critical care eaq

which are the PRIORITY nursing actions when providing care to a trauma client? SATA 1. start large bore IV 2. immobilizing any obvious deformities 3. providing emotional support 4. assigning team members to support caregivers 5. removing clothing to allow for adequate exam

1, 2, 5

which actions would the nurse take when caring for a client with a chest tube in place after thoracotomy? select all that apply 1. administer prescribed analgesic medications 2. check around chest tube insertion site for crepitus 3. clamp chest tube before ambulation 4. milk tubing toward collection chamber 5. check for air bubbling in water seal chamber 6. add fluid to suction control chamber as needed

1, 2, 5, 6

which statements about handling mass casualty disaster situations in the field made by the student nurse show the need for further education? SATA 1. i will work with a. goal of doing the greatest good for the greatest number of people 2. i will try to provide max care and save the clients tagged expectant or critically ill 3. i will provide green tagged clients the least priority of care compared with other categories 4. i will manage the walking wounded clients with fractures and abrasions in a delayed fashion 5. i will categorize clients according to disaster triage tag system based on the severity of injuries

2, 3

a client sustains a fractured right femur after an automobile accident and is admitted to the ED. which assessments would the nurse make? SATA 1. observe the client's ability to turn to the side-lying position 2. take the client's pedal pulse in the affected extremity 3. instruct the client to wiggle the toes of the right foot 4. ask the client if numbness or tingling is present in the right foot 5. instruct the client to attempt to weight bearing on the right leg.

2, 3, 4

a client was admitted ot the hospital with blunt trauma to the abdomen. the client was treated fora. lacerated liver and abdominal hemorrhage. during the recovery period, the nurse would monitor the client for which indications of peritonitis? 1. jaundice 2. boardlike abdomen 3. abdominal tenderness 4. decreased bowel sounds 5. rapid decrease in coagulation ability

2. boardlike abdomen 3. abdominal tenderness 4. decreased bowel sounds

which changes that occur with aging increase the risk for hypothermia in older adults? SATA 1. increased metabolic rate 2. increased shivering response 3. decreased amount of body fat 4. diminished energy reserves 5. chronic medical conditions

3.decreased amount of body fat 4. diminished energy reserves 5. chronic medical conditions

a client has mild hypothermia based on which body temperature? 1. 29 C 2. 30 C 3. 33 C 4. 35 C

35

nurse is measuring the body temp of four clients in a clinical setting. which client is in need of rewarming through cardiopulmonary bypass? 1. 94.2 F 2. 85.3 F 3. 89.4 F 4. 91.5 F

85.3

which client is appropriately tagged? 1. Massive head injury- RED 2. compound fracture-GREEN 3. 90% full thickness burns- BLACK 4. skin lacerations- YELLOW

90% full thickness burns-BLACK

which statement made by the student nurse indicates ineffective learning about the disaster triage tag system? 1. i will use a yellow tag for clients with shock 2. i will use a green tag for clients with closed fractures 3. i will use a red tag for clients with airway obstruction 4. i will use a black tag for clients with massive head trauma

I will use a yellow tag for clients with shock

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? 1. dull sounds on percussion 2. vocal fremitus on palpation 3. rales with rhonchi on auscultation 4. absence of breath sounds on auscultation

absence of breath sounds on auscultation

for clients with which conditions would the nurse seek immediate care? SATA 1. hip fracture 2. simple laceration 3. active hemorrhage 4. substernal chest pain 5. closed extremity trauma

active hemorrhage, substernal chest pain

which would the nurses' immediate interventions be for ether client with moderate hypothermia 1. admin heated O2 2. positioning the client in supine position 3. admin high carb liquids 4. apply external heat with heating blankets 5. performing cardiopulmonary bypass technique

admin heated O2, positioning in supine position, applying external heat with heating blankets

which assessment would the nurse perform FIRST for a client with severe trauma? 1. airway 2. disability 3. breathing 4. circulation

airway

which client would be treated first? 1. airway obstruction 2. extensive, full thickness body burns 3. open fracture 4. closed fracture and abrasions

airway obstruction

which condition will be given the HIGHEST priority for a client admitted to the ED who has an airway obstruction, chest wall trauma, external hemorrhage, and hypoglycemia? 1. hypoglycemia 2. chest wall trauma 3. airway obstruction 4. external hemorrhage

airway obstruction

the nurse is caring for clients on a medsurg unit and identifies that which client has the HIGHEST risk for developing a PE 1. an obese client with leg trauma 2. pregnant client with acute asthma 3. client with diabetes who has cholecystitis 4. client with pneumonia who is immunocompromised

