OG burns, emergency and trauma quiz

In the work setting, what is the nurse's primary responsibility in preparing for management of disasters, including natural disasters and bioterrorism incidents? 1. Knowing the agency's emergency response plan 2. Being aware of the signs and symptoms of potential agents of bioterrorism 3. Knowing how and what to report to the Centers for Disease Control and Prevention (CDC) 4. Making ethical decisions about exposing self to potentially lethal substances

1. Knowing the agency's emergency response plan

the nurse is caring for a client with multiple injuries sustained during a head-on car collision. which assessment finding takes priority? 1. a deviated trachea 2. unequal pupils 3. ecchymosis in the flank area 4. irregular apical pulse

1. a deviated trachea

The nurse is giving discharge instructions to a woman who has been treated for contusions and bruises sustained during an episode of domestic violence. What is the priority intervention for this client? 1. encourage client to go to a safe house 2. make a referral to a counselor 3. advise the client about contacting the police 4. make an appointment to follow up on the injuries

1. encourage client to go to a safe house

in the work setting, what is the nurse's priority responsibility in preparing for management of disasters,including natural and bioterrorism incidents? 1. knowing the agency's emergency response plan 2. being aware of the signs and symptoms of potential agents of bioterrorism 3. knowing how and what to report to the CDC 4. making ethical decisions about exposing self to potentially lethal substances

1. knowing the agency's emergency response plan

A man, with a known history of alcohol abuse, has been in police custody for 48 hours. Initially, anxiety, sweating, and tremors were noted. Now, disorientation, hallucination, and hyperreactivity are observed. The medical diagnosis is delirium tremens. What is the priority nursing concept to consider in planning interventions for this emergency condition? 1. safety 2. psychosis 3. thermoregulation 4. addiction

1. safety

a newly graduated nurse overhears a senior ED nurse making sarcastic remarks toward a medical student and refusing to help the student find the equipment for a nonemergent client procedure. what should the new nurse do first? 1. step in and offer to assist the medical student because the other nurse is unwilling 2. confront the senior nurse and indicate that an apology is the right thing to do 3. observe the situation and then report behaviors of both parties to the charge nurse 4. watch and observe the dynamics the scenario is probably typical of unit norms

1. step in and offer to assist the medical student because the other nurse is unwilling

The nurse is assessing a client who has sustained a cat bite to the left hand. that cat's immunizations are up to date. the date of the client's last tetanus shot is unknown what is the priority concern? 1. treating the infection specific to cat bites 2. suturing punctured wounds 3. adminsitering tetanus vaccine 4. maintaining mobility of the finger joints

1. treating the infection specific to cat bites

According to the Joint Commission, hospitals are required to form emergency management committees to periodically exercise the disaster operations plan. hospital administration has selected various HCP to join. members from which other key departments should be included? SATA 1. security and communications 2. nursing and UAP 3. lab and diagnostic services 4. medical and information technology 5. maintenance and engineering 6. physical therapy and occupational therapy

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A client comes to the ED and reports nausea, vomiting, colicky abdominal pain, fever, and tachycardia. the health care provider informs the nurse that the client probably has a strangulated intestinal obstruction with perforation. what diagnostic testing and interventions does the nurse anticipate for this emergency condition? SATA 1. preparation for surgery 2. barium enema examination 3. NG tube insertion 4. abdominal radiography 5. IV fluid administration 6. IV administration of spectrum antibiotics

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A group of people arrive at the ED by private car reporting extreme periorbital swelling, cough, and tightness in the throat. There is a strong odor emanating from their clothes. They report exposure to a "gas bomb" that was set off in their house. What is the priority action? 1. Measure vital signs and listen to lung sounds. 2. Direct the clients to the decontamination area. 3. Instruct clients to don personal protective equipment. 4. Direct the clients to the cold or clean zone for immediate treatment.

2. Direct the clients to the decontamination area.

a newly hired ED clinical nurse specialist is reviewing the hospitals disaster plan and finds that it has or been reviewed or revised for 3 years. which finding will be the most important for the nurse specialist to address related to the status of the disaster plan? 1. stockpiles of abx and resuscitation equipment may be depleted 2. current staff is unlikely to have training and practice in using the plan 3. resources within and outside of the hospital are likely to have changed 4. surrounding communities are at increased risk for technological disasters

2. current staff is unlikely to have training and practice in using the plan

the nurse notifies the ED HCP about a client who reports abdominal pain, nausea and vomiting, and fever. the abdomen is distended, rigid, and boardlike, and there is rebound tenderness. later the nurse sees that the client and the symptoms seems worse. what should the nurse do first? 1. contact the nursing supervisor 2. express findings and concerns to the HCP 3. discharge the client but stress the importance of follow-up 4. follow the discharge orders and write an incidence report

2. express findings and concerns to the HCP

a young woman is brought to the ED by EMS. EMS reports they were called because the woman has been depressed and threatening to commit suicide. on arrival to the Ed, the woman is confused, her speech is slurred and there is vomit on her clothes. EMS found several empty prescription bottles at the house. what are the priority interventions for this client? 1. identify toxic substances by history and analysis of blood, urine, and gastric contents 2. initiate supportive care such as checking airway and giving o2 with IV fluids 3. reduce absorption by giving activated charcoal or performing gastric lavage 4. promote poison removal by using drugs to facilitate excretion or by starting hemodialysis

2. initiate supportive care such as checking airway and giving o2 with IV fluids

The nurse is working in the triage area of an ED and the following four clients approach the triage desk at the same time. List the order in which the nurse will assess these clients. 1. an ambulatory, dazed 25-year old man with a bandaged head wound 2. an irritable newborn with a fever, petechia and nuchal rigidity 3. a 35 year old jogger with a twisted ankle who has a pedal pulse and no deformity 4. A 50 year old women with moderate abdominal pain and occasional vomiting.

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A nurse is assessing a client with second degree burns. The shaded areas in the illustration indicate the parts of the body where the client sustained burns. Calculate the percentage fo the body that was burned using the Rule of Nines. Record your answer using one decimal place.

22.5%

identify the five most critical elements in performing disaster triage for multiple victims. SATA 1. obtain past medical and surgical history 2. check ABCs 3. assess the LOC 4. visually inspect for gross deformities, bleeding and obvious injuries 5. note the color, presence of moisture and temperature of skin 6. check vitals

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The nurse is performing a sterile dressing change for a client who infected deep partial thickness burns of the chest and abdomen. list the steps in order in which each should be accomplished. a. apply sliver sulfadiazine ointment b. obtain specimens for aerobic and anaerobic wound cultures c. administer morphine sulfate 10mg IV d. debride the wound of eschar using gauze spongese. e. cover the wound with a sterile gauze dressing

3, 4, 2, 1, 5

when a primary survey of a trauma client is conducted, what is one of the priority actions that would be performed first? 1. obtain a complete set of vitals 2/ palpate and auscultate the abdomen 3. perform a brief neurologic assessment 4. check the pulse oximetry reading

3. perform a brief neurologic assessment

a confused client admits to frequently drinking alcohol. the ED HCP makes a preliminary diagnosis of Wernicke encephalopathy. which medication does the nurse anticipate that the HCP will prescribe initially? 1. glucagon IV 2. Naltrexone IM 3. Thiamine IV 4. Nalaxone IV

3. Thiamine IV

a 56 year old client comes to the triage area with left-sided chest pain, diaphoresis, and dizziness. what is the priority action? 1. initiate continuous electrocardiogram monitoring 2. notify the emergency department health care provider 3. administer oxygen via nasal cannula 4. draw blood and establish IV access

3. administer oxygen via nasal cannula

an experienced traveling nurse has been assigned to work in the ED however this is the nurses first week on the job. which area of the ED is the most appropriate assignment for this nurse? 1. trauma team 2. triage 3. ambulatory or fast-track clinic 4. pediatric medicine team

3. ambulatory or fast-track clinic

The nurse is caring for a client who is on the cardiac monitor because of these symptoms: syncope, dizziness, and intermittent episodes of palpitations. what should the nurse do first? 1. call the RRT 2. obtain the automated external defibrillator 3. assess the client and take vitals 4. check the adherence of the gel pads on chest

3. assess the client and take vitals

when an unexpected death occurs inthe ED, which task is most appropriate to delegate to a UAP? 1. escorting the family to a place of privacy 2. accompanying organ donor specialist to talk to the family 3. assisting the postmortem care 4. helping the family to collect belongings

3. assisting the postmortem care

he LPN is performing care for a client who sustained an amputation of the first and second digits in a chainsaw accident. what instructions would the RN give to the LPN? 1. clean the amputated digits and the hand with a povidone-iodine and normal saline solution; then wrap with gauze 2. clean the amputated digits, wrap them in gauze, and place cleansed digits directly into an ice slurry 3. clean the amputated digits with saline, wrap in moist gauze, seal in a plastic bag, and place in ice slurry 4. clean the digits with sterile normal saline and submerge the digits in sterile normal saline in a sterile cup

3. clean the amputated digits with saline, wrap in moist gauze, seal in a plastic bag, and place in ice slurry

the clients blood alcohol level is 0.45%. based on this information, what is the priority nursing concept that underlies emergency medical and nursing interventions for this client? 1. cognition 2. addiction 3. gas exchange 4. functional ability

3. gas exchange

a healthy but anxious 24 year old college student reports tingling sensations, palpations, and sore chest muscles. deep rapid breathing and carpal spasms are noted. what priority action should the nurse take? 1. notify the health care provider immediately 2. administer supplemental oxygen 3. have the student breathe into a paper bag 4. obtain an order for an anxiolytic medication

3. have the student breathe into a paper bag

a victim of heat stroke arrives int he ED. His skin is hot and dry; his body temperature is 105 F he is confused and demonstrates bizarre behavior. his BP is 85/60 Hg, pulse 130, RR 40. which task should be assigned to an experienced LPN? 1. insert a rectal probe to measure core body temperature 2. administer aspirin or another antipyretic 3. insert an indwelling urinary drainage catheter 4. assess respiratory effort, hemodynamics, and mental status

