AH3 Exam 3

The nurse in the ED is caring for a client who has a closed lower extremity fracture that has just been realigned and splinted by the physician. Which of the following actions should the nurse take first?

Palpating for a dorsalis pedis pulse is an appropriate way to assess arterial circulation in a fractured lower extremity

Mild hypothermia

Placing the client in a warm room and using warming

The nurse in the ED is caring for a client who has hyperthermia. The client's family member asks why the nurse is placing a urinary catheter. It is appropriate for the nurse to explain that placement of a urinary catheter in the client helps the nurse:

The nurse monitors the urine carefully for color, amount, pH, and myoglobin (To monitor kidney function)

The nurse is planning an education conference about administering insulin to clients with diabetes mellitus. Which of the following information should the nurse include in the conference?

The nurse should include that insulin pens are a great alternative for client's with poor vision because the client can hear the clicks of the pen as the dose is selected.

The nurse in the ED attended a staff training about family and intimate partner violence. Which of the following statements by the nurse would indicate a correct understanding of the training?

"Do you feel safe at home?" is an appropriate way to screen for family and intimate partner violence because it addresses the topic tactfully but directly.

The nurse is participating in a mass causality drill. Which of the following clients should the nurse see first?

(Abd pain, weak thready pulse, and cap refill of 3-4 sec) The client is showing signs of decreased perfusion but is treatable and if not treated immediately they could have life-threatening complications.

Mannitol for cerebral edema. Prescription is for 0.5g/kg as 25% solution, once over 30 minutes and client weighs 143#. You have 25% solution. How many grams do you administer? Do not round.

. Answer: 32.5 143 divided by 2.2 = 65 kg65 x 0.5 = 32.5

The nurse administered NPH insulin to an assigned client at 0700. Which of the following times should the nurse expect the insulin to begin peaking?

1100

The nurse in the ED is caring for a client who has ethylene glycol poisoning. The health care provider instructs the nurse to prepare for activated charcoal administration. The nurse should gather supplies for which of the following to be placed? *SIMILAR SCENARIO*

Activated charcoal is administered through a nasogastric tube (I will insert a tube into one of your nares that will go into your stomach where we can absorb the poison)

The nurse in the ED has just received a client who might have been exposed to anthrax. The client is afraid and says, "I know there is no treatment for anthrax exposure." Which of the following would be a correct response by the nurse?

treated with antibiotics

The nurse in the ED is stabilizing an unconscious client who was in a car accident. A family member asks why the nurse is inserting a nasogastric tube. The nurse should explain that the purpose is to do which of the following?

Prevent stomach fluid from entering the lungs

The nurse in the ED is caring for a group of clients who have experienced poisoning. Which of the following actions by the nurse would be appropriate?

A client who has ingested an excessive dose of aspirin (salicylic acid) may develop severe acidosis. Hemodialysis can help to correct this imbalance.

The nurse in the ED is caring for a client with severe hypothermia. It is important for the nurse to monitor the client's:

A client with severe hypothermia is particularly prone to bradycardia, ventricular fibrillation, and asystole, so the nurse must monitor cardiac telemetry for these dysrhythmias.

The nurse in the ED is assessing a client who arrived by ambulance following a traumatic injury at a construction site. Which of the following assessment findings should be a priority for the nurse to address?

A deviated trachea may represent a life-threatening tension pneumothorax and requires immediate intervention if the client is to be saved.

The nurse is assessing a client with a blunt force chest trauma after hitting the handlebars of a bicycle. The nurse suspects the client has a flail chest. Which of the following findings should the nurse expect with a flail chest?

A flail chest is a complication of blunt chest trauma, occurring when b, resulting in free floating rib segments. On inspiration, the rib sections will pull inward aka PARADOXICAL breathing and then sections will bulge out expiration.

The charge nurse in the ED is observing nursing colleagues care for clients who has suffered various traumatic injuries. The charge nurse must intervene if a nursing colleague is observed doing which of the following?

A nurse should not insert an indwelling catheter for a client with blood present in the urinary meatus because bleeding is a sign of tissue trauma and placement of a catheter might cause further trauma.

The nurse is assessing a client who sustained a blunt injury to the chest wall. Which of the following findings would indicate to the nurse that the client has a pneumothorax?

