A diving accident occurs at the community pool and the victum is consciours and in pain. Which intervention is most appropriate pending the arrival of emergency medical personnel?A. Position the patient on the side of the poolB. Move the patient to the shallow end and cover with a towelC. Leave the patient in the pool and support with a large floatD. Leave the patient in the pool and attempt cardiopulmonary rescuscitation (CPR)
Leave the patient in the pool and support with a large float*Care should be taken to avoid movement of the patient and increasing injury to the spinal cord. Leaving the patient in the pool and supporting the patient on a float will not increase a possible spinal injury. Pulling the patient may cause further injury to the spine. CPR is not indicated as the patient is not experiencing cardiopulmonary arrest
A drowning victim is brough to shore and is semiconscious and breathing. The camp counselor recognizes that which positioning is the most appropriate for this victim? A. Supine to receive CPRB. Supine with knees flexedC. On the side in recovery positionD. Prone with head turned to side
On the side in recovery position*The patient who is breathing should be placed in the recovery position to allow the patient to vomit out water without danger of aspiration. CPR is not indicated as the patient is not experiencing the absence of cardiopulmonary activity. Lying supine or prone will not prevent aspiration in the even of vomiting
In the memory prompt for emergency care, ABCDE, what does the "E" represent?A. EndB. ExecuteC. ExpediteD. Expose
Expose*This reminder is to assist the first responder to assess for other injuries that may be hidden under clothing
The nurse is teaching a CPR class. During the class, the nurse correctly includes which statement when discussing the Good Samaritan Law?A. The Good Samaritan Law only protects medical professionals from liabilityB. The Good Samaritan Law protects all people from liabilityC. The Good Samaritan Law limits the liability of a medical professionalD. The Good Samaritan Law defines specific situations in which no liability will occur
The Good Samaritan Law protects all people from liability*The Good Samaritan Law is designed to protect passersby who render first aid so they will not be held liable for the outcome of emergency care. Individuals who choose to render care will be held to the standard consistent with their training. The law is not limited to medical personnel. It does not address limitations of liability. There is no definition of specific scenarios protected by the law
A victim of a knife fight is found lying in a parking lot with a loop of bowel protruding from an abdominal wound. What should the first responder do first?A. Attempt to replace the bowel back into the abdomenB. Wrap the victim's shirt tightly around his bodyC. Cover the evisceration with a plastic shopping bagD. Assist the victim to flex his thighs against his abdomen
Cover the evisceration with a plastic shopping bag*Covering evisceration with a nonadhesive covering will keep the bowel moist. Attempts to return the bowel into the abdomen may result in further injury. Tightly wrapping the shirt around the body may compromise circulation. Flexion of the thighs onto the abdomen may compress and cause further damage to the bowel
A worker in a department store fell through a plate glass window, causing a deep laceration on the right mid-thigh that is pumping bright red arterial blood. Which initial action is most important for the first responder to take?A. Elevate the legB. Bunch up the worker's shirt and press it against the woundC. Press the palm of the hand in the groin to compress the femoral arteryD. Tie the worker's belt tightly around his upper thigh to stop bleeding
Bunch up the worker's shirt and press it against the wound*A guideline published by the American College of Surgeons Committee on Trauma in 2014 recommends holding direct pressure on the bleeding area for prehospital control of bleeding. If this approach is impractical or ineffective, a tourniquet may be implemented. It is not always possible to compress the artery at the needed location, so this choice is not a first line intervention. Elevation if an injured extremity is no longer recommended
The nurse cautions that, when cooling down a victim of heatstroke, one must be careful to prevent shivering. Shivering can lead to which complication?A. A parylytic ileusB. Cardia arrhythmiasC. An increase in temperatureD. A seizure
An increase in temperature*Shivering is a homeostatic activity that generates heat and increases body temperature. Shivering would not cause a paralytic ileus, cardiac arrhythmias, or seizures
The nurse is teaching a group of CNAs about the fastes and simplest technique to reduce temperature in a patient with a fever. Which method should the nurse include in the teaching plan?A. Apply ice packs to the groinB. Bathe the patient in tepid waterC. Remove clothing and bed linenD. Give the patient chilled drinks
Remove clothing and bed linen*Removing the patient's clothing and bed linen covering the patient is a quick, simple, and usually effective way to reduce temperature. The application of ice packs may result in excessive cooling and result in shivering, which acts to increase metabolic rate. Bathing in tepid water is effective but requires more time and interaction than simply removing clothing and bed linens. Chilled drinks will not adequately reduce the total body temperature
A spectator at the Little League playoffs in August in Texas faints in the sun-drenched stands. His face is flushed and his skin is hot to the touch. What action should the first responder take?A. Lay the spectator down on the bleacher seatB. Help the spectator drink a large iced drinkC. Seat the spectator upright and shield him from the sun with an umbrellaD. Move the responder to a shady area, and sprinkle his clothing with water
