1. Which of the following will be included on the plan of care for…

QuestionAnswered step-by-step1. Which of the following will be included on the plan of care for…1. Which of the following will be included on the plan of care for a client receivingmechanical ventilation?a. Turn off the ventilator alarmsb. Provide mouth care once a shiftc. Reposition the client every 4 hrd. Place the head of the client’s bed at 40 degrees when supine 2. When an IV pump alarms because of pressure, what action does the nurse take first?a. Check the IV site for swellingb. Flush the catheter with a thrombolytic enzymec. Get a new IV pumpd. Remover the IV catheter 3. Which of the following actions will the nurse anticipate for the client following a lumbarpuncture?a. Client will maintain fetal positionb. Client will remain flat for 1 hourc. Client will ambulate immediately post-procedured. Client will recover with head of bed elevated 4. A client has suffered a deep laceration to the femoral artery. Which type of shock wouldthe nurse anticipate?a. Cardiogenicb. Neurogenicc. Hypovolemicd. Septic 5. A thoracentesis is performed to remove fluid. After assisting the provider with theprocedure, the nurse notices that the client is short of breath, producing small amountsof hemoptysis and is slightly cyanotic around the mouth. What is the priority nursingintervention?a. Provide oxygenb. Notify the providerc. Keep the client in semi-Fowler positiond. Provide intravenous fluids 6. A nurse is assisting with a sterile procedure. Which of the following practices will helpmaintain a sterile field?a. Keeping hands in sight and above waist levelb. Using clean gloves to handle sterile itemsc. Placing a moist dressing directly on the sterile fieldd. Allowing sterile instruments to touch the outer edge of the field 7. A client is admitted to the medical-surgical unit with a diagnosis of gastrointestinalbleeding. The nurse notes that the client’s hourly urine output is decreasing. What is thenormal output of urine per hour?a. 100 mL/hrb. 70 ml/hrc. 50 ml/hrd. 30 ml/hr 8. Which type of fluid would the nurse expect the provider to order for a client inhypovolemic shock?a. Isotonicb. Hypertonicc. Hypotonicd. Oral hydration 9. Nursing care for a client who is admitted with frostbite of the foot includes which of thefollowing?a. Applying a heating pad to the frostbitten areab. Giving the client hot fluids to drinkc. Wrapping the foot in warmed blanketsd. Immersing the foot in warm water 10. A nurse is caring for a client in rehab who is recovering from burgs to his face, ears, andeyelids. Which of the following situations would require immediate notification of theprovider?a. Urinary output 30 mL/hrb. Difficulty swallowingc. Heart rate 122 beats/mind. Blood pressure of 92/60 11. A 15-year-old male arrives at the ambulatory dienic. He is conscious, coherent andambulatory. His shirt and pants are covered with blood. He and his friends state that theywere playing and he fell onto a sharp stick. The victim pulled the stick out of hisabdomen because it was causing him pain. Which of the following comments cause themost concern?a. “He has diabetes.”b. There was a lot of blood; it soaked three t-shirts.”c. The stick was dirty and covered with mud.”d. “He pulled the stick out!” 12. As a part of community education on Dengue fever, what is most beneficial to teach tothe population affected?a. Mosquito controlb. Isolate victimsc. Handwashingd. Use of PPE 13. A client has pneumonia and is encouraged to increase fluid intake. He had 240 mL atbreakfast, 100 mL with pills, 260 mL midmorning, and 400 mL with lunch and 300 mLmidafternoon. How much more fluid does he need to reach the goal of 3000 mL for theday?a. 1700b. 1600c. 1750d. 1650 14. A 60-year-old client arrives at the triage area with a complaint of diaphoresis, dizziness,and left-sided chest pain. The LPN will expect the client to be prioritized into whichcategory?a. Non-urgentb. Urgentc. Emergentd. High urgent 15. What is the priority action for the nurse when the IV site is red and edematous (swollen)?a. Apply cold compresses to the IV siteb. Elevate the extremity on a pillowc. Flush the catheterd. Stop the infusion of IV fluids 16. A nurse is planning to administer amoxicillin 350 mg PO to their client. On hand isamoxicillin 250 mg/5 mL. How many mL will the nurse administer to the client? (Do notlabel answer. Round to the nearest whole number. Do not use a trailing zero.)