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Flashcards in Chapter 13 Deck (35):
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?

Application of silver sulfadiazine cream

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?

0.4 mL

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?

Syrup of ipecac

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?

Midline

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?

Esophageal burns

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?

12

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?

Elevate the patient’s limb.

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?

Wash with soap and water.

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?

Tongue and face

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?

Hypovolemic shock

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?

Risk for injury

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?

I feel calm

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?

Reduce psychosis

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?

Maintain ventilation

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?

Breathing

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?

Complete out a rapid head-to-toe assessment.

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?

Wheezing

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?

Internal bleeding

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?

Monitor respirations

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?

A severely injured patient with full potential for recovery

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?

Heat exhaustion

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?

Provide oral fluids

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?

Bp 104/52

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?

Determine if alcohol or illicit drugs have been used recently.

25

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

3

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?

80.6

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?

35

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?

Right lung tension pneumothorax

29

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

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

30

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

Amnesia
Headache
Drowsiness
Nausea and vomiting

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

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.

32

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

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

33

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

Steroids
Epinephrine
Antihistamine

34

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

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

35

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

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