Title RECALLS 5 - NP4 - SC ✅

4 | Page A. Insert a urinary catheter into the client. B. Complete a neurological assessment. C. Put the client in the Trendelenburg position. D. Palpate the client’s bladder. 40. The nurse is caring for clients in a Neurological Intensive Care unit. Which client should be assessed first?  A. The client with increased intracranial pressure whose Glasgow Coma Scale went from 11 to 14. B. The client was diagnosed with a C-6 SCI who has bradycardia, hypotension, and hyperreflexia. C. The client with a brain stem herniation whose big toe moves toward the top surface of the foot and the other toes fan out after the sole of the foot has been firmly stroked. 4. D. The client was diagnosed with West Nile virus who has a temperature of 101.2°F and generalized body aches. TOPIC: EMERGENCY NURSING - HEAT STROKE, CHOKING, and OTHER COMMON EMERGENCY SITUATIONS   Situation: Emergency Nursing 41. The nursing educator is reviewing the signs and symptoms of heat stroke with a group of nurses. The educator should describe what sign or symptom?  A. Hypertension with a wide pulse pressure B. Anhidrosis C. Copious diuresis D. Cheyne Stokes Respiration 42. A triage nurse is talking to a patient when the patient begins choking on his lunch. The patient is coughing forcefully. What should the nurse do?  A. Stand him up and perform the abdominal thrust maneuver from behind. B. Lay him down, straddle him, and perform the abdominal thrust maneuver. C. Leave him to get assistance. D. Stay with him and encourage him, but not intervene at this time. 43. A male patient with multiple injuries is brought to the ED by ambulance. He has had his airway stabilized and is breathing on his own. The ED nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding?  A. Absence of bruising at contusion sites B. Rapid pulse and decreased capillary refill C. Increased BP with narrowed pulse pressure D. Sudden diaphoresis 44. A patient is brought to the ER in an unconscious state. The physician notes that the patient is in need of emergency surgery. No family members are present, and the patient does not have identification. What action by the nurse is most important regarding consent for treatment? A. Ask the social worker to come and sign the consent. B. Contact the police to obtain the patient's identity. C. Obtain a court order to treat the patient. D. Clearly document LOC and health status on the patient's chart. 45. A patient is brought by friends to the ED after being involved in a motor vehicle accident. The patient sustained blunt trauma to the abdomen. What nursing action would be most appropriate for this patient? A. Ambulate the patient to expel flatus. B. Place the patient in a high Fowler's position. C. Immobilize the patient on a backboard. D. Place the patient in a left lateral position. TOPIC: EMERGENCY NURSING - DIFFERENT TYPES OF SHOCK Situation: Shock  46. The nurse is caring for a client diagnosed with septic shock. Which assessment data warrant immediate intervention by the nurse?  A. Vital signs T 38*C, P 104, R 26, and BP 102/60. B. A white blood cell count of 18,000/mm. C. A urinary output of 90 mL in the last four (4) hours. D. The client complains of being thirsty. 47. The client is diagnosed with neurogenic shock. Which signs/symptoms should the nurse assess in this client?  A. Cool, moist skin. B. Bradycardia. C. Wheezing. D. Decreased bowel sounds. 48. The client has recently experienced a myocardial infarction. Which action by the nurse helps prevent cardiogenic shock?  A. Monitor the client’s telemetry. B. Turn the client every two (2) hours. C. Administer oxygen via nasal cannula. D. Place the client in the Trendelenburg position 49. The elderly female client with vertebral fractures who has been self-medicating with ibuprofen, a nonsteroidal anti- inflammatory drug (NSAID), presents to the ED complaining of abdominal pain, is pale and clammy, and has a P of 110 and a BP of 92/60. Which type of shock should the nurse suspect?  A. Cardiogenic shock. B. Hypovolemic shock. C. Neurogenic shock. D. Septic shock. 50. The client is admitted into the emergency department with diaphoresis, pale clammy skin, and BP of 90/70. Which intervention should the nurse implement first?  A. Start an IV with an 18-gauge catheter. B. Administer dopamine intravenous infusion. C. Obtain arterial blood gases (ABGs). D. Insert an indwelling urinary catheter TOPIC: PHARMACOLOGY NURSING - MEDS FOR ANGINA/M.I Situation: Medication for a patient with angina/myocardial infarction   51. The nurse is teaching the client diagnosed with angina about sublingual nitroglycerin (NTG). Which statement indicates the client needs more medication teaching?  A. “I will always carry my nitroglycerin in a dark-colored bottle.” B. “If I have chest pain, I will put a tablet underneath my tongue.” C. “If my pain is not relieved with one tablet, I will get medical help.” D. “I should expect to get a headache after taking my nitroglycerin. 52. The nurse is preparing to administer an nitroglycerin (NTG) transdermal patch to the client diagnosed with a myocardial infarction (MI). Which intervention should the nurse implement?  A. Question applying the patch if the client’s blood pressure is less than 110/70. B. Use non sterile gloves when applying the transdermal patch. C. Date and time the transdermal patch prior to applying to the client's skin. D. Place the transdermal patch on the site where the old patch was removed 53. The client diagnosed with angina who is prescribed nitroglycerin (NTG) tells the nurse, “I don’t understand why I can’t take my sildenafil. I need to take it so that I can make love to my wife.” Which statement is the nurse’s best response?  A. “If you take the medications together, they may cause you to have very low blood pressure.” B. “You are worried your wife will be concerned if you cannot make love.” C. “If you wait at least 8 hours after taking your nitroglycerin, you can take your sildenafil.” D. “You should get clarification with your HCP about taking sildenafil.” 54. The client being discharged after sustaining an acute MI is prescribed lisinopril. Which instruction should the nurse include when teaching about this medication?  A. Instruct the client to monitor the blood pressure weekly.