- A nurse in an emergency department is caring for a client. Physical Examination Client presents to the ED with upper abdominal pain that radiates to the right shoulder. -Encourage a minimum intake of 2000 Study with Quizlet and memorize flashcards containing terms like A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. A nurse in an emergency department is caring for a client ad finds a razor blade hidden in the client's belongings. Hold the Study with Quizlet and memorize flashcards containing terms like The nurse employed in an emergency department is assisting in caring for an adult client who is a victim of family violence. Which a. Which action should the nurse take? a. The homeless A nurse in an emergency department s caring for a client who has a blood pressure of 254/139 mm hg. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. To which of the following interprofessional team members should the nurse refer the client? a. Dilated pupils C. retraction of sternal muscles. Unlock. 1° C), pulse 132 beats/min, respirations 26 breaths/min, blood pressure 106/66 mm Hg. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration? A nurse is caring for a client who has a new prescription for total parenteral nutrition (TPN). The client's symptoms started 1 hr prior to arrival at the ED. Presenting symptoms in a crisis situation are similar for all clients experiencing a crisis d. Which of the following A nurse is caring for a client who came to the emergency department reporting chest pain. Hypersomnia D. which of the A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past 3 days. B. Which of the following findings should the nurse report to the provider?, A nurse is caring for a client who is post operative and has a respiratory rate of 9/min secondary to general anesthesia effects and incisional pain. Encourage the Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client whose wounds are covered with a heterograft dressing. b. Prepare to administer recombinant tissue plasminogen activator (rt-PA). Which of the following clients should the nurse ask the provider to care for first? A toddler who has asthma and has a pulse oximetry reading of 95% while receiving oxygen at 2 L/min A toddler who has otitis media, a temperature of 39. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has an epidural hematoma. Using the rule of nines the nurse should document the burns to which percentage of the client's total body surface area (TBSA)? A. An ER (Emergency Room) nurse is a registered nurse (RN) who specializes in providing care to patients in emergency situations. A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client reports muscle cramps, and tingling sensation in their hands. The nurse should identify that which of the following interventions is CI? A nurse in an emergency department is caring for a client who has a BP of 254/139 mm Hg. Oriented x 3, able to move all extremities. The provider suspects a myocardial infarction. Which of the following actions should the nurse take first? A. Which of the following actions should the nurse plan to take? a. Infection c. Study with Quizlet and memorize flashcards containing terms like a nurse in an emergency department is assessing a client who is having a suspected acute myocardial infarction (MI). What is the nurse's priority The Correct Answer is D. Study with Quizlet and memorize flashcards containing terms like A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. A nurse is caring for a client who has fluid volume overload. which of the following assessments indicates that the respiratory status is declining? (select all that apply). Emergency medicine physician b. Case manager c. The client's spouse asks the nurse what the procedure entails. Diabetes ketoacidosis is suspected. Every 2 hours 2. Which of the following clients requires mandatory reporting? A young adult client who is positive for tuberculosis Diseases and illnesses that are considered a threat to public health, such as tuberculosis, HIV, and influenza, require mandatory reporting to the health department to track and Study with Quizlet and memorize flashcards containing terms like A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. Administer regular insulin 10 U by IV push C. Every 4 hours 4. Administer epinephrine IM Rationale: When using the urgent vs. The client's vital signs are as follows: BP 198/110, HR 82, RR 24, Temp 100. The client has a grilled ham and cheese sandwich, a banana, and yogurt on his lunch tray C. Increased Which of the following findings is the nurses priority?, A nurse is caring for a client who is undergoing hemodialysis to treat end stage kidney disease. The nurse is planning care for the client who has chest pain. A nurse in the emergency department is caring for a client who has a compression fracture of a spinal vertebra. Pharmacist A nurse in an emergency department is caring for a female adolescent who has a diagnosis of bulimia nervosa and had a fainting episode during a ballet performance. Take the client’s vital signs. This is an emergency because ultimately it Study with Quizlet and memorize flashcards containing terms like A nurse in the emergency department is assisting with the care of a client who has acute haloperidol toxicity. The client reports that she has lost 30 lb Decreased vascular volume INCORRECT Decreased vascular volume is not a finding associated with dilated cardiomyopathy. The provider suspects a ruptured ectopic pregnancy. Which nursing intervention A nurse in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and thrown from the vehicle. Which of the following actions should the nurse take? a. Cranberry juice, A nurse in an emergency department is caring for an Study with Quizlet and memorize flashcards containing terms like A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following central venous access devices should the nurse anticipate being inserted? Study with Quizlet and memorize flashcards containing terms like A nurse in an emergency department is assessing a client for suspected cocaine intoxication. The nurse should A nurse in an emergency department is caring for a client who received a dose of penicillin and is now anxious, flushing, tachycardic and has difficulty swallowing. 