NURS 401, Quiz 13: Burns & Emergency/Trauma
A patient sustained a bite from a pit viper and is admitted for observation. Which potential complications does the nurse observe for? SATA A. Hemorrhagic bullae B. Tingling of scalp, lips, or face C. Hypertension D. Excessive salivation with drooling E. Clotting abnormalities F. Seizure
A. Hemorrhagic bullae B. Tingling of scalp, lips, or face E. Clotting abnormalities F. Seizure
What should the nurse do in caring for the patient with impaired thermoregulation as a result of a cold-related injury? SATA A. Monitor the patient's response to pain medication and rewarming techniques B. Monitor for further injury from rewarming techniques C. Monitor for signs and symptoms of pulmonary edema D. Evaluate the patient and family's knowledge about the injury and treatment plan E. Educate the patient and family on ways to prevent future cold-related injury F. Monitor for signs of high altitude cerebral edema
A. Monitor the patient's response to pain medication and rewarming techniques B. Monitor for further injury from rewarming techniques D. Evaluate the patient and family's knowledge about the injury and treatment plan E. Educate the patient and family on ways to prevent future cold-related injury
a patient has severe burns to the anterior surface of the body from a short exposure to high temperatures at a worksite furnace. which area of the body is most vulnerable to a deep burn injury? a. anterior chest b. upper arms c. palmar surface of hands d. eyelids
d. eyelids
The school nurse is preparing for a field trip to a farm with middle school-aged children. What instructions does the nurse provide to the children for bee and wasp sting prevention? SATA A. Place all jackets or sweaters in a pile on the ground B. Try to outrun bees if attacked by a swarm C. Keep garbage or leftover food in covered containers D. Inspect clothing and shoes for insects before putting on E. Do not swat at bees or wasp close to you F. Do not place unprotected hands where the eyes cannot see
B. Try to outrun bees if attacked by a swarm C. Keep garbage or leftover food in covered containers D. Inspect clothing and shoes for insects before putting on E. Do not swat at bees or wasp close to you F. Do not place unprotected hands where the eyes cannot see
A patient sustained a closed tibia-fibula fracture after falling 50 feet while rock climbing. What is the priority order for the assessments and interventions that the emergency department nurse would perform for this patient? Highest to lowest priority. A. Evaluate the neuromuscular status of the left lower extremity B. Assess the head, chest, and abdomen for injuries C. Assess airway, breathing, and circulation D. Immobilize the injured extremity E. Monitor for degree of pain or discomfort
C (highest priority), B, A, D, E (lowest priority)
Which patient should be triaged as urgent? A. 44-year-old man with a dislocated elbow B. 35-year-old man with chest pain and diaphoresis C. 85-year-old man with new onset confusion and BP grossly elevated compared to his usual D. 65-year-old woman with redness and swelling on the forearm associated with a bee sting
A. 44-year-old man with a dislocated elbow
Several people are looking out across a lake and pointing to a swimmer in the distance who appears to be struggling to stay afloat. What is the correct sequence of emergency steps to take? Put in order of priority. A. Handle gently to prevent ventricular fibrillation B. Safely rescue the victim C. Begin delivering rescue breaths as soon as possible D. Assess neurologic status E. Assess airway patency
B (Highest priority), E, C, A, D (lowest priority)
Which patients are most likely to undergo care via triage nurse-initiated protocols? SATA A. 36-year-old female with flulike symptoms that started two days ago B. 55-year-old male with left anterior chest pain that started after exercising C. 88-year-old male with sudden onset of confusion and shallow respirations D. 3-year-old female with an earache and a low-grade fever E. 45-year-old female with left-sided weakness, slurred speech, and drooling F. 18-year-old male with tenderness of testicles that started after sexual intercourse
B. 55-year-old male with left anterior chest pain that started after exercising C. 88-year-old male with sudden onset of confusion and shallow respirations E. 45-year-old female with left-sided weakness, slurred speech, and drooling
The nurse is caring for a patient who sustained severe frostbite to the lower leg. The patient reports increasing pain despite receiving analgesic medication 1 hour ago. What should the nurse do first? A. Ensure that the leg is elevated B. Assess for pulses and muscle weakness C. Obtain an order for additional pain medication D. Ask the patient to wait and see if the medication will work
B. Assess for pulses and muscle weakness
The nurse is caring for a patient who has been bitten by a black widow spider. Which vital sign change is cause for greatest concern? A. Patient appears anxious and is intermittently hyperventilating B. Blood pressure is significantly higher than the patient's typical BP C. Temperature is elevated and patient shows signs of dehydration D. Pulse is elevated and patient seems hypervigilant and nervous
B. Blood pressure is significantly higher than the patient's typical BP
An older patient reports being outside when temperatures reached 110F and forgetting to drink water. Now he reports weakness and nausea with dizziness. His body temperature is 98.9F. What is the priority assessment? A. Assess for medications that increase risk for heat stroke B. Check for orthostatic hypotension and tachycardia C. Observe skin turgor and other signs of dehydration D. Assess the size and responsiveness of the pupils
B. Check for orthostatic hypotension and tachycardia
The nurse is interviewing a patient who has been verbally aggressive for the past several hours, according to the family. The family states, "He won't hurt anybody." However, the patient is pacing and appears suspicious and angry. Which strategy does the nurse use to conduct the interview? A. Sit at eye level with the patient in a quiet, secluded room B. Conduct the interview standing near the door in a quiet room C. Bring the entire family in and have everyone sit in comfortable chairs D. Have the security guard stand by the patient during the interview
B. Conduct the interview standing near the door in a quiet room
Which signs/symptoms indicate the most severe case of hypothermia? SATA A. Tachycardia B. Depressed respiratory rate C. Decreased pain response D. Acid-base imbalance E. Shivering F. Hyperemia and edema after rewarming
B. Depressed respiratory rate C. Decreased pain response D. Acid-base imbalance
The nurse is caring for a patient who was admitted for heat stroke. In reviewing the medication administration record, the nurse sees that the patient received a dose of intravenous benzodiazepine. Based on this information, which action is the nurse most likely to perform? A. Asks the patient about level of pain or discomfort B. Ensures that seizure precautions have been initiated C. Assess the patient for cardiac dysrhythmias D. Auscultates the lung fields and assess respiratory effort
B. Ensures that seizure precautions have been initiated
Which intervention would be addressed during the primary survey? A. Insert a urinary catheter B. Establish patent airway C. Stabilize a fracture D. Insert a nasogastric tube
B. Establish patent airway
Three people who accompanied a patient to the emergency department (ED) become verbally argumentative and physically threaten each other. Which actions does the ED nurse take to ensure the safety of staff and others? SATA A. Tell individuals that they are being filmed B. Follow the hospital's security plan C. Attempt to deescalate the situation D. Quietly ask the individuals to leave E. Identify potential escape routes F. Obtain assistance from the security department as needed
B. Follow the hospital's security plan C. Attempt to deescalate the situation E. Identify potential escape routes F. Obtain assistance from the security department as needed
The nurse's next-door neighbor has sustained a deep laceration to the right upper arm, and there is active bright-red bleeding. What does the nurse do to immediately control the bleeding? SATA A. Apply a tourniquet just above the laceration B. Have the neighbor lie flat and elevate the arm C. Apply direct pressure with a thick, dry towel D. Apply sterile gauze and wrap with a gauze roller bandage E. Flush the wound with tap water and apply a thick dressing F. Have the neighbor sit down and splint the arm in anatomical position
B. Have the neighbor lie flat and elevate the arm C. Apply direct pressure with a thick, dry towel
The nurse has administered pain medications to a patient who has a migraine headache. What instructions should be given to unlicensed assistive personnel? A. Wait 45 minutes and then ask the patient if the pain is relieved B. Help the patient out of bed, sit him up, then dangle his feet, then assist to stand C. Check the patient frequently to make sure he arouses and is not getting worse D. Ask the patient if he has a ride home; if not, call a family member to make arrangements
B. Help the patient out of bed, sit him up, then dangle his feet, then assist to stand
A patient comes to the emergency department for gastric distress, vomiting large amounts of dark-brown emesis, and passing small amounts of bright-red blood rectally. Which preexisting health condition is most likely to be a factor in determine triage classification? A. History of diabetes mellitus B. History of anticoagulant use C. History of high blood pressure D. History of recent alcohol intoxication
B. History of anticoagulant use
For which patients would the nurse try to obtain a social service consult? SATA A. Toddler who bumped her head on a table; observation for 24 hours is required B. Homeless woman who will be discharged with a splint to the lower leg and crutches C. Woman who was punched and beaten by her husband and sustained a broken jaw D. Man who drove himself to the hospital for a dressing change of an infected wound on his back E. Preteen admitted for vaginal bleeding and sexually transmitted infection F. Elderly man who lives alone and has no means to obtain medications from the pharmacy
B. Homeless woman who will be discharged with a splint to the lower leg and crutches C. Woman who was punched and beaten by her husband and sustained a broken jaw E. Preteen admitted for vaginal bleeding and sexually transmitted infection F. Elderly man who lives alone and has no means to obtain medications from the pharmacy
During a summer marathon, the temperature is over 100F and the humidity is high. Suddenly a runner collapses after running in the race for 1 hour. The runner's body temperature is 105.2F and she is confused and sweating. What evidence-based intervention should be used for this patient? A. Give oxygen and start several IV lines with normal saline B. Initiate rapid cooling using on-site cold-water immersion C. Have patient rest in a cool environment and drink cold water D. Place in a supine position and call 911
B. Initiate rapid cooling using on-site cold-water immersion
The patient was repeatedly kicked and punched in the abdomen. The initial assessment and diagnostic testing revealed no life-threatening damage. The emergency provider tells the nurse that the patient should remain in the emergency department for observation. What is the most important action for the nurse to perform? A. Administer pain medication in a timely fashion B. Initiate serial abdominal assessments C. Delegate vital signs every 4 hours D. Find a quiet space where the patient can rest
B. Initiate serial abdominal assessments
An elderly woman is brought to the emergency department by her son, who tells the nurse, "Mom just seems weak, tired, and more confused than usual." Which combination of question and assessment is the nurse most likely to perform for this patient? A. Ask if she has difficulty sleeping and observe for pedal edema B. Inquire if she has any changes in urination and auscultate the lung fields C. Question her about appetite changes and check for pupillary response D. Ask if she has noticed a vaginal discharge and observe gait and balance
B. Inquire if she has any changes in urination and auscultate the lung fields
The emergency department clinical nurse specialist (CNS) is designing ways to teach newly hired nurses about priority setting in the triage area. Which strategy is the CNS most likely to recommend? A. Assign new nurses to triage during low-volume period B. Pair a new nurse with an experienced nurse in the triage area C. Prepare handouts and tip sheets for the principles of triage D. Have the new nurse observe the triage process for several days
B. Pair a new nurse with an experienced nurse in the triage area
Which emergency department (ED) scenario represents a concern that has been addressed by the Core Measure Sets for the ED that are established by The Joint Commission? A. Patient lacks health insurance and has no steady source of income B. Patient has waited 7 hours to be transferred to the medical-surgical unit C. Patient with a history of falls sustains a fall in the ED waiting room D. Patient has respiratory arrest and requires emergency intubation
B. Patient has waited 7 hours to be transferred to the medical-surgical unit
The nurse is reviewing the complete blood count (CBC) results for a patient who lives in a high mountain town. The patient's red blood cell count (RBC) is 6.8 million. What does this lab value combined with the patient's environment indicate? A. Anemia related to a decreased production of erythropoietin B. Polycythemia related to chronic hypoxia C. Pernicious anemia related to a regional dietary deficiency D. Hemolytic anemia elated to cold temperature
B. Polycythemia related to chronic hypoxia
The nurse is trying to prepare an intravenous antibiotic medication for a patient, but the emergency department is very busy, chaotic, and noisy, and the nurse is continuously interrupted. What should the nurse do first? A. Ask the charge nurse to administer the antibiotic medication or send additional help B. Prioritize the urgency of the medication in relation to the urgency of the interruptions C. Shut the door and proceed through the six rights of medication administration D. Preparing the medication while fielding the interruptions and delegating appropriately
B. Prioritize the urgency of the medication in relation to the urgency of the interruptions
The pathophysiology of drowning involves a washing out of surfactant, which leads to decreased surface tension, increased lung compliance, and increased airway resistance. What disorder is a result of this pathophysiology? A. Pulmonary emboli B. Pulmonary edema C. Chemical pneumonitis D. Aspiration pneumonia
B. Pulmonary edema
The emergency department (ED) nurse is caring for a patient who was found in an alley with no identification and no known family. The nurse must give medication to the patient. What is the correct procedure for patient identification? A. Emergent conditions prevent identification, so the nurse gives the medication as ordered B. The patient is designated as John Doe and the nurse uses two unique identifiers C. The nurse validates the order with another nurse and both verify that the patient is unidentified D. The nurse gives the medication and identification is made as soon as possible
B. The patient is designated as John Doe and the nurse uses two unique identifiers
