NCLEX: Emergency planning, Mass Casualties, Disaster

The mother of a 3-year-old boy calls the emergency department and states that she found an empty bottle of acetaminophen on the floor. She states that she thinks her child ingested all of the medication. What is the priority question for the nurse to ask the mother? 1. "Is your child breathing okay?" 2. "Is your child alert and oriented?" 3. "Where is your child at this moment?" 4. "Do you know how many tablets were in the bottle?"

1. "Is your child breathing okay?"

Acetylcysteine is prescribed for a client in the hospital emergency department after diagnosis of acetaminophen overdose. The nurse prepares to administer the medication using which procedure? 1. Diluting the medication in cola and administering it to the client orally 2. Calling the respiratory department to administer the medication via inhaler 3. Obtaining a 1-mL syringe to administer the small dose via the subcutaneous route 4. Obtaining an appropriate-size syringe and needle for intramuscular injection in the ventrogluteal muscle

1. Diluting the medication in cola and administering it to the client orally

The nurse is the first responder at the scene of a 6-car crash on a highway. Which victim should the nurse attend to first? 1.A victim experiencing dyspnea 2.A victim experiencing confusion 3.A victim experiencing tachycardia 4.A victim experiencing intense pain

1.A victim experiencing dyspnea

A client with chronic kidney disease being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious, and the nurse suspects air embolism. What are the priority nursing actions? Select all that apply. 1.Administer oxygen to the client. 2.Continue dialysis at a slower rate after checking the lines for air. 3.Notify the primary health care provider (PHCP) and Rapid Response Team. 4.Stop dialysis, and turn the client on the left side with head lower than feet. 5.Bolus the client with 500 mL of normal saline to break up the air embolus.

1.Administer oxygen to the client. 3.Notify the primary health care provider (PHCP) and Rapid Response Team. 4.Stop dialysis, and turn the client on the left side with head lower than feet.

The nurse is caring for a client experiencing acute lower gastrointestinal bleeding. In developing the plan of care, which priority problem should the nurse assign to this client? 1.Deficient fluid volume related to acute blood loss 2.Risk for aspiration related to acute bleeding in the GI tract 3.Risk for infection related to acute disease process and medications 4.Imbalanced nutrition, less than body requirements, related to lack of nutrients and increased metabolism

1.Deficient fluid volume related to acute blood loss

The nurse is developing a nursing care plan for a client with a circumferential burn injury of the right arm. What is the nurse's priority action? 1.Monitor the radial pulse every hour. 2.Keep the extremity in a dependent position. 3.Document any changes that occur in the pulse. 4.Place pressure dressings and wraps around the burn sites.

1.Monitor the radial pulse every hour.

A client experienced an open pneumothorax (sucking wound), which has been covered with an occlusive dressing. The client begins to experience severe dyspnea, and the blood pressure begins to fall. The nurse should first perform which action? 1.Remove the dressing. 2.Reinforce the dressing. 3.Call the primary health care provider (PHCP). 4.Measure oxygen saturation by oximetry.

1.Remove the dressing.

A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition? 1.Right pneumothorax 2.Pulmonary embolism 3.Displaced endotracheal tube 4.Acute respiratory distress syndrome

1.Right pneumothorax

The nurse is monitoring the intravenous (IV) infusion of an antineoplastic medication. During the infusion, the client complains of pain at the insertion site. On inspection of the site, the nurse notes redness and swelling and that the infusion of the medication has slowed in rate. The nurse suspects extravasation and should take which actions? Select all that apply. 1.Stop the infusion. 2.Prepare to apply ice or heat to the site. 3.Restart the IV at a distal part of the same vein. 4.Notify the primary health care provider (PHCP). 5.Prepare to administer a prescribed antidote into the site. 6.Increase the flow rate of the solution to flush the skin and subcutaneous tissue.

1.Stop the infusion. 2.Prepare to apply ice or heat to the site. 4.Notify the primary health care provider (PHCP). 5.Prepare to administer a prescribed antidote into the site.

The nurse has a prescription to administer acetylcysteine to a client admitted to the emergency department with acetaminophen overdose. Before giving this medication, what is the nurse's best action? 1. Administer the full-strength solution. 2. Empty the stomach by emesis or lavage. 3. Check that the antidote is readily available. 4. Ensure that the client knows how to use a nebulizer.

2. Empty the stomach by emesis or lavage.

A client begins experiencing wheezing, anxiety, swelling, and hives after eating shellfish and is brought to the emergency department. Which immediate action should the nurse implement? 1. Administer epinephrine. 2. Maintain a patent airway. 3. Administer a corticosteroid. 4. Apply a MedicAlert bracelet.

