Exam 2

Which are the most common types of injuries that should be identified along with treatment options in an organizational disaster plan for the use of explosive devices as agents of terrorism? Select all that apply. 1) Burn 2) Blast 3) Crush 4) Penetration 5) Psychological

234

A nurse working in the intensive care unit (ICU) is receiving a patient diagnosed with early septic shock from the emergency department (ED). The nurse will recognize which symptoms associated with this condition? Select all that apply. 1) Shallow respirations 2) Normal blood pressure 3) Warm and flushed skin 4) Lethargic mental status 5) Decreased urine output 6) Rapid and deep respirations

236

A patient is admitted to the intensive care unit with a systemic infection. Which manifestations will the nurse most likely assess in this patient? Select all that apply. 1) Pain 2) Fever 3) Edema 4) Anorexia 5) Tachycardia

245

A patient with cardiomyopathy is scheduled for a biventricular implantable cardioverter defibrillator. What should the nurse include when teaching the patient about this device? Select all that apply. 1) Part of the thickened overgrown septum is removed 2) A pacer wire is placed in the right and left ventricles 3) A small part of the thickened heart muscle is destroyed 4) The automatic defibrillator will deliver a shock if necessary 5) The automatic defibrillator monitors the heart for dysrhythmias

245

The nurse is contributing to a disaster plan for a possible terrorist attack. Which biological agents should be included in the plan? Select all that apply. 1) Rubella 2) Anthrax 3) Measles 4) Botulism 5) Tularemia

245

Which nursing actions are appropriate during the primary survey of the emergency assessment process? Select all that apply. 1) Inserting a nasogastric tube 2) Immobilizing the cervical spine 3) Arranging for diagnostic studies 4) Preparing for chest tube insertion 5) Applying direct pressure to a wound

245

A patient becomes unresponsive without a palpable pulse despite showing bradycardia on the rhythm strip. What action should the nurse take immediately? Select all that apply. 1) Auscultate heart sounds 2) Begin cardiac compressions 3) Adjust cardiac monitor leads 4) Prepare for chest tube insertion 5) Place epinephrine at the bedside

25

A patient has a heart rate of 132 beats per minute. What should the nurse assess to help determine the reason for this rate? Select all that apply. 1) Muscle tone 2) Temperature 3) Urine output 4) Bowel sounds 5) Blood pressure

25

A nurse is developing a plan of care for a patient with traumatic injuries from a motor vehicle crash. Which nursing intervention does the nurse include in the plan of care to reduce the risk of integumentary complications? 1) Provide active or passive exercises at least once every eight hours 2) Encourage coughing, deep breathing, and incentive spirometry 3) Assist the patient in turning at least every two hours 4) Assist the patient in turning at least every eight hours

3

A nurse manager is a member of the emergency response planning team for a hospital located in the Rocky Mountains. Which type of natural disaster will the nurse manager recommend be included in their hospital disaster plan? 1) Tornado 2) Hurricane 3) Avalanche 4) Earthquake

3

A patient asks why cardiac leads are being placed on the chest. What should the nurse respond to this patient? 1) "It shows where the heart vessels are blocked." 2) "It is used to evaluate the effectiveness of dietary changes." 3) "It provides a graphic picture of the heart's electrical activity." 4) "It determines which medications are needed to improve heart function."

3

A patient being treated for hypovolemic shock is prescribed a low dose of dopamine. Which outcome does the nurse anticipate for this patient? 1) Increased cardiac output 2) Stabilization of fluid loss 3) Urinary output of at least 30 mL/hour 4) Vasoconstriction and increased blood pressure

3

A patient develops hypovolemic shock secondary to pancreatitis. Which action by the nurse is most appropriate? 1) Starting an 18-gauge intravenous catheter in the patient's nondominant hand 2) Ordering a type and cross-match of packed red blood cells 3) Preparing to assist with central line placement 4) Inserting a nasogastric tube

3

A patient is admitted for treatment for a low junctional rhythm. Where should the nurse expect to assess the P wave on this patient's electrocardiogram? 1) Prior to the QRS wave 2) Buried within the QRS wave 3) At the tail end of the QRS wave 4) Superimposed over the previous T wave

3

A patient is being cardioverted for symptomatic atrial fibrillation. At which point of the cardiac cycle will the electric impulse occur? 1) At the end of the P wave 2) Before the QRS complex 3) At the peak of the R wave 4) After the QRS complex but before the T wave

3

A patient with a cardiac dysrhythmia is experiencing nausea and vomiting. What is the reason for this to occur? 1) Poor contractile function 2) Altered electrolyte levels 3) Blood shunted away from nonessential organ systems 4) An imbalance in myocardial oxygen supply and demand

