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Which information should the nurseinclude in the presentation?a. Contaminated water is the only source of transmission of biological agents. b. Vaccines are available and being prepared to counteract biological agents.c. Biological weapons are less of a threat than chemical agents.d. Biological weapons are easily obtained and result in significant mortality. 2. Which signs/symptoms would the nurse assess in the client who has been exposed to theanthrax bacillus via the skin?a. A scabby, clear fluid±filled vesicle. b. Edema, pruritus, and a 2-mm ulcerated vesicle.c. Irregular brownish-pink spots around the hairline.d. Tiny purple spots flush with the surface of the skin. 3. The client has expired secondary to smallpox. Which information about funeral arrangementsis most important for the nurse to provide to the client¶s family?a. The client must be cremated. b. Suggest an open casket funeral.c. Bury the client within 24 hours.d. Notify the public health department. 4. A chemical exposure has just occurred at an airport. An off-duty nurse, knowledgeable about biochemical agents, is giving directions to the travelers. Which direction should the nurse provide to the travelers?a. Hold their breath as much as possible. b. Stand up to avoid heavy exposure.c. Lie down to stay under the exposure.d. Attempt to breathe through their clothing. 5. The nurse is caring for a client in the prodromal phase of radiation exposure. Whichsigns/symptoms would the nurse assess in the client?a. Anemia, leukopenia, and thrombocytopenia. b. Sudden fever, chills, and enlarged lymph nodes.c. Nausea, vomiting, and diarrhea.d. Flaccid paralysis, diplopia, and dysphagia. 6. The off-duty nurse hears on the television of a bioterrorism act in the community.Which action should the nurse take first?a. Immediately report to the hospital emergency room. b. Call the American Red Cross to find out where to go.c. Pack a bag and prepare to stay at the hospital. d. Follow the nurse¶s hospital policy for responding. 7. Which situation would warrant the nurse obtaining information from a material safety datasheet (MSDS)?a. The custodian spilled a chemical solvent in the hallway. b. A visitor slipped and fell on the floor that had just been mopped.c. A bottle of antineoplastic agent broke on the client¶s floor.d. The nurse was stuck with a contaminated needle in the client¶s room. 8. The triage nurse is working in the emergency department. Which client should be assessedfirst? a. The 10-year-old child whose dad thinks the child¶s leg is broken. b. The 45-year-old male who is diaphoretic and clutching his chest. c. The 58-year-old female complaining of a headache and seeing spots. d. The 25-year-old male who cut his hand with a hunting knife.
Answer: DRationale: The nurse should follow the hospital¶s policy. and lethality of the agents. c. which cause edema with pruritus and the formation of macules or papules that ulcerate.9. anorexia. The nurse may be assigned as a first assistant in the operating room. Answer: ARationale: Cremation is recommended because the virus can stay alive in the scabs of the body for 13 years. which falls off in one (1) to 2 weeks. Which statement best describes the role of the medical-surgical nurse during a disaster?a. and fatigue. Individuals in this group can progress rapidly to expectant if treatment is delayed. which situationwould be considered a level red (Priority 1)? a.c. diarrhea. d. 10. Answer: DRationale: Because of the variety of agents. biological weapons. b. forming a 1-3 mm vesicle. The nurse may be assigned to crowd control. vomiting. 3. d. Answer: BRationale: Standing up will avoid heavy exposure the chemical will sink toward the floor or ground. respiratory distress.smallpox. Answer: DRationale: New settings and atypical roles for nurses may be required during disasters. It is required for every chemical that is found in the hospital. The nurse may be assigned to the emergency department. Answer: CRationale: The prodromal phase (presenting symptoms) of radiation exposure occurs 48± 72 hours after exposure and the signs/symptoms arenausea. According to the North Atlantic Treaty Organization (NATO) triage system. Many times nurses will stay at home until decisions are made as to where the employeesshould report. 10. 4. 6. Then a painless eschar develops. including anthrax. The nurse may be assigned to ride in the ambulance. 7. andexcitability. Answer: BRationale: The triage nurse should see this client first because these are symptoms of a myocar. 8. and spill information for a variety of chemicals. health information. Injuries are life threatening but survivable with minimal interventions. medical-surgical nurses can provide first aid and berequired to work in unfamiliar settings. Answer: ARationale: The MSDS provides chemical information regarding specific agents. . Injuries are extensive and chances of survival are unlikely.dial infarction. and plague. which potentially life isthreatening. Answer: DRationale: This is called the immediate category. b. Higher exposures of radiation signs/symptoms include fever. Injuries are minor and treatment can be delayed hours to days. is especially dangerous. 9. 2. Answer: BRationale: Exposure to anthrax bacilli via the skin results in skin lesions. the means of transmission. Injuries are significant but can wait hours without threat to life or limb. 5. RATIONALES 1.
