Critical Care- NCLEX

The nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to check which item? - Vital signs Rationale: A change in the vital signs may indicate that a transfusion reaction is occurring. The nurse assesses the client's vital signs before the procedure to obtain a baseline every 15 minutes for the first half hour after beginning the transfusion and every half hour thereafter. Skin color, oxygen saturation, and most recent hematocrit may be checked but are not the most important. A client who is receiving a blood transfusion pushes the call light for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. How should the nurse correctly interpret these findings? - Transfusion reaction Rationale: The signs and symptoms exhibited by the client are consistent with a transfusion reaction. With bacteremia, the client would have a fever, which is not part of the clinical picture presented. With fluid (circulatory) overload, the client would have crackles in addition to dyspnea. There is no correlation between the signs mentioned in the question and hypovolemic shock. The signs identified in the question are indicative of an allergic reaction, which is one type of blood transfusion reaction. A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which area? - The blood bank Rationale: The nurse prepares to return the blood transfusion bag containing any remaining blood to the blood bank. This allows the blood bank to complete any follow-up testing procedures that are needed after a transfusion reaction has been documented. The remaining options are incorrect. The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100° F (37.7° C) orally. The nurse reports the finding to the registered nurse (RN) and anticipates that which action will take place? - The blood will be held, and the primary health care provider (PHCP) will be notified. Rationale: If the client has a temperature of 100° F (37.7° C) or more, the unit of blood should be held until the primary health care provider (PHCP) is notified and has the opportunity to give further prescriptions. The other options are incorrect actions. The nurse is doing a routine assessment of a client's peripheral intravenous (IV) site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which has probably occurred? - Infiltration Rationale: An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. The pallor, coolness, and swelling are the result of IV fluid being deposited into the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The other options identify complications that are likely to be accompanied by warmth at the site rather than coolness. The nurse is checking the insertion site of a peripheral intravenous (IV) catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is likely the result of which? - Phlebitis of the vein Rationale: Phlebitis at an IV site results in discomfort at the site and redness, warmth, and swelling proximal to the IV catheter. The IV catheter should be removed, and a new IV line should be inserted at a different site. The remaining options are incorrect; the signs and symptoms in the question are not associated with these conditions. The nurse has been instructed to remove an intravenous (IV) line. The nurse removes the catheter by withdrawing the catheter while applying pressure to the site with which item? - Sterile 2 × 2 gauze Rationale: A dry, sterile dressing such as sterile 2 × 2 gauze is used to apply pressure to the site while the catheter is discontinued and removed. This material is absorbent, sterile, and nonirritating to the site. A Band-Aid may be used to cover the site after hemostasis has occurred. An alcohol swab or Betadine would irritate the opened puncture site and would not stop the blood flow. A client is going to be transfused with a unit of packed red blood cells (PRBCs). The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started? - 15 minutes Rationale: The nurse must remain with the client for the first 15 minutes of a transfusion, which is the most likely time that a transfusion reaction will occur. This enables the nurse to detect a reaction and intervene quickly. The nurse engages in safe nursing practice by obtaining coverage for the other clients during this time. Five minutes is too short of a time period, while 30 and 45 minutes are lengthy time periods. The nurse is assisting with caring for a client who is receiving a unit of packed red blood cells (PRBCs). The nurse should tell the client that it is most important to report which sign(s) immediately? - Chills, itching, or rash Rationale: The client is told to report chills, itching, or rash immediately, because these could be signs of a possible transfusion reaction. Mild discomfort at the catheter site may be indicative of a problem, or it could result from the size of the IV catheter required to infuse the blood product. Sore throat, earache, sleepiness, and fatigue are unrelated to a transfusion reaction. The nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which finding? - A decrease in oozing from puncture sites and gums Rationale: Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or the oozing of blood from puncture sites, wounds, and mucous membranes. The client's temperature would decline to normal after the infusion of granulocytes if those transfused cells were then instrumental in fighting infection in the body. Increased hemoglobin and hematocrit levels would be seen when the client has received a transfusion of red blood cells. A mother calls a neighborhood nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. Which action should the nurse