MED-SURG CH. 16 NCLEX QUESTIONS

The nurse witnesses a motor vehicle accident that injured four people, all of which have a decreased level of consciousness. After an initial assessment of each individual's condition, the nurse determines that which person should be treated first? 1. A 30-year-old woman with paradoxical chest movement 2. A 35-year-old man with clear fluid leaking from his nose 3. A 25-year-old woman hemorrhaging from a right thigh laceration 4. A 20-year-old man complaining of an inability to move his arms and legs

1. A 30-year-old woman with paradoxical chest movement The nurse should triage the patients according to their injuries. The first patient to be treated should be the patient with an alteration in respiratory function, which is the individual with paradoxical chest movement. The next person to be treated is the one hemorrhaging from a thigh laceration; the laceration could have severed the femoral artery, which is a life-threatening emergency. The patient with clear fluid leaking from his nose and the person complaining of an inability to move his arms and legs have likely sustained neurologic injuries, which are triaged lower than respiratory and cardiovascular emergencies. REF: p. 235

The nurse is driving home from the hospital and witnesses a one-car accident on the highway. The nurse assesses the scene to ensure it is safe and approaches the vehicle. What should the nurse do next? 1. Ask the victim's name. 2. Assess for signs of bleeding. 3. Assess for symmetrical chest wall movement. 4. Determine the best way to get the victim out of the car.

1. Ask the victim's name. The nurse should first ask the victim his or her name because this helps to determine if there is a neurologic injury and if the patient is breathing. The nurse should then assess for signs of bleeding and for symmetrical chest wall movement. Determining the best way to get the victim out of the car should be done when emergency medical services arrive to ensure safety for the victim and the nurse. REF: p. 234

Your assessment of a person who has sustained a head injury reveals the following: headache, decreasing blood pressure, increasing respiratory rate, unequal pupils, and confusion. Which of these findings would cause you to suspect increased intracranial pressure? (Select all that apply) 1. Headache 2. Decreasing blood pressure 3. Increasing respiratory rate 4. Unequal pupils 5. Confusion

1. Headache 4. Unequal pupils 5. Confusion Signs of increased intracranial pressure include headache, unequal pupils, and confusion as well as decreasing level of consciousness, impaired sensory or motor function, and projectile vomiting. Blood pressure is increased, not decreased, with a widening pulse pressure. Respiratory rate is decreased, not increased, along with a decreased pulse.

During a hike, a participant fell and injured his leg. Suspecting a fracture, the first-aid care provider should take what action? 1. Immobilize the leg in the position in which it was found 2. Gently straighten the leg and immobilize it 3. Apply a tourniquet above the fracture if bleeding is present 4. Elevate the injured part above the level of the victim's heart

1. Immobilize the leg in the position in which it was found When suspecting a leg fracture, the first aid provider should immobilize the leg in the same position in which it was found. The injured parts need to be immobilized, including the joints above and below the injury. Trying to straighten a broken bone could cause further trauma to the bone and surrounding soft tissue. If there is severe bleeding, direct pressure to the artery above the injury, and not a tourniquet, needs to be applied. Do not elevate the injured part above the level of the victim's heart but instead splint the bone in the same position in which it was found and use as little movement as possible.

A patient has developed food poisoning as a result of Staphylococcus aureus. In caring for this patient, what should be the LPN's HIGHEST priority? 1. Monitor the administration of intravenous (IV) fluids. 2. Administer an antidiarrheal medication. 3. Assist with gastric lavage. 4. Assist with mechanical ventilation.

1. Monitor the administration of intravenous (IV) fluids. When a patient develops food poisoning as a result of Staphylococcus aureus, the nurse would be responsible for monitoring the administration of IV fluids, antiemetic medications, and sedation. Administering an antidiarrheal medication is an intervention unique to food poisoning from either Clostridium perfringens or Salmonella. Assisting with gastric lavage and mechanical ventilation are interventions unique to food poisoning from Clostridium botulinum. REF: p. 247

A high school football player collapses during practice on a hot, humid day. He is breathing but not responding verbally. His skin is hot, red, and dry. Which of the following actions should be taken? (Select all that apply.) 1. Move him to a cool location 2. Activate the emergency medical services system 3. Notify his parents to take him to the hospital 4. Encourage him to take sips of ice cold liquids 5. Apply cool, wet towels

1. Move him to a cool location 2. Activate the emergency medical services system 5. Apply cool, wet towels If the football player collapses on a hot, humid day and is breathing and not responding, then he is probably suffering from hyperthermia. The first intervention is to move the player to a cool location and then activate the Emergency Medical Services (EMS). Then apply wet, cool towels to the trunk and the extremities, and place ice packs on the forehead and axillae. Since he is not verbally responding, do not give him anything orally. Also, EMS should be called before the parents are notified, and EMS will transport him to the hospital.

