Exam 3: Emergency Nursing

A nurse in the Emergency Department is triaging patients. The nurse should first attend to which of the following patients?

18-year-old female with severe pelvic and abdominal pain that appeared 10 hours ago

A nurse is caring for a group of patients that have experience poisoning. Which of the following actions by the nurse would be appropriate?

Preparing a patient who ingested an excessive amount of aspirin for hemodialysis

A nurse gives NPH insulin at 0700. When should the nurse expect it to peak?

1100

A nurse is received a 5-year-old with flu-like symptoms and a erythematous lesion on their flank that is 8 cm in diameter. It is important to ask the parents if the child has been around:

A wooded area

A nurse is caring for a patient receiving gastric lavage for treatment of NSAID overdose. Which of the following actions by the nurse is appropriate for monitoring for complications from the procedure?

Auscultating the lungs

A nurse is preparing to administer an oral antidiabetic medication that enhances cellular sensitivity to insulin. Which of the following types would be administered?

Biguanide

A patient has choked on a piece of food and is now unconscious. After unsuccessful attempts to remove the food, what should the nurse prepare to do to secure the airway?

Prepare the patient for a tracheostomy

A nurse in the Emergency Department is caring for a patient with a closed lower extremity fracture that has been realigned and splinted by the physician. What action should the nurse take first?

Check both feet for warmth and color

A nurse is caring for a patient in the Emergency Department that survived a near drowning event. Which intervention would be a priority?

Correcting the patient's hypoxia

A nurse is providing discharge teaching for the parents of a 18-month-old toddler that was brought into the Emergency Department after being found face down in the bathtub by the parent. What information should the nurse include?

Do not leave your child unattended in the bathtub even for only few minutes

A nurse is working with the hospital on the emergency preparedness plan and is aware of the potential for ethical dilemmas. Ethical dilemmas are best resolved by:

Having an ethical framework in place prior to an emergency

A nurse has attended staff training about family and intimate partner violence. Which of the following indicates a correct understanding by the nurse?

I can screen clients for abuse by asking if the patient feels safe at home

A nurse is caring for a patient in the Emergency Department who has ethylene glycol poisoning. The health care provider tells the nurse to prepare activated charcoal administration. What information should the nurse explain to the client?

I will insert a tube into one of your nares which will help absorb the poison.

A nurse and a colleague are caring for patient in the Emergency Department with frostbite on their feet. The nurse should internee when observing the colleague doing what action?

Immersing the patient's feet in circulating water set to a temperature of 120ºF

A charge nurse in the Emergency Department is observing colleagues caring for patients with various traumatic injuries. The charge nurse would intervene if she observes a nurse doing which of the following?

Inserting a catheter for a patient that has blood in the urethral meatus

A nurse is planning an education conference about administering insulin to clients with diabetes. Which of the following information should be included?

Insulin pens are a great alternative for clients with poor vision

An unconscious patient with a C-collar arrives by ambulance from a motor vehicle accident. What action would be appropriate for the nurse to take while attempting to stabilize the client?

Lifting the lower jaw forward while the patient is supine

A nurse in the Emergency Department caring for patient with hyperthermia. The patient's family member asks why placing a urinary catheter is necessary. It is appropriate to explain that placing the catheter because it helps the nurse:

Monitor for signs of kidney damage

A nurse in the Emergency Department receives a patient by ambulance following a traumatic accident. The paramedic reports the patient has asymmetric chest wall movement. The nurse demonstrates a correct understanding of this report by taking which of the following actions?

Palpate the thorax for crepitus

A nurse is caring for a patient that fell at home and suffered a right hip fracture. Which of the following is the most important for the nurse to assess?

Pedal pulse and capillary refill

A nurse is planning care for a patient who is homeless that was admitted with mild hypothermia. Which intervention would be most appropriate for rewarming the patient?

Place the patient in a warm room and use warm blankets

A nurse is caring for a patient involved in a workplace accident with a penetrating wound to the chest that led to acute respiratory failure. Which of the following goals of treatment should the care team prioritize when planning care for this patient?

