Med Surg 3

The nurse is preparing to care for a client with a poisonous snake wound. Which method should the nurse use to cleanse the site? a. Wash with soap and water. b. Scrub with hydrogen peroxide. c. Rinse with normal saline, and apply Betadine. d. Soak in povidone-iodine (Betadine) for 10 minutes.

NS: A The site of the bite is cleaned with soap and water. B. C. D. Cytotoxic agents such as hydrogen peroxide and Betadine are not used to clean the wound of a snake bite.

The nurse provides care to a trauma victim. Which clinical manifestation most suggests a pneumothorax? 1. Inspiratory crackles 2. Pronounced crackles 3. Dullness on percussion 4. Absence of breath sounds

4. Absence of breath sounds A pneumothorax indicates that one of the lungs has collapsed and is not functioning. On auscultation no sounds of air movement will be heard. Because no air movement occurs with a pneumothorax, no breath sounds, including crackles, will be heard. Dullness may be a finding on percussion over the area of the pneumothorax, but an absence of breath sounds is the definitive finding.

A nurse is caring for a client following exposure to inhalational anthrax due to bioterrorism. Which of the following medications should the nurse prepare to administer? (SATA) A. Ciprofloxacin (Cipro) B. Doxycycline (Vibramycin) C. Amoxicillin (Amoxil) D. Penicillin G (Bicillin) E. Cefotaxime (Claforan)

A, B, C

The START triage tool was developed to be able to triage adult patients within 30 seconds and is the most commonly used tool in the United States. What are the 5 basic parameters to this tool? (select all that apply) A. The ability to walk B. The presence or absence of spontaneous respirations C. The respiratory rate D. An assessment of perfusion E. The ability to obey commands

A,B,C,D,E

The nurse is caring for a patient who was bitten by a snake. Which action should the nurse take to decrease the effects of the venom? a. Keep the patient calm. b. Elevate the patients limb. c. Encourage the patient to ambulate. d. Perform passive range of motion on the affected limb.

ANS: A Interventions are focused on decreasing the circulation of venom throughout the patients system by keeping the patient calm and immobilizing the affected part. B. C. D. Elevating the limb, ambulation, and range of motion will encourage the venom to circulate through the patients system.PTS: 1 DIF: Moderate

An unresponsive patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first? a. Pulse c. Breath sounds b. Heart rhythm d. Body temperature

ANS: A The priority assessment in an unresponsive patient relates to CAB (circulation, airway, breathing) so a pulse check should be performed first. While assessing the pulse, the nurse should look for signs of breathing. The other data will also be collected rapidly but are not as essential as determining if there is a pulse.DIF: Cognitive Level: Apply (application)

During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next? A. Palpate extremities for bilateral pulses. B. Observe the patients respiratory effort. C. Check the patients level of consciousness. D. Examine the patient for any external bleeding.

ANS: B Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patients breathing. The other actions are also part of the initial survey but assessment of breathing should be done immediately after assessing for airway patency

23. When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient? a. Emergency pericardiocentesis b. Stabilization of the chest wall with tape c. Administration of an inhaled bronchodilator d. Insertion of a chest tube with a chest drainage system

ANS: D The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient's clinical manifestations are not consistent with these problems.

49. After change-of-shift report, which patient should the nurse assess first? a. 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet b. 28-year-old with a history of a lung transplant and a temperature of 101° F (38.3° C) c. 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain d. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion

ANS: D The patient's history and symptoms suggest possible tension pneumothorax, a medical emergency. The other patients also require assessment as soon as possible, but tension pneumothorax will require immediate treatment to avoid death from inadequate cardiac output or hypoxemia.

During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion? a. Check skin turgor. c. Assess mucous membranes. b. Monitor daily weight. d. Measure hourly urine output.

ANS: D When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hr. The patient's weight is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion.

A patient is brought to the ED by paramedics, who report that the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is the priority in the care of a patient who has been burned and suffered smoke inhalation? A) Pain B) Fluid balance C) Anxiety and fear D) Airway management

Ans: D Feedback:Systemic threats from a burn are the greatest threat to life. The ABCs of all trauma care apply during the early postburn period. While all options should be addressed, pain, fluid balance, and anxiety and fear do not take precedence over airway management.

