Prioritizing HESI

Which consideration would a health care organization address before implementing differentiated nursing practice ? Select all that apply . 1. Salary ranges 2. Client caseloads 3. Position descriptions 4. Expected competencies 5. Degree of participation in decision - making

1 345

In which order would the nurse implement interventions for a client who has an allergic reaction to a bee sting ? 1. Inject epinephrine through the intramuscular route in the mid portion of the outer thigh . 2. Establish an intravenous ( IV ) infusion with normal saline . 3. Administer oral liquid diphenhydramine . 4. Remove the stinger gently by scraping with a needle .

1, 4, 3,2

Which intervention would the nurse perform first for a client with a spinal cord injury who is experiencing autonomic dysreflexia ? 1.Assess for the cause . 2. Place the client in sitting position 3. Check the client for fecal impaction . 4. OGive an alpha blocker prophylactically .

2

Which priority assessment finding would the nurse expect to see when caring for a client with sinus tachycardia ? 1. Anxiety 2. Orthopnea 3. Restlessness 4. Shortness of breath 5. Decreased blood pressure

2,45

Which nursing intervention would be the priority action for a patient experiencing cardiac arrest from ventricular fibrillation ? 1. Treating pain 2, Assessing respirations 3. Initiating defibrillation 4. Monitoring blood pressure ( BP )

3

According to the emergency assessment protocol , which action would the nurse take when caring for a client with a chest injury ? 1. Palpate for bony crepitus 2. Auscultate bowel sounds 3. Examine the neck for stiffness 4. Assess for external signs of injury 5. Observe the rate , depth , and effort of breathing

1 45

Which nursing intervention would the nurse perform first for a client with multiple injuries resulting from a severe motor vehicle accident ? 1. Provide bag - valve - mask ventilation 2. Administer glucose by intravenous ( IV ) route 3. Apply direct pressure to the severe bleeding areas 4. Insert large - bore peripheral intravenous ( IV ) lines in the antecubital area

1, Then 2, 3, 4 in order

A preschooler is seen in the emergency department for suspected poisoning . In which order would the nurse perform the following actions ? 1 Terminate poison exposure . 2 Identify the poison . 3 . Prevent poison absorption . 4 . Assess the victim .

4.1.2. 3

In which order would the nurse perform resuscitation efforts on a trauma client ?1. Clear the airway . 2. Provide supplemental oxygen to trauma client 3. Initiate chest compressions . 4. Protect the cervical spine .

1. 4. 2, 3 in order

Which nursing action would be conducted during the primary survey airway assessment in the emergency department 1. Assessing for edema 2. Counting respiratory rate 3. Checking for foreign bodies 4. Noting use of accessory muscles 5. Monitoring for respiratory distress

1.36 Rationale Nursing actions that are appropriate when conducting a primary survey during the airway assessment include assessing for edema , checking for foreign bodies , and monitoring for respiratory distress . Counting the respiratory rate and noting use of accessory muscles are nursing actions appropriate during the breathing assessment

which order would the nurse perform care activities for a client with complete partial seizures ? 1. Maintaining airway 2. Recording the time and duration of seizure 3. Assessing vital signs 4. Performing neurological checks

1234 in order

In which order would the nurse teach a client the supraglottic method of swallowing ? 1 . " Place yourself in an upright position . " 2 . " Take a deep breath 3 . " Place a half to 1 teaspoon of food into your mouth 4 . " Swallow twice 5 . " Hold your breath . 6. " Clear your throat .

1.6.2.3.5.4.

Which action would the nurse take when providing care for a client who has compartment syndrome ? 1. Assist with splitting the cast 2. Monitor urine output 3. Evaluate pain using a pain scale 4. Apply splints to the injured part 5. Place cold compresses on the affected area

123 Rationale Compartment syndrome is increased pressure in a limited space , which compromises the compartmental blood vessels , nerves , and tendons . The cast may be split to reduce the external circumferential pressures . The nurse would assess urine output because the myoglobin released from damaged muscle cells may precipitate and cause obstruction in renal tubules . The nurse would evaluate the pain on a scale from 0 to 10 ; this helps plan care . Application of external pressure by splints , casts , and dressing to the injured area may worsen the client's symptoms . Application of cold compresses may result in vasoconstriction and exacerbate the symptoms

Which ptvwould the nurse teach to report sob due to the medication ? A Hydroxychloroquine B Infliximab C Methotrexate D Ephedrine

