Test 1 Acute Care
If the chest tube is not working, what do you check first?
Auscultate!!!
Bipap does what type of pressures?
BOTH NEG AND POS. Completely takes over.
Where is the chest tube supposed to be placed?
Below clients chest level and BELOW tubing. ENSURE the tubing is not on the floor to promote gravity
Respiratory Acidosis Caused by
COPD Pneumonia Lowering RR
Dx test to determine Pneumothorax/hemothorax
CXR
Metabolic acidosis caused by
***DKA***, Renal failure, dehydration, liver failure
Encourage coughing and deep breathing every ___________ hrs for chest tube pts
2
HCO3 range
22-26
PaCO2 range
35-45
Tidal Volume formula
7-9 ML per KG
PH range
7.35-7.45
Heat stroke temp
>104F
GCS Eye opening acronym?
AVPU
Pulmonary Empyema def
Accumulation of pus in the pleural space due to pulmonary infection
A nurse is caring for a client who had a myocardial infarction 5 days ago. The client has a sudden onset of shortness of breath and begins coughing frothy, pink sputum. The nurse auscultates loud, bubbly sounds on inspiration. Which of the following adventitious breath sounds should the nurse document? A. Coarse crackles B. Wheezes C. Rhonchi D. Friction rub
Correct Answer: A. Coarse crackles A client who had a recent myocardial infarction is at risk for left-sided heart failure. Crackles are breath sounds caused by movement of air through airways partially or intermittently occluded with fluid and are associated with heart failure and frothy sputum. Crackling sounds are heard at the end of inspiration and are not cleared by coughing.
A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD) and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan? A. Eat high-calorie foods first B. Increase intake of water at meal times C. Perform active range-of-motion exercises before meals D. Keep saltine crackers nearby for snacking
Correct Answer: A. Eat high-calorie foods first Clients who have COPD often experience early satiety. Therefore, the client should eat calorie-dense foods first.
A nurse on a medical-surgical unit is assessing a client who recently transferred from the ICU following endotracheal extubation. Which of the following findings should the nurse identify as a possible manifestation of tracheal stenosis and report to the provider? A. Increased coughing B. Diaphragmatic breathing C. Hemoptysis D. Kussmaul respirations
Correct Answer: A. Increased coughing The nurse should identify increased coughing as a manifestation of tracheal stenosis. Other manifestations include an inability to cough up secretions and difficulty talking or breathing.
A nurse is caring for a client who received naloxone for a suspected opioid overdose. Which of the following findings should the nurse identify as an adverse effect of this medication? A. Report of pain B. Respiratory rate 8/min C. Report of numbness D. Report of abdominal cramping and diarrhea
Correct Answer: A. Report of pain The nurse should identify that naloxone is used to reverse the effects of an opioid overdose administered for pain, sedation euphoria, and respiratory depression. Excess doses of naloxone can cause the return of pain but can improve the client's respiratory rate.
A nurse is caring for a client immediately following extubation. Which of the following manifestations indicates that the nurse should call the rapid response team? A. Stridor B. Coughing C. Hoarseness D. Extensive oral secretions
Correct Answer: A. Stridor The nurse should identify that stridor (a high-pitched crowing sound heard during inspiration) is caused by laryngeal edema and can indicate impending airway obstruction. The nurse should call the rapid response team for assistance before the airway becomes completely obstructed.
A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. Which of the following findings should the nurse recognize as an indication of pulmonary embolism? A. Sudden onset of dyspnea B. Tracheal deviation C. Bradycardia D. Difficulty swallowing
Correct Answer: A. Sudden onset of dyspnea Clinical manifestations of pulmonary embolism have a rapid onset. Dyspnea occurs due to reduced blood flow to the lungs.
A nurse is assessing an infant who develops respiratory distress, absence of breath sounds on one side, and deviation of the trachea away from the affected side. Based on these manifestations, which of the following conditions is the infant experiencing? A. Tension pneumothorax B. Flail chest C. Pulmonary contusion D. Fractured rib
Correct Answer: A. Tension pneumothorax The nurse should identify these manifestations as an indication the infant is developing a tension pneumothorax. The infant might also become cyanotic and show asymmetry of the thorax.
A nurse is caring for a client who is undergoing conservative treatment for deep-vein thrombosis. The client asks the nurse what will happen to the clot. Which of the following responses should the nurse make? A. "Your body has a process called fibrinolysis that will eventually dissolve the clot." B. "Your body has a mechanism that will keep the clot stable in its present location." C. "The clot will break into tiny fragments and float harmlessly in your bloodstream." D. "Treatment with heparin will dissolve the clot and keep other clots from forming." Check Answer Challenge a FriendQuestion Feedback Show Explanation Grade Pause Previous
Correct Answer: A. "Your body has a process called fibrinolysis that will eventually dissolve the clot."
A nurse on a medical-surgical unit is caring for 4 clients. Which of the following clients should the nurse monitor for crepitus? A. A client who has a chest tube following a pneumothorax B. A client who has an acute exacerbation of Crohn's disease C. A client who is postoperative following a laparoscopic appendectomy D. A client who is recovering from thyroid storm Check Answer
Correct Answer: A. A client who has a chest tube following a pneumothorax
A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following clients should the nurse plan to see first? A. A client who has heart failure and is receiving 100% oxygen via partial rebreather mask B. A client who has emphysema and is receiving oxygen at 3L/min via transtracheal oxygen cannula C. A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar D. A client who has COPD and is receiving oxygen at 2 L/min via nasal cannula
Correct Answer: A. A client who has heart failure and is receiving 100% oxygen via partial rebreather mask
A nurse in the emergency department is caring for a group of clients who all have an odor of alcohol on their breath and multiple injuries to the head and extremities. Which of the following clients should the nurse assess first? A. A client who is difficult to arouse and is unable to respond to questions B. A client who has slurred speech and exhibits anger C. A client who reports nausea and vomiting D. A client who is uncooperative and has uncoordinated movements
Correct Answer: A. A client who is difficult to arouse and is unable to respond to questions
A nurse in the emergency department is assessing a client for closed pneumothorax and significant bruising of the left chest following a motor-vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax? A. Absence of breath sounds B. Expiratory wheezing C. Inspiratory stridor D. Rhonchi
Correct Answer: A. Absence of breath sounds
A charge nurse in an emergency department receives notification of a massive explosion at a local industrial plant. More than 30 casualties from the explosion will begin arriving shortly. Which of the following actions should the nurse take first? A. Activate the emergency response plan. B. Call in available personnel. C. Obtain additional supplies. D. Move current clients to hospital rooms.
