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Someone with ARDS and their incubated and receiving mechanical ventilation and develop a right pneumo? What is the first thing you do? - Turn down the PEEP PEEP vent - Pressure given at the end of each breathing cycle to KEEP ALVEOLI OPEN Caring for someone they have ARF, bronchitis what medication prescription should we question? - Methylprednisolone by neb Someone with COPD into the ER with dyspnea and SOB? Which findings is priority? - Resp. rate of 10 Receive report on 4 clients, which is priority to see first? - 12 month old with diminished lung sounds Assessment pt. is SOB, diminished breath sounds in R lower lobe, x-ray shows large right plural effusion, what procedure is coming next? - Thoracentesis Evaluation of assist control vent. For ARF. What finding would indicate the client is tolerating this mode of ventilation? - Initiating spontaneous breath Preparing to suction a client with ET tube, what would be the first thing we do? - Listen to lung sounds and look at SaO2 (assess client first) Plan of care for pt. low potassium level, provide information on effects of medications and the dietary intakes of foods high in potassium. Outcome of plan would be evaluated how? - labs Caring for a client with ARDS with mechanical ventilation, looking at labs results, what would indicate to the RN that the ventilation is providing adequate gas exchange of the client? - Decrease CO2 and increase PO Administer IV morphine to a client who is 18hrs. post op and the pt.s reports feeling anxious and having incisional pain, 7.50, po2 29, Hco3 of 23. After morphine what would be expected to happen? - Decreased respiration, decrease pain, decrease pH Caring for client who had lung surgery and now has shallow respiration pattern and reluctant to cough? what should we assess for? - Atelectasis
Assess a client who has metabolic alkalosis due to food poisoning, we gave them fluid therapy? How do we evaluate if the treatment was successful? - pH decreased and HCO3 decreased Caring for a client with ARDS, vent. Evaluate gas exchange, adequate findings - VQ adequate ventilation perfusion ratio Child has cystic fibrosis. What prescribed intervention would we provide in the teaching? - Chest PT., digestive enzymes, postural drainage Caring for patient who has increased urination, blurred vision. Ph 7.30, HCO3 19, PCO 35? - (DKA) give fluids and insulin Explaining how to do postural drainage to a client, what intervention is appropriate when providing postural drainage? - Use pillows to help position the client Caring for client in ER, look at x-ray and see rib fractures and small flail chest injury, what is the appropriate action to take for this patient? - suction Long term aminoglycoside amnio therapy for infection, potassium is 5.4, ecg shows peak t-waves. What action do we take? - Polystyrene sulfonate Acute hypoxemic respiratory failure due to VQ mismatch, what intervention is appropriate for their care? - 24% to 32 % O2 via face mask Assessing a client with end stage kidney disease, serum lab results hypocalcemia, and hyperphosphatemia? - - LABS/FINDINGS
- Cardiac arrhythmia
- trousseau sign
- Fractures Acute resp. failure ineffective airway clearance? - - Promote fluid hydration
- encourage deep breathing
- incentive spirometry
- monitor secretions Provide DC resp. acidosis for COPD, what information would you include to prevent episodes of Resp. acidosis? - - Purse lipped breathing Blood gases with resp. failure. pH 7. poc2 20 o2 75 HCo3 28 sat. 92 (metabolic alkalosis) - - Vent. Patient
Blood gases. ph 7.48, o2 85, paco2 32 low , bicarb 25? - - Resp. alkalosis IV fluids and put in at 50ml/hr., 300 ml in 24 hours, have a headache. Lab shows low urine specific gravity. What action do we take? - - Increase their fluid intake Plan of care in ARF on mechanical vent? Suctioning can prevent? - SATA - All except (NOT dense space) Change of shift for assigned clients? Who do we assess first? - - Mag. 1. Prone positioning, how to evaluate that it was successful - - Pao2 60 to 85 Attending staff education about fluid balance, which statement would indicate correct understanding, regulation of body fluid? - - Fluid output
- Thirst triggers
- Lack of ADH ARF from COPD, intubated with ET, Vent. What action is priority to take? - - Auscultate first Telephone triage, spouse of client who as asthma and px. For short acting beta agonist. My spouse personal best is 290 now at 220? - - Use the beta agonist ER caring for client acute dyspnea, pain, anxiety, p 110, sat 85. ABGS 7.50, 29co2, bi
- What action should we take? (respiratory alkalosis) SATA - - Give pain
- give O
- have client breath slowly Opioid overdose, how to evaluate the goal is achieved - - Resp. rate of 20 with reg. rhythm