Which patient would best benefit from always carrying an epinephrine autoinjector? A. Frequently works outside in the yard or tends to the garden B. Lives a long way from the nearest hospital or medical facility C. Had a previous severe allergic reaction to a wasp sting D. Has a history of severe pain with bee or wasp stings
C. Had a previous severe allergic reaction to a wasp sting
For which circumstances would the use of standard precautions be adequate to ensure the safety of the nurse, staff, and other patients? A. Performing hygienic care for a patient with copious watery diarrhea B. Assisting with intubation of a patient with symptoms of tuberculosis C. Initiating a peripheral intravenous access on a patient who is HIV positive D. Assessing a child with a fever and rash and known exposure to chickenpox
C. Initiating a peripheral intravenous access on a patient who is HIV positive
The nurse is working with at a level II trauma center. A patient involved in a chemical plant explosion arrives with burns, probably closed head injury, extremity fractures, and blunt trauma to the abdomen. What action is the nurse most likely to perform in the care of this patient? A. Preparing the patient for emergency surgery B. Debriding and cleansing the burned area C. Initiating large-bore intravenous access for fluids D. Assisting with procedures to diagnose internal hemorrhage
C. Initiating large-bore intravenous access for fluids
Which function represents an appropriate referral to the emergency department (ED) case manager? A. Check with the admissions office to get a count of available intensive care beds B. Contact the peripherally inserted central catheter (PICC) nurse, because the patient has bad veins C. Investigate whether the patient is misusing and overusing ED services D. Follow the patient into the community setting and evaluate the home environment
C. Investigate whether the patient is misusing and overusing ED services
Which patient is most likely to require the skills that the nurse learned during Advanced Cardiac Life Support (ACLS) training? A. Patient who was just informed that he will be put on the heart transplant list B. Patient who has low oxygen saturation with a history of heart failure and fluid retention C. Patient who arrives unresponsive, secondary to unwitnessed cardiac arrest D. Patient who is pending transfer to the telemetry unit for atrial fibrillation
C. Patient who arrives unresponsive, secondary to unwitnessed cardiac arrest
For which patient is the forensic nurse examiner most likely to be consulted? A. Elderly patient who died under mysterious circumstances in the emergency department B. Prisoner who was injured by a police officer while resisting arrest C. Patient who was gang-raped by a group of football players D. Patient who accidentally received a large dose of opioid medication
C. Patient who was gang-raped by a group of football players
A college student was drinking beer and dove from a 20-foot ledge into a lake. He was pulled from the lake by a friend and given mouth-to-mouth. The patient is currently in the emergency department, awake, and receiving supplemental oxygen. What type of serial assessment is the nurse most likely to initiate for this patient? A. Cardiac monitoring for possible myocardial infarction B. Level of consciousness and orientation to monitor for alcohol intoxication C. Peripheral sensation and movement related to spinal cord injury D. Frequent blood glucose checks to monitor for hypoglycemia
C. Peripheral sensation and movement related to spinal cord injury
The nurse is participating in a local community sports day. The day is hot and humid, and older adults are walking around. Prevention of heat-related injuries would include which intervention? A. Encouraging participants to eat high-energy snacks, such as sports bars B. Advising that people with disabilities should not participate C. Setting up a shade tent with areas for rest and relaxed activities D. Limiting direct sun exposure to 2 hours during the hottest time of the day
C. Setting up a shade tent with areas for rest and relaxed activities
The nurse is volunteering at the first-aid station at a local community fair. The weather is predicted to be hot and humid. In planning care for people who may experience heat-related illness in this setting, what equipment should the nurse obtain? A. Supply of salt tablets and bottles of water B. Bags of IV normal saline and IV insertion equipment C. Several water spray bottles and a portable fan D. Supply of educational pamphlets and sunscreen samples
C. Several water spray bottles and a portable fan
A patient sustained a coral snakebite and calls the emergency department for instructions. Besides calling for an ambulance, what does the nurse instruct the patient to do? A. Apply an ice pack to the wound and refresh every 20 minutes B. Incise the wound to allow the blood to flow freely and then apply sterile dressing C. Snugly wrap an elastic bandage, check arterial pulse, and apply a splint D. Place a tourniquet that is tight enough to reduce arterial flow of the venom
C. Snugly wrap an elastic bandage, check arterial pulse, and apply a splint
The nurse is assisting a neighbor with a gardening project. The neighbor sustains a snakebite when reaching to move a rock. What is the best action to perform to identify the snake? A. Crush the body of the snake with a rock but preserve the head B. Note the markings of the snake and seek pictures on the Internet C. Stand at a distance and take a digital picture of the snake D. Trap the snake using a long garden tool and bucket
C. Stand at a distance and take a digital picture of the snake
The emergency department health care team is administering emergency trauma to a drowning victim. Which task can be delegated to unlicensed assistive personnel? A. Insert the nasogastric tube B. Advise the family about the patient's status C. Take and report vital signs every 15 minutes D. Assist with bag-valve-mask during intubation
C. Take and report vital signs every 15 minutes
The emergency health care provider is currently involved in the care of several critical patients. The emergency nurse must initiate care for patients under interdisciplinary and medical protocols. Which intervention is the least likely to be covered by a standing protocol? A. Give 50% dextrose IV push for low blood sugar B. Initiate pulse oximetry monitoring and start oxygen therapy C. Ventilate with bag-valve mask at 100% oxygen and intubate D. Start a peripheral IV with normal saline at 125 mL/hr
C. Ventilate with bag-valve mask at 100% oxygen and intubate
The nurse is conducting a community presentation on cold weather safety. Which point is the nurse sure to include in the presentation? A. Hydration and water intake are not an issue, so pack extra clothes, not extra water B. Wear multiple layers of socks when participating in winter sports C. When driving in cold winter weather, carry extra clothes, food, and fluids D. Hypothermia occurs only in the winter months in the United States
C. When driving in cold winter weather, carry extra clothes, food, and fluids
The nurse is caring for patient who had cardiac and respiratory arrest after being struck by lightning. The patient was resuscitated, and he is now alert and appears to be progressing toward recovery. The nurse observes tea-colored urine in the urinary drainage bag. What does the nurse suspect? A. Chronic renal failure B. Dehydration C. Urinary tract infection D. Rhabdomyolysis
D. Rhabdomyolysis
which event would be considered an internal disaster? a. a fire in a long term care facility b. gunfire in the hospital parking lot c. a tornado devastates the community d. several people dying from flulike symptoms
a. a fire in a long term care facility
the nurse is changing a burn patients dressing. which factors would affect the number of gauze layers applied after a topical agent has been used to treat the wound? sata a. amount of drainage b. patient mobility c. amount of pain d. depth of injury e. positioning of patient f. frequency of dressing changes
a. amount of drainage b. patient mobility d. depth of injury f. frequency of dressing changes
at 0300, the emergency department charge nurse of a large suburban hospital receives notification that a commercial plane has just crashed outside the city limits. what does the nurse do? SATA a. collaborate with the medical command physician b. activate hospital emergency management plan c. initiate the staff telephone tree d. collaborate with the triage officer e. organize nursing and ancillary services f. alert the critical incident stress debriefing team
a. collaborate with the medical command physician c. initiate the staff telephone tree d. collaborate with the triage officer e. organize nursing and ancillary services
a person on the beach sustains a deep partial-thickness burn because of a severe sunburn. what is the best first aid measure that a nurse should instruct the person to apply before seeking health care? a. cool, moist towels b. dry, sterile dressings c. analgesic sunburn spray d. vitamin A and D ointment
a. cool, moist towels
following a tornado disaster, a charge nurse is assigned to be the group co-leader of a critical incident stress debriefing session. during the session, a nurse says, "we weren't prepared for this! The administration at this hospital is a joke." What is the best response? a. "this session is not about pointing fingers or fixing blame b. "tell us about what you experienced while you were caring for victims" c. "improving the emergency plan will be discussed at the administrative review" d. "we are all pretty stressed out. lets take a deep breath and calm down"
b. "tell us about what you experienced while you were caring for victims"
a client rescued from a burning building has partial and full thickness burns over 40% of the body. which is the initial physiologic change that the nurse can expect? a. an increase in blood volume b. an increase in serum potassium c. a decrease in capillary permeability d. a decrease in urinary specific gravity
b. an increase in serum potassium
which information should the nurse include in a teaching plan for a client whose burns are being treated with the exposure method? a. bathing will not be permitted b. aseptic techniques are required c. dressings will be changed every 3 days d. room temperature must be kept at 72 degree F
b. aseptic techniques are required
the nurse has just received a change of shift report for the burn unit. which client should be assessed first? a. client with deep partial thickness burns on both legs who reports severe and continuous leg pain b. client who has just arrived from the emergency department with facial burns sustained in a house fire c. client who has just been transferred from the post anesthesia care unity after having skin grafts applied to the anterior chest d. client admitted 3 weeks ago with full thickness leg and buttock burns who has been waiting for 3 hours to receive discharge teaching
b. client who has just arrived from the emergency department with facial burns sustained in a house fire
which vaccine is routinely administered when a burn patient is admitted to the hospital? a. hepatitis B b. tetanus c. influenza d. pneumonia
b. tetanus
which criteria describes a full thickness burn wound? SATA a. the wound is red, moist, and blanches easily b. there is destruction to the epidermis and dermis c. there are no skin cells for regrowth d. the burned tissue is avascular e. the burn wound will not be painful f. the burn wound has a dry, hard, leathery eschar
b. there is destruction to the epidermis and dermis c. there are no skin cells for regrowth d. the burned tissue is avascular f. the burn wound has a dry, hard, leathery eschar
at what point does fluid mobilization occur in patients with burns? a. after the scar tissue is formed and fluid are no longer being lost b. within the first 4 hours after the burns were sustained c. about 24 hours after the burn injury when the fluid is reabsorbed from the interstitial tissue d. immediately after the burns occur
c. about 24 hours after the burn injury when the fluid is reabsorbed from the interstitial tissue
a nurse in the ED is assigned to care for four clients with serious health problems. which health problem should the nurse identify as priority? a. head injury b. fractured femur c. ventricular fibrillation d. penetrating abdominal wound
c. ventricular fibrillation
a patient has sustained a relatively large burn. the nurse anticipates that the patients nutritional requirements may exceed how many kcal/day? a. 1500 b. 2000 c. 3000 d. 5000
d. 5000
which scenario is most likely to require activation of the emergency preparedness plan? a. a private six passenger plane crashes b. there is an outbreak of food-borne illness at a long-term care center on Tuesday afternoon c. an ice storm strikes a city on Monday morning and causes falls and vehicular accidents d. a multi-car accident occurs in front of a small rural hospital after midnight on a Sunday
d. a multi-car accident occurs in front of a small rural hospital after midnight on a Sunday
to prevent the development of PTSD in hospital staff, what action is likely to be taken by the facility? a. conducting administrative debriefings b. providing employees with information on PTSD c. offering employees psychological counseling d. conducting critical incident stress debriefings
d. conducting critical incident stress debriefings
for which event would a large urban hospital's emergency management plan typically be activated? a. three-car collision on the freeway b. fight between two local street gangs c. school bus involved in an accident d. explosion at a chemical factory
d. explosion at a chemical factory
what is the most effective intervention for preventing transmission of infection to a burn patient? a. use of personal protective equipment (PPE) by anyone entering the patients room b. maintaining reverse isolation during the resuscitation phase c. equipment designated for patient use d. performing correct, proper, and consistent hand hygiene
d. performing correct, proper, and consistent hand hygiene
a nurse places a client with severe burns on a circulating air bed. what is the primary reason why the nurse implements this action? a. increase mobility b. prevent contractures c. limit orthostatic hypotension d. prevent pressure on peripheral blood vessels
d. prevent pressure on peripheral blood vessels
the nurse is using the impact of event scale-revised (IES-R) to assess a UAP who was working in a long-term care facility that was devastated by a fire. the IES-R score is high on all sub-scales. what should the nurse do? a. reinforce coping strategies that the UAP is successfully doing b. suggest additional coping strategies that the UAP can use to decrease stress c. refer the UAP to a social worker or support group for survivors d. refer the UAP to a psychiatrist or clinical psychologist for additional evaluation
d. refer the UAP to a psychiatrist or clinical psychologist for additional evaluation
a nurse in the ED is assessing a client who was beaten and sexually assaulted. which is the nurse's priority assessment? a. the family's feelings about the attack b. the clients feelings of social isolation c. disturbance in the client's thought process d. the client's ability to cope with the situation
d. the client's ability to cope with the situation
a nurse is assessing a client with 2nd degree burns. the shaded areas in the illustration indicate the parts of the body where the client sustained burns. calculate the % of the body that was burned using rule of 9s (front of torso and face)...
