Evolve Questions- Exam II
The nurse administers amiodarone (Cordarone) to a patient with ventricular tachycardia. Which monitoring by the nurse is necessary with this drug? Respiratory rate QT interval Heart rate Heart rhythm Urine output
QT interval Heart rate Heart rhythm
A newly admitted client has deep partial-thickness burns. The nurse expects to see which clinical manifestations? Red and white wounds with mild pain to palpation Painless, brownish yellow eschar Painful reddened blisters Black skin with eschar and no pain
Red and white wounds with mild pain to palpation
The nurse is caring for a client with a burn injury who is receiving silver sulfadiazine (Silvadene) to the burn wounds. Which best describes the goal of topical antimicrobials? Reduction of bacterial growth in the wound and prevention of systemic sepsis Prevention of cross-contamination from other clients in the unit Enhanced cell growth Reduced need for a skin graft
Reduction of bacterial growth in the wound and prevention of systemic sepsis
When caring for a client with a pulmonary embolism, which priority intervention will the nurse use to reduce anxiety? Remain with the client and provide oxygen in a calm manner. Have the client breathe into a brown paper bag using pursed lips. Offer the client a mild sedative. Allow a family member to remain in the room.
Remain with the client and provide oxygen in a calm manner.
Which assessment is the nurse's highest priority in caring for a client in the acute phase of burn injury? Bowel sounds Muscle strength Signs of infection Urine output
Signs of infection
Which teaching is essential for a patient who has had a permanent pacemaker inserted? Avoid talking on a cell phone. Avoid operating electrical appliances over the pacemaker. Avoid sexual activity. Do not take tub baths.
Avoid operating electrical appliances over the pacemaker.
The nurse is caring for a client who developed GI bleeding 3 weeks after a diagnosis of pulmonary embolism (PE). The international normalized ratio (INR) is 6.9. Which one of these questions is most appropriate for the nurse to ask at this time? "Have you eaten a lot of green leafy vegetables?" "Have you experienced swelling of your legs?" "Were you massaging your calves?" "Have you taken any aspirin or salicylates?"
"Have you taken any aspirin or salicylates?"
The nurse is caring for a client who has burns. Which question does the nurse ask the client and family to best assess their coping strategies? "Do you support each other?" "How do you plan to manage this situation?" "How have you handled similar situations?" "Would you like to see a counselor?"
"How have you handled similar situations?"
The nurse is caring for a client who has burns to the face. Which statement by the client requires further evaluation by the nurse? "I am getting used to looking at myself." "I don't know what I will do when people stare at me." "I know that I will never look the way I used to, even after the scars heal." "My spouse does not stare at the scars as much now as in the beginning."
"I don't know what I will do when people stare at me."
As a direct result of overcrowding in emergency departments (ED), for whom must the emergency department nurse expect to provide care? A variety of age groups and cultures "Boarding" or holding inpatient clients Clients with a broad spectrum of issues, illnesses, and injuries Uninsured and underinsured clients
"Boarding" or holding inpatient clients
A client with a burn injury due to a house fire is admitted to the burn unit. The client's family asks the nurse why the client received a tetanus toxoid injection on admission. What is the nurse's best response to the client's family member? "The last tetanus injection was less than 5 years ago." "Burn wound conditions promote the growth of Clostridium tetani." "The wood in the fire had many nails, which penetrated the skin." "The injection was prescribed to prevent infection from Pseudomonas."
"Burn wound conditions promote the growth of Clostridium tetani."
When teaching fire safety to parents at a school function, which advice does the school nurse offer about the placement of smoke and carbon monoxide detectors? "Every bedroom should have a separate smoke detector." "Every room in the house should have a smoke detector." "If you have a smoke detector, you don't need a carbon monoxide detector." "The kitchen and the bedrooms are the only rooms that need smoke detectors."
"Every bedroom should have a separate smoke detector."
The nurse is teaching a patient with a new permanent pacemaker. Which statement by the patient indicates a need for further discharge education? "I will be able to shower again soon." "I need to take my pulse every day." "I might trigger airport security metal detectors." "I no longer need my heart pills."
"I no longer need my heart pills."
