Chapter 68

1. A patient has suffered a severe blow to the head during a tornado. Which observation during the nursing assessment places this patient at the greatest risk and must therefore be addressed first?

Hematoma to the left neck

1. A patient was classified as emergency severity index (ESI)-2. Which parameters were most likely assessed to make this determination? Select all that apply.

· Breathing · Circulation

1. After assessing a patient with a neck injury, the nurse prepares to do the jaw-thrust maneuver. Which symptoms would prompt the nurse to perform this procedure? Select all that apply.

· Dyspnea · Inability to speak

1. A mass casualty incident (MCI) overwhelms a community's ability to respond with existing resources, and it requires assistance from resources outside of the affected community. Which are examples of MCIs that would require outside resources? Select all that apply.

· Hurricane · Terrorist attack with anthrax · Terrorist attack with phosgene gas

1. A patient reports tingling and burning sensations in the foot. The nurse records the patient's body temperature at 87° F (30.5° C) and notes that the patient has a waxy, pale yellow discoloration of the toes. Which nursing interventions will be beneficial for the patient? Select all that apply.

· Performing hemodialysis · Performing peritoneal lavage · Providing warmed intravenous fluids

1. An explosion at a large industrial plant has left many injured. Which victim should receive a black tag?

A patient with a gaping head wound and no pulse

1. Which part of the assessment will the nurse address during the secondary survey of a patient in triage?

Assess patient allergies

1. What are the clinical manifestations of superficial frostbite?

Blisters

1. A patient has been hospitalized with iron toxicity. Which medication does the nurse suspect will be prescribed?

Deferoxamine

1. The nurse responds to a mass casualty incident (MCI). The nurse finds a patient whose condition is not life threatening but who has multiple traumas. What colored tag does the nurse use for the patient?

Yellow

1. What is a factor that contributes to cold-related injuries?

Age

1. Which part of the body is most vulnerable to frostbite in a superficial injury?

Skin

1. A land slide occurs, injuring a group of people. Victims who are moaning and clearly in pain are still at the scene. How long will the rescue nurse assess each victim before placing the appropriate triage tag?

15 seconds

1. What is the appropriate nursing action in the initial treatment for animal and human bites?

Administer tetanus prophylaxis.

1. Which statement refers to frostbite?

Condition of tissue damage due to freezing

1. The nurse is caring for a patient 24 hours after the patient received amphetamine therapy. The patient is experiencing a new onset of right upper quadrant pain and decreased urinary flow. What should be included on the patient's plan of care?

Intravenous infusion of fluids containing vitamin C

1. A patient has sought care three days after experiencing a series of tick bites. Which manifestation would indicate that a patient is experiencing tick paralysis?

Respiratory distress

1. A storm causes flooding in the two lower levels of a hospital. The hospital must evacuate. Which patient is given immediate transfer to another full-service hospital?

A dialysis patient whit a potassium level of 6.0

1. A group of patients have suffered injuries following a building collapse. Which patient with an open wound requires a tetanus vaccine?

A patient who received a tetanus vaccine seven years ago and has already received two vaccines

1. A patient fell through the ice on a pond near his farm and is admitted to the emergency department with somnolence. Vital signs are blood pressure (BP) 82 mm Hg systolic with Doppler, respirations 9 breaths/minute, and core temperature of 90 o F (32.2 o C). The nurse should anticipate which intervention?

Active core rewarming

1. A patient arrives in the emergency department under the influence of cyanide and has been unconscious for more than an hour. Which order by the provider does the nurse expect for this patient?

Administer amyl nitrate

1. A parent brings a child to the emergency department with a bee sting. The child has nausea, feels faint, and is having difficulty breathing. Which of the following health care provider's prescriptions should the nurse implement first?

Administering 0.4 mg epinephrine subcutaneously

1. What finding indicates mild hypothermia?

Body temperature of 93.2 degrees to 98.6 degrees F, (34-35 degrees C)

1. A patient is suspected to have Lyme disease. The nurse recalls that the causative organism of the disease is what?

Borelia burgdorferi

1. The nurse creates a plan of care for a patient with frostbite of the hands. What is the most desirable outcome for the patient?

Brisk capillary refill

1. Which drug controls shivering in a patient being treated for hyperthermia?

Chlorpromazine

1. A large group of people were involved in a tractor trailer accident. Gasoline was spilled, and several people experienced skin contact with the substance. What is the recommended solution to rinse most toxins from the skin?

