ENV EMERGENCY DISASTER

25. A client has a shoulder injury and is scheduled for a magnetic resonance imaging (MRI). The nurse notes the presence of an aneurysm clip in the client's record. What action by the nurse is best? a. Ask the client how long ago the clip was placed. b. Have the client sign an informed consent form. c. Inform the provider about the aneurysm clip. d. Reschedule the client for computed tomography.

ANS: A Some older clips are metal, which would preclude the use of MRI. The nurse should determine how old the clip is and relay that information to the MRI staff. They can determine if the client is a suitable candidate for this examination. The client does not need to sign informed consent. The provider will most likely not know if the client can have an MRI with this clip. The nurse does not independently change the type of diagnostic testing the client receives. REF: 940

17. A client who had a severe traumatic brain injury is being discharged home, where the spouse will be a full-time caregiver. What statement by the spouse would lead the nurse to provide further education on home care? a. "I know I can take care of all these needs by myself." b. "I need to seek counseling because I am very angry." c. "Hopefully things will improve gradually over time." d. "With respite care and support, I think I can do this."

ANS: A This caregiver has unrealistic expectations about being able to do everything without help. Acknowledging anger and seeking counseling show a realistic outlook and plans for accomplishing goals. Hoping for improvement over time is also realistic, especially with the inclusion of the word "hopefully." Realizing the importance of respite care and support also is a realistic outlook. REF: 957

20. A nurse assesses a client with the National Institutes of Health (NIH) Stroke Scale and determines the client's score to be 36. How should the nurse plan care for this client? a. The client will need near-total care. b. The client will need cuing only. c. The client will need safety precautions. d. The client will be discharged home.

ANS: A This client has severe neurologic deficits and will need near-total care. Safety precautions are important but do not give a full picture of the client's dependence. The client will need more than cuing to complete tasks. A home discharge may be possible, but this does not help the nurse plan care for a very dependent client. REF: 935

4. An emergency department nurse cares for a middle-aged mountain climber who is confused and exhibits bizarre behaviors. After administering oxygen, which priority intervention should the nurse implement? a. Administer dexamethasone (Decadron). b. Complete a minimental state examination. c. Prepare the client for computed tomography of the brain. d. Request a psychiatric consult.

ANS: A The client is exhibiting signs of mountain sickness and high altitude cerebral edema (HACE). Dexamethasone (Decadron) reduces cerebral edema by acting as an anti-inflammatory in the central nervous system. The other interventions will not treat mountain sickness or HACE.

10. A nurse is seeing many clients in the neurosurgical clinic. With which clients should the nurse plan to do more teaching? (Select all that apply.) a. Client with an aneurysm coil placed 2 months ago who is taking ibuprofen (Motrin) for sinus headaches b. Client with an aneurysm clip who states that his family is happy there is no chance of recurrence c. Client who had a coil procedure who says that there will be no problem following up for 1 year d. Client who underwent a flow diversion procedure 3 months ago who is taking docusate sodium (Colace) for constipation e. Client who underwent surgical aneurysm ligation 3 months ago who is planning to take a Caribbean cruise

ANS: A, B After a coil procedure, up to 20% of clients experience re-bleeding in the first year. The client with this coil should not be taking drugs that interfere with clotting. An aneurysm clip can move up to 5 years after placement, so this client and family need to be watchful for changing neurologic status. The other statements show good understanding. REF: 940

9. A client has a small-bore feeding tube (Dobhoff tube) inserted for continuous enteral feedings while recovering from a traumatic brain injury. What actions should the nurse include in the client's care? (Select all that apply.) a. Assess tube placement per agency policy. b. Keep the head of the bed elevated at least 30 degrees. c. Listen to lung sounds at least every 4 hours. d. Run continuous feedings on a feeding pump. e. Use blue dye to determine proper placement.

ANS: A, B, C, D All of these options are important for client safety when continuous enteral feedings are in use. Blue dye is not used because it can cause lung injury if aspirated. REF: 955

7. A client has meningitis following brain surgery. What comfort measures may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Applying a cool washcloth to the head b. Assisting the client to a position of comfort c. Keeping voices soft and soothing d. Maintaining low lighting in the room e. Providing antipyretics for fever

ANS: A, B, C, D The client with meningitis often has high fever, pain, and some degree of confusion. Cool washcloths to the forehead are comforting and help with pain. Allowing the client to assume a position of comfort also helps manage pain. Keeping voices low and lights dimmed also helps convey caring in a nonthreatening manner. The nurse provides antipyretics for fever. REF: 962

8. A nurse is working with many stroke clients. Which clients would the nurse consider referring to a mental health provider on discharge? (Select all that apply.) a. Client who exhibits extreme emotional lability b. Client with an initial National Institutes of Health (NIH) Stroke Scale score of 38 c. Client with mild forgetfulness and a slight limp d. Client who has a past hospitalization for a suicide attempt e. Client who is unable to walk or eat 3 weeks post-stroke

ANS: A, B, D, E Clients most at risk for post-stroke depression are those with a previous history of depression, severe stroke (NIH Stroke Scale score of 38 is severe), and post-stroke physical or cognitive impairment. The client with mild forgetfulness and a slight limp would be a low priority for this referral. REF: 935

2. An emergency department (ED) nurse is preparing to transfer a client to the trauma intensive care unit. Which information should the nurse include in the nurse-to-nurse hand-off report? (Select all that apply.) a. Mechanism of injury b. Diagnostic test results c. Immunizations d. List of home medications e. Isolation precautions

ANS: A, B, E Hand-off communication should be comprehensive so that the receiving nurse can continue care for the client fluidly. Communication should be concise and should include only the most essential information for a safe transition in care. Hand-off communication should include the clients situation (reason for being in the ED), brief medical history, assessment and diagnostic findings, Transmission-Based Precautions needed, interventions provided, and response to those interventions.

4. An emergency department nurse moves to a new city where heat-related illnesses are common. Which clients does the nurse anticipate being at higher risk for heat-related illnesses? (Select all that apply.) a. Homeless individuals b. Illicit drug users c. White people d. Hockey players e. Older adults

ANS: A, B, E Some of the most vulnerable, at-risk populations for heat-related illness include older adults; blacks (more than whites); people who work outside, such as construction and agricultural workers (more men than women); homeless people; illicit drug users (especially cocaine users); outdoor athletes (recreational and professional); and members of the military who are stationed in countries with hot climates (e.g., Iraq, Afghanistan).

2. A nurse teaches a client who has severe allergies to prevent bug bites. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. Consult an exterminator to control bugs in and around your home. b. Do not swat at insects or wasps. c. Wear sandals whenever you go outside. d. Keep your prescribed epinephrine auto-injector in a bedside drawer. e. Use screens in your windows and doors to prevent flying insects from entering.

ANS: A, B, E To prevent arthropod bites and stings, clients should wear protective clothing, cover garbage cans, use screens in windows and doors, inspect clothing and shoes before putting them on, consult an exterminator, remove nests, avoid swatting at insects, and carry a prescription epinephrine auto-injector at all times if they are known to be allergic to bee or wasp stings.

1. A nursing student studying the neurologic system learns which information? (Select all that apply.) a. An aneurysm is a ballooning in a weakened part of an arterial wall. b. An arteriovenous malformation is the usual cause of strokes. c. Intracerebral hemorrhage is bleeding directly into the brain. d. Reduced perfusion from vasospasm often makes stroke worse. e. Subarachnoid hemorrhage is caused by high blood pressure.

ANS: A, C, D An aneurysm is a ballooning of the weakened part of an arterial wall. Intracerebral hemorrhage is bleeding directly into the brain. Vasospasm often makes the damage from the initial stroke worse because it causes decreased perfusion. An arteriovenous malformation (AVM) is unusual. Subarachnoid hemorrhage is usually caused by a ruptured aneurysm or AVM. REF: 932

6. A nurse cares for older clients who have traumatic brain injury. What should the nurse understand about this population? (Select all that apply.) a. Admission can overwhelm the coping mechanisms for older clients. b. Alcohol is typically involved in most traumatic brain injuries for this age group. c. These clients are more susceptible to systemic and wound infections. d. Other medical conditions can complicate treatment for these clients. e. Very few traumatic brain injuries occur in this age group.

ANS: A, C, D Older clients often tolerate stress poorly, which includes being admitted to a hospital that is unfamiliar and noisy. Because of decreased protective mechanisms, they are more susceptible to both local and systemic infections. Other medical conditions can complicate their treatment and recovery. Alcohol is typically not related to traumatic brain injury in this population; such injury is most often from falls and motor vehicle crashes. The 65- to 76-year-old age group has the second highest rate of brain injuries compared to other age groups. REF: 951

2. The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? (Select all that apply.) a. Alcohol intake b. Diabetes c. High-fat diet d. Obesity e. Smoking

ANS: A, C, D, E Alcohol intake, a high-fat diet, obesity, and smoking are all modifiable risk factors for stroke. Diabetes is not modifiable but is a risk factor that can be controlled with medical intervention. REF: 933

3. A nurse is providing health education at a community center. Which instructions should the nurse include in teaching about prevention of lightning injuries during a storm? (Select all that apply.) a. Seek shelter inside a building or vehicle. b. Hide under a tall tree. c. Do not take a bath or shower. d. Turn off the television. e. Remove all body piercings. f. Put down golf clubs or gardening tools.

ANS: A, C, D, F When thunder is heard, shelter should be sought in a safe area such as a building or an enclosed vehicle. Electrical equipment such as TVs and stereos should be turned off. Stay away from plumbing, water, and metal objects. Do not stand under an isolated tall tree or a structure such as a flagpole. Body piercings will not increase a persons chances of being struck by lightning.

5. A nursing student studying traumatic brain injuries (TBIs) should recognize which facts about these disorders? (Select all that apply.) a. A client with a moderate trauma may need hospitalization. b. A Glasgow Coma Scale score of 10 indicates a mild brain injury. c. Only open head injuries can cause a severe TBI. d. A client with a Glasgow Coma Scale score of 3 has severe TBI. e. The terms "mild TBI" and "concussion" have similar meanings.

ANS: A, D, E "Mild TBI" is a term used synonymously with the term "concussion." A moderate TBI has a Glasgow Coma Scale (GCS) score of 9 to 12, and these clients may need to be hospitalized. Both open and closed head injuries can cause a severe TBI, which is characterized by a GCS score of 3 to 8. REF: 947

4. A nurse has applied to work at a hospital that has National Stroke Center designation. The nurse realizes the hospital adheres to eight Core Measures for ischemic stroke care. What do these Core Measures include? (Select all that apply.) a. Discharging the client on a statin medication b. Providing the client with comprehensive therapies c. Meeting goals for nutrition within 1 week d. Providing and charting stroke education e. Preventing venous thromboembolism

ANS: A, D, E Core Measures established by The Joint Commission include discharging stroke clients on statins, providing and recording stroke education, and taking measures to prevent venous thromboembolism. The client must be assessed for therapies but may go elsewhere for them. Nutrition goals are not part of the Core Measures. REF: 945

5. An emergency department nurse plans care for a client who is admitted with heat stroke. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Administer oxygen via mask or nasal cannula. b. Administer ibuprofen, an antipyretic medication. c. Apply cooling techniques until core body temperature is less than 101 F. d. Infuse 0.9% sodium chloride via a large-bore intravenous cannula. e. Obtain baseline serum electrolytes and cardiac enzymes.

ANS: A, D, E Heat stroke is a medical emergency. Oxygen therapy and intravenous fluids should be provided, and baseline laboratory tests should be performed as quickly as possible. The client should be cooled until core body temperature is reduced to 102 F. Antipyretics should not be administered.

1. A nurse is teaching a wilderness survival class. Which statements should the nurse include about the prevention of hypothermia and frostbite? (Select all that apply.) a. Wear synthetic clothing instead of cotton to keep your skin dry. b. Drink plenty of fluids. Brandy can be used to keep your body warm. c. Remove your hat when exercising to prevent the loss of heat. d. Wear sunglasses to protect skin and eyes from harmful rays. e. Know your physical limits. Come in out of the cold when limits are reached.

ANS: A, D, E To prevent hypothermia and frostbite, the nurse should teach clients to wear synthetic clothing (which moves moisture away from the body and dries quickly), layer clothing, and wear a hat, facemask, sunscreen, and sunglasses. The client should also be taught to drink plenty of fluids, but to avoid alcohol when participating in winter activities. Clients should know their physical limits and come in out of the cold when these limits have been reached.

4. The complex care provided during an emergency requires interdisciplinary collaboration. Which interdisciplinary team members are paired with the correct responsibilities? (Select all that apply.) a. Psychiatric crisis nurse Interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis b. Forensic nurse examiner Performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources c. Triage nurse Provides basic life support interventions such as oxygen, basic wound care, splinting, spinal immobilization, and monitoring of vital signs d. Emergency medical technician Obtains client histories, collects evidence, and offers counseling and followup care for victims of rape, child abuse, and domestic violence e. Paramedic Provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration

ANS: A, E The psychiatric crisis nurse evaluates clients with emotional behaviors or mental illness and facilitates followup treatment plans. The psychiatric crisis nurse also works with clients and families when experiencing a crisis. Paramedics are advanced life support providers who can perform advanced techniques that may include cardiac monitoring, advanced airway management and intubation, establishing IV access, and administering drugs en route to the emergency department. The forensic nurse examiner is trained to recognize evidence of abuse and to intervene on the clients behalf. The forensic nurse examiner will obtain client histories, collect evidence, and offer counseling and follow-up care for victims of rape, child abuse, and domestic violence. The triage nurse performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources. The emergency medical technician is usually the first caregiver and provides basic life support and transportation to the emergency department.

15. A nurse is caring for four clients who might be brain dead. Which client would best meet the criteria to allow assessment of brain death? a. Client with a core temperature of 95° F (35° C) for 2 days b. Client in a coma for 2 weeks from a motor vehicle crash c. Client who is found unresponsive in a remote area of a field by a hunter d. Client with a systolic blood pressure of 92 mm Hg since admission

ANS: B In order to determine brain death, clients must meet four criteria: 1) coma from a known cause, 2) normal or near-normal core temperature, 3) normal systolic blood pressure, and 4) at least one neurologic examination. The client who was in the car crash meets two of these criteria. The clients with the lower temperature and lower blood pressure have only one of these criteria. There is no data to support assessment of brain death in the client found by the hunter. REF: 954

19. After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse is best? a. Assess the client's magnesium level. b. Assess the client's sodium level. c. Increase the rate of the IV infusion. d. Provide oral care every hour.

ANS: B This client has manifestations of hypernatremia, which is a possible complication after craniotomy. The nurse should assess the client's serum sodium level. Magnesium level is not related. The nurse does not independently increase the rate of the IV infusion. Providing oral care is also a good option but does not take priority over assessing laboratory results. REF: 961

5. A nurse is triaging clients in the emergency department (ED). Which client should the nurse prioritize to receive care first? a. A 22-year-old with a painful and swollen right wrist b. A 45-year-old reporting chest pain and diaphoresis c. A 60-year-old reporting difficulty swallowing and nausea d. An 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101 F

ANS: B A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable.

13. A provider prescribes diazepam (Valium) to a client who was bitten by a black widow spider. The client asks, What is this medication for? How should the nurse respond? a. This medication is an antivenom for this type of bite. b. It will relieve your muscle rigidity and spasms. c. It prevents respiratory difficulty from excessive secretions. d. This medication will prevent respiratory failure.

ANS: B Black widow spider venom produces a syndrome known as latrodectism, which manifests as severe abdominal pain, muscle rigidity and spasm, hypertension, and nausea and vomiting. Diazepam is a muscle relaxant that can relieve pain related to muscle rigidity and spasms. It does not prevent respiratory difficulty or failure.

9. A nurse plans care for a client admitted with a snakebite to the right leg. With whom should the nurse collaborate? a. The facilitys neurologist b. The poison control center c. The physical therapy department d. A herpetologist (snake specialist)

ANS: B For the client with a snakebite, the nurse should contact the regional poison control center immediately for specific advice on antivenom administration and client management.

2. The emergency department team is performing cardiopulmonary resuscitation on a client when the clients spouse arrives at the emergency department. Which action should the nurse take first? a. Request that the clients spouse sit in the waiting room. b. Ask the spouse if he wishes to be present during the resuscitation. c. Suggest that the spouse begin to pray for the client. d. Refer the clients spouse to the hospitals crisis team.

ANS: B If resuscitation efforts are still under way when the family arrives, one or two family members may be given the opportunity to be present during lifesaving procedures. The other options do not give the spouse the opportunity to be present for the client or to begin to have closure.

6. A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center? a. Level I Located within remote areas and provides advanced life support within resource capabilities b. Level II Located within community hospitals and provides care to most injured clients c. Level III Located in rural communities and provides only basic care to clients d. Level IV Located in large teaching hospitals and provides a full continuum of trauma care for all clients

ANS: B Level I trauma centers are usually located in large teaching hospital systems and provide a full continuum of trauma care for all clients. Both Level II and Level III facilities are usually located in community hospitals. These trauma centers provide care for most clients and transport to Level I centers when client needs exceed resource capabilities. Level IV trauma centers are usually located in rural and remote areas. These centers provide basic care, stabilization, and advanced life support while transfer arrangements to higher-level trauma centers are made.

1. On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1 F (40.1 C), pulse 132 beats/min, respirations 26 breaths/min, blood pressure 106/66 mm Hg. Which action should the nurse take? a. Encourage the client to drink cool water or sports drinks. b. Start an intravenous line and infuse 0.9% saline solution. c. Administer acetaminophen (Tylenol) 650 mg orally. d. Encourage rest and re-assess in 15 minutes.

ANS: B The client demonstrates signs of heat stroke. This is a medical emergency and priority care includes oxygen therapy, IV infusion with 0.9% saline solution, insertion of a urinary catheter, and aggressive interventions to cool the client, including external cooling and internal cooling methods. Oral hydration would not be appropriate for a client who has symptoms of heat stroke because oral fluids would not provide necessary rapid rehydration, and the confused client would be at risk for aspiration. Acetaminophen would not decrease this clients temperature or improve the clients symptoms. The client needs immediate medical treatment; therefore, rest and re-assessing in 15 minutes is inappropriate.

1. A nurse is caring for clients in a busy emergency department. Which actions should the nurse take to ensure client and staff safety? (Select all that apply.) a. Leave the stretcher in the lowest position with rails down so that the client can access the bathroom. b. Use two identifiers before each intervention and before mediation administration. c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors. d. Search the belongings of clients with altered mental status to gain essential medical information. e. Isolate clients who have immune suppression disorders to prevent hospital-acquired infections.

ANS: B, C, D To ensure client and staff safety, nurses should use two identifiers per The Joint Commissions National Patient Safety Goals; follow the hospitals security plan, including de-escalation strategies for people who demonstrate aggressive or violent tendencies; and search belongings to identify essential medical information. Nurses should also use standard fall prevention interventions, including leaving stretchers in the lowest position with rails up, and isolating clients who present with signs and symptoms of contagious infectious disorders.

3. An emergency room nurse is caring for a trauma client. Which interventions should the nurse perform during the primary survey? (Select all that apply.) a. Foley catheterization b. Needle decompression c. Initiating IV fluids d. Splinting open fractures e. Endotracheal intubation f. Removing wet clothing g. Laceration repair

ANS: B, C, E, F The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic ABC, with an added D and E: Airway and cervical spine control; Breathing; Circulation; Disability; and Exposure. After the completion of primary diagnostic and laboratory studies, and the insertion of gastric and urinary tubes, the secondary survey (a complete head-to-toe assessment) can be carried out.

3. A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assess neurologic status with the Glasgow Coma Scale. b. Check and document oxygen saturation every 1 to 2 hours. c. Cluster client care to allow periods of uninterrupted rest. d. Elevate the head of the bed to 45 degrees to prevent aspiration. e. Position the client supine with the head in a neutral midline position.

ANS: B, E The UAP can take and document vital signs, including oxygen saturation, and keep the client's head in a neutral, midline position with correct direction from the nurse. The nurse assesses the Glasgow Coma Scale score. The nursing staff should not cluster care because this can cause an increase in the intracranial pressure. The head of the bed should be minimally elevated, up to 30 degrees. REF: 938

8. A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that a priority goal for this problem has been met? a. Chooses preferred items from the menu b. Eats 75% to 100% of all meals and snacks c. Has clear lung sounds on auscultation d. Gains 2 pounds after 1 week

ANS: C Impaired swallowing can lead to aspiration, so the priority goal for this problem is no aspiration. Clear lung sounds is the best indicator that aspiration has not occurred. Choosing menu items is not related to this problem. Eating meals does not indicate the client is not still aspirating. A weight gain indicates improved nutrition but still does not show a lack of aspiration. REF: 942

30. A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit, sedated and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time? a. Inability to communicate b. Nutritional deficit c. Risk for acquiring an infection d. Risk for skin breakdown

ANS: C The positive halo sign indicates a leak of cerebrospinal fluid. This places the client at high risk of acquiring an infection. Communication and nutrition are not priorities compared with preventing a brain infection. The client has a definite risk for a skin breakdown, but it is not the immediate danger a brain infection would be. REF: 952

6. A client had an embolectomy for an arteriovenous malformation (AVM). The client is now reporting a severe headache and has vomited. What action by the nurse takes priority? a. Administer pain medication. b. Assess the client's vital signs. c. Notify the Rapid Response Team. d. Raise the head of the bed.

ANS: C This client may be experiencing a rebleed from the AVM. The most important action is to call the Rapid Response Team as this is an emergency. The nurse can assess vital signs while someone else notifies the Team, but getting immediate medical attention is the priority. Administering pain medication may not be warranted if the client must return to surgery. The optimal position for the client with an AVM has not been determined, but calling the Rapid Response Team takes priority over positioning. REF: 941

13. A nurse is triaging clients in the emergency department. Which client should the nurse classify as nonurgent? a. A 44-year-old with chest pain and diaphoresis b. A 50-year-old with chest trauma and absent breath sounds c. A 62-year-old with a simple fracture of the left arm d. A 79-year-old with a temperature of 104 F

ANS: C A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with a simple arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration.

9. A nurse is triaging clients in the emergency department. Which client should be considered urgent? a. A 20-year-old female with a chest stab wound and tachycardia b. A 45-year-old homeless man with a skin rash and sore throat c. A 75-year-old female with a cough and a temperature of 102 F d. A 50-year-old male with new-onset confusion and slurred speech

ANS: C A client with a cough and a temperature of 102 F is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. The client with a chest stab wound and tachycardia and the client with new-onset confusion and slurred speech should be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent.

4. While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action should the nurse take first? a. Apply oxygen via nasal cannula. b. Administer intravenous 0.9% saline solution. c. Transfer the client to a negative-pressure room. d. Obtain a sputum culture and sensitivity.

ANS: C A client with signs and symptoms of tuberculosis or other airborne pathogens should be placed in a negativepressure room to prevent contamination of staff, clients, and family members in the crowded emergency department.

1. An emergency room nurse assesses a client who has been raped. With which health care team member should the nurse collaborate when planning this clients care? a. Emergency medicine physician b. Case manager c. Forensic nurse examiner d. Psychiatric crisis nurse

ANS: C All other members of the health care team listed may be used in the management of this clients care. However, the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing with the victim of an assault.

11. An emergency department (ED) case manager is consulted for a client who is homeless. Which intervention should the case manager provide? a. Communicate client needs and restrictions to support staff. b. Prescribe low-cost antibiotics to treat community-acquired infection. c. Provide referrals to subsidized community-based health clinics. d. Offer counseling for substance abuse and mental health disorders.

ANS: C Case management interventions include facilitating referrals to primary care providers who are accepting new clients or to subsidized community-based health clinics for clients or families in need of routine services. The ED nurse is accountable for communicating pertinent staff considerations, client needs, and restrictions to support staff (e.g., physical limitations, isolation precautions) to ensure that ongoing client and staff safety issues are addressed. The ED physician prescribes medications and treatments. The psychiatric nurse team evaluates clients with emotional behaviors or mental illness and facilitates the follow-up treatment plan, including possible admission to an appropriate psychiatric facility.

12. A provider prescribes Crotalidae Polyvalent Immune Fab (CroFab) for a client who is admitted after being bitten by a pit viper snake. Which assessment should the nurse complete prior to administering this medication? a. Assess temperature and for signs of fever. b. Check the clients creatinine kinase level. c. Ask about allergies to pineapple or papaya. d. Inspect the skin for signs of urticaria (hives).

ANS: C CroFab is an antivenom for pit viper snakebites. Clients should be assessed for hypersensitivity to bromelain (a pineapple derivative), papaya, and sheep protein prior to administration. During and after administration, the nurse should assess for urticaria, fever, and joint pain, which are signs of serum sickness.

8. A nurse assesses a client recently bitten by a coral snake. Which assessment should the nurse complete first? a. Unilateral peripheral swelling b. Clotting times c. Cardiopulmonary status d. Electrocardiogram rhythm

ANS: C Manifestations of coral snake envenomation are the result of its neurotoxic properties. The physiologic effect is to block neurotransmission, which produces ascending paralysis, reduced perception of pain, and, ultimately, respiratory paralysis. The nurse should monitor for respiratory rate and depth. Severe swelling and clotting problems do not occur with coral snakes but do occur with pit viper snakes. Electrocardiogram rhythm is not affected by neurotoxins.

