Unit 5 Flashcards

Question 1

Q

The critical care unit environment is very stressful for patients, families, and staff. What
nursing action is directed at reducing environmental stress?
A) Constant evaluation of patient status
B) Limiting visits to immediate family
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C) Bathing all patients during hours of sleep
D) Maintaining quiet during hours of sleep

Question 2

Q

A patient is transferred to the ICU from the Birth Center of the hospital in the middle of
the night after experiencing complications during delivery of her baby. The patients
husband is anxious and explains to the ICU nurse that he doesnt understand why his wife
has been moved to the ICU. She is going to die, isnt she? he asks the nurse. What is the
nurses best response?
A) Explain that every measure will be taken to provide his wife with the best care
possible.
B) Explain that the nurse is fully trained and has years of experience.
C) Offer the husband a place to relax.
D) Have appropriate staff discuss his health insurance with him

Question 3

Q

A patient is admitted to the ICU with injuries sustained from a fall from a third-story
window. The patient is conscious, his breathing is labored, and he is bleeding heavily
from the abdomen. He groans constantly and complains of severe pain, but his
movements are minimal. His heart rate is elevated. Which of these is a sign that he is in
the second phase of the stress response? Select all that apply.
A) Bleeding heavily from his abdomen
B) Labored, slow breathing
C) Severe pain
D) Elevated heart rate
E) Minimal movement

Question 4

Q

A patient in the ICU is recovering from open-heart surgery. The nurse enters his room
and observes that his daughter is performing effleurage on his arms and talking in a low
voice about an upcoming family vacation that is planned. The room is dimly lit, and she
hears the constant beeping of his heart monitor. From the hall she hears the cries of a
patient in pain. Which of the following are likely stressors for the patient? Select all that
apply.
A) His daughters conversation
B) His daughters effleurage
C) The beeping of the heart monitor
D) The dim lighting of the room
E) The cries of the other patient from the hall

Question 5

Q

A patient in the ICU is complaining that he is not sleeping well at night because of
anxiety. Which of the following would be the most helpful intervention for the nurse to
make?
A) Provide the patient with a bath immediately following his first 90-minute REM
sleep cycle.
B) Increase the patients pain medication.
C) Provide the patient with 5 minutes of effleurage and then minimize disruptions.
D) Monitor the patients brain waves by polysomnography to determine his sleep
pattern.

Question 6

Q

A nurse walks into a patients room and begins preparing a syringe to perform a blood
draw on the patient. The nurse observes that the patient is firmly gripping the side of the
bed, averting her eyes, and sweating from her forehead when she sees the needle. What
would be the best intervention for the nurse to make?
A) Proceed with blood draw as quickly as possible, to get it over with.
B) Offer to come back later to perform the blood draw.
C) Encourage the patient to deep breathe.
D) Describe briefly the blood draw procedure and explain why it is necessary

Question 7

Q

A 15-year-old boy is in the ICU and preparing for an appendectomy. He is clearly
anxious and fidgets with his IV constantly. He complains that he doesnt want to be there
and he is sick of everyone telling him what to do. What would be the best way for the
nurse to address this patients anxiety?
A) Use physical restraints to keep him from pulling out his IV.
B) Offer him the remote to the television.
C) Lower the head of his bed so that he can rest more easily.
D) Explain to the patient in detail what the appendectomy will consist of

Question 8

Q

A nurse in a burn unit observes that a patient is tensed up and frowning but silent. The
nurse asks the patient, Can you tell me what you are thinking now? The patient responds,
I cant take this pain any more! I feel like Im about to die. What would be the best
response for the nurse to give to the patient, considering that the patient is already
receiving the maximum amount pain medication that is safe?
A) Try to get rid of those negative thoughtsthey only make it worse.
B) Try thinking instead, This pain will go away; I can overcome it.
C) Your pain medication is already at the highest possible dose.
D) Would you like me to raise the head of your bed?