an obese client with leg trauma

which nursing action is of HIGHEST priority when a client's chest tube has dislodged? 1. place client in left-side lying position 2. apply O2 via NRBM 3. apply a petroleum gauze dressing over site 4. prepare to insert a new chest tube

apply a petroleum gauze dressing over site

which location would the nurse consider for triage of casualties when planning for a community disaster drill that will include a bombing in a shopping mall with hundreds of casualties? 1. in a hospital parking lot 2. at the scene of the disaster 3. in the ED 4. at the closest school gym

at the scene of the disaster

After thoracic surgery a client has a chest tube connected to a water-seal drainage system that is attached to suction. When excessive bubbling is observed in the water-seal chamber, the nurse should: 1. Strip the chest tube catheter 2. Check the system for air leaks 3. Decrease the amount of suction pressure 4. Recognize that the system is functioning correctly

check the system for air leaks

which action would the nurse take when caring for a client with pneumothorax who has a chest tube and closed drainage system in place? 1. avoid adding any additional water to the suction control chamber 2. check the water seal chamber for bubbling during expiration 3. milk the chest tube periodically to prevent clots from obstructing the tubing 4. call the health care provider if there is bubbling in the suction control chamber

check the water seal chamber for bubbling during expiration

which actions will the nurse include in the plan of care fora. client with a left pneumothorax who has a chest tube in place? SATA 1. immobilize the left arm in a sling 2. check water seal chamber for bubbles 3. avoid using NSAIDS 4. keep client on bed rest in semi fowler 5. observe frequently for drainage in the collection chamber 6. assess client to cough and deep breath every hour while awake

check water seal chamber for air bubbling, assist client to cough and deep breathe every hour while awake

based on their conditions, which client would be triaged first according to the 3-tiered triage system? -A- chest pain -B- displaced or multiple fractures -C- renal colic -D- strains and sprains

chest pain

which group of clients who survived a bus accident would the nurse assess first 1. multiple soft tissue injuries 2. strains and sprains 3. displaced or multiple fractures 4. chest pain with diaphoresis

chest pain with diaphoresis

after the initial assessment, which earthquake survivor with chest trauma would the disaster management nurse treat first? 1. client A with muffled, distant heart sounds, neck vein distention 2. client B with paradoxical movement of chest wall, respiratory distress 3. client c with cyanosis, air hunger, violent agitation, tracheal deviation away from affected side 4. client D with hyper resonance to percussion, diminished or absent breath sounds on affected side

client c with cyanosis, air hunger, violent agitation, tracheal deviation away from affected side

applying the emergency severity index (ESI) criteria, which client condition is considered LEAST severe? 1. cardiac arrest 2. abdominal pain 3. multiple trauma 4. closed extremity trauma

closed extremity trauma

which client with complications of fracture would the nurse expect may be treated with a fasciotomy? 1. acute respiratory distress syndrome 2. compartment syndrome 3. VTE 4. fat embolism syndrome

compartment syndrome

which finding in a. client who has had a chest tube removed would be of MOST concern to the nurse? 1. poor cough effort 2. pain at chest tube site 3. crepitus at the chest tube site 4. two centimeters of pink drainage on dressing

crepitus at the chest tube site

which nursing action allows for a thorough assessment of a trauma client to prioritize the client's care? 1. avoiding manipulation of the client's limbs 2. asking a family member about client med allergies 3. cutting fabric that is stuck to the client's skin with scissors 4. auscultating heart and lung sounds through clients clothes

cutting fabric that is stuck to the client's skin with scissors

which client conditions if selected by the student nurse as LOWEST priorities of care would indicate effective understanding of prioritizing care for clients with different conditions in the ED? Select all that apply 1. cystitis 2. cold symptoms 3. closed fracture 4. intubation trauma 5. moderate abdominal pain

cystitis cold symptoms

a client experiences a complete pneumothorax. the nurse recognizes that there is a danger of a mediastinal shift, which could cause which life threatening condition? 1. rupture of the pericardium 2. infection of the sub pleural lining 3. decreased filling of the right side of the heart 4. increased volume of the unaffected lung

decreased filling of the right side of the heart

when a client has a right pneumothorax, which type of breath sounds will the nurse expect to hear on the right chest? 1. crackling 2. wheezing 3. decreased sounds 4. vesicular sounds

decreased sounds

a client sustains fractured ribs as a result of an accident. which clinical indicator suggests the client may be experiencing a complication of fractured ribs? 1. report of pain when taking deep breaths 2. client is observed splinting the fracture site 3. diminished breath sounds on the affected side 4. bowel sounds are auscultated in the lower chest

