Emergency (iggy) (4th semester 1st time)
A patient seeking treatment after being in a house fire has thermal burns to the neck and shoulders and singed nasal hairs. Which action should the nurse take first? a. Monitor respirations. b. Monitor urine output. c. Obtain blood pressure. d. Place the patient in a private room.
a. Monitor respirations.
Which situation does not cover nurses who respond to a mass casualty incident (MCI) for malpractice or negligent lawsuits under the Good Samaritan Act? A. Terrorist act B. Neighborhood fire C. Roadside car accident D. High school sporting event
A. Terrorist act
Which organization in the United States mandates ongoing disaster preparedness for hospitals? A. The Joint Commission (TJC) B. The local government C. The state government D. The Occupational Safety and Health Administration (OSHA)
A. The Joint Commission (TJC)
The nurse is planning care for a patient with a mental health disorder. Which nursing diagnosis should the nurse select if the patient is demonstrating manic behavior? a. Grieving b. Confusion c. Risk for Injury d. Defensive Coping
c. Risk for Injury
The nurse is conducting triage under mass casualty conditions. Which tag should the nurse use for a patient who is experiencing hypovolemic shock due to a penetrating wound? A. Red B. Black C. Green D. Yellow
A. Red
Which nursing actions are appropriate during the primary survey of the emergency assessment process? Select all that apply. A. Inserting a nasogastric tube B. Immobilizing the cervical spine C. Arranging for diagnostic studies D. Preparing for chest tube insertion E. Applying direct pressure to a wound
B. Immobilizing the cervical spine D. Preparing for chest tube insertion E. Applying direct pressure to a wound
Which is the essential nursing skill for the triage process in the emergency department? A. Evaluating care B. Setting priorities C. Formulating diagnoses D. Implementing interventions
B. Setting priorities
Which is the priority nursing action when providing care to a patient with a penetrating abdominal wound? A. Assessing bowel sounds B. Stabilizing the impaled object C. Administering prescribed pain medication D. Scheduling a CT scan to determine retroperitoneal bleeding
B. Stabilizing the impaled object
Which treatment for anthrax should be included in the biological agent portion of a disaster plan for terrorist attacks? A. Antivirals B. Antitoxins C. Antibiotics D. Vaccinations
C. Antibiotics
The nurse assists with the provision of an educational program on they symptoms of smallpox. Which response indicates that the participates understand the location that the rash first appears? A. Legs and feet B. neck and back C. tongue and face D, abdomen and perineum
C. tongue and face
A patient recovering from a motor vehicle crash develops hypotension and jugular distension with a tracheal deviation. Based on this data, which should the nurse suspect occurred? A. Hemorrhage B. Compensatory shock C. Hypovolemic shock D. Tension pneumothorax
D. Tension pneumothorax
Which public health risk became a major focus for hospitals after the September 11, 2001 terrorist attacks? A. Anthrax exposure B. Multi-casualty incidents C. Mass casualty incidents (MCI) D. Weapons of mass destruction (WMD)
D. Weapons of mass destruction (WMD)
A nurse is teaching a wilderness survival class. Which statements should the nurse include about the prevention of hypothermia and frostbite? (Select all that apply.) a. "Wear synthetic clothing instead of cotton to keep your skin dry." b. "Drink plenty of fluids. Brandy can be used to keep your body warm." c. "Remove your hat when exercising to prevent the loss of heat." d. "Wear sunglasses to protect skin and eyes from harmful rays." e. "Know your physical limits. Come in out of the cold when limits are reached."
a. "Wear synthetic clothing instead of cotton to keep your skin dry." d. "Wear sunglasses to protect skin and eyes from harmful rays." e. "Know your physical limits. Come in out of the cold when limits are reached."
The hospital administration arranges for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation? a. "You are free to express your feelings; whatever is said here stays here." b. "Let's evaluate what went wrong and develop policies for future incidents." c. "This session is only for nursing and medical staff, not for ancillary personnel." d. "Let's pass around the written policy compliance form for everyone."
a. "You are free to express your feelings; whatever is said here stays here."
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? a. Administer dexamethasone (Decadron). (actually O2) b. Complete a mini-mental state examination. c. Prepare the client for computed tomography of the brain. d. Request a psychiatric consult.
a. Administer dexamethasone (Decadron). (O2)
Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action should the nurse take first? a. Assess that the client is breathing adequately. b. Insert a large-bore intravenous line. c. Place the client on a cardiac monitor. d. Assess for the best neurologic response.
a. Assess that the client is breathing adequately.
