CC EAQ questions

What should be the nurse's focus when caring for a client after abdominal surgery?

Identifying signs of bleeding

What are the reasons for performing a lumbar puncture on a client? Select all that apply.

Reading cerebrospinal fluid pressure Injecting contrast medium for diagnostic study

The nurse is assigning emergency severity index (ESI) levels to clients who survived with traumatic injuries after a train derailment. Which client should be triaged under ESI-1 based on stability in vital function and life threat? A-Cardiac arrest due to severe respiratory depression B - Chest pain resulting from ischemia C - Hip fracture in an older client D - Simple laceration

A

A client who had extensive pelvic surgery 24 hours ago becomes cyanotic, is gasping for breath, and reports right-sided chest pain. What should the nurse do first?

Administer oxygen using a face mask

The client is in atrial fibrillation. Which information should the nurse consider about atrial fibrillation when planning care for this client?

A loss of atrial kick

Because of multiple physical injuries and emotional concerns, a hospitalized client is at high risk to develop a stress ulcer (Curling). Which of these is evidence of a stress ulcer?

A sudden massive hemorrhage

A client has undergone nasal hypophysectomy surgery. During post-operative care, which finding indicates cerebrospinal leakage?

A yellow edge around nasal discharge

A client admitted in the emergency department has airway obstruction, chest wall trauma, external hemorrhage, and hypoglycemia. Which condition of the client will be given the highest priority?

Airway obstruction

What assessment is the nurse's main priority during the early postoperative period after a subtotal thyroidectomy?

Airway obstruction

Which activity is performed first when a client is bitten by a brown recluse spider?

Applying cold compresses over the site

Which action should be the nurse's first priority for a client with major burns?

Assessing airway patency

A client has a diagnosis of partial-thickness burns. While planning care, the nurse recalls that the client's burn is different than full-thickness burns. Which information did the nurse recall?

Partial-thickness burns are often painful, reddened, and have blisters.

The nurse is caring for a client with a pneumothorax and chest tube. To evaluate the effectiveness of a chest tube, the nurse assesses for which finding?

Return of breath sounds

The nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the priorityconcern of the nurse when caring for this client?

Skin integrity

A client has second degree atrioventricular (AV) block. Which information will the nurse consider when planning care? Select all that apply.

Some P waves are conducted to the ventricles. Treatment consists of atropine or a pacemaker.

A client is experiencing severe respiratory distress. Which response should the nurse expect the client to exhibit?

Tachycardia

A client presenting to the emergency department with chest pain and dizziness is found to be having a myocardial infarction and subsequently suffers cardiac arrest. The healthcare team is able to successfully resuscitate the client. Lab work shows that the client now is acidotic. How does the nurse interpret the cause of the acidosis?

The decreased tissue perfusion caused lactic acid production.

A nurse is preparing for an unconscious client with a head injury to be transferred from the emergency department to a neurologic trauma unit. Which nursing action is the priority?

Checking that a bag-valve mask is available during the transfer

Which clinical manifestation can a client experience during a fat embolism syndrome (FES)?

Dyspnea

A client is to be transferred from the coronary care unit to a progressive care unit. The client asks the nurse, "Are you sure I'm ready for this move?" What should the nurse determine that the client most likely is experiencing based on this statement?

Fear

A client with heart failure has anxiety. Which effect of anxiety makes it particularly important for the nurse to reduce the anxiety of this client?

Increases the cardiac workload

The client is admitted with paroxysmal supraventricular tachycardia at a rate of 140 beats per minute. The client's blood pressure is 110/55 mm Hg, and the client is asymptomatic except for a "fluttering feeling" in the chest. Which treatments should the nurse be prepared to administer? Select all that apply.

Intravenous adenosine Intravenous beta blockers Intravenous amiodarone Intravenous calcium channel blockers

The nurse is caring for a client who is hyperventilating. The nurse recalls that the client is at risk for what?

Respiratory alkalosis

A client who had a craniotomy is transferred to the intensive care unit from the postanesthesia care unit. Which nursing action is most important when caring for this client?

