RNSG 1324 Priority Graded Quiz Spring 2018

In preparing for a client's admission to the unit, what is the nurse's responsibility? A. Ensuring the completion of room preparation responsibilities that may have been delegated to ancillary staff. B. Delegating the admission assessment to a nursing assistant. C. Greeting the client in the emergency department or admitting office. D. Ensuring that all staff caring for the client are in the client's room when he or she arrives at the unit.

A. Ensuring the completion of room preparation responsibilities that may have been delegated to ancillary staff. Although the nurse might delegate most activities in preparing the room for admission, it is the nurse's responsibility to ensure that the other personnel complete the preparation. It is not necessary for all care staff to be present when the client arrives and, in fact, it might be quite overwhelming to the client to have them all present. The nurse will greet the client and family members upon their arrival to the unit. An admission assessment is the responsibility of the nurse, not a nursing assistant, who is not educated to perform this skill

An adolescent client comes to the emergency department with acute asthma. The respiratory rate is 44 breaths/minute, and the client is experiencing severe respiratory distress. What is the priority nursing action by the nurse? A. Give a bronchodilator by nebulizer. B. Take a full medical history. C. Apply a cardiac monitor to the client. D. Provide emotional support to the client.

A. Give a bronchodilator by nebulizer. The client having an acute asthma attack needs to increase oxygen delivery to the lung and body. Nebulized bronchodilators open airways and increase the amount of oxygen delivered. The priority at this time is the respiratory status, and the client will be anxious until this is resolved. First, resolve the acute phase of the attack; afterward, obtain a full medical history to determine the cause of the attack and how to prevent attacks in the future. Application of a cardiac monitor is not a priority at this point in the treatment plan.

A young adult is admitted to the emergency department after an automobile accident. The client has severe pain in the right chest from contact with the steering wheel. What should the nurse do first? A. Maintain adequate oxygenation. B. Maintain adequate circulating volume. C. Decrease chest pain. D. Reduce the client's anxiety.

A. Maintain adequate oxygenation. Blunt chest trauma may lead to respiratory failure, and maintenance of adequate oxygenation is the priority for the client. Decreasing the client's anxiety is related to maintaining effective respirations and oxygenation. Although pain is distressing to the client and can increase anxiety and decrease respiratory effectiveness, pain control is secondary to maintaining oxygenation. Maintaining adequate circulatory volume is also secondary to maintaining adequate oxygenation.

A client presents to the emergency department, reporting that he has been vomiting every 30 to 40 minutes for the past 8 hours. Frequent vomiting puts this client at risk for which imbalances? A. Metabolic alkalosis and hypokalemia B. Metabolic acidosis and hypokalemia C. Metabolic alkalosis and hyperkalemia D. Metabolic acidosis and hyperkalemia

A. Metabolic alkalosis and hypokalemia Gastric acid contains large amounts of potassium, chloride, and hydrogen ions. Excessive vomiting causes loss of these substances, which can lead to metabolic alkalosis and hypokalemia. Excessive vomiting doesn't cause metabolic acidosis or hyperkalemia.

A child is brought to the emergency department experiencing severe right lower quadrant pain. The child's pulse and respirations are elevated, and there are localized tenderness and sluggish bowel sounds. Shortly after the initial assessment, the child states that the pain has suddenly resolved. Which of the following would the nurse suspect? A. The child has signs that the appendix has ruptured. B. The child is recovering from a mild case of gastroenteritis. C. The child was experiencing symptoms of a food allergy. D. The child had a bowel obstruction that has now resolved.

A. The child has signs that the appendix has ruptured. When a child with severe right lower quadrant pain has a sudden relief of pain, a ruptured appendix should be suspected. None of the other options reflects this symptom change.

A child is brought to the emergency department with a full-thickness burn involving the epidermis, dermis, and underlying subcutaneous tissue, but does not report pain at this time. Which of the following statements by the nurse are correct about this type of burn? Select all that apply. A. The child must be monitored for signs of fluid shift. B. This is a severe burn and nerve endings have been destroyed. C. Pain medication has been administered orally and was effective. D. Rehabilitation and skin grafting will be necessary. E. This is a superficial burn, so no pain is present.

A. The child must be monitored for signs of fluid shift. B. This is a severe burn and nerve endings have been destroyed. D. Rehabilitation and skin grafting will be necessary. This is an example of a third-degree burn, which is very serious. This child must be carefully monitored for complications. The fact that there is no pain is due to the destruction of the nerve endings. Fluid shift can occur and result in shock. A burn of this degree will also require a long rehabilitation with skin grafting. Oral pain medication would not be administered as the child would be NPO and oral medication would not be effective. This burn is not superficial.

After completing initial assessment rounds, which client should the nurse discuss with the health care provider (HCP) first? A. a client who was admitted from the emergency department last evening after a blow to the head who is now vomiting and confused as to time and place B. a client admitted for lower extremity vasculitis and wound care who is requesting more pain medication before the next dressing change in 2 hours C. a client who had a right total knee replacement 2 days ago and now is reporting constipation and abdominal discomfort D. a client who returned from abdominal surgery last evening and now has a dime-sized bright red spot on the dressing

A. a client who was admitted from the emergency department last evening after a blow to the head who is now vomiting and confused as to time and place Any change in level of consciousness (vomiting, severe headache that is not improving or is getting worse, memory changes, confusion, irritability, change in pupils) should be immediately reported to the HCP and further evaluated, especially in a client with head trauma. The nurse should mark a circle around the amount of drainage on a dressing after surgery so it can be monitored and reported to the HCP if it grows in size, but a dime-sized spot is not an immediate priority. Constipation and abdominal discomfort after surgery require attention but are not priority. Obtaining proper pain medication in order to promote wound care and healing must be addressed with the HCP but it is not the first priority.

