critical thinking

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

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?"

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

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

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

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

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

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

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.

Initiate breathing Open the client's airway. Determine unconsciousness by shaking the client and asking, "Are you OK?" Perform chest compressions.

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.

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

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.

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

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

Remove the IV.

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

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

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

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.

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

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

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

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

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."

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

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

Administer oxygen by face mask, as prescribed.

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

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).

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.

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.

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.

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

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.

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.

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

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

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

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

Insert a Foley catheter.

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.

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.

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.

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.

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.

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.

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.

1

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

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

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.10

16

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

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

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

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

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

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.

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.

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.

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

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.

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

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.

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.

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

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

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

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.

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

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

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

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

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

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.

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.

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.

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

Resume cardiopulmonary resuscitation (CPR)

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

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

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.

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.

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

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