PUCH67 PART I
A backcountry skier has been airlifted to the ED after becoming lost and developing hypothermia and frostbite. How should the nurse best manage the client's frostbite? a. Immerse affected extremities in water slightly above normal body temperature. b. Immerse the client's frostbitten extremities in the warmest water the client can tolerate. c. Gently massage the client's frozen extremities in between water baths. d. Perform passive range-of-motion exercises of the affected extremities to promote circulation.
a
A client is admitted to the ED after being involved in a motor vehicle accident. The client has multiple injuries. After establishing an airway and adequate ventilation, the ED team should prioritize what aspect of care? a. Control the client's hemorrhage. b. Assess for cognitive effects of the injury. c. Splint the client's fractures. d. Assess the client's neurologic status.
a
A client is admitted to the ED with suspected alcohol intoxication. The ED nurse is aware of the need to assess for conditions that can mimic acute alcohol intoxication. In light of this need, the nurse should perform what action? a. Check the client's blood glucose level. b. Assess for a documented history of major depression. c. Determine whether the client has ingested a corrosive substance. d. Arrange for assessment of serum potassium levels.
a
A client is brought to the emergency department by ambulance. The client is seriously ill and unconscious. No family or friends are present. Which of the following would be most appropriate to do? a. Document the client's condition and absence of friends or family for obtaining consent to treatment. b. Check the client's record for the name of a family member to call to allow care to be provided. c. Ask the ambulance team for information about the client's family to ensure informed consent. d. Explain to the client that care is going to be provided because he is seriously ill.
a
A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's: a. blood pressure. b. hemoglobin level. c. temperature. d. heart rate.
a
A client present to the ED following a work-related injury to the left hand. The client has an avulsion of the left ring finger. Which correctly describes an avulsion? a. Tissue tearing away from supporting structures b. Incision of the skin with well-defined edges, usually long rather than deep c. Skin tear with irregular edges and vein bridging d. Denuded skin
a
A client presents to the ED after an unsuccessful suicide attempt. The client is diagnosed with an acetaminophen overdose. The nurse anticipates the administration of which medication? a. N-acetylcysteine b. Flumazenil c. Naloxone d. Diazepam
a
A client presents to the ED reporting choking on a chicken bone. The client is breathing spontaneously. The nurse applies oxygen and suspects a partial airway obstruction. Which action should the nurse do next? a. Encourage the client to cough forcefully. b. Insert a nasopharyngeal airway. c. Prepare the client for a bronchoscopy. d. Insert an oropharyngeal airway.
a
A homeless client presents to the ED. Upon assessment, the client is experiencing hypothermia. The nurse will plan to complete which priority intervention during the rewarming process? a. Attach a cardiac monitor b. Insert a Foley urinary catheter c. Assist with endotracheal intubation d. Administer inotropic drugs
a
A nurse is providing care to a client in the emergency department and walks into the hallway to get equipment. All of a sudden, gunshots are heard. Which of the following would be the nurse's priority? a. Protecting himself or herself b. Securing the area c. Gaining control of the situation d. Providing care to the injured
a
A patient brought to the ED by the rescue squad after getting off a plane at the airport is complaining of severe joint pain, numbness, and an inability to move the arms. The patient was on a diving vacation and went for a last dive this morning before flying home. What is a priority action by the nurse? a. Ensure a patent airway and that the patient is receiving 100% oxygen. b. Send the patient for a chest x-ray. c. Send the patient to the hyperbaric chamber. d. Draw labs for a chemistry panel.
a
Following a motor vehicle collision, a client is brought to the ED for evaluation and treatment. The client is being assessed for intra-abdominal injuries. The client reports severe left shoulder pain (pain score of 10 on a 1 to 10 scale). The nurse suspects injury to the a. spleen. b. liver. c. gallbladder. d. large intestine.
a
The nurse has received a client into care who was admitted with a heroin overdose. The client has a 5-year history of illicit substance use with cocaine, heroine and oxycodone. The client develops a sudden onset of wheezing, restlessness and a cough that produces a frothy, pink sputum. The nurse suspects the client has most likely developed which complication of opioid overdose? a. Pulmonary edema b. Pneumonia c. Congestive heart failure d. Panic attack
a
The nurse in the hospital emergency department is assessing a patient who fell while intoxicated with alcohol. The nurse is using the Clinical Institute Withdrawal Assessment-Alcohol (CIWA-A) scale to assess the patient's need for a benzodiazepine medication. In order to assess for auditory disturbances, which question should the nurse ask the patient? a. "Are you hearing anything that is disturbing you?" b. "Are you experiencing any burning or numbness?" c. "Are you finding the light is too harsh or bothering your eyes?" d. "Does it feel like there is a tight band around your head?"