2. Maintain a patent airway.

A client arrives in the emergency department following an automobile crash. The client's forehead hit the steering wheel, and a hyphema is diagnosed. The nurse should place the client in which position? 1.Flat in bed 2.A semi-Fowler's position 3.Lateral on the affected side 4.Lateral on the unaffected side

2.A semi-Fowler's position

The police arrive at the emergency department with a client who has lacerated both wrists. Which is the initial nursing action? 1.Administer an antianxiety agent. 2.Assess and treat the wound sites. 3.Secure and record a detailed history. 4.Encourage and assist the client to ventilate feelings.

2.Assess and treat the wound sites.

A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply. 1.Restrict fluids. 2.Assess for airway patency. 3.Administer oxygen as prescribed. 4.Place a cooling blanket on the client. 5.Elevate extremities if no fractures are present. 6.Prepare to give oral pain medication as prescribed.

2.Assess for airway patency. 3.Administer oxygen as prescribed. 5.Elevate extremities if no fractures are present.

A client who attempted suicide by hanging is brought to the emergency department by emergency medical services. Which is the immediate nursing action? 1.Take the client's vital signs, including pulse oximetry reading. 2.Assess the client's respiratory status and for the presence of neck injuries. 3.Perform a focused assessment, paying particular attention to the client's neurological status. 4.Call the mental health crisis team and notify them that a client who attempted suicide is being admitted.

2.Assess the client's respiratory status and for the presence of neck injuries.

A depressed client is found unconscious on the floor in the dayroom of a health care facility. The nurse finds several empty bottles of a prescribed tricyclic antidepressant lying near the client. Which is the priority action of the nurse? 1.Call the poison control center. 2.Call the emergency response team. 3.Determine the exact number of pills taken. 4.Induce vomiting and notify the primary health care provider

2.Call the emergency response team.

A client is brought to the emergency room with a snake bite to the arm. Which treatment interventions should the nurse anticipate? Select all that apply. 1.Apply ice to the site. 2.Deliver supplemental oxygen. 3.Apply a tourniquet just above the site. 4.Maintain the extremity at the level of the heart. 5.Infuse crystalloid fluids through 2 large-bore intravenous (IV) lines. 6.Immobilize the affected extremity in a position of function with a splint.

2.Deliver supplemental oxygen. 4.Maintain the extremity at the level of the heart. 5.Infuse crystalloid fluids through 2 large-bore intravenous (IV) lines. 6.Immobilize the affected extremity in a position of function with a splint.

A client experiencing cocaine toxicity is brought to the emergency department. The nurse should prepare to take which initial action? 1. Administer naloxone. 2.Ensure a patent airway. 3.Establish an intravenous access. 4.Obtain a 12-lead electrocardiogram (ECG).

2.Ensure a patent airway.

The nurse is caring for a client who sustained a thermal burn caused by the inhalation of steam 24 hours ago. The nurse determines that the priority nursing action is to assess which item? 1.Pain level 2.Lung sounds 3.Ability to swallow 4.Laboratory results

2.Lung sounds

The nurse has developed a nursing care plan for a client with a burn injury to implement during the emergent phase. Which priority intervention should the nurse include in the plan of care? 1.Monitor vital signs every 4 hours. 2.Monitor mental status every hour. 3.Monitor intake and output every shift. 4.Obtain and record weight every other day.

2.Monitor mental status every hour.

The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply. 1.Open doors to client rooms. 2.Move beds away from windows. 3.Close window shades and curtains. 4.Place blankets over clients who are confined to bed. 5.Relocate ambulatory clients from the hallways back into their rooms.

2.Move beds away from windows. 3.Close window shades and curtains. 4.Place blankets over clients who are confined to bed.

A client arrives in the emergency department with a penetrating eye injury from wood chips that occurred while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the initial nursing action? 1.Apply an eye patch. 2.Perform visual acuity tests. 3.Irrigate the eye with sterile saline. 4.Remove the piece of wood using a sterile eye clamp.

2.Perform visual acuity tests.

A client with myocardial infarction is developing cardiogenic shock. What condition should the nurse carefully assess the client for? 1. Pulsus paradoxus 2.Ventricular dysrhythmias 3.Rising diastolic blood pressure 4.Falling central venous pressure

2.Ventricular dysrhythmias

Which client should the emergency department triage nurse classify as emergent? 1.A client with a displaced fracture who is crying 2.A client with a simple laceration and soft tissue injury 3.A client with crushing substernal pain who is short of breath 4.A client with a temperature of 101º F (38.3º C) with a productive cough

3.A client with crushing substernal pain who is short of breath

The nurse is performing an assessment on a client who sustained circumferential burns of both legs. Which assessment would be the initial priority in caring for this client? 1.Assessing heart rate 2.Assessing respiratory rate 3.Assessing peripheral pulses 4.Assessing blood pressure (BP)

