The nurse is assessing a client's burn for the zones of injury. Which of the following will the nurse NOT assess in the client at this time? - correct
... [Show More] answer Zone of Eschar
Which of the following will the nurse most likely assess in a client diagnosed with a second-degree burn? - correct answer Pain and blisters
The nurse, caring for a client with severe burns, realizes that the client's care will progress through specific periods of treatment EXCEPT: - correct answer stabilization
A client who has experienced a burn is in the emergent phase of treatment that usually occurs during which of the following periods? - correct answer 24 to 48 hours
A client is beginning the initial treatment of a major burn in the emergency room. Which of the following interventions would NOT be completed? - correct answer Giving oral medications for pain management
The formula used to calculate the volume of IV fluid required for fluid resuscitation of a client receiving care in the first 24 hours after a burn is - correct answer 2 to 4 mL of lactated Ringer's solution x weight(KG) x burn %
*Parkland Formula*
A client is being evaluated in the emergency department following a burn injury at home. The client has second and third degree burns to the right and left arms, back, and both posterior legs. Using the rule of nines, the nurse would calculate the client's burn as being: - correct answer 54%
The nurse is assessing a client diagnosed with second and third degree burns. Which of the following assessment signs would NOT need to be reported by the nurse? - correct answer Urine output of 30 mL in the first hour
The nurse is initiating care for a client diagnosed with burns to the chest, back, neck, and face. For this client, which of the following nursing diagnoses would receive the highest priority? - correct answer Ineffective airway clearance
A client is recovering from a skin graft to her right arm. Which of following nursing interventions would not be indicated for this client? - correct answer Encourage exercise of the right arm
A client diagnosed with major burn is being prescribed medication for pain. The nurse realized that the drug of choice for this client will be? - correct answer morphine sulfate
The goals of management during the emergent period after a burn include which of the following? *(Select all that apply)* - correct answer -Airway management
-Aseptic Technique
-Emotional Support
-Fluid Replacement
-Pain Management
An individual's sleeve catches on fire while cooking. He runs through the kitchen and out the back door. Which of the following interventions should the family perform? *(select all that apply)* - correct answer -Remove any loose debris
-Remove jewelry
-Use water hose to cool the burn
-Cover the burned areas with a clean dry material
The nurse is determining if a client who sustained a burn should be referred to a burn unit for care. Which of the following types of burn injuries should be referred to this type of care area? *(select all that apply)* - correct answer -Burn of the face
-Burn to the genitalia
-Burn to a fractured limb
-Burn caused by chemicals
The nurse is preparing to provide wound care to a client newly diagnosed with a burn. Which of the following are goals of this initial wound care? *(select all that apply)* - correct answer -Cleanse the skin
-Prevent further skin destruction
-Provide comfort
-Prevent Infection
The nurse in the emergency department is using a triage system because this system ranks clients by: - correct answer Severity of illness or injury
In the event of a mass casualty situation, the best triage nurse is: - correct answer The RN with the most experience and best assessment skills
The nurse, triaging victims of a mass casualty incident, will focus attention on the victims who are color coded as: - correct answer RED
The emergency room nurse is utilizing a triage approach for a mass casualty incident that is different from traditional triage. The difference between these two triage approaches is that: - correct answer mass casualty is most likely to survive first, traditional is most critical first
The emergency department nurse is preparing to triage victims of an internal event. Which of the following would be considered an internal event? - correct answer Fire in the hospital
The nurse is a member of the emergency preparedness committee, and she learns that anthrax is a bio-terrorism threat that could infect and kill large numbers of people. Because of this, the organization should have which of the following on stock to treat anthrax? - correct answer IV or Oral ciprofloxacin
Victims of a chemical spill are brought to the hospital for treatment. The nurse learns that 50 victims will be arriving within the hour. When preparing for these victims, the nurse should ensure that which of the following is available? - correct answer A large area to decontaminate the victims
The nurse is preparing to assess a client who was a victim of a blast injury. Prior to assessing the client, which are the mechanisms of a blast injury that the nurse will review? - correct answer -Primary
-Secondary
-Tertiary
-Quaternary
The nurse believes a client is experiencing a reaction to a traumatic event when which of the following is assessed? - correct answer -Client is not responding verbally to assessment questions
-Client complains of dizziness
-Client complains of nausea
-Client asks for medication for a headache
The nurse is concerned about developing post-traumatic stress disorder after working for several years in the ED. Which of the following should the nurse do to ensure this disorder does not manifest? - correct answer -Eat a well-balanced diet
-Drink Water
-Limit Caffeine
-Limit Sugar Intake
-Exercise at least 4 times a week for 30 minutes
The nurse determines that a client's cardiac output is normal. Which of the following values would be considered normal? - correct answer 6 L/min
*4-8 L/min is normal*
The nurse is caring for a client who is experiencing an increase in cardiac contractility. Which of the following will decrease contractility and reduce myocardial oxygen demand for this client? - correct answer Administer beta-blocker as perscribed
A client is perscribed a vasoactive IV medication to maintain a normal blood pressure. Which of the following is not a vasoactive medication? - correct answer Amiodarone
A client is diagnosed with increased ICP. Which of the following interventions can be used to reduce this pressure? - correct answer Adminster Mannitol
A client who has an endotracheal tube is being considered for a tracheostomy. Which of the following criteria would support the placement of a trach in this client? - correct answer Client is unable to maintain airway when extubated
A client who is being mechanically ventilated has positive and expiratory pressure set at 20 cm of water. Which of the following should the nurse assess in this client? - correct answer Pneumothorax
The nurse, planning care for a client who is mechanically ventilated, would plan to administer medication to prevent the onset of which of the following complications? - correct answer stress ulcers
A client has been participating in weaning from the ventilator for several days. Which of the following should be done to assist this client to regain strength? - correct answer Provide full ventilatory support during overnight hours.
