Trauma

1001 OBJ: 3 (clinical) TOP: Disaster: Establishing Order KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity 9. The news reported that a train derailment 5 miles away from the clinic spilled a large amount of liquid chlorine that has been vaporized by the atmosphere. An indication that the chlorine gas is an imminent threat to the clinic would be: a. sighting of a low-lying green cloud. b. smelling almonds or burning feathers. c. sudden nausea. d. skin blistering.

A Chlorine gas can be seen as a low-lying green cloud. The smell of almonds is associated with cyanide. Skin blistering is the result of contact with liquid chlorine. DIF: Cognitive Level: Application

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareContinuity of Care) MSC: Integrated Process: Nursing Process (Assessment) 10. The emergency medical technicians (EMTs) arrive at the emergency department with an unresponsive client with an oxygen mask in place. What will the nurse do first? a. Assess that the client is breathing adequately b. Insert a large-bore intravenous line c. Place the client on a cardiac monitor d. Assess for best neurologic response

A The highest-priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he may not be breathing, or he may be breathing inadequately with the device in place. DIF: Cognitive Level: Application/Applying or higher

1615-1616 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 22. A patient with respiratory failure has arterial pressurebased cardiac output (APCO) monitoring and is receiving mechanical ventilation with peak end-expiratory pressure (PEEP) of 12 cm H2O. Which information indicates that a change in the ventilator settings may be required? a. The arterial pressure is 90/46. b. The heart rate is 58 beats/minute. c. The stroke volume is increased. d. The stroke volume variation is 12%.

A The hypotension suggests that the high intrathoracic pressure caused by the PEEP may be decreasing venous return and (potentially) cardiac output. The other assessment data would not be a direct result of PEEP and mechanical ventilation. DIF: Cognitive Level: Apply (application)

1009 OBJ: 7 (theory) TOP: Monitoring for Radiation Exposure: Badges KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 12. The nurse takes into consideration that if terrorists were to use category B agents that produce low death rates and moderate illness, the organisms would most probably be delivered by which route? a. Vaporization b. Through water sources c. By an explosion d. From person-to-person contact

B Category B agents are usually delivered via a water source. DIF: Cognitive Level: Comprehension

1027 OBJ: 3 (theory) TOP: Frostbite: Staging KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 12. While attempting to revive a person brought to the emergency department with extreme hypothermia (rectal temperature of 94 F), unconscious, and shivering, the nurse is alarmed when assessment reveals that the patient has: a. reddened, cold ears. b. stopped shivering. c. blanched, hardened fingers. d. blisters on hands and arms.

B Cessation of shivering indicates that the bodys homeostatic response to generate heat has ceased and the patients condition is deteriorating. DIF: Cognitive Level: Analysis

1027 OBJ: 3 (theory) TOP: Hypothermia: Prevention KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 24. The nurse explains that the older adult is prone to hypothermia because the older adult: (Select all that apply.) a. eats less. b. has more subcutaneous fat. c. has lower metabolism. d. has atherosclerosis. e. is less active.

A, C, D, E The older adult has less subcutaneous fat. DIF: Cognitive Level: Application

112 KEY: Discharge planning| older adult MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Health Promotion and Maintenance 1. During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next? a. Palpate extremities for bilateral pulses. b. Observe the patients respiratory effort. c. Check the patients level of consciousness. d. Examine the patient for any external bleeding.

B Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patients breathing. The other actions are also part of the initial survey but assessment of breathing should be done immediately after assessing for airway patency. DIF: Cognitive Level: Apply (application)

1687 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 16. Gastric lavage and administration of activated charcoal are ordered for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which action should the nurse plan to do first? a. Insert a large-bore orogastric tube. b. Assist with intubation of the patient. c. Prepare a 60-mL syringe with saline. d. Give first dose of activated charcoal.

B In an unresponsive patient, intubation is done before gastric lavage and activated charcoal administration to prevent aspiration. The other actions will be implemented after intubation. DIF: Cognitive Level: Apply (application)

1006 OBJ: 6 (theory) TOP: Chlorine Gas: Assessing Threat KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 10. A tornado has touched down 1 mile from the hospital and a tornado warning has been issued with sirens. The nursing staff caring for the 36 patients on the second floor medical-surgical unit should move the patients to: a. the evacuation center across the street. b. the hall, closing room doors and windows. c. their rooms, padding the windows with bed linens. d. the basement in wheelchairs using the elevators.

B Movement to the hall is the safest and fastest and does not expose the patients to being out of doors, in elevators, or near exterior windows. DIF: Cognitive Level: Application

1602 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 29. When caring for a patient who has an arterial catheter in the left radial artery for arterial pressurebased cardiac output (APCO) monitoring, which information obtained by the nurse is most important to report to the health care provider? a. The patient has a positive Allen test. b. There is redness at the catheter insertion site. c. The mean arterial pressure (MAP) is 86 mm Hg. d. The dicrotic notch is visible in the arterial waveform.

B Redness at the catheter insertion site indicates possible infection. The Allen test is performed before arterial line insertion, and a positive test indicates normal ulnar artery perfusion. A MAP of 86 is normal and the dicrotic notch is normally present on the arterial waveform. DIF: Cognitive Level: Apply (application)

1609 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 5. When caring for a patient with pulmonary hypertension, which parameter is most appropriate for the nurse to monitor to evaluate the effectiveness of the treatment? a. Central venous pressure (CVP) b. Systemic vascular resistance (SVR) c. Pulmonary vascular resistance (PVR) d. Pulmonary artery wedge pressure (PAWP)

C PVR is a major contributor to pulmonary hypertension, and a decrease would indicate that pulmonary hypertension was improving. The other parameters also may be monitored but do not directly assess for pulmonary hypertension. DIF: Cognitive Level: Apply (application)

116 KEY: Primary survey| emergency nursing MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 8. A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action should the nurse take prior to providing advanced cardiac life support? a. Contact the on-call orthopedic surgeon. b. Don personal protective equipment. c. Notify the Rapid Response Team. d. Obtain a complete history from the paramedic.

B Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions should be taken in all resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers. DIF: Applying/Application

1027 OBJ: 4 (theory) TOP: Heatstroke: Prevention KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 27. The nurse is caring for a patient suspected of having heatstroke. Which findings are consistent with this diagnosis? (Select all that apply.) a. Bradycardia b. Tachycardia c. Irregular pulse patterns d. Visual disturbances e. Decreased urinary output

B, C, D, E Heatstroke may cause an alteration in neurologic function. Other symptoms include visual disturbances, dizziness, nausea, and a weak, rapid, irregular pulse. DIF: Cognitive Level: Application

1030 OBJ: 4 (theory) TOP: Carbon Monoxide Poisoning: Significant Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 14. A restaurant patron sitting at the next table begins to choke. The patron yells, Im choking! I cant breathe! The first responder should: a. initiate the Heimlich maneuver immediately. b. strike the victim sharply between the scapulae. c. encourage him to keep coughing and deep breathe. d. offer him a small sip of fluid.

C Because the victim can cough and speak, the airway is not compromised. Support his efforts to clear the foreign matter by coughing. The Heimlich maneuver can be initiated at such a time that the victims airway becomes occluded. DIF: Cognitive Level: Application

1000 OBJ: 2 (theory) TOP: Institutional Disaster Plans KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 3. The nurse assures a patient that accredited health care facilities test their emergency plan with a drill at least _____ time(s) each year. a. 4 b. 3 c. 2 d. 1

C Disaster drills should be conducted 2 times a year. DIF: Cognitive Level: Comprehension

1681 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 2. The emergency department (ED) nurse is initiating therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/LVN) (select all that apply)? a. Continuously monitor heart rhythm. b. Check neurologic status every 2 hours. c. Place cooling blankets above and below patient. d. Give acetaminophen (Tylenol) 650 mg per nasogastric tube. e. Insert rectal temperature probe and attach to cooling blanket control panel.

C, D, E Experienced LPN/LVNs have the education and scope of practice to implement hypothermia measures (e.g., cooling blanket, temperature probe) and administer medications under the supervision of a registered nurse (RN). Assessment of neurologic status and monitoring the heart rhythm require RN-level education and scope of practice and should be done by the RN. DIF: Cognitive Level: Apply (application)

115 KEY: Primary survey| emergency nursing MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. The complex care provided during an emergency requires interdisciplinary collaboration. Which interdisciplinary team members are paired with the correct responsibilities? (Select all that apply.) a. Psychiatric crisis nurse Interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis b. Forensic nurse examiner Performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources c. Triage nurse Provides basic life support interventions such as oxygen, basic wound care, splinting, spinal immobilization, and monitoring of vital signs d. Emergency medical technician Obtains client histories, collects evidence, and offers counseling and follow-up care for victims of rape, child abuse, and domestic violence e. Paramedic Provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration

A, E The psychiatric crisis nurse evaluates clients with emotional behaviors or mental illness and facilitates follow-up treatment plans. The psychiatric crisis nurse also works with clients and families when experiencing a crisis. Paramedics are advanced life support providers who can perform advanced techniques that may include cardiac monitoring, advanced airway management and intubation, establishing IV access, and administering drugs en route to the emergency department. The forensic nurse examiner is trained to recognize evidence of abuse and to intervene on the clients behalf. The forensic nurse examiner will obtain client histories, collect evidence, and offer counseling and follow-up care for victims of rape, child abuse, and domestic violence. The triage nurse performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources. The emergency medical technician is usually the first caregiver and provides basic life support and transportation to the emergency department. DIF: Understanding/Comprehension

1608 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 11. Which assessment finding obtained by the nurse when caring for a patient with a right radial arterial line indicates a need for the nurse to take immediate action? a. The right hand is cooler than the left hand. b. The mean arterial pressure (MAP) is 77 mm Hg. c. The system is delivering 3 mL of flush solution per hour. d. The flush bag and tubing were last changed 3 days previously.

A The change in temperature of the left hand suggests that blood flow to the left hand is impaired. The flush system needs to be changed every 96 hours. A mean arterial pressure (MAP) of 75 mm Hg is normal. Flush systems for hemodynamic monitoring are set up to deliver 3 to 6 mL/hour of flush solution. DIF: Cognitive Level: Apply (application)

1626 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 37. After change-of-shift report on a ventilator weaning unit, which patient should the nurse assess first? a. Patient who failed a spontaneous breathing trial and has been placed in a rest mode on the ventilator b. Patient who is intubated and has continuous partial pressure end-tidal CO2 (PETCO2) monitoring c. Patient with a central venous oxygen saturation (ScvO2) of 69% while on bilevel positive airway pressure (BiPAP) d. Patient who was successfully weaned and extubated 4 hours ago and now has no urine output for the last 6 hours

D The decreased urine output may indicate acute kidney injury or that the patients cardiac output and perfusion of vital organs have decreased. Any of these causes would require rapid action. The data about the other patients indicate that their conditions are stable and do not require immediate assessment or changes in their care. Continuous PETCO2 monitoring is frequently used when patients are intubated. The rest mode should be used to allow patient recovery after a failed SBT, and an ScvO2 of 69% is within normal limits. DIF: Cognitive Level: Analyze (analysis)

1606 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 9. Which action will the nurse need to do when preparing to assist with the insertion of a pulmonary artery catheter? a. Determine if the cardiac troponin level is elevated. b. Auscultate heart and breath sounds during insertion. c. Place the patient on NPO status before the procedure. d. Attach cardiac monitoring leads before the procedure.

D Dysrhythmias can occur as the catheter is floated through the right atrium and ventricle, and it is important for the nurse to monitor for these during insertion. Pulmonary artery catheter insertion does not require anesthesia, and the patient will not need to be NPO. Changes in cardiac troponin or heart and breath sounds are not expected during pulmonary artery catheter insertion. DIF: Cognitive Level: Apply (application)

1613 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 16. To verify the correct placement of an oral endotracheal tube (ET) after insertion, the best initial action by the nurse is to a. auscultate for the presence of bilateral breath sounds. b. obtain a portable chest x-ray to check tube placement. c. observe the chest for symmetric chest movement with ventilation. d. use an end-tidal CO2 monitor to check for placement in the trachea.

