QUESTIONS AND ANSWERS The nurse witnesses the collapse of a child while outdoors. The child is not breathing and has a pulse of 50/min. The nurse calls emergency services and initiates rescue breathing. After 2 minutes of rescue breaths, the child is still not breathing and is pale with a pulse of 30/min. What is the nurse's next action? 1. Initiate chest compressions Rescue breathing is performed at a rate of 1 breath every 2-3 seconds. If the pulse remains <60/min and there are signs of poor perfusion (skin pallor), the nurse should initiate chest compressions and reassess the pulse every 2 minutes The charger nurse is responsible for making room assignments multiple clients. Which pari of client assignments to a shared room is appropriate? 3. Client who had a bowel resection 1 day ago and client with asthma exacerbation. When making room assignments, it is important to remember that a client with an active or suspected infection should not be paired with a client who has a fresh surgical wound or is immunocompromised. A client having an asthma exacerbation does not have an infection and is not at risk for spreading infection to a client who had a recent bowel resection surgery. The clinic nurse is assessing a client who is being treated for depression and suicidal ideation. Which client statement best indicates that the client is not currently at risk for suicide? 2. "I plan to attend my grandchild's graduation next month" Clients receiving treatment for depression and suicidal ideation must be carefully monitored for indications of increasing suicidal intent. During a client interview, the nurse should assess: - Access to psychiatric medications - Availability of help during a crisis (counselor, family) - Future goals and plans - Home and environment risks - Overall affect and level of energy - Possible access to weapons Clients who articulate long-term personal goals and family milestones are less likely to attempt death by suicide The nurse is caring for a client who had an anterior wall myocardial infarction 2 days ago. The telemetry technician notifies the nurse at 8:30 AM that the client is in ventricular trigeminy. What is the nurse's priority intervention? 1. Administer potassium supplement In ventricular trigeminy, premature ventricular contractions (PVCs) occur every third heartbeat. Myocardial injury (eg, myocardial infarction) predisposes the client to ectopy (eg, PVCs), which increases the client's risk for lethal dysrhythmias (eg, ventricular tachycardia). PVCs are caused and/or exacerbated by hypoxia, electrolyte imbalances, emotional stress, stimulants, fever, and exercise. This client's morning laboratory results show hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]); therefore, the priority is treatment of the underlying cause of the ectopy by administering the prescribed potassium replacement (Option 1). Health care providers (HCPs) often prescribe electrolyte replacement algorithms to clients at risk for electrolyte imbalances (eg, myocardial injury, receiving diuretics) unless a contraindication exists (eg, serum creatinine >1.5 mg/dL [133 µmol/L], anuric, weight <99.2 lb [45 kg]). The nurse cares for a client with a terminal disease who created a do not attempt resuscitation (DNAR) directive. The client stops breathing and loses their pulse. The client's adult child states, "Please, do whatever you can to save them!" Which intervention is appropriate? 3. Explain the client's resuscitation directive to the client's child Clients can create a do not attempt resuscitation (DNAR) directive instructing that CPR and other life-saving measures be withheld. With an advance directive in place, the client's wishes should be followed, even if they conflict with the wishes of loved ones The nurse in the cardiac intensive care unit receives report on 4 clients. Which client should the nurse assess first? 2. Client who underwent coronary artery stent placement via femoral approach 3 hours ago and is reporting severe back pain A client who undergoes percutaneous coronary intervention (PCI) and intracoronary stent placement using the femoral approach is at increased risk for retroperitoneal hemorrhage. Administration of antithrombotic drugs before, during, and after PCI can exacerbate potentially life-threatening bleeding from the femoral artery. Hypotension, back pain, flank ecchymosis (eg, Grey Turner sign), hematoma formation, and diminished distal pulses can be early signs of bleeding into the retroperitoneal space and require immediate intervention (eg, notify health care provider, serial complete blood count, CT scan of the abdomen) The nurse is reviewing the medical history of a client who has sustained a right tibia/fibula fracture from a fall. The nurse identifies which finding as most likely to hinder healing? 4. Peripheral arterial disease Bone healing depends on multiple factors, including nutrition, adequate circulation, and age. A client with peripheral arterial disease has decreased perfusion to the extremities due to atherosclerotic changes in the arteries. Without adequate perfusion, the bone is not supplied with the oxygen and nutrients required for healing Based on the nursing assessment progress notes, what is the correct staging of the client's pressure injury? Click on the exhibit button for additional information. WRONG 2. Stage 2: Stage 2 pressure injuries have partial-thickness skin loss (abrasion, blister, or shallow crater). The skin blisters or forms an open sore, and the area around the sore may be red and irritated. (shallow, open ulcer, red-pink wound with no sloughing and possible intact or ruptured blister)
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