Question 9

Q

A patient on mechanical ventilation is experiencing severe agitation due to being on the
ventilator. Which nursing intervention would be best?
A) Performing breathing exercises with the patient
B) Offering the patient a patient-controlled analgesic device
C) Asking the physician to prescribe an antianxiety medication
D) Offering the patient the patients own MP3 player to listen to

Question 10

Q

A 10-year-old female patient in ICU receiving chemotherapy has requested that her dog
be allowed to visit her. She is currently sharing a room with another patient. The nurse
knows that the hospital does allow for pet visits with owners, but has strict guidelines.
Which of the following scenarios is most likely to be permitted?
A) The girls father may bring the dog in on a leash for a 20-minute visit.
B) The girls sister may bring the dog in with a shirt on (to prevent shedding) for an
overnight stay.
C) The girls mother may bring the dog in on a leash for a visit as long as he has had all
his vaccinations.
D) The dog may be brought in for a brief visit once the girl is moved to a private room.

Question 11

Q

The nurse understands that a patient being cared for in a critical care unit experiences an
acute stress response. What nursing action best demonstrates understanding of the
physiological parts of the initial stress response?
A) Adequate pain control
B) Intravenous sedation
C) Treatment for elevated blood pressure
D) Ignoring an elevated glucose level

Question 12

Q

A critically ill patient experiences stress and anxiety from many factors. Treatment of the
patient focuses on reducing stressors and providing supportive care such as nutrition,
oxygenation, pain management, control of anxiety, and specific care of the illness or
injury. What is the best rationale for these interventions?
A) Helps to support the patients immune system
B) Part of good nursing care
C) Mandated by hospital policy
D) Reassures the patient and family

Question 13

Q

A patient in a critical care unit has increased stress from the constant noise and light
levels. What nursing intervention best attenuates these sources of stress?
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A) Need for constant observation and evaluation
B) Dimming lights during the night
C) Frequent nursing group rounds for all patients
D) Use of tile floors for ease in cleaning

Question 14

Q

The nurse is caring for a patient who is orally intubated and on a mechanical ventilator.
The nurse believes that the patient is experiencing excess anxiety. For this patient, what
behavior best indicates anxiety?
A) Restlessness
B) Verbalization
C) Increased respiratory rate
D) Glasgow Coma Scale score of 3

Question 15

Q

The critical care unit environment is very stressful for patients, families, and staff. What
nursing action is directed at reducing environmental stress?
A) Constant expert evaluation of patient status
B) Limiting visits to immediate family
C) Bathing all patients during hours of sleep
D) Maintaining a quiet environment during hours of sleep

Question 16

Q

The nurse wishes to enhance sleep cycles in her critically ill patient. Research has shown
that which nursing action improves sleep in critically ill patients?
A) Repositioning every 2 hours
B) Hypnotic medications
C) Five-minute back effleurage
D) Adequate pain control

Question 17

Q

The nurse is caring for a critically ill patient with a very concerned family. Given that the
family is under high stress, what nursing intervention will best ameliorate their stress
while preserving independence?
A) Encourage the family to participate in patient care tasks.
B) Teach the family to ask questions of the health care team.
C) Ask the family to select a family representative for communication.
D) Limit visits to immediate family members for limited times

Question 18

Q

While caring for a critically ill patient, the nurse knows that fostering patient control over
the environment is a method for stress reduction. What nursing intervention gives the
patient the most environmental control while still adhering to best practice principles?
A) Ask the patient whether he or she wants to get out of bed.
B) Give the patients bath at the same time every day.
C) Explain painful procedures only after giving pain medication.
D) Choose menu items for the patient to ensure a balanced diet.