3

A patient with atrial fibrillation has a heart rate of 90 beats per minute. Which manifestation should the nurse expect to assess in this patient? 1) Headache 2) Chest pain 3) Palpitations 4) Hypotension

3

A patient with cardiogenic shock has an intra-aortic balloon pump (IABP). What should the nurse include when caring for this patient? 1) Elevated the affected leg on a pillow 2) Elevate the head of the bed 45 degrees 3) Keep the affected leg straight at all times 4) Keep the bed flat with a small pillow under the head

3

A patient with cardiomyopathy asks for salt when the breakfast tray arrives. What should the nurse respond to this request? 1) "I will get some for you." 2) "You should avoid adding salt if at all possible." 3) "Restricting salt helps prevent the development of other health problems." 4) "I know the food tastes bad. I'll see if there is some salt in the staff kitchen."

3

A patient's heart rate is 48 beats per minute. Which structure is most likely generating this heart rate? 1) Purkinje fibers 2) Sinoatrial node 3) Atrioventricular node 4) Ventricular pacer cells

3

An older adult patient is experiencing hypovolemic shock. Which is the priority intervention for this patient? 1) Assessing the cause of bleeding 2) Providing replacement of volume 3) Establishing invasive cardiac monitoring 4) Administering analgesics for control of pain

3

The health-care provider wants to determine a patient's cardiac contractility. What should be used to make this determination? 1) Cardiac output 2) Mean arterial pressure 3) Pulmonary artery measurement 4) Central venous pressure measurement

3

The nurse has just completed the assessment of a patient admitted with a gunshot wound to the femoral artery. Which is the priority nursing diagnosis for this patient? 1 Ineffective Coping 2 Deficient Fluid Volume 3) Decreased Cardiac Output 4) Ineffective Airway Clearance

3

The nurse instructs a patient recovering from an acute myocardial infarction on the Life's Simple 7 actions. Which patient statement indicates that additional teaching is required? 1) "I will not smoke." 2) "I will eat a heart healthy-diet." 3) "I will walk for at least 30 minutes three times a week." 4) "I will make sure my blood sugar level stays under 100 mg/dL."

3

The nurse is a first responder for a health-care organization for a mass casualty incident. Which injury would the nurse tag as yellow during the triage process? 1) Ankle sprain 2) Hypovolemic shock 3) Open femur fracture 4) Massive head trauma

3

The nurse is caring for a patient experiencing an acute myocardial infarction. Which assessment finding indicates a decrease in this patient's cardiac output? 1) Chest pain 2) Restlessness 3) Low urine output 4) ST segment elevation

3

The nurse is observed marching out the rhythm on a patient's cardiac monitor tracing. What is this nurse assessing? 1) Rate 2) Polarity 3) Regularity 4) Amplitude

3

The nurse is preparing medications for a patient experiencing an acute myocardial infarction. Which medication will dilate the patient's coronary blood vessels? 1) Heparin 2) Fibrinolytics 3) Nitroglycerin 4) Beta blockers

3

The nurse is providing care for a patient receiving treatment for cardiogenic shock. Which assessment finding indicates that the compensatory mechanism of vasoconstriction has occurred in this patient? 1) Increased heart rate 2) Increased injection fraction 3) Decreased urine output 4) Decreased temperature

3

The nurse is providing care to a patient admitted to the emergency department (ED) with a gunshot wound and profound blood loss. Which order does the nurse anticipate for this patient? 1) Normal saline 2) Dextrose in water 3) Packed red blood cells 4) Albumin

3

The nurse is providing care to a patient who is admitted to the emergency department with symptoms of a myocardial infarction (MI). Which is the primary purpose of the interventions administered to this patient? 1) Providing pain relief 2) Preventing extension of damage 3) Preventing cardiogenic shock 4) Reducing blood pressure

3

The nurse is providing care to several patients in the emergency department. Which patient would require priority care from the nurse? 1) An adult patient with an ankle sprain 2) An infant with a rash of unknown origin 3) An adult patient with unstable vital signs and chest pain 4) A pediatric patient with multiple fractures following a motor vehicle accident

3

The nurse is reviewing medications prescribed for a patient with hypertrophic cardiomyopathy. Which medication should the nurse question before administering? 1) ACE-I 2) Diuretic 3) Digoxin 4) Beta blocker

3

Which health-care team member is a first responder when an emergency or mass casualty incident (MCI) occurs? 1) Fireman 2) Police officer 3) Critical care nurse 4) Unlicensed assistive personnel

3

Which treatment for anthrax should be included in the biological agent portion of a disaster plan for terrorist attacks? 1) Antivirals 2) Antitoxins 3) Antibiotics 4) Vaccinations

