Adv. Med Surg final

A nurse is teaching personal hygiene care techniques to a client with genital herpes. Which statement by the client indicates the teaching has been effective? "I will wear loose cotton underwear." "I will apply a water-based lubricant to my lesions." "I should rub rather than scratch in response to itching." "I can pour moisturizer over my lesions."

"I will wear loose cotton underwear." Rationale: Wearing loose cotton underwear promotes drying and helps avoid irritation of the lesions. The use of lubricants is contraindicated because they can prolong healing time and increase the risk of secondary infection. Lesions shouldn't be rubbed or scratched because of the risk of tissue damage and additional infection. Cool, wet compresses can be used to soothe the itch. The use of moisturizer on lesions isn't recommended.

All people who have household or face-to-face contact with the client diagnosed with smallpox after the fever begins should be vaccinated within what time frame to prevent infection and death? 4 days 1 week 10 days 2 weeks

4 days Rationale: All people who have household or face-to-face contact with the client after the fever begins should be vaccinated within 4 days to prevent infection and death.

If a client has been exposed to radiation, the presenting symptoms, such as nausea, vomiting, loss of appetite, diarrhea, or fatigue, can be expected to occur within how many hours after exposure? 6 to 12 12 to 24 24 to 48 48 to 72

48 to 72 Rationale: The prodromal phase (presenting symptoms) of radiation exposure occurs within 48 to 72 hours after exposure. Signs and symptoms include nausea, vomiting, loss of appetite, diarrhea, and fatigue. With high-dose radiation exposure, the signs and symptoms may include fever, respiratory distress, and increased excitability.

Which of the following medications are used to suppress viral load of the HSV-2 infection? Acyclovir (Zovirax) Penicillin Metronidazole (Flagyl) Clindamycin (Cleocin)

Acyclovir (Zovirax) Rationale: The antiviral agents acyclovir (Zovirax), valacyclovir (Valtrex), and famciclovir (Famvir) are recommended to suppress the viral load and decreases recurrence and shedding. Flagyl and Cleocin are not used for this action.

Which is a goal of case management? Appropriateness of services Prescriptive authority Attainment of fixed price reimbursement Utilization of the nursing process

Appropriateness of services

In which location are most brain angiomas located? Cerebellum Hypothalamus Thalamus Brainstem

Cerebellum Rationale: Brain angiomas occur most often in the cerebellum. Most brain angiomas do not occur in the hypothalamus, thalamus, or brainstem (midbrain, pons, medulla).

A patient was suspected of being in direct contact with anthrax but is exhibiting no signs or symptoms. What type of prophylaxis does the nurse know this patient will have to take? Penicillin G IM for 1 dose Rocephin (Ceftriaxone) IV for 7 days Ciprofloxacin (Cipro) for 60 days Erythromycin for 2 weeks

Ciprofloxacin (Cipro) for 60 days

Which of the following outcomes would be most appropriate to include in the plan of care for a client diagnosed with a muscular dystrophy? Client participates in activities of daily living using adaptive devices. Client demonstrates understanding of the need to adhere to medication therapy. Client verbalizes understanding of the chronic nature of the disorder. Client describes the importance of diagnostic follow-up to evaluate the disorder.

Client participates in activities of daily living using adaptive devices. Rationale: The muscular dystrophies are a group of incurable muscle disorders characterized by progressive weakening and wasting of the skeletal or voluntary muscles. Nursing care focuses on maintaining the client at his or her optimal level of functioning and enhancing the quality of life. Therefore, the outcome of participating in activities of daily living with adaptive devices would be most appropriate. Medications are not used to treat these disorders; however, they may be necessary if the client develops a complication such as respiratory dysfunction. The disorder is incurable and progressive, not chronic. Diagnostic follow-up would provide little if any information about the course of the disorder.

During a mass disaster, the nurse is caring for a victim whose status has been categorized as yellow during triage. How should the nurse best allocate time and resources to this client's care? Forego immediate care because the client is unlikely to survive Place a low priority on the client's care because the client will likely recover independently Provide high-priority, immediate care to save the client's life Delay the client's treatment for a few hours if other clients need immediate care

Delay the client's treatment for a few hours if other clients need immediate care Rationale: For a client categorized as yellow, care can be safely delayed for six to eight hours. Death is not imminent, but spontaneous recovery is unlikely.

The nurse is caring for a client hospitalized after a motor vehicle accident. The client has a comorbidity of Parkinson's disease. Why should the nurse closely monitor the condition and the drug regimen of a client with Parkinson's disease? Drugs administered may not cause the requisite therapeutic effect. Clients take an assortment of different drugs. Clients generally do not adhere to the drug regimen. Drugs administered may cause a wide variety of adverse effects.

Drugs administered may cause a wide variety of adverse effects. Rationale: Drugs administered for Parkinsonism may cause a wide variety of adverse effects, which requires careful observation of the client. Over time, clients may respond less and less to their standard drug therapy and have more frequent "off episodes" of hypomobility. As a result, the nurse should administer the drugs closely to the schedule. Generally, a single drug called levodopa is administered to clients with Parkinson's disease. It is also not true that drugs may not cause the requisite therapeutic effect or such clients do not adhere to the drug regimen.

The greatest risk of seizures for clients with brain tumors occurs in those who have tumors in which regions of the brain? Select all that apply. Frontal Parietal Temporal Occipital Brain stem

Frontal Parietal Temporal Rationale: Tumors of the frontal, parietal, and temporal lobes carry the greatest risk of seizures; seizures are unusual with brainstem or cerebellar tumors. Occipital lobe tumors are more likely to produce visual impairments such as contralateral homonymous hemianopsia.

The nurse is assessing a client in the emergency department who grimaces and reports swelling of the testicles, burning on urination and a green discharge from the penis. The nurse suspects the client will be diagnosed with which infection? Gonorrhea Primary syphilis Herpes genitalis Trichomoniasis

Gonorrhea Rationale: When symptoms of gonorrhea are present in male clients, the symptoms may include burning during urination and penile discharge. Clients with Neisseria gonorrhoeae infection also may report painful swollen testicles. The latter symptoms distinguishes this infection from the infections in the alternate options. Primary syphilis occurs 2 to 3 weeks after initial inoculation with the organism. A painless lesion at the site of infection is called a chancre. Untreated, these lesions usually resolve spontaneously within about 2 months. With herpes genitalis primary infection may begin with macules (small flat spots on skin) and papules (small circumscribed elevations) and progress to vesicles (small, serous-filled elevated spots) and ulcers. The vesicular state often appears as a blister, which later coalesces, ulcerates, and encrusts. Influenza-like symptoms may occur 3 or 4 days after the lesions appear, often with inguinal lymphadenopathy (enlarged lymph nodes in the groin). Men with trichomoniasis may notice itching or irritation inside the penis, burning after urination or ejaculation, discharge from the penis. Reference:

Which phase of the psychological reaction to rape is characterized by fear and flashbacks? Heightened anxiety phase Acute disorganization phase Denial phase Reorganization phase

Heightened anxiety phase Rationale: During the heightened anxiety phase, the client demonstrates anxiety, hyperalertness, and psychosomatic reactions, in addition to fear and flashbacks. The acute disorganization phase is characterized by shock, disbelief, guilt, humiliation, and anger. The denial phase is characterized by an unwillingness to talk. The reorganization phase occurs when the incident is put into perspective. Some clients never fully recover from rape trauma.

A client comes to the emergency department with a suspected airway obstruction. The emergency department team prepares to manage the client as if he has a complete airway obstruction based on which of the following? Forceful coughing Wheezing between coughs High-pitched noise on inhalation Refusal to lie flat

High-pitched noise on inhalation Rationale: A client who demonstrates a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis should be managed as if he or she has a complete airway obstruction. Forceful coughing, wheezing between coughs, and a refusal to lie flat suggest a partial airway obstruction that can be managed as such.

The nurse is instructing an adolescent female on potential vaccinations available. Which vaccination would the nurse state that decreases the risk of cervical cancer? Hepatitis B Human papilloma viral (HPV) Herpes zoster Meningococcal

Human papilloma viral (HPV) Rationale: Human papilloma viral (HPV) infection is the most commonly transmitted sexual disease in the United States. A strain of this infection can cause cervical cancer. An HPV vaccine is available to both females and males. For females, the vaccine decreases the risk of cervical cancer and genital warts. For males, the vaccine decreases the risk of genital warts and anal cancers. Hepatitis B vaccine protects against a liver disease. Herpes zoster is the vaccine for shingles. The meningococcal vaccine protects against several diseases including meningitis.

Which disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive, involuntary dancelike movements and dementia? Multiple sclerosis Huntington disease Parkinson disease Creutzfeldt-Jakob disease

Huntington disease Rationale: Because it is transmitted as an autosomal dominant genetic disorder, each child of a parent with Huntington disease has a 50% risk of inheriting the illness. Multiple sclerosis is a chronic, degenerative, progressive disease of the central nervous system (CNS) characterized by the occurrence of small patches of demyelination in the brain and spinal cord. Parkinson disease is associated with decreased levels of dopamine due to destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain. Creutzfeldt-Jakob disease is a rare, transmissible, progressive and fatal disease of the CNS characterized by spongiform degeneration of the gray matter of the brain.

