COA3 STUDY for EXAM 5

The patient with chronic renal failure is hypoglycemic. Which juice is the most appropriate to give to the patient? A. Apple B. Grapefruit C. Prune D. Orange

Apple *Many patients with chronic renal failure are diabetic. If they become hypoglycemic, do not give juice that is high in potassium, such as prune, orange, or grapefruit juice. Instead, use apple, cranberry, or grape juice.

Crushed chest, paraplegia A. Red tag: ermergent B. Yellow tag: urgent C. Green tag: nonurgent D. Black tag: terminal

Black tag: terminal

During a tornado warning with sirens, the nursing staff are caring for 36 patients on the second floor medical-surgical unit. How should the staff protect the patients? A. Move all patients to the evacuation center across the street B. Bring all patients into the hall and close doors and windows C. Seal all patients in their bathrooms and cover windows with bed mattresses D. Evacuate patients to the basement via the elevators

Bring all patients into the hall and close doors and windows *Movement to the hall is the safest and fastest and does not expose the patients to being out of doors, in elevators, or near exterior windows

An occupation health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? A. Irrigate the affected area with running water B. Wash the affected area with antibacterial soap C. Brush the chemical off the skin and clothing D. Leave the clothing in place until emergency personnel arrive

Brush the chemical off the skin and clothing

The patient is admitted for a diagnosis of anthrax. What is the health care provider most likely to order to treat this patient? A. IV fluids and oxygen therapy B. Ciproflaxacin (Cipro) C. Gentamicin (Garamycin) D. Antitoxin type A or B

Ciproflaxacin (Cipro)

A high priority in the immediate treatment of burns of the hands is A. Cool burned areas quickly with cool water B. Assess ROM of joints and circumferential burns C. Cover with blankets or sheets to prevent chilling D. Determine the area and degree of the burns

Cool burned areas quickly with cool water

Bacillus anthracis, the causative agent of anthrax, is a potentially threatening biologic weapon for which reason? A. It has no known treatment or cure. B. It is highly contagious. C. It is airborne. D. It has no vaccine.

It is airborne. *Dispersal would be highly effective if the bacteria were released into the environment. Anthrax is not contagious. The bacillus must be inhaled as it is being dispersed; it is not infectious. Anthrax can be treated and cured with ciprofloxacin, doxycycline, or penicillin. There is a vaccine for anthrax; it is available in limited supply. Current recommendations are that it be administered only to individuals known to have been exposed to the anthrax bacillus.

A teenager--alert, oriented, and in no apparent distress--is brought to the ED by EMS on a blackboard with spine immobilization in place. He reports diving into a lake and bumping his head. Based on the mechanism of injury, which assessment are you most likely to initiate? A. Assessment of water safety behavior B. Serial abdominal assessments with hematocrit C. Frequent vital signs to monitor for shock D. Peripheral motion and sensation with mental status checks

Peripheral motion and sensation with mental status checks *The mechanism of injury is diving, and although the youth is currently alert and oriented, the possibility of head or spinal cord injury must be considered. (1) Water safety behaviors should be assessed, but this is not a priority. (2, 3) For trauma patients, any of the other assessments may be performed as part of the routine until other injuries have been ruled out.

When the nurse is assigned to decontaminate patients exposed to chlorine, which primary decontamination material is used in the first step of the process? A. Hydrogen peroxide B. Bleach C. Plain water D. Soap and water

Plain water *The primary decontamination material is plain water. Exposed skin and hair should be flushed with plain water for 2 to 3 minutes; then washed twice with soap and water. Bleach and hydrogen peroxide are not the primary decontamination materials.

What is a simple way to purify water when the supply has been disrupted? A. Rolling boil for 1-3 minutes B. Adding 16 teaspoons of household liquid bleach C. Water that drips from a source into a clean cup D. Low-boil the water for 20 minutes

Rolling boil for 1-3 minutes

The nurse is advising a community group about what to do in the event of a natural disaster such as an earthquake, tornado, or flood. What is appropriate information and advice? A. Evacuate the area and leave immediately B. Take refuge in the basement during a tornado warning C. During an earthquake, drop to the floor and crawl to an exit D. For flood warnings, push towels into the cracks under the doors

Take refuge in the basement during a tornado warning

The nurse is teaching a CPR class. During the class, the nurse correctly includes which statement when discussing the Good Samaritan Law? A. The Good Samaritan Law only protects medical professionals from liability B. The Good Samaritan Law protects all people from liability C. The Good Samaritan Law limits the liability of a medical professional D. The Good Samaritan Law defines specific situations in which no liability will occur

The Good Samaritan Law protects all people from liability *The Good Samaritan Law is designed to protect passersby who render first aid so they will not be held liable for the outcome of emergency care. Individuals who choose to render care will be held to the standard consistent with their training. The law is not limited to medical personnel. It does not address limitations of liability. There is no definition of specific scenarios protected by the law

In a terrorist attack, which period of time poses the greates chance for inhalation of aerosilized anthrax? A. The day of the attack B. The day after the attack C. 2 days after the attack D. 1 week after the attack

The day after the attack *Anthrax is an aerosolized form is most potent 1 day after the explosion. After that time, the organism dies very quickly and anthrax is not communicable from person to person

How many times per year should accredited health care facilities test their emergency plans? A. Once B. Twice C. Three times D. Four times

Twice *Distaster drills should be conducted at least two times per year

Toddler with partial-thickness burns on both legs A. Red tag: ermergent B. Yellow tag: urgent C. Green tag: nonurgent D. Black tag: terminal

Yellow tag: urgent

An older client is a victim of elder abuse, and the client's family has been attending weekly counseling sessions. Which statement by the abusive family member indicates that he or she has learned positive coping skills? A. "I will be more careful to make sure that my father's needs are met." B. "Now that my father is moving into my home, I will need to change my ways." C. "I feel better able to care for my father now that I know where to obtain assistance." D. "I am so sorry and embarrassed that the abusive evet occurred. It won't happen again."

"I feel better able to care for my father now that I know where to obtain assistance." *Elder abuse sometimes occurs with family members who are being expected to care for their aging parents. This can cause family members to become overextended, frustrated, or financially depleted. Knowing where in the community to turn for assistance with careing for aging family members can bring much needed relief. Taking advantage of these alternatives is a postive alternative coping strategy, which many families use

A security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses. Which of the following statements by a nurse indicates understanding? A. "I will get the caller off the phone as soon as possible so I can alert the staff." B. "I will begin evacuating clients using the elevators." C. "I will not ask any questions and just let the caller talk." D. "I will listen for background noises."

"I will listen for background noises."

You are participating in a disaster drill. A mock victim with a green tag asks, "What does this tag mean?" What is the best response? A. "You can go home because you no longer need health management." B. "You potentially pose a health hazard, so you must sit in the green area." C. "You will have to wait for care because your injuries are not life threatening." D. "You will be seen and treated immediately by a health care provider."

"You will have to wait for care because your injuries are not life threatening." *Green tags signify relatively minor injuries that can wait 4 to 6 hours for treatment. Examples include closed fractures and contusions. (1) Telling the patient to go home is not appropriate because the patient needs some medical attention. (2) Green-tagged patients may be contaminated or pose a health risk, but the green tag does not specifically signify contamination. (4) Red-tagged patients are seen immediately. Examples of their injuries include shock or airway problems (those with a high chance of survival if the problem is corrected).

The nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department. The nurse should assign priority to which client? 1. A client complaining of muscle ache, headache, and malaise 2. A client who twisted their ankle when they fell in-line skating 3. A client with a minor laceration on the index finger sustained while cutting an eggplant 4. A client with chest pain who states that they just ate pizza that was made with a very spicy sauce

*A client with chest pain who states that they just ate pizza that was made with a very spicy sauce In an emergency department, triage involves classifying clients according to their need for care, and it includes establishing priorities of care, the type of illness, the severity of the problem, and the resources available to govern the process. Clients with trauma, chest pain, severe respiratory distress, cardiac arrest, limb amputation, or acute neurological deficits, and those who sustained a chemical splash to the eyes are classified as emergent, and these clients are the number 1 priority. Clients with conditions such as simple fractures, asthma without respiratory distress, fever, hypertension, abdominal pain, or renal stones have urgent needs, and these clients are classified as the number 2 priority. Clients with conditions such as minor lacerations, sprains, or cold symptoms are classified as nonurgent, and they are the number 3 priority.

A nurse is collecting data from a preschool-age child who reports abdominal pain. Which of the following findings should alert the nurse to possible abuse? (select all that apply) A. Abrasions on knees B. Round burn marks on forearms C. Mismatched clothing D. Abdominal rebound tenderness E. Areas of ecchymosis on torso

1. Round burn marks on forearms 2. Areas of ecchymosis on torso *Minor injuries (abrasions) on the arms and legs are common in this age group *Mismatched clothing is consistent with the child's need for independence at this age *Abdominal rebound tenderness is a possible indication of appendicitis rather than abuse

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse collect data from first? 1. A client scheduled for a chest x-ray 2. A client requiring daily dressing changes 3. A postoperative client preparing for discharge 4. A client receiving oxygen who is having difficulty breathing

A client receiving oxygen who is having difficulty breathing *The airway is always a priority, and the nurse would attend to the client who has been experiencing an airway problem first. The clients described in options 1, 2, and 3 would have intermediate priority.

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse check first? 1. A client in skeletal traction 2. A client who is dependent on a ventilator 3. A postoperative client preparing for discharge 4. A client admitted during the previous shift with a diagnosis of gastroenteritis

A client who is dependent on a ventilator *The airway is always a priority, and the nurse first checks the client on a ventilator. The clients described in options 1, 3, and 4 have needs that would be identified as intermediate priorities.

