client would have a fever, which is not part of the clinical picture presented. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Blood Administration Integrated Process: Nursing Process/Assessment Priority Concepts: Fluid and Electrolyte Balance, Safety Strategy(ies): Data in the Question, Strategic Words

one unit of packed RBCs has been prescribed for a client with severe anemia. the client has received multiple transfusions. the nurse anticipates that which medication will be prescribed before administration of the RBCs to prevent this type of reaction? a. ibuprofen b. acetaminophen c. diphenhydramine d. acetylsalicylic acid

c. diphenhydramine an urticaria-type reaction is characterized by a rash accompanied by pruritus. this type of transfusion reaction is prevented by pretreating the client with an antihistamine such as diphenhydramine. the remaining medications would not prevent a urticaria-type reaction. acetaminophen may be prescribed before the administration to assist in preventing an elevated temperature. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Blood Administration Health Problem: Adult Health: Hematological: Anemias Integrated Process: Nursing Process/Analysis Priority Concepts: Clinical Judgment, Safety Strategy(ies): Subject

the nurse is assessing the functioning of a chest tube drainage system in a client with a chest injury who has just returned from the recovery room following a thoracotomy with wedge resection. which are the expected assessment findings? select all that apply. a. excessive bubbling in the water seal chamber b. vigorous bubbling in the suction control chamber c. drainage system maintained below the client's chest d. 50 mL of drainage int he drainage collection chamber e. occlusive dressing in place over the chest tube insertion site f. fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

c. drainage system maintained below the client's chest d. 50 mL of drainage int he drainage collection chamber e. occlusive dressing in place over the chest tube insertion site f. fluctuation of water in the tube in the water seal chamber during inhalation and exhalation the bubbling of water in the water seal chamber indicated air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure; it may occur during exhalation, coughing, or sneezing. excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. an absence of fluctuation may indicate that the chest tube is obstructed or that the lung has re-expanded and that no more air is leaking into the pleural space. gentle (not vigorous) bubbling should be noted in the suction control chamber. a total of 50 mL/hr is considered excessive and requires notification of the surgeon. the chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. positioning the drainage system below the client's chest allows gravity to drain the pleural space. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Invasive Devices Health Problem: Adult Health: Respiratory: Chest Injuries Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Gas Exchange Strategy(ies): Subject

a client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. the nursing assessment reveals a BP of 90/50, a HR of 110 BPM, and a urine output of 20 mL over the past hour. the nurse reports the findings to the PHCP and anticipates which prescription? a. transfusing 1 unit of packed RBCs b. administering a diuretic to increase urine output c. increasing the amount of IV LR solution administered per hour d. changing the IV LR solution to one that contains 5% dextrose in water

c. increasing the amount of IV LR solution administered per hour Fluid management during the first 24 hours following a burn injury generally includes the infusion of (usually) lactated Ringer's solution. Lactated Ringer's solution is an isotonic solution that contains electrolytes that will maintain fluid volume in the circulation. Fluid resuscitation is determined by urine output, and hourly urine output should be at least 30 mL/hour. The client's urine output is indicative of insufficient fluid resuscitation, which places the client at risk for inadequate perfusion of the brain, heart, kidneys, and other body organs. Therefore, the PHCP would prescribe an increase in the amount of IV lactated Ringer's solution administered per hour. There is nothing in the situation that calls for blood replacement, which is not used for fluid therapy for burn injuries. Administering a diuretic would not correct the problem because fluid replacement is needed. Diuretics promote the removal of the circulating volume, thereby further compromising the inadequate tissue perfusion. Intravenous 5% dextrose solution is isotonic before administered but is hypotonic once the dextrose is metabolized. Hypotonic solutions are not appropriate for fluid resuscitation of a client with significant burn injuries. Client Needs: Physiological Integrity Cognitive Ability: Synthesizing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Integumentary: Burns Integrated Process: Nursing Process/Analysis Priority Concepts: Perfusion, Tissue Integrity Strategy(ies): Subject

the nurse is teaching chest compressions for CPR to a group of lay clients. which behavior by one of the participants indicates a need for further teaching? a. keeping the shoulders directly over the hands b. straightening the arms and locking the elbows c. letting the right and left fingers rest on the chest d. performing compressions on the lower half of the sternum

