Exam 1 - Emergency Nursing, Cardiac, Chronicity

8. A client rings the call light and complains of pain at the site of an intravenous (IV) infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which actions in the care of this client? (SATA) 1. Remove the IV catheter at that site. 2. Apply warm moist packs to the site. 3. Notify the health care provider (HCP). 4. Start a new IV line in a proximal portion of the same vein. 5. Document the occurrence, actions taken, and the client's response.

1,2,3,5

10. The nurse, caring for a group of adult clients on an acute care medical-surgical nursing unit, determines that which clients would be the most likely candidates for parenteral nutrition (PN)? Select all that apply. 1. A client with extensive burns 2. A client with cancer who is septic 3. A client who has had an open cholecystectomy 4. A client with severe exacerbation of Crohn's disease 5. A client with persistent nausea and vomiting from chemotherapy

1,2,4,5

The nurse is caring for a client in the latent phase of radiation exposure. Which signs/symptoms should the nurse assess in the client? 1. Anemia, leukopenia, and thrombocytopenia. 2. Sudden fever, chills, and enlarged lymph nodes. 3. Nausea, vomiting, and diarrhea. 4. Flaccid paralysis, diplopia, and dysphagia.

1. Anemia, leukopenia, and thrombocytopenia.

26. A client receiving total parenteral nutrition (TPN) through a single-lumen central intravenous (IV) line is scheduled to receive an antibiotic by the IV route. Which action by the nurse is appropriate before hanging the antibiotic solution? 1. Ensure a separate IV access for the antibiotic. 2. Turn off the solution for 30 minutes before administering the antibiotic. 3. Flush the central IV line with 60 mL of normal saline before giving the antibiotic. Check with the pharmacy to be sure the antibiotic can be given through the TPN solution line

1. Ensure a separate IV access for the antibiotic.

1. The community health nurse is preparing to teach personnel and family preparedness for disasters to a group of parents of school-age children. Which items should the nurse plan to include in disaster preparedness? (SATA) 1. Flashlight 2. Supply of batteries 3. Battery-operated radio 4. Extra pair of eyeglasses 5. 4-week supply of water 6. 4-week supply of nonperishable food

1. Flashlight 2. Supply of batteries 3. Battery-operated radio 4. Extra pair of eyeglasses *3 day supply needed

14. The ED nurse is caring for a client who had a severe allergic reaction to a bee sting. Which discharge instructions should the nurse discuss with the client? 1. Instruct the client to wear a medical identification bracelet. 2. Apply corticosteroid cream to the site to prevent anaphylaxis. 3. Administer epinephrine 1: 10,000 intravenously every three (3) minutes. 4. Teach the client to avoid attracting insects by wearing bright colors.

1. Instruct the client to wear a medical identification bracelet. Clients who have severe reactions to insect stings should wear identifying bracelets to provide information. If the client is unconscious, the bracelet can alert the health-care provider so treatment can be started.

4. Which nursing action is essential prior to initiating a new prescription for 500 mL of fat emulsion (lipids) to infuse at 50 mL/hour? 1. Ensure that the client does not have diabetes. 2. Determine whether the client has an allergy to eggs. 3. Add regular insulin to the fat emulsion, using aseptic technique. 4. Contact the health care provider (HCP) to have a central line inserted for fat emulsion infusion.

2. Determine whether the client has an allergy to eggs.

9. The elderly female client with vertebral fractures who has been self-medicating with ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), presents to the ED complaining of abdominal pain, is pale and clammy, and has a P of 110 and a BP of 92/60. Which type of shock should the nurse suspect? 1. Cardiogenic shock. 2. Hypovolemic shock. 3. Neurogenic shock. 4. Septic shock.

2. Hypovolemic shock. These client's signs/symptoms make the nurse suspect the client is losing blood, which leads to hypovolemic shock, which is the most common type of shock and is characterized by decreased intravascular volume. The client's taking of NSAID medications puts her at risk for hemorrhage because NSAIDs inhibit prostaglandin production in the stomach, which increases the risk of developing ulcers,

34. A client in shock is receiving dopamine hydrochloride by intravenous (IV) infusion. The nurse should have which medication available for local injection if IV infiltration and medication extravasation occur? 1. Vitamin K 2. Phentolamine 3. Atropine sulfate 4. Protamine sulfate

2. Phentolamine

35. A client admitted with hypertensive crisis has an intravenous (IV) infusion of 1000 mL of normal saline with 20 mEq of potassium chloride added. A prescription is written to administer sodium nitroprusside by continuous IV infusion. The nurse should plan to do which to administer this medication? 1. Monitor the blood pressure every 15 minutes during administration. 2. Protect the sodium nitroprusside from light with an opaque material. 3. Check the solution for a faint brown coloration and discard it if this is noticed. 4. Piggyback the sodium nitroprusside into the IV line containing the potassium chloride.

