End of life and Emergency response lab test
A nurse is assessing a terminally ill female client. Which client statement indicates that the client is in the bargaining stage of dying? "I can't believe this. I'm going to get a second opinion." "Why is this happening to me. I've led a good life. Why is God punishing me?" "I just want to see my daughter graduate from college. That's all." "I don't know how my husband is going to manage things when I'm gone."
"I just want to see my daughter graduate from college. That's all."
Pulseless Electrical Activity (PEA)
condition in which electrical activity is present on an electrocardiogram, but there is not an adequate pulse or blood pressure
Cardiac arrest clinical manifestations
consciousness, pulse, and blood pressure are lost immediately Breathing usually ceases, but ineffective respiratory gasping may occur The pupils of the eyes begin dilating in less than a minute, and seizures may occur. Pallor and cyanosis are seen in the skin and mucous membranes.
euthanasia
Greek for "good death"; has evolved to mean the intentional killing by act or omission of a dependent human being for their alleged benefit
A terminally ill patient in pain asks the nurse to administer enough pain medication to end the suffering forever. What is the best response by the nurse? "I can't do that, I will go to jail." "I am surprised that you would ask me to do something like that." "I will see if the physician will order enough for that to occur." "I will notify the physician that the current dose of medication is not relieving your pain."
"I will notify the physician that the current dose of medication is not relieving your pain."
The nurse is caring for a client in the ED with frostbite to the left hand. During the rewarming process of the hand, the nurse should perform which action? Administer analgesic medications as ordered. Keep the hand in the circulating bath for 1 hour. Rupture any hemorrhagic blebs that are noted. Have the client complete active range-of-motion exercises.
Administer analgesic medications as ordered.
A client is experiencing anorexia and the physician is to order a medication to stimulate the client's appetite. Which of the following would the nurse least likely expect the physician to prescribe? Megestrol Dexamethasone Dronabinol Atropine
Atropine
A homeless client presents to the ED. Upon assessment, the client is experiencing hypothermia. The nurse will plan to complete which priority intervention during the rewarming process? Attach a cardiac monitor Insert a Foley urinary catheter Assist with endotracheal intubation Administer inotropic drugs
Attach a cardiac monitor
A client comes to the emergency department with a suspected airway obstruction. The emergency department team prepares to manage the client as if he has a complete airway obstruction based on which of the following? Forceful coughing Wheezing between coughs High-pitched noise on inhalation Refusal to lie flat
High-pitched noise on inhalation
A client who is on hospice care and has no immediate family has been given less than 1 week to live. The nurse caring for the client recognizes that providing presence is most important, especially when a client is dying. What would be the best way for this nurse to provide presence to this client? Check on this client every hour. Sit in the chair on the other side of the room for 10 minutes each hour. Hold the client's hand and sit by the bedside as often as possible. Tell the client that you are there when needed and to just ring the call bell.
Hold the client's hand and sit by the bedside as often as possible.
The family members of a dying client are finding it difficult to verbalize their feelings for and show tenderness to the client. Which nursing interventions should a nurse perform in such a situation? Encourage the family members to express their feelings and listen to them in their frank communication. Encourage conversations about the impending death of the client. Be a silent observer and allow the client to communicate with the family members. Encourage the client's family members to spend time with the client.
Encourage the family members to express their feelings and listen to them in their frank
A patient brought to the ED by the rescue squad after getting off a plane at the airport is complaining of severe joint pain, numbness, and an inability to move the arms. The patient was on a diving vacation and went for a last dive this morning before flying home. What is a priority action by the nurse? Ensure a patent airway and that the patient is receiving 100% oxygen. Send the patient for a chest x-ray. Send the patient to the hyperbaric chamber. Draw labs for a chemistry panel.
Ensure a patent airway and that the patient is receiving 100% oxygen.
A client present to the ED following a work-related injury to the left hand. The client has an avulsion of the left ring finger. Which correctly describes an avulsion? Tissue tearing away from supporting structures Incision of the skin with well-defined edges, usually long rather than deep Skin tear with irregular edges and vein bridging Denuded skin
Tissue tearing away from supporting structures
A client with metastatic bone cancer has signed a Do Not Resuscitate (DNR) order specifying comfort care only. Which would be included in the client's plan of care? Select all that apply. placing a feeding tube to ensure adequate caloric intake suctioning thick secretions to relieve dyspnea intubating the client to facilitate mechanical ventilation administering antibiotic therapy to treat a respiratory infection administering oral pain medication every hour
suctioning thick secretions to relieve dyspnea administering oral pain medication every hour
Cricothyroidotomy (Cricothyroid Membrane Puncture)
surgical opening of the cricothyroid membrane to obtain an airway that is maintained with a tracheostomy or endotracheal tube
Avulsion
tearing away of tissue from supporting structures
prognosis
the expected course of an illness and the chance for recovery
palliative sedation
the use of pharmacologic agents, at the request of the terminally ill patient or the patient's legal proxy, to induce sedation, or near-sedation, when symptoms have not responded to other management measures; the purpose is not to hasten the patient's death but to relieve intractable symptoms
A client arrives at the emergency department and is experiencing a severe allergic reacton to a bee sting. The client received treatment and is being discharged. Which client statement indicates that additional teaching about exposure prevention is needed? "I should always wear something on my feet when I'm outside." "Brightly colored clothes help to ward off bees." "If a bee comes near me, I should stay still." "I need to avoid using perfumes and scented soaps when I'm going outside."
"Brightly colored clothes help to ward off bees."
