Critical Care - Emergency Situations

The nurse in a neonatal intensive care nursery (NICU) receives a telephone call to prepare for the admission of a 43-week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what is the nurse's highest priority?
1. Turn on the apnea and cardiorespiratory monitors.
2. Connect the resuscitation bag to the oxygen outlet.
3. Set up the intravenous line with 5% dextrose in water.
4. Set the radiant warmer control temperature at 36.5° C (97.6° F).

A client is brought to the emergency department with partial thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply.
1. Restrict fluids.
2. Assess for airway patency.
3. Administer oxygen as prescribed.
4. Place a cooling blanket on the client.
5. Elevate extremities if no fractures are present.
6. Prepare to give oral pain medication as prescribed.

A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client?
1. 100% oxygen via an aerosol mask
2. Oxygen via nasal cannula at 6 L/minute
3. Oxygen via nasal cannula at 15 L/minute
4. 100% oxygen via a tight-fitting, nonrebreather face mask

A client is admitted to an emergency department with chest pain that is consistent with myocardial infarction based on elevated troponin levels. Heart sounds are normal and vital signs are noted on the client's chart. The nurse should alert the health care provider because these changes are most consistent with which complication?

1. Cardiogenic shock
2. Cardiac tamponade
3. Pulmonary embolism
4. Dissecting thoracic aortic aneurysm

A client in sinus bradycardia, with a heart rate of 45 beats/minute, complains of dizziness and has a blood pressure of 82/60 mm Hg. Which prescription should the nurse anticipate will be prescribed?
1. Defibrillate the client.
2. Administer digoxin (Lanoxin).
3. Continue to monitor the client.
4. Prepare for transcutaneous pacing.

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the health care provider and prepares to implement which priority interventions? Select all that apply.
1. Administering oxygen
2. Inserting a Foley catheter
3. Administering furosemide (Lasix)
4. Administering morphine sulfate intravenously
5. Transporting the client to the coronary care unit
6. Placing the client in a low Fowler's side-lying position

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds?
1. Stridor
2. Crackles
3. Scattered rhonchi
4. Diminished breath sounds

A client with myocardial infarction is developing cardiogenic shock. Because of the risk of myocardial ischemia, what condition should the nurse carefully assess the client for?
1. Bradycardia
2. Ventricular dysrhythmias
3. Rising diastolic blood pressure
4. Falling central venous pressure

A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL and the serum creatinine level is 2.2 mg/dL. On the basis of these findings, the nurse would anticipate that the client is at risk for which problem?
1. Hypovolemia
2. Acute kidney injury
3. Glomerulonephritis
4. Urinary tract infection

The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 beats/minute. The nurse determines that the client is experiencing which dysrhythmia?
1. Sinus tachycardia
2. Ventricular fibrillation
3. Ventricular tachycardia
4. Premature ventricular contractions

A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most concerned about with this dysrhythmia?
1. It can develop into ventricular fibrillation at any time.
2. It is almost impossible to convert to a normal rhythm.
3. It is uncomfortable for the client, giving a sense of impending doom.
4. It produces a high cardiac output that quickly leads to cerebral and myocardial ischemia.

A client has developed atrial fibrillation, with a ventricular rate of 150 beats/minute. The nurse should assess the client for which associated signs/symptoms?
1. Flat neck veins
2. Nausea and vomiting
3. Hypotension and dizziness
4. Hypertension and headache

The nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How should the nurse correctly interpret the client's heart rhythm?
1. Atrial fibrillation
2. Sinus tachycardia
3. Ventricular fibrillation
4. Ventricular tachycardia

The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an intravenous infusion at a rate of 150 mL/hour, unchanged for the last 10 hours. The client's urine output for the last 3 hours has been 90, 50, and 28 mL (28 mL most recent). The client's blood urea nitrogen level is 35 mg/dL and the serum creatinine level is 1.8 mg/dL, measured this morning. Which nursing action is the priority?
1. Check the urine specific gravity.
2. Call the health care provider (HCP).
3. Check to see if the client had a sample for a serum albumin level drawn.
4. Put the intravenous (IV) line on a pump so that the infusion rate is sure to stay stable.

The nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves, no definable QRS complexes, and coarse wavy lines of varying amplitude. How should the nurse correctly interpret this rhythm?
1. Asystole
2. Atrial fibrillation
3. Ventricular fibrillation
4. Ventricular tachycardia

A client receiving thrombolytic therapy with a continuous infusion of alteplase (Activase) suddenly becomes extremely anxious and complains of itching. The nurse hears stridor and notes generalized urticaria and hypotension. Which nursing action is the priority?
1. Administer oxygen and protamine sulfate.
2. Cut the infusion rate in half and sit the client up in bed.
3. Stop the infusion and call the health care provider (HCP).
4. Administer diphenhydramine (Benadryl) and continue the infusion.