a
The nurse is caring for a 21-year-old client with a diagnoses of brain death due to injuries sustained in a snowboarding accident. The family has chosen to remove life support measures to allow the client's death. Upon hearing the family's decision, what is the nurse's first action? a. Request senior medical staff discuss organ donation b. Ask the family if the client had advanced directives c. Assess for interrupted family processes d. Provide family members with PRN sedation
a
The nurse is caring for a client in the ED with frostbite to the left hand. During the rewarming process of the hand, the nurse should perform which action? a. Administer analgesic medications as ordered. b. Keep the hand in the circulating bath for 1 hour. c. Rupture any hemorrhagic blebs that are noted. d. Have the client complete active range-of-motion exercises.
a
The nurse is caring for a client with right ventricular heart failure. The nurse understands hypervolemia will have what effect on the client's heart? a. The client's myocardial oxygen requirements will be higher b. The client's stroke volume will be decreased c. The client's ventricles will not have to work as hard d. The client's will experience systemic vasodilation
a
The nurse is conducting a secondary survey on a client in the ED. Which action is completed during the secondary survey? a. Diagnostic and laboratory testing b. Assessment of peripheral pulses c. Establishing a patent airway d. Undressing the client
a
When providing care to a client who has experienced multiple trauma, which of the following would be most important for the nurse to keep in mind? a. The client is assumed to have a spinal cord injury until proven otherwise. b. The most lethal injuries are often the most readily apparent. c. Most multiple trauma victims exhibit evidence of the trauma. d. Injuries have occurred to at least three distinct organ systems.
a
Which medication reverses severe respiratory depression and coma? a. Naloxone hydrochloride b. Diazepam c. Flumazenil d. N-acetylcysteine
a
Which phase of the psychological reaction to rape is characterized by fear and flashbacks? a. Heightened anxiety phase b. Acute disorganization phase c. Denial phase d. Reorganization phase
a
A patient is brought to the ED by a friend, who states that a tree fell on the patient's leg and crushed it while they were cutting firewood. What priority actions should the nurse perform? (Select all that apply.) a. Applying a clean dressing to protect the wound b. Elevating the site to limit the accumulation of fluid in the interstitial spaces c. Inserting an indwelling catheter d. Splinting the wound in a position of rest to prevent motion e. Performing a fasciotomy
a b d
The nurse is caring for a client in the intensive care unit who is recovering from trauma as a result of a motor vehicle accident that claimed the life of the client's friend. While the nurse is performing a dressing change on the client's surgical wound, the client states, "I don't deserve to live. I have just been thinking about ending it all." As the nurse assesses the client's imminent risk for suicide, what contributing factors need to be considered? Select all that apply. a. The client attempted suicide as a teenager. b. The client's maternal uncle committed suicide. c. The client's parents visit on a daily basis. d. The client had a close relationship to the accident victim. e. The client is not able to ambulate unassisted.
a b d
A nurse suspects an older adult is experiencing heat stroke based on which assessment findings? Select all that apply. a. Temperature 105 degrees F (40.6 degrees C) b. Lack of sweating c. Increased thirst d. Weakness e. Delirium f. Bradypnea
a b e
A 6-year-old is admitted to the ED after being rescued from a pond after falling through the ice while ice skating. What action should the nurse perform while rewarming the client? a. Assessing the client's oral temperature frequently b. Ensuring continuous ECG monitoring c. Massaging the client's skin surfaces to promote circulation d. Administering bronchodilators by nebulizer
b
A client presents to the ED with serious health problems that are not immediately life threatening. The nurse will correctly triage the client into which category? a. Emergent b. Urgent c. Nonurgent d. Psychological support
b
A nurse is providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate? a. Providing an analgesic for pain b. Massaging the feet c. Restricting ambulation d. Placing sterile cotton between the toes after rewarming
b
In which triage category would the nurse include a client who requires simple first aid or basic primary care? a. Urgent b. Fast track c. Nonurgent d. Emergent
b
Permanent brain injury or death will occur within which time frame secondary to hypoxia? a. 1 to 2 minutes b. 3 to 5 minutes c. 6 to 8 minutes d. 9 to 10 minutes
b
Several clients in the emergency department are being categorized by the triage nurse. Which client will the nurse place in the urgent category? a. A 24-year-old client with multiple gunshot wounds to the chest, arms, and legs b. A 54-year-old client with a history of diabetes presenting with anemia and abdominal pain c. A 56-year-old client with a cut to the left hand that requires wound debridement and stitches d. A 60-year-old client presenting with chest pain and ST elevation on electrocardiogram
b
The nurse is caring for a client who is being prepared for the placement of a central intravenous line. The nurse recognizes this client requires this type of intravenous access for which reason? a. The client will require intravenous access for three days b. The client requires total parenteral nutrition c. The client requires infusion of intravenous antibiotics d. The client requires infusion of a dextrose 5% water (D5W)
b
The nurse observes that the family members of a client who was injured in an accident are blaming each other for the circumstances leading up to the accident. The nurse appropriately lets the family members express their feelings of responsibility, while explaining that there was probably little they could do to prevent the injury. In what stage of crisis is this family? a. Anxiety and denial b. Remorse and guilt c. Anger d. Grief
b
The nurse received a patient from a motor vehicle accident who is hemorrhaging from a femoral wound. What is the initial nursing action for the control of the hemorrhage? a. Apply a tourniquet. b. Apply firm pressure over the involved area or artery. c. Elevate the injured part. d. Immobilize the area to control blood loss.
