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Fundamental exam 7 review
Fundamental exam 7 review
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1
The nurse is caring for a client suffering from burns. What are the nurse’s priority actions. Select all that apply
Remove heat source
Remove jewelry
Do not remove burned fabric or materials
Apply ice
2
A potentially life threatening condition which often develops rapidly and required immediate treatment
Heat exhaustion
Heat camps
Heat stroke
Burns
3
Treatment of a dog bite what intervention should the nurse implement immediately when caring for this client
Apply direct firm pressure at the site
Cleanse the wound with warm soapy water
Swab the area with alcohol
Apply an ice pack to the bite area
4
The nurse is preparing to discharge a client who is on supplemental o2 to his home which o2 delivery system is widely
Large oxygen cylinder
Wall outlet unit
Hyperbaric chamber
Concentrator
5
The nurse can legally perform first aid only to the level of training and local laws
True
False
6
What benefit results from isometric exercise
Prevents joint deformities
Prevents stiffness of joints
Prevents skin breakdown
Preserves muscle mass
7
The nurse is selecting an oxygen mask for a client diagnosed with pneumonia who requires an o2 concentration of 75% with
Simple mask
Non rebreathing mask
Venturi mask
Partial rebreathing mask
8
A nurse finished educating the parent of toddlers on ways to reduce poisoning at home. Statement objective were met?
We will keep syrup of ipecac in our medicine cabinet
Will keep all cleaning supple on top shelf or locked cabin
We will put the poison control center # on refrigerator
We will stop giving animal shape vitamins
9
When adjusting the height of a clients crutches, what distance need to place the bottom of each crutch from outside feet
5in
4in
6 in
3in
10
What intervention should the nurse implement when caring for the client experiencing a pneumothorax
Assess for signs of inhalation injuries
Seal wound using petroleum jelly gauze
Initiate cardiopulmonary resuscitation(CPR)
Place ice packs on the client’s forehead
11
type of assessment should be completed by first aid trained to arrive at a scene of an accident life threatening injuri
Primary
Secondary
ABCDE
Tertiary
12
Emergency care always begin with determining if the client has an intact airway and is breathing
False
True
13
For which sign of raising intracranial pressure should the nurse monitor when caring for a client who has a head injury
Excessive perspiration
Falling body temperature
Falling blood pressure
Persistent vomiting
14
Lifts an object by bending at the knees and hips and keeping the back straight which principle being followed maintain b
Line of gravity
Gravital plane
Center of gravity
Base of support
15
A nurse is caring for a client receiving o2 through a portable liquid o2 stroller that measure should the nurse implemen
Refill the stroller using small o2 cylinders
Connect the tubing of the stroller to an electric plug
Take measures to keep the stroller upright at all times
Reduce the pressure in the stroller before connecting it to the client
16
What interventions should the nurse implement during the rewarding process for severe hypothermia?select all that apply
Monitor for cardiac dysrhthmias
Remove and replace all wet clothing
Monitor for nausea and vomiting
Provide warm oral fluids, if client is alert
17
Make use of the client’s abilities as much as possible this protects the nurse builds strength confidence self esteem
False
True
18
Which intervention will assist a client to build the muscle strength needed to safety ambulate with crutches
Perform passive range of motion exercise
Demonstrate the crutch walking gait
Assist in exercising the joints in the body
Teach the use of short crutches
19
Signs of upper GI bleeding select all that apply
Passing bloody or black stools
Rectal bleeding
Vomiting bright red blood
Coffee ground like emesis
20
Patient comes to the ER complaining of difficult breathing, weak and rapid pulse,restlessness signs of
Head injury
Hypothermia
Pneumothorax
Frostbite
21
The freezing of body tissues resulting from exposure to cold temperture
Hypothermia
Frostbite
22
When pushing a wheeled stretcher you steer from the end that has rotating wheels
True
False
23
A nurse is applying an o2 mask for a client diagnosed with chronic obstructive pulmonary disease that provides the most
Non rebreathing mask
Venturi mask
Simple mask
Partial rebreathing mask
24
The nurse is explaining to a client diagnosed with cystic fibrosis the goals of the o2 therapy being prescribed which is
It increasesthew work of the respiratory system allowing it to work more
It reverses high and low o2 concentrations in the blood
It affects ventilator drive control mechanisms and increases the stimulus t
It decreases the heart’s work in pumping blood and eases the heart’s load
25
Which pulse oximetry reading indicates that the client needs immediate supplemental oxygen
100%
95%
85%
90%
26
