TEST 5 (Emergency)
Which is the priority nursing action to include in a disaster plan for the radioactive dust and smoke that can cause illness from a radiologic dispersal device (RDD)? A. Covering the nose B. Protecting the eyes C. Decontaminating the skin D. Administering prophylactic antibiotics
A. Covering the nose
which category of personal protective equipment is the highest of protection A. level A B. level B C. level C D. level D
A. level A
The nurse understands the purpose of damage control surgery is which of the following? A. investigate cause of injury B. Control hemorrhage C. control hypoxia D. avoid further sugery
B. Control hemorrhage
Which emergency medical system (EMS) first responders can perform triage during mass casualty incidents? A. Unlicensed assistive personnel B. Nurses appointed to a field team C. A physician who survives the incident D. Community response team members
B. Nurses appointed to a field team
Treatment and/or prevention of rhabdomyolysis in at-risk patients include aggressive fluid resuscitation to achieve how much urine output? A. 30 mL/hr B. 50 mL/hr C. 100 mL/hr D. 300 mL/hr
C. 100 mL/hr
The nurse is a first responder for a health-care organization for a mass casualty incident. Which injury would the nurse tag as yellow during the triage process? A. Ankle sprain B. Hypovolemic shock C. Open femur fracture D. Massive head trauma
C. Open femur fracture
the father of a child brought to the ED is yelling at the staff and obviously intoxicated. How should the nurse approach A. call the police dept to come arrest him B. Notify the childs mother to come to the ED C. talk to the father in a calm and low voice D. tell the father to wait in the waiting room
C. talk to the father in a calm and low voice
Which assessment data indicates the patient is experiencing a late symptom associated with chronic aspirin overdose? A. Emesis B. Nausea C. Tinnitus D. Ecchymosis
D. Ecchymosis
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primary survey is done in A. 1-2 minutes B. 2-3 minutes C. 3-4 minutes D. 5 minutes or less
A. 1-2 minutes
Which is the most critical element of pediatric emergency care? A. Airway management B. Prevention of neurologic impairment C. Maintaining adequate circulation D. Supporting the child's family
A. Airway management
What is the goal of the initial intervention for a child in cardiopulmonary arrest? A. Establishing a patent airway B. Determining a pulse rate C. Removing clothing D. Reassuring the parents
A. Establishing a patent airway
What is the nurse's immediate action when a child comes to the emergency department with sweating, chills, and fang bite marks on the thigh? A. Secure antivenin therapy. B. Apply a tourniquet to the leg. C. Ambulate the child. D. Reassure the child and parent.
A. Secure antivenin therapy.
Which action should the nurse working in the emergency department implement in order to decrease fear in a 2-year-old child? A. Keep the child physically restrained during nursing care. B. Allow the child to hold a favorite toy or blanket. C. Direct the parents to remain outside the treatment room. D. Let the child decide whether to sit up or lie down for procedures.
B. Allow the child to hold a favorite toy or blanket.
The nurse understands priority prehospital interventions include which of the following? A. Notifying the local hospital of the transport of a trauma patient B. Assessing the patient using ABCs, treating life-threatening conditions C. Transport the patient as quickly as possible to the nearest trauma center D. Treating ill injuries found and then transporting the patient
B. Assessing the patient using ABCs, treating life-threatening conditions
Epinephrine dose in a code is 2 mg every 2 minutes A. true B. false
B. false
A nurse manager is a member of the emergency response planning team for a hospital located in the Rocky Mountains. Which type of natural disaster will the nurse manager recommend be included in their hospital disaster plan? A. Tornado B. Hurricane C. Avalanche D. Earthquake
C. Avalanche
Which action should the nurse incorporate into a care plan for a 14-year-old child in the emergency department? A. Limit the number of choices to be made by the adolescent. B. Insist that parents remain with the adolescent. C. Provide clear explanations and encourage questions. D. Give rewards for cooperation with procedures.
C. Provide clear explanations and encourage questions.
A 3-year-old is brought to the emergency department by ambulance after her body was found submerged in the family pool. The child has altered mental status and shallow respirations. She did not require resuscitative interventions. Which condition should the nurse monitor first in this child? A. Neurologic status B. Hypothermia C. Hypoglycemia D. Hypoxia
D. Hypoxia
The nurse should call the rapid response EMS for which patients? (Select all that apply.) A. 53-year-old with pneumonia and severe respiratory distress B. 17-year-old with apnea following a head injury C. 24-year-old experiencing a severe asthmatic attack with stridor D. 73-year-old patient with bradycardia of 40 beats per minute E. 52-year-old patient with no palpable pulse
A. 53-year-old with pneumonia and severe respiratory distress C. 24-year-old experiencing a severe asthmatic attack with stridor D. 73-year-old patient with bradycardia of 40 beats per minute
C-spine stabilization should be done during A. A-Airway B. B-Breathing C. C-Circulation D. D-Disability
A. A-Airway
When doing manual ventilations during a code, the nurse would administer ventilations following which guideline? A. Approximately 10 to 12 breaths per minute B. During the fifth chest compression C. Every 3 seconds or 20 times per minute D. While compressions are stopped
A. Approximately 10 to 12 breaths per minute
The nurse is a member of the critical incident stress management unit that looks to meet the psychosocial needs of first responders after a mass casualty incident. Which action by the nurse is appropriate when conducting a session? A. Arranging group discussion B. Administering anti-anxiety medication C. Scheduling individual therapy appointments D. Documenting individual responses to the session
A. Arranging group discussion
The patient's monitor shows bradycardia (heart rate of 40 beats/min) and frequent premature ventricular contractions (PVCs) with a measured blood pressure of 85/50 mm Hg. The nurse anticipates the use of which drug? A. Atropine 0.5 to 1 mg intravenous push B. Dopamine drip—continuous infusion C. Lidocaine 1 mg/kg intravenous push D. Transcutaneous pacemaker
A. Atropine 0.5 to 1 mg intravenous push
The nurse chooses which method and concentration of oxygen administration until intubation is established in a patient who has sustained a cardiopulmonary arrest? A. Bag-valve-mask at FiO2 of 100% B. Bag-valve-mask at FiO2 of 50% C. Mouth-to-mask ventilation with supplemental oxygen D. Non-rebreather mask at FiO2 of 100%
A. Bag-valve-mask at FiO2 of 100%
A medical-surgical unit is expecting a large volume of patient admissions after a train derailment. Which member of the nursing care team will prioritize care for the unit? A. Charge nurse B. Nurse supervisor C. Licensed practical nurse D. Unlicensed assistive personnel
A. Charge nurse
During the assessment of a patient after a high-speed motor vehicle crash, which of the following findings would increase the nurse's suspicion of a pulmonary contusion? (Select all that apply.) A. Chest wall ecchymosis B. Diminished or absent breath sounds C. Pink-tinged or blood secretions D. Signs of hypoxia on room air E. Fractured ribs
A. Chest wall ecchymosis C. Pink-tinged or blood secretions D. Signs of hypoxia on room air E. Fractured ribs
An emergency department nurse is making a general appearance assessment on a preschool child just admitted to the emergency department. Which general assessment findings indicate the child "looks bad"? Select all that apply. A. Color pale B. Capillary refill less than 2 seconds C. Unwilling to separate from parents D. Cold extremities E. Lethargic
A. Color pale D. Cold extremities E. Lethargic
Which of the following patients would require greater amounts of fluid resuscitation to prevent acute kidney injury associated with rhabdomyolysis? (Select all that apply.) A. Crush injury to right arm B. Gunshot wound to the abdomen C. Lightning strike of the left arm and chest D. Pulmonary contusion and rib fracture E. Second degree burns to 40% of the body
A. Crush injury to right arm C. Lightning strike of the left arm and chest E. Second degree burns to 40% of the body
You are the nurse working triage in the emergency department. A school-age child is brought in for treatment, carried by her mother. What is part of a primary assessment that should be performed first on this child? A. Determine level of consciousness. B. Obtain a health history. C. Obtain a full set of vital signs. D. Evaluate for pain.
