Emergency Nursing

1. 1. Nitroglycerin should be mixed with D5W or normal saline (NS) only. 2. There are compatibility issues with many medications. The medication is best running through its own lumen. No medication not in the TPN bag should be administered through the TPN line. 3. Regular intravenous tubing can absorb 40%-80% of the nitroglycerin. This medication should be administered in the special tubing that comes with the medication. 4. Nitroglycerin patches should be removed when administering Tridil to prevent overdosage.

1. The nurse is preparing to administer a nitroglycerin (Tridil) drip to a client in cardiogenic shock. The client has total parental nutrition (TPN) running through a triple lumen catheter. Which intervention should the nurse implement? 1. Mix the nitroglycerin in 500 mL of lactated Ringer's. 2. Initiate the drip in its own line. 3. Use regular intravenous tubing when administering Tridil. 4. Ensure that the client's nitroglycerin patch is in a nonhairy area.

10. 1. This would be appropriate when injecting medications intramuscularly or subcutaneously, but dopamine can only be administered intravenously. 2. Sympathomimetics are incompatible with sodium bicarbonate or alkaline solutions. 3. The client in hypovolemic shock is in critical condition, and a thorough assessment must be completed on the client frequently. 4. This intervention is not specific for the dopamine administration, but a client in cardiogenic shock taking dopamine is in critical condition. An advance directive would be an appropriate intervention for this client. 5. Dopamine is not administered via Y-tubing. Blood and blood products are administered via Y-tubing. MEDICATION MEMORY JOGGER: "Select all that apply" questions require the test taker to view each option as a True/False question. One option cannot assist the test taker to eliminate another option.

10. The nurse is caring for a client diagnosed with cardiogenic shock who is receiving a dopamine drip, a sympathomimetic. Which interventions should the nurse implement? Select all that apply. 1. Aspirate the injection site to avoid injecting directly into the vein. 2. Do not administer any alkaline solutions in the same tubing as dopamine. 3. Assess the client's lung sounds, vital signs, and hemodynamic parameters. 4. Ask if the client has a living will or durable power of attorney for health care. 5. Administer the dopamine via a Y-tubing along with normal saline (0.9%).

11. 1. Chlorine is a gas, and, although the clothing may have some chlorine on it, decontamination procedures are not required. 2. Chlorine is a gas, and, although the clothing may have some chlorine on it, the chlorine in the clothing should not pose a threat to the ED. 3. Intravenous access is important, but not as important as supplying the clients with oxygen and ventilatory support. 4. Chlorine is a gas that when inhaled separates the alveoli from the capillary bed. Oxygenation and ventilatory support are the most important interventions.

11. The nurse working in an emergency department (ED) receives a call that the ED will be receiving multiple casualties from a chlorine chemical explosion. Which intervention is the most important in preparing for the victims? 1. Prepare to decontaminate the clients in a decontamination room. 2. Do not touch any of the clothing the clients are wearing. 3. Have intravenous supplies ready to start IV lines. 4. Prepare to administer oxygen immediately to all casualties.

12. 1. The incubation period is about 12 days. 2. The organism can survive on clothing and blankets in cool temperatures for at least 24 hours. 3. Smallpox spreads by direct contact with an infected person, by droplet contact, or by coming into contact with a contaminated item of bedding or clothing. During the French and Indian War (1756-1767), smallpox was used as a weapon when contaminated bedding was sent into Indian villages, resulting in a 50% casualty rate. 4. The rash begins on the face, mouth, pharynx, and forearms and then proceeds to the trunk and the rest of the body.

12. The nurse is discussing the bioterrorism threat with a group in the community. Which information regarding smallpox should be included in the discussion? 1. The incubation period for smallpox is 3-4 days after exposure. 2. The organism can only live for 5-6 minutes outside the host body. 3. It can be spread by direct or indirect contact with an infected person. 4. The rash begins on the lower half of the body and progresses from there.

13. 1. Assessing is usually the first intervention, but in this case a delay of any kind in starting the antibiotics could result in death. 2. If antibiotics are initiated within 24 hours of the onset of symptoms of inhaled anthrax, death can be prevented. The nurse must keep in mind that the client will have had the symptoms for some hours before seeking medical attention. 3. Standard precaution procedures are all that are necessary. However, if the client dies, cremation should be the method of disposal of the body because the body can harbor the spores for decades and pose a threat to mortuary and medical examiner personnel. 4. The client's blood pressure should remain stable unless sepsis overwhelms the client's body, in which case the treatment is antibiotics. MEDICATION MEMORY JOGGER: The nurse must remember that if initiation of treatment can prevent a complication (death), then treatment has priority over assessment.

13. The client is suspected of being exposed to inhaled anthrax. Which priority intervention should the nurse implement? 1. Assess the client's lungs. 2. Start the IVPB antibiotics. 3. Place the client on respiratory isolation. 4. Maintain the client's blood pressure.

14. 1. Tularemia is extremely contagious and can be contracted by direct contact with infected animals or by breathing aerosolized tularemia bacteria used as a biologic weapon. The initial symptoms are a sudden onset of fever, fatigue, chills, headache, lower backache, malaise, rigor, coryza (profuse discharge from the mucous membranes of the nose), dry cough, sore throat without adenopathy, and nausea and vomiting. 2. These are not symptoms of tularemia. 3. These are not symptoms of tularemia. 4. These are not symptoms of tularemia.

14. The Homeland Security Office has issued a warning of suspected biological warfare using the Francisella tularensis (tularemia) bacteria. Which signs and symptoms support the initial diagnosis of tularemia? 1. Fever, chills, headache, and malaise. 2. Hypotension; red, raised rash; and nasal congestion. 3. Enlarged cervical lymph nodes and polydipsia. 4. Metallic taste and disorientation.

15. 1. Airborne precautions are used for clients suspected of having tuberculosis. Hospital staff must use 0.3-micron filtration masks when caring for these clients. This is not needed for clients diagnosed with botulism. 2. Clients diagnosed with botulism were infected by direct contact with the bacteria. It is not transmitted from human to human. Standard precautions are required for all clients. 3. Contact precautions are used to prevent contact with bacteria in wounds or infected gastrointestinal secretions. Botulism is not transmitted from human to human. 4. Droplet precautions are used for respiratory illnesses where transmission can occur when in close contact with the client. Botulism is not transmitted from human to human.

15. The client has been diagnosed with botulism. Which isolation procedures should the nurse implement? 1. Airborne precautions. 2. Standard precautions. 3. Contact precautions. 4. Droplet precautions.

16. 1. The client should wash the chemical off the body with a mild soap and water, not with normal saline. 2. The client should wash the chemical off the body with a mild soap and water, not with milk products. 3. The client should wash the chemical off the body with a mild soap and water. 4. The client should wash the chemical off the body with a mild soap and water, not with diluted baking soda.

