hot ch70 - emergency, trauma, environmental injuries

After the nurse secures the airway of a trauma patient in the emergency department (ED), what is the next conduct in the primary survey? 1. Assess the patient's respiratory rate. 2. Monitor the patient's blood pressure. 3. Assess the patient's pupillary reaction. 4. Cover the patient with a warm blanket.

1 Think ABC Once the patient's airway is secured, the next step in the primary survey is to monitor the patient's ventilations and apply high-flow oxygen, if needed.

A medical-surgical unit is expecting a large volume of patient admissions after a train derailment. Which member of the nursing care team will prioritize care for the unit? 1) Charge nurse 2) Nurse supervisor 3) Licensed practical nurse 4) Unlicensed assistive personnel

1 A charge nurse coordinates care and assignments and may ultimately be the only person familiar with all the needs of any individual patient; therefore, it is this member of the team that will prioritize care for the patients who are being admitted.

The nurse correlates the pathophysiological response to the toxins in snake venom to the blocking of which neurotransmitter? 1. Acetylcholine 2. Dopamine 3. Norepinephrine 4. Serotonin

1 Immobilization from snakebites occurs because of the neurotoxic properties of venom, blocking the transmission of acetylcholine at the neuromuscular junction, causing weakness or paralysis.

The nurse prepares to administer which medication to treat a patient with acetaminophen overdose? 1. N-acetylcysteine 2. Flumazenil 3. Sodium bicarbonate 4. Glucagon

1 N-acetylcysteine is given by mouth or intravenously to prevent or minimize hepatotoxicity with acetaminophen toxicity. 2 Flumazenil is the antidote for benzodiazepines overdose. 3 Sodium bicarbonate is not indicated in an acetaminophen overdose because acidosis is not a side effect. 4 Glucagon is administered for beta blocker toxicity.

In caring for a patient being rewarmed for treatment of hypothermia, the nurse correlates which laboratory value to "afterdrop"? 1. Calcium 14.5 mg/dL 2. Glucose 55 mg/dL 3. Sodium 150 mEq/L 4. Potassium 2.8 mEq/L

1 Rewarming the core at a prescribed rate is important to prevent significant complications. Rewarming too rapidly can cause hyperkalemia as potassium shifts out of the cells and a condition known as afterdrop. Afterdrop is defined as a precipitous reduction in core temperature due to redistribution of body heat to improperly warmed peripheral tissues, with rapid shunting of cold blood from the periphery to the core as the direct result of vasodilation. This causes a bolus of cold, hyperkalemic, acidotic blood to return from the periphery to the heart, which results in a biochemical injury that leads to severe hypotension and dysrhythmias.

The nurse is conducting a secondary survey as part of the emergency assessment. Which is the priority nursing action during the health history portion of the assessment? 1) Determining drug allergies 2) Noting the general appearance 3) Examining the neck for stiffness 4) Auscultating for heart and lung sounds

1 The priority nursing action during the health history portion of the assessment is to determine drug allergies.

Which are the priority nursing actions after the completion of the secondary survey when providing care for a trauma patient with a penetrating wound? 1) Documenting the patient's care 2) Formulating the patient's plan of care 3) Reassessing the patient's level of consciousness 4) Transferring the patient to the general medical unit

1 The priority nursing actions after completion of the secondary survey during the emergency assessment include documenting all patient care and administering tetanus prophylaxis.

The nurse is conducting a primary survey during an emergency assessment. Which is the priority nursing action related to breathing in response to this assessment? 1) Having suction available 2) Assessing pupil size and reactivity 3) Immobilizing any obvious deformities 4) Obtaining blood samples for type and crossmatch

1 The priority nursing actions related to breathing when conducting a primary survey during an emergency assessment include having suction available and giving supplemental oxygen.

Which member of the health-care team, when using the team nursing approach, is responsible for prioritizing patient care? 1) Team leader 2) Charge nurse 3) Licensed practical nurse 4) Unlicensed assistive personnel

1 When using the team nursing approach, the team leader, who is a registered nurse, is responsible for coordinating a group of licensed and unlicensed personnel to provide patient care to a small group of patients, including the prioritization of patient care.