A. Determine level of consciousness.
The nurse is conducting a secondary survey as part of the emergency assessment. Which is the priority nursing action during the health history portion of the assessment? A. Determining drug allergies B. Noting the general appearance C. Examining the neck for stiffness D. Auscultating for heart and lung sounds
A. Determining drug allergies
Which are the priority nursing actions after the completion of the secondary survey when providing care for a trauma patient with a penetrating wound? A. Documenting the patient's care B. Formulating the patient's plan of care C. Reassessing the patient's level of consciousness D. Transferring the patient to the general medical unit
A. Documenting the patient's care
Which of the following statements about defibrillation are correct? (Select all that apply.) A. Early defibrillation (if warranted) is recommended before other actions. B. It is not necessary to ensure that personnel are clear of the patient if hands-off defibrillation is used. C. It is not necessary to synchronize the defibrillation shocks. D. Paddles/patches can be placed anteriorly and posteriorly on the chest. E. All models of defibrillators are the same to assure standardization.
A. Early defibrillation (if warranted) is recommended before other actions. C. It is not necessary to synchronize the defibrillation shocks. D. Paddles/patches can be placed anteriorly and posteriorly on the chest.
Which interventions can the nurse implement to assist the patient's family in coping with the traumatic event? (Select all that apply.) A. Establish a family spokesperson. B. Ask the family about their normal coping mechanisms. C. Limit visitation to set times throughout the day. D. Coordinate a family conference. E. Provide an effective communication system between staff and family
A. Establish a family spokesperson. B. Ask the family about their normal coping mechanisms D. Coordinate a family conference. E. Provide an effective communication system between staff and family
Benefits of having the family present during resuscitation include which of the following? (Select all that apply.) A. Facilitates the grief process B. Letting family sees that everything is being done C. Sustaining patient-family relationships D. Allows the staff easy access to ask for organ transplant E. Provides a sense of closure
A. Facilitates the grief process B. Letting family sees that everything is being done C. Sustaining patient-family relationships E. Provides a sense of closure
The nurse is conducting a primary survey during an emergency assessment. Which is the priority nursing action related to breathing in response to this assessment? A. Having suction available B. Assessing pupil size and reactivity C. Immobilizing any obvious deformities D. Obtaining blood samples for type and crossmatch
A. Having suction available
A front end high speed MVC should be monitored for what injuries. Seat belt on, no airbags, bent steering wheel. A. Head, C-spine, sternal/rib, cardiac contusion, hollow abdominal organ injury B. Sternal/rib, collarbone fracture, pelvic fracture, facial fracture injuries C. Sternal/rib, Tspine, pelvic fracture injuries D. Head, C-spine, solid abdominal organ injuries
A. Head, C-spine, sternal/rib, cardiac contusion, hollow abdominal organ injury
A 2-year-old child is in the playroom. The nurse observes him picking up a small toy and putting it in his mouth. The child begins to choke. He is unable to speak. Which intervention is appropriate? A. Heimlich maneuver B. Abdominal thrusts C. Five back blows D. Five chest thrusts
A. Heimlich maneuver
What is the major reason for using a treatment to lower body temperature after cardiac arrest to promote better neurological recovery? A. Hypothermia decreases the metabolic rate by 7% for each decrease of 1° C. B. Lower body temperatures are beneficial in patients with low blood pressure. C. Temperatures of 40° C may reduce neurological impairment. D. The lower body temperature leads to decreased oxygen delivery.
A. Hypothermia decreases the metabolic rate by 7% for each decrease of 1° C.
Which is the priority in the preparedness of health-care professionals in any type of disaster plan? A. Identification of hazards B. Cooperation with state authorities C. Collaboration with local authorities D. Implementation of federal mandates
A. Identification of hazards
A green-tagged patient arrives at the emergency department after a mass casualty incident (MCI) involving radiation. Which is the priority nursing action for this patient? A. Implementing decontamination measures B. Performing a head-to-toe physical examination C. Placing a special bracelet with a disaster number D. Taking a digital photo and placing it on the medical record
A. Implementing decontamination measures
Trauma patients are at high risk for multiple complications not only due to the mechanism of injury but also due to the patients' long-term management. Which of the following statements apply to trauma patients? (Select all that apply.) A. Indwelling urinary catheters are a source of infection. B. Patients often develop infection and sepsis secondary to central line catheters. C. Pneumonia is often an adverse outcome of mechanical ventilation. D. Wounds require sterile dressings to prevent infection. E. Early ambulation is critical to achieving desired outcomes
A. Indwelling urinary catheters are a source of infection. B. Patients often develop infection and sepsis secondary to central line catheters. C. Pneumonia is often an adverse outcome of mechanical ventilation.
