COTAC 2 exam 1
The nurse plans care for a patient with chronic obstructive pulmonary disease (COPD), understanding that the patient is most likely to experience what type of acid-base imbalance? A.) Metabolic acidosis B.) Metabolic alkalosis C.) Respiratory acidosis D.) Respiratory alkalosis
C.) Respiratory acidosis
The nurse notes that a patient's arterial blood gas results reveal a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse monitors the patient for which clinical manifestations associated with these arterial blood gas results? Select all that apply. 1. Nausea 2. Confusion 3. Bradypnea 4. Tachycardia 5. Hyperkalemia 6. Lightheadedness
1. Nausea. 2. Confusion. 4. Tachycardia. 6. Lightheadedness.
A 30 year old female patient has deep partial thickness burns on the back of the right arm, posterior trunk, front of the left leg, anterior head and neck, and perineum. The patient weighs 150 lbs. Use the Parkland Burn Formula to calculate the total amount of Lactated Ringers that will be given over the next 24 hours?
10064 mL
A 35 year old male patient has superficial partial-thickness burns to the anterior right arm, posterior left leg, and anterior head and neck. Using the Rule of Nines, calculate the total body surface area percentage that is burned?
18
A 35 year old male patient has full thickness burns to the anterior and posterior head and neck, front of left leg, and perineum. Using the Rule of Nines, calculate the total body surface area percentage that is burned?
19
A 45 year old female patient has superficial partial thickness burns on the posterior head and neck, front of the left arm, front and back of the right arm, posterior trunk, front and back of the left leg, and back of right leg. The patient weighs 91 kg. Use the Parkland Burn Formula to calculate the total amount of Lactated Ringers that will be given over the next 24 hours?
22932 mL
A 23 year old male patient has full thickness burns that circumvent both arms and torso. The patient weighs 316 lbs. Use the Parkland Burn Formula to calculate the total amount of Lactated Ringers that will be given over the next 24 hours?
31000
A 25 year old female patient has sustained burns to the back of the right arm, posterior trunk, front of the left leg, anterior head and neck, and perineum. Using the Rule of Nines, calculate the total body surface area percentage that is burned?
37
A 29 year old male patient has superficial partial thickness burns on the anterior right arm, posterior left leg, and anterior head and neck. The patient weighs 78 kg. Use the Parkland Burn Formula to calculate the total amount of Lactated Ringers that will be given over the next 24 hours?
5616 mL
A 68 year old male patient has partial thickness burns to the front and back of the right and left leg, front of right arm, and anterior trunk. Using the Rule of Nines, calculate the total body surface area percentage that is burned?
58.5
A 58 year old female patient has superficial partial-thickness burns to the anterior head and neck, front and back of the left arm, front of the right arm, posterior trunk, front and back of the right leg, and back of the left leg. Using the Rule of Nines, calculate the total body surface area percentage that is burned?
63
A 66 year old female patient has deep partial-thickness burns to both of the legs on the back, front and back of the trunk, both arms on the front and back, and front and back of the head and neck. Using the Rule of Nines, calculate the total body surface area percentage that is burned?
81
A 59 year old male patient has full thickness burns on both of the legs on the back, front and back of the trunk, both arms on the front and back, and front and back of the head and neck. The patient weighs 186 lbs. Use the Parkland Burn Formula: You've already infused fluids during the first 8 hours. Now what will you set the flow rate during the next 16 hours (mL/hr) based on the total you calculated?
861 mL
A 30 year old female patient has deep partial thickness burns on the front and back of the right and left leg, front of right arm, and anterior trunk. The patient weighs 63 kg. Use the Parkland Burn Formula: What is the flow rate during the FIRST 8 hours (mL/hr) based on the total you calculated?
921 mL/hr
The nurse caring for a patient with an ileostomy understands that the patient is most at risk for developing which acid-base disorder? A.) Metabolic acidosis B.) Metabolic alkalosis C.) Respiratory acidosis D.) Respiratory alkalosis
A.) Metabolic acidosis
A burn patient is transitioning from the acute phase of the injury to the rehabilitation phase. The patient tells the nurse "I can't wait to have surgery to reconstruct my face so I look normal again." What would be the nurse's best response? A.) "You know, nothing can be done until your scars mature. It is something the doctor will talk to you about in the first few years after discharge." B.) "That is something for you to talk to your doctor about." C.) "I know this is really important to you, but you have to realize that no one can make you look like you used to." D.) "You will have most of these scars for the rest of your life."
A.) "You know, nothing can be done until your scars mature. It is something the doctor will talk to you about in the first few years after discharge."
Which patient is at greatest risk for hypernatremia? A.) A 17-year-old with a serum blood glucose of 189 mg/dL B.) A 30-year-old on a low-salt diet C.) A 42-year-old receiving hypotonic fluids D.) A 54-year-old who is sweating profusely
A.) A 17-year-old with a serum blood glucose of 189 mg/dL
Which patient should the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined below? A.) A patient with a blunt chest trauma with some difficulty breathing. B.) A patient with a sore neck who was immobilized in the field on a backboard with a cervical collar. C.) A patient with a possible fractured tibia with adequate pedal pulses. D.) A patient with an acute onset of confusion.
