Test 6 PrepU
The nurse is caring for a client in the ED following a sexual assault. The client is hysterical and crying. The client states, "I know I'm pregnant now, maybe I have HIV. Why did this happen to me?" Which is the best response by the nurse? "Do you want the phone number for the National Sexual Assault Hotline?" "Would you like us to complete HIV testing?" "Do you want to discuss antipregnancy measures?" "Let's talk about this. Do you want me to call a support person?"
"Let's talk about this. Do you want me to call a support person?" The client should be reassured that anxiety is natural and asked whether a support person may be called. The goals of management are to provide support, reduce the client's emotional trauma, and gather available evidence for possible legal proceedings. Throughout the client's stay in the ED, the client's privacy and sensitivity must be respected. The client may exhibit a wide range of emotional reactions, such as hysteria, stoicism, or feelings of being overwhelmed. Support and caring are crucial.
A nurse is caring for a client who has arrived at the emergency department in shock. The nurse intervenes based on the knowledge that which of the following is the most common cause of shock? Cardiac dysfunction Sepsis Anaphylaxis Hypovolemia
Hypovolemia Types of shock include cardiogenic, neurogenic, anaphylactic, and septic. Of these, the most common cause is hypovolemia.
A nurse is providing care to a client who has been exposed to phosgene vapor. Which nursing diagnosis would the nurse identify as the priority? Impaired gas exchange related to destruction of the pulmonary membrane Disturbed sensory preception: visual related to bilateral miosis and visual disturbances Decreased cardiac output related to altered aerobic metabolism from agent exposure Impaired skin integrity related to vesicant contact with skin
Impaired gas exchange related to destruction of the pulmonary membrane Phosgene vapor is a pulmonary agent that destroys the pulmonary membrane leading to pulmonary edema, with shortness of breath. Therefore, impaired gas exchange would be the priority. Impaired skin integrity would be appropriate for exposure to a vesicant. Disturbed sensory perception, visual would be appropriate for a client exposed to a nerve agent. Decreased cardiac output would be appropriate for a client exposed to a blood agent, such as cyanide, which inhibits aerobic metabolism.
A patient who has accidentally ingested toilet bowel cleaner is brought to the emergency department. Which action would NOT be appropriate for the nurse to implement? Gastric lavage Dilution with water or milk Administration of activated charcoal Induced vomiting
Induced vomiting Vomiting is never induced after ingestion of caustic substances (acid or alkaline) such as toilet bowl cleaner because the substance is corrosive to the tissues. Appropriate actions include dilution with milk or water, gastric lavage, and administration of activated charcoal.
A patient is being brought into the ED who is probably infected with anthrax. The nurse should ensure what level of personal protective equipment to wear for everyone who will come in contact with the patient? Level C Level A Level D Level B
Level D Standard precautions are the only ones indicated to protect the caregiver exposed to a patient infected with anthrax. The patient is not contagious, and the disease cannot spread from person to person. Thus, only level D protection, the typical work uniform, is required.
Which solid organ is most frequently injured in a penetrating trauma? Liver Pancreas Brain Lung
Liver The most frequently injured solid organ in a penetrating trauma is the liver because of its size and anterior placement in the right upper quadrant of the abdomen.
A nurse is providing care to a client who was exposed to a nerve agent. Which of the following would the nurse most likely assess? Constipation Miosis Bullae Tachycardia
Miosis Exposure to a nerve agent manifests with signs and symptoms of cholinergic crisis including bilateral miosis, increased gastrointestinal motility, nausea, vomiting, diarrhea, substernal spasm, indigestion, bradycardia, bronchoconstriction, laryngeal spasm, weakness, fasciculations, and incontinence. Bullae are seen with vesicants.
A client comes to the emergency department complaining of vision changes, nausea, vomiting, diarrhea, and tightness in the chest. The client reports that he was out on his farm spraying some pesticides. Based on the client's information, the nurse would suspect exposure to which of the following? Nerve agent Vesicant Pulmonary agent Blood agent
Nerve agent The client was working with pesticides, organophosphates, which are considered nerve agents. The client's signs and symptoms also reflect exposure to a nerve agent.
