Saving vomitus for laboratory analysis
Placing the client in the supine position
Determining the type and amount of substance ingested
Removing any visible materials from the nose and mouth
Inducing vomiting if a household cleaner has been ingested
Assessing the client’s airway patency, breathing, and circulation
38. A nurse is assigned to care for a client with an infection caused
by methicillin-resistant Staphylococcus aureus (MRSA). The client has
an abdominal wound that requires irrigation and has a tracheostomy
attached to a mechanical ventilator that requires frequent
suctioning. While gathering the needed supplies before entering the
client’s room, which necessary protective items does the nurse
obtain? Select all that apply.
Mask
Gown
Gloves
Face shield
Shoe protectors
39. A nurse is assisting with disaster relief after a tornado. The
nurse’s goal with the overall community is to prevent as much injury
and death resulting from the uncontrollable event as possible.
Finding safe housing for survivors, providing support to families,
organizing counseling sessions, and securing physical care when
needed are all examples of which level of prevention?
Initial
Primary
Tertiary
Secondary
40. A nurse in a postanesthesia care unit (PACU) receives a client
from the operating room. For what finding should the PACU nurse
assess the client first?
Airway patency
Active bowel sounds
Adequate urine output
Orientation to surroundings
41. A staf nurse caring for a client with a head injury notes that the
client is restless and pulling at the intravenous (IV) line. The client’s
primary health care provider does not want to prescribe sedation,
and the family has requested that the client not be restrained. Which
action by the nurse is best?
Asking a family member to sit with the client
Asking a nursing assistant to monitor the client
Staying with the client and consulting with the nurse manager
about the situation
Telling the family that the application of wrist restraints is critical
in preventing injury to the client
42.
A nurse manager of an emergency department (ED) arrives at
work and is told that four registered nurses scheduled to work will
not be reporting to work because they are ill. Every trauma room is
busy, and emergency medical services (EMS) has just called to report
that several victims involved in a 10-car wreck on the interstate will
be brought to the ED. The nurse manager initially manages this
situation by:
Telling EMS to take the victims to another hospital
Closing the emergency department temporarily to incoming
clients
Calling the nursing supervisor to discuss activation of the disaster
plan
Demanding that the nurses from the night shift stay until all of
the victims have been treated
43. A nurse responds to an external disaster that occurred in a large
city when a building collapsed. Numerous victims require treatment.
