CM IV, EXAM 1 CHAPTERS 8, 9, 10,

CM IV, EXAM 1 CHAPTERS 8, 9, 10, 1.) A patient who attempted suicide being treated in the ED is accompanied by his mother, father, and brother. When planning the nursing care of this family, the nurse should perform which of the following action? a. Ensure that the family receives appropriate crisis intervention services 2.) A patient is admitted to the ED with an apparent overdose of IV heroin. After stabilizing the patient’s cardiopulmonary status, the nurse should prepare to perform what intervention? a. Administer naloxone hydrochloride - (Narcan) 3.) The ED nurse admitting a patient with a history of depression is screening the patient for suicide risk. What assessment question should the nurse ask when screening the patient? a. Have you ever thought about taking your own life? 4.) An ED nurse is triaging patients according to the Emergency Severity Index (ESI). When assigning patients to a triage level, the nurse will consider the patients acuity as well as what another variable? a. The resources that the patient is likely to require 5.) A patient who has been exposed to anthrax is being treated in the local hospital. The nurse should prioritize what health assessments? a. Assessment of respiratory status 6.) While developing an emergency operations plan (EOP), the committee is discussing the components of the EOP. During the post-incident response of an emergency operations plan, what activity will take place? a) Conducting a critique and debriefing for all involved in the incident 7.) Emergency department (ED) staff members have been trained to follow steps that will decrease the risk of secondary exposure to a chemical. When conducting decontamination, staff members should remove the patients clothing and then perform what action? a. Rinse the patient with water. 8.) An industrial site has experienced a radiation leak and workers who have been potentially affected are en-route to the hospital. To minimize the risks of contaminating the hospital, managers should perform what action? a. Establish a triage outside the hospital. 9.) A hospitals emergency operations plan has been enacted following an industrial accident. While one nurse performs the initial triage, what should other emergency medical services personnel do? a. Perform life-saving measures. 10.) A nurse is triaging patients after a chemical leak at a nearby fertilizer factory. The guiding principle of this activity is what? a. Doing the greatest good for the greatest number of people 11.)A nurse is triaging clients in the emergency department. Which client should the nurse classify as nonurgent? a. A 62-year-old with a simple fracture of the left arm 12.)The complex care provided during an emergency requires interdisciplinary collaboration. Which interdisciplinary team members are paired with the correct responsibilities? (Select all that apply.) a. Psychiatric crisis nurse Interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis e. Paramedic Provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration 13.)A nurse assesses a client recently bitten by a coral snake. Which assessment is the priority? a. Respiratory rate and depth 14.)Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action should the nurse take first? a. Assess that the client is breathing adequately 15.) The nurse in the emergency department is performing an assessment on a client who sustained a right finger laceration from a fishhook while fishing. The nurse asks the client which priority question? a. “When did you receive your last tetanus immunization?” 16.) A client is brought to the emergency department by the police after having seriously lacerated both wrists. The initial action that the nurse should take is which step? a. Assess and treat the wound sites 17.) ***With a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid strength? (Question got blurred out) 18.) A nurse is assisting with disaster triage following a bomb explosion in a bus station. Which of the following clients should the nurse identify as being the highest priority? a. A conscious adult with second degree burns on both lower legs 19.) A 6-year-old is admitted to the ED after being rescued from a pond after falling through the ice while ice skating. What action should the nurse perform while rewarming patient? a. Ensuring continuous ECG monitoring 20.) A nurse enters a client’s room and sees that ashes from a cigarette are beginning to ignite trash in a waste basket. Which of the following actions should the nurse take first? a. Rescue the client from immediate danger 21.) A client is admitted to the emergency department with complaints of severe radiating chest pain, and a myocardial infarction is suspected the nurse immediately applies oxygen to the client and plans to take which action first? a. Call the laboratory to prescribe stat blood work b. Notify the coronary care unit to inform them that the client will need admission c. Obtain a 12-lead ECG d. Call radiology to prescribe a chest radiograph 22.) A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first? a. Wash the area of the puncture thoroughly with soap and water. 