The nurse should report which assessment finding to the health care provider (HCP) before initiating thrombolytic therapy in a client with pulmonary embolism?
1. Adventitious breath sounds
2. Temperature of 99.4° F orally
3. Blood pressure of 198/110 mm Hg
4. Respiratory rate of 28 breaths/minute

A client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious and the nurse suspects air embolism. What is the priority nursing action?
1. Monitor vital signs every 15 minutes for the next hour.
2. Discontinue dialysis and notify the health care provider (HCP).
3. Continue dialysis at a slower rate after checking the lines for air.
4. Bolus the client with 500 mL of normal saline to break up the air embolus.

During the early postoperative period, a client who has undergone a cataract extraction complains of nausea and severe eye pain over the operative site. What should be the initial nursing action?
1. Call the health care provider (HCP).
2. Reassure the client that this is normal.
3. Turn the client onto his or her operative side.
4. Administer the prescribed pain medication and antiemetic.

A client arrives in the emergency department following an automobile crash. The client's forehead hit the steering wheel and a hyphema is diagnosed. The nurse should place the client in which position?
1. Flat in bed
2. A semi-Fowler's position
3. Lateral on the affected side
4. Lateral on the unaffected side

The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention should be initiated immediately?
1. Apply ice to the affected eye.
2. Irrigate the eye with cool water.
3. Notify the health care provider (HCP).
4. Accompany the client to the emergency department.

A client arrives in the emergency department with a penetrating eye injury from wood chips that occurred while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the initial nursing action?
1. Apply an eye patch.
2. Perform visual acuity tests.
3. Irrigate the eye with sterile saline.
4. Remove the piece of wood using a sterile eye clamp.

A woman was working in her garden. She accidentally sprayed insecticide into her right eye. She calls the emergency department, frantic and screaming for help. The nurse should instruct the woman to take which immediate action?
1. Irrigate the eyes with water.
2. Come to the emergency department.
3. Call the health care provider (HCP).
4. Irrigate the eyes with diluted hydrogen peroxide.

A client develops an anaphylactic reaction after receiving morphine sulfate. The nurse should plan to institute which actions? Select all that apply.
1. Administer oxygen.
2. Quickly assess the client's respiratory status.
3. Document the event, interventions, and client's response.
4. Leave the client briefly to contact a health care provider.
5. Keep the client supine regardless of the blood pressure readings.
6. Start an intravenous (IV) infusion of D5W and administer a 500-mL bolus.

A child is receiving succimer (Chemet) for the treatment of lead poisoning. A nurse should monitor which most important laboratory result?
1. Iron level
2. Calcium level
3. Red blood cell count
4. Blood urea nitrogen level

A client with a probable minor head injury resulting from a motor vehicle crash is admitted to the hospital for observation. The nurse leaves the cervical collar applied to the client in place until when?
1. The family comes to visit.
2. The nurse needs to do physical care.
3. The health care provider makes rounds.
4. The results of spinal radiography are known.

A client experienced an open pneumothorax (sucking wound), which has been covered with an occlusive dressing. The client begins to experience severe dyspnea, and the blood pressure begins to fall. The nurse should first perform which action?
1. Remove the dressing.
2. Reinforce the dressing.
3. Call the health care provider (HCP).
4. Measure oxygen saturation by oximetry.

The nurse is performing an assessment on a client admitted to the nursing unit who has sustained an extensive burn injury involving greater than 25% of total body surface area. In performing the assessment, the nurse knows that the maximum amount of edema that occurs from a burn normally is noted at which time frame?
1. Immediately after the injury
2. Within 12 hours after the injury
3. Between 18 and 24 hours after the injury
4. Between 42 and 72 hours after the injury

The nurse in the emergency department is caring for a client who was in a motor vehicle crash and is experiencing hypovolemic shock. A pneumatic antishock garment (PASG), also known as shock trousers, is applied for treatment until the client can be transferred to the intensive care unit (ICU). While awaiting client transfer to the ICU, the emergency department nurse should perform which critical assessment?
1. Assessing radial pulses
2. Monitoring hemoglobin and hematocrit levels
3. Assessing vascular status of the upper extremities
4. Monitoring vascular status of the lower extremities

A left atrial catheter is inserted into a client during cardiac surgery. The nurse is monitoring the left atrial pressure (LAP) and documents the following pressure. Which readings are within normal limits (WNL) for the client? Select all that apply.
1. 6 mm Hg
2. 8 mm Hg
3. 15 mm Hg
4. 25 mm Hg
5. 32 mm Hg

The nursing educator has just completed a lecture to a group of nurses regarding care of the client with a burn injury. A major aspect of the lecture was care of the client at the scene of a fire. Which statement, if made by a nurse, indicates a need for further instruction?
1. "Flames should be doused with water."
2. "Flames may be extinguished by rolling the client on the ground."
3. "Flames may be smothered by the use of a blanket or another cover."
4. "The client should be maintained in a standing position because the flames may spread to the other parts of the body."

