chap 69
The patient has a prescription for 0.9% normal saline intravenous (IV) at a rate of 75 mL/hour. The IV tubing has a drop factor of 10 gtts/mL. At how many drops per minute should the nurse regulate the flow of the IV solution?
13
The nurse reviews a patient's medical record. After informing the primary health care provider, what important actions should the nurse take? Select all that apply.
A body temperature greater than 104° F with shivering, an increased respiratory rate, hypotension, myoglobinuria, hallucinations, combativeness, and loss of coordination are clinical presentations of heatstroke. Chlorpromazine (Thorazine) can effectively reduce shivering in the patient. Therefore, the nurse will administer this medication to the patient. The patient with myoglobinuria is characterized by tea-colored urine. Therefore, the nurse will check whether the patient's urine is tea colored. The nurse obtains blood-clotting studies in the patient to monitor for signs of disseminated intravascular coagulation (DIC). Heatstroke is also characterized by decreased electrolytes, particularly sodium levels. Therefore, the nurse administers fluids and electrolytes to the patient. Antipyretics reduce the body temperature that is elevated due to infection, but not temperature due to heatstroke. Therefore, antipyretics do not help to reduce this patient's body temperature. Salt tablets can cause gastric irritations and hypernatremia in the patient. Therefore they should not be administered to the patient. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. Text Reference - p. 1683
A patient has sought care three days after experiencing a series of tick bites. Which manifestation would indicate that a patient is experiencing tick paralysis?
A classic manifestation of tick paralysis is flaccid ascending paralysis, which develops over one to two days. Without tick removal, the patient dies as respiratory muscles become paralyzed. Aggression, decreased level of consciousness, fever, and necrosis at the bite sites are not characteristic of the problem. TEST-TAKING TIP: As you answer each question, write a few words about why you think that answer is correct; in other words, justify why you selected that answer. If an answer you provide is a guess, mark the question to identify it. This will permit you to recognize areas that need further review. It will also help you to see how correct your "guessing" can be. Remember: on the licensure examination you must answer each question before moving on to the next question. Text Reference - p. 1687
Which substance is absorbed by activated charcoal?
Activated charcoal absorbs acids and ethylene glycol. Activated charcoal does not alkylate substances such as lithium and cyanide. Activated charcoal does not absorb weakly acidic substances such as boric acid. Text Reference - p. 1689
An 18-year-old male who fell through the ice on a pond near his farm was admitted to the emergency department with somnolence. Vital signs are blood pressure (BP) 82 mm Hg systolic with Doppler, respirations 9/min, and core temperature of 90 degrees F (32.2 degrees C). The nurse should anticipate which intervention?
Active internal or core rewarming is used for moderate to severe hypothermia and involves the application of heat directly to the core. Immersion in a hot bath, rehydration, and massage are not appropriate interventions in the treatment of severe hypothermia. Passive rewarming is used in mild hypothermia. Text Reference - p. 12
A patient seeks treatment following a cat bite. The nurse recognizes that the bite may result in which condition?
Cat bites cause deep puncture wounds that can damage tendons and joint capsules, resulting in tenosynovitis. Dog ticks or wood ticks may cause tick paralysis. Lyme disease is a tick-borne disease that is caused by a tick infected with Borrelia burgdorferi. Immersion syndrome is caused when an individual immerses in cold water for a long time. Text Reference - p. 1688
A patient has been hospitalized with iron toxicity. Which medication does the nurse suspect will be prescribed?
Deferoxamine (Desferal) is a chelating agent that binds with excess iron in the blood and reduces the symptoms of iron toxicity. Midazolam (Versed) is a sedative medication that causes central nervous system depression. Etomidate (Amidate) is an anesthetic agent. Succinylcholine (Anectine) is a neuromuscular blocking agent. Midazolam (Versed), etomidate (Amidate), and succinylcholine (Anectine) cause bronchodilation and reduce the risk of aspiration in a patient who is undergoing rapid-sequence intubation. Text Reference - p. 1689
A patient arrives in the emergency department after taking an overdose of aspirin. The patient is awake and alert. The nurse should be prepared to assist with the administration of:
Emergency treatment for aspirin poisoning involves the induction of vomiting. An emetic such as syrup of ipecac is usually administered. Vomiting will stop the absorption of the aspirin by removing it from the stomach. Oxygen may be required but is not as urgent as administration of an emetic. Neither a diuretic nor a sedative is appropriate for administration to a patient who has taken an overdose of aspirin. Text Reference - p. 1689
The nurse is assisting with an endotracheal intubation. The health care provider experiences difficulty inserting an endotracheal tube due to airway obstruction. What intervention would be most helpful in preventing hypoxia in the patient?