Question 19

Q

The nurse is using presence to reduce the anxiety of a critically ill patient. What nursing
behavior demonstrates an effective use of presence?
A) Staying in the patients room to complete documentation
B) Having a conversation in the patients room that excludes the patient
C) Maintaining eye contact with the patient during explanations
D) Focusing on specific nursing care tasks while in the patients room

Question 20

Q

The nurse is caring for a critically ill patient who can speak. The nurse notices that the
patient is demonstrating behaviors indicative of anxiety but is silent. What nursing
strategy would give the nurse the most information about the patients feelings?
A) Explain procedures to the patient and family.
B) Ask the patient to share his or her internal dialogue.
C) Encourage the patient to nap before visiting hours.
D) Ensure that the patient has adequate pain control.

Question 21

Q

The patient is undergoing a necessary but painful procedure that is greatly increasing her
anxiety. The nurse decides to use guided imagery to help alleviate the patients anxiety.
What is a key part of this technique?
A) Provide the patient with an external focus point such as a picture.
B) Have the patient take slow, shallow breaths while staring at a focus point.
C) Have the patient remember tactile sensations of a pleasant experience.
D) Encourage the patient to consciously relax all of her muscles.

Question 22

Q

One of the strategies shown to reduce perception of stress in critically ill patients and
their families is support of spirituality. What nursing action is most clearly supportive of
the patients spirituality?
A) Referring patients to the Catholic chaplain
B) Providing prayer booklets to patients and families
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C) Asking about beliefs about the universe
D) Avoiding discussing religion with those of other faiths

Question 23

Q

A critically ill patient tells the nurse that he is not afraid to die because he believes in
reincarnation. What is the most appropriate nursing response?
A) What if reincarnation is not real?
B) This belief gives you strength.
C) I dont believe in reincarnation.
D) You shouldnt base your hopes on such a belief.

Question 24

Q

A critically ill patient who is intubated and agitated is restrained with soft wrist restraints.
Based on research findings, what is the best nursing action?
A) Maintain the restraints to protect patient safety.
B) Remove the restraints periodically to check skin integrity.
C) Remove the restraints periodically for range of motion.
D) Assess and intervene for causes of agitation

Question 25

Q

A patient has just been admitted to the ICU after being in a severe auto accident and
losing one of her legs. Her husband has his hand over his heart and complains of a rapid
heart rate. The nurse recognizes his condition as a sign of which stage of the general
adaptation syndrome to stress?
A) Alarm stage
B) Exhaustion stage
C) Resistance stage
D) Adaptation stage

Question 26

Q

The nurse observes that an elderly woman, whose granddaughter has been admitted to the
ICU, is struggling to manage her two great-grandsons, who are toddlers, in the waiting
room. What is the most likely explanation for the womans inability to manage the
children in this situation?
A) She is senile.
B) She is in the exhaustion stage of the general adaptation syndrome to stress.
C) She is assuming the role of caregiver in place of the patient, a role she is not used to.
D) She has macular degeneration and cannot see well

Question 27

Q

A nurse needs to communicate with a patients family regarding consent to treat an
unconscious patient in the ICU. Which member of the group should the nurse approach
first?
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A) A man she recognizes as the patients brother
B) A teenage boy who approaches the nurse
C) A woman who originally escorted the patient in
D) A woman in the group whom the others look at and call over when the nurse
approaches

Question 28

Q

A new nurse has recently joined the ICU from a different hospital, which had a much
stricter policy regarding visiting hours. She expresses concern about the impact of open
visiting hours on patient well-being. Which of the following would be the best
explanation for the purpose of open visiting hours? Select all that apply.
A) To better provide rest and quiet
B) To strengthen the relationship between the family and health care provider
C) To control the number of visitors for a patient
D) To provide an undisturbed environment
E) To decrease the patients anxiety
F) To increase the satisfaction of the family with the experience

Question 29

Q

A nurse observes that a 38-year-old single father whose 11-year-old daughter is in the
ICU is struggling to explain to his 6-year-old son the likelihood that the daughter will die.
The young boy asks what will happen to his sister when she dies, but the father breaks
down in tears and seems unable to respond. Which of the following would be the most
appropriate intervention for the nurse to make?
A) Suggest that the father contact his pastor, rabbi, or other spiritual leader for counsel
for him and his son
B) Sit down with the father and son and share her own religious beliefs
C) Ask the patients doctor to explain to the father the odds of the daughter surviving
D) Leave the father and son to grieve alone