Move the responder to a shady area, and sprinkle his clothing with water*The best action is to remove the victim from the sun and cool by evaporation until emergency medical personnel arrive. The spectator should not remain in the sun on the hot bleachers in any capacity
A student nuse is assisting with the care of a 50 year old man is being treated in the emergency department for hypothermia. The student asks the charge nurse why the patient is having his heart monitored. How should the nurse best respond?A. Infusing intravenous (IV) fluids rapidly raise blood pressure (BP) and heart rateB. Adrenal output of epinephrine increases in response to cold stressC. Lactic acid from pooled blood in the extremities shunts back to the heartD. The warming process causes vasodilation
Lactic acid from pooled blood in the extremities shunts back to the heart*Lactic acid in the blood that was pooled in the extremities while being exposed to cold will shunt back to the heart throught systemic perfusion as the warming process becomes effective. The lactic acid can cause arrhythmias
The nurse is caring for a patient with frostbite. Which assessment findings would lead the nurse to conclude that the patient has second-degree frostbite?A. Reddened skin with hard white plaquesB. Waxy skin with sensory deficitsC. Reddened skin with milky fluid-filled blistersD. Waxy skin with blood-filled blisters
Reddened skin with milky fluid-filled blisters*Frostbite is catergorized by degree of injury, much like burns. Second-degree injury is characterized by redness, swelling, and formation of blisters filled with clear or milky fluid that forms within 24 h injury. A first-degree injury includes reddened skin, swelling, waxy appearance, hard white plaques, and sensory deficit. Third-degree injury consists of blood-filled blisters followed by black exchar forming over several weeks. Fourth-degree injury involves full-thickness damage affecting muscles, tendons, and bone, resulting in tissue loss
The emergency department nurse is attempting to revive an unconscious, shivering person with extreme hypothermia (rectal temperature of 94F). The nurse should be most alarmed with which change?A. The patient's cold ears turn redB. The patient stops shiveringC. The patient's hands clenchD. The patient's reflexes return
The patient stops shivering*Cessation of shivering indicates that the body's homeostatic response to generate heat has ceased and the patient's condition is deteriorating. Clenching hands are an insignificant finding. Reddened ears and returning reflexes would indicate warming
An 80-year-old woman is brought to the emergency department after being found unconscious in her garage sitting in her car. Which assessment finding is most concerning to the nurse?A. Temperature, 97.6 F; pulse, 98; and blood pressure, 100/60B. Oxygen (O2) saturation of 78%C. Cherry red mucous membranesD. Cold extremities
Cherry red mucous membranes*The cherry red mucous membranes are classic signs of carbon monoxide poisoning; unfortunately, they are very late signs. The temperature, pulse, and blood pressure are withing normal limits. An O2 saturation of 78% could be corrected if accurate, and O2 saturation measurements are inaccurate in cases of carbon monoxide poisoning. Cold extremities do not necessarily indicate an urgent problem
A restaurant patron sitting at a next table begins to choke and cough. The patrin yells, "I'm chokin! I can't breathe!" What action should the first responder take?A. Initiate the Heimlich maneuver immediatelyB. Strike the victim sharply between the scapulaeC. Encourage the patient to cough and deep-breatheD. Offer him a small sip of fluid
Encourage the patient to cough and deep-breathe*Because the victiim can cough and speak, the airway is not compromised and can make an effort to clear the foreign matter by coughing. The Heimlich maneuver can be initiated at such a time that the victim's airway becomes occluded. The patron should not attempt to drink or eat until the foreign matter is cleared
A delivery man comes to the emergency department with dog bites on his legs. He states that the dog ran away after the attack and could not be identified. After treating the bites, the nurse educates the man about which next step?A. Notification of Animal ControlB. Receipt of immune globulin for passive immunityC. Receipt of the first five rabies vaccination injectionsD. Infusion of IV fluids
Receipt of immune globulin for passive immunity*The administration of immune globulin will build up his immediate defenses. As a delivery man, he would be considered to be in a high-risk group of animal bites and should be advised to acquire the vaccine, but the vaccine will not be of any use to him at this point. IV fluids are not likely inidicated unless blood loss was severe
The first responder to an automobile accident finds a victim with a sucking chest wound. What action should the responder take?A. Tightly bind the injury with a folded magazine and the patient's beltB. Place a plastic sandwich bag over the wound and tape on three sides to make a flutter dressingC. Turn the patient to the affected side and instruct the patient to deep breatheD. Place the patient's hand over the wound and tell the patient to press down
Place a plastic sandwich bag over the wound and tape on three sides to make a flutter dressing*The flutter dressing will allow the air to leave the pleural space, but not allow any more air in. The collapsed lung will begin to re-expand.
