VN 42 MIDTERM

The nurse reinforces discharge instructions regarding skin care to a client after the grafting of burn injuries of the left chest and left arm. Which statement by the client indicates the need for further teaching?

"I should never wear warm clothing over the newly healed skin area."

The nurse is caring for a client in spinal shock after a diving accident. The client asks how long the spinal shock is going to last. What would be the nurse's best response?

"Spinal shock can last for a week to months until the body adjusts to the damage caused by the injury."

The emergency department nurse is caring for a client admitted with hypovolemic shock. IV fluids have been ordered. What ratio is usually ordered for replacement fluids?

3:1

A group of people arrived at the emergency unit by a private car with complaints of periorbital swelling, cough, and tightness in the throat. There is a strong odor emanating from their clothes. They report exposure to a "gas bomb" that was set off in the house. What is the priority action?

Direct the clients to the decontamination area

A client was brought to the emergency department after suffering a closed head injury and lacerations around the face due to a hit-run accident. The client is unconscious and has a minimal response to noxious stimuli. Which of the following assessment findings if observed after few hours, should be reported to the physician immediately?

Drainage of a clear fluid from the client's nose

The nurse caring for victims of a volcano eruption knows that this disaster is categorized as a natural disaster. What is the other category of disaster?

Human

An elderly female patient with severe dehydration has been admitted to the critical care unit and is being treated for hypovolemic shock through aggressive fluid resuscitation. How should the nurse on the unit ideally position this patient?

In the trendelenburg position

The nurse is caring for a patient in liver failure who is exhibiting signs and symptoms of hypovolemic shock. The nurse should anticipate that the health care provider will order the administration of what crystalloid for the management of this patient

Normal saline

The nurse is caring for a client in septic shock. The nurse knows to closely monitor the client. What finding would the nurse observe when the client's condition is in its initial stages?

a rapid, bounding pulse

A client is in shock. The nurse assesses this client for inadequate oxygen delivery to the tissues. What is the first sign the nurse will observe in the initial stage of shock?

altered cerebral function

The nurse is caring for a victim of a chemical disaster. Medications given in the treatment of this client include amyl nitrite, sodium nitrite, and sodium thiosulfate. What chemical agent does the nurse know this client has been exposed to?

cyanide

The nurse is caring for a client with a head injury after a fall from a hayloft. What aspect helps the nurse to detect cerebrospinal fluids (CSF) drainage when examining a client after a significant head injury?

halo sign

A nurse educator is teaching students the types of shock and associated causes. Which combination of shock type and causative factors is correct? Select all that apply.

Septic shock; infection Cardiogenic shock; myocardial infarction Anaphylactic shock; nut allergy Hypovolemic shock; blood loss

A nurse is giving an educational class to members of the local disaster team. What should the nurse instruct members of the disaster team to do in a chemical bioterrorist attack from inhalation?

Stand up.

A nurse is assisting with the care of a client who is in hypovolemic shock and has a prescription for packed red blood cells. Which type of blood can be administered to the client while awaiting blood from a type and cross-match?

Type O

The nurse is caring for a client who is receiving large volumes of crystalloid fluid to treat hypovolemic shock. In light of this intervention, for what sign or symptom should the nurse monitor ?

hypothermia

A client with impaired physical mobility has been hospitalized. What nursing intervention helps reduce the potential for formation of thrombi and renal calculi in a client with impaired physical mobility?

keep the client hydrated

The nursing instructor is talking with students about botulism. The instructor tells the students that when caring for a client with botulism what condition is most likely to cause death?

paralysis of the respiratory muscles

Which isolation category should the nurse use to guide care when caring for a client with anthrax?

standard precautions

A client has been brought to the emergency department after a fall off a roof. The client has no cord function below the point of injury. What does the ED nurse know about this client?

the client is in spinal shock

A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation?

the client's urinary output is 30ml/hr

Which activities would the client with a T4 spinal cord injury be able to perform independently? Select all that apply.

transferring to wheelchair eating breathing writing

A client with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this client? Select all that apply.

· Autonomic dysreflexia · Orthostatic hypotension · DVT

The nurse is working the triage and phone answering questions about the radiological disaster. When in the fallout period of the disaster, which suggestion is most appropriate?

remove all outer garments before entering a house or shelter

The nurse is caring for a client exposed to a blistering agent. While the nurse is quickly decontaminating the client by showering and bagging all the client's clothing, what is the nurse simultaneously assessing for?

respiratory compromise

The nurse is caring for a client with shock accompanied by lung congestion. How would the nurse position this client?

semi-fowlers with lower extremities raised to approximately 15 degrees

The nurse is evaluating a skin lesion on a client brought to the emergency department. The nurse notes characteristics of chickenpox but has the physician evaluate the lesion for which biologic disaster agent

smallpox

The nurse is caring for three clients who have been diagnosed with anthrax. They were exposed after boarding a flight where a white powdery substance was found in one of the restrooms. The nurse knows that these clients would be classed as being victims of which of the following?

A biologic disaster

A client with a burn injury is scheduled for an autograft. The nurse is planning care for the client for immediately after the graft procedure. Which would the nurse include in the plan of care? Select all that apply.

Administering pain medications as prescribed Monitoring the donor site and the graft site for signs of infection

A client with a burn injury is scheduled for an autograft. The nurse is planning care for the client for immediately after the graft procedure. Which would the nurse include in the plan of care? Select all that apply.

Administering pain medications as prescribed Monitoring the donor site and the graft site for signs of infection The graft area is immobilized for 3 to 7 days

A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect

Autonomic dysreflexia

A nurse is caring for a client who was exposed to anthrax . Which of the following antibiotics should the nurse plan to administer?

Ciprofloxacin

The nurse obtains a blood pressure of 120/78 mm Hg from a patient in hypovolemic shock. Since the blood pressure is within normal range for this patient, what stage of shock does the nurse realize this patient is experiencing?

Compensatory stage