emergency care

A nurse is providing care to a client in the emergency department and walks into the hallway to get equipment. All of a sudden, gunshots are heard. Which of the following would be the nurse's priority?

Protecting himself or herself

When reviewing the results of a client's lumbar puncture, a nurse notes a glucose level of 32 mg/dl. What does this result suggest to the nurse?

The client may have bacterial meningitis.

A client suspected of acetaminophen (Tylenol) toxicity reports that he ingested the medication at 7 p.m. At what time should the nurse anticipate laboratory tests to assess the acetaminophen level?

11:00 p.m.

A nurse is establishing a patient's airway. Which action would the nurse perform first?

Repositioning the patient's head

A patient arrives at the emergency department after sustaining a gunshot wound to the abdomen. When assessing the patient, the nurse pays particular attention to which of the following?

liver

When assessing a client with suspected carbon monoxide poisoning, which finding would be least reliable?

Cherry red skin color

A finger sweep is only to be used in which client population?

Unconscious adult

A patient is brought to the emergency department. Assessment reveals that the patient is lethargic and diaphoretic and complaining of right upper quadrant pain. Acetaminophen toxicity is suspected and an acetaminophen level is drawn. Which result would the nurse interpret as indicating toxicity for the patient if he weighs 70 kg?

10,500 mg (An acetaminophen level greater than or equal to 140 mg/kg would be considered toxic. For a patient weighing 70 kg, the toxic level would be 9800 mg. A level of 10,500 mg would be greater, thus indicating toxicity.)

A client has been brought to the ED after suffering genitourinary trauma in an assault. Initial assessment reveals that the client's bladder is distended. What is the nurse's most appropriate action?

Await orders following the urologist's assessment.

A patient working in a chemical facility sustains a chemical burn to his arms. The chemical involved was white phosphorus. Which of the following would be the priority nursing action?

Brushing off all traces of the chemical from the patient's skin

A client is brought to the emergency department with severe hemorrhage requiring massive blood replacement. The nurse warms the blood in a commercial warmer based on the understanding that infusion of large amounts of blood could result in which of the following?

Cardiac arrest

A client is brought to the emergency department after being involved in a motor vehicle collision. Which of the following would lead the nurse to suspect internal bleeding?

Delayed capillary refill

Which statement reflects the nursing management of the client with a white phosphorus chemical burn?

Do not apply water to the burn

The nurse educator is providing orientation to a group of nurses newly hired to an intensive care unit. The group of nurses are correct in stating which is the most common type of shock managed in critical care?

Hypovolemic

Which of the following would the nurse identify as indicating that a client is experiencing a complete airway obstruction? Select all that apply. Inability to speak Clutching of the neck Stridor Spontaneous coughing Cyanosis

Inability to speak Clutching of the neck Stridor Cyanosis

Nursing students are reviewing information about anaphylactic reactions and their possible causes. The students demonstrate understanding of this information when they identify which of the following as a common cause? Select all that apply. Insect stings Medications Latex Eggs Shellfish Green vegetables

Insect stings Medications Latex Eggs Shellfish

A bone graft may be used for which of the following reasons? Select all that apply. Joint stabilization Defect filling Stimulation of bone healing Improvement of motion Reduction of a fracture

Joint stabilization Defect filling Stimulation of bone healing

A client presents to the ED following a chemical burn. The client identifies the source of the burn as white phosphorus. The nurse knows that treatment will include

No application of water to the burn.

A patient is hemorrhaging from an open wound on his leg. The nurse implements care using the following steps. Place them in the order in which the nurse would perform them. Use all options. Immobilize the leg Provide firm direct pressure Apply a pressure dressing Elevate the leg

Provide firm direct pressure Apply a pressure dressing Elevate the leg Immobilize the leg

A patient is brought to the emergency department following an overdose of a selective serotonin reuptake inhibitor (SSRI). While assessing the patient, the nurse suspects that the patient may be developing serotonin syndrome based on which of the following?

Seizures

A client 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?

Small bowel

A nurse is assessing a patient who is suspected of having a partial airway obstruction. Which of the following would the nurse expect to find?

Spontaneous coughing

A patient with a history of major depressive disorder is brought to the emergency department by a friend, who reports that the patient took an overdose of prescribed amitriptyline. Which of the following findings would the nurse expect to assess? Select all that apply. Tachycardia Hypoactive reflexes Visual hallucinations Clonus Hypothermia

Tachycardia Visual hallucinations Clonus

The nurse is caring for a client with right ventricular heart failure. The nurse understands hypervolemia will have what effect on the client's heart?