A nurse is caring for a client who has arrived at the emergency department in shock. The nurse intervenes based on the knowledge that which of the following is the most common cause of shock? Anaphylaxis Sepsis Hypovolemia Cardiac dysfunction

Hypovolemia Rationale: Types of shock include cardiogenic, neurogenic, anaphylactic, and septic. Of these, the most common cause is hypovolemia.

Which is a true statement regarding severe acute respiratory syndrome (SARS)? Constipation usually develops. It is spread by fecal contamination. Hypothermia will occur. It is most contagious during the second week of illness.

It is most contagious during the second week of illness. Rationale: Based on available information, SARS is most likely to be contagious only when symptoms are present, and clients are most contagious during the second week of illness. Diarrhea and hyperthermia may occur with SARS. Respiratory droplets spread the SARS virus when an infected person coughs or sneezes.

A male client who has undergone a cervical discectomy is being discharged with a cervical collar. Which of the following would be most appropriate to include the client's discharge plan? Keeping the head in a neutral position Wearing the cervical collar when sleeping Removing the entire collar when shaving Moving the neck from side to side when the collar is off

Keeping the head in a neutral position Rationale: After a cervical discectomy, the client typically wears a cervical collar. The client should be instructed to keep his head in a neutral position and wear the collar at all times unless the physician has instructed otherwise. The front part of the collar is removed for shaving and the neck should be kept still while the collar is open or off.

A patient arrives at the emergency department after sustaining a gunshot wound to the abdomen. When assessing the patient, the nurse pays particular attention to which of the following? Liver Stomach Large intestine Kidneys

Liver Rationale: Penetrating abdominal injuries, such as from a gunshot wound, are serious and result in a high incidence of injury to hollow and solid organs. Although any organs can be injured, the liver is the most frequently injured solid organ. The small bowel is a frequently injured hollow organ. Thus, of the options shown, the nurse would assess the liver area most closely.

A client with spinal cord compression from a tumor must undergo diagnostic testing. Which of the following is the most likely procedure for this client? Core needle biopsy Ultrasonography Computed tomography Magnetic resonance imaging

Magnetic resonance imaging Rationale: Magnetic resonance imaging is the most commonly used diagnostic procedure. It is the most sensitive diagnostic tool that is particularly helpful in detecting epidural spinal cord compression and vertebral bone metastases.

Acetaminophen overdose is treated with administration of which medication? N-acetylcysteine Flumazenil Naloxone Diazepam

N-acetylcysteine Rationale: Treatment of acetaminophen overdose includes administration of N-acetylcysteine. Flumazenil is administered in the treatment of nonbarbiturate sedative overdoses. Naloxone is administered in the treatment of narcotic overdoses. Diazepam may be administered to treat uncontrolled hyperactivity in the client with a hallucinogen overdose.

A client seeks care for lower back pain of 2 weeks' duration. Which assessment finding suggests a herniated intervertebral disk? Pain radiating down the posterior thigh Back pain when the knees are flexed Atrophy of the lower leg muscles Homans' sign

Pain radiating down the posterior thigh Rationale: A herniated intervertebral disk may compress the spinal nerve roots, causing sciatic nerve inflammation that results in pain radiating down the leg. Slight knee flexion should relieve, not precipitate, lower back pain. If nerve root compression remains untreated, weakness or paralysis of the innervated muscle group may result; lower leg atrophy may occur if muscles aren't used. Homans' sign is more typical of phlebothrombosis.

A nurse is caring for a client in the clinic. Which sign or symptom may indicate that the client has gonorrhea? Burning on urination Dry, hacking cough Diffuse skin rash Painless chancre

Painless chancre Rationale: Burning on urination may be a symptom of gonorrhea or urinary tract infection. A dry, hacking cough is a sign of a respiratory infection, not gonorrhea. A diffuse rash may indicate secondary stage syphilis. A painless chancre is the hallmark of primary syphilis. It appears wherever the organisms enter the body, such as on the genitalia, anus, or lips.

Homeland Security has alerted the disaster response teams in your region of a potential terrorist attack in the form of a nuclear blast. You are a part of the disaster response system and you know that with a nuclear blast you would need to be prepared for what classification of disaster? Radiologic Chemical Biologic Manmade

Radiologic

A patient is diagnosed with a spinal cord tumor and has had a course of radiation and chemotherapy. Two months after the completion of the radiation, the patient complains of severe pain in the back. What is pain an indicator of in a patient with a spinal cord tumor? Lumbar sacral strain The development of a skin ulcer from the radiation Hematoma formation Spinal metastasis

Spinal metastasis Rationale: Pain is the hallmark of spinal metastasis. Patients with sensory root involvement may suffer excruciating pain, which requires effective pain management.

The nurse is seeing the mother of a client who states, "I'm so relieved because my son's doctor told me his brain tumor is benign." The nurse knows what is true about benign brain tumors? They can affect vital functioning. They do not require surgical removal. The prognosis is very poor. They are all metastatic.

They can affect vital functioning. Rationale: Benign tumors are usually slow growing but can occur in a vital area, where they can grow large enough to cause serious effects. Surgical removal of a benign tumor is dependent on many factors; even if the tumor is slow growing or not growing at all, the location of the tumor in the brain factors into the decision for surgical removal. The prognosis for all brain tumors is not necessarily poor. Treatment is individualized and can have varying prognostic outcomes. Benign tumors are not metastatic, meaning they do not grow rapidly or spread into surrounding tissue, but they can still be considered life-threatening.

The nurse is presenting a community lecture about STIs, and emphasizes that some STIs are easily cured with early and adequate treatment. Which is not among these easily treated diseases? genital herpes chlamydia gonorrhea syphilis

genital herpes Rationale: Chlamydia, gonorrhea, and syphilis are easily cured with early and adequate treatment. Genital herpes is not.

An 82-year-old client is admitted to the hospital with a diagnosis of pneumonia. The nurse learns that the client lives alone and hasn't been eating or drinking properly. When assessing the client for dehydration, the nurse would expect to find: distended jugular veins. hypothermia. hypertension. tachycardia.

tachycardia. Rationale: With an extracellular fluid or plasma volume deficit, compensatory mechanisms stimulate the heart, causing an increase in heart rate. Distended jugular veins and hypertension may be signs of fluid volume overload. Body temperature may be elevated with dehydration. Blood pressure, in particular systolic blood pressure, falls with dehydration, and orthostatic hypotension may occur.

You are a school nurse teaching a health class about the chain of infection in the transmission of sexually transmitted diseases (STDs). A student asks you which part of the chain of infection can be missing when transmission occurs. What would be your best answer? "Not everyone is susceptible to STDs, but they still get them." "STDs can be gotten from bed linens and toilet seats, so you don't really need a reservoir." "You can be missing any part of the chain of infection except the infectious agent." "All parts of the chain of infection have to be present for the disease to be passed to another human."

"All parts of the chain of infection have to be present for the disease to be passed to another human." Rationale: All components in the chain of infection must be present for an infectious disease to be transmitted from one human or animal to a susceptible host. This makes options A, B, and C incorrect.

The nurse in the hospital emergency department is assessing a patient who fell while intoxicated with alcohol. The nurse is using the Clinical Institute Withdrawal Assessment-Alcohol (CIWA-A) scale to assess the patient's need for a benzodiazepine medication. In order to assess for auditory disturbances, which question should the nurse ask the patient? "Are you hearing anything that is disturbing you?" "Are you experiencing any burning or numbness?" "Are you finding the light is too harsh or bothering your eyes?" "Does it feel like there is a tight band around your head?"

"Are you hearing anything that is disturbing you?" Rationale:The Clinical Institute Withdrawal Assessment-Alcohol (CIWA-A) scale is used in the assessment of alcohol withdrawal. The patient's score on this scale helps determine the level of intervention that is required to support safe, withdrawal from alcohol. Assessing for auditory disturbances is one subsection on the scale. In order to effectively assess for this symptom, the nurse should ask the patient if they are hearing anything that is disturbing. By asking the patient if they are experiencing any numbness or burning would help to assess for tactile disturbances. By asking the patient if the light is bothering their eyes would support the assessment for visual disturbances. Asking the patient if it feels like there is a tight band around their head would help determine if the patient has a headache or fullness of the head. These are all symptom items that are measured by this scale.

A client arrives at the emergency department and is experiencing a severe allergic reaction to a bee sting. The client received treatment and is being discharged. Which client statement indicates that additional teaching about exposure prevention is needed? "I should always wear something on my feet when I'm outside." "Brightly colored clothes help to ward off bees." "If a bee comes near me, I should stay still." "I need to avoid using perfumes and scented soaps when I'm going outside."

"Brightly colored clothes help to ward off bees." Rationale: To prevent insect stings, the client should avoid wearing brightly colored clothing because it attracts bees. The client should wear covering on the feet and avoid going barefoot because yellow jackets nest and pollinate on the ground. Staying still or motionless reduces the likelihood of being stung. Perfumes and scented soaps attract bees and should be avoided.

The nurse is instructing the family on home care of a client with shingles. The family member asks whether their teenage children should stay in a different room. What is the best response by the nurse? "Yes, shingles is highly contagious." "Have they had chickenpox or the varicella vaccine?" "No, shingles is not contagious." "Because the client is in quite a bit of pain, it would probably be best."