- 97 on room air,
- ABGS show compensation
- paco2 return to baseline Calcium 5.8, nurse obtaining blood pressure pt. experience carpal spasms? - - Assist client to breath into paper bag Client R. side pneumonia, help position client in left sims, evaluate the client outcome? -
- Pao2 compare to see if position helped Teaching a client who is being treated with bronchodilators, what teaching do we include? - - This med. can make you have difficulty breathing, notify right away ARDS, pulmonary embolism. What action should we take? - Assess breathing pattern
Report. Client intubated for Acute resp. failure an hour ago. What test result is priority? -
- End tidal CO Client with pneumonia, documentation of diagnosis of activity intolerance, implement which thing into plan of care? - - Check V/S and o2 sats. DKA potassium of 2.9, what action should we take first? - - Put them on tele monitor ICU after MVA, blunt trauma to chest, ARF, minimal sedation and trach. Monitor what? -
- Resp. system, V/S, ABGS ARF, restless and decrease cardiac output? Priority - - Prepare to incubate 7.32, pao2 88, co2 37, bicarb 16 - metabolic acidosis ER, non-productive cough, fever, fatigue, Assessment finding needs immediate action?
- Pao2 45 Client is on long term vent. Frustration when trying to communicate? - - Picture board and alphabet board. You are working in a mental health unit. A patient has a verbal outburst, pacing around the unit, and appears angry. What statement is appropriate by the nurse? - Please take a time out in your room. A nurse is planning care for a client with Rheumatoid Arthritis.What non pharmacological interventions should be included in their plan of care? - - Apply splints to inflamed joint
- select clothing with a hook and loop
- apply moist heat A client with a new diagnosis of HIV should expect what prophylactic measure? - - Hep B
- Pneumococcal
- Influenza What interventions should be included for a patient with a new diagnosis of MS? - Daily muscle strengthening A patient with a history of Chrons Disease an ascending colostomy bad. What finding would be a priority to follow up on? - Stoma that is dark purple, black, and dry A nurse is doing a genital assessment on a 22 year old male. The nurse notices multiple cauliflower shaped papules. What should the nurse document these as? - Genital warts
Caring for a patient with increased ICP. Nursing diagnosis of ineffective cerebra tissue perfusion. What is the expected outcome? - Obeys commands with appropriate motor responses Caring a a patient with increased ICP, looking at urine output - 1500 mL in 2 hours. Wat do you expect for diagnosis? - Diabetes insipidus Caring for a patient with a TBI from a fall. What medication do you anticipate to reduce cerebral edema? - Mannitol Caring for a patient with increased ICP and developed SIADH. What intervention should be implemented? - Fluid restriction Patient with ventriculostomy and monitoring ICP. What indicates that the patient is experiencing complication of ventriculostomy? - Nuchal rigidity 16 year old coming home from summer camp with fever, severe headache, and vomiting. What intervention should we take first? - Collect a blood culture Acute subdural hematoma after a fall at home. What finding indicates complication? - Unilateral pupil dilation In outpatient clinic. Assessing client's risk for ischemic stroke. What conditions add to their risk? - - Diabetes mellitus
- Atrial Fibrillation
- Carotid stenosis Patient with aphasia after stroke. Trying to facilitate communication, what would you do? - - Ask questions the patient can answer with one word
- Decrease environmental stimuli Neuro unit, talking to spouse of patient with ischemic stroke. Why are you doing an echo? - Trying to assess if there is a clot Planning care for a patient with a right hemispheric stroke. What intervention should be included? - Place stuff on the right side Patient with right hemispheric stroke being evaluated by speech therapists. Has motor and visual deficits. During first meal, what do we do? - Swallow twice after each bite of food Nurse provided information about urinary elimination to spouse of patient with a recent stroke. What indicates correct understanding? - - Limit fluid intake after 7PM
- Encourage bladder emptying Q2H
- It's best to have elastic waists
- Use bedpan at night and set spouse upright Observing family caring for a patient with multiple deficits after stroke 2 weeks ago. When do you intervene? - Massaging reddened area on the client's sacrum On neurosurgical unit and taking care of patient with TIAs and intracranial stent placed 30 minutes ago. What should the nurse do? - Keep the patient's legs straight Providing discharge teaching about post concussion syndrome. Client might experience? - - Headache
