Critical Care- NCLEX

The nurse arrives at the scene of a code and begins to assist in performing cardiopulmonary resuscitation (CPR) on an adult client. The nurse knows that interruptions in performing chest compressions should be limited to less than how many seconds?

10

The nurse observes the following rhythm on the cardiac monitor. Which action should the nurse take first? Refer to the figure.

Evaluate the client for hypotension and assess mental status. Rationale: After determining that the client is in sinus bradycardia with a heart rate of 40 beats per minute, the nurse should evaluate the client first for signs and symptoms of decreased cardiac output. Signs and symptoms of decreased cardiac output include hypotension, altered mental status, weak peripheral pulses, and decreased urinary output. If the bradycardia is new or the client has evidence of decreased cardiac output, the primary health care provider would then be notified. Transcutaneous pacing or atropine administration may be instituted if evidence of decreased cardiac output is present.

The nurse is assisting in admitting a child who arrived from the emergency department after treatment for acetaminophen overdose. The nurse reviews the child's record and expects to note that the child received which for the acetaminophen overdose?

Acetylcysteine

The nurse is initiating cardiopulmonary resuscitation on an adult client. The nurse should place the hands in which position to begin chest compressions?

On the lower half of the sternum

The nurse determines that which client is most likely to be a candidate for cardioversion?

Client with unstable rapid atrial fibrillation

A client rings the call bell and complains of pain at the site of an intravenous (IV) infusion. The licensed practical nurse (LPN) inspects the site and determines that the client has developed phlebitis. The LPN should plan to avoid which action in the care of this client?

Prepare to start a new line in a proximal portion of the same vein.

The nurse on a telemetry unit checks a client's chart and notes that the potassium level is 6.3 mEq/L. Based on this laboratory result, which signs/symptoms should the nurse anticipate? Select all that apply.

1. Anxiety 2. Electrocardiogram (ECG) changes

The nurse has a prescription to give ear drops to a 2-year-old child. To administer the drops, the nurse should pull the pinna of the ear in which direction?

Downward and backward

The licensed practical nurse is assisting the registered nurse (RN) in the care of a child who is receiving a blood transfusion and notifies the RN if the child displays which signs/symptoms of fluid overload? Select all that apply.

Dry cough Distended neck veins

The nurse is monitoring a client at risk for placental abruption. Which findings are indicative of this complication? Select all that apply.

Fetal distress Dark red vaginal bleeding

The nurse notes that the 4-hour postpartum client has cool, clammy skin and that she is restless and excessively thirsty. The nurse immediately notifies the registered nurse and then performs which action?

Checks the vital signs Rationale: Signs/symptoms of hypovolemia include cool, clammy, and pale skin; feelings of anxiety and restlessness; and thirst. The nurse should check the vital signs. The nurse does not ambulate the client or encourage fluids until specific prescriptions are given to do so. There is no information in the question to indicate the need for fundal massage.

When a client progresses from preeclampsia to eclampsia, which is the nurse's first action?

Clear and maintain an open airway. Rationale: It is important as a first action to clear and maintain an open airway and prevent injuries to the client.

The nurse enters a client's room to check the client who began receiving a blood transfusion 45 minutes earlier. The client is flushed and dyspneic. The nurse listens to the client's lung sounds and notes the presence of crackles in the lung bases. The nurse determines that this client is most likely experiencing which complication of blood transfusion therapy?

Fluid (circulatory) overload

A client with a major burn is admitted to the emergency department. In priority order, which actions should the nurse take? Arrange the actions in the order that they should be used. All options must be used.

1. Establish Airway 2. Initiate IV therapy 3. Insert foley catheter 4. Insert nasogastric tube

The nurse is caring for a client with a permanent pacemaker. The nurse knows that which three primary problems can occur when cardiac pacemakers malfunction? Select all that apply.

1. Failure to sense 2. Failure to capture 3. Failure to pace of fire

A client who weighs 50 kg has arrived in the emergency department complaining of severe chest pain. The telemetry monitor shows an evolving anterior myocardial infarction (MI). The nurse anticipates that the primary health care provider will initially prescribe which treatments? Select all that apply.

1. Oxygen 2 L, per nasal cannula 2. Chewable aspirin 324 mg, oral 3. Nitroglycerin 0.4 mg, sublingual 4.Morphine sulfate 4 mg, intravenously

The nurse is caring for a client in the critical care unit. The nurse is reviewing the Critical Care Family Needs Inventory. The nurse knows that the most important issues of family members of critically ill clients include which factors? Select all that apply.

1. Receiving assurance 2.Receiving information 3. Having support available 4. Remaining near the client

A client uses the call system to notify the nurse to say that "the IV hurts and my left hand is swollen." The nurse assesses the site and determines infiltration has occurred. In order of priority, which actions should the nurse take? Arrange the actions in the order they should be performed. All options must be used.

1. Stop the infusion 2. Remove the intravenous catheter 3. Apply a compress to the site 4. Notify the Registered nurse to start a new IV on the right extremity.

An adult client is admitted to the emergency department following a burn injury. The burn initially affected the client's upper half of the anterior torso, and there were circumferential burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the entire face (anterior half of the head) and the upper half of the posterior torso. Using the rule of nines, which percentage would characterize the burn injury? Refer to the figure.

31.5% Rationale: According to the rule of nines, with the initial burn, the upper half of the anterior torso equals 9% and the lower half of both arms equals 9%. The subsequent burn included the anterior half of the head equaling 4.5% and the upper half of the posterior torso equaling 9%. This totals 31.5%.

The nurse is monitoring a client with a diagnosis of gastric ulcer. Which finding would indicate perforation of the ulcer?

A rigid, boardlike abdomen

The nurse assists in administering first aid to a client who has been bitten by a snake on the right leg. The nurse should take which action?

Ensure that the victim is lying down, and remove restrictive items. Rationale: Initial first aid at the site of a snakebite includes having the victim lie down, removing constrictive items such as clothing or rings, providing warmth, cleansing the wound, covering the wound with a light sterile dressing, and immobilizing the injured body part below the level of the heart. Ice or a tourniquet is not applied during the acute stage.

A client suffered smoke inhalation and burns to the anterior trunk during a house fire. The nurse reviews the plan of care and notes that the client has an airway problem. Which findings support an airway problem? Select all that apply.

Hoarse voice Guttural respiratory sounds

The nurse is doing a routine assessment of a client's peripheral intravenous (IV) site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which has probably occurred?

Infiltration Rationale: An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. The pallor, coolness, and swelling are the result of IV fluid being deposited into the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The other options identify complications that are likely to be accompanied by warmth at the site rather than coolness.

An adult client presents to the emergency department (ED) with complaints of substernal chest pain and is taken directly to a stretcher in the department. Which priority intervention should the nurse undertake?

Obtain an electrocardiogram (ECG).

The nurse is caring for a client who was admitted to the maternity unit at 8:00 am with contractions occurring every 2 minutes, lasting 1½ minutes, and who is dilated 4 cm with a cervical effacement of 60%. At 10:30 am, the contractions cease. The client reports chest pain and manifests signs and symptoms of shock. The nurse quickly plans care, suspecting which complication?

Ruptured uterus Rationale: The characteristics of a ruptured uterus include the cessation of contractions, pain in the chest, and signs of shock caused by bleeding in the abdomen. The signs/symptoms identified in the question are not characteristic of abruptio placentae, placenta previa, or preterm labor.

The nurse assists in developing a plan of care for a client admitted to the hospital with an acute myocardial infarction (MI). Which is the priority problem during the acute phase?

The client's pain Rationale: Pain is the prevailing symptom of acute MI. Relief of pain is a priority. Pain stimulates the autonomic nervous system, increasing myocardial oxygen demand. Although options 1, 3, and 4 are also appropriate problems, the presence of pain is the priority.

The nurse notes redness, warmth, and a yellowish drainage at the insertion site of a central venous catheter in a client receiving parenteral nutrition. These findings indicate which potential complication?

There may be an infection at the central catheter site, which can lead to septicemia. Rationale: Redness, warmth, and purulent drainage are signs of an infection, not an allergic reaction. Infiltration causes the surrounding tissue to become cool and pale.

A client with suspected opioid overdose has received a dose of nalmefene. The client subsequently becomes restless, starts to vomit, and complains of abdominal cramping. The blood pressure increases from 110/72 to 160/86 mm Hg. The nurse provides emotional support and reassurance while administering care to the client, knowing which statement is true?

These are signs of opioid withdrawal.

The nurse enters a client's room and finds the client slumped down in the chair. Breathing is shallow and a pulse is present. Based on this data, the nurse determines that which action is the priority?

Check the vital signs and level of consciousness. Rationale: The client is breathing and has a pulse; therefore, further data are needed before any other action is taken. The vital signs and level of consciousness should be checked. Once that assessment is made, the primary health care provider is notified, who will then contact the family. Activating the emergency response system is not indicated at present.

The nurse administering medications to a client notes a prescription to give a subcutaneous dose of heparin sodium. The nurse should perform which action to give this medication safely?

Give the injection using a 25- to 27-gauge, ½-inch needle.

An automatic external defibrillator (AED) interprets that the rhythm of a pulseless client is ventricular fibrillation. The nurse takes which action next?

Orders personnel away from the client, charges the machine, and depresses the discharge buttons

A client with complaints of mild shortness of breath and weakness comes to the medical clinic. The nurse reviews the client's chart and immediately contacts the primary health care provider about which life-threatening finding? Refer to chart.

Potassium level

The nurse is assisting in caring for a client who is receiving a dose of nalmefene intravenously to treat opioid overdose. The nurse plans to have which supplies available as supportive equipment in case it is needed?

Resuscitation equipment

A nursing student is assisting the clinic nurse with the administration of immunizations in the well-baby clinic. The student is asked to administer a measles, mumps, and rubella (MMR) vaccine to a child and prepares to administer the vaccine in which way?

Subcutaneously in the upper arm

The nurse is assisting with caring for a client with abruptio placentae. While caring for the client, the nurse notes that the client begins to develop signs of shock. The nurse should take which action first?

Turn the client onto her side. Rationale: With a pregnant client who is in shock, the nurse should want to increase perfusion to the placenta to minimize fetal distress. A simple way to do this that requires no equipment is to turn the mother on her side. This increases blood flow to the placenta by relieving pressure from the gravid uterus on the great vessels. The nurse should immediately contact the registered nurse, who then contacts the health care provider. The other options should follow quickly.

An emergency department nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area. The client sustained the burn from a home fire that occurred in the basement. Which data would indicate that the client sustained a respiratory injury as a result of the burn?

Use of accessory muscles for breathing Rationale: Clinical indicators in a burn client that would indicate respiratory injury include the presence of facial burns, the presence of soot around the mouth or nose, and singed nasal hairs. Signs of respiratory difficulty include changes in respiratory rate and the use of accessory muscles for breathing. Although anxiety may be a sign of hypoxemia, anxiety along with bradycardia, dysrhythmias, and lethargy would most likely indicate a concern related to a respiratory injury. Abnormal breath sounds and abnormal arterial blood gas values would also be noted. Pain is not specifically related to a respiratory injury.

