Nokea
The emergency department nurse is caring for a client with sudden onset of edema of the lips and acute shortness of breath following a bee sting. The nurse knows that the first-line medication for this presentation is:
- A. Oral diphenhydramine
- B. Nebulized albuterol
- C. Oral prednisone
- D. Parenteral epinephrine
Correct Answer: D
Rationale: Anaphylaxis from a bee sting requires immediate parenteral epinephrine to reverse airway edema and respiratory distress.
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The nurse is teaching a client with hypertension about dietary modifications. Which of the following statements by the client would require follow-up?
- A. I'm glad I can still eat beef and pork daily.
- B. I will need to get used to eating fruits and vegetables.
- C. I should avoid eating canned foods.
- D. I already told my spouse to buy me some yogurt when I get home.
Correct Answer: A
Rationale: Daily consumption of red meats like beef and pork is not recommended for hypertension due to high sodium and fat content.
The nurse is caring for a client who has been prescribed sertraline. The nurse understands that this medication is prescribed for which of the following conditions?
- A. Major Depressive Disorder
- B. Attention Deficit Hyperactivity Disorder
- C. Obsessive-Compulsive Disorder
- D. Generalized Anxiety Disorder
- E. Bipolar Disorder
Correct Answer: A, C, D
Rationale: Sertraline, an SSRI, is indicated for Major Depressive Disorder, Obsessive-Compulsive Disorder, and Generalized Anxiety Disorder, but not for ADHD or Bipolar Disorder.
The following scenario applies to the next 1 items
The nurse in the emergency department (ED) is caring for a 70-year-old client.
Item 1 of 1
Nurses' Notes
1100: Client was brought into the ED via emergency medical services (EMS) after he was found wandering the streets and completely disoriented. He was carrying a wallet and identification. His previous medical history was obtained from medical records—history of atrial fibrillation and diabetes mellitus (type two). On assessment, the client is lethargic, disoriented, and mumbling incoherent words. Breathing appears slightly labored, and wheezes with scattered rhonchi are noted in the bilateral lung fields—productive cough with a large amount of mucous. Skin is hot to touch, pale in tone; pulses 2+ and irregular. The client has an unkempt appearance and is malodorous. Peripheral venous access device (VAD) placed in right forearm. Vital signs: T 102° F (38.9° C), P 92, RR 24, BP 144/89, pulse oximetry reading 91% on room air. Orders received from the physician.
The nurse reviews the physician's orders and plans implementation. For each potential nursing action, click to specify whether the action is a high priority or a low priority.
- A. Educate the client on using the incentive spirometer
- B. Perform a head-to-toe skin assessment
- C. Notify radiology to obtain the portable chest radiograph (x-ray)
- D. Administer albuterol via nebulizer
- E. Apply supplemental oxygen via nasal cannula
- F. Collect ordered laboratory work (CBC, CMP, blood cultures)
- G. Perform admission medication reconciliation
Correct Answer: C, D, E, F (high priority); A, B, G (low priority)
Rationale: High priority: Chest x-ray, albuterol, oxygen, and labs address acute respiratory distress and infection. Low priority: Spirometer education, skin assessment, and medication reconciliation can be delayed.
The following scenario applies to the next 1 items
The nurse is caring for a 72-year-old client in the emergency department (ED)
Item 1 of 1
Nurses' Notes
1430: 72-year-old male was brought to the ED with reports of dyspnea, chest pain, diaphoresis, and restlessness. The client's daughter reports that he recently took a long drive across several states and that the symptoms started abruptly. The client's oxygen saturation was 80% on room air and improved to 86% on 100% FiO2 via a nonrebreather mask. The physician was immediately notified at this time of the client's condition and came to the bedside for evaluation.
1442: The physician ordered rapid sequence intubation medications for immediate endotracheal intubation (ETT). The physician intubated the client using a #8 ETT and connected the client to mechanical ventilation using assist-control at a tidal volume of 500 mL, rate of 12/minute, 100% FiO2, PEEP 5 cm H2O. Post-intubation vital signs: T 99° F (37° C), P110, RR 12, BP 90/62, pulse oximetry reading 98%.
The nurse has reviewed both of the Nurses' Note entries and is planning care for the client. For each potential nursing intervention, click to specify whether the intervention is indicated or contraindicated for the care of the client.
- A. Request an order for a chest radiograph (x-ray)
- B. Obtain an order for an arterial blood gas (ABG)
- C. Collaborate with respiratory therapy to assist in the client's care
- D. Place the client in low-Fowler's position
- E. Request an order to administer an 0.45% saline intravenous fluid bolus
- F. Turn the client every four hours
- G. Suction the endotracheal tube (ETT) every two hours
Correct Answer: A, B, C, F (indicated); D, E, G (contraindicated)
Rationale: Indicated: Chest x-ray confirms tube placement, ABG assesses ventilation, respiratory therapy collaboration optimizes care, and turning prevents complications. Contraindicated: Low-Fowler€™s position worsens respiratory distress, 0.45% saline is inadequate for hypovolemia, and routine ETT suctioning is unnecessary.
The nurse is providing teaching to a client experiencing chronic constipation. Which of the following meals would be the best choice for this client in order to promote a bowel movement?
- A. steak and a baked potato
- B. brussels sprouts and a whole grain roll
- C. white rice with chicken
- D. ham sandwich with tomato soup
Correct Answer: B
Rationale: Brussels sprouts and whole grain rolls are high in fiber, promoting bowel movements.