The registered nurse (RN) is the team leader for a group of patients using the functional model of nursing. The team of nurses includes two licensed practical nurses (LPNs) and an unlicensed assistive personnel (UAP). Which task will the RN delegate to the UAP? 1) Taking vital signs 2) Providing wound care 3) Conducting discharge teaching 4) Administering oral medications

1 When working in an environment that uses the functional model of nursing, each team member will be delegated tasks for a group of patients by the team leader, the RN. The RN will delegate taking vital signs to the UAP.

The nurse is providing care to a trauma patient. What is the correct order of steps the nurse will implement when providing care to this patient? 1) Clear the airway 2) Protect the cervical spine 3) Perform chest compressions 4) Provide supplemental oxygen

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What would the nurse working in the emergency department identify as clinical priorities for the treatment of a patient with a gunshot wound? Select all that apply. 1) Airway maintenance 2) Obtaining medical history 3) Ventilation assistance 4) Hemorrhage control 5) Hypothermia prevention

1 3 4 5 Clinical priorities for the treatment of gunshot wound are the following: maintain airway and assist ventilation as necessary, control hemorrhage, prevent hypothermia. Also necessary is a rapid, recurrent assessment of the patient's neurological status, as well as prevention of infection.

The nurse correlates which three factors as related to the triad of death? Select all that apply. 1. Coagulopathy 2. Hemorrhage 3. Hypothermia 4. Hypoxemia 5. Metabolic acidosis

1 3 5 the trauma triad of death is a term describing the lethal combination of hypothermia, metabolic acidosis, and coagulopathy in the trauma patient.

Which are the top priorities when conducting a primary patient survey during the emergency assessment? Select all that apply. 1) Airway 2) Disability 3) Breathing 4) Circulation 5) Cervical spine

1 5 Airway and stabilization of the cervical spine are the top priorities when conducting a primary patient survey during the emergency assessment.

The nurse correlates damage to which cardiac chamber in the patient with trauma to the sternum? 1. Right atrium 2. Right ventricle 3. Left atrium 4. Left ventricle

2 Sternum fractures can result in right ventricular perforation, and fractured ribs can lacerate either the right or left ventricle.

Which is a potentially life-threatening condition found during the primary triage survey that would necessitate priority nursing care? 1) Cystitis 2) Concussion 3) Lacerated arm 4) Fractured femur

2 A concussion, which is a type of head injury, is a potentially life-threatening condition found during the primary triage survey that would necessitate priority nursing care.

The nurse is conducting a primary survey during the emergency assessment. Which nursing action is appropriate during the breathing assessment? 1) Assessing for edema 2) Counting respiratory rate 3) Checking for foreign bodies 4) Monitoring for respiratory distress

2 Counting the respiratory rate is a nursing action appropriate during the breathing assessment.

The nurse monitors for which clinical manifestations in the patient diagnosed with heat stroke? 1. Vertigo 2. Red, dry skin 3. Profuse sweating 4. Nausea

2 Heat stroke is a medical emergency. The body's thermoregulatory mechanism has failed, and the body temperature rises uncontrollably. Immediate intervention is necessary to prevent organ damage and death. Classic heatstroke develops over several days during a heat wave and typically affects elderly, sedentary people with preexisting conditions. Patients usually present with red, dry skin; the patient has stopped sweating altogether.

The nurse monitors for which initial clinical manifestations in the patient being treated for drowning? 1. Alkalosis 2. Tachycardia 3. Elevated temperature 4. Hypocarbia

2 Initially, the victim is hypertensive and tachycardic with activation of the sympathetic nervous system.

In attempting resuscitation in a patient who is hypothermic, to what temperature does the patient need to be rewarmed for treatment to be effective? 1. 80°F/26.7°C 2. 86°F/30°C 3. 90°F/32°C 4. 98°F/36.6°C

2 Resuscitation medications and defibrillation are not effective until the patient is greater than 86°F (30°C). Defibrillation should be attempted one time, but if ineffective, further attempts are deferred until temperature reaches greater than 86°F (30°C).

Which is the essential nursing skill for the triage process in the emergency department? 1) Evaluating care 2) Setting priorities 3) Formulating diagnoses 4) Implementing interventions

2 Setting priorities is an essential nursing skill for the triage, or assessment, process that occurs in the emergency department.

The nurse recognizes that the highest suicide rate in the United States is in which population? 1. African American 2. Caucasian 3. Hispanic 4. Native American

2 The highest rate for suicide is found in the Caucasian population, and Caucasian men have the greatest number of fatalities in motor vehicle collisions.