B Rationale Infliximab can cause chest discomfort , tachycardia , shortness of breath , or light - headedness . Client B , who is receiving infliximab therapy , is taught to report shortness of breath . Hydroxychloroquine causes retinal damage . Client A , who is receiving hydroxychloroquine therapy , is taught to report blurred vision . Client C , who is receiving methotrexate , is taught to report signs of infection . Client D , who is receiving ephedrine , is taught to report the presence of dry mouth and increased blood pressure .

order would the nurse prioritize care based on client condition ? 1 . Severe respiratory distress 2. Chest pain due to ischemia . 3. Cystitis 4. Gynecological disorder

1.2.4.3 in order Because #4 are come to ER for bleeding

List in order of priority the actions the nurse would take when providing care for an infant with suspected bacterial meningitis . 1 . Institute respiratory isolation . 2 Insert an intravenous access device . 3 . Administer prescribed antibiotics . 4 . Monitor for signs of increased intracranial pressure 5 . Assist with a lumbar puncture .

1.2.5.3.4

Place the clients in the order in which the nurse would provide care . 1 . Infant having a seizure 2 . Adult with acute chest pain Adolescent with a blood glucose level of 190 ( 12 mmol Adult with acute pancreatitis . Child with a non - life - threatening cut that needs stitches

1.24.5.3

Which medication would the nurse expect to be prescribed first to reduce the symptoms of a female client who reports severe cramping , pain , backache , anxiety , mood swings , and a migraine headache ? Sertraline Buspirone Ibuprofen Spironolactone $ Rationale A client with severe cramps , backache , and a migraine with anxiety and mood swings likely has premenstrual syndrome ( PMS ) . Selective serotonin reuptake inhibitors ( SSRIs ) such as sertraline are effective in relieving the symptoms of severe PMS . Buspirone is useful only to relieve anxiety in the client with PMS . Ibuprofen is used to reduce physiological symptoms . Diuretics such as spironolactone are effective in reducing fluid overload .

1 Rationale A client with severe cramps , backache , and a migraine with anxiety and mood swings likely has premenstrual syndrome ( PMS ) . Selective serotonin reuptake inhibitors ( SSRIs ) such as sertraline are effective in relieving the symptoms of severe PMS . Buspirone is useful only to relieve anxiety in the client with PMS . Ibuprofen is used to reduce physiological symptoms . Diuretics such as spironolactone are effective in reducing fluid overload .

A client with severe abdominal pain is on meperidine treatment and later develops seizures . Which action would be most important for the nurse to implement ? 1. Stop administration of meperidine . 2. Administer transdermal scopolamine . 3. Administer oxygen ( O2 ) through facial mask 4. Monitor respiratory status and sedation level .

1 Rationale Opioids such as meperidine are associated with neurotoxicity and seizures , which are caused by accumulation its metabolite , normeperidine . The administration of the medication must be stopped immediately Transdermal scopolamine helps reduce nausea and vomiting associated with administration of the meperidine . O₂ is administered when the client has oversedation and respiratory meperidine . Frequent monitoring of both the sedation level and respiratory rate is essential in clients distress because of receiving opioid analgesics but is of moderate priority in this situation .

Which health care provider would be the best choice to help a homeless client receive needed medication for a communicable disease ? 1. Navigator 2. Case manager 3. Primary nurse 4. Unlicensed assistive personnel ( UAP )

1 Rationale The navigator role was conceived to reduce barriers to care for vulnerable clients who may cope with delays in access , diagnosis , treatment , and / or fragmented and uncoordinated care . A homeless person would be appropriately cared for by a navigator . The case manager , primary nurse , or UAP would not be appropriate to aid the homeless client receive medication for a communicable disease .

Which statement made by a client who underwent a myringotomy indicates to the nurse the need for further postoperative teaching ? 1. can wash my hair after 2 days . 2. " should refrain from air travel for 2 to 3 weeks . 3. " need to change the ear dressing every 24 hours . " 4. should stay away from people with respiratory infections . "

1 Rationale The priority care to be taken after a myringotomy is to keep the external ear and ear canal clean and dry while . the incision is healing . Hair should not be washed for several days . The client is to refrain from air travel for 2 to 3 weeks after surgery , because the ear may be disturbed by the high altitudes . The ear dressing can be changed by every 24 hours . The client should stay away from others with respiratory infections to prevent infections to the incision site and affected ear .