Correct Answer: A. Activate the emergency response plan.
A nurse in an emergency department is teaching newly licensed nurses about planning interventions for clients who experience sexual assault. Which of the following actions should be included in the teaching? A. Determine if the client is experiencing thoughts of self-harm B. Postpone collection of forensic evidence if a sexual assault nurse examiner is not available C. Encourage the client to shower before undergoing a physical examination D. Assess the client for the presence of a maturational crisis
Correct Answer: A. Determine if the client is experiencing thoughts of self-harm
A charge nurse in an emergency department is informed that a tornado touched down in a nearby town, and mass casualties are on the way. Which of the following actions should the nurse take first? A. Follow facility policy to activate the disaster plan. B. Prepare the triage rooms. C. Obtain additional supplies. D. Call in off-duty staff members.
Correct Answer: A. Follow facility policy to activate the disaster plan.
A nurse is caring for a client who has emphysema and chronic respiratory acidosis. The nurse should monitor the client for which of the following electrolyte imbalances? A. Hyperkalemia B. Hyponatremia C. Hypercalcemia D. Hypomagnesemia
Correct Answer: A. Hyperkalemia
A nurse in the emergency department is caring for a client who has a snakebite on her arm. Which of the following interventions should the nurse implement? A. Immobilize the limb at the level of the heart B. Apply a tourniquet to the affected limb C. Use a sterile scapula to incise the wound D. Apply ice to the skin over the snakebite wound
Correct Answer: A. Immobilize the limb at the level of the heart
A nurse is caring for a client who is receiving mechanical ventilation and develops acute respiratory distress. Which of the following actions should the nurse take first? A. Initiate bag-valve-mask ventilation B. Provide the client with a communication board C. Obtain a blood sample for ABG analysis D. Document the ventilator settings
Correct Answer: A. Initiate bag-valve-mask ventilation
A nurse is caring for an older adult client who is having a stroke. After assessing the client's airway, breathing, and circulation, which of the following assessments is the nurse's priority? A. Level of consciousness B. Muscle tone C. Sensory changes D. Gag reflex
Correct Answer: A. Level of consciousness
A nurse is reviewing a client's laboratory report. The client's ABG levels are pH 7.5, PaCO2 32 mmHg, and HCO3- 24 mEq/L. The nurse should determine that the client has which of the following acid-base imbalances? A. Respiratory alkalosis B. Metabolic acidosis C. Respiratory acidosis D. Metabolic alkalosis
Correct Answer: A. Respiratory alkalosis
A nurse in a medical-surgical unit is assessing a client. The nurse should identify that which of the following findings is a manifestation of a pulmonary embolism? A. Stabbing chest pain B. Calf tenderness C. Elevated temperature D. Bradycardia
Correct Answer: A. Stabbing chest pain
A nurse is providing teaching to a client about pulmonary function testing. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation? A. Total lung capacity B. Vital lung capacity C. Functional residual capacity D. Residual volume
Correct Answer: A. Total lung capacity
A nurse is providing discharge teaching about improving gas exchange for a client who has emphysema. Which of the following instructions should the nurse include in the teaching? A. Use pursed-lip breathing during periods of dyspnea B. Limit fluid intake to 1,500 mL per day C. Practice chest breathing each day D. Wear home oxygen to maintain an SaO2 of at least 94%
Correct Answer: A. Use pursed-lip breathing during periods of dyspnea
A nurse is providing discharge teaching to a client who has emphysema. Which of the following instructions should the nurse include? A. "Be sure to take cough medicine to avoid coughing." B. "Try to drink at least 2 to 3 liters of fluid per day." C. "Try to reduce your smoking to 2 cigarettes per day." D. "Be sure to eat 3 full meals each day."
Correct Answer: B. "Try to drink at least 2 to 3 liters of fluid per day." Although adequate hydration is essential for all clients, clients who have emphysema should drink 2 to 3 L per day to help liquefy secretions. INCORRECT C. The nurse should encourage clients who have emphysema to quit smoking completely.
A nurse is caring for a client who has a pelvic fracture. The client reports sudden shortness of breath, stabbing chest pain, and feelings of doom. This client is experiencing which of the following complications? A. Pneumonia B. Pulmonary embolus C. Tension pneumothorax D. Tuberculosis
Correct Answer: B. Pulmonary embolus
A nurse is assessing a child who is postoperative. Which of the following findings should the nurse identify as an indication that naloxone should be administered? A. Crackles in the lung bases B. Respiratory depression C. Nausea and vomiting D. Tachycardia
Correct Answer: B. Respiratory depression
A nurse is providing discharge teaching to a client who had a pulmonary embolism. Which of the following statements indicates that the client understands the information? A. "I'll expect a little leg swelling since I won't be that active for a while." B. "I'll see the doctor every week to change my vena cava filter." C. "I'll call the doctor if I see any blood in my urine or stool." D. "I'll have to take the blood thinner for a few more days."
Correct Answer: C. "I'll call the doctor if I see any blood in my urine or stool." Bleeding precautions are essential for clients who had a pulmonary embolism because they take an anticoagulant. They should report any signs of bleeding immediately.
A client who has thrombocytopenia asks the nurse why platelets are so important. Which of the following responses should the nurse make? A. "Platelets help the body fight infection." B. "Platelets help break down clots in the body." C. "Platelets plug breaks in blood vessels." D. "Platelets produce the molecules that carry oxygen."
Correct Answer: C. "Platelets plug breaks in blood vessels." Platelets help maintain hemostasis and coagulation by plugging disruptions in the integrity of blood vessels. When an injury occurs to a blood vessel, platelets collect at the edge of the break and adhere to each other to plug the injured area and limit blood loss.
A nurse is caring for a client who has a prescription for naloxone. Which of the following is the intended action of the medication in relation to the central nervous system (CNS)? A. Accentuate the effects of narcotics on the CNS B. Depress activity of the CNS C. Block the effects of narcotics on the CNS D. Stimulate activity of the CNS
Correct Answer: C. Block the effects of narcotics on the CNS By blocking the effects of narcotics on the CNS, naloxone prevents CNS and respiratory depression in the newborn following delivery.
A nurse is providing anticipatory guidance about the accidental ingestion of a toxic substance to the parents of a toddler. The nurse should instruct the parents to take which of the following actions first if the child ingests a hazardous substance? A. Give the toddler milk. B. Go to an emergency department. C. Call the poison control center. D. Induce vomiting.
Correct Answer: C. Call the poison control center. According to evidence-based practice, the nurse should instruct the parents to call the poison control center, which will then identify what further actions the parents should take.
