Neuro/ER Lip/Saunders L2
a child who was intubated after a craniotomy now shows signs of decreased level of consciousness. the HCP prescribes manual hyperventilation to keep the PaCO2 between 25 and 29 mm and the PaO2 between 80 and 100 mm. the nurse interprets this prescription based on the understanding that this action will accomplish which goal? 1. decrease intracranial pressure 2. ensure a patient airway 3. lower the arousal level 4. produce hypoxia
1. decrease intracranial pressure
the nurse is caring for a preschool age client with a neuroblastoma who has been receiving chemotherapy for the last 4 weeks. his lab results indicate an Hgb of 12.5, HCT 36.8%, WBC 2,000, platelet count 150,000. based on the child's lab values, what is the highest priority nursing intervention? 1. encourage meticulous handwashing by the client and visitors 2. prepare to give the child a transfusion of platelets 3. encourage mouth care with a soft toothbrush 4. prepare to give the child a transfusion of packed red blood cells
1. encourage meticulous handwashing by the client and visitors
An airplane crash results in mass casualties. The nurse is directing personnel to tag all victims. Which information should be placed on the tag? Select all that apply. 1. triage priority 2. identifying information when possible (such as name and age) 3. medications and treatments administered 4. presence of jewelry 5. next of kin
1. triage priority 2. identifying information when possible (such as name and age) 3. medications and treatments administered
a client is brought to the ED with abdominal trauma following an automobile accident. vital signs, heart rate 132, respirations 28, BP 84/58, temp 97.0, and oxygen saturation 89% on room air. which prescription should the nurse implement first? 1. administer 1 L .9% normal saline IV 2. draw a complete blood count with hematocrit and hemoglobin 3. obtain an abdominal xray 4. insert an indwelling urinary catheter
1. administer 1 L .9% normal saline IV
which statement made by the parent of a school age child who has had a craniotomy for a brain tumor would warrant further exploration by the nurse? 1. after this, I will never let her out of my sight again 2. I hope that she'll be able to go back to school soon 3. I wonder how long it will be before she can ride her bike 4. her best friend is eager to see her. I hope she won't be upset
1. after this, I will never let her out of my sight again
four people who have been injured in a car accident are admitted to ED. using the emergency severity index, in which order from first to last should the victims be seen by a HCP? 1. an adult with severe bleeding from a laceration in the leg 2. a child with lacerations on the arms and legs 3. an adult with a history of asthma and respirations of 30 breaths/min 4. an older adult with normal vital signs, but is confused
1. an adult with severe bleeding from a laceration in the leg 3. an adult with a history of asthma and respirations of 30 breaths/min 2. a child with lacerations on the arms and legs 4. an older adult with normal vital signs, but is confused
the nurse is assessing the client (see photo, pg 713 #33) who has recently returned from a 2 month mission in africa. what type of respiratory protection is appropriate for the staff? 1. N95 particulate respirator 2. double layered surgical mask 3. surgical mask with eye shield 4. no respiratory protection needed
1. N95 particulate respirator
which client admitted to the ED should the nurse see first? 1. a client experiencing a ripping sensation in the chest 2. a client with a BP of 170/95 3. a client with a urine output of 240 mL in 12 hours 4. a client taking anticoagulants with bloody stool
1. a client experiencing a ripping sensation in the chest
the nurse notices a pair of nervously acting individuals entering the ED. when reporting suspicious activity, the nurse should include which information in the report? sata 1. vehicle/vehicle description 2. current location of parties involved 3. names and phone numbers of parties involved 4. relationship to hospitalized client 5. tone of voice of each party involved
1. vehicle/vehicle description 2. current location of parties involved
there has been an increase in medication errors and errors in prescribing laboratory studies in the ED. the nurse manager is conducting a staff education session on when to use "read back" procedures. read back procedures should be performed in which situations? sata 1. when a medication prescription or critical laboratory result is received verbally or over the telephone 2. when any verbal or phone prescription is received 3. whenever a written prescription or printed critical test result is received 4. when the unit secretary takes a phone prescription 5. when the agency uses computerized health care records
1. when a medication prescription or critical laboratory result is received verbally or over the telephone 2. when any verbal or phone prescription is received
