Quiz 3 Triage and Burns

a 75 year old female with a cough and a temperature of 102 F

A nurse is triaging clients in the emergency department. Which client should be considered "urgent"? a 20 year old female with a chest stab wound and tachycardia a 75 year old female with a cough and a temperature of 102 F a 45 year old homeless man with a skin rash and sore throat a 50 year old male with new onset confusion and slurred speech

a 62 year old with a simple fracture of the left arm

A nurse is triaging clients in the emergency department. Which client should the nurse classify as "non urgent"? a 62 year old with a simple fracture of the left arm a 44 year old with chest pain and diaphoresis a 79 year old with a fever of 104 F and coughing up yellow mucous a 50 year old with chest trauma and absent breath sounds

"It helps prevent stomach ulcers, which are common after burns"

A nurse prepared to administer IV pantoprazole (protonix) to a client who has a new burn injury. The client asks, "Why am I taking this medication?" How should the nurse respond? "Protonix stimulates intestinal movement so you can eat more" "Protonix protects the kidney from from damage caused by dehydration" "Protonix improves fluid retention, which helps prevent hypovolemic shock" "It helps prevent stomach ulcers, which are common after burns"

partial thickness superficial

A nurse reviews the following data in the chart of a client with burn injuries: 65 year old with burns to bilateral arms. The burns are red, swollen with blisters and a pain score of 10/10. Based on the data provided. How should the nurse categorize the client's injuries? partial thickness deep superficial full thickness partial thickness superficial

serum potassium 6.5 mEq/L

A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately? serum sodium 131 mEq/L arterial pH 7.33 serum potassium 6.5 mEq/L hematocrit 52%

performs gloved dressing changes performs frequent handwashing uses disposable dishes

A nursing student is caring for a client with open wound burns. Which nursing interventions does the nursing student provide for this client? (select all that apply) performs gloved dressing changes provides cushions and rugs for comfort performs frequent handwashing places plants in the client's room for distractions uses disposable dishes

30 minutes

A patient admitted for abdominal pain and is listed as "urgent" should be seen within what time frame? 8 hours 1-2 hours there is no time frame 30 minutes

45%

A patient arrives at the emergency department with burns to the front and back of both legs and one arm. Using the rule of nines, what percentage of the patient's body surface area has been burned? 54% 27% 40.5% 45%

Lactated Ringer's solution

A patient is admitted to the emergency department with deep partial-thickness burns over 35% of the body. What IV solution will be started initially? dextrose 5% with water dextrose 5% with normal saline 0.45% saline solution Lactated Ringer's solution

use standard precautions use two patient identifiers call security for assistance with hostile patients search the patient's belongings for weapons

According to QSEN's best practice for staff safety, which interventions below would you include as a safety standard for nurses in the emergency department? (select all that apply) use standard precautions use two patient identifiers call security for assistance with hostile patients check the patient for a medical alert bracelet search the patient's belongings for weapons

mechanism of injury isolation precautions diagnostic test results

An emergency department nurse is preparing to transfer a client to the trauma intensive care unit. Which information is important for the nurse to include in the nurse-to-nurse hand-off report? (select all that apply) mechanism of injury isolation precautions diagnostic test results immunizations list of home medications

apply oxygen and continuous pulse oximetry

An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud brassy cough. Which action should the nurse take first? ask the respiratory therapist to provide humidified air apply oxygen and continuous pulse oximetry request a prescription for an antitussive medication provide small quantities of ice chips and sips of water

a 26 year old male who has pale, cool, clammy skin and a heart rate of 160

An emergency room nurse is triaging victims of a multi-casualty event. Which client should the receive care first? a 48 year old female with a compound fracture of the lower leg a 30 year old distraught mother holding her crying child a 26 year old male who has pale, cool, clammy skin and a heart rate of 160 a 65 year old conscious male with a head laceration

change gloves between wound care on different parts of the client's body

The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by auto contamination? use a disposable blood pressure chug to avoid sharing with other clients change gloves between wound care on different parts of the client's body use the closed method of burn wound management for all wound care advocate for proper and consistent hand washing by all members of the staff

"Sometimes I wake up at night an smoke"

The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern? "Sometimes I wake up at night an smoke" "I get my chimney swept every other year" "I use a space heater when it gets below zero" "My hot water heater is set at 120 degrees"

cervical spine stabilization

Which of the following is part of the primary survey in emergency care? CT scan of body within 20 minutes cervical spine stabilization insertion of a foley catheter full set of vital signs

electrical burn

Which type of burn is considered the most fatal? radiation burn chemical burn thermal burn electrical burn

morphine 4mg IV every 4 hours

A patient recovering from a major burn injury is complaining of pain. Which of the following medications will be most therapeutic to the patient? fentanyl citrate 75mcg patch every 3 days hydromorphone (dilaudid) 2mg po every 6 hours morphine 4mg IV every 4 hours morphine 8mg IM every 3 hours

determination of the type of burn injury

A patient has experienced a burn injury and is brought to the emergency room. Which of the following interventions by the nurse is of the highest priority at this time? assessment of the past medical history determination of body weight determination of the type of home remedies attempted prior to the patient's coming to the hospital determination of the type of burn injury

check to see if all of the clothing has been removed and begin flushing the patient's skin with water

A patient is brought to the emergency department with chemical burns. Which of the following should the nurse do to help this patient? keep the patient's contact lenses in place and flush only with warm water do not remove any jewelry begin flushing the patient's clothes and skin with warm water check to see if all of the clothing has been removed and begin flushing the patient's skin with water

a patient with small pieces of shrapnel embedded in both eyes a patient with open fractures of both legs with absent pedal pulses a patient with a neck injury and unable to move his legs

Emergency medical services brings a large number of patients to the emergency department following a mass casualty incident. Which patients are currently classified with red tags? (select all that apply) a patient who walked in the emergency department while deep cut on his forehead a patient with small pieces of shrapnel embedded in both eyes a patient with open fractures of both legs with absent pedal pulses a child who fell off a swing and has a deformity of her wrist a patient with a neck injury and unable to move his legs a patient with superficial partial thickness burns covering both legs

pink to red skin, slight edema, pain relieved by cooling pink to red in color with pain, often with blisters destruction of epidermis and upper layers of dermis, white or red, very edematous and sensitive to touch and cold air destruction of epidermis and dermis, reddened areas do not blanch with pressure, not painful and waxy white skin to brown, leathery

Math the following burns to their descriptions superficial superficial partial thickness deep partial thickness full thickness

start an IV line and infuse 0.9% saline solution

On a hot humid day, an emergency department nurse scaring for a client who is confused and has these vital signs: temp 104.1 F, pulse 132, respirations 26 breaths/min, blood pressure 106/66 mmHg. Which action should the nurse take? administer acetaminophen 650 mg orally encourage the client to drink cool water or sports drink encourage rest and reassess in 15 minutes start an IV line and infuse 0.9% saline solution

ask the spouse if he wishes to be present during the resuscitation

The emergency department is performing cardiopulmonary resuscitation on a client when the client's spouse arrives at the emergency department. Which action should the nurse take first? ask the spouse if he wishes to be present during the resuscitation refer the client's spouse to the hospitals's crisis team request that the spouse sit in the waiting room suggest that the spouse begin to pray for the client

disability section

The emergency room nurse is assessing the patient's Glascow coma scale. As a nursing student, you are aware that this procedure is what part of the primary survey? disability section airway/ stabilization section neurology section circulation section