A nurse is planning discharge teaching for a client who is postoperative following a traditional open cholecystectomy. Which of the following learning needs of the client is the nurse's priority? A. Dietary recommendations B. Incision care C. Coughing and deep-breathing exercises D. Pain management
Correct Answer: C. Coughing and deep-breathing exercises The greatest risk to the client is respiratory compromise. Therefore, learning how to perform coughing and deep-breathing exercises to promote lung expansion and secretion removal is the priority.
A client is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation upon palpation of the right side of the client's chest. After notifying the provider, the nurse should document this finding as which of the following? A. Friction rub B. Crackles C. Crepitus D. Tactile fremitus
Correct Answer: C. Crepitus Crepitus, also called subcutaneous emphysema, is a coarse crackling sensation that the nurse can feel when palpating the skin surface over the client's chest. Crepitus indicates an air leak into the subcutaneous tissue, which is often a clinical manifestation of pneumothorax.
A nurse in an emergency department is caring for a toddler who is in acute respiratory distress. Which of the following findings should alert the nurse to the possibility of epiglottitis? A. Lethargy B. Spontaneous coughing C. Drooling D. Hoarseness
Correct Answer: C. Drooling Epiglottitis is a disorder caused by an inflammation of the epiglottis. It results in rapid swelling of the epiglottis, which can obstruct breathing. Drooling is an expected finding due to the toddler's inability to swallow saliva.
A nurse is caring for a client for whom the respiratory therapist has just removed the endotracheal tube. Which of the following actions should the nurse take first? A. Instruct the client to cough B. Administer oxygen via face mask C. Evaluate the client for stridor D. Keep the client in a semi- to high-Fowler's position
Correct Answer: C. Evaluate the client for stridor The first action the nurse should take using the nursing process is to assess the client. After extubation, the nurse should continuously evaluate the client's respiratory status. Stridor is a high-pitched sound during inspiration that indicates laryngospasm or swelling around the glottis. Stridor reflects a narrowed airway and might require emergency reintubation.
A nurse is caring for a client who has a 20-year history of COPD and is receiving oxygen at 2 L/min via nasal cannula. The client is dyspneic and has an oxygen saturation via pulse oximetry of 85%. Which of the following actions should the nurse take? A. Place a nonrebreather mask on the client and increase the oxygen flow to 3 L/min B. Prepare the client for possible endotracheal intubation and mechanical ventilation C. Increase the oxygen flow and request an arterial blood gas determination D. Position the client supine and administer an antianxiety medication
Correct Answer: C. Increase the oxygen flow and request an arterial blood gas determination The client requires oxygen therapy at a rate that will keep the oxygen saturation between 88% and 92%. The nurse should increase the client's oxygen flow and evaluate its effectiveness with ABG results and oxygen saturation via pulse oximetry measurements.
A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following findings should the nurse expect? A. Urine negative for ketones B. Distended neck veins C. Kussmaul respirations D. Elevated blood pressure
Correct Answer: C. Kussmaul respirations The nurse should expect this client with DKA to experience Kussmaul respirations. These deep and rapid respirations are the body's attempt to exhale carbon dioxide to reverse the metabolic acidosis that occurs with DKA.
A nurse is reviewing the medication administration record of a client who is receiving an opioid medication for pain. Which of the following prescriptions should the nurse clarify with the provider? A. Metoprolol B. Ondansetron C. Lorazepam D. Naloxone
Correct Answer: C. Lorazepam The nurse should identify that lorazepam can cause central nervous system depression, which can result in increased respiratory depression and sedation when administered with an opioid. The nurse should clarify the prescription with the provider.
A nurse is caring for a client who was brought to the emergency department by friends after a reported heroin overdosed. Which of the following findings should the nurse expect to assess? A. Temperature 39.2°C (102.6°F) B. Respiratory rate 30/min C. Pinpoint pupils D. Severe abdominal cramping
Correct Answer: C. Pinpoint pupils Pinpoint pupils are an expected finding in opioid toxicity. Increased pupil size is seen in opioid withdrawal.
A nurse is caring for a client who is extremely anxious and is hyperventilating. The client's ABG results are pH 7.50, PaCO2 27 mmHg, and HCO3- 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances? A. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis
Correct Answer: C. Respiratory alkalosis Because of rapid breathing, the client is exhaling excessive amounts of carbon dioxide. This loss of carbon dioxide decreases the hydrogen ion level of the blood, which causes the pH to increase and results in respiratory alkalosis.
A nurse is assessing the respiratory status of a client who has COPD. Which of the following manifestations should the nurse identify as an indication of impending respiratory failure? A. Wheezing B. Bradypnea C. Tachycardia D. Diaphoresis
Correct Answer: C. Tachycardia Tachycardia, dyspnea, restlessness, headaches, and increased blood pressure are indications of impending respiratory failure. A. Wheezing indicates asthma, not respiratory failure. B. Bradypnea is an indication of respiratory depression. Tachypnea is an indication of respiratory failure. D. Diaphoresis develops as hypoxemia worsens; therefore, it is a manifestation of worsening, not impending, respiratory failure.
A nurse is planning care for a client following placement of a chest tube 1 hr ago. Which of the following actions should the nurse include in the plan of care? A. Clamp the chest tube if there is continuous bubbling in the water seal chamber B. Keep the chest tube drainage system at the level of the right atrium C. Tape all connections between the chest tube and drainage system D. Empty the collection chamber and record the amount of drainage every 8 hr
Correct Answer: C. Tape all connections between the chest tube and drainage system The nurse should tape all connections to ensure that the system is airtight and prevent the chest tubing from accidentally disconnecting.
A nurse is assessing a preschooler who has influenza and reports the new onset of a sore throat and difficulty swallowing. Which of the following findings is the priority for the nurse to report to the provider? A. The child's temperature is 39°C (102°F) B. The child's skin is sallow C. The child is drooling D. The child's voice is hoarse
Correct Answer: C. The child is drooling When using the urgent versus nonurgent approach to client care, the nurse should determine that the presence of drooling is the priority finding because it can indicate the child might have developed epiglottitis, a medical emergency. Left untreated, the child can develop a complete respiratory obstruction.
A nurse in the emergency department is caring for a 12-year-old child who has ingested bleach. Which of the following statements by the nurse indicates an understanding of this ingestion? A. "The absence of oral burns excludes the possibility of esophageal burns." B. "Treatment focuses on neutralization of the chemical." C. "Injury by a corrosive liquid is more extensive than by a corrosive solid." D. "Immediate administration of activated charcoal is warranted."