The nurse is providing education about the management of respiratory failure to the family of a client who is receiving mechanical ventilation. Which statement reflects appropriate information that the nurse will communicate? "Sedation is needed so your loved one does not rip the breathing tube out." "Suctioning is important to remove organisms from the lower airway." "Paralytics and sedatives help decrease the demand for oxygen." "We are encouraging oral and IV fluids to keep your loved one hydrated."
"Paralytics and sedatives help decrease the demand for oxygen."
What teaching does the nurse include for a patient with atrial fibrillation who has a new prescription for warfarin? "It is important to consume a diet high in green leafy vegetables." "You would take aspirin or ibuprofen for headache." "Report nosebleeds to your provider immediately." "Avoid caffeinated beverages."
"Report nosebleeds to your provider immediately."
A client who was the sole survivor of a house fire says, "I feel so guilty. Why did I survive?" What is the best response by the nurse? "Do you want to pray about it?" "I know, and you will have to learn to adapt to a new body image." "Tell me more." "There must be a reason."
"Tell me more."
The nurse is overseeing a nursing student who is administering medications to a group of clients receiving treatment for pulmonary embolism. The nurse recognizes the student understands safety and administration of anticoagulant therapy when the student makes which of these statements? "The client will receive a dose of enoxaparin (Lovenox) intramuscularly for 3 days." "Therapy with warfarin (Coumadin) is effective when the INR is between 2 and 3." "Once the health care provider orders warfarin (Coumadin), the intravenous heparin can be discontinued." "If bleeding develops, we will give platelets to reverse the anticoagulant."
"Therapy with warfarin (Coumadin) is effective when the INR is between 2 and 3."
In teaching patients at risk for bradydysrhythmias, what information does the nurse include? "Avoid potassium-containing foods." "Stop smoking and avoid caffeine." "Take nitroglycerin for a slow heartbeat." "Use a stool softener."
"Use a stool softener."
After losing her home to a hurricane several years ago, the client says, "I get very nervous during a thunderstorm and want to hide under the bed." What is the nurse's best response? "But it's just a thunderstorm. You would have warning if a hurricane was approaching." "I understand. That is normal and is nothing to worry about." "That is post-traumatic stress disorder (PTSD). You might want to see a counselor." "What do you do when you feel this way?"
"What do you do when you feel this way?"
A client was intubated 30 minutes ago for acute respiratory distress syndrome (ARDS) and possible sepsis. The following prescriptions have been given for the client. In what sequence will the nurse perform these actions? 1. Infuse levofloxacin (Levaquin) 500 mg IV. 2. Obtain baseline aerobic and anaerobic sputum cultures. 3. Teach the client and family methods of communicating. 4. Analyze post-intubation arterial blood gases (ABGs). 2, 1, 3, 4 4, 3, 1, 2 3, 4, 2, 1 4, 2, 1, 3
4, 2, 1, 3
Which waveform indicates proper function of the sinoatrial (SA) node? The QRS complex is present. The PR interval is 0.24 second. A P wave precedes every QRS complex. The ST segment is elevated.
A P wave precedes every QRS complex.
When receiving report on a group of clients on the step down unit, which client needs immediate attention by the nurse? A client who is receiving continuous positive airway pressure (CPAP) and has intermittent wheezing A client receiving mechanical ventilation who has tracheal deviation A client who was recently extubated and is reporting a sore throat A client who is receiving O2 by facemask and whose respiratory rate is 24 breaths/min
A client receiving mechanical ventilation who has tracheal deviation
The nurse is caring for a group of clients on a medical surgical unit. For which of these individuals does the nurse provide immediate interventions to reduce the risk for pulmonary embolism (PE)? A client with diabetes and cellulitis of the leg A client receiving IV fluids through a peripheral line A client returning from an open reduction and internal fixation of the tibia A client with fluid volume deficit and hypokalemia receiving potassium supplements
A client returning from an open reduction and internal fixation of the tibia
The nurse is caring for a group of clients on a Telemetry unit. When providing client education, which client will the nurse determine most needs information regarding preventing pulmonary embolism (PE)? A woman who frequently flies to Europe A man who works on a farm A man admitted for a myocardial infarction A woman with a bleeding disorder
A woman who frequently flies to Europe
The triage nurse has a suggestion for improving response in the next mass casualty event. Which option does the nurse use to introduce this idea? Administrative review Hospital suggestion box Medical Reserve Corp Supervisor
Administrative review
A patient with atrial fibrillation (AF) with rapid ventricular response has received medication to slow the ventricular rate. The pulse is now 88 beats/min. For which additional therapy does the nurse plan? Synchronized cardioversion Electrophysiology studies (EPS) Anticoagulation Radiofrequency ablation therapy
Anticoagulation
The nurse is reviewing the medical record of a client with pulmonary embolism (PE). What priority does the nurse set after reviewing the blood gas result below? pH 7.46, PaCO2 30 mm Hg, HCO3- 26 mEq/L (26 mmol/L), PaO2 62 mm Hg Have the client breathe rapidly and deeply Apply oxygen Administer sodium bicarbonate Collaborate with the provider to increase the pH
Apply oxygen
A client in the intensive care unit (ICU) who is receiving mechanical ventilation begins to pick at the bedcovers. Which action will the nurse take next? Increase the sedation. Assess for adequate oxygenation. Explain that the tube in the client's throat helps with breathing. Request that the family leave to decrease the client's agitation.
