Quiz 11 Burns and Emergency/Trauma

the nurse is working in the triage area of an ED and the following four clients approach at the triage desk at the same time. list the order in which the nurse will assess these clients. 1. an ambulatory, dazed 25-year-old man with a bandaged head wound 2. an irritable newborn with a fever, petechiae, and nuchal rigidity 3. a 35-year-old jogger with a twisted ankle who has a pedal pulse and no deformity 4. a 50-year-old woman with moderate abdominal pain and occasional vomiting

2, 1, 4, 3 2. an irritable newborn with a fever, petechiae, and nuchal rigidity 1. an ambulatory, dazed 25-year-old man with a bandaged head wound 4. a 50-year-old woman with moderate abdominal pain and occasional vomiting 3. a 35-year-old jogger with a twisted ankle who has a pedal pulse and no deformity

the nurse responds to a call for help from the ED waiting room. an older adult client is lying on the floor. list the order in which the nurse must carry out the following actions. 1. perform the chin lift or jaw thrust maneuver 2. establish unresponsiveness 3. initiate CPR 4. call for help and activate the code team 5. instruct the UAP to get the crash cart

2, 4, 1, 3, 5 2. establish unresponsiveness 4. call for help and activate the code team 1. perform the chin lift or jaw thrust maneuver 3. initiate CPR 5. instruct the UAP to get the crash cart

identify the five most critical elements in performing disaster triage for multiple victims. 1. obtains past medical and surgical histories 2. check airway, breathing, and circulation 3. assess LOC 4. visually inspect for gross deformities, bleeding, and obvious injuries 5. note the color, presence of moisture, and temperature of skin 6. check VS, including pulse and RR

2. check airway, breathing, and circulation 3. assess LOC 4. visually inspect for gross deformities, bleeding, and obvious injuries 5. note the color, presence of moisture, and temperature of skin 6. check VS, including pulse and RR

a nurse is assessing a client with 2nd degree burns. the shaded areas in the illustration indicate the parts of the body where the client sustained burns. calculate the % of the body that was burned using rule of 9s (front of torso and face)...

22.5%

the nurse is caring for a client with frostbite to the feet. place the following interventions in the correct order. 1. apply a loose, sterile, bulky dressing 2. give pain medication 3. remove the client from the cold environment 4. immerse feet in warm water of 105 to 115 degrees 5. monitor for compartment syndrome

3, 2, 4, 1, 5 3. remove the client from the cold environment 2. give pain medication 4. immerse feet in warm water of 105 to 115 degrees 1. apply a loose, sterile, bulky dressing 5. monitor for compartment syndrome

a client involved in a one-car rollover comes in with multiple injuries. list in order of priority the interventions that must be initiated for this client. 1. secure two large-bore IV lines and infuse NS 2. use the chin lift or jaw thrust maneuver to open the airway 3. assess for spontaneous respirations 4. give supplemental O2 via mask 5. obtain full set of VS 6. remove or cut away the client's clothing

3, 2, 4, 1, 5, 6 3. assess for spontaneous respirations 2. use the chin lift or jaw thrust maneuver to open the airway 4. give supplemental O2 via mask 1. secure two large-bore IV lines and infuse NS 5. obtain full set of VS 6. remove or cut away the client's clothing

the nurse is performing a sterile dressing change for a client who infected deep partial thickness burns of the chest and abdomen. list the steps in order in which each should be accomplished. a. apply sliver sulfadiazine ointment b. obtain specimens for aerobic and anaerobic wound cultures c. administer morphine sulfate 10mg IV d. debride the wound of eschar using gauze sponges e. cover the wound with a sterile gauze dressing

3, 4, 2, 1, 5

Emergency and ambulatory care nurses are among the first health care workers to encounter victims of a bioterrorist attack. List in order of priority the actions that should be taken by ED staff in the event of a biochemical incident. 1. Report to the public health department or CDC per protocol. 2. Decontaminate the affected individuals in a separate area. 3. Protect the environment for the safety of personnel and nonaffected clients. 4. Don personal protective equipment. 5. Perform triage according to protocol

3, 4, 2, 5, 1 3. Protect the environment for the safety of personnel and nonaffected clients. 4. Don personal protective equipment. 2. Decontaminate the affected individuals in a separate area. 5. Perform triage according to protocol 1. Report to the public health department or CDC per protocol.

the nurse is working in a small rural community hospital. there is a fire in a local church, and six injured clients have arrived at the hospital. many others are expected to arrive soon, and other hospitals are 5 hrs away. using disaster triage principles, place the following six clients in the order in which they should receive medical attention. 1. 52-year-old man in full cardiac arrest who has been receiving CPR continuously for the past 60 min 2. firefighter who is showing combative behavior and has respiratory stridor 3. 60-year-old woman with full-thickness burns to hands and forearms 4. teenager with crushed leg that is very swollen; he is anxious and has tachycardia 5. 3-year-old child with respiratory distress and burns over more than 70% of anterior body 6. 12-year-old child with wheezing and very labored respirations unrelieved by an asthma inhaler

6, 2, 4, 3, 5, 1 6. 12-year-old child with wheezing and very labored respirations unrelieved by an asthma inhaler 2. firefighter who is showing combative behavior and has respiratory stridor 4. teenager with crushed leg that is very swollen; he is anxious and has tachycardia 3. 60-year-old woman with full-thickness burns to hands and forearms 5. 3-year-old child with respiratory distress and burns over more than 70% of anterior body 1. 52-year-old man in full cardiac arrest who has been receiving CPR continuously for the past 60 min

A parent brings her 2-year-old child to the emergency department, stating, "She fell and bumped her head and forearm." Which behavior by the child causes the nurse the least concern during the initial triage interview? A. Crying and reaching for the parent as the nurse approaches B. Alert and still, quietly watching as the nurse approaches C. Asleep, limp, with even and unlabored respirations D. Crying loudly and inconsolably since she was brought in

A. Crying and reaching for the parent as the nurse approaches

The nurse is working in a mountain clinic where there is a high incidence of cold-related injuries. Which signs/symptoms indicate the most severe case of frostbite? A. Large fluid-filled blisters with partial-thickness skin necrosis B. Numbness, coldness, and bloodlessness of affected area C. Small blisters that contain dark fluid; skin is cool D. Pain, numbness, and pallor of the affected area

B. Numbness, coldness, and bloodlessness of affected area

The emergency department clinical nurse specialist (CNS) is designing ways to teach newly hired nurses about priority setting in the triage area. Which strategy is the CNS most likely to recommend? A. Assign new nurses to triage during low-volume period B. Pair a new nurse with an experienced nurse in the triage area C. Prepare handouts and tip sheets for the principles of triage D. Have the new nurse observe the triage process for several days

B. Pair a new nurse with an experienced nurse in the triage area

Two teenagers bring their friend to the emergency department because "he was drowning." The patient is unconscious but breathing spontaneously, and he is immediately taken to the resuscitation area. Which question is most important for the nurse to ask the patient's friends in determining the outcomes for this patient? A. "Was this a freshwater or saltwater drowning?" B. "Does he have any medical conditions, such as seizures?" C. "Was the water contaminated with chemicals or algae?" D. "How long was he under the water and not breathing?"