a client is admitted to the ED with a full thickness burn to the right arm. upon assessment, the arm is edematous, fingers are mottled, and radial pulse is now absent. the client states that the pain is 8 on a scale of 1 to 10. what should the nurse do next? 1. administer morphine sulfate IV push for the severe pain 2. call the HCP to report the loss of radial pulse 3. continue to assess the arm every hour for any additional changes 4. instruct the client to exercise the fingers and wrist
2. call the HCP to report the loss of radial pulse
an adult has been admitted to the ED diagnosed with food poisoning following an outdoor picnic. what should the nurse do? sata 1. tell the family to discard contaminated food 2. collect specimens for laboratory examination 3. assess vital signs 4. initiate support for the respiratory system 5. monitor fluid and electrolyte status 6. provide antiemetics as prescribed
2. collect specimens for laboratory examination 3. assess vital signs 4. initiate support for the respiratory system 5. monitor fluid and electrolyte status 6. provide antiemetics as prescribed
a client who was a victim of a gunshot wound was treated in the ED and died. what should the nurse direct the UAP to do during post mortem care? sata 1. remove all tubes and IV lines 2. cover the body with a sheet 3. notify the family 4. transport the body to the morgue 5. notify the chaplain
2. cover the body with a sheet 4. transport the body to the morgue
before placement of a ventriculoperitoneal shunt for hydrocephalus, an infant is irritable, lethargic and difficult to feed. to maintain the infant's nutritional status, which action would be most appropriate? 1. feed the infant just before doing any procedures 2. give the infant small frequent feedings 3. feed the infant in a horizontal position 4. give large, less frequent feedings
2. give the infant small frequent feedings
the nurse in the ED is triaging victims of an airplane crash. prioritize the clients in the order in which they should be treated from first to last. 1. 75 year old with a 2 inch laceration to the left forearm 2. a 22 year old with a 2 inch laceration to the left temple, slightly confused 3. a 14 year old with a 2 inch laceration to the chin, history of asthma, respirations 26/min, audible wheezing 4. a 22 year old female, 36 weeks pregnant with contractions every 10 to 15 min
3. a 14 year old with a 2 inch laceration to the chin, history of asthma, respirations 26/min, audible wheezing 2. a 22 year old with a 2 inch laceration to the left temple, slightly confused 4. a 22 year old female, 36 weeks pregnant with contractions every 10 to 15 min 1. 75 year old with a 2 inch laceration to the left forearm
a client is in the ED with sneezing and coughing. the client is in the triage area, waiting to be seen by a HCP. to prevent spread of infection to others in the area and to the health care staff, what should the nurse do? 1. place the client in an isolation room 2. ask the others in the area to move away from the client 3. give the client a surgical mask to wear 4. ask the client to wash the hands before being examined
3. give the client a surgical mask to wear
which action should the nurse take when providing postoperative nursing care to a child after insertion of a ventriculoperitoneal shunt? 1. administer narcotics for pain control 2. check the urine for glucose and protein 3. monitor for increased temperature 4. test cerebrospinal fluid leakage for protein
3. monitor for increased temperature
Thirty people are injured in a train derailment. Which client should be transported to the hospital first? 1. a 20-year-old who is unresponsive and has a high injury to his spinal cord 2. an 80-year-old who has a compound fracture of the arm 3. a 10-year-old with a laceration on his leg 4. a 25-year-old with a sucking chest wound
4. a 25-year-old with a sucking chest wound
a SARS epidemic is suspected in a community of 10,000 people. as clients with SARS are admitted to the hospital, what type of precautions should the nurse institute? 1. enteric precautions 2. handwashing precautions 3. reverse isolation precautions 4. airborne precautions
4. airborne precautions
a visitor to the hospital has a cardiac arrest. when determining to use an AED, the nurse should consider that AEDs are used in cardiac arrest in which circumstances? 1. early defibrillation in cases in atrial fibrillation 2. cardioversion in cases of atrial fibrillation 3. pacemaker placement 4. early defibrillation in cases of ventricular fibrillation
4. early defibrillation in cases of ventricular fibrillation
a small airplane crashes in a neighborhood of 10 houses. one of the victims appears to have a cervical spine injury. what should first aid for this victim include? sata 1. establish an airway with the jaw thrust maneuver 2. immobilize the spine 3. logroll the victim to a side lying position 4. elevate the feet 6 inches 5. place a cervical collar around the neck
1. establish an airway with the jaw thrust maneuver 2. immobilize the spine
a client is experiencing an allergic response. the nurse should perform the actions in which order from first to last? 1. assess for urticaria 2. assess the airway and breathing pattern 3. notify the HCP 4. activate the rapid response team
2. assess the airway and breathing pattern 1. assess for urticaria 4. activate the rapid response team 3. notify the HCP