Correct Answer: C. "Injury by a corrosive liquid is more extensive than by a corrosive solid."
A nurse is caring for a client who is postoperative following a thoracic lobectomy. The client has 2 chest tubes in place: 1 in the lower portion of the thorax and the other higher on the chest wall. When a family member asks why the client has 2 chest tubes, which of the following responses should the nurse make? A. "Two tubes were necessary due to excessive bleeding from the area of the surgery." B. "The tubes drain blood from 2 different lung areas." C. "The lower tube will drain blood, and the higher tube will remove air." D. "The second tube will take over if blood clots block the first tube."
Correct Answer: C. "The lower tube will drain blood, and the higher tube will remove air."
A nurse is teaching breathing techniques to a client who has emphysema. Which of the following statements indicates that the client understands the mechanics of pursed-lip breathing? A. "I'll inhale slowly through pursed lips to help me breathe better." B. "When I do my pursed-lip breathing, I'll lie down first." C. "When I breathe out through pursed lips, my airways don't collapse between breaths." D. "I'll relax my stomach muscles when I am doing my pursed-lip breathing exercises."
Correct Answer: C. "When I breathe out through pursed lips, my airways don't collapse between breaths."
A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate. The client begins to show indications of magnesium sulfate toxicity. Which of the following medications should the nurse prepare to administer? A. Protamine sulfate B. Naloxone C. Calcium gluconate D. Flumazenil
Correct Answer: C. Calcium gluconate
A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which of the following findings should the nurse report to the provider? A. Ecchymosis of the thigh B. Serous drainage at the pin site C. Chest petechiae D. Muscle spasms in the left leg
Correct Answer: C. Chest petechiae
A charge nurse in an emergency department is notified by the county's emergency medical services of a multiple-casualty crash involving a truck carrying radioactive waste. Which of the following actions should the nurse take first? A. Designate a decontamination area to accommodate clients who are irradiated. B. Notify the admissions office to clear as many critical care beds as possible. C. Clear the department of all non-urgent clients and move those awaiting admission to a holding area. D. Determine the number of casualties the emergency department can accommodate.
Correct Answer: C. Clear the department of all non-urgent clients and move those awaiting admission to a holding area.
A nurse is caring for a client who is having difficulty breathing. The nurse should assist the client into which of the following positions? A. Supine B. Lateral C. Fowler's D. Trendelenburg
Correct Answer: C. Fowler's
A nurse is assessing a client who has pharyngitis. Which of the following findings is the nurse's priority to report to the provider? A. Elevated temperature B. Swollen cervical lymph nodes C. Inspiratory stridor D. Purulent nasal discharge
Correct Answer: C. Inspiratory stridor
A charge nurse is coordinating the evacuation of clients from a facility following a bomb threat. Which of the following actions should the nurse take when implementing the evacuation process? A. Call the clients' family members to provide additional help with moving the clients. B. Ask clients who are able to ambulate to assist in moving the unstable clients. C. Instruct clients who are able to ambulate to leave. D. Direct staff members to close the doors and windows as each room is evacuated.
Correct Answer: C. Instruct clients who are able to ambulate to leave.
A nurse is caring for a client who is scheduled to have his chest tube removed. Which of the following actions should the nurse take? A. Cover the insertion site with a hydrocolloid dressing after removal B. Provide pain medication immediately after removal C. Instruct the client to perform the Valsalva maneuver during removal D. Delegate removal of the chest tube to a licensed practical nurse (LPN)
Correct Answer: C. Instruct the client to perform the Valsalva maneuver during removal
A nurse is caring for a client who had a left lower lobectomy to treat lung cancer. Which of the following factors will have a significant impact on the plan of care for this client? A. The client will need intensive smoking-cessation education. B. After surgery, the prognosis for clients with lung cancer is usually good. C. Lung cancer usually has metastasized before the client presents with symptoms. D. Oxygen therapy is ineffective following a lobectomy.
Correct Answer: C. Lung cancer usually has metastasized before the client presents with symptoms.
A nurse is preparing to assist a provider with an arterial blood withdrawal from a client's radial artery for ABG measurement. Which of the following actions should the nurse plan to take? A. Hyperventilate the client with 100% oxygen prior to obtaining the specimen B. Apply ice to the site after obtaining the specimen C. Perform an Allen's test prior to obtaining the specimen D. Release the pressure applied to the puncture site 1 min after the needle is withdrawn
Correct Answer: C. Perform an Allen's test prior to obtaining the specimen
A nurse is assessing the skin of a client who has frostbite. The client has small blisters that contain blood, and the skin of the affected area does not blanch. The nurse should classify this injury as which of the following? A. First-degree frostbite B. Second-degree frostbite C. Third-degree frostbite D. Fourth-degree frostbite
Correct Answer: C. Third-degree frostbite
A nurse is prioritizing care for a group of clients. The nurse should plan to attend to which of the following clients first? A. A client who requires a sterile dressing change B. A client who requires gastrostomy tube feeding C. A client who requires urinary catheter care D. A client who requires endotracheal suctioning
Correct Answer: D. A client who requires endotracheal suctioning When using the airway, breathing, and circulation (ABC) approach to client care, the nurse should attend to a client who requires endotracheal suctioning first. Without this intervention, mucus and secretions could accumulate and block the client's airway.
A nurse in the emergency department is caring for a child who accidentally ingested an overdose of acetaminophen. Which of the following medications should the nurse expect to administer? A. Naloxone B. Diphenhydramine C. Glucagon D. Acetylcysteine
Correct Answer: D. Acetylcysteine The nurse should expect to administer acetylcysteine to the child because it is an antidote to acetaminophen.
A nurse is responding to a community-wide request for health care providers to assist at the scene of an explosion. When using the North Atlantic Treaty Organization triage system, the nurse should put which of the following tags on a client who is unresponsive and has third-degree burns over 75% of her body? A. Red B. Yellow C. Green D. Black
Correct Answer: D. Black The nurse should put a black tag on clients who have extensive injuries to indicate a minimal chance of survival, such as a client who is unresponsive and has third-degree burns over 75% of her body.
A nurse is triaging clients during a mass casualty event. Which of the following labels should the nurse assign to a client who has a head injury with fixed, dilated pupils? A. Red tag B. Yellow tag C. Green tag D. Black tag
Correct Answer: D. Black tag The nurse should assign a black tag, or a class IV label, to clients who are not expected to live and will be allowed to die naturally. Dilated pupils that are fixed or nonreactive to light are a poor prognostic sign and indicate severely increased intracranial pressure. In a mass casualty situation, the overall goal is to provide lifesaving treatment to the greatest number of people possible.