There has been a car accident involving four vehicles on a remote highway. The nearest emergency department is 15 minutes away. Which victim should be transported by helicopter rather than an ambulance to the nearest hospital? A. a middle-aged female with cold, clammy skin; heart rate of 120 bpm; and is unconscious B. a 10-year-old with a simple fracture of the femur, who is crying and cannot find his parents C. middle-aged male with severe asthma, heart rate of 120 bpm, and is having difficulty breathing D. an older adult with severe headache, but conscious

A. a middle-aged female with cold, clammy skin; heart rate of 120 bpm; and is unconscious The middle-aged female is likely in shock; she is classified as a triage level I, requiring immediate care. The child with moderate trauma is classified as triage level III, urgent, and can be treated within 30 min. The man with asthma and the man with the severe headache are classified as emergent, triage level II, and can be transported by ambulance and reach the hospital within 15 min.

A client is receiving emergency care following a motor vehicle collision. The health care provider has diagnosed a left pneumothorax. Which sign would typically be present upon auscultation of the client's lungs? A. absence of breath sounds over the left lung field B. clear breath sounds bilaterally C. wheezing on expiration throughout the lung fields D. crackles one-third up the posterior lung fields

A. absence of breath sounds over the left lung field Pneumothorax can occur as a result of trauma where the pleurae separating the lung from the chest wall are damaged, allowing air to enter the pleural space. This air causes the lung to collapse, resulting in absent breath sounds

The client has returned to the surgery unit from the postanesthesia care unit (PACU). The client's respirations are rapid and shallow, the pulse is 120 bpm, and the blood pressure is 88/52 mm Hg. The client's level of consciousness is declining. The nurse should first: A. call the rapid response team (RRT)/medical emergency team. B. call the health care provider (HCP). C. call the PACU. D. call the respiratory therapist.

A. call the rapid response team (RRT)/medical emergency team. The nurse should first call the rapid response team (RRT) or medical emergency team that provides a team approach to evaluate and treat immediately clients with alterations in vital signs or neurological deterioration. The client's vital signs have changed since the client was in the PACU, and immediate action is required to manage the changes; the staff in PACU are not responsible for managing care once the client is transferred to the surgical unit. The respiratory therapist may be a part of the RRT but should not be called first.

A nurse is helping a suspected choking victim. The nurse should perform the Heimlich maneuver when the victim: A. cannot speak due to airway obstruction. B. is coughing vigorously. C. can make only minimal vocal noises. D. starts to become cyanotic.

A. cannot speak due to airway obstruction. The Heimlich maneuver should be administered only to a victim who cannot make any sounds due to airway obstruction. If the victim can whisper words or cough, some air exchange is occurring and the emergency medical system should be called instead of attempting the Heimlich maneuver. Cyanosis may accompany or follow choking; however, the Heimlich maneuver should only be initiated when the victim cannot speak.

A client with type 1 diabetes mellitus is admitted to the emergency department. Which respiratory pattern in a client with diabetes mellitus requires immediate action? A. deep, rapid respirations with long expirations B. short expirations and inspirations C. regular depth of respirations with frequent pauses D. shallow respirations alternating with long expirations

A. deep, rapid respirations with long expirations Deep, rapid respirations with long expirations are indicative of Kussmaul's respirations, which occur in metabolic acidosis. The respirations increase in rate and depth, and the breath has a "fruity" or acetone-like odor. This breathing pattern is the body's attempt to blow off carbon dioxide and acetone, thus compensating for the acidosis. The other breathing patterns listed are not related to ketoacidosis and would not compensate for the acidosis.

For a child who's admitted to the emergency department with an acute asthma attack, nursing assessment is most likely to reveal: A. expiratory wheezing. B. inspiratory stridor. C. apneic periods. D. fine crackles throughout.

A. expiratory wheezing. Expiratory wheezing is common during an acute asthma attack and results from narrowing of the airway caused by edema. Acute asthma rarely causes apneic periods. Inspiratory stridor more commonly accompanies croup. The child may have some fine crackles but wheezing is much more common in an acute asthma attack.

Which goal is a priority for the diabetic client who is taking insulin and has nausea and vomiting from a viral illness or influenza? A. obtaining adequate food intake B. managing own health C. relieving pain D. increasing activity

A. obtaining adequate food intake The priority goal for the client with diabetes mellitus who is experiencing vomiting with influenza is to obtain adequate nutrition. The diabetic client should eat small, frequent meals of 50 g of carbohydrate or food equal to 200 cal every 3 to 4 hours. If the client cannot eat the carbohydrates or take fluids, the health care provider (HCP) should be called, or the client should go to the emergency department. The diabetic client is in danger of complications with dehydration, electrolyte imbalance, and ketoacidosis. Increasing the client's health management skills is important to lifestyle behaviors, but it is not a priority during this acute illness of influenza. Pain relief may be a need for this client, but it is not the priority at this time; neither is increasing activity during the illness.

The friend of a client brought to the emergency department states, "I guess she had some bad junk (heroin) today." The client is drowsy and verbally non-responsive. Which finding is of immediate concern to the nurse? A. respiratory rate of 9 breaths/min B. hypotension C. reduced pupil size D. urinary retention

A. respiratory rate of 9 breaths/min A respiratory rate of less than 12 breaths/minute is cause for concern because it indicates central nervous system depression. Respiratory depression and arrest is the primary cause of death among clients who abuse opioids. Peripheral nervous system effects associated with opioid abuse include urinary retention, hypotension, reduced pupil size, constipation, and decreased gastric, biliary, and pancreatic secretions. Pinpoint pupils are a sign of opioid overdose. However, respiratory depression is the immediate concern.

A client on the oncology floor is ordered a blood transfusion. The nurse explains the procedure and informs the client that an informed consent form must be signed before the blood may be administered. The client asks why consent is necessary. Which response by the nurse best explains why consent is necessary for blood transfusions? A. "When clients who require blood sign an informed consent, it indicates they understand blood transfusions can be hazardous." B. "The consent allows you to make an informed decision about the indications, possible alternatives, risks, and benefits of a blood transfusion." C. "We can administer blood transfusions without a signed informed consent only in the event of an emergency." D. "The Joint Commission(Health Canada) requires a signed informed consent from all clients receiving blood transfusions."