The community health nurse is providing a teaching session to firefighters in a small community regarding care of a burn victim at the scene of injury. The nurse instructs the firefighters that in the event of a tar burn, which is the immediate action?
1. Cooling the injury with water
2. Removing all clothing immediately
3. Removing the tar from the burn injury
4. Leaving any clothing that is saturated with tar in place

The industrial nurse is providing instructions to a group of employees regarding care to a client in the event of a chemical burn injury. The nurse instructs the employees that which is the first consideration in immediate care?
1. Removing all clothing, including gloves and shoes
2. Determining the antidote for the chemical and placing the antidote on the burn site
3. Leaving all clothing in place until the client is brought to the emergency department
4. Lavaging the skin with water and avoiding brushing powdered chemicals off the clothing

A client who sustained an inhalation injury arrives in the emergency department. On initial assessment, the nurse notes that the client is very confused and combative. The nurse determines that the client is most likely experiencing which condition?
1. Pain
2. Fear
3. Hypoxia
4. Anxiety

A client is brought to the emergency department immediately after a smoke inhalation injury. The nurse initially prepares the client for which treatment?
1. Pain medication
2. Endotracheal intubation
3. Oxygen via nasal cannula
4. 100% humidified oxygen by face mask

The nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area from a fire. Which assessment finding would indicate that the client sustained a respiratory injury as a result of the burn?
1. Fear and anxiety
2. Complaints of pain
3. Clear breath sounds
4. Use of accessory muscles for breathing

The nurse is performing an assessment on a client who sustained circumferential burns of both legs. Which assessment would be the initial priority in caring for this client?
1. Assessing heart rate
2. Assessing respiratory rate
3. Assessing peripheral pulses
4. Assessing blood pressure (BP)

The nurse has developed a client problem of ineffective airway clearance for a client who sustained an inhalation burn injury. Which nursing intervention should the nurse include in the plan of care for this client?
1. Elevate the head of the bed.
2. Monitor oxygen saturation levels every 4 hours.
3. Encourage coughing and deep breathing every 4 hours.
4. Assess respiratory rate and breath sounds every 4 hours.

The nurse has developed a nursing care plan for a client with a burn injury. The client problem states deficient fluid volume. Which intervention should the nurse include in the plan of care as a priority intervention?
1. Monitor vital signs every 4 hours.
2. Monitor mental status every hour.
3. Monitor intake and output every shift.
4. Obtain and record weight every other day.

The nurse is developing a nursing care plan for a client with a circumferential burn injury of the extremity. The client problem states ineffective tissue perfusion. Which nursing intervention should the nurse include in the plan of care for the client?
1. Monitor peripheral pulses every hour.
2. Keep the extremities in a dependent position.
3. Document any changes that occur in the pulse.
4. Place pressure dressings and wraps around the burn sites.

Vasopressin is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse should prepare to administer this medication by which route?
1. Orally
2. By inhalation
3. By intramuscular route
4. Through a Sengstaken-Blakemore tube

Vasopressin therapy is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse is preparing to administer the medication to the client. Which essential item is needed during the administration of this medication?
1. An airway
2. A suction setup
3. A cardiac monitor
4. A tracheotomy set

The nurse is monitoring a client who required a Sengstaken-Blakemore tube because other measures for treating bleeding esophageal varices were unsuccessful. The client complains of severe pain of abrupt onset. Which nursing action is most appropriate?
1. Cut the tube.
2. Reposition the client.
3. Assess the lumens of the tubes.
4. Administer the prescribed analgesics.

A postpartum client who received an epidural analgesic after giving birth by cesarean section is lethargic and has a respiratory rate of 8 breaths per minute. The nurse should obtain which medication from the emergency cart after notifying the health care provider?
1. Betamethasone
2. Morphine sulfate
3. Naloxone (Narcan)
4. Meperidine hydrochloride (Demerol)

The nurse is reviewing the medical record of a client transferred to the medical unit from the critical care unit. The nurse notes that the client received intra-aortic balloon pump (IABP) therapy while in the critical care unit. The nurse suspects that the client received this therapy for which condition?
1. Heart failure
2. Pulmonary edema
3. Cardiogenic shock
4. Aortic insufficiency