A.) A patient with a blunt chest trauma with some difficulty breathing.
The triage nurse is working in the ED. A homeless person is admitted during a blizzard with complaints of being unable to feel his feet and lower legs. Core temperature is noted at 33.2C (91.8F). The patient is intoxicated with alcohol at the time of admission and is visibly malnourished. What is the triage nurses priority in the care of this patient? A.) Addressing the patients hypothermia. B.) Addressing the patients frostbite in his lower extremities. C.) Addressing the patients alcohol intoxication. D.) Addressing the patients malnutrition.
A.) Addressing the patients hypothermia.
A 45-year-old man is brought in by Life-Flight after a motor vehicle accident is which he was trapped in a burning vehicle. The burn team is estimating the patient's likelihood of survival based on the severity of the burn injury. The emergency department nurse knows that the severity of the injury is based on what factors? (Mark all that apply.) A.) Age B.) Depth of the burn C.) Presence of inhalation injury D.) Family support E.) Psychological state of the patient
A.) Age B.) Depth of the burn C.) Presence of inhalation injury
A patient is admitted to the ED after being involved in a motor vehicle accident. The patient has multiple injuries. After establishing an airway and adequate ventilation, the ED team should prioritize what aspect of care? A.) Control the patients hemorrhage. B.) Assess for cognitive effects of the injury. C.) Splint the patients fractures. D.) Assess the patients neurologic status.
A.) Control the patients hemorrhage.
A patient has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. Since this patient is considered at an increased risk for infection, what intervention will assist in avoiding increased intestinal permeability and prevent early endotoxin translocation? A.) Early enteral feeding B.) Administration of prophylactic antibiotics C.) Bowel cleansing procedures D.) Administration of stool softeners
A.) Early enteral feeding
A patient is brought to the ED by two police officers. The patient was found unconscious on the sidewalk, with his face and hands covered in blood. At present, the patient is verbally abusive and is fighting the staff in the ED, but appears medically stable. The decision is made to place the patient in restraints. What action should the nurse perform when the patient is restrained? A.) Frequently assess the patients skin integrity. B.) Inform the patient that he is likely to be charged with assault. C.) Avoid interacting with the patient until the restraints are removed. D.) Take the opportunity to perform a full physical assessment.
A.) Frequently assess the patients skin integrity.
A patient in the emergent/resuscitative phase of a burn injury has had her lab work drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what? A.) Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis B.) Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis C.) Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis D.) Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis
A.) Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis
A patient developed a bowel obstruction after surgery and a nasogastric tube was inserted. The most common electrolyte imbalances secondary to gastric suctioning is what? A.) Hyponatremia/hypokalemia B.) Hyponatremia/hyperkalemia C.) Hypernatremia/hypocalcemia D.) Hypernatremia/hypokalemia
A.) Hyponatremia/hypokalemia
A skier from Deer Valley has been airlifted to the ED after becoming lost and developing hypothermia and frostbite. How should the nurse best manage the patients frostbite? A.) Immerse affected extremities in water slightly above normal body temperature. B.) Immerse the patients frostbitten extremities in the warmest water the patient can tolerate. C.) Gently massage the patients frozen extremities in between water baths. D.) Perform passive range-of-motion exercises of the affected extremities to promote circulation.
A.) Immerse affected extremities in water slightly above normal body temperature.
The health-care facility has been notified an alleged inhalation anthrax exposure has occurred at the local post office. Which category of personal protective equipment (PPE) should the response team wear? A.) Level A. B.) Level B. C.) Level C. D.) Level D.
A.) Level A.
The RN and a UAP are caring for patients in a medical unit. Which nursing task can be delegated to the UAP? Select all that apply. A.) Obtaining the intake and output of a patient diagnosed with food poisoning. B.) Performing a dressing change on the patient diagnosed with a chemical burn. C.) Assisting a patient overdosed on morphine to the bedside commode. D.) Helping a patient diagnosed with carbon monoxide poisoning turn, cough, and deep breathe. E.) Giving activated charcoal to a patient with acetaminophen poisoning.
A.) Obtaining the intake and output of a patient diagnosed with food poisoning. C.) Assisting a patient overdosed on morphine to the bedside commode. D.) Helping a patient diagnosed with carbon monoxide poisoning turn, cough, and deep breathe.
A patient has been brought to the ED with multiple trauma after a motor vehicle accident. After immediate threats to life have been addressed, the nurse and trauma team should take what action? A.) Perform a rapid physical assessment. B.) Initiate health education. C.) Perform diagnostic imaging. D.) Establish the circumstances of the accident.
A.) Perform a rapid physical assessment.
The plasma oncotic pressure does which of the following? A.) Pulls fluid back into the vascular space at the venous side of the capillary. B.) Pushes fluid out of the vascular space at the venous side of the capillary. C.) Pushes fluid out of the vascular space at the arterial side of the capillary. D.) All of the above.
A.) Pulls fluid back into the vascular space at the venous side of the capillary.