there has been a car accident involving four vehicles on a remote highway. the nearest ED is 15 minutes away. which victim should be transported by helicopter rather than an ambulance to the nearest hospital? 1. a 10 year old with a simple fracture of the femur, who is crying and cannot find his parents 2. a middle aged female with cold clammy skin, heart rate 120, and is unconscious 3. middle aged male with severe asthma, heart rate 120 and is having difficulty breathing 4. an older adult with severe headache but conscious
2. a middle aged female with cold clammy skin, heart rate 120, and is unconscious
An apartment fire spreads to seven apartment units. Victims suffer burns, minor injuries, and broken bones from jumping from windows. Which client should be transported first? 1. a woman who is 5 months pregnant with no apparent injuries 2. a middle aged man with no injuries who has rapid respirations and coughs 3. a 10 year old with a simple fracture of the humerus who is in severe pain 4. a 20 year old with 1st degree burns on her hands and forearms
2. a middle aged man with no injuries who has rapid respirations and coughs
which action should the nurse do first when noting clear drainage on the child's dressing and bed linen after a craniotomy for a brain tumor? 1. change the dressing 2. elevate the head of the bed 3. test the fluid for glucose 4. notify the HCP
3. test the fluid for glucose
which clinical manifestation would lead the nurse to suspect an infant has hydrocephaly? select all that apply 1. depressed fontanelle 2. headache 3. vomiting 4. low pitched cry 5. irritability 6. pupillary changes
3. vomiting 5. irritability 6. pupillary changes
a school age child is admitted to the hospital with the diagnosis of probable infratentorial brain tumor. during the child's admission to the pediatric unit, which action should the nurse anticipate taking first? 1. eliminate the child's anxiety 2. implement seizure precautions 3. introduce the child to other clients of the same age 4. prepare the child and parents for diagnostic procedures
4. prepare the child and parents for diagnostic procedures
Proper hand placement for chest compressions during CPR is essential to reduce the risk of which complication? 1. gastrointestinal bleeding 2. myocardial infarction 3. emesis 4. rib fracture
4. rib fracture
several clients who work in the same building are brought to the ED. they all have fever, headache, a rash over the entire body, and abdominal pain with vomiting and diarrhea. upon initial assessment, the nurse finds that each client has low blood pressure and has developed petechiae in the area where the blood pressure cuff was inflated. which isolation precautions should the nurse initiate? 1. contact isolation with double gloving and shoe covers 2. respiratory isolation with positive pressure rooms 3. enteric precautions 4. reverse isolation
1. contact isolation with double gloving and shoe covers
a middle aged man collapses in the ED waiting room. what should the nurse do first? 1. ask the client to state his name 2. perform the head tilt/chin lift to open up the victim's airway 3. feel for and air movement from the victim's nose or mouth 4. watch the client's chest for respirations
1. ask the client to state his name
the nurse notices a fire in a wastebasket in a client's room. in which order of priority from first to last should the nurse perform the actions? 1. confine the fire by closing the door to the client's room 2. extinguish the fire 3. remove the client from the room 4. pull the fire alarm at the alarm pull station
3. remove the client from the room 4. pull the fire alarm at the alarm pull station 1. confine the fire by closing the door to the client's room 2. extinguish the fire
after a child undergoes a craniotomy for an infratentorial brain tumor, the nurse should place the child in which position to prevent undue strain on the sutures? 1. prone 2. semi fowlers 3. side lying 4. trendelenburg
3. side lying
the nurse is discharging a client who had a fish hook embedded in the eye. the fish hook was removed surgically in the ED, but the client currently has no vision in that eye. the surgeon has informed the client that a corneal transplant may restore some vision but the surgery cannot be performed for 6 to 8 weeks and only if no infection occurs. what information should the nurse include in the discharge teaching plan? 1. resting to reduce the strain to the eye and promote healing after surgery 2. washing hands carefully to keep the eye and promote healing after surgery 3. verbalizing feelings regarding vision loss 4. eating a healthy diet to promote healing and prevent constipation
2. washing hands carefully to keep the eye and promote healing after surgery
a coworker brings a colleague to the ED with a headache, weakness, and slight confusion. the HCP diagnoses carbon monoxide poisoning. what should the nurse do first? 1. initiate gastric lavage 2. maintain body temperature 3. administer 100% oxygen by mask 4. obtain a psychiatric referral
3. administer 100% oxygen by mask
