334 final stuff

Which nursing actions during a mass casualty incident should be included in the triage portion of an organizational disaster plan? Select all that apply. 1) Treatment 2) Stabilization 3) Evaluation of interventions 4) Formulation of nursing diagnosis 5) Decontamination for suspected contamination

1.2.5

A nurse is caring for a patient who is perimenopausal and states that she has recently had frequent bacterial vaginal infections. Which reason for these infections will the nurse include in the response to the patient? 1) Decreased vaginal pH 2) Increased vaginal pH 3) Increased estrogen level 4) Decreased vasomotor stability

2

Which treatment should the nurse prepare to administer when providing care to a toddler who presents after an accidental overdose of aspirin? 1) Gastric lavage 2) Activated charcoal 3) Peritoneal dialysis 4) Vitamin D injection

2

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? 1) Tornado 2) Hurricane 3) Avalanche 4) Earthquake

3

Which assessment data indicates the patient is experiencing a late symptom associated with chronic aspirin overdose? 1) Emesis 2) Nausea 3) Tinnitus 4) Ecchymosis

4

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? 1) Red 2) Black 3) Green 4) Yellow

1

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? 1) Taking vital signs 2) Providing wound care 3) Conducting discharge teaching 4) Administering oral medications

1

Which observation indicates that interventions provided to a patient with neck injuries from a motor vehicle crash have been successful? 1) Urine is clear and odorless from indwelling catheter 2) Moves all four extremities independently, feeds self, and participates in partial bath 3) Unable to move independently in bed 4) Rests in bed with lights and television turned off

2

A menopausal patient is concerned that intercourse with her spouse has become increasingly painful. What should the nurse explain about the changes in this patient's body after menopause? 1) Cervical mucus is thicker. 2) Estrogen levels increase. 3) Sexual desire diminishes. 4) Vaginal lubrication decreases.

4

Which patient has an increased risk for being diagnosed with cervical cancer in the later stages of the disease process? 1) 35-year-old Hispanic woman with a Pap smear one year ago 2) 45-year-old Caucasian woman with a Pap smear three years ago 3) 50-year-old Native American woman with a Pap smear four years ago 4) 55-year-old African American woman with a Pap smear six years ago

4

The nurse is reviewing the plan of care for a patient being treated with brachytherapy for breast cancer. Which assessment finding indicates that the patient's skin integrity has been maintained? 1) Skin intact 2) Skin dry and excoriated 3) Skin stretched 4) Skin damp and sweaty

1

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? 1) Two 2) Three 3) Four 4) Five

1

Which situation does not cover nurses who respond to a mass casualty incident (MCI) for malpractice or negligent lawsuits under the Good Samaritan Act? 1) Terrorist act 2) Neighborhood fire 3) Roadside car accident 4) High school sporting event

1

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? 1) Cooperation 2) Classification 3) Collaboration 4) Communication

4

Which nursing action is appropriate when conducting a secondary survey during the emergency assessment? 1) Maintaining privacy 2) Having suction available 3) Giving supplemental oxygen 4) Assigning a nurse to support family members

4

Which are the priority nursing actions after the completion of the secondary survey when providing care for a trauma patient with a penetrating wound? 1) Documenting the patient's care 2) Formulating the patient's plan of care 3) Reassessing the patient's level of consciousness 4) Transferring the patient to the general medical unit

1

Which is the priority in the preparedness of health-care professionals in any type of disaster plan? 1) Identification of hazards 2) Cooperation with state authorities 3) Collaboration with local authorities 4) Implementation of federal mandates

1

Which member of the health-care team, when using the team nursing approach, is responsible for prioritizing patient care? 1) Team leader 2) Charge nurse 3) Licensed practical nurse 4) Unlicensed assistive personnel

1

A patient with a history of breast cancer who is entering menopause is seeking information about how to manage hot flashes. What information can be provided to the patient? 1) Soy and black cohosh can be used to manage the hot flashes associated with menopause. 2) The patient should be advised that she will have to wait until menopause has finished for the hot flashes to cease. 3) Estrogen is the only reliable method of treatment for hot flashes. 4) Olive oil and black cohosh are effective in the management of hot flashes.