16. The client has been exposed to nitrogen mustard gas. Which solution should be used to decontaminate the client? 1. Normal saline. 2. Milk and dairy products. 3. Soap and water. 4. Diluted baking soda.

17. 1. Valium is the drug of choice for the potential convulsions that are associated with nerve-agent toxicity. 2. Steroid medications would not be administered for excessive nerve stimulation. 3. Charcoal is administered to prevent absorption of ingested poisons. 4. Intravenous atropine 2-4 mg, followed by 2 mg every 3-8 minutes for 24 hours, is the drug of choice to reverse the toxic drug effects of malathion, a nerve agent. The ingredients in many pesticides bond with acetylcholinesterase so that acetylcholine cannot be removed from the body. The result is hyperstimulation of the nerve endings. MEDICATION MEMORY JOGGER: Atropine is the medication administered for symptomatic bradycardia. This might lead the test taker to choose option 4 as the correct answer.

17. The client working in a chemical plant that processes malathion for agricultural use presents to the emergency department with profuse sweating, visual disturbances, gastrointestinal disturbances, and bradycardia. Which medication should the nurse prepare to administer? 1.Dilantin, an anticonvulsant, IV every 4 hours. 2. Solu-Medrol, a glucocorticosteroid, IV every 8 hours. 3. Activated charcoal, an absorbent agent, PO every 2 hours. 4. Atropine, an anticholinergic, IV every 5 minutes.

18. 1. The smell of bitter almonds is associated with cyanide gas, a deadly poison. The nurse should evacuate the area. 2. The smell of bitter almonds is associated with cyanide gas, a deadly poison. The nurse should attempt to contain the gas to the area in question. 3. The nurse would notify local authorities and the administration of the plant, not federal emergency personnel. Nurses must know and follow emergency procedures and guidelines. 4. The administration of the plant or the local authorities are responsible for notifying the public. There are procedures designed to limit mass panic. 5. The signs of cyanide poisoning include respiratory muscle failure, respiratory or cardiac failure, and death.

18. The employee health nurse working in an industrial plant that manufactures cyanide smells the odor of bitter almonds. Which actions should the nurse implement? Select all that apply. 1. Have the workers evacuate the area. 2. Close off the area in question. 3. Notify the Office of Emergency Management. 4. Call the emergency broadcast system to alert the public. 5. Assess the workers for respiratory distress.

19. 1. Elevated blood pressure and bradycardia occur in the last phase of radiation sickness and death occurs soon after. 2. Fluid and electrolyte imbalance and shock occur in the illness phase after 4 or more weeks. 3. Decreased lymphocytes, leukocytes, and erythrocytes occur in the latent phase and can last for 3 weeks or more. 4. Nausea, vomiting, diarrhea, and fatigue are the initial presenting symptoms of exposure to radiation and occur within 48-72 hours after exposure.

19. The client is diagnosed with acute radiation syndrome (ARS). Which signs and symptoms would the nurse assess in the acute phase? 1. Elevated blood pressure and bradycardia. 2. Fluid and electrolyte imbalance and shock. 3. Decreased lymphocytes, leukocytes, and erythrocytes. 4. Nausea, vomiting, diarrhea, and fatigue.

2. 1. Clients must be connected to a cardiac monitor prior to and during the infusion of cardiotonic drugs. The client in cardiogenic shock will be in the intensive care department. 2. Dopamine is administered to increase the blood pressure, and the blood pressure must be monitored every 5 to 15 minutes. 3. The client's urinary output should be monitored hourly to ensure the client has at least 30 mL of urine output an hour. 4. Extravasation of dopamine causes severe, localized vasoconstriction, resulting in a slough of the tissue and tissue necrosis. The client should report burning at the IV site immediately. 5. Septic shock does not specifically affect the neurological system; therefore, the nurse does not need to assess this system every hour, just every shift.

2. The nurse is preparing to administer dopamine, a beta and alpha agonist, to a client in cardiogenic shock. Which intervention should the nurse implement? 1. Ensure the client is on a cardiac monitor. 2. Monitor the blood pressure every 15 minutes. 3. Evaluate the intake and output every hour. 4. Instruct the client to report burning at the intravenous site. 5. Assess the client's neurological status every hour.

20. 1. This would not be done until it is determined that all the clients have botulism. Then it is the individual who has the responsibility of working with the public health department who will notify the agency, not the emergency department nurse. 2. The clients' CBC results will not indicate if the clients have botulism. 3. Severe abdominal cramping, nausea, vomiting, and diarrhea are the symptoms of botulism, but it has not been determined that this is the diagnosis in the triage area. Determining whether the clients ate in the same place recently is the first step in determining if the client has been exposed to botulism. 4. The person with the responsibility for the facility should be notified whenever there is a potential situation where the press and the public will be arriving at the facility, but this is not the first intervention.

20. The emergency department triage nurse notes five clients have been admitted within 6 hours with complaints of severe abdominal cramping, nausea, vomiting, and diarrhea. Which intervention should the nurse implement first? 1. Notify the public health department of a botulism outbreak. 2. Check the clients' complete blood count results. 3. Determine if the clients ate at the same place recently. 4. Discuss the situation with the house supervisor

21. 1. Epinephrine is the first medication administered in a code because it constricts the periphery and shunts the blood to the trunk of the body. 2. Lidocaine is administered in ventricular fibrillation, but it is not administered first in a code. 3. Atropine is administered for asystole. 4. Digoxin is administered for cardiac failure.

21. A code has been called for the client experiencing ventricular fibrillation. Which medication should the nurse prepare to administer to the client? 1. Epinephrine, an adrenergic agonist, intravenous push. 2. Lidocaine, an antidysrhythmic, intravenous push. 3. Atropine, an antidysrhythmic, intravenous push. 4. Digoxin, a cardiac glycoside, intravenous push.

22. 1. Dopamine is administered to increase blood pressure. 2. The ABGs indicate the client is in metabolic acidosis, and the drug of choice is sodium bicarbonate. 3. Calcium gluconate is administered in clients experiencing hypocalcemia. 4. Adenosine is the drug of choice for supraventricular tachycardia (SVT).

22. The client in a code has the following arterial blood gases: pH 7.31, PaO2 60, PaCO2 58, and HCO3 19. Which medication should the nurse prepare to administer to the client? 1. Dopamine, a vasopressor medication. 2. Sodium bicarbonate, an alkalinizing agent. 3. Calcium gluconate, electrolyte replacement. 4. Adenosine, an antidysrhythmic medication.

23. 1. The medication should be pushed as fast as possible in a code situation. 2. Epinephrine is compatible with the primary intravenous line; therefore, there is no reason to flush the tubing before and after administering the medication. 3. A client in a code does not have blood circulating in the vascular system. Elevating the client's arm will help the medication get into the central circulation. 4. The epinephrine in the crash cart is diluted in 10 mL of normal saline in a bristojet and ready for administration; therefore, the nurse should not dilute the medication.