Level D 8. c. ³Do you work or live near any large power lines?´ b. 4. Which statement explains the scientific rationale for having emergency suction equipmentavailable during resuscitation efforts? a. The EPA has divided PPE into four levels of protection .d. 6. Cardiac death is the time that the physician officially declares the client dead.c. Gastric distention can occur as a result of ventilation. A person is ventilating with an ambu bag. b. The nurse is teaching CPR to a class. A person is performing chest compressions correctly. A person is administering medications as ordered. Insert an oral airway prior to performing mouth to mouth. Use the mouth to cover the client¶s mouth and nose. 5. b. Which category of personal protective equipment (PPE) wouldthe response team wear?a.c. It keeps the vomitus away from the health-care provider. ³Where were you immediately before you got sick?´c. Which statement is the most important fact that must be shared with the participants?a. ³Can you write down everything you ate today?´d. b. Which intervention is the most important for the nurse to implement when performing mouthto-mouth resuscitation on a client who has pulseless ventricular fibrillation?a. Which question would be most appropriatefor the nurse to ask each client to determine if there is a bioterrorism threat?a. When assessing the situation. A person is keeping an accurate record of the code. The death is caused by myocardial ischemia resulting from coronary artery disease. b. Portable oxygen.Nursing Board Exam Review Questions in Emergency Part 5/20 1. d. Level Bc. A ventilator. Which statement best explains the definition of suddencardiac death?a. b. A crash cart.d. The nurse in the emergency department has admitted five (5) clients in the last two (2) hourswith complaints of fever and gastrointestinal distress. The nursing administrator responds to a code situation. It is needed to assist when intubating the client. This equipment will ensure a patent airway. Perform the jaw thrust maneuver to open the airway.d. Cardiac death occurs after being removed from a mechanical ventilator. whichrole must the administrator ensure is performed for legal purposes and continuity of care of theclient?a.d. b. ³What other health problems do you have?´ 7.c.d. The respondent should be trained in the proper use of PPE. 2. Level A b. Health-care facilities should keep masks at entry doors. Use a pocket mouth shield to cover client¶s mouth. 3. Which equipment must be immediately brought to the client¶s bedside when a code is calledfor a client who has experienced a cardiac arrest?a. Cardiac death occurs within one (1) hour of the onset of cardiovascular symptoms. The nurse is teaching a class on bioterrorism and is discussing personal protective equipment(PPE).c. Level Cd. A gurney. No single combination of PPE protects against all hazards.c. The health-care facility has been notified that an alleged inhalation anthrax exposure hasoccurred at the local post office.
When compressions are performed. skin. Remove the clients¶ clothing and have them shower.c. The nurse is teaching a class on bioterrorism. The nurse should takenote of any unusual illness for the time of year or clusters of clients coming from a singlegeographical location who all exhibit signs/symptoms of possible biological terrorism. The triage nurse in a large trauma center has been notified of an explosion in a major chemical manufacturing plant. Triage the clients and send them to the appropriate areas.d. 8.In this situation of possible inhalation of anthrax. c. . Answer: CRationale: Unexpected death occurring within1 hour of the onset of cardiovascular symptoms isthe definition of sudden cardiac death. Answer: ARationale: Level A protection is worn when the highest level of respiratory. the safer the community and area.9. b. 10. Answer: CRationale: The health-care providers are not guaranteed absolute protects. eye. 3. Answer: DRationale: Nurses should protect themselves against possible communicable disease. such protection is required. b. Answer: BRationale: The nurse should take note of any unusual illness for the time of year or clusters of clients coming from a single geographical location who all exhibit signs/symptoms of possible biological terrorism. Depending on the type of exposure.ion. 5. It prevents secondary contamination to the health-care providers. Answer: CRationale: This is the first step. hepatitis. Which action should the nurse implement first when the clientsarrive at the emergency department?a. Answer: BRationale: The crash cart is the mobile unit that has the defibrillator and all the medications andsupplies needed to conduct a code. Answer: DRationale: The chart is a legal document and the code must be documented in the chart and provide information that may be needed in the intensive care unit. Nursing Board Exam Review Questions in Emergency Part 5/20(ANSWER KEY) 1. 4. It provides a centralized area for stocking the needed supplies. 9. or any types of sexually transmitted disease. Answer: ARationale: Gastric distention occurs from overventilating clients.d. Showers and privacy can be provided to the client in this area. What is the scientific rationale for designating aspecific area for decontamination?a. and mucous membrane protection is required. 7. This area isolates the clients who have been exposed to the agent. Assume the clients have been decontaminated at the plant. 10. 6. evenwith all the training and protective equipment. Answer: DRationale: Avoiding cross contamination is a priority for personnel and equipment²the fewer number of people exposed. Thoroughly wash the clients with soap and water and then rinse. the pressure will cause vomiting that could be aspirated into the lungs. such asHIV. this step alone can remove alarge portion of exposure. 2.