The nurse is an immunization clinic notices a peculiar ring-shaped, reddened area on the leg of a child. When asked about it, the mother states that she removed a tick from that area last week. What should the nurse do? 1. Suspect early Lyme disease and refer the child for medical treatment 2. Advise the mother to apply antibiotic ointment to the lesion daily 3. Recognize the bite of a black widow spider and apply a constrictive band 4. Contact the physician for an order for brown recluse spider antivenin.

1. Suspect early Lyme disease and refer the child for medical treatment A tick bite that 1 week later appears as a ring-shaped, reddened area at the bite site could be a sign of early Lyme disease. This finding would call for a referral for medical treatment. Application of antibiotic ointment would not treat the Lyme disease. Neurotoxic reactions to black widow spider bites include pain, nausea, vomiting, fever, weakness, muscle cramps, and headache occurring right after the bite. Constricting bands are not recommended. The swelling from brown recluse spider bites usually occurs within a few hours after the bite and there is no specific antivenin available for treatment.

Appropriate intervention for a completely avulsed ear is to retrieve the tissue and then perform which intervention? 1. Wrap it in plastic, keep it cool, and transport it with the victim. 2. Place it in a cup of warm water and transport it with the victim. 3. Wrap it in plastic, keep it warm, and transport it with the victim. 4. Apply antibiotic ointment, wrap it in gauze, and transport it with the victim.

1. Wrap it in plastic, keep it cool, and transport it with the victim. The ear should be wrapped in plastic to protect it from the elements and potential contaminants. It needs to be kept cool to lower the tissue temperature, keep the vessels constricted, and preserve the tissue. The ear should not be placed in water because this could contaminate the tissue and cause the tissue to become water logged. Warming the tissue progresses the state of deterioration and decreases the chance for healthy reattachment. Applying ointment and gauze are not an approved treatment recommendations prior to reattachment. REF: p. 241

Which intervention is most appropriate for emergency care of a pneumothorax? 1. Apply direct pressure over any chest wounds. 2. Apply a vented dressing, sealed on three sides. 3. Observe the patient's chest for paradoxical motion of the chest. 4. Hold or tape a small pad or pillow to the injury site to splint the ribs.

2. Apply a vented dressing, sealed on three sides. A vented dressing sealed on three sides allows air to escape but not enter the chest wound. Applying direct pressure over chest wounds will not treat a pneumothorax. Paradoxical motion describes the motion of a flail chest of inward motion of the affected section on inspiration and outward motion on expiration. Splinting of the ribs is necessary in a flail chest but not a pneumothorax. REF: p. 242

The nurse enters a room to find the patient unresponsive. What should be the nurse's priority action? 1. Call a code. 2. Assess for a pulse. 3. Begin high-quality compressions. 4. Increase the patient's oxygen to 10 L/min.

2. Assess for a pulse. The nurse should first assess for a pulse and then begin high-quality compressions if necessary. While doing compressions, the nurse should call for help and instruct the first person to arrive to call a code. If the patient's heart is not beating, he or she is likely not breathing; therefore, increasing the patient's oxygen is not helpful unless someone is using a bag mask to ventilate the patient. REF: p. 235

What should be the HIGHEST priority nursing action of the licensed practical nurse (LPN) when caring for a patient who has experienced perforation of the globe of the eye? 1. Explain to the patient the reason both eyes need to be covered. 2. Caution the patient not to remove the object. 3. Instruct the patient to wear a patch on both the unaffected and the affected eye. 4. Instruct the patient to limit movement in both eyes.

