MED-SURG CH. 16 EAQ QUESTIONS

The nurse is contributing to data collection for a victim of a motor vehicle accident who complains of abdominal pain. Upon inspection, the abdomen is distended and appears taut. What should the nurse do next? 1. Call the health care provider. 2. Offer prescribed stool softener. 3. Palpate for rebound tenderness. 4. Offer prescribed pain medication

1. Call the health care provider. A distended, boardlike abdomen is a sign of internal bleeding. The nurse should stop the physical examination and call the health care provider immediately. Palpating the abdomen may cause more harm to the patient with internal bleeding. It is not appropriate to give stool softeners to a patient with undiagnosed abdominal pain. Pain medication is also inappropriate at this time.

Select the appropriate nursing intervention for eviscerated abdominal organs. 1. Cover the organs with material such as plastic wrap or foil to keep the organs moist and warm. 2. Once covered with a moist dressing, apply ice packs to keep the organs cooled during transport. 3. Replace eviscerated organs in the abdomen immediately to prevent further potential harm or drying. 4. Have the patient drink plenty of fluid to help keep the body and eviscerated organs hydrated during transport.

1. Cover the organs with material such as plastic wrap or foil to keep the organs moist and warm. At the scene of an accident, it is unlikely that sterile saline and dressing will be immediately available. Application of some material such as plastic wrap or foil will help conserve moisture and warmth of the organs. The nurse should not attempt to replace eviscerated organs in the abdomen because additional harm may result. Applying ice packs to an eviscerated organ is not recommended, but rather for it to be kept moist and warm. Nothing should be given to the patient by mouth as the patient will be taken to surgery upon arrival at the hospital.

The nurse enters a patient's room while the patient is eating lunch. Which symptoms of severe airway obstruction would prompt the nurse to intervene and activate emergency response? Select all that apply. 1. Cyanosis 2. Inability to speak 3. Forceful coughing 4. Clutching of the neck 5. High-pitched noise on inhalation

1. Cyanosis 2. Inability to speak 4. Clutching of the neck 5. High-pitched noise on inhalation Signs of severe airway obstruction include cyanosis, inability to speak, clutching of the neck, high-pitched noise on inhalation, poor or no cough, respiratory distress, inability to move air, and poor or no air exchange. This requires immediate intervention and activation of emergency response. If the victim has good air exchange, is responsive, and can cough forcefully, he or she has a mild airway obstruction. Do not interfere.

In the event of poisoning, what is the priority intervention? 1. Immediately call the poison control center. 2. Immediately administer Ipecac to induce vomiting. 3. Locate the container of the drug or chemical involved. 4. Ask the victim how long ago they ingested the substance.

1. Immediately call the poison control center. The American Association of Poison Control Centers recommends that you immediately call the poison control center. Administration of Ipecac is questionable and has significant contraindications and adverse effects. Locating the container of the drug or chemical involved and asking the victim how long ago he or she ingested the substance are important actions to take and are questions the poison control center will ask, but they are not the first actions for the nurse to take.

The LPN finds a patient who appears to be a victim of carbon monoxide poisoning. What would be the nurse's priority action? 1. Start rescue breathing. 2. Move the patient to fresh air. 3. Administer oxygen to the patient. 4. Place the victim in a hyperbaric oxygen chamber.

2. Move the patient to fresh air. The priority for the patient with carbon monoxide poisoning is to move him or her to fresh air. Only the patient who has stopped breathing would require rescue breathing. Although oxygen will be administered, the priority would be to move the patient to fresh air. All patients may not require the use of a hyperbaric oxygen chamber.

The nurse is teaching a CPR class in the community. Which statement by a student indicates an understanding of the importance of prompt recognition and treatment of cardiopulmonary arrest? 1. Only health care providers should do CPR. 2. Chest compressions will usually restart the heart. 3. Four minutes without oxygen can cause brain cell death. 4. Brain damage due to hypoxia can be reversed with therapy.

3. Four minutes without oxygen can cause brain cell death. Brain cell death begins to occur in as little as 4 minutes without oxygen. Anyone can do CPR, especially if they are certified. Chest compressions do not usually start the heart, but they aid in circulation until medications or a defibrillator can be used. Brain damage due to hypoxia is irreversible; the individual may be able to increase his or her functional ability with therapy, however.

Cardiopulmonary arrest is the absence of which signs? 1. Heartbeat 2. Respirations 3. Heartbeat and respirations 4. Heartbeat, respirations, and nonreactive pupils

3. Heartbeat and respirations Cardiopulmonary arrest is the absence of both a heartbeat and respirations. When the heart stops beating, a person is in cardiac arrest. When respirations cease, the person is in respiratory or pulmonary arrest. Nonreactive pupils are not part of the definition of cardiopulmonary arrest.

The student nurse is caring for a patient who develops epistaxis. Which initial intervention made by the student nurse demonstrates an ability to care for patients with epistaxis? 1. Call the charge nurse 2. Call the health care provider 3. Lean the patient's head forward and pinch the nostrils 4. Lean the patient's head backward and pinch the nostrils

3. Lean the patient's head forward and pinch the nostrils The student nurse should lean the patient's head forward and pinch the nostrils for 10 minutes. Leaning the patient's head forward helps decrease the amount of blood the patient ingests. Leaning the patient's head backward increases the amount of blood the patient ingests. Unless the patient's nose bleeds for a long time, the charge nurse does not need to be notified. The health care provider should be made aware of the nosebleed, but this is not the priority intervention.