The nurse has arrived on the scene of an accident. The victim is conscious and has a large bleeding laceration on his thigh. The nurse uses an available towel to provide compression to the wound. What action should the nurse perform next?A. Turn the patient to his left sideB. Elevate the patient's affected legC. Blend the affected leg at the kneeD. Use the patient's belt as a tourniquet
Use the patient's belt as a tourniquet*After holding direct pressure on the bleeding area, a tourniquet may be implanted. The nurse should immobilize the leg and avoid position changes that could exacerbate bleeding. Elevation of an injured extremity is no longer recommended
The nurse is reviewing the physician's notes on a patient's chart. The nurse notes that the patient demonstrated Cullen sign. The nurse correctly recognizes that this patient most likely had which manifestation?A. Sharp flank painB. Pain in the upper right quadrant of the abdomenC. Pain with inspirationD. A bluish tinge around the umbilicus
A bluish tinge around the umbilicus*Cullen sign refers to a bluish tinge around the umbilicus. It may be noted in the presence of internal abdominal hemorrhage
The nurse is caring for a conscious patient who has symptoms consistent with hypoglycemia. After a serum glucose reading supports this diagnosis, which substance is preferred to initially increase the patient's glucose level?A. A carbonated sodaB. A teaspoon of white sugarC. A glass of milkD. IV glucose
A glass of milk*When the patient is conscious, an oral glucose-containing substance is suggested. A glass of milk, glucose tablets, or hard candy is preferred
The nurse recognizes which indications of respiratory distress? (select all that apply)A. GaspingB. WheezingC. StridorD. ChokingE. Stupor
1. Gasping2. Wheezing3. Stridor4. Choking*All options except stupor are indicators of respiratory distress
In which situation(s) is moving a victim of an automobil accident necessary? (select all that apply)A. Presence of pooled gasolineB. Oncoming trafficC. Submersion in snowD. Request from the victim to be movedE. Exposure to hot pavement
1. Presence of pooled gasoline2. Oncoming traffic3. Submersion in snow4. Exposure to hot pavement*A victim request to be moved is not a valid reason to do so if the victim is safe. The patient should be removed from pooled gasoline, oncoming traffic, submerging snow, and hot pavement
The nurse counsels a group of young track athletes about heatstroke prevention. Which information should the nurse include? (select all that apply)A. Drink plenty of fluids with high sugar contentB. Wear lightweight, loose clothingC. Practice in the early morningD. Rest frequently in cool placesE. Wear dark-colored clothing to block sun rays
1. Wear lightweight, loose clothing2. Practice in the early morning3. Rest frequently in cool places*Athletes should weat lightweight and loose clothing, practice in the morning to avoid peak heat hours, and rest frequently in the shade to prevent overheating. While athletes should drink plenty of fluids for hydration, liquids should be nonalcoholic, noncaffeinated, and low sugar; liquids with alcohol, caffeine, and sugar increase dehydration. Dark-colored clothing will absorb heat; athletes should wear light-colored clothing
The home health nurse in Wyoming gives instructions to an 80 year old patient in the prevention of hypothermia. Which information should the nurse include? (select all that apply)A. Wear multiple layers of clothingB. Wear a loose-fitting hatC. Move about brisklyD. Drink warm fluids from a thermosE. Wear gloves and earmuffs
1. Wear multiple layers of clothing2. Move about briskly3. Drink warm fluids from a thermos4. Wear gloves and earmuffs*The patient should wear multiple layers of clothing, move about briskly, drink warm fluids, and wear ear and hand protection. The patient should also wear a hat, but it should fit snugly
Which physiological differences explain why the older adult is prone to hypothermia? (Select all that apply)A. Decreasing appetite with less food intakeB. Increasing subcutaneous fatC. Decreasing metabolismD. Increased likelihood of athersclerosisE. Decreasing activity level
1. Decreasing appetite with less food intake2. Decreasing metabolism3. Increased likelihood of athersclerosis4. Decreasing activity level*The older adult is prone to hypothermia because of less food intake, lower metabolism, possibility of atherosclerosis, decreased activity level, and less subcutaneous fat
Treatment for frostbite includes which actions? (Select all that apply)A. Chafing the hands and fingers gently to reestablish circulationB. Immersion of hands and feet in warm waterC. Wrapping hands in mitten-like dressings to retain warmthD. Administering opioids to reduce painE. Elevating affected limbs
