1. A client is being evaluated in the emergency (ED) department…

Question1. A client is being evaluated in the emergency (ED) department…1. A client is being evaluated in the emergency (ED) department following burn after falling backward into a brush fire at home. The client obtained burns to the following areas: bilateral posterior arms, posterior chest and back, and bilateral right and left posterior legs. Using the rule of nines, calculate the clients total burn surface area percentage?36%45%72%54% 2. The nurse is aware that which phase begins 36 to 48 hours after a burn injury when the fluid shift resolves and lasts until the wound closure is complete?Rehabilitation phaseChronic phaseResuscitation phaseAcute phase 3. A client presents with a pulmonary embolism that requires immediate treatment. Which of the following are included in the plan of care for this client? (Select all that apply)Continuous monitoring of pulse oximetryRefrain from massaging/compressing leg musclesApply oxygen therapySurgical chest tube placementAdministration of anticoagulants and thrombolytic therapy 4. In the event of a mass casualty situation, which of the following is selected as the triage nurse?The licensed vocational nurse (LVN) with 2 years of experienceThe recently graduated registered nurse (RN)The registered nurse (RN) with the most experience with efficient assessment skillsThe recently graduated licensed vocational nurse (LVN) 5. The nurse is initiating care for a client diagnosed with burns to the chest, neck, and face. Which of the following nursing diagnosis is the highest priority?Impaired skin integrityRisk for infectionDisturbed body imageIneffective airway clearance 6. A client has sustained 50% total body surface area (TBSA) burns to the chest and extremities in a house fire. The client weighs 154lbs. Using the Parkland Formula of 4 mL, how much fluid would this client be given in the first 24 hours?12,000 ml16,000 ml14,000 ml26,000 ml 7. A client presents to the emergency department (ED) complaining of light-headedness and chest palpitations. Heart rate is 90-120 beats per minute, and blood pressure is 70/40 mmHg. The cardiac monitor shows the following rhythm. What is the appropriate treatment?Unsynchronized defibrillationSynchronized cardioversionHigh-quality chest compressionsAdminister intravenous (IV) atropine 8. The nurse is caring for a client that has been in a car accident. The nurse notices the client’s chest movements are paradoxical. This clinical manifestation is consistent with which of the following?Pulmonary embolismFlail chestTension pneumothoraxHemothorax 9. A client with decreased cardiac output from supraventricular tachycardia (SVT) exhibits which of the following clinical manifestations? (Select all that apply)HypertensionHypotensionChest discomfortWarm, dry skinPalpitations 10. The client has been intubated related to acute respiratory distress syndrome (ARDS). After repositioning the client for a chest x-ray, the nurse assesses that the abdomen is now distended. Which of the following interventions is the nurse’s top priority?Push on the client’s right upper quadrant to decompress the stomachMaintain a patent airway and insert a nasogastric tube to decompress the stomachPlace the client on his right side to decompress the stomachAdminister pantoprazole PO per order to decompress the stomach 11. The nurse is caring for a mechanically ventilated clients and knows that older adults are at the highest risk for weaning failure. What age-related changes contribute to failure with weaning off a ventilator? (Select all that apply)Less lung elasticityInability to cooperate Poor vision and hearingChest wall stiffnessDecreased muscle strength 12. An elderly client was found unresponsive in the home by firefighters after a gas leak inspection. Upon assessment, the client presents with a headache, drowsiness, nausea, and confusion. The nurse recognizes the assessment findings are clinical manifestations of which of the following?Hemorrhagic strokeCardiac arrestCarbon monoxide poisoningCyanide poisoning  13. A nurse in the ER is caring for a client who has extensive partial, and thickness burns to the face, head, neck and chest. While planning the clients care, the nurse should identify the following risks as the priority for an assessment?Airway obstruction 14. 15. A client is diagnosed with supraventricular tachycardia with a heart rate of 180 beats per minute. The nurse should prepare to administer which of the following medications for this dysrhythmia?VerapamilProcainamideAmiodaroneAdenosine 16. A nurse is developing a plan of care for a client who is recovering from major burns. Which of the following interventions should the nurse include to provide psychosocial support to the client?Keep family members aware of the client’s conditionRotate nursing staff so the client can have varied interactionsAssign assistive personal to keep the client’s room neat and cleanUtilize therapeutic communication techniques with the client 17. The nurse is caring for a client with burns to the face, neck, and bilateral upper arms prior to arrival to the emergency department (ED). Which of the following interventions would the nurse do first?Assess for airway obstructionAdminister oral acetaminophen for pain managementAssess for airway patency and apply oxygen per orderAdminister intravenous isolated crystalloids according to the resuscitation Parkland Formula 