D. "How long was he under the water and not breathing?"

A patient was involved in a high-speed motor vehicle accident. The healthcare provider instructs the nurse to prepare for several urgent procedures because of severe injury and physical compromise. Which procedure does the nurse prepare for first? A. Central line insertion B. Peritoneal lavage C. Chest tube insertion D. Endotracheal intubation

D. Endotracheal intubation

which patient has the most predisposing factors that are associated with heat-related illness? a. obese older male who drinks beer in the afternoon at a baseball game. b. middle-aged female with hypothyroidism who lives in the southern united states. c. malnourished young female with an eating disorder who exercises in the morning. d. young female with iron-deficiency anemia who is in the first trimester of pregnancy.

a. obese older male who drinks beer in the afternoon at a baseball game.

the nurse is assessing a client who has sustained a cat bite to the left hand. the cat's immunizations are up to date. the dat of the client's last tetanus shot is unknown. what is the priority concern? a. treating infection specific to cat bites b. suturing the puncture wounds c. administering tetanus vaccine d. maintaining mobility of finger joints

a. treating infection specific to cat bites

a confused client admits to frequently drinking alcohol. the ED HCP makes a preliminary diagnosis of Wernicke encephalopathy. which medication does the nurse anticipate the HCP will prescribe initially? a. glucagon IV b. naltrexone IM c. thiamine IV d. naloxone IV

c. thiamine IV

to promote effective coping for survivors of a mass casualty event, the nurse uses which principles while interacting with patients in crisis? SATA a. actively listen to feelings and expression of experiences b. reassuring that everything will be okay and things will return to normal c. encouraging exploration about why the event occurred and who caused it d. helping to problem solve e. conveying caring behaviors f. advocating resumption of daily routines ASAP

a. actively listen to feelings and expression of experiences d. helping to problem solve e. conveying caring behaviors

the charge nurse in an ED must assign two staff members to cover the triage area. which team is the most appropriate for this assignment? a. an advanced practice nurse and experienced RN b. an experienced LPN/LVN and an inexperienced RN c. an experienced RN and an inexperienced RN d. an experienced RN and an experienced UAP

a. an advanced practice nurse and experienced RN

which nurse activity would best help the hospital to meet the joint commissions mandate for emergency preparedness? a. assist in panning drills that include patient simulations b. help other nurses make a personal emergency preparedness plan c. attend training classes to learn how to handle hazardous materials d. identify the credible threats to the safety of the community

a. assist in panning drills that include patient simulations

the nurse is caring for a client with multiple injuries sustained during a head-on car collisions. which assessment finding takes priority? a. deviated trachea b. unequal pupils c. ecchymosis in the flank area d. irregular apical pulse

a. deviated trachea

a community hospital is reviewing the activation and implementation of its emergency preparedness plan after a recent mass casualty event. which outcome statement reflects the goal of an administrative review? a. emergency preparedness plan was activated in a timely fashion, but telephone tree was outdated and did not include new employees b. 300 employees were offered a debriefing session, and two employees have symptoms of PTSD c. the mass casualty event was handled well, and we expect to see positive reports in the media and to receive additional funding d. the mass casualty event resulted in an influx of 35 walking wounded, and six patients came via emergency medical transport

a. emergency preparedness plan was activated in a timely fashion, but telephone tree was outdated and did not include new employees

the nurse is giving discharge instructions to a woman who has been treated for contusions and bruises sustained during an episode of domestic violence. what is the priority intervention for this client? a. encourage client to go to a safe house b. make a referral to a counselor c. advise the client about contacting the police d. make an appointment to follow up on the injuries

a. encourage client to go to a safe house

a client with 35% of TBSA burned in a fire is now 48 hours postern. the nurse concludes that the client is moving from the emergent to the acute phase of burn management. which response supports this conclusion? a. hypokalemia b. hypoglycemia c. decreased blood pressure d. increased urine specific gravity

a. hypokalemia

in the work setting, what is the nurse's primary responsibility in preparing for management of disasters, including natural disasters and bioterrorism incidents? a. knowing the agency's emergency response plan b. being aware of the signs and symptoms of potential agents of bioterrorism c. knowing how and what to report to the centers for disease control and prevention d. making ethical decisions about exposing self to potentially lethal substances

a. knowing the agency's emergency response plan

emergency medical services has transported a client with severe chest pain. as the client is being transferred to the emergency stretcher, the nurse notes unresponsiveness, cessation of breathing, and no palpable pulse. which task is appropriate to delegate to the UAP? a. performing chest compressions b. initiating bag-valve mask ventilation c. assisting with oral intubation d. placing the defibrillator pads

a. performing chest compressions

a client comes to the ED and reports nausea, vomiting, colicky abdominal pain, fever, and tachycardia. the HCP informs the nurse that the client probably has a strangulated intestinal obstruction with perforation. what diagnostic testing and interventions does the nurse anticipate for the emergency condition? SATA a. prep for surgery b. barium enema examination c. NG tube insertion d. abdominal radiography e. IV fluid administration f. IV administration of broad-spectrum antibiotics

a. prep for surgery c. NG tube insertion d. abdominal radiography e. IV fluid administration f. IV administration of broad-spectrum antibiotics

a client is shot in the chest during a holdup and is transported to the hospital via ambulance. in the ED, chest tubes are inserted, one in the second intercostal space and one at the base of the lung. what does the nurse expect the tube in the second intercostal space to accomplish? a. remove the air that is present in the intrapleural space b. drain serosanguineous fluid from the intrapleural compartment c. permit the development of positive pressure between the layers of pleura d. provide access for instillation of medication into the pleural space

a. remove the air that is present in the intrapleural space

a man with a known history of alcohol abuse has been in police custody for 48 hours. Initially, anxiety, sweating, and tremors were noted. Now, disorientation, hallucination, and hyperactivity are observed. the medical diagnosis is delirium tremors. what is the priority nursing concept to consider in planning intervention for this emergency condition? a. safety b. psychosis c. thermoregulation d. addiction

a. safety

according to the joint commission, hospitals are required to form emergency management committees, to periodically exercise the disaster operations plan. hospital administration has selected various HCPs to join the committee. members from which other key departments should be included? SATA a. security and communications b. nursing and UAP c. lab and diagnostic services d. medical and information technology e. maintenance and engineering f. PT and OT

a. security and communications b. nursing and UAP c. lab and diagnostic services d. medical and information technology e. maintenance and engineering

which is the most difficult problem for the nurse to manage when meeting the needs of an extensively burned client 3 days after admission? a. severe pain b. maintenance of sterility c. alteration in body image d. frequent dressing changes

a. severe pain

a newly graduated nurse overhears a senior ED nurse making sarcastic remarks toward a medical student and refusing to help the student find the equipment for a non-emergent client procedure. what should the new nurse do first? a. step in and offer to assist the medical student because the other nurse is unwilling b. confront the senior nurse and indicate that an apology is the right thing to do c. observe the situation and then report behaviors of both parties to the charge nurse d. watch and observe the dynamics; the scenario is probably typical of unit norms

a. step in and offer to assist the medical student because the other nurse is unwilling

a nurse working at a small rural hospital gets a frantic phone call about a rumor of a student attacking other students at a local high school. which information is the most important to determine potential for a multi casualty event versus a mass casualty event? a. "how long ago did the event occur?" b. "what are the number and severity of the injuries?" c. "what are the school officials saying about the incident?" d. "have emergency medical services been notified?"

b. "what are the number and severity of the injuries?"

a newly hired ED clinical nurse specialist (CNS) is reviewing the hospital's disaster plan and finds that it has not been reviewed or revised for 3 years. what finding will be most important for the CNS to address related to the status of the disaster plan? a. stockpiles of antibiotics and resuscitation equipment may be depleted b. current staff is unlikely to have training and practice in using the plan c. resources within and outside of the hospital are likely to have changed d. surrounding communities are at increased risk for technologic disasters

b. current staff is unlikely to have training and practice in using the plan

a group of people arrive at the ED by private car. they all have extreme periorbital swelling, coughing, and tightness in the throat. there is a strong odor emanating from their clothes. they report exposure to a "gas bomb" that was set off in their house? what is the priority action? a. measure VS and listen to lung sounds b. direct clients to the decontamination area c. alert security of possible terrorism activity d. direct clients to cold or clean zones for immediate treatment

b. direct clients to the decontamination area

the nurse notifies the ED HCP about a client who reports abdominal pain, nausea and vomiting, and fever. the abdomen is distended, rigid and board-like, and there is rebound tenderness. later the nurse sees that the client is to be discharged with a follow-up appt in the morning. the nurse reexamines the client and the symptoms seem worse. what should the nurse do first? a. contact the nursing supervisor and express concerns b. express findings and concerns to the HCP c. discharge the client but stress the importance of follow-up d. follow the discharge orders and write an incident report

b. express findings and concerns to the HCP

a young woman is brought to the ED by EMS. EMS reports they were called because the woman has been depress and threatening to commit suicide. on arrival to the ED, the woman is confused; her speech is slurred, and there is vomit on her clothes. EMS found several empty prescription bottles at the house. what are the priority interventions for this client? a. identify toxic substances by history and analysis of blood, urine, and gastric contents b. initiate supportive care, such as checking airway and giving O2 and IV fluids c. reduce absorption by giving activated charcoal or performing gastric lavage d. promote poison removal using drugs to facilitate excretion or by starting hemodialysis