D End-tidal CO2 monitors are currently recommended for rapid verification of ET placement. Auscultation for bilateral breath sounds and checking chest expansion are also used, but they are not as accurate as end-tidal CO2monitoring. A chest x-ray confirms the placement but is done after the tube is secured. DIF: Cognitive Level: Apply (application)

1006 OBJ: 3 (clinical) TOP: Food Supply: Temperature KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 7. The nurse takes into consideration that a freezer that was full at the time of the power failure will keep food safe to eat for approximately _____ hours. a. 8 b. 12 c. 24 d. 48

D Food frozen in a full freezer will keep the food safe for 48 hours. A partially filled freezer will keep food safe for 24 hours. DIF: Cognitive Level: Application

1676 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 5. A 19-year-old is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the left hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. The nurse will anticipate giving a. tetanus immunoglobulin (TIG) only. b. TIG and tetanus-diphtheria toxoid (Td). c. tetanus-diphtheria toxoid and pertussis vaccine (Tdap) only. d. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap).

D For an adult with no previous tetanus immunizations, TIG and Tdap are recommended. The other immunizations are not sufficient for this patient. DIF: Cognitive Level: Apply (application)

1019 OBJ: 2 (theory) TOP: Near-Drowning: Positioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 3. The nurse using the memory prompt for emergency care, ABCDE, is aware that the E stands for: a. end. b. execute. c. expedite. d. expose.

D The E stands for expose. This reminder is to assist the first responder to assess for other injuries that may be hidden under clothing. DIF: Cognitive Level: Comprehension

1617 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 21. Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease (COPD), the patients arterial blood gas (ABG) results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO3 of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to a. increase the FIO2. b. increase the tidal volume. c. increase the respiratory rate. d. decrease the respiratory rate.

D The patients PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory rate. The PaO2 is appropriate for a patient with COPD and increasing the respiratory rate and tidal volume would further lower the PaCO2. DIF: Cognitive Level: Analyze (analysis)

p. 122 TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareCollaboration with Interdisciplinary Team) MSC: Integrated Process: Nursing Process (Planning) 2. On admission to the emergency department, a client states that he feels like killing himself. When planning this clients care, it is most important for the nurse to coordinate with which member of the health care team? a. Case manager b. Forensic nurse examiner c. Physician d. Psychiatric crisis nurse

D The psychiatric crisis nurse interacts with clients and families in crisis. This health care team member can offer valuable expertise to the emergency health care team, which also includes the case manager and the physician. DIF: Cognitive Level: Comprehension/Understanding

1608 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 10. When assisting with the placement of a pulmonary artery (PA) catheter, the nurse notes that the catheter is correctly placed when the monitor shows a a. typical PA pressure waveform. b. tracing of the systemic arterial pressure. c. tracing of the systemic vascular resistance. d. typical PA wedge pressure (PAWP) tracing.

D The purpose of a PA line is to measure PAWP, so the catheter is floated through the pulmonary artery until the dilated balloon wedges in a distal branch of the pulmonary artery, and the PAWP readings are available. After insertion, the balloon is deflated and the PA waveform will be observed. Systemic arterial pressures are obtained using an arterial line and the systemic vascular resistance is a calculated value, not a waveform. DIF: Cognitive Level: Understand (comprehension)

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Planning) 15. A client in the emergency department has died from a suspected homicide. What is the nurses priority intervention? a. Remove all tubes and wires in preparation for the medical examiner. b. Limit the number of visitors to minimize the familys trauma. c. Consult the bereavement committee to follow up with the grieving family. d. Communicate the clients death to the family in a simple and concrete manner.

D When dealing with clients and families in crisis, communicate in a simple and concrete manner to minimize confusion. Tubes must remain in place for the medical examiner. Family should be allowed to view the body. Offering to call for additional family support during the crisis is suggested. The bereavement committee should be consulted, but this is not the priority at this time. DIF: Cognitive Level: Application/Applying or higher

1686 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 9. When planning the response to the potential use of smallpox as an agent of terrorism, the emergency department (ED) nurse manager will plan to obtain adequate quantities of a. vaccine. b. atropine. c. antibiotics. d. whole blood.

A Smallpox infection can be prevented or ameliorated by the administration of vaccine given rapidly after exposure. The other interventions would be helpful for other agents of terrorism but not for smallpox. DIF: Cognitive Level: Understand (comprehension)

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Assessment) 9. A client has been injured in a stabbing incident. Assessment reveals the following: Blood pressure: 80/60 mm Hg Heart rate: 140 beats/min Respiratory rate: 35 breaths/min Bleeding from stabbing wound site Client is lethargic Based on these assessment data, to which trauma center should the nurse ensure transport of the client? a. Level I b. Level II c. Level III d. Level IV

A The Level I trauma center is able to provide a full continuum of care for all client areas. Level II can provide care to most injured clients, but given the extent of his injuries, a Level I center would be better if it is available. Both Levels III and IV can stabilize major injuries, but transport to a higher-level center is preferred, when possible. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Psychosocial Integrity (Grief and Loss) MSC: Integrated Process: Caring 16. A new nurse is orienting to the emergency department (ED). Which statement made by the nurse would indicate the need for further education by the preceptor? a. The emergency medicine physician coordinates care with all levels of the emergency health care team. b. Emergency departments have specialized teams that deal with high-risk populations of patients. c. Many older adults seek emergency services when they are ill because they do not want to bother their primary health care provider. d. Emergency departments are responsible for public health surveillance and emergency disaster preparedness.

A The emergency nurse is one member of the large interdisciplinary team that provides care for clients in the ED. A collaborative team approach to emergency care is considered a standard of practice. In this setting, the nurse coordinates care with all levels of health care team providers, from prehospital emergency medical services (EMS) personnel to physicians, hospital technicians, and professional and ancillary staff. DIF: Cognitive Level: Application/Applying or higher

1623 OBJ: Special Questions: Delegation TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment 33. A patient who is orally intubated and receiving mechanical ventilation is anxious and is fighting the ventilator. Which action should the nurse take next? a. Verbally coach the patient to breathe with the ventilator. b. Sedate the patient with the ordered PRN lorazepam (Ativan). c. Manually ventilate the patient with a bag-valve-mask device. d. Increase the rate for the ordered propofol (Diprivan) infusion.

A The initial response by the nurse should be to try to decrease the patients anxiety by coaching the patient about how to coordinate respirations with the ventilator. The other actions may also be helpful if the verbal coaching is ineffective in reducing the patients anxiety. DIF: Cognitive Level: Apply (application)

1686 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 11. When assessing an older patient admitted to the emergency department (ED) with a broken arm and facial bruises, the nurse observes several additional bruises in various stages of healing. Which statement or question by the nurse is most appropriate? a. Do you feel safe in your home? b. You should not return to your home. c. Would you like to see a social worker? d. I need to report my concerns to the police.

A The nurses initial response should be to further assess the patients situation. Telling the patient not to return home may be an option once further assessment is done. A social worker may be appropriate once further assessment is completed. DIF: Cognitive Level: Apply (application)

1689 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 13. A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10 abdominal pain and states, I had a temperature of 103.9 F (39.9 C) at home. The nurses first action should be to a. assess the patients current vital signs. b. give acetaminophen (Tylenol) per agency protocol. c. ask the patient to provide a clean-catch urine for urinalysis. d. tell the patient that it will 1 to 2 hours before being seen by the doctor.

A The patients pain and statement about an elevated temperature indicate that the nurse should obtain vital signs before deciding how rapidly the patient should be seen by the health care provider. A urinalysis may be appropriate, but this would be done after the vital signs are taken. The nurse will not give acetaminophen before confirming a current temperature elevation. DIF: Cognitive Level: Apply (application)

1676 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 15. The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first? a. Remove the patients rings. b. Apply ice packs to both hands. c. Apply calamine lotion to any itching areas. d. Give diphenhydramine (Benadryl) 50 mg PO.

A The patients rings should be removed first because it might not be possible to remove them if swelling develops. The other orders should also be implemented as rapidly as possible after the nurse has removed the jewelry. DIF: Cognitive Level: Apply (application)

1690 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 18. An unresponsive 79-year-old is admitted to the emergency department (ED) during a summer heat wave. The patients core temperature is 105.4 F (40.8 C), blood pressure (BP) 88/50, and pulse 112. The nurse initiallywill plan to a. apply wet sheets and a fan to the patient. b. provide O2 at 6 L/min with a nasal cannula. c. start lactated Ringers solution at 1000 mL/hr. d. give acetaminophen (Tylenol) rectal suppository.

A The priority intervention is to cool the patient. Antipyretics are not effective in decreasing temperature in heat stroke, and 100% oxygen should be given, which requires a high flow rate through a non-rebreather mask. An older patient would be at risk for developing complications such as pulmonary edema if given fluids at 1000 mL/hr. DIF: Cognitive Level: Apply (application)

1685 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 20. Following an earthquake, patients are triaged by emergency medical personnel and are transported to the emergency department (ED). Which patient will the nurse need to assess first? a. A patient with a red tag b. A patient with a blue tag c. A patient with a black tag d. A patient with a yellow tag

A The red tag indicates a patient with a life-threatening injury requiring rapid treatment. The other tags indicate patients with less urgent injuries or those who are likely to die. DIF: Cognitive Level: Remember (knowledge)

1002 OBJ: 5 (theory) TOP: Flood: Water Provision and Protection KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 6. The nurse is aware that during a power failure, perishable food should be kept at _____ F to prevent possibility of food poisoning. a. 40 b. 45 c. 50 d. 55

A To prevent spoilage, perishable foods should be kept at 40 F. DIF: Cognitive Level: Comprehension

1676 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 3. After the return of spontaneous circulation following the resuscitation of a patient who had a cardiac arrest, therapeutic hypothermia is ordered. Which action will the nurse include in the plan of care? a. Apply external cooling device. b. Check mental status every 15 minutes. c. Avoid the use of sedative medications. d. Rewarm if temperature is <91 F (32.8 C).

A When therapeutic hypothermia is used postresuscitation, external cooling devices or cold normal saline infusions are used to rapidly lower body temperature to 89.6 F to 93.2 F (32 C to 34 C). Because hypothermia will decrease brain activity, assessing mental status every 15 minutes is not needed at this stage. Sedative medications are administered during therapeutic hypothermia. DIF: Cognitive Level: Apply (application)

115 KEY: Trauma center| emergency nursing MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 7. Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action should the nurse take first? a. Assess that the client is breathing adequately. b. Insert a large-bore intravenous line. c. Place the client on a cardiac monitor. d. Assess for the best neurologic response.

A The highest-priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he or she may not be breathing, or may be breathing inadequately with the device in place. DIF: Applying/Application

1697 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. When preparing to cool a patient who is to begin therapeutic hypothermia, which intervention will the nurse plan to do (select all that apply)? a. Assist with endotracheal intubation. b. Insert an indwelling urinary catheter. c. Begin continuous cardiac monitoring. d. Obtain an order to restrain the patient. e. Prepare to give sympathomimetic drugs.

A, B, C Cooling can produce dysrhythmias, so the patients heart rhythm should be continuously monitored and dysrhythmias treated if necessary. Bladder catheterization and endotracheal intubation are needed during cooling. Sympathomimetic drugs tend to stimulate the heart and increase the risk for fatal dysrhythmias such as ventricular fibrillation. Patients receiving therapeutic hypothermia are comatose or do not follow commands so restraints are not indicated. DIF: Cognitive Level: Apply (application)

1026 OBJ: 1 (theory) TOP: Hypoglycemia: Treatment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential MULTIPLE RESPONSE 20. The nurse recognizes indications of respiratory distress, which include: (Select all that apply.) a. gasping. b. wheezing. c. stridor. d. choking. e. stupor.

A, B, C, D All options except stupor are indicators of respiratory distress. DIF: Cognitive Level: Knowledge

1015 OBJ: 3 (clinical) TOP: Pandemic Infections KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE 21. The nurse explains that the essential elements in a disaster plan are the preparation and organization to provide: (Select all that apply.) a. shelter for victims. b. transportation. c. communication. d. welfare of victims. e. food.

A, B, C, D, E All options are essential elements in a disaster plan. DIF: Cognitive Level: Comprehension

998 OBJ: 3 (clinical) TOP: Disaster Kits: Minimal Provisions KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 23. The nurse encourages civic-minded people to enroll in local civil defense courses on disaster preparedness to better understand the role of the: (Select all that apply.) a. state government. b. federal government. c. law enforcement. d. individual service agencies. e. nurse as a volunteer.

A, B, C, D, E All options are part of the course presentation. DIF: Cognitive Level: Comprehension

1026 OBJ: 3 (theory) TOP: Heatstroke: Prevention KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 23. The home health nurse in Wyoming gives instruction to an 80-year-old patient in the prevention of hypothermia when outdoors for long periods of time, which includes: (Select all that apply.) a. wearing multiple layers of clothing. b. wearing a snug-fitting hat. c. moving about briskly. d. drinking warm fluids from thermos. e. wearing gloves and earmuffs.