The nurse is providing care for a client who sustained burns over 30% of the body from a fire. On assessment, the nurse notes that the client is edematous in both burned and unburned body areas. The nurse documents this assessment finding as expected because the edema is caused by which factor?
1. A decrease in capillary permeability and hypoproteinemia
2. A decrease in capillary permeability and hyperproteinemia
3. An increase in capillary permeability and hypoproteinemia
4. An increase in capillary permeability and hyperproteinemia

The emergency department nurse is monitoring a client who received treatment for a severe asthma attack. The nurse determines that the client's respiratory status had worsened if which is noted on assessment?
1. Diminished breath sounds
2. Wheezing during inhalation
3. Wheezing during exhalation
4. Wheezing throughout the lung fields

The nurse is performing an assessment on a client who was admitted with a diagnosis of carbon monoxide poisoning. Which assessment performed by the nurse would primarily elicit data related to a deterioration of the client's condition?
1. Skin color
2. Apical rate
3. Respiratory rate
4. Level of consciousness

The nurse is reviewing the laboratory test results for a client admitted to the burn unit 3 hours after an explosion that occurred at a worksite. The client has a severe burn injury that covers 35% of the total body surface area (TBSA). The nurse is most likely to note which finding on the laboratory report?
1. Hematocrit 60%
2. Serum albumin 4.8 g/dL
3. Serum sodium 144 mEq/L
4. White blood cell (WBC) count 9000 cells/mm³

The nurse is caring for a client who sustained a thermal burn caused by the inhalation of steam 24 hours ago. The nurse determines that the priority nursing action is to assess which item?
1. Pain level
2. Lung sounds
3. Ability to swallow
4. Laboratory results

Acetylcysteine (Mucomyst) is prescribed for a client in the hospital emergency department after diagnosis of acetaminophen (Tylenol) overdose. The nurse prepares to administer the medication using which procedure?
1. Diluting the medication in cola and administering it to the client orally
2. Calling the respiratory department to administer the medication via inhaler
3. Obtaining a 1-mL syringe to administer the small dose via the subcutaneous route
4. Initiating an intravenous line and diluting the medication in 100 mL of normal saline for administration

A nurse receives a telephone call from a neighbor, who states that her 3-year-old child was found sitting on the kitchen floor with an empty bottle of liquid furniture polish. The mother of the child tells the nurse that the bottle was half full, that the child's breath smells like the polish, and that spilled polish is present on the front of the child's shirt. What should the nurse tell the mother to do?
1. Call the pediatrician.
2. Induce vomiting immediately.
3. Call the poison control center.
4. Wait until the nurse comes to bring the child to the emergency department.

The nurse is caring for a client who sustained multiple fractures in a motor vehicle crash 12 hours earlier. The client now exhibits severe dyspnea, tachycardia, and mental confusion, and the nurse suspects fat embolism. Which is the initial nursing action?
1. Reassess the vital signs.
2. Perform a neurological assessment.
3. Position the client in a supine position.
4. Position the client in a Fowler's position.

The home health nurse is visiting an older client whose family has gone out for the day. During the visit, the client experiences chest pain that is unrelieved by sublingual nitroglycerin tablets given by the nurse. Which action by the nurse would be appropriate at this time?
1. Notify a family member who is the next of kin.
2. Drive the client to the health care provider's (HCP) office.
3. Inform the home care agency supervisor that the visit may be prolonged.
4. Call for an ambulance to transport the client to the hospital emergency department.

The client who has experienced a myocardial infarction (MI) is recovering from cardiogenic shock. The nurse knows that which observation of the client's clinical condition is most favorable?
1. Urine output of 40 mL/hr
2. Heart rate of 110 beats/min
3. Frequent premature ventricular contractions
4. Central venous pressure (CVP) of 15 mm Hg

A client in cardiogenic shock has a pulmonary artery catheter (Swan-Ganz type) placed. The nurse would interpret which cardiac output (CO) and pulmonary capillary wedge pressure (PCWP) readings as indicating that the client is most unstable?
1. CO 5 L/min, PCWP low
2. CO 3 L/min, PCWP low
3. CO 4 L/min, PCWP high
4. CO 3 L/min, PCWP high

A client in cardiogenic shock had an intra-aortic balloon pump inserted 24 hours earlier via the left femoral approach. The nurse notes that the client's left foot is cool and mottled and the left pedal pulse is weak. Which action should the nurse take?
1. Call the health care provider immediately.
2. Re-evaluate the neurovascular status in 1 hour.
3. Increase the rate of intravenous nitroglycerin that is infusing.
4. Document these findings, which are expected because of the catheter size.

A nurse reading the operative record for a client who has undergone cardiac surgery notes that the client's cardiac output immediately after surgery was 3.6 L/min. The nurse determines that this measurement indicates which finding?
1. Above the normal range
2. In the high-normal range
3. In the low-normal range
4. Below the normal range

The nurse has a prescription to administer acetylcysteine (Mucomyst) to a client admitted to the emergency department with acetaminophen (Tylenol) overdose. Before giving this medication, the nurse should ensure that which measure is done?
1. The solution is given full strength.
2. The client knows how to use a nebulizer.
3. The stomach is empty by emesis or lavage.
4. The antidote to acetylcysteine is readily available.

A postoperative client receives a dose of naloxone hydrochloride for respiratory depression shortly after transfer to the nursing unit from the postanesthesia care unit. After administration of the medication, the nurse should assess the client for which change?
1. Pupillary changes
2. Scattered lung wheezes
3. Sudden increase in pain
4. Sudden episodes of vomiting

A new nursing graduate is caring for a client who is attached to a cardiac monitor. While assisting the client with bathing, the nurse observes the sudden development of ventricular tachycardia (VT), but the client remains alert and oriented and has a pulse. Which interventions would the nurse take? Select all that apply.
1. Administer oxygen.
2. Defibrillate the client.
3. Obtain an electrocardiogram (ECG).
4. Contact the health care provider (HCP).
5. Assess circulation, airway, and breathing.
6. Initiate cardiopulmonary resuscitation (CPR).

An emergency department nurse is caring for a child with suspected acute epiglottitis. Which nursing interventions apply in the care of this child? Select all that apply.
1. Ensure a patent airway.
2. Obtain a throat culture.
3. Maintain the child in a supine position.
4. Obtain a pediatric-size tracheostomy tray.
5. Prepare the child for a chest radiographic study.
6. Place the child on an oxygen saturation monitor.

A client with a left arm fracture supported in a cast complains of loss of sensation in the left fingers. The nursing assessment identifies pallor in the distal portion of the arm, poor capillary refill, and a diminished left radial pulse. On the basis of these findings, the nurse would take which as a priority action?
1. Apply ice to the site.
2. Document the findings.
3. Administer pain medication.
4. Contact the health care provider (HCP).

A delivery room nurse is caring for a client in labor. The client tells the nurse that she feels that something is coming through the vagina. The nurse performs an assessment and notes the presence of the umbilical cord protruding from the vagina. The nurse should immediately place the client in which position?
1. Prone
2. Supine
3. On the side
4. Reverse Trendelenburg

The nurse is assessing a client hospitalized with acute pericarditis. The nurse monitors the client for cardiac tamponade, knowing that which signs are associated with this complication of pericarditis? Select all that apply.
1. Bradycardia
2. Pulsus paradoxus
3. Distant heart sounds
4. Falling blood pressure
5. Distended jugular veins

A client has frequent runs of ventricular tachycardia. The health care provider has prescribed an antidysrhythmic, flecainide (Tambocor). What is the best nursing action related to the effects of this medication?
1. Monitor the client's urinary output.
2. Assess the client for neurological changes.
3. Keep the call bell within the client's reach.
4. Monitor the client's vital signs and cardiac rhythm frequently.

The nurse suspects that a pulmonary embolism has developed in a postpartum client with femoral thrombophlebitis. What is the nurse's priority action for this client?
1. Check the vital signs.
2. Elevate the head of the bed to 30 to 45 degrees.
3. Initiate an intravenous line if one is not already in place.
4. Administer oxygen by face mask as per protocol at 8 to 10 L/min.

The child with croup is being discharged from the hospital. The nurse provides instructions to the mother and advises the mother to bring the child to the emergency department if which occurs?
1. The child is irritable.
2. The child appears tired.
3. The child develops stridor.
4. The child takes fluids poorly.

The nurse employed at an industrial work site is summoned to attend to an employee who experienced a traumatic amputation of a finger. Which actions should the nurse take to provide emergency care and prepare the client for transport to the hospital? Select all that apply.
1. Elevate the extremity above heart level.
2. Assess the employee for airway or breathing problems.
3. Remove the layered gauze every 10 minutes to check the bleeding.
4. Wrap the severed finger in moistened gauze, and place it in a bag of ice water.
5. Examine the amputation site and apply direct pressure to the site using layers of gauze.

An emergency department nurse is caring for a conscious child who was brought to the emergency department after the ingestion of half of a bottle of acetylsalicylic acid (aspirin). The nurse anticipates that most likely what will be the initial treatment?
1. Dialysis
2. The administration of an emetic
3. The administration of vitamin K
4. The administration of sodium bicarbonate

The nurse is providing care for a client with new onset of a dysrhythmia. The nurse anticipates which prescriptions from the health care provider? Select all that apply. Refer to Figure.