a client admitted to the ED with atrial fibrillation has a heart rate of 160 BPM. the nurse should implement which prescription first? 1. administer a heparin bolus 2. administer a beta blocker 3. administer oxygen via a nasal cannula 4. prepare the client for an immediate cardioversion
3. administer oxygen via a nasal cannula
a client is admitted to the ED with atrial fibrillation and does not recall how the rapid pulse and irregular heart rate has been occurring. the nurse should indicate which goals of care at this time? select all that apply 1. convert the heart rate to sinus rhythm 2. decrease cardiac output and workload 3. limit activity to being out of bed 4. maintain a ventricular response below 100 bpm 5. prevent an embolic stroke
3. limit activity to being out of bed 4. maintain a ventricular response below 100 bpm 5. prevent an embolic stroke
the nurse assesses a 2 month old with hydrocephalus with a ventriculoperitoneal shunt. the nurse obtains the infant's vital signs. in order to obtain the most significant information about the child's status, which assessment should the nurse make next? 1. status of posterior fontanelle 2. pupillary reaction to light 3. occipital frontal head circumference 4. presence of the primitive reflex
3. occipital frontal head circumference
a nurse evaluates discharge teaching as successful when the parents of a school aged child with a ventriculoperitoneal shunt insertion identify which signs as signaling a blocked shunt? 1. decreased urine with stable intake 2. tense fontanelle and increased head circumference 3. elevated temperature and reddened incisional site 4. irritability and increasing difficulty with eating
4. irritability and increasing difficulty with eating
eight farm workers are admitted to the ED after they were splashed with "a couple chemicals" at work 30 minutes ago. they have watery itchy eyes, slight cough, diaphoresis, and constricted pupils and are conscious and oriented. their clothes are wet. what action should the nurse do first? 1. apply oxygen at 3 L per nasal cannula 2. remove their clothing 3. begin decontamination shower 4. isolate the clients
4. isolate the clients
a client is admitted to the ED after being found in a daze walking away from her burning car after an accident. she was not injured in her accident, but the other driver died. she states "I can't handle it anymore. there's no point to it all." the crisis nurse recommends hospital admission based on the identification of which concern? 1. the client was walking around in a daze 2. the client has a lack of knowledge of what to do next 3. the client is having delusions and is not in touch with reality 4. the client is expressing helplessness and hopelessness and is a risk for suicide
4. the client is expressing helplessness and hopelessness and is a risk for suicide
the nurse is providing postoperative care for an infant who had a ventriculoperitoneal shunt placed to correct hydrocephalus. which clinical finding warrants immediate intervention? 1. abdominal distension 2. lethargy 3. facial edema 4. headache
1. abdominal distension
the nurse in the ED reports that there is a possibility of having had direct contact with blood of a client who is suspected of having HIV/AIDS. the nurse requests that the client have a blood test. consent for HIV testing can only be completed when which circumstances are present? sata 1. an emergency medical provider had been exposed to the clients blood or bodily fluids 2. testing is prescribed by a HCP under emergency circumstances 3. testing is prescribed by a court, based on evidence that the client poses a threat to others 4. testing is done on blood collected anonymously in an epidemiologic survey 5. an HCP who is taking care of a client suspected of having HIV/AIDS requests a blood test
1. an emergency medical provider had been exposed to the clients blood or bodily fluids 2. testing is prescribed by a HCP under emergency circumstances 3. testing is prescribed by a court, based on evidence that the client poses a threat to others 4. testing is done on blood collected anonymously in an epidemiologic survey
an 8 year old child does well after infratentorial tumor removal and is transferred back to the pediatric unit. although she had been told about having her head shaved for surgery, she is very upset. after exploring the child's feelings, the nurse should take which action? 1. ask the child if she would like to wear a hat 2. reassure the child that her hair will grow back 3. explain to the child's parents that her reaction is normal 4. suggest that the parents buy the child a wig as a surprise
1. ask the child if she would like to wear a hat
the nurse is assessing a child diagnosed with a brain tumor. which signs and symptoms should the nurse expect the child to demonstrate? select all that apply 1. head tilt 2. vomiting 3. polydipsia 4. lethargy 5. increased appetite 6. increased pulse
1. head tilt 2. vomiting 4. lethargy
the nurse is giving care to an infant with a brain tumor. the observes the infant arches the back. (see figure, page 282, question 65) what action should the nurse take first? 1. notify the HCP 2. stroke the back to release the arching 3. pad the side rails of the crib 4. place the child prone
1. notify the HCP