- Decreased short term memory
- Personality changes On the neuro unit, doing staff education on subdural hematomas. What information should we include? - Older patients at risk due to increased subdural space Neuro unit, doing staff education about conditions requiring ICP monitoring device. What conditions do you include? - - Subdural hematoma
- Brain tumor
- Encephalitis Patient with ventriculostomy. What action is appropriate? - Transducer at level of client's ear Patient suffered sull fracture, positive halo sign. Recognize that finding relates to increased risk of? - Meningitis Preparing to calculate GCS. What actions do you take? - Press firmly on nailbed and observe patient's reaction. Patient with expressive apahsia has a possible stroke. Have taught spouse how to facilitate communication. What requires follow up? - I act like I understand when I dont so my spouse doesn't become frustrated Caring for a patient with basilar skull fracture. What remark is a priority to follow up on?
- I would like some tissues for my runny nose Patient with hemiparesis after right hemispheric stroke. Have taught spouse how to care for the patient. What requires intervention? - Use left hand to reach for wheelchair when transferring from bed On neuro unit, patient with TBI. GCS has changed from 10 to 9 and they're snoring. What do we do? - Suction oral secretions On neuro unit, reviewed provider prescriptions for assigned clients. What prescriptions requires follow up with provider? - 0.45 NaCL for patient with high ICP
e. Dog bite- YES Caring for someone who arrived by ambulance, unconscious hypotensive, fell from second story balcony, which of the following actions would be appropriate SATA - a. Insert two 22G- NO b. Inspect posterior surfaces- YES c. IV pain medications- NO d. O- on standby- YES e. Ventilate with nonrebreather mask- YES Triaging a set of clients who just arrived in the ER, multi car crash, which of the following clients is priority? - Traumatic amputation in and out of conscious Blunt injury to the chest wall, following finding indicate pneumothorax - Diminished breath sounds A nurse in the ED is caring for a patient who has Ethileyne glycol poisoning (antifreeze). The healthcare provider tells nurse to prepare for activated charcoal administration. What information should the nurse explain to client? - I will inset a tube through one of your nares that will go into your stomach and absorb the poison A nurse is caring for a group of clients in the ED. Which of the following interventions will the nurse implement? Select all that apply: - a. Administer antibiotics with a. puncture wound froma. Cat - YES b. Tweezers to remove a tick- YES c. Administer rabies from human bite- NO d. Administer rabies post exposure venously - NO e. Needle or finger nail to remove bee sting- YES
- Triaging clients who arrived from mass casualty, which of the following factors would we consider SATA - Nearest to death level of resources required ER, caring for a female has spiral fracture of right arm, ecchymosis to right eye, spouse tells us she fell at home, notes there are multiple ER visits in the last six months. What would be most appropriate - a. Prove information to client about a safe house-YES b. Report findings of abuse to charge nurse- YES c. Attempt to interview client alone- Yes d. Ask spouse if he caused the injuries- NO e. Call police to arrest spouse- NO Moderate hyperthermia, monitor for which of the following complications - Stroke Assessing a client came by ambulance, traumatic injury at a construction site, which assessment finding would be a priority for us to assess - Trachea left of midline
You are In the ED and receive a five year old who has flu like symptoms and a arithamtus lesion on their flank that is 8cm in diameter. It is important to ask the five years old's parents if they have they recently been around which of the following? - A wooded area You are in the ED and are caring for a client who has a puncture wound from a human bite on their hand that happened 12 hours ago. The physician wrote some prescriptions. Which of the following prescriptions need to be clarified? - Rabies sterile dressing You are in the ED and assessing clients that came in by ambulance following the collapse of a bridge. You should recognize which of the following? - Subcutaneous emphysema (rice crispy/bubble wrap) may indicate laryngeal tracheal disruption You are caring for a client that is critically ill and at risk for stress ulcers. Which of the following prescribed medications is expected from the healthcare provider as profylactic therapy for stress ulcers? - misoprostol - PPI pantoprazole-PPI You are in the ED and caring for a group