14. After teaching a client how to prevent altitude-related illnesses, a nurse assesses the clients understanding. Which statement indicates the client needs additional teaching? a. If my climbing partner cant think straight, we should descend to a lower altitude. b. I will ask my provider about medications to help prevent acute mountain sickness. c. My partner and I will plan to sleep at a higher elevation to acclimate more quickly. d. I will drink plenty of fluids to stay hydrated while on the mountain.

ANS: C Teaching to prevent altitude-related illness should include descending when symptoms start, staying hydrated, and taking acetazolamide (Diamox), which is commonly used to prevent and treat acute mountain sickness. The client should be taught to sleep at a lower elevation.

14. The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first? a. Client with cerebral perfusion pressure of 72 mm Hg b. Client who has a Glasgow Coma Scale score of 12 c. Client with a PaCO2 of 36 mm Hg who is on a ventilator d. Client who has a temperature of 102° F (38.9° C)

ANS: D A fever is a poor prognostic indicator in clients with brain injuries. The nurse should see this client first. A Glasgow Coma Scale score of 12, a PaCO2 of 36, and cerebral perfusion pressure of 72 mm Hg are all desired outcomes. REF: 953

4. A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain? a. Loss of bladder control b. Other medical conditions c. Progression of symptoms d. Time of symptom onset

ANS: D The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5 hours, so the exact time of symptom onset is the most important information for this client. The other information is not as critical. REF: 938

18. A client in the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best? a. Ensure that informed consent is on the chart. b. Document these findings in the client's record. c. Give the prescribed preprocedure sedation. d. Notify the provider of the findings immediately.

ANS: D This client is exhibiting signs of increased intracranial pressure. The nurse should notify the provider immediately because performing the LP now could lead to herniation. Informed consent is needed for an LP, but this is not the priority. Documentation should be thorough, but again this is not the priority. The preprocedure sedation (or other preprocedure medications) should not be given as the LP will most likely be canceled. REF: 952

3. A nurse receives a report on a client who had a left-sided stroke and has homonymous hemianopsia. What action by the nurse is most appropriate for this client? a. Assess for bladder retention and/or incontinence. b. Listen to the client's lungs after eating or drinking. c. Prop the client's right side up when sitting in a chair. d. Rotate the client's meal tray when the client stops eating.

ANS: D This condition is blindness on the same side of both eyes. The client must turn his or her head to see the entire visual field. The client may not see all the food on the tray, so the nurse rotates it so uneaten food is now within the visual field. This condition is not related to bladder function, difficulty swallowing, or lack of trunk control. REF: 936

11. A nurse assesses a client admitted with a brown recluse spider bite. Which priority assessment should the nurse perform to identify complications of this bite? a. Ask the client about pruritus at the bite site. b. Inspect the bite site for a bluish purple vesicle. c. Assess the extremity for redness and swelling. d. Monitor the clients temperature every 4 hours.

ANS: D Fever and chills indicate systemic toxicity, which can lead to hemolytic reactions, kidney failure, pulmonary edema, cardiovascular collapse, and death. Assessing for a fever should be the nurses priority. All other symptoms are normal for a brown recluse bite and should be assessed, but they do not provide information about complications from the bite, and therefore are not the priority.

2. While at a public park, a nurse encounters a person immediately after a bee sting. The persons lips are swollen, and wheezes are audible. Which action should the nurse take first? a. Elevate the site and notify the persons next of kin. b. Remove the stinger with tweezers and encourage rest. c. Administer diphenhydramine (Benadryl) and apply ice. d. Administer an EpiPen from the first aid kit and call 911.

ANS: D The clients swollen lips indicate that anaphylaxis may be developing, and this is a medical emergency. 911 should be called immediately, and the client transported to the emergency department as quickly as possible. If an EpiPen is available, it should be administered at the first sign of an anaphylactic reaction. The other answers do not provide adequate interventions to treat airway obstruction due to anaphylaxis.

7. A major earthquake has occurred within the vicinity of the local hospital. The nursing supervisor working the night shift at the hospital receives information that the hospital disaster plan will be activated. The supervisor will need to work with what organization responsible for coordinating interagency relief assistance? A) Office of Emergency Management B) Incident Command System C) Centers for Disease Control and Prevention (CDC) D) American Red Cross

Ans: A Feedback: The Office of Emergency Management coordinates the disaster relief efforts at state and local levels. The Incident Command System is a management tool to organize personnel, facilities, equipment, and communication in an emergency situation. The CDC is the agency for disease prevention and control and it supports state and local health departments. The American Red Cross provides additional support.

12. Emergency department (ED) staff members have been trained to follow steps that will decrease the risk of secondary exposure to a chemical. When conducting decontamination, staff members should remove the patients clothing and then perform what action? A) Rinse the patient with water. B) Wash the patient with a dilute bleach solution. C) Wash the patient chlorhexidine. D) Rinse the patient with hydrogen peroxide.

Ans: A Feedback: The first step in decontamination is removal of the patients clothing and jewelry and then rinsing the patient with water. This is usually followed by a wash with soap and water, not chlorhexidine, bleach, or hydrogen peroxide.

13. A nurse takes a shift report and finds he is caring for a patient who has been exposed to anthrax by inhalation. What precautions does the nurse know must be put in place when providing care for this patient? A) Standard precautions B) Airborne precautions C) Droplet precautions D) Contact precautions

Ans: A Feedback: The patient is not contagious, and anthrax cannot be spread from person to person, so standard precautions are initiated. Airborne, contact, and droplet precautions are not necessary.

19. A 44-year-old male patient has been exposed to severe amount of radiation after a leak in a reactor plant. When planning this patients care, the nurse should implement what action? A) The patient should be scrubbed with alcohol and iodine. B) The patient should be carefully protected from infection. C) The patients immunization status should be promptly assessed. D) The patients body hair should be removed to prevent secondary contamination.

Ans: B Feedback: Damage to the hematopoietic system following radiation exposure creates a serious risk for infection. There is no need to remove the patients hair and the patients immunization status is not significant. Alcohol and iodine are ineffective against radiation.

20. The nurse is coordinating the care of victims who arrive at the ED after a radiation leak at a nearby nuclear plant. What would be the first intervention initiated when victims arrive at the hospital? A) Administer prophylactic antibiotics. B) Survey the victims using a radiation survey meter. C) Irrigate victims open wounds. D) Perform soap and water decontamination.

Ans: B Feedback: Each patient arriving at the hospital should first be surveyed with the radiation survey meter for external contamination and then directed toward the decontamination area as needed. This survey should precede decontamination efforts or irrigation of wounds. Antibiotics are not indicated.

4. A nurse is caring for patients exposed to a terrorist attack involving chemicals. The nurse has been advised that personal protective equipment must be worn in order to give the highest level of respiratory protection with a lesser level of skin and eye protection. What level protection is this considered? A) Level A B) Level B C) Level C D) Level D

Ans: B Feedback: Level B personal protective equipment provides the highest level of respiratory protection, with a lesser level of skin and eye protection. Level A provides the highest level of respiratory, mucous membrane, skin, and eye protection. Level C incorporates the use of an air-purified respirator, a chemical resistant coverall with splash hood, chemical resistant gloves, and boots. Level D is the same as a work uniform.

1. The nurse manager in the ED receives information that a local chemical plant has had a chemical leak. This disaster is assigned a status of level II. What does this classification indicate? A) First responders can manage the situation. B) Regional efforts and aid from surrounding communities can manage the situation. C) Statewide or federal assistance is required. D) The area must be evacuated immediately.

Ans: B Feedback: Level II disasters indicate that regional efforts and aid from the surrounding communities will be able to manage the situation. Local efforts are likely to be overwhelmed, while state and federal assistance are not likely necessary. The disaster level does not indicate the necessity of evacuation.

8. While developing an emergency operations plan (EOP), the committee is discussing the components of the EOP. During the post-incident response of an emergency operations plan, what activity will take place? A) Deciding when the facility will go from disaster response to daily activities B) Conducting practice drills for the community and facility C) Conducting a critique and debriefing for all involved in the incident D) Replacing the resources in the facility

Ans: C Feedback: A post-incident response includes critiquing and debriefing all parties involved immediately and at later dates. It does not include the decision to go from disaster response to daily activities; it does not include practice drills; and it does not include replacement of resources in the facility.

10. A group of disaster survivors is working with the critical incident stress management (CISM) team. Members of this team should be guided by what goal? A) Determining whether the incident was managed effectively B) Educating survivors on potential coping strategies for future disasters C) Providing individuals with education about recognizing stress reactions D) Determining if individuals responded appropriately during the incident

Ans: C Feedback: In defusing, patients are given information about recognizing stress reactions and how to deal with handling the stress they may experience. Debriefing involves asking patients about their current emotional coping and symptoms, following up, and identifying patients who require further assessment and assistance in dealing with the stress experienced. The CISM team does not focus primarily on the management of the incident or on providing skills for future incidents.

11. Level C personal protective equipment has been deemed necessary in the response to an unknown substance. The nurse is aware that the equipment will include what? A) A self-contained breathing apparatus B) A vapor-tight, chemical-resistant suit C) A uniform only D) An air-purified respirator

Ans: D Feedback: Level C incorporates the use of an air-purified respirator, a chemical resistant coverall with splash hood, chemical-resistant gloves, and boots. Level A provides the highest level of respiratory, mucous membrane, skin, and eye protection, incorporating a vapor-tight, chemical-resistant suit and selfcontained breathing apparatus (SCBA). Level B personal protective equipment provides the highest level of respiratory protection, with a lesser level of skin and eye protection, incorporating a chemicalresistant suit and SCBA. Level D is the same as a work uniform.

6. When assessing patients who are victims of a chemical agent attack, the nurse is aware that assessment findings vary based on the type of chemical agent. The chemical sulfur mustard is an example of what type of chemical warfare agent? A) Nerve agent B) Blood agent C) Pulmonary agent D) Vesicant

Ans: D Feedback: Sulfur mustard is a vesicant chemical that causes blistering and results in burning, conjunctivitis, bronchitis, pneumonia, hematopoietic suppression, and death. Nerve agents include sarin, soman, tabun, VX, and organophosphates (pesticides). Hydrogen cyanide is a blood agent that has a direct effect on cellular metabolism, resulting in asphyxiation through alterations in hemoglobin. Chlorine is a pulmonary agent, which destroys the pulmonary membrane that separates the alveolus from the capillary bed.

3. A patient has been witness to a disaster involving a large number of injuries. The patient appears upset, but states that he feels capable of dealing with his emotions. What is the nurses most appropriate intervention? A) Educate the patient about the potential harm in denying his emotions. B) Refer the patient to social work or spiritual care. C) Encourage the patient to take a leave of absence from his job to facilitate emotional healing. D) Encourage the patient to return to normal social roles when appropriate.

Ans: D Feedback: The patient should be encouraged to return to normal social roles when appropriate if he is confident and genuine about his ability to cope. The nurse should use active listening to the patients concerns and emotions to enable the patient to process the situation. The patient is not necessarily being unrealistic or dishonest. As a result, social work or spiritual care may not be needed. Time away from work may not be required.

All people who have household or face-to-face contact with the patient diagnosed with smallpox after the fever begins should be vaccinated within what timeframe to prevent infection and death? a) 1 week b) 2 weeks c) 10 days d) 4 days

4 days All people who have household or face-to-face contact with the patient after the fever begins should be vaccinated within 4 days to prevent infection and death.

The disaster team in your region is responding to a local chemical plant leak. They are required to wash exposed areas of the victim's skin with a solution containing bleach and then flushed with plain water. What have these victims been exposed to?

A nerve agent pg. 2166

A young client comes to the emergency department (ED) after being bitten by a scorpion on the playground at school. Which action does the nurse perform first? Administer a tetanus shot. Apply an ice pack to the sting site. Assess the client's vital signs. Call the poison control center.

Assess the client's vital signs. The first priority for the nurse to perform is vital sign assessment and continuous monitoring for several hours. This is done in the hospital ED or critical care unit to enable rapid intervention if symptoms progress.Although important, a tetanus shot and ice packs are not the immediate priority. Calling the poison control center is a secondary priority. This client may also benefit from transfer to a pediatric facility, if one is available.

The nurse is triaging people that have been involved in a bus accident. A triaged patient with psychological disturbances would be tagged with which color? a) Green b) Red c) Black d) Yellow

Green Triage category "Minimal" is coded green and includes injuries that are minor and for which treatment can be delayed hours to days, such as psychological disturbances.

While at a soccer match, a player drops to the ground with heat exhaustion and a diminished level of consciousness. After ensuring the ABC's are intact, what does the team nurse do first? Give salt tablets. Move the player to the shade. Place ice packs under the arms. Provide a cool electrolyte fluid drink.

Move the player to the shade. After ensuring the ABC's are intact, the nurse would first move the player into the shade.After the player is in the shade, the nurse would place ice packs under the arms as well as in the groin to cool the client. Due to a diminished level of consciousness, nothing would be given by mouth to prevent aspiration. Salt tablets are not given.

Which term refers to the tendency for a chemical to become a vapor?

Volatility pg. 2165

The clinic nurse is triaging a client who had visited a smallpox affected community 14 days ago. The client has developed a fever but no rash. Should the nurse consider the client at risk for smallpox?

Yes, fever and rash may follow 14 asymptomatic days. pg. 2164

10. An emergency department nurse is caring for a client who has died from a suspected homicide. Which action should the nurse take? a. Remove all tubes and wires in preparation for the medical examiner. b. Limit the number of visitors to minimize the familys trauma. c. Consult the bereavement committee to follow up with the grieving family. d. Communicate the clients death to the family in a simple and concrete manner.

ANS: D When dealing with clients and families in crisis, communicate in a simple and concrete manner to minimize confusion. Tubes must remain in place for the medical examiner. Family should be allowed to view the body. Offering to call for additional family support during the crisis is suggested. The bereavement committee should be consulted, but this is not the priority at this time.

24. A patient is admitted to the ED after being involved in a motor vehicle accident. The patient has multiple injuries. After establishing an airway and adequate ventilation, the ED team should prioritize what aspect of care? A) Control the patients hemorrhage. B) Assess for cognitive effects of the injury. C) Splint the patients fractures. D) Assess the patients neurologic status.

Ans: A Feedback: After establishing airway and ventilation, the team should evaluate and restore cardiac output by controlling hemorrhage. This must precede neurologic assessments and treatment of skeletal injuries.

A patient was involved in an avalanche that killed many people on a ski trip, including the patient's brother. The nurse is educating the patient about recognition of stress reactions and ways to manage stress. What type of process is the nurse introducing to the patient? a) Demobilization b) Preparedness c) Defusing d) Debriefing

Defusing Components of a management plan include education (preparedness) before an incident occurs about critical incident stress and coping strategies; field support (ensuring that staff get adequate rest, food, and fluids, and rotating workloads) during an incident; and defusings, debriefings, demobilization, supportive services to the family, and follow-up care after the incident (Veenema, 2013). Defusing is a process by which the person receives education about recognition of stress reactions and management strategies for handling stress. Debriefing is a more complicated intervention; it involves a 2- to 3-hour process during which participants are asked about their emotional reactions to the incident, what symptoms they may be experiencing (e.g., flashbacks, difficulty sleeping, intrusive thoughts), and other psychological ramifications.

The NATO triage system uses color-coded tagging to identify severity of injuries. A patient with survivable but life-threatening injuries (i.e., incomplete amputation) would be tagged with which color?

Red pg. 2156

A nurse is providing disaster care in an event that is known to involve gamma radiation. When admitting victims of the disaster, what should the nurse do to best reduce victims' risks of injury?

Remove victims' clothing and have them wash themselves thoroughly. pg. 2159

A nurse volunteers to help decontaminate a victim. Which is the first action that the nurse should take?

Removing the victim's clothing and jewelry pg. 2159

A patient is brought to the emergency department following an overdose of a selective serotonin reuptake inhibitor (SSRI). While assessing the patient, the nurse suspects that the patient may be developing serotonin syndrome based on which of the following? a) Lethargy b) Lack of perspiration c) Seizures d) Hypotension

Seizures Serotonin syndrome is manifested by agitation, seizures, hyperthermia, diaphoresis, and hypertension.

The nurse is caring for victims who have inhaled anthrax. The nurses assesses for symptoms that mimic which of the following disease processes? a) Respiratory distress b) Burns c) Bronchospasm d) Flu

Flu When anthrax has been inhaled, symptoms mimic those of the flu. Treatment is usually sought only when the second stage of severe respiratory distress occurs. Burns occur with sulfur mustard. Bronchospasm can occur with phosgene or chlorine. Respiratory distress may occur with cyanide.

The Department of Homeland Security indicates a threat level "Imminent" relative to a situation. What does the nurse know that this indicates? a) Risk of attack, without a site specified b) Risk of attack, without timing specified c) Elevated risk of attack d) Severe, credible impending threat, usually with a site specified

Severe, credible impending threat, usually with a site specified Imminent threat level indicates a severe, credible impending threat, usually with a site specified.

The nurse is instructing on bioterrorism agents. Which of the following does the nurse emphasize as an agent which is transmitted from person to person?

Smallpox pg. 2164

A patient has undergone a diagnostic peritoneal lavage. The nurse interprets which result as indicating a positive test? a) Red blood cell count of 50,000/mm3 b) Absence of bile c) White blood cell count of 300/mm3 d) Evidence of feces

Evidence of feces A diagnostic peritoneal lavage is considered positive if there is bile, feces, or food in the specimen, a red blood cell count greater than 100,000/mm3, and a white blood cell count greater than 500/mm3.

A high school athlete recently suffered heat exhaustion. The school nurse is instructing the student on how to prevent a recurrence of this situation. Which student statement demonstrates that the nurse's teaching has been effective? "I should try to exercise between noon and 3 PM." "I will limit my fluids to drinking 'sports' drinks after I exercise." "Taking frequent rests is important when in a hot environment." "Wearing dark-colored clothing to deflect the sun away from me will help me stay cooler."

"Taking frequent rests is important when in a hot environment." The statement that demonstrates that the teaching about heat exhaustion is effective is the comment that stresses the importance of frequent rest periods when in a hot environment. Frequent rest periods will decrease the risk of heat exhaustion.Exercising during times of peak sun exposure (midday) will increase the risk of heat exhaustion. Fluids, particularly water, have to be consumed throughout the exercise period and not be limited to a certain type. Light colored clothing, not dark, reflects the sun away from the individual.

After losing her home to a hurricane several years ago, the client says, "I get very nervous during a thunderstorm and want to hide under the bed." What is the nurse's best response? "But it's just a thunderstorm. You would have warning if a hurricane was approaching." "I understand. That is normal and is nothing to worry about." "That is post-traumatic stress disorder (PTSD). You might want to see a counselor." "What do you do when you feel this way?"

"What do you do when you feel this way?"The nurse's best response to a client who says she is very nervous during a hurricane is to ask the client what do you do when you feel this way? This statement helps to acknowledge the client's statement and further evaluates whether the thought is causing maladaptive behavior to the situation.Weather-related concerns, particularly stemming from past experience, can be normal for one's life and are not necessarily an indication of maladaptive behavior. Minimizing the client's concerns is not therapeutic. Telling the client he/she has PTSD is not appropriate

12. An obtunded patient is admitted to the ED after ingesting bleach. The nurse should prepare to assist with what intervention? A) Prompt administration of an antidote B) Gastric lavage C) Administration of activated charcoal D) Helping the patient drink large amounts of water

Ans: D Feedback: The patient who has ingested a corrosive poison, such as bleach, is given water or milk to drink for dilution. Gastric lavage is not used to treat ingestion of corrosives and activated charcoal is ineffective. There is no antidote for a corrosive substance such as bleach.

2. A workplace explosion has left a 40-year-old man burned over 65% of his body. His burns are secondand third-degree burns, but he is conscious. How would this person be triaged? A) Green B) Yellow C) Red D) Black

Ans: D Feedback: The purpose of triaging in a disaster is to do the greatest good for the greatest number of people. The patient would be triaged as black due to the unlikelihood of survival. Persons triaged as green, yellow, or red have a higher chance of recovery.

You are caring for radiation victims. What is the most important factor that you should consider to assess a client's chance of survival in acute radiation syndrome (ARS)? a) Dosage of gamma radiation b) Direct physical contact c) Mode of infection d) Concentration of nerve gas

Dosage of gamma radiation The chance of surviving ARS depends on the dosage of gamma radiation a person receives. ARS is not related to chemical (gas) or biologic (infection, contact) disasters.

Which of the following solid organs is most frequently injured in a penetrating trauma? a) Brain b) Liver c) Pancreas d) Lungs

Liver The most frequently injured solid organ in a penetrating trauma is the liver.

A nurse is providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate? a) Placing sterile cotton between the toes after rewarming b) Restricting ambulation c) Massaging the feet d) Providing an analgesic for pain

Massaging the feet For a client with frostbite, massaging the affected body part is contraindicated. Analgesia is given for pain during the rewarming process because it can be very painful. Ambulation would be restricted. Once rewarmed, sterile gauze or cotton is placed between the affected toes to prevent maceration.

Acetaminophen overdose is treated with the administration of which of the following medications? a) Flumazenil (Romazicon) b) Diazepam (Valium) c) Naloxone (Narcan) d) N-acetylcysteine (Mucomyst)

N-acetylcysteine (Mucomyst) Treatment of acetaminophen overdose includes administration of N-acetylcysteine (Mucomyst). Flumazenil is administered in the treatment of nonbarbiturate sedative overdoses. Naloxone (Narcan) is administered in the treatment of narcotic overdoses. Diazepam (Valium) may be administered to treat uncontrolled hyperactivity in the patient with a hallucinogen overdose.

Which of the following is a vesicant? a) Nitrogen mustard b) Hydrogen cyanide c) Sarin d) Chlorine

Nitrogen mustard Examples of vesicants are phosgene, nitrogen mustard, and sulfur mustard. Sarin is a nerve agent. Hydrogen cyanide is a blood agent. Chlorine is a pulmonary agent.

Several patients that have been involved in a bombing are unlikely to survive. What priority are these patients given during triage?

Priority 4 pg. 2156

A nurse who is working as part of a disaster response team is performing triage at a mass casualty incident. One of the victims has a sucking chest wound. The nurse would triage this client using which color-coded tag?

Red pg. 2156

A male patient presents to the ED with a stab wound to the abdomen following an assault. It is suspected that the patient has an injury to his pancreas. Which of the following laboratory studies is used to detect pancreatic injury? a) Urinalysis b) Serum amylase c) White blood cell count d) Hemoglobin and hematocrit

Serum amylase Serum amylase analysis is done to detect increasing levels, which suggests pancreatic injury or perforation of the GI tract. A white blood cell count is done to detect an elevation. A urinalysis is done to detect hematuria. A hemoglobin and hematocrit test is done to evaluate trends reflecting the presence or absence of bleeding.

The nurse is evaluating a skin lesion on a client brought to the emergency department. The nurse notes characteristics of chickenpox but has the physician evaluate the lesion for which biologic disaster agent?

Smallpox pg. 2164

A client has been exposed to a vesicant and is undergoing decontamination. Which of the following most likely would be used? a) Chlorhexidine b) Alcohol c) Soap and water d) Sodium hypochlorite

Soap and water A client who is exposed to a vesicant agent undergoes decontamination with soap and water. Scrubbing with sodium hypochlorite solutions is avoided because they increase penetration of the nerve agent. Alcohol and chlorhexidine are inappropriate choices for decontamination.

You are caring for clients who have been exposed to a toxic nerve agent. You will need to use diazepam with these clients. Why is diazepam given when managing the effects of toxic nerve agent toxicity?

To control possible seizures pg. 2166

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? a) Immediate b) Emergent c) Delayed d) Urgent

Urgent A basic and widely used triage system that had been in use for many years utilized three categories: emergent, urgent, and nonurgent. In this system, emergent patients had the highest priority, urgent patients had serious health problems but not immediately life-threatening ones, and nonurgent patients had episodic illnesses.

A patient presents to the ED with serious health problems that are not immediately life threatening. The nurse will correctly triage the patient into which of the following categories? a) Emergent b) Nonurgent c) Urgent d) Psychological support

Urgent Patients triaged have serious health problems that are not immediately life threatening. They must be seen within 1 hour. The emergent category is for patients who have the highest priority conditions that are life-threatening and they must be seen immediately. Nonurgent is for patients who have episodic illness that can be addressed within 24 hours without increased morbidity. Patients in the less urgent category must be reassessed at least every 60 minutes and do not have serious health problems.

Following a motor vehicle collision, a patient is brought to the ED for evaluation and treatment. The patient is being assessed for intra-abdominal injuries. The patient states severe left shoulder pain (pain score of 10 on a 1 to 10 pain scale). The nurse suspects injury to which of the following? a) Large intestines b) Spleen c) Gallbladder d) Liver

Spleen The location of pain can indicate certain types of intra-abdominal injuries. Pain in the left shoulder is common in a patient with bleeding from a ruptured spleen, whereas pain in the right shoulder can result from laceration of the liver.