22.5%
the nurse is performing a sterile dressing change for a client who infected deep partial thickness burns of the chest and abdomen. list the steps in order in which each should be accomplished. a. apply sliver sulfadiazine ointment b. obtain specimens for aerobic and anaerobic wound cultures c. administer morphine sulfate 10mg IV d. debride the wound of eschar using gauze sponges e. cover the wound with a sterile gauze dressing
3, 4, 2, 1, 5
Because of the high risk for healthcare acquired urinary tract infections, the nurse would question an order for a catheterized specimen for which patient? A. 78-year-old female transferred from a long-term care facility for dysuria B. 25-year-old female with back pain and hematuria, currently menstruating C. 3-year-old with severe dehydration after prolonged diarrhea and vomiting D. 43-year-old multiple trauma patient with signs of hypovolemic shock
A. 78-year-old female transferred from a long-term care facility for dysuria
The nurse is conducting a class about cold-weather hiking. What are the early signs of frostbite, which hiking partners should frequently observe for? A. White, waxy, or pale gray appearance to ears, nose, and cheeks B. Edema and redness over the exposed skin C. Mottled discoloration of the lower extremities D. Small blisters that contain clear fluid and areas that do not blanch
A. White, waxy, or pale gray appearance to ears, nose, and cheeks
The nurse is caring for a patient with a head injury whose Glasgow Coma Scale score is 3. This score indicates the patient is most likely to do what? A. Withdraw from painful stimuli B. Open eyes spontaneously C. Moan with incoherent speech D. Present as totally unresponsive
D. Present as totally unresponsive
Based on the nurse's knowledge of normal versus abnormal findings related to age and acuity, which assessment finding is of greatest concern to this nurse? A. Mottling of extremities in a newborn B. Dry skin with tenting in a 72-year-old female C. Slow pulse rate in a 35-year-old athletic male D. Rapid, shallow respirations in a healthy 18-year-old
D. Rapid, shallow respirations in a healthy 18-year-old
the nurse is caring for a patient with 45% total body surface area (TBSA) burns. which are priority medical surgical concepts for this patient? sata a. tissue integrity b. cellular regulation c. perfusion d. elimination e. fluid and electrolyte balance f. gas exchange
a. tissue integrity c. perfusion e. fluid and electrolyte balance
which feelings are most typically expressed by the burn patient? sata a. suspicion b. regression c. apathy d. denial e. suicidal ideation f. anger
b. regression d. denial f. anger
which drug therapy reduces the risk of wound infection for burn patients? a. large doses of oral anti fungal medications every 4 hours b. silver nitrate solution covered by dry dressings applied every 4 hours c. silver sulfadiazine on full-thickness injuries every 4 hours d. broad-spectrum antibiotics given intravenously
c. silver sulfadiazine on full-thickness injuries every 4 hours
a nurse is assessing a client during the first 24 hours after a burn injury. which sign indicates to the nurse that fluid replacement therapy is adequate? a. decreasing CVP readings b. urinary output of 15-20 mL/hr c. slowing of a previously rapid pulse d. hematocrit level increasing from 50-55%
c. slowing of a previously rapid pulse
A patient is admitted to the emergency department for high-altitude sickness. In the morning, he appears apathetic and declines to perform basic activities of daily living (ADLs). Later in the shift, the patient is unable to move himself in bed or to independently sit upright. What condition does the nurse suspect? A. High-altitude cerebral edema B. Severe hypoxemia C. Acute mountain sickness D. Severe hypothermia
A. High-altitude cerebral edema
Several people on a cross-country ski trip return to the ski lodge with mild hypothermia. Which items does the nurse offer or obtain for the hypothermia victims? SATA A. Synthetic-fiber hats B. Warm blankets C. Cups of hot coffee or tea D. Polyester fleece shirts E. Dry socks and gloves F. Electric space heaters
A. Synthetic-fiber hats B. Warm blankets D. Polyester fleece shirts E. Dry socks and gloves
The emergency department (ED) nurse is caring for several patients, all of whom are currently lying on stretchers awaiting discharge or transfer to a hospital bed. Which patient's have the greatest risk for falls? SATA A. Patient with chronic pain who received 10 mg PO oxycodone for myalgia B. Opioid-naive teenager with a fracture who received 3 mg IV morphine for pain C. Middle-aged woman with severe vomiting and frequent watery stools for 3 days D. Young child with a fever of 102, crying, with an ear infection E. Older adult patient with acute dementia secondary to an infection F. Young woman with heavy vaginal bleeding secondary to miscarriage
B. Opioid-naive teenager with a fracture who received 3 mg IV morphine for pain C. Middle-aged woman with severe vomiting and frequent watery stools for 3 days E. Older adult patient with acute dementia secondary to an infection F. Young woman with heavy vaginal bleeding secondary to miscarriage
A patient is being treated for a bark scorpion sting. He is currently alert but somewhat confused. He reports localized pain (7/10) at the site and requires frequent oral suction. Vital signs are Temperature 102F, pulse 95/min, respirations 12/min, and blood pressure 140/85 mm Hg. Which medication prescription does the nurse question? A. Acetaminophen 650 mg prn (as needed) B. Tetanus toxoid 0.5 mL intramuscularly x 1 dose C. Morphine 20 mg intravenous push for severe pain D. Atropine 0.4 mg subcutaneously for hyper-salivation
C. Morphine 20 mg intravenous push for severe pain
An experienced nurse is working in triage. For which circumstance is the nurse most likely to seek input from the emergency health care provider or advanced practice nurse about acuity level of the patient? A. A 65-year-old man is having severe left anterior chest pain and shortness of breath B. A 35-year-old man with history of kidney stones has severe back pain and hematuria C. A 1-year-old child with history of frequent ear infections is screaming and pulling at his ear D. A 23-year-old female with previous good health has sudden, severe, flulike symptoms
D. A 23-year-old female with previous good health has sudden, severe, flulike symptoms
the nurse is monitoring the nutritional status of a burn patient. which indicators will the nurse use? sata a. amount of food the patient eats b. weight to height ratio c. serum albumin d. amount of water the patient drinks e. blood glucose f. serum potassium
a. amount of food the patient eats b. weight to height ratio c. serum albumin e. blood glucose
a client is shot in the chest during a holdup and is transported to the hospital via ambulance. in the ED, chest tubes are inserted, one in the second intercostal space and one at the base of the lung. what does the nurse expect the tube in the second intercostal space to accomplish? a. remove the air that is present in the intrapleural space b. drain serosanguineous fluid from the intrapleural compartment c. permit the development of positive pressure between the layers of pleura d. provide access for instillation of medication into the pleural space
a. remove the air that is present in the intrapleural space
which is the most difficult problem for the nurse to manage when meeting the needs of an extensively burned client 3 days after admission? a. severe pain b. maintenance of sterility c. alteration in body image d. frequent dressing changes
a. severe pain
what is the primary reason to prevent infection with burn injuries? a. prevent extensive scar formation b. avoid sepsis c. avert worsening of pain d. avoid fever and inflammation
b. avoid sepsis
a patient has sustained significant burns that have created a hyper metabolic state. in planning care for this patient, what does the nurse consider? a. increased retention of sodium b. decreased secretion of catecholamines c. increased caloric needs d. the decrease in core temperature
c. increased caloric needs
The emergency department (ED) nurse is preparing a Situation, Background, Assessment, Recommendation (SBAR) report on a patient being admitted for bacterial meningitis. Which points are included in the ED nurse's report to the medical-surgical nurse? SATA A. "Patient reports severe headache with high fever that started 4 days ago" B. "Patient is currently alert and oriented x 2; speech clear but rambling" C. "Patient is very demanding and has used the call bell repeatedly since arriving in the ED" D. "IV normal saline into left anterior forearm; received first dose of IV ceftriaxone at 0700" E. "Lumbar puncture results are pending, but meningococcal meningitis is suspected" F. "Patient has male characteristics but prefers to be called Mrs. Jenny Jones"
A. "Patient reports severe headache with high fever that started 4 days ago" B. "Patient is currently alert and oriented x 2; speech clear but rambling" D. "IV normal saline into left anterior forearm; received first dose of IV ceftriaxone at 0700" E. "Lumbar puncture results are pending, but meningococcal meningitis is suspected" F. "Patient has male characteristics but prefers to be called Mrs. Jenny Jones"
A homeless man is found lying in a vacant lot in the middle of July. He is lethargic and confused, and he has sustained severe sunburns on the exposed areas of his skin. His core temperature is 106F. Which laboratory test can be used to predict severity and organ damage? A. Cardiac troponin I B. Creatine kinase C. Clotting studies D. Complete blood count
A. Cardiac troponin I
A parent brings her 2-year-old child to the emergency department, stating, "She fell and bumped her head and forearm." Which behavior by the child causes the nurse the least concern during the initial triage interview? A. Crying and reaching for the parent as the nurse approaches B. Alert and still, quietly watching as the nurse approaches C. Asleep, limp, with even and unlabored respirations D. Crying loudly and inconsolably since she was brought in
A. Crying and reaching for the parent as the nurse approaches
The nurse is working in a large urban hospital. In what circumstances is the nurse most likely to refer to the emergency departments automated electronic tracking system? A. Desires to know if a patient's computerized tomography scan is completed B. Is seeking a complete previous medical record for a patient C. Needs a medication for a patient that should be coming from the pharmacy D. Believes that a patient frequently visits the ED and request prescriptions for opioids
A. Desires to know if a patient's computerized tomography scan is completed
A patient is admitted for a brown recluse spider bite. The nurse observes that the patient has hemorrhagic complications of hematuria, hemoptysis, petechiae, and extensive bruising. These clinical observations indicate to the nurse that the patient may be experiencing which complication associated with the bite? A. Disseminated intravascular coagulation B. Agranulocytosis C. Thrombocytopenia D. Aplastic anemia
A. Disseminated intravascular coagulation
What might the nurse notice if the patient has impaired thermoregulation as a result of cold-related injury? SATA A. Hyperemia and edema of fingers or toes B. Shivering C. Possible atrial fibrillation D. Numbness and pain of nose or ears E. Profuse diaphoresis F. Headache, weakness, nausea, and/or vomiting
A. Hyperemia and edema of fingers or toes B. Shivering D. Numbness and pain of nose or ears
The nurse has volunteered at a storm shelter to identify potential problems associated with cold-related injuries. Which conditions predispose people to a greater risk for cold injury? SATA A. Hypothyroidism B. Advanced age C. Crohn's disease D. Alcohol intoxication or substance abuse E. Malnutrition F. Cold water immersion
A. Hypothyroidism B. Advanced age D. Alcohol intoxication or substance abuse E. Malnutrition F. Cold water immersion
A young migrant worker has been living in a garden shed for several months. He is brought to the emergency department (ED) and is alert and conversant but appears fearful and confused. His skin is hot and dry, and his lips are cracked and bleeding. His skin turgor is poor, and he is malnourished. His blood pressure is 96/60 mm Hg, pulse is 130, respirations are 30 and temperature is 105F. In addition to high-flow oxygen, what does the nurse anticipate the ED healthcare provider will initially order? A. IV normal saline and an indwelling urinary catheter B. IV Ringer's lactate and a nasogastric tube C. IV 5% dextrose and acetaminophen D. IV 45% saline and chlorpromazine
A. IV normal saline and an indwelling urinary catheter
Which combination of factors is likely to contribute to the highest survival rate for drowning victims who are immediately transported to the emergency department for care? A. In very cold fresh water for 7 minutes; arrives in ED with pulse of 40 B. In warm salt water for 12 minutes; arrives in ED with pulse of 150 C. In very cold salt water for 10 minutes; arrives in ED with no pulse D. In warm contaminated water for 6 minutes; arrives in ED with no pulse
A. In very cold fresh water for 7 minutes; arrives in ED with pulse of 40
A 37-year-old woman was stung by bees while gardening. Which factor is most likely to cause her to develop a systemic effect? A. Multiple bee stings B. Immediate local reaction C. Desensitization to the venom D. First time incident of bee sting
A. Multiple bee stings
Which complications are related to a black widow spider bite? SATA A. Muscle rigidity and spasms of large muscles B. Severe tinnitus C. Severe abdominal pain D. Lactrodectism E. Hypertension F. Seizures
A. Muscle rigidity and spasms of large muscles C. Severe abdominal pain D. Lactrodectism E. Hypertension F. Seizures
Which patient has the most predisposing factors that are associated with heat-related illness? A. Obese older male who drinks beer in the afternoon at a baseball game B. Middle-aged female with hypothyroidism who lives in the southern United States C. Malnourished young female with an eating disorder who exercises in the morning D. Young female with iron-deficiency anemia who is in the first trimester of pregnancy
A. Obese older male who drinks beer in the afternoon at a baseball game
What is the fastest way for the nurse to estimate the systolic blood pressure in a patient with multiple injuries who has just been moved from the transport stretcher to the emergency department resuscitation stretcher? A. Palpate for presence of a radial pulse B. Use the automated blood pressure cuff C. Place the patient on a cardiac monitor D. Check for the presence of capillary refill
A. Palpate for presence of a radial pulse
The healthcare provider orders IV infusion of epinephrine for an older adult patient for an allergic reaction to a bee sting. In conjunction with the epinephrine administration, which action does the nurse take? A. Places the patient on a cardiac monitor B. Inserts an indwelling urinary catheter C. Obtains an order for an electrocardiogram D. Obtains an order for an arterial blood gas
A. Places the patient on a cardiac monitor
The nurse is interviewing a homeless patient in the triage area. The patient says, "I'm a nurse too. Flying pictures say God is me. I am god, taking noise away." The patient then stands up and kicks over the garbage can. What should the nurse do first? A. Remain calm and slowly step away from the patient B. Run toward the panic button and immediately push it C. Gently take the patient's arm and lead him to a quiet space D. Call for help and instruct bystanders to get out of the way
A. Remain calm and slowly step away from the patient
A patient is brought to the emergency department (ED) by the family because he has verbally threatened others and attempted to stab the neighbor's dog. What does the nurse do to ensure the safety of the patient and others? SATA A. Search the patient's belongings and secure personal effects B. Instruct the patient's family to stay with him and call for help as necessary C. Remove dangerous equipment from the room, such as sharps containers or portable instruments D. Escort the patient to the waiting area, where he can readily be observed by the triage nurse E. Use a metal detector to search for objects that could be used as weapons F. Put the patient into 4-point restraint until a psychiatric consult can be obtained
A. Search the patient's belongings and secure personal effects C. Remove dangerous equipment from the room, such as sharps containers or portable instruments E. Use a metal detector to search for objects that could be used as weapons
The nurse is advising a group of parents who are organizing a winter cross-country skiing trip. In assisting the parents to develop an appropriate winter clothing list, which articles should be taken on the trip? SATA A. Synthetic socks B. Cotton underwear C. Polyester fleece shirt D. Windproof outer jacket E. Hat made from waterproof, breathable fabric F. Sunglasses
A. Synthetic socks C. Polyester fleece shirt D. Windproof outer jacket E. Hat made from waterproof, breathable fabric F. Sunglasses
What are the most common signs/symptoms of high-altitude pulmonary edema? SATA A. Tachypnea at rest B. Persistent dry cough C. Abdominal pain and cramping D. Waxy appearance of ears, cheeks, and nose E. Cyanotic lips and nail beds F. Bradycardia at rest
A. Tachypnea at rest B. Persistent dry cough E. Cyanotic lips and nail beds
The nurse sees that the emergency provider has written an order to discharge an elderly patient to go home. The patient cannot walk independently and has no relatives. What should the nurse do first? A. Talk to the provider about the patient's self-care abilities B. Ask the patient if a friend could come to the hospital C. Obtain a taxicab voucher for the patient D. Consult social services for nursing home placement
A. Talk to the provider about the patient's self-care abilities
What should the nurse interpret for the patient with impaired thermoregulation as a result of a cold-related injury? SATA A. Temperature B. Cardiac assessment C. Neurologic assessment D. Gastrointestinal assessment E. Fluid status F. Skin integrity
A. Temperature B. Cardiac assessment C. Neurologic assessment E. Fluid status F. Skin integrity
A patient comes to the emergency department after falling off a roof. He displays absent breath sounds over the left chest, severe respiratory distress, hypotension, jugular vein distention, and tracheal deviation to the right. Based on these assessments findings, for which condition does the nurse anticipate the patient must receive immediate treatment? A. Tension pneumothorax B. Cardiac arrest C. Airway obstruction D. Multiple fractured ribs
A. Tension pneumothorax
How should the nurse respond to the patient with impaired thermoregulation as a result of a cold-related injury? SATA A. Thaw frozen body parts in a warm-water bath and handle gently B. Provide pain control measures C. Advocate for increased drug doses as a result of lowered metabolism D. Administer tetanus prophylaxis and possible antibiotics for open wounds E. Initiate passive external rewarming by covering with blankets F. Prepare patient for possible amputation of frostbitten body parts
A. Thaw frozen body parts in a warm-water bath and handle gently B. Provide pain control measures D. Administer tetanus prophylaxis and possible antibiotics for open wounds E. Initiate passive external rewarming by covering with blankets
The healthcare provider orders core warming methods for a conscious patient with moderate hypothermia. What equipment would the nurse obtain to provide this therapy? A. Three-way urinary catheter with warmed lavage fluid B. Axillary thermometer to monitor core temperature C. Bag-valve mask with warmed humidified oxygen D. Several warm blankets and warming pads
A. Three-way urinary catheter with warmed lavage fluid
A patient was bitten by a brown recluse spider 4 days ago. The nurse observes prolonged bleeding after venipuncture and notes that the patient has a low platelet count. What do these findings indicate? A. Thrombocytopenia B. Hemolytic anemia C. Aplastic anemia D. Agranulocytosis
A. Thrombocytopenia
A patient arrives at the emergency department after prolonged cold exposure. The staff avoids rough and vigorous movements during the transfer from stretcher to bed to prevent which complication? A. Ventricular fibrillation related to rough handling B. Third-degree heart block related to cold autotransfusion C. After-drop due to cold blood moving to the central circulation D. Pulmonary emboli related to dislodgment of a clot
A. Ventricular fibrillation related to rough handling
The nurse is instructing a patient who has a history of severe allergic reaction to bee stings on what to do if he experiences a bee sting in the future. What information does the nurse relay to the patient? SATA A. Wear a medical alert bracelet B. Take an antihistamine before trying the EpiPen injection C. Administer epinephrine immediately D. Call 911 to be transported to a medical facility E. Immediately apply a moist warm towel F. Obtain a prescription for prophylactic corticosteroids
A. Wear a medical alert bracelet C. Administer epinephrine immediately D. Call 911 to be transported to a medical facility
Each patient listed below has entered the emergency department's waiting area. Place them in order of priority, with 1 being the highest priority and 4 being the lowest priority. A. 3-year-old child with inconsolable high-pitched cry, high fever, headache, and nuchal rigidity B. 65-year-old man having diaphoresis with crushing left anterior chest pain C. 32-year-old woman reporting upper abdominal pain and vomiting green bile emesis D. 16-year-old boy with a broken arm from skateboarding and pulse and sensation intact
B (highest priority), A, C, D (lowest priority)
An older gentlemen is brought to the emergency department by a neighbor who tells the nurse, "Mr. S has been drinking heavily and seems depressed and is saying strange things." What is the priority question for the nurse to include in the assessment? A. "What makes you think that Mr. S is depressed?" B. "Has Mr. S expressed any thoughts about suicide or self-harm?" C. "How much alcohol has Mr. S drunk in the past few days?" D. "Who would normally provide emotional support for Mr. S?"