1

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? 1) "We have to implement annual drills." 2) "Nursing homes are not required to have a plan." 3) "Our facility is held to the same standards as hospital facilities." 4) "This is an important component to receive insurance payments for care."

1

The nurse instructs a patient recovering from a mastectomy on ways to prevent lymphedema. Which patient statement indicates that teaching has been successful? 1) "I should do the exercises on my affected arm every day." 2) "I have to take no special precautions." 3) "I should avoid cleansing my skin with soap." 4) "Eating fresh fruits and vegetables will prevent my arm from swelling."

1

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? 1) Arranging group discussion 2) Administering anti-anxiety medication 3) Scheduling individual therapy appointments 4) Documenting individual responses to the session

1

The nurse is caring for a patient with metastatic breast cancer receiving chemotherapy. Even though the prognosis is poor, the patient tells the nurse that the plan is to do everything to survive. How should the nurse respond to this patient? 1) "You have a great attitude, and I am here to support you through education." 2) "It is important to plan for your death, even though there is a chance you will survive." 3) "You should face the reality of the situation. You do not have a good chance of survival." 4) "I am going to speak with your family regarding your unrealistic expectations."

1

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? 1) Having suction available 2) Assessing pupil size and reactivity 3) Immobilizing any obvious deformities 4) Obtaining blood samples for type and crossmatch

1

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? 1) Determining drug allergies 2) Noting the general appearance 3) Examining the neck for stiffness 4) Auscultating for heart and lung sounds

1

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)? 1) Covering the nose 2) Protecting the eyes 3) Decontaminating the skin 4) Administering prophylactic antibiotics

1

Which medication should be listed as the antidote to a nerve agent in the disaster plan for a terrorist attack? 1) Atropine 2) Dopamine 3) Epinephrine 4) Norepinephrine

1

Which organization in the United States mandates ongoing disaster preparedness for hospitals? 1) The Joint Commission (TJC) 2) The local government 3) The state government 4) The Occupational Safety and Health Administration (OSHA)

1

The nurse is providing care to a trauma patient. What is the correct order of steps the nurse will implement when providing care to this patient? Select all that apply. (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) Clear the airway 2) Protect the cervical spine 3) Perform chest compressions 4) Provide supplemental oxygen

1243

A female patient is prescribed an androgen medication to treat an estrogen-sensitive type of breast cancer. What should the nurse instruct this patient about the medication? 1) There is an increased risk of multiple births. 2) Monitor weight weekly. 3) Report calf pain or dyspnea. 4) It must be taken with food.

2

A nurse is caring for a patient who complains of pain with menstruation. What is true regarding the etiology and pathophysiology of this condition? 1) Primary dysmenorrhea is caused by decreased levels of prostaglandins, causing the contractions of the uterus to increase in strength. 2) Primary dysmenorrhea begins within the first three or four menstrual periods after menarche and will occur with each ovulatory cycle during the teens and 20s of a woman's life. 3) Secondary dysmenorrhea is more common than primary dysmenorrhea. 4) Primary dysmenorrhea causes include endometriosis, tumors, cysts, pelvic adhesions, pelvic inflammatory disease, infections, cervical stenosis, uterine leiomyomas, and adenomyosis.

2

A patient prescribed tamoxifen (Nolvadex) for breast cancer treatment asks the nurse how the medication works. What is the best response by the nurse? 1) "Tamoxifen works by inhibiting the cellular mitosis of breast cancer." 2) "Tamoxifen works by blocking estrogen receptors on breast tissue." 3) "Tamoxifen works by binding to the DNA of breast cancer cells." 4) "Tamoxifen works by inhibiting the metabolism of breast cancer cells."

2

The nurse is assessing a patient who is at risk for endometrial cancer. Which is the priority question for the nurse to include in the health history? 1) "How many times have you been pregnant?" 2) "Do you experience irregular or heavy periods?" 3) "How often do you engage in sexual intercourse?" 4) "Have you ever been diagnosed with a sexually transmitted infection?"