An emergency department nurse assesses a client admitted after a lightning strike. Which assessment should the nurse complete first? a. Electrocardiogram (ECG) b. Wound inspection c. Creatinine kinase d. Computed tomography of head
a. Electrocardiogram (ECG)
A nurse wants to become involved in community disaster preparedness and is interested in helping set up and staff first aid stations or community acute care centers in the event of a disaster. Which organization is the best fit for this nurse's interests? a. The Medical Reserve Corps b. The National Guard c. The health department d. A Disaster Medical Assistance Team
a. The Medical Reserve Corps
After a hospital's emergency department (ED) has efficiently triaged, treated, and transferred clients from a community disaster to appropriate units, the hospital incident command officer wants to "stand down" from the emergency plan. Which question should the nursing supervisor ask at this time? a. "Are you sure no more victims are coming into the ED?" b. "Do all areas of the hospital have the supplies and personnel they need?" c. "Have all ED staff had the chance to eat and rest recently?" d. "Does the Chief Medical Officer agree this disaster is under control?"
b. "Do all areas of the hospital have the supplies and personnel they need?"
A nurse is triaging clients in the emergency department (ED). Which client should the nurse prioritize to receive care first? a. A 22-year-old with a painful and swollen right wrist b. A 45-year-old reporting chest pain and diaphoresis c. A 60-year-old reporting difficulty swallowing and nausea d. An 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101° F
b. A 45-year-old reporting chest pain and diaphoresis
The emergency department team is performing cardiopulmonary resuscitation on a client when the client's spouse arrives at the emergency department. Which action should the nurse take first? a. Request that the client's spouse sit in the waiting room. b. Ask the spouse if he wishes to be present during the resuscitation. c. Suggest that the spouse begin to pray for the client. d. Refer the client's spouse to the hospital's crisis team.
b. Ask the spouse if he wishes to be present during the resuscitation.
A patient is admitted for mild hypothermia. Which manifestations should the nurse expect when assessing this patient? (Select all that apply.) *NOT EXACT QUESTION* a. Pinpoint pupils b. Depleted glucose stores ** c. Increased respiratory rate d. Decreased respiratory rate e. Decreased muscular activity f. Decreased heart rate and cardiac output
b. Depleted glucose stores ** d. Decreased respiratory rate e. Decreased muscular activity f. Decreased heart rate and cardiac output
A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action should the nurse take prior to providing advanced cardiac life support? a. Contact the on-call orthopedic surgeon. b. Don personal protective equipment. c. Notify the Rapid Response Team. d. Obtain a complete history from the paramedic.
b. Don personal protective equipment.
The nurse is caring for a patient experiencing acute psychosis. What should the nurse realize as being the purpose of medication for this patient? a. Encourage sleep b. Reduce psychosis c. Improve cognition d. Enhance oxygenation
b. Reduce psychosis
On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, blood pressure 106/66 mm Hg. Which action should the nurse take? a. Encourage the client to drink cool water or sports drinks. b. Start an intravenous line and infuse 0.9% saline solution. c. Administer acetaminophen (Tylenol) 650 mg orally. d. Encourage rest and re-assess in 15 minutes.
b. Start an intravenous line and infuse 0.9% saline solution.
A nurse cares for clients during a community-wide disaster drill. Once of the clients asks, "Why are the individuals with black tags not receiving any care?" How should the nurse respond? a. "To do the greatest good for the greatest number of people, it is necessary to sacrifice some." b. "Not everyone will survive a disaster, so it is best to identify those people early and move on." c. "In a disaster, extensive resources are not used for one person at the expense of many others." d. "With black tags, volunteers can identify those who are dying and can give them comfort care."
c. "In a disaster, extensive resources are not used for one person at the expense of many others."
When using the Glasgow Coma Scale for a patient involved in a motor vehicle crash, the patient opens the eyes when spoken to and points to the location of pain but is confused in conversation. What score should the nurse assign to this patient? a. 8 b. 10 c. 12 d. 14
c. 12
A nurse is triaging clients in the emergency department. Which client should be considered "urgent"? a. A 20-year-old female with a chest stab wound and tachycardia b. A 45-year-old homeless man with a skin rash and sore throat c. A 75-year-old female with a cough and a temperature of 102° F d. A 50-year-old male with new-onset confusion and slurred speech
c. A 75-year-old female with a cough and a temperature of 102° F
An emergency department charge nurse notes an increase in sick calls and bickering among the staff after a week with multiple trauma incidents. Which action should the nurse take? a. Organize a pizza party for each shift. b. Remind the staff of the facility's sick-leave policy. c. Arrange for critical incident stress debriefing. d. Talk individually with staff members.
c. Arrange for critical incident stress debriefing.
A patient who sustained multiple injuries in a motor vehicle crash is brought to the emergency department. After the primary survey, what should be the nurse's next action? a. Explain to the patient what happened. b. Prepare patient for surgery immediately. c. Complete out a rapid head-to-toe assessment. d. Obtain a medical history from a family member.
c. Complete out a rapid head-to-toe assessment.