3

The nurse is concerned that a patient is demonstrating early signs of hypovolemic shock. Which assessment findings support the nurse's concern? Select all that apply. 1) Rapid weak pulse 2) Normal respirations 3) Normal blood pressure 4) Slight increase in pulse 5) Prolonged capillary refill time

345

Which psychosocial nursing actions are appropriate when providing patient care after a community disaster? Select all that apply. 1) Performing triage of injuries 2) Administering first aid to wounds 3) Offering choices whenever possible 4) Establishing rapport through active listening 5) Requesting assistance from crisis counselors

345

A patient is being evaluated for a blockage in the cardiac ventricles. On which part of the electrocardiogram should the nurse focus as evidence of this blockage? 1) T wave 2) U wave 3) PR interval 4) QRS interval

4

A patient is brought into the emergency department after being assaulted. It is suspected that the patient has a spinal cord injury. Which diagnostic test does the nurse anticipate based on the data collected? 1) Computed tomography (CT) scan 2) X-ray 3) Ultrasound 4) Magnetic resonance imaging (MRI)

4

A patient recovering from a motor vehicle crash develops hypotension and jugular distension with a tracheal deviation. Based on this data, which should the nurse suspect occurred? 1) Hemorrhage 2) Compensatory shock 3) Hypovolemic shock 4) Tension pneumothorax

4

A patient recovering from cardiogenic shock is observed walking to the patient lounge. What should the nurse recommend to this patient? 1) Call for help when wanting to walk 2) Limit sitting out of bed to 30 minutes 3) Increase activity by 15 minutes every day 4) Important to obtain as much rest as possible

4

A patient with atrial fibrillation is being considered for cardioversion. Which diagnostic test should the nurse anticipate being prescribed prior to this procedure being completed? 1) Chest x-ray 2) CT scan of the chest 3) 12-lead electrocardiogram 4) Transesophageal echocardiogram (TEE)

4

A patient with dilated cardiomyopathy has developed a productive cough. What additional manifestation supports fluid overload in this patient? 1) Fainting 2) Sleeplessness 3) Loss of appetite 4) Jugular vein distention

4

A patient's cardiac rhythm has no identifiable P or QRS waves. What action should the nurse take first? 1) Apply oxygen 2) Assess a radial pulse 3) Insert an intravenous line 4) Begin chest compressions

4

A workplace violence prevention plan is often one component of a hospital disaster plan. Which unit assumes priority for implementation and evaluation of this component to the plan? 1) Medical unit 2) Surgical unit 3) Radiology department 4) Emergency department

4

During a home visit the nurse notes that a patient recovering from an acute myocardial infarction has not had medication prescriptions filled at the pharmacy. What should the nurse say in response to this observation? 1) "I don't blame you. I don't like to take medications every day either." 2) "As long as you aren't having any symptoms, delaying the medications is acceptable." 3) "Most people don't like to take medications but try to remember to get the prescriptions filled." 4) "The medications will help treat the effects of your current health problem and prevent any future events."

4

During the initial stage of shock, which clinical manifestation should the nurse monitor for when assessing the patient? 1) Lethargy 2) Hypotension 3) Respiratory alkalosis 4) Subtle changes in heart rate

4

The emergency department nurse is triaging patients. Which patient should be prioritized? 1) An adult patient experiencing mild chest pain 2) An adolescent patient with a possible fractured wrist 3) An older adult patient with a hip fracture who is in pain 4) A school-age patient with asthma presenting with dyspnea

4

The nurse hears crackles when auscultating the lung sounds of a patient with cardiomyopathy. What should this finding indicate to the nurse? 1) Atelectasis 2) Pneumothorax 3) Stasis pneumonia 4) Pulmonary edema

4

The nurse is caring for a patient experiencing cardiogenic shock. Which medication should the nurse expect to be prescribed to improve this patient's cardiac output? 1) Nitroglycerin 2) Morphine sulfate 3) Norepinephrine (Levophed) 4) Dobutamine hydrochloride (Dobutamine)

4

The nurse is conducting medication teaching for a patient who is prescribed an epi-pen. Which statements made by the patient indicates the need for additional instruction? 1) "I will carry an epi-pen with me at all times." 2) "I will check the expiration date on my epi-pen regularly." 3) "I should hold the epi-pen in place for 10 seconds after injection." 4) "I should use the epi-pen to inject the drug into my abdominal wall."

