Chapter 72 AH

A nurse is providing care to the family of a client who was brought to the emergency department and suddenly died. Which of the following would be appropriate for the nurse to do? Select all that apply.
Ask the family if they would like to view the body.

Provide a private place for the family to be together.

Allow the family to express their emotions freely.

A client comes to the emergency department with a suspected airway obstruction. The emergency department team prepares to manage the client as if he has a complete airway obstruction based on which of the following?
High-pitched noise on inhalation

Acetaminophen overdose is treated with the administration of which of the following medications?
N-acetylcysteine (Mucomyst)

A patient is admitted to the ED after a near-drowning accident. The patient is diagnosed with saltwater aspiration. The nurse will observe the patient for several hours to monitor for symptoms of which of the following?
Pulmonary edema

A family member brings a patient to the emergency department. The family member states, “I think he overdosed on heroin.” Which of the following would the nurse expect to assess?
Pinpoint pupils

Which of the following guidelines is appropriate for a nurse to implement while helping family members cope with the sudden death of a loved one?
Show acceptance of the body by touching it, giving the family permission to touch.

A client has a gaping wound on his forearm that is bleeding profusely. Applying pressure to which pressure point would be most helpful?
Brachial

Which of the following solutions should the nurse anticipate for fluid replacement in the male patient?
Lactated Ringer’s solution

A client comes to the emergency department after experiencing a wound. Inspection reveals an opening in the skin with distinct edges and whose depth is greater than the length of the wound. The nurse documents this as which type of wound?
Stab

A client arrives at the emergency department and is experiencing a severe allergic reacton to a bee sting. The client received treatment and is being discharged. Which client statement indicates that additional teaching about exposure prevention is needed?
“Brightly colored clothes help to ward off bees.”

A patient with frostbite to both lower extremities from exposure to the elements is preparing to have rewarming of the extremities. What intervention should the nurse provide prior to the procedure?
Administer an analgesic as ordered.

The nurse in the ED is triaging patients during the shift. What does the nurse know is the first priority in treating any patient in the ED?
Establishing an airway.

A patient presents to the ED following a motor vehicle collision. The patient is suspected of having internal hemorrhage. The nurse assesses the patient for signs and symptoms of shock. Signs and symptoms of shock include which of the following? Select all that apply.
Cool, moist skin

Decreasing blood pressure

Increasing heart rate

Delayed capillary refill

A nurse is completing her annual cardiopulmonary resuscitation training. The class instructor tells her that a client has fallen off a ladder and is lying on his back; he is unconscious and isn’t breathing. What maneuver should the nurse use to open his airway?
Jaw-thrust

Which of the following data is most important for the nurse to record while assessing a patient with an open wound?
Time when the patient last received a tetanus immunization

A female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing interventions should be provided? (Select all that apply.)
Assess and document any bruises and lacerations.

Record a history of the event, using the patient’s own words.

Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police.

A client is brought to the emergency department by ambulance. The client is seriously ill and unconscious. No family or friends are present. Which of the following would be most appropriate to do?
Document the client’s condition and absence of friends or family for obtaining consent to treatment.

A nurse is providing an educational program for a group of occupational health nurses working in chemical facilities. Which of the following would the nurse include as the priority in the case of a chemical burn?
Rinsing the area with copious amounts of water

A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client’s:
Blood pressure

What is the most frequently injured solid organ in a penetrating trauma?
Liver

A client with depression and behavioral changes is transferred from a local assisted living center to the emergency department. The nurse notes that the client cries out when she approaches. When the nurse gains the client’s confidence and performs an assessment, the nurse notes bruising of the labia and a lateral laceration in the perineal area. When the nurse asks the client about the injury, the client shakes her head and begins to cry “don’t tell, don’t tell.” The nurse suspects sexual abuse. How should the nurse proceed?
Attend to the client’s physiological needs.

A nurse is assessing a patient who is suspected of having a partial airway obstruction. Which of the following would the nurse expect to find?
Spontaneous coughing

A patient has experienced blunt abdominal trauma from a motor vehicle crash. The nurse assesses the patient, knowing that which organ is the most frequently injured solid abdominal organ?
Liver

Nursing students are reviewing the categories of intra-abdominal injuries. The students demonstrate understanding of the information when they identify which of the following as examples of penetrating trauma? Select all that apply.
Gunshot wound

Knife-stab wound

A nurse is caring for a client who is experiencing alcohol withdrawal. Which statement best indicates that the client understands the need for long-term treatment?
The client agrees to detoxification, rehabilitation, and participation in an aftercare program.

A homeless patient presents to the ED. Upon assessment, the patient is experiencing hypothermia. The nurse will plan to complete which of the following priority interventions during the rewarming process?
Attach a cardiac monitor.

