Chapter 68: Emergency and Disaster Nursing Lewis:
Medical-Surgical Nursing, 10th Edition
1. After the return of spontaneous circulation following the resuscitation of a
patient who had a cardiac arrest, therapeutic hypothermia is ordered. Which
action will the nurse include in the plan of care?
a. Initiate cooling per protocol.
b. Avoid the use of sedative drugs.
c. Check mental status every 15 minutes.
d. Rewarm if temperature is below 91° F (32.8° C).: ANS: A
When therapeutic hypothermia is used postresuscitation, external cooling devices
or cold normal saline infusions are used to rapidly lower body temperature to
89.6° F to 93.2° F (32° C to 34° C). Because hypothermia will decrease brain
activity, assessing mental status every 15 minutes is not done at this stage.
Sedative drugs are given during therapeutic hypothermia.
DIF: Cognitive Level: Apply (application)
2. 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'll take salt tablets when I work outdoors in the summer."
b. "I should take acetaminophen (Tylenol) if I start to feel too warm."
c. "I need to drink extra fluids when working outside in hot weather."
d. "I'll move to a cool environment if I notice that I'm feeling confused": ANS:
C
Oral fluids and electrolyte replacement 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 drugs are not effective in lowering body temperature elevations caused
by excessive exposure to heat. A patient who is confused is likely to have more
severe hyperthermia and will be unable to remember to take appropriate action.
DIF: Cognitive Level: Apply (application)
1/5
, Chapter 68: Emergency and Disaster Nursing Lewis:
Medical-Surgical Nursing, 10th Edition
3. 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. c. Auscultate breath sounds.
b. Palpate peripheral pulses. d. Check mental orientation.: ANS: C
Because pulmonary edema is a common complication after drowning, the nurse
should assess the breath sounds frequently. The other information also will be
obtained by the nurse, but it is not as pertinent to the patient's admission
diagnosis.
DIF: Cognitive Level: Analyze (analysis)
4. When rewarming a patient who arrived in the emergency department
(ED) with a temperature of 87° F (30.6° C), which finding indicates that the
nurse should discontinue active rewarming?
a. The patient begins to shiver.
b. The BP decreases to 86/42 mm Hg.
c. The patient develops atrial fibrillation.
d. The core temperature is 94° F (34.4° C).: ANS: D
A core temperature of at least 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.
DIF: Cognitive Level: Apply (application)
5. 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. assess the patient's current vital signs.
b. give acetaminophen (Tylenol) per agency protocol.
c. ask the patient to provide a clean-catch urine for urinalysis.
2/5
Medical-Surgical Nursing, 10th Edition
1. After the return of spontaneous circulation following the resuscitation of a
patient who had a cardiac arrest, therapeutic hypothermia is ordered. Which
action will the nurse include in the plan of care?
a. Initiate cooling per protocol.
b. Avoid the use of sedative drugs.
c. Check mental status every 15 minutes.
d. Rewarm if temperature is below 91° F (32.8° C).: ANS: A
When therapeutic hypothermia is used postresuscitation, external cooling devices
or cold normal saline infusions are used to rapidly lower body temperature to
89.6° F to 93.2° F (32° C to 34° C). Because hypothermia will decrease brain
activity, assessing mental status every 15 minutes is not done at this stage.
Sedative drugs are given during therapeutic hypothermia.
DIF: Cognitive Level: Apply (application)
2. 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'll take salt tablets when I work outdoors in the summer."
b. "I should take acetaminophen (Tylenol) if I start to feel too warm."
c. "I need to drink extra fluids when working outside in hot weather."
d. "I'll move to a cool environment if I notice that I'm feeling confused": ANS:
C
Oral fluids and electrolyte replacement 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 drugs are not effective in lowering body temperature elevations caused
by excessive exposure to heat. A patient who is confused is likely to have more
severe hyperthermia and will be unable to remember to take appropriate action.
DIF: Cognitive Level: Apply (application)
1/5
, Chapter 68: Emergency and Disaster Nursing Lewis:
Medical-Surgical Nursing, 10th Edition
3. 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. c. Auscultate breath sounds.
b. Palpate peripheral pulses. d. Check mental orientation.: ANS: C
Because pulmonary edema is a common complication after drowning, the nurse
should assess the breath sounds frequently. The other information also will be
obtained by the nurse, but it is not as pertinent to the patient's admission
diagnosis.
DIF: Cognitive Level: Analyze (analysis)
4. When rewarming a patient who arrived in the emergency department
(ED) with a temperature of 87° F (30.6° C), which finding indicates that the
nurse should discontinue active rewarming?
a. The patient begins to shiver.
b. The BP decreases to 86/42 mm Hg.
c. The patient develops atrial fibrillation.
d. The core temperature is 94° F (34.4° C).: ANS: D
A core temperature of at least 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.
DIF: Cognitive Level: Apply (application)
5. 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. assess the patient's current vital signs.
b. give acetaminophen (Tylenol) per agency protocol.
c. ask the patient to provide a clean-catch urine for urinalysis.
2/5