A, B, C, D, E All options listed are helpful in the prevention of hypothermia. DIF: Cognitive Level: Application

1023 OBJ: 6 (theory) TOP: Signs of Respiratory Distress: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 21. The nurse stresses that moving a victim of an automobile accident is necessary if there is: (Select all that apply.) a. pooled gasoline. b. oncoming traffic. c. submersion in snow. d. request from the victim to be moved. e. exposure to hot pavement.

A, B, C, E A victim request to be moved is not a valid reason to do so if the victim is safe. DIF: Cognitive Level: Comprehension

1614 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse is caring for a patient who has an intraortic balloon pump (IABP) following a massive heart attack. When assessing the patient, the nurse notices blood backing up into the IABP catheter. In which order should the nurse take the following actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Ensure that the IABP console has turned off. b. Assess the patients vital signs and orientation. c. Obtain supplies for insertion of a new IABP catheter. d. Notify the health care provider of the IABP malfunction.

A, B, D, C Blood in the IABP catheter indicates a possible tear in the balloon. The console will shut off automatically to prevent complications such as air embolism. Next, the nurse will assess the patient and communicate with the health care provider about the patients assessment and the IABP problem. Finally, supplies for insertion of a new IABP catheter may be needed, based on the patient assessment and the decision of the health care provider. DIF: Cognitive Level: Analyze (analysis)

1027 OBJ: 3 (theory) TOP: Frostbite: Treatment KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 26. The nurse is working with a group of hikers who range in age from 25 to 35 years. They have been instructed on ways to prevent heatstroke. Which drink selection by a participant indicates the need for further education? (Select all that apply.) a. Clear carbonated soda b. Diet caffeinated cola c. Water d. Beer e. Sugar-sweetened energy drinks

A, B, D, E To aid in the prevention of heatstroke, the hiker should drink plenty of fluids that are nonalcoholic, caffeine free, and low in sugar content as the wrong fluids can increase fluid loss. Clear carbonated soda and sweetened energy drinks are high in sugar. Diet cola contains caffeine. DIF: Cognitive Level: Analysis

1027 OBJ: 3 (theory) TOP: Hypothermia: Older Adult KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 25. The nurse is aware that the treatment for frostbite includes: (Select all that apply.) a. chafing the hands and fingers gently to reestablish circulation. b. immersion of hands and feet in warm water. c. wrapping hands in mitten-like dressings to retain warmth. d. administering opioids to reduce pain. e. elevating affected limbs.

A, B, E Analgesia will be accomplished with nonsteroidal anti-inflammatory drugs as opioids decrease function and delay circulatory recovery. Fingers should be wrapped individually, not touching each other. DIF: Cognitive Level: Application

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareContinuity of Care) MSC: Integrated Process: Communication and Documentation 2. The nurse is discharging an older adult client home from the emergency department (ED) after an acute episode of angina. What should the nurse do to ensure client safety upon discharge? (Select all that apply.) a. Reconcile the clients prescription and over-the-counter medications b. Screen the client for functional and cognitive abilities, as well as risk for falls c. Consult physical therapy to organize for home health services d. Arrange for the clients car keys to be taken to prevent an accident e. Review discharge instructions with the client and a family member

A, B, E Before discharge, the nurse should ensure that the clients prescription and over-the-counter medications are evaluated to determine whether the drug regimen should be continued. Discharge education should be provided to the client and a significant other or family member. To prevent future ED visits, screen older adults per agency policy for functional assessment, cognitive assessment, and risk for falls. Case management should be consulted to organize home health services. The nurse should emphasize safety when driving but cannot organize to take the clients keys away. DIF: Cognitive Level: Application/Applying or higher

p. 129 TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareCollaboration with Interdisciplinary Team) MSC: Integrated Process: Nursing Process (Planning) MULTIPLE RESPONSE 1. The emergency department (ED) nurse is preparing to transfer a client to the critical care unit. What information should the nurse include in the nurse-to-nurse hand-off report? (Select all that apply.) a. Allergies b. Vital signs c. Immunizations d. Marital status e. Isolation precautions

A, B, E Hand-off communication should be comprehensive so that the nurse can continue care for the client fluidly. Communication should be concise and should include only the most essential information for a safe transition in care. Hand-off communication should include the clients situation (reason for being in the ED), brief medical history, assessment and diagnostic findings, transmission-based precautions needed, interventions provided, and response to those interventions. DIF: Cognitive Level: Application/Applying or higher

108 KEY: Safety| patient safety| staff safety MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 2. An emergency department (ED) nurse is preparing to transfer a client to the trauma intensive care unit. Which information should the nurse include in the nurse-to-nurse hand-off report? (Select all that apply.) a. Mechanism of injury b. Diagnostic test results c. Immunizations d. List of home medications e. Isolation precautions

A, B, E Hand-off communication should be comprehensive so that the receiving nurse can continue care for the client fluidly. Communication should be concise and should include only the most essential information for a safe transition in care. Hand-off communication should include the clients situation (reason for being in the ED), brief medical history, assessment and diagnostic findings, Transmission-Based Precautions needed, interventions provided, and response to those interventions. DIF: Applying/Application

1003 OBJ: 2 (clinical) TOP: Preparing Safe Drinking Water: Techniques KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 25. The nurse is aware that organisms that may be released in a bioterrorism attack because of their high lethality include: (Select all that apply.) a. Ebola. b. avian flu. c. botulism. d. smallpox. e. tularemia.

A, C, D, E Avian flu (bird flu) is not on the category A list. DIF: Cognitive Level: Comprehension

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareContinuity of Care) MSC: Integrated Process: Teaching/Learning 3. Which interventions will be performed during the primary survey for a trauma client? (Select all that apply.) a. Removing wet clothing b. Splinting open fractures c. Initiating IV fluids d. Endotracheal intubation e. Foley catheterization f. Needle decompression g. Laceration repair

A, C, D, F The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic ABC, with an added Dand E: A, airway and cervical spine control; B, breathing; C, circulation; D, disability; and E, exposure. After completion of primary diagnostic studies and laboratory studies, and insertion of gastric and urinary tubes, the secondary survey, a complete head-to-toe assessment, can be carried out. DIF: Cognitive Level: Application/Applying or higher

p. 122 TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareContinuity of Care) MSC: Integrated Process: Communication and Documentation 7. The emergency department (ED) nurse is caring for the following clients. Which client does the nurse prioritize to see first? a. 22-year-old with a painful and swollen right wrist b. 45-year-old reporting chest pain and diaphoresis c. 60-year-old reporting difficulty swallowing and nausea d. 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101 F

B A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable. DIF: Cognitive Level: Application/Applying or higher

1602 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 4. Following surgery for an abdominal aortic aneurysm, a patients central venous pressure (CVP) monitor indicates low pressures. Which action is a priority for the nurse to take? a. Administer IV diuretic medications. b. Increase the IV fluid infusion per protocol. c. Document the CVP and continue to monitor. d. Elevate the head of the patients bed to 45 degrees.

B A low CVP indicates hypovolemia and a need for an increase in the infusion rate. Diuretic administration will contribute to hypovolemia and elevation of the head may decrease cerebral perfusion. Documentation and continued monitoring is an inadequate response to the low CVP. DIF: Cognitive Level: Apply (application)

1676 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE CHOICE 1. The nurse informs a high school class that one of the differences between an emergency situation and a disaster is that, in an emergency situation: a. fewer than 50 people require emergent treatment. b. the community emergency rooms can meet the need. c. there is no need for a prearranged management plan. d. the community population is not affected by the event.

B An emergency situation, such as a plane crash at a local airport, can be handled by community emergency departments. Each community has in place an emergency plan as to dispersal of people needing to be treated, law enforcement participation, and transportation. Communities are always affected when a large scale emergency situation occurs. DIF: Cognitive Level: Comprehension

1010 OBJ: 7 (theory) TOP: Radiation Exposure: Chelating Agents KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 14. The nurse takes into consideration that the period of time during which there is the greatest chance that aerosolized anthrax could be inhaled after a terrorist attack would be _____ the attack. a. the day of b. the day after c. 2 days after d. 7 days after

B Anthrax in an aerosolized form is most potent 1 day after the explosion as the organism dies very quickly and anthrax is not communicable from person to person. DIF: Cognitive Level: Comprehension

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareCollaboration with Interdisciplinary Team) MSC: Integrated Process: Communication and Documentation 17. An unresponsive client with poor ventilator effort and a pulse rate of 120 beats/min arrives at the emergency department. What should the nurse do first? a. Place the client on a non-rebreather mask. b. Begin bag-valve-mask ventilation. c. Initiate cardiopulmonary resuscitation. d. Prepare for chest tube insertion.

B Apneic clients and those with poor ventilatory effort need bag-valve-mask (BVM) ventilation for support until endotracheal intubation is performed and a mechanical ventilator is used. A non-rebreather mask would be appropriate only if the client had adequate spontaneous ventilation. Cardiopulmonary resuscitation is necessary only if the client is pulseless. Chest tubes are inserted for decompression and pneumothorax. DIF: Cognitive Level: Application/Applying or higher

1029 OBJ: 4 (theory) TOP: Food Contamination: Staphylococcus aureus KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 1. A 68-year-old patient has been in the intensive care unit for 4 days and has a nursing diagnosis of disturbed sensory perception related to sleep deprivation. Which action should the nurse include in the plan of care? a. Administer prescribed sedatives or opioids at bedtime to promote sleep. b. Cluster nursing activities so that the patient has uninterrupted rest periods. c. Silence the alarms on the cardiac monitors to allow 30- to 40-minute naps. d. Eliminate assessments between 0100 and 0600 to allow uninterrupted sleep.

B Clustering nursing activities and providing uninterrupted rest periods will minimize sleep-cycle disruption. Sedative and opioid medications tend to decrease the amount of rapid eye movement (REM) sleep and can contribute to sleep disturbance and disturbed sensory perception. Silencing the alarms on the cardiac monitors would be unsafe in a critically ill patient, as would discontinuing assessments during the night. DIF: Cognitive Level: Apply (application)

1606 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 12. The central venous oxygen saturation (ScvO2) is decreasing in a patient who has severe pancreatitis. To determine the possible cause of the decreased ScvO2, the nurse assesses the patients a. lipase. b. temperature. c. urinary output. d. body mass index.

B Elevated temperature increases metabolic demands and oxygen use by tissues, resulting in a drop in oxygen saturation of central venous blood. Information about the patients body mass index, urinary output, and lipase will not help in determining the cause of the patients drop in ScvO2. DIF: Cognitive Level: Apply (application)

1603-1604 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 6. The intensive care unit (ICU) nurse educator will determine that teaching about arterial pressure monitoring for a new staff nurse has been effective when the nurse a. balances and calibrates the monitoring equipment every 2 hours. b. positions the zero-reference stopcock line level with the phlebostatic axis. c. ensures that the patient is supine with the head of the bed flat for all readings. d. rechecks the location of the phlebostatic axis when changing the patients position.

B For accurate measurement of pressures, the zero-reference level should be at the phlebostatic axis. There is no need to rebalance and recalibrate monitoring equipment hourly. Accurate hemodynamic readings are possible with the patients head raised to 45 degrees or in the prone position. The anatomic position of the phlebostatic axis does not change when patients are repositioned. DIF: Cognitive Level: Apply (application)

1681 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 6. A patient who has experienced blunt abdominal trauma during a motor vehicle collision is complaining of increasing abdominal pain. The nurse will plan to teach the patient about the purpose of a. peritoneal lavage. b. abdominal ultrasonography. c. nasogastric (NG) tube placement. d. magnetic resonance imaging (MRI).

B For patients who are at risk for intraabdominal bleeding, focused abdominal ultrasonography is the preferred method to assess for intraperitoneal bleeding. An MRI would not be used. Peritoneal lavage is an alternative, but it is more invasive. An NG tube would not be helpful in diagnosis of intraabdominal bleeding. DIF: Cognitive Level: Apply (application)

p. 122 TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareCollaboration with Interdisciplinary Team) MSC: Integrated Process: Nursing Process (Planning) 3. The emergency department team is performing cardiopulmonary resuscitation on a client when the clients spouse arrives at the emergency department. What should the nurse do next? a. Request that the clients spouse sit in the waiting room. b. Ask the spouse if he wishes to be present during the resuscitation. c. Suggest that the spouse begin to pray for the client. d. Refer the clients spouse to the hospitals crisis team.