Question 30

Q

A patient is experiencing severe pain, despite receiving pain medication for the past 24
hours. The patients wife expresses concern about this to the nurse. Which response by the
nurse would be most empowering to the patients family?
A) Explain that the doctor is an expert on pain medication and that the current level of
medication is the best.
B) Recommend that the family members take turns massaging the patients feet to
distract from the pain.
C) Encourage the family to request that the physician evaluate the patients pain control.
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D) Ask the family to wait another 24 hours to see whether the patients pain level will
go down.

Question 31

Q

The sister of a patient in the ICU has been at the patients bedside non-stop for 48 hours.
The nurse suggests to her that she return home to rest. Which of the following is the
proper rationale for the nurse making such a suggestion?
A) The sister is in the way of the health care providers.
B) The patient may become annoyed by her continual presence.
C) The patient will recover more easily in peace and quiet.
D) The sister needs to maintain her own health during this time.

Question 32

Q

A young man has just arrived at the ICU from out of town and received news that his
girlfriend, who is admitted there, likely only has a few days left to live. Which of the
following would be the best approach for the nurse to take in caring for the needs of this
young man?
A) Recommending that he go home and rest
B) Giving him unrestricted visiting hours with the patient
C) Suggesting that he meet with the hospital chaplain
D) Recommending that he ask the doctor to evaluate the patients pain control measures

Question 33

Q

A family of a young girl who has been diagnosed with leukemia has travelled 12 hours by
car to admit her to the ICU and be with her during her treatment. Which aspect of the
critical care family assistance program would most likely be needed by this family
initially?
A) Educational materials
B) Weekly group family information sessions
C) Hospitality programs
D) Pet therapy

Question 34

Q

A Muslim woman is admitted to the ICU after suffering severe burns over most of her
body. Which of the following would be the most appropriate measure for the nurse, a
woman, to take in respect for the cultural practices of this patient?
A) Insist that only a female doctor be assigned to this patient.
B) Ensure that no pork products are included in the patients diet.
C) Ensure that direct eye contact is not made with the patients husband.
D) Ask the patients husband what religious and cultural preferences should be
considered in the patients care.

Question 35

Q

A client has been admitted after experiencing multiple trauma and is intubated and
sedated. When the five members of the immediate family arrive, they are anxious, angry,
and very demanding. They all speak loudly at once and ask for many services and
answers. What is the best nursing response?
A) Ask the family to leave until visiting hours begin.
B) Take them to a private area for initial explanations.
C) Page security to have them removed from unit.
D) Show them to the clients bedside and leave them alone

Question 36

Q

The client has been in the CCU for several weeks and has been very unstable. One family
member stays at the bedside constantly and even naps in a bedside chair. The nurse
understands that the family member is exhibiting which family member response to
critical illness?
A) Exhibiting extreme distrust of the health care team
B) Seeking evidence for future legal or punitive action
C) Trying to maintain a level of control over the situation
D) Experiencing extreme fatigue from constant stress

Question 37

Q

The nurse is caring for a very seriously ill patient in the CCU. The family visits
sporadically, stays for only a short time, and does not ask many questions. How could the
nurse best begin to involve the family in the patients care?
A) Ask one family member to assist with the patients bath.
B) Encourage family members to stay longer at each visit.
C) Focus nursing efforts on the patients legal next of kin.
D) Ask the family to complete the Critical Care Family Needs Inventory

Question 38

Q

As part of the admission process, the nurse asks several questions about family
relationships. The nurse bases these actions on which rationale?
A) Assessing family relationships is an initial step in including the family in patient
care.
B) These questions are part of the admission assessment tool required by this CCU.
C) The nurse has a natural curiosity and wishes to know how the family members relate
for her own knowledge.
D) There is an ongoing research study to identify variant family patterns related to
disease incidence

