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A patient who was injured in a motor vehicle accident is a potential organ donor. Before the nurse contacts the organ procurement organization for a referral, which information should be collected? A. Past medical history B. Height and weight C. Age, sex and race D. Past social history
Answer: B Height and weight determinants regarding suitability of the organ for transplant.
The nurse is caring for a client who has overdosed on amphetamines. The nurse anticipates noting which assessment finding in this client? A. Bradypnea B. Bradycardia C. Hypothermia D. Hypertension
D. Hypertension Rationale: An overdose from amphetamines can cause agitation, increased temperature, increased pulse, increased respiratory rate, increased blood pressure, cardiac dysrhythmias, myocardial infarction, hallucinations, seizures, and possible death. Therefore, the remaining options are incorrect. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Assessment Content Area: Critical Care: Emergency Situations/Management Strategy(ies): Subject Priority Concepts: Clinical Judgment, Safety
The nurse is caring for a client who has overdosed on phenobarbital. The nurse anticipates which assessment finding with this client? A. Hyperthermia B. Hyperreflexia C. Deep respirations D. Shallow respirations
D. Shallow respirations Rationale: A client experiencing an overdose from barbiturates (such as phenobarbital) will experience shallow respirations; cold, clammy skin; weak, rapid pulse; hyporeflexia; coma; and possible death. Therefore, the remaining options are incorrect. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Assessment Content Area: Critical Care: Emergency Situations/Management Strategy(ies): Subject Priority Concepts: Clinical Judgment, Gas Exchange
Compare and contrast manager roles and leadership roles by choosing the options that are more aligned with the manager role. Select all that apply. 1. Focus is change. 2. Have the ability to influence others. 3. Control the environment. 4. Focus is on people. 5. Focus on efficiency
ANSWER: 3. Control the environment. 5. Focus on efficiency. RATIONALE: 1: The manager accepts the status quo, while the leader challenges it. 2: The manager controls people, while the leader influences 3: The manager controls the environment, patient care, and the staff that deliver that care. 4: The leader focuses on people while the manager focuses on systems and structure. 5: Managers focus on efficiency, while leaders focus on effectiveness.
An emergency department nurse is caring for a conscious child who was brought to the emergency department after the ingestion of half a bottle of acetylsalicylic acid (aspirin). The nurse anticipates that which will be the initialtreatment? A. Placement of a dialysis catheter B. The administration of an emetic C. The administration of vitamin K D. The administration of sodium bicarbonate
B. The administration of an emetic Rationale: Initial treatment of acetylsalicylic acid overdose includes the administration of an emetic or gastric lavage. Activated charcoal may be administered to decrease absorption. Fluids and sodium bicarbonate may be administered intravenously to enhance excretion but would not be the initial treatment. Dialysis is used in extreme cases if the child is unresponsive to therapy. Vitamin K is the antidote for warfarin sodium overdose. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Planning Content Area: Critical Care: Emergency Situations/Management Strategy(ies): Subject, Strategic Words Priority Concepts: Clinical Judgment, Safety
A client arrives at the emergency department who suffered multiple injuries from a head-on car collision. Which of the following assessment should take the highest priority to take? A. Irregular pulse B. Ecchymosis in the flank area C. A deviated trachea D. Unequal pupils
C!!!! A deviated trachea is a symptom of a tension pneumothorax, a condition that, if left untreated, can cause a life threatening emergency! (tension pneumothorax)
The nurse wishes to improve personal Emotional Intelligence (EI) in hopes of a promotion to nurse manager. Which skills are important for this nurse to improve? Select all that apply. 1. Self-confidence. 2. Knowledge base of nursing. 3. Proficiency in technical skills. 4. Empathy. 5. Ability to initiate change.
ANSWER: 1. Self-confidence. 4. Empathy. 5. Ability to initiate change. RATIONALE: 1: EI competencies are self-confidence, empathy, change catalyst, and visionary leadership. 2: While this is an important aspect of professional nursing, it is not a competency of EI. 3: While this is an important aspect of professional nursing, it is not a competency of EI. 4: EI competencies are self-confidence, empathy, change catalyst, and visionary leadership. 5: EI competencies are self-confidence, empathy, change catalyst, and visionary leadership.
A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which intravenous (IV) solution from the IV storage area to hang with the blood product at the client's bedside? A. Lactated Ringer's B. 0.9% sodium chloride C. 5% dextrose in 0.9% sodium chloride D. 5% dextrose in 0.45% sodium chloride
Answer B: - Rationale: Sodium chloride 0.9% (normal saline) is a standard isotonic solution used to precede and follow infusion of blood products. Dextrose is not used because it could result in clumping and subsequent hemolysis of red blood cells. Lactated Ringer's is not the solution of choice with this procedure. - Test-Taking Strategy: Eliminate options that contain dextrose first because they are comparable or alike . From the remaining options, remember that normal saline is an isotonic solution and the solution compatible with red blood cells
Emergency department triage is an important nursing function. A nurse working the evening shift is presented with four patients at the same time. Which of the following patients should be assigned the highest priority? A. A patient with low-grade fever, headache, and myalgias for the past 72 hours. B. A patient who is unable to bear weight on the left foot, with swelling and bruising following a running accident. C. A patient with abdominal and chest pain following a large, spicy meal. D. A child with a one-inch bleeding laceration on the chin but otherwise well after falling while jumping on his bed.