Assess for adequate oxygenation.
The nurse coming on shift prepares to perform an initial assessment of a client receiving sedation and mechanical ventilation through a tracheostomy. Which are priorities for the nurse to carry out? Ask visitors to leave the room. Assess the client's color and respirations. Confirm alarms and ventilator settings. Ensure that the tube is in proper position. Auscultate for bilateral breath sounds. Provide routine tracheostomy and mouth care.
Assess the client's color and respirations. Confirm alarms and ventilator settings. Ensure that the tube is in proper position. Auscultate for bilateral breath sounds.
How does the high school nurse react directly after a random shooting at a high school after injuries are taken care of? Actively listens to students Assesses his or her own individual feelings Encourages students to vent feelings Facilitates community cohesion
Assesses his or her own individual feelings
A client comes into the emergency department (ED) clutching the chest. Which core competency for ED nurses is the first one used in this situation? Assessment Communication Priority setting Technical and procedural skills
Assessment
Which risk factors are known to contribute to atrial fibrillation? Use of beta-adrenergic blockers Excessive alcohol use Advancing age High blood pressure Palpitations
Excessive alcohol use Advancing age High blood pressure
A client with partial-thickness burns of the face and chest caused by a campfire is admitted to the burn unit. The nurse plans to carry out which health care provider request first? Give oxygen per facemask. Infuse lactated Ringer's solution at 150 mL/hr. Give morphine sulfate 4 to 10 mg IV for pain control. Insert a 14 Fr retention catheter.
Give oxygen per facemask.
The nurse is caring for a patient who has developed a bradycardia. Which possible causes does the nurse investigate? Bearing down for a bowel movement Possible inferior wall myocardial infarction (MI) Patient stating that he just had a cup of coffee Patient becoming emotional when visitors arrived Diltiazem (Cardizem) administered 1 hour ago
Bearing down for a bowel movement Possible inferior wall myocardial infarction (MI) Diltiazem (Cardizem) administered 1 hour ago
The nurse is caring for a client with impending respiratory failure who refuses intubation and mechanical ventilation. Which respiratory modality does the nurse suggest to the interdisciplinary team as an alternative to mechanical ventilation? Oropharyngeal airway Bi-level positive airway pressure (BiPAP) Non-rebreather mask with 100% oxygen Positive end-expiratory pressure (PEEP)
Bi-level positive airway pressure (BiPAP)
A patient admitted after using crack cocaine develops ventricular fibrillation. After determining unresponsiveness, which action does the nurse take next? Prepare for defibrillation. Establish IV access. Place an oral airway and ventilate. Start cardiopulmonary resuscitation (CPR).
Prepare for defibrillation.
A client with a gunshot wound is admitted to the emergency department (ED). Which minimum Standard Precaution activity does the nurse require for staff safety? Blood and body fluid precautions Metal detector screening of the client Placement of a security guard Use of a positive air-purifying respirator (PAPR)
Blood and body fluid precautions
Emergency Medical Services arrives at the scene of an automobile crash. On primary assessment, the driver is found to be unresponsive, not breathing, and has a grossly deformed left leg with no pulse. What is the first resuscitation intervention to be performed? Carry out artificial respirations. Clear the airway. Place a cervical collar. Realign the leg and check for pulse.
Clear the airway.
What is the best method to prevent autocontamination for a client with burns? Change gloves when handling wounds on different areas of the body. Ensure that the client is in isolation therapy. Restrict visitors. Use sterile gloves when changing dressings.