3. insert an indwelling urinary drainage catheter

Tetanus immunizations are routinely administered during childhood and in the ED for clients who sustain wounds. although the incidence of tetanus has decreased, there is still a danger. which client represents the group that is most vulnerable for risk? 1. child who helps with the farm work sustained scratches while feeding the animals 2. newborn infant delivered in the ED, mother has no prenatal care 3. older adult who lives alone sustained a minor cut while cleaning the basement 4. young adult who works in an auto repair shop sustained a deep cut on a metal edge

3. older adult who lives alone sustained a minor cut while cleaning the basement

in the care of a client who has experienced sexual assault, which task is most appropriate for the LPN to perform? 1. assessing immediate emotional state and physical injuries 2. collecting hair samples, saliva, and scraping beneath fingernails 3. providing emotional support and supportive communication 4. ensuring that the chain of custody of evidence is maintained

3. providing emotional support and supportive communication

the nurse is caring for a client with frostbite to the feet. place the following interventions in the correct order. 1. apply loose, sterile, bulky dressing 2. give pain medication 3. remove the client from the cold environment 4. immerse the feet in warm water of 105 degrees to 115 degrees 5. monitor for compartment syndrome

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A client involved in a one-car rollover comes in with multiple injuries. List in order of priority the interventions that must be initiated for this client. 1. Secure two large-bore IV lines and infuse normal saline. 2. Use the chin lift or jaw thrust maneuver to open the airway. 3. Assess for spontaneous respirations. 4. Give supplemental oxygen via mask. 5. Obtain a full set of vital sign measurements. 6. Remove the client's clothing.

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Emergency and ambulatory care nurses are among the first health care workers to encounter victims of a bioterrorist attack. List in order of priority the actions that should be taken by ED staff in the event of a biochemical incident. 1. Report to the public health department or CDC per protocol. 2. Decontaminate the affected individuals in a separate area. 3. Protect the environment for the safety of personnel and nonaffected clients. 4. Don personal protective equipment. 5. Perform triage according to protocol.

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emergency and ambulatory care nurses are some of the first health care workers to encounter victims of bioterrorist attack. list in order of priority the actions that should be taken by ED staff in the event of a biochemical incident. 1. report to the public health department of CDC per protocol 2. decontaminate the affected individuals in a separate area 3. protect the environment for the safety of personnel and nonaffected clients 4. don PPE 5. perform triage according to protocol

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the nurse is assigned to telephone triage. a client who was just stung by a common honeybee calls for advice. which question would the nurse ask first? 1. is this the first time you have been stung by a wasp? 2. do you have access to and know how to use an epinephrine auto injection? 3. what type of first aid measures have you tried? 4. are you having any facial swelling, wheezing or SOB?

4. are you having any facial swelling, wheezing or SOB?

It is the summer season, and clients with signs and symptoms of heat-related illness come to the ED. Which client needs attention first? 1. Older person with reports of dizziness and syncope after standing in the sun for several hours to view a parade 2. Marathon runner who reports severe leg cramps and nausea, and shows tachycardia, diaphoresis, pallor, and weakness 3. Relatively healthy homemaker who reports that the air conditioner has been broken for days and who manifests tachypnea, hypotension, fatigue, and profuse diaphoresis 4. Homeless person with altered mental status, poor muscle coordination, and hot, dry, ashen skin; and whose duration of heat exposure is unknown

4. Homeless person with altered mental status, poor muscle coordination, and hot, dry, ashen skin; and whose duration of heat exposure is unknown

the nurse manager decides to form a committee to address the issue of violence against ED personnel. which combination of employees would be best suited to fulfill this assignment? 1. ED physician and charge nurses 2. experienced RN and experienced paramedics 3. RNs, LPNs, and UAPs 4. at least one person from all ED groups

4. at least one person from all ED groups

after the emergency endotracheal intubation, the healthcare team and the nurse must verify tube placement before securing the tube. what is the most accurate bedside assessment that can be performed immediately after the tube is placed? 1. visualize the movement of the thoracic cage 2. auscultate the chest during assisted ventialtion 3. confirm that the breath sounds are equal bilaterally 4. check exhaled carbon dioxide levels with capnography

4. check exhaled carbon dioxide levels with capnography

the nurse is talking to a group of people about the industrial explosion in which many people were killed or injured. which individual has the greatest risk for psychiatric difficulties such as PTSD related to the incident? 1. individual who repeatedly watched television coverage of the event 2. person who recently learned that her son was killed in the incident 3. individual who witnessed the death of a co-worker during the explosion 4. person who was injured and trapped for several hours before rescue

4. person who was injured and trapped for several hours before rescue

the nurse and group of friends are at the lake. suddenly someone says, "look across the table! it looks like someone might be drowning!" what is the nurses first action? 1. determine who is the strongest swimmer in the group 2. direct someone to locate a cell phone and call 911 3. find a boat, raft, or some type of flotation device 4. use a pair of binoculars and look across the lake

4. use a pair of binoculars and look across the lake

the nurse is working in a small rural community hospital. ther is a fire in a local chrch, and six injured clients have arrived at the hospital. many other are expected to arrive soon an other hospitals are 5 hours away. using disaster triage principles, place the following six clients in the order in which they should receive medical attention, with 1 being the first to receive attention and 6 being the last. 1. 52 year old man in full cardiac arrest who has been receiving cardiopulmonary resuscitation for the past 60 minutes 2. a firefighter who is showing combative behavior and has respiratory stridor 3. 60 year old woman with full-thickness burns to the hands and forearms 4. teenager with a crushed leg that is very swollen; he is anxious with tachycardia 5. a 3 year old child with respiratory distress and burns over more than 70% of the anterior body 6. 12 year old child with wheezing and very labored respirations unrelieved by an asthma inhaler

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The ED is preparing a situation, background, assessment, recommendation (SBAR) report on a patient being admitted for bacterial meningitis. Which points are included in the ED nurse's report to the medical surgical nurse? SATA A. "Patient reports severe headache with high fever that started 4 days ago" B."Patient is currently alert and oriented x2; speech clear but rambling" C. "Patient is very demanding and has used the call bell repeatedly since arriving in the ED" D. "IV normal saline into left anterior forearm; received first dose of IV cefriaxone at 0700" E. "Lumbar puncture results are pending, but meningococcal meningitis is suspected" F. "Patient has male characteristics but prefers to be called Mrs. Jenny Jones"

A. "Patient reports severe headache with high fever that started 4 days ago" B."Patient is currently alert and oriented x2; speech clear but rambling" D. "IV normal saline into left anterior forearm; received first dose of IV cefriaxone at 0700" E. "Lumbar puncture results are pending, but meningococcal meningitis is suspected" F. "Patient has male characteristics but prefers to be called Mrs. Jenny Jones"

Which event would be considered an internal disaster? A. A fire in a long term care facility B. Gunfire in the hospital parking lot C. A tornado devastates the community D. Several people dying from flulike symptoms

A. A fire in a long term care facility

To promote effective coping for survivors of a mass-casualty event, the nurse uses which principles while interacting with patients in crisis? SATA A. Actively listening to feelings and expression of experiences B. Reassuring that everything will be okay and things will return to normal C. Encouraging exploring about why the event occurred and who caused it D. Helping to problem solve E. conveying caring behaviors F. Advocating resumption of daily routines as soon as possible

A. Actively listening to feelings and expression of experiences D. Helping to problem solve E. conveying caring behaviors

Which nurse activity would best help the hospital to meet The Joint Commission's mandate for emergency preparedness? A. Assist in planning drills that include patient simulations B. Help other nurses make a personal emergency preparedness plan C. Attend training classes to learn how to handle hazardous materials D. Identify the credible treats to the safety of the community

A. Assist in planning drills that include patient simulations

The nurse is assigned to assist the hospital incident commander during a disaster drill. Which responsibility is appropriate for the nurse in this capacity? A. Call all nursing units to determine the number of patients who could potentially be discharged B. Call the physical therapy department and direct therapists to assist in the operating room or the ICU C. Go to the emergency department and assist with the triage of disaster victims to appropriate clinical areas D. Contact the security department and instruct them to control the number of people who attempt to enter the hospital

A. Call all nursing units to determine the number of patients who could potentially be discharged

A patient arrives at the ED after a prolonged cold exposure. The staff avoids rough and vigorous movements during the transfer from stretcher to bed to prevent which complication? A. Ventricular fibrillation related to rough handling B. Third degree heart block related to cold autotransfusion C. After-drop due to cold blood moving to the central circulation D. Pulmonary emboli related to dislodgment of a clot

A. Ventricular fibrillation related to rough handling

At 3:00 AM, the emergency department charge nurse of a large suburban hospital receives notification that a commercial plane has just crashed outside the city limits. What does the nurse do? A. Collaborate with the medical command physician B. Activate the hospital's emergency management plan C. Initiate the staff telephone tree D. Collaborate with the triage officer E. Organize nursing and ancillary services F. Alert the critical incident stress debriefing team

A. Collaborate with the medical command physician C. Initiate the staff telephone tree D. Collaborate with the triage officer E. Organize nursing and ancillary services

The nurse is assigned to assist the incident commander who is evaluating the feasibility of deactivating the emergency management plan. The commander directs the nurse to accomplish certain tasks. Which task is the priority? A. Contact all hospital departments and determine if needs have been met B. Go to the emergency department and supervise inventory and restocking of supplies C. Arrange for temporary sleeping quarters for exhausted staff members D. Assist in the preparations of the critical incident stress debriefing

A. Contact all hospital departments and determine if needs have been met

A nurse is caring or a client who has a disturbed body image as a result of a burn injury. Which is an important nursing intervention for this client? A. Conveying a positive attitude toward the client B. Arranging for the client to meet other clients with burns C. Removing mirrors until the client's physical appearance has improved D. Reminding family members to avoid comments about the client's appearance