A pipe bomb detonated on a city bus, causing numerous casualties. This would be an example of which type of disaster? biologic natural unintentional human intentional human
intentional human Intentional human disasters include bombings, biologic disasters, and chemical disasters. Natural disasters are caused by nature; examples include tornadoes and hurricanes. Unintentional disasters are accidents that may result in mass trauma and disruptions of services depending on their scale. A biologic disaster is one in which pathogens or their toxins cause harm to many humans and other living species.
The nurse is instructing volunteers at an emergency bioterrorism drill about the management and medications required to combat various viruses, bacteria, and toxins. The nurse knows that the volunteers understand the instruction when they state that managing clients who exhibit symptoms of the variola virus (smallpox) includes acyclovir. radiation. decontamination. isolation.
isolation. Smallpox is spread by droplet or direct contact and spreads rapidly. Clients exhibiting symptoms should be immediately placed in isolation.
A client is admitted to the ED after a near-drowning accident. The client is diagnosed with saltwater aspiration. The nurse will observe the client for several hours to monitor for symptoms of hyponatremia. pulmonary edema. head injury. hypothermia.
pulmonary edema. Resultant pathophysiologic changes and pulmonary injury depend on the type of fluid (fresh or salt water) and the volume aspirated. Freshwater aspiration results in a loss of surfactant and therefore an inability to expand the lungs. Saltwater aspiration leads to pulmonary edema from the osmotic effects of the salt within the lungs. If a person survives submersion, acute respiratory distress syndrome, resulting in hypoxia, hypercarbia, and respiratory or metabolic acidosis, can occur. The client would experience hypernatremia. Hypothermia and head injury may be associated with near drowning but would be apparent at the time of admission and would not develop after several hours.
A patient with intra-abdominal injuries is brought to the emergency department. Which of the following would most likely alert the nurse to suspect internal bleeding secondary to a ruptured spleen? Pain in the left shoulder Rebound abdominal tenderness Contusion of the right upper quadrant Abdominal distention
Pain in the left shoulder Pain in the left shoulder is common in a patient with bleeding from a ruptured spleen. Pain in the right shoulder is consistent with a laceration of the liver. The spleen is located in the left upper quadrant, not the right. Rebound tenderness and abdominal distention are generalized signs suggesting intraperitoneal injury. Although these generalized signs may accompany a ruptured spleen, they are less specific than pain in the left shoulder.
When preparing to perform abdominal thrusts on a client with an airway obstruction, which of the following would be most appropriate? Placing the thumb side of one hand at the xiphoid process Having the conscious client lie down Positioning the hands in the midline slightly above the umbilicus Using a sequence of four thrusts, each progressing in intensity
Positioning the hands in the midline slightly above the umbilicus When performing abdominal thrusts, the nurse would place the thumb side of one fist against the client's abdomen in the midline slighlty above the umbilicus and well below the xiphoid process, grasping the fist with the other hand. Then the nurse would press the fist into the client's abdomen with a quick inward and upward thrust such that each new thrust should be a separate and distinct maneuver. The unconscious client is positioned on the back. The client who is conscious should be standing or sitting.
The nurse is triaging patients from a 10-car pile-up on the interstate and assesses a patient with a sucking chest wound. What category should this patient be placed in? Priority 4 Priority 2 Priority 3 Priority 1
Priority 1 Triage category "Immediate" is priority 1 (red) and includes injuries that are life threatening but survivable with minimal intervention, such as sucking chest wound, airway obstruction secondary to mechanical cause, and shock.
Several patients that have been involved in a bombing are unlikely to survive. What priority are these patients given during triage? Priority 1 Priority 3 Priority 2 Priority 4
Priority 4 Triage category "Expectant" is priority 4 (black) and applies to patients with injuries that are extensive and whose chances of survival are unlikely even with definitive care, such as unresponsive patients with penetrating head wounds, high spinal cord injuries, and wounds involving multiple anatomic sites and organs.
You are caring for clients who have been exposed to a toxic nerve agent. You will need to use diazepam with these clients. Why is diazepam given when managing the effects of toxic nerve agent toxicity? To reactivate acetylcholinesterase To control possible seizures To control hypersecretion To counter excess acetylcholine
To control possible seizures Seizures are likely to occur only after exposure to a nerve agent. Diazepam controls seizures. Atropine sulfate counteracts excess acetylcholine at muscarinic sites. Pralidoxime chloride reactivates acetylcholinesterase. Atropine is typically administered to stop any kind of hypersecretion.