3.Assessing peripheral pulses

The nurse is caring for a child who was burned in a house fire. The nurse develops a plan of care for monitoring the child during the treatment for burn shock. The nurse identifies which assessment as providing the most accurate guide to determine the adequacy of fluid resuscitation? 1.Heart rate 2.Lung sounds 3.Level of consciousness 4.Amount of edema at the site of the burn injury

3.Level of consciousness

A client receiving thrombolytic therapy with a continuous infusion of alteplase suddenly becomes extremely anxious and complains of itching. The nurse hears stridor and notes generalized urticaria and hypotension. Which nursing action is the priority? 1.Administer oxygen and protamine sulfate. 2.Cut the infusion rate in half and sit the client up in bed. 3.Stop the infusion and call for the Rapid Response Team (RRT). 4.Administer diphenhydramine and epinephrine and continue the infusion.

3.Stop the infusion and call for the Rapid Response Team (RRT).

A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client? 1. 100% oxygen via an aerosol mask 2.Oxygen via nasal cannula at 6 L/minute 3.Oxygen via nasal cannula at 15 L/minute 4. 100% oxygen via a tight-fitting, nonrebreather face mask

4. 100% oxygen via a tight-fitting, nonrebreather face mask

The nurse witnesses an accident whereby a pedestrian is hit by an automobile. The nurse stops at the scene and assesses the victim. The nurse notes that the victim is responsive and has suffered trauma to the thorax resulting in a flail chest involving at least 3 ribs. What is the nurse's priority action for this victim? 1. Assist the victim to sit up. 2. Remove the victim's shirt. 3. Turn the victim onto the side opposite the flail chest. 4. Apply firm but gentle pressure with the hands to the flail segment.

4. Apply firm but gentle pressure with the hands to the flail segment.

The nurse is caring for a client who sustained multiple fractures in a motor vehicle crash 12 hours earlier. The client now exhibits severe dyspnea, tachycardia, and mental confusion, and the nurse suspects fat embolism. Which is the initial nursing action? 1. Reassess the vital signs. 2. Palpate bilateral peripheral pulses. 3. Perform a neurological assessment. 4. Position the client in a Fowler's position.

4. Position the client in a Fowler's position.

The nurse has administered a dose of salmeterol to a client. The client develops a generalized rash and urticaria, and the eyelids begin to swell. Which action should the nurse take? 1.Apply a lanolin-based cream to the rash. 2.Encourage the client to drink fluids quickly. 3.Assess the client's vision with a Snellen chart. 4.Call the primary health care provider (PHCP) immediately.

4.Call the primary health care provider (PHCP) immediately.

The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an intravenous (IV) infusion at a rate of 150 mL/ hr, unchanged for the last 10 hours. The client's urine output for the last 3 hours has been 90, 50, and 28 mL (28 mL is most recent). The client's blood urea nitrogen level is 35 mg/dL (12.6 mmol/L), and the serum creatinine level is 1.8 mg/dL (159 mcmol/L), measured this morning. Which nursing action is the priority? 1.Check the serum albumin level. 2.Check the urine specific gravity. 3.Continue monitoring urine output. 4.Call the primary health care provider (PHCP).

4.Call the primary health care provider (PHCP).

The nurse is caring for a client in the emergency department who has sustained a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing that this sequence is compatible with which most likely condition? 1.Concussion 2.Skull fracture 3.Subdural hematoma 4.Epidural hematoma

4.Epidural hematoma

A client who sustained an inhalation injury arrives in the emergency department. On initial assessment, the nurse notes that the client is very confused and combative. The nurse determines that the client is most likely experiencing which condition? 1.Pain 2.Fear 3.Anxiety 4.Hypoxia

4.Hypoxia

The nurse is performing an assessment on a client who was admitted with a diagnosis of carbon monoxide poisoning. Which assessment performed by the nurse would primarily elicit data related to a deterioration of the client's condition? 1.Skin color 2.Apical rate 3.Respiratory rate 4.Level of consciousness

4.Level of consciousness

The nurse in the recovery room is caring for a client who underwent neurosurgery. Sequential compression devices (SCDs) have been applied to prevent venous stasis. While awaiting client transfer to the intensive care unit, the recovery room nurse should perform which critical assessment? 1.Assess radial pulses. 2.Log roll client to check skin integrity. 3.Monitor hemoglobin and hematocrit levels. 4.Monitor vascular status of the lower extremities.

4.Monitor vascular status of the lower extremities.

