PN3 Exam 2 (1)
A client is receiving mechanical ventilation via an endotracheal tube. Despite several attempts to extubate the client, the client remains ventilator-dependent for 2 weeks after the initial intubation. What does the nurse plan to tell the client's family about the plan of care?
"A tracheostomy will be performed to minimize complications."
The nurse is analyzing a client's electrocardiogram tracing and realizes that each small square on the paper is equal to: 1. 0.04 second. 2. 0.12 second. 3. 0.20 second. 4. 0.40 second.
1. 0.04 second The small square on the ECG graph paper equals 0.04 second. The large square equals 0.20 second. The PR interval is 0.12 to 0.20 second. Two large squares would be equal to 0.40 second.
Which patient is at greatest risk of developing acute respiratory distress syndrome (ARDS)?
24-year-old male admitted with blunt chest trauma and aspiration
A client with a heart rate of 40 who is experiencing shortness of breath and nausea is diagnosed with second-degree AV block type II. Which of the following will be included in this client's treatment? (Select all that apply.) 1. Administer digoxin 2. Administer antiemetic 3. Administer atropine sulfate 4. Insert external pacemaker 5. Decrease intravenous fluids 6. Lower the head of the bed
3. Administer atropine sulfate 4. Insert external pacemaker For second-degree AV block type II, treatment will almost always consist of external pacemaker insertion. Atropine sulfate may be used to increase the heart rate until the pacemaker can be inserted. Digitalis toxicity can cause this heart rhythm so digoxin should not be administered to this client. An antiemetic will not solve the client's underlying problem. The client may or may not need additional fluids. Lowering the head of the bed could compromise this client's respiratory status and should not be done.
The electrocardiogram tracing for a client shows premature junctional complexes. Which of the following should the nurse do to assist this client? 1. Administer oxygen 2. Increase intravenous fluids 3. Check on the serum digoxin level 4. Assist the client to a side-lying position
3. Check on the serum digoxin level The most common cause of premature junctional complexes is digitalis toxicity. The nurse should check on the client's serum digoxin level. Oxygen, intravenous fluids, or position changes will not help treat this rhythm.
The nurse is reading an ECG rhythm strip and notes that there are nine QRS complexes in a 6-second strip. The heart rate is: 1. 36. 2. 54. 3. 81. 4. 90.
4. 90 A heart rate can be determined by multiplying the QRS complexes in a 6-second strip by 10. The heart rate is 90. This method of calculating the heart rate is the most common method used because it is quick and can be used when the heart rate is irregular.
An elderly client is demonstrating a change in heart rate that occurs with respirations. When planning care for the client, the nurse knows that treatment may include: 1. Oxygen therapy 2. Analgesics 3. Antibiotics 4. Pacemaker insertion
4. Pacemaker insertion A change in heart rate that occurs with respirations defines a sinus arrhythmia. If the client becomes symptomatic during periods of bradycardia, treatment will include atropine sulfate or pacemaker insertion. Treatment for sinus arrhythmia might include oxygen if the client is symptomatic. Treatment for this arrhythmia does not include analgesics or antibiotics.
A client is receiving mechanical ventilation via an endotracheal tube. Despite several attempts to extubate the client, the client remains ventilator-dependent for 2 weeks after the initial intubation. What does the nurse plan to tell the client's family about the plan of care?
A tracheostomy will be performed to minimize complications
The nurse is assessing a patient's differential white blood cell count. What implications would this test have on evaluating the adequacy of a patient's gas exchange? a. An elevation of the total white cell count indicates generalized inflammation. b. Eosinophil count will assist to identify the presence of a respiratory infection. c. White cell count will differentiate types of respiratory bacteria. d. Level of neutrophils provides guidelines to monitor a chronic infection.
ANS: A Elevation of total white cell count is indicative of inflammation that is often due to an infection. Upper respiratory infections are common problems in altering a patient's gas exchange. Eosinophil cells are increased in an allergic response. Neutrophils are more indicative of an acute inflammatory response. White cells do not assist to differentiate types of respiratory bacteria. Monocytes are an indicator of progress of a chronic infection.
10. The emergency medical technicians (EMTs) arrive at the emergency department with an unresponsive client with an oxygen mask in place. What will the nurse do first? a. Assess that the client is breathing adequately b. Insert a large-bore intravenous line c. Place the client on a cardiac monitor d. Assess for best neurologic response
ANS: A The highest-priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he may not be breathing, or he may be breathing inadequately with the device in place.
1. While assessing a client in the emergency department, the nurse identifies that the client has been raped. Which health care team member should the nurse collaborate with when planning this client's care? a. Emergency medicine physician b. Case manager c. Forensic nurse examiner d. Psychiatric crisis nurse
ANS: C All other members of the health care team listed may be used in the management of this client's care. However, the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing with the victim of an assault. DIF: Cognitive Level: Comprehension/Understanding REF: p. 122 TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with Interdisciplinary Team) MSC: Integrated Process: Nursing Process (Planning)
Which expected client outcome is the priority during the initial phase of treatment for a pulmonary embolism?
Attain adequate gas exchange and oxygenation
Which critically ill client has the greatest risk for developing acute respiratory distress syndrome (ARDS)?