B. "The consent allows you to make an informed decision about the indications, possible alternatives, risks, and benefits of a blood transfusion." Informed consent provides clients with information needed to make informed decisions about their health care. Clients need information about their health care regardless of the requirements mandated by the Joint Commission (Health Canada). Telling the client that blood transfusions may be administered without a signed informed consent in an emergency doesn't explain the purpose of signing a consent form. Informed consent provides the client with more information about blood transfusions than the hazards.

A client is brought to the emergency department with abdominal trauma following an automobile accident. The vital signs are as follows: heart rate, 132 bpm; respirations, 28 breaths/min; blood pressure, 84/58 mm Hg; temperature, 97.0° F (36.1° C); oxygen saturation 89% on room air. Which prescription should the nurse implement first? A. Draw a complete blood count (CBC) with hematocrit and hemoglobin. B. Administer 1 liter 0.9% saline IV. C. Obtain an abdominal x-ray. D. Insert an indwelling urinary catheter.

B. Administer 1 liter 0.9% saline IV. The client is demonstrating vital signs consistent with fluid volume deficit, likely due to bleeding and/or hypovolemic shock as a result of the automobile accident. The client will need intravenous fluid volume replacement using an isotonic fluid (e.g., 0.9% normal saline) to expand or replace blood volume and normalize vital signs. The other prescriptions can be implemented once the intravenous fluids have been initiated.

A client is admitted to the emergency department with a headache, weakness, and slight confusion. The physician diagnoses carbon monoxide poisoning. What should the nurse do first? A. Maintain body temperature. B. Administer 100% oxygen by mask. C. Initiate gastric lavage. D. Obtain a psychiatric referral.

B. Administer 100% oxygen by mask. Carbon monoxide poisoning develops when carbon monoxide combines with hemoglobin. Because carbon monoxide combines more readily with hemoglobin than oxygen does, tissue anoxia results. The nurse should administer 100% oxygen by mask to reduce the half-life of carboxyhemoglobin. Gastric lavage is used for ingested poisons. With tissue anoxia, metabolism is diminished, with a subsequent lowering of the body's temperature, thus steps to increase body temperature would be required. Unless the carbon monoxide poisoning is intentional, a psychiatric referral would be inappropriate.

A health care provider (HCP) has just inserted nasal packing for a client with epistaxis. The client is taking ramipril for hypertension. What should the nurse instruct the client to do? A. Use 81 mg of aspirin daily for relief of discomfort. B. Avoid rigorous aerobic exercise. C. Remove the packing if there is difficulty swallowing. D. Omit the next dose of ramipril.

B. Avoid rigorous aerobic exercise. Epistaxis, or nosebleed, is a common, sudden emergency. Commonly, no apparent explanation for the bleeding is known. With significant blood loss, systemic symptoms, such as vertigo, increased pulse, shortness of breath, decreased blood pressure, and pallor, will occur. Because aerobic exercise may increase blood pressure and increased blood pressure can cause epistaxis, the client with hypertension should avoid it. Aspirin inhibits platelet aggregation, reducing the ability of the blood to clot. The client should continue to take his antihypertension medication, ramipril. Posterior nasal packing should be left in place for 1 to 3 days.

A client arrives at the emergency department reporting chest and stomach pain and a history of black, tarry stools for the past 2 months. Which orders should the nurse anticipate? A. prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen, and fibrin split product values B. ECG, complete blood count, testing for occult blood, and comprehensive serum metabolic panel C. cardiac monitor, oxygen, creatine kinase, and lactate dehydrogenase (LD) levels D. EEG, alkaline phosphatase and aspartate aminotransferase levels, and basic serum metabolic panel

B. ECG, complete blood count, testing for occult blood, and comprehensive serum metabolic panel An ECG evaluates the report of chest pain, complete blood count (CBC) determines anemia, and the test for occult blood determines blood in the stool. Cardiac monitoring, oxygen, creatine kinase, and LD levels are appropriate for a cardiac primary problem. A basic metabolic panel (includes glucose, electrolytes, BUN, creatinine) and alkaline phosphatase and aspartate aminotransferase levels assess liver function. PT, PTT, fibrinogen, and fibrin split products are measured to verify bleeding dyscrasias. An EEG evaluates brain electrical activity.

A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance? A. Respiratory alkalosis B. Metabolic alkalosis C. Respiratory acidosis D. Metabolic acidosis

B. Metabolic alkalosis A pH over 7.45 with a HCO3- level over 26 mEq/L indicates metabolic alkalosis. Metabolic alkalosis is always secondary to an underlying cause and is marked by decreased amounts of acid or increased amounts of base HCO3-. The client isn't experiencing respiratory alkalosis because the PaCO2 is normal. The client isn't experiencing respiratory or metabolic acidosis because the pH is greater than 7.35.

An adult client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric region along with a rigid, board-like abdomen. After obtaining the client's vital signs, what should the nurse do next? A. Raise the head of the bed. B. Notify the health care provider. C. Prepare to insert a nasogastric tube. D. Administer pain medication as prescribed.

B. Notify the health care provider. The client is likely experiencing a perforation of the ulcer, and the nurse should notify the health care provider immediately. The body reacts to perforation of an ulcer by immobilizing the area as much as possible. This results in board-like abdominal rigidity, usually with extreme pain. Perforation is a medical emergency requiring immediate surgical intervention because peritonitis develops quickly after perforation. Administering pain medication is not the first action, although the nurse later should institute measures to relieve pain. Elevating the head of the bed will not minimize the perforation. A nasogastric tube may be used following surgery.

Which topic is most important to include in the teaching plan for a client newly diagnosed with Addison's disease who will be taking corticosteroids? A. The need to adjust the steroid dose based on dietary intake and exercise. B. The importance of watching for signs of hyperglycemia. C. How to decrease the dose of the corticosteroids when the client experiences stress. D. To notify the health care provider (HCP) when the blood pressure is suddenly high.

