Test SATA

Left-side heart catheterization and coronary arteriography

- Myocardial infarction -Stroke -Arterial bleeding or thromboembolism -Dysrhtmias

A patient with neurogenic shock after a spinal cord injury is to receive lactated Ringer's solution 400 mL over 20 minutes. When setting the IV pump to deliver the IV fluid, the nurse will set the rate at how many milliliters per hour?

1,200

A patient is to receive methylprednisolone (Solu-Medrol) 100 mg. The label on the medication states: methylprednisolone 125 mg in 2 mL. How many milliliters will the nurse administer?

1.6

At what rate does the nurse set the infusion pump for a client with a spinal cord injury (SCI) to receive the prescribed 500 mL of dextran over 4 hours? ml/hr

125

An emergency room nurse cares for a client admitted with a 50% burn injury at 10:00 this morning. The client weighs 90 kg. Using the Parkland formula, calculate the rate at which the nurse should infuse intravenous fluid resuscitation when started at noon. (Record your answer using a whole number.) mL/hr

1500

An emergency room nurse implements fluid replacement for a client with severe burn injuries. The provider prescribes a liter of 0.9% normal saline to infuse over 1 hour and 30 minutes via gravity tubing with a drip factor of 30 drops/mL. At what rate should the nurse administer the infusion? (Record your answer using a whole number and rounding to the nearest drop.)

333 gtts/min

Order: Betamethasone (Celestone) 2.4 mg, PO, daily Drug available: Betamethasone 0.6-mg tablets How many tablet(s) would you give?

4

Order: Tagamet 0.4 g, PO, bid, and 0.8 g, at hour of sleep. Drug available: Tagamet 200 mg/tab. How many tablets) would you give per dose at hour of sleep?

4

A 29 year old male patient has superficial partial thickness burns on the anterior right arm, posterior left leg, and anterior head and neck. The patient weighs 78 kg and has arrived immediately after injury. Use the Parkland Burn Formula to calculate the total amount of Lactated Ringers that will be given over the next 24 hours?

5,616

An 80-kg patient with burns over 30% of total body surface area (BSA) is admitted to the burn unit immediately after injury. Using the Parkland formula of 4 mL/kg/%TBSA, what is the IV infusion rate (mL/hour) for lactated Ringer's solution that the nurse will give during the first 8 hours?

600

An emergency department nurse assesses a female client. Which assessment findings would alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.) a. Hypertension b. Fatigue despite adequate rest c. Indigestion d. Abdominal pain e. Shortness of breath

B C E

Both R/L heart failure

Cardiac tamponade Hypovolemia Pulmonary Edema Hematoma or blood loss injection site reaction to contrast medium

. A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately? O Serum potassium: 6.5 mEg/L O Serum sodium: 131 mEg/L O Hematocrit: 52% O Arterial pH: 7.32

O Serum potassium: 6.5 mEg/L

An emergency room nurse is caring for a trauma client. Which interventions are considered appropriate during primary survey? (Select all that apply.) a Removing wet clothing O Splinting open fractures c Endotracheal intubation d Needle decompression O Laceration repair f Initiating IV fluids O Foley catheterization

a c d f

A nurse arrives to the emergency room to receive victims of a mass shooting at a nearby middle school. Which clients would the triage nurse designate as red- tagged? (Select all that apply) a. 43-year-old female gasping and coughing up blood O 12-year-old with massive head trauma and no pulse O 65-year-old with a scratches on the right arm d. 13-year-with visible wound to the chest and tracheal deviation? e. 14-year-old with a bleeding groin wound breathing 50 times per minute

a d e

The nurse is caring for a client who suffered a stroke on the right side of the brain. The nurse is careful to implement what safety measures? (Select all that apply.) a. Make sure there are no trip hazards in the client's room. O Place the call light on the client's left side O Offer clear liquids as tolerated d. Place the call light on the client's right side. e.Leave on a light in the bathroom at night for good visibility.

a d e

A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain? a. Time of symptom onset O Other medical conditions O Progression of symptoms O Loss of bladder control

a.

A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag? a. Multiple fractured ribs and shortness of breath O Closed fracture of the right clavicle and arm numbness O Large contusion to the forehead and a bloody nose O Dislocated right hip and an open fracture of the right lower leg

a.

A nurse receives a report on a client who had a left-sided stroke and has homonymous hemianopsia. What action by the nurse is most appropriate for this client? a. Rotate the client's meal tray when the client stops eating. O Prop the client's right side up when sitting in a chair. O Listen to the client's lungs after eating or drinking. O Assess for bladder retention and/or incontinence.

a.