Client w/ aspiration pneumonia
The nurse hears the ventilator alarm come from the room of a client who is receiving mechanical ventilation. When arriving in the client's room, which assessment does the nurse perform first?
Client's color, perfusion, and chest rise
Which intervention for a client in the intensive care unit will decrease the incidence of "ICU psychosis?"
Decreasing Nighttime disruptions
The client w/ which condition is in the greatest need of immediate intubation?
Hypoventilation and decreased breath sounds
The nurse is caring for a client who is receiving mechanical ventilation and hears the high-pressure alarm. Which action should the nurse take first?
Listen to the client's breath sounds
What are the manifestations of hypoxemia
Pallor, Cyanosis, Restlessness
A client is receiving heparin sodium (Hepalean) therapy for a pulmonary embolism. Which antidote does the nurse confirm is available on the unit?
Protamine Sulfate
A patient is being discharged to home on warfarin (Coumadin) therapy to manage an acute pulmonary embolism. Which patient response indicates a need for further teaching by the nurse?
"I should eat more green leafy vegetables like spinach."
The nurse is providing teaching for a client who will be discharged home to continue therapy with warfarin (Coumadin). Which statement by the client indicates a correct understanding of the teaching?
"I'll use a soft-bristled toothbrush to brush my teeth."
A client is refusing to allow the nurse to apply pneumatic compression stockings while in bed, stating he doesn't like how they feel and they keep him awake. What is the nurse's best response?
"It is important to wear them in bed so don't develop a blood clot in your legs"
A client is suspected of having cardiac damage. The nurse realizes that which of the following diagnostic tests is most commonly used to help diagnose this client's possible cardiac damage or disease? 1. 12-lead electrocardiogram 2. Arterial blood gases 3. Cardiac angiogram 4. Cardiac enzymes
1. 12-lead electrocardiogram A 12-lead electrocardiogram is a quick and accurate diagnostic tool used to evaluate heart damage and disease. The other diagnostic tests require a longer time for results and/or are invasive procedures requiring some preparation.
A client's electrocardiogram rhythm strip is a straight line. Which of the following should the nurse do to help this client? (Select all that apply.) 1. Assess for loose leads. 2. Assess for power to the monitor. 3. Assess the strip for possible fine ventricular fibrillation. 4. Begin cardiopulmonary resuscitation once verified the client has no pulse. 5. Raise the head of the bed. 6. Stop intravenous fluid infusion.
1. Assess for loose leads. 2. Assess for power to the monitor. 3. Assess the strip for possible fine ventricular fibrillation. 4. Begin cardiopulmonary resuscitation once verified the client has no pulse. The absence of electrical activity will create the rhythm of asystole. The rhythm strip is a straight line. The nurse should confirm that the straight line is not due to another reason such as loose leads, lack of power to the monitor, or fine ventricular fibrillation. Once it is confirmed that the client has no pulse, cardiopulmonary resuscitation should be implemented. Raising the head of the bed or stopping intravenous fluid infusions is not going to help the client experiencing asystole.
A client is recovering from insertion of a pacemaker to pace the activity of the ventricles. At which point on the electrocardiogram tracing will the nurse assess pacer spikes? 1. Before the QRS complex 2. Before the P wave 3. After the QRS complex 4. After the P wave
1. Before the QRS complex If the ventricles are being paced, there will be a pacer spike just prior to the QRS complex. If the atria are being paced, there will be a pacer spike just before the P wave. Pacer spikes that occur after the QRS complex or P wave would indicate pacemaker malfunction and should be addressed immediately.
Which of the following should be implemented to ensure the safe use of a defibrillator? (Select all that apply.) 1. Do not place over monitoring electrodes. 2. Do not place over an implanted pacemaker. 3. Place the paddles at 1⁄2 inch from the implanted pacemaker site. 4. Apply transdermal medication to the chest before using the paddles. 5. Insert an oral airway before using the paddles. 6. Have another person hold the client's airway open while using the paddles.
1. Do not place over monitoring electrodes. 2. Do not place over an implanted pacemaker. The safe use of defibrillator paddles include: do not place over monitoring electrodes or implanted devices. Paddles should be at least 1 inch away from an implanted device. Transdermal medication should be removed from the client's chest before using the paddles. An oral airway is not needed before using the paddles. No one should be touching the client when using the paddles.
The nurse is assessing a client who is diagnosed with pulseless electrical activity. Which of the following will the nurse include in this assessment? (Select all that apply.) 1. Hypovolemia 2. Hypoxia 3. Hypothermia 4. Tamponade 5. Thrombosis 6. Throat pain
1. Hypovolemia 2. Hypoxia 3. Hypothermia 4. Tamponade 5. Thrombosis Assessment of pulseless electrical activity includes a review of the 5 H's and the 5 T's. The 5 H's are: hypovolemia, hypoxia, hydrogen ion status, hyperkalemia/hypokalemia, and hypothermia. The 5 T's include tablets, tamponade, tension pneumothorax, thrombosis coronary, and thrombosis pulmonary. Throat pain does not cause pulseless electrical activity.