23. The nurse is administering epinephrine 0.5 mg intravenous push to a client in a code. The client has a primary intravenous line of D5W at to keep open (TKO) rate. Which intervention should the nurse implement? 1. Administer the medication over 5 minutes. 2. Flush the tubing before and after administering epinephrine. 3. Elevate the arm after administering the medication. 4. Dilute the medication with 10 mL normal saline.

24. 45 mL. Drip rates are set per hour. A drip rate of 3 mg/min is 180 mg/hour. If 500 mL contains 2000 mg (2 g) of lidocaine, then each milliliter contains 4 mg of lidocaine (2000 ÷ 500 = 4). To determine how many milliliters per hour are needed, divide 180 mg ÷ 4 = 45. The nurse should set the intravenous rate at 45 mL. MEDICATION MEMORY JOGGER: There is a way to remember this in an emergency situation: 1 mg (15 mL), 2 mg (30 mL), 3 mg (45 mL), 4 mg (60 mL). This is the rate if the medication is 2 g in 500 mL, which is how it comes, prepackaged.

24. The HCP orders a lidocaine drip at 3 mg/min for a client who has just converted from ventricular fibrillation to normal sinus rhythm with multiple premature ventricular contractions (PVCs). The intravenous bag has 2 g of lidocaine in 500 mL normal saline. How would the nurse set the intravenous rate?

25. 1. The client in asystole would not benefit from defibrillation because there is no heart activity. The client must have some heart activity (ventricular activity) for defibrillation to be successful. 2. Synchronized cardioversion is used for new-onset atrial fibrillation or unstable ventricular tachycardia. 3. Atropine is the drug of choice for asystole because it decreases vagal stimulation and increases heart rate. 4. The nurse should initiate and perform CPR on the client in asytole. 5. The nurse should determine if the client has a DNR, because if that is the case CPR should be discontinued.

25. The client who is coding is in asystole. Which interventions should the nurse implement? Select all that apply. 1. Prepare to defibrillate the client at 300 joules. 2. Prepare for synchronized cardioversion. 3. Prepare to administer atropine, intravenous push. 4. Initiate cardiopulmonary resuscitation (CPR). 5. Determine if the client has a do not resuscitate (DNR) order.

26. 1. This medication increases blood pressure, and the blood pressure should be monitored every 15 minutes, not every 2 hours. 2. The client's telemetry reading will not indicate the effectiveness of dopamine or identify complications secondary to the dopamine. Therefore, assessing the client's telemetry reading every hour is not a pertinent intervention for the dopamine administration. 3. The client's urine output must be assessed every hour to determine the effectiveness of the dopamine administration because dopamine increases the blood pressure. If the client's blood pressure increases, then the urine output increases; if the client's blood pressure decreases, then the urine output decreases. The kidneys will retain water to help increase the blood pressure. The client should have at least 30 mL/hour. 4. The glucose level is not used when evaluating the effectiveness of dopamine, nor does it identify complications secondary to the dopamine. Therefore, this is not a pertinent intervention for dopamine administration.

26. The client in a code is in ventricular fibrillation and then is in sinus rhythm with PVCs. After taking vital signs the HCP orders a dopamine, vasopressor, drip at 3 mg/kg per hour. Which intervention should the nurse implement concerning this medication? 1. Monitor the client's blood pressure every 2 hours. 2. Assess the client's telemetry reading every 1 hour. 3. Check the client's urine output every 1 hour. 4. Evaluate the client's glucometer readings every 4 hours.

27. 1. Dopamine is used to increase blood pressure. 2. Ventricular fibrillation is a very common dysrhythmia in a code situation, and lidocaine is the drug of choice because it suppresses ventricular ectopy. 3. Procainamide is an antidysrhythmic (Class 1A) medication that is used for ventricular and atrial dysrhythmias, but it is not the medication the nurse would prepare to administer for this specific dysrhythmia. 4. This medication is only used for cardiac failure.

27. The client is in a code and is exhibiting ventricular fibrillation. Which medication would the nurse prepare to administer? 1. Dopamine, a vasopressor, intravenous drip. 2. Lidocaine, an antidysrhythmic, intravenous push. 3. Procainamide, an antidysrhythmic, intravenous push. 4. Dobutamine, an inotropic medication, intravenous drip.

28. 1. Dopamine is incompatible with all other intravenous fluids; therefore, the nurse must initiate another intravenous line to infuse the dopamine in a separate line. 2. Dopamine is incompatible with all other intravenous fluids; therefore, it cannot be piggybacked with lidocaine. 3. The nurse does not need to question the order because the nurse can start another saline lock without talking to the healthcare provider. 4. The dopamine drip does not have to be administered via a subclavian line as long as it is not piggybacked through any other medication.

28. The nurse is preparing to hang a dopamine drip on the client who has just been successfully coded. The client is receiving lidocaine 2 mg/min in the existing IV site. Which intervention should the nurse implement when hanging the dopamine drip? 1. Initiate another intravenous line to administer the dopamine drip. 2. Piggyback the dopamine drip in the lidocaine tubing. 3. Question the order because dopamine cannot be administered with lidocaine. 4. Prepare to help the HCP insert a subclavian line for the dopamine drip.

29. 1. The ABGs do not indicate metabolic acidosis, so sodium bicarbonate should not be administered. 2. The PaO2 is low (normal is 80-100); therefore, the nurse should administer oxygen via a nasal cannula. Oxygen is considered a medication. 3. The ABGs are not normal and intervention is needed. 4. The client's ABGs reveal a low arterial oxygen level and do not need to be verified by a pulse oximeter reading.

29. The client has just been successfully resuscitated and has the following arterial blood gases (ABGs): pH 7.35, PaO2 78, PaCO2 46, and HCO3 22. Which intervention should the nurse implement? 1. Prepare to administer sodium bicarbonate IVP. 2. Administer oxygen 8 L/min via nasal cannula. 3. Take no action because the ABGs are within normal limits. 4. Assess the client's pulse oximeter reading.

3. 1. A blood pressure of 102/78 is a stable blood pressure reading for a client in hypovolemic shock. A B/P of less than 90/60 would warrant intervention by the nurse. 2. A pulse oximeter reading of greater than 93% indicates the arterial oxygen level is between 80 and 100, which is normal. 3. Because of the ability of all colloids, including dextran, to pull fluid into the vascular space, circulatory overload is a serious adverse outcome. Crackles in the lungs reflect pulmonary congestion, a sign of fluid-volume overload. 4. A urinary output of 120 mL in 3 hours indicates that the client is urinating 40 mL an hour. If the client has at least 30 mL of urine output an hour, then the kidneys are being perfused adequately. MEDICATION MEMORY JOGGER: If the client verbalizes a complaint, if the nurse assesses data, or if laboratory data indicates an adverse effect secondary to a medication, the nurse must intervene. The nurse must implement an independent intervention or notify the health-care provider because medications can result in serious or even life-threatening complications.