After the return of spontaneous circulation following the resuscitation of a patient who had a cardiac arrest, therapeutic hypothermia is ordered. Which action will the nurse include in the plan of care? A. Initiate cooling per protocol. B. Avoid the use of sedative drugs. C. Check mental status every 15 minutes. D. Rewarm if temperature is below 91° F (32.8° C
A. Initiate cooling per protocol.
Which statement best describes an AED A. It analyzes the rhythm and shocks the client diagnosed with fib B. It will keep the health care provider informed of the clients oxygen level C. The AED will perform cardiac compressions on the client D. The client will be able to have synchronized cardioversion with the AED
A. It analyzes the rhythm and shocks the client diagnosed with fib
An 18-year-old unrestrained passenger who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. This patient should be treated at which level trauma center? A. Level I B. Level II C. Level III D. Level IV
A. Level I
Which of the following findings require immediate nursing interventions related to the assessment of a patient with a traumatic brain injury? (Select all that apply.) A. Mean arterial pressure 48 mm Hg B. Elevated serum blood alcohol level C. Non-reactive pupils D. Respiratory rate of 10 breaths per minute E. History of posttraumatic stress disorder (PTSD)
A. Mean arterial pressure 48 mm Hg C. Non-reactive pupils D. Respiratory rate of 10 breaths per minute
Which of the following are documented as part of the cardiopulmonary arrest record? (Select all that apply.) A. Medication administration times B. Defibrillation times, joules, outcomes C. Rhythm strips of cardiac rhythm(s) noted D. Signatures of recorder and other personnel E. Model of defibrillator used
A. Medication administration times B. Defibrillation times, joules, outcomes C. Rhythm strips of cardiac rhythm(s) noted D. Signatures of recorder and other personnel
The nurse is having difficulty inserting a large caliber intravenous catheter to facilitate fluid resuscitation to a hypotensive trauma patient. The nurse recommends which of the following emergency procedures to facilitate rapid fluid administration? A. Placement of an intraosseous catheter B. Placement of a central line placement C. Insertion of a femoral catheter by a trauma surgeon D. Rapid transfer to the operating room
A. Placement of an intraosseous catheter
Nursing priorities to prevent ineffective coagulation include which of the following? (Select all that apply.) A. Prevention of hypothermia B. Administration of fresh frozen plasma as ordered C. Administration of potassium as ordered D. Administration of calcium as ordered E. Prevention of infection
A. Prevention of hypothermia B. Administration of fresh frozen plasma as ordered D. Administration of calcium as ordered
The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first? A. Remove the patient's rings. B. Apply ice packs to both hands. C. Apply calamine lotion to itching areas. D. Give diphenhydramine (Benadryl) 50 mg PO
A. Remove the patient's rings.
A nurse is working an evening shift when a fire breaks out at the hospital. Which actions by the nurse are appropriate? Select all that apply. A. Removing patients from immediate danger B. Discontinuing the use of oxygen for all patients C. Using a wheelchair to move a bedridden patient D. Directing ambulatory patients to walk to a safe location E. Containing the fire immediately to avoid patient evacuation
A. Removing patients from immediate danger C. Using a wheelchair to move a bedridden patient D. Directing ambulatory patients to walk to a safe location
Which nursing actions are necessary when initiating care for patients who have been injured in a natural disaster? Select all that apply. A. Taking risks B. Using principles C. Stepping into the unknown D. Showing a commanding presence E. Formulating individualized plans of care
A. Taking risks B. Using principles C. Stepping into the unknown D. Showing a commanding presence
The registered nurse (RN) is the team leader for a group of patients using the functional model of nursing. The team of nurses includes two licensed practical nurses (LPNs) and an unlicensed assistive personnel (UAP). Which task will the RN delegate to the UAP? A. Taking vital signs B. Providing wound care C. Conducting discharge teaching D. Administering oral medications
A. Taking vital signs
Which organization in the United States mandates ongoing disaster preparedness for hospitals? A. The Joint Commission (TJC) B. The local government C. The state government D. The Occupational Safety and Health Administration (OSHA)
A. The Joint Commission (TJC)
Which nursing actions during a mass casualty incident should be included in the triage portion of an organizational disaster plan? Select all that apply. A. Treatment B. Stabilization C. Evaluation of interventions D. Formulation of nursing diagnosis E. Decontamination for suspected contamination
A. Treatment B. Stabilization E. Decontamination for suspected contamination
An unresponsive 79-yr-old patient is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 105.4° F (40.8° C), blood pressure (BP) is 88/50 mm Hg, and pulse is 112 beats/min. The nurse will plan to A. apply wet sheets and a fan to the patient. B. provide O2 at 2 L/min with a nasal cannula. C. start lactated Ringer's solution at 1000 mL/hr. D. give acetaminophen (Tylenol) rectal suppository
A. apply wet sheets and a fan to the patient.
A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10 abdominal pain and states, "I had a temperature of 103.9° F (39.9° C) at home." The nurse's first action should be to A. assess the patient's current vital signs. B. give acetaminophen (Tylenol) per agency protocol. C. ask the patient to provide a clean-catch urine for urinalysis. D. tell the patient that it will be 1 to 2 hours before seeing a health care provider
A. assess the patient's current vital signs.
Gastric lavage and administration of activated charcoal are ordered for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action should the nurse plan to do first? A. Insert a large-bore orogastric tube. B. Assist with intubation of the patient. C. Prepare a 60-mL syringe with saline D. Give first dose of activated charcoal
B. Assist with intubation of the patient.
A 74-year-old patient is admitted to the coronary care unit with an inferior wall myocardial infarction and develops symptomatic bradycardia with premature ventricular contractions every third beat (trigeminy). The nurse knows to prepare to administer which drug? A. Amiodarone B. Atropine C. Lidocaine D. Magnesium
B. Atropine
Which code drugs can be given safely through an endotracheal tube? (Select all that apply.) A. Adenosine B. Atropine C. Epinephrine D. Vasopressin E. Lidocaine
B. Atropine C. Epinephrine D. Vasopressin E. Lidocaine
Which are the most common types of injuries that should be identified along with treatment options in an organizational disaster plan for the use of explosive devices as agents of terrorism? Select all that apply. A. Burn B. Blast C. Crush D. Penetration E. Psychological
B. Blast C. Crush D. Penetration
It is important to prevent hypothermia in the trauma patient because hypothermia is associated with which of the following? (Select all that apply.) A. Acute respiratory distress syndrome (ARDS) B. Coagulopathies C. Dysrhythmias D. Myocardial dysfunction E. Reduced tissue perfusion
B. Coagulopathies C. Dysrhythmias D. Myocardial dysfunction E. Reduced tissue perfusion
Which is a potentially life-threatening condition found during the primary triage survey that would necessitate priority nursing care? A. Cystitis B. Concussion C. Lacerated arm D. Fractured femur
B. Concussion
The nurse is conducting a primary survey during the emergency assessment. Which nursing action is appropriate during the breathing assessment? A. Assessing for edema B. Counting respiratory rate C. Checking for foreign bodies D. Monitoring for respiratory distress
B. Counting respiratory rate
Which of the following factors contributes the most to positive patient outcomes in a mass casualty disaster? A. Availability of air transportation B. Disaster triage C. Transport of all victims to the closest hospital D. On-site patient treatment
B. Disaster triage
Which statement about mass casualty triage during a disaster is true? A. Priority treatments and interventions focus primarily on young victims. B. Disaster victims with the greatest chances for survival receive priority for treatment. C. Once interventions have been initiated, healthcare providers cannot stop the treatment of disaster victims. D. Color-coded systems in which green indicates the patient of greatest need are used during disasters.