Question 39

Q

On their first visit to a critically ill patient, family members stand in the doorway of the
room, making no effort to approach the patient. What is the most appropriate nursing
action?
A) Instruct the family where the patient can be touched and what to say.
B) Engage the family in social conversation to ease them into the milieu.
C) Use visiting hours to explain to the family the general status of the patient.
D) Leave the family to adjust to the situation when they are ready

Question 40

Q

A critically ill patient is not expected to survive this admission. The family asks the nurse
how the patient is doing. When answering this question, what should the nurse include?
A) Emphasize that the patient is young and strong and may still survive.
B) Refer the family to the physician for all details and answers.
C) Give specific information such as descending trends in parameters.
D) Ask if the family has determined which funeral home will be called.

Question 41

Q

A patients family is exhibiting increasingly impaired coping as the patients condition
deteriorates. The nurse asks the family to state the biggest concern from their perspective.
What is the most important rationale for this question?
A) The question indicates active listening on the part of the nurse.
B) The question is used as a way to validate the familys knowledge.
C) The question clarifies the nurses understanding of current family needs.
D) The question promotes problem definition, which helps define the degree of family
understanding

Question 42

Q

The nurse recommends that the family of a critically ill patient seek help from the Critical
Care Family Assistance Program. What benefit for the family does the nurse anticipate?
A) Reduction of health care cost
B) More physical comfort
C) Multidisciplinary support
D) Health promotion information

Question 43

Q

While interacting with the family of a critically ill patient, the nurse suggests that the
family must be feeling very anxious and perhaps angry. How does this nursing action
benefit the family?
A) Removes the focus of the conversation from the patient
B) Focusing on feelings helps the family avoid delayed grief and unhealthy coping
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C) Gives validation of need for psychological counseling
D) Reduces family insistence for patient progress information

Question 44

Q

The nurse is caring for a patient from a very different cultural group. In delivering care,
how can the nurse best demonstrate cultural sensitivity?
A) Ask the family about their cultural beliefs and customs that may apply.
B) Assume that the patient and family will adjust to the hospital culture.
C) Inform the patient and family that the routines of the hospital take precedence.
D) Do a literature search on the patients culture to determine beliefs.

Question 45

Q

A nurse from the ICU is participating in the hospitals disaster response preparedness
team. One issue that proves difficult for the team to agree on is a statement regarding the
standard of medical care observed during a disaster. Which of the following do you think
the nurse should recommend to the team?
A) The goal should be to provide the highest care possible, with limited resources and
equipment.
B) The lack of resources should not diminish the standard of care that the hospital
provides.
C) The medical staff should tend to the needs of the most critically ill first.
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D) If electrical power should be lost to the facility, patients on life support should be
given lowest priority.

Question 46

Q

A nurse learns that local law enforcement officials have informed the hospital that an
imminent terrorist attack has been threatened in a building just down the street from the
hospital. Which of the following are appropriate responses? Select all that apply.
A) Explain to the patients in the ICU that a terrorist attack is expected and that their
care may be interrupted.
B) Begin making preparations to move all ICU patients to other hospital facilities in the
area in the event of an attack.
C) Review the hospitals disaster plan and make sure that it is distributed to the rest of
the medical staff.
D) Determine what her specific role in the disaster plan is.
E) Not be concerned because federal deployable medical teams will likely be sent to
the hospital in the event of an attack.
F) Check the number of ventilators available in the ICU to determine whether more
would be needed in the event of an attack.