2. Caution the patient not to remove the object. The greatest harm could be produced by attempting to remove the object from the eye. Although it is important to explain to the patient the reason both eyes need to be covered and instruct the patient to limit movement in both eyes, it is not the priority intervention. REF: p. 241

An LPN finds a patient who appears to be a victim of carbon monoxide poisoning. What should be the nurse's HIGHEST priority action? 1. Place the victim in a hyperbaric oxygen chamber. 2. Move the patient to fresh air. 3. Start rescue breathing. 4. Administer oxygen to the patient.

2. Move the patient to fresh air. The first priority for the patient with carbon monoxide poisoning is to move him or her to fresh air. All patients may not require the use of a hyperbaric oxygen chamber. Only the patient who has stopped breathing would require rescue breathing. Although oxygen will be administered, the first priority would be to move the patient to fresh air. REF: p. 244

An LPN is administering first aid to a patient who has developed a flail chest. What should be the LPN's highest priority? 1. Apply vented dressing. 2. Provide support for the injured area. 3. Apply airtight dressing. 4. Transport to a medical facility.

2. Provide support for the injured area. The LPN should provide support for the injured area and hold or tape a small pad or pillow over the injury to splint the ribs. Applying vented and airtight dressings are interventions unique to a pneumothorax. Transporting the patient to a medical facility is an intervention that could apply to a hemothorax or a cardiac tamponade. REF: p. 242

A person with dementia living at home is found with an empty bottle of aspirin. The caregiver suspects that the patient has consumed an unknown quantity of the drug. What should the caregiver's first action be? 1. Have the victim drink a large glass of water 2. Administer syrup of ipecac 3. Call the poison control center for guidance 4. Drive the victim to the emergency department

3. Call the poison control center for guidance In this situation, the Poison Control Center needs to be called immediately, and the caregiver should follow their directions. Do not give the client anything to drink or any syrup of ipecac, but follow the Poison Control Center's directions for intervention. Then drive the client to the emergency department (ED).

The nurse is working in the emergency department during the winter. A patient who is homeless is brought in wearing no shoes, with symptoms of confusion, violent shivering, and a core temperature of 30° C. What are the appropriate assessment and treatment? (Select all that apply.) 1. Mild hypothermia 2. Severe hypothermia 3. Moderate hypothermia 4. Moderate hyperthermia 5. Warm the victim quickly by wrapping the entire body with warming blankets and additional layers on the hands and feet and administer warmed intravenous fluids and warmed oxygen. 6. Warm the victim gradually by wrapping the torso with warming blankets and peritoneal lavage until the core temperature reaches 35° C; then focus on the extremities.

3. Moderate hypothermia 6. Warm the victim gradually by wrapping the torso with warming blankets and peritoneal lavage until the core temperature reaches 35° C; then focus on the extremities. Moderate hypothermia is classified as a core body temperature of 28° to 32° C and is characterized by confusion, poor motor coordination, slurred speech, violent shivering, and possible irrational behavior. The victim must be rewarmed aggressively but gradually because excessive rewarming sends lactic acid and cold blood from the extremities to the heart, possibly triggering cardiac dysrhythmias. The torso or body core must be warmed first. When the core body temperature reaches 35° C, the focus is turned to warming the extremities. Warming efforts include warming blankets, warmed intravenous fluids, warmed oxygen, and warmed peritoneal lavage. Mild hypothermia is classified as a core body temperature of 32° to 35° C. Severe hypothermia is classified as 28° C or lower. Hyperthermia is excessive heat exposure, with a core body temperatures of 37.2° or higher. REF: pp. 244, 245

The nurse is the first on the scene of a motor vehicle collision, with an injured motorist. What is the nurse's first priority? 1. Look for a medical alert tag. 2. Soothe and reassure the victim. 3. Preserve life and minimize the effects of injuries. 4. Get the patient to the emergency department.

3. Preserve life and minimize the effects of injuries. The first priority is to preserve life and minimize the effects of injuries. The other options identify components of important nursing interventions in emergency situations. Looking for a medical alert tag is important, but it is not the first priority in preserving life. Soothing and reassuring the victim are helpful, but they are not life sustaining. Getting the patient to an emergency department is important; however, that is the role of emergency medical services and paramedics. REF: p. 234

The nurse in the hospital cafeteria sees a pregnant woman stand up and clutch her throat. The nurse asks the woman if she is choking, but the woman is unable to speak. The nurse moves behind the patient. What should the nurse do next? 1. Perform five back blows to the victim's lower back. 2. Perform five back blows to the victim's upper back. 3. Reach under the victim's arms and deliver firm thrusts to the victim's chest. 4. Reach under the victim's arms and deliver firm thrusts to the victim's abdomen.