If the health care provider has difficulty inserting an endotracheal tube in the patient, he or she can make a temporary emergency airway by performing a cricothyroidotomy. A cricothyroidotomy is a surgical procedure in which the health care provider will make a hole in the patient's cricothyroid membrane, through which air can enter the lungs. The nurse should administer 100% oxygen to the patient before a cricothyroidotomy is performed in order to prevent respiratory distress. Bronchodilators should be administered before the surgery to dilate the airways, but not during the surgery. The jaw-thrust maneuver helps to improve breathing and prevent respiratory distress in the patient. It does not help clear an obstruction in the airway. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response. Text Reference - p. 1677
The nurse recalls that phosgene gas causes a patient to develop what condition?
Phosgene gas causes pulmonary edema and impairs pulmonary functioning, resulting in death. Mustard gas causes skin burns. Explosives such as TNT and dynamite may cause middle ear disorders. If a patient is exposed to ionizing radiation, then it results in acute radiation syndrome. Text Reference - p. 1690
A mother comes into the emergency department with her son and states that he was stung by a bee on his upper right arm. The mother states that after removing the stinger with tweezers, she noted that her son started to have some nausea and began complaining of feeling faint and having difficulty breathing. Which of the following health care provider's prescriptions should the nurse implement first?
Removing the stinger with tweezers may have caused additional venom to be released into the body. This would increase the severity of the reaction as seen with the nausea, syncope, and breathing difficulties. Therefore, the priority intervention would be to administer epinephrine to treat the reaction. Cool compresses, administering diphenhydramine, and elevating the arm are all appropriate treatments if the reaction is mild, that is, stinging, swelling, headache, and so forth. Text Reference - p. 1687
During the physical examination of a patient, the nurse finds that the patient has subcutaneous emphysema, absence of "Raccoon eyes," and negative Battle's sign. What does the nurse conclude from these findings?
Subcutaneous emphysema occurs from an accumulation of air under the subcutaneous tissue present over the chest wall. Subcutaneous emphysema may cause trauma to the organs in the chest region, resulting in laryngotracheal disruption. Compartment syndrome is caused by the accumulation of fluids in the lower limbs. If a patient has, "Raccoon eyes," then the nurse would suspect that the patient has a fracture at the base of the frontal portion of the skull. If the patient has Battle's sign, then it indicates that the patient has a fracture at the base of the posterior portion of the skull. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response. Text Reference - p. 1680
The nurse is caring for patients in the emergency department. Which patient does the nurse see first?
The Emergency Severity Index (ESI) is a five-level triage system used to critically analyze the priority of patient care. ESI indicates that patients with severe respiratory distress, cardiac arrest, and intubated trauma patients are prioritized for treatment (ESI-1). Patients with abdominal pain are given third preference (ESI-3). Patients with minor burns such as first-degree burns are given the last preference (ESI-5). Patients with chest pain likely due to ischemia are given second preference (ESI-2). Test-Taking Tip: Look for answers that focus on the patient or are directed toward feelings. Text Reference - p. 1675
The nurse is providing care for a patient who is admitted to the emergency department following a near-drowning event. Assessment findings indicate that the patient has significant pulmonary edema. The nurse expects that the plan of care will include what treatment strategy?
The near-drowning victim may have intravascular volume depletion and pulmonary edema due to aspiration of fluids. Therefore, providing mechanical ventilation with positive end-expiratory pressure or continuous positive airway pressure improves gas exchange across the alveolar-capillary membrane and maintains adequate oxygenation in the victim. Doxycycline (Monodox) is an antibiotic and deferoxamine (Desferal) is a chelating agent. Therefore, these medications do not help to prevent respiratory distress in the patient. If the patient has symptoms of persistent hypothermia, then the nurse would administer warmed intravenous fluids to the patient. Test-Taking Tip: Avoid taking a wild guess at an answer. However, should you feel insecure about a question, eliminate the alternatives that you believe are definitely incorrect, and reread the information given to make sure you understand the intent of the question. This approach increases your chances of randomly selecting the correct answer or getting a clearer understanding of what is being asked. Text Reference - p. 1686
The nurse is assessing the circulation of a patient in the emergency unit of the hospital. Arrange the interventions in the order in which the nurse would perform them.
The nurse assessing the circulation of the patient must first check a central pulse and assess the pulse rate and quality because peripheral pulses may be absent due to injury or vasoconstriction. The skin should be assessed for color, temperature, and moisture. A delayed capillary refill accompanied by altered mental status is a sign of shock. Text Reference - p. 1677
A patient is brought to the emergency unit of the hospital with several bee stings. What is the nursing care for this patient? Select all that apply.