A. Conveying a positive attitude toward the client

A person on the beach sustains a deep partial-thickness burn because of a severe sunburn. What is the best first aid measure that a nurse should instruct the person to apply before seeking health care? A. Cool, moist towels B. Dry, sterile dressing C. Analgesic sunburn spray D. Vitamin A and D ointment

A. Cool, moist towels

A parent brings her 2-year-old child to the ER stating, "She fell and bumped her head and forearm." Which behavior by the child causes the least concern during the initial triage interview? A. Crying and reaching for the parent as the nurse approaches B. Alert and still, quietly watching as the nurse approaches C. Asleep, limp with even and unlabored respirations D. Crying loudly and inconsolably since she was brought in

A. Crying and reaching for the parent as the nurse approaches

A patient is admitted for a brown recluse spider bite. The nurse observes that the patient has hemorrhagic complications of hematuria, hemoptysis, petechiae, and extensive bruising. These clinical observations indicate to the nurse that the patient may be experiencing which complication associated with the bite? A. DIC B. Agranulocytosis C. Thrombocytopenia D. Aplastic Anemia

A. DIC

A community hospital is reviewing the activation and implementation of its emergency preparedness plan after a recent mass-casualty event. Which outcome statement reflects the goal of an administrative review? A. Emergency preparedness plan was activated in a timely fashion, but telephone tree was outdated and did not include new employees B. Three hundred employees were offered a debriefing session, and two employees have symptoms of post traumatic stress disorder C. The mass-casualty event was handled well, and we expect to see positive reports in the media and to receive additional funding D. The mass-casualty event resulted in an influx of 35 walking wounded, and 6 patients came via emergency medical transport

A. Emergency preparedness plan was activated in a timely fashion, but telephone tree was outdated and did not include new employees

A patient sustained a bite from a pit viper and is admitted for observation. Which potential complications does the nurse observe for? SATA A. Hemorrhagic bullae B. Tingling of scalp, lips or face C. Hypertension D. Excessive salivation with drooling E. Clotting abnormalities F. Seizures

A. Hemorrhagic bullae B. Tingling of scalp, lips or face E. Clotting abnormalities F. Seizures

What might the nurse notice if the patient has impaired thermoregulation as a result of a cold-related injury? SATA A. Hyperemia and edema of fingers or toes B. Shivering C. Possible atrial fibrillation D. Numbness and pain of the nose and ears E. Profuse diaphoresis F. Headache, weakness, nausea and vomiting

A. Hyperemia and edema of fingers or toes B. Shivering D. Numbness and pain of the nose and ears

A client with 35% of total body surface area burned in a fire is now 48 hours postburn. The nurse concludes that the client is moving from the emergent to the acute phase of burn management. Which response supports this conclusion? A. Hypokalemia B. Hypoglycemia C. Decreased blood pressure D. Increased urine specific gravity

A. Hypokalemia

A young migrant worker has been living in a garden shed for several months. He is brought to the ED and is alert and conversant but appears fearful and confused. His skin is hot and dry, and his lips are cracked and bleeding. His skin turgor is poor, and he is malnourished. His BP is 96/60, pulse is 130, respirations are 30 and temp is 105. In addition to high flow oxygen, what does the nurse anticipate the ED health care provider will initially order? A. IV normal saline and an indwelling urinary catheter B. IV Ringer's lactate and a nasogastric tube C. IV 5% dextrose and acetaminophen D. IV 45% saline and chlorpromazine

A. IV normal saline and an indwelling urinary catheter

Which combination of factors is likely to contribute to the highest survival rate for drowning victims who are immediately transported to the emergency department for care? A. In very cold fresh water for 7 minutes; arrives in the ED with pulse of 40 B. In warm salt water for 12 minutes; arrives in the ED with pulse of 150 C. In very cold water for 10 minutes; arrives in the ED with no pulse D. In warm contaminated water for 6 minutes; arrives in the ED with no pulse

A. In very cold fresh water for 7 minutes; arrives in the ED with pulse of 40

A nurse is caring for a client during the emergent phase of a severe burn injury. Which parenteral intervention prescribed by the health care provider should the nurse question? A. Colloids B. Potassium C. Hypertonic saline D. Lactated Ringer solution

B. Potassium

The nurse is making a personal emergency preparedness plan. What is the nurse sure to include in the plan? A. Make a disaster supply kit with clothing and basic survival supplies B. Resolve the ethical conflict of family and professional obligations C. Stockpile antibiotics, first-aid supplies, and resuscitation equipment D. Teach family members about radiation and bioterrorism safety issues

A. Make a disaster supply kit with clothing and basic survival supplies

Which patient has the most predisposing factors that are associated with heat-related illness? A. Obese older male who drinks beer in the afternoon at a baseball game B. Middle aged female with hypothyroidism who lives in the southern united states C. Malnourished young female with an eating disorder who exercises in the morning D. Young female with iron deficiency anemia who is in the first trimester of pregnancy

A. Obese older male who drinks beer in the afternoon at a baseball game

What is the fastest way for the nurse to estimate the systolic blood pressure in a patient with multiple injuries who has just been moved from the transport stretcher to the emergency department resuscitation stretcher? A. Palpate for presence of a radial pulse B. Use the automated blood pressure cuff C. Place the patient on a cardiac monitor D. Check for the presence of capillary refill

A. Palpate for presence of a radial pulse

The healthcare provider orders IV infusion of epinephrine for an older adult patient for an allergic reaction to a bee sting. In conjunction with the epinephrine administration, which action does the nurse take? A. Places the patient on a cardiac monitor B. Inserts an indwelling urinary cathter C. Obtains an order for an electrocardiogram D. Obtains an order for an arterial blood gas

A. Places the patient on a cardiac monitor

The nurse is interviewing a homeless patient in the triage area. The patient says, "I'm a nurse too. Flying pictures say God is me. I'm a god, taking noise away." The patient then stands up and kicks over the garbage can. What should the nurse do first? A. Remain calm and slowly step away from the patient B. Run toward the panic button and immediately push it C. Gently take the patient's arm and lead her to a quiet space. D. Call for help and instruct bystanders to get out of the way

A. Remain calm and slowly step away from the patient

A client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department chest tubes are inserted, one in the second intercostal space and one at the base of the lung. What does the nurse expect the tube in the second intercostal space to accomplish? A. Remove the air that is present in the intrapleural space B. Drain serosanguinous fluid from the intrapleural compartment C. Permit the development of positive pressure between the layers of the pleura D. Provide access for the instillation of medication into the pleural space

A. Remove the air that is present in the intrapleural space

The nurse is advising a group of parents who are organizing a winter cross-country skiing trip. In assisting the parents to develop and appropriate winter clothing list, which articles should be taken on this trip? SATA A. Synthetic socks B. Cotton underwear C. Polyester fleece shirt D. Windproof outer jacket E. Hat made from waterproof, breathable fabric F. Sunglasses

A. Synthetic socks C. Polyester fleece shirt D. Windproof outer jacket E. Hat made from waterproof, breathable fabric F. Sunglasses

What are the most common s/s of high altitude pulmonary edema? SATA A. Tachypnea at rest B. Persistent dry cough C. Abdominal pain and cramping D. Waxy appearance of ears, cheeks and nose E. Cyanotic lips and nail beds F. Bradycardia at rest

A. Tachypnea at rest B. Persistent dry cough E. Cyanotic lips and nail beds

What should the nurse respond to the patient with impaired thermoregulation as a result of a cold-related injury? SATA A. Thaw frozen body parts in a warm water bath and handle gently B. Provide pain control measures C. Advocate for increased drug doses as a result of lowered metabolism D. Administer tetanus prophylaxis and possible antibiotics for open wounds E. Initiate passive external rewarming by covering with blankets F. Prepare patients for possible amputation of frostbitten body part

A. Thaw frozen body parts in a warm water bath and handle gently B. Provide pain control measures D. Administer tetanus prophylaxis and possible antibiotics for open wounds E. Initiate passive external rewarming by covering with blankets

A patient was bitten by a brown recluse spider 4 days ago. The nurse observes prolonged bleeding after venipuncture and notes that the patient has a low platelet count. What do these findings indicate? A. Thrombocytopenia B. Hemolytic anemia C. Aplastic anemia D. Agranulocytosis

A. Thrombocytopenia

The nurse is instructing a patient who has a history of severe allergic reaction to bee stings on what to do if he experiences a bee sting in the future. What information does the nurse relay to the patient? SATA A. Wear a medical alert bracelet B. Take an antihistamine before trying the epipen injection C. Administer epinephrine immediately D. Call 911 to be transported to a medical facility E. Immediately apply a moist warm towel F. Obtain a prescription for prophylactic corticosteroids

A. Wear a medical alert bracelet C. Administer epinephrine immediately D. Call 911 to be transported to a medical facility

The nurse is conducting a class about cold weather hiking. What are the early signs of frostbite, which hiking partners should frequently observe for? A. White, waxy or pale gray appearance to ears, nose and cheeks B. Edema, and redness over the exposed skin C. mottled discoloration of the lower extremities D. Small blisters that contain clear fluid and areas that do not blanch

A. White, waxy or pale gray appearance to ears, nose and cheeks

Which is the most difficult problem for the nurse to manage when meeting the needs of an extensively burned client 3 days after admission? A. severe pain B. Maintenance of sterility C. Alteration in body image D. Frequent dressing changes

A. severe pain

Each patient list below has entered the emergency departments wait area. Place them in order of priority, with 1 being the highest priority and 4 being the lowest priority A. a three year old child with inconsolable high-pitched cry, high fever, headache, and nuchal rigidity B. 65 year ld man having diaphoresis with crushing left anterior chest pain C. 32 year old woman reporting upper abdominal pain and vomiting green bile emesis D. 16 year old boy with a broken arm from skateboarding and pulse and sensation intact

