Final exam 2
A 22-yr-old patient who had a drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period?
Auscultate breath sounds
A patient who has deep human bite wounds on the left hand is being treated in the urgent care center. Which action will the nurse plan to take?
Teach the patient the reason for the use of prophylactic antibiotics.
A triage nurse in the emergency department assesses a patient who reports 7/10 abdominal pain and states, "I had a temperature of 103.9° F (39.9° C) at home." The nurse's first action should be to:
assess the patient's current vital signs
When planning the response to the potential use of smallpox as a biological weapon, the emergency department nurse manager will plan to obtain adequate quantities of:
vaccine
Which interventions will the nurse plan for a comatose patient who is to begin therapeutic hypothermia? (Select all that apply.)
-Assist with endotracheal intubation. -Insert an indwelling urinary catheter. -Begin continuous cardiac monitoring
Following an earthquake, patients are triaged by emergency medical personnel and transported to the emergency department (ED). Which patient will the nurse need to assess first?
A patient with a red tag
The emergency department triage nurse is assessing 4 victims involved in a motor vehicle collision. Which patient has the highest priority for treatment?
A patient with paradoxical chest movement
Family members are in the patient's room when the patient has a cardiac arrest and the staff start resuscitation measures. Which action should the nurse take next?
Ask the family members whether they would prefer to remain in the patient's room or wait outside the room
Gastric lavage and administration of activated charcoal are ordered for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action should the nurse plan to do first?
Assist with intubation of the patient.
A patient arrives in the emergency department (ED) after topical exposure to powdered lime at work. Which action should the nurse take first?
Brush off any visible powder on the skin and clothing
The emergency department (ED) nurse is starting therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/VN)? (Select all that apply.)
Give acetaminophen (Tylenol) 650 mg. Place cooling blankets above and below patient. Attach rectal temperature probe to cooling blanket control panel.
When assessing an older patient admitted to the emergency department (ED) with a broken arm and facial bruises, the nurse observes several additional bruises in various stages of healing. Which statement or question by the nurse should be first?
Do you feel safe at home?
A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department. The nurse determines that discharge teaching has been effective when the patient makes which statement?
I need to drink extra fluids when working outside in hot weather
During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient has an unobstructed airway. Which action should the nurse take next?
Observe the patient's respiratory effort.
An unresponsive patient is admitted to the emergency department after falling through the ice while ice skating. Which assessment will the nurse obtain first?
Pulse
The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?
Remove the patient's rings.
During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next?
Start normal saline fluid infusion with a large-bore IV line
The urgent care center protocol for tick bites includes the following actions. Which action will the nurse take first when caring for a patient with a tick bite?
Use tweezers to remove any remaining ticks.
A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should:
obtain a Glasgow Coma Scale score.