c. letting the right and left fingers rest on the chest to maximize the effectiveness of chest compressions, the rescuer avoids letting the fingers rest on the chest. this also helps prevent accidental injury to internal organs. the actions listed in the other options are all part of correct CPR procedures. Client Needs: Physiological Integrity Cognitive Ability: Evaluating Content Area: Complex Care: Basic Life Support/CPR/ Cardiac Arrest Health Problem: Adult Health: Cardiovascular: Dysrhythmias Integrated Process: Teaching and Learning Priority Concepts: Client Education, Perfusion Strategy(ies): Negative Event Query, Strategic Words

which clinical findings are consistent with sepsis diagnostic criteria? select all that apply. a. urine output 50 mL/hr b. hypoactive bowel sounds c. temperature of 102 F (38.9 C) d. HR of 96 BPM e. MAP of 65 mmHg f. systolic BP of 110 mmHg

c. temperature of 102 F (38.9 C) d. HR of 96 BPM e. MAP of 65 mmHg sepsis diagnostic criteria with regard to s/s include the following: fever (higher than 100.9 F/38.3 C) or hypothermia (core temp lower than 97 F/36 C), tachycardia (HR >90 BPM), tachypnea (RR >22), systolic BP </= 100mmHg, altered mental status, edema or positive fluid balance, oliguria, ileus (absent bowel sounds), and decreased cap refill or mottling of skin. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Sepsis Health Problem: Adult Health: Cardiovascular: Shock Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Subject

the nurse is conducting a BLS recertification class and is discussing chest compressions on a pregnant woman. the nurse should tell the class that which action should be taken in an advanced pregnancy client whose fundal height is at or above the umbilicus? a. perform the chest compressions directly over the umbilicus b. turn the pregnant client on her side and perform back thrusts c. maintain manual left uterine displacement during compressions d. perform chest thrusts midway between the umbilicus and the pubic bone

c. maintain manual left uterine displacement during compressions according to the AHA's current guidelines for performing CPR, recognition of the critical importance of high-quality CPR and the incompatibility of the lateral tilt with high-quality CPR have prompted the elimination of the recommendation for using the lateral tilt with high-quality CPR have prompted the elimination of the recommendation for using the lateral tilt and strengthening of the recommendation for lateral uterine displacement. priorities for the pregnant woman in cardiac arrest are provisions of high-quality CPR and relief of aortocaval compression. if the fundus height is at or above the level of the umbilicus, manual left uterine displacement can be beneficial in relieving aortocaval compression during chest compressions. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Basic Life Support/CPR/ Cardiac Arrest Health Problem: Adult Health: Cardiovascular: Dysrhythmias Integrated Process: Nursing Process/Implementation Priority Concepts: Client Education, Perfusion Strategy(ies): Subject

the nurse is assessing a client in the 4th stage of labor and notes that the fundus is firm, but that bleeding is excessive. which should be the initial nursing action? a. record the findings b. massage the fundus c. notify the OB d. place the client in Trendelenburg's position

c. notify the OB if bleeding is excessive, the cause may be laceration of the cervix or birth canal. massaging the fundus if it is firm would not assist in controlling the bleeding. Trendelenburg's position should be avoided because it may interfere with cardiac and respiratory function. although the nurse would record the findings, the initial nursing action would be to notify the OB. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Maternity: Hematoma and Hemorrhage Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Clotting Strategy(ies): Data in the Question, Strategic Words

the nurse is caring for a client following enucleation to treat an ocular tumor and notes the presence of bright red drainage on the dressing. which action should the nurse take at this time? a. document the finding b. continue to monitor the drainage c. notify the PHCP d. mark the drainage on the dressing and monitor for any increase in bleeding

c. notify the PHCP if the nurse notes the presence of bright red drainage on the dressing, it must be reported to the PHCP, because this indicates hemorrhage. options (a), (b), and (c) are inappropriate at this time. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Eye: Ocular Tumors, Retinoblastoma Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Tissue Integrity Strategy(ies): Abnormality Exists