23.) A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. Which of the following clients should the nurse tag to be the priority for care? a. A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site 24.) An emergency department nurse is transferring a client to the medical-surgical unit. What is the most important nursing intervention in this situation? a. Clearly communicate client data to the unit nurse 25.) A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following is the priority intervention? a. Count the Respiratory rate 26.) An emergency department nurse is caring for a patient who had been taking in the mountains for the past 2 days. What are the most important indicators that a patient is experiencing high- altitude pulmonary edema (HAPE)? (NOT SURE IF I GOT THIS RIGHT) a. Confusion b. Ataxia c. Decreased level of consciousness d. Crackles in both lung fields e. Persistent dry cough 27.) A nursing is caring for a client who develops and airway obstruction from a foreign body but remains conscious. Which of the following actions should the nurse take first? a. Administer the abdominal thrust maneuver 28.) The nurse in trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first? a. Evaluate chest expansion 29.) A nurse is triaging clients following a mass casualty event. Which of the following clients should the nurse assess first? a. A client who has severe respiratory stridor and a deviated trachea 30.) A patient is admitted with a thermal injury, the mechanism of injury that this patient would most likely experience would be which of the following? a. Fire 31.) An ER assesses a patient who has been raped, with which health care team would the nurse collaborate with while planning this patient care a. Forensic nurse 32.)A spouse of a patient admitted with a gunshot wound ask the nurse when her husband will be discharged so that they could resume their life together. With which should the nurse respond to the spouse? a. "Right now, there is no way of knowing how soon your husband can return to his previous life." 33.)The patient is admitted with possible head and spinal injuries after falling from a ladder, the diagnostic test that will identify the extent of injuries a. MRI 34.)How can a nurse assist disaster victim to cope with their experiences? a. Active listening 35.)A client presents to the ER after prolonged exposure to the cold, the client is shivering, has slurred speech and is slow to respond to questions, what treatment would the nurse provide for this client? a. Administer warmed intravenous fluids to the client. 36.)An Elderly patient fell and hit their head was transported by ambulance, was unconscious at the scene but is conscious on arrival, triage is urgent, what is the priority assessment the nurse includes during the primary survey of the patient? a. Neurological status? 37.)A nurse is at the scene of a lightning strike during a thunderstorm, what is the priority action of the nurse? a. Move victims and first responders to a sheltered area 38.)A client presents to the ER after prolonged exposure to the cold, the client is shivering, has slurred speech and is slow to respond to questions, what treatment would the nurse provide for this client? a. d. Administer warmed intravenous fluids to the client 39.)The nurse is working ER on hot humid day when a hiker is brought in after collapsing. The hiker is confused and tachycardic temp 105.6. Which IV solution and medication would the nurse administer? a. d. Normal saline and lorazepam 40.)A man survived a workplace accident that claimed the lives of many of his colleagues several months ago. The man has recently sought care for the treatment of depression. How should the nurse best understand the man’s current mental health problem? a. a. Common response following a disaster 41.). On a hot humid day several client present to the ER with symptoms of heat exposure which client will be treated first? a. a. Client who is anxious and confused 42.)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. d. Immobilize the extremity with a splint 43.). A nurse has been assigned the role triage nurse after a weather-related disaster. What is the priority action of the nurse? a. a. Perform rapid assessments and determine priority of care 44.)4. On admission to the emergency department a client states that he feels like killing himself. When planning this client care is it most important for the nurse to coordinate care with which member of the health care team? a. Psychiatric crisis nurse 45.)A nurse caring for a client who is vomiting. Which of the following actions should the nurse take first? a. b. Prevent the client from aspirating 46.)A community nurse assesses a client who has an allergy to bees. The client lips are swollen, and wheezes are audible. Priority action of the nurse? a. b. Administer EPI pen 47.). A trauma patient with multiple open wounds is brought the ER in cardiac arrest. Which action would the nurse do prior to providing advanced cardiac life support? a. d. Don on PPE 48.). A back-country skier has been airlifted after becoming lost developing hypothermia and frostbite how should the nurse handle the patient’s frostbites? a. Immerse affected extremities in water slightly above normal body temperature 49.)Patient was brought to the ER with injuries from a wall that collapsed on his home. A nurse realized that this patients’ injuries are most likely caused by which of the following. a. b. Crushing 50.)A nurse is dining at a restaurant when a woman begins to scream the her partner is choking Which of the following actions should the nurse take? a. b. Ask the patient if he can speak 51.)The nurse is teaching a wilderness survival class. Which statement by a participant indicates that additional teaching is needed? a. c. If I get too cold, I can have some brandy CM Exam #2 Ch 26, 37, 51 52.) The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client? d. Wash your hands on entering the client’s room. 53.)The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern? c. Sometimes I wake up at night and smoke. 54.) A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance? c. I will bathe and dress before breakfast. 55.) The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury? a. It is normal to feel some depression. A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first? a. Assess the level of consciousness and pupillary reactions. c. Auscultate breath sounds over the trachea and bronchi. 56.) A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately? c. Serum potassium: 6.5 mEq/L 57.) A nurse teaches a client being treated for a full-thickness burn. Which statement should the nurse include in this clients discharge teaching? c. I will demonstrate how to change your wound dressing for you and your family. 58.) A student is caring for a client who suffered massive blood loss after trauma. How does the student correlate the blood loss with the clients mean arterial pressure (MAP)? b. Lower blood volume lowers MAP. 59.)A nurse is caring for a client after surgery. The clients respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed 4 hours ago. What action by the nurse is best? b. Assess the clients tissue perfusion further. 60.) The nurse gets the hand-off report on four clients. Which client should the nurse assess first? a. Client with a blood pressure change of 128/74 to 110/88 mm Hg 61.) A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock? b. Drink fluids on a regular schedule. 62.) A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority? b. Ensure the client has a patent airway. 63.) A nurse assesses a client with a fracture who is being treated with skeletal traction. Which assessment should alert the nurse to urgently contact the health provider? b. Traction weights are resting on the floor 64.) A trauma nurse cares for several clients with fractures. Which client should the nurse identify as at highest risk for developing deep vein thrombosis? d. A 74-year-old man who smokes and has a fractured pelvis 65.) A nurse delegates care of a client in traction to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene care for this client? d. Ensure that the weights remain freely hanging at all times. 66.)A nurse caring for a client notes the following assessments: white blood cell counts 3800/mm3, blood glucose level 198 mg/dL, and temperature 96.2 F (35.6 C). What action by the nurse takes priority? c. Notify the health care provider immediately. 67.) A nurse assesses an older adult client who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless. The client’s vital signs are heart rate 98 beats/min, respiratory rate 32 breaths/min, blood pressure 132/78 mm Hg, and SpO2 88%. Which action should the nurse take first? a. Administer oxygen via nasal cannula. 68.)A nurse in the ICU is planning the care of a patient who is being treated for shock. Which of the following statements best describes the pathophysiology of this patient’s health problem? A. Cells lack an adequate blood supply and are deprived of oxygen and nutrients. 69. In an acute care setting, the nurse is assessing an unstable patient. When prioritizing the patients care, the nurse should recognize that the patient is at risk for hypovolemic shock in which of the following circumstances? A) Fluid volume circulating in the blood vessels decreases. 70. When caring for a patient in shock, one of the major nursing goals is to reduce the risk that the patient will develop complications of shock. How can the nurse best achieve this goal? D) Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment. 71. A critical care nurse is planning assessments in the knowledge that patients in shock are vulnerable to developing fluid replacement complications. For what signs and symptoms should the nurse monitor the patient? Select all that apply. B) Difficulty breathing C) Cardiovascular overload D) Pulmonary edema 72. The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a patient in shock. The nurse knows that vasoactive medications are given in all forms of shock. What is the primary goal of this aspect of treatment? D) To maintain adequate mean arterial pressure 73. An immunocompromised older adult has developed a urinary tract infection and the care team recognizes the need to prevent an exacerbation of the patient’s infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the patient’s risk of septic shock? D) Remove invasive devices as soon as they are no longer needed 74. A nurse is performing a shift assessment on an elderly patient who is recovering after surgery for a hip fracture. The nurse notes that the patient is complaining of chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the patient is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this patient is likely demonstrating symptoms of what complication? C) Fat embolism syndrome 29. A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion? Confusion – Answer 31. An elderly female with osteoporosis has been hospitalized. Prior to discharge, when teaching the patient, the nurse should include information about which major complication of osteoporosis? A) Bone fracture 32. A nurse is caring for a client who is postoperative following a below-the-knee-amputation and will soon undergo fitting for a leg prosthesis. which of the following is an appropriate intervention for this client at this time? a) wrap the stump with an elastic bandage in a figure-eight configuration 33. A nurse is caring for a client who is sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs? b. The client develops a life-threatening situation 34. A client returns to the surgical unit from the post anesthesia care unit in skeletal traction. The nurse should take action to correct which of the following problems with the traction setup? B. The weights rest against the foot of the bed 35. A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client? D. Packed Red blood cells