Which is defined as the potential of an agent to cause injury to the body? Persistence Latency Toxicity Volatility
Toxicity The median lethal dose (LD50) is the amount of the chemical that will cause death in 50% of those who are exposed. Persistence means that the chemical is less likely to vaporize and disperse. Volatility is the tendency for a chemical to become a vapor. Latency is the time from absorption to the appearance of symptoms.
Often, treatments used for exposure to biologic agents manage the symptoms; the disease process must run its course. Which biologic agent exposure requires the use of ventilation support of breathing, possibly for up to 2 to 3 months? bubonic plague smallpox botulism anthrax
botulism Generally, initial treatment of botulism follows a clinical rather than a laboratory diagnosis. Tests on serum, gastric, and fecal specimens tend to be too time consuming to justify a delay in treatment. Mechanical ventilation is required to support breathing for 2 to 3 months.
A nurse suspects an older adult is experiencing heat stroke based on which assessment findings? Select all that apply. Bradypnea Weakness Delirium Lack of sweating Increased thirst Temperature 105 degrees F (40.6 degrees C)
Delirium Lack of sweating Temperature 105 degrees F (40.6 degrees C) A patient with heat stroke typically exhibits a temperature of 105 degrees F (40.6 degrees C) or higher; profound central nervous system dysfunction; hot, dry skin; anhidrosis (absence of sweating); tachypnea; hypotension; and tachycardia. Increased thirst and weakness would suggest heat exhaustion.
Chap 72: A client is brought to the emergency department by ambulance. The client is seriously ill and unconscious. No family or friends are present. Which of the following would be most appropriate to do? Explain to the client that care is going to be provided because he is seriously ill. Ask the ambulance team for information about the client's family to ensure informed consent. Document the client's condition and absence of friends or family for obtaining consent to treatment. Check the client's record for the name of a family member to call to allow care to be provided.
Document the client's condition and absence of friends or family for obtaining consent to treatment. Consent is needed to examine and treat a client unless he or she is unconscious or in critical condition and unable to make decisions. In this situation, the client is unconscious and no friends or family are around to provide consent to treatment. The nurse should document this fact and provide care. Checking the client's record and asking the ambulance team for information would waste valuable time. Explaining to the client that care will be provided is appropriate even though the client is unconscious, but documentation is essential.
Which triage category refers to life-threatening or potentially life-threatening injury or illness requiring immediate treatment? Urgent Nonacute Emergent Immediate
Emergent The client triaged as emergent must be seen immediately. The triage category of urgent refers to minor illness or injury needing first-aid-level treatment. The triage category of immediate refers to nonacute, non-life-threatening injury or illness.
During a disaster, the nurse triages a victim with a fractured wrist. Which color triage tag should the nurse apply? Black Green Yellow Red
Green A green triage tag (priority 3, or minimal) indicates injuries that are minor, and treatment can be delayed hours to days. A red triage tag (priority 1, or immediate) indicates injuries that are life threatening but survivable with minimal intervention. A yellow triage tag (priority 2, or delayed) indicates injuries that are significant and require medical care, but they can wait hours without threat to life or limb. A black triage tag (priority 4, or expectant) indicates injuries that are extensive; chances of survival are unlikely even with definitive care.
Nursing students are reviewing the categories of intra-abdominal injuries. The students demonstrate understanding of the information when they identify which of the following as examples of penetrating trauma? Select all that apply. Gunshot wound Being struck with a baseball bat Fall from a roof Motor-vehicle crash Knife-stab wound
Gunshot wound Knife-stab wound Examples of penetrating trauma include gunshot wounds and stab wounds. Motor vehicle crashes, falls, and being struck with a baseball bat are examples of blunt trauma.
A nurse is working as a camp nurse during the summer. A camp counselor comes to the clinic after receiving a snakebite on the arm. What is the first action by the nurse? Apply a tourniquet to the arm above the bite. Have the patient lie down and place the arm below the level of the heart. Apply ice to the area. Make an incision and suck the venom out.
Have the patient lie down and place the arm below the level of the heart. Initial first aid at the site of the snakebite includes having the person lie down, removing constrictive items such as rings, providing warmth, cleansing the wound, covering the wound with a light sterile dressing, and immobilizing the injured body part below the level of the heart. Airway, breathing, and circulation are the priorities of care. Ice, incision and suction, or a tourniquet is not applied.
