MSS Ch 15: Emergency Nursing Practice Questions

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Question 13

The nurse in the emergency department has admitted five (5) clients in the last two (2) hours with complaints of fever and gastrointestinal distress. Which question is most appropriate for the nurse to ask each client to determine if there is a bioterrorism threat?

1. “Do you work or live near any large power lines?”
2. “Where were you immediately before you got sick?”
3. “Can you write down everything you ate today?”
4. “What other health problems do you have?”

Answer 13

1. Power lines are not typical sources of biological terrorism, which is what these symptoms represent.
2. The nurse should take note of any unusual illness for the time of year or clusters of clients coming from a single geographical location who all exhibit signs/symptoms of possible biological terrorism.
3. This might be appropriate for gastroen- teritis secondary to food poisoning but is not the nurse’s first thought to determine a biological threat. The nurse must determine if the clients have anything in common.
4. This is important information to obtain for all clients but is not pertinent to determine a biological threat.

Question 14

The health-care facility has been notified an alleged inhalation anthrax exposure has occurred at the local post office. Which category of personal protective equipment (PPE) should the response team wear?

1. Level A.
2. Level B.
3. Level C.
4. Level D.

Answer 14

1. Level A protection is worn when the highest level of respiratory, skin, eye, and mucous membrane protection is required. In this situation of possible inhalation of anthrax, such protection is required.
2. Level B protection is similar to Level A protection, but it is used when a lesser level of skin and eye protection is needed.
3. Level C protection requires an air-purified respirator (APR), which uses filters or absorbent materials to remove harmful substances.
4. Level D is basically the work uniform.

Question 15

The nurse is teaching a class on bioterrorism and is discussing personal protective equipment (PPE). Which statement is the most important fact for the nurse to share with the participants?

1. Health-care facilities should keep masks at entry doors.
2. The respondent should be trained in the proper use of PPE.
3. No single combination of PPE protects against all hazards.
4. The EPA has divided PPE into four levels of protection.

Answer 15

1. Masks are kept at designated areas, not at every entry door.
2. This is a true statement, but it is not the most important information; in an emer- gency situation, the respondent should use the equipment even if not trained.
3. The health-care providers are not guaranteed absolute protection, even with all the training and protective equipment. This is the most important information individuals wearing protective equipment should know because all other procedures should be followed at all times.
4. This is a true statement, but it is not the most important statement.

Question 16

The nurse is teaching a class on bioterrorism. Which statement is the scientific rationale for designating a specific area for decontamination?

1. Showers and privacy can be provided to the client in this area.
2. This area isolates the clients who have been exposed to the agent.
3. It provides a centralized area for stocking the needed supplies.
4. It prevents secondary contamination to the health-care providers.

Answer 16

1. This is not a rationale; this is a statement of what is done at the area.
2. This separates the clients until decontami- nation occurs, but the question is asking for the scientific rationale.
3. This is false statement—the supplies should not be kept in the decontamination area.
4. Avoiding cross-contamination is a priority for personnel and equipment— the fewer the number of people exposed, the safer the community and area.

Question 17

The triage nurse in a large trauma center has been notified of an explosion in a major chemical manufacturing plant. Which action should the nurse implement first when the clients arrive at the emergency department?

1. Triage the clients and send them to the appropriate areas.
2. Thoroughly wash the clients with soap and water and then rinse.
3. Remove the clients’ clothing and have them shower.
4. Assume the clients have been decontaminated at the plant.

Answer 17

In most situations this is the first step, but with a potential chemical or biological ex- posure, the first step must be the safety of

the hospital; therefore, the client must be decontaminated.
This is the second step in the decontami- nation process.

This is the first step. Depending on the type of exposure, this step alone can remove a large portion of exposure. This assumption could cost many people in the hospital staff, as well as clients,

their lives.

Question 18

The nurse is teaching a class on biological warfare. Which information should the nurse include in the presentation?

1. Contaminated water is the only source of transmission of biological agents.
2. Vaccines are available and being prepared to counteract biological agents.
3. Biological weapons are less of a threat than chemical agents.
4. Biological weapons are easily obtained and result in significant mortality.

Answer 18

1. Sources of biological agents include inhalation, insects, animals, and people.
2. The only known vaccine against a possible bioterrorism agent is the smallpox vaccine, which is not available in quantities sufficient to inoculate the public.
3. Because of the vast range of agents, biological weapons are more of a threat. A biological agent could be released in one city and affect people in other cities thousands of miles away.
4. Because of the variety of agents, the means of transmission, and lethality of the agents, biological weapons, including anthrax, smallpox, and plague, are especially dangerous.

