NUR 220 Quiz 1 review questions and answers pass at first attempt.

An unresponsive 79-yr-old patient is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 105.4° F (40.8° C), blood pressure (BP) is 105/60 mm Hg, spO2 94% and pulse is 112 beats/min. The nurse will plan to; A)start lactated Ringer's solution at 1000 mL/hr. B)apply wet sheets and a fan to the patient. C)provide O2 at 2 L/min with a nasal cannula. D)give acetaminophen (Tylenol) rectal suppository. - correct answers B)apply wet sheets and a fan to the patient. Family members are in the patient's room when the patient has a cardiac arrest and the staff start resuscitation measures. Which action should the nurse take next? A)Keep the family in the room and assign a staff member to explain the care given and answer questions. B)Ask the family to wait outside the patient's room with a designated staff member to provide emotional support. C)Ask the family members whether they would prefer to remain in the patient's room or wait outside the room. D)Tell the family members that patients are comforted by having family members present during resuscitation efforts. - correct answers C)Ask the family members whether they would prefer to remain in the patient's room or wait outside the room. A patient arrives in the emergency department (ED) after topical exposure to powdered lime at work. Which action should the nurse take first? A)Brush off any visible powder on the skin and clothing. B)Decontaminate the patient by showering with water. C)perform a secondary survey. D)Obtain a baseline complete blood count. - correct answers A)Brush off any visible powder on the skin and clothing. A man arrives to the clinic after being attacked by a fox that was "acting strange". Which medications need to be administered? Select all that apply A)prophylactic antibiotics. B)Rabies immune globulin C)rabies vaccine D)epinephrine E)tetanus vaccine if not current - correct answers A)prophylactic antibiotics. B)Rabies immune globulin C)rabies vaccine E)tetanus vaccine if not current A patient presents to the ED with an overdose. The paramedics states they found a prescription bottle of alprazolam (Xanax) on the patient's bedside table. The nurse will expect to administer A)naloxone B)atropine C)flumazenil D)sublimaze - correct answers C)flumazenil A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10 abdominal pain and states, "I had a temperature of 103.9° F (39.9° C) at home." The nurse's first action should be to A)tell the patient that it will be 1 to 2 hours before seeing a health care provider. B)give acetaminophen (Tylenol) per agency protocol. C)assess the patient's current vital signs. D)ask the patient to provide a clean-catch urine for urinalysis. - correct answers C)assess the patient's current vital signs. A patient arrives in the emergency department (ED) several hours after taking "25 to 30" acetaminophen (Tylenol) tablets. Which action will the nurse plan to take? A)Give N-acetylcysteine by IV or PO route B)Administer activated charcoal C)Discuss the use of chelation therapy D)Start oxygen using a non-rebreather mask - correct answers A)Give N-acetylcysteine by IV or PO route A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). The nurse determines that discharge teaching has been effective when the patient makes which statement? A)"I should take acetaminophen (Tylenol) if I start to feel too warm." B)"I'll move to a cool environment if I notice that I'm feeling confused" C)"I'll take salt tablets when I work outdoors in the summer." D)"I need to drink extra fluids when working outside in hot weather." - correct answers D)"I need to drink extra fluids when working outside in hot weather." After the return of spontaneous circulation following the resuscitation of a patient who had a cardiac arrest, targeted temperature management is ordered. Which action will the nurse include in the plan of care? A)Avoid the use of sedative drugs. B)Initiate cooling if patient is unconscious C)Rewarm if temperature is below 91° F (32.8° C). D)Check mental status every 30 minutes. - correct answers B)Initiate cooling if patient is unconscious Management for the patient with core temperature below 29 degrees Celsius. includes (select all that apply) A)continuous cardiac monitoring B)removing any wet clothing C)Examine the patient for any external injury D)immediate internal and external rewarming - correct answers A)continuous cardiac monitoring B)removing any wet clothing C)Examine the patient for any external injury D)immediate internal and external rewarming The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment? A)A patient with paradoxical chest movement B)A patient with an open femur fracture C)A patient with no pedal pulses D)A patient with small amount bleeding from facial lacerations - correct answers A)A patient with paradoxical chest movement A patient presents to the ED with multiple wasp stings showing signs of swollen tongue and hoarse voice. All of the following medications should be considered except A)epinephrine B)diphenhydramine C)dexamethasone D)doxycycline - correct answers D)doxycycline Gastric lavage and administration of activated charcoal are ordered for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action should the nurse plan to do first? A)Insert a large-bore orogastric tube. B)Give first dose of activated charcoal. C)Assist with intubation of the patient to reduce risk of aspiration D)Prepare a 60-mL syringe with saline. - correct answers C)Assist with intubation of the patient to reduce risk of aspiration A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should (Select all that apply) A)obtain a complete set of vitals B)attach an electrocardiogram monitor C)palpate the abdomen D)ask about chronic medical conditions E) obtain a Glasgow Coma Scale score - correct answers A)obtain a complete set of vitals B)attach an electrocardiogram monitor E) obtain a Glasgow Coma Scale score A 22-yr-old patient who experienced a drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period? A)auscultate heart sounds B)palpate peripheral pulses C)check mental orientation D)auscultate breath sounds - correct answers D)auscultate breath sounds The urgent care center protocol for tick bites includes the following actions. Which action will the nurse take first when caring for a patient with a tick bite? A)Obtain information about recent outdoor activities. B)Use tweezers to remove any remaining ticks. C)Give doxycycline (Vibramycin) 100 mg orally. D)Check the vital signs, including temperature. - correct answers B)Use tweezers to remove any remaining ticks. A 3 year old arrives to the ED via ambulance with decreased level of consciousness after ingesting 10 of their grandmothers Cardizem ( calcium channel blocker) tablets. Once the airway is secure, the nurse prepares to administer which medication? A)naloxone B)digibind C)calcium gluconate D)flumazenil - correct answers C)calcium gluconate Which interventions will the nurse plan for a comatose patient who will have targeted temperature management/therapeutic hypothermia? (Select all that apply.) A)Begin continuous cardiac monitoring. B)Prepare to give sympathomimetic drugs. C)Obtain a prescription for patient restraints. D)Insert an indwelling urinary catheter for continuous temperature monitoring E)Assist with endotracheal intubation. - correct answers A)Begin continuous cardiac monitoring. D)Insert an indwelling urinary catheter for continuous temperature monitoring E)Assist with endotracheal intubation. During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient has an unobstructed airway. Which action should the nurse take next? A)Examine the patient for any external bleeding B)Observe the patient's respiratory effort. C)Check the patient's level of consciousness. D)Palpate extremities for bilateral pulses. - correct answers Observe the patient's respiratory effort. During the primary survey of a patient with severe leg trauma, the nurse observes there is an open wound that is bleeding profusely. Which action will the nurse take next? A)Start normal saline fluid infusion with a large-bore IV line. B)Finish the airway, breathing, circulation, disability survey. C)Assess further for a cause of the decreased circulation. D)Send blood to the lab for a complete blood count. - correct answers A)Start normal saline fluid infusion with a la