Chapter 16: Care of Patients Experiencing Urgent Alterations in Health

34. When two nurses perform two-person CPR, there should be slow breaths for every compressions.

ANS: 2, 30 two, thirty Two slow breaths are given after every 30 compressions. PTS: 1 DIF: Cognitive Level: Application REF: Page 420 OBJ: 4 TOP: Two-person CPR KEY: Nursing Process Step: Implementation

36. A burn patient is brought into the emergency department with the following burns: half of the front torso, entire left arm, and front of left leg. The nurse should record that the patient has a % burn.

ANS: 27 twenty-seven Half of the front torso = 9, entire left arm = 9, front of the left leg = 9 PTS: 1 DIF: Cognitive Level: Analysis REF: Page 438, Figure 16-17 OBJ: 12 TOP: Rule of nines KEY: Nursing Process Step: Assessment

37. When performing CPR on an infant, the breastbone is depressed approximately to inch(es).

ANS: 0.5 to 1 one-half to one The breastbone is depressed 0.5 to 1 inch when doing CPR on an infant. PTS: 1 DIF: Cognitive Level: Application REF: Page 420 OBJ: 4 TOP: Cardiopulmonary resuscitation (CPR) KEY: Nursing Process Step: Implementation

32. When treating an infant choking on a foreign body, the nurse should use a combination of and chest thrusts.

ANS: back blows If the nurse is assisting a child who has aspirated a foreign body, the nurse may treat the child in a manner similar to the adult with performance of abdominal thrusts. However, there is a potential for injury if the nurse uses this maneuver in the infant. The nurse should use a combination of back blows and chest thrusts with an infant. PTS: 1 DIF: Cognitive Level: Application REF: Pages 422-423 OBJ: 6 TOP: Choking KEY: Nursing Process Step: Implementation

35. The acronym RICE directs the nurse in the care of a sprain. The "C" in the acronym stands for .

ANS: compression The acronym stands for Rest, Ice, Compression, and Elevation. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 437 OBJ: 13 TOP: Sprain KEY: Nursing Process Step: Application

33. If a spinal injury is suspected, before the rescuer starts CPR, the trachea should be opened with a maneuver.

ANS: jaw thrust The jaw thrust maneuver does not hyperextend the neck. PTS: 1 DIF: Cognitive Level: Application REF: Page 418 OBJ: 14 TOP: Cardiopulmonary resuscitation (CPR) KEY: Nursing Process Step: Implementation

15. When other methods have failed to stop the bleeding and the victim's life is in danger, the rescuer at the scene applies a tourniquet to a young woman's leg above the knee. What is another step that is essential for the rescuer to follow? a. Never release the tourniquet b. Wrap the tourniquet around the limb twice c. Mark the patient with a "T" d. Leave the limb elevated

ANS: A A tourniquet must never be released once it is in place. All other options are enhancements to the procedure of the tourniquet application, but not essential. PTS: 1 DIF: Cognitive Level: Application REF: Page 427, Skill 16-1 OBJ: 8 TOP: Tourniquet KEY: Nursing Process Step: Implementation

16. The nurse is teaching a patient with epistaxis about the best way to control bleeding. What information will the nurse relay to this patient? a. Place ice on the nose and pinch the nostrils b. Maintain a flat position c. Pack nostrils with cotton d. Lean backward

ANS: A Apply steady pressure to both nostrils while applying ice to the nose is the best way to attempt to control the bleeding of epistaxis. PTS: 1 DIF: Cognitive Level: Application REF: Page 426 OBJ: 8 TOP: Epistaxis KEY: Nursing Process Step: Implementation

9. CPR has been initiated on an adult patient. How will the nurse confirm the effectiveness of CPR? a. Assessing an EKG pattern with each compression b. Assessing a palpable carotid pulse during each compression c. Assuring a compression depth of to 2 inches d. Observing pupils that change from pinpoint to dilated

ANS: B During effective CPR, a carotid pulse is palpable during each compression. PTS: 1 DIF: Cognitive Level: Application REF: Pages 417-418 OBJ: 4 TOP: Cardiopulmonary resuscitation (CPR) KEY: Nursing Process Step: Implementation

31. While on break in the hospital cafeteria a nurse witnesses her pregnant co-worker start to choke. The co-worker is conscious, but unable to breathe. Where should the nurse administer thrusts? a. Below the navel b. The chest c. At the xiphoid process d. The upper back