The nurse in the hospital cafeteria sees a pregnant woman stand up and clutch her throat. The nurse asks the woman if she is choking, but the woman is unable to speak. The nurse moves behind the patient. What should the nurse do next? 1. Perform five back blows to the victim's lower back. 2. Perform five back blows to the victim's upper back. 3. Reach under the victim's arms, and deliver firm thrusts to the victim's chest. 4. Reach under the victim's arms, and deliver firm thrusts to the victim's abdomen.

3. Reach under the victim's arms, and deliver firm thrusts to the victim's chest. The safest intervention for the victim and fetus is to reach under the victim's arms and deliver firm thrusts to the victim's upper chest. The nurse should not perform thrusts to the victim's abdomen or back blows to the victim's back.

A victim of carbon monoxide poisoning usually dies when the carbon monoxide bound with hemoglobin exceeds which value? 1. 40 percent 2. 50 percent 3. 60 percent 4. 70 percent

4. 70 percent A victim of carbon monoxide poisoning usually dies when the carbon monoxide bound with hemoglobin exceeds 70 percent. There is a chance for recovery at lesser concentrations of carbon monoxide.

Select the correct statement regarding the purpose of HIPAA Privacy Rules in Disaster Situations. 1. Allows patient information to be shared to assist in disaster relief efforts. 2. Prevents health plans from gathering information regarding patients' health status during a disaster situation. 3. Protects patient confidentiality by preventing health care providers from releasing information to the media when trying to identify family members. 4. Protects patient confidentiality by preventing health care providers from disclosing patient location and condition to anyone that contacts the facility.

1. Allows patient information to be shared to assist in disaster relief efforts. The purpose of the HIPAA Privacy Rules in Disaster Situations is to allow patient information to be shared in order to assist in disaster relief efforts including coordination of care and location of family members when many people are displaced and separated from their family, medical providers, and medications. The purpose of the Privacy Rules is to allow health plans to gather information regarding patients' health status during a disaster situation. Its purpose is also to allow health care providers to release information to the media when trying to identify family members and to be able to disclose patient location and condition to anyone that contacts the facility, all in efforts to reconnect families and appropriate care coordination.

The nurse is observing a chair-bound resident of a long-term care facility eat dinner. The resident suddenly appears to attempt to cough and clutches his neck. What should be the nurse's priority intervention? 1. Ask the patient if he is choking. 2. Pat the resident gently on the back. 3. Lift the resident to a standing position. 4. Perform a blind finger sweep of the patient's mouth.

1. Ask the patient if he is choking. The nurse should first determine the extent to which the resident's airway is obstructed. The best way to do this is to ask the patient if he is choking; if the airway is truly obstructed, he will be unable to make a sound. If the patient's airway is obstructed, the nurse should look into the patient's mouth and only do a finger sweep if an object is visible. The nurse should never perform a blind finger sweep due to the risk for pushing the object farther into the airway. Patting the resident gently on the back is not an effective intervention. Firm back blows and then abdominal thrusts from the front is the proper intervention. Lifting the resident into a standing position is not an effective patient intervention.

The nurse is driving home from the hospital and witnesses a one-car accident on the highway. The nurse assesses the scene to ensure it is safe, and approaches the vehicle. What should the nurse do next? 1. Ask the victim's name. 2. Assess for signs of bleeding. 3. Assess for symmetrical chest wall movement. 4. Determine the best way to get the victim out of the car.

1. Ask the victim's name. The nurse should first ask the victim his or her name because this helps to determine if there is a neurological injury and if the patient is breathing. The nurse should then assess for signs of bleeding and for symmetrical chest wall movement. Determining the best way to get the victim out of the car should be done when emergency medical services arrive to ensure safety for the victim and the nurse.

Upon assessing a conscious victim removed from a house fire, the nurse notes coughing; singed areas around the mouth, nose, and facial hair; the left upper arm has open wounds with white and red tissue exposed; areas of blistering to the hands and fingers; and burned clothing to the remainder of the upper body. Place the nursing interventions in order of priority. 1. Anticipate an order for arterial blood gas analysis. 2. Assess respirations and airway patency, and apply oxygen. 3. Apply cool water to the upper arm wounds only until the wound is cool. 4. Remove water from the cooled wound to prevent loss of body heat.

1. Assess respirations and airway patency, and apply oxygen. 2. Apply cool water to the upper arm wounds only until the wound is cool. 3. Remove water from the cooled wound to prevent loss of body heat. 4. Anticipate an order for arterial blood gas analysis. As the victim was in a burning house and smoke-filled area, the nurse should anticipate smoke inhalation. Ensuring a patent airway and respirations is critical. As the victim is coughing, supplemental oxygen is necessary to aid in air exchange. Applying cool water to the wounds is important to cool down the tissues and prevent further tissue damage and death. Once the wound is cool, the water should be removed to prevent loss of body warmth and chilling. The nurse should anticipate the health care provider ordering arterial blood gases to analyze the circulating oxygen level. Though the victim is demonstrating air exchange as evidenced by coughing, coughing is a sign of airway inflammation and the victim can quickly develop respiratory failure.

Place the nursing interventions in the proper sequence for performing the primary survey for a life-threatening injury. 1. Look for a medical alert tag. 2. Perform a head-to-toe examination. 3. Initiate CPR or rescue breathing as needed. 4. Look for uncontrolled bleeding, identify the source, and apply pressure to the source. 5. Assess the ABCs: airway, breathing, circulation.