Question 19

Which signs/symptoms should the nurse assess in the client who has been exposed to the anthrax bacillus via the skin?

1. A scabby, clear fluid–filled vesicle.
2. Edema, pruritus, and a 2-mm ulcerated vesicle.
3. Irregular brownish-pink spots around the hairline.
4. Tiny purple spots flush with the surface of the skin.

Answer 19

1. Scabby, clear fluid–filled vesicles are characteristic of chickenpox.
2. Exposure to anthrax bacilli via the skin results in skin lesions, which cause edema with pruritus and the formation of macules or papules which ulcerate, forming a one (1)- to (3)-mm vesicle. Then a painless eschar develops, which falls off in one (1) to two (2) weeks.
3. 3. Irregular brownish-pink spots around the hairline are characteristic of rubella.
4. 4. Tiny purple spots flush with the skin surface are petechiae.

Question 20

The client has expired secondary to smallpox. Which information about funeral arrangements is most important for the nurse to provide to the client’s family?

1. The client should be cremated.
2. Suggest an open casket funeral.
3. Bury the client within 24 hours.
4. Notify the public health department.

Answer 20

1. Cremation is recommended because the virus can stay alive in the scabs of the body for 13 years.
2. An open casket might allow for the spread of the virus to the general public; there- fore, the nurse should not make this suggestion. The nurse should not tell the client’s family how to make funeral arrangement for viewing.
3. Burying the body quickly is the second best option for safety of the funeral home personnel and anyone who could come in contact with the body. The quicker the burial, the safer the situation (if the family refuses cremation).
4. The hospital, not the client’s family, must notify the public health department.

Question 21

A chemical exposure has just occurred at an airport. An off-duty nurse, knowledgeable about biochemical agents, is giving directions to the travelers. Which direction should the nurse provide to the travelers?

1. Hold their breath as much as possible.
2. Stand up to avoid heavy exposure.
3. Lie down to stay under the exposure.
4. Attempt to breathe through their clothing.

Answer 21

1. The absence of breathing is death, and this is neither a viable option nor a sensible recommendation to terrified people.
2. Standing up will avoid heavy exposure because the chemical will sink toward the floor or ground.
3. Staying below the level of the smoke is the instruction for a fire.
4. Breathing through the clothing, which is probably contaminated with the chemical, will not provide protection from the chemical entering the lung.

Question 22

The nurse is caring for a client in the prodromal phase of radiation exposure. Which signs/symptoms should the nurse assess in the client?

1. Anemia, leukopenia, and thrombocytopenia.
2. Sudden fever, chills, and enlarged lymph nodes.
3. Nausea, vomiting, and diarrhea.
4. Flaccid paralysis, diplopia, and dysphagia.

Answer 22

1. Anemia, leukopenia, and thrombocytope- nia, signs of bone marrow depression, are signs/symptoms the client experiences in the latent phase of radiation exposure, which occurs from 72 hours to years after exposure. The client is usually asympto- matic in the prodromal phase of radiation exposure.
2. Sudden fever, chills, and enlarged lymph nodes are signs/symptoms of bubonic plague.
3. The prodromal phase (presenting symptoms) of radiation exposure occurs 48 to 72 hours after exposure and the signs/symptoms are nausea, vomiting, diarrhea, anorexia, and fatigue. Signs/symptoms of higher exposures of radiation include fever, respiratory distress, and excitability.
4. These are signs/symptoms of inhalation botulism.

Question 23

Which cultural issues should the nurse consider when caring for clients during a bioterrorism attack? Select all that apply.

1. Language difficulties.
2. Religious practices.
3. Prayer times for the people.
4. Rituals for handling the dead.
5. Keeping the family in the designated area.

Answer 23

1. Language difficulties can increase fear and frustration on the part of the client.
2. Some religions have specific practices related to medical treatments, hygiene, and diet, and these should be honored if at all possible.
3. Prayers in time of grief and disaster are important to an individual and actually can have a calming affect on the situation.
4. Caring for the dead is as important as caring for the living based on religious beliefs.
5. For purposes of organization this may be needed, but it is not addressing cultural sensitivity and in some instances may violate cultural needs of the client and the family.

Question 24

The off-duty nurse hears on the television of a bioterrorism act in the community. Which action should the nurse take first?

1. Immediately report to the hospital emergency room.
2. Call the American Red Cross to find out where to go.
3. Pack a bag and prepare to stay at the hospital.
4. Follow the nurse’s hospital policy for responding.