2. Protect the sodium nitroprusside from light with an opaque material. Sodium nitroprusside can be degraded by light and should be protected with an opaque material. It is dispensed in powdered form and must be dissolved and diluted for the IV solution. A fresh solution may have a faint brown coloration, but solutions that are deeply colored, such as blue-green or dark red, should be discarded

3. The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. Which assessment findings are consistent with infiltration? (SATA) 1. Pain and erythema 2. Pallor and coolness 3. Numbness and pain 4. Edema and blanched skin 5. Formation of a red streak and purulent drainage

3,4,5 1,5 = phlebitis or infection

13. The nurse is monitoring the status of a client's fat emulsion (lipid) infusion and notes that the infusion is 1 hour behind. Which action should the nurse take? 1. Adjust the infusion rate to catch up over the next hour. 2. Increase the infusion rate to catch up over the next 2 hours. 3. Ensure that the fat emulsion infusion rate is infusing at the prescribed rate. 4. Adjust the infusion rate to run wide open until the solution is back on time.

3. Ensure that the fat emulsion infusion rate is infusing at the prescribed rate.

18. A client develops atrial fibrillation with a ventricular rate of 140 beats/minute and signs of decreased cardiac output. Which medication should the nurse anticipate administering first? 1. Warfarin 2. Lidocaine 3. Metoprolol 4. Atropine sulfate

3. Metoprolol Beta blockers such as metoprolol slow conduction of impulses through the atrioventricular node and decrease the heart rate. In rapid atrial fibrillation, the goal first is to slow the ventricular rate and improve the cardiac output and then attempt to restore normal sinus rhythm

24. The client has been brought to the ED by ambulance following a motor-vehicle accident with a flail chest, an intravenous line, and a Heimlich valve. Which intervention should the nurse implement first? 1. Start a large-bore intravenous access. 2. Request a portable chest x-ray. 3. Prepare to insert chest tubes. 4. Assess the cardiac rhythm on the monitor.

3. Prepare to insert chest tubes.

41. A client hospitalized with a diagnosis of myocardial infarction calls for the unit nurse because the client is experiencing chest pain. The nurse administers a sublingual nitroglycerin tablet as prescribed. The client, who is receiving oxygen by nasal cannula, reports that her chest pain is unrelieved by the nitroglycerin. Which is the next nursing action for this client? 1. Call the client's family. 2. Increase the flow rate of oxygen. 3. Contact the health care provider (HCP). 4. Administer another nitroglycerin tablet.

4 Rationale: For the hospitalized client, nitroglycerin tablets are administered 1 tablet every 5 minutes, for a total of 3 tablets per episode of chest pain, as long as the client maintains a systolic blood pressure of 100 mm Hg or higher.

38. A client being admitted to the coronary care unit from the emergency department has a stat prescription to receive a dose of intravenous procainamide followed by a continuous infusion. Based on this prescription, the nurse should assess for which condition? 1. Dyspnea 2. Bradycardia 3. Hypertension 4. Ventricular ectopy

4. Ventricular ectopy Rationale: Procainamide is an antidysrhythmic medication used to treat ventricular dysrhythmias unresponsive to lidocaine. The other options are not indications for giving this medication.

A depressed client is found unconscious on the floor in the dayroom. The nurse finds several empty bottles of a prescribed tricyclic antidepressant lying near the client. Which is the priority action of the nurse? 1. Call the Poison Control Center. 2. Try to figure out the number of pills taken. 3. Induce vomiting and notify the health care provider for further prescriptions. 4. Call the emergency response team because this incident presents a medical emergency.

Answer 1. Call the Poison Control Center, as this represents a medical emergency

In the intensive care unit, the nurse cares for a client who is being treated for hypotension with a continuous infusion of dopamine. Which assessment finding indicates that the infusion rate may need to be adjusted? A.Central venous pressure is 6 mmHg B.Heart rate is 120/min C.Mean arterial pressure is 78 mmHg D.Systemic vascular resistance is 900 dynes/sec/ cm-5

B.Heart rate is 120/min

The nurse plans to administer Dopamine (Intropin) at a rate of 12 mcg/kg/min to a client who is in septic shock. What parameter should the nurse use to evaluate a therapeutic response to dopamine? A. Pupil response B. Urinary output C. Temperature D. Heart sounds E. Blood pressure