instruct the mother to take first? - Call the poison control center. Rationale: If a suspected poisoning occurs, the poison control center should be contacted immediately. The nurse can assist the mother with contacting the poison control center. Vomiting should not be induced without instructions from the poison control center. Inducing vomiting is not done if the client is unconscious or the substance ingested is a strong corrosive or petroleum product. Bringing the child to the emergency department or calling an ambulance would delay treatment. The poison control center may advise the mother to bring the child to the emergency department; if this is the case, the mother should call an ambulance. The nurse is assigned to assist with caring for a client who is at risk for eclampsia. If the client progresses from preeclampsia to eclampsia, the nurse should take which action first? - Clear and maintain an open airway. Rationale: The first actions are to maintain an open airway and to prevent injuries to the client. The client should be turned to the side and monitored for airway compromise. Options 1, 3, and 4 may be components of care, but they are not the first actions. The nurse is assisting with caring for a client with abruptio placentae. While caring for the client, the nurse notes that the client begins to develop signs of shock. The nurse should take which action first? - Turn the client onto her side. Rationale: With a pregnant client who is in shock, the nurse should want to increase perfusion to the placenta to minimize fetal distress. A simple way to do this that requires no equipment is to turn the mother on her side. This increases blood flow to the placenta by relieving pressure from the gravid uterus on the great vessels. The nurse should immediately contact the registered nurse, who then contacts the health care provider. The other options should follow quickly. A woman in active labor has contractions every 2 to 3 minutes that last for 45 seconds. The fetal heart rate between contractions is 100 beats per minute. On the basis of these findings which is the priority nursing action? - Notify the registered nurse (RN) immediately. Rationale: Fetal bradycardia between contractions may indicate the need for immediate medical management. The nurse should immediately contact the RN, who then contacts the health care provider. Monitoring maternal vital signs, labor progress, and encouraging relaxation and breathing techniques will delay necessary and immediate interventions. The nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The client suddenly complains of chest pain and dyspnea. The nurse should initially check which item? - Vital signs Rationale: Pulmonary embolism is a complication of thrombophlebitis. Changes in the vital signs are one of the first things to occur with pulmonary embolism, because pulmonary blood flow is compromised. Fundal height is unrelated to the information in the question. Calf pain is an indicator of thrombophlebitis. Level of consciousness may change as the condition worsens; worsening would indicate hypoxia. The nurse suspects that the client has a pulmonary embolism. Which is the most important nursing action? - Administer oxygen by face mask, as prescribed. Rationale: Because pulmonary circulation is compromised in the presence of an embolus, cardiorespiratory support is initiated by oxygen administration. Monitoring vital signs and elevating the head of the bed may be components of the plan of care, but they are not the most important actions from the options provided. The nurse should not increase the intravenous rate without a prescription from the PHCP to do so. The nurse notes that the 4-hour postpartum client has cool, clammy skin and that she is restless and excessively thirsty. The nurse immediately notifies the registered nurse and then performs which action? - Checks the vital signs Rationale: Signs/symptoms of hypovolemia include cool, clammy, and pale skin; feelings of anxiety and restlessness; and thirst. The nurse should check the vital signs. The nurse does not ambulate the client or encourage fluids until specific prescriptions are given to do so. There is no information in the question to indicate the need for fundal massage. The nurse in the newborn nursery receives a telephone call to prepare for the admission of a neonate born at 43 weeks' gestation with Apgar scores of 1 and 4. When planning for the admission of this infant, which is the nurse's highest priority? - Connecting the resuscitation bag to the oxygen outlet Rationale: The highest priority during the admission to the nursery of a newborn with low Apgar scores is airway support, which would involve preparing respiratory resuscitation equipment. The remaining options are also important, although they are of lower initial priority. The newborn infant will be placed on a cardiorespiratory monitor. Setting up an intravenous line with 5% dextrose in water would provide circulatory support and may be prescribed. The radiant warmer will provide an external heat source, which is necessary to prevent further respiratory distress. A child is brought to the emergency room and the mother reports that the child accidentally swallowed paint thinner after mistaking it for water. The nurse should perform which action first? - Check the circulation, airway, and breathing status of the child. Rationale: A,B,C's of nursing. Actions to take in the case of a child swallowing poison include assessing the child and treating the child first, not the poison. Circulation, airway and breathing, and vital signs need to be assessed. Resuscitation