Chapter 16: Care of Patients Experiencing Urgent Alterations in Health

The nurse arrives on the scene of a fire. What is the first thing the nurse will do for a burn victim?

Cool the burn immediately

A patient arrives in the emergency department with a sucking wound to the left chest. What is the first action the nurse should take?

Cover the wound with an airtight dressing taped on three sides

A farm worker who has been kicked in the stomach by a mule passes a foul, black, tarry stool. What is this called?

Melena

When performing CPR on an infant, the breastbone is depressed approximately to ____ inch(es).

0.5 to 1 one-half to one The breastbone is depressed 0.5 to 1 inch when doing CPR on an infant.

A patient who had taken a poisonous substance is brought to the emergency department. What is the first action the nurse should take?

Contact the poison control center

The worried mother of an accident victim asks the nurse how much circulating blood an average adult male is supposed to have.What will the nurse reply?

12 pints

When two nurses perform two-person CPR, there should be ___ slow breaths for every ____ compressions.

2, 30 two, thirty Two slow breaths are given after every 30 compressions.

A burn patient is brought into the emergency department with the following burns: half of the front torso, entire left arm, and front of left leg. The nurse should record that the patient has a % burn.

27 twenty-seven Half of the front torso = 9, entire left arm = 9, front of the left leg = 9

A patient has been stung by a bee and is brought to the emergency department. The nurse observes the sting site and identifies that the stinger is still in the skin. What action should the nurse take?

Scrape the stinger with the side of a knife

A visitor in the hospital slips and falls. The patient's arm appears dislocated and the visitor is unable to move it. What is the first action the nurse should implement?

Splint the arm

While on break in the hospital cafeteria a nurse witnesses her pregnant co-worker start to choke. The co-worker is conscious, but unable to breathe. Where should the nurse administer thrusts?

The chest

The Good Samaritan law will protect all people who offer assistance. What is necessary for this protection?

The person acts prudently

When administering first aid in emergency situations, the nurse must first survey victims for severity of injuries. What term correctly describes this process?

Triage

A machinist visits the industrial nurse's clinic with a deep laceration of the thigh. What should be the nurse's first action?

Wash the laceration with an antiseptic

The nurse is assessing a patient who is severely bleeding and at risk for hypovolemic shock. What can the nurse anticipate?

Weak, thready pulse

The patient is admitted to the emergency department, having suffered frostbite to the hands, which are grayish-white in color. What action should the nurse implement when attempting to warm the hands?

Wrap the hands in hot, moist towels

The patient arrived at the emergency department in pain and bleeding profusely with the following vital signs: BP 80/54, P 102, RR 22. What does the nurse recognize that these symptoms indicate?

Circulatory shock

When assessing a patient who has suffered a burn injury, the nurse classifies the burn as a deep partial-thickness burn. What is this observation most likely based upon?

Erythema and blisters

When treating an infant choking on a foreign body, the nurse should use a combination of ____ and chest thrusts.

back blows If the nurse is assisting a child who has aspirated a foreign body, the nurse may treat the child in a manner similar to the adult with performance of abdominal thrusts. However, there is a potential for injury if the nurse uses this maneuver in the infant. The nurse should use a combination of back blows and chest thrusts with an infant.

The acronym RICE directs the nurse in the care of a sprain. The "C" in the acronym stands for .

compression The acronym stands for Rest, Ice, Compression, and Elevation.

CPR has been initiated on an adult patient. How will the nurse confirm the effectiveness of CPR?

Assessing a palpable carotid pulse during each compression

A patient with multiple serious injuries sustained in a motorcycle accident is lying beside his wrecked motorcycle unconscious and bleeding when the rescuer arrives at the scene. What will be the rescuer's priority action?

Assessing respiratory status

When assessing the adult victim for pulselessness, the CPR rescuer should palpate the most reliable and accessible pulse. Which pulse will be palpated?

Carotid

The patient is brought to the emergency department after having fractured an arm 12 hours ago. The arm is very edematous from the fingers to the elbow, and the patient cannot move it. What should be the initial action of the nurse?

Check fingers for capillary refill

A patient is admitted to the hospital after receiving a blow to the head. The patient begins to show signs of shock. How should the patient be positioned?

Flat on the back

The nurse determines clinical death and initiates CPR immediately. How long is resuscitation considered possible?

If cardiopulmonary arrest has existed for no more 4 minutes

The patient's lower chest has been punctured with a knife that is still in place. What should the nurse's first action be?

Immobilize the knife with dressings and tape

The nurse is assisting a victim of an accident who requires bandaging of the right lower extremity. What should the nurse do when applying the bandage?

Leave the toes exposed

When other methods have failed to stop the bleeding and the victim's life is in danger, the rescuer at the scene applies a tourniquet to a young woman's leg above the knee. What is another step that is essential for the rescuer to follow?

Never release the tourniquet

CPR has been initiated at an accident site. When can CPR be terminated?

Paramedics arrive

The nurse is teaching a patient with epistaxis about the best way to control bleeding. What information will the nurse relay to this patient?

Place ice on the nose and pinch the nostrils

The patient with heat stroke has been undressed and treated with cold packs and a fan. The patient's temperature is now down to 101.2° F. The patient starts to shiver. What action should the emergency department nurse take?

Remove cold packs and fan

A nurse assesses an accident victim who has bright red blood spurting from a laceration on his right forearm. Where will the nurse apply pressure after applying direct pressure and elevating the limb?

Right brachial artery

If a spinal injury is suspected, before the rescuer starts CPR, the trachea should be opened with a ____ maneuver.

jaw thrust The jaw thrust maneuver does not hyperextend the neck.

When a patient suddenly experiences respiratory difficulty in the cafeteria, the nurse begins assessment for foreign body airway obstruction. What is the most appropriate question to ask the victim?

Are you choking?

A nurse is assessing victims in an emergency situation. What will the nurse assess for first?

Abnormal breathing

The nurse is attempting to control bleeding in a patient with a profusely bleeding scalp wound. What is the most effective initial treatment of this bleeding?

Apply direct pressure