2

Which amount of time is appropriate for nurse to spend triaging each patient during a mass casualty incident? 1) Less than 10 seconds 2) Less than 15 seconds 3) Less than 30 seconds 4) Less than 60 seconds

2

Which emergency medical system (EMS) first responders can perform triage during mass casualty incidents? 1) Unlicensed assistive personnel 2) Nurses appointed to a field team 3) A physician who survives the incident 4) Community response team members

2

Which is a potentially life-threatening condition found during the primary triage survey that would necessitate priority nursing care? 1) Cystitis 2) Concussion 3) Lacerated arm 4) Fractured femur

2

Which is the essential nursing skill for the triage process in the emergency department? 1) Evaluating care 2) Setting priorities 3) Formulating diagnoses 4) Implementing interventions

2

Which is the priority nursing action when providing care to a patient with a penetrating abdominal wound? 1) Assessing bowel sounds 2) Stabilizing the impaled object 3) Administering prescribed pain medication 4) Scheduling a CT scan to determine retroperitoneal bleeding

2

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. 1) Rubella 2) Anthrax 3) Measles 4) Botulism 5) Tularemia

2,4,5

Which nursing actions are appropriate during the primary survey of the emergency assessment process? Select all that apply. 1) Inserting a nasogastric tube 2) Immobilizing the cervical spine 3) Arranging for diagnostic studies 4) Preparing for chest tube insertion 5) Applying direct pressure to a wound

2,4,5

A nurse working in an outpatient women's health clinic is caring for a patient in menopause. When discussing hormone replacement therapy (HRT) with the patient, the nurse should include which statement? 1) "Most healthy, recently menopausal women should not use HRT for relief of hot flashes and vaginal dryness." 2) "HRT is the least effective treatment for menopausal hot flashes and vaginal dryness." 3) "If vaginal dryness and painful intercourse are the only symptoms, then low-dose vaginal estrogen is preferred." 4) "The risk of blood clots in the legs or lungs is further increased by using transdermal patches, gels, or sprays."

3

A patient recovering from a hysterectomy does not want to take the prescribed estrogen replacement therapy because of the fear of developing breast cancer. Which response by the nurse is the most appropriate? 1) "The risk of breast cancer is slightly increased for women who opt to take estrogen replacement therapy." 2) "Perhaps you should consider an estrogen-progestin combination therapy." 3) "The risk of breast cancer is not increased for women who have had a hysterectomy and take estrogen replacement medications." 4) "Taking estrogen replacement is required after a hysterectomy."

3

A young adolescent patient is concerned about experiencing severe cramps with menstruation. How should the nurse respond to this patient? 1) "This is not normal but is something that can be treated." 2) "You have cramps because you started your periods too early." 3) "Cramps are seen in those who just start having periods and will become less severe as you get older." 4) "You need to see a gynecologist for a pelvic examination."

3

During an assessment, the nurse notes that a patient receiving radiation treatments for breast cancer has excoriated skin. What is the priority nursing diagnosis for this patient? 1) Excess Fluid Volume 2) Ineffective Breathing Pattern 3) Risk for Infection 4) Activity Intolerance

3

The nurse has identified the diagnosis of Ineffective Coping for a patient with severe premenstrual syndrome. What should be included in this patient's plan of care? 1) Encourage frequent rest periods 2) Suggest four ounces of wine each day 3) Encourage exercise and relaxation techniques 4) Instruct to avoid contraception during menstruation if engaging in sexual intercourse

3

The nurse identifies that a patient is at risk for dysfunctional uterine bleeding. What did the nurse assess in this patient to lead to this clinical diagnosis? 1) Low level of stress 2) Weight gain of 5 lbs in five years 3) Uses birth control pills for contraception 4) Limits intake of high-fat foods

3

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? 1) Ankle sprain 2) Hypovolemic shock 3) Open femur fracture 4) Massive head trauma

3

The nurse is caring for a patient recovering from a total hysterectomy. What should the nurse include when instructing this patient prior to discharge? 1) The importance of douching after intercourse for at least 6 weeks 2) Why bed rest is indicated for at least a month after the surgery 3) The risks and benefits of hormone replacement therapy 4) The importance of returning to normal activities of daily living as soon as possible

3

The nurse is developing strategies to be used for the relief of menstrual cramping in a teaching session to a group of young women. What should be the focus of these strategies? 1) Minimization of menstrual flow 2) Avoidance of uterine contraction 3) Increase of blood flow to the uterine muscle 4) Decrease in estrogen production