What does the nurse expect will be the appearance of a client with the hand-off report states that the client has a Glasgow Coma Scale of 3? a. Client will be completely unresponsive. O Client will moan but speech will be coherent. O Client with withdrawal from painful stimuli. O Client will open eyes spontaneously.

a.

Which client assessment finding will help the nurse to differentiate a transient ischemic attack (TIA) from a brain attack (stroke)? a. Symptoms resolve within 30 to 60 minutes O One-sided numbness of face and arm O Unilateral weakened hand grasp O Slurred speech

a.

Which task would the nurse assign to the unlicensed assistive personnel (UAP) when the emergency department (ED) team is giving emergency care to a drowning victim? a. Take, report, and record vital signs every 15 minutes. O Assist with the bag-valve-mask device during intubation. O Insert the nasogastric tube and attach to suction. O Advise the victim's family of the resuscitation status.

a.

An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first? a. Request a prescription for an antitussive medication. b. Apply oxygen and continuous pulse oximetry. c. Ask the respiratory therapist to provide humidified air. d. Provide small quantities of ice chips and sips of water.

b

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.) O Blood pressure of 185/65 mm Hg b. Decreased level of consciousness c. Heart rate of 34 beats/min O Increased oxygen saturation e. Urine output less than 30 mL/hr

b c e

A nurse is caring for clients in a busy emergency department. Which actions should the nurse take to ensure client and staff safety? (Select all that apply.) O Isolate clients who have immune suppression disorders to prevent hospital- acquired infections. b. Search the belongings of clients with altered mental status to gain essential medical information. c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors. O Leave the stretcher in the lowest position with rails down so that the client can access the bathroom. e. Use two identifiers before each intervention and before mediation administration.

b c e

A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.) O Initiate physical therapy. b. Administer analgesics. O Decrease core temperature. d. Provide fluid replacement. e. Prevent wound infections.

b d e

A client in the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best? O Ensure that informed consent is on the chart. b. Notify the provider of the findings immediately. O Give the prescribed preprocedure sedation. O Document these findings in the client's record.

b.

A client is brought to the emergency room after being rescued from a mountain top during a severe winter storm and is experiencing hypotension and tachycardia with an internal temperature of 26.7 degrees C (80 degrees F). Which treatment does the nurse most likely expect for this client? O Heated oxygen or inspired gas to prevent further heat loss via the respiratory tract b. Extracorporeal rewarming methods such as cardiopulmonary bypass O Application of external heat with heating blankets Core rewarming using heated intravenous fluids.

b.

A nurse is caring for a client whose wife died in a recent mass casualty accident. The client says, "I can't believe that my wife is gone and I am left to raise my children all by myself." How should the nurse respond? O "At least your children still have you in their lives." b "You sound anxious about being a single parent." O "I can call the hospital chaplain if you wish." O "Please accept my sympathies for your loss."

b.

A nurse is caring for four clients in the neurologic/neurosurgical intensive care unit. Which client should the nurse assess first? O Client who has been diagnosed with meningitis with a fever of 101° F (38.3° C) b. Client receiving tissue plasminogen activator (t-PA) who has a change in respiratory pattern and rate O Client who had a transient ischemic attack and is waiting for teaching on clopidogrel (Plavix) O Client who is waiting for subarachnoid bolt insertion with the consent form already signed

b.

A student nurse is preparing morning medications for a client with a spinal cord injury (SCI). The student plans to hold the docusate sodium (Colace) because the client had a large stool yesterday. What action by the supervising nurse is best? O Have the student ask the client if it is desired or not. b. Inform the student that the docusate should be given. O Tell the student to document the rationale. O Tell the student to give it unless the client refuses.

b.

An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event? O Call additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in. b. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims. O Ask ED staff to discharge clients from the medical-surgical units in order to make room for critically injured victims. O Inform the incident commander at the mass casualty scene about how many victims may be handled by the ED.

b.

The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination? O Use a disposable blood pressure cuff to avoid sharing with other clients. b. Change gloves between wound care on different parts of the client's body. O Use the closed method of burn wound management for all wound care. O Advocate for proper and consistent handwashing by all members of the staff.

b.

While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action should the nurse take first? O Administer intravenous 0.9% saline solution. b. Transfer the client to a negative-pressure room. O Obtain a sputum culture and sensitivity. O Apply oxygen via nasal cannula.

b.