Report yellow or bloody drainage on the dressing to the healthcare provider immediately.

What should the nurse consider when providing care to a client in the acute phase of treatment for a full-thickness burn?

The risk of septicemia and its potential complications from treatment

A client has surgery to replace a prolapsed mitral valve. What should the nurse teach the client?

The signs and symptoms of heart failure

The registered nurse is teaching a coworker about the care to be taken in clients with neurologic changes associated with aging. Which statement made by the coworker indicates the nurse needs to intervene?

"Clients with decreased sensory perception of touch should be carefully monitored for infection."

A client has a mitral valve replacement, and the nurse provides health teaching to promote optimum health. Which client statement supports the nurse's conclusion that the client needs further teaching?

"I will start a vigorous aerobic exercise program."

A client receives an autograft for a severe burn and is taught how to change the dressing. One week after receiving the graft, the client identifies that the edges of the graft are curling up and asks the nurse about it. Which is the best response by the nurse?

"May I take a look at it?"

A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding?

Absence of breath sounds on auscultation

A nurse is preparing medications. Which client's health problem motivates the nurse to question a prescription for a beta blocker?

Acute heart failure

A nurse observes the cardiac monitor of a client who has had a pacemaker inserted. At which letter on the rhythm strip is evidence of pacemaker impulse?

B (the spike)

A client was admitted to the hospital with blunt trauma as a result of a collision with the steering wheel during a motor vehicle accident. The client was treated for a lacerated liver and abdominal hemorrhage. Which clinical findings should the nurse be alert for when assessing the client for peritonitis during the recovery period? Select all that apply.

Boardlike abdomen Abdominal tenderness Decreased bowel sounds

How does the human body conserve heat? Select all that apply.

By decreasing muscle activity in the body Through peripheral vasoconstriction in body By shunting blood away from the skin surface

A hospitalized client puts the call light on and reports a sudden onset of chest pain that feels like a pressure or weight on the chest. The client also states, "I feel nauseated and very weak." Which action should the nurse take?

Call the rapid response team.

The nurse is planning to triage clients according to emergency severity index (ESI). Which client should be triaged under ESI-1 based on threat to life and stability of vital functions?

Cardiac Arrest

Which client would the nurse treat first according to a three-tiered triage system?

Client with respiratory distress

After surgery, a client is extubated in the postanesthesia care unit. Which clinical manifestations should the nurse expect if the client is experiencing acute respiratory distress? Select all that apply.

Confusion Hypocapnia Tachycardia

A client with an inferior myocardial infarction has a heart rate of 120 beats per minute. Which goal achievements are priority?

Decrease the workload on the heart and promote maximum coronary artery filling

A client is experiencing tachycardia. Which adverse hemodynamic effects will the nurse consider when planning care for this client? Select all that apply.

Decreased ventricular filling time Decreased cardiac output

A client presents to the emergency department with weakness and dizziness. The blood pressure is 90/60 mm Hg, pulse is 92 and weak, and body weight reflects a 3-pound (1.4 kilogram) loss in two days. The weather has been hot. Which condition should the nurse conclude is the priority for this client?

Deficient fluid volume

A client who has partial-thickness burns on the chest, abdomen, and right side arrives in the emergency department. Which action will the nurse take first?

Evaluate whether the client has inhaled smoke.

A nurse uses the Glasgow Coma Scale to assess a client's status after a head injury. When the nurse applies pressure to the nail bed of a finger, which movement of the client's upper arm should cause the most concern?

Extending

A nurse is caring for a client who has a burn in the emergent stage. Which assessment is the highest priority?

Extent of burn

A client is recovering from a myocardial infarction. Which action should the nurse take before developing the client's teaching plan?

Identify the learning needs of the client.

What is the priority nursing intervention for a client bitten by a snake?

Immobilizing the effected extremity using a splint

A client who has acquired human immunodeficiency syndrome (HIV) develops bacterial pneumonia. On admission to the emergency department, the client's PaO 2 is 80 mm Hg. When the arterial blood gases are drawn again, the level is determined to be 65 mm Hg. What should the nurse do first?

