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Terms in this set (148)
Which condition would the nurse keep in mind while performing a rewarming procedure for a client with severe hypothermia? The client should be monitored for a after drop during rewarming. When performing a rewarming procedure with warmed intravenous fluids for a client with severe hypothermia, which core temperature is lowest temperature in which the nurse would stop rewarming the client?
Which action would the nurse take to decrease the risk of ventilator-associated pneumonia (VAP) for a client receiving mechanical ventilation? Elevate the he of the bed to at least 30 degress. In which order would the nurse implement the steps for cooling a client with heatstroke who has a a body temperature of 104°F (40°C) so that breathing and circulation are not impaired?
- Remove Clients clothing
- Palce Ice packs on the clients neck
- immerse the client in cold water
- Fan the client rapidly to aid in cooling by evaporation Which client activity warrants the highest priority for education about health promotion to prevent he and neck cancer? Select all that apply. One, some, or all responses may be correct.
- Chews Tobacco
- Multiple sex partners
- History of alcohol abuse for 5 years Which intervention would be a priority for the nurse to implement topromote client safety directly after esophagogastroduodenoscopy (EGD)? Select all that apply. One, some, or all responses may be correct.
- Positioning to prevent aspiration
- Monitoring for signs of perforation Which nursing intervention would be the priority for an older client with depression who is prescribed a tricyclic antidepressant? REquest that the health care provider change the medication 1.Using a jaw-thrust maneuver to establish an airway Correct 2.Providing bag-valve-mask (BVM) ventilation Correct 3.Palpating for the presence of a rial pulse Correct 4.Monitoring systolic blood pressure Correct 5.Assessing the score of eye opening Correct 6.Removing the clothing with scissors
major injuries with yellow tag Which condition in a client with carbon monoxide poisoning would be given priority nursing care? Cardiopulmonary instability In which order based on priority would the nurse perform interventions for a severely traumatized client with difficulty breathing because of debris in the mouth, external hemorrhaging, symptoms of severe hypoglycemia, and bruises on the skin?
- Remove the debris from the mouth (Airway) 2.Apply pressure bandages to the bleeding areas
- minister intravenous glucose
- apply bandage on the bruises Which client would the nurse categorize in an emergent level based on condition according to the 3- tiered triage system? Client A. Respiratory Distress The client with which change in vital signs measurements would be treated first to ensure safety? Client B. = Vital are RR: 17--> 10 HR: 72-->120 bpm Which client would the nurse classify as requiring immediate care based on condition and stability?
- Overdoes with brypnea 2. Cardiac arrest 3. Chest pain due to ischemia 4. Hip Fracture ANswer Client B= Cardiac Arrest
The emergency department nurse would provide immediate care based on priority to the client with which condition? Repeated tonic-clonic seizures Which client would the triage nurse classify as requiring the least priority of care? client D, foreign body aspiration/pneumonia Once a client mitted with shock secondary to severe gastrointestinal (GI) bleeding is stabilized, which action would the nurse take? Take a blood sample for laboratory test Based on laboratory values, which client's needs would the nurse dress first? Client B: A1C%: 6.8Fasting plasma glucose level (mg/dL): 130Two-hour plasma glucose level (mg/dL): 200 Which client condition would the triage nurse classify as needing immediate care? Select all that apply. One, some, or all responses may be correct.
- ACtive hemorrhage
- Substernal chest pain Which client condition would the triage nurse provide care for first?
Aspirate the medication from a short peripheral catheter When the nurse is caring for a client who h an open cholecystectomy, which assessment finding most indicates the need for action by the nurse? Decreased breath sounds at lung base Which statement me by the nurse regarding the prevention of human immunodeficiency virus (HIV) transmission by health care workers is correct? Select all that apply. One, some, or all responses may be correct.
- "If I perform exposure-prone procedures, I should know my HIV antibody status."
- "I should identify exposure-prone procedures by institutions where they are performed."
- "If I have exudative lesions or weeping dermatitis, I should not perform direct client care or handle client care equipment." Using the Five-Level Emergency Severity Index (ESI), which client would the triage nurse designate as needing to receive prioritized care when triaging clients in the emergency department? A school-age client with asthma presenting with dyspnea Which ophthalmic conditions can cause a client to have photophobia? Select all that apply. One, some, or all responses may be correct.
- Chalazion
- Trachoma
- Keratoconjuntivitis sicca
Which nursing action would be the priority when providing care for a trauma client with a penetrating wound after the completion of the secondary survey?