Copious amounts of water

1. What differentiates heatstroke from heat exhaustion?

Core body temperature

1. Which description is accurate about secondary drowning?

Delayed death from drowning

1. Which instruction should the nurse give to a patient to avoid cold-related injuries?

Dress in layers for cold weather.

1. During the primary survey of a trauma victim, it is determined that a patient has a patent airway. What is the priority nursing action?

Examine the chest for signs of breathing.

1. A patient has an injury due to an explosive device. Which is an example of an explosive device?

Fireworks

1. A patient is brought in to the emergency department with a suspected overdose of aspirin. The nurse notes that the patient is lethargic, confused, and has rapid breathing. Which of the following interventions should the nurse prepare to implement?

Hemodialysis

1. Which risk factor predisposes an individual to submersion injury?

Inability to swim

1. Chemical agents were used to cause harm to a group of patients. What parts of the body are most affected by chemical agents?

Lungs and skin

1. While examining the chest of a patient after a motor vehicle accident, which finding during the assessment will prompt the nurse to take immediate action?

Muffled and low-pitched heart sounds

1. Which chemical causes a patient to experience eye irritation and skin burns?

Mustard gas

1. What are the clinical manifestations the nurse will expect for the first 24 hours after a patient is admitted to the hospital for the treatment of poisoning from Tylenol overdose?

Nausea and vomiting

1. The nurse assesses a group of patients in an emergency department. Which patient's treatment strategy is appropriate?

Patient A- (Has sweet aromatic breath, respiratory depression, and lethargy. Treated with activated charcoal)

1. The nurse is assisting with an endotracheal intubation. The health care provider experiences difficulty inserting an endotracheal tube due to airway obstruction. What intervention would be most helpful in preventing hypoxia in the patient?

Performing a cricothyroidotomy

1. After completing a full set of vital signs on a patient who was injured severely in a motor-vehicle accident, the nurse begins to insert a Foley catheter per the health care provider's prescription. Which of the following would warrant the nurse to notify the health care provider?

Perineal ecchymosis

1. The nursing emergency disaster team is planning an event to help the staff prepare for potential disasters. What is the best way to prepare staff?

Provide a mass casualty community drill

1. A nurse is conducting an assessment of a patient in the emergency room after a violent attack. The patient is unwilling to share what happened. What can the nurse do to help the patient be more comfortable talking about the event?

Provide a private space for the patient.

1. Which effect does the nurse anticipate in a patient who has ingested contaminated freshwater during a submersion injury?

Pulmonary edema

1. A patient seeks treatment following a cat bite. The nurse recognizes that the bite may result in which condition?

Tenosynovitis

1. The nurse is rewarming a patient being treated for frostbite. What indication should the nurse look for as a signal to discontinue the rewarming?

The core temperature reaches 89.6 degrees to 93.2 degrees F.

1. A patient is admitted to the emergency department with a traumatic head injury. What is an appropriate nursing action during the primary survey?

Using the Glasgow Coma Scale

1. While in the emergency department, a patient dies unexpectedly as a result of complications from an injury. What are appropriate nursing actions when initially approaching the patient's family? Select all that apply.

· Provide support · Provide the family members with a place of privacy.

1. Which characteristics confirm deep frostbite? Select all that apply.

· The skin appears white. · The skin is insensitive to touch.

1. Which intervention helps to reduce the risk of aspiration in a patient who is undergoing rapid-sequence intubation?

Administering succinylcholine

1. A flu outbreak in a small town has infected 50 people, with many requiring medical attention. The local emergency department is overwhelmed. Which organization is best able to help?

American Red Cross

1. The nurse is caring for a patient who has consumed a poisonous substance. Assessment findings include an almond odor on the patient's breath, hypertension, and bradycardia. The treatment strategy that would be most beneficial for the patient would be to administer what?

Amyl nitrate nasally

1. In the triage area, a patient complains of pain in the right foot. The nurse assesses an injury sustained during a natural disaster. What should the nurse do while the patient waits for a full assessment?

Elevate the right leg and place ice on the injury.

1. A sportsman presents to the emergency department with suspected superficial frostbite on the feet. Which finding confirms this diagnosis?

The skin appears waxy pale yellow to blue

1. The nurse is caring for a patient with superficial frostbite on the nose, fingers, and toes. What interventions should the nurse perform? Select all that apply.