B. The importance of watching for signs of hyperglycemia Since Addison's disease can be life threatening, treatment often begins with administration of corticosteroids. Corticosteroids, such as prednisone, may be taken orally or intravenously, depending on the client. A serious adverse effect of corticosteroids is hyperglycemia. Clients do not adjust their steroid dose based on dietary intake and exercise; insulin is adjusted based on diet and exercise. Addisonian crisis can occur secondary to hypoadrenocorticism, resulting in a crisis situation of acute hypotension, not increased blood pressure. Addison's disease is a disease of inadequate adrenal hormone, and therefore the client will have inadequate response to stress. If the client takes more medication than prescribed, there can be a potential increase in potassium depletion, fluid retention, and hyperglycemia. Taking less medication than was prescribed can trigger Addisonian crisis state, which is a medical emergency manifested by signs of shock.

At 11 p.m., a client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He's anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone I.V. At 11:30 p.m., the client's arterial blood oxygen saturation is 86%, and he's still wheezing. The nurse should plan to administer: A. alprazolam. B. albuterol. C. propranolol. D. morphine.

B. albuterol Propranolo is for blood pressure Alprazolam is for anxiety The client is hypoxemic because of bronchoconstriction as evidenced by wheezes and a subnormal arterial oxygen saturation level. The client's greatest need is bronchodilation, which can be accomplished by administering bronchodilators. Albuterol is a beta2 adrenergic agonist, which causes dilation of the bronchioles. It's given by nebulization or metered-dose inhalation and may be given as often as every 30 to 60 minutes until relief is accomplished. Alprazolam is an anxiolytic and central nervous system depressant, which could suppress the client's breathing. Propranolol is contraindicated in a client who's wheezing because it's a beta2 adrenergic antagonist. Morphine is a respiratory center depressant and is contraindicated in this situation.

Which medication should be available to provide emergency treatment if a client develops tetany after a subtotal thyroidectomy? A. sodium bicarbonate B. calcium gluconate C. echothiophate iodide D. sodium phosphate

B. calcium gluconate The client with tetany is suffering from hypocalcemia, which is treated by administering an IV preparation of calcium, such as calcium gluconate or calcium chloride. Oral calcium is then necessary until normal parathyroid function returns. Sodium phosphate is a laxative. Echothiophate iodide is an eye preparation used as a miotic for an antiglaucoma effect. Sodium bicarbonate is a potent systemic antacid.

For a client with a sucking stab wound in the chest wall, the nurse should first: A. administer oxygen. B. cover the wound with a petroleum-impregnated dressing. C. prepare for endotracheal intubation. D. notify the health care provider.

B. cover the wound with a petroleum-impregnated dressing. The first course of action for a client with a sucking chest wound is to stop air from entering the chest cavity. Air entry will cause the lung to collapse. Stopping air entry is best done in an emergency situation by applying an air-occlusive dressing over the wound. The nurse can next notify the health care provider. Starting oxygen therapy and preparing for endotracheal intubation may be necessary later, but neither has the same priority on admission as closing the wound.

After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client's immediate needs, then prepares to perform an initial neurologic assessment. The nurse should perform an: A. assessment of the client's gait. B. evaluation of the corneal reflex response. C. examination of the fundus of the eye. D. evaluation of bowel and bladder functions.

B. evaluation of the corneal reflex response. During an acute crisis, the nurse should check the corneal reflex response to rapidly assess brain stem function. Other components of the brief initial neurologic assessment usually include level of consciousness, pupillary response, and motor response in the arms and legs. If appropriate and if time permits, the nurse also may assess sensory responses of the arms and legs. Emergency assessment doesn't include fundus examination unless the client has sustained direct eye trauma. The client shouldn't be moved unnecessarily until the extent of injuries is known, making gait evaluation impossible. Bowel and bladder functions aren't vital, so the nurse should delay their assessment.

An incoherent client with a history of hypothyroidism is brought to the emergency department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and pretibial area. Knowing that these findings suggest severe hypothyroidism, the nurse prepares to take emergency action to prevent the potential complication of: A. thyroid storm. B. myxedema coma. C. cretinism. D. Hashimoto's thyroiditis.

B. myxedema coma. Severe hypothyroidism may result in myxedema coma, in which a drastic drop in the metabolic rate causes decreased vital signs, hypoventilation (possibly leading to respiratory acidosis), and nonpitting edema. Thyroid storm is a life-threatening health condition that is associated with untreated or undertreated hyperthyroidism. During thyroid storm, an individual's heart rate, blood pressure, and body temperature can soar to dangerously high levels. Cretinism is a condition of severely stunted physical and mental growth owing to untreated congenital deficiency of thyroid hormone (congenital hypothyroidism) usually owing to maternal hypothyroidism. Hashimoto's thyroiditis is an autoimmune disorder in which antibodies directed against the thyroid gland lead to chronic inflammation.

The nurse is admitting a client with acute appendicitis to the emergency department. The client has abdominal pain of 10 on a pain scale of 1 to 10. The client will be going to surgery as soon as possible. The nurse should: A. maintain the client in a recumbent position. B. place the client on nothing-by-mouth (NPO) status. C. contact the surgeon to request a prescription for a narcotic for the pain. D. apply heat to the abdomen in the area of the pain.

B. place the client on nothing-by-mouth (NPO) status. The nurse should place the client on NPO status in anticipation of surgery. The nurse can initiate pain relief strategies, such as relaxation techniques, but the surgeon will likely not prescribe narcotic medication prior to surgery. The nurse can place the client in a position that is most comfortable for the client. Heat is contraindicated because it may lead to perforation of the appendix.

