Exam 7 Emergency and Community Nursing
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the ED nurse receives a call that a tornado has hit a local residential area and that numerous casualties have occurred. the victims will be brought into the ED. take which initial action?
activate emergency response plan specific to the facility
the nurse enters a room and finds a waste basket on fire. the nurse immediately assists the client out of the room. what is the next nursing action?
activate fire alarm
charge nurse is planning the assignment for the day. which factors would the nurse remain mindful of when delegating tasks?
acuity level pt needs, workers needs, and abilities
unresponsive patient with pinpoint pupils
administer naloxone
casted femur fracture, fat embolus manifestations
altered mental status
which action by the nurse will best facilitate adherence to a treatment regimen for a patient with a chronic illness?
arranging home health
an older adult patient is brought into the emergency department for treatment of a fracture. on physical assessment the nurse notes old and new ecchymotic areas on the clients chest and legs and asks the patient how the bruises were sustained. the client although reluctant tells the nurse a family member frequently hits the client. nurse plans to make which appropriate response?
as a nurse i am legally bound to report abuse.
client is brought into the emergency department with partial thickness burns to the face, neck, arms, and chest after trying to put out a car fire. the nurse needs to implement which nursing actions?
assess airway oxygen as prescribed elevate extremities
cardiac arrest
black tag
massive head trauma
black tag
home health nurse, working with an older adult client, assesses broken arm and burns on chest
call adult protective services
the nurse employed in a hospital is waiting to receive report from the lab via fax machine. the fax machine activates and the nurse expects the report but instead receives a sexually oriented photo. most appropriate action?
call nursing supervisor, report occurrence
the nurse who works night shift enters the medication room and finds a nurse with a tourniquet wrapped around the upper arm. the coworker us about to insert a needle attached onto a syringe containing a clear liquid in the antecubital space. nurses best action?
call the nurse supervisor
ingestion of a toxic agent
charcoal gastric lavage iv fluids
toxic agent
charcoal lavage
the nurse arrives at work and is told to float to the ICU for the day, since the ICU is understaffed and needs extra nurses to care for the clients. the nurse has never worked the icu, nurses best action?
clarify the ICU assignment with the team and ensure it is a safe assignment
the nurse hears a client calling out for help and hurries down the hallway to the clients room and finds the client lying on the floor. the nurse performs an assessment, assists client to bed, notifies the PCP, and completes an occurrence report. which statement would the nurse document?
client found lying on the floor
which notations indicate accurate nursing documentation by the nurse?
client slept through the night abdominal dressing is dry and intact without drainage clients left lower medial leg wound is 3cm in length without redness, drainage, or edema.
the nurse is volunteering with an outreach program to provide basic health care for homeless people. which finding if noted should the nurse address first?
complaints of pain associated with numbness and tingling in both feet
the nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. an assistive personnel is resistant to the change and is not taking an active part in the change. best approach?
confront the AP and encourage verbalization of feelings.
the nurse is preparing to initiate an iv line containing potassium using an IV pump. while preparing to plug the pump into the wall, the nurse finds no outlet is available. nurse would take which action?
contact the electrical maintenance department
the nurse calls the PCP regarding a new medication prescription, because the dosage is higher than the recommended dosage. the nurse is unable to locate the PCP, and the medication is due to be administered. Which action should the nurse take?
contact the nursing supervisor
spinal cord injury, complications that can occur due to prolonged immobilization
contractures atelectasis pressure sores thrombus
multiple rib fractures, experiencing flail chest
cyanosis hypotension dyspnea paradoxical chest movements
home health nurses witnesses a school aged child fall 2 stories
do not move
MRSA
don't share equipment shower rather than bath wash unaffected area first double glove dirty bandages keep infected part covered?
headache, neck stiffness precautions?
droplet (meningitis)
the nurse has received the assignment for day shift. after making initial rounds and checking all of the assigned patients. which patient would the nurse plan to care for first?
elevated wbc and temp
alcohol use disorder
give phenobarbitol
contact precautions are initiated for a client with a health care associated infection caused by mrsa. the nurse begins to provide colostomy care. what ppe?
gloves, gown, goggles, and mask
closed fracture
green tag
walking
green tag
a hospitalized client tells the nurse that an instructional detective is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. the client asks the nurse for assistance in obtaining a witness for the will. nurse response?
i will call the nurse supervisor
fall from ladder, results in femur fracture
immobilize limb
the nurse is assessing a patient with multiple trauma who is at risk for developing acute respiratory distress syndrome. the nurse would assess for which earliest sign of ARDS?