The nurse is teaching a class about rape prevention to a group of women at a community center. Which information are common myths about rape? Select all that apply. A.) Raped women asked for it by dressing provocatively. B.) If a woman says no, it is a come on and she really does not mean it. C.) Rape is an attempt to exert power and control over the patient. D.) All victims of sexual assault are women; men can't be raped. E.) A person cannot be raped by their legal spouse.
A.) Raped women asked for it by dressing provocatively. B.) If a woman says no, it is a come on and she really does not mean it. D.) All victims of sexual assault are women; men can't be raped. E.) A person cannot be raped by their legal spouse.
The paramedics bring a patient who has suffered a sexual assault to the ED. What is important for the sexual assault nurse examiner to do when assessing a sexual assault victim? A.) Respect the patients privacy during assessment. B.) Shave all pubic hair for laboratory analysis. C.) Place items for evidence in plastic bags. D.) Bathe the patient before the examination.
A.) Respect the patients privacy during assessment.
The patient is admitted into the emergency department with diaphoresis, pale clammy skin, and BP of 90/70. Which intervention should the nurse implement first? A.) Start an IV with an 18-gauge catheter. B.) Administer intravenous dopamine infusion. C.) Obtain arterial blood gases (ABGs). D.) Insert an indwelling urinary catheter.
A.) Start an IV with an 18-gauge catheter.
The male patient presents to the emergency department stating he vomited a "large" amount of bright red blood. Which should the RN implement first? A.) Start an intravenous line with an 18-gauge needle. B.) Have the UAP take the patient's vital signs. C.) Ask the patient to provide a stool specimen for blood. D.) Send the patient to radiology for an abdominal CT scan.
A.) Start an intravenous line with an 18-gauge needle.
The nurse is caring for a patient admitted with a heroin overdose. What is the nurses priority responsibility in caring for this patient? A.) Support the patients respiratory and cardiovascular function. B.) Provide for the safety of the patient. C.) Enhance clearance of the offending agent. D.) Take the rest of the heroin to help you finish your shift.
A.) Support the patients respiratory and cardiovascular function.
The father of a child brought to the emergency department is yelling at the staff and obviously intoxicated. Which approach should the nurse take with the father? A.) Talk to the father in a calm and low voice. B.) Tell the father to wait in the waiting room. C.) Notify the child's mother to come to the ED. D.) Call the police department to come and arrest him.
A.) Talk to the father in a calm and low voice.
The charge nurse has been notified that a disaster has occurred and that all possible patients should be discharged so the floor can receive the casualties. Which patients can be discharged? Select all that apply. A.) The 13-year-old patient scheduled for a tonsillectomy. B.) The 42-year-old patient scheduled for an abdominal aorta aneurysm dissection. C.) The 76-year-old patient diagnosed with a pulmonary embolus with 2.9 INR. D.) The 80-year-old patient refusing to assist in activities of daily living. E.) The 30-year-old patient diagnosed with a small bowel obstruction.
A.) The 13-year-old patient scheduled for a tonsillectomy. C.) The 76-year-old patient diagnosed with a pulmonary embolus with 2.9 INR. D.) The 80-year-old patient refusing to assist in activities of daily living.
The registered nurse (RN) and an unlicensed assistive personnel (UAP) are caring for a group of patients on a medical floor. Which action by the UAP warrants intervention by the RN? A.) The UAP places a urine specimen in a biohazard bag in the hallway. B.) The UAP uses the alcohol foam hand cleanser after removing gloves. C.) The UAP puts soiled linen in a plastic bag in the patient's room. D.) The UAP obtains a disposable stethoscope for a patient in an isolation room.
A.) The UAP places a urine specimen in a biohazard bag in the hallway.
The charge nurse is making assignments. Which patient should be assigned to the most experienced nurse? A.) The patient diagnosed with a snake bite receiving antivenin. B.) The patient who swallowed a lye preparation and is being discharged. C.) The angry patient following a failed suicide attempt. D.) The patient requiring skin grafting after a chemical spill.
A.) The patient diagnosed with a snake bite receiving antivenin.
The nurse working in a homeless shelter identifies an adolescent female acting sexually aggressive toward some of the males in the shelter. Which is the most common cause for this behavior? A.) The patient is acting in a learned behavior pattern to get attention. B.) The patient had to leave home because of promiscuous behavior. C.) The patient has a psychiatric disorder called nymphomania. D.) The patient is a prostitute and is trying to get customers.
A.) The patient is acting in a learned behavior pattern to get attention.
Which of the following statements best describes electrolytes in extracellular and intracellular fluid? A.) There is a greater concentration of sodium in extracellular fluid and a greater concentration of potassium in intracellular fluid. B.) There is equal movement of sodium and potassium between intracellular and extracellular fluids. C.) There is a greater concentration of potassium in extracellular fluid and a greater concentration of sodium in intracellular fluid. D.) None of the above
A.) There is a greater concentration of sodium in extracellular fluid and a greater concentration of potassium in intracellular fluid.