3. The client in hypovolemic shock is receiving dextran, a nonblood colloid. Which assessment data warrants immediate intervention by the nurse? 1. The client's blood pressure is 102/78. 2. The client's pulse oximeter reading is 95%. 3. The client's lung sounds reveal bilateral crackles. 4. The client's urine output is 120 mL in 3 hours.

30. 1. Amiodarone suppresses ventricular ectopy and is prescribed for life-threatening ventricular dysrhythmias unresponsive to less toxic agents. The nurse would not question this order. 2. Lidocaine is the drug of choice for ventricular dysrhythmias because it suppresses ventricular ectopy. The nurse would not question this order. 3. Defibrillation is the treatment of choice for a client in ventricular fibrillation. 4. Pacemakers are used for clients in symptomatic sinus bradycardia or asystole. This client is in ventricular fibrillation; therefore, the nurse would question this order.

30. The client in a code is in ventricular fibrillation. Which HCP order should the nurse question? 1. Administer amiodarone, an antidysrhythmic. 2. Administer lidocaine, an antidysrhythmic. 3. Prepare to defibrillate at 360 joules. 4. Prepare to insert an external pacemaker.

31. 1. The child must receive supportive care to maintain life until the poison can be identified and further specific measures can be implemented. 2. Treatment is facilitated by identifying the specific poison and the amount ingested. Then specific treatment can be instituted. 3. Limiting the amount of poison absorbed by the body can limit the damage. 4. Measures to eliminate the poison from the body prevent further absorption. 5. An antidote is administered to counteract the effects of the poison.

31. A 4-year-old child is brought to the emergency department as a suspected poisoning victim. Which interventions should the nurse implement? Select all that apply. 1. Implement supportive care. 2. Identify the poison. 3. Prevent further absorption of the poison. 4. Promote poison removal. 5. Administer the antidote.

32. 1. Charcoal does not change the pH of a substance. 2. Charcoal binds with the poison to form an inert substance that can be eliminated through the bowel because the body is incapable of absorbing charcoal molecules. The charcoal must be administered within 60 minutes of ingesting the poison. The feces will be black. 3. Charcoal can absorb the antidote. Charcoal should not be administered before, with, or immediately after the antidote. 4. Charcoal does not cause emesis. An emetic such as ipecac would induce vomiting.

32. Which statement best describes the scientific rationale for administering activated charcoal to a child who has ingested a poison? 1. Charcoal neutralizes toxic substances by changing the pH of the poison. 2. The charcoal binds with the poison, and it is excreted through the bowel. 3. Charcoal enhances antidotes for better results than antidotes given alone. 4. The charcoal induces vomiting, and the client eliminates much of the poison.

33. 1. Gastric lavage would not be contraindicated for a 2-year-old child in a coma who ingested the contents of a bottle of Tylenol. 2. Gastric lavage would not be contraindicated for a 3-year-old child who ate a bottle of unknown tablets. 3. Gastric lavage should not be attempted when there has been ingestion of caustic agents, convulsions are occurring, high-viscosity petroleum products have been ingested, cardiac dysrhythmias are present, or there is emesis of blood. Antidotes, supportive care, and prevention of aspiration are implemented if gastric lavage is not to be performed. 4. Gastric lavage would not be contraindicated for a 10-year-old who took painkillers.

33. The emergency department is caring for pediatric clients who have ingested poisons. Which client would the nurse question administering a gastric lavage? 1. The 2-year-old child in a coma who took a bottle of Tylenol. 2. The 3-year-old child who ate a bottle of unknown tablets. 3. The hyperactive 6-year-old child who swallowed motor oil. 4. The 10-year-old child who took a prescription of painkillers

34. 1. Ipecac stimulates vomiting, which can remove the medication from the stomach. It takes 20-30 minutes to work. 2. Telemetry monitoring is not as important as preparing the parent for the child's response to the medication. It is hoped that the medication will be removed from the child's system before significant impact on the heart can occur. 3. The child is unstable, and the nurse cannot delegate a client who is unstable to unlicensed personnel. 4. The digoxin should not remain in the child's body long enough for this to become important.

34. The nurse administered syrup of ipecac to an 18-month-old girl who swallowed her grandparent's prescription of digoxin. Which intervention is most important for the nurse to implement? 1. Tell the parent to expect vomiting to occur in 20 minutes. 2. Place the child on telemetry to monitor the cardiac status. 3. Have the unlicensed assistive personnel monitor the vital signs. 4. Order a STAT digoxin level to be drawn.

35. 1. 0.5 L of GoLYTELY every hour is the dose for children younger than 6 years old. 2. 1.0 L GoLYTELY every hour is the dose for children 6-12 years old. 3. 1.5-2.0 L of GoLYTELY is the dose for clients 12 years old or older. Whole bowel irrigation is effective following ingestion of lead, lithium, iron, and sustained-release medications. 4. This dosage is not recommended for any client.

35. The 13-year-old child admitted to the intensive care department diagnosed with an overdose of Ambien CR, a sedative hypnotic, is ordered whole bowel irrigation. Which intervention should the nurse implement? 1. Administer 0.5 L of GoLYTELY every hour. 2. Administer 1.0 L of GoLYTELY every hour. 3. Administer 1.5-2.0 L of GoLYTELY every hour. 4. Administer 2.5-3.0 L of GoLYTELY every hour.

36. 1. Material Safety Data safety information is required for every chemical in a healthcare facility, but it is not an agency to contact regarding specific poisons and the antidotes. 2. The National Poison Control Hotline (1-800-222-1222) is the equivalent of dialing 911 locally. The hotline can be dialed from anywhere in the United States, and the organization's representative will connect the nurse with the local poison control agency. 3. Child Protective Services (CPS) will not be able to help the nurse with information regarding the poison. 4. The police department will not be able to help the nurse with information regarding the poison. MEDICATION MEMORY JOGGER: In an emergency situation, the client must be cared for first, and then other agencies such as Child Protective Services (CPS) or the police may be notified.

36. The nurse working in the emergency department receives a child who has ingested a poison. Which referral agency should be contacted for specific information regarding the poison? 1. The Material Safety Data information line. 2. The National Poison Control Hotline. 3. Child Protective Services (CPS). 4. The local police department.

