Exam1a Flashcards
-Q: The nurse is setting up a patient controlled PCA containing morphine for a client who has multiple fractures from being hit by a car. The Nurse programs a lock. Into the pump. An important aspect of patient education regarding use of the PCA pump involves which of the following points? SATA.
- a small amount of morphine will be given intravenously
- The nurse will be assessing respiratory status and sedation level
-Q: The nursing instructor is preparing to teach a class on chest trauma. Which information should be included when describing a tension pneumothorax?
Allows air into the plural space, but prevents it from escaping.
-Q: which situation would most likely initiate a critical incident, stress management staff meeting by the nurse manager of the ED?
Death of a four month old from shaken baby syndrome.
– Q: an ED nurse is treating a three-year-old child who has ingested a corrosive substance while left alone at home.
Assess for airway obstruction
– Q: a client who is experiencing panic, erratic and violent behavior, and psychosis is brought to the ED by police.
Gaining control of the situation
– Q: the nurses caring for a client client who was admitted due to hypervolemic shot from hemorrhage. The nurse should expect to initially administer what fluids?
0.9% normal saline
-Q: the nurses assisting in rewarming a patient diagnosed with hypothermia whose temperature is 88°. Which of the following complications should the nurse look for the patient during the rewarming process?
Ventricular fibrillation
-Q: the nurse is caring for patient who has a laceration of the forearm. Which intervention should the nurse perform first?
Assess tetanus toxoid vaccination status
-Q: At triage nurse is working in the ED. Which of the following clients should the nurse consider as having the highest priority?
A 56-year-old who is diaphoretic with substernal chest pain
-Q: the nurse develops the nursing diagnosis of alteration and comfort related to fever and chills in a patient with septicemia. Which of the following interventions?
Administer an antibiotic every four hours, PRN
-Q: The nurse is caring for a patient who has suffered from a myocardial infarction, experiencing angina and sinus tachycardia. The nurse should anticipate which of the following orders. SATA.
- Provide supplemental oxygen
- administer 1 L of NS over one hour
- administer morphine
- maintain bedrest
-Q: A client has come to the ED reporting she has been sexually assaulted. Which of the following orders with the nurse anticipate at this time? SATA
- Pregnancy test
- forensics exam
- prophylactic antibiotic
maybe one more?
-Q: A client is brought to the ED for an allergic reaction to shellfish eaten at a local restaurant. The client is experiencing wheezing and swelling of the tongue. Which medication with the nurse expect to administer first?
Epinephrine
-Q: A patient with a diagnosis of decompression sickness is being monitored by the ED nurse. Which of the following nursing interventions would be appropriate to prevent complications?
Keep the head of the bed and supine position
-Q: the nurse is preparing to teach a class on Lyme disease. Which of the following should be included in the presentation?
Stage three can present more than a year after the bite.
-Q: The ED nurse is caring for a client who has experience acetaminophen overdose. The nurse prepares to administer which of the following antidote?
ACETYLCYSTEINE
-Q: A client is admitted to the ED with the BP of 94/78, pulse 110, respirations, 22, temperature 97.1 and cold, claiming skin. Which nursing intervention takes priority?
Establish an iv line with an 18 gauge Angiocath
-Q: a client who was brought to the ED after a gunshot wound. Which of the following manifestations would alert the nurse to the initial sign of hypovolemic shock?
Increase traumatic blood loss
-Q: The triage nurse is working in the ED. Which of the following clients who present to the ED should be seen first?
A client who reports that she has been raped
-Q: A woman comes into the emergency room with her boyfriend who has abused her. The father of the girl points gun at him and says I told you I was going to kill you if you touched her again. What should the nurse do?
Get out of the line of fire and protect yourself
-Q: The family of a deceased client asked the ED nurse if they can see their family member. The most therapeutic response to the families request would be what?
I’ll see what I can arrange so you can see and spend time with your loved one
-Q: the nurses monitoring a patient in shock who is receiving rapid IV infusions for fluid resuscitation. The patient is experiencing shortness of breath, decreased pressure, absent bowel, sounds, and oligoria. Which of the following conditions with the Nurse suspect?
Abdominal compartment syndrome
-Q: An elderly old man arrives in the ED from the nursing home with confusion and lethargy. Vital signs are temperature 100.5, pulse 104, respirations, 28, blood pressure, 99/58, oxygen, 89% and pale, mottled skin. The cardiac monitor shows atrial fibrillation. The nurse recognizes the symptoms as being most consistent with which of the following?
Septic shock
-Q: the nurse is preparing to administer intravenous potassium to a client with severe hypokalemia from a heat stroke. Which of the following nursing actions is appropriate?
Verifying adequate urine output
-Q: the nurse manager is conducting a review class on shock for a group of newly hired ICU nurses.