B If resuscitation efforts are still under way when the family arrives, one or two family members may be given the opportunity to be present during lifesaving procedures. The other options do not give the spouse the opportunity to be present for the client or to begin to have closure. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlAccident/Injury Prevention) MSC: Integrated Process: Nursing Process (Implementation) 13. A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. What should the nurse do before providing advanced cardiac life support? a. Contact the on-call orthopedic surgeon. b. Don personal protective equipment. c. Notify the Rapid Response Team. d. Obtain a complete history from the paramedic.

B Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions should be taken in all resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Psychosocial Integrity (Crisis Intervention) MSC: Integrated Process: Caring 4. The emergency department nurse is assigned an older adult client who is confused and agitated. Which intervention should the nurse include in the clients plan of care? a. Administer a sedative medication. b. Ask a family member to stay with the client. c. Use restraints to prevent the client from falling. d. Place the client in a wheelchair at the nurses station.

B Older adults who are confused are at increased risks for falls. Fall prevention includes measures such as siderails up, reorientation, call light in reach, and, in some cases, asking the family member, significant other, or sitter to stay with the client to prevent falls. DIF: Cognitive Level: Application/Applying or higher

1025 OBJ: 2 (theory) TOP: Sucking Chest Wound: First Aid Intervention KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 17. The nurse has arrived on the scene of an accident. The victim is conscious and has a large bleeding laceration on his thigh. After the nurse uses an available towel to provide compression to the wound, what action should be performed next? a. The nurse should turn the patient to his left side. b. The nurse should elevate the patients affected leg. c. The nurse should bend the affected leg at the knee. d. The nurse should encourage the patient to perform leg pump exercises.

B Once the bleeding has stopped, a compression dressing and bulky bandage are applied and left in place to prevent disturbing clots gently. Elevating and immobilizing the injured part will help to control bleeding. DIF: Cognitive Level: Application

1012 OBJ: 8 (theory) TOP: Plague: Respiratory Precautions KEY: Nursing Process Step: NA MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 16. The nurse is aware that the plague, caused by Yersinia pestis, will most probably be introduced as an aerosolized weapon in a terrorist attack. Although exposed individuals can die in 24 hours, the organism is very vulnerable and can be destroyed by: a. cold temperatures of 40 F. b. exposure to sunlight. c. strong chlorine solution. d. dry environment.

B Plague organisms can be destroyed by exposure to sunlight. DIF: Cognitive Level: Comprehension

1009 OBJ: 5 (theory) TOP: Chemical Disaster: KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 20. The nurse is teaching a course in the community concerning the actions that need to be taken in the event a pandemic occurs. A participant questions the nurse about how long she should be prepared to stay at home. What response by the nurse is most correct? a. The greatest danger during the pandemic will be in the first 48 to 72 hours. b. You should be prepared to remain at home for about 2 weeks. c. Residents should be prepared to stay home for 4 to 6 days. d. Staying home for a full 10 days will be needed.

B Preparations for pandemics include teaching people to be prepared to stay at home for at least 2 weeks. DIF: Cognitive Level: Comprehension

999-1000 OBJ: 6 (theory) TOP: Tornado: Patient Evacuation KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 11. The nurse explains that health workers who are caring for people exposed to radiation after the explosion of a nuclear bomb are monitored daily for exposure by way of: a. urinalysis. b. radiation badges. c. Geiger counters. d. sputum analysis.

B Radiation detection badges are worn under protective clothing and are analyzed for number of rads absorbed. DIF: Cognitive Level: Comprehension

1604 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 3. While family members are visiting, a patient has a respiratory arrest and is being resuscitated. Which action by the nurse is best? a. Tell the family members that watching the resuscitation will be very stressful. b. Ask family members if they wish to remain in the room during the resuscitation. c. Take the family members quickly out of the patient room and remain with them. d. Assign a staff member to wait with family members just outside the patient room.

B Research indicates that family members want the option of remaining in the room during procedures such as cardiopulmonary resuscitation (CPR) and that this decreases anxiety and facilitates grieving. The other options may be appropriate if the family decides not to remain with the patient. DIF: Cognitive Level: Apply (application)

1601 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 2. Which hemodynamic parameter is most appropriate for the nurse to monitor to determine the effectiveness of medications given to a patient to reduce left ventricular afterload? a. Mean arterial pressure (MAP) b. Systemic vascular resistance (SVR) c. Pulmonary vascular resistance (PVR) d. Pulmonary artery wedge pressure (PAWP)

B Systemic vascular resistance reflects the resistance to ventricular ejection, or afterload. The other parameters will be monitored, but do not reflect afterload as directly. DIF: Cognitive Level: Apply (application)

1681 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 4. A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should a. obtain a complete set of vital signs. b. obtain a Glasgow Coma Scale score. c. ask about chronic medical conditions. d. attach a cardiac electrocardiogram monitor.

B The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the secondary survey. DIF: Cognitive Level: Apply (application)

1022 OBJ: 2 (theory) TOP: ABCDE Memory Prompt: Definition KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 4. The nurse is teaching a CPR class. During the class the nurse correctly includes which statement when discussing the Good Samaritan Law? a. The Good Samaritan Law protects only medical professionals from liability. b. The Good Samaritan Law protects all people from liability. c. The Good Samaritan Law limits the liability of a medical professional. d. The Good Samaritan Law defines specific situations in which no liability will occur.

B The Good Samaritan Law is designed to protect passersby who render first aid so they will not be held liable for the outcome of emergency care. Individuals who choose to render care will be held to the standard consistent with their training. The law is not limited to medical personnel. It does not address limitations of liability. There is no definition of specific scenarios protected by the law. DIF: Cognitive Level: Comprehension

997 OBJ: 1 (theory) TOP: Disaster vs. Emergency Situation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 2. The nurse stresses that emergency preparedness plans are required for accredited hospitals by the: a. American Red Cross (ARC). b. Joint Commission (JC). c. Federal Emergency Management Agency (FEMA). d. Office of Civil Defense (OCD).

B The Joint Commission requires that all accredited facilities have a written emergency preparedness plan with designated roles and responsibilities. The American Red Cross is a voluntary organization that traditionally provides the basic essentials of shelter, food, and first aid during a natural disaster. Federal Emergency Management Agency (FEMA) is an organization under the federal government. It is activated by the Department of Homeland Security. It acts when states require assistance in times of disaster. The Office of Civil Defense (OCD) is no longer in existence. It was a federal agency that acted in cases of large scale disasters. It was replaced by FEMA. DIF: Cognitive Level: Comprehension

1025 OBJ: 7 (theory) TOP: Choking: Intervention KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 15. A deliveryman comes to the emergency department with dog bites on his legs. He states that the dog ran away after the attack and could not be identified. After treatment of the bites, the patient should immediately: a. notify Animal Control. b. receive immune globulin for passive immunity. c. receive the first of five rabies vaccination injections to be continued over the next several weeks. d. go home and elevate his legs.

B The administration of immune globulin will build up his immediate defenses. As a deliveryman, he would be considered to be in a high-risk group for animal bites and should be advised to acquire the vaccine, but the vaccine will not be of any use to him at this point. DIF: Cognitive Level: Application

1623 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 34. The nurse educator is evaluating the performance of a new registered nurse (RN) who is providing care to a patient who is receiving mechanical ventilation with 15 cm H2O of peak end-expiratory pressure (PEEP). Which action indicates that the new RN is safe? a. The RN plans to suction the patient every 1 to 2 hours. b. The RN uses a closed-suction technique to suction the patient. c. The RN tapes connection between the ventilator tubing and the ET. d. The RN changes the ventilator circuit tubing routinely every 48 hours.

B The closed-suction technique is used when patients require high levels of PEEP (>10 cm H2O) to prevent the loss of PEEP that occurs when disconnecting the patient from the ventilator. Suctioning should not be scheduled routinely, but it should be done only when patient assessment data indicate the need for suctioning. Taping connections between the ET and the ventilator tubing would restrict the ability of the tubing to swivel in response to patient repositioning. Ventilator tubing changes increase the risk for ventilator-associated pneumonia (VAP) and are not indicated routinely. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlAccident/Injury Prevention) MSC: Integrated Process: Nursing Process (Planning) 5. An emergency department nurse is transferring a client to the medical-surgical unit. What is the most important nursing intervention in this situation? a. Triage the client to determine the urgency of care. b. Clearly communicate client data to the unit nurse. c. Evaluate the need for ongoing medical treatment. d. Perform a thorough assessment of the client.

B The emergency nurse needs to be able to triage, assess, and evaluate. However, these steps have already been carried out in the early phases of the emergency department (ED) admission. When a client is ready to be transferred from the ED, communication with staff nurses from the inpatient units is essential. This report should be a concise but comprehensive report of the clients ED experience. DIF: Cognitive Level: Application/Applying or higher

1030 OBJ: 5 (theory) TOP: Animal Bite: Prophylaxis KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 16. The first responder to an automobile accident finds a victim with a sucking chest wound. The responder should: a. tightly bind the injury with a folded magazine and the patients belt. b. place a plastic sandwich bag over the wound and tape on three sides to make a flutter dressing. c. turn the patient to the affected side and instruct the patient to deep breathe. d. place the patients hand over the wound and tell the patient to press down.

B The flutter dressing will allow the air to leave the pleural space, but not allow any more air in. The collapsed lung will begin to reexpand. DIF: Cognitive Level: Analysis

1608 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 26. When evaluating a patient with a central venous catheter, the nurse observes that the insertion site is red and tender to touch and the patients temperature is 101.8 F. What should the nurse plan to do next? a. Give analgesics and antibiotics as ordered. b. Discontinue the catheter and culture the tip. c. Change the flush system and monitor the site. d. Check the site more frequently for any swelling.

B The information indicates that the patient has a local and systemic infection caused by the catheter, and the catheter should be discontinued. Changing the flush system, giving analgesics, and continued monitoring will not help prevent or treat the infection. Administration of antibiotics is appropriate, but the line should still be discontinued to avoid further complications such as endocarditis. DIF: Cognitive Level: Apply (application)

1611 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 27. An 81-year-old patient who has been in the intensive care unit (ICU) for a week is now stable and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion. The nurse will plan to a. give PRN lorazepam (Ativan) and cancel the transfer. b. inform the receiving nurse and then transfer the patient. c. notify the health care provider and postpone the transfer. d. obtain an order for restraints as needed and transfer the patient.

B The patients history and symptoms most likely indicate delirium associated with the sleep deprivation and sensory overload in the ICU environment. Informing the receiving nurse and transferring the patient is appropriate. Postponing the transfer is likely to prolong the delirium. Benzodiazepines and restraints contribute to delirium and agitation. DIF: Cognitive Level: Apply (application)

1683 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 19. A patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first? a. Heart rate b. Breath sounds c. Body temperature d. Level of consciousness

B The priority assessment relates to ABCs (airway, breathing, circulation) and how well the patient is oxygenating, so breath sounds should be assessed first. The other data will also be collected rapidly but are not as essential as the breath sounds. DIF: Cognitive Level: Apply (application)

1001 OBJ: 3 (theory) TOP: Psychological Response: Stage I KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 5. The nursing staff of a medical clinic and 15 of their patients have moved to the third floor of an office building to escape flood waters. Public water supply has been contaminated. This floor has eight commode stalls in two different bathrooms. To provide drinking water, the nurse should: a. designate which commodes can be used for body waste. b. protect water in commode tanks to use for drinking. c. run cold water in sinks to have reservoirs of water. d. assign people to use specific bathrooms.

B The water in the tanks of the commodes has not been contaminated and the water in the hot water tanks has not been contaminated. Using any of the water for waste disposal is inappropriate. Using cold water pulls from the contaminated water supply. DIF: Cognitive Level: Analysis

108 KEY: Infection control| Transmission-Based Precautions| emergency nursing| staff safety MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 5. A nurse is triaging clients in the emergency department (ED). Which client should the nurse prioritize to receive care first? a. A 22-year-old with a painful and swollen right wrist b. A 45-year-old reporting chest pain and diaphoresis c. A 60-year-old reporting difficulty swallowing and nausea d. An 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101 F

B A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable. DIF: Applying/Application

106 KEY: Interdisciplinary team| emergency nursing MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 2. The emergency department team is performing cardiopulmonary resuscitation on a client when the clients spouse arrives at the emergency department. Which action should the nurse take first? a. Request that the clients spouse sit in the waiting room. b. Ask the spouse if he wishes to be present during the resuscitation. c. Suggest that the spouse begin to pray for the client. d. Refer the clients spouse to the hospitals crisis team.