Permanent brain injury or death will occur within which time frame secondary to hypoxia? 1 to 2 minutes 3 to 5 minutes 6 to 8 minutes 9 to 10 minutes
3 to 5 minutes
Chest compression ratio
30:2
A patient with amyotrophic lateral sclerosis (ALS) wishes to use his Medicare Hospice Benefit in an effort to maximize his quality of life prior to death. What criterion will determine whether the patient qualifies for this benefit? A life expectancy of less than 6 months Exhaustion of all reasonable treatment options Copayment by a health insurance provider A demonstrated lack of a support system
A life expectancy of less than 6 months
Sodium Bicarbonate (NaHCO3)
Action: -corrects metabolic acidosis Indications: -Given to correct metabolic acidosis that is refractory to standard advanced cardiac life support interventions (cardiopulmonary resuscitation, intubation, and respiratory management) Nursing Considerations: -Administer initial dose of 1 mEq/kg IV; then administer dose based on base deficit -Recognize that to prevent development of rebound metabolic alkalosis, complete correction of acidosis is not indicated
Vasopressin
Action: -increases systemic vascular resistance and BP Indications: -An alternative to epinephrine Nursing Considerations: -Give 40 U IV one time only
All nurses care for clients who are grieving. It is important for the nurse to understand the grieving process for which reason? Allows for the nurse to facilitate the grieving process Allows for the nurse to take the client through in the appropriate order Allows for the nurse to understand when the grieving process should be concluded Allows the nurse to express his or her feelings
Allows for the nurse to facilitate the grieving process
A client states, "My children still need me. Why did I get cancer? I am only 30." This client is exhibiting which stage according to Kübler-Ross? Denial Anger Bargaining Acceptance
Anger
A family of a dying client reports that their loved one is experiencing more shortness of breath. Which nursing intervention is most appropriate at this time? Offer the bedpan to urinate or defecate Call the health care provider to obtain an oxygen order Get the client out of bed to the chair. Offer the client sips to drink.
Call the health care provider to obtain an oxygen order
The nurse has come on shift to find that a client newly admitted to the ICU is confused and persistently trying to get out of bed despite being comforted and re-oriented by the nurse. The client begins to pull on the peripheral intravenous line in the hand and speaking in non-sensical terms. The client's history indicates a sudden onset of neurological symptoms after developing a bacterial infection. The nurse anticipates providing care for which health problem? Delirium Pain Anxiety Fever
Delirium
A client diagnosed with a terminal illness appoints her oldest son as the authorized individual to make medical decisions on her behalf when she is no longer able to speak for herself. Which proxy directive is the patient using? Medical directive by proxy Living will declaration Durable power of attorney for health care End-of-life treatment directive
Durable power of attorney for health care
Which triage category refers to life-threatening or potentially life-threatening injury or illness requiring immediate treatment? Urgent Immediate Nonacute Emergent
Emergent
The family members of a dying client are finding it difficult to verbalize their feelings for and show tenderness to the client. Which intervention should a nurse perform in such a situation? Encourage the family members to express their feelings and listen to them in their frank communication Encourage conversations about the impending death of the client Be a silent observer and allow the client to communicate with the family members Encourage the client's family members to spend time with the client
Encourage the family members to express their feelings and listen to them in their frank
The nurse is caring for a client with diabetes who requires a peripheral intravenous (PIV) line for antibiotic administration and to treat dehydration. The nurse must avoid inserting which type of PIV? Forearm Hand Foot Upper arm
Foot
Which solid organ is most frequently injured in a penetrating trauma? Lung Liver Pancreas Brain
Liver
Diagnoses associated with cardiac arrest
MI massive pulmonary emboli hyperkalemia hypothermia severe hypoxia medication overdose
Fluid replacement (Hemorrhage)
Maintains circulation Typically, two large-gauge IV catheters are inserted, preferably in an uninjured extremity, to provide a means for fluid and blood replacement Control of external hemorrhage Control of internal bleeding
Asystole during CPR
No shock is administered Continue CPR and IV epinephrine is administered An attempt to determine the cause of the arrest is made -Ex: severe hypovolemia or hypoxia
When preparing to perform abdominal thrusts on a client with an airway obstruction, which of the following would be most appropriate? Having the conscious client lie down Placing the thumb side of one hand at the xiphoid process Positioning the hands in the midline slightly above the umbilicus Using a sequence of four thrusts, each progressing in intensity
Positioning the hands in the midline slightly above the umbilicus
Airway and breathing during CPR
Rescue breathing is no longer recommended unless health care providers are present; if that is the case, it is then started after chest compressions The airway is opened using a head-tilt/chin-lift maneuver, and any obvious material in the mouth or throat is removed An oropharyngeal airway may be inserted if available to help maintain patency of the airway. Rescue ventilations are provided using a bag-valve mask or mouth-mask device Oxygen is given at 100% during resuscitation to correct hypoxemia and improve tissue oxygenation
A client has been declared to have a terminal illness. What intervention will a nurse perform regarding the final decision of a dying client? Respect the client's and family members' choices Share emotional pain Abide by the dying client's wishes Ask the family members about spiritual care
Respect the client's and family members' choices
Which is one level of hospice care covered under Medicare and Medicaid hospice benefits, includes a 5-day inpatient stay, and is provided occasionally to relive the family caregivers? Routine home care Respite care Continuous care General inpatient care
Respite care
A client comes to the emergency department after experiencing a wound. Inspection reveals an opening in the skin with distinct edges and whose depth is greater than the length of the wound. The nurse documents this as which type of wound? Laceration Avulsion Stab Patterned
Stab
A nurse is caring for a client who is experiencing alcohol withdrawal. Which statement best indicates that the client understands the need for long-term treatment? The client agrees to attend supportive counseling. The client agrees to involve his family in psychotherapy. The client agrees to ongoing participation in one or more support groups. The client agrees to detoxification, rehabilitation, and participation in an aftercare program.
