Exam 1

A nurse is preparing to administer dextrose 5% in 0.45% sodium chloride 1 L to infuse at 100 ml/hour. The nurse is using microtubing. The nurse should set the manual IV infusion to deliver how many gtts/minute? (round to the nearest whole number )

100

a provider prescribes dextrose 5% in water IV to infuse at 100 ml/hour. the drop Factor on the manual IV tubing is 60 gtt/minute. the nurse should set the IV flow rate to deliver how many gtts/minute round to the nearest whole number

100gtt/min

The nurse would assure a family member that for the first 24 hours after he burn injury, pain is kept to a minimum by administering a. intravenous narcotic agents b. liquid narcotics via the nasogastric c. narcotics via an intramuscular route into non-burn tissue d. tepid soaks and oral morphine

a. intravenous narcotic agents'

A nurse is preparing to administer 0.9% sodium chloride 3,000 ml IV to infuse over 24 hours. The drop Factor on the manual IV tubing is 10 gtt/mL. the nurse should set the manual IV infusion to deliver how many gtt/min? (round to the nearest whole number )

21 gtt/min

A nurse is preparing to administer lactated ringers 400 ml IV bolus to infuse over 3 hours. The drop factor of the manual IV tubing is 20 gtts/mL. The nurse should set the manual IV infusion to deliver how many gtts/min? (round to the nearest whole number)

44 gtt/min

A nurse is preparing to administer total parenteral nutrition 1800 ml to infuse over 24 hours. the nurse should set the IV pump to deliver how many ml/hr? (round to the nearest whole number

75 mL/hr

A nurse teaches a patient who is being discharged home with a peripherally inserted central catheter (PICC. Which statement will the nurse include in this patients teaching? A "Avoid carving your grandchild with the arm that has the central catheter." B. "Be sure to place the arm with the central catheter in a sling during the day." C "Flush the peripherally inserted central catheter line with normal saline dailv" D. "You can use the arm with the central catheter for most activities of daily living."

A "Avoid carving your grandchild with the arm that has the central catheter."

A nurse responds to an IV pump alarm related to increased pressure. What action will the nurse take first? A. Assess the infusion system starting at the insertion site B. Flush the catheter with saline followed by a thrombolytic enzyme C. Silence the alarm and restart the infusion on a new infusion bump D. Remove the IV catheter and insert a new IV at a new site

A. Assess the infusion system starting at the insertion site

A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. which intervention will the nurse suggest to the management team to make the biggest impact on decreasing complications? A. Initiate a dedicated team to insert access devices B Require additional education for all nurses C LimIt the use or peripheral venous access devices. D. Perform quality control testing on skin preparation products

A. Initiate a dedicated team to insert access devices

A nurse prepares to administer a blood transfusion to a patient, and checks the blood label with a second registered nurse using the international Society of blood Transfusion (ISBT) universal barcoding system to ensure the right blood for t he right patient. Which components must be present on the blood label bar code and in the eye-readable format? (Select all that apply.) A. Unique facility identifier B. Lot number related to the donor C. Name of the patient receiving blood D. ABO group and Rh type of the donor E. blood type of the patient receiving blood.

A. Unique facility identifier B. Lot number related to the donor D. ABO group and Rh type of the donor

A patient with extensive electrical burn injuries is admitted to the emergency department. which of these healthcare provider orders should the nurse implement first? A. place on cardiac monitor b. start two large bore IV's c. access for pain at contact points d. apply dressings to burned areas

A. place on cardiac monitor

A nurse is caring for a patient who has just had a central venous access line inserted. What action will the nurse take next? A. Begin the prescribed infusion via the new access B. Ensure that an x-ray is completed to confirm placement. C. Check medication calculations with a second RN D. Make sure that the solution is appropriate for a central line

B. Ensure that an x-ray is completed to confirm placement.

A nurse is caring for a patient with a peripheral vascular access device who is experiencing pain, redness, andswelling at the site. After removing the device, what action will the nurse take to relieve pain? A. Administer topical lidocaine to the site B. Place a warm compress on the site. C. Administer prescribed oral pain medication D. Massage the site with scented oils.

B. Place a warm compress on the site

A nurse is caring for a patient who is receiving an epidural infusion for pain management. which assessment finding requires immediate intervention from the nurse? A. Redness at the catheter insertion site B. Report of headache and stiff neck C. Temperature of 100.1? - (37.8? C) D Pain rating of 8 on a scale of 0 to 16

B. Report of headache and stiff neck

A nurse's triaging patients in the emergency department. which patient with the nurse prioritize to receive care first? a. and 81-year-old with a respiratory rate of 28 breaths per minute and a temperature of 101 b. a 22-year-old with a painful and swollen right wrist C. a 45-year-old reporting chest pain and diaphoresis d. a 60-year-old reporting difficulty swallowing and nausea

C. a 45-year-old reporting chest pain and diaphoresis

A nurse asses a patient's peripheral IV site and notices edema and tenderness above the site. What action will the nurse take next? A. Apply cold compresses to the IV site B. Elevate the extremity on a pillow C. Flush the catheter with normal saline D. Stop the infusion of intravenous fluids

D. Stop the infusion of intravenous fluids

A nurse is assessing patients who have intravenous therapy prescribed. Which assessment finding for a patient with a peripherall inserted central catheter (PICC reguires immediate attention? A. The initial site dressing is 3 days old B The PICC was inserted 4 weeks ado C. A securement device is absent D. Upper extremity swelling is noted.

D. Upper extremity swelling is noted.

A nurse delegates care to an unlicensed assistive personnel (UP). Which statement will the nurse include when delegating hygiene for a patient who has a vascular access device? A. Provide a bed bath instead of letting the patient take a shower. B. Use sterile technique when changing the dressing." C. Disconnect the intravenous fluid tubing prior to the patient's bath." D. Use a plastic bag to cover the extremity with the device.

D. Use a plastic bag to cover the extremity with the device

A nursing and emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. which of the following should the nurse identify as a priority focus of care? a. Airway protection b. decreasing intracranial pressure c. stabilizing cardiac arrhythmias D. preventing musculoskeletal disability

a. Airway protection

A nurse is performing triage for a group of clients following the mass casualty incident. which of the following clients should the nurse plan to care for first? a. a client experiencing a tension pneumothorax b. a client who has closed upper extremity fracture c. a client who has full thickness Burns over 80% of the body d. a client who has agonal respirations

a. a client experiencing a tension pneumothorax

A nurse in the emergency department is triaging clients following a mass casualty event. the nurse should identify which of the following clients as emergent? a. a client who has a punctured femoral artery b. a client who has multiple fractures c. a client who has a red rash over his d A client who reports severe flank pain radiating from the groin

a. a client who has a punctured femoral artery

Well at a park, a nursing counter is a person immediately after a bee sting. the person's lips are swollen, and audible wheezes heard. what action with the nurse take first a. administer an EpiPen from the first aid kit and call 911 b. remove the Stinger with tweezers and encourage rest C. administer diphenhydramine(Benedryl) and apply ice D. Elevate the site and notify the patient's next of kin

a. administer an EpiPen from the first aid kit and call 911

A client has a circumferential third degree burn on the upper left arm. the nursing assessment specific for this client would include a. assessing capillary refill on the left hand b. evaluating left hand Str c. measuring left forearm circumference D. monitoring blood pressure in the left arm

a. assessing capillary refill on the left hand

a new graduate nurse has started working on a medical surgical unit. what actions would the nurse take to be prepared for a disaster? select all that apply a. know the institutions emergency response plan b. understand nurses role in every phase c. be prepared to report immediately to the emergency department d. participate in the institutions disaster drill e. develop a personal preparedness plan

a. know the institutions emergency response plan b. understand nurses role in every phase d. participate in the institutions disaster drill e. develop a personal preparedness plan

During the early emergent phase of burns, the nurse will anticipate giving opioid analgesics by the IV route so that a. the medications will be rapidly effective b. less frequent Administration is needed c. larger doses of medications can be given d. respiratory depression can be easily treated

a. the medications will be rapidly effective

A nurse is teaching a group of clients about emergency care for a snake bite. which of the following information should the nursing include in the teaching? a. raise the affected extremity above the Heart level b. immobilize the affected extremity with the splint c. apply ice to the bite area D. apply tourniquet to the affected extremity

b. immobilize the affected extremity with the splint

A nurse working in an emergency room is caring for a client who has 3rd degree frostbite to both lower extremities. the nurse should plan to take which of the following actions? a. immerse the legs in Cool Water b. Elevate the legs c. massage the legs d. applied dry heat to the legs

b. Elevate the legs

Which among these rhythms is not considered a cardiac arrest rhythm? a. pulseless electrical activity(PEA) b. afib rapid ventricular response c. pulseless ventricular tachycardia d. ventricular fibrillation