020 BUN 15 mg/dL A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain. The client asks the nurse about the effects that taking over-the-counter drugs will have on her newborn. The A nurse in the emergency department is caring for a client who reports chest pain, headache, and shortness of breath. Encourage the A nurse in the emergency department is caring for a client who collapsed after playing football on a hot day. The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. Discuss self-defense techniques with the client. A client scheduled for a chest x-ray b. The nurse should identify that this finding is consistent with which Nursing care in the emergency department 1100. During an anaphylactic reaction, histamine release causes bronchoconstriction and vasodilation. cadaver skin b. a client with dysuria and urinary urgency for a day and a temp of 100. Question: A nurse in an emergency department is caring for a 52 -year-old male client. Which of the following medications should the nurse plan to administer? Study with Quizlet and memorize flashcards containing terms like A nurse in an emergency department is admitting clients following an earthquake. Study with Quizlet and memorize flashcards containing terms like The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. A nurse in an emergency department is caring for a client who has a sucking chest wound resulting A nurse in an emergency department is caring for a client who has heroin toxicity. Severe D. Which of the following neurologic disorders should the nurse suspect? Find step-by-step Health solutions and your answer to the following textbook question: A nurse in a emergency department is caring for a client who is to receive tissue plasminogen activator (TPA) for the treatment of an ischemic stroke. Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a pregnant client with a decreased alpha-fetoprotein level. The family states the client has been uncharacteristically confused and appears to have abnormal perception of movement. After reviewing the admission laboratory findings, the nurse recognizes that these findings are consistent with which of the following conditions? Sodium 152 mEq/L ,Glucose 102 mg/dL , potassium 3. Insert an IV line. the client Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a patient in the emergency department with complaints of acute abdominal pain, nausea, and vomiting. Nurses' Notes Vital Signs Medical History Nurses' Notes Client is admitted to the emergency department Adult Protective Services hotline: 1- (833) 401-0832. , A charge nurse in the emergency department is assigning acuity levels to four clients. Daily Allergic, A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). Which of the following assessments indicates that the respiratory status is declining? (select all that apply) A. Which nursing interventions should the nurse take? Select all that apply. The Study with Quizlet and memorize flashcards containing terms like A nurse is planning an educational program about basal cell carcinoma. The nurse notifies the client's provider A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical ventilation. When assessing the client, the nurse observes clear fluid draining from the client's nose. 31, PaCO2 50 mm Hg, and HCO3 25 mEq/L after experiencing an airway obstruction. The nurse observes the client’s thorax A nurse in an emergency department is caring for a client who has received a dose of penicillin and is now anxious, flushing, tachycardic, and having difficulty swallowing. Which of the following actions is the nurse's priority? a. Occupational therapist b. 4), and SaO2 92% on room air. This chapter is divided into two parts. Which assessment finding is the most important for the The nurse is caring for a client with asthma who has a baseline peak flow reading of 600 mL and calls the nurse, stating that the current peak flow is 420 mL. Which interventions would the nurse include in the plan of care to prevent a suicide attempt? Study with Quizlet and memorize flashcards containing terms like A nurse is caring for an adult client who has alcohol use disorder. Which of the following findings indicates to the nurse the client is possibly experiencing a tension pneumothorax? A. Which of the following signs indicates to the nurse that the client Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client in the emergency department (ED). a client who was admitted for pneumonia and reports having no heat running water at home c. instruct the client to increase their intake of folic acid. Study with Quizlet and memorize flashcards containing terms like A nurse in an emergency department is caring for a client who has diabetic ketoacidosis (DKA) and a blood glucose level of 925 mg/dL. c. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38. Reverse the toxicity with naloxone C. 1cm ( 0. Which of the following interventions should the nurse take? -Teach controlled coughing and deep breathing. beef collagen, A Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client who has thrombophlebitis and a prescription to receive heparin via continuous IV infusion. Which of the following guidelines should the nurse include for emergency care? (Select all that apply. 5 mcg/kg/min, The nurse in the emergency department is caring for a client recently diagnosed with Graves' disease who was admitted following a motor vehicle accident. A nurse educator is providing an inservice program to emergency department nurses about the signs of inhalation anthrax. the dressing on the chest and a sucking noise coming from the wound. The nurse is unable to locate members of the client's family to obtain consent. A nurse in an emergency department is caring for a 52 year-old male dient. , 2. A client requiring daily dressing changes c. Specific gravity of urine B. , Case Study: A nurse in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and thrown from the vehicle. The nurse recognizes that the client is in a hypertensive crisis. D. Nurses' Notes Day 1, 1000: Client presents to the emergency department (ED) with right-sided hemiparesis, lethargy, and aphasia. The nurse in an emergency department is caring for a minimally responsive 27-year-old victim of a motorcycle accident. Study with Quizlet and memorize flashcards containing terms like A nurse is triaging four clients in the emergency department (ED). ) A nurse is caring for a client who is 1 day postoperative following a mastectomy. The provider determines that the client needs immediate central venous access for fluid and blood replacement. Which of the following resources will provide the most effective support immediately following the incident? A nurse is caring for a client who refuses treatment and asks to be discharged from the hospital AMA. Which finding would indicate the presence of a pneumothorax in this client? 1. In which order should the nurse complete the following actions? (Move the steps into the order of performance. PaCO2 25 mm C. The client must be transported to a treatment facility as soon as possible. A nurse in an emergency department is caring for a client who has diabetic ketoacidosis (DKA) and has a blood glucose level of 925 mg/dL. A nurse is caring for a client who is postoperative following a total knee arthroplasty and has been prescribed a continuous passive motion A nurse in an emergency department is assessing a client who has extensive burns, including on her face. A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past three days A nurse in an emergency department receives report from an emergency responder who states a client is beingtransported following exposure to a "dirty bomb". The nurse would include which interventions in the plan of care for the client? Select all that apply. The client's family brings in a silk flower Study with Quizlet and memorize flashcards containing terms like A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. When collecting data, which of the following findings should the nurse identify as consistent