1. Oxygen therapy
2. An echocardiogram
3. An intravenous dose of metoprolol (Lopressor)
4. One dose of atropine to promote slowing of the rate
5. A bolus of intravenous heparin followed by a continuous infusion

A depressed client is found unconscious on the floor in the dayroom. The nurse finds several empty bottles of a prescribed tricyclic antidepressant lying near the client. Which is the priority action of the nurse?
1. Call the Poison Control Center.
2. Try to figure out the number of pills taken.
3. Induce vomiting and notify the health care provider for further prescriptions.
4. Call the emergency response team because this incident presents a medical emergency.

A client who is experiencing an anaphylactic reaction from eating shellfish is brought to the emergency department. Which immediate action should the nurse implement?
1. Maintain a patent airway.
2. Administer a corticosteroid.
3. Administer epinephrine (Adrenalin).
4. Instruct the client on the importance of obtaining a Medic-Alert bracelet.

The nurse prepares to administer acetylcysteine (Mucomyst) to the client with an overdose of acetaminophen (Tylenol). What is the appropriate action when administering this antidote?
1. Administer the medication subcutaneously in the deltoid muscle.
2. Administer the medication by intramuscular (IM) injection in the gluteal muscle.
3. Mix the medication in a flavored ice drink and allowing the client to drink the medication.
4. Administer the medication by an intravenous (IV) line, mixed in 50 mL of normal saline and piggybacked through the main IV line.

A client who has just suffered a large flail chest is experiencing severe pain and dyspnea. The client's central venous pressure (CVP) is rising, and the arterial blood pressure is falling. Which condition should the nurse interpret that the client is experiencing?
1. Fat embolism
2. Mediastinal shift
3. Mediastinal flutter
4. Hypovolemic shock

A client develops atrial fibrillation with a ventricular rate of 140 beats/min and signs of decreased cardiac output. Which medication should the nurse anticipate administering first?
1. Atropine sulfate
2. Warfarin (Coumadin)
3. Lidocaine (Xylocaine)
4. Metoprolol (Lopressor)

A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath and is visibly anxious. Which complication should the nurse immediately assess the client for?
1. Pneumonia
2. Pulmonary edema
3. Pulmonary embolism
4. Myocardial infarction

A client with no history of respiratory disease is admitted to the hospital with respiratory failure. Which results on the arterial blood gas report should the nurse expect to note, that are consistent with this disorder?
1. Pao2 58 mm Hg, Paco2 32 mm Hg
2. Pao2 60 mm Hg, Paco2 45 mm Hg
3. Pao2 49 mm Hg, Paco2 52 mm Hg
4. Pao2 73 mm Hg, Paco2 62 mm Hg

The nurse in the labor room is performing an initial assessment on a newborn. The infant is evidencing mild to moderate respiratory distress, audible bowel sounds in the chest, and a scaphoid abdomen. The infant is responding poorly to bag and mask ventilation. The nurse plans for which actions in the care of this infant? Select all that apply.
1. Start chest compressions.
2. Notify the health care provider.
3. Orally administer a sucrose solution.
4. Position the infant flat on his right side.
5. Insert an orogastric tube and connect it to low suction.
6. Provide support for respiratory distress via an endotracheal (ET) tube.

A child is admitted to the hospital after being seen in the emergency department with complaints of right lower quadrant abdominal pain, nausea and vomiting, fever, and chills. The health care provider suspects appendicitis. Which assessment finding should the nurse immediately report to the health care provider?
1. Sudden relief of pain
2. Decreasing oral temperature
3. Increasing complaints of pain
4. Refusal to take fluids by mouth

The mother of a 5-year-old boy is brought to the emergency department after ingesting a bottle of acetylsalicylic acid (ASA). Which procedure should be initially instituted with this child?
1. Administer ipecac by mouth and monitor emesis.
2. Institute a gastric lavage and administer activated charcoal.
3. Administer a chelating agent such as calcium disodium edetate (calcium EDTA).
4. Institute a gastric lavage and administer the antidote acetylcysteine (Mucomyst).

A mother brings her child to the emergency department. Based on the child's sitting position, drooling, and apparent respiratory distress, a diagnosis of epiglottitis is suspected. In anticipation of the health care provider's prescriptions, in which order of priority would the nurse implement the actions? Arrange the actions in the order that they should be performed. All options must be used.
1. Maintain a patent airway.
2. Administer an antipyretic.
3. Obtain an axillary temperature.
4. Assess breath sounds by auscultation.
5. Insert an intravenous line for fluid administration.
6. Obtain an oxygen saturation level using pulse oximetry.