A 4-year-old child has been brought to the emergency department after the grandparents found him with an open bottle of chewable, orange-flavored 81-mg aspirin tablets. In order to determine whether the child is experiencing a toxic effect, which question should the nurse ask the child?

"Do you hear a sound like a bell ringing in your ears?" Rationale: Ringing in the ears is a common sign of salicylate toxicity, and it is appropriate to ask a 4-year-old whether they hear an unusual sound. Unusual skin sensations, trouble seeing, and unusual odors are not indicative of salicylate toxicity.

A client is admitted to the emergency department with a diagnosis of acute myocardial infarction (MI). Which prescriptions should the nurse anticipate implementing? Select all that apply.

1. Aspirin 2. Oxygen 3. Morphine 4. Nitroglycerin

The nurse is suctioning an endotracheal tube (ET) for an intensive care unit client who is being mechanically ventilated. Five minutes after suctioning, which primary outcomes should tell the nurse that the suctioning has been successful? Select all that apply.

1. Clear lung sounds 2. Increase in O2 saturation 3. Heart rate on monitor within normal limits

A client with a peripheral intravenous (IV) site calls the nurse to the room and tells the nurse, "The IV is not running right." Which findings would indicate an infiltrated IV? Select all that apply.

1. Cool to touch 2. Swelling at site 3. May not have a blood return

The nurse is caring for a client with a multilumen catheter and is monitoring for signs of an air embolism. Which signs and symptoms would be noted in this complication? Select all that apply.

1. Cyanosis 2. Chest pain 3. Coughing 4. A churning "windmill" sound heard over the right ventricle on auscultation

The nursing student is asked to describe the correct steps for performing adult cardiopulmonary resuscitation (CPR). Arrange the steps of adult CPR in the order of priority. All options must be used.

1. Determine unconsciousness by shaking the client and asking, "Are you OK?" 2. Perform chest compressions. 3. Open the client's airway 4. Initiate breathing. Rationale: The sequence for basic CPR for primary health care providers follows the CAB—compressions, airway, breathing—procedure. After determining unconsciousness, compressions are started.

An adult client is admitted to the emergency department with acute extensive partial thickness burns to the lower extremities. The nurse anticipates the primary health care provider will initially prescribe which medications and route for pain control? Select all that apply.

1. Hydromorphone intravenously 2. Morphine sulfate intravenously

A 50-year-old client with a history of cardiac disease has been admitted to the intensive care unit (ICU) with a diagnosis of acute alcohol withdrawal. Which initial client data should the nurse expect to find? Select all that apply.

1. Insomnia 2. Diaphoresis 3. Tachycardia 4. Increased serum total bilirubin

The nurse employed in the pediatric unit working on the 11:00 pm to 7:00 am shift finds an infant unresponsive and without respiration or a pulse. The nurse plans to deliver chest compressions at which rate?

100 times per minute

A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. Which prescription should the nurse anticipate for the client?

100% oxygen via a tight-fitting non-rebreather face mask Rationale: If inhalation injury is suspected, administration of 100% oxygen via a tight-fitting non-rebreather mask is prescribed until carboxyhemoglobin levels fall below 15%. In inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation is also assessed.

A client is going to be transfused with a unit of packed red blood cells (PRBCs). The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started?

15 minutes Rationale: The nurse must remain with the client for the first 15 minutes of a transfusion, which is the most likely time that a transfusion reaction will occur. This enables the nurse to detect a reaction and intervene quickly. The nurse engages in safe nursing practice by obtaining coverage for the other clients during this time. Five minutes is too short of a time period, while 30 and 45 minutes are lengthy time periods.

A client sustains a burn injury to the anterior right and left legs and perineal area. According to the rule of nines, the nurse should determine that this injury constitutes which body percentage?

19% Rationale: According to the rule of nines, the right arm is equal to 9% and the left arm is equal to 9%. The right leg is equal to 18% and the left leg is equal to 18%. The anterior thorax is equal to 18% and the posterior thorax is equal to 18%. The head is equal to 9% and the perineum is 1%. If the anterior right leg (9%), the anterior left leg (9%), and the perineum (1%) were burned, the area of injury would equal 19%, according to the rule of nines.

The nurse is reinforcing instructions regarding cardiopulmonary resuscitation (CPR) to a group of nursing students. The nurse tells the group that when performing chest compressions on adults, the sternum should be depressed to at least which depth?

2 inches Rationale: When performing CPR on adults, the sternum is depressed at least 2 inches. The remaining depths of compression could be ineffective or harmful.

The nurse is providing cardiopulmonary resuscitation (CPR) to an adult cardiac arrest victim. Which is the proper compression-to-ventilation ratio for one-person CPR?

30:2 Rationale: Current cardiopulmonary resuscitation guidelines based on evidence-based practice for one-person cardiopulmonary resuscitation recommend a 30 compression:2 respiration ratio. All other options are incorrect and will be less effective in the resuscitation of this victim.

A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which intravenous (IV) solution will most likely be prescribed for this client?

5% dextrose in lactated Ringer's solution Rationale: For this client, the goal of therapy is to expand intravascular volume as quickly as possible. In this situation, the client will likely experience a decrease in intravascular volume from blood loss, resulting in decreased blood pressure. Therefore, a solution that increases intravascular volume, replaces immediate blood loss volume, and increases blood pressure is needed. The 5% dextrose in lactated Ringer's (hypertonic) solution would increase intravascular volume and immediately replace lost fluid volume until a transfusion could be administered, resulting in an increase in the client's blood pressure. The solutions in the remaining options would not be given to this client because they are hypotonic solutions and, instead of increasing intravascular space, the solutions would move into the cells via osmosis.

The nurse employed in the emergency department receives a telephone call from the emergency alert system informing the department that a child who ingested a bottle of acetaminophen is en route to the emergency department. The nurse prepares the room for the arrival of the child and checks the medication supply to determine whether which medication that is the antidote is available?

Acetylcysteine Rationale: Acetylcysteine is the antidote for acetaminophen. Phytonadione is the antidote for warfarin sodium. Protamine sulfate is the antidote for heparin. Pancreatin is a pancreatic enzyme replacement or supplement.

The nurse is caring for a client who is a victim of a major burn injury. Which are the names of the primary phases of burn care assessment? Select all that apply.

Acute Resuscitative Rehabilitative

A hospitalized client with coronary artery disease complains of substernal chest pain. After checking the client's heart rate and blood pressure, the nurse administers nitroglycerin, 0.4 mg sublingually. After 5 minutes, the client states, "My chest still hurts." If the vital signs have remained stable, which action should the nurse perform?

Administer another nitroglycerin tablet.

The nurse suspects that the client has a pulmonary embolism. Which is the most important nursing action?

Administer oxygen by face mask, as prescribed. Rationale: Because pulmonary circulation is compromised in the presence of an embolus, cardiorespiratory support is initiated by oxygen administration. Monitoring vital signs and elevating the head of the bed may be components of the plan of care, but they are not the most important actions from the options provided. The nurse should not increase the intravenous rate without a prescription from the PHCP to do so.

An assessment of a woman at 32 weeks of gestation indicates moderate fetal distress. Which intervention is the nurse's priority?

Administer oxygen with a face mask at 7 to 10 L/min. Rationale: Administering oxygen will increase the amount of oxygen for transport to the fetus. This action is essential regardless of the cause of the distress. Although the remaining options may be needed at some point during the care of the client, they are not priorities.

A lethargic, yet easily aroused 6-year-old child is brought to the emergency department with a diagnosis of an overdose with diazepam. During the initial data collection, the nurse determines that the child's blood pressure and respirations are below normal for his age. The Glasgow Coma Scale is performed and reveals a score of 10. Based on this information the nurse determines that which problem should have the highest priority?

Altered respiratory status Rationale: Although all of the problems may be appropriate, airway is always the highest priority. The other problems can be addressed once a patent airway is ensured and maintained.

A client requiring upcoming surgery is extremely anxious about the need for a possible blood transfusion and is concerned about the risk of infection from contaminated blood. The nurse suggests that the client consider which as an effective method to minimize this risk?

Arrange an autologous blood donation before the planned surgery. Rationale: Donating autologous blood to be reinfused as needed during or after surgery minimizes the risk of cross-infection from contaminated blood. The next most effective way is to ask a family member to donate blood before surgery. Blood banks do not provide extra screening on request. Preoperative iron supplements are helpful for iron deficiency anemia but are not helpful in affecting the possibility of infection.

A toddler ingested drain cleaner found under the sink. The frantic mother calls poison control and asks what she should do because the child has started vomiting blood. What is the nurse's immediate response?

Ask the mother if the child is breathing on his own. Rationale: Initial emergency procedures following poisoning relate to ensuring that the child's airway, breathing, and circulation (ABCs) are stabilized. Water is used as a diluent if a strong corrosive is ingested but not if the child is vomiting because this would increase the risk of aspiration. Options 2 and 4 are inappropriate.

A toddler is rushed to the emergency department by her father, who states that he found the child sitting on the floor with an empty bottle of vitamins. He is not sure how many vitamins were in the bottle. The child is responsive but crying. What is the nurse's immediate action?

Assess the child and take the vital signs. Rationale: Initial emergency procedures relate to ensuring that the child's airway, breathing, and circulation (ABCs) are stabilized. Because the child is responsive and crying, vital signs should be taken initially as the immediate action. Cardiorespiratory support is not indicated because the child is responsive by crying. In this situation, further data collection and instituting primary health care provider's prescriptions would be done after ensuring that the child is stable and vital signs are assessed.

The nurse is caring for a client with liver disease. Laboratory studies are performed, and the client's serum calcium level is 13 mg/dL. The nurse checks to see that which medication is available in the stock medication supply area on the clinical nursing unit that may be needed to treat this calcium imbalance?

Calcitonin Rationale: The normal serum calcium level is 8.6 to 10 mg/dL. This client is experiencing hypercalcemia. Calcium gluconate and calcium chloride are used to treat tetany that results from acute hypocalcemia. In hypercalcemia, large doses of vitamin D should be avoided. Calcitonin, a thyroid hormone, decreases the plasma calcium level by increasing the incorporation of calcium into the bones, thus, keeping it out of the serum.

A depressed client is found unconscious on the floor in the dayroom of a psychiatric nursing unit. The nurse finds several empty bottles of a prescribed tricyclic antidepressant lying near the client. What is the immediate action of the nurse?

Call a rapid response. Rationale: Tricyclic antidepressants can be fatal when taken as an overdose regardless of the amount ingested. Serious, life-threatening symptoms can develop after an overdose. Immediate emergency medical attention and cardiac monitoring are needed in the event of an overdose of tricyclic antidepressants.

The nurse is visiting an older client whose family has gone out for the day. During the visit, the client experiences chest pain that is unrelieved by nitroglycerin given by the nurse. Which action by the nurse would be appropriate at this time?