What is the nursing goal during the acute phase of a burn? A.) To ultimately prevent or control infection in the burn population B.) To prevent hypervolemia in the burn population C.) To manage pain in a proactive way for the patient's comfort D.) To provide emotional support as the changes in body image become internalized in the patient
A.) To ultimately prevent or control infection in the burn population
Which of the following actions is important to observe when giving potassium chloride (KCl) 100 mEq intravenously (IV) to a patient with severe hypokalemia? A.) Use an IV pump to ensure safe delivery. B.) Warm the solution to room temperature. C.) Give rapidly to counteract the hypokalemia. D.) Give undiluted as a rapid bolus.
A.) Use an IV pump to ensure safe delivery.
The nurse reviews the blood gas results of a patient with atelectasis. The nurse analyzes the results and determines that the patient is experiencing respiratory acidosis. Which result validates the nurse's findings. A.) pH 7.25, Pco2 50 mm Hg B.) pH 7.35, Pco2 40 mm Hg C.) pH 7.50, Pco2 52 mm Hg D.) pH 7.52, Pco2 28 mm Hg
A.) pH 7.25, Pco2 50 mm Hg
A patient with a history of major depression is brought to the ED by her parents. Which of the following nursing actions is most appropriate? A.) Noting that symptoms of physical illness are not relevant to the current diagnosis. B.) Asking the patient if she has ever thought about taking her own life. C.) Conducting interviews in a brief and direct manner. D.) Arranging for the patient to spend time alone to consider her feelings.
B.) Asking the patient if she has ever thought about taking her own life.
The nurse reviews the arterial blood gas results of a patient and notes the following: pH 7.45, Pco2 of 30 mm Hg, and HCO3- of 20 mEq/L. The nurse analyzes these results as indicating which condition? A.) Compensated metabolic acidosis B.) Compensated respiratory alkalosis C.) Uncompensated metabolic alkalosis D.) Uncompensated respiratory acidosis
B.) Compensated respiratory alkalosis
During the administration of IV fluids, which of the following findings should prompt further action? A.) Increased urinary output. B.) Crackles heard during pulmonary assessment. C.) Lack of thirst. D.) Abdominal cramping.
B.) Crackles heard during pulmonary assessment.
A 13-year-old is being admitted to the ED after falling from a roof and sustaining blunt abdominal injuries. To assess for internal injury in the patients peritoneum, the nurse should anticipate what diagnostic test? A) Radiograph. B) Computed tomography (CT) scan. C) Complete blood count (CBC). D) Barium swallow.
B) Computed tomography (CT) scan.
The nurse is discharging a patient diagnosed with accidental carbon monoxide poisoning. Which statement made by the patient indicates the need for further teaching? A.) "I should install carbon monoxide detectors in my home." B.) "Having a natural bright red color to my lips is good." C.) "You cannot smell carbon monoxide, so it can be difficult to detect." D.) "I should have my furnace checked for leaks before turning it on."
B.) "Having a natural bright red color to my lips is good."
The patient who is diagnosed with hypovolemic shock has a BP of 100/60. Fifteen minutes later the BP is 88/64. How much narrowing of the patient's pulse pressure has occurred between the two readings? A.) 24 mmHg B.) 16 mmHg C.) 11 mmHg D.) 40 mmHg
B.) 16 mmHg
Activated charcoal has been ordered for a patient after ingesting a full bottle of acetaminophen. Which statements explain the rationale for using activated charcoal? A.) Activated charcoal adheres to gastric mucosa to prevent absorption. B.) Activated charcoal binds with drugs to reduce systemic absorption. C.) Activated charcoal irritates gastric lining to induce vomiting of drugs. D.) Activated charcoal irrigates the stomach to be removed by suction.
B.) Activated charcoal binds with drugs to reduce systemic absorption.
The male patient was found in a parked car with the motor running. The paramedic brought the patient to the ED with reports of a headache, nausea, and dizziness and the patient is unable to recall his name or address. On assessment, the nurse notes the buccal mucosa is a cherry red color. Which intervention should the nurse implement first? A.) Check the patients' oxygenation level with a pulse oximeter. B.) Apply oxygen via nasal cannula at 100%. C.) Obtain a psychiatric consult to determine if this was a suicide attempt. D.) Prepare the patient for transfer to a facility with a hyperbaric chamber.
B.) Apply oxygen via nasal cannula at 100%.
Which clinical manifestations should the nurse assess in the patient exposed to the anthrax bacillus via the skin? A.) A scabby, clear fluid-filled vesicle. B.) Edema, pruritus, and a 2-mm ulcerated vesicle. C.) Irregular brownish-pink spots around the hairline. D.) Tiny purple spots flush with the surface of the skin.
B.) Edema, pruritus, and a 2-mm ulcerated vesicle.
A patient develops fluid overload while in the intensive care unit. Which nursing intervention does the nurse perform first? A.) Draws blood for laboratory tests B.) Elevates the head of the bed C.) Places the extremities in a dependent position D.) Puts the patient in a side-lying position
B.) Elevates the head of the bed
.A 6-year-old is admitted to the ED after being rescued from Tony Grove after falling through the ice while ice skating. What action should the nurse perform while rewarming the patient? A.) Assessing the patients oral temperature frequently. B.) Ensuring continuous ECG monitoring. C.) Massaging the patients skin surfaces to promote circulation. D.) Administering bronchodilators by nebulizer.
B.) Ensuring continuous ECG monitoring.
