Block 3 Exam

. A nurse wants to become part of a Disaster Medical Assistance Team (DMAT) but is concerned about maintaining licensure in several different states. Which statement best addresses these concerns?

"Deployed DMAT providers are federal employees, so their licenses are good in all 50 states."

After a hospital's emergency department (ED) has efficiently triaged, treated, and transferred clients from a community disaster to appropriate units, the hospital incident command officer wants to "stand down" from the emergency plan. Which question should the nursing supervisor ask at this time?

"Do all areas of the hospital have the supplies and personnel they need?"

A nurse teaches a community health class about water safety. Which statement by a participant indicates that additional teaching is needed?

"I can go swimming all by myself because I am a certified lifeguard."

A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance?

"I will bathe and dress before breakfast."

A nurse teaches a client being treated for a full-thickness burn. Which statement should the nurse include in this client's discharge teaching?

"I will demonstrate how to change your wound dressing for you and your family."

A nurse cares for clients during a community-wide disaster drill. Once of the clients asks, "Why are the individuals with black tags not receiving any care?" How should the nurse respond?

"In a disaster, extensive resources are not used for one person at the expense of many others."

A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, "Why am I taking this medication?" How should the nurse respond?

"It helps prevent stomach ulcers, which are common after burns."

The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury?

"It is normal to feel some depression."

A provider prescribes diazepam (Valium) to a client who was bitten by a black widow spider. The client asks, "What is this medication for?" How should the nurse respond?

"It will relieve your muscle rigidity and spasms."

A nurse delegates hydrotherapy to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this activity?

"Keep the water temperature constant when showering the client."

After teaching a client how to prevent altitude-related illnesses, a nurse assesses the client's understanding. Which statement indicates the client needs additional teaching?

"My partner and I will plan to sleep at a higher elevation to acclimate more quickly."

The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern?

"Sometimes I wake up at night and smoke."

The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client?

"Wash your hands on entering the client's room."

A nurse cares for a client who has burn injuries. The client's wife asks, "When will his high risk for infection decrease?" How should the nurse respond?

"When all of his burn wounds have closed."

The hospital administration arranges for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation?

"You are free to express your feelings; whatever is said here stays here."

A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at a nurse when dinner is served late. How should the nurse respond?

"You seem upset. I have time to talk if you'd like."

A nurse is caring for a client whose wife died in a recent mass casualty accident. The client says, "I can't believe that my wife is gone and I am left to raise my children all by myself." How should the nurse respond?

"You sound anxious about being a single parent."

A nurse cares for a client who has facial burns. The client asks, "Will I ever look the same?" How should the nurse respond?

"You will not look exactly the same but cosmetic surgery will help."

A nurse teaches a client who has severe allergies to prevent bug bites. Which statements should the nurse include in this client's teaching? (Select all that apply.)

1. "Consult an exterminator to control bugs in and around your home." 2. "Do not swat at insects or wasps." 3. "Use screens in your windows and doors to prevent flying insects from entering."

A nurse is teaching a wilderness survival class. Which statements should the nurse include about the prevention of hypothermia and frostbite? (Select all that apply.)

1. "Wear synthetic clothing instead of cotton to keep your skin dry." 2. "Wear sunglasses to protect skin and eyes from harmful rays." 3. "Know your physical limits. Come in out of the cold when limits are reached."

A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? (Select all that apply.)

1. A 35-year-old female with severe chest pain: red tag 2. A 60-year-old male with an open fracture with distal pulses: yellow tag

A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.)

1. Administer analgesics. 2. Prevent wound infections. 3. Provide fluid replacement.

An emergency department nurse plans care for a client who is admitted with heat stroke. Which interventions should the nurse include in this client's plan of care? (Select all that apply.)

1. Administer oxygen via mask or nasal cannula 2. Infuse 0.9% sodium chloride via a large-bore intravenous cannula 3. Obtain baseline serum electrolytes and cardiac enzymes

A nurse plans care for a client with burn injuries. Which interventions should the nurse implement to prevent infection in the client? (Select all that apply.)

1. Ask all family members and visitors to perform hand hygiene before touching the client. 2. Carefully monitor burn wounds when providing each dressing change. 3. Use aseptic technique and wear gloves when performing wound care.

A hospital prepares to receive large numbers of casualties from a community disaster. Which clients should the nurse identify as appropriate for discharge or transfer to another facility? (Select all that apply.)