4

The nurse is preparing to defibrillate a patient. Which setting should the nurse use for this treatment? 1) 50 J 2) 100 J 3) 150 J 4) 200 J

4

The nurse is providing care to a patient diagnosed with hypovolemic shock. Which nursing action is appropriate for this patient during the initial compensatory phase? 1) Placing a cool blanket over the patient 2) Raising the patient's head to a 30-degree angle 3) Positioning the patient in the left-lateral recumbent position 4) Turning the patient's head to one side if no neck injury is suspected

4

The nurse is providing care to several patients in the emergency department. Which patient is the priority when using the three-tiered triage system? 1) A patient with a simple fracture 2) A patient experiencing renal colic 3) A patient with severe abdominal pain 4) A patient with chest pain and diaphoresis

4

The nurse notes that a patient with a cardiac dysrhythmia is developing shortness of breath. What is the pathophysiological reason for this manifestation? 1) Decreased oxygen in the brain 2) Stimulation of the sympathetic nervous system 3) Imbalance in myocardial oxygen demand and supply 4) Increase in oxygenation because of a drop in cardiac output

4

The nurse suspects that a patient in cardiogenic shock is experiencing oxygen deprivation. What would confirm the nurse's suspicion? 1) Sudden drop in serum lactate level 2) Slowly increasing serum calcium level 3) Acute reduction in hemoglobin and hematocrit 4) Metabolic acidosis upon arterial blood gas analysis

4

The nurse suspects that a patient with cardiomyopathy is experiencing heart failure. What finding did the nurse use to make this clinical decision? 1) Dizziness 2) Chest pain 3) Palpitations 4) SOB when supine

4

What should the nurse do to assist a patient brought to the emergency department as a victim of a gunshot wound? 1) Ask the patient who shot him 2) Bathe the patient and provide a clean gown 3) Ask the patient where the weapon is 4) Preserve the chain of evidence

4

When analyzing a patient's electrocardiogram, the nurse notes that the P wave is normal. What criteria did the nurse use to make this decision? 1) Pointed and skinny in width 2) Small and rounded in lead II 3) Upright and rounded in lead II 4) Length 0.10 seconds and height 2.5 mm

4

Which assessment data indicates the patient is experiencing a late symptom associated with chronic aspirin overdose? 1) Emesis 2) Nausea 3) Tinnitus 4) Ecchymosis

4

Which assessment data related to the patient's airway would indicate the need for priority intervention by the nurse? 1) Eupnea 2) Tachycardia 3) Hypotension 4) Agonal breaths

4

Which entity is responsible for activating the disaster plan during a mass casualty incident (MCI)? 1) Local emergency management system 2) State emergency management system 3) Federal emergency management agency 4) Hospital-level emergency management system

4

Which intervention would be a priority when providing care to a patient recovering from thoracic injuries sustained from a motor vehicle crash? 1) Monitor urine output 2) Assess vital signs 3) Perform passive range of motion to all extremities 4) Assist to deep breathe and cough every two hours

4

Which is the critical factor among health-care professionals, state agencies, and federal agencies to determine when and how to evacuate safely during a natural disaster? 1) Cooperation 2) Classification 3) Collaboration 4) Communication

4

Which nursing action is appropriate when conducting a secondary survey during the emergency assessment? 1) Maintaining privacy 2) Having suction available 3) Giving supplemental oxygen 4) Assigning a nurse to support family members

4

Which patient injury would receive a black tag by the triage nurse during a mass casualty incident? 1) Concussion 2) Ankle sprain 3) Open femur fracture 4) Full-thickness body burns

4

Which public health risk became a major focus for hospitals after the September 11, 2001 terrorist attacks? 1) Anthrax exposure 2) Multi-casualty incidents 3) Mass casualty incidents (MCI) 4) Weapons of mass destruction (WMD)

4

A green-tagged patient arrives at the emergency department after a mass casualty incident (MCI) involving radiation. Which is the priority nursing action for this patient? 1) Implementing decontamination measures 2) Performing a head-to-toe physical examination 3) Placing a special bracelet with a disaster number 4) Taking a digital photo and placing it on the medical record

1

A medical-surgical unit is expecting a large volume of patient admissions after a train derailment. Which member of the nursing care team will prioritize care for the unit? 1) Charge nurse 2) Nurse supervisor 3) Licensed practical nurse 4) Unlicensed assistive personnel

1

A nurse is caring for a patient who was involved in a motor vehicle accident who has lost approximately 1,500 mL of blood. Based on this data, which type of shock is the patient experiencing? 1) Hypovolemic 2) Cardiogenic 3) Distributive 4) Obstructive

1

A patient in neurogenic shock is receiving rapid intravenous fluids. Which assessment finding indicates the need for additional nursing interventions? 1) The patient's mean arterial pressure (MAP) is 60 mmHg. 2) The patient is unconscious. 3) The patient has received two liters of infused fluid. 4) The patient is perspiring heavily.