B. "Has Mr. S expressed any thoughts about suicide or self-harm?"
A patient reports having throbbing headache with nausea and vomiting "like the worst hangover of my life" after recently returning from a hiking trip to the mountains. The nurse suspects high-altitude sickness. Which question helps the nurse gather relevant information about this condition? A. "Did you experience any episodes of hypothermia during your trip?" B. "How quickly did you ascend to the top of the mountain range?" C. "Did you go skiing or hiking in a nearby area?" D. "Did you have trouble sleeping while you were in the mountains?"
B. "How quickly did you ascend to the top of the mountain range?"
Which patient should be triaged as emergent? A. 56-year-old man with severe unilateral back pain and previous history of kidney stones B. 23-year-old woman with severe abdominal pain, positive home pregnancy test, and BP 80/40 mm Hg C. 6-year-old with a temperature of 101 and flulike symptoms D. 10-year-old girl with vomiting, diarrhea, and abdominal cramps onset 4 hours after eating fish
B. 23-year-old woman with severe abdominal pain, positive home pregnancy test, and BP 80/40 mm Hg
The nurse is assessing a patient who reports being bitten by a black widow spider. The patient may have clinical signs and symptoms that mimic which disorder? A. Myocardial infarction B. Acute abdomen C. Acute renal failure D. Deep vein thrombosis
B. Acute abdomen
A patient treated for severe allergic reaction to a bee sting tells the nurse, "The doctor told me that I had to be careful about getting bee stings in the future because I could have another allergic reaction." Based on the patient's statement, what is the nurse's first action? A. Repeat the information that the healthcare provider gave her B. Assess the patient's understanding of allergic reactions and first aid C. Advise the patient to obtain a medical alert bracelet D. Ensure that the patient has a prescription for an epinephrine autoinjector
B. Assess the patient's understanding of allergic reactions and first aid
A person is stung by a wasp at a picnic. The person has no difficulty breathing and no history of allergic reaction to bee or wasp stings. What is the priority first-aid action for this person? A. Place a tourniquet proximal to the sting B. Gently scrape the stinger off with the edge of a credit card C. Apply a warm pack to the area and elevate D. Observe the area for signs of inflammation prior to taking any action
B. Gently scrape the stinger off with the edge of a credit card
The patient died in the emergency department despite resuscitation efforts. Homicide is suspected. Which nursing action would be incorrect because of the likelihood of forensic investigation? A. Invites the family to spend time with the deceased patient B. Gives the patient's clothes and other belongings to the family C. Declines to give information to friends of the deceased D. Leaves intravenous lines and indwelling tubes in place
B. Gives the patient's clothes and other belongings to the family
Based on mechanism of injury, which patient is most likely to automatically require trauma team intervention? A. Stab wound to the leg B. Gunshot wound to the chest C. Possible drowning D. Unwitnessed cardiac arrest
B. Gunshot wound to the chest
Which occurrence in the patient treated for acute mountain sickness indicates that treatment with acetazolamide was effective? A. Decreased pulse rate and decreased urine output B. Increased urine output and increased respiratory rate C. Periodic respirations during sleep and decreased pulse D. Decreased sleep disturbance and decreased respiratory rate
B. Increased urine output and increased respiratory rate
An older adult is in the emergency department (ED) for over 12 hours awaiting transfer to an inpatient bed. The charge nurse delegates turning the patient every 2 hours the the unlicensed assistive personnel (UAP) because the patient is at risk for skin breakdown. The patient is not turned and begins to develop a pressure ulcer. What does the charge nurse do to prevent a recurrence of this type of problem for future patients? SATA A. Nothing; in the overall priorities of the ED, the situation is unfortunate but unavoidable B. Make anecdotal notes and counsel all the involved UAPs C. Delegate the duty of turning and repositioning to the family members D. File an incident report and seek assistance at the system level E. Reeducate staff on the need to turn patients at risk for skin breakdown F. Evaluate UAP-patient ratios when patients require frequent turning
B. Make anecdotal notes and counsel all the involved UAPs D. File an incident report and seek assistance at the system level E. Reeducate staff on the need to turn patients at risk for skin breakdown F. Evaluate UAP-patient ratios when patients require frequent turning
Which lightning-strike victim should receive attention first? A. Teenager who is motionless except for shallow respirations; he has a weak pulse B. Middle-aged man, unconscious, with no palpable pulse C. Confused older adult woman with apparent paralysis in lower extremities D. Child crying, with bleeding from ears, mottled skin, and decreased pulses in left leg
B. Middle-aged man, unconscious, with no palpable pulse
The nurse is teaching a class on water safety to a group of 5-year-old children. Which point is the nurse most likely to emphasize with this group? A. Take swimming lessons and learn how to use floatation devices B. Never swim alone; a parent or other adult should always be with you C. Always test the water depth before jumping in head-first D. If your friends don't know how to swim, always watch out for them
B. Never swim alone; a parent or other adult should always be with you
The nurse is working in a mountain clinic where there is a high incidence of cold-related injuries. Which signs/symptoms indicate the most severe case of frostbite? A. Large fluid-filled blisters with partial-thickness skin necrosis B. Numbness, coldness, and bloodlessness of affected area C. Small blisters that contain dark fluid; skin is cool D. Pain, numbness, and pallor of the affected area
B. Numbness, coldness, and bloodlessness of affected area
At a park, the nurse observes a mother of a toddler attempting to remove the stinger of a bee with tweezers. What should the nurse do? A. Instruct the mother to stop, because tweezing the stinger injects additional venom B. Reinforce that removing the stinger with tweezers or by scraping is correct C. Suggest applying an ice pack for local anesthesia before removing the stinger D. Place a bandage over the stinger and suggest immediately going to the hospital
B. Reinforce that removing the stinger with tweezers or by scraping is correct
An anaphylactic reaction to a wasp or bee sting manifests as which condition? SATA A. Hypertension B. Respiratory distress C. Hypoglycemia D. Laryngeal edema E. Deterioration in mental status F. Bronchospasm
B. Respiratory distress D. Laryngeal edema E. Deterioration in mental status F. Bronchospasm
The emergency department nurse receives a phone call from someone stating that he and his friends have been out in the cold weather and his friend's fingers of the right hand appear white and waxy. What does the nurse direct the caller to do? A. Seek shelter immediately and massage and briskly rub the fingers B. Seek shelter immediately and place the hands under the armpits C. Seek medical attention and place hands on car heating vents while en route D. Seek medical attention and place fingers in cool water while en route
B. Seek shelter immediately and place the hands under the armpits
A patient comes to the emergency department with severe respiratory distress. He has a long history of chronic respiratory disease and now requires endotracheal intubation. How does the nurse assess this patient's lung compliance? A. Auscultate the lung fields, especially for coarse crackles B. Sense the degree of difficulty in ventilating with a bag-valve mask C. Monitor the pulse oximeter for decreasing saturation levels D. Count the respiratory rate and observe the respiratory effort
B. Sense the degree of difficulty in ventilating with a bag-valve mask
Which measures are correct when rewarming a victim of deep frostbite? SATA A. Briskly rub the area to speed the warming process B. Use rapid rewarming in a 104F-108F water bath C. Apply a heating pad and adjust temperature to the lowest setting D. Elevate the extremity above the heart level after rewarming E. Administer an opioid analgesic for pain associated with rewarming F. Administer tetanus immunization for prophylaxis
B. Use rapid rewarming in a 104F-108F water bath D. Elevate the extremity above the heart level after rewarming E. Administer an opioid analgesic for pain associated with rewarming F. Administer tetanus immunization for prophylaxis
A patient calls the healthcare provider's office asking for advice about whether to seek immediate medical attention for a bee sting. She has no shortness of breath of swelling to the face, throat, or lips. Which question will elicit information to assist the patient in making the decision? A. "Were you stung by an African 'killer bee'?" B. "Is the affected area red, painful, or swollen?" C. "Did you receive multiple stings?" D. "Were you able to remove the stinger?"
C. "Did you receive multiple stings?"
The emergency department (ED) nurse is attempting to transfer a patient to the medical-surgical unit. When the receiving nurse answers the phone, he says, "You people always dump these admissions on us during shift change." Which response by the ED nurse represents the best attempt at respectful negotiation and collaboration? A. "I am sorry. I realize you are busy, but we are busy too." B. "I am also trying to finish handoff report. Should I call the supervisor?" C. "I apologize for the timing. How much time do you need for shift change?" D. "I apologize. We just received the bed assignment."
C. "I apologize for the timing. How much time do you need for shift change?"
The emergency health care provider and the nurse go together to tell the family that a patient died despite resuscitation efforts. What is the best way to inform the family? A. "We did everything that we could, but Mr. S expired" B. "Mr. S never woke up, but we are sure that he passed on without discomfort" C. "We are sorry to inform you that Mr. S died due to extensive injuries" D. "We want to extend our sympathies because Mr. S is not with us anymore"
C. "We are sorry to inform you that Mr. S died due to extensive injuries"
A patient with a sprained ankle says, "I have been here for 4 hours, and other people who came after me have been taken back to see the doctor. My ankle hurst! Why am I being ignored?" What is the best response? A. "Sir, other patients have problems that are more serious than yours" B. "This is a system fault; if you would like to complain, I'll call a supervisor" C. "We have to attend to life-threatening or unstable conditions first" D. "Sir, I see that you are frustrated but please sit down and wait your turn"
C. "We have to attend to life-threatening or unstable conditions first"
An elderly patient is brought to the emergency department by the paramedics. The patient is alert but disoriented, and the left lower leg has swelling and deformity; an air splint is in place. Which question is most essential to ask the paramedics? A. "How did the patient describe the level of pain?" B. "Does the patient normally walk independently?" C. "What was the mechanism of injury?" D. "What time was the air splint applied?"
C. "What was the mechanism of injury?"
An elderly man is brought to the emergency department by his son. The patient is alert but is disoriented to person, place, and time and is unable to follow simple instructions. Which question is the most important to ask the son? A. "Do you think your father would consent to emergency care?" B. "Did you bring a list of your father's medications and allergies?" C. "When did you first notice your father's disorientation and confusion?" D. "Do you have the power of attorney for health for your father?"
