Kilgore College NURSING 1429041 MODULE 4 WEEK 4 EXAM

1. A client with carbon monoxide poisoning is treated in the emergency department of an acute care facility. Which clinical manifestations should the nurse expect in this client? Select all that apply.  dizziness  pulse oximetry of 99% on room air  headache  nausea and vomiting 2. A client arrives to the emergency department (ED), with reports of chest pain. Electrocardiograph (ECG) exhibits an elevated ST segment. What are the priority actions by the nurse? Select all that apply.  improving myocardial oxygenation  relieving pain  reduce cardiac output 3. A nurse is caring for a client after a lung biopsy. Which assessment findings would be anticipated? Select all that apply.  respiratory rate of 28 breaths/minute  oxygen saturation level of 94% on 3 L of oxygen  client stating pain level of 4 out of 10 that decreases with pain medication  client dozing when left alone but awakening easily  pink tinged sputum expectorated with coughing 4. The nurse is caring for a client who has sickle cell disease (SCD). The client is reporting pain in the back, chest, and extremities. The nurse anticipates that the client may present with what other clinical manifestation(s)? Select all that apply.  nausea  hypertension  tachypnea  swelling 5. A neonate has been placed on cardiac and apnea monitoring in the neonatal nursery. The nurse notes that the apnea alarm repeatedly triggers. Place the following actions in the order they would be completed by the nurse. All options must be used.  Perform a focused assessment on the neonate.  Count the respiratory rate for 60 seconds.  Silence the alarm to decrease environmental stimuli.  Check all connections on the apnea monitor.  Document the assessment findings, interventions, and neonate’s response. 6. The nurse working in a critical care unit is a caring for a client that experiences respiratory arrest. In what order will the nurse respond? All options must be used.  Call for emergency help.  Begin emergency resuscitation.  Document the resuscitation.  Complete an incident report.  Alert the family to the event.  Restock the room with emergency equipment. 7. A client was admitted to the emergency department (ED) following a workplace accident and has just experienced brainstem death. The nurse recognizes that the client is likely an appropriate donor for tissue and organs. What actions related to organ donation should the (ED) nurse perform?  Ensure that the family has a quiet, private place to discuss their decision around tissue donation.  Support and validate the decision that the client's family makes. 8. The unlicensed assistive personnel (UAP) reports to the registered nurse that a client admitted with pneumonia is very diaphoretic. The nurse reviews the following vital signs in the medical record obtained by the UAP. What should the nurse do? Select all that apply.  Check the urine output.  Ask the client to drink more fluids.  Notify the health care provider (HCP).  Administer acetaminophen as prescribed. 9. A nurse, on the pediatric unit, received shift handoff on a 15-month-old with the following needs. Using Maslow’s hierarchy framework, prioritize the following nursing care activities for the toddler. All options must be used.  clearing the airway of thick secretions  notifying the health care provider about suspected compartment syndrome  changing a soiled diaper  administering antipyretics for an axillary temperature of 103°F (39.4°C)  progressing the diet after surgery 10. The nurse is teaching a client how to use a metered-dose inhaler. Place the steps for using a metered-dose inhaler in order. All options must be used.  Remove cap and hold the inhaler upright.  Shake the inhaler.  Tilt head back slightly and breathe out slowly all the way.  Open mouth and position inhaler 1 to 2 in (2.5 to 5 cm) away from mouth.  Press the button on the inhaler while breathing in.  Breathe in slowly and deeply for as long as possible. 11. The nurse is caring for a pediatric client that is having an allergic reaction to food. Place the nursing actions for providing care to this client in chronological order. All options must be used.  Assess respiratory effort.  Administer a histamine blocker.  Ask the family what foods the child is allergic to.  Document the reaction.  Provide teaching about medications. 12. A client on mechanical ventilation continues to be hypoxic following therapy with positive endexpiratory pressure (PEEP). The nurse prioritizes what intervention to reduce oxygen demand?  Administer neuromuscular blockers. 13. The nurse is caring for a 7-year-old client with asthma on a pediatric medical unit. What aspect of the client's medical history alerts the nurse to a higher risk for an acute, severe asthma exacerbation?