Maintain sterile technique throughout the code. Which behavior by the unlicensed assistive personnel who is performing cardiac compressionson an adult client during a code warrants immediate intervention by the nurse?a. ³I should write down all my questions so I can ask them when I see the HCP.c. It will keep the health-care provider informed of the client¶s oxygen level. The client diagnosed with cancer of the pancreas is being discharged to start chemotherapy inthe HCP¶s office.d.5 to one (1) inch during compressions. Shake the client and shout. Has one hand on the lower half of the sternum above the xiphoid process. Refer to the dietitian. Monitor for elevated blood glucose at random intervals.d.d. do not watch the monitor. Which statement made by the client indicates the client understands thedischarge instructions?a. Call radiology for a STAT x-ray of the extremity. It analyzes the rhythm and shocks the client in ventricular fibrillation. b. 7.Nursing Board Exam Review Questions in Emergency Part 4/20 1. 5. ³The nurse will give me an injection in my leg and I will get to go home.c. Which action should thenurse implement first?a.´ b. Assess the carotid artery for a pulse. ³I am sure that this is not going to be a serious problem for me to deal with. The nurse finds the client unresponsive on the floor of the bathroom. Depresses the sternum 0. Assess for food preferences. Check the client for breathing.c. b. The AED will perform cardiac compressions on the client. b.c. Which is the most important intervention for the nurse to implement when participating in acode?a. Which self-care activity should the nurse teach that is anexample of primary nursing care?a. ³I will have to see the HCP every day for six (6) weeks for my treatments. Treat the client¶s signs/symptoms. b. Call a code via the bathroom call light. Instruct the client with hyperglycemia about insulin injections. 8. The client will be able to have synchronized cardioversion with the AED. The client is taken to the emergency department with an injury to the left arm. c. Performs cardiac compressions and allows for rescue breathing. Inspect the skin and sclera of the eyes for a yellow tint. . Which actionshould the nurse take first?a.d. Continuous feedings via PEG tube. Requests to be relieved from performing compressions because of exhaustion. 6. Which statement best describes an AED?a.c. Be sure to provide accurate documentation of what happened in the code. b. Limit meat in the diet and eat a diet that is low in fats.d.d.´ Which intervention should the nurse include in the plan of care?a.´d. The CPR instructor is explaining what an automated external defibrillator (AED) does tostudents in a CPR class. 2. 4.d. Remove the client¶s clothing from the arm. Prepare the client for the application of a cast. Have the family bring in foods from home. b.´c. Elevate the arm after administering medication. The nurse caring for a client diagnosed with cancer of the pancreas writes the collaborative problem of ³altered nutrition.c. Assess the nail beds for capillary refill time.´ 3. The nurse is planning a program for clients at a health fair regarding the prevention and earlydetection of cancer of the pancreas. b.
6. 9. Answer: CRationale: The sternum should be depressed 1. Answer: CRationale: Ventricular fibrillation is the most common dysrhythmia associated with suddencardiac death. Research has proved that the more involved a client becomes in his or her care.Clients should have a chance to ask all the questions that they have. Nursing Board Exam Review Questions in Emergency Part 4/20(ANSWER KEY) 1.5 to 2 inches during compressions to ensureadequate circulation of blood to the body.9. b. Other risk factors includegenetic predisposition and exposure to industrial chemicals. Which client is most likely to experiencesudden cardiac death?a. ventricular fibrillation is responsible for 65% to 85% of sudden cardiac deaths.c. . 3. therefore.d. A prolonged time(greater than three seconds) indicates impaired circulation to the extremity. The nurse is caring for clients on a medical floor. The 65-year-old client exhibiting supraventricular tachycardia. the better the prognosis. Risk factors for the development of cancer of the pancreas are cigarette smokingand eating a high-fat diet that is high in animal protein.The nurse should always treat the client based on the nurse¶s assessment and data from themonitors. an intervention should not be based on data from the monitors without the nurse¶sassessment. 10. The hospital chaplain.c. 8. 10. The 60-year-old client exhibiting asymptomatic sinus bradycardia. Answer: ARationale: This is the correct statement explaining what an AED does when used in a code. The respiratory therapist. the nurse needs to correct the assistant. Answer: CRationale: This is the most important intervention. The 84-year-old client exhibiting uncontrolled atrial fibrillation. 2. 5. Answer: DRationale: A collaborative intervention would be to refer to the nutrition expert. By changing these behaviors the clientcould possibly prevent the development of cancer of the pancreas. Which health-care team member referral should be made when a code is being conducted ona client in a community hospital?a. Answer: CRationale: This is the first intervention the nurse should implement after finding the clientunresponsive on the floor. 7. Answer: CRationale: Limiting the intake of meat and fats in the diet would be an example of primaryinterventions. 4.d. The director of nurses. the dietitian. b. The social worker. Answer: ARationale: The nurse should assess the nail beds for the capillary refill time.A small community hospital would not have a 24-hour on-duty pastoral service. Answer: BRationale: The most important person in the treatment of the cancer is the client. The 53-yearold client exhibiting ventricular fibrillation. Answer: ARationale: The chaplain should be called to help address the client¶s family or significant others.
Assess tissue turgor. CT is admittedin the area due to a fractured skull from a motor accident. Start an IV with an 18-gauge needle and infuse NS rapidly. You are a nurse in the emergency department and it is during the shift that Mr.d.d.d. Monitor for increased intracranial pressure. intracranial pressured. Do inspection and palpation to check extent of his injuries 5. the total volume and rate of IV fluid repalcement are gauged by the patient¶s responseand by the patient¶s response and by the resuscitation formula. A rupturedspleen is diagnosed and he is scheduled for emergency splenectomy. you noticed anxious he looks. In starting fluid replacementtherapy. b.c. Identify yourself and state your purpose in being with the client b. Which discharge instruction should the nurse teach the client¶s significant other?a. Have the client wait in the waiting room until a bed is available. In determining the adequacy of fluid resuscitation. cardiac output 3. urine output b. Collect urinalysis and blood samples for a CBC and calcium level. A client with multiple injury following a vehicular accident is transferred to the critical careunit. b. blood pressurec. Awaken the client every two hours. After you managed to stabilize the respiratory function of your burn patient. it is essential for you to monitor the:a. Apply antifungal creams. You establish rapport with him and to reducehis anxiety. The nurse caring for a client diagnosed with cancer of the pancreas writes the nursingdiagnosis of ³risk for altered skin integrity related to pruritus. 7. and weak. Offer the client food every three to four hours. Expectation of postoperative bleedingc. In preparing the client for surgery. Presence of abdominal drains for several days after surgery 2. Lucky was in a vehicular acccident where he sustained injury to his left ankle. Urgent b. forgetful. Talk to the physician for an order of valiumd. The client is lethargic. the nurse should emphasize in his teaching plan the:a. Monitor bony prominences for breakdown. Complete safety of the procedure b. b.Nursing Board Exam Review Questions in Emergency Part 3/20 1. You scheduled him for surgery under which classification?a.c. your next goal isto prevent this you have to replace the lost fluid and electrolytes. The client diagnosed with a mild concussion is being discharged from the emergencydepartment. Risk of the procedure with his other injuries d. . The client diagnosed with Addison¶s disease is admitted to the emergency department after aday at the lake. 6.c. He begins to complain of increased abdominal pain in the left upper quadrant. Perform a complete head-to-toe assessment. Emergentc. In theEmergency room. you initially:a. Take him to the radiology section for x-ray of affected extremityc. Observe frequently for hypervigilance. Requiredd. Elective 4. Have the client keep the fingernails short.´ Which interventions should thenurse implement?a. Which intervention should be theemergency department nurse¶s first action?a.