Call for an ambulance to transport the client to the emergency department. Rationale: Chest pain that is unrelieved by rest and nitroglycerin may not be typical anginal pain but may signal myocardial infarction (MI). Because the risk of sudden cardiac death is greatest in the first 24 hours after MI, it is imperative that the client receive emergency cardiac care. A primary health care provider's office is not equipped to treat MI. Communication with the family or home care agency delays client treatment, which is needed immediately.

The nurse receives a telephone call from a neighbor who states that her child was found sitting on the floor near the kitchen sink playing with several bottles of cleaning fluids. The bottles of cleaning fluid were opened and spilled on the child and the floor, and the mother suspects that the child may have consumed some of the cleaning fluid. Which action should the nurse tell the mother to do immediately?

Call the area poison control center. Rationale: The area poison control center should be called if an unknown toxic agent has been ingested or if it is necessary to identify an antidote for a known toxic agent. Syrup of ipecac is not recommended for home use. It may be prescribed in a hospitalized setting under medical supervision. It induces vomiting but vomiting is not induced in an unconscious or after ingestion of caustic substances (acid or alkaline) or petroleum distillates. Calling an ambulance or calling the primary health care provider will delay necessary life-saving measures.

The nurse discusses emergency nursing measures that are implemented at the site of an injury with a nursing student. Which initial action does the nurse tell the student to perform in the event of carbon monoxide poisoning?

Carry the client to fresh air. Rationale: Whenever a victim inhales a poison, the victim is carried immediately to fresh air. Any tight clothing is then loosened and CPR is initiated if necessary. Oxygen is administered as soon as possible. Chilling is prevented, and the victim is wrapped in blankets and kept as quiet as possible.

The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to attach the distal end of the IV tubing to a needleless device, the tubing drops and hits the top of the medication cart. Which is the appropriate action by the nurse?

Change the IV tubing.

The nurse is caring for a cardiac client who has recently displayed this monitored rhythm. Which actions by the nurse are most appropriate? Refer to figure. Select all that apply.

Check all telemetry leads. Check blood pressure (BP). Obtain stat electrocardiogram (ECG). Assess client's level of consciousness (LOC).

The nurse is assigned to care for a client being admitted to the mental health unit following a suicide attempt. The client attempted the suicide by lacerating both wrists. Which is the initial nursing action upon admission of the client?

Check the wound sites. Rationale: The physiological integrity of the client is always assessed first. Although options 2, 3, and 4 may be appropriate at some point, the initial action should be to assess the wounds.

A client has experienced pulmonary embolism. The nurse should assess for which symptom that is most commonly reported?

Chest pain that occurs suddenly Rationale: The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness,

A primary health care provider prescribes a parenteral nutrition solution to start at 50 mL/hr by infusion pump via an established subclavian central line. After 2 hours of initiating the parenteral nutrition infusion, the client suddenly complains of difficulty in breathing and chest pain. Which action would the nurse prepare to do first?

Clamp the parenteral nutrition infusion. Rationale: A complication of a subclavian central line can be an embolism resulting from air or thrombus. A sudden onset of chest pain shortly after the initiation of parenteral nutrition may mean that this complication has developed. The central line is clamped, not discontinued, and the primary health care provider is notified immediately. Option 1 is an appropriate action but not the first action. Option 3 is not a priority because the client's symptoms do not indicate the presence of hypoglycemia or hyperglycemia. The primary health care provider will probably prescribe an ECG, but this action would not be the initial action in this situation.

The nurse is assigned to assist with caring for a client who is at risk for eclampsia. If the client progresses from preeclampsia to eclampsia, the nurse should take which action first?

Clear and maintain an open airway. Rationale: The first actions are to maintain an open airway and to prevent injuries to the client. The client should be turned to the side and monitored for airway compromise. Options 1, 3, and 4 may be components of care, but they are not the first actions.

A client has sustained full-thickness circumferential burns of the trunk. Which should be the priority concern of the nurse?

Client's ability to adequately ventilate Rationale: When a full-thickness burn of the trunk is circumferential, the chest movement can be restricted and breathing will be affected. This is because full-thickness burns are hard, dry, leathery eschar (dead tissue) that does not expand to accommodate edema underlying the eschar. Urine output of 30 to 50 mL/hr is indicative of adequate response to fluid resuscitation measures. When layers of skin are destroyed, barriers to invasion by microorganisms are removed, increasing the risk for infection. In addition, burn injuries are extremely painful, and the nurse must institute measures to manage pain. Although these are important, options 1, 2, and 3 are not priorities over the client's ventilatory status.

Intravenous (IV) fluids have been infusing at 100 mL/hour via a central line catheter in the right internal jugular for approximately 24 hours to increase urine output and maintain the client's blood pressure. Upon entering the client's room, the nurse notes that the client is breathing rapidly and coughing. For which additional signs of a complication should the nurse assess based on the previously known data?

Crackles in the lungs Rationale: Circulatory (fluid) overload is a complication of therapy. Signs include rapid breathing, dyspnea, a moist cough, and crackles. Blood pressure and heart rate also increase if circulatory overload is present. Therefore, since the nurse previously noted rapid breathing and coughing, the nurse should then assess for a moist cough and crackles. Hematoma is another potential complication and is characterized by ecchymosis, swelling, and leakage at the IV insertion site, as well as hard and painful lumps at the site. Allergic reaction is a complication of administration of IV fluids or medication and is characterized by chills, fever, malaise, headache, nausea, vomiting, backache, and tachycardia; this type of reaction could also occur if the IV solutions infused are incompatible; however, there was no indication of multiple solutions being infused simultaneously in this question. Chest pain radiating to the left arm is a classic sign of cardiac compromise and is not specifically related to a complication of IV therapy.

A client with a Sengstaken-Blakemore tube in place to treat esophageal varices suddenly becomes restless, the heart rate and blood pressure increase, and the client's pulse oximetry reading is decreasing. The nurse calls for the registered nurse and plans to take which immediate nursing action?

Cut the tube, and pull it out. Rationale: Sudden rupture of the esophageal balloon can cause airway obstruction, aspiration, and/or asphyxiation. The tube should be cut and removed to prevent airway obstruction. The remaining options also may be done once the nurse first takes action to safeguard the client's airway.

A client receiving a blood transfusion begins to exhibit flushing, stridor, and a drop in blood pressure. The nurse should obtain which medication from the emergency cart to have ready for use as prescribed?

Epinephrine Rationale: The symptoms exhibited by the client are compatible with an allergic reaction to the transfusion. Other common symptoms of allergic reaction are nausea and vomiting, diarrhea, and loss of consciousness. The nurse prepares to administer epinephrine and corticosteroid medications as prescribed. Norepinephrine is a sympathetic agonist used to treat hypotension but is not indicated in an allergic reaction. Lidocaine is an antidysrhythmic medication. Theophylline is a bronchodilator, which could be prescribed if needed to treat bronchospasm.

The nurse is caring for a client with heart failure. The client suddenly becomes anxious and restless, has a sudden onset of breathlessness, and becomes cyanotic. The nurse suspects pulmonary edema and immediately places the client in which best position?

High-Fowler's Rationale: Positioning the client upright (high-Fowler's position), with the legs dangling over the side of the bed, has an immediate effect of decreasing venous return and decreasing lung congestion. Low-Fowler's position will not achieve this effect. The supine position is a flat position, and when in Trendelenburg's position, the client is flat with the head lower than the rest of the body. These positions would worsen the client's condition.

A client receiving intravenous (IV) fluid therapy complains of burning and a feeling of tightness at the IV insertion site. On data collection, the nurse detects coolness and swelling at the site and notes that the IV rate has slowed. The nurse determines that which has occurred?

Infiltration Rationale: An infiltrated IV line is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness, and swelling at the IV site result when IV fluid is deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of IV solution will slow down or stop. The corrective action is to remove the catheter and start a new IV line at another site. Infection, phlebitis, and thrombosis are likely to be accompanied by warmth at the site, not coolness.

A client who is receiving antineoplastic medication by the intravenous (IV) route complains of pain at the insertion site of the IV. The nurse inspects the site and finds the area is swollen and reddened. The nurse further observes that the solution is no longer infusing. The nurse immediately takes which priority nursing action?

Notifies the registered nurse (RN)

The nurse is caring for a client who has bilateral vocal cord paralysis. The client begins to experience severe dyspnea; the nurse listens to the client's breath sounds and hears this sound. (Refer to audio.) Which intervention should the nurse take immediately?

Notify the registered nurse.

The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the primary health care provider's prescriptions and should question which prescription?

Obtain equipment for a manual pelvic examination. Rationale: Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent until a diagnosis is made and placenta previa is ruled out. Digital examination of the cervix can lead to hemorrhage. A diagnosis of placenta previa is made by ultrasound. The hemoglobin and hematocrit levels are monitored, and external electronic fetal heart rate monitoring is initiated. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus, who is at risk for severe hypoxia

A client newly admitted to the labor unit reports to the nurse that she felt a large gush of fluid before arriving at the hospital. The nurse checks the client and notes that the umbilical cord is protruding from the vagina. Which action should the nurse take first?

Place the client in the Trendelenburg position. Rationale: When an umbilical cord is protruding, nursing actions are directed at reducing cord compression and facilitating delivery of the fetus. The client should be placed in extreme Trendelenburg, Sims', or knee-chest position to reduce cord compression. The primary health care provider is notified, and an IV is started after initiating emergency care for the client.

A client receiving total parenteral nutrition (TPN) is demonstrating signs and symptoms of an air embolism. Which action should the nurse take first?

Place the client on the left side with the head lowered. Rationale: Lying on the left side may prevent air from flowing into the pulmonary veins. Placing the head lower than the body increases intrathoracic pressure, which decreases the amount of blood pulled into the vena cava during inspiration. The primary health care provider is notified, but this is not the first action. Stopping the TPN will not treat the problem.

One unit of packed red blood cells has been prescribed for a client postoperatively because the client's hemoglobin level is low. The primary health care provider prescribes diphenhydramine to be administered before the administration of the transfusion. Why is this medication being given?

Prevent a rash and pruritus Rationale: An urticarial reaction is characterized by a rash accompanied by pruritus. This type of transfusion reaction is prevented by pretreating the client with an antihistamine, such as diphenhydramine. All other options are incorrect. Acetaminophen, however, may be prescribed before the administration to assist in preventing an elevated temperature.

The nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. What is the most appropriate action?

Pull back on the tube and wait until the respiratory distress subsides. Rationale: During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. It is not necessary to notify the primary health care provider immediately or remove the tube.

The nurse assisting in caring for a client hospitalized with acute pericarditis is monitoring the client for signs of cardiac tamponade. The nurse determines that which finding is unrelated to possible cardiac tamponade?

Pulse rate of 58 beats per minute Rationale: Assessment findings with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention, and a falling blood pressure, accompanied by pulsus paradoxus (a drop in inspiratory blood pressure by greater than 10 mm Hg). Bradycardia is the symptom that is unrelated.

