NP4 Unit Four (Shocks, Burns, & Emergencies)

Which level of trauma center offers advanced life support care in rural or remote settings?

Level IV

The nurse is assisting the triage team at an earthquake site. Which patient does the nurse refer to as the "walking wounded?"

Patient with several bruises and a closed fracture of the elbow.

A female patient is admitted into the emergency department (ED) with bruises around her breasts and genitals. Her clothes are also torn and stained with blood. Which nursing team should be assigned to the patient?

Sexual Assault Nurse Examiners (SANEs)

A patient with a penetrating trauma is admitted to the emergency department with cervical trauma, impaired consciousness, and respiratory depression. The nurse should intervene when what action is performed during resuscitative efforts?

Use of a non-rebreather mask.

The nurse is assessing a patient who is admitted with an arthropod bite. Which findings indicate that the patient is suffering from a black widow spider bite?

facial edema

A patient is admitted to the emergency department after reporting being raped. Who is the best team member for the admitting nurse to locate to provide care for this patient?

forensic nurse examiner

The nurse is caring for a patient who is the victim of domestic violence. To which health care professional who counsels victims of domestic violence will the nurse refer this patient?

forensic nurse examiner

A patient received a burn due to contact with hydrochloric acid. The burn is brown in color with severe edema and absence of blisters. Which category of burn does the patient have?

full-thickness burn

The nurse should apply which color tag to nonurgent patients during a mass casualty event?

green tag

Which condition can be managed by the administration of hypertonic saline?

head trauma

Which condition is a medical emergency in which the body temperature may exceed 104°F (40°C)?

heat stroke

The nurse is teaching a group of school-aged children about different insect bites and stings. The nurse teaches the students that which arthropod has a stinger that becomes lodged in the victim?

honey bee

Which electrolyte abnormality does the nurse anticipate during the resuscitation phase in a patient with burn injury?

hyperkalemia

The nurse finds that the patient with burns has developed a low-grade fever. Which patient condition could be the reason for developing a low-grade fever?

hypermetabolic condition

A patient in the allergy clinic develops all of these clinical manifestations after receiving an intradermal injection of an allergen. Which symptom requires the most immediate action by the nurse?

stridor

Which type of burn injury has a moist, pink wound bed and blanches when gentle pressure is applied?

superficial partial-thickness

A patient recovering from an open reduction of the femur suddenly feels lightheaded, with increased anxiety and agitation. Which key vital sign differentiates a pulmonary embolism from early sepsis?

temperature

In which case can the nurse clean and prepare the body of a deceased patient for viewing by the family.

terminal illness

Which field encompasses the continuum of care from injury prevention and prehospital services to acute care, rehabilitation, and, ultimately, community reintegration?

trauma nursing

Who is said to be the gatekeeper in the emergency care system?

triage nurse

Which physiological action of carbon-monoxide manifests as "cherry red" coloration of skin in a patient with carbon-monoxide poisoning?

vasodilating effect

What passive external rewarming method is typically applied to treat mild hypothermia?

warm clothing

A nurse is caring for patients who were brought to the emergency department following an earthquake. Which tag will the nurse use for patients who have an open fracture with large wound?

yellow tag

The nurse is caring for a patient with burns. Which question does the nurse ask the patient and family to assess their coping strategies?

"How have you handled similar situations before?"

The nurse is caring for a patient with burns to the face. Which statement by the patient requires further evaluation by the nurse?

"I don't know what I will do when people stare at me."

At what core body temperature does the nurse stop cooling interventions for a patient with heat stroke?

102° F (39° C)

Which assessment scale should a nurse use to record the responsiveness and consciousness of a victim who had been violently raped?

AVPU scale

A patient admitted to the emergency department following a snakebite tells the nurse that he did not see the snake. How does the nurse identify that the patient may have been bitten by a coral snake?

Absence of clear fang marks.

An escharotomy must be performed in a patient admitted for burns. Which statement accurately describes this procedure?

An incision is made through the burn eschar.

The nurse is directing the care of a newly admitted patient who is severely hypothermic, but breathing on their own. What does the nurse advise the rapid assessment team to do first?

Apply electrocardiographic (ECG) monitor leads to monitor cardiac activity.

What first aid measure is appropriate for a brown recluse spider bite?

Apply ice packs.

What is the first intervention to be performed for a patient bitten by a black widow spider?

Apply ice packs.

Which nursing action would cause an "after-drop" in a patient with moderate hypothermia?

Applying a heating blanket.

A patient presents with severe angioedema of the lips, face, and tongue. Which medication is most likely to have caused this hypersensitivity reaction?

Benanzepril (Lotensin)

Which body systems are most profoundly affected by lightning injuries?

Cardiopulmonary and central nervous systems.

Which physiologic effect may indicate mild carbon monoxide poisoning?

Decreased visual acuity.

A patient with heat stroke has arrived at the hospital for medical intervention. The patient develops chills during the cooling process. What is the drug of choice to prevent chills in this patient?

Diazepam (Valium)

Why do blisters not form in deep partial-thickness wounds?

Due to the thick dead tissue layer which sticks to the underlying dermis.