diminished breath sounds on the affected side

which condition of the client with laryngeal trauma and hemoptysis stands first in the PRIORITY list? 1. dyspnea 2. aphonia 3. hoarseness 4. subcutaneous emphysema

dyspnea

a client with chest trauma is admitted to the ED. which intervention takes PRIORITY? 1. ensure patent airway 2. monitor cardiac rhythm 3. release dressing in tension pneumothorax 4. assess client for pain

ensure patent airway

which sign of compartment syndrome would the nurse assess for in the client who has sustained blunt trauma to the forearm? 1. warm skin at the site of injury 2. escalating pain in the fingers 3. rapid capillary refill in affected hand 4. bounding radial pulse in the injured arm

escalating pain in the fingers

when a client is admitted tot eh unit with a crushed chest, abdominal trauma, a probable head injury, and multiple fractures, which actions would the nurse take FIRST? 1. establish an airway and stabilize cervical spine 2. assess heart sounds and find carotid and femoral pulses 3. check for alertness, orientation, and pupil reaction to light 4. remove clothing to enable further assessment of injuries

establish an airway and stabilize cervical spine

which care level would the nurse say is the difference between triage under usual conditions and triage under mass casualty conditions? 1. urgent care 2. expectant care 3. emergent care 4. non urgent care

expectant

an older adult client states, "i walk 2 miles a day for exercise, but now that the weather is hot, i am worried about becoming dehydrated" which statement would the nurse use to respond to this client? 1. drink fruit juices if you start to feel dehydrated 2. thirst is a good guide to use to determine fluid intake 3. fluids should be increased if the urine becomes darker 4. water should be consumed when the skin becomes dry

fluids should be increased if urine becomes darker

which finding BEST indicates that the chest tube for a client with a pneumothorax may be discontinued? 1. clear breath sounds heard in both lungs 2. O2 reading is higher than 90% 3. absence of bubbling in the chamber 4. full re-expansion of the lungs seen on chest x ray

full re-expansion of the lungs seen on chest x ray

which health concern has the HIGHEST priority for the nurse to monitor for after removing clothing from a client with burn trauma? 1. bradypnea 2. bradycardia 3.hypotension 4. hypothermia

hypothermia

when categorizing victims of hypothermia as having mild, moderate, and severe hypothermia, which assessment findings will help the nurse identify the clients with moderate hypothermia? SATA 1. asystole 2. lethargy 3. hypovolemia 4. respiratory acidosis 5. fixed and dilated pupils

hypovolemia, respiratory acidosis

which statement about 4 clients along with their conditions made by the student nurse indicates effective learning about the disaster triage tag system? - A- open fractures -B- airway obstruction -C- sprain -D- shock 1. i will issue a red tag to client A 2. i would issue a black tag to client B 3. i would issue a green tag to client C 4. i would issue a yellow tag to client D

i would issue a green tag to client C

which characteristics aligns with prioritizing care into the triage level of "emergent" 1. immediate threat to life or limb 2. condition is unlikey to deteriorate 3. could wait for several hours for care 4. may be seen soon but not immediately

immediate threat to life or limb

a client is admitted with head injury and has large amounts of clear, colorless urine draining from catheter. which physiological response is possibly the cause of increased urine output? 1. increased serum glucose 2. deficient renal perfusion 3. inadequate ADH secretion 4. excess amounts of IV fluid

inadequate ads secretion

which client condition requires high resource intensity and continuous staff at the bedside? 1. cystitis 2. hip fracture 3. intubation resulting from trauma 4. closed extremity trauma

intubation resulting from trauma

a client with a chest tube is to be transported via a stretcher. when transporting the client, what would the nurse do? 1. keep collection device attached to mechanical suction 2. keep chest tube clamped distal to the water seal chamber 3. keep collection device below the level of the clients chest 4. keep chest tube end covered with sterile gauze pads taped to the client

keep collection device below the level of clients chest

which level of trauma center provides a full continuum of care for the trauma client? 1. level I 2. level II 3. level III 4. level IV

level 1

which is the purpose of an occlusive dressing over a client's sucking chest wound? 1. protects the lungs 2. seals off major vessels 3. prevents additional contamination of the wound 4. maintains negative pressure within the chest cavity

maintains negative pressure within the chest cavity

which condition would the nurse consider to be responsible of the client's increasing incoherence and periods of stupor after wandering outside in the cold without a coat? 1. frostnip 2. mild hypothermia 3. severe hypothermia 4. moderate hypothermia