b. initiate supportive care, such as checking airway and giving O2 and IV fluids

a client presents to triage with fever, myalgia, severe headache, abdominal pain, vomiting, diarrhea, and unexplained bruising that started after returning from Africa, the triage nurse suspects, but is unsure, that the client may have ebola. What should the nurse do first? a. delay any additional assessment or questioning and don full PPE b. isolate the client in a private room and initiate standard, contact, and droplet precautions c. direct all clients and staff out of the triage area, and call the infection control department d. continue assessment and questioning to determine the likelihood of exposure to ebola

b. isolate the client in a private room and initiate standard, contact, and droplet precautions

which action meets the joint commission's 2015 mandate for the hospitals emergency preparedness plan? a. all nursing staff are certified annually in basic and advanced cardiac life support b. plan is tested twice a year using simulated patients to assess collaboration and command c. stockpiles of equipment and supplies needed for a pandemic influenza outbreak are inventoried d. emergency department staff meets annually with administration to review plan and update as needed

b. plan is tested twice a year using simulated patients to assess collaboration and command

a nurse is caring for a client during the emergent phase of a severe burn injury. which parenteral intervention prescribed by the health care provider should the nurse question? a. colloids b. potassium c. hypertonic saline d. lactated ringer solution

b. potassium

the following clients come to the ED triage desk reporting acute abdominal pain. which client has the most severe condition? a. 35-year-old man reporting severe intermittent cramps with three episodes of watery diarrhea 2hrs after eating b. 11-year-old boy with low-grade fever, RLQ tenderness, nausea, and anorexia for the past two days c. 23-year-old woman reporting dizziness and severe LLQ pain who states she is possibly pregnant d. 50-year-old woman who reports gnawing midepigastric pain that is worse between meals and during the night

c. 23-year-old woman reporting dizziness and severe LLQ pain who states she is possibly pregnant

When an unexpected death occurs in the ED, which task is most appropriate to delegate to the UAP? a. Escorting the family to a place of privacy b. accompanying organ donor specialist to talk to the family c. Assisting with postmortem care d. Helping the family to collect belongings

c. Assisting with postmortem care

When a primary survey of a trauma client is conducted, what is one of the priority actions that would performed first? a. Obtain a complete set of vital sign measurements b. Palpate and auscultate the abdomen c. Perform a brief neurologic assessment d. Check the pulse oximetry reading

c. Perform a brief neurologic assessment

In the care of a client who has experienced sexual assault, which task is most appropriate for an LPN/LVN to perform? a. Assessing immediate emotional state and physical injuries b. Collecting hair samples, saliva specimens, and scrapings beneath fingernails c. Providing emotional support and supportive communication d. Ensuring that the chain of custody of evidence is maintained

c. Providing emotional support and supportive communication

a 56-year-old client comes to the triage area with left-sided chest pain, diaphoresis, and dizziness. what is the priority action? a. initiate continuous electrocardiographic monitoring b. notify the ED HCP c. administer O2 via NC d. draw blood and establish IV access

c. administer O2 via NC

an experienced traveling nurse has been assigned to work in the ED; however, this is the nurse's first week on the job. which are of the ED is most appropriate assignment for this nurse? a. trauma team b. triage c. ambulatory or fast-track clinic d. pediatric medicine team

c. ambulatory or fast-track clinic

an ED nurse is admitting a client after an automobile collision. the HCP estimates that the client has lost about 15-20% of blood volume. which assessment finding should the nurse expect this client to exhibit? a. urine output of 50 ml/hr b. BP of 150/90mmHg c. apical HR of 142 bpm d. RR of 16 breaths/min

c. apical HR of 142 bpm

the nurse is caring for a client who is on the cardiac monitor because of these symptoms; syncope, dizziness, and intermittent episodes of palpitations. below is a display of what the nurse sees on the cardiac monitor (Heart strip of sinus rhythm with PVCs) a. call the rapid response team b. obtain the automated external defibrillator c. assess the client and take VS d. check the adherence of the gel pads on the chest

c. assess the client and take VS

a long-term care facility formed a committee to review the facility's emergency preparedness plan. which element needs to be resolved in order to meet the guidelines of the life safety code, which is published by the national fire protection association? a. fire extinguishers are heavy and difficult to use b. fire safety training is difficult because of high staff turnover c. building has one main front door, and side doors are sealed shut d. many residents are unwilling or incapable of participating in fire drills

c. building has one main front door, and side doors are sealed shut

a severely burned client has been hospitalized fro 2 days. until now recovery has been uneventful, but the client begins to exhibit extreme restlessness. what does the nurse conclude the client is most likely developing? a. kidney failure b. fluid overload c. cerebral hypoxia d. metabolic acidosis

c. cerebral hypoxia

the LPN/LVN is performing care for a client who sustained an amputation of the first and second digits in a chainsaw accident. what instructions would the RN give to the LPN/LVN? a. clean the amputated digits and the hand with a providine-iodine and normal saline solution; then wrap with gauze b. clean the amputated digits, wrap them in gauze, and place cleansed digits directly into an ice slurry c. clean the amputated digits with saline, wrap in moist gauze, seal in a plastic bag, and place in ice slurry d. clean the digits with sterile NS and submerge digits in sterile NS in a sterile cup

c. clean the amputated digits with saline, wrap in moist gauze, seal in a plastic bag, and place in ice slurry

the client's blood alcohol level is 0.45%. based on this information, what is the priority nursing concept that underlies emergency medical and nursing interventions for this client? a. cognition b. addiction c. gas exchange d. functional ability

c. gas exchange

a healthy but anxious 24-year-old college student reports tingling sensations, palpitations, and sore chest muscles. deep, rapid breathing and carpal spasms are noted. what priority action should the nurse take? a. notify HCP immediately b. administer supplemental O2 c. have the student breathe into a paper bag d. obtain an order for an anxiolytic medication

c. have the student breathe into a paper bag

a victim of heat stroke arrives in the ED. his skin is hot and dry; his body temperature is 105 degrees. he is confused and demonstrates bizarre behavior. BP is 85/60, HR 130, RR 40. which task should be assigned by an experience LPN/LVN? a. insert a rectal probe to measure core body temp b. administer aspirin or another antipyretic c. insert and indwelling urinary drainage catheter d. assess respiratory effort, hemodynamics, and mental status

c. insert and indwelling urinary drainage catheter

tetanus immunizations are routinely administered during childhood and in the ED for clients who sustain wounds. although the incidence of tetanus has decreased, there is still a danger. Which client represents the group that is most vulnerable for risk? a. child who helps with farm work sustained scratches while feeding the animals b. newborn infant delivered in the ED; mother had no prenatal care c. older adult who lives alone sustained minor cut while cleaning the basement d. young adult who works in an auto repair shop sustained a deep cut on a metal edge

c. older adult who lives alone sustained minor cut while cleaning the basement

a nurse in the ED is assigned to care for four clients with serious health problems. which health problem should the nurse identify as priority? a. head injury b. fractured femur c. ventricular fibrillation d. penetrating abdominal wound

c. ventricular fibrillation

the nurse is assigned to telephone triage. a client is was just stung by a common honeybee calls for advice. which question would the nurse ask first? a. "is this the first time you have been stung by a bee or wasp?" b. "do you have access to and know how to use and epinephrine autoinjector?" c. "what type of first aid measures have you tried?" d. "are you having any facial swelling, wheezing, or SOB?"

d. "are you having any facial swelling, wheezing, or SOB?"