The nurse is caring for a 71 kg patient during the first 12 hours after a thermal burn injury. Which outcomes if observed by the nurse would indicate adequate fluid resuscitation (select all that apply)? A. Heart rate is 94 beats/minute. B. Mean arterial pressure is 54 mm Hg. C. Urine output is 46 mL/hour. D. Urine specific gravity is 1.040. E. Systolic blood pressure 88 mm Hg

Answer: A, C. Rationale:Assessment of the adequacy of fluid resuscitation is best made using either urine output or cardiac factors. Urine output should be 0.5 to 1 mL/kg/hr (or 75 to 100 mL/hr for an electrical burn patient with evidence of hemoglobinuria/myoglobinuria). Cardiac factors include a mean arterial pressure (MAP) greater than 65 mm Hg, systolic blood pressure (BP) greater than 90 mm Hg, heart rate less than 120 beats/minute. Normal range for urine specific gravity is 1.003 to 1.030

A nurse is performing triage in the emergency department. Which patient should the nurse see first? A. 18-year-old patient with type 1 diabetes mellitus who has a 4-cm laceration on right leg. B. 32-year-old patient with drug overdose who is unresponsive with poor respiratory effort .C. 56-year-old patient with substernal chest pain who is diaphoretic with shortness of breath. D. 78-year-old patient with right hip fracture who is confused; blood pressure is 98/62 mm Hg.

Answer:B. 32-year-old patient with drug overdose who is unresponsive with poor respiratory effort.Rationale: Patient with drug overdose is unstable and needs to be seen immediately. Patient with chest pain (possible myocardial infarction) should be seen second. Patient with hip fracture should be seen third. Patient with laceration is the most stable and should be seen last.

An unresponsive 78-year-old is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 106.2° F (41.2° C), blood pressure(BP) 86/52, and pulse 102.The nurse initially will plan to a. administer an aspirin rectal suppository. b. start O2 at 6 L/min with a nasal cannula. c. apply wet sheets and a fan to the patient. d. infuse lactated Ringer's solution at 1000 mL/hr.

C The priority intervention is to cool the patient. Antipyretics are not effective in decreasingtemperature in heat stroke, and 100% oxygen should be given, which requires a high flowrate through a non-rebreather mask. An older patient would be at risk for developingcomplications such as pulmonary edema if given fluids at 1000 mL/hr.

A nurse is reviewing treatment protocols for clients exposed to bioterrorism agents. For which of the following agents should the nurse plan to administer a vaccine following exposure? A. Anthrax B. Botulism C. Plague D. Smallpox

D. Small pox

A nurse is reviewing treatment protocols for clients exposed to bioterrorism agents. For which of the following agents should the nurse plan to administer a vaccine following exposure? A. Anthrax B. Botulism C. Plague D. Smallpox

D. Smallpox

A nurse is prepared to administer ciprofloxacin to a client. The nurse should identify that the medication is treatment for exposure to which of the following agents? A. Smallpox B. Sarin gas C. Ebola virus D. Anthrax

D. anthrax

The nurse is caring for a client with a chest tube. While assessing the tubing, the nurse notes a clot in the tubing. What action is appropriate in order to remove the clot from the tubing? a. Squeeze by sections moving from the client to the chest tube chamber b. Strip the tubing starting from the client toward the chest tube chamber c. Milk the tubing d. Strip the tubing starting from the chest tube and moving toward the client

The answer is A. Squeezing with one hand then releasing before squeezing further down is the best evidence-based way to clear a chest tube of a clot.

The nurse is caring for a client with a chest tube. The nurse will refrain from clamping the chest tube because which of the following could happen? a. Barrel chest b. Tension pneumothorax c. Airway constriction d. Pneumonia

The answer is B. Clamping a chest tube can cause a tension pneumothorax, because it becomes a one-way valve for air to enter the pleural space, but the air cannot escape because the tube is clamped. The trachea will deviate away from the affected side in this situation, and the client will present with chest pain, dyspnea, hypoxia and hypotension.

A nurse is caring for a client with a chest tube after being injured in a car accident. Which action of the nurse best describes how to maintain the water seal on the tube? a. Maintain the water at 12 cm or more in the chamber b. Ensure that the chest tube chamber is kept upright c. Keep the head of the client's bed flat d. Maintain the chest tube at the level of the client's waist or abov

The answer is B. A chest tube has more than one compartment that manages fluid and air that is removed from the client's pleural cavity. The water seal allows the air to be removed from the pleural space but prevents air and fluid from entering by acting as a one-way valve. The nurse can ensure the patency of the water seal by ensuring that the chamber is upright and by keeping 2cm of water in the water seal chamber.