A nurse is assessing a patient who is suspected of having a partial airway obstruction. Which of the following would the nurse expect to find? a) Spontaneous coughing b) High-pitched noises on inhalation c) Cyanosis d) Severe respiratory distress

Spontaneous coughing If a patient can breathe and cough spontaneously, a partial airway obstruction should be suspected. If the patient demonstrates a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis, the patient should be managed as if there were a complete airway obstruction.

You are the nurse caring for three clients who have been diagnosed with anthrax. They were exposed after boarding a flight where a white powdery substance was found in one of the restrooms. You know that these clients would be classed as being victims of which of the following? a) A radiologic disaster b) A chemical disaster c) A natural disaster d) A biologic disaster

A biologic disaster Anthrax is a biologic agent that could be the cause of a biologic disaster, one in which pathogens or their toxins cause harm to many humans and other living species. Anthrax is not a natural, radiologic, or chemical agent of disaster.

On a hot summer day, an older adult is found by a neighbor lying on the floor, agitated and confused. After calling 911, the neighbor places ice bags on the client's groin area and armpits. Upon arrival at the hospital, which action does the emergency department (ED) nurse perform first? Administer two acetylsalicylic acid (aspirin) tablets orally. Check the client's airway and administer high-flow oxygen therapy. Monitor the client's vital signs. Place a cooling blanket on the client.

Check the client's airway and administer high-flow oxygen therapy. The first action made by the ED nurse is to check the client's airway and give high-flow oxygen therapy. Once in a clinical setting, the nurse monitors and supports the client's airway, breathing, and circulatory status. High-concentration oxygen therapy and IV lines with 0.9% saline solution are also indicated.This client is at risk for aspiration. Nothing would be given by mouth when a client is at risk for aspiration. Vital signs must be monitored, but they are not the immediate priority in this scenario. Use of a cooling blanket is important although not a top priority, especially if ice bags are already in place.

The provider is planning to discharge a client home. The nurse suspects domestic violence as the cause of injury, although the client denies this. What is the best course of action for the nurse to take? Call the police. Consult with Social Services. Discharge the client as instructed. Instruct the client to go to a safe place.

Consult with Social Services. Consulting with social workers or case managers is the best course of action to investigate resource needs for this client and to plan accordingly.Contacting law enforcement, discharging the client, or telling the client to go to a safe place as instructed may not be in this client's best interest.

A nuclear accident (intentional or unintentional) can cause significant harm to those living nearby or at a distance. Harmful levels of invisible gamma radiation penetrate the body, creating not only devastating injuries but the radioactive contamination can also be spread to contaminate others. What type of transmission precaution prevents this person-to-person contamination? a) Airborne b) Droplet c) Contact d) Standard

Contact Invisible gamma radiation penetrates the body and can be eliminated in blood, sweat, urine, and feces. Consequently, a contaminated person can contaminate others through contact with body fluids or surfaces he or she touches. Airborne transmission requires the suspension and transport on air currents beyond 3 feet and is the way in which many pathogens or toxins are transmitted. Invisible gamma rays do not fall into this category, however. Gamma radiation does not travel in a liquid, or droplet, form. Standard precautions encompass more than person-to-person contamination.

A patient presents to the ED complaining of choking on a chicken bone. The patient is breathing spontaneously. The nurse applies oxygen and suspects a partial airway obstruction. Which of the following should the nurse do next? a) Encourage the patient to cough forcefully. b) Prepare the patient for a bronchoscopy. c) Insert a nasopharyngeal airway. d) Insert an oropharyngeal airway.

Encourage the patient to cough forcefully. If the patient can breathe and cough spontaneously, a partial obstruction should be suspected. The patient is encouraged to cough forcefully and to persist with spontaneous coughing and breathing efforts as long as good air exchange exists. There may be some wheezing between coughs. If the patient demonstrates a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis, the patient should be managed as if there were complete airway obstruction. If the person is unconscious, inspection of the oropharynx may reveal the offending object. X-ray study, laryngoscopy, or bronchoscopy also may be performed. There is no indication that an artificial airway is indicated.

A is patient being cared for in the ED. The patient is assigned to the triage category of "urgent." How often must the nurse reassess the patient? a) Every 60 minutes b) Every 30 minutes c) Every 120 minutes d) Every 15 minutes

Every 30 minutes Patients assigned to the resuscitation category must receive continuous nursing surveillance, those in the emergent category must be reassessed at least every 15 minutes, patients in the urgent category must be reassessed at least every 30 minutes, patients in the less urgent category must be reassessed at least every 60 minutes, and those in the nonurgent category must be reassessed at least every 120 minutes.

A nursing instructor is reviewing the various security threat levels associated with the Department of Homeland Security. When describing the orange level, which of the following would the nurse include? a) Security and screenings are increased. b) Monitoring activities are increased. c) Lockdown occurs for security. d) A specific site has been identified.

Security and screenings are increased. The orange level as identified by the Department of Homeland Security indicates a high threat level risk of attack but the specific site may not yet be identified. There are increased security and screenings and activation of the Incident Command System. The identification of a specific site and lockdown occurs with the red level of security threat. Increased monitoring activities occur with the yellow level of security threat.

The nurse is evaluating a skin lesion on a client brought to the emergency department. The nurse notes characteristics of chickenpox but has the physician evaluate the lesion for which biologic disaster agent? a) Rubella b) Smallpox c) Botulism d) Anthrax

Smallpox Smallpox may be mistaken for chickenpox due to the characteristics of the lesions. Botulism is a neurological toxin. Rubella is a communicable disease. Anthrax is a spore-forming bacterium that is inhaled or injected.

You are an Emergency Department nurse who has to care for three victims of anthrax. The first victim inhaled the toxin, the second victim ingested it, and the third victim suffered a skin infection. Which client should be cared for first?

The one who inhaled the toxin pg. 2163

A client has been exposed to and inhaled botulism. When providing care to this client, which of the following would be necessary for the nurse to follow? a) Droplet precautions b) Standard precautions c) Contact precautions d) Airborne precautions

Standard precautions Standard precautions are used when providing care to clients with botulism because the agent is not contagious through human-to-human contact. Other precautions such as droplet, airborne, or contact precautions are not necessary.

After successful treatment of clients involved in a mass casualty incident, the incident commander deactivates the emergency response plan. Which activity is most important for the emergency department (ED) charge nurse to initiate at this time? Analyze the ED response to the mass casualty incident. Follow up with survivors to determine the need for additional referrals. Initiate critical incident stress debriefing (CISD) for staff members. Take inventory and restock the ED with supplies and equipment.

Take inventory and restock the ED with supplies and equipment. The most important priority for the ED charge nurse at this time is to take inventory and restock the ED to return to normal operation.Analysis of the ED response, CISD debriefing, and follow-up with survivors and referrals can occur after the ED is restored to operational status.

While watching a television newscast, a nurse hears that the Department of Homeland Security has identified the security threat level as yellow. The nurse interprets to mean which of the following? a) The risk is low with little information known. b) The risk of a credible attack is extremely high. c) There is an elevated risk but no defined site. d) The condition is guarded with a generalized risk.

There is an elevated risk but no defined site. A security threat level of yellow indicates an elevated threat with a possible risk but no defined identified site. A threat level of red indicates that the threat is severe wtih a high risk and specified site. A threat level of blue indicates that the situation is guarded, with a generalized risk without any specific risks identified. A threat level of green indicates low, little, or no risk as being perceived or known.

You are caring for clients who have been exposed to a toxic nerve agent. You will need to use diazepam with these clients. Why is diazepam given when managing the effects of toxic nerve agent toxicity? a) To control possible seizures b) To counter excess acetylcholine c) To reactivate acetylcholinesterase d) To control hypersecretion

To control possible seizures Seizures are likely to occur only after exposure to a nerve agent. Diazepam controls seizures. Atropine sulfate counteracts excess acetylcholine at muscarinic sites. Pralidoxime chloride reactivates acetylcholinesterase. Atropine is typically administered to stop any kind of hypersecretion.

Which of the following is defined as the potential of an agent to cause injury to the body? a) Latency b) Toxicity c) Persistence d) Volatility

Toxicity Persistence means that the chemical is less likely to vaporize and disperse. Volatility is the tendency for a chemical to become a vapor. Toxicity is the potential of an agent to cause injury to the body. Latency is the time from absorption to the appearance of symptoms.

Which category of triage encompasses patients with serious health problems that are not immediately life threatening? a) Nonurgent b) Emergent c) Psychological support d) Urgent

Urgent Urgent patients have serous health problems that not immediately life threatening. They must be seen within 1 hour. Emergent patients have the highest priority with conditions are life threatening and they must be seen immediately. Nonurgent patients have episodic illness that can be addressed within 24 hours without increased morbidity. Fast track patients require simple first aid or basic primary care and may be treated in the ED or safely referred to a clinic or physician's office.

A nursing instructor is describing the role of a nurse during a disaster. Which of the following would best reflect the nurse's role?

Variable depending on the needs of the situation pg. 2157

The clinic nurse is triaging a client who had visited a smallpox affected community 14 days ago. The client has developed a fever but no rash. Should the nurse consider the client at risk for smallpox? a) No, in smallpox a rash develops before fever. b) Yes, fever and rash may follow 14 asymptomatic days. c) No, fever and rash develop immediately on exposure. d) No, smallpox rash develops within 7 days.

Yes, fever and rash may follow 14 asymptomatic days. A client infected with smallpox may be asymptomatic for the first 7 to 14 days. A few days before the rash develops, the person becomes noticeably ill with high fever. In the case of the client, rash may follow the fever. If there is no rash for 7 days, smallpox infection is not ruled out. Usually, rash develops a few days after the fever. In many cases, there are no symptoms for at least 7 days after infection.

The nurse is instructing volunteers at an emergency bioterrorism drill about the management and medications required to combat various viruses, bacteria, and toxins. The nurse knows that the volunteers understand the instruction when they state that managing clients who exhibit symptoms of the variola virus (smallpox) includes

isolation. pg. 2164

Following an earthquake, a client who was rescued from a collapsed building is seen in the emergency department. He has blunt trauma to the thorax and abdomen. The nursing observation that most suggests the client is bleeding is: a) orthostatic hypotension. b) a prolonged partial thromboplastin time (PTT). c) diminished breath sounds. d) a recent history of warfarin (Coumadin) usage.

orthostatic hypotension. Bleeding is a volume-loss problem, which causes a drop in blood pressure. As the bleeding persists and the body's ability to compensate declines, orthostatic hypotension becomes evident. A prolonged PTT and a history of warfarin usage are causes of bleeding but aren't evidence of bleeding. As bleeding persists and the client's level of consciousness declines, breathing will become more shallow and breath sounds will diminish; however, this is a late and unreliable manifestation of bleeding.

During a mass casualty incident (hurricane), a triage nurse participated in separating patients according to the severity of their injuries. She tagged a patient with a sucking chest wound with the color: a) red b) yellow c) black d) green

red Red refers to a life-threatening but survivable injury. Refer to Table 56-3 in the text for an explanation of the other colors.

As a direct result of overcrowding in emergency departments (ED), for whom must the emergency department nurse expect to provide care? A variety of age groups and cultures "Boarding" or holding inpatient clients Clients with a broad spectrum of issues, illnesses, and injuries Uninsured and underinsured clients

"Boarding" or holding inpatient clients ED overcrowding has led to frequent boarding or holding of admitted clients in the ED because of lack of beds in the hospital. The ED nurse must be adept at providing safe and competent care to clients who are awaiting bed placement. The focus becomes one of ongoing care instead of one-time orders.Although a variety of clients spanning all age ranges, cultures and illnesses may present to the ED for treatment, this is not a direct result of overcrowding. Overcrowding has nothing to do with clients who may be uninsured or underinsured.

A client arrives at the emergency department and is experiencing a severe allergic reacton to a bee sting. The client received treatment and is being discharged. Which client statement indicates that additional teaching about exposure prevention is needed? a) "I need to avoid using perfumes and scented soaps when I'm going outside." b) "If a bee comes near me, I should stay still." c) "I should always wear something on my feet when I'm outside." d) "Brightly colored clothes help to ward off bees."

"Brightly colored clothes help to ward off bees." To prevent insect stings, the client should avoid wearing brightly colored clothing because it attracts bees. The client should wear covering on the feet and avoid going barefoot because yellow jackets nest and pollinate on the ground. Staying still or motionless reduces the likelihood of being stung. Perfumes and scented soaps attract bees and should be avoided.

The elementary school nurse is teaching children how to prevent injuries from cold exposure in the winter. Which student statement demonstrates that the teaching has been effective? "Dressing in layers is important." "I will drink lots of water when I exercise." "Taking frequent breaks will help me rest." "Wearing three pairs of cotton socks is very important."

"Dressing in layers is important." Teaching has been effective when the student states that "Dressing in layers is important." Layering is very helpful in preventing cold injuries. The inner layer of clothing will provide insulation and the outer layers will help protect from wind and moisture. Lightweight and synthetic fabrics are preferable.Drinking lots of water and taking frequent breaks are more often associated with heat-related injuries. Although wearing layers is important, cotton socks are not the best choice as they will prevent evaporation of any moisture and can lead to hypothermia. Wearing three pairs of socks can decrease circulation to the toes increasing the risk of frostbite.

The nurse is caring for a patient in the ED following a sexual assault. The patient is hysterical and crying. The patient states, "I know I'm pregnant now, maybe I have HIV; why did this happen to me?" The nurse's best response is which of the following? a) "Do you want to discuss antipregnancy measures?" b) "Do you want the phone number for the National Sexual Assault Hotline?" c) "Would you like us to complete HIV testing?" d) "Let's talk about this; do you want me to call a support person?"

"Let's talk about this; do you want me to call a support person?" The patient should be reassured that anxiety is natural and asked whether a support person may be called. The goals of management are to provide support, reduce the patient's emotional trauma, and gather available evidence for possible legal proceedings. Throughout the patient's stay in the ED, the patient's privacy and sensitivity must be respected. The patient may exhibit a wide range of emotional reactions, such as hysteria, stoicism, or feelings of being overwhelmed. Support and caring are crucial.

A client suspected of acetaminophen (Tylenol) toxicity reports that he ingested the medication at 7 p.m. At what time should the nurse anticipate laboratory tests to assess the acetaminophen level? a) 24 hours from the last dose b) 8 p.m. c) 11:00 p.m. d) Stat

11:00 p.m. The duration of action of acetaminophen ranges from 3 to 5 hours. Its half-life ranges from 1 to 3 hours. At least 4 hours should pass between the last dose and laboratory assessment of the acetaminophen level.

2. A client had an embolic stroke and is having an echocardiogram. When the client asks why the provider ordered "a test on my heart," how should the nurse respond? a. "Most of these types of blood clots come from the heart." b. "Some of the blood clots may have gone to your heart too." c. "We need to see if your heart is strong enough for therapy." d. "Your heart may have been damaged in the stroke too."

ANS: A An embolic stroke is caused when blood clots travel from one area of the body to the brain. The most common source of the clots is the heart. The other statements are inaccurate. REF: 931

A nurse is providing discharge instruction to a victim who has been exposed to anthrax but who does not have any symptoms. The nurse's teaching includes that prophylactic antibiotics must be taken for how many days? a) 60 days b) 10 days c) 30 days d) 14 days

60 days Victims who have been exposed to anthrax but who are not exhibiting symptoms should take the prescribed prophylactic antibiotic for 60 days. The aim of the prophylaxis is to ensure that if spores were inhaled, bacteria will be killed immediately upon release from spores. Those who have symptoms of fever, cough, headache, chills, and especially evidence of mediastinal lymph node involvement should be treated with IV antibiotics and respiratory support, if needed.

A nurse working as part of a disaster response team is triaging clients. Which of the following clients would the nurse color code as green? Select all that apply.

Client with a first-degree burn to the forearm Client with a fractured arm pg. 2156

Which client is at greatest risk for heat exhaustion? A 24-year-old construction worker A 34-year-old police officer A 42-year-old swimming instructor A 78-year-old gardener

A 78-year-old gardener Older adults are particularly at risk for heat-related illnesses because of decreased body fluid volume. Heat exhaustion is a condition whose symptoms may include heavy sweating and a rapid pulse as a result of the body overheating. It's one of three heat-related syndromes, with heat cramps being the mildest and heatstroke being the most severe.Older adults may also be at risk due to medications they are taking that lead to electrolyte imbalances for treatment of medical co-morbidities.The young construction worker is at risk, but is not the one at highest risk. These workers will typically have a "thirst" response and will keep hydrated as needed. The police officer is a young adult who is probably in an acceptable state of fitness. The swimming instructor may also be at risk but has the ability to cool off rapidly by getting into the water

Clients who have been admitted to the emergency department (ED) are assessed by the ED triage nurse for an oncoming shift. Which client is most appropriate to assign to an LPN/LVN? A client with heat exhaustion, receiving an IV of normal saline, with normal chemistry laboratory results and a temperature of 98.6° C (37° C) A client reporting right forearm swelling secondary to a "bug bite" with capillary refill in the right hand of greater than 3 seconds A client who was hiking and is now confused, and has crackles throughout all lung fields A client stung by an unknown insect who reports shortness of breath

A client with heat exhaustion, receiving an IV of normal saline, with normal chemistry laboratory results and a temperature of 98.6° C (37° C) It is appropriate to assign an LPN/LVN to care for the stable, heat exhaustion client who is already receiving appropriate treatment.The data from the other three clients all support the need for ongoing assessment and intervention by an RN. The client who presents with vascular instability and compromise needs quick intervention. The client who has an unclear picture at present but has the potential to deteriorate rapidly and the client with the unknown insect bite also need assessment by the RN.

28. After a stroke, a client has ataxia. What intervention is most appropriate to include on the client's plan of care? a. Ambulate only with a gait belt. b. Encourage double swallowing. c. Monitor lung sounds after eating. d. Perform post-void residuals.

ANS: A Ataxia is a gait disturbance. For the client's safety, he or she should have assistance and use a gait belt when ambulating. Ataxia is not related to swallowing, aspiration, or voiding. REF: 934

11. A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by the nurse takes priority? a. Call the provider or Rapid Response Team. b. Increase the rate of the IV fluid administration. c. Notify respiratory therapy for a breathing treatment. d. Prepare to give IV pain medication.

ANS: A These manifestations indicate Cushing's syndrome, a potentially life-threatening increase in intracranial pressure (ICP), which is an emergency. Immediate medical attention is necessary, so the nurse notifies the provider or the Rapid Response Team. Increasing fluids would increase the ICP. The client does not need a breathing treatment or pain medication. REF: 952

8. A nurse wants to become involved in community disaster preparedness and is interested in helping set up and staff first aid stations or community acute care centers in the event of a disaster. Which organization is the best fit for this nurses interests? a. The Medical Reserve Corps b. The National Guard c. The health department d. A Disaster Medical Assistance Team

ANS: A The Medical Reserve Corps (MRC) consists of volunteer medical and public health care professionals who support the community during times of need. They may help staff hospitals, establish first aid stations or special needs shelters, or set up acute care centers in the community. The National Guard often performs search and rescue operations and law enforcement. The health department focuses on communicable disease tracking, treatment, and prevention. A Disaster Medical Assistance Team is deployed to a disaster area for up to 72 hours, providing many types of relief services.

11. A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention should the nurse complete first? a. Provide a calm location for the family to cope and discuss needs. b. Call the hospital chaplain to stay with the family and pray for the deceased. c. Do not allow visiting of the victims until the bodies are prepared. d. Provide privacy for law enforcement to interview the family.

ANS: A The nurse should first provide emotional support by encouraging relaxation, listening to the familys needs, and offering choices when appropriate and possible to give some personal control back to individuals. The family may or may not want the assistance of religious personnel; the nurse should assess for this before calling anyone. Visiting procedures should take into account the needs of the family. The family may want to see the victim immediately and do not want to wait until the body can be prepared. The nurse should assess the familys needs before assuming the body needs to be prepared first. The family may appreciate privacy, but this is not as important as assessing the familys needs.

1. Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies the clients with which injuries with yellow tags? (Select all that apply.) a. Partial-thickness burns covering both legs b. Open fractures of both legs with absent pedal pulses c. Neck injury and numbness of both legs d. Small pieces of shrapnel embedded in both eyes e. Head injury and difficult to arouse f. Bruising and pain in the right lower abdomen

ANS: A, C, D, F Clients with burns, spine injuries, eye injuries, and stable abdominal injuries should be treated within 30 minutes to 2 hours, and therefore should be identified with yellow tags. The client with the open fractures and the client with the head injury would be classified as urgent with red tags.

2. A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? (Select all that apply.) a. A 35-year-old female with severe chest pain: red tag b. A 42-year-old male with full-thickness body burns: green tag c. A 55-year-old female with a scalp laceration: black tag d. A 60-year-old male with an open fracture with distal pulses: yellow tag e. An 88-year-old male with shortness of breath and chest bruises: green tag

ANS: A, D Red-tagged clients need immediate care due to life-threatening injuries. A client with severe chest pain would receive a red tag. Yellow-tagged clients have major injuries that should be treated within 30 minutes to 2 hours. A client with an open fracture with distal pulses would receive a yellow tag. The client with fullthickness body burns would receive a black tag. The client with a scalp laceration would receive a green tag, and the client with shortness of breath would receive a red tag.

5. A client is being prepared for a mechanical embolectomy. What action by the nurse takes priority? a. Assess for contraindications to fibrinolytics. b. Ensure that informed consent is on the chart. c. Perform a full neurologic assessment. d. Review the client's medication lists.

ANS: B For this invasive procedure, the client needs to give informed consent. The nurse ensures that this is on the chart prior to the procedure beginning. Fibrinolytics are not used. A neurologic assessment and medication review are important, but the consent is the priority. REF: 938

7. A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the docusate sodium (Colace) because the client had a large stool earlier. What action by the supervising nurse is best? a. Have the student ask the client if it is desired or not. b. Inform the student that the docusate should be given. c. Tell the student to document the rationale. d. Tell the student to give it unless the client refuses.

ANS: B Stool softeners should be given to clients with neurologic disorders in order to prevent an elevation in intracranial pressure that accompanies the Valsalva maneuver when constipated. The supervising nurse should instruct the student to administer the docusate. The other options are not appropriate. The medication could be held for diarrhea. REF: 942

10. A client's mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg. Based on the client's cerebral perfusion pressure, what should the nurse anticipate for this client? a. Impending brain herniation b. Poor prognosis and cognitive function c. Probable complete recovery d. Unable to tell from this information

ANS: B The cerebral perfusion pressure (CPP) is the intracranial pressure subtracted from the mean arterial pressure: in this case, 60 - 20 = 40. For optimal outcomes, CPP should be at least 70 mm Hg. This client has very low CPP, which will probably lead to a poorer prognosis with significant cognitive dysfunction should the client survive. This data does not indicate impending brain herniation or complete recovery. REF: 949

1. A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt like his legs were very heavy. Currently the client's neurologic examination is normal. About what drug should the nurse plan to teach the client? a. Alteplase (Activase) b. Clopidogrel (Plavix) c. Heparin sodium d. Mannitol (Osmitrol)

ANS: B This client's manifestations are consistent with a transient ischemic attack, and the client would be prescribed aspirin or clopidogrel on discharge. Alteplase is used for ischemic stroke. Heparin and mannitol are not used for this condition. REF: 930

10. After a hospitals emergency department (ED) has efficiently triaged, treated, and transferred clients from a community disaster to appropriate units, the hospital incident command officer wants to stand down from the emergency plan. Which question should the nursing supervisor ask at this time? a. Are you sure no more victims are coming into the ED? b. Do all areas of the hospital have the supplies and personnel they need? c. Have all ED staff had the chance to eat and rest recently? d. Does the Chief Medical Officer agree this disaster is under control?

ANS: B Before standing down, the incident command officer ensures that the needs of the other hospital departments have been taken care of because they may still be stressed and may need continued support to keep functioning. Many more walking wounded victims may present to the ED; that number may not be predictable. Giving staff the chance to eat and rest is important, but all areas of the facility need that too. Although the Chief Medical Officer (CMO) may be involved in the incident, the CMO does not determine when the hospital can stand down.

3. A client presents to the emergency department after prolonged exposure to the cold. The client is difficult to arouse and speech is incoherent. Which action should the nurse take first? a. Reposition the client into a prone position. b. Administer warmed intravenous fluids to the client. c. Wrap the clients extremities in warm blankets. d. Initiate extracorporeal rewarming via hemodialysis.

ANS: B Moderate hypothermia manifests with muscle weakness, increased loss of coordination, acute confusion, apathy, incoherence, stupor, and impaired clotting. Moderate hypothermia should be treated by core rewarming methods, which include administration of warm IV fluids, heated oxygen, and heated peritoneal, pleural, gastric, or bladder lavage, and by positioning the client in a supine position to prevent orthostatic changes. The clients trunk should be warmed prior to the extremities to prevent peripheral vasodilation. Extracorporeal warming with cardiopulmonary bypass or hemodialysis is a treatment for severe hypothermia.

8. A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action should the nurse take prior to providing advanced cardiac life support? a. Contact the on-call orthopedic surgeon. b. Don personal protective equipment. c. Notify the Rapid Response Team. d. Obtain a complete history from the paramedic.

ANS: B Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions should be taken in all resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers.