1. Chafing the hands and fingers gently to reestablish circulation2. Immersion of hands and feet in warm water3. Elevating affected limbs*Gently chafing hands and fingers, immersing extremities in water, and elevating affected limbs are indicated treatments for hypothermia. Nonsteroidal anti-inflammatory drugs are the analgesic of choice, because opioids decrease function and dealy circulatory recovery. Fingers should be wrapped individually, and touching each other
The nurse is instructing a group of 25 to 35 year old hikers about heatsroke prevention. Which participant drink selection indicates the need for further education? (select all that apply)A. Clear carbonated sodaB. Diet caffeinated colaC. WaterD. BeerE. Sugar-sweetened drinks
1. Clear carbonated soda2. Diet caffeinated cola3. Beer4. Sugar-sweetened drinks*The wrong fluids can increase fluid loss. To aid in the prevention of heatstroke, the hiker should drink plenty of fluids that are nonalcoholic, caffeine free, and low in sugar content. Clear carbonated soda and sweetened energy drinks are high in sugar. Diet cola contains caffeine
The nurse is caring for a patient suspected of having heatstroke. Whcih findings are consistent with this diagnosis? (select all that apply)A. BradycarduaB. TachycardiaC. Irregular pulse patternsD. Visual disturbancesE. Increased urinary output
1. Tachycardia2. Irregular pulse patterns3. Visual disturbances*Heatstroke may cause a weak, rapid, irregular pulse, and visual disturbances. Other manifestations may include decreased urinary output, an alteration in neurologic function, dizziness, and nausea
A neighbor is found slumped over the lawn mower and is unconscious. Arrange the interventions made by the first responder in appropriate orderA. Tell neighbor's wife to call 911B. Assess for heartbeatC. Initiate CPR if no respiration or circulation can be assessedD. Assess for signs of breathingE. Shake patient and call name to assess for level of consciousness (LOC)
1. Tell neighbor's wife to call 9112. Shake patient and call name to assess for level of consciousness (LOC)3. Assess for signs of breathing4. Assess for heartbeat5. Initiate CPR if no respiration or circulation can be assessed
The patient with chronic renal failure is hypoglycemic. Which juice is the most appropriate to give to the patient?A. AppleB. GrapefruitC. PruneD. Orange
Apple*Many patients with chronic renal failure are diabetic. If they become hypoglycemic, do not give juice that is high potassium, such as prune, orange, or grapefruit juice. Instead, use apple, cranberry, or grape juice.
The nurse is caring for a patient who was admitted to the emergency department with fractured ribs. Her boyfriend dropped her off and left. The patient is anxious, is nervous, appears depressed, and is evasive about how she fractured her ribs. What does the nurse suspect about the injury?A. The patient is a drug abuser.B. The patient is a victim of domestic violence.C. The patient falls frequently.D. The patient is an alcohol user.
The patient is a victim of domestic violence.*The patient is a victim of domestic abuse. Psychologically, the person may display signs of depression, low self-esteem, anxiety, and stress. The patient does not show signs of drug or alcohol use. She did not mention falling frequently.
A patient is brought to the emergency department with injuries sustained in an automobile accident. While assessing the patient, the nurse notes the presence of Cullen sign. This is suggestive of which medical emergency?A. Ruptured spleenB. Neurologic injuryC. Abdominal hemorrhageD. Bowel perforation
Abdominal hemorrhage*Cullen sign (ecchymosis around the umbilicus) is suggestive of abdominal hemorrhage. Cullen sign is not associated with neurologic injury, ruptured spleen, or bowel perforation.
The nurse is a first responder at the site of an accident involving multiple vehicles. Which patient should receive priority during triage?A. Burns of the head and neckB. Contusions of the head without loss of consciousnessC. Crushing injury of the armD. Open fractures of the tibia and fibula
Burns of the head and neck*One of the most common methods for triage of patients uses "ABCDE" as a memory trigger for the sequence of assessment. A is airway, B is breathing, and C is circulation. D can mean either the need for defibrillation or, in a trauma setting, assessment of neurologic disability. E is exposed: all areas of the body should be exposed so that injuries are not missed underneath clothing. Burns of the head and neck pose an immediate threat of airway compromise. Crushing injury of the arm, open fractures of the tibia and fibula, and head contusion without loss of consciousness are all painful but do not represent an immediate threat to life.