If a pneumothorax is present and the client has a chest tube, what type of bubbling would be expected in the water chamber? a. Tiny bubbles b. Intermittent c. Constant d. No bubbling

The answer is B. I ntermittent bubbling is noted when a pneumothorax occurs. As long as there is air in the pleural space, there will be intermittent bubbling in the chamber

A nurse has just received report on 4 clients who all have chest tubes in place. Which client is the priority to see first? a. The client with tidaling in the drainage tubing b. The client with suction pressure set at -20 cmH2O c. The client with continuous bubbling in the drainage chamber d. The client whose drainage system is standing on the floor

The answer is C. Continuous bubbling in the chamber reflects an air leak, meaning there could be a hole in the tubing or it could be dislodged. This client is the priority to be seen first. Note - a client with a pneumothorax will have bubbling in the chamber during breathing, which is a normal, expected finding. But it will fluctuate with breathing, not be continuous.

A 36-year-old client must have a chest tube placed after an injury from a motor vehicle accident. The nurse is preparing to assist the provider with a chest tube placement in the left lung. In which position should the nurse place the client? a. Prone with a support under the abdomen b. Trendelenburg c. Supine with the left arm behind the head d. Left side-lying

The answer is C. When assisting with a chest tube insertion, the nurse should place the client in the supine position for the best access for the provider to reach the chest site. A towel or roll of blankets may be placed behind the shoulder blades to elevate the chest slightly and to cause chest expansion. If able, the client may be alternatively positioned sitting at the side of the bed, leaned over a table.

A nurse is caring for a client with a chest tube. He notes that the dressing around the client's tube insertion site is wet and there is some crepitus with mild palpation. Which actions by the nurse are most appropriate in this situation? Select all that apply. a. Prepare for replacement of the tube b. Keep the tubing below the level of the insertion site c. Remove the tube and place an occlusive dressing over the sited. d. Notify the provider to evaluate the level of suction e. Gently milk the tubing to remove clots, if present

The answers are: A, B, and D. To avoid back flow of fluid, the tubing must be kept below the insertion site. Crepitus indicates subcutaneous emphysema. The tube will need to be replaced to correct the air leak. Subcutaneous emphysema may develop in a client with a chest tube if air leaks under the skin, causing crepitus and swelling of the face and neck. The nurse should notify the physician right away and prepare to replace the tube.

Priority Decision: What is the priority of management of the near-drowning patient? a. Correction of hypoxia b. Correction of acidosis c. Maintenance of fluid balance d. Prevention of cerebral edema

a. Airway and oxygenation are the first priorities. A lifethreatening consequence of near-drowning of any type is hypoxia from fluid-filled and poorly ventilated alveoli. Correction of metabolic acidosis occurs with effective ventilation and oxygenation. Lactated Ringer's solution or normal saline solution is started to manage fluid balance and mannitol or furosemide may be used to treat free water and cerebral edema

When should the nurse check for leaks in the chest tube and pleural drainage system? a. There is continuous bubbling in the water-seal chamber b. There is constant bubbling of water in the suction control chamber c. Fluid in the water-seal chamber fluctuates with the patient's breathing d. The water levels in the water-seal and suction control chambers are decreased

a. There is continuous bubbling in the water-seal chamber

In which situation would therapeutic hypothermia be instituted in the ED? a. 48-year-old male found unconscious by neighbors; on ED arrival, he is moaning and moving all extremities b. 62-year-old man defibrillated by emergency medical technicians (EMTs); on ED arrival, he is not responsive although his heart rhythm and blood pressure (BP) are stable c. 30-year-old female who suffered heat exhaustion following a marathon; on ED arrival, she is hypotensive and extremely diaphoretic with a temperature of 102.6°F (39.2°C) d. 38-year-old female found face down in her bathtub; she has a history of seizures; on ED arrival, she is responsive to pain only and she was intubated by paramedics with evidence of pulmonary edema; her pulse oximetry is 91%

b. Therapeutic hypothermia post-cardiac arrest for 24 hours after the return of spontaneous circulation (post defibrillation) improves mortality and neurologic outcomes. Patient "b" might benefit from this therapy. Patient "a" will need airway maintenance and evaluation of the cause of unconsciousness. Patient "c" should have ABCs monitored and begin the cooling process. Watch for dysrhythmias and provide fluid and electrolyte replacement. Patient "d" will need mechanical ventilation and diuretics.

