exam 1

A nurse is caring for a client after a thoracentesis. Which sign, if noted in the client, should be reported to the physician immediately?

"Client is becoming agitated and complains of pleuritic pain."

During a mass disaster, the nurse is caring for a victim whose status has been categorized as yellow during triage. How should the nurse best allocate time and resources to this client's care?

Delay the client's treatment for a few hours if other clients need immediate care

A nurse is preparing to assist with a gastric lavage for a client who has ingested an unknown poison and is obtunded. To ensure that the tube reaches the stomach, the nurse would measure the distance from the bridge of the nose to which of the following?

Ear lobe and then to the xiphoid process

The nurse is assessing a patient who has been admitted with possible ARDS. What findings would distinguish ARDS from cardiogenic pulmonary edema?

Elevated B-type natriuretic peptide (BNP) levels

Which phase of the psychological reaction to rape is characterized by fear and flashbacks?

Heightened anxiety phase; During the heightened anxiety phase, the client demonstrates anxiety, hyperalertness, and psychosomatic reactions, in addition to fear and flashbacks. The acute disorganization phase is characterized by shock, disbelief, guilt, humiliation, and anger. The denial phase is characterized by an unwillingness to talk. The reorganization phase occurs when the incident is put into perspective. Some clients never fully recover from rape trauma.

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?

Impaired gas exchange

An 85-year-old client is admitted to the ED. Heat stroke is suspected. The client's core temperature is 106.2°F (41.2°C), blood pressure (BP) 90/60 mm Hg, and pulse 102 bpm. The nurse understands that the primary treatment measure for the client will include

immersion of the client in a cold-water bath.

The nurse is triaging people that have been involved in a bus accident. A triaged patient with psychological disturbances would be tagged with which color?

Green

You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure?

Progressive loss of lung function associated with chronic disease

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?

Run a normal saline line to keep the vein open

A patient comes to the clinic with fever, cough, and chest discomfort. The nurse auscultates crackles in the left lower base of the lung and suspects that the patient may have pneumonia. What does the nurse know is the most common organism that causes community-acquired pneumonia?

Streptococcus pneumoniae

A nurse admits a new client with acute respiratory failure. What are the clinical findings of a client with acute respiratory failure?

Sudden onset of lung impairment in a client who had normal lung function

The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation?

Tension pneumothorax

A client with a minor burn would be triaged as

minimal.

Arterial blood gas analysis would reveal which value related to acute respiratory failure?

pH 7.28

A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as

pleural effusion.

A patient was brought into the ED after sustaining injuries due to an explosion while welding. The patient is breathing but has an oxygen saturation of 90%, a respiratory rate of 32, and is coughing. What is the priority action by the nurse?

Administer oxygen with a nonrebreather mask.

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

During a disaster, the nurse triages a victim with a fractured wrist. Which color triage tag should the nurse apply?

Green

A client is being cared for in the ED. The client is assigned to the triage category of "urgent." How often must the nurse reassess the client?

Every 30 minutes

The nurse knows the mortality rate is high in lung cancer clients due to which factor?

Few early symptoms

A victim of a motor vehicle accident has been brought to the emergency room. The patient is exhibiting paradoxical chest expansion and respiratory distress. Which of the following chest disorders should be suspected?

Flail chest

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?

Hypercapnia, hypoventilation, and hypoxemia

A client suffering from carbon monoxide poisoning would exhibit which manifestation?

Intoxication

A client presents to the ED following a chemical burn. The client identifies the source of the burn as white phosphorus. The nurse knows that treatment will include

No application of water to the burn.

A client is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessments is significant in diagnosing this client with flail chest?

Paradoxical chest movement

A nurse who is working as part of a disaster response team is performing triage at a mass casualty incident. One of the victims has a sucking chest wound. The nurse would triage this client using which color-coded tag?

Red

Clients involved in a mass casualty incident are triaged and assigned a color-coded tag. When prioritizing care, clients tagged with which color would be treated first?

Red

The NATO triage system uses color-coded tagging to identify severity of injuries. A patient with survivable but life-threatening injuries (i.e., incomplete amputation) would be tagged with which color?

Red

The student nurse is working with a nurse manager at a hospital when a disaster drill is announced over the hospital P.A. system. The nurse manager asks the nursing student what color triage tag is used for clients who have life threatening, but survivable conditions, if rapid medical attention is provided. What color is the triage tag for these clients?

Red

You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive?

See if there are leaks in the system.

The nurse is providing discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client correctly mentions which early sign of exacerbation?

Shortness of breath

The nurse is caring for a patient with pleurisy. What symptoms does the nurse recognize are significant for this patient's diagnosis?

Stabbing pain during respiratory movement

You are caring for clients who have been exposed to a toxic nerve agent. You will need to use diazepam with these clients. Why is diazepam given when managing the effects of toxic nerve agent toxicity?

To control possible seizures

The nurse is caring for a client with suspected ARDS with a pO2 of 53. The client is placed on oxygen via face mask and the PO2 remains the same. What does the nurse recognize as a key characteristic of ARDS?

Unresponsive arterial hypoxemia

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?

Upside down and then rotated 180 degrees

A client presents to the ED with serious health problems that are not immediately life threatening. The nurse will correctly triage the client into which category?

Urgent