Critical Care

An adult client sustains partial- and full-thickness burns of the left thigh and left arm. Using the Lund-Browder chart, the nurse calculates the percentage of total body surface area burned. Which percentage will the nurse record? a. 16.5% b. 23.5% c. 28.5% d. 30.5%

16.5%

Which of these clients in the emergency department would the nurse see first? a. A client with a head injury b. A client with a fractured femur c. A client with ventricular fibrillation d. A client with a penetrating abdominal wound

A client with ventricular fibrillation

Which condition of the client with laryngeal trauma and hemoptysis stands first in the priority list? a. Dyspnea b. Aphonia c. Hoarseness d. Subcutaneous emphysema

Dyspnea

Which is a common metabolic cause of hypothermia? a. Hypocalcemia b. Hyperadrenalism c. Hypoglycemia d. Hyperthyroidism

Hypoglycemia

Which goal is the nurse trying to achieve when placing a client with severe burns on a circulating air bed? a. Increasing mobility b. Preventing contractures c. Limiting orthostatic hypotension d. Preventing pressure on peripheral blood vessels

Preventing pressure on peripheral blood vessels

Which condition of a client with hemorrhagic stroke resulting from a motor bike accident requires immediate attention? a. Glasgow Coma score of 10 b. Body temperature of 81.2°F c. Oxygen (O 2) saturation of 90% d. Presence of carotid pulse with blood pressure (BP) of 80 mm Hg

Body temperature of 81.2°F

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 health care provider. Which prescription would the nurse be prepared to administer? a. Add potassium chloride (KCl) to the existing intravenous (IV) lactated Ringer solution. b. Add sodium chloride (NaCl) to the existing IV lactated Ringer solution. c. Discontinue the IV NaCl with 20 mEq KCl solution and replace with IV 5% dextrose in water (D 5W) solution. d. Discontinue the IV 5% D 5W with 40 mEq KCl solution and replace with IV 5% D 5W solution.

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

Which are the priority emergency assessments the nurse will perform for a client with bomb blast injuries? Select all that apply. One, some, or all responses may be correct. Airway Breathing Circulation Giving comfort measures Facilitating family presence Exposure or environmental control

Airway Breathing Circulation Exposure or environmental control

Which emergency assessments are performed by the nurse in a primary survey for a client with injuries from a bomb blast? Select all that apply. One, some, or all responses may be correct. Airway Breathing Circulation Focused adjuncts Identify deformities Give comfort measures

Airway Breathing Circulation Identify deformities

A client rescued from a burning building has partial- and full-thickness burns over 40% of the body. Which initial physiological change will the nurse expect? a. An increase in blood volume b. An increase in serum potassium c. A decrease in capillary permeability d. A decrease in urinary specific gravity

An increase in serum potassium

When a client has sinus tachycardia, which potential causes of the dysrhythmia would the nurse consider when assessing the client? Select all that apply. One, some, or all responses may be correct. Anxiety Caffeine Exercise Anemia Hypothermia

Anxiety Caffeine Exercise Anemia

Which action would the nurse take first after noting a flat line on a client's cardiac monitor? a. Assess the client's pulse. b. Start cardiopulmonary resuscitation. c. Check another lead to confirm asystole. d. Call the hospital emergency response team.

Assess the client's pulse

When a client who has had a myocardial infarction suddenly develops a heart rate of 120 beats/minute, which action would the nurse take first? a. Offer reassurance. b. Check blood pressure. c. Call for an electrocardiogram (ECG). d. Activate the hospital rapid response team.

Check blood pressure

When a client's cardiac monitor shows ventricular tachycardia, which action would the nurse take first? a. Check for a pulse. b. Start cardiac compressions. c. Prepare to defibrillate the client. d. Administer oxygen via an Ambu bag.

Check for a pulse.