The client's myocardial oxygen requirements will be higher

Which of the following are associated with compartment syndrome? Select all that apply. Trauma from accidents Surgery Casts Tight bandages Crushing injuries

Trauma from accidents Surgery Casts Tight bandages Crushing injuries

A client has had surgical repair of a hip injury after joint manipulation was unsuccessful. During postoperative recovery, what specific complication might develop in this client's case?

compartment syndrome

An x-ray demonstrates a fracture in which the fragments of bone are driven inward. This type of fracture is referred to as

depressed.

Following a motor vehicle collision, a client is brought to the ED for evaluation and treatment. The client is being assessed for intra-abdominal injuries. The client reports severe left shoulder pain (pain score of 10 on a 1 to 10 scale). The nurse suspects injury to the

spleen.

Which is one of the most common causes of death in clients diagnosed with fat emboli syndrome?

Acute respiratory distress syndrome

The nurse in an intensive care unit is assigned to two clients. One of the clients has just passed away. The deceased client's family members have arrived to be at the client's bedside. Despite wanting to support the client's family, the nurse is must assess the other client's vital signs every 15 minutes, because the client is receiving a blood transfusion. In this situation, what is the nurse's best action?

Request that the pastor be present to support the family at the client bedside

Which data is important for the nurse to record while assessing the client with an open wound?

Time when the client last received a tetanus immunization

A triage nurse determines that a client with non-life-threatening injuries requires imaging studies and moderate sedation. The triage nurse would document this client as which of the following?

Urgent

Following an earthquake, a client who was rescued from a collapsed building is seen in the emergency department. He has blunt trauma to the thorax and abdomen. The nursing observation that most suggests the client is bleeding is:

orthostatic hypotension.

A patient in the emergency department is bleeding profusely from numerous large and deep lacerations on the top of his head, right side of his face, and forehead. The nurse determines the need to apply pressure at the appropriate pressure point. The nurse would use which of the following pressure points?

proximal to the temporal artery

The nurse is providing care for a client who is experiencing alcohol withdrawal. The client reports, "I cannot fall or stay asleep." The nurse observes that the client is agitated, having difficulty falling asleep and crying uncontrollably, with confused speech and a tachycardic pulse. Which intervention should the nurse implement first?

Administer lorazepam as ordered by the health care provider

A patient is brought to the ED by a friend, who states that a tree fell on the patient's leg and crushed it while they were cutting firewood. What priority actions should the nurse perform? (Select all that apply.) Applying a clean dressing to protect the wound Elevating the site to limit the accumulation of fluid in the interstitial spaces Inserting an indwelling catheter Splinting the wound in a position of rest to prevent motion Performing a fasciotomy

Applying a clean dressing to protect the wound Elevating the site to limit the accumulation of fluid in the interstitial spaces Splinting the wound in a position of rest to prevent motion

After inserting an oropharyngeal airway, the nurse determines that it is in the proper position when the flange is located at which position?

Approximately at the patient's lips

A 40-year-old client is admitted to the ED with facial bruises and a broken right wrist. Upon further assessment, the nurse notes multiple bruises in various stages of healing. Which is the best course of action by the nurse?

Asking the client whether they are experiencing abuse

The ED staff work collaboratively and follow the ABCDE method to establish and treat health priorities effectively in a client experiencing a trauma. Which action is completed by the nurse when implementing the "D" element of this method?

Assessing the client's Glasgow Coma Scale score

Emergency medical technicians transport a client to the emergency department and inform the nurse that the client fell from a two-story building. The comatose client has a large contusion on the left side of the chest, a hematoma in the left parietal area, and a compound fracture of the left femur. The client was intubated and is maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual-resuscitation bag. Which intervention by the nurse has the highest priority?

Assessing the left leg

The nurse is caring for a client who has just been intubated and started on mechanical ventilation in the intensive care unit. The nurse recognizes that it is possible to inadvertently intubate the right lung only. What nursing assessment and monitoring is required to determine if this complication has occurred? Select all that apply. Auscultate both sides of the chest Mark the endotracheal tube at the corner of the mouth and nose Monitor for both high and low pressure alarms Apply suctioning to clear the airway Re-set the ventilator rate as needed

Auscultate both sides of the chest Mark the endotracheal tube at the corner of the mouth and nose Monitor for both high and low pressure alarms

The nurse is caring for a patient with a pelvic fracture. What nursing assessment for a pelvic fracture should be included? (Select all that apply.) Checking the urine for hematuria Palpating peripheral pulses in both lower extremities Testing the stool for occult blood Assessing level of consciousness Assessing pupillary response

Checking the urine for hematuria Palpating peripheral pulses in both lower extremities Testing the stool for occult blood

A nurse is preparing an in-service education program about emergency nursing to a group of newly hired nurses who will be working in the emergency department. When describing the current status of visits to the emergency department, which of the following would the nurse include in the presentation?

