Quiz 6

39. When planning the care of the patient in cardiogenic shock, what does the nurse understand is the primary treatment goal?

Treat the oxygenation needs to the heart muscle

31. A client who is blind is admitted for treatment of gastroenteritis. What does the nurse recognize as the highest priority for this client?

fluid volume deficit

27. A nurse is providing care to the family of a client who was brought to the emergency department and suddenly died. Which of the following would be appropriate for the nurse to do? SATA

Ask the family if they would like to view the body. Provide a private place for the family to be together. Allow the family to express their emotions freely.

33. The nurse is admitting a patient with a penetrating abdominal injury from a knife wound. What should the nursing measures for a penetrating abdominal injury include? (Select all that apply.)

Assessing for manifestations of hemorrhage. Covering any protruding viscera with sterile dressings soaked in normal saline solution. Looking for any associated chest injuries.

3. When assessing a with suspected carbon monoxide poisoning which finding would be least

Cherry red skin color

5. A client with a history of allergies comes to the emergency department. The nurse suspects anaphylaxis based on which of the following? Select all that apply.

Chest tightness Pallor Facial angioedema

28. The nurse educator is teaching a group of young adult women about sexually transmitted infections. The nurse explains that which infection is most likely to be "silent" with no overt symptoms in women?

Chlamydia

26. A nurse is preparing to insert a peripheral intravenous access device into the arm of a client. When preparing the skin for insertion, which of the following should the nurse use to prevent possible health-care associated bloodstream infections?

Chlorhexidine

38. 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

41. A patient in the emergency department is bleeding profusely from numerous large and deep lacerations on the top of his head, right side of his face, and forehead. The nurse determines the need to apply pressure at the appropriate pressure point. The nurse would use which of the following pressure points?

Image of finger on the right side near the head

40. Which of the following would the nurse identify as indicating that a client is experiencing a complete airway obstruction? Select all that apply.

Inability to speak Clutching of the neck Stridor Cyanosis

44. A client comes to the emergency department reporting severe diarrhea. The client is pale with dry mucous membranes and poor skin turgor. The nurse would suspect Eschericha coli (E. coli) as the potential cause when the client states which of the following?

"Yesterday for lunch, I ate a hamburger that was on the rare side."

9. A patient has developed chickenpox and asks the nurse what the incubation period would be. What should the nurse inform the patient?

10-21 days

Which nursing actions are appropriate during the primary survey of the emergency assessment process? Select all that apply. 1) Inserting a nasogastric tube 2) Immobilizing the cervical spine 3) Arranging for diagnostic studies 4) Preparing for chest tube insertion 5) Applying direct pressure to a wound

2,4,5

21. Permanent brain injury or death will occur within which time frame secondary to hypoxia?

3-5 minutes

15. A client is brought to the emergency department with severe hemorrhage requiring massive blood replacement. The nurse warms the blood in a commercial warmer based on the understanding that infusion of large amounts of blood could result in which of the following?

Cardiac arrest

1. How should vasoactive medications be administered?

Central venous line

18. The nurse assesses a patient who experienced a reaction to a bee sting. The patient's clinical findings indicate a pre-shock condition, which is evidenced by:

Cold, clammy skin, and tachycardia

23. A confused client exhibits a systolic blood pressure of 108, heart rate of 112 beats per minute, and respirations of 28 breaths per minute. The client's skin is cold and clammy. The nurse assesses this shock as

Compensatory

30. A client presents to the ED following a motor vehicle collision. The client is suspected of having internal hemorrhage. The nurse assesses the client for signs and symptoms of shock. Which are signs and symptoms of shock? Select all that apply.

Cool, moist skin Decreasing blood pressure Increased heart rate Delayed capillary refill

35. A client presents to the ED in shock. At what point in shock does the nurse know that metabolic acidosis is going to occur?

Decompensation

13. What is a negative effect of IV nitroglycerin for shock management that the nurse should assess for in a client?

Decreased blood pressure

The nurse is conducting a secondary survey on a client in the ED. Which action is completed during the secondary survey?

Diagnostic & laboratory testing

25. A nurse is caring for a client in a critical care unit. With what type of shock does a client experience a pooling of blood flow to the peripheral blood vessels?

Distributive

6. The nurse is caring for a client who is in neurogenic shock. The nurse knows that it is subcategory of what kind of shock?