1

A patient is being evaluated for chest pain in the emergency department. Which laboratory test is the best to determine if this patient has experienced an acute myocardial infarction? 1) Troponin 2) Prothrombin time 3) Creatine kinase-MB 4) Complete blood count

1

A patient is being prepared for a transvenous pacemaker. What should the nurse include when explaining this pacemaker to the family? 1) "It is inserted using an internal jugular vein." 2) "It is done by placing defibrillator pads on the torso using an anterior/posterior position." 3) "It is done by placing a pacer wire in the atrium or the ventricle and fed out through the skin, where it is attached to an external pacemaker." 4) "It is inserted by placing pacer wires in the atrium, ventricle, or both and attached to a small pacemaker generator placed under the skin near the clavicle."

1

A patient is diagnosed with third-degree AV block. For which type of pacemaker should the nurse prepare this patient? 1) Transvenous 2) Biventricular 3) Transthoracic 4) Transcutaneous

1

A patient is in normal sinus rhythm with prolonged PR intervals. What treatment should the nurse expect to be prescribed for this patient? 1) Continue to monitor 2) Anticipate defibrillating 3) Prepare for cardioversion 4) Prepare for pacemaker insertion

1

A patient is prescribed epinephrine for the prevention of anaphylactic shock. The patient states, "I thought shock was about heart failure." Which response by the nurse is most appropriate? 1) "There are many kinds of shock that also include infection, nervous system damage, and loss of blood." 2) "Heart failure is the most serious kind of shock; others include infection, kidney failure, and loss of blood." 3) "There are many kinds of shock: heart failure, nervous system damage, loss of blood, and respiratory failure." 4) "Allergic response is the most fatal type of shock; other types involve loss of blood, heart failure, and liver failure."

1

A patient with a cardiac dysrhythmia asks why it is important to recognize the signs of a stroke. What should the nurse respond to this patient? 1) "So you can respond quickly and prevent adverse effects." 2) "To encourage you to take your medication as prescribed." 3) "So that you can recognize the signs of stroke in a family member." 4) "Most people with a heart arrhythmia develop strokes as a side effect."

1

A patient with cardiomyopathy comes into the emergency department with chest pain and dyspnea after running a 5K race. What should the nurse explain to this patient? 1) Signs of overexertion 2) Importance to limit activity 3) Need for frequent rest periods 4) Alternatives to physical exercise

1

A patient with shortness of breath has a heart rhythm of 46 beats per minute. Which medication should the nurse anticipate being prescribed for this patient? 1) Atropine sulfate 2) Atenolol (Tenormin) 3) Diltiazem (Cardizem) 4) Adenosine (Adenocard)

1

An older adult patient is recovering in the intensive care unit (ICU) from septicemia. Which intervention will help prevent further infection for this patient? 1) Provide oral and skin care 2) Implement sterile wound care 3) Encourage turn, cough, and deep breathe every shift. 4) Place the Foley drainage on the bed at the patient's feet

1

The health-care provider wants an SvO2 level on a patient with a pulmonary artery catheter. From where should this sample be taken? 1) Distal lumen 2) Balloon inflation lumen 3) Proximal injectable port 4) Proximal infusion port

1

The nurse administrator for a long-term care facility is implementing a disaster response plan for staff and residents. Which staff member statements indicate correct understanding of the plan? 1) "We have to implement annual drills." 2) "Nursing homes are not required to have a plan." 3) "Our facility is held to the same standards as hospital facilities." 4) "This is an important component to receive insurance payments for care."

1

The nurse explains the purpose of an infusion of albumin 5% to a patient recovering from hypovolemic shock. Which statement indicates that the patient understands the instructions? 1) "It is a protein that pulls water into my blood vessels." 2) "It is a protein that causes my kidneys to conserve fluid." 3) "It is a super-concentrated salt solution that helps me conserve body fluid." 4) "It is a liquid that has electrolytes in it to pull water into my blood vessels."

1

The nurse identifies the nursing diagnosis of Ineffective Peripheral Tissue Perfusion as being appropriate for a patient with septicemia. Which intervention will address this patient's health problem? 1) Monitor for cyanosis. 2) Monitor heart rate every hour. 3) Assess temperature every four hours. 4) Monitor pupil reactions every eight hours.