_________________mL17. A nurse is on the disaster preparedness team at the hospital. During the training, theylearn the definition of a disaster. Which of the following situations meets the criteria for adisaster?a. A car crash with three victimsb. A bus crash with five injured transported to the local hospitalc. A chemical leak resulting in multiple fatalities and injuriesd. A handheld canister of pepper spray is accidentally deployed 18. A nurse is caring for a client in a rehab center who is being treated for partial-thicknessand full-thickness burns of his head, neck and chest. A client who sustains burns on theirface, neck, and chest is most at risk for which of the following?a. Airway obstructionb. Infectionc. Fluid and electrolyte imbalanced. Loss of motor function 19. A nurse is attending yearly training about triaging clients after a mass casualty event.Which of the following clients would receive priority care?a. A client with an open fracture of the humerusb. A client with a large head lacerationc. A client who has severe respiratory distressd. A client who has a small circular partial thickness burn of their hand 20. During a little league game one of the parents says, “1 just got stung by a bee and I amextremely allergic to them. What is the priority action?a. Call 911 and encourage her to stay calmb. Examine for evidence of a stingerc. Elevate the arm and apply an ice packd. Evaluate for hives21. A nurse is caring for a client with a new order for digoxin 0.25 mg PO daily. On hand isdigoxin 0.125 mg/tablet. How many tablets will be administered with each dose? (Do notlabel answer. Round to the nearest whole number. Do not use a trailing zero.)_________________mL 22. A client admitted to the emergency department with chest pain is diagnosed withmyocardial infarction (MI). The provider explains that the client could have complicationsfrom the MI such as cardiogenic shock. Which of the following are signs and symptomsof cardiogenic shock? Select all that apply.a. significant drop in blood pressureb. Diaphoresisc. Rapid pulsed. Elevated temperaturee. Flushed skin 23. A nurse is preparing to administer hydrocodone/acetaminophen 5 mg PO every 6 hr forpain. The amount available is hydrocodone/acetaminophen 7.5 mg/500 mg/15 mL elixir.How many mL should the nurse administer? (Do not label answer. Round the answer tothe nearest whole number. Do not use a trailing zero.)10 mL 24. At a disaster scene, a nurse notices that a person has been triaged with a black tag.What is the best action for the nurse at this time?a. Immediately obtain a oxygen tank and apply an oxygen mask portableb. Seek out emergency services personnel to transport the client to the hospitalc. Try to locate family members so that they can be present when the client diesd. Stay with the person for as long as possible to give support and comfort25. A nurse is assisting with the care of a client who was transferred from the hospitalfollowing a motor vehicle crash 2 weeks previously. In the early phase of these injuries,what is the priority for data collection?a. Respiratory statusb. Neurological statusc. Cardiovascular statusd. Muscle function26. The nurse enters the client’s room to administer medications and find him lyingmotionless on the floor. What is the priority action?a. Go to the nurses station to alert the RNb. Initiate cardiopulmonary resuscitation (CPR)c. Perform the chin lift or jaw thrust maneuverd. Call for help from the patient’s room27. Which of the following is an early symptom of shock?a. Hypotensionb. Bradypneac. Cold and clammy skind. Tachycardia28. The client receiving mechanical ventilation has become more restless throughout theshift. Which is the nurse’s first action?a. Sedate the clientb. Call the health care providerc. Evaluate the client for paind. Evaluate the client’s oxygenation29. Which of the following are indications for a thoracentesis? (Select all that apply.)a. Remove pleural fluidb. Instill medicationsc. Assess lung ventilation and perfusiond. Locate a pulmonary embolisme. Diagnostic procedures30. Calculate the correct flow rate Ordered: 1000 mL D5RL over 8 hours. Administration setdelivers 20 gtts/mL. How many drops per minute should be administered? Round to thenearest whole number.a. 41.6666 gtts/mLb. 41 gtts/mLc. 42 gtts/mL.d. 41.7 gtts/mL31. A nurse is learning about disaster management and triage, which includes a discussionabout using different colored tags to identify the timeframe in which the client shouldreceive treatment. Which of the following color tags should the nurse include asidentifying a client who requires treatment within 30 min to 2 hr?a. Redb. Greenc. Yellowd. Black32. To evaluate the effectiveness of Lasix and morphine for the treatment of pulmonaryedema, the nurse would do which of the