with neuroleptic malignant syndrome?RSONs?, A nurse is reinforcing Study with Quizlet and memorize flashcards containing terms like 1. Which of the following statements by the mother acknowledges her daughter's diagnosis? A nurse is caring for a client who has attempted suicide and has alcohol use disorder A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. Monitor blood glucose every 4 hr. Moderate C. Nurses' Notes Vital Signs Medical History Nurses' Notes Client is admitted to the emergency department with periodic episodes of wheezing and shortness of breath. which of the following actions should the nurse take first. Which of the following actions should the nurse take first?, The nurse is caring for a client who was brought to the emergency department after binge drinking at a party. The nurse should advise the Study with Quizlet and memorize flashcards containing terms like A nurse in the emergency department is caring for a patient who has a sucking chest wound resulting from a gunshot. Which nursing action is the priority when administering chelation therapy for a preschool-age client? 1 Assessing vital signs 2 Monitoring urine output 3 Conducting a A nurse in an emergency department is caring for an adolescent client who reports being sexually assaulted just prior to admission. Which of the following findings indications a need for intervention? A. On physical Study with Quizlet and memorize flashcards containing terms like A nurse in an emergency department is caring for an adolescent following a suicide attempt. , A client is returned to the nursing unit after thoracic surgery with chest tubes in place. 5 B. The client reports relief from the chest pain but now he is experiencing a headache. The client has a blood pressure of 100/60, a weak pulse rate of 118 and a respiratory rate of 40. Administer warmed IV fluids to counteract hypothermia B. 4 d. Client states they need to urinate frequently during the day and wake up 2 to 3 times during the night to urinate. 1 units/kg/hr D. Prepare the client for gastric lavage Study with Quizlet and memorize flashcards containing terms like A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Which of the following actions should the nurse take?, A nurse in the emergency department is assessing a client who has extensive burns, including on A nurse in the emergency department is caring for a client who experienced abuse by an intimate partner and is scared to return home. The nurse reinforces which instruction to the victim in the discharge plan? Information regarding the location of An older adult client is brought to an emergency department by a family member. Which of the following findings should the nurse expect? A. Study with Quizlet and memorize flashcards containing terms like A nurse in an intensive care unit is planning care for a client who has myxedema coma. Recognize Cues Highlight the direct assessment findings that indicate the client currently has impaired cardiac output related to compromised perfusion. The client is vomiting and is diaphoretic. A nurse in an emergency department is caring for a client. Initiate airborne precautions d. 0 × 109/L) and a temperature of 101°F (38. A nurse in the emergency department is caring for a client who was in a motor-vehicle crash. Chemical B. Which of the following actions should The client complains of coolness in the hands and feet only, A client arriving at the emergency department has experienced frostbite to the right hand. Pale -colored stools B. The nurse should anticipate which of the following prescriptions from the provider?, A nurse is reviewing the arterial blood gas values for a a client who fell and has wrist pain with an obvious deformity b. These nurses work in fast-paced, high-stress environments and are often the first medical professionals to see patients in critical condition. The emergency disaster plan has been implemented due to the anticipated arrival of a large number of casualties. A pink, edematous hand b. PaO2 58 mm A nurse is caring for an adolescent client who has long history of diabetes mellitus and is being admitted to the emergency department confused, flushed, and with an acetone odor on the breath. Tell the client to go to the hospital emergency department. After reviewing the client's history, the nurse should determine that which of the following is the priority risk factor for suicide completion?, A nurse in a mental health clinic is caring for Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a child who is 2 hr postoperative following a tonsillectomy. obtain a urine specimen. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has borderline personality disorder. Which interventions should be included in the client's plan of care? Select all that Study with Quizlet and memorize flashcards containing terms like · Nurse is caring for a client who reports an area of redness, warmth, tenderness and pain in the right calf. " Returned client to Sally is a nurse working in an emergency department and receives a client after a radiological accident. The nurse reinforces which instruction to the victim in the discharge plan?, The nurse is assigned to care for a client who is suicidal. When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Study with Quizlet and memorize flashcards containing terms like You are a nurse in the Emergency Department (ED) caring for a client presenting with vasodilation. A nurse is caring for a client who has meningitis, a temperature of 39. Providing tracheostomy care for a client. Administer ondansetron, 13. Ask security to Study with Quizlet and memorize flashcards containing terms like A patient with diabetic ketoacidosis is brought to the emergency department. The client's left leg has bruising, swelling, and displacement of the bones. 9% sodium chloride IV bolus. A nurse is caring for a client who is scheduled for a coronary artery bypass graft in 2 hours. Inform the client photographs of injuries are required for a police report. Which nursing intervention is priority? 1. Which of the following clients should the nurse recommend for treatment first? Measure the client's daily weight. "A headache is an indication of an allergy to the medication" b. The nurse should identify that which of the following findings require immediate follow-up? The nurse should first address the client's TEMPERATURE followed by the client's PAIN. Crushed ice b. ) Low blood pressure Wheezing Bradycardia Peripheral edema Difficulty swallowing, A nurse is Study with Quizlet and memorize flashcards containing terms like An occupational health nurse is instructing workers at an industrial facility in emergency procedures in the event of a traumatic amputation. Assessing a client who just returned from surgery. the client has a blood pressure of 100/60 mm Hg and a weak pulse rate of 118/min and a respiratory rate of 40/min. Individuals can enter their 5-digit ZIP code to be connected to their county Adult Protective Services staff, 7 days a week, 24 Study with Quizlet and memorize flashcards containing terms like A nurse in the emergency department (ED) is caring for a client who reports abdominal pain. Monitor for A nurse in an emergency department is caring for a child who is experiencing an acute asthma attack. Which finding would the nurse note on assessment of the client's hand? a. The nurse notes a thick dressing on the chest and a sucking noise coming from the wound. the client is experiencing excessive stools. Every 3 hours 3. Administer ammonium chloride The nurse is creating a plan of care for a client in crisis state. This indicates a high level of consciousness and a normal Glasgow A nurse in an emergency department is caring for a client who is bleeding from a deep laceration on his left lower forearm. Yellowing of the sclera C. The client asks about the effects of this medication. 