37. 1. Ipecac is not the preferred method for removal of a poison because it should not be given to clients experiencing convulsions or who have a reduced level of consciousness or otherwise cannot protect their airway. 2. Gastric lavage is not the preferred method of removal of an ingested poison because of the potential for aspiration of stomach contents into the lungs. 3. Catharsis (administration of harsh stimulant laxatives) may help to remove the poison, but this method has not been shown to improve clinical outcomes. 4. Activated charcoal and whole bowel irrigation are the preferred methods of removal of ingested poisons from the body. Activated charcoal binds with the poison and the body cannot absorb charcoal so the poison is eliminated in the feces.

37. The nurse is admitting a client suspected of poison ingestion to the emergency department. Which method is preferred to aid in the removal of ingested poisons? 1. Emesis. 2. Gastric lavage. 3. Catharsis. 4. Activated charcoal.

38. 1. Calcium EDTA is administered IM or IV because it is poorly absorbed though the gastrointestinal tract. 2. The drug and lead will be excreted though glomerular filtration. Therefore, kidney function is monitored, not liver function. 3. The drug and lead will be excreted through glomerular filtration; the nurse should ensure adequate renal function before administering the medication. 4. Calcium EDTA is not an emetic medication.

38. The health-care provider has prescribed edetate calcium disodium (Calcium EDTA), a chelating agent, for a child diagnosed with lead poisoning. Which intervention should the nurse implement? 1. Administer orally with a large glass of water. 2. Monitor the client's liver function tests. 3. Check the client's intake and output. 4. Tell the child to prepare to vomit.

39. 1. Narcan has a short half-life and could wear off before the effects of the narcotic cough syrup. The nurse should observe for signs of returning respiratory depression and be ready to intervene. 2. Negative pressure ventilators (the old iron lung) are not used anymore. Currently, positive pressure ventilation is preferred. 3. The narcotic cough syrup has depressed the client's respiratory status; therefore, the nurse should assess the child. 4. The child would have an endotracheal tube placed first, not a tracheostomy, for a few days until it is determined if the child needs permanent ventilatory support because of brain damage. 5. This is not the nurse's responsibility. The nurse would report the case to Child Protective Services (CPS), who could call the police if necessary.

39. The nurse administered the narcotic agonist naloxone (Narcan) to a 7-year-old child who drank a large bottle of narcotic cough syrup. Which interventions should the nurse implement? Select all that apply. 1. Prepare to administer Narcan again in 30 minutes. 2. Place the child on a negative pressure ventilator. 3. Assess the client's respiratory status. 4. Prepare the child for a tracheostomy. 5. Have the parents discuss the situation with the police.

49. 1. Epinephrine is the first medication administered intravenously or intratracheally, but oxygen should be administered when CPR is instituted. 2. Oxygen is the first medication administered to all clients experiencing cardiac arrest. It will be administered through an Ambu-bag via a face mask until the client is intubated. 3. Lidocaine is the drug of choice for ventricular dysrhythmias, but the client must be monitored by telemetry to determine the specific rhythm. 4. Atropine is the drug of choice for asystole, but the client must be monitored by telemetry to determine the specific rhythm.

49. Which medication should the nurse administer first to the client experiencing cardiac arrest? 1. Epinephrine, a sympathomimetic. 2. Oxygen via Ambu bag. 3. Lidocaine, an antidysrhythmic. 4. Atropine, an antidysrhythmic.

4. 1. Septic shock is secondary to an infection of the blood and a broad-spectrum antibiotic (such as Rocephin) is prescribed until cultures and sensitivity results are obtained. The antibiotic that is specific to the bacteria causing the septic shock—in this case, vancomycin—should be administered as soon as possible. 2. There is no reason for the nurse to call the HCP and question this order. 3. The nurse should not wait 10 hours to administer an antibiotic that will help save the client's life. Septic shock is life threatening and must be treated with the appropriate antibiotic as soon as possible. 4. The client's white blood cell count does not affect the nurse's responsibility to administer the vancomycin antibiotic as soon as possible.

4. The nurse is caring for the client in septic shock. The nurse administered the twice-a-day, intravenous, broad-spectrum antibiotic ceftriaxone (Rocephin) at 0900. At 1100 the health-care provider prescribed daily intravenous vancomycin, an aminoglycoside antibiotic. Which intervention should the nurse implement? 1. Administer the vancomycin within 2 hours. 2. Notify the HCP and question the antibiotic order. 3. Schedule the vancomycin to be administered at 2100. 4. Assess the client's white blood cell count

40. 1. A pulse oximeter would give a falsely high reading because the blood is saturated with carbon monoxide. 2. Arterial blood gases are not priority. 3. The client should receive high levels of oxygen. Carbon monoxide binds to the hemoglobin molecule with a greater affinity than oxygen. It is imperative to get oxygen to the client as quickly as possible. 4. The child should be prevented from chilling, but oxygen is the priority.

40. The school-age child is brought to the emergency department with carbon monoxide poisoning. Which intervention should the nurse implement first? 1. Place the child on a pulse oximeter. 2. Have respiratory therapy draw blood gases. 3. Administer oxygen at 10 L per minute. 4. Prevent chilling by wrapping the child in blankets.

41. 1. The weight of the child is pertinent information, but it is not the most important question. 2. If the prenatal vitamins have iron, this is a life-threatening situation. The child can hemorrhage because of the ulcerogenic effects of unbound iron, causing shock. As few as 10 tablets of ferrous sulfate (3 g) taken at one time can be fatal within 12 to 48 hours. This is the most important question to ask to determine what treatment the child should have for the accidental overdose. 3. Because the mother has called the emergency department, it is not priority to know if she called the Poison Control Center. 4. Determining if the vitamins may have lost potency if they were purchased months ago is not as high a priority as determining if the prenatal vitamins have iron.

41. The mother of a 2-year-old child calls the emergency department and reports that the child has swallowed a bottle of prenatal vitamins. Which question is most important for the nurse to ask the mother? 1. "How much does your daughter weigh?" 2. "Is it prenatal vitamins with or without iron?" 3. "Have you called the Poison Control Center?" 4. "When did you purchase the prenatal vitamins?"

42. 1. The first action the nurse should implement is to start an IV and infuse fluids, which will help rehydrate the client. 2. Antipyretic medication will not help decrease the temperature when the hyperpyrexia is secondary to a heatstroke. 3. The client should be kept NPO to prevent vomiting and possible aspiration. 4. Seizure precautions are not instituted for a client experiencing a heatstroke. MEDICATION MEMORY JOGGER: The stem of the question told the test taker that the situation is a "crisis." The first step in many crises is to make sure that an IV access is available to administer fluids and medications.

42. The client is admitted to the emergency department diagnosed with heatstroke. The client has a temperature of 104°F along with hot, dry skin. Which intervention should the nurse implement? 1. Start an IV to infuse intravenous fluids. 2. Administer the antipyretic acetaminophen (Tylenol). 3. Encourage the client to drink cold water. 4. Institute seizure precautions per hospital protocol.