The client agrees to detoxification, rehabilitation, and participation in an aftercare program.
The intensive care unit nurse is assessing a client who is going to require a peripheral intravenous (PIV) line for fluids. The nurse should consider what information in the client's health history when deciding the site for the PIV? The client has had a mastectomy on the right side The client has hypertension The client has a fluid volume restriction The client has a history of falls
The client has had a mastectomy on the right side
The nurse received a patient from a motor vehicle accident who is hemorrhaging from a femoral wound. What is the initial nursing action for the control of the hemorrhage? Apply a tourniquet. Apply firm pressure over the involved area or artery. Elevate the injured part. Immobilize the area to control blood loss.
The nurse received a patient from a motor vehicle accident who is hemorrhaging from a femoral wound. What is the initial nursing action for the control of the hemorrhage? Apply a tourniquet. Apply firm pressure over the involved area or artery. Elevate the injured part. Immobilize the area to control blood loss.
The nurse is caring for a client who just learned of his terminal diagnosis. After the physician leaves, the nurse remains to answer further questions so that the client can make an informed decision about further treatment. By providing all available information, the nurse is promoting which ethical principle? The principle of justice The principle of nonmaleficence The principle of fidelity The principle of autonomy
The principle of autonomy
An ED nurse is triaging patients according to the Australasian Triage System (ATI). When assigning patients to a triage level, the nurse will consider the patients' acuity as well as what other variable? The likelihood of a repeat visit to the ED in the next 7 days The resources that the patient is likely to require The patient's or insurer's ability to pay for care Whether the patient is known to ED staff from previous visits
The resources that the patient is likely to require
The nurse educator is explaining the difference between indications for nasopharyngeal airway insertion versus endotracheal intubation. Which responses from learners indicate correct reasons for the use of endotracheal tubes in clients? Select all that apply. To support ventilation in a client with basal skull trauma To provide airway support to a client with facial trauma To bypass an upper airway obstruction To support connecting to mechanical ventilation To facilitate removal of tracheobronchial secretions
To bypass an upper airway obstruction To support connecting to mechanical ventilation To facilitate removal of tracheobronchial secretions
Airway obstruction clinical manifestations
Typically, a person with a foreign-body airway obstruction cannot speak, breathe, or cough. The patient may clutch the neck between the thumb and fingers (i.e., universal distress signal). Other common signs and symptoms include choking, apprehensive appearance, refusing to lie flat, inspiratory and expiratory stridor, labored breathing, the use of accessory muscles (suprasternal and intercostal retraction), flaring nostrils, increasing anxiety, restlessness, and confusion. Cyanosis and loss of consciousness, which develop as hypoxia worsens, are late signs. Action must be taken before these manifestations develop, if possible, or immediately if the patient has already exhibited these signs.
Abrasion
denuded skin
A terminally ill client is being cared for at home and receiving hospice care. The hospice nurse is helping the family cope with the client's deteriorating condition, educating them on the signs of approaching death. Which sign would the nurse include in this education plan? decreased pain difficulty swallowing increased urinary output increased sensory stimulation
difficulty swallowing
Endotracheal Intubation
purpose is to establish and maintain the airway in patients with respiratory insufficiency or hypoxia. ndicated to establish an airway for a patient who cannot be adequately ventilated with an oropharyngeal or nasopharyngeal airway, bypass an upper airway obstruction, prevent aspiration, permit connection of the patient to a resuscitation bag or mechanical ventilator, or facilitate the removal of tracheobronchial secretions
Laceration
skin tear with irregular edges and vein bridging
Hematoma
tumorlike mass of blood trapped under the skin
A nurse is evaluating a client with a terminal illness. What should the nurse report so that the health care team can consider alternative nutritional approaches and fluid administration routes for the client at the end of life? altered gastrointestinal function drop in blood pressure and rapid heart rate weight loss and inadequate food intake irregular eating habits
weight loss and inadequate food intake
Patterned
wound representing the outline of the object (e.g., steering wheel) causing the wound
The nurse is caring for a hospitalized client with an inoperable brain tumor. A family member expresses disappointment with being unable to care for the client at home, because the client requested to die at home. Which response by the nurse is best? "I recently went through this with my grandmother. It can be stressful." "Have you and your family explored hospice care?" "Your family member would not want you to be upset, please do not worry.'" "Having a family member with a terminal illness is very difficult."
"Have you and your family explored hospice care?"
A terminally ill patient is admitted to the hospital. The patient grabs the nurse's hand and asks, "Am I dying?" What response would be best for the nurse to give? "Why do you think that?" "Did someone tell you that you are dying?" "Tell me more about what's on your mind." "I am not at liberty to disclose that information."
"Tell me more about what's on your mind."
Which statements made by the nurse demonstrates that the nurse is providing spiritually sensitive care? "A key component of hospice care is following your family for up to a year after your death." "Denial, sadness, anger, fear, and anxiety are normal grief reactions." "Mourning may be demonstrated by emotional feelings of sadness, anger, guilt, and numbness." "Tell me who or what gives you strength."
"Tell me who or what gives you strength."
When preparing for palliative care with the dying client, the nurse should provide the family with which explanation? "The goal of palliative care is to give clients the best quality of life by the aggressive management of symptoms." "In palliative care, no attempts are to be made to resuscitate a client whose breathing or heart stops." "Palliative care is the gradual withdrawal of mechanical ventilation from a client with terminal illness and poor prognosis." "The client will have to go to an inpatient hospice unit in order to receive palliative care."
"The goal of palliative care is to give clients the best quality of life by the aggressive management of symptoms."