ANS: B If the victim is pregnant or obese, chest thrusts are acceptable instead of abdominal thrusts. To provide chest thrusts, the nurse should place his or her hands in the same position that is used for chest compressions during CPR. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 422 OBJ: 5 TOP: Choking KEY: Nursing Process Step: Implementation

10. A patient with multiple serious injuries sustained in a motorcycle accident is lying beside his wrecked motorcycle unconscious and bleeding when the rescuer arrives at the scene. What will be the rescuer's priority action? a. Assessing blood loss b. Assessing respiratory status c. Obtaining vital signs d. Organizing laypeople at the scene

ANS: B Priority intervention is to assess respiratory status. PTS: 1 DIF: Cognitive Level: Application REF: Pages 415-416 OBJ: 4 TOP: First aid KEY: Nursing Process Step: Assessment

8. The patient arrived at the emergency department in pain and bleeding profusely with the following vital signs: BP 80/54, P 102, RR 22. What does the nurse recognize that these symptoms indicate? a. Inadequate perfusion b. Circulatory shock c. Massive vasodilation d. Heart failure

ANS: B Shock results from failure of the circulatory system to provide sufficient blood circulation. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 423 OBJ: 7 TOP: Shock KEY: Nursing Process Step: Assessment

2. The Good Samaritan law will protect all people who offer assistance. What is necessary for this protection? a. A license b. The person acts prudently c. Licensed supervision d. The patient improves

ANS: B The Good Samaritan law will protect any person who follows a prudent course of action. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 415 OBJ: 2 TOP: Good Samaritan law KEY: Nursing Process Step: N/A

14. The nurse is attempting to control bleeding in a patient with a profusely bleeding scalp wound. What is the most effective initial treatment of this bleeding? a. Elevate the head b. Apply direct pressure c. Apply an ice pack d. Apply indirect pressure

ANS: B The most effective general treatment of bleeding is to apply direct pressure. PTS: 1 DIF: Cognitive Level: Application REF: Page 425 OBJ: 10 TOP: Control of bleeding KEY: Nursing Process Step: Implementation

22. A patient who had taken a poisonous substance is brought to the emergency department. What is the first action the nurse should take? a. Give syrup of ipecac b. Contact the poison control center c. Give milk to coat the stomach d. Observe for symptoms

ANS: B The nurse should immediately call the poison control center. PTS: 1 DIF: Cognitive Level: Application REF: Page 431 OBJ: 11 TOP: Poison KEY: Nursing Process Step: Implementation

21. The nurse is assisting a victim of an accident who requires bandaging of the right lower extremity. What should the nurse do when applying the bandage? a. Use sterile material b. Leave the toes exposed c. Bandage the extremity tightly d. Bend the knee after bandaging

ANS: B The tips of the toes should remain exposed to assess circulation. PTS: 1 DIF: Cognitive Level: Application REF: Page 429 OBJ: 1 TOP: Bandaging KEY: Nursing Process Step: Implementation

17. A farm worker who has been kicked in the stomach by a mule passes a foul, black, tarry stool. What is this called? a. Loose stool b. Melena c. Hematuria d. Hemoptysis

ANS: B When internal bleeding occurs, the patient may demonstrate hemoptysis (bloody sputum), hematemesis (bloody vomit), melena (foul black tarry stool), or hematuria (bloody urine). PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 426 OBJ: 2 TOP: Melena KEY: Nursing Process Step: Assessment

7. When a patient suddenly experiences respiratory difficulty in the cafeteria, the nurse begins assessment for foreign body airway obstruction. What is the most appropriate question to ask the victim? a. "What did you swallow?" b. "Are you choking?" c. "Are you OK?" d. "Can I help you?"

ANS: B With complete airway obstruction, the victim cannot speak. Ask, "Are you choking?" With this question the nurse pinpoints the problem and can perform the Heimlich maneuver with no wasted time. PTS: 1 DIF: Cognitive Level: Application REF: Page 421 OBJ: 1 TOP: Heimlich maneuver KEY: Nursing Process Step: Implementation

11. The worried mother of an accident victim asks the nurse how much circulating blood an average adult male is supposed to have.What will the nurse reply? a. 8 pints b. 10 pints c. 12 pints d. 14 pints

ANS: C An average adult male has 12 pints of blood. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 425 OBJ: 8 TOP: Circulating blood volume KEY: Nursing Process Step: Implementation