An alert and oriented older adult female with metastatic lung cancer is admitted to the medical-surgical unit for treatment of heart failure. She was given 80 mg of furosemide in the emergency department. Although the client is ambulatory, the unlicensed assistive personnel (UAP) are concerned about urinary incontinence because the client is frail and in a strange environment. The nurse should instruct the UAP to assist with implementing the nursing plan of care by: A. prescribing adult diapers for the client so she will not have to worry about incontinence B. placing a commode at the bedside and instructing the client in its use C. padding the bed with extra absorbent linens D. requesting an indwelling urinary catheter to avoid incontinence

B. placing a commode at the bedside and instructing the client in its use A bedside commode should be near the client for easy, safe access. Measurement of urine output is also important in a client with heart failure. Putting diapers on an alert and oriented individual would be demeaning and inappropriate. Indwelling catheters are associated with increased risk of infection and are not a solution to possible incontinence. There is no reason to think that the client would not be able to use the bedside commode.

A client presents to the emergency department complaining of a dull, constant ache along the right costovertebral angle along with nausea and vomiting. The most likely cause of the client's symptoms is: A. interstitial cystitis. B. renal calculi. C. an overdistended bladder. D. acute prostatitis.

B. renal calculi. Renal calculi usually presents as a dull, constant ache at the costovertebral angle. The client may also present with nausea and vomiting, diaphoresis, and pallor. The client with an overdistended bladder and interstitial cystitis presents with dull, continuous pain at the suprapubic area that's intense with voiding. The client also complains of urinary urgency and straining to void. The client with acute prostatitis presents with a feeling of fullness in the perineum and vague back pain, along with frequency, urgency, and dysuri

A nurse is caring for five clients on the orthopedic unit with the help of a nursing assistant. Which task may the nurse delegate to the nursing assistant? A. Notifying the physician of a change in a client's blood pressure B. Auscultating and recording breath sounds in the medical record C. Assisting a client to the bathroom and recording the output in the medical record D. Taking a verbal report from the emergency department for a client being admitted to the orthopedic unit

C. Assisting a client to the bathroom and recording the output in the medical record The nurse may safely delegate activities of daily living such as assisting the client to the bathroom to the nursing assistant. Notifying the physician, auscultating breath sounds, and taking a verbal report are all tasks that must be performed by a registered nurse.

It is acceptable for the nurse to accept a verbal order from the physician in which of these situations? A. Prior to the client leaving the floor for therapy. B. Upon admission of the client to the unit. C. During a medical emergency. D. Immediately prior to discharge.

C. During a medical emergency. In most agencies, the only circumstance in which an attending physician, nurse practitioner, or house officer may issue orders verbally is in a medical emergency, when the physician/nurse practitioner is present but finds it impossible, due to the emergency, to write the order.

An unconscious client with multiple injuries arrives in the emergency department. What should the nurse do first? A. Determine the identity of the client. B. Stop bleeding from open wounds. C. Establish an airway. D. Check for a neck fracture.

C. Establish an airway. The highest priority for a client with multiple head and neck injuries is to establish an open airway for effective ventilation and oxygenation. Unless the client has a patent airway, other care measures will be futile. Determining the client's identify, blood loss, stopping bleeding from open wounds, and checking for a neck fracture are important nursing interventions to be completed after the airway and ventilation are established.

A nursing coordinator calls the intensive care unit (ICU) to inform the department that a client with a suspected pheochromocytoma will be admitted from the emergency department. The ICU nurse should prepare to administer which drug to the client? A. Insulin B. Lidocaine C. Nitroprusside D. Dopamine

C. Nitroprusside Excess catecholamine release occurs with pheochromocytoma and causes hypertension. The nurse should prepare to administer nitroprusside to control the hypertension until the client undergoes adrenalectomy to remove the tumor. Dopamine is used to treat hypotension, which is not associated with pheochromocytoma. Pheochromocytoma does not affect blood glucose levels, so insulin is not indicated in this client unless there is an underlying diagnosis of diabetes mellitus. Lidocaine is sometimes used to treat ventricular arrhythmias, which are not associated with pheochromocytoma.

A 23-month-old child pulls a pan of hot water off the stove and spills it onto her chest and arms. Her mother is right there when it happens. What should the mother do immediately? A. Apply ice directly to the burned areas. B. Apply antibiotic ointment to the burned areas. C. Place the child in a bathtub of cool water. D. Call the neighbor to come over and help her.

C. Place the child in a bathtub of cool water The emergency treatment of both minor and major burns includes stopping the burning process by immersing the burned area in cool, but not cold, water. Thus, the mother should place the child in a bathtub of cool water. Applying ice directly to the burned area is inappropriate at this time because more tissue damage can result. Antibiotic ointment should not be applied to the burned area at this time because the burning process must be stopped first. Calling a neighbor for help is appropriate after the mother has placed and then removed her child from the bathtub.

A client with a history of peptic ulcer disease is admitted to the hospital. Initial assessment reveals that his blood pressure is 96/60 mm Hg, his pulse rate is 120 bpm, and he has vomited coffee-ground-like material. Based on this assessment, what is the nurse's priority action? A. Collect data regarding recent client stressors. B. Place the client in a modified Trendelenburg position. C. Prepare to insert a nasogastric (NG) tube. D. Administer an antiemetic.

C. Prepare to insert a nasogastric (NG) tube. The nurse should prepare to insert an NG tube. The data collected provide evidence that the client is experiencing an upper gastrointestinal bleed secondary to a peptic ulcer. The client will be placed on nothing-by-mouth status, and an NG tube will be inserted to provide gastric decompression and alleviate vomiting. Administering antiemetics is not a priority action for a client who is hypotensive and vomiting coffee-ground emesis. Assessment of client stressors is appropriate after emergency care has been provided and the client stabilized. A modified Trendelenburg position is inappropriate for clients who are vomiting.