The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the first-priority intervention in the event of this occurrence is which action? 1.Immobilize the affected extremity. 2.Remove jewelry and constricting clothing from the victim. 3.Place the extremity in a position so that it is below the level of the heart. 4.Move the victim to a safe area away from the snake and encourage the victim to rest.

4.Move the victim to a safe area away from the snake and encourage the victim to rest.

A child undergoes surgical removal of a brain tumor. During the postoperative period, the nurse notes that the child is restless, the pulse rate is elevated, and the blood pressure has decreased significantly from the baseline value. The nurse suspects that the child is in shock. Which is the most appropriate nursing action? 1.Place the child in a supine position. 2.Place the child in Trendelenburg's position. 3.Increase the flow rate of the intravenous fluids. 4.Notify the primary health care provider (PHCP).

4.Notify the primary health care provider (PHCP).

The primary health care provider (PHCP) arrives on the nursing unit and deflates the esophageal balloon of a client's Sengstaken-Blakemore tube. The nurse should contact the PHCP immediately if which occurs? 1.The client has some diarrhea that is bloody. 2.The client's blood pressure is 128/78 mm Hg. 3.The client complains of abdominal discomfort. 4.The client complains of nausea and vomits blood.

4.The client complains of nausea and vomits blood.

The nurse is the first responder at the scene of an accident in which a tire blowout caused a bus to roll over several times. Which victim should the nurse attend to first? 1.The 11-year-old with burns to 10% of both legs 2.The sobbing 10-year-old with an obvious fracture of the forearm 3.The unconscious 14-year-old whose breathing is shallow at 12 respirations per minute 4.The confused 12-year-old with bright red blood pulsing from an open fracture of the femur

4.The confused 12-year-old with bright red blood pulsing from an open fracture of the femur

The nurse is admitting a young child who arrived from the emergency department after treatment for acetaminophen overdose. After administering the antidote, the nurse should reassess the child, including which priority laboratory value? 1.Thyroid panel 2.Urine drug screen 3.Liver function panel 4.Kidney function tests

3.Liver function panel

A 5-year-old boy is brought by his mother to the emergency department after ingesting a bottle of acetylsalicylic acid. Which procedure should be initially instituted with this child? 1. Administer ipecac by mouth and monitor emesis. 2. Institute a gastric lavage and administer activated charcoal. 3. Administer a chelating agent such as edetate calcium disodium. 4.Institute a gastric lavage and administer the antidote acetylcysteine.

2. Institute a gastric lavage and administer activated charcoal.

The nursing educator has just completed a lecture to a group of nurses regarding care of the client with a burn injury. A major aspect of the lecture was care of the client at the scene of a fire. Which statement, if made by a nurse, indicates a need for further instruction? 1."Flames should be doused with water." 2."The client should be maintained in a standing position." 3."Flames may be extinguished by rolling the client on the ground." 4."Flames may be smothered by the use of a blanket or another cover."

2."The client should be maintained in a standing position."

The nurse is providing care for a client who sustained burns over 30% of the body from a fire. On assessment, the nurse notes that the client is edematous in both burned and unburned body areas. The client's wife asks why her husband "looks so swollen." What is the nurse's best response? 1."Constricted blood vessels have caused a loss of protein in the blood." 2."Leaking blood vessels have led to increased protein amounts in the blood." 3."Leaking blood vessels have led to decreased protein amounts in the blood." 4."Constricted blood vessels have led to increased protein amounts in the blood."

3."Leaking blood vessels have led to decreased protein amounts in the blood."

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the primary health care provider (PHCP) and anticipates which prescription? 1.Transfusing 1 unit of packed red blood cells 2.Administering a diuretic to increase urine output 3.Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour 4.Changing the IV lactated Ringer's solution to one that contains 5% dextrose in water

3.Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour

The nurse receives a telephone call from a mother, who states that her 3-year-old child was found sitting on the kitchen floor with an empty bottle of liquid furniture polish. The mother of the child tells the nurse that the bottle was half full, that the child's breath smells like the polish, and that spilled polish is present on the front of the child's shirt. What should the nurse tell the mother to do first? 1. Call the pediatrician. 2. Induce vomiting immediately. 3. Call the poison control center. 4. Bring the child to the emergency department.