Which observation indicates that interventions provided to a patient with neck injuries from a motor vehicle crash have been successful? 1) Urine is clear and odorless from indwelling catheter 2) Moves all four extremities independently, feeds self, and participates in partial bath 3) Unable to move independently in bed 4) Rests in bed with lights and television turned off

2 The patient sustained neck injuries from a motor vehicle accident. With these types of injuries, there is a risk for paralysis. Evidence that interventions have been successful for this patient includes moving all four extremities independently, feeding self, and participating in partial bath care. This means the patient has mobility, which is a successful outcome.

Which is the priority nursing action when providing care to a patient with a penetrating abdominal wound? 1) Assessing bowel sounds 2) Stabilizing the impaled object 3) Administering prescribed pain medication 4) Scheduling a CT scan to determine retroperitoneal bleeding

2 The priority nursing action when providing care to a patient with a penetrating abdominal wound is to stabilize the impaled object to prevent further injury.

Which treatment should the nurse prepare to administer when providing care to a toddler who presents after an accidental overdose of aspirin? 1) Gastric lavage 2) Activated charcoal 3) Peritoneal dialysis 4) Vitamin D injection

2 the nurse would prepare to administer activated charcoal to the client and repeat every four hours, if needed, for a client with active bowel sounds.

Which interventions does the nurse implement when providing care to a patient who is at risk for hypothermia? Select all that apply. 1. Keeping wet clothing on the patient 2. Placing a warming blanket on the patient 3. Infusing warm intravenous fluids to the patient 4. Increasing the temperature in the patient's room 5. Providing the patient with room temperature oral fluids

2 3 4 keep pt warm room temp not warm

In preparing an educational program regarding drug overdoses, what information does the nurse include? Select all that apply. 1. People rarely overdoes on heroin. 2. Overdoses occur most often from opioids, benzodiazepines, and stimulants. 3. The number of overdose deaths from prescription medications is greater than the deaths from heroin and cocaine combined. 4. Nonsteroidal inflammatory medications are one of the classes with the greatest number of overdoses. 5. Pain management issues are a source of the increased incidence of overdoses from prescription medications.

2 3 5 The most commonly used drugs resulting in overdose include 10 drugs in 3 classes: opioids (heroin, oxycodone, methadone, hydrocodone and fentanyl), benzodiazepines (alprazolam and diazepam), and stimulants (cocaine and methamphetamine).

Which nursing actions are appropriate during the primary survey of the emergency assessment process? Select all that apply. 1) Inserting a nasogastric tube 2) Immobilizing the cervical spine 3) Arranging for diagnostic studies 4) Preparing for chest tube insertion 5) Applying direct pressure to a wound

2 4 5 The primary survey focuses on airway, breathing, circulation (ABC), disability, and exposure or environmental control. It aims to identify life-threatening conditions so that appropriate interventions can be started. Nursing actions that are appropriate during the primary survey include immobilizing the cervical spine, preparing for chest tube insertion, and applying direct pressure to a wound.

in completing a primary survey, the nurse assesses which factor to determine the "E" in the ABCDE sequence? 1. Emotion 2. Estimated blood loss 3. Exposure 4. Extremities

3 ABCDE are the major components of the primary survey. "E" correlates with exposure/environment.

In administering calcium gluconate 10% intravenously to a patient who suffered a black widow spider bite, the nurse correlates the rationale for this medication to which mechanism of action? 1. Decreases spread of venin 2. Decreases airway resistance 3. Decreases muscle rigidity 4. Decreases pain

3 Treatment for a black widow bite includes opioids or muscle relaxants. Calcium gluconate 10% intravenously may relieve muscle rigidity.

In providing care to a patient who sustained lower rib fractures, the nurse assesses the patient for which complication of this injury? 1. Hemothorax 2. Pneumothorax 3. Liver laceration 4. Pulmonary contusion

3 A lower rib injury is likely to cause a liver laceration; therefore, the nurse prepares to assess the patient for this injury. other options = middle rib injury

The nurse is providing care to several patients in the emergency department. Which patient would require priority care from the nurse? 1) An adult patient with an ankle sprain 2) An infant with a rash of unknown origin 3) An adult patient with unstable vital signs and chest pain 4) A pediatric patient with multiple fractures following a motor vehicle accident

3 An adult patient with unstable vital signs would receive priority care based on the three- tiered triage system due to emergent, or life-threatening, injury.