A woman arrives at the emergency department complaining of abdominal pain of 4 on a scale of 1 to 10. She states that she thinks she is about 10 weeks pregnant. Her vital signs are pulse, 86 beats per minute; respirations,16 breaths per minute; and blood pressure,112/78 mm Hg. Which signs/symptoms should the nurse report to the primary health care provider immediately? Select all that apply.

Pulse, 112 beats per minute Pain rating of 8 on a scale of 1 to 10 States "I feel like I am about to faint."

The client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client's vital signs, what are the nurse's actions in order of priority? Arrange the actions in the order that they should be performed. All options must be used.

Raise the head of bed Loosen tight clothing on the client Check for bladder distention Prepare to administer antihypertensive medication as prescribed Document the occurrence

A client has been on total parenteral nutrition for 8 weeks. The primary health care provider prescribes that the total parenteral nutrition be weaned down by 50 mL/hr/day until discontinued. The client asks the nurse, "Why doesn't the doctor just stop the parenteral nutrition instead of dragging it on for 3 days?" The nursing response should be to explain that the primary health care provider is concerned about which phenomenon?

Rebound hypoglycemia Rationale: Clients receiving total parenteral nutrition are receiving high concentrations of glucose. To give the pancreas time to adjust to decreasing glucose loads, the infusion rates are tapered down. Before discontinuing the parenteral nutrition, the body must adjust to the lowered glucose levels. If the total parenteral nutrition were suddenly withdrawn, the client would probably have rebound hypoglycemia. Options 1, 2, and 3 are not concerns when the parenteral nutrition is discontinued.

The nurse caring for a client at home arrives to find the client in the bedroom, unconscious and with a pill bottle of the selective serotonin reuptake inhibitor, sertraline on the bed. Which assessment has priority?

Respirations Rationale: In a suspected poisoning, the nurse should check the respiratory status and the pulse. Blood pressure would be checked after these parameters were determined. Urinary output is also important but not the priority at this time.

An emergency department nurse is assigned to assist in caring for a client who has suffered a head injury following a motor vehicle crash. The nurse understands that the initial data collection should focus on which sign/symptom?

Respiratory status Rationale: The initial data collection focuses on ensuring that the client has an adequate airway and respiratory status. In rapid sequence, the client's circulatory status is evaluated, followed by evaluation of the neurological status. Range of motion is not a priority. In fact, the extent of the injuries should be well established before assessing range of motion.

A client who experienced ventricular fibrillation has just been defibrillated. Following the defibrillation, which action should the nurse take immediately?

Resume cardiopulmonary resuscitation (CPR). Rationale: Following defibrillation, the nurse immediately resumes CPR for 2 minutes. Even if a normal rhythm has been restored, the heart pump needs to be reprimed to provide improved cerebral blood flow to improve neurological outcome. Options 1, 2, and 3 are not immediate actions following defibrillation.

A client is receiving thrombolytic therapy by continuous infusion. The client suddenly becomes extremely anxious and complains of itching. The nurse hears stridor, and on examination of the client, notes generalized urticaria and hypotension. Which should be the priority action of the nurse?

Stop the infusion, and notify the registered nurse. Rationale: The client is experiencing an anaphylactic reaction to thrombolytic therapy. The infusion should be stopped; the registered nurse notified; and the client treated with epinephrine, antihistamines, and corticosteroids as prescribed.

The critical care nurse is caring for a client with a subclavian central line catheter. The nurse knows that a specific central-line bundle was developed to reduce the client's risk for developing a catheter-related bloodstream infection (CLABSI). The interventions include which essential actions? Select all that apply.

Strict hand washing Optimal catheter site selection Strict sterile technique with maximal barrier precautions during placement

The nurse is assisting in caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide level reveals a level of 45%. Based on this level, the nurse should anticipate which sign in the client?

Tachycardia Rationale: Carbon monoxide levels between 5% and 10% result in impaired visual acuity, levels of 11% to 20% result in flushing and headache, and levels of 21% to 30% result in nausea and impaired dexterity. Levels of 31% to 40% result in vomiting, dizziness, and syncope; levels of 41% to 50% result in tachypnea and tachycardia; and levels greater than 50% result in coma and death.

The nurse is caring for a new postoperative client and is monitoring the client for signs of shock. The nurse monitors for which signs of this postoperative complication?

Tachycardia, cold skin, and hypotension Rationale: Postoperative hypotension or shock can have numerous causes such as inadequate ventilation, side effects of anesthetic agents or preoperative medications, and fluid or blood loss. The symptoms of shock include hypotension; tachycardia; cold, moist, pale, or cyanotic skin; and increased restlessness and apprehension.

The emergency department nurse is caring for a child brought to the emergency department following the ingestion of approximately one half bottle of acetylsalicylic acid (aspirin) 10 minutes before arrival. Which should the nurse anticipate as the likely initial treatment?

The administration of activated charcoal Rationale: Initial treatment of salicylate overdose includes administration of activated charcoal to decrease absorption of the aspirin. Intravenous (IV) fluids and inducing emesis may be prescribed to enhance excretion but would not be the initial treatment. Dialysis is used in extreme cases if the child is unresponsive to therapy. Vitamin K is the antidote for warfarin overdose

A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which area?

The blood bank Rationale: The nurse prepares to return the blood transfusion bag containing any remaining blood to the blood bank. This allows the blood bank to complete any follow-up testing procedures that are needed after a transfusion reaction has been documented. The remaining options are incorrect.

The nurse is caring for a client who has just been admitted to the nursing unit after receiving flame burns to the face and chest. The nurse notes a hoarse cough, and the client is expectorating sputum with black flecks. The client suddenly becomes restless and his color is becoming dusky. Based on this data, which interpretation should the nurse make?

The burn has probably caused laryngeal edema, which has occluded the airway. Rationale: The client exhibits several warning signs of an inhalation injury: a history of a flame burn to the face, hoarseness, cough, carbonaceous sputum, singed facial hair, facial edema, and color change. Additionally, one of the cardinal signs of hypoxia is restlessness.

The nurse evaluates the client following treatment for carbon monoxide poisoning. The nurse should document that the treatment has been successful if which result is obtained?

The carboxyhemoglobin levels are less than 5%. Rationale: Normal carboxyhemoglobin levels are less than 5%. Clients can be awake and talking with abnormally high levels. Other symptoms of carbon monoxide poisoning are tachycardia and tachypnea, but a normal sinus rhythm is insufficient evidence to assure normal carbon monoxide levels.

An adolescent is admitted to the pediatric intensive care unit after suffering a seizure at school. She is alert on admission and tells the nurse that she has asthma and takes theophylline every day. She has a heart rate of 116 beats per minute with some shortness of breath. She also is complaining of nausea and vomiting. Which should the nurse suspect as the reason for the complaints that were gathered during the data collection process?

The child might have a toxic theophylline level. Rationale: The early signs of theophylline toxicity are nausea, vomiting, tachycardia, headache, and irritability. Seizures indicate a toxicity level greater than 30 mcg/mL. A normal theophylline level is 10 to 20 mcg/mL. Options 1, 2, and 4 are incorrect interpretations.

The nurse is assisting to administer acetylcysteine to a client admitted with acetaminophen overdose. Before this medication is given, the nurse ensures which factor is in place?

The stomach is empty from emesis or lavage.

The nurse notes that an 8-year-old child is choking. As the nurse rushes to aid the conscious and alert child, the nurse plans to place the hands between which landmarks to remove the foreign body?

The umbilicus and xiphoid process

A primary health care provider prescribes an intravenous fat emulsion solution for a client who will be receiving parenteral nutrition (PN). The nurse should explain to the client the administration of the fat emulsion solution is for which reason?

To provide essential fatty acids and additional calories Rationale: Clients receiving their nutrition parenterally for a prolonged period of time are at risk for developing essential fatty acid deficiency. Fat emulsions are given to meet client nonprotein caloric needs and provide essential fatty acids, which cannot be met by PN administration alone. Options 1, 2, and 3 are incorrect.

The nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to check which item?

Vital signs Rationale: A change in the vital signs may indicate that a transfusion reaction is occurring. The nurse assesses the client's vital signs before the procedure to obtain a baseline every 15 minutes for the first half hour after beginning the transfusion and every half hour thereafter. Skin color, oxygen saturation, and most recent hematocrit may be checked but are not the most important.

An emergency department nurse prepares to collect data from a pregnant woman. The woman tells the nurse that she felt a large gush of fluid on the way to the hospital. The nurse checks the fetal heart rate (FHR) and notes that it is 90 beats per minute. On physical examination, the nurse notes that the umbilical cord is protruding from the vagina. Which is the initial nursing action?

Wrap the cord loosely in a sterile normal saline saturated towel. Rationale: When an umbilical cord is protruding, the cord must be protected from drying out and becoming compressed. Tocolytic agents are used for inadequate uterine relaxation. Although an IV may be needed, this is not the initial action. When the umbilical cord is protruding, the client is placed in an extreme Trendelenburg's or modified Sims' position or knee-chest position to reduce compression.

The nurse is conducting a teaching session on basic life support (BLS) for nursing students. Which statement made by a nursing student indicates a need for further teaching?

"I will remember the algorithm airway, breathing, and compressions to guide my actions when providing BLS."

When performing cardiopulmonary resuscitation (CPR), the nurse should deliver how many breaths per minute to an adult client?

10 Rationale: During CPR, the nurse would deliver 10 breaths per minute to an adult client. Therefore, 8, 16, and 20 are incorrect.

The nurse witnesses a person starting to choke in the hospital cafeteria. Before performing abdominal thrusts, which action should the nurse perform?

Ask the client, "Are you choking?"

A family of a spinal cord-injured client rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic, with a flushed face and neck, and complains of a severe headache. The pulse is 40 beats per minute, and the blood pressure is 230/100 mm Hg. The nurse acts quickly, knowing that the client is experiencing which condition?

Autonomic dysreflexia Rationale: The client with spinal cord injury above the level of T7 is at risk for autonomic dysreflexia. It is characterized by severe, throbbing headache; flushing of the face and neck; bradycardia; and sudden, severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea, and sweating. It is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury.

The nurse is assisting in monitoring a client who is receiving a transfusion of packed red blood cells. Before leaving the room, the nurse tells the client that it is important to immediately report which sign if it occurs?

Backache

The nurse is monitoring a child who is receiving calcium disodium edetate for the treatment of lead poisoning. The nurse reviews the laboratory results of the child during treatment with this medication and is particularly concerned with monitoring which laboratory test result?

Blood urea nitrogen

The nurse discovers an unresponsive, breathing newborn infant. To assess circulatory status, the nurse should palpate which arterial pulse area?

Brachial

The nurse in the emergency department is listening to the breath sounds of a client with respiratory distress and hears this sound. (Refer to audio.) The nurse determines that this finding is characteristic of which disorder?

