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A 22-yr-old patient who had a drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period? Auscultate heart sounds. Palpate peripheral pulses. Auscultate breath sounds. Assess mental orientation.

Auscultate breath sounds

When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87° F (30.6° C), which finding indicates that the nurse should discontinue active rewarming? The patient begins to shiver. The BP decreases to 86/42 mm Hg. The patient develops atrial fibrillation.Incorrect Answer The core temperature is 94° F (34.4° C).

The core temperature is 94° F (34.4° C).

A triage nurse in the emergency department assesses a patient who reports 7/10 abdominal pain and states, "I had a temperature of 103.9° F (39.9° C) at home." The nurse's first action should be to: assess the patient's current vital signs. give acetaminophen (Tylenol) per agency protocol. ask the patient to provide a clean-catch urine for urinalysis. tell the patient that it will be 1 to 2 hours before seeing a health care provider.

assess the patient's current vital signs.

When planning the response to the potential use of smallpox as a biological weapon, the emergency department nurse manager will plan to obtain adequate quantities of: vaccine. atropine.Incorrect Answer antibiotics. whole blood.

vaccine.

When assessing an older patient admitted to the emergency department (ED) with a broken arm and facial bruises, the nurse observes several additional bruises in various stages of healing. Which statement or question by the nurse should be first? "You should not go home." "Do you feel safe at home?" "Would you like to see a social worker?" "I need to report my concerns to the police."

"Do you feel safe at home?"

A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department. The nurse determines that discharge teaching has been effective when the patient makes which statement? "I'll take salt tablets when I work outdoors in the summer." "I should take two acetaminophens if I start to feel too warm." "I need to drink extra fluids when working outside in hot weather." "I'll move to a cool environment if I notice that I'm feeling confused."

"I need to drink extra fluids when working outside in hot weather."

Following an earthquake, patients are triaged by emergency medical personnel and transported to the emergency department (ED). Which patient will the nurse need to assess first? A patient with a red tagCorrect Answer A patient with a blue tag A patient with a black tag A patient with a yellow tag

A patient with a red tag

The emergency department triage nurse is assessing 4 victims involved in a motor vehicle collision. Which patient has the highest priority for treatment? A patient with no pedal pulses A patient with an open femur fracture A patient with bleeding facial lacerations A patient with paradoxical chest movement

A patient with paradoxical chest movement

A patient arrives in the emergency department (ED) after topical exposure to powdered lime at work. Which action should the nurse take first? Obtain the patient's vital signs. Obtain a baseline complete blood count. Decontaminate the patient by showering with water. Brush off any visible powder on the skin and clothing.

Brush off any visible powder on the skin and clothing.

During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient has an unobstructed airway. Which action should the nurse take next? Palpate extremities for bilateral pulses. Observe the patient's respiratory effort. Check the patient's level of consciousness. Examine the patient for any external bleeding.

Observe the patient's respiratory effort.

The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first? Remove the patient's rings. Apply ice packs to both hands. Apply calamine lotion to itching areas. Give diphenhydramine (Benadryl) 50 mg PO.

Remove the patient's rings.

A patient arrives in the emergency department several hours after taking "25 to 30" acetaminophen (Tylenol) tablets. Which action will the nurse plan to take? Give N-acetylcysteine. Discuss the use of chelation therapy. Start oxygen using a non-rebreather mask. Have the patient drink large amounts of water

Give N-acetylcysteine.

Family members are in the patient's room when the patient has a cardiac arrest and the staff start resuscitation measures. Which action should the nurse take next? Keep the family in the room and assign a staff member to explain the care given and answer questions. Ask the family members whether they would prefer to remain in the patient's room or wait outside the room. Ask the family to wait outside the patient's room with a designated staff member to provide emotional support. Tell the family members that patients are comforted by having family members present during resuscitation efforts.

Ask the family members whether they would prefer to remain in the patient's room or wait outside the room.

