A nurse is performing triage in the emergency department. Which patient should the nurse see first?
A. 18-year-old patient with type 1 diabetes mellitus who has a 4-cm laceration on right leg.
B. 32-year-old patient with drug overdose who is unresponsive
Answer:
B. 32-year-old patient with drug overdose who is unresponsive with poor respiratory effort.
Rationale: Patient with drug overdose is unstable and needs to be seen immediately. Patient with chest pain (possible myocardial infarction) should be seen
A patient arrives in the emergency department after ingesting 8 g of acetaminophen (Tylenol). Which question is most important for the nurse to ask?
A. Have you tried to commit suicide before?
B. Do you feel like you have a fever?
C. What time did you tak
Answer:
C. What time did you take the Tylenol?
Rationale: Acetaminophen will bind to activated charcoal and pass through the gastrointestinal tract without being absorbed. Activated charcoal is most effective if administered within 1 hour of ingestion of
The nurse provides information to a patient who was exposed to anthrax by inhalation. The nurse determines the teaching has been successful if the patient makes which statement?
A. "Anthrax can be spread by person-to-person contact."
B. "It is not necessa
Answer:
C. "An antibiotic will be prescribed for 2 months."
Rationale: Postexposure prophylaxis includes a 60-day course of antibiotics. Ciprofloxacin (Cipro) is the treatment of choice. Anthrax is not spread by person-to-person contact; anthrax is spread
A patient is admitted to the emergency department with cold exposure and a core body temperature of 86.6o F (30.3o C). Which action is most appropriate for the nurse to take?
A. Immerse the extremities in a water bath (102� to 108� F) [38.9� to 42.2� C])
Answer:
D. Administer warmed intravenous (IV) fluids.
Rationale: A patient with a core body temperature of 86.6o F (30.3o C) has moderate hypothermia. Active core rewarming is used for moderate to severe hypothermia and includes administration of warmed I
A nurse manager educates the emergency department staff about their roles during a disaster with mass casualties. Which primary responsibility should the nurse manager discuss with the staff?
A. Learn the hospital emergency response plan.
B. Report acts o
Answer:
A. Learn the hospital emergency response plan.
Rationale: All health care providers need to be prepared for a mass casualty incident; the priority responsibility is to know the agency's emergency response plan.
Ch. 69
The nurse is providing emergent care for a patient with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. Which action should the nurse take first?
A. Assist the patient to
Answer:
D. Administer 100% humidified oxygen.
Rationale:
Carbon monoxide (CO) poisoning may occur in house fires; CO displaces oxygen on the hemoglobin molecule resulting in hypoxia. High levels of CO in the blood result in a skin color that is described
The nurse is caring for a patient who sustained a deep partial thickness burn to the anterior chest area. Which statement would be appropriate for the nurse to include when documenting the appearance of this type of burn?
]A. Skin is hard with a dry, waxy
Answer:
C. Skin is red and shiny with the presence of clear fluid-filled blisters.
Rationale:
Deep partial thickness burns have fluid-filled vesicles that are red and shiny; may appear wet (if vesicles have ruptured); and mild to moderate edema may be pre
The nurse is planning to change the dressing covering a deep partial-thickness burn of the right lower leg. Which prescribed medication should the nurse administer 30 minutes before the scheduled dressing change?
A. zolpidem (Ambien)
B. morphine sulfate
C
Answer:
B. morphine sulfate
Rationale:
Deep partial-thickness burns result in severe pain related to nerve injury. The nurse should plan to administer analgesics before the dressing change to promote patient comfort. Morphine sulfate is a common opioid us
Which patient should the nurse prepare to transfer to a regional burn center?
A. A 53-year-old patient with a chemical burn to the anterior chest and neck
B. A 25-year-old pregnant patient with a carboxyhemoglobin level of 1.5%
C. A 42-year-old patient wh
Answer:
A. A 53-year-old patient with a chemical burn to the anterior chest and neck
Rationale:
The American Burn Association (ABA) has established referral criteria to determine which burn injuries should be treated in burn centers where specialized faci
The nurse is caring for a 71 kg patient during the first 12 hours after a thermal burn injury. Which outcomes if observed by the nurse would indicate adequate fluid resuscitation (select all that apply)?
A. Heart rate is 94 beats/minute.
B. Mean arterial
Answer:
A. Heart rate is 94 beats/minute.
C. Urine output is 46 mL/hour.
Rationale:
Assessment of the adequacy of fluid resuscitation is best made using either urine output or cardiac factors. Urine output should be 0.5 to 1 mL/kg/hr (or 75 to 100 mL/hr f
During the primary assessment of a trauma victim, the nurse determines that the patient is breathing and has an unobstructed airway.