increased respirations
burns on 35% of the body, the patient is hoarse. what kind of injury?
inhalation injury
the community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about methods of transmission. which answers would indicate teaching was effective?
inhalation of bacterial spores cut or abrasion on the skin ingestion of contaminated undercooked meat
administering fentanyl to a patient with deep, full thickness burns, 60% BSA how to administer
intravenous
treatment of a newly applied cast
it will not be warm and painful b, c, d, e
sealed radiation implant
lead apron 6 ft from patient caution sign on the door
the nurse is working in a correctional facility is caring for a new prisoner. the client asks about the health risks associated with living in a prison. how would the nurse respond?
living in a prison can predispose a person to different health conditions
the nurse manager is discussing with the staff the facility's protocol in the event of a tornado. which instructions would the nurse manager include?
move beds from windows close window shades and curtains place blankets over bed confined patients
requires droplet precautions
mumps pertussis pnemonia
a nursing instructor delivers a lecture to nursing students regarding the issue of client rights and asks a student to identify a situation that represents an example of invasion of privacy. which situation if identified by the student indicates an understanding of a violation of this client right?
observing care provided to the client without client permission
education to preschoolers, teaching method
one on one demo
a client develops an anaphylactic reaction after receiving morphine, the nurse should institute which actions?
oxygen quick respiratory assessment document event, interventions, client response
nurse pulled from ED to medsurg, call rapid response team to which patient
pain and shortness of air
the registered nurse is planning the client assignments for the day. assignment for the assistive personnel?
patient that requires urine specimens
reviewing a plan of care for a client with an internal radiation implant. which intervention uf noted in the plan, indicates the need for revision?
placing client in semi private room
the nurse is caring for a client with meningitis and implements which transmission based precautions?
private room or cohort client droplet!
level a ppe
provides the highest level of respiratory, mucous membrane, skin, and eye protection incorporating a vapor-tight, chemical-resistant suit and self- contained breathing apparatus (SCBA)
the nurse employed in a long term care facility is planning assignments for the patients on a nursing unit. the nurse needs to assign 4 patients and has an LPN and 3 AP's on a nursing team. Most appropriate patient for the LPN?
pt requiring abdominal wound irrigation and dressing changes every 4 hours
spinal cord injury, patient complains of a severe headache, sweating profusely, BP 200/110 nurse action
raise HOB
the nurse has just assisted a client to bed after a fall. the nurse and the pcp have assessed the client, they're uninjured. after completing the occurrence report the nurse would implement what next action?
re assess the client
airway
red tag
shock
red tag
caring for a patient in the emergency department, presenting with SOA and fatigue. which physical assessment finding if noted by the nurse warrants a need for a follow up?
reddish purple mark on the neck
facial trauma
reg tag
pt fell through ice, unresponsive, and breathing slowly
remove clothes warm blanket rapid rewarming water warmed iv fluids
osteoporosis
remove clutter remove throw rugs maintain lighting use assistive devices
the nurse has made an error in documentation of the dose administered of an opioid pain medication in the clients record. the nurse drew one mg from the vial with another rn as a witness wasting of the remaining one mg. when scanning the medication, the nurse entered into the mar that 2mg of morphine was administered instead of the 1mg dose. the nurse would take which actions to correct the error?
right click the entry and modify it to reflect the correct information document correct information and end with the nurses signature and title document in a nurses note in the clients record detailing corrected information
the nurse obtains a prescription from the phcp to restrain a client and instructs the ap to apply the safety device to the client. which observation of unsafe application of the device would indicate further instruction is required?
securing the straps to the side rails
adolescent sexually assaulted one hour ago
self assessment in a private room?
gunshot wound to chest, how to detect a pneumothorax?
tachypnea tracheal deviation pleuritic pain
which teaching method is most effective when providing health care instructions to members of specific populations?
teach back
patient becomes angry, observing other nurse
the nurse walks away
client is brought into the emergency department by EMS after being hit by a car. clients name is unknown, patient has sustained a severe head injury and multiple fractures and is unconscious. an emergency craniotomy is required. regarding informed consent for the surgical procedure, what is the nurses best action?
transport patient to surgery
patient hit by a car, severe head injury, emergency craniotomy indicated
transport to the OR
which is most appropriate when communicating with a transgender person?
using identified pronouns
pt temp is 34 degrees celsius (93F) rewarming method?
warming blanket
distal fracture with a pulse
yellow tag