A client comes to the emergency department in severe respiratory distress following left-sided blunt chest trauma. The nurse notes absent breath sounds on the client's left side and a tracheal shift to the right. For which of the following procedures should the nurse prepare the client? A. Tracheostomy placement B. Thoracentesis C. CT scan of the chest D. Chest tube insertion
Correct Answer: D. Chest tube insertion The client's manifestations indicate pneumothorax due to blunt chest trauma. The nurse should prepare for the provider to insert a chest tube and connect it to a water-seal drainage system.
A nurse is preparing a client for discharge following a bronchoscopy. Which of the following assessments is the nurse's monitoring priority? A. Measuring heart rate B. Palpating peripheral pulses C. Observing sputum for blood D. Confirming the gag reflex
Correct Answer: D. Confirming the gag reflex The greatest risk to the client's safety is aspiration resulting from a depressed gag reflex. The nurse's priority is to make sure the client's gag reflex has returned before discharge so that the client can maintain hydration and nutrition without risk.
A nurse is developing a plan of care for a client who has alcohol use disorder. Which of the following medications should the nurse plan to administer? A. Methadone B. Varenicline C. Buprenorphine D. Diazepam
Correct Answer: D. Diazepam The nurse should plan to administer diazepam to a client who has alcohol use disorder to minimize manifestations of alcohol withdrawal.
A nurse is caring for a client who is using patterned-paced breathing during the first stage of labor. The client reports a lightheaded feeling and tingling of the fingers. Which of the following actions should the nurse take? A. Instruct the client to hold her breath and bear down B. Ensure that the client's breathing rate is more than twice her normal rate C. Apply counter-pressure to the client's lower back D. Have the client breathe into a paper bag
Correct Answer: D. Have the client breathe into a paper bag The nurse should recognize that the client is experiencing respiratory alkalosis from hyperventilation, which is a possible adverse effect of patterned-paced breathing. To correct hypocarbia, the client should breathe into a paper bag or her cupped hands, rebreathing CO2 and correcting the respiratory alkalosis.
A nurse is reviewing laboratory values for an adult client who has sickle cell anemia and a history of receiving blood transfusions. For which of the following complications should the nurse monitor? A. Hypokalemia B. Lead poisoning C. Hypercalcemia D. Iron toxicity
Correct Answer: D. Iron toxicity A client who has received several blood transfusions is at risk of hemosiderosis, which is the excess storage of iron in the body. Excessive iron can come from overuse of supplements or from receiving frequent blood transfusions as in sickle cell anemia.
A nurse is reviewing laboratory findings of an adolescent who has acute renal failure. Which of the following findings should the nurse expect? A. Hypokalemia B. Hypercalcemia C. Decreased plasma creatinine level D. Metabolic acidosis
Correct Answer: D. Metabolic acidosis Metabolic acidosis is an expected finding for clients who have acute renal failure.
A nurse is auscultating the lungs of a client who is having an acute asthma attack. Which of the following sounds should the nurse expect to hear? A. Soft blowing B. Loud bubbling C. Dry grating D. Noisy wheezing
Correct Answer: D. Noisy wheezing Asthma causes the bronchioles of the lungs to constrict, creating a wheezing sound.
A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and is experiencing shortness of breath. Which of the following actions should the nurse perform first? A. Monitor the client's arterial blood gas results B. Instruct the client to perform controlled coughing C. Teach the client how to use pursed-lip breathing D. Place the client in an upright position
Correct Answer: D. Place the client in an upright position Using the airway, breathing, and circulation (ABC) approach to client care, the nurse should place the client in an upright position to facilitate chest expansion and proper diaphragmatic contraction. Positioning the client upright will also assist with mobilizing secretions that might be impeding airflow.
A nurse in the PACU is assessing a newly admitted client and observes intercostal retractions and a high-pitched inspiratory sound. The nurse should identify these findings as manifestations of which of the following complications? A. Pulmonary edema B. Tension pneumothorax C. Flail chest D. Respiratory obstruction
Correct Answer: D. Respiratory obstruction Intercostal retractions and a high-pitched inspiratory noise (i.e. stridor) are manifestations of an airway obstruction caused by laryngospasm and edema. The nurse should notify the rapid response team and plan to administer racemic epinephrine.
A nurse is preparing a client for thoracentesis. In which of the following positions should the nurse place the client? A. Lying flat on the affected side B. Prone with the arms raised over the head C. Supine with the head of the bed elevated D. Sitting while leaning forward over the bedside table
Correct Answer: D. Sitting while leaning forward over the bedside table When preparing a client for thoracentesis, the nurse should have the client sit on the edge of the bed and lean forward over the bedside table. This position maximizes the space between the client's ribs and allows aspiration of accumulated fluid and air.
A nurse in an emergency department is assessing a school-aged child who is experiencing an acute asthma exacerbation. Which of the following findings is the priority for the nurse to report to the provider? A. Excessively prolonged expiration B. Increased diaphoresis C. Increased production of frothy sputum D. Sudden decrease in wheezing
Correct Answer: D. Sudden decrease in wheezing When applying the urgent versus nonurgent priority-setting framework, the nurse should consider urgent needs to be the priority because they pose a larger risk to the client. A sudden decrease in wheezing can indicate that the child is experiencing decreased air movement and should be reported to the provider. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the most urgent. A sudden decrease in wheezing (silent chest) indicates ventilatory failure and imminent respiratory arrest.
A nurse is providing preoperative teaching to a client who is to undergo a pneumonectomy. The client states, "I am afraid coughing will hurt after the surgery." Which of the following statements by the nurse is appropriate? A. "After the surgeon removes the lung, you will not need to cough." B. "I'll make sure you get a cough suppressant to keep you from straining the incision when you cough." C. "Don't worry. You will have a pump that delivers pain medication as needed, so you will have very little pain." D. "I will show you how to splint your incision while coughing."
Correct Answer: D. "I will show you how to splint your incision while coughing."
A nurse is admitting a client following care in the emergency department for an intentional overdose of opioids. The client states, "I feel so alone. No one can help me." Which of the following responses by the nurse is therapeutic? A. "Let's finish your admission, and then we can talk about your feelings." B. "Why do you feel that no one can help you when you are receiving help now?" C. "What kind of help do you want?" D. "I would like to sit and talk with you."
Correct Answer: D. "I would like to sit and talk with you."
