Final Advanced Med Surg II

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?

- "We have to implement annual drills."

The ED nurse is triaging patients. Which patient should be prioritized?

- A school-age patient with asthma presenting with dyspnea

A nurse is developing a plan of care for a patient with traumatic injuries from a MVA. Which nursing interventions does the nurse include in the plan of care to reduce the risk of integumentary complications?

- Assist the patient in turning at least every two hours

What should the nurse do in the field to prevent the spread of venom after a snake bite?

- Immobilize the affected extremity - place in a dependent position lower than the heart

A pt is brought into the ED after being assaulted. It is suspected that the pt has a spinal cord injury. Which diagnostic test does the nurse anticipate based on the data collected?

- MRI

rifampin for TB

- Rusty-orange/red colored urine and body fluids - watch for jaundice to skin, joint swelling - can interfere with contraceptives

What is the first priority for first aid interventions in the field?

- To move the person to a safe place away from the snake and encourage rest to decrease the venom circulation

Which type of event can often be handled by an individual hospital disaster plan without collaboration with other systems?

- a MVA involving 5 cars

The nurse is providing care to several patients in the emergency department. Which patient is the priority when using the three-tiered triage system?

- a patient with chest pain and diaphoresis

leukocytosis

- abnormally high WBC count indicates bacterial/viral infection

Which treatment should the nurse prepare to administer when providing care to a toddler who presents after an accidental overdose of aspirin?

- activated charcoal

Which assessment data related to the patient's airway would indicate the need for priority intervention by the nurse?

- agonal breaths

Which are the top priorities when conducting a primary patient survey during the emergency assessment? Select all that apply.

- airway - cervical spine

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.

- airway maintenance - ventilation assistance - hemorrhage control - hypothermia prevention

The nurse is providing care to several patients in the emergency department. Which patient would require priority care from the nurse?

- an adult patient with unstable vital signs and chest pain

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?

- an avalanche

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

- anthrax - botulism - tularemia

Which treatment for anthrax should be included in the biological agent portion of a disaster plan for terrorist attacks?

- antibiotics

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?

- arranging group discussion

Nursing interventions for a snake bite

- assess for tissue edema q15 to 30 min

Which nursing action is appropriate when conducting a secondary survey during the emergency assessment?

- assigning a nurse to support family members

Which intervention would be a priority when providing care to a patient recovering from thoracic injuries sustained from a MVA?

- assist to cough and deep breath every two hours

Which medication should be listed as the antidote to a nerve agent in the disaster plan for a terrorist attack?

- atropine

Glascow Coma Scale (GCS)

- best possible score is 15 - score >13 minor head trauma - score 9 to 12 moderate head injury - <8 severe head injury

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

- blast - crush - penetration

A MS unit is experiencing a large volume of patient admissions after a train derailment. Which member of the nursing care team will prioritize care for the unit?

- charge nurse

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?

- communication

Which is a potentially life threatening condition found during the primary triage survey that would necessitate priority nursing care?

- concussion

The nurse is conducting a primary survey during the emergency assessment. Which nursing action is appropriate during the breathing assessment?

- counting respiratory rate

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)?

- covering the nose

Which health-care team member is a first responder when an emergency or mass casualty incident (MCI) occurs?

- critical care nurse

Late signs of increased ICP

- decreased LOC, decreased motor response to command, decreased sensory response to painful stimuli, loss of PERRLA, papilledema

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?

- determining drug allergies

Isoniazid (INH) for TB

- do not drink alcohol - monitor LFT prior to starting & throughout therapy - ^vitamin b6 or take pyridoxine

Which are the priority nursing actions after the completion of the secondary survey when providing care for a trauma patient with a penetrating wound?

- documenting the patient's care

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?

- drills

Which assessment data indicated the patient is experiencing a late symptom associated with chronic aspirin overdose?

- ecchymosis

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?

- emergency department

Which patient injury would receive a black tag by the triage nurse during a mass casualty incident?

- full-thickness body burns

The nurse is conducting a primary survey during an emergency assessment. Which is the priority nursing action related to breathing in response to the assessment?

- having suction available

Which entity is responsible for activating the disaster plan during a mass casualty incident (MCI)?

- hospital level emergency management system

Which is the priority in the preparedness of health-care professionals in any type of disaster plan?

- identification of hazards

Which nursing actions are appropriate during the primary survey of the emergency assessment process? Select all that apply.

- immobilizing the cervical spine - preparing for chest tube insertion - applying direct pressure to a wound

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?

- implementing decontamination measures

ICP

- intracranial pressure (normal pressure is 10 to 15 mm Hg)

Which amount of time is appropriate for nurse to spend triaging each patient during a mass casualty incident?

- less than 15 seconds

Early signs of increased ICP

- level of consciousness, disorientation, confusion, lethargy, agitation - Headache (SEVERE), seizures, unequal or sluggish pupils

ethambutol for TB

- monitor visual acuity tests/color discrimination ability

Which observation indicates that interventions provided to a patient with neck injuries from a MVA have been successful?

- moves all 4 extremities independently, feeds self and participates in partial bath

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.

- nuclear - biological - nipah virus

Which emergency medical system (EMS) first responders can perform triage during mass casualty incidents?

- nurses appointed to a field team

Which psychosocial nursing actions are appropriate when providing patient care after a community disaster? Select all that apply.

- offering choices whenever possible - establishing rapport through active listening - requesting assistance from crisis counselors

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?

- open femur fracture

What should the nurse do to assist a pt brought to the ED as a victim of a GSW?

- preserve the chain of evidence

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?

- red

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

- removing patients from immediate danger - using a wheelchair to move a bedridden patient - directing ambulatory patients to walk to a safe location

Which is the essential nursing skill for the triage process in the emergency department?

- setting priorities

Which is the priority nursing action when providing care to a patient with a penetrating abdominal wound?

- stabilizing the impaled object

Which nursing actions are necessary when initiating care for patients who have been injured in a natural disaster? Select all that apply.

- taking risks - using principles - stepping into the unknown - showing a commanding prescence

The RN is the team leader for a group of patients using the functional model of nursing. The team of nurses includes two LPNs and an UAP. Which task will the RN delegated to the UAP?

- taking vital signs

Which member of the HC team, when using the team nursing approach, is responsible for prioritizing patient care?

- team leader

A pt recovering from a MVA develops hypotension and jugular distention with a tracheal deviation. Based on this data, which should the nurse expect occurred?

- tension pneumothorax

Which situation does not cover nurses who respond to a mass casualty incident (MCI) for malpractice or negligent lawsuits under the Good Samaritan Act?

- terrorist act

Which organization in the United States mandates ongoing disaster preparedness for hospitals?

- the joint commission

Which nursing actions during a mass casualty incident should be included in the triage portion of an organizational disaster plan? Select all that apply.

- treatment - stabilization - decontamination for suspected contamination

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?

- two

Which public health risk became a major focus for hospitals after the September 11, 2001 terrorist attacks?

- weapons of mass destruction

The nurse is providing care to a trauma patient. What is the correct order of steps the nurse will implement when providing care to this patient? Select all that apply. (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) Clear the airway 2) Protect the cervical spine 3) Perform chest compressions 4) Provide supplemental oxygen

1243

The nurse is providing care to several patients in the emergency department. In which order should the nurse assess and provide care to the patients? (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) A patient with a leg laceration requiring sutures 2) A patient with abdominal pain rated as a 7 on a numeric pain scale 3) A patient who has multiple trauma due to a motor vehicle accident 4) A patient who took an overdose of opioids with a respiratory rate of eight breaths per minute

4321