Answer 24

1. Many hospital procedures mandate off-duty nurses should not report immediately so relief can be provided for initial responders.
2. The nurse’s first responsibility is to the facility of employment, not the community.
3. This is a good action to take when the nurse is notified of the next action. For example, if the hospital is quarantined, the nurse may not report for days.
4. The nurse should follow the hospital’s policy. Many times nurses will stay at home until decisions are made as to where the employees should report.

Question 25

The nurse finds the client unresponsive on the floor of the bathroom. Which action should the nurse implement first? 1. Check the client for breathing. 2. Assess the carotid artery for a pulse. 3. Shake the client and shout. 4. Notify the Rapid Response Team.

Answer 25

1. This is the third intervention based on the answer options available in this question. 2. This is the fourth intervention based on the options available in this question. 3. **This is the first intervention the nurse should implement after finding the client unresponsive on the floor.** 4. The Rapid Response Team is called if the client is breathing; a code would be called if the client were not breathing.

Question 26

The unlicensed assistive personnel (UAP) is performing cardiac compressions on an adult client during a code. Which behavior warrants immediate intervention by the nurse? 1. The UAP has hand placement on the lower half of the sternum. 2. The UAP performs cardiac compressions and allows for rescue breathing. 3. The UAP depresses the sternum 0.5 to one (1) inch during compressions. 4. The UAP asks to be relieved from performing compressions because of exhaustion.

Answer 26

1. This hand position will help prevent posi- tioning the hand over the xiphoid process, which can break the ribs and lacerate the liver during compressions. 2. This is the correct two-rescuer CPR; therefore, no intervention is needed. 3. **The sternum should be depressed one and one-half (1.5) to two (2) inches during compressions to ensure adequate circulation of blood to the body; therefore, the nurse needs to correct the UAP.** 4. The UAP should request another health-care provider to perform compressions when exhausted.a

Question 27

Which intervention is most important for the nurse to implement when participating in a code? 1. Elevate the arm after administering medication. 2. Maintain sterile technique throughout the code. 3. Treat the client’s signs/symptoms; do not treat the monitor. 4. Provide accurate documentation of what happened during the code.

Answer 27

1. This is an appropriate intervention, but it is not the most important. 2. Sterile technique should be maintained as much as possible, but the nurse can treat a live body with an infection without using sterile technique; however, the nurse cannot treat a dead body without an infection. 3. **This is the most important intervention. The nurse should always treat the client based on the nurse’s assessment and data from the monitors; an inter- vention should not be based on data from the monitors without the nurse’s assessment.** 4. Documentation is important but not priority over treating the client.

Question 28

The CPR instructor is discussing an automated external defibrillator (AED) during class. Which statement best describes an AED? 1. It analyzes the rhythm and shocks the client in ventricular fibrillation. 2. The client will be able to have synchronized cardioversion with the AED. 3. It will keep the health-care provider informed of the client’s oxygen level. 4. The AED will perform cardiac compressions on the client.

Answer 28

1. **This is the correct statement explaining what an AED does when used in a code.** 2. The Life Pack on the crash cart must be used to perform synchronized cardioversion. 3. This is the explanation for a pulse oximeter. 4. This is not the function of the AED.a

Question 29

The nurse is caring for clients on a medical floor. Which client is most likely to experience sudden cardiac death? 1. The 84-year-old client exhibiting uncontrolled atrial fibrillation. 2. The 60-year-old client exhibiting asymptomatic sinus bradycardia. 3. The 53-year-old client exhibiting ventricular fibrillation. 4. The 65-year-old client exhibiting supraventricular tachycardia.

Answer 29

1. Atrial fibrillation is not a life-threatening dysrhythmia; it is chronic. 2. Asymptomatic sinus bradycardia may be normal for the client, especially for athletes or long-distance runners. 3. **Ventricular fibrillation is the most common dysrhythmia associated with sudden cardiac death; ventricular fibrillation is responsible for 65% to 85% of sudden cardiac deaths.** 4. “Supraventricular” means “above the ventricle.” The atrium is above the ventricle, and atrial dysrhythmias are not life threatening.

Question 30

Which health-care team member referral should be made by the nurse when a code is being conducted on a client in a community hospital? 1. The hospital chaplain. 2. The social worker. 3. The respiratory therapist. 4. The director of nurses.

Answer 30

1. **The chaplain should be called to help address the client’s family or significant others. A small community hospital does not have a 24-hour on-duty pastoral service. A chaplain is part** 2. of the code team in large medical center hospitals. 3. The social worker does not need to be notified of a code. 4. The respiratory therapist responds to the code automatically without a referral. The respiratory therapist is part of the code team and one (1) is on duty 24 hours a day, even in a small community hospital. The director of nurses does not need to be notified of codes, but possibly the house supervisor should be notified.