1. Client who had open reduction and internal fixation of a femur fracture 3 days ago 2. Client on the medical unit for wound care

An emergency department nurse moves to a new city where heat-related illnesses are common. Which clients does the nurse anticipate being at higher risk for heat-related illnesses? (Select all that apply.)

1. Homeless individuals 2. Illicit drug users 3. Older adults

A hospital prepares for a mass casualty event. Which functions are correctly paired with the personnel role? (Select all that apply.)

1. Hospital incident commander - Assumes overall leadership for implementing the emergency plan 2. Triage officer - Rapidly evaluates each client to determine priorities for treatment

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.)

1. Mechanism of injury 2. Diagnostic test results 3. Isolation precaution

A nurse cares for a client with burn injuries who is experiencing anxiety and pain. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.)

1. Music as a distraction 2. Tactile stimulation 3. Increasing client control

An emergency room nurse is caring for a trauma client. Which interventions should the nurse perform during the primary survey? (Select all that apply.)

1. Needle decompression 2. Initiating IV fluids 3. Endotracheal intubation 4. Removing wet clothing

Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies the clients with which injuries with yellow tags? (Select all that apply.)

1. Partial-thickness burns covering both legs 2. Neck injury and numbness of both legs 3. Small pieces of shrapnel embedded in both eyes 4. Bruising and pain in the right lower abdomen

A nurse plans care for a client with burn injuries. Which interventions should the nurse include in this client's plan of care to ensure adequate nutrition? (Select all that apply.)

1. Provide at least 5000 kcal/day 2. Administer a diet high in protein 3. Collaborate with a registered dietitian 4. Offer frequent high-calorie snacks.

The complex care provided during an emergency requires interdisciplinary collaboration. Which interdisciplinary team members are paired with the correct responsibilities? (Select all that apply.)

1. Psychiatric crisis nurse - Interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis 2. Paramedic - Provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration

A nurse is providing health education at a community center. Which instructions should the nurse include in teaching about prevention of lightning injuries during a storm? (Select all that apply.)

1. Seek shelter inside a building or vehicle. 2. Do not take a bath or shower. 3. Turn off the television. 4. Put down golf clubs or gardening tools.

A nurse cares for an older client with burn injuries. Which age-related changes are paired appropriately with their complications from the burn injuries? (Select all that apply.)

1. Slower healing time - Increased risk for loss of function from contracture formation 2. Reduced thoracic compliance - Increased risk for atelectasis 3. High incidence of cardiac impairments - Increased risk for acute kidney injury

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.)

1. Use two identifiers before each intervention and before mediation administration. 2.Attempt de-escalation strategies for clients who demonstrate aggressive behaviors. 3.Search the belongings of clients with altered mental status to gain essential medical information.

An emergency room nurse cares for a client admitted with a 50% burn injury at 10:00 this morning. The client weighs 90 kg. Using the Parkland formula, calculate the rate at which the nurse should infuse intravenous fluid resuscitation when started at noon. (Record your answer using a whole number.) _____ mL/hr

1500 mL/hr

A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the client's body that sustained burns?

27%

An emergency room nurse implements fluid replacement for a client with severe burn injuries. The provider prescribes a liter of 0.9% normal saline to infuse over 1 hour and 30 minutes via gravity tubing with a drip factor of 30 drops/mL. At what rate should the nurse administer the infusion? (Record your answer using a whole number and rounding to the nearest drop.) ____ drops/min

333 drops/min

An emergency room nurse is triaging victims of a multi-casualty event. Which client should receive care first?

A 26-year-old male who has pale, cool, clammy skin

A nurse is triaging clients in the emergency department (ED). Which client should the nurse prioritize to receive care first?

A 45-year-old reporting chest pain and diaphoresis

A nurse is triaging clients in the emergency department. Which client should the nurse classify as "nonurgent?"

A 62-year-old with a simple fracture of the left arm

A nurse is triaging clients in the emergency department. Which client should be considered "urgent"?

A 75-year-old female with a cough and a temperature of 102° F

While at a public park, a nurse encounters a person immediately after a bee sting. The person's lips are swollen, and wheezes are audible. Which action should the nurse take first?

Administer an EpiPen from the first aid kit and call 911

An emergency department nurse cares for a middle-aged mountain climber who is confused and exhibits bizarre behaviors. After administering oxygen, which priority intervention should the nurse implement?