18. The nurse is caring for a client who is experiencing upper abdominal pain. The electrocardiogram tracing interprets heart rate 80 beats/minute, QRS <0.10 second, PR-Interval 0.16 second. This rhythm is identified as which of the following?Sinus bradycardiaSinus arrhythmiaNormal sinus rhythmSinus tachycardia 19. A nurse is performing cardiopulmonary resuscitation (CPR) for an unresponsive adult client. The nurse is assessing the circulation by palpating the client's pulse for 5 seconds. Which of the following is the correct landmark the nurse should palpate the pulse on an adult client?CarotidPedalPoplitealApical 20. A client who is one day post-operative knee replacement is experiencing an acute onset of chest pain, dyspnea, tachypnea, impending doom, and hemoptysis. These clinical manifestations indicate which of the following?Musculoskeletal painPulmonary embolismGastrointestinal (GI) bleedST-elevation myocardial infarction (STEMI) 21. A client is admitted with superficial thickness burns to the shoulders from sunburn. Which of the following clinical manifestations would the nurse expect to assess?Painful pink to red wounds with mild edema, no blisters notedBlack, brown, yellow, white, and red wounds with hard necrotic tissueRed and white wounds with mild pain upon palpitationPainful pink to red wounds with blisters noted 22. A client has just been intubated following a cardiac arrest. To assure the endotracheal tube has been placed properly, the nurse will implement which of the following nursing interventions? (Select all that apply)Assess for symmetric chest movementAssess for sounds over the gastric areaVerify placement by checking the end-tidal carbon dioxicde levelsAssess breath sounds bilaterallyAuscultate the apical pulse for three full minutes 23. A client is unresponsive with no palpable pulse. The electrocardiogram tracing interprets continuous large and bizarre QRS complexes measured greater than 0.12 second and heart rate of 180 beats/minute with no defined P waves. This rhythm is identified as which of the following?Ventricular fibrillationPremature ventricular complexesVentricular tachycardiaAtrial tachycardia 24. A client has sustained circumferential full-thickness burns to the chest. Upon assessment, the client is short of breath form the eschar leading to compression of the chest preventing full lung expansion. Which of the following immediate surgical interventions is necessary to restore effective gas exchange?EscharotomyEmbolectomyLoosen the sterile garmentThrombectomy 25. A client was admitted with a pneumothorax. Which of the following interventions would the nurse implement first?Administer oral analgesicsAssess for tracheal deviationApply a wet dressing on the woundAssess respiratory and circulatory function 26. A nurse completing discharge teaching with a client who has a permanent pacemaker. Which of the following statements by the client is correct?"I do not have to tell airport security about my pacemaker""I don't have to check my pulse anymore since I have a pacemaker""I will wear a medical bracelet and carry the pacemaker identification card indicating I have an implanted pacemaker""I will start range of motion exercises with my arms immediately" 27. A client presents to the emergency department (ED) with 30% total body surface area (TSA) burns. The client weighs 80 kg. Use the Parkland Formula (4 mL/kg/% TBSA burn of crystalloid solution) to calculate the hourly drip rate in mL/hr for the first 8 hours of resuscitation.600 mL/hr1760 mL/hr2670 mL/hr1200 mL/hr 28. When caring for a client with severe burns to bilateral upper extremities, the nurse can expect to administer opioid pain medication via which route?SubcutaneousOralIntravenous (IV)Intramuscular (IM) 29. The client presents to the emergency department (ED) with high pitched stridor, dyspnea, and cyanosis. The nurse is preparing or which intervention after receiving the crash cart and airway management box?Assist the health care provider with endotracheal intubationPrepare the client for a surgical thoracotomy (needle decompression)Assist the health care provider with chest tube placementPrepare the client for a surgical embolectomy 30. The emergency department nurse is preparing to triage victims of an internal event. Which of the following would be considered an internal event?Fire in the hospitalBus crash in front of the ambulance entranceTrain crash 5 miles awayExplosion in a nearby oil station 31. 32. The nurse is concerned about developing post-traumatic stress disorder (PTSD) after working for several years in the emergency department. Which of the following actions should the nurse implement to ensure PTSD does not manifest? (Select all that apply)Drink water to stay hydratedEat healthy, well-balanced mealsUse available counseling servicesIngest at least one alcoholic drink every eveningTake breaks when needed to prevent burnout 33. A nurse is interpreting the electrocardiogram (ECG) rhythm stirp of a client who has bradycardia. Which of the following cardiac components should the nurse identify as the role of the P wave?Early ventricular repolarizationSlow repolarization of ventricular Purkinje fibersAtrial depolarizationVentricular depolarization 34. A 55-year-old client is admitted to the hospital with a gastrointestinal (GI) bleed, and the physician orders a blood transfusion of packed red blood cells (PRBCs). Order: 1-unit PRBC's (400 mL) IV to infuse