Acetaminophen overdose is treated with administration of which medication? Naloxone Flumazenil Diazepam N-acetylcysteine
N-acetylcysteine Treatment of acetaminophen overdose includes administration of N-acetylcysteine. Flumazenil is administered in the treatment of nonbarbiturate sedative overdoses. Naloxone is administered in the treatment of narcotic overdoses. Diazepam may be administered to treat uncontrolled hyperactivity in the client with a hallucinogen overdose.
The NATO triage system uses color-coded tagging to identify severity of injuries. A patient with survivable but life-threatening injuries (i.e., incomplete amputation) would be tagged with which color? Green Red Black Yellow
Red Triage category "Immediate" is coded red and includes injuries that are life threatening but survivable with minimal intervention, such as an incomplete amputation.
The nurse receives a call from EMS personnel that they are bringing in eight patients who have been exposed to a chemical after a spill. The patients have been "washed off." After the initial assessment, what should be done? Have the patients wash with soap and water and then rinse. Remove clothing and jewelry and rinse the patients off with water. Treat the patients for any burned areas from the chemical since they have already been decontaminated. Start an IV with lactated Ringer's solution at 125 mL/h.
Remove clothing and jewelry and rinse the patients off with water. Decontamination must include a minimum of two steps. The first step is removal of the patient's clothing and jewelry and then rinsing the patient with water. Depending on the type of exposure, this step alone can remove a large amount of the contamination and decrease secondary contamination. The second step consists of a thorough soap-and-water wash and rinse. When patients arrive at the facility after being assessed and treated by a prehospital provider, it should not be assumed that they have been thoroughly decontaminated.
A nurse is providing disaster care in an event that is known to involve gamma radiation. When admitting victims of the disaster, what should the nurse do to best reduce victims' risks of injury? Carefully apply personal protective equipment over victims' clothing. Remove victims' clothing and have them wash themselves thoroughly. Apply chlorhexidine to all skin surfaces that may have been contaminated. House victims in a well-ventilated area.
Remove victims' clothing and have them wash themselves thoroughly. The nurse should have victims shower and change clothes and irrigate or wash open wounds with soap and water. Cleansing the skin helps to reduce the transition from external to internal radiologic contamination. Infectious microorganisms are not involved, so chlorhexidine is of no particular benefit. Applying PPE over contaminated clothing could worsen the risk for injury. Adequate ventilation is important, but removal of contaminants is the priority because of the increased risk for injury.
The emergency department nurse is caring for clients involved in a chlorine exposure accident at a local chemical plant. The nurse is aware that permanent damage can occur to which body systems? Renal Hepatic Respiratory Cardiac
Respiratory The consequences of exposure to chlorine and other respiratory toxins are related to the amount, route, and length of chemical exposure. Death occurs as fluid infiltrates the pulmonary air spaces and terminal bronchioles interfering with gas exchange. Following recovery from an acute event, victims may develop chronic bronchitis and emphysema.
A nurse is performing triage at the scene of a building collapse and is using a five-level triage system. Place the categories below in the proper order from most to least immediate.
Resuscitation Emergent Urgent Nonurgent Minor The five-level system of triage classifies patients as follows: resuscitation (need immediate treatment to prevent death); emergent (may deteriorate rapidly and develop a major life-threatening situation or require time-sensitive treatment); urgent(need two or more resources to provide care and conditions are not life-threatening); nonurgent (need only one resource for needs and condition is not life-threatening); and minor (require no resources for care with no life-threatening condition).
The nurse is instructing on bioterrorism agents. Which of the following does the nurse emphasize as an agent which is transmitted from person to person? Smallpox Varicella Anthrax Botulism
Smallpox Smallpox is highly contagious and caused by a variola virus. Individuals infected with the botulinum toxin and anthrax are not at risk to others; there are no reports of person to person transmission. Varicella, commonly called the chickenpox, is contagious but not a bioterrorism agent.
