NCLEX: Emergency Nursing

The toddler was brought to the emergency room after taking her mother's prenatal vitamins. Which interventions should the nurse implement? Select all that apply. 1. Determine if the prenatal vitamins had iron. 2. Administer activated charcoal to the toddler. 3. Assess the toddler's vital signs frequently. 4. Notify child protective services of the situation. 5. Ask the parents if they have the vitamin bottle.

1,3,5 Iron can destroy a toddler's liver; vital signs must be assessed; and by looking at the vitamin bottle the nurse can see how many vitamins were in the bottle when it was purchased and if the vitamins have iron. Activated charcoal is administered for poisons, and at this time there is no evidence to support that the parents are negligent or unfit to care for their child.

The Muslim client who was exposed to anthrax has died. Which statement indicates the family understands the information discussed concerning anthrax exposure? 1. "We should cremate our loved one as soon as possible." 2. "We will take our loved one back to our homeland." 3. "We need to be vaccinated against polio within 3 days." l4. "We shall have an open casket ceremony for our loved one."

1. "We should cremate our loved one as soon as possible." Cremation is recommended because the anthrax spores can survive for decades and represent a threat to morticians and forensic medicine personnel. There is no vaccination for anthrax.

The client overdosed by taking too much narcotic cough syrup. The nurse administers naloxone (Narcan). Which priority intervention should the nurse implement? 1. Assess for signs of respiratory depression. 2. Monitor the client's pulse oximeter reading. 3. Place a tracheostomy tray at the client's bedside. 4. Determine if the overdose was accidental.

1. Assess for signs of respiratory depression.

The Homeland Security Office has issued a warning of suspected biological warfare using the Franciscella tularensis (tularemia) bacteria. Which signs and symptoms would support the initial diagnosis of tularemia? 1. Fever, chills, headache, and malaise. 2. Vomiting, diarrhea, and fatigue. 3. The nurse smells the odor of bitter almonds. 4. Visual and gastrointestinal disturbances.

1. Fever, chills, headache, and malaise. Tularemia is extremely contagious and is contracted by exposure to infected animals or an aerosolized or biological weapon. Symptoms area sudden onset of fever, fatigue, chills, headache, lower backache, malaise, rigor, and coryza. Option 2 lists signs/symptoms of radiation exposure, option 3 of cyanide poisoning, and option 4 of malathion exposure.

The client who is 1 day postoperative abdominal surgery has a blood pressure (BP) of 88/60 and an apical pulse of 122; is diaphoretic; and has pale, cold, and clammy skin. Which intervention would the nurse implement first? 1. Increase the client's intravenous fluid rate. 2. Administer an intravenous dopamine drip. 3. Obtain arterial blood gases (ABGs). 4. Assess the client's abdominal dressing.

1. Increase the client's intravenous fluid rate. The client is exhibiting symptoms of hypovolemic shock; therefore, the nurse should maintain the client's circulatory volume by increasing the fluid rate. Remember: do not assess when in dis- tress. Assessing the abdominal dressing, obtaining the ABGs, and administering dopamine are appropriate, but the first intervention is to maintain fluid volume.

According to the North Atlantic Treaty Organization (NATO) triage system, which situation would be considered priority 4, color black? 1. Injuries are extensive, and chances of survival are unlikely. 2. Injuries are life-threatening but survivable with minimal interventions. 3. Injuries are significant but can wait hours without threat to life or limb. 4. Injuries are minor, and treatment can be delayed hours to days.

1. Injuries are extensive, and chances of survival are unlikely. A client tagged Priority 4, color black, is considered expectant, which means the client will probably die. Option 2 is color red, Priority 1 option 3 is color yellow, Priority 2; option 3 is green, Priority 3.

The nurse and an unlicensed assistive personnel (UAP) are working in an ED. Which nursing task should the nurse delegate to the UAP? 1. Instruct the UAP to take the client with a fractured arm to the car. 2. Ask the UAP to escort the battered woman to the restroom. 3. Tell the UAP to give the medication prescription to the client. 4. Discuss having the UAP relay discharge instructions to a client.

1. Instruct the UAP to take the client with a fractured arm to the car. The UAP can take a client to a car for discharge after the nurse provides instructions. The nurse should escort the battered woman to the rest- room so that assessment of the client's situation can be achieved when the client is alone. The nurse should give the prescriptions to the client and answer ques- tions about the medications.

The employee health nurse working in an industrial plant has been informed employees smell the odor of bitter almonds. Which intervention should the nurse implement? 1. Notify security to evacuate all employees. 2. Tell the employees to continue working. 3. Instruct employees to wear face shields. 4. Assess the employees for respiratory distress.

1. Notify security to evacuate all employees. The smell of bitter almonds is associated with cyanide gas, a deadly poison. The nurse should evacuate the area. Face shields will not protect against cyanide poisoning. Cyanide poison- ing includes respiratory muscle failure, but assess- ment will not save the employees' lives.