In which order would the nurse implement the interventions for a client who sustained a soft tissue injury ? 1. Assess the neurovascular status 2. Obtain x - rays of the extremity 3. Elevate the involved limb 4. Apply a compression bandage

1, 3, 4, 2

In which order would the nurse treat the infiltration of a nonvesicant intravenous ( IV ) solution leaking into the extravascular tissue ? 1. Stop infusion and remove peripheral venous catheter . 2. Elevate the extremity . 3. Use warm or cold compresses according to the solution infiltrated . 4. Apply a sterile dressing 5. Obtain a study to determine the cause of the problem . 6. Rate the infiltration using the INS Infiltration Scale and document procedure 7. insert a new catheter in the opposite extremity .

1. 4.2.3.7.5.6

client who has arrived at the medical - surgical unit after discharge from the postanesthesia Which observation would the nurse make first in a focused assessment of the airway of a care unit ? 1. O If the client's neck is in proper alignment 2. Rate and the depth of the respirations O 3. Quality and the pattern of the breathing 4. If the client is using accessory muscles to breathe

1

Which statement describes the case management method of care delivery ? 1. The case manager advocates for the client and family 2. The case manager identifies outcomes and coordinates care activities 3. " Case managers help control the costs for high - risk , high - cost client populations . " 4. Identifying tasks that can be performed by other care providers is just one activity . " 5. Case management includes the client , family , and all health care provider involvement . "

135

Place in the correct order the steps the nurse would follow to detect paradoxical blood pressure ( BP ) in clients with pericarditis . 1. Palpate the BP . 2. Deflate the cuff . 3. Inflate the cuff above the systolic pressure . 4. Identify when sounds are audible on inspiration 5. Note when sounds are first audible on expiration 6. Subtract the inspiratory pressure from expiratory pressure .

1.3.2.5.4.6

Which issue must hospital administrators consider before the implementation of the primary care nursing model ? 1. Salaries of care providers 2. Number of support staff to hire 3. Disposition of current support staff 4. Educational preparation of the staff 5. Number of registered nurses ( RNS ) needed )

1.345 Rationale Primary nursing uses an all - RN staff , which can cost the organization additional money for salaries . If an organization is moving from one care delivery system to primary nursing , the disposition of nonlicensed and licensed staff will need to be determined . The nursing staff will need to be educationally prepared to assume the role of primary nurse . The organization will need to determine the number of RNs , not support staff , needed to support the care delivery approach .

@D eagng Which nursing action would be the priority when providing care for a trauma client with a penetrating wound after the completion of the secondary survey ? 1. Documenting the client's care 2. Formulating the client's plan of care 3. Reassessing the client's level of consciousness 4. Administering tetanus prophylaxis to the client 5. Transferring the client to the general medical unit

1.4 Rationale The priority nursing actions after completion of the secondary survey during the emergency assessment care , reassessing level of consciousness , and transferring the client include documenting all client care and administering tetanus prophylaxis . Formulating the client's plan of to the general medical unit are nursing actions implemented once the client is stable .

According to the three - tiered triage system , which client condition requires urgent . treatment ? 1. Renal colic 2. Strains and sprains 3. Respiratory distress 4. Severe abdominal pain 5. Multiple displaced fractures

1.45 Rationale According to the three - tiered triage system , renal colic , severe abdominal pain , and multiple displaced fractures require urgent treatment . Strains and sprains require nonurgent treatment , and respiratory distress requires emergent treatment .

Which assessment data related to the client's airway would indicate the need for priority intervention by the nurse ? 1. Dyspnea 2. Tachycardia 3. Hypotension . 4. Agonal breaths 5. Inability to speak

1.45 Rationale Dyspnea , agonal breaths , and an inability to speak are all assessment data that indicate a compromised airway and the need for priority intervention by the nurse . Tachycardia and hypotension are also priority assessment data that indicate the need for intervention ; however , this data indicates circulatory , and not respiratory , compromise .

Which activity would the nurse prepare to complete in order to secure a position as a clinical nurse leader ( CNL ) in a major urban hospital 1. Pass the certification examination . 2. Complete a master's degree in nursing . 3. Learn how to prepare clinical pathways . 4. Attend 30 hours of continuing education about the role 5. Pass the NCLEX - RN state board of nursing examination . .

