Exam 1 Prep U Flashcards
The nurse has received a client into care who was admitted with a heroin overdose. The client has a 5-year history of illicit substance use with cocaine, heroine and oxycodone. The client develops a sudden onset of wheezing, restlessness and a cough that produces a frothy, pink sputum. The nurse suspects the client has most likely developed which complication of opioid overdose?
Pulmonary edema
Explanation:
The nurse should suspect the client has developed pulmonary edema, which is frequently seen in clients who abuse/overdose on narcotics. Many drugs — ranging from illegal drugs such as heroin and cocaine to aspirin — are known to cause noncardiogenic pulmonary edema. Pneumonia is not the likely cause given the sudden onset of respiratory symptoms accompanied but coughing up the pink frothy sputum. The client’s history of illicit substance use and now overdose on these drugs should lead the nurse to suspect pulmonary edema is the cause of the sudden onset of these symptoms over congestive heart failure, in which clients have a more gradual onset of respiratory issues. Although a panic attack can manifest in shortness or breath and restlessness, the client would not be wheezing or producing blood tinged sputum with a cough. Panic attacks do, however, have a sudden onset and can cause the client chest pain and a sense of doom.
For a patient who is experiencing multiple injuries, which sequence of medical or nursing management would the nurse identify as a priority?
Establish an airway, control hemorrhage, prevent hypovolemic shock, assess for head injuries.
Explanation:
The goals of treatment are to determine the extent of injuries and to establish priorities of treatment. Priority management includes 1) establishing an airway and ventilation, 2) controlling hemorrhage, 3) preventing hypovolemic shock, and 4) assessing for head and neck injuries.
A homeless client presents to the ED. Upon assessment, the client is experiencing hypothermia. The nurse will plan to complete which priority intervention during the rewarming process?
Attach a cardiac monitor
Explanation:
Continuous electrocardiograph (ECG) monitoring is performed during the rewarming process because cold-induced myocardial irritability leads to conduction disturbances, especially ventricular fibrillation. A urinary catheter should be inserted to monitor urinary output; however, ECG monitoring is the priority. There is no indication for endotracheal intubation. Inotropic medications are contraindicated because they can stimulate the heart and increase the risk for fatal dysrhythmias, such as ventricular fibrillation.
A backcountry skier has been airlifted to the ED after becoming lost and developing hypothermia and frostbite. How should the nurse best manage the client’s frostbite?
Immerse affected extremities in water slightly above normal body temperature.
Explanation:
Frozen extremities are usually placed in a 37°C to 40°C (98.6°F to 104°F) circulating bath for 30- to 40-minute spans. To avoid further mechanical injury, the body part is not handled. Massage is contraindicated.
A client is admitted to the ED after being involved in a motor vehicle accident. The client has multiple injuries. After establishing an airway and adequate ventilation, the ED team should prioritize what aspect of care?
Control the client’s hemorrhage.
Explanation:
After establishing airway and ventilation, the team should evaluate and restore cardiac output by controlling hemorrhage. This must precede neurologic assessments and treatment of skeletal injuries.
Permanent brain injury or death will occur within which time frame secondary to hypoxia?
3 to 5 minutes
Explanation:
If the airway is completely obstructed, permanent brain injury or death will occur within 3 to 5 minutes secondary to hypoxia. Air movement is absent in the presence of complete airway obstruction. Oxygen saturation of the blood decreases rapidly because obstruction of the airway prevents air from entering the lungs. Oxygen deficit occurs in the brain, resulting in unconsciousness, with death following rapidly. The other time frames are incorrect.
An 83-year-old client is brought in by ambulance from a long-term care facility. The client’s symptoms are weakness, lethargy, incontinence, and a change in mental status. The nurse knows that emergencies in older adults may be more difficult to manage for what reason?
Older adults may have an altered response to treatment.
Explanation:
Emergencies in this age group may be more difficult to manage because elderly clients may have an atypical presentation, an altered response to treatment, a greater risk of developing complications, or a combination of these factors. The elderly client may perceive the emergency as a crisis signaling the end of an independent lifestyle or even resulting in death. Stigmatization and nonadherence to treatment are not commonly noted. Older adults do not necessarily have difficulty giving a health history.
When preparing to perform abdominal thrusts on a client with an airway obstruction, which of the following would be most appropriate?
Positioning the hands in the midline slightly above the umbilicus
Explanation:
When performing abdominal thrusts, the nurse would place the thumb side of one fist against the client’s abdomen in the midline slightly above the umbilicus and well below the xiphoid process, grasping the fist with the other hand. Then the nurse would press the fist into the client’s abdomen with a quick inward and upward thrust such that each new thrust should be a separate and distinct maneuver. The unconscious client is positioned on the back. The client who is conscious should be standing or sitting.
A patient with frostbite to both lower extremities from exposure to the elements is preparing to have rewarming of the extremities. What intervention should the nurse provide prior to the procedure?
Administer an analgesic as ordered.
Explanation:
During rewarming, an analgesic for pain is administered as prescribed, because the rewarming process may be very painful. To avoid further mechanical injury, the body part is not handled. Massage is contraindicated.
A nurse is providing an educational program for a group of occupational health nurses working in chemical facilities. Which of the following would the nurse include as the priority in the case of a chemical burn?
Rinsing the area with copious amounts of water
Explanation:
The priority for any chemical burn is to immediately drench the area with running water, unless the chemical is lye or white phosphorus, which should be brushed off the patient. Antimicrobial ointments, sterile dressings, and tetanus prophylaxis are measures instituted later in the course of treatment, depending on the characteristics of the chemical agent and the size and location of the burn.