4°C) Rationale: The nurse should plan to care for the client who has an elevated white blood cell count and a fever first because this client's needs are the priority. After ensuring a patent airway and A nurse in an emergency department is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood. The client's physical assessment is complete, and physical evidence has been collected. What is the priority nursing action for this client?, An 87-year-old person is brought to the emergency department for treatment of a fractured arm. 1° F (40. The nurse is unable to locate members of the A nurse in an emergency department is caring for a client who has sustained multiple injuries. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is 3 days postoperative following a right total hip arthroplasty. Nystagmus B. Airway obstruction b. Request a prescription for restraints from the provider b. pig skin c. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit? Heart rate 110/min Blood pressure 138/90 mm Hg Urine specific gravity 1. It is important for the nurse to Study with Quizlet and memorize flashcards containing terms like A nurse is admitting a client to a healthcare facility the nurse is placing the client on isolation precautions which of the following interventions should the nurse include, A client who is postoperative is verbalizing pain as a two on a pain scale of 0 to 10 which of the following statements are A nurse is caring fora client who has neutropenia. A nurse in an emergency department is caring for an adolescent client who reports being sexually assaulted just prior to admission. With which health care team member should the nurse collaborate when planning this client's care? a. The client reports severe left chest pain on inspiration. ER nurses are responsible for assessing patients' conditions, administering A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. Mild B. Social worker c. Nurses: Notes The client reports new onset of thirst and increased hunger. 4 in) stage 2 A triage nurse in an emergency department (ED) is caring for a client who has a gunshot wound to the right side of her chest. Extra drainage system B. The nurse observes the client’s thorax moving inward during inspiration and outward during expiration. Assess the client's visual acuity prior to irrigation b. The nurse notes that the client's chest movement inward during inspiration and bulges out during expiration. which of the following client statements indicates a need for further clarification by the nurse?, a nurse in an emergency department is caring for a client who had an anterior myocardial Study with Quizlet and memorize flashcards containing terms like A nurse in an emergency department is caring for a client. A nurse working in the emergency department is caring for a client following an acute chest trauma. Study with Quizlet and memorize flashcards containing terms like a nurse is planning care for a client who has, A nurse is monitoring a client following a thyroidectomy. A referral for self A nurse in an emergency department receives report from an emergency responder who states a client is being transported following exposure to a "dirty bomb". Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who arrived at an emergency department following a bee sting. A nurse in the emergency department is caring for a client who has a compression fracture of a Study with Quizlet and memorize flashcards containing terms like A nurse in an emergency department is performing triage for a group of clients following a motor-vehicle crash. Study with Quizlet and memorize flashcards containing terms like a nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. A nurse is caring for a client who is hyperventilating and A nurse in an emergency department is caring for a client who is experiencing acute respiratory failure. 3 C (101 F), pulse rate 114/min, and respiratory rate 22/min. Elevated blood pressure, A nurse is caring for a client who is about to begin taking epoetin. When assessing the patient, the nurse observes clear fluid draining from the client's nose. A nurse in an emergency department is caring for a client who had an anterior MI. The client begins to A nurse working in an emergency department is caring for a client who has benzodiazepine toxicity due to an overdose. Which of the following medications should the nurse plan to administer?, A nurse is reviewing the medication Study with Quizlet and memorize flashcards containing terms like A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. Wheezing C. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Forensic nurse examiner d. Which of the following should the nurse expect the client to report?, The client is one day post-surgical repair of a retinal detachment. Which of the following finding requires the nurse to act as a mandatory reporter a. d. The client is experiencing numbness, and assessment shows mottled skin. 6° F), and purulent ear discharge A school-age A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the emergency department confused, flushed, and with an acetone odor on the breath. A client Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a leg cast and is returning demonstration on the proper use of crutches while climbing the stairs, A nurse in an emergency department is caring fro a client who is experiencing a thyroid storm. 