32 children are brought to the ED after a school bus accident. two children were killed along with the three people in the car that caused the crash. before the victims arrive, in addition to ensuring that the hospital staff are prepared for the emergency, which step should the nurse anticipate carrying out? 1. calling the nearest crisis response team 2. alerting the news media 3. notifying the hospital volunteer office 4. calling the school to inform teachers of the accident
1. calling the nearest crisis response team
an explosion at a chemical plant produces flames and smoke. more than 20 persons have burn injuries. which victims, all adults, should be transported to a burn center? sata the victim who has: 1. chemical spills on both arms 2. 3rd degree burns of both legs 3. 1st degree burns of both legs 4. respiratory distress 5. inhaled smoke
1. chemical spills on both arms 2. 3rd degree burns of both legs 4. respiratory distress 5. inhaled smoke
the nurse in the ED is administering a prescription for 20 mg IV furosemide, which is to be given immediately. the nurse scans the client's identification band and the medication barcode. the medication administration system does not verify that furosemide is prescribed for this client; however, the furosemide is prepared in the accurate dose for IV infusion. what should the nurse do next? 1. contact the pharmacist immediately to check the prescription and the barcode label for accuracy 2. administer the medication now, knowing the medication is labeled and the client is identified 3. report the problem to information technology team to have the barcode system recalibrated 4. ask another nurse to verify the medication and the client so the medication can be given now
1. contact the pharmacist immediately to check the prescription and the barcode label for accuracy
a suspected outbreak of anthrax has been transmitted by skin exposure. a client is admitted to the ED with lesions on the hands. the HCP prescribes antibiotics and sends the client home. what should the nurse instruct the client to do? sata 1. take the prescribed antibiotics for 60 days 2. avoid contact with other members of the family during the treatment period 3. wear a mask for 60 days 4. expect the skin lesions to clear up within 1 to 2 weeks 5. wash hands frequently
1. take the prescribed antibiotics for 60 days 4. expect the skin lesions to clear up within 1 to 2 weeks
the nurse is triaging victims of an earthquake who were removed from a building following its collapse. which victims should be classified as red? sata 1. 10 year old male with crushing chest wound, tachypnea, with labored breathing, unconscious, impaled object in the forehead 2. 49 year old male with crushing chest pain radiating to the jaw, is diaphoretic, nauseated, and has an open fracture of the left wrist 3. 75 year old female with obvious fracture of the femur, absent pedal pulses on the affected side; heart rate 110 bpm, respirations 34/min, skin diaphoretic, awake/alert, states pain is 10 on a scale of 1 to 10 4. 32 year old female who is unconscious, 3 inch laceration to her forehead, ecchymosis behind the ears, respiratory rate 10 breaths/min and shallow; radial pulse is weak/thready/rapid; no breaths on the right side
2. 49 year old male with crushing chest pain radiating to the jaw, is diaphoretic, nauseated, and has an open fracture of the left wrist 3. 75 year old female with obvious fracture of the femur, absent pedal pulses on the affected side; heart rate 110 bpm, respirations 34/min, skin diaphoretic, awake/alert, states pain is 10 on a scale of 1 to 10
3 hours ago, an adult was thrown from a car into a ditch. the client is now in the ED with in a stable condition. vital signs are within normal limits. the client has an open fracture of the right tibia. for which sign should the nurse be especially alert? 1. hemorrhage 2. infection 3. deformity 4. shock
2. infection
a child with a brain tumor has a decreased respiratory rate and is less responsive to verbal commands than he was when the nurse assessed the client the previous hour. what should the nurse do next? 1. raise the head of the bed 2. notify the HCP 3. implement seizure precaution 4. obtain an oximeter reading
2. notify the HCP
there is a shooting in a shopping mall. three victims with gunshot wounds are brought to the ED. what should the nurse do to preserve forensic evidence? sata 1. cut around blood stains to remove clothing 2. place each item of clothing in a separate paper bag 3. hang wet clothing to dry 4. refrain from documenting client statements 5. place bullets in a sterile container
2. place each item of clothing in a separate paper bag 3. hang wet clothing to dry
an adolescent client has seen the school nurse several times with headache, vomiting, and difficulty walking. when calling the adolescent's mother about these symptoms, the nurse should suggest the mother do what first? 1. schedule an appointment with the eye HCP 2. begin psychological counseling for her adolescent 3. make an appointment with the adolescents HCP 4. meet with the adolescent's teachers to determine academic progress
3. make an appointment with the adolescents HCP