12

client with which condition would be triaged at the emergent level by the nurse after a natural disaster ? 1. Unstable vital signs 2. Active arterial bleeding 3. Chest pain with nausea 4. Simple fracture of the forearm 5. Displaced fracture of the femur

123

In which order would the nurse perform the following interventions for a client with injuries from a motor vehicle accident ? Control external bleeding . Elevate the injured . Apply ice packs . Monitor for temperature elevation

1234 orderly

In which order would the nurse prioritize the nursing actions for a client brought to the emergency department after a bomb blast ? Establish a patent airway . Protect the cervical spine by maintaining alignment . 3 . Assess breath sounds and respiratory effort . 4 . Monitor blood pressure ( BP ) and pulse rate . 5 . Cover the client with a blanket . Evaluate client's level of consciousness .

123465

Which role requires the nurse to prioritize when implementing a primary nursing model of client care ? 1. Manager 2. Advocate 3. Decision maker 4. Cost accountant 5. Care coordinator.

1235 Rationale When using the primary nursing model for client care , the registered nurse will assume the role of manager , advocate , decision maker , and care coordinator . All of these roles require prioritization of care . Case managers coordinate care of select clients to manage costs and ensure quality of care

In which order would the nurse perform the following actions for a client the emergency department with a snake bite ? 1. Give supplemental oxygen ( 02 ) 2. Start continuous heart function and blood pressure monitoring 3. Establish intravenous access 4. Mark , measure , and record circumference of bitten extremity every 15 to 20 minutes 5. Provide pain medication as prescribed

12354

Which client activity warrants the highest priority for education about health promotion to prevent head and neck cancer ? Chews tobacco Multiple sex partners Uses condoms when having sex History of alcohol abuse for 5 years Brushes with a soft - bristle toothbrush

124

Which action would the nurse immediately implement for a client with moderate hypothermia ? 1. Administer heated oxygen ( O₂ ) gas 2. Position the client supine 3. Provide high - carbohydrate liquids . 4. Apply external heat with heating blankets 5. Perform cardiopulmonary bypass technique

124 Rationale Clients with moderate hypothermia should be administered heated Oy or inspired gas to prevent heat loss via the respiratory tract . Positioning the client in the supine position prevents orthostatic changes in blood pressure from cardiovascular instability . Applying external heat with heating blankets can promote the core . temperature by producing peripheral vasodilation . High - carbohydrate liquids without alcohol or caffeine should be administered in clients with mild hypothermia . Cardiopulmonary bypass technique should performed in a client with severe hypothermia .

Which action would the circulating nurse classify as a priority during surgery ? 1. Protecting client's privacy 2. Assessing blood loss and urine 3. Monitoring ventilation for nonintubated clients 4. Monitoring the level of anesthesia provided to the client 5. Providing supplies and equipment on the basis of the surgical team's needs

125 Rationale . The nursing priority of the circulating nurse involves the protection of the client's privacy . The circulating nurse is also involved in making the assessment about the blood loss and urine of the client during the operative procedure . The nurse also provides supplies and equipment based on the needs of the surgical team . The anesthesiologist is responsible for monitoring the ventilation of nonintubated clients and the anesthesia provided to the client .

Which intervention would the nurse implement first based on priority to a client with low dose amitriptyline poisoning ? 1. Perform gastric lavage 2. Administer activated charcoal 3. Provide emetics to induce vomiting 4. Initiate cardiopulmonary resuscitation

2 Rationale Clients with amitriptyline poisoning should be administered activated charcoal to decrease the absorption of poison into the systemic circulation . Gastric lavage should be performed after administration of activated charcoal . Vomiting should not be induced in the client . The client with low - dose amitriptyline poisoning may not have respiratory distress ; therefore , cardiopulmonary resuscitation is not required .

Which snakebite would require the implementation of a priority nursing intervention to ensure that the client's airway is patent and resuscitation equipment is immediately available ? Rattlesnake Coral snake Copperhead Cottonmouth Rationale The client has been bitten by a coral snake , and the physiological effect of the venom involves blocking of neurotransmission , which produces weakness , cranial nerve deficits , an altered level of consciousness , and , ultimately , respiratory paralysis . Rattlesnakes , copperheads , and cottonmouths are in the category of pit vipers .