b. afib rapid ventricular response

A nurse is the triage officer in the emergency department when four clients arrived following a factory explosion. which of the following client should the nurse care for first? a. a conscious adult client who report shortness of breath, has respiratory rate of 24 per minute, and a cap refill of under 2 seconds. b. and unconscious adult client who has a sucking chest wound, respirations of 38 per minute, and a cap refill of under 2 seconds c. a conscious adult client who has a dislocated right shoulder, respiratory rate of 18 per minute and a cap refill of under 2 seconds D and unconscious adult client who has no respirations cap refill over 2 seconds and paramedics have already tried to reposition Airway without result

b. and unconscious adult client who has a sucking chest wound, respirations of 38 per minute, and a cap refill of under 2 seconds

and emergency department charge nurse notes and increase in sick calls and bickering among the staff after a week with multiple trauma incidents. what action should the nurse take? a. organize a pizza party for each shift b. arrange a critical incident stress debriefing see. remind the staff of the facilities sick leave policy d. talk individually with staff members

b. arrange a critical incident stress debriefing

The emergency department team is performing cardiopulmonary resuscitation on a patient when the patient's spouse arrives at the emergency department. what action should the nurse take first? a. request at the patient's spouse sit in the waiting room b. ask the spouse if he wishes to be present during the resuscitation c. suggested the spouse begin to pray for the patient d. refer the patient spouse to the hospital's crisis team

b. ask the spouse if he wishes to be present during the resuscitation

The nurse would explain to a client that when a major burn occurs the body's initial systemic response includes a. elevated pulse rate decreased cardiac output and polyuria b. increased capillary permeability, decreased cardiac output, and oliguria c. plasma leakage into surrounding tissue, decrease hematocrit, and oliguria d. production of epinephrine, vasodilation, and increased cardiac output

b. increased capillary permeability, decreased cardiac output, and oliguria

A nurse and an emergency department is assessing a client Who Was Bitten on the left leg by a poisonous snake. the client has placed elastic bandages snugly above and below the bite marks and is in no apparent distress. which of the following actions should the nurse take? a. discharge the client b. obtain a prescription for the appropriate Anti-Venom C. Remove both the elastic bandages from the leg d. obtain a prescription for pain medication

b. obtain a prescription for the appropriate Anti-Venom

A nurse's assisting with field triage following a motor vehicle crash involving a bus with multiple victims. the nurse assesses a child who has an open fracture of the femur. which of the following actions should the nurse take? a. locate the child's parents to obtain consent for treatment b. place a yellow triage tag on the on the child c. notify the emergency department of the child's imminent arrival d. perform a complete head to toe assessment

b. place a yellow triage tag on the on the child

a patient who was found unconscious in a burning bedroom and has Burns to the lower legs is assessed by the nurse in the emergency department. the nurse notes that the patient's face is bright red. which of these action should the nurse take first a. Elevate the legs and the pillows b. place the patient on 100% O2 using a non-rebreather mask c. assess for ascensional hair or dark oral mucous membranes D. insert two large bore IV lines

b. place the patient on 100% O2 using a non-rebreather mask

A nurse is caring for a patient in a busy emergency department what action should the nurse take to ensure patient and staff safety? select all that apply a. leave the stretcher in the lowest position with rails down so that the patient can access the bathroom b. use two identifiers before each intervention and before medication Administration c. attempt de-escalation strategies for patients who demonstrate aggressive behaviors d. search the belongings of the patient with altered mental status to gain Essential Medical information e isolate patients who have immune suppression disorders to prevent Hospital acquired infections

b. use two identifiers before each intervention and before medication Administration c. attempt de-escalation strategies for patients who demonstrate aggressive behaviors d. search the belongings of the patient with altered mental status to gain Essential Medical information

A patient with deep partial thickness and full thickness Burns of the face and chest has the wounds treated with the open method. the nurse identifies and is expected patient outcome of absence of wound infections. and appropriate nursing action to help the patient meet the outcome is to a. restrict all visitors to prevent cross-contamination of wounds b. wear gowns caps mask and gloves during all care of the patient c. you sterile water for cleansing and debridement in the hydrotherapy tank D. administer prophylactic antibiotics to prevent bacterial colonization of wounds

b. wear gowns caps mask and gloves during all care of the patient

A hospital prepares for a mass casualty event. which functions are correctly paired with the Personnel role? select all that apply a. public information officer - provides Advanced life support during transportation to the hospital b. paramedic - decides the number Acuity and resource needs of the patient c. Hospital Incident Commander - assumes over a leadership for implementing the emergency plan d. officer - rapidly evaluates each patient to determine priorities for treatment e. medical command physician - serves as a liaison between the health care facility and the media

c. Hospital Incident Commander - assumes over a leadership for implementing the emergency plan d. officer - rapidly evaluates each patient to determine priorities for treatment