What is a common source of airway obstruction in an unconscious client?
The tongue
Explanation:
In an unconscious client, the muscles controlling the tongue commonly relax, causing the tongue to obstruct the airway. When this situation occurs, the nurse should use the head-tilt, chin-lift maneuver to cause the tongue to fall back into place. If she suspects the client has a neck injury she must perform the jaw-thrust maneuver.
A nurse is preparing to assist with a gastric lavage for a client who has ingested an unknown poison and is obtunded. To ensure that the tube reaches the stomach, the nurse would measure the distance from the bridge of the nose to which of the following?
Ear lobe and then to the xiphoid process
Explanation:
The nurse measures the tube from the bridge of the nose to the xiphoid process to ensure that the tube reaches the stomach on insertion.
A nurse who is a member of an emergency response team anticipates that several patients with airway obstruction may need a cricothyroidotomy. For which of the following patients would this procedure be appropriate? Select all that apply.
Cricothyroidotomy is used in emergencies when endotracheal intubation is either not possible or contraindicated. Examples include airway obstruction from extensive maxillofacial trauma, cervical spine injury, laryngospasm, laryngeal edema after an allergic reaction or extubation, hemorrhage into neck tissue, and obstruction of the larynx.
The nurse is conducting a secondary survey on a client in the ED. Which action is completed during the secondary survey?
Diagnostic and laboratory testing
Explanation:
Diagnostic and laboratory testing is completed during the secondary survey, along with a complete health history, a head-to-toe assessment, insertion or application of monitoring devices, splinting of suspected fractures, cleansing, closure, and dressing of wounds, and performance of other necessary interventions based on the client’s condition. The other interventions are completed during the primary survey.
A triage nurse in the ED determines that a patient with dyspnea and dehydration is not in a life-threatening situation. What triage category will the nurse choose?
Urgent
Explanation:
A basic and widely used triage system that had been in use for many years utilized three categories: emergent, urgent, and nonurgent. In this system, emergent patients had the highest priority, urgent patients had serious health problems but not immediately life-threatening ones, and nonurgent patients had episodic illnesses.
Which phase of the psychological reaction to rape is characterized by fear and flashbacks?
Heightened anxiety phase
Explanation:
During the heightened anxiety phase, the client demonstrates anxiety, hyperalertness, and psychosomatic reactions, in addition to fear and flashbacks. The acute disorganization phase is characterized by shock, disbelief, guilt, humiliation, and anger. The denial phase is characterized by an unwillingness to talk. The reorganization phase occurs when the incident is put into perspective. Some clients never fully recover from rape trauma.
A client presents to the ED after an unsuccessful suicide attempt. The client is diagnosed with an acetaminophen overdose. The nurse anticipates the administration of which medication?
N-acetylcysteine
Explanation:
Treatment of acetaminophen overdose includes administration of N-acetylcysteine. Flumazenil is administered in the treatment of nonbarbiturate sedative overdoses. Naloxone is administered in the treatment of narcotic overdoses. Diazepam may be administered to treat uncontrolled hyperactivity in the client with a hallucinogen overdose.
A nurse is providing disaster care in an event that is known to involve gamma radiation. When admitting victims of the disaster, what should the nurse do to best reduce victims’ risks of injury?
The nurse should have victims shower and change clothes and irrigate or wash open wounds with soap and water. Cleansing the skin helps to reduce the transition from external to internal radiologic contamination. Infectious microorganisms are not involved, so chlorhexidine is of no particular benefit. Applying PPE over contaminated clothing could worsen the risk for injury. Adequate ventilation is important, but removal of contaminants is the priority because of the increased risk for injury.
The nurse is instructing on bioterrorism agents. Which of the following does the nurse emphasize as an agent which is transmitted from person to person?
Smallpox
Explanation:
Smallpox is highly contagious and caused by a variola virus. Individuals infected with the botulinum toxin and anthrax are not at risk to others; there are no reports of person to person transmission. Varicella, commonly called the chickenpox, is contagious but not a bioterrorism agent.
A client with hypervolemia asks the nurse by what mechanism the sodium–potassium pump will move the excess body fluid. What is the nurse’s best answer?
Active transport
Explanation:
Active transport is the physiologic pump maintained by the cell membrane that results in the movement of fluid from an area of lower concentration to one of higher concentration. Active transport requires adenosine triphosphate (ATP) for energy. The sodium–potassium pump actively moves sodium against the concentration gradient out of the cell, and fluid follows. Passive osmosis does not require energy for transport. Free flow is the natural transport of water. Passive elimination is a filter process carried out in the kidneys.
The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client’s laboratory reports first for an electrolyte imbalance?
A 52-year-old with diarrhea
Explanation:
Electrolytes are in both intracellular and extracellular water. Electrolyte deficiency occurs from an inadequate intake of food, conditions that deplete water such as nausea and vomiting, or disease processes that cause an excess of electrolyte amounts. The 52-year-old with diarrhea would be the client most likely to have an electrolyte imbalance. The orthopedic client will not likely have an electrolyte imbalance. Myocardial infarction clients will occasionally have electrolyte imbalance, but this is the exception rather than the rule.
A nurse is providing care to clients who were involved in an explosion and have sustained secondary blast injuries. Which types of injuries would the nurse expect to find? Select all that apply.