Change gloves when handling wounds on different areas of the body.
The nurse receives a report that a patient with a pacemaker has experienced loss of capture. Which situation is consistent with this? The pacemaker spike falls on the T wave. Pacemaker spikes are noted, but no P wave or QRS complex follows. The heart rate is 42 beats/min, and no pacemaker spikes are seen on the rhythm strip. The patient demonstrates hiccups.
Pacemaker spikes are noted, but no P wave or QRS complex follows.
The nurse is caring for a patient with unstable angina whose cardiac monitor shows ventricular tachycardia. Which action is appropriate to implement first? Defibrillate the patient at 200 joules. Check the patient for a pulse. Cardiovert the patient at 50 joules. Give the patient IV lidocaine.
Check the patient for a pulse.
The nurse is assessing a client who is receiving mechanical ventilation with positive end-expiratory pressure. Which findings would cause the nurse to suspect a left-sided tension pneumothorax? The left chest caves in on inspiration and "puffs out" on expiration. Chest asymmetry and jugular vein distention are present. The left lung field is dull to percussion with crackles present on auscultation. The client has bloody sputum and wheezes.
Chest asymmetry and jugular vein distention are present.
When delegating care for clients on the burn unit, which client does the charge nurse assign to an RN who has floated to the burn unit from the intensive care unit (ICU)? Burn unit client who is being discharged after 6 weeks and needs teaching about wound care Recently admitted client with a high-voltage electrical burn A client who has a 25% total body surface area (TBSA) burn injury, for whom daily wound débridement has been prescribed Client receiving IV lactated Ringer's solution at 150 mL/hr
Client receiving IV lactated Ringer's solution at 150 mL/hr
When caring for a group of clients at risk for or diagnosed with pulmonary embolism, the nurse calls the Rapid Response Team (RRT) for intervention for which client? Client treated for pulmonary embolism with IV heparin who has hemoptysis and tachycardia Client with deep vein thrombosis who is receiving low-molecular-weight heparin and has ongoing calf pain Client with a right pneumothorax who is being treated with a chest tube and has a pulse oximetry reading of 94% Client who was extubated 3 days ago and has decreased breath sounds at the posterior bases of both lungs
Client treated for pulmonary embolism with IV heparin who has hemoptysis and tachycardia
The emergency department charge nurse is making client assignments and delegating care after a mass casualty event. Which of these clients could be delegated to an unlicensed assistive personnel (UAP)? Client who has multiple left rib fractures and reports dyspnea Client who reports severe left anterior chest pain Client who has a femoral fracture with palpable distal pulses Client who is unconscious with massive aortic bleeding from the chest
Client who is unconscious with massive aortic bleeding from the chest
The nurse is caring for a group of clients on a medical surgical unit. Which clients will the nurse monitor closely for respiratory failure? Client with a brainstem tumor Client with acute pancreatitis Client with a C5 spinal cord injury Client using client-controlled analgesia Client experiencing cocaine intoxication
Client with a brainstem tumor Client with acute pancreatitis Client with a C5 spinal cord injury Client using client-controlled analgesia
The charge nurse in the intensive care unit is overseeing care for a group of clients. The nurse is especially vigilant in collaboration with the primary nurse and interprofessional team in assessing for acute respiratory distress syndrome (ARDS) in which of these clients? Client with diabetic ketoacidosis (DKA) Client with atrial fibrillation Client with aspiration pneumonia Client with acute kidney failure
Client with aspiration pneumonia
The nurse is caring for a group of clients with respiratory disorders. For which of these clients does the nurse plan for immediate intubation? Client who requires suctioning of oral secretions Client with hypoventilation and decreased breath sounds Client with O2 saturation of 90% Client with thick, purulent secretions and crackles
Client with hypoventilation and decreased breath sounds
The provider is planning to discharge a client home. The nurse suspects domestic violence as the cause of injury, although the client denies this. What is the best course of action for the nurse to take? Call the police. Consult with Social Services. Discharge the client as instructed. Instruct the client to go to a safe place.
Consult with Social Services.