1. Assess the ABCs: airway, breathing, circulation.Look for a medical alert tag. 2. Initiate CPR or rescue breathing as needed. 3. Look for uncontrolled bleeding, identify the source, and apply pressure to the source. 4. Perform a head-to-toe examination. 5. Look for a medical alert tag. It is important to perform the primary assessments and interventions in the order that will optimize life-saving measures. Knowing the order in which to perform them is critical in an emergency. The order of interventions should be: 1) Assess the ABCs; 2) Initiate CPR; 3) Look for uncontrolled bleeding and apply pressure; 4) Systemically examine head-to-toe for injuries; and 5) Look for a medical alert tag. After these measures are completed, then a secondary survey can be performed to detect significant changes or other findings that might have been missed.

The nurse is caring for a patient in status asthmaticus who has been wheezing severely for the past hour. The nurse enters the room to administer a corticosteroid and hears the wheezing stop. What should be the nurse's priority intervention? 1. Call a code. 2. Administer the medication. 3. Document the change in the patient's breathing. 4. Hold the medication; the patient's breathing has improved.

1. Call a code. A patient with severe asthma whose wheezing stops is in danger of respiratory arrest, and a code should be called immediately. The decision to administer a corticosteroid or not is not a priority since the patient is not breathing. Although the nurse would document the change in the patient's breathing, this is not a priority. The patient's breathing has not improved, it has worsened.

What would be the LPN's priority nursing action when caring for a patient who has experienced foreign object penetration of the globe of the eye? 1. Caution the patient not to remove the object. 2. Instruct the patient to limit movement in both eyes. 3. Explain to the patient the reason both eyes need to be covered. 4. Instruct the patient to wear a patch on both the unaffected and the affected eye.

1. Caution the patient not to remove the object. The greatest harm could be produced by attempting to remove the object from the eye. Although it is important to limit movement in both eyes, explain the reason both eyes need to be covered, and instruct the patient to wear a patch on both the unaffected and affected eye, it is not the priority intervention.

Select the appropriate nursing interventions or statements for a traumatically amputated limb. (Select all that apply.) 1. Clean the wound surfaces with sterile water or saline. 2. Apply antibiotic ointment to the wound edges to prevent infection. 3. Wrap the body part in saline-soaked gauze in a sealed plastic bag, and keep warm for transport. 4. Wrap the body part in saline-soaked gauze in a sealed plastic bag, and place in an iced saline bath for transport. 5. An amputated limb may be reattached up to 4 to 6 hours post injury; however, if it will take longer, place the limb on ice for preservation.

1. Clean the wound surfaces with sterile water or saline. 4. Wrap the body part in saline-soaked gauze in a sealed plastic bag, and place in an iced saline bath for transport. If supplies are available, cleaning the wound surface with sterile water or saline will help clean the limb of debris or contaminants. Wrapping the body part in saline gauze and keeping it in a sealed water-tight container prevents the limb from being soaked in a solution and becoming water-logged. An iced saline bath helps to preserve the limb, slowing down the deterioration process and constricting the blood vessels. It is not appropriate to apply antibiotic ointment to the wound edges. Keeping the limb warm increases the risk for bacterial growth and infection, as well as increases the chances of tissue deterioration. The limb should never come in contact with ice or be frozen as it will no longer be viable, causing tissue death.

Which are symptoms of severe airway obstruction? (Select all that apply.) 1. Cyanosis 2. Inability to speak 3. Forceful coughing 4. Swallowing and breathing 5. High-pitched noise on inhalation

1. Cyanosis 2. Inability to speak 5. High-pitched noise on inhalation Severe airway obstructions indicates poor air exchange. Cyanosis, a dark bluish or purplish discoloration of the skin and mucous membrane, is due to deficient oxygenation of the blood. The inability to speak is indicative of air being unable to pass over the vocal cords. A high-pitched noise on inhalation is indicative of a significantly blocked airway as air tries to pass through the trachea. In a mild airway obstruction, a victim will have good air exchange, being able to forcefully cough in an attempt to remove an obstruction. The ability to swallow and breathe are not possible with a complete or severe airway obstruction.

The nurse is volunteering in the first aid tent during a summer fair when a patient seeks treatment with symptoms of dizziness, nausea, and vomiting. Upon further assessment, the nurse notes that the patient's skin is red, hot, and dry. Select the appropriate type of heat injury and intervention required. (Select all that apply.) 1. Heat stroke 2. Heat exhaustion 3. Move the patient to an air-conditioned area, loosen clothing, apply cool water to the skin, and offer and electrolyte drink. 4. Move the patient to an air-conditioned area, remove shoes, and have him or her sit forward with his or her head placed between the knees. 5. Arrange to immediately transport the patient for medical care, move him or her to an air-conditioned area, and apply cool towels and ice packs to the forehead and axillae.

1. Heat stroke 5. Arrange to immediately transport the patient for medical care, move him or her to an air-conditioned area, and apply cool towels and ice packs to the forehead and axillae. Heat stroke is most notable for the lack of perspiration. This patient was noted to have dry skin, which is a symptom of depressed organ function, causing the patient to be unable to sweat. This is a critical condition. The patient must be transported immediately for medical attention and quickly cooled with cool towels, ice packs, or a cool bath if available. If the body core temperature cannot be lowered and the patient's condition reversed, the patient may develop seizures and could die. Heat exhaustion symptoms also include dizziness, nausea, and vomiting, but the patient is able to sweat and usually exhibits pale, damp skin. The patient should be moved to an air-conditioned area in both cases. It is important to treat heat exhaustion by cooling the patient and rehydrating fluid loss with electrolyte drinks. Removing shoes may help in cooling the patient, but having the patient place the head between the knees will not help to reduce the body temperature.