Increase the oxygen flow rate per facility protocol.

When completing a neurologic assessment, the nurse determines that a client has a positive Romberg test. Which finding supports the nurse's conclusion?

Inability to stand with feet together when eyes are closed

While in the postanesthesia care unit, a client reports shortness of breath and chest pain. Which is the most appropriate initial response by the nurse?

Initiate oxygen via a nasal cannula

When performing a neurologic check on a client with a head injury, the nurse identifies a diminished corneal reflex in the left eye. What does appropriate nursing care for a client with an absent corneal reflex include?

Instilling artificial tears frequently

Which landmark is correct for a nurse to use when auscultating the mitral valve?

Left fifth intercostal space, midclavicular line

A client who was in a motor bike accident has a severe neck injury. Which priority nursing care is most needed?

Maintaining a patent airway

A client is admitted to the postanesthesia care unit after a segmental resection of the right lower lobe of the lung. A chest tube drainage system is in place. When caring for this tube, what should the nurse do?

Mark the time and fluid level on the side of the drainage chamber

Twelve hours after a subtotal gastrectomy, a nurse identifies large amounts of bloody drainage from the client's nasogastric (NG) tube. Which action should the nurse take?

Obtain vital signs

When assessing a client, the nurse auscultates a murmur at the second left intercostal space (ICS) along the sternal border. This reflects sound from which valve?

Pulmonic

The nurse is assessing the pulse of a client who has a demand pacemaker. If the client's demand pacemaker is functioning effectively, the nurse would identify which assessment finding?

Pulse rate at least at the preset rate

The student nurse is performing a rapid baseline assessment using a disability mnemonic (AVPU) in a client with drug abuse. Which parameters should the student nurse consider for proper assessment? Select all that apply.

Reaction to pain Response to voice

While receiving a blood transfusion, the client suddenly shouts, "I feel like someone is lowering a heavy weight on my chest. I feel like I'm going to die!" Which actions are priority?

Stop the transfusion and administer normal saline.

The nurse notes that the client's cardiac rhythm strips show more P waves than QRS complexes. There is no relationship between the atria and the ventricles. How should the nurse interpret this rhythm strip?

Third degree AV block (complete heart block)

A client who sustained a burn injury involving 36% of the body surface area is receiving hydrotherapy. Which is the best nursing intervention when providing wound care?

Use a consistent approach to care and encourage participation.

A client admitted with the diagnosis of subarachnoid hemorrhage exhibits aphasia and hemiparesis. The nurse concludes that these neurologic deficits are caused primarily by which response?

Vascular spasms

During a routine physical examination, an abdominal aortic aneurysm is diagnosed. The client immediately is admitted to the hospital, and surgery is scheduled for the next morning. Which clinical finding should the nurse expect when performing an assessment of this client?

Visible pulsating abdominal mass

A client is admitted to the emergency department with head trauma resulting from an accident. The client opens both eyes to painful stimuli, makes incomprehensible sounds, and flexes to pain. Using the Glasgow Coma Scale, which score will the nurse document in the client's medical record?

8

A nurse in the emergency department is assigned to care for four clients. Which client should the nurse see first?

A client with ventricular fibrillation

A nurse is caring for a client who sustained a transection of the spinal cord with no other injuries. The nurse continually monitors this client for which medical emergency?

Autonomic hyperreflexia

A client is admitted to the hospital with partial- and full-thickness burns of the chest and face sustained while trying to extinguish a brush fire. Which is the nurse's priority concern?

Inadequate gas exchange caused by smoke inhalation

The nurse is reviewing the cerebrospinal fluid (CSF) laboratory findings of four neurologically compromised clients. Which client does the nurse suspect to have had a previous meningeal hemorrhage?

The client with brown CSF

The nurse in the emergency department identifies that the admission consent form signed by an alert but critically ill client is not legible. Which statement best reflects the status of this consent?

Consent is legal.

A client is admitted to the hospital with a diagnosis of restrictive airway disease. The nurse expects the client to exhibit which early signs of respiratory acidosis? Select all that apply.

Headache Irritability Restlessness

What is a common metabolic cause of hypothermia?