The nurse is caring for a patient on a telemetry unit who has a regular heart rhythm and rate of 60 beats/min; a P wave precedes each QRS complex, and the PR interval is 0.20 second. Additional vital signs are as follows: blood pressure 118/68 mm Hg, respiratory rate 16 breaths/min, and temperature 98.8°F (37°C). All of these medications are available on the medication record. What action does the nurse take? Administer atropine. Administer digoxin. Administer clonidine. Continue to monitor.
Continue to monitor.
When caring for the client receiving mechanical ventilation, the nurse includes which of these interventions to prevent ventilator-associated pneumonia (VAP)? Administering antibiotic prophylaxis Continuous removal of subglottic secretions Elevating the head of the bed at least 30 degrees whenever possible Handwashing before and after contact with the client Placing a nasogastric tube Placing the client in a negative-airflow room
Continuous removal of subglottic secretions Elevating the head of the bed at least 30 degrees whenever possible Handwashing before and after contact with the client
Which wound assessment characteristics suggest a superficial partial-thickness burn injury? Black-brown coloration Painful blisters Moderate to severe edema Absence of blisters
Painful blisters
A client from a local care facility has sustained a cardiac arrest in the emergency department (ED), and resuscitation was unsuccessful. The client's family wishes to view the body. What steps should the ED nurse take? Remove all lines and indwelling tubes. Cover the client with a sheet, leaving the face exposed. Call a chaplain or social worker to accompany the family. Tell the family that the client "is in a better place now." Dim the lights in the client's room.
Cover the client with a sheet, leaving the face exposed. Dim the lights in the client's room.
The nurse is caring for a patient with advanced heart failure who develops asystole. The nurse corrects the graduate nurse when the graduate offers to perform which intervention? Defibrillation Cardiopulmonary resuscitation (CPR) Administration of epinephrine Administration of oxygen
Defibrillation
The nurse is assessing a client with possible pulmonary embolism (PE). For which symptoms consistent with PE will the nurse assess? Dizziness and syncope Shortness of breath (SOB) worsening over the last 2 weeks Inspiratory chest pain Productive cough Pink, frothy sputum Tachycardia
Dizziness and syncope Inspiratory chest pain Tachycardia
Which factors indicate that a client's burn wounds are becoming infected? Dry, crusty granulation tissue Elevated blood pressure Hypoglycemia Edema of the skin around the wound Tachycardia
Dry, crusty granulation tissue Edema of the skin around the wound Tachycardia
The nurse is caring for a patient with heart rate of 143 beats/min. For which manifestations does the nurse observe? Palpitations Increased energy Chest discomfort Flushing of the skin Hypotension
Palpitations Chest discomfort Hypotension
A client with burn injuries states, "I feel so helpless." Which nursing intervention is most helpful for this client? Encouraging participation in wound care Encouraging visitors Reassuring the client that he or she will be fine Telling the client that these feelings are normal
Encouraging participation in wound care
The nurse on a burn unit has just received change-of-shift report about these clients. Which client does the nurse assess first? Adult client admitted a week ago with deep partial-thickness burns over 35% of the body who is reporting pain Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!" An electrician who suffered external burn injuries a month ago and is asking the nurse to contact the health care provider immediately about discharge plans Older adult client admitted yesterday with partial- and full-thickness burns over 40% of the body who is receiving IV fluids at 250 mL/hr
Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!"
A client with burn injuries is admitted. Which priority does the nurse anticipate within the first 24 hours? Range-of-motion exercises Emotional support Fluid resuscitation Sterile dressing changes
Fluid resuscitation
A client is admitted to the emergency department after reporting being raped. Who is the best team member for the admitting nurse to locate to provide care for this client? Forensic nurse examiner Physician or health care provider Psychiatric crisis nurse Police officer
Forensic nurse examiner
The nurse is reviewing the health history for an older adult client recently admitted to the burn unit with severe burns to the upper body from a house fire. The nurse plans to contact the health care provider if the client's history reveals which condition? Heart failure Diverticulitis Hypertension Emphysema
Heart failure
The nurse is caring for a patient with acute coronary syndrome (ACS) and atrial fibrillation who has a new prescription for metoprolol (Toprol). Which monitoring is essential when administering the medication? ST segment Heart rate Troponin Myoglobin
Heart rate
The nurse is caring for a patient with atrial fibrillation (AF). In addition to an antidysrhythmic, what medication does the nurse plan to administer? Heparin Atropine Dobutamine Magnesium sulfate
Heparin
The nurse is developing a plan of care for a client with pulmonary embolism (PE). Which client problem does the nurse establish as the priority? Inadequate nutrition related to food-drug interactions with anticoagulant therapy Risk for infection related to leukocytosis Hypoxemia related to ventilation-perfusion mismatch Insufficient knowledge related to the cause of PE
Hypoxemia related to ventilation-perfusion mismatch
In assessing a client in the rehabilitative phase of burn therapy, which priority problem does the nurse anticipate? Intense pain Potential for inadequate oxygenation Impaired self-image Potential for infection
Impaired self-image
To position a client's burned upper extremities appropriately, how does the nurse position the client's elbow? In a neutral position In a position of comfort Slightly flexed Slightly hyperextended
In a neutral position
A client is in the resuscitation phase of burn injury. Which route does the nurse use to administer pain medication to the client? Intramuscular Intravenous Sublingual Topical
Intravenous
The nurse is caring for a client who has just been extubated after receiving mechanical ventilation. Which action will the nurse delegate to unlicensed assistive personnel (UAP)? Keep the head of the bed elevated. Teach about incentive spirometer use. Monitor vital signs every 5 minutes. Adjust the nasal oxygen flow rate.