A patient with a burn injury is receiving treatment in the hospital. There is redness of the skin with moderate edema and pain. The symptoms do not decrease even after proper treatment for 6 weeks. Which type of burn injury uses grafting as a part of the treatment plan to reduce the healing time of the injury?

Full-thickness wounds, deep full-thickness wounds, and deep partial-thickness wounds.

A patient is diagnosed with a type I hypersensitivity. Which antibody level increases during this type of allergy?

IgE

To position a patient's burned upper extremities appropriately, how does the nurse position the patient's elbow?

In a neutral position.

A golfer who is caught in a thunderstorm is struck by lightning. A fellow golfer, who is a nurse, runs to the victim's aid. What does the nurse do initially?

Palpate to check for the presence of a pulse.

A patient with a cardiopulmonary disorder is admitted into the emergency department (ED). Which action can a nurse who is certified in basic life support (BLS) training perform?

Perform cardiopulmonary resuscitation.

What is an important clinical indication of high altitude pulmonary edema (HAPE)?

Persistent dry cough.

Which protective gear is most important when caring for patients with tuberculosis or other airborne pathogens?

Powered air-purifying respirator (PAPR)

A patient with heat stroke is admitted to the emergency department with a body temperature of 106° F. While using the rapid cooling method to reduce the body temperature in the patient, the nurse notices that the patient is shivering. What action should the nurse take?

Provide a parenteral benzodiazepine.

How does the nurse ensure a patent airway for a patient with significantly impaired consciousness?

Provide an endotracheal tube and mechanical ventilation.

What is the first collaborative intervention that should be performed on a patient with heat stroke?

Provide high-concentration oxygen therapy.

What does the nurse understand about scorpion stings?

Scorpion stings have neurotoxic effects.

Which interventions may worsen the outcome in a patient who has suffered from a pit viper's bite?

Sucking the wound, applying ice to the wound, and using tourniquet at the wound.

What is the main characteristic of fourth-degree frostbite?

The affected part is numb, cold, and bloodless.

Which health care personnel within the institution's emergency response plan decides the number, acuity, and resource needs of patients in a mass casualty event or disaster?

The medical command physician.

When caring for a patient with hypothermia, why does the nurse administer intravenous (IV) drugs only after the core temperature is above 86° F (30° C)?

There is a potential for drug toxicity.

In the military form of triage, why are "expectant" patients attended to after others receive care?

They are highly critical with little chance of survival.

When is grafting required in the treatment of burn injuries?

When there is absence of skin cells.

Which arthropod bite is associated with a wheal-and-flare skin reaction?

bee

What information does the nurse use on the identification band of a patient brought to the triage area of the hospital?

disaster number

In a mass casualty incident, a patient is given a black tag with the "expectant" category during disaster triage. How would this patient be classified in civilian triage?

emergent

What type of burn injury may require the nurse to remove smoldering clothing and metal objects that are close to the patient's body?

flame burns

Which finding would be associated with a scorpion sting?

hyperactivity

Which category of burn injury reflects deep partial-thickness burns affecting 20% of the total body surface area (TBSA)?

moderate burn

The nurse is assessing a patient who underwent a rewarming procedure following frostbite. What primary observation is indicative of compartment syndrome?

painful tingling

Which may be a typical clinical feature of a black widow spider bite?

papule

What is the clinical sign of a bite from a pit viper?

seizure

Which topical agent is typically used on a burn wound for rapid debridement?

Collagenase

What is the nurse's first step when caring for any patient in an emergency?

Establishing a patent airway.

Which intervention can lead to complications in a patient who is suspected of having heat exhaustion?

Giving salt tablets.

A 70-year-old male patient who underwent an open reduction internal fixation (ORIF) surgery experiences a seizure after 24 hours. Which drug can cause seizures related to its toxic metabolites?

Meperidine

The nurse is caring for a conscious patient with a fractured elbow following a fall at home. What does the nurse do to ensure a patent airway for the patient?

Clear the airway of secretion or debris.

Which types of burn injuries require grafting as a part of treatment plan?

Full-thickness wounds, and deep full-thickness wounds.

A patient with cardiovascular problems was admitted to the emergency department (ED). Which nursing action is appropriate?

Initiating drug therapy.

What training does an Advanced Cardiac Life Support (ACLS) certification offer?

Invasive airway management skills and electrical therapies.

What is the feature of the Emergency Severity Index (ESI) triage system?

It categorizes patients into five groups.

How does a hospital in the United States test its disaster preparedness according to mandates set by The Joint Commission in 2017?

It involves community-wide resources in at least two drills per year.

The nurse in the triage area of an emergency unit is preparing identification tags for patients. What information is used to identify a patient brought in from a disaster site?

a digital photo

Which arthropod bite is associated with "red, white, and blue sign"?

brown recluse spider

The nurse is caring for a patient with a poison ivy skin rash. What type of hypersensitive reaction is the patient experiencing?

delayed reaction

The nurse is teaching preventive measures to prevent drowning incidents. Which statement made by the patient indicates ineffective learning?

"I will make sure I swim alone."

What is the most appropriate response by the nurse when a patient's family asks about the time needed for the patient's deep partial-thickness burns to heal?

"It may take 2 to 6 weeks for the wound to heal."