1

The nurse is a member of the critical incident stress management unit that looks to meet the psychosocial needs of first responders after a mass casualty incident. Which action by the nurse is appropriate when conducting a session? 1) Arranging group discussion 2) Administering anti-anxiety medication 3) Scheduling individual therapy appointments 4) Documenting individual responses to the session

1

The nurse is administering albumin 5% to a patient in shock. Which nursing action is appropriate when assessing this patient? 1) Auscultate breath sounds for crackles 2) Auscultate breath sounds for hyperresonance 3) Auscultate breath sounds for inspiratory stridor 4) Auscultate for an absence of breath sounds in the lower lobes

1

The nurse is concerned that a patient is at risk for pulseless electrical activity. What information from the assessment did the nurse use to make this clinical decision? 1) Blood pH 7.30 2) Temperature 100.5°F 3) Serum glucose level 170 mg/dL 4) Serum potassium level 4.1 mEq/L

1

The nurse is conducting a primary survey during an emergency assessment. Which is the priority nursing action related to breathing in response to this assessment? 1) Having suction available 2) Assessing pupil size and reactivity 3) Immobilizing any obvious deformities 4) Obtaining blood samples for type and crossmatch

1

The nurse is conducting a secondary survey as part of the emergency assessment. Which is the priority nursing action during the health history portion of the assessment? 1) Determining drug allergies 2) Noting the general appearance 3) Examining the neck for stiffness 4) Auscultating for heart and lung sounds

1

The nurse is conducting triage under mass casualty conditions. Which tag should the nurse use for a patient who is experiencing hypovolemic shock due to a penetrating wound? 1) Red 2) Black 3) Green 4) Yellow

1

The nurse is helping devise a training plan to familiarize health-care providers with emergency response procedures. Which training measure is most effective to adequately prepare the trainees? 1) Drills 2) Tabletop exercises 3) Access to the policy 4) Computer simulations

1

The nurse is preparing an educational session on sepsis. Which should the nurse include as a major risk factor for the development of this health problem? 1) Immunosuppression 2) Elevated temperature 3) Pneumococcal bacteria 4) Leukocytosis on the complete blood count

1

The nurse is preparing to obtain a pulmonary artery wedge pressure (PAWP) on a patient. What action should be taken to ensure for the patient's safety? 1) Inflate the balloon 1.5 mL 2) Place the patient in the Trendelenburg position 3) Monitor the waveform after inflating the balloon 4) Deflate the balloon within five minutes of obtaining the pressure

1

The nurse is reviewing the manifestations of an acute myocardial infarction with a patient diagnosed with type 2 diabetes mellitus. What should the nurse emphasize as being an atypical manifestation of this cardiac disorder? 1) Fatigue 2) Dyspnea 3) Tachycardia 4) Hypertension

1

The nurse manager is reviewing the hospital disaster plan with other members of the committee. Which is the minimum number of disaster drills the committee must plan and implement each year? 1) Two 2) Three 3) Four 4) Five

1

The nurse notes that PR intervals are getting progressively longer before a QRS complex is dropped on a patient's cardiac rhythm strip. Which health problem should the nurse realize this patient is experiencing? 1) Mobitz I 2) Mobitz II 3) First-degree AV block 4) Third-degree AV block

1

The nurse notes that a patient with cardiomyopathy has been prescribed an angiotensin-converting enzyme inhibitor. What is the purpose of this medication? 1) Reduce afterload 2) Improve heart muscle contractions 3) Reduce fluid accumulation in the lungs 4) Decrease sympathetic response to decreased cardiac output

1

The registered nurse (RN) is the team leader for a group of patients using the functional model of nursing. The team of nurses includes two licensed practical nurses (LPNs) and an unlicensed assistive personnel (UAP). Which task will the RN delegate to the UAP? 1) Taking vital signs 2) Providing wound care 3) Conducting discharge teaching 4) Administering oral medications

1

Which are the priority nursing actions after the completion of the secondary survey when providing care for a trauma patient with a penetrating wound? 1) Documenting the patient's care 2) Formulating the patient's plan of care 3) Reassessing the patient's level of consciousness 4) Transferring the patient to the general medical unit

1

Which is the priority in the preparedness of health-care professionals in any type of disaster plan? 1) Identification of hazards 2) Cooperation with state authorities 3) Collaboration with local authorities 4) Implementation of federal mandates

1

Which is the priority nursing action to include in a disaster plan for the radioactive dust and smoke that can cause illness from a radiologic dispersal device (RDD)? 1) Covering the nose 2) Protecting the eyes 3) Decontaminating the skin 4) Administering prophylactic antibiotics

1

Which medication should be listed as the antidote to a nerve agent in the disaster plan for a terrorist attack? 1) Atropine 2) Dopamine 3) Epinephrine 4) Norepinephrine

1

Which member of the health-care team, when using the team nursing approach, is responsible for prioritizing patient care? 1) Team leader 2) Charge nurse 3) Licensed practical nurse 4) Unlicensed assistive personnel

1

Which organization in the United States mandates ongoing disaster preparedness for hospitals? 1) The Joint Commission (TJC) 2) The local government 3) The state government 4) The Occupational Safety and Health Administration (OSHA)

1

Which situation does not cover nurses who respond to a mass casualty incident (MCI) for malpractice or negligent lawsuits under the Good Samaritan Act? 1) Terrorist act 2) Neighborhood fire 3) Roadside car accident 4) High school sporting event

1

Which type of event can often be handled by an individual hospital disaster plan without collaboration with other systems? 1) A motor vehicle accident involving five cars 2) A tornado destroying 50 homes and businesses 3) An act of terrorism injuring and kills hundreds of people 4) A hurricane causing flooding, displacing thousands of people

1

A nurse working in the intensive care unit (ICU) is receiving a patient diagnosed with late septic shock from the emergency department (ED). The nurse will recognize which symptoms associated with this condition? Select all that apply. 1) Shallow respirations 2) Lethargic mental status 3) Decreased urine output 4) Normal blood pressure 5) Warm and flushed skin 6) Rapid and deep respirations

123

The nurse is preparing to determine a patient's left heart afterload. What measurements are needed to make this calculation? Select all that apply. 1) Cardiac output 2) Mean arterial pressure 3) Central venous pressure 4) Pulmonary artery pressure 5) Pulmonary artery wedge pressure

123

A patient is receiving intravenous nitroprusside (Nipride) for shock. Which adverse reactions will the nurse assess this patient for when administering the infusion? Select all that apply. 1) Confusion 2) Tachycardia 3) Disorientation 4) Muscle spasms 5) Gastrointestinal bleeding

1234

The nurse is caring for a patient with a potentially life-threatening cardiac dysrhythmia. What should be included in this patient's plan of care? Select all that apply. 1) Document frequency of dysrhythmia 2) Administer antiarrhythmic medications 3) Maintain continuous cardiac monitoring 4) Prepare to administer advanced cardiac life support 5) Complete preoperative checklist for pacemaker insertion

1234

Which nursing actions are necessary when initiating care for patients who have been injured in a natural disaster? Select all that apply. 1) Taking risks 2) Using principles 3) Stepping into the unknown 4) Showing a commanding presence 5) Formulating individualized plans of care

1234

Which threats, included in the term "NBC," lead to the implementation of improved emergency medical services (EMS) and hospital safety programs? Select all that apply. 1) Nuclear 2) Biological 3) Botulism 4) Chemical 5) Nipah virus

124

The nurse is assigned to a patient with a newly inserted central line. What actions should be taken to prevent the patient from developing an infection? Select all that apply. 1) Perform line care 2) Use aseptic technique 3) Minimize handling the line 4) Use normal saline to flush the line 5) Ensure an occlusive dressing is applied

1245

Which nursing actions during a mass casualty incident should be included in the triage portion of an organizational disaster plan? Select all that apply. 1) Treatment 2) Stabilization 3) Evaluation of interventions 4) Formulation of nursing diagnosis 5) Decontamination for suspected contamination

125

A patient with atypical chest pain is prescribed a 12-lead electrocardiogram. What findings would support this patient experiencing an acute myocardial infarction? Select all that apply. 1) Q waves 2) Junctional rhythm 3) ST segment elevation 4) Prolonged PR interval 5) Premature ventricular contractions

13

A nurse is working an evening shift when a fire breaks out at the hospital. Which actions by the nurse are appropriate? Select all that apply. 1) Removing patients from immediate danger 2) Discontinuing the use of oxygen for all patients 3) Using a wheelchair to move a bedridden patient 4) Directing ambulatory patients to walk to a safe location 5) Containing the fire immediately to avoid patient evacuation

134

Which will the nurse closely monitor due to the pathophysiology associated with early shock? Select all that apply. 1) Bowel sounds 2) Level of consciousness 3) Urine output 4) Peripheral pulses 5) Heart rate

134

An older client is being evaluated for a new onset of a cardiac dysrhythmia. What should the nurse consider as being the cause for this abnormal heart rhythm? Select all that apply. 1) Advanced age 2) Protein malnutrition 3) Fat deposits around the SA node 4) Fewer pacemaker cells in the SA node 5) Calcification around the SA node and valves

1345

The nurse suspects that a patient is experiencing a complication from a pulmonary artery catheter. What findings did the nurse use to make this clinical determination? Select all that apply. 1) Bleeding 2) Increased urine output 3) Elevated body temperature 4) Acute onset of shortness of breath 5) Development of a cardiac dysrhythmia

1345

What would the nurse working in the emergency department identify as clinical priorities for the treatment of a patient with a gunshot wound? Select all that apply. 1) Airway maintenance 2) Obtaining medical history 3) Ventilation assistance 4) Hemorrhage control 5) Hypothermia prevention

1345

Which assessment findings would indicate to the nurse that a patient is exhibiting early symptoms of shock? Select all that apply. 1) Pallor 2) Increased bowel sounds 3) Restlessness 4) Decreased blood glucose 5) Increased respiratory rate