Which of the following interventions would be appropriate for a client recovering from a pacemaker insertion? (Select all that apply.) 1. Monitor vital signs every 15 minutes until stable. 2. Assess for chest pain. 3. Restrict movement of affected extremity. 4. Monitor electrocardiogram every 8 hours. 5. Begin intravenous fluid infusion at 150 mL/hr. 6. Reinforce dressing with excessive bleeding.
1. Monitor vital signs every 15 minutes until stable. 2. Assess for chest pain. 3. Restrict movement of affected extremity. Interventions appropriate for a client recovering from a pacemaker insertion include monitoring vital signs every 15 minutes until stable, assessing for chest pain, restricting movement of the affected extremity, monitoring electrocardiogram ongoing and post a strip every 4 hours, and report excessive bleeding from the surgical site to the health care provider. Intravenous fluids at the rate of 150 mL/hr may or may not be needed.
A client's electrocardiogram tracing shows a sawtooth pattern with F waves. The nurse realizes this client is demonstrating: 1. atrial flutter. 2. atrial fibrillation. 3. premature atrial contractions. 4. atrial tachycardia.
1. atrial flutter Atrial flutter is characterized by F waves that occur in a characteristic sawtooth pattern. Atrial fibrillation is characterized by coarse waves with the baseline between the QRS complexes as being rough and uneven. Premature atrial contractions occur when an electrical impulse is generated in an area of the atria outside of the SA node. Atrial tachycardia is three or more premature atrial contractions. Neither premature atrial contractions or atrial tachycardia have an F wave on the tracing.
The nurse notes that on a client's electrocardiogram tracing, there is one P wave for every QRS complex and a delay in the impulse transmission at the AV node. This regular rhythm is identified as: 1. first-degree AV block. 2. second-degree AV block type I. 3. second-degree AV block type II. 4. complete heart block.
1. first-degree AV block First-degree atrioventricular (AV) block occurs when there is a delay in the impulse transmission at the AV node. This delay occurs with every impulse and can be seen on every beat on the recorded rhythm strip. Second-degree and complete heart block have differences with the P wave and the associated QRS complexes.
Which of the following should the nurse instruct a client who has been diagnosed with an arrhythmia? 1. Exercise level 2. Avoidance of calorie-dense foods 3. How to take his own pulse 4. Reasons why fatigue is expected
3. How to take his own pulse Instructions for a client diagnosed with an arrhythmia include symptom management, how to take own pulse, and substances to avoid the onset of an arrhythmia. The nurse may or may not instruct on exercise level. The client does not need to avoid calorie-dense foods. Fatigue is a symptom that should be reported to a health care provider.
A client is diagnosed with supraventricular tachycardia. The nurse should prepare to administer which of the following medications? 1. Procainamide 2. Amiodarone 3. Verapamil 4. Adenosine
4. Adenosine Adenosine has a short half-life, is given intravenous push, and is used to abruptly stop supraventricular tachycardia. Procainamide is used for tachyarrhythmias and ventricular ectopy. Amiodarone is helpful to treat ventricular fibrillation. Verapamil helps slow the heart rate with atrial fibrillation.
A client is experiencing an alteration in heart rate. The nurse realizes this client is experiencing a disorder of which part of the heart? 1. Atrioventricular node 2. Bundle branches 3. Purkinje fibers 4. Sinoatrial node
4. Sinoatrial node The sinoatrial node is the dominant pacemaker of the heart. The sinoatrial node has an inherent rate of 60 to 100 bpm. The atrioventricular node has an intrinsic rate of 40 to 60 bpm. The impulse enters the right and left bundle branches and then enters the Purkinje fibers. Impulses at this level are at 15 to 40 times per minute.
The nurse is analyzing a client's electrocardiogram tracing. Which of the following complexes is not normally seen on an electrocardiogram tracing? 1. P wave 2. QRS complex 3. T wave 4. U wave
4. U wave A U wave is not always seen and can be very small. It can indicate electrolyte imbalance, medication effects, and ischemia. The P wave, QRS complex, and T wave are normally seen in the electrocardiogram tracing.
A client is unresponsive and has no pulse. The nurse notes that the electrocardiogram tracing shows continuous large and bizarre QRS complexes measured greater than 0.12 each. This rhythm is identified as: 1. premature ventricular complexes. 2. torsades de pointes. 3. ventricular fibrillation. 4. ventricular tachycardia.
4. ventricular tachycardia Ventricular tachycardia occurs when the patient experiences sustained consecutive premature ventricular complexes. Torsades de pointes is characterized by a wide-to-narrow pattern of the QRS complexes. Ventricular fibrillation shows a coarse wavy baseline.
The nurse is assessing clients on site at a multi-vehicle accident. Triage clients in the order they should receive care. (Place in order of priority.) a. A 50-year-old with chest trauma and difficulty breathing b. A mother frantically looking for her 6-year-old son c. An 8-year-old with a broken leg in his father's arms d. A 60-year-old with facial lacerations and confusion e. A pulseless male with a penetrating head wound
ANS: a, d, b, c, e Clients should be prioritized with ABCs and emergent, urgent, and nonurgent status. The client with chest trauma and difficulty breathing is the priority because no clients have an airway problem, and this is the only client with a breathing problem. The client with confusion should be seen next. Confusion can be caused by lack of oxygen to the brain due to a circulation problem. The pulseless client with a penetrating head wound is seen last because there are multiple clients to be seen, and care for this client would be futile. The client with a broken leg is nonurgent and can wait. The mother looking for her son should be seen third. Finding the child is urgent to identify potential injuries.