Secondary-phase blast injuries, which result from debris or shrapnel within the bomb or from the scene, include penetrating trunk, skin, and soft tissue injuries, fractures, and traumatic amputations. Head injuries are related to the primary phase of the blast injury. Crush injuries and exacerbations of pre-existing conditions are related to the quaternary phase of the blast injury.
Exposure to gamma radiation can be decreased by completing which action?
Providing distance from radiation source
Explanation:
Gamma radiation can penetrate clothing and skin. Thick clothes do not provide any kind of protection. Lead blocks radiation, but it is safest to limit exposure and to distance oneself from the source.
A nurse is providing care to a client who has been exposed to phosgene vapor. Which nursing diagnosis would the nurse identify as the priority?
Impaired gas exchange related to destruction of the pulmonary membrane
Explanation:
Phosgene vapor is a pulmonary agent that destroys the pulmonary membrane leading to pulmonary edema, with shortness of breath. Therefore, impaired gas exchange would be the priority. Impaired skin integrity would be appropriate for exposure to a vesicant. Disturbed sensory perception, visual would be appropriate for a client exposed to a nerve agent. Decreased cardiac output would be appropriate for a client exposed to a blood agent, such as cyanide, which inhibits aerobic metabolism.
A client is brought to the ED by family members who tell the nurse that the client has been exhibiting paranoid, agitated behavior. What should the nurse do when interacting with this client?
Give the client honest answers about likely treatment.
Explanation:
The nurse should offer appropriate and honest explanations in order to foster rapport and trust. Confinement is likely to cause escalation, as is touching the client. The nurse should not normally engage in trying to convince the client that his or her fears are unjustified, as this can also cause escalation.
A client presents to the ED with a stab wound to the abdomen following an assault. It is suspected that the client has an injury to the pancreas. Which laboratory study is used to detect pancreatic injury?
Serum amylase
Explanation:
Serum amylase is analyzed to detect increasing levels, which suggests pancreatic injury or perforation of the gastrointestinal tract. A white blood cell count is done to detect an elevation. Urinalysis is done to detect hematuria. A hemoglobin and hematocrit test is done to evaluate trends reflecting the presence or absence of bleeding.
A client is diagnosed with hypocalcemia and the nurse is teaching the client about symptoms. What symptom would the nurse include in the teaching?
tingling sensation in the fingers
Explanation:
Tingling or numbness in the fingers is a symptom of hypocalcemia. Flank pain, polyuria, and hypertension are symptoms of hypercalcemia.
A nurse is providing client teaching about the body’s plasma pH and the client asks the nurse what is the major chemical regulator of plasma pH. What is the best response by the nurse?
bicarbonate–carbonic acid buffer system
Explanation:
The major chemical regulator of plasma pH is the bicarbonate–carbonic acid buffer system. The renin–angiotensin–aldosterone system regulates blood pressure. The sodium–potassium pump regulate homeostasis. The ADH-ANP buffer system regulates water balance in the body.
Which condition leads to chronic respiratory acidosis in older adults?
Thoracic skeletal change
Explanation:
Poor respiratory exchange as the result of chronic lung disease, inactivity, or thoracic skeletal changes may lead to chronic respiratory acidosis. Decreased renal function in older adults can cause an inability to concentrate urine and is usually associated with fluid and electrolyte imbalance. A poor appetite, erratic meal patterns, inability to prepare nutritious meals, or financial circumstances may influence nutritional status, resulting in imbalances of electrolytes. Overuse of sodium bicarbonate may lead to metabolic alkalosis.
The nurse has commenced a transfusion of fresh frozen plasma (FFP) and notes the client is exhibiting symptoms of a transfusion reaction. After the nurse stops the transfusion, what is the next required action?
If the nurse suspects a transfusion reaction, the transfusion must be stopped immediately and the nurse’s next action is to ensure the normal saline line is running at a rate that permits administration of IV fluids or medications that are required to treat the reaction. The nurse should ensure IV access is maintained. The “to keep vein open” (TKVO) rate allows the nurse to keep the IV client without the potential to cause fluid volume overload. It would be unsafe for the nurse to remove the peripheral IV because continued access is required for urgent IV administration of medications or fluids to treat the reaction. Obtaining a blood culture at the IV site would be necessary if an infection was suspected. This is not required for a transfusion reaction. Normal saline is the solution of choice when transfusing blood products because there is a risk for incompatibility with all other IV solutions.
The nurse is analyzing the arterial blood gas (ABG) results of a client diagnosed with severe pneumonia. Which of the following ABG results indicates respiratory acidosis?
pH: 7.20, PaCO2: 65 mm Hg, HCO3–: 26 mEq/L
Explanation:
Respiratory acidosis is a clinical disorder in which the pH is less than 7.35–7.40 and the PaCO2 is greater than 40–45 mm Hg and a compensatory increase in the plasma HCO3– occurs. Respiratory acidosis may be either acute or chronic.
The ABG of pH: 7.32, PaCO2: 40 mm Hg, HCO3–: 18 mEq/L indicates metabolic acidosis.
The ABGs of pH: 7.50, PaCO2: 30 mm Hg, and HCO3–: 24 mEq/L indicate respiratory alkalosis.
The ABGs of pH 7.40, PaCO2: 40 mm Hg, and HCO3–: 24 mEq/L indicate a normal result/no imbalance.
A client with suspected inhalation anthrax is admitted to the emergency department. Which action by the nurse takes the highest priority?
Monitor vital signs and oxygen saturation every 15 to 30 minutes.