To determine whether a tension pneumothorax is developing in a patient with chest trauma, for what does the nurse assess the patient? a. Dull percussion sounds on the injured side b. Severe respiratory distress and tracheal deviation c. Muffled an distant heart sounds with decreasing blood pressured. d. Decreased movement and diminished breath sounds on the affected side

b. Severe respiratory distress and tracheal deviation

Priority Decision: A patient is brought to the ED following a skiing accident after which he was not found for several hours. He is rigid and has slowed respiratory and heart rates. What should the nurse do during the primary assessment of the patient? a. Initiate active core rewarming interventions. b. Monitor the core temperature via the axillary route. c. Manage and maintain ABCs (airway, breathing, circulation). d. Expose the patient to check for areas of frostbite and other injuries.

c. Rigidness, bradycardia, and slowed respiratory rate are signs of moderate hypothermia. The ABCs are the initial priority. Active core rewarming is indicated for moderate to severe hypothermia. Axillary temperatures are inadequate to monitor core temperature, so esophageal, rectal, or indwelling urinary catheter thermometers are used. The patient should be assessed for other injuries but should not be exposed, to prevent further loss of heat.

A UAP is taking care of a patient with a chest tube. The nurse should intervene when she observes the UAP a. looping the drainage tubing on the bed b. securing the drainage container in an upright position c. stripping or milking the chest tube to promote drainage d. reminding the patient to cough and deep breathe every 2 hours

c. stripping or milking the chest tube to promote drainage

Priority Decision: During the primary survey the nurse identified asymmetric chest wall movement in the patient. What intervention should the nurse do first? a. Check a central pulse. b. Stabilize the cervical spine. c. Apply direct pressure to the wound. d. Administer bag-mask ventilation with 100% oxygen.

d. Asymmetric chest wall movement may indicate a flail chest, which requires bag-mask ventilation with 100% oxygen and may require intubation. A central pulse is checked and pressure is applied to a wound when there is profuse bleeding. The cervical spine is stabilized if there is any suspicion of a head or neck injury

What will be the immediate nursing action if the nurse, while caring for a patient with chest trauma, finds that the drainage system in the patient is broken? 1. Milking the drainage tubes 2. Stripping the drainage tubes 3. Emptying the collection chamber 4. Placing the chest tubing in a sterile water container

4. Placing the chest tubing in a sterile water containerThe drainage system should be properly checked to lessen the risk of complications. If the drainage system is found to be broken, then the distal end of the chest tubing connection should be placed in a sterile water container at a 2-cm level as an emergency water seal. Milking and stripping the drainage tubes are done only when there is an order from the physician. The collection chamber should never be emptied but should be replaced.

Following an earthquake, patients are triaged by emergency medical personnel and are transported to the hospital.Which of these patients will the nurse need to assess first? a. A patient with a red tag b. A patient with a blue tagc . A patient with a yellow tag d. A patient with a green tag

A The red tag indicates a patient with a life-threatening injury requiring rapid treatment.The other tags indicate patients with less urgent injuries or those who are likely to die.

A nurse is preparing a response protocol for botulism as a bioterrorism agent. The nurse should prepare protocol based on which of the following? (SATA) A. Botulism can produce paralysis B. The Centers for Disease Control and Prevention (CDC) should be notified when more than three cases are suspected C. Botulism is acquired through contact D. Vomiting and diarrhea are expected findings E. Botulism is a toxin found in castor beans

A, D

A nurse is providing staff education about smallpox as a bioterrorism threat. Which of the following statements indicates an understanding of this agent (SATA) A. "Smallpox is transmitted person to person." B. "Infection is characterized by severe respiratory distress." C. "Smallpox vaccination ensures lifelong immunity." D. "Naturally occurring smallpox has been eradicated from the world." E. "Smallpox is often confused with varicella."

A, D, E

The nurse is providing emergent care for a patient with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. Which action should the nurse take first? A. Assist the patient to a high Fowler's position. B. Teach the patient deep breathing exercises. C. Allow the patient to verbalize feelings. D. Administer 100% humidified oxygen.

Answer:D. Administer 100% humidified oxygen. Rationale:Carbon monoxide (CO) poisoning may occur in house fires; CO displaces oxygen on the hemoglobin molecule resulting in hypoxia. High levels of CO in the blood result in a skin color that is described as cherry red. Hypoxia may cause anxious behaviors and altered mental status. Emergency treatment for inhalation injury and CO poisoning includes the immediate administration of 100% humidified oxygen. The other interventions are appropriate for inhalation injury but are not as emergent as oxygen administration.