4. A hospital prepares for a mass casualty event. Which functions are correctly paired with the personnel role? (Select all that apply.) a. Paramedic Decides the number, acuity, and resource needs of clients b. Hospital incident commander Assumes overall leadership for implementing the emergency plan c. Public information officer Provides advanced life support during transportation to the hospital d. Triage officer Rapidly evaluates each client to determine priorities for treatment e. Medical command physician Serves as a liaison between the health care facility and the media

ANS: B, D The hospital incident commander assumes overall leadership for implementing the emergency plan. The triage officer rapidly evaluates each client to determine priorities for treatment. The paramedic provides advanced life support during transportation to the hospital. The public information officer serves as a liaison between the health care facility and the media. The medical command physician decides the number, acuity, and resource needs of clients.

11. A nurse is dismissing a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.) a. Does not want to purchase a thermometer b. Is allergic to acetaminophen (Tylenol) c. Laughing, says "Strenuous? What's that?" d. Lives alone and is new in town with no friends e. Plans to have a beer and go to bed once home

ANS: B, D, E Clients should take acetaminophen for headache. An allergy to this drug may mean the client takes aspirin or ibuprofen (Motrin), which should be avoided. The client needs neurologic checks every 1 to 2 hours, and this client does not seem to have anyone available who can do that. Alcohol needs to be avoided for at least 24 hours. A thermometer is not needed. The client laughing at strenuous activity probably does not engage in any kind of strenuous activity, but the nurse should confirm this. REF: 957

3. A hospital prepares to receive large numbers of casualties from a community disaster. Which clients should the nurse identify as appropriate for discharge or transfer to another facility? (Select all that apply.) a. Older adult in the medical decision unit for evaluation of chest pain b. Client who had open reduction and internal fixation of a femur fracture 3 days ago c. Client admitted last night with community-acquired pneumonia d. Infant who has a fever of unknown origin e. Client on the medical unit for wound care

ANS: B, E The client with the femur fracture could be transferred to a rehabilitation facility, and the client on the medical unit for wound care should be transferred home with home health or to a long-term care facility for ongoing wound care. The client in the medical decision unit should be identified for dismissal if diagnostic testing reveals a noncardiac source of chest pain. The newly admitted client with pneumonia would not be a good choice because culture results are not yet available and antibiotics have not been administered long enough. The infant does not have a definitive diagnosis.

26. A nurse is caring for four clients in the neurologic/neurosurgical intensive care unit. Which client should the nurse assess first? a. Client who has been diagnosed with meningitis with a fever of 101° F (38.3° C) b. Client who had a transient ischemic attack and is waiting for teaching on clopidogrel (Plavix) c. Client receiving tissue plasminogen activator (t-PA) who has a change in respiratory pattern and rate d. Client who is waiting for subarachnoid bolt insertion with the consent form already signed

ANS: C The client receiving t-PA has a change in neurologic status while receiving this fibrinolytic therapy. The nurse assesses this client first as he or she may have an intracerebral bleed. The client with meningitis has expected manifestations. The client waiting for discharge teaching is a lower priority. The client waiting for surgery can be assessed quickly after the nurse sees the client who is receiving t-PA, or the nurse could delegate checking on this client to another nurse. REF: 938

7. A nurse cares for clients during a community-wide disaster drill. Once of the clients asks, Why are the individuals with black tags not receiving any care? How should the nurse respond? a. To do the greatest good for the greatest number of people, it is necessary to sacrifice some. b. Not everyone will survive a disaster, so it is best to identify those people early and move on. c. In a disaster, extensive resources are not used for one person at the expense of many others. d. With black tags, volunteers can identify those who are dying and can give them comfort care.

ANS: C In a disaster, military-style triage is used; this approach identifies the dead or expectant dead with black tags. This practice helps to maintain the goal of triage, which is doing the most good for the most people. Precious resources are not used for those with overwhelming critical injury or illness, so that they can be allocated to others who have a reasonable expectation of survival. Clients are not sacrificed. Telling students to move on after identifying the expectant dead belittles their feelings and does not provide an adequate explanation. Clients are not black-tagged to allow volunteers to give comfort care.

12. An emergency department charge nurse notes an increase in sick calls and bickering among the staff after a week with multiple trauma incidents. Which action should the nurse take? a. Organize a pizza party for each shift. b. Remind the staff of the facilitys sick-leave policy. c. Arrange for critical incident stress debriefing. d. Talk individually with staff members.

ANS: C The staff may be suffering from critical incident stress and needs to have a debriefing by the critical incident stress management team to prevent the consequences of long-term, unabated stress. Speaking with staff members individually does not provide the same level of support as a group debriefing. Organizing a party and revisiting the sick-leave policy may be helpful, but are not as important and beneficial as a debriefing.

6. A nurse is caring for a client whose wife died in a recent mass casualty accident. The client says, I cant believe that my wife is gone and I am left to raise my children all by myself. How should the nurse respond? a. Please accept my sympathies for your loss. b. I can call the hospital chaplain if you wish. c. You sound anxious about being a single parent. d. At least your children still have you in their lives.

ANS: C Therapeutic communication includes active listening and honesty. This statement demonstrates that the nurse recognizes the clients distress and has provided an opening for discussion. Extending sympathy and offering to call the chaplain do not give the client the opportunity to discuss feelings. Stating that the children still have one parent discounts the clients feelings and situation.

2. A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at a nurse when dinner is served late. How should the nurse respond? a. Do you need something for pain right now? b. Please stop yelling. I brought dinner as soon as I could. c. I suggest that you get control of yourself. d. You seem upset. I have time to talk if youd like.

ANS: D Clients should be allowed to ventilate their feelings of anger and despair after a catastrophic event. The nurse establishes rapport through active listening and honest communication and by recognizing cues that the client wishes to talk. Asking whether the client is in pain as the first response closes the door to open communication and limits the clients options. Simply telling the client to stop yelling and to gain control does nothing to promote therapeutic communication.

3. A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag? a. Dislocated right hip and an open fracture of the right lower leg b. Large contusion to the forehead and a bloody nose c. Closed fracture of the right clavicle and arm numbness d. Multiple fractured ribs and shortness of breath

ANS: D Clients who have an immediate threat to life are given the highest priority, are placed in the emergent or class I category, and are given a red triage tag. The client with multiple rib fractures and shortness of breath most likely has developed a pneumothorax, which may be fatal if not treated immediately. The client with the hip and leg problem and the client with the clavicle fracture would be classified as class II; these major but stable injuries can wait 30 minutes to 2 hours for definitive care. The client with facial wounds would be considered the walking wounded and classified as nonurgent.

4. An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event? a. Ask ED staff to discharge clients from the medical-surgical units in order to make room for critically injured victims. b. Call additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in. c. Inform the incident commander at the mass casualty scene about how many victims may be handled by the ED. d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims.

ANS: D The ED charge nurse should direct additional nursing staff to help care for current ED clients while the ED staff prepares to receive mass casualty victims; however, they should not be assigned to the most critically ill or injured clients. The house supervisor and unit directors would collaborate to discharge stable clients. The hospital incident commander is responsible for mobilizing resources and would have the responsibility for calling in staff. The medical command physician would be the person best able to communicate with on-scene personnel regarding the ability to take more clients.

5. A nurse prepares to discharge an older adult client home from the emergency department (ED). Which actions should the nurse take to prevent future ED visits? (Select all that apply.) a. Provide medical supplies to the family. b. Consult a home health agency. c. Encourage participation in community activities. d. Screen for depression and suicide. e. Complete a functional assessment.

ANS: D, E Due to the high rate of suicide among older adults, a nurse should assess all older adults for depression and suicide. The nurse should also screen older adults for functional assessment, cognitive assessment, and risk for falls to prevent future ED visits.

A patient with frostbite to both lower extremities from exposure to the elements is preparing to have rewarming of the extremities. What intervention should the nurse provide prior to the procedure? a) Administer an analgesic as ordered. b) Apply a heat lamp. c) Elevate the legs. d) Massage the extremities.

Administer an analgesic as ordered. During rewarming, an analgesic for pain is administered as prescribed, because the rewarming process may be very painful. To avoid further mechanical injury, the body part is not handled. Massage is contraindicated.

A patient was brought into the ED after sustaining injuries due to an explosion while welding. The patient is breathing but has an oxygen saturation of 90%, a respiratory rate of 32, and is coughing. What is the priority action by the nurse? a) Start an IV of normal saline solution at 125 mL/h. b) Obtain a chest x-ray. c) Administer oxygen at 2 L/min via nasal cannula. d) Administer oxygen with a nonrebreather mask.

Administer oxygen with a nonrebreather mask. Blast lung results from the blast wave as it passes through air-filled lungs. The result is hemorrhage and tearing of the lung, ventilation-perfusion mismatch, and possible air emboli. Typical signs and symptoms include dyspnea, hypoxia, tachypnea or apnea (depending on severity), cough, chest pain, and hemodynamic instability. Management involves providing respiratory support that includes administration of supplemental oxygen with a nonrebreathing mask but may also require endotracheal intubation and mechanical ventilation.

The nurse is coordinating care for a client who was bitten by a black widow spider. Which nursing action is assigned to the LPN/LVN? Administering tetanus toxoid vaccine intramuscularly Assessing the client for neurologic changes Monitoring for respiratory compromise in the client Providing discharge instructions to the client when the family arrives

Administering tetanus toxoid vaccine intramuscularly Administration of intramuscular medication is within the scope of practice and education level of an LPN/LVN.Physical assessment and ongoing monitoring for complications, as well as client education and planning for discharge, are all actions that require broader education and scope of practice and would be done by an RN.

The triage nurse has a suggestion for improving response in the next mass casualty event. Which option does the nurse use to introduce this idea? Administrative review Hospital suggestion box Medical Reserve Corp Supervisor

Administrative review The triage nurse uses the Administrative review committee to present suggestions to improve responses in the next mass casualty event. The goal of the administrative review is to discern what went right and what went wrong during activation and implementation of the emergency preparedness plan. In this way, changes can be made.The hospital suggestion box and the supervisor are not the most effective ways to implement change in this situation. The purpose of the Medical Reserve Corp is to help with staffing and providing care, not revising policy or protocol.

25. A nurse has been called for duty during a response to a natural disaster. In this context of care, the nurse should expect to do which of the following? A) Practice outside of her normal area of clinical expertise. B) Perform interventions that are not based on assessment data. C) Prioritize psychosocial needs over physiologic needs. D) Prioritize the interests of older adults over younger patients.

Ans: A Feedback: During a disaster, nurses may be asked to perform duties outside their areas of expertise and may take on responsibilities normally held by physicians or advanced practice nurses.

4. A patient has been brought to the ED with multiple trauma after a motor vehicle accident. After immediate threats to life have been addressed, the nurse and trauma team should take what action? A) Perform a rapid physical assessment. B) Initiate health education. C) Perform diagnostic imaging. D) Establish the circumstances of the accident.

Ans: A Feedback: Once immediate threats to life have been corrected, a rapid physical examination is done to identify injuries and priorities of treatment. Health education is initiated later in the care process and diagnostic imaging would take place after a rapid physical assessment. It is not the care teams responsibility to determine the circumstances of the accident.

34. The ED staff has been notified of the imminent arrival of a patient who has been exposed to chlorine. The nurse should anticipate the need to address what nursing diagnosis? A) Impaired gas exchange B) Decreased cardiac output C) Chronic pain D) Excess fluid volume

Ans: A Feedback: Pulmonary agents, such as phosgene and chlorine, destroy the pulmonary membrane that separates the alveolus from the capillary bed, disrupting alveolarcapillary oxygen transport mechanisms. Capillary leakage results in fluid-filled alveoli and gas exchange ceases to occur. Pain is likely, but is acute rather than chronic. Fluid volume excess is unlikely to be a priority diagnosis and cardiac output will be secondarily affected by the pulmonary effects.

35. The nursing supervisor at the local hospital is advised that your hospital will be receiving multiple trauma victims from a blast that occurred at a local manufacturing plant. The paramedics call in a victim of the blast with injuries including a head injury and hemorrhage. What phase of blast injury should the nurse expect to treat in this patient? A) Primary phase B) Secondary phase C) Tertiary phase D) Quaternary phase

Ans: A Feedback: Pulmonary barotraumas, including pulmonary contusions; head injuries, including concussion, other severe brain injuries; tympanic membrane rupture, middle ear injury; abdominal hollow organ perforation; and hemorrhage are all injuries that can occur in the primary phase of a blast. These particular injuries are not characteristic of the subsequent phases.

1. Which patient should the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined below? A) A patient with a blunt chest trauma with some difficulty breathing B) A patient with a sore neck who was immobilized in the field on a backboard with a cervical collar C) A patient with a possible fractured tibia with adequate pedal pulses D) A patient with an acute onset of confusion

Ans: A Feedback: The patient with blunt chest trauma possibly has a compromised airway. Establishment and maintenance of a patent airway and adequate ventilation is prioritized over other health problems, including skeletal injuries and changes in cognition.

8. The paramedics bring a patient who has suffered a sexual assault to the ED. What is important for the sexual assault nurse examiner to do when assessing a sexual assault victim? A) Respect the patients privacy during assessment. B) Shave all pubic hair for laboratory analysis. C) Place items for evidence in plastic bags. D) Bathe the patient before the examination.

Ans: A Feedback: The patients privacy and sensitivity must be respected, because the patient will be experiencing a stress response to the assault. Pubic hair is combed or trimmed for sampling. Paper bags are used for evidence collection because plastic bags retain moisture, which promotes mold and mildew that can destroy evidence. Bathing the patient before the examination would destroy or remove key evidence.

27. A nurse is undergoing debriefing with the critical incident stress management (CISM) team after participating in the response to a disaster. During this process, the nurse will do which of the following? A) Evaluate the care that he or she provided during the disaster. B) Discuss own emotional responses to the disaster. C) Explore the ethics of the care provided during the disaster. D) Provide suggestions for improving the emergency operations plan.

Ans: B Feedback: In debriefing, participants are asked about their emotional reactions to the incident, what symptoms they may be experiencing (e.g., flashbacks, difficulty sleeping, intrusive thoughts), and other psychological ramifications. The EOP and the care the nurse provided are not evaluated.

24. A nurse is triaging patients after a chemical leak at a nearby fertilizer factory. The guiding principle of this activity is what? A) Assigning a high priority to the most critical injuries B) Doing the greatest good for the greatest number of people C) Allocating resources to the youngest and most critical D) Allocating resources on a first come, first served basis

Ans: B Feedback: In nondisaster situations, health care workers assign a high priority and allocate the most resources to those who are the most critically ill. However, in a disaster, when health care providers are faced with a large number of casualties, the fundamental principle guiding resource allocation is to do the greatest good for the greatest number of people. A first come, first served approach is unethical.

3. A patient is brought to the ED by ambulance with a gunshot wound to the abdomen. The nurse knows that the most common hollow organ injured in this type of injury is what? A) Liver B) Small bowel C) Stomach D) Large bowel

Ans: B Feedback: Penetrating abdominal wounds have a high incidence of injury to hollow organs, especially the small bowel. The liver is also injured frequently, but it is a solid organ.

31. A nurse who is a member of the local disaster response team is learning about blast injuries. The nurse should plan for what event that occurs in the tertiary phase of the blast injury? A) Victims pre-existing medical conditions are exacerbated. B) Victims are thrown by the pressure wave. C) Victims experience burns from the blast. D) Victims suffer injuries caused by debris or shrapnel from the blast.

Ans: B Feedback: The tertiary phase of the blast injury results from the pressure wave that causes the victims to be thrown, resulting in traumatic injury. None of the other listed events occurs in this specific phase of a blast.

21. An industrial site has experienced a radiation leak and workers who have been potentially affected are enroute to the hospital. To minimize the risks of contaminating the hospital, managers should perform what action? A) Place all potential victims on reverse isolation. B) Establish a triage outside the hospital. C) Have hospital staff put on personal protective equipment. D) Place hospital staff on abbreviated shifts of no more than 4 hours.

Ans: B Feedback: Triage outside the hospital is the most effective means of preventing contamination of the facility itself. None of the other listed actions has the potential to prevent the contamination of the hospital itself.

40. A 23-year-old woman is brought to the ED complaining of stomach cramps, nausea, vomiting, and diarrhea. The care team suspects food poisoning. What is the key to treatment in food poisoning? A) Administering IV antibiotics B) Assessing immunization status C) Determining the source and type of food poisoning D) Determining if anyone else in the family is ill

Ans: C Feedback: Determining the source and type of food poisoning is essential to treatment, and is more important than determining other sick family members. Antibiotics are not normally indicated and immunizations are not relevant to diagnosis or treatment of food poisoning.

25. A patient with multiple trauma is brought to the ED by ambulance after a fall while rock climbing. What is a responsibility of the ED nurse in this patients care? A) Intubating the patient B) Notifying family members C) Ensuring IV access D) Delivering specimens to the laboratory

Ans: C Feedback: ED nursing responsibilities include ensuring airway and IV access. Nurses are not normally responsible for notifying family members. Nurses collect specimens, but are not responsible for their delivery. Physicians or other team members with specialized training intubate the patient.

17. A patient is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the physician will perform which of the following actions? A) Insert an oropharyngeal airway. B) Perform the jaw thrust maneuver. C) Perform endotracheal intubation. D) Perform a cricothyroidotomy.

Ans: C Feedback: Endotracheal tubes are used in cases when the patient cannot be ventilated with an oropharyngeal airway, which is used in patients who are breathing spontaneously. The jaw thrust maneuver does not establish an airway and cricothyroidotomy would be performed as a last resort.

18. A patient is brought by friends to the ED after being involved in a motor vehicle accident. The patient sustained blunt trauma to the abdomen. What nursing action would be most appropriate for this patient? A) Ambulate the patient to expel flatus. B) Place the patient in a high Fowlers position. C) Immobilize the patient on a backboard. D) Place the patient in a left lateral position.

Ans: C Feedback: When admitted for blunt trauma, patients must be immobilized until spinal injury is ruled out. Ambulation, side-lying, and upright positioning would be contraindicated until spinal injury is ruled out.

37. The emergency response team is dealing with a radiation leak at the hospital. What action should be performed to prevent the spread of the contaminants? A) Floors must be scrubbed with undiluted bleach. B) Waste must be promptly incinerated. C) The ventilation system should be deactivated. D) Air ducts and vents should be sealed.

Ans: D Feedback: All air ducts and vents must be sealed to prevent spread. Waste is controlled through double-bagging and the use of plastic-lined containers outside of the facility rather than incineration. Bleach would be ineffective against radiation and the ventilation system may or may not be deactivated.

21. A patient who has been diagnosed with cholecystitis is being discharged home from the ED to be scheduled for surgery later. The patient received morphine during the present ED admission and is visibly drowsy. When providing health education to the patient, what would be the most appropriate nursing action? A) Give written instructions to patient. B) Give verbal instructions to one of the patients family members. C) Telephone the patient the next day with verbal instructions. D) Give verbal and written instructions to patient and a family member.

Ans: D Feedback: Before discharge, verbal and written instructions for continuing care are given to the patient and the family or significant others. Discharge teaching is completed prior to the patient leaving the ED, so phoning the patient the next day in not acceptable.

10. A triage nurse is talking to a patient when the patient begins choking on his lunch. The patient is coughing forcefully. What should the nurse do? A) Stand him up and perform the abdominal thrust maneuver from behind. B) Lay him down, straddle him, and perform the abdominal thrust maneuver. C) Leave him to get assistance. D) Stay with him and encourage him, but not intervene at this time.

Ans: D Feedback: If the patient is coughing, he should be able to dislodge the object or cause a complete obstruction. If complete obstruction occurs, the nurse should perform the abdominal thrust maneuver with the patient standing. If the patient is unconscious, the nurse should lay the patient down. A nurse should never leave a choking patient alone.

5. A patient who has been exposed to anthrax is being treated in the local hospital. The nurse should prioritize what health assessments? A) Integumentary assessment B) Assessment for signs of hemorrhage C) Neurologic assessment D) Assessment of respiratory status

Ans: D Feedback: The second stage of anthrax infection by inhalation includes severe respiratory distress, including stridor, cyanosis, hypoxia, diaphoresis, hypotension, and shock. The first stage includes flu-like symptoms. The second stage of infection by inhalation does not include headache, vomiting, or syncope.

29. The nurse has been notified that the ED is expecting terrorist attack victims and that level D personal protective equipment is appropriate. What does level D PPE include? A) A chemical-resistant coverall with splash hood, chemical-resistant gloves, and boots B) A self-contained breathing apparatus (SCBA) and a fully encapsulating, vapor-tight, chemicalresistant suit with chemical-resistant gloves and boots. C) The SCBA and a chemical-resistant suit, but the suit is not vapor tight D) The nurses typical work uniform

Ans: D Feedback: The typical work uniform is appropriate for Level D protection

Nursing students are reviewing the various weapons of mass destruction, specifically biologic agents. The students demonstrate understanding of the information when they identify which of the following as the most likely weaponized agent? a) Tularemia b) Plague c) Anthrax d) Botulism

Anthrax Although tularemia, botulism, and plague are biologic agents that can be used as weapons of mass destruction, anthrax is recognized as the most likely weaponized biologic agent.

The nurse is on a community awareness safety committee. When prioritizing biological agents according to potential morbidity and mortality, which cluster of biological agents hold the highest mortality?

Anthrax, smallpox pp. 2162-2164.

The nurse is caring for a client diagnosed with botulism. Which medication classification does the nurse anticipate?

Antitoxins pg. 2163

A 40-year-old female patient is admitted to the ED with facial bruises and a broken right wrist. Upon further assessment, the nurse notes multiple bruises in various stages of healing. Which of the following is the nurse's best course of action? a) Asking the patient how she obtained the various bruises b) Providing the patient with information about local shelters c) Contacting the local police and report the suspected abuse d) Asking the patient if someone is abusing her

Asking the patient if someone is abusing her The priority is to ask the patient if someone is harming/abusing her, and proceed as the situation dictates. Nurses must be mindful that competent adults are free to accept or refuse the help that is offered to them. Some patients insist on remaining in the home environment where the abuse or neglect is occurring. The wishes of patients who are competent and not cognitively impaired should be respected. However, all possible alternatives, available resources, and safety plans should be explored with the patient. Mandatory reporting laws in most states require health care workers to report suspected child abuse or abuse of older adults to an official agency, usually Adult (or Child) Protective Services. All that is required for reporting is the suspicion of abuse; the health care worker is not required to prove abuse or neglect.

How does the high school nurse react directly after a random shooting at a high school after injuries are taken care of? Actively listens to students Assesses his or her own individual feelings Encourages students to vent feelings Facilitates community cohesion

Assesses his or her own individual feelings After injuries have been taken care after a random shooting at a high school, the high school nurse needs to first assess his/her own individual feelings. One cannot be an effective caregiver if one's own needs are not also met.Active listening, allowing students to express their feelings, and facilitating community cohesion are important, but are not what needs to be done first.

Which medications are contraindicated with a scorpion sting? Select all that apply. Acetaminophen (Tylenol) Barbiturates Benzodiazepines Opiates Tetanus toxoid

Barbiturates Benzodiazepines Opiates Medications contraindicated for a client with a scorpion sting include barbiturates, benzodiazepines, and opiates. These medications need to be avoided in clients with a scorpion sting because they can cause a loss of airway reflexes and can precipitate respiratory airway failure.It is safe to administer Tylenol to a client with a scorpion sting for fever and pain. Because the scorpion sting is a puncture wound, tetanus toxoid would be administered.

During a mass casualty event, a person whose injuries are extensive and whose chances of survival are unlikely even with definitive care would receive which color tag? a) Black b) Red c) Green d) Yellow

Black A black tag means expectant death, and that the injuries are extensive and chances of survival are unlikely even with definitive care. A green tag is used when injuries are minor and treatment can be delayed hours to days. A red tag means that the person's injuries are life-threatening but survivable with minimal intervention. A yellow tag indicates a person whose injuries are significant and require medical care, but can wait hours without threat to life or limb.

During a terrorist attack, multiple victims were exposed to nitrogen mustard. While caring for one of the victims admitted to the hospital, the nurse notes large, serous fluid-filled, circumscribed areas resembling a dome over the victim's axillae and antecubital spaces. The nurse should document this find as being which of the following? a) Macules b) Bullae c) Papules d) Abscesses

Bullae The nurse should document the large, serous fluid-filled, circumscribed areas as bullae. Papules are solid elevated superficial lesions. Macules are flat circumscribed areas less than 1 cm in diameter. An abscess is a nodule/tumor greater than 1 cm that contains pus.

The nurse is providing reminders to a Red Cross class about safety procedures to prevent drowning. In which situation does this present the greatest risk? A couple going swimming together at a local lake Children swimming at the community pool College students going to a party at a boat house Families going to the quarry to swim

College students going to a party at a boat house The college party at the boat house is the situation that poses the greatest risk for drowning, due to the potential presence of alcohol or other mood-altering substances. The use of alcoholic beverages when swimming, boating, or near water increases the risk of water-related injuries and death.The couple swimming in the local lake is using the "buddy system." This situation does not present the greatest risk. Community pools frequently have life guards and safety equipment present. Because adults will be present at the quarry, this situation does not present the greatest risk.