Clients with Medicaid use the emergency department more often than clients with private health insurance.

A client presents to the ED following a motor vehicle collision. The client is suspected of having internal hemorrhage. The nurse assesses the client for signs and symptoms of shock. Which are signs and symptoms of shock? Select all that apply. Cool, moist skin Decreasing blood pressure Increasing heart rate Delayed capillary refill Increasing urine volume

Cool, moist skin Decreasing blood pressure Increasing heart rate Delayed capillary refill

A client admitted to the ED with severe diarrhea and vomiting is subsequently diagnosed with food poisoning. The nurse caring for this client assesses for signs and symptoms of fluid and electrolyte imbalances. For what signs and symptoms would this nurse assess? Select all that apply. Dysrhythmias Hypothermia Hypotension Hyperglycemia Delirium

Dysrhythmias Hypotension Delirium

A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until the femur can be rodded in surgery. For what early complication(s) should the nurse monitor this client? Select all that apply. Systemic infection Complex regional pain syndrome Deep vein thrombosis Compartment syndrome Fat embolism

Deep vein thrombosis Compartment syndrome Fat embolism

The nurse is providing care to a client who was brought to hospital with a opioid overdose. The nurse should expect to include which immediate interventions in the care of this client? Select all that apply. Ensure the head of the bed remains elevated Monitor naloxone intravenous infusion Apply warming blankets to client Assess the client using the CIWA-A scale Assess respiratory rate every 4 to 6 hours

Ensure the head of the bed remains elevated Monitor naloxone intravenous infusion

A 6-year-old is admitted to the ED after being rescued from a pond after falling through the ice while ice skating. What action should the nurse perform while rewarming the client?

Ensuring continuous ECG monitoring

A teenage client is brought to the clinic by a parent and reports pain in the arm. The client is a member of a high school crew team and practices for 2 ½ hours every day after school. Which of the following would the nurse suspect?

Epicondylitis

The nurse is assigned to a client admitted to the ICU from the emergency department. The client sustained multiple injuries from a motor vehicle accident. When reviewing the client chart, the notes indicate the client's emergency care was managed in what sequence of steps? Establish airway and start ventilation Application of pressure to control abdominal bleeding Assess for head and neck injuries Start peripheral intravenous insertion and infusion of fluids Examine client for additional injuries to the body Reassess pulses and neurovascular status

Establish airway and start ventilation Application of pressure to control abdominal bleeding Start peripheral intravenous insertion and infusion of fluids Assess for head and neck injuries Examine client for additional injuries to the body Reassess pulses and neurovascular status

A nurse is caring for a patient with multiple injuries and performs the following. Place these actions in the order in which the nurse would perform them. Use all options. Assess for head and neck injuries Assess for abdomen, back, and extremity injuries Establish airway and ventilation Control hemorrhage Splint fractures Prevent and treat shock

Establish airway and ventilation Control hemorrhage Prevent and treat shock Assess for head and neck injuries Assess for abdomen, back, and extremity injuries Splint fractures

A nurse is performing a primary survey of a client brought to the emergency department. Which of the following would the nurse include? Select all that apply. Obtaining a complete health history Establishing airway patency Applying monitoring devices Providing adequate ventilation Assessing neurologic function

Establishing airway patency Providing adequate ventilation Assessing neurologic function

In which triage category would the nurse include a client who requires simple first aid or basic primary care?

Fast track

A patient arrives at the emergency department after taking more than 20 lorazepam tablets. Which of the following would the nurse anticipate that the patient would be given to reverse the effects of the drug?

Flumazenil

A client is brought to the ED by ambulance after swallowing highly acidic toilet bowl cleaner 2 hours earlier. The client is alert and oriented. What is the care team's most appropriate treatment?

Giving milk to drink

A nurse is providing initial first-aid care to a patient who was bitten by a snake. Place the following actions in the order in which the nurse would perform them. Use all options. Have the patient lie down Immobilize the injury below the level of the heart Remove constricting clothing Clean the wound Cover the wound with a light sterile dressing Provide warmth

Have the patient lie down Remove constricting clothing Provide warmth Clean the wound Cover the wound with a light sterile dressing Immobilize the injury below the level of the heart

An emergency nurse has collected evidence from a patient who was shot during a robbery. The nurse is preparing to transfer the evidence to law enforcement. Which of the following would be important for the nurse to include when documenting this transfer? Select all that apply. Name of the law-enforcement official Date that the evidence was collected Time of the transfer of evidence The labels placed on the collection bags Family members who witnessed the transfer

Name of the law-enforcement official Date that the evidence was collected Time of the transfer of evidence

A nurse is providing an in-service program for fellow emergency nurses about hypothermia and rewarming methods used. The nurse determines that the presentation was successful when the group identifies which of the following as a passive active rewarming method?