*A nurse in an emergency department is caring for a victim of a suspected exposure to cutaneous anthrax. Which of the following is expected symptoms? A. Immediate onset of respiratory distress B. Flu-like symptoms 48 hr after exposure C. Itching of the skin progressing to ulceration over 1-7 D. Immediate onset of vascular lesions of the skin

C

What instruction does the nurse give the patient while removing the chest tube? 1. "You should sleep in a side-lying position." 2. "You should sleep with your leg elevated." 3. "You should hold your breath or bear down." 4. "You should drink juice before the procedure."

3. "You should hold your breath or bear down." While removing the chest tube, the nurse instructs the patient to perform the Valsalva maneuver because it eases the process of removal. Therefore, the nurse instructs the patient to hold his or her breath or bear down. Sleeping in a side-lying position will reduce lung expansion. Therefore, the patient's condition may be aggravated. The nurse instructs the patient to elevate the leg when he or she has risk of thromboembolism. The nurse does not instruct the patient to drink juice because it may result in nausea.

A patient comes to the emergency room presenting with dyspnea, tachycardia, violent agitation, tracheal deviation, neck vein distension, and hyperresonance to percussion. Which condition should the nurse suspect? 1. Hemothorax 2. Flail chest 3. Tension pneumothorax 4. Cardiac tamponade

3. Tension pneumothroax Tension pneumothorax is the result of increased air in the pleural space; it causes shifting of bodily organs and an increase in intrathoracic pressure. The patient usually presents with cyanosis, air hunger, violent agitation, tracheal deviation, neck vein distension, and hyperresonance to percussion. Hemothorax is an accumulation of blood in the pleural space; the patient usually presents with dyspnea, diminished breath sounds, dullness to percussion, and shock, depending on blood loss. Flail chest is a fracture of two or more ribs; the patient presents with paradoxical movement of the chest wall and respiratory distress. Cardiac tamponade occurs when blood collects in the pericardial sac; the patient presents with muffled, distant heart sounds, hypotension, neck vein distension, and increased central venous pressure.

48. The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Document the amount of drainage every eight hours. b. Obtain samples of drainage for culture from the system. c. Assess patient pain level associated with the chest tube. d. Check the water-seal chamber for the correct fluid level.

ANS: A UAP education includes documentation of intake and output. The other actions are within the scope of practice and education of licensed nursing personnel.

The nurse is assessing a young male patient who came to the emergency department complaining of sudden shortness of breath. He has no other visible problems. The nurse notes that, upon auscultation, there are no breath sounds on the right upper lobe of the lung. The nurse suspects that the patient has which of these conditions? 1. Tension pneumothorax 2. Iatrogenic pneumothorax 3. Traumatic pneumothorax 4. Spontaneous pneumothorax

4. Spontaneous pneumothrorax A lack of breath sounds over a portion of the lung fields indicates the presence of a pneumothorax. A spontaneous pneumothorax typically occurs because of the rupture of small blebs (air-filled blisters) located on the apex of the lung. These blebs can occur in healthy, young individuals, especially tall, thin males. Tension pneumothorax occurs when air enters the pleural space but cannot escape. The continued accumulation of air in the pleural space causes increasingly elevated intrapleural pressures. Tension pneumothorax can occur with mechanical ventilation and resuscitative efforts. Iatrogenic pneumothorax can occur because of laceration or

Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action should the nurse take first? a. Assess that the client is breathing adequately. b. Insert a large-bore intravenous line. c. Place the client on a cardiac monitor. d. Assess for the best neurologic response.

A The highest-priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he or she may not be breathing, or may be breathing inadequately with the device in place.

A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first? a. Auscultate the patient's lung sounds. b. Determine the extent and depth of the burns. c. Give the prescribed hydromorphone (Dilaudid). d. Infuse the prescribed lactated Ringer's solution.

ANS: A A patient with facial and chest burns is at risk for inhalation injury and assessment of airway and breathing is the priority. The other actions will be completed after airway management is assured.

A patient arrives in the emergency department (ED) several hours after taking "25 to30" acetaminophen (Tylenol) tablets. Which action will the nurse plan to take? a. Give N-acetylcysteine. b. Discuss the use of chelation therapy. c. Start oxygen using a non-rebreather mask. d. Have the patient drink large amounts of water.

ANS: A N-acetylcysteine is the recommended treatment to prevent liver damage after acetaminophen overdose.The other actions might be used for other types of poisoning, but they will not be appropriate for a patientwith acetaminophen poisoning.

