MIDTERM

The nurse arrives on the scene of a fire. What is the first thing the nurse will do for a burn victim?

Cool the burn immediately.

A patient arrives in the emergency department with a sucking wound to the left chest. What is the first action the nurse should take?

Cover the wound with an airtight dressing taped on three sides.

What should the nurse do when preparing the patient for a bone scan?

Encourage water intake.

Sodium is the most abundant electrolyte in the body. The location of electrolytes is important for maintaining homeostasis. Sodium is the major electrolyte in which fluid compartment?

Extracellular

A patient is admitted to the hospital after receiving a blow to the head. The patient begins to show signs of shock. How should the patient be positioned?

Flat on the back

What should the nurse encourage the patient to consume when preparing for an electroencephalogram (EEG)?

Food

Signs that are perceived by an examiner and can be seen, __, measured, or felt are known as objective data.

Heard

A nurse is performing an admission assessment on a patient with suspected tuberculosis. What assessment findings by the nurse are consistent with tuberculosis?

Hemoptysis

What should the nurse do when preparing the patient for a brain scan?

Inform the patient that a clicking noise will be heard during the scan.

The nurse is assisting a victim of an accident who requires bandaging of the right lower extremity. What should the nurse do when applying the bandage?

Leave the toes exposed.

What should the nurse expect when assessing a patient with respiratory alkalosis?

Muscle weakness

The nurse is collecting a specimen for a wound culture. What should be avoided when collecting this specimen?

Old drainage

What type of organism causes malaria?

Protozoan

When two nurses perform two-person CPR, there should be two slow breaths for every 30 __.

Compressions

Electrolytes are not measured by weight; their chemical activity is expressed in milliequivalents. What does 1 mEq of potassium have the same combining power as?

1 mEq of hydrogen

When performing a venipuncture, the tourniquet should be left on no more than __ to __ minutes.

1-2

The nurse accidently spills blood from a specimen container. The first action the nurse takes is to don gloves. What should the nurse then spray the fluid with?

10% bleach solution

A patient who had taken a poisonous substance is brought to the emergency department. What is the first action the nurse should take?

Contact the poison control center.

When collecting a stool specimen for a guaiac (occult blood in stool), the nurse should take a specimen from __ different parts of the stool.

2

Following an intravenous pyelogram, the nurse should watch the patient closely for a delayed reaction to the dye, usually occurring within __ to __ hours following the procedure.

2-6

When performing __ on an infant, the breastbone is depressed approximately one-third of the chest diameter or 1½ in.

2500ml

A burn patient is brought into the emergency department with the following burns: half of the front torso, entire left arm, and front of left leg. The nurse should record that the patient has a ______% burn.

27

The procedure for collecting a sterile urine specimen via a catheter port includes clamping the Foley catheter tubing below the catheter port. How long will the clamp remain in place?

30 minutes

The nurse must keep an accurate intake and output record to assess kidney efficiency. In order for the kidneys to remove waste, what is the least amount of hourly urine output the kidneys must produce to remove waste?

30ml

The patient is admitted to the emergency department, having suffered frostbite to the hands, which are grayish-white in color. What action should the nurse implement when attempting to warm the hands?

Wrap the hands in hot, moist towels.

A child has been having an asthma attack for the last 8 hours. Because of the child's inability to exhale effectively, the nurse assesses for respiratory __.

acidosis

A condition in which there is a lack of appetite resulting in the inability to eat is known as __.

anorexia

The nurse observes that an older adult patient has no hair on the lower legs. The nurse should assess further for the sufficiency of ______ flow.

arterial

A condition of debility, loss of strength and energy, and depleted vitality is known as __.

asthenia

What intervention should the nurse implement when preparing the patient for a glucose tolerance test (GTT)?

Keep patient NPO 8 hours before the test.

A patient has been stung by a bee and is brought to the emergency department. The nurse observes the sting site and identifies that the stinger is still in the skin. What action should the nurse take?

Scrape the stinger with the side of a knife.

A person can spread a bacterial infection by which actions? (Select all that apply.)

Sneezing at work Kissing others Leaving used tissue on the lavatory

What is a method used to kill all microorganisms, including spores?

Sterilizing

While on break in the hospital cafeteria a nurse witnesses her pregnant coworker start to choke. The coworker is conscious, but unable to breathe. Where should the nurse administer thrusts?

The chest

The nurse is preparing to perform a physical assessment. What essential supplies should this nurse gather? (Select all that apply.)

Thermometer Flashlight Gloves Scissors

The nurse is instructing a bioterrorism class regarding anthrax. How can anthrax be transmitted?

Through inhalation of the spores

The nurse is providing teaching to elementary students regarding vectors. What example will the nurse provide as an example of a vector?

Tick whose bite causes Lyme disease

The infection control officer is observing hospital staff for appropriate use of aseptic technique. What observation demonstrates the need for more instruction on surgical asepsis?