Which action should the nurse take next?
a. Observe the patient's respiratory effort.
b. Check the patient's level of cons
A
Even with a patent airway, patients can have other problems that compromise ventilation,
so the next action is to assess the patient's breathing. The other actions also are part of the
initial survey but assessment of breathing should be done immediatel
During the primary survey of a patient with multiple traumatic injuries, the nurse observes that the patient's right pedal pulses are absent and the leg is swollen.
Which of these actions will the nurse take next?
a. Assess further for a cause of the decr
D
The assessment data indicate that the patient may have arterial trauma and hemorrhage.
When a possibly life-threatening injury is found during the primary survey, the nurse
should immediately start interventions before proceeding with the survey. Althou
After resuscitation, a patient who had a cardiac arrest is nonresponsive to commands and therapeutic hypothermia is prescribed.
Which action will the nurse include in the plan of
care?
a. Rapidly infuse cold normal saline.
b. Avoid the use of sedative med
A
When therapeutic hypothermia is used postresuscitation, cold normal saline is infused to
rapidly lower body temperature to 89.6� F to 93.2� F (32� C to 34� C). Since hypothermia
will decrease brain activity, neurologic assessment every 30 minutes is not
A patient who is unconscious after a fall from a ladder is transported to the emergency department by family members. During the primary survey of the patient, the nurse
should
a. assess the patient's vital signs.
b. attach a cardiac electrocardiogram (EC
C
The Glasgow Coma Scale is included when assessing for disability during the primary
survey. The other information is part of the secondary survey.
An 18-year-old is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the right hand. When asked about tetanus immunization, the patient
denies having any previous vaccinations.
The nurse will anticipate administratio
D
For an adult with no previous tetanus immunizations, TIG and Tdap are recommended.
The other immunizations are not sufficient for this patient.
A patient who has experienced blunt abdominal trauma during a car accident is complaining of increasing abdominal pain.
The nurse will plan to teach the patient about the purpose of
a. ultrasonography.
b. peritoneal lavage.
c. nasogastric (NG) tube placem
A
For patients who are at risk for intraabdominal bleeding, focused abdominal
ultrasonography is the preferred method to assess for intraperitoneal bleeding. An MRI
would not be used. Peritoneal lavage is an alternative, but it is more invasive. An NG
tub
A patient with hypotension and temperature elevation after doing yard work on a hot day is treated in the ED. After the nurse has completed discharge teaching, which statement
by the patient indicates that the teaching has been effective?
a. "I will take
C
Electrolyte solutions such as sports drinks help replace fluid and electrolytes lost when
exercising in hot weather. Salt tablets are not recommended because of the risks of
gastric irritation and hypernatremia. Antipyretic medications are not effective
When preparing to rewarm a patient with hypothermia, the nurse will plan to
a. attach a cardiac monitor.
b. insert a urinary catheter.
c. assist with endotracheal intubation.
d. have sympathomimetic drugs available.
A
Rewarming can produce dysrhythmias, so the patient should be monitored and treated if
necessary. Urinary catheterization and endotracheal intubation are not needed for
rewarming. Sympathomimetic drugs tend to stimulate the heart and increase the risk fo
A patient who experienced a near drowning accident in a local lake, but now is awake and breathing spontaneously, is admitted for observation.
Which action will be most important for the nurse to take during the observation period?
a. Listen to heart soun
C
Since pulmonary edema is a common complication after near drowning, the nurse should
assess the breath sounds frequently. The other information also will be collected by the
nurse, but it is not as pertinent to the patient's admission diagnosis.
When planning the response to the potential use of smallpox as an agent of terrorism, the emergency department (ED) nurse-manager will plan to obtain sufficient quantities of
a. blood.
b. vaccine.
c. atropine.
d. antibiotics.
B
Smallpox infection can be prevented or ameliorated by the administration of vaccine
given rapidly after exposure. The other interventions would be helpful for other agents of
terrorism but not for smallpox.
When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87� F, which assessment indicates that the nurse should discontinue the
rewarming?
a. The patient stops shivering.
b. The BP decreases to 85/40 mm Hg.
c. The patie
D
A core temperature of 89.6� F to 93.2� F (32� C to 34� C) indicates that sufficient
rewarming has occurred. Dysrhythmias, hypotension, and shivering may occur during
rewarming and should be treated but are not an indication to stop rewarming the patient
When assessing a patient admitted to the emergency department (ED) with a broken arm and facial bruises, the nurse notes multiple additional bruises in various stages of healing.