E. Blood pressure

NCLEX QUESTION: The nurse teaches a class on bioterrorism. Which methods of transmission are possible with the biologic agent Bacillus anthracis (Anthrax)? (Select all that apply.) A. Inhalation of powder form B. Handling of infected animals C. Spread from person to person through coughing D. Eating undercooked meat from infected animals E. Direct cutaneous contact with the powder

A,B,D,E

Emergency medical service personnel are transporting a near-drowning victim who is currently hypothermic. Based on anticipated vital signs, the nurse needs to prepare for which interventions? Select all that apply. A.Covering client with warm blankets B.Logrolling the client from side to side frequently C.Mechanical ventilation D.Warmed blood administration E.Warmed IV fluids

A,C,E

53. A gastric lavage has been ordered for a client who is comatose and who ingested a full bottle of acetaminophen, a nonnarcotic analgesic. Which intervention should be included in the procedure? Select all that apply. 1. Place the client on the left side with the head 15 degrees lower than the body. 2. Insert a small-bore feeding tube into the naris. 3. Have standby suction available. 4. Withdraw stomach contents and then instill an irrigating solution. 5. Send samples of the stomach contents to the lab for analysis.

1,3,4,5

20. The nurse is discharging a client from the ED with a sutured laceration on the right knee. Which information is most important for the nurse to obtain? 1. The date of the client's last tetanus injection. 2. The name of the client's regular health-care provider. 3. Explain the sutures must be removed in 10 to 14 days. 4. Determine if the client has any drug or food allergies.

1. The date of the client's last tetanus injection. Any client who has not had a tetanus injection within five (5) years will need to receive an injection as prophylaxis.

25. A client receiving total parenteral nutrition (TPN) experiences sudden development of chest pain, dyspnea, tachycardia, cyanosis, and a decreased level of consciousness. What should the nurse suspect as a complication of the TPN? 1. Air embolism 2. Hyperglycemia 3. Catheter-related sepsis 4. Allergic reaction to the catheter

1. Air embolism

27. The nurse notes that a client's total parenteral nutrition (TPN) solution is 4 hours behind. Which action should the nurse take? 1. Assess the infusion pump to be sure it is functioning properly and is set at the correct rate. 2. Increase the infusion rate to a rate that allows the infusion volume to correct itself within a 2-hour period. 3. Replace the TPN solution with 10% dextrose, and restart the solution the following day. 4. Administer the TPN solution using gravity flow because the infusion pump is malfunctioning.

1. Assess the infusion pump to be sure it is functioning properly and is set at the correct rate.

The nurse in the hospital emergency department is notified by emergency medical services that several victims who survived a plane crash will be transported to the hospital. Victims are suffering from cold exposure because the plane plummeted and was submerged in a local river. What is the initial action of the nurse? 1. Call the nursing supervisor to activate the agency disaster plan. 2. Supply the triage rooms with bottles of sterile water and normal saline. 3. Call the intensive care unit to request that nurses be sent to the emergency department. 4. Call the laundry department, and ask the department to send as many warm blankets as possible to the emergency department.

1. Call the nursing supervisor to activate the agency disaster plan.

40. The nurse is caring for a client with a diagnosis of myocardial infarction (MI). The client is experiencing chest pain that is unrelieved by the administration of nitroglycerin. The nurse administers morphine sulfate to the client as prescribed by the health care provider. After administration of the morphine sulfate, what is the priority assessment? 1. Respirations 2. Mental status 3. Urinary output 4. Blood pressure

1. Respirations

20. The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium chloride and needs to add the medication to the IV bag. The nurse should plan to take which action immediately after injecting the potassium chloride into the port of the IV bag? 1. Rotate the bag gently. 2. Attach the tubing to the client. 3. Prime the tubing with the IV solution. 4. Check the solution for yellowish discoloration.

1. Rotate the bag gently. Rationale: After adding a medication to a bag of IV solution, the nurse should agitate or rotate the bag gently to mix the medication evenly in the solution.

38. The nurse is caring for a client receiving total parenteral nutrition (TPN) via a central line. What assessment should the nurse perform to detect the most common complication of TPN? 1. Vital signs 2. Auscultate lungs 3. Kidney function tests 4. Listen for bowel sounds

1. Vital signs

10. The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client needs further instructions if the client made which statement? 1. "I need to wear a MedicAlert tag or bracelet." 2. "I need to restrict my activity while this catheter is in place." 3. "I need to keep the insertion site protected when in the shower or bath." 4. "I need to check the markings on the catheter each time the dressing is changed."

2. "I need to restrict my activity while this catheter is in place."