over 4 hours. Drop factor of tubing: 15 gtt/mL. what is the infusion rate in gtt/min? (Record answer as a whole number)  35. The nurse is providing care for a 22-year-old client that presented with burns to the anterior head and neck. The nurse understands that the client should be positioned in which of the following positions to prevent contractures of the head and neck?Dorsiflexion, place the client in prone positionHyperextension with no pillowFlexion, place the client in supine positionExtension, place the client in supine position and use a splint 36. A nurse is triaging clients in the emergency department. Which client would the nurse classify as "non-urgent?"A client with chest pain and diaphoresisA client with a runny nose and a coughA client with a temperature of 104F (40C) and difficulty breathingA client with chest trauma and absent breath sounds 37. A client with severe burns will progress through which phase of burn injury 24 hours to 48 hours (about 2 days) after the injury until diuresis occurs?Resuscitation phaseAcute phaseChronic phase Recovery phase 38. A client is on mechanical ventilation, and the clients spouse wonders why esomeprazole is needed since the client "only has lung problems, not stomach." What response by the nurse is best?"It will prepare the gastrointestinal tract for enteral feedings.""It will prevent ulcers from the stress of mechanical ventilation.""It will increase the motility of gastrointestinal tract.""It will keep the gastrointestinal tract functioning normally." 39. An emergency department charge nurse notices an increase in sick calls and bickering among the nursing staff after a week of caring for multiple high acuity trauma clients. Identify what action is the charge nurse's top priority?Arrange for critical incident stress debriefing to promote effective copingTalk individually to all the staff members about the disruptive behaviorConfront the staff in a huddle to address the disruptive behaviorRemind all the staff of the facility's sick-leave policy 40. Which drug will minimize the growth of an existing clot and prevent the development of additional clots in clients with pulmonary embolisms?SurfactantNorepinephrineHeparinAlteplase 41. The nurse in the emergency department (ED) is using a triage system. The triage system identifies the highest treatment priority for clients based on which of the following?Lowest severity of illness or injuryHighest severity of illness or injuryAge of the clientNumber of resources used 42. 43. A client is receiving a large volume of isolated crystalloids intravenously after sustaining 50% total body surface area (TBSA) burns to their body. Which of the following assessments are clinical manifestations of fluid volume overload? (Select all that apply)Clear bilateral lung sounds on auscultationNew onset of 2+ dependent edema to bilateral distal extremitiesPresence of lung crackles on auscultationDecreased skin turgorEngorged neck veins, jugular venous distention (JVD) 44. A client sustained burns to the anterior chest, anterior bilateral right and left legs, and the anterior right arm after a gasoline explosion fire. Using the rule of nines, calculate the client's total body surface area (TBSA) percentage?45% TBSA36% TBSA40.5% TBSA31.5% TBSA 45.  46. A nurse is field triaging clients after an industrial accident. Which client condition would the nurse triage with a red tag?A client with a head injury who is unresponsive with no respiratory effortA client with multiple rib fractures and shortness of breath with a non-obstructed airwayA client with a laceration to the right arm whose bleeding is controlledA client with a closed right ankle fracture 47. The client sustained a blunt chest trauma and has a life-threatening tension pneumothorax. Which of the following is the nurse's top priority for the management of a tension pneumothorax?Place the client in a supine positionPrepare the client for a bedside needle thoracostomyPrepare the client for a chest x-rayRefer the client to surgery to drain the blood from the pleural space 48. The nurse is preparing to discharge the client from the burn unit. Which of the following needs are the nurse's top priority to address before the client's discharge? (Select all that apply)Rehabilitation referralClient and family teaching (home care)Send employer the work release with client's medical information attached.Develop of a teaching planSend the clients medical record to law enforcement for investigation 49. A client is admitted to the intensive care unit (ICU) with a flail chest after being kicked in the chest from a horse. The client was chemically sedated and placed on a mechanical ventilator. The nurse should monitor for which of the following ventilator-associated complications?Cor pulmonale because the chest wall is unstableTuberculosis because the client will have prolonged close contact with other individualsPneumonia because the client is a high risk for acquiring an infectionChest tube placement because the lung has collapsed 50. A client is sedated on a ventilator. The nurse may safely delegate which action to the unlicensed assistive personnel (UAP) with this client?Provide daily hygiene cares per protocolObtain family written consent for restraintsAssess the client's nonverbal pain assessmentAssess the client for sedation needs Health ScienceScienceNursingNUR 2790Share Question

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