It is feared his leg mayhave to be amputated.d. abdomen and legs. When assessing the patient. Abdominal contusions and other woundsc. decrease mucosal swelling c. 10.When Eddie arrives in the emergency room. Which should be the first intervention implemented by the nurse?a.c. decrease bronchial secretions 4. Level of consciousness and pupil size b. He is pronounced dead onarrival. Nausea and coffee-ground emesis. Speak to one parent at a time so that each can ventilate feelings of loss without upsetting the other d. Start an IV with D5W. Nursing Board Exam Review Questions in Emergency Part 2/20 1 Which nursing intervention would be appropriate when caring for a client who has sustained anelectrical burn?a. Left lower abdominal cramps and tenesmus. Hehas suffered multiple crushing wounds of the chest. Preparing to administer the chemical antidote 2. Altered nutrition. increase BP b. the nurse should:a. Clay-colored stools and dark urine. is brought to the emergency room after the crash of his private plane. Give the client some orange juice.c. D. ask them to stay in the waiting area until she can spend time alone with them b. Quality of respirations and presence of pulses. Flushing the burn area with large amounts of water c. Respiratory rate and blood pressured. Intervention for a pt. Acute incisional pain. Monitoring the client with cardiac telemetryd. Applying ice to the burned area b. Fluid volume imbalance. Notify the health-care provider. b. The client admitted to rule out pancreatic islet tumors complains of feeling weak. Perform a bedside glucose check. relax the bronchial smooth muscled. Eddie. Which nursing problem has the highest priority?a. b. Anticipatory grieving. . shaky. speak to both parents together and encourage them to support each other and express their emotions freely c. This is given to:a. administering an irritant that will stimulate vomiting b.c. 3. ask the MD to medicate the parents so they can stay calm to deal with their son¶s death. the assessment that assume the greatest priority are:a. andsweaty. The client diagnosed with cancer of the head of the pancreas is two (2) days postpancreatoduodenectomy (Whipple¶s procedure). aspirating secretions from the pharynx if respirations are affectedc.d. When his parents arrive at the hospital. b. The client is diagnosed with cancer of the head of the pancreas. 9. washing the esophagus with large volumes of water via gastric lavage 5. John. Pain.d. An emergency treatment for an acute asthmatic attack is Adrenaline 1:1000 givenhypodermically. Night sweats and fever. neutralizing the chemicald.which signs and symptoms would the nurse expect to find?a. who has swallowed a Muriatic Acid includes all of the following except a. 16 years old. is brought to the ER after a vehicular accident.8. 40 years old.
When his parents arrive at the hospital. ask them to stay in the waiting area until she can spend time alone with them b. is brought to the ER after a vehicular accident. 16 years old. Perform 5 abdominal thrustsd. He is pronounced dead onarrival. Adrenaline or Epinephrine is anadrenergic agent that causes bronchial dilation by relaxing the bronchial smooth muscles. When performing chest compressions. Answer: CRationale: Because of the effects of the electrical current on the cardiovascular system. A nurse is eating in the hospital cafeteria when a toddler at a nearby table chokes on a piece of food and appears slightly blue. upper third of the sternum c. Give the child water to help in swallowingc.6. Chemical antidotes may be used for chemical burns for which an antidote has beenidentified. Put pressure on the apex of the heart 9. Applying ice is inappropriate for any type of burn. Answer: CRationale: Acute asthmatic attack is characterized by severe bronchospasm which can berelieved by the immediate administration of bronchodilators. A nurse is performing CPR on an adult patient. These are top priorities to trauma management. ask the MD to medicate the parents so they can stay calm to deal with their son¶s death. Administer salicylates to minimize the inflammatory reaction. Speak to one parent at a time so that each can ventilate feelings of loss without upsetting theother d. Nursing Board Exam Review Questions in Emergency Part 2/20(ANSWER KEY) 1. John. Increase systemic circulationc. speak to both parents together and encourage them to support each other and express their emotions freely c. the nurse should:a. lower third of the sternum 10. 4. A client is admitted from the emergency department with severe-pain and edema in the rightfoot. lower half of the sternumd. attempts to:a. His diagnosis is gouty arthritis. for acute airway obstruction. Only chemical burns should be flushed with large amounts of water. Begin mouth to mouth resuscitation b. upper half of the sternum b.d. Basic life functions must be maintained or reestablished 3. The Heimlich maneuver (abdominal thrust). Call for the emergency response team 7. Apply hot compresses to the affected joints. Measures are taken to immediately remove . The appropriate initial action should be toa. b. thenurse understands the correct hand placement is located over the a. 8. Induce emptying of the stomachd. Answer: DRationale: Respiratory and cardiovascular functions are essential for oxygenation. 2.c. Stress the importance of maintaining good posture to prevent deformities. When developing a plan of care. Force air out of the lungs b. Answer: ARationale: Swallowing of corrosive substances causes severe irritation and tissue destruction of the mucous membrane of the GI tract. which action would havethe highest priority?a. Ensure an intake of at least 3000 ml of fluid per day. all clientsexperiencing electrical burns should be placed on a cardiac monitor.