22. A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment? a. Paradoxic chest movement b. Complaint of chest wall pain c. Heart rate of 110 beats/minute d. Large bruised area on the chest

ANS: A Paradoxic chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange.

After the return of spontaneous circulation following the resuscitation of a patient whohad a cardiac arrest, therapeutic hypothermia is ordered. Which action will the nurse include in theplan of care? a. Initiate cooling per protocol. b. Avoid the use of sedative drugs. c. Check mental status every 15 minutes. d. Rewarm if temperature is below 91° F (32.8° C).

ANS: A When therapeutic hypothermia is used postresuscitation, external cooling devices or cold normal salineinfusions are used to rapidly lower body temperature to 89.6° F to 93.2° F (32° C to 34° C). Becausehypothermia will decrease brain activity, assessing mental status every 15 minutes is not done at thisstage. Sedative drugs are given during therapeutic hypothermia.

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? a. Insert a large-bore orogastric tube. b. Assist with intubation of the patient. c. Prepare a 60-mL syringe with saline. d. Give first dose of activated charcoal.

ANS: B In an unresponsive patient, intubation is done before gastric lavage and activated charcoal administration to prevent aspiration. The other actions will be implemented after intubation.DIF: Cognitive Level: Analyze (analysis)

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 nurseshould a. obtain a complete set of vital signs. b. obtain a Glasgow Coma Scale score. c. attach an electrocardiogram monitor. d. ask about chronic medical conditions.

ANS: B The Glasgow Coma Scale is included when assessing for disability during the primary survey. The otherinformation is part of the secondary survey.

39. A patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take? a. Position the patient so that the left chest is dependent. b. Tape a nonporous dressing on three sides over the chest wound. c. Cover the sucking chest wound firmly with an occlusive dressing d. Keep the head of the patient's bed at no more than 30 degrees elevation.

ANS: B The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the left side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30 to 45 degrees to facilitate breathing.

A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take? a. Encourage the patient to cough and auscultate the lungs again. b. Notify the health care provider and prepare for endotracheal intubation. c. Document the results and continue to monitor the patient's respiratory rate. d. Reposition the patient in high-Fowler's position and reassess breath sounds.

ANS: B The patient's history and clinical manifestations suggest airway edema, and the health care provider should be notified immediately so that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur.

Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA), the nurse assesses the patient. The patient weighs 92 kg (202.4 lb). Which information would be a priority to communicate to the health care provider? a. Blood pressure is 95/48 per arterial line. b. Urine output of 41 mL over past 2 hours. c. Serous exudate is leaking from the burns. d. Heart monitor shows sinus tachycardia of 108.

ANS: B The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 mm Hg systolic and the pulse rate should be less than 120 beats/min. Serous exudate from the burns is expected during the emergent phase.

Which patient should the nurse assess first? a. A patient with burns who is complaining of level 8 (0 to 10 scale) pain b. A patient with smoke inhalation who has wheezes and altered mental status c. A patient with full-thickness leg burns who is scheduled for a dressing change. d. A patient with partial thickness burns who is receiving IV fluids at 500 mL/hr

ANS: B This patient has evidence of lower airway injury and hypoxemia, and should be assessed immediately to determine the need for O2 or intubation (or both). The other patients should also be assessed as rapidly as possible, but they do not have evidence of life-threatening complications.

A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take first? a. Monitor the pulses every hour. b. Notify the health care provider. c. Elevate both legs above heart level with pillows. d. Encourage the patient to flex and extend the toes.

ANS: B The decrease in pulse and numbness in a patient with circumferential burns indicates decreased circulation to the legs and the need for an escharotomy. Monitoring the pulses is not an adequate response to the decrease in circulation. Elevating the legs or increasing toe movement will not improve the patient's circulation.

21. The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed? a. A large air leak in the water-seal chamber b. 400 mL of blood in the collection chamber c. Complaint of pain with each deep inspiration d. Subcutaneous emphysema at the insertion site

ANS: B The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. An air leak would be expected immediately after chest tube placement for a pneumothorax. Initially, brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax. A small amount of subcutaneous air is harmless and will be reabsorbed.

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? a.Prepare to administer rabies immune globulin (BayRab). b.Assist the health care provider with suturing of the bite wounds. c.Teach the patient the reason for the use of prophylactic antibiotics. d.Keep the wounds dry until the health care provider can assess them.

ANS: C Because human bites of the hand frequently become infected, prophylactic antibiotics are usually prescribed to prevent infection. To minimize infection, deep bite wounds on the extremities are left open. Rabies immune globulin might be used after an animal bite. Initial treatment of bite wounds includes copious irrigation to help clean out contaminants and microorganisms.