The nurse is caring for a 3-year-old client being treated for severe status asthmaticus. After comparing clinical manifestations with laboratory results (reported below), a nurse determines evidence that this client has progressed to which condition? ABG = pH 7.28; PaCO2 55; HCO3 26 A. Metabolic alkalosis B. Metabolic acidosis C. Respiratory acidosis D. Respiratory alkalosis

C. Respiratory acidosis A pH less than 7.35 and a PaCO2 greater than 45 mm Hg (6.0 kPa) indicate respiratory acidosis. Status asthmaticus is a medical emergency that's characterized by respiratory distress. At first, the client hyperventilates; then respiratory alkalosis occurs, followed by metabolic acidosis. If treatment is ineffective or has not begun, symptoms can progress to hypoventilation and respiratory acidosis, both of which are life-threatening. A client with respiratory alkalosis would have a pH greater than 7.45 and a PaCO2 less than 35 mm Hg (4.7 kPa). Metabolic acidosis is characterized by a pH less than 7.35 and a bicarbonate (HCO3-) level less than 22 mEq/L (22 mmol/L). Metabolic alkalosis is characterized by a pH greater than 7.45 and HCO3- above 26 mEq/L (26 mmol/L).

A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3--) of 26 mEq/L. What disorder is indicated by these findings? A. Metabolic acidosis B. Respiratory acidosis C. Respiratory alkalosis D. Metabolic alkalosis

C. Respiratory alkalosis Respiratory alkalosis results from alveolar hyperventilation. It's marked by a decrease in PaCO2 to less than 35 mm Hg and an increase in blood pH over 7.45. Metabolic acidosis is marked by a decrease in HCO3-- to less than 22 mEq/L, and a decrease in blood pH to less than 7.35. In respiratory acidosis, the pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg. In metabolic alkalosis, the HCO3-- is greater than 26 mEq/L and the pH is greater than 7.45.

A client experienced a pneumothorax after the placement of a central venous pressure line. Which of the following assessments supports a diagnosis of pneumothorax? A. Bradypnea and elevated blood pressure. B. Tracheal deviation toward the affected side. C. Sudden, sharp pain on the affected side. D. Presence of crackles and wheezes.

C. Sudden, sharp pain on the affected side. Signs and symptoms of a pneumothorax include sudden, sharp pain with breathing or coughing on the affected side, tachypnea, dyspnea, diminished or absent breath sounds on the affected side, tachycardia, anxiety, and restlessness. Tracheal deviation away from the affected side indicates a tension pneumothorax, which is a medical emergency.

The nurse assigns an unlicensed assistive personnel (UAP) to provide care for a client with peptic ulcer disease. Concerned about possible ulcer perforation, the nurse should instruct the UAP to report to the nurse immediately if the client has: A. an elevated pulse. B. constipation. C. severe abdominal pain. D. confusion.

C. severe abdominal pain. A sign of ulcer perforation is the onset of sudden, severe abdominal pain. The nurse should instruct all unlicensed assistive personnel to report this symptom immediately because a perforated ulcer is a medical emergency. An elevated pulse and confusion may occur for various reasons; the assistant should report all vital signs, but the severe pain must be brought to the nurse's attention immediately. Constipation will not require immediate intervention.

The nurse auscultates inspiratory and expiratory wheezes with a decreased forced expiratory volume in a client with asthma. Which class of medication would the nurse expect to administer immediately? A. inhaled steroids B. oral steroids C. beta blockers D. bronchodilators

D. bronchodilators Bronchodilators are the first line of treatment for asthma because bronchoconstriction is the cause of reduced airflow. Inhaled or oral steroids may be given to reduce the inflammation but aren't used for emergency relief. Beta blockers aren't used to treat asthma and can cause bronchoconstrictio

A client is admitted to the emergency department with crushing chest injuries sustained in a car accident. Which sign indicates a possible pneumothorax? A. decreased sensation on the affected side B. increased fremitus C. Cheyne-Stokes respirations D. diminished or absent breath sounds on the affected side

D. diminished or absent breath sounds on the affected side DECREASED Fremitus is a sign of pneumothorax Accumulation of air in the pleural cavity after a crushing chest injury may be assessed by unilateral diminished or absent breath sounds. Cheyne-Stokes respirations with periods of apnea commonly precede death. They indicate heart failure or brain death. Fremitus is increased with lung consolidation and decreased with pleural effusion or pneumothorax. Pain occurs at the injury site and increases with inspiration.

A client receives 12 units of intermediate- or long-acting insulin and 6 units of fast-acting insulin each morning. Place the following actions in chronological order of how the nurse would demonstrate how to mix insulins. Use all options. 1. Inject 12 units of air into the intermediate- or long-acting insulin vial. 2. Withdraw 12 units of intermediate- or long-acting insulin insulin. 3. Inject 6 units of air into the fast-acting insulin vial. 4. Wipe off the vials with an alcohol swab. 5. Withdraw 6 units of fast-acting insulin

4. Wipe off the vials with an alcohol swab. 1. Inject 12 units of air into the intermediate- or long-acting insulin vial. 3. Inject 6 units of air into the fast-acting insulin vial 5. Withdraw 6 units of fast-acting insulin 2. Withdraw 12 units of intermediate- or long-acting insulin insulin. The nurse should wipe the insulin bottles with an alcohol swab before each use to eliminate contamination. Then the nurse should inject 12 units of air into the intermediate- or long-acting insulin vial, without touching the insulin. Next, the nurse should insert 6 units of air into the fast-acting insulin and draw up the insulin into the syringe. Fast-acting insulin should be drawn into the syringe first to avoid the risk of mixing the long-acting insulin into the vial and delaying the onset of action of the regular insulin in an emergency. Lastly, the nurse should draw 12 units of intermediate- or long-acting insulin) into the syringe.

A client comes to the emergency department complaining of severe pain in the right flank, nausea, and vomiting. The physician tentatively diagnoses right ureterolithiasis (renal calculi). When planning this client's care, the nurse should assign highest priority to which nursing diagnosis? A. Acute pain B. Risk for infection C. Imbalanced nutrition: Less than body requirements D. Deficient knowledge related to medication regimen

A. Acute pain Ureterolithiasis typically causes such acute, severe pain that the client can't rest and becomes increasingly anxious. Therefore, the nursing diagnosis of Acute pain takes highest priority. Diagnoses of Risk for infection and Deficient knowledge related to medication regimen are appropriate when the client's pain is controlled. A diagnosis of Imbalanced nutrition: Less than body requirements isn't pertinent at this time.