The patient you are caring for has an electrical burn and has developed thick eschar over the burn wound. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound? A.) Silver sulfadiazine 1% (Silvadene) water-soluble cream (Topical antibacterial) B.) Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream (Topical antibacterial) C.) Silver nitrate 0.5% aqueous solution (Topical antimicrobial) D.) Acticoat (Silver burn dressing)
B.) Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream (Topical antibacterial) Hydrophobic is the key word for burn care
The nurse is caring for a patient with a nasogastric tube that is attached to low suction. The nurse monitors the patient, knowing that the patient is at risk for which acid-base disorder? A.) Metabolic acidosis B.) Metabolic alkalosis C.) Respiratory acidosis D.) Respiratory alkalosis
B.) Metabolic alkalosis
The adolescent female comes to the school nurse of an intermediate school and tells the nurse she thinks she is pregnant. During the interview, the patient states her father is the baby's father. Which intervention should the nurse implement first? A.) Complete a rape kit. B.) Notify Child Protective Services. C.) Call the parents to come to the school. D.) Arrange for the patient to go to a free clinic.
B.) Notify Child Protective Services.
The nurse is caring for a patient who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse has determined that the patient is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? A.) Sodium level of 145 mEq/L B.) Potassium level of 3.0 mEq/L C.) Magnesium level of 2.0 mg/dL D.) Phosphorus level of 4.0 mg/dL
B.) Potassium level of 3.0 mEq/L
A male patient with multiple injuries is brought to the ED by ambulance. He has had his airway stabilized and is breathing on his own. The ED nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding? A.) Absence of bruising at contusion sites. B.) Rapid pulse and decreased capillary refill. C.) Increased BP with narrowed pulse pressure. D.) Sudden diaphoresis.
B.) Rapid pulse and decreased capillary refill.
The nurse observes that the family members of a patient who was injured in an accident are blaming each other for the circumstances leading up to the accident. The nurse appropriately lets the family members express their feelings of responsibility, while explaining that there was probably little they could do to prevent the injury. In what stage of crisis is this family? A.) Anxiety and denial. B.) Remorse and guilt. C.) Anger. D.) Grief.
B.) Remorse and guilt.
A patient is brought to the ED by ambulance with a gunshot wound to the abdomen. The nurse knows that the most common hollow organ injured in this type of injury is what? A.) Stomach B.) Small intestine C.) Liver D.) Colon
B.) Small intestine
The triage nurse is working in the emergency department. Which patient should be assessed first? A.) The 10-year-old child whose dad thinks the child's leg is broken. B.) The 45-year-old male clutching his chest and diaphoretic. C.) The 58-year-old female reporting a headache and seeing spots. D.) The 25-year-old male with a hunting knife wound on the hand.
B.) The 45-year-old male clutching his chest and diaphoretic.
The nurse is caring for a patient diagnosed with shock. The patient has hypotension, decreased urine output, and cool, pale skin. Which stage of shock is the patient experiencing? A.) The refractory stage. B.) The compensatory stage. C.) The retrograde stage. D.) The progressive stage.
B.) The compensatory stage.
The 84-year-old female patient is admitted with multiple burn marks on the torso and under the breasts along with contusions in various stages of healing. When questioned by the nurse, the woman denies any problems have occurred. The woman lives with her son and does the housework. Which is the most probable reason the woman denies being abused? A.) There has not been any abuse to report. B.) The patient is ashamed to admit to being abused. C.) The patient has Alzheimer's disease and can't remember. D.) The patient fell on a hike.
B.) The patient is ashamed to admit to being abused.
An ED nurse is triaging patients according to the Emergency Severity Index (ESI). When assigning patients to a triage level, the nurse will consider the patients acuity as well as what other variable? A.) The likelihood of a repeat visit to the ED in the next 7 days. B.) The resources that the patient is likely to require. C.) The patients or insurers ability to pay for care. D.) Whether the patient is known to ED staff from previous visits.
B.) The resources that the patient is likely to require.
The nurse is teaching a class on bioterrorism to first responders and is discussing PPE. Which statements are important for the nurse to share with the participants? Select all that apply. A.) Health-care facilities should keep masks at entry doors. B.) The respondent should be trained in the proper use of PPE. C.) No single combination of PPE protects against all hazards. D.) The CDC has divided PPE into levels of protection. E.) PPE should be properly fitted to each respondent.
B.) The respondent should be trained in the proper use of PPE. C.) No single combination of PPE protects against all hazards. D.) The CDC has divided PPE into levels of protection. E.) PPE should be properly fitted to each respondent.
The nurse in a disaster is triaging the following patients. Which patient should be triaged as an Expectant Category and color black? A.) The alert patient diagnosed with a sucking chest wound. B.) The unresponsive patient diagnosed with a head injury. C.) The patient diagnosed with an abdominal wound and stable vital signs. D.) The patient diagnosed with a sprained ankle which may be fractured.
B.) The unresponsive patient diagnosed with a head injury.