135

Which are the top priorities when conducting a primary patient survey during the emergency assessment? Select all that apply. 1) Airway 2) Disability 3) Breathing 4) Circulation 5) Cervical spine

15

A nurse working in the intensive care unit (ICU) is caring for a patient in refractory stage of shock. When planning care, which does the nurse anticipate? 1) A subtle change in heart rate 2) A change from aerobic to anaerobic metabolism 3) The development of hyperglycemia 4) The development of cardiac dysrhythmias

2

A patient in the intensive care unit is experiencing chest pain. What assessment finding indicates that cardiogenic shock is being compensated? 1) Hypotension 2) Increased heart rate 3) Absent urine output 4) Mottled and cyanotic skin

2

A patient is experiencing supraventricular tachycardia. What should be done before determining this patient's treatment? 1) Assess for thyroid disease 2) Identify the underlying rhythm 3) Evaluate serum electrolyte values 4) Study lifestyle and behavioral habits

2

During a home visit the nurse learns that a patient has been skipping doses of antiarrhythmic medication. What should the nurse include when counseling this patient? 1) Taking the medication as prescribed reduces the occurrence of side effects 2) Skipping doses increases the risk of developing chest pain and diaphoresis. 3) Adequate medication level decreases the adverse effects of the dysrhythmia. 4) Insufficient amounts of medication in the blood stream affect pacemaker functioning.

2

The nurse is conducting a primary survey during the emergency assessment. Which nursing action is appropriate during the breathing assessment? 1) Assessing for edema 2) Counting respiratory rate 3) Checking for foreign bodies 4) Monitoring for respiratory distress

2

The nurse is preparing to administer diphenhydramine to a patient who is experiencing a severe allergic reaction to peanuts. Which information about the drug should the nurse provide to the patient? 1) "This is the medication of choice to treat airway obstruction." 2) "This medication will help relieve your itching and runny nose." 3) "This medication will prevent you from going into anaphylactic shock." 4) "This medication will take a while to be effective but will control your symptoms for several hours."

2

The nurse is providing care to a patient admitted with a spinal cord injury. The patient is bradycardic, hypotensive, and has cold and clammy skin. Which is the priority nursing action for this patient? 1) Starting two large intravenous catheters 2) Notifying the Rapid Response Team 3) Calling the patient's physician to report the changes 4) Placing oxygen on the patient

2

The nurse is providing care to a patient who is admitted with cardiogenic shock. The nurse administers the prescribed atropine with no results. Which prescription does the nurse anticipate from the health-care provider based on this data? 1) A beta blocker 2) Transcutaneous pacing 3) Cardiac defibrillation 4) A preload reducer

2

The nurse wants to evaluate a patient's right heart preload. Which approach should be used to obtain this measurement? 1) Zero the arterial line 2) Measure the central venous pressure 3) Measure the pulmonary artery wedge pressure 4) Attach the proximal infusion port to an intravenous solution

2

Which amount of time is appropriate for nurse to spend triaging each patient during a mass casualty incident? 1) Less than 10 seconds 2) Less than 15 seconds 3) Less than 30 seconds 4) Less than 60 seconds

2

Which emergency medical system (EMS) first responders can perform triage during mass casualty incidents? 1) Unlicensed assistive personnel 2) Nurses appointed to a field team 3) A physician who survives the incident 4) Community response team members

2

Which is a potentially life-threatening condition found during the primary triage survey that would necessitate priority nursing care? 1) Cystitis 2) Concussion 3) Lacerated arm 4) Fractured femur

2

Which is the essential nursing skill for the triage process in the emergency department? 1) Evaluating care 2) Setting priorities 3) Formulating diagnoses 4) Implementing interventions

2

Which is the highest priority nursing action when providing care to a patient with shock? 1) Starting two large intravenous catheters 2) Recognizing early clinical manifestations 3) Administering high-flow oxygen 4) Calling for help immediately

2

Which is the priority nursing action when providing care to a patient with a penetrating abdominal wound? 1) Assessing bowel sounds 2) Stabilizing the impaled object 3) Administering prescribed pain medication 4) Scheduling a CT scan to determine retroperitoneal bleeding

2

Which observation indicates that interventions provided to a patient with neck injuries from a motor vehicle crash have been successful? 1) Urine is clear and odorless from indwelling catheter 2) Moves all four extremities independently, feeds self, and participates in partial bath 3) Unable to move independently in bed 4) Rests in bed with lights and television turned off

2

Which treatment should the nurse prepare to administer when providing care to a toddler who presents after an accidental overdose of aspirin? 1) Gastric lavage 2) Activated charcoal 3) Peritoneal dialysis 4) Vitamin D injection

2