· Use warm soaks for the face. · Apply a sterile dressing following debridement. · Immerse toes and fingers in a water bath 98.6 to 104 degrees F.

1. A patient arrives in the emergency department after taking an overdose of aspirin. The patient is awake and alert. The nurse should be prepared to assist with the administration of what?

An emetic

1. Radiation exposure is expected after an explosion. What does the nurse say to the victims after they arrive at the hospital? Select all that apply.

· "Radiation dust cannot be smelled." · "It is great that you covered your nose and mouth." · "You need a second shower upon arrival at the hospital."

1. A patient presents with myalgia, chills, a headache, and a pink macular rash on the palms, wrist, soles, and ankle. The nurse anticipates that what medication will be prescribed?

Doxycycline

1. Which are nursing interventions provided specifically by sexual assault nurse examiners (SANEs)? Select all that apply.

· Providing expert emergency care · Collecting and documenting evidence

52. The nurse is providing support for the family of a patient who died immediately after arrival in the emergency department. Which intervention by the nurse would be most supportive of the family's spiritual needs?

Ask the family whether they would like to visit with the hospital chaplain, who is standing by.

1. A nurse is directed to travel with a patient during transport to another hospital. About which condition does the nurse immediately call the doctor during the transport?

The patient has 200 mL of fresh blood from the chest tube.

1. A patient is brought to the emergency unit of the hospital with several bee stings. What is the nursing care for this patient? Select all that apply.

· Administer antihistamines as prescribed. · Remove restrictive clothing around the sting site.

1. In the event of a mass casualty, prioritized medical care is provided based on the triage of victims using colored tags. Which patient receives immediate intervention?

A patient with a red tag

1. While caring for a patient with heatstroke, the nurse suspects that the patient is at risk for skeletal muscle breakdown. Which symptom supports the nurse's suspicion?

Color of urine

1. A patient is admitted to the emergency department after falling from a roof. To which assessment finding should the nurse assign the highest priority?

Asymmetrical chest movement

1. An elderly patient is being discharged from the hospital after treatment for heat cramps sustained during a strenuous workout. What should the nurse emphasize during discharge teaching?

Avoid intense activity for at least 12 hours.

1. The nurse assesses a patient with ischemia and chest pain. The patient should be assigned what Emergency Severity Index (ESI) rating?

ESI-2

1. The nurse is working to prepare a disaster team. What is the function of a community emergency response team (CERT)?

It is a term of community volunteers trained to provide help first on the scene.

1. A patient is in the critical care unit after being found unresponsive in the field. CPR was performed, and the patient is now on a ventilator. Upon reviewing the electronic health record, which data would the nurse identify as being the most critical?

Left pupil 10 mm, not reactive to light

1. A patient is brought into the emergency department (ED) with multiple stab wounds to the legs, one stab wound to the left abdomen, and gang tattoos on both arms. The patient refuses to identify the attacker and loses consciousness. Police identify this patient as the assailant in the fatal stabbing of another person. What is the nurse's priority?

Maintain personal and workplace safety

1. Decontamination is required after disasters involving toxins. Which personal protective equipment is required to prevent a nurse's secondary exposure to a toxin?

Nonsterile gloves

1. The nurse recalls that phosgene gas causes a patient to develop what condition?

Pulmonary edema

1. An elderly patient is brought to the hospital with puncture wounds caused by a cat bite. Which complication can arise?

Septic arthritis

1. Which core body temperature readings confirm hyperthermia?

99.6 degrees to 105.8 degrees F (37.5-41 degrees C)

1. Which is an appropriate intervention in the treatment of aspirin ingestion?

Hemodialysis

1. The patient has a prescription for lactated Ringer's intravenously (IV) at a rate of 175 mL/hour. While making initial shift rounds at 0730, the nurse notes that 525 mL is left in the bag. The nurse calculates that the IV solution will be completed at what time?

1030

1. Which is the most significant problem related to dog bites of children?

Destruction of skin

1. A bomb explosion is most appropriately categorized as which type of disaster?

Violence

1. The patient has a prescription for 0.9% normal saline intravenous (IV) at a rate of 75 mL/hour. The IV tubing has a drop factor of 10 gtts/mL. At how many drops per minute should the nurse regulate the flow of the IV solution?