The emergency department (ED) nurse is caring for a client with a head injury secondary to a motorcycle accident who in response to painful stimuli assumes decerebrate posturing. Which data would indicate the client's condition is improving? 1. The client has purposeful movement when the nurse rubs the sternum. 2. The client extends the upper and lower extremities in response to painful stimuli. 3. The client is flaccid when the nurse applies painful pressure to the sternum. 4. The client has a Glasgow Coma Scale Rating of 4 on a 1-15 scale.

1. The client has purposeful movement when the nurse rubs the sternum. Purposeful movement following painful stimuli would indicate an improvement in the client's condition. Extending the upper and lower extremities is assuming a decerebrate posture. Flaccidity and a Glasgow Coma Scale of 4 indicate a worsening of the client's condition

The nurse is triaging phone calls in an outpatient clinic. Which client should the nurse inform to come to the emergency clinic today? 1. The client who reports burning and pain upon urination. 2. The client who calls is complaining of severe chest pain. 3. The client who has had a stuffy nose and cough for 2 days. 4. The client who needs a physical examination for football.

1. The client who reports burning and pain upon urination. The client needs to come to the clinic for a midstream urinalysis because the problem sounds like a urinary tract infection and the client will need antibiotics. The client with chest pain should call 911 immediately; the client with a possi- ble cold does not need to be seen today; and a physi- cal examination does not need to be performed today.

The client has an advance directive for health care. Which situation would require the nurse to consult the surrogate decision-maker? 1. The client with a head injury who has Glasgow Coma Scale of 13. 2. The client with COPD who is having difficulty being weaned from the ventilator. 3. The client in a hyperglycemic hyperosmolar nonketotic coma. 4. The client in a hyperbaric chamber for nonhealing wounds on the legs.

1. The client with a head injury who has Glasgow Coma Scale of 13. The client in a coma cannot make decisions. A Glasgow Coma Scale of 13 indicates a cognizant functioning individual. A client on the ventilator can relate wishes to the nurse, and a client in a hyperbaric chamber can make decisions.

The charge nurse is making client assignments in the critical care unit. Which client should be assigned to the most experienced nurse? 1. The client with diabetic ketoacidosis (DKA) with arterial blood gases (ABGs) of pH 7.29, PaO2 98, PaCO2 30, HCO3 15. 2. The client with chronic obstructive pulmonary disease (COPD) with ABGs of pH 7.35, PaO2 78, PaCO2 54, and HCO3 20. 3. The client with a myocardial infarction (MI) with ABGs of pH 7.4, PaO2 91, PaCO2 43, and HCO3 25. 4. The client with a pulmonary embolism (PE) with ABGs of pH 7.35, PaO2 88, PaCO2 44.

1. The client with diabetic ketoacidosis (DKA) with arterial blood gases (ABGs) of pH 7.29, PaO2 98, PaCO2 30, HCO3 15. This client's ABGs reflect that the DKA has not resolved, and the most experi- enced nurse should care for the most unstable client. The client with COPD has good ABGs for the diagnosis, and the other ABGs are normal.

Which assessment data would indicate to the nurse the client is experiencing hypovolemic shock? 1. The client's BP is 80/40 and apical pulse 128. 2. The client's cardiac output is 5 L/min. 3. The client's central venous pressure (CVP) is 8 cm H2O pressure. 4. The client is hypertensive and bradycardic.

1. The client's BP is 80/40 and apical pulse 128. The hallmark signs of hypo- volemic shock are decreased blood pressure and tachycardia. Normal cardiac output is 4-6 L/min, and normal CVP pressure is 4-10 cm H2O pressure.

Which statement is the primary goal of the emergency department (ED) nurse in caring for a client who has ingested a poison? 1. To stop the action of the poison and maintain organ functioning 2. To determine why the client ingested the poisonous substance. 3. To document the interventions taken to treat the client's condition. 4. To implement treatment that increases the elimination of the poison.

1. To stop the action of the poison and maintain organ functioning The primary goal is to inactivate the poison before it is absorbed and causes permanent organ damage or death. The nurse should attempt to determine why the client ingested the poison, but this is not priority. Documentation is vital, but the nurse must first take care of the client. Eliminating the poi- son is not always priority; neutralizing the poison is sometimes priority

A gastric lavage has been ordered for a comatose client who ingested a full bottle of sleeping pills in an attempt to commit suicide. Which interventions should the nurse implement? Select all that apply. 1. Place the client supine with the head of the bed flat. 2. Insert a large-bore gastric tube into the client's mouth. 3. Make sure there is standby suction at the bedside. 4. Withdraw all stomach contents and then instill irritating solution. 5. Use gloves to dispose all stomach contents into the commode.

