ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 9 Questions
Question 1 of 5
On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 100.1°F, pulse 120 beats/min, respirations 20 breaths/min, blood pressure 100/66 mm Hg. Which action should the nurse take?
Correct Answer: B
Rationale: The client is showing signs of heat exhaustion, characterized by confusion, elevated temperature, and low blood pressure. Starting an IV and infusing normal saline is critical to restore hydration and stabilize blood pressure. Encouraging oral fluids may not be sufficient for a confused patient, cooling blankets are more appropriate for heat stroke, and acetaminophen does not address the underlying dehydration.
Question 2 of 5
An emergency department nurse cares for a middle-aged mountain climber who is confused and exhibits bizarre behaviors. After administering oxygen, which priority intervention should the nurse implement?
Correct Answer: A
Rationale: The client is exhibiting signs of mountain sickness and high altitude cerebral edema (HACE). Dexamethasone reduces cerebral edema by acting as an anti-inflammatory in the central nervous system. The other interventions will not treat mountain sickness or HACE.
Question 3 of 5
An emergency department nurse assesses a client admitted after a lightning strike. Which assessment should the nurse complete first?
Correct Answer: A
Rationale: Clients who survive a lightning strike can have serious myocardial injury. An ECG is the priority to assess for cardiac complications. Other assessments should be completed but are not the priority.
Question 4 of 5
A nurse teaches a community health class about water safety. Which statement by a participant indicates that additional teaching is needed?
Correct Answer: A
Rationale: People should never swim alone, regardless of lifeguard status, due to the risk of drowning. The other statements indicate good understanding of water safety principles.
Question 5 of 5
A provider prescribes a rewarming bath for a client who presents with partial-thickness frostbite. Which action should the nurse take prior to starting this treatment?
Correct Answer: A
Rationale: Rapid rewarming in a water bath is recommended for frostbite, but it causes severe pain. Administering IV morphine prior to treatment is essential for pain management. Wrapping with a compression dressing or massaging the area can cause further tissue damage, and assessing for compartment syndrome is not the priority before rewarming.