It is the summer season, and clients with signs and symptoms of heat-related illness come to the ED. Which client needs attention first? a. older adult reports of dizziness and syncope after standing in the sun for several hours to view a parade b. Marathon runner who reports severe leg cramps and nausea, and shows tachycardia, diaphoresis, pallor, and weakness c. Healthy homemaker reports that the air conditioner has been broken for days; she has tachypnea, hypotension, fatigue, and profuse diaphoresis d. Homeless person displays altered mental status, poor muscle coordination, and hot, dry, ashen skin; and whose duration of heat exposure is unknown

d. Homeless person displays altered mental status, poor muscle coordination, and hot, dry, ashen skin; and whose duration of heat exposure is unknown

which scenario is most likely to require activation of the emergency preparedness plan? a. a private six passenger plane crashes b. there is an outbreak of food-borne illness at a long-term care center on Tuesday afternoon c. an ice storm strikes a city on Monday morning and causes falls and vehicular accidents d. a multi-car accident occurs in front of a small rural hospital after midnight on a Sunday

d. a multi-car accident occurs in front of a small rural hospital after midnight on a Sunday

the nurse is working in the emergency department where several local gang members are being treated for gunshot and knife wounds. the nurse hears gunshots in the waiting room, followed by screaming and cries for help. What does the nurse do first? a. grab the resuscitation box and run to the waiting room b. assist all the ambulatory patients to leave through the back entrance c. alert the ED health care provider that additional trauma victims need care d. assess the level of threat to self and others and call for help

d. assess the level of threat to self and others and call for help

a nurse manager decides to form a committee to address the issue of violence against ED personnel. which combination of employees would be best suited to fulfill this assignment? a. ED physicians and charge nurses b. experienced RNs and experienced paramedics c. RNs, LPNs/LVNs, and UAPs d. at least one person from all ED groups

d. at least one person from all ED groups

after emergency endotracheal intubation, the health care team and nurse must verify tube placement before securing the tube. what is the most accurate bedside assessment that can be performed immediately after the tube is placed? a. visualize the movement of the thoracic cage b. auscultate the chest during assisted ventilation c. confirm that breath sounds are equal and bilateral d. check exhaled carbon dioxide levels with capnography

d. check exhaled carbon dioxide levels with capnography

an emergency department clinical nurse specialist is training staff in how to don and doff PPE when caring for clients with infections, such as ebola. which staff member has demonstrated the most grievous error during the practice session? a. triage nurse forgets to perform hand hygiene before donning PPE b. UAP performs self inspection; then begins to doff PPE c. HCP forgets to wipe shoes with disinfectant after doffing shoe covers d. emergency medical technician doffs with pairs of gloves first

d. emergency medical technician doffs with pairs of gloves first

a committee is reviewing the hospital's emergency management plan. in the event of a large-scale multi-casualty event, which group is likely to require the largest amount if physical space to accommodate the number of victims? a. black-tagged patients b. red-tagged patients c. yellow-tagged patients d. green-tagged patients

d. green-tagged patients

the nurse is talking to a group of people about an industrial explosion in which many people were killed or injured. which individual has the greatest risk for psychiatric difficulties, such as PTSD, related to the incident? a. individual who repeatedly watched television coverage for the event b. person who recently learned that her son was killed in the incident c. individual who witnessed death of a coworker during the explosion d. person who was injured and trapped for several hours before rescue

d. person who was injured and trapped for several hours before rescue

the nurse is using the impact of event scale-revised (IES-R) to assess a UAP who was working in a long-term care facility that was devastated by a fire. the IES-R score is high on all sub-scales. what should the nurse do? a. reinforce coping strategies that the UAP is successfully doing b. suggest additional coping strategies that the UAP can use to decrease stress c. refer the UAP to a social worker or support group for survivors d. refer the UAP to a psychiatrist or clinical psychologist for additional evaluation

d. refer the UAP to a psychiatrist or clinical psychologist for additional evaluation

a nurse in the ED is assessing a client who was beaten and sexually assaulted. which is the nurse's priority assessment? a. the family's feelings about the attack b. the clients feelings of social isolation c. disturbance in the client's thought process d. the client's ability to cope with the situation

d. the client's ability to cope with the situation

the nurse and group of friends are at the lake. suddenly, someone says, "look across the look! it looks like someone might be drowning out there!" what is the nurse's first action? a. determine who is the strongest swimmer in the group b. direct someone to locate a cell phone and cal 911 c. find a boat, raft, or some type of flotation device d. use a pair of binoculars and look across the lake

d. use a pair of binoculars and look across the lake

The nurse is conducting a class about cold-weather hiking. What are the early signs of frostbite, which hiking partners should frequently observe for? A. White, waxy, or pale gray appearance to ears, nose, and cheeks B. Edema and redness over the exposed skin C. Mottled discoloration of the lower extremities D. Small blisters that contain clear fluid and areas that do not blanch

A. White, waxy, or pale gray appearance to ears, nose, and cheeks

How should the nurse respond to the patient with impaired thermoregulation as a result of a cold-related injury? SATA A. Thaw frozen body parts in a warm-water bath and handle gently B. Provide pain control measures C. Advocate for increased drug doses as a result of lowered metabolism D. Administer tetanus prophylaxis and possible antibiotics for open wounds E. Initiate passive external rewarming by covering with blankets F. Prepare patient for possible amputation of frostbitten body parts

A. Thaw frozen body parts in a warm-water bath and handle gently B. Provide pain control measures D. Administer tetanus prophylaxis and possible antibiotics for open wounds E. Initiate passive external rewarming by covering with blankets

A patient was bitten by a brown recluse spider 4 days ago. The nurse observes prolonged bleeding after venipuncture and notes that the patient has a low platelet count. What do these findings indicate? A. Thrombocytopenia B. Hemolytic anemia C. Aplastic anemia D. Agranulocytosis

A. Thrombocytopenia

Several people are looking out across a lake and pointing to a swimmer in the distance who appears to be struggling to stay afloat. What is the correct sequence of emergency steps to take? Put in order of priority. A. Handle gently to prevent ventricular fibrillation B. Safely rescue the victim C. Begin delivering rescue breaths as soon as possible D. Assess neurologic status E. Assess airway patency

B (Highest priority), E, C, A, D (lowest priority)

Each patient listed below has entered the emergency department's waiting area. Place them in order of priority, with 1 being the highest priority and 4 being the lowest priority. A. 3-year-old child with inconsolable high-pitched cry, high fever, headache, and nuchal rigidity B. 65-year-old man having diaphoresis with crushing left anterior chest pain C. 32-year-old woman reporting upper abdominal pain and vomiting green bile emesis D. 16-year-old boy with a broken arm from skateboarding and pulse and sensation intact

B (highest priority), A, C, D (lowest priority)

For which circumstances would the use of standard precautions be adequate to ensure the safety of the nurse, staff, and other patients? A. Performing hygienic care for a patient with copious watery diarrhea B. Assisting with intubation of a patient with symptoms of tuberculosis C. Initiating a peripheral intravenous access on a patient who is HIV positive D. Assessing a child with a fever and rash and known exposure to chickenpox

C. Initiating a peripheral intravenous access on a patient who is HIV positive

A patient sustained severe frostbite to the toes and lower legs. He received rewarming therapy in the emergency department and arrives to the medical-surgical unit with a splint on both legs. IV normal saline is infusing at 125 mL/hr. He reports pain in the lower extremities. Which health care provider order does the nurse question? A. Give morphine 1-2 mg IV push prn for pain in extremities B. Elevate bilateral lower extremities above the level of the heart C. Perform neurologic and circulation checks on bilateral lower extremities every hour D. Apply compression bandage to bilateral lower extremities

D. Apply compression bandage to bilateral lower extremities

A patient is brought to the emergency department (ED) by friends who report, "He probably overdosed on downers." The patient has a decreased level of consciousness and a decreased gag reflex; his face and chest are covered with emesis; he demonstrates spontaneous sonorous respirations; and pulse oximetry is 87% on room air. What type of airway management does the nurse expect this patient to receive? A. Supplemental oxygen per nasal cannula at 4-6 L/min B. Bag-valve mask and 100% oxygen to assist with ventilatory effort C. Non-rebreather mask with high-flow oxygen D. Endotracheal intubation with initial high-concentration oxygen

D. Endotracheal intubation with initial high-concentration oxygen

A patient reports a scorpion sting on the back of the hand. There is no obvious redness or inflammation at the suspected sting site. Which assessment technique does the nurse use to confirm a bark scorpion sting? A. Raise the arm and observe for blanching B. Observe for the stinger embedded in the skin C. Look for puncture marks surrounded by fine hairs D. Gently tap at the suspected sting site to elicit pain