2, 3, 4 A large-bore tube is used with a comatose client; suction is to prevent aspiration; and removing stomach contents before the lavage helps to prevent overdistention of the stomach. The client should be placed on the left side to allow the gastric contents to pool in the stomach, decreasing passage of fluid into the duodenum during lavage. Samples are sent to the lab to be analyzed for chemical compounds.

The nurse is preparing to administer morphine sulfate 2 mg intravenous push (IVP) to a client complaining of chest pain who has a saline lock in the left forearm. Which interventions should the nurse implement? Rank in order. 1. Administer the medication over 5 minutes. 2. Sign out the medication from the narcotics cabinet. 3. Flush the saline lock with 2 mL of normal saline. 4. Ask the client about allergies to medications. 5. Draw up the medication in 10 mL syringe

2-5-4-3-1 The nurse should first sign out the appropriate medication from the narcotics cabinet. Morphine should be adminis- tered over 5 minutes, so diluting the medication to 10 mL will allow for a controlled administration time. Then, the nurse should make sure the client is not allergic to morphine. After that, the nurse should flush the saline lock and administer the medication over 5 minutes

The client diagnosed with septicemia is admitted to the emergency department. Which intervention should the nurse implement first? 1. Insert an indwelling urinary catheter. 2. Administer the intravenous (IV) antibiotic therapy. 3. Obtain a stat basic metabolic profile (BMP). 4. Place the client in the Trendelenburg position.

2. Administer the intravenous (IV) antibiotic therapy. The IV antibiotic is the priority medication for the client with septicemia, a systemic bacterial infection of the blood. Inserting an indwelling catheter, obtaining a BMP, and placing the patient in the Trendelenburg position are interventions used for clients in hypovolemic shock, not septic shock.

Which medication intervention is the most important for the nurse to implement when functioning as the medication nurse in a code? 1. Check the armband against the medication administration record (MAR). 2. Administer the medications rapidly and then raise the client's arm. 3. Feel for a pulse to make sure the medications are being delivered. 4. Document the amount of medication administered and the route.

2. Administer the medications rapidly and then raise the client's arm. The medication nurse administers the medications and then raises the client's arm to help the medications reach the central circulation. The MAR will not have the emergency medications, and the nurse works from standard protocols and verbal orders in a code. Another nurse will document the medications in the record. This is an emergency.

The nurse caring for a client with sepsis writes the client diagnosis of "alteration in comfort related to chills and hyperpyrexia." Which independent intervention should be included in the plan of care? 1. Place a hyperthermia blanket on the client. 2. Assess the client's vital signs every 2 hours. 3. Obtain blood sputum cultures. 4. Administer an antipyretic medication every 4 hours.

2. Assess the client's vital signs every 2 hours. The client has an elevated tempera- ture; therefore, taking the client's vital signs would be an appropriate independent intervention. The client would need a hypothermia blanket, not a hyperthermia blanket, for a fever (hyperpyrexia). Administering med- ication and obtaining a blood culture are collaborative interventions.

A potential chemical spill has occurred on the medical floor. Which intervention should the charge nurse implement first? 1. Instruct the staff to evacuate the immediate area. 2. Contain the area where the chemical spill occurred. 3. Notify the hazard management team. 4. Contact the hospital shift supervisor.

2. Contain the area where the chemical spill occurred. The first intervention is to contain the spill area and make sure no clients, staff, or visi- tors come near the area. The nurse should then notify the shift supervisor (following chain of command) and then the hazardous materials team. Evacuation is done only if that team instructs that it be done.

The nurse and unlicensed assistive personnel (UAP) are caring for clients in the ED. Which task would be most appropriate to delegate to the UAP? 1. Tell the UAP to take the vital signs of a client with a gunshot wound to the chest. 2. Instruct the UAP to flush the eyes of a client who splashed bleach in the eyes. 3. Ask the UAP to use the Rule of Nines to determine the percentage body surface burned. 4. Request the UAP complete the discharge teaching for the client diagnosed with scabies.

2. Instruct the UAP to flush the eyes of a client who splashed bleach in the eyes. The UAP could flush the eyes continuously with normal saline because this take a long time, and the nurse will not have to be tied up with the client for an extended period. A client with a gunshot wound would require assessment; the Rule of Nines is assessment; and the UAP cannot teach.

The nurse hiking on a trail is providing first aid to a victim of a poisonous snakebite on the right lower leg. Which action should the nurse implement first? 1. Remove the client's right shoe 2. Instruct the client to lie very still. 3. Immobilize the client's right leg. 4. Keep the client warm as possible.

2. Instruct the client to lie very still. The client should lie down and remove all restrictive items. Then, the wound should be cleaned and covered with a sterile dressing. The af- fected body part should be immobilized, and the client should be kept warm

The medical unit staff admitted seven clients who were exposed to anthrax. Which type of precaution should the infection control nurse implement on the unit? 1. Airborne precautions. 2. Standard precautions. 3. Contact precautions. 4. Droplet precautions.