Which nursing intervention is appropriate for a snake bite? 1. Keep the patient still. 2. Elevate the body part that was bitten. 3. Apply a tourniquet above the site of the bite, and apply ice. 4. Get the patient out of bed every 15 minutes to keep him or her alert.

1. Keep the patient still. Keeping the patient still limits absorption of the venom and circulation through the system. The body part that was bitten should not be elevated but kept in the dependent position or below the level of the heart to limit venom absorption. A tourniquet and ice are no longer recommended treatments, as the risks outweigh the benefits. The patient should not ambulate frequently, but should limit activity to prevent venom absorption and circulation.

Select the correct interventions in a patient with epistaxis. Select all that apply. 1. Once the bleeding has stopped, instruct the patient not to blow the nose for several hours. 2. Have the patient sit down, lean the head back, and pinch the nostrils for at least 10 minutes. 3. Have the patient sit down, lean the head forward, and pinch the nostrils for at least 10 minutes. 4. Place the patient in a semi-Fowler's position, and pack the nostrils with sterile gauze for 30 minutes. 5. Once the bleeding has stopped, instruct the patient that it is okay to blow the nose, but to repack with gauze afterward.

1. Once the bleeding has stopped, instruct the patient not to blow the nose for several hours. 3. Have the patient sit down, lean the head forward, and pinch the nostrils for at least 10 minutes. Sitting down with the head held forward directs the blood to drain anteriorly toward the nostrils. It is important to apply pressure to the bleeding site for at least 10 minutes, which for an anterior nosebleed, responds to pressure and helps to clot the bleeding site. Once the bleeding has stopped, the patient should be instructed not to blow the nose for several hours to prevent the clotting from being dislodged, which could cause recurrent bleeding. Patients should not lean their head back or lie in a semi-Fowler's position, as this will direct the blood to drain posteriorly and down the esophagus. Nurses or patients should not put anything in the nose, including gauze. Continued bleeding or bleeding from the posterior area of the nose requires medical treatment by a health care provider.

The nurse witnesses a motor vehicle accident that injured four people, all of which have a decreased level of consciousness. After an initial assessment of each individual's condition, the nurse determines that which person should be treated first? 1. The 30-year-old female with paradoxical chest movement 2. The 35-year-old male with clear fluid leaking from his nose 3. The 25-year-old female hemorrhaging from a right thigh laceration 4. The 20-year-old male complaining of an inability to move his arms and legs

1. The 30-year-old female with paradoxical chest movement The nurse should triage the patients according to their injuries. The first patient to be treated should be the patient with an alteration in respiratory function, which is the individual with paradoxical chest movement. The next person to be treated is the one hemorrhaging from a thigh laceration; the laceration could have severed the femoral artery, which is a life-threatening emergency. The patient with clear fluid leaking from his nose and the person complaining of an inability to move his arms and legs have likely suffered neurologic injuries, which are triaged lower than respiratory and cardiovascular emergencies.

The nurse is called to the scene of a victim who has been found unconscious on the ground with an open fracture of a hemorrhaging forearm and a foreign object penetrating the abdomen. What should the nurse do? (Select all that apply.) 1. Tilt the victim's head back, and assess for respirations. 2. Remove the foreign object, and apply pressure to the abdomen. 3. Realign the arm fracture in the proper position, and apply a splint. 4. Apply direct, continuous pressure to the forearm above the site of the fracture with a clean cloth. 5. Activate the emergency response system, elevate and tilt the victim's head forward, and have the victim drink small sips of orange juice.

1. Tilt the victim's head back, and assess for respirations. 4. Apply direct, continuous pressure to the forearm above the site of the fracture with a clean cloth. The first priority is to preserve life by assessing and protecting the airway, which is accomplished by tilting the victim's head back to assure an open airway with proper neck alignment and evaluate for breathing. It is also important to stop hemorrhaging as large amounts of blood loss may lead to hypovolemic shock or death. Applying direct, continuous pressure is an appropriate intervention in an attempt to stop the bleeding. The open wound should be covered with a clean bandage; however, apply pressure above the fracture site to prevent movement of the fracture, which could cause potential further tissue or blood vessel injury, resulting in further vascular compromise. It is improper to elevate a victim's head as it could compromise the spinal column in case of fracture. Tilting the head forward can close off the airway. One should never administer oral fluids to unconscious victims as they are at significant risk for choking or aspiration. The movement or realigning of an obvious fracture could cause additional damage to the tissues and vessels and potential additional vascular compromise. A penetrating object should not be removed as internal injury and severing of blood vessels is highly suspicious. The object is temporarily slowing internal bleeding at the penetration site, and removal of the item would then also remove the pressure of the organs and blood vessels, which would result in faster loss of blood into the body cavity.

Which intervention is most appropriate for emergency care of a pneumothorax? 1. Apply direct pressure over any chest wounds. 2. Apply a vented dressing, sealed on three sides. 3. Observe the patient's chest for paradoxical motion of the chest. 4. Hold or tape a small pad or pillow to the injury site to splint the ribs.