measures would be initiated if the assessment indicates a need. The next step is to terminate exposure to the poison, such as emptying the mouth of pills or other materials or flushing the skin with water. Then identify the poison, if possible, and take measures to prevent absorption of the poison, such as administering the antidote if known. Transport the child to an emergency department for further treatment. A 4-year-old child sustains a fall at home injuring the right arm and is brought to the emergency department by the mother. The nurse should perform which emergency actions in the care of the child? Select all that apply. - Elevate the right arm. Check the neurovascular status of the right extremity. Determine the level of pain using a pediatric pain assessment tool. Rationale: Emergency nursing actions to take for a child sustaining an extremity fracture include elevating the injured extremity, checking the extent of the injury including pain level, immobilizing the affected extremity, applying cold packs to the injured area, and monitoring the neurovascular status of the extremity. The client arrives at the emergency department after a burn injury that occurred in their home basement and an inhalation injury is suspected. Which should the nurse anticipate as being prescribed for the client? - 100% oxygen via a tight-fitting, nonrebreather face mask Rationale: If an inhalation injury is suspected, the administration of 100% oxygen via a tight-fitting, nonrebreather face mask is prescribed until the carboxyhemoglobin level falls below 15%. With inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation is also determined. Options 1, 2, and 3 are incorrect. The nurse is caring for a client who has just been admitted to the nursing unit after receiving flame burns to the face and chest. The nurse notes a hoarse cough, and the client is expectorating sputum with black flecks. The client suddenly becomes restless and his color is becoming dusky. Based on this data, which interpretation should the nurse make? - The burn has probably caused laryngeal edema, which has occluded the airway. Rationale: The client exhibits several warning signs of an inhalation injury: a history of a flame burn to the face, hoarseness, cough, carbonaceous sputum, singed facial hair, facial edema, and color change. Additionally, one of the cardinal signs of hypoxia is restlessness. The nurse is assisting with caring for a client who is receiving intravenous fluids and who has sustained full-thickness burn injuries of the back and legs. The nurse understands that which would provide the most reliable indicator for determining the adequacy of the fluid resuscitation? - Urine output Rationale: Successful or adequate fluid resuscitation in the adult is signaled by stable vital signs, adequate urine output, palpable peripheral pulses, and a clear sensorium. The most reliable indicator for determining the adequacy of fluid resuscitation is the urine output. For an adult, the hourly urine volume should be 30 mL to 50 mL. A client is admitted to the emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially? - Maintain a patent airway. Rationale: The initial nursing action would be to maintain a patent airway. Oxygen would be administered, followed by fluid replacement. The nurse would also keep the client warm, monitor intravenous fluids, and administer thyroid hormones. The nurse is caring for a client on a cardiac monitor who is alone in a room at the end of the hall. The client has a short burst of ventricular tachycardia (VT), followed by ventricular fibrillation (VF). The client suddenly loses consciousness. Which intervention should the nurse do first? - Call for help and initiate cardiopulmonary resuscitation (CPR). Rationale: When ventricular fibrillation occurs, the nurse remains with the client and initiates CPR until a defibrillator is available and attached to the client. To use an external cardiac defibrillator on a client, which action should be performed to check the cardiac rhythm? - Applying the adhesive patch electrodes to the skin and moving away from the client Rationale: The nurse or rescuer puts two large adhesive patch electrodes on the client's chest in the usual defibrillator position. The nurse stops cardiopulmonary resuscitation and orders anyone near the client to move away and not touch the client. The defibrillator then analyzes the rhythm which may take up to 30 seconds. The machine then indicates if it is necessary to defibrillate. Although automatic external defibrillation can be done transtelephonically, it is done through the use of patch electrodes (not standard electrocardiographic electrodes) that interact via telephone lines to a base station that controls any actual defibrillation. It is not necessary to hold defibrillator paddles against the client's chest with this device. The client brought to the emergency department is experiencing an anaphylactic reaction from eating shellfish. The nurse should implement which immediate action? - Maintaining a patent airway Rationale: If the client experiences an anaphylactic reaction, the immediate action would be to maintain a patent airway. The client then would receive epinephrine. Corticosteroids may also be prescribed. The client will need to be instructed about obtaining and wearing a Medic-Alert bracelet, but this is not the immediate action. Skin breakdown occurs on a client's hand at the site of an intravenous catheter that had medication infusing. The nurse determines that which adverse effect occurred? Refer to figure. - Extravasation Rationale: Extravasation