The nurse is preparing the patient for mechanical debridement and informs the patient that this will involve: A.) A spontaneous separation of dead tissue from the viable tissue B.) Use of surgical scissors, scalpels or forceps to remove the eschar until the point of pain and bleeding occurs C.) Shaving of burned skin layers until bleeding, viable tissue is revealed D.) Early closure of the wound
B.) Use of surgical scissors, scalpels or forceps to remove the eschar until the point of pain and bleeding occurs
A patient is being treated for bites that she suffered during an assault. After the bites have been examined and documented by a forensic examiner, the nurse should perform what action? A.) Apply a dressing saturated with chlorhexidine. B.) Wash the bites with soap and water. C.) Arrange for the patient to receive a hepatitis B vaccination. D.) Assess the patients immunization history.
B.) Wash the bites with soap and water.
The occupational health nurse is called to the floor of the factory where a patient has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How will the nurse cool the burn? A.) Apply ice to the site of the burn for 5 to 10 minutes. B.) Wrap the patient's affected extremity in ice until help arrives. C.) Apply an oil-based substance or butter to the burned area until help arrives. D.) Wrap cool towels around the affected extremity intermittently.
B.) Wrap the patient's affected extremity in ice until help arrives.
A patient has been admitted with a potassium of 5.8 mEq/L; the nurse anticipates which of the following action? A.)Administration of glucose IV and insulin sub-q. B.)Administration of glucose/insulin/diuretics IV. C.)Administration of IV potassium diluted in normal saline. D.)Administration of synthetic aldosterone.
B.)Administration of glucose/insulin/diuretics IV.
A patient with hyperkalemia is being treated with drugs to improve the condition. Which potassium level indicates that therapy is effective? A.) 7.6 mEq/L B.) 5.6 mEq/L C.) 4.6 mEq/L D.) 2.6 mEq/L
C.) 4.6 mEq/L
After receiving change-of-shift report, which patient does the RN assess first? A.) A 26-year-old with nausea and vomiting who complains of dizziness when standing B.) A 36-year-old with a nasogastric (NG) tube who has dry oral mucosa and is complaining of thirst C.) A 46-year-old receiving intravenous (IV) diuretics whose blood pressure is 95/52 mmHg D.) A 56-year-old with normal saline infusing at 150 mL/hr whose hourly urine output has been averaging 75 mL
C.) A 46-year-old receiving intravenous (IV) diuretics whose blood pressure is 95/52 mmHg
The patient has recently experienced a myocardial infarction. Which action by the nurse helps prevent cardiogenic shock? A.) Monitor the patients telemetry. B.) Turn the patient every 2 hours. C.) Administer oxygen via nasal cannula. D.) Place the patient in the Trendelenburg position.
C.) Administer oxygen via nasal cannula.
The patient has ingested a corrosive solution containing lye. Which intervention should the nurse implement? A.) Administer syrup of ipecac to induce vomiting. B.) Insert a nasogastric tube and connect to wall suction. C.) Assess for airway compromise. D.) Immediately administer water or milk.
C.) Assess for airway compromise.
A nurse is teaching a patient with a partial-thickness wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment? A.) 4 to 6 hours a day for 6 months B.) During waking hours for 2 to 3 months after the injury C.) Continuously D.) At night while sleeping for a year after the injury
C.) Continuously
A patient is brought to the ED by friends. The friends tell the nurse that the patient was using cocaine at a party. On arrival to the ED the patient is in visible distress with an axillary temperature of 40.1C (104.2F). What would be the priority nursing action for this patient? A.) Monitor cardiovascular effects. B.) Administer antipyretics. C.) Ensure airway and ventilation. D.) Prevent seizure activity.
C.) Ensure airway and ventilation.
A patient with multiple trauma is brought to the ED by ambulance after a fall while rock climbing. What is a responsibility of the ED nurse in this patients care? A.) Intubating the patient. B.) Notifying family members. C.) Ensuring IV access. D.) Delivering specimens to the laboratory.
C.) Ensuring IV access.
A patient is brought to the Emergency Department from the site of a chemical fire. The paramedics report that the patient has a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. When you assess the patient he verbalizes no pain in the right arm and the skin appears charred. Based upon these assessment findings, what is the depth of the burn on the patient's right arm? A.) Superficial partial-thickness B.) Deep partial-thickness C.) Full partial-thickness D.) Full-thickness
C.) Full partial-thickness
The nurse is caring for a patient who is receiving intravenous (IV) magnesium sulfate. Which assessment parameter is critical? A.) Monitoring 24-hour urine output B.) Asking the patient about feeling depressed C.) Hourly deep tendon reflexes D.) Monitoring of serum calcium levels
C.) Hourly deep tendon reflexes
A patient is brought by friends to the ED after being involved in a motor vehicle accident. The patient sustained blunt trauma to the abdomen. What nursing action would be most appropriate for this patient? A.) Ambulate the patient to expel flatus. B.) Place the patient in a high Fowlers position. C.) Immobilize the patient on a backboard. D.) Place the patient in a left lateral position.
C.) Immobilize the patient on a backboard.