Restoration of adequate gas exchange

A nurse is caring for patient with moderate hypothermia. It's important for the nurse to monitor the patient for which of the following complications?

Stroke

A nurse is assessing a group of patients in the Emergency Department following the collapse of bridge. The nurse should recognize which of the following:

Subcutaneous emphysema may indicate laryngeal tracheal disruption

A nurse is caring for a patient on the Critical Care Unit who reports severe sleep disturbances. The nurse would call the provider and request a prescription for which of the following medications?

Temazepam

A nurse is assessing a patient with blunt force chest trauma after hitting the handlebars of a bicycle. The nurse suspects the client has flail chest. Which of the following findings would the nurse expect to find?

The fractured rib section pulls inward on inspiration and outward on expiration

A nurse is providing teaching to a patient with Type 1 Diabetes about exercise and glucose control. Which action stated by the patient indicates a need for further teaching?

The patient increases exercise when ketones are present in the urine

A nurse is stabilizing an unconscious patient that was in a car accident. A family member asks why the nurse is inserting an NG tube. What is the best explanation?

To decompress the stomach and keep fluid from building up and entering the lungs

A nurse is assessing a patient that came into the Emergency Department by ambulance with a traumatic injury from construction site. Which assessment finding is the priority?

Trachea deviated left of the midline

A nurse is triaging patients at a disaster site of a workplace explosion. A 40-year-old client has an open leg fracture, minor bruising, and is conscious. What color tag should be assigned to this patient?

Yellow

A nurse asks another nurse about tetanus prophylaxis for clients with an unknown vaccination status. Which of these reasons would be an indication to give the client a tetanus shot? Select all that apply. a. A human bite wound b. Severe frostbite c. Hyperthermia d. A laceration sustained while gardening e. A dog bite wound

a. A human bite wound b. Severe frostbite d. A laceration sustained while gardening e. A dog bite wound

A nurse is triaging four patients that have arrived to the Emergency Department following a car accident. Which of the following patients should be seen first? a. A patient with a traumatic amputation going in and out of consciousness b. A patient who reports abdominal pain and nausea with a strong pulse c. A patient with a 5-6in laceration actively bleeding on their forehead and is following commands d. A Female patient who is 38 weeks' gestation and crying next to her deceased husband

a. A patient with a traumatic amputation going in and out of consciousness

A nurse is caring for a group of patients in the Emergency Department. Which of the following interventions would the nurse implement? Select all that apply. a. Administer antibiotics to patient who has puncture wounds from a cat b. Use tweezers to remove a tick from a patient's leg c. Administer rabies postexposure prophylaxis to a patient that was bitten by a human d. Administer rabies postexposure prophylaxis through a patient's IV e. Use a needle or fingernail to remove a bee-sting from a patient's arm

a. Administer antibiotics to patient who has puncture wounds from a cat b. Use tweezers to remove a tick from a patient's leg e. Use a needle or fingernail to remove a bee-sting from a patient's arm

A nurse is caring for a patient with heat stroke. Which of the following actions would be appropriate intentions to lower the patient's core temperature? Select all that apply. a. Apply ice packs to the patient's groin and axillae b. Position a large fan to blow on the patient c. Cover the patient with wet sheets d. Have the patient drink as much ice water as possible e. Immerse the patient in an ice bath

a. Apply ice packs to the patient's groin and axillae b. Position a large fan to blow on the patient c. Cover the patient with wet sheets

A nurse is assessing a patient who sustained a blunt injury to chest wall. Which of the following alerts the nurse that they have a pneumothorax? a. Diminished breath sounds b. Sucking sounds at site of injury c. Asymmetrical chest movement d. Bradypnea and cyanosis

a. Diminished breath sounds

A nurse is preparing for an educational conference about agents of terrorism. Which information should be included? Select all that apply. a. Explosive devices can result in blast, crush, or traumatic injuries b. Sarin, anthrax, and smallpox are all biologic agents c. A vaccine is available to prevent botulism d. Atropine can be used as an antidote for nerve agent poisoning e. Radioactive dispersal devices include a mix of radioactive and explosive material

a. Explosive devices can result in blast, crush, or traumatic injuries d. Atropine can be used as an antidote for nerve agent poisoning e. Radioactive dispersal devices include a mix of radioactive and explosive material