A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.) Blood pressure of 140/88 mm Hg b. Serum potassium of 2.9 mEq/L (2.9 mmol/L) Warmth and redness at the site d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor Oxygen saturation 93% on room air

b.Serum potassium of 2.9 mEq/L (2.9 mmol/L) d.Expanding groin hematoma e.Rhythm changes on the cardiac monitor

A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take? a. Raise the head of the bed to a semi-Fowler's position. b. Document the findings and reassess in 1 hour. c. Gather appropriate equipment and prepare for an emergency airway. d. Loosen any constrictive dressings on the chest.

c

A nurse uses the rule or nines to assess a client with burn injuries to the entire back region and left arm How should the nurse document the percentage of the client's body that sustained burns? 018% 0 9% c 27% 0 36%

c

For which client is the forensic nurse examiner most likely to be consulted? O Older adult client who dies under mysterious circumstances in the ED." O Client who accidentally received a large dose of opioid medication. c Client who was gang-raped by a group of students at a college party. O Client who was injured by a police officer while resisting arrest.

c

The management of a rural community hospital is trying to encourage a more collaborative environment among staff members in preparation of a disaster preparedness drill. Which statement is important to communicate regarding disaster preparedness? O "It is important that staff members remain in their department during any disaster for consistency. O "The facility's model of care will not change during a disaster." c "During a disaster, no single department is able to meet the needs of the facility." O "Since we are a small hospital, disaster preparedness is not as important for us."

c

What must a nurse based in Texas, who is a member of the Disaster Medical Assistance Team (DMAT) and has been asked to serve in Colorado, do when he or she does not hold an active Colorado nursing license. a. Delay deployment until he or she has reviewed the Nurse Practice Act that is specific to Colorado. b. Discover whether Colorado has reciprocity with Texas before accepting deployment. c. Prepare for deployment because he or she will be considered a federal employee with valid licensure. d. Decline deployment because his or her nursing license will not allow him or her to practice in Colorado.

c

. A nurse assesses a client with the National Institutes of Health (NIH) Stroke Scale and determines the client's score to be 36. How should the nurse plan care for this client? O The client will need cuing only. O The client will need safety precautions. c. The client will need near-total care. O The client will be discharged home.

c.

A 58-year-old client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt like his legs were very heavy. Currently the client's neurologic examination is normal and he is diagnosed with a transient ischemic attack (TIA). What medication does the nurse anticipate in the patient's plan of care? O Heparin drip per protocol O Mannitol (Osmitrol) c. Clopidogrel (Plavix) O Alteplase (Activase)

c.

A client in the operating room has developed malignant hyperthermia. The client's potassium is 6.5 mEq/L. What priority prescription does the nurse anticipate after notifying the physician? O Administer nefedipine (Procardia). O Assess urine for myoglobin or blood. c. Administer 10 units of regular insulin. O Monitor the client for dysrhythmias.

c.

A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first? O Administer a prescribed beta blocker. O Place the client in a supine position. c. Palpate the bladder for distention. O Initiate oxygen via a nasal cannula.

c.

A nurse assesses a client with the National Institutes of Health (NIH) Stroke Scale and determines the client's score to be 36. How should the nurse plan care for this client? O The client will need safety precautions. O The client will need cuing only. c. The client will need near-total care. O The client will be discharged home

c.

A nurse if caring for a client with impaired swallowing following a stroke and is collaborating with the speech therapy department on safe eating. Which priority nursing assessment best indicates that the collaborative goals for this problem have been met? O Gains 2 pounds after 1 week O Chooses preferred items from the menu c. Has clear lung sounds on auscultation O Eats 75% to 100% of all meals and snacks

c.

A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first? O Client who is requesting pain medication for a headache O Client with a Glasgow Coma Scale score that was 9 and is now is 12 c. Client with a Glasgow Coma Scale score that was 10 and is now is 8 O Client with a moderate brain injury who is amnesic for the event

c.

A nurse is triaging clients in the emergency department. Which client should the nurse classify as "nonurgent?" O A 79-vear-old with a temperature of 104° F O A 44-year-old with chest pain and diaphoresis c. A 62-year-old with a simple fracture of the left arm O A 50-year-old with chest trauma and absent breath sounds

c.

A provider prescribes a rewarming bath for a client who presents with partial-thickness frostbite. Which action should the nurse take prior to starting this treatment? O Assess the limb for compartment syndrome. O Massage the frostbitten areas. c. Administer intravenous morphine. O Wrap the limb with a compression dressing.

c.