"Have they had chickenpox or the varicella vaccine?" Rationale: To answer the question correctly, the nurse needs to know whether the children have had chickenpox or received the varicella vaccine. If the children have been vaccinated or had the disease, then they are immune and no precautions are needed. If the children have not been vaccinated for chickenpox nor had the disease, it would be best to maintain distance. Shingles is contagious. Even though the client may be in pain, this should not guide the nurse's response.

The nurse is seeing a client who came into the sexual health clinic after discovering condylomata along her labia. The client states, "This makes no sense, I don't even know who I got this from and I have been so careful!" What is the nurse's best response? "If you make a list of your sexual partners over the past month you should be able to narrow down the person who is the source of your infection." "If a condom was used during all sexual contacts, it is unlikely the warts that you have were caused by the human papillomavirus (HPV)." "It sounds like you are feeling angry. Let's talk more about human papillomavirus (HPV) and strategies to stay healthy while you are being treated." "You are high risk simply because you are sexually active with more than one partner. Do you know how many partners all your partners have had?"

"It sounds like you are feeling angry. Let's talk more about human papillomavirus (HPV) and strategies to stay healthy while you are being treated." Rationale: In many cases, clients are angry about having warts from HPV and do not know who infected them because the incubation period can be long and partners may have no symptoms. Acknowledging emotional distress that occurs when a sexually transmitted infection is diagnosed and providing support and facts are important nursing actions. The client in this case is clearly feeling angry and overwhelmed. The nurse should first provide empathy and help the client focus on information regarding treatment in a solution focused way. Discussing the number of sexual partners and risk factors is important in prevention; however, given the client's emotional state the alternative responses would not be helpful and supportive. In addition, to inform the client that if a condom was used the virus cannot be transmitted is incorrect. Transmission can also occur through skin-on-skin contact in areas not covered by condoms.

The nurse is giving an educational talk to a local parent-teacher association. A parent asks how he can help his family avoid community-acquired infections. What would be the nurse's best response to help prevent and control community-acquired infections? "Encourage your family to adopt a healthy diet and exercise regimen." "Encourage your family to stop smoking." "Make sure your family has all their childhood immunizations." "Make sure your family has regular checkups."

"Make sure your family has all their childhood immunizations." Rationale: To help prevent and control community-acquired infections, nurses should encourage childhood immunizations. Vaccines stimulate the body to produce antibodies against a specific disease organism. The immunization of children protects children as well as adults who may not have developed sufficient immunity. Following a proper diet and exercise regimen and going for regular checkups are important, but these measures do not help prevent or control community-acquired infections. Smoking cessation does not reduce the risk of such infections either.

The nurse is caring for a client who has just been diagnosed with chlamydia and is very upset. The client says, "I don't understand this. The person I had sex with did not have any symptoms at all. How could I have known?" What is the best response by the nurse to this client? "It is very hard to see signs of infection in the heat of passion." "Many people with chlamydia won't have symptoms for up to 3 weeks after being infected." "I think you realize that if you had used some form of a barrier protection such as a condom, it would have helped prevent this situation." "It is really important that you know the sexual history of every potential lover. It may be uncomfortable but it will prevent the situation you are dealing with right now."

"Many people with chlamydia won't have symptoms for up to 3 weeks after being infected." Rationale: As many as 75% of infected women and 25% of infected men are symptom free. It may take 1-3 weeks for symptoms to appear. Whether in passion or not, if symptoms are present, an individual would be able to see them. It is true that a condom would help decrease the incidence of an STI but the nurse should not try to condemn or judge the client with the STI. Knowing a client's sexual history is important but it does not answer the question that the client posed?

Which of the following statements would most lead a nurse to suspect that a patient is experiencing food poisoning? "I've been feeling sick to my stomach for about 3 or 4 days now." "The food I ate seemed to look and taste like it should." "My brother got sick like me after eating the same food." "I have a pain in my left side, down low near my groin."

"My brother got sick like me after eating the same food." Rationale: The statement about the patient's brother also being sick after eating the same food suggests food poisoning. Feeling sick to the stomach for 3 to 4 days could indicate various problems, not just food poisoning. Food tasting or looking fine does not really indicate anything definitive about the patient's condition. Most foods causing bacterial poisoning do not have unusual odor or taste. A pain in the left groin area is more suggestive of appendicitis, not food poisoning.

The nurse is orienting to the emergency department and finds cases of potassium iodine tablets located in the supply closet. The nurse asked the nurse manager why this is stored in the closet. The nurse manager's best response is: "Potassium iodine is given to individuals who come to the emergency department dehydrated to replenish their potassium level." "Potassium iodine is given to individuals diagnosed with hypothyroidism in the emergency department." "Potassium iodine is given to individuals as a prophylaxis for protecting the thyroid gland from absorption of radiation in case of an accident at the local nuclear plant." "Potassium iodine is given to individuals who are given furosemide intravenously in the emergency department to replenish their potassium level."

"Potassium iodine is given to individuals as a prophylaxis for protecting the thyroid gland from absorption of radiation in case of an accident at the local nuclear plant."

A 36-year-old client is in the clinic for an annual physical. The client asks the nurse, "Should I get a flu shot?" Which is the best response by the nurse? "No, you are not in the age range for the flu shot." "Do you have any chronic illnesses?" "The flu shot is recommended for all people over 6 months of age." "Only if you work around children or the elderly."

"The flu shot is recommended for all people over 6 months of age." Rationale: The influenza vaccine is recommended for all people over 6 months of age; therefore the client is in the recommended age range. Ascertaining whether the client has any chronic illnesses is important, but it does not change the recommendation by the Centers for Disease Control and Prevention. No recommendation suggests that the immunization be given only if the client works around children or the elderly.

The nurse is providing education to a client who has been diagnosed with trichomoniasis. When providing information about metronidazole, what should the nurse be certain to include? "You will need to have a follow up appointment to determine if you have been cured." "You will need to avoid alcohol during treatment and for 3 days after the medication is complete." "Sexual activity with your partner can continue as usual while you are being treated." "This infection is not curable and treatment is aimed at symptom management."

"You will need to avoid alcohol during treatment and for 3 days after the medication is complete." Rationale: The client should be advised to avoid alcohol for the duration of treatment with metronidazole and for 3 days after it is complete. Test of cure is not required after treatment with metronidazole for trichomoniasis. Nursing education on abstaining from sexual activity until both partners are treated is imperative. The most effective treatment for trichomoniasis is metronidazole or tinidazole. Trichomoniasis is the most common curable sexually transmitted infection.

A patient is brought to the emergency department. Assessment reveals that the patient is lethargic and diaphoretic and complaining of right upper quadrant pain. Acetaminophen toxicity is suspected and an acetaminophen level is drawn. Which result would the nurse interpret as indicating toxicity for the patient if he weighs 70 kg? 6300 mg 7700 mg 9100 mg 10,500 mg

10,500 mg Rationale: An acetaminophen level greater than or equal to 140 mg/kg would be considered toxic. For a patient weighing 70 kg, the toxic level would be 9800 mg. A level of 10,500 mg would be greater, thus indicating toxicity.

Permanent brain injury or death will occur within which time frame secondary to hypoxia? 1 to 2 minutes 3 to 5 minutes 6 to 8 minutes 9 to 10 minutes

3 to 5 minutes Rationale: If the airway is completely obstructed, permanent brain injury or death will occur within 3 to 5 minutes secondary to hypoxia. Air movement is absent in the presence of complete airway obstruction. Oxygen saturation of the blood decreases rapidly because obstruction of the airway prevents air from entering the lungs. Oxygen deficit occurs in the brain, resulting in unconsciousness, with death following rapidly. The other time frames are incorrect.

The nurse received a patient from a motor vehicle accident who is hemorrhaging from a femoral wound. What is the initial nursing action for the control of the hemorrhage? Apply a tourniquet. Apply firm pressure over the involved area or artery. Elevate the injured part. Immobilize the area to control blood loss.

Apply firm pressure over the involved area or artery. Rational: Direct, firm pressure is applied over the bleeding area or the involved artery at a site that is proximal to the wound (Fig. 72-3). Most bleeding can be stopped or at least controlled by application of direct pressure. Otherwise, unchecked arterial bleeding results in death. A firm pressure dressing is applied, and the injured part is elevated to stop venous and capillary bleeding, if possible. If the injured area is an extremity, the extremity is immobilized to control blood loss. A tourniquet is applied to an extremity only as a last resort when the external hemorrhage cannot be controlled in any other way and immediate surgery is not feasible.

You are caring for a client with an impaired immune system. You are concerned about the client acquiring a nosocomial infection. What intervention would help nurses control nosocomial infections? Apply principles of medical and surgical asepsis. Maintain a proper diet and exercise regimen. Use proper antibiotics. Ensure childhood immunizations.

Apply principles of medical and surgical asepsis. Rationale: Nosocomial infections are acquired when receiving care in a healthcare facility. To help prevent and control nosocomial infections, nurses should apply principles of medical and surgical asepsis whenever they care for clients. Childhood immunizations control community-acquired infections. Maintaining a proper diet and exercise regimen and use of antibiotics do not help control nosocomial infections.

A female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing interventions should be provided? (Select all that apply.) Have the patient shower or wash the perineal area before the examination. Assess and document any bruises and lacerations. Record a history of the event, using the patient's own words. Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police. Ensure that the police are present when the examination is performed.