2. Standard precautions. Standard precautions are all that is necessary because the client is not contagiousand the disease cannot be spread from person to person. Equipment should be cleaned using standard hospital disinfectant.

The triage nurse is working in the emergency department. Which client should be assessed first? 1. The 10-year-old child who has a compound fracture of the right arm. 2. The 17-year-old adolescent who has a pencil sticking out of his eye. 3. The 38-year-old female who accidentally spilled hot grease on her leg. 4. The 55-year-old man with hypertension who has an occipital headache.

2. The 17-year-old adolescent who has a pencil sticking out of his eye. This nurse should see this client first because the pencil needs to be stabilized in the eye, the operating room needs to be notified, and more than likely the eye will be enucleated. The compound fracture, the burned leg, and an occipital headache are not potentially life-threatening.

The nurse in a disaster is triaging clients. Which client would be triaged as an Expectant Category, Priority 4, and color black? 1. The client who has a hard, distended abdomen. 2. The client who is exhibiting decerebrate posturing. 3. The client who has a possible L1-L2 spinal cord injury. 4. The client who has paresthesia in the left lower leg.

2. The client who is exhibiting decerebrate posturing. The client who is decerebrate posturing has severe increased intracranial pressure secondary to a head injury and has a very poor prognosis; even with treatment, survival is unlikely. A hard distended abdomen, a possible spinal cord injury, and paresthesia in the lower leg are injuries that could be treated.

Which data would the nurse expect to assess in a client diagnosed with neurogenic shock? 1. The client has cool, clammy skin. 2. The client's apical pulse is 56. 3. The client has bilateral wheezing. 4. The client urine will be diluted.

2. The client's apical pulse is 56. The client diagnosed with neuro- genic shock will have bradycardia, instead of the tachycardia seen in other forms of shock. The client's skin will be dry and warm, rather than the cool moist skin seen in hypovolemic shock. Wheezing would be associated with anaphylactic shock, and the client would not have dilute urine.

Which intervention should the nurse implement for clients who have been exposed to a liquid form of the chemical nerve agent sarin? 1. Prepare to administer sodium nitrate intravenously. 2. Wash the skin with copious amounts of soap and water. 3. Instruct the clients not to burst any blister formation. 4. Administer the antibiotic penicillin intravenously.

2. Wash the skin with copious amounts of soap and water. Liquid forms of nerve agents evap- orate into colorless, odorless vapors that can be inhaled or absorbed through the skin; therefore, washing the skin with soap and water is an appropriate treatment. Sodium nitrate is used to treat cyanide exposure. Vesicants cause blistering. Oral penicillin is the treat- ment for anthrax exposure.

The nurse is teaching a class on biological warfare. Which statement indicates one of the students needs more teaching concerning the information presented? 1. "Anthrax, smallpox, and plagues are examples of biological agents." 2. "Chemical agents are more apparent and problems occur more quickly than with biological agents." 3. "Biological weapons are less of a threat than chemical agents." 4. "Biological agents can be released in one city and affect cities thousands of miles away."

3. "Biological weapons are less of a threat than chemical agents." Because of the variety of biological agents (anthrax, smallpox, plague), the means of transmission, and the lethality of agents, they are more of a threat and more dangerous than chemical agents. Chemical agents (nerve agents, cyanide, vesi- cant agents, pulmonary agents) are more apparent.

Which assessment data indicates the client diagnosed with septic shock is responding to the medical regime? 1. Vital signs: T 100.4°F, P 104, R 26, and BP 102/60. 2. A white blood cell count of 18,000 mm3. 3. A urinary output of 200 mL in the last 4 hours. 4. Dry, mucous membranes and tented skin turgor.

3. A urinary output of 200 mL in the last 4 hours. The client must have a urinary output of at least 30 mL an hour; therefore, an output of 200 mL in 4 hours indicates the client's kidneys are functioning normally, which, in turn, indicates the client is responding to the medical regime. The vital signs, white blood cell count, and dehydration indicate the client is not responding to the medical regime.

The female client took an overdose of Ambien CR, a sedative hyponotic, and is admitted to the intensive care unit (ICU). Which priority intervention should the ICU nurse implement? 1. Refer the client to a psychiatric nurse practitioner. 2. Allow the client to ventilate her feelings. 3. Administer 1.5 L of Go-Lytely, a whole bowel irrigation. 4. Ensure the client turns, coughs, and deep-breathes every 2 hours.

3. Administer 1.5 L of Go-Lytely, a whole bowel irrigation. Whole bowel irrigation is effec- tive following ingestion of sustained-released medica- tion, such as Ambien CR, lead, lithium, and iron. Therapeutic communication, referrals, and prevent- ing complications of immobility are all appropriate interventions, but the most important intervention is to rid the body of the sustained-release medication.