7° C (103. Which of the following clients should the nurse request the provider to assess first? a. a client with new onset slurred speech and right arm weakness c. The client's most recent complete blood count (CBC) is shown in the table below. The nurse is caring for a client in an intensive care unit receiving IV lorazepam to reduce anxiety related to mechanical ventilation. Intake and Output C. SaO2 95%. Hair is thin and sparse. In planning client rounds, which client should the nurse assess first? a. Study with Quizlet and memorize flashcards containing terms like A nurse in the emergency department is caring for a homeless client just brought in with frostbite to the fingers and toes. Which of the following nursing statements is appropriate? A. 5° F Study with Quizlet and memorize flashcards containing terms like An emergency room nurse assesses a client who has been raped. A nurse in the emergency department is assessing a client for a closed pneumothorax and significant bruising of the left chest following a motor-vehicle crash. Nurses Notes 1900: Client is disoriented, confused. To deselect a finding, click on the finding again. A nurse is caring for a client who is receiving cisplatin for treatment of ovarian cancer. Prepare the client for a chest x-ray c. Rapid Pulse D. pink mucous A nurse in an emergency department is caring for four clients. Decontaminate the client’s clothing. SaO2 95% B. a client with a small laceration who has not received a recent tetanus shot, A nurse in the emergency department is caring for a client who has Study with Quizlet and memorize flashcards containing terms like A nurse in the emergency department is caring for a client who comes to the emergency department reporting severe abdominal pain in the left lower quadrant. A nurse is planning care for a client following placement of a chest tube 1 hr ago. The first part concerns basic first aid and emergency care principles A nurse in an emergency department is caring for a client who has received a dose of penicillin and is now anxious, flushing, tachycardia, and having difficulty swallowing . Study with Quizlet and memorize flashcards containing terms like a nurse is assessing a client who is experiencing diarrhea and vomitting and has a sodium level of 124 meq/l. Specify the 4 anticipated prescriptions Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that A nurse in an emergency department is caring for a client who has full-thickness burns over 20% of their total body surface area. A client calls the emergency department and tells the nurse that he has been cleaning a wooded area and that he came into direct contact with poison ivy shrubs. Call emergency medical services to transport the client to a proper treatment facility Reasoning: Client safety is the nurse's primary concern. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a central venous access device in place. Which of the following interventions should the nurse expect to perform? select all that apply monitor for postural hypotension weight the client daily assess for neck vein distention assess blood glucose level monitor for a irregular A nurse is caring for a client who is postpartum and breastfeeding. Which of the following procedures should A nurse is caring for a an adolescent client who has a long history of diabetes mellitus and is being admitted to the emergency department confused, flushed, and with an acetone odor breath. Sarin The nurse in the emergency department is caring for a young female victim of sexual assault. Findings include absent breath in the left lower lobe with dyspnea, blood pressure 118/68, HR 124/min, RR 38/min, temp 38. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention? a. The client is reporting anxiety, discomfort, and a feeling of bloating. " The nurse notes the client has multiple lacerations and ecchymoses and sees in the client's medical record that she visited 2 months ago for similar injuries. B Inform the client photographs of injuries are required for a police report. This means that the client knows who they are, where they are, and what time it is. The client Study with Quizlet and memorize flashcards containing terms like The emergency department nurse is caring for a child brought to the emergency department following the ingestion of approximately one half bottle of acetylsalicylic acid (aspirin) 10 minutes before arrival. The client's history reveals they are 1 week post-op following an open cholecystectomy. While transferring to a chair, the client cries out in pain. Panic The nurse should maintain situational awareness while caring for clients in emergency department. which of the following manifestations sould the nurse expect?, A nurse is caring for a client who is experiencing an astham attack. Depression Mod 4 post quiz, A nurse is caring for a client who has Study with Quizlet and memorize flashcards containing terms like 1. Which of the following instructions should the nurse include?, A nurse is caring for a client who has a right-sided stroke and is exhibiting homonymous hemianopsia when A nurse in an emergency department is caring for a client who reports abdominal pain, vomiting, and appears dehydrated. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. Identify clinical manifestations of anaphylactic shock. Nonadherent pads, A nurse in the emergency A. -Elevate the head of the bed 20°. Which of the following should the nurse recognize as the most reliable indicator of fluid loss? A. How frequently should the nurse instruct the AP to check the tightness of the restrained hands? 1. 28, PaCO2 36 mm Hg, and HCO3 14 mEq/L. To which of the following should the nurse give priority in the immediate postoperative period?, A community health nurse is assisting with planning an immunization clinic for older adult clients. The nurse shoudl prepare to care for a client that has been exposed to which of the following types of agents? A. amniotic membranes d. Teaching a client who is preoperative how to use an incentive spirometer. During assessment, the nurse notices diminished pedal pulses and cyanotic skin color to the left leg. Infuse IV fluids d. Identify the client's level of orientation c. During the assessment, the nurse detects a strong smell of alcohol from the client's breath. The client reports dyspnea and severe pain. Cachectic, with flaccid muscle tone. the nurse recognizes that the client is in a hypertensive crisis. The client receives a prescription for pancuronium. Suture removal kit C. wheezing. Orange juice c. A low respiratory rate 2. Which of the following manifestations should the nurse A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. Psychiatric crisis nurse, The Other measures include having telephone numbers for the physician, nurse, and oxygen vendor available and teaching the client signs and symptoms requiring emergency care. Place a fan in the client's room 4. A crisis state indicates that the client has an emotional illness c. A nurse is caring for a client who arrived at an emergency department following a bee sting. Your assessment indicates that the client's central blood flow is reduced and their peripheral vascular area is hypervolemic. Which of the following interventions should the nurse take? (select all that apply) Study with Quizlet and memorize flashcards containing terms like The nurse is giving report to an assistive personnel (AP) who will be caring for a client in hand restraints (safety devices). The presence of a barrel chest 4. Which of the following explanations should the nurse provide to the client? The nurse is caring for a client in the emergency department who states that he or she is homeless. On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104. Which of the following actions should the nurse take? A. Which of the following actions should the nurse include? A) observe cardiac monitor for dysrhythmias B) observe for evidence of UTI C) initiate IV fluids using 0. Which of the following laboratory tests are used to diagnose a myocardial infarction? A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. Which of the following findings indicates an anaphylactic reaction? (Select all that apply. Diabetic Ketoacidosis is suspected. A nurse is an emergency department is caring for a client who has myasthenia gravis and is in a cholinergic crisis. Using the rule of nines A nurse in an emergency department is caring for a client who has sustained multiple injuries. A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his chest, abdomen, and upper arms. You notify the physician that this client is in what kind of A nurse in the emergency department is caring for a client who was in a motor vehicle crash. The nurse should first _____, followed by_____, A nurse is preparing to obtain a client's vital signs. Which of the following medications should the nurse plan to administer? - potassium iodide - glucagon - atropine - protamine. Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who has emphysema. Diminished breath sounds 3. Fluid imbalance d. Study with Quizlet and memorize flashcards containing terms like A nurse in an emergency department is caring for a client who has heroin toxicity. Not the question you’re looking for? Post any question and get expert help quickly. A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The nurse should anticipate which of the following prescriptions form the provider? 0. " Which of the following statements should the nurse make?, A nurse is caring for a client who has borderline personality disorder. A nurse in an emergency department 1. 8° F). Start a regular insulin infusion a 0. Medication to calm the perpetrator of the violence b. The provider a nurse in an emergency department is caring for a client and finds a razor blade hidden in the client's personal belongings. Which of the following assessments should the nurse perform first? The nurse is caring for a client with a severe burn who is scheduled for an autographed to be placed on the lower extremity. A nurse in the emergency department (ED) is caring for a 13-year-old client who presented with right lower quadrant abdominal pain, nausea, and fever. Which of the following fluid items should the nurse offer the child at this time? a. notify the primary healthcare provider (PHCP) of the results. A list of community resources c. SaO2 92% D. Every 30 The nurse caring for the client is assessing the client and observes significant changes in the client's status. The patient was not wearing a helmet. Which of the following interventions should the nurse take?, Which of the following interventions are included as part of milieu management in the plan of care for Study with Quizlet and memorize flashcards containing terms like On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104. The client sustained the burn from a home fire that occurred in the basement. Client is febrile 1200: Client appears fatigued with no energy. Which of the following actions should the nurse take? A nurse is caring for a 48-year-old client who is grieving following the death of her husband seven months ago. The nurse employed in an emergency department Study with Quizlet and memorize flashcards containing terms like Case Study: Decreased Cardiac Output (1) The nurse in the emergency department (ED) is caring for a 78-year-old client. In addition, the nurse should not leave the client alone until he is safely evaluated by or admitted to a proper care facility. Which of the following items should the nurse keep easily accessible for the client? A. A client with a white blood cell count of 14,000 mm3 (14. Radiologic C. A A nurse in the emergency department is caring for a client who was in a motor-vehicle crash. Administer oxygen D. Which finding would the nurse note on assessment of the client's hand? 1. Obtain a sputum sample for culture b. Study with Quizlet and memorize flashcards containing terms like A nurse in an emergency department is caring for a client who states, "I tripped over the dog again. , The Study with Quizlet and memorize flashcards containing terms like The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Discuss the precipitating factors that caused the Question: A nurse in an emergency department is caring for a client. Which of the following actions should the nurse take first? Assess the client's level of consciousness. Warm, dry skin B. When attempting to get out of bed without assistance, client stated, "I'm going home. The client has fractured vertebrae at T3 and T4. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? 18 g. When assessing the patient's head and neck, the nurse should prioritize the assessment for which of the following? A client presents to the emergency department with reports of neck A nurse in an emergency department is caring for a client who has burns on the front and back of both legs and arms. document the result as normal. A crisis state indicates that the client has a mental illness b. Infuse 1 L of normal saline per hour B. Obtaining a blood pressure for a client who is to be discharged later in the day. An increase in which of the following laboratory values should indicate to the nurse that the therapy is effective? A nurse in an emergency department is assessing a client who has A nurse in the emergency department is caring for a client who was sexually assaulted. The nurse realizes the client's findings support which level of anxiety? A. Leave me alone. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock? A. The nurse should plan to include what A nurse is triaging clients in the emergency department. When developing the plan, the nurse should consider which factor? a. The nurse plans to A. 3. She states that she started taking birth control pills 3 weeks ago and that she smokes. This promotes optimal blood flow & reduces the risk for increased ICP = C 34. Which of the following actions should the nurse take first? a. Client rates pain as 7 on a scale of 0 to 10. The client looks at the nurse and says, "Back off. Which of the following information should the nurse plan to include?, A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Verbally attempt to calm the client D. After observing standard precautions, which of the A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. Which statement, if made by the nurse, requires the need for further teaching? 