For which client would the health care provider avoid harm by not performing a lumbar puncture? O Client with muscle weakness in all four extremities O Client who is unable to ambulate c. Client with severe increase in intracranial pressure O Client with hyperactive deep tendon reflexes

c.

On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, blood pressure 106/66 mm Hg. Which action should the nurse take? O Encourage rest and re-assess in 15 minutes. O Encourage the client to drink cool water or sports drinks. c. Start an intravenous line and infuse 0.9% saline solution. O Administer acetaminophen (Tylenol) 650 mg orally.

c.

When a rescue team's descent is delayed by weather from taking a client to the hospital for symptoms of high-altitude pulmonary edema (HAPE), what is the most important immediate treatment for this client during the delay? O Keep the client as warm as possible O Plan rapid descent when weather breaks c. Oxygen administration O Dexamethasone administration

c.

A client who had a severe traumatic brain injury is being discharged home, where the spouse will be a full-time caregiver. What statement by the spouse would lead the nurse to provide further education on home care? O "With respite care and support, I think I can do this." O "Hopefully things will improve gradually over time." O "I need to seek counseling because I am very angry." d "I know I can take care of all these needs by myself."

d

An 25-year-old mail arrives unconscious to the emergency department (ED) after a motorcycle accident. He is screaming, "My head and my neck hurt! Help!" He then becomes unconscious. What should the nurse do first? O Assess for a neck fracture O Apply a dry sterile dressing to a noted scalp wound O Determine the identity of the client d. Establish an airway

d

An emergency room is preparing to activate an emergency preparedness plan to care for victims of a flash flood following a recent hurricane. The nurse knows that the role of the hospital incident commander (HIC) includes all of the following EXCEPT: a. The HIC assumes overall leadership of the emergency plan. b. The HIC ensures availability of medical supplies. c. The HIC has the authority to reassign unit operations. d. The HIC provides direct care to incoming victims on an individual basis

d

Which client would the triage nurse categorize as urgent? O 35-year old with chest pain and diaphoresis 0 65-vear-old with a facial rash from using new wrinkle cream 0 83-year-old with new confusion and very elevated blood pressure compared with his baseline d. 44-year-old with a productive cough, wheezing and a fever of 103.2

d

A nurse is triaging clients in the emergency department (ED). Which client should the nurse prioritize to receive care first? O A 60-year-old reporting difficulty swallowing and nausea O A 22-year-old with a painful and swollen right wrist O An 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101° F d. A 45-year-old reporting chest pain and diaphoresis

d.

An emergency department charge nurse notes an increase in sick calls and bickering among the staff after a week with multiple trauma incidents. Which action should the nurse take? O Organize a pizza party for each shift. O Talk individually with staff members. O Remind the staff of the facility's sick-leave policy. d. Arrange for critical incident stress debriefing.

d.

The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first? O Client with a Glasgow Coma Scale score of 12 O Client with an intracranial pressure measurement of 13 mm Hg O Client with a PaCO2 of 40 mm Hg who is on a ventilator d. Client who has a temperature of 102° F (38.9° C)

d.

What is the best way for the emergency health care provider and nurse to inform a family that their family member has died of extensive injuries despite resuscitation efforts? O "We did everything we could, but your loved one expired." O "Your loved one never woke up, but I am sure they passed without discomfort." O "We want to extend our sympathies because your loved one is not with us anymore." d. "We are sorry to inform you that your loved ones died of extensive injuries.

d.

Which neurological status check finding does the nurse recognize as an early indicator of declining neurologic status? O Loss of remote memory O Decorticate posturing O Nonreactive and dilated pupils d. Change in level of consciousness

d.

A perioperative nurse is caring for a client with a family history of malignant hyperthermia. What signs and symptoms of this reaction would the nurse assess for in the post anesthesia care unit (PACU)? (Select all that apply) a. Temperature great than 105.0 F b. Tachycardia O Nausea and vomiting d. Muscle rigidity in the jaw O Serosanguinous drainage on the abdominal dressing

idk a b d

Which new-onset symptoms indicate to the nurse that a client with spinal cord injury (SCI) is experiencing autonomic dysreflexia (AD)? (Select all that apply.) O Tachypnea b. Profuse sweating of face, neck, and shoulders O Flaccid paralysis d. Blurred vision e. Sudden hypertension with bradycardia O Severe throbbing headache

idk b d e

Right side heart failure

thrombophlebitis pulmonary embolism vagal response