Explanation:
Monitoring vital signs and oxygen saturation every 15 to 30 minutes takes priority. Suctioning the client as needed to obtain a sputum specimen may be necessary, but assessing the client for changes in his respiratory status takes priority. Assessing intake and output and providing adequate hydration are important steps for liquefying secretions; however, they don’t take priority. Reassuring the client that intubation and mechanical ventilation is temporary is inappropriate. The client may not require intubation and mechanical ventilation; however, if he does, the nurse can’t predict the length of time it may be necessary.
The nurse is caring for a client exposed to a blistering agent. While the nurse is quickly decontaminating the client by showering and bagging all client clothing, what is the nurse simultaneously assessing for?
Respiratory compromise
Explanation:
A person exposed to a blistering agent or vesicant must be decontaminated immediately, with clothing removed and bagged. Irrigation of the victim’s eyes and application of topical analgesia, antibiotics, and lubricants to the skin occur. Simultaneously, the nurse is assessing the respiratory system for airway obstruction because blisters from inhaled toxics can swell obstructing respiratory passages.
A client is to receive hypotonic IV solution in order to provide free water replacement. Which solution does the nurse anticipate administering?
0.45% NaCl
Explanation:
Half-strength saline (0.45%) is hypotonic. Hypotonic solutions are used to replace cellular fluid because it is hypotonic compared with plasma. Another is to provide free water to excrete body wastes. At times, hypotonic sodium solutions are used to treat hypernatremia and other hyperosmolar conditions. Lactated Ringer solution and normal saline (0.9% NaCl) are isotonic. A solution that is 5% NaCl is hypertonic.
A nurse is reviewing a report of a client’s routine urinalysis. Which value requires further
Urine pH of 3.0
Explanation:
Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal and requires further investigation. Urine specific gravity normally ranges from 1.010 to 1.025, making this client’s value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field. Urine should be clear, with color ranging from pale yellow to deep amber.
Inhalation of anthrax mimics which disease process?
Flu
Explanation:
Anthrax symptoms mimic those of the flu, and usually treatment is sought only when the second stage of severe respiratory distress occurs. Burns occur with sulfur mustard. Bronchospasm can occur with phosgene or chlorine. Respiratory distress may occur with cyanide.
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
Explanation:
Types of shock include cardiogenic, neurogenic, anaphylactic, and septic. Of these, the most common cause is hypovolemia.
A 6-year-old is admitted to the ED after being rescued from a pond after falling through the ice while ice skating. What action should the nurse perform while rewarming the client?
Ensuring continuous ECG monitoring
Explanation:
A hypothermic client requires continuous ECG monitoring and assessment of core temperatures with an esophageal probe, bladder, or rectal thermometer. Massage is not performed and bronchodilators would normally be insufficient to meet the client’s respiratory needs.
A patient with frostbite to both lower extremities from exposure to the elements is preparing to have rewarming of the extremities. What intervention should the nurse provide prior to the procedure?
Administer an analgesic as ordered.
Explanation:
During rewarming, an analgesic for pain is administered as prescribed, because the rewarming process may be very painful. To avoid further mechanical injury, the body part is not handled. Massage is contraindicated.
The nurse received a patient from a motor vehicle accident who is hemorrhaging from a femoral wound. What is the initial nursing action for the control of the hemorrhage?
Apply firm pressure over the involved area or artery.
Explanation:
Direct, firm pressure is applied over the bleeding area or the involved artery at a site that is proximal to the wound (Fig. 72-3). Most bleeding can be stopped or at least controlled by application of direct pressure. Otherwise, unchecked arterial bleeding results in death. A firm pressure dressing is applied, and the injured part is elevated to stop venous and capillary bleeding, if possible. If the injured area is an extremity, the extremity is immobilized to control blood loss. A tourniquet is applied to an extremity only as a last resort when the external hemorrhage cannot be controlled in any other way and immediate surgery is not feasible.
The nurse is caring for a client who is being prepared for the placement of a central intravenous line. The nurse recognizes this client requires this type of intravenous access for which reason?
The client requires total parenteral nutrition
Explanation:
For a patient who requires total parenteral nutrition (TPN), a central intravenous line is required due to the length of time the client will require the infusion as well as the nature of the solution itself. A large vein is required to safely infuse TPN. For this reason, a central line is needed. A peripheral intravenous line is safe to used when IV access is required under six days. Beyond this time, either a new peripheral IV will need to be inserted. If it is known in advance that IV treatment will last beyond six days, the client’s health care provider will order the placement of a central intravenous line. Intravenous antibiotics can be administered peripherally unless the course is longer than six days. D5W is an intravenous solution that can be administered either peripherally or centrally. The nature of this IV solution would not determine which type of IV access the client requires.
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.
The primary survey addresses airway, breathing, circulation, and disability. The nurse would establish a patent airway, provide adequate ventilation, evaluate and restore cardiac output, and determine neurologic disability by assessing neurologic function. Obtaining a complete health history and applying monitoring devices are activities involved with the secondary survey.
Which category of triage encompasses clients with serious health problems that are not immediately life threatening?
Urgent
Explanation:
Urgent clients have serious health problems that not immediately life threatening. They must be seen within 1 hour. Emergent clients have the highest priority with life-threatening conditions and they must be seen immediately. Nonurgent clients have episodic illness that can be addressed within 24 hours without increased morbidity. Fast-track clients require simple first aid or basic primary care and may be treated in the ED or safely referred to a clinic or physician’s office.
A nurse is completing her annual cardiopulmonary resuscitation training. The class instructor tells her that a client has fallen off a ladder and is lying on his back; he is unconscious and isn’t breathing. What maneuver should the nurse use to open his airway?