refers to the tissue injury that occurs from leakage of medication into surrounding skin and subcutaneous tissue; it can also cause tissue necrosis. Phlebitis is an inflammation of the vein that can occur from mechanical or chemical (medication) trauma or from a local infection. Phlebitis can cause the development of a clot (thrombophlebitis). Infiltration is seepage of the intravenous fluid out of the vein and into the surrounding interstitial spaces. It is a form of tissue injury, but the injury is not to the extent that occurs with extravasation. A client who is receiving total parenteral nutrition (TPN) complains of a headache. The nurse notes that the client has an increased blood pressure and a bounding pulse. The nurse reports the findings, knowing that these signs/symptoms are indicative of which complication of this therapy? - Fluid overload Rationale: The client's signs and symptoms are consistent with fluid overload. The increased intravascular volume increases the blood pressure, whereas the pulse rate increases as the heart tries to pump the extra fluid volume. A fever would be present in a client with sepsis. Signs and symptoms of an air embolus include confusion, pallor, lightheadedness, tachycardia, tachypnea, hypotension, anxiety, and unresponsiveness. Polyuria, polydipsia, and polyphagia are manifestations of hyperglycemia. The primary health care provider prescribes one unit of packed red blood cells to infuse over 4 hours. One unit of blood contains 250 mL, and the drop factor is 10 gtt/1 mL. Although an infusion pump will be used, the registered nurse asks the licensed practical nurse (LPN) to assist with monitoring the flow rate during the infusion. The LPN monitors the flow rate, knowing that how many gtt/min should infuse? Fill in the blank and round answer to the nearest whole number. - 10gtt/min Rationale: The prescribed 250 mL is to be infused over 4 hours. Follow the formula, and multiply 250 mL by 10 (gtt factor). Then divide the result by 240 minutes (4 hours × 60 minutes). The infusion is to run at 10.4 or 10 gtt/min. The nursing student is asked to describe the correct steps for performing adult cardiopulmonary resuscitation (CPR). Arrange the steps of adult CPR in the order of priority. All options must be used. - 1. Determine unconsciousness by shaking the client and asking, "Are you OK?" 2. Perform chest compressions. 3. Open the client's airway 4. Initiate breathing. Rationale: The sequence for basic CPR for primary health care providers follows the CAB—compressions, airway, breathing—procedure. After determining unconsciousness, compressions are started. A client presents to the emergency department with upper gastrointestinal (GI) bleeding and is in moderate distress. Which nursing action should be the priority for this client? - Determine vital signs. Rationale: The determination of vital signs indicates whether the client is in shock from blood loss and provides a baseline blood pressure and pulse by which to monitor the progress of treatment. Signs and symptoms of shock include low blood pressure; rapid, weak pulse; increased thirst; cold, clammy skin; and restlessness. Vital signs and level of consciousness should be monitored at least every 15 to 30 minutes for signs of hemodynamic compromise, and the primary health care provider should be informed of any significant changes. The client may not be able to provide subjective data until the immediate physical needs are met. Although completing an abdominal assessment and inserting a nasogastric tube and testing the emesis for the presence of blood may be components of care, they are not the priorities. The nurse is assisting in monitoring the condition of a client after pericardiocentesis for cardiac tamponade. Which observation indicates that the procedure was unsuccessful? - Distant and muffled heart sounds Rationale: Following pericardiocentesis, the client usually expresses immediate relief. Heart sounds are no longer muffled or distant. Clear breath sounds and clearly audible heart sounds are positive signs. A client is receiving thrombolytic therapy by continuous infusion. The client suddenly becomes extremely anxious and complains of itching. The nurse hears stridor, and on examination of the client, notes generalized urticaria and hypotension. Which should be the priority action of the nurse? - Stop the infusion, and notify the registered nurse. Rationale: The client is experiencing an anaphylactic reaction to thrombolytic therapy. The infusion should be stopped; the registered nurse notified; and the client treated with epinephrine, antihistamines, and corticosteroids as prescribed. A family of a spinal cord-injured client 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 complains of a severe headache. The pulse is 40 beats per minute, and the blood pressure is 230/100 mm Hg. The nurse acts quickly, knowing that the client is experiencing which condition? - Autonomic dysreflexia Rationale: The client with spinal cord injury above the level of T7 is at risk for autonomic dysreflexia. It is characterized by severe, throbbing headache; flushing of the face and neck; bradycardia; and sudden, severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea, and sweating. It is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury. A client who has been receiving total parenteral nutrition by way of a central venous access device complains of chest pain and dyspnea. The nurse quickly assesses the client's vital signs and notes that the pulse rate has increased and that the blood pressure has dropped. The nurse determines that the