CPR is immediately initiated on a client who is unconscious and has no pulse. a monitor is attached, it is determined that the rhythm is shockable, and defibrillation with 1 shock is delivered. which action should the nurse plan to take next? a. defibrillate 1 more time, and then terminate the resuscitation effort b. administer a bolus of fluid IV, and resume defibrillation attempts c. perform CPR for 5 cycles, and then defibrillate again if the rhythm is shockable d. perform CPR for 1 min, assess, and then defibrillate up to 3 more times

c. perform CPR for 5 cycles, and then defibrillate again if the rhythm is shockable if a client is unconscious and has no pulse, the nurse would shout for help (activate emergency response) and immediately initiate CPR. if the rhythm is shockable, a shock is delivered and CPR is delivered for 5 cycles. this pattern is repeated 2 more times if the rhythm remains shockable. treatment with medications is also done during this time to reverse the cause of the v-fib. each of the other options is incorrect. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Basic Life Support/CPR/ Cardiac Arrest Health Problem: Adult Health: Cardiovascular: Dysrhythmias Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Strategic Words

the nurse is caring for a client who is pulseless and experiencing v-tach. which interventions should the nurse anticipate implementing in collaboration with the PHCP? select all that apply. a. prepare for cardioversion b. prepare to administer digoxin c. prepare to administer amiodarone d. prepare to administer epinephrine e. provide CPR

c. prepare to administer amiodarone d. prepare to administer epinephrine e. provide CPR pulseless v-tach is treated the same way as v-fib with measures that include defibrillation, CPR, and medication therapy (with agents such as epinephrine, amiodarone, and others). Client Needs: Physiological Integrity Cognitive Ability: Synthesizing Content Area: Complex Care: Basic Life Support/CPR/ Cardiac Arrest Health Problem: Adult Health: Cardiovascular: Dysrhythmias Integrated Process: Nursing Process/Planning Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Subject

the nurse has just obtained a unit of blood from the blood bank to transfuse into a client as prescribed. before preparing the blood for transfusion, the nurse looks for which member of the health care team to assist in checking the unit of blood? a. phlebotomist b. medical student c. registered nurse (RN) d. blood bank technician

c. registered nurse (RN) depending on agency policy, 2 RNs or 1 RN and one LPN must check the label on the blood product together against the client's identification number, blood group, and complete name. this minimizes the risk of error in checking information on the blood bag and thereby minimizes the risk of harm or injury to the client. a blood bank technician verifies data with the nurse when the blood is obtained from the blood bank but does not verify information on the nursing unit or at the client's bedside. the other options are also incorrect. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Blood Administration Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Safety Strategy(ies): Subject

the nurse notes that a client with sinus rhythm has a PVC that falls on the T wave of the preceding beat. the client's rhythm suddenly changes to one with no P waves, no definable QRS complexes, and coarse wavy lines of varying amplitude. how should the nurse interpret this rhythm? a. asystole b. a-fib c. v-fib d. v-tach

c. v-fib v-fib is characterized by irregular chaotic undulations of varying amplitudes. v-fib has no measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Cardiovascular: Dysrhythmias Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Subject

the low-pressure alarm sounds on a ventilator. the nurse assesses the client and then attempts to determine the cause of the alarm. if unsuccessful in determining the cause of the alarm, the nurse should take what initial action? a. administer O2 b. check the client's VS c. ventilate the client manually d. start CPR

c. ventilate the client manually if at any time an alarm is sounding and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and manual resuscitation is used to support respirations until the problem can be corrected. no reason is given to begin CPR. checking VS is not the initial action. although O2 is helpful, it will not provide ventilation to the client. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Gas Exchange Strategy(ies): Strategic Words, Subject

a client arrives at the ED following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. what would the nurse anticipate to be prescribed for the client? a. 100% O2 via an aerosol mask b. O2 via NC @6L/min c. O2 via NC @15L/min d. 100% O2 via a tight-fitting, NRB face mask

d. 100% O2 via a tight-fitting, NRB face mask If an inhalation injury is suspected, administration of 100% oxygen via a tight-fitting nonrebreather face mask is prescribed until carboxyhemoglobin levels fall (usually below 15%). In inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation also is assessed. Administration of oxygen by aerosol mask and cannula are incorrect and would not provide the necessary oxygen supply needed for adequate tissue perfusion for the client with a likely inhalation injury. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Integumentary: Burns Integrated Process: Nursing Process/Analysis Priority Concepts: Gas Exchange, Perfusion Strategy(ies): Subject