b
Which category of triage encompasses clients with serious health problems that are not immediately life threatening? a. Emergent b. Urgent c. Nonurgent d. Psychological support
b
A female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing interventions should be provided? (Select all that apply.) a. Have the patient shower or wash the perineal area before the examination. b. Assess and document any bruises and lacerations. c. Record a history of the event, using the patient's own words. d. Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police. e. Ensure that the police are present when the examination is performed.
b c d
A client is brought to the ED by family members who tell the nurse that the client has been exhibiting paranoid, agitated behavior. What should the nurse do when interacting with this client? a. Keep the client in a confined space. b. Use therapeutic touch appropriately. c. Give the client honest answers about likely treatment. d. Attempt to convince the client that his or her fears are unfounded.
c
A client is brought to the ED by friends. The friends tell the nurse that the client was using cocaine at a party. On arrival to the ED the client is in visible distress with an axillary temperature of 40.1ºC (104.2°F). What would be the priority nursing action for this client? a. Monitor cardiovascular effects. b. Administer antipyretics. c. Ensure airway and ventilation. d. Prevent seizure activity.
c
A client is brought to the emergency department after being involved in a motor vehicle collision. Which of the following would lead the nurse to suspect internal bleeding? a. Bradycardia b. Rising blood pressure c. Delayed capillary refill d. Pale pink dry skin
c
A client is brought to the emergency department with severe hemorrhage requiring massive blood replacement. The nurse warms the blood in a commercial warmer based on the understanding that infusion of large amounts of blood could result in which of the following? a. Hyperthermia b. Hemolytic transfusion reaction c. Cardiac arrest d. Fluid overload
c
A client is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the health care provider will perform which of the following actions? a. Insert an oropharyngeal airway. b. Perform the jaw thrust maneuver. c. Perform endotracheal intubation. d. Perform a cricothyroidotomy.
c
A patient was bitten by a tick 3 months ago and is now having muscle aches as well as joint pain and swelling. The patient is having difficulty with self care and requires assistance with activities of daily living (ADLs). What stage of Lyme disease does the nurse recognize the patient is in? a. Stage I b. Stage II c. Stage III d. Stage IV
c
The health care team in an intensive care unit have experienced a critical incident in which a young client died unexpectedly and the client's father physically attacked the senior physician treating the client. The client's father was arrested and escorted from the intensive care unit by police, against his will and in handcuffs. A critical incident stress management (CISM) staff meeting held 3 days after the incident took place. What would be the purpose for that meeting? a. Counselling b. Defusing c. Debriefing d. Follow up
c
The nurse has commenced a transfusion of fresh frozen plasma (FFP) and notes the client is exhibiting symptoms of a transfusion reaction. After the nurse stops the transfusion, what is the next required action? a. Remove the peripheral IV line b. Start a dextrose 5% water infusion c. Run a normal saline line to keep the vein open d. Obtain a blood culture from the IV insertion site
c
What is a common source of airway obstruction in an unconscious client? a. A foreign object b. Saliva or mucus c. The tongue d. Edema
c
When preparing to perform abdominal thrusts on a client with an airway obstruction, which of the following would be most appropriate? a. Having the conscious client lie down b. Placing the thumb side of one hand at the xiphoid process c. Positioning the hands in the midline slightly above the umbilicus d. Using a sequence of four thrusts, each progressing in intensity
c
A nurse is providing care to the family of a client who was brought to the emergency department and suddenly died. Which of the following would be appropriate for the nurse to do? Select all that apply. a. Talk with the family about the client having "passed on." b. Provide sedation to family members as needed. c. Ask the family if they would like to view the body. d. Provide a private place for the family to be together. e. Allow the family to express their emotions freely.
c d e
A nurse is caring for a client who is experiencing alcohol withdrawal. Which statement best indicates that the client understands the need for long-term treatment? a. The client agrees to attend supportive counseling. b. The client agrees to involve his family in psychotherapy. c. The client agrees to ongoing participation in one or more support groups. d. The client agrees to detoxification, rehabilitation, and participation in an aftercare program.
d
A nurse is providing in-service education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step? a. Collecting semen b. Performing the pelvic examination c. Obtaining consent for examination d. Supporting the client's emotional status
d
The nurse is administering 100% oxygen to a patient with carbon monoxide poisoning and obtains a carboxyhemoglobin level. Which level would the nurse interpret as indicating that oxygen therapy can be discontinued? a. 9% b. 7% c. 6% d. 4%
d
A nurse is providing initial first-aid care to a patient who was bitten by a snake. Place the following actions in the order in which the nurse would perform them. Use all options. 1 Clean the wound 2 Have the patient lie down 3 Cover the wound with a light sterile dressing 4 Remove constricting clothing 5 Immobilize the injury below the level of the heart 6 Provide warmth
2 4 6 1 3 5