Answer: C A patient with abdominal and chest pain following a large, spicy meal. Emergency triage involves quick patient assessment to prioritize the need for further evaluation and care. Patients with trauma, chest pain, respiratory distress, or acute neurological changes are always classified number one priority. Though the patient with chest pain presented in the question recently ate a spicy meal and may be suffering from heartburn, he also may be having an acute myocardial infarction and require urgent attention.
What are signs and symptoms of Ricin inhalation? A. Redness and Pain B. Vomiting and Diarrhea that becomes bloody, severe dehydration, hypotension, hallucinations and seizures and hematuria C. Respiratory distress, fever, nausea, chest tightness, heavy sweating, pulmonary edema, decreased blood pressure, respiratory failure, death
Correct Answer C Respiratory distress, fever, nausea, chest tightness, heavy sweating, pulmonary edema, decreased blood pressure, respiratory failure, death.
The community health nurse is providing a teaching session about terrorism to members of the community and is discussing information regarding anthrax. The nurse tells those attending that anthrax can be transmitted by which route(s)? Select all that apply. a) Bites from ticks or deer flies b) Inhalation of bacterial spores c) Through a cut or abrasion in the skin d) Direct contact with an infected individual e) Sexual contact with an infected individual f) Ingestion of contaminated undercooked meat
Correct Answers: B, C, F Rationale: Anthrax is caused by Bacillus anthracis and can be contracted through the digestive system or abrasions in the skin, or inhaled through the lungs. It cannot be spread from person to person or from animal to person, and it is not contracted via bites from ticks or deer flies
What statement, made in the morning shift report, would help an effective manager develop trust on the nursing unit? 1. "I know I told you that you could have the weekend off, but I really need you to work." 2. "The others work many extra shifts, why can't you?" 3. "I'm sorry, but I do not have a nurse to spare today to help on your unit. I cannot make a change now, but we should talk further about schedules and needs." 4. "I can't believe you need help with such a simple task. Didn't you learn that in school?"
ANSWER: 3. "I'm sorry, but I do not have a nurse to spare today to help on your unit. I cannot make a change now, but we should talk further about schedules and needs." RATIONALE: 1: To develop trust, managers who make promises to staff must keep the promise. 2: This statement implies that the staff nurse is not a team player. It also sets up one nurse against the remainder of the staff. Effective managers must be fair and supportive with all staff. 3: This manager is standing up for staff by not allowing another unit to take a nurse today. 4: This statement is belittling to the staff nurse. This attitude does not demonstrate trust that staff performances will be effective.
Which behavior demonstrates the nurse's competency as an emotionally intelligent leader? 1. The nurse is proficient in technical skills. 2. The nurse relies on policies, not options. 3. The nurse supports team members. 4. Productivity is not a major concern.
ANSWER: 3. The nurse supports team members. RATIONALE: 1: While technical skill is important for all nurses, it is not a hallmark of a competent leader. 2: Chaos theory states that solutions are not always clear and policies might not always be applied easily; other options might need to be considered. 3: In Emotional Intelligent theory, team members support each other and feel supported by the team leader. 4: This statement reflects the country club leadership style.
As a young manager, one knows that conflict occurs in any organization. Which of the following statements regarding conflict is NOT true? 1. Can be destructive if the level is too high 2. Is not beneficial; hence it should be prevented at all times 3. May result in poor performance 4. May create leaders
ANSWER: 2 RATIONALE: Conflicts are beneficial because it surfaces out issues in the open and can be solved right away. Likewise, members of the team become more conscientious with their work when they are aware that other members of the team are watching them.
When an individual, who is to receive the smallpox vaccine, asks the nurse what type of vaccine this is, what information should the nurse give the client? A. A live vaccinia virus is used in the preparation of smallpox vaccine. B. The vaccine carries the risk of infecting a person with smallpox. C. Lifelong immunity from the smallpox virus is provided by vaccination. D. The vaccine is given as a single injection with a hypodermic needle.
Answer A A live vaccinia virus is used in the preparation of smallpox vaccine. Rationale: A live virus vaccine contains a living virus that is able to give and produce immunity, usually without causing illness. The vaccinia virus is another pox-type virus that is related to smallpox but milder. It may cause rash fever headache and body aches but in certain group of people complications may be severe.