3. Reach under the victim's arms and deliver firm thrusts to the victim's chest. The safest intervention for the victim and fetus is to reach under the victim's arms and deliver firm thrusts to the victim's upper chest. The nurse should not perform thrusts to the victim's abdomen or back blows to the victim's back. REF: p. 237

An LPN is administering first aid to a burn victim. What should be the HIGHEST priority nursing action for this patient? 1. Determine the type of burn that has occurred. 2. Assess the patency of the airway. 3. Stop the burning process. 4. Administer rescue breathing.

3. Stop the burning process. When a burn accident occurs, the first and immediate priority is to stop the burning process. Only after the burning process has been stopped would it be appropriate to assess the patency of the airway, administer rescue breathing, and determine the type of burn that has occurred. REF: p. 242

While at a picnic at the lake, a person catches his clothing on fire while trying to start a charcoal fire. What should bystanders do first? 1. Tell him to run and jump in the lake 2. Try to extinguish the flames with their hands 3. Tell him to drop to the ground and roll 4. Run to a telephone to call for help

3. Tell him to drop to the ground and roll The immediate concern is to stop the burning process. If a victim's clothing is burning, have him drop to the ground and roll to extinguish the flames. Then try to smother the flames with a coat or blanket or extinguish with water if flames are not due to chemicals or flammable liquids. Telling him to run and jump in the lake would aggravate the burning process and increase the client's injuries. Trying to extinguish the flames with your hands would be ineffective and only cause severe hand burns to the bystander. Running to the phone to call for help would take too much time and would increase the victim's injuries and could lead to death.

In an emergency, the nurse is collecting data for a brief medical history by using the acronym "AMPLE." Which aspects of data collection should be included? 1. Antibiotics, medication allergies, past illness or injury, last medication, and essential information 2. Allergies, mood disorders, past illness or pregnancy, last medication, and events related to injury 3. Antibiotics, current medications, past complications of pregnancy, last food or drink, and exposure 4. Allergies, current medications, past illness or pregnancy, last food or drink, and events related to injury

4. Allergies, current medications, past illness or pregnancy, last food or drink, and events related to injury The acronym AMPLE may help you to inquire about allergies, current medications, past illness or pregnancy, last food or drink, and events related to injury. Although the other options include important elements of a detailed history (mood disorders, past complications of pregnancies), an emergency history gathering should be brief and succinct to focus on the most important details. Exposure relates to removing a victim's clothing in order to be fully examined for injuries. REF: p. 235

Circulation must be restored within 4 minutes of cardiopulmonary arrest because: 1. Irreversible kidney failure develops 2. The blood begins to coagulate 3. The lungs fill with fluid 4. Brain cells begin to die

4. Brain cells begin to die If circulation is not restored within 4 minutes after a cardiac arrest, brain cells are the first cells to begin to die. Irreversible kidney failure and coagulation of blood begins after a prolonged episode of cardiac arrest. The lungs do not fill with fluid during cardiac arrest because there is no blood flow to the lungs

_______ ______ are used to dislodge a foreign body from the airway.

Abdominal thrusts Use abdominal thrusts to dislodge a foreign body from the airway of a conscious or unconscious choking victim according to the American Heart Association (AHA) guidelines for choking. Signs of severe airway obstruction include poor or no air exchange, poor or no cough, high-pitched noise or no noise on inhalation, respiratory distress, cyanosis, inability to speak and move air, and clutching the neck in the universal choking sign.

After determining that an accident victim is breathing and has a pulse, you should next assess for __________.

Bleeding Bleeding should be the next assessment after determining that an accident victim is breathing and has a pulse. If the bleeding is uncontrolled, then the source needs to be identified, and pressure applied to the source.

The patient with hypothermia must be gradually rewarmed to prevent _____________________.

cardiac dysrhythmias Excessive rewarming of hypothermic victims sends lactic acid and cold blood from the extremities to the heart, leading to a risk for cardiac dysrhythmias.