2. Apply a vented dressing, sealed on three sides. A vented dressing sealed on three sides allows air to escape but not enter the chest wound. Applying direct pressure over chest wounds will not treat a pneumothorax. Paradoxical motion describes the motion of a flail chest of inward motion of the affected section on inspiration and outward motion on expiration. Splinting of the ribs is necessary in a flail chest, but not a pneumothorax.

The nurse enters a room to find the patient unresponsive. What should be the nurse's priority action? 1. Call a code 2. Assess for a pulse 3. Begin high-quality compressions 4. Increase the patient's oxygen to 10 L/min

2. Assess for a pulse The nurse should first assess for a pulse, and then begin high-quality compressions if necessary. While doing compressions, the nurse should call for help and instruct the first person to arrive to call a code. If the patient's heart is not beating, he or she is likely not breathing; therefore, increasing the patient's oxygen is not helpful unless someone is using a bag mask to ventilate the patient.

A patient returns to the nursing unit from abdominal surgery with vital signs as follows: blood pressure 119/82 mm Hg, heart rate 82 beats/minute, 98 percent oxygen saturation, and 18 respirations/minute. Thirty minutes later, the patient's vital signs are: blood pressure 80/52 mm Hg, heart rate 135 beats per minute, 95 percent oxygen saturation, and 25 respirations/minute. What should be the nurse's priority intervention? 1. Call the health care provider. 2. Call the rapid response team. 3. Document the new set of vital signs. 4. Prepare the patient to return to the operating room.

2. Call the rapid response team. The increase in heart rate and decrease in blood pressure indicate hemorrhagic shock due to internal bleeding. Although the patient will probably return to the operating room, the nurse should first call the rapid response team because the patient is deteriorating rapidly. The health care provider should be called and the vital signs documented, but expertise and assistance from the rapid response team is an essential first step.

When a sitting, nonpregnant victim is conscious and choking, it is appropriate to perform which interventions? (Select all that apply.) 1. Place the victim in the lying down position. 2. Repeat the fist thrusts until the obstruction is removed. 3. Repeat the fist thrusts until the victim loses consciousness. 4. Wrap your arms around the victim from behind and perform quick, upward thrusts with your fist below the sternum and slightly above the umbilicus. 5. Wrap your arms around the victim from behind and perform quick, upward thrusts with your fist slightly above the sternum or slightly below the umbilicus.

2. Repeat the fist thrusts until the obstruction is removed. 3. Repeat the fist thrusts until the victim loses consciousness. 4. Wrap your arms around the victim from behind and perform quick, upward thrusts with your fist below the sternum and slightly above the umbilicus. The appropriate way to remove an obstruction from a sitting, conscious choking victim is to wrap your arms from behind the victim, delivering quick, upward abdominal thrusts with your fist below the sternum, but slightly above the umbilicus. This motion should be continued until the obstruction is either removed or the victim becomes unconscious, at which point the emergency response system should be activated. It is not appropriate to place the conscious victim in the lying down position. Placing your fist across the upper chest, above the sternum is used in a pregnant victim to prevent causing damage to the baby or being ineffective in an obese victim. Placing the fist below the umbilicus is not effective in removing an obstruction lodged in the throat or trachea

The nurse is caring for a patient with superficial frostbite on the nose, fingers, and toes. What interventions should the nurse perform? Select all that apply. 1. Massage the injured area. 2. Use warm soaks for the face. 3. Apply a sterile dressing following debridement. 4. Use a heavy blanket to keep the patient warm. 5. Immerse toes and fingers in a water bath at 100-105° F.

2. Use warm soaks for the face. 3. Apply a sterile dressing following debridement. 5. Immerse toes and fingers in a water bath at 100-105° F. The nurse should use warm soaks for the face. Blisters that form within a few hours should be debrided and covered with a sterile dressing. The affected toes and fingers should be immersed in a water bath at 100-105° F. The frostbitten area should be handled carefully; massaging causes damage to the tissues. The nurse should avoid using heavy blankets for the patient because they could cause friction and sloughing of damaged tissue.

The nurse is a first responder to a town devastated by a tornado. The first victim has an open chest wound; upon assessment, the nurse notes a sucking sound with each breath, abnormal chest wall movement, and dyspnea. What should be the nurse's priority intervention? 1. Apply an airtight bandage to the wound. 2. Sterilize the wound and periwound areas. 3. Apply a dressing that is sealed on three sides. 4. Auscultate to determine if the lung has collapsed.

3. Apply a dressing that is sealed on three sides. The nurse should immediately apply a vented dressing that is sealed on three sides. This allows air to escape the wound while preventing air from entering the wound. An airtight bandage is not appropriate at this time. Although it is a good idea to cleanse the wound, sterilization is not a priority in this situation. Auscultation of the lungs wastes valuable time; the lung is expected to be collapsed.

The nurse working in the emergency department is preparing for the arrival of victims from a mass casualty train wreck. The first patient arrives via ambulance hemorrhaging from multiple wounds. The patient's blood pressure is 60/30 mm Hg, heart rate is 135 beats/minute and irregular, and respiratory effort is rapid and labored. As the patient is being wheeled into a trauma room, the portable ECG monitor attached to the patient alarms and the ECG shows no electrical activity. What would be the nurse's priority action? 1. Obtain IV access. 2. Check the ECG leads. 3. Assess for a carotid pulse. 4. Begin high-quality chest compressions.