The nurse is assessing a patient who has lost a large volume of blood from multiple deep lacerations. Which finding would indicate that the patient is in shock?A. Bounding pulse, rate 88 beats per minuteB. Bounding pulse, rate 56 beats per minuteC. Strong pulse, rate 60 beats per minuteD. Thready pulse, rate 110 beats per minute
Thready pulse, rate 110 beats per minute*A rapid, thready pulse indicates compensation for loss of blood volume.
The nurse caring for a patient who is bleeding from a lacerated radial artery. The patient's blood pressure is 85/40, pulse is 130 and thready, and her skin is cold and clammy. The patient has likely experienced how much blood loss?A. 50%B. 30%C. 20%D. 40%
40%*When blood loss is at 40%, the clinical manifestations include below normal blood pressure, central venous pressure, and cardiac output at rest; and a rapid thready pulse with cold and clammy skin. Manifestations of a 20% blood volume loss are no signs or symptoms when at rest; however, the patient has slight postural hypotension when standing and tachycardia with exercise. The patient with a 30% blood volume loss will have normal blood pressure and pulse when supine; postural hypotension and tachycardia with exercise. At 50% the patient experiences shock and potential death.
The LPN/LVN is out with a friend one evening when the nurse witnesses a man suddenly collapse. What is the nurse's first action?A. Call for help.B. Start CPR.C. Defibrillate with an AED.D. Check the pulse.
Call for help.*The sudden collapse of an adult is likely to be cardiac in origin; call for help, start CPR, and defibrillate as soon as the AED is available. Any adult that is unresponsive or has breathing issues needs EMS care. The sooner the call is placed, the sooner help will arrive.
A patient has frostbite of her right hand. What should the nurse do first?A. Place ice on the hand.B. Gently massage the hand.C. Place the hand in water that is 45° to 48° C.D. Place the hand in water that is 40° to 42° C.
Place the hand in water that is 40° to 42° C.*After the patient arrives at the health care facility, rewarming is accomplished in a whirlpool bath with water at 40° to 42° C for 15 to 30 minutes for superficial injuries and up to an hour for deep injuries. Health care workers must handle the frostbitten part gently. Skin that has been frozen should never be rubbed or massaged. Rubbing snow or ice on the part is dangerous and can cause further damage to the fragile tissues.
A nurse is discharging an elderly patient who has been in the hospital with hypothermia for the past 3 days. The patient wants to know how to stay warm at home so she can stay out of the hospital. What is the nurse's best response? (Select all that apply.)A. "Cover your head when sleeping to prevent heat loss."B. "Keep doors open so all your rooms are heated."C. "Use your fireplace in the colder months to help keep you warmer."D. "Keep your room temperature checked, and never keep it lower than 65° F."E. "Wear multiple layers of clothes in your house and when going outdoors.
1. "Cover your head when sleeping to prevent heat loss."2. "Keep your room temperature checked, and never keep it lower than 65° F."3. "Wear multiple layers of clothes in your house and when going outdoors."*Hypothermia is more prevalent in the elderly because they are less active; therefore, less heat is generated. The nurse should teach the patient to cover her head when sleeping to prevent heat loss, to wear multiple layers of clothes in her house and when going outdoors, and to keep her room temperature checked and never keep it lower than 65° F. She should never keep her thermostat below 65° F anytime of the year. She should not use the fireplace in extremely cold weather because a substantial amount of heat is lost through the flue. An energy audit with suggestions from the utility company can prevent heat loss from the home. Suggest heating one or two rooms and closing off the other rooms of the house. Suggest aids, such as a throw or quilt, extra socks, and warm hats to be worn indoors. Arrange for someone to check in daily with elderly persons who live alone. Suggest an early alert system be installed, allowing the individual to call for help by pressing a button, if unable to get to the phone.