D. Gently tap at the suspected sting site to elicit pain

which information should the nurse include in a teaching plan for a client whose burns are being treated with the exposure method? a. bathing will not be permitted b. aseptic techniques are required c. dressings will be changed every 3 days d. room temperature must be kept at 72 degree F

b. aseptic techniques are required

the nurse has just received a change of shift report for the burn unit. which client should be assessed first? a. client with deep partial thickness burns on both legs who reports severe and continuous leg pain b. client who has just arrived from the emergency department with facial burns sustained in a house fire c. client who has just been transferred from the post anesthesia care unity after having skin grafts applied to the anterior chest d. client admitted 3 weeks ago with full thickness leg and buttock burns who has been waiting for 3 hours to receive discharge teaching

b. client who has just arrived from the emergency department with facial burns sustained in a house fire

which event would be considered an internal disaster? a. a fire in a long term care facility b. gunfire in the hospital parking lot c. a tornado devastates the community d. several people dying from flulike symptoms

a. a fire in a long term care facility

the nurse is assigned to assist the hospital incident commander during a disaster drill. which responsibility is appropriate for the nurse in this capacity? a. call all nursing units to determine the number of patients who could potentially be discharged b. call the physical therapy department and direct therapists to assist in the operating room or intensive care unit c. go to the emergency department and assist with the triage of disaster victims to appropriate clinical areas d. contact the security department and instruct them to control the number of people who attempt to enter the hospital

a. call all nursing units to determine the number of patients who could potentially be discharged

at 0300, the emergency department charge nurse of a large suburban hospital receives notification that a commercial plane has just crashed outside the city limits. what does the nurse do? SATA a. collaborate with the medical command physician b. activate hospital emergency management plan c. initiate the staff telephone tree d. collaborate with the triage officer e. organize nursing and ancillary services f. alert the critical incident stress debriefing team

a. collaborate with the medical command physician c. initiate the staff telephone tree d. collaborate with the triage officer e. organize nursing and ancillary services

the nurse is assigned to assist the incident commander who is evaluating the feasibility of deactivating the emergency management plan. the commander directs the nurse to accomplish certain tasks. which task is priority? a. contact all hospital department and determine if needs have been met b. go to the ED and supervise inventory and restocking of supplies c. arrange for temporary sleeping quarters for exhausted staff members d. assist in the preparations of the critical incident stress debriefing

a. contact all hospital department and determine if needs have been met

a nurse caring for a client during the first few hours after the admission to the burn unit with partial thickness burns of the trunk and head. which potential problem is the least concern for the nurse during the emergent phase of a burn injury? a. pain b. leukopenia c. laryngeal edema d. fluid volume deficit

b. leukopenia

the hospital committee is reviewing the emergency management plan of their small community hospital in a suburban area of a large city. What is a priority to include in this hospitals emergency management plan? a. plan for evacuation routes out of the city b. plan for transporting patients to other hospitals c. method to contact the national disaster medical system d. stockpiling postexposure prophylactic antibiotics

b. plan for transporting patients to other hospitals

a person sustains deep partial thickness burns while working on a boat in a town Marina and seeks advice from the nurse in the first aid station. the nurse encourages the client to seek medical attention, but the client refuses. the nurse advises the person to go to the health care provider if: a. blisters appear b. urinary output decreases c. edema and redness occur d. low-grade fever develops

b. urinary output decreases

A worker is involved in an explosion of a steam pipe and receives a scalding burn to the chest and arms. The burned areas are painful, mottled red, weeping, and edematous. Which should the nurse conclude is an appropriate classification for these burns? a. Eschar b. Full-thickness c. Deep partial-thickness d. Superficial partial-thickness.

c. Deep partial-thickness

which client is best for the nurse manager on the burn unit to assign to an RN who has floated from the oncology unit? a. a 23 year old client who has just been admitted with burns over 30% of the body after a warehouse fire b. a 36 year old client who requires discharge teaching about nutrition and would care after having skin grafts c. a 45 year old client with infected partial thickness back and chest burns who has a dressing change scheduled d. a 57 year old client with full thickness burns on both arms who needs assistance in positioning hand splints

c. a 45 year old client with infected partial thickness back and chest burns who has a dressing change scheduled

the nurse has just received the change of shift report in the burn unit. which client requires the most immediate assessment or intervention? a. a 22 year old client admitted 4 days previously with facial burns due to a house fire who has been crying since recent visitors left b. a 34 year old client who returned from skin graft surgery 3 hours ago and is reporting level 8 pain (0-10 scale) c. a 45 year old client with partial thickness leg burns who has a temperature of 102.6F (39.2C) and a blood pressure of 98/46mmHg d. a 57 year old client who was admitted with electrical burns 24 hours ago and has a blood potassium level of 5.1 mEq/L

c. a 45 year old client with partial thickness leg burns who has a temperature of 102.6F (39.2C) and a blood pressure of 98/46mmHg

a nurse is evaluating a clients fluid loss resulting from extensive burns. what is the most valuable blood test to use when monitoring a clients fluid loss? a. BUN b. blood pH c. hematocrit d. sedimentation rate

c. hematocrit

a nurse based in Iowa is a volunteer member of the medical reserve corps and has been called to serve in Ohio where he does not hold an active nursing license. What should the nurse do? a. determine if Ohio has reciprocity with Iowa before accepting deployment b. decline deployment because his nursing license will not allow him to practice in Ohio c. prepare for deployment because he will be considered a federal employee with a valid licensure d. delay deployment until he has review the nurse practice act that is specific to Ohio

c. prepare for deployment because he will be considered a federal employee with a valid licensure

a nurse is assessing a client during the first 24 hours after a burn injury. which sign indicates to the nurse that fluid replacement therapy is adequate? a. decreasing CVP readings b. urinary output of 15-20 mL/hr c. slowing of a previously rapid pulse d. hematocrit level increasing from 50-55%

c. slowing of a previously rapid pulse

to prevent the development of PTSD in hospital staff, what action is likely to be taken by the facility? a. conducting administrative debriefings b. providing employees with information on PTSD c. offering employees psychological counseling d. conducting critical incident stress debriefings

d. conducting critical incident stress debriefings

a nurse is caring for a client who experienced serious burns in a fire. which relationship between a clients burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns? a. equal b. unrelated c. inversely related d. directly proportional

d. directly proportional

a nurse is caring for a client who sustained a partial thickness burn to the lower leg accounting for 5% of the TBSA 1 day ago. a primary short-term outcome established by the nurse and client is "the clients: a. airway will remain open" b. burns will heal free of infection" c. urine output will exceed 30mL every hour" d. pain will remain at 2 or less on a scale of 0 to 10"

d. pain will remain at 2 or less on a scale of 0 to 10"

the emergency management plan is activated because a major earthquake has caused many serious and minor injuries. which nurse reassignment is most likely to meet the needs of the patients while best utilizing available personnel? a. OR nurse is reassigned to the ER to assist in triage b. ER nurse is reassigned ti care for patients in the med surge unit c. critical care nurse is reassigned to the ER to care for "black tag" patients d. performance improvement nurse is reassigned to care for "green tag" patients

d. performance improvement nurse is reassigned to care for "green tag" patients

a nurse places a client with severe burns on a circulating air bed. what is the primary reason why the nurse implements this action? a. increase mobility b. prevent contractures c. limit orthostatic hypotension d. prevent pressure on peripheral blood vessels

d. prevent pressure on peripheral blood vessels

Which combination of factors is likely to contribute to the highest survival rate for drowning victims who are immediately transported to the emergency department for care? A. In very cold fresh water for 7 minutes; arrives in ED with pulse of 40 B. In warm salt water for 12 minutes; arrives in ED with pulse of 150 C. In very cold salt water for 10 minutes; arrives in ED with no pulse D. In warm contaminated water for 6 minutes; arrives in ED with no pulse

A. In very cold fresh water for 7 minutes; arrives in ED with pulse of 40

What is the fastest way for the nurse to estimate the systolic blood pressure in a patient with multiple injuries who has just been moved from the transport stretcher to the emergency department resuscitation stretcher? A. Palpate for presence of a radial pulse B. Use the automated blood pressure cuff C. Place the patient on a cardiac monitor D. Check for the presence of capillary refill

A. Palpate for presence of a radial pulse

The healthcare provider orders IV infusion of epinephrine for an older adult patient for an allergic reaction to a bee sting. In conjunction with the epinephrine administration, which action does the nurse take? A. Places the patient on a cardiac monitor B. Inserts an indwelling urinary catheter C. Obtains an order for an electrocardiogram D. Obtains an order for an arterial blood gas

A. Places the patient on a cardiac monitor

The nurse is interviewing a homeless patient in the triage area. The patient says, "I'm a nurse too. Flying pictures say God is me. I am god, taking noise away." The patient then stands up and kicks over the garbage can. What should the nurse do first? A. Remain calm and slowly step away from the patient B. Run toward the panic button and immediately push it C. Gently take the patient's arm and lead him to a quiet space D. Call for help and instruct bystanders to get out of the way

A. Remain calm and slowly step away from the patient

The nurse is advising a group of parents who are organizing a winter cross-country skiing trip. In assisting the parents to develop an appropriate winter clothing list, which articles should be taken on the trip? SATA A. Synthetic socks B. Cotton underwear C. Polyester fleece shirt D. Windproof outer jacket E. Hat made from waterproof, breathable fabric F. Sunglasses