A charge nurse is assembling a list of clients who can be safely discharged home to accommodate incoming casualties following an earthquake. The nurse should recognize that discharging which of the following clients would be unsafe? A. A client who has osteomyelitis and will require 6 weeks of IV antibiotic therapy B. A client who has Crohn's disease and is 1 day preoperative for an ileostomy C. A client who has Alzheimer's disease and is awaiting placement in a long-term care facility D. A client who has an ileus following spinal surgery 5 days ago and is ambulatory in a brace
Correct Answer: D. A client who has an ileus following spinal surgery 5 days ago and is ambulatory in a brace
A nurse is reviewing the laboratory values of a client who has diabetic ketoacidosis. Which of the following laboratory values is consistent with diabetic ketoacidosis? A. Blood glucose 30 mg/dL B. Negative urine ketones C. Blood pH 7.38 D. Bicarbonate level 12 mEq/L
Correct Answer: D. Bicarbonate level 12 mEq/L
A nurse is providing postoperative care for a client who has 2 chest tubes in place following a lobectomy. The client asks the nurse the reason for having 2 chest tubes. The nurse should inform the client that the lower chest tube is placed for which of the following reasons? A. Removing air from the pleural space B. Creating access for irrigating the chest cavity C. Evacuating secretions from the bronchioles and alveoli D. Draining blood and fluid from the pleural space
Correct Answer: D. Draining blood and fluid from the pleural space
A nurse is working in the triage area of an emergency department. Which of the following activities is unlikely to be the nurse's responsibility in this setting? A. Fostering positive public relations for the facility B. Performing a comprehensive client assessment C. Preventing cross-contamination of infectious clients D. Educating a client and his family members
Correct Answer: D. Educating a client and his family members
A nurse is caring for a client who has a chest tube. The nurse notes that the chest tube has become disconnected from the chest drainage system. Which of the following actions should the nurse take? A. Place the drainage system at the head of the client's bed B. Increase the suction to the chest drainage system C. Place the client on low-flow oxygen via nasal cannula D. Immerse the end of the chest tube in a bottle of sterile water
Correct Answer: D. Immerse the end of the chest tube in a bottle of sterile water
A nurse in the emergency department has assessed a client's airway, breathing, and circulation (ABC) following a head injury from a fall at work. Which of the following actions is the priority for the nurse to perform next? A. Question the client's coworkers about the mechanism of injury B. Check the client's pupils for equality and reaction to light C. Measure the client's alertness using the Glasgow Coma Scale D. Immobilize the client's cervical spine
Correct Answer: D. Immobilize the client's cervical spine
A nurse in the emergency department is assessing a client who has deep, rapid respirations. Arterial blood gas analysis includes the following values: pH 7.25, PaCO2 40, and HCO3- 18. Which of the following acid-base imbalances should the nurse identify and report to the provider? A. Respiratory alkalosis B. Metabolic alkalosis C. Respiratory acidosis D. Metabolic acidosis
Correct Answer: D. Metabolic acidosis
A nurse is planning care for a client who is postoperative following a hip arthroplasty. In the client's medical record, the nurse notes a history of chronic obstructive pulmonary disease (COPD). Which of the following oxygen-delivery methods should the nurse plan to use for this client? A. Simple face mask B. Nonrebreather mask C. Bag-valve-mask device D. Nasal cannula
Correct Answer: D. Nasal cannula
A nurse is caring for a 5-year-old child who has a fever and begins to have a seizure. Which of the following actions should the nurse take? A. Give acetaminophen 240 mg PO immediately following the seizure B. Sponge the child's skin with a mixture of cold water and rubbing alcohol C. Administer rectal diazepam if the seizure lasts longer than 2 minutes D. Place the child in a side-lying position
Correct Answer: D. Place the child in a side-lying position
A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the client's airway secretions? A. The client is unable to speak. B. The client's airway secretions were last suctioned 2 hr ago. C. The client coughs and expectorates a large mucous plug. D. The nurse auscultates coarse crackles in the lung fields.
Correct Answer: D. The nurse auscultates coarse crackles in the lung fields.
A nurse is accepting a transfer from the postanesthesia care unit (PACU) of a client who has had a subtotal thyroidectomy. Which of the following pieces of equipment should the nurse have available at the bedside for this client? A. Cardiac monitor B. Defibrillator C. Thoracotomy tray D. Tracheostomy tray
Correct Answer: D. Tracheostomy tray
A client is being discharged home with oxygen therapy delivered through a nasal cannula. Which of the following instructions should the nurse provide to the client and family members? A. Use battery-operated equipment for personal care. B. Apply mineral oil to protect the facial skin from irritation. C. Remove the television set from the client's bedroom. D. Wear cotton clothing to avoid static electricity.
Correct Answer: D. Wear cotton clothing to avoid static electricity.
A nurse is reviewing the laboratory results of a client who has metabolic alkalosis. Which of the following laboratory values should the nurse expect? A. pH 7.31, HCO3- 22 mEq/L, PaCO2 50 mmHg B. pH 7.48, HCO3- 23 mEq/L, PaCO2 25 mmHg C. pH 7.32, HCO3- 18 mEq/L, PaCO2 40 mmHg D. pH 7.49, HCO3- 32 mEq/L, PaCO2 40 mmHg
Correct Answer: D. pH 7.49, HCO3- 32 mEq/L, PaCO2 40 mmHg
A nurse is providing preoperative teaching to a client who has lung cancer and will undergo a pneumonectomy. Which of the following statements should the nurse include? (Select all that apply.) A. "You will have a chest tube in place after surgery." B. "We'll frequently help you turn, cough, and breathe deeply after surgery." C. "You will have to remain in bed for about 2 days after the surgery." D. "We'll give you oxygen to support your breathing if you need it." E. "You should expect pain for the first few days after surgery."
Correct Answers: A. "You will have a chest tube in place after surgery." B. "We'll frequently help you turn, cough, and breathe deeply after surgery." D. "We'll give you oxygen to support your breathing if you need it." Incorrect Answer E: You should maintain pain management, don't scare the pt. C: get them moving asap
A charge nurse receives notification of the admission of a client who is coughing frequently and whose sputum is pink, frothy, and copious. The client has a history of night sweats, anorexia, and weight loss. Which of the following actions should the nurse take? (Select all that apply.) A. Assign the client to a private room with negative-pressure airflow. B. Add contact precautions to the client's plan of care. C. Wear an N95 respirator when entering the client's room. D. Ensure the client's environment provides 4 exchanges of fresh air per minute. E. Institute protective environment precautions as soon as the client arrives on the unit.
Correct Answers: A. Assign the client to a private room with negative-pressure airflow. C. Wear an N95 respirator when entering the client's room.