2 Rationale The client has been bitten by a coral snake , and the physiological effect of the venom involves blocking of neurotransmission , which produces weakness , cranial nerve deficits , an altered level of consciousness , and , ultimately , respiratory paralysis . Rattlesnakes , copperheads , and cottonmouths are in the category of pit vipers .

Which nursing intervention has the highest priority for implementationwhen caring for aclient who has a suspected pelvic fracture as the result of a motor vehicle accident ? 1. Logrolling for transfers 2. Inspecting the genitalia 3. Preparing for a pelvic examination 4. Administering prescribed pain medication

2 Rationale The priority nursing action for this client is to inspect the genitalia for bleeding and obvious injury . The logrolling technique does not need to be implemented when transferring this client . Preparing for a pelvic examination is not an appropriate action . Administering prescribed pain medication is an appropriate action but would be done only after inspecting the genitalia for injury .

which order would the nurse perform the actions when inspecting the chest of a client with a suspected heart attack after a fire Obtain a chest x - ray and 12 - lead electrocardiogram ( ECG ) Inspect the chest for paradoxical chest movements . Auscultate breath sounds and heart sounds . Palpate the sternum , clavicles , and ribs Evaluate the client for rib fractures , pulmonary contusion cardiac injury , and hemothorax .

2. 4. 3. 5. 1

In which order would the nurse perform interventions for a client in the emergency department ( ED ) with facial trauma , dyspnea , cyanosis , and external bleeding ? 1. Administer supplemental oxygen ( 02 ) . 2. Perform jaw - thrust maneuver 3. Measure client's level of consciousness 4. Remove the client's clothing to perform a thorough examination 5. Apply direct pressure with a sterile dressing .

2.1.5.3.4

Which statement made by the nurse regarding the prevention of human immunodeficiency virus ( HIV ) transmission by health care workers is correct ? correct . should never reuse equipment used in invasive procedures . " " If I perform exposure - prone procedures , I should know my HIV antibody status . " should identify exposure - prone procedures by institutions where they are performed . " " If I am infected with HIV , I am restricted from practice of non - exposure - prone procedures . " " If I have exudative lesions or weeping dermatitis , I should not perform direct client care or handle client care equipment .

2.3.5

Which nursing action would the nurse implement during the primary survey of the emergency assessment process for a client ? 1. Inserting nasogastric tube 2. Immobilizing the cervical spine 3. Arranging for diagnostic studies 4. Preparing for chest tube insertion 5. Applying direct pressure to a wound

2.45 Rationale The primary survey focuses on airway - breathing - circulation ( ABC ) , disability , and exposure or environmental not primary , survey include inserting a nasogastric tube and arranging for diagnostic studies brief , systematic process that aims to identify all injuries . Nursing actions appropriate during the secondary , addressing each step of the primary survey and starting any lifesaving interventions . The secondary survey is a preparing for chest tube insertion , and applying direct pressure to a wound . The Nursing actions that are appropriate during the primary survey include immobilizing the cervical spine control . It aims to identify life - threatening conditions so that appropriate interventions can be started . secondary survey begins after

The hospital's board of directors would evaluate cost information about which activities when considering implementing client - focused care delivery for a 300 - bed community hospital ? Select answers were Training charge nurses Redesigning all care areas Cross - training support personnel Hiring additional nurse managers Hiring an all registered nurse ( RN ) staff Rationale Additional charge nurses , nurse managers , and creating an all - RN staff are not needed for this care delivery For client - focused care units , all care areas need to be redesigned and support personnel need to be trained .

23 Rationale Additional charge nurses , nurse managers , and creating an all - RN staff are not needed for this care delivery For client - focused care units , all care areas need to be redesigned and support personnel need to be trained .

Which area of content would the nurse training for a role as a nurse navigator expect to focus on 1. Approaches to reduce the cost of health care 2. Methods to work through complex health systems 3. Strategies to teach clients about disease , including prevention and treatment 4. Solutions to barriers that clients encounter while attempting to receive care 5. Methods to help clients cope with delays in receiving treatment uqtil barriers are overcome

2345

Which statement correctly describes components of the five - level triage system of the Emergency Severity Index ESI ) ? 1. Clients in the ESI - 2 category do not have life - threatening injuries 2. Clients who are in the ESI - 4 category present with stable vital signs . 3. " ESI - 1 clients should be seen by the provider within 10 minutes . 4. " Clients with severe respiratory distress fall within the ESI - 1 category . 5. " high intensity of resources is required to care for the clients in ES1-4 .