A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. which of the following client should the nurse tag to be the priority for care? a. a client who has severe head injuries, respiratory rate of six per minute and is unresponsive b. a client who has a simple fracture of the femur, multiple scratches on both legs, as and is crying hysterically c. a client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site d. a female who is pregnant in at 20 weeks of gestation has multiple cuts and abrasions, and is walking around

c. a client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site

A nurse's triaging clients following a mass casualty event. Which of the following clients should the nurse assess first? a. a client who has a splinted open fracture of the left medial malleolus b. a client who has a massive head injury and is experiencing seizures c. a client who has severe respiratory Stridor and a deviated trachea d. a client who has a small circular partial thickness burn on the left calf

c. a client who has severe respiratory Stridor and a deviated trachea

A newly hired nurse found a 10-year-old patient unresponsive. the nurse asked her preceptor what's the best way to check for a pulse? based on aha guidelines, the preceptor responded accurately that for patients at this age, the most appropriate locations check for pulse is a. Brachial b. Radial c. carotid d. apical

c. carotid

What is the primary goal of a triage system used by the nurse when patients presenting to the emergency department? a. assess the status of the airway breathing circulation and presence of deficits B evaluate the Department's resources to adequately treat the patient c. determine the Acuity of the patient's condition to determine priority of care d. determine whether the patient is responsible enough to provide needed information

c. determine the Acuity of the patient's condition to determine priority of care

An emergency department charge nurse prepares to receive patients from a mass casualty within the community what is the role of this nurse during the event? a inform the incident commander of the mass casualty scene about how many victims may be handled by the Ed b. ask Ed staff to discharge patients from the medical surgical units in order to make room for critically injured patients c. direct medical Surgical and critical care nurses to assist with patients currently in the Ed while ER staff prepared to receive the mass casualty victims d. call additional medical Surgical and Critical Care Nursing staff to come to the hospital to assist when victims arrive

c. direct medical Surgical and critical care nurses to assist with patients currently in the Ed while ER staff prepared to receive the mass casualty victims

A 75 year old female brought in by ambulance(BIBA) is for altered mental status. further test suggests severe dehydration. A bolus of 250 ml of lactated ringer was ordered and indwelling catheter was put in for strict I&O. later in the afternoon, the patient went into cardiac arrest and see pair was initiated however the team failed to achieve Return of spontaneous circulation(ROSC). since it is considered a Coroner's case the nurse would A. call the next of kin for Mortuary information b. immediately perform post-mortem care c. keep all lines/tubes and tag until giving clearance by the deputy officer d. Place patient in cadaver bag and sent to hospitals more

c. keep all lines/tubes and tag until giving clearance by the deputy officer

A 53 year old woman collapses while gardening. she is unresponsive and is not breathing and it's not have a pulse. a neighbor who is an emergency medical technician Russia's to her with an aed. when the AED arrives what is the first step for using it? a. press the shock button b. apply the pads to the chest c. turn on the AED d. clear the patient

c. turn on the AED

A nurse and an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. the client has a blood pressure of 100 over 60 mmhg, a weak pulse rate of 118 per minute, and a respiratory rate of 40 beats per minute. which of the following actions should the nurse take? a. raise the foot of the bed to a 90° angle b. remove the dressing to inspect the wound c. prepared to insert a central line d. administer oxygen via nasal cannula

d. administer oxygen via nasal cannula

a middle-aged Mountain hiker is admitted to the emergency department exhibiting a cough with pink, frothy sputum, and cyanosis of the lips and nail beds. what priority action should the nurse implement first? a. obtain arterial blood gas (ABG) specimen for analysis b. complete a thorough pulmonary assessment c. administrate acetazolamide (diamox) d. administer oxygen via non-rebreather mask

d. administer oxygen via non-rebreather mask

A nurse is caring for a client who is brought into the emergency department immediately following a snake bite to his forearm. the client suspects the snake to be venomous. which of the following interventions should the nurse take? a. apply an ice pack to the site of the bite b. apply tourniquet just above the elbow c. administer a corticosteroid d. place the extremity in a dependent position

d. place the extremity in a dependent position

the nurse caring for a burn client would monitor the client's tools for a cold blood as assessment for development of a. bleeding caused by bowel distension b. gastric irritation related to c . intestinal Ileus d. stress ulcers

d. stress ulcers