The nurse is caring for an intensive care unit client who has died with family members at the bedside. The death was sudden and unexpected resulting from a car accident that took place three days ago. The family is upset and the client's partner, crying loudly, yells, "How did this happen? We were just about to celebrate his birthday. He can't be gone!" The family member continues to cry inconsolably. How should the nurse respond? " I will get you some medication that will help you feel more calm." "He has passed on to a better place now." "It is important to face the reality that he is gone." "We did everything we could possibly do to try to save his life."
"We did everything we could possibly do to try to save his life."
A patient with end-stage chronic obstructive pulmonary disease is admitted to a hospice facility and asks the admitting nurse, "How long will I be allowed to stay here?" What is the best response by the nurse? "You will be able to stay only for approximately 1 month and then you will be discharged." "You will be able to stay for 2 months before being discharged." "There is no time limit for your stay. You can stay until you die." "When your stay reaches 6 months, you will be recertified for a continued stay."
"When your stay reaches 6 months, you will be recertified for a continued stay."
The nurse identifies a nursing diagnosis of Imbalanced nutrition: less than body requirements for a terminally ill client who is near the end of life. Which of the following would the nurse expect to include in the client's plan of care? Suggestions that the family offer the client foods that are hot. Encouragement of the family to serve the client meat, especially beef. Advice for the family to have fruit juices readily available at the client's bedside. Arrangements for the client to eat meals while others are out of the home.
Advice for the family to have fruit juices readily available at the client's bedside.
Maintaining ventilation for patients with obstruction
After the airway is determined to be unobstructed, the nurse must ensure that ventilation is adequate by checking for equal bilateral breath sounds. Satisfactory management of ventilations may prevent hypoxia and hypercapnia. The nurse must quickly assess for absent or diminished breath sounds, open chest wounds, and difficulty delivering artificial breaths for the patient. The nurse should monitor pulse oximetry, capnography, and arterial blood gases if the patient requires airway or ventilatory assistance. A tension pneumothorax can mimic hypovolemia, so ventilatory assessment precedes assessment for hemorrhage. A pneumothorax (both simple and tension) or sucking (open) chest wound is managed with a chest tube and occlusion of the sucking wound; immediate relief of increasing positive intrathoracic pressure and maintenance of adequate ventilation should occur.
The nurse receives a "do not resuscitate" (DNR) order for a dying client. What should the nurse do next? Assess the client's spiritual needs Inform the client that a priest will be in to see her very soon. Avoid talking about suicide and its effects. Inform the family that this order does not keep the nurse from doing her job.
Assess the client's spiritual needs
A nurse has been working in hospice care for 10 years. Based on her experience, she drafts her plan of care with the understanding that the most significant barrier to improving care at the end of life is the: Attitude of health care professionals toward terminal illness. Lack of social support systems for the dying patient. Fear of over-medicating the patient when pain is severe. Patient's resistance to accepting care.
Attitude of health care professionals toward terminal illness.
Glaser and Strauss (1965) identified four "awareness contexts." Which awareness context occurs when the client is unaware of their terminal state, whereas others are aware? Suspected awareness Open awareness Closed awareness Mutual pretense awareness
Closed awareness
The nurse is conducting a secondary survey on a client in the ED. Which action is completed during the secondary survey? Diagnostic and laboratory testing Assessment of peripheral pulses Establishing a patent airway Undressing the client
Diagnostic and laboratory testing
A patient is brought to the emergency department and diagnosed with decompression sickness. The nurse interprets this as indicating that the patient most likely has been involved with which of the following? Swimming in a lake Diving in an ocean Running a race in hot humid weather Working in a chemical plant
Diving in an ocean
Hemorrhage management
Fluid replacement Control of external hemorrhage Control of internal bleeding
Nursing students are reviewing the categories of intra-abdominal injuries. The students demonstrate understanding of the information when they identify which of the following as examples of penetrating trauma? Select all that apply. Gunshot wound Knife-stab wound Motor-vehicle crash Fall from a roof Being struck with a baseball bat
Gunshot wound Knife-stab wound
Airway obstruction management
If the patient can breathe and cough spontaneously, a partial obstruction should be suspected. The victim is encouraged to cough forcefully and to persist with spontaneous coughing and breathing efforts as long as good air exchange exists. There may be some wheezing between coughs. If the patient demonstrates a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis, the patient should be managed as if there were complete airway obstruction. After the obstruction is removed, rescue breathing is initiated. If the patient has no pulse, cardiac compressions are instituted.
For individuals known to be dying by virtue of age and/or diagnosis, which sign indicates approaching death? Increased wakefulness Increased eating Increased restlessness Increased urinary output
Increased restlessness
A patient who has accidentally ingested toilet bowel cleaner is brought to the emergency department. Which action would NOT be appropriate for the nurse to implement? Dilution with water or milk Gastric lavage Administration of activated charcoal Induced vomiting
Induced vomiting
A nurse is completing her annual cardiopulmonary resuscitation training. The class instructor tells her that a client has fallen off a ladder and is lying on his back; he is unconscious and isn't breathing. What maneuver should the nurse use to open his airway? Head tilt-chin lift Jaw-thrust Abdominal thrust Seldinger
Jaw-thrust
When the nurse is assisting the parents in the grieving process after the death of their neonate, what is the nurse's most important action? Keep the communication lines open. Leave the parents alone. Remove the infant quickly. Contact a grief counselor.
Keep the communication lines open.
A nurse is providing care to a client who has just been diagnosed with a terminal illness. Which of the following would be most appropriate for the nurse to do? Engage the client in conversation to provide distraction. Explain to the client that the nurse understands how he or she must feel. Listen nonjudgmentally while allowing time for client reflection. Attempt to help the client make decisions about care.