Jaw-thrust
Explanation:
If a neck or spine injury is suspected, the jaw-thrust maneuver should be used to open the client’s airway. To perform this maneuver, the nurse should position herself at the client’s head and rest her thumbs on his lower jaw, near the corners of his mouth. She should then grasp the angles of his lower jaw with her fingers and lift the jaw forward. The head tilt-chin lift maneuver is used to open the airway when a neck or spine injury isn’t suspected. To perform this maneuver the nurse places two fingers on the chin and lifts while pushing down on the forehead with the other hand. The abdominal thrust is used to relieve severe or complete airway obstruction caused by a foreign body. The Seldinger maneuver is a method of percutaneous introduction of a catheter into a vessel.
A client is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the health care provider will perform which of the following actions?
Perform endotracheal intubation.
Explanation:
Endotracheal tubes are used in cases when the client cannot be ventilated with an oropharyngeal airway, which is used in clients who are breathing spontaneously. The jaw thrust maneuver does not establish an airway and cricothyroidotomy would be performed as a last resort.
A client is admitted to the ED after being involved in a motor vehicle accident. The client has multiple injuries. After establishing an airway and adequate ventilation, the ED team should prioritize what aspect of care?
Control the client’s hemorrhage.
Explanation:
After establishing airway and ventilation, the team should evaluate and restore cardiac output by controlling hemorrhage. This must precede neurologic assessments and treatment of skeletal injuries.
A patient brought to the ED by the rescue squad after getting off a plane at the airport is complaining of severe joint pain, numbness, and an inability to move the arms. The patient was on a diving vacation and went for a last dive this morning before flying home. What is a priority action by the nurse?
Ensure a patent airway and that the patient is receiving 100% oxygen.
Explanation:
Decompression sickness, also known as “the bends,” occurs in patients who have engaged in diving (lake/ocean diving), high-altitude flying, or flying in commercial aircraft within 24 hours after diving. Signs and symptoms include joint or extremity pain, numbness, hypesthesia, and loss of range of motion. A patent airway and adequate ventilation are established before all other interventions, as described previously, and 100% oxygen is administered throughout treatment and transport.
A patient is brought to the emergency department. Assessment reveals that the patient is lethargic and diaphoretic and complaining of right upper quadrant pain. Acetaminophen toxicity is suspected and an acetaminophen level is drawn. Which result would the nurse interpret as indicating toxicity for the patient if he weighs 70 kg?
10,500 mg
Explanation:
An acetaminophen level greater than or equal to 140 mg/kg would be considered toxic. For a patient weighing 70 kg, the toxic level would be 9800 mg. A level of 10,500 mg would be greater, thus indicating toxicity.
The nurse is administering 100% oxygen to a patient with carbon monoxide poisoning and obtains a carboxyhemoglobin level. Which level would the nurse interpret as indicating that oxygen therapy can be discontinued?
4%
Explanation:
Oxygen is administered until the carboxyhemoglobin level is less than 5%
A patient has undergone a diagnostic peritoneal lavage. The nurse interprets which result as indicating a positive test?
Evidence of feces
Explanation:
A diagnostic peritoneal lavage is considered positive if there is bile, feces, or food in the specimen, a red blood cell count greater than 100,000/mm3, and a white blood cell count greater than 500/mm3.
A client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later, the nurse identifies which finding as an early sign of shock?
Increasing heart rate
Explanation:
Early in shock, heart rate increases. Inadequate tissue perfusion causes pale, cool, clammy skin (not pale, warm, dry skin). In the early stages of shock, the client’s heart rate will become elevated above normal. In early shock the client’s blood pressure will remain normal, but as shock progresses the mechanisms that regulate blood pressure will not be able to compensate.
A client is brought to the emergency department after being involved in a motor vehicle collision. Which of the following would lead the nurse to suspect internal bleeding?
Delayed capillary refill
Explanation:
If a client exhibits tachycardia, falling blood pressure, thirst, apprehension, cool moist skin, or delayed capillary refill, internal bleeding should be suspected.
The ED staff work collaboratively and follow the ABCDE method to establish and treat health priorities effectively in a client experiencing a trauma. Which action is completed by the nurse when implementing the “D” element of this method?
Assessing the client’s Glasgow Coma Scale score
Explanation:
The primary survey focuses on stabilizing life-threatening conditions. The ED staff work collaboratively and follow the ABCDE (airway, breathing, circulation, disability, exposure) method. While implementing the D element, the nurse determines neurologic disability by assessing neurologic function using the Glasgow Coma Scale and performing a motor and sensory evaluation of the spine. A quick neurologic assessment may be performed using the AVPU mnemonic: A, alert: is the client alert and responsive? V, verbal: does the client respond to verbal stimuli? P, pain: does the client respond only to painful stimuli? U, unresponsive: is the client unresponsive to all stimuli, including pain? The other interventions are not included in this element of the primary survey.
A high school football player is brought to the emergency department after collapsing at practice in extremely hot and humid weather. Which of the following would lead the nurse to suspect that the client is experiencing heat stroke?
Delirium
Explanation:
Manifestations of heat stroke include a temperature of 105 degrees F or greater (40.5 degrees C or greater), anhidrosis (absence of sweating), central nervous system dysfunction (bizarre behavior, delirium, confusion, or coma), hot, dry skin, tachycardia, tachypnea, and hypotension.
A client presents to the ED reporting choking on a chicken bone. The client is breathing spontaneously. The nurse applies oxygen and suspects a partial airway obstruction. Which action should the nurse do next?