moderate hypothermia

Which action would the nurse take when caring for a client who has a possible skull fracture as a result of trauma? 1. monitor the client for signs of brain injury 2. check for hemorrhaging in oral cavity 3. elevate FOB if client develops symptoms of shock 4. observe for indicators of decreased ICP and temp

monitor the client for signs of brain injury

the client with which treatment needs belongs to class 1 according to the disaster triage tag system? 1. can wait a short time for treatment 2. is dead or expected to die 3. needs emergent treatment 4. has no urgent needs for treatment

needs emergent treatment

which are the nurse's PRIORITY assessments of the breathing component of a primary survey of a client. SATA 1. observe for chest wall trauma 2. establish a patent airway by positioning 3. evaluate the clients LOC 4. assess breath sounds and respiratory effort 5. remove all clothing for a complete physical assessment

observe chest wall trauma, assess breath sounds and respiratory effort

which action would the nurse take to determine patency of the chest tube and closed chest drainage system in a client after left lower lobectomy? 1. milk the chest tube toward the drainage unit 2. check the amount of bubbling in the suction control chamber 3. observe for fluctuations of the fluid in the water-seal chamber 4. assess for extent of chest expansion in relation to breath sounds

observe for fluctuations of the fluid in the water seal chamber

which action will the urgent care clinic nurse anticipate taking for a 24 year old who is dehydrated after a long run and has a pulse of 103 and BP of 102/56 1. offer oral fluids at frequent intervals 2. give fluid boluses through nasogastric tube 3. admin IV antiemetic med 4. insert a peripheral IV line for fluid infusion

offer oral fluids at frequent intervals

when a client is admitted with dehydration, which clinical manifestation would the nurse expect to find? SATA 1. oliguria 2. dyspnea 3. hypotension 4. pulmonary crackles 5. tenting skin turgor

oliguria, hypotension, tenting skin turgor

which procedure may benefit the client who was in a traffic accident, is choking and may have a spinal cord injury? 1. performing a vagal maneuver 2. performing a valsalva maneuver 3. performing a jaw thrust maneuver 4. performing a oculocephalic maneuver

performing a jaw thrust maneuver

which nursing interventions are MOST appropriate for a client who survived a fire in the hospital and is found to have neck trauma, dyspnea, gasping breathing, and is unable to speak? SATA 1. placing a nasogastric tube 2. performing jaw-thrust maneuver 3. prepare assist in performing endotracheal intubation 4. monitoring RR and O2 5. monitoring HR and rhythm continuously

performing jaw thrust maneuver, prepare assist in performing ET intubation

which activity places a client at risk for hyperthermia? 1. snowmobiling 2. skiing in the winter 3. hiking alaskan mountains 4. performing strenuous activity in high humidity

performing strenuous activity in high humidity

which nursing action has the HIGHEST priority when the nurse is providing care to a trauma client whose primary survey indicates GSC score of 7 1. preparing for intubation 2. observing for chest wall trauma 3. covering the client with a blanket 4. applying direct pressure to the client's wounds

prepare for intubation

after being notified that a client with a sucking chest wound is being transported to the ED, the nurse will anticipate which INITIAL collaborative intervention? 1. obtaining CXR 2. notifying on call surgeon 3. preparing for chest tube insertion 4. darwinian blood for lab studies

preparing for chest tube insertion

which action would the nurse perform as the HIGHEST priority for a client with trauma in ED 1. applying dry dressing 2. evaluating chest expansion 3. providing adequate O2 4. applying direct pressure on bleeding site

providing adequate O2

the client is admitted to the ED with a stab wound of the chest. which is a PRIORITY nursing assessment? 1. level of pain 2. quality and depth of respirations 3. amount of serosanguinous drainage 4. blood pressure and pupillary response

quality and depth of respirations

a client arrives in the ED with multiple crushing wounds of the chest, abdomen, and legs. what are the priority nursing assessments? 1. level of consciousness and pupil size 2. characteristics of pain and BP 3. quality of respiration and presence of pulses 4. observation of abdominal contusions and other wounds

quality of respirations and presence of pulses

a client has a chest tube in place for treatment of pneumothorax. upon entering the room, the nurse finds the client in respiratory difficulty, with the chest tube separated from the drainage system. which action would the nurse take? 1. notify the rapid response team 2. obtain a new sterile drainage system 3. use two clamps to close drainage tube 4. reconnect the clients tube to drainage system