Bronchitis

The primary health care provider prescribes one unit of packed red blood cells to infuse over 4 hours. One unit of blood contains 250 mL, and the drop factor is 10 gtt/1 mL. Although an infusion pump will be used, the registered nurse asks the licensed practical nurse (LPN) to assist with monitoring the flow rate during the infusion. The LPN monitors the flow rate, knowing that how many gtt/min should infuse? Fill in the blank and round answer to the nearest whole number.

10gtt/min Rationale: The prescribed 250 mL is to be infused over 4 hours. Follow the formula, and multiply 250 mL by 10 (gtt factor). Then divide the result by 240 minutes (4 hours × 60 minutes). The infusion is to run at 10.4 or 10 gtt/min.

A registered nurse has just hung a 250-mL bag of packed red blood cells (PRBCs) on a client. The licensed practical nurse assisting in caring for the client plans to remain with the client for at least how many minutes following the start of the infusion?

15 minutes Rationale: The nurse must remain with the client for the first 15 minutes of a transfusion, which is the most frequent period during which a transfusion reaction may occur. This enables the nurse to quickly detect a reaction and intervene quickly. Option 1 is not enough time to remain with the client. The time frames in options 3 and 4 are unnecessary.

The nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which finding?

A decrease in oozing from puncture sites and gums Rationale: Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or the oozing of blood from puncture sites, wounds, and mucous membranes. The client's temperature would decline to normal after the infusion of granulocytes if those transfused cells were then instrumental in fighting infection in the body. Increased hemoglobin and hematocrit levels would be seen when the client has received a transfusion of red blood cells.

The nurse is monitoring a client who is receiving a unit of packed red blood cells. Within an hour after the initiation of a transfusion, the nurse finds the client to be restless, with reports of chills and back pain. The nurse notes that there is dark urine in the Foley catheter drainage bag. The nurse interprets that the client is experiencing which reaction?

Acute hemolytic Rationale: The client is experiencing an acute hemolytic reaction to the transfusion. The nurse in this instance would immediately stop the infusion and notify the primary health care provider. A delayed hemolytic reaction typically occurs from 2 to 14 days after transfusion. A hyperkalemic reaction occurs when blood is transfused that has been stored for too long, resulting in red blood cell hemolysis. The client experiencing a hyperkalemic reaction would exhibit nausea, muscle weakness or paresthesias, apprehension, bradycardia, electrocardiogram (ECG) changes, and possibly cardiac arrest. An allergic reaction is characterized by flushing, nausea and vomiting, respiratory stridor, hypotension, and other signs of anaphylaxis.

A client who has been receiving total parenteral nutrition by way of a central venous access device complains of chest pain and dyspnea. The nurse quickly assesses the client's vital signs and notes that the pulse rate has increased and that the blood pressure has dropped. The nurse determines that the client is most likely experiencing which sign?

Air embolism Rationale: The signs and symptoms of air embolism include chest pain, dyspnea, hypoxia, anxiety, tachycardia, and hypotension. The nurse also should hear a loud churning sound over the pericardium on auscultation of the chest. The signs and symptoms of sepsis include fever, chills, and general malaise. The signs and symptoms of a fluid imbalance depend on the type of imbalance that the client is experiencing. Fluid overload causes increased intravascular volume, which increases the blood pressure and the pulse rate as the heart tries to pump the extra fluid volume. Fluid overload also causes neck vein distention and the shifting of fluid into the alveoli, resulting in lung crackles. Complications should be reported to the registered nurse and/or the primary health care provider immediately.

A client undergoing a computed tomography (CT) scan develops chest pain, wheezing, and stridor after injection of contrast media. Which type of shock is this client most likely exhibiting?

Anaphylactic Rationale: Injection of contrast media may result in anaphylaxis and most likely occurs as a result of mast cell degranulation. If not recognized and treated immediately, the client will progress to anaphylactic shock. Septic shock is a systemic inflammatory response to a documented or suspected infection. Neurogenic shock occurs when there is loss of sympathetic tone. Cardiogenic shock occurs when the heart fails as a pump.

The nurse who is assisting in caring for a client with a tracheostomy tube notes heavy bleeding from the stoma. The nurse also notes that the tracheostomy tube pulsates with the client's heartbeat. The nurse immediately performs which action?

Applies pressure to the artery at the stoma site Rationale: Heavy bleeding from a tracheostomy site is a life-threatening complication. Direct pressure is applied to the innominate artery at the stoma site. The client is then prepared for immediate surgical repair. An IV line will need to be initiated, but this is not the immediate action.

An automatic external defibrillator (AED) is available to treat a client who goes into cardiac arrest. The nurse uses this equipment to determine cardiac rhythm by doing which?

Applying the adhesive patch electrodes to the skin and moving away from the client

To use an external cardiac defibrillator on a client, which action should be performed to check the cardiac rhythm?

Applying the adhesive patch electrodes to the skin and moving away from the client Rationale: The nurse or rescuer puts two large adhesive patch electrodes on the client's chest in the usual defibrillator position. The nurse stops cardiopulmonary resuscitation and orders anyone near the client to move away and not touch the client. The defibrillator then analyzes the rhythm which may take up to 30 seconds. The machine then indicates if it is necessary to defibrillate. Although automatic external defibrillation can be done transtelephonically, it is done through the use of patch electrodes (not standard electrocardiographic electrodes) that interact via telephone lines to a base station that controls any actual defibrillation. It is not necessary to hold defibrillator paddles against the client's chest with this device.

The nurse in the newborn nursery receives a telephone call to prepare for the admission of a neonate born at 43 weeks' gestation with Apgar scores of 1 and 4. When planning for the admission of this infant, which is the nurse's highest priority?

Connecting the resuscitation bag to the oxygen outlet Rationale: The highest priority during the admission to the nursery of a newborn with low Apgar scores is airway support, which would involve preparing respiratory resuscitation equipment. The remaining options are also important, although they are of lower initial priority. The newborn infant will be placed on a cardiorespiratory monitor. Setting up an intravenous line with 5% dextrose in water would provide circulatory support and may be prescribed. The radiant warmer will provide an external heat source, which is necessary to prevent further respiratory distress.

An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription?

Delivery of the fetus Rationale: Abruptio placentae is the premature separation of the placenta from the uterine wall after the twentieth week of gestation and before the fetus is delivered. The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible.

A child is hospitalized with a diagnosis of lead poisoning. The nurse caring for the child should prepare to assist in administering which medication?

Dimercaprol Rationale: Dimercaprol is a chelating agent that is administered to remove lead from the circulating blood and from some tissues and organs for excretion in the urine. Sodium bicarbonate may be used in salicylate poisoning. Syrup of ipecac is used in the hospital setting in poisonings to induce vomiting. Activated charcoal is used to decrease absorption in certain poisoning situations. Note that dimercaprol is prepared with peanut oil, and hence should be avoided by clients with known or suspected peanut allergy.

A 4-year-old child sustains a fall at home injuring the right arm and is brought to the emergency department by the mother. The nurse should perform which emergency actions in the care of the child? Select all that apply.

Elevate the right arm. Check the neurovascular status of the right extremity. Determine the level of pain using a pediatric pain assessment tool. Rationale: Emergency nursing actions to take for a child sustaining an extremity fracture include elevating the injured extremity, checking the extent of the injury including pain level, immobilizing the affected extremity, applying cold packs to the injured area, and monitoring the neurovascular status of the extremity.

A postpartum client has lost 700 mL of blood. The vital signs indicate hypovolemia and the uterus remains atonic in spite of treatment. The nurse assisting in caring for the client understands what is necessary in this situation and prepares the client for which treatment?

Emergency surgery Rationale: When uterine atony cannot be reversed, surgery is required.

The nurse has been assigned to the care of four adult clients who are receiving continuous intravenous (IV) infusions. The nurse planning the work assignment for the shift makes a notation to check the IV sites of these clients at which time interval?

Every hour

A client presents to the urgent care center with a chemical burn of the right eye. The priority for the nurse is to prepare the client for which nursing intervention?

Flushing the right eye with copious amounts of sterile solution Rationale: When the client has suffered a chemical burn of the eye, the nurse immediately flushes the eye with a sterile solution continuously for 15 minutes. If a sterile eye irrigation solution is not available, running water may be used. Applying compresses or bandages does not rid the eye of the damaging chemical. Warm compresses may be used for eye infections. Cold compresses are used for blows to the eye, whereas light bandages may be placed over cuts of the eye or eyelid.

A client who is receiving total parenteral nutrition (TPN) complains of a headache. The nurse notes that the client has an increased blood pressure and a bounding pulse. The nurse reports the findings, knowing that these signs/symptoms are indicative of which complication of this therapy?

Fluid overload Rationale: The client's signs and symptoms are consistent with fluid overload. The increased intravascular volume increases the blood pressure, whereas the pulse rate increases as the heart tries to pump the extra fluid volume. A fever would be present in a client with sepsis. Signs and symptoms of an air embolus include confusion, pallor, lightheadedness, tachycardia, tachypnea, hypotension, anxiety, and unresponsiveness. Polyuria, polydipsia, and polyphagia are manifestations of hyperglycemia.

A client who has undergone a cardiac catheterization using the right femoral approach is returned to the nursing unit. Thirty minutes later the client complains of numbness and tingling of the right foot. The pedal pulse is weak, and the foot is pale. The nurse notifies the registered nurse because these symptoms are consistent with which problem?

Femoral artery thrombus or hematoma Rationale: Adverse changes such as numbness and tingling, coolness, pallor, cyanosis, or sudden loss of peripheral pulses indicate serious circulatory impairment and are reported to the registered nurse immediately, who then contacts the primary health care provider. Allergic reaction to the dye is a systemic problem, not a local one. The data in the question are not consistent with sciatic pain. Infection does not become apparent this quickly.

A client who sustained an inhalation injury arrives in the emergency department. On data collection, the nurse notes that the client is very confused and combative. The nurse determines that the client is experiencing which problem?

Hypoxia Rationale: After a burn injury, clients are normally alert. If a client becomes confused or combative, hypoxia may be the cause. Hypoxia occurs after inhalation injury and may occur after an electrical injury. The data in the question is not specifically related to options 1, 2, or 4.

The nurse is assisting in the preparation of a client for a blood transfusion. Which item is the most important for the completion of the identification process?

Identification bracelet Rationale: The identification bracelet that is placed on the client at admission is the most important item for proper client identification. The ID bracelet contains the client's name, age, primary health care provider's name, room number, and a hospital and/or medical record identification number. It contains the same information that is present on the client's computer generated forms, which is present on all client requisitions. The Social Security number and address are irrelevant for the procedure described. The medical record number would most likely be present on the client ID bracelet.

During the emergent phase after a major burn injury, which abnormalities should the nurse expect to note?

Increased hematocrit and increased potassium Rationale: During the emergent phase of a burn injury, the client's hemoglobin and hematocrit will be elevated because of fluid loss. Sodium will be decreased because of trapping in edema fluid and loss through plasma leakage. Potassium will be increased because of disruption of the sodium-potassium pump, tissue destruction, and red blood cell hemolysis, and albumin will be low because of loss through the wound and increased capillary permeability.