B, A, C, D

Several people are looking out across a lake and pointing to a swimmer in the distance who appears to be struggling to stay afloat. What is the correct sequence of emergency steps to take? Select in order or priority. A. Handle gently to prevent ventricular fibrillation B. Safely rescue the victim C. Begin delivering rescue breaths as soon as soon as possible D. Assess neurologic status E. Assess airway patency

B, E, C, A, D

Which patient should be triaged as emergent? A. A 56 year old man with severe unilateral back pain and previous history of kidney stones B. 23 year old woman with severe abdominal pain, positive home pregnancy test and BP 80/40 C. 6 year old with a temperature of 101 degrees and flulike symptoms D. 10 year old girl with vomiting, diarrhea, and abdominal cramps onset 4 hours after eating fish

B. 23 year old woman with severe abdominal pain, positive home pregnancy test and BP 80/40

Which patient's are most likely to undergo care via triage nurse-initiated protocols? SATA A. 36 year-old female with flulike symptoms that started two days ago B. 55 year-old male with left anterior chest pain that started after exercising C. 88 year old male with sudden onset of confusion and shallow respirations D. 3 year old female with an earache and a low-grade fever E. 45 year old female with left sided weakness, slurred speech and drooling F. 18 year old male with tenderness of testicles that started after sexual intercourse

B. 55 year-old male with left anterior chest pain that started after exercising C. 88 year old male with sudden onset of confusion and shallow respirations E. 45 year old female with left sided weakness, slurred speech and drooling

The nurse is assessing a patient who reports being bitten by a black widow spider. The patient may have clinical s/s that mimic which disorder? A. Myocardial infarction B. Acute abdomen C. Acute renal failure D. Deep vein thrombosis

B. Acute abdomen

A client is rescued from a burning building has partial and full thickness burns over 40% of the body. Which is the initial physiologic change that the nurse can expect? A. An increase in blood volume B. An increase in serum potassium C. A decrease in capillary permeability D. A decrease in urine specific gravity

B. An increase in serum potassium

Which information should the nurse include in a teaching plan for a client whose burns are being treated with the exposure method? A. Bathing will not be permitted B. Aseptic techniques are required C. Dressings will be changed every 3 days D. Room temperature must be kept at 72 degrees

B. Aseptic techniques are required

The nurse is caring for a patient who sustained severe frostbite to the lower leg. The patient reports increasing pain despite receiving analgesic medication 1 hour ago. What should the nurse do first? A. ensure that the leg is elevated B. Assess for pulses and muscle weakness C. Obtain an order for additional pain medication D. Ask the patient to wait and see if the medication will work

B. Assess for pulses and muscle weakness

A patient is treated for a severe allergic reaction to a bee sting tells the nurse, "the doctor told me that I had to be careful about getting bee stings in the future because I could have another allergic reaction." Based on the patients statement, what is the nurse's first action? A. Repeat the information that the HCP gave her B. Assess the patient's understanding of allergic reactions and first aid C. Advise the patient to obtain a medical alert bracelet D. Ensure that the patient has a prescription for an epinephrine autoinjector

B. Assess the patient's understanding of allergic reactions and first aid

An older patient reports being outside when temperatures reached 110 degrees and forgetting to drink water. Now he reports weakness and nausea with dizziness. His body temperature is 98.9 degrees. What is the priority assessment? A. Assess for medications that increase risk for heat stroke B. Check for orthostatic hypotension and tachycardia C. Observe skin turgor and other signs of dehydration D. Assess the size and responsiveness of the pupils

B. Check for orthostatic hypotension and tachycardia

The nurse is interviewing a patient who has been verbally aggressive for the past several hours, according to the family. The family states, "He won't hurt anybody." However, the patient is pacing and appears suspicious and angry. Which strategy does the nurse use to conduct the interview? A. Sit at eye level with the patient in a quiet, secluded room B. Conduct the interview standing near the door in a quiet room C. Bring the entire family in and have every one sit in comfortable chairs D. Have the security guard stand by the patient during the interview

B. Conduct the interview standing near the door in a quiet room

Three people accompanied a patient to the ED become verbally argumentative and physically threaten each other. Which actions does the ED nurse take to ensure the safety of staff and others? SATA A. Tell individuals that they are being filmed B. Follow the hospitals security plan C. Attempt to deescalate the situation D. Quietly ask the individuals to leave E. Identify possible escape routes F. Obtain assistance from the security department as needed

B. Follow the hospitals security plan C. Attempt to deescalate the situation E. Identify possible escape routes F. Obtain assistance from the security department as needed

A person is stung by a wasp at a picnic. The person has no difficulty breathing and no history of an allergic reaction to bee or wasp stings. What is the priority first-aid action for this person? A. Place a tourniquet proximal to the sting B. Gently scrape the stinger off with the edge of a credit card C. Apply a warm pack to the area and elevate D. Observe the area for signs of inflammation prior to taking any action

B. Gently scrape the stinger off with the edge of a credit card

The patient died in the ED despite resuscitation efforts. Homicide is suspected. Which nursing action would be incorrect because of the likelihood of forensic investigation? A. Invites the family to spend tie with the deceased patient B. Gives the patient's clothes and other belongings to the family C. Declines to give information to friends and the deceased D. Leaves intravenous lines and indwelling tubes in place

B. Gives the patient's clothes and other belongings to the family

The nurse has administered pain medication to a patient who has a migraine headache. What instructions should be given to the UAP? A. Wait 45 minutes and then ask the patient if the pain is relieved B. Help the patient out of bed, sit him up, then dangle his feel, then assist to stand C. Check the patient frequently to make sure he arouses and is not getting worse D. Ask the patient if he has a ride home; it not, call family member to make arrangements

B. Help the patient out of bed, sit him up, then dangle his feel, then assist to stand

A patient who was struck by lightening and sustained temporary paralysis of the lower limbs, which resolved with no physical effects, but the patient developed emotional problems. Which mental health disorder is the most likely complication? A. Generalized anxiety disorder B. Schizophrenia C. Post-traumatic stress disorder D. Acute onset dementia

C. Post-traumatic stress disorder

For which patients would the nurse try to obtain a social service consult? SATA A. Toddler who bumped her head on a table; observation for 24 hours is required B. Homeless woman who will be discharged with a splint to the lower leg and crutches C. Woman who was punched and beaten by her husband and sustained a broken jaw D. Man who drove himself to the hospital for a dressing change of an infected wound on his back E. Preteen admitted for vaginal bleeding and STI F. Elderly man who lives alone and has no means to obtain medications from the pharmacy

B. Homeless woman who will be discharged with a splint to the lower leg and crutches C. Woman who was punched and beaten by her husband and sustained a broken jaw E. Preteen admitted for vaginal bleeding and STI F. Elderly man who lives alone and has no means to obtain medications from the pharmacy

A patient reports having a throbbing headache with n/v "like the worst hangover of my life" after recently returning from a hiking trip to the mountains. The nurse suspects high-altitude sickness. Which question helps the nurse gather relevant information about this condition? A. Did you experience any episodes of hypothermia during your trip? B. How quickly did you ascend to the top of the mountain range? C. Did you go skiing or hiking In a nearby area? D. Did you have trouble sleeping while you were in the mountains?

B. How quickly did you ascend to the top of the mountain range?

Which occurrence is the patient treated for acute mountain sickness indicates that treatment with acetazolamide was effective? A. Decreased pulse rate and decreased urine output B. Increased urine output and increased respiratory rate C. Periodic respirations during sleep and decreased pulse D. Decreased sleep disturbance and decreased respiratory rate

B. Increased urine output and increased respiratory rate

During a summer marathon, the temp is over 100 degrees and the humidity is high. Suddenly a runner collapses after running in the race for 1 hour. The runner's body temp is 105.2 degrees and she is confused and sweating. What evidence based intervention should be used for this patient? A. Give oxygen and start several IV lines with normal saline B. Initiate rapid cooling using on-site cold-water immersion C. Have patient rest in a cool environment and drink cold water D. Place in a supine position and call 911

B. Initiate rapid cooling using on-site cold-water immersion

The patient was repeatedly kicked and punched in the abdomen. The initial assessment and diagnostic testing reveal no life threatening damage. The emergency provider tell the nurse that the patient should remain in the ED for observation. What is the most important action for the nurse to perform? A. Administer pain medication in a timely fashion B. Initiate serial abdominal assessments C. Delegate vital signs every 4 hours D. Find a quiet space where the patient can rest

B. Initiate serial abdominal assessments

An elderly woman is brought to the ED by her own son, who tells the nurse, "mom just seems weak, tired and more confused than usual." Which combination of question and assessment is the nurse most likely to perform for this patient? A. Ask if she has difficulty sleeping and observe for pedal edema B. Inquire if she has any changes in urination and auscultate the lung fields C. Question her about appetite changes and check for pupillary response D. Ask if she has noticed a vaginal discharge and observe gait and balance

B. Inquire if she has any changes in urination and auscultate the lung fields

A nurse is caring for a client during the first few hours after admission to the burn unit with partial thickness burns of the trunk and head. Which potential problem is the last concern for the nurse during the emergent phase of a burn injury? A. Pain B. Leukopenia C. Laryngeal edema D. Fluid volume deficit

B. Leukopenia

An older adult is in the ED for over 12 hours awaiting transfer to an inpatient bed. The charge nurse delegates turning the patient every 2 hours to the UAP because the patient is at risk for skin breakdown. The patient is not turned and begins to develop a pressure ulcer. What does the charge nurse do to prevent a recurrence of this type of problem for future patients? SATA A. Nothing; in the overall priorities of the ED, the situation is unfortunate but unavoidable B. Make anecdotal notes and counsel all the involved UAPs C. Delegate the duty of turning and repositioning to family members D. File an incident report and seek assistance at the system level E. Reeducate staff on the need to turn patients at risk for skin breakdown F. Evaluate UAP-patient ratios when patients require frequent turning

B. Make anecdotal notes and counsel all the involved UAPs D. File an incident report and seek assistance at the system level E. Reeducate staff on the need to turn patients at risk for skin breakdown F. Evaluate UAP-patient ratios when patients require frequent turning