- Documenting the clients care
- ministering tetanus prophylaxis to the client When a client has difficulty swallowing after a stroke, which action by the nurse would be most important in preventing pneumonia? Having suction available during meals Which statement me by a new nurse would indicate to the nurse mentor that ditional teaching is needed regarding emergency treatment procedures for the local complication of intravenous therapy involving thrombosis? Select all that apply. One, some, or all responses may be correct. "I should lower the extremity of the client." "I should apply warm compresses to stabilize the clot." "I should apply cold compresses to decrease the blood flow." "I should use low-dose thrombolytic agent that can lyse the clot." "I should stop the infusion but keep the short peripheral catheter in pla
- Should lower the extremity of the client
- I should apply warm compress to stabilize the clot
- I should stop the infusion but keep the short peripheral catheter in place Which action by a client with asthma indicates that the client teaching about use of a peak flow meter has been effective? Uses a quick relief inhaled medication when peak flow is in yellow zone
Which action would the nurse implement for a client who has overdosed on barbiturates? Select all that apply. One, some, or all responses may be correct. 1.Maintain Airway
- Give activated charcoal
- Give intravenous fluids Which problem would the nurse rank as high priority when planning care for a group of clients? Select all that apply. 1.Complaints of chest pain following ambulation in the hallway 2.Decreased levels of consciousness after an automobile accident 3.Respiratory depression after narcotic pain medication ministration Which intervention would be the priority for the nurse to implement when providing care to a child brought to the emergency department with partial and full thickness burns of the lower extremities? 4.Starting an intravenous (IV) line with a large-bore catheter Which is the priority nursing action immediately after the insertion of a subclavian central venous access catheter for a client who is to begin total parenteral nutrition (TPN)? Auscultate the lung to evaluate breath sounds We have an expert-written solution to this problem! Which statement by a student indicates teaching about the ministration of total parenteral nutrition (TPN) via a central venous access device/catheter was effective? TPN is typically ministered continuously, not intermittently.
Which medication would the nurse anticipate developing a teaching plan for when a client reports becoming panicked and having an irrational fear of talking in public? Alprazolam Which action would the nurse take when a client arrives for an influenza vaccination and reports a low- gre fever with a cough? Check the temperature and current history. Which action is contraindicated in the care of a client prescribed chlorpromazine for schizophrenia who experiences involuntary choreoathetotic movements of the tongue and face? minister diphendrymine While reviewing the laboratory reports on a client with bipolar disorder, the nurse finds the client's lithium levels are 1.2 mEq/L (1.2 mmol/L). Which nursing intervention would be most appropriate in this client? continue ministering the drug The health care provider has prescribed an intravenous piggyback (IVPB) of 1200 mg vancomycin, which must be ded to 50 mL of 5% dextrose in water (D W). The nurse has a solution contains 1 gram of vancomycin per 3 mL. How much antibiotic solution will be ded to the 50 mL of D W? Record your answer using one decimal place. m
Establishing an IV lines A pregnant client is mitted with abdominal pain and heavy vaginal bleeding. Which is the immediate nursing action? Establishing IV access We have an expert-written solution to this problem! A few hours after being mitted to the hospital with a diagnosis of inevitable abortion, a client at 16 weeks' gestation begins to experience a bearing-down sensation and suddenly expels the products of conception in the bed. Which would be the nurse's immediate action? Monitor and measure vaginal bleeding We have an expert-written solution to this problem! Which of these clinical manifestations would the nurse report to the healthcare provider immediately in a client with preeclampsia? Severe Heache Which nursing assessment would performed by a nurse before ministering intravenous (IV) infusion of potassium chloride (KCl) 40 mEq in 100 mL of 5% dextrose and water to be infused over 2 hours? Select all that apply. One, some, or all responses may be
- Urinary output
- Last serum potassium level
- Patency of the IV access Which personal protective equipment would the nurse use when giving a bath to a client with acquired immunodeficiency syndrome (AIDS), pneumonia, and AIDS wasting syndrome with fecal incontinence? Select all that apply. One, some, or all responses may be correct.
- Goggles
- Surgical Mask
- Gown
- Gloves Which personal protective equipment would the nurse use when giving a bath to a client with acquired immunodeficiency syndrome (AIDS), pneumonia, and AIDS wasting syndrome with fecal incontinence? Select all that apply. One, some, or all responses may be correct.
