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A nurse in the ER is assessing a client who was in a MVA. Findings include absent breath sounds
in the left lower lobe, dyspnea, BP 118/68, HR 124, RR 38, T 101.4F, and O2 92% on RA.
Which of the following actions should the nurse take first?
a. obtain chest x-ray
b. prepare for chest tube insertion
c. administer oxygen via high-flow mask
d. initiate IV access - (answer)c. administer oxygen via high flow mask
A nurse is orientating a newly licensed nurse on the purpose of administrating vecuronium to a
client who has ARDS. Which of the following statements by the newly licensed nurse indicates
understanding of teaching?
a. "This medication is given to treat infection"
b. "This medication is given to facilitate oxygenation"
,c. "This medication is given to decrease inflammation"
d. "This medication is given to reduce anxiety" - (answer)b. "This medication is given to
facilitate oxygenation"
A nurse is reviewing the health record of 5 clients. Which of the following clients are at risk for
developing ARDS? Select all that apply
a. client who experienced a near-drowning
b. client following coronary artery bypass surgery
c. client who's Hgb of 15.1 mg/dL
d. client with dysphagia
e. client who experienced acute drug toxicity - (answer)a. client who experienced a near-
drowning
b. client following coronary artery bypass surgery
d. client with dysphagia
e. client who experienced acute drug toxicity
,A nurse is planning care for a client who has SARS. Which of the following actions should the
nurse include in care? Select all that apply
a. administer ABX
b. provide supplemental O2
c. administer antiviral medication
d. administer bronchodilator
e. maintain ventilatory support - (answer)b. provide supplemental O2
d. administer bronchodilator
e. maintain ventilatory support
A nurse is caring for a client who is receiving vecuronium during mechanical ventilation. Which
of the following medications should the nurse anticipate administering with this medication?
a. fentanyl
b. furosemide
c. midazolam
, d. famotidine
e. dexamethasone - (answer)a. fentanyl - reduce pain
c. midazolam- sedative
A nurse is in the ER caring for a client who is experiencing an acute asthma attack. Which of the
following assessments indicate that the respiratory status is declining? Select all that apply
a. SaO2 95%
b. wheezing
c. retraction of sternal muscles
d. pink mucous membranes
e. tachycardia - (answer)b. wheezing
c. retraction of sternal muscles
e. tachycardia