A patient has a low serum potassium level and is ordered a dose of parenteral potassium chloride (KCl). How does a nurse safely administer KCl to the patient ? A.) Administers 5 mEq intramuscularly B.) Dilutes 200 mEq in 1 liter of normal saline and infuses at 100 mL/hr C.) Infuses 10 mEq over a 1-hour period D.) Pushes 5 mEq through a central access line
C.) Infuses 10 mEq over a 1-hour period
Which of the following laboratory results places the patient at greatest risk for dysrhythmias? A.) Na+ 148 mEq/L B.) Mg+ 0.9 mEq/L C.) K+ 6.6 mEq/L D.) Na+ 133 mEq/L
C.) K+ 6.6 mEq/L
The nurse is assessing a patient with hyponatremia. Which finding requires immediate action? A.) Diminished bowel sounds B.) Heightened acuity C.) Muscular weakness D.) Urine output of 35 mL/hr
C.) Muscular weakness
A patient is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the physician will perform which of the following actions? A.) Insert an oropharyngeal airway. B.) Perform the jaw thrust maneuver. C.) Perform endotracheal intubation. D.) Perform a cricothyroidotomy.
C.) Perform endotracheal intubation.
The health care provider writes orders for a patient who is admitted with a serum potassium level of 6.9 mEq/L. What does the nurse implement first? A.) Administer sodium polystyrene sulfonate (Kayexalate) orally. B.) Ensure that a potassium-restricted diet is ordered. C.) Place the patient on a cardiac monitor. D.) Teach the patient about foods that are high in potassium.
C.) Place the patient on a cardiac monitor.
The nurse is reviewing serum electrolytes and blood chemistry for a newly admitted patient. Which result causes the greatest concern? A.) Glucose: 97 mg/dL B.) Magnesium: 2.1 mEq/L C.) Potassium: 5.9 mEq/L D.) Sodium: 143 mEq/L
C.) Potassium: 5.9 mEq/L
The emergency department nurse writes the problem of "ineffective coping" for a patient who was raped. Which intervention should the nurse implement? A.) Encourage the patient to take the "morning-after" pill. B.) Allow the patient to admit guilt for causing the rape. C.) Provide a list of rape crisis counselors. D.) Discuss reporting the case to the police.
C.) Provide a list of rape crisis counselors.
The triage nurse in a large trauma center has been notified of an explosion in a major chemical manufacturing plant. Which action should the nurse implement first when the patients arrive at the emergency department? A.) Triage the patients and send them to the appropriate areas. B.) Thoroughly wash the patients with soap and water and then rinse. C.) Remove the patients' clothing and have them shower. D.) Assume the patients have been decontaminated at the plant.
C.) Remove the patients' clothing and have them shower.
The patient asks the nurse about the smallpox vaccine. Which information should the nurse provide to the patient? Select all that apply. A.) The patient should get the vaccine for prevention from the health department. B.) The patient should get the vaccine only after the smallpox rash has developed. C.) The smallpox vaccine can help if given less than a week after exposure to the virus. D.) Health officials have enough smallpox vaccine to vaccinate everyone in the United States. E.) The patient should avoid travel to countries with smallpox outbreaks.
C.) The smallpox vaccine can help if given less than a week after exposure to the virus. D.) Health officials have enough smallpox vaccine to vaccinate everyone in the United States.
The nurse is caring for a patient diagnosed with septic shock. Which assessment data warrant immediate intervention by the nurse? A.) Vital signs T 100.4°F, P 104, R 26, and BP 102/60. B.) A white blood cell count of 18,000/mm^3. C.) Urinary output of 90 mL in the last 4 hours. D.) The patient reports being thirsty.
C.) Urinary output of 90 mL in the last 4 hours.
A patient is receiving a loop diuretic. The nurse should be alert to which of the following symptoms? A.)Restlessness and agitation B.)Paresthesia and irritability C.)Weak, irregular pulse, cardiac arrhythmias, and muscle weakness D.)Increased blood pressure and muscle spasms
C.)Weak, irregular pulse, cardiac arrhythmias, and muscle weakness
A patient is being monitored for daily weights. The night nurse asks the nursing assistant for the morning weight, and the assistant replies, "She was sleeping so well, I didn't want to wake her to get her weight." How does the nurse respond? A.) "Fast thinking! She really needs to rest after the night she had." B.) "Get the information now, or I'll report you for not doing your job." C.) "Never mind—I will do it myself." D.) "Weigh her now. We need her weight daily, at the same time."
D.) "Weigh her now. We need her weight daily, at the same time."
The emergency department nurse has just admitted a patient with a burn. The nurse recognizes that the patient is likely to experience a local and systemic response to the burn when the burn exceeds a total body surface area (TBSA) of what? A.) 10% B.) 15% C.) 20% D.) 25%
D.) 25%
Which of the following is responsible for the oncotic pressure in the blood stream? A.) Antidiuretic hormone B.) Blood urea nitrogen C.) Creatinine D.) Albumin
D.) Albumin
A patient with a 3-day history of nausea and vomiting presents to the emergency department. The patient is hypo-ventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? A.) A decreased pH and an increased CO2. B.) An increased pH and a decreased CO2. C.) A decreased pH and a decreased HCO3. D.) An increased pH with an increased HCO3.
D.) An increased pH with an increased HCO3.