the nurse is teaching adult CPR guidelines to a group of laypeople. the nurse observes the group correctly demonstrate 2-rescuer CPR when which ratio of compressions to ventilations is performed on the mannequin? a. 10:1 b. 15:2 c. 20:1 d. 30:2

d. 30:2 when performing CPR on adults, the ratio of chest compressions to breaths should be 30:2 for both 1-rescuer and 2-rescuer CPR. the ratio of 15:2 is used for children and infants during 2-rescuer CPR. Client Needs: Physiological Integrity Cognitive Ability: Evaluating Content Area: Complex Care: Basic Life Support/CPR/ Cardiac Arrest Health Problem: Adult Health: Cardiovascular: Dysrhythmias Integrated Process: Teaching and Learning Priority Concepts: Client Education, Perfusion Strategy(ies): Subject

the nurse is monitoring a client who is receiving a blood trasfusion. after 30 minutes of the infusion, the client begins to have chills and back pain. his temperature is 100.1 F (37.8 C). what action should the nurse take first? a. assess the client for other symptoms b. slow the blood transfusion and monitor the client's vital signs c. remind the client that these are expected reactions to a blood trasfusion d. DC the infusion and start a new infusion of NS using new tubing

d. DC the infusion and start a new infusion of NS using new tubing signs of a trasfusion reaction include fever, chills, tachycardia, tachypnea, dyspnea, hives or skin rash, flushing, backache, and decreased BP. if the client shows any symptoms of a blood transfusion reaction, the nurse needs to DC the infusion immediately and start an infusion of NS using new tubing connected to the hub of the IV insertion site. the nurse should stay with the client and monitor his/her condition while asking a colleague to notify the PHCP immediately. Client Needs: Safe and Effective Care Environment Cognitive Ability: Synthesizing Content Area: Complex Care: Blood Administration Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Safety Strategy(ies): Strategic Words

the nurse is documenting information in a client's chart when the ECG telemetry alarm sounds, and the nurse notes that the client is in v-tach/VT. the nurse rushes to the bedside and should perform which assessment first? a. HR b. BP c. RR d. check responsiveness

d. check responsiveness VT is associated with a significant decrease in CO. assessing for unresponsiveness determines whether the client is affected by the decreased CO. therefore, the first action is to determine responsiveness of the client. then the nurse should check the client's pulse to determine the next treatment strategy. Client Needs: Physiological Integrity Cognitive Ability: Synthesizing Content Area: Complex Care: Basic Life Support/CPR/ Cardiac Arrest Health Problem: Adult Health: Cardiovascular: Dysrhythmias Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Strategic Words

the nurse, listening to the morning report, learns that an assigned client received a unit of granulocytes the previous evening. the nurse makes a note to assess the results of which daily serum lab study to assess the effectiveness of the transfusion? a. Hct level b. erythrocyte level c. Hgb level d. WBC count

d. WBC count the client who has neutropenia may receive a transfusion of granulocytes, or WBCs. these clients often have severe infections and are unresponsive to antibiotic therapy. the nurse notes that the results of follow-up WBC counts and differential to evaluate the effectiveness of the therapy. the nurse also continues to monitor the client for s/s of infection. erythrocyte count and H&H levels are determined after transfusion of packed RBCs. Client Needs: Physiological Integrity Cognitive Ability: Evaluating Content Area: Complex Care: Blood Administration Integrated Process: Nursing Process/Evaluation Priority Concepts: Evidence, Infection Strategy(ies): Comparable or Alike Options, Strategic Words

a client in a postpartum unit complains of sudden sharp chest pain and dyspnea. the nurse notes that the client is tachycardia and the RR is elevated. the nurse suspects a pulmonary embolism. which should be the initial nursing action? a. initiate an IV line b. assess the client's BP c. prepare to administer morphine sulfate d. administer O2 8-10 L/min by face mask

