Week 8 Clinical Review Questions

A client was brought to the emergency department after suffering a closed head injury and lacerations around the face due to a hit-run accident. The client is unconscious and has a minimal response to noxious stimuli. Which of the following assessment findings if observed after few hours, should be reported to the physician immediately? A. Drainage of a clear fluid from the client's nose B. Withdrawal of the client in response to painful stimuli C. Bruises and minimal edema of the eyelids D. Bleeding around the lacerations

A. Drainage of a clear fluid from the client's nose

In caring for a victim of sexual assault, which task is most appropriate for an LPN/LVN? A. Provide emotional support and supportive communication B. Assess immediate emotional state and physical injuries C. Ensure that the "chain of custody" is maintained D. Collect hair samples, saliva swabs, and scrapings beneath fingernails

A. Provide emotional support and supportive communication

Nurse Ejay is assigned to telephone triage. A client called who was stung by a honeybee and is asking for help. The client reports pain and localized swelling but has no respiratory distress or other symptoms of anaphylactic shock. What is the appropriate initial action that the nurse should direct the client to perform? A. Removing the stinger by scraping it B. Applying a cold compress C. Taking an oral antihistamine D. Calling 911

A. Removing the stinger by scraping it

A prisoner, with a known history of alcohol abuse, has been in police custody for 48 hours. Initially, anxiety, sweating, and tremors were noted. Now, disorientation, hallucination, and hyper-reactivity are observed. The medical diagnosis is delirium tremens. What is the priority nursing diagnosis? A. Risk for Injury related to seizures B. Risk for Situational Low Self-esteem related to police custody C. Risk for Nutritional Deficit related to chronic alcohol abuse D. Risk for Other-Directed Violence related to hallucinations

A. Risk for Injury related to seizures

You are assessing a patient who has sustained a cat bite to the left hand. The cat is up-to-date immunizations. The date of the patient's last tetanus shot is unknown. Which of the following is the priority nursing diagnosis? A. Impaired Skin Integrity related to puncture wounds B. Ineffective Health Maintenance related to immunization status C. Risk for Infection related to organisms specific to cat bites D. Risk for Impaired Mobility related to potential tendon damage

C. Risk for Infection related to organisms specific to cat bites

A 5-year-old client was admitted to the emergency unit due to the ingestion of an unknown amount of chewable vitamins for children at an unknown time. Upon assessment, the child is alert and with no symptoms. Which of the following information should be reported to the physician immediately? A. The child was nauseated and vomited once at home B. The child has been treated several times for toxic substance ingestion C. The vitamin that was ingested contains iron D. The child has been treated multiple times for injuries caused by accidents

C. The vitamin that was ingested contains iron

A client was brought to the ED due to an abdominal trauma caused by a motorcycle accident. During the assessment, the client complains of epigastric pain and back pain. Which of the following is true regarding the diagnosis of pancreatic injury? A. Redness and bruising may indicate the site of the injury in blunt trauma B. The client is symptom-free during the early post-injury period C. Signs of peritoneal irritation may indicate pancreatic injury D. All of the above

D. All of the above

The nursing manager decides to form a committee to address the issue of violence against ED personnel. Which combination of employees would be best suited to fulfill this assignment? A. ED physicians and charge nurses B. RNs, LPNs, and nursing assistants C. Experienced RNs and experienced paramedics D. At least one representative from each group of ED personnel

D. At least one representative from each group of ED personnel

A client arrives in the emergency unit and reports that a concentrated household cleaner was splashed in both eyes. Which of the following nursing actions is a priority? A. Examine the client's visual acuity B. Patch the eye C. Use Restasis (Allergan) drops in the eye D. Flush the eye repeatedly using sterile normal saline

D. Flush the eye repeatedly using sterile normal saline

A client arrived at the emergency department after suffering multiple physical injuries including a fractured pelvis from a vehicular accident. Upon assessment, the client is incoherent, pale, and diaphoretic. With vital signs as follows: temperature of 97°F (36.11° C), blood pressure of 60/40 mm Hg, heart rate of 143 beats/minute, and a respiratory rate of 30 breaths/minute. The client is mostly suffering from which of the following shock? A. Distributive B. Hypovolemic C. Obstructive D. Cardiogenic