3. Assess for a carotid pulse. The nurse should assess for a carotid pulse first to determine if the patient's heart has actually stopped. It is possible that the ECG leads have become disconnected from the patient. However, the nurse should check the ECG leads after determining the patient has a pulse because checking the ECG leads first could waste valuable time if the patient's heart did stop. If it is determined that the patient's heart has stopped, high-quality chest compressions should be started immediately. After the patient is determined to have a pulse or compressions have been started, then another individual should obtain IV access.

A patient is recovering from abdominal surgery. While assisting the patient to a chair as ordered, a ripping sound is heard and the nurse can see loops of bowel through the incision when the bandage is pulled back. The nurse helps the patient back to bed and covers the wound with a sterile saline dressing. Immediately after the patient is settled, the nurse calls the provider to report which event? 1. Epistaxis 2. Avulsion 3. Evisceration 4. Pneumothorax

3. Evisceration Evisceration is the protrusion of internal organs through a wound. Epistaxis is the term for a nosebleed. Avulsion refers to all or part of a body part being torn loose. Pneumothorax occurs when air enters the pleural cavity, which causes the lung to collapse.

A nurse is caring for a patient involved in a car accident. The patient is unconscious and has multiple injuries on the head. What are the most important interventions for the nurse to perform as part of the primary survey? (Select all that apply.) 1. Obtain a full set of vital signs. 2. Provide comfort measures including pain management to the patient. 3. Immobilize the spine (and limbs if needed). 4. Assess the airway, breathing, and circulation. 5. Look for uncontrolled bleeding and locate the source; apply pressure.

3. Immobilize the spine (and limbs if needed). 4. Assess the airway, breathing, and circulation. 5. Look for uncontrolled bleeding and locate the source; apply pressure. The nurse should suspect cervical spine trauma in any patient with head and neck injuries. Immediate interventions include assessing the airway, breathing, and circulation as well as initiating CPR or rescue breathing as needed. Look for uncontrolled bleeding, locate the source, and apply pressure. These measures are part of the primary survey and may even be done at the accident site. Obtaining a full set of vital signs and providing comfort measures or pain control to the patient are interventions that should be done later during the secondary survey. This assessment is intended to identify all injuries in a more systematic way.

A maintenance worker on the nursing unit has a chemical splash to the eye. Which are the most appropriate nursing interventions for immediate care? (Select all that apply.) 1. Flush the eye for 15 minutes with sterile normal saline or water. 2. Patch both eyes, and take the worker to the emergency room for further care. 3. Instruct the patient that the eye should be examined by a health care provider. 4. Direct the irrigating fluid to flow from the inner canthus to the outer canthus of the eye. 5. Direct the irrigating fluid to flow from the outer canthus to the inner canthus of the eye.

3. Instruct the patient that the eye should be examined by a health care provider. 4. Direct the irrigating fluid to flow from the inner canthus to the outer canthus of the eye. The irrigating fluid should be directed to flow from the inner canthus, away from the tear duct, toward the outer canthus of the eye to protect the tear duct from infection and/or irritation. Flushing should be performed for 30 minutes. Even though the eye symptoms may seem to have been relieved with flushing, the patient should still be examined by a health care provider to assess for injury to the eye. Directing the irrigating fluid toward the inner canthus of the eye could cause further irritation or infection of the tear duct by the chemical exposure. It is not appropriate to patch both eyes. The delay in treatment caused by taking the worker to the emergency department could cause serious eye damage.

The nurse is working in the emergency department during the winter. A patient who is homeless is brought in wearing no shoes, with symptoms of confusion, violently shivering, and a core temperature of 30° Celsius. What is the appropriate assessment and treatment? (Select all that apply.) 1. Mild hypothermia 2. Severe hypothermia 3. Moderate hypothermia 4. Moderate hyperthermia 5. Warm the victim quickly by wrapping the entire body with warming blankets and additional layers on the hands and feet, and administer warmed IV fluids and warmed oxygen. 6. Warm the victim gradually by wrapping the torso with warming blankets and peritoneal lavage until the core temperature reaches 35° Celsius, and then focus on the extremities.

3. Moderate hypothermia 6. Warm the victim gradually by wrapping the torso with warming blankets and peritoneal lavage until the core temperature reaches 35° Celsius, and then focus on the extremities. Moderate hypothermia is classified as a core body temperature of 28° C to 32° C and is characterized by confusion, poor motor coordination, slurred speech, violent shivering, and possible irrational behavior. The victim must be rewarmed aggressively but gradually, as excessive rewarming sends lactic acid and cold blood from the extremities to the heart, possibly triggering cardiac dysrhythmias. The torso or body core must be warmed first. Once the core body temperature reaches 35° C, the focus is turned to warming the extremities. Warming efforts include warming blankets, warmed IV fluids, warmed oxygen, and warmed peritoneal lavage. Mild hypothermia is classified as a core body temperatures of 32° C to 35° C. Severe hypothermia is classified as 28° C or lower. Hyperthermia is excessive heat exposure, with a core body temperatures of 37.2° or higher.

Which statements are correct in the prevention of carbon monoxide poisoning? Select all that apply. 1. Use a smoke alarm device. 2. Keep electric stoves in proper repair. 3. Never let an engine run in a closed garage. 4. Use a space heater instead of a gas furnace. 5. Keep gas furnaces and stoves in proper repair.