The nurse is performing triage in the emergency department. List the patients in the order they should be seen in the emergency department.A. A 14-year-old patient who is alert and oriented following a blow to the head during football practiceB. A 76-year-old patient with chronic obstructive pulmonary disorder with nasal flaring and supraclavicular retractionsC. A 3-year-old crying patient with a forehead bump and bruiseD. A 15-year-old patient with a severe allergy to peanuts and swollen tongue and lipsE. A 48-year-old patient with a firm, distended abdomen complaining of severe painF. A 64-year-old light-headed patient with a pulse of 134 who reports vomiting and bloody stools once a week
They are in order*The nurse should use the ABCDE mnemonic to triage the patients. The first patient to be seen is the patient with the impending compromised airway. Swollen tongue and lips in the patient with a severe peanut allergy indicates looming anaphylaxis. Nasal flaring and supraclavicular retractions indicate impending respiratory failure; this patient should be seen second. The patient with vomiting and bloody stools for a week who is extremely tachycardic should be seen next, as this patient is at risk for circulatory collapse. The patient with decreased level of consciousness following a blow to the head should be seen next. This injury represents the D in the mnemonic, neurological disability. The patient with a firm and distended abdomen should be seen next because this is likely an intestinal obstruction. The child with a bump and bruise on the forehead can be seen last. The crying child likely has no neurological damage; a silent child would be more concerning.
To control a gushing bleed of the lower leg, what should you do initially?A. Apply direct pressure to the woundB. Compress the artery above the woundC. Check the circulation to the footD. Snugly secure a bulky dressing
Apply direct pressure to the wound*First, apply direct pressure to the wound. (2) If that does not work, try compressing the artery above the wound. (3) Check the pulses after controlling bleeding or if you have placed a pressure dressing. (4) Apply a bulky dressing and reinforce layers once the gushing is controlled.
In the event of any type of poisoning that occurs in the home setting, what is the initial course of action?A. Save the poison container and contentsB. Save a sample of vomitus for analysisC. Call poison controlD. Induce vomiting
Call poison control*People in the community should immediately call poison control for advice. One possible exception is contamination of the eye, in which case flushing with copious amounts of water for 15 to 20 minutes should precede calling poison control. (1, 2) Saving the container and the emesis is helpful for analysis, but this can be done after the victim is attended to. (4) Inducing vomiting is never recommended in cases of caustic poisonings; therefore poison control should be called first.
A teenager--alert, oriented, and in no apparent distress--is brought to the ED by EMS on a blackboard with spine immobilization in place. He reports diving into a lake and bumping his head. Based on the mechanism of injury, which assessment are you most likely to initiate?A. Assessment of water safety behaviorB. Serial abdominal assessments with hematocritC. Frequent vital signs to monitor for shockD. Peripheral motion and sensation with mental status checks
Peripheral motion and sensation with mental status checks*The mechanism of injury is diving, and although the youth is currently alert and oriented, the possibility of head or spinal cord injury must be considered. (1) Water safety behaviors should be assessed, but this is not a priority. (2, 3) For trauma patients, any of the other assessments may be performed as part of the routine until other injuries have been ruled out.
You make a home visit to a 70-year-old patient on a cold winter day. On your arrival, the patient demonstrates excessive coughing, shortness of breath, drowsiness, and confusion. Mucous membranes are cherry red. What is your first action?A. Question the patient about recent food or fluid consumptionB. Call for emergency help and open the windowsC. Search the house for evidence of poisons and then call poison controlD. Locate the source of odors or try to get the patient to walk out of the house
Call for emergency help and open the windows*The patient's symptoms and the circumstances suggest carbon monoxide poisoning. The rescuer could be overwhelmed by an inhaled poison, so open the windows and call for help first before attempting to help the victim or to discover the problem. (1) The patient's symptoms do not suggest food poisoning. (3) The symptoms do not indicate ingestion of poison. (4) Locating a source for odors is not a priority and getting a confused drowsy patient out into cold weather is not the best option.
You are talking to a community group about strategies to prevent heat-related illness. What advice is appropriate to give to the group? (select all that apply)A. Drink fluid that are nonalcoholic, noncaffeinated, and low in sugar contentB. When you are thirsty, drink fluids and avoid eating salty foodsC. Stay indoors with cooling systemsD. In the heat, wear lightweight, light-colored, loose-fitting clothingE. Limit outdoor activities to spring or fall when the weather is coolerF. Use sun protection such as wide-brimmed hats, sunglasses, and sunscreen
1. Drink fluid that are nonalcoholic, noncaffeinated, and low in sugar content2. Stay indoors with cooling systems3. In the heat, wear lightweight, light-colored, loose-fitting clothing4. Use sun protection such as wide-brimmed hats, sunglasses, and sunscreen*Do not drink alcohol or fluids with caffeine or high sugar content, as these types of fluid can actually increase the likelihood of dehydration. Do stay indoors where cooling systems are functional. Wearing lightweight clothes and using sun protection also helps reduce heat exposure. (2) Do not wait until you are thirsty to drink fluids. Eating excessive salt is never recommended, but total avoidance of salty foods is not necessary. (5) Healthy people should not be discouraged from enjoying the outdoors in the summer months. Limit activities during hot weather to mornings or evenings.