Listen nonjudgmentally while allowing time for client reflection.
A patient arrives at the emergency department after sustaining a gunshot wound to the abdomen. When assessing the patient, the nurse pays particular attention to which of the following? Liver Stomach Large intestine Kidneys
Liver
A nurse is providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate? Providing an analgesic for pain Massaging the feet Restricting ambulation Placing sterile cotton between the toes after rewarming
Massaging the feet
A family member brings a patient to the emergency department. The family member states, "I think he overdosed on heroin." Which of the following would the nurse expect to assess? Pinpoint pupils Hyperventilation Hypertension Flushed face
Pinpoint pupils
A nurse is providing care to a client in the emergency department and walks into the hallway to get equipment. All of a sudden, gunshots are heard. Which of the following would be the nurse's priority? Protecting himself or herself Securing the area Gaining control of the situation Providing care to the injured
Protecting himself or herself
The nurse is providing care for a client who was admitted to the intensive care unit after suffering cardiovascular collapse secondary to a methamphetamine overdose. The client is semi-conscious and has a nasopharyngeal in place. The nurse anticipates this client may require which interventions? Select all that apply. Provide airway support and ventilation Minimize lights and noise disturbances Apply warming blankets Administer antipsychotic medication Follow the unit seizure protocol
Provide airway support and ventilation Minimize lights and noise disturbances Administer antipsychotic medication Follow the unit seizure protocol
The nurse has received a client into care who was admitted with a heroin overdose. The client has a 5-year history of illicit substance use with cocaine, heroine and oxycodone. The client develops a sudden onset of wheezing, restlessness and a cough that produces a frothy, pink sputum. The nurse suspects the client has most likely developed which complication of opioid overdose? Pulmonary edema Pneumonia Congestive heart failure Panic attack
Pulmonary edema
What is a common source of airway obstruction in an unconscious client? A foreign object Saliva or mucus The tongue Edema
The tongue
A nurse is monitoring a client diagnosed with Lyme disease. Which finding would suggest that the disease is in the early stages? Breathlessness Red macule or papule Bony nodule Swollen painful knees
Red macule or papule
Which action by the nurse demonstrates an effective method to assess the client and the client's family's ability to cope with end-of-life interventions? Filling voids in conversation with information related to death and dying to avoid awkward moments during the admission interview Providing evidenced-based advice for end-of-life care based on the nurse's experiences with previous clients in hospice Remaining silent, allowing the client and family to respond after asking a question related to end-of-life care Offering reassurance that the nurse has had 5 years of assisting clients in hospice and their families care for loved ones at the end of life
Remaining silent, allowing the client and family to respond after asking a question related to end-of-life care
A nurse is providing an educational program for a group of occupational health nurses working in chemical facilities. Which of the following would the nurse include as the priority in the case of a chemical burn? Applying antimicrobial ointment Administering tetanus prophylaxis Covering the area with a sterile dressing Rinsing the area with copious amounts of water
Rinsing the area with copious amounts of water
When providing care to a client who has experienced multiple trauma, which of the following would be most important for the nurse to keep in mind? The client is assumed to have a spinal cord injury until proven otherwise. The most lethal injuries are often the most readily apparent. Most multiple trauma victims exhibit evidence of the trauma. Injuries have occurred to at least three distinct organ systems.
The client is assumed to have a spinal cord injury until proven otherwise.
The nurse is caring for a client who is terminally ill and recently immigrated to the country. The nurse understands that in order to provide quality end-of-life care for the client, what would be the priority action by the nurse? Make every effort to involve the client and the client's family with the end-of-life care. Understand the client's personal and cultural views regarding death and dying. Arrange for end-of-life care to be provided by personnel familiar with the client's culture. Share the client's concerns regarding the dying process with the interdisciplinary care team.
Understand the client's personal and cultural views regarding death and dying.
The nurse is caring for a patient in the ED who is breathing but unconscious. In order to avoid an upper airway obstruction, the nurse is inserting an oropharyngeal airway. How would the nurse insert the airway? At an angle of 90 degrees Upside down and then rotated 180 degrees With the concave portion touching the posterior pharynx With the convex portion facing upward
Upside down and then rotated 180 degrees
Which category of triage encompasses clients with serious health problems that are not immediately life threatening? Emergent Urgent Nonurgent Psychological support
Urgent
Despite having been administered prescribed pain medication, a dying client is still experiencing dyspnea due to fear and anxiety. Which nursing intervention should the nurse use to potentiate the effects of pain medication and help reduce the dyspnea? Offer small amounts of nourishment frequently Gently massage the arms and legs Use imagery, humor, and progressive relaxation Encourage the patient to sleep
Use imagery, humor, and progressive relaxation
Medicare Hospice Benefit
a Medicare Part A entitlement that provides for comprehensive, interdisciplinary palliative care and services for eligible beneficiaries who have a terminal illness and a life expectancy of less than 6 months
Hospice
a coordinated program of interdisciplinary care and services for terminally ill patients and their families that in the United States is provided primarily in the home
Control of External Hemorrhage
a rapid physical assessment is performed as the patient's clothing is cut away in an attempt to identify the area of hemorrhage Direct, firm pressure is applied over the bleeding area or the involved artery at a site that is proximal to the wound Most bleeding can be stopped or at least controlled by application of direct pressure. Otherwise, unchecked arterial bleeding results in death. A firm pressure dressing is applied, and the injured part is elevated to stop venous and capillary bleeding, if possible. If the injured area is an extremity, the extremity is immobilized to control blood loss. Most bleeding can be stopped or at least controlled by application of direct pressure. Otherwise, unchecked arterial bleeding results in death. A firm pressure dressing is applied, and the injured part is elevated to stop venous and capillary bleeding, if possible. If the injured area is an extremity, the extremity is immobilized to control blood loss.