The client has ingested a corrosive solution containing lye. Which intervention should the nurse implement first? 1. Monitor the client's neurological status 2. Insert a nasogastric (NG) tube in the client's nares. 3. Assess for the client's ability to breathe. 4. Administer milk to dilute the corrosive solution.

3. Assess for the client's ability to breathe. Airway edema or obstruction can occur as a result of the burning action of corrosive substances. Neurological assessment is important but not priority over airway. Inserting an NG tube and administering milk are appropriate interventions, but they are not prior to airway management

The school nurse has had five students in the last 3 hours present to the school health clinic with complaints of severe abdominal cramping, nausea, vomiting, and diarrhea. Which intervention should the nurse implement first? 1. Notify the public health department of the situation. 2. Administer an antiemetic medication to the students. 3. Determine if the students ate the same food in the cafeteria. 4. Contact the parents or legal guardians of the students.

3. Determine if the students ate the same food in the cafeteria. These could be signs of botulism, but the nurse should first assess to determine if all the students ate the same food. The parents should be notified, and the public health department may need to be notified. The school nurse would not have antiemetic medications in the nurse's office.

The client diagnosed with septic shock has an elevated temperature, a BP of 110/70, and a high cardiac output with systemic vasodilation. Which phase of septic shock is the client experiencing? 1. Hypodynamic phase. 2. Compensatory phase. 3. Hyperdynamic phase. 4. Progressive phase.

3. Hyperdynamic phase. The hyperdynamic phase, the first phase of septic shock, is characterized by high cardiac output with systemic vasodilation. The BP may remain within normal limits, but the heart rate increases to tachycardia, and the client becomes febrile

The emergency department (ED) has received a phone call reporting an implosion of a building with multiple injuries. Which action should the charge nurse implement first? 1. Contact the local blood bank to report the incident. 2. Call nurses off-duty to come into work. 3. Notify the house supervisor of the incident. 4. Instruct staff to check the supplies in the ED.

3. Notify the house supervisor of the incident. The house supervisor should be notified so that staff can be mobilized, client census evaluated, and plans made for multiple admissions to the ED. The blood bank may need to be notified, off-duty nurses may need to be called in, and sup- plies should be checked, but the first intervention is to notify the house supervisor.

The emergency department (ED) has been notified of an accident at a chlorine chemical plant and to expect 10-12 casualties. Which priority intervention should the ED department implement? 1. Prepare to decontaminate the clients in a decontamination room. 2. Discharge clients from the ED to make room for victims. 3. Notify the respiratory therapy department of the disaster. 4. Prepare to place clients on ventilatory support.

3. Notify the respiratory therapy department of the disaster. Chlorine is a gas that, when in- haled, separates the alveoli from the capillary bed. The respiratory therapy department is responsible for oxygen therapy and setting up/maintaining ventila- tors; therefore, this would be the priority interven- tion. Clearing out the ED should be done but not before preparing for clients. Clients would not need to be decontaminated.

A 23-year-old male was brought to the emergency department after trying to kill himself by drinking motor oil. Which HCP order should the nurse question? 1. Initiate intravenous fluids with a 20-gauge angiocatheter. 2. Insert an indwelling urinary catheter with a urometer. 3. Place a nasogastric tube and perform gastric lavage. 4. Monitor the client's cardiac status on telemetry.

3. Place a nasogastric tube and perform gastric lavage. Gastric lavage should not be attempted with ingestion of caustic agents such as high-viscosity petroleum products. Intravenous fluids, monitoring intake and output, and monitoring the cardiac status are appropriate interventions.

The triage nurse has coded a client as priority 2, color yellow. Which action would warrant immediate intervention by the nurse? 1. The American Red Cross (ARC) volunteer documents the tag number in the disaster log. 2. The licensed practical nurse (LPN) documents the client's vital signs on the tag. 3. The HCP removes the tag to examine the client's injured right leg. 4. The UAP attaches the tag to the client's foot.

3. The HCP removes the tag to examine the client's injured right leg. The tag should never be removed until the client is admitted, and the tag becomes a part of the client's record. The HCP needs to be informed immediately of the action. The ARC volunteer, the LPN, and UAP actions would not warrant intervention.

The charge nurse of an emergency department (ED) must send one nurse to the intensive care unit (ICU) for the shift. Which nurse should be assigned to the ICU for the day? 1. The RN who is orienting to the emergency department from a medical unit. 2. The RN who frequently functions as charge nurse of the emergency department. 3. The RN who has floated between the ED and ICU. 4. The RN who is interested in training for the ICU.