A patient who works in a non-air conditioned manufacturing plant is experiencing weakness and a headache. The patient's skin is cool and clammy, temperature is slightly elevated, and pulse rate is rapid. For which health problem should the nurse plan care for this patient? a. Heatstroke b. Heat cramps c. Heat exhaustion d. Initial signs of infection
c. Heat exhaustion
An emergency department nurse is caring for a client who is homeless. Which action should the nurse take to gain the client's trust? a. Speak in a quiet and monotone voice. b. Avoid eye contact with the client. c. Listen to the client's concerns and needs. d. Ask security to store the client's belongings.
c. Listen to the client's concerns and needs.
While at a public park, a nurse encounters a person immediately after a bee sting. The person's lips are swollen, and wheezes are audible. Which action should the nurse take first? a. Elevate the site and notify the person's next of kin. b. Remove the stinger with tweezers and encourage rest. c. Administer diphenhydramine (Benadryl) and apply ice. d. Administer an EpiPen from the first aid kit and call 911.
d. Administer an EpiPen from the first aid kit and call 911.
While assessing a victim of a motor vehicle crash, the nurse notes that the patient's trachea is shifted towards the left. What does this finding indicate to the nurse? a. Cardiac tamponade b. Right lung hemothorax c. Left lung pneumothorax d. Right lung tension pneumothorax
d. Right lung tension pneumothorax
A nurse prepares to discharge an older adult client home from the emergency department (ED). Which actions should the nurse take to prevent future ED visits? (Select all that apply.) a. Provide medical supplies to the family. b. Consult a home health agency. c. Encourage participation in community activities. d. Screen for depression and suicide. e. Complete a functional assessment.
d. Screen for depression and suicide. e. Complete a functional assessment.
Which assessment data related to the patient's airway would indicate the need for priority intervention by the nurse? A. Eupnea B. Tachycardia C. Hypotension D. Agonal breaths
D. Agonal breaths
The nurse is reviewing a 40 year old patient's immunization schedule. At which age should the patient have received the most recent tetanus booster vaccination? A. 2 months B. 6 years C. 20 years D. 35 years
D. 35 years
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? a. Administer intravenous morphine. b. Wrap the limb with a compression dressing. c. Massage the frostbitten areas. d. Assess the limb for compartment syndrome.
a. Administer intravenous morphine.
The nurse is receiving a victim of a traumatic amputation in the emergency department. What should the nurse do with the amputated limb? (Select all that apply.) a. Place on ice b. Rinse with saline c. Place in ice water d. Wrap in sterile gauze e. Place in a sealed plastic bag
a. Place on ice b. Rinse with saline d. Wrap in sterile gauze e. Place in a sealed plastic bag
The nurse administrator for a long-term care facility is implementing a disaster response plan for staff and residents. Which staff member statements indicate correct understanding of the plan? A. "We have to implement annual drills." B. "Nursing homes are not required to have a plan." C. "Our facility is held to the same standards as hospital facilities." D. "This is an important component to receive insurance payments for care."
A. "We have to implement annual drills."
Which type of event can often be handled by an individual hospital disaster plan without collaboration with other systems? A. A motor vehicle accident involving five cars B. A tornado destroying 50 homes and businesses C. An act of terrorism injuring and kills hundreds of people D. A hurricane causing flooding, displacing thousands of people
A. A motor vehicle accident involving five cars
Which are the top priorities when conducting a primary patient survey during the emergency assessment? Select all that apply. A. Airway B. Disability C. Breathing D. Circulation E. Cervical spine
A. Airway E. Cervical spine
Which medication should be listed as the antidote to a nerve agent in the disaster plan for a terrorist attack? A. Atropine B. Dopamine C. Epinephrine D. Norepinephrine
A. Atropine
A medical-surgical unit is expecting a large volume of patient admissions after a train derailment. Which member of the nursing care team will prioritize care for the unit? A. Charge nurse B. Nurse supervisor C. Licensed practical nurse D. Unlicensed assistive personnel
A. Charge nurse
Which is the priority nursing action to include in a disaster plan for the radioactive dust and smoke that can cause illness from a radiologic dispersal device (RDD)? A. Covering the nose B. Protecting the eyes C. Decontaminating the skin D. Administering prophylactic antibiotics
A. Covering the nose
The nurse is conducting a secondary survey as part of the emergency assessment. Which is the priority nursing action during the health history portion of the assessment? A. Determining drug allergies B. Noting the general appearance C. Examining the neck for stiffness D. Auscultating for heart and lung sounds
A. Determining drug allergies
Which are the priority nursing actions after the completion of the secondary survey when providing care for a trauma patient with a penetrating wound? A. Documenting the patient's care B. Formulating the patient's plan of care C. Reassessing the patient's level of consciousness D. Transferring the patient to the general medical unit
A. Documenting the patient's care
The nurse is helping devise a training plan to familiarize health-care providers with emergency response procedures. Which training measure is most effective to adequately prepare the trainees? A. Drills B. Tabletop exercises C. Access to the policy D. Computer simulations