Keep the head of the bed elevated.
An air medical helicopter arrives on the scene of a high-speed motorcycle collision with a train. The client was not wearing a helmet and is very confused, with a Glasgow Coma Scale score of 13. There is an apparent partial amputation of both hands. Vital signs are stable and the airway is secure. Which level of trauma center would be the most appropriate destination for this client? Level I Level II Level III Level IV
Level I
The nurse is caring for a client who is receiving mechanical ventilation and hears the high-pressure alarm. Which action will the nurse take first? Check the ventilator alarm settings. Assess the set tidal volume. Listen to the client's breath sounds. Call the respiratory therapist.
Listen to the client's breath sounds.
A client has been admitted with a diagnosis of pulmonary embolism and is receiving heparin infusion. What safety priority does the nurse include in the plan of care? Teach the client to avoid using dental floss. Monitor the platelet count daily. Ensure adequate staffing for the unit. Notify radiology of an impending scan.
Monitor the platelet count daily.
A client is admitted to the emergency department after being in a motor vehicle crash. The client was wearing a seat belt and the airbag deployed. There are no apparent injuries besides an abrasion from the shoulder harness across the clavicle and anterior chest. First vital signs are BP 110/70, HR 98, R 18, SaO2 98% on room air. The client's Glasgow Coma Scale score is 15. What does the nurse do next? Allows the client to go home Checks blood alcohol levels Prepares the client for surgery Monitors the client
Monitors the client
The intensive care nurse is working on a unit-based project to prevent intensive care unit (ICU) psychosis. Which intervention does the nurse recommend to best decrease the incidence of ICU psychosis? Providing frequent explanations and reassurance Keeping the lights on to promote orientation Administering sedation Providing television or radio for stimulation
Providing frequent explanations and reassurance
What is the main role of the incident commander in a disaster? Call in extra staff Contact other facilities to arrange transfers Oversee the movement of clients through the system Notify the media of hospital capacity
Oversee the movement of clients through the system
A nursing student is caring for a client with open-wound burns. Which nursing interventions does the nursing student provide for this client? Provides cushions for comfort Performs frequent handwashing Places plants in the client's room Performs gloved dressing changes Uses disposable dishes
Performs frequent handwashing Performs gloved dressing changes Uses disposable dishes
A client is in the acute phase of burn injury. For which action does the nurse decide to coordinate with the registered dietitian? Discouraging having food brought in from the client's favorite restaurant Providing more palatable choices for the client Helping the client maintain a desirable weight Planning additions to the standard nutritional pattern
Planning additions to the standard nutritional pattern
Which essential item is added to a personal-readiness supplies "go bag?" Fruits and vegetables Laptop computer Potable water Television
Potable water
Which clinical manifestation is indicative of wound healing for a client in the acute phase of burn injury? Pale, boggy, dry, or crusted granulation tissue Increasing wound drainage Scar tissue formation Sloughing of grafts
Scar tissue formation
Which intervention provides safety during cardioversion? Setting the defibrillator at 220 joules Obtaining informed consent Setting the defibrillator to the synchronized mode Removing oxygen
Setting the defibrillator to the synchronized mode
A patient's rhythm strip shows a heart rate of 116 beats/min, one P wave occurring before each QRS complex, a PR interval measuring 0.16 second, and a QRS complex measuring 0.08 second. How does the nurse interpret this rhythm strip? Normal sinus rhythm Sinus bradycardia Sinus tachycardia Sinus rhythm with premature ventricular contractions
Sinus tachycardia
During a mass casualty, which injury receives care first? Abdominal evisceration Open fracture of the left forearm Sprained ankle Sucking chest wound
Sucking chest wound
After successful treatment of clients involved in a mass casualty incident, the incident commander deactivates the emergency response plan. Which activity is most important for the emergency department (ED) charge nurse to initiate at this time? Analyze the ED response to the mass casualty incident. Follow up with survivors to determine the need for additional referrals. Initiate critical incident stress debriefing (CISD) for staff members. Take inventory and restock the ED with supplies and equipment.