A client comes to the emergency department after experiencing a wound. Inspection reveals an opening in the skin with distinct edges and whose depth is greater than the length of the wound. The nurse documents this as which type of wound? Avulsion Laceration Stab Patterned
Stab A stab wound is an incision of the skin with well-defined edges and is typically deeper than long. It is usually caused by a sharp instrument. A laceration is a tear in the skin with irregular edges and vein bridging. An avulsion is manifested as a tearing away of tissue from the supporting structures. A patterned wound takes on the outline of the object causing the wound.
A patient was bitten by a tick 3 months ago and is now having muscle aches as well as joint pain and swelling. The patient is having difficulty with self care and requires assistance with activities of daily living (ADLs). What stage of Lyme disease does the nurse recognize the patient is in? Stage I Stage II Stage IV Stage III
Stage III Lyme disease has three stages. Stage I presents with a classic "bull's-eye" rash (i.e., erythema migrans) and flulike signs and symptoms that may include chills, fever, myalgia, fatigue, and headache. If antibiotics are not administered, stage II Lyme disease may present within 4 to 10 weeks following the tick bite and may manifest with joint pain, memory loss, poor motor coordination, and meningitis. Stage III can begin anywhere from weeks to more than a year after the bite and has serious long-term chronic sequelae, including arthritis, neuropathy, myalgia, and myocarditis.
A nurse is providing inservice education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step? Obtaining consent for examination Collecting semen Performing the pelvic examination Supporting the client's emotional status
Supporting the client's emotional status The teaching session is successful when staff members focus first on supporting the client's emotional status. Next, staff members should gain consent to perform the pelvic examination, perform the examination, and collect evidence, such as semen if present.
When providing care to a client who has experienced multiple trauma, which of the following would be most important for the nurse to keep in mind? The most lethal injuries are often the most readily apparent. The client is assumed to have a spinal cord injury until proven otherwise. Injuries have occurred to at least three distinct organ systems. Most multiple trauma victims exhibit evidence of the trauma.
The client is assumed to have a spinal cord injury until proven otherwise. With clients experiencing multiple trauma, the nurse must assume that the client has a spinal cord injury until proven otherwise. Multiple trauma cleints experience life-threatening injuries to at least two distinct organs or organ systems. Evidence of the trauma may be sparse or absent. Additionally, the injury that may seem the least significant may be the most lethal.
The nurse is orienting to the emergency department and finds cases of potassium iodine tablets located in the supply closet. The nurse asked the nurse manager why this is stored in the closet. The nurse manager's best response is: "Potassium iodine is given to individuals who come to the emergency department dehydrated to replenish their potassium level." "Potassium iodine is given to individuals diagnosed with hypothyroidism in the emergency department." "Potassium iodine is given to individuals as a prophylaxis for protecting the thyroid gland from absorption of radiation in case of an accident at the local nuclear plant." "Potassium iodine is given to individuals who are given furosemide intravenously in the emergency department to replenish their potassium level."
"Potassium iodine is given to individuals as a prophylaxis for protecting the thyroid gland from absorption of radiation in case of an accident at the local nuclear plant."
As a member of a disaster response team that is responding to a large industrial fire that may involve chemical exposure, a nurse is gathering information from several bystanders. Which statement would lead the nurse to suspect that cyanide is involved? "All of a sudden, I felt my skin burning and stinging." "The air had a strange smell of bitter almonds." "Many people were complaining of an upset stomach and started vomiting." "Everyone started coughing and complaining of shortness of breath."
"The air had a strange smell of bitter almonds." Cyanide is often associated with the smell of bitter almonds. Therefore, the statement of the air having a stange smell would suggest cyanide involvement. Burning and stinging of the skin would be associated with exposure to vesicants. Gastrointestinal upset and vomiting would lead to suspicions of nerve gas involvement. Coughing and shortness of breath would be related to exposure to pulmonary agents.
All people who have household or face-to-face contact with the client diagnosed with smallpox after the fever begins should be vaccinated within what time frame to prevent infection and death? 4 days 1 week 10 days 2 weeks
4 days All people who have household or face-to-face contact with the client after the fever begins should be vaccinated within 4 days to prevent infection and death.
The nurse is administering 100% oxygen to a patient with carbon monoxide poisoning and obtains a carboxyhemoglobin level. Which level would the nurse interpret as indicating that oxygen therapy can be discontinued? 6% 9% 7% 4%
4% Oxygen is administered until the carboxyhemoglobin level is less than 5%.