A. Drills
The nurse is conducting a primary survey during an emergency assessment. Which is the priority nursing action related to breathing in response to this assessment? A. Having suction available B. Assessing pupil size and reactivity C. Immobilizing any obvious deformities D. Obtaining blood samples for type and crossmatch
A. Having suction available
Which is the priority in the preparedness of health-care professionals in any type of disaster plan? A. Identification of hazards B. Cooperation with state authorities C. Collaboration with local authorities D. Implementation of federal mandates
A. Identification of hazards
A green-tagged patient arrives at the emergency department after a mass casualty incident (MCI) involving radiation. Which is the priority nursing action for this patient? A. Implementing decontamination measures B. Performing a head-to-toe physical examination C. Placing a special bracelet with a disaster number D. Taking a digital photo and placing it on the medical record
A. Implementing decontamination measures
Which threats, included in the term "NBC," lead to the implementation of improved emergency medical services (EMS) and hospital safety programs? Select all that apply. A. Nuclear B. Biological C. Botulism D. Chemical E. Nipah virus
A. Nuclear B. Biological D. Chemical
The registered nurse (RN) is the team leader for a group of patients using the functional model of nursing. The team of nurses includes two licensed practical nurses (LPNs) and an unlicensed assistive personnel (UAP). Which task will the RN delegate to the UAP? A. Taking vital signs B. Providing wound care C. Conducting discharge teaching D. Administering oral medications
A. Taking vital signs
Which treatment should the nurse prepare to administer when providing care to a toddler who presents after an accidental overdose of aspirin? A. Gastric lavage B. Activated charcoal C. Peritoneal dialysis D. Vitamin D injection
B. Activated charcoal
Which are the most common types of injuries that should be identified along with treatment options in an organizational disaster plan for the use of explosive devices as agents of terrorism? Select all that apply. A. Burn B. Blast C. Crush D. Penetration E. Psychological
B. Blast C. Crush D. Penetration
The nurse is conducting a primary survey during the emergency assessment. Which nursing action is appropriate during the breathing assessment? A. Assessing for edema B. Counting respiratory rate C. Checking for foreign bodies D. Monitoring for respiratory distress
B. Counting respiratory rate
Which observation indicates that interventions provided to a patient with neck injuries from a motor vehicle crash have been successful? A. Urine is clear and odorless from indwelling catheter B. Moves all four extremities independently, feeds self, and participates in partial bath C. Unable to move independently in bed D. Rests in bed with lights and television turned off
B. Moves all four extremities independently, feeds self, and participates in partial bath
Which emergency medical system (EMS) first responders can perform triage during mass casualty incidents? A. Unlicensed assistive personnel B. Nurses appointed to a field team C. A physician who survives the incident D. Community response team members
B. Nurses appointed to a field team
The nurse is providing care to several patients in the emergency department. Which patient would require priority care from the nurse? A. An adult patient with an ankle sprain B. An infant with a rash of unknown origin C. An adult patient with unstable vital signs and chest pain D. A pediatric patient with multiple fractures following a motor vehicle accident
C. An adult patient with unstable vital signs and chest pain
A nurse is developing a plan of care for a patient with traumatic injuries from a motor vehicle crash. Which nursing intervention does the nurse include in the plan of care to reduce the risk of integumentary complications? A. Provide active or passive exercises at least once every eight hours B. Encourage coughing, deep breathing, and incentive spirometry C. Assist the patient in turning at least every two hours D. Assist the patient in turning at least every eight hours
C. Assist the patient in turning at least every two hours
Which health-care team member is a first responder when an emergency or mass casualty incident (MCI) occurs? A. Fireman B. Police officer C. Critical care nurse D. Unlicensed assistive personnel
C. Critical care nurse
Which psychosocial nursing actions are appropriate when providing patient care after a community disaster? Select all that apply. A. Performing triage of injuries B. Administering first aid to wounds C. Offering choices whenever possible D. Establishing rapport through active listening E. Requesting assistance from crisis counselors
C. Offering choices whenever possible D. Establishing rapport through active listening E. Requesting assistance from crisis counselors
A patient brought into the emergency department is diagnosed with shock. Which interventions should the nurse prepare to provide to this patient? (Select all that apply) A. Raise the head of the bed B. Encourage sips of warm fluid C. Provide oxygen as prescribed D. Measure and record vital signs E. Provide IV fluids as prescribed
C. Provide oxygen as prescribed D. Measure and record vital signs E. Provide IV fluids as prescribed
A patient with severe hypothermia is comatose with fixed dilated pupils, flaccid muscles, and ventricular fibrillation. Which body temperature should the nurse expect to assess in the patient? A. 95.0 B. 90.0 C. 82.1 D. 80.6
D. 80.6