Which medical assistant statement regarding tiers of a triage system indicates a need for further teaching by the nurse?

"Patients in the emergent tier need quick treatment, but they are not in a life-threatening situation."

Which statement made by the student nurse indicates a need for further teaching about the important factors of standard wound dressing and the number of gauze layers to be used?

"The number of gauze layers depends on the cause of the injury."

The nursing instructor asks the student nurse to explain a type IV hypersensitivity reaction. Which statement by the student best describes type IV hypersensitivity?

"The reaction of sensitized T-cells with antigen and release of lymphokines activate macrophages and induce inflammation."

After losing her home to a hurricane several years ago, the patient says, "I get very nervous during a thunderstorm and want to hide under the bed." What is the nurse's best response?

"What do you do when you feel this way?"

How many hours after death can a dead or decapitated snake inflict venom?

1

A patient planning an expedition to the mountains is prescribed acetazolamide (Diamox). When must the patient take the first dose of this medication so that it is effective?

24 hours before ascent.

Patients who have been admitted to the emergency department (ED) are assessed by the ED triage nurse for an oncoming shift. Which patient is most appropriately assigned to an LPN/LVN?

24-year-old with heat exhaustion, receiving an IV of normal saline, with normal chemistry laboratory results and a temperature of 37° C

A patient spilled a large open frying pan of hot cooking grease and received burns to the entire anterior chest and abdomen, the entire anterior section of the left arm, and the anterior portion of the left leg from the groin to the knee. At what percentage of total body surface area does the nurse calculate the injury using the rule of nines?

25% to 27%

Which score on the Glasgow Coma Scale (GCS) would the nurse give to an unresponsive patient with no verbal or motor response?

3

A patient sustained deep partial-thickness burns to the anterior and posterior surface of bilateral lower extremities. Using the rule of nines, which percentage of body surface area does the nurse estimate the patient's burn to be?

36%

Accredited health care institutions are required to take an "all hazards approach" to disaster planning. Which disaster drill uses this approach?

A hospital in North Carolina plans a response to a hurricane.

Which patient should the nurse refer to a social worker before discharge from the emergency department?

A patient who was treated for bruises and cuts after being attacked by a spouse.

Four patients who sustained injuries during mob violence are admitted to the emergency department. Which will require an endotracheal tube and mechanical ventilation for breathing?

A patient with a Glasgow Coma Scale (GCS) score of 7.

Which patient condition would necessitate the nurse to wear latex-free gloves when providing care?

A patient with spina bifida.

Which member may be designated as the team leader of a critical incident stress debriefing (CISD) team during a mass casualty incident?

A person who has a background in a mental health or behavioral health field.

Which victim of intimate partner violence requires an endotracheal tube?

A rape victim who has been strangled and is unconscious.

A woman who is breastfeeding is diagnosed with rheumatoid arthritis. She does not want to stop breastfeeding. Which medication is safest for her to take?

Adalibumab (Humira)

Which systemic signs of infection can be seen in the patient with burn injuries?

Altered level of consciousness.

The nurse is caring for a patient experiencing an anaphylactic reaction to an intravenous (IV) infusion. Which action would the nurse take immediately after stopping the infusion?

Apply oxygen using a high-flow non-rebreather mask.

The nurse is caring for a patient who presents to the hospital with profuse sweating and a temperature of 104° F (40° C). Assessment findings include a patent airway, tachycardia, acute confusion, and anxiety. What is the priority intervention?

Applying ice packs.

What are the duties of the nurse case manager in the emergency department (ED)?

Arrange appropriate referrals for the patient.

What is the best nursing intervention when talking with the family members of a patient who died suddenly in the emergency room?

Ask the family members if they would like to have a clergy member present.

How can the nurse ensure that an older patient, admitted to the emergency department (ED) after a fall, does not return to the ED with a similar incident?

Ask the patient to provide adequate lighting at home, and to avoid throw rugs.

What practice does a nurse follow to preserve evidence when treating a rape victim?

Asking the patient not to take a bath until after a physical exam.

What is the priority nursing intervention when caring for a patient who is a victim of interpersonal violence who is breathing and talking?

Assessing any threats to the patient's life with the standard ABCDE mnemonic.

How long must a patient with burns wear pressure garments after undergoing biological dressing?

At least 23 hours per day.

The nurse is caring for a patient who is on mechanical ventilation because of severe burns. Which medication is appropriate for this patient?

Atracurium

Which method is used in assessing the measurement of burns in a patient whose weight and height are in proportion?

Body area is divided into multiples of 9%.

A disoriented patient involved in a motor vehicle crash is admitted to the emergency department (ED). What action must the nurse take first when assessing this patient?

Check for a medical alert necklace or bracelet.

The triage nurse is assessing the acuity level of patients rushed to the emergency department. What sign or symptom reported by the patient prompts the nurse to classify the patient as emergent?

Chest pain with diaphoresis.

What is the cause of classic heat stroke?

Chronic exposure to a hot, humid environment.

The nurse is providing reminders to a Red Cross class about safety procedures to prevent drowning or submersion. In which situation does this present the greatest risk?

College students going to a fraternity party at a boat house.

