Adult Nursing 5 Test 2
A 22-yr-old patient who experienced a 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
Auscultate breath sounds
When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87° F (30.6° C), which finding indicates that the nurse should discontinue active rewarming
The core temperature is 94° F (34.4° C).
During the secondary survey of a trauma patient in the ED, why is it important that the nurse obtain details of the incident
The mechanism of injury can predict specific injuries
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 should be first
"Do you feel safe at home?"
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
"I need to drink extra fluids when working outside in hot weather."
The following four patients arrive in the emergency department (ED) after a motor vehicle collision. In which order should the nurse assess them
-A 21-yr-old patient with multiple fractures of the face and jaw -A 74-yr-old patient with palpitations and chest pain -A 43-yr-old patient complaining of 7/10 abdominal pain -A 37-yr-old patient with a misaligned lower left leg with intact pulses
Which interventions will the nurse plan for a comatose patient who is to begin therapeutic hypothermia (select all that apply
-Assist with endotracheal intubation. -Insert an indwelling urinary catheter. -Begin continuous cardiac monitoring
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 patient with paradoxical chest movement
When planning the response to the potential use of smallpox as a biological weapon, the emergency department (ED) nurse manager will plan to obtain adequate quantities of
vaccine
For which ingested poisons may gastric lavage be considered (select all that apply
-Bleach -Aspirin -Iron supplements -Amitriptyline (Elavil)
The emergency department (ED) nurse is starting 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
-Give acetaminophen (Tylenol) 650 mg. -Place cooling blankets above and below patient. -Attach rectal temperature probe to cooling blanket control panel
Which biologic agents of terrorism can currently be protected against with a vaccine (select all that apply)?
-Smallpox -Hemorrhagic fever
What describes heat exhaustion (select all that apply
-Volume and electrolyte depletion -Rectal temperature of 99.6° F to 104° F (37.5° C to 40° C) -Causes mild confusion, diaphoresis, and dilation of pupils
In which patient situation would therapeutic hypothermia be instituted in the ED
62-yr-old man defibrillated by emergency medical technicians (EMTs); on ED arrival, he is not responsive, although his heart rhythm and blood pressure (BP) are stable
Following an earthquake, patients are triaged by emergency medical personnel and transported to the emergency department (ED). Which patient will the nurse need to assess first
A patient with a red tag
An unresponsive patient is admitted to the ED with nausea, vomiting, and diaphoresis. The patient's family brought an empty container of acetaminophen that was found near him. A large oral gastric tube is inserted. What does the nurse prepare to administer first
Activated charcoal
A 68-yr-old patient was bitten by the neighbor's dog 8 hours ago. What treatment should the nurse plan to provide for the patient
Administer IV antibiotics prophylactically
During the primary survey, the nurse identified asymmetric chest wall movement in the patient. What intervention should the nurse do first
Administer bag-mask ventilation with 100% oxygen.
Family members are in the patient's room when the patient has a cardiac arrest and the staff start resuscitation measures. Which action should the nurse take next
Ask the family members whether they would prefer to remain in the patient's room or wait outside the room.
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 prescribed action should the nurse plan to do first?
Assist with intubation of the patient
Which biologic agent of terrorism is a bacterial neurotoxin that causes paralysis and respiratory failure with death occurring without treatment
Botulism
A patient arrives in the emergency department (ED) after topical exposure to powdered lime at work. Which action should the nurse take first
Brush off any visible powder on the skin and clothing
What is the first priority in the management of the drowning patient
Correction of hypoxia
As a member of a volunteer disaster medical assistance team (DMAT), what would the nurse be expected to do
Deploy to local or other communities with disasters to provide medical assistance
What should the nurse do during rewarming of a patient's toes that have suffered deep frostbite?
Ensure that IV analgesics are administered
A homeless man is brought to the ED in severe hypothermia with a temperature of 85° F (29.4° C). What should the nurse expect to find on initial assessment
Fixed and dilated pupils
What condition occurs with saltwater drowning but not with freshwater drowning?
Fluid is drawn into the alveoli from the pulmonary capillaries
A 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?
Give N-acetylcysteine
When is the placement of a nasogastric tube contraindicated during emergency care
Head or facial trauma
What heat-related emergency would the healthy athlete with inadequate fluid intake be most likely to experience after exercise
Heat cramps
The patient is admitted with severe acidosis from trying to commit suicide by ingesting aspirin. What should be used to treat this patient
Hemodialysis
Which agent of terrorism does not have an established treatment for those exposed to it
Hemorrhagic fever
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
Initiate cooling per protocol
A 63-yr-old trauma patient has open wounds and the nurse questions the patient about her tetanus immunization status. In which situation should tetanus and diphtheria toxoids with acellular pertussis (Tdap) vaccine be administered to the patient
Is unsure of the history of tetanus toxoid vaccinations
A patient is brought to the ED following a skiing accident after which he was not found for several hours. He is rigid and has slowed respiratory and heart rates. What should the nurse do first during the primary assessment of the patient
Manage and maintain ABCs (airway, breathing, circulation
Following a death in the ED of a 36-yr-old man from a massive head injury, what would be appropriate for the nurse to do
Notify an organ procurement agency that a death has occurred that could result in organ donation.
During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient has an unobstructed airway. Which action should the nurse take next
Observe the patient's respiratory effort
An unresponsive patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first
Pulse
What nursing intervention is performed during the "E" step of the primary survey
Remove the patient's clothing and assess
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?
Remove the patient's rings
During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent and the entire leg is swollen. Which action will the nurse take next
Start normal saline fluid infusion with a large-bore IV line
When a patient is admitted with hemorrhagic fever, what nursing treatment should be provided?
Supportive treatment
In assessing the emergency patient's health history, what information is obtained with the use of the mnemonic SAMPLE
Symptoms, allergies, medications, past health history, last meal, and events/environment leading to the illness or injury
A 19-yr-old patient 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
TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap).
A 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
Teach the patient the reason for the use of prophylactic antibiotics
When a nurse is performing a primary survey in the ED, what is being assessed
The status of airway, breathing, circulation, disability, and exposure/environmental control
The ascending paralysis caused by the bite of a wood tick or dog tick may cause respiratory arrest unless what happens
The tick is removed
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
Use tweezers to remove any remaining ticks
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
abdominal ultrasonography
An unresponsive 79-yr-old patient is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 105.4° F (40.8° C), blood pressure (BP) is 88/50 mm Hg, and pulse is 112 beats/min. The nurse will plan to
apply wet sheets and a fan to the patient
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 nurse's first action should be to
assess the patient's current vital signs
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
obtain a Glasgow Coma Scale score