C. "When did you first notice your father's disorientation and confusion?"
A teenager is brought to the emergency department with a reported bee sting. The nurse observes facial swelling, an audible wheeze, and labored rapid breathing. The teen's friend reports he has been vomiting and having trouble speaking and breathing. What does the nurse anticipate the priority medication order will be? A. IV normal saline bolus of 400 mL B. 50 mg diphenhydramine PO (by mouth) C. 0.5 mL of 1:1000 epinephrine IV D. 100 mg methylprednisolone sodium succinate IV infusion
C. 0.5 mL of 1:1000 epinephrine IV
A patient calls the emergency department for advice on immediate first aid for a brown recluse spider bite on his hand. He denies allergic response or shortness of breath and states that he plans to see his health care provider but is currently about 2 to 3 hours away. What does the nurse advice the patient to do? A. Apply a warm pack and elevate the extremity B. Scrub the bite area several times with soap and water C. Apply cold compress and rest as much as possible D. Apply a snug constricting band at the wrist level
C. Apply cold compress and rest as much as possible
What responses does the "diving reflex" cause in the body? SATA A. Tachypnea B. Metabolic alkalosis C. Bradycardia D. Decreased cardiac output E. Vasoconstriction of vessels in the intestines and kidneys F. Increased blood flow into peripheral circulation
C. Bradycardia D. Decreased cardiac output E. Vasoconstriction of vessels in the intestines and kidneys
A man is found in an alley in cold weather for an unknown length of time. His hands, toes, and face show evidence of frostbite; otherwise, there are no obvious injuries. He is severely obtunded with a pulse of 43 beats/min, respirations of 9/min, and a core temperature of 90F. What is this patient's most immediate physiologic risk? A. Acute respiratory distress syndrome B. Pulmonary edema C. Cardiac arrest D. Acute renal failure
C. Cardiac arrest
A construction worker who was struck by lightning is brought to the emergency department (ED). He was found unconscious, but cardiopulmonary resuscitation was started immediately, and he awoke just before arrival of emergency medical service personnel. In the ED, he is alert but confused and reports pain to his right hand and foot with fern-like marks. Which assessment tool is the priority for this patient? A. Glasgow Coma Scale B. Pulse oximeter C. Cardiac monitor D. Rule of nines chart
C. Cardiac monitor
The nurse is helping the healthcare provider treat a patient with a tension pneumothorax. What type of equipment does the nurse obtain to immediately alleviate this life-threatening condition? A. Large adult endotracheal tube B. Transvenous pacemaker insertion C. Chest tube insertion tray D. Tracheostomy tray
C. Chest tube insertion tray
A man who was stung by a wasp is treated and observed for several hours for symptoms of urticaria, pruritus, and swelling of the lips and then discharged home with medication instructions. Which medication is most likely to be prescribed to prevent delayed allergic effects? A. Epinephrine autoinjector B. Acetaminophen as needed C. Corticosteroids in tapered doses D. Albuterol
C. Corticosteroids in tapered doses
A patient sustained a coral snakebite and developed severe complications. Which diagnostic test result will reveal the physiologic damage that occurs with envenomation? A. Complete blood count B. Coagulation profile C. Creatine kinase D. Electrolytes
C. Creatine kinase
A patient sustained a brown recluse bite and has been admitted for IV antibiotics and wound management. Which laboratory value indicates that the patient may be developing severe systemic complications from the bite? A. Increased red blood cell count B. Increased glucose level C. Decreased platelet level D. Decreased blood urea nitrogen
C. Decreased platelet level
The nurse is evaluating the lower extremities of several patients. Which description represents the least serious physical presentation? A. Pain in calf; lower leg is swollen and red B. Progressively increasing pain; distal portion is cool and bluish C. Decreased sensation; lower leg has widespread brownish discoloration D. Tight sensation in ankle; skin appears tight, shiny, and edematous
C. Decreased sensation; lower leg has widespread brownish discoloration
The nurse observes that a homeless woman frequently comes to the emergency department during the winter for symptoms of dizziness and generalized pain. The patient typically stays for several hours, undergoes diagnostic testing, and is discharged with a referral to a primary care provider. What is the nurse's best action? A. Assess and treat the patient as if she were any other patient B. Offer food and a blanket and encourage her to leave after she warm up C. Develop an individual care plan using an interdisciplinary team approach D. Talk to the patient and attempt to establish validity of symptoms
C. Develop an individual care plan using an interdisciplinary team approach
A patient died in the emergency department after sustaining multiple injuries that occurred during an aggravated assault. The family arrives after the patient is pronounced dead, and they ask to see the body. What does the nurse do? A. Explain that viewing the body would be too traumatic because all of the tubes must remain in place for the forensic exam B. Remove any tubes or debris that is near the patient's face and then cover the rest of the body with a blanket C. Explain what they will see; dim the lights; leave the patient's face exposed; and cover the rest of the body with a blanket D. Suggest that the family could spend time with their loved one at the mortuary after the medical examiner is finished
C. Explain what they will see; dim the lights; leave the patient's face exposed; and cover the rest of the body with a blanket
Which person has the greatest risk for injury from lightening strike? A. Jogger in the park at mid-morning in December B. Deer hunter walking through the woods in the evening in October C. Golfer out on the green in the late afternoon in June D. Camper walking on the beach during the early morning in April
C. Golfer out on the green in the late afternoon in June
The emergency department (ED) trauma team is preparing to receive a motor vehicle crash victim with severe chest trauma who is coughing up blood and has a crush injury to the right leg. What type of personal protective equipment (PPE) does the nurse who is assigned to do the recording put on? A. No PPE is necessary because the nurse is only recording and not giving direct care B. Gloves only, but hand-washing is required before and after all emergency care C. Gown, gloves, eye protection, face mask, cap, and shoe covers D. Patient situation must first be assessed before determining what PPE to wear
C. Gown, gloves, eye protection, face mask, cap, and shoe covers
The day camp nurse is with a group of children who have been participating in hiking, swimming, and crafts. The nurse sees a child who is soaking wet, stumbling, and taking off all her clothes. What does the nurse suspect is wrong with this child? A. Water snakebite B. High-altitude sickness C. Hypothermia D. Nearly drowned
C. Hypothermia
The nurse is on a backpacking trip. One of the hikers sustains a pit viper bite to the lower leg. Which first-aid measure will the nurse perform while waiting for transportation to the hospital? A. Elevate the leg and apply cool packs B. Incise the fang marks with a pocket knife C. Immobilize the leg with a splint in a functional position D. Apply a constricting band proximal to the fang marks
C. Immobilize the leg with a splint in a functional position
A patient arrives in the emergency department after sustaining a cottonmouth snakebite. What is included in the immediate interventions for this patient? A. Assessing for cranial nerve deficits B. Applying a pressure bandage C. Monitoring blood pressure and cardiac function D. Administering packed red blood cells
C. Monitoring blood pressure and cardiac function
The nurse is participating in a summer hike with a group of children. Suddenly the children start screaming, "Snake! Snake!" One little girl is sitting in a tall grassy area, clutching her ankle and crying. What is the priority in the field care of this child? A. Remove any constricting clothing from the child's leg B. Maintain the child's extremity below the level of the heart C. Move children to a safe area and encourage the child to rest D. Keep the child warm and provide calm reassurance
C. Move children to a safe area and encourage the child to rest
Which factor is most likely to hinder the nurse's ability to objectively and accurately perform triage duties? A. Nurse has ambiguity about which triage model is the best for selected patients B. Several patients arrive simultaneously at the triage area C. Nurse is personally experiencing compassion fatigue and burnout D. Patient has a complex health history and is a poor historian
C. Nurse is personally experiencing compassion fatigue and burnout
A rescue team is attempting to take the patient to the hospital for symptoms of high-altitude pulmonary edema. The descent to the hospital is delayed due to severe weather conditions. What is the most important treatment for this patient during the delay? A. Dexamethasone B. Furosemide C. Oxygen administration D. Keep patient as warm as possible
C. Oxygen administration
A patient was struck by lightning and sustained temporary paralysis of the lower limbs, which resolved with no physical effects, but the patient developed emotional problems. Which mental health disorder is the most likely complication? A. Generalized anxiety disorder B. Schizophrenia C. Post-traumatic stress disorder D. Acute-onset dementia
C. Post-traumatic stress disorder
Which person is best demonstrating behaviors that would prevent heat-related illness? A. Sits in a shaded patio and drinks ice-cold beer and mixed alcohol drinks B. Plays touch football in the mid-afternoon wearing a hat and sunscreen C. Works in the garden in the morning and frequently rests and take breaks D. Wears short pants and sleeveless shirt while hiking on a hot day
C. Works in the garden in the morning and frequently rests and take breaks
Two teenagers bring their friend to the emergency department because "he was drowning." The patient is unconscious but breathing spontaneously, and he is immediately taken to the resuscitation area. Which question is most important for the nurse to ask the patient's friends in determining the outcomes for this patient? A. "Was this a freshwater or saltwater drowning?" B. "Does he have any medical conditions, such as seizures?" C. "Was the water contaminated with chemicals or algae?" D. "How long was he under the water and not breathing?"
D. "How long was he under the water and not breathing?"
The nurse is using the SBAR method to give a handoff report to the nurse who will assume care of the patient. What would the nurse say first? A. "Mr. S is very uncomfortable, and we should get him admitted as soon as possible" B. "Mr, S has a history of high blood pressure but stopped taking medication 3 months ago" C. "Mr. S's vital signs are T 98.6, P: 80/min, R 16/min, and BP 160/80" D. "Mr. S is a 65-year-old male who came to the emergency department for a severe headache"
D. "Mr. S is a 65-year-old male who came to the emergency department for a severe headache"
The nurse receives a phone call from a child who says, "Mommy was hit by lightning! She's outside. I am afraid to touch her! I'll get shocked too!" How does the nurse advice the child? A. "There is no danger in touching your mom. You won't get hurt." B. "It will be okay, just quickly run outside and see if she is breathing" C. "Is there anybody at home with you? I need to speak to an adult?" D. "You stay in the house, and someone will come to help very soon."
D. "You stay in the house, and someone will come to help very soon."
The nurse is working alone in triage. It is a busy night and the waiting room is full of people who are restless and unhappy about having to wait. Which situation warrants the nurse to activate the panic button? A. The line for patients waiting to be triaged becomes overwhelming long B. Emergency medical services calls en route with a patient in full arrest C. Several patients in the waiting room start to complain very loudly D. A person walks in and starts threatening the registration staff with a weapon
D. A person walks in and starts threatening the registration staff with a weapon
A patient sustained severe frostbite to the toes and lower legs. He received rewarming therapy in the emergency department and arrives to the medical-surgical unit with a splint on both legs. IV normal saline is infusing at 125 mL/hr. He reports pain in the lower extremities. Which health care provider order does the nurse question? A. Give morphine 1-2 mg IV push prn for pain in extremities B. Elevate bilateral lower extremities above the level of the heart C. Perform neurologic and circulation checks on bilateral lower extremities every hour D. Apply compression bandage to bilateral lower extremities
D. Apply compression bandage to bilateral lower extremities
Which action would typically be performed by the emergency department bereavement committee? A. Assigns a staff nurse to sit with the family during resuscitation efforts of the patient B. Advocates that one or two family members be allowed at bedside during resuscitation C. Provides grief counseling and group support for nurses who care for patients who die D. Attends funerals, sends sympathy cards, and makes follow-up calls to family
D. Attends funerals, sends sympathy cards, and makes follow-up calls to family
An older couple on vacation comes to the emergency department (ED). The man is unable to speak clearly or coherently. His wife is very distraught and states, "He has many allergies and takes many medications, but I can't remember anything right now!" What should the nurse do first to quickly obtain drug and allergy information? A. Call the patient's family health care provider for a phone report about is drugs and allergies B. Remind the wife to keep a list of patient's drugs and allergies in her purse C. Call the pharmacy where the patient obtains most of his medications D. Check for a medical alert bracelet and help the wife to look in the patient's suitcase
D. Check for a medical alert bracelet and help the wife to look in the patient's suitcase
A Foreign Service employee normally lives in a costal area, but he must take an emergency trip to a high-altitude mountain area. He asks the nurse what he can do if acute mountain sickness occurs when he is at high altitude. What is the best advice? A. Rest as much as possible B. If available, administer oxygen C. Take the oral form of furosemide D. Descend to a lower altitude
D. Descend to a lower altitude
A patient was involved in a high-speed motor vehicle accident. The healthcare provider instructs the nurse to prepare for several urgent procedures because of severe injury and physical compromise. Which procedure does the nurse prepare for first? A. Central line insertion B. Peritoneal lavage C. Chest tube insertion D. Endotracheal intubation
D. Endotracheal intubation
A patient is brought to the emergency department (ED) by friends who report, "He probably overdosed on downers." The patient has a decreased level of consciousness and a decreased gag reflex; his face and chest are covered with emesis; he demonstrates spontaneous sonorous respirations; and pulse oximetry is 87% on room air. What type of airway management does the nurse expect this patient to receive? A. Supplemental oxygen per nasal cannula at 4-6 L/min B. Bag-valve mask and 100% oxygen to assist with ventilatory effort C. Non-rebreather mask with high-flow oxygen D. Endotracheal intubation with initial high-concentration oxygen
D. Endotracheal intubation with initial high-concentration oxygen
Several patients have been waiting for more than 36 hours to be transferred to an inpatient room because the census is high during flu season. The emergency department (ED) staff is attempting to meet basic health needs in these circumstances. Which need is the priority? A. Helping the patients with hygiene B. Making sure that patients are fed C. Informing patients about admission status D. Ensuring safety of environment and care
D. Ensuring safety of environment and care
A patient reports a scorpion sting on the back of the hand. There is no obvious redness or inflammation at the suspected sting site. Which assessment technique does the nurse use to confirm a bark scorpion sting? A. Raise the arm and observe for blanching B. Observe for the stinger embedded in the skin C. Look for puncture marks surrounded by fine hairs D. Gently tap at the suspected sting site to elicit pain
D. Gently tap at the suspected sting site to elicit pain
The nurse has received report on several patients who were seen and treated for heat-related illnesses. The patient who has the most severe case of heat-related illness exhibits which signs/symptoms? A. Headache, heavy perspiration, temperature of 101F B. Subjective feeling of illness with nausea and vomiting C. Significant sunburn to extremities, face, and neck; temperature 102F D. Hot and dry skin, alert, oriented to person, with pulse of 120/min
D. Hot and dry skin, alert, oriented to person, with pulse of 120/min
An older adult man comes to the emergency department for a snakebite. Which assessment finding suggests the highest risk for envenomation? A. Fang marks with local pain and swelling B. Progressive swelling with nausea and vomiting C. Localized swelling, with no systemic reactions D. Marked swelling and manifestations of coagulopathy
D. Marked swelling and manifestations of coagulopathy
It is the middle of summer, and the weather has been hot and humid for several weeks. Which patient has the highest risk for severe heat-related illness? A. Young child who is participating in an organized sports team B. Well-conditioned athlete who is participating in a marathon C. Experienced construction worker who is working on an outdoor structure D. Older adult who lives alone and uses a fan during hot weather
D. Older adult who lives alone and uses a fan during hot weather
to promote effective coping for survivors of a mass casualty event, the nurse uses which principles while interacting with patients in crisis? SATA a. actively listen to feelings and expression of experiences b. reassuring that everything will be okay and things will return to normal c. encouraging exploration about why the event occurred and who caused it d. helping to problem solve e. conveying caring behaviors f. advocating resumption of daily routines ASAP
a. actively listen to feelings and expression of experiences d. helping to problem solve e. conveying caring behaviors
which nurse activity would best help the hospital to meet the joint commissions mandate for emergency preparedness? a. assist in panning drills that include patient simulations b. help other nurses make a personal emergency preparedness plan c. attend training classes to learn how to handle hazardous materials d. identify the credible threats to the safety of the community
a. assist in panning drills that include patient simulations
the hospital in a small mountain town is updating its emergency management plan to incorporate the "all hazards approach" and to address all credible threats to the area. which disaster events are likely priorities in this community's emergency management plan? SATA a. avalanches b. floods c. "active shooter" d. car accidents e. tornados f. pandemic influenza
a. avalanches c. "active shooter" d. car accidents f. pandemic influenza
the nurse is assigned to assist the hospital incident commander during a disaster drill. which responsibility is appropriate for the nurse in this capacity? a. call all nursing units to determine the number of patients who could potentially be discharged b. call the physical therapy department and direct therapists to assist in the operating room or intensive care unit c. go to the emergency department and assist with the triage of disaster victims to appropriate clinical areas d. contact the security department and instruct them to control the number of people who attempt to enter the hospital
a. call all nursing units to determine the number of patients who could potentially be discharged
the nurse is assigned to assist the incident commander who is evaluating the feasibility of deactivating the emergency management plan. the commander directs the nurse to accomplish certain tasks. which task is priority? a. contact all hospital department and determine if needs have been met b. go to the ED and supervise inventory and restocking of supplies c. arrange for temporary sleeping quarters for exhausted staff members d. assist in the preparations of the critical incident stress debriefing
a. contact all hospital department and determine if needs have been met
to protect hospital staff from experience PTSD what are appropriate recommendations by the facility to its employees? a. drink plenty of water and eat healthy snacks b. avoid putting emotional burden on your family c. seek counseling when stress becomes debilitating d. avoid coworkers who dwell on unpleasant details
a. drink plenty of water and eat healthy snacks
a community hospital is reviewing the activation and implementation of its emergency preparedness plan after a recent mass casualty event. which outcome statement reflects the goal of an administrative review? a. emergency preparedness plan was activated in a timely fashion, but telephone tree was outdated and did not include new employees b. 300 employees were offered a debriefing session, and two employees have symptoms of PTSD c. the mass casualty event was handled well, and we expect to see positive reports in the media and to receive additional funding d. the mass casualty event resulted in an influx of 35 walking wounded, and six patients came via emergency medical transport
a. emergency preparedness plan was activated in a timely fashion, but telephone tree was outdated and did not include new employees
a patient comes to the emergency department (ED) worried that he has been exposed to an infectious bioterrorism agent that was sent to him though the mail. what is the priority action for the ED nurse to take? a. escort the patient to the quarantined area b. take a history and assess for symptoms c. call local police and department of public health d. activate the emergency preparedness plan
a. escort the patient to the quarantined area
a client with 35% of TBSA burned in a fire is now 48 hours postern. the nurse concludes that the client is moving from the emergent to the acute phase of burn management. which response supports this conclusion? a. hypokalemia b. hypoglycemia c. decreased blood pressure d. increased urine specific gravity
a. hypokalemia
the nurse serves on a committee that is tasked with developing tools and aids that the medical command physician could use during a disaster event. What is an appropriate project for this purpose? a. make a current list, including contact information, of trauma and orthopedic surgeons b. make a telephone tree for contacting the nursing and ancillary staff c. design a triage algorithm that addresses different types of disaster events d. design an algorithm for contacting the federal emergency management agency
a. make a current list, including contact information, of trauma and orthopedic surgeons
the nurse is making a personal emergency preparedness plan. what is the nurse sure to include in this plan? a. make a disaster supply kit with clothing an basic survival supplies b. resolve the ethical conflicts of family and professional obligations c. stockpile antibiotics, first-aid supplies, and resuscitation equipment d. teach family members about radiation and bioterrorism safety issues
a. make a disaster supply kit with clothing an basic survival supplies
a nurse working at a small rural hospital gets a frantic phone call about a rumor of a student attacking other students at a local high school. which information is the most important to determine potential for a multi casualty event versus a mass casualty event? a. "how long ago did the event occur?" b. "what are the number and severity of the injuries?" c. "what are the school officials saying about the incident?" d. "have emergency medical services been notified?"