The nurse is assisting with creating a plan of care for the client in a crisis state. When developing the plan, the nurse should consider which about a crisis response? A. A crisis state indicates that the individual is suffering from a mental illness B. A crisis state indicates that the individual is suffering from an emotional illess C. Presenting symptoms in a crisis situation are similar for all individuals experiencing a crisis D. A client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person

A client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person *Although each crisis response can be described in similar terms as far as presenting symptoms are concerned, what constitutes a crisis for one person may not constitute a crisis for another person because each is a unique individual. Being in a crisis state does not mean that the client is suffering from an emotional or mental illness

The nurse is assisting with creating a plan of care for the client in a crisis state. When developing the plan, the nurse should consider which about a crisis response? A. A crisis state indicates that the individual is suffering from a mental illness B. A crisis state indicates that the individual is suffering from an emotional illness C. Presenting symptoms in a crisis situation are similar for all individuals experiencing a crisis D. A client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person

A client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person *Although each crisis response can be described in similar terms as far as presenting symptoms are concerned, what constitutes a crisis for one person may not constitute a crisis for another person because each is a unique individual. Being in a crisis state does not mean that the client is suffering from an emotional or mental illness

A patient is brought to the emergency department with injuries sustained in an automobile accident. While assessing the patient, the nurse notes the presence of Cullen sign. This is suggestive of which medical emergency? A. Ruptured spleen B. Neurologic injury C. Abdominal hemorrhage D. Bowel perforation

Abdominal hemorrhage *Cullen sign (ecchymosis around the umbilicus) is suggestive of abdominal hemorrhage. Cullen sign is not associated with neurologic injury, ruptured spleen, or bowel perforation.

The nurse cautions that, when cooling down a victim of heatstroke, one must be careful to prevent shivering. Shivering can lead to which complication? A. A parylytic ileus B. Cardia arrhythmias C. An increase in temperature D. A seizure

An increase in temperature *Shivering is a homeostatic activity that generates heat and increases body temperature. Shivering would not cause a paralytic ileus, cardiac arrhythmias, or seizures

Which statement by the nurse indicates that the goals of critical incident stress debriefing are being met? A. "I still have nightmares about the disaster, but I don't think about it during the day." B. "I am surviving, although I guess I am still drinking more than I should." C. "I went out with friends the other night and we talked about how we were all doing." D. "I am super-prepared now. I check the disaster equipment every day."

"I went out with friends the other night and we talked about how we were all doing."

The nurse is gathering data from a client in crisis. When determining the client's perception of the precipitating event that led to the crisis, which is the most appropriate question to ask? A. "With whom do you live?" B. "Who is available to help you?" C. "What leads you to seek help now?" D. "What do you usually do to feel better?"

"What leads you to seek help now?" *The nurse's initial task when gathering data from a client in crisis is to assess the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found. Option C will assist with determining data related to the precipitating event that led to the crisis. Options A and B identify situational supports. Option D identifies personal coping skills

The nurse recognizes which indications of respiratory distress? (select all that apply) A. Gasping B. Wheezing C. Stridor D. Choking E. Stupor

1. Gasping 2. Wheezing 3. Stridor 4. Choking *All options except stupor are indicators of respiratory distress

A nurse educator is teaching staff members about facility protocol in the event of a tornado. Which of the following should the nurse include? (select all that apply) A. Open doors to client rooms B. Place blankets over clients who are confined to beds C. Move beds away from the windows D. Draw shades and close drapes E. Instruct ambulatory clients in the hallways to return to their rooms

1. Place blankets over clients who are confined to beds 2. Move beds away from the windows 3. Draw shades and close drapes

In which situation(s) is moving a victim of an automobile accident necessary? (select all that apply) A. Presence of pooled gasoline B. Oncoming traffic C. Submersion in snow D. Request from the victim to be moved E. Exposure to hot pavement

1. Presence of pooled gasoline 2. Oncoming traffic 3. Submersion in snow 4. Exposure to hot pavement *A victim request to be moved is not a valid reason to do so if the victim is safe. The patient should be removed from pooled gasoline, oncoming traffic, submerging snow, and hot pavement

The nurse is caring for multiple victims who are rapidly arriving from a nearby disaster site. Which communication strategy is the nurse most likely to use? A. Active listening B. Short directive statements C. Therapeutic touch D. Silence and reflection

Active listening *CHECK BOOK*

A nurse is caring for an adult client who has injuries resulting from partner violence to law enforcement authorities. Which of the following nursing actions is the highest priority? A. Advise the client about the location of safe houses and shelters B. Encourage the client to participate in a support group for survivors of abuse C. Implement case management to coordinate community and social services D. Educate the client about the use of stress management techniques

Advise the client about the location of safe houses and shelters *The greatest risk to this client is injury from further abuse; therefore, the priority action is to assist the client with the development of a safety plan that includes the identification of safe places to live

When can patients with plague who have been treated with appropriate antibiotics be released from respiratory droplet precautions? A. After resolution of all symptoms B. After three sputum samples are negative for blood C. After all lesions are dried D. After the patient receives 48 h of antibiotic treatment

After the patient receives 48 h of antibiotic treatment *The patient with plague can be released from respiratory precautions 48 h after initiation of antibiotic therapy

There is a multi-car accident and several people stop to assist. Under Good Samaritan laws, what applies to voluntary rescuers who assist at the scene? A. All rescuers are equally protected against liabilty B. Rescuers are only protected against liability C. Physicians who stop are held to a higher standard of care than others D. Bad outcomes usually result in liability suits

All rescuers are equally protected against liabilty

To control a gushing bleed of the lower leg, what should you do initially? A. Apply direct pressure to the wound B. Compress the artery above the wound C. Check the circulation to the foot D. Snugly secure a bulky dressing

Apply direct pressure to the wound *First, apply direct pressure to the wound. (2) If that does not work, try compressing the artery above the wound. (3) Check the pulses after controlling bleeding or if you have placed a pressure dressing. (4) Apply a bulky dressing and reinforce layers once the gushing is controlled.

A nurse is caring for a patient with acute radiation sickness syndrome. The patient states she did not receive a very high dose of radiation. What subsyndrome may be seen depending on the dose of radiation she received? A. Bone-marrow syndrome B. Gastrointestinal (GI) lining syndrome C. Cardiovascular system syndrome D. Central nervous system (CNS) syndrome

Bone-marrow syndrome *Exposure to high doses of radiation rays that penetrate the body even for a few minutes may result in acute radiation sickness syndrome. Bone-marrow tissue is affected first; then with increased dosage, the GI lining is affected. The person who receives a high enough dose of radiation to cause cardiovascular/central nervous system syndrome will experience effects on the bone-marrow and GI system as well.

A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include? A. Carbon monoxide has a distinct colot B. Water heaters should be inspected every 5 years C. The lungs are damaged from carbon monoxide inhalation D. Carbon monoxide binds with hemoglobin in the body

Carbon monoxide binds with hemoglobin in the body

The nurse is at a restaurant and observes a person who appears to be choking. He is conscious and partially able to speak. What is the priority action? A. Have a bystander call 911 and stay with the patient B. Encourage him to cough and breathe as deeply as he can C. Get behind him and perform abdominal thrusts D. Strike him sharply between the shoulder blades

Encourage him to cough and breathe as deeply as he can

The police arrive at the emergency room with a client who has seriously lacerated both wrists. What is the initial nursing action? A. Administer an antianxiety agent B. Examine and treat the wound sites C. Secure and record a detailed history D. Encourage and assist the client with venting their feelings

Examine and treat the wound sites *The initial nursing action is to examine and treat the self-inflicted injuries. Injuries from lacerated wrists can lead to a life-threatening situation. Other interventions may follow after the client has been treated medically

A smallpox outbreak has occurred, and victims are reporting to the hospital for treatment, which includes the smallpox vaccine. The nurse knows patients with what symptoms will be admitted? A. Eczema, edema, and headache B. Double vision, droopy eyelids, and difficulty swallowing C. Fever, headache, and myalgia D. Fatigue, dizziness, and muscle aches

Fever, headache, and myalgia *Patients with smallpox will have high fever, headaches, myalgia, backache, malaise, vomiting, and delirium. They will develop a rash that contains firm, deep-seated vesicles or pustules all in the same stage of development on any one area of the body. Eczema, edema, and headache are not signs of smallpox. Fatigue, dizziness, and muscle aches are signs of a hemorrhagic fever. Double vision, droopy eyelids, and difficulty swallowing are signs of botulism.

There are multiple victims during a disaster. The majority of these victims will be triaged and identified with which color of tag? A. Red tag B. Black tag C. Yellow tag D. Green tag

Green tag

Closed fracture of arm, head laceration A. Red tag: ermergent B. Yellow tag: urgent C. Green tag: nonurgent D. Black tag: terminal

Green tag: nonurgent

A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea

Hypotension *hypotension, tachypnea, hot, dry skin, dyspnea

An elderly patient is at high risk for septic shock. Which symptom is more frequently associated with septic shock in elderly patients compared to younger patients? A. Decreased urinary output B. Tachycardia C. Hypothermia D. Slightly elevated temperature

Hypothermia

Implementation of nursing care for the emergency patient who is admitted with frostbite of the foot includes A. Applying a heating pad to the frostbitten area B. Giving the patient hot fluids to drink C. Wrapping the foot in warmed blankets D. Immersing the foot in warm water

Immersing the foot in warm water

The nurse explains the difference between an emergency situation and a disaster to a high school class. Which statement is true? A. An emergency consists of fewer than 50 people who require emergent treatment B. In an emergency situation, the local emergency rooms can meet the need C. An emergency situation lacks the need for a prearranged management plan D. In an emergency situation, the community population is not affected by the event

In an emergency situation, the local emergency rooms can meet the need *An emergency situation, such as a plane crash at a local airport, can be handled by community emergency departments. Each community has in place an emergency plan as to dispersal of people needing to be treated, law enforcement participation, and transportation. Communities are always affected when a large-scale emergency situation occurs

A patient is 6 hours postoperative with signs of deficient fluid volume. The health care provider orders a fluid challenge of 400 mL lactated Ringer solution stat over 20 minutes. What could be considered a desirable response to the treatment? A. Decrease in blood pressure B. Increase in urinary output C. Increase in body weight D. Increase in pulse rate

Increase in urinary output *An increase in urinary output is the desired response, which indicates adequate renal perfusion. (1, 4) A decrease in blood pressure or an increase in pulse indicates that the patient is becoming more fluid deficient and that the therapy is insufficient. (3) Weight gain indicates fluid volume excess.