Over-the-bed heaters

A patient with intra-abdominal injuries is brought to the emergency department. Which of the following would most likely alert the nurse to suspect internal bleeding secondary to a ruptured spleen?

Pain in the left shoulder

A nurse who is a member of an emergency response team anticipates that several patients with airway obstruction may need a cricothyroidotomy. For which of the following patients would this procedure be appropriate? Select all that apply. Patient with extensive facial trauma Patient with a lumbar spine injury Patient with laryngeal edema secondary to anaphylaxis Patient who is bleeding from the chest Patient with an obstructed larynx

Patient with extensive facial trauma Patient with laryngeal edema secondary to anaphylaxis Patient with an obstructed larynx

A 75-year-old client had surgery for a left hip fracture yesterday. When completing the plan of care, the nurse should include assessment for which complications? Select all that apply. Pneumonia Necrosis of the humerus Skin breakdown Sepsis Delirium

Pneumonia Skin breakdown Sepsis Delirium

A client is involved in a motorcycle accident and injures an arm. The health care provider diagnoses the man with an intra-articular fracture and splints the injury. The nurse implements the teaching plan developed for this client. What sequela of intra-articular fractures should the nurse describe regarding this client?

Posttraumatic arthritis

The nurse is providing care for a client who was admitted to the intensive care unit after suffering cardiovascular collapse secondary to a methamphetamine overdose. The client is semi-conscious and has a nasopharyngeal in place. The nurse anticipates this client may require which interventions? Select all that apply. Provide airway support and ventilation Minimize lights and noise disturbances Apply warming blankets Administer antipsychotic medication Follow the unit seizure protocol

Provide airway support and ventilation Minimize lights and noise disturbances Administer antipsychotic medication Follow the unit seizure protocol

The nurse is caring for a 21-year-old client with a diagnoses of brain death due to injuries sustained in a snowboarding accident. The family has chosen to remove life support measures to allow the client's death. Upon hearing the family's decision, what is the nurse's first action?

Request senior medical staff discuss organ donation

The nurse is monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs) for impaired tissue oxygenation resulting from hemorrhage. After 15 minutes of the transfusion, the nurse notes the client has a fever and shortness of breath. Place in order the steps the nurse should take in response to these findings. Use all options. Stop the transfusion Assess need for airway support Ensure the normal saline IV line is open Check full vital signs Notify the physician Intervene for any signs and symptoms as appropriate

Stop the transfusion Ensure the normal saline IV line is open Assess need for airway support Check full vital signs Notify the physician Intervene for any signs and symptoms as appropriate

A nurse suspects an older adult is experiencing heat stroke based on which assessment findings? Select all that apply. Temperature 105 degrees F (40.6 degrees C) Lack of sweating Increased thirst Weakness Delirium Bradypnea

Temperature 105 degrees F (40.6 degrees C) Lack of sweating Delirium

The nurse is caring for a client in the intensive care unit who is recovering from trauma as a result of a motor vehicle accident that claimed the life of the client's friend. While the nurse is performing a dressing change on the client's surgical wound, the client states, "I don't deserve to live. I have just been thinking about ending it all." As the nurse assesses the client's imminent risk for suicide, what contributing factors need to be considered? Select all that apply. The client attempted suicide as a teenager. The client's maternal uncle committed suicide. The client's parents visit on a daily basis. The client had a close relationship to the accident victim. The client is not able to ambulate unassisted.

The client attempted suicide as a teenager. The client's maternal uncle committed suicide. The client had a close relationship to the accident victim.

A client arrives in the emergency room complaining of severe pain in her left hip after falling out of the bed. What indication upon assessment does the nurse recognize as a dislocated left hip? Select all that apply. The left leg is shorter than the right. Limited range of motion of the left hip. The skin over the left hip is warm. The skin of the lower left leg is pale. The client is able to bend the knee but not move toes.

The left leg is shorter than the right. Limited range of motion of the left hip. The skin of the lower left leg is pale.

The nurse educator is explaining the difference between indications for nasopharyngeal airway insertion versus endotracheal intubation. Which responses from learners indicate correct reasons for the use of endotracheal tubes in clients? Select all that apply. To support ventilation in a client with basal skull trauma To provide airway support to a client with facial trauma To bypass an upper airway obstruction To support connecting to mechanical ventilation To facilitate removal of tracheobronchial secretions

To bypass an upper airway obstruction To support connecting to mechanical ventilation To facilitate removal of tracheobronchial secretions

A client is being treated for bites suffered during an assault. After the bites have been examined and documented by a forensic examiner, the nurse should perform what action?

Wash the bites with soap and water.