Question 47

Q

The nurse is at the bedside of her 90-year-old patient, Ruth, who is comatose and on life
support in the ICU, when she begins to feel the room shaking violently. The power
suddenly fails and emergency generators have not started yet. The nurse provides bagmask resuscitation for Ruth while she waits for the power to be restored. Moments later,
the ICU is inundated with patients injured by the collapse of a nearby apartment building
as a result of the earthquake. The nurse is called to help. Kevin has been impaled by a
metal rod through the chest, is in a state of shock, and will die without immediate
intervention. Gwyneth has compound fractures of the femur and a dislocated shoulder, is
in pain, but is responsive. Mason is unconscious and unresponsive. Based on the START
triage categories, whom should the nurse assist first in this situation?
A) Ruth
B) Kevin
C) Gwyneth
D) Mason

Question 48

Q

A patient arrives at the ICU after being injured by car bomb that exploded 20 feet away.
The patient sustained only primary blast injuries. Which of the following are injuries he
might have sustained? Select all that apply.
A) Perforated eardrum caused by a sudden change in atmospheric pressure
B) Laceration from a shard of glass that struck the patient
C) Concussion as a result of his body being thrown against a brick wall
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D) Hemorrhagic contusion of the lungs
E) Gastrointestinal hemorrhage
F) Blunt force trauma from a piece of metal shrapnel that struck the patients head

Question 49

Q

A group of patients, colleagues from the same office, arrive at the ICU with symptoms of
nausea, vomiting, and diarrhea. It is determined that they are suffering from radiation
exposure as a result of an inconspicuous device placed in the office that leaked radiation
over a period of days. The nurse suspects that which of the following was used in this
terrorist attack?
A) Radiological dispersal device
B) Improvised nuclear device
C) Nuclear weapon
D) Simple radiological device

Question 50

Q

A patient arrives at the ICU with symptoms of radiation exposure. While in the ICU, he
begins gasping for air and clutching his throat with his hand. What intervention should
take priority at this point?
A) Perform CPR on the patient to restore normal respiratory function.
B) Evaluate the degree of radiation exposure in the patient using a Geiger counter.
C) Undress the patient and have him shower and wash with soap to decontaminate
himself.
D) Administer potassium iodide

Question 51

Q

A woman arrives at the ICU after being the victim of a terrorist attack in a nearby
shopping center involving a gas that spewed from a metal canister. The woman complains
of a burning sensation in her eyes, mouth, and throat, and the nurse observes blistering on
her face and arms. What chemical agent should the nurse suspect, and what intervention
should she implement?
A) Vesicant agent; apply lotion
B) Nerve agent; administer benzodiazepine
C) Vesicant agent; soap and water blot
D) Nerve agent; provide ventilatory support

Question 52

Q

A worker at a local chemical plant arrives at the ICU following an industrial accident
involving a gas leak. The patient shows signs of pulmonary edema and bronchospasm.
What chemical should the nurse suspect is involved, and what intervention would be most
appropriate?
A) Nitrogen mustard; soap and water blot
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B) Chlorine; airway management and ventilatory support
C) Tear gas; irrigation of eyes with water
D) Cyanide; sodium nitrate

Question 53

Q

A man presents to the ICU with a severe case of H1N1 viral infection. What would be the
most appropriate intervention for this patient?
A) Administer an H1N1 vaccine.
B) Administer an antibiotic.
C) Administer an antiviral agent.
D) Administer potassium iodide.

Question 54

Q

A young man arrives at the ICU after being held hostage while a passenger on a
commercial airplane. He sustained a bullet wound in his chest and has undergone surgery
to repair his lung. He is now receiving an analgesic for his pain. The nurse observes that
the patient frequently complains that he is sick to his stomach and has no appetite. His
sleep is regularly interrupted by nightmares, and he is prone to outbursts of anger and
grief. What is the most likely cause of these symptoms?
A) Adverse reaction to pain medication
B) Reaction to severe pain
C) Post-traumatic stress disorder
D) Delirium resulting from an infection

Question 55

Q

The nurse is caring for a group of patients from the same workplace who have similar
symptoms of cough, respiratory distress, and nausea and vomiting. What should the nurse
suspect?
A) Food poisoning at local restaurant
B) Mass exposure to an inhaled agent
C) Allergic response to a new cleaning agent
D) Acute asthma exacerbation syndrome