Assessment findings reveal that a patient admitted to the hospital has a contact type I hypersensitivity to latex. Which preventive nursing intervention is best in planning care for this patient?

Communicate the need for avoidance therapy to the health care team.

A patient receiving antibiotic therapy for 2 months reports high fever, arthralgia, and rashes. Diagnostic reports of the patient indicate polyarthritis and enlarged lymph nodes. What is the best explanation for these clinical manifestations?

Deposition of immune complexes in blood vessel walls.

What nursing intervention is appropriate for a patient who is the victim of domestic violence and is afraid to return to his or her partner?

Develop a safety plan that will help the victim escape the violent relationship.

A patient with a history of patent airways who is stung by a scorpion is brought to the hospital. Following drug therapy, the patient has shortness of breath and air hunger. Which medication is the reason for these symptoms?

Diazepam (Valium)

What are the responsibilities of the emergency medicine physician?

Direct overall care in the department.

Which is the priority nursing intervention for maintaining mobility in a patient with burns to the head and neck?

Do not allow the use of pillows under the head or neck.

The forensic nurse examiner is assessing a patient who is a victim of intimate partner violence (IPV). What interventions does the nurse perform for this patient?

Document injuries and collect photographic evidence.

Which of the following findings would indicate a major burn?

Electrical injury, inhalation injury, and injury of eyes, ears, face.

A patient who experienced an anaphylactic reaction is hypotensive and has a rapid, weak, and irregular pulse. What is the priority nursing intervention?

Elevate the legs and feet.

When caring for a patient with septic shock who has disseminated intravascular coagulation (DIC), the nurse anticipates which finding?

Elevated d-dimer levels.

What does the nurse teach the community about human waste management if toilets do not flush?

Emphasize the importance of using a hand sanitizer.

The registered nurse teaches a student nurse about ways to reduce the risk of falls in a geriatric patient. The registered nurse should intervene when the student nurse performs what action when caring for an older adult with orthostatic hypotension?

Encourages the patient to ambulate.

A trauma patient has been brought in to the emergency department after sustaining severe injuries during a violent rape. What is the priority nursing intervention?

Establishing a patent airway by positioning, suctioning, and giving oxygen as required.

What nursing assessments are necessary prior to the discharge of an older adult patient from the emergency department (ED) to his or her home?

Evaluate for the risk for falls, perform a functional assessment, and screen the patient for depression.

A patient is admitted with an electrical burn injury. Which nursing intervention is a priority for this patient?

Evaluate the urine volume and color.

The nurse is reviewing the orders for a patient admitted with 25% body surface area burns. Which order does the nurse clarify with the health care provider?

Hold omeprazole.

A patient who was successfully fluid resuscitated following a burn injury begins diuresis 3 days after admission. Once diuresis begins, which complications would the nurse monitor for?

Hypotension, hyponatremia, and metabolic acidosis.

A patient is scheduled to undergo desensitization therapy during which a very dilute solution of allergen (1:100,000) is injected. This process induces the formation of antibodies against the allergen. Which antibody is produced during this process?

IgG

The nurse is caring for a patient transported to the emergency room after sustaining burns to the arms from a fire. The nurse is unable to secure an intravenous access. What is the most appropriate nursing intervention?

Implementing an intraosseous normal saline infusion.

Which alteration observed in a patient rescued from a fire indicates pulmonary injury?

Inability to swallow fluids.

What causes polycythemia in some people who remain in a high-altitude environment?

Increase in hemoglobin.

A patient with burns who was admitted to the hospital 3 days ago develops paralytic ileus. Which pathophysiological phenomenon may be the cause of the patient's condition?

Increased secretion of epinephrine.

A 2-year-old child falls into the community swimming pool and does not resurface. A lifeguard dives in to save the child. What does the lifeguard do first after the rescue?

Initiates rescue breathing on the child.

Which statement of the student nurse indicates inadequate understanding about precautionary measures to take while treating a patient with a history of allergic reaction during an emergency situation?

Intravenous fluid administration is avoided in the patient.

An emergency room nurse is working when she hears about a 60-car pileup on the expressway. The nurse knows that a military form of triage may be instituted. What is the rationale for using a military form of triage?

It is based on doing the greatest good for the greatest number of people.

What is the desired outcome of a disease management program for patients with chronic conditions?

Keep the patient out of the hospital for as long as possible.

The nurse is assessing a patient with severe pet-induced allergy. The patient has two pet dogs. What action is the most beneficial for this patient?

Keep the pets out of the house.

A patient who underwent treatment for severe burns complains to the primary health care provider of respiratory discomfort. Which physiological change may be causing this discomfort?

Leakage of capillaries.

The school nurse is educating children about preventing injury from lightning strikes. What does the nurse teach them?

Leave water when there is thunder.

The health care provider has ordered a blood transfusion for a female patient with serious electrical burns. What hematocrit level reflects the need for transfusion when symptoms of hypoxia are present?

Less than 20-25%.

While at a soccer match, a player drops to the ground with heat exhaustion and a diminished level of consciousness. What does the team nurse do first?

Move the player to the shade.

Which organization offers training in disaster management to all levels of health care professionals?

