Ex#2 PN3 (study if you want to pass)

Emergent interventions for a client with burns to the face and trunk/arms may include which of the following? (SATA)

-Inserting an indwelling urinary catheter -Intubating the client -Starting an intravenous solution of Ringer's lactate

A client who ignited a rubbish pile with gasoline-sustained burns to his anterior torso, bilateral anterior legs and right anterior arm. Using the rule of nines, what is the total body surface area (TBSA) % of burns?

40.5%

A client is being evaluated in the emergency department following a burn injury at home. The client has second- and third-degree burns to the right and left arms, back and both posterior legs. Using the rule of nines, the nurse would calculate this client's burn as being:

54%

A client presents to the Emergency Department with 30% total body surface area (TBSA) burns. The client weighs 176lbs. Use the Parkland Formula (4ml) to calculate the hourly rate for the first 8 hours.

600ml/hr

A client is diagnosed with superior ventricular tachycardia, the nurse should prepare to administer which of the following medications?

Adenosine

In the event of a mass casualty situation the best triage nurse is:

The RN with the most experience and best assessment skills

An elderly man was found unresponsive in his home and unable to give a history of any contributing events. The nurse recognizes the man's skin color of "cherry red" as a sign that he has suffered from?

Carbon monoxide poisoning

A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)?

Provide frequent oral care per protocol

A one day post operative client is experiencing a sudden onset of chest pain, SOB, and hemoptysis. Based on history and presenting symptoms, which condition does the nurse expect?

Pulmonary Embolism (PE)

The nurse is in the emergency department is using a triage system because this system ranks clients by:

Severity of illness or injury

You are the nurse caring for a client who has developed a tension pneumothorax. The physician performs an emergency ECHO at the bedside and determines that your clients cardiac output is 3L/min. As the nurse caring for this client you understand that a cardiac output of 3L/min is:

→ 3L/min is below normal and puts the client at increased risk of poor perfusion and death. (normal 4-8 range)

A nurse in the intensive care unit is providing teaching for a client prior to removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching?

"Avoid speaking for long periods"

A client is on mechanical ventilation and the client's spouse wonders why ranitidine (Zantac) is needed since the client "only has lung problems." What response by the nurse is best?

"It will prevent ulcers from the stress of mechanical ventilation"

The nurse is caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this?

-Chest wall stiffness -Decreased muscle strength -Less lung elasticity

A client is suspected of having cardiac damage. The nurse realizes which of the following diagnostic tests is most commonly used to help diagnose this client's possible cardiac damage or disease?

12-lead electrocardiogram

A client has sustained a 50% TBSA burns to torso and extremities in a house fire. The main weighs 154lbs (70kg). Using the Parkland formula, how much fluid would this client be given in the first 24 hours?

14,000ml

A nurse is completing discharge teaching with a client who has a permanent pacemaker. Which of the following statements by the client is correct?

"I will call my doctor about prolonged hiccups"

A nurse is triaging clients in the emergency department. Which client would the nurse classify as "non-urgent?"

A 62-year old with a simple fracture of the left arm

A client with a history of dysrhythmias is placed on a cardiac monitor. The following rhythm is observed. The nurse correctly documents is as which rhythm?

Atrial flutter

A client has sustained circumferential full thickness burns to the left arm. The nurse knows that the fluid buildup under the burns and the eschar can lead to compression of the arterial circulation of the extremity. To restore the blood flow to the extremity which intervention will be necessary?

Escharotomy

The emergency department nurse is preparing to triage victims of an internal event. Which of the following would be considered an internal event?

Fire in the hospital

A nurse is field-triaging clients after an industrial accident. Which client condition would the nurse triage with a red tag?

Multiple fractured ribs and shortness of breath

A client is unresponsive and has no pulse, the nurse notes the electrocardiogram tracing shows continuous larger and bizarre QRS complexes measured greater than 0.12, this rhythm is identified as:

Ventricular tachycardia (DEFIBRILLATE)

Which of the following should be implemented to ensure the safe use of defibrillator? (SATA)

-Do not place over monitor electrodes -No note place over implanted pacemaker

The nurse is concerned about developing post-traumatic stress disorder after working for several years in the emergency department. Which of the following should the nurse do to ensure this disorder does not manifest? (SATA)

-Eat well balanced meals -Drink water -Take breaks when needed -Do not work more than 12 hours per day

A client is receiving a large amount of fluids using the Parkland Formula following burns of 50% TBSA. the nurse knows that signs of fluid overload includes? (SATA)

-Formation of dependent edema -Presence of lung crackles on auscultation -Engorged neck veins

A client with pulmonary embolism will have which of the following interventions? (SATA)