Assess and document any bruises and lacerations. Record a history of the event, using the patient's own words. Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police. Rationale: A history is obtained only if the patient has not already talked to a police officer, social worker, or crisis intervention worker. The patient should not be asked to repeat the history. Any history of the event that is obtained should be recorded in the patient's own words. The patient is asked whether he or she has bathed, douched, brushed his or her teeth, changed clothes, urinated, or defecated since the attack, because these actions may alter interpretation of subsequent findings. Each item of clothing is placed in a separate paper bag. The bags are labeled and given to appropriate law enforcement authorities. The patient is examined (from head to toe) for injuries, especially injuries to the head, neck, breasts, thighs, back, and buttocks. The exam focuses on external evidence of trauma (bruises, contusions, lacerations, stab wounds).

A client comes to the emergency department complaining of sudden onset of diarrhea, anorexia, malaise, cough, headache, and recurrent chills. Based on the client's history and physical findings, the physician suspects legionnaires' disease. While awaiting diagnostic test results, the client is admitted to the facility and started on antibiotic therapy. What's the drug of choice for treating legionnaires' disease? Azithromycin (Zithromax) Rifampin (Rifadin) Amantadine (Symmetrel) Amphotericin B (Fungizone)

Azithromycin (Zithromax) Rationale: Azithromycin is the drug of choice for treating legionnaires' disease. Rifampin is used to treat tuberculosis. Amantadine, an antiviral agent, and amphotericin B, an antifungal agent, are ineffective against legionnaires' disease, which is caused by bacterial infection.

A client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later, the nurse identifies which finding as an early sign of shock? Confusion Pale, warm, dry skin Heart rate of 70 beats/minute Elevated blood pressure

Confusion Rationale: Early in shock, inadequate perfusion leads to anaerobic metabolism, which causes metabolic acidosis. As the respiratory rate increases to compensate, the client's carbon dioxide level decreases, causing alkalosis and subsequent confusion and combativeness. Inadequate tissue perfusion causes pale, cool, clammy skin (not pale, warm, dry skin). In the early stages of shock, the client's heart rate will become elevated above normal. In early shock the client's blood pressure will remain normal, but as shock progresses the mechanisms that regulate blood pressure will not be able to compensate.

In which group is it most important for the client to understand the importance of an annual Papanicolaou test? Clients with a history of recurrent candidiasis Clients with a pregnancy before age 20 Clients infected with the human papillomavirus (HPV) Clients with a long history of hormonal contraceptive use

Clients infected with the human papillomavirus (HPV) Rationale: HPV causes genital warts, which are associated with an increased incidence of cervical cancer. Recurrent candidiasis, pregnancy before age 20, and use of hormonal contraceptives don't increase the risk of cervical cancer.

Which of the following describes microorganisms present without host interference or interaction? Colonization Infection Infectious disease Reservoir

Colonization Rationale: The term colonization is used to describe microorganisms present without host interference or interaction. Infection indicates a host interaction with an organism. Infectious disease is the state in which the infected host displays a decline in wellness due to the infection. Reservoir is the term used for any person, plant, animal, substance, or location that provides nourishment for microorganisms and enables further dispersal of the organisms.

A nurse who was working as part of an emergency response team for a mass casualty incident is engaging in a Critical Incident Stress Management program. The nurse has received information about how to recognize stress reactions and ways to manage them. The nurse is involved in which of the following? Field support Debriefing Defusing Follow-up

Defusing Rationale: Defusing is a process by which a person receives education about recognition of stress reactions and management strategies for handling stress. Field support occurs during the incident to ensure that the staff get adequate rest, food, fluids, and rotating work loads. Debriefing is a complication intervention that involves a 2- to 3-hour process during which participants are asked about their emotional reactions to the incident, what symptoms they may be experiencing, and other psychological ramifications. In follow-up, members of the Critical Incident Stress Management team contact the participants of a debriefing and schedule a follow-up meeting if necessary.

A client is brought to the emergency department after being involved in a motor vehicle collision. Which of the following would lead the nurse to suspect internal bleeding? Bradycardia Rising blood pressure Delayed capillary refill Pale pink dry skin

Delayed capillary refill Rationale: If a client exhibits tachycardia, falling blood pressure, thirst, apprehension, cool moist skin, or delayed capillary refill, internal bleeding should be suspected.

The nurse has come on shift to find that a client newly admitted to the ICU is confused and persistently trying to get out of bed despite being comforted and re-oriented by the nurse. The client begins to pull on the peripheral intravenous line in the hand and speaking in non-sensical terms. The client's history indicates a sudden onset of neurological symptoms after developing a bacterial infection. The nurse anticipates providing care for which health problem? Delirium Pain Anxiety Fever

Delirium Rationale: Delirium is a confused state that has a sudden onset and can last hours to days or weeks; it is characterized by hyperactivity and has the potential to be reversible. The client who quickly becomes confused and agitated while attempting to pull out IV lines and get out of bed is experiencing delirium. The nurse caring for this client should anticipate the need to provide close monitoring to prevent injury. Although clients can experience a high level of stress with both pain and anxiety, which often accompany one another, these problems do not cause confusion and disorientation. Nursing interventions would be aimed at reducing pain and anxiety with the use of medications and other non-pharmacological interventions that enhance client comfort. Although fever can accompany delirium, it does not produce confusion and disorientation on its own.

The nurse is conducting a secondary survey on a client in the ED. Which action is completed during the secondary survey? Diagnostic and laboratory testing Assessment of peripheral pulses Establishing a patent airway Undressing the client

Diagnostic and laboratory testing Rationale: Diagnostic and laboratory testing is completed during the secondary survey, along with a complete health history, a head-to-toe assessment, insertion or application of monitoring devices, splinting of suspected fractures, cleansing, closure, and dressing of wounds, and performance of other necessary interventions based on the client's condition. The other interventions are completed during the primary survey.

A patient is brought to the emergency department and diagnosed with decompression sickness. The nurse interprets this as indicating that the patient most likely has been involved with which of the following? Swimming in a lake Diving in an ocean Running a race in hot humid weather Working in a chemical plant

Diving in an ocean Rationale: Decompression sickness occurs when patients have engaged in diving in a lake or ocean or high-altitude flying or flying in a commercial aircraft within 24 hours of diving. Swimming in a lake could lead to a near-drowning episode. Running a race in hot humid weather would increase a person's risk for heat stroke. Working in a chemical plant would increase the risk for chemical burns.

You are caring for radiation victims. What is the most important factor that you should consider to assess a client's chance of survival in acute radiation syndrome (ARS)? Dosage of gamma radiation Concentration of nerve gas Mode of infection Direct physical contact

Dosage of gamma radiation Rationale: The chance of surviving ARS depends on the dosage of gamma radiation a person receives. ARS is not related to chemical (gas) or biologic (infection, contact) disasters.

A nurse is preparing to assist with a gastric lavage for a client who has ingested an unknown poison and is obtunded. To ensure that the tube reaches the stomach, the nurse would measure the distance from the bridge of the nose to which of the following? Ear lobe and then to the xiphoid process Chin and then to the xiphoid process Ear lobe and then to the umbilicus Chin and then to the umbilicus

Ear lobe and then to the xiphoid process Rationale: The nurse measures the tube from the bridge of the nose to the xiphoid process to ensure that the tube reaches the stomach on insertion.

The nurse is caring for a client who appears to have some type of sexually transmitted infection. The nurse will observe which signs or symptoms if the client has secondary stage syphilis? Select all that apply. Itchy rash on the soles of the feet Fever Lymph node enlargement Chest pain Headache

Fever Lymph node enlargement Headache Rationale: Symptoms of secondary syphilis include a non-itchy rash on the soles of the feet, fever, malaise, lymph node enlargement, patchy hair loss, sore throat, and headache.

The nurse educator is preparing a presentation about the indicators of chemical terrorism. The nurse educator would include which indicators in the presentation. Select all that apply. Fog-like or low-lying cloud in the atmosphere Numerous dead animals and birds Increase in temperature in area of the event Strong wind in area of the event Unexplained odor atypical for the location

Fog-like or low-lying cloud in the atmosphere Numerous dead animals and birds Unexplained odor atypical for the location

A nurse is providing care to clients who were involved in an explosion and have sustained secondary blast injuries. Which types of injuries would the nurse expect to find? Select all that apply. Head injuries Crush injuries Penetrating trauma Traumatic amputations Exacerbation of pre-existing conditions

Penetrating trauma Traumatic amputations Rationale: Secondary-phase blast injuries, which result from debris or shrapnel within the bomb or from the scene, include penetrating trunk, skin, and soft tissue injuries, fractures, and traumatic amputations. Head injuries are related to the primary phase of the blast injury. Crush injuries and exacerbations of pre-existing conditions are related to the quaternary phase of the blast injury.

The nurse is caring for a client with diabetes who requires a peripheral intravenous (PIV) line for antibiotic administration and to treat dehydration. The nurse must avoid inserting which type of PIV? Forearm Hand Foot Upper arm

Foot Rationale: PIV lines should rarely be used in the foot for various reasons. They limit the client's ability to ambulate and tend to occlude easily. These types of IVs should never be used in clients with diabetes due to the risk that the client has neuropathy and cannot feel injury caused by the IV catheter. IV lines in the forearm and hands are acceptable and are commonly used sites. These sites would be safe to use for a client with diabetes. The upper arm is a site of choice for the insertion of a peripherally inserted central line (PICC) not a PIV line. Although, this site would not be an option for a PIV line, it would be safe for use in a client with diabetes if warranted.