Take inventory and restock the ED with supplies and equipment.
A client comes to the emergency department covered with coagulated blood and a white powder. The client is hysterical and fears that it is anthrax. What does the nurse do first? Administers antibiotics Provides emotional support Takes the client to the decontamination room Triages the client
Takes the client to the decontamination room
Which patient is appropriate for the cardiac care unit charge nurse to assign to the float RN from the medical-surgical unit? The 64-year-old patient admitted for weakness who has a sinus bradycardia with a heart rate of 58 beats/min The 71-year-old patient admitted for heart failure who is short of breath and has a heart rate of 120 to 130 beats/min The 88-year-old patient admitted with an elevated troponin level who is hypotensive with a heart rate of 96 beats/min The 92-year-old patient admitted with chest pain who has premature ventricular complexes and a heart rate of 102 beats/min
The 64-year-old patient admitted for weakness who has a sinus bradycardia with a heart rate of 58 beats/min
How does the nurse recognize that atropine has produced a positive outcome for the patient with bradycardia? The patient states he is dizzy and weak. The nurse notes dyspnea. The patient has a heart rate of 42 beats/min. The monitor shows an increase in heart rate.
The monitor shows an increase in heart rate.
The professional nurse is supervising a nursing student performing a 12-lead electrocardiogram (ECG). Under which circumstance does the nurse correct the student? The patient is semi-recumbent in bed. Chest leads are placed as for the previous ECG. The patient is instructed to breathe deeply through the mouth. The patient is instructed to lie still.
The patient is instructed to breathe deeply through the mouth.
Which assessment information about a 60-kg client admitted 12 hours ago with a full-thickness burn over 30% of the total body surface area is of greatest concern to the nurse? Bowel sounds are absent. The pulse oximetry level is 91%. The serum potassium level is 6.1 mEq/L (6.1 mmol/L). Urine output since admission is 370 mL.
The serum potassium level is 6.1 mEq/L (6.1 mmol/L).
The client is a burn victim who is noted to have increasing edema and decreased urine output as a result of the inflammatory compensation response. What does the nurse do first? Administer a diuretic. Provide a fluid bolus. Recalculate fluid replacement based on time of hospital arrival. Titrate fluid replacement.
Titrate fluid replacement.
During a mass casualty, staff roles are defined. If the triage officer is incapacitated, who is the best choice for replacement? Communications officer Hospital incident commander Medical command physician Triage nurse
Triage nurse
The nurse is evaluating the effectiveness of fluid resuscitation for a client in the resuscitation phase of burn injury. Which finding does the nurse correlate with clinical improvement? Blood urea nitrogen (BUN), 36 mg/dL (12.9 mmol/L) Creatinine, 2.8 mg/dL (248 mcmol/L) Urine output, 40 mL/hr Urine specific gravity, 1.042
Urine output, 40 mL/hr
There has been an explosion at a local refinery. Numerous injuries have occurred. The following clients arrive from the scene by private vehicle. Which client is considered a priority for treatment? Child with an open fracture of the arm Man with a contusion on the head Teenager with a closed fracture of the leg Woman bleeding heavily
Woman bleeding heavily
Several clients have been brought to the emergency department after an office building fire. Which client is at greatest risk for inhalation injury? Middle-aged adult who is frantically explaining to the nurse what happened Young adult who suffered burn injuries in a closed space Adult with burns to the extremities Older adult with thick, tan-colored sputum
Young adult who suffered burn injuries in a closed space