3. Never let an engine run in a closed garage. 5. Keep gas furnaces and stoves in proper repair. Gas engines, furnaces, and stoves can emit carbon monoxide fumes and must be given proper circulation to function properly to prevent carbon monoxide poisoning. A smoke alarm will not detect carbon monoxide. Though a stove should always be in proper repair, an electric stove does not emit carbon monoxide. Space heaters are not the best option, and may present a fire hazard.

The nurse is the first on the scene of a motor vehicle collision, and there is an injured motorist. What is the nurse's first priority? 1. Look for a medical alert tag. 2. Soothe and reassure the victim. 3. Preserve life, and minimize effects of injuries. 4. Get the patient to the emergency department.

3. Preserve life, and minimize effects of injuries. The first priority is to preserve life and minimize effects of injuries. The other options identify components of important nursing interventions in emergency situations. Looking for a medical alert tag is important, but it is not the first priority in preserving life. Soothing and reassuring the victim is helpful, but it is not life sustaining. Getting the patient to an emergency department is important; however, that is the role of emergency medical services and paramedics.

Upon assessing a conscious victim removed from a house fire, the nurse notes coughing; singed areas around the mouth, nose, and facial hair; left upper arm has open wounds with white and red tissue exposed; areas of blistering to the hands and fingers; and burned clothing to the remainder of the upper body. What is the correct analysis of the symptoms? 1. The singed area to the mouth and nose are indicative of a chemical burn. 2. The singed areas to the mouth and nose are indicative of an electrical burn. 3. The singed areas to the mouth and nose are indicative of an inhalation injury. 4. The arm burn is considered a superficial burn because there is white tissue exposed.

3. The singed areas to the mouth and nose are indicative of an inhalation injury. Singed areas to the mouth and nose are indicative of inhaled smoke. Chemical burns can cause inhalation injuries, but do not produce singed areas to the mouth and nose. Electrical burns produce burn marks to the point of entry and exit. White tissue is indicative of a deep tissue wound. Superficial burns include areas of pink skin, such as with a sunburn.

The nurse is a first responder immediately after an earthquake. Which action by a fellow first responder would prompt the nurse to intervene? 1. Covering the victim with a blanket 2. Securing the shard of wood that impaled an arm 3. Using a splint to straighten a broken femur before securing it 4. Tenting a shirt loosely over the nose and mouth of an unconscious victim

3. Using a splint to straighten a broken femur before securing it The nurse would intervene if someone attempted to straighten a broken limb. Broken bones should be splinted in the position in which they are found to prevent further injury. Covering a victim with a blanket prevents the victim from becoming chilled. Embedded objects should not be removed; it would be beneficial to secure the impaling object to prevent it from coming loose during transport. Immediately after an earthquake, there is likely to be residual dust and particles that could block the airway of an unconscious victim. Tenting cloth loosely over the airway of the unconscious victim allows the victim to breathe while protecting the airway from blockage by falling particles.

The nurse arrives on the scene of a car accident in which a victim is found unconscious, supine on the embankment next to the road. The victim's left pupil is 3 mm, and the right pupil is 5 mm. There is clear drainage from the left ear, hemorrhaging from a deformed left forearm with bone fragments piercing through the skin, and a foreign object penetrating the abdomen. What should the nurse do? Select all that apply. 1. Remove the foreign object, and apply pressure to the abdomen. 2. Realign the arm fracture in the proper position, and apply a splint. 3. Using the jaw thrust motion, position the head and support the neck. 4. Move the victim to the flat surface of the road for better alignment, until help arrives. 5. Activate the emergency response system, and assess the victim's breathing and circulation. 6. Apply direct, continuous pressure to the forearm above the site of the fracture with a clean cloth.

3. Using the jaw thrust motion, position the head and support the neck. 5. Activate the emergency response system, and assess the victim's breathing and circulation. 6. Apply direct, continuous pressure to the forearm above the site of the fracture with a clean cloth. The first priority is to preserve life by assessing and protecting the airway and assessing the circulation. Appropriate measures for the unconscious victim include the jaw thrust motion to assure an open airway and evaluating for breathing. The nurse should consider the possibility of a cervical spine fracture and place the neck in proper alignment to prevent improper movement of the fracture. It is prudent to call 911 for additional medical assistance and intervention. It is also important to control hemorrhaging as large amounts of blood loss may lead to hypovolemic shock or death. The open wound should be covered with a clean bandage, and pressure must be applied above the fracture site to prevent movement of the fracture, which could cause potential further tissue or blood vessel injury resulting in further vascular compromise. A penetrating object should not be removed as internal injury and severing of blood vessels is highly suspicious. The object temporarily slows internal bleeding at the penetration site, and removal of the item would then also remove the pressure of the organs and blood vessels, which would result in faster blood loss into the body cavity. Though proper spinal alignment is the optimal goal, a victim should not be moved until he or she can be properly immobilized with a backboard and immobilization equipment to prevent further potential injury to the spine. The movement or realigning of an obvious fracture could cause additional damage to the tissues and vessels and potential additional vascular compromise, thus it should be splinted in the manner in which it is found

While shopping, a woman is observed to clutch her chest and fall to the ground. A group of people gather around the woman. A few in the group state that they are health care professionals and begin a primary survey by looking for life-threatening injuries. Once it is determined that no life-threatening injuries have occurred, they begin to intervene. What is the first intervention? 1. Look for a medical alert tag. 2. Look for uncontrolled bleeding. 3. Initiate cardiopulmonary resuscitation. 4. Assess airway, breathing, and circulation.