d. administer O2 8-10 L/min by face mask if PE is suspected, O2 should be administered, 8-10 L/min, by face mask. O2 is used to decrease hypoxia. the client also is kept on bed rest with the HOB slightly elevated to reduce dyspnea. morphine sulfate may be prescribed for the client, but this would not be the initial nursing action. an IV line also will be required, and VS need to be monitored, but these actions would follow the administration of oxygen. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Respiratory: Pulmonary Embolism Integrated Process: Nursing Process/Implementation Priority Concepts: Gas Exchange, Perfusion Strategy(ies): ABCs-Airway, Breathing, Circulation, Strategic Words

the nurse enters the room of a client who began receiving a blood transfusion 45 minutes earlier to check on the client. the client is complaining of "itching all over" and has a generalized rash. the client's temperature has not changed from baseline and the lungs are clear to auscultation. which complication of blood transfusion therapy should the nurse determine that this client is most likely experiencing? a. bacteremia b. fluid overload c. hypovolemic shock d. allergic trasfusion reaction

d. allergic trasfusion reaction the client is most likely experiencing an allergic transfusion reaction based on the clinical manifestation of pruritus. bacteremia usually manifests with fever. with fluid volume overload, the client has the presence of crackles in the lungs in addition to dyspnea. other clinical manifestations of fluid overload include HTN, bounding pulse, distended jugular veins, restlessness, and confusion. hypovolemic shock is not likely a transfusion reaction because IV fluid is being administered. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Blood Administration Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Safety Strategy(ies): Strategic Words

a client with severe blood loss resulting from multiple trauma requires rapid transfusion of several units of blood. the nurse asks another health team member to obtain which device for use during the transfusion procedure to help reduce the risk of cardiac dysrhythmias? a. infusion pump b. pulse oximeter c. cardiac monitor d. blood-warming device

d. blood-warming device if several units of blood are to be administered rapidly, a blood warmer should be used. rapid transfusion of cool blood places the client at risk for cardiac dysrhythmias. to prevent this, the nurse warms the blood with a blood-warming device. pulse ox and cardiac monitoring equipment are useful for the early assessment of complications but do not reduce the occurrence of them. electronic infusion devices are not helpful in this case because the infusion must be rapid, and infusion devices generally are used to control the flow rate. in addition, not all infusion devices are made to handle blood or blood products. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Blood Administration Integrated Process: Nursing Process/Planning Priority Concepts: Perfusion, Thermoregulation Strategy(ies): Comparable or Alike Options

the nurse is undergoing annual recertification in BLS. the BLS instructor asks the nurse to identify the most appropriate pulse point to use when determining pulselessness on an infant. which response by the nurse identifies the most appropriate pulse point? a. carotid b. popliteal c. radial d. brachial

d. brachial when assessing a pulse in an infant (< 1 year), the pulse should be checked at the brachial artery. this is because the relatively short, fat neck of an infant makes palpation of the carotid artery difficult. the pulses in the remaining options are also difficult to locate and palpate in an infant. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Basic Life Support/CPR/ Cardiac Arrest Health Problem: Adult Health: Cardiovascular: Dysrhythmias Integrated Process: Nursing Process/Implementation Priority Concepts: Development, Perfusion Strategy(ies): Strategic Words, Subject

the nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. the client had an IV infusion at a rate of 150 mL/hr, unchanged for the last 10 hours. the client's urine output for the last 3 hours has been 90 mL, 50 mL, 28 mL (most recent). the client's BUN is 35 mg/dL, and the serum Cr is 1.8 mg/dL, measured this morning. which nursing action is the priority? a. check the serum albumin level b. check the urine SG c. continue monitoring urine output d. call the PHCP

d. call the PHCP following abdominal aortic aneurysm resection or repair, the nurse monitors the client for signs of AKI. AKI can occur because often much blood is lost during the surgery and, depending on the aneurysm location, the renal arteries may be hypoperfused for a short period during surgery. normal reference levels are BUN 10-20 mg/dL (3.6-7.1 mmol/L), and Cr 0.6-1.2 mg/dL (53-106 mcmol/L) for males and 0.5-1.1 mg/dL (44-97 mcmol/L) for females. continuing to monitor urine output or checking other parameters can wait. urine output < 30 mL/hr is reported to the PHCP for urgent treatment. Client Needs: Physiological Integrity Cognitive Ability: Synthesizing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Cardiovascular: Vascular Disorders Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Data in the Question, Strategic Words

