MEDSURG 3 Ch 21: Emergency and Disaster Nursing

24. Which interventions will the nurse plan for a comatose patient who will have targeted temperature management/therapeutic hypothermia? (Select all that apply.) a. Assist with endotracheal intubation. b. Insert an indwelling urinary catheter. c. Begin continuous cardiac monitoring. d. Prepare to give sympathomimetic drugs. e. Obtain a prescription for patient restraints.

a. Assist with endotracheal intubation. b. Insert an indwelling urinary catheter. c. Begin continuous cardiac monitoring.

12. A patient arrives in the emergency department (ED) several hours after taking ―25 to 30‖ acetaminophen (Tylenol) tablets. Which action will the nurse plan to take? a. Administer N-acetylcysteine. b. Prepare for chelation therapy. c. Start oxygen using a non-rebreather mask. d. Have the patient drink large amounts of water.

a. Administer N-acetylcysteine.

18. An unresponsive 79-yr-old patient is admitted to the emergency department (ED) during a summer heat wave. the patient's core temperature is 105.4 F (40.8 C), blood pressure (BP) is 88/50 mm Hg, and pulse is 112 beats/min. Which action would the nurse plan to take? a. Apply wet sheets and a fan to the patient. b. Provide O2 at 2 L/min with a nasal cannula. c. Start lactated Ringer's solution at 1000 mL/hr. d. Give acetaminophen (Tylenol) rectal suppository.

a. Apply wet sheets and a fan to the patient.

19. An unresponsive patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first? a. Pulse b. Heart rhythm c. Breath sounds d. Body temperature

a. Pulse

20. Following an earthquake, patients are triaged by emergency medical personnel and transported to the emergency department (ED). Which color tag indicates that the nurse need to assess that patient first? a. Red b. Blue c. Black d. Yellow

a. Red

23. The urgent care center protocol for tick bites includes the following actions. Which action will the nurse take first when caring for a patient with a tick bite? a. Use tweezers to remove any remaining ticks. b. Check thevital signs, including temperature. c. Give doxycycline (Vibramycin) 100 mg orally. d. Obtain information about recent outdoor activities.

a. Use tweezers to remove any remaining ticks.

9. The emergency department (ED) nurse is requested to plan for a response to the potential use of smallpox as a biological weapon. Which resource would the nurse recommend be obtained? a. Vaccine b. Atropine c. Antibiotics d. Whole blood

a. Vaccine

6. A patient who experienced blunt abdominal trauma during a motor vehicle collision reports increasing abdominal pain. For which procedure would the nurse expect to prepare the patient? a. Peritoneal lavage b. Abdominal ultrasonography c. Nasogastric (NG) tube placement d. Magnetic resonance imaging (MRI)

b. Abdominal ultrasonography

13. A triage nurse in a busy emergency department (ED) assesses a patient who reports 7/10 abdominal pain and states, I had a temperature of 103.9 F (39.9 C) at home. Which action would the nurse take first? a. Administer acetaminophen (Tylenol). b. Assess the patient's current vital signs. c. Ask the patient to provide a clean-catch urine for urinalysis. d. Tell the patient that it may be 2 hours before seeing a health care provider.

b. Assess the patient's current vital signs.

16. Gastric lavage and administration of activated charcoal are prescribed for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action would the nurse plan to take first? a. Insert a large-bore orogastric tube. b. Assist with endotracheal intubation. c. Prepare a 60-mL syringe with saline. d. Give first dose of activated charcoal.

b. Assist with endotracheal intubation.

15. The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action would the nurse take first? a. Apply ice packs to both hands. b. Attempt to remove the patient's rings. c. Apply calamine lotion to itching areas. d. Give prescribed diphenhydramine (Benadryl)

b. Attempt to remove the patient's rings.

4. A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. Which action would the nurse complete during the primary survey of the patient? a. Obtain a complete set of vital signs. b. Check a Glasgow Coma Scale score. c. Attach an electrocardiogram monitor. d. Ask about chronic medical conditions.

b. Check a Glasgow Coma Scale score.

11. When assessing an older patient admitted to the emergency department (ED) with a broken arm and facial bruises, the nurse observes several additional bruises in various stages of healing. Which statement or question would the nurse provide first? a. You should not go home. b. Do you feel safe at home? c. Would you like to see a social worker? d. I need to report my concerns to the police.

b. Do you feel safe at home?