of clients who experienced poisoning. Which of the following actions by the nurse is appropriate? - Preparing a client who ingested an excessive dose of aspirin for hemodialysis A nurse gives NPH insulin to client at 7:00am. When does the nurse expect the NPH insulin to begin peaking? - 1100 A nurse is giving care to a patient who survived near drowning. Which intervention is the nurse's priority to take? - Correcting hypoxia You are in the ED and received training about ways to protect yourself from potential violence from clients. Which actions by the nurse indicates a correct understanding of the potential anti violence type training? Select all that apply: - Including Qs of clients arrest record Performing activities while nursing assistant is in the room- YES Position oneself between client and door-YES Caring pepper spray in a uniform pocket-NO Making oneself aware of staff rooms that can be locked- YES
- Providing discharge teaching for a parent of 18 mo old toddler, being found face tub in bath by parent, treated fully recovered what information - Do not leave your child in a bathtub alone or unattended, even for a few mins.
- S/S of pulmonary congestion feeling anxious, request prescription of - a. Furosemide b. Lorazepam
You and a colleague are caring for a client in the ED with frostbite on their feet. You should intervene if your colleague is observed doing which action? - Immersing the client's feet in a circulating water bath with a temperature of 120 degrees F A nurse in the ED is caring for a client with a closed lower extremity fracture and the client has just been realigned and splinted by the physician. What action does the nurse take first? - Check both feet for warmth and color You are planning care for a homeless client who gets admitted with mild hypothermia. What intervention would be most appropriate for rewarming the client? - Place the client in a warm room with warm blankets You are caring for an alert client who is having an acute asthma attack. Which of the following prescribed medications would you plan to administer? Select all that apply: - Methylprednisolone, Albuterol The charge nurse in the ED is observing nursing colleagues care for clients who have suffered various traumatic injuries. The charge nurse would intervene if a nursing colleague is observed doing which of the following? - Inserting an indwelling catheter for a client who has blood in the urinary meatus A nurse in the ED is receiving a client by ambulance who is coming in after having a traumatic accident. A paramedic tells the nurse that the client has asymmetric chest wall movement. The nurse demonstrates a correct understanding of this report by taking which of the following actions? - Palpate the thorax for crepitus/ flail chest A nurse is preparing to administer an oral antidiabetic medication that was prescribed to a patient that enhances cellular insensitivity to insulin. Which of the following types of medications would the nurse be administering? - Biguanide A nurse in the ED is triaging clients. The nurse should first attempt to which of the following clients first? - An 18 year old female client who has severe pelvic and abdominal pain that began 10 hours ago A nurse is caring for a client who was involved in a work place accident and has a penetrating wound to their chest that lead to acute respiratory failure. Which of the following goals of treatment should the care team prioritize when planning care for this client? - Restoration of adequate gas exchange The nurse is assessing a client with blunt force chest trauma after hitting the handle bars of a bicycle. The nurse suspects the client has a flail chest. Which of the following findings would the nurse expect to find in flail chest? - The fractured rib sections pull inward on inspiration and outward on expiration
The nurse receives an unconscious client with a c collar applied that arrived by ambulance after an automobile accident. What action is appropriate for the nurse to take while attempting to stabalize the client? - Lift the lower jaw forward while the client is supine A nurse is doing triage at a disaster cite of a work place explosion. A conscious 40 year old client has an open leg fracture and minor bruising. What color tag should be applied to this client? - Yellow tag A nurse is caring for a client with heat stroke. Which actions by the nurse is appropriate to lower client's core temperature? Select all that apply: - Applying an ice pack to the client's groin and axilla positioning a large fan so it's blowing on client covering the client with wet sheets Deal with CHF, monitor with remote tele, going into v-fib, what is NOT important to report? - Serum sodium 130 Choliride 90 Which patient do we assess first?