3

The nurse is instructing a group of women between the ages of 40 and 50 about early detection of breast cancer. What should the nurse include in this teaching? 1) Perform monthly breast self-exams 2) See a health-care provider if there is a strong family history of breast cancer 3) Have a yearly mammogram 4) Have a clinical breast exam performed by a health-care provider every five years

3

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? 1) Computed tomography (CT) scan 2) X-ray 3) Ultrasound 4) Magnetic resonance imaging (MRI)

4

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? 1) Medical unit 2) Surgical unit 3) Radiology department 4) Emergency department

4

The emergency department nurse is triaging patients. Which patient should be prioritized? 1) An adult patient experiencing mild chest pain 2) An adolescent patient with a possible fractured wrist 3) An older adult patient with a hip fracture who is in pain 4) A school-age patient with asthma presenting with dyspnea

4

The nurse instructs a patient on ways to reduce premenstrual difficulty. Which patient statement indicates the instruction was beneficial? 1) The patient states the need to increase dietary sugar intake to promote energy. 2) The patient states that guided imagery does not help with the symptoms. 3) The patient states the need to increase intake of simple carbohydrates. 4) The patient states that reducing caffeine intake will help.

4

The nurse is conducting a health history interview for a female patient with a family history of ovarian cancer. Which information noted by the nurse indicates this patient has an increased risk for developing this type of cancer? 1) Two noted pregnancies 2) Long term oral contraceptive use 3) Currently breastfeeding an infant 4) Body mass index indicates obesity

4

The nurse is providing care to several patients in the emergency department. Which patient is the priority when using the three-tiered triage system? 1) A patient with a simple fracture 2) A patient experiencing renal colic 3) A patient with severe abdominal pain 4) A patient with chest pain and diaphoresis

4

What should the nurse do to assist a patient brought to the emergency department as a victim of a gunshot wound? 1) Ask the patient who shot him 2) Bathe the patient and provide a clean gown 3) Ask the patient where the weapon is 4) Preserve the chain of evidence

4

Which entity is responsible for activating the disaster plan during a mass casualty incident (MCI)? 1) Local emergency management system 2) State emergency management system 3) Federal emergency management agency 4) Hospital-level emergency management system

4

Which intervention would be a priority when providing care to a patient recovering from thoracic injuries sustained from a motor vehicle crash? 1) Monitor urine output 2) Assess vital signs 3) Perform passive range of motion to all extremities 4) Assist to deep breathe and cough every two hours

4

Which public health risk became a major focus for hospitals after the September 11, 2001 terrorist attacks? 1) Anthrax exposure 2) Multi-casualty incidents 3) Mass casualty incidents (MCI) 4) Weapons of mass destruction (WMD)

4

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? 1) Implementing decontamination measures 2) Performing a head-to-toe physical examination 3) Placing a special bracelet with a disaster number 4) Taking a digital photo and placing it on the medical record

1

Which type of event can often be handled by an individual hospital disaster plan without collaboration with other systems? 1) A motor vehicle accident involving five cars 2) A tornado destroying 50 homes and businesses 3) An act of terrorism injuring and kills hundreds of people 4) A hurricane causing flooding, displacing thousands of people

1

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. 1) Removing patients from immediate danger 2) Discontinuing the use of oxygen for all patients 3) Using a wheelchair to move a bedridden patient 4) Directing ambulatory patients to walk to a safe location 5) Containing the fire immediately to avoid patient evacuation

1.3.4

Which nursing actions are necessary when initiating care for patients who have been injured in a natural disaster? Select all that apply. 1) Taking risks 2) Using principles 3) Stepping into the unknown 4) Showing a commanding presence 5) Formulating individualized plans of care

1,2,3,4

The nurse is providing care to a patient who was recently diagnosed with breast cancer. The nurse is providing education regarding the possible treatment options. Which options will the nurse include in the teaching session? Select all that apply. 1) Mastectomy 2) Hormone therapy 3) Lumpectomy 4) Palliative care 5) Radiation

1,2,3,5

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. 1) Nuclear 2) Biological 3) Botulism 4) Chemical 5) Nipah virus

1,2,4

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. 1) Airway maintenance 2) Obtaining medical history 3) Ventilation assistance 4) Hemorrhage control 5) Hypothermia prevention