the nurse has just received a prescription to transfuse a unit of packed RBCs for an assigned client. what action should the nurse take next? a. check a set of vital signs b. order the blood from the blood bank c. obtain Y-site blood administration tubing d. check to be sure that consent for the transfusion has been signed

d. check to be sure that consent for the transfusion has been signed after receiving a prescription for a blood transfusion, the first action the nurse should take should be to check to be sure that consent for the transfusion has been signed by the client. if the client has consented, the nurse should then check a set of VS to be sure there is no contraindication for a transfusion at that time, such as a elevation in temperature. if the VS are acceptable, the nurse can then gather supplies to administer the transfusion and order the blood from the blood bank. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Blood Administration Integrated Process: Nursing Process/Planning Priority Concepts: Care Coordination, Health Care Law Strategy(ies): Strategic Words

the nurse is caring for a client who is receiving a blood transfusion and is complaining of a cough. the nurse checks the client's VS, which include a temperature of 97.2 F (36.2 C), pulse of 108 BPM, BP of 152/76, RR of 24, and an O2 sat of 95% on RA. the client denies pain at this time. based on this information, what initial action should the nurse take? a. collect a urine sample for analysis b. place the client in a upright position c. slow the rate of the blood transfusion d. compare current data to baseline data

d. compare current data to baseline data for the client receiving a blood transfusion, the nurse should monitor for potential complications of a transfusion. one of the complications is circulatory overload. s/s of circulatory overload include cough, dyspnea, chest pain, HTN, tachycardia, ad a bounding pulse, and distended neck veins. based on the data in question, the nurse should compare current data to baseline data. the nurse should also further assess the client for other s/s of circulatory overload. if the nurse still suspects this complication after comparing to baseline data, the nurse should then place the client in an upright position and slow the rate of the infusion. collection of a urine sample should occur if the nurse suspects a transfusion reaction, such as a hemolytic reaction. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Blood Administration Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Safety Strategy(ies): Abnormality Exists, Strategic Words

the nurse is assisting to defibrillate a client in v-fib. after placing the pad on the client's chest and before discharge, which intervention is a priority? a. ensure that the client has been intubated b. set the defibrillator to the "synchronize" mode c. administer an amiodarone bolus IV d. confirm that the rhythm, is actually v-fib

d. confirm that the rhythm, is actually v-fib until the defibrillator is attached and charged, the client is resuscitated by using CPR. once the defibrillator has been attached, the ECG is checked to verify that the rhythm is v-fib or pulseless v-tach. leads also are checked for any loose connections. a nitroglycerin patch, if present, is removed. the client does not have to be intubated to be defibrillated. the machine is not set to the synchronous mode because there is no underlying rhythm with which to synchronize. amiodarone may be given subsequently but is not required before defibrillation. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Basic Life Support/CPR/ Cardiac Arrest Health Problem: Adult Health: Cardiovascular: Dysrhythmias Integrated Process: Nursing Process/Assessment Priority Concepts: Perfusion, Safety Strategy(ies): Strategic Words, Subject

the nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. how should the nurse respond to this finding initially? a. document the finding b. encourage the client to ambulate c. encourage the client to increase fluid intake d. contact the OB and inform him/her of this finding

d. contact the OB and inform him/her of this finding lochia is the discharge from the uterus in the postpartum period; it consists of blood from the vessels of the placental site and debris from the decidua. the following can be used as a guide to determine the amount of flow: scant (< 2.5 cm/1 in on menstrual pad in 1 hour), light (< 10 cm/4 in on menstrual pad in 1 hour), moderate (< 15 cm/6 in on menstrual pad in 1 hour), heavy (saturated menstrual pad in 1 hour), excessive (saturated menstrual pad in 15 min). If the client is experiencing excessive bleeding, the nurse should contact the OB in the event that postpartum hemorrhage is occurring. it may be appropriate to encourage increased fluid intake, but this is not the initial action. it is not appropriate to encourage ambulation at this time. documentation should occur once the client has been stabilized. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Maternity: Postpartum Uterine Problems Integrated Process: Nursing Process/Implementation Priority Concepts: Clotting, Reproduction Strategy(ies): Abnormality Exists, Data in the Question, Strategic Words