Administer dexamethasone (Decadron)

A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The client's urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question?

Administer furosemide (Lasix) 40 mg IV push.

A provider prescribes a rewarming bath for a client who presents with partial-thickness frostbite. Which action should the nurse take prior to starting this treatment?

Administer intravenous morphine

A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the client's pain?

Administer the prescribed intravenous morphine sulfate.

A client presents to the emergency department after prolonged exposure to the cold. The client is difficult to arouse and speech is incoherent. Which action should the nurse take first?

Administer warmed intravenous fluids to the client

An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first?

Apply oxygen and continuous pulse oximetry

An emergency department charge nurse notes an increase in sick calls and bickering among the staff after a week with multiple trauma incidents. Which action should the nurse take?

Arrange for critical incident stress debriefing

A provider prescribes Crotalidae Polyvalent Immune Fab (CroFab) for a client who is admitted after being bitten by a pit viper snake. Which assessment should the nurse complete prior to administering this medication?

Ask about allergies to pineapple or papaya

The emergency department team is performing cardiopulmonary resuscitation on a client when the client's spouse arrives at the emergency department. Which action should the nurse take first?

Ask the spouse if he wishes to be present during the resuscitation

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?

Assess that the client is breathing adequately

A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first?

Auscultate breath sounds over the trachea and bronchi.

A nurse assesses a client recently bitten by a coral snake. Which assessment should the nurse complete first?

Cardiopulmonary status

The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination?

Change gloves between wound care on different parts of the client's body

An emergency department nurse is caring for a client who has died from a suspected homicide. Which action should the nurse take?

Communicate the client's death to the family in a simple and concrete manner

A nurse administers topical gentamicin sulfate (Garamycin) to a client's burn injury. Which laboratory value should the nurse monitor while the client is prescribed this therapy?

Creatinine

While on a camping trip, a nurse cares for an adult client who had a drowning incident in a lake and is experiencing agonal breathing with a palpable pulse. Which action should the nurse take first?

Deliver rescue breaths

An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event?

Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims

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?

Don personal protective equipment

A nurse cares for a client with burn injuries from a house fire. The client is not consistently oriented and reports a headache. Which action should the nurse take?

Draw blood for a carboxyhemoglobin level

An emergency department nurse assesses a client admitted after a lightning strike. Which assessment should the nurse complete first?

Electrocardiogram (ECG)

An emergency room nurse assesses a client who has been raped. With which health care team member should the nurse collaborate when planning this client's care?

Forensic nurse examiner

Based on the data provided, how should the nurse categorize this client's injuries?

Full thickness

A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take?

Gather appropriate equipment and prepare for an emergency airway

A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center?

Level II - Located within community hospitals and provides care to most injured clients

An emergency department nurse is caring for a client who is homeless. Which action should the nurse take to gain the client's trust?

Listen to the client's concerns and needs

A nurse assesses a client admitted with a brown recluse spider bite. Which priority assessment should the nurse perform to identify complications of this bite?

Monitor the client's temperature every 4 hours

A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag?

Multiple fractured ribs and shortness of breath

A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next?

Place the client in an upright position.

Based on the documented data, which action should the nurse take next?

Prepare to obtain blood and wound cultures.

A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention should the nurse complete first?

Provide a calm location for the family to cope and discuss needs

An emergency department (ED) case manager is consulted for a client who is homeless. Which intervention should the case manager provide?

Provide referrals to subsidized community-based health clinics

A hospital responds to a local mass casualty event. Which action should the nurse supervisor take to prevent staff post-traumatic stress disorder during a mass casualty event?

Provide water and healthy snacks for energy throughout the event.

A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately?

Serum potassium: 6.5 mEq/L

On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, blood pressure 106/66 mm Hg. Which action should the nurse take?

Start an intravenous line and infuse 0.9% saline solution

A nurse wants to become involved in community disaster preparedness and is interested in helping set up and staff first aid stations or community acute care centers in the event of a disaster. Which organization is the best fit for this nurse's interests?

The Medical Reserve Corps

A nurse plans care for a client admitted with a snakebite to the right leg. With whom should the nurse collaborate?

The poison control center

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?

Transfer the client to a negative-pressure room

A nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication?

Urine output of 20 mL/hr