3. The RN who has floated between the ED and ICU. This RN will provide the most help to the ICU for the shift. The RN in orientation should stay and continue orientation. The relief charge nurse is the strength of the ED, and the nurse who would like to cross-train should be given a chance to orient to the unit first before being assigned to take a client load in the ICU.

The nurse and a female unlicensed assistive personnel (UAP) are caring for a group of clients on the medical floor. Which action by the UAP would warrant immediate intervention by the nurse? 1. The UAP places a urine specimen in a biohazard bag. 2. The UAP washes her hands with alcohol foam hand cleanser. 3. The UAP puts soiled linen in a plastic bag in the hallway. 4. The UAP uses a disposable stethoscope for a client in the isolation room.

3. The UAP puts soiled linen in a plastic bag in the hallway. Soiled linen should be put in a plastic bag in the client's room, not in the hallway. Specimens should be put in biohazard bags; the UAP should wash her hands with alcohol foam hand cleanser; and using a disposable stethoscope is an appropriate intervention.

The charge nurse is responding to a code on a surgical unit. Which personal protective equipment should the nurse utilize? 1. The nurse should glove and gown before entering the room. 2. The nurse should use a bag/mask to ventilate the client. 3. The nurse may not need any personal protective equipment. 4. The nurse should don a face shield and mask when in a code.

3. The nurse may not need any personal protective equipment. The charge nurse is responsible for ensuring that all the roles of the code team are being performed. The charge nurse does not person- ally perform the roles.

The nurse is preparing to administer dopamine, a beta and alpha agonist, to a client in cardiogenic shock. What intervention should the nurse implement? 1. Request the respiratory therapist to perform a 12-lead ECG. 2. Assess the client's blood pressure (BP) every 2 hours. 3. Use an urimeter to evaluate the intake and output every hour. 4. Cover the intravenous bag and tubing with foil.

3. Use an urimeter to evaluate the intake and output every hour. The urinary output should be monitored via a urometer hourly to ensure the client has an output of at least 30 mL/hr. Dopamineis administered to increase the BP, so it should be as- sessed every 5-15 minutes, not every 2 hours. The client should be on a cardiac monitor, not a one-time 12-lead ECG. The medication is not sensitive to light, so the intravenous bag and tubing need not be cov- ered with foil.

The client in a code is now in ventricular bigimeny. The HCP orders a lidocaine drip at 4 mg/min. The lidocaine comes prepackaged 2g of lidocaine in 500-mL D5W. At what rate will the nurse set the infusion pump?

Answer: 65mL/hr 1. convert g to mg -> 2g x 1000mg = 2000mg 2. 2000mg/ 500mL= 4mg/mL 3. Use the principle 4mg = 65mL/hr p.s. 1mg = 15mL; 2mg = 30mL; 3mg = 45mL; 4mg = 65mL/hr

Which statement indicates the client understands the teaching concerning carbon monoxide poisoning? 1. "I should install smoke detectors in my home." 2. "Carbon monoxide will make you sick but it is not lethal." 3. "You can smell carbon monoxide, so it easy to detect." 4. "I should have my furnace checked for leaks before turning it on."

4. "I should have my furnace checked for leaks before turning it on." One of the major causes of accidental carbon monoxide poisoning is faulty furnaces; the client understands the teaching. A smoke detector will not detect carbon monoxide; the client should install a carbon monoxide detector. Carbon monoxide is colorless and odorless, and it can be lethal.

Which situation would require the emergency department manager to schedule and conduct a Critical Incident Stress Management (CISM) session? 1. A policeman received a gunshot wound to the abdomen in the line of duty. 2. A 4-year-old who had an accidental poisoning and was admitted to the ICU. 3. A 22-year-old client who died after taking an overdose of sleeping pills. 4. A school bus accident that resulted in 14 hospital admissions and 11 deaths.

4. A school bus accident that resulted in 14 hospital admissions and 11 deaths. CISM is an approach to prevent- ing and treating the emotional trauma that can affect emergency responders as a consequence of their job; a major accident is a traumatic experience. The ED staff often care for gunshot wounds, survivors in accidental poisonings, and clients who overdose.

Which activity is most important for the hospital staff when planning disaster preparedness and implementing the hospital's emergency operations plan (EOP)? 1. Evaluate how other hospitals implement disaster drills. 2. Discuss the disaster plan with small groups of employees. 3. Instruct all staff to read the EOP disaster procedure. 4. Have community and hospital practice disaster drills.

4. Have community and hospital practice disaster drills. The most important activity isto implement practice drills, which allow for trou- bleshooting any issues before a real incident occurs. Reading the procedure, discussing the procedure, and evaluating other facilities are not as important as having a practice drill.

