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During a mass casualty event, a volunteer nurse hears an explosion and observes multiple casualties. What is the nurse's priority action to ensure safety and initiate care?
Assess personal safety and then use the START triage method to categorize victims
During a mass casualty incident, a nurse is triaging a client with a sucking chest wound and another with an abdominal wound. Which client should the nurse categorize as "Immediate" for treatment?
The client with the sucking chest wound
A client with a traumatic brain injury is being medicated for seizures. Which nursing action is most important to consider when managing this client?
Observe for side effects of anticonvulsant medications, such as altered mental status
A client is undergoing a surgical procedure that requires prolonged immobilization in the Trendelenburg position. What priority nursing action can prevent pressure positioning injury?
Use padded shoulder braces to prevent sliding
The nurse is caring for a client with a diagnosis of cardiogenic shock. Which reason will the nurse give to the client about the administration of morphine sulfate IV? Select all that apply.
Dilates the blood vessels
Helps manage chest pain
Decrease gastric secretions
Promotes coping and slows catecholamine release
The nurse is caring for a client whose worsening infection places the client at high risk for shock. Which assessment finding would the nurse consider a potential sign of shock?
Shallow, rapid respirations
A triage nurse in the emergency department is on shift when a 4-year-old is carried into the ED by their grandparent. The child is not breathing, and the grandparent states the child was stung by a bee in a nearby park while waiting for the child's parent. Rapid onset of which condition would lead the nurse to suspect anaphylactic shock?
Respiratory distress
A client with a traumatic brain injury is at risk for developing diabetes insipidus. What action should the nurse take first?
Monitor urine output and specific gravity
A client with a history of atrial fibrillation has been admitted with an embolic stroke. Which interventions should the nurse implement to prevent further embolic events? Select all that apply.
Encourage the return of early ambulation
Apply sequential compression devices (SCDs)
The nurse is caring for a client in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS) with likely progression to the irreversible stage. The nurse's plan of care should include which intervention?
Promoting communication with the client and family along with addressing end-of-life issues
A nurse is caring for a client exposed to a chemical agent during a suspected terrorist attack. The client presents with symptoms of cholinergic crisis. Which agent is most likely causing the client's condition?
Nerve agent
A nurse in the emergency department suspects a client may have COVID-19. What precautions are a priority for the nurse to implement?
Use airborne precautions, including an N95 respirator, and isolate the client
A client with a traumatic brain injury is being treated in the ICU. Which action will the nurse take to maintain adequate cerebral perfusion pressure?
Administer hypertonic saline to reduce cerebral edema and maintain blood volume
An immunocompromised 65-year-old client has developed a urinary tract infection, and the care team recognizes the need to prevent an exacerbation of the client's infection that could result in urosepsis and septic shock. Which action should the nurse perform to reduce the client's risk of septic shock?
Remove invasive devices as soon as they are no longer needed
The nurse is caring for a client in intensive care whose condition is deteriorating. The nurse receives orders to initiate an infusion of dopamine. Which assessments and interventions should the nurse prioritize?
Frequent monitoring of vital signs, central line site, and providing accurate drug titration
A client arrives at the hospital with suspected anthrax exposure. What should the nurse include in the client's plan of care?
Begin treatment with ciprofloxacin or doxycycline immediately
A client with an intracerebral hemorrhage has a systolic blood pressure of 190 mmHg. What priority action should the nurse take to reduce the blood pressure?
Initiate a continuous IV infusion of an antihypertensive agent
A nurse is caring for a client with metastatic brain tumor who is experiencing severe headaches. What priority intervention should the nurse perform?
Administer prescribed analgesics and assess the client's pain level regularly
A client is experiencing a generalized tonic-clonic seizure. Which action should the nurse prioritize?
Protect the client in a side-lying position
A client is being treated in the ICU for neurogenic shock secondary to a spinal cord injury. Despite aggressive interventions, the client develops acute kidney injury. Which findings support this diagnosis? Select all that apply.
Blood urea nitrogen (BUN) level
Creatinine level
The emergency nurse is admitting a client experiencing a gastrointestinal (GI) bleed likely in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation? Select all that apply.
Cool, clammy skin
Expressions of anxiety
Decreased urine output
A client recovering from a hemorrhagic stroke is being prepared for discharge. Which statement indicates a correct understanding of discharge teaching?
"I will frequently monitor my blood pressure and report changes."
A client is one day postoperative and is showing signs of wound infection with increased pain, redness, and drainage at the surgical site. What is the nurse's best initial action?
Reinforce the dressing and notify the surgeon
Following a craniotomy via a transsphenoidal approach, a client is instructed to avoid certain activities to prevent cerebrospinal fluid leakage. Select all that apply.
Blowing the nose
Strenuous exercise
The high-pressure alarm sounds on the ventilator. After assessing the client and the ventilator, what action should the nurse take next
Suction the client to remove excess secretions