A. Synthetic socks C. Polyester fleece shirt D. Windproof outer jacket E. Hat made from waterproof, breathable fabric F. Sunglasses

What are the most common signs/symptoms of high-altitude pulmonary edema? SATA A. Tachypnea at rest B. Persistent dry cough C. Abdominal pain and cramping D. Waxy appearance of ears, cheeks, and nose E. Cyanotic lips and nail beds F. Bradycardia at rest

A. Tachypnea at rest B. Persistent dry cough E. Cyanotic lips and nail beds

A patient sustained a bite from a pit viper and is admitted for observation. Which potential complications does the nurse observe for? SATA A. Hemorrhagic bullae B. Tingling of scalp, lips, or face C. Hypertension D. Excessive salivation with drooling E. Clotting abnormalities F. Seizure

A. Hemorrhagic bullae B. Tingling of scalp, lips, or face E. Clotting abnormalities F. Seizure

What might the nurse notice if the patient has impaired thermoregulation as a result of cold-related injury? SATA A. Hyperemia and edema of fingers or toes B. Shivering C. Possible atrial fibrillation D. Numbness and pain of nose or ears E. Profuse diaphoresis F. Headache, weakness, nausea, and/or vomiting

A. Hyperemia and edema of fingers or toes B. Shivering D. Numbness and pain of nose or ears

A young migrant worker has been living in a garden shed for several months. He is brought to the emergency department (ED) and is alert and conversant but appears fearful and confused. His skin is hot and dry, and his lips are cracked and bleeding. His skin turgor is poor, and he is malnourished. His blood pressure is 96/60 mm Hg, pulse is 130, respirations are 30 and temperature is 105F. In addition to high-flow oxygen, what does the nurse anticipate the ED healthcare provider will initially order? A. IV normal saline and an indwelling urinary catheter B. IV Ringer's lactate and a nasogastric tube C. IV 5% dextrose and acetaminophen D. IV 45% saline and chlorpromazine

A. IV normal saline and an indwelling urinary catheter

The emergency department (ED) nurse is preparing a Situation, Background, Assessment, Recommendation (SBAR) report on a patient being admitted for bacterial meningitis. Which points are included in the ED nurse's report to the medical-surgical nurse? SATA A. "Patient reports severe headache with high fever that started 4 days ago" B. "Patient is currently alert and oriented x 2; speech clear but rambling" C. "Patient is very demanding and has used the call bell repeatedly since arriving in the ED" D. "IV normal saline into left anterior forearm; received first dose of IV ceftriaxone at 0700" E. "Lumbar puncture results are pending, but meningococcal meningitis is suspected" F. "Patient has male characteristics but prefers to be called Mrs. Jenny Jones"

A. "Patient reports severe headache with high fever that started 4 days ago" B. "Patient is currently alert and oriented x 2; speech clear but rambling" D. "IV normal saline into left anterior forearm; received first dose of IV ceftriaxone at 0700" E. "Lumbar puncture results are pending, but meningococcal meningitis is suspected" F. "Patient has male characteristics but prefers to be called Mrs. Jenny Jones"

A patient is admitted for a brown recluse spider bite. The nurse observes that the patient has hemorrhagic complications of hematuria, hemoptysis, petechiae, and extensive bruising. These clinical observations indicate to the nurse that the patient may be experiencing which complication associated with the bite? A. Disseminated intravascular coagulation B. Agranulocytosis C. Thrombocytopenia D. Aplastic anemia

A. Disseminated intravascular coagulation

A patient arrives at the emergency department after prolonged cold exposure. The staff avoids rough and vigorous movements during the transfer from stretcher to bed to prevent which complication? A. Ventricular fibrillation related to rough handling B. Third-degree heart block related to cold autotransfusion C. After-drop due to cold blood moving to the central circulation D. Pulmonary emboli related to dislodgment of a clot

A. Ventricular fibrillation related to rough handling

The nurse is instructing a patient who has a history of severe allergic reaction to bee stings on what to do if he experiences a bee sting in the future. What information does the nurse relay to the patient? SATA A. Wear a medical alert bracelet B. Take an antihistamine before trying the EpiPen injection C. Administer epinephrine immediately D. Call 911 to be transported to a medical facility E. Immediately apply a moist warm towel F. Obtain a prescription for prophylactic corticosteroids

A. Wear a medical alert bracelet C. Administer epinephrine immediately D. Call 911 to be transported to a medical facility

A patient reports having throbbing headache with nausea and vomiting "like the worst hangover of my life" after recently returning from a hiking trip to the mountains. The nurse suspects high-altitude sickness. Which question helps the nurse gather relevant information about this condition? A. "Did you experience any episodes of hypothermia during your trip?" B. "How quickly did you ascend to the top of the mountain range?" C. "Did you go skiing or hiking in a nearby area?" D. "Did you have trouble sleeping while you were in the mountains?"

B. "How quickly did you ascend to the top of the mountain range?"

Which patient should be triaged as emergent? A. 56-year-old man with severe unilateral back pain and previous history of kidney stones B. 23-year-old woman with severe abdominal pain, positive home pregnancy test, and BP 80/40 mm Hg C. 6-year-old with a temperature of 101 and flulike symptoms D. 10-year-old girl with vomiting, diarrhea, and abdominal cramps onset 4 hours after eating fish

B. 23-year-old woman with severe abdominal pain, positive home pregnancy test, and BP 80/40 mm Hg

Which patients are most likely to undergo care via triage nurse-initiated protocols? SATA A. 36-year-old female with flulike symptoms that started two days ago B. 55-year-old male with left anterior chest pain that started after exercising C. 88-year-old male with sudden onset of confusion and shallow respirations D. 3-year-old female with an earache and a low-grade fever E. 45-year-old female with left-sided weakness, slurred speech, and drooling F. 18-year-old male with tenderness of testicles that started after sexual intercourse

B. 55-year-old male with left anterior chest pain that started after exercising C. 88-year-old male with sudden onset of confusion and shallow respirations E. 45-year-old female with left-sided weakness, slurred speech, and drooling

The nurse is assessing a patient who reports being bitten by a black widow spider. The patient may have clinical signs and symptoms that mimic which disorder? A. Myocardial infarction B. Acute abdomen C. Acute renal failure D. Deep vein thrombosis

B. Acute abdomen

The nurse is helping the healthcare provider treat a patient with a tension pneumothorax. What type of equipment does the nurse obtain to immediately alleviate this life-threatening condition? A. Large adult endotracheal tube B. Transvenous pacemaker insertion C. Chest tube insertion tray D. Tracheostomy tray

C. Chest tube insertion tray

Which patient is most likely to require the skills that the nurse learned during Advanced Cardiac Life Support (ACLS) training? A. Patient who was just informed that he will be put on the heart transplant list B. Patient who has low oxygen saturation with a history of heart failure and fluid retention C. Patient who arrives unresponsive, secondary to unwitnessed cardiac arrest D. Patient who is pending transfer to the telemetry unit for atrial fibrillation

C. Patient who arrives unresponsive, secondary to unwitnessed cardiac arrest

For which patient is the forensic nurse examiner most likely to be consulted? A. Elderly patient who died under mysterious circumstances in the emergency department B. Prisoner who was injured by a police officer while resisting arrest C. Patient who was gang-raped by a group of football players D. Patient who accidentally received a large dose of opioid medication

C. Patient who was gang-raped by a group of football players

A college student was drinking beer and dove from a 20-foot ledge into a lake. He was pulled from the lake by a friend and given mouth-to-mouth. The patient is currently in the emergency department, awake, and receiving supplemental oxygen. What type of serial assessment is the nurse most likely to initiate for this patient? A. Cardiac monitoring for possible myocardial infarction B. Level of consciousness and orientation to monitor for alcohol intoxication C. Peripheral sensation and movement related to spinal cord injury D. Frequent blood glucose checks to monitor for hypoglycemia

C. Peripheral sensation and movement related to spinal cord injury

A patient was struck by lightning and sustained temporary paralysis of the lower limbs, which resolved with no physical effects, but the patient developed emotional problems. Which mental health disorder is the most likely complication? A. Generalized anxiety disorder B. Schizophrenia C. Post-traumatic stress disorder D. Acute-onset dementia