3. Call the poison control center.

The nurse is reviewing the medical record of a client transferred to the medical unit from the critical care unit. The nurse notes that the client received intra-aortic balloon pump (IABP) therapy while in the critical care unit. The nurse suspects that the client received this therapy for which condition? 1.Heart failure 2.Pulmonary edema 3.Cardiogenic shock 4.Aortic insufficiency

3. Cardiogenic shock

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? 1.A client who is ambulatory demonstrating steady gait 2.A postoperative client who has just received an opioid pain medication 3.A client scheduled for physical therapy for the first crutch-walking session 4.A client with a white blood cell count of 14,000 mm3 (14 x 109/L) and a temperature of 38.4° C

4. client with a white blood cell count of 14,000 mm3 (14 x 109/L) and a temperature of 38.4° C

A client is brought to the emergency department immediately after a smoke inhalation injury. The nurse initially prepares the client for which treatment? 1.Pain medication 2.Endotracheal intubation 3.Oxygen via nasal cannula 4.100% humidified oxygen by face mask

4.100% humidified oxygen by face mask

A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? 1.Initiate an intravenous line. 2.Assess the client's blood pressure. 3.Prepare to administer morphine sulfate. 4.Administer oxygen, 8 to 10 L/minute, by face mask.

4.Administer oxygen, 8 to 10 L/minute, by face mask.

A child is receiving succimer for the treatment of lead poisoning. The nurse should monitor which most important laboratory result? 1.Iron level 2.Calcium level 3.Red blood cell count 4.Blood urea nitrogen level

4.Blood urea nitrogen level

A pulmonary artery catheter is inserted into a client during cardiac surgery. The nurse is monitoring the right atrial pressure (RAP). Which finding requires immediate nursing intervention? 1. 4 mm Hg 2. 6 mm Hg 3. 8 mm Hg 4. 12 mm Hg

4. 12 mm Hg Normal range 1-8. Elevated RAP may indicate right ventricular failure.

A client is admitted to the hospital with a diagnosis of neurogenic shock after a traumatic motor vehicle collision. Which manifestation best characterizes this diagnosis? 1.Bradycardia 2.Hyperthermia 3.Hypoglycemia 4.Increased cardiac output

1.Bradycardia

The nurse is monitoring a client who required a Sengstaken-Blakemore tube because other measures for treating bleeding esophageal varices were unsuccessful. The client complains of severe pain of abrupt onset. Which nursing action is most appropriate? 1.Cut the tube. 2.Reposition the client. 3.Assess the lumens of the tubes. 4.Administer the prescribed analgesics.

1.Cut the tube.

The community health nurse is preparing to teach personnel and family preparedness for disasters to a group of parents of school-age children. Which items should the nurse plan to include in disaster preparedness? Select all that apply. 1. Flashlight 2. Supply of batteries 3. Battery-operated radio 4. Extra pair of eyeglasses 5. 4-week supply of water 6. 4-week supply of nonperishable food

1. Flashlight 2. Supply of batteries 3. Battery-operated radio 4. Extra pair of eyeglasses

The client who has experienced a myocardial infarction (MI) is recovering from cardiogenic shock. The nurse knows that which observation of the client's clinical condition is most favorable? 1. Urine output of 40 mL/hr 2. Heart rate of 110 beats/minute 3. Frequent premature ventricular contractions 4. Central venous pressure (CVP) of 15 mm Hg

1. Urine output of 40 mL/hr

The nurse in the hospital emergency department is notified by emergency medical services that several victims who survived a plane crash will be transported to the hospital. Victims are suffering from cold exposure because the plane plummeted and was submerged in a local river. What is the initial action of the nurse? 1.Call the nursing supervisor to activate the agency disaster plan. 2.Supply the triage rooms with bottles of sterile water and normal saline. 3.Call the intensive care unit to request that nurses be sent to the emergency department. 4.Call the laundry department and ask the department to send as many warm blankets as possible to the emergency department.

1.Call the nursing supervisor to activate the agency disaster plan.

The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. Which statement indicates that the student correctly identifies the priority client needs? 1.Actual or life-threatening concerns 2.Completing care in a reasonable time frame 3.Time constraints related to the client's needs 4.Obtaining needed supplies to care for the client

1.Actual or life-threatening concerns

A client develops an anaphylactic reaction after receiving morphine. The nurse should plan to institute which actions? Select all that apply. 1.Administer oxygen. 2.Quickly assess the client's respiratory status. 3.Document the event, interventions, and client's response. 4.Keep the client supine regardless of the blood pressure readings. 5.Leave the client briefly to contact a primary health care provider (PHCP). 6.Start an intravenous (IV) infusion of D5W and administer a 500-mL bolus.

1.Administer oxygen. 2.Quickly assess the client's respiratory status. 3.Document the event, interventions, and client's response.

A client develops an anaphylactic reaction after receiving morphine. The nurse should plan to institute which actions? Select all that apply. 1.Administer oxygen. 2.Quickly assess the client's respiratory status. 3.Document the event, interventions, and client's response. 4.Leave the client briefly to contact a primary health care provider (PHCP). 5.Keep the client supine regardless of the blood pressure readings. 6.Start an intravenous (IV) infusion of D5W and administer a 500-mL bolus.