A 24-year-old man is brought to the ED with respiratory distress after being stung by a bee. Which order from the health care provider should you anticipate as a priority intervention?A. Administer racemic epinephrine by inhalationB. Establish peripheral IV accessC. Give 0.5 mg of epinephrine intramuscularly in the lateral thighD. Draw blood for laboratory tests
Give 0.5 mg of epinephrine intramuscularly in the lateral thigh*The patient is showing signs of anaphylaxis and requires immediate administration of intramuscular epinephrine. (1) Racemic epinephrine can be used to decrease airway inflammation and might help this patient, but it is not the priority action. (2, 4) An IV access needs to be started, and blood can be drawn for laboratory tests at the same time, but these actions should not delay epinephrine administration.
A patient is brought to the ED with severe gastrointestinal bleeding and hypovolemic shock. What is the priority intervention for this patient?A. Insert a nasogastric tube and attach it to low wall suctionB. Draw a blood sample for a type and crossmatchC. Measure the amount of emesis and check for bloodD. Establish two large-bore peripheral IV sites
Establish two large-bore peripheral IV sites*Fluid replacement via IV access is the priority for this patient. (1, 2, 3) All of the other interventions are also likely to be ordered for this patient eventually, but they are not considered immediate lifesaving actions. Blood can be obtained for the type and crossmatch when the IV is started. (Note: Normal saline is started until blood from the blood bank can be obtained.)
When taking care of a patient with sepsis, what is the first sign that would signal impending septic shock?A. Increasing urine outputB. Decreasing heart rateC. Decreasing blood pressureD. Change in mental status
Change in mental status*A change in mental status is likely to be the first sign. (1) Urine output would decrease, not increase. (2) Pulse would increase, not decrease, in an attempt to compensate. (3) A decrease in blood pressure is a later sign.
A patient is 6 hours postoperative with signs of deficient fluid volume. The health care provider orders a fluid challenge of 400 mL lactated Ringer solution stat over 20 minutes. What could be considered a desirable response to the treatment?A. Decrease in blood pressureB. Increase in urinary outputC. Increase in body weightD. Increase in pulse rate
Increase in urinary output*An increase in urinary output is the desired response, which indicates adequate renal perfusion. (1, 4) A decrease in blood pressure or an increase in pulse indicates that the patient is becoming more fluid deficient and that the therapy is insufficient. (3) Weight gain indicates fluid volume excess.
A patient was bitten by a stray dog and rushed to the ED. Which measure must be done first?A. Apply antibiotic ointment on affected sitesB. Cover with a clean bandage and immobilizeC. Rinse wound with soap and warm running water for 5 to 10 minutesD. Give tetanus shot if patient has not had one in the past 5 years
Rinse wound with soap and warm running water for 5 to 10 minutes*Animal bites are prone to infection. Cleaning the area would precede the other options. (1, 2, 4) All of the other options are part of the care.