A client with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/min, nasal flaring, and use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath sounds. What should the nurse do first? A. Administer bronchodilators as prescribed. B. Encourage the client to relax and breathe slowly through the mouth. C. Draw blood for an arterial blood gas. D. Initiate oxygen therapy as prescribed, and reassess the client in 10 minutes.

A. Administer bronchodilators as prescribed. In an acute asthma attack, diminished or absent breath sounds can be an ominous sign indicating lack of air movement in the lungs and impending respiratory failure. The client requires immediate intervention with inhaled bronchodilators, IV corticosteroids, and, possibly, IV theophylline. Administering oxygen and reassessing the client 10 minutes later would delay needed medical intervention, as would drawing blood for an arterial blood gas analysis. It would be futile to encourage the client to relax and breathe slowly without providing the necessary pharmacologic intervention.

A client with type 1 diabetes is admitted to an acute care facility with diabetic ketoacidosis. To correct this acute diabetic emergency, which measure should the health care team take first? A. Administer insulin. B Initiate fluid replacement therapy. C. Determine the cause of diabetic ketoacidosis. D. Correct diabetic ketoacidosis.

B Initiate fluid replacement therapy. The health care team first initiates fluid replacement therapy to prevent or treat circulatory collapse caused by severe dehydration. Although diabetic ketoacidosis results from insulin deficiency, the client must have an adequate fluid volume before insulin can be administered; otherwise, the drug won't circulate throughout the body effectively. Therefore, insulin administration follows fluid replacement therapy. Determining and correcting the cause of diabetic ketoacidosis are important steps, but the client's condition must first be stabilized to prevent life-threatening complications.

The nurse is evaluating the effectiveness of fluid resuscitation during the emergency period of burn management. Which finding indicates that adequate fluid replacement has been achieved in the client? A. an increase in body weight B. urine output greater than 35 mL/hour C. blood pressure of 90/60 mm Hg D. fluid intake less than urinary output

B. urine output greater than 35 mL/hour A urine output of 30 to 50 mL/h indicates adequate fluid replacement in the client with burns. An increase in body weight may indicate fluid retention. A urine output greater than fluid intake does not represent a fluid balance. Depending on the client, blood pressure of 90/60 mm Hg could indicate the presence of a hypovolemic state; by itself, it does not indicate adequate fluid replacement.

A client with colorectal carcinoma is devastated after learning that the cancer has spread to the liver and lungs and the client has only a 5% chance of surviving for 5 years. Which comment by the nurse would best help the client cope with this news? A "Those are just numbers. You have to live each day fully and not worry about dying." B. "I've seen clients in your situation who have lived almost 20 years." C. "It must be hard to hear that prognosis. Would it help you to talk to me or the chaplain?" D. "This might be a good time to think about an advance directive in case you run into problems while you're here."

C. "It must be hard to hear that prognosis. Would it help you to talk to me or the chaplain?" This response is most therapeutic because it encourages the client to express feelings and concerns. Options 1 and 4 offer false hope and reflect the nurse's empirical observations, not statistics. Option 3 is inappropriate because an informed person who isn't a member of the health care team should discuss (at the client's request) which level of care the client wishes to receive in case of an emergency.

A client presents to the emergency department with reports of acute GI distress, bloody diarrhea, weight loss, and fever. A family history of which of the following would be significant to this client's diagnosis? A. Peptic ulcers B. Crohn's disease C. Ulcerative colitis D. Appendicitis

C. Ulcerative colitis A family history of ulcerative colitis, particularly if the relative affected is a first-degree relative, increases the likelihood of the client having ulcerative colitis. Crohn's disease does not have inflammatory symptoms, but rather more abdominal pain related. A family history of peptic ulcers is not a genetic risk factor as well as appendicitis.

A client who has undergone a subtotal thyroidectomy is subject to complications in the first 48 hours after surgery. The nurse should obtain and keep at the bedside equipment to: A. administer tube feedings. B. initiate defibrillation. C. begin total parenteral nutrition. D. perform a tracheotomy.

D. perform a tracheotomy. Equipment for an emergency tracheotomy should be kept in the room, in case tracheal edema and airway occlusion occur. Laryngeal nerve damage can result in vocal cord spasm and respiratory obstruction. A tracheostomy set, oxygen and suction equipment, and a suture removal set (for respiratory distress from hemorrhage) make up the emergency equipment that should be readily available. Total parenteral nutrition is not anticipated for the client undergoing thyroidectomy. Arrhythmias requiring defibrillation is not an expected possible treatment after thyroidectomy. Tube feedings are not anticipated emergency care.

The nurse is removing the client's staples from an abdominal incision when the client sneezes and the incision splits open, exposing the intestines. What should the nurse do first? A. Cover the abdominal organs with sterile dressings moistened with sterile normal saline. B. Press the emergency alarm to call the resuscitation team. C. Have all visitors and family leave the room. D. Call the surgeon to come to the client's room immediately.

A. Cover the abdominal organs with sterile dressings moistened with sterile normal saline. When a wound eviscerates (abdominal organs protruding through the opened incision), the nurse should cover the open area with a sterile dressing moistened with sterile normal saline and then cover it with a dry dressing. The surgeon should then be notified to take the client back to the operating room to close the incision under general anesthesia. The nurse should not press the emergency alarm because this is not a cardiac or respiratory arrest. The nurse should have the visitors and family leave the room to decrease the chance of airborne contamination, but the primary focus should be on covering the wound with a moist, sterile covering

An older adult with a history of heart failure is admitted to the emergency department with pulmonary edema. On admission, what should the nurse assess first? A. skin breakdown B. urine output C. blood pressure D. serum potassium level

C. blood pressure It is a priority to assess blood pressure first because people with pulmonary edema typically experience severe hypertension that requires early intervention. The client probably does not have skin breakdown, but when the client is stable and when the nurse obtains a complete health history, the nurse should inspect the client's skin for any signs of breakdown; however, when the client is stable, the nurse should inspect the skin. Potassium levels are not the first priority. The nurse should monitor urine output after the client is stable.