1.Administer oxygen. 2.Quickly assess the client's respiratory status. 3.Document the event, interventions, and client's response.

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles. The nurse immediately asks another nurse to contact the primary health care provider and prepares to implement which priority interventions? Select all that apply 1.Administering oxygen 2.Inserting a Foley catheter 3.Administering furosemide 4.Administering morphine sulfate intravenously 5.Transporting the client to the coronary care unit 6.Placing the client in a low-Fowler's side-lying position

1.Administering oxygen 2.Inserting a Foley catheter 3.Administering furosemide 4.Administering morphine sulfate intravenously

The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention should be initiated immediately? 1.Apply ice to the affected eye. 2.Irrigate the eye with cool water. 3.Notify the primary health care provider (PHCP). 4.Accompany the client to the emergency department.

1.Apply ice to the affected eye.

A client presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client? 1.Assessment of vital signs 2.Completion of abdominal examination 3.Insertion of the prescribed nasogastric tube 4.Thorough investigation of precipitating events

1.Assessment of vital signs

The community health nurse is providing a teaching session to firefighters in a small community regarding care of a burn victim at the scene of injury. The nurse instructs the firefighters that in the event of a tar burn, which is the immediate action? 1.Cooling the injury with water 2.Removing all clothing immediately 3.Removing the tar from the burn injury 4.Leaving any clothing that is saturated with tar in place

1.Cooling the injury with water

The emergency department nurse is monitoring a client who received treatment for a severe asthma attack. The nurse determines that the client's respiratory status has worsened if which is noted on assessment? 1.Diminished breath sounds 2.Wheezing during inhalation 3.Wheezing during exhalation 4.Wheezing throughout the lung fields

1.Diminished breath sounds

The nurse is developing a plan of care for a client who sustained an inhalation burn injury. Which nursing intervention should the nurse include in the plan of care for this client? 1.Elevate the head of the bed. 2.Monitor oxygen saturation levels every 4 hours. 3.Encourage coughing and deep breathing every 4 hours. 4.Assess respiratory rate and breath sounds every 4 hours.

1.Elevate the head of the bed.

The nurse is reviewing the laboratory test results for a client admitted to the burn unit 3 hours after an explosion that occurred at a worksite. The client has a severe burn injury that covers 35% of the total body surface area (TBSA). The nurse is most likely to note which finding on the laboratory report? 1.Hematocrit 60% (0.60) 2.Serum albumin 4.8 g/dL (48 g/L) 3.Serum sodium 144 mEq/L (144 mmol/L) 4.White blood cell (WBC) count 9000 mm3 (9 × 109/L)

1.Hematocrit 60% (0.60)

A client with depression receiving phenelzine sulfate suddenly complains of a severe headache and neck stiffness and soreness and then begins to vomit. The nurse takes the client's blood pressure and notes that it is 210/102 mm Hg. On the basis of the findings, the nurse should obtain which medication from the emergency drawer of the medication cart? 1.Phentolamine 2.Protamine sulfate 3.Calcium gluconate 4.Phenobarbital sodium

1.Phentolamine

The industrial nurse is providing instructions to a group of employees regarding care to a client in the event of a chemical burn injury. The nurse instructs the employees that which is the first consideration in immediate care? 1.Removing all clothing, including gloves, shoes, and any undergarments 2.Determining the antidote for the chemical and placing the antidote on the burn site 3.Leaving all clothing in place until the client is brought to the emergency department 4. Lavaging the skin with water and avoiding brushing powdered chemicals off the clothing

1.Removing all clothing, including gloves, shoes, and any undergarments

The nurse in charge of a nursing unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply. 1.A client with chest pain 2.A client with a Holter monitor 3.A client receiving oral antibiotics 4.A client experiencing sinus rhythm 5.A client newly diagnosed with atrial fibrillation 6.A client experiencing third-degree heart block who requires a pacemaker

2.A client with a Holter monitor 3.A client receiving oral antibiotics 4.A client experiencing sinus rhythm

The nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the nurse attend to first? 1.A pregnant woman who exclaims, "My baby is not moving." 2.A woman who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!" 3.A young child standing next to an adult family member who is screaming, "I want my mommy!" 4.An older victim who is sitting next to her husband sobbing, "My husband is dead. My husband is dead."

2.A woman who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!"

The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which initial action? 1.Prepare the triage rooms. 2.Activate the emergency response plan. 3.Obtain additional supplies from the central supply department. 4.Obtain additional nursing staff to assist in treating the casualties.

2.Activate the emergency response plan.