5. The nurse determines clinical death and initiates CPR immediately. How long is resuscitation considered possible? a. If cardiopulmonary arrest has existed for no more 2 minutes b. If cardiopulmonary arrest has existed for no more 3 minutes c. If cardiopulmonary arrest has existed for no more 4 minutes d. If cardiopulmonary arrest has existed for no more 5 minutes

ANS: C CPR can reverse clinical death if initiated before 4 minutes. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 416 OBJ: 3 TOP: Cardiopulmonary resuscitation (CPR) KEY: Nursing Process Step: Implementation

30. A patient is admitted to the hospital after receiving a blow to the head. The patient begins to show signs of shock. How should the patient be positioned? a. With the head lower than the body b. Flat with the legs elevated c. Flat on the back d. In a side-lying position

ANS: C If head injuries are suspected, the victim must be kept flat. PTS: 1 DIF: Cognitive Level: Application REF: Page 424 OBJ: 1 TOP: Shock KEY: Nursing Process Step: Implementation

20. A patient arrives in the emergency department with a sucking wound to the left chest. What is the first action the nurse should take? a. Place several layers of gauze dressing over the wound b. Place the patient in a supine position c. Cover the wound with an airtight dressing taped on three sides d. Turn the patient to the left side

ANS: C Sucking chest wounds should be dressed with a flutter dressing so that air can escape the pleural space, but no more air can be sucked in. PTS: 1 DIF: Cognitive Level: Application REF: Page 429 OBJ: 9 TOP: Sucking chest wounds KEY: Nursing Process Step: Implementation

29. The nurse arrives on the scene of a fire. What is the first thing the nurse will do for a burn victim? a. Apply dressings b. Cover with a blanket c. Cool the burn immediately d. Apply topical ointment

ANS: C The burn should be cooled immediately to stop the burning process. PTS: 1 DIF: Cognitive Level: Application REF: Page 438 OBJ: 12 TOP: Burns KEY: Nursing Process Step: Implementation

24. The patient with heat stroke has been undressed and treated with cold packs and a fan. The patient's temperature is now down to 101.2° F. The patient starts to shiver. What action should the emergency department nurse take? a. Raise the head of the bed b. Offer warm liquids c. Remove cold packs and fan d. Continue with cooling interventions

ANS: C The cooling techniques have caused the patient to shiver, which will increase the patient's temperature. PTS: 1 DIF: Cognitive Level: Application REF: Page 435 OBJ: 12 TOP: Heat stroke KEY: Nursing Process Step: Implementation

26. A visitor in the hospital slips and falls. The patient's arm appears dislocated and the visitor is unable to move it. What is the first action the nurse should implement? a. Apply cold packs b. Check range of motion c. Splint the arm d. Apply an Ace bandage

ANS: C The nurse should splint the arm where it lies and not attempt to move or rearrange the limb. PTS: 1 DIF: Cognitive Level: Application REF: Pages 436-437 OBJ: 13 TOP: Fracture KEY: Nursing Process Step: Implementation

23. A patient has been stung by a bee and is brought to the emergency department. The nurse observes the sting site and identifies that the stinger is still in the skin. What action should the nurse take? a. Remove it with sterile tweezers b. Soak the area with a cold compress c. Scrape the stinger with the side of a knife d. Squeeze the surrounding tissue to expel the stinger

ANS: C The stinger should be removed with the side of a knife by scraping to avoid forcing more venom into the skin. PTS: 1 DIF: Cognitive Level: Application REF: Page 432 OBJ: 1 TOP: Wounds KEY: Nursing Process Step: Implementation

4. CPR has been initiated at an accident site. When can CPR be terminated? a. Victim is clinically dead b. Victim is brain dead c. Paramedics arrive d. Rescuer perceives CPR is futile

ANS: C There is a moral obligation to continue CPR once it has been initiated unless the rescuer is exhausted and cannot continue, trained medical personnel take over CPR, or a licensed physician pronounces the victim dead. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 416 OBJ: 4 TOP: Cardiopulmonary resuscitation (CPR) KEY: Nursing Process Step: Implementation

1. When administering first aid in emergency situations, the nurse must first survey victims for severity of injuries. What term correctly describes this process? a. The Good Samaritan law b. An emergency interview c. Triage d. Taking vital signs

ANS: C This process of patient classification is called triage. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 414 OBJ: 1 TOP: First aid KEY: Nursing Process Step: Assessment

6. When assessing the adult victim for pulselessness, the CPR rescuer should palpate the most reliable and accessible pulse. Which pulse will be palpated? a. Radial b. Brachial c. Carotid d. Femoral

