CC Final Review Questions
Which intervention is the highest priority nursing action for a client with a scorpion bite? 1 Assessing the client's vital signs 2 Applying an ice pack to the sting site 3 Contacting the poison control center 4 Covering the client with cooling blanket
Assessing the client's vital signs The first priority is vital sign assessment for a client who sustained a scorpion sting. Continuous monitoring for several hours in the critical care unit helps ensure the client's safety. The nurse has to then apply an ice pack to the sting site to reduce pain. The poison control center assists with client management, particularly in regard to the use of medications for scorpion stings, and this is a medium priority. Covering the client with cooling blanket to reduce fever is of lowest priority.
After a client has had a permanent demand pacemaker implanted, which finding by the nurse would be of most concern? Blood on the dressing Pulse rate 40 beats/minute Blood pressure 104/76 mm Hg Pain at the incisional site
Correct2 Pulse rate 40 beats/minute Because a demand pacemaker would be set at a rate of at least 60 beats/minute, a pulse of 40 beats/minute indicates a need for rapidly assessing the cardiac monitor for failure of the pacemaker to capture or sense the client's underlying rate and notification of the health care provider. Blood on the dressing is normal after surgery, and the nurse would continue to monitor the dressing. Blood pressure of 104/76 mm Hg is at the low end of normal; the nurse would continue to monitor the blood pressure. Pain after pacemaker implantation is expected, and the nurse would administer prescribed analgesics.
Which type of burn or injury may cause a client to have a cervical spine injury? 1 Electrical burns 2 Chemical burns 3 Inhalation injury 4 Cold thermal injury
Electrical burns Electrical burns may cause injuries to the cervical spine because intense electrical currents can fracture long bones and vertebrae. Chemical burns may cause eye and tissue damage. Inhalation injuries may damage the respiratory tract. Cold thermal injuries may cause tissue damage.
A client is experiencing severe acute respiratory distress. Which response would the nurse expect the client to exhibit? 1 Tremors 2 Anasarca 3 Bradypnea 4 Tachycardia
Tachycardia The heart rate increases in an attempt to compensate for the lack of oxygen to body cells. Tremors are not associated with respiratory distress; tremors are associated with neurological problems. Severe generalized edema (anasarca) is not associated with respiratory distress; anasarca is associated with renal failure. An increased respiratory rate (tachypnea), not a decreased respiratory rate (bradypnea), is associated with respiratory distress.
Which early sign of increased intracranial pressure (ICP) would the nurse monitor in a client who sustained a head injury while playing soccer? 1 Nausea 2 Lethargy 3 Sunset eyes 4 Hyperthermia
Lethargy Lethargy is an early sign of a changing level of consciousness; a changing level of consciousness is one of the first signs of increased ICP. Nausea is a subjective symptom, not a sign, potentially present with increased ICP. Sunset eyes is a late sign of increased ICP that occurs in children with hydrocephalus. Hyperthermia is a late sign of increased ICP that occurs as compression of the brainstem increases.
In which order would four clients admitted to an emergency department after a bus accident with different conditions be seen? 1.Chest pain 2.Abdominal pain resulting from ischemia 3.Closed extremity trauma 4. Cardiac Arrest
1.Cardiac arrest 2.Chest pain resulting from ischemia 3.Abdominal pain 4.Closed Extremity Trauma The client in cardiac arrest is triaged under emergency severity index 1 (ESI-1) and should be seen immediately because the condition is severe. The client with abdominal pain is triaged as ESI-3 and is seen within up to 1 hour. The client with closed extremity trauma could be delayed and is assigned ESI-4. The client with chest pain resulting from ischemia is triaged as ESI-2. This client should be seen by the health care provider within 10 minutes but not immediately as should the client with cardiac arrest.