Which of the following nursing interventions would be appropriate for a client who has has an endotracheal tube removed? - correct answer Provide oral care immediately after extubation
A client's pulmonary artery wedge pressure is 1mmHg. Which of the following health problems can cause this low pressure? *(Select all that apply)* - correct answer -Dehydration
-Hemorrhage
-Hypovalemia
Which of the following interventions would be appropriate for a client who is being mechanically ventilated? *(select all that apply)* - correct answer -Secure artificial airway
-Auscultate lungs every 4 hours as needed
-Monitor endotracheal tube cuff pressure once per shift
-Provide alternative form of communication
-Monitor arterial blood gas analysis results and adjust ventilator as needed
A client is diagnosed with fractured ribs. Which of the following should the nurse instruct this patient? - correct answer Splint the rib cage when deep breathing and coughing
A client is prescribed a diuretic for treatment of pulmonary hypertension. Which of the following should the nurse instruct the client regarding this medication? - correct answer This medication reduces the amount of water in the body
The nurse is assessing a client experiencing manifestations of cor pulmonale. Which of the following will the nurse most likely assess in this client? - correct answer hoarseness
The nurse, planning care for a client diagnosed with a pneumothorax, Identifies which type of pneumothorax? *(select all that apply)* - correct answer -Spontaneous
-traumatic
-tension
-latrogenic
Which of these instructions are for a client diagnosed with a pneumothorax? *(select all that apply)* - correct answer -Remove air from the pleual space
-Correct acid-base imbalances
-Minimize damage
-Re-expand the lung
A client is experiencing an alteration in heart rate. The nurse realizes the client is experiencing a disorder of which part of the heart? - correct answer Sinoatrial node
A client is suspected of having cardiac damage. The nurse realized that which of the following diagnostic tests is most commonly used to help diagnose this client's possible cardiac damage or disease? - correct answer 12-lead electrocardiogram
The nurse is analyzing a client's ECG tracing. Which of the following complexes is NOT normally seen on an ECG tracing? - correct answer The U wave
A client is unresponsive and has no pulse. The nurse notes that the ECG tracing shows continuous large and bizarre QRS complexes measured greater than 0.12 each. This rhythm is identified as - correct answer Ventricular Tachycardia
An elderly client is demonstrating a change in heart rate that occurs with respiration. When planning care for the client, the nurse knows that treatment may include: - correct answer pacemaker insertion
A clients ECG tracing shows a sawtooth pattern with F waves. The nurse realized this client is demonstrating? - correct answer atrial flutter
Which of the following should the nurse instruct a client who has been diagnosed with an arrhythmia? - correct answer How to take his own pulse
A client is diagnosed with supraventricular tachycardia. The nurse should prepare to administer which of the following meds? - correct answer Adenosine
A client is recovering from insertion of a pacemaker to pace the activity of the ventricles. At which point on the ECG tracing will the nurse assess pacer spikes? - correct answer Before the QRS
A client with a heart rate of 40 who is experiencing shortness of breath and nausea is diagnosed with second degree av-block, type II. Which of the following will be included int his clients treatment? *(select all that apply)* - correct answer -Administer atropine sulfate
-Insert external pacemaker
A client's ECG rhythm strip is a straight line. Which of the following should the nurse do to help the client? *(Select all that apply)* - correct answer -assess for loose leads
-assess for power to the monitor
-assess the strop for possible fine ventricular fibrillation
-begin cardiopulmonary resuscitation once verified the client has no pulse
The nurse is assessing a client who is diagnosed with pulse-less electrical activity. Which of the following will the nurse include in this assessment? *(select all that apply)* - correct answer -hypovalemia
-hypoxia
-hypothermia
-tamponade
-thrombosis
Which of the following should be implemented to ensure the safe use of a defibrillator? *(select all that apply)* - correct answer -do not place over monitoring electrodes
-do not place over an implanted pacemaker
An emergency room nurse assesses a client who has been raped. Which health care team member should the nurse collaborate when planning this clients care? - correct answer forensic nurse examiner
The ED team is performing cardiopulmonary resuscitation on a client when the clients spouse arrives at the ED. What action should the nurse take first? - correct answer Ask the spouse if he wishes to be present during resuscitation
An ER nurse is triaging victims of a multi casualty event. Which client should receive care first? - correct answer a 26-year old male who has pale, cool, clammy extremities
While triaging clients in a crowded ED, a nurse assesses a client who presents with symptoms of TB. Which action should the nurse take first? - correct answer Transfer the client to a negative pressure room
A nurse triaging clients in the ED. Which client should the nurse prioritize to receive care first? - correct answer a 45-year old reporting chest pain and diaphoresis
A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center? - correct answer Level II, located within a community hospitals and provides care to most injured clients
Emergency medical technicians arrive at the ED with an unresponsive client who has an oxygen mask in place. Which action should the nurse take first? - correct answer Assess that the client is breathing adequately
A trauma center with multiple open wounds is brought to the ED in cardiac arrest. Which action should the nurse take prior to providing advance cardiac life support? - correct answer Don personal protective equipment
A nurse is triaging clients in the ED. Which client should be considered urgent but not emergent? - correct answer a 75-year old female with a cough and a temp of 102
An ED nurse is caring for a client who has died from a suspected homicide. Which action should the nurse take? - correct answer Communicate the clients death to the family in a simple and concrete manner
An ED nurse case manage is consulted for a client who is homeless. Which intervention should the case manager provide? - correct answer Provide referrals to subsidized community-based health clinics
An ED nurse is caring for a client who is homeless. Which action should the nurse take to gain the clients trust? - correct answer Listen to the clients concerns and needs
A nurse is triaging clients in the ED. Which client should the nurse classify as nonurgent? - correct answer A 62-year old with a simple fracture of the left arm
A nurse is caring for clients in a busy ED. Which actions should the nurse take to ensure client and staff safety? *(Select all the Apply)* - correct answer -Use two identifiers before each intervention and before medication administration
-Attempt De-escalation strategies for clients who demonstrate aggressive behaviors.
-Search the belongings of clients with altered mental status to gain essential medical information
AN Ed nurse is preparing to transfer a client to the trauma ICU. Which info should the nurse include in the nurse-to-nurse hand off report? *(select all that apply)* - correct answer -mechanisms of injury
-diagnostic test results
-Isolation precautions
An ER nurse is caring for a trauma client. What interventions should the nurse perform during the primary survey? *(select all that apply)* - correct answer -Needle decompression
-Initiating IV fluids
-Endotracheal intubation
-Removing wet clothing
A nurse prepared to discharge an older adult client home from the ED. Which actions should the nurse take to prevent future ED visits? *(select all that apply)* - correct answer -Screen for depression and suicide
-Complete a functional assessment
A hospital responds to a local mass casualty event. Which action should the nurse supervisor take to prevent staff post-traumatic stress disorder during a mass casualty event? - correct answer Provide water and healthy snacks for energy throughout the event
A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at a nurse when dinner is served late. How should the nurse respond? - correct answer you seem upset. I have time to talk if you'd like.
A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag? - correct answer Multiple fractured ribs and shortness of breath
An ED charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during this event? - correct answer Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims.
The hospital administration arranges for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation? - correct answer You are free to express your feelings; whatever is said here stays here
A nurse is caring for a client whose wife died in a recent mass casualty accident. The client says, I can't believe my wife is gone and I am left to raise my children all by myself. How should the nurse respond? - correct answer You sound anxious about being a single parent
A nurse cares for clients during a community-wide disaster drill. One of the clients asks, Why are the individuals with black tags not receiving any care? How should the nurse respond? - correct answer In a disaster, extensive resources are not used for one person at the expense of many others.
A nurse wants to become involved in community disaster preparedness and is interested in helping set up and staff first aid stations or community acute care centers in the event of a disaster. Which organization is the best fir for this nurses interests? - correct answer The medical reserve corps.
A nurse wants to become part of a Disaster Medical Assistance Team, but is concerned about maintaining licensure in several different states. Which statement best addresses these concerns? - correct answer Deployed DMAT providers are federal employees, so their licenses are good in all 50 states. [Show Less]