Implementation of nursing care for the emergency patient who is admitted with frostbite of the foot includes A. Applying a heating pad to the frostbitten areaB. Giving the patient hot fluids to drinkC. Wrapping the foot in warmed blanketsD. Immersing the foot in warm water
Immersing the foot in warm water
A toddler is brought to the ED alert and crying; however, EMS reports that the child was pulled from a neighbor's swimming pool and resuscitated at the scene. The toddler is admitted for 23-hour observation. What is the most important observation that the nurse makes during the assessment of this child?A. Observing for signs of previous injury that suggest potential child neglectB. Monitoring the pulse oximetry readings and auscultating the breath soundsC. Assessing the quality of the pulse and rhythm of the heartbeatD. Assessing the need for education related to the child's developmental needs
Monitoring the pulse oximetry readings and auscultating the breath sounds
To evaluate the effectiveness of Lasix and morphine for the treatment of pulmonary edema in an emergency patient, then nurse wouldA. Monitor intake and outputB. Assess respiratory statusC. Assess for decreased painD. Check the strength of peripheral pulses
Monitor intake and output
The priority goal when planning the care of the emergency patient admitted in shock would be toA. Maintain the patient's body warmth to prevent vasodilationB. Decrease the patient's pain to lessen vasocontrictionC. Restore the patient's circulating blood volume to promote perfusionD. Restore the patient's acid-base balance to aid respiration
Restore the patient's circulating blood volume to promote perfusion
A high priority in the immediate treatment of burns of the hands isA. Cool burned areas quickly with cool waterB. Assess ROM of joints and circumferential burnsC. Cover with blankets or sheets to prevent chillingD. Determine the area and deggree of the burns
Cool burned areas quickly with cool water
The nurse is at a restaurant and observe a person who appears to be choking. He is conscious and partially able to speak. What is the priority action?A. Have a bystander call 911 and stay with the patientB. Encourage him to cough and breathe as deeply as he canC. Get behind him and perform abdominal thrustsD. Strike him sharply between the shoulder blades
Encourage him to cough and breathe as deeply as he can
There is a multi-car accident and several people stop to assist. Under Good Samaritan laws, what applies to voluntary rescuers who assist at the scene?A. All rescuers are equally protected against liabiltyB. Rescuers are only protected against liabilityC. Physicians who stop are held to a higher standard of care than othersD. Bad outcomes usually result in liability suits
All rescuers are equally protected against liabilty
The patient sustains a venomous snakebite. What is included in the current emergency first-aid treatment?A. Wash the wound and lower the extremityB. Apply suction to the area immediately after the biteC. Make an incision over the wound with a sterile toolD. Place a tourniquet above the wound and check the pulses
Wash the wound and lower the extremity
A group ofe xcited teenagers come to the walk-in clinic; they drag in an adolescent who is unresponsive. There are no obvious signs of injury or bleeding, but his skin is pale and clammy. What questions should the nurse initially ask? (select all that apply)A. "Where are his parents?"B. "What school does he attend?"C. "What is his name?"D. "What happened to him?"E. "How long has he been like this?"F. "Why didn't you call 911?"G. "What was the group doing before he passed out?
1. "What is his name?"2. "What happened to him?"3. "How long has he been like this?"4. "What was the group doing before he passed out?
The nurse is at a community event and a child accidentally sustains a laceration with apparent arterial bleeding. The nurse's immediate action to control the bleeding is toA. Apply pressure directly over the wound with the covered palm of the handB. Tape a sterile or clean dressing over the open woundC. Elevate the injured part and immobilize the child and the woundD. Periodically remove the original dressing to assess for active bleeding
Apply pressure directly over the wound with the covered palm of the hand
The nurse is maning a home health visit to an elderly patient. The temperature in the house is very hot. The elderly patient is responsive but confused. He skin is hot an dry and he says he feels weak and nauseous. What is the priority action?A. Take the patient's temperature and administer an antipyreticB. Notify the health care provider and update the home health agencyC. Remove extra clothing and wipe the skin with cool waterD. Start an IV infusion of cool fluids and a cool saline lavage
Remove extra clothing and wipe the skin with cool water
The patient is in cardiogenic shock secondary to a myocardial infarction. Which emergency treatment will the health care provider most likely order for this patient?A. Fluid bolus and volume expandersB. Epinephrine and bronchdilatorsC. Norepinephrine, dopamine, or dobutamineD. Fluid bolus and corticosteroids
Norepinephrine, dopamine, or dobutamine
An elderly patuent is at high risk for septic shock. Which symptom is more frequently associated with septic shock in elderly patients compared to younger patients?A. Decreased urinary outputB. TachycardiaC. HypothermiaD. Slightly elevated temperature
Hypothermia
The staff is attemptinf to deescalate the behavior of a patient who is becoming increasingly upset and frustrated. What is the best approach?A. Several staff members should surround the patientB. Allow a family member to privately speak to the patientC. Restrain the patient to give a tranquilizing drugD. Explain the purpose of any planned procedures
Explain the purpose of any planned procedures
The nurse has just completed a community presentation about ways to prevent hypothermia during cold-water outings. Which statement from an audience member demonstrates a need for additional teaching?A. "Wearing a hat prevents heat loss through the head."B. "I should carry high-energy snacks in case I get lost."C. "I should wear or take layers of warm clothing."D. "If I get lost I should sit quietly to conserve energy.
If I get lost I should sit quietly to conserve energy.
The nurse has just completed a community presentation about ways to prevent hypothermia during cold-water outings. Which statement from an audience member demonstrates a need for additional teaching?A. "Wearing a hat prevents heat loss through the head."B. "I should carry high-energy snacks in case I get lost."C. "I should wear or take layers of warm clothing."D. "If I get lost I should sit quietly to conserve energy.
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