The nurse monitors for which clinical manifestations in the patient who overdoses on beta blockers? 1. Tachycardia 2. Respiratory depression 3. Hypotension 4. Elevated body temperature

3 An overdose of beta blockers affects the heart by controlling the rate or intensity of cardiac contraction, blood vessel diameter, or blood volume, and these changes may result in hypotension and bradycardia.

A nurse is developing a plan of care for a patient with traumatic injuries from a motor vehicle crash. Which nursing intervention does the nurse include in the plan of care to reduce the risk of integumentary complications? 1) Provide active or passive exercises at least once every eight hours 2) Encourage coughing, deep breathing, and incentive spirometry 3) Assist the patient in turning at least every two hours 4) Assist the patient in turning at least every eight hours

3 Assisting the patient to turn at least every two hours is the most appropriate intervention for the nurse to include in the plan of care to reduce the risk of integumentary complications.

Which diagnostic results are most relevant to the patient being evaluated for rhabdomyolysis secondary to a snakebite? 1. BUN 4 mg/dL 2. Calcium 14.5 mg/dL 3. Creatinine 1.8 mg/dL 4. Osmolality 285 mOsm/L

3 Blood urea nitrogen and creatinine are elevated in renal failure, which is a risk with rhabdomyolysis. This is an elevated creatinine level.

In reviewing arterial blood gas (ABG) results in the patient with a salicylate overdose and a respiratory rate of 36, the nurse correlates which ABG value to this patient's clinical presentation? 1. pH 7.48 2. HCO3- 19 mEq/L 3. PaCO2 32 mm Hg 4. PaO2 80 mm Hg

3 Salicylate levels greater than 35 mg/dL cause increases in rate and depth of respirations, resulting in respiratory alkalosis. This PaCO2 is consistent with a respiratory alkalosis.

The nurse conducts a Glasgow Coma Scale (GCS) assessment for a patient who presents in the emergency department after a motor vehicle crash (MVC). The patient opens the eyes spontaneously, is confused, and withdrawals from pain. Which score does the nurse document for this patient? 1. 10 2. 11 3. 12 4. 13

3 Spontaneous eye opening scores as a 4 (eye opening); confusion scores a 4 (verbal response), and withdrawal from pain scores a 4 (motor response). The total score for this patient is a 12, which indicates moderate brain injury.

Which action does the nurse take in the management of a patient with a snake bite? 1. Placing a tourniquet above the bite 2. Applying ice to the bite 3. Cleaning the site with soap and water 4. Scrubbing the bite with alcohol

3 The wound should be cleansed, and the patient should receive tetanus prophylaxis if the immunization is outdated or unknown. It is not recommended to provide antibiotics for snakebites unless the wound is heavily contaminated.

Which nurse monitors for which late clinical manifestations of chronic aspirin overdose? 1. Emesis 2. Nausea 3. Tinnitus 4. Hyperthermia

4 Hyperthermia is a clinical manifestation of severe aspirin toxicity, a late clinical manifestation of acute aspirin poisoning. Emesis, tinnitus, and nausea are all early clinical manifestations of acute aspirin poisoning.

Which nursing action is appropriate when conducting a secondary survey during the emergency assessment? 1) Maintaining privacy 2) Having suction available 3) Giving supplemental oxygen 4) Assigning a nurse to support family members

4 A nursing action that is appropriate during the secondary survey is assigning a nurse, or other team member, to support family members.

A patient recovering from a motor vehicle crash develops hypotension and jugular distension with a tracheal deviation. Based on this data, which should the nurse suspect occurred? 1) Hemorrhage 2) Compensatory shock 3) Hypovolemic shock 4) Tension pneumothorax

4 A tension pneumothorax is life threatening and requires immediate intervention. On inspiration, air enters the pleural space, does not escape on expiration, and increases the intrapleural pressure. This pressure collapses the injured lung and shifts the mediastinal contents, compressing the heart, great vessels, trachea, and eventually the uninjured lung.

The emergency department nurse is triaging patients. Which patient should be prioritized? 1) An adult patient experiencing mild chest pain 2) An adolescent patient with a possible fractured wrist 3) An older adult patient with a hip fracture who is in pain 4) A school-age patient with asthma presenting with dyspnea

4 According to the Five-Level Emergency Severity Index (ESI), a patient experiencing severe respiratory distress such as the school-age patient with asthma who is having difficulty breathing (dyspnea) would receive priority care as an ESI-1.