A client comes to the ED after attempting suicide with nerve gas. Which is an appropriate nursing intervention? Decontamination with saline solution for 3 minutes Wiping skin dry after cleansing with saline Frequent suctioning, as needed Administration of IV Benadryl

Frequent suctioning, as needed Rationale: Appropriate nursing interventions after exposure to nerve gas include frequent suctioning, as needed; decontaminating the skin by rinsing with saline or soap and water for 8 to 20 minutes; blotting versus wiping skin dry to prevent rubbing more of the agent into the skin; and administration of intravenous atropine or pralidoxime.

Nursing students are reviewing the categories of intra-abdominal injuries. The students demonstrate understanding of the information when they identify which of the following as examples of penetrating trauma? Select all that apply. Gunshot wound Knife-stab wound Motor-vehicle crash Fall from a roof Being struck with a baseball bat

Gunshot wound Knife-stab wound Rationale: Examples of penetrating trauma include gunshot wounds and stab wounds. Motor vehicle crashes, falls, and being struck with a baseball bat are examples of blunt trauma.

A nurse is providing care to a client who has been exposed to phosgene vapor. Which nursing diagnosis would the nurse identify as the priority? Impaired gas exchange related to destruction of the pulmonary membrane Impaired skin integrity related to vesicant contact with skin Disturbed sensory perception: visual related to bilateral miosis and visual disturbances Decreased cardiac output related to altered aerobic metabolism from agent exposure

Impaired gas exchange related to destruction of the pulmonary membrane Rationale: Phosgene vapor is a pulmonary agent that destroys the pulmonary membrane leading to pulmonary edema, with shortness of breath. Therefore, impaired gas exchange would be the priority. Impaired skin integrity would be appropriate for exposure to a vesicant. Disturbed sensory perception, visual would be appropriate for a client exposed to a nerve agent. Decreased cardiac output would be appropriate for a client exposed to a blood agent, such as cyanide, which inhibits aerobic metabolism.

A nuclear reactor overheated, releasing radiation throughout the plant. A worker close to reactor received at least 800 rads and has had an onset of vomiting, bloody diarrhea, and, when brought to the hospital, was in shock. What is this patient's predicted survival? Possible Probable Likely Improbable

Improbable

The nurse is completing the admission assessment on a client with renal failure. The client states, "I was diagnosed with impetigo yesterday." Which is the appropriate nursing intervention? Obtain the name of the antiviral medication used to treat the impetigo. Initiate contact isolation protocol. Transfer the client to a negative-pressure room. Educate the client about wearing a mask outside of the assigned room.

Initiate contact isolation protocol. Rationale: Impetigo is a bacterial infection transmitted via contact. Therefore, the nurse should initiate contact isolation protocol. The client would not be taking an antiviral medication for impetigo, would not need a negative-pressure room, and would not wear a mask when outside the room.

A client has been admitted with diarrhea. He has mild dehydration (less than 5%). The nurse is reviewing the laboratory report of the stool specimen, as indicated in the following:WBC: Mildly elevated RBC: Few Bacteria: Positive for Escherichia coli Ova and parasites: Negative Based on the laboratory report, what should the nurse do first? Start an I.V. infusion. Institute enteric precautions. Instruct the family to wash all family bed linens in hot water. Clean and protect the anal area.

Institute enteric precautions Rationale: The stool specimen indicates that the client has E. coli in his stool. The nurse should institute enteric precautions, and all who come in contact with this client should observe good hand washing and gown technique to prevent the spread of infection. Restoring fluid balance is a goal of therapy, but because the dehydration is mild, oral rehydration will be the first choice for replacing fluids. The nurse should also clean and protect the anal area from irritation from diarrhea, but on an ongoing basis, not as the priority for care. It is not necessary for the family to wash all of their bed linens because only those in contact with the client are contaminated.

A nurse implements aseptic technique as a means to break the chain of infection at which element? Reservoir Portal of exit Means of transmission Portal of entry

Portal of entry Rationale: The use of aseptic technique interrupts the chain of infection at the portal of entry. Employee health, environmental sanitation, and disinfection and sterilization interfere with the reservoir element. Hand hygiene, control of secretions, and excretions and proper trash and waste disposal interfere with the portal of exit. Isolation, proper food handling, airflow control, standard precautions, sterilization, and hand hygiene interfere with the means of transmission.

A nurse is completing her annual cardiopulmonary resuscitation training. The class instructor tells her that a client has fallen off a ladder and is lying on his back; he is unconscious and isn't breathing. What maneuver should the nurse use to open his airway? Head tilt-chin lift Jaw-thrust Abdominal thrust Seldinger

Jaw-thrust Rationale: If a neck or spine injury is suspected, the jaw-thrust maneuver should be used to open the client's airway. To perform this maneuver, the nurse should position herself at the client's head and rest her thumbs on his lower jaw, near the corners of his mouth. She should then grasp the angles of his lower jaw with her fingers and lift the jaw forward. The head tilt-chin lift maneuver is used to open the airway when a neck or spine injury isn't suspected. To perform this maneuver the nurse places two fingers on the chin and lifts while pushing down on the forehead with the other hand. The abdominal thrust is used to relieve severe or complete airway obstruction caused by a foreign body. The Seldinger maneuver is a method of percutaneous introduction of a catheter into a vessel.

A nurse is providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate? Providing an analgesic for pain Massaging the feet Restricting ambulation Placing sterile cotton between the toes after rewarming

Massaging the feet Rationale: For a client with frostbite, massaging the affected body part is contraindicated. Analgesia is given for pain during the rewarming process because it can be very painful. Ambulation would be restricted. Once rewarmed, sterile gauze or cotton is placed between the affected toes to prevent maceration.

During a disaster, the nurse sees a victim with a green triage tag. The nurse knows that the person has which type of injury? Life-threatening but survivable with minimal intervention Minor; treatment can be delayed hours to days Significant; injuries require medical care but can wait hours without threat to life or limb Extensive; chances of survival are unlikely even with definitive care

Minor; treatment can be delayed hours to days Rationale: A green triage tag (priority 3, or minimal) indicates injuries that are minor; treatment can be delayed hours to days. A red triage tag (priority 1, or immediate) indicates injuries that are life threatening but survivable with minimal intervention. A yellow triage tag (priority 2, or delayed) indicates injuries that are significant and require medical care but can wait hours without threat to life or limb. A black triage tag (priority 4, or expectant) indicates injuries that are extensive; chances of survival are unlikely even with definitive care.

A client presents to the ED after an unsuccessful suicide attempt. The client is diagnosed with an acetaminophen overdose. The nurse anticipates the administration of which medication? N-acetylcysteine Flumazenil Naloxone Diazepam

N-acetylcysteine Rationale: Treatment of acetaminophen overdose includes administration of N-acetylcysteine. Flumazenil is administered in the treatment of nonbarbiturate sedative overdoses. Naloxone is administered in the treatment of narcotic overdoses. Diazepam may be administered to treat uncontrolled hyperactivity in the client with a hallucinogen overdose.

When preparing to perform abdominal thrusts on a client with an airway obstruction, which of the following would be most appropriate? Having the conscious client lie down Placing the thumb side of one hand at the xiphoid process Positioning the hands in the midline slightly above the umbilicus Using a sequence of four thrusts, each progressing in intensity

Positioning the hands in the midline slightly above the umbilicus Rationale: When performing abdominal thrusts, the nurse would place the thumb side of one fist against the client's abdomen in the midline slightly above the umbilicus and well below the xiphoid process, grasping the fist with the other hand. Then the nurse would press the fist into the client's abdomen with a quick inward and upward thrust such that each new thrust should be a separate and distinct maneuver. The unconscious client is positioned on the back. The client who is conscious should be standing or sitting.

Three victims of radiation exposure are brought into the Emergency Department. As the nurse caring for these clients, you would expect what substance to be ordered to reduce radiologic organ damage? Cyan red Potassium iodide Russian blue Medical iodine

Potassium iodide Rationale: Taking substances called potassium iodide, Prussian blue, and diethylenetriamine pentaacetate can prevent or reduce radiologic organ damage. Option A, C and D are incorrect and used only as distractors.

The nurse has been called in to the local hospital along with all staff to respond to a mass casualty disaster. The nurse is assessing a victim whose serious injuries are certain to cause death within minutes or hours. How should the nurse and the other members of the care team best respond? Prioritize the care of less seriously injured victims over this victim Prioritize the victim's care to increase the odds of survival Prioritize comfort care and address the client's spiritual needs Delegate the victim's care to other members of the team

Prioritize the care of less seriously injured victims over this victim Rationale: Though it seems counterintuitive, it is often necessary to put a lower priority on the care of seriously injured victims than those who are less seriously injured, since the goal is to maximize survival with limited time and resources. Consequently, there would not likely be time or staff to address spirituality in a disaster situation.