-IVC (inferior vena cava filter) -Embolectomy -Heparin drug therapy

Which of the following interventions are for a client diagnosed with pneumothorax? (SATA)

-Monitor respiratory and circulatory function -Assess for tracheal deviation -Provide analgesics -Insertion of a chest tube

A client has just been intubated following cardiac arrest. The nurse knows that in order to ensure the endotracheal tube (ET) has been placed properly is to: (SATA)

-Observe for symmetrical chest movement -Assess breath sounds bilaterally -Verify with chest x-ray

Post-operative complications after pacemaker insertion will include which of the following? (SATA)

-Pericardial effusion -Infection -Hematoma at insertion site -arrhythmias

Which of the following interventions would be appropriate for a client who is being mechanically ventilated? (SATA)

-Secure artificial airway -Auscultate lungs every 4 hours and as needed -Monitor endotracheal tube cuff pressure once per shift -Provide alternative form of communication -Monitor arterial blood gas analysis results and adjust the ventilator as needed

A client with decreased cardiac output will exhibit which of the following signs and symptoms? (SATA)

-Tachycardia -Elevated respirations -Dizziness (syncope) -Pallor

A nurse who is caring for a client who has a deep vein thrombosis and is prescribed continuous IV infusion at 1,200 units/hr. Available is heparin 25,000 units in 500 mL D5W. The nurse should set the IV pump to deliver how many ml/hr?

24ml/Hr

Mr. M. is admitted to the hospital with a GI bleed and his physician orders a blood transfusion of packed red blood cells. Order: 1 unit PRBCs (40 ml) IV to infuse over 4 hours. Drop factor: 15gtt/ml. What is the infusion rate in gtt/min?

25gtt/min

The nurse is caring for a client who is experiencing an increase in cardiac contractility, which of the following will decrease cardiac contractility and reduce myocardial oxygen?

Administer beta-blockers as prescribed

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care. The nurse should identify which of the following risks as the priority for assessment and intervention?

Airway obstruction

An emergency department charge nurse notes an increase in sick calls and bickering amongst the staff after a week with multiple trauma incidents. What action should the nurse take?

Arrange for critical incident stress debriefing

A client complains of fluttering in his chest, the nurse applies the cardiac monitor and correctly identifies the following rhythm as:

Atrial fibrillation

A 56 year old female presents to the emergency department complaining of lightheadedness and chest palpitations, HR is 190, BP 70/40 the cardiac monitoring shows the following. What is the appropriate treatment?

Cardiovert

A nurse is performing cardiopulmonary resuscitation (CPR) for an adult client who is unresponsive. The nurse should evaluate the client's circulation by palpating which of the following pulses?

Carotid

The nurse is caring for a client that has been in a car accident. The nurse notices the client's chest are movements are paradoxical (inward movement of the thorax with inspiration with outward movement of the thorax with expiration). The nurse knows this condition is:

Flail chest

The nurse knows this drug will minimize the growth of existing clots and prevent the development of additional clots in the client with pulmonary embolism:

Heparin

You are providing care to Mary, a 22-year old female who received burns to much of her head and anterior neck. As the nurse, you understand that Mary should be positioned in which of the following positions to prevent contractures of the head and neck?

Hyperextension with no pillow

The nurse is initiating care for a client diagnosed with burns to chest, back, neck, and face. For this client which following diagnosis would receive the highest priority?

Ineffective airway clearance

The client has been intubated due to Acute Respiratory Distress Syndrome. Following a chest x-ray for ET tube placement, the tube was readjusted. The client's abdomen is distended. In order to decompress the abdomen the intervention necessary will be:

Insert a nasogastric tube (NG)

When caring for a client with severe burns, the nurse can expect to administer pain medication via which route?

Intravenous (IV)

The nurse is preparing for which intervention when she gets the code (crash) cart, airway equipment box, calls for the appropriate personnel and sets up suction?

Intubation

A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center?

Level II- located within community hospitals and provides care to most injured clients

The client sustained a blunt chest trauma and has a life threatening tension pneumothorax. Initial management of a tension pneumothorax is an immediate:

Needle thoracostomy

A client is admitted to the ICU with a flail chest and placed on mechanical ventilation. The nurse should monitor for which of the following?

Pneumonia because the client is a high risk for acquiring infection

The nurse is aware that this phase in burn injury began at admission, however it is technically defined when there has been wound closure?

Rehabilitation phase

The nurse caring for a client with severe burns, realizes that the clients care will progress through specific periods of treatment EXCEPT:

Stabilization period

A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support?

Talk with the client during wound care

A nurse is interpreting the ECG of a client who has bradycardia. Which of the following cardiac components should the nurse identify as the role of the P wave?

→ Atrial depolarization