The nurse is caring for a victim of a chemical disaster. Medications given in the treatment of this client include amyl nitrate, sodium nitrate, and sodium thiosulfate. What chemical agent does the nurse know this client has been exposed to?

Cyanide pg. 2167

The nurse is working at a natural disaster scene. A client was found to have a compound fracture of the left lower leg. He was triaged accordingly. Which category would the client be assigned to?

Delayed pg. 2156

A patient is brought to the emergency department and diagnosed with decompression sickness. The nurse interprets this as indicating that the patient most likely has been involved with which of the following? a) Diving in an ocean b) Working in a chemical plant c) Running a race in hot humid weather d) Swimming in a lake

Diving in an ocean Decompression sickness occurs when patients have engaged in diving in a lake or ocean or high-altitude flying or flying in a commercial aircraft within 24 hours of diving. Swimming in a lake could lead to a near-drowing episode. Running a race in hot humid weather would increase a person's risk for heat stroke. Working in a chemical plant would increase the risk for chemical burns.

A client is brought to the emergency department by ambulance. The client is seriously ill and unconscious. No family or friends are present. Which of the following would be most appropriate to do? a) Ask the ambulance team for information about the client's family to ensure informed consent. b) Document the client's condition and absence of friends or family for obtaining consent to treatment. c) Explain to the client that care is going to be provided because he is seriously ill. d) Check the client's record for the name of a family member to call to allow care to be provided.

Document the client's condition and absence of friends or family for obtaining consent to treatment. Consent is needed to examine and treat a client unless he or she is unconscious or in critical condition and unable to make decisions. In this situation, the client is unconscious and no friends or family are around to provide consent to treatment. The nurse should document this fact and provide care. Checking the client's record and asking the ambulance team for information would waste valuable time. Explaining to the client that care will be provided is appropriate even though the client is unconscious, but documentation is essential.

The nurse in the ED is triaging patients during the shift. What does the nurse know is the first priority in treating any patient in the ED? a) Controlling hemorrhage. b) Establishing an airway. c) Restoring cardiac output. d) Obtaining consent for treatment.

Establishing an airway. The primary survey focuses on stabilizing life-threatening conditions. The ED staff work collaboratively and follow the ABCDE (airway, breathing, circulation, disability, exposure) method. The first priority is always to establish a patent airway.

A patient has been field triaged and categorized as blue. The nurse recognizes that the patient requires which of the following type of treatment? a) Fast-track or psychological support b) Immediate care c) Urgent care d) Emergent care

Fast-track or psychological support When a patient is categorized as blue, field triage has identified fast-track or psychological support needs. Field triaged patients who require emergent care will be categorized as red. Field triaged patients who require immediate care will be categorized as yellow. Field triaged patients who require urgent care will be categorized as green.

A client is admitted to the emergency department after reporting being raped. Who is the best team member for the admitting nurse to locate to provide care for this client? Forensic nurse examiner Physician or health care provider Psychiatric crisis nurse Police officer

Forensic nurse examiner The forensic nurse examiner is the best and most appropriate team member able to recognize evidence of abuse and to intervene on the client's behalf.Although the forensic nurse examiner is the best team member to provide care for this client, physicians or other health care providers or a psychiatric crisis nurse may also play a role in the client's care. Law enforcement may or may not be involved dependent on local laws.

Which of the following phases of psychological reaction to rape is characterized by fear and flashbacks? a) Heightened anxiety phase b) Reorganization phase c) Denial phase d) Acute disorganization phase

Heightened anxiety phase During the heightened anxiety phase, the patient demonstrates anxiety, hyperalertness, and psychosomatic reactions, in addition to fear and flashbacks. The acute disorganization phase is characterized by shock, disbelief, guilt, humiliation, and anger. The denial phase is characterized by an unwillingness to talk. The reorganization phase occurs when the incident is put into perspective. Some patients never fully recover from rape trauma.

A nuclear reactor overheated, releasing radiation throughout the plant. A worker close to reactor received at least 800 rads and has had an onset of vomiting, bloody diarrhea, and, when brought to the hospital, was in shock. What is this patient's predicted survival? a) Likely b) Possible c) Probable d) Improbable

Improbable Improbable survivors have received more than 800 rad of total-body penetrating irradiation. People in this group demonstrate an acute onset of vomiting, bloody diarrhea, and shock. Any neurologic symptoms suggest a lethal dose of radiation (CDC, 2006). Possible survivors present with nausea and vomiting that persist for 24 to 48 hours. Probable survivors have either no initial symptoms or only minimal symptoms (e.g., nausea and vomiting), or these symptoms resolve within a few hours. "Likely" is not a survival category.

A nurse is preparing to provide care to clients who are victims of an earthquake. Which of the following would the nurse identify as a factor that would least likely affect the emergency response? a) Absence of potable water b) Loss of electricity c) Lack of communication systems d) Loss of building structures

Loss of building structures In the event of a natural disaster, loss of communications, potable water, and electricity is usualy the greatest obstacle to a well-coordinated emergency response. Loss of building structures could increase the risk to emergency response personnel but they would have the least effects on the emergency response.

A patient with a minor burn would be triaged as which of the following? a) Immediate b) Expectant c) Delayed d) Minimal

Minimal A minor burn would be triaged as minimal. Conditions related to the immediate category include a sucking chest wound and shock. Conditions related to the delayed category include sift tissue injuries and most eye and CNS injuries. Conditions related to the expectant category include unresponsive patients with penetrating head wounds.

During a disaster, the nurse sees a victim with a green triage tag. The nurse knows that the person has which type of injuries? a) Minor and treatment can be delayed hours to days b) Life-threatening but survivable with minimal intervention c) Extensive and chances of survival are unlikely even with definitive care d) Significant and require medical care, but can wait hours without threat to life or limb

Minor and treatment can be delayed hours to days A green triage tag (priority 3 or minimal) indicates injuries that are minor and treatment can be delayed hours to days. A red triage tag (priority 1 or immediate) indicates injuries that are life threatening but survivable with minimal intervention. A yellow triage tag (priority 2 or delayed) indicates injuries that are significant and require medical care, but can wait hours without threat to life or limb. A black triage tag (priority 4 or expectant) indicates injuries that are extensive and chances of survival are unlikely even with definitive care.

A client with suspected inhalation anthrax is admitted to the emergency department. Which action by the nurse takes the highest priority?

Monitor vital signs and oxygen saturation every 15 to 30 minutes. pg. 2164

Which essential item is added to a personal-readiness supplies "go bag?" Fruits and vegetables Laptop computer Potable water Television

Potable water The "go bag" would contain 1 gallon of potable water per person per day. Potable water is drinking water and is required to prevent dehydration.Any foods included in a "go bag" would be nonperishable. Fruits and vegetables are perishable. A television would not be practical. A radio (battery-powered or hand-crank generated) would be better. A laptop computer would also not be practical. A "go bag" is a disaster supply kit for the home and automobile with clothing and basic survival supplies. It allows for a rapid response for disaster staffing coverage (Table 10-3). "Go bags" are needed for all members of the family, including pets, in the event the disaster requires evacuation of the community or for people to take shelter in their own homes.

Three victims of radiation exposure are brought into the Emergency Department. As the nurse caring for these clients, you would expect what substance to be ordered to reduce radiologic organ damage? a) Medical iodine b) Potassium iodide c) Cyan red d) Russian blue

Potassium iodide Taking substances called potassium iodide, Prussian blue, and diethylenetriamine pentaacetate can prevent or reduce radiologic organ damage. Option A, C and D are incorrect and used only as distractors.

A patient comes to the ED after ingesting cyanide. The first thing the nurse should anticipate doing is which of the following? a) Administer sodium thiosulfate. b) Prepare the patient for intubation. c) Administer sodium nitrate. d) Prepare the patient for nasogastric insertion.

Prepare the patient for intubation. The nurse should prepare the patient for intubation. After the patient is placed on the ventilator, amyl nitrate pearls are crushed and placed in the ventilator reservoir. Then, the nurse should prepare to administer IV sodium nitrate and then sodium thiosulfate according to the physician's orders.

The nurse is triaging patients from a 10-car pile-up on the interstate and assesses a patient with a sucking chest wound. What category should this patient be placed in?

Priority 1 pg. 2156

Several patients that have been involved in a bombing are unlikely to survive. What priority are these patients given during triage? a) Priority 3 b) Priority 4 c) Priority 1 d) Priority 2

Priority 4 Triage category "Expectant" is priority 4 (black) and applies to patients with injuries that are extensive and whose chances of survival are unlikely even with definitive care, such as unresponsive patients with penetrating head wounds, high spinal cord injuries, and wounds involving multiple anatomic sites and organs.

A patient is suspected to have an air embolus after being in close proximity to an explosion at a sports arena. What position should the nurse place the patient in to prevent migration of the embolus? a) Supine with head of the bed at 30 degrees b) Lithotomy c) High-Fowler's position d) Prone left lateral position

Prone left lateral position In the event of an air embolus, the patient should be immediately placed in the prone left lateral position to prevent migration of the embolus and will require emergent treatment in a hyperbaric chamber (CDC, 2013).

Exposure to gamma radiation can be decreased by completing which action?

Providing distance from radiation source pg. 2168

The nurse is caring for clients in the emergency department who have been admitted from the area surrounding a nuclear power plant. There had been a small explosion at the plant and a small amount of radiation had escaped. The nurse knows that this is what type of a disaster?

Radiologic pg. 2167

A client is brought to the emergency department with suspected genitourinary injury. The nurse prepares the client for insertion of an indwelling urinary catheter for bladder decompression and urine output monitoring. The nurse reviews the client's medical record to ensure that which of the following has been completed? a) Rectal examination b) Computed tomography scan c) Diagnostic peritoneal lavage d) Bladder ultrasound

Rectal examination In a client with a suspected genitourinary injury, an indwelling urinary catheter is inserted for bladder decompression and urine output monitoring only after a rectal examination has been completed. Computed tomography or bladder ultrasound are not necessary. A diagnostic peritoneal lavage is a backup procedure for evaluating intraperitoneal injury.

A nurse who is working as part of a disaster response team is performing triage at a mass casualty incident. One of the victims has a sucking chest wound. The nurse would triage this client using which color-coded tag? a) Black b) Yellow c) Green d) Red

Red A client with a sucking chest wound is triaged as needing immediate care and would be tagged red. Clients with injuries that are significant and require immediate care but can wait hours without threat to life or limb would be tagged yellow. Clients with minor injuries would be tagged green. Clients with injuries that are extensive and whose chances of survival are unlikely even with definitive care are tagged black.

Prevention is a tool we all can use to decrease our potential for gamma radiation contamination in the event of a nuclear accident or attack. Being aware of ways to limit external contamination empowers individuals to feel safer and to protect themselves and their loved ones. If caught outside during such an event, which of the following is the most effective way to decrease the potential for external gamma radiation contamination by an individual? a) Remove all garments and shoes before entering a house or public shelter. b) Cover the mouth and nose with a scarf or handkerchief. c) Turn on window fans or air conditioners to blow out contaminated air. d) Don't worry, gamma radiation is harmless.

Remove all garments and shoes before entering a house or public shelter. Removing all garments can eliminate 90% of external radioactive contamination. To limit external contamination, you should turn off window fans, air conditioners, and forced-air heating units. This is a way to limit internal, not external, contamination. Exposure to gamma radiation may cause acute radiation syndrome (ARS) and lead to death. Long-term effects experienced by those exposed to radiologic disasters include thyroid cancer, leukemia, and non-Hodgkin's lymphoma.

The Department of Homeland Security indicates a threat level "Imminent" relative to a situation. What does the nurse know that this indicates? a) Severe, credible impending threat, usually with a site specified b) Risk of attack, without timing specified c) Risk of attack, without a site specified d) Elevated risk of attack

Severe, credible impending threat, usually with a site specified Imminent threat level indicates a severe, credible impending threat, usually with a site specified.

Which of the following guidelines is appropriate to helping family members cope with sudden death? a) Provide details of the factors attendant to the sudden death b) Inform the family that the patient has passed on c) Obtain orders for sedation for family members d) Show acceptance of the body by touching it, giving the family permission to touch

Show acceptance of the body by touching it, giving the family permission to touch The nurse should encourage the family to view and touch the body if they wish, since this action helps the family to integrate the loss. The nurse should avoid using euphemisms such as passed on. The nurse should avoid giving sedation to family members, since this may mask or delay the grieving process. The nurse should avoid volunteering unnecessary information (eg, patient was drinking at the time of the accident).

When preparing for an emergency bioterrorism drill, the nurse instructs the drill volunteers that each biological agent requires specific client management and medications to combat the virus, bacteria, or toxin. Which statement reflects the client management of variola virus (smallpox)?

Smallpox spreads rapidly and requires immediate isolation. pg. 2164

A client comes to the emergency department covered with coagulated blood and a white powder. The client is hysterical and fears that it is anthrax. What does the nurse do first? Administers antibiotics Provides emotional support Takes the client to the decontamination room Triages the client

Takes the client to the decontamination room Decontamination must precede triage. Only the most basic life-sustaining interventions would be performed before or during decontamination. The coagulated blood indicates that any major active bleeding has likely subsided.Taking antibiotics unnecessarily will promote the growth of resistant bacteria and may cause serious drug-related side effects. In addition, anthrax exposure has not yet been verified. Emotional support is important but is not the priority here. Although triage is important, safety is a higher priority.

A patient present to the ED following a work-related injury to the left hand. The patient has an avulsion of the left ring finger. Which of the following correctly describes an avulsion? a) Denuded skin b) Tearing away of tissue from supporting structures c) Incision of the skin with well-defined edges, usually longer than deep d) Skin tear with irregular edges and vein bridging

Tearing away of tissue from supporting structures An avulsion is described as a tearing away of tissue from supporting structures. A laceration is a skin tear with irregular edges and vein bridging. Abrasion is denuded skin. A cut is an incision of the skin with well-defined edges, usually longer than deep.

What is a common source of airway obstruction in an unconscious client? a) Edema b) Saliva or mucus c) The tongue d) A foreign object

The tongue In an unconscious client, the muscles controlling the tongue commonly relax, causing the tongue to obstruct the airway. When this situation occurs, the nurse should use the head-tilt, chin-lift maneuver to cause the tongue to fall back into place. If she suspects the client has a neck injury she must perform the jaw-thrust maneuver.

A client who has been exposed to radiation develops acute radiation syndrome. It has been about 2 weeks since he initially showed signs and symptoms and the client is undergoing laboratory testing. Which of the following would the nurse expect to find?

Thrombocytopenia pg. 2169

Which is defined as the potential of an agent to cause injury to the body?

Toxicity pg. 2165

The student nurse is completing a simulation where a client is the victim of nerve gas. The instructions are for the student to set up the room and have all needed supplies available. Which medication does the student nurse ensure is in the medication administration system to control seizures? a) Neurontin tablets b) Valium intravenous injection c) Dilantin tablets d) Phenobarbital intramuscular

Valium intravenous injection The students nurse is correct to have Valium intravenously on hand for seizure activity. When seizure activity occurs, the intravenous route is the best option to deliver the medication safely and rapidly into the system. It would be very difficult to administer medication both orally and intramuscularly.

A patient who has been triaged as delayed would receive which color tag? a) Red b) Green c) Yellow d) Black

Yellow A yellow triage tag indicates delayed triage category. A red triage tag indicates immediate injuries. A green triage tag indicates a minimal triage category. Black triage tags indicate expectant injuries that are extensive and chances of survival are unlikely even with definitive care.

Smallpox is considered a biological agent of warfare. Which of the following are correct statements about the virus that will direct responses? Select all that apply. a) The rash appears one week after exposure b) A large amount of the virus is present in the saliva and pustules c) One form, variola major, has a 30% mortality rate d) It has an incubation period of 72 hours e) It is extremely contagious after appearance of a rash

• A large amount of the virus is present in the saliva and pustules • It is extremely contagious after appearance of a rash • One form, variola major, has a 30% mortality rate The incubation period for smallpox is 10 to 12 days. A flat, red-lesioned rash appears 2 to 3 days postexposure.

Nursing students are reviewing the categories of intra-abdominal injuries. The students demonstrate understanding of the information when they identify which of the following as examples of penetrating trauma? Select all that apply. a) Gunshot wound b) Fall from a roof c) Knife-stab wound d) Motor-vehicle crash e) Being struck with a baseball bat

• Gunshot wound • Knife-stab wound Examples of penetrating trauma include gunshot wounds and stab wounds. Motor vehicle crashes, falls, and being struck with a baseball bat are examples of blunt trauma.

Which of the following would the nurse identify as indicating that a client is experiencing a complete airway obstruction? Select all that apply. a) Spontaneous coughing b) Stridor c) Clutching of the neck d) Inability to speak e) Cyanosis

• Inability to speak • Clutching of the neck • Stridor • Cyanosis Manifestations of a complete airway obstruction include the inability to speak, breathe, or cough; clutching the neck; inspiratory and expiratory stridor; and cyanosis (a late sign). If the client can cough spontaneously, then a partial airway obstruction is most likely.

A patient with a history of major depressive disorder is brought to the emergency department by a friend, who reports that the patient took an overdose of prescribed amitriptyline. Which of the following findings would the nurse expect to assess? Select all that apply. a) Visual hallucinations b) Hypoactive reflexes c) Clonus d) Hypothermia e) Tachycardia

• Tachycardia • Visual hallucinations • Clonus Amitriptyline is a tricyclic antidepressant. In cases of overdose, the patient would likely experience tachycardia, hypotension, confusion, visual hallucinations, clonus, tremors, hyperactive reflexes, seizures, blurred vision, flushing, and hyperthermia.

9. A client with a stroke has damage to Broca's area. What intervention to promote communication is best for this client? a. Assess whether or not the client can write. b. Communicate using "yes-or-no" questions. c. Reinforce speech therapy exercises. d. Remind the client not to use neologisms.

ANS: A Damage to Broca's area often leads to expressive aphasia, wherein the client can understand what is said but cannot express thoughts verbally. In some instances the client can write. The nurse should assess to see if that ability is intact. "Yes-or-no" questions are not good for this type of client because he or she will often answer automatically but incorrectly. Reinforcing speech therapy exercises is good for all clients with communication difficulties. Neologisms are made-up "words" often used by clients with sensory aphasia. REF: 943

10. While on a camping trip, a nurse cares for an adult client who had a drowning incident in a lake and is experiencing agonal breathing with a palpable pulse. Which action should the nurse take first? a. Deliver rescue breaths. b. Wrap the client in dry blankets. c. Assess for signs of bleeding. d. Check for a carotid pulse.

ANS: A In this emergency situation, the nurse should immediately initiate airway clearance and ventilator support measures, including delivering rescue breaths.

6. A nurse teaches a community health class about water safety. Which statement by a participant indicates that additional teaching is needed? a. I can go swimming all by myself because I am a certified lifeguard. b. I cannot leave my toddler alone in the bathtub for even a minute. c. I will appoint one adult to supervise the pool at all times during a party. d. I will make sure that there is a phone near my pool in case of an emergency.

ANS: A People should never swim alone, regardless of lifeguard status. The other statements indicate good understanding of the teaching.

12. A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first? a. Client with a Glasgow Coma Scale score that was 10 and is now is 8 b. Client with a Glasgow Coma Scale score that was 9 and is now is 12 c. Client with a moderate brain injury who is amnesic for the event d. Client who is requesting pain medication for a headache

ANS: A A 2-point decrease in the Glasgow Coma Scale score is clinically significant and the nurse needs to see this client first. An improvement in the score is a good sign. Amnesia is an expected finding with brain injuries, so this client is lower priority. The client requesting pain medication should be seen after the one with the declining Glasgow Coma Scale score. REF: 952

3. An emergency room nurse is triaging victims of a multi-casualty event. Which client should receive care first? a. A 30-year-old distraught mother holding her crying child b. A 65-year-old conscious male with a head laceration c. A 26-year-old male who has pale, cool, clammy skin d. A 48-year-old with a simple fracture of the lower leg

ANS: C The client with pale, cool, clammy skin is in shock and needs immediate medical attention. The mother does not have injuries and so would be the lowest priority. The other two people need medical attention soon, but not at the expense of a person in shock.

15. A patient is being treated in the ED following a terrorist attack. The patient is experiencing visual disturbances, nausea, vomiting, and behavioral changes. The nurse suspects this patient has been exposed to what chemical agent? A) Nerve agent B) Pulmonary agent C) Vesicant D) Blood agent

Ans: A Feedback: Nerve agent exposure results in visual disturbances, nausea and vomiting, forgetfulness, irritability, and impaired judgment. This presentation is not suggestive of vesicants, pulmonary agents, or blood agents.

9. The announcement is made that the facility may return to normal functioning after a local disaster. In the emergency operations plan, what is this referred to as? A) Demobilization response B) Post-incident response C) Crisis diffusion D) Reversion

Ans: A Feedback: The demobilization response occurs when it is deemed that the facility may return to normal daily functioning. This is not known as the post-incident response, crisis diffusion or reversion.

23. A client has a subarachnoid bolt. What action by the nurse is most important? a. Balancing and recalibrating the device b. Documenting intracranial pressure readings c. Handling the fiberoptic cable with care to avoid breakage d. Monitoring the client's phlebostatic axis

ANS: A This device needs frequent balancing and recalibration in order to read correctly. Documenting readings is important, but it is more important to ensure the device's accuracy. The fiberoptic transducer-tipped catheter has a cable that must be handled carefully to avoid breaking it, but ensuring the device's accuracy is most important. The phlebostatic axis is not related to neurologic monitoring. REF: 956

5. An emergency department nurse assesses a client admitted after a lightning strike. Which assessment should the nurse complete first? a. Electrocardiogram (ECG) b. Wound inspection c. Creatinine kinase d. Computed tomography of head

ANS: A Clients who survive an immediate lightning strike can have serious myocardial injury, which can be manifested by ECG and myocardial perfusion abnormalities. The nurse should prioritize the ECG. Other assessments should be completed but are not the priority.

16. A client with a traumatic brain injury is agitated and fighting the ventilator. What drug should the nurse prepare to administer? a. Carbamazepine (Tegretol) b. Dexmedetomidine (Precedex) c. Diazepam (Valium) d. Mannitol (Osmitrol)

ANS: B Dexmedetomidine is often used to manage agitation in the client with traumatic brain injury. Carbamazepine is an antiseizure drug. Diazepam is a benzodiazepine. Mannitol is an osmotic diuretic. REF: 955

24. A nurse is providing community screening for risk factors associated with stroke. Which client would the nurse identify as being at highest risk for a stroke? a. A 27-year-old heavy cocaine user b. A 30-year-old who drinks a beer a day c. A 40-year-old who uses seasonal antihistamines d. A 65-year-old who is active and on no medications

ANS: A Heavy drug use, particularly cocaine, is a risk factor for stroke. Heavy alcohol use is also a risk factor, but one beer a day is not considered heavy drinking. Antihistamines may contain phenylpropanolamine, which also increases the risk for stroke, but this client uses them seasonally and there is no information that they are abused or used heavily. The 65-year-old has only age as a risk factor. REF: 933

13. A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The client's spouse is very frustrated, stating that the client's personality has changed and the situation is intolerable. What action by the nurse is best? a. Explain that personality changes are common following brain injuries. b. Ask the client why he or she is acting out and behaving differently. c. Refer the client and spouse to a head injury support group. d. Tell the spouse this is expected and he or she will have to learn to cope.

ANS: A Personality and behavior often change permanently after head injury. The nurse should explain this to the spouse. Asking the client about his or her behavior isn't useful because the client probably cannot help it. A referral might be a good idea, but the nurse needs to do something in addition to just referring the couple. Telling the spouse to learn to cope belittles the spouse's concerns and feelings. REF: 953

29. A client in the emergency department is having a stroke and needs a carotid artery angioplasty with stenting. The client's mental status is deteriorating. What action by the nurse is most appropriate? a. Attempt to find the family to sign a consent. b. Inform the provider that the procedure cannot occur. c. Nothing; no consent is needed in an emergency. d. Sign the consent form for the client.

ANS: A The nurse should attempt to find the family to give consent. If no family is present or can be found, under the principle of emergency consent, a life-saving procedure can be performed without formal consent. The nurse should not just sign the consent form. REF: 938

18. There has been a radiation-based terrorist attack and a patient is experiencing vomiting, diarrhea, and shock after the attack. How will the patients likelihood of survival be characterized? A) Probable B) Possible C) Improbable D) Extended

Ans: C Feedback: Patients who experience vomiting, diarrhea, and shock after radiation exposure are categorized as improbable survival, because they are demonstrating symptoms of exposure levels of more than 800 rads of total body-penetrating irradiation.

The nurse is teaching a class of park ranger trainees about prioritizing care for clients who have received snakebites. Which ranger's statement demonstrates a need for further teaching? "Do not allow the victim to ingest any alcohol or caffeine." "The extremity should be kept below the level of the heart." "The first priority is to call for EMS transport to a trauma center." "You should first place a tourniquet above the bite."