A client wishes to donate blood for a family member and asks the nurse about the procedure for identifying compatibility. The nurse tells the client that which test will be done to test compatibility?

Indirect Coombs Rationale: The indirect Coombs test detects circulating antibodies against red blood cells (RBCs) and is the "screening" component of the prescription to "type and screen" a client's blood. This test is used in addition to the ABO typing, which is normally done to determine blood type. The direct Coombs test is used to detect idiopathic hemolytic anemia, by detecting the presence of autoantibodies against the client's RBCs. Eosinophil and monocyte counts are part of a complete blood count, a routine hematological screening test. A red blood cell count is also part of a complete blood count and determines the number of circulating red blood cells but does not determine compatibility.

A comatose client received therapeutic hypothermia after a cardiac arrest. The nurse anticipates which primary complications associated with this treatment? Select all that apply.

Infection Bleeding Metabolic and electrolyte disturbances

A client is scheduled for insertion of a peripherally inserted central catheter (PICC), and the nurse explains the advantages of this catheter. Which statement by the client indicates a lack of understanding about this type of catheter?

It is specifically designed for short-term use.

The nurse should use which best method to open the airway of a victim who has a suspected neck injury?

Jaw thrust maneuver

The nurse is caring for a client who had a small bowel resection the previous day and has continuous gastric suction attached to the nasogastric tube. Which intravenous solution should the nurse anticipate to be prescribed for the client?

Lactated Ringer's solution Rationale: Electrolyte solutions such as lactated Ringer's are used to replace fluid from gastrointestinal (GI) tract losses. Albumin is used for shock and protein replacement; 5% dextrose in water contains only glucose and no electrolytes to replace gastrointestinal losses. Normal saline contains no glucose, and glucose is essential for calories when a client takes nothing by mouth (NPO).

The nurse is assisting in preparing to administer acetylcysteine to a client with an overdose of acetaminophen. How should the nurse administer the medication?

Mix the medication in a flavored ice drink, and allow the client to drink the medication through a straw. Rationale: Because acetylcysteine has a pervasive odor of rotten eggs, it must be disguised in a flavored ice drink. It is consumed preferably through a straw to minimize contact with the mouth. It is not administered by the intramuscular or subcutaneous route.

A client is admitted to the emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially?

Maintain a patent airway. Rationale: The initial nursing action would be to maintain a patent airway. Oxygen would be administered, followed by fluid replacement. The nurse would also keep the client warm, monitor intravenous fluids, and administer thyroid hormones.

A client in the clinical unit who is allergic to shellfish unknowingly ate a dish brought by a friend that had shellfish as an ingredient. The client quickly develops anaphylaxis. The nurse should focus on which intervention first until additional help arrives?

Maintaining a patent airway

The client brought to the emergency department is experiencing an anaphylactic reaction from eating shellfish. The nurse should implement which immediate action?

Maintaining a patent airway Rationale: If the client experiences an anaphylactic reaction, the immediate action would be to maintain a patent airway. The client then would receive epinephrine. Corticosteroids may also be prescribed. The client will need to be instructed about obtaining and wearing a Medic-Alert bracelet, but this is not the immediate action.

The nurse is assigned to care for a client receiving total parenteral nutrition via the subclavian vein. The nurse should identify which intervention in the plan of care for the client as the priority?

Monitoring the insertion site for signs of infection Rationale: Total parenteral nutrition that is infusing via a central line, such as through the subclavian vein, is more likely to become infected than a standard peripheral intravenous line. Infection may quickly lead to sepsis. At least every 4 to 6 hours, the insertion site should be inspected. It is not necessary to place the client in the semi-Fowler's position on his back at all times. It is advisable to encourage a client to cough and deep breathe, but this action does not relate to the subject of the question. It is not necessary to take the blood pressure hourly.

The nurse is assisting in caring for a client who is receiving morphine sulfate by continuous intravenous infusion. The nurse ensures that which medication is readily available if a morphine overdose occurs?

Nalmefene Rationale: Nalmefene is a long-acting antagonist that is used to treat opioid overdose. Naloxone is also used to treat opioid overdose. Atropine sulfate is an anticholinergic used in the treatment of cholinergic crisis. Protamine sulfate is the antidote for heparin therapy, and promethazine is an antiemetic.

A client is admitted to the emergency department with a diagnosis of drug-induced anxiety related to over ingestion of his prescribed antipsychotic medication. Which important piece of information should the nurse obtain initially?

Name of the ingested medication and the amount ingested Rationale: The name and the amount of medication ingested are of utmost importance in treating this potentially life-threatening situation. The relatives and the reason for the suicide attempt are not the most important initial data. The length of time on the medication and symptom control are also not priorities in this situation. In an emergency, lifesaving facts are obtained first.

A licensed practical nurse (LPN) assisting a registered nurse in the cardiac care unit (CCU) prepares to admit a client with a diagnosis of myocardial infarction (MI). The LPN should be certain to have which item(s) readily available on the unit when the client arrives by stretcher?

Oxygen cannula and flowmeter Rationale: The client will require oxygen therapy following MI to decrease pain because of ischemia and help minimize the risk of its recurrence. Oxygen decreases pain to the myocardium by improving oxygen supply. An electrocardiogram machine and bedside commode may be used but are not priorities at this time. An overhead trapeze could actually be harmful by causing the client to use the Valsalva maneuver while pulling up in bed.

The nurse is collecting data on a client who sustained circumferential burns of both legs. The nurse should check which first?

Peripheral pulses Rationale: The client who receives circumferential burns to the extremities is at risk for impaired peripheral circulation. The priority assessment should be to check for peripheral pulses to ensure that adequate circulation is present. Although the temperature, heart rate, and BP should also be assessed, the priority with a circumferential burn is the assessment for peripheral pulses.

A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 15:00. The nurse, making rounds at 15:45, finds that the client is complaining of a pounding headache, is dyspneic with chills, is apprehensive, and has an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action?

Shut off the infusion.

The nurse is assisting in admitting a client to the emergency department with suspected carbon monoxide poisoning. The nurse understands that which sign/symptom is least reliable for determining the oxygenation status of this client?

Skin color Rationale: Skin color is the least reliable sign for determining the oxygenation status of the client with carbon monoxide poisoning. Skin color may vary and range from pink to cherry red, or pale to cyanotic. Other signs that result from the lack of oxygen include dizziness, headache, muscular weakness, palpitations, and mental confusion, which can progress rapidly to coma.

A client who is receiving a blood transfusion pushes the call light for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. How should the nurse correctly interpret these findings?

Transfusion reaction Rationale: The signs and symptoms exhibited by the client are consistent with a transfusion reaction. With bacteremia, the client would have a fever, which is not part of the clinical picture presented. With fluid (circulatory) overload, the client would have crackles in addition to dyspnea. There is no correlation between the signs mentioned in the question and hypovolemic shock. The signs identified in the question are indicative of an allergic reaction, which is one type of blood transfusion reaction.

The nurse collecting data on a client during the second stage of labor notes a slowing of the fetal heart rate (FHR) with a loss of variability and determines that these are indicators of possible complications. Which priority interventions should the nurse perform?

Turn client to her side and administer oxygen by mask at 8 to 10 L/min. Rationale: Prompt treatment must be initiated when the FHR begins to slow or a loss of variability is identified during labor. To facilitate oxygenation of the mother and fetus, the mother is turned to her side to reduce uterine pressure on the ascending vena cava and descending aorta. The greater flow rate for oxygen is also indicated.

A licensed practical nurse (LPN) is a certified basic life support (BLS) instructor. The LPN is conducting a BLS recertification class and is discussing automated external defibrillation. A member of the class asks the LPN to identify the correct location for the placement of conductive gel pads to treat ventricular fibrillation. The LPN tells the class that the conductive gel pads are placed in which location on the client's chest?

Under the right clavicle and to the left of the precordium

The nurse has been instructed to remove an intravenous (IV) line. The nurse removes the catheter by withdrawing the catheter while applying pressure to the site with which item?

Sterile 2 × 2 gauze Rationale: A dry, sterile dressing such as sterile 2 × 2 gauze is used to apply pressure to the site while the catheter is discontinued and removed. This material is absorbent, sterile, and nonirritating to the site. A Band-Aid may be used to cover the site after hemostasis has occurred. An alcohol swab or Betadine would irritate the opened puncture site and would not stop the blood flow.

The nurse is working in the primary care office and is conducting an interview with the parents of a child. The parents of the child state that they would like some syrup of ipecac for use at home in case of an accidental poisoning. The nurse provides which appropriate instruction specific to the use of this medication?

"Ipecac syrup is not for home use and is administered only under medical supervision." Rationale: In the event of an accidental poisoning, the parents are instructed to immediately contact the poison control center. Syrup of ipecac is a medication that may be prescribed for the induction of emesis. It is indicated following ingestion of some poisons. It is contraindicated following ingestion of strong acids or bases and for clients who are comatose, delirious, or experiencing convulsions. It is not recommended for home use but may be prescribed in a hospital setting under medical supervision.

A client has had extensive surgery on the gastrointestinal tract and has been started on total parenteral nutrition (TPN). The client tells the nurse, "I think I'm going crazy. I feel like I'm starving, and yet that bag is supposed to be feeding me." Which is the best response from the nurse?

"That is because the empty stomach sends signals to the brain to stimulate hunger." Rationale: The stomach does send signals to the brain when it is empty to stimulate hunger. The client should be told that this is normal. Some clients also experience food cravings for the same reason. Options 1 and 4 will block the communication process. Option 2 will produce fear in the client.

The nurse determines that a student in a basic cardiac life support (BCLS) course correctly performs cardiopulmonary resuscitation (CPR) on an infant when the nurse observes which rate of chest compressions delivered to the infant mannequin?

100 times per minute Rationale: In an infant, the rate of chest compressions is at least 100 per minute. All other options are incorrect rates of compression based on current recommendations.

A client is brought to the emergency department following a smoke inhalation injury. The initial nursing action is to prepare the client to receive which treatment?

100% humidified oxygen by face mask Rationale: If the client sustains a smoke inhalation injury, the client is treated immediately with 100% humidified oxygen delivered by face mask. Oxygen via nasal cannula will not provide adequate oxygenation. Endotracheal intubation is needed if the client exhibits respiratory stridor, which then indicates airway obstruction. Pain management is necessary but is not the initial concern.

The client arrives at the emergency department after a burn injury that occurred in their home basement and an inhalation injury is suspected. Which should the nurse anticipate as being prescribed for the client?

100% oxygen via a tight-fitting, nonrebreather face mask Rationale: If an inhalation injury is suspected, the administration of 100% oxygen via a tight-fitting, nonrebreather face mask is prescribed until the carboxyhemoglobin level falls below 15%. With inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation is also determined. Options 1, 2, and 3 are incorrect.

One unit of packed red blood cells is infusing into a client over a 4-hour period. The unit of blood contains 250 mL. The drop factor is 15 drops (gtt) per 1 mL. The nurse determines that the flow rate should be set at how many drops per minute? Fill in the blank and round answer to the nearest whole number.