Which interventions will the nurse plan for a comatose patient who is to begin therapeutic hypothermia? (Select all that apply.) Assist with endotracheal intubation.correct answer Insert an indwelling urinary catheter.correct answer Begin continuous cardiac monitoring.correct answer Obtain an order to restrain the patient. Prepare to give sympathomimetic drugs.

Assist with endotracheal intubation. Insert an indwelling urinary catheter. Begin continuous cardiac monitoring.

Gastric lavage and administration of activated charcoal are ordered for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action should the nurse plan to do first? Insert a large bore orogastric tube. Assist with intubation of the patient. Prepare a 60-mL syringe with saline. Give first dose of activated charcoal.

Assist with intubation of the patient.

The emergency department (ED) nurse is starting therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/VN)? (Select all that apply.) Continuously monitor heart rhythm. Give acetaminophen (Tylenol) 650 mg. Assess neurologic status every 2 hours. Place cooling blankets above and below patient. Attach rectal temperature probe to cooling blanket control panel.

Give acetaminophen (Tylenol) 650 mg. Place cooling blankets above and below patient. Attach rectal temperature probe to cooling blanket control panel.

After the return of spontaneous circulation following the resuscitation of a patient who had a cardiac arrest, therapeutic hypothermia is ordered. Which action will the nurse include in the plan of care? Initiate cooling per protocol. Avoid the use of sedative drugs. Check mental status every 15 minutes. Rewarm if temperature is below 91° F (32.8° C).

Initiate cooling per protocol.

An unresponsive patient is admitted to the emergency department after falling through the ice while ice skating. Which assessment will the nurse obtain first? Pulse Heart rhythm Breath sounds Body temperature

Pulse

During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next? Send blood to the lab for a complete blood count. Assess further for a cause of the decreased circulation.Incorrect Answer Finish the airway, breathing, circulation, disability survey. Start normal saline fluid infusion with a large-bore IV line.

Start normal saline fluid infusion with a large-bore IV line.

A 19-yr-old patient is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the left hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. The nurse will anticipate giving: tetanus immunoglobulin (TIG) only. TIG and tetanus-diphtheria toxoid (Td).Incorrect Answer tetanus-diphtheria toxoid and pertussis vaccine (Tdap) only. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap).

TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap).

A patient who has deep human bite wounds on the left hand is being treated in the urgent care center. Which action will the nurse plan to take? Assist the provider with suturing the bite wounds. Prepare to administer rabies immune globulin (BayRab). Keep the wounds dry until the provider can assess them. Teach the patient the reason for prophylactic antibiotics

Teach the patient the reason for prophylactic antibiotics.

The urgent care center protocol for tick bites includes the following actions. Which action will the nurse take first when caring for a patient with a tick bite? Use tweezers to remove any remaining ticks. Check the vital signs, including temperature. Give doxycycline (Vibramycin) 100 mg orally. Obtain information about recent outdoor activities.

Use tweezers to remove any remaining ticks.

A patient with blunt abdominal trauma from a motor vehicle collision reports increasing abdominal pain. The nurse will plan to teach the patient about the purpose of: peritoneal lavage. abdominal ultrasonography. nasogastric (NG) tube placement. magnetic resonance imaging (MRI).

abdominal ultrasonography.

An unresponsive 79-yr-old patient is admitted to the emergency department during a summer heat wave. The patient's core temperature is 105.4° F (40.8° C), blood pressure (BP) is 88/50 mm Hg, and pulse is 112 beats/min. The nurse will plan to: apply wet sheets and a fan to the patient. provide O2 at 2 L/min with a nasal cannula. start lactated Ringer's solution at 1000 mL/hr. give acetaminophen (Tylenol) rectal suppository.

apply wet sheets and a fan to the patient.

A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should: obtain laboratory tests. auscultate bowel sounds. obtain a Glasgow Coma Scale score.Correct Answer ask about chronic medical conditions.

obtain a Glasgow Coma Scale score.