reconnect the clients tube to drainage system

which colors are often included in an organizational disaster plan for use during triage? SATA 1. red 2. black 3. green 4. white 5. yellow

red, black, green, yellow

a client has a closed chest drainage system in place. how would the nurse determine the amount of chest tube drainage? 1. aspirate the drainage from the collection chamber 2. clamp chest tube and empty fluid from the collection chamber 3. refer to the date and time markings on the outside of the collection chamber 4. replace the existing system with a new one to access the drainage in the existing system

refer to the date and time markings on the outside of the collection chamber

a client with which condition would the nurse treat first according to the triage system? 1. respiratory distress 2. multiple soft tissue injuries 3. new onset of respiratory tract infection 4. skin rash and a simple lower limb fracture

respiratory distress

the nurse is caring for a client with a pneumothorax and chest tube. which assessment findings indicates that the chest tube has been effective? 1. productive coughing 2. return of breath sounds 3. increased pleural drainage in the chamber 4. constant bubbling in the water seal chamber

return of breath sounds

when a client with blunt trauma to the nose is noted to have nasal swelling, ecchymosis around the eyes, and water pink-tinged nasal drainage, which action will the nurse take? 1. assist client to supine position with pillow 2. have client squeeze the lower nose for 10 minutes 3. send specimens of fluid to lab for analysis 4. apply warm moist packs to clients nose and eyes

send specimens of fluid to lab for analysis

the nurse provides teaching to a client who is being discharged after treatment for a pneumothorax. the nurse instructs the client to notify the HCP immediately if experiencing which system of a reccuring pneumothorax? 1. substernal chest pain 2. episodes of palpitation 3. severe shortness of breath 4. dizziness when standing up

severe SOB

which group of clients who were in a bus accident and admitted ot the ED with injuries is considered urgent according to the three-tier triage system? 1. sprains 2. simple fractures 3. severe abdominal pain 4. chest pain with diaphoresis

severe abdominal pain

a client sustains a crushing injury to the lower left leg, and below the knee amputation is performed. for which common clinical manifestation of a PE would the nurse assess this client? SATA 1. sharp chest pain 2. acute onset of dyspnea 3. pain in the residual limb 4. absence of the popliteal pulse 5. blanching of the affected extremity

sharp chest pain, acute onset of dyspnea

which client condition would require the HIGHEST priority for treatment 1. massive head trauma 2. open fracture with a distal pulse 3. shock 4. strains and contusions

shock

which conditions of the clients admitted with injuries due to a bus crash are PRIORITIZED under the emergent classification? SATA 1. shock 2. contusion 3. open fracture 4. airway obstruction 5. high cervical spinal cord injury

shock, airway obstruction

which injuries would likely be given a green tag after a disaster? SATA 1. shock 2. strains 3. sprains 4. abrasions 5. airway obstruction

shock, sprains, strains

which conditions are given a green tag according to triage disaster tag system? SATA 1. strains 2. abrasions 3. open fractures 4. airway obstruction 5. high cervical spinal cord injury

strains, abrasions

which conditions are triaged using the 3 tier system as life threatening conditions among a group of clients injured in a tornado? SATA 1. stroke 2. skin rash 3. active hemorrhage 4. respiratory distress 5. chest pain with diaphoresis 6. displaced or multiple fractures

stroke, active hemorrhage, respiratory distress, chest pain with diaphoresis

according to triage based on tier levels, which client conditions would receive higher PRIORITY? SATA 1. stroke 2. skin rash 3. active hemorrhage 4. respiratory distress 5. chest pain with diaphoresis 6. displaced or multiple fractures

stroke, hemorrhage, respiratory distress, chest pain with diaphoresis

which client condition would the nurse keep in mind while rewarming procedure in a client with severe hypothermia? 1. the client is at risk for hypertension from rewarming shock 2. the client should be monitored for after drop during rewarming 3. the cold myocardium should be stimulated in a hypothermic client 4. the core of the client with severe hypothermia should be warmed after the extremities

the client should be monitored for after drop during rewarming

the nurse assess for which client symptoms that indicate hyperthermia? SATA 1. vasodilation 2. dry and flushed skin 3. pale and cyanotic skin 4. decreased cap refill 5. decreased urinary output

vasodilation, dry and flushed skin, decreased urinary output

which clinical finding released to a supracondylar fracture of the right humerus would the nurse report IMMEDIATELY? 1. bruise near right elbow 2. restlessness and apprehension 3. weak radial pulse in the right wrist 4. pain at the affected elbow and along the humerus

weak radial pulse in the right wrist