You are a nurse caring for a patient who was just brought into the emergency department after falling off a roof at a construction site. Upon assessment, you note that the patient's respirations are 32/min and the blood pressure is falling. The patient's trachea appears to be right of midline, and the patient's respiratory effort appears to be becoming more and more labored. What is your MOST likely PRIORITY action?

Prepare to administer Albuterol to aid the patient's breathing

Prepare for chest tube insertion

Prepare to apply oxygen via non-rebreather mask at 8L/Min

Sit the patient up in high-fowler's position

Answer and Explanation

The Correct Answer is B

A. Prepare to administer Albuterol to aid the patient's breathing: Albuterol is used for bronchodilation in asthma or COPD. The priority is addressing the potential life-threatening condition, such as a pneumothorax or hemothorax, indicated by the patient's tracheal deviation and labored breathing.

B. Prepare for chest tube insertion: The tracheal deviation, falling blood pressure, and labored breathing suggest a possible tension pneumothorax or hemothorax, both of which require immediate chest tube insertion. This is necessary to relieve pressure in the chest and allow the lungs to re-expand, addressing the respiratory and circulatory distress.

C. Prepare to apply oxygen via non-rebreather mask at 8L/Min: While oxygen is necessary, simply applying oxygen will not resolve the underlying mechanical issue of a tension pneumothorax. The pressure in the chest needs to be relieved for the lung to re-expand and effectively take up oxygen.

D. Sit the patient up in high-fowler's position: While sitting the patient up may help with breathing in some conditions, the most likely cause of the patient’s symptoms is a traumatic injury that requires chest tube insertion, not just positioning.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. The burned area is pink in color with blisters present: This is characteristic of a partial thickness (second-degree) burn, not a full-thickness burn. Blisters and pink or red coloring are typically seen in second-degree burns, which involve the epidermis and part of the dermis.

B. The burned area is red in color with eschar present: Red coloring with eschar is typically seen in a deep partial-thickness (second-degree). Full-thickness burns often present with eschar, but the color is usually waxy white, leathery, brown, or black.

C. The burned area is black in color and pain is absent: Full-thickness burns (third-degree) often appear black or charred. Pain is usually absent because the nerve endings in the affected area are destroyed and it involves all layers of the skin.

D. The burned area is yellow in color with severe edema: Yellow coloring and severe edema are more indicative of a superficial or partial-thickness burn. Full-thickness burn is more likely to be black and painless.

A. Asystole B. Sinus Tachycardia C. Sinus Bradycardia D. Supraventricular Tachycardia (SVT)

Correct Answer is A

Explanation

A. Asystole: Asystole is defined as the complete absence of electrical and mechanical cardiac activity. The EKG strip displays a flatline, indicating no ventricular depolarization or contraction, which is the hallmark of asystole. This rhythm is a non-shockable cardiac arrest rhythm.

B. Sinus Tachycardia: Sinus tachycardia is a regular rhythm with a heart rate greater than 100 bpm, characterized by clear P waves and QRS complexes. This is clearly not present in the given flatline strip.

C. Sinus Bradycardia: Sinus bradycardia is a regular rhythm with a heart rate less than 60 bpm, characterized by clear P waves and QRS complexes.

D. Supraventricular Tachycardia (SVT): SVT is a rapid rhythm, typically 150-250 bpm, with narrow QRS complexes and often obscured P waves.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is brought to the emergency room with burn injuries. Which of the following findings should the nurse identify as a full-thickness burn?

Correct Answer is C

Explanation

You note the cardiac electrical rhythm below (see 6-second EKG strip). Which of the following would BEST describe the client's rhythm?

Correct Answer is A

Explanation

A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make?

A nurse is caring for a client who is scheduled to receive heparin 3,800 units subcutaneously. Available is heparin 5,000 units/mL How many ml. should the nurse administer? (Round the answer to the nearest tenth.)

A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

A nurse is caring for a client who has symptomatic sinus bradycardia. The Atropine was given but was not successful. Which one of the following is the next intervention?

A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical ventilation. The client receives an order for fentanyl. The nurse recognizes that this medication is for which of the following purposes?

A nurse is caring for a client who is postoperative and whose respirations are shallow and 9/min. Which of the following acid- based imbalances should the nurse identify the client as being at risk for developing initially?

A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider?