Detailed Answer Key
TTS NUR 445
TTS NUR 445 Detailed Answer Key for Emergency Care Scenarios Questions and Answers
with Rationales
1. A nurse is teaching a group of clients about emergency care for a snake bite. Which of the following information
should the nurse include in the teaching?
A. Raise the affected extremity above the level of the heart.
Rationale: Maintaining the affected extremity at the level of the heart will limit the spread of the venom in
the circulatory system.
B. Immobilize the affected extremity with a splint.
Rationale: Immobilizing the client's affected extremity with a splint will limit the spread of the venom in the
circulatory system.
C. Apply ice to the bite area.
Rationale: Applying ice to the bite area is ineffective and can worsen the client's condition.
D. Apply a tourniquet to the affected extremity.
Rationale: Applying a tourniquet is ineffective and can worsen the client’s condition.
2. A nurse is caring for a client who is brought into the emergency department immediately following a snake bite to
his forearm. The client suspects the snake to be venomous. Which of the following interventions should the nurse
take?
A. Apply an ice pack to the site of the bite.
Rationale: The client should be kept warm following a snake bite and ice should not be applied to the site.
B. Apply a tourniquet just above the elbow.
Rationale: The application of a tourniquet is generally avoided following a snake bite due to the risk of
nerve and tissue damage.
C. Administer a corticosteroid.
Rationale: Corticosteroids are not administered immediately following a snake bite due to the risk of
decreasing the effects of antivenin.
D. Place the extremity in a dependent position.
Rationale: The affected area should be placed in a dependent position to decrease the circulation of
venom.
3. A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his
chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation of
phase of injury?
A. Initiate fluid resuscitation.
Rationale:
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,Detailed Answer Key
TTS NUR 445
The nurse should prepare to administer fluids to support circulation and tissue perfusion.
However, there is another intervention that the nurse should take first.
B. Medicate for pain.
Rationale: The nurse should prepare to administer an opioid medication for pain. However, there is another
intervention that the nurse should take first.
C. Insert an indwelling urinary catheter.
Rationale: The nurse should prepare to insert an indwelling urinary catheter to promote accurate
measurement of urinary output. However, there is another intervention that the nurse should
take first.
D. Maintain the airway.
Rationale: The client is at risk for respiratory obstruction.Using the airway, breathing, circulation approach
to client care is the first action the nurse should take to ensure that the client has a patent
airway.
4. A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the
following is the priority finding to report to the provider?
A. Urinary output 25 mL/hr
Rationale: The nurse should report a urinary output of 25 mL/hr because it is below the expected reference
range of 30 to 50 mL/hr; however, this is not the priority finding to report.
B. Difficulty swallowing
Rationale: Using the airway, breathing, circulation approach to client care, the nurse should determine that
the priority finding is difficulty swallowing as this is can be an indication that the client's airway is
obstructed.
C. Heart rate 122/min
Rationale: The nurse should report a heart rate of 122/min because it is above the expected reference
range; however, this is not the priority finding to report.
D. Pain of 6 on a scale of 0 to 10
Rationale: The nurse should report pain of a 6 on a scale of 0 to10 to obtain a prescription for pain relief;
however, this is not the priority finding to report.
5. A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities.
Which of the following interventions should the nurse perform first?
A. Clean and dress the wound.
Rationale: It is important for the nurse to clean and dress the wound in order to prevent the wound from
becoming infected and to provide pain relief. However, there is another action that the nurse
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TTS NUR 445
should take first.
B. Administer pain medication.
Rationale: The client who has a burn injury can experience severe pain. It is important for the nurse to
assess and treat the client's pain to provide comfort and make the cleansing and dressing of the
wound more tolerable. However, there is another action that the nurse should take first.
C. Administer a tetanus booster.
Rationale: The client who experiences a significant injury, such as a large burn, is at increased risk for
developing an infection involving Clostridium tetani. While it is important to administer a tetanus
booster to prevent infection, there is another action that the nurse should take first.
D. Administer IV fluids.
Rationale: Using the airway, breathing, circulation framework, the priority action the nurse should take is to
initiate fluid resuscitation to maintain blood volume and preserve cardiac output. The nurse can
utilize large bore peripheral IV cannulas. However, in extensive burns a central line should be
inserted to allow for rapid infusion of fluids.
6. A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper
extremities. Which of the following factors is the nurse’s priority when assessing the severity of the client’s burns?
A. Age of the client
Rationale: The client’s age is important in the assessment of the client’s burns, but is not the priority action
by the nurse.
B. Associated medical history
Rationale: The client’s associated medical history is important in the assessment of the client’s burns, but is
not the priority action by the nurse.
C. Location of the burn
Rationale: When using the urgent vs. nonurgent approach to client care, the nurse determines the priority is
to assess the location of the burns that can lead to respiratory distress.