4. Assess airway, breathing, and circulation. After performing a primary survey and determining that no life-threatening injuries have occurred, the first intervention is to assess the airway, breathing, and circulation. The remaining steps are to initiate cardiopulmonary resuscitation or rescue breathing as needed; look for uncontrolled bleeding, identify the source, and apply pressure to the source; systematically examine for injuries from the head to the feet, and immobilize the spine, limbs, or both as indicated; and look for a medical alert tag.

A 5-year-old patient is admitted to the emergency department with a compound fracture of the left arm after falling out of a tree. Which signs would the nurse expect to see in this patient? 1. Injury to a ligament 2. Break in a bone that does not break the skin 3. Break in a bone where the ends are not separated 4. Break in a bone in which the ends of the broken bone protrude through the skin

4. Break in a bone in which the ends of the broken bone protrude through the skin A compound (open) fracture is one in which the ends of the broken bone protrude through the skin. A simple (closed) fracture does not break the skin. The bone ends in an incomplete fracture are not separated. A sprain is an injury to a ligament.

The nurse is a first responder to the scene of a motor vehicle accident. Which symptom exhibited by a victim would alert the nurse to a possible basilar skull fracture? 1. Rapid, thready pulse 2. Equally reactive pupils 3. Inability to turn the head 4. Clear fluid leaking from the nose

4. Clear fluid leaking from the nose Clear fluid leaking from the nose may be a sign of basilar skull fracture. A rapid, thready pulse may indicate shock. Equally reactive pupils are a normal finding. An inability to turn the head may be a spinal fracture.

The nurse witnesses the traumatic amputation of an individual's right hand. What would be the nurse's priority intervention? 1. Give the victim aspirin for pain. 2. Place the right hand in a cooler full of ice. 3. Wrap a tourniquet around the distal end of the arm. 4. Get the victim and the hand to a hospital in less than 4 hours.

4. Get the victim and the hand to a hospital in less than 4 hours. The nurse should get the victim and the hand to a hospital for reattachment in less than 4 hours. The victim should not take aspirin, as this increases bleeding. Amputated extremities should not be placed in direct contact with ice. A tourniquet around the distal end of the arm could lead to necrosis of the limb.

A patient comes into the emergency department complaining of extreme thirst and vomiting on a very hot day. The nurse notes that the patient has profuse diaphoresis and is ashen in color. Vital signs are blood pressure 90/50 mm Hg, pulse 98 beats/min, and temperature is 101° F. Which is the immediate priority for the nurse? 1. Administer salt tablets. 2. Assess for areas of poor skin perfusion. 3. Initiate oral fluid and electrolyte replacement. 4. Place the patient in a cool area and remove any restrictive clothing.

4. Place the patient in a cool area and remove any restrictive clothing. The patient is experiencing heat exhaustion, and the initial treatment step is to place the patient in a cool area and remove any restrictive clothing. The nurse would not administer salt tablets as it could lead to complications, such as gastric irritation or hypernatremia. The nurse would not administer oral fluid and electrolyte replacement for a patient experiencing nausea or vomiting. Poor skin perfusion is associated with frostbite and other cold emergencies.

The LPN is administering first aid to a patient who has developed a flail chest. What is the LPN's priority action? 1. Apply vented dressing. 2. Apply airtight dressing. 3. Transport to a medical facility. 4. Provide support for the injured area.

4. Provide support for the injured area. The LPN should provide support for the injured area and hold or tape a small pad or pillow over the injury to splint the ribs. Applying vented dressing is an intervention unique to a pneumothorax. Applying an airtight dressing is an intervention unique to a pneumothorax. Transporting the patient to a medical facility is an intervention that could apply to a hemothorax or a cardiac tamponade.

Exposure to which bioterrorism biologic agent causes symptoms of double vision, drooping eyelids, slurred speech, dry mouth, and paralysis that progresses downward to arms, chest, and legs and can cause paralysis of the respiratory muscles? 1. Anthrax 2. Botulism 3. Smallpox 4. Pneumonic plague

2. Botulism Botulism causes symptoms of double vision, drooping eyelids, slurred speech, dry mouth, and paralysis that progresses downward to arms, chest, and legs and can cause paralysis of the respiratory muscles. Anthrax exposure can cause skin, lung, or digestive tract symptoms including lesions, sore throat, fever, muscle aches, respiration complaints, nausea, bloody diarrhea, and abdominal pain. Smallpox causes high fever, pain, and a worsening rash. Pneumonic plague causes fever, weakness, and rapidly developing pneumonia and respiratory complaints.

A nursing instructor is educating the student nurses on emergency interventions for eyelid trauma. Information provided to the students would include which instruction? 1. Immediately remove any foreign body. 2. Immediately flush the eye for 30 minutes. 3. Apply direct pressure to the bleeding eyelid. 4. Apply a loose dressing, and transport the patient to medical care.

4. Apply a loose dressing, and transport the patient to medical care. Applying a loose dressing and transporting the patient to a medical care facility is an appropriate emergency intervention for eyelid trauma. Embedded foreign bodies should only be removed by the provider. Flushing the eye is an intervention for chemical contact in the eye. Direct pressure should not be applied to a bleeding eyelid. If the globe has been injured, pressure could cause greater harm.