b. "what are the number and severity of the injuries?"
the ED nurse is instructing a group of UAP on how to use PPE when caring for patients who may have been exposed bioterrorism agents. one of the group is clowning around and making jokes, what should the nurse do first? a. suggest that he report to the supervisor if he doesn't settle down and pay attention b. ask him to demonstrate the use of PPE in the care of a pt with ebola c. advise him that PPE is for safety, but ignoring safety protocols is a personal choice d. ignore him and continue instructing, because clowning around a coping method for him
b. ask him to demonstrate the use of PPE in the care of a pt with ebola
after a major city wide environmental crisis, which type of intervention is most appropriate for hospital staff? a. administrative debriefing b. critical incident stress debriefing c. small discussion groups that include family d. mandatory referrals for mental health counseling
b. critical incident stress debriefing
the hospital committee is reviewing the emergency management plan of their small community hospital in a suburban area of a large city. What is a priority to include in this hospitals emergency management plan? a. plan for evacuation routes out of the city b. plan for transporting patients to other hospitals c. method to contact the national disaster medical system d. stockpiling postexposure prophylactic antibiotics
b. plan for transporting patients to other hospitals
which action meets the joint commission's 2015 mandate for the hospitals emergency preparedness plan? a. all nursing staff are certified annually in basic and advanced cardiac life support b. plan is tested twice a year using simulated patients to assess collaboration and command c. stockpiles of equipment and supplies needed for a pandemic influenza outbreak are inventoried d. emergency department staff meets annually with administration to review plan and update as needed
b. plan is tested twice a year using simulated patients to assess collaboration and command
the nurse is caring for a patient brought to the emergency department (ED) with facial burns that occurred after the patient bent over the engine of his car. what is the priority for this patient? a. initiate fluid resuscitation b. secure the airway c. manage pain and discomfort d. prevent infection
b. secure the airway
a person sustains deep partial thickness burns while working on a boat in a town Marina and seeks advice from the nurse in the first aid station. the nurse encourages the client to seek medical attention, but the client refuses. the nurse advises the person to go to the health care provider if: a. blisters appear b. urinary output decreases c. edema and redness occur d. low-grade fever develops
b. urinary output decreases
a local news station calls the hospital seeking permission to verify the number of victims and details of a local disaster. What is the nurse's best response? a. "please don't bother us now. we are trying to care for the victims" b. "we have a lot of stable victims and so far no one has died" c. "please hold and I will connect you to the community relations officer." d. "I will connect you with the emergency command center"
c. "please hold and I will connect you to the community relations officer."
a nurse working on a med-surg unit is informed by the charge nurse that the emergency preparedness plan has been activated and a large number of injured patients are expected to arrive over the next few hours. Which question is the charge most likely to ask? a. "have you read the disaster plan, and do you know your role?" b. "could you check the emergency equipment and see if everything works?" c. "potentially, could any of your patients be immediately discharged?" d. "would you be willing to care for patients in the hallway if there is no other option?"
c. "potentially, could any of your patients be immediately discharged?"
which client is best for the nurse manager on the burn unit to assign to an RN who has floated from the oncology unit? a. a 23 year old client who has just been admitted with burns over 30% of the body after a warehouse fire b. a 36 year old client who requires discharge teaching about nutrition and would care after having skin grafts c. a 45 year old client with infected partial thickness back and chest burns who has a dressing change scheduled d. a 57 year old client with full thickness burns on both arms who needs assistance in positioning hand splints
c. a 45 year old client with infected partial thickness back and chest burns who has a dressing change scheduled
the nurse has just received the change of shift report in the burn unit. which client requires the most immediate assessment or intervention? a. a 22 year old client admitted 4 days previously with facial burns due to a house fire who has been crying since recent visitors left b. a 34 year old client who returned from skin graft surgery 3 hours ago and is reporting level 8 pain (0-10 scale) c. a 45 year old client with partial thickness leg burns who has a temperature of 102.6F (39.2C) and a blood pressure of 98/46mmHg d. a 57 year old client who was admitted with electrical burns 24 hours ago and has a blood potassium level of 5.1 mEq/L
c. a 45 year old client with partial thickness leg burns who has a temperature of 102.6F (39.2C) and a blood pressure of 98/46mmHg
the nursing director of a long-term care facility is designated as the "incident commander" for the facility's emergency management plan. what is the priority action for the incident commander? a. call all the off-duty staff and ask them to come into work b. take inventory of supplies according to the emergency management plan c. activate the disaster management process according to the plan d. call the national guard to move all patients to other facilities
c. activate the disaster management process according to the plan
using disaster triage principles, which patient has been correctly triaged and marked with the appropriate color tag? a. a toddler who has died from his injuries: green tag b. an older woman with a fractured ankle: yellow tag c. an older man with SOB and hemothorax: red tag d. a teenager with profuse bleeding from an arm laceration: black tag
c. an older man with SOB and hemothorax: red tag
an ED nurse is admitting a client after an automobile collision. the HCP estimates that the client has lost about 15-20% of blood volume. which assessment finding should the nurse expect this client to exhibit? a. urine output of 50 ml/hr b. BP of 150/90mmHg c. apical HR of 142 bpm d. RR of 16 breaths/min
c. apical HR of 142 bpm
which disaster situation is most likely to increase the complexity of managing the green-tagged patients who are more likely to self-transport from the scene of the incident to the health care facility? a. collapse of a church roof during sunday services b. human stampede at a poorly controlled music festival c. breach of containment at a nuclear plant d. demonstration with rioting on a college campus
c. breach of containment at a nuclear plant
a long-term care facility formed a committee to review the facility's emergency preparedness plan. which element needs to be resolved in order to meet the guidelines of the life safety code, which is published by the national fire protection association? a. fire extinguishers are heavy and difficult to use b. fire safety training is difficult because of high staff turnover c. building has one main front door, and side doors are sealed shut d. many residents are unwilling or incapable of participating in fire drills
c. building has one main front door, and side doors are sealed shut
a severely burned client has been hospitalized fro 2 days. until now recovery has been uneventful, but the client begins to exhibit extreme restlessness. what does the nurse conclude the client is most likely developing? a. kidney failure b. fluid overload c. cerebral hypoxia d. metabolic acidosis
c. cerebral hypoxia
a gang related incident has occurred involving major casualties from gun shot wounds to eleven victims. which intervention would be included in the critical stress incident debriefing? a. reviewing mistakes and recommending corrective actions to be taken b. identifying those who are experiencing PTSD c. encouraging unconditional acceptance of all thoughts and feelings d. encouraging self-acceptance of blame and guilt for errors in judgment
c. encouraging unconditional acceptance of all thoughts and feelings
which priority intervention would be more likely to occur during an internal disaster compared to an external disaster? a. extra staff would be called in to assist b. emergency management plan would be activated c. patients and staff would be evacuated d. staff would don PPE
c. patients and staff would be evacuated
a nurse based in Iowa is a volunteer member of the medical reserve corps and has been called to serve in Ohio where he does not hold an active nursing license. What should the nurse do? a. determine if Ohio has reciprocity with Iowa before accepting deployment b. decline deployment because his nursing license will not allow him to practice in Ohio c. prepare for deployment because he will be considered a federal employee with a valid licensure d. delay deployment until he has review the nurse practice act that is specific to Ohio
c. prepare for deployment because he will be considered a federal employee with a valid licensure
The triage method for multi-casualty or mass response utilizes what sorting methods? SATA a. patients are alphabetized by name b. health care providers triage most critical pts c. pts are labeled by number d. pts are ranked by assessment scores e. pts are ranked used colored labels f. pts are categorized as john does with unique identifiers
c. pts are labeled by number e. pts are ranked used colored labels
a city committee reviews possible scenarios related to a disaster event. which is an example of the "greatest good for the greatest number of people"? a. the city's supply of antibiotics is sent to one hospital that has 25 victims with exposure to a bioterrorism agent b. twenty victims infected by a bioterrorism agent are placed on life support and mechanical ventilation c. thirty people with possible exposure to a bioterrorism agent are quarantined, including five children who are asymptomatic d. elderly community members are treated with prophylactic antibiotics for a bioterrorism agent
c. thirty people with possible exposure to a bioterrorism agent are quarantined, including five children who are asymptomatic
the nurse is working in the emergency department where several local gang members are being treated for gunshot and knife wounds. the nurse hears gunshots in the waiting room, followed by screaming and cries for help. What does the nurse do first? a. grab the resuscitation box and run to the waiting room b. assist all the ambulatory patients to leave through the back entrance c. alert the ED health care provider that additional trauma victims need care d. assess the level of threat to self and others and call for help
d. assess the level of threat to self and others and call for help
a committee is reviewing the hospital's emergency management plan. in the event of a large-scale multi-casualty event, which group is likely to require the largest amount if physical space to accommodate the number of victims? a. black-tagged patients b. red-tagged patients c. yellow-tagged patients d. green-tagged patients
d. green-tagged patients
the hospital staff is participating in a disaster drill, and the nurse is assigned to organize personnel who are called in from home. which task would be appropriate to delegate to UAP who usually work in labor and delivery area? a. stay with "black tag" patients in the holding area b. talk to the families of the "red tag" patients c. care for and support the "green tag" patients d. obtain vital signs of the "yellow tag" patients
d. obtain vital signs of the "yellow tag" patients
the emergency management plan is activated because a major earthquake has caused many serious and minor injuries. which nurse reassignment is most likely to meet the needs of the patients while best utilizing available personnel? a. OR nurse is reassigned to the ER to assist in triage b. ER nurse is reassigned ti care for patients in the med surge unit c. critical care nurse is reassigned to the ER to care for "black tag" patients d. performance improvement nurse is reassigned to care for "green tag" patients
d. performance improvement nurse is reassigned to care for "green tag" patients
a multiple car accident with mass casualties has occurred near an urban hospital. the hospitals emergency preparedness plan is activated. for what purposes is the post plan administrative review conducted? a. to focus on the errors that were made and things that went wrong during the plan b. to identify employees who need financial assistance or reimbursement c. to establish a system of networking and support for the employees d. to provide all employees to opportunity to express positive and negative comments
d. to provide all employees to opportunity to express positive and negative comments
the nurse is reviewing the laboratory results for several burn patients who are approximately 24-36 hours post injury. what laboratory results r/t the fluid remobilization in these patients does the nurse expect to see? a. anemia b. metabolic alkalosis c. hypernatremia d. hyperkalemia
a. anemia
a patient who lives in a rural community sustained severe burns during a house fire at 10am. the rural emergency medical services (EMS) started a peripheral IV at 1100 am at a keep-vein-open (KVO) rate. the patient was admitted to the hospital at 1:00pm. in calculating the fluid replacement, at what time is the fluid for the first 8 hour period completed? a. 6:00pm b. 7:00pm c. 8:00pm d. 9:00pm
a. 6:00pm
the nurse is caring for several patients on the burn unit. which patients have the greatest risk for developing respiratory problems? SATA a. patient who was in a storage room where chemicals caught fire b. patient who was workin gin an area where steam escaped from a pipe c. patient who sustained a circumferential burn to the chest area d. patient who was burned when a firecracker exploded prematurely e. patient who was found unconscious in a slow burning house fire f. patient whose clothes caught fire while burning leaves
a. patient who was in a storage room where chemicals caught fire b. patient who was workin gin an area where steam escaped from a pipe c. patient who sustained a circumferential burn to the chest area e. patient who was found unconscious in a slow burning house fire
the nurse has just received report on a patient admitted for steam inhalation burns. the patient is alert and conversant but reports that his throat feels raw. his wife says that he sounds harsh compared to usual. considering these findings, which order should the nurse question? a. continuous pulse oximetry b. vital signs and airway assessment twice a day c. intubation equipment at the bedside d. oxygen 2L via nasal cannula to maintain saturation of greater than 90%
b. vital signs and airway assessment twice a day
a burn patient must have pressure dressings applied to prevent contractors and reduce scarring. for maximum effective, what procedure pertaining to the pressure garments is implemented? a. changed every 24-48 hours to prevent infection b. worn at least 23 hours a day until the scar tissue matures c. removed for hygiene and during sleeping d. applied with aseptic technique
b. worn at least 23 hours a day until the scar tissue matures
a patient in the burn intensive care unit weighed 80kg (preburn weight). the provider orders titration of IV fluid to achieve 0.5mL/kg/hr urine output. what is the minimal hourly urine output for this patient? a. 30 mL/hr b. 35 mL/hr c. 40 mL/hr d. 45 mL/hr
c. 40 mL/hr