D. Cause of the burn
Rationale: The client’s cause of the burns is important in the assessment of the client’s burns, but is not the
priority action by the nurse.
7. A nurse in an emergency department is assessing a client who was bitten on the left leg by a poisonous snake.
The client has placed elastic bandages snuggly above and below the bite marks and is in no apparent distress.
Which of the following actions should the nurse take?
A. Discharge the client.
Rationale: Discharging the client is not indicated. The client needs to be treated and assessed by the
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TTS NUR 445
nurse.
B. Obtain a prescription for the appropriate anti-venom.
Rationale: Anti-venom is used to treat the bites of certain poisonous snakes. The appropriate anti-venom
must be administered for the specific species of snake. Regional poison control centers should
be called for specific advice.
C. Remove both of the elastic bandages from the leg.
Rationale: Releasing the bandages prior to administering the appropriate anti-venom may allow the spread
of the venom, resulting in serious systemic consequences. The nurse should check that the
elastic bandages are not wrapped too tightly as with a tourniquet; the goal is to impede only
lymphatic flow, not arterial.
D. Obtain a prescription for pain medication.
Rationale: Obtaining an order for pain medication is not indicated and may mask other symptoms the client
may be experiencing. Opioids are used for the pain of pit viper bites, but not until emergency
measures are taken.
8. A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot.
The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min.
Which of the following actions should the nurse take?
A. Raise the foot of the bed to a 90° angle.
Rationale: Trendelenburg position increases pressure on the heart and lungs and is contraindicated for a
client who has an open chest wound. The nurse should place the client in a moderate to
high-Fowler’s position.
B. Remove the dressing to inspect the wound.
Rationale: A dressing should not be removed from a sucking chest wound until immediately prior to chest
tube insertion. Removal of the dressing will cause an increase in size of the pneumothorax and
increased respiratory difficulty.
C. Prepare to insert a central line.
Rationale: Although the client may need IV access, a central line is not usually needed in this situation.
D. Administer oxygen via nasal cannula.
Rationale: The client has an increased respiratory rate and heart rate, indicating that she is having
respiratory difficulty. The sucking chest wound indicates the client has a pneumothorax and/or a
hemothorax. Administering oxygen will increase the oxygen exchange in the lungs and the
oxygen available to the tissues.
9. A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the
head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the
priority for assessment and intervention?
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TTS NUR 445
TTS NUR 445 Detailed Answer Key for Emergency Care Scenarios Questions and Answers
with Rationales
1. A nurse is teaching a group of clients about emergency care for a snake bite. Which of the following information
should the nurse include in the teaching?
A. Raise the affected extremity above the level of the heart.
Rationale: Maintaining the affected extremity at the level of the heart will limit the spread of the venom in
the circulatory system.
B. Immobilize the affected extremity with a splint.
Rationale: Immobilizing the client's affected extremity with a splint will limit the spread of the venom in the
circulatory system.
C. Apply ice to the bite area.
Rationale: Applying ice to the bite area is ineffective and can worsen the client's condition.
D. Apply a tourniquet to the affected extremity.
Rationale: Applying a tourniquet is ineffective and can worsen the client’s condition.
2. A nurse is caring for a client who is brought into the emergency department immediately following a snake bite to
his forearm. The client suspects the snake to be venomous. Which of the following interventions should the nurse
take?
A. Apply an ice pack to the site of the bite.
Rationale: The client should be kept warm following a snake bite and ice should not be applied to the site.
B. Apply a tourniquet just above the elbow.
Rationale: The application of a tourniquet is generally avoided following a snake bite due to the risk of
nerve and tissue damage.
C. Administer a corticosteroid.
Rationale: Corticosteroids are not administered immediately following a snake bite due to the risk of
decreasing the effects of antivenin.
D. Place the extremity in a dependent position.
Rationale: The affected area should be placed in a dependent position to decrease the circulation of
venom.
3. A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his
chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation of
phase of injury?
A. Initiate fluid resuscitation.
Rationale:
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,Detailed Answer Key
TTS NUR 445
The nurse should prepare to administer fluids to support circulation and tissue perfusion.
However, there is another intervention that the nurse should take first.
B. Medicate for pain.
Rationale: The nurse should prepare to administer an opioid medication for pain. However, there is another
intervention that the nurse should take first.
C. Insert an indwelling urinary catheter.
Rationale: The nurse should prepare to insert an indwelling urinary catheter to promote accurate
measurement of urinary output. However, there is another intervention that the nurse should
take first.
D. Maintain the airway.
Rationale: The client is at risk for respiratory obstruction.Using the airway, breathing, circulation approach
to client care is the first action the nurse should take to ensure that the client has a patent
airway.
4. A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the
following is the priority finding to report to the provider?