Increase intracranial pressure can occur from trauma to the head which position is priority for the client to be in
Left side lying
Flat
Fowler’s semi-Fowler’s
Sitting
27
A client after cardiac arrest is receiving o2 therapy via a mask what unit should the nurse use to document the amount
Liters per square inch
Liters per minute
Pounds per square inch
Milliliter s per minute
28
What statements present accurate information about the concept of triage? Select all that apply
Process of sorting and classifying to determine priority of needs
Involves the identification of trauma victims so consent to treat can be
Focuses on determine clients with non-life- threatening
Process of victim identification so next of kin can be notified
29
A nurse is caring for a client receiving o2 from a large o2 cylinder what measure should the nurse implement to minimize
Connect the cylinder to the client without changing the pressure
Ensure that the cylinder is always kept away from heat
Remember to keep the valve of the cylinder turned on at all times
Roll the cylinder in a horizontal position when moving it
30
Possible causes of internal bleeding includes select all that apply
GI bleeding
Vaginal bleeding
Blunt trauma
Fractures
31
Can develop life-threatening shock before the bleeding is discovered
Anaphylaxis
Internal bleeding
Hemorrhage
Arterial bleeding
32
Activated charcoal
Treatment for poisoning
Minor wounds
Hemorrhage
Psychiatric emergencies
33
Sign of inhalation injury select all that apply
Flecks of soot in the clients saliva
Burned or singed nasal hairs or burns in or around the mouth
Hoarse voice
Smell of smoke on the client’s breath
34
Monitoring for signs of increased ICP is crucial
False
True
35
A nurse is caring for a newborn receiving 100% o2 for resuscitation through an o2 mask what potential complication is of
Dry and irritated nares
Thermal burns
Decreases pulse
Vision difficulties
36
A child who nearly drowned admitted to a local healthcare facility which associated injury will the nurse monitor for
Anxiety
Hypothermia
Pneumonia
Airway obstruction
37
Signs and symptoms of pneumothorax.select all that apply
Chest and shoulder pain
Distended neck veins
Cyanosis
Hypotension
38
When planning the ambulation of a client when should the nurse medicate the client for pain
45 mins before the client is to get up
15 mins before the client is to get up
Immediately upon returning the client to bed
30 mins before the client is to get up
39
The nurse is using a simple mask on a client prescribed supplemental o2 what is the minimum o2 flow rate for o2 delivery
6 LPM
12 LPM
8 LPM
10 LPM
40
Twisting of s joint with rupture of ligaments and other possible damage
Sprain
Dislocation
Fracture
Strain
41
Treat frostbite like its a burn
True
False
42
Which statement accurately describes a lofstrand crutch
Gives more support because it stays in contact with the floor
Reaches from the ground to the clients axillary or forearm
Two bard extending straight down to the floor connected by a round end
Single hand bar for the user to grip and a cuff that fits around the arm
43
Which procedure should the nurse follow for assessing a client’s eye in an emergency
BCLS procedure
ABCDE procedure
AVPU procedure
PERRLA+C procedure
44
The nurse is facilitating the weaning of a client from mechanical ventilation the nurse uses ventilation that allows
Continuous positive airway pressure
Synchronized intermittent mandatory ventilation
Volume ventilation
Pressure support ventilation
45
The client doing individual self-directed exercises is performing
Active range of motion
Passive range of motion
Continuous passive motion
46
Patient comes to hospital with symptoms of tachycardia hyperpnea weakness anxiety decrease urinary output. What’s wrong
Hypovolemic shock
Heat cramps
Hypothermia
Frostbite
47
The nurse caring for clients in the ICU notices that a client is not breathing what should be the immediate nursing inte
Call for assistance
Initiate chest compressions
Stabilize the neck
Initiate respiration’s
48
A person center of gravity
Equal weigh on each foot
Is in the pelvic area
A person feet
Is vertical line
49
What type of crutch-walking gait recommend to the client who is only able to partially bear weigh on either leg
Four point gait
Two-point gait
Swing through gait
Three point gait
50
After activating the EMS for a heat stroke victim what priority action by the nurse. Select all that apply
Give cool liquids with salt
Induce shivering with ice packs to speed cooling
Move to a cool place
Provide circulating air
51
The respiratory therapist explains to the nurse that the positive pressure ventilator pushes air into the lungs of a cli
Assisted breath ventilation
Controlled breath ventilation
Volume ventilation
Pressure ventilation
52
A client is suffering from heat cramps which action should not be performed by the nurse
Use mist on skin
Give mild salt solution
Massage the muscle cramps
Uncover the head
53
Which symptoms are classically associated with suspected heart attack?
