Nokea
A client is admitted with a 6.5-cm thoracic aneurysm. The nurse records fi ndings from the initial assessment in the client’s chart, as shown below. At 10:30 a.m., the client complains of sharp midchest pain after having a bowel movement. What should the nurse do first?
- A. Assess the client’s vital signs.
- B. Administer a bolus of lactated Ringer’s solution.
- C. Assess the client’s neurologic status.
- D. Contact the physician.
Correct Answer: A
Rationale: The size of the thoracic aneurysm is rather large, so the nurse should anticipate rupture. A sudden incidence of pain may indicate leakage or rupture. The blood pressure and heart rate will provide useful information in assessing for hypovolemic shock. The nurse needs more data before initiating other interventions. After assessment of vital signs, neurologic status, and pain, the nurse can then contact the physician. Administering lactated Ringer’s solution would require a physician’s order
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The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 2 of 6
Triage Note
1700:
• The client was brought to the ED after collapsing on a tennis court.
• Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.
For each client finding below, click to specify if the finding is consistent with the disease process of heat exhaustion or heat stroke. Each finding may support more than 1 disease process.
- A. Temperature 105° F (40.5° C)
- B. Confusion
- C. Perspiration
- D. Tachycardia
- E. Signs of dehydration
- F. Hypotension
Correct Answer: A,B,C,D,E,F
Rationale: A (Heat Stroke), B (Heat Stroke), C (Heat Exhaustion), D (Both), E (Both), F (Both). Temperature 104°F and confusion are hallmark signs of heat stroke. Perspiration is typical in heat exhaustion but absent in heat stroke. Tachycardia, dehydration, and hypotension occur in both conditions due to heat stress.
The nurse is to administer subcutaneous heparin to an older adult. What facts should the nurse keep in mind when administering this dose? Select all that apply.
- A. It should be administered in the anterior area of the iliac crest.
- B. The onset is immediate.
- C. Use a 27G, 5/8€ needle.
- D. Cephalosporin potentiates the effects of heparin.
- E. Double check the dose with another nurse.
Correct Answer: C,E
Rationale: Subcutaneous heparin should be administered using a 27-gauge, 5/8-inch needle to ensure proper delivery into subcutaneous tissue. Due to the risk of bleeding, the dose should be double-checked with another nurse. The anterior iliac crest is not a standard site (abdomen is preferred), onset is not immediate (takes hours), and cephalosporins do not potentiate heparin's effects.
The nurse is developing a discharge plan for a client who had a phacoemulsification procedure. Which of the following should the nurse include? Select all that apply.
- A. Teach the client how to instill eye drops.
- B. Instruct the client not to lie on the affected side.
- C. Remind the client that a reduction of vision is normal.
- D. Provide the client with an eye patch for the affected eye.
- E. Educate the client to avoid bending at the waist.
Correct Answer: A,B,D,E
Rationale: Post-phacoemulsification care includes teaching eye drop instillation, avoiding lying on the affected side, using an eye patch for protection, and avoiding bending to prevent pressure increase. Reduced vision is not normal and requires evaluation.
A client with an ileal conduit asks how to reduce pouch odor. The nurse suggests:
- A. Avoiding broccoli.
- B. Using bleach to clean the pouch.
- C. Drinking less water.
- D. Applying powder to the stoma.
Correct Answer: A
Rationale: Odor-producing foods like broccoli should be avoided to minimize pouch odor.
An airplane crash results in mass casualties. The nurse is directing personnel to tag all victims. Which is normal should be placed on the tag? Select all that apply.
- A. Triage priority.
- B. Identifying information when possible (such as name, age, and address).
- C. Medications and treatments administered.
- D. Presence of jewelry.
- E. Next of kin.
Correct Answer: A,B,C
Rationale: Victim tags should include triage priority, identifying information, and treatments administered to ensure proper care and identification. Jewelry and next of kin are secondary considerations.