The nurse is working in a mountain clinic where there is a high incidence of cold-related injuries. Which s/s indicates the most severe frostbite? A. Large fluid filled blisters with partial-thickness skin necrosis B. Numbness, coldness, and bloodlessness of the affected area C. Small blisters that contain dark fluid; skin is cool D. Pain, numbness and pallor of the affected area

B. Numbness, coldness, and bloodlessness of the affected area

The ED clinical nurse specialist is designing ways to teach newly hired nurses about priority setting in the triage area. Which strategy is the CNS most likely to recommend? A. Assign new nurses to triage during low-volume periods B. Pair a new nurse with an experienced nurse in the triage area C. Prepare handouts and tip sheets for the principles of triage D. Have the new nurses observe the triage process for several days

B. Pair a new nurse with an experienced nurse in the triage area

Which action meets the Joint Commission's 2015 mandate for the hospital's emergency preparedness plan? A. All nursing staff are certified annually in basic and advanced cardiac life support B. Plan Is tested twice a year using simulated patients to assess collaboration and command C. Stockpiles of equipment and supplies needed for a pandemic influenza outbreak are inventoried D. Emergency department staff meets annually with administration to review plan and update as needed

B. Plan Is tested twice a year using simulated patients to assess collaboration and command

The hospital committee is reviewing the emergency management plan of their small community hospital in a suburban area of a large city. What is the priority to include in this hospital's emergency management plan? A. Plan for evacuation routes out of the city B. Plan for transporting patients to other hospitals C. Method to contact the National Disaster Medical System D. Stockpiling postexposure prophylactic antibiotics

B. Plan for transporting patients to other hospitals

The nurse is trying to prepare an IV antibiotic medication for a patient, but the emergency department is very busy, chaotic, and noisy, and the nurse is continuously interrupted. What should the nurse do first? A. Ask the charge nurse to administer the antibiotic medication or send additional help B. Prioritize the urgency of the medication in relation to the urgency of the interruptions C. Shut the door and proceed through the six rights of medication administration D. Prepare the medication while fielding the interruptions and delegating appropriately

B. Prioritize the urgency of the medication in relation to the urgency of the interruptions

The ED nurse is caring for a patient who was found in the alley with no identification and no known family. The nurse must give medication to the patient. What is the correct procedure for patient identification? A. Emergent conditions prevent identification, so the nurse gives the medication as ordered B. The patient is designated as John Doe and the nurse uses two unique identifiers C. The nurse validates the order with another nurse and both verify that the patient is unidentified D. The nurse gives the medication and identification as soon as possible

B. The patient is designated as John Doe and the nurse uses two unique identifiers

A person who sustains deep partial-thickness burns while working on a boat in a town marina and seeks advice from the nurse in the first aid station. The nurse encourages the client to seek medical attention, but the client refuses. The nurse advises the person to go to a health care provider if: A. Blisters appear B. Urinary output decreases C. Edema and redness occur D. Low grade fever develops

B. Urinary output decreases

A nurse working at a small rural hospital gets a frantic phone call about a rumor of a student attacking other students at a local high school. Which information is the most important to determine potential for multi-casualty event versus a mass casualty event? A. How long ago did the event occur? B. What are the number and severity of the injuries? C. What are school officials saying about the incident D. Have emergency medical services been notified?

B. What are the number and severity of the injuries?

An elderly patient is brought to the ED by the paramedics. The patient is alert but disoriented, and the left lower leg has swelling, and deformity; an air splint is in place. Which question is most essential to ask the paramedics? A. "How did the patient describe the level of his pain?" B. "Does the patient normally walk independently?" C. "What was the mechanism of injury?" D. "What time was the air splint applied?"

C. "What was the mechanism of injury?"

An elderly man is brought to the emergency department by his son. The patient is alert but is disoriented to person, place and time and is unable to follow simple instructions. Which question is the most important to ask the son? A. "Do you think your father would consent to emergency care?" B. "Did you bring a list of your father's medications and allergies?" C. "When did you first notice your father's disorientation and confusion?" D. "Do you have the power of attorney for health for your father?"

C. "When did you first notice your father's disorientation and confusion?"

An emergency department nurse is admitting a client after an automobile collision. The health care provider estimates that the client has lost about 15% to 20% of blood volume. Which assessment finding should the nurse expect this client to exhibit? A. Urine output of 50 mL/hr B. Blood pressure of 150/90 C. Apical heart rate of 142 beats/min D. Respiratory rate of 16 breaths/min

C. Apical heart rate of 142 beats/min

A patient calls the ED for advice on immediate first aid for a brown recluse spider bite on his hand. He denies allergic response on shortness of breath and states that he plans to see his health care provider but is currently 2-3 hours away. What does the nurse advise the patient to do? A. Apply a warm pack and elevate the extremity B. Scrub the bite area several times with soap and water C. Apply a cold compress and rest as much as possible D. Apply a snug constricting band at the wrist level

C. Apply a cold compress and rest as much as possible

A long term care facility formed a committee to review the facility's emergency preparedness plan. Which element needs to be resolved in order to meet the guidelines of the Life Safety Code, which is published by the National Fire Protection Association? A. Fire extinguishers are heavy and difficult to use B. Fire safety training is difficult because of high staff turnover C. Building one main front door, and side doors are sealed shut D. Many residents are unwilling or incapable of participating in fire drills

C. Building one main front door, and side doors are sealed shut

A man is found lying in an alley in cold weather for an unknown length of time. His hands, toes, and face show evidence of frostbite; otherwise there are no obvious injuries. He is severely obtunded with a pulse of 43 beats/min, respirations of 9/min and a core body temp of 90 degrees. What is this patient's most immediate physiologic risk? A. Acute respiratory distress syndrome B. Pulmonary edema C. Cardiac arrest D. Acute renal failure

C. Cardiac arrest

A construction worker who was struck by lightning is brought to the ED. He was found unconscious, but cardiopulmonary resuscitation was started immediately, and he awoke just before the arrival of emergency medical personnel. In the ED, he is alert but confused and reports pain to his right hand and foot with fern like marks. Which assessment tool is the priority for this patient? A. Glasgow coma scale B. Pulse oximeter C. Cardiac monitor D. Rule of nine charts

C. Cardiac monitor

A severely burned client has been hospitalized for 2 days. Until now recovery has been uneventful, but the client begins to exhibit extreme restlessness. What does that nurse conclude the client is most likely developing? A. Kidney failure B. Fluid overload C. Cerebral hypoxia D. Metabolic acidosis

C. Cerebral hypoxia

The nurse is helping the health care provider treat a patient with a tension pneumothorax. What type of equipment does the nurse obtain to immediately alleviate this life-threatening condition? A. Large adult endotracheal tube B. Transvenous pacemaker insertion C. Chest tube insertion tray D. Tracheostomy tray

C. Chest tube insertion tray

A worker is involved in an explosion of a steam pipe and receives a scalding burn to the chest and arms. The burned areas are painful, mottled red, weeping and edematous. Which should the nurse conclude is an appropriate classification of these burns? A. Eschar B. Full-thickness C. Deep partial-thickness D. Superficial partial-thickness

C. Deep partial-thickness

A patient calls the health care providers office asking for advice about whether to seek immediate medical attention for a bee sting. She has no SOB or swelling to the face, throat or lips. Which question will elicit information to assist the patient in making the decision? A. Were you stung by an African killer bee? B. Is the affected area red, painful or swollen? C. Did you receive multiple stings? D. Were you able to remove the stinger?

C. Did you receive multiple stings?

A patient died in the emergency department after sustaining multiple injuries that occurred during an aggravated assault. The family arrives after the patient is pronounced dead, and they ask to see the body. What does the nurse do? A. Explain that viewing the body would be too traumatic because all the tubes must remain in place for the forensic exam B. Remove any tubes or debris that is near the patient's face and then cover the rest of the body with a blanket C. Explain what they will see; dim the lights; leave the patient's face exposed; and cover the rest of the body with a blanket D. Suggest that the family could spend time with their loved one at the mortuary after the medical examiner is finished

C. Explain what they will see; dim the lights; leave the patient's face exposed; and cover the rest of the body with a blanket

Which person has the greatest risk for injury from lightning strike? A. Jogger in the park at mid-morning in December B. Deer hunter walking through the woods in the evening in October C. Golfer out on the green in the late afternoon in June D. Camper walking on the beach during the early morning in April

C. Golfer out on the green in the late afternoon in June

Which patient would best benefit from always carrying an epinephrine autoinjector? A. Frequently works outside in the yard or tends to the garden B. Lives a long way from the nearest hospital or medical facility C. Had a previous severe allergic reaction to a wasp sting D. Has a history of severe pain with bee or wasp stings

C. Had a previous severe allergic reaction to a wasp sting

A nurse is evaluating a client's fluid loss resulting from extensive burns. What is the most valuable blood test to use when monitoring a client's fluid loss? A. BUN B. blood pH C. Hematocrit D. Sedimentation rate

C. Hematocrit

The nurse is on a backpacking trip. One of the hikers sustains a pit viper bite to the lower leg. Which first aid measure will the nurse perform while waiting for transportation to the hospital? A. Elevate the leg and apply cool packs B. Incise the fang marks with a pocket knife C. Immobilize the leg with a splint in a functional position D. Apply a constricting band proximal to the fang marks

C. Immobilize the leg with a splint in a functional position

For which circumstance would the use of standard precautions be adequate to ensure the safety of the nurse, staff and other patients? A. Performing hygienic care for a patient with copious watery diarrhea B. Assisting with intubation of a patient with symptoms of tuberculosis C. Initiating a peripheral intravenous access on a patient who is HIV positive D. Assessing a child with a fever and rash and known exposure to chickenpox