The nurse is caring for a client who has overdosed on phenobarbital (Luminal). The nurse anticipates which assessment finding with this client?
1. Hyperthermia
2. Hyperreflexia
3. Deep respirations
4. Shallow respirations

The nurse is caring for a client who has overdosed on amphetamines. The nurse anticipates noting which assessment finding in this client?
1. Bradypnea
2. Bradycardia
3. Hypothermia
4. Hypertension

A client experiencing cocaine toxicity is brought to the emergency department. The nurse should prepare to take which initial action?
1. Ensure a patent airway.
2. Administer naloxone (Narcan).
3. Establish an intravenous access.
4. Obtain a 12-lead electrocardiogram (ECG).

Which readings obtained from a client's pulmonary artery catheter suggest that the client is in left-sided heart failure?
1. Cardiac output of 5 L/min
2. Right atrial pressure of 9 mm Hg
3. Pulmonary capillary wedge pressure (PCWP) 20 mm Hg
4. Pulmonary artery systolic/diastolic pressures of 24/10 mm Hg

When developing a mechanically ventilated client's plan of care for prevention of ventilator-associated pneumonia (VAP), the nurse should include which measures in the plan? Select all that apply.
1. Suction the oral cavity whenever needed.
2. Apply topical antibiotics to the oral cavity.
3. Change the ventilator circuit tubing every 2 hours.
4. Maintain the client in a supine position at all times.
5. Practice frequent oral hygiene, including teeth brushing.
6. Practice meticulous hand hygiene, and wear gloves when suctioning or handling the endotracheal tube.

Which steps should occur first when using an automated external defibrillator (AED)?
1. Place the AED in the analyze mode.
2. Press the shock button if indicated.
3. Check to see that no one is touching the client.
4. Apply defibrillator pads on the client and attach cables to the AED.

Which should the nurse do when setting up an arterial line?
1. Tighten all tubing connections.
2. Use macrodrop intravenous tubing.
3. Level the transducer to the ventricle.
4. Raise the height of the normal saline infusion to prevent backup.

Which interventions would be included in the care of a client with a head injury and a subarachnoid bolt? Select all that apply.
1. Monitor vital signs.
2. Monitor neurological status.
3. Monitor the dressing for signs of infection.
4. Monitor for signs of increased intracranial pressure.
5. Drain cerebrospinal fluid when the intracranial pressure is elevated.

Which clinical manifestations of a tension pneumothorax should be of immediate concern to the nurse? Select all that apply.
1. Bradypnea
2. Flattened neck veins
3. Decreased cardiac output
4. Hyperresonance to percussion
5. Tracheal deviation to the opposite side

The nurse recognizes that which arterial blood gas value indicates impending hypoxemic respiratory failure?
1. Pao₂ 65 mm Hg
2. Paco₂ 70 mm Hg
3. Pao₂ 55 mm Hg
4. Paco₂ 60 mm Hg

A client is admitted to the hospital for an acute episode of angina pectoris. Which parameter is the priority for the nurse to monitor?
1. Pulse and blood pressure
2. Temperature and chest pain
3. Food tolerance and urinary output
4. Right upper quadrant pain and fatigue

The nurse is caring for a client in the emergency department who has sustained a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing that this sequence is compatible with which most likely condition?
1. Concussion
2. Skull fracture
3. Subdural hematoma
4. Epidural hematoma

The family of a client with a spinal cord injury rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic with a flushed face and neck and is complaining of a severe headache. The pulse rate is 40 beats/minute and the blood pressure is 230/100 mm Hg. The nurse acts quickly, suspecting that the client is experiencing which condition?
1. Spinal shock
2. Pulmonary embolism
3. Autonomic dysreflexia
4. Malignant hyperthermia

A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client's vital signs, the nurse takes the following actions. Arrange the actions in the order that they should be performed. All options must be used.
1. Raise the head of the bed.
2. Check for bladder distention.
3. Contact the health care provider.
4. Loosen tight clothing on the client.
5. Administer an antihypertensive medication.
6. Document the occurrence treatment, and response.

A client in the postpartum unit complains of sudden, sharp chest pain. The client is tachycardic, and the respiratory rate is increased. The health care provider diagnoses a pulmonary embolism. Which actions should the nurse plan to take? Select all that apply.
1. Administer oxygen.
2. Assess the blood pressure.
3. Start an intravenous (IV) line.
4. Prepare to administer morphine sulfate.
5. Place the client on bed rest in a supine position.
6. Prepare to administer warfarin sodium (Coumadin).

A client whose cardiac rhythm was normal sinus rhythm suddenly exhibits a different rhythm on the monitor. The nurse should take which action?