The patient may become uncooperative and combative in the compensatory phase, so safety is paramount
-Q: Which of the following is important for the nurse to do when administering CROTALIDAE POLYVALENT immune FAB anti-venom, CROFAB, to a snakebite?
Administer CIMETIDINE prior to the infusion
-Q: the nurse is caring for a patient diagnosed with septicemia. Which of the following objective data would prompt the nurse to call the healthcare provider?
You’re an output of 50 mL over the last two hours
-Q: a client is brought to the emergency department after an automobile accident. The client has multiple abdominal contusions with internal bleeding and is required emergency surgery. Which of the following information reported by the client would prompt the nurse to notify the OR staff right away?
Last meal was one hour ago
-Q: The ED nurse is precepting a student and is providing information about different types of pneumothorax. Which patient with the nurse identify as the greatest risk for developing a spontaneous pneumothorax?
a patient with chronic severe emphysema.
-Q: the nurses preparing to administer an antidote for a patient who was experienced an overdose of heparin from a medication error.
Have equipment and personnel ready for possible resuscitation
-Q: the nurses assessing a client after a non-fatal drowning event at a beach. Which assessment finding would require immediate intervention?
The onset of pink frothy sputum
-Q: the nurse is caring for a client receiving a norepinephrine infusion through a peripheral IV for severe hypertension related to neurogenic shock. Which of the following severe complications that can occur?
Extravasation of infusion site
-Q: the nurse is caring for a patient with frostbite of the feet. Which of the following interventions is appropriate for the nurse?
Soak the feet and warm water
-Q: the nurse is preparing to administer diazepam to a 10-year-old with seizures from a near drowning event. The child weighs 66 pounds. What is the safe dosage for this child?
4.5–6 mg
-Q: The nurse in the ED is assessing a client who has suspected flail chest. Which of the following findings should the nurse expect? SATA?
- Paradox chest movement
- Respiratory acidosis
- Atelectasis
-Q: a client is admitted to the ED with blunt chest trauma from a car accident. Which of the following manifestations would indicate to the nurse pneumothorax?
Tracheal shift and central cyanosis
-Q: a nurse in the ED is receiving a client after an automobile accident. The client is complaining of severe abdominal pain, has cool, diaphoretic, skin tachycardia, and extremely anxious. The nurse notes that the client has a large hematoma on the left flank. What is the nurses initial action?
Start an IV with a large bore Angiocath.
-Q the nurses administering PHENYLEPHRINE to a patient experiencing shock with severe hypotension. The nurse monitors for which of the following?
Vasoconstriction
and
elevation of blood pressure
-Q: a patient brought to the ED by EMS for an injury to the hand after it was caught in a wood grinder. The nurse would describe the wound type as what?
Avulsion
-Q: A 3yo patient with muscular dystrophy is brought to the ED wheezing and coughing from swallowing a piece of a toy.
Monitor for possible side effects from anesthesia
-Q: A client is admitted to the ED with an elevated, vital signs and probable sepsis has the following orders from the nurse practitioner. Which order is likely?
Obtained blood cultures
-Q: a public health nurse is teaching a class on environmental safety to a group at a senior center. To assist the audience and understanding heat exhaustion. SATA.
- Syncope
- Diaphoresis
- Headache
- Tachycardia
-Q: A client is admitted to the emergency room for alcohol withdrawal syndrome. The client has received intravenous lorazepam to control agitation, and hallucinations. What interventions is most important for the nurse to initiate?
Vital signs every 30 minutes
Q: Client has been admitted to the Neuro ICU with the spinal cord injury at level C4 in neurogenic shock. Which of the following signs and symptoms with the nurse suspect? SATA
- Bradycardia
- Hypotension
- Warm, dry skin
-Q: A client returns to the ED after initially being seen eight hours ago for tibia/fibula fracture from a four wheeler accident. The client has a lower leg cast and complaining of pain, tightness, PARASTHESIA, and trouble moving his toes. The nurse recognizes these signs and symptoms as which of the following?
Compartment syndrome
-Q: the nurses caring for a patient who has suffered a crush in injury from a condominium collapse. Which of the following manifestations would alert the nurse the patient the patient may be experiencing RHABDOMYOLYSIS as a complication?
Malaysia
muscle weakness
dark amber urine
-Q: the nurse is caring for a client who presented to the ED with the fracture, forearm and multiple bruises on the face and neck. The clients partner is there as well. Which of the following interventions would be appropriate for the nurse to perform next?
Request that the partner wait outside the exam room
-Q: which of the following is the priority and intervention of the nurse caring for a client who comes in the ED with hypovolemic shock?
Fluid resuscitation
-Q: the ICU nurse is monitoring a patient with sepsis from complications of multiple organ dysfunction syndrome. The nurse looks for which symptoms?
Dyspnea