following? (Select all that apply)a. Monitor intake and outputb. Monitor respiratory statusc. Monitor for decreased paind. Monitor strength of peripheral pulsese. Monitor bowel sounds33. A client arrives at the emergency department with a bee sting.he has swollen tongue,labored breathing and flushed face. He can talk but sounds muffled. Which of thefollowing orders would the nurse perform first?a. Administer epinephrine subcutaneouslyb. Initiate intravenous accessc. Administer intravenousd. Administer intravenous cortisone34. What is the priority action for the nurse to take if phlebitis (inflammation) at the IV site issuspected?a. Apply continuous heatb. Continue to monitor sitec. Elevate the extremityd. Remove the catheter35. The CDC has identified an outbreak of cholera in a small remote village. The nursevolunteers to treat victims and educate the village on preventative measures. Whatwould the nurse focus on in teaching the people that live in the village? Select all thatapply.a. Handwashingb. Boil water before drinkingc. Prevent raw sewage from entering water sourced. Proper wound caree. Cook food well before eating36. An Epi-Pen is prescribed for a client following an anaphylactic reaction. The nurse isdischarging the client and has reviewed how to use an Epi-Pen. Which of the followingstatements most accurately demonstrates an understanding of how to inject themedication?a. “I will have someone give the injection in my arm deep into the muscle.”b. “I will administer deeply into the muscle in my thigh.”c. “I will administer it into my stomach area.”d. “I will administer in the outer area of my thigh, hold firmly, and inject.”37. Which of the following interventions should the nurse identify as the priority for along-term care client who is receiving mechanical ventilation?a. Application of antiembolism stockingsb. Begin continuous tube feeding through a nasogastric tubec. Suctioning the airway as neededd. Providing a communication board for the client38. The nurse is assigned to assist in triage. Which of the following most accuratelydescribes the purpose of triage?a. Prioritize based on need for treatmentb. Ensure that all clients receive treatment eat ac. Ensure that medical equipment is availabled. Identify the need for supplies and support39. A client is in cardiogenic shock with significant hypotension. What position wouldincrease the blood flow to the brain?a. Supine with legs elevatedb. High Fowlersc. Side-lyingd. Semi-Fowlers40. The client is admitted for a diagnosis of inhalation anthrax. What is the health careprovider most likely to order to treat this client?a. IV fluids and oxygen therapyb. Ciprofloxacin (Cipro)c. Gentamicin (Garamycin)d. Antitoxin type A or B  41. A provider requires assistance performing a thoracentesis at the bedside. Which of thefollowing actions will the nurse take prior to the procedure?a. Verify consent has been signedb. Place client in side-lying positionc. Identify client by asking their named. Prepare a non-sterile field for use during procedure42. Which nursing intervention helps prevent ventilator-associated pneumonia? Select allthat apply.a. Elevate the head of bed 30 to 45 degreesb. Frequent removal of subglottic secretionsc. Hand hygiene before and after contact with every clientd. Provide oral caree. Turn the client daily43. A nurse enters the room of a client whose mechanical ventilator low-pressure alarm issounding. What is the priority action?a. Check the ventilator settingsb. Check the client’s respiratory statusc. Check the client’s vital signsd. Start cardiopulmonary resuscitation (CPR)44. What of the following actions would help reduce the risk of infections in the older adultwho is receiving IV therapy?a. Apply skin protectant before applying the dressingb. Avoid the use of alcohol pads when removing the tapec. Shave the skin before attempting the venipunctured. Use paper tape to help prevent skin tears45. Which of the following situations put someone at risk for hypovolemic shock?a. Well controlled bleedingb. Bites or stingsc. Third degree burnsd. Bacteria46. Clients who are receiving mechanical ventilation are at risk for pneumonia. Which of thefollowing actions will help decrease the risk of pneumonia? Select all that apply.a. Administering antibiotic prophylaxisb. Suction as needed to remove subglottic secretionsc. Elevate the head of the bed at least 30 degrees whenever possibled. Handwashing before and after contact with the cliente. Placing a nasogastric tubef. Placing the client in a negative airflow room.47. A client received their first dose of oral antibiotic at 1230. At 1330 the