a client has received a transfusion of platelets. the nurse evaluated that the client is benefiting most from this therapy if the client exhibits which finding? a. increased Hct level b. increased Hgb level c. decline of elevated temperature to normal d. decreased oozing of blood from puncture sites and gums

d. decreased oozing of blood from puncture sites and gums platelets are necessary for proper blood clotting. the client with insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds, and mucous membranes. increased H&H levels would occur when the client has received a transfusion of RBCs. an elevated temperature would decline to normal after infusion of granulocytes because these cells were instrumental inn fighting infection in the body. Client Needs: Physiological Integrity Cognitive Ability: Evaluating Content Area: Complex Care: Blood Administration Integrated Process: Nursing Process/Evaluation Priority Concepts: Clinical Judgment, Clotting Strategy(ies): Comparable or Alike Options, Strategic Words

packed RBCs have been prescribed for a female client with anemia who has a Hgb level of 7.6 g/dL and a Hct level of 30%. the nurse takes the client's temperature before hanging the blood transfusion and records 100.6 F (38.1 C) orally. which action should the nurse take? a. begin the transfusion as prescribed b. administer an antihistamine and begin the transfusion c. administer 2 tablets of acetaminophen and begin the transfusion d. delay hanging the blood and notify the PHCP

d. delay hanging the blood and notify the PHCP if the client has a temperature higher than 100 F (37.8 C), the unit of blood should not be hung until the PHCP is notified and has the opportunity to give further prescriptions. the PHCP likely will prescribe that the blood be administered regardless of the temperature, or may instruct the nurse to administer acetaminophen and wait until the temperature has decreased before administration, but the decision is not within the nurse's scope of practice to make. the nurse needs a PHCP's prescription to administer medications to the client. Client Needs: Physiological Integrity Cognitive Ability: Synthesizing Content Area: Complex Care: Blood Administration Health Problem: Adult Health: Hematological: Anemias Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Safety Strategy(ies): Comparable or Alike Options

a client in shock develops a CVP of 2 mmHg. which prescribed intervention should the nurse implement first? a. increase the rate of O2 flow b. obtain ABG results c. insert an indwelling urinary catheter d. increase the rate of IV fluids

d. increase the rate of IV fluids the MAP and CVP are both low for this client, indicating a shock state. shock is the result of inadequate tissue perfusion. fluid volume should be immediately restored first to provide adequate perfusion for the client in a shock state. although increasing the rate of O2 flow may be necessary intervention, perfusion is the first priority. obtaining ABG results and inserting and inserting a catheter may be necessary interventions to monitor the client's response to prescribed therapy, but these are not priority. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Shock Health Problem: Adult Health: Cardiovascular: Shock Integrated Process: Nursing Process/Assessment Priority Concepts: Clinical Judgment, Perfusion Strategy(ies): Strategic Words

the nurse is assessing a client with multiple trauma who is at risk for developing ARDS. the nurse should assess for which earliest sign of ARDS? a. bilateral wheezing b. inspiratory crackles c. intercostal retractions d. increased RR

d. increased RR the earliest detectable sign of ARDS is an increased RR, which can begin from 1-96 hours after the initial insult to the body. this is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Acute Respiratory Failure Health Problem: Adult Health: Respiratory: Acute Respiratory Distress Syndrome/Failure Integrated Process: Nursing Process/Assessment Priority Concepts: Gas Exchange, Perfusion Strategy(ies): Strategic Words

an external PAD interprets that the rhythm of a pulseless victim is v-fib and advises defibrillation. which action should the rescuer take next? a. administer rescue breathing during the defibrillation b. perform CPR for 1 minute before defibrillating c. charge the machine and immediately push the discharge buttons d. order people away from the client, charge the machine, and depress the discharge buttons