The nurse is providing care to several patients in the emergency department. Which patient is the priority when using the three-tiered triage system? A. A patient with a simple fracture B. A patient experiencing renal colic C. A patient with severe abdominal pain D. A patient with chest pain and diaphoresis
D. A patient with chest pain and diaphoresis
The emergency department nurse is triaging patients. Which patient should be prioritized? A. An adult patient experiencing mild chest pain B. An adolescent patient with a possible fractured wrist C. An older adult patient with a hip fracture who is in pain D. A school-age patient with asthma presenting with dyspnea
D. A school-age patient with asthma presenting with dyspnea
Which nursing action is appropriate when conducting a secondary survey during the emergency assessment? A. Maintaining privacy B. Having suction available C. Giving supplemental oxygen D. Assigning a nurse to support family members
D. Assigning a nurse to support family members
Which intervention would be a priority when providing care to a patient recovering from thoracic injuries sustained from a motor vehicle crash? A. Monitor urine output B. Assess vital signs C. Perform passive range of motion to all extremities D. Assist to deep breathe and cough every two hours
D. Assist to deep breathe and cough every two hours
Which is the critical factor among health-care professionals, state agencies, and federal agencies to determine when and how to evacuate safely during a natural disaster? A. Cooperation B. Classification C. Collaboration D. Communication
D. Communication
Which assessment data indicates the patient is experiencing a late symptom associated with chronic aspirin overdose? A. Emesis B. Nausea C. Tinnitus D. Ecchymosis
D. Ecchymosis
A workplace violence prevention plan is often one component of a hospital disaster plan. Which unit assumes priority for implementation and evaluation of this component to the plan? A. Medical unit B. Surgical unit C. Radiology department D. Emergency department
D. Emergency department
Which patient injury would receive a black tag by the triage nurse during a mass casualty incident? A. Concussion B. Ankle sprain C. Open femur fracture D. Full-thickness body burns
D. Full-thickness body burns
Which entity is responsible for activating the disaster plan during a mass casualty incident (MCI)? A. Local emergency management system B. State emergency management system C. Federal emergency management agency D. Hospital-level emergency management system
D. Hospital-level emergency management system
Which amount of time is appropriate for nurse to spend triaging each patient during a mass casualty incident? A. Less than 10 seconds B. Less than 15 seconds C. Less than 30 seconds D. Less than 60 seconds ***
D. Less than 60 seconds ***
A patient is brought into the emergency department after being assaulted. It is suspected that the patient has a spinal cord injury. Which diagnostic test does the nurse anticipate based on the data collected? A. Computed tomography (CT) scan B. X-ray C. Ultrasound D. Magnetic resonance imaging (MRI)
D. Magnetic resonance imaging (MRI)
What should the nurse do to assist a patient brought to the emergency department as a victim of a gunshot wound? A. Ask the patient who shot him B. Bathe the patient and provide a clean gown C. Ask the patient where the weapon is D. Preserve the chain of evidence
D. Preserve the chain of evidence
A nurse wants to become part of a Disaster Medical Assistance Team (DMAT) but is concerned about maintaining licensure in several different states. Which statement best addresses these concerns? a. "Deployed DMAT providers are federal employees, so their licenses are good in all 50 states." b. "The government has a program for quick licensure activation wherever you are deployed." c. "During a time of crisis, licensure issues would not be the government's priority concern." d. "If you are deployed, you will be issued a temporary license in the state in which you are working."
a. "Deployed DMAT providers are federal employees, so their licenses are good in all 50 states."
The nurse determines that a patient has a normal capillary refill time. What was this patient's refill time? a. 3 seconds b. 4 seconds c. 5 seconds d. 6 seconds
a. 3 seconds
A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? (Select all that apply.) a. A 35-year-old female with severe chest pain: red tag b. A 42-year-old male with full-thickness body burns: green tag c. A 55-year-old female with a scalp laceration: black tag d. A 60-year-old male with an open fracture with distal pulses: yellow tag e. An 88-year-old male with shortness of breath and chest bruises: green tag
a. A 35-year-old female with severe chest pain: red tag d. A 60-year-old male with an open fracture with distal pulses: yellow tag
The nurse in the emergency department is triaging victims of a building collapse. Which victim should the nurse determine is a priority for care? a. A severely injured patient with full potential for recovery b. A severely injured patient with slight potential for survival c. A severely injured patient with moderate potential for survival d. A severely injured patient with less than 1% chance of survival
a. A severely injured patient with full potential for recovery
A hospital responds to a local mass casualty event. Which action should the nurse supervisor take to prevent staff post-traumatic stress disorder during a mass casualty event? a. Provide water and healthy snacks for energy throughout the event. b. Schedule 16-hour shifts to allow for greater rest between shifts. c. Encourage counseling upon deactivation of the emergency response plan. d. Assign staff to different roles and units within the medical facility.
a. Provide water and healthy snacks for energy throughout the event.