Chest pain with radiation to the left arm
Indigestion
Pain radiating to the back
Restlessness
54
Man running a marathon collapse he had signs of hypotension fever confusion bizarre behavior collapse and possible coma
Heat cramps
Heat index
Heat stroke
Heat exhaustion
55
It stands for rest, ice, compress, elevate
SIRES
PERRLA+C
ABCDE
R.I.C.E
56
The nurse knows that when administering o2 to an individual who is having difficulty breathing the type of device that i
Ease of oxygen delivery
Comfort of the client
Monitoring of ABGs
Delivery of desired concentration
57
Signs of hypovolemic shock. Select all that apply
Hypertension
Cool,clammy skin
Hypotension
Weak,thready pulse
58
What common signal would the nurse in a hospital setting initiate for a cardiopulmonary emergency
Code yellow
Code green
Code blue
Code red
59
A strain is twisting or stretching that damages a muscle or tendon
False
True
60
Due to bleeding
Hypoglycemic shock
Hypovolemic shock
Cardiac shock
Lung shock
61
Client came in with hypothermia what are the best treatments select all that apply
Remove wet clothes
Gradual rewarding
Cover head hands and feet
Cover with blanket or dry clothes
62
A trauma victim is admitted to the ED which client assessment data is a priority fir the nurse
O2 saturation 90%
Blood pressure 112/64
Heat rate 50-56 beats per min
ICP 23 mmhg
63
For a sprain, strain, or fracture, the nurse should then check the pedal pulses
True
False
64
A collapsing of the lungs where the lung cannot adequately expand is a condition of
Pneumothorax
Intubation
Extrication
Mediastinal
65
It’s fine to go up or down a curb with a gurney
False
True
66
Even though a pedal pulse is present it is not difficult to differentiate between strain sprain and fracture
False
True
67
What condition might occur if an endotracheal tube is incorrectly placed
Anergy
Hyperventilation
Gastric distinction
Pneumothorax
68
The nurse has assisted with the intubation of a client diagnosed with status asthmaticus what should the nurse do to
Slightly pull on the tubing
Obtain a MRI
Obtain a chest x-ray
Palpate the neck
69
Broken bone
Strain
Fracture
Sprain
Dislocation
70
What type of assessment involves taking n recording the victim’s vital signs and performing a head to toe assessment
Primary
Secondary
Tertiary
ABCDE
71
A client is having shortness of breath flu-like symptoms chest pain radiate to the left or right arm heartburn
MI
Heat stroke
Heat exhaustion
Head injury
72
A nurse is caring for a client receiving o2 through a non rebreathing mask what measure should the nurse employ
Keep an emergency manual breathing bag readily available
Allow the client to turn and reposition every 1 to 2 hours
Avoid leaving a client alone while they are wearing an NRM
Set a flow rate that keeps the bag completely inflated
73
A nurse is caring for a client who underwent a tracheostomy following throat surgery what is the rationale for swabbing
To remove encrusted secretions
To relieve bronchospasm
To reduce inflammation
To hydrate thick sputum
74
The nurse is taking care of client sho is being treated for shock into which position should the nurse place the client
Lateral
Litho to my
Reverse trendelenbrug
Trendelenburg
75
Coffee ground emesis or rectal bleeding usually indicates bleeding in the lower GI tract
True
False
76
Admitted for a heat related injury which is a cardinal sign the nurse will most likely observe when assessing
The client is sweating profusely
The client is having heat cramp
The client is not sweating
The client sacrum sodium is low
77
Intermittent positive pressure breathing treatments are prescribed for a young client diagnosed with cystic fibrosis
Hydrate sputum
Fight infection
Relax bronchioles
Liquefy mucus
78
A nurse is caring for a client diagnosed with chronic obstructive pulmonary disease receiving supplemental o2 through a
Place a folded towel behind the clients neck to hyperextend it
Connect a humidifier at one end of the mask adapter
Set flow rate required to keep the bag inflated one third full
Ensure that the windows of the mask remain exposed to room air
79
Process of sorting and classifying to determine priority of needs, involving life threatening situation assisting first
Tourniquet
Trauma
Thrombolytic
Triage
80
Which procedure should the nurse implement when assessing an ill or injured person in an emergency situation
PERRLA+C procedure
ABCDE procedure
AVPU procedure
BCLS procedure
81
Diagnosed with hypovolemic shock which diagnostic procedure should the nurse review to obtain additional information
Blood sugar level
Serum electrolyte level
Hemoglobin level
PH level urine
82
Person experiencing heat cramps what are some of the treatments. Select all that apply
