EXAM QUESTIONS AND ANSWERS 100%
CORRECT!!
, A nurse on a Medical Surgical unit is caring for a group of clients. The nurse should
notify the rapid response team for which of the following clients?
A. Client who has a pressure injury of the right heel whose blood glucose is 300mg/dL
B. Client who reports right calf pain and shortness of breath
C. Client who has blood on a pressure dressing in the femoral area following a cardiac
catheterization
D. Client who has dark red coloration of left toes and absent pedal pulse -ANSWER B.
Client who reports right calf pain and shortness of breath
Rational: SOB could be from a PE
A nurse is caring for a client who has ingested a toxic agent. Which of the following
actions should the nurse plan to take? (Select all that apply)
A. Induce vomitting
B. Instill activated charcoal
C. Perform a gastric lavage with aspiration
D. Administer syrup of ipecac
D. Infuse IV fluids -ANSWER B. Instill activated charcoal
C. Perform a gastric lavage with aspiration
D. administer IV fluids
A nurse in the emergency department is caring for a client who fell through the ice on a
pond and is unresponsive and breathing slowly. Which of the following actions should
the nurse take? (Select all that apply)
A. Remove wet clothing
B. Maintain normal room temperature
C. Apply warm blankets
D. Use a rapid rewarming water of 40 to 42
E. Infuse warmed IV fluids -ANSWER A. Remove wet clothing
C. Apply warm blankets
D. Use a rapid rewarming water of 40 to 42
E. Infuse warmed IV fluids
A nurse in the emergency department is assessing a client who is unresponsive. The
clients partner states, "He was pulling weeds in the yard and slumped to the ground."
Which of the following techniques should the nurse use to open the clients airway?
A. Head tilt, chin lift
B. Modified Jaw thrust
C. Hyperextension of the head
D. Flexion of the head -ANSWER A. Head tilt, chin lift