The complex care provided during an emergency requires interdisciplinary collaboration. Which interdisciplinary team members are paired with the correct responsibilities? (Select all that apply.) a. Psychiatric crisis nurse - Interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis b. Forensic nurse examiner - Performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources c. Triage nurse - Provides basic life support interventions such as oxygen, basic wound care, splinting, spinal immobilization, and monitoring of vital signs d. Emergency medical technician - Obtains client histories, collects evidence, and offers counseling and follow-up care for victims of rape, child abuse, and domestic violence e. Paramedic - Provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration
a. Psychiatric crisis nurse - Interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis e. Paramedic - Provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration
The physician orders haloperidol (Haldol) 2 mg intramuscularly (IM) for a patient who is experiencing a psychiatric crisis. Haldol 5 mg/mL is available. How many milliliters should the nurse give? a. 0.3 mL b. 0.4 mL c. 1 mL d. 1.5 mL
b. 0.4 mL
A hospital prepares to receive large numbers of casualties from a community disaster. Which clients should the nurse identify as appropriate for discharge or transfer to another facility? (Select all that apply.) a. Older adult in the medical decision unit for evaluation of chest pain b. Client who had open reduction and internal fixation of a femur fracture 3 days ago c. Client admitted last night with community-acquired pneumonia d. Infant who has a fever of unknown origin e. Client on the medical unit for wound care
b. Client who had open reduction and internal fixation of a femur fracture 3 days ago e. Client on the medical unit for wound care
The nurse is providing care to a college student having a psychiatric emergency and related suicide attempt. Which action should the nurse take first? a. Obtain a list of drug allergies from the student. b. Determine if alcohol or illicit drugs have been used recently. c. Instruct the student how to place an order with dietary services. d. Encourage the patient to verbalize his or her feelings about the event.
b. Determine if alcohol or illicit drugs have been used recently
A patient is brought to the emergency department after a motor vehicle crash. Which symptom assessed during data collection should the nurse report promptly? a. Oliguria b. Wheezing c. Ecchymosis d. Tachycardia
b. Wheezing
A nurse is triaging clients in the emergency department. Which client should the nurse classify as "nonurgent?" a. A 44-year-old with chest pain and diaphoresis b. A 50-year-old with chest trauma and absent breath sounds c. A 62-year-old with a simple fracture of the left arm d. A 79-year-old with a temperature of 104° F
c. A 62-year-old with a simple fracture of the left arm
An emergency department (ED) case manager is consulted for a client who is homeless. Which intervention should the case manager provide? a. Communicate client needs and restrictions to support staff. b. Prescribe low-cost antibiotics to treat community-acquired infection. c. Provide referrals to subsidized community-based health clinics. d. Offer counseling for substance abuse and mental health disorders.
c. Provide referrals to subsidized community-based health clinics.
While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action should the nurse take first? a. Apply oxygen via nasal cannula. b. Administer intravenous 0.9% saline solution. c. Transfer the client to a negative-pressure room. d. Obtain a sputum culture and sensitivity.
c. Transfer the client to a negative-pressure room.
A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at a nurse when dinner is served late. How should the nurse respond? a. "Do you need something for pain right now?" b. "Please stop yelling. I brought dinner as soon as I could." c. "I suggest that you get control of yourself." d. "You seem upset. I have time to talk if you'd like."
d. "You seem upset. I have time to talk if you'd like."
An emergency department nurse is caring for a client who has died from a suspected homicide. Which action should the nurse take? a. Remove all tubes and wires in preparation for the medical examiner. b. Limit the number of visitors to minimize the family's trauma. c. Consult the bereavement committee to follow up with the grieving family. d. Communicate the client's death to the family in a simple and concrete manner.
d. Communicate the client's death to the family in a simple and concrete manner.