C. Post-traumatic stress disorder

The nurse has received report on several patients who were seen and treated for heat-related illnesses. The patient who has the most severe case of heat-related illness exhibits which signs/symptoms? A. Headache, heavy perspiration, temperature of 101F B. Subjective feeling of illness with nausea and vomiting C. Significant sunburn to extremities, face, and neck; temperature 102F D. Hot and dry skin, alert, oriented to person, with pulse of 120/min

D. Hot and dry skin, alert, oriented to person, with pulse of 120/min

a nurse is caring for a client who has a disturbed body image as a result of a burn injury. which is an important nursing intervention for this client? a. conveying a positive attitude toward the client b. arranging for the client to meet other clients with burns c. removing mirrors until the clients physical appearance has improved d. reminding family members to avoid comments about the clients appearance

a. conveying a positive attitude toward the client

a person on the beach sustains a deep partial-thickness burn because of a severe sunburn. what is the best first aid measure that a nurse should instruct the person to apply before seeking health care? a. cool, moist towels b. dry, sterile dressings c. analgesic sunburn spray d. vitamin A and D ointment

a. cool, moist towels

the nurse is making a personal emergency preparedness plan. what is the nurse sure to include in this plan? a. make a disaster supply kit with clothing an basic survival supplies b. resolve the ethical conflicts of family and professional obligations c. stockpile antibiotics, first-aid supplies, and resuscitation equipment d. teach family members about radiation and bioterrorism safety issues

a. make a disaster supply kit with clothing an basic survival supplies

a client rescued from a burning building has partial and full thickness burns over 40% of the body. which is the initial physiologic change that the nurse can expect? a. an increase in blood volume b. an increase in serum potassium c. a decrease in capillary permeability d. a decrease in urinary specific gravity

b. an increase in serum potassium

The nurse is caring for a patient who sustained severe frostbite to the lower leg. The patient reports increasing pain despite receiving analgesic medication 1 hour ago. What should the nurse do first? A. Ensure that the leg is elevated B. Assess for pulses and muscle weakness C. Obtain an order for additional pain medication D. Ask the patient to wait and see if the medication will work

B. Assess for pulses and muscle weakness

A patient treated for severe allergic reaction to a bee sting tells the nurse, "The doctor told me that I had to be careful about getting bee stings in the future because I could have another allergic reaction." Based on the patient's statement, what is the nurse's first action? A. Repeat the information that the healthcare provider gave her B. Assess the patient's understanding of allergic reactions and first aid C. Advise the patient to obtain a medical alert bracelet D. Ensure that the patient has a prescription for an epinephrine autoinjector

B. Assess the patient's understanding of allergic reactions and first aid

An older patient reports being outside when temperatures reached 110F and forgetting to drink water. Now he reports weakness and nausea with dizziness. His body temperature is 98.9F. What is the priority assessment? A. Assess for medications that increase risk for heat stroke B. Check for orthostatic hypotension and tachycardia C. Observe skin turgor and other signs of dehydration D. Assess the size and responsiveness of the pupils

B. Check for orthostatic hypotension and tachycardia

The nurse is interviewing a patient who has been verbally aggressive for the past several hours, according to the family. The family states, "He won't hurt anybody." However, the patient is pacing and appears suspicious and angry. Which strategy does the nurse use to conduct the interview? A. Sit at eye level with the patient in a quiet, secluded room B. Conduct the interview standing near the door in a quiet room C. Bring the entire family in and have everyone sit in comfortable chairs D. Have the security guard stand by the patient during the interview

B. Conduct the interview standing near the door in a quiet room

Three people who accompanied a patient to the emergency department (ED) become verbally argumentative and physically threaten each other. Which actions does the ED nurse take to ensure the safety of staff and others? SATA A. Tell individuals that they are being filmed B. Follow the hospital's security plan C. Attempt to deescalate the situation D. Quietly ask the individuals to leave E. Identify potential escape routes F. Obtain assistance from the security department as needed

B. Follow the hospital's security plan C. Attempt to deescalate the situation E. Identify potential escape routes F. Obtain assistance from the security department as needed

A person is stung by a wasp at a picnic. The person has no difficulty breathing and no history of allergic reaction to bee or wasp stings. What is the priority first-aid action for this person? A. Place a tourniquet proximal to the sting B. Gently scrape the stinger off with the edge of a credit card C. Apply a warm pack to the area and elevate D. Observe the area for signs of inflammation prior to taking any action

B. Gently scrape the stinger off with the edge of a credit card

The patient died in the emergency department despite resuscitation efforts. Homicide is suspected. Which nursing action would be incorrect because of the likelihood of forensic investigation? A. Invites the family to spend time with the deceased patient B. Gives the patient's clothes and other belongings to the family C. Declines to give information to friends of the deceased D. Leaves intravenous lines and indwelling tubes in place

B. Gives the patient's clothes and other belongings to the family

The nurse has administered pain medications to a patient who has a migraine headache. What instructions should be given to unlicensed assistive personnel? A. Wait 45 minutes and then ask the patient if the pain is relieved B. Help the patient out of bed, sit him up, then dangle his feet, then assist to stand C. Check the patient frequently to make sure he arouses and is not getting worse D. Ask the patient if he has a ride home; if not, call a family member to make arrangements

B. Help the patient out of bed, sit him up, then dangle his feet, then assist to stand

For which patients would the nurse try to obtain a social service consult? SATA A. Toddler who bumped her head on a table; observation for 24 hours is required B. Homeless woman who will be discharged with a splint to the lower leg and crutches C. Woman who was punched and beaten by her husband and sustained a broken jaw D. Man who drove himself to the hospital for a dressing change of an infected wound on his back E. Preteen admitted for vaginal bleeding and sexually transmitted infection F. Elderly man who lives alone and has no means to obtain medications from the pharmacy

B. Homeless woman who will be discharged with a splint to the lower leg and crutches C. Woman who was punched and beaten by her husband and sustained a broken jaw E. Preteen admitted for vaginal bleeding and sexually transmitted infection F. Elderly man who lives alone and has no means to obtain medications from the pharmacy

Which occurrence in the patient treated for acute mountain sickness indicates that treatment with acetazolamide was effective? A. Decreased pulse rate and decreased urine output B. Increased urine output and increased respiratory rate C. Periodic respirations during sleep and decreased pulse D. Decreased sleep disturbance and decreased respiratory rate

B. Increased urine output and increased respiratory rate

During a summer marathon, the temperature is over 100F and the humidity is high. Suddenly a runner collapses after running in the race for 1 hour. The runner's body temperature is 105.2F and she is confused and sweating. What evidence-based intervention should be used for this patient? A. Give oxygen and start several IV lines with normal saline B. Initiate rapid cooling using on-site cold-water immersion C. Have patient rest in a cool environment and drink cold water D. Place in a supine position and call 911

B. Initiate rapid cooling using on-site cold-water immersion

The patient was repeatedly kicked and punched in the abdomen. The initial assessment and diagnostic testing revealed no life-threatening damage. The emergency provider tells the nurse that the patient should remain in the emergency department for observation. What is the most important action for the nurse to perform? A. Administer pain medication in a timely fashion B. Initiate serial abdominal assessments C. Delegate vital signs every 4 hours D. Find a quiet space where the patient can rest

B. Initiate serial abdominal assessments

An elderly woman is brought to the emergency department by her son, who tells the nurse, "Mom just seems weak, tired, and more confused than usual." Which combination of question and assessment is the nurse most likely to perform for this patient? A. Ask if she has difficulty sleeping and observe for pedal edema B. Inquire if she has any changes in urination and auscultate the lung fields C. Question her about appetite changes and check for pupillary response D. Ask if she has noticed a vaginal discharge and observe gait and balance

B. Inquire if she has any changes in urination and auscultate the lung fields

An older adult is in the emergency department (ED) for over 12 hours awaiting transfer to an inpatient bed. The charge nurse delegates turning the patient every 2 hours the the unlicensed assistive personnel (UAP) because the patient is at risk for skin breakdown. The patient is not turned and begins to develop a pressure ulcer. What does the charge nurse do to prevent a recurrence of this type of problem for future patients? SATA A. Nothing; in the overall priorities of the ED, the situation is unfortunate but unavoidable B. Make anecdotal notes and counsel all the involved UAPs C. Delegate the duty of turning and repositioning to the family members D. File an incident report and seek assistance at the system level E. Reeducate staff on the need to turn patients at risk for skin breakdown F. Evaluate UAP-patient ratios when patients require frequent turning