A 22-yr-old patient who experienced 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? a. Auscultate heart sounds. c. Auscultate breath sounds. b. Palpate peripheral pulses. d. Check mental orientation.

ANS: C Because pulmonary edema is a common complication after drowning, the nurse should assess the breathsounds frequently. The other information also will be obtained by the nurse, but it is not as pertinent tothe patient's admission diagnosis.

24. A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is most appropriate? a. Document the presence of a large air leak. b. Notify the surgeon of a possible pneumothorax. c. Take no further action with the collection device. d. Adjust the dial on the wall regulator to decrease suction.

ANS: C Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction pressure. The amount of suction applied is regulated by the amount of water in this chamber and not by the amount of suction applied to the system.

On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which of the following prescribed actions should be the nurse's priority? a. Monitoring urine output every 4 hours. b. Continuing to monitor the laboratory results. c. Increasing the rate of the ordered IV solution. d. Typing and crossmatching for a blood transfusion.

ANS: C The patient's laboratory results show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Because the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase once the patient's fluid balance has been restored. On admission to a burn unit, the urine output would be monitored more often than every 4 hours (likely every1 hour).

Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA) the nurse assesses the patient. Which information would be a priority to communicate to the health care provider? a. Blood pressure is 95/48 per arterial line. b. Serous exudate is leaking from the burns. c. Cardiac monitor shows a pulse rate of 108. d. Urine output is 20 mL per hour for the past 2 hours.

ANS: D The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 systolic, and the pulse rate should be less than 120. Serous exudate from the burns is expected during the emergent phase.

When planning the response to the potential use of smallpox as an agent of terrorism, the emergency department (ED) nurse-manager will plan to obtain sufficient quantities of a. blood. b. vaccine. c. atropine. d. antibiotics.

B Smallpox infection can be prevented or ameliorated by the administration of vaccinegiven rapidly after exposure. The other interventions would be helpful for other agents ofterrorism but not for smallpox.

When a patient is admitted to the emergency department after a submersion injury, which assessment will the nurse obtain first? a. Apical pulse b. Lung sounds c. Body temperature d. Level of consciousness

B The priority assessment data are how well the patient is oxygenating, so lung soundsshould be assessed first. The other data also will be collected rapidly but are not asessential as the lung sounds.

The nurse provides information to a patient who was exposed to anthrax by inhalation. The nurse determines the teaching has been successful if the patient makes which statement? A. "Anthrax can be spread by person-to-person contact." B. "It is not necessary to receive the anthrax vaccine." C. "An antibiotic will be prescribed for 2 months." D. "Antibiotics are only indicated for an active infection."

Answer:C. "An antibiotic will be prescribed for 2 months." Rationale: Postexposure prophylaxis includes a 60-day course of antibiotics. Ciprofloxacin (Cipro) is the treatment of choice. Anthrax is not spread by person-to-person contact; anthrax is spread by direct contact with the bacteria and its spores. The patient may receive the anthrax vaccine (three doses); if vaccinated, the course of antibiotic therapy is reduced to 30 days. Antibiotics are indicated after exposure to inhaled anthrax.Ch. 69

The nurse is caring for a patient who sustained a deep partial thickness burn to the anterior chest area. Which statement would be appropriate for the nurse to include when documenting the appearance of this type of burn?] A. Skin is hard with a dry, waxy white appearance with visible venous patterns. B. Skin blanches with pressure and is red with delayed blister formation. C. Skin is red and shiny with the presence of clear fluid-filled blisters. D. Skin is charred and leathery with visible muscles, tendons, and bones

Answer:C. Skin is red and shiny with the presence of clear fluid-filled blisters. Rationale:Deep partial thickness burns have fluid-filled vesicles that are red and shiny; may appear wet (if vesicles have ruptured); and mild to moderate edema may be present. Deep partial thickness burns result in severe pain related to nerve injury. Superficial partial thickness burns are red and blanch with pressure; pain and mild edema are present. Superficial partial thickness burns may have vesicles that appear 24 hours after the burn injury. Full-thickness burns are dry, waxy white, leathery, or hard; thrombosed vessels may be visible. Full-thickness burns result in an insensitivity to pain because of nerve destruction, and there may be involvement of muscles, tendons, and bones.

An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action should the nurse take? a. Clamp the chest tube in two places. b. Administer the prescribed morphine. c. Milk the chest tube to remove any clots. d. Assist the patient with incentive spirometry.