Answer: CRationale: The exact and safe location to do cardiac compression is the lower half of the sternum. Brief neurologic assessment d.answering their questions and listening to them will provide the needed support for them to moveon and be of support to one another. Assisting them with information they need to know. Answer: DRationale: Ensure an intake of at least 3000 ml of fluid per day.Administering an irritant with the concomitant vomiting to remove the swallowed poison willfurther cause irritation and damage to the mucosal lining of the digestive tract. 5. which of the following is considered one of the priority elements of the primary survey? a. An experienced RN and a nursing assistant 2. The patient should be urgedto increase his fluid intake to prevent the development of urinary uric acid stones. 7. You are the charge nurse in an emergency department (ED) and must assign two staff members to cover the triage area.answering their questions and listening to them will provide the needed support for them to moveon and be of support to one another. gastric emptying procedure is immediately instituted. A 50-year-old female with moderate abdominal pain and occasional vomiting _____. Answer: CRationale: Perform 5 abdominal thrusts. Palpation and auscultation of the abdomen c. having pedal pulse and no deformity d. _____. and nuchal rigidity c. dazed 25year-old male with a bandaged head wound b. Thisincludes gastric lavage and the administration of activated charcoal to absorb the poison. a. 9. Doing it at the lower third of the sternum may cause gastric compression which canlead to a possible aspiration. forces air out of the lungs and creates an artificialcough that expels the aspirated material. An experienced RN and an inexperienced RN d. 1. Gouty arthritis is a metabolicdisease marked by urate deposits that cause painful arthritic joints. and four patients approach the triage desk at the same time. Which team is the most appropriate for this assignment? a. At this age. The pressure from the thrusts lifts the diaphragm. Vomiting is onlyindicated when non-corrosive poison is swallowed. In conducting a primary survey on a trauma patient. _____ BADC 3. List the order in which you will assess these patients. 6. An experienced LPN/LVN and an inexperienced RN c. 10. You are working in the triage area of an ED. _____. They go intoa stage of denial and anger in their grieving. Complete set of vital signs b. An irritable infant with a fever. Initiation of pulse oximetry . A 35-year-old jogger with a twisted ankle. An advanced practice nurse and an experienced LPN/LVN b. They go intoa stage of denial and anger in their grieving. For corrosive poison ingestion. 8. Answer: BRationale: Sudden death of a family member creates a state of shock on the family.the toxin or reduce its absorption. Answer: BRationale: Sudden death of a family member creates a state of shock on the family. Assisting them with information they need to know. the most effective way to clear the airway of food is to perform abdominal thrusts. Answer: ARationale: The Heimlich maneuver is used to assist a person choking on a foreign object. such as in muriatic acid where burn or perforation of the mucosa may occur. petechiae. An ambulatory.
The child is currently alert and asymptomatic. The child has been treated several times for accidental injuries. and chest tightness. hypotension.A tearful parent brings a child to the ED for taking an unknown amount of children’s chewable vitamins at an unknown time. Chest compressions b. d. b. d. ashen skin. d. b. however. . Which patient needs attention first? a. _____. An anxious 24-year-old college student complains of tingling sensations. A 56-year-old patient presents in triage with left-sided chest pain. e. What information should be immediately reported to the physician? a. Assist the child to remove outer clothing. Placing the defibrillator pads 9. Ambulatory or fats track clinic d. Have the student breathe into a paper bag. Pediatric medicine team 11. cessation of breathing. Which of the following would be appropriate to delegate to the nursing assistant? a. Non-urgent d. Administer supplemental oxygen. presents with altered mental status. Obtain an order for an anxiolytic medication. _____. b. and hot. The child has been treated several times for ingestion of toxic substances. There is an elderly patient lying on the floor. A previously healthy homemaker reports broken air conditioner for days. Establish unresponsiveness. You respond to a call for help from the ED waiting room. A marathon runner complains of severe leg cramps and nausea. Which area of the ED is the most appropriate assignment for the nurse? a. and weakness are observed. 10. a. List the order for the actions that you must perform. diaphoresis. fatigue. Explain the need for cool fluids. Duration of exposure is unknown. This patient should be prioritized into which category? a. Emergent 5. Tachycardia. Call for help and activate the code team. Tachypnea. Bag-valve mask ventilation c. c. Triage c. diaphoresis. A homeless person. and dizziness. Which task is appropriate to delegate to the nursing assistant? a. d. Advise the parent to use acetaminophen instead of aspirin. Trauma team b. Notify the physician immediately. b. Perform the chin lift or jaw thrust maneuver. and patients with signs and symptoms of heat-related illness present in the ED. Prepare and administer a tepid bath. c. poor muscle coordination. High urgent b. _____. As the patient is being transferred to the emergency stretcher.4. c. d. Assisting with oral intubation d. The child was nauseated and vomited once at home. What priority nursing action should you take? a. rapid breathing and carpal spasms are noted. The physician has ordered cooling measures for a child with fever who is likely to be discharged when the temperature comes down. dry. palpitations. 7. pallor. poor historian. _____ BDACE 8. and profuse diaphoresis are observed. Initiate cardiopulmonary resuscitation (CPR). you note unresponsiveness. The emergency medical service (EMS) has transported a patient with severe chest pain. Urgent c. Deep. c. _____. Instruct a nursing assistant to get the crash cart. this is the nurse’s first week on the job. An elderly person complains of dizziness and syncope after standing in the sun for several hours to view a parade b. 6. It is the summer season. The ingested children’s chewable vitamins contain iron.An experienced traveling nurse has been assigned to work in the ED. and no palpable pulse. c.