After surgery, a client is extubated in the postanesthesia care unit. Which clinical manifestations would the nurse expect if the client is experiencing acute respiratory distress? Select all that apply. One, some, or all responses may be correct. Confusion Hypocapnia Tachycardia Constricted pupils Slow respiratory rate

Confusion Hypocapnia Tachycardia

A client had a wedge resection of a lobe of the lung and now has a chest tube with a three-chamber underwater drainage system in place. The nurse recalls that the third chamber of the underwater drainage system has which main purpose? a. Acts as a drainage container b. Provides an airtight water seal c. Controls the amount of suction d. Allows for escape of air bubbles

Controls the amount of suction

An adolescent child is in the terminal stage of cancer. The parents ask how they will know when death is imminent. The nurse discusses the physical manifestations with the parents. Which are the signs and symptoms of approaching death? Select all that apply. One, some, or all responses may be correct. Decreased thirst Weak pulse Increased pulse rate Difficulty swallowing Loss of bladder control

Decreased thirst Weak pulse Difficulty swallowing Loss of bladder control

Which intervention would the plan of care for a client with a tentative diagnosis of partial abruptio placentae include? a. Bed rest with sedation b. Trendelenburg position and hydration c. Preparation for emergency cesarean birth d. External fetal monitoring and oxygenation

External fetal monitoring and oxygenation

When preparing to admit a near-drowning victim to the emergency department, which action by the nurse has the highest priority? a. Obtain equipment for nasogastric tube insertion to decompress the stomach. b. Get the endotracheal intubation tray ready for insertion of an artificial airway. c. Have warming blankets and hyperthermia machine available to warm the client. d. Call for laboratory personnel to be in the emergency department to draw blood.

Get the endotracheal intubation tray ready for insertion of an artificial airway.

Which two factors in a client's history prompt the nurse to monitor closely for signs of puerperal infection? a. Malnutrition and anemia b. Hemorrhage and trauma during labor c. Preeclampsia and retention of placental fragments d. Organisms in the birth canal and trauma during labor

Hemorrhage and trauma during labor

Which action would the nurse take before developing the teaching plan for a client who has had a myocardial infarction? a. Identify the learning needs of the client. b. Determine the nursing goals for the client. c. Explore the use of group teaching for the client. d. Evaluate the community resources available to the client.

Identify the learning needs of the client.

A preterm neonate admitted to the neonatal intensive care nursery exhibits muscle twitching, seizures, cyanosis, abnormal respirations, and a short, shrill cry. Which complication would the nurse suspect? a. Tetany b. Spina bifida c. Hyperkalemia d. Intracranial hemorrhage

Intracranial hemorrhage

A health care provider prescribes tissue plasminogen activator (t-PA) to be administered intravenously over 1 hour for a client experiencing a myocardial infarction. Which assessment component can identify problems caused by this medication's effect? a. Respiratory rate b. Peripheral pulses c. Level of consciousness d. Intravenous insertion site

Intravenous insertion site

The nurse will anticipate the need to administer which type of medication when a client with cardiogenic shock has an increased pulmonary artery wedge pressure reading of 30 mm Hg? a. Vasopressor b. Loop diuretic c. Antidysrhythmic d. Beta-adrenergic blocker

Loop diuretic

When the emergency department nurse is caring for a client with acute coronary syndrome who reports severe crushing chest pressure, which prescribed medication is best for the nurse to administer? a. Ibuprofen 650 mg orally b. Acetaminophen 650 mg orally c. Nitroglycerin 0.4 mg sublingually d. Morphine sulfate 4 mg intravenously

Morphine sulfate 4 mg intravenously

A client is admitted to the emergency department with deep partial-thickness burns on the face and full-thickness burns on the neck, entire anterior chest, and one arm. The nurse recognizes that which assessment finding is an early indication of heat inhalation? a. Changes in the chest x-ray findings b. Sputum that contains particles of blood c. Nasal discharge that contains carbon particles d. Changes in the arterial blood gases consistent with acidosis

Nasal discharge that contains carbon particles

A client who had an infratentorial craniotomy is admitted to the intensive care unit after discharge from the postanesthesia care unit. Frequent assessments reveal that the client's intracranial pressure is increasing. Which action would the nurse take? a. Notify the health care provider. b. Elevate the head of the bed. c. Reduce the prescribed flow rate of intravenous (IV) fluid. d. Administer the next scheduled dose of osmotic diuretic early.

Notify the health care provider.