A. Urinary output 25 mL/hr
Rationale: The nurse should report a urinary output of 25 mL/hr because it is below the expected reference
range of 30 to 50 mL/hr; however, this is not the priority finding to report.
B. Difficulty swallowing
Rationale: Using the airway, breathing, circulation approach to client care, the nurse should determine that
the priority finding is difficulty swallowing as this is can be an indication that the client's airway is
obstructed.
C. Heart rate 122/min
Rationale: The nurse should report a heart rate of 122/min because it is above the expected reference
range; however, this is not the priority finding to report.
D. Pain of 6 on a scale of 0 to 10
Rationale: The nurse should report pain of a 6 on a scale of 0 to10 to obtain a prescription for pain relief;
however, this is not the priority finding to report.
5. A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities.
Which of the following interventions should the nurse perform first?
A. Clean and dress the wound.
Rationale: It is important for the nurse to clean and dress the wound in order to prevent the wound from
becoming infected and to provide pain relief. However, there is another action that the nurse
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TTS NUR 445
should take first.
B. Administer pain medication.
Rationale: The client who has a burn injury can experience severe pain. It is important for the nurse to
assess and treat the client's pain to provide comfort and make the cleansing and dressing of the
wound more tolerable. However, there is another action that the nurse should take first.
C. Administer a tetanus booster.
Rationale: The client who experiences a significant injury, such as a large burn, is at increased risk for
developing an infection involving Clostridium tetani. While it is important to administer a tetanus
booster to prevent infection, there is another action that the nurse should take first.
D. Administer IV fluids.
Rationale: Using the airway, breathing, circulation framework, the priority action the nurse should take is to
initiate fluid resuscitation to maintain blood volume and preserve cardiac output. The nurse can
utilize large bore peripheral IV cannulas. However, in extensive burns a central line should be
inserted to allow for rapid infusion of fluids.
6. A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper
extremities. Which of the following factors is the nurse’s priority when assessing the severity of the client’s burns?
A. Age of the client
Rationale: The client’s age is important in the assessment of the client’s burns, but is not the priority action
by the nurse.
B. Associated medical history
Rationale: The client’s associated medical history is important in the assessment of the client’s burns, but is
not the priority action by the nurse.
C. Location of the burn
Rationale: When using the urgent vs. nonurgent approach to client care, the nurse determines the priority is
to assess the location of the burns that can lead to respiratory distress.
D. Cause of the burn
Rationale: The client’s cause of the burns is important in the assessment of the client’s burns, but is not the
priority action by the nurse.
7. A nurse in an emergency department is assessing a client who was bitten on the left leg by a poisonous snake.
The client has placed elastic bandages snuggly above and below the bite marks and is in no apparent distress.
Which of the following actions should the nurse take?
A. Discharge the client.
Rationale: Discharging the client is not indicated. The client needs to be treated and assessed by the
Page 3
, Detailed Answer Key
TTS NUR 445
nurse.
B. Obtain a prescription for the appropriate anti-venom.
Rationale: Anti-venom is used to treat the bites of certain poisonous snakes. The appropriate anti-venom
must be administered for the specific species of snake. Regional poison control centers should
be called for specific advice.
C. Remove both of the elastic bandages from the leg.
Rationale: Releasing the bandages prior to administering the appropriate anti-venom may allow the spread
of the venom, resulting in serious systemic consequences. The nurse should check that the
elastic bandages are not wrapped too tightly as with a tourniquet; the goal is to impede only
lymphatic flow, not arterial.
D. Obtain a prescription for pain medication.
Rationale: Obtaining an order for pain medication is not indicated and may mask other symptoms the client
may be experiencing. Opioids are used for the pain of pit viper bites, but not until emergency
measures are taken.
8. A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot.
The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min.
Which of the following actions should the nurse take?
A. Raise the foot of the bed to a 90° angle.
Rationale: Trendelenburg position increases pressure on the heart and lungs and is contraindicated for a
client who has an open chest wound. The nurse should place the client in a moderate to
high-Fowler’s position.
B. Remove the dressing to inspect the wound.
Rationale: A dressing should not be removed from a sucking chest wound until immediately prior to chest
tube insertion. Removal of the dressing will cause an increase in size of the pneumothorax and
increased respiratory difficulty.
C. Prepare to insert a central line.
Rationale: Although the client may need IV access, a central line is not usually needed in this situation.
D. Administer oxygen via nasal cannula.
Rationale: The client has an increased respiratory rate and heart rate, indicating that she is having
respiratory difficulty. The sucking chest wound indicates the client has a pneumothorax and/or a
hemothorax. Administering oxygen will increase the oxygen exchange in the lungs and the
oxygen available to the tissues.
9. A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the
head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the
priority for assessment and intervention?
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