13 gtt/minute

1. A patient has been admitted to the emergency department after ingesting an entire bottle of chewable multivitamins in a suicide attempt. The nurse should anticipate which intervention?

Administration of activated charcoal

1. Which factors predispose an individual to heat stress?

Alcohol

1. The nurse is triaging in a mass casualty incident. Which patient would likely be designated "red" during triage at the site of this occurrence?

An individual whose femoral artery has been severed and is bleeding profusely.

1. Following a terrorist attack, the people injured in the bomb blast have inhaled anthrax-causing biologic agents. Which treatment strategy would provide effective management of the condition?

Antibiotics

1. A professional swimmer experiences a seizure under water and is brought to the emergency department with a submersion injury. Which nursing action is part of the primary survey?

Assessing airway, breathing, and circulation

1. After stabilization of a trauma victim's airway, breathing, and circulation, what is the nurse's next priority action?

Assessing neurologic status

1. A mail room worker was exposed to anthrax (Bacillus anthracis). The patient is not sure if any of the anthrax was inhaled or if it got on the skin because the patient dropped the envelope upon seeing the powder. What treatment(s) should the nurse anticipate?

Ciprofloxacin to prevent systemic manifestations

1. After assessing and treating a patient affected by a chemical spill, while completing documentation, what is the nurse's priority action?

Continue to monitor the patient for changes.

1. A nurse is administering cool fluids to a patient admitted to the hospital due to heatstroke. Which actions should the nurse take to avoid any complications?

Control shivering.

1. Which is the focus area in the treatment of submersion injuries? Correcting fluid imbalances

Correcting fluid imbalances

1. A terrorist's dirty bomb scattered radioactive material in the city. What initial measure does the nurse take to limit radioactive contamination?

Cover patients' noses and mouths.

1. A patient had a near-drowning experience after having a seizure while swimming. The patient is exhausted and is in respiratory distress. What other findings would the nurse anticipate in the initial assessment?

Crackles and rhonchi breath sounds.

1. A trauma patient has arrived in the emergency department after a tornado. Which actions can the nurse delegate to the unlicensed assistance personnel (UAP)? Select all that apply.

· Remove the patient's clothes and valuables. · Show the patient's family to the trauma room. · Gather equipment for rapid sequence intubation. · Transport packed red blood cells to the emergency department.

1. Which trained team or team member may a nurse voluntarily assist at a disaster site for up to two weeks?

Disaster medical assistance team (DMAT)

1. The nurse notices bruise marks on the hands and forehead of a patient being treated for hip injury and suspects family violence. What is the appropriate nursing inquiry in this scenario?

Do you feel safe at home? Is anyone hurting you?

1. A patient reports headache, fatigue, and a stiff neck after sustaining a tick bite. Borrelia burgdorferi is present in the patient's blood. The nurse anticipates that which medication will be prescribed?

Doxycycline

1. The nurse is examining the abdomen of the patient in the emergency unit of the hospital. What finding indicates excessive fluid in the abdomen?

Dullness on percussion

1. A patient is brought to the emergency unit of the hospital with a compound fracture of the radius. How should the nurse rate the patient as per the Emergency Severity Index (ESI)?

ESI-3

1. Which event is defined as requiring a rapid and skilled medical response that existing resources can manage easily?

Emergency

1. An Alzheimer's disease patient has ingested large amounts of iron tablets. Which intervention is appropriate in the treatment of this patient?

Gastric lavage

1. A terrorist attack involving a nuclear bomb occurred in a nearby city, and the closest hospital is expected to receive a large volume of victims. The hospital has activated its emergency response plan and patients are beginning to arrive. To utilize resources effectively and efficiently, there are colored tags available for triaging patients in order to determine the seriousness of injury and the likelihood of survival. A nurse is triaging a patient who is able to walk, has no obvious deformities, is in no distress, and is complaining of wrist pain. What tag should the nurse give this patient?

Green tag

1. An emergency response program is being developed at a local hospital. Which educational programs are best for preparing staff for mass casualty incidents? Select all that apply.

· Table top exercises · Computer simulations · Hospital disaster drills

1. A nurse is eating out with a friend and witnesses several people injured in a building fire at the restaurant. Considering the Good Samaritan Law, which statement concerning this situation is correct?

If the nurse does try to assist, he or she must not leave until trained responders arrive.