Hypoglycemia

A client is postoperative from open heart surgery. What should the nurse do to decrease or control the sensory and cognitive disturbances?

Plan for maximum periods of rest

A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. Which are the priority nursing assessments?

Quality of respirations and presence of pulses

The nurse is analyzing the client's rhythm when the nurse notes multiple premature ventricular contractions (PVCs). Each PVC occurs in no particular pattern and looks like all other PVCs. How will the nurse interpret this finding?

Unifocal

On the morning of surgery a client is admitted for resection of an abdominal aortic aneurysm. While awaiting surgery, the client suddenly develops symptoms of shock. Which nursing action is priority?

Notify the surgeon immediately.

A woman fractured her left tibia and fibula one week ago and has a cast in place. She is taking acetaminophen (Tylenol) with codeine for pain and an oral contraceptive. She began experiencing left calf pain 3 days ago and began having shortness of breath and chest pain 15 minutes ago. When the shortness of breath and chest pain increase, she calls the emergency department and communicates this information to the triage nurse. What is the triage nurse's best response?

"Give me your name and address. I am sending an ambulance to your home. You need emergency care."

Several individuals who sustained urgent but nonemergent injuries are seated in the emergency department when an ambulance arrives with a client suspected of having a myocardial infarction. The nurse must explain to the waiting clients that they will have to wait longer for care. Which is the best explanation for the nurse to give?

"I know you have been waiting, but a client's life depends on immediate treatment. You will receive the same attention when you are seen."

A client's extensive burns are being treated with silver nitrate 0.5% dressings. A week after treatment is begun, the nurse identifies that the client's sodium level is 135 mEq/L (135 mmol/L) and the potassium level is 3.0 mEq/L (3.0 mmol/L). The nurse notifies the primary healthcare provider. Which prescription should the nurse be prepared to administer?

Add potassium chloride (KCl) to the existing intravenous (IV) lactated Ringer solution.

A client with a spontaneous pneumothorax asks, "Why did they put this tube into my chest?" Which information should the nurse provide about the purpose of the chest tube?

It removes air from the pleural space.

A client with a chest tube is to be transported via a stretcher. When transporting the client, what should the nurse do?

Keep collection device below the level of the client's chest

A child is brought to the emergency department after sustaining a blow to the head while playing football after school. The nurse performs a neurologic assessment to determine whether the child has an acute head injury. What should the nurse assess first?

Level of consciousness

A client had a craniotomy for excision of a brain tumor. After surgery, the nurse monitors the client for increased intracranial pressure. Which clinical finding supports an increase in intracranial pressure?

Lowered level of consciousness

A client who is admitted with emphysema shows progressive respiratory failure and has a Paco 2 of 60. To address the problems, the nurse expects to receive a prescription for:

Mechanical ventilation

Which nursing interventions are important when caring for clients receiving IV digoxin?

Monitor the heart rate closely Check the blood levels of digoxin Monitor the serum potassium level

After a 4-year-old child undergoes craniotomy the nurse performs a neurologic assessment that includes level of consciousness, pupillary activity, and reflex activity. What else should the nurse include in this assessment?

Motor function

A client comes into the emergency department with neurologic deficits after falling off a ladder. Which client assessment will the nurse perform for the Glasgow Coma Scale?

Motor response to verbal commands

A client has been diagnosed as brain dead. The nurse understands that this means that the client has what?

No cortical functioning with some reflex breathing

A client sustains a vertebral fracture at the T1 level and is admitted to the emergency department. During a detailed neurologic assessment, the nurse expects to identify which clinical manifestation?

Normal biceps reflexes in the arms

A nurse is assessing a client's ECG reading. The client's atrial and ventricular heart rates are equal at 88 beats per min. The PR interval is 0.14 seconds, and the QRS width is 0.10 seconds. Rhythm is regular with normal P waves and QRS complexes. How will the nurse interpret this rhythm?

Normal sinus rhythm

The nurse is providing postprocedure care to a client who had a cardiac catheterization. The client begins to manifest signs and symptoms associated with embolization. Which action should the nurse take?