1. What action would the nurse take? a. Which prescribed action should the nurse implement first? A. During transport to the facility, the client was medicated with intravenous morphine. The nurse should assess the need to isolate the client in case of airborne diseases. The client states she missed one menstrual cycle and cannot be pregnant because she has an intrauterine device. " A nurse in the emergency department is treating a child who has bruises. " The client receives a diagnosis of anxiety. Start nitroprusside infusion at 0. ) Wrap the part in dry sterile gauze. Which of the following actions should the nurse take first?, A nurse in the emergency department is assessing a client who has internal injuries from a car crash. While Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client after a radical neck dissection. After examining the Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a patient in the emergency department who has been a victim of intimate partner violence. A nurse in an emergency department is caring for a female client who has ecchymosis of the trunk and face A nurse in the emergency department is caring for a client who has abdominal trauma. C. Click to highlight the findings that indicate the client is malnourished. A nurse is caring for a client who is a local public official. Client also reports nausea, vomiting, and dyspepsia. which of the following actions should the A nurse is caring for a client who is experiencing acute alcohol withdrawal. Substance use counselor d. 6 mEq/L , BUN 18 mg/dL ,Chloride 105 A triage nurse in an emergency department is caring for a client who has a gunshot wound to the right side of her chest. Today, the client states she is refusing further treatment and is leaving the mental health facility. Monitor the client’s ECG B. Give Sodium The nurse is caring for a client with a diagnosis of pemphigus. Which of the A nurse in an emergency department is caring for a client who has a blood pressure of 254/139 mm Hg. Which of the following central venous access devices should the nurse anticipate being inserted? A nurse in an emergency department (ED) is assisting in the care of a client. A client who has a closed leg fracture and reports peripheral paresthesia. Which of the following action should the nurse perform immediately? An emergency department nurse is admitting a client brought in by the paramedics after falling from a tree stand. 3,1,4,2 Rationale: Interventions that may be performed by the nurse when caring for a client who is a victim of abuse or neglect include administering pain medications, providing wound care, using assistive devices to support sprains or fractures, educating the client and family about self-care, as well as education on support programs that provide A nurse in the emergency department (ED) is caring for a client. 1° C), pulse 132 beats/min, respirations 26 breaths/min, and blood pressure 106/66 mm Hg. What findings indicates a tension pneumothorax?, A nurse is discharging a client who has pulmonary tuberculosis and is to start therapy with refampin. Which of An emergency department nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area. Encourage the A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. Study with Quizlet and memorize flashcards containing terms like A nurse working in the emergency department is caring for a client following a chest trauma. The nurse anticipated which of the following orders when notifying the provider of this finding?, · A nurse in an emergency department is caring for a client who reports substernal Study with Quizlet and memorize flashcards containing terms like A nurse in the emergency department is caring for a client who reports abrupt, sharp, right-sided lower quadrant abdominal pain and bright red vaginal bleeding. In response to the client's questions about the dressing, the nurse explains that it is obtained from which of the following sources? a. Draw labs to assess electrolyte panel 2. Which of the following statements should the nurse make? a. Client is awake, A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. A nurse is caring for Study with Quizlet and memorize flashcards containing terms like a nurse in the emergency department is caring for a client who is having an acute asthma attack. The client Study with Quizlet and memorize flashcards containing terms like A nurse in the emergency department is assessing a client. 2° C (102. The client is unresponsive with pinpoint pupils and a respiratory rate of 6/min. Which task is the utmost priority for the nurse to do first? A. Which of the following actions is the nurse’s priority? A. Fiery red skin with edema in the nail beds 3. 2. Previous question Next question. , A nurse is caring for a client who presents to the emergency department with a blood pressure of 254/139 mm Hg. A nurse in an emergency department is caring for a client who has diabetic ketoacidosis (DKA) and a blood glucose level of 925 mg/dL. a nurse in an emergency department is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood. A nurse in the emergency department is assessing a client who was in a motor-vehicle crash 2 days ago and sustained Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a chest tube following a lobectomy. The Study with Quizlet and memorize flashcards containing terms like A nurse in an emergency department is assessing a client who has a detached retina. For which of the following findings should the Study with Quizlet and memorize flashcards containing terms like A nurse in the emergency department is caring for a client who has alcohol toxicity and is unresponsive. The nurse should prepare to care for a client that has beenexposed An ER (Emergency Room) nurse is a registered nurse (RN) who specializes in providing care to patients in emergency situations. Container of sterile water D. A nurse in an emergency department is caring for four clients. The client is to receive 2,000 kcal per day Study with Quizlet and memorize flashcards containing terms like A nurse is caring for an 82-year-old client in the emergency department who has an oral body temperature of 38. A nurse in the emergency department is caring for a client who has pulmonary edema Study with Quizlet and memorize flashcards containing terms like a nurse is caring for a client who is scheduled for a coronary artery bypass graft (CABG) in 2 hr. Pink 4. The homeless population can be victims of physical and emotional trauma. Cluster nursing care. Client states they Study with Quizlet and memorize flashcards containing terms like A nurse in an emergency department is caring for a client who has acute haloperidol toxicity. 8 F. The client who is ambulatory with steady gait and the client scheduled for physical therapy Study with Quizlet and memorize flashcards containing terms like A nurse is teaching a middle-aged client about hypertension. Arterial ph 7. Auscultate for wheezing. Which of the following routine interventions should the nurse use to prevent lumen occlusion?, A nurse in the emergency department is caring for a client who was in a motor-vehicle crash. -Provide a brightly lit environment. The nurse creates a postoperative plan of Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has increased intracranial pressure. Which of the following actions should the nurse take when washing their hands?, A nurse is collecting data from a A nurse in an emergency department is caring for a client who has diabetic ketoacidosis and a blood glucose level of 925 mg/dl. Nurses Notes 1100:Client arrives to ED with report of nausea, vomiting, and diarrhea for 3 days. Which A nurse in an emergency department is caring for a 4-year-old child who was rescued from a home fire by emergency medical services (EMS). non-urgent approach to client care, the nurse should determine that the priority action is administering epinephrine IM to the child. Administer flumazenil b. Which of the following laboratory findings should the nurse expect? A. the nurse should identify that this finding is consistent with which of the following disorders? A nurse in an emergency department is assessing a client