A client is admitted with a diagnosis of thrombophlebitis and deep vein thrombosis of the right leg. A loading dose of heparin has been given in the emergency department, and IV heparin will be continued for the next several days. The nurse should develop a plan of care for this client that will involve: A. administering aspirin as ordered. B. encouraging green leafy vegetables in the diet. C. monitoring the client's activated partial thromboplastin time (aPTT) and International Normalized Ratio (PT/INR). D. monitoring the client's prothrombin time (PT).

C. monitoring the client's activated partial thromboplastin time (aPTT) and International Normalized Ratio (PT/INR). Heparin dosage is usually determined by the health care provider (HCP) based on the client's aPTT and INR laboratory values. Therefore, the nurse monitors these values to prevent complications. Administering aspirin when the client is on heparin is contraindicated. Green leafy vegetables are high in vitamin K and therefore are not recommended for clients receiving heparin. Monitoring of the client's PT is done when the client is receiving warfarin sodium.

While making rounds, the nurse finds a client with COPD sitting in a wheelchair, slumped over a lunch tray. After determining the client is unresponsive and calling for help, the nurse's first action should be to: A. call the rapid response team. B. push the "code blue" (emergency response) button. C. open the client's airway. D. call for a defibrillator.

C. open the client's airway. The nurse has already called for help and established unresponsiveness so the first action is to open the client's airway; opening the airway may result in spontaneous breathing and will help the nurse determine whether or not further intervention is required. Pushing the "code blue" button may not be the appropriate action if the client is breathing and becomes responsive once the airway is open. A quick assessment upon opening the client's airway will help the nurse to determine if the rapid response team is needed. Calling for a defibrillator may not be the necessary or appropriate action once the client's airway has been opened.

A staff nurse on a pediatric unit has a four-client assignment. Which child should the nurse assess first? A. A 7-year-old child whose mother is waiting for discharge instructions B. An 8-year-old child admitted from the postanesthesia care unit who's complaining of pain C. A 9-year-old child with a broken leg who wants help moving from the bed to the chair D. A 10-year-old child with asthma whose oxygen saturation levels are dropping

D. A 10-year-old child with asthma whose oxygen saturation levels are dropping Decreasing oxygen saturation levels indicate difficulty breathing and increased work of breathing. Airway, breathing, and circulation always take priority. The children complaining of pain and waiting for discharge instructions are not life-threatening situations and don't take priority because administration of pain medication and reviewing discharge instructions can be delegated to another registered nurse. Moving a client from the bed to the chair is also not a life-threatening situation and can be delegated to a nursing assistant.

The nurse in the emergency department is administering a prescription for 20 mg intravenous 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 unit dose for intravenous infusion. What should the nurse do next? A. Administer the medication now, knowing the medication is labeled and the client is identified. B. Ask another nurse to verify the medication and the client so the medication can be given now. C. Report the problem to the information technology team to have the barcode system recalibrated. D. Contact the pharmacist immediately to check the order and the barcode label for accuracy.

D. Contact the pharmacist immediately to check the order and the barcode label for accuracy. The nurse should contact the pharmacist first to be sure the medication is labeled for administration to this client. The nurse should not administer the drug until all safety precautions have been observed; the nurse should also not ask another nurse to verify the medication or client. Later, if the problem cannot be resolved with relabeling the medication, the nurse or pharmacist can contact the information technology team to check the barcode system.

A client comes to the emergency department after hitting his or her head in a motor vehicle collision. The client is alert and oriented. Which nursing intervention should be done first? A. Open airway using head tilt/chin lift maneuver. B. Call for an immediate chest x-ray. C. Perform full range of motion (ROM). D. Immobilize the client's head and neck.

D. Immobilize the client's head and neck. All clients with a head injury are treated as if a cervical spine injury is present until x-rays confirm its absence. Performing ROM would be contraindicated at this time. There's no indication the client needs a chest x-ray. The airway doesn't need to be opened because the client appears alert and not in respiratory distress. In addition, the head tilt/chin lift maneuver wouldn't be used until cervical spine injury is ruled out.

A client comes to the emergency department with an acute asthma attack. The client is anxious, restless, and diaphoretic, and his respirations are labored. A nurse administers a high-flow nebulizer treatment as prescribed. Which finding suggests that this treatment has been effective? A. Oxygen saturation decreases and respiratory effort increases. B. Oxygen saturation increases and respiratory effort increases. C. Oxygen saturation and respiratory effort decrease. D. Oxygen saturation increases and respiratory effort decreases.

D. Oxygen saturation increases and respiratory effort decreases. In an acute asthma attack, the lumina of the small bronchi become narrow and edematous as a result of an inflammatory response. Increased mucus production obstructs the narrow passages of the bronchi. High-flow nebulizer treatments cause bronchial dilation and moisten thick bronchial secretions, which allows them to be expectorated. As secretions are expectorated, oxygen saturation increases and respiratory effort decreases.

A nurse in the emergency department is caring for a client with acute heart failure. Which laboratory value is most important for the nurse to check before administering medications to treat heart failure? A. Platelet count B. White blood cell (WBC) count C. Calcium D. Potassium

D. Potassium Diuretics, such as furosemide, are commonly used to treat acute heart failure. Most diuretics increase the renal excretion of potassium. The nurse should check the client's potassium level before administering diuretics, and obtain an order to replace potassium if the level is low. Other medications commonly used to treat heart failure include angiotensin-converting enzyme inhibitors, digoxin, and beta-adrenergic blockers. Although checking the platelet count, calcium level, and WBC count are important, these values don't affect medication administration for acute heart failure.