d. order people away from the client, charge the machine, and depress the discharge buttons if the victim is in v-fib, defibrillation is necessary. if the PAD advises to defibrillate, the rescuer orders all people away from the client, charges the machine, and pushes both of the discharge buttons on the console at the same time. the charge is delivered through the patch electrodes, so this method is known as "hands off" defibrillation, which is safer for the rescuer. the sequence of charges is similar to that of conventional defibrillation. Client Needs: Safe and Effective Care Environment Cognitive Ability: Applying Content Area: Complex Care: Basic Life Support/CPR/ Cardiac Arrest Health Problem: Adult Health: Cardiovascular: Dysrhythmias Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Safety Strategy(ies): Subject

the nurse assigned to the pediatric unit finds an infant unresponsive and without respirations or a pulse. what is the nurse's next action after calling for help? a. check for carotid pulse b. call anesthesia for intubation c. begin rescue breathing with head tilt-chin lift d. perform compressions at 100-120 times/min

d. perform compressions at 100-120 times/min after pressing the emergency response button in the room, the nurse should begin CPR on the infant, starting with chest compressions. The rate of chest compressions is 100-120 times/min. the brachial pulse is assessed on infants; the carotid pulse is difficult to palpate due to their short, thick necks. when a cardiopulmonary arrest alert is called, an experienced staff member with intubation skills is usually included on the response team. compressions are started before rescue breathing. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Basic Life Support/CPR/ Cardiac Arrest Health Problem: Adult Health: Cardiovascular: Dysrhythmias Integrated Process: Nursing Process/Implementation Priority Concepts: Development, Perfusion Strategy(ies): Strategic Words, Subject

a client in sinus brady with a HR of 45 BPM complains of dizziness and has a BP of 82/60. which prescription should the nurse anticipate will be prescribed? a. administer digoxin b. defibrillate the client c. continue to monitor the client d. prepare for transcutaneous pacing

d. prepare for transcutaneous pacing sinus brady is noted with a HR < 60 BPM. this rhythm becomes a concern when the client becomes symptomatic. hypotension and dizziness are signs of decreased CO. transcutaneous pacing provides a temporary measure to increase the HR and thus perfusion in the symptomatic client. defibrillation is used for treatment of pulseless v-tach and v-fib. digoxin will further decrease the client's HR. continuing to monitor the client delays necessary intervention. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Complex Care: Emergency Situations/ Management Health Problem: Adult Health: Cardiovascular: Dysrhythmias Integrated Process: Nursing Process/Planning Priority Concepts: Gas Exchange, Perfusion Strategy(ies): Subject

the PHCP arrives on the nursing unit and deflates the esophageal balloon of a client's Sengstaken-Blakemore tube. the nurse should contact the PHCP immediately if which occurs? a. the client has some diarrhea that is bloody b. the client's BP is 128/78 c. the client complains of abdominal discomfort d. the client complains of nausea and vomits blood

d. the client complains of nausea and vomits blood A Sengstaken-Blakemore tube may be used in a client with a diagnosis of cirrhosis and ruptured esophageal varices if other interventions are unsuccessful. The tube has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated, the client may begin to bleed again from the esophageal varices; this would be manifested by vomiting of blood (hematemesis). The remaining options are not specifically associated with esophageal deflation. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Emergency Situations/ Management Integrated Process: Nursing Process/Implementation Priority Concepts: Clinical Judgment, Clotting Strategy(ies): Strategic Words

a client is brought into the ED in v-fib/VF. the nurse prepares to defibrillate by placing defibrillation pads on which part of the chest? a. the upper and lower halves of the sternum b. parallel between the umbilicus and the right nipple c. the right shoulder and the back of the left shoulder d. to the right of the sternum and to the left of the precordium

d. to the right of the sternum and to the left of the precordium the nurse would place 1 gel pad to the right of the sternum just below the clavicle and the other gel pad to the left of the precordium. the nurse would then place the electrode paddles over the pads. the remaining options identify incorrect positions. Client Needs: Physiological Integrity Cognitive Ability: Applying Content Area: Complex Care: Basic Life Support/CPR/ Cardiac Arrest Health Problem: Adult Health: Cardiovascular: Dysrhythmias Integrated Process: Nursing Process/Implementation Priority Concepts: Gas Exchange, Perfusion Strategy(ies): Subject