43. 1. The Poison Control Center needs to know the type of poison ingested; therefore, this would not warrant intervention by the charge nurse. 2. The Poison Control Center needs to know the type and estimated time the poison was taken; therefore, this would not warrant intervention by the charge nurse. 3. The Poison Control Center does not need to know the client's vital signs; therefore, this would warrant intervention by the charge nurse. The center's responsibility is to inform the nurse of the antidote and treatment to decrease the possibility of life-threatening complications secondary to the poisoning. 4. The Poison Control Center needs to know the age and weight of the child to determine the severity of the poisoning; therefore, this would not warrant intervention by the charge nurse.

43. The emergency department (ED) nurse is notifying the Poison Control Center concerning an accidental poisoning of a 4-year-old child. Which action by the ED nurse warrants intervention by the charge nurse? 1. The ED nurse tells the center the type of poison ingested. 2. The ED nurse tells the center the type and estimated time the poison was taken. 3. The ED nurse informs the center of the client's vital signs. 4. The ED nurse tells the center the age and weight of the child ingesting the poison.

44. 1. There is no American First Aid Association. 2. The Board of Nurse Examiners does not have a section addressing emergency care outside the hospital. 3. The Good Samaritan Act protects nurses and lay rescuers when they are caring for individuals outside the hospital. Nurses are held to a different standard because the nurse has received teaching on first aid. 4. There is no Lay Rescuer Administration Act.

44. Which document protects the nurse from liability as long as no grossly negligent care or wilful misconduct is provided that deliberately harms a person outside the hospital? 1. The American First Aid Association mission. 2. The Board of Nurse Examiners First Aid section. 3. The Good Samaritan Act. 4. The Lay Rescuer Administration Act.

45. 1. Asking the client if he or she can speak is the correct action if the client is choking, not vomiting. 2. Because the client had a CVA, the client may not be able to sit on the side of the bed. 3. The client should be lying on the side to help prevent aspirating vomit contents into the lungs. 4. The client is vomiting; therefore, assessing the bowel sounds is not an appropriate nursing intervention. MEDICATION MEMORY JOGGER: When answering test questions or when caring for clients at the bedside, the nurse should remember that assessing the client may not be the first action to take when the client is in distress. The nurse may need to intervene directly to help the client.

45. The nurse has just completed administering medication to a client with a cerebrovascular accident (CVA) via a gastrostomy tube. As the nurse is leaving the room, the client starts vomiting. Which action should the nurse implement? 1. Ask the client if he or she can speak. 2. Assist the client to sit on the side of the bed. 3. Place the client in the side-lying position. 4. Assess the client's bowel sounds.

46. 1, 5, 3, 2, 4 1. The nurse must cleanse the area with soap and water to remove any debris. 5. The nurse should make sure the student is not allergic to any type of antibiotics before applying the ointment. Topical medication can cause allergic reactions. 3. The nurse should then apply the antibiotic ointment to help prevent a wound infection. 2. A dressing should be applied over the wound to help prevent infection. 4. The nurse should then determine when the last tetanus shot was administered to determine if the student needs a booster.

46. The school nurse is caring for a 14-year-old student who stepped on a rusty nail that punctured the skin. Which interventions should the nurse implement? Rank in the order of performance. 1. Cleanse the puncture site with soap and water. 2. Put sterile, nonadhesive dressings on the wound. 3. Apply an antibiotic ointment to the puncture site. 4. Determine when the child last had a tetanus shot. 5. Ask the student if he or she is allergic to any antibiotic.

47. 1. Physiologic stress, such as might occur after a head injury, increases the blood glucose level; therefore, the client must take insulin as prescribed but needs glucose (carbohydrates) to prevent hypoglycemia. Therefore, the client should drink the amount of carbohydrates in the prescribed ADA diet, which includes popsicles, regular Jell-O, or regular cola. This statement indicates the client needs more teaching prior to discharge. 2. The client can take acetaminophen (Tylenol) for a headache secondary to a head injury. The client does not need more teaching. 3. Nausea and vomiting are signs of increasing intracranial pressure, and the client should call the HCP. This statement indicates the client does not need more teaching. 4. The client should not take any type of sedatives, which may cause further neurologic deficit. The client does not need more teaching prior to discharge.

47. The client with Type 2 diabetes is being discharged from the emergency room after sustaining a head injury. Which statement indicates the client needs more teaching prior to discharge from the emergency room? 1. "I should not take my insulin if I am unable to eat." 2. "I should take a couple of Tylenol if I have a headache." 3. "If I become nauseated or start vomiting, I will call my doctor." 4. "I will not take any type of sedative medications."

48. 1. Dopamine is administered to increase the client's blood pressure, but the client must have an IV route. Because the client does not have an IV route, this is not the nurse's first intervention. 2. Laboratory tests are important, but not more important than preventing circulatory collapse, which is inevitable in a client in hypovolemic shock, as this client is. 3. Protonix is administered to decrease gastric acid production, but the client must have an IV route; therefore, this is not the first intervention. 4. The client's vital signs indicate shock, and with the history of PUD, the nurse should suspect hypovolemic shock; however, no matter what type of shock, the nurse must first initiate intravenous therapy because of the low blood pressure and increased heart rate.

48. The client who has a history of peptic ulcer disease presents to the emergency department with a B/P of 86/42 and an apical pulse of 128. Which intervention should the nurse implement first? 1. Administer dopamine, a sympathomimetic, by IV constant infusion. 2. Request a stat CBC, Chem 7, and type and crossmatch. 3. Prepare to administer intravenous Protonix, a proton-pump inhibitor. 4. Initiate an IV with lactated Ringer's with an 18-gauge angiocath.

5. 1. Levophed must be tapered, but this is not the priority nursing intervention when administering this medication. Caring for the client is always priority. 2. Administering medication on an infusion pump is important, but the priority intervention is caring for the client, not a machine. 3. The nurse should check the client's renal status, but the priority nursing intervention is assessing the data for which the client is receiving the medication. 4. Norepinephrine is a powerful vasoconstrictor; therefore, continuous monitoring of the blood pressure is required to avoid hypertension.

5. The client in cardiogenic shock is receiving norepinephrine (Levophed), a sympathomimetic. Which priority intervention should the nurse implement? 1. Do not abruptly discontinue the medication. 2. Administer medication on an infusion pump. 3. Check the client's creatinine level and BUN. 4. Monitor the client's blood pressure continuously.

50. 1. The client's vital signs must be monitored every 15 minutes throughout the 6-hour intravenous infusion because of the great potential for a lifethreatening reaction to the antivenin. 2. Benadryl must be administered prior to the initiation of the antivenin infusion to decrease the allergic response to the antivenin. This is an H1 antihistamine. 3. The leg circumference should be measured every 30-60 minutes for 48 hours after the infusion. 4. Tagamet must be administered prior to the initiation of the antivenin infusion to decrease the allergic response to the antivenin. This is an H2 antihistamine.