B If resuscitation efforts are still under way when the family arrives, one or two family members may be given the opportunity to be present during lifesaving procedures. The other options do not give the spouse the opportunity to be present for the client or to begin to have closure. DIF: Applying/Application

111 KEY: Triage| emergency nursing MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 6. A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center? a. Level I Located within remote areas and provides advanced life support within resource capabilities b. Level II Located within community hospitals and provides care to most injured clients c. Level III Located in rural communities and provides only basic care to clients d. Level IV Located in large teaching hospitals and provides a full continuum of trauma care for all clients

B Level I trauma centers are usually located in large teaching hospital systems and provide a full continuum of trauma care for all clients. Both Level II and Level III facilities are usually located in community hospitals. These trauma centers provide care for most clients and transport to Level I centers when client needs exceed resource capabilities. Level IV trauma centers are usually located in rural and remote areas. These centers provide basic care, stabilization, and advanced life support while transfer arrangements to higher-level trauma centers are made. DIF: Remembering/Knowledge

1024 OBJ: 2 (theory) TOP: Moving an Accident Victim: Rationale KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 22. The nurse counsels a group of young track athletes that to prevent heatstroke they should: (Select all that apply.) a. drink plenty of fluids with high sugar content. b. wear lightweight, loose clothing. c. practice in the early morning. d. rest frequently in cool places. e. wear dark-colored clothing to block sun rays.

B, C, D Liquids should be nonalcoholic, noncaffeinated, and low sugar as liquids with alcohol, caffeine, and sugar increase dehydration. Light-colored clothing should be worn as dark colors absorb heat. DIF: Cognitive Level: Comprehension

997 OBJ: 2 (theory) TOP: Disaster Preparation: Courses KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 24. The nurse demonstrates how water can be rendered safe for drinking in the event of a disruption of service by: (Select all that apply.) a. letting the water sit for 24 hours and dipping from the top. b. boiling the water for 3 to 5 minutes. c. adding 1 mL (16 drops) of household bleach to a gallon of water and letting it stand for 30 minutes. d. draining water from hot water heater and using without treatment. e. pouring water through several layers of cotton towels.

B, C, D Water can be rendered safe for drinking by boiling or treating with household bleach or using water in hot water heater or commode tank. DIF: Cognitive Level: Analysis

111 KEY: Triage| emergency nursing MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. A nurse is caring for clients in a busy emergency department. Which actions should the nurse take to ensure client and staff safety? (Select all that apply.) a. Leave the stretcher in the lowest position with rails down so that the client can access the bathroom. b. Use two identifiers before each intervention and before mediation administration. c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors. d. Search the belongings of clients with altered mental status to gain essential medical information. e. Isolate clients who have immune suppression disorders to prevent hospital-acquired infections.

B, C, D To ensure client and staff safety, nurses should use two identifiers per The Joint Commissions National Patient Safety Goals; follow the hospitals security plan, including de-escalation strategies for people who demonstrate aggressive or violent tendencies; and search belongings to identify essential medical information. Nurses should also use standard fall prevention interventions, including leaving stretchers in the lowest position with rails up, and isolating clients who present with signs and symptoms of contagious infectious disorders. DIF: Applying/Application

997 OBJ: 2 (theory) TOP: Disaster Plan: Essentials KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 22. The nurse is preparing a list of items that are needed in a disaster kit. The list will correctly include which items? (Select all that apply.) a. Water for 12 days b. Nonperishable food items c. Prescription medication d. Portable radio e. Bedding f. First aid kit

B, C, D, E, F It is suggested that water for 3 days be included in a disaster kit. All other options should be included in a disaster kit. DIF: Cognitive Level: Comprehension

108 KEY: SBAR| hand-off communication MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. An emergency room nurse is caring for a trauma client. Which interventions should the nurse perform during the primary survey? (Select all that apply.) a. Foley catheterization b. Needle decompression c. Initiating IV fluids d. Splinting open fractures e. Endotracheal intubation f. Removing wet clothing g. Laceration repair

B, C, E, F The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic ABC, with an added D and E: Airway and cervical spine control; Breathing; Circulation; Disability; and Exposure. After the completion of primary diagnostic and laboratory studies, and the insertion of gastric and urinary tubes, the secondary survey (a complete head-to-toe assessment) can be carried out. DIF: Applying/Application

1609 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 13. An intraaortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which assessment data indicate to the nurse that the goals of treatment with the IABP are being met? a. Urine output of 25 mL/hr b. Heart rate of 110 beats/minute c. Cardiac output (CO) of 5 L/min d. Stroke volume (SV) of 40 mL/beat

C A CO of 5 L/min is normal and indicates that the IABP has been successful in treating the shock. The low SV signifies continued cardiogenic shock. The tachycardia and low urine output also suggest continued cardiogenic shock. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Assessment) 8. A nurse is triaging clients in the emergency department. Which client complaint would the triage nurse classify as nonurgent? a. Chest pain and diaphoresis b. Decreased breath sounds due to chest trauma c. Left arm fracture with palpable radial pulses d. Sore throat and a temperature of 104 F

C A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration. The client with an arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis) MSC: Integrated Process: Nursing Process (Planning) 14. The nurse is triaging clients in the emergency department. Which client should be considered urgent? a. 20-year-old female with a chest stab wound and tachycardia b. 45 year-old homeless man with a skin rash and sore throat c. 75-year-old female with a cough and of temperature of 102 F d. 50-year-old male with new-onset confusion and slurred speech

C A client with a cough and a temperature of 102 F is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. Clients with a chest stab wound and tachycardia, and with new-onset confusion and slurred speech, should be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent. DIF: Cognitive Level: Application/Applying or higher

1. While assessing a client in the emergency department, the nurse identifies that the client has been raped. Which health care team member should the nurse collaborate with when planning this clients care? a. Emergency medicine physician b. Case manager c. Forensic nurse examiner d. Psychiatric crisis nurse

C All other members of the health care team listed may be used in the management of this clients care. However, the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing with the victim of an assault. DIF: Cognitive Level: Comprehension/Understanding

1692 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 21. Family members are in the patients room when the patient has a cardiac arrest and the staff start resuscitation measures. Which action should the nurse take next? a. Keep the family in the room and assign a staff member to explain the care given and answer questions. b. Ask the family to wait outside the patients room with a designated staff member to provide emotional support. c. Ask the family members about whether they would prefer to remain in the patients room or wait outside the room. d. Tell the family members that patients are comforted by having family members present during resuscitation efforts.

C Although many family members and patients report benefits from family presence during resuscitation efforts, the nurses initial action should be to determine the preference of these family members. The other actions may be appropriate, but this will depend on what is learned when assessing family preferences. DIF: Cognitive Level: Apply (application)

1679 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 22. A 28-year-old patient who has deep human bite wounds on the left hand is being treated in the urgent care center. Which action will the nurse plan to take? a. Prepare to administer rabies immune globulin (BayRab). b. Assist the health care provider with suturing of the bite wounds. c. Teach the patient the reason for the use of prophylactic antibiotics. d. Keep the wounds dry until the health care provider can assess them.

C Because human bites of the hand frequently become infected, prophylactic antibiotics are usually prescribed to prevent infection. To minimize infection, deep bite wounds on the extremities are left open. Rabies immune globulin might be used after an animal bite. Initial treatment of bite wounds includes copious irrigation to help clean out contaminants and microorganisms. DIF: Cognitive Level: Apply (application)

1682 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 8. A 22-year-old patient who experienced a near drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period? a. Auscultate heart sounds. b. Palpate peripheral pulses. c. Auscultate breath sounds. d. Check pupil reaction to light.

C Because pulmonary edema is a common complication after near drowning, the nurse should assess the breath sounds frequently. The other information also will be obtained by the nurse, but it is not as pertinent to the patients admission diagnosis. DIF: Cognitive Level: Apply (application)

1616 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 20. The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is receiving mechanical ventilation. Which intervention will be most effective in addressing this problem? a. Increase suctioning to every hour. b. Reposition the patient every 1 to 2 hours. c. Add additional water to the patients enteral feedings. d. Instill 5 mL of sterile saline into the ET before suctioning.

C Because the patients secretions are thick, better hydration is indicated. Suctioning every hour without any specific evidence for the need will increase the incidence of mucosal trauma and would not address the etiology of the ineffective airway clearance. Instillation of saline does not liquefy secretions and may decrease the SpO2. Repositioning the patient is appropriate but will not decrease the thickness of secretions. DIF: Cognitive Level: Apply (application)

MULTIPLE CHOICE 1. A diving accident occurs at the community pool and the victim is conscious and in pain. Which intervention is most appropriate pending the arrival of emergency medical personnel? a. Pulled up onto the side of the pool b. Pulled to the shallow end and covered with a towel c. Left in the pool and supported by a large float d. Supported in the pool while CPR is attempted

C Care should be taken to avoid movement of the patient and increasing injury to the spinal cord. Leaving the patient in the pool and supporting the patient on a float will not increase a possible spinal injury. Pulling the patient may cause further injury to the spine. CPR is not indicated as the patient is not experiencing cardiopulmonary arrest. DIF: Cognitive Level: Application

p. 127 TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Assessment) 20. The nurse is caring for a homeless client and consults the emergency department (ED) case manager. What can the ED case manager do for this client? a. Communicate client needs and restrictions to support staff. b. Prescribe low-cost antibiotics to treat community-acquired infection. c. Provide referrals to subsidized community-based health clinics. d. Offer counseling for substance abuse and mental health disorders.

C Case management interventions include facilitating referrals to primary care providers who are accepting new clients or to subsidized community-based health clinics for clients or families in need of routine services. The ED nurse is accountable for communicating pertinent staff considerations, client needs, and restrictions to support staff (e.g., physical limitations, isolation precautions) to ensure that ongoing client and staff safety issues are addressed. The ED physician prescribes medications and treatments. The psychiatric nurse team evaluates clients with emotional behaviors or mental illness and facilitates the follow-up treatment plan, including possible admission to an appropriate psychiatric facility. DIF: Cognitive Level: Knowledge/Remembering

1025 OBJ: 2 (theory) TOP: Evisceration: First Aid KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 6. A worker in a department store fell through a plate glass window, causing a deep laceration on the right mid-thigh that is pumping bright red arterial blood. The best initial intervention of the first responder should be to: a. elevate the leg. b. bunch up the workers shirt and press it against the wound. c. press the palm of hand in the groin to compress the femoral artery. d. tie the workers belt tightly around his upper thigh to stop bleeding.

C Compression of the artery is the best initial move, followed by compression with dressing and elevation. DIF: Cognitive Level: Application

1020 OBJ: NA TOP: Good Samaritan Law: Provisions KEY: Nursing Process Step: NA MSC: NCLEX: NA 5. A victim of a knife fight is found lying in a parking lot with a loop of bowel protruding from an abdominal wound. The first responder should: a. attempt to replace the bowel back into the abdomen. b. wrap the victims shirt tightly around his body. c. cover the evisceration with a plastic shopping bag. d. assist the victim to flex his thighs against his abdomen.

C Covering evisceration with a nonadhesive covering will keep the bowel moist. Attempts to return the bowel into the abdomen may result in further injury. Tightly wrapping the shirt around the body may compromise circulation. Flexion of the thighs onto the abdomen may compress and cause further damage to the bowel. DIF: Cognitive Level: Application

1615 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 18. The nurse notes premature ventricular contractions (PVCs) while suctioning a patients endotracheal tube. Which action by the nurse is a priority? a. Decrease the suction pressure to 80 mm Hg. b. Document the dysrhythmia in the patients chart. c. Stop and ventilate the patient with 100% oxygen. d. Give antidysrhythmic medications per protocol.

C Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system stimulation. The nurse should stop suctioning and ventilate the patient with 100% oxygen. Lowering the suction pressure will decrease the effectiveness of suctioning without improving the hypoxemia. Because the PVCs occurred during suctioning, there is no need for antidysrhythmic medications (which may have adverse effects) unless they recur when the suctioning is stopped and patient is well oxygenated. DIF: Cognitive Level: Apply (application)

p. 126 TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology) MSC: Integrated Process: Nursing Process (Assessment) 19. The emergency department (ED) nurse is assigned to triage clients. What is the purpose of triage? a. Treat clients on a first-come, first-serve basis. b. Identify and treat clients with low acuity first. c. Prioritize clients based on illness severity. d. Determine health needs from a complete assessment.

C ED triage is an organized system for sorting or classifying clients into priority levels, depending on illness or injury severity. The key concept is that clients who present to the ED with the greatest acuity needs receive the quickest evaluation, treatment, and prioritized resource utilization. A person with a lower-acuity problem may wait longer in the ED because the higher-acuity client is moved to the head of the line. DIF: Cognitive Level: Knowledge/Remembering

1678 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 7. A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). The nurse determines that discharge teaching has been effective when the patient makes which statement? a. I will take salt tablets when I work outdoors in the summer. b. I should take acetaminophen (Tylenol) if I start to feel too warm. c. I should drink sports drinks when working outside in hot weather. d. I will move to a cool environment if I notice that I am feeling confused.