nurse enters theroom to re-evaluate the client and notices a fine red rash on the client’s arms Which ofthe following is the priority intervention by the nurse?a. A Initiate a peripheral IVb. Check the client’s respiratory ratec. Initiate oxygend. Prepare for administration of epinephrine48. A nurse is observing the care of a client in the emergency department. The client reportssevere radiating chest pain and shortness of breath. The client is restless, slightlycyanotic, and reports being frightened. The provider prescribes oxygen by nasal cannulaat 4 L/min stat, cardiac enzyme levels, IV fluids, and a 12-lead ECG. Which of thefollowing actions will be taken first?a. Initiating the 12-lead ECGb. Blood draw for cardiac enzymesc. Application of oxygen at 4 L/mind. Inserting the peripheral IV49. The nurse is caring for a postoperative client who had major abdominal surgery. Whichassessment finding is consistent with hypovolemic shock?a. Pulse pressure of 40 mm Hgb. A rapid, weak, and thready pulsec. Warm, flushed skind. Increased urinary output50. During a disaster drill, the nurse becomes suspicious that the clients are victims of abiological event. What action should the nurse take next?a. Calmly apply PPEb. Alert hospital leadership to activate an internal disasterc. Alert the charge nurse to activate an internal disasterd. Remove all victims from the ER waiting area to a decontamination area51. A local train wreck has released the chemical agent chlorine. Victims of exposure arriveat local hospitals. As a part of the internal disaster team, the nurse is assigned todecontaminate the victims. What measure would the nurse take first to decontaminatethe skin?a. Remove contaminated clothingb. Wash skin with soap and waterc. Flush skin with plain water for 2-3 minutesd. Use bleach to decontaminate skin52. Which client needs to be placed immediately in isolation?a. A client diagnosed with botulism poisoningb. A probable case of inhalation anthraxc. Known exposure to high dose radiation raysd. Suspected smallpox, but probable chickenpox53. A nurse is monitoring a client who is receiving continuous enteral feeding. Which of thefollowing findings should the nurse identify as the priority?a. Temperature 38.2° C (100.8° F)b. Respiratory rate 12/minc. Hematocrit 45%d. Urine specific gravity 1.01554. A nurse is assisting with the care of a client immediately following a lumbar puncture.Which of the following actions should the nurse take?a. Insert a urinary catheterb. Elevate the client’s head of bedc. Decrease fluid intaked. Monitor the puncture site for hematoma55. Which position is best for the client undergoing a thoracentesis?a. Sitting up, leaning forward on an overbed tableb. Side-lying affected side up, head slightly raisedc. Side-lying, affected side down, head flatd. High Fowler’s position56. Which of the following interventions is a priority for a client following a lumbar puncture?a. Provide the client a low-sodium dietb. Change the client’s dressing every 12 hrc. Place the client in high-Fowler’s positiond. Encourage oral fluids57. A nurse is assisting the RN in triage. There are four clients to be triaged. Which of thefollowing clients would need to be seen first?a. A 45-year-old male with vomiting and abdominal painb. A 35-year-old jogger who reports ankle painc. A 25-year-old male with a minor forehead lacerationd. An irritable infant with a fever, petechiae, and nuchal rigidity58. A nurse is working in an ambulatory clinic. A client enters the clinic and is bleedingprofusely from a deep laceration on his left lower forearm. After donning gloves, what isthe priority action?a. Administer epinephrine subcutaneouslyb. Initiate intravenous accessc. Administer intravenous antihistaminesd. Administer intravenous cortisone59. A provider writes an order for potassium chloride 30 mEq PO daily. On hand ispotassium chloride 20 mEq/15mL. (How many mL will be administered with each dose?Do not label answer. Round the answer to the nearest tenth. Use a leading zero if itapplies. Do not use a trailing zero.)