In what sequence would a client move through the process of admission to disposition in emergency care? (Place in order of priority.) a. Client is transported to the medical-surgical floor. b. Emergency department (ED) nurse gives a report on the client. c. Paramedics arrive and start IV access. d. Nurse and other health care provider(s) perform assessment. e. Emergency medical technicians (EMTs) provide oxygen and vital sign monitoring. f. Laboratory technician obtains blood specimens.
ANS: e, c, d, f, b, a When clients are in an emergency situation, EMTs arrive on the scene first. EMTs apply oxygen and obtain vital signs to determine a baseline for further care. EMTs can provide basic life support measures and can assess ABCs. Second on the scene are paramedics. Starting IV access and performing advanced life support is within the paramedic's scope of practice. The client is then transported to an ED, where nurses and other health care providers perform an initial assessment. Laboratory technicians are notified and appropriate blood specimens are obtained for diagnostic testing. When the client is stable, the ED nurse gives report to the medical-surgical unit nurse, and the client is finally transferred to an inpatient room.
Which patient would the nurse identify as being at an increased risk for altered transport of oxygen? A patient with a. hemoglobin level of 8.0 b. bronchoconstriction and mucus c. peripheral arterial disease d. decreased thoracic expansion
ANS: A Altered transportation of oxygen refers to patients with insufficient red blood cells to transport the oxygen present. Bronchoconstriction and decreased thoracic expansion (spinal cord injury) would result in impairment of ventilation. Peripheral vascular disease would result in inadequate perfusion.
18. The nurse is triaging clients in the emergency department (ED). Which is true about the presentation of client symptoms? a. Older adults frequently have symptoms that are vague or less specific. b. Young adults present with nonspecific symptoms for serious illnesses. c. Diagnosing children's symptoms often keeps them in the ED longer. d. Symptoms of confusion always represent neurologic disorders.
ANS: A Older adults present with symptoms that often are different or less specific than those of younger adults. For example, increasing weakness, fatigue, and confusion may be the only admission concerns. These vague symptoms can be caused by serious illness, such as an acute myocardial infarction (MI), urinary tract infection, or pneumonia. Diagnosing older adults often keeps them in the ED for extended periods of time.
The nurse would identify which patient as having a problem of impaired gas exchange secondary to a perfusion problem? A patient with a. peripheral arterial disease of the lower extremities b. chronic obstructive pulmonary disease (COPD) c. chronic asthma d. severe anemia secondary to chemotherapy
ANS: A Perfusion relates to the ability of the blood to deliver oxygen to the cellular level and return the carbon dioxide to the lung for removal. COPD and asthma are examples of a ventilation problem. Severe anemia is an example of a transport problem of gas exchange.
The acid-base status of a patient is dependent on normal gas exchange. Which patient would the nurse identify as having an increased risk for the development of respiratory acidosis? A patient with a. chronic lung disease with increased carbon dioxide retention b. acute anxiety, hyperventilation, and decreased carbon dioxide retention c. decreased cardiac output with increased serum lactic acid production d. gastric drainage with increased removal of gastric acid
ANS: A Respiratory acidosis is caused by an increase in retention of carbon dioxide, regardless of the underlying disease. A decrease in carbon dioxide retention may lead to respiratory alkalosis. An increase in production of lactic acid leads to metabolic acidosis. Removal of an acid (gastric secretions) will lead to a metabolic alkalosis.
9. A client has been injured in a stabbing incident. Assessment reveals the following: Blood pressure: 80/60 mm Hg Heart rate: 140 beats/min Respiratory rate: 35 breaths/min Bleeding from stabbing wound site Client is lethargic Based on these assessment data, to which trauma center should the nurse ensure transport of the client? a. Level I b. Level II c. Level III d. Level IV
ANS: A The Level I trauma center is able to provide a full continuum of care for all client areas. Level II can provide care to most injured clients, but given the extent of his injuries, a Level I center would be better if it is available. Both Levels III and IV can stabilize major injuries, but transport to a higher-level center is preferred, when possible.
16. A new nurse is orienting to the emergency department (ED). Which statement made by the nurse would indicate the need for further education by the preceptor? a. "The emergency medicine physician coordinates care with all levels of the emergency health care team." b. "Emergency departments have specialized teams that deal with high-risk populations of patients." c. "Many older adults seek emergency services when they are ill because they do not want to bother their primary health care provider." d. "Emergency departments are responsible for public health surveillance and emergency disaster preparedness."
ANS: A The emergency nurse is one member of the large interdisciplinary team that provides care for clients in the ED. A collaborative team approach to emergency care is considered a standard of practice. In this setting, the nurse coordinates care with all levels of health care team providers, from prehospital emergency medical services (EMS) personnel to physicians, hospital technicians, and professional and ancillary staff.