National Disaster Life Support Foundation (NDLSF)

A mountain climber developed fatigue and weakness on the second day of the climb. On the fourth day, the client then developed a dry cough, cyanosis of the lips and nail beds, a heart rate of 90 beats/min, and a respiratory rate of 30 breaths/min. When the patient arrives at the hospital, which medication should the nurse anticipate being prescribed by the primary health care provider?

Nifedipine (Procardia)

A patient presents with fang marks from a rattlesnake but no local systemic reactions. Which envenomation grade does the nurse assign this patient?

None

Which method must be employed during hydrotherapy for the debridement of a wound in the patient with acid burns?

Nonviable tissue must be removed by forceps.

Which patient does the triage nurse treat with highest priority?

Patient with a stab wound to the stomach.

The nurse is caring for a patient with chronic renal impairment who presents with acute confusion, delirium, and bizarre thinking. Which intervention is appropriate to include in the patient's plan of care?

Placing a clock and calendar at the patient's bedside.

What signs/symptoms classify the severity of a pit viper bite as "moderate?"

Presence of swelling beyond the site of bite, presence of nausea and hypotension.

Which is the emergency department nurse's priority action when caring for a patient with head, neck, and facial trauma resulting from domestic violence that has already been established a patent airway?

Protecting the cervical spine in positioning the patient.

A patient who has been in a car accident is unconscious and is admitted to the emergency department (ED). What is the priority nursing intervention after an airway has been established?

Provide special identification to the patient.

What is the role of a forensic nurse examiner?

Recognize evidence of physical abuse.

Which physiologic outcome describes the goal of topical sulfadiazine in the care of a patient with a burn injury?

Reduction of bacterial growth in the wound and prevention of sepsis.

What must the nurse anticipate from a patient in the emergency department (ED) who is a Jehovah's Witness?

Refusal of blood transfusions.

A patient recently admitted to the hospital is to receive an antibiotic intravenously for the first time for a urinary tract infection. Before checking the five rights prior to administration, what is the nurse's first action?

Review the clinical records and ask the patient about any known allergies.

Which method of communication system would be beneficial when the nurse communicates the patient's status to the nurse working the next shift?

SBAR (situation, background, assessment, response)

A patient with heat stroke arrives at the hospital, undergoes treatment, and is stabilized. What parameters are assessed to prevent further complications?

Serum sodium, serum bilirubin, and serum creatinine.

The nurse is assessing the wound of a patient who was burned while burning leaves in the yard. Which assessment finding of the burned areas on the patient's feet, legs, and hands suggests a deep partial-thickness injury?

The area is red and dry and blanches slowly when firm pressure is applied.

A patient is brought to the emergency department following a painful bite. A clinical test reveals myoglobinuria. What does the health care provider conclude?

The bite is from a coral snake.

While assessing a trauma patient, the nurse is unable to obtain the radial pulse. What does the nurse infer from this finding?

The blood pressure is less than 80 mm Hg systolic.

Following a mass casualty event, a nurse who treated victims is referred to a critical incidence stress debriefing team, where a co-leader begins addressing the emotional needs of the health care team. Which statement is true about the co-leader?

The co-leader is a nurse.

Who is responsible for determining the number of staff needed to care for the anticipated victims of a mass casualty situation?

The medical command physician.

Which description of minor burn wound care defines open technique?

The medication is applied on the burn without the dressing.

Which statement is accurate regarding the management of a family in a crisis involving death?

The nurse should provide concrete terms such as "the patient died" while communicating with family.

Which team member of the emergency department, other than the hospital incident commander, plays a leadership role in emergency situations?

The nursing supervisor.

A nurse is administering dopamine to a patient who is in shock. After the therapy, the patient's mean arterial pressure is 22 mm Hg from the baseline value. Which intervention should the nurse perform to prevent severe vasoconstriction and tissue necrosis?

The patient's IV site should be assessed every 30 minutes.

Which rationale best supports the intravenous (IV) administration of fentanyl to a burn patient?

The risk of overdose from rapid absorption of drug from the interstitial space is reduced.

During a mass casualty, staff roles are defined. If the triage officer is incapacitated, who is the best choice for replacement?

The triage nurse.

After a bomb blast, the injured patients were brought to the emergency department. Which health care team member will be responsible to assign order of priority to patients for providing care?

The triage officer.

Which instruction would the nurse give to a patient who has had an allergic reaction to environmental airborne allergens?

Thoroughly clean cloth drapes, carpeting, and upholstered furniture.

A patient arrives in the emergency department with burns as a result of spilling boiling water while cooking. Which assessment finding of the burned areas on the tops of both hands and chest does the nurse use as a basis to document a probable full-thickness injury?

Thrombosed blood vessels are visible beneath the skin surface.

The patient is a burn victim who is noted to have increasing edema and decreased urine output as a result of the inflammatory compensation response. What does the nurse do first?

Titrate fluid replacement.

A rape victim's report includes interventions taken, family history, assessment, and diagnostic findings. Which vital piece of information should have also been included considering the fact that the victim has been raped?

Transmission-based precautions taken.

Which type of hypersensitivity may be associated with rhinorrhea?

Type I hypersensitivity.

A patient who is admitted to the emergency department (ED) is assigned an emergency severity index (ESI) level 4. Which nursing action is appropriate?