B. Hypovolemic

An anxious female client complains of chest tightness, tingling sensations, and palpitations. Deep, rapid breathing, and carpal spasms are noted. Which of the following priority action should the nurse do first? A. Provide oxygen therapy B. Notify the physician immediately C. Administer anxiolytic medication as ordered D. Have the client breathe into a brown paper bag

D. Have the client breathe into a brown paper bag

A 33-year-old patient with a history of seizures and medication compliance of phenytoin (Dilantin) and carbamazepine (Tegretol) is brought to the ED by the MS personnel for repetitive seizure activity that started 45 minutes prior to arrival. You anticipate that the physician will order which drug for status epilepticus? A. Phenytoin and Carbamazepine PO B. Carbamazepine (Tegretol) IV C. Magnesium sulfate IV D. Lorazepam (Ativan) IV

D. Lorazepam (Ativan) IV

An ER nurse is handling a 50-year-old woman complaining of dizziness and palpitations that occur from time to time. ECG confirms the diagnosis of paroxysmal supraventricular tachycardia. The client seems worried about it. Which of the following is an appropriate response of the nurse? A. "You can be discharged now; this is a probable sign of anxiety." B. "The physician will prescribe you blood-thinning medications to lessen the episodes of palpitations." C. "We'll need to keep you for further assessment; you may develop blood clots." D. "You have to stay here for a few hours to undergo blood tests to rule out myocardial infarction."

C. "We'll need to keep you for further assessment; you may develop blood clots."

The following clients are presented with signs and symptoms of heat-related illness. Which of them needs to be attended first? A. A relatively healthy homemaker who reports that the air conditioner has been broken for days and who manifest fatigue, hypotension, tachypnea, and profuse sweating. B. An elderly person who complains of dizziness and syncope after standing in the sun for several hours to view a parade. C. A homeless person who is a poor historian; has altered mental status, poor muscle coordination, and hot, dry ashen skin; and whose duration of heat exposure is unknown. D. A marathon runner who complains of severe leg cramps and nausea, and manifests weakness, pallor, diaphoresis, and tachycardia.

C. A homeless person who is a poor historian; has altered mental status, poor muscle coordination, and hot, dry ashen skin; and whose duration of heat exposure is unknown.

The physician has ordered cooling measures for a child with a fever who is likely to be discharged when the temperature comes down. Which task would be appropriate to delegate to a nursing assistant? A. Prepare and administer a tepid sponge bath B. Explain the need for giving cool fluids C. Assist the child in removing outer clothing D. Advise the parent to use acetaminophen (Tylenol) instead of aspirin

C. Assist the child in removing outer clothing

In the work setting, what is the primary responsibility of the nurse in preparation for disaster management, that includes natural disasters and bioterrorism incidents? A. Being aware of the signs and symptoms of potential agents of bioterrorism B. Making ethical decisions regarding exposing self to potentially lethal substances C. Being aware of the agency's emergency response plan D. Being aware of what and how to report to the Centers for Disease Control and Prevention

C. Being aware of the agency's emergency response plan

The emergency medical service has transported a client with severe chest pain. As the client is being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and unpalpable pulse. Which of the following task is appropriate to delegate to the nursing assistant? A. Assisting with the intubation B. Placing the defibrillator pads C. Doing chest compressions D. Initiating bag valve mask ventilation

C. Doing chest compressions

In relation to submersion injuries, which task is most appropriate to delegate to an LPN/LVN? A. Stabilize the cervical spine for an unconscious drowning victim B. Talk to a community group about water safety issues C. Monitor an asymptomatic near-drowning victim D. Remove wet clothing and cover the victim with a warm blanket

C. Monitor an asymptomatic near-drowning victim

An intoxicated client comes into the emergency unit with uncooperative behavior, mild confusion, and slurred speech. The client is unable to provide a good history but he verbalizes that he has been drinking a lot. Which of the following is a priority action of the nurse? A. Administer IV fluid incorporated with Vitamin B1 as ordered B. Administer Naloxone (Narcan) 4 mg as ordered C. Contact the family to get information about the client D. Obtain an order for the determination of blood alcohol level