B. Make anecdotal notes and counsel all the involved UAPs D. File an incident report and seek assistance at the system level E. Reeducate staff on the need to turn patients at risk for skin breakdown F. Evaluate UAP-patient ratios when patients require frequent turning

The nurse is trying to prepare an intravenous antibiotic medication for a patient, but the emergency department is very busy, chaotic, and noisy, and the nurse is continuously interrupted. What should the nurse do first? A. Ask the charge nurse to administer the antibiotic medication or send additional help B. Prioritize the urgency of the medication in relation to the urgency of the interruptions C. Shut the door and proceed through the six rights of medication administration D. Preparing the medication while fielding the interruptions and delegating appropriately

B. Prioritize the urgency of the medication in relation to the urgency of the interruptions

The emergency department (ED) nurse is caring for a patient who was found in an alley with no identification and no known family. The nurse must give medication to the patient. What is the correct procedure for patient identification? A. Emergent conditions prevent identification, so the nurse gives the medication as ordered B. The patient is designated as John Doe and the nurse uses two unique identifiers C. The nurse validates the order with another nurse and both verify that the patient is unidentified D. The nurse gives the medication and identification is made as soon as possible

B. The patient is designated as John Doe and the nurse uses two unique identifiers

A patient calls the healthcare provider's office asking for advice about whether to seek immediate medical attention for a bee sting. She has no shortness of breath of swelling to the face, throat, or lips. Which question will elicit information to assist the patient in making the decision? A. "Were you stung by an African 'killer bee'?" B. "Is the affected area red, painful, or swollen?" C. "Did you receive multiple stings?" D. "Were you able to remove the stinger?"

C. "Did you receive multiple stings?"

An elderly patient is brought to the emergency department by the paramedics. The patient is alert but disoriented, and the left lower leg has swelling and deformity; an air splint is in place. Which question is most essential to ask the paramedics? A. "How did the patient describe the level of pain?" B. "Does the patient normally walk independently?" C. "What was the mechanism of injury?" D. "What time was the air splint applied?"

C. "What was the mechanism of injury?"

An elderly man is brought to the emergency department by his son. The patient is alert but is disoriented to person, place, and time and is unable to follow simple instructions. Which question is the most important to ask the son? A. "Do you think your father would consent to emergency care?" B. "Did you bring a list of your father's medications and allergies?" C. "When did you first notice your father's disorientation and confusion?" D. "Do you have the power of attorney for health for your father?"

C. "When did you first notice your father's disorientation and confusion?"

A patient calls the emergency department for advice on immediate first aid for a brown recluse spider bite on his hand. He denies allergic response or shortness of breath and states that he plans to see his health care provider but is currently about 2 to 3 hours away. What does the nurse advice the patient to do? A. Apply a warm pack and elevate the extremity B. Scrub the bite area several times with soap and water C. Apply cold compress and rest as much as possible D. Apply a snug constricting band at the wrist level

C. Apply cold compress and rest as much as possible

A man is found in an alley in cold weather for an unknown length of time. His hands, toes, and face show evidence of frostbite; otherwise, there are no obvious injuries. He is severely obtunded with a pulse of 43 beats/min, respirations of 9/min, and a core temperature of 90F. What is this patient's most immediate physiologic risk? A. Acute respiratory distress syndrome B. Pulmonary edema C. Cardiac arrest D. Acute renal failure

C. Cardiac arrest

A construction worker who was struck by lightning is brought to the emergency department (ED). He was found unconscious, but cardiopulmonary resuscitation was started immediately, and he awoke just before arrival of emergency medical service personnel. In the ED, he is alert but confused and reports pain to his right hand and foot with fern-like marks. Which assessment tool is the priority for this patient? A. Glasgow Coma Scale B. Pulse oximeter C. Cardiac monitor D. Rule of nines chart

C. Cardiac monitor

A patient died in the emergency department after sustaining multiple injuries that occurred during an aggravated assault. The family arrives after the patient is pronounced dead, and they ask to see the body. What does the nurse do? A. Explain that viewing the body would be too traumatic because all of the tubes must remain in place for the forensic exam B. Remove any tubes or debris that is near the patient's face and then cover the rest of the body with a blanket C. Explain what they will see; dim the lights; leave the patient's face exposed; and cover the rest of the body with a blanket D. Suggest that the family could spend time with their loved one at the mortuary after the medical examiner is finished

C. Explain what they will see; dim the lights; leave the patient's face exposed; and cover the rest of the body with a blanket

Which person has the greatest risk for injury from lightening strike? A. Jogger in the park at mid-morning in December B. Deer hunter walking through the woods in the evening in October C. Golfer out on the green in the late afternoon in June D. Camper walking on the beach during the early morning in April

C. Golfer out on the green in the late afternoon in June

Which patient would best benefit from always carrying an epinephrine autoinjector? A. Frequently works outside in the yard or tends to the garden B. Lives a long way from the nearest hospital or medical facility C. Had a previous severe allergic reaction to a wasp sting D. Has a history of severe pain with bee or wasp stings

C. Had a previous severe allergic reaction to a wasp sting

The nurse is on a backpacking trip. One of the hikers sustains a pit viper bite to the lower leg. Which first-aid measure will the nurse perform while waiting for transportation to the hospital? A. Elevate the leg and apply cool packs B. Incise the fang marks with a pocket knife C. Immobilize the leg with a splint in a functional position D. Apply a constricting band proximal to the fang marks

C. Immobilize the leg with a splint in a functional position

Which factor is most likely to hinder the nurse's ability to objectively and accurately perform triage duties? A. Nurse has ambiguity about which triage model is the best for selected patients B. Several patients arrive simultaneously at the triage area C. Nurse is personally experiencing compassion fatigue and burnout D. Patient has a complex health history and is a poor historian

C. Nurse is personally experiencing compassion fatigue and burnout

The nurse is volunteering at the first-aid station at a local community fair. The weather is predicted to be hot and humid. In planning care for people who may experience heat-related illness in this setting, what equipment should the nurse obtain? A. Supply of salt tablets and bottles of water B. Bags of IV normal saline and IV insertion equipment C. Several water spray bottles and a portable fan D. Supply of educational pamphlets and sunscreen samples

C. Several water spray bottles and a portable fan

The nurse is assisting a neighbor with a gardening project. The neighbor sustains a snakebite when reaching to move a rock. What is the best action to perform to identify the snake? A. Crush the body of the snake with a rock but preserve the head B. Note the markings of the snake and seek pictures on the Internet C. Stand at a distance and take a digital picture of the snake D. Trap the snake using a long garden tool and bucket

C. Stand at a distance and take a digital picture of the snake

The emergency health care provider is currently involved in the care of several critical patients. The emergency nurse must initiate care for patients under interdisciplinary and medical protocols. Which intervention is the least likely to be covered by a standing protocol? A. Give 50% dextrose IV push for low blood sugar B. Initiate pulse oximetry monitoring and start oxygen therapy C. Ventilate with bag-valve mask at 100% oxygen and intubate D. Start a peripheral IV with normal saline at 125 mL/hr

C. Ventilate with bag-valve mask at 100% oxygen and intubate

The nurse is conducting a community presentation on cold weather safety. Which point is the nurse sure to include in the presentation? A. Hydration and water intake are not an issue, so pack extra clothes, not extra water B. Wear multiple layers of socks when participating in winter sports C. When driving in cold winter weather, carry extra clothes, food, and fluids D. Hypothermia occurs only in the winter months in the United States

C. When driving in cold winter weather, carry extra clothes, food, and fluids

An experienced nurse is working in triage. For which circumstance is the nurse most likely to seek input from the emergency health care provider or advanced practice nurse about acuity level of the patient? A. A 65-year-old man is having severe left anterior chest pain and shortness of breath B. A 35-year-old man with history of kidney stones has severe back pain and hematuria C. A 1-year-old child with history of frequent ear infections is screaming and pulling at his ear D. A 23-year-old female with previous good health has sudden, severe, flulike symptoms

D. A 23-year-old female with previous good health has sudden, severe, flulike symptoms

Which action would typically be performed by the emergency department bereavement committee? A. Assigns a staff nurse to sit with the family during resuscitation efforts of the patient B. Advocates that one or two family members be allowed at bedside during resuscitation C. Provides grief counseling and group support for nurses who care for patients who die D. Attends funerals, sends sympathy cards, and makes follow-up calls to family

D. Attends funerals, sends sympathy cards, and makes follow-up calls to family