C Electrolyte solutions such as sports drinks help replace fluid and electrolytes lost when exercising in hot weather. Salt tablets are not recommended because of the risks of gastric irritation and hypernatremia. Antipyretic medications are not effective in lowering body temperature elevations caused by excessive exposure to heat. A patient who is confused is likely to have more severe hyperthermia and will be unable to remember to take appropriate action. DIF: Cognitive Level: Apply (application)

1027 OBJ: 3 (theory) TOP: Hypothermia: Arrhythmias KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 11. The nurse assesses the frostbite on the victims hands and feet to be second-degree frostbite because the skin is: a. reddened and has hard white plaques. b. waxy and has sensory deficits. c. reddened and has blisters filled with milky fluid. d. waxy and has blisters filled with blood.

C Frostbite is categorized by degree of injury, much like burns. The appearance of a first-degree injury includes reddened skin, swelling, waxy appearance, hard white plaques, and sensory deficit. Second-degree injury also has redness and swelling and formation of blisters filled with clear or milky fluid that form within 24 hours of injury. In third-degree injury, the blisters are blood filled followed by black eschar forming over several weeks. Fourth-degree injury involves full-thickness damage affecting muscles, tendons, and bone, resulting in tissue loss. DIF: Cognitive Level: Application

1601 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 28. The family members of a patient who has just been admitted to the intensive care unit (ICU) with multiple traumatic injuries have just arrived in the ICU waiting room. Which action should the nurse take next? a. Explain ICU visitation policies and encourage family visits. b. Immediately take the family members to the patients bedside. c. Describe the patients injuries and the care that is being provided. d. Invite the family to participate in a multidisciplinary care conference.

C Lack of information is a major source of anxiety for family members and should be addressed first. Family members should be prepared for the patients appearance and the ICU environment before visiting the patient for the first time. ICU visiting should be individualized to each patient and family rather than being dictated by rigid visitation policies. Inviting the family to participate in a multidisciplinary conference is appropriate but should not be the initial action by the nurse. DIF: Cognitive Level: Apply (application)

1027 OBJ: 3 (theory) TOP: Heatstroke: First Aid KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 10. A student nurse is assisting with the care of a 50-year-old man who is being treated in the emergency department for hypothermia. The student asks the charge nurse why the patient is having his heart monitored. The nurses best explanation would be that the heart is being monitored because serious arrhythmias can be caused by: a. rapidly rising blood pressure from infusing IV fluids. b. adrenal output of epinephrine in response to cold stress. c. lactic acid being shunted from pooled blood in the extremities. d. vasodilation from the warming process.

C Lactic acid in the blood that was pooled in the extremities while being exposed to cold will shunt back to the heart through systemic perfusion as the warming process becomes effective. The lactic acid can cause arrhythmias. DIF: Cognitive Level: Application

1603 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 14. The nurse is caring for a patient who has an intraaortic balloon pump in place. Which action should be included in the plan of care? a. Position the patient supine at all times. b. Avoid the use of anticoagulant medications. c. Measure the patients urinary output every hour. d. Provide passive range of motion for all extremities.

C Monitoring urine output will help determine whether the patients cardiac output has improved and also help monitor for balloon displacement. The head of the bed can be elevated up to 30 degrees. Heparin is used to prevent thrombus formation. Limited movement is allowed for the extremity with the balloon insertion site to prevent displacement of the balloon. DIF: Cognitive Level: Apply (application)

1027 OBJ: 3 (theory) TOP: Heatstroke: Cooling Technique KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 8. The nurse reminds a group of CNAs that for a patient with an elevated temperature, the quickest and simplest technique to reduce the temperature is to: a. apply ice packs to the groin. b. bathe in tepid water. c. remove clothing and bed linen. d. give chilled drinks.

C Removing the patients clothing and bed linen covering the patient is a quick, simple, and usually effective way to reduce temperature. The application of ice packs may result in excessive cooling and result in shivering, which acts to increase metabolic rate. Bathing in tepid water is effective but requires more time and interaction than simply removing clothing and bed linens. Chilled drinks will not adequately reduce the total body temperature. DIF: Cognitive Level: Comprehension

1024 OBJ: 2 (theory) TOP: Arterial Bleed: Intervention KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 7. The nurse cautions that, when cooling down a victim of heatstroke, one must be careful to prevent shivering because shivering can cause: a. a paralytic ileus. b. cardiac arrhythmias. c. an increase in temperature. d. a seizure.

C Shivering is a homeostatic activity that generates heat and increases body temperature. DIF: Cognitive Level: Analysis

1622-1624 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 23. A nurse is weaning a 68-kg male patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which patient assessment finding indicates that the weaning protocol should be stopped? a. The patients heart rate is 97 beats/min. b. The patients oxygen saturation is 93%. c. The patient respiratory rate is 32 breaths/min. d. The patients spontaneous tidal volume is 450 mL.

C Tachypnea is a sign that the patients work of breathing is too high to allow weaning to proceed. The patients heart rate is within normal limits, although the nurse should continue to monitor it. An oxygen saturation of 93% is acceptable for a patient with COPD. A spontaneous tidal volume of 450 mL is within the acceptable range. DIF: Cognitive Level: Apply (application)

1027 OBJ: 3 (theory) TOP: Hypothermia: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 13. An 80-year-old woman is brought to the emergency department by her daughter, who found the woman unconscious in her garage sitting in her car. A significant assessment of this patient as to cause of her condition would be: a. temperature, 97.6 F; pulse, 98; and blood pressure, 110/60. b. O2 saturation of 78%. c. cherry red mucous membranes. d. cold extremities.

C The cherry red mucous membranes are classic signs of carbon monoxide poisoning; unfortunately, they are very late signs. DIF: Cognitive Level: Application

1016 OBJ: 10 (theory) TOP: Debriefing: Purpose KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity 19. A patient comes to the emergency department with reports of exposure to a toxic chemical spill. The assessment reveals that the patient has inhaled the chemical and had the chemical on his clothing. What actions by the nurse are appropriate? a. The nurse advises the patient to leave in contact lenses to continue to provide protection to the eyes. b. The nurse will proceed to irrigate the patients eyes for 5 to 7 minutes with water. c. The nurse will use tongs to handle items taken off by the patient. d. The nurse will place the clothing in a metal receptacle for disposal.

C The clothing and contact lenses will be considered contaminated. They will need to be removed. Tongs will be included in the types of protective equipment needed to manage the patient. Eye irrigation will need to be performed for a period of 10 to 15 minutes. The clothing will need to be placed in a plastic bag for disposal. DIF: Cognitive Level: Analysis

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Assessment) 12. The nurse is providing care for a client admitted for suicidal precautions. What priority intervention should the nurse implement first? a. Administer prescribed anti-anxiety drugs. b. Decrease the noise level and the harsh lighting. c. Remove oxygen tubing from the room. d. Set firm behavioral limits.

C The first priority in caring for a mentally ill client is providing a safe environment. This would include removing any item that the client could use to harm himself or herself (or others). All the other interventions can be used in providing a therapeutic environment. However, they are not as imperative as the safety of the client and staff. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Assessment) 11. A client arrives at the emergency department following a motor vehicle collision. The client is not awake and is being bagged with a bag-valve-mask by paramedics. The client has sustained obvious injuries to the head and face, as well as an open right femur fracture that is bleeding profusely. What will the nurse do first? a. Splint the right lower extremity. b. Apply direct pressure to the leg. c. Assess for a patent airway. d. Start two large-bore IVs.

C The highest-priority intervention in the primary survey is to establish a patent airway. Without an adequate airway to supply oxygen to the cells, a cerebral injury could progress to anoxic brain death. After an airway is established, resuscitation may continue to B for breathing and C for circulation assessment. DIF: Cognitive Level: Application/Applying or higher

1616 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 19. Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning? a. The patients oxygen saturation is 93%. b. The patient was last suctioned 6 hours ago. c. The patients respiratory rate is 32 breaths/minute. d. The patient has occasional audible expiratory wheezes.

C The increase in respiratory rate indicates that the patient may have decreased airway clearance and requires suctioning. Suctioning is done when patient assessment data indicate that it is needed, not on a scheduled basis. Occasional expiratory wheezes do not indicate poor airway clearance, and suctioning the patient may induce bronchospasm and increase wheezing. An oxygen saturation of 93% is acceptable and does not suggest that immediate suctioning is needed. DIF: Cognitive Level: Apply (application)

1012 OBJ: 8 (theory) TOP: Plague: Fragility of Organism KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 17. Following a terrorist attack using smallpox virus, the nurse assesses a newly admitted patient with large vesicles all over her body that could be either smallpox or chickenpox. The nurse feels confident that the lesions are those of smallpox because of the lesions assessed on the: a. face. b. mucous membranes. c. soles of the feet. d. axilla.

C The lesions of smallpox can be found on the palms of the hands and soles of the feet. The lesions of chickenpox do not appear there. DIF: Cognitive Level: Comprehension

1607 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 8. Which action is a priority for the nurse to take when the low pressure alarm sounds for a patient who has an arterial line in the left radial artery? a. Fast flush the arterial line. b. Check the left hand for pallor. c. Assess for cardiac dysrhythmias. d. Rezero the monitoring equipment.

C The low pressure alarm indicates a drop in the patients blood pressure, which may be caused by cardiac dysrhythmias. There is no indication to rezero the equipment. Pallor of the left hand would be caused by occlusion of the radial artery by the arterial catheter, not by low pressure. There is no indication of a need for flushing the line. DIF: Cognitive Level: Apply (application)

1617 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 31. The nurse notes that a patients endotracheal tube (ET), which was at the 22-cm mark, is now at the 25-cm mark and the patient is anxious and restless. Which action should the nurse take next? a. Offer reassurance to the patient. b. Bag the patient at an FIO2 of 100%. c. Listen to the patients breath sounds. d. Notify the patients health care provider.

C The nurse should first determine whether the ET tube has been displaced into the right mainstem bronchus by listening for unilateral breath sounds. If so, assistance will be needed to reposition the tube immediately. The other actions are also appropriate, but detection and correction of tube malposition are the most critical actions. DIF: Cognitive Level: Apply (application)

1019 OBJ: 2 (theory) TOP: Diving Injury: First Aid KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 2. A drowning victim is brought to shore and is semiconscious and breathing. The most appropriate initial action of the camp counselor will require that the victim will be placed in what position? a. Supine to receive CPR b. Supine with knees flexed c. On the side in recovery position d. Prone with head turned to side

C The patient who is breathing should be placed in the recovery position to allow the patient to vomit out water without danger of aspiration. CPR is not indicated as the patient is not experiencing the absence of cardiopulmonary activity. Lying supine or prone will not prevent aspiration in the event of vomiting. DIF: Cognitive Level: Comprehension

1627 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 24. The nurse is caring for a patient receiving a continuous norepinephrine (Levophed) IV infusion. Which patient assessment finding indicates that the infusion rate may need to be adjusted? a. Heart rate is 58 beats/minute. b. Mean arterial pressure (MAP) is 56 mm Hg. c. Systemic vascular resistance (SVR) is elevated. d. Pulmonary artery wedge pressure (PAWP) is low.

C Vasoconstrictors such as norepinephrine (Levophed) will increase SVR, and this will increase the work of the heart and decrease peripheral perfusion. The infusion rate may need to be decreased. Bradycardia, hypotension (MAP of 56 mm Hg), and low PAWP are not associated with norepinephrine infusion. DIF: Cognitive Level: Apply (application)

1025-1026 OBJ: 3 (theory) TOP: Abdominal Trauma KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity: Physiological Adaptation 19. The nurse is caring for a conscious patient who has symptoms consistent with hypoglycemia. After a serum glucose reading supports this diagnosis, which substance is preferred to initially increase the patients glucose level? a. Carbonated cola beverage b. A teaspoon of white sugar c. A glass of milk d. Intravenous glucose

C When the patient is conscious, an oral glucose-containing substance is suggested. A glass of milk, glucose tablets, or hard candy is preferred. DIF: Cognitive Level: Application

114 KEY: Interdisciplinary team| emergency nursing| case management MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 13. A nurse is triaging clients in the emergency department. Which client should the nurse classify as nonurgent? a. A 44-year-old with chest pain and diaphoresis b. A 50-year-old with chest trauma and absent breath sounds c. A 62-year-old with a simple fracture of the left arm d. A 79-year-old with a temperature of 104 F

C A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with a simple arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration. DIF: Applying/Application

116 KEY: Infection control| Standard Precautions| emergency nursing| staff safety MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 9. A nurse is triaging clients in the emergency department. Which client should be considered urgent? a. A 20-year-old female with a chest stab wound and tachycardia b. A 45-year-old homeless man with a skin rash and sore throat c. A 75-year-old female with a cough and a temperature of 102 F d. A 50-year-old male with new-onset confusion and slurred speech

C A client with a cough and a temperature of 102 F is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. The client with a chest stab wound and tachycardia and the client with new-onset confusion and slurred speech should be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent. DIF: Applying/Application

117 KEY: Triage| emergency nursing MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 4. While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action should the nurse take first? a. Apply oxygen via nasal cannula. b. Administer intravenous 0.9% saline solution. c. Transfer the client to a negative-pressure room. d. Obtain a sputum culture and sensitivity.