B. Disaster victims with the greatest chances for survival receive priority for treatment.
You are the nurse caring for a child who is diagnosed with septic shock. He begins to develop an dysrhythmia and hemodynamic instability. Endotracheal intubation is necessary. The physician feels that cardiac arrest may soon develop. What drug do you anticipate the physician will order? A. Atropine sulfate B. Epinephrine C. Sodium bicarbonate D. Inotropic agents
B. Epinephrine
Fluid resuscitation is an important component of managing the trauma patient. Which of the following statements are true regarding the care of a trauma patient? (Select all that apply.) A. 5% Dextrose is recommended for rapid crystalloid infusion. B. IV fluids may need to be warmed to prevent hypothermia. C. Massive transfusions should be avoided to improve patient outcomes. D. Only fully cross-matched blood products are administered. E. Type O blood can be administered in emergency situations.
B. IV fluids may need to be warmed to prevent hypothermia. C. Massive transfusions should be avoided to improve patient outcomes. E. Type O blood can be administered in emergency situations.
Which nursing actions are appropriate during the primary survey of the emergency assessment process? Select all that apply. A. Inserting a nasogastric tube B. Immobilizing the cervical spine C. Arranging for diagnostic studies D. Preparing for chest tube insertion E. Applying direct pressure to a wound
B. Immobilizing the cervical spine D. Preparing for chest tube insertion E. Applying direct pressure to a wound
Which nursing action facilitates care being provided to a child in an emergency situation? A. Encourage the family to remain in the waiting room. B. Include parents as partners in providing care for the child. C. Always reassure the child and family. D. Give explanations using professional terminology.
B. Include parents as partners in providing care for the child.
Which observation indicates that interventions provided to a patient with neck injuries from a motor vehicle crash have been successful? A. Urine is clear and odorless from indwelling catheter B. Moves all four extremities independently, feeds self, and participates in partial bath C. Unable to move independently in bed D. Rests in bed with lights and television turned off
B. Moves all four extremities independently, feeds self, and participates in partial bath
During the treatment and management of the trauma patient, maintaining tissue perfusion, oxygenation, and nutritional support are strategies to prevent what potential complication? A. Disseminated intravascular coagulation B. Multisystem organ dysfunction C. Septic shock D. Wound infection
B. Multisystem organ dysfunction
Which is the priority nursing action when providing care to a patient with a penetrating abdominal wound? A. Assessing bowel sounds B. Stabilizing the impaled object C. Administering prescribed pain medication D. Scheduling a CT scan to determine retroperitoneal bleeding
B. Stabilizing the impaled object
Which observations made by an emergency department nurse raises the suspicion that a 3-year-old child has been maltreated? A. The parents are extremely calm in the emergency department. B. The injury is unusual for a child of that age. C. The child does not remember how he got hurt. D. The child was doing something unsafe when the injury occurred.
B. The injury is unusual for a child of that age.
Range-of-motion exercises, early ambulation, and adequate hydration are interventions to prevent this common complication observed in trauma patients? A. Catheter-associated infection B. Venous thromboembolism C. Fat embolism D. Nosocomial pneumonia
B. Venous thromboembolism
A patient who has experienced blunt abdominal trauma during a motor vehicle collision is complaining of increasing abdominal pain. The nurse will plan to teach the patient about the purpose of A. peritoneal lavage. B. abdominal ultrasonography. C. nasogastric (NG) tube placement. D. magnetic resonance imaging (MRI
B. abdominal ultrasonography.
The nurse knows that in advanced cardiac life support, the secondary survey includes steps A-B-C-D where "D" refers to A. defibrillate. B. differential diagnosis. C. diltiazem intravenous push. D. do not resuscitate.
B. differential diagnosis.
A patient had been successfully converted from ventricular tachycardia with a pulse to a sinus rhythm. Upon further assessment, it is noted that the patient is hypotensive. What is the appropriate treatment for hypotension in this situation? (Select all that apply.) A. Adenosine B. dopamine infusion C. Magnesium D. Normal saline infusion E. Sodium bicarbonate
B. dopamine infusion D. Normal saline infusion
A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should A. obtain a complete set of vital signs. B. obtain a Glasgow Coma Scale score. C. attach an electrocardiogram monitor. D. ask about chronic medical conditions
B. obtain a Glasgow Coma Scale score.
A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). The nurse determines that discharge teaching has been effective when the patient makes which statement? A. "I'll take salt tablets when I work outdoors in the summer." B. "I should take acetaminophen (Tylenol) if I start to feel too warm." C. "I need to drink extra fluids when working outside in hot weather." D. "I'll move to a cool environment if I notice that I'm feeling confused"
C. "I need to drink extra fluids when working outside in hot weather."
Which patient has the greatest risk of developing acute respiratory distress syndrome (ARDS) after traumatic injury? A. A patient who has a closed head injury with a decreased level of consciousness B. A patient who has a fractured femur and is currently in traction C. A patient who has received large volumes of fluid and/or blood replacement D. A patient who has underlying chronic obstructive pulmonary disease
C. A patient who has received large volumes of fluid and/or blood replacement
Family members are in the patient's room when the patient has a cardiac arrest and the staff start resuscitation measures. Which action should the nurse take next? A. Keep the family in the room and assign a staff member to explain the care given and answer questions. B. Ask the family to wait outside the patient's room with a designated staff member to provide emotional support. C. Ask the family members whether they would prefer to remain in the patient's room or wait outside the room. D. Tell the family members that patients are comforted by having family members present during resuscitation efforts
C. Ask the family members whether they would prefer to remain in the patient's room or wait outside the room.
The code team has just defibrillated a patient in ventricular fibrillation. Following CPR for 2 minutes, what is the next action to take? A. Administer amiodarone. B. Administer lidocaine. C. Assess rhythm and pulse. D. Prepare for transcutaneous pacing.
C. Assess rhythm and pulse.
A nurse is developing a plan of care for a patient with traumatic injuries from a motor vehicle crash. Which nursing intervention does the nurse include in the plan of care to reduce the risk of integumentary complications? A. Provide active or passive exercises at least once every eight hours B. Encourage coughing, deep breathing, and incentive spirometry C. Assist the patient in turning at least every two hours D. Assist the patient in turning at least every eight hours
C. Assist the patient in turning at least every two hours
Which rhythm would be an emergency indication for the application of a transcutaneous pacemaker? A. Asystole B. Bradycardia (heart rate 40 beats/min) normotensive and alert C. Bradycardia (heart rate 50 beats/min) with hypotension and syncope D. Supraventricular tachycardia (heart rate 150 beats/min), hypotensive
C. Bradycardia (heart rate 50 beats/min) with hypotension and syncope
Ventricular fibrillation should initially be treated by which of the following? (Select all that apply.) A. Administration of dobutamine, followed by defibrillation at 360 J B. Atropine 1 mg, followed by defibrillation at 200 J C. Defibrillation at 200 J with biphasic defibrillation D. Defibrillation at 360 J with monophasic defibrillation E. Dopamine by continuous infusion
C. Defibrillation at 200 J with biphasic defibrillation D. Defibrillation at 360 J with monophasic defibrillation
A 24-year-old unrestrained driver who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. What should the primary survey of this patient upon arrival to the ED include? A. A cervical spine x-ray study to determine the presence of a fracture. B. Turning the patient from side to side to get a look at his back. C. Getting a baseline assessment and establish priorities. D. A methodical head-to-toe assessment identifying injuries and treatment priorities.