client is most likely experiencing which sign? - Air embolism Rationale: The signs and symptoms of air embolism include chest pain, dyspnea, hypoxia, anxiety, tachycardia, and hypotension. The nurse also should hear a loud churning sound over the pericardium on auscultation of the chest. The signs and symptoms of sepsis include fever, chills, and general malaise. The signs and symptoms of a fluid imbalance depend on the type of imbalance that the client is experiencing. Fluid overload causes increased intravascular volume, which increases the blood pressure and the pulse rate as the heart tries to pump the extra fluid volume. Fluid overload also causes neck vein distention and the shifting of fluid into the alveoli, resulting in lung crackles. Complications should be reported to the registered nurse and/or the primary health care provider immediately. A client receiving intravenous (IV) fluid therapy complains of burning and a feeling of tightness at the IV insertion site. On data collection, the nurse detects coolness and swelling at the site and notes that the IV rate has slowed. The nurse determines that which has occurred? - Infiltration Rationale: An infiltrated IV line is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness, and swelling at the IV site result when IV fluid is deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of IV solution will slow down or stop. The corrective action is to remove the catheter and start a new IV line at another site. Infection, phlebitis, and thrombosis are likely to be accompanied by warmth at the site, not coolness. One unit of packed red blood cells is infusing into a client over a 4-hour period. The unit of blood contains 250 mL. The drop factor is 15 drops (gtt) per 1 mL. The nurse determines that the flow rate should be set at how many drops per minute? Fill in the blank and round answer to the nearest whole number. - 15.625 or 16 gtt/min Rationale: Total volume × gtt factor ------------------------- = gtt/min Time in minutes 250 mL × 15 gtt 3750 ------------------ = ---- 240 (4 hr × 60 min) 240 = 15.625 or 16 gtt/min The nurse is performing a vaginal check of a pregnant client in labor. The nurse notes that the umbilical cord is protruding from the vagina. Which action should the nurse immediately perform? - Exert upward pressure against the presenting part with gloved fingers. Rationale: If the umbilical cord is protruding from the vagina, no attempt should be made to replace it because to do so could traumatize it and further reduce blood flow. The nurse should place a gloved hand into the vagina toward the cervix and exert upward pressure against the presenting part to relieve compression of the cord. The nurse also should wrap the cord loosely in a sterile towel saturated with warm, sterile normal saline solution. Oxygen, 8 to 10 L/minute by face mask, is administered to the mother to increase fetal oxygenation, and the client is prepared for immediate delivery. However, the immediate action is to relieve pressure on the cord. The client would already have an external fetal monitor in place. A client in the postpartum unit complains of sudden, sharp chest pain. The client is tachycardic and the respiratory rate is increased, and the primary health care provider diagnoses a pulmonary embolism. Which interventions apply to the care of this client? Select all that apply. - Administer oxygen. Monitor the blood pressure. Prepare to administer morphine sulfate. Prepare to start an intravenous (IV) line. The nurse is checking the date of an intravenous (IV) insertion in a client. The insertion date on the dressing is 2/9 (February 9). The nurse calculates that the site should be changed on which date? - 2/12 Rationale: The IV site should be changed very 72 to 96 hours based on the Center for Disease Control guidelines. With an insertion date of 2/9, the due date for change should be 2/12. Changing the IV site every 5 to 7 days would place the client at risk for site infection. The nurse is reinforcing instructions regarding cardiopulmonary resuscitation (CPR) to a group of nursing students. The nurse tells the group that when performing chest compressions on adults, the sternum should be depressed to at least which depth? - 2 inches Rationale: When performing CPR on adults, the sternum is depressed at least 2 inches. The remaining depths of compression could be ineffective or harmful. A child is admitted to the burn unit with partial- and full-thickness burns over 35% of the body. The nurse assisting in caring for the child develops the plan of care. Which nursing intervention is the priority? - Inserting a Foley catheter Rationale: A Foley catheter is inserted into the child's bladder so that urine output can be accurately measured hourly. Although pain medication may be required, the child should not be sedated. IV fluids are not restricted and are administered at a rate sufficient to maintain adequate tissue perfusion. A child is hospitalized with a diagnosis of lead poisoning. The nurse caring for the child should prepare to assist in administering which medication? - Dimercaprol Rationale: Dimercaprol is a chelating agent that is administered to remove lead from the circulating blood and from some tissues and organs for excretion in the urine. Sodium bicarbonate may be used in salicylate poisoning. Syrup of ipecac is used in the hospital setting in poisonings to induce vomiting. Activated charcoal is used to decrease absorption in certain poisoning situations. Note that dimercaprol is prepared with peanut oil, and hence should be avoided by clients with known or suspected peanut