A simple pneumothorax will cause diminished breath sounds, increased respiratory rate, chest pain, and dyspnea.

The nurse in the ED is triaging clients. The nurse should first attend to which of the following clients?

A woman of childbearing age who reports severe pelvic and/or abdominal pain for several hours might be experiencing ectopic pregnancy

40-year-old with an open leg fracture who is conscious. What color are they?

yellow, not life threatening

The nurse in the emergency department is providing discharge teaching for a client who arrived with hypothermia. The nurse should include in the teaching that which of the following increases the risk for hypothermia? *Schaetzka mentioned in powerpooint*

Alcohol consumption

Script for diphenhydramine 1.25mg/kg, IV times one dose. You have 50mg/mL available. Client weighs 79.2# How many mL do you administer? Do not round

Answer: 0.9 79.2 divided by 2.2 = 36kg x 1.25 = 45mg/kg divided by 50mg = 0.9

Client to receive ciprofloxacin 400mg, every 12 hours, IV for 60 days. You have 400mg/200mL in D5W to be infused over 2 hours. How many mL per hour do you administer? Do not round.

Answer: 100 200ml divided by 2 hours = 100ml/hr

Furosemide for diuresis. Script is for 80mg/day, IV in 4 divided doses. You have 10mg/mL available. How many mL per dose should you administer? Do not round.

Answer: 2 80 divided by 4 doses = 20mg a dose Comes 10mg/ml 20 divided by 10 = 2

0.9% NS 1.5L over 8 hours. Drop factor of 15. Gtt/min? Round to a whole number

Answer: 47 1500 x 15 = 22,500 divided by 480 = 46.875 or 47

The nurse is caring for a client who fell at home and is diagnosed with a right hip fracture. Which of the following would be most important for the nurse to assess?

Because impaired circulation can cause permanent damage, neurovascular assessment of the affected leg is always a priority assessment.

The nurse is assessing an assigned client with a left fractured femur for complications. Which of the following findings would require immediate action by the nurse?

Fat emboli may occur with fractures of the long bones and pelvis which can be fatal

The nurse in the ED is working to stabilize an unconscious client who has just arrived via ambulance and is suspected to have internal bleeding following a trauma. The nurse anticipates that which of the following would most likely be used for aggressive fluid resuscitation?

Lactated Ringers Solution

The nurse is providing care for a client who survived near drowning. Which of the following interventions should be a priority for the nurse to take?

Maslow's hierarchy air/oxygen is the most important thing needed to maintain life.

A nurse is participating in the planning of a hospital's emergency operations plan. The nurse is aware of the potential for ethical dilemmas during a disaster or other emergency. Ethical dilemmas in these contexts are best addressed by which of the following actions?

Nurses can plan for ethical dilemmas they may face during disasters by establishing a framework.

A nurse and a nursing colleague are caring for a client in the ED who has frostbite on the feet. The nurse should intervene if the colleague is observed taking which of the following actions?

One hundred twenty degrees is too hot and could cause further tissue damage, so the nurse should intervene if the coworker places the client's feet in a bath of that temperature.

The nurse in the ED is caring for a client who received gastric lavage for treatment of nonsteroidal anti-inflammatory drug overdose. Which of the following actions by the nurse would be appropriate for monitoring the client for complications from the procedures?

Signs of aspiration include adventitious lung sounds, so the nurse demonstrates an understanding of potential complications of gastric lavage by auscultating the client's lungs.

The nurse in the ED is assessing clients who arrived by ambulance following a bridge collapse. The nurse must recognize that: *Schaetzka highlighted in lecture*

Subcutaneous emphysema (crepitus) is air that has become trapped under the skin.

The nurse is caring for a client on the critical care unit who reports severe sleep disturbance. The nurse should call the health care provider and request a prescription for which of the following to help the client sleep?

Temazepam.

The nurse in the emergency department is assessing the vaccination of a client who has a penetrating injury sustained while working with farming equipment. It would be a priority for the nurse to assess whether the client is vaccinated against which of the following?

Tetanus

The nurse in the ED has received a 5-year-old client who has flu-like symptoms and erythematous lesion on the flank that is 8 cm in diameter. It is important for the nurse to ask the clients parents if the child has recently been around which of the following?

