Course point

Permanent brain injury or death will occur within which time frame secondary to hypoxia?

3 to 5 minutes

The nurse is administering 100% oxygen to a patient with carbon monoxide poisoning and obtains a carboxyhemoglobin level. Which level would the nurse interpret as indicating that oxygen therapy can be discontinued?

4% or less

A nurse is establishing a patient's airway. Which action would the nurse perform first?

Repositioning the patient's head

A patient is brought to the ED by a friend, who states that a tree fell on the patient's leg and crushed it while they were cutting firewood. What priority actions should the nurse perform? (Select all that apply.)

Applying a clean dressing to protect the wound Elevating the site to limit the accumulation of fluid in the interstitial spaces Splinting the wound in a position of rest to prevent motion

As part of an emergency department team, an emergency nurse is conducting a secondary survey on a client. Which of the following would the nurse include?

Applying electrocardiogram electrodes

A nurse is providing care to the family of a client who was brought to the emergency department and suddenly died. Which of the following would be appropriate for the nurse to do? Select all that apply.

Ask the family if they would like to view the body. Provide a private place for the family to be together. Allow the family to express their emotions freely.

A patient working in a chemical facility sustains a chemical burn to his arms. The chemical involved was white phosphorus. Which of the following would be the priority nursing action?

Brushing off all traces of the chemical from the patient's skin

The nurse is caring for a client who is agitated and confused. The client is persistently trying to get out of bed and attempted to remove the peripheral IV. The nurse has attempted to re-orient the client; however, this was not effective in de-escalating the client's agitation. The client yells, "I am going to punch you in the face!" What is the nurse's next action?

Call security personnel to assist

A client presents to the ED reporting choking on a chicken bone. The client is breathing spontaneously. The nurse applies oxygen and suspects a partial airway obstruction. Which action should the nurse do next?

Encourage the client to cough forcefully.

A high school football player is brought to the emergency department after collapsing at practice in extremely hot and humid weather. Which of the following would lead the nurse to suspect that the client is experiencing heat stroke?

Delirium

is used to treat seizures associated with drug overdose

Diazepam

A patient has undergone a diagnostic peritoneal lavage. The nurse interprets which result as indicating a positive test?

Evidence of feces

A patient arrives at the emergency department after taking more than 20 lorazepam tablets. Which of the following would the nurse anticipate that the patient would be given to reverse the effects of the drug?

Flumazenil

A client suffering from carbon monoxide poisoning would exhibit which manifestation?

Intoxication

is the antidote for acetaminophen toxicity

N-acetylcysteine

A client presents to the ED following a chemical burn. The client identifies the source of the burn as white phosphorus. The nurse knows that treatment will include

No application of water to the burn.

The nurse is preparing to transfer a client from the ICU to a medical unit in the hospital. To ensure consistent communication regarding the client's care needs to the receiving unit, in what sequence of steps should the nurse organize the report?

Obtain the client's health record State the client's admission date and current diagnosis Provide a brief statement of current concerns Give the client's pertinent medical history Provide the most recent vital signs and assessment findings Give recommendations for what needs to be done for the client

A nurse who is a member of an emergency response team anticipates that several patients with airway obstruction may need a cricothyroidotomy. For which of the following patients would this procedure be appropriate? Select all that apply.

Patient with extensive facial trauma Patient with laryngeal edema secondary to anaphylaxis Patient with an obstructed larynx

The nurse in an intensive care unit is caring for a client who requires blood work to assess for changes in blood coagulation due to heparin therapy. Which test should the nurse expect to see prescribed for this value to be assessed?

Prothrombin time (PTT)

The nurse has commenced a transfusion of fresh frozen plasma (FFP) and notes the client is exhibiting symptoms of a transfusion reaction. After the nurse stops the transfusion, what is the next required action?

Run a normal saline line to keep the vein open

Following a motor vehicle collision, a client is brought to the ED for evaluation and treatment. The client is being assessed for intra-abdominal injuries. The client reports severe left shoulder pain (pain score of 10 on a 1 to 10 scale). The nurse suspects injury to the

Spleen

The nurse is caring for a client who is being prepared for the placement of a central intravenous line. The nurse recognizes this client requires this type of intravenous access for which reason?

TPN needed

Which data is important for the nurse to record while assessing the client with an open wound?

Time when the client last received a tetanus immunization

A client presents to the ED with serious health problems that are not immediately life threatening. The nurse will correctly triage the client into which category?

Urgent

A triage nurse in the ED determines that a patient with dyspnea and dehydration is not in a life-threatening situation. What triage category will the nurse choose?

Urgent