Notify the primary healthcare provider immediately

During the first 48 hours after a client has sustained a thermal injury, which conditions should the nurse assess for?

Hyperkalemia and hyponatremia

A woman comes to the office of her healthcare provider reporting shortness of breath and epigastric distress that is not relieved by antacids. To which question would a woman experiencing a myocardial infarction respond differently than a man?

"Do you have chest pain?"

A nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral side of a client's foot is stroked with an applicator stick during a neurologic examination. What should the nurse document in the client's medical record?

"Exhibits a positive Babinski sign"

A registered nurse is educating a client who has just undergone thoracentesis on the manifestations of pneumothorax. Which statements made by the client indicate effective learning? Select all that apply.

"I'll report any instance of blue skin right away." "I'll report any feeling of air hunger immediately."

After a hurricane, the nurse is assessing the response of a client to stimuli on the Glasgow Coma Scale (GCS) as a part of the primary survey. The nurse observes that the client opens his eyes when his name is stated, uses disorganized words, and is unable to follow commands, but attempts to remove the offending stimulus. What is the Glasgow coma score for this client?

11

The nurse uses the Glasgow Coma Scale to assess a client with a head injury. Which Glasgow Coma Scale score indicates that the client is in a coma?

6

A nurse is assessing a group of clients. Which client is considered at the highest risk for a dissecting aneurysm?

65-year-old male with uncontrolled hypertension

Which nursing action is most important to promote the nutritional status of a client during the acute phase of treatment after extensive burns?

Administer the prescribed intravenous fluid with the added vitamin C.

A client with acute respiratory distress syndrome is intubated and placed on a ventilator. What should the nurse do when caring for this client and the mechanical ventilator?

Assess the need for suctioning when the high-pressure alarm of the ventilator is activated.

Which noninvasive assessment and management skills certification would the nurse be required to use for airway maintenance and cardiopulmonary resuscitation (CPR)?

Basic Life Support (BLS)

The nurse observes a window washer fall 25 feet (7.6 m) to the ground, rushes to the scene, and determines that the person is in cardiopulmonary arrest. What should the nurse do first?

Begin chest compressions

A client who was hospitalized with partial- and full-thickness burns over 30% of the total body surface area is to be discharged. The client asks the nurse, "How will my spouse be able to care for me at home?" How should the nurse interpret this statement?

Beginning realization of implications for the future

The nurse is performing a neurologic assessment on a client and is completing the Glasgow Coma Scale (GCS). What components make up this assessment tool? Select all that apply.

Best verbal response Best motor response Best eye-opening response

A client falls from a two-story building and is taken to the hospital unconscious. Which finding identified during the initial nursing assessment should be of most concern to the nurse?

Bleeding from the ears

A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first?

Check for a pulse

A nurse is caring for a client with a chest tube. How will complete lung expansion be determined before removal of the chest tube?

Comparison of chest radiographs

The nurse is reassessing level of consciousness and mental status in a client who survived a fire. Which type of emergency assessment of the trauma client is the nurse performing?

Disability

A nurse is caring for a client with a pneumothorax who has a chest tube in place. What should the nurse do when caring for this client?

Encourage range of motion to the client's arm on the affected side

A nurse is caring for a client who recently had a kidney transplant. Which priority assessment finding requires follow up by the nurse?

Fever

A postoperative client returned from the postanesthesia care unit (PACU) this morning with a patient-controlled analgesia (PCA) pump running with a basal rate of hydromorphone. The nurse assesses the client's vital signs as blood pressure 90/60 mm Hg, heart rate 96 beats per min, and respiratory rate of 10 breaths per min. Which action should the nurse take next?

Give naloxone intravenous push med (IVP) per protocol.

The arterial blood gases of a client with chronic obstructive pulmonary disease (COPD) deteriorate, and respiratory failure is impending. Which clinical indicator should the nurse assess first?

Mental confusion

During the progressive stage of shock, anaerobic metabolism occurs. The nurse expects that initially the anaerobic metabolism will cause what?