The nurse should administer oral, IV, or intramuscular antihistamines as prescribed by the health care provider. The patient may develop edema, so restrictive clothing, rings, or watches around the sting site should be removed. A cool, not warm, compress is used to soothe the skin after the stinger is removed with a knife or a needle in a scraping motion. Tweezers should not be used because they squeeze the stinger and release more venom. The skin is not cleaned with soap and water; instead, antipruritic lotions are applied to the skin. STUDY TIP: Focus your study time on the common health problems that nurses most frequently encounter. Text Reference - p. 1687
The nurse is caring for an athlete with severe heat cramps in the leg. What intervention should the nurse perform?
The nurse should provide oral or parenteral replacement of sodium and water. A patient experiencing heat exhaustion is placed in a cool area with a moist sheet over the body to decrease core body temperature through evaporative heat loss. The cramped leg should be elevated, not placed in a horizontal position and should be gently massaged. Text Reference - p. 1682
A patient is brought to the emergency unit of the hospital with a compound fracture of the radius. How should the nurse rate the patient as per the Emergency Severity Index (ESI)?
The nurse should rate the patient with a compound fracture of the radius with ESI-3. The patient is stable and can be attended by a health care provider within an hour. A patient rated as ESI-1 would be unstable and in need of immediate attention, as in the case of a patient with cardiac arrest. A patient rated as ESI-2 has a threat to the stability of vital functions and needs continuous monitoring, as in the case of a patient with chest pain. A patient rated as ESI-4 is stable and may need simple procedures or diagnostic study, as in the case of a patient with cystitis. TEST-TAKING TIP: If you are unable to answer a multiple-choice question immediately, eliminate the alternatives that you know are incorrect and proceed from that point. The same goes for a multiple-response question that requires you to choose two or more of the given alternatives. If a fill-in-the-blank question poses a problem, read the situation and essential information carefully and then formulate your response. Text Reference - p. 1675
A nurse is caring for a patient involved in a car accident. The patient is unconscious and has multiple injuries on the head. What are the most important interventions for the nurse to perform as part of the primary survey? Select all that apply.
The nurse should suspect cervical spine trauma in any patient with head and neck injuries. Immediate interventions include application of a cervical collar and a CID to the patient. The patient's forehead is then secured to the backboard. These measures are part of the primary survey and may even be done at the accident site. Obtaining a full set of vital signs and providing comfort measures or pain control to the patient are interventions that should be done later during the secondary survey. This assessment is intended to identify all injuries in a more systematic way. TEST-TAKING TIP: Do not select answers that contain exceptions to the general rule, controversial material, or degrading responses. Text Reference - p. 1677
A nurse on the emergency medical team is required to triage victims at the site of an accident. How should the nurse tag a patient with a feeble pulse and severe head injury?
The nurse should tag the patient blue to indicate that the patient is expected to die. Green indicates that the patient has a minor injury such as a sprain. Yellow indicates urgent, non-life-threatening injuries such as open fractures. Red indicates life-threatening injuries requiring immediate intervention, and a black tag is used to identify the dead. Text Reference - p. 1692
The nurse is caring for a patient with superficial frostbite on the nose, fingers, and toes. What interventions should the nurse perform? Select all that apply.
The nurse should use warm soaks for the face. Blisters that form within a few hours should be debrided and covered with a sterile dressing. The affected toes and fingers should be immersed in a water bath at 98.6° to 104° F. The frostbitten area should be handled carefully; massaging causes damage to the tissues. The nurse should avoid using heavy blankets for the patient because they could cause friction and sloughing of damaged tissue. Text Reference - p. 1684
After completing a full set of vital signs on a patient who was injured severely in a motor-vehicle accident, the nurse begins to insert a Foley catheter per the health care provider's prescription. Which of the following would warrant the nurse to notify the health care provider?
The nurse would not want to insert a Foley catheter if the patient has blood at the urinary meatus, scrotal hematoma, or perineal ecchymosis, as these are signs of possible damage to the urinary tract, and the Foley catheter could possibly cause additional damage. A Foley catheter may still be inserted in a patient experiencing priapism. Abdominal distention and rectal bleeding do not affect the urinary tract. Text Reference - p. 1679
A male patient is brought into the emergency department (ED) with multiple stab wounds to the legs, one stab wound to the left abdomen, and gang tattoos on both arms. He refuses to identify his attacker and then loses consciousness. Police identify him as the assailant in the fatal stabbing of another man. What is the nurse's priority?
The nurse's priority is to maintain personal and work place safety. Violence can erupt in the ED when treating gang members if the rival gang seeks revenge or the patient's gang members seek to protect the patient with their presence. Staff members can be victims of that violence, so they should maintain a safe work environment by seeking law enforcement and security assistance in maintaining safety for the staff and the patient. Airway, breathing, and circulation (ABCs) are the usual priority, but this situation does not show any problem with the patient's airway or breathing. Text Reference - p. 1690
A patient is brought in to the emergency department with a suspected overdose of aspirin. The nurse notes that the patient is lethargic, confused, and has rapid breathing. Which of the following interventions should the nurse prepare to implement?