the nurse is performing a morning assessment on a patient admitted for serious burns to the extremities. for what reason does the nurse assess the patients abdomen? a. to perform a daily full head to toe assessment b. to assess for nausea and vomiting related to pain medication c. to assess for a paralytic ileum secondary to reduced blood flow d. to monitor increased motility that may result in cramps and diarrhea
c. to assess for a paralytic ileum secondary to reduced blood flow
the nurse is caring for several patients on the burn unit. which of these patients has the most acute need for cardiac monitoring? a. older adult woman who spilled hot water over her legs while boiling noodles b. teenager with facial burns that occurred when he threw gasoline on a campfire c. young woman who was struck by lightning while jogging on the beach d. middle aged man who fell asleep while smoking and sustained burns to the chest
c. young woman who was struck by lightning while jogging on the beach
which statement about the resuscitation phase of a burn injury is accurate? a. it occurs in the prehospital timeframe b. it continues for about 8 hours after the burn c. it continues for about 24-48 hours after the burn d. it continues until the patient is stable
c. it continues for about 24-48 hours after the burn
a patient with burn injuries is being discharged from the hospital. what important points does the nurse include in the discharge teaching? sata a. signs and symptoms of infection b. drug regimens and potential medication side effects c. definition of full-thickness burns d. correct application and care of pressure garments e. comfort measures to reduce scarring f. dates for follow-up appointments
a. signs and symptoms of infection b. drug regimens and potential medication side effects d. correct application and care of pressure garments f. dates for follow-up appointments
the nurse is caring for a burn patient who received rigorous fluid resuscitation in the emergency department (ED) for hypotension and hypovolemic shock. in assessing renal function for the first 24 hours, what finding does the nurse anticipate? a. output will be approximately equal to fluid intake b. output will be decreased compared to fluid intake c. urine will have a very low specific gravity and a pale yellow color d. output will be managed with diuretics
b. output will be decreased compared to fluid intake
a patient with a burn injury had an autograft. the nurse learns in report that the donor site is on the upper thigh. what type of wound does the nurse expect to find at the donor site? a. stage 1 b. partial thickness c. full thickness d. stage 4
b. partial thickness
which are expected outcomes when evaluating the care of a patient with burn injuries? sata a. patients infection was treated rapidly b. patients airway remained patent c. patients pain was decreased or relieved d. patients perception of self is positive e. patients weight loss was only 10% f. patients wounds are all in the process of healing
b. patients airway remained patent c. patients pain was decreased or relieved d. patients perception of self is positive
a nurse is caring for a client during the emergent phase of a severe burn injury. which parenteral intervention prescribed by the health care provider should the nurse question? a. colloids b. potassium c. hypertonic saline d. lactated ringer solution
b. potassium
a patient was involved in a house fire and suffered extensive full thickness burns. in the long term, what issue may this patient have trouble with? a. intolerance for vitamin C b. metabolism of vitamin K c. activation of vitamin D d. absorption of vitamin A
c. activation of vitamin D
a patient was admitted for burns to the upper extremities after being rapped in a burning structure. the patient is also at risk for inadequate oxygenation related to inhalation of smoke and superheated fumes. which diagnostic test best monitors this patients gas exchange? a. complete blood count b. myoglobin level c. carboxyhemoglobin level d. chest x ray
c. carboxyhemoglobin level
the vasodilation effects of carbon monoxide in patients with carbon monoxide poisoning causes what clinical manifestation? a. cyanosis around the lips b. generalized pallor c. cherry-red skin color d. mottled skin color
c. cherry-red skin color
the nurse is caring for a patient with chronic pain associated with an old burn injury. which nonpharmacologic intervention does the nurse use to help relieve the patients pain? a. cooling blanket to decrease edema b. lower room temperature to reduce discomfort c. massaging non burned areas d. range-of-motion exercises
c. massaging non burned areas
the nurse is caring for a patient who sustained carbon monoxide poisoning. what assessment finding does the nurse anticipate? a. patient will be cyanotic because of hypoxia b. blood gas value of Pao2 will be very low c. patient will report a headache d. patient will report a dry and irritated throat
c. patient will report a headache
what is the most essential patient data needed for calculating the fluid rates, energy requirements, and drug doses for the burn patient? a. age b. health history c. preburn weight d. current weight
c. preburn weight
which patient has the highest risk for a fatal burn injury? a. 4-year-old child b. 32-year-old man c. 45-year-old woman d. 77-year-old man
d. 77-year-old man
which type of burn wound damages the epidermis, dermis, fascia, and tissues? a. superficial b. partial thickness c. full thickness d. deep full thickness
d. deep full thickness
the heath care provider has ordered an escharotomy for a patient because of constriction around the patients chest. the nurse is teaching the patent and family about the procedure. which statement by the family indicates a need for additional teaching? a. "he will have to receive general anesthesia" b. "he'll be awake for the procedure" c. "he will receive medication for sedation and pain" d. "we could stay with him at the bedside during the procedure"
a. "he will have to receive general anesthesia"
a patient sustained a superficial thickness burn over a large area of the body. the patient is crying with discomfort and is very concerned about the long term effects. what does the nurse tell the patient to expect? a. "healing should occur in 3-6 days with no scarring or complications" b. "the pain should be less because more of the nerve endings were destroyed" c. "the wound will appear red and dry with some white areas" d. "the leathery eschar will have to be removed before healing can occur"
a. "healing should occur in 3-6 days with no scarring or complications"
a 28-year-old male patient sustained second and third-degree burns on his legs (30%) when his clothing caught fire while he was burning leaves. he was hosed down by his neighbor and arrived at the ED in severe discomfort. what is the priority problem for the patient at this time? a. acute pain r/t damaged or exposed nerve endings b. decreased fluid volume r/t electrolyte imbalance c. potential for inadequate oxygenation d. diminished self-image r/t the appearance of legs
a. acute pain r/t damaged or exposed nerve endings
a patient comes to the clinic to be treated for burns from a barbecue fire. although the patient does not appear to be in any respiratory distress, the nurse suspects an inhalation injury after observing which findings? SATA a. burns to the face b. bright cherry red color to lips c. singed nose hairs d. edema of the nasal septum e. black carbon particles around the mouth f. sweet, sugary smell to the breath
a. burns to the face c. singed nose hairs d. edema of the nasal septum e. black carbon particles around the mouth
the nurse is applying a dressing to cover a burn on a patients left leg. what technique does the nurse use? a. consider the depth of the injury and amount of drainage, and work distal to proximal b. change the dressing every 4 hours or when the drainage leaks through the dressing c. consider the patients mobility and the area of injury, and work proximal to distal d. use multiple gauze layers and roller gauze to pad and protect the joint areas
a. consider the depth of the injury and amount of drainage, and work distal to proximal
a nurse is caring for a client who has a disturbed body image as a result of a burn injury. which is an important nursing intervention for this client? a. conveying a positive attitude toward the client b. arranging for the client to meet other clients with burns c. removing mirrors until the clients physical appearance has improved d. reminding family members to avoid comments about the clients appearance
a. conveying a positive attitude toward the client
a patient has been depressed and withdrawn since her injury and has expressed that 'life will never be the same'. which nursing intervention best promotes a positive image for this burn patient? a. discussing the possibility of reconstructive surgery with the patient b. allowing the patient to choose a colorful scarf to cover the burned area c. playing cards or board games with the patient d. encouraging the patient to consider how fortunate she is to be alive
a. discussing the possibility of reconstructive surgery with the patient
a patient has sustained a burn to the right ankle. the health care provider applied the initial dressing to the ankle, and the nurse assists the patient into bed and positions the ankle to prevent contracture. what is the correct position the nurse uses? a. dorsiflexion b. adduction c. external rotation d. hyperextension
a. dorsiflexion
a burn patient in the fluid resuscitation phase is experiencing dyspnea. what are the priority interventions for this patient? sata a. elevate the head of bed to 45 degrees b. maintain patient in the supine position c. notify the rapid response team d. administer an analgesic to calm the patient e. apply humidified oxygen f. attempt distraction using music therapy
a. elevate the head of bed to 45 degrees c. notify the rapid response team e. apply humidified oxygen
the nurse is educating a patient who has sustained burns to the dominant hand. what kind of active range-of-motion exercises does the nurse instruct the patient to perform? a. exercise the hand, thumb, and fingers every house while awake b. exercise the fingers and thumb atleast three times a day c. use the hands to perform activities of daily living d. squeeze a soft rubber ball several times a day
a. exercise the hand, thumb, and fingers every house while awake
what does the process of full-thickness wound healing include? sata a. healing occurs by wound contraction b. eschar must be removed c. large blisters are protective and left undisturbed d. skin grafting may be necessary e. fasciotomy may be needed to relieve pressure and allow normal blood flow f. complete healing occurs within 3-6 weeks
a. healing occurs by wound contraction b. eschar must be removed d. skin grafting may be necessary e. fasciotomy may be needed to relieve pressure and allow normal blood flow
the nurse is reviewing the hemoglobin and hematocrit results for a patient recently admitted for a severe burn. which result is most likely related to vascular dehydration? a. hematocrit of 58% b. hemoglobin of 14 g/dL c. hematocrit of 42% d. hemoglobin of 10 g/dL
a. hematocrit of 58%
as a result of third spacing, during the acute phase, which electrolyte imbalances may occur? sata a. hyperkalemia b. hypokalemia c. hypernatremia d. hyponatremia e. hypercalcemia f. hypocalcemia
a. hyperkalemia d. hyponatremia
a patient was burned on the forearm after tripping and falling against a wood burning stove. there are currently several small blisters over the turn area. what does the nurse advise the patine to do about the blisters? a. leave the blisters intact because they protect the wound from infection b. use a sterile needle to open a tiny hole in each blister to drain the fluid c. allow blisters to increase in size; then open them to release the fluid inside d. leave the blisters intact unless the pain and pressure increase
a. leave the blisters intact because they protect the wound from infection
a patient has sustained a severe burn greater that 30% total body surface area (TBSA). what is the best way to assess renal function in this patient? a. measure urine output and compare this value with fluid intake b. weight the patient every day and compare that to the dry weight c. note the amount of edema and measure abdominal girth d. assist the patient with a urinal or bedpan every 2 hours
a. measure urine output and compare this value with fluid intake
the nurse is caring for a firefighter who was brought I for burns around the face and upper chest. airway maintenance for this patient with respiratory involvement includes what action? a. monitoring for signs and symptom of upper airway edema during fluid resusciation b. inserting a nasopharyngeal airway when the patients airway in completely obstructed c. obtaining an order for as-needed (PRN) oxygen per nasal cannula d. frequently suctioning the mouth with yankauer suction
a. monitoring for signs and symptom of upper airway edema during fluid resusciation
the nurse is assessing a patient with a burn wound to the back and chest area. which assessment findings are consistent with a superficial thickness burn wound? SATA a. pink to red b. pain c. mild edema d. moisture e. eschar f. blanch to pressure
a. pink to red b. pain c. mild edema f. blanch to pressure
the nurse is caring for a burn patient who was stabilized by and transferred from a small rural hospital. the patient develops on a new complaint of shortness of breath. on auscultation, the nurse hears crackles thought the lung fields. what does the nurse suspect is causing this patients symptoms? a. pulmonary fluid overload r/t fluid resuscitation b. exposure to carbon monoxide that was undiagnosed c. fat emboli secondary to extensive injury d. excessive oxygen therapy at the first facility
a. pulmonary fluid overload r/t fluid resuscitation
a patient was rescued from a burning house and treated with oxygen. initially, the patient had audible wheezing and wheezing on auscultation, but after approximately 30 minutes the wheezing stopped. the patient now demonstrates substernal retractions and anxiety. what action does the nurse take at this time? a. recognize an impending airway obstruction and prepare for immediate intubation b. continue to monitor the patients respiratory status and initiate pulse oximetry c. document this finding as evidence of improvement and continue to observe d. stay with and encourage the patient to remain calm and breathe deeply
a. recognize an impending airway obstruction and prepare for immediate intubation
the nursing student notes on the care plan that the burn patient she is caring for is at risk for organ ischemia. tased on the students knowledge of the pathophysiology of burns, which etiology does the nursing student select? a. related to hypovolemia and hypotension b. related to fluid overload and peripheral edema c. related to prolonged resuscitation and hypoxia d. related to direct blunt trauma to the kidneys
a. related to hypovolemia and hypotension
the student nurse is preparing to assist with hydrotherapy for a burn patient. the supervising nurse instructs the student to obtain the necessary equipment before beginning the procedure. what equipment does the student nurse obtain? sata a. scissors and forceps b. hydrogen peroxide c. mild soap or detergent d. pressure dressings e. washcloths and gauze sponges f. chlorhexidine sponges
a. scissors and forceps c. mild soap or detergent e. washcloths and gauze sponges
the nurse is caring for an African American patient with a burn injury. the patient is experiencing severe pain and discomfort that are unrelated to the burned areas. the nurse advocates that the provider order which additional test? a. sickle cell for trait b. drug screen for opiate use c. x rays to identify bone injuries d. ecg to identify cardiac dysrhythmias
a. sickle cell for trait