50. The client presented to the emergency department (ED) with a rattlesnake bite on the left foot 2 hours ago. Which intervention should the nurse implement during the administration of the antivenin? 1. Take the client's vital signs every 15 minutes. 2. Administer diphenhydramine (Benadryl), an H1 antagonist. 3. Monitor the circumference of the left leg every 4 hours. 4. Administer cimetidine (Tagamet), an H2 histamine blocker.

51. 1. The UAP can assist the client to the bathroom, but the UAP does not have the knowledge to determine if the stool color is normal for this client. If the client received charcoal, the stool should be black. 2. IV fluids are considered medications, and the nurse cannot delegate medication administration to a UAP. 3. An overdose of sleeping pills should be considered a suicide attempt until proved otherwise. The client should be on one-to-one suicide precautions. A UAP could sit with the client. 4. The Glasgow Coma Scale assesses the client's neurologic status, and this cannot be delegated to a UAP.

51. The 22-year-old college student is admitted to the medical department with an overdose of sleeping pills. Which task should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Ask the UAP to assess the stool for color. 2. Have the UAP reset the rate on the IV pump. 3. Instruct the UAP to sit with the client. 4. Evaluate the client's Glasgow Coma Scale.

52. 1. Lye must be removed by brushing because water can initiate an explosion or deepening of the wound. Using a biohazard bag ensures the lye does not contaminate the environment. This action would not warrant intervention by the charge nurse. 2. Because lye is an alkaline substance and can causing burning of the skin or of the respiratory membranes if inhaled, the nurse should wear PPE. This action would not warrant intervention for the charge nurse. 3. For a burn secondary to lye, the client will be administered blood, which should be infused with an 18-gauge angiocath. The nurse starting the IV with a 20-gauge angiocath would not warrant immediate intervention from the nurse. 4. Water should not be applied to burns from lye or white phosphorus because of the potential for an explosion or deepening of the wound. Lye should be brushed off the client.

52. The client with a chemical burn with lye is brought to the emergency department by the paramedics. Which action by the staff nurse warrants immediate intervention by the charge nurse? 1. The nurse is brushing the lye into a biohazard bag. 2. The nurse wears personal protective equipment. 3. The nurse starts an IV with a 20-gauge angiocath. 4. The nurse is washing the lye off the client with water.

53. 1. The client will not be able to tolerate oral medications until the nausea is controlled; therefore, Lomotil will be administered. The client needs to rid the body of the offending substance; therefore, diarrhea is not stopped. 2. Antibiotics are not administered to clients with food poisoning. 3. Medications administered to decrease gastric acid may or may not be given to the client, but it is not the first medication administered. 4. Measures to control nausea and vomiting will prevent further fluid and electrolyte loss; therefore, an antiemetic is the first medication that should be administered.

53. The client tells the triage nurse in the emergency department (ED) she has food poisoning like the rest of the people who ate at a local restaurant. The client has been vomiting and has had diarrhea for the past 6 hours and needs help. Which medication should the nurse administer first? 1. Diphenoxylate (Lomotil), an antidiarrheal. 2. Ceftriaxone (Rocephin), an antibiotic, intravenous piggyback. 3. Pantoprazole (Protonix), a proton-pump inhibitor. 4. Diluted promethazine (Phenergan), an antiemetic, intravenous push.

54. 1. Mifepristone and misoprostol do not prevent STDs. 2. Mifepristone and misoprostol will cause the client to abort any potential fetus. They must be taken within 3-5 days after the act of sexual intercourse. 3. Antianxiety medications, not mifepristone and misoprostol, would be prescribed for anxiety and nervousness. 4. Mifepristone and misoprostol do not promote wound healing.

54. The client who is being discharged from the emergency department (ED) after being raped is offered the medications mifepristone (RU-486), a birth control pill, and misoprostol (Cytotec), a prostaglandin. Which statement best describes the scientific rationale for administering these medications? 1. These medications will help prevent the client from getting a sexually transmitted disease. 2. These medications are known as the "morning after pills" and will prevent implantation of an ovum. 3. These medications will help decrease the anxiety and nervousness of the client. 4. These medications will promote the healing process of the vaginal tissues.

55. 1. The client with an open fracture will be receiving antibiotics to prevent infection. 2. The nurse should apply ice, not heat, to an acute injury. 3. The client with a fracture will have pain; therefore, the nurse should evaluate the effectiveness of the medication given for pain. 4. The client with an open fracture will have to go to surgery; therefore, preparing to administer the pre-op medication is an appropriate intervention. 5. The HCP or surgeon is responsible for explaining the surgical procedure; this is not within the realm of the nurse's responsibility.

55. The client has an open fracture of the right forearm. Which interventions should the emergency department nurse implement? Select all that apply. 1. Administer a prophylactic antibiotic. 2. Apply a warm pack to the right forearm. 3. Evaluate the effectiveness of the pain medication. 4. Prepare to administer the preoperative medication on call. 5. Explain the surgical procedure to the client and family.

56. 1. Dextrose 50% is the drug of choice to treat hypoglycemia if the client is in a comatose state or not able to cooperate. This client exhibits signs of hypoglycemia. 2. The client who is uncooperative may refuse fluids or choke when being belligerent. If the client were cooperative, the family could have given the client juice. 3. The nurse should determine how much and when the client last took insulin and when the client last ate any foods. 4. Glucagon is provided in an emergency kit to be used by significant others at home to treat hypoglycemic reactions. It takes longer to elevate the client's glucose level and is dependent on the client's glycogen stores. 5. The nurse should obtain a glucose level as soon as possible.

56. The client with Type 1 diabetes is brought to the emergency department (ED) by the family. The client is belligerent, confused, and uncooperative. Which interventions should the nurse implement? Select all that apply. 1. Administer 1 amp of dextrose 50%. 2. Give the client 2 cups of orange juice. 3. Determine when the client took the last insulin shot. 4. Inject glucagon subcutaneously in the abdomen. 5. Obtain a glucose level via glucometer.

57. 1. Determining if the client is right- or lefthanded really does not matter because the sutures must be placed in the hand with the laceration. 2. The nurse should determine the client's allergies. The HCP must inject the laceration with lidocaine prior to suturing; therefore, the nurse must determine if the client is allergic to lidocaine. The wound may be cleaned with Betadine (allergy to iodine) and the client may be prescribed antibiotics (allergy to antibiotic); therefore, the nurse must determine any allergies to these substances. In addition, a tetanus injection may be administered. 3. The history of how the accident occurred is not the most important information. 4. The statement could possibly initiate an anxiety reaction, and the nurse cannot do anything if the client is afraid of needles.

57. The HCP is preparing to suture a laceration on the client's right hand. Which question is most important for the nurse to ask the client? 1. "Are you right- or left-handed?" 2. "Do you have any allergies?" 3. "How did you cut yourself?" 4. "Are you afraid of needles?"