C. Initiating a peripheral intravenous access on a patient who is HIV positive

Which factor is most likely to hinder the nurse's ability to objectively and accurately perform triage duties? A. Nurse has ambiguity about which triage model is the best for selected patients B. Several patients arrive simultaneously at the triage area C. Nurse is personally experiencing compassion fatigue and burnout D. Patient has a complex health history and is a poor historian

C. Nurse is personally experiencing compassion fatigue and burnout

For which patient is the forensic nurse examiner most likely to be consulted? A. Elderly patient who died under mysterious circumstances in the ED B. Prisoner who was injured by a police officer while resisting arrest C. Patient who was gang raped by a group of football players D. Patient who accidentally received a large dose of opioid medication

C. Patient who was gang raped by a group of football players

A college student was drinking beer and dove from a 20-foot ledge into a lake. He was pulled from the lake by a friend and given mouth to mouth. The patient is currently in the emergency department, awake, and receiving supplemental oxygen. What type of serial assessment is the nurse most likely to initiate for this patient? A. Cardiac monitoring for possible myocardial infarction B. Level of consciousness and orientation to monitor for alcohol intoxication C. Peripheral sensation and movement related to spinal cord injury D. Frequent blood glucose checks to monitor for hypoglycemia

C. Peripheral sensation and movement related to spinal cord injury

A nurse based in Iowa is a volunteer member of the Medical Reserve Corps and has been called to serve in Ohio, where he does not hold an active nursing license. What should the nurse do? A. Determine if Ohio has reciprocity with Iowa before accepting deployment B. Decline deployment because his nursing license will not allow him to practice in Ohio C. Prepare for deployment because he will be considered a federal employee with valid licensure D. Delay deployment until he has reviewed the nurse practice act that is specific to Ohio

C. Prepare for deployment because he will be considered a federal employee with valid licensure

The nurse is volunteering at the fist aid water station at a local community fair. The water is predicted to be hot and humid. In planning care for people who may experience heat-related illness in this setting, what equipment should the nurse obtain? A. Supply of salt tablets and bottles of water B. Bags of IV normal saline and IV insertion equipment C. Several water spray bottles and a portable fan D. Supply of educational pamphlets and sunscreen samples

C. Several water spray bottles and a portable fan

A nurse is assessing a client during the first 24 hours after a burn injury. Which sign indicates to the nurse that fluid replacement therapy is adequate? A. Decreasing CVP readings B. Urinary output of 15-20 mL/hr C. Slowing of a previously rapid pulse D. Hematocrit level increasing from 50% to 55%

C. Slowing of a previously rapid pulse

The nurse is assisting a neighbor with a gardening project. The neighbor sustains a snakebite when reaching to move a rock. What is the best action to perform to identify the snake? A. Crush the body of the snake with a rock but preserve the head B. Note the markings of the snake and seek pictures on the internet C. Stand at a distance and take a digital picture of the snake D. Trap the snake using a long garden tool and bucket

C. Stand at a distance and take a digital picture of the snake

The emergency health care provider is currently involved in the care of several acute critical patients. The emergency nurse must initiate care for patients under interdisciplinary and medical protocols. Which intervention is the least likely to be covered by a standing protocol? A. Give 50% dextrose IV push for low blood sugar B. Initiate pulse oximetry monitoring and start oxygen therapy C. Ventilate with bag valve mask at 100% oxygen and intubate D. Start a peripheral IV with normal saline at 125 mL/hr

C. Ventilate with bag valve mask at 100% oxygen and intubate

A nurse in the ED is assigned to care for four clients with serious health problems. Which health problem should the nurse identify as the priority? A. Head injury B. Fractured femur C. Ventricular fibrillation D. Penetrating abdominal wound

C. Ventricular fibrillation

The nurse is conducting a community presentation on cold weather safety. Which point is the nurse sure to include in the presentation? A. Hydration and water intake are not an issue, so pack extra clothes, not extra water B. Wear multiple layers of socks when participating in winter sports C. When driving in cold winter weather, carry extra clothes, food and fluid D. Hypothermia occurs only in the winter months in the US

C. When driving in cold winter weather, carry extra clothes, food and fluid

The following clients are seen in the emergency department triage desk reporting acute abdominal pain. which client has the most severe conditions? A. a 35 year old man reporting severe intermittent cramps with three episodes of watery diarrhea 2 hours after eating B. an 11 year old boy with low grade fever, right lower quadrant tenderness, nausea, and anorexia for the past 2 days C. a 23 year old woman reporting dizziness and severe left lower quadrant pain ho states she is possibly pregnant D. a 50 year old woman who reposts gnawing mid epigastric pain that is worse between meals and during the night

C. a 23 year old woman reporting dizziness and severe left lower quadrant pain ho states she is possibly pregnant

Which client is best for the nurse manager on the burn unit to assign to an RN who has floated from the oncology unit? A. a 23 year old client who has just been admitted with burns over 30% of the body after a warehouse fire B. a 36 year old client who requires discharge teaching about nutrition and would care after having skin grafts C. a 45 year old client with infected partial thickness back and chest burns who has a dressing change scheduled D. a 57 year old client with full thickness burns on both arms who needs assistance in positioning hand splints

C. a 45 year old client with infected partial thickness back and chest burns who has a dressing change scheduled

The nurse has just received the change of shift report in the burn unit. which client requires the most immediate assessment or intervention? A. a 22 year old client admitted 4 days previously with facial burns due to a house fire who has been crying since recent visitors left B. a 34 year old client who returned from skin graft surgery 3 hours ago and is reporting level 8 pain (0-10 scale) C. a 45 year old client with partial thickness leg burns who has a temperature of 102.6F (39.2C) and a blood pressure of 98/46mmHg D. a 57 year old client who was admitted with electrical burns 24 hours ago and has a blood potassium level of 5.1 mEq/L

C. a 45 year old client with partial thickness leg burns who has a temperature of 102.6F (39.2C) and a blood pressure of 98/46mmHg

An experienced nurse is working in triage. For which circumstance is the nurse most likely to seek input from the emergency health care provider or advanced practice nurse about acuity level of the patient? A. A 65 year old man is having severe left anterior chest pain and SOB B. A 35 year old man with history of kidney stones have severe back pain and hematuria C. A 1 year old child with history of frequent ear infections is screaming and pulling at his ear D. A 23 year old female with previous good health has sudden, severe flu like symptoms

D. A 23 year old female with previous good health has sudden, severe flu like symptoms

Which scenario is most likely to require activation of the emergency preparedness plan? A. A private six-passenger plan crashes at a large urban airport on wednesday morning B. There Is an outbreak of foodborne illness at a long term care center on Tuesday afternoon C. An ice storm strikes a city on Monday morning and causes falls and vehicular accidents D. A multi-car accident occurs in front of a small rural hospital after midnight on Sunday

D. A multi-car accident occurs in front of a small rural hospital after midnight on Sunday

A patient has sustained severe frostbite to the toes and lower legs. He received rewarming therapy in the ED and arrives to the medical surgical unit with a splint on both legs. IV normal saline is infusing at 125 mL/hr. He reports severe pain in the lower extremities. Which health care provider oder does the nurse question? A. Give morphine 1-2 mg IV push PRN for pain in extremities B. Elevate bilateral lower extremities about the level of the heart C. Perform neurologic and circulation checks on bilateral lower extremities every hour D. Apply compression bandage to bilateral lower extremities

D. Apply compression bandage to bilateral lower extremities

The nurse is working in the ED where several local gang members are being treated for gunshot and knife wounds. The nurse hears gunshots in the waiting room, followed by screams and cries for help. What does the nurse do first? A. Grab the resuscitation box and run to the waiting room B. Assist all the ambulatory patients to leave through a back entrance C. Alert the ED health care provider that additional trauma victims need care D. Asses the level of threat to self and others and call for help

D. Asses the level of threat to self and others and call for help

Which action would typically be performed by the ED bereavement committee? A. Assigns a staff nurse to sit with the family during resuscitation efforts of patient B. Advocates that one or two family members be allowed at bedside during resuscitation C. Provides grief counseling and group support for nurses who care for patients who die D. Attends funerals, send sympathy cards, and makes follow-up calls to family

D. Attends funerals, send sympathy cards, and makes follow-up calls to family

To prevent the development of PTSD in hospital staff, what action is likely to be taken by the facility? A. conducting administrative debriefings B. Providing employees with information on PTSD C. Offering employees psychological counseling D. Conducting critical incident stress debriefings

D. Conducting critical incident stress debriefings

A nurse is caring for a client who experienced serious burns in a fire. Which relationship between a client's burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns? A. Equal B. Unrelated C. Inversely related D. Directly proportional

D. Directly proportional

A patient was involved in a high speed motor vehicle accident. The HCP instructs the nurse to prepare for several urgent procedures because of severe injury and physical compromise. Which procedure does the nurse prepare for first? A. Central line insertion B. Peritoneal lavage C. Chest tube insertion D. Endotracheal intubation

D. Endotracheal intubation

A patient is brought to the ED by friends, who report, "He probably overdose on downers." The patient has decreased LOC and a decreased gag reflex; his face and chest are covered with emesis; he demonstrates spontaneous sonorous respirations; and pulse oximetry is 87% on room air. What type of airway management does the nurse expect this patient to receive? A. Supplemental oxygen per nasal cannula at 4-6 L/min B. Bag valve mask and 100% oxygen to assist with ventilatory effort C. Nonrebreather mark with high flow oxygen D. Endotracheal intubation with initial high-concentration oxygen

D. Endotracheal intubation with initial high-concentration oxygen

A patient reports a scorpion sting to the back of the hand. These is no obvious redness or inflammation at the suspected sting site. Which assessment technique does the nurse use to confirm a bark scorpion sting? A. Raise the arm and observe for blanching B. Observe for the stinger embedded in the skin C. Look for puncture marks surrounded by fine hairs D. Gently tap at the suspected sting site to elicit pain

D. Gently tap at the suspected sting site to elicit pain

A committee is reviewing the hospital's emergency management plan. In the event of a large-scale multi-casualty event, which group is likely to require the largest amount of physical space to accommodate the number of victims? A. Black-tagged patients B. Red- tagged patients C. Yellow-tagged patients D. Green-tagged patients

D. Green-tagged patients

The nurse has received report on several patients who were seen and treated for heat-related illnesses. The patient who has the most severe case of heat related illness exhibits which s/s? A. Headache, heavy perspiration, temperature of 101 B. Subjective feeling of illness with nausea and vomiting C. Significant sunburn to extremities, face, and neck; temperature of 102 degree D. Hot and dry skin, alert and oriented to person, with pulse of 120/min

D. Hot and dry skin, alert and oriented to person, with pulse of 120/min

Two teenagers bring their friend to the ED because "he was drowning." The patient is unconscious but breathing spontaneously, and he is immediately taken to the resuscitation area. Which question is most important for the nurse to ask the patient's friends in determining the outcomes for the patient. A. Was this a freshwater or salter drowning? B. Does he have any medical conditions, such as seizures? C. Was the water contaminated with chemicals or algae? D. How long was he under the water and not breathing?