Question 31

Which intervention is the most important for the nurse to implement when performing mouth-to-mouth resuscitation on a client who has pulseless ventricular fibrillation? 1. Perform the jaw thrust maneuver to open the airway. 2. Use the mouth to cover the client’s mouth and nose. 3. Insert an oral airway prior to performing mouth-to-mouth. 4. Use a pocket mouth shield to cover client’s mouth.

Answer 31

1. A jaw thrust is used for a possible fractured neck. The nurse should use the head-tilt, chin-lift maneuver to open the airway. 2. The nurse should cover the client’s mouth and nose with the nurse’s mouth when giving mouth-to-mouth resuscitation to an infant but not when giving mouth-to-mouth resuscitation to an adult. 3. An oral airway is not mandatory to do effective breathing; therefore, it is not the most important intervention. 4. **Nurses should protect themselves against possible communicable dis- ease, such as HIV and hepatitis, and should be protected if the client vomits during CPR.**

Question 32

The nurse is teaching CPR to a class. Which statement best explains the definition of sudden cardiac death? 1. Cardiac death occurs after being removed from a mechanical ventilator. 2. Cardiac death is the time the HCP officially declares the client dead. 3. Cardiac death occurs within one (1) hour of the onset of cardiovascular symptoms. 4. The death is caused by myocardial ischemia resulting from coronary artery disease.

Answer 32

1. This is not the definition of sudden cardiac death; this is sometimes known as “pulling the plug” on clients who are diagnosed as brain dead. 2. This is not the definition of sudden cardiac death. 3. **Unexpected death occurring within one (1) hour of the onset of cardiovas- cular symptoms is the definition of sudden cardiac death.** 4. This is not the definition of sudden cardiac death.

Question 33

Which statement explains the scientific rationale for having emergency suction equipment available during resuscitation efforts? 1. Gastric distention can occur as a result of ventilation. 2. It is needed to assist when intubating the client. 3. This equipment will ensure a patent airway. 4. It keeps the vomitus away from the health-care provider.

Answer 33

1. **Gastric distention occurs from over-ventilating clients. When compressions are performed, the pressure will cause vomiting which may cause aspiration into the lungs.** 2. The health-care provider does not require suctioning equipment to intubate. 3. Nothing ensures a patent airway, except a correctly inserted endotracheal tube, and suction is needed to clear the airway. 4. Suction equipment is for the client’s needs, not the health-care provider’s needs.

Question 34

Which equipment must be immediately brought to the client’s bedside when a code is called for a client who has experienced a cardiac arrest? 1. A ventilator. 2. A crash cart. 3. A gurney. 4. Portable oxygen.

Answer 34

1. A ventilator is not kept on the medical- surgical floors and is not routinely brought to the bedside. The client is manually ventilated until arriving in the intensive care unit. 2. **The crash cart is the mobile unit with the defibrillator and all the medications and supplies needed to conduct a code.** 3. The gurney, a stretcher, may be needed when the client is being transferred to another unit, but it is not an immediate need, and in some hospitals the client is transferred in the bed. 4. Oxygen is available in the room and portable oxygen is on the crash cart, so it doesn’t need to be brought separately.

Question 35

The nursing administrator responds to a code situation. When assessing the situation, which role must the administrator ensure is performed for legal purposes and continuity of care of the client? 1. A person is ventilating with an Ambu bag. 2. A person is performing chest compressions correctly. 3. A person is administering medications as ordered. 4. A person is keeping an accurate record of the code.

Answer 35

1. This is providing immediate direct care to the client and is not performed for legal purposes. 2. The key to answering the question is “legal,” and direct care is not performed for legal purposes. 3. This is providing immediate direct care to the client and is not performed for legal purposes. This is an occasion where some- one else is allowed to document another nurse’s medication administration. 4. **The chart is a legal document, and the code must be documented in the chart and provide information needed in the intensive care unit.**

Question 36

The client in a code is now in ventricular bigeminy. The HCP orders a lidocaine drip at three (3) mg/min. The lidocaine comes prepackaged with two (2) grams of lidocaine in 500 mL of D5W. At which rate will the nurse set the infusion pump?

Answer 36

**45 mL/hr.**

Question 37

Which situation warrants the nurse obtaining information from a material safety data sheet (MSDS)? 1. The custodian spilled a chemical solvent in the hallway. 2. A visitor slipped and fell on the floor that had just been mopped. 3. A bottle of antineoplastic agent broke on the client’s floor. 4. The nurse was stuck with a contaminated needle in the client’s room.