1. Continue to watch the monitor.
2. Contact the health care provider.
3. Check to see if cardiac medications are due.
4. Call respiratory therapy to do a respiratory treatment.

The nurse is assisting in the care of a client who is being seen in the clinic with a suspected acetaminophen (Tylenol) overdose. Which medication should the nurse plan to have readily available if the suspected diagnosis is confirmed?
1. Auranofin (Ridaura)
2. Pentostatin (Nipent)
3. Fludarabine (Fludara)
4. Acetylcysteine (Mucomyst)

A client presents to the urgent care center with complaints of abdominal pain and vomits bright red blood. Which is the priority nursing action?
1. Take the client's vital signs.
2. Perform a complete abdominal assessment.
3. Obtain a thorough history of the recent health status.
4. Prepare to insert a nasogastric tube and test pH and occult blood.

The nurse is admitting a child who arrived from the emergency department after treatment for acetaminophen (Tylenol) overdose. The nurse reviews the child's record and expects to note that the child received which medication for the acetaminophen overdose?
1. Protamine sulfate
2. Epoetin alfa (Epogen)
3. Acetylcysteine (Mucomyst)
4. Ethylenediaminetetraacetic acid (EDTA)

The nurse is monitoring a child who is receiving ethylenediaminetetraacetic acid (EDTA) with BAL (British anti-Lewisite) for the treatment of lead poisoning. The nurse reviews the laboratory results of the child during treatment with this medication and is particularly concerned with monitoring which laboratory test result?
1. Cholesterol level
2. Blood urea nitrogen (BUN) level
3. Complete blood cell (CBC) count
4. Hemoglobin and hematocrit (H&H) levels

A 2-year-old child is being transported to the trauma center from a local community hospital for treatment of a burn injury that is estimated as covering over 40% of the body. The burns are both partial- and full-thickness burns. The nurse is asked to prepare for the arrival of the child and gathers supplies, anticipating that which treatment will be prescribed initially?
1. Insertion of a Foley catheter
2. Insertion of a nasogastric tube
3. Administration of an anesthetic agent for sedation
4. Application of an antimicrobial agent to the burns

A mother brings her child to the emergency department. Based on the child's sitting position, drooling, and apparent respiratory distress, a diagnosis of epiglottis is suspected. In anticipation of the health care providers prescriptions, in which order should the nurse deliver interventions for this child? Arrange the actions in the order that they should be performed. All options much be used.
1. Assess breath sounds.
2. Obtain a pulse oximetry reading.
3. Ask the mother about the precipitating events.
4. Obtain weight for correct antibiotic dose infusion.
5. Prepare for assisted ventilation and have necessary equipment available.

A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse, making rounds at 1545, finds the client is apprehensive, complaining of a pounding headache, is dyspneic with chills, and has an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first?
1. Shut off the infusion.
2. Sit the client up in bed.
3. Remove the angiocatheter and IV quickly.
4. Place the client in Trendelenburg's position.

When performing a surgical dressing change of a client's abdominal dressing, the nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. What should the nurse do next?
1. Apply a sterile dressing soaked with normal saline.
2. Irrigate the wound, and apply a dry sterile dressing.
3. Leave the incision exposed to the air to dry the area.
4. Apply a povidone-iodine (Betadine)–soaked sterile dressing.

The nurse is caring for a client with a chest tube who accidentally disconnects the tube from the drainage system when trying to get out of bed. The nurse should take which immediate action?
1. Immerses the end of the tube in sterile saline
2. Applies oxygen per nasal cannula at 2 L per minute
3. Places in prone position while the client holds a breath
4. Places a sterile dressing over the end of the chest tube

Which client situation is most appropriate for the nurse to consult with the rapid response team (RRT)?
1. A 56-year-old, fourth hospital day after coronary artery bypass procedure, sore chest, pain with walking, temperature 97° F, heart rate 84 beats/min, respirations 22 breaths/min, blood pressure 122/78 mm Hg, bored with hospitalization
2. A 45-year-old, 2 years after kidney transplant, second hospital day for treatment of pneumonia, no urine output for 6 hours, temperature 101.4° F, heart rate 98 beats/min, respirations 20 breaths/min, blood pressure 168/94 mm Hg
3. A 72-year-old, 24 hours after removal of a chest tube that was used to drain pleural fluid (effusion), temperature 97.8° F, heart rate 92 beats/min, respirations 28 breaths/min, blood pressure 136/86 mm Hg, anxious about going home
4. An 86-year-old, 48 hours after operative repair of fractured hip (nail inserted), alert, oriented, using patient-controlled analgesia (PCA) pump, temperature 96.8° F, heart rate 60 beats/min, respirations 16 breaths/min, blood pressure 120/82 mm Hg, talking with daughter