Oropharyngeal airway
a semicircular tube or tubelike plastic device that is inserted over the back of the tongue into the lower posterior pharynx in a patient who is breathing spontaneously but who is unconscious adjunct This type of airway prevents the tongue from falling back against the posterior pharynx and obstructing the airway. It also allows health care providers to suction secretions.
A patient with frostbite to both lower extremities from exposure to the elements is preparing to have rewarming of the extremities. What intervention should the nurse provide prior to the procedure? Administer an analgesic as ordered. Massage the extremities. Elevate the legs. Apply a heat lamp.
Administer an analgesic as ordered.
A client is brought to the emergency department by ambulance. The client is seriously ill and unconscious. No family or friends are present. Which of the following would be most appropriate to do? Document the client's condition and absence of friends or family for obtaining consent to treatment. Check the client's record for the name of a family member to call to allow care to be provided. Ask the ambulance team for information about the client's family to ensure informed consent. Explain to the client that care is going to be provided because he is seriously ill.
A client is brought to the emergency department by ambulance. The client is seriously ill and unconscious. No family or friends are present. Which of the following would be most appropriate to do? Document the client's condition and absence of friends or family for obtaining consent to treatment. Check the client's record for the name of a family member to call to allow care to be provided. Ask the ambulance team for information about the client's family to ensure informed consent. Explain to the client that care is going to be provided because he is seriously ill.
A patient's family member asks the nurse what the purpose of hospice is. What is the best response by the nurse? "It will hasten the death of the patient." "It will prolong life in a dignified manner." "It will use artificial means of life support if the patient requests it." "It will enable the patient to remain home if that is what is desired."
A patient's family member asks the nurse what the purpose of hospice is. What is the best response by the nurse? "It will hasten the death of the patient." "It will prolong life in a dignified manner." "It will use artificial means of life support if the patient requests it." "It will enable the patient to remain home if that is what is desired."
communication and cooperation among members of diverse health care disciplines jointly to plan, implement, and evaluate care
communication and cooperation among members of diverse health care disciplines jointly to plan, implement, and evaluate care
Amiodarone
Action: -acts on sodium-potassium and calcium channels to prolong action potential and refractory period Indications: -Used to treat pulseless VT and VF unresponsive to shock delivery Nursing Considerations: -Give 300 mg IV; may give second dose of 150 mg in 3-5 min
Atropine
Action: -blocks parasympathetic action; increases SA node automaticity and AV conduction Indications: -Given to patients with symptomatic bradycardia (i.e., hemodynamically unstable with hypotension) Nursing Considerations: -Give rapidly as 0.5-mg IV push; may repeat to dose of 3 mg
Magnesium Sulfate
Action: -promotes adequate functioning of cellular sodium—potassium pump Indications: -Given to patients with torsade de pointes, a type of VT Nursing Considerations: -May give 1-2 g diluted in 10 mL D5W over 5-20 min
Norepinephrine
Action: -vasopressor given to increase BP Indications: -Given for hypotension and shock Nursing Considerations: -Give 0.1-0.5 mcg/kg/min as IV infusion, preferably through a central line
Dopamine
Action: -vasopressor given to increase BP and contractility Indications: -Given for hypotension and shock Nursing Considerations: -Give 5-10 mcg/kg/min as IV infusion, preferably through a central line
A patient who has been admitted to the intensive care unit (ICU) with extensive burns is conscious but unable to speak due to upper airway trauma. When communicating with this patient, the ICU nurse should adopt which of the following strategies? Provide brief explanations and directions to the patient. Ask the patient questions that can be answered with a nod or a shake of the head. Defer to a friend or family member of the patient when information is needed. Speak to the patient slowly and with increased volume.
Ask the patient questions that can be answered with a nod or a shake of the head.
Stopping CPR
CPR may be stopped when pulse and BP are detected, respirations detected, and patient responds CPR efforts may also be stopped when rescuers are exhausted or at risk (e.g., a building is at risk of collapsing), or death is considered to be inevitable. If the patient does not respond to therapies given during the arrest, the resuscitation effort may be stopped by the physician or other provider in charge of the resuscitation. Many factors are considered in the decision, such as the initiating dysrhythmia, potential etiology, length of time for initiation of life support, and the patient's response to treatment.
A nurse is providing care to a client experiencing symptoms associated with terminal illness. Which of the following would be most appropriate to use as a means for managing the client's symptoms? Physician's orders Client's goals Length of required treatment Invasiveness of the treatment
Client's goals
Medicare and Medicaid hospice benefit criteria allow clients with a life expectancy of 6 months or less to be admitted to hospice. However, the median length of stay in a hospice program is just 21.3 days. Which reason explains the underuse of hospice care services? Lack of fully credentialed and trained hospice nurses Clients and families view palliative care as giving up Lack of Medicare/Medicaid funding for hospice Difficulty obtaining Medicare certification for hospice services
Clients and families view palliative care as giving up
Which of the following is an appropriate method of assessing the dying client? Stimulate the client every 30 minutes. Focus on the client's basic needs. Repeat assessments as necessary. Sedate the client before completing range-of-motion exercises.
Focus on the client's basic needs.
