NURS 370 Practice Questions ALL ANSWERS 100% CORRECT SPRING FALL-2023/24 EDITION GUARANTEED GRADE A+

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A 4-year-old is brought to Emergency by his parents, who report he swallowed a small toy. What symptom suggests complete airway obstruction by a foreign body? A. Gagging B. Coughing C. Inability t ... o speak D. Rapid respirations C. Inability to speak The adult client is newly admitted to the ward following surgery. Which assessment finding should be the RN's priority? A.The surgical site dressing has a scant amount of bright red blood. B.The client is sleeping but easily arouses when touched. C.The client's respirations are 6 to 8 breaths per minute. D.The client's blood pressure is 100/68 mm Hg. C. The client's respirations are 6 to 8 breaths per minute. The nurse is caring for a client who had a total hip replacement four days ago. Which assessment requires the nurse's immediate attention? A."I have bad pain in my lower leg" B."I just can't 'catch my breath" C. "I have to use the bedpan to pee at least every hour." D. "The pain medication is not working today." B. "I just can't 'catch my breath" There has been a train derailment and four people are injured. Which patient should the RN see first? A.Client who is 20 years of age who has unequal pupils and is tachypneic B.Client who is 80 years old complaining of a "racing heart" and has a laceration on his arm C.Client who is 10 years old with a swollen wrist D.Client who is 25 years old with an open chest wall wound D. Client who is 25 years old with an open chest wall wound Because of open-chest wall wound = at risk for pneumothorax or hemothorax = life-threatening. The client just returned to the nursing unit following surgery. Which observation by the RN requires the most immediate intervention? A. The client is sleepy B. The client coughed up blood-tinged sputum C. Oxygen saturation level is 82% D. Jackson-Pratt wound drain is half full C. Oxygen saturation level is 82% At 0730 hours, the oncoming RN is planning care for four clients. Which client should the RN plan to assess first? A.The 23-year-old client with cystic fibrosis who has pulmonary function tests scheduled in ten minutes B.The 35-year-old client admitted the previous day with bacterial pneumonia and now has a temperature of 39.4oC C.The 46-year-old client who had a chest tube removed an hour ago and now has dyspnea D.The 77-year-old client with tuberculosis who has four anti-tubercular medications due at 08:00 hours C. The 46-year-old client who had a chest tube removed an hour ago and now has dyspnea What is the purpose of the ABCDE approach? To provide life-saving treatment To break down complex clinical situations into more manageable parts To serve as an assessment and treatment algorithm To establish common situational awareness among all treatment providers To buy time to establish a final diagnosis and treatment (identifies priority needs and guides nursing practice) Can be initiated without any equipment and more advanced interventions can be applied on arrival of emergency medical services, in a clinic, or at the hospital. Assessments should be repeated until the patient is stable, regularly, and/or at any sign of deterioration. What are strategies for prioritizing care? Central focus on prioritization of Client care: -Priority 1 - life threatening illness (ex: airway obstruction, myocardial infarction) -Priority 2 - safety (ex: of patient and family, nurse and health professionals) -Priority 3 - client priorities (ex: pain, nausea) -Priority 4 - nurse priorities (ex: a nursing intervention appropriate for the situation) What are normal/expected airway findings? Patient responds in a normal voice Regular and visible respirations What are abnormal/unexpected airway findings? Partial obstruction = voice changes, noisy breathing, and increased breathing effort Complete obstruction = there is no respiration despite great effort, unconscious What are possible airway interventions? List them. Head tilt and chin tilt to open airway Suction of the airways Removal of foreign bodies Conscious - 5 back blows or 5 abdominal thrusts High oxygen flow should be given ASAP Endotracheal tube What are normal/expected breathing findings? Respiratory rate appropriate for age, normal O2Sat Symmetrical and visible movements of the thoracic Percussed unilateral dullness or resonance What are abnormal/unexpected breathing findings? Cyanosis Distended neck veins Lateralization of the trachea Tension pneumothorax (air trapped in pleural space) Bronchospasms What are possible breathing interventions? List them. Seat comfortably Rescue breaths Tension pneumothorax (relieve immediately by inserting cannula between 2nd intercostal space (needle thoracentesis) Treat with oxygen Inhalations of meds (ex: Ventolin) Assisted ventilation (bag mask or intubation) Elevate head of bed What are normal/expected circulation findings? Capillary refill within range Pulse rate appropriate for age (equal/bilateral) Inspect skin colour Blood pressure within normal limits What are abnormal/unexpected circulation findings? Colour changes, sweating, and decreased LOC = decreased perfusion Hypotension/hypertension Hypovolemia (grey/blue skin) What are possible circulation interventions? List them. Stop bleeding IV access, infuse saline Heart auscultation Electrocardiography Blood pressure measurements Elevating legs and placing patient in recovery position (supine) What are normal/expected disability findings? LOC intact A - alert V - voice P - pain responsive U - unresponsive GCS (total 9-15): Eye opening - 4, 3, 2, 1; Verbal - 5, 4, 3, 2, 1; Motor - 6, 5, 4, 3, 2, 1 CONTINUED.. [Show More]

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