The nurse is reviewing the patient's arterial blood gas results. The PaO2 is 96 mm Hg, pH is 7.20, PaCO2 is 55 mm Hg, and HCO3 is 25 mEq/L. What would the nurse expect to observe on assessment of this patient? a. Disorientation and tremors b. Tachycardia and decreased blood pressure c. Increased anxiety and irritability d. Hyperventilation and lethargy
ANS: A The patient is experiencing respiratory acidosis ( pH, and PaCO2 ) which may be manifested by disorientation, tremors, possible seizures, and decreased level of consciousness. Tachycardia and decreased blood pressure are not characteristic of a problem of respiratory acidosis. Increased anxiety and hyperventilation will cause respiratory alkalosis, which is manifested by an increase in pH and a decrease in PaCO2.
The nurse is discharging an older adult client home from the emergency department (ED) after an acute episode of angina. What should the nurse do to ensure client safety upon discharge? (Select all that apply.) a. Reconcile the client's prescription and over-the-counter medications b. Screen the client for functional and cognitive abilities, as well as risk for falls c. Consult physical therapy to organize for home health services d. Arrange for the client's car keys to be taken to prevent an accident e. Review discharge instructions with the client and a family member
ANS: A, B, E Before discharge, the nurse should ensure that the client's prescription and over-the-counter medications are evaluated to determine whether the drug regimen should be continued. Discharge education should be provided to the client and a significant other or family member. To prevent future ED visits, screen older adults per agency policy for functional assessment, cognitive assessment, and risk for falls. Case management should be consulted to organize home health services. The nurse should emphasize safety when driving but cannot organize to take the client's keys away.
The emergency department (ED) nurse is preparing to transfer a client to the critical care unit. What information should the nurse include in the nurse-to-nurse hand-off report? (Select all that apply.) a. Allergies b. Vital signs c. Immunizations d. Marital status e. Isolation precautions
ANS: A, B, E Hand-off communication should be comprehensive so that the nurse can continue care for the client fluidly. Communication should be concise and should include only the most essential information for a safe transition in care. Hand-off communication should include the client's situation (reason for being in the ED), brief medical history, assessment and diagnostic findings, transmission-based precautions needed, interventions provided, and response to those interventions.
Which interventions will be performed during the primary survey for a trauma client? (Select all that apply.) a. Removing wet clothing b. Splinting open fractures c. Initiating IV fluids d. Endotracheal intubation e. Foley catheterization f. Needle decompression g. Laceration repair
ANS: A, C, D, F a. Removing wet clothing c. Initiating IV fluids d. Endotracheal intubation f. Needle decompression The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic ABC, with an added D and E: A, airway and cervical spine control; B, breathing; C, circulation; D, disability; and E, exposure. After completion of primary diagnostic studies and laboratory studies, and insertion of gastric and urinary tubes, the secondary survey, a complete head-to-toe assessment, can be carried out.
The nurse would identify which body systems as directly involved in the process of normal gas exchange? (Select all that apply.) a. Neurologic system b. Endocrine system c. Pulmonary system d. Immune system e. Cardiovascular system f. Hepatic system
ANS: A, C, E The neurologic system controls respiratory drive; the respiratory system controls delivery of oxygen to the lung capillaries; and the cardiac system is responsible for the perfusion of vital organs. These systems are primarily responsible for the adequacy of gas exchange in the body. The endocrine and hepatic systems are not directly involved with gas exchange. The immune system primarily protects the body against infection.
7. The emergency department (ED) nurse is caring for the following clients. Which client does the nurse prioritize to see first? a. 22-year-old with a painful and swollen right wrist b. 45-year-old reporting chest pain and diaphoresis c. 60-year-old reporting difficulty swallowing and nausea d. 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101° F
ANS: B A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable.
17. An unresponsive client with poor ventilator effort and a pulse rate of 120 beats/min arrives at the emergency department. What should the nurse do first? a. Place the client on a non-rebreather mask. b. Begin bag-valve-mask ventilation. c. Initiate cardiopulmonary resuscitation. d. Prepare for chest tube insertion.
ANS: B Apneic clients and those with poor ventilatory effort need bag-valve-mask (BVM) ventilation for support until endotracheal intubation is performed and a mechanical ventilator is used. A non-rebreather mask would be appropriate only if the client had adequate spontaneous ventilation. Cardiopulmonary resuscitation is necessary only if the client is pulseless. Chest tubes are inserted for decompression and pneumothorax.
3. The emergency department team is performing cardiopulmonary resuscitation on a client when the client's spouse arrives at the emergency department. What should the nurse do next? a. Request that the client's spouse sit in the waiting room. b. Ask the spouse if he wishes to be present during the resuscitation. c. Suggest that the spouse begin to pray for the client. d. Refer the client's spouse to the hospital's crisis team.
ANS: B If resuscitation efforts are still under way when the family arrives, one or two family members may be given the opportunity to be present during lifesaving procedures. The other options do not give the spouse the opportunity to be present for the client or to begin to have closure. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Crisis Intervention) MSC: Integrated Process: Caring
13. A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. What should the nurse do before providing advanced cardiac life support? a. Contact the on-call orthopedic surgeon. b. Don personal protective equipment. c. Notify the Rapid Response Team. d. Obtain a complete history from the paramedic.
ANS: B Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions should be taken in all resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers.
