Nokea
A nurse is the first on the scene of a motor vehicle accident. The victim has sucking sounds with respirations at a chest wound site and tracheal deviation toward the uninjured side. Until others arrive, the priority nursing action would be to
- A. loosely cover the wound, preferably with a sterile dressing.
- B. place a sandbag over the wound.
- C. monitor chest wound drainage.
- D. place a firm, airtight, sterile dressing over the wound.
Correct Answer: A
Rationale: implementation, in an open pneumothorax, air enters the pleural cavity through an open wound; placing a sterile dressing loosely over the wound allows air to escape but not reenter the pleural space
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The nurse is caring for a patient who experienced a thermal injury two weeks ago. The nurse would be MOST concerned if which of the following is observed?
- A. Increased heart rate and elevated blood pressure.
- B. Temperature of 100.6°F (38.1°C) and decreased respiratory rate.
- C. Increased heart rate and decreased respiratory rate.
- D. Increased respiratory rate and decreased blood pressure.
Correct Answer: D
Rationale: may indicate burn wound sepsis, a life-threatening complication of thermal injury
Which of the following nursing actions should be the priority for an infant admitted with a positive stool culture for Salmonella?
- A. Change the diet to clear liquids.
- B. Initiate intravenous fluids.
- C. Maintain contact precautions.
- D. Apply cloth diapers.
Correct Answer: C
Rationale: prevents transmission of this bacterium to other individuals
An elderly client receiving IV fluids of 0.9% NaCl at 125 cc/h into her left arm. During a routine assessment, the nurse finds that the client has distended neck veins, shortness of breath, and crackles in both lung bases.
The nurse should
- A. decrease the IV rate to 20 cc/h and notify the physician.
- B. decrease the IV rate to 100 cc/h and continue to monitor the client.
- C. discontinue the IV and start oxygen at 6 L/min.
- D. assess for infiltration of the IV solution.
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation. (1) correct-KVO (20 cc/h) will keep access open (2) need to notify physician, rate still too much since patient is in fluid overload (3) IV line may be necessary, diuretics may be ordered (4) description indicates circulatory overload, not infiltration
A nurse is the first on the scene of a motor vehicle accident. The victim has sucking sounds with respirations at a chest wound site and tracheal deviation toward the uninjured side. Until others arrive, the priority nursing action would be to
- A. loosely cover the wound, preferably with a sterile dressing.
- B. place a sandbag over the wound.
- C. monitor chest wound drainage.
- D. place a firm, airtight, sterile dressing over the wound.
Correct Answer: A
Rationale: implementation, in an open pneumothorax, air enters the pleural cavity through an open wound; placing a sterile dressing loosely over the wound allows air to escape but not reenter the pleural space
The nurse is caring for clients in the outpatient clinic. The nurse returns to the desk and finds four phone messages. Which of the following messages should the nurse return FIRST?
- A. A client with cold symptoms has an oral temperature of 103°F (39.4°C).
- B. A client with stage II decubitus ulcer reports that the dressing has come off.
- C. A client is nauseated and has vomited 6 times in the previous 24 hours.
- D. A client is complaining of leg pain after walking half a mile.
Correct Answer: C
Rationale: assess amount, character, symptoms of fluid volume deficit