The first step in the management of a patient being treated for hyperthermia includes which nursing action? 1. Inserting an indwelling catheter 2. Initiating intravenous access 3. Implementing low flow oxygen 4. Relocating to a cool environment

4 All interventions for hyperthermia start with removal to a cooler environment and hydration. Heat stress or heat edema may require nothing more than removing to a cooler environment. The patient with heat syncope requires safety maneuvers to help prevent injury from falling. After being gently helped to the floor, the patient should be placed in the recovery position until full recovery of consciousness. Heat cramping requires rehydration with oral fluids containing electrolytes to correct the fluid and electrolyte loss.

A patient is brought into the emergency department after being assaulted. It is suspected that the patient has a spinal cord injury. Which diagnostic test does the nurse anticipate based on the data collected? 1) Computed tomography (CT) scan 2) X-ray 3) Ultrasound 4) Magnetic resonance imaging (MRI)

4 An MRI will be performed if there is a risk for spinal cord injuries, injuries to the muscles, or abdominal injuries.

Which nursing action is appropriate when conducting a secondary survey during the emergency assessment? 1. Maintaining privacy 2. Having suction available 3. Giving supplemental oxygen 4. Completing a pain assessment

4 At the beginning of the secondary survey, a complete set of vital signs are obtained and pain is assessed.

What should the nurse do to assist a patient brought to the emergency department as a victim of a gunshot wound? 1) Ask the patient who shot him 2) Bathe the patient and provide a clean gown 3) Ask the patient where the weapon is 4) Preserve the chain of evidence

4 Because the majority of gunshot wounds require an investigation by law enforcement, nurses working in emergency departments and trauma centers should be familiar with their agency's protocols for maintaining evidence required by law enforcement. Often, law enforcement does not want the victim's hands or the area around the victim's wounds cleansed. Clothes and personal items are often wanted as evidence. The nurse should not bathe the patient and provide a clean gown. The nurse should not ask the patient who shot him or where the weapon is. The nurse should preserve the chain of evidence.

Which assessment data related to the patient's airway would indicate the need for priority intervention by the nurse? 1) Eupnea 2) Tachycardia 3) Hypotension 4) Agonal breaths

4 Dyspnea, agonal breaths, and an inability to speak are all assessment data that indicate a compromised airway and the need for priority intervention by the nurse

Which assessment data indicates the patient is experiencing a late symptom associated with chronic aspirin overdose? 1) Emesis 2) Nausea 3) Tinnitus 4) Ecchymosis

4 Ecchymosis is a late symptom associated with a chronic aspirin overdose.

The nurse monitors for which acid-base disorder in the patient with early hypothermia? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

4 Mild hypothermia is when the body's core temperature is 89.6°F to 95°F (32°C to 35°C). The human body tries to compensate for decreases in body temperature by stimulating the sympathetic nervous system to shiver and increase heart rate, blood pressure, respirations, and promote peripheral vasoconstriction. Tachypnea causes a decrease in carbon dioxide (CO2) levels, resulting in a respiratory alkalosis.

The nurse is providing care to several patients in the emergency department. Which patient is the priority when using the three-tiered triage system? 1) A patient with a simple fracture 2) A patient experiencing renal colic 3) A patient with severe abdominal pain 4) A patient with chest pain and diaphoresis

4 The patient with chest pain and diaphoresis is classified as emergent and would require priority care.

Which intervention would be a priority when providing care to a patient recovering from thoracic injuries sustained from a motor vehicle crash? 1) Monitor urine output 2) Assess vital signs 3) Perform passive range of motion to all extremities 4) Assist to deep breathe and cough every two hours

4 the patient has thoracic injuries and might be reluctant to deep breathe and cough because of pain. The nurse needs to ensure that the patient breathes deeply and coughs every two hours to mobilize secretions and prevent respiratory complications.

The nurse is providing care to several patients in the emergency department. In which order should the nurse assess and provide care to the patients? 1) A patient with a leg laceration requiring sutures 2) A patient with abdominal pain rated as a 7 on a numeric pain scale 3) A patient who has multiple trauma due to a motor vehicle accident 4) A patient who took an overdose of opioids with a respiratory rate of eight breaths per minute

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