The nurse is triaging patients from a 10-car pile-up on the interstate and assesses a patient with a sucking chest wound. What category should this patient be placed in? Priority 1 Priority 2 Priority 3 Priority 4

Priority 1

The nurse has received a client into care who was admitted with a heroin overdose. The client has a 5-year history of illicit substance use with cocaine, heroin, and oxycodone. The client develops a sudden onset of wheezing, restlessness, and a cough that produces frothy, pink sputum. The nurse suspects the client has most likely developed which complication of opioid overdose? Pulmonary edema Pneumonia Congestive heart failure Panic attack

Pulmonary edema Rationale: The nurse should suspect the client has developed pulmonary edema, which is frequently seen in clients who abuse/overdose on narcotics. Many drugs — ranging from illegal drugs such as heroin and cocaine to aspirin — are known to cause noncardiogenic pulmonary edema. Pneumonia is not the likely cause given the sudden onset of respiratory symptoms accompanied but coughing up the pink frothy sputum. The client's history of illicit substance use and now overdose on these drugs should lead the nurse to suspect pulmonary edema is the cause of the sudden onset of these symptoms over congestive heart failure, in which clients have a more gradual onset of respiratory issues. Although a panic attack can manifest in shortness of breath and restlessness, the client would not be wheezing or producing blood-tinged sputum with a cough. Panic attacks do, however, have a sudden onset and can cause the client chest pain and a sense of doom.

The nurse has received a client into care who was admitted with a heroin overdose. The client has a 5-year history of illicit substance use with cocaine, heroine and oxycodone. The client develops a sudden onset of wheezing, restlessness and a cough that produces a frothy, pink sputum. The nurse suspects the client has most likely developed which complication of opioid overdose? Pulmonary edema Pneumonia Congestive heart failure Panic attack

Pulmonary edema Rationale: The nurse should suspect the client has developed pulmonary edema, which is frequently seen in clients who abuse/overdose on narcotics. Many drugs — ranging from illegal drugs such as heroin and cocaine to aspirin — are known to cause noncardiogenic pulmonary edema. Pneumonia is not the likely cause given the sudden onset of respiratory symptoms accompanied but coughing up the pink frothy sputum. The client's history of illicit substance use and now overdose on these drugs should lead the nurse to suspect pulmonary edema is the cause of the sudden onset of these symptoms over congestive heart failure, in which clients have a more gradual onset of respiratory issues. Although a panic attack can manifest in shortness or breath and restlessness, the client would not be wheezing or producing blood tinged sputum with a cough. Panic attacks do, however, have a sudden onset and can cause the client chest pain and a sense of doom.

The nurse is caring for clients in the emergency department who have been admitted from the area surrounding a nuclear power plant. There had been a small explosion at the plant and a small amount of radiation had escaped. The nurse knows that this is what type of a disaster? Natural Explosive Chemical Radiologic

Radiologic Rationale: Radiologic disasters can occur in the following ways: Explosion of a dirty bomb; Damage to or human error in a nuclear power plant facility; Nuclear blast. The scenario does not describe a natural disaster or a chemical disaster. Explosive is only a distractor.

The nurse is assigned to a client admitted to the ICU from the emergency department. The client sustained multiple injuries from a motor vehicle accident. When reviewing the client chart, the notes indicate the client's emergency care was managed in what sequence of steps? 1Establish airway and start ventilation 2Application of pressure to control abdominal bleeding 3Start peripheral intravenous insertion and infusion of fluids 4Assess for head and neck injuries 5Examine client for additional injuries to the body 6Reassess pulses and neurovascular status

Rationale: The goals of treatment are to determine the extent of injuries and to establish priorities of treatment. Any injury interfering with a vital physiologic function (e.g., airway, breathing, circulation) is an immediate threat to life and has the highest priority for immediate treatment. Essential lifesaving procedures are performed simultaneously by the emergency team. Establishing the airway and performing ventilation is necessary to support airway and breathing. Hypovolemic shock is prevented by applying pressure to bleeding sites and initiating a peripheral IV and immediate start of infusion of intravenous fluids. As soon as the client is resuscitated, clothes are removed or cut off and a rapid physical assessment is performed. The physical assessment should prioritize head and neck injuries and then injuries over the rest of the body. Ongoing examination, assessment and diagnostic evaluation are necessary. The health care team will continue to assess vascular and neurological status as these can change quickly.

The student nurse is working with a nurse manager at a hospital when a disaster drill is announced over the hospital P.A. system. The nurse manager asks the nursing student what color triage tag is used for clients who have life threatening, but survivable conditions, if rapid medical attention is provided. What color is the triage tag for these clients? Red Yellow Green Black

Red Rationale: The nurse is asking about clients that are labeled immediate when the clients suffer with life threatening, but survivable conditions, if rapid medical attention is provided. Immediate clients are given a red triage tag. Clients with yellow triage tags are labeled delayed, and have injuries serious but stable enough to survive if treatment is delayed 6-8 hours. Clients with green triage tags are labeled minimal, and have injuries that are more minor that can wait longer than 6-8 hours to be addressed. Clients with black triage tags are labeled expectant, and are expected to die. With an expectant client, when the airway is opened, the client has no spontaneous respirations.

A nurse is providing disaster care in an event that is known to involve gamma radiation. When admitting victims of the disaster, what should the nurse do to best reduce victims' risks of injury? Remove victims' clothing and have them wash themselves thoroughly. Carefully apply personal protective equipment over victims' clothing. Apply chlorhexidine to all skin surfaces that may have been contaminated. House victims in a well-ventilated area.

Remove victims' clothing and have them wash themselves thoroughly. Rationale: The nurse should have victims shower and change clothes and irrigate or wash open wounds with soap and water. Cleansing the skin helps to reduce the transition from external to internal radiologic contamination. Infectious microorganisms are not involved, so chlorhexidine is of no particular benefit. Applying PPE over contaminated clothing could worsen the risk for injury. Adequate ventilation is important, but removal of contaminants is the priority because of the increased risk for injury.

A nurse volunteers to help decontaminate a victim. Which is the first action that the nurse should take? Washing victim with soap and water, then rinsing Removing the victim's clothing and jewelry Dressing the victim in personal protective equipment Applying chemical decontamination foam to the area

Removing the victim's clothing and jewelry Rationale: To be effective, decontamination must include a minimum of two steps. The first step is removing the client's clothing and jewelry and then rinsing the client with water. The second step consists of a thorough soap and water wash and rinse.

A client reports nausea, vomiting, and diarrhea for 5 days. The nurse assesses the mucous membranes as pale and dry. The client has sunken eyes with the following vital signs: pulse 122 and thready, respirations 23, blood pressure 78/55, temperature 101.8°F oral. Which is the priority nursing intervention? Initiate oral rehydration therapy at 100 mL/kg of oral rehydration solution over 4 hours. Request an order from the physician for IV rehydration therapy. Assess vital signs every 15 minutes. Obtain stool specimen for analysis.

Request an order from the physician for IV rehydration therapy. Rationale: The client is demonstrating hemodynamic instability that could lead to shock; therefore IV rehydration therapy is indicated. Oral rehydration therapy can begin once the client becomes hemodynamically stable. Although it is appropriate for the nurse to take vital signs frequently, the client needs fluid replacement and that need should be addressed first. Stool specimens can be obtained once the client is hemodynamically stable.

The nurse in an intensive care unit is assigned to two clients. One of the clients has just passed away. The deceased client's family members have arrived to be at the client's bedside. Despite wanting to support the client's family, the nurse is must assess the other client's vital signs every 15 minutes, because the client is receiving a blood transfusion. In this situation, what is the nurse's best action? Request that the pastor be present to support the family at the client bedside Delegate the blood transfusion to the licensed practical/vocational nurse Hand off care of the other client to another nurse Explain to the family it is a busy time on the unit but someone will be with them soon

Request that the pastor be present to support the family at the client bedside Rationale: The death of a family member in the intensive care unit is a difficult and often time-consuming process. If nurses are unable to spend much time with grieving client's family, it is imperative to find the family alternate help: a colleague with more experience with grieving clients, a pastor, a social worker, hospital volunteers, family, or friends. It would be best if the nurse requests a pastor be available to the family in advance of their arrival to the deceased client's bedside. Much of the pastor's role in hospital settings is to support grieving families; therefore, the pastor would have more time to be with the family during this difficult time. The blood transfusion in the intensive care unit is not within the scope of practice for the licensed practical/vocational nurse. The nurse cannot delegate the monitoring of blood products to this health care provider. The intensive care unit is a busy environment and as difficult as it is for the assigned nurse to remain with the deceased client, it would be even more difficult for a nurse with a full assignment to take on the support role for the family. Explaining to the family that the unit is busy demonstrates a lack of empathy and would be countertherapeutic communication. It would not be appropriate to explain this to the family.

The emergency department nurse is caring for clients involved in a chlorine exposure accident at a local chemical plant. The nurse is aware that permanent damage can occur to which body systems? Cardiac Respiratory Renal Hepatic

Respiratory Rationale: The consequences of exposure to chlorine and other respiratory toxins are related to the amount, route, and length of chemical exposure. Death occurs as fluid infiltrates the pulmonary air spaces and terminal bronchioles interfering with gas exchange. Following recovery from an acute event, victims may develop chronic bronchitis and emphysema.