Understand that the patient will tolerate waiting for a brief period before receiving treatment.

What rewarming technique does the nurse use for partial-thickness to full-thickness frostbite injury?

Use a water bath set to 104° F to 108° F.

What methods can be used to prevent hypothermia in a patient?

Use heat lamps and warming blankets.

An older patient admitted to the emergency department is on a stretcher awaiting bed availability. What intervention does the nurse perform to protect the skin integrity of this patient?

Use mobility techniques that reduce shearing force when moving the patient.

A nurse is caring for a non-English-speaking adult patient who is the victim of domestic abuse and will not speak. What is the appropriate nursing action to take with this patient?

Use telephone language lines and arrange for interpreters.

Which arthropod bite is associated with latrodectism?

black widow spider

A patient's burn injury was caused by an exposure to pool chemicals. Which laboratory result does the nurse monitor closely for possible signs of organ injury?

liver function tests

A hiker begins to feel ill within 48 hours after arriving at a resort in Colorado. Symptoms include poor activity tolerance, tachycardia, tachypnea, and a dry cough. Which treatment provides the most effective relief for this hiker?

lower altitude

A patient sustains severe burn injuries from contact with a hot liquid. Which type of burn injury would the nurse anticipate?

moist heat injury

Which type of burns result in a reduction in the activation of vitamin D when exposed to sunlight?

partial-thickness burns

Which rewarming method is used to treat severe hypothermia?

performing hemodialysis

A patient has developed a type II hypersensitivity. Which mechanism is involved in this type of allergic reaction?

phagocytosis of self cells

Which team member is authorized to decide where a patient will be sent after discharge?

physician

Which blood product is mostly preferred in patients with septic shock?

platelets

Which essential item is added to a personal-readiness supplies "go bag?"

potable water

Which member of the emergency care team reports a patient's mechanism of injury (MOI)?

prehospital care provider

What may happen if a black widow spider bites a pregnant patient?

premature delivery

What condition related to prolonged immobility in the emergency department (ED) does the nurse seek to prevent in a patient?

pressure ulcers

Which condition can be prevented by maintaining quite environment for better sleep?

psychosis

Which clinical sign demonstrates the neurotoxic effects of both a coral snakebite and a black widow spider bite?

ptosis

Which type of hypersensitivity is anaphylaxis?

rapid hypersensitivity

The nurse should use which color tags for patients who need priority emergency treatment during a disaster?

red tag

What is the role of decongestants in the treatment of a type I hypersensitivity?

reduce edema

A mechanical ventilator in the emergency department (ED) has stopped functioning properly. Who should the nurse contact to troubleshoot the problem with the mechanical ventilator?

respiratory therapist

Which clinical manifestation is indicative of wound healing for a patient in the acute phase of burn injury?

scar tissue formation

Which is considered a late complication of burn injuries?

scarring

A patient presents with fever, arthralgia, rash, malaise, lymphadenopathy, nephritis, and polyarthritis. The patient has been admitted to the hospital several times in the past month and was last discharged one week ago. What does the nurse suspect this patient is experiencing?

serum sickness

Where does the nurse know "Africanized" or "killer" bees are found in the United States?

southwest

The camp nurse is providing snakebite prevention tips. Which statement by a camper indicates a need for additional education?

"A dead snake is a safe snake."

As a direct result of overcrowding in emergency department (ED) environments, for whom must the emergency department nurse expect to provide care?

"Boarding" or holding inpatient patients.

A patient with a burn injury due to a house fire is admitted to the burn unit. The patient's family asks the nurse why the patient received a tetanus toxoid injection on admission. What is the nurse's best response to the patient's family member?

"Burn wound conditions promote the growth of Clostridium tetani."

The nurse is caring for a patient who has renal failure and who has received a prescription for propranolol therapy. Which instruction should the nurse give to the patient?

"Do not sit up or stand up too fast."

The nurse is educating a patient on safety regarding lightning strikes. Which patient statement requires further teaching?

"I should use a computer to warn my friends about lightning."

The nurse is working with a group of patients after an emergency event in the community regarding the potential for post-traumatic stress disorder (PTSD). Which statement of a patient indicates a need for further instruction?

"I will avoid talking about this event with others who also experienced it."

Which statement made by a nursing student regarding vulnerable populations is accurate?

"They have unique health care problems."

The nurse is coordinating care for a patient who was bitten by a black widow spider. Which nursing action is assigned to the LPN/LVN?

Administering tetanus toxoid vaccine intramuscularly.

A patient who is a Jehovah's Witness is admitted into the emergency department (ED) suffering from blood loss. Which nursing action is appropriate?

Administering volume expanders.

A patient with 32% total body surface area burns has a hematocrit of 54% 10 hours after a burn injury and 8 hours after fluid resuscitation was started. Which action would the nurse take?

Assess the patient's blood pressure and urine output.

The provider is planning to discharge a patient home. The nurse suspects domestic violence as the cause of injury, although the patient denies this. What is the best course of action for the nurse to take?

Consult with Social Services.

A patient brought to the trauma center dies following a suicide attempt. What action does the nurse take to prepare the body for family viewing?

Cover the body and only expose the face.