A nurse is preparing a client for a bronchoscopy. Which of the following actions should the nurse take? (Select all that apply.) A. Explain that the client will receive sedation and will not remember the procedure. B. Verify that the client understands the purpose and nature of the procedure. C. Offer the client sips of clear liquids until 1 hr before the test. D. Obtain a pre-procedural sputum specimen. E. Instruct the client to keep his neck in a neutral position.
Correct Answers: A. Explain that the client will receive sedation and will not remember the procedure. B. Verify that the client understands the purpose and nature of the procedure.
A nurse is planning postoperative education for a client who will undergo a radical neck dissection for cancer of the larynx. The nurse should include which of the following topics? (Select all that apply.) A. NPO status B. Alternative methods of communication C. Endotracheal intubation D. Changes in body image E. Swallowing exercises
Correct Answers: A. NPO status B. Alternative methods of communication D. Changes in body image E. Swallowing exercises
A nurse is caring for a client following a right pleural thoracentesis. The nurse measures a total of 35 mL of purulent drainage. Which of the following findings should the nurse recognize as an indication of a tension pneumothorax? (Select all that apply.) A. Tracheal deviation to the left B. Temperature of 38.8°C (102°F) C. Absent breath sounds on the right side D. Neck vein distention E. Bradypnea
Correct Answers: A. Tracheal deviation to the left C. Absent breath sounds on the right side D. Neck vein distention
A nurse is caring for a client who has a cuffed endotracheal tube in place. The nurse should identify that the purpose of inflating the cuff includes which of the following? (Select all that apply.) A. Allowing the client to speak B. Stabilizing the position of the tube C. Preventing aspiration of secretions D. Preventing air leaks E. Preventing tracheal injury
Correct Answers: B. Stabilizing the position of the tube C. Preventing aspiration of secretions D. Preventing air leaks
What do you emphasize a smoker to do when using o2?
DON'T smoke That makes stuff go boom
What acronym is for checking when the chest tube is not working?
DOPE Displacement Obstruction Pneumothorax Equipment Failure
What do you administer for seizures?
Diazepam
Benzo reversalagent
Flumazenil
Ventricular Fibrillation VF def
Fluttering of the ventricles causing Loss of Consciousness, pulselessness and no breathing.
What does the A-line check?
Gives the BP at the exact moment and monitors hemodynamic status.
Respiratory Alkalosis Caused by
HYPERVENTILATION (anxiety, Pulmonary EMBOLISM, FEAR) Mechanical Vent
Prior to suction, what should you do?
Hyperoxygenate w/ 100% o2.
What sounds would a percussed pneumothorax present with?
Hyperresonance
hypoxia vs hypoxemia
Hypoxia: Underoxygenation of organs/tissues Hypoxemia:Low blood o2
Respiratory Acidosis Symptoms
Increased CO2 retention Less O2 retention Rapid, Shallow Respirations
Why prone pt for respiratory failure after rescue measures completed?
Increases the rate of blood and o2 exchange.
What is bubbling/tidal for chest tubes?
Indicates that the chest tube is working.
Metabolic Acidosis sx
Kussmaul Respirations Hyperkalemia
Respiratory Alkalosis sx
Less CO2 Too Much O2 ***They need to inhale more Co2 to balance, use a PAPER BAG***
Benzo meds?
Lorazepam, Midazolam(Versed)
Chest tube, the suction "should" be at what level?
NEGATIVE 20
Opioid reversal agent
Naloxone
Vecronium therapeutic effect?
PARALYZE AND SUPPRESS clients respiratory. This causes the need to bag the pt or intubate. This is useful for pt's who have poor lung compliance.
Active shooter. What do you do?
Per the test: Run Hide Fight
What tests as a nurse can you do to "assume" that the pleural cavity is presenting with hemo/pnemo
Percussion
Metabolic Alkalosis caused by
TUMS
Other than a CXR, what test can dx Hemothorax?
Thoracentesis
Sleep apnea RF (3)
Weight Male Older
When do you remove the chest tube?
When fluctuation(bubbling/tidal) stops, this indicates that the lungs have reexpanded. NOW ENSURE THAT THIS IS NOT A MALFUNCTION. Verify if the lungs present with equal chest rise and fall and the sounds are equalclearbilat.
Ventricular asystole: def
a complete absence of electrical activity and ventricular movement of the heart. The client is in complete cardiac arrest and requires implementation of BLS and ACLS protocol.
Pulseless electrical activity (PEA): def
a rhythm that appears to have electrical activity but is not sufficient to stimulate effective cardiac contractions and requires implementation of BLS and ACLS protocol
First sign for a pt undergoing anything respiratory?
agitation, restlessness
Pulseless ventricular tachycardia (VT): def
an irritable firing of ectopic ventricular beats at a rate of 140 to 180/min. The client over time will become unconscious and deteriorate into VF.
frostbite tx
bath 104-108 degree Tetanus shot
Bipap
bilevel positive airway pressure
2nd degree Frostbite: Clinical Presentation
blisters cover the exposed skin areas causing necrotic tissue death and swelling
Sleep apnea def
breathing stops during sleep for at least 10 sec at least 5 times per hour.
Where EXACTLY should the tubing be for the chest tube??
coiled on the bed. secured in some fashion.
CPAP
continuous positive airway pressure
Dyspnea definition
difficulty breathing
3 chambers of a chest tube system
drainage water seal suction
What sounds would a percussed hemothorax present with?
dullness/flatness
If a pt's r side of the chest rises but not the left after insertion of et tube, what is that indicative of?
et tube inserted too far and is now located in the r main bronchus
A triage nurse is in the emergency department when several hundred clients who were injured in a train collision arrive at the facility for treatment. Which of the following clients requires immediate treatment? A. A client who has neck pain and was transported to the facility on a backboard B. A client who has epigastric and left arm pain and is diaphoretic C. A client who has nasal and orbital ecchymosis and a respiratory rate of 16/min D. A client who has abdominal pain and is 2 months pregnant
Correct Answer: B. A client who has epigastric and left arm pain and is diaphoretic The nurse should apply the unstable versus stable priority-setting framework. Using this framework, unstable clients are the priority because of needs that threaten survival. Threats or problems involving the airway, breathing, or circulatory status are life-threatening needs that the nurse should address first. Clients whose vital signs or laboratory values indicate a risk for becoming unstable are also a higher priority than clients who are stable. The nurse may need to use nursing knowledge to determine which option describes the most unstable client. A report of severe epigastric and left arm pain accompanied by diaphoresis is a classic manifestation of a myocardial infarction, which is life-threatening and requires immediate treatment. Incorrect Answers: A. A client who has neck pain and was transported to the facility on a backboard is stable. Neck pain is most commonly associated with a whiplash injury. C. A client who has nasal and orbital ecchymosis and a respiratory rate of 16/min is stable. A broken nose or a black eye is common following a collision. This respiratory rate indicates an adequate airway. D. A client who has abdominal pain and is 2 months pregnant is stable. Although the client's pregnancy can cause a complication, at 2 months of gestation, little can be done to prevent fetal demise if she has suffered serious abdominal trauma.
