jennraq2u's version from 2016-10-15 22:54


Question Answer
After stabilizing a trauma victim's airway, breathing, and circulation what is the next item the nurse with assess?Neurologic status
A client is brought to the ED with a suspected neck injury. What is the nurse's priority action?Apply a hard cervical collar to the nuchal area.
A client has been injured in a stabbing incident. Assessment reveals the following Blood pressure - 80/60 mm Hg Heart rate - 130 beats/min Respiratory rate - 35 breaths/min Bleeding from stabbing wound site Client is lethargicLevel 1
40-year-old man burned over 60% of his body. Second, third degree burns, bur is conscious. The nurse would triage this person asBlack
Patient exposed to anthrax.The nurse should perform what health assessment?Assessment of respiratory status
Earthquake. The nursing supervisor will need to work with what organization responsible for coordinating interagency relief assistance?Office of Emergency Management
5 clients admitted in the last 2 hours with complaints of fever and gastrointestinal distress. What question is most appropriate for the nurse to ask each client to determine id there is a bio-terrorism threat?Where were you immediately before your got sick?
Which signs and symptoms should the nurse assess in the client who has been exposed to the anthrax bacillus via the skin?Edema, pruritus, and 2 mm ulcerated vesicle
You are off-duty and hear on the television of a bio-terrorism act in the community. Which action should the nurse take first?Follow the nurse's hospital policy for responding
A nurse is assessing the fluid status of the client with second-degree burns who weighs 60 kg. The client is 5 hours postburn. The nurse determines that the client's fluid is inadequate and immediately notifies the physician when the client exhibits?Pulse rate 130 bpm and urine output 25 ml/h
Which is the priority nursing diagnosis during the first 24 hours for a client with chemical burns to the arms that are red in color, edematous and without pain?Decreased tissue perfusion.
The current phase of a patient's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is in what phase burn care?Acute
Just admitted patient with a burn. What characteristic of the burn primarily determine whether a patient experiences a systemic response to this injury?The total body surface areas (TBSA) affected by the burn.
Occupational health nurse in factory. Flash burn, flames have been extinguished. The next step is to 'cool the burn' . How should the nurse cool the burn?Wrap cool towels around the affected extremity intermittently.
A client in intensive care unit with extensive full-thickness burns over 25% of body. After ensuring cardiopulmonary stability what would be the nurse's immediate, priority concern planning this client's care?Fluid status
A clients burns cover face and the left forearm. What extent of burns does the client most likely have? Use Rule of Nir18%
Client's burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered by the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid?Lactated ringers
Client complains of severe pain, boiling water spilled over lower legs. Assessment reveals blistered, mottled red skin, and both feet are edematous. Which depths of burns should the nurse document?Deep partial thickness
A nurse see a client get struck by lightening during a thunder storm at the beach. What should be the first action?Check breathing and circulation
Client found unconscious, Medic Alert bracelet indicates the client has type 1 diabetes and the blood glucose is 2 mg/dl. The nurse should anticipate what intervention?IV administration of 50% dextrose in water
Student with diabetes is feeling nervous and hungry. Nurse assess child and finds he has tachycardia and is diaphoretic with a blood glucose level of 50mg/dl. What should the school nurse administer?Half a cup of juice, followed by cheese and crackers
The nurse administers 30 units of NPH insulin at 7:00 am to a client with a blood glucose level of 200 mg/dl. The nurse monitors the client for a hypoglycemic reaction. The nurse knows that this would occur1600
The nurse is evaluating a client's understanding of the signs of hyperglycemia. What statement by the client reflects and understanding?I may notice signs of fatigue, dry skin and increased urination.