A patient who has fallen has superficial abrasions and an abdomen that is distended, firm, and tender when touched. Which complication should the nurse consider that this patient is experiencing? a. Anaphylaxis b. Emotional stress c. Cardiac arrhythmia d. Internal abdominal bleeding
d. Internal abdominal bleeding
A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag? a. Dislocated right hip and an open fracture of the right lower leg b. Large contusion to the forehead and a bloody nose c. Closed fracture of the right clavicle and arm numbness d. Multiple fractured ribs and shortness of breath
d. Multiple fractured ribs and shortness of breath
What would the nurse working in the emergency department identify as clinical priorities for the treatment of a patient with a gunshot wound? Select all that apply. A. Airway maintenance B. Obtaining medical history C. Ventilation assistance D. Hemorrhage control E. Hypothermia prevention
A. Airway maintenance C. Ventilation assistance D. Hemorrhage control E. Hypothermia prevention
The nurse is a member of the critical incident stress management unit that looks to meet the psychosocial needs of first responders after a mass casualty incident. Which action by the nurse is appropriate when conducting a session? A. Arranging group discussion B. Administering anti-anxiety medication C. Scheduling individual therapy appointments D. Documenting individual responses to the session
A. Arranging group discussion
A nurse is working an evening shift when a fire breaks out at the hospital. Which actions by the nurse are appropriate? Select all that apply. A. Removing patients from immediate danger B. Discontinuing the use of oxygen for all patients C. Using a wheelchair to move a bedridden patient D. Directing ambulatory patients to walk to a safe location E. Containing the fire immediately to avoid patient evacuation
A. Removing patients from immediate danger C. Using a wheelchair to move a bedridden patient D. Directing ambulatory patients to walk to a safe location
Which nursing actions are necessary when initiating care for patients who have been injured in a natural disaster? Select all that apply. A. Taking risks B. Using principles C. Stepping into the unknown D. Showing a commanding presence E. Formulating individualized plans of care
A. Taking risks B. Using principles C. Stepping into the unknown D. Showing a commanding presence
Which member of the health-care team, when using the team nursing approach, is responsible for prioritizing patient care? A. Team leader B. Charge nurse C. Licensed practical nurse D. Unlicensed assistive personnel
A. Team leader
Which nursing actions during a mass casualty incident should be included in the triage portion of an organizational disaster plan? Select all that apply. A. Treatment B. Stabilization C. Evaluation of interventions D. Formulation of nursing diagnosis E. Decontamination for suspected contamination
A. Treatment B. Stabilization E. Decontamination for suspected contamination
The nurse manager is reviewing the hospital disaster plan with other members of the committee. Which is the minimum number of disaster drills the committee must plan and implement each year? A. Two B. Three C. Four D. Five
A. Two
The nurse is contributing to a disaster plan for a possible terrorist attack. Which biological agents should be included in the plan? Select all that apply. a. Rubella B. Anthrax C. Measles D. Botulism E. Tularemia
B. Anthrax D. Botulism E. Tularemia
Which is a potentially life-threatening condition found during the primary triage survey that would necessitate priority nursing care? A. Cystitis B. Concussion C. Lacerated arm D. Fractured femur
B. Concussion
A nurse manager is a member of the emergency response planning team for a hospital located in the Rocky Mountains. Which type of natural disaster will the nurse manager recommend be included in their hospital disaster plan? A. Tornado B. Hurricane C. Avalanche D. Earthquake
C. Avalanche
The nurse is a first responder for a health-care organization for a mass casualty incident. Which injury would the nurse tag as yellow during the triage process? A. Ankle sprain B. Hypovolemic shock C. Open femur fracture D. Massive head trauma
C. Open femur fracture
A nurse teaches a community health class about water safety. Which statement by a participant indicates that additional teaching is needed? a. "I can go swimming all by myself because I am a certified lifeguard." b. "I cannot leave my toddler alone in the bathtub for even a minute." c. "I will appoint one adult to supervise the pool at all times during a party." d. "I will make sure that there is a phone near my pool in case of an emergency."
a. "I can go swimming all by myself because I am a certified lifeguard."
The nurse is evaluating care provided to a patient recovering from a psychotic episode. Which patient statement should the nurse recognize as an indication of reduced anxiety? a. "I feel calm." b. "I like the nurses." c. "The restraints can be removed." d. "I do not need any tranquilizers."
a. "I feel calm."
An emergency department (ED) nurse is preparing to transfer a client to the trauma intensive care unit. Which information should the nurse include in the nurse-to-nurse hand-off report? (Select all that apply.) a. Mechanism of injury b. Diagnostic test results c. Immunizations d. List of home medications e. Isolation precautions
a. Mechanism of injury b. Diagnostic test results e. Isolation precautions
Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies the clients with which injuries with yellow tags? (Select all that apply.) a. Partial-thickness burns covering both legs b. Open fractures of both legs with absent pedal pulses c. Neck injury and numbness of both legs d. Small pieces of shrapnel embedded in both eyes e. Head injury and difficult to arouse f. Bruising and pain in the right lower abdomen
a. Partial-thickness burns covering both legs c. Neck injury and numbness of both legs d. Small pieces of shrapnel embedded in both eyes f. Bruising and pain in the right lower abdomen
A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention should the nurse complete first? a. Provide a calm location for the family to cope and discuss needs. b. Call the hospital chaplain to stay with the family and pray for the deceased. c. Do not allow visiting of the victims until the bodies are prepared. d. Provide privacy for law enforcement to interview the family.
a. Provide a calm location for the family to cope and discuss needs
A homeless person is brought to the hospital for weakness, feeling faint, and having a headache. The patient's skin is cool and clammy and vital signs are temperature 99.9°F, pulse 100 bpm, respirations 18/minute, blood pressure 108/60 mm Hg. What action should the nurse take? a. Provide oral fluids. b. Provide Ciprofloxin 400 mg intravenously (IV). c. Prepare the patient for a chest x-ray. d. Provide acetaminophen (Tylenol) 500 mg orally.
a. Provide oral fluids.