Immerse the feet in warm water 100o F to 105o F (40. The patient is a poor historian but admits to “drinking a few on the weekend. b. b. d. Assist the family to collect belongings. IV lorazepam (Ativan) c. _____. Contact the family to obtain additional history and baseline information. Obtain an order for a blood alcohol level. .A 36-year-old patient with a history of seizures and medication compliance of phenytoin (Dilantin) and carbamazepine (Tegretol) is brought to the ED by the MS personnel for repetitive seizure activity that started 45 minutes prior to arrival. Ensure that the “chain of custody” is maintained. Remove the victim from the cold environment. 13. Apply a loose. Store the amputated digits in a solution of sterile normal saline. a.You are caring for a victim of frostbite to the feet. sterile.6o C to 46. Which task should be delegated to the LPN/LVN? a. Assess immediate emotional state and physical injuries b. The parent wants information about the IV conscious sedation. and uncooperative behavior. which task is most appropriate for an LPN/LVN? a.com 16.A patient sustains an amputation of the first and second digits in a chainsaw accident. Place the following interventions in the correct order. and scrapings beneath fingernails. saliva swabs. c.12. d. What information should you immediately report to the physician? a. Administer IV fluid support with supplemental thiamine as ordered. The parent is unsure about the child’s tetanus immunization status. Go with the organ donor specialist to talk to the family. c. Place the amputated digits directly into ice slurry. 17.In caring for a victim of sexual assault. c. bulky dressing.When an unexpected death occurs in the ED.” What is the priority nursing action for this patient? a. Wrap the amputated digits in sterile gauze moistened with saline. Give pain medication. Assist with postmortem care. Collect hair samples. mild confusion. The child is upset and pulls out the IV. d. b. _____ CBDA 14. which of the following tasks is most appropriate to delegate to the nursing assistant? a. 15. d. b. c.You are preparing a child for IV conscious sedation prior to repair of a facial laceration. Provide emotional support and supportive communication. b. You anticipate that the physician will order which drug for status epilepticus? a. d. _____. PO phenytoin and carbamazepine b. d. IV carbamazepam d. c. Escort the family to a place of privacy. The parent declines the IV conscious sedation. Gently cleanse the amputated digits with Betadine solution. 18. Administer naloxone (Narcan) 2 – 4 mg as ordered.1o C) _____.An intoxicated patient presents with slurred speech. c. IV magnesium sulfate Read more at Nurseslabs.
Risk for Nutritional Deficit related to chronic alcohol abuse 22. Ineffective Health Maintenance related to immunization status d. _____. Call 911. Remove the stinger by scraping. A 56-year-old male with a pulsating abdominal mass and sudden onset of pressure-like pain in the abdomen and flank within the past hour _____.Following emergency endotracheal intubation. Risk for Infection related to organisms specific to cat bites b. and anorexia for the past 2 days c. intermittent cramps with three episodes of watery diarrhea. Risk for Other-Directed Violence related to hallucinations c. What is the action that you should direct the caller to perform? a. Obtain an order for a chest x-ray to document tube placement. sweating. but denies any respiratory distress or other systemic signs of anaphylaxis. Prioritize them in order of severity.” 21. Monitor an asymptomatic near-drowning victim. 23. and tremors were noted. and worsening symptoms over the past week d. _____. “There was a lot of blood and we used three bandages. d. The cat is up-to-date immunizations.A prisoner. which task is most appropriate to delegate to an LPN/LVN? a.” d. The date of the patient’s last tetanus shot is unknown. Confirm that the breath sounds are equal and bilateral. Risk for Impaired Mobility related to potential tendon damage 25.” c.These patients present to the ED complaining of acute abdominal pain. vomiting small amounts of yellow bile. hallucination. c. _____. Secure the tube in place. A 40-year-old female with moderate left upper quadrant pain. The medical diagnosis is delirium tremens. c.In relation to submersion injuries.” b. He is alert and ambulatory. with a known history of alcohol abuse. a. Stabilize the cervical spine for an unconscious drowning victim. What is the priority nursing diagnosis? a. _____ CDBA 20. A patient who was stung by a common honey bee calls for advice. 2 hours after eating b. so he needs attention right away. you must verify tube placement and secure the tube. reports pain and localized swelling. because it was hurting him. He and his hysterical friends are yelling and trying to explain that that they were goofing around and he got poked in the abdomen with a stick. A 35-year-old male complaining of severe. List in order the steps that are required to perform this function? a. left lower quadrant tenderness. Risk for Injury related to seizures b. Initially. has been in police custody for 48 hours. anxiety. “The stick was really dirty and covered with mud. Now. Remove wet clothing and cover the victim with a warm blanket. b.You are assigned to telephone triage. _____. Talk to a community group about water safety issues. b. Take an oral antihistamine. b. nausea. 24. but this shirt and pants are covered with blood. disorientation. Auscultate the chest during assisted ventilation. _____ DBCA . A 11-year-old boy with a low-grade fever. Impaired Skin Integrity related to puncture wounds c. “He’s a diabetic.19. Risk for Situational Low Self-esteem related to police custody d. and hyper-reactivity are observed. “He pulled the stick out. c. d.A teenager arrives by private car. just now. Which of the following is the priority nursing diagnosis? a. Apply a cool compress.You are assessing a patient who has sustained a cat bite to the left hand. _____. d. Which of the following comments should be given first consideration? a.