C. Getting a baseline assessment and establish priorities.
The emergency department (ED) nurse is starting therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/LVN) (select all that apply)? A. Continuously monitor heart rhythm B. Assess neurologic status every 2 hours. C. Give acetaminophen (Tylenol) 650 mg. D. Place cooling blankets above and below patient. E. Attach rectal temperature probe to cooling blanket control panel
C. Give acetaminophen (Tylenol) 650 mg. D. Place cooling blankets above and below patient. E. Attach rectal temperature probe to cooling blanket control panel
which nursing intervention can be delegated to the nursing assistant A. performing a dressing change on the client diagnosed with a chemical burn B. give activated charcoal to a client with tylenol poisoning C. Helping a client diagnosed with carbon monoxide poisoning reposition D. inserting a catheter for accurate I & O for a patient with food poisoning
C. Helping a client diagnosed with carbon monoxide poisoning reposition
The nurse observes abdominal breathing in a 2-year-old child. What does this finding indicate? A. Imminent respiratory failure B. Hypoxia C. Normal respiration D. Airway obstruction
C. Normal respiration
Which psychosocial nursing actions are appropriate when providing patient care after a community disaster? Select all that apply. A. Performing triage of injuries B. Administering first aid to wounds C. Offering choices whenever possible D. Establishing rapport through active listening E. Requesting assistance from crisis counselors
C. Offering choices whenever possible D. Establishing rapport through active listening E. Requesting assistance from crisis counselors
The patient has a transcutaneous pacemaker in place. Pacemaker spikes followed by QRS complexes are noted on the cardiac rhythm strip. To determine if the pacemaker is working, the nurse must do which of the following? A. Obtain a 12-lead electrocardiogram (ECG). B. Call for a pacemaker interrogation. C. Palpate the pulse. D. Run a 2-minute monitor strip for analysis.
C. Palpate the pulse.
The nurse has admitted a patient to the ED following a fall from a first-floor hotel balcony. The patient, 22 years old and smelling of alcohol, begins to vomit. Which intervention is most appropriate? A. Insert an oral airway to prevent aspiration and to protect the airway. B. Offer the patient an emesis basin so that you can measure the amount of emesis. C. Prepare to suction the oropharynx while maintaining cervical spine immobilization. D. Send a specimen of the emesis to the laboratory for analysis of blood alcohol content.
C. Prepare to suction the oropharynx while maintaining cervical spine immobilization.
During a code, the nurse would place paddles for anterior defibrillation in what locations? A. Second intercostal space, left sternal border and fourth intercostal space, left midclavicular line B. Second intercostal space, right sternal border and fourth intercostal space, left midaxillary line C. Second intercostal space, right sternal border and fifth intercostal space, left midclavicular line D. Fourth intercostal space, right sternal border and fifth intercostal space, left midclavicular line
C. Second intercostal space, right sternal border and fifth intercostal space, left midclavicular line
What is the most important for first responders to implement when performing mouth to mouth resuscitation? A. use their mouth to cover the client's mouth and nose B. Inserting an oral airway before performing mouth to mouth C. Use a pocket mouth shield to cover the clients mouth D. perform the jaw thrust maneuver to open the airway
C. Use a pocket mouth shield to cover the clients mouth
A staff member is performing compressions on an adult client. What warrants immediate intervention by the RN? A. performs cardiac compressions and allows for rescue breathing B. hand placement on lower half of the sternum C. depresses the sternum 0.5 to 1 inch during compressions D. asks to be relieved from performing compressions because of exhaustion
C. depresses the sternum 0.5 to 1 inch during compressions
The emergency department nurse is triaging patients. Which patient should be prioritized? A. An adult patient experiencing mild chest pain B. An adolescent patient with a possible fractured wrist C. An older adult patient with a hip fracture who is in pain D. A school-age patient with asthma presenting with dyspnea
D. A school-age patient with asthma presenting with dyspnea
Which of the following contributes to a successful disaster response? A. Immediate response for patients as soon as they arrive to the ED B. Decontamination area located in the ED C. Aggressive resuscitation efforts for patients without a pulse D. Appropriate PPE to protect all staff from contamination
D. Appropriate PPE to protect all staff from contamination
A workplace violence prevention plan is often one component of a hospital disaster plan. Which unit assumes priority for implementation and evaluation of this component to the plan? A. Medical unit B. Surgical unit C. Radiology department D. Emergency department
D. Emergency department
What is an appropriate nursing intervention for a 6-month-old infant in the emergency department? A. Distract the infant with noise or bright lights. B. Avoid warming the infant. C. Remove any pacifiers from the baby. D. Encourage the parent to hold the infant.
D. Encourage the parent to hold the infant.
Which entity is responsible for activating the disaster plan during a mass casualty incident (MCI)? A. Local emergency management system B. State emergency management system C. Federal emergency management agency D. Hospital-level emergency management system
D. Hospital-level emergency management system
A 90-year-old nursing home patient is admitted to the critical care unit with a severe case of pneumonia. No living will or designation of healthcare surrogate is noted on the chart. In the event this patient needs intubation and/or cardiopulmonary resuscitation, what should be the nurse's action? A. Activate the code team, but initiate a "slow" code. B. Call the nursing home to determine the patient's or family's wishes. C. Code the patient for 5 minutes and then cease efforts. D. Initiate intubation and/or cardiopulmonary resuscitation efforts.
D. Initiate intubation and/or cardiopulmonary resuscitation efforts.
A patient is brought into the emergency department after being assaulted. It is suspected that the patient has a spinal cord injury. Which diagnostic test does the nurse anticipate based on the data collected? A. Computed tomography (CT) scan B. X-ray C. Ultrasound D. Magnetic resonance imaging (MRI)
D. Magnetic resonance imaging (MRI)
The nurse is caring for a patient who sustained rib fractures after hitting the steering wheel of a car. The patient is spontaneously breathing and receiving oxygen via a face mask; the oxygen saturation is 95%. During the nurse's assessment, the oxygen saturation drops to 80%. The patient's blood pressure has dropped from 128/76 mm Hg to 84/60 mm Hg. The nurse assesses that breath sounds are absent throughout the left lung fields. The nurse notifies the physician and anticipates what prescribed intervention? A. Administration of lactated Ringer's solution (1 L) wide open. B. Chest x-ray study to determine the etiology of the symptoms. C. Endotracheal intubation and mechanical ventilation. D. Needle thoracostomy and chest tube insertion.