Touching the edges of the sterile field with sterile gloves

What should the nurse do when preparing the patient for an arteriography?

Verify if the patient has been taking anticoagulants.

A machinist visits the industrial nurse's clinic with a deep laceration of the thigh. What should be the nurse's first action?

Wash the laceration with an antiseptic.

The nurse weighs a patient at the same time of day with the same scale and same clothing. What is this a simple and accurate method of determining?

Water balance

The nurse is preparing a patient for a barium enema. What color will the nurse inform the patient his stools will be following this procedure?

White

A 45 year old female patient has superficial partial thickness burns on the posterior head and neck, front of the left arm, front and back of the right arm, posterior trunk, front and back of the left leg, and back of right leg. The patient weighs 91 kg. Use the Parkland Burn Formula to calculate the total amount of Lactated Ringers that will be given over the next 24 hours?

22,932 mL FORMULA: 4 x 63 x 91 = 22,932 mL

What should the nurse focus on when creating a nursing care plan for a patient with metabolic acidosis?

Deep-breathing exercises

When assessing a patient who has suffered a burn injury, the nurse classifies the burn as a deep partial-thickness burn. What is this observation most likely based upon?

Erythema and blisters

A 29 year old male patient has superficial partial thickness burns on the anterior right arm, posterior left leg, and anterior head and neck. The patient weighs 78 kg. Use the Parkland Burn Formula to calculate the total amount of Lactated Ringers that will be given over the next 24 hours?

5,616 mL

A 59 year old male patient has full thickness burns on both of the legs on the back,front and back of the trunk, both arms on the front and back, and front and back of the head and neck. The patient weighs 186 lbs. Use the Parkland Burn Formula: You'vealready infused fluids during the first 8 hours. Now what will you set the flow rate during the next 16 hours (mL/hr) based on the total you calculated?

861 mL/hr

A 30 year old female patient has deep partial thickness burns on the front and back of the right and left leg, front of right arm, and anterior trunk. The patient weighs 63 kg. Use the Parkland Burn Formula: What is the flow rate during the FIRST 8 hours (mL/hr) based on the total you calculated?

921 mL/hr

A circulatory condition in which the myocardium contracts steadily but at a rate of less than 60 contractions per minute is known as __.

bradycardia

A patient is distressed that an antibiotic has not been effective for the control of the infection. The nurse explains that some bacteria are capable of defending against antibiotics by the formation of a _______.

capsule

The acronym RICE directs the nurse in the care of a sprain. The "C" in the acronym stands for __.

compression

When performing __ on an infant, the breastbone is depressed approximately one-third of the chest diameter or 1½ in.

cpr

A condition in which a patient experiences bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood is known as __.

cyanosis

When initiating a 24-hour urine collection, the nurse asks the patient to void. The nurse then __ the specimen.

discards

Symptoms that are perceived by the patient are known as __ data.

subjective

A nurse is performing an admission assessment on a patient with suspected tuberculosis. What is the greatest risk of exposure to tuberculosis?

Before a diagnosis is made

Three body systems work at different speeds to keep the pH in the narrow range of normal. What is the order of effectiveness for these three systems?

Blood buffers, lungs, and kidneys

The nurse has an order to perform occult blood testing on a patient's emesis. What color will the sample turn to indicate that the test is positive for occult blood?

Blue

What is the nurse closely assessing for in a patient with hypokalemia?

Cardiac complications

The patient is brought to the emergency department after having fractured an arm 12 hours ago. The arm is very edematous from the fingers to the elbow, and the patient cannot move it. What should be the initial action of the nurse?

Check fingers for capillary refill.

What does actively transporting electrolytes from an area of higher concentration to an area of lower concentration require?

Hydrostatic pressure

A nurse assesses an edematous cardiac patient. The nurse is aware that this condition is a result of retained fluid. What is the patient considered to be?

Hypernatremic

The patient's lower chest has been punctured with a knife that is still in place. What should the nurse's first action be?

Immobilize the knife with dressings and tape.

The nurse is pouring a sterile solution from a bottle. What direction should the label on the bottle be in for appropriate technique?

In the palm of the hand

When a patient takes substances into the body, they first enter the extracellular compartment. What must the substances enter to carry out their function?

Intracellular compartment

What are some characteristics of microorganisms? (Select all that apply.)

Involved in a life process of their own. Can enter the body via skin, air, or blood. Pathogens that cause disease. May be infectious.

The nurse is providing instruction to an anxious mother of a child with Rocky Mountain spotted fever. When discussing this diagnosis, what information will the nurse relay about this disease?

It is a serious disease contracted from the bite of a tick.

When reading the laboratory report of a patient with excessive diarrhea, the nurse notes that the pH is 7.10, and the PaCO2 and the PaO2 are normal. What should the nurse recognize as this patient's state from this information alone?