C A client with signs and symptoms of tuberculosis or other airborne pathogens should be placed in a negative-pressure room to prevent contamination of staff, clients, and family members in the crowded emergency department. DIF: Applying/Application

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical Emergencies) MSC: Integrated Process: Nursing Process (Implementation) 1. An emergency room nurse assesses a client who has been raped. With which health care team member should the nurse collaborate when planning this clients care? a. Emergency medicine physician b. Case manager c. Forensic nurse examiner d. Psychiatric crisis nurse

C All other members of the health care team listed may be used in the management of this clients care. However, the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing with the victim of an assault. DIF: Understanding/Comprehension

114 KEY: Death| emergency nursing MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity 11. An emergency department (ED) case manager is consulted for a client who is homeless. Which intervention should the case manager provide? a. Communicate client needs and restrictions to support staff. b. Prescribe low-cost antibiotics to treat community-acquired infection. c. Provide referrals to subsidized community-based health clinics. d. Offer counseling for substance abuse and mental health disorders.

C Case management interventions include facilitating referrals to primary care providers who are accepting new clients or to subsidized community-based health clinics for clients or families in need of routine services. The ED nurse is accountable for communicating pertinent staff considerations, client needs, and restrictions to support staff (e.g., physical limitations, isolation precautions) to ensure that ongoing client and staff safety issues are addressed. The ED physician prescribes medications and treatments. The psychiatric nurse team evaluates clients with emotional behaviors or mental illness and facilitates the follow-up treatment plan, including possible admission to an appropriate psychiatric facility. DIF: Understanding/Comprehension

114 KEY: Death| emergency nursing MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity 3. An emergency room nurse is triaging victims of a multi-casualty event. Which client should receive care first? a. A 30-year-old distraught mother holding her crying child b. A 65-year-old conscious male with a head laceration c. A 26-year-old male who has pale, cool, clammy skin d. A 48-year-old with a simple fracture of the lower leg

C The client with pale, cool, clammy skin is in shock and needs immediate medical attention. The mother does not have injuries and so would be the lowest priority. The other two people need medical attention soon, but not at the expense of a person in shock. DIF: Applying/Application

114 KEY: Interdisciplinary team| emergency nursing MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 12. An emergency department nurse is caring for a client who is homeless. Which action should the nurse take to gain the clients trust? a. Speak in a quiet and monotone voice. b. Avoid eye contact with the client. c. Listen to the clients concerns and needs. d. Ask security to store the clients belongings.

C To demonstrate behaviors that promote trust with homeless clients, the emergency room nurse should make eye contact (if culturally appropriate), speak calmly, avoid any prejudicial or stereotypical remarks, show genuine care and concern by listening, and follow through on promises. The nurse should also respect the clients belongings and personal space. DIF: Understanding/Comprehension

15-16 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment OTHER 1. The following four patients arrive in the emergency department (ED) after a motor vehicle collision. In which order should the nurse assess them? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. A 74-year-old with palpitations and chest pain b. A 43-year-old complaining of 7/10 abdominal pain c. A 21-year-old with multiple fractures of the face and jaw d. A 37-year-old with a misaligned left leg with intact pulses

C, A, B, D The highest priority is to assess the 21-year-old patient for airway obstruction, which is the most life-threatening injury. The 74-year-old patient may have chest pain from cardiac ischemia and should be assessed and have diagnostic testing for this pain. The 43-year-old patient may have abdominal trauma or bleeding and should be seen next to assess circulatory status. The 37-year-old appears to have a possible fracture of the left leg and should be seen soon, but this patient has the least life-threatening injury. DIF: Cognitive Level: Analyze (analysis)

1006 OBJ: 8 (theory) TOP: Bioterrorism: Organisms with High Lethality KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 26. The nurse is participating in an educational program concerning nuclear disasters. The nurse correctly recognizes that the level of exposure will be determined by which factors? (Select all that apply.) a. Age of the victim b. Body surface area of the victim c. Length of exposure d. Distance of the victim from the nuclear source e. Shielding of the victim from the nuclear source

C, D, E The amount of damage to each person depends on the type of radiation, the dose received, the length of time of exposure, and the route of the exposure. Time, distance, and shielding are key to the quantity of radiation an individual will receive. The shorter the time of exposure, the farther away from the radiation source, and whether or not the person was shielded by materials that are impermeable to radiation are details pertinent to radiation risk. DIF: Cognitive Level: Comprehension

1690 TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 10. When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87 F (30.6 C), which assessment indicates that the nurse should discontinue active rewarming? a. The patient begins to shiver. b. The BP decreases to 86/42 mm Hg. c. The patient develops atrial fibrillation. d. The core temperature is 94 F (34.4 C).

D A core temperature of 89.6 F to 93.2 F (32 C to 34 C) indicates that sufficient rewarming has occurred. Dysrhythmias, hypotension, and shivering may occur during rewarming and should be treated but are not an indication to stop rewarming the patient. DIF: Cognitive Level: Apply (application)

1024 OBJ: 1 (theory) TOP: Control of Bleeding: Safety Alert KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 18. The nurse is reviewing the physicians notes on a patients chart. The nurse notes that the patient demonstrated Cullens sign. The nurse correctly recognizes that this patient most likely had which manifestation? a. Sharp flank pain b. Pain in the upper right quadrant of the abdomen c. Pain with inspiration d. A bluish tinge around the umbilicus

D Cullens sign refers to a bluish tinge around the umbilicus. It may be noted in the presence of internal abdominal hemorrhage. DIF: Cognitive Level: Comprehension

1616 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 35. The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a mechanical ventilator with 10 cm H2O of peak end-expiratory pressure (PEEP). When monitoring the patient, the nurse will need to notify the health care provider immediately if the patient develops a. oxygen saturation of 93%. b. respirations of 20 breaths/minute. c. green nasogastric tube drainage. d. increased jugular venous distention.

D Increases in jugular venous distention in a patient with a subarachnoid hemorrhage may indicate an increase in intracranial pressure (ICP) and that the PEEP setting is too high for this patient. A respiratory rate of 20, O2saturation of 93%, and green nasogastric tube drainage are within normal limits. DIF: Cognitive Level: Apply (application)

1675-1676 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 14. The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment? a. A patient with no pedal pulses. b. A patient with an open femur fracture. c. A patient with bleeding facial lacerations. d. A patient with paradoxic chest movements.

D Most immediate deaths from trauma occur because of problems with ventilation, so the patient with paradoxic chest movements should be treated first. Face and head fractures can obstruct the airway, but the patient with facial injuries only has lacerations. The other two patients also need rapid intervention but do not have airway or breathing problems. DIF: Cognitive Level: Apply (application)

1605 TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment 7. When monitoring for the effectiveness of treatment for a patient with a large anterior wall myocardial infarction, the most important information for the nurse to obtain is a. central venous pressure (CVP). b. systemic vascular resistance (SVR). c. pulmonary vascular resistance (PVR). d. pulmonary artery wedge pressure (PAWP).

D PAWP reflects left ventricular end diastolic pressure (or left ventricular preload) and is a sensitive indicator of cardiac function. Because the patient is high risk for left ventricular failure, the PAWP must be monitored. An increase will indicate left ventricular failure. The other values would also provide useful information, but the most definitive measurement of changes in cardiac function is the PAWP. DIF: Cognitive Level: Apply (application)

1027 OBJ: 3 (theory) TOP: Increased Temperature: Initial Intervention KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 9. A spectator at the Little League playoffs in August in Texas faints in the sun-drenched stands. His face is flushed and his skin is hot to the touch. The first responder should assist him to: a. lie down on the bleacher seat. b. drink a large iced drink. c. be seated in the stands, shielded from the sun with an umbrella. d. a shady area, and sprinkle his clothing with water.

D Remove the victim from the sun and cool by evaporation until emergency medical personnel arrive. DIF: Cognitive Level: Application

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareContinuity of Care) MSC: Integrated Process: Communication and Documentation 6. The nurse manager is assessing current demographics of the facilitys emergency department (ED) clients. Which population would most likely present to the ED for treatment of a temperature and a sore throat? a. Older adults b. Immunocompromised people c. Pediatric clients d. Underinsured people

D The ED serves as an important safety net for clients who are ill or injured but lack access to basic health care. Especially vulnerable populations include the underinsured and the uninsured, who may have nowhere else to go for health care. DIF: Cognitive Level: Comprehension/Understanding

1676 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2. During the primary survey of a patient with severe leg trauma, the nurse observes that the patients left pedal pulse is absent and the leg is swollen. Which action will the nurse take next? a. Send blood to the lab for a complete blood count. b. Assess further for a cause of the decreased circulation. c. Finish the airway, breathing, circulation, disability survey. d. Start normal saline fluid infusion with a large-bore IV line.

D The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a possibly life-threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey. Although a complete blood count is indicated, administration of IV fluids should be started first. Completion of the primary survey and further assessment should be completed after the IV fluids are initiated. DIF: Cognitive Level: Apply (application)

1012 OBJ: 8 (theory) TOP: Smallpox vs. Chickenpox KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 18. The nurse is aware that the purpose of debriefing as outlined in the disaster plan for the health professionals who were involved in caring for the victims of a disaster a month ago is to: a. analyze the effectiveness of the disaster plan. b. assess the efficiency of the service provided by various agencies. c. modify the disaster plan. d. help allay post-traumatic stress disorders.

D The debriefing is for the purpose of allowing the health professionals to ventilate about their experiences in an effort to allay long-term psychological problems. DIF: Cognitive Level: Comprehension

1625 | 1627 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 38. After change-of-shift report, which patient should the progressive care nurse assess first? a. Patient who was extubated in the morning and has a temperature of 101.4 F (38.6 C) b. Patient with bilevel positive airway pressure (BiPAP) for sleep apnea whose respiratory rate is 16 c. Patient with arterial pressure monitoring who is 2 hours postpercutaneous coronary intervention who needs to void d. Patient who is receiving IV heparin for a venous thromboembolism and has a partial thromboplastin time (PTT) of 98 sec

D The findings for this patient indicate high risk for bleeding from an elevated (nontherapeutic) PTT. The nurse needs to adjust the rate of the infusion (dose) per the health care providers parameters. The patient with BiPAP for sleep apnea has a normal respiratory rate. The patient recovering from the percutaneous coronary intervention will need to be assisted with voiding and this task could be delegated to unlicensed assistive personnel. The patient with a fever may be developing ventilator-associated pneumonia, but addressing the bleeding risk is a higher priority. DIF: Cognitive Level: Analyze (analysis)

1614 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 32. The nurse educator is evaluating the care that a new registered nurse (RN) provides to a patient receiving mechanical ventilation. Which action by the new RN indicates the need for more education? a. The RN increases the FIO2 to 100% before suctioning. b. The RN secures a bite block in place using adhesive tape. c. The RN asks for assistance to reposition the endotracheal tube. d. The RN positions the patient with the head of bed at 10 degrees.

D The head of the patients bed should be positioned at 30 to 45 degrees to prevent ventilator-associated pneumonia. The other actions by the new RN are appropriate. DIF: Cognitive Level: Apply (application)

1689 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 17. A 54-year-old patient arrives in the emergency department (ED) after exposure to powdered lime at work. Which action should the nurse take first? a. Obtain the patients vital signs. b. Obtain a baseline complete blood count. c. Decontaminate the patient by showering with water. d. Brush off any visible powder on the skin and clothing.

