Chapter 13

Question 1

The nurse in the emergency department is caring for a patient with a partial-thickness thermal burn. Which treatment should the nurse expect to be prescribed for this patient?

Answer 1

Application of silver sulfadiazine cream

Question 2

The physician orders haloperidol (Haldol) 2 mg intramuscularly (IM) for a patient who is experiencing a psychiatric crisis. Haldol 5 mg/mL is available. How many milliliters should the nurse give?

Answer 2

0.4 mL

Question 3

The nurse is preparing teaching for the home treatment of ingested poisons. Which medication is no longer recommended for use at home to induce vomiting for certain ingested poisons?

Answer 3

Syrup of ipecac

Question 4

A patient with a head injury is diagnosed with increased intracranial pressure. In which position should the nurse maintain the patient’s head to assist in reducing intracranial pressure?

Answer 4

Midline

Question 5

A patient who has ingested a corrosive product is vomiting. For which potential complication should the nurse prepare to provide care to this client?

Answer 5

Esophageal burns

Question 6

When using the Glasgow Coma Scale for a patient involved in a motor vehicle crash, the patient opens the eyes when spoken to and points to the location of pain but is confused in conversation. What score should the nurse assign to this patient?

Answer 6

12

Question 7

The nurse is caring for a patient who was bitten by a snake. Which action should the nurse take to decrease the effects of the venom?

Answer 7

Elevate the patient’s limb.

Question 8

The nurse is preparing to care for a client with a poisonous snake wound. Which method should the nurse use to cleanse the site?

Answer 8

Wash with soap and water.

Question 9

The nurse assists with the provision of an educational program on the symptoms of smallpox. Which response indicates that the participants understand the location that the rash first appears?

Answer 9

Tongue and face

Question 10

The results of a primary survey reveal that a victim of a motor vehicle crash has an open airway, is breathing, and is conscious but bleeding heavily from severe leg injuries. For which complication should the nurse plan care for this client?

Answer 10

Hypovolemic shock

Question 11

The nurse is planning care for a patient with a mental health disorder. Which nursing diagnosis should the nurse select if the patient is demonstrating manic behavior?

Answer 11

Risk for injury

Question 12

The nurse is evaluating care provided to a patient recovering from a psychotic episode. Which patient statement should the nurse recognize as an indication of reduced anxiety?

Answer 12

I feel calm

Question 13

The nurse is caring for a patient experiencing acute psychosis. What should the nurse realize as being the purpose of medication for this patient?

Answer 13

Reduce psychosis

Question 14

The nurse is planning care for a patient who experienced a near-drowning. What should the nurse identify as the goal of care for this patient?

Answer 14

Maintain ventilation

Question 15

The nurse ensures that a trauma patient has an effective airway. On what should the nurse focus after the airway has been established for this patient?

Answer 15

Breathing

Question 16

A patient who sustained multiple injuries in a motor vehicle crash is brought to the emergency department. After the primary survey, what should be the nurse’s next action?

Answer 16

Complete out a rapid head-to-toe assessment.

Question 17

A patient is brought to the emergency department after a motor vehicle crash. Which symptom assessed during data collection should the nurse report promptly?

Answer 17

Wheezing

Question 18

A patient who has fallen has superficial abrasions and an abdomen that is distended, firm, and tender when touched. Which complication should the nurse consider that this patient is experiencing?

Answer 18

Internal bleeding

Question 19

A patient seeking treatment after being in a house fire has thermal burns to the neck and shoulders and singed nasal hairs. Which action should the nurse take first?

Answer 19

Monitor respirations

Question 20

The nurse in the emergency department is triaging victims of a building collapse. Which victim should the nurse determine is a priority for care?

Answer 20

A severely injured patient with full potential for recovery

Question 21

A patient who works in a non-air conditioned manufacturing plant is experiencing weakness and a headache. The patient’s skin is cool and clammy, temperature is slightly elevated, and pulse rate is rapid. For which health problem should the nurse plan care for this patient?

Answer 21

Heat exhaustion

Question 22

A homeless person is brought to the hospital for weakness, feeling faint, and having a headache. The patient’s skin is cool and clammy and vital signs are temperature 99.9°F, pulse 100 bpm, respirations 18/minute, blood pressure 108/60 mm Hg. What action should the nurse take?

Answer 22

Provide oral fluids

Question 23

The nurse is caring for a patient who has sustained an abdominal injury in a motor vehicle crash. Which symptom should be the most concerning to the nurse?

Answer 23

Bp 104/52

Question 24

The nurse is providing care to a college student having a psychiatric emergency and related suicide attempt. Which action should the nurse take first?

Answer 24

Determine if alcohol or illicit drugs have been used recently.

Question 25

The nurse determines that a patient has a normal capillary refill time. What was this patient’s refill time?

Answer 25

3

Question 26

A patient with severe hypothermia is comatose with fixed dilated pupils, flaccid muscles, and ventricular fibrillation. Which body temperature should the nurse expect to assess in this patient?

Answer 26

80.6

Question 27

The nurse is reviewing a 40-year-old patient’s immunization schedule. At which age should the patient have received the most recent tetanus booster vaccination?

Answer 27

35

Question 28

While assessing a victim of a motor vehicle crash, the nurse notes that the patient’s trachea is shifted towards the left. What does this finding indicate to the nurse?

Answer 28

Right lung tension pneumothorax

Question 29

A patient is admitted for mild hypothermia. Which manifestations should the nurse expect when assessing this patient? (Select all that apply.)

Answer 29

Depleted glucose stores
Decreased respiratory rate
Decreased muscular activity
Decreased heart rate and cardiac output

Question 30

The nurse is caring for a patient with a tbi. What should the nurse recognize as manifestations of early increased icp.

Answer 30

Amnesia
Headache
Drowsiness
Nausea and vomiting

Question 31

The nurse is caring for a patient who reports being bitten by a coral snake less than an hour ago. Which symptoms should the nurse expect to assess in this patient

Answer 31

Two small puncture wounds
Localized swelling at the site of the bite
Discoloration surrounding the site of the bite
A pale mottled cyanosis center at the site of injury.

Question 32

A patient brought into the Ed is diagnosed with shock. Which interventions should the nurse prepare to provide this patient

Answer 32

Provide oxygen as prescribed
Measure and record vital signs
Provide IV fluids as prescribed

Question 33

A patient is experiencing an anaphylactic reaction to peanuts. Which medication should the nurse prepare to administer to this patient

Answer 33

Steroids
Epinephrine
Antihistamine

Question 34

The nurse is receiving a victim of traumatic amputation in the ED. What should the amputated limb

Answer 34

Place on ice
Rinse with saline
Wrap in sterile gauze
Place in a sealed plastic bag

Question 35

The nurse is helping triage in the ED as victims of an explosion are being brought in rank of 1-5

Answer 35

A 70 year old with Sob
A 58 year old with distended abd
A 5 year old suspected fracture
A15 year old with lacerations to the foot
A 36 year old with no pulse