A nurse is caring for a client who has a tracheostomy and is receiving mechanical ventilation. When the low-pressure alarm on the ventilator sounds, it indicates which of the following to the nurse? A. Excessive airway secretions B. A leak within the ventilator's circuitry C. Decreased lung compliance D. The client coughing or attempting to talk
Correct Answer: B. A leak within the ventilator's circuitry The low-pressure alarm means that either the ventilator tubing has come apart or the tubing detached from the client. Low-pressure alarms are often the result of a malfunction or displacement of connections somewhere between the endotracheal or tracheostomy tube and the ventilator.
A nurse is caring for a child who is in the emergency department after ingesting a bottle of acetaminophen. Which of the following medications should the nurse plan to administer? A. Digoxin immune fab B. Acetylcysteine C. Naloxone D. Vitamin K
Correct Answer: B. Acetylcysteine Acetylcysteine is the antidote for acetaminophen overdose or poisoning.
A nurse is assessing a client who is unconscious. The client has a rhythmical breathing pattern of rapid deep respirations followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations? A. Orthopnea B. Cheyne-Stokes C. Paradoxical D. Kussmaul
Correct Answer: B. Cheyne-Stokes Cheyne-Stokes respirations is a breathing pattern of deep to shallow breaths followed by periods of apnea. Cheyne-Stokes respirations can be the result of a drug overdose or increased intracranial pressure and can precede death.
A nurse working in a mental health facility is admitting a client with opioid use disorder who is experiencing withdrawal. The nurse should anticipate a prescription for which of the following medications from the provider? A. Methylnaltrexone B. Methadone C. Naloxone D. Hydromorphone
Correct Answer: B. Methadone The nurse should anticipate a prescription from the provider for methadone for a client who is experiencing opioid withdrawal. Methadone is an opioid medication that is used for pain management and treatment of withdrawal manifestations in clients who have opioid use disorder.
A nurse is providing instructions about pursed-lip breathing for a client who has chronic obstructive pulmonary disease (COPD) with emphysema. This breathing technique accomplishes which of the following? A. Increases oxygen intake B. Promotes carbon dioxide elimination C. Uses the intercostal muscles D. Strengthens the diaphragm
Correct Answer: B. Promotes carbon dioxide elimination A client who has COPD with emphysema should use pursed-lip breathing when experiencing dyspnea. This simple method slows the client's pace of breathing, making each breath more effective. Pursed-lip breathing releases trapped air in the lungs and prolongs exhalation in order to slow the breathing rate. This improved breathing pattern moves carbon dioxide out of the lungs more efficiently.
A nurse is caring for an older adult client who has chronic obstructive pulmonary disease (COPD) with pneumonia. The nurse should monitor the client for which of the following acid-base imbalances? A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis
Correct Answer: B. Respiratory acidosis Respiratory acidosis is a common complication of COPD. This complication occurs because clients who have COPD are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs.
A nurse in the emergency department is caring for a 2-year-old child who was found by his parents crying and holding a container of toilet bowl cleaner. The child's lips are edematous and inflamed, and he is drooling. Which of the following is the priority action by the nurse? A. Remove the child's contaminated clothing B. Check the child's respiratory status C. Administer an antidote to the child D. Establish IV access for the child
Correct Answer: B. Check the child's respiratory status
A nurse is caring for a client who is experiencing acute opioid toxicity. Which of the following actions should the nurse identify as the priority? A. Insert a large-bore IV catheter B. Ensure an adequate airway C. Obtain an accurate medication history D. Prepare to administer an antagonist
Correct Answer: B. Ensure an adequate airway
A nurse in the emergency department is assessing a client who was in a motor-vehicle crash 2 days ago and sustained fractures of his tibia, ulna, and several ribs. The client is now disoriented to time and place and has a SaO2 of 87%. The nurse notes generalized petechiae on the client's skin. Which of the following complications should the nurse suspect? A. Hypovolemic shock B. Fat embolism syndrome C. Thrombophlebitis D. Avascular bone necrosis
Correct Answer: B. Fat embolism syndrome
A nurse on a medical unit is caring for a client who aspirated gastric contents prior to admission. The nurse administers 100% oxygen by nonrebreather mask after the client reports severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS)? A. Tympanic temperature 38°C (100.4°F) B. PaO2 50 mmHg C. Rhonchi D. Hypopnea
Correct Answer: B. PaO2 50 mmHg
A nurse in an emergency department is assisting with the care of a 4-year-old child who ingested toilet bowl cleaner. The child has hemoptysis, is crying, and states, "It burns." Which of the following actions should the nurse perform? (Select all that apply.) A. Identify how much cleaner was in the bottle B. Administer activated charcoal C. Perform immediate gastric lavage D. Insert an IV for morphine administration E. Apply a pulse oximeter
Correct Answers: A. Identify how much cleaner was in the bottle D. Insert an IV for morphine administration E. Apply a pulse oximeter The nurse should ask the parent or guardian about the size of the container, its contents prior to ingestion, and its contents remaining following ingestion. This information provides an estimate of the amount of cleaner the child ingested and can assist the provider in directing treatment. A child who ingests a corrosive agent is likely to have intense pain due to burns in the gastrointestinal system. The nurse should administer morphine as prescribed via IV to provide pain relief. The child is also at risk for airway occlusion due to edema following ingestion of a corrosive agent. Monitoring the child's oxygen saturation level will help the nurse recognize if the child's airway is becoming obscured. Incorrect Answers:B. Activated charcoal is contraindicated for the treatment of poisoning with a corrosive agent because these substances can burn tissue, which the charcoal could then infiltrate. C. Gastric lavage is contraindicated for the treatment of poisoning with a corrosive agent because this could re-expose the upper gastrointestinal system to the corrosive substance, which can result in further injury.
PE RF
oral contraceptive Prego Tob use Increased platelet count Obesity LONG BONE FRACTURE(FEMUR) etc
pneumothorax def
presence of air in pleural cafvity
Hemothorax def
presence of blood in pleural cavity
Oral Care suction toothbrush timeframe?
q12 hrs
First actions for PE exacerbation?
sit them upright, O2, rapid.