A nurse is conducting chart reviews of multiple clients at a mental health facility. Which of the following events should the nurse identify as an example of a maturational crisis? A. Rape B. Marriage C. Severe physical illness D. Job loss

Marriage *Marriage is an example of a maturational crisis, which is a naturally occurring event during the life span *Rape is an example of an adventitious crisis *Severe physical illess is an example of a situational crisis *Loss of a job is an example of a situational crisis

To evaluate the effectiveness of Lasix and morphine for the treatment of pulmonary edema in an emergency patient, then nurse would A. Monitor intake and output B. Assess respiratory status C. Assess for decreased pain D. Check the strength of peripheral pulses

Monitor intake and output

The patient is in cardiogenic shock secondary to a myocardial infarction. Which emergency treatment will the health care provider most likely order for this patient? A. Fluid bolus and volume expanders B. Epinephrine and bronchdilators C. Norepinephrine, dopamine, or dobutamine D. Fluid bolus and corticosteroids

Norepinephrine, dopamine, or dobutamine (epinephrine and nitroglycerin if BP is stable)

A patient is tentatively diagnosed with chickenpox. During a skin assessment, what are you likely to find that confirms the diagnosis? A. Skin lesions are firm B. Skin lesions are found on palms and soles C. Skin lesions occur in various stages D. Skin lesions with other signs and symptoms

Skin lesions occur in various stages *Skin lesions in various stages are characteristic of chickenpox. (1, 2, 4) The symptoms provided in the other options are more associated with smallpox.

In a terrorist attack, introduction of the plague would most likely occur as an aerosolized weapon. The nurse understands that this organism is very vulnerable to exposure to which element? A. Temperature of 40°F B. Sunlight C. Strong chlorine solution D. Nitrogen gas

Sunlight *Plague organisms can be destroyed by exposure to sunlight

Which patient needs to be put into isolation immediately? A. Diagnosed case of botulism poisoning B. Probable case of inhalation anthrax C. Known exposure to a high dose of radiation rays D. Suspected smallpox but probable chickenpox

Suspected smallpox but probable chickenpox *Isolate cases of smallpox or chickenpox; smallpox, although exceptionally rare these days, is highly contagious. (1, 2, 3) The other patients do not need immediate isolation; however, the patient who received a high dose of radiation will eventually need protective isolation.

The emergency department nurse is attempting to revive an unconscious, shivering person with extreme hypothermia (rectal temperature of 94°F). The nurse should be most alarmed with which change? A. The patient's cold ears turn red B. The patient stops shivering C. The patient's hands clench D. The patient's reflexes return

The patient stops shivering *Cessation of shivering indicates that the body's homeostatic response to generate heat has ceased and the patient's condition is deteriorating. Clenching hands are an insignificant finding. Reddened ears and returning reflexes would indicate warming

The nurse is assessing a patient who has lost a large volume of blood from multiple deep lacerations. Which finding would indicate that the patient is in shock? A. Bounding pulse, rate 88 beats per minute B. Bounding pulse, rate 56 beats per minute C. Strong pulse, rate 60 beats per minute D. Thready pulse, rate 110 beats per minute

Thready pulse, rate 110 beats per minute *A rapid, thready pulse indicates compensation for loss of blood volume.

Why is a chelating agent administered after a person has been exposed to particulate radioactive material? A. To bind with radioactive material and allow it to be excreted B. To reduce radioactivity to nonharmful levels C. To form a protective coat in the gastrointestinal system D. To dissolve particulate material

To bind with radioactive material and allow it to be excreted *Chelating agents bind with radioactive material, allowing it to be excreted without absorption

What is the purpose of debriefing after caring for victims of a disaster? A. To analyze the effectiveness of the disaster plan B. To assess the efficiency of the response C. To modify the disaster plan D. To help allay posttraumatic stress disorders

To help allay posttraumatic stress disorders *The debriefing is for the purpose of allowing the health professionals to ventilate about their experiences in an effort to allay long-term psychological problems

The nurse has arrived on the scene of an accident. The victim is conscious and has a large bleeding laceration on his thigh. The nurse uses an available towel to provide compression to the wound. What action should the nurse perform next? A. Turn the patient to his left side B. Elevate the patient's affected leg C. Bend the affected leg at the knee D. Use the patient's belt as a tourniquet

Use the patient's belt as a tourniquet *After holding direct pressure on the bleeding area, a tourniquet may be implanted. The nurse should immobilize the leg and avoid position changes that could exacerbate bleeding. Elevation of an injured extremity is no longer recommended

If terrorists were to use category B agents that produce low death rates and moderate illness, by which route would the organisms likely be delivered? A. Vaporization B. Water sources C. Explosion D. Person-to-person contact

Water sources *Category B agents are delivered via a water source. Category A agents may be transmitted without detection and can be easily spread from person to person. Category C agents are agents that have not yet been weaponized

Sucking chest wound, fully conscious A. Red tag: ermergent B. Yellow tag: urgent C. Green tag: nonurgent D. Black tag: terminal

Yellow tag: urgent

Victims who may have residual particulate after radiation or chemical exposure should be decontaminated. Victims should be instructed to A. remove and burn clothing B. wear protective gear and double gloves C. scrub skin with water and soap and rinse well D. brush off and vacuum residual particulates

scrub skin with water and soap and rinse well

The nurse is assigned to assist in triage. The purpose and goal of triage is to A. sort patients by priority of need for treatment B. ensure that all patients receive treatment C. ensure that medical equipment is available D. identify the need for supplies and support

sort patients by priority of need for treatment

A nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? A. "I will place the client on their side." B. "I will go to the nurse's stations for assistance." C. "I will note the time that the seizure begins." D. "I will prepare to insert an airway."

"I will go to the nurse's stations for assistance."

The nurse has just completed a community presentation about ways to prevent hypothermia during cold-water outings. Which statement from an audience member demonstrates a need for additional teaching? A. "Wearing a hat prevents heat loss through the head." B. "I should carry high-energy snacks in case I get lost." C. "I should wear or take layers of warm clothing." D. "If I get lost I should sit quietly to conserve energy."

"If I get lost I should sit quietly to conserve energy."

Based on a patient's answers to interview questions, the nurse suspects that the patient may have been exposed to a possible Category A infectious agent. What should the nurse do first? A. Notify the supervisor about the possibility of contagion B. Don an N-95 or P-100 respirator mask C. Have the patient and family perform hand hygiene D. Isolate the patient in a negative-pressure room

Notify the supervisor about the possibility of contagion *CHECK BOOK*

The nurse is caring for a patient with frostbite. Which assessment findings would lead the nurse to conclude that the patient has second-degree frostbite? A. Reddened skin with hard white plaques B. Waxy skin with sensory deficits C. Reddened skin with milky fluid-filled blisters D. Waxy skin with blood-filled blisters

Reddened skin with milky fluid-filled blisters *Frostbite is catergorized by degree of injury, much like burns. Second-degree injury is characterized by redness, swelling, and formation of blisters filled with clear or milky fluid that forms within 24 h injury. A first-degree injury includes reddened skin, swelling, waxy appearance, hard white plaques, and sensory deficit. Third-degree injury consists of blood-filled blisters followed by black exchar forming over several weeks. Fourth-degree injury involves full-thickness damage affecting muscles, tendons, and bone, resulting in tissue loss

The patient has been diagnosed with the pneumonic plague. The nurse knows which isolation precautions are most appropriate? A. Strict isolation precautions with Standard Precautions B. Contact precautions C. Droplet precautions D. Standard Precautions plus droplet precautions

Standard Precautions plus droplet precautions *Precautions include Standard Precautions plus droplet precautions (eye protection and surgical mask) for 48 to 72 h after antibiotic administration has begun. Isolation and contact precautions are not necessary.

The LPN/LVN is out with a friend one evening when the nurse witnesses a man suddenly collapse. What is the nurse's first action? A. Call for help. B. Start CPR. C. Defibrillate with an AED. D. Check the pulse.

Call for help. *The sudden collapse of an adult is likely to be cardiac in origin; call for help, start CPR, and defibrillate as soon as the AED is available. Any adult that is unresponsive or has breathing issues needs EMS care. The sooner the call is placed, the sooner help will arrive.

A victim of a knife fight is found lying in a parking lot with a loop of bowel protruding from an abdominal wound. What should the first responder do first? A. Attempt to replace the bowel back into the abdomen B. Wrap the victim's shirt tightly around his body C. Cover the evisceration with a plastic shopping bag D. Assist the victim to flex his thighs against his abdomen

Cover the evisceration with a plastic shopping bag *Covering evisceration with a nonadhesive covering will keep the bowel moist. Attempts to return the bowel into the abdomen may result in further injury. Tightly wrapping the shirt around the body may compromise circulation. Flexion of the thighs onto the abdomen may compress and cause further damage to the bowel

The staff is attempting to deescalate the behavior of a patient who is becoming increasingly upset and frustrated. What is the best approach? A. Several staff members should surround the patient B. Allow a family member to privately speak to the patient C. Restrain the patient to give a tranquilizing drug D. Explain the purpose of any planned procedures

Explain the purpose of any planned procedures

During a flood, the public water supply has been contaminated. Which action is most important for the nurse to take? A. Designate which commodes can be used for body waste B. Gather a large pot, household bleach, and other supplies C. Run cold water in sinks to have reservoirs of water D. Reserve existing water for handwashing only

Gather a large pot, household bleach, and other supplies *The nurse will need to purify water and should gather supplies that are necessary to do so. Using any of the water for waste disposal is inappropriate. using cold water pulls from the contaminated water supply. Contaminated water should not be used to wash hands, prepare food, make ice, or prepare baby formula

A 24-year-old man is brought to the ED with respiratory distress after being stung by a bee. Which order from the health care provider should you anticipate as a priority intervention? A. Administer racemic epinephrine by inhalation B. Establish peripheral IV access C. Give 0.5 mg of epinephrine intramuscularly in the lateral thigh D. Draw blood for laboratory tests

Give 0.5 mg of epinephrine intramuscularly in the lateral thigh *The patient is showing signs of anaphylaxis and requires immediate administration of intramuscular epinephrine. (1) Racemic epinephrine can be used to decrease airway inflammation and might help this patient, but it is not the priority action. (2, 4) An IV access needs to be started, and blood can be drawn for laboratory tests at the same time, but these actions should not delay epinephrine administration.

Woman in labor, pains 10 minutes apart A. Red tag: ermergent B. Yellow tag: urgent C. Green tag: nonurgent D. Black tag: terminal

Green tag: nonurgent

A large number of patients are arriving at the hospital from the scene of a chemical disaster. What is the priority action? A. Take vital signs to determine which patients are in distress B. Call poison control for assistance in determining antidotes C. Decontaminate all patients outside the hospital by showering D. Instruct all caregivers to don personal protective equipment

Instruct all caregivers to don personal protective equipment *In a chemical emergency, caregivers should don personal protective equipment prior to assisting patients. Patients are likely to be physically and emotionally in need of attention; however, health care personnel must be protected in order to serve the greater numbers that may follow. (1, 2, 3) The other options are correct but should be accomplished after protecting personnel.