1. During the wintertime, a patient comes into the emergency department acting very strange and confused. The nurse notes that the patient appears to be wet and is shivering. Vital signs read pulse 60 beats/minute, respirations 16 breaths/minute, temperature 93.9 o Fahrenheit, blood pressure 120/65. What would the nurse suspect?

Mild hypothermia

1. The nurse is caring for patients in the emergency room. Which patient does the nurse see first?

Patient with severe respiratory distress

1. Which guideline for the assessment of intimate partner violence (IPV) should the emergency nurse follow?

Patients should be screened routinely for family and IPV.

1. A patient injured in a radioactive explosion requires immediate medical attention. What are the appropriate measures that should be taken in this scenario?

Provide for decontamination

1. The nurse is caring for a patient with severe hypothermia. What is the appropriate nursing intervention for this patient?

Provide heated, humidified oxygen.

1. A patient arrives in the emergency department reporting severe chest pain and difficulty breathing. What is the priority nursing action?

Provide oxygenation via non-rebreather mask.

1. During the physical examination of a patient, the nurse finds that the patient has subcutaneous emphysema, absence of "Raccoon eyes," and negative Battle's sign. What does the nurse conclude from these findings?

The patient has a risk of laryngotracheal disruption.

1. A patient has arrived in the emergency department after surviving a hurricane. The primary survey focuses on which priority assessment of this patient?

Tracheal deviation

1. The local hospital has accepted several patients who arrived on their own shortly after a local natural disaster. After such an event, what is the total estimated number of victims to expect to arrive on their own?

Twice the number who arrived the first hour

1. The nurse observes the graduate nurse caring for a patient who has multiple bee stings to the hands. Which action by the graduate nurse requires correction?

Using tweezers to remove the stingers

1. After a land slide leaves many injured, what is the role of the off-shift nurse employed in a hospital?

Wait for a call from the unit of work.

1. After a bomb has exploded in a public place, the nurse assesses a patient who has an open fracture to the left leg, a blood pressure of 160/90 mmHg, heart rate of 90 beats/minute, and respiratory rate of 24 breaths/minute. The patient is also anxious and crying in pain. Which color tag should the patient receive?

Yellow

1. A group of people accidentally came in contact with anthrax while cleaning a storage space. What is important for nurses to ask such patients after anthrax exposure? Select all that apply.

· "Are you allergic to antibiotics?" · "Do you have any shortness of breath?" · "Have you received the anthrax vaccine?" · "Have you flushed your skin to decontaminate?"

1. While assessing an unresponsive apneic spinal cord injury patient, the nurse understands the need to open the airway with the jaw thrust maneuver and apply a cervical collar. What intervention would be the priority for the nurse to complete next?

Ventilating with a bag-valve mask at 100% oxygen

1. Which is the most effective process in the cleansing of swallowed objects?

Whole-bowel irrigation

1. A patient telephones the emergency department and says to the triage nurse, "I have a tick stuck to my leg. What should I do?" Which instruction by the nurse is most appropriate?

"Carefully remove the tick with tweezers and inspect the site."

1. The nurse on duty receives a call requiring an emergency first responder team to deploy to the incident location. Which statement by the caller confirms an emergency situation in an extraordinary event?

"I need to report a multivehicle crash on the highway."

1. During an educational program about emergency response provided to hospital staff nurses, which nursing statement indicates he or she requires further education?

"Nurses are part f the community emergency response teams."

1. After identifying the need for a critical incident stress management session after a serious accident involving many local residents, what resource does the nurse manager provide?

A group discussion to allow staff top verbalize feelings and emotions

1. Many people lost power for a long period during a snow storm, and a large group of people developed frostbite while trying to walk to a shelter. Which patient requires the nurse's priority attention?

A patient who is insensitive to touch on a mottled leg

1. A nurse on the emergency medical team is required to triage victims at the site of an accident. How should the nurse tag a patient with a feeble pulse and severe head injury?

Blue

1. A patient has his or her eyes closed at the scene of a disaster. What method will the nurse use first to assess level of consciousness?

Call the patient by name.

1. A patient in the emergency department has been fully assessed using the primary survey. What is the nurse's next step in emergency management at this time?

Complete a secondary survey

1. Which medication is useful in the treatment of a sting by an African honey bee?

Diphenhydramine

1. A nurse is interested in getting involved with helping after natural disasters. Guided by the Federal Emergency Management Agency (FEMA), what action will the nurse first take?