"You should first place a tourniquet above the bite." The ranger trainee's statement that the first thing to do is to place a tourniquet above the bite indicates a need for further teaching. Placing a tourniquet above the bite could worsen local tissue necrosis by retaining venom in the tissues. If transportation and treatment are delayed, a constricting band may be applied proximal to an extremity wound to slow venom circulation via lymphatic flow. However, it would not be used as a tourniquet.Alcohol or stimulants such as caffeinated beverages must not be offered because they may speed up the absorption of venom. Affected extremities are kept below the level of the heart. The first priority is not to call for EMS transport although it will be important for the client to be evaluated and treated at an appropriate facility that is equipped to handle snakebites.

39. A group of military nurses are reviewing the care of victims of biochemical terrorist attacks. The nurses should identify what agents as having the shortest latency? A) Viral agents B) Nerve agents C) Pulmonary agents D) Blood agents

Ans: B Feedback: Latency is the time from absorption to the appearance of signs and symptoms. Sulfur mustards and pulmonary agents have the longest latency, whereas vesicants, nerve agents, and cyanide produce signs and symptoms within seconds.

16. A patient is admitted to the ED who has been exposed to a nerve agent. The nurse should anticipate the STAT administration of what drug? A) Amyl nitrate B) Dimercaprol C) Erythromycin D) Atropine

Ans: D Feedback: Atropine is administered when a patient is exposed to a nerve agent. Exposure to blood agents, such as cyanide, requires treatment with amyl nitrate, sodium nitrite, and sodium thiosulfate. Dimercaprol is administered IV for systemic toxicity and topically for skin lesions when exposed to vesicants. Erythromycin is an antibiotic, which is ineffective against nerve agents.

One of the nuclear power plants experiences a crack in the protection of the core when the cooling system malfunctions. The thought is that the cooling system was tampered with. Healthcare facilities in the area are inundated with victims residing in the area around the power plant. What category of disaster would this be? a) A biologic disaster b) A chemical disaster c) A nuclear blast d) A radiologic disaster

A radiologic disaster The devices that initiate, control, and sustain the nuclear reactions as well as spent fuel are a potential concern for the escape of radiation. The scenario described does not indicate option A, B, or C; therefore, they are incorrect.

5. The hospital administration arranges for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation? a. You are free to express your feelings; whatever is said here stays here. b. Lets evaluate what went wrong and develop policies for future incidents. c. This session is only for nursing and medical staff, not for ancillary personnel. d. Lets pass around the written policy compliance form for everyone.

ANS: A Strict confidentiality during stress debriefing is essential so that staff members can feel comfortable sharing their feelings, which should be accepted unconditionally. Brainstorming improvements and discussing policies would occur during an administrative review. Any employee present during a mass casualty situation is eligible for critical incident stress management services.

1. A hospital responds to a local mass casualty event. Which action should the nurse supervisor take to prevent staff post-traumatic stress disorder during a mass casualty event? a. Provide water and healthy snacks for energy throughout the event. b. Schedule 16-hour shifts to allow for greater rest between shifts. c. Encourage counseling upon deactivation of the emergency response plan. d. Assign staff to different roles and units within the medical facility.

ANS: A To prevent staff post-traumatic stress disorder during a mass casualty event, the nurses should use available counseling, encourage and support co-workers, monitor each others stress level and performance, take breaks when needed, talk about feelings with staff and managers, and drink plenty of water and eat healthy snacks for energy. Nurses should also keep in touch with family, friends, and significant others, and not work for more than 12 hours per day. Encouraging counseling upon deactivation of the plan, or after the emergency response is over, does not prevent stress during the casualty event. Assigning staff to unfamiliar roles or units may increase situational stress and is not an approach to prevent post-traumatic stress disorder.

9. A nurse wants to become part of a Disaster Medical Assistance Team (DMAT) but is concerned about maintaining licensure in several different states. Which statement best addresses these concerns? a. Deployed DMAT providers are federal employees, so their licenses are good in all 50 states. b. The government has a program for quick licensure activation wherever you are deployed. c. During a time of crisis, licensure issues would not be the governments priority concern. d. If you are deployed, you will be issued a temporary license in the state in which you are working.

ANS: A When deployed, DMAT health care providers are acting as agents of the federal government, and so are considered federal employees. Thus their licenses are valid in all 50 states. Licensure is an issue that the government would be concerned with, but no programs for temporary licensure or rapid activation are available.

A pipe bomb detonated on a city bus, causing numerous casualties. This would be an example of which type of disaster? a) Unintentional human b) Intentional human c) Biologic d) Natural

Intentional human Intentional human disasters include bombings, biologic disasters, and chemical disasters. Natural disasters are caused by nature; examples include tornadoes and hurricanes. Unintentional disasters are accidents that may result in mass trauma and disruptions of services depending on their scale. A biologic disaster is one in which pathogens or their toxins cause harm to many humans and other living species.

12. An emergency department nurse is caring for a client who is homeless. Which action should the nurse take to gain the clients trust? a. Speak in a quiet and monotone voice. b. Avoid eye contact with the client. c. Listen to the clients concerns and needs. d. Ask security to store the clients belongings.

ANS: C To demonstrate behaviors that promote trust with homeless clients, the emergency room nurse should make eye contact (if culturally appropriate), speak calmly, avoid any prejudicial or stereotypical remarks, show genuine care and concern by listening, and follow through on promises. The nurse should also respect the clients belongings and personal space.

The RN working at a long-term-care facility places priority on providing interventions for which resident? A 65-year-old paraplegic man who is demanding to see the health care provider about insurance benefits A 76-year-old woman with a total hip replacement who is showering for the first time since entering rehabilitation after surgery An 80-year-old man with congestive heart failure (CHF) who is outdoor for some "fresh air" when the temperature is 95° F (35° C) An 82-year-old woman with dementia who is requesting "something" for a headache

An 80-year-old man with congestive heart failure (CHF) who is outdoor for some "fresh air" when the temperature is 95° F (35° C) The nurse's priority would be to intervene on behalf of the elderly CHF resident. The 80-year-old resident is outside when it is 95° F (35° C) and needs to be assisted back indoors with some alternatives provided for him to receive some "fresh air." This will help him meet his personal desires as well as maintain his safety and prevent potential heat-related illness.Although the 65-year-old paraplegic man has valid concerns, these concerns are not the nurse's highest priority in the group. The 76-year-old woman with a total hip replacement needs to be handled carefully and safely during a new activity, but she is not the nurse's greatest priority resident. Although the 82-year-old woman with dementia has a valid request, she is not the nurse's highest priority in this scenario.

28. A man survived a workplace accident that claimed the lives of many of his colleagues several months ago. The man has recently sought care for the treatment of depression. How should the nurse best understand the mans current mental health problem? A) The man is experiencing a common response following a disaster. B) The man fails to appreciate the fact that he survived the disaster. C) The man most likely feels guilty about his actions during the disaster. D) The mans depression most likely predated the disaster.

Ans: A Feedback: Depression is a common response to disaster. It does not suggest that the patient feels guilty about his actions or that he does not appreciate the fact that he survived. It is possible, but less likely, that the patient was depressed prior to the disaster.

38. An 83-year-old patient is brought in by ambulance from a long-term care facility. The patients symptoms are weakness, lethargy, incontinence, and a change in mental status. The nurse knows that emergencies in older adults may be more difficult to manage. Why would this be true? A) Older adults may have an altered response to treatment. B) Older adults are often reluctant to adhere to prescribed treatment. C) Older adults have difficulty giving a health history. D) Older adults often stigmatize their peers who use the ED.

Ans: A Feedback: Emergencies in this age group may be more difficult to manage because elderly patients may have an atypical presentation, an altered response to treatment, a greater risk of developing complications, or a combination of these factors. The elderly patient may perceive the emergency as a crisis signaling the end of an independent lifestyle or even resulting in death. Stigmatization and nonadherence to treatment are not commonly noted. Older adults do not necessarily have difficulty giving a health history.

19. A backcountry skier has been airlifted to the ED after becoming lost and developing hypothermia and frostbite. How should the nurse best manage the patients frostbite? A) Immerse affected extremities in water slightly above normal body temperature. B) Immerse the patients frostbitten extremities in the warmest water the patient can tolerate. C) Gently massage the patients frozen extremities in between water baths. D) Perform passive range-of-motion exercises of the affected extremities to promote circulation.

Ans: A Feedback: Frozen extremities are usually placed in a 37C to 40C (98.6F to 104F) circulating bath for 30- to 40- minute spans. To avoid further mechanical injury, the body part is not handled. Massage is contraindicated.

7. A patient is admitted to the ED with suspected alcohol intoxication. The ED nurse is aware of the need to assess for conditions that can mimic acute alcohol intoxication. In light of this need, the nurse should perform what action? A) Check the patients blood glucose level. B) Assess for a documented history of major depression. C) Determine whether the patient has ingested a corrosive substance. D) Arrange for assessment of serum potassium levels.

Ans: A Feedback: Hypoglycemia can mimic alcohol intoxication and should be assessed in a patient suspected of alcohol intoxication. Potassium imbalances, depression, and poison ingestion are not noted to mimic the characteristic signs and symptoms of alcohol intoxication.

23. A hospitals emergency operations plan has been enacted following an industrial accident. While one nurse performs the initial triage, what should other emergency medical services personnel do? A) Perform life-saving measures. B) Classify patients according to acuity. C) Provide health promotion education. D) Modify the emergency operations plan.

Ans: A Feedback: In an emergency, patients are immediately tagged and transported or given life-saving interventions. One person performs the initial triage while other emergency medical services (EMS) personnel perform lifesaving measures and transport patients. Health promotion is not a priority during the acute stage of the crisis. Classifying patients is the task of the triage nurse. EMS personnel prioritize life-saving measures; they do not modify the operations plan.

37. A patient is brought to the ED by two police officers. The patient was found unconscious on the sidewalk, with his face and hands covered in blood. At present, the patient is verbally abusive and is fighting the staff in the ED, but appears medically stable. The decision is made to place the patient in restraints. What action should the nurse perform when the patient is restrained? A) Frequently assess the patients skin integrity. B) Inform the patient that he is likely to be charged with assault. C) Avoid interacting with the patient until the restraints are removed. D) Take the opportunity to perform a full physical assessment.

Ans: A Feedback: It is important to assess skin integrity when physical restraints are used. Criminal charges are not the responsibility of the nurse and the nurse should still interact with the patient. A full physical assessment, however, would likely be delayed until the patient is not combative.

38. A patient has been exposed to a nerve agent in a biochemical terrorist attack. This type of agent bonds with acetylcholinesterase, so that acetylcholine is not inactivated. What is the pathologic effect of this type of agent? A) Hyperstimulation of the nerve endings B) Temporary deactivation of the nerve endings C) Binding of the nerve endings D) Destruction of the nerve endings

Ans: A Feedback: Nerve agents can be inhaled or absorbed percutaneously or subcutaneously. These agents bond with acetylcholinesterase, so that acetylcholine is not inactivated; the adverse result is continuous stimulation (hyperstimulation) of the nerve endings. Nerve endings are not deactivated, bound, or destroyed.

26. A nurse is participating in the planning of a hospitals emergency operations plan. The nurse is aware of the potential for ethical dilemmas during a disaster or other emergency. Ethical dilemmas in these contexts are best addressed by which of the following actions? A) Having an ethical framework in place prior to an emergency B) Allowing staff to provide care anonymously during an emergency C) Assuring staff that they are not legally accountable for care provided during an emergency D) Teaching staff that principles of ethics do not apply in an emergency situation

Ans: A Feedback: Nurses can plan for the ethical dilemmas they may face during disasters by establishing a framework for evaluating ethical questions before they arise and by identifying and exploring possible responses to difficult clinical situations. Ethical principles do not become wholly irrelevant in emergencies. Care cannot be given anonymously and accountability for practice always exists, even in an emergency.

34. The ED nurse is planning the care of a patient who has been admitted following a sexual assault. The nurse knows that all of the nursing interventions are aimed at what goal? A) Encouraging the patient to gain a sense of control over his or her life B) Collecting sufficient evidence to secure a criminal conviction C) Helping the patient understand that this will not happen again D) Encouraging the patient to verbalize what happened during the assault

Ans: A Feedback: The goals of management are to provide support, to reduce the patients emotional trauma, and to gather available evidence for possible legal proceedings. All of the interventions are aimed at encouraging the patient to gain a sense of control over his or her life. The patients well-being should be considered a priority over criminal proceedings. No health professional can guarantee the patients future safety and having the patient verbalize the event is not a priority.

27. The triage nurse is working in the ED. A homeless person is admitted during a blizzard with complaints of being unable to feel his feet and lower legs. Core temperature is noted at 33.2C (91.8F). The patient is intoxicated with alcohol at the time of admission and is visibly malnourished. What is the triage nurses priority in the care of this patient? A) Addressing the patients hypothermia B) Addressing the patients frostbite in his lower extremities C) Addressing the patients alcohol intoxication D) Addressing the patients malnutrition

Ans: A Feedback: The patient may also have frostbite, but hypothermia takes precedence in treatment because it is systemic rather than localized. The alcohol abuse and the alteration in nutrition do not take precedence over the treatment of hypothermia because both problems are a less acute threat to the patients survival.

30. The nurse is caring for a patient admitted with a drug overdose. What is the nurses priority responsibility in caring for this patient? A) Support the patients respiratory and cardiovascular function. B) Provide for the safety of the patient. C) Enhance clearance of the offending agent. D) Ensure the safety of the staff.

Ans: A Feedback: Treatment goals for a patient with a drug overdose are to support the respiratory and cardiovascular functions, to enhance clearance of the agent, and to provide for safety of the patient and staff. Of these responsibilities, however, support of vital physiologic function is a priority.

29. A patient admitted to the ED with severe diarrhea and vomiting is subsequently diagnosed with food poisoning. The nurse caring for this patient assesses for signs and symptoms of fluid and electrolyte imbalances. For what signs and symptoms would this nurse assess? Select all that apply. A) Dysrhythmias B) Hypothermia C) Hypotension D) Hyperglycemia E) Delirium

Ans: A, C, E Feedback: The patient is assessed for signs and symptoms of fluid and electrolyte imbalances, including lethargy, rapid pulse rate, fever, oliguria, anuria, hypotension, and delirium. Hyperglycemia and hypothermia are not typically associated with fluid and electrolyte imbalances.

13. A 6-year-old is admitted to the ED after being rescued from a pond after falling through the ice while ice skating. What action should the nurse perform while rewarming the patient? A) Assessing the patients oral temperature frequently B) Ensuring continuous ECG monitoring C) Massaging the patients skin surfaces to promote circulation D) Administering bronchodilators by nebulizer

Ans: B Feedback: A hypothermic patient requires continuous ECG monitoring and assessment of core temperatures with an esophageal probe, bladder, or rectal thermometer. Massage is not performed and bronchodilators would normally be insufficient to meet the patients respiratory needs.

32. A patient is being treated for bites that she suffered during an assault. After the bites have been examined and documented by a forensic examiner, the nurse should perform what action? A) Apply a dressing saturated with chlorhexidine. B) Wash the bites with soap and water. C) Arrange for the patient to receive a hepatitis B vaccination. D) Assess the patients immunization history.

Ans: B Feedback: After forensic evidence has been gathered, cleansing with soap and water is necessary, followed by the administration of antibiotics and tetanus toxoid as prescribed. The patients immunization history does not directly influence the course of treatment and hepatitis B vaccination is not indicated. Chlorhexidine bandages are not recommended.

15. A 13-year-old is being admitted to the ED after falling from a roof and sustaining blunt abdominal injuries. To assess for internal injury in the patients peritoneum, the nurse should anticipate what diagnostic test? A) Radiograph B) Computed tomography (CT) scan C) Complete blood count (CBC) D) Barium swallow

Ans: B Feedback: CT scan of the abdomen, diagnostic peritoneal lavage, and abdominal ultrasound are appropriate diagnostic tools to assess intra-abdominal injuries. X-rays do not yield sufficient data and a CBC would not reveal the presence of intraperitoneal injury.

9. A patient with a history of major depression is brought to the ED by her parents. Which of the following nursing actions is most appropriate? A) Noting that symptoms of physical illness are not relevant to the current diagnosis B) Asking the patient if she has ever thought about taking her own life C) Conducting interviews in a brief and direct manner D) Arranging for the patient to spend time alone to consider her feelings

Ans: B Feedback: Establishing if the patient has suicidal thoughts or intents helps identify the level of depression and intervention. Physical symptoms are relevant and should be explored. Allow the patient to express feelings, and conduct the interview at a comfortable pace for the patient. Never leave the patient alone, because suicide is usually committed in solitude.

5. The nursing educator is reviewing the signs and symptoms of heat stroke with a group of nurses who provide care in a desert region. The educator should describe what sign or symptom? A) Hypertension with a wide pulse pressure B) Anhidrosis C) Copious diuresis D) Cheyne-Stokes respirations

Ans: B Feedback: Heat stroke is manifested by anhidrosis confusion, bizarre behavior, coma, elevated body temperature, hot dry skin, tachypnea, hypotension, and tachycardia. This health problem is not associated with anhidrosis or Cheyne-Stokes respirations.

31. A patient is admitted to the ED with an apparent overdose of IV heroin. After stabilizing the patients cardiopulmonary status, the nurse should prepare to perform what intervention? A) Administer a bolus of lactated Ringers. B) Administer naloxone hydrochloride (Narcan). C) Insert an indwelling urinary catheter. D) Perform a focused neurologic assessment.

Ans: B Feedback: Narcan is an opioid antagonist that is administered for the treatment of narcotic overdoses. There is no definitive need for a urinary catheter or for a bolus of lactated Ringers. The patients basic neurologic status should be ascertained during the rapid assessment, but a detailed examination would be take precedence over administration of an antidote.

2. The nurse observes that the family members of a patient who was injured in an accident are blaming each other for the circumstances leading up to the accident. The nurse appropriately lets the family members express their feelings of responsibility, while explaining that there was probably little they could do to prevent the injury. In what stage of crisis is this family? A) Anxiety and denial B) Remorse and guilt C) Anger D) Grief

Ans: B Feedback: Remorse and guilt are natural processes of the stages of a crisis and should be facilitated for the family members to process the crisis. The familys sense of blame and responsibility are more suggestive of guilt than anger, grief, or anxiety.

35. The ED nurse admitting a patient with a history of depression is screening the patient for suicide risk. What assessment question should the nurse ask when screening the patient? A) How would you describe your mood over the past few days? B) Have you ever thought about taking your own life? C) How do you think that your life is most likely to end? D) How would you rate the severity of your depression right now on a 10-point scale?

Ans: B Feedback: The nurse should address the patients possible plans for suicide in a direct yet empathic manner. The nurse should avoid oblique or indirect references to suicide and should not limit questions to the patients depression.

14. A male patient with multiple injuries is brought to the ED by ambulance. He has had his airway stabilized and is breathing on his own. The ED nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding? A) Absence of bruising at contusion sites B) Rapid pulse and decreased capillary refill C) Increased BP with narrowed pulse pressure D) Sudden diaphoresis

Ans: B Feedback: The nurse would anticipate that the pulse would increase and BP would decrease. Urine output would also decrease. An absence of bruising and the presence of diaphoresis would not suggest internal hemorrhage.

39. An ED nurse is triaging patients according to the Emergency Severity Index (ESI). When assigning patients to a triage level, the nurse will consider the patients acuity as well as what other variable? A) The likelihood of a repeat visit to the ED in the next 7 days B) The resources that the patient is likely to require C) The patients or insurers ability to pay for care D) Whether the patient is known to ED staff from previous visits

Ans: B Feedback: With the ESI, patients are assigned to triage levels based on both their acuity and their anticipated resource needs. Ability to pay, the likelihood of repeat visits, and the history of prior visits are not explicitly considered.

22. A patient is admitted to the ED complaining of abdominal pain. Further assessment of the abdomen reveals signs of peritoneal irritation. What assessment findings would corroborate this diagnosis? Select all that apply. A) Ascites B) Rebound tenderness C) Changes in bowel sounds D) Muscular rigidity E) Copious diarrhea

Ans: B, C, D Feedback: Signs of peritoneal irritation include abdominal distention, involuntary guarding, tenderness, pain, muscular rigidity, or rebound tenderness along with changes in bowel sounds. Diarrhea and ascites are not signs of peritoneal irritation.

22. After a radiation exposure, a patient has been assessed and determined to be a possible survivor. Following the resolution of the patients initial symptoms, the care team should anticipate what event? A) A return to full health B) Internal bleeding C) A latent phase D) Massive tissue necrosis

Ans: C Feedback: A latent phase commonly follows the prodromal phase of radiation exposure. The patient is deemed a possible survivor, not a probable survivor, so an immediate return to health is unlikely. However, internal bleeding and massive tissue necrosis would not be expected in a patient categorized as a possible survivor.

6. A patient is brought to the ED by ambulance after swallowing highly acidic toilet bowl cleaner 2 hours earlier. The patient is alert and oriented. What is the care teams most appropriate treatment? A) Administering syrup of ipecac B) Performing a gastric lavage C) Giving milk to drink D) Referring to psychiatry

Ans: C Feedback: A patient who has swallowed an acidic substance, such as toilet bowl cleaner, may be given milk or water to drink for dilution. Gastric lavage must be performed within 1 hour of ingestion. A psychiatric consult may be considered once the patient is physically stable and it is deemed appropriate by the physician. Syrup of ipecac is no longer used in clinical settings.

36. A nurse has had contact with a patient who developed smallpox and became febrile after a terrorist attack. This nurse will require what treatment? A) Watchful waiting B) Treatment with colony-stimulating factors (CSFs) C) Vaccination D) Treatment with ceftriaxone

Ans: C Feedback: All people who have had household or face-to-face contact with a patient with small pox after the fever begins should be vaccinated within 4 days to prevent infection and death. Watchful waiting would be inappropriate and CSFs are not used for treatment. Vaccination, rather than antibiotics, is the treatment of choice.

28. A patient is brought to the ED by friends. The friends tell the nurse that the patient was using cocaine at a party. On arrival to the ED the patient is in visible distress with an axillary temperature of 40.1C (104.2F). What would be the priority nursing action for this patient? A) Monitor cardiovascular effects. B) Administer antipyretics. C) Ensure airway and ventilation. D) Prevent seizure activity.

Ans: C Feedback: Although all of the listed actions may be necessary for this patients care, the priority is to establish a patent airway and adequate ventilation.

33. A patient has been admitted to the medical unit with signs and symptoms that are suggestive of anthrax infection. The nurse should anticipate what intervention? A) Administration of acyclovir B) Hematopoietic stem cell transplantation (HSCT) C) Administration of penicillin D) Hemodialysis

Ans: C Feedback: Anthrax infection is treated with penicillin. Acyclovir is ineffective because anthrax is a bacterium. Dialysis and HSCT are not indicated.

32. A patient suffering from blast lung has been admitted to the hospital and is exhibiting signs and symptoms of an air embolus. What is the nurses most appropriate action? A) Place the patient in the Trendelenberg position. B) Assess the patients airway and begin chest compressions. C) Position the patient in the prone, left lateral position. D) Encourage the patient to perform deep breathing and coughing exercises.

Ans: C Feedback: In the event of an air embolus, the patient should be placed immediately in the prone left lateral position to prevent migration of the embolus and will require emergent treatment in a hyperbaric chamber. Chest compressions, deep breathing, and coughing would exacerbate the patients condition. Trendelenberg positioning is not recommended.

40. A nurse is giving an educational class to members of the local disaster team. What should the nurse instruct members of the disaster team to do in a chemical bioterrorist attack? A) Cover their eyes. B) Put on a personal protective equipment mask. C) Stand up. D) Crawl to an exit.

Ans: C Feedback: Most chemicals are heavier than air, except for hydrogen cyanide. Therefore, in the presence of most chemicals, people should stand up to avoid heavy exposure because the chemical will sink toward the floor or ground. For this reason, covering their eyes, putting on a PPE mask, or crawling to an exit will not decrease exposure.

36. A patient is brought to the ED by family members who tell the nurse that the patient has been exhibiting paranoid, agitated behavior. What should the nurse do when interacting with this patient? A) Keep the patient in a confined space. B) Use therapeutic touch appropriately. C) Give the patient honest answers about likely treatment. D) Attempt to convince the patient that his or her fears are unfounded.

Ans: C Feedback: The nurse should offer appropriate and honest explanations in order to foster rapport and trust. Confinement is likely to cause escalation, as is touching the patient. The nurse should not normally engage in trying to convince the patient that his or her fears are unjustified, as this can also cause escalation.

11. You are a floor nurse caring for a patient with alcohol withdrawal syndrome. What would be an appropriate nursing action to minimize the potential for hallucinations? A) Engage the patient in a process of health education. B) Administer opioid analgesics as ordered. C) Place the patient in a private, well-lit room. D) Provide television or a radio as therapeutic distraction

Ans: C Feedback: The patient should be placed in a quiet single room with lights on and in a calm nonstressful environment. TV and radio stimulation should be avoided. Analgesics are not normally necessary, and would potentially contribute to hallucinations. Health education would be inappropriate while the patient is experiencing acute withdrawal.

20. A patient with a fractured femur presenting to the ED exhibits cool, moist skin, increased heart rate, and falling BP. The care team should consider the possibility of what complication of the patients injuries? A) Myocardial infarction B) Hypoglycemia C) Hemorrhage D) Peritonitis

Ans: C Feedback: The signs and symptoms the patient is experiencing suggest a volume deficit from an internal bleed. That the symptoms follow an acute injury suggests hemorrhage rather than myocardial infarction or hypoglycemia. Peritonitis would be an unlikely result of a femoral fracture.