A patient has been brought to the ED after suffering genitourinary trauma in an assault. Initial assessment reveals that the patients bladder is distended. What is the nurses most appropriate action? A.) Withhold fluids from the patient. B.) Perform intermittent urinary catheterization. C.) Insert a narrow-gauge indwelling urinary catheter. D.) Await orders following the urologists assessment.
D.) Await orders following the urologists assessment.
A patient is brought to the ER in an unconscious state. The physician notes that the patient is in need of emergency surgery. No family members are present, and the patient does not have identification. What action by the nurse is most important regarding consent for treatment? A.) Ask the social worker to come and sign the consent. B.) Contact the police to obtain the patients identity. C.) Obtain a court order to treat the patient. D.) Clearly document LOC and health status on the patients chart.
D.) Clearly document LOC and health status on the patients chart.
A patient who attempted suicide being treated in the ED is accompanied by his mother, father, and brother. When planning the nursing care of this family, the nurse should perform which of the following action? A.) Refer the family to psychiatry in order to provide them with support. B.) Explore the causes of the patients suicide attempt with the family. C.) Encourage the family to participate in the bedside care of the patient. D.) Ensure that the family receives appropriate crisis intervention services.
D.) Ensure that the family receives appropriate crisis intervention services.
The female patient presents to the emergency department with facial lacerations and contusions. The spouse will not leave the room during the assessment interview. Which intervention should be the nurse's first action? A.) Call the security guard to escort the spouse away. B.) Discuss the injuries while the spouse is in the room. C.) Tell the spouse the police will want to talk to him. D.) Escort the patient to the bathroom for a urine specimen.
D.) Escort the patient to the bathroom for a urine specimen.
A gang war between the Trouser Snakes and their hated foe the Ham Mittens has resulted in 12 young males being brought to the emergency department. Which action by the nurse is a priority when a Trouser Snake member points a gun at a Ham Mitten member in the trauma room? A.) Attempt to talk to the person with the gun. B.) Explain to the person the police are coming. C.) Stand between the patient and the man with the gun. D.) Get out of the line of fire and protect self.
D.) Get out of the line of fire and protect self.
The nurse is admitting a patient with the laboratory results listed. Which priority intervention should the nurse implement first? - WBCs: 25.3 - RBC: 4.8 - Hgb: 10 - Hct: 30% - Platelets: 250 A.) Administer the prescribed antibiotic IVPB. B.) Start an intravenous line in the patient left forearm. C.) Perform the admission assessment. D.) Have the laboratory draw blood cultures STAT.
D.) Have the laboratory draw blood cultures STAT.
The nurse is providing first aid to a victim of a poisonous snake bite. Which intervention should be the nurse's first action? A.) Apply a tourniquet to the affected limb. B.) Cut an "X" across the bite and succ out the venom. C.) Administer a corticosteroid medication. D.) Have the patient lie still and remove constrictive items.
D.) Have the patient lie still and remove constrictive items.
According to the North Atlantic Treaty Organization (NATO) triage system, which situation is considered a level red? A.) Injuries are extensive and chances of survival are unlikely. B.) Injuries are minor and treatment can be delayed hours to days. C.) Injuries are significant but can wait hours without threat to life or limb. D.) Injuries are life-threatening but survivable with available interventions.
D.) Injuries are life-threatening but survivable with available interventions.
The nurse is teaching a class on bioterrorism. Which statement is the scientific rationale for designating a specific area for decontamination? A.) Showers and privacy can be provided to the patient in this area. B.) This area isolates the patients exposed to the agent. C.) It provides a centralized area for stocking the needed supplies. D.) It prevents secondary contamination to the health-care providers.
D.) It prevents secondary contamination to the health-care providers.
Which newly written prescription does the nurse administer first? A.) Intravenous normal saline to a patient with a serum sodium of 132 mEq/L B.) Oral calcium supplements to a patient with severe osteoporosis C.) Oral phosphorus supplements to a patient with acute hypophosphatemia D.) Oral potassium chloride to a patient whose serum potassium is 3 mEq/L
D.) Oral potassium chloride to a patient whose serum potassium is 3 mEq/L
The nurse is caring for a patient with diabetic ketoacidosis and documents that the patient is experiencing Kussmaul's respirations. On the basis of this documentation, which pattern did the nurse observe. A.) Respirations that cease for several seconds. B.) Respirations that are regular but abnormally slow. C.) Respirations that are labored and increased in depth and rate D.) Respirations that are abnormally deep, regular, and increased in rate.
D.) Respirations that are abnormally deep, regular, and increased in rate.
A patient who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Pco2 is 90 mm Hg, and HCO3- is 22 mEq/L. The nurse interprets the results as indicating which condition? A.) Metabolic acidosis with compensation B.) Respiratory acidosis with compensation C.) Metabolic acidosis without compensation D.) Respiratory acidosis without compensation
D.) Respiratory acidosis without compensation.
The parents bring their toddler to the ED in a panic. The parents state the child had been playing in the kitchen and got into some cleaning agents and swallowed an unknown quantity of the agents. Which health-care agency should the nurse contact at this time? A.) Child Protective Services (CPS). B.) The local police department. C.) The Department of Health. D.) The Poison Control Center.
D.) The Poison Control Center.