A patient comes to the emergency department after exposure to a toxic chemical spill. Which action indicates that the nurse accurately understands proper management of this patient? A. disinfecting contact lenses before reinserting them B. Irrigating the patient's eyes for 5 to 7 minutes with water C. Using tongs to handle removed clothing D. Placing the clothing in a metal receptacle for disposal

Using tongs to handle removed clothing *Clothing and contact lenses are considered contaminated and should be removed and discarded. The nurse should use tongs to prevent touching the clothing directly. Contact lenses should be discarded, eyes should be irrigated for 10 to 15 minutes, and clothing should be placed in a plastic bag for disposal

A charge nurse is leading a peer group discussion about family and community violence. Which of the following statements by a member of the group indicates an understanding of teaching? A. "Children older than 5 are at greater risk for abuse." B. "Substance use disorder does not increase the risk for violence." C. "Entering an intimate relationship increases the risk for violence." D. "Pregnancy increases the risk for violence from a spouse of partner."

"Pregnancy increases the risk for violence from a spouse of partner." *Pregancy tends to increase the likelihood of violence from a spouse or partner *Children younger than 4 years of age are at an increased risk for abuse *Substance use disorder increases the risk for violence *Vulnerable persons are an increased risl for violence when they try to leave the relationship

The nurse is a first responder at the site of an accident involving multiple vehicles. Which patient should receive priority during triage? A. Burns of the head and neck B. Contusions of the head without loss of consciousness C. Crushing injury of the arm D. Open fractures of the tibia and fibula

Burns of the head and neck *One of the most common methods for triage of patients uses "ABCDE" as a memory trigger for the sequence of assessment. A is airway, B is breathing, and C is circulation. D can mean either the need for defibrillation or, in a trauma setting, assessment of neurologic disability. E is exposed: all areas of the body should be exposed so that injuries are not missed underneath clothing. Burns of the head and neck pose an immediate threat of airway compromise. Crushing injury of the arm, open fractures of the tibia and fibula, and head contusion without loss of consciousness are all painful but do not represent an immediate threat to life.

After a truck crashes into the dayroom of a long-term care facility, many of the residents are injured, and noninjured residents are stunned and frightened. What action should the nurse take? A. Firmly instruct two CNAs to start wheeling residents to the dining room in their wheelchairs B. Begin wheeling residents back to their rooms herself C. Shout for everyone to hurry to the dining room D. Begin treating the injured in the center of the dayroom

Firmly instruct two CNAs to start wheeling residents to the dining room in their wheelchairs *The nurse should recognize that everyone is in the impact stage. In the impact stage, firm direction is needed to get people to a central place for safety and information. The nurse should not try to single-handedly correct the situation, shout and increase confustion, or treate patients in the middle of the chaotic environment

Which agency requires preparedness plans for accredited hospitals? A. American Red Cross (ARC) B. The Joint Commission (TJC) C. Federal Emergency Management Agency (FEMA) D. Office of Civil Defense (OCD)

The Joint Commission (TJC) *TJC requires that all accredited facilities have a written emergency preparedness plan with designated roles and responsibilities. The ARC is a voluntary organization that traditionally provides the basic essentials of shelter, food, and first aid during a natural disaster. FEMA is an organization under the federal government. It is activated by the Department of Homeland Security. It acts when states require assistance in times of disaster. The Office of Civil Defense (OCD) is no longer in existence. It was a federal agency that acted in cases of large-scale disasters. It was replace by FEMA

While admitting a young, previously healthy patient with a severe respiratory illness, you become suspicious of a bioterrorism event. Which question would you ask to confirm the suspicion? A. "Have you been washing your hands frequently?" B. "Has the illness progressed rapidly?" C. "Do you have a fever?" D. "Are you a local resident?"

"Has the illness progressed rapidly?" *Rapid progression of illness in a previously healthy young adult is suggestive of a bioterrorism event because it is not an expected pattern. (1, 3) These questions could be indirectly related to an event, but they are general questions that could be relevant to a large number of typical disease patterns. (4) Asking about recent travel or participation in a large local event would be better than asking the patient if they are a local resident.

The psychiatric nurse is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the appropriate nursing response? A. "I cannot discuss any client situation with you." B. "I'm not supposed to discuss this, but because you are my neighbor, I can tell you that she is doing great!" C. "You may want to know about Carol, so you need to ask her yourself so you can get the story firsthand." D. "I'm not supposed to discuss this, but because you are my neighbor, I can tell you that she really has some problems!"

"I cannot discuss any client situation with you." *The nurse is required to maintain confidentiality regarding clients and their care. Confidentiality is basic to the therapeutic relationship and is a client's right. Option C is correct in a sense, but it is a rather blunt statement. Both options B and D identify statements that do not maintaining client confidentiality

An older client is a victim of elder abuse, and the client's family has been attending weekly counseling sessions. Which statement by the abusive family member indicates that he or she has learned positive coping skills? A. "I will be more careful to make sure that my father's needs are met." B. "Now that my father is moving into my home, I will need to change my ways." C. "I feel better able to care for my father now that I know where to obtain assistance." D. "I am so sorry and embarrassed that the abusive evet occurred. It won't happen again."

"I feel better able to care for my father now that I know where to obtain assistance." *Elder abuse sometimes occurs with family members who are being expected to care for their aging parents. This can cause family members to become overextended, frustrated, or financially depleted. Knowing where in the community to turn for assistance with caring for aging family members can bring much needed relief. Taking advantage of these alternatives is a positive alternative coping strategy, which many families use

The nursing staff is participating in a discussion about practical measures to prepare for a possible pandemic flu event. Which comment by a staff member indicates an understanding of what should be done? A. "The hospital needs to get more ventilators for the intensive care unit." B. "None of the nurses with children should have to come under those conditions." C. "We need to review respiratory isolation precautions and reinforce handwashing." D. "This is not a third-world country; we will be okay if we just use common sense."

"We need to review respiratory isolation precautions and reinforce handwashing."

The nurse observes that a client with a potential for violence is agitated, pacing up and down in the hallway, and making aggressive and belligerent gestures at other clients. Which statement is appropriate to make to this client? A. "You need to stop that behavior now!" B. "You will need to be placed in seclusion!" C. "What is causing you to become agitated?" D. "You will need to be restrained if you do not change your behavior."

"What is causing you to become agitated?" *The best statement is to ask the client what is causing the agitation. This will assist the client with becoming aware of the behavior and will assist the nurse with planning appropriate interventions for the client. Option A is demanding behavior, which could cause increased agitation in the client. Option B and D are threats to the client and are inappropriate

The nurse is caring for an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic? A. "Right! Why not just 'pack it in?" B. "That seems rather unlikely to me." C. "I don't believe that, and neither do you." D. "You must be feeling all alone at this point."

"You must be feeling all alone at this point." *The client is experiencing loss and is feeling hopeless. The therapeutic response by the nurse is the one that attempts to translate words into feelings. In option A, the nurse uses sarcasm, which gives advice and is nontherapeutic as a nursing response. In option B, the nurse is voicing doubt, which is often used when a client verbalizes delusional ideas. In option C, the nurse is disagreeing with the client, which implies that the nurse has passed judgment on the client's ideas or opinions

Which category A organisms may be released in a bioterrorism attack because of lethality? (select all that apply) A. Ebola B. Avian flu C. Botulism D. Smallpox E. Tularemia

1. Ebola 2. Botulism 3. Smallpox 4. Tularemia *Avian flu (bird flu) is not on the category A list

A nurse is discharging an elderly patient who has been in the hospital with hypothermia for the past 3 days. The patient wants to know how to stay warm at home so she can stay out of the hospital. What is the nurse's best response? (Select all that apply.) A. "Cover your head when sleeping to prevent heat loss." B. "Keep doors open so all your rooms are heated." C. "Use your fireplace in the colder months to help keep you warmer." D. "Keep your room temperature checked, and never keep it lower than 65° F." E. "Wear multiple layers of clothes in your house and when going outdoors."

1. "Cover your head when sleeping to prevent heat loss." 2. "Keep your room temperature checked, and never keep it lower than 65° F." 3. "Wear multiple layers of clothes in your house and when going outdoors." *Hypothermia is more prevalent in the elderly because they are less active; therefore, less heat is generated. The nurse should teach the patient to cover her head when sleeping to prevent heat loss, to wear multiple layers of clothes in her house and when going outdoors, and to keep her room temperature checked and never keep it lower than 65° F. She should never keep her thermostat below 65° F anytime of the year. She should not use the fireplace in extremely cold weather because a substantial amount of heat is lost through the flue. An energy audit with suggestions from the utility company can prevent heat loss from the home. Suggest heating one or two rooms and closing off the other rooms of the house. Suggest aids, such as a throw or quilt, extra socks, and warm hats to be worn indoors. Arrange for someone to check in daily with elderly persons who live alone. Suggest an early alert system be installed, allowing the individual to call for help by pressing a button, if unable to get to the phone.

You are teaching a group of people about water and food safety after a disaster. Which comments by the learners indicate successful teaching? (select all that apply) A. "Contaminated water should be boiled for at least 20 minutes." B. "Eight drops of bleach to a gallon of water will purify the water." C. "A full freezer will keep food safe for 48 hours." D. "Any food that has an unusual odor, color, or texture should be thrown away." E. "Tightly sealed containers of food are safe to use even if in contact with flood waters."

1. "Eight drops of bleach to a gallon of water will purify the water." 2. "A full freezer will keep food safe for 48 hours." 3. "Any food that has an unusual odor, color, or texture should be thrown away." *After a disaster, 8 drops of bleach per 1 gallon of water will purify the water. A full freezer will keep food safe for 48 hours. Any food that has an unusual odor, color, or texture should be thrown away. (1) Boiling water for 3 to 5 minutes is sufficient; additional time does not hurt, but fuel may be an issue, and prolonged boiling will cause evaporation if there is a water shortage. (5) Lids that screw on, snap on, or are crimped cannot be disinfected and should be discarded if they come in contact with flood water.