D. Needle thoracostomy and chest tube insertion.
The need for fluid resuscitation can be assessed best in the trauma patient by monitoring and trending which of the following tests? A. Arterial oxygen saturation B. Hourly urine output C. Mean arterial pressure D. Serum lactate levels
D. Serum lactate levels
What is an initial symptom of a suspected compartment syndrome? A. Absence of pulse in affected extremity B. Pallor in the affected area C. Paresthesia in the affected area D. Severe, throbbing pain in the affected area
D. Severe, throbbing pain in the affected area
The nurse finds a client unresponsive on the floor of the bathroom. Which action should the nurse implement first? A. Check the client for breathing B. Assess the carotid artery for a pulse C. notify the rapid response team D. Shake the client and shout
D. Shake the client and shout
The nurse needs to evaluate arterial blood gases before the administration of which drug? A. Calcium chloride B. Magnesium sulfate C. Potassium D. Sodium bicarbonate
D. Sodium bicarbonate
Which intervention is a strategy to prevent fat embolism syndrome? A. Administer lipid-lowering statin medications. B. Intubate the patient early after the injury to provide mechanical ventilation. C. Provide prophylaxis with low-molecular weight heparin. D. Stabilize extremity fractures early.
D. Stabilize extremity fractures early.
During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent and the entire leg is swollen. Which action will the nurse take next? A. Send blood to the lab for a complete blood count. B. Assess further for a cause of the decreased circulation. C. Finish the airway, breathing, circulation, disability survey. D. Start normal saline fluid infusion with a large-bore IV line
D. Start normal saline fluid infusion with a large-bore IV line
The father of a child in the emergency department is yelling at the physician and nurses. Which action is contraindicated in this situation? A. Provide a nondefensive response. B. Encourage the father to talk about his feelings. C. Speak in simple, short sentences. D. Tell the father he must wait in the waiting room.
D. Tell the father he must wait in the waiting room.
When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87° F (30.6° C), which finding indicates that the nurse should discontinue active rewarming? A. The patient begins to shiver. B. The BP decreases to 86/42 mm Hg. C. The patient develops atrial fibrillation. D. The core temperature is 94° F (34.4° C)
D. The core temperature is 94° F (34.4° C)
Which intervention is most important for the nurse to implement when participating in a code? A. Elevate the arm when administering medication B. Maintain sterile technique throughout the code C. Provide accurate documentation of what happened during the code D. Treat the clients clinical manifestations; do not treat the monitor
D. Treat the clients clinical manifestations; do not treat the monitor
Which nursing action is most appropriate to assist a preschool-age child in coping with the emergency department experience? A. Explain procedures and give the child at least 1 hour to prepare. B. Remind the child that she is a big girl. C. Avoid the use of bandages. D. Use positive terms and avoid terms such as "shot" and "cut."
D. Use positive terms and avoid terms such as "shot" and "cut."
A patient found in apartment with no air has temp of 105F. what should the nurse to do first? A. Establish IV access B. Obtain laboratory specimens C. administer tylenol D. apply cooling blankets
D. apply cooling blankets
client found in parking lot by EMS with motor running. He reports HA, nausea, dizziness and is unable to recall name A. check the clients oxygenation level with a pulse ox B. obtain a psychiatric consult to determine if this was a suicide attempt C. Prepare the client for transfer to a facility with a hyperbaric chamber D. apply oxygen via nasal cannula at 100%
D. apply oxygen via nasal cannula at 100%
Which patient injury would receive a black tag by the triage nurse during a mass casualty incident? A. Concussion B. Ankle sprain C. Open femur fracture D. Full-thickness body burns
D. Full-thickness body burns
What should be the emergency department nurse's next action when a 6-year-old child has a systolic blood pressure of 58 mm Hg? A. Alert the physician about the systolic blood pressure. B. Comfort the child and assess respiratory rate. C. Assess the child's responsiveness to the environment. D. Alert the physician that the child may need intravenous fluids.
A. Alert the physician about the systolic blood pressure.
The emergency department nurse notices that the mother of a young child is making a lot of phone calls and getting advice from her friends about what she should do. This behavior is an indication of A. Stress B. Healthy coping skills C. Attention-getting behaviors D. Low self-esteem
A. Stress
During cardioversion, the nurse would synchronize the electrical charge to coincide with which wave of the ECG complex? A. P B. R C. S D. T
B. R
The nurse is caring for clients on a medical floor. Which client is most likely to experience sudden cardiac death? A. 65 year old client exhibiting supra ventricular tachycardia B. 60 year old asymptomatic sinus bradycardia C. 53 year old client exhibiting ventricular fibrillation D. 84 year old client exhibiting uncontrolled Afib
C. 53 year old client exhibiting ventricular fibrillation
what education should a nurse give regarding radiation A. live, love, lead B. stop, drop, roll C. Time, distance, shield D. stop, collaborate, and listen
C. Time, distance, shield
A patient recovering from a motor vehicle crash develops hypotension and jugular distension with a tracheal deviation. Based on this data, which should the nurse suspect occurred? A. Hemorrhage B. Compensatory shock C. Hypovolemic shock D. Tension pneumothorax
D. Tension pneumothorax
Which initial assessment made by the triage nurse suggests that a child requires immediate intervention? A. The child has thick yellow rhinorrhea. B. The child has a frequent nonproductive cough. C. The child's oxygen saturation is 95% by pulse oximeter. D. The child is grunting.
D. The child is grunting.
end of med surge
critical care now
The patient is diagnosed with abrupt onset of supraventricular tachycardia (SVT). The nurse prepares which medication that has a short half-life and is recommended to treat symptomatic SVT? A. Adenosine B. Amiodarone C. Diltiazem D. Procainamide
A. Adenosine
Post-resuscitation goals include which of the following? (Select all that apply.) A. Control dysrhythmias B. Maintain airway C. Maintain blood pressure D. Wean off oxygen E. Early ambulation
A. Control dysrhythmias B. Maintain airway C. Maintain blood pressure
The nurse manager is reviewing the hospital disaster plan with other members of the committee. Which is the minimum number of disaster drills the committee must plan and implement each year? A. Two B. Three C. Four D. Five
A. Two
Disability in ABCD assessment means A. assess for hemorrhage B. assess for broke bones C. Assess GCS score D. assess for obstruction
C. Assess GCS score
A patient develops frequent ventricular ectopy. The nurse prepares to administer which drug? A. Adenosine B. Atropine C. Lidocaine D. Magnesium
C. Lidocaine
Which assessment data related to the patient's airway would indicate the need for priority intervention by the nurse? A. Eupnea B. Tachycardia C. Hypotension D. Agonal breaths
D. Agonal breaths
Which public health risk became a major focus for hospitals after the September 11, 2001 terrorist attacks? A. Anthrax exposure B. Multi-casualty incidents C. Mass casualty incidents (MCI) D. Weapons of mass destruction (WMD)
D. Weapons of mass destruction (WMD)
The nurse administrator for a long-term care facility is implementing a disaster response plan for staff and residents. Which staff member statements indicate correct understanding of the plan? A. "We have to implement annual drills." B. "Nursing homes are not required to have a plan." C. "Our facility is held to the same standards as hospital facilities." D. "This is an important component to receive insurance payments for care."