The child is exhibiting classic manifestations of the early stages of Lyme disease. Lyme disease is caused by a tick bite, and ticks are prevalent in wooded areas.

The nurse provided teaching for a client who is scheduled to have a laparoscopic cholecystectomy. Which of the following statements by the client would indicate a correct understanding of the teaching?

The client having a laparoscopic cholecystectomy can shower 24 to 48 hours after the procedure and is usually discharged if there are no complications the same day or day after the procedure.

A nurse is providing triage at a disaster site of a workplace explosion. A 40-year-old client is burned over 65% of the body; the burns are second and third-degree burns, but the client is conscious. The nurse should tag the client with which of the following triage colors?

The client would be triaged blue due to the unlikelihood of survival.

The nurse working in the ED is caring for a female client who has a spiral fracture to the right arm and ecchymosis to the right eye. The clients spouse states the client fell at home and the nurse notes the client has multiple ED visits in the last 6 months for other injuries. Which of the following actions would be most appropriate for the nurse to take? Select all that apply.

a. The nurse should report the findings to the charge nurse who will then call the appropriate agencies to investigate the suspected abuse. b. The nurse should also attempt to interview the client alone so the client feels safe answering questions honestly. c. The nurse can additionally provide information to the client about legal rights and a safe house or escape plan.

The nurse is providing discharge teaching for the parent of an 18-month-old toddler who was brought into the ED after being found face down in the bathtub by the parent. The toddler fully recovered and is ready for discharge. Which of the following information should the nurse include during discharge teaching?

The nurse should reinforce to the parents that an 18-month-old shouldn't be left unattended in the bathtub even for a few minutes, to prevent accidental drowning.

The nurse is caring for a client who was involved in a workplace accident and has a penetrating wound of the chest that led to acute respiratory failure. Which of the following goals of treatment should the care team prioritize when planning this client's care?

The objectives of treatment are to correct the underlying cause of respiratory failure and to restore adequate gas exchange in the lung.

The nurse has provided dietary education to a client with gallbladder disease. The nurse should reinforce teaching if the client chose which of the following food choices for a meal?

The patient should avoid fried foods such as fried chicken, as fatty foods may bring on an episode of cholecystitis.

The nurse has taught a client with diabetes mellitus, type 1 (DM-1) about exercise and glucose control. Which of the following actions by the client would indicate the need for further teaching?

When the client is ketonic, exercise may result in an increase in blood glucose level.

The nurse is caring for clients in the ED. Which of the following interventions should the nurse implement? SATA

a. To remove a tick, the nurse should use tweezers to grasp the tick and pull the tick's body up and away from the skin with a steady motion. b. Bee stingers should be removed by using a fingernail, knife, or needle in a scraping motion. c. Administering antibiotics to a pt. who has a puncture wound from a cat

The nurse in the ED has received training about ways to protect oneself from potential violence from clients. Which of the following actions by the nurse would indicate a correct understanding of the training? SATA

a. Avoiding working alone - work with others in room b. Avoiding being physically trapped in a room (ex. keeping oneself between the client and the door). c. Making oneself aware of a staff lounge or other spaces where one could be behind a locked door if necessary.

The nurse in the ED is caring for a client who has a heatstroke. Which of the following actions would be appropriate to lower the client's core temperature? SATA

a. Covering the client with wet sheets b. Positioning a fan so it is blowing on the client. c. Ice packs applied to the client's groin and axillae

The nurse is planning an education conference about contractility of the heart. Which of the following medications should the nurse include when discussing positive inotropes that improve contractility? SATA

a. Epinephrine b. Isoproterenol c. Dopamine

The nurse is preparing a conference about agents of terrorism. Which of the following information should the nurse include in the conference? SATA

a. Explosive devices can include TNT, dynamite and cause blast, crush or penetrating injuries. b. Nerve agent poisoning can be treated with atropine and pralidoxime chloride. c. Radioactive dispersal devices (RDDs) include a mix of explosives and radioactive material like pellets.

The nurse is caring for a client with chest trauma after a fall. The nurse should assess for which of the following complications of chest trauma? SATA

a. Hypoxemia from disruption of the airway (respiratory distress) b. Hypovolemia from massive fluid loss from the great vessels, cardiac rupture, or hemothorax (bleeding?). c. Cardiac failure from cardiac tamponade, cardiac contusion, or increased intrathoracic pressure.