Metabolic acidosis

A patient began vomiting and continued to do so for several hours. What is the result of this loss of stomach contents?

Metabolic alkalosis

What should the nurse do when preparing the patient for an amniocentesis?

Monitor fetal heart tones.

Following a liver biopsy, the nurse should observe for hemorrhage and ensure that the patient is kept on bed rest for 24 hours. How should the nurse keep the patient for the first 1 to 2 hours?

On his or her right side

The nurse explains to a patient that the drug Lasix reduces edema by drawing water from the interstitial space into the intravascular space. What is this process called?

Osmosis

What type of stool specimen must be sent to the laboratory immediately?

Ova and parasites

What is the method by which inhaled oxygen is moved into the intravascular compartment called?

Passive transport

A patient is unable to obtain a sputum specimen by coughing and expectorating. What is the best way for the nurse to collect this specimen?

Perform tracheal suctioning.

Recognizing the stages of an infection assists the nurse in identifying the progression of an infection. What is the nonspecific to specific symptom stage of an infection?

Prodromal

What should the nurse do when preparing the patient for a bronchoscopy?

Reassure the patient that he or she will be able to breathe during the procedure.

The patient with heatstroke has been undressed and treated with cold packs and a fan. The patient's temperature is now down to 101.2°F (38.4°C). The patient starts to shiver. What action should the emergency department nurse take?

Remove cold packs and fan.

The nurse modifies the care plan for the immobilized patient after assessing a calcium level of 6.2 mEq/L. What nursing assessment should the nurse include when modifying this care plan?

Renal calculi

A patient admitted in a state of extreme anxiety has vital signs of T 98.6°F (37°C), P 81, BP 130/86, R 32. What will result if this hyperventilation continues?

Respiratory alkalosis

What can result from the nurse consistently performing hand hygiene and using sterile supplies when caring for patients in the hospital setting?

Risk of infection is reduced

The nurse is preparing to collect a urine specimen. What will this nurse include when labeling this specimen? (Select all that apply.)

Room number Medical record number' Date and time of collection

A visitor in the hospital slips and falls. The patient's arm appears dislocated and the visitor is unable to move it. What is the first action the nurse should implement?

Splint the arm.

What is the most dependable and practical method to use when sterilizing instruments for the operating room?

Steam under pressure

The patient has undergone a lumbar puncture. What position will the nurse place the patient in for up to 12 hours to avoid discomfort from postpuncture spinal headache?

Supine

A patient has just had a liver biopsy. What should the nurse do immediately following this procedure?

Tell the patient to avoid coughing.

Discoloration of an area of the skin or mucous membrane that is caused by the extravasation of blood into the subcutaneous tissues as a result of trauma to the underlying blood vessels or by fragility of the vessel walls is known as __.

ecchymosis

Redness or inflammation of the skin or mucous membranes that is the result of dilation and congestion of superficial capillaries is known as __.

erythema

A yellow tinge to the skin that may indicate obstruction in the flow of bile from the liver is known as __.

jaundice

When assessing a patient for signs of an infection, the nurse recognizes which laboratory result as indicative of an infection?

leukocytosis

An abnormal condition in which a person must sit or stand to breathe deeply or comfortably is known as __.

orthopnea

An unpleasant sensation caused by noxious (extremely destructive or harmful) stimulation of the sensory nerve endings is __.

pain

A symptom of itching and an uncomfortable sensation leading to an urge to scratch is known as __.

pruritus

The nurse reminds a group of nursing students that the type of asepsis that destroys all microorganisms and their spores is _______ asepsis.

surgical

A condition in which there is a temporary loss of consciousness associated with an increased rate of respiration, tachycardia, pallor, perspiration, and coolness of the skin is known as __.

syncope

An abnormal condition in which the heart contracts regularly but at a rate greater than 100 beats/min is known as __.

tachycardia

An abnormally rapid rate of breathing that is seen in many disease conditions is known as __.

tachypnea

If a spinal injury is suspected, before the rescuer starts CPR, the trachea should be opened with a jaw __ maneuver.

thrust

A creamy, viscous, pale yellow or yellow-green fluid exudate that is the result of fluid remains of liquefied necrosis of __ is known as purulent drainage.

tissues

After a bone scan, the nurse assesses a hematoma at the injection site of the dye. The nurse should apply __ soaks or compresses.

warm

What should the nurse do when preparing the patient for an abdominal scan?

Assess patient for allergies to dye or shellfish.

What should the nurse do when preparing the patient for an exercise tolerance test (treadmill)?

Allow the patient to drink water before the test.

The emergency department nurse is assessing a puncture wound of the foot. What is the most likely type of infection in this wound?

Anaerobic bacterial infection

The nurse is educating a patient regarding the need to avoid foods high in potassium. What food choices led the nurse to conclude that teaching was not effective?

Apricots and asparagus