A. "We have to implement annual drills."
Which type of event can often be handled by an individual hospital disaster plan without collaboration with other systems? A. A motor vehicle accident involving five cars B. A tornado destroying 50 homes and businesses C. An act of terrorism injuring and kills hundreds of people D. A hurricane causing flooding, displacing thousands of people
A. A motor vehicle accident involving five cars
Following an earthquake, patients are triaged by emergency medical personnel and transported to the emergency department (ED). Which patient will the nurse need to assess first? A. A patient with a red tag B. A patient with a blue tag C. A patient with a black tag D. A patient with a yellow tag
A. A patient with a red tag
Which are the top priorities when conducting a primary patient survey during the emergency assessment? Select all that apply. A. Airway B. Disability C. Breathing D. Circulation E. Cervical spine
A. Airway E. Cervical spine
What would the nurse working in the emergency department identify as clinical priorities for the treatment of a patient with a gunshot wound? Select all that apply. A. Airway maintenance B. Obtaining medical history C. Ventilation assistance D. Hemorrhage control E. Hypothermia prevention
A. Airway maintenance C. Ventilation assistance D. Hemorrhage control E. Hypothermia prevention
The nurse is caring for a patient unconscious after an overdose of an unknown substance 1 hour ago. nurses first action A. Assess vital signs with pulse ox B. insert two large bore IV C. Insert nasogastric tube D. initiate gastric lavage
A. Assess vital signs with pulse ox
Which interventions will the nurse plan for a comatose patient who is to begin therapeutic hypothermia (select all that apply)? A. Assist with endotracheal intubation. B. Insert an indwelling urinary catheter. C. Begin continuous cardiac monitoring. D. Obtain an order to restrain the patient. E. Prepare to give sympathomimetic drugs
A. Assist with endotracheal intubation. B. Insert an indwelling urinary catheter. C. Begin continuous cardiac monitoring.
A patient is admitted to the critical care unit with bradycardia at a heart rate of 39 beats/min and frequent premature ventricular contractions. Upon assessment, you note that she is lethargic and has complained of dizziness for the past 12 hours. Which of the following are acceptable treatments for symptomatic bradycardia? (Select all that apply.) A. Atropine B. Epinephrine C. Lidocaine D. Transcutaneous pacemaker E. Magnesium sulfate infusion
A. Atropine B. Epinephrine D. Transcutaneous pacemaker
The nurse is helping devise a training plan to familiarize health-care providers with emergency response procedures. Which training measure is most effective to adequately prepare the trainees? A. Drills B. Tabletop exercises C. Access to the policy D. Computer simulations
A. Drills
Which member of the health-care team, when using the team nursing approach, is responsible for prioritizing patient care? A. Team leader B. Charge nurse C. Licensed practical nurse D. Unlicensed assistive personnel
A. Team leader
Which situation does not cover nurses who respond to a mass casualty incident (MCI) for malpractice or negligent lawsuits under the Good Samaritan Act? A. Terrorist act B. Neighborhood fire C. Roadside car accident D. High school sporting event
A. Terrorist act
When assessing an older patient admitted to the emergency department (ED) with a broken arm and facial bruises, the nurse observes several additional bruises in various stages of healing. Which statement or question by the nurse should be first? A. "You should not go home." B. "Do you feel safe at home?" C. "Would you like to see a social worker?" D. "I need to report my concerns to the police."
B. "Do you feel safe at home?"
Which of the following injuries would result in a greater likelihood of internal organ damage and risk for infection? A. A fall from a 6-foot ladder onto the grass B. A shotgun wound to the abdomen C. A knife wound to the right chest D. A motor vehicle crash in which the driver hits the steering wheel
B. A shotgun wound to the abdomen
Which treatment should the nurse prepare to administer when providing care to a toddler who presents after an accidental overdose of aspirin? A. Gastric lavage B. Activated charcoal C. Peritoneal dialysis D. Vitamin D injection
B. Activated charcoal
The monitor technician notifies the nurse "stat" that the patient has a rapid, chaotic rhythm that looks like ventricular tachycardia. What is the nurse's first action? A. Call a code overhead. B. Check the patient immediately. C. Go to the nurse's station and look at the rhythm strip. D. Take the crash cart to the room.
B. Check the patient immediately.
Which amount of time is appropriate for nurse to spend triaging each patient during a mass casualty incident? A. Less than 10 seconds B. Less than 15 seconds C. Less than 30 seconds D. Less than 60 seconds
B. Less than 15 seconds
During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient has an unobstructed airway. Which action should the nurse take next? A. Palpate extremities for bilateral pulses. B. Observe the patient's respiratory effort. C. Check the patient's level of consciousness. D. Examine the patient for any external bleeding
B. Observe the patient's respiratory effort.
How should the nurse instruct the mother who calls the emergency department because her 9-year-old child has just fallen on his face and one of his front teeth fell out? A. Put the tooth back in the child's mouth and call the dentist right away. B. Place the tooth in milk or water and go directly to the emergency department. C. Gently place the tooth in a plastic zippered bag until she makes a dental appointment. D. Clean the tooth and call the dentist for an immediate appointment.
B. Place the tooth in milk or water and go directly to the emergency department.
When providing information on trauma prevention, it is important to realize that individuals age 25 to 44 years are most likely to experience which type of trauma incident? A. High-speed motor vehicle crashes B. Poisonings from prescription or illegal drugs C. Violent or domestic traumatic altercations D. Work-related falls
B. Poisonings from prescription or illegal drugs
It is determined that the patient needs a transcutaneous pacemaker until a transvenous pacemaker can be inserted. What is the most appropriate nursing intervention? A. Apply conductive gel to the skin. B. Provide adequate sedation and analgesia. C. Recheck leads to make sure that the rhythm is asystole. D. Set the milliamperes to 2 mA below the capture level.