Take on online training course offered by FEMA.

1. A group of people have suffered hypothermia after an ice storm on a highway. Which patient is exhibiting moderate hypothermia?

The patient whose heart rate is 50 beats/minute and whose blood pressure is hard to obtain

1. Power was disrupted in a long-term care facility for a prolonged period of time. The air temperature has been 95˚F (35˚C) for several hours. Transport has been arranged to a local emergency department. Which are priority patients for the nurse? Select all that apply.

· A 70-year-old patient with uncontrolled atrial fibrillation · 85-year-old patient with mild confusion and blood pressure of 86/40 mmHg · 68-year-old patient who is combative and whose skin is hot and dry · 57-year-old patient on oxygen who complains of shortness of breath

1. A school bus crash leaves many children injured. Which children will be given a yellow tag? Select all that apply.

· A child with a broken leg · A child with a bruised and swollen arm

1. The nurse is triaging a group of patients after a natural disaster. For which patients can the nurse delegate care to an unlicensed assistance personnel (UAP) who has floated from the medical unit? Select all that apply.

· A patient on a ventilator who needs to be turned · A patient who needs to be transported to radiology · A patient with a fracture of the leg who has to go to the bathroom

1. A storm arrives quickly at an outdoor concert location. The stage collapses, injuring many people and killing several. Which patients are given priority transfer to the hospital and will arrive first? Select all that apply.

· A patient with an amputated leg · A patient who is crying and vomiting blood · A patient with chest pain and shortness of breath

1. A recent flood disaster has left the local emergency department staff angry and frustrated. Which conditions may prevent the staff from coping well? Select all that apply.

· A staff member recently died from cancer. · There was also a tornado disaster last year. · Close friends of staff died during the disaster. · The staff received the victims with the worst conditions.

1. The patient has been part of a community emergency response team (CERT) for a tropical storm where it has been 100 oF (37.7 oC) or more for the last two weeks. With assessment, the nurse finds hypotension, body temperature of 104 oF (40 oC), dry and ashen skin, and neurologic symptoms. What treatments should the National Disaster Medical System (NDMS) nurse anticipate? Select all that apply.

· Administer 100% O2. · Administer cool intravenous (IV) fluids

1. A patient suffered cardiac arrest while manually shoveling snow after a blizzard. The patient's temperature is 96.8˚F (36˚C) on arrival to the emergency department. Which methods are used to provide therapeutic hypothermia? Select all that apply.

· Cold saline infusion · Cooled ventilator circuit

1. The east coast of the United States is experiencing a hurricane, and the emergency departments in the area are informed that they will be receiving hundreds of patients in the next hour. What organizations will health care organizations contact in order to obtain more resources to manage the mass casualty incident (MCI)? Select all that apply.

· National Disaster Medical System (NDMS) · National Incident Management System (NIMS) · The local community emergency response team (CERT)

1. A disaster medical assistance team (DMAT) has been activated to the site of a flood. Which members are included in the DMAT? Select all that apply.

· Nurses · Doctors · Security · Logistics · Communications team members

1. The nurse is completing the secondary survey on a patient who survived a tornado. Which does the nurse include in the secondary assessment? Select all that apply.

· Palpating the spine for deformities and pain · Inspecting the genitalia for bleeding and obvious injuries · Inspecting the back for ecchymosis, abrasions, and wounds · Checking for circulation, pain, and numbness of any areas that have swelling

1. The patient is brought to the emergency department feeling weak, and presenting with dehydration, a body temperature of 102° F (38.8ºC), and pale skin. What are the appropriate nursing interventions in this situation? Select all that apply.

· Placing patient in a cool environment · Providing high-flow oxygen in a nonrebreather mask · Managing and maintaining airway, breathing, and circulation

1. An earthquake has left many injured. The nurse has just completed the primary and secondary survey for a male victim. Which conditions prompt the nurse to refrain from placing an indwelling catheter? Select all that apply.

· The penis head is bloody. · A hematoma is present on the scrotum. · There is bruising around the perineal area.

1. A teenager who attempted suicide is brought into the emergency department by the mother. The mother suspects that the teenager consumed the liquid bleach kept in the bathroom. Which clinical manifestation in the child's body confirms poisoning?

Irritation of lips, mouth, and eyes

1. Which nursing intervention would be included in the exposure and environmental control assessment component of the primary survey in the emergency department?