The nurse is educating a new nurse about mass casualty events (disasters). Which statement by the new nurse indicates a need for further teaching? (Select all that apply.) 1. "An event is termed a mass casualty when it overwhelms local medical capabilities." 2. "Mass casualty events do not require an increase in the number of staff that are needed." 3. "A mass casualty event occurs only within the heath care facility and could endanger staff." 4. "Mass casualty events may require the collaboration of many local agencies to handle the situation." 5. "A mass casualty event occurs if a fight between visitors occurs in the emergency department."

1. "Mass casualty events do not require an increase in the number of staff that are needed." 2. "A mass casualty event occurs only within the heath care facility and could endanger staff." 3. "A mass casualty event occurs if a fight between visitors occurs in the emergency department." *Mass casualty events, also known as disasters, overwhelm local medical capabilities and may require the collaboration of multiple agencies and health care facilities to handle the crises. This type of event can occur in the health care facility or outside of it. Fights in the emergency department are not termed mass casualty events but are agency security and local enforcement issues. Mass casualty events almost always require an increase in staffing to ensure safe client care.

A group of excited teenagers come to the walk-in clinic; they drag in an adolescent who is unresponsive. There are no obvious signs of injury or bleeding, but his skin is pale and clammy. What questions should the nurse initially ask? (select all that apply) A. "Where are his parents?" B. "What school does he attend?" C. "What is his name?" D. "What happened to him?" E. "How long has he been like this?" F. "Why didn't you call 911?" G. "What was the group doing before he passed out?"

1. "What is his name?" 2. "What happened to him?" 3. "How long has he been like this?" 4. "What was the group doing before he passed out?"

According to the CDC, which psychological stages do individuals go through after a major disaster? (Select all that apply.) A. Honeymoon stage B. Impact stage C. Acceptance stage D. Heroic stage E. Reconstruction stage F. Disillusionment stage

1. Honeymoon stage 2. Impact stage 3. Heroic stage 4. Reconstruction stage 5. Disillusionment stage *According to the CDC, psychological stages individuals go through after a major disaster include the impact stage, the heroic stage, the honeymoon stage, the disillusionment stage, and the reconstruction stage. The acceptance stage is most commonly associated with death and grieving stages.

The nurse is performing triage in the emergency department. List the patients in the order they should be seen in the emergency department. A. A 14-year-old patient who is alert and oriented following a blow to the head during football practice B. A 76-year-old patient with chronic obstructive pulmonary disorder with nasal flaring and supraclavicular retractions C. A 3-year-old crying patient with a forehead bump and bruise D. A 15-year-old patient with a severe allergy to peanuts and swollen tongue and lips E. A 48-year-old patient with a firm, distended abdomen complaining of severe pain F. A 64-year-old light-headed patient with a pulse of 134 who reports vomiting and bloody stools once a week

1. A 15-year-old patient with a severe allergy to peanuts and swollen tongue and lips 2. A 76-year-old patient with chronic obstructive pulmonary disorder with nasal flaring and supraclavicular retractions 3. A 64-year-old light-headed patient with a pulse of 134 who reports vomiting and bloody stools once a week 4. A 14-year-old patient who is alert and oriented following a blow to the head during football practice 5. A 48-year-old patient with a firm, distended abdomen complaining of severe pain 6. A 3-year-old crying patient with a forehead bump and bruise *The nurse should use the ABCDE mnemonic to triage the patients. The first patient to be seen is the patient with the impending compromised airway. Swollen tongue and lips in the patient with a severe peanut allergy indicates looming anaphylaxis. Nasal flaring and supraclavicular retractions indicate impending respiratory failure; this patient should be seen second. The patient with vomiting and bloody stools for a week who is extremely tachycardic should be seen next, as this patient is at risk for circulatory collapse. The patient with decreased level of consciousness following a blow to the head should be seen next. This injury represents the D in the mnemonic, neurological disability. The patient with a firm and distended abdomen should be seen next because this is likely an intestinal obstruction. The child with a bump and bruise on the forehead can be seen last. The crying child likely has no neurological damage; a silent child would be more concerning.

A nurse on a medical-surgical unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge stable clients to make beds available for injury victims. Which of the following clients should the nurse recommend for discharge? (select all that apply) A. A client who is dehydrated and receiving IV fluid and electrolytes B. A client who has a nasogastric tube to treat a small bowel obstruction C. A client who is scheduled for elective surgery D. A client who has chronic hypertension and blood pressure 135/85 mm Hg E. A client who has acute appendicitis and is scheduled for an appendectomy

1. A client who is scheduled for elective surgery 2. A client who has chronic hypertension and blood pressure 135/85 mm Hg

Which statement accurately describes how water can be rendered safe for drinking in the event of a disruption of service? (select all that apply) A. Allow water to sit for 24 h before using B. Boil water for 1 to 3 minutes C. Add 0.5 mL (8 drops) of household bleach to a gallon of water and let it stand for 30 minutes D. Drain water from hot water heaters E. Pour water through several layers of cotton towels

1. Boil water for 1 to 3 minutes 2. Add 0.5 mL (8 drops) of household bleach to a gallon of water and let it stand for 30 minutes 3. Drain water from hot water heaters *Water can be rendered safe for drinking by boiling, treating with household bleach, or removing from hot water heaters or commode tanks. Allowing water to sit for 24 h or pouring water through layers of cotton towels does not adequately render the water safe to drink. Add 0.5 mL (8 drops) of household bleach to a gallon of water and let it stand for 30 minutes.

Treatment for frostbite includes which actions? (Select all that apply) A. Chafing the hands and fingers gently to reestablish circulation B. Immersion of hands and feet in warm water C. Wrapping hands in mitten-like dressings to retain warmth D. Administering opioids to reduce pain E. Elevating affected limbs

1. Chafing the hands and fingers gently to reestablish circulation 2. Immersion of hands and feet in warm water 3. Elevating affected limbs *Gently chafing hands and fingers, immersing extremities in water, and elevating affected limbs are indicated treatments for hypothermia. Nonsteroidal anti-inflammatory drugs are the analgesic of choice, because opioids decrease function and dealy circulatory recovery. Fingers should be wrapped individually, and touching each other

The nurse is instructing a group of 25 to 35 year old hikers about heatsroke prevention. Which participant drink selection indicates the need for further education? (select all that apply) A. Clear carbonated soda B. Diet caffeinated cola C. Water D. Beer E. Sugar-sweetened drinks

1. Clear carbonated soda 2. Diet caffeinated cola 3. Beer 4. Sugar-sweetened drinks *The wrong fluids can increase fluid loss. To aid in the prevention of heatstroke, the hiker should drink plenty of fluids that are nonalcoholic, caffeine free, and low in sugar content. Clear carbonated soda and sweetened energy drinks are high in sugar. Diet cola contains caffeine

Which physiological differences explain why the older adult is prone to hypothermia? (Select all that apply) A. Decreasing appetite with less food intake B. Increasing subcutaneous fat C. Decreasing metabolism D. Increased likelihood of atherosclerosis E. Decreasing activity level

1. Decreasing appetite with less food intake 2. Decreasing metabolism 3. Increased likelihood of atherosclerosis 4. Decreasing activity level *The older adult is prone to hypothermia because of less food intake, lower metabolism, possibility of atherosclerosis, decreased activity level, and less subcutaneous fat

You are talking to a community group about strategies to prevent heat-related illness. What advice is appropriate to give to the group? (select all that apply) A. Drink fluid that are nonalcoholic, noncaffeinated, and low in sugar content B. When you are thirsty, drink fluids and avoid eating salty foods C. Stay indoors with cooling systems D. In the heat, wear lightweight, light-colored, loose-fitting clothing E. Limit outdoor activities to spring or fall when the weather is cooler F. Use sun protection such as wide-brimmed hats, sunglasses, and sunscreen

1. Drink fluid that are nonalcoholic, noncaffeinated, and low in sugar content 2. Stay indoors with cooling systems 3. In the heat, wear lightweight, light-colored, loose-fitting clothing 4. Use sun protection such as wide-brimmed hats, sunglasses, and sunscreen *Do not drink alcohol or fluids with caffeine or high sugar content, as these types of fluid can actually increase the likelihood of dehydration. Do stay indoors where cooling systems are functional. Wearing lightweight clothes and using sun protection also helps reduce heat exposure. (2) Do not wait until you are thirsty to drink fluids. Eating excessive salt is never recommended, but total avoidance of salty foods is not necessary. (5) Healthy people should not be discouraged from enjoying the outdoors in the summer months. Limit activities during hot weather to mornings or evenings.

The nurse is participating in an educational program concerning nuclear disasters. Which factor(s) determine a victim's level of exposure to radiation? (select all that apply) A. Age of victim B. Body surface area of the victim C. Length of exposure D. Distance of the victim from the nuclear source E. Shielding of the victim from the nuclear source

1. Length of exposure 2. Distance of the victim from the nuclear source 3. Shielding of the victim from the nuclear source *The amount of damage to each person depends on the type of radiatio, the dose received, the length of time of exposure, and the route of the exposure. Time, distance, and shielding are key to the quantity of radiation an individual will receive. The short the time of exposure, the farther away from the radiation source, and whether or not the person was shielded by materials that are impermeable to radiation are details pertinent to radiation risk

The nurse is preparing a list of items that are needed in a disaster kit. Which items should the nurse include? (select all that apply) A. A 12 day supply of bottled water B. Nonperishable food items C. Prescription medications D. Portable radio E. Bedding F. First aid kit

1. Nonperishable food items 2. Prescription medications 3. Portable radio 4. Bedding 5. First aid kit *Nonperishable food items, prescription medication, a portable radio, bedding, and a first aid kit are essential components of an adequate disaster kit. A water supply that will last 3 days is sufficient for a disaster kit

A nurse is caring for a client who is experiencing a crisis. Which of the following medications should the nurse plan to administer? (select all that apply) A. Lithium carbonate B. Paroxetine C. Risperidone D. Haloperidol E. Lorazepam

1. Paroxetine 2. Lorazepam *SSRI antidepressants (paroxetine) can be prescribed to decrease the anxiety and depression of a client who is experiencing a crisis *Benzodiazepines (lorazepam) can be prescribed to decrease the anxiety of a client who is experiencing a crisis *Mood stabililizers (lithium carbonate) are prescribed for bipolar disorder *Antipsychotic medications (risperidone and haloperidol) can be prescribed for disturbed thought processes, usually when accompanied by other psychotic manifestations (hallucinations, delusions, blunt affect)