A patient is brought to the emergency department and diagnosed with decompression sickness. The nurse interprets this as indicating that the patient most likely has been involved with which of the following?
Diving in an ocean

A nurse is providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate?
Massaging the feet

When providing care to a client who has experienced multiple trauma, which of the following would be most important for the nurse to keep in mind?
The client is assumed to have a spinal cord injury until proven otherwise.

A nurse is caring for a patient with multiple injuries and performs the following. Place these actions in the order in which the nurse would perform them. Use all options.
Establish airway and ventilation

Control hemorrhage

Prevent and treat shock

Assess for head and neck injuries

Assess for abdomen, back, and extremity injuries

Splint fractures

The nurse is caring for a victim of a sexual assault. The patient is fearful and experiencing flashbacks. The nurse recognizes that the patient is experiencing which of the following phases of the psychological reaction to rape?
Heightened anxiety phase

A patient was bitten by a tick 3 months ago and is now having muscle aches as well as joint pain and swelling. The patient is having difficulty with self care and requires assistance with activities of daily living (ADLs). What stage of Lyme disease does the nurse recognize the patient is in?
Stage III

The nurse received a patient from a motor vehicle accident who is hemorrhaging from a femoral wound. What is the initial nursing action for the control of the hemorrhage?
Apply firm pressure over the involved area or artery.

An adolescent is brought to the ED after a vehicular accident and is pronounced dead on arrival (DOA). When the parents arrive at the hospital, what is the priority action by the nurse?
Speak to both parents together and encourage them to support each other and express their emotions freely.

Which of the following triage categories refers to life-threatening or potentially life-threatening injury or illness requiring immediate treatment?
Urgent

A patient present to the ED following a work-related injury to the left hand. The patient has an avulsion of the left ring finger. Which of the following correctly describes an avulsion?
Tearing away of tissue from supporting structures

A nurse is caring for a client who has arrived at the emergency department in shock. The nurse intervenes based on the knowledge that which of the following is the most common cause of shock?
Hypovolemia

When preparing to perform abdominal thrusts on a client with an airway obstruction, which of the following would be most appropriate?
Positioning the hands in the midline slightly above the umbilicus

A nurse is providing care to a client who is a victim of trauma resulting from injuries sustained in a convenience store robbery. The client has been stabbed numerous times in the abdomen and chest. His shirt is bloody and torn. Which of the following would be most appropriate when collecting forensic evidence?
Hanging up any damp or wet clothing to dry before securing

A patient with intra-abdominal injuries is brought to the emergency department. Which of the following would most likely alert the nurse to suspect internal bleeding secondary to a ruptured spleen?
Pain in the left shoulder

The nurse is caring for a patient in the ED with frostbite to the left hand. During the rewarming process of the hand, the nurse should perform which of the following actions?
Administer analgesic medications as ordered.

A patient is hemorrhaging from an open wound on his leg. The nurse implements care using the following steps. Place them in the order in which the nurse would perform them. Use all options.
Provide firm direct pressure

Apply a pressure dressing

Elevate the leg

Immobilize the leg

The nurse is conducting a secondary survey on a patient in the ED. Which of the following is completed during the secondary survey?
Diagnostic and laboratory testing

A nurse is preparing to assist with a gastric lavage for a client who has ingested an unknown poison and is obtunded. To ensure that the tube reaches the stomach, the nurse would measure the distance from the bridge of the nose to which of the following?
Xiphoid process

A patient presents to the ED after an unsuccessful suicide attempt. The patient is diagnosed with an acetaminophen overdose. The nurse anticipates the administration of which of the following medications?
N-acetylcysteine (Mucomyst)

A patient arrives at the emergency department after sustaining a gunshot wound to the abdomen. When assessing the patient, the nurse pays particular attention to which of the following?
Liver

A nurse suspects an older adult is experiencing heat stroke based on which assessment findings? Select all that apply.
Temperature 105 degrees F (40.6 degrees C)

Lack of sweating

Delirium

A patient who has accidentally ingested toilet bowel cleaner is brought to the emergency department. Which action would NOT be appropriate for the nurse to implement?
Induced vomiting

The nurse in the ED is triaging patients during the shift. What does the nurse know is the first priority in treating any patient in the ED?
Establishing an airway.