The nurse reviews the assessment findings of four clients with burns. Which client's findings are consistent with chemical burns? a. cardiac arrest b. minimal or absent pain c. paralysis d. hoarseness

Paralysis

Which effect is seen in clients exposed to sarin? a. Acute radiation syndrome b. Paralysis of cardiac muscles c. Burns and blisters on the skin d. Paralysis of respiratory muscles

Paralysis of respiratory muscles

Which are most likely to be the nurse's assessment findings in clients who have sustained submersion injuries? Select all that apply. One, some, or all responses may be correct. Ronchi Areflexia Hypertension Fixed, dilated pupils Cough with pink, frothy sputum

Ronchi Cough with pink, frothy sputum

Which statement would the nurse know to be true regarding the characteristics of sarin? a. Sarin causes skin burns and blisters. b. Sarin can cause death within minutes of exposure. c. A garlic-like odor and brown color are characteristics of sarin. d. A single dose of pralidoxime chloride (2-PAM chloride) reverses the effects of long-term sarin exposure.

Sarin can cause death within minutes of exposure.

The nurse is providing immediate postpartum care to a client. The nurse would monitor the client for which condition that is characterized by hemorrhage? a. Sheehan syndrome b. Cushing syndrome c. Addison syndrome d. Schwartz-Bartter syndrome

Sheehan syndrome

The nurse is assessing a client during the first 24 hours after a burn injury. Which sign indicates to the nurse that fluid replacement therapy is adequate? a. Decreasing central venous pressure (CVP) readings b. Hematocrit level increasing from 50% to 55% c. Slowing of a previously rapid pulse d. Urinary output of 15 to 20 mL/h

Slowing of a previously rapid pulse

When a client's cells are deprived of oxygen during a cardiac arrest, which medication corrects for deleterious effects of anaerobic energy production? a. Regular insulin b. Calcium gluconate c. Potassium chloride d. Sodium bicarbonate

Sodium bicarbonate

A newborn has an Apgar score of 3 at 1 minute after birth. Which is the immediate nursing action in response to this Apgar score? a. Start resuscitation. b. Administer oxygen. c. Place in a heated crib. d. Stimulate by tapping the toes.

Start resuscitation.

A client who has paroxysmal supraventricular tachycardia reports a mild "fluttering feeling" in the chest and has a blood pressure of 110/55 mm Hg. Which potential treatment by the health care provider would the nurse question? a. Intravenous adenosine b. Intravenous metoprolol c. Carotid sinus massage d. Synchronized cardioversion

Synchronized cardioversion

A family has decided to withhold extraordinary care for a newborn with severe congenital abnormalities. How would the nurse interpret this decision? a. The newborn has no rights. b. It is the same as euthanasia. c. It is illegal professional practice. d. The newborn is being allowed to die.

The newborn is being allowed to die.

Which statement effectively describes the steps to be taken by health care personnel when responding to health care facility fires? a. Oxygen should be continued for clients. b. The nurse should not attempt to contain the fire. c. The respiratory status of clients on life support should be maintained manually. d. Immobile clients should be removed from the fire area only by stretchers or wheelchairs.

The respiratory status of clients on life support should be maintained manually.

Which steps would the nurse take for managing an adolescent who sustained drug poisoning? Select all that apply. One, some, or all responses may be correct. Induce gastric lavage. Give ipecac syrup to the client. Turn the head of the client to the side. Empty the mouth to clean the residue of the drug. Call local poison control center before any intervention.

Turn the head of the client to the side. Empty the mouth to clean the residue of the drug. Call local poison control center before any intervention.

There are five clients in the emergency unit. Which client conditions require immediate treatment? Select all that apply. One, some, or all responses may be correct. Skin rash Unstable vital signs Severe abdominal pain Chest pain with diaphoresis Multiple complex soft tissue injuries

Unstable vital signs Severe abdominal pain Chest pain with diaphoresis

Which is the first action the nurse would take when responding to an apnea monitor alarm that signifies a 10-second cessation of respirations? a. Assess for changes in skin color. b. Use tactile stimuli on the chest or extremities. c. Check the monitor for signs of a malfunction. d. Resuscitate with a face mask and an Ambu bag.

Use tactile stimuli on the chest or extremities.