24 Rationale A Vital signs of the clients triaged in ES1-4 are stable because they do not have any life - threatening complications . Clients in ESI - 2 are likely to have life - threatening injuries , though these are not always obvious . Respiratory obstruction and severe respiratory distress are life - threatening conditions that require immediate action ; therefore , these clients are assigned to ESI - 1 ; clients in ESI - 1 have life - threatening injuries . The clients in ESI - 1 should be given care immediately by the health care provider resource intensity is sufficient to care for the clients in ES1-4 .

1 . Follow aseptic technique . 2 . Warm intravenous ( IV ) and irrigation fluids as indicated by agency policy and manufacturer's recommendations . 3 . Cover the client's head and feet .. 4 . Lift the client into position to prevent shearing forces . 5 . Use a small pillow under the client's head , 6 Pad bony prominences to prevent pressure 7 . Use warming device to prevent hypothermia 8 Carefully monitor the input and output , including blood 9 Position arthritic and artificial joints carefully to prevent postoperative pain

5. 4.9.6.7.3.2.1.8

Which intervention would be the priority for the nurse to incorporate into the plan of care for the client status post mastectomy and breast augmentation receiving anthracycline chemotherapy ? 1. O Reminding the client to expect soreness in the chest . 2. Teaching the client that they may have difficulty in raising their arm 3. Instructing the client to report a chronic cough and shortness of breath 4. Teaching the client to avoid blood pressure measurements on the affected side

3 Rationale Anthracyclines can cause cardiotoxic side effects . A client who is undergoing chemotherapy with anthracyclines is instructed to report a chronic cough and shortness of breath . After breast augmentation , a client is taught that she should expect soreness in the chest . After mastectomy and breast augmentation , a client is taught that she may have difficulty in raising the arm.After a mastectomy , a client is taught to avoid blood pressure measurements in the affected limb .

For which client condition would the triage nurse assign a red tag based on priority ? 1. O Arrhythmia 2. Pressure injuries 3. Abdominal trauma 4. Second - degree burns

3 Rationale The client with abdominal trauma should be treated immediately because it is a life - threatening complication The client with arrhythmia may be given next priority of care . Care for the client with pressure ulcers can be delayed because it is not a life - threatening complication . The client with second - degree burns should be give third priority of care because the client's condition may worsen if treatment is not provided as early possible .

After returning from surgery an infant suddenly becomes cyanotic . Which action would the nurse take first ? Checking vital signs Administering oxygen Suctioning the nasopharynx Placing the infant in the side - lying position Rationale The most likely cause of cyanosis is secretions in the airway . The airway must be cleared of secretions for effective air exchange . Taking vital signs is unsafe , because valuable time is lost while the infant's brain is deprived of oxygen . Oxygenation is ineffective if secretions are not first cleared from the airway . The side - lying position helps promote drainage of secretions , but this intervention should be undertaken only after the airway is cleared .

3 Rationale The most likely cause of cyanosis is secretions in the airway . The airway must be cleared of secretions for effective air exchange . Taking vital signs is unsafe , because valuable time is lost while the infant's brain is deprived of oxygen . Oxygenation is ineffective if secretions are not first cleared from the airway . The side - lying position helps promote drainage of secretions , but this intervention should be undertaken only after the airway is cleared

Which assessment is a nursing priority to prevent complications in clients with respiratory acidosis ? 1. Observing the nail beds 2. Listening to breath sounds 3. Monitoring breathing status 4. Checking muscle contractions

3 Rationale The nursing priority for preventing complications when caring for clients with respiratory acidosis is t monitor breathing status hourly and to intervene as needed . Assessing the nail beds for cyanosis , which is usually a late finding in acidosis , is not a priority intervention . Listening to breath sounds and assessing how easily air moves into and out of the lungs can be a second priority intervention . Checking muscle contractions the neck region is a later priority intervention .

Once a client admitted with shock secondary to severe gastrointestinal ( GI ) bleeding is stabilized which action would the nurse take ? 1. Monitor the peripheral pulses . 2. Check the level of consciousness . 3. Take a blood sample for laboratory tests . 4. Control the bleeding with a pressure dressing .