What is a common source of airway obstruction in an unconscious client?
tongue

Which category of triage encompasses patients with serious health problems that are not immediately life threatening?
Urgent

Permanent brain injury or death will occur within which timeframe secondary to hypoxia?
3 to 5 minutes

A nurse is providing care to a client in the emergency department and walks into the hallway to get equipment. All of a sudden, gunshots are heard. Which of the following would be the nurse’s priority?
Protecting himself or herself

The nurse is caring for a patient in the ED who is breathing but unconscious. In order to avoid an upper airway obstruction, the nurse is inserting an oropharyngeal airway. How would the nurse insert the airway?
Upside down and then rotated 180 degrees

For a patient who is experiencing multiple injuries, which sequence of medical or nursing management would the nurse identify as a priority?
Establish an airway, control hemorrhage, prevent hypovolemic shock, assess for head injuries.

A patient brought to the ED by the rescue squad after getting off a plane at the airport is complaining of severe joint pain, numbness, and an inability to move the arms. The patient was on a diving vacation and went for a last dive this morning before flying home. What is a priority action by the nurse?
Ensure a patent airway and that the patient is receiving 100% oxygen.

A client is brought to the emergency department after being involved in a motor vehicle collision. Which of the following would lead the nurse to suspect internal bleeding?
Delayed capillary refill

A nurse is preparing an in-service education program about emergency nursing to a group of newly hired nurses who will be working in the emergency department. When describing the current status of visits to the emergency department, which of the following would the nurse include in the presentation?
Clients with Medicaid use the emergency department more often than clients with private health insurance.

The nurse is admitting a patient with a penetrating abdominal injury from a knife wound. What should the nursing measures for a penetrating abdominal injury include? (Select all that apply.)
Assessing for manifestations of hemorrhage

Covering any protruding viscera with sterile dressings soaked in normal saline solution

Looking for any associated chest injuries

A patient presents to the ED complaining of choking on a chicken bone. The patient is breathing spontaneously. The nurse applies oxygen and suspects a partial airway obstruction. Which of the following should the nurse do next?
Encourage the patient to cough forcefully.

A nurse is providing inservice education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step?
Supporting the client’s emotional status

An emergency nurse has collected evidence from a patient who was shot during a robbery. The nurse is preparing to transfer the evidence to law enforcement. Which of the following would be important for the nurse to include when documenting this transfer? Select all that apply.
Name of the law-enforcement official

Date that the evidence was collected

Time of the transfer of evidence

A patient is brought to the emergency department after being locked outside of her house in the frigid weather for several hours. The nurse suspects that the patient has sustained frostbite of her hand based on which of the following findings?
Hand that is insensitive to touch

A high school football player is brought to the emergency department after collapsing at practice in extremely hot and humid weather. Which of the following would lead the nurse to suspect that the client is experiencing heat stroke?
Delirium

The nurse is administering antivenin to a patient who was bitten on the arm by a poisonous snake. What intervention provided by the nurse is required prior to the procedure and every 15 minutes after?
Measure the circumference of the arm.

A patient with a history of major depressive disorder is brought to the emergency department by a friend, who reports that the patient took an overdose of prescribed amitriptyline. Which of the following findings would the nurse expect to assess? Select all that apply.
Tachycardia

Visual hallucinations

Clonus

The ED staff work collaboratively and follow the ABCDE method to establish and treat health priorities in a trauma patient effectively. Which of the following actions is completed by the nurse when implementing the “D” element of this method?
Assessing the patient’s Glasgow Coma Scale

Which of the following terms refers to injuries that occur when a person is caught between objects, run over by a moving vehicle, or compressed by machinery?
crush injuries

Which of the following would the nurse identify as indicating that a client is experiencing a complete airway obstruction? Select all that apply.
• Inability to speak
• Clutching of the neck
• Stridor
• Cyanosis

A person suffering from carbon monoxide poisoning would exhibit which of the following manifestations?
intoxication

Which of the following triage categories refers to life-threatening or potentially life-threatening injury or illness requiring immediate treatment?
emergent

A nurse is providing wound care to a patient who arrived at the emergency department after being hit by flying glass from a broken window. The nurse asks the patient about his last tetanus shot. Which statement would indicate to the nurse that the patient needs a tetanus booster?
“It must be at least 6 or 7 years since I had one.”

A high school athlete has suffered a nasal fracture. What is the priority action of the nurse caring for the client? Assess for airway patency. After facial trauma, a client has a nasal fracture and is reporting constant nasal drainage, …

A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. Which of the following interventions is the nurse’s priority? Monitor pulse oximetry findings. A nurse is caring for a client who has viral meningitis. Which of the …

A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management …

A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse …

A nurse in a mental health facility observes a client who is experiencing panic level of anxiety. Which of the following actions should the nurse take first? Accompany the client to a quiet room. A nurse is obtaining a history …

The nurse is caring for a client receiving heparin and warfarin therapy for a pulmonary embolus. The client’s international normalized ratio (INR) is 2.0. What is the nurse’s best action? Discontinue the heparin. The nurse is caring for a postoperative …

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