allergy. The emergency department nurse is caring for a child brought to the emergency department following the ingestion of approximately one half bottle of acetylsalicylic acid (aspirin) 10 minutes before arrival. Which should the nurse anticipate as the likely initial treatment? - The administration of activated charcoal Rationale: Initial treatment of salicylate overdose includes administration of activated charcoal to decrease absorption of the aspirin. Intravenous (IV) fluids and inducing emesis may be prescribed to enhance excretion but would not be the initial treatment. Dialysis is used in extreme cases if the child is unresponsive to therapy. Vitamin K is the antidote for warfarin overdose The nurse is assisting in preparing to administer acetylcysteine to a client with an overdose of acetaminophen. How should the nurse administer the medication? - Mix the medication in a flavored ice drink, and allow the client to drink the medication through a straw. Rationale: Because acetylcysteine has a pervasive odor of rotten eggs, it must be disguised in a flavored ice drink. It is consumed preferably through a straw to minimize contact with the mouth. It is not administered by the intramuscular or subcutaneous route. The nurse is assigned to care for a client who has experienced uterine rupture. The nurse plans care knowing that which is the priority concern in caring for the client? - Impaired gas exchange Rationale: The priority should always deal with airway. Although options 1, 2, and 3 are also appropriate concerns for this client, they are not the priority and assume a lesser priority than impaired gas exchange. The nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. Which is the most appropriate action? - Remove the IV. Rationale: Blanching, coolness, and edema of the IV site are signs of infiltration. Because infiltration can be damaging to the surrounding tissue, the most appropriate action is to remove the IV to prevent any further damage. The nurse should not depend solely on the blood return for assurance that the cannula is in the vein because a blood return may be present even if the cannula is only partially in the vein. Warm compresses may be applied to the infiltrated area only after the IV is removed and only if the infiltrated solution is not damaging to the surrounding tissues. Measuring the area of infiltration should only be done after the IV has been removed so that further tissue damage is assessed. A client who sustained an inhalation injury arrives in the emergency department. On data collection, the nurse notes that the client is very confused and combative. The nurse determines that the client is experiencing which problem? - Hypoxia Rationale: After a burn injury, clients are normally alert. If a client becomes confused or combative, hypoxia may be the cause. Hypoxia occurs after inhalation injury and may occur after an electrical injury. The data in the question is not specifically related to options 1, 2, or 4. A client is brought to the emergency department following a smoke inhalation injury. The initial nursing action is to prepare the client to receive which treatment? - 100% humidified oxygen by face mask Rationale: If the client sustains a smoke inhalation injury, the client is treated immediately with 100% humidified oxygen delivered by face mask. Oxygen via nasal cannula will not provide adequate oxygenation. Endotracheal intubation is needed if the client exhibits respiratory stridor, which then indicates airway obstruction. Pain management is necessary but is not the initial concern. An emergency department nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area. The client sustained the burn from a home fire that occurred in the basement. Which data would indicate that the client sustained a respiratory injury as a result of the burn? - Use of accessory muscles for breathing Rationale: Clinical indicators in a burn client that would indicate respiratory injury include the presence of facial burns, the presence of soot around the mouth or nose, and singed nasal hairs. Signs of respiratory difficulty include changes in respiratory rate and the use of accessory muscles for breathing. Although anxiety may be a sign of hypoxemia, anxiety along with bradycardia, dysrhythmias, and lethargy would most likely indicate a concern related to a respiratory injury. Abnormal breath sounds and abnormal arterial blood gas values would also be noted. Pain is not specifically related to a respiratory injury. A postpartum client has lost 700 mL of blood. The vital signs indicate hypovolemia and the uterus remains atonic in spite of treatment. The nurse assisting in caring for the client understands what is necessary in this situation and prepares the client for which treatment? - Emergency surgery Rationale: When uterine atony cannot be reversed, surgery is required. The nurse assists in administering first aid to a client who has been bitten by a snake on the right leg. The nurse should take which action? - Ensure that the victim is lying down, and remove restrictive items. Rationale: Initial first aid at the site of a snakebite includes having the victim lie down, removing constrictive items such as clothing or rings, providing warmth, cleansing the wound, covering the wound with a light sterile dressing, and immobilizing the injured body part below the level of the heart. Ice or a tourniquet is not applied during the acute stage. The nurse receives a telephone call from a neighbor who states that her child was found sitting on the floor near the kitchen sink playing with several bottles of cleaning