D. How long was he under the water and not breathing?

A nurse is caring for a client who sustained a partial thickness burn to the lower leg accounting for 5% of the total body surface area 1 day ago. A primary short-term outcome established by the nurse and client is "The client's: A. Airway will remain patent B. Burns will heal free of infection C. Urine output will exceed 30 mL every hour D. Pain will remain at 2 or less on a scale of 0 to 10

D. Pain will remain at 2 or less on a scale of 0 to 10

The emergency management plan is activated because a major earthquake has caused many serious and minor injuries. Which nurse reassignment is most likely to meet the needs of the patients while best utilizing available personnel? A. Operating room nurse is reassigned to the emergency department to assist in triage B. Emergency department nurse is reassigned to care for patients on the medical surgical unit C. Critical care nurse is reassigned to the emergency department to care for "black tag" patients D. Performance improvement nurse is reassigned to care for "green tag" patients

D. Performance improvement nurse is reassigned to care for "green tag" patients

A nurse places a client with severe burns on a circulating air bed. What is the primary reason why the nurse implements this action? A. Increase mobility B. Prevent contractures C. Limit orthostatic hypotension D. Prevent pressure on peripheral blood vessels

D. Prevent pressure on peripheral blood vessels

The nurse is using the Impact of Event Scale-Revised to assess an UAP who was working in a long term care facility that was devastated by a fire. The IES-R score is high on all subscales. What should the nurse do? A. Reinforce the coping strategies that the UAP is successfully using? B. Suggest additional coping strategies that the UAP can use to decrease stress C. Refer the UAP to a social worker or a support group for survivors D. Refer the UAP to a psychiatrist or clinical psychologist for additional evaluation

D. Refer the UAP to a psychiatrist or clinical psychologist for additional evaluation

A nurse in the emergency department is assessing a client who was beaten and sexually assaulted. Which is the nurse's priority assessment? A. The family's feeling about the attack B. The client's feelings of social isolation C. Disturbance in the client's thought process D. The client's ability to cope with the situation

D. The client's ability to cope with the situation

the heath care provider has ordered an escharotomy for a patient because of constriction around the patients chest. the nurse is teaching the patent and family about the procedure. which statement by the family indicates a need for additional teaching? a. "he will have to receive general anesthesia" b. "he'll be awake for the procedure" c. "he will receive medication for sedation and pain" d. "we could stay with him at the bedside during the procedure"

a. "he will have to receive general anesthesia"

a patient sustained a superficial thickness burn over a large area of the body. the patient is crying with discomfort and is very concerned about the long term effects. what does the nurse tell the patient to expect? a. "healing should occur in 3-6 days with no scarring or complications" b. "the pain should be less because more of the nerve endings were destroyed" c. "the wound will appear red and dry with some white areas" d. "the leathery eschar will have to be removed before healing can occur"

a. "healing should occur in 3-6 days with no scarring or complications"

a patient who lives in a rural community sustained severe burns during a house fire at 10am. the rural emergency medical services (EMS) started a peripheral IV at 1100 am at a keep-vein-open (KVO) rate. the patient was admitted to the hospital at 1:00pm. in calculating the fluid replacement, at what time is the fluid for the first 8 hour period completed? a. 6:00pm b. 7:00pm c. 8:00pm d. 9:00pm

a. 6:00pm

a 28-year-old male patient sustained second and third-degree burns on his legs (30%) when his clothing caught fire while he was burning leaves. he was hosed down by his neighbor and arrived at the ED in severe discomfort. what is the priority problem for the patient at this time? a. acute pain r/t damaged or exposed nerve endings b. decreased fluid volume r/t electrolyte imbalance c. potential for inadequate oxygenation d. diminished self-image r/t the appearance of legs

a. acute pain r/t damaged or exposed nerve endings

the nurse is changing a burn patients dressing. which factors would affect the number of gauze layers applied after a topical agent has been used to treat the wound? sata a. amount of drainage b. patient mobility c. amount of pain d. depth of injury e. positioning of patient f. frequency of dressing changes

a. amount of drainage b. patient mobility d. depth of injury f. frequency of dressing changes

the nurse is monitoring the nutritional status of a burn patient. which indicators will the nurse use? sata a. amount of food the patient eats b. weight to height ratio c. serum albumin d. amount of water the patient drinks e. blood glucose f. serum potassium

a. amount of food the patient eats b. weight to height ratio c. serum albumin e. blood glucose

the charge nurse is in an ED and must assign two staff members to cover the triage area. which team is the most appropriate for this assignment? a. an advanced practice nurse and an experienced RN b. an experienced LPN/LVN and an inexperienced RN c. an experienced RN and an inexperienced RN d. an experienced RN and an experienced UAP

a. an advanced practice nurse and an experienced RN

a patient comes to the clinic to be treated for burns from a barbecue fire. although the patient does not appear to be in any respiratory distress, the nurse suspects an inhalation injury after observing which findings? SATA a. burns to the face b. bright cherry red color to lips c. singed nose hairs d. edema of the nasal septum e. black carbon particles around the mouth f. sweet, sugary smell to the breath

a. burns to the face c. singed nose hairs d. edema of the nasal septum e. black carbon particles around the mouth

the nurse is applying a dressing to cover a burn on a patients left leg. what technique does the nurse use? a. consider the depth of the injury and amount of drainage, and work distal to proximal b. change the dressing every 4 hours or when the drainage leaks through the dressing c. consider the patients mobility and the area of injury, and work proximal to distal d. use multiple gauze layers and roller gauze to pad and protect the joint areas

a. consider the depth of the injury and amount of drainage, and work distal to proximal

a patient has sustained a severe burn greater that 30% total body surface area (TBSA). what is the best way to assess renal function in this patient? a. measure urine output and compare this value with fluid intake b. weight the patient every day and compare that to the dry weight c. note the amount of edema and measure abdominal girth d. assist the patient with a urinal or bedpan every 2 hours

a. measure urine output and compare this value with fluid intake

the nurse is caring for several patients on the burn unit. which patients have the greatest risk for developing respiratory problems? SATA a. patient who was in a storage room where chemicals caught fire b. patient who was workin gin an area where steam escaped from a pipe c. patient who sustained a circumferential burn to the chest area d. patient who was burned when a firecracker exploded prematurely e. patient who was found unconscious in a slow burning house fire f. patient whose clothes caught fire while burning leaves

a. patient who was in a storage room where chemicals caught fire b. patient who was workin gin an area where steam escaped from a pipe c. patient who sustained a circumferential burn to the chest area e. patient who was found unconscious in a slow burning house fire

emergency medical services has transported a client with severe chest pain. as the client is being transferred to the emergency stretcher, the nurse notes unresponsiveness, cessation of breathing and no palpable pulse. which task is appropriate to delegate to the UAP? a. performing chest compressions b. initiating bag-valve mask ventilations c. assisting with oral intubation d. placing the defibrillator pads

a. performing chest compressions

the nursing student notes on the care plan that the burn patient she is caring for is at risk for organ ischemia. tased on the students knowledge of the pathophysiology of burns, which etiology does the nursing student select? a. related to hypovolemia and hypotension b. related to fluid overload and peripheral edema c. related to prolonged resuscitation and hypoxia d. related to direct blunt trauma to the kidneys

a. related to hypovolemia and hypotension

The priority expected outcome during the resuscitation phase of a burn injury is to maintain which factor? a. the airway b. cardiac output c. fluid replacement d. patient comfort

a. the airway

the nurse is caring for a patient with 45% total body surface area (TBSA) burns. which are priority medical surgical concepts for this patient? sata a. tissue integrity b. cellular regulation c. perfusion d. elimination e. fluid and electrolyte balance f. gas exchange

a. tissue integrity c. perfusion e. fluid and electrolyte balance

the nurse responds to a call for help from the ED waiting room. an older adult client is lying on the floor. list the order in which the nurse must carry out the following actions. a. perform the chin lift or jaw or thrust maneuver b. establish unresponsiveness c. initiate CPR d. call for help and activate the code team e. instruct the UAP to get the crash cart

b d a c e

a patient with a burn injury had an autograft. the nurse learns in report that the donor site is on the upper thigh. what type of wound does the nurse expect to find at the donor site? a. stage 1 b. partial thickness c. full thickness d. stage 4

b. partial thickness

which feelings are most typically expressed by the burn patient? sata a. suspicion b. regression c. apathy d. denial e. suicidal ideation f. anger

b. regression d. denial f. anger

which vaccine is routinely administered when a burn patient is admitted to the hospital? a. hepatitis B b. tetanus c. influenza d. pneumonia

b. tetanus

which criteria describes a full thickness burn wound? SATA a. the wound is red, moist, and blanches easily b. there is destruction to the epidermis and dermis c. there are no skin cells for regrowth d. the burned tissue is avascular e. the burn wound will not be painful f. the burn wound has a dry, hard, leathery eschar

