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The nurse is caring for a hospice client who is scheduled for a surgical procedure to reduce the size of a spinal tumor in an effort to relieve pain. The nurse should plan this client's care with the knowledge that this surgical procedure is classified as which of the following?
Palliative
A client in the post-anesthesia care unit (PACU) is recovering from abdominal surgery and begins to exhibit signs of hypopharyngeal obstruction. What should the nurse do first?
Perform a head-tilt or jaw thrust maneuver to open the airway
A client with a history of COPD presents with an acute exacerbation and ARDS. What are the priority actions for the nurse to take?
Administer nebulized bronchodilators
Initiate non-invasive positive pressure ventilation (NIPPV) = BiPAP
Administer corticosteroids
A nurse is caring for a client who has sustained burns over 30% of TBSA. The client’s voice has become hoarse. A brassy cough has developed and the client is drooling. The nurse should identify these findings as indications that the client has which of the following?
Inhalation injury
The PACU nurse is caring for a patient who has arrived from the OR. During the initial assessment, the nurse observes that the client's skin has become blue and dusky. The nurse looks, listens, and feels for breathing and determines the patient is not breathing. What is the priority intervention?
Treat airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw
During a surgical procedure, the circulating nurse observes that the anesthesiologist is preparing to administer Succinylcholine. What is the priority parameter to monitor following administration?
Potential for malignant hyperthermia
The nurse is caring for a client who is scheduled for a lobectomy for lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes that the client's oxygen saturation is rapidly dropping. The client reports SOB and becomes tachypneic. The nurse suspects a pneumothorax has developed. Which further assessment finding would support the presence of a pneumothorax?
Diminished or absent breath sounds on the affected side
A client with a burn injury is scheduled for a dressing change. The nurse notes that the client's pain is well controlled with IV analgesics. Which additional intervention should the nurse consider to enhance comfort during the dressing change?
Encourage the client to listen to music through headphones
Patient with 3rd degree burn. What are the characteristics of a 3rd degree burn?
Painless, dry, leathery
During the care of a preoperative client, the nurse has given the client a preoperative benzodiazepine. The client is now requesting to void. What action should the nurse take?
Offer the client a bedpan or urinal
A client with a history of fatigue, high fever, and productive cough for a week is diagnosed with right lower lobe pneumonia. What cues would the nurse expect?
Increased HR
Decreased breath sounds in right lower lobe
Dullness upon percussion
A nurse is planning care for a client with a 40% TBSA burn injury who is at risk for hypertrophic scarring. Which priority intervention should the nurse take to minimize the risk of scar formation?
Apply pressure garments as prescribed
A client in respiratory failure is diagnosed with a flail chest. After the client is intubated, which treatment does the nurse expect to be implemented?
Positive end-expiratory pressure (PEEP)
A nurse is assisting the provider in caring for a client who has developed a tension pneumothorax. Which action should be performed first?
Prepare for large-bore needle thoracotomy
Patient with spinal anesthesia, what is the proper positioning?
Supine
A client with a burn injury is at risk for contractures. Which nursing intervention is most effective in preventing this complication?
Apply splints to the affected limbs
An 18 y/o client with suspected EVALI (e-cigarette or vaping use-associated lung injury) is admitted to the ICU and requires mechanical ventilation. What intervention will the nurse take to prevent ventilator-associated pneumonia (VAP)?
Regular oral care with chlorhexidine
A nurse is assessing four clients. Which of the following clients should the nurse assess first?
A client that has self-extubated his ET tube
A postoperative patient reports sudden onset of SOB and pleuritic chest pain. Assessment findings include diaphoresis, hypotension and crackles in the left lower lobe. What condition do these findings indicate?
Pulmonary Embolism
The nurse is caring for a patient on a med-surg unit postoperative day 5. During each assessment, the nurse evaluates for infection. Which finding is most indicative of infection?
Redness, warm & tender incision that is painful
A client is brought to the ED by ambulance after a motor vehicle accident in which the client received blunt trauma to the chest. The client is in acute respiratory failure, intubated, and transferred to the ICU. Which assessment parameters should the nurse monitor most closely?
Level of consciousness
Vital signs
ABGs
Coping mechanisms
A nurse is caring for a client following knee surgery that was performed under a spinal anesthetic. Which intervention should the nurse implement to prevent a spinal headache?
Keep the client positioned supine
An older adult arrives in the emergency department after falling off a roof. The nurse observes “sucking inward” of the loose chest area during inspiration and a “puffing out” of the same area during expiration. ABG results show severe hypoxemia and hypercapnia. Which procedure does the nurse prepare for?
Endotracheal intubation (ET tube)
A client with a history of COPD presents with dyspnea and tachypnea, restlessness, hypotension, and bradycardia, and ABG shows the client is hypoxemic with PaO2 of 55mmHg. Which of the following is the priority intervention for this client?
Prepare to intubate the client
A nurse in a burn treatment center is caring for a client admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client’s spouse asks the nurse what the procedure entails. Which nursing statement is appropriate?
A large surgical incision will be made in the hardened dermal layer to improve circulation