8. Which statement explains the scientific rationale for administering epinephrine, a catecholamine, to a client during a code? 1. It will prevent gastric distention resulting from overventilation with the ambu-bag. 2. Epinephrine will treat any potential anaphylactic reaction to the medications administered. 3. Epinephrine dries secretions and makes it easier for the HCP to intubate the client. 4. It vasoconstricts the peripheral circulation and shunts the blood to the central circulation.

4. It vasoconstricts the peripheral circulation and shunts the blood to the central circulation. Epinephrine is a potent vasocon- strictor that keeps the blood in the central circulationof the heart, lungs, and brain. It is given in allergic reac- tions, but this client has no pulse or respirations and is not having an allergic reaction.

The nurse is caring for three clients who have botulism. Which category of personal protective equipment (PPE) should the nurse wear? 1. Level A 2. Level B 3. Level C 4. Level D

4. Level D Standard precautions are used when caring for clients with botulism; therefore, the nurse should wear the work uniform, whichis Level D. Level A protection is worn for the highest-level protection, Level B protection when a lesser level of protection is needed, and Level C protection requires an air-purified respirator (APR).

The emergency department (ED) has been notified of an explosion in a chemical manufacturing plant. Which intervention should be implemented first as the clients arrive at the ED? 1. Triage the explosion victims in the ambulances. 2. Find out if family members have been notified. 3. Prepare charts for the clients as they come into the ED. 4. Remove the client's clothes before entering the ED.

4. Remove the client's clothes before entering the ED. Removing the clothing is the first step. Depending on the type of exposure, this step alone can remove a large portion of exposure. Triage is usually the first step, but preventing potential chemical exposure to staff and clients in the ED is the first step (safety of the hospital); therefore, the clients must be decontaminated.

The male client is experiencing a cardiac arrest, and his wife is distraught. Which intervention should the nurse implement at this time? 1. Notify hospital security to keep an eye on the wife. 2. Stay with the significant other until the client's minister arrives. 3. Ask the UAP to talk to the wife. 4. Request the hospital chaplain to come to the station and support the wife.

4. Request the hospital chaplain to come to the station and support the wife. The chaplain should be called to help address the concerns of the client's family and/or significant others. A small community hospital would not have a 24-hour pastoral service but may have a chaplain on call. The nurse and UAP must see that the other clients on the unit are cared for. Hospital secu- rity is called when there is a danger to self or others, and this is not the case

The nurse is triaging clients in the emergency department (ED). Which client can wait to be seen by the ED staff? 1. The 57-year-old client complaining of right-sided chest pain and diaphoresis. 2. The 13-year-old client with a headache and a purple spotted rash. 3. The 78-year-old client who became disoriented and has slurred speech. 4. The 35-year-old client who has a possible fracture of the right tibia.

4. The 35-year-old client who has a possible fracture of the right tibia A fracture, although painful, is not life-threatening. Chest pain, right- or left-sided, must be assessed to make sure it is not cardiac pain. A client with a headache and purple spotted rash is exhibiting symptoms of meningitis, and if antibiotics are not ini- tiated immediately, the meningitis could be deadly. Disorientation and slurred speech are symptoms of a cerebrovascular accident (CVA), or stroke.

The client in hypovolemic shock is receiving dextran, a non-blood colloid. Which assessment data would warrant immediate intervention by the nurse? 1. The client has a negative Chvostek sign. 2. The client's pulse oximeter reading is 95%. 3. The client refuses to cough and deepbreathe. 4. The client has bilateral jugular vein distention (JVD).

4. The client has bilateral jugular vein distention (JVD). Because of the ability of all colloids to pull fluid into the vascular space, circulatory over- load is a serious adverse outcome; JVD is a sign of circulatory overload. The Chvostek sign indicates hypocalcemia; a pulse oximeter reading of greater than 93% is within normal limits (WNLs); and refusing to cough and deep-breathe is a concern but does not war- rant immediate intervention.

The nurse in a disaster is triaging clients. Which client should be triaged as a Minimal category, Priority 3, and color green? 1. The client with a sucking chest wound who is alert. 2. The client with a head injury who is unresponsive. 3. The client with an abdominal wound and stable vital signs. 4. The client with a sprained ankle that may be fractured.

4. The client with a sprained ankle that may be fractured. Minimal Category, Priority 3, and color green are clients who could wait for days until treated. An ankle, even if it is fractured, could wait. Remember the traffic light—red needs to be seen immediately, yellow should be seen within a few hours, and green a few days. Black has a very low survival rate

The health-care provider has prescribed edetate calcium disodium (calcium EDTA), a chelating agent, for a client diagnosed with lead poisoning. Which laboratory data would warrant immediate intervention? 1. The client's ALT/GPT is 30 IU/mL. 2. The client's calcium level is 9.5 mg/dL. 3. The client's blood urea nitrogen (BUN) is 15 mg/dL. 4. The client's creatinine level is 2.4 mg/dL.

