CM IV, EXAM 1 CHAPTERS 8, 9, 10,

20.) A nurse enters a client’s room and sees that ashes from a cigarette are beginning to ignite trash in a waste basket. Which of the following actions should the nurse take first? a. Rescue the client from immediate danger 21.) A client is admitted to the emergency department with complaints of severe radiating chest pain, and a myocardial infarction is suspected the nurse immediately applies oxygen to the client and plans to take which action first? a. Call the laboratory to prescribe stat blood work b. Notify the coronary care unit to inform them that the client will need admission c. Obtain a 12-lead ECG d. Call radiology to prescribe a chest radiograph 22.) A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first? a. Wash the area of the puncture thoroughly with soap and water. 23.) A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. Which of the following clients should the nurse tag to be the priority for care? a. A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site 24.) An emergency department nurse is transferring a client to the medical-surgical unit. What is the most important nursing intervention in this situation? a. Clearly communicate client data to the unit nurse 25.) A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following is the priority intervention? a. Count the Respiratory rate 26.) An emergency department nurse is caring for a patient who had been taking in the mountains for the past 2 days. What are the most important indicators that a patient is experiencing high- altitude pulmonary edema (HAPE)? (NOT SURE IF I GOT THIS RIGHT) a. Confusion b. Ataxia c. Decreased level of consciousness d. Crackles in both lung fields e. Persistent dry cough 27.) A nursing is caring for a client who develops and airway obstruction from a foreign body but remains conscious. Which of the following actions should the nurse take first? a. Administer the abdominal thrust maneuver