A client presents to the emergency department after prolonged exposure to the cold. The client is difficult to arouse and speech is incoherent. Which action should the nurse take first? a. Reposition the client into a prone position. b. Administer warmed intravenous fluids to the client. c. Wrap the client's extremities in warm blankets. d. Initiate extracorporeal rewarming via hemodialysis.
b. Administer warmed intravenous fluids to the client.
The nurse is caring for a patient who has sustained an abdominal injury in a motor vehicle crash. Which symptom should be the most concerning to the nurse? a. pH 7.35 b. Blood pressure 104/52 mm Hg c. A red macular rash on the patient's back d. Weak distal pulses in the lower extremities
b. Blood pressure 104/52 mm Hg
A hospital prepares for a mass casualty event. Which functions are correctly paired with the personnel role? (Select all that apply.) a. Paramedic - Decides the number, acuity, and resource needs of clients b. Hospital incident commander - Assumes overall leadership for implementing the emergency plan c. Public information officer - Provides advanced life support during transportation to the hospital d. Triage officer - Rapidly evaluates each client to determine priorities for treatment e. Medical command physician - Serves as a liaison between the health care facility and the media
b. Hospital incident commander - Assumes overall leadership for implementing the emergency plan d. Triage officer - Rapidly evaluates each client to determine priorities for treatment
A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center? a. Level I - Located within remote areas and provides advanced life support within resource capabilities b. Level II - Located within community hospitals and provides care to most injured clients c. Level III - Located in rural communities and provides only basic care to clients d. Level IV - Located in large teaching hospitals and provides a full continuum of trauma care for all clients
b. Level II - Located within community hospitals and provides care to most injured clients
An emergency room nurse is caring for a trauma client. Which interventions should the nurse perform during the primary survey? (Select all that apply.) a. Foley catheterization b. Needle decompression c. Initiating IV fluids d. Splinting open fractures e. Endotracheal intubation f. Removing wet clothing g. Laceration repair
b. Needle decompression c. Initiating IV fluids e. Endotracheal intubation f. Removing wet clothing
A nurse is caring for clients in a busy emergency department. Which actions should the nurse take to ensure client and staff safety? (Select all that apply.) a. Leave the stretcher in the lowest position with rails down so that the client can access the bathroom. b. Use two identifiers before each intervention and before mediation administration. c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors. d. Search the belongings of clients with altered mental status to gain essential medical information. e. Isolate clients who have immune suppression disorders to prevent hospital-acquired infections.
b. Use two identifiers before each intervention and before mediation administration. c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors. d. Search the belongings of clients with altered mental status to gain essential medical information.
An emergency room nurse assesses a client who has been raped. With which health care team member should the nurse collaborate when planning this client's care? a. Emergency medicine physician b. Case manager c. Forensic nurse examiner d. Psychiatric crisis nurse
c. Forensic nurse examiner
A nurse is caring for a client whose wife died in a recent mass casualty accident. The client says, "I can't believe that my wife is gone and I am left to raise my children all by myself." How should the nurse respond? a. "Please accept my sympathies for your loss." b. "I can call the hospital chaplain if you wish." c. "You sound anxious about being a single parent." d. "At least your children still have you in their lives."
c. "You sound anxious about being a single parent."
An emergency room nurse is triaging victims of a multi-casualty event. Which client should receive care first? a. A 30-year-old distraught mother holding her crying child b. A 65-year-old conscious male with a head laceration c. A 26-year-old male who has pale, cool, clammy skin d. A 48-year-old with a simple fracture of the lower leg
c. A 26-year-old male who has pale, cool, clammy skin
The nurse ensures that a trauma patient has an effective airway. On what should the nurse focus after the airway has been established for this patient? a. Exposure b. Disability c. Breathing d. Circulation
c. Breathing
An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event? a. Ask ED staff to discharge clients from the medical-surgical units in order to make room for critically injured victims. b. Call additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in. c. Inform the incident commander at the mass casualty scene about how many victims may be handled by the ED. d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims.
d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims
The results of a primary survey reveal that a victim of a motor vehicle crash has an open airway, is breathing, and is conscious but bleeding heavily from severe leg injuries. For which complication should the nurse plan care for this client? a. Anaphylaxis b. Hemothorax c. Cardiogenic shock d. Hypovolemic shock
d. Hypovolemic shock