A client who suffered carbon monoxide poisoning from working on an automobile in a closed garage has a carbon monoxide level of 15%. The nurse should anticipate observing which sign or symptom? 1.Coma 2.Flushing 3.Dizziness 4.Tachycardia

2.Flushing

An emergency department nurse is caring for a conscious child who was brought to the emergency department after the ingestion of half a bottle of acetylsalicylic acid (aspirin). The nurse anticipates that which will be the initial treatment? 1.Placement of a dialysis catheter 2.The administration of an emetic 3.The administration of vitamin K 4.The administration of sodium bicarbonate

2.The administration of an emetic

The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first? 1.A victim experiencing excruciating pain 2.A victim experiencing moderate anxiety 3.A victim experiencing airway obstruction 4.A victim experiencing altered level of consciousness

3.A victim experiencing airway obstruction

The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first? 1.A middle-aged man with 1 foot trapped under the wreckage 2.A crying teenager who is holding pressure on an arm laceration 3.A young woman who appears dazed and confused and is shivering 4.A screaming middle-aged woman looking frantically for her husband

3.A young woman who appears dazed and confused and is shivering

The nurse is performing an assessment on a client admitted to the nursing unit who has sustained an extensive burn injury involving 45% of total body surface area. When planning for fluid resuscitation, the nurse should consider that fluid shifting to the interstitial spaces is greatest during which time period? 1.Immediately after the injury 2.Within 12 hours after the injury 3.Between 18 and 24 hours after the injury 4.Between 42 and 72 hours after the injury

3.Between 18 and 24 hours after the injury

The nurse should report which assessment finding to the primary health care provider (PHCP) before initiating thrombolytic therapy in a client with pulmonary embolism? 1.Adventitious breath sounds 2.Temperature of 99.4º F (37.4º C) orally 3.Blood pressure of 198/110 mm Hg 4.Respiratory rate of 28 breaths/minute

3.Blood pressure of 198/110 mm Hg

The nurse from a medical unit is called to assist with care for clients coming into the hospital emergency department during an external disaster. Using principles of triage during a disaster, the nurse should attend to the client with which problem first? 1.Fractured tibia 2.Penetrating abdominal injury 3.Bright red bleeding from a neck wound 4.Open massive head injury in deep coma

3.Bright red bleeding from a neck wound

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the primary health care provider? 1.Dry cough 2.Hematuria 3.Bronchospasm 4.Blood-streaked sputum

3.Bronchospasm

The nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. The nurse immediately applies sterile gauze over the chest tube insertion site. Which is the nurse's next action? 1.Replace the chest tube system. 2.Obtain a pulse oximetry reading. 3.Call the primary health care provider. 4.Place the client in a Trendelenburg's position.

3.Call the primary health care provider.

The community health nurse is working with disaster relief after a tornado. The nurse assists in finding safe housing for survivors, providing support to families, organizing counseling, and securing physical care when needed. Which level of prevention does the nurse exercise? 1.Primary level of prevention 2.Secondary level of prevention 3.Tertiary level of prevention 4.Quaternary level of prevention

3.Tertiary level of prevention

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? 1.Obtain a court order for the surgical procedure. 2.Ask the EMS team to sign the informed consent. 3.Transport the victim to the operating room for surgery. 4.Call the police to identify the client and locate the family.

3.Transport the victim to the operating room for surgery.

An emergency department nurse is preparing to receive 4 clients as a result of a motor vehicle crash. Which victim should the nurse attend to first? 1. A child with a bleeding laceration 2. A 54-year-old woman with a fractured wrist 3. A 67-year-old woman with first-degree burns on her hands and arms 4. A 45-year-old man with chest pain, shortness of breath, and diaphoresis

4. A 45-year-old man with chest pain, shortness of breath, and diaphoresis

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? 1.A postoperative client preparing for discharge with a new medication 2.A client requiring daily dressing changes of a recent surgical incision 3.A client scheduled for a chest x-ray after insertion of a nasogastric tube 4.A client with asthma who requested a breathing treatment during the previous shift

4. A client with asthma who requested a breathing treatment during the previous shift Airway is priority!! You would want to assess if the treatment

The nurse is giving a bed bath to an assigned client when an assistive personnel (AP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action? 1.Finish the bed bath and then administer the pain medication to the other client. 2.Ask the AP to find out when the last pain medication was given to the client. 3.Ask the AP to tell the client in pain that medication will be administered as soon as the bed bath is complete. 4.Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

4.Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client. Although I would NEVER think to do this... it is counted as correct. I personally would choose option 1 or delegate the UAP to finish bed bath and then you leave.

A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be performed. During assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot. Which action should the nurse take? 1.Administer an analgesic. 2.Release the skin traction. 3.Apply ice to the extremity. 4.Notify the primary health care provider (PHCP).

4.Notify the primary health care provider (PHCP).