A nurse is caring for a client who has severe acute respiratory syndrome (SARS). The nurse knows that health care professionals are required to report communicable and infectious disease. Which of the following illustrate the rationale for reporting? (select all that apply) A. Planning and evaluating control and prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment D. Identifying endemic disease E. Monitoring for common-source outbreaks

1. Planning and evaluating control and prevention strategies 2. Determining public health priorities 3. Ensuring proper medical treatment 4. Monitoring for common-source outbreaks

A nurse is preparing to collect data from an infant. Which of the following is an expected finding of shaken baby syndrome? (select all that apply) A. Sunken fontanels B. Respiratory distress C. Retinal hemorrhage D. Altered level of consciousness E. Increase in head circumference

1. Respiratory distress 2. Retinal hemorrhage 3. Altered level of consciousness 4. Increase in head circumference *Bulging, rather than sunken, fontanels are an expected finding of shaken baby syndrome

Essential elements in a disaster plan include provision of which components? (select all that apply) A. Shelter for victims B. Transportation C. Communication D. Welfare of victims E. Food

1. Shelter for victims 2. Transportation 3. Communication 4. Welfare of victims 5. Food *All options are essential elements in a disaster plan

Local civil defense courses on disaster preparedness explain the roles of which people/entities? (select all that apply) A. State government B. Federal government C. Law enforcement agencies D. Individual service agencies E. Nurse as a volunteer

1. State government 2. Federal government 3. Law enforcement agencies 4. Individual service agencies 5. Nurse as a volunteer *Civil defense courses should explain the role of all of these participants

The nurse is caring for a patient suspected of having heatstroke. Which findings are consistent with this diagnosis? (select all that apply) A. Bradycardia B. Tachycardia C. Irregular pulse patterns D. Visual disturbances E. Increased urinary output

1. Tachycardia 2. Irregular pulse patterns 3. Visual disturbances *Heatstroke may cause a weak, rapid, irregular pulse, and visual disturbances. Other manifestations may include decreased urinary output, an alteration in neurologic function, dizziness, and nausea

A neighbor is found slumped over the lawn mower and is unconscious. Arrange the interventions made by the first responder in appropriate order A. Tell neighbor's wife to call 911 B. Assess for heartbeat C. Initiate CPR if no respiration or circulation can be assessed D. Assess for signs of breathing E. Shake patient and call name to assess for level of consciousness (LOC)

1. Tell neighbor's wife to call 911 2. Shake patient and call name to assess for level of consciousness (LOC) 3. Assess for signs of breathing 4. Assess for heartbeat 5. Initiate CPR if no respiration or circulation can be assessed

In the event of a disaster requiring evacuation of homes, what items should be in a "go bag"? (select all that apply) A. All personal valuables B. Water and medications C. Flashlight and batteries D. Camp stove and eating utensils E. Clothing and important documents

1. Water and medications 2. Flashlight and batteries 3. Clothing and important documents *Water, medications, flashlights and batteries, clothing, and important documentation should all be included in a "go bag." (1) It is not practical to try to evacuate with all items considered personally valuable. (4) A camp stove would be a nice thing to have but is bulky and requires flammable fuel that may not be safe to carry.

The nurse is teaching disaster preparedness at a community center. The nurse knows that which water sources may be used in the event of the water supply being disrupted? (Select all that apply.) A. Water that has been distilled. B. Flood or storm water. C. Water that has been brought to a rolling boil for 1 to 3 minutes. D. Water that has had household bleach containing 5.25% sodium hypochlorite (8 drops of bleach/gallon of water and let stand for 30 minutes). E. Stored bottled water.

1. Water that has been distilled. 2. Water that has been brought to a rolling boil for 1 to 3 minutes. 3. Water that has had household bleach containing 5.25% sodium hypochlorite (8 drops of bleach/gallon of water and let stand for 30 minutes). 4. Stored bottled water. *A drinking water source that may be used safely in the event of the water supply being disrupted includes use of stored bottled water and the use of water that has been distilled. In addition, use of boiled water that has been brought to a rolling boil for 1 to 3 minutes and use of water that has had household bleach containing 5.25% sodium hypochlorite (8 drops of bleach/gallon of water and let stand for 30 minutes) is safe. Use of flood or storm water is not safe for drinking.

The nurse counsels a group of young track athletes about heatstroke prevention. Which information should the nurse include? (select all that apply) A. Drink plenty of fluids with high sugar content B. Wear lightweight, loose clothing C. Practice in the early morning D. Rest frequently in cool places E. Wear dark-colored clothing to block sun rays

1. Wear lightweight, loose clothing 2. Practice in the early morning 3. Rest frequently in cool places *Athletes should weat lightweight and loose clothing, practice in the morning to avoid peak heat hours, and rest frequently in the shade to prevent overheating. While athletes should drink plenty of fluids for hydration, liquids should be nonalcoholic, noncaffeinated, and low sugar; liquids with alcohol, caffeine, and sugar increase dehydration. Dark-colored clothing will absorb heat; athletes should wear light-colored clothing

The home health nurse in Wyoming gives instructions to an 80 year old patient in the prevention of hypothermia. Which information should the nurse include? (select all that apply) A. Wear multiple layers of clothing B. Wear a loose-fitting hat C. Move about briskly D. Drink warm fluids from a thermos E. Wear gloves and earmuffs

1. Wear multiple layers of clothing 2. Move about briskly 3. Drink warm fluids from a thermos 4. Wear gloves and earmuffs *The patient should wear multiple layers of clothing, move about briskly, drink warm fluids, and wear ear and hand protection. The patient should also wear a hat, but it should fit snugly

The nurse caring for a patient who is bleeding from a lacerated radial artery. The patient's blood pressure is 85/40, pulse is 130 and thready, and her skin is cold and clammy. The patient has likely experienced how much blood loss? A. 50% B. 30% C. 20% D. 40%

40% *When blood loss is at 40%, the clinical manifestations include below normal blood pressure, central venous pressure, and cardiac output at rest; and a rapid thready pulse with cold and clammy skin. Manifestations of a 20% blood volume loss are no signs or symptoms when at rest; however, the patient has slight postural hypotension when standing and tachycardia with exercise. The patient with a 30% blood volume loss will have normal blood pressure and pulse when supine; postural hypotension and tachycardia with exercise. At 50% the patient experiences shock and potential death.

During a power failure, at what temperature should perishable food be maintained to prevent a possibility of food poisoning? A. 40°F B. 45°F C. 50°F D. 55°F

40°F *To prevent spoilage, perishable foods should be kept at 40°F

A freezer full of food at the time of the power failure will keep food to eat for what period of time? A. 8 h B. 12 h C. 24 h D. 48 h

48 h *Food frozen in a full freezer will keep the food safe for 48 h. A partially filled freezer will keep food safe for 24 h

The nurse is reviewing the physician's notes on a patient's chart. The nurse notes that the patient demonstrated Cullen sign. The nurse correctly recognizes that this patient most likely had which manifestation? A. Sharp flank pain B. Pain in the upper right quadrant of the abdomen C. Pain with inspiration D. A bluish tinge around the umbilicus

A bluish tinge around the umbilicus *Cullen sign refers to a bluish tinge around the umbilicus. It may be noted in the presence of internal abdominal hemorrhage

A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the nurse's priority? A. A client who received crush injuries to the chest and abdomen and is expected to die B. A client who has a 4-inch laceration to the head C. A client who has partial thickness and full thickness burns to his face, neck, and chest D. A client who has a fractured fibula and tibia

A client who has partial thickness and full thickness burns to his face, neck, and chest

The nurse is caring for a conscious patient who has symptoms consistent with hypoglycemia. After a serum glucose reading supports this diagnosis, which substance is preferred to initially increase the patient's glucose level? A. A carbonated soda B. A teaspoon of white sugar C. A glass of milk D. IV glucose

A glass of milk *When the patient is conscious, an oral glucose-containing substance is suggested. A glass of milk, glucose tablets, or hard candy is preferred

The nurse is at a community event and a child accidentally sustains a laceration with apparent arterial bleeding. The nurse's immediate action to control the bleeding is to A. Apply pressure directly over the wound with the covered palm of the hand B. Tape a sterile or clean dressing over the open wound C. Elevate the injured part and immobilize the child and the wound D. Periodically remove the original dressing to assess for active bleeding

Apply pressure directly over the wound with the covered palm of the hand

Which behavior by a nurse indicates that there is a need for additional counseling beyond the counseling offered through a critical incident stress debriefing? A. Talks openly about the incident but is not ruminating B. Avoids coworkers and friends for a prolonged period C. Takes extra vacation time away from the city D. Attempts to resume a health lifestyle but is not sleeping well

Avoids coworkers and friends for a prolonged period *Avoiding friends, family, and routine relationships is a sign that the nurse is not coping well in the post-trauma period, particularly if the behavior is prolonged. (1, 3) Openly talking without ruminating and taking vacation time are both good coping strategies. (4) Not sleeping well is another cause for concern, but the attempt to reestablish routines is a healthy sign; this person would probably benefit from counseling if normal sleep does not resume.

The nurse is teaching community members about precautions related to a pandemic occurrence. Which information is most helpful for the nurse to include in the teaching plan? A. Be sure to cover your mouth when coughing B. Be prepared to stay at home for at least 2 weeks C. Dispose of tissues after using them D. Avoid shaking hands

Be prepared to stay at home for at least 2 weeks *The nurse should be sure to include information that differentiates pandemic flu occurrences from normal respiratory illness. The priority education about pandemic flu involves teaching people to be prepared to stay at home for at least 2 weeks. While covering the mouth when coughing or sneezing, tissue disposal, and avoiding handshakes are important, all of these considerations are precautions for prevention of any respiratory illness

A worker in a department store fell through a plate glass window, causing a deep laceration on the right mid-thigh that is pumping bright red arterial blood. Which initial action is most important for the first responder to take? A. Elevate the leg B. Bunch up the worker's shirt and press it against the wound C. Press the palm of the hand in the groin to compress the femoral artery D. Tie the worker's belt tightly around his upper thigh to stop bleeding

Bunch up the worker's shirt and press it against the wound *A guideline published by the American College of Surgeons Committee on Trauma in 2014 recommends holding direct pressure on the bleeding area for prehospital control of bleeding. If this approach is impractical or ineffective, a tourniquet may be implemented. It is not always possible to compress the artery at the needed location, so this choice is not a first line intervention. Elevation if an injured extremity is no longer recommended

You make a home visit to a 70-year-old patient on a cold winter day. On your arrival, the patient demonstrates excessive coughing, shortness of breath, drowsiness, and confusion. Mucous membranes are cherry red. What is your first action? A. Question the patient about recent food or fluid consumption B. Call for emergency help and open the windows C. Search the house for evidence of poisons and then call poison control D. Locate the source of odors or try to get the patient to walk out of the house

Call for emergency help and open the windows *The patient's symptoms and the circumstances suggest carbon monoxide poisoning. The rescuer could be overwhelmed by an inhaled poison, so open the windows and call for help first before attempting to help the victim or to discover the problem. (1) The patient's symptoms do not suggest food poisoning. (3) The symptoms do not indicate ingestion of poison. (4) Locating a source for odors is not a priority and getting a confused drowsy patient out into cold weather is not the best option.