b. there is destruction to the epidermis and dermis c. there are no skin cells for regrowth d. the burned tissue is avascular f. the burn wound has a dry, hard, leathery eschar

the release of myoglobin from damaged muscle in patients with major burns can result in which potential complication? a. paralytic ileus b. acute kidney injury c. limited mobility d. hypovolemia

b. acute kidney injury

several patients are transported from an industrial fire to a local emergency department (ED). which factors increase the risk of death for these patients? sata a. male gender b. age greater than 60 years c. burn greater than 40% TBSA d. presence of an inhalation injury e. presence of contact burns f. history of kidney disease

b. age greater than 60 years c. burn greater than 40% TBSA d. presence of an inhalation injury

a patient has sustained a burn that appears red and moist. the nurse gently applies pressure to the area to assess for what sign/symptom? a. intensity of pain b. blanching c. pitting edema d. fluid-filled blisters

b. blanching

the nurse is caring for several patients who have sustained burns. the patient with which initial injury is the least likely to experience severe pain when a sharp stimulus is applied? a. severe sunburn after lying in the sun for several hours b. deep full thickness burn from an electrical accident c. partial thickness burn from picking up a hot pan d. deep partial thickness burn after a motorcycle accident

b. deep full thickness burn from an electrical accident

Because of fluid shifts in burn patients, what effects on cardiac output does the nurse expect to see? a. an initial increase, then normalized in 24-48 hours b. depressed up to 36 hours after the burn c. improved with fluid restrictions d. responsive to diuretics as evidenced by urinary output

b. depressed up to 36 hours after the burn

the nurse observes peeling of dead skin on the legs of a patient with superficial thickness burn wound. what is the most accurate description of this assessment finding? a. blanching b. desquamation c. slough d. fluid shift

b. desquamation

the nurse is caring for a young woman who sustained burns on the upper extremities and anterior chest while attempting to put out a kitchen grease fire. which laboratory results does the nurse expect to see during the resuscitation phase? sata a. potassium level of 3.2 mEq/L b. glucose level of 180 mg/dL c. hematocrit of 49% d. pH of 7.20 e. sodium level of 139 mEq/L f. albumin level of 2.9 g/dL

b. glucose level of 180 mg/dL c. hematocrit of 49% d. pH of 7.20 f. albumin level of 2.9 g/dL

a client presents to triage with fever, myalgia, severe headache, abdominal pain, vomiting, diarrhea and unexplained bruising that started after returning from Africa. The triage nurse suspects, but is unsure, that the client may have Ebola. What should the nurse do first? a. delay any additional assessment or questioning and don full PPE. b. isolate the client in a private room and initiate standard, contact and droplet precautions. c. direct all clients and staff out of the triage area and call the infection control department. d. continue assessment and questioning to determine the likelihood of exposure to Ebola.

b. isolate the client in a private room and initiate standard, contact and droplet precautions.

which statement about the third-spacing or capillary leak syndrome in a patient with severe burns is accurate? a. it usually happens in the first 36-48 hours b. it is a leak of plasma fluids into the interstitial space c. it is present only in the burned tissues d. it can usually be prevented with diuretics

b. it is a leak of plasma fluids into the interstitial space

the nurse is providing care for a burn patient who recently received a graft. on assessment of the patients wound, redness and swelling as well as some foul smelling drainage is noted. what does the nurse suspect? a. partial thickness burn b. local infection of burn wound c. failure of the graft d. systemic sepsis

b. local infection of burn wound

the nurse has just received report on a patient admitted for steam inhalation burns. the patient is alert and conversant but reports that his throat feels raw. his wife says that he sounds harsh compared to usual. considering these findings, which order should the nurse question? a. continuous pulse oximetry b. vital signs and airway assessment twice a day c. intubation equipment at the bedside d. oxygen 2L via nasal cannula to maintain saturation of greater than 90%

b. vital signs and airway assessment twice a day

a burn patient must have pressure dressings applied to prevent contractors and reduce scarring. for maximum effective, what procedure pertaining to the pressure garments is implemented? a. changed every 24-48 hours to prevent infection b. worn at least 23 hours a day until the scar tissue matures c. removed for hygiene and during sleeping d. applied with aseptic technique

b. worn at least 23 hours a day until the scar tissue matures

an adult patient is admitted to the burn unit after being burned in a house fire. assessment reveals burns to the entire face, back of the head, and anterior torso and circumferential burns to both arms. using the rule of nines what is the extent of the burn injury? a. 18% b. 24% c. 45% d. 54%

c. 45%

the nurse is performing a morning assessment on a patient admitted for serious burns to the extremities. for what reason does the nurse assess the patients abdomen? a. to perform a daily full head to toe assessment b. to assess for nausea and vomiting related to pain medication c. to assess for a paralytic ileum secondary to reduced blood flow d. to monitor increased motility that may result in cramps and diarrhea

c. to assess for a paralytic ileum secondary to reduced blood flow

at what point does fluid mobilization occur in patients with burns? a. after the scar tissue is formed and fluid are no longer being lost b. within the first 4 hours after the burns were sustained c. about 24 hours after the burn injury when the fluid is reabsorbed from the interstitial tissue d. immediately after the burns occur

c. about 24 hours after the burn injury when the fluid is reabsorbed from the interstitial tissue

a patient was involved in a house fire and suffered extensive full thickness burns. in the long term, what issue may this patient have trouble with? a. intolerance for vitamin C b. metabolism of vitamin K c. activation of vitamin D d. absorption of vitamin A

c. activation of vitamin D

a patient was admitted for burns to the upper extremities after being rapped in a burning structure. the patient is also at risk for inadequate oxygenation related to inhalation of smoke and superheated fumes. which diagnostic test best monitors this patients gas exchange? a. complete blood count b. myoglobin level c. carboxyhemoglobin level d. chest x ray

c. carboxyhemoglobin level

the vasodilation effects of carbon monoxide in patients with carbon monoxide poisoning causes what clinical manifestation? a. cyanosis around the lips b. generalized pallor c. cherry-red skin color d. mottled skin color

c. cherry-red skin color

a burn patient with which condition is most likely to have mannitol (osmitrol) ordered as part of the drug therapy? a. peripheral edema associated with burns on the lower extremities b. inhalation burns around the mouth causing mucosal swelling c. electrical burn with myoglobin in the urine d. smoke inhalation and superficial burns to the forearms

c. electrical burn with myoglobin in the urine

which type of burn destroys the seat glands, resulting in decreased excretory ability? a. superficial b. partial thickness c. full thickness d. deep full thickness

c. full thickness

over a period of 4 days the patient developed an elevated temperature associated with disorientation and lethargy. lab values include a normal platelet level. which type of infection does the nurse suspect? a. viral b. fungal c. gram-positive bacterial d. gram-negative bacterial

c. gram-positive bacterial

a patient has sustained significant burns that have created a hyper metabolic state. in planning care for this patient, what does the nurse consider? a. increased retention of sodium b. decreased secretion of catecholamines c. increased caloric needs d. the decrease in core temperature

c. increased caloric needs

the nurse is caring for a patient who sustained carbon monoxide poisoning. what assessment finding does the nurse anticipate? a. patient will be cyanotic because of hypoxia b. blood gas value of Pao2 will be very low c. patient will report a headache d. patient will report a dry and irritated throat

c. patient will report a headache

which drug therapy reduces the risk of wound infection for burn patients? a. large doses of oral anti fungal medications every 4 hours b. silver nitrate solution covered by dry dressings applied every 4 hours c. silver sulfadiazine on full-thickness injuries every 4 hours d. broad-spectrum antibiotics given intravenously

c. silver sulfadiazine on full-thickness injuries every 4 hours

the nurse is caring for a patient who has 30% total body surface area (TBSA) burn. during the first 12-36 hours, the nurse carefully monitors the patient for which status changes related to capillary leak syndrome? a. bradycarida and pitting edema b. hypertension and increased urine output c. tachycardia and hypotension d. respiratory depression and lung crackles

c. tachycardia and hypotension

the nurse is caring for several patients on the burn unit. which of these patients has the most acute need for cardiac monitoring? a. older adult woman who spilled hot water over her legs while boiling noodles b. teenager with facial burns that occurred when he threw gasoline on a campfire c. young woman who was struck by lightning while jogging on the beach d. middle aged man who fell asleep while smoking and sustained burns to the chest

c. young woman who was struck by lightning while jogging on the beach

An emergency department clinical nurse specialist is training staff in how to don and doff PPE when caring for clients with infections such as Ebola. Which staff member has demonstrated the most grievous error during the practice session? a. triage nurse forgets to perform hand hygiene before donning PPE. b. UAP performs self-inspection; then begins to doff PPE c. health care provider forgets to wipe shoes with disinfectant after doffing shoe covers d. emergency medical tech doff both pairs of gloves first

d. emergency medical tech doff both pairs of gloves first

a patient who sustained severe burns to the face with significant scarring and disfigurement will soon be discharged from the hospital. which intervention is best to help the patient make the transition into the community? a. discuss cosmetic surgery that could occur over the next several years b. focus on the positive aspects of going home and being with family c. teach the family to perform all aspects of care for the patient d. encourage visits from friends and short public appearances before discharge

d. encourage visits from friends and short public appearances before discharge

the nurse is caring for several patients on the burn unit who have sustained extensive tissue damage. the nurse should monitor for which electrolyte imbalance that is typically associated with the initial third-spacing fluid shift? a. hypercalcemia b. hypernatremia c. hypokalemia d. hyperkalemia

d. hyperkalemia

a burn patient refuses to eat. the potential problem of weight loss r/t increased metabolic rate and reduced calorie intake is identified for this patient. what method does the nurse use to weigh this patient correctly? a. weigh once a week after morning hygiene and compare to previous weight b. weigh daily at the same time of day and compare to preburn weight c. use a bed scale and subtract the estimated weight of linens d. weigh daily without dressings or splints and compare to preburn weight

d. weigh daily without dressings or splints and compare to preburn weight