If the client can breathe and cough spontaneously, a partial obstruction should be suspected. The client is encouraged to cough forcefully and to persist with spontaneous coughing and breathing efforts as long as good air exchange exists. There may be some wheezing between coughs. If the client demonstrates a weak, ineffective cough, a high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis, the client should be managed as if there were complete airway obstruction. If the client is unconscious, inspection of the oropharynx may reveal the offending object. X-ray study, laryngoscopy, or bronchoscopy also may be performed. There is no indication that an artificial airway is indicated.
A nurse is working as a camp nurse during the summer. A camp counselor comes to the clinic after receiving a snakebite on the arm. What is the first action by the nurse?
Have the patient lie down and place the arm below the level of the heart.
Explanation:
Initial first aid at the site of the snakebite includes having the person lie down, removing constrictive items such as rings, providing warmth, cleansing the wound, covering the wound with a light sterile dressing, and immobilizing the injured body part below the level of the heart. Airway, breathing, and circulation are the priorities of care. Ice, incision and suction, or a tourniquet is not applied.
A nurse who is a member of an emergency response team anticipates that several patients with airway obstruction may need a cricothyroidotomy. For which of the following patients would this procedure be appropriate? Select all that apply.
Cricothyroidotomy is used in emergencies when endotracheal intubation is either not possible or contraindicated. Examples include airway obstruction from extensive maxillofacial trauma, cervical spine injury, laryngospasm, laryngeal edema after an allergic reaction or extubation, hemorrhage into neck tissue, and obstruction of the larynx.
A patient is brought to the ED by a friend, who states that a tree fell on the patient’s leg and crushed it while they were cutting firewood. What priority actions should the nurse perform? (Select all that apply.)
Major soft tissue injuries are dressed and splinted promptly to control bleeding and pain. If an extremity is injured, it is elevated to relieve swelling and pressure.
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.
Signs and symptoms of shock include cool, moist skin (resulting from poor peripheral perfusion), decreasing blood pressure, increasing heart rate, delayed capillary refill, and decreasing urine volume.
The nurse is caring for a client who is agitated and confused. The client is persistently trying to get out of bed and attempted to remove the peripheral IV. The nurse has attempted to re-orient the client; however, this was not effective in de-escalating the client’s agitation. The client yells, “I am going to punch you in the face!” What is the nurse’s next action?
Call security personnel to assist
Explanation:
Clients at risk for harming staff members require specific interventions. It is important to first notification of security and administration of the potential for violence. Although medication and physical restraints maybe required, the nurse will not be able to carry out these interventions in a safe manner independently. The nurse should first call for security personnel to assist, all other interventions can be carried out with the support of trained staff. When a client is agitated and has the potential to be violent, they should not be left unattended. Moving out of the client’s view can lead to further agitation for the client and increase the risk for escalating to violence.
A nurse is establishing a patient’s airway. Which action would the nurse perform first?
Repositioning the patient’s head
Explanation:
Establishing an airway may be as simple as repositioning the patient’s head to prevent the tongue from obstructing the pharynx. Subsequent measures would include abdominal thrusts to dislodge a foreign body, head-tilt chin-lift or jaw-thrust maneuver, or insertion of an artificial airway.
The nurse is caring for a 21-year-old client with a diagnoses of brain death due to injuries sustained in a snowboarding accident. The family has chosen to remove life support measures to allow the client’s death. Upon hearing the family’s decision, what is the nurse’s first action?
Request senior medical staff discuss organ donation
Explanation:
Clients who meet the criteria for past health and current diagnosis of brain death are eligible to donate organs to those on the various transplant lists. This places nurses in a difficult position at times due to their simultaneous obligations to care for a particular client and the family while informing organ donation services of a potential donor. When the diagnosis of brain death is made, it is usually up to the senior medical staff and organ procurement services to approach the family about the possibility of organ donation. The nurse’s next best action is to request a senior physician speak to the family in a timely manner so organs can be harvested and made available as needed. Advance directives are typically in place for clients who are older and for whom death may be expected. In this case, the client is young and death is unexpected, advanced directives are not likely and this question would be inappropriate. Although the nurse should assess for interrupted family process, this is not the nurse’s initial action after hearing the family has decided to remove life support. This nursing assessment goes beyond acute care and into the provision of community health services which the family will need throughout their grieving process.
A client presents to the ED following a chemical burn. The client identifies the source of the burn as white phosphorus. The nurse knows that treatment will include
No application of water to the burn.
Explanation:
Water should not be applied to burns from lye or white phosphorus because of the potential for an explosion or for deepening of the burn. All evidence of these chemicals should be brushed off the client before any flushing occurs.
When assessing a client with suspected carbon monoxide poisoning, which finding would be least reliable?
Cherry red skin color
Explanation:
Skin color can range from pink or cherry-red to cyanotic and pale is not a reliable sign. In clients with carbon monoxide poisoning, central nervous system signs such as headache and confusion predominate. Palpitations also may occur.
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
Explanation:
The nurse should insert the oropharyngeal airway with the tip facing up toward the roof of the mouth until it passes the uvula and then rotate the tip 180 degrees so that the tip is pointed down toward the pharynx. This displaces the tongue anteriorly, and the patient then breathes through and around the airway.`
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?
The location of the injuries and site of bleeding determine which pressure point to use. In this case, the patient’s bleeding is proximal to the temporal artery; therefore, pressure should be applied to this area, as shown in option A. If the patient was bleeding from the lower portion of the face, pressure would be applied to the facial artery, as in option B. The carotid artery would be used to control bleeding proximal to that area. The subclavian artery would be used to control bleeding proximal to it, such as the lower neck and shoulder area.