f.com RATIONALES/ANSWER KEY 1.In a multiple-trauma victim. . Secure/start two large-bore IVs with normal saline b.You are giving discharge instructions to a woman who has been treated for contusions and bruises sustained during an episode of domestic violence. Decreased bowel sounds d. D. Advise about contacting the police d. Use the chin lift or jaw thrust method to open the airway. RNs. Ethical decision-making about exposing self to potentially lethal substances 30.The nursing manager decides to form a committee to address the issue of violence against ED personnel. what is your primary responsibility in preparing for disaster management that includes natural disasters or bioterrorism incidents? a. Pairing an experienced RN with inexperienced RN provides opportunities for mentoring. At least one representative from each group of ED personnel 27. ____ CBDAEFG 29. Experienced RNs and experienced paramedics c.A patient in a one-car rollover presents with multiple injuries. because the assistant can obtain vital signs and assist in transporting. c. Awareness of the signs and symptoms for potential agnets of bioterrorism c. 2. What is your priority intervention for this patient? a. Answer: B. ____. An LPN/LVN is not qualified to perform the initial patient assessment or decision making. Which combination of employees is best suited to fulfill this assignment? a. Transportation arrangements to a safe house b. Prioritize the interventions that must be initiated for this patient. The patient with the head wound needs additional history and assessment for intracranial pressure.In the work setting. Answer: C – Triage requires at least one experienced RN. Knowledge of how and what to report to the CDC d. _____. Give supplemental oxygen per mask. Insert a Foley catheter if not contraindicated. Pairing an experienced RN with a nursing assistant is the second best option. g. Obtain a full set of vital signs. ____. Hematuria 28. Referral to a counselor c. which assessment finding signals the most serious and lifethreatening condition? a. C – An irritable infant with fever and petechiae should be further assessed for other meningeal signs. however. _____. Gross deformity in a lower extremity c. _____. A. Follow-up appointment for injuries Read more at Nurseslabs. A deviated trachea b. ED physicians and charge nurses b. Assess for spontaneous respirations d. Remove patient’s clothing. LPN/LVNs. e. Knowledge of the agency’s emergency response plan b. a. The patient with moderate abdominal pain is uncomfortable.26. their services are usually required in other areas of the ED. _____. and nursing assistants d. Advanced practice nurses are qualified to perform triage.
Answer: A – Nursing assistants are trained in basic cardiac life support and can perform chest compressions. 11. Tepid baths are not usually performed because of potential for rebound and shivering. but will not change the immediate diagnostic testing or treatment plan. D. Answer: B. The other tasks are the responsibility of an RN or.g. For the ankle injury. 8. A. which can be managed with rest and fluids. Answer: C – A brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary survey. and management includes fluids (IV or parenteral) and cooling measures. kidney stones). (High urgent is not commonly used. which allows the heat to dissipate from the child’s sk in.but not unstable at this point. collect and safeguard evidence. The nurse or the respiratory therapist should provide PRN assistance during intubation. CPR should not be interrupted until the patient recovers or it is determined that heroic efforts have been exhausted. trauma. Vital signs. 7. basic CPR can be effectively performed until the team arrives. and breathing into a paper bag will allow rebreathing of carbon dioxide. however. Elderly patients are at risk for heat syncope and should be educated to rest in cool area and avoid future similar situations. and care for these victims. which increases risk for brain damage. Triage. Advising and explaining are teaching functions that are the responsibility of the RN. a SANE (sexual assault nurse examiner) who has received training to assess. Other information needs additional investigation. 4. however. Non-urgent conditions can wait for hours or even days. however. . shock. The defibrillator pads are clearly marked. The use of the bag-valve mask requires practice and usually a respiratory therapist will perform this function. The housewife is experiencing heat exhaustion. Patients with urgent priority need treatment within 2 hours of triage (e. Answer: C – The patient is hyperventilating secondary to anxiety. get help and have someone initiate the code. if available. 12. The runner is having heat crams. assessment of the abdomen. 5. Answer: D – The homeless person has symptoms of heat stroke. The prognosis for recovery is good. placement should be done by the RN or physician because of the potential for skin damage and electrical arcing. The nurse is then responsible for starting CPR. which is defined as potentially life-threatening. Performing the chin lift or jaw thrust maneuver opens the airway. a medical emergency. Answer: D – Chest pain is considered an emergent priority. encouraging slow breathing will help.) If the patient is unresponsive. in 5-tier triage systems. and pediatric medicine should be staffed with experienced nurses who know the hospital routines and policies and can rapidly locate equipment. and hepatic failure. Answer: A – The nursing assistant can assist with the removal of the outer clothing. Also. and initiation of pulse oximetry are considered part of the secondary survey. 6. Deferoxame is an antidote that can be used for severe cases of iron poisoning. 9. 3. Answer: C – The fast track clinic will deal with relatively stable patients. E – Establish unresponsiveness first. Answer: A – Iron is a toxic substance that can lead to massive hemorrhage. Other treatments such as oxygen and medication may be needed if other causes are identified. High urgent patients fall between emergent and urgent in terms of the time lapsing prior to treatment). medical evaluation can be delayed 24 – 48 hours if necessary. Answer: C – The LPN/LVN is able to listen and provide emotional support for her patients. (The patient may have fallen and sustained a minor injury. 10. A crash cart should be at the site when the code team arrives. C. coma.