_________________mL60. The Plague was caused by bacteria found in rodents and fleas. The Plague is on the listof bioterrorist agents. As a part of the disaster preparedness team, the nurse is requiredto know the signs and symptoms of the Plague. What are the signs and symptoms of thePlague?a. Hemoptysis, high fever, headache, respiratory failureb. Nausea, vomiting, anorexiac. Fever, backache, pustular lesionsd. Swollen lymph nodes, edema61. A nurse is working with several clients. Which of the following clients requires the nurse’simmediate attention?a. A client who had a tonsillectomy and is swallowing frequentlyb. A client who had an appendectomy and refuses to ambulatec. A client who has an IV infusion and reports pain at the insertion sited. A client who reports pain of 6 on a 1 to 10 pain scale62. In a disaster triage situation, which of the following is an example of the emergent (redtag) category?a. A client who has an open fractureb. A client who has several closed fractures with bruisingc. A client who has a punctured femoral arteryd. A client who exhibits manifestations of multiple organ failure63. A client receiving gentamycin intravenously reports that she is itching and has a rash onher arms. What is the priority action in this situation?a. Report the client’s problem to the primary health care providerb. Document findings and actions in the electronic medical recordc. Change the IV insertion site to a new locationd. Stop the infusion of the drug immediately64. A client who has taken their first dose of penicillin reports shortness of breath and a redrash on their chest and abdomen. Which of the following medications would beadministered first?a. Albuterolb. Hydrocortisone sodium succinatec. Diphenhydramined. Epinephrine65. Older adult clients often have fragile skin which puts them at risk for skin tears. Which ofthe following interventions would increase the risk of skin tear?a. Using a lift sheet to reposition clientb. Maintain adequate nutrition and hygienec. Use non adherent dressingsd. Remove tape and dressings quickly66. Which of the following actions is the responsibility of the nurse during a disaster?a. A Reinforce discharge teaching to clientsb. Focus on clients with life-threatening emergenciesc. Delegate the AP to focus on clients’ ADLSd. Maintain appropriate stock in the unit67. During anaphylactic shock, the body reacts by rapidly vasodilating blood vessels. Thebody’s response also includes an airway reaction to histamine. What is the expectedairway response during anaphylaxis?a. Bronchoconstrictionb. Bronchodilationc. Bronchophonyd. Bronchoscopy68. A nurse is collecting data on a client who has a major burn injury. The nurse shouldrecognize which of the following findings as a Priority?a. The client has first degree burns on their handsb. The client reports moderate discomfort at burn sitesc. The client has a cough productive of black colored sputumd. The client’s heart rate is 122 beats/minute69. A nurse is working with the RN and is monitoring a client following a thoracentesis.Which of the following clinical manifestations has the highest priority?a. Serosanguineous drainage at the insertion siteb. Mild discomfort at the insertion sitec. Increased heart rated. Decreased temperature70. Which of the following is a high priority in the immediate treatment of chemical burns ofthe hands?a. In all cases, apply water to cool the burnb. In most cases, except for dry lime, flush with large amounts of water to removechemicalc. Cover the burn with dressing, but do not flush the chemical from the skind. Use alcohol to clean the chemical of the skin71. A nurse is preparing to exit an isolation room. Which of the following pieces of personalprotective equipment (PPE) should the nurse remove last?a. Maskb. Gownc. Eyeweard. Gloves72. Smallpox was eradicated in the US in 1971 due to the development of a vaccine.Smallpox is listed in the category of bioterrorist agents. How is smallpox transmitted as abiologic agent?a. Airborneb. Contactc. Indirectly in food sourcesd. Contaminated water73. A client is in hypovolemic shock. The nurse knows that with any type of shock, there willbe a decrease in circulating blood volume resulting in decreased tissue perfusion. Theinadequate tissue perfusion causes what observable sign in the client evaluation?a. Delayed capillary refillb. Increased urine outputc. Vasodilationd. Flushed skin74. During a training session at work, the presenter talks about possible complicationsrelated to peripheral V therapy. After attending the session, the nurse understands that ared streak arising from the IV site and a vein that is firm to palpation would most likelymean which of the following?a. Phlebitis at IV siteb. Infection at IV sitec. Thrombosed area at IV sited. Infiltration at IV site75. A client presents to the outpatient clinic with a two-day history of fever. fatigue, coughing,and difficulty breathing. She is short of breath and is unable to speak in completesentences. What is the priority action?a. Obtain blood pressureb. Obtain oxygen saturationc. Review the physician orders and implementd. Weigh the clientHealth ScienceScienceNursingPRN 1032LLShare Question