15.625 or 16 gtt/min Rationale: Total volume × gtt factor ------------------------- = gtt/min Time in minutes 250 mL × 15 gtt 3750 ------------------ = ---- 240 (4 hr × 60 min) 240 = 15.625 or 16 gtt/min

The nurse is checking the date of an intravenous (IV) insertion in a client. The insertion date on the dressing is 2/9 (February 9). The nurse calculates that the site should be changed on which date?

2/12 Rationale: The IV site should be changed very 72 to 96 hours based on the Center for Disease Control guidelines. With an insertion date of 2/9, the due date for change should be 2/12. Changing the IV site every 5 to 7 days would place the client at risk for site infection.

Several clients arrive simultaneously at the emergency department after sustaining burn injuries in a house fire. Which client will require the closest observation for signs of respiratory distress?

A client who has singed nasal hairs and worsening hoarseness Rationale: Singed nasal hairs and hoarseness indicate possible inhalation injury, which can result in respiratory distress. The other options present symptoms that are on the chest area; these do not necessarily indicate that respiratory distress will result.

Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action?

Administer oxygen, 8 to 10 L/minute, via face mask. Rationale: Oxygen is administered, 8 to 10 L/minute, via face mask to optimize oxygenation of the circulating blood. Option 1 is incorrect because the intravenous infusion should be increased (per health care provider prescription) to increase the maternal blood volume. Option 2 is incorrect because oxytocin.

A client in the postpartum unit complains of sudden, sharp chest pain. The client is tachycardic and the respiratory rate is increased, and the primary health care provider diagnoses a pulmonary embolism. Which interventions apply to the care of this client? Select all that apply.

Administer oxygen. Monitor the blood pressure. Prepare to administer morphine sulfate. Prepare to start an intravenous (IV) line.

The nurse notes that a client who is attached to a cardiac monitor suddenly develops atrial fibrillation at a rate of 130 beats per minute. The nurse immediately notifies the registered nurse and prepares the client for which initial intervention?

Administration of a calcium channel blocker Rationale: The initial treatment goal when atrial fibrillation suddenly occurs is to control the rate of impulses with the administration of a calcium channel blocker or a beta blocker. Defibrillation is indicated when a client is in pulseless ventricular tachycardia or ventricular fibrillation. Electrical cardioversion is an option for atrial fibrillation if the client is clinically unstable or if the client has not responded to chemical cardioversion after a 6-week period of anticoagulant therapy. Anticoagulant therapy, for example, with a continuous heparin infusion, is indicated to prevent development of thrombus formation in the atria but is not the priority over rate control.

A client with myasthenia gravis is receiving pyridostigmine. The nurse monitors for signs and symptoms of cholinergic crisis caused by overdose of the medication. The nurse checks the medication supply to ensure that which medication is available for administration if a cholinergic crisis occurs?

Atropine sulfate Rationale: The antidote for cholinergic crisis is atropine sulfate. Vitamin K is the antidote for warfarin. Protamine sulfate is the antidote for heparin, and acetylcysteine is the antidote for acetaminophen.

When assisting in the identification process required before a blood transfusion, which action will the nurse take when it is noted that all of the necessary information is correct, except for the client's name?

Call the blood bank about the discrepancy. Rationale: The nurse would notify the registered nurse of the discrepancy. Then should call the blood bank and notify the personnel about the discrepancy per the registered nurse's guidance. The unit should not be hung, and information on the requisition or bag should not be altered in any way. The nurse assigned to the client may choose to call the primary health care provider, but the nature of that communication would be to report a delay in the transfusion because of the problem, not to report that there would be no transfusion.

A mother calls a neighborhood nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. Which action should the nurse instruct the mother to take first?

Call the poison control center. Rationale: If a suspected poisoning occurs, the poison control center should be contacted immediately. The nurse can assist the mother with contacting the poison control center. Vomiting should not be induced without instructions from the poison control center. Inducing vomiting is not done if the client is unconscious or the substance ingested is a strong corrosive or petroleum product. Bringing the child to the emergency department or calling an ambulance would delay treatment. The poison control center may advise the mother to bring the child to the emergency department; if this is the case, the mother should call an ambulance.

The nurse is assisting with caring for a client who is receiving a unit of packed red blood cells (PRBCs). The nurse should tell the client that it is most important to report which sign(s) immediately?

Chills, itching, or rash Rationale: The client is told to report chills, itching, or rash immediately, because these could be signs of a possible transfusion reaction. Mild discomfort at the catheter site may be indicative of a problem, or it could result from the size of the IV catheter required to infuse the blood product. Sore throat, earache, sleepiness, and fatigue are unrelated to a transfusion reaction.

The nurse is performing a vaginal check of a pregnant client in labor. The nurse notes that the umbilical cord is protruding from the vagina. Which action should the nurse immediately perform?

Exert upward pressure against the presenting part with gloved fingers. Rationale: If the umbilical cord is protruding from the vagina, no attempt should be made to replace it because to do so could traumatize it and further reduce blood flow. The nurse should place a gloved hand into the vagina toward the cervix and exert upward pressure against the presenting part to relieve compression of the cord. The nurse also should wrap the cord loosely in a sterile towel saturated with warm, sterile normal saline solution. Oxygen, 8 to 10 L/minute by face mask, is administered to the mother to increase fetal oxygenation, and the client is prepared for immediate delivery. However, the immediate action is to relieve pressure on the cord. The client would already have an external fetal monitor in place.

Skin breakdown occurs on a client's hand at the site of an intravenous catheter that had medication infusing. The nurse determines that which adverse effect occurred? Refer to figure.

Extravasation Rationale: Extravasation refers to the tissue injury that occurs from leakage of medication into surrounding skin and subcutaneous tissue; it can also cause tissue necrosis. Phlebitis is an inflammation of the vein that can occur from mechanical or chemical (medication) trauma or from a local infection. Phlebitis can cause the development of a clot (thrombophlebitis). Infiltration is seepage of the intravenous fluid out of the vein and into the surrounding interstitial spaces. It is a form of tissue injury, but the injury is not to the extent that occurs with extravasation.

The nurse is assigned to care for a client who has experienced uterine rupture. The nurse plans care knowing that which is the priority concern in caring for the client?

Impaired gas exchange Rationale: The priority should always deal with airway. Although options 1, 2, and 3 are also appropriate concerns for this client, they are not the priority and assume a lesser priority than impaired gas exchange.

During the emergent phase of a client with severe burns the nurse expects to perform which action?

Insert a Foley catheter. Rationale: In the emergent phase of severe burns, a Foley catheter is inserted to monitor hourly urine output and provide data to determine whether fluid resuscitation is adequate. The minimum acceptable urine flow for an adult is 30 mL/hr. The other options would not be implemented in the emergent phase.

A child is admitted to the burn unit with partial- and full-thickness burns over 35% of the body. The nurse assisting in caring for the child develops the plan of care. Which nursing intervention is the priority?

Inserting a Foley catheter Rationale: A Foley catheter is inserted into the child's bladder so that urine output can be accurately measured hourly. Although pain medication may be required, the child should not be sedated. IV fluids are not restricted and are administered at a rate sufficient to maintain adequate tissue perfusion.

The nurse is monitoring a client receiving a blood transfusion for circulatory overload. The nurse understands that which is a clinical indication of circulatory overload?

Moist, productive cough Rationale: Chest or lumbar pain, cyanosis, dyspnea, moist productive cough, crackles in the lung bases, distended neck veins, and an increase in blood pressure are clinical indications of circulatory overload caused by excessive infusion amounts or too rapid an infusion rate. All other options are incorrect.

A woman in active labor has contractions every 2 to 3 minutes that last for 45 seconds. The fetal heart rate between contractions is 100 beats per minute. On the basis of these findings which is the priority nursing action?

Notify the registered nurse (RN) immediately. Rationale: Fetal bradycardia between contractions may indicate the need for immediate medical management. The nurse should immediately contact the RN, who then contacts the health care provider. Monitoring maternal vital signs, labor progress, and encouraging relaxation and breathing techniques will delay necessary and immediate interventions.

The nurse has administered a dose of salmeterol to a client. Following administration, the client develops a generalized rash and urticaria and the eyelids begin to swell. Which action should the nurse take?

Notify the registered nurse immediately. Rationale: Hypersensitivity reaction can occur in clients taking ephedrine, epinephrine, isoproterenol, or salmeterol. Signs and symptoms include rash, urticaria, and swelling of the face, lips, or eyelids. The nurse would notify the registered nurse immediately, who would then contact the primary health care provider. The other options are incorrect.

The nurse is checking the insertion site of a peripheral intravenous (IV) catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is likely the result of which?

Phlebitis of the vein Rationale: Phlebitis at an IV site results in discomfort at the site and redness, warmth, and swelling proximal to the IV catheter. The IV catheter should be removed, and a new IV line should be inserted at a different site. The remaining options are incorrect; the signs and symptoms in the question are not associated with these conditions.

The nurse is assisting in caring for a client admitted to the emergency department with diabetic ketoacidosis. The nurse anticipates that the primary health care provider will prescribe which type of insulin for intravenous administration to treat this disorder?

Regular Rationale: Regular insulin is a short-acting insulin and can be administered by the intravenous route. Lantus is a long-acting insulin. Humulin N and isophane insulin NPH injection are intermediate-acting insulin.

A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client?

Remain with the client until the anxiety decreases. Rationale: This client is in a severe state of anxiety. When a client is in a severe or panic state of anxiety, it is crucial for the nurse to remain with the client. The client in a severe state of anxiety would be unable to learn relaxation techniques. Discussing the assault at this point would increase the client's level of anxiety further. Placing the client in a quiet room alone may also increase the anxiety level.

A client rings the call light and complains of pain at the site of an intravenous (IV) infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which actions in the care of this client? Select all that apply.

Remove the IV catheter at that site. Apply warm moist packs to the site. Notify the primary health care provider (PHCP). Document the occurrence, actions taken, and the client's response.

The nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. Which is the most appropriate action?

Remove the IV. Rationale: Blanching, coolness, and edema of the IV site are signs of infiltration. Because infiltration can be damaging to the surrounding tissue, the most appropriate action is to remove the IV to prevent any further damage. The nurse should not depend solely on the blood return for assurance that the cannula is in the vein because a blood return may be present even if the cannula is only partially in the vein. Warm compresses may be applied to the infiltrated area only after the IV is removed and only if the infiltrated solution is not damaging to the surrounding tissues. Measuring the area of infiltration should only be done after the IV has been removed so that further tissue damage is assessed.

The nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. Based on these findings, the nurse plans to take which initial nursing action?

Remove the IV. Rationale: Phlebitis at an IV site can be determined by client discomfort at the site, as well as by redness, warmth, and swelling proximal to the catheter. The line should be removed, and a new line should be inserted at a different site. Options 2 and 4 are incorrect. The primary health care provider should be notified if phlebitis occurred, but this is not the initial action.

The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100° F (37.7° C) orally. The nurse reports the finding to the registered nurse (RN) and anticipates that which action will take place?