- Aortic valve stenosis with syncope
- Endocarditis with temp 101.
- Heart failure with bilateral 4+ edema
- Chronic angina with New onset chest pain unrelieved with rest - Chronic angina with New onset chest pain unrelieved with rest Caring for a pt. with afib, schedule for cardioversion in 24hrs. what prescribed test or interventions will NOT be required? TEE (is required) anticoagulation for 4 weeks after procedure (is required) diet modification teaching (is required) VQ scan bed rest for 24 hrs. after procedure - VQ scan bed rest for 24 hrs. after procedure Assess who first?
- A fib on warfarin 1 hour ago with no P waves
- Permanent pace-maker placed showering spikes
- CHF received dig and has prolonged PR interval
- Acute MI showing ventricular bigeminy - Acute MI showing ventricular bigeminy In patients' room, we see on monitor (spikes, no p waves,) pt. is unresponsive? - Begin CPR Taught a client about implantable cardioverter placed, what statement by client require follow up by the nurse?
- Can travel by airplane if I notify TSA
- Instruct client to gag
- Hold their breath
- Immerse face in ice-water
- Place ice-packs on clients carotid - Place ice-packs on clients carotid Taught a client who is newly diagnosed with Raynaud's disease, what statement is correct from client?
- Turn pale put them in hot water
- Take pseudoephedrine for cold
- Do not take NSAIDS
- I will exercise indoors when cold out - I will exercise indoors when cold out Cardiovascular unit and assessing clients assigned to us, which reported symptom is priority to follow up with? - Back pain in client going in for thoracic aortic repair Discharge home with Holter monitor, what statements by the client indicates they understand instructions?
- While wearing monitor I should do normal activities
- Monitor will record heart rhythm
- I can use an app on my smart phone to save information from the monitor
- Keep diary of symptoms
- If I feel anything abnormal, push button - While wearing monitor I should do normal activities Monitor will record heart rhythm Keep diary of symptoms Inferior Wall MI 4 days ago, report dizzy, discomfort in chest, 96/48, second degree AV block type 2, HR is 52 beats a min. Which even would we prepare the patient for? - Transcutaneous pacing Working at health clinic and pre-employment physical on someone. 25 yr. old Male, denies any physical discomfort or issues, EKG shows narrow complex, normal PQ RST , HR is 40? - Continue with physical and keep going, make note Client, wide qrs complex, blood pressure is 82/40, resp. 22, not arousable, can't palpate a pulse. What action is most appropriate?
- Iv fluid bolus
- Cardioversion
- Defibrillation client
- Check bp - Defibrillation client Providing education for lower extremities DVT, what statement by client require followup?
- I will need to remain in bed until blood clot is gone
- Might decrease the risk of this type of blood clot from happening again if I stop smoking
- I will take a prescribed oral medication to stop the clot getting bigger
- I might develop chronic symptoms of vein valve dysfunction as a result of this blood clot - Develop chronic systems from blood clot Planning care for a client and diagnosed with Bergers disease, what intervention should we include in care plan?