25. The emergency department (ED) nurse is starting targeted temperature management/therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/VN)? (Select all that apply.) a. Evaluate changes in heart rhythm. b. Insert a urinary catheter to drainage. c. Assess neurologic status every 2 hours. d. Place cooling blankets above and below patient. e. Attach rectal temperature probe to cooling blanket control panel.

b. Insert a urinary catheter to drainage. d. Place cooling blankets above and below patient. e. Attach rectal temperature probe to cooling blanket control panel.

1. The nurse is doing the primary survey of an adult who was in a motor vehicle collision. After the nurse determines that the patient has an unobstructed airway, which action would the nurse take next? a. Palpate extremities for bilateral pulses. b. Observe the patient's respiratory effort. c. Check the patient's level of consciousness. d. Examine the patient for external bleeding.

b. Observe the patient's respiratory effort.

14. The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient requires the most immediate treatment? a. A patient with no pedal pulses b. A patient with an open femur fracture c. A patient with paradoxical chest motion d. A patient with bleeding facial lacerations

c. A patient with paradoxical chest motion

21. Family members are in the patient's room when the patient has a cardiac arrest and the staff start resuscitation measures. Which action would the nurse take first? a. Keep the family in the room and assign a staff member to explain the care given and answer questions. b. Ask the family to wait outside the patient's room with a staff member to provide emotional support. c. Ask the family members whether they would prefer to remain in the patient's room or wait outside the room. d. Tell the family members that patients are comforted by having family members present during resuscitation efforts.

c. Ask the family members whether they would prefer to remain in the patient's room or wait outside the room.

17. A patient arrives in the emergency department (ED) after topical exposure to powdered lime at work. Which action would the nurse take first? a. Obtain the patient's vital signs. b. Obtain a baseline complete blood count. c. Brush visible powder from the skin and clothing. d. Decontaminate the patient by showering with water.

c. Brush visible powder from the skin and clothing.

7. A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). Which patient statement indicates to the nurse that discharge teaching has been effective? a. I'll take salt tablets when I work outdoors in the summer. b. I should take acetaminophen (Tylenol) if I start to feel too warm. c. I need to drink extra fluids when working outside in hot weather. d. I'll move to a cool environment if I notice that I'm feeling confused.

c. I need to drink extra fluids when working outside in hot weather.

3. A patient who had a cardiac arrest has been resuscitated and therapeutic hypothermia is prescribed. Which action will thenurse include in theplan of care? a. Hold theprescribed sedative drugs. b. Check mental status every 15 minutes. c. Initiate protocol for temperature management. d. Rewarm if temperature is below 91 F (32.8 C).

c. Initiate protocol for temperature management.

22. A patient who has deep human bite wounds on the left hand is being treated in the urgent care center. Which action will the nurse plan to take? a. Prepare to administer rabies immune globulin. b. Assist the health care provider with suturing the wounds. c. Teach the patient about the use of prophylactic antibiotics. d. Keep the wounds dry until the health care provider can assess them.

c. Teach the patient about the use of prophylactic antibiotics.

8. A 22-yr-old patient who experienced a drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period? a. Assess heart sounds. b. Palpate peripheral pulses. c. Check mental orientation. d. Auscultate breath sounds.

d. Auscultate breath sounds.

2. During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next? a. Send blood to the lab for a complete blood count. b. Assess further for a cause of the decreased circulation. c. Finish the airway, breathing, circulation, disability survey. d. Start normal saline fluid infusion with two large-bore IV lines.

d. Start normal saline fluid infusion with two large-bore IV lines.

5. A 19-yr-old patient presents to the emergency department (ED) with multiple lacerations and tissue avulsion of the left hand. the patient denies having any previous vaccinations. What would the nurse anticipate administering? a. Tetanus immunoglobulin (TIG) only b. TIG and tetanus-diphtheria toxoid (Td) c. Tetanus-diphtheria toxoid and pertussis vaccine (Tdap) only d. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap)

d. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap)

10. Which finding indicates that the nurse should discontinue active rewarming of a patient admitted with hypothermia? a. The patient begins to shiver. b. The BP decreases to 86/42 mm Hg. c. The patient develops atrial fibrillation. d. The core temperature is 94 F (34.4 C).

d. The core temperature is 94 F (34.4 C).