3 Rationale The primary nursing intervention that should be followed in the client's condition with GI bleeding is collection of a blood sample for laboratory diagnosis to determine if the client will require transfusion . Peripheral pulses are monitored in an ongoing manner . Level of consciousness may not be required to be monitored based on the client's condition . Controlling bleeding with a pressure dressing is usually done in case of deep lacerations and external wounds .

which order would the nurse provide care for a client injured with frostbite 1. Rewarm in a water bath at a temperature of 106 ° F 2. Elevate the injured areas above the heart level 3. Observe for signs of frostbite and preventing further tissue damage 4. Assess for the development of compartment syndrome

3. 1, 2, 4 inorder

In which order would the nurse perform the steps when conducting a secondary survey on a client ? 1. History taking and head - to - toe assessment 2. Give comfort measures 3. Assessment of full set of vital signs 4. Inspect posterior surfaces

3.2 1,4

In which order would the nurse implement the steps for cooling a client with heatstroke who has a a body temperature of 104 ° F ( 40 ° C ) so that breathing and circulation are not impaired ? Immerse the client in cold water . 2 Place ice packs on the client's neck , axillae , chest , and groin E 3 . Remove client's clothing . Fan the client rapidly to aid in cooling by evaporation .

3214

In which environment would the functional model of care most likely be used ? 1. Home care 2. Operating rooms 3. Ambulatory clinics 4. Extended care facilities 5. - Postoperative medical - surgical units

34

Which client would the nurse provide care for first based on priority of condition and findings ? 1. Client A Cardiomyopathy Lower extremities swollen Weight gain 2. Client B Peripheral artery disease Painful cramping in hip region Weakness and numbness in leg 3. Client C Aortic aneurysm Breathing difficulty Chest pain 4. Client D Chest trauma Breathing difficulty Coughing up blood

4 Rationale Client D with chest trauma who is coughing up blood and experiencing difficulty breathing should be cared for first . Client A with cardiomyopathy and swelling of the lower extremities and weight gain can be treated later because the client can wait for treatment . Client B with peripheral artery disease can be treated after treating the clients with emergency conditions because this client can wait for treatment . Client C with an aortic aneurysm and chest pain with difficulty breathing can be cared for after client D because there is no sign that the aneurysm has ruptured

Which client complication involving a simple venous catheter requires the nurse to assess history of catheter use ? 1. Catheter rupture 2. Catheter migration 3. Catheter dislodgement 4. Catheter lumen occlusion .

4 Rationale The nurse must assess the history of catheter use in cases of catheter lumen occlusion , Cases such catheter rupture can be resolved by repairing the damaged segment using the repair kit designed for the specific brand of catheter . In the case of both catheter migration and dislodgement , the nurse would stop the infusion and flush the catheter . In case of migration , the nurse would notify the primary health care provider . In case of dislodgement , the nurse would never readvance the catheter into the insertion site .

Using the Five - Level Emergency Severity Index ( ESI ) , which client would the triage nurse designate as needing to receive prioritized care when triaging clients in the emergency department ? 1. Adult client experiencing mild chest pain 2. Adolescent client with a possible fractured wrist 3. Older adult client with a hip fracture who is in pain 4. A school - age client with asthma presenting with dyspnea

4. Rationale According to the Five - Level Emergency Severity Index ( ESI ) , a client experiencing severe respiratory distress such as the school - age client with asthma who is having difficulty breathing ( dyspnea ) would receive priority . care as an ESI - 1 . An adult client experiencing mild chest pain would be an ESI - 2 . An adolescent client with a possible wrist fracture would be an ESI - 4 . An older adult client with a hip fracture who is experiencing pain would be an ESI - 3 .

A 55 years Abnormal uterine bleeding Tumors of 8 mm in uterus , B 28 years Carotene of 90mcg / dL Creatine of 1.8 mg / dL Folate ( folic acid ) of 23 ng / mL C 67 years Blood urea nitrogen of 25 mg / dL Respiratory rate of 38 breaths / min Blood pressure 80/60 mm Hg D 33 year Folate ( folic acid ) of 3 ng / mL Haptoglobin of 16 mg / dL Based on age and findings , which client would the nurse consider at the highest risk for developing pneumonia ? 1. Client A 2. Client B 3. Client C 4. Client D

C Rationale A blood urea nitrogen level of 25 mg / dL , a respiratory rate of 38 breaths per minute , and a blood pressure of 80/60 mm Hg are symptoms of pneumonia . Client C has the highest risk for pneumonia