23. A patient who attempted suicide being treated in the ED is accompanied by his mother, father, and brother. When planning the nursing care of this family, the nurse should perform which of the following action? A) Refer the family to psychiatry in order to provide them with support. B) Explore the causes of the patients suicide attempt with the family. C) Encourage the family to participate in the bedside care of the patient. D) Ensure that the family receives appropriate crisis intervention services.

Ans: D Feedback: It is essential that family crisis intervention services are available for families of ED patients. It would be inappropriate and insensitive to explore causes of the patients suicide attempt with the family. Family participation in bedside care is often impractical in the ED setting. Psychiatry is not the normal source of psychosocial support and crisis intervention.

33. A nurse is caring for a patient who has been the victim of sexual assault. The nurse documents that the patient appears to be in a state of shock, verbalizing fear, guilt, and humiliation. What phase of rape trauma syndrome is this patient most likely experiencing? A) Reorganization phase B) Denial phase C) Heightened anxiety phase D) Acute disorganization phase

Ans: D Feedback: The acute disorganization phase may manifest as an expressed state in which shock, disbelief, fear, guilt, humiliation, anger, and other such emotions are encountered. These varied responses to the assault are not associated with a denial, heightened anxiety, or reorganization phase.

30. The nurse is preparing to admit patients who have been the victim of a blast injury. The nurse should expect to treat a large number of patients who have experienced what type of injury? A) Chemical burns B) Spinal cord injury C) Meningeal tears D) Tympanic membrane rupture

Ans: D Feedback: Tympanic membrane (TM) rupture is the most frequent injury after subjection to a pressure wave resulting from a blast injury because the TM is the bodys most sensitive organ to pressure. In most cases, other injuries such as meningeal tears, spinal cord injury, and chemical injuries are likely to be less common.

26. A patient has been brought to the ED after suffering genitourinary trauma in an assault. Initial assessment reveals that the patients bladder is distended. What is the nurses most appropriate action? A) Withhold fluids from the patient. B) Perform intermittent urinary catheterization. C) Insert a narrow-gauge indwelling urinary catheter. D) Await orders following the urologists assessment.

Ans: D Feedback: Urethral catheter insertion when a possible urethral injury is present is contraindicated; a urology consultation and further evaluation of the urethra are required. The nurse would withhold fluids, but urologic assessment is the priority.

16. A patient is brought to the ER in an unconscious state. The physician notes that the patient is in need of emergency surgery. No family members are present, and the patient does not have identification. What action by the nurse is most important regarding consent for treatment? A) Ask the social worker to come and sign the consent. B) Contact the police to obtain the patients identity. C) Obtain a court order to treat the patient. D) Clearly document LOC and health status on the patients chart.

Ans: D Feedback: When patients are unconscious and in critical condition, the condition and situation should be documented to administer treatment quickly and timely when no consent can be obtained by usual routes. A social worker is not asked to sign the consent. Finding the patients identity is not a priority. Obtaining a court order would take too long.

The nurse is directing the care of a newly admitted client who is severely hypothermic. What does the nurse advise the rapid response team (RRT) to do first? Apply electrocardiographic (ECG) monitor leads to monitor cardiac activity. Draw blood samples to rule out coagulation problems. Insert a nasogastric tube for rewarming purposes. Obtain intravenous (IV) access to provide fluids and administer drugs.

Apply electrocardiographic (ECG) monitor leads to monitor cardiac activity. **The nurse will advise the RRT to first place ECG leads on the client in order to monitor cardiac activity. People who are hypothermic are at risk for lethal cardiac dysrhythmias and need continual monitoring.Samples for laboratory testing and IV access would be implemented rapidly. Medications may not be effective until a client is normothermic, however warmed fluids may be administered to hasten the process. The same is true of inserting a nasogastric (NG) or orogastric (OG) tube as a means to rewarm the client.

The nurse received a patient from a motor vehicle accident who is hemorrhaging from a femoral wound. What is the initial nursing action for the control of the hemorrhage? a) Immobilize the area to control blood loss. b) Elevate the injured part. c) Apply firm pressure over the involved area or artery. d) Apply a tourniquet.

Apply firm pressure over the involved area or artery. Direct, firm pressure is applied over the bleeding area or the involved artery at a site that is proximal to the wound (Fig. 72-3). Most bleeding can be stopped or at least controlled by application of direct pressure. Otherwise, unchecked arterial bleeding results in death. A firm pressure dressing is applied, and the injured part is elevated to stop venous and capillary bleeding, if possible. If the injured area is an extremity, the extremity is immobilized to control blood loss. A tourniquet is applied to an extremity only as a last resort when the external hemorrhage cannot be controlled in any other way and immediate surgery is not feasible.

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? a) Establishing a patent airway b) Assessing neurologic function c) Applying electrocardiogram electrodes d) Providing adequate ventilation

Applying electrocardiogram electrodes A secondary survey is completed after the primary survey priorities of airway, breathing, circulation, and disability have been addressed. Applying electrocardiogram electrodes would be a component of the secondary survey. Establishing a patent airway, providing adequate ventilation, and determining neurologic disability by assessing neurologic function are components of the primary survey.

After inserting an oropharyngeal airway, the nurse determines that it is in the proper position when the flange is located at which position? a) Just below the tip of the patient's nose b) At the level of the patient's epiglottis c) Directly in front of the patient's teeth d) Approximately at the patient's lips

Approximately at the patient's lips When an oropharyngeal airway is properly inserted, the tip is in the hypopharynx and the flange is approximately at the patient's lips.

A client comes into the emergency department (ED) clutching the chest. Which core competency for ED nurses is the first one used in this situation? Assessment Communication Priority setting Technical and procedural skills

Assessment The first core competency that is essential in this situation is assessment and is the foundation of the ED nurse's skill base to determine normal from abnormal client findings.Communication, priority setting, and technical and procedural skills are not the first competencies to be used in this situation. Until the client has been accurately assessed, care can begin.

A client is being treated for cyanide exposure. The nurse would least likely expect which agent to be used as part of the client's treatment? a) Sodium nitrite b) Sodium thiosulfate c) Amyl nitrate d) Atropine

Atropine Cyanide exposure is treated with amyl nitrate, sodium nitrite, and sodium thiosulfate. Atropine is used for nerve agent exposure.

A client with depression and behavioral changes is transferred from a local assisted living center to the emergency department. The nurse notes that the client cries out when she approaches. When the nurse gains the client's confidence and performs an assessment, the nurse notes bruising of the labia and a lateral laceration in the perineal area. When the nurse asks the client about the injury, the client shakes her head and begins to cry "don't tell, don't tell." The nurse suspects sexual abuse. How should the nurse proceed? a) Notify the rape crisis team. b) Notify the client's family. c) Notify the physician of her findings immediately. d) Attend to the client's physiological needs.

Attend to the client's physiological needs. The nurse should attend to the client's immediate physiological needs, including physical safety. Next, the nurse can notify the physician and the rape crisis team. The family should be notified if the client consents, but not until the rape investigation is complete.

After receiving a change-of-shift report, the client with which condition would be assessed by the emergency department (ED) nurse first? Bee sting on the jawline with an inability to swallow Bite on the hand from a stray dog with minimal bleeding Severe muscle cramps after running Suspected spider bite with a red and swollen forearm

Bee sting on the jawline with an inability to swallow The nurse would first assess the client who was stung by a bee and is unable to swallow. This client is showing potential signs of respiratory compromise and needs immediate assessment and intervention.Neither the client with the spider bite nor the dog bite client have life-threatening injuries. The current tetanus immunization status would be checked for each client and administered if needed. The client bitten by the dog might also require rabies vaccination follow-up. The client with muscle cramping after running would need to be assessed thoroughly for the potential of heat-related injury although this does not appear to be a life threat at this time.

A client with a gunshot wound is admitted to the emergency department (ED). Which minimum Standard Precaution activity does the nurse require for staff safety? Blood and body fluid precautions Metal detector screening of the client Placement of a security guard Use of a positive air-purifying respirator (PAPR)

Blood and body fluid precautions The ED nurse uses Standard Precautions at all times when there is the potential for contamination by blood or other body fluids.Screening of the client with a metal detector, appointing a security guard, and use of a PAPR, although beneficial are not minimum Standard Precautions issues.

A patient was suspected of being in direct contact with anthrax but is exhibiting no signs or symptoms. What type of prophylaxis does the nurse know this patient will have to take? a) Erythromycin for 2 weeks b) Rocephin (Ceftriaxone) IV for 7 days c) Penicillin G IM for 1 dose d) Ciprofloxacin (Cipro) for 60 days

Ciprofloxacin (Cipro) for 60 days At present, anthrax is penicillin sensitive; however, strains of penicillin-resistant anthrax are thought to exist. Recommended treatment includes penicillin ( Penicillin V), erythromycin (Erythrocin), gentamicin ( Garamycin), or doxycycline (Vibramycin). If antibiotic treatment begins within 24 hours after exposure, death can be prevented. In a mass casualty situation, treatment with ciprofloxacin (Cipro) or doxycycline is recommended, because these easily administered oral antibiotic agents are stockpiled and there should be sufficient dosages to fully treat many anthrax-exposed patients.

When assessing a client with suspected carbon monoxide poisoning, which finding would be least reliable? a) Headache b) Palpitations c) Confusion d) Cherry red skin color

Cherry red skin color Skin color can range from pink or cherry-red to cyanotic and pale is not a reliable sign. In clients with carbon monoxide poisoning, central nervous system signs such as headache and confusion predominate. Palpitations also may occur.

Emergency Medical Services arrives at the scene of an automobile crash. On primary assessment, the driver is found to be unresponsive, not breathing, and has a grossly deformed left leg with no pulse. What is the first resuscitation intervention to be performed? Carry out artificial respirations. Clear the airway. Place a cervical collar. Realign the leg and check for pulse.

Clear the airway. The airway should first be cleared of any secretions or debris with a suction catheter or manually, if necessary. The primary survey for a trauma client is based on the mnemonic "ABCDE", with "A" being airway.A cervical collar will need to be applied and respiration will need to be assisted with a bag-valve-mask (BVM) connected to 100% oxygen source. Although the leg does not have a pulse, life threats must be addressed before limb threats.

The emergency department charge nurse is making client assignments and delegating care after a mass casualty event. Which of these clients could be delegated to an unlicensed assistive personnel (UAP)? Client who has multiple left rib fractures and reports dyspnea Client who reports severe left anterior chest pain Client who has a femoral fracture with palpable distal pulses Client who is unconscious with massive aortic bleeding from the chest

Client who is unconscious with massive aortic bleeding from the chest The client who is unconscious and has massive aortic bleeding is unlikely to survive and would be "black-tagged" and assigned to a UAP for comfort.The client with rib fractures and dyspnea, the client with chest pain, and the client with a femoral fracture with palpable pulses are likely to survive and would not be delegated to licensed staff members.

A client from a local care facility has sustained a cardiac arrest in the emergency department (ED), and resuscitation was unsuccessful. The client's family wishes to view the body. What steps should the ED nurse take? Select all that apply. Remove all lines and indwelling tubes. Cover the client with a sheet, leaving the face exposed. Call a chaplain or social worker to accompany the family. Tell the family that the client "is in a better place now." Dim the lights in the client's room.

Cover the client with a sheet, leaving the face exposed. Dim the lights in the client's room. Covering the client with a sheet, leaving the face exposed, and dimming the lights in the client's room are steps the ED nurse would take prior to the viewing. Sometimes by leaving the hands out from underneath the sheet it allows the family more "permission" to touch the client if they desire. The nurse's response needs to be one of empathy and dignity in all interactions.This death may be reportable as a medical examiner's case therefore, IV lines and tubes may need to be maintained. The nurse may ask the family if they want a chaplain or social worker. Statements to the effect that the client "is in a better place now" are inappropriate.

The nurse is caring for a victim of a chemical disaster. Medications given in the treatment of this client include amyl nitrate, sodium nitrate, and sodium thiosulfate. What chemical agent does the nurse know this client has been exposed to? a) Sarin b) Mustard gas c) Cyanide d) Anthrax

Cyanide They administer one or all of the following antidotes: amyl nitrate, sodium nitrate, and sodium thiosulfate. Amyl nitrate promotes the formation of methemoglobin, which combines with cyanide to form nontoxic cyanmethemoglobin. Therefore, options A, B, and D are incorrect.

Which triage category would a patient that requires simple first aid or basic primary care? a) Fast track b) Nonurgent c) Urgent d) Emergent

Fast track Fast track patients require simple first aid or basic primary care and may be treated in the ED or safely referred to a clinic or physician's office. Urgent patients have serious health problems that are not immediately life threatening. They must be seen within 1 hour. Emergent patients have the highest priority, their conditions are life threatening and they must be seen immediately. Nonurgent patients have episodic illness that can be addressed within 24 hours without increased morbidity.

When describing the use of smallpox as a biologic agent, which of the following would the nurse include as the primary means of infection? a) Percutaneous absorption b) Inhalation c) Ingestion d) Direct contact

Direct contact Smallpox is extremely contagious and infection occurs by direct contact, contact with clothing or linens, or droplets from person to person only after the fever has decreased and the rash phase has begun. Anthrax occurs via inhalation, skin contact, or gastrointestinal ingestion. Nerve agents can be precutaneously absorbed.

You are caring for radiation victims. What is the most important factor that you should consider to assess a client's chance of survival in acute radiation syndrome (ARS)?

Dosage of gamma radiation pg. 2167

You are caring for radiation victims. What is the most important factor that you should consider to assess a client's chance of survival in acute radiation syndrome (ARS)?

Dosage of gamma radiation pg. 2168

Which of the following triage categories refers to life-threatening or potentially life-threatening injury or illness requiring immediate treatment? a) Emergent b) Nonacute c) Immediate d) Urgent

Emergent The patient triaged as emergent must be seen immediately. The triage category of urgent refers to minor illness or injury needing first-aid-level treatment. The triage category of immediate refers to non-acute, non-life threatening injury or illness.

Which of the following triage categories refers to life-threatening or potentially life-threatening injury or illness requiring immediate treatment? a) Nonacute b) Immediate c) Urgent d) Emergent

Emergent The patient triaged as emergent must be seen immediately. The triage category of urgent refers to minor illness or injury needing first-aid-level treatment. The triage category of immediate refers to non-acute, non-life threatening injury or illness.

While on the school playground, a child is stung by a bee, resulting in redness and swelling. The school nurse is nearby when it happens. What does the nurse do first? Apply an ice pack to the stinger. Gently scrape out the stinger with a credit card. Inject the child with an epinephrine pen (EpiPen auto-injector). Remove the bee and save it for identification.

Gently scrape out the stinger with a credit card. The nurse first needs to quickly remove the stinger by gently scraping or brushing it off with the edge of a knife blade, credit card, or needle.Once the stinger is removed, applying an ice pack to the area may decrease the pain in the area as well as venom distribution. Unless the child has had an allergic reaction in the past, an epinephrine pen would not be used. The bee does not need to be saved for identification.

A patient is brought to the emergency department after being locked outside of her house in the frigid weather for several hours. The nurse suspects that the patient has sustained frostbite of her hand based on which of the following findings? a) Hand that is firm to palpation b) Hand that is insensitive to touch c) Hand that is cool with pale nailbeds d) Hand that appears pink with some white spotting

Hand that is insensitive to touch Indicators of frostbite include an extremity that is hard, cold, and insensitive to touch and appears white or mottled blue-white.

Question: A nurse is providing initial first-aid care to a patient who was bitten by a snake. Place the following actions in the order in which the nurse would perform them. Use all options. 1. Provide warmth 2. Remove constricting clothing 3. Immobilize the injury below the level of the heart 4. Clean the wound 5. Have the patient lie down 6. Cover the wound with a light sterile dressing

Have the patient lie down Remove constricting clothing Provide warmth Clean the wound Cover the wound with a light sterile dressing Immobilize the injury below the level of the heart Initial first aid for a snake bite includes having the person lie down, removing constrictive items, providing warmth, cleaning the wound, covering the wound with a light and sterile dressing, and immobilizing the injured body part below the level of the heart.

A nurse is working as a camp nurse during the summer. A camp counselor comes to the clinic after receiving a snakebite on the arm. What is the first action by the nurse? a) Make an incision and suck the venom out. b) Have the patient lie down and place the arm below the level of the heart. c) Apply ice to the area. d) Apply a tourniquet to the arm above the bite.

Have the patient lie down and place the arm below the level of the heart. Initial first aid at the site of the snakebite includes having the person lie down, removing constrictive items such as rings, providing warmth, cleansing the wound, covering the wound with a light sterile dressing, and immobilizing the injured body part below the level of the heart. Airway, breathing, and circulation are the priorities of care. Ice, incision and suction, or a tourniquet is not applied.

The nurse is caring for a client who was admitted after a diving accident in a lake. Which task is appropriate to delegate to an experienced unlicensed assistive personnel (UAP)? Assessing the client's lung sounds and neurologic status Drawing arterial blood gases (ABGs) and phoning results to the health care provider Helping to maintain cervical spine stability during transfer to a stretcher Notifying the flight team of a possible transfer

Helping to maintain cervical spine stability during transfer to a stretcher Transferring and positioning clients is included in a UAP's education and scope of practice. An experienced UAP would be able to help with maintenance of cervical spine stability while under the supervision of licensed nursing staff.Nursing activities such as making assessments, arranging for client transfers, and communicating laboratory results to the health care provider require broader education and scope of practice and must be done by an RN. The actual drawing of ABGs is usually done by a respiratory therapist.

A client comes to the emergency department with a suspected airway obstruction. The emergency department team prepares to manage the client as if he has a complete airway obstruction based on which of the following? a) Refusal to lie flat b) Forceful coughing c) High-pitched noise on inhalation d) Wheezing between coughs

High-pitched noise on inhalation A client who demonstrates a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis should be managed as if he or she has a complete airway obstruction. Forceful coughing, wheezing between coughs, and a refusal to lie flat suggest a partial airway obstruction that can be managed as such.

A nuclear reactor overheated, releasing radiation throughout the plant. A worker close to reactor received at least 800 rads and has had an onset of vomiting, bloody diarrhea, and, when brought to the hospital, was in shock. What is this patient's predicted survival? a) Possible b) Probable c) Improbable d) Likely

Improbable Improbable survivors have received more than 800 rad of total-body penetrating irradiation. People in this group demonstrate an acute onset of vomiting, bloody diarrhea, and shock. Any neurologic symptoms suggest a lethal dose of radiation (CDC, 2006). Possible survivors present with nausea and vomiting that persist for 24 to 48 hours. Probable survivors have either no initial symptoms or only minimal symptoms (e.g., nausea and vomiting), or these symptoms resolve within a few hours. "Likely" is not a survival category.

A patient who has accidentally ingested toilet bowel cleaner is brought to the emergency department. Which action would NOT be appropriate for the nurse to implement? a) Administration of activated charcoal b) Dilution with water or milk c) Induced vomiting d) Gastric lavage

Induced vomiting Vomiting is never induced after ingestion of caustic substances (acid or alkaline) such as toilet bowl cleaner because the substance is corrosive to the tissues. Appropriate actions include dilution with milk or water, gastric lavage, and administration of activated charcoal.

A patient who has accidentally ingested toilet bowel cleaner is brought to the emergency department. Which action would NOT be appropriate for the nurse to implement? a) Dilution with water or milk b) Administration of activated charcoal c) Induced vomiting d) Gastric lavage

Induced vomiting Vomiting is never induced after ingestion of caustic substances (acid or alkaline) such as toilet bowl cleaner because the substance is corrosive to the tissues. Appropriate actions include dilution with milk or water, gastric lavage, and administration of activated charcoal.

A 2-year-old child falls into the community swimming pool and does not resurface. A lifeguard dives in to save the child. What does the lifeguard do first after the rescue? Initiates rescue breathing on the child Rapidly rewarms the child Removes water from the child's lungs Stabilizes the child's spine

Initiates rescue breathing on the child The first action by the lifeguard would be to initiate rescue breathing on the child. Airway clearance and ventilatory support measures must be started as soon as possible.There is no indication this child was exposed to cold water, however any water exposure can pose the risk of hypothermia in a small child. No attempt would be made to remove water from the lungs. Spinal cord injury would always be considered in a water-related emergency. However, it is not likely in this scenario.

The nurse is instructing volunteers at an emergency bioterrorism drill about the management and medications required to combat various viruses, bacteria, and toxins. The nurse knows that the volunteers understand the instruction when they see that managing patients who exhibit symptoms of the variola virus (smallpox) includes which of the following? a) Isolation b) Radiation c) Decontamination d) Acyclovir

Isolation Smallpox is spread by droplet or direct contact and spreads rapidly. Patients exhibiting symptoms should be immediately placed in isolation.

A nurse is completing her annual cardiopulmonary resuscitation training. The class instructor tells her that a client has fallen off a ladder and is lying on his back; he is unconscious and isn't breathing. What maneuver should the nurse use to open his airway? a) Head tilt-chin lift b) Abdominal thrust c) Seldinger d) Jaw-thrust

Jaw-thrust If a neck or spine injury is suspected, the jaw-thrust maneuver should be used to open the client's airway. To perform this maneuver, the nurse should position herself at the client's head and rest her thumbs on his lower jaw, near the corners of his mouth. She should then grasp the angles of his lower jaw with her fingers and lift the jaw forward. The head tilt-chin lift maneuver is used to open the airway when a neck or spine injury isn't suspected. To perform this maneuver the nurse places two fingers on the chin and lifts while pushing down on the forehead with the other hand. The abdominal thrust is used to relieve severe or complete airway obstruction caused by a foreign body. The Seldinger maneuver is a method of percutaneous introduction of a catheter into a vessel.

Which of the following solutions should the nurse anticipate for fluid replacement in the male patient? a) Lactated Ringer's solution b) Hypertonic saline c) Type O negative blood d) Dextrose 5% in water

Lactated Ringer's solution Replacement fluids may include isotonic electrolyte solutions and blood component therapy. O negative blood is prepared for emergency use in women of childbearing age.Dextrose 5% in water should not be used to replace fluids in hypovolemic patients. Hypertonic saline is used only to treat severe symptomatic hyponatremia and should be used only in intensive care units.

An air medical helicopter arrives on the scene of a high-speed motorcycle collision with a train. The client was not wearing a helmet and is very confused, with a Glasgow Coma Scale score of 13. There is an apparent partial amputation of both hands. Vital signs are stable and the airway is secure. Which level of trauma center would be the most appropriate destination for this client? Level I Level II Level III Level IV

Level I A Level I Trauma Center would be most appropriate to handle the complex level of care required by this client with a potential traumatic brain injury and apparent partial amputation of both hands. A Level I Trauma Center is a regional resource facility that provides leadership and collaborative care for every type of injury.Since the airway is secure and the vital signs are stable, there is no need to stop at a Level II, II or IV Trauma Center for stabilization. This client would require initial transfer to a Level I facility for likely surgery and rehabilitation in this situation.

A client presents to a clinic stating, "I got bit by something cleaning out the shed." On assessment, the nurse notices a bite mark with a bluish-purple center on the client's posterior calf. What treatment would the nurse anticipate as first line care? Application of ice to bite Elevation of affected extremity Initiation of transfer to trauma center Localized wound care

Localized wound care The nurse would anticipate localized wound care as first line care for this client. A brown recluse spider bite is characterized by a wound that develops a bluish-purple center. Since the bite has already developed a dark center, this type of wound care needs to be initiated as soon as possible.Although cold compresses are beneficial initially, applying ice directly to a wound would potentially cause more tissue damage. Elevation of the extremity is more beneficial in the early stages immediately after the bite. This client does not require transfer to a trauma center for surgical intervention at this time, although the bite must be monitored for further tissue destruction and the need for debridement.

A hiker begins to feel ill within 48 hours after arriving at a resort in Colorado. Symptoms include poor activity tolerance, tachycardia, tachypnea, and a dry cough. Which treatment provides the most effective relief for this hiker? Acetazolamide sodium (Diamox) Dexamethasone (Decadron) Lower altitude Oxygen therapy

Lower altitude The most effective intervention to manage serious altitude-related illness is gradual descent to a lower altitude.Diamox needs to be taken before and during the trip for prevention, but will not help after symptoms of altitude-related illness have begun. Decadron can be administered during descent to help with symptoms, but is not the most effective treatment at this time. Oxygen is not the most effective treatment.

A soldier is preparing to enter an area in which there is a high risk for chemical exposure to a nerve agent. What should the soldier be given prior to entering this area? a) Mark I automatic injectors that contain 2 mg atropine and 600 mg pralidoxime chloride b) Mark I automatic injector filled with morphine 10 mg c) Mark I automatic injectors that contain an antiseizure medication such as carbamazepine d) Mark I automatic injector filled with cyanide

Mark I automatic injectors that contain 2 mg atropine and 600 mg pralidoxime chloride Military personnel believed to be at risk for chemical attack are provided with Mark I automatic injectors, which contain 2 mg atropine and 600 mg pralidoxime chloride. Diazepam may be administered by a partner.

