MED/SURG: EMERGENCIES AND DISTASTERS NCLEX QUESTIONS

Question 1

Which of the following solutions should the nurse anticipate for fluid replacement in the male patient?

a) Dextrose 5% in water
b) Type O negative blood
c) Lactated Ringer’s solution
d) Hypertonic saline

Answer 1

Lactated Ringer’s
Explanation:
Infusion of lactated Ringer’s solution is useful initially because it approximates plasma electrolyte composition and osmolality, allows time for blood typing and screening, restores calcium, and serves as an adjunct to blood component therapy. Any solution that contains glucose must be given with caution; the patient must be monitored for cerebral edema formation.

Question 2

1. Which of the following medications is used for patients with bronchospasm?
2. Name function of each drug listed

a) Albuterol (Proventil)
b) Crystalloids
c) Diphenhydramine (Benadryl)
d) Diazepam (Valium)

Answer 2

1. Albuterol (Proventil, Ventolin) inhalers or humidified treatments are used to decrease bronchoconstriction.
2. Valium is used to control seizures.
3. Crystalloids are given for hypotension.
4. Benadryl is used to block further histamine binding at target cells.

Question 3

A young male patient has been brought to the emergency department with a knife wound to the abdomen. When the patient’s hands are removed from the area of the wound to facilitate assessment, the patient’s intestine protrudes from the wound. How should the nurse respond to this development?

a) Cover the protruding viscera with saline-soaked, sterile gauze.
b) Apply a pressure dressing to the wound.
c) Irrigate the protruding intestine with sterile water or normal saline.
d) Don sterile gloves and attempt to push the organ back inside the wound.

Answer 3

If abdominal viscera protrude, the area is immediately covered with sterile, moist saline dressings to keep the viscera from drying and the patient is expected to go directly to the operating room for closure.

Question 4

An alarm has reached your ED regarding a serious MVA between a full tour bus and a school bus – the number of casualties expected is quite high. As you reach the site and being your assessments, you find many abrasions and lacerations. Which of the following nursing interventions are required to maintain the skin integrity when caring for clients in disaster situations?

a) Apply cold water over the wound
b) Apply a semiocclusive dressing over the wound
c) Administer IM antibiotic to prevent wound infection
d) Administer a prescribed colony-stimulating agent

Answer 4

Apply a semiocclusive dressing over the wound
Explanation:
The nurse should apply a semiocclusive dressing over the wound. A moist wound can increase the rate of epithelialization.

Question 5

semi-permeable and semi-occlusive

Answer 5

semi-permeable and semi-occlusive

1. semi-permeable allows diffusion of water vapor from under the dressings (moisture vapor transfer rate), (and maybe oxygen molecules into wound from outside dressing [gaseous exchange], and
2. semi-occlusive’s function to keep contaminates from getting into the wound from the outside, such as feces, or other environmental contaminates.

Question 6

The triage nurse’s assessment of a girl who has been brought in by her frantic parents reveals that the girl is likely in anaphylaxis. After establishing a patent airway, what action should the emergency department care team prioritize?

a) IV administration of hydrocortisone
b) Sublingual administration of nitroglycerin
c) Parenteral administration of epinephrine
d) Nebulized administration of albuterol

Answer 6

Parenteral administration of epinephrine
Explanation:
Simultaneously with airway management, aqueous epinephrine is administered as prescribed to provide rapid relief of the hypersensitivity reaction.

Epinephrine may be administered again, if necessary and as prescribed. Bronchodilators, corticosteroids, and nitroglycerin do not directly relieve the acute signs and symptoms of anaphylaxi

Question 7

A patient is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the health care provider will implement which of the following interventions?

a) Administration of bronchodilators
b) Endotracheal intubation
c) Jaw thrust maneuver
d) Cricothyroidotomy

Answer 7

Endotracheal intubation is used to establish and maintain the airway in patients with respiratory insufficiency or hypoxia. Bronchodilators, the jaw thrust maneuver, and cricothyroidotomy will not resolve respiratory insufficiency.

Question 8

Which level of the triage system is implemented when the patient requires two or more resources?

a) Emergent
b) Minor
c) Nonurgent
d) Urgent

Answer 8

Urgent
Explanation:
The urgent level is implemented when the patient is predicted to require two or more resources. The emergent levels states that the patient should not wait. At the nonurgent level, the patient is predicted to require one resource. When the patient is predicted to require no resources, the patient’s disorder is classified as minor

Question 9

An 82 year-old woman who lives on her own has been brought to the emergency department after being found down in her apartment for two days. The woman is showing early signs of hypovolemic shock with tachycardia, lethargy, and hypotension. At what level would this patient most likely be triaged?

a) Level 4: Nonurgent
b) Level 2: Emergent
c) Level 3: Urgent
d) Level 1: Resuscitation

Answer 9

Level 2: Emergent
Correct
Explanation:
A patient who is in preshock requires prompt, aggressive intervention. Resuscitation, however, is not yet necessary.