The nurse is caring for a client exposed to a blistering agent. While the nurse is quickly decontaminating the client by showering and bagging all client clothing, what is the nurse simultaneously assessing for? Neurological compromise Respiratory compromise Cardiovascular compromise Sensory neglect

Respiratory compromise Rationale: A person exposed to a blistering agent or vesicant must be decontaminated immediately, with clothing removed and bagged. Irrigation of the victim's eyes and application of topical analgesia, antibiotics, and lubricants to the skin occur. Simultaneously, the nurse is assessing the respiratory system for airway obstruction because blisters from inhaled toxics can swell obstructing respiratory passages.

The nurse has commenced a transfusion of fresh frozen plasma (FFP) and notes the client is exhibiting symptoms of a transfusion reaction. After the nurse stops the transfusion, what is the next required action? Remove the peripheral IV line Start a dextrose 5% water infusion Run a normal saline line to keep the vein open Obtain a blood culture from the IV insertion site

Run a normal saline line to keep the vein open Rationale: If the nurse suspects a transfusion reaction, the transfusion must be stopped immediately and the nurse's next action is to ensure the normal saline line is running at a rate that permits administration of IV fluids or medications that are required to treat the reaction. The nurse should ensure IV access is maintained. The 'to keep vein open (TKVO) rate allows the nurse to keep the IV client without the potential to cause fluid volume overload. It would be unsafe for the nurse to remove the peripheral IV because continued access is required for urgent IV administration of medications or fluids to treat the reaction. Obtaining a blood culture at the IV site would be necessary if an infection was suspected. This is not required for a transfusion reaction. Normal saline is the solution of choice when transfusing blood products because there is a risk for incompatibility with all other IV solutions.

The Department of Homeland Security indicates a threat level "Imminent" relative to a situation. What does the nurse know that this indicates? Elevated risk of attack Severe, credible impending threat, usually with a site specified Risk of attack, without a site specified Risk of attack, without timing specified

Severe, credible impending threat, usually with a site specified Rationale: Imminent threat level indicates a severe, credible impending threat, usually with a site specified.

Which guideline is appropriate for a nurse to implement while helping family members cope with the sudden death of a loved one? Inform the family that the client has passed on. Obtain orders for sedation for family members. Show acceptance of the body by touching it, giving the family permission to touch. Provide details of the factors attendant to the sudden death.

Show acceptance of the body by touching it, giving the family permission to touch. Rationale: The nurse should encourage the family to view and touch the body if they wish, since this action helps the family to integrate the loss. The nurse should avoid using euphemisms such as "passed on." The nurse should avoid giving sedation to family members, because this may mask or delay the grieving process. The nurse should avoid volunteering unnecessary information (e.g., client was drinking at the time of the accident).

The nurse is instructing on bioterrorism agents. Which of the following does the nurse emphasize as an agent which is transmitted from person to person? Anthrax Botulism Smallpox Varicella

Smallpox Rationale: Smallpox is highly contagious and caused by a variola virus. Individuals infected with the botulinum toxin and anthrax are not at risk to others; there are no reports of person to person transmission. Varicella, commonly called the chickenpox, is contagious but not a bioterrorism agent.

When preparing for an emergency bioterrorism drill, the nurse instructs the drill volunteers that each biological agent requires specific client management and medications to combat the virus, bacteria, or toxin. Which statement reflects the client management of variola virus (smallpox)? Acyclovir is effective against smallpox. Smallpox is spread by inhalation of spores. A vaccination is effective only if administered within 12 to 24 hours of exposure. Smallpox spreads rapidly and requires immediate isolation.

Smallpox spreads rapidly and requires immediate isolation Rationale: Smallpox is spread by droplet or direct contact. No antiviral agents are effective against smallpox; however, vaccination within 2 to 3 days of exposure is protective. In 4 to 5 days, vaccination may prevent death and should be administered with vaccinia immune globulin. Smallpox spreads rapidly and requires immediate isolation. Even in death, the disease can be transmitted.

A client has been exposed to a vesicant and is undergoing decontamination. Which of the following most likely would be used? Sodium hypochlorite Soap and water Alcohol Chlorhexidine

Soap and water Rationale: A client who is exposed to a vesicant agent undergoes decontamination with soap and water. Scrubbing with sodium hypochlorite solutions is avoided because they increase penetration of the nerve agent. Alcohol and chlorhexidine are inappropriate choices for decontamination.

A client comes to the emergency department after experiencing a wound. Inspection reveals an opening in the skin with distinct edges and whose depth is greater than the length of the wound. The nurse documents this as which type of wound? Laceration Avulsion Stab Patterned

Stab Rationale: A stab wound is an incision of the skin with well-defined edges and is typically deeper than long. It is usually caused by a sharp instrument. A laceration is a tear in the skin with irregular edges and vein bridging. An avulsion is manifested as a tearing away of tissue from the supporting structures. A patterned wound takes on the outline of the object causing the wound.

A patient was bitten by a tick 3 months ago and is now having muscle aches as well as joint pain and swelling. The patient is having difficulty with self care and requires assistance with activities of daily living (ADLs). What stage of Lyme disease does the nurse recognize the patient is in? Stage I Stage II Stage III Stage IV

Stage III Rationale: Lyme disease has three stages. Stage I presents with a classic "bull's-eye" rash (i.e., erythema migrans) and flulike signs and symptoms that may include chills, fever, myalgia, fatigue, and headache. If antibiotics are not administered, stage II Lyme disease may present within 4 to 10 weeks following the tick bite and may manifest with joint pain, memory loss, poor motor coordination, and meningitis. Stage III can begin anywhere from weeks to more than a year after the bite and has serious long-term chronic sequelae, including arthritis, neuropathy, myalgia, and myocarditis.

A patient was bitten by a tick 3 months ago and is now having muscle aches as well as joint pain and swelling. The patient is having difficulty with self care and requires assistance with activities of daily living (ADLs). What stage of Lyme disease does the nurse recognize the patient is in? Stage I Stage II Stage III Stage IV

Stage III Rationale: Lyme disease has three stages. Stage I presents with a classic "bull's-eye" rash (i.e., erythema migrans) and flulike signs and symptoms that may include chills, fever, myalgia, fatigue, and headache. If antibiotics are not administered, stage II Lyme disease may present within 4 to 10 weeks following the tick bite and may manifest with joint pain, memory loss, poor motor coordination, and meningitis. Stage III can begin anywhere from weeks to more than a year after the bite and has serious long-term chronic sequelae, including arthritis, neuropathy, myalgia, and myocarditis.

A nurse is providing in-service education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step? Collecting semen Performing the pelvic examination Obtaining consent for examination Supporting the client's emotional status

Supporting the client's emotional status Rationale: The teaching session is successful when staff members focus first on supporting the client's emotional status. Next, staff members should gain consent to perform the pelvic examination, perform the examination, and collect evidence, such as semen if present.

A nurse is caring for a client who is experiencing alcohol withdrawal. Which statement best indicates that the client understands the need for long-term treatment? The client agrees to attend supportive counseling. The client agrees to involve his family in psychotherapy. The client agrees to ongoing participation in one or more support groups. The client agrees to detoxification, rehabilitation, and participation in an aftercare program.

The client agrees to detoxification, rehabilitation, and participation in an aftercare program. Detoxification, rehabilitation, and participation in an aftercare program are the only options that address the client's long-term treatment needs. Supportive counseling, family involvement, and support-group participation are important aspects of the treatment process, but they don't address the client's need for long-term treatment.

The nurse is caring for a client who is being prepared for the placement of a central intravenous line. The nurse recognizes this client requires this type of intravenous access for which reason? The client will require intravenous access for three days The client requires total parenteral nutrition The client requires infusion of intravenous antibiotics The client requires infusion of a dextrose 5% water (D5W)

The client requires total parenteral nutrition Rationale: For a patient who requires total parenteral nutrition (TPN), a central intravenous line is required due to the length of time the client will require the infusion as well as the nature of the solution itself. A large vein is required to safely infuse TPN. For this reason, a central line is needed. A peripheral intravenous line is safe to used when IV access is required under six days. Beyond this time, either a new peripheral IV will need to be inserted. If it is known in advance that IV treatment will last beyond six days, the client's health care provider will order the placement of a central intravenous line. Intravenous antibiotics can be administered peripherally unless the course is longer than six days. D5W is an intravenous solution that can be administered either peripherally or centrally. The nature of this IV solution would not determine which type of IV access the client requires.

When a hospitalized client requires contact precautions, which responses is necessary? The client's door should be closed. Masks are worn when caring for the client. The client should be placed in a private room when possible. The client should be in a room with negative air pressure.

The client should be placed in a private room when possible. Rationale: When possible, the client requiring contact isolation is placed in a private room to facilitate hand hygiene and decreased environmental contamination. Masks are not needed, doors do not need to be closed, and a room with negative air pressure is not required.

A nurse is preparing a presentation for a group of nurses involved in a disaster training program at their facility. The nurse is describing blast injuries. Which statement would be most appropriate to include in this presentation? Most blast injuries result from debris that comes off the bomb. The most commonly used explosive device is a pipe bomb. Secondary devices are usually of little concern with a blast injury. Triaging of clients with a blast injury differs because of the severity of injuries.