D The initial action should be to protect staff members and decrease the patients exposure to the toxin by decontamination. Patients exposed to powdered lime should not be showered; instead any/all visible powder should be brushed off. The other actions can be done after the decontamination is completed. DIF: Cognitive Level: Apply (application)

1613 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 15. While waiting for cardiac transplantation, a patient with severe cardiomyopathy has a ventricular assist device (VAD) implanted. When planning care for this patient, the nurse should anticipate a. giving immunosuppressive medications. b. preparing the patient for a permanent VAD. c. teaching the patient the reason for complete bed rest. d. monitoring the surgical incision for signs of infection.

D The insertion site for the VAD provides a source for transmission of infection to the circulatory system and requires frequent monitoring. Patients with VADs are able to have some mobility and may not be on bed rest. The VAD is a bridge to transplantation, not a permanent device. Immunosuppression is not necessary for nonbiologic devices like the VAD. DIF: Cognitive Level: Apply (application)

1614-1615 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 17. To maintain proper cuff pressure of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse should a. inflate the cuff with a minimum of 10 mL of air. b. inflate the cuff until the pilot balloon is firm on palpation. c. inject air into the cuff until a manometer shows 15 mm Hg pressure. d. inject air into the cuff until a slight leak is heard only at peak inflation.

D The minimal occluding volume technique involves injecting air into the cuff until an air leak is present only at peak inflation. The volume to inflate the cuff varies with the ET and the patients size. Cuff pressure should be maintained at 20 to 25 mm Hg. An accurate assessment of cuff pressure cannot be obtained by palpating the pilot balloon. DIF: Cognitive Level: Understand (comprehension)

1606 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 30. The nurse responds to a ventilator alarm and finds the patient lying in bed holding the endotracheal tube (ET). Which action should the nurse take next? a. Activate the rapid response team. b. Provide reassurance to the patient. c. Call the health care provider to reinsert the tube. d. Manually ventilate the patient with 100% oxygen.

D The nurse should ensure maximal patient oxygenation by manually ventilating with a bag-valve-mask system. Offering reassurance to the patient, notifying the health care provider about the need to reinsert the tube, and activating the rapid response team are also appropriate after the nurse has stabilized the patients oxygenation. DIF: Cognitive Level: Apply (application)

1011 OBJ: 8 (theory) TOP: Aerosolized Anthrax: Life Span of Organism KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 15. People who have plague and have been treated with appropriate antibiotics can be released from respiratory droplet precautions after: a. all symptoms are gone. b. there is no longer any blood in the sputum. c. the lesions are dried. d. 48 hours of antibiotic treatment.

D The patient with plague can be released from respiratory precautions 48 hours after initiation of antibiotic therapy. DIF: Cognitive Level: Comprehension

1604 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 25. When caring for the patient with a pulmonary artery (PA) pressure catheter, the nurse observes that the PA waveform indicates that the catheter is in the wedged position. Which action should the nurse take next? a. Zero balance the transducer. b. Activate the fast flush system. c. Notify the health care provider. d. Deflate and reinflate the PA balloon.

D When the catheter is in the wedge position, blood flow past the catheter is obstructed, placing the patient at risk for pulmonary infarction. A health care provider or advanced practice nurse should be called to reposition the catheter. The other actions will not correct the wedging of the PA catheter. DIF: Cognitive Level: Apply (application)

112 KEY: Triage| emergency nursing MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 10. An emergency department nurse is caring for a client who has died from a suspected homicide. Which action should the nurse take? a. Remove all tubes and wires in preparation for the medical examiner. b. Limit the number of visitors to minimize the familys trauma. c. Consult the bereavement committee to follow up with the grieving family. d. Communicate the clients death to the family in a simple and concrete manner.

D When dealing with clients and families in crisis, communicate in a simple and concrete manner to minimize confusion. Tubes must remain in place for the medical examiner. Family should be allowed to view the body. Offering to call for additional family support during the crisis is suggested. The bereavement committee should be consulted, but this is not the priority at this time. DIF: Applying/Application

106 KEY: Interdisciplinary team| emergency nursing MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 5. A nurse prepares to discharge an older adult client home from the emergency department (ED). Which actions should the nurse take to prevent future ED visits? (Select all that apply.) a. Provide medical supplies to the family. b. Consult a home health agency. c. Encourage participation in community activities. d. Screen for depression and suicide. e. Complete a functional assessment.

D, E Due to the high rate of suicide among older adults, a nurse should assess all older adults for depression and suicide. The nurse should also screen older adults for functional assessment, cognitive assessment, and risk for falls to prevent future ED visits. DIF: Understanding/Comprehension

1603 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity OTHER 1. When assisting with oral intubation of a patient who is having respiratory distress, in which order will the nurse take these actions? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Obtain a portable chest-x-ray. b. Position the patient in the supine position. c. Inflate the cuff of the endotracheal tube after insertion. d. Attach an end-tidal CO2 detector to the endotracheal tube. e. Oxygenate the patient with a bag-valve-mask device for several minutes.

E, B, C, D, A The patient is pre-oxygenated with a bag-valve-mask system for 3 to 5 minutes before intubation and then placed in a supine position. Following the intubation, the cuff on the endotracheal tube is inflated to occlude and protect the airway. Tube placement is assessed first with an end-tidal CO2 sensor, then with a chest x-ray. DIF: Cognitive Level: Analyze (analysis)

1600 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment COMPLETION 1. A patients vital signs are pulse 87, respirations 24, and BP of 128/64 mm Hg and cardiac output is 4.7 L/min. The patients stroke volume is _____ mL. (Round to the nearest whole number.)

54 Stroke volume = cardiac output/heart rate DIF: Cognitive Level: Understand (comprehension)

1688 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 23. The urgent care center protocol for tick bites includes the following actions. Which action will the nurse take first when caring for a patient with a tick bite? a. Use tweezers to remove any remaining ticks. b. Check the vital signs, including temperature. c. Give doxycycline (Vibramycin) 100 mg orally. d. Obtain information about recent outdoor activities.

A Because neurotoxic venom is released as long as the tick is attached to the patient, the initial action should be to remove any ticks using tweezers or forceps. The other actions are also appropriate, but the priority is to minimize venom release. DIF: Cognitive Level: Apply (application)

1011 OBJ: 8 (theory) TOP: Category B Agents: Delivery Mode KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 13. The nurse clarifies that when a person has been exposed to particulate radioactive material, a chelating agent such as calcium edentate (EDTA) is given to: a. bind with radioactive material and allow it to be excreted. b. reduce radioactivity to nonharmful levels. c. form a protective coat in the gastrointestinal system. d. dissolve particulate material.

A Chelating agents bind with radioactive material, allowing it to be excreted without absorption. DIF: Cognitive Level: Comprehension

1006 OBJ: 3 (clinical) TOP: Food Supply: Preservation KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 8. To help restore order in a group of 18 people who are trapped in a third-floor office building by rising flood water, the nurse should: a. give everyone a specific duty, for example, arranging furniture for sleeping. b. let the people direct themselves to helpful tasks. c. make a list of essential jobs and ask the others to volunteer. d. put all the food in a central place and direct people to take what they need.

A During the impact stage, firm direction is needed, and executing essential helpful jobs will help restore order. Asking for volunteers when there is a loss of order and control would be counterproductive and would lack the direction needed by those affected. Food will need to be rationed in the event there is no rescue for an extended period of time. The rationing should be performed with direction and not allow the people to take whatever they wish. DIF: Cognitive Level: Analysis

1000 OBJ: 2 (theory) TOP: Disaster Drills: Frequency KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 4. A truck has just smashed into the dayroom of a long-term health care facility with enormous damage and injuring many of the residents. The noninjured residents are stunned and frightened and totally disorganized. Recognizing that everyone is in the impact stage, the nurse should: a. firmly instruct two CNAs to start wheeling residents to the dining room in their wheelchairs. b. begin wheeling residents back to their rooms herself. c. shout for everyone to hurry to the dining room. d. start treating the injured in the dayroom.

A In the impact stage, firm direction is needed to get people to a central place for safety and information. DIF: Cognitive Level: Analysis

1623-1624 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 36. A patient who is receiving positive pressure ventilation is scheduled for a spontaneous breathing trial (SBT). Which finding by the nurse is most important to discuss with the health care provider before starting the SBT? a. New ST segment elevation is noted on the cardiac monitor. b. Enteral feedings are being given through an orogastric tube. c. Scattered rhonchi are heard when auscultating breath sounds. d. HYDROmorphone (Dilaudid) is being used to treat postoperative pain.

A Myocardial ischemia is a contraindication for ventilator weaning. The ST segment elevation is an indication that weaning should be postponed until further investigation and/or treatment for myocardial ischemia can be done. The other information will also be shared with the health care provider, but ventilator weaning can proceed when opioids are used for pain management, abnormal lung sounds are present, or enteral feedings are being used. DIF: Cognitive Level: Apply (application)

1682 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 12. A 20-year-old patient arrives in the emergency department (ED) several hours after taking 25 to 30 acetaminophen (Tylenol) tablets. Which action will the nurse plan to take? a. Give N-acetylcysteine (Mucomyst). b. Discuss the use of chelation therapy. c. Start oxygen using a non-rebreather mask. d. Have the patient drink large amounts of water.

A N-acetylcysteine is the recommended treatment to prevent liver damage after acetaminophen overdose. The other actions might be used for other types of poisoning, but they will not be appropriate for a patient with acetaminophen poisoning. DIF: Cognitive Level: Understand (comprehension)

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical Emergencies) MSC: Integrated Process: Nursing Process (Implementation) 18. The nurse is triaging clients in the emergency department (ED). Which is true about the presentation of client symptoms? a. Older adults frequently have symptoms that are vague or less specific. b. Young adults present with nonspecific symptoms for serious illnesses. c. Diagnosing childrens symptoms often keeps them in the ED longer. d. Symptoms of confusion always represent neurologic disorders.

A Older adults present with symptoms that often are different or less specific than those of younger adults. For example, increasing weakness, fatigue, and confusion may be the only admission concerns. These vague symptoms can be caused by serious illness, such as an acute myocardial infarction (MI), urinary tract infection, or pneumonia. Diagnosing older adults often keeps them in the ED for extended periods of time. DIF: Cognitive Level: Knowledge/Remembering

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical Emergencies) MSC: Integrated Process: Nursing Process (Implementation) OTHER 1. The nurse is assessing clients on site at a multi-vehicle accident. Triage clients in the order they should receive care. (Place in order of priority.) a. A 50-year-old with chest trauma and difficulty breathing b. A mother frantically looking for her 6-year-old son c. An 8-year-old with a broken leg in his fathers arms d. A 60-year-old with facial lacerations and confusion e. A pulseless male with a penetrating head wound

a, d, b, c, e Clients should be prioritized with ABCs and emergent, urgent, and nonurgent status. The client with chest trauma and difficulty breathing is the priority because no clients have an airway problem, and this is the only client with a breathing problem. The client with confusion should be seen next. Confusion can be caused by lack of oxygen to the brain due to a circulation problem. The pulseless client with a penetrating head wound is seen last because there are multiple clients to be seen, and care for this client would be futile. The client with a broken leg is nonurgent and can wait. The mother looking for her son should be seen third. Finding the child is urgent to identify potential injuries. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Assessment) 2. In what sequence would a client move through the process of admission to disposition in emergency care? (Place in order of priority.) a. Client is transported to the medical-surgical floor. b. Emergency department (ED) nurse gives a report on the client. c. Paramedics arrive and start IV access. d. Nurse and other health care provider(s) perform assessment. e. Emergency medical technicians (EMTs) provide oxygen and vital sign monitoring. f. Laboratory technician obtains blood specimens.

e, c, d, f, b, a When clients are in an emergency situation, EMTs arrive on the scene first. EMTs apply oxygen and obtain vital signs to determine a baseline for further care. EMTs can provide basic life support measures and can assess ABCs. Second on the scene are paramedics. Starting IV access and performing advanced life support is within the paramedics scope of practice. The client is then transported to an ED, where nurses and other health care providers perform an initial assessment. Laboratory technicians are notified and appropriate blood specimens are obtained for diagnostic testing. When the client is stable, the ED nurse gives report to the medical-surgical unit nurse, and the client is finally transferred to an inpatient room. DIF: Cognitive Level: Application/Applying or higher

1026 OBJ: 4 (theory) TOP: Heatstroke KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation COMPLETION 28. When all five of the contestants in a custard pieeating contest arrive at the emergency department with vomiting and diarrhea, the nurse suspects that these signs are related to the contamination of the pies by _______________.

Staphylococcus aureus Staphylococcus aureus is the prime offender in contamination of custards, mayonnaise, and processed foods. DIF: Cognitive Level: Comprehension