- Sexual Dysfunction
- Insomnia and restlessness
- Urinary Frequency A client is to receive an antibiotic by intravenous piggyback (IVPB). The antibiotic is available in 50 mL of solution to infuse in 20 minutes. The drop factor of the IV set is 15 gtt/mL. The nurse will set the piggyback to flow at how many drops per minute? Record your answer using a whole number. 38 We have an expert-written solution to this problem! Which verse effect would prompt the nurse ministering a course of aminoglycoside treatment to a client with Klebsiella infection to hold treatment and contact the health care provider? Select all that apply. One, some, or all responses may be correct.
- Vertigo
- Tinnitus
- Dizziness
- Persistent HA
- Verify the number of doses in the locked cabinet before ministering the prescribed dose Which statement by a client with rheumatoid arthritis prescribed ibuprofen 800 mg by mouth three times a day indicates that the nurse's education about the medication's side effects was effective? Select all that apply. One, some, or all responses may be correct.
- I need to report any dark tarry stools
- I will need to stop taking this medication before any scheduled surgery The nurse reviews the serum laboratory values of a client. The nurse suspects hypofunctioning of the renal gland based on which results? Select all that apply. One, some, or all responses may be correct.
- Increased Calcium
- Decreased Cortisol
- Decreased Sodium The nurse is providing discharge instructions for a client receiving unsealed rioactive isotope. Which actions me by the client indicate an understanding of the instructions provided? Select all that apply. One, some, or all responses may be correct.
- Avoids contact with pregnant women
- Takes laxatives 3 days after tx
- Washes clothes separately from others Which strategies will promote safety and quality of client care on the unit? Select all that apply. One, some, or all responses may be correct.
- Communicate with clarity and precision when designing multidisciplinary plans of care.
- Create a safety huddle so all health care professionals are aware of the clinical objectives.
- Conduct communication simulations to increase knowledge about expertise of other health care disciplines. The nurse manager is educating a group of nurses regarding older ults and the risk for suicide. Which factors would be included in this presentation? Select all that apply. One, some, or all responses may be correct.
- Loss of Independence
- Chronic health conditions
- Access to many medication We have an expert-written solution to this problem! The nursing staff used seclusion for a client due to behavior that placed other clients and staff at risk for harm. Which intervention would the nurse perform first when reintegrating the client into the unit? Discuss behavior that necessitated seclusion We have an expert-written solution to this problem! The nurse educator is presenting to a group of nurses about the use of de-escalatory techniques. Which actions would the nurse include in the presentation? Select all that apply. One, some, or all responses may be correct.
- Identify client needs
- Determine stressors and triggers
- Refrain from arguing with the client
Which activities would the nurse perform to meet the client's safety and security needs based on Maslow's hierarchy of needs? Select all that apply. One, some, or all responses may be correct. Positioning the bed in a low position and keeping the side rails up Monitoring vital signs, such as blood pressure to decrease the risk of falls Observing a client who has suicidal tendencies to prevent verse incidents Place these nursing assessment questions in the appropriate order to best ensure safety for a client with suicidal ideations. "Are you thinking about hurting yourself?" "Have you decided on a plan to harm yourself?" " What is your plan for killing yourself?" "How would you get what you need to end your life?" Which beliefs or situations are barriers to effective delegation by the registered nurse (RN)? Select all that apply.One, some, or all responses may be correct. The nurse believes delegation is too time-consuming. The nurse lacks confidence in the delegatee's abilities. The nurse overburdens the delegatee with too many tasks.
Which nursing action is most important for a client with urinary retention related to benign prostatic hyperplasia who has a secondary diagnosis of delirium related to urosepsis and a prescription for the insertion of an indwelling urinary retention catheter? Determine whether any unsafe behavior pattern exist Which intervention would be in the plan of care of a client with kidney dysfunction who is about to undergo renal testing using a contrast medium? Select all that apply. One, some, or all responses may be correct.
- Assessing the client for a history of cirrhosis
- Asking the client about shellfish allergies
- Evaluating the cleints hydration status by checking BP and RR Which action by nursing staff during a facility fire drill requires correction? Use an ABC extinguisher to put out a small trash can fire before evacuation Which conditions of clients who have been exposed to cold temperatures in a snowstorm put them at a high risk of sustaining cold injuries? Select all that apply. One, some, or all responses may be correct.
- Hypoglycemia
- Opiod medication use
- A heavy smoker for years Which potential life-threatening conditions would be considered during the primary survey for a client mitted after a fire accident? Select all that apply. One, some, or all responses may be correct.
- Shock
- Inhalation injury
- Direct cardiac injury