which factors in the older adult increase the risk of complications from a burn injury? sata a. slower healing time b. thinner skin c. increased inflammatory response d. increased pulmonary compliance e. altered glucose metabolism f. history of heart failure
a. slower healing time b. thinner skin e. altered glucose metabolism f. history of heart failure
The priority expected outcome during the resuscitation phase of a burn injury is to maintain which factor? a. the airway b. cardiac output c. fluid replacement d. patient comfort
a. the airway
the release of myoglobin from damaged muscle in patients with major burns can result in which potential complication? a. paralytic ileus b. acute kidney injury c. limited mobility d. hypovolemia
b. acute kidney injury
for which patient would the rule of nines method of calculating burn size be most appropriate? a. child who weighs atleast 50 lbs b. adult whose weight is proportionate to height c. adult who weighs under 300 lbs d. child whose weight is proportionate to height
b. adult whose weight is proportionate to height
several patients are transported from an industrial fire to a local emergency department (ED). which factors increase the risk of death for these patients? sata a. male gender b. age greater than 60 years c. burn greater than 40% TBSA d. presence of an inhalation injury e. presence of contact burns f. history of kidney disease
b. age greater than 60 years c. burn greater than 40% TBSA d. presence of an inhalation injury
the home health nurse is visiting an older couple for he initial visit. in observing the household, the nurse identifies several behaviors and environmental factors to address. which identified factors increase the risk for burns and/or household fires? a. several potholders hanging within easy reach of the stove b. ashtray with old cigarette butts on the bedside table c. space heater very close to the bed d. single smoke detector in the house e. back exit hall of the house used as a storage space f. small throw rug near the front door
b. ashtray with old cigarette butts on the bedside table c. space heater very close to the bed d. single smoke detector in the house e. back exit hall of the house used as a storage space
during shift report, the nurse learns that a new patient was admitted for an inhalation injury. auscultation of the lungs has revealed wheezing over the mainstream bronchi since admission. during the nurses assessment of the patient, the wheezing sounds are absent. what does the nurse do next? a. document these findings because they indicate that the patient is improving b. assess for respiratory distress because of potential airway obstruction c. obtain an order to discount oxygen therapy because it is no longer needed d. encourage use of incentive spirometry to prevent atelectasis
b. assess for respiratory distress because of potential airway obstruction
a patient is transported to the emergency department (ED) for severe and extensive burns that occurred while he was trapped in a burning building. the patient is severely injured with respiratory distress and the resuscitation team must immediately begin multiple interventions. which test should be delegated to the UAP? a. position the patients head to open the airway and assist with intubation b. assist the respiratory therapist to maintain a seal during bag valve mask ventilation c. prepare the intubation equipment and set up the oxygen flowmeter d. elevate the head of the bed to achieve a high fowlers position
b. assist the respiratory therapist to maintain a seal during bag valve mask ventilation
a patient has sustained a burn that appears red and moist. the nurse gently applies pressure to the area to assess for what sign/symptom? a. intensity of pain b. blanching c. pitting edema d. fluid-filled blisters
b. blanching
the nurse is caring for several patients who have sustained burns. the patient with which initial injury is the least likely to experience severe pain when a sharp stimulus is applied? a. severe sunburn after lying in the sun for several hours b. deep full thickness burn from an electrical accident c. partial thickness burn from picking up a hot pan d. deep partial thickness burn after a motorcycle accident
b. deep full thickness burn from an electrical accident
Because of fluid shifts in burn patients, what effects on cardiac output does the nurse expect to see? a. an initial increase, then normalized in 24-48 hours b. depressed up to 36 hours after the burn c. improved with fluid restrictions d. responsive to diuretics as evidenced by urinary output
b. depressed up to 36 hours after the burn
the nurse observes peeling of dead skin on the legs of a patient with superficial thickness burn wound. what is the most accurate description of this assessment finding? a. blanching b. desquamation c. slough d. fluid shift
b. desquamation
a patient in the burn intesive care unit is receiving vecuronium (nurcuron). what is the priority nursing intervention for this patient? a. have emergency intubation equipment at the bedside b. ensure that all the equipment alarms are on and functional c. closely monitor the patients urinary output every hour d. ensure that daily drug levels and electrolyte values are obtained
b. ensure that all the equipment alarms are on and functional
the nurse is caring for a young woman who sustained burns on the upper extremities and anterior chest while attempting to put out a kitchen grease fire. which laboratory results does the nurse expect to see during the resuscitation phase? sata a. potassium level of 3.2 mEq/L b. glucose level of 180 mg/dL c. hematocrit of 49% d. pH of 7.20 e. sodium level of 139 mEq/L f. albumin level of 2.9 g/dL
b. glucose level of 180 mg/dL c. hematocrit of 49% d. pH of 7.20 f. albumin level of 2.9 g/dL
the prevent to complication of curlings ulcer, what does the nurse anticipate the health care provider will order? a. nasogastric tube insertion b. histamine-2 blockers c. abdominal assessment every 4 hours d. systemic antibiotic
b. histamine-2 blockers
a patient was admitted to the bun unit approximately 6 hours after being rescued from a burning building. in the emergency department (ED) he reported a dry, irritated throat "from breathing in the fumes" but otherwise had no airway complaints. during the shift, the nurse notes that the patient has suddenly developed marked stridor. the nurse anticipates preparing the patient for which emergency procedure? a. bronchoscopy b. intubation c. needle thoracotomy d. escharotomy
b. intubation
which statement about the third-spacing or capillary leak syndrome in a patient with severe burns is accurate? a. it usually happens in the first 36-48 hours b. it is a leak of plasma fluids into the interstitial space c. it is present only in the burned tissues d. it can usually be prevented with diuretics
b. it is a leak of plasma fluids into the interstitial space
a nurse caring for a client during the first few hours after the admission to the burn unit with partial thickness burns of the trunk and head. which potential problem is the least concern for the nurse during the emergent phase of a burn injury? a. pain b. leukopenia c. laryngeal edema d. fluid volume deficit
b. leukopenia
the nurse is providing care for a burn patient who recently received a graft. on assessment of the patients wound, redness and swelling as well as some foul smelling drainage is noted. what does the nurse suspect? a. partial thickness burn b. local infection of burn wound c. failure of the graft d. systemic sepsis
b. local infection of burn wound
the nurse is reviewing arterial blood gas (ABG) results for a patient with 35% total body surface area (TBSA) burn in the resuscitation phase: pH is 7.26, Pco2 is 36 mmHg, and HCO3 is 19 mEq/L. what condition does the nurse suspect? a. metabolic alkalosis b. metabolic acidosis c. respiratory acidosis d. respiratory alkalosis
b. metabolic acidosis
the nurse just received phone report on a burn patient being transferred from the burn intensive care unit to the step-down burn unit. which of these tasks is appropriate to delegate to the UAP in order to prepare the room? a. place sterile sheets and a sterile pillowcase on the bed b. place a new disposable stethoscope in the room c. clear a space in the corner for the patients flowers d. hang a sign on the door to prohibit entry of visitors
b. place a new disposable stethoscope in the room
the nurse is caring for a burn patient about to undergo hydrotherapy. which complementary therapies are appropriate for pain management in this patient ? sata a. administering IV opioid analgesics b. allowing the patient to make decisions regarding pain control c. playing music in the background d. using meditative breathing e. using guided imagery f. providing healing or therapeutic touch
c. playing music in the background d. using meditative breathing e. using guided imagery f. providing healing or therapeutic touch
the family reports that the burn patient is unable to perform self-care measures, so someone has been "doing everything for her". the nurse finds that the patient has the knowledge and the physical capacity to independently perform self care. what is the nurses best response? a. "what can your family do to help you feel better and stronger?" b. "you should be doing these things for yourself to increase your self esteem" c. "can you tell me about what been happening since you were discharged from the hospital?" d. "lets review the principles of self care that you learned in the hospital"
c. "can you tell me about what been happening since you were discharged from the hospital?"
an adult patient is admitted to the burn unit after being burned in a house fire. assessment reveals burns to the entire face, back of the head, and anterior torso and circumferential burns to both arms. using the rule of nines what is the extent of the burn injury? a. 18% b. 24% c. 45% d. 54%
c. 45%
A worker is involved in an explosion of a steam pipe and receives a scalding burn to the chest and arms. The burned areas are painful, mottled red, weeping, and edematous. Which should the nurse conclude is an appropriate classification for these burns? a. Eschar b. Full-thickness c. Deep partial-thickness d. Superficial partial-thickness.
c. Deep partial-thickness
a burn patient with which condition is most likely to have mannitol (osmitrol) ordered as part of the drug therapy? a. peripheral edema associated with burns on the lower extremities b. inhalation burns around the mouth causing mucosal swelling c. electrical burn with myoglobin in the urine d. smoke inhalation and superficial burns to the forearms
c. electrical burn with myoglobin in the urine
which type of burn destroys the seat glands, resulting in decreased excretory ability? a. superficial b. partial thickness c. full thickness d. deep full thickness
c. full thickness
over a period of 4 days the patient developed an elevated temperature associated with disorientation and lethargy. lab values include a normal platelet level. which type of infection does the nurse suspect? a. viral b. fungal c. gram-positive bacterial d. gram-negative bacterial
c. gram-positive bacterial
a nurse is evaluating a clients fluid loss resulting from extensive burns. what is the most valuable blood test to use when monitoring a clients fluid loss? a. BUN b. blood pH c. hematocrit d. sedimentation rate
c. hematocrit
the nurse is caring for a firefighter who was trapped for a prolonged period of time by burning debris. during the shift, the nurse notes a progressive hoarseness, a brassy cough, and the patient reports increased difficulty with swallowing. how does the nurse interpret these changes? a. temporary discomfort that can be treated with sips of cool fluids b. signs and symptoms of probable carbon monoxide poisoning c. signs indicating a pulmonary injury and possible airway obstruction d. expected findings considering the mechanism of injury
c. signs indicating a pulmonary injury and possible airway obstruction
the nurse is caring for a patint who has 30% total body surface area (TBSA) burn. during the first 12-36 hours, the nurse carefully monitors the patient for which status changes related to capillary leak syndrome? a. bradycarida and pitting edema b. hypertension and increased urine output c. tachycardia and hypotension d. respiratory depression and lung crackles
c. tachycardia and hypotension
the student nurse is caring for a patent who has been in the burn unit for several weeks. the patient needs assistance with the bedpan to have a bowel movement, and the student nurse notes the the stool is black with a tarry appearance. what is the most important priority action at this time? a. check the patients CBC relates including hematocrit and hemoglobin b. ask if the patient is currently taking an iron supplement c. test for the presence of occult blood with a hemoccult card and reagent d. perform a dietary assessment to determine if the stool color is related to food
c. test for the presence of occult blood with a hemoccult card and reagent
a nurse is caring for a client who experienced serious burns in a fire. which relationship between a clients burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns? a. equal b. unrelated c. inversely related d. directly proportional
d. directly proportional
a patient who sustained severe burns to the face with significant scarring and disfigurement will soon be discharged from the hospital. which intervention is best to help the patient make the transition into the community? a. discuss cosmetic surgery that could occur over the next several years b. focus on the positive aspects of going home and being with family c. teach the family to perform all aspects of care for the patient d. encourage visits from friends and short public appearances before discharge
d. encourage visits from friends and short public appearances before discharge
the nurse is interviewing and assessing an electrician who was brought to the emergency department (ED) after being "electrocuted". bystanders report that he was holding onto the electrical source "for a long time". the patient is currently alert with no respiratory distress. during the interview, what does the nurse assess for? a. knowledge of electrical safety b. burn marks on the dominant hand c. injuries based on reports of pain d. entrance and exit wounds
d. entrance and exit wounds
the nurse is caring for several patients on the burn unit who have sustained extensive tissue damage. the nurse should monitor for which electrolyte imbalance that is typically associated with the initial third-spacing fluid shift? a. hypercalcemia b. hypernatremia c. hypokalemia d. hyperkalemia
d. hyperkalemia
during the early phase of a burn injury, there Is a drastic increase in capillary permeability. this physiologic change places the patient at risk for which problem? a. acute kidney injury b. fluid overload c. increased cardiac output d. hypovolemic shock
d. hypovolemic shock
a nurse is caring for a client who sustained a partial thickness burn to the lower leg accounting for 5% of the TBSA 1 day ago. a primary short-term outcome established by the nurse and client is "the clients: a. airway will remain open" b. burns will heal free of infection" c. urine output will exceed 30mL every hour" d. pain will remain at 2 or less on a scale of 0 to 10"
d. pain will remain at 2 or less on a scale of 0 to 10"
a burn patient refuses to eat. the potential problem of weight loss r/t increased metabolic rate and reduced calorie intake is identified for this patient. what method does the nurse use to weigh this patient correctly? a. weigh once a week after morning hygiene and compare to previous weight b. weigh daily at the same time of day and compare to preburn weight c. use a bed scale and subtract the estimated weight of linens d. weigh daily without dressings or splints and compare to preburn weight
d. weigh daily without dressings or splints and compare to preburn weight