B Treat the pain. The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy. Milking or stripping chest tubes is no longer recommended because these practices can dangerously increase intrapleural pressures and damage lung tissues. Position tubing so that drainage flows freely to negate need for milking or stripping.An air leak is expected in the initial postoperative period after thoracotomy. Clamping the chest tube is not indicated and may lead to dangerous development of a tension pneumothorax.

*A public health nurse has just completed an educational program community who may have been exposed to agents of bioterrorism one of the nurses who attended the program regarding the clinical indicates a need for further education? A. "Smallpox has been considered eradicated worldwide." B. "People who were immunized against smallpox before to be protected." C. "It is easy for providers to distinguish smallpox from present early with the disease." D. "Unlike chickenpox, the vesicles of smallpox are m

C

These four patients arrive in the emergency department after a motor vehicle crash.In which order should they be assessed?Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. A 72-year-old with palpitations and chest pain b. A 45-year-old complaining of 6/10 abdominal pain c. A 22-year-old with multiple fractures of the face and jaw d. A 30-year-old with a misaligned right leg with intact pulses

C, A, B, D The highest priority is to assess the 22-year-old patient for airway obstruction, which isthe most life-threatening injury. The 72-year-old patient may have chest pain fromcardiac ischemia and should be assessed and have diagnostic testing for this pain. The 45-year-old patient may have abdominal trauma or bleeding and should be seen next toassess circulatory status. The 30-year-old appears to have a possible fracture of the rightleg and should be seen soon, but this patient has the least life-threatening injury.

A client has a right chest tube in place after recovering from a pneumothorax. The provider is preparing to remove the chest tube. Which nursing action is most appropriate as part of chest tube removal? a. Apply direct pressure to the chest wall for five minutes after tube removal b. Place a clamp on the tube after it has been removed from the client's chest c. Instruct the client to perform the Valsalva maneuver while the tube is being removed d. Administer pain medication five minutes before starting

C. Chest tube removal is typically done by a provider, who removes the sutures holding the tube in place and pulls it out of the client's chest. The nurse can assist by administering pain medication to the client approximately 30 minutes before starting the procedure. The nurse should ask the client to bear down or perform the Valsalva maneuver as the tube is coming out. This increases pressure inside the chest cavity and reduces the risk of an air embolism.

During the primary survey of a patient with multiple traumatic injuries, the nurse observes that the patient's right pedal pulses are absent and the leg is swollen.Which of these actions will the nurse take next? a. Assess further for a cause of the decreased circulation. b. Send blood to the lab for a complete blood count (CBC). c. Finish the airway, breathing, circulation, disability survey. d. Initiate isotonic fluid infusion through two large-bore IV lines

D The assessment data indicate that the patient may have arterial trauma and hemorrhage.When a possibly life-threatening injury is found during the primary survey, the nurseshould immediately start interventions before proceeding with the survey. Although aCBC is indicated, administration of IV fluids should be started first. Completion of theprimary survey and further assessment should be completed after the IV fluids areinitiated.

The nurse is assessing the functioning of a chest tube drainage system in a client with chest injury who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply a. excessive bubbling in the water seal chamber b. vigorous bubbling in the suction control chamber c. drainage system maintained below the client's chest d. 50 mL of drainage in the drainage collection chamber e. occlusive dressing in place over the chest tube insertion site f. fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

The answers are: C, D, E, and F. The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure; it may occur during exhalation, coughing, or sneezing. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more than 70 to 100 mL/hr is considered excessive and requires notification of the surgeon. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.

When a nurse is performing a primary survey in the ED, what is she assessing? a. Whether the resources of the ED are adequate to treat the patient b. The acuity of the patient's condition to determine priority of care c. Whether the patient is responsive enough to provide needed information d. The status of airway, breathing, circulation, disability, and exposure/environmental control

d. During the primary survey of emergency care, assessment and immediate interventions are made for life-threatening problems affecting airway, breathing, circulation, disability, and exposure/environmental control. The triage system is used initially to determine the priority of care for patients and history of the illness or accident is part of the secondary survey. Any emergency department should be able to stabilize and initially treat a patient who requires specialized care before transferring to another facility if needed.

Following a motor vehicle accident, the nurse assesses the driver for which distinctive sign of flail chest? a. Severe hypotension b. Chest pain over ribs c. Absence of breath sounds d. Paradoxical chest movement

d. Paradoxical chest movement