If a client has been exposed to radiation, the presenting symptoms, such as nausea, vomiting, loss of appetite, diarrhea, or fatigue, can be expected to occur within how many hours after exposure? 6 to 12 12 to 24 24 to 48 48 to 72
48 to 72 The prodromal phase (presenting symptoms) of radiation exposure occurs within 48 to 72 hours after exposure. Signs and symptoms include nausea, vomiting, loss of appetite, diarrhea, and fatigue. With high-dose radiation exposure, the signs and symptoms may include fever, respiratory distress, and increased excitability.
The nurse is on a community awareness safety committee. When prioritizing biological agents according to potential morbidity and mortality, which cluster of biological agents hold the highest mortality? Botulism, Salmonella Escherichia coli, Brucella species Hantavirus, tuberculosis Anthrax, smallpox
Anthrax, smallpox The cluster of agents with the highest mortality includes anthrax and smallpox. The Hantavirus and tuberculosis agents are not presently used for bioterrorism. Botulism and Salmonella as well as Escherichia coli and Brucella species are of low mortality.
The nurse received a patient from a motor vehicle accident who is hemorrhaging from a femoral wound. What is the initial nursing action for the control of the hemorrhage? Elevate the injured part. Apply a tourniquet. Immobilize the area to control blood loss. Apply firm pressure over the involved area or artery.
Apply firm pressure over the involved area or artery. Direct, firm pressure is applied over the bleeding area or the involved artery at a site that is proximal to the wound (Fig. 72-3). Most bleeding can be stopped or at least controlled by application of direct pressure. Otherwise, unchecked arterial bleeding results in death. A firm pressure dressing is applied, and the injured part is elevated to stop venous and capillary bleeding, if possible. If the injured area is an extremity, the extremity is immobilized to control blood loss. A tourniquet is applied to an extremity only as a last resort when the external hemorrhage cannot be controlled in any other way and immediate surgery is not feasible.
A female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing interventions should be provided? (Select all that apply.) Assess and document any bruises and lacerations. Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police. Record a history of the event, using the patient's own words. Have the patient shower or wash the perineal area before the examination. Ensure that the police are present when the examination is performed.
Assess and document any bruises and lacerations. Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police. Record a history of the event, using the patient's own words. A history is obtained only if the patient has not already talked to a police officer, social worker, or crisis intervention worker. The patient should not be asked to repeat the history. Any history of the event that is obtained should be recorded in the patient's own words. The patient is asked whether he or she has bathed, douched, brushed his or her teeth, changed clothes, urinated, or defecated since the attack, because these actions may alter interpretation of subsequent findings. Each item of clothing is placed in a separate paper bag. The bags are labeled and given to appropriate law enforcement authorities. The patient is examined (from head to toe) for injuries, especially injuries to the head, neck, breasts, thighs, back, and buttocks. The exam focuses on external evidence of trauma (bruises, contusions, lacerations, stab wounds).
A homeless client presents to the ED. Upon assessment, the client is experiencing hypothermia. The nurse will plan to complete which priority intervention during the rewarming process? Assist with endotracheal intubation Attach a cardiac monitor Insert a Foley urinary catheter Administer inotropic drugs
Attach a cardiac monitor Continuous electrocardiograph (ECG) monitoring is performed during the rewarming process because cold-induced myocardial irritability leads to conduction disturbances, especially ventricular fibrillation. A urinary catheter should be inserted to monitor urinary output; however, ECG monitoring is the priority. There is no indication for endotracheal intubation. Inotropic medications are contraindicated because they can stimulate the heart and increase the risk for fatal dysrhythmias, such as ventricular fibrillation.
A client has a gaping wound on his forearm that is bleeding profusely. Applying pressure to which pressure point would be most helpful? Radial Brachial Femoral Subclavian
Brachial The pressure point at the brachial artery would be most appropriate because this site is proximal to the bleeding site. The femoral pressure point would be useful for bleeding in the lower extremities. The radial pressure point would be appropriate for bleeding in the wrist and hands. The subclavian pressure point would be used for bleeding in the upper anterior chest area.