A client present to the ED following a work-related injury to the left hand. The client has an avulsion of the left ring finger. Which correctly describes an avulsion?
Tissue tearing away from supporting structures
Explanation:
An avulsion is described as a tearing away of tissue from supporting structures. A laceration is a skin tear with irregular edges and vein bridging. Abrasion is denuded skin. A cut is an incision of the skin with well-defined edges, usually long rather than deep.
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.
Explanation:
The location of pain can indicate certain types of intra-abdominal injuries. Pain in the left shoulder is common in a client with bleeding from a ruptured spleen, whereas pain in the right shoulder can result from laceration of the liver.
With which condition should the nurse expect that a decrease in serum osmolality will occur?
Kidney failure
Explanation:
Failure of the kidneys results in multiple fluid and electrolyte abnormalities including fluid volume overload. If renal function is so severely impaired that pharmacologic agents cannot act efficiently, other modalities are considered to remove sodium and fluid from the body.
A 64-year-old client is brought in to the clinic with thirsty, dry, sticky mucous membranes, decreased urine output, fever, a rough tongue, and lethargy. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for this client?
No, sodium intake should be restricted.
Explanation:
The symptoms and the high level of serum sodium suggest hypernatremia, (excess of sodium). It is necessary to restrict sodium intake. Salt tablets and sodium chloride IV can only worsen this condition but may be required in hyponatremia (sodium deficit). Hypotonic solution IV may be a part of the treatment but not along with the salt tablets.
The nurse is caring for a client with a serum sodium concentration of 113 mEq/L (113 mmol/L). The nurse should monitor the client for the development of which condition?
Confusion
Explanation:
Normal serum concentration ranges from 135 to 145 mEq/L (135–145 mmol/L). Hyponatremia exists when the serum concentration decreases below 135 mEq/L (135 mmol/L). When the serum sodium concentration decreases to <115 mEq/L (<115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, seizures, and death, may occur. General manifestations of hyponatremia include poor skin turgor, dry mucosa, headache, decreased saliva production, orthostatic fall in blood pressure, nausea, vomiting, and abdominal cramping. Neurologic changes, including altered mental status, status epilepticus, and coma, are probably related to cellular swelling and cerebral edema associated with hyponatremia. Hallucinations are associated with increased serum sodium concentrations.
A nurse correctly identifies a urine specimen with a pH of 4.3 as being which type of solution?
Acidic
Explanation:
Normal urine pH is 4.5 to 8.0; a value of 4.3 reveals acidic urine pH. A pH above 7.0 is considered an alkaline or basic solution. A pH of 7.0 is considered neutral.
A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3–, 24 mEq/L. What do these values indicate?
Respiratory alkalosis
Explanation:
A client with pneumonia may hyperventilate in an effort to increase oxygen intake. Hyperventilation leads to excess carbon dioxide (CO2) loss, which causes alkalosis — indicated by this client’s elevated pH value. With respiratory alkalosis, the kidneys’ bicarbonate (HCO3–) response is delayed, so the client’s HCO3– level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3– level is normal, this imbalance has no metabolic component. Therefore, the client is experiencing respiratory alkalosis.
A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis?
The client had a liver transplant 2 years ago.
Explanation:
A history of immunocompromised status, such as that which occurs with liver transplantation, places the client at a higher risk for contracting tuberculosis. Other risk factors include inadequate health care, traveling to countries with high rates of tuberculosis (such as southeastern Asia, Africa, and Latin America), being a health care worker who performs procedures in which exposure to respiratory secretions is likely, and being institutionalized.
A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3–) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance?
Metabolic alkalosis
Explanation:
A pH over 7.45 with a HCO3– level over 26 mEq/L indicates metabolic alkalosis. Metabolic alkalosis is always secondary to an underlying cause and is marked by decreased amounts of acid or increased amounts of base HCO3–. The client isn’t experiencing respiratory alkalosis because the PaCO2 is normal. The client isn’t experiencing respiratory or metabolic acidosis because the pH is greater than 7.35.
An elderly client takes 40 mg of furosemide twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use?
Hypokalemia
Explanation:
Hypokalemia (potassium level below 3.5 mEq/L) usually indicates a deficit in total potassium stores. Potassium-losing diuretics, such as furosemide, can induce hypokalemia. Hyperkalemia refers to increased potassium levels. Loop diuretics can bring about lower sodium levels, not hypernatremia. Furosemide does not affect phosphorus levels.
Which of the following may be the first sign of respiratory acidosis in anesthetized patients?
Ventricular fibrillation
Explanation:
Ventricular fibrillation may be the first sign of respiratory acidosis in anesthetized patients. Clinical signs in acute and chronic respiratory acidosis include sudden hypercapnia that can cause increased pulse and respiratory rate, mental cloudiness, dull headache or weakness.
A nurse caring for a patient with metabolic alkalosis knows to assess for the primary, compensatory mechanism of:
b. Increased PaCO2.
Explanation:
The respiratory system compensates by decreasing ventilation to conserve CO2 and increase the PaCO2.
Kusmal breathing- hold onto CO2 which is acidic and will help lower blood pH
Which of the following arterial blood gas results would be consistent with metabolic alkalosis?
Serum bicarbonate of 28 mEq/L
Explanation:
Evaluation of arterial blood gases reveals a pH greater than 7.45 and a serum bicarbonate concentration greater than 26 mEq/L.