4. The emergency department nurse is assigned an older adult client who is confused and agitated. Which intervention should the nurse include in the client's plan of care? a. Administer a sedative medication. b. Ask a family member to stay with the client. c. Use restraints to prevent the client from falling. d. Place the client in a wheelchair at the nurses' station.
ANS: B Older adults who are confused are at increased risks for falls. Fall prevention includes measures such as siderails up, reorientation, call light in reach, and, in some cases, asking the family member, significant other, or sitter to stay with the client to prevent falls. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention) MSC: Integrated Process: Nursing Process (Planning)
5. An emergency department nurse is transferring a client to the medical-surgical unit. What is the most important nursing intervention in this situation? a. Triage the client to determine the urgency of care. b. Clearly communicate client data to the unit nurse. c. Evaluate the need for ongoing medical treatment. d. Perform a thorough assessment of the client.
ANS: B The emergency nurse needs to be able to triage, assess, and evaluate. However, these steps have already been carried out in the early phases of the emergency department (ED) admission. When a client is ready to be transferred from the ED, communication with staff nurses from the inpatient units is essential. This report should be a concise but comprehensive report of the client's ED experience. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Continuity of Care) MSC: Integrated Process: Communication and Documentation
The nurse is assessing a patient for the adequacy of ventilation. What assessment findings would indicate the patient has good ventilation? (Select all that apply.) a. Respiratory rate is 24 breaths/min. b. Oxygen saturation level is 98%. c. The right side of the thorax expands slightly more than the left. d. Trachea is just to the left of the sternal notch. e. Nail beds are pink with good capillary refill. f. There is presence of quiet, effortless breath sounds at lung base bilaterally.
ANS: B, E, F Oxygen saturation level should be between 95 and 100%; nail beds should be pink with capillary refill of about 3 seconds; and breath sounds should be present at base of both lungs. Normal respiratory rate is between 12 and 20 breaths/min. The trachea should be in midline with the sternal notch. The thorax should expand equally on both sides.
8. A nurse is triaging clients in the emergency department. Which client complaint would the triage nurse classify as nonurgent? a. Chest pain and diaphoresis b. Decreased breath sounds due to chest trauma c. Left arm fracture with palpable radial pulses d. Sore throat and a temperature of 104° F
ANS: C A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration. The client with an arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent.
14. The nurse is triaging clients in the emergency department. Which client should be considered urgent? a. 20-year-old female with a chest stab wound and tachycardia b. 45 year-old homeless man with a skin rash and sore throat c. 75-year-old female with a cough and of temperature of 102° F d. 50-year-old male with new-onset confusion and slurred speech
ANS: C A client with a cough and a temperature of 102° F is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. Clients with a chest stab wound and tachycardia, and with new-onset confusion and slurred speech, should be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent.
19. The emergency department (ED) nurse is assigned to triage clients. What is the purpose of triage? a. Treat clients on a first-come, first-serve basis. b. Identify and treat clients with low acuity first. c. Prioritize clients based on illness severity. d. Determine health needs from a complete assessment.
ANS: C ED triage is an organized system for sorting or classifying clients into priority levels, depending on illness or injury severity. The key concept is that clients who present to the ED with the greatest acuity needs receive the quickest evaluation, treatment, and prioritized resource utilization. A person with a lower-acuity problem may wait longer in the ED because the higher-acuity client is moved to the "head of the line."
12. The nurse is providing care for a client admitted for suicidal precautions. What priority intervention should the nurse implement first? a. Administer prescribed anti-anxiety drugs. b. Decrease the noise level and the harsh lighting. c. Remove oxygen tubing from the room. d. Set firm behavioral limits.
ANS: C The first priority in caring for a mentally ill client is providing a safe environment. This would include removing any item that the client could use to harm himself or herself (or others). All the other interventions can be used in providing a therapeutic environment. However, they are not as imperative as the safety of the client and staff.
The nurse is assigned a group of patients. Which patient would the nurse identify as being at increased risk for impaired gas exchange? A patient a. with a blood glucose of 350 mg/dL b. who has been on anticoagulants for 10 days c. with a hemoglobin of 8.5 g/dL d. with a heart rate of 100 beats/min and blood pressure of 100/60
ANS: C The hemoglobin is low (anemia), therefore the ability of the blood to carry oxygen is decreased. High blood glucose and/or anticoagulants do not alter the oxygen carrying capacity of the blood. A heart rate of 100 beats/min and blood pressure of 100/60 are not indicative of oxygen carrying capacity of the blood.
11. A client arrives at the emergency department following a motor vehicle collision. The client is not awake and is being bagged with a bag-valve-mask by paramedics. The client has sustained obvious injuries to the head and face, as well as an open right femur fracture that is bleeding profusely. What will the nurse do first? a. Splint the right lower extremity. b. Apply direct pressure to the leg. c. Assess for a patent airway. d. Start two large-bore IVs.
ANS: C The highest-priority intervention in the primary survey is to establish a patent airway. Without an adequate airway to supply oxygen to the cells, a cerebral injury could progress to anoxic brain death. After an airway is established, resuscitation may continue to B for breathing and C for circulation assessment.