In the event of any type of poisoning that occurs in the home setting, what is the initial course of action? A. Save the poison container and contents B. Save a sample of vomitus for analysis C. Call poison control D. Induce vomiting

Call poison control *People in the community should immediately call poison control for advice. One possible exception is contamination of the eye, in which case flushing with copious amounts of water for 15 to 20 minutes should precede calling poison control. (1, 2) Saving the container and the emesis is helpful for analysis, but this can be done after the victim is attended to. (4) Inducing vomiting is never recommended in cases of caustic poisonings; therefore poison control should be called first.

When taking care of a patient with sepsis, what is the first sign that would signal impending septic shock? A. Increasing urine output B. Decreasing heart rate C. Decreasing blood pressure D. Change in mental status

Change in mental status *A change in mental status is likely to be the first sign. (1) Urine output would decrease, not increase. (2) Pulse would increase, not decrease, in an attempt to compensate. (3) A decrease in blood pressure is a later sign.

An 80-year-old woman is brought to the emergency department after being found unconscious in her garage sitting in her car. Which assessment finding is most concerning to the nurse? A. Temperature, 97.6° F; pulse, 98; and blood pressure, 100/60 B. Oxygen (O2) saturation of 78% C. Cherry red mucous membranes D. Cold extremities

Cherry red mucous membranes *The cherry red mucous membranes are classic signs of carbon monoxide poisoning; unfortunately, they are very late signs. The temperature, pulse, and blood pressure are withing normal limits. An O2 saturation of 78% could be corrected if accurate, and O2 saturation measurements are inaccurate in cases of carbon monoxide poisoning. Cold extremities do not necessarily indicate an urgent problem

A restaurant patron sitting at a next table begins to choke and cough. The patron yells, "I'm choking! I can't breathe!" What action should the first responder take? A. Initiate the Heimlich maneuver immediately B. Strike the victim sharply between the scapulae C. Encourage the patient to cough and deep-breathe D. Offer him a small sip of fluid

Encourage the patient to cough and deep-breathe *Because the victiim can cough and speak, the airway is not compromised and can make an effort to clear the foreign matter by coughing. The Heimlich maneuver can be initiated at such a time that the victim's airway becomes occluded. The patron should not attempt to drink or eat until the foreign matter is cleared

A patient is brought to the ED with severe gastrointestinal bleeding and hypovolemic shock. What is the priority intervention for this patient? A. Insert a nasogastric tube and attach it to low wall suction B. Draw a blood sample for a type and crossmatch C. Measure the amount of emesis and check for blood D. Establish two large-bore peripheral IV sites

Establish two large-bore peripheral IV sites *Fluid replacement via IV access is the priority for this patient. (1, 2, 3) All of the other interventions are also likely to be ordered for this patient eventually, but they are not considered immediate lifesaving actions. Blood can be obtained for the type and crossmatch when the IV is started. (Note: Normal saline is started until blood from the blood bank can be obtained.)

A visitor in the hospital lobby threatens bystanders and brandishes a firearm. Which action is the nurse's priority? A. Evacuate the area. B. Activate the fire alarm. C. Notify the nursing supervisor. D. Try to take down the perpetrator.

Evacuate the area. *If a firearm is seen, health care workers should evacuate if possible, hide in a location, not visible to the shooter, lock the doors, and silence pagers and cell phones. A call to 911 should be made when it is safe to do so. As a last resort and if life is in imminent danger, incapacitating or acting with physical aggression and throwing items at the shooter may be attempted. Activating the fire alarm to alert people of about a potentially violent situation is not an appropriate use of the fire alarm system. The nursing supervisor can be notified after the incident is over.

In the memory prompt for emergency care, ABCDE, what does the "E" represent? A. End B. Execute C. Expedite D. Expose

Expose *This reminder is to assist the first responder to assess for other injuries that may be hidden under clothing

A nurse is attempting to restore order to a group of people trapped in a building by rising flood waters. Which action is best for the nurse to take? A. Give each person a specific duty B. Allow people to direct themselves to helpful tasks C. Make a list of essential jobs and ask for volunteers D. Compile all food in a central location and direct people to form a line to take what they need

Give each person a specific duty *During the impact stage, firm direction is needed, and executing essential helpful jobs will help restore order. Asking for volunteers when there is a loss of order and control would be counterproductive and would lack the direction needed by those affected. Food will need to be rationed in the event there is no rescue for an extended period of time. The rationing should be performed with direction and should not allow the people to take whatever they wish

The nurse is assisting in a temporary housing shelter that has been created for displaced victims of a hurricane. What is the priority diagnosis for this group? A. Potential for grief related to loss of property, friends, family, etc. B. Limited coping ability related to sudden catastrophic event C. High potential for infection related to crowding, poor hygienic conditions D. Fatigue related to unfamiliar surroundings and stress

High potential for infection related to crowding, poor hygienic conditions

The nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire, but despite the client's efforts, the neighbor died. Which action should the nurse take to enable the client to work through the meaning of the crisis? A. Identifying the client's ability to function B. Identifying the client's potential for self-harm C. Inquiring about the client's feelings that may affect coping D. Inquiring about the client's perception of the cause of the neighbor's death

Inquiring about the client's feelings that may affect coping *The client must first deal with feelings and negative responses before the client is able to walk through the meaning of the crisis. Option C pertains directly to the client's feelings. Options A, B, and D do not directly address the client's feelings

A nurse is assisting with the preparation of a community education seminar about family violence. When discussing types of violence, the nurse should recommend to include which of the following? A. Refusing to pay bills for a dependent, even when funds are available, is neglect B. Intentionally causing someone to fall is an example of physical violence C. Striking a sexual partner is an example of sexual violence D. Failure to provide a stimulating environment for normal development is emotional abuse

Intentionally causing someone to fall is an example of physical violence *Physical violence occurs when physical pain or harm is directed toward another individual *Refusing to pay bills for a dependent is economic abuse, rather than neglect *Striking a sexual partner or other individual is an example of physical, rather than sexual, violence. Sexual violence occurs when sexual contact takes place without consent *Failure to provide a stimulating environment for normal development in neglect, rather than emotional abuse

The nurse is assigned to assist the health care provider with "reverse" triage during a disaster event. What information is most relevant to this process? A. Identifying the patient's blood type and history of transfusions B. Knowing the pattern of pain and vital signs over the past few days C. Reviewing the past and present medication history D. Evaluating the patient's emotional response to the disaster event

Knowing the pattern of pain and vital signs over the past few days *CHECK BOOK*

A student nuse is assisting with the care of a 50 year old man who is being treated in the emergency department for hypothermia. The student asks the charge nurse why the patient is having his heart monitored. How should the nurse best respond? A. Infusing intravenous (IV) fluids rapidly raise blood pressure (BP) and heart rate B. Adrenal output of epinephrine increases in response to cold stress C. Lactic acid from pooled blood in the extremities shunts back to the heart D. The warming process causes vasodilation

Lactic acid from pooled blood in the extremities shunts back to the heart *Lactic acid in the blood that was pooled in the extremities while being exposed to cold will shunt back to the heart throught systemic perfusion as the warming process becomes effective. The lactic acid can cause arrhythmias

A diving accident occurs at the community pool and the victum is conscious and in pain. Which intervention is most appropriate pending the arrival of emergency medical personnel? A. Position the patient on the side of the pool B. Move the patient to the shallow end and cover with a towel C. Leave the patient in the pool and support with a large float D. Leave the patient in the pool and attempt cardiopulmonary resuscitation (CPR)

Leave the patient in the pool and support with a large float *Care should be taken to avoid movement of the patient and increasing injury to the spinal cord. Leaving the patient in the pool and supporting the patient on a float will not increase a possible spinal injury. Pulling the patient may cause further injury to the spine. CPR is not indicated as the patient is not experiencing cardiopulmonary arrest

After a terrorist attack with smallpox virus, the nurse assesses a newly admitted patient with large vesicles. The nurse understands that which assessment finding differentiates smallpox vesicles from chickenpox vesicles? A. Lesions on the face B. Lesions on mucous membranes C. Lesions on the soles of the feet D. Lesion in the axilla

Lesions on the soles of the feet *The lesions of smallpox can be found on the palms of the hands and soles of the feet. The lesions of chickenpox do not appear there

A toddler is brought to the ED alert and crying; however, EMS reports that the child was pulled from a neighbor's swimming pool and resuscitated at the scene. The toddler is admitted for 23-hour observation. What is the most important observation that the nurse makes during the assessment of this child? A. Observing for signs of previous injury that suggest potential child neglect B. Monitoring the pulse oximetry readings and auscultating the breath sounds C. Assessing the quality of the pulse and rhythm of the heartbeat D. Assessing the need for education related to the child's developmental needs

Monitoring the pulse oximetry readings and auscultating the breath sounds

A spectator at the Little League playoffs in August in Texas faints in the sun-drenched stands. His face is flushed and his skin is hot to the touch. What action should the first responder take? A. Lay the spectator down on the bleacher seat B. Help the spectator drink a large iced drink C. Seat the spectator upright and shield him from the sun with an umbrella D. Move the responder to a shady area, and sprinkle his clothing with water

Move the responder to a shady area, and sprinkle his clothing with water *The best action is to remove the victim from the sun and cool by evaporation until emergency medical personnel arrive. The spectator should not remain in the sun on the hot bleachers in any capacity

Which task related to disaster management would be appropriate to assign to a nursing assistant? A. Assisting victims to shower after exposure to toxin B. Debriefing others during a critical incident C. Triaging incoming green-tag victims D. Moving black-tagged victims to designated areas

Moving black-tagged victims to designated areas

A patient is admitted with radiation sickness. What would the nurse expect to find documented in the patient's chart? A. Cardiac arrhythmias and low blood pressure B. Nausea, vomiting, diarrhea, and hair loss C. Lethargy, constipation, and blurred vision D. Renal failure and electrolyte imbalances

Nausea, vomiting, diarrhea, and hair loss

The nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which describes the team-based model of nursing practice? 1. A task approach method is used to provide care to clients. 2. Managed care concepts and tools are used when providing client care. 3. Nursing staff are led by the nurse when providing care to a group of clients. 4. A single registered nurse is responsible for providing nursing care to a group of clients.