What is the final component of the primary survey in the care of a patient who is admitted to the health care facility in critical condition after a sexual assault?

Cutting away the clothing with scissors to preserve any evidence.

The nurse is preparing to administer an intravenous (IV) solution to a critically ill patient who is in a state of shock. The nurse finds it difficult to access the patient's veins. Which nursing action will benefit the patient?

Establish intraosseous vascular access.

Which clinical manifestation of the patient brought to the hospital following a snake bite would indicate that the patient is suffering from a pit viper's bite?

Metallic taste in mouth.

The nurse is caring for a patient whose medical record indicates moderate grade pit viper envenomation. What can the nurse expect to find in this patient?

Nausea and vomiting.

A patient has sustained a burn injury affecting 15% of the total body surface area (TBSA). The entire epidermis is affected, but there is no damage to the eyes, ears, feet, hands, or perineum. Which description accurately defines the severity of the burns?

Partial-thickness wounds at a moderate level.

The emergency department charge nurse is making patient assignments and delegating care after a mass casualty event. Which of these patients could be delegated to a nursing assistant?

Patient who is unconscious with massive aortic bleeding from the chest.

What is the most essential intervention performed by the nurse to prevent complications when administering mafenide acetate topically for a patient with burn wounds?

Premedicating for pain before application of the drug.

The nurse enters a patient room in the emergency department and finds the patient is hostile, screaming, and making threats. What should be the nurse's first intervention?

Press the panic button in the room.

Which factor differentiates full-thickness wounds from deep full-thickness wounds?

Severity of edema.

While assessing a patient, the nurse notes that the patient's vagina and buccal and nasal mucous membranes are dry. The laboratory reports indicate the presence of elevated levels of IgM rheumatoid factor. The nurse suspects what syndrome?

Sjögren's Syndrome

A patient is exhibiting shivering, slurred speech, and clumsiness. The nurse suspects the patient has hypothermia. What steps should the nurse take according to the American Heart Association (AHA)?

Space administration of medications at longer intervals, keep in mind that drug toxicity may occur when giving medication, and initiate cardiopulmonary resuscitation (CPR) if circulation is impaired.

A patient has developed a type IV hypersensitivity reaction. Which immune cells or components are involved in this type of reaction?

T-cells

A patient is getting ready to go on vacation in the Colorado mountains. What education does the nurse provide to the patient about the use of acetazolamide?

Take the drug to acclimatize faster to high altitudes.

A patient comes to the emergency department covered with coagulated blood and a white powder. The patient is hysterical and fears that it is anthrax. What does the nurse do first?

Takes the patient to the decontamination room.

A 3-year-old child was injured when placed in extremely hot bath water. The water was more than 50 °C. The child's skin was yellow at the injury site with severe edema and pain. What should the nurse infer?

The child has full-thickness wounds.

In a mass casualty event, who has the role of facilitating patient movement through the system?

The hospital incident commander.

Which dietary guideline must be followed for a patient with a large burn area?

The patient who can eat solid foods should be encouraged to ingest as many calories as possible.

Which nursing student statement regarding the role of the psychiatric crisis nurse team indicates a need for further teaching?

The team collects forensic evidence.

Which action is taken for critically ill or injured patients in the military form of the triage process?

They are triaged into the expectant category.

What is the major concern when "green-tagged" patients evacuate themselves and go to a hospital for treatment on their own?

They may unknowingly carry contaminants from the disaster site to the hospital.

The nurse is assigned to a patient who has just arrived in the emergency department (ED). The patient is diagnosed with tuberculosis (TB). What action should the nurse take?

Wear a powder air-purifying respirator (PAPR).

When managing the care of a patient with a major full-thickness burn, when would the nurse begin to see fluid shifts resulting in edema?

Within 12 hours.

What is the foundation of an emergency nurse's skill base?

assessment

Which type of grafting method is preferred in regards to reducing the risk of infection?

autograft

A patient has developed a type II hypersensitivity reaction. Which condition is associated with this type of hypersensitivity?

autoimmune hemolytic anemia

A patient with burns has pulmonary edema. Which drug will likely be administered to the patient?

beta blockers

The nurse is caring for a young patient who was bitten by a spider after playing in a pile of rocks outside. The child described the spider as having a red spot on its back. Which kind of spider most likely bit the child?

black widow

Which is a clinical sign of severe hypothermia?

bradycardia

Which arthropod bite results in a dark and necrotic wound (eschar)?

brown recluse spider

A patient is admitted to the emergency department after prolonged exposure to extreme cold. Both feet are numb, cold, and nonblanchable. The skin over the feet is red and blue. Both feet are swollen. The nurse recognizes that the patient is experiencing what complication?

compartment syndrome

What type of hypersensitivity occurs when a patient receives the wrong blood type during a transfusion, leading to a hemolytic transfusion reaction?

cytotoxic reaction

What is a symptom of moderate hypothermia?

decreased clotting

Which type of hypersensitivity is a cell-mediated immunity with T-lymphocyte as the reactive cell?

delayed hypersensitivity

What is the characteristic feature of minimal envenomation?

local swelling

The nurse is assisting with triage in the field after a large airplane crash. She is assessing a victim who has an open tibial fracture and a large laceration to his head, but is otherwise stable. What is the appropriate color tag for the victim?

yellow tag

Which level of trauma center is capable of providing total collaborative care?