4. The client's creatinine level is 2.4 mg/dL. The creatinine level indicates renal failure, and adequate renal function is required before administering the drug as both the drug and the lead will be excreted through glomerular filtration. The client's liver, calcium, and BUN levels are all within normal limits.

The charge nurse is making assignments in the medical department and has one RN, one recent graduate nurse, two licensed practical nurses (LPN), and an unlicensed assistive personnel (UAP). Which client should be assigned to the graduate nurse who has just completed orientation? 1. The client diagnosed with a snakebite who is receiving antivenin. 2. The client who swallowed poison and is on a one-to-one suicide watch. 3. The client who was exposed to the powder form of anthrax. 4. The elderly client with septicemia who is receiving IV antibiotic therapy

4. The elderly client with septicemia who is receiving IV antibiotic therapy The newly graduated nurse has the knowledge to care for a client receiving antibiotic therapy. Antivenin administration requires specific assessment, infusion rates, and has many complica- tions, and anthrax is a biological agent; therefore, a more experienced nurse should care for these clients. The UAP could sit with a client on a one-to-one suicide watch.

Which situation would warrant the charge nurse in a long-term care facility to obtain information from a material safety data sheet (MSDS)? 1. The nurse was accidentally stuck with a used insulin syringe 2. The custodian spilled bleach water on the floor of the lobby. 3. The family member brought the resident's dog into the building. 4. The resident had a mercury thermometer that broke in the bathroom.

4. The resident had a mercury thermometer that broke in the bathroom. The MSDS provides chemical information regarding specific agents, health infor- mation, and spill information for a variety of chemicals. Mercury thermometers have been removed from health-care facilities because of the risk of inhaling the mercury

Which behavior by the unlicensed assistant personnel (UAP) who is performing cardiac compressions during a code warrants immediate intervention by the nurse? 1. The UAP has two hands on the upper half of the sternum. 2. The UAP notifies the team when getting tired of performing compressions. 3. The UAP depresses the sternum 1.5-2 inches during compressions. 4. The UAP counts out loud to keep the rhythm of compressions.

Correct answer 1: The UAP has two hands on the upper half of the sternum. The correct hand placement is the lower half of the sternum just above the xiphoid process. The nurse should have the UAP reposition the hands. The other actions by the UAP are appropriate.

Which is the primary responsibility of the supervising nurse during a code? 1. Escort family members from the room. 2. Ensure that all roles are being performed. 3. Notify the client's health-care provider (HCP) of the event. 4. Document what happened in the code.

Correct answer 2: Ensure that all roles are being performed. The supervisor should make sure that all the roles in a code are being performed: com- pression, ventilation, medication, equipment, and documentation. Then, if needed, the supervisor nurse can worry about crowd control. The HCP

The nurse is caring for clients on a telemetry floor. Which client is most likely to experience sudden cardiac death? 1. The client exhibiting uncontrolled atrial fibrillation at a rate of 136 bpm. 2. The client exhibiting symptomatic sinus bradycardia who received a pacemaker. 3. The client exhibiting multifocal premature ventricular contractions. 4. The client exhibiting supraventricular tachycardia at a rate of 110 bpm.

Correct answer 3: The client exhibiting multifocal premature ventricular contractions. Premature ventricular contractions occur when the ventricle initiates a beat; when there are several areas of the ventricles competing to initiate a beat, then the client is at risk for cardiac arrest. The client with bradycardia may have been symptomatic but now has a pacemaker. Atrial problems are not life- threatening as in options 1 and 4.

1. The nurse working on a medical unit finds the client unresponsive in the bed. After establishing the client is not breathing and giving two rescue breaths with a mask, which action should the nurse implement next? 1. Check the client for airway obstruction. 2. Assess the carotid artery for a pulse. 3. Begin chest compressions. 4. Call a code via the call light.

Correct answer 4: Call a code via the call light. The nurse should notify the code team to come to the room so that a defibrillator is brought to the bedside. The earlier the client is defib- rillated, the better the chance of success. Then, the nurse should assess for a carotid pulse and then start compressions. The nurse has already checked for airway obstruction before giving the two rescue breaths. Content-Emergency; Category of Health Alteration- Cardiovascular; Integrated Process-Implementation; Client Needs-Safe Effective Care Environment, Manage- ment of Care; Cognitive Level-Synthesis.

The nurse is teaching cardiopulmonary resuscitation (CPR) to a UAP class. Which statement best explains the definition of sudden cardiac death? 1. Death that occurs after being removed from a mechanical ventilator. 2. Cardiac death is the time that the physician declares the heart has stopped. 3. Unexpected death occurring within 1 hour of onset of cardiovascular symptoms. 4. The client is found unresponsive without a pulse or respirations.

Unexpected death occurring within 1 hour of onset of cardiovascular symptoms. This is the definition of sudden cardiac death. Removal from a ventilator is not sudden.