The nurse is administering antivenin to a patient who was bitten on the arm by a poisonous snake. What intervention provided by the nurse is required prior to the procedure and every 15 minutes after? a) Assess peripheral pulses. b) Administer cimetidine (Tagamet). c) Administer diphenhydramine (Benadryl). d) Measure the circumference of the arm.

Measure the circumference of the arm. Before administering antivenin and every 15 minutes thereafter, the circumference of the affected part is measured. Premedication with diphenhydramine (Benadryl) or cimetidine (Tagamet) may be indicated, because these antihistamines may decrease the allergic response to antivenin. Antivenin is administered as an IV infusion whenever possible, although intramuscular administration can be used.

During a disaster, the nurse sees a victim with a green triage tag. The nurse knows that the person has which type of injuries? a) Minor and treatment can be delayed hours to days b) Significant and require medical care, but can wait hours without threat to life or limb c) Life-threatening but survivable with minimal intervention d) Extensive and chances of survival are unlikely even with definitive care

Minor and treatment can be delayed hours to days A green triage tag (priority 3 or minimal) indicates injuries that are minor and treatment can be delayed hours to days. A red triage tag (priority 1 or immediate) indicates injuries that are life threatening but survivable with minimal intervention. A yellow triage tag (priority 2 or delayed) indicates injuries that are significant and require medical care, but can wait hours without threat to life or limb. A black triage tag (priority 4 or expectant) indicates injuries that are extensive and chances of survival are unlikely even with definitive care.

During a disaster, the nurse sees a victim with a green triage tag. The nurse knows that the person has which type of injury?

Minor; treatment can be delayed hours to days pg. 2156

A client is admitted to the emergency department after being in a motor vehicle crash. The client was wearing a seat belt and the airbag deployed. There are no apparent injuries besides an abrasion from the shoulder harness across the clavicle and anterior chest. First vital signs are BP 110/70, HR 98, R 18, SaO2 98% on room air. The client's Glasgow Coma Scale score is 15. What does the nurse do next? Allows the client to go home Checks blood alcohol levels Prepares the client for surgery Monitors the client

Monitors the client Blunt force injuries are from acceleration/deceleration forces, and can cause trauma to bones, blood vessels, and soft tissue. An injury may not be evident right away. A seat belt abrasion across the chest would alert the nurse to monitor closely for signs of potential internal injuries.While the nurse is monitoring the client, routine labs, including blood alcohol levels, may be obtained as well as computerized tomography (CT) scans. Based on these results, a decision regarding disposition will be made. Allowing the client to go home or preparing for surgery are not appropriate actions in this situation.

What is the main role of the incident commander in a disaster? Call in extra staff Contact other facilities to arrange transfers Oversee the movement of clients through the system Notify the media of hospital capacity

Oversee the movement of clients through the system The main role of the incident commander in a disaster is to oversee the movement of clients through the system and assist in the organization of hospital-wide services. This activity rapidly expands hospital capacity, recruits paid or volunteer staff, and ensures the availability of medical supplies.

A golfer who is caught in a thunderstorm is struck by lightning. A fellow golfer, who is a nurse, runs to the victim's aid. What does the nurse do initially? Apply a dressing over the skin burn where the lightning entered. Instruct everyone to not to touch the victim to avoid being hurt. Immediately begin cardiopulmonary resuscitation. Palpate to check for the presence of a pulse.

Palpate to check for the presence of a pulse. Initially, the nurse would palpate to check for the presence of a pulse.The most lethal initial effect of the massive current discharge of lightning on the cardiopulmonary system is cardiac arrest.If the client does not have a pulse, CPR will be started utilizing BLS protocols. The golfer is not electrically charged so he/she is not a danger to anyone else. The skin burn can be dressed when everyone is in a safe location from further lightning strikes.

The nursing instructor is talking with the students about botulism. The instructor tells the students that when caring for a client with botulism, what condition is most likely to cause death? a) Dysarthria b) Paralysis of respiratory muscles c) Dysphagia d) Diplopia

Paralysis of respiratory muscles In botulism, paralysis of respiratory muscles poses the greatest potential for lethality. Diplopia (double vision), dysarthria (difficulty in speaking), and dysphagia (difficulty in swallowing) are all early signs of botulism.

A client, contaminated following exposure to radiation, is brought to the hospital for assessment. Which nursing action is essential? a) Refer the client to the triage area. b) Place the client in strict isolation. c) Obtain vital signs and lab work. d) Assess the client for respiratory concerns.

Place the client in strict isolation. It is important for the nurse to realize that a contaminated person can contaminate others through contact with body fluids or surfaces which he or she touches. Upon arrival to the hospital, the client is placed in strict isolation to minimize the exposure of others. The client will then have vital signs and a complete assessment.

The nurse is triaging patients from a 10-car pile-up on the interstate and assesses a patient with a sucking chest wound. What category should this patient be placed in? a) Priority 3 b) Priority 4 c) Priority 2 d) Priority 1

Priority 1 Triage category "Immediate" is priority 1 (red) and includes injuries that are life threatening but survivable with minimal intervention, such as sucking chest wound, airway obstruction secondary to mechanical cause, and shock.

A patient is admitted to the ED after a near-drowning accident. The patient is diagnosed with saltwater aspiration. The nurse will observe the patient for several hours to monitor for symptoms of which of the following? a) Head injury b) Hyponatremia c) Hypothermia d) Pulmonary edema

Pulmonary edema Resultant pathophysiologic changes and pulmonary injury depend on the type of fluid (fresh or salt water) and the volume aspirated. Freshwater aspiration results in a loss of surfactant and, therefore, an inability to expand the lungs. Saltwater aspiration leads to pulmonary edema from the osmotic effects of the salt within the lungs. If a person survives submersion, acute respiratory distress syndrome (ARDS), resulting in hypoxia, hypercarbia, and respiratory or metabolic acidosis, can occur. The patient would experience hypernatremia. Hypothermia and head injury may be associated with near drowning, but would be apparent at the time of admission and would not develop after several hours.

Homeland Security has alerted the disaster response teams in your region of a potential terrorist attack in the form of a nuclear blast. You are a part of the disaster response system and you know that with a nuclear blast you would need to be prepared for what classification of disaster? a) Biologic b) Radiologic c) Manmade d) Chemical

Radiologic Radiologic disasters can occur in the following ways: Explosion of a dirty bomb; Damage to or human error in a nuclear power plant facility; Nuclear blast.

Homeland Security has alerted the disaster response teams in your region of a potential terrorist attack in the form of a nuclear blast. You are a part of the disaster response system and you know that with a nuclear blast you would need to be prepared for what classification of disaster? a) Radiologic b) Manmade c) Chemical d) Biologic

Radiologic Radiologic disasters can occur in the following ways: Explosion of a dirty bomb; Damage to or human error in a nuclear power plant facility; Nuclear blast.

You are a nurse caring for clients in the emergency department who have been admitted from the area surrounding a nuclear power plant. There had been a small explosion at the plant and a small amount of radiation had escaped. You know that this is what type of a disaster? a) Explosive b) Natural c) Chemical d) Radiologic

Radiologic Radiologic disasters can occur in the following ways: Explosion of a dirty bomb; Damage to or human error in a nuclear power plant facility; Nuclear blast. The scenario does not describe a natural disaster or a chemical disaster. Option B is only a distractor.

The NATO triage system uses color-coded tagging to identify severity of injuries. A patient with survivable but life-threatening injuries (i.e., incomplete amputation) would be tagged with which color? a) Yellow b) Red c) Black d) Green

Red Triage category "Immediate" is coded red and includes injuries that are life threatening but survivable with minimal intervention, such as an incomplete amputation.

A nurse volunteers to help decontaminate a victim. Which of the following is the first action that the nurse should take? a) Dressing victim in personal protective equipment b) Applying chemical decontamination foam to area c) Washing victim with soap and water and rinsing d) Removing victim's clothing and jewelry

Removing victim's clothing and jewelry To be effective, decontamination must include a minimum of two steps. The first step is removing the patient's clothing and jewelry and then rinsing the patient with water. The second step consists of a thorough soap and water wash and rinse.

A home health nurse is visiting a 74-year-old client with Alzheimer's disease. During the visit, the nurse notes bruising on the client's upper arms, and the client is more withdrawn than normal. The client is unable to communicate effectively because of his disease progression. The nurse suspects elder abuse. What is the nurse's responsibility in this situation? a) Do nothing because the nurse has no proof of wrongdoing. b) Report the suspicion to the local agency on aging within 24 hours of the visit. c) Try to convince the client to report the problem. d) Monitor the situation during subsequent visits.

Report the suspicion to the local agency on aging within 24 hours of the visit. The nurse must report the suspicion to the local agency on aging within 24 hours of the visit. Doing nothing and monitoring the situation during subsequent visits go against the nurse's legal and professional obligation, which is to report suspected abuse when it occurs. The client's disease process prevents him from reporting the problem.

A nurse is establishing a patient's airway. Which action would the nurse perform first? a) Using the jaw-thrust maneuver b) Inserting an artificial airway c) Giving abdominal thrusts d) Repositioning the patient's head

Repositioning the patient's head Establishing an airway may be as simple as repositioning the patient's head to prevent the tongue from obstructing the pharynx. Subsequent measures would include abdominal thrusts to dislodge a foreign body, head-tilt chin-lift or jaw-thrust manuever, or insertion of an artificial airway.

The nurse is caring for a client exposed to a blistering agent. While the nurse is quickly decontaminating the client by showering and bagging all client clothing, what is the nurse simultaneously assessing for? a) Sensory neglect b) Respiratory compromise c) Cardiovascular compromise d) Neurological compromise

Respiratory compromise A person exposed to a blistering agent or vesicant must be decontaminated immediately, with clothing removed and bagged. Irrigation of the victim's eyes and application of topical analgesia, antibiotics, and lubricants to the skin occur. Simultaneously, the nurse is assessing the respiratory system for airway obstruction because blisters from inhaled toxics can swell obstructing respiratory passages.

An adolescent is brought to the ED after a vehicular accident and is pronounced dead on arrival (DOA). When the parents arrive at the hospital, what is the priority action by the nurse? a) Ask them to sit in the waiting room until she can spend time alone with them. b) Speak to one parent at a time in a private setting so that each can ventilate feelings of loss without upsetting the other. c) Speak to both parents together and encourage them to support each other and express their emotions freely. d) Ask the emergency physician to medicate the parents so that they can handle their child's unexpected death quietly and without hysteria.

Speak to both parents together and encourage them to support each other and express their emotions freely. The nurse should take the family to a private place and talk to the family together so that they can grieve together and hear the information given together. The nurse should Encourage family members to support each other and to express emotions freely (grief, loss, anger, helplessness, tears, disbelief). The nurse should avoid giving sedation to family members; this may mask or delay the grieving process, which is necessary to achieve emotional equilibrium and to prevent prolonged depression.

A patient was bitten by a tick 3 months ago and is now having muscle aches as well as joint pain and swelling. The patient is having difficulty with self care and requires assistance with activities of daily living (ADLs). What stage of Lyme disease does the nurse recognize the patient is in? a) Stage IV b) Stage II c) Stage I d) Stage III

Stage III Lyme disease has three stages. Stage I presents with a classic "bull's-eye" rash (i.e., erythema migrans) and flulike signs and symptoms that may include chills, fever, myalgia, fatigue, and headache. If antibiotics are not administered, stage II Lyme disease may present within 4 to 10 weeks following the tick bite and may manifest with joint pain, memory loss, poor motor coordination, and meningitis. Stage III can begin anywhere from weeks to more than a year after the bite and has serious long-term chronic sequelae, including arthritis, neuropathy, myalgia, and myocarditis.

During a mass casualty, which injury receives care first? Abdominal evisceration Open fracture of the left forearm Sprained ankle Sucking chest wound

Sucking chest wound A sucking chest wound receives care first during a mass casualty. This type of injury is a red tag, or emergent, injury because it can be quickly resolved until further help can be given. Remember the A,B,Cs. Airway, breathing, and circulation always come first.The abdominal evisceration would be considered a black tag because of the amount of time it would require to provide adequate care. The open fracture of the left forearm would be yellow tagged. The injury requires care but can wait. The sprained ankle would be green tagged and considered "walking wounded."

During a mass casualty, staff roles are defined. If the triage officer is incapacitated, who is the best choice for replacement? Communications officer Hospital incident commander Medical command physician Triage nurse

Triage nurse When the triage officer is incapacitated, the triage nurse is the best choice for replacement. When physician resources are limited, an experienced nurse may assume this role.The communications officer serves as the liaison between the health care facility and the media. Typically, the hospital incident commander and the medical command physician are too busy to serve as triage officer as well.

The nurse is triaging victims after an explosion at an oil refinery. One victim complains of tinnitus, dizziness, and otorrhea. For what probable condition should the nurse prepare care? a) Blast lung b) Tympanic rupture c) Head injury d) Abdominal injury

Tympanic rupture The nurse should prepare to care for a patient with probable tympanic rupture. Signs and symptoms of tympanic rupture include hearing loss, tinnitus, pain, dizziness, and otorrhea. Symptoms of blast lung include dyspnea, hypoxia, tachypnea or apnea, cough, chest pain, and hemodynamic instability. Symptoms of head injury include postconcussive syndrome. Symptoms of abdominal injury include pain, guarding, rebound tenderness, rectal bleeding, nausea, and vomiting.

The nurse is triaging victims after an explosion at an oil refinery. One victim reports tinnitus, dizziness, and otorrhea. For what probable condition should the nurse prepare care?

Tympanic rupture pg. 2161

A finger sweep is only to be used in which patient population? a) Child b) Unconscious adult c) Adolescent d) Conscious adult

Unconscious adult A finger sweep should be used only in the unconscious adult patient. This action draws the tongue away from the back of the throat and away from the foreign body that may be lodged there. A finger sweep should not be done on a conscious adult, child, or adolescent.

Which category of triage encompasses patients with serious health problems that are not immediately life threatening? a) Psychological support b) Urgent c) Nonurgent d) Emergent

Urgent Urgent patients have serous health problems that not immediately life threatening. They must be seen within 1 hour. Emergent patients have the highest priority with conditions are life threatening and they must be seen immediately. Nonurgent patients have episodic illness that can be addressed within 24 hours without increased morbidity. Fast track patients require simple first aid or basic primary care and may be treated in the ED or safely referred to a clinic or physician's office.

There has been an explosion at a local refinery. Numerous injuries have occurred. The following clients arrive from the scene by private vehicle. Which client is considered a priority for treatment? Child with an open fracture of the arm Man with a contusion on the head Teenager with a closed fracture of the leg Woman bleeding heavily

Woman bleeding heavily The critically injured woman with active hemorrhage is the emergent priority in this situation. This condition is potentially life threatening.The child with an open fracture of the arm, the man with a contusion of the head, and the teenager with a closed fracture of the leg are urgent and treatment can wait.

The nurse is triaging victims during a mass casualty incident. The nurse uses which color tag for a victim whose care can be delayed? a) Red b) Black c) Yellow d) Green

Yellow A yellow triage tag indicates delayed triage category. A red triage tag indicates immediate injuries. A green triage tag indicates a minimal triage category. Black triage tags indicate expectant injuries that are extensive and chances of survival are unlikely even with definitive care.

The nurse is triaging victims during a mass casualty incident. The nurse uses which color tag for a victim whose care can be delayed? a) Green b) Black c) Red d) Yellow

Yellow A yellow triage tag indicates delayed triage category. A red triage tag indicates immediate injuries. A green triage tag indicates a minimal triage category. Black triage tags indicate expectant injuries that are extensive and chances of survival are unlikely even with definitive care.

Nursing students are reviewing information about endotracheal intubation. They demonstrate understanding of the information when they identify which of the following as a reason for this procedure? Select all that apply. a) Decrease tracheobronchial secretions b) Prevent aspiration into the lungs c) Facilitate removal of an upper airway obstruction d) Establish an airway for ventilation e) Allow connection to a manual resuscitation bag

• Allow connection to a manual resuscitation bag • Prevent aspiration into the lungs • Establish an airway for ventilation Endotracheal intubation is indicated to establish an airway for a patient who cannot be adequately ventilated with an oropharyngeal airway, bypass an upper airway obstruction, prevent aspiration, permit connection to a resuscitation bag or mechanical ventilator, or facilitate removal of tracheobronchial secretions

You are teaching a disaster preparedness workshop at the local community center. Which of the following points would specifically apply to a biologic, chemical, or radiologic disaster? Select all that apply. a) Keep a 7-day supply of medications on hand at all times. b) Avoid drinking water from the faucet. c) Do not consume fresh fruit or vegetables. d) Stock a supply of canned or dried packaged food.

• Avoid drinking water from the faucet. • Do not consume fresh fruit or vegetables. While keeping a supply of medications, dried food, and canned food would be preparation for all types of disasters, clients should be aware that consuming fresh food or drinking local water supplies may be hazardous during a biologic, chemical, or radiologic disaster because they might be contaminated with pathogens, chemicals, or fallout.

A nurse working as part of a disaster response team is triaging clients. Which of the following clients would the nurse color code as green? Select all that apply. a) Client with multiple injuries in profound shock b) Client with a fractured arm c) Client with a sucking chest wound d) Client with a first-degree burn to the forearm e) Unresponsive client with a penetrating head wound

• Client with a first-degree burn to the forearm • Client with a fractured arm In triage, green indicates minor injuries for which treatment can be delayed hours to days. A client with a fractured arm or with a first-degree burn would be triaged green. A client with a sucking chest wound would require immediate care and be triaged red. An unresponsive client with a penetrating head wound or with multiple injuries and in profound shock would be triaged black because the injuries are extensive and chances of survival are unlikely, even with definitive care.

A nurse working as part of a disaster response team is triaging clients. Which of the following clients would the nurse color code as green? Select all that apply. a) Unresponsive client with a penetrating head wound b) Client with a sucking chest wound c) Client with multiple injuries in profound shock d) Client with a first-degree burn to the forearm e) Client with a fractured arm

• Client with a first-degree burn to the forearm • Client with a fractured arm In triage, green indicates minor injuries for which treatment can be delayed hours to days. A client with a fractured arm or with a first-degree burn would be triaged green. A client with a sucking chest wound would require immediate care and be triaged red. An unresponsive client with a penetrating head wound or with multiple injuries and in profound shock would be triaged black because the injuries are extensive and chances of survival are unlikely, even with definitive care.

A patient presents to the ED following a motor vehicle collision. The patient is suspected of having internal hemorrhage. The nurse assesses the patient for signs and symptoms of shock. Signs and symptoms of shock include which of the following? Select all that apply. a) Decreasing blood pressure b) Increasing urine volume c) Increasing heart rate d) Delayed capillary refill e) Cool, moist skin

• Decreasing blood pressure • Cool, moist skin • Increasing heart rate • Delayed capillary refill Signs and symptoms of shock include cool, moist skin (resulting from poor peripheral perfusion), decreasing blood pressure, increasing heart rate, delayed capillary refill, and decreasing urine volume.

Nursing students are reviewing information about endotracheal intubation. They demonstrate understanding of the information when they identify which of the following as a reason for this procedure? Select all that apply. a) Facilitate removal of an upper airway obstruction b) Allow connection to a manual resuscitation bag c) Decrease tracheobronchial secretions d) Establish an airway for ventilation e) Prevent aspiration into the lungs

• Establish an airway for ventilation • Allow connection to a manual resuscitation bag • Prevent aspiration into the lungs Endotracheal intubation is indicated to establish an airway for a patient who cannot be adequately ventilated with an oropharyngeal airway, bypass an upper airway obstruction, prevent aspiration, permit connection to a resuscitation bag or mechanical ventilator, or facilitate removal of tracheobronchial secretions

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. a) Patient with laryngeal edema secondary to anaphylaxis b) Patient with a lumbar spine injury c) Patient with extensive facial trauma d) Patient with an obstructed larynx e) Patient who is bleeding from the chest

• Patient with laryngeal edema secondary to anaphylaxis • Patient with an obstructed larynx • Patient with extensive facial trauma Cricothyroidotomy is used in emergencies when endotracheal intubation is either not possible or contraindicated. Examples include airway obstruction from extensive maxillofacial trauma, cervical spine injury, laryngospasm, laryngeal edema after an allergic reaction or extubation, hemorrhage into neck tissue, and obstruction of the larynx.

A female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing interventions should be provided? (Select all that apply.) a) Record a history of the event, using the patient's own words. b) Ensure that the police are present when the examination is performed. c) Assess and document any bruises and lacerations. d) Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police. e) Have the patient shower or wash the perineal area before the examination.

• Record a history of the event, using the patient's own words. • Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police. • Assess and document any bruises and lacerations. A history is obtained only if the patient has not already talked to a police officer, social worker, or crisis intervention worker. The patient should not be asked to repeat the history. Any history of the event that is obtained should be recorded in the patient's own words. The patient is asked whether he or she has bathed, douched, brushed his or her teeth, changed clothes, urinated, or defecated since the attack, because these actions may alter interpretation of subsequent findings. Each item of clothing is placed in a separate paper bag. The bags are labeled and given to appropriate law enforcement authorities. The patient is examined (from head to toe) for injuries, especially injuries to the head, neck, breasts, thighs, back, and buttocks. The exam focuses on external evidence of trauma (bruises, contusions, lacerations, stab wounds).

7. A provider prescribes a rewarming bath for a client who presents with partial-thickness frostbite. Which action should the nurse take prior to starting this treatment? a. Administer intravenous morphine. b. Wrap the limb with a compression dressing. c. Massage the frostbitten areas. d. Assess the limb for compartment syndrome.

ANS: A Rapid rewarming in a water bath is recommended for all instances of partial-thickness and full-thickness frostbite. Clients experience severe pain during the rewarming process and nurses should administer intravenous analgesics.

22. A client has an intraventricular catheter. What action by the nurse takes priority? a. Document intracranial pressure readings. b. Perform hand hygiene before client care. c. Measure intracranial pressure per hospital policy. d. Teach the client and family about the device.

ANS: B All of the actions are appropriate for this client. However, performing hand hygiene takes priority because it prevents infection, which is a possibly devastating complication. REF: 961

14. A group of medical nurses are being certified in their response to potential bioterrorism. The nurses learn that if a patient is exposed to the smallpox virus he or she becomes contagious at what time? A) 6 to 12 hours after exposure B) When pustules form C) After a rash appears D) When the patient becomes febrile

Ans: C Feedback: A patient is contagious after a rash develops, which initially develops on the face, mouth, pharynx, and forearms. The patient exposed to the smallpox virus is not contagious immediately after exposure; only when pustules form, or with a body temperature of 38C.

7. Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action should the nurse take first? a. Assess that the client is breathing adequately. b. Insert a large-bore intravenous line. c. Place the client on a cardiac monitor. d. Assess for the best neurologic response.

ANS: A The highest-priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he or she may not be breathing, or may be breathing inadequately with the device in place.

2. A client in the emergency department is having a stroke. The client weighs 225 pounds. After the initial bolus of t-Pa, at what rate should the nurse set the IV pump? (Record your answer using a decimal rounded to the nearest tenth.) ____ mL/hr

ANS: 1.4 mL/hr The client weighs 102 kg. The dose of t-PA is 0.9 mg/kg with a maximum of 90 mg, so the client's dose is 90 mg. 10% of the dose is given as a bolus IV over the first minute (9 mg). That leaves 81 mg to run in over 59 minutes. , which rounds to 1.4 mL/hr. REF: 939

1. A client in the emergency department is having a stroke and the provider has prescribed the tissue plasminogen activator (t-PA) alteplase (Activase). The client weighs 146 pounds. How much medication will this client receive? (Record your answer using a whole number.) _____ mg

ANS: 60 mg The dose of t-PA is 0.9 mg/kg with a maximum dose of 90 mg. The client weighs 66.4 kg. 0.9 mg ´ 66.4 = 59.76 mg, which rounds to 60 mg. REF: 939

21. A client has a brain abscess and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best? a. "Increased pressure from the abscess can cause seizures." b. "Preventing febrile seizures with an abscess is important." c. "Seizures always occur in clients with brain abscesses." d. "This drug is used to sedate the client with an abscess."

ANS: A Brain abscesses can lead to seizures as a complication. The nurse should explain this to the spouse. Phenytoin is not used to prevent febrile seizures. Seizures are possible but do not always occur in clients with brain abscesses. This drug is not used for sedation. REF: 955

27. The nurse assesses a client's Glasgow Coma Scale (GCS) score and determines it to be 12 (a 4 in each category). What care should the nurse anticipate for this client? a. Can ambulate independently b. May have trouble swallowing c. Needs frequent re-orientation d. Will need near-total care

ANS: C This client will most likely be confused and need frequent re-orientation. The client may not be able to ambulate at all but should do so independently, not because of mental status. Swallowing is not assessed with the GCS. The client will not need near-total care. REF: 934

17. A patient was exposed to a dose of more than 5,000 rads of radiation during a terrorist attack. The patients skin will eventually show what manifestation? A) Erythema B) Ecchymosis C) Desquamation D) Necrosis

Ans: D Feedback: Necrosis of the skin will become evident within a few days to months at doses of more than 5,000 rads. With 600 to 1,000 rads, erythema will occur; it can disappear within hours and then reappear. At greater than 1,000 rads, desquamation (radiation dermatitis) of the skin will occur. Ecchymosis does not occur.