A client in sinus bradycardia, with a heart rate of 45 beats per minute and blood pressure of 82/60 mm Hg, reports dizziness. Which intervention should the nurse anticipate will be prescribed? 1.Administer digoxin. 2.Defibrillate the client. 3.Continue to monitor the client. 4.Prepare for transcutaneous pacing.

4.Prepare for transcutaneous pacing.

The nurse is a responder at the scene of a building collapse. Which victim should the nurse care for first? 1. Victim with an open fracture of the left lower extremity 2.Victim who is crying hysterically and complaining of pain in the right ankle 3.Victim who is unresponsive and not breathing and whose left pupil is fixed and dilated 4.Victim with an apparent chest wall defect and asymmetrical chest wall movement

4.Victim with an apparent chest wall defect and asymmetrical chest wall movement Victim number 3 is dead, so you go to the next most urgent

The occupational health nurse is called to care for an employee who experienced a traumatic amputation of a finger. Which actions should the nurse take to provide emergency care and prepare the client for transport to the hospital? Select all that apply. 1. Elevate the extremity above heart level. 2. Assess the employee for airway or breathing problems. 3. Remove the layered gauze every 10 minutes to check the bleeding. 4. Wrap the severed finger in moistened gauze, and place it in a bag of ice water. 5. Examine the amputation site and apply direct pressure to the site using layers of gauze.

1. Elevate the extremity above heart level. 2. Assess the employee for airway or breathing problems. 5. Examine the amputation site and apply direct pressure to the site using layers of gauze.

A client with type 1 diabetes mellitus in the emergency department is diagnosed with diabetic ketoacidosis (DKA). Which interventions should the nurse anticipate being prescribed initially? Select all that apply. 1.Monitoring urine for ketones 2.Intravenous potassium replacement 3.Administration of intravenous insulin 4.A bolus of 5% dextrose intravenously 5.Administration of a liter of 0.9% NaCl intravenously

1.Monitoring urine for ketones 2.Intravenous potassium replacement 3.Administration of intravenous insulin 5.Administration of a liter of 0.9% NaCl intravenously

A client begins to experience drainage of small amounts of bright red blood from the tracheostomy tube 24 hours after a supraglottic laryngectomy. Which is the best nursing action? 1.Notify the primary health care provider (PHCP). 2.Increase the frequency of suctioning. 3.Add moisture to the oxygen delivery system. 4.Document the character and amount of drainage.

1.Notify the primary health care provider (PHCP).

A 2-year-old child is being transported to the trauma center from a local community hospital for treatment of a burn injury that is estimated as covering more than 40% of the body. The burns are both partial- and full-thickness burns. The nurse is asked to prepare for the arrival of the child and gathers supplies, anticipating that which treatment will be prescribed initially? 1.Insertion of a Foley catheter 2.Insertion of a nasogastric tube 3.Administration of an anesthetic agent for sedation 4.Application of an antimicrobial agent to the burns

1.Insertion of a Foley catheter

A woman was working in her garden. She accidentally sprayed insecticide into her right eye. She calls the emergency department, frantic and screaming for help. The nurse should instruct the woman to take which immediate action? 1.Irrigate the eyes with water. 2.Come to the emergency department. 3.Call the primary health care provider (PHCP). 4.Irrigate the eyes with diluted hydrogen peroxide.

1.Irrigate the eyes with water.

A client has had radical neck dissection and begins to hemorrhage at the incision site. The nurse should take which actions in this situation? Select all that apply. 1.Monitor vital signs. 2.Monitor the client's airway. 3.Apply manual pressure over the site. 4.Lower the head of the bed to a flat position. 5.Call the primary health care provider (PHCP) immediately.

1.Monitor vital signs. 2.Monitor the client's airway. 3.Apply manual pressure over the site. 5.Call the primary health care provider (PHCP) immediately.

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? 1.A client complaining of muscle aches, a headache, and history of seizures 2.A client who twisted her ankle when rollerblading and is requesting medication for pain 3.A client with a minor laceration on the index finger sustained while cutting an eggplant 4.A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce Although option 1 is high priority, remember to always take chest pain serious

A client with a probable minor head injury resulting from a motor vehicle crash is admitted to the hospital for observation. The nurse leaves the cervical collar applied to the client in place until when? 1.The family comes to visit. 2.The nurse needs to do physical care. 3.The primary health care provider makes rounds. 4.The results of spinal radiography are known.

4.The results of spinal radiography are known.

The nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area from a fire. Which assessment finding would indicate that the client sustained a respiratory injury as a result of the burn? 1.Fear and anxiety 2.Complaints of pain 3.Clear breath sounds 4.Use of accessory muscles for breathing

4.Use of accessory muscles for breathing