fluids. The bottles of cleaning fluid were opened and spilled on the child and the floor, and the mother suspects that the child may have consumed some of the cleaning fluid. Which action should the nurse tell the mother to do immediately? - Call the area poison control center. Rationale: The area poison control center should be called if an unknown toxic agent has been ingested or if it is necessary to identify an antidote for a known toxic agent. Syrup of ipecac is not recommended for home use. It may be prescribed in a hospitalized setting under medical supervision. It induces vomiting but vomiting is not induced in an unconscious or after ingestion of caustic substances (acid or alkaline) or petroleum distillates. Calling an ambulance or calling the primary health care provider will delay necessary life-saving measures. The nurse discusses emergency nursing measures that are implemented at the site of an injury with a nursing student. Which initial action does the nurse tell the student to perform in the event of carbon monoxide poisoning? - Carry the client to fresh air. Rationale: Whenever a victim inhales a poison, the victim is carried immediately to fresh air. Any tight clothing is then loosened and CPR is initiated if necessary. Oxygen is administered as soon as possible. Chilling is prevented, and the victim is wrapped in blankets and kept as quiet as possible. During the emergent phase of a client with severe burns the nurse expects to perform which action? - Insert a Foley catheter. Rationale: In the emergent phase of severe burns, a Foley catheter is inserted to monitor hourly urine output and provide data to determine whether fluid resuscitation is adequate. The minimum acceptable urine flow for an adult is 30 mL/hr. The other options would not be implemented in the emergent phase. The nurse is assisting in caring for a victim of a burn injury during the emergent/resuscitative phase. On data collection of the client, the nurse notes that the urine output has decreased and the blood pressure is dropping. The nurse should perform which immediate action? - Notify the registered nurse. Rationale: The nurse notifies the registered nurse, who will then notify the primary health care provider immediately if the burn client exhibits a decreased urine output or blood pressure or an increased pulse rate. Because of the rapid fluid shifts that occur in burn shock, fluid deficit must be detected early so that distributive shock does not occur. The nurse does not increase an IV rate without a specific prescription to do so. Checking the client in 30 minutes will delay necessary interventions to prevent the development of distributive shock. A warm environment is maintained, but this is not the immediate action. The nurse notes that a client who is attached to a cardiac monitor suddenly develops atrial fibrillation at a rate of 130 beats per minute. The nurse immediately notifies the registered nurse and prepares the client for which initial intervention? - Administration of a calcium channel blocker Rationale: The initial treatment goal when atrial fibrillation suddenly occurs is to control the rate of impulses with the administration of a calcium channel blocker or a beta blocker. Defibrillation is indicated when a client is in pulseless ventricular tachycardia or ventricular fibrillation. Electrical cardioversion is an option for atrial fibrillation if the client is clinically unstable or if the client has not responded to chemical cardioversion after a 6-week period of anticoagulant therapy. Anticoagulant therapy, for example, with a continuous heparin infusion, is indicated to prevent development of thrombus formation in the atria but is not the priority over rate control. A client who experienced ventricular fibrillation has just been defibrillated. Following the defibrillation, which action should the nurse take immediately? - Resume cardiopulmonary resuscitation (CPR). Rationale: Following defibrillation, the nurse immediately resumes CPR for 2 minutes. Even if a normal rhythm has been restored, the heart pump needs to be reprimed to provide improved cerebral blood flow to improve neurological outcome. Options 1, 2, and 3 are not immediate actions following defibrillation. The nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. Based on these findings, the nurse plans to take which initial nursing action? - Remove the IV. Rationale: Phlebitis at an IV site can be determined by client discomfort at the site, as well as by redness, warmth, and swelling proximal to the catheter. The line should be removed, and a new line should be inserted at a different site. Options 2 and 4 are incorrect. The primary health care provider should be notified if phlebitis occurred, but this is not the initial action. A client rings the call light and complains of pain at the site of an intravenous (IV) infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which actions in the care of this client? Select all that apply. - Remove the IV catheter at that site. Apply warm moist packs to the site. Notify the primary health care provider (PHCP). Document the occurrence, actions taken, and the client's response. The nurse determines that a student in a basic cardiac life support (BCLS) course correctly performs cardiopulmonary resuscitation (CPR) on an infant when the nurse observes which rate of chest compressions delivered to the infant mannequin? - 100 times per minute Rationale: In an infant, the rate of chest compressions is at least 100 per minute. All other options are incorrect rates of compression based on current recommendations. A