The nurse is planning an educational conference about insulin for clients with diabetes. Which of the following medications would be included when discussing rapid acting insulin? Select all that apply. a. Glulisine b. Lispro c. Detemir d. Aspart e. Regular

a. Glulisine b. Lispro d. Aspart

A nurse is caring for a patient who is alert but is having an acute asthma attack. Which of the following prescribed medications would the nurse plan to administer? Select all that apply. a. Methylprednisolone b. Albuterol c. Fentanyl d. Norepinephrine e. Dobutamine

a. Methylprednisolone b. Albuterol

A nurse is working in the Emergency Department caring for a female patient with a spiral fracture of the right arm and ecchymosis in the right eye. The spouse states that she fell at home. The patient's record notes multiple ED visits in the last six months for other injuries. Which of these actions would be most appropriate for the nurse to take? Select all that apply. a. Provide information to the client about a safehouse when the spouse is not present b. Report findings of suspected abuse to charge nurse c. Attempt to interview the client alone d. Ask the spouse if he caused the injuries e. Call the police to arrest the spouse

a. Provide information to the client about a safehouse when the spouse is not present b. Report findings of suspected abuse to charge nurse c. Attempt to interview the client alone

A nurse is caring for a patient that has arrived by ambulance who is unconscious and hypotensive after falling from a second story balcony. Which of the following actions would be appropriate for the nurse to take? Select all that apply. a. Insert two 22-gauge peripheral IVs in the patient's arm b. Inspect the posterior surface by logrolling the patient while holding the head still c. Administer prescribed IV pain medications d. Arrange to have several units of O- packed blood products on standby e. Ventilate the patient with 100% oxygen via a nonrebreather mask

b. Inspect the posterior surface by logrolling the patient while holding the head still d. Arrange to have several units of O- packed blood products on standby e. Ventilate the patient with 100% oxygen via a nonrebreather mask

A nurse is triaging patients in the Emergency Department that arrive following a mass casualty event. Which of the following factors should the nurse consider when making triage decisions? Select all that apply. a. Client's age b. Nearness to death c. Insurance status d. Religion e. Level of resources required

b. Nearness to death e. Level of resources required

A nurse in the Emergency Department has received training about how to protect themselves from violence from patients. Which actions by the nurse indicates a correct understanding of the anti-violence training? Select all that apply. a. Including questions about patient's arrest record when taking the patient's history b. Performing nursing activities while the nursing assistant is also in the room c. Positioning oneself between the patient and the room's door d. Carrying pepper spray in the uniform pocket e. Making oneself aware of staff rooms that can be locked

b. Performing nursing activities while the nursing assistant is also in the room c. Positioning oneself between the patient and the room's door e. Making oneself aware of staff rooms that can be locked

A patient in the Emergency Department has a puncture wound from a human bite on their hand from around 12 hours ago. Which of the following prescriptions written by the physician should the nurse clarify? Select all that apply. a. Antibiotic therapy b. Rabies immune globulin c. Acetaminophen d. Sterile dressing e. Tetanus prophylaxis f. Irrigation

b. Rabies immune globulin d. Sterile dressing

A nurse is caring for a patient with signs and symptoms of pulmonary congestion who reports feeling anxious. Which medications would the nurse expect the provider to prescribe? Select all that apply. a. Diltiazem b. Albuterol c. Furosemide d. Lorazepam

c. Furosemide d. Lorazepam

A nurse is caring for a critically ill patient at risk for stress ulcers. Which of the following prescribed medications should the nurse expect to be ordered from the provider for prophylaxis treatment? Select all that apply. a. Famotidine b. Ranitidine c. Cimetidine d. Misoprostol e. Pantoprazole

d. Misoprostol e. Pantoprazole