*NURSING > TEST BANK > Test Bank for Medical-Surgical Nursing Critical Thinking in Client Care, 4th Edition Priscilla LeMon (All)

Test Bank for Medical-Surgical Nursing Critical Thinking in Client Care, 4th Edition Priscilla LeMon

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A client is admitted to the ICU (intensive care unit) after sustaining multiple injuries. The physician has ordered for the client to receive a colloid solution. Which one of the following solutions... would be appropriate for the nurse to infuse, based on the physician’s orders? 1. 9% saline 2. D5 ½ NS 3. 5% dextrose in water (D5W) 4. 25% albumin A client is admitted to the medical intensive unit after being involved in a motor vehicle collision. During the nurse’s initial assessment, the client develops hypotension, and severe jugular distension with a tracheal deviation. What does the nurse suspect has occurred? 1. Hemorrhage 2. Tension pneumothorax 3. Compensatory shock 4. Hypovolemic shock When assessing a client with a traumatic brain injury, the nurse assesses the client for which of the following signs and symptoms that would be consistent with brain death? Select all that apply. 1. Absence of gag or corneal reflex 2. Toxic metabolic disorders 3. Response to deep stimuli 4. Absence of oculovestibular reflex 5. Apnea with PaCO2 of 66 mm Hg A client is admitted with a diagnosis of blunt trauma to the abdomen after a motor vehicle collision. What should be the initial action by the nurse when the client arrives in the Emergency Department (ED)? 1. Assess the client’s abdomen for any abnormalities. 2. Assess the client’s cervical spine for tenderness. 3. Assess the client for signs of neurological deficits. 4. Assess the client’s airway for patency. Answer: 4 Rationale: Assessment of the airway is the highest priority in the trauma client. Assessment includes determining airway patency. If the client is unresponsive, manual opening of the airway using a jaw thrust or chin lift maneuver is necessary. Once the airway is opened, the practitioner must identify any potential obstruction from the tongue, loose teeth, foreign bodies, bleeding, secretions, vomitus, or edema. If the client is responsive and can vocalize, that is a good indication that the airway is clear. All of the other responses are important, but certainly the nurse should address airway initially. The nurse should assess the cervical spine area after initial ABC assessment. The nurse is always concerned about the neurological assessment of a client, but this client has a blunt trauma injury from a motor vehicle, therefore this would not be the initial assessment for the client. Cognitive Level: Application Client Needs: Physiological Integrity Nursing Process: AnalySIS The nurse is preparing to administer pork insulin to an underweight client. Which of the following techniques should be observed when planning this therapy? Select all that apply. a. Inject insulin that is at room temperature. b. Make sure no air bubbles are present in the syringe. c. Massage the site of insertion. d. Rotation within sites e. Insert the needle at a 90-degree angle. Hint: Preparing the Injection Strategy: Utilize knowledge of insulin administration practices and the process of elimination to make the correct selection. Objective: Discuss the nursing implications for insulin and oral hypoglycemic agents used to treat clients with diabetes mellitus. [Show More]

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