The nurse is teaching a client how to mix regular insulin and NPH insulin in the same syringe. What action should the nurse tell the client to take?Rotate the NPH insulin bottle in the hands before mixing
The client with type 1 diabetes mellitus has diabetic ketoacidosis. What find has the greatest effect on fluid loss?rapid, deep respirations
Which condition is the most significant risk factor for the development of type 2 diabetes mellitus?Obesity
Which physician's orders should the nurse question for a newly admitted client diagnosed with Diabetic ketoacidosis (DKA)?D5W at ml/hour
The client is having blood drawn for glycosylated hemoglobin (HGA1C). In teaching the purpose of this laboratory test, the nurse explains is it used?To determine average of blood glucose levels of the previous three to four months
When planning for the client with type II diabetes mellitus, the nurse validates with the client that a priority goal is toMaintain ideal body weight
The primary care provider has ordered a correction scale (sliding scale) with accuchecks (fingersticks) hs. Also order is Lantus 25 units every AM. The correction scale (sliding scale) is Regular Insulin/ Less than 150 - no coverage/ 151 to 225 - 6 units/ 226 to 260 - 10 units/ above 260 call MD 7am correction scale or sliding scale is 226. The nurse would administer how much insulin at 7 am.Only administer 10 units of regular insulin now.
The client diagnosed with type 2 diabetes is admitted to the ICU with hyperosmolar hyperglycemic nonketonic syndrome (HHNS) coma. Which assessment data should the nurse expect the client to exhibit?Dry mucous membranes
Client in post-surgical unit following thyroidectomy. To promote comfort and safety, how should the nurse best position the patient?Semi-fowlers with the head supported on 2 pillows
Caring for client with diagnosis of Addison's disease. What sign or symptom is most closely associated with this health problemBronze pigmentation, hypotension, and anorexia
A client is prescribed corticosteroid therapy. What would be priority information for the nurse to give the client who is prescribed long-term corticosteroid therapy?The client is at an increased risk for developing infection
The nurse assess the client with a diagnosis of thyroid storm. Which manifestations associated with thyroid storm indicate the need for immediate nursing intervention?Fever, tachycardia and hypertension
A client is admitted to the hospital with Cushing's disease. The nurse should monitor the client's laboratory studies for which finding that occurs in the disorder?Hyperglycemia
The nurse is completing a health assessment of a 42-year-old female with suspected Grave's disease. The nurse should assess this client forTachycardia fine muscle tremors
Propylthiouracil (PTU) is prescribed for a client with Graves disease. The nurse should teach the client to immediately report which of the following?Sore throat & fever
A client with Graves disease is treated with radioactive iodine (RAI) in the form of sodium iodide 131 I. What statement by the nurse will explain to the client how the drug work?The RAI destroys thyroid tissue so that thyroid hormones are no longer produced
What medication should the nurse have on hand to provide emergency treatment if a client develops tetany after a subtotal throidectomyCalcium gluconate
The nurse should assess a client with hypothyroidism for what?Decreased activity due to fatigue
Developing care plan for client with Cushing syndrome. What nursing diagnosis would have the highest priority in this care plan?Risk for injury to weakness
Caring for a client with hyperparathyroidism. What level of activity would the nurse expect to promote?Ambulation and activity as tolerated
A client has developed syndrome of inappropriate antidiuretic hormone (SIADH) secondary to a pituitary tumor. The client's symptoms include thirst, weight gain, and fatigue. The client's serum sodium is 127 mEq/L. What physician order should the nurse anticipate when treating SIADH?Fluid restriction of 800 to 1200 ml per day
Which finding should the nurse anticipate when assessing a client newly diagnosed with diabetes insipidus (DI)?Polyuria
A nurse is caring for a client who is experiencing symptoms associated with pheochromocytoma. What intervention should be included in the care of this client?Administer nicardipine (cardene) to control hypertension
What action should the nurse implement to prevent ventilator-associated pneumonia (VAP) in the client who is intubated and on mechanical ventilator?Practice meticulous hand hygeine
The nurse is assigned to care for a client with a chest tube attached to closed chest drainage. What should the nurse determine is an indicator the client's lung has completely inflated?Fluctuations in the water-seal chamber ceased
The nurse is checking the client's chest tube and drainage system and notes continuous bubbling in the water seal chamber. What should the nurse determine as the cause?There is an air leak somewhere in the systems
Which assessment finding should the nurse expect when completing an assessment on a client with chronic obstruction pulmonary disease (COPD)?Barrel chest, clubbed fingers & toes, dysprea on excertion