ANS: C When assessing the adult victim for pulselessness, the most reliable and accessible pulse is the carotid. PTS: 1 DIF: Cognitive Level: Application REF: Page 417 OBJ: 4 TOP: Cardiopulmonary resuscitation (CPR) KEY: Nursing Process Step: Assessment

28. When assessing a patient who has suffered a burn injury, the nurse classifies the burn as a deep partial-thickness burn. What is this observation most likely based upon? a. Painful reddened skin b. Charred skin with milky-white areas c. Erythema and blisters d. Erythema, pain, and swelling

ANS: C With deep partial-thickness burns, blister formation may be seen with erythema. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 439 OBJ: 12 TOP: Burns KEY: Nursing Process Step: Assessment

3. A nurse is assessing victims in an emergency situation. What will the nurse assess for first? a. Hemorrhage b. Fractures c. Mobility d. Abnormal breathing

ANS: D A life-threatening situation of the highest priority is arrested or abnormal breathing. PTS: 1 DIF: Cognitive Level: Application REF: Page 415 OBJ: 1 TOP: ABC of assessment KEY: Nursing Process Step: Assessment

13. A nurse assesses an accident victim who has bright red blood spurting from a laceration on his right forearm. Where will the nurse apply pressure after applying direct pressure and elevating the limb? a. Right subclavian artery b. Right radial artery c. Right ulnar artery d. Right brachial artery

ANS: D Arterial bleeding is characterized by the spurting of bright red blood and can be controlled by direct pressure, elevation, and indirect pressure on the appropriate pressure point. The brachial artery is the closest pressure point to the injury. PTS: 1 DIF: Cognitive Level: Application REF: Page 425 OBJ: 10 TOP: Pressure points KEY: Nursing Process Step: Implementation

18. A machinist visits the industrial nurse's clinic with a deep laceration of the thigh. What should be the nurse's first action? a. Splint the thigh and apply tape to approximate the edges b. Apply ice and a pressure dressing to the thigh c. Give a tetanus booster injection d. Wash the laceration with an antiseptic

ANS: D Lacerations should be cleaned thoroughly and bandaged to approximate the edges. PTS: 1 DIF: Cognitive Level: Application REF: Page 429 OBJ: 9 TOP: Wounds KEY: Nursing Process Step: Implementation

27. The patient is brought to the emergency department after having fractured an arm 12 hours ago. The arm is very edematous from the fingers to the elbow, and the patient cannot move it. What should be the initial action of the nurse? a. Test range of motion b. Take the vital signs c. Place ice packs on the arm d. Check fingers for capillary refill

ANS: D Swelling from the fracture can impede circulation. PTS: 1 DIF: Cognitive Level: Application REF: Page 436 OBJ: 13 TOP: Injuries KEY: Nursing Process Step: Assessment

12. The nurse is assessing a patient who is severely bleeding and at risk for hypovolemic shock. What can the nurse anticipate? a. Slow, labored breathing b. Hot, flushed skin c. Edematous extremities d. Weak, thready pulse

ANS: D The pulse becomes weak and thready with hypovolemic shock. PTS: 1 DIF: Cognitive Level: Application REF: Page 424 OBJ: 7 TOP: Symptoms of shock KEY: Nursing Process Step: Assessment

25. The patient is admitted to the emergency department, having suffered frostbite to the hands, which are grayish-white in color. What action should the nurse implement when attempting to warm the hands? a. Have the patient rub the hands together briskly b. Wipe the hands vigorously with a warm towel c. Run tepid water over the hands to warm slowly d. Wrap the hands in hot, moist towels

ANS: D Warming the hands in moist towels will warm the hands slowly. Friction of frozen body parts should be avoided. PTS: 1 DIF: Cognitive Level: Application REF: Page 436 OBJ: 12 TOP: Frostbite KEY: Nursing Process Step: Implementation

19. The patient's lower chest has been punctured with a knife that is still in place. What should the nurse's first action be? a. Remove the knife b. Apply an airtight dressing over the wound c. Place the patient in a modified Trendelenburg position d. Immobilize the knife with dressings and tape

ANS: D When the patient's lower chest has been punctured with the weapon still in place, the nurse should immobilize the weapon with dressings and tape. PTS: 1 DIF: Cognitive Level: Application REF: Page 428 OBJ: 9 TOP: Wounds KEY: Nursing Process Step: Implementation