During a mass disaster, the nurse is caring for a victim whose status has been categorized as yellow during triage. How should the nurse best allocate time and resources to this client's care? Provide high-priority, immediate care to save the client's life Delay the client's treatment for a few hours if other clients need immediate care Place a low priority on the client's care because the client will likely recover independently Forego immediate care because the client is unlikely to survive
Delay the client's treatment for a few hours if other clients need immediate care For a client categorized as yellow, care can be safely delayed for six to eight hours. Death is not imminent, but spontaneous recovery is unlikely.
The nurse is conducting a secondary survey on a client in the ED. Which action is completed during the secondary survey? Diagnostic and laboratory testing Undressing the client Assessment of peripheral pulses Establishing a patent airway
Diagnostic and laboratory testing Diagnostic and laboratory testing is completed during the secondary survey, along with a complete health history, a head-to-toe assessment, insertion or application of monitoring devices, splinting of suspected fractures, cleansing, closure, and dressing of wounds, and performance of other necessary interventions based on the client's condition. The other interventions are completed during the primary survey.
Anthrax acquired by which method develops into the most severe? Ingestion Skin infection Contact with body fluids or contaminated objects Inhalation
Inhalation The most severe form of anthrax develops through inhalation. At the onset, it may be mistaken for a cold or flu, but if it is diagnosed wrongly and untreated, the infections can lead into severe respiratory distress and almost certain death. Ingesting the bacteria is slightly less lethal, with symptoms of nausea, vomiting, diarrhea, and abdominal pain because they infect the gastrointestinal tract and circulatory and mesenteric lymph nodes. Skin infection is the least deadly form and the only one that may be transmitted by direct contact. One of the ways smallpox spreads is through contact with body fluids or contaminated objects that contain the live virus.
Exposure to gamma radiation can be decreased by completing which action? Wearing thick clothes Providing distance from radiation source Lengthening the duration of exposure Providing plastic shielding
Providing distance from radiation source Gamma radiation can penetrate clothing and skin. Thick clothes do not provide any kind of protection. Lead blocks radiation, but it is safest to limit exposure and to distance oneself from the source.
The student nurse is working with a nurse manager at a hospital when a disaster drill is announced over the hospital P.A. system. The nurse manager asks the nursing student what color triage tag is used for clients who have life threatening, but survivable conditions, if rapid medical attention is provided. What color is the triage tag for these clients? Black Green Yellow Red
Red The nurse is asking about clients that are labeled immediate when the clients suffer with life threatening, but survivable conditions, if rapid medical attention is provided. Immediate clients are given a red triage tag. Clients with yellow triage tags are labeled delayed, and have injuries serious but stable enough to survive if treatment is delayed 6-8 hours. Clients with green triage tags are labeled minimal, and have injuries that are more minor that can wait longer than 6-8 hours to be addressed. Clients with black triage tags are labeled expectant, and are expected to die. With an expectant client, when the airway is opened, the client has no spontaneous respirations.
Which guideline is appropriate for a nurse to implement while helping family members cope with the sudden death of a loved one? Obtain orders for sedation for family members. Provide details of the factors attendant to the sudden death. Show acceptance of the body by touching it, giving the family permission to touch. Inform the family that the client has passed on.
Show acceptance of the body by touching it, giving the family permission to touch. The nurse should encourage the family to view and touch the body if they wish, since this action helps the family to integrate the loss. The nurse should avoid using euphemisms such as "passed on." The nurse should avoid giving sedation to family members, because this may mask or delay the grieving process. The nurse should avoid volunteering unnecessary information (e.g., client was drinking at the time of the accident).
A client presents to the ED with a stab wound to the abdomen following an assault. It is suspected that the client has an injury to the pancreas. Which laboratory study is used to detect pancreatic injury? Urinalysis Serum amylase Hemoglobin and hematocrit White blood cell count
Serum amylase Serum amylase is analyzed to detect increasing levels, which suggests pancreatic injury or perforation of the gastrointestinal tract. A white blood cell count is done to detect an elevation. Urinalysis is done to detect hematuria. A hemoglobin and hematocrit test is done to evaluate trends reflecting the presence or absence of bleeding.
When preparing for an emergency bioterrorism drill, the nurse instructs the drill volunteers that each biological agent requires specific client management and medications to combat the virus, bacteria, or toxin. Which statement reflects the client management of variola virus (smallpox)? Smallpox is spread by inhalation of spores. Acyclovir is effective against smallpox. A vaccination is effective only if administered within 12 to 24 hours of exposure. Smallpox spreads rapidly and requires immediate isolation.