The cardiac monitor reveals several runs of ventricular tachycardia. Which medication is used to treat this dysrhythmia? 1 Atropine 2 Epinephrine 3 Amiodarone 4 Sodium bicarbonate
Amiodarone Amiodarone suppresses ventricular activity; therefore it is used for treatment of premature ventricular complexes (PVCs). It works directly on the heart tissue and slows the nerve impulses in the heart. Atropine blocks vagal stimulation; it increases the heart rate and is used for bradycardia, not PVCs. Epinephrine increases myocardial contractility and heart rate; therefore it is contraindicated in the treatment of PVCs. Sodium bicarbonate increases the serum pH level; therefore it combats metabolic acidosis.
After surgery, a client is extubated in the postanesthesia care unit. Which clinical manifestations would the nurse expect if the client is experiencing acute respiratory distress? Select all that apply. One, some, or all responses may be correct. Confusion Hypocapnia Tachycardia Constricted pupils Slow respiratory rate
Confusion Hypocapnia Tachycardia Inadequate cerebral oxygenation produces restlessness and confusion. Tachycardia occurs as the body attempts to compensate for the lack of oxygen. A low carbon dioxide level in the blood (hypocapnia) occurs with an increase in respiratory rate. The pupils dilate, not constrict, with hypoxia. An elevated respiratory rate (tachypnea), not a slow respiratory rate (bradypnea), occurs.
In which order would the nurse caring for a client suffering from heatstroke provide emergency interventions? 1. Remove the client from the hot environment. 2. Remove the client's clothing. 3. Ensure a patent airway. 4. Pour or spray cold water on the client's body and scalp. 5. Place ice in cloth or bags and position the packs on the client's scalp. 6. Fan the client with newspapers or whatever is available.
Emergency care should be provided to the client with heatstroke to restore thermoregulation. First the nurse would ensure a patent airway. Then the nurse would remove the client from the hot environment into air conditioning or shade and remove his or her clothing. Then the nurse would pour or spray cold water on the client's body and scalp. The client should be fanned with newspapers or whatever is available. This should be followed by placing ice in cloth or bags and positioning the packs on the client's scalp.
Which medication would the nurse expect to administer to actively reverse the overdose sedative effects of benzodiazepines? 1 Lithium 2 Flumazenil 3 Methadone 4 Chlorpromazine
Flumazenil Flumazenil is the medication of choice in the management of overdose when a benzodiazepine is the only agent ingested by a client not at risk for seizure activity. Flumazenil competitively inhibits activity at benzodiazepine recognition sites on gamma-aminobutyric acid-benzodiazepine receptor complexes. Lithium is used in the treatment of mood disorders. Methadone is used for narcotic addiction withdrawal. Chlorpromazine is contraindicated in the presence of central nervous system depressants.
Which assessment findings alert the nurse that the client who has a spinal cord injury is developing autonomic hyperreflexia (autonomic dysreflexia)? 1 Hypertension and bradycardia 2 Flaccid paralysis and numbness 3 Absence of sweating and pyrexia 4 Escalating tachycardia and shock
Hypertension and bradycardia Hypertension and bradycardia occur as a result of exaggerated autonomic responses. If autonomic hyperreflexia is identified, immediate intervention is necessary to prevent serious complications. Paralysis is related to transection, not autonomic hyperreflexia; the client will have no sensation below the injury. Profuse diaphoresis occurs above the level of injury. Bradycardia occurs rather than tachycardia.
How would the nurse prepare a client for cranial surgery? 1 Assist the client with securing a wig onto the head. 2 Obtain the client's consent to have the head shaved. 3 Shampoo the client's hair with a medicated shampoo. 4 Tell the client that head shaving is needed before anesthesia.
Obtain the client's consent to have the head shaved. Because of legal and cosmetic concerns, consent for head shaving must be obtained before a client receives anesthesia. Because head shaving is a nursing intervention, the nurse should obtain this consent. The surgeon will obtain the consent for surgery. The client will not be able to wear a wig to surgery because wigs could become a source of infection and should not be worn until healing occurs. Washing the client's hair with a medicated shampoo is unnecessary because the hair will be shaved to help prevent contamination of the surgical site. Shaving of some areas of the head or the entire head is typically performed after the client is anesthetized.