The most commonly used explosive device is a pipe bomb. Rationale: The most commonly used bomb is the pipe bomb, which consists of relatively low-velocity explosives and may also contain nails or other implements that cause more damage when the explosive ignites. Most injuries associated with any blast injury are caused by the primary blast wave. After a bombing incident, risk for secondary devices is increased; these are often set to explode at a predetermined time, typically after arrival of rescue personnel. Clients experiencing blast injury are triaged in the same manner as for any disaster.

You are an Emergency Department nurse who has to care for three victims of anthrax. The first victim inhaled the toxin, the second victim ingested it, and the third victim suffered a skin infection. Which client should be cared for first? The one who ingested the toxin The one who inhaled the toxin The one with the skin infection Any convenient order

The one who inhaled the toxin Rationale: The nurse should first treat the client who is at greatest risk. The most serious form of anthrax develops upon inhalation. If diagnosed incorrectly and untreated, the infection progresses to severe respiratory distress, and in severe situations, death may also occur. Ingesting the bacteria is less lethal, with symptoms of nausea, vomiting, diarrhea, and abdominal pain. Skin infection is the least deadly form characterized by painless lesions usually on the head, hands, and arms. Therefore, the client who inhaled the toxin should always get first priority.

A client present to the ED following a work-related injury to the left hand. The client has an avulsion of the left ring finger. Which correctly describes an avulsion? Tissue tearing away from supporting structures Incision of the skin with well-defined edges, usually long rather than deep Skin tear with irregular edges and vein bridging Denuded skin

Tissue tearing away from supporting structures Rationale: An avulsion is described as a tearing away of tissue from supporting structures. A laceration is a skin tear with irregular edges and vein bridging. Abrasion is denuded skin. A cut is an incision of the skin with well-defined edges, usually long rather than deep.

You are caring for clients who have been exposed to a toxic nerve agent. You will need to use diazepam with these clients. Why is diazepam given when managing the effects of toxic nerve agent toxicity? To counter excess acetylcholine To control possible seizures To reactivate acetylcholinesterase To control hypersecretion

To control possible seizures Rationale: Seizures are likely to occur only after exposure to a nerve agent. Diazepam controls seizures. Atropine sulfate counteracts excess acetylcholine at muscarinic sites. Pralidoxime chloride reactivates acetylcholinesterase. Atropine is typically administered to stop any kind of hypersecretion.

Which is defined as the potential of an agent to cause injury to the body? Volatility Latency Persistence Toxicity

Toxicity Rationale: The median lethal dose (LD50) is the amount of the chemical that will cause death in 50% of those who are exposed. Persistence means that the chemical is less likely to vaporize and disperse. Volatility is the tendency for a chemical to become a vapor. Latency is the time from absorption to the appearance of symptoms.

The nurse is triaging victims after an explosion at an oil refinery. One victim reports tinnitus, dizziness, and otorrhea. For what probable condition should the nurse prepare care? Blast lung Tympanic rupture Head injury Abdominal injury

Tympanic rupture rationale: The nurse should prepare to care for a client with probable tympanic rupture. Signs and symptoms of tympanic rupture include hearing loss, tinnitus, pain, dizziness, and otorrhea. Symptoms of blast lung include dyspnea, hypoxia, tachypnea or apnea, cough, chest pain, and hemodynamic instability. Symptoms of head injury include post-concussive syndrome. Symptoms of abdominal injury include pain, guarding, rebound tenderness, rectal bleeding, nausea, and vomiting.

A nursing instructor is describing the role of a nurse during a disaster. Which of the following would best reflect the nurse's role? Variable depending on the needs of the situation Client care within the area of expertise Provision of comprehensive client-specific care Directly specified by the physician in charge

Variable depending on the needs of the situation Rationale: The role of the nurse during a disaster varies and depends on the needs or situation. Nurses may be asked to perform duties outside their areas of expertise and may take on responsibilities normally held by physicians or advanced practice nurses. During a disaster, nursing care focuses on essential care from a perspective of what is best for all clients.

Which term refers to the tendency for a chemical to become a vapor? Persistence Volatility Toxicity Latency

Volatility Rationale: The most common volatile agents are phosgene and cyanide. Persistence means that the chemical is less likely to vaporize and disperse. Toxicity is the potential of an agent to cause injury to the body. Latency is the time from absorption to the appearance of symptoms.

A nurse would perform handwashing instead of using an alcohol-based product for which situation? Before putting on sterile gloves for inserting a urinary catheter After taking a client's vital signs When hands are visibly soiled from client care During client care when moving from a contaminated body site to a clean one

When hands are visibly soiled from client care Rationale: Handwashing would be done when the hands become visibly dirty or contaminated with biologic material from client care. Otherwise, an alcohol-based product could be used, for example, before putting on gloves for inserting a urinary catheter, after taking a client's temperature or blood pressure, or during client care when moving from a contaminated body site to clean body site.

After a routine physical exam, a female client is devastated to receive a diagnosis of the sexually transmitted infection, gonorrhea. What would contribute to the client's ignorance of this condition? being asymptomatic knowing the signs and symptoms of STIs being sexually inactive All options are correct.

being asymptomatic Rationale: Many women who have gonorrhea are asymptomatic, a factor that contributes to the spread of the disease. Knowing the signs and symptoms of STIs will not help with an asymptomatic disease. Being sexually inactive currently will not prevent having been infected with a disease in the past.

A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's: blood pressure. hemoglobin level. temperature. heart rate.

blood pressure. Rationale: With adequate fluid replacement, fluid volume in the intravascular space expands, raising the client's blood pressure. The hemoglobin level reflects red blood cell concentration, not overall fluid status. Temperature and heart rate aren't directly related to fluid status.

A nurse is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include: coma or seizures. sunken eyeballs and poor skin turgor. increased heart rate with hypotension. thirst or irritability.

thirst or irritability. Rationale: Early signs and symptoms of dehydration include thirst, irritability, dry mucous membranes, and dizziness. Coma, seizures, sunken eyeballs, poor skin turgor, and increased heart rate with hypotension are all later signs.

According to the U.S. Department of Homeland Security, what are indications of bioterrorism? Select all that apply. clusters of sick people from a shared location dead or dying vegetation higher numbers of people seeking healthcare atypical incidence of illness for the time of year unexplained odor atypical for the location

clusters of sick people from a shared location atypical incidence of illness for the time of year unexplained odor atypical for the location Rationale: The U.S. government has identified several key indications of bioterrorism to assist in its identification. These include high outbreak of similar symptoms among previously healthy people, increased numbers of sick people seeking healthcare, atypical incidence of illness for the time of year and geographic location, clusters of sick people from a shared locale, unusual mortality rates among people following a brief illness, and unexplained deaths or illness among domestic and wild animals.

A nuclear accident (intentional or unintentional) can cause significant harm to those living nearby or at a distance. Harmful levels of invisible gamma radiation penetrate the body, not only causing devastating injuries but possibly contaminating others. What type of transmission precaution prevents such person-to-person contamination? contact airborne droplet standard

contact Rationale: Invisible gamma radiation penetrates the body and can be eliminated in blood, sweat, urine, and feces. Consequently, a contaminated person can contaminate others through contact with body fluids or surfaces he or she touches. Airborne transmission requires the suspension and transport on air currents beyond 3 feet and is the way in which many pathogens or toxins are transmitted. Invisible gamma rays do not fall into this category, however. Gamma radiation does not travel in a liquid, or droplet, form. Standard precautions encompass more than person-to-person contamination.

During flu season, a nurse is teaching clients about the chain of infection. What components are considered "links" in this chain? Select all that apply. virulence infectious agent portal of entry susceptible host fomites

infectious agent portal of entry susceptible host Rationale: The six components involved in the transmission of microorganisms are described as the chain of infection. All components in the chain of infection must be present to transmit an infectious disease from one human or animal to a susceptible host: an infectious agent, an appropriate reservoir, exit route, means of transmission, portal of entry, and susceptible host.

A college student comes to the campus health care center complaining of headache, malaise, and a sore throat that has worsened over the past 10 days. The nurse measures a temperature of 102.6° F (39.2° C) and finds an enlarged spleen and liver and exudative tonsillitis. Laboratory tests reveal a leukocyte count of 20,000/mm3, antibodies to Epstein-Barr virus, and abnormal liver function tests. These findings suggest: mumps. poliomyelitis. herpangina. infectious mononucleosis.

infectious mononucleosis. Rationale: The client's clinical manifestations and laboratory test results suggest infectious mononucleosis. Mumps, a viral disease, usually causes an earache and fever from parotid gland involvement. Poliomyelitis is an acute communicable disease that has been largely eradicated by the polio vaccine. Although its symptoms resemble those of mononucleosis, it typically has a central nervous system component, causing back, neck, and arm pain or paralysis. Herpangina is an acute viral infection that causes seizures, vomiting, stomach pain, and grayish papulovesicles on the soft palate.

The nurse is instructing volunteers at an emergency bioterrorism drill about the management and medications required to combat various viruses, bacteria, and toxins. The nurse knows that the volunteers understand the instruction when they state that managing clients who exhibit symptoms of the variola virus (smallpox) includes acyclovir. decontamination. radiation. isolation.

isolation. Rationale: Smallpox is spread by droplet or direct contact and spreads rapidly. Clients exhibiting symptoms should be immediately placed in isolation.