NSG-401 Quiz 4

Which procedure should the nurse follow for assessing a client's eye in an emergency?

PERRLA+C procedure.

A nurse is caring for a client who has been diagnosed with hypovolemic shock. Which diagnostic procedure should the nurse review to obtain additional information about the client's condition? (SATA)

serum electrolyte levels. hemoglobin level.

Which situations are considered a psychiatric emergency that require medical assistance? (SATA)

1) client reports having suicidal thoughts. 2) client reports having a history of prior suicide attempts. 3) client makes a credible threat to harm someone else. 4) client threatens to harm themselves.

Which information demonstrates an accurate understanding of the process of anaphylaxis? (SATA)

1) in anaphylaxis, the antigen antibody reaction is dangerous. 2) the release of a chemical in the body causes reaction that are often systemic. 3) anaphylaxis is responsible for a shock reaction.

What statements present accurate information about the concepts of triage? (SATA)

1) process of sorting and classifying to determine priority of needs. 2) contains disaster plan initiated when an accident involves multiple victims. 3) process of victim identification so next of kin can be notified.

What interventions should the nurse implement when providing care to a client during the rewarming process for severe hypothermia? (SATA)

1) provide warm oral fluids, if client is alert. 2) monitor for cardiac dysrhythmias. 3) remove and replace all wet clothing.

Which symptoms are classically associated with suspected heart attack? (SATA)

1) restlessness. 2) indigestion. 3) chest pain with radiation to the left arm. 4) pain radiating to the back.

Hazardous substances are used daily in healthcare facilities. What are key safety tips that healthcare workers must practice when using and storing hazardous substance? 1. Have the telephone number for the healthcare agency's Poison Control Center readily available. 2. Read labels carefully and note emergency information. 3. Follow instructions for use, storage, and disposal. 4. Avoid spills.

1, 2, 3.

Healthcare facilities often use some sort of emergency staff notification system during a disaster. A hurricane has disrupted the telephone service. What methods of communication would be most appropriate at this time? 1. Amateur radio ham operator. 2. Runners who transport messages on foot. 3. Computers via email. 4. Portable of handheld radios.

1, 2, 4.

The nurse is reviewing with the client the use of the emergency signal in the client's bathroom. What instructions should the nurse review with the client about the use of the emergency signal? 1. Causes a light to flash or a buzzer to sound at a central nurse's station. 2. Use when experiencing difficulty while in the bathroom. 3. Staff will respond to the signal within 5 minutes. 4. Used by staff to request immediate assistance.

1, 2, 4.

Every facility must have on file a material safety data sheet (MSDS) describing any substance that is considered hazardous. What information is included on the MSDS? 1. Substance's potential dangers. 2. Maintenance of potential industrial hazards in intensive care units. 3. First-aid interventions for accidental exposure. 4. Information on protective equipment.

1, 3, 4.

A major goal in all healthcare is the prevention of falls. What are examples of routine fall prevention measures that nurses must institute? 1. Making sure wheelchairs are lock when the client is in bed. 2. Assisting with ambulation when needed. 3. Making sure spills are labeled with a sign and cleaned up within 1 hour. 4. Assessing clients and documenting in the client's record at least once every 24 hours.

2, 4.

All staff are required to received instructions on the use of material safety data sheets and protective gear. A question from one of the participants to the presenter of an in-service session wants to know how long the material safety data sheets for toxic substance must be kept on file for reference. What would be the best response about the length of time that material safety data sheets must be kept on file for toxic substances?

30 years.

Which procedure should the nurse implement when assessing an ill or injured person in an emergency situation?

ABCDE procedure.

What type of assessment should be completed by the first trained healthcare professional to arrive at a scene of an accident when life-threatening problems or injuries are identified?

ABCDE.

During a mock training session, student nurse are taught the acronym "PASS" to be followed during a fire. What does "A" stand for?

aim at the base of the fire, near the edge.

A nurse on duty in the pediatric ward notices an unidentified person carrying a baby in her arms. The baby is dressed in hospital garb. What immediate action should the nurse take?

alert the supervisor and call- "Code Pink"

A nurse in a local health care facility is caring for a client suspected of bleeding internally. Which observation should the nurse report to a physician immediately?

breathing that is becoming shallow and rapid.

Many home care clients can activate an alert system when they are having difficulty or feel they have an emergency. When the alarm is activated by the client, what is the first step that occurs?

the client is contacted by telephone.

A safety committee in a healthcare facility provides a safe environment for the client, staff, and visitors. The nurse is reviewing with a group of nursing student the importance of a safe environment. What is the best response by the nursing student about the responsibilities associated with the safety committee?

to track injury and illness rates.

What common signal would the nurse in a hospital setting initiate for a cardiopulmonary emergency?

code blue.

During a mock training session, student nurse are taught the acronym "RACE" to be followed during a fire. What does "C" stand for?

contain or confine the fire.

A nurse is evaluating a client's risk of falling. What is a key way that the nurse could review with a nursing student that would quickly identify a client's risk of falling?

falling star sign outside the room.

A nurse is asked to help with triage after an earthquake hits the area. What is expected of the triage nurse?

identify people who require immediate medical care.

A nurse in a healthcare facility receives a call that the facility will be bombed. What action should the nurse take after receiving the bomb threat?

notify the facility's security personnel.

There are many hazardous materials in the health care facility. The nurse is reviewing the procedure manual about potentially hazardous materials on the clinical unit. The nurse notices in the procedure manual that a sign has to be placed with a flammable hazard. What is an example of a flammable hazard for the client and nurse?

oxygen.

For which sign of rising intracranial pressure should the nurse monitor when caring for a client who has sustained a head injury?

persistent vomiting.

A nurse is caring for a client with severe hypothermia. What should the nurse do when providing care to the client during the rewarming process?

provide warm fluids, if the client can swallow.

What intervention should the nurse implement when caring for the client experiencing a pneumothorax?

seal wound using petroleum jelly gauze.

What type of assessment involves taking and recording the victim's vital signs and performing a head-to-toe assessment?

secondary.