Question 10

A 15-year-old boy has been brought to the emergency department by his friends after severing his brachial artery while trying to scale a fence. In order to stop this patient’s bleeding, the nurse should:

a) Apply direct pressure to the wound.
b) Administer platelets.
c) Apply a tourniquet distal to the wound.
d) Apply a tourniquet proximal to the site of the wound.

Answer 10

Apply direct pressure to the wound.
Explanation:
Direct, firm pressure is applied over the bleeding area or the involved artery at a site that is proximal (above) to the wound. A tourniquet is applied to an extremity only as a last resort when the external hemorrhage cannot be controlled in any other way and immediate surgery is not feasible. Administration of platelets will not halt active bleeding.

Question 11

Which of the following is a procedure done in emergency situations when endotracheal intubation is not possible?

a) Parathyroidectomy
b) Radical neck dissection
c) Thyroidectomy
d) Cricothyroidotomy

Answer 11

Cricothyroidotomy is the opening of the cricothyroid membrane to establish an airway. This procedure is used in emergency situations in which endotracheal intubation is either not possible or contraindicated, as in airway obstruction from extensive maxillofacial trauma, cervical spine injuries, laryngospasm, laryngeal edema, hemorrhage into the neck tissues, or obstruction of the larynx.

Question 12

A trauma patient in the emergency department (ED) is showing signs of acute renal failure that the care team suspects are due to myoglobinuria. The ED nurse should recognize that these problems are most closely associated with what type of injury?

a) Hemorrhage
b) Crush injury
c) Severe lacerations
d) Blunt force trauma

Answer 12

Crushing injuries can cause myoglobinuria, a problem that can ultimately result in acute tubular necrosis and acute renal failure. Severe laceration, blunt trauma, and hemorrhage are less likely to cause myoglobinuria or rhabdomyolysis

Coke colored urine

Question 13

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

a) Cherry red skin coloring
b) Intoxication
c) Severe hypertension
d) Hyperactivity

Answer 13

Intoxication
Explanation:
A person suffering from carbon monoxide poisoning appears intoxicated (from cerebral hypoxia). Other signs and symptoms include headache, muscular weakness, palpitation, dizziness, and mental confusion. The skin coloring in the patient with carbon monoxide poisoning can range from pink to cherry red to cyanotic and pale and is not a reliable diagnostic sign.

Question 14

Loss of 15% to 30% of blood volume would be classified as which type of shock?

a) Class II
b) Class IV
c) Class III
d) Class I

Answer 14

Class II
Correct
Explanation:
Loss of 15% to 30% of blood volume is classified as Class II hemorrhage. A Class I hemorrhage is loss of up to 15% of blood volume. Class III is loss of 30% to 40% of blood volume. Class IV is loss of >40% of blood volume.

Question 15

Which category of triage encompasses patients who have serious health problems but whose injuries are not immediately life-threatening?

a) Urgent
b) Emergent
c) Nonurgent
d) Psychological support

Answer 15

Urgent patients have serious health problems but not immediately life-threatening ones. They must be seen within 1 hour. Emergent patients have the highest priority; their conditions are life-threatening, and they must be seen immediately. Nonurgent patients have episodic illness that can be addressed within 24 hours without increased morbidity. Fast-track patients require simple first aid or basic primary care and may be treated in the ED or safely referred to a clinic or physician’s office. (less)

Question 16

Choice Multiple question – Select all answer choices that apply.
Components of the secondary survey include which of the following? Select all that apply.

a) Complete health history
b) Control of hemorrhage
c) Electrocardiogram
d) Establish patent airway
e) Dressing of wounds

Answer 16

Electrocardiogram
• Dressing of wounds
• Complete health history
Correct
Explanation:
The secondary survey includes dressing wounds, a complete health history, head-to-toe assessment, and insertion or application of monitoring devices such as an ECG. Establishing a patent airway and controlling hemorrhage is part of the primary survey

Question 17

1. Which of the following is referred pain due to diaphragmatic irritation associated with splenic injuries if the patient complains of left shoulder pain?
2. Describe all the signs below

a) Kernig’s sign
b) Babinski’s sign
c) Brudzinski’s sign
d) Kehr’s sign

Answer 17

The nurse suspects hemoperitoneum and splenic injuries if the patient complains of left shoulder pain. This symptom is termed Kehr’s sign and is referred pain due to diaphragmatic irritation associated with splenic injury or intra-abdominal hemorrhaging.

A positive Kernig’s and Brudzinski’s sign is seen with meningeal irritation.

One of the physically demonstrable symptoms of meningitis is Kernig’s sign. Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees.

One of the physically demonstrable symptoms of meningitis is Brudzinski’s sign. Severe neck stiffness causes a patient’s hips and knees to flex when the neck is flexed.

Babinski’s sign is a neurological manifestation (toes fanning out)

Babinski reflex is one of the reflexes that occurs in infants. Reflexes are responses that occur when the body receives a certain stimulus.

The Babinski reflex occurs after the sole of the foot has been firmly stroked. The big toe then moves upward or toward the top surface of the foot. The other toes fan out.

This reflex is normal in children up to 2 years old. It disappears as the child gets older. It may disappear as early as 12 months.