Nursing staff are led by the nurse when providing care to a group of clients. *In team nursing, nursing personnel are led by the nurse when providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 4 identifies primary nursing.

A drowning victim is brought to shore and is semiconscious and breathing. The camp counselor recognizes that which positioning is the most appropriate for this victim? A. Supine to receive CPR B. Supine with knees flexed C. On the side in recovery position D. Prone with head turned to side

On the side in recovery position *The patient who is breathing should be placed in the recovery position to allow the patient to vomit out water without danger of aspiration. CPR is not indicated as the patient is not experiencing the absence of cardiopulmonary activity. Lying supine or prone will not prevent aspiration in the even of vomiting

The nurse has delegated several nursing tasks to staff members. Which is the nurse's primary responsibility after the delegation of tasks? 1. Document that the task was completed. 2. Assign the tasks that were not completed to the next nursing shift. 3. Allow each staff member to make judgments when performing the tasks. 4. Perform follow-up with each staff member regarding the performance and outcome of the task.

Perform follow-up with each staff member regarding the performance and outcome of the task. *The ultimate responsibility for a task lies with the person who delegated it. Therefore, it is the nurse's primary responsibility to follow-up with each staff member regarding the performance of the task and the outcomes related to implementing the task. Not all staff members have the education, knowledge, and ability to make judgments about tasks being performed. The nurse documents that the task has been completed, but this would not be done until follow-up was implemented and outcomes were identified. It is not appropriate to assign the tasks that were not completed to the next nursing shift.

The first responder to an automobile accident finds a victim with a sucking chest wound. What action should the responder take? A. Tightly bind the injury with a folded magazine and the patient's belt B. Place a plastic sandwich bag over the wound and tape on three sides to make a flutter dressing C. Turn the patient to the affected side and instruct the patient to deep breathe D. Place the patient's hand over the wound and tell the patient to press down

Place a plastic sandwich bag over the wound and tape on three sides to make a flutter dressing *The flutter dressing will allow the air to leave the pleural space, but not allow any more air in. The collapsed lung will begin to re-expand.

A patient has frostbite of her right hand. What should the nurse do first? A. Place ice on the hand. B. Gently massage the hand. C. Place the hand in water that is 45° to 48° C. D. Place the hand in water that is 40° to 42° C.

Place the hand in water that is 40° to 42° C. *After the patient arrives at the health care facility, rewarming is accomplished in a whirlpool bath with water at 40° to 42° C for 15 to 30 minutes for superficial injuries and up to an hour for deep injuries. Health care workers must handle the frostbitten part gently. Skin that has been frozen should never be rubbed or massaged. Rubbing snow or ice on the part is dangerous and can cause further damage to the fragile tissues.

Which measurement best detects the daily amount of radiation to which a health worker is exposed? A. Radiation urinalysis B. Radiation badges C. Radiation spectrometer D. Radiation sputum analysis

Radiation badges *Radiation detection badges are worn under protective clothing and are analyzed for the amount of radiation absorbed

A delivery man comes to the emergency department with dog bites on his legs. He states that the dog ran away after the attack and could not be identified. After treating the bites, the nurse educates the man about which next step? A. Notification of Animal Control B. Receipt of immune globulin for passive immunity C. Receipt of the first five rabies vaccination injections D. Infusion of IV fluids

Receipt of immune globulin for passive immunity *The administration of immune globulin will build up his immediate defenses. As a delivery man, he would be considered to be in a high-risk group of animal bites and should be advised to acquire the vaccine, but the vaccine will not be of any use to him at this point. IV fluids are not likely inidicated unless blood loss was severe

Compound fracture of both femurs, concussion A. Red tag: ermergent B. Yellow tag: urgent C. Green tag: nonurgent D. Black tag: terminal

Red tag: emergent

Amputated arm, conscious, but in shock A. Red tag: ermergent B. Yellow tag: urgent C. Green tag: nonurgent D. Black tag: terminal

Red tag: ermegent

The nurse is teaching a group of CNAs about the fastest and simplest technique to reduce temperature in a patient with a fever. Which method should the nurse include in the teaching plan? A. Apply ice packs to the groin B. Bathe the patient in tepid water C. Remove clothing and bed linen D. Give the patient chilled drinks

Remove clothing and bed linen *Removing the patient's clothing and bed linen covering the patient is a quick, simple, and usually effective way to reduce temperature. The application of ice packs may result in excessive cooling and result in shivering, which acts to increase metabolic rate. Bathing in tepid water is effective but requires more time and interaction than simply removing clothing and bed linens. Chilled drinks will not adequately reduce the total body temperature

The nurse is making a home health visit to an elderly patient. The temperature in the house is very hot. The elderly patient is responsive but confused. His skin is hot and dry and he says he feels weak and nauseous. What is the priority action? A. Take the patient's temperature and administer an antipyretic B. Notify the health care provider and update the home health agency C. Remove extra clothing and wipe the skin with cool water D. Start an IV infusion of cool fluids and a cool saline lavage

Remove extra clothing and wipe the skin with cool water

The priority goal when planning the care of the emergency patient admitted in shock would be to A. Maintain the patient's body warmth to prevent vasodilation B. Decrease the patient's pain to lessen vasocontriction C. Restore the patient's circulating blood volume to promote perfusion D. Restore the patient's acid-base balance to aid respiration

Restore the patient's circulating blood volume to promote perfusion

A patient was bitten by a stray dog and rushed to the ED. Which measure must be done first? A. Apply antibiotic ointment on affected sites B. Cover with a clean bandage and immobilize C. Rinse wound with soap and warm running water for 5 to 10 minutes D. Give tetanus shot if patient has not had one in the past 5 years

Rinse wound with soap and warm running water for 5 to 10 minutes *Animal bites are prone to infection. Cleaning the area would precede the other options. (1, 2, 4) All of the other options are part of the care.

The news reports that a train derailment 5 miles from a clinic spilled a large amount of liquid chlorine that has been vaporized by the atmosphere. Which finding indicates that the chlorine gas is an imminent threat to the clinic? A. Sighting of a low-lying green cloud. B. Smelling "almonds" or "burning feathers" C. Onset of sudden nausea in multiple patients D. Onset of skin blisters in multiple patients

Sighting of a low-lying green cloud. *Chlorine gas can be seen as a low-lying green cloud. The smell of almonds is associated with cyanide. Nausea is a non-specific finding. Skin blistering is a result of contact with liquid chlorine

At a disaster scene, you notice that a person who has respiratory distress and severe total body burns has been triaged with a black tag. What should you do? A. Immediately obtain a portable oxygen tank and apply an oxygen mask B. Seek out emergency services personnel to transport the patient to the hospital C. Try and locate family members so that they can be present when the person dies D. Stay with the person for as long as possible to give support and comfort

Stay with the person for as long as possible to give support and comfort *Being present with the patient in the final moments is the only thing you can do; however, you are considered a resource, so you cannot linger to give comfort and support if dying is prolonged. (1, 2) No treatment is allocated for patients with black tags because the resources must be used to help those with a better likelihood of surviving. (3) Taking time to seek out the family is not a good use of your time. Family members also may be injured, and it will be excessively time-consuming to help them understand why the black tag means no treatment.

The nurse is caring for a patient who was admitted to the emergency department with fractured ribs. Her boyfriend dropped her off and left. The patient is anxious, is nervous, appears depressed, and is evasive about how she fractured her ribs. What does the nurse suspect about the injury? A. The patient is a drug abuser. B. The patient is a victim of domestic violence. C. The patient falls frequently. D. The patient is an alcohol user.

The patient is a victim of domestic violence. *The patient is a victim of domestic abuse. Psychologically, the person may display signs of depression, low self-esteem, anxiety, and stress. The patient does not show signs of drug or alcohol use. She did not mention falling frequently.

The nurse participating in a disaster drill knows to triage which patients with a yellow tag? A. The patient with an open femur fracture B. The patient with a large abrasion to the torso C. The patient with an uncontrolled arterial bleed D. The patient with Cheyne-Stokes breathing

The patient with an open femur fracture *Yellow tags are applied to patients with major injuries, open fractures, and large wounds. Red tags are applied to patients with injuries that are an immediate threat to life such as airway compromise or hemorrhagic shock. The patient with an uncontrolled arterial bleed would fit in this category. The patient with a large abrasion to the torso would receive a white tag. These patients have minor injuries such as abrasions and bruises. Patients who are dead or imminently dying are given black tags. The patient with Cheyne-Stokes breathing is imminently dying.

The patient sustains a venomous snakebite. What is included in the current emergency first-aid treatment? A. Wash the wound and lower the extremity B. Apply suction to the area immediately after the bite C. Make an incision over the wound with a sterile tool D. Place a tourniquet above the wound and check the pulses

Wash the wound and lower the extremity

If a disaster occurs, one example of how the disaster will affect the infrastructure of a city is by the effect it will have on which component? A. Houses and land B. First responders C. People who live there D. Water supply

Water supply *The infrastructure of a city includes transportation, electrical equipment, communications, fuel supplies, and water. Water could be affected by disruption of service, inadequate supply to fight a fire, and increased public health risk if the supply is not pure. People, including first responders, and housing are not part of the infrastructure.

A patient is being treated for radiation exposure. A chelating agent functions to reduce radiation damage by A. binding the radioactive material B. blocking specific isotopes C. mobilizing radioactive material D. reducing concentration of radioactive material

blocking specific isotopes