58. 1. This question is appropriate if the nurse suspects elder abuse, but the client's physiologic status is priority at this time. 2. This question is appropriate if the nurse suspects elder abuse, but the client's physiological status is priority at this time. 3. The nurse should suspect elder abuse including unfilled medication prescriptions and other forms of neglect. This client's blood pressure is extremely high and could lead to a lifethreatening condition if antihypertensive medications are not administered immediately. According to Maslow's Hierarchy of Needs, physiological needs are priority over potential other problems. 4. This question is appropriate if the nurse suspects elder abuse, but the client's physiological status is priority at this time.

58. The elderly client with chronic hypertension is brought to the emergency department by the caregiver. The client has a blood pressure of 198/120 and has multiple contusions on the abdomen and forearms. Which question is most important for the nurse to ask the client? 1. "How did you get the bruises on your abdomen and forearm?" 2. "Has anyone forced you to sign papers against your will?" 3. "When was the last time you took your blood pressure medication?" 4. "You seem frightened. Are you afraid of anyone in your home?"

59. 1. This is a warning, not an actual event; therefore, the nurse should not initiate the disaster plan. 2. Tularemia is not contagious from humanto- human contact; it is acquired through direct contact with infected animals or by inhaling aerosolized bacteria. There is no decontamination for this. 3. Antitoxins are available for botulism but not for tularemia. 4. For persons exposed to this biologic bacterium, doxycycline is recommended for 14 days. The nurse should ensure that a supply of doxycycline is available.

59. The Homeland Security Office has issued a warning of suspected biological warfare using the Francisella tularensis (tularemia) bacteria. Which intervention should the charge nurse implement? 1. Initiate the hospital's external emergency disaster plan. 2. Instruct the staff to prepare the decontamination area. 3. Prepare to administer the antitoxin intravenously. 4. Check on the supply of oral doxycycline, an antibiotic.

6. 1. This is the scientific rationale for administering vasodilators such as nitroglycerin (Tridil) or nitroprusside (Nipride), not colloid solutions. 2. This is the scientific rationale for administering adrenergics (sympathomimetics) such as norepinephrine (Levophed), not colloid solutions. 3. This is the scientific rationale for administering a colloid solution. They are blood volume expanders that promote circulatory volume and tissue perfusion. 4. Crystalloid solutions, such as isotonic (0.9% normal saline) or hypotonic (0.45% normal saline) solutions, increase fluid volume in both the intravascular and the interstitial space.

6. The nurse is preparing to administer albumin 5% (Albuminar-5), a colloid solution. Which statement is the scientific rationale for administering this medication? 1. Albumin acts directly on the smooth muscles to cause vasodilatation. 2. Albumin mimics the fight-or-flight response of the sympathetic nervous system. 3. Albumin is a blood volume expander that promotes circulatory volume. 4. Albumin contains dextrose and increases fluid volume in the interstitial space.

60. 250 mL. The nurse must know that aminoglycoside antibiotics are very ototoxic and nephrotoxic and must be administered via an infusion pump over a minimum of 1 hour. The IV pump is regulated to infuse mL/hour.

60. The client with botulism poisoning is prescribed gentamycin, an aminoglycoside antibiotic. The medication is available in 250 mL of normal saline. At which rate should the nurse set the IV pump?

7. 1. Shortness of breath, low back pain, and itching all over the body are signs of anaphylactic shock and epinephrine is the drug of choice to treat anaphylaxis. 2. The client's assessment data indicates an anaphylactic reaction to the blood transfusion, which is life threatening. The nurse should take action and assess the client. 3. The nurse should keep an intravenous access so that normal saline and medication can be administered to help prevent anaphylactic shock. 4. Discontinuing the blood at the hub of the intravenous catheter is the first intervention because the client is exhibiting signs of an anaphylactic reaction, which can lead to anaphylactic shock if the allergen (blood) is not stopped immediately. Many different allergens can cause anaphylactic shock, including medications, blood administration, latex, foods, snake venom, and insect stings. 5. The client is having an allergic reaction to the blood and the health-care provider should be notified. MEDICATION MEMORY JOGGER: When answering test questions or when caring for clients at the bedside, the nurse should remember assessing the client may not be the first action to take when the client is in distress. The nurse may need to intervene directly to help the client.

7. During the first 15 minutes of administering blood to a client, the client complains of shortness of breath, low back pain, and itching all over the body. Which interventions should the nurse implement? Select all that apply. 1. Administer 0.5 mL of epinephrine, an adrenergic, intravenously. 2. Assess the client's temperature, pulse, and blood pressure. 3. Infuse normal saline at 125 mL an hour via a peripheral IV. 4. Discontinue the blood at the hub of the intravenous catheter. 5. Notify the client's health-care provider of the situation.

8. 1. An infusion pump should be used when administering dobutamine because an overdose, which could occur if a drip via gravity is used, could cause the client's death. This action by the primary nurse would warrant immediate intervention by the charge nurse. 2. A urometer is a plastic triangular container that can be attached to a Foley catheter and allows the nurse to obtain hourly urinary outputs. This action would not require intervention by the charge nurse. 3. Monitoring the client's peripheral oxygen saturation would be appropriate for a client in cardiogenic shock; therefore, this action would not warrant intervention by the charge nurse. 4. The nurse should always check the client for any types of allergies; therefore, this action would not warrant intervention by the nurse.

8. The primary nurse is preparing to administer dobutamine (Dobutrex), a beta1-adrenergic agonist, to a client in cardiogenic shock. Which action by the primary nurse warrants intervention by the charge nurse? 1. The primary nurse is administering the dobutamine drip via gravity. 2. The primary nurse attaches a urometer to the client's Foley catheter. 3. The primary nurse applies a pulse oximeter to the client's finger. 4. The primary nurse checks the client for any medication allergies.

9. 1. The nurse should address the infiltrated site because of the toxic effects of the medication in the tissue. The blood pressure reading and apical pulse rate will not help the infiltrated site. 2. This is not the appropriate action to take when dopamine infiltrates. 3. Extravasation of dopamine causes severe, localized vasoconstriction, resulting in a slough of the tissue and tissue necrosis if not reversed with the antidote phentolamine (Regitine) injections at the site of the infiltration. 4. The IV should be discontinued, but the nurse must take further action or the IV site may have tissue necrosis.

9. The client in cardiogenic shock is receiving dopamine, a beta and alpha agonist. The peripheral intravenous site becomes infiltrated. Which intervention should the nurse implement? 1. Assess the client's blood pressure and apical pulse. 2. Elevate the arm and apply ice to the infiltrated area. 3. Inject phentolamine (Regitine) at the site of infiltration. 4. Discontinue the IV and take no other action.