The patient is experiencing acidosis related to the aspirin overdose; therefore, hemodialysis is the recommended treatment. Chelation therapy is used mainly with heavy metal poisoning. Activated charcoal would not be priority treatment in this situation. Whole bowel irrigation is used mainly for swallowed objects or heavy metals. Text Reference - p. 1690
A patient comes into the emergency department complaining of extreme thirst and vomiting on a very hot day. The nurse notes that the patient has profuse diaphoresis and is ashen in color. Vital signs are: blood pressure 90/50, pulse 98, and temperature is 101 degrees Fahrenheit. Which of the following is the immediate priority for the nurse?
The patient is experiencing heat exhaustion, and the initial treatment step is to place the patient in a cool area and remove any restrictive clothing. The nurse would not administer salt tablets as it could lead to complications, such as gastric irritation or hypernatremia. The nurse would not administer oral fluid and electrolyte replacement for a patient experiencing nausea or vomiting. An intravenous bolus may be started, but it would consist of 0.9% normal saline, not lactated Ringers. Text Reference - p. 1683
The patient has been part of a community emergency response team (CERT) for a tropical storm in Dallas where it has been 100 degrees F (37.7 degrees C) or more for the last two weeks. With assessment, the nurse finds hypotension, body temperature of 104 degrees F (40 degrees C), dry and ashen skin, and neurologic symptoms. What treatments should the National Disaster Medical System (NDMS) nurse anticipate? Select all that apply.
The patient is experiencing heatstroke. Treatment focuses first on stabilizing the patient's airway, breathing, and circulation (ABCs) and rapidly reducing the core temperature. Administration of 100% O2 compensates for the patient's hypermetabolic state. Cooling the body with IV fluids is effective. Immersion in an ice bath will cause shivers that increase core temperature, so a cool water bath should be used for conductive cooling. Removing the clothing, covering the patient with wet sheets, and placing the patient in front of a fan will cause evaporative cooling. Excessive covers will not be used. Acetaminophen will not be effective because the increase in temperature is not related to infection. Text Reference - p. 1683
Five patients are brought in to the emergency department from a fire at a nearby chemical plant. In what priority should the nurse treat these patients? Order the following from the highest priority to the lowest priority.
This patient experiencing cardiac arrest is unstable and obviously experiencing a life-threatening emergency, so needs to be seen immediately. Next, as the patient with multiple trauma and burns to the lower extremities may likely have a life-threatening emergency, but it is not obvious. Therefore, patient should be seen within 10 minutes. The patient experiencing abdominal pain is stable, but will need some diagnostics done to verify that he or she is not experiencing anything life-threatening. Therefore, the patient should be seen within an hour. The patient experiencing a closed fracture of the right tibia is not experiencing a life-threatening emergency and is stable, but may require some diagnostics or a procedure. Last, the patient experiencing a minor burn to the left arm is not experiencing a life-threatening emergency and is stable, and does not require any diagnostics or procedures. Text Reference - p. 1675
While assessing an unresponsive apneic spinal cord injury patient, the nurse understands the need to open the airway with the jaw thrust maneuver and apply a cervical collar. What intervention would be the priority for the nurse to complete next?
Ventilating with the bag-valve mask at 100% oxygen would be the priority, as breathing is the priority after the airway has been stabilized. The nurse would not assess skin color, temperature, and moisture or insert an intravenous line until after the patient's airway and breathing have been assessed and treated, as this is part of the circulation assessment or treatment. The patient's level of consciousness has been determined already; he or she is unresponsive. Text Reference - p. 1676
The nurse is caring for a patient 24 hours after the patient received amphetamine (Adderall) therapy. The patient is experiencing a new onset of right upper quadrant pain and decreased urinary flow. What should be included on the patient's plan of care?
When a patient complains of pain in the right upper quadrant along with urinary retention 24 hours after taking Adderall, it indicates that the patient has amphetamine (Adderall) toxicity. Vitamin C increases the elimination of amphetamine and decreases its toxic effects. Therefore, adding vitamin C to intravenous fluids will be beneficial in reducing the patient's symptoms. Polyethylene glycol (GoLYTELY) is a nonabsorbable bowel evacuant solution. It should be administered every 4 to 6 hours to eliminate the drug through the stools, but administering it every hour would be too much. Chelation therapy should be provided to patients with heavy metal poisoning. Edetate calcium disodium is not effective for the treatment of amphetamine toxicity. N-acetylcysteine (Mucomyst) is a neutralizing antidote that reduces the effect of amphetamine poisoning. Activated charcoal absorbs N-acetylcysteine (Mucomyst) and reduces its effectiveness. Therefore, the nurse should not administer N-acetylcysteine (Mucomyst) simultaneously or immediately with activated charcoal. Test-Taking Tip: Identifying the content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options Text Reference - p. 1690