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A nurse on a Medical Surgical unit is caring for a group of clients. The nurse should notify the
rapid response team for which of the following clients?
A. Client who has a pressure injury of the right heel whose blood glucose is 300mg/dL
B. Client who reports right calf pain and shortness of breath
C. Client who has blood on a pressure dressing in the femoral area following a cardiac
catheterization
D. Client who has dark red coloration of left toes and absent pedal pulse
B. Client who reports right calf pain and shortness of breath
Rational: SOB could be from a PE
A nurse is caring for a client who has ingested a toxic agent. Which of the following actions
should the nurse plan to take? (Select all that apply)
A. Induce vomitting
B. Instill activated charcoal
C. Perform a gastric lavage with aspiration
D. Administer syrup of ipecac
D. Infuse IV fluids
B. Instill activated charcoal
C. Perform a gastric lavage with aspiration
,D. administer IV fluids
A nurse in the emergency department is caring for a client who fell through the ice on a pond
and is unresponsive and breathing slowly. Which of the following actions should the nurse take?
(Select all that apply)
A. Remove wet clothing
B. Maintain normal room temperature
C. Apply warm blankets
D. Use a rapid rewarming water of 40 to 42
E. Infuse warmed IV fluids
A. Remove wet clothing
C. Apply warm blankets
D. Use a rapid rewarming water of 40 to 42
E. Infuse warmed IV fluids
A nurse in the emergency department is assessing a client who is unresponsive. The clients
partner states, "He was pulling weeds in the yard and slumped to the ground." Which of the
following techniques should the nurse use to open the clients airway?
A. Head tilt, chin lift
B. Modified Jaw thrust
C. Hyperextension of the head
D. Flexion of the head
A. Head tilt, chin lift
, A nurse is reviewing the common emergency management protocol for clients who have
asystole. Which of the following actions should the nurse plan to take during this cardiac
emergency?
A. Perform Defibrillation
B. Prepare for transcutaneous pacing
C. Administer epinephrine
D. Elevate the clients lower extremities
C. Administer epinephrine
A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus and reports
difficulty following the diet and remembering to take the prescribed medication. Which of the
following actions should the nurse take to promote client compliance? Select all that apply
A. Ask the dietitian to assist with meal planning
B. Contact the clients support system
C. Assess for age related cognitive awareness
D. Encourage the use of daily medication dispenser
E. Provide educational materials for home use
A. Ask the dietitian to assist with meal planning
B. Contact the clients support system
D. Encourage the use of daily medication dispenser
E. Provide educational materials for home use
A nurse in a health care clinic is evaluating the level of wellness for clients using the illness
wellness continuum tool. The nurse should identify which of the following clients as being at the
center of the continuum?
A. A college student who has influenza