Level I

Which class of drugs would be administered to a patient experiencing a constant, dull, and burning phantom limb pain (PLP)?

beta blockers

Which type of burn injury is caused by an open flame?

dry heat

What is the initial bolus dose of morphine through patient-controlled analgesia (PCA)?

5 to 10 mg of morphine

A 70-year-old patient has an infected tibial fracture. What is the estimated healing time?

90 days

The nurse is caring for a patient with orthostatic hypotension. What is the correct intervention for this patient?

Assist the patient to move slowly from a supine to an upright position.

Which environmental injury can cause elevations in creatinine kinase (CK) levels from muscle breakdown and myoglobinuria?

Coral snake bite.

An RN is designated as a triage officer in a hospital. What action does the nurse take as triage officer?

Evaluates each patient to determine priorities for treatment.

What is a manifestation of post-traumatic stress disorder (PTSD)?

Feeling "numb" 2 weeks or more after a disaster.

What happens when salt water is aspirated into the lungs of a drowning person?

Fluid from vascular spaces moves into the alveoli.

An older patient injured in an accidental fire shows burn injuries on more than 10% of the total body surface area (TBSA). The skin has turned a black color with severe edema and eschar that is hard and inelastic. What should the nurse infer about the degree of burns?

Full-thickness wounds at a major level.

A patient sustained chemical burns and is admitted to the emergency room. The patient shows black coloring to the skin with severe edema and no damage to the eyes or face. Eight percent of the total body surface area (TBSA) is injured. What should the nurse infer about the degree of burn?

Full-thickness wounds at a moderate level.

What is the characteristic of a burn caused by brief contact with a hot plate?

Heals in about 2 weeks.

After assessing a patient with high altitude illness, the nurse anticipates that a phosphodiesterase inhibitor will be prescribed to treat what condition?

High altitude pulmonary edema.

A school bus overturns in a small, rural community that is served by a critical access hospital and one volunteer fire department. How is the incident of the overturned school bus categorized?

May be a mass casualty.

A new nurse is learning about the nurse's role in a disaster as part of her orientation. Which statement about the nurse's role in a mass casualty incident is accurate?

Nurses may have to assume roles in making decisions for the most appropriate treatment of casualties.

The triage nurse is a member of the medical relief team who has been delegated to a hurricane-hit area. What supplies does the nurse take along in the "go bag," assuming they have already packed potable water?

Personal ID with emergency contacts in a waterproof bag.

The nurse is giving discharge instructions to a patient who is Mexican-American. Which nursing action is appropriate?

Printing the instructions in Spanish.

The home nurse is caring for an older patient with mild hypothermia at home. What first aid care does the nurse provide to the patient?

Provide warm high-carbohydrate liquids.

While monitoring a patient with a burn injury the nurse observes that the cardiac output is 3.5 liters/minute. Which nursing intervention is done to prevent further complications?

Providing fluid replacement for the patient.

The nurse is caring for a patient who was stung by a honeybee, and is sitting up and talking. What will the nurse do first?

Pull out the stinger and sac left in the patient.

A patient calls the ER and tells you that he cut his finger off and is holding it in his hand. You tell him to...?

Put it in a sealed bag with one part ice and three parts water and come to the ER immediately.

Which action by the forensic nurse examiner is appropriate when a victim refuses to answer questions regarding domestic violence?

Respect the victim's response.

Which team member is responsible for "standing down" or deactivating the emergency response plan?

The hospital incident commander.

The nurse is caring for a patient who came to the hospital after being stung by a honey bee. The stinger is still in the patient's forearm. There are no objective signs of hypersensitivity related to the bee sting. What first aid measures does the nurse teach the patient to perform, should this event reoccur?

Use tweezers to pull out the stinger, but scraping it out with a credit card is preferred to avoid squeezing it.

While on the school playground, a child is stung by a bee, resulting in redness and swelling. The school nurse is nearby when it happens. What does the nurse do first?

Use tweezers to pull out the stinger, but scraping it out with a credit card is preferred to avoid squeezing it.

How do health care workers identify people of position in the chaotic work environment during an emergency situation?

Using brightly colored vests with large lettering.

How does the nurse determine accurate calorie requirements for a patient with burns?

Using indirect calorimetry.

Which of the following skin grafts are obtained from human cadavers?

allograft

A patient has been admitted to the health care facility after an electrical burn to the lower extremity, exposing the muscles and bone. On diagnosis, infection is found in the lower extremity. What is the most appropriate treatment method for the patient?

amputation

Which is an example of a type I hypersensitivity reaction?

angioedema

A patient has developed serum sickness. What is the most likely cause?

antibiotic therapy

A patient comes into the emergency department (ED) clutching the chest. Which core competency for ED nurses is the first one used in this situation?

assessment

A patient is in the resuscitation phase of burn injury. Which route does the nurse use to administer pain medication to the patient?

intravenous

What would be the first intervention performed by the nurse to prevent airway obstruction for a patient who suffered smoke inhalation injury during a fire accident?

intubation