The blood will be held, and the primary health care provider (PHCP) will be notified. Rationale: If the client has a temperature of 100° F (37.7° C) or more, the unit of blood should be held until the primary health care provider (PHCP) is notified and has the opportunity to give further prescriptions. The other options are incorrect actions.

The nurse is assisting with caring for a client who is receiving intravenous fluids and who has sustained full-thickness burn injuries of the back and legs. The nurse understands that which would provide the most reliable indicator for determining the adequacy of the fluid resuscitation?

Urine output Rationale: Successful or adequate fluid resuscitation in the adult is signaled by stable vital signs, adequate urine output, palpable peripheral pulses, and a clear sensorium. The most reliable indicator for determining the adequacy of fluid resuscitation is the urine output. For an adult, the hourly urine volume should be 30 mL to 50 mL.

The nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The client suddenly complains of chest pain and dyspnea. The nurse should initially check which item?

Vital signs Rationale: Pulmonary embolism is a complication of thrombophlebitis. Changes in the vital signs are one of the first things to occur with pulmonary embolism, because pulmonary blood flow is compromised. Fundal height is unrelated to the information in the question. Calf pain is an indicator of thrombophlebitis. Level of consciousness may change as the condition worsens; worsening would indicate hypoxia.

The nurse employed in the emergency department is preparing to administer syrup of ipecac to a 7-month-old child. The nurse prepares 5 mL of the syrup and administers one half glass of water following administration of the ipecac syrup. Which response should the nurse expect?

Vomiting Rationale: Syrup of ipecac is a medication that may be prescribed for the induction of emesis. It is indicated following ingestion of some poisons. It is contraindicated following ingestion of strong acids or bases and for clients who are comatose, delirious, or experiencing convulsions. It is not recommended for home use but may be prescribed in a hospital setting under supervision. The dose for children younger than 1 year of age is 5 to 10 mL followed by one half to one glass of water. Diarrhea or sedation may occur as side effects of the medication. Blood pressure is not related to the administration of this medication.

The nurse is caring for a client in labor. The nurse notes the presence of fetal bradycardia on the fetal monitor and suspects that the umbilical cord is compressed. The nurse should immediately place the client in which position?

With the hips elevated Rationale: When cord compression is suspected, the woman is immediately repositioned. The client may be turned from side to side or the hips elevated to shift the fetal presenting part toward her diaphragm, thus relieving cord compression. A hand-and-knees position may also reduce compression on the cord that is entrapped behind the fetus. Several position changes may be required before the fetal pattern improves or resolves. Options 1, 2, and 3 are inappropriate positions and may cause further cord compression.

Following surgical removal of a brain tumor, the primary health care provider writes a prescription to maintain the child in a semi-Fowler's position. In the postoperative period, the nurse is monitoring the child and notes that the child is restless, the pulse rate is elevated, and the blood pressure has dropped significantly from the baseline value. The nurse suspects that the child is in shock. Which nursing action would be appropriate?

Notify the registered nurse. Rationale: The child is never placed in the Trendelenburg's position because it increases intracranial pressure (ICP) and the risk of bleeding. In the event of shock, the registered nurse is notified, who immediately notifies the primary health care provider. Elevating the heads of the bed may worsen the shock state. Increasing IV fluids can cause an increase in ICP and should not be done without a primary health care provider's prescription.

The nurse is assisting in caring for a victim of a burn injury during the emergent/resuscitative phase. On data collection of the client, the nurse notes that the urine output has decreased and the blood pressure is dropping. The nurse should perform which immediate action?

Notify the registered nurse. Rationale: The nurse notifies the registered nurse, who will then notify the primary health care provider immediately if the burn client exhibits a decreased urine output or blood pressure or an increased pulse rate. Because of the rapid fluid shifts that occur in burn shock, fluid deficit must be detected early so that distributive shock does not occur. The nurse does not increase an IV rate without a specific prescription to do so. Checking the client in 30 minutes will delay necessary interventions to prevent the development of distributive shock. A warm environment is maintained, but this is not the immediate action.

The nurse is caring for a client who had a tracheostomy tube inserted 1 week ago. The client begins to cough vigorously, and accidental decannulation of the tracheostomy tube occurs. Which action should be the nurse's immediate response?

Replace the tracheostomy tube. Rationale: If decannulation of a tracheostomy tube occurs 72 hours after surgical placement of the tracheostomy, the nurse prepares to replace the tube. The nurse also calls the registered nurse for help immediately. The nurse extends the client's neck and opens the tissues of the stoma to secure an airway. With the obturator inserted into the new tracheostomy tube, the nurse quickly and gently replaces the tube and immediately removes the obturator. The nurse checks for airflow through the tube and for bilateral breath sounds. If unable to secure the airway, the nurse notifies the respiratory therapist and attempts to ventilate the client with a bag-valve mask (resuscitation bag) while waiting for help. If the client is in distress and further attempts to secure the airway fail, the nurse calls the resuscitation team, including an anesthesiologist, for assistance and calls a code if necessary.

The nurse is caring for a client on a cardiac monitor who is alone in a room at the end of the hall. The client has a short burst of ventricular tachycardia (VT), followed by ventricular fibrillation (VF). The client suddenly loses consciousness. Which intervention should the nurse do first?

Call for help and initiate cardiopulmonary resuscitation (CPR). Rationale: When ventricular fibrillation occurs, the nurse remains with the client and initiates CPR until a defibrillator is available and attached to the client.

A child is brought to the emergency room and the mother reports that the child accidentally swallowed paint thinner after mistaking it for water. The nurse should perform which action first?

Check the circulation, airway, and breathing status of the child. Rationale: A,B,C's of nursing. Actions to take in the case of a child swallowing poison include assessing the child and treating the child first, not the poison. Circulation, airway and breathing, and vital signs need to be assessed. Resuscitation measures would be initiated if the assessment indicates a need. The next step is to terminate exposure to the poison, such as emptying the mouth of pills or other materials or flushing the skin with water. Then identify the poison, if possible, and take measures to prevent absorption of the poison, such as administering the antidote if known. Transport the child to an emergency department for further treatment.

The nurse assisting in caring for a client with a myocardial infarction is monitoring for cardiogenic shock. The nurse should monitor for which peripheral vascular symptoms?

Cool, clammy skin with either weak or thready pedal pulses Rationale: Classic signs of cardiogenic shock include increased pulse (weak and thready); decreased blood pressure; decreased urine output; signs of cerebral ischemia (confusion, agitation); and cool, clammy skin.

A client presents to the emergency department with upper gastrointestinal (GI) bleeding and is in moderate distress. Which nursing action should be the priority for this client?

Determine vital signs. Rationale: The determination of vital signs indicates whether the client is in shock from blood loss and provides a baseline blood pressure and pulse by which to monitor the progress of treatment. Signs and symptoms of shock include low blood pressure; rapid, weak pulse; increased thirst; cold, clammy skin; and restlessness. Vital signs and level of consciousness should be monitored at least every 15 to 30 minutes for signs of hemodynamic compromise, and the primary health care provider should be informed of any significant changes. The client may not be able to provide subjective data until the immediate physical needs are met. Although completing an abdominal assessment and inserting a nasogastric tube and testing the emesis for the presence of blood may be components of care, they are not the priorities.

The nurse is assisting in monitoring the condition of a client after pericardiocentesis for cardiac tamponade. Which observation indicates that the procedure was unsuccessful?

Distant and muffled heart sounds Rationale: Following pericardiocentesis, the client usually expresses immediate relief. Heart sounds are no longer muffled or distant. Clear breath sounds and clearly audible heart sounds are positive signs.

A mother of a 6-year-old child calls the nurse who lives in the neighborhood and tells the nurse that her child accidentally rubbed waterproof sunscreen in his eyes. Which action should the nurse tell the mother to immediately perform?

Call the poison control center. Rationale: Waterproof sunscreen should never be placed near the eyes. Waterproof sunscreen causes severe pain and a chemical burn that can damage the child's vision. Flushing the eyes with water does not stop the burning. The mother should be instructed to call the poison control center and to take the child to the emergency department. Special chemicals will be needed to flush the sunscreen out of the eyes and preserve vision. Wiping the eyes will increase the pain and burning. Blinking will not alleviate the pain or remove the sunscreen from the eyes.

The nurse checks the peripheral intravenous (IV) site dressing and notes that it is damp and that the tape is loose. Which is the first action by the nurse?

Check that the tubing is securely attached. Rationale: If there is leakage at the IV site, the nurse should first locate the source. The nurse should assess the site further to be certain that all connections are secure. The nurse should not increase the IV flow rate. Although it is true that it may leak more, it may also cause more tissue damage if the IV were infiltrating. Information about the IV must first be gathered so that the cause of the leaking can be determined before interventions can be planned.

A client has been receiving parenteral nutrition at 125 mL/hr for 5 days. On data collection, the LPN notes bilateral crackles and 2+ pedal edema and that the client has gained 3 pounds in 5 days. Which would be appropriate as the initial nursing action?

Notify the registered nurse of the findings. Rationale: The client is showing signs of fluid retention and possible excess fluid intake. Crackles, edema, and weight gain signify fluid shifts from intravascular spaces to the interstitial spaces. The problem may or may not be related to the parenteral nutrition. Other possible causes of fluid retention include impaired respiratory and cardiovascular function, impaired kidney function, or a combination of factors. The nurse needs to notify the registered nurse of the findings. The registered nurse will then notify the primary health care provider for further prescriptions. Option 2 will have little, if any, effect on peripheral edema and weight gain. Option 3 infers that a diuretic will help the situation, and it is possible that the primary health care provider will prescribe a diuretic; however, the primary health care provider needs to be aware of the change in the physical condition of the client. The nurse should not increase or decrease the rate of parenteral nutrition infusions without a primary health care provider's prescription to do so.

A mother of a 9-year-old child calls the emergency department and tells the nurse that her child received a minor burn on the hand after accidentally touching a grill during a family cookout. The mother asks the nurse for advice on how to treat the burn. Which action should the nurse tell the mother to immediately perform?

Place the child's hand under cool running water. Rationale: Most minor burns can be handled at home by the parents. For minor burns, exposure to cool running water is the best treatment. This stops the burning process and helps alleviate pain. Ice is contraindicated because it may add more damage to already injured skin. Option 4 is an incorrect measure. In addition, the mother may not have a sterile dressing available.

The nurse is preparing for the intershift report when a nurse's aide pulls an emergency call light in a client's room. On answering the light, the nurse finds a client experiencing tachycardia and tachypnea. The client's blood pressure is 88/60 mm Hg. Which action should the nurse take first?

Place the client in modified Trendelenburg's position. Rationale: The client is exhibiting signs of shock and requires emergency intervention. Placing the client in the modified Trendelenburg's position increases blood return from the legs, which increases venous return and subsequently the blood pressure. The nurse can then verify the client's blood volume status by assessing the urine output and ensuring that the IV is infusing without complications. The nurse should also check the client's pulse oximetry and notify the registered nurse.