Keeping the patient warm with blankets

1. Which is an initial manifestation of Rocky Mountain spotted fever?

Pink rash

1. A patient comes into the emergency department complaining of extreme thirst and vomiting on a very hot day. The nurse assesses that the patient has profuse diaphoresis and is ashen in color. Vital signs are blood pressure 90/50, pulse 98, and temperature is 101 o Fahrenheit. Which of the following is the immediate priority for the nurse?

Place the patient in a cool area and remove any restrictive clothing.

1. The nurse is providing care for a patient who is admitted to the emergency department following a near-drowning event. Assessment findings indicate that the patient has significant pulmonary edema. The nurse expects that the plan of care will include what treatment strategy?

Placing the patient on positive end-expiratory pressure therapy

1. A patient is admitted to the emergency department following a near-drowning. The patient asks how the brain was almost damaged. The nurse explains to the patient that with this type of submersion injury, fluid is drawn from the vascular space into the alveoli, impairing alveolar ventilation and resulting in hypoxia.

Hypertonic saltwater

1. The nurse assesses that a patient who sustained a severe trauma injury has asymmetric chest wall movement and no breath sounds on the left side of the chest. Which treatment strategy will help to alleviate the patient's symptoms?

Applying a bag valve mask (BVM)

1. Which substance is absorbed by activated charcoal?

Ethylene glycol

1. A patient is kept under observation to monitor the reactions that develop following sting injuries during a bee attack. What signs and symptoms does the nurse anticipate in the next 24 hours?

Headache

1. Which physiologic changes may be observed during heatstroke when, over a period of 10 to 15 minutes, a patient's sweat glands have stopped functioning and the core body temperature has increased? Select all that apply. ·

Hot and dry skin · Loss of muscle coordination · Temperature of 105 degree F

1. Which is a clinical manifestation of a low dose of amitriptyline poisoning?

Hypertension

1. The nurse is caring for an athlete with severe heat cramps in the leg. What intervention should the nurse perform?

Provide parenteral replacement of sodium and water.

1. A nurse is conducting a primary survey in an emergency department. What is the purpose of the survey?

To evaluate status of airway, breathing, circulation, disability and exposure and environmental control

1. When treating a severely hypothermic patient, what is the clinical reason behind warming the patient's core first before the extremities?

To prevent a further drop in temperature

1. The nurse reviews a patient's medical record. After informing the primary health care provider, what important actions should the nurse take? Select all that apply.

· Administer chlorpromazine · Assess for tea-colored urine. · Obtain blood-clotting studies. · Administer fluids and electrolytes.

1. A snowstorm survivor is brought to the hospital in a comatose state. Initial assessment findings reflect a core body temperature of 85° F. Which nursing actions are necessary in the care of this patient? Select all that apply.

· Administer warmed IV fluids. · Administer heated and humidified oxygen.

1. What is the regimen to be followed in the prevention of rabies? Select all that apply

· Administration of a series of five injections of human diploid cell vaccine (HDCV) · Administration of weight-based dosage of rabies immune globulin (RIG)

1. A nurse obtains a medical history from a patient that is admitted to the emergency department, using the mnemonic AMPLE to gather what patient information? Select all that apply.

· Allergies to food · Medication history · Tetanus immunization

1. A nurse is caring for a patient involved in a car accident. The patient is unconscious and has multiple injuries on the head. What are the most important interventions for the nurse to perform as part of the primary survey? Select all that apply.

· Apply a cervical collar to the patient. · Secure the patient's forehead to the backboard. · Apply a cervical immobilization device (CID) to the patient.

1. The nurse provides care for a patient with carbon monoxide poisoning. The nurse expects what assessment findings? Select all that apply.

· Confusion · Tachypnea

1. The nurse identifies that a patient is at an increased risk for frostbite if the patient has what condition? Select all that apply.

· Diabetes mellitus · Peripheral vascular disease

1. During the primary survey the nurse observes a patient exhibit paradoxical movement of the chest wall during respiration. What actions does the nurse take? Select all that apply.

· Give supplemental oxygen therapy. · Ventilate with bag-valve mask with 100% oxygen.

1. A patient informs the nurse that he or she is planning on going camping and ice fishing next weekend. The patient is concerned about how cold it can get at night. What type of patient teaching should the nurse provide? Select all that apply.

· Keep head covered · Dress in multiple layers · Eat snacks such as dried fruit