Question 18

Beck’s Triad

1. What condition is it associated with?
2. What is it?

Answer 18

Signs of classical cardiac tamponade include three signs, known as Beck’s triad.

1. Hypotension occurs because of decreased stroke volume,
2. jugular-venous distension due to impaired venous return to the heart, and
3. muffled heart sounds due to fluid buildup inside the pericardium.[10]

Other signs of tamponade include pulsus paradoxus (a drop of at least 10 mmHg in arterial blood pressure on inspiration),[3] and ST segment changes on the electrocardiogram,[10] which may also show low voltage QRS complexes,[6] as well as general signs and symptoms of shock (such astachycardia, breathlessness and decreasing level of consciousness)

Question 19

Cushing’s Triad

1. Associated with what condition?
2. What it the Triad?

Answer 19

Cushing’s Triad is a set of three primary signs that often indicate an increase in intracranial pressure (ICP). These signs include the following:

1. A change in respirations, often irregular and deep, such as cheyne stokes
2. A widening pulse pressure (the difference between the Systolic and the Diastolic BP)
3. Bradycardia (slow heart rate).

Cushing’s Triad was originally identified by a famous Neurosurgeon by the name of Harvey William Cushing.

Cushing’s Triad is an important, but late sign of raised intracranial pressure that doctors, paramedics and nurses must be on the look for with patients who have had a recent head injury, brain injury, neurosurgery, or anyone with a sudden altered level of consciousness.

Question 20

Pulse Pressure

Answer 20

Generally, a pulse pressure greater than 40 mm Hg is abnormal. A pulse pressure lower than 40 may mean you have poor heart function, while a higher pulse pressure may mean your heart’s valves are leaky (valve regurgitation).

The most important cause of elevated pulse pressure is stiffness of the aorta, the largest artery in the body. The stiffness may be due to high blood pressure or fatty deposits on the walls of the arteries (atherosclerosis). The greater your pulse pressure, the stiffer and more damaged the vessels are thought to be. Other conditions — including severe iron deficiency (anemia) and overactive thyroid (hyperthyroidism) — can increase pulse pressure as well.

Question 21

A patient is brought to the emergency department by ambulance with a gunshot wound to the abdomen. The nurse knows that the most common hollow organ injured in this type of injury is what?

a) Large bowel
b) Stomach
c) Small bowel
d) Liver

Answer 21

Small bowel
Explanation:
Penetrating abdominal wounds have a high incidence of injury to hollow organs, especially the small bowel.

Question 22

An older adult who used a propane heater to warm his apartment has been admitted to the emergency department with suspected carbon monoxide poisoning. The emergency department nurse can most accurately gauge the patient’s status by which of the following assessments?

a) Analysis of hemoglobin, hematocrit, and red blood cell levels
b) Assessment of oxygen saturation by pulse oximetry
c) Analysis of carboxyhemoglobin levels
d) Anterior and posterior lung auscultation

Answer 22

Analysis of carboxyhemoglobin levels
Correct
Explanation:
For the patient with carbon monoxide poisoning, carboxyhemoglobin levels are analyzed on arrival at the emergency department and before treatment with oxygen if possible. Pulse oximetry and red blood cell indices do not provide an accurate picture of the patient’s oxygenation status. Similarly, chest auscultation does not provide an accurate indication of the patient’s clinical status. (less)

Question 23

Diagnostic peritoneal lavage (DPL) has been ordered for a patient who has suffered abdominal injuries in a farm accident. When explaining this procedure to the patient, what information should the nurse provide?

a) “Fluid will be put into your abdomen and then pulled out and examined to see if blood or gastrointestinal contents are present.”
b) “You’ll have some fluid injected into your abdomen and then it will be withdrawn to see if the same amount is returned.”
c) “You’ll have fluid injected into your abdomen and then you’ll be monitored to see if it comes out in your urine or when you have a bowel movement.”
d) “Fluid will be put into your abdomen and removed. This will be repeated several times in order to flush out your abdominal space.”

Answer 23

“Fluid will be put into your abdomen and then pulled out and examined to see if blood or gastrointestinal contents are present.”
Explanation:
DPL involves the instillation of 1 L of warmed lactated Ringer’s or normal saline solution into the abdominal cavity. After a minimum of 400 mL has been returned, a fluid specimen is sent to the laboratory for analysis. Positive laboratory findings include a red blood cell count greater than 100,000/mm3; a WBC count greater than 500/mm3; or the presence of bile, feces, or food. (less)

Question 24

A patient has been brought to the emergency department with multiple trauma after a motor vehicle accident. After immediate threats to life have been corrected, the nurse and trauma team should:

a) Splint the patient’s fractures.
b) Perform a detailed physical examination.
c) Perform a rapid physical assessment.
d) Establish the patient’s previous medical history.

Answer 24

Perform a rapid physical assessment.
Explanation:
Once immediate threats to life have been corrected, a rapid physical examination is done to identify injuries and priorities of treatment. This is a priority over detailed assessment, establishment of medical history and treatment of fractures.