A. Administer IV fluid incorporated with Vitamin B1 as ordered

Nurse Kelly, a triage nurse encountered a client who complained of mid-sternal chest pain, dizziness, and diaphoresis. Which of the following nursing action should take priority? A. Administer oxygen therapy via nasal cannula B. Notify the physician C. Complete history taking D. Put the client on ECG monitoring

A. Administer oxygen therapy via nasal cannula

A nurse is providing discharge instructions to a woman who has been treated for contusions and bruises due to domestic violence. What is the priority intervention for this client? A. Arranging transportation to a safe house B. Advising the client about contacting the police C. Making an appointment to follow up on the injuries D. Making a referral to a counselor

A. Arranging transportation to a safe house

When an unexpected death occurs in the emergency department, which task is the most appropriate to delegate to a nursing assistant? A. Assisting with postmortem care B. Facilitate meetings between the family and the organ donor specialist C. Escorting the family to a place of privacy D. Help the family to collect belongings

A. Assisting with postmortem care

In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? A. Brief neurologic assessment B. Client's allergy history C. Initiation of pulse oximetry D. Complete set of vital signs

A. Brief neurologic assessment

A 15-year-old male client arrives at the emergency department. He is conscious, coherent, and ambulatory, but his shirt and pants are covered with blood. He and his hysterical friends are yelling and trying to explain that they were goofing around and he got poked in the abdomen with a stick. Which of the following comments should be given first consideration? A. "The stick was really dirty and covered with mud." B. "He pulled the stick out, just now, because it was hurting him." C. "He's a diabetic, so he needs attention right away." D. "There was a lot of blood and we used three bandages."

B. "He pulled the stick out, just now, because it was hurting him."

Nurse Anna is an experienced travel nurse who was recently employed and is assigned to the emergency unit. In her first week of the job, which of the following area is the most appropriate assignment for her? A. Triage B. Ambulatory section C. Trauma team D. Psychiatric care

B. Ambulatory section

A client arrives at the emergency department who suffered multiple injuries from a head-on car collision. Which of the following assessment should take the highest priority to take? A. Unequal pupils B. Irregular pulse C. Ecchymosis in the flank area D. A deviated trachea

D. A deviated trachea

A client suffered an amputation of the first and second digits in a chainsaw accident. Which task should be delegated to an LPN/LVN? A. Cleansing the amputated digits and placing them directly into an ice slurry B. Wrapping the cleansed digits in saline-moistened gauze, sealing in a plastic container, and placing it in icy water C. Gently cleansing the amputated digits and the hand with povidone-iodine D. Cleansing the digits with sterile normal saline and placing it in a sterile cup with sterile normal saline

B. Wrapping the cleansed digits in saline-moistened gauze, sealing in a plastic container, and placing it in icy water

A 20-year-old male client was brought to the emergency department with a gunshot wound to the chest. In obtaining a history of the incident to determine possible injuries, the nurse should ask which of the following? A. "How long ago did the incident occur?" B. "What was the initial first aid done?" C. "Where did the incident happen?" D. "What direction did the bullet enter into the body?"

D. "What direction did the bullet enter into the body?"

You are preparing a child for IV conscious sedation before the repair of a facial laceration. What information should you report immediately to the physician? A. The child suddenly pulls out the IV B. The parent is not sure regarding the child's tetanus immunization status C. The parent wants information about the IV conscious sedation D. The parent's refusal of the administration of the IV sedation

D. The parent's refusal of the administration of the IV sedation

A group of people arrived at the emergency unit by a private car with complaints of periorbital swelling, cough, and tightness in the throat. There is a strong odor emanating from their clothes. They report exposure to a "gas bomb" that was set off in the house. What is the priority action? A. Instruct personnel to don personal protective equipment B. Direct the clients to the cold or clean zone for immediate treatment C. Immediately remove other clients and visitors from the area D. Measure vital signs and auscultate lung sounds E. Direct the clients to the decontamination area

E. Direct the clients to the decontamination area