1. A client is being weaned from parenteral nutrition (PN) and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hour. The nurse anticipates that which prescription regarding the PN solution will accompany the diet prescription? 1. Discontinue the PN. 2. Decrease PN rate to 50 mL/hour. 3. Start 0.9% normal saline at 25 mL/hour. 4. Continue current infusion rate prescriptions for PN.

2. Decrease PN rate to 50 mL/hour.

37. A client with rapid-rate atrial fibrillation has a new prescription for diltiazem hydrochloride by intravenous (IV) bolus followed by a continuous IV infusion of the same medication. What should the nurse plan for with the administration of this medication? 1. Applying a nonrebreather mask 2. Discontinuing the infusion after 24 hours 3. Monitoring the cardiac rhythm every hour 4. Administering the IV bolus over 2 to 3 seconds

2. Discontinuing the infusion after 24 hours Diltiazem hydrochloride is a calcium channel blocker used in the treatment of atrial flutter and fibrillation. It decreases myocardial contractility and workload, thereby decreasing the need for oxygen. A bolus of 0.25 mg/kg is given slowly over 2 minutes, and a continuous infusion of 5 to 10 mg/hour may be administered for up to 24 hours

7. The nurse is preparing to hang fat emulsion (lipids) and notes that fat globules are visible at the top of the solution. The nurse should take which action? 1. Roll the bottle of solution gently. 2. Obtain a different bottle of solution. 3. Shake the bottle of solution vigorously. 4. Run the bottle of solution under warm water.

2. Obtain a different bottle of solution.

22. The client with a temperature of 94˚F is being treated in the ED. Which intervention should the nurse implement to directly elevate the client's temperature? 1. Remove the client's clothing. 2. Place a warm air blanket over the client. 3. Have the client change into a hospital gown. 4. Raise the temperature in the room.

2. Place a warm air blanket over the client.

12. The ED nurse is caring for a client diagnosed with frostbite of the feet. Which intervention should the nurse implement? 1. Massage the feet vigorously. 2. Soak the feet in warm water. 3. Apply a heating pad to feet. 4. Apply petroleum jelly to feet.

2. Soak the feet in warm water.

17. The nurse prepares to administer acetylcysteine to the client with an overdose of acetaminophen. What is the appropriate action when administering this antidote? 1. Administer the medication subcutaneously in the deltoid muscle. 2. Administer the medication by intramuscular (IM) injection in the gluteal muscle. 3. Mix the medication in a flavored ice drink, and allow the client to drink the medication. 4. Administer the medication mixed in 50 mL of normal saline and piggybacked through the main intravenous (IV) line.

3. Mix the medication in a flavored ice drink, and allow the client to drink the medication.

42. A client is admitted to the hospital with a diagnosis of myocardial infarction (MI) and is going to have an intravenous (IV) nitroglycerin infusion started. Noting that the client does not have an intra-arterial monitoring line in place, what piece of equipment should the nurse obtain for use at the bedside? 1. Defibrillator 2. Pulse oximeter 3. Noninvasive blood pressure monitor 4. Central venous pressure (CVP) insertion tray

3. Noninvasive blood pressure monitor

23. The ED nurse is caring for the client who has taken an overdose of cocaine. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Evaluate the airway and breathing. 2. Monitor the rate of intravenous fluids. 3. Place the cardiac monitor on the client. 4. Transfer the client to the intensive care unit.

3. Place the cardiac monitor on the client.

2. The nurse is preparing to change the parenteral nutrition (PN) solution bag and tubing. The client's central venous line is located in the right subclavian vein. The nurse asks the client to take which essential action during the tubing change? 1. Breathe normally. 2. Turn the head to the right. 3. Exhale slowly and evenly. 4. Take a deep breath, hold it, and bear down.

4. Take a deep breath, hold it, and bear down.

13. A student reports to the school nurse with complaints of stinging and burning from a wasp sting. Which intervention should the nurse implement? 1. Grasp the stinger and pull it out. 2. Apply a warm, moist soak to the area. 3. Cleanse the site with alcohol. 4. Apply an ice pack to the site.

4. Apply an ice pack to the site.

57. The nurse is providing first aid to a victim of a poisonous snake bite. Which intervention should be the nurse's first action? 1. Apply a tourniquet to the affected limb. 2. Cut an "X" across the bite and suck out the venom. 3. Administer a corticosteroid medication. 4. Have the client lie still and remove constrictive items.

4. Have the client lie still and remove constrictive items.

The emergency department nurse is caring for a client who requires gastric lavage for a drug overdose. Which action would be appropriate? A.Lavage through a small-bore nasogastric tube B.Place client in Trendelenburg position during lavage C.Prepare intubation and suction supplies at the bedside D.Wait an hour after gastric decompression to initiate lavage

C.Prepare intubation and suction supplies at the bedside