Question 56

Q

The nurse is part of a planning committee developing a disaster response plan for a
hospital that serves as the major trauma center for the local area. The committee has
identified that the most likely cause of a disaster in the community is a devastating
tornado that significantly damages most major structures, including hospitals of all sizes,
in the community. What component of the plan is least likely to be realistic?
A) Transfer all noncritical patients to smaller hospitals in the community.
B) Provide for secure storage of emergency supplies and equipment.
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C) Agree with other hospitals in town to share supplies and equipment.
D) Interface with the city disaster management plan and command center

Question 57

Q

The nurse is preparing to assist with triage of victims from a large mass casualty incident.
The patients are sorted into categories at the door of the facility. What category will
receive care last?
A) Minimal
B) Delayed
C) Immediate
D) Expectant

Question 58

Q

The nurse is assisting with triage in the emergency department. A large group of patients
from a mass casualty incident arrive. These patients have been classified at the scene as
minimal, delayed, immediate, and expectant. What is the best nursing approach?
A) Use the classifications from the scene to determine the order of treatment.
B) Reassess and reclassify patients quickly to determine the order of treatment.
C) Treat the patients in the order they arrive at the emergency department.
D) After the first 20 patients, refer all others to another emergency care facility.

Question 59

Q

The nurse is caring for a patient who was exposed to a high dose of external radiation.
What is the least likely nursing action?
A) Assess for and facilitate treatment of life-threatening injuries.
B) Assess radiological measurements with a Geiger counter.
C) Remove clothing and shower patient as soon as possible.
D) Assist in removing penetrating radioactive materials

Question 60

Q

The nurse is caring for a patient who has been exposed to radiation. The patient has been
increasingly unstable, with decreasing lymphocytes, leukocytes, thrombocytes, and
erythrocytes, along with shock, diarrhea, and altered level of consciousness for some
weeks. Today, there is clear evidence of worsening shock, subnormal body temperature,
and increased intracranial pressure. The family asks what the patients prognosis is. The
best nursing response is based on what rationale?
A) Increased intracranial pressure following other symptoms is a sign of impending
death.
B) The symptoms listed are typical of the latent phase of recovery, which lasts several
weeks.
C) Full recovery from radiation exposure can take many weeks to months.
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D) The absence of fever indicates the patient has entered the latent phase of recovery

Question 61

Q

The nurse is caring for a patient with a suspected cyanide exposure. The patient is
anxious and hyperventilating. What is the nursing priority of care?
A) Give antiseizure medications.
B) Send toxicology screen.
C) Give cyanide antidote.
D) Obtain history of exposure

Question 62

Q

The nurse is assisting with the initial care and assessment of a group of patients with a
massive topical toxic chemical exposure. What is the best way to decontaminate these
patients?
A) Use an antidote to the chemical of exposure.
B) Use an alkaline substance for an acid contaminant.
C) Soap-and-water shower first for most chemicals
D) Administer 100% oxygen under positive pressure

Question 63

Q

A worker in a tanning factory comes to the emergency department with itchy, papular
lesions on his hands and arms. Some of the lesions have black eschar in the center and
some are vesicular. What biological exposure is most likely?
A) Cutaneous anthrax
B) Pulmonary anthrax
C) Cutaneous smallpox
D) Pneumonic plague

Question 64

Q

A patient and his family have been exposed to probable anthrax spores through
contaminated postal contents within the past 8 hours. Upon arrival at the emergency
department, all members of the family are anxious and say they are afraid of dying. The
best nursing response is based on what rationale?
A) There is no treatment for anthrax exposure and their fears are realistic.
B) A vaccine given in the first 3 days after exposure will stop the disease.
C) Antibiotic therapy is very effective for cutaneous anthrax.
D) A toxicology screen is necessary to determine whether there really was an exposure

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Unit 5 Flashcards

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