Distributive

17. Which vasodilator medication is used in the treatment of shock?

Dobutamine

45. A client with an acute myocardial infarction demonstrates signs of cardiogenic shock. Which medications will the nurse expect to be prescribed for this client? Select all that apply.

Dobutamine Dopamine Nitroglycerin Vasopressin

19. The nurse is caring for a patient with a meningococcal infection. What type of precautions should be used for this

Droplet

4. A patient presents to the ED complaining of choking on a chicken bone. The patient is breathing spontaneously. The nurse applies oxygen and suspects a partial airway obstruction. Which of the following should the nurse do next?

Encourage the patient to cough forcefully.

32. A nurse is caring for a patient with multiple injuries and performs the following. Place these actions in the order in which the nurse would perform them. Use all options.

Establish airway and ventilation Control hemorrhage Prevent and treat shock Assess for head and neck injuries Assess for abdomen, back, and extremity injuries Splint fractures

36. 36. A patient arrives at the emergency department after taking more than 20 lorazepam tablets. Which of the following would the nurse anticipate that the patient would be given to reverse the effects of the drug?

Flumazenil

10. A client is being cared for in the Neurological Intensive Care Unit following a spinal cord injury . Which assessment finding indicates that the client may be experiencing neurogenic shock ?

HR 48 bmp, BP 90/60 mm Hg

8. A client is brought to the emergency department with injuries obtained from a motor vehicle crash. Which action will the nurse take during the secondary survey of the client? Select all that apply.

Head-to-toe assessment Results of laboratory tests History of current event

12. A nurse is caring for a client who has arrived at the emergency department in shock. The nurse intervenes based on the knowledge that which of the following is the most common cause of shock?

Hypovolemia

22. A nurse is evaluating a client's drop in mean arterial pressure to 50 mm Hg during progressive shock. What client assessment would follow with the drop in pressure?

Low urine output

34. The nurse is caring for a client with known myocardial ischemia. The client will be getting up to ambulate for the first time in three days after being on bedrest since admission to the intensive care unit. Which medication should the nurse administer before the client ambulates?

Nitroglycerin

7. A nurse is performing a primary survey of a client brought to the emergency department . Which of the following would the nurse include ? Select all that apply .

Providing adequate ventilation Assessing neurologic function Establishing airway patency

11. A nurse is establishing a patient's airway. Which action would the nurse perform first?

Repositioning the patient's head

24. A nurse is performing triage at the scene of a building collapse and is using a five-level triage system. Place the categories below in the proper order from most to least immediate.

Resuscitation Emergent Urgent Non urgent Minor

42. The nurse is providing care to a client who was brought to hospital with a opioid overdose. The nurse should expect to include which immediate interventions in the care of this client? Select all that apply.

Monitor naloxone intravenous infusion Apply warming blankets to client Assess the client using the CIWA-A scale

43. A patient with intra-abdominal injuries is brought to the emergency department. Which of the following would most likely alert the nurse to suspect internal bleeding secondary to a ruptured spleen?

Pin in the left shoulder

29. The nurse is teaching students about the West Nile virus. Which statement by the nurse is accurate?

"There is no treatment for West Nile virus infection."

16. The nurse is providing care for a client who is experiencing alcohol withdrawal. The client reports, "I cannot fall or stay asleep." The nurse observes that the client is agitated, having difficulty falling asleep and crying uncontrollably, with confused speech and a tachycardic pulse. Which intervention should the nurse implement first?

Administer lorazepam as ordered by the health care provider

2. Which colloid solution is used to treat tissue hypoperfusion due to hemorrhage

Albumin

14. 14. The nurse is reviewing the medical records of several have the following infections: Patient A: Mumps Patient B: Respiratory Syncytial virus Patient C: Tuberculosis Patent D: Impetigo Patient E: Scabies The nurse would implement contact precautions for which patients? SATA

Patient B, D, E

20. When assessing a client with infectious diarrhea, which of the following would lead the nurse to suspect that the client is experiencing severe dehydration?

Rapid, thready pulse

37. Following a motor vehicle collision, a client is brought to the ED for evaluation and treatment. The client is being assessed for intra-abdominal injuries. The client reports severe left shoulder pain (pain score of 10 on a 1 to 10 scale): The nurse suspects injury to the

Spleen