A nurse is working in the ER when a patient is brought in by ambulance after a motor vehicle accident. The patient has a neck brace in place and has blood on the face and down the torso. The patient is breathing and has a pulse that is rapid but palpable. The nurse knows the next intervention should be which of the following?
• In trauma patients, the first action is to secure the neck to prevent any injury to the cervical spine.
• If the patient is breathing, the level of consciousness should be determined next by asking simple questions such as name and birthday while checking the pupils for responsiveness.
• IV access should already be established if the patient is brought in by ambulance. If no IV is in place, at this point the nurse should insert one.
• Vital signs should be obtained after the patient is situated and assessment has begun.
The nurse is assisting the physician with a liver biopsy performed at the patient’s bedside. Which of the following should the nurse do after the procedure is completed?
The home health nurse observes the nurse aide transfer a patient with hemiplegia from a sitting position on the bed to the wheelchair. Which of the following actions needs correction by the home health nurse? The aide
A nurse caring for a client on neutropenic precautions needs to be alert to which early sign, indicating a change in the client’s condition?
A patient who is scheduled for a bone marrow transplant is concerned about the cost of the procedure. How should the nurse respond?
Which of the following clinical findings would the nurse be most concerned with in a client with chronic kidney disease?
A 13-year-old patient has been diagnosed with impetigo, caused by Staphylococcus aureus, which is being treated with antibiotics. While doing a physical assessment, the nurse would expect to find skin lesions on which of the following areas of the body?
The nurse is caring for a post-op client after renal artery bypass for an arterial occlusion. To promote the goal of effective kidney function, the nurse includes which intervention(s) in the plan of care?
A patient attends a wound clinic for a foot ulcer that will not heal. The patient asks for an explanation as to why the ulcer is not healing. Which of the following diseases would have a negative impact on wound healing, and in turn would require further patient education by the nurse?
A nurse is implementing fluid resuscitation on a patient with full-thickness burns. Vital signs show a blood pressure of 85/55,
A nurse is using the Braden scale to help predict a patient's pressure ulcer risk. The patient's sensory perception is very limited, she is occasionally moist, she is bedfast, her mobility is very limited, nutrition is adequate, and friction is a potential problem. What is this patient's total Braden score?
A patient received a bite wound from an animal and developed cellulitis as a result. The nurse explains to the patient that this infection is most likely caused by:
A nurse is monitoring the electrocardiogram (EKG) of a patient in the intensive care unit (ICU). The monitor shows a regular P to P interval with intermittent QRS waves that have regular intervals when occurring, but are often missing. The EKG demonstrates no correlation between P waves and QRS waves. The nurse knows that this indicates which of the following heart rhythms?
A patient presents in the emergency room (ER) with complaints of chest pain. The electrocardiogram (EKG) shows regular PR interval with a QRS wave missing every third beat. The nurse evaluates the EKG and recognizes this rhythm as which of the following? )
The nurse is caring for a patient that suddenly goes into uncontrolled atrial fibrillation. To determine if the patient has an adequate stroke volume, the nurse would assess for
The nurse is auscultating the heart of a patient with congestive heart failure. The nurse hears an extra sound with a very low pitch, immediately after the second heart sound (S2). The nurse interprets this as
The nurse is caring for a patient in the early stages of heart failure. The family is curious as to how the body adapts to heart failure. The nurse knows that during the early stages of heart failure, which specific compensatory mechanisms occur?
A newly diagnosed diabetic is receiving consultation about the disease process. The nurse explains that insulin is normally secreted from the
A nurse is caring for a patient who has left hemiparesis after a stroke. To avoid the risk of disuse syndrome, the nurse should do which of the following?
A patient is scheduled for a computerized tomography (CT) scan. Which of the following is an appropriate statement by the nurse?
A 46-year-old patient will undergo a bone marrow transplant and an informed consent form has been signed. The nurse is about to administer a sedative before the procedure when the patient says, "How many bones will be taken out?" What should the nurse do next?
A 72-year-old patient verbalized that he has very loud, overpowering ringing in both ears, intermittent hearing loss on the right side, and severe vertigo with nausea. The nurse assessing the patient suspects that he has
A patient is admitted to the inpatient unit with difficulty breathing, a productive cough, and audible wheezes. Which lab value should be reported to the physician immediately?
An overweight elderly patient with arthritis wants to control his disease and pain without the use of medications. Which of the following should the nurse include in the patient's care plan?
The nurse is examining a patient with systemic lupus erythematosus (SLE). Which of the following symptoms would the nurse expect?
A 38-year-old female patient comes in with complaints of double vision, visual loss, weakness, numbness of hands, fatigue, and tremors that have been worsening over the past several months. During admission, the nurse notes nystagmus, scanning speech, ataxia, muscular weakness, and incontinence. Considering these findings, the nurse suspects that the patient has
A patient with pancreatitis is at risk for developing a paralytic ileus. Which of the following assessment data indicates this complication?
A nurse is teaching a patient with hyperparathyroidism how to prevent hypercalcemia. The nurse should include which of the following in her medical counseling?
A nurse received an order to initiate early ambulation with a patient post appendectomy. The nurse recognizes this activity to be helpful in preventing possible complications associated with prolonged bed rest. To assist the patient to start walking after surgery, the nurse will: