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Mariah Shaina Sanchez BSN-3a1 1.

The emergency medical service (EMS) has transported a patient with severe chest pain. As the patient is being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and no palpable pulse. Which task is appropriate to delegate to the nursing assistant? a. Chest compressions b. Bag-valve mask ventilation c. Assisting with oral intubation d. Placing the defibrillator pads
ANSWER A – Nursing assistants are trained in basic cardiac life support and can perform chest compressions. The use of the bag-valve mask requires practice and usually a respiratory therapist will perform this function. The nurse or the respiratory therapist should provide PRN assistance during intubation. The defibrillator pads are clearly marked; however, placement should be done by the RN or physician because of the potential for skin damage and electrical arcing.

2. You are preparing a child for IV conscious sedation prior to repair of a facial laceration. What information should you immediately report to the physician? a. The parent is unsure about the child’s tetanus immunization status. b. The child is upset and pulls out the IV. c. The parent declines the IV conscious sedation. d. The parent wants information about the IV conscious sedation.
ANSWER C – Parent refusal is an absolute contraindication; therefore, the physician must be notified. Tetanus status can be addressed later. The RN can restart the IV and provide information about conscious sedation; if the parent still notsatisfied, the physician can give more information. 3. An anxious 24-year-old college student complains of tingling sensations, palpitations, and

chest tightness. Deep, rapid breathing and carpal spasms are noted. What priority nursing action should you take? a. Notify the physician immediately. b. Administer supplemental oxygen. c. Have the student breathe into a paper bag. d. Obtain an order for an anxiolytic medication.
ANSWER C – The patient is hyperventilating secondary to anxiety, and breathing into a paper bag will allow rebreathing of carbon dioxide. Also, encouraging slow breathing will help. Other treatments such as oxygen and medication may be needed if other causes are identified

Medicate the client with narcotic analgesic c. Assess the pain further c. Larry’s anterior trunk. Redness around the insertion site . Coldness around the insertion site d. A change in flow rate c. the female client complains of lumbar pain. and then normal saline should be infused to keep the line patent and maintain blood volume ANSWER Situation: Larry was admitted at Manila Doctor's Hospital because of a second-degree burn wound. 62% d. The blood must be stopped at once. Obtain vital signs. Administer acylovir (Zovirax) IV d. 5. 61% Answer B. Increase the flow of normal saline b.63% c. After stopping the infusion Nurse Hazel should: a. Apply a topical antimicrobial ointment Answer B. Before debriding a second-degree burn wound in the left lower leg. both front upper extremities. Pain at the site b.4. 60% b. Estimate the total percentage of body surface area burned using the Rule of Nines. Halfway through the administration of blood. Notify the blood bank d. Medicate the client with narcotic analgesic 6. Apply Lindane (Kwell) to the affected area b. A. the nurse should do which of the following? a. both lower extremities sustained second and third degree burn. 63% 7. The nurse is caring for a client who is receiving IV fluids. Which observation the nurse makes best indicates that the IV has infiltrated? a. a.

neck veins are distended when the client is in the supine position. ankles. Which order takes priority at this time? a. Maintain accurate intake and output. The client’s potassium level is 6. Which finding on assessment supports this nursing diagnosis? a. Teach family members to assist client with fluid intake ANSWER B – The nursing assistant can reinforce additional fluild intake once it is part of the care plan. Shallow respirations with crackles on auscultation ANSWER A – Normally. b. and teaching families require additional education and skills that are within the scope of practice for the RN.7 mEq/L. Weight client every morning. Coldness around the insertion site 8. Administer furosemide (Lasix) 40 mg IV push ANSWER D – Bilateral moist crackles indicate fluid-filled alveoli. The physician has written the following orders for the client with Excess Fluid volume. and calves d. weight gain of 2 pounds. Which intervention should you delegate to the student nurse under your supervision? . Provide straws and offer fluids between meals. The veins flatten as the client moves to a sitting position. b. The client’s morning assessment includes bounding peripheral pulses. Full and bounding pedal and post-tibial pulses c. which interferes with gas exchange. developing plans. Flattened neck veins when client is in supine position b. 9. c. Develop plan for added fluid intake over 24 hours d. Pitting edema located in feet. pitting ankle edema.ANSWER C. Administer IV fluids as prescribed by the physician. Restrict fluid to 1500 mL per day d. 10. Furosemide is a potent loop diuretic that will help mobilize the fluid in the lungs. The client also has the nursing diagnosis Decreased Cardiac Output related to decrease plasma volume. The other three responses are characteristic of Excess Fluid Volume. Which action related to the fluid management should be delegated to a nursing assistant? a. A client’s nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. The other orders are important but not urgent. 11. Administering IV fluids. and moist crackles bilaterally. c.