B. Provide adequate sedation and analgesia.
Assessment of a child with a submersion injury focuses on which system? A. Cardiovascular B. Respiratory C. Neurologic D. Gastrointestinal
B. Respiratory
Which statement best defines the term traumatic injury? A. All trauma patients can be successfully rehabilitated. B. Traumatic injuries cause more deaths than heart disease and cancer. C. Alcohol consumption, drug abuse, or other substance abuse contribute to traumatic events. D. Trauma mainly affects the older adult population.
C. Alcohol consumption, drug abuse, or other substance abuse contribute to traumatic events.
The nurse is providing care to several patients in the emergency department. Which patient would require priority care from the nurse? A. An adult patient with an ankle sprain B. An infant with a rash of unknown origin C. An adult patient with unstable vital signs and chest pain D. A pediatric patient with multiple fractures following a motor vehicle accident
C. An adult patient with unstable vital signs and chest pain
Which treatment for anthrax should be included in the biological agent portion of a disaster plan for terrorist attacks? A. Antivirals B. Antitoxins C. Antibiotics D. Vaccinations
C. Antibiotics
The patient has been admitted to a critical care unit with a diagnosis of acute myocardial infarction. Suddenly his monitor alarms and the screen shows a flat line. What action should the nurse take first? A. Administer epinephrine by intravenous push. B. Begin chest compressions. C. Check patient for unresponsiveness. D. Defibrillate at 360 J.
C. Check patient for unresponsiveness
Which health-care team member is a first responder when an emergency or mass casualty incident (MCI) occurs? A. Fireman B. Police officer C. Critical care nurse D. Unlicensed assistive personnel
C. Critical care nurse
Which action should the nurse implement first when caring for clients after a chemical manufacture plant explosion? A. Triage the clients and send them to the appropriate area B. Assume the clients have been decontaminated at the plant C. Remove the clients clothing and have them shower D. Thoroughly wash the clients with soap and water and rinse
C. Remove the clients clothing and have them shower
A child is brought to the emergency department. When he is called to triage, which vital sign should be measured first? A. Temperature B. Heart rate C. Respiratory rate D. Blood pressure
C. Respiratory rate
The nurse is providing care to several patients in the emergency department. Which patient is the priority when using the three-tiered triage system? A. A patient with a simple fracture B. A patient experiencing renal colic C. A patient with severe abdominal pain D. A patient with chest pain and diaphoresis
D. A patient with chest pain and diaphoresis
The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment? A. A patient with no pedal pulses B. A patient with an open femur fracture C. A patient with bleeding facial lacerations D. A patient with paradoxical chest movement
D. A patient with paradoxical chest movement
Which nursing action is appropriate when conducting a secondary survey during the emergency assessment? A. Maintaining privacy B. Having suction available C. Giving supplemental oxygen D. Assigning a nurse to support family members
D. Assigning a nurse to support family members
Which intervention would be a priority when providing care to a patient recovering from thoracic injuries sustained from a motor vehicle crash? A. Monitor urine output B. Assess vital signs C. Perform passive range of motion to all extremities D. Assist to deep breathe and cough every two hours
D. Assist to deep breathe and cough every two hours
Which is the critical factor among health-care professionals, state agencies, and federal agencies to determine when and how to evacuate safely during a natural disaster? A. Cooperation B. Classification C. Collaboration D. Communication
D. Communication
What is the leading cause of unintentional death in children younger than 19 years of age in the United States? A. Drowning B. Airway obstruction C. Pedestrian injury D. Motor vehicle injuries
D. Motor vehicle injuries
During a code situation, the nurse would prepare to use which preferred intravenous fluid? A. 5% Dextrose in 0.45 normal saline B. 5% Dextrose in water C. Dopamine infusion D. Normal saline
D. Normal saline
What should the nurse do to assist a patient brought to the emergency department as a victim of a gunshot wound? A. Ask the patient who shot him B. Bathe the patient and provide a clean gown C. Ask the patient where the weapon is D. preserve the chain of evidence
D. preserve the chain of evidence
In the trauma patient, what is the most common cause of symptoms of decreased cardiac output? A. Cardiac contusion B. Cardiogenic shock C. Hypovolemia D. Pericardial tamponade
C. Hypovolemia
Laypersons should use which device to treat lethal ventricular dysrhythmias that occur outside a hospital setting? A. Automatic external defibrillator B. Carbon dioxide detector C. Pocket mask D. Transcutaneous pacemaker
A. Automatic external defibrillator
A patient arrives in the emergency department (ED) several hours after taking "25 to 30" acetaminophen (Tylenol) tablets. Which action will the nurse plan to take? A. Give N-acetylcysteine. B. Discuss the use of chelation therapy. C. Start oxygen using a non-rebreather mask. D. Have the patient drink large amounts of water
A. Give N-acetylcysteine.
Which threats, included in the term "NBC," lead to the implementation of improved emergency medical services (EMS) and hospital safety programs? Select all that apply. A. Nuclear B. Biological C. Botulism D. Chemical E. Nipah virus
A. Nuclear B. Biological D. Chemical
Several patients present to the ED with skin redness, itching, vomiting, and diarrhea. The nurse suspects exposure to? A. Radiation B. Biotoxin agent C. Chemical agents D. Influenza
A. Radiation
The nurse is conducting triage under mass casualty conditions. Which tag should the nurse use for a patient who is experiencing hypovolemic shock due to a penetrating wound? A. Red B. Black C. Green D. Yellow
A. Red
hypothermia is a preventable contributory factor of the triad of death A. true B. false
A. true
signs of hypotension may not be clinically obvious until a patient has lost more than 1500 mL of blood A. true B. false
A. true
The nurse is contributing to a disaster plan for a possible terrorist attack. Which biological agents should be included in the plan? Select all that apply. A. Rubella B. Anthrax C. Measles D. Botulism E. Tularemia
B. Anthrax D. Botulism E. Tularemia
A preschool child in the emergency department has a respiratory rate of 10 breaths per minute. How should the nurse interpret this finding? A. The child is relaxed. B. Respiratory failure is likely. C. This child is in respiratory distress. D. The child's condition is improving.
B. Respiratory failure is likely.
Which is the essential nursing skill for the triage process in the emergency department? A. Evaluating care B. Setting priorities C. Formulating diagnoses D. Implementing interventions
B. Setting priorities
A patient is brought to the critical care unit after a motor vehicle crash. On admission, the patient is reporting dyspnea and chest pain. Upon examination, the nurse notes a lack of breath sounds on the left side and a tracheal shift. What would be the most likely diagnosis? A. Pericardial tamponade B. Symptomatic bradycardia C. Tension pneumothorax D. Unstable tachycardia
C. Tension pneumothorax
Which client should be triaged as an expectant category of black tag A. sprained ankle which may be fractured B. abdominal wound and stable vital signs C. unresponsive client diagnosed with a head injury D. the alert client diagnosed with a sucking chest wound
C. unresponsive client diagnosed with a head injury