Acetylcysteine is prescribed for a client in the hospital emergency department after diagnosis of acetaminophen overdose. The nurse prepares to administer the medication using which procedure? A. Diluting the medication in cola and administering it to the client orally B. Calling the respiratory department to administer the medication via inhaler C. Obtaining a 1-mL syringe to administer the small dose via the subcutaneous route D. Obtaining an appropriate-size syringe and needle for intramuscular injection in the ventrogluteal muscle
A. Diluting the medication in cola and administering it to the client orally Rationale: Acetylcysteine can be given orally or by nasogastric tube to treat acetaminophen overdose. It is administered by inhalation for use as a mucolytic. Before administration of the medication as an antidote, the nurse would ensure that the client's stomach is empty through emesis or gastric lavage. The solution is diluted in cola, water, or juice to make the solution more palatable. It is not administered via nebulizer, subcutaneously, or intramuscularly for the client experiencing acetaminophen overdose. Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process: Implementation Content Area: Critical Care: Emergency Situations/Management Strategy(ies): Subject Priority Concepts: Clinical Judgment, Safety
A very young nurse has been promoted to nurse manager of an inpatient surgical unit. The nurse is concerned that older nurses may not respect the manager's authority because of the age difference. How can this nurse manager best exercise authority? 1. Use critical thinking to solve problems on the unit 2. Give assignments clearly, taking staff expertise into consideration 3. Understand complex health care environments 4. Maintain an autocratic approach to influence results.
ANSWER: 2. Give assignments clearly, taking staff expertise into consideration. RATIONALE: 1: Critical thinking is important for every RN, not just a manager 2: Giving clear assignments is a characteristic of authority. The young nurse who takes staff expertise into consideration when making assignments is likely to be more successful in leading the group. 3: Nurse managers do work in complex health care environments but must create an appropriate organizational environment as a way of exercising authority. 4: In autocratic leadership, one person has all of the power. This is not a good approach for a younger leader to adopt when working with a group of older, more experienced nurses.
A forensic nurse is appointed as an expert witness by the court for a sexual assault case. What is the responsibility of the forensic nurse as an expert witness? A. The nurse should make the defendant feel comfortable. B. The nurse should prove that the defendant is innocent. C. The nurse should testify about the initial care provided to the victim. D. The nurse should provide concise information to the court.
Answer D: The nurse should communicate in a concise and convincing fashion in the court. The nurse should give an expert opinion about the victim's condition and should give a clear medical condition of the victim. This helps the court to make an appropriate judgment. The nurse should not support the defendant and should not try to make the defendant feel comfortable. The nurse should be objective and neutral. The nurse should not act as an advocate to prove the innocence of the defendant. This is considered a breach of professional boundaries. The forensic nurse does not testify regarding the first or initially performed assessments of the victim.
A depressed client is found unconscious on the floor in the dayroom of a health care facility. The nurse finds several empty bottles of a prescribed tricyclic antidepressant lying near the client. Which is the priority action of the nurse? A. Call the Poison Control Center. B. Call the emergency response team. C. Determine the exact number of pills taken. D. Induce vomiting and notify the health care provider.
B. Call the emergency response team. Rationale: Tricyclic antidepressants can be fatal when taken as an overdose, regardless of the amount ingested. Life-threatening symptoms can develop after an overdose. Immediate emergency medical attention and cardiac monitoring are necessary with an overdose of tricyclic antidepressants. Options that delay immediate intervention would not be the priority actions. Vomiting is not induced in an unconscious client. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Implementation Content Area: Critical Care: Emergency Situations/Management Strategy(ies): Strategic Words Priority Concepts: Clinical Judgment, Safety
A client experiencing cocaine toxicity is brought to the emergency department. The nurse should prepare to take which initial action? A. Administer naloxone. B. Ensure a patent airway. C. Establish an intravenous access. D. Obtain a 12-lead electrocardiogram (ECG).
B. Ensure a patent airway. Rationale: Initial management when caring for a client with cocaine toxicity is to ensure a patent airway. Although options 1, 3, and 4 are components of care, airway is the priority. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Implementation Content Area: Critical Care: Emergency Situations/Management Strategy(ies): ABCs—Airway, Breathing, Circulation, Strategic Words Priority Concepts: Clinical Judgment, Safety
A patient is placed in ventilator support with the diagnosis of botulism and failure to thrive. Which nursing actions would be most appropriate for this patient? Select all that apply. 1. Maintaining intravenous fluids at KVO (keep vein open) 2. Assessing bowel sounds once a shift 3. Referring the patient for a physical therapy consult 4. Recording the patient's ongoing calorie count 5. Assessing the patient's urinary output every hour
Correct Answer: 3,4,5 Rationale: Maintaining fluids at KVO is inappropriate since this patient will be placed on NPO (nothing by mouth) status while ventilated. It is important that the patient receive adequate fluids for hydration and nutrition since nothing will be consumed by mouth. The patient's bowel sounds need to be assessed more often than once a shift (every one to two hours while in the ICU) since the patient is at risk for a paralytic ileus. Physical therapy will be beneficial for maintaining ROM (range of motion) while the patient is immobile from ventilation and sedation. The nurse must closely monitor the patient's calorie intake to determine nutritional needs while NPO. Any time a patient is on maintenance intravenous fluids urinary output must be monitored