12. Metabolic acidosis d.5 mg/dL). Which are all good sources of dietary calcium. Administer potassium 10 mEq orally ANSWER A – The client’s potassium level is high (normal range 3. and spinach. Increasing the ventilator rate will blow off more CO2 and decrease the acidosis. The nursing assistant reports to you that a client seems very anxious and that vital signs included a respiratory rate of 38 per minute. Decrease the ventilator rate from 10 to 6 per minute c. Administer Kayexalate 15 g orally b. Assess WCG strip for tall T waves d. A client with respiratory failure is receiving mechanical ventilation and continues to produce ABG results indicating respiratory acidosis. Respiratory alkalosis c. Spironolactone is a potassium-sparing diuretic that may cause the client’s potassium level to go even higher. The nursing student may not have the skill to assess ECG strips and this should be done by the RN.0). Respiratory acidosis b. broccoli. Which action should you expect to correct this problem? a. “I will call my doctor if I experience muscle twitching or seizures. Which statement by the client indicates the need for additional teaching? a. nuts. You are preparing to discharge a client whose calcium level was low but is now just slightly within the normal range (9-10. “I will take my calcium pill every morning before breakfast. Kayexalate removes potassium from the body through the gastrointestinal system. “I will avoid dairy products.” b. 13. Increase the oxygen concentration fro 30% to 40% d.” c. seafood. Increase the ventilator rate from 6 to 10 per minute b. broccoli.5-5.a. Metabolic alkalosis . Changes in the oxygen setting may improve oxygenation but will not affect respiratory acidosis.” d. Administer spironolactone 25 mg orally c. 15.” ANSWER D – Clients with low calcium levels should be encouraged to consume dairy products. and spinach when I eat. Decrease the oxygen concentration fro 40% to 30% ANSWER A – the blood gas component responsible for respiratory acidosis is CO2 (Carbon dioxide). “I will make sure to take my vitamin D with my calcium each day. Which acid-base imbalance should you suspect? a.

” c. 17. pain present and high). has blisters. increasing the respiratory rate helps correct the problem. The third and fourth answers are inaccurate. and is very painful. Partial-thickness burns reduce the activation of vitamin D. The client’s increase in rate and depth of ventilation is an attempt to compensate by blowing off CO2. The burned area appears red. Partial-thickness superficial C. Activation of vitamin D is lost completely in fullthickness burns. 18. Which vitamin deficiency is most likely to be a long-term consequence of a full-thickness burn injury? A. 16. How should this injury be categorized? A. . Vitamin C D. “It’s common for clients with uncomfortable procedures such as nasogastric tubes to have a higher rate to breathing. Respiratory acidosis results from respiratory depression and retained CO2. Vitamin A B. The newly admitted client has a large burned area on the right arm. Partial-thickness deep D.” ANSWER B – Nasogastric suctioning can result in a decrease in acid components and metabolic alkalosis.” b. Full thickness ANSWER B The characteristics of the wound meet the criteria for a superficial partialthickness injury (color that is pink or red. The student nurse asks why the client’s respiratory rate has increased. “The client is hyperventilating because of anxiety and we will have to stay alert for development of a respiratory acidosis.ANSWER B – The client is most likely hyperventilating and blowing off CO2. What your best response? a. Vitamin B C. “The client may have a metabolic alkalosis due to the NG suctioning and the increased respiratory rate is a compensatory mechanism. Metabolic acidosis and alkalosis result from problems related to renal acid-base control. “Whenever a client develops a respiratory acid-base problem. blisters. Superficial B. causing respiratory alkalosis. A client has a nasogastric tube connected to intermittent wall suction. This decrease in CO2 will lead to an increase in pH. Vitamin D ANSWER D Skin exposed to sunlight activates vitamin D.” d. the first response maybe true but does not address all the components of the question.

When the client's family asks why this drug is being given. 20. . “To stimulate intestinal movement and prevent abdominal bloating. an H2 histamine blocking agent. “To inhibit loss of fluid from the circulatory system and prevent hypovolemic shock.” ANSWER C Ulcerative gastrointestinal disease may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and decreased mucosal barrier. during the emergent phase.” D. what is the nurse’s best response? A. “To increase the urine output and prevent kidney damage. potassium movement back into the cells.” C.” B. Cimetidine inhibits the production and release of hydrochloric acid. Immediately following the injury B. At what point after a burn injury should the nurse be most alert for the complication of hypokalemia? A. During the late acute phase ANSWER C Hypokalemia is most likely to occur during the fluid remobilization period as a result of dilution. During the fluid shift C. The burned client is ordered to receive intravenous cimetidine.19. “To decrease hydrochloric acid production in the stomach and prevent ulcers. During fluid remobilization D. and increased potassium excreted into the urine with the greatly increased urine output.