A 3-month-old infant is at increased risk for developing anemia. The nurse would identify which principle contributing to this risk? a. The infant is becoming more active. b. There is an increase in intake of breast milk or formula. c. The infant is unable to maintain an adequate iron intake. d. A depletion of fetal hemoglobin occurs.
ANS: D Fetal hemoglobin is present for about 5 months. The fetal hemoglobin begins deteriorating, and around 2 to 3 months the infant is at increased risk of developing an anemia due to decreasing levels of hemoglobin. Breast milk or formula is the primary food intake up to around 6 months. Often iron supplemented formula is offered, and/or an iron supplement is given if the infant is breastfed.
Which clinical management prevention concept would the nurse identify as representative of secondary prevention? a. Decreasing venous stasis and risk for pulmonary emboli b. Implementation of strict hand washing routines c. Maintaining current vaccination schedules d. Prevention of pneumonia in patients with chronic lung disease
ANS: D Prevention of and treatment of existing health problems to avoid further complications is an example of secondary prevention. Primary prevention includes infection control (hand washing), smoking cessation, immunizations, and prevention of postoperative complications.
6. The nurse manager is assessing current demographics of the facility's emergency department (ED) clients. Which population would most likely present to the ED for treatment of a temperature and a sore throat? a. Older adults b. Immunocompromised people c. Pediatric clients d. Underinsured people
ANS: D The ED serves as an important safety net for clients who are ill or injured but lack access to basic health care. Especially vulnerable populations include the underinsured and the uninsured, who may have nowhere else to go for health care. DIF: Cognitive Level: Comprehension/Understanding REF: p. 122 TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Continuity of Care) MSC: Integrated Process: Communication and Documentation
2. On admission to the emergency department, a client states that he feels like killing himself. When planning this client's care, it is most important for the nurse to coordinate with which member of the health care team? a. Case manager b. Forensic nurse examiner c. Physician d. Psychiatric crisis nurse
ANS: D The psychiatric crisis nurse interacts with clients and families in crisis. This health care team member can offer valuable expertise to the emergency health care team, which also includes the case manager and the physician. DIF: Cognitive Level: Comprehension/Understanding REF: p. 122 TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with Interdisciplinary Team) MSC: Integrated Process: Nursing Process (Planning)
15. A client in the emergency department has died from a suspected homicide. What is the nurse's priority intervention? a. Remove all tubes and wires in preparation for the medical examiner. b. Limit the number of visitors to minimize the family's trauma. c. Consult the bereavement committee to follow up with the grieving family. d. Communicate the client's death to the family in a simple and concrete manner.
ANS: D When dealing with clients and families in crisis, communicate in a simple and concrete manner to minimize confusion. Tubes must remain in place for the medical examiner. Family should be allowed to view the body. Offering to call for additional family support during the crisis is suggested. The bereavement committee should be consulted, but this is not the priority at this time.
A newly admitted client with respiratory distress has a chest x-ray that shows a ground-glass appearance in both lungs. The nurse notifies the provider and anticipates orders to treat which condition?
Acute Respiratory Distress Syndrome (ARDS)
Which risk factors increase a client's risk for venous thromboembolism that may progress to a pulmonary embolism? Select all that apply.
Age 72 years Admission weight of 290 lbs Presence of central venous catheter
The nurse notifies the Rapid Response Team for a client who develops distended neck veins, severe dyspnea, cyanosis, and syncope. The client is hypoxic and hypotensive and has an abnormal electrocardiogram. Which medication does the nurse anticipate will be ordered immediately?
Alteplase (Activase)
The nurse is preparing to suction a patient with an endotracheal tube. What should be the nurse's first step in the suctioning process?
Assess the patient's lungs sounds and SAO2 via pulse ox
A client recovering from a pulmonary embolism after surgery is receiving low-molecular-weight heparin (Lovenox) and warfarin (Coumadin). The client's international normalized ratio (INR) is 2.4 today. After reporting this lab value to the provider, which order does the nurse anticipate?
Discontinue the heparin and continue the warfarin
A client with a pulmonary embolism has begun taking oral warfarin (Coumadin) while still receiving intravenous heparin. The nurse notifies the provider that the client has an international normalized ratio (INR) of 2.5. What order does the nurse anticipate?
Discontinuing the Heparin
A client who is taking warfarin (Coumadin) after an acute a pulmonary embolism is transferred from the ICU after 5 days of heparin therapy. The nurse reviews the client's electronic medical record and notes an international normalized ratio (INR) of 3.4. After notifying the provider of this result, which order does the nurse expect for this client?
Give Phytonadione
The nurse is teaching a client recovering from a pulmonary embolism who will take warfarin (Coumadin) for several weeks about long-term management of medications. Which statement by the client indicates a need for further teaching?
I may use enemas to help w/ constipation
The nurse is teaching a client receiving warfarin sodium (Coumadin) about avoiding certain foods during this drug therapy. Which client statement indicates a correct understanding of the teaching?
I will be careful to avoid anything w/ Vitamin K in it
A client who is a lifetime smoker, obese, and has a previous history of thromboembolism is preparing to have major surgery that will require prolonged immobility. Past treatments with anticoagulant medications caused serious bleeding. Which management strategy will be best for this client?