who is having a suspected acute myocardial infarction (MI). A pink, edematous hand 2. Give acetaminophen 650 mg by mouth as needed for headache 3. Have the client turn their head toward the unaffected eye c. The client's granddaughter is visiting and telling him about her first day of kindergarten B. Vanilla milkshake d. The nurse employed in an emergency department is assisting in caring for an adult client who is a victim of family violence. which of the following manifestations should the nurse expect to find for a client experiencing an acute MI?, a nurse in an emergency room is caring for a client An emergency department nurse is caring for a client in hypovolemic shock, a result of external hemorrhage caused by a gunshot wound. Skin dry and scaly with bruises on extremities. Which of the following information should the nurse include in the teaching?, A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. which of the following actions should the nurse take? A Discuss self-defense techniques with the client. He continues to state "I don't know why my wife left me. Exhibit Answer. Place the Study with Quizlet and memorize flashcards containing terms like A nurse in an emergency department is preparing to perform an ocular irrigation for a client. Instruct the client to use the prescribed albuterol. While waiting for the troponin levels report, the client asks what this blood test will show. 9% sodium chloride D) administer a Study with Quizlet and memorize flashcards containing terms like A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following indicates an anaphylactic reaction? (Select all that Keep the lights in the client's room dim. 2° C (100. Administer epinephrine. Based on these findings, the nurse should identify that the client has which of the following acid-base imbalances? Study with Quizlet and memorize flashcards containing terms like A nurse enters a clients room and observes that the client is agitated and pacing rapidly. Retraction of sternal muscles D. Which of the following findings should the nurse identify as consistent with neuroleptic malignant syndrome?, A nurse is providing education to a client about the process of When reviewing the provider's order's; the nurse recognizes that clarification is needed for which of the following medications? A)Propranolol B) Theophylline C) Montelukast D)Prednisone, A nurse is caring for a client who is brought into the emergency department immediately following a snake bite to his forearm. Black fingertips surrounded by an erythematous rash 9. which of the following findings is an adverse effect of the medication?, a nurse is caring for a client who has emphysema and is receiving An older adult client is brought to the emergency department by family members. Which would the nurse anticipate as the likely initial treatment?, The Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has Cushing's syndrome. Which client is most at risk for developing obstructive shock?, A nurse in the emergency department (ED) is caring for a client who was recently stung by a bee. Which of the following actions should the nurse plan to take? A. Client is awake, A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's ABG results are pH 7. These nurses work in fast-paced, high-stress A nurse in the emergency department is caring for a client who has chest pain. He is restless and his skin is warm. The nurse enters the client's room and finds the client cutting into his flesh with a paper clip. What is most important for the nurse to include in the plan of care? a. A newspaper reporter repeatedly phones the unit seeking information and states, "The public has a right to know the health status of elected officials. Anthrax D. A postoperative client preparing for discharge d. A nurse in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and throw from the vehicle. Which of the following clients should the nurse recommend the provider Study with Quizlet and memorize flashcards containing terms like A client arriving at the emergency department has experienced frostbite to the right hand. A nurse is caring for a client in the emergency department who, 2 hr earlier, severed the tip of a finger in an accident. A nurse in an emergency department is assessing a client who reports a right lower quadrant pain, nausea and vomiting for the past 48 hours? Which of the following A nurse in an emergency department is caring for a client whose ABG results are pH 7. On arrival, the neurosurgeon determined urgent surgical intervention is indicated for the fracture. The nurse notes that the client is withdrawn, distracted, tremulous, and bewildered at times. The nurse instructs the client that which positions alleviate dyspnea? Select all that apply. Client reports wheezing, chest tightness, and persistent dry cough that increases at night. Nurses' NotesDiagnostic ResultsNurses' NotesThe client reports new onset of thirst and increased hunger. Paralytic ileus A nurse in the emergency department is caring for a client who reports pain in her left leg following a motor-vehicle crash. The homeless population is at risk for prolonged environmental exposures. The nurse has notified the provider of the client's 0700 assessment data and lab results. Whats priority? Which terminology does the nurse use to document the findings in the client's medical record?, The nurse is providing care for a toddler admitted to the burn unit for scalding burns to both legs. Which of the following actions Question: A nurse in an emergency department is caring for a client. Which of the following central venous access devices should the nurse anticipate being inserted A nurse in the emergency department is planning care for a client who is admitted for an overdose of phencyclidine (PCP). Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI? (Select all that apply. A nurse is caring for a client who is postoperative and whose respirations are shallow and 9/min Study with Quizlet and memorize flashcards containing terms like A nurse in the emergency department is caring for a client who is experiencing an acute asthma attack. Which of the following manifestations should the nurse expect? a- a lucid period followed by an immediate loss of consciousness b- a change in the level of consciousness that develops over 48 hours c-neurologic deficits . The nurse suspects child abuse, but the provider A nurse working in an emergency department is triaging four clients. A child who is left unsupervised for several hours at home and is being treated for a fractured leg b. A nurse in an emergency department is preparing to administer theophylline by continuous intravenous (IV) infusion to a client who is experiencing an asthma attack. A client receiving nasal oxygen who had difficulty breathing during the previous shift. Which of the following medications should the nurse expect to administer first? A nurse is caring for a client who has endometriosis and will receive depot injections of leuprolide. 6 (101. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client in the emergency department (ED). kwe fch ldrcvj zxsg ivuaxvxw fuothe bcaxkq bft qhro avixpo