Drinking very dilute salt solutions
Sports drinks
Cup of milk
Mixture of up to 1/4 teaspoon of salt per quart of water
83
Those involving bones, muscles, or joints
Hypothermia
Mediastinal shift
Musculoskeletal injuries
Pneumothorax
84
A nurse is caring for a client receiving mechanical ventilation through a tracheostomy tube what measure should the nurs
Hyperextend the clients neck sufficiently
Secure the tube in place using a sterile dressing
Ask the client to avoid turning in bed
Perform tracheal suctioning as needed
85
The nurse is teaching a student nurse the use of mechanical ventilators for clients in ventilator failure which teaching
Mechanical ventilation is used if a client can achieve adequate tissue oxyg
In all settings the nurse is responsible for adjusting the settings on the
A mechanical ventilator is a machine that can be connected to the client vi
A mechanical ventilator is a machine that forces carbon dioxide into lungs
86
A nurse is caring for an unconscious client who has undergone a tracheostomy what measure should the nurse take while
Avoid applying suction when inserting the suction catheter
Insert the suction Catheter about an inch into the trachea
Place the client in a semi or high Fowler position
Suction the tube continuously for at least 30 seconds
87
A nurse is caring for a client who has been ordered o2 using a nasal cannula what care should the nurse take to ensure
Set the o2 flow rate to not less than 6 liters per minutes LPM
Guide the elastic strap over the top of the clients head
Attach the humidifier to the flow meter
Clean the cannula and examine the clients nares every hour
88
Confusion loss of memory decrease LOC numbness persistent vomiting severe headache speech problems seizure signs of
AVPU
MVA
ICP
CVA
89
An individual has been brought to the healthcare facility immediately after ingesting poison. The most suitable
Administer sugar
Give emetic medication
Support the blood pressure
Perform gastric lovage
90
The nurse administering o2 to clients with respiratory disorders is careful to monitor concentrations to prevent o2 toxi
Change in heart rate
Changes in blood pressure
Changes in level of consciousness
Changes in lung tissue
91
A construction worker is seen in the ER with dizziness,nausea,vomiting and temp 101.8f the nurse would prepare to treat
Heat cramp
Hydration
Heat stroke
Heat exhaustion
92
What precautions should the nurse implement when moving client from the bed to a wheeled stretcher select all that apply
Side rails and wheel brakes must be in working order
Provide enough blankets to keep the client warm
Move the client using appropriate transferring techniques
Be sure to secure that client with a waist strap
93
Which client would most likely require chronic mechanical ventilation
A client who has had extensive surgery
A client who experienced a drug overdose
A client who has a spinal cord injury
A client who has pneumonia
94
When assisting a client when a sprained ankle from the bed to the wheelchair
Check for the presence of an IV a catheter or other equipment
Lock the wheels of the bed and wheelchair
Put a transfer belt along the clients waist if the client is heavy
Place the wheelchair on the clients strong side
95
A mom bring a alert playful child to ER says found him playing with an empty bottle of aspirin what ?is most helpful ask
Has he ever done anything like this before
How many pills do u think were in the bottle
Did you contact poison control before coming to the clinic
How many times has he vomited since the injection
96
Dislocation
Displacement of a bone from a joint
Stretching
Twisting of a joint
Broken bone
97
What is the most important safety issue related to O2 administration that the nurse should consider
O2 should be given to all clients postoperatively to prevent nosocomial inf
Oxygen allows common flammable materials to burn faster and hotter
O2 can increase the heart’s work of pumping blood
Decrease o2 concentration weakens the stimulus to breathe
98
Nurse is caring for a client with multiple injuries sustained during head on collision which assessment finding priority
Unequal pupils
Ecchymosis in the flank area
A deviated trachea
Irregular Apical pulse
99
What term describe the technique of crutch walking being used by the client who is using each crutch n each leg separate
Three-point gait
Two-point gait
Swing- through gait
Four-point gait
100
The nurse is caring for a client who is incubated following trauma to the chest which nursing measures should the nurse
Provide oral care every 4 hours
Monitor placement of the endotracheal tubem
Monitoring respiratory status
Keep the client lying flat to prevent tube slippage