A nurse is caring for a client who has arrived at the emergency department in shock. The nurse intervenes based on the knowledge that which of the following is the most common cause of shock? Anaphylaxis Sepsis Hypovolemia Cardiac dysfunction
Hypovolemia
Secondary survey
an assessment of the patient triaged to the emergent or resuscitation category that commences after the primary survey is completed and life-threatening insults addressed; includes obtaining vital signs, completing a head-to-toe examination, and obtaining the patient's pertinent medical-surgical history, including the history of the current event
Primary survey
an assessment of the patient triaged to the emergent or resuscitation category that focuses on stabilizing life-threatening conditions; uses the mnemonic ABCDE, which stands for airway, breathing, circulation, disability, and exposure
Ecchymosis/contusion
blood trapped under the surface of the skin
Stab
incision of the skin with well-defined edges, usually caused by a sharp instrument; a stab wound is typically deeper than long
Cut
incision of the skin with well-defined edges, usually longer than deep
Mourning
individual, family, group, and cultural expressions of grief and associated behaviors
Establishing an airway for patients with obstruction
may be as simple as repositioning the patient's head to prevent the tongue from obstructing the pharynx. Alternatively, other maneuvers, such as the head-tilt/chin-lift maneuver, the jaw-thrust maneuver, or insertion of specialized equipment, may be needed to open the airway, remove a foreign body, or maintain the airway. In all maneuvers, the cervical spine must be protected from injury. After these maneuvers are performed, the patient is assessed for breathing by watching for chest movement and listening and feeling for air movement. Types: -Oropharyngeal airway insertion -Nasopharyngeal airway insertion -Endotracheal intubation
The cltient tells the doctor that he and his family have accepted the terminal diagnosis of pancreatic cancer. The client further explains that he is interested in being comfortable and that he no longer wishes to fight the cancer. This approach to end-of-life care is known as terminal care. palliative care. euthanasia care. interdisciplinary care.
palliative care.
Spirituality
personal belief systems that focus on a search for meaning and purpose in life, intangible elements that impart meaning and vitality to life, and a connectedness to a higher or transcendent dimension
grief
personal feelings that accompany an anticipated or actual loss
Triage
process of assessing patients to determine management priorities
The nurse in the hospital emergency department is assessing a patient who fell while intoxicated with alcohol. The nurse is using the Clinical Institute Withdrawal Assessment-Alcohol (CIWA-A) scale to assess the patient's need for a benzodiazipine medication. In order to assess for auditory disturbances, which question should the nurse ask the patient? "Are you hearing anything that is disturbing you?" "Are you experiencing any burning or numbness?" "Are you finding the light is too harsh or bothering your eyes?" "Does it feel like there is a tight band around your head?"
"Are you hearing anything that is disturbing you?"
4 basic steps of CPR
1. Recognition of sudden cardiac arrest. (The patient is checked for responsiveness and breathing.) 2. Activation of the Emergency Response System (ERS). (Within a medical facility, a call is made to alert the emergency response team, often called the "Code 4" or "Code Blue" team. Outside of a medical facility, 911 is called to activate the Emergency Medical Service (EMS).) 3. Performance of high-quality CPR. (If no carotid pulse is detected and no defibrillator is yet available, chest compressions are initiated. Rescue breathing may be added by a health care provider in a ratio of 30 compressions to 2 ventilations.) 4. Rapid cardiac rhythm analysis and defibrillation as soon as it is available. (Patients in ventricular fibrillation must be defibrillated as soon as possible)
Advanced Cardiovascular Life Support (ACLS)
Placement of an advanced airway such as an ET tube may be performed by a physician, nurse anesthetist, or respiratory therapist during resuscitation to ensure a patent airway and adequate ventilation. -tracheal intubation must be confirmed by assessment of specific parameters: auscultation of breath sounds, observation of chest expansion, and a carbon dioxide detector. -A chest x-ray is always obtained after ET tube placement to confirm that the tube is in the proper position within the trachea. Arterial blood gases may also be obtained to assess ventilation and oxygenation Specific subsequent advanced support interventions depend on the assessment of the patient's condition and response to therapy
Epinephrine
Action: -vasopressor used to optimize BP and cardiac output; improves perfusion and myocardial contractility Indications: -Given to patients in cardiac arrest caused by asystole, pulseless electrical activity, pulseless VT or VF Nursing Considerations: -Administer 1 mg every 3-5 min by IV push or via IO route -Follow peripheral IV administration with 20-mL flush and elevate extremity for 10-20 s
The physician is attending to a 72-year-old client with a malignant brain tumor. Family members report that the client rarely sleeps and frequently reports seeing things that are not real. Which intervention is an appropriate request for the hospice nurse to suggest to the physician? Perform surgery to remove the tumor from the brain. Begin radiation therapy to prevent cellular growth. Obtain a biopsy to analyze the lymph nodes. Add haloperidol to the client's treatment plan.
Add haloperidol to the client's treatment plan.
Defibrillation during CPR
As soon as a monitor/defibrillator is available, monitor electrodes are applied to the patient's chest and the heart rhythm is analyzed. When an automated external defibrillator (AED) is used, the device is turned on, the pads are applied to the patient's chest, and the rhythm is analyzed by the defibrillator to determine whether a shock is indicated. When the ECG shows ventricular fibrillation or pulseless ventricular tachycardia, immediate defibrillation is the treatment of choice. The survival time decreases for every minute that defibrillation is delayed. Following defibrillation, high-quality CPR is resumed immediately.
The nurse is caring for a 90-year-old male who has never completed an advanced directive. The man has a son but has not seen him in several years. A neighbor has assisted him with meals and housecleaning for many years. The neighbor states that the client expressed only wanting to have comfort measures. The estranged son wants his father to be treated aggressively. Which would be the nurse's initial step? Follow the son's directive. Follow the neighbor's directive. Assess the client's ability to state wishes. Notify the physician of the discrepancy.
Assess the client's ability to state wishes.