Metabolic acidosis

During the progressive stage of shock, anaerobic metabolism occurs. Which complication should the nurse anticipate in this client?

Metabolic acidosis

A low-dose intravenous dopamine hydrochloride infusion drip is prescribed for a client in acute renal failure (ARF). Which method is most appropriate for the nurse to administer this medication to the client?

Peripherally inserted central catheter (PICC) line

A client who is recuperating from a spinal cord injury at the T4 level wants to use a wheelchair. What should the nurse teach the client to do in preparation for this activity?

Push-ups to strengthen arm muscles

The nursing student is learning about submersion injuries. Which component of sea water does the nurse know to be responsible for making it hypertonic compared to body fluids?

Salt

A client's burn wounds are scheduled to be debrided mechanically. Which equipment will the nurse prepare?

Scissors and forceps

A client is admitted to the emergency department with multiple injuries, including fractured ribs. Which assessment is priority?

Respiratory acidosis

A client is admitted to the hospital after an accident. The nurse uses the Glasgow Coma Scale (GCS) with the client. The client is alert and opens his or her eyes when there is a sound or when someone talks. When questions are asked, the client answers in a confused manner. The client obeys commands, such as being asked to move a leg. What would be the client's total score?

13

The nurse is planning to triage four clients based on their conditions. Which client should be triaged first according to the three-tiered triage system? A - Chest Pain B - Displaced multiple fractures C - Renal Colic D - Strains and sprains

A - Chest Pain

After surgery for insertion of a coronary artery bypass graft (CABG), a client develops a temperature of 102° F (38.9° C). Which priority concern related to elevated temperatures does a nurse consider when notifying the healthcare provider about the client's temperature?

A fever increases the cardiac workload.

The client's serum sodium is 123 mEq/L (123 mmol/L). Which prescription should the nurse question?

Administer intravenous fluid of one-half normal saline (NS) at 125 mL/hr.

A client who was recently diagnosed with emphysema develops a malignancy in the right lower lobe of the lung, and a lobectomy is performed. After surgery, the client is receiving oxygen by nasal cannula at 2 L per minute. Blood gas results demonstrate respiratory acidosis. What should be the initial nursing intervention?

Encourage deep breathing.

A client has undergone hypophysectomy. Which action would the nurse consider to be most appropriate during postoperative care to prevent a cerebrospinal fluid (CSF) leak?

Prohibiting coughing or sneezing

A 12-year-old child is admitted to the hospital for observation after sustaining a head injury. Twelve hours after the injury the child has none of the signs or symptoms of a head injury. What is the nurse's priority intervention at this time?

Assessing the level of consciousness every hour

To begin the administration of total parenteral nutrition (TPN), a client has a right subclavian central venous access device inserted. Immediately after insertion of the catheter, what is the priority nursing action?

Auscultate the lungs to evaluate breath sounds.

A client was admitted with full-thickness burns 2 weeks ago. Since admission, the client has lost an average of 1 lb (0.5 kg) of weight each day. Which action will the nurse most likely take based upon the adjusted dietary plan?

Provide high-protein drinks.

The nurse is caring for a client with trauma in the emergency unit. Which action should the nurse perform as the highest priority?

Providing adequate oxygen supply.

What interventions should the nurse implement when caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH)? Select all that apply.

Providing frequent oral care Instituting fall risk precautions Monitoring for and reporting neurologic changes

Upon assessment the nurse discovers a client with heart failure has crackles in lower lung fields and dyspnea. Upon notifying the primary healthcare provider, the provider prescribes intravenous (IV) normal saline at 200 mL/hr and furosemide 120 mg orally stat. Which action should the nurse take next?

Question the choice of solution, the amount to be given, and the dose of furosemide that has been prescribed.

A client with a history of heart failure is experiencing dyspnea with a respiratory rate of 32. Crackles are noted bilaterally. The client is in Sims position, receiving oxygen at 2 L/min via nasal cannula. Which action should the nurse take first?

Raise the client to high-Fowler position

A nurse assesses a client who is suspected of being in myasthenic crisis. Which assessment finding is most definitive in support of this conclusion?