A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3??’) of 26 mEq/L. What disorder is indicated by these findings?
Respiratory alkalosis
Explanation:
Respiratory alkalosis results from alveolar hyperventilation. It’s marked by a decrease in PaCO2 to less than 35 mm Hg and an increase in blood pH over 7.45. Metabolic acidosis is marked by a decrease in HCO3? to less than 22 mEq/L, and a decrease in blood pH to less than 7.35. In respiratory acidosis, the pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg. In metabolic alkalosis, the HCO3? is greater than 26 mEq/L and the pH is greater than 7.45.
A client is diagnosed with hypocalcemia and the nurse is teaching the client about symptoms. What symptom would the nurse include in the teaching?
tingling sensation in the fingers
Explanation:
Tingling or numbness in the fingers is a symptom of hypocalcemia. Flank pain, polyuria, and hypertension are symptoms of hypercalcemia.
Oral intake is controlled by the thirst center, located in which of the following cerebral areas?
Hypothalamus
Explanation:
Oral intake is controlled by the thirst center located in the hypothalamus. The thirst center is not located in the cerebellum, brainstem, or thalamus.
A patient is admitted with severe vomiting for 24 hours as well as weakness and “feeling exhausted.” The nurse observes flat T waves and ST-segment depression on the electrocardiogram. Which potassium level does the nurse observe when the laboratory studies are complete?
2.5 mEq/L
Explanation:
Symptoms of hypokalemia (<3.0 mEq/L) include fatigue, anorexia, nausea and vomiting, muscle weakness, polyuria, decreased bowel motility, ventricular asystole or fibrillation, paresthesias, leg cramps, hypotension, ileus, abdominal distention, and hypoactive reflexes. Electrocardiogram findings associated with hypokalemia include flattened T waves, prominent U waves, ST depression, and prolonged PR interval.
A client seeks medical attention for an acute onset of severe thirst, polyuria, muscle weakness, nausea, and bone pain. Which health history information will the nurse report to the health care provider?
Takes high doses of vitamin D
Explanation:
Hypercalcemia can affect many organ systems and symptoms occur when the calcium level acutely rises. Hypercalcemia crisis refers to an acute rise in the serum calcium level. Severe thirst and polyuria are often present. Additional findings include muscle weakness, nausea, and bone pain. Excessive ingestion of vitamin D supplements may cause excessive absorption of calcium. Therefore, the nurse would report this finding to the health care provider. The client’s symptoms are not associated with occasional alcohol intake, a high-fiber eating plan, or the client’s employment status. These findings would not need to be reported.
Which is the most common cause of symptomatic hypomagnesemia?
Alcoholism
Explanation:
Alcoholism is currently the most common cause of symptomatic hypomagnesemia. Intravenous drug use, sedentary lifestyle, and burns are not the most common causes of hypomagnesemia.
A client experiencing a severe anxiety attack and hyperventilating presents to the emergency department. The nurse would expect the client’s pH value to be
7.50
Explanation:
The patient is experiencing respiratory alkalosis. Respiratory alkalosis is a clinical condition in which the arterial pH is >7.45 and the PaCO2 is <38 mm Hg. Respiratory alkalosis is always caused by hyperventilation, which causes excessive “blowing off” of CO2 and, hence, a decrease in the plasma carbonic acid concentration. Causes include extreme anxiety, hypoxemia, early phase of salicylate intoxication, gram-negative bacteremia, and inappropriate ventilator settings.
The weight of a client with congestive heart failure is monitored daily and entered into the medical record. In a 24-hour period, the client’s weight increased by 2 lb. How much fluid is this client retaining?
1 L
Explanation:
A 2-lb weight gain in 24 hours indicates that the client is retaining 1L of fluid.
Which is considered an isotonic solution?
0.9% normal saline
Explanation:
An isotonic solution is 0.9% normal saline (NaCl). Dextran in normal saline is a colloid solution, 0.45% normal saline is a hypotonic solution, and 3% NaCl is a hypertonic solution.
A priority nursing intervention for a client with hypervolemia involves which of the following?
Monitoring respiratory status for signs and symptoms of pulmonary complications.
Explanation:
Hypervolemia, or fluid volume excess (FVE), refers to an isotonic expansion of the extracellular fluid. Nursing interventions for FVE include measuring intake and output, monitoring weight, assessing breath sounds, monitoring edema, and promoting rest. The most important intervention in the list involves monitoring the respiratory status for any signs of pulmonary congestion. Breath sounds are assessed at regular intervals.
The nurse is caring for a client with a serum potassium concentration of 6.0 mEq/L (6.0 mmol/L) and a fluid volume excess. The client is ordered to receive oral sodium polystyrene sulfonate and furosemide. What other order should the nurse anticipate giving?
Discontinue the intravenous lactated Ringer solution.
Explanation:
The lactated Ringer intravenous (IV) fluid is contributing to both the fluid volume excess and the hyperkalemia. In addition to the volume of IV fluids contributing to the fluid volume excess, lactated Ringer solution contains more sodium than daily requirements, and excess sodium worsens fluid volume excess. Lactated Ringer solution also contains potassium, which would worsen the hyperkalemia.
To evaluate a client for hypoxia, the physician is most likely to order which laboratory test?
Arterial blood gas (ABG) analysis
Explanation:
Red blood cell count, sputum culture, total hemoglobin, and ABG analysis all help evaluate a client with respiratory problems. However, ABG analysis is the only test that evaluates gas exchange in the lungs, providing information about the client’s oxygenation status.