1,3,4,5

The nurse is reviewing data collected during a health history and physical assessment and determines that a patient is at risk for developing breast cancer. Which data supports this patient's risk for developing breast cancer? Select all that apply. 1) Age 60 2) Breastfed both children 3) Sister had breast cancer 4) Body mass index 22 5) Menopause at age 58

1,3,5

Which are the top priorities when conducting a primary patient survey during the emergency assessment? Select all that apply. 1) Airway 2) Disability 3) Breathing 4) Circulation 5) Cervical spine

1,5

The nurse is conducting a primary survey during the emergency assessment. Which nursing action is appropriate during the breathing assessment? 1) Assessing for edema 2) Counting respiratory rate 3) Checking for foreign bodies 4) Monitoring for respiratory distress

2

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. 1) Burn 2) Blast 3) Crush 4) Penetration 5) Psychological

2,3,4

The nurse is teaching a 34-year-old patient who has a sister and mother with a history of breast cancer about early screening for the health problem. Which should the nurse include in this teaching session? Select all that apply. 1) Routine monthly breast self-examination 2) Annual screening mammography 3) Routine breast exams to begin after age 35 4) Clinical breast examination every three years 5) Reporting of any changes in breast tissue to the health provider at the next routine visit

2,4

A female patient asks what causes the symptoms of menopause. On which hormonal function should the nurse focus when responding to this patient's question? 1) Increased estrogen levels 2) Increased progesterone levels 3) Estrone as the major hormone 4) Increased luteinizing hormone levels

3

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? 1) Provide active or passive exercises at least once every eight hours 2) Encourage coughing, deep breathing, and incentive spirometry 3) Assist the patient in turning at least every two hours 4) Assist the patient in turning at least every eight hours

3

The nurse is providing care to several patients in the emergency department. Which patient would require priority care from the nurse? 1) An adult patient with an ankle sprain 2) An infant with a rash of unknown origin 3) An adult patient with unstable vital signs and chest pain 4) A pediatric patient with multiple fractures following a motor vehicle accident

3

Which health-care team member is a first responder when an emergency or mass casualty incident (MCI) occurs? 1) Fireman 2) Police officer 3) Critical care nurse 4) Unlicensed assistive personnel

3

Which treatment for anthrax should be included in the biological agent portion of a disaster plan for terrorist attacks? 1) Antivirals 2) Antitoxins 3) Antibiotics 4) Vaccinations

3

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? 1) Hemorrhage 2) Compensatory shock 3) Hypovolemic shock 4) Tension pneumothorax

4

Which psychosocial nursing actions are appropriate when providing patient care after a community disaster? Select all that apply. 1) Performing triage of injuries 2) Administering first aid to wounds 3) Offering choices whenever possible 4) Establishing rapport through active listening 5) Requesting assistance from crisis counselors

3,4,5

Which patient injury would receive a black tag by the triage nurse during a mass casualty incident? 1) Concussion 2) Ankle sprain 3) Open femur fracture 4) Full-thickness body burns

4

The nurse is providing care to several patients in the emergency department. In which order should the nurse assess and provide care to the patients? (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) A patient with a leg laceration requiring sutures 2) A patient with abdominal pain rated as a 7 on a numeric pain scale 3) A patient who has multiple trauma due to a motor vehicle accident 4) A patient who took an overdose of opioids with a respiratory rate of eight breaths per minute

4321

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? 1) Charge nurse 2) Nurse supervisor 3) Licensed practical nurse 4) Unlicensed assistive personnel

1

A patient who is postmenopausal confides in the nurse about pain experienced during intercourse. What should the nurse instruct the patient to do? 1) Use vaginal lubricants during intercourse 2) Avoid intercourse 3) Tolerate this problem because it is a normal part of aging 4) Decrease the frequency of intercourse to decrease the pain

1

The nurse is preparing education for a patient who is diagnosed with endometriosis. Which should the nurse plan to include in the teaching session as a first-line treatment option? 1) Oral contraceptives 2) Aromatase inhibitors 3) Laparoscopy with biopsy 4) Gonadotropin-releasing hormone agonists

1

Which assessment data related to the patient's airway would indicate the need for priority intervention by the nurse? 1) Eupnea 2) Tachycardia 3) Hypotension 4) Agonal breaths

4

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? 1) Drills 2) Tabletop exercises 3) Access to the policy 4) Computer simulations

1