Which statement or question by the nurse is most appropriate?
a. "Is someone
A
The nurse's initial response should be to further assess the patient's situation. Telling the
patient not to return home may be an option once further assessment is done. The patient,
not the nurse, is responsible for reporting the abuse. A social worke
A patient arrives in the emergency department (ED) a few hours after taking "20 to 30" acetaminophen (Tylenol) tablets.
Which action will the nurse plan to take?
a. Give N-acetylcysteine (Mucomyst).
b. Discuss the use of chelation therapy.
c. Have the pat
A
N-acetylcysteine is the recommended treatment to prevent liver damage after
acetaminophen overdose. The other actions might be used for other types of poisoning,
but they will not be appropriate for a patient with acetaminophen poisoning.
A triage nurse in a busy emergency department assesses a patient who complains of 6/10 abdominal pain and states, "I had a temperature of 104.6� F (40.3� C) at home."
The nurse's first action should be to
a. assess the patient's current vital signs.
b. ob
A
The patient's pain and statement about an elevated temperature indicate that the nurse
should obtain vital signs before deciding how rapidly the patient should be seen by the
health care provider. A urinalysis may be needed, but vital signs will provide
The emergency department (ED) triage nurse is assessing four victims of an automobile accident.
Which patient has the highest priority for treatment?
a. A patient with absent pedal pulses
b. A patient with an open femur fracture
c. A patient with a suckin
C
Most immediate deaths from trauma occur because of problems with ventilation, so the
patient with a sucking chest wound should be treated first. Face and head fractures can
obstruct the airway, but the patient with facial injuries has lacerations only.
The following actions are part of the routine emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands.
Which action should the nurse take first?
a. Remove the patient's rings.
b. Place ice packs on both
A
The patient's rings should be removed first because it might not be possible to remove
them if swelling develops. The other orders also should be implemented as rapidly as
possible after the nurse has removed the jewelry.
Gastric lavage and administration of activated charcoal are prescribed for an unconscious
patient who has been admitted to the emergency department (ED) after ingesting 30 diazepam (Valium) tablets.
Which action will the nurse plan to take first?
a. Admin
D
In an unresponsive patient, intubation is done before gastric lavage and activated charcoal
administration to prevent aspiration. The other actions will be implemented after
intubation.
A patient arrives in the emergency department after exposure to radioactive dust.
Which action should the nurse take first?
a. Place the patient in a shower.
b. Obtain the patient's vital signs.
c. Determine the type of radioactive agent.
d. Obtain a base
A
The initial action should be to protect staff members and decrease the patient's exposure
to the radioactive agent by decontamination. The other actions can be done after the
decontamination is completed.
An unresponsive 78-year-old is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 106.2� F (41.2� C), blood pressure
(BP) 86/52, and pulse 102.
The nurse initially will plan to
a. administer an aspirin r
C
The priority intervention is to cool the patient. Antipyretics are not effective in decreasing
temperature in heat stroke, and 100% oxygen should be given, which requires a high flow
rate through a non-rebreather mask. An older patient would be at risk
When a patient is admitted to the emergency department after a submersion injury, which assessment will the nurse obtain first?
a. Apical pulse
b. Lung sounds
c. Body temperature
d. Level of consciousness
B
The priority assessment data are how well the patient is oxygenating, so lung sounds
should be assessed first. The other data also will be collected rapidly but are not as
essential as the lung sounds.
Following an earthquake, patients are triaged by emergency medical personnel and are transported to the hospital.
Which of these patients will the nurse need to assess first?
a. A patient with a red tag
b. A patient with a blue tag
c. A patient with a yel
A
The red tag indicates a patient with a life-threatening injury requiring rapid treatment.
The other tags indicate patients with less urgent injuries or those who are likely to die.
A patient's family members are in the patient room when the patient has a cardiac arrest and emergency personnel start resuscitation measures.
Which action is best for the nurse to take initially?
a. Have the family wait outside the patient room with a de
C
Although many family members and patients report benefits from family presence during
resuscitation efforts, the nurse's initial action should be to determine the preference of
these family members. The other actions may be appropriate, but this will de
These four patients arrive in the emergency department after a motor vehicle crash.
In which order should they be assessed?
Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________
a. A 72-year-old with palpitations and che
C, A, B, D
The highest priority is to assess the 22-year-old patient for airway obstruction, which is
the most life-threatening injury. The 72-year-old patient may have chest pain from
cardiac ischemia and should be assessed and have diagnostic testing fo