The nurse is planning an education conference about insulin for clients with diabetes mellitus. Which of the following medications should the nurse include when discussing rapid-acting insulin? SATA

a. Lispro b. Aspart c. Glulisine

The nurse in the ED is asked by another nurse about tetanus prophylaxis for clients with unknown vaccination status. The nurse should confirm for the colleague that tetanus prophylaxis is indicated for clients with which of the following? SATA

a. Severe frostbite b. Human bite wounds c. Dog bite d. Other wounds sustained while gardening

The nurse in the ED has received an unconscious client who arrived by ambulance following an automobile accident. Which of the following actions would be appropriate for the nurse to take while attempting to stabilize the client? *C-SPINE COLLAR*

a. The jaw-thrust maneuver is a safe way to open the airway of a client for whom possible spinal injury is a concern.

The nurse in the ED is caring for a client with a wound from a human bite on the hand 12 hours ago. Which of the following prescriptions should the nurse clarify? SATA

a. The nurse should clarify the order for the rabies immune globulin. b. The nurse should also clarify the order for the sterile dressing

The nurse is caring for a client who has signs and symptoms of pulmonary congestion and reports feelings of anxiety. Which of the following prescriptions should the nurse expect from the health care provider? SATA

a. The nurse should expect a diuretic like furosemide b. The nurse should also expect an anti-anxiety medication like lorazepam.

The nurse is caring for a client who is critically ill and is at risk for stress ulcers. Which of the following prescribed medications should the nurse expect from the healthcare provider as a prophylactic therapy? SATA

a. The nurse should expect a mucosal-protecting medication like misoprostol. b. The nurse should also expect a PPI or antiulcer medication like pantoprazole.

The nurse is caring for a client who is alert and having an acute asthma attack. Which of the following prescribed medications should the nurse plan to administer? SATA

a. The nurse should plan to administer a bronchodilator like albuterol b. The nurse should also plan to administer a corticosteroid to reduce inflammation like methylprednisolone.

The nurse in the ED is caring for a client who arrived by ambulance unconscious and hypotensive following a fall from a second-story balcony. It would be appropriate for the nurse to take which of the following actions? SATA

a. Transfusion of O-negative packed RBCs is indicated during emergencies when the client's blood type is unknown. b. Proper cervical alignment must be maintained to prevent potential cervical spine-injury, so log-rolling the client while one staff member holds the client's head in a neutral position is appropriate. c. A critically injured client has increased metabolic and oxygen demand and should be ventilated with 100% oxygen via non-rebreather mask.

The nurse in the ED is triaging clients who have arrived following a mass casualty incident. The nurse should consider which of the following factors when triaging clients? SATA

a. Triage systems take into account a client's physiologic stability b. Resource Utilization (ex. what kind of diagnostic testing and personnel is required)

Chest trauma after a fall. Assess for what complications? SATA a. PE b. hypertension c. hypovolemia d. bleeding e. cardiace failure f. respiratroy distress g. hypoxemia

c,d,e,f,g Hypovolemia, bleeding, cardiac failure, Respiratory distress, and hypoxemia. Not hypertension or a PE

The nurse in the ED receives a client who has choked on a piece of food and is unconscious. Abdominal thrusts and suctioning have failed to remove the foreign object, and the physician has determined intubation is impossible due to the obstruction. The nurse should emergently prepare for which of the following procedures?

emergent tracheotomy

The nurse in the ED is receiving a client who is arriving by ambulance after a traumatic accident. The paramedic reports that the client has asymmetric chest wall movement. The nurse demonstrates a correct understanding of this report by taking which of the following actions?

palpate for thoracic crepitus

The nurse in the emergency room is caring for a client whose serum blood sugar is 821 mg/dL. The nurse should expect the health care provider to prescribe which of the following insulins for intravenous infusion?

regular insulin

Moderate hypothermia and monitoring for which complication?

stroke

The nurse is preparing to administer an oral antidiabetic medication that stimulates release of insulin from pancreatic islets which in turn enhances cellular sensitivity to insulin. Which of the following types of oral medication should the nurse be administering?

sulfonylureas >>BIGUANIDES<<