and the nursing assistant is able to assist with these duties. Answer: A – The patient demonstrates neurologic hyperactivity and is on the verge of a seizure. 22. and removal can precipitate sudden hemodynamic decompensation. but it does not come in an IV form. Thiamine and haloperidol (Haldol) will also be ordered to address the other problems. 17.13. Answer: B – An impaled object may be providing a tamponade effect. 21. It will be painful. 16. 24. 23. absence or mixed type seizures. Multiples drug abuse is not uncommon. so the chain of custody would have to be maintained. so give pain medication prior to immersing the feet in warmed water.. and medical history should be obtained. such as the dirt on the stick or history of diabetes. lifting. Answer: C – The only correct intervention is C. A – Auscultating and confirming equal bilateral breath sounds should be performed in rapid succession. The container is then placed on ice. These wounds are usually not sutured. however. depth of penetration. The RN should take responsibility for the other tasks to help the family begin the grieving process. D. the digits should be gently cleansed with normal saline. Patient safety is the priority. and then the rewarming process can be initiated. The patient needs chlordiazepoxide (Librium) to decrease neurologic irritability and phenytoin (Dilantin) for seizures. the physician must be notified. wrapped in sterile gauze moistened with saline. The caller should be further advised about symptoms that require 911 assistance. cerebral edema. The RN can restart the IV and provide information about conscious sedation. 20. Answer: C – Parent refusal is an absolute contraindication. there is nothing in the question that suggests an opiate overdose that requires naloxone. etc. B. B. Answer: A – Cat’s mouths contain a virulent organism. so prompt removal of the stinger is advised. Other information. 19. . Securing the tube is appropriate while waiting for the x-ray study. that can lead to septic arthritis or bacteremia. If the sounds are not equal or if the sounds are heard over the mid-epigastric area. PO (per os) medications are inappropriate for this emergency situation. Additional information or the results of the blood alcohol level are part of the total treatment plan but should not delay the immediate treatment. Tegretol is used in the management of generalized tonic-clonic. 18. cleaning. Magnesium sulfate is given to control seizures in toxemia of pregnancy. 14. which is caused by a thiamine deficiency. Answer: B – The stinger will continue to release venom into the skin. if the parent still notsatisfied. Additional history including a more definitive description of the blood loss. A tetanus shot can be given before discharge. is important in the overall treatment plan. the physician can give more information. or pneumonia. The other diagnoses are pertinent but not as immediate. There is also a risk for tendon damage due to deep puncture wounds. Answer: B – IV Lorazepam (Ativan) is the drug of choice for status epilepticus. Answer: D – The asymptomatic patient is currently stable but should be observed for delayed pulmonary edema. Answer: C. Answer: C – Postmortem care requires some turning. tube placement must be corrected immediately. but can be addressed later. A – The victim should be removed from the cold environment first. belongings may be retained for evidence. Cool compresses and antihistamines can follow. Answer: C. Teaching and care of critical patients is an RN responsibility. therefore. Answer: D – The patient presents with symptoms of alcohol abuse and there is a risk for Wernicke’s syndrome. 15. Tetanus status can be addressed later. Pasteurella multocida. D. Removing clothing can be delegated to a nursing assistant. and placed in a plastic bag or container. In cases of questionable death.
. Answer: A – Safety is a priority for this patient. but are of lesser priority. (EMS will usually establish at least one IV in the field.25. All of the other symptoms need to be addressed. Answer: C. and mechanisms of reporting. Answer: A – In preparing for disasters. which is usually self-limiting. Answer: A – A deviated trachea is a symptoms of tension pneumothorax. 29. airway and oxygenation are priority. Answer: D – At least one representative from each group should be included because all employees are potential targets fro violence in the ED. The woman needs evaluation for gallbladder problems that appear to be worsening. The plan gives guidance that includes roles of team members. However. G – For a multiple trauma victim. and she should not return to a place where violence could reoccur. Starting IVs for fluid resuscitation is part of supporting circulation. C. A. 30. 26. Answer: D. B. such as flu-like symptoms. The other options are important for the long term management of this care. 28. Discussions with colleagues and supervisors may help the individual nurse to sort through ethical dilemmas related to potential danger to self. Signs and symptoms of many agents will mimic common complaints. The 11-year-old boy needs evaluation to rule out appendicitis. Methods to open the airway such as the chin lift or jaw thrust can be used simultaneously while assessing for spontaneous respirations. Foley catheter is necessary to closely monitor output. 27. D. B. F. A – The patient with a pulsating mass has an abdominal aneurysm that may rupture and he may decompensate suddenly. responsibilities. many interventions will occur simultaneously as team members assist in the resuscitation. E.) Nursing assistants can be directed to take vitals and remove clothing. the RN should be aware of the emergency response plan. The 35-year-old man has food poisoning.
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