- Educated about quitting smoking (yes)
- Teaching avoid trauma in extremities (yes)
- Assess extremities for ulcers (yes)
- Encourage to avoid exposure to cold temperature
- Give analgesics to treat pain - education about quitting smoking teaching avoiding trauma in extremitites assessing extremities for ulcers encourage to avoid exposure to cold temperature give analgesics to treat pain Pt. who had a CABG (coronary artery bypass graph) 4hrs ago. Looking at chest tube drainage, no drainage in two hours. Muffled heart sounds. What would the nurse suspect?
- pulmonary edema
- cardiac tamponade
- hypovolemic shock
- thromboembolysim - cardiac tamponade Supervising actions from a UAP (cna) what actions require intervention by RN?
- rubbing lotion on legs
- Placing three pillows under the legs of pt. with capillary refill time longer than 3 seconds - Placing three pillows under the legs of pt. with capillary refill time longer than 3 seconds Local clinic and see pt. who says they always walk after dinner, but lately they are having leg cramps and the pain goes away after they stop and rest. What action should the nurse take?
- Assess for swelling on legs
- Palpate for lower pulses (tibial and dorsalis pedis)
- Ask about skin color changes in response to cold - Palpate for lower pulses (tibial and dorsalis pedis) Pts who has Afib and now has sudden pain, tingling in left lower extremity, extremity is pale, cool to touch and can't find a pulse. What would be priority action for nurse to take?
- check with Doppler
- gain prescription for IV Heparin
- Check vital signs
- prepare for surgery - gain prescription for IV Heparin
- Topical antibiotic ointment on wound if signs of infection develop Keep leg in elevated position - - Goal of dressing is to dry the wound out
- Drug and compression may be necessary for healing
- Topical antibiotic ointment on wound if signs of infection develop MI 10 days, self-monitoring activity, when do we teach them to stop exercising? What information would we include?
- Cramping in legs after 10 mins
- Stop and rest if any swelling occurs
- Feelings of palpitaions and dyspnea should tell them to stop
- Increase to 30resp. a min means to increase - Feelings of palpitations and dyspnea should tell them to stop LPN caring for client after fempop, RN would intervene if LPN does any of the following? - - Sit in the chair for two hours Caring for pt. in ER, has thoracic aortic aneurysm during chest x-ray, what should we ask about? - - Hoarse voice Education conference about blood pressure and age, what information should we include in conference? - - Changes in body that effect blood pressure Segmental blood pressure required to diagnosis PAD, provide which information regarding this test?
- Get BP at different time of day
- Get BP from arms and legs
- I will be using a Doppler, ultrasound and BP will be used
- Will need to be seated during test - Doppler and BP will be used Pt. in sinus rhythm, 4 r to r 4 intervals in 6 sec. strip, which medications would we clarify? - - Perform vagal maneuvers Medications review for clients, we should withhold medication and clarify for which patient?
- Atropine for HR of 104
- Dig. For client with low ejection fraction - Atropine for HR of 104 Caring for pt. who has atropine IV for symptomatic type 1 second degree AV block. Which findings tells us the medication is effective? - - Heart rate went up In ER and someone tells us they have chest pain, perform 12 lead and there is ST elevation in leads 1AVL, V5, and V6. Which of the following would we expect? - - Lateral wall MI Cardiac Cath., which of the following should we include in teaching?
- You will get anesthesia at insertion site (yes)
- Do you have allergy to contrast (yes)
- Do not need to fast before (no)
- Procedure will remove plaque from artery (yes) - you will get anesthesia at insertion site I need to know if you have an allergy to contrast dye procedure will remove plaque from artery We are reviewing medications for our assigned clients and we should withhold medication and contact MD for which medication orders?
- warfarin for client with no p waves on tele
- atenalol for a client who has a blood pressure of 168- 90
- atropine for pt. with HR of 104
- Dig. for pt. with low ejection fraction - atropine for pt. with HR of 104 Newly diagnoses with Berger's disease, which statement indicated further teaching is needed?
- No diagnostic test for bergers disease
- Bergers is autoimmune disease
- I should avoid trauma to extremities I will notice color and temperature changes - Bergers is autoimmune disease