client has had extensive surgery on the gastrointestinal tract and has been started on total parenteral nutrition (TPN). The client tells the nurse, "I think I'm going crazy. I feel like I'm starving, and yet that bag is supposed to be feeding me." Which is the best response from the nurse? - "That is because the empty stomach sends signals to the brain to stimulate hunger." Rationale: The stomach does send signals to the brain when it is empty to stimulate hunger. The client should be told that this is normal. Some clients also experience food cravings for the same reason. Options 1 and 4 will block the communication process. Option 2 will produce fear in the client. A mother of a 6-year-old child calls the nurse who lives in the neighborhood and tells the nurse that her child accidentally rubbed waterproof sunscreen in his eyes. Which action should the nurse tell the mother to immediately perform? - Call the poison control center. Rationale: Waterproof sunscreen should never be placed near the eyes. Waterproof sunscreen causes severe pain and a chemical burn that can damage the child's vision. Flushing the eyes with water does not stop the burning. The mother should be instructed to call the poison control center and to take the child to the emergency department. Special chemicals will be needed to flush the sunscreen out of the eyes and preserve vision. Wiping the eyes will increase the pain and burning. Blinking will not alleviate the pain or remove the sunscreen from the eyes. A mother of a 9-year-old child calls the emergency department and tells the nurse that her child received a minor burn on the hand after accidentally touching a grill during a family cookout. The mother asks the nurse for advice on how to treat the burn. Which action should the nurse tell the mother to immediately perform? - Place the child's hand under cool running water. Rationale: Most minor burns can be handled at home by the parents. For minor burns, exposure to cool running water is the best treatment. This stops the burning process and helps alleviate pain. Ice is contraindicated because it may add more damage to already injured skin. Option 4 is an incorrect measure. In addition, the mother may not have a sterile dressing available. The nurse is caring for a client in labor. The nurse notes the presence of fetal bradycardia on the fetal monitor and suspects that the umbilical cord is compressed. The nurse should immediately place the client in which position? - With the hips elevated Rationale: When cord compression is suspected, the woman is immediately repositioned. The client may be turned from side to side or the hips elevated to shift the fetal presenting part toward her diaphragm, thus relieving cord compression. A hand-and-knees position may also reduce compression on the cord that is entrapped behind the fetus. Several position changes may be required before the fetal pattern improves or resolves. Options 1, 2, and 3 are inappropriate positions and may cause further cord compression. The nurse who is assisting in caring for a client with a tracheostomy tube notes heavy bleeding from the stoma. The nurse also notes that the tracheostomy tube pulsates with the client's heartbeat. The nurse immediately performs which action? - Applies pressure to the artery at the stoma site Rationale: Heavy bleeding from a tracheostomy site is a life-threatening complication. Direct pressure is applied to the innominate artery at the stoma site. The client is then prepared for immediate surgical repair. An IV line will need to be initiated, but this is not the immediate action. The nurse is caring for a client who had a tracheostomy tube inserted 1 week ago. The client begins to cough vigorously, and accidental decannulation of the tracheostomy tube occurs. Which action should be the nurse's immediate response? - Replace the tracheostomy tube. Rationale: If decannulation of a tracheostomy tube occurs 72 hours after surgical placement of the tracheostomy, the nurse prepares to replace the tube. The nurse also calls the registered nurse for help immediately. The nurse extends the client's neck and opens the tissues of the stoma to secure an airway. With the obturator inserted into the new tracheostomy tube, the nurse quickly and gently replaces the tube and immediately removes the obturator. The nurse checks for airflow through the tube and for bilateral breath sounds. If unable to secure the airway, the nurse notifies the respiratory therapist and attempts to ventilate the client with a bag-valve mask (resuscitation bag) while waiting for help. If the client is in distress and further attempts to secure the airway fail, the nurse calls the resuscitation team, including an anesthesiologist, for assistance and calls a code if necessary. The nurse is preparing for the intershift report when a nurse's aide pulls an emergency call light in a client's room. On answering the light, the nurse finds a client experiencing tachycardia and tachypnea. The client's blood pressure is 88/60 mm Hg. Which action should the nurse take first? - Place the client in modified Trendelenburg's position. Rationale: The client is exhibiting signs of shock and requires emergency intervention. Placing the client in the modified Trendelenburg's position increases blood return from the legs, which increases venous return and subsequently the blood pressure. The nurse can then verify the client's blood volume status by assessing the urine output and ensuring that the IV is infusing without complications. The nurse should also check the client's pulse oximetry and notify the registered nurse.