Smallpox spreads rapidly and requires immediate isolation. Smallpox is spread by droplet or direct contact. No antiviral agents are effective against smallpox; however, vaccination within 2 to 3 days of exposure is protective. In 4 to 5 days, vaccination may prevent death and should be administered with vaccinia immune globulin. Smallpox spreads rapidly and requires immediate isolation. Even in death, the disease can be transmitted.
A client has been exposed to a vesicant and is undergoing decontamination. Which of the following most likely would be used? Chlorhexidine Sodium hypochlorite Alcohol Soap and water
Soap and water A client who is exposed to a vesicant agent undergoes decontamination with soap and water. Scrubbing with sodium hypochlorite solutions is avoided because they increase penetration of the nerve agent. Alcohol and chlorhexidine are inappropriate choices for decontamination.
A nurse is caring for a client who is experiencing alcohol withdrawal. Which statement best indicates that the client understands the need for long-term treatment? The client agrees to ongoing participation in one or more support groups. The client agrees to detoxification, rehabilitation, and participation in an aftercare program. The client agrees to attend supportive counseling. The client agrees to involve his family in psychotherapy.
The client agrees to detoxification, rehabilitation, and participation in an aftercare program. Detoxification, rehabilitation, and participation in an aftercare program are the only options that address the client's long-term treatment needs. Supportive counseling, family involvement, and support-group participation are important aspects of the treatment process, but they don't address the client's need for long-term treatment.
What is a common source of airway obstruction in an unconscious client? A foreign object Edema The tongue Saliva or mucus
The tongue In an unconscious client, the muscles controlling the tongue commonly relax, causing the tongue to obstruct the airway. When this situation occurs, the nurse should use the head-tilt, chin-lift maneuver to cause the tongue to fall back into place. If she suspects the client has a neck injury she must perform the jaw-thrust maneuver.
You are an Emergency Department nurse who has to care for three victims of anthrax. The first victim inhaled the toxin, the second victim ingested it, and the third victim suffered a skin infection. Which client should be cared for first? The one with the skin infection The one who ingested the toxin Any convenient order The one who inhaled the toxin
The one who inhaled the toxin The nurse should first treat the client who is at greatest risk. The most serious form of anthrax develops upon inhalation. If diagnosed incorrectly and untreated, the infection progresses to severe respiratory distress, and in severe situations, death may also occur. Ingesting the bacteria is less lethal, with symptoms of nausea, vomiting, diarrhea, and abdominal pain. Skin infection is the least deadly form characterized by painless lesions usually on the head, hands, and arms. Therefore, the client who inhaled the toxin should always get first priority.
The nurse educator is preparing a presentation about the indicators of chemical terrorism. The nurse educator would include which indicators in the presentation. Select all that apply. Unexplained odor atypical for the location Strong wind in area of the event Increase in temperature in area of the event Numerous dead animals and birds Fog-like or low-lying cloud in the atmosphere
Unexplained odor atypical for the location Numerous dead animals and birds Fog-like or low-lying cloud in the atmosphere The indicators that the nurse educator would include in the presentation are fog-like or low-lying cloud in the atmosphere, numerous dead animals and birds, and unexplained odor atypical for the location. The temperature in the area would not increase after a chemical event. There would be no wind associated with a chemical event.
A nursing instructor is describing the role of a nurse during a disaster. Which of the following would best reflect the nurse's role? Client care within the area of expertise Directly specified by the physician in charge Variable depending on the needs of the situation Provision of comprehensive client-specific care
Variable depending on the needs of the situation The role of the nurse during a disaster varies and depends on the needs or situation. Nurses may be asked to perform duties outside their areas of expertise and may take on responsibilities normally held by physicians or advanced practice nurses. During a disaster, nursing care focuses on essential care from a perspective of what is best for all clients.
Chap 73: Which term refers to the tendency for a chemical to become a vapor? Latency Volatility Toxicity Persistence
Volatility The most common volatile agents are phosgene and cyanide. Persistence means that the chemical is less likely to vaporize and disperse. Toxicity is the potential of an agent to cause injury to the body. Latency is the time from absorption to the appearance of symptoms.