Difficulty breathing

A nurse is caring for a client who experienced serious burns in a fire. Which relationship between a client's burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns?

Directly proportional

A group of clients is admitted with neurologic injury after hiking at high altitude. The nurse is assessing using the "AVPU" mnemonic. Which type of emergency assessment is the nurse performing?

Disability

A client with a history of emphysema is admitted with a diagnosis of acute respiratory failure with respiratory acidosis. Oxygen is being administered at 3 L/min nasal cannula. Four hours after admission, the client has increased restlessness and confusion followed by a decreased respiratory rate and lethargy. What should the nurse do?

Discontinue or decrease the oxygen flow rate.

For what clinical manifestations should the nurse assess a client during the first few hours of the alcohol withdrawal? Select all that apply.

Irritability Tachycardia Increasing anxiety

The nurse is conducting a neurologic assessment on a client brought to the emergency room after a motor vehicle accident. While assessing the client's response to pain, the client pulls his arms upward and inward. The nurse recognizes that this response represents an injury to what part of the brain?

Midbrain

The nurse concludes that a client is experiencing hypovolemic shock. Which physical characteristic supports this conclusion?

Oliguria

A client on a mechanical ventilator is receiving positive end-expiratory pressure (PEEP). The nurse understands that this treatment improves oxygenation primarily by doing what?

Opening collapsed alveoli and keeping them open

A nurse is assessing a client with cardiogenic shock. Which clinical findings should the nurse expect? Select all that apply.

Pallor Agitation Tachycardia Narrow pulse pressure

A client with internal bleeding is in the intensive care unit (ICU) for observation. At the change of shift an alarm sounds, indicating a decrease in blood pressure. What is the initialnursing action?

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

A burn client is receiving the open method for wound treatment. Which information will the nurse explain to the client?

Personal protective equipment will be worn by staff.

A nurse is caring for a client with severe burns. The nurse determines that this client is at risk for hypovolemic shock. Which physiologic finding supports the nurse's conclusion?

Plasma proteins moving out of the intravascular compartment

A client is en route to the emergency department after sustaining a gunshot wound to the chest. Which priority nursing action should the nurse take to prepare for the arrival of the client?

Prepare equipment for chest tube insertion.

What are the potential life-threatening conditions that should be considered during the primary survey for a client admitted after a fire accident?

Shock Inhalation injury Direct cardiac injury

A client has been taking 3 mg of risperidone twice a day for the past 8 days. At the follow-up appointment, the client reports tremors, shortness of breath, a fever, and sweating. What will the nurse do?

Take the client's vital signs and arrange for immediate transfer to a hospital.

A nurse is notified that the latest potassium level for a client in acute kidney injury is 6.2 mEq (6.2 mmol/L). Which action should the nurse take first?

Take vital signs and notify the primary healthcare provider.

A client is experiencing hypovolemic shock with decreased tissue perfusion. Which information should the nurse consider when planning care?

The body initially attempts to compensate by maintaining peripheral vasoconstriction.

Why is the Glasgow Coma Scale used by the nurse while performing an assessment in a traumatized client?

To assess level of consciousness

A nurse is performing a neurologic assessment of a client. Which equipment is required when preparing to assess the vagus nerve (cranial nerve X) of the client?

Tongue depressor

A nurse is developing a health teaching plan for clients with pacemakers. Which activity should the nurse teach these clients to avoid?

Touring a power plant

A nurse plans to set up emergency equipment at the bedside of a client in the immediate postoperative period after a thyroidectomy. What should the nurse include in the bedside setup?

Tracheostomy set and oxygen

A client with a head injury is admitted to the hospital. Which assessment finding alerts the nurse to increasing intracranial pressure?

Widening pulse pressure

A young adult who is unconscious after an accident is brought to the emergency department. The client's pupils are equal and responsive to light. As part of the neurologic assessment, the nurse applies a painful stimulus to the client's left lower leg. Which is an expected response in a healthy adult?

Withdrawing the leg

Which color of cerebrospinal fluid (CSF) may indicate subarachnoid hemorrhage in the client?

Yellow