Inferior Vena Cava Filtration
A client sitting upright and receiving high-flow oxygen with a nonrebreather mask appears anxious and has a respiratory rate of 30 breaths/min, a heart rate of 110 beats/min, and an oxygen saturation of 88%. The client is using accessory muscles to breathe and appears fatigued. The nurse notifies the provider and prepares to receive an order for which intervention?
Intubation & mechanical ventilation
A family member of a client who has acute respiratory distress syndrome (ARDS) asks the nurse how long it will take for the client to get better. The nurse reviews the medical record and notes that the client has been receiving mechanical ventilation for 2 weeks. What does the nurse tell the family member?
Lung changes have occurred that are irreversible
A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this patient is necessary. What is the main rationale for this?
Maintaining a patent airway
A patient in acute respiratory failure is classified as having ventilatory failure. The nurse understands that which finding is a potential cause of ventilatory failure?
Opioid Analgesic Overdose
A client with acute respiratory distress syndrome (ARDS) is being mechanically ventilated. The provider has ordered 10 cm H2O of positive end-expiratory pressure (PEEP) to be used with mechanical ventilation. What assessment will inform the nurse that the PEEP was effective in supporting the client's respiratory needs?
Oxygen saturation increaes from 85% to 92%
A client has a Pao2 of 55 mm Hg, an arterial oxygen saturation of 85%, and a hemoglobin of 9.2 g/dL. The client also has normal lung function and clear breath sounds, but has exertional dyspnea. What does the nurse suspect the client is experiencing?
Oxygenation Failure
Which assessment finding best indicates that the endotracheal tube remains correctly placed in the client's trachea and is not in the esophagus?
PACO2 level is 38mm Hg
The nurse is teaching the family of a client who is receiving mechanical ventilation. Which statement reflects appropriate information that the nurse should communicate?
Paralysis and sedatives help decrease the demand for oxygen
A client has developed a pulmonary embolism. The nurse anticipates orders for which lab values before beginning heparin therapy for this condition?
Partial Thromboplastin Time (PTT)
The nurse receives a report about a client with chronic obstructive pulmonary disease (COPD) and learns that the client has orthopnea. The nurse plans to perform which comfort measure for this client?
Place the client in an upright position to facilitate breathing
A client has been receiving heparin subcutaneously for 4 days. Which laboratory blood test value does the nurse report immediately to the provider?
Platelet count of 50,000mm
A client with chronic obstructive pulmonary disease (COPD) reports acute difficulty breathing and right-side pleuritic pain. Auscultation reveals decreased breath sounds in the right lung field compared to the left lung field. Which possible condition does the nurse contact the provider for based on these assessment data?
Pneumothorax
The nurse assesses extreme shortness of breath, agitation, and apprehension in a client who had knee surgery. A heart rate of 119 beats/min and a respiratory rate of 24 breaths/min with an oxygen saturation of 84% are also noted. The nurse suspects which postoperative complication?
Pulmonary Embolism
A client recovering from an osteotomy and pin fixation for a femur fracture suddenly experiences shortness of breath, chest pain, and tachycardia. What does the nurse suspect is causing the client's symptoms?
Pulmonary embolism
The nurse expects which changes in a client with acute respiratory distress syndrome (ARDS)? Select all that apply.
Reduction in surfactant activity Damage to type II pneumocytes Edema around terminal airways
Which intervention will be most effective in reducing anxiety in a client with a pulmonary embolism (PE)?
Remain with the client and provide oxygen in a calm manner
A 17-year-old client was ejected from a car after hitting a tree at a fast speed. The client was believed to have aspirated at the scene and a nasogastric tube was placed. The client underwent emergent surgery to control bleeding from a lacerated liver and several long bone fractures. Four units of packed red blood cells were given during the surgery. The nurse monitors the client for the development of acute lung injury based on which risk factors? Select all that apply.
Shock Trauma Blood Transfusions Aspiration
An x-ray of a trauma patient reveals rib fractures and the patient is diagnosed with a small flail chest injury. Which intervention should the nurse include in the patient's plan of care?
Suction the patient's airway secretions
A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube?
To remove air from the pleural space
While caring for a patient with an endotracheal tube, the nurses recognizes that suctioning is required how often?
When adventitious breath sounds are auscultated
20. The nurse is caring for a homeless client and consults the emergency department (ED) case manager. What can the ED case manager do for this client? a. Communicate client needs and restrictions to support staff. b. Prescribe low-cost antibiotics to treat community-acquired infection. c. Provide referrals to subsidized community-based health clinics. d. Offer counseling for substance abuse and mental health disorders.
c. Provide referrals to subsidized community-based health clinics. Case management interventions include facilitating referrals to primary care providers who are accepting new clients or to subsidized community-based health clinics for clients or families in need of routine services. The ED nurse is accountable for communicating pertinent staff considerations, client needs, and restrictions to support staff (e.g., physical limitations, isolation precautions) to ensure that ongoing client and staff safety issues are addressed. The ED physician prescribes medications and treatments. The psychiatric nurse team evaluates clients with emotional behaviors or mental illness and facilitates the follow-up treatment plan, including possible admission to an appropriate psychiatric facility.