A client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later, the nurse identifies which finding as an early sign of shock? Confusion Pale, warm, dry skin Heart rate of 70 beats/minute Elevated blood pressure
Confusion
The nurse is discussing measures about how to prevent Lyme disease with a client and his family. Which of the following would the nurse include? Wear dark colored clothing to prevent ticks from being attracted to the body. Wear short sleeved shirts and shorts to allow for easy identification of ticks. Don a hat, pulling any long hair back so it doesn't come in contact with shrubs. Remove fences from around the house and garden to allow deer to be seen.
Don a hat, pulling any long hair back so it doesn't come in contact with shrubs.
Wound cleaning
Hair around the wound may be clipped (only as directed) if it is anticipated that the hair will interfere with wound closure. Typically, the area around the wound is cleansed with normal saline solution or a polymer agent (e.g., Shur-Clens). The antibacterial agent povidone-iodine (Betadine) should not be allowed to get deep into the wound without thorough rinsing. Povidone-iodine is used only for the initial cleansing because it injures exposed and healthy tissue, resulting in further tissue damage If indicated, the area is infiltrated with a local intradermal anesthetic through the wound margins or by regional block. Patients with soft tissue injuries usually have localized pain at the site of injury. The wound is irrigated gently and copiously with sterile isotonic saline solution to remove surface dirt. Devitalized tissue and foreign matter are removed because they impede healing and may promote infection. Any small bleeding vessels are clamped, tied, or cauterized. After wound treatment, a nonadherent dressing is applied to protect the wound and to serve as a splint and as a reminder to the patient that the area is injured.
Control of internal bleeding
If the patient shows no external signs of bleeding but exhibits tachycardia, falling blood pressure, thirst, apprehension, cool and moist skin, or delayed capillary refill, internal hemorrhage is suspected. Typically, packed red blood cells, plasma, and platelets are given at a rapid rate, and the patient is prepared for more definitive treatment arterial blood gas specimens are obtained to evaluate pulmonary function and tissue perfusion and to establish baseline hemodynamic parameters, which are then used as an index for determining the amount of fluid replacement the patient can tolerate and the response to therapy. The patient is maintained in the supine position and monitored closely until hemodynamic or circulatory parameters improve, or until he or she is transported to the operating room or intensive care unit.
AVPU
Mnemonic used for a quick neurologic assessment A—alert. Is the patient alert and responsive? V—verbal. Does the patient respond to verbal stimuli? P—pain. Does the patient respond only to painful stimuli? U—unresponsive. Is the patient unresponsive to all stimuli, including pain?
A client presents to the ED after an unsuccessful suicide attempt. The client is diagnosed with an acetaminophen overdose. The nurse anticipates the administration of which medication? N-acetylcysteine Flumazenil Naloxone Diazepam
N-acetylcysteine
The nurse has commenced a transfusion of fresh frozen plasma (FFP) and notes the client is exhibiting symptoms of a transfusion reaction. After the nurse stops the transfusion, what is the next required action? Remove the peripheral IV line Start a dextrose 5% water infusion Run a normal saline line to keep the vein open Obtain a blood culture from the IV insertion site
Run a normal saline line to keep the vein open
Trauma
an unintentional or intentional wound or injury inflicted on the body from a mechanism against which the body cannot protect itself the fourth leading cause of death in the United States. Leading cause of death in children and in adults younger than 44 years. The incidence is increasing in adults older than 44 years. Alcohol and drug abuse are often implicated as factors in both blunt and penetrating
Delayed Primary Closure
may be indicated if tissue has been lost or there is a high potential for infection. A thin layer of gauze (to ensure drainage and prevent pooling of exudate), covered by an occlusive dressing, may be used. The wound is splinted in a functional position to prevent motion and decrease the possibility of contracture. If there are no signs of suppuration (formation of purulent drainage), the wound may be sutured (with the patient receiving a local anesthetic). The use of antibiotic agents to prevent infection depends on factors such as how the injury occurred, the age of the wound, and the risk of contamination. The site is immobilized and elevated to limit accumulation of fluid in the interstitial spaces of the wound. Tetanus prophylaxis is given as prescribed, based on the condition of the wound and the patient's immunization status. If the patient's last tetanus booster was given more than 5 years ago, or if the patient's immunization status is unknown, a tetanus booster must be given (ACS, 2013). The patient is instructed about signs and symptoms of infection and is instructed to contact the primary provider or clinic if there is sudden or persistent pain, fever or chills, bleeding, rapid swelling, foul odor, drainage, or redness surrounding the wound.
A type of comprehensive care for clients whose disease is not responsive to cure is a terminal illness. palliative care. euthanasia. interdisciplinary collaboration.
palliative care.
bereavement
period during which mourning for a loss takes place
Palliative care
philosophy of and system for delivering care that expands on traditional medical care for serious, progressive illness to include a focus on quality of life, function, decision making, and opportunities for personal growth
terminal illness
progressive, irreversible illness that despite cure-focused medical treatment will result in the patient's death
nasopharyngeal airway
provides airway access through the nose by being inserted through the nares adjunct
Assisted Suicide
providing another person the means to end their own life
Autonomy
self-determination; in the health care context, the right of the individual to make choices about the use and discontinuation of medical interventions
Primary Closure
the wound is sutured or stapled, usually by the physician, with the patient receiving either local anesthesia or moderate sedation Wound closure begins when subcutaneous fat is brought together loosely with a few sutures to close off the dead space. The subcuticular layer is then closed, and finally the epidermis is closed. Sutures are placed near the wound edge, with the skin edges leveled carefully to promote optimal healing. Instead of sutures, sterile strips of reinforced microporous tape or a bonding agent (skin glue) may be used to close clean, superficial wounds.