Answer 37

1. **The MSDS provides chemical informa- tion regarding specific agents, health information, and spill information for a variety of chemicals. It is required for every chemical found in the hospital.** 2. This situation requires an occurrence or accident report. 3. Any facility administering antineoplastic agents (medications used to treat cancer) is required to have specific chemotherapy spill kits available and a policy and proce- dure included; in this situation the nurse already knows the chemical involved. 4. This requires a hospital variance report and notifying the employee health or infection control nurse.

Question 38

The triage nurse is working in the emergency department. Which client should be assessed first? 1. The 10-year-old child whose dad thinks the child’s leg is broken. 2. The 45-year-old male who is diaphoretic and clutching his chest. 3. The 58-year-old female complaining of a headache and seeing spots. 4. The 25-year-old male who cut his hand with a hunting knife.

Answer 38

1. The child needs an x-ray to confirm the fracture, but the client is stable and does not have a life-threatening problem. 2. **The triage nurse should see this client first because these are symptoms of a myocardial infarction, which is potentially life threatening.** 3. These are symptoms of a migraine headache and are not life threatening. 4. A laceration on the hand is priority, but not over a client having a myocardial infarction.

Question 39

The nurse is teaching a class on disaster preparedness. Which are components of an Emergency Operations Plan (EOP)? Select all that apply. 1. A plan for practice drills. 2. A deactivation response. 3. A plan for internal communication only. 4. A pre-incident response. 5. A security plan.

Answer 39

1. **Practice drills allow for troubleshoot- ing any issues before a real-life incident occurs.** 2. **A deactivation response is important so resources are not overused, and the facility can then get back to daily activities and routine care.** 3. Communication between the facility and external resources and an internal communication plan are critical. 4. A postincident response is important to in- clude a critique and debriefing for all parties involved; a pre-incident response is the plan itself. Be sure to read adjectives closely. 5. **A coordinated security plan involving facility and community agencies is the key to controlling an otherwise chaotic situation.**

Question 40

According to the North Atlantic Treaty Organization (NATO) triage system, which situation is considered a level red (Priority 1)? 1. Injuries are extensive and chances of survival are unlikely. 2. Injuries are minor and treatment can be delayed hours to days. 3. Injuries are significant but can wait hours without threat to life or limb. 4. Injuries are life threatening but survivable with minimal interventions.

Answer 40

1. This describes injures color-coded black or Priority 4 and is called the Expectant Category. 2. This is a description of injuries color-coded green or Priority 3 and is called the Minimal Category. 3. These are injures color-coded yellow or Priority 2 and is called the Delayed Category. 4. **This is called the Immediate Category. Individuals in this group can progress rapidly to Expectant if treatment is delayed.**

Question 41

Which statement best describes the role of the medical-surgical nurse during a disaster? 1. The nurse may be assigned to ride in the ambulance. 2. The nurse may be assigned as a first assistant in the operating room. 3. The nurse may be assigned to crowd control. 4. The nurse may be assigned to the emergency department.

Answer 41

1. The nurse should not leave the hospital area; the nurse must wait for the casualties to come to the facility. 2. This is a position requiring knowledge of instruments and procedures not common to the medical-surgical floor. 3. The people in this area are usually chaplains or social workers, not direct client care personnel. In a disaster, direct care personnel cannot be sparedfor this duty. 4. **New settings and atypical roles for nurses may be required during disasters; medical-surgical nurses can provide first aid and may be required to work in unfamiliar settings.**

Question 42

The nurse in a disaster is triaging the following clients. Which client should be triaged as an Expectant Category, Priority 4, and color black? 1. The client with a sucking chest wound who is alert. 2. The client with a head injury who is unresponsive. 3. The client with an abdominal wound and stable vital signs. 4. The client with a sprained ankle which may be fractured.

Answer 42

1. This client should be classified as an Immediate Category, Priority 1, and color red. If not treated STAT, a tension pneumothorax will occur. 2. **This client has a very poor prognosis, and even with treatment, survival is unlikely.** 3. This client should be classified as a Delayed Category, Priority 2, and color yellow. This client receives treatment after the casualties requiring immediate treatment are treated. 4. This client is a Minimal Category, Priority 3, and color green. This client can wait days for treatment.

Question 43

Which federal agency is a resource for the nurse volunteering at the American Red Cross who is on a committee to prepare the community for any type of disaster? 1. The Joint Commission (JC). 2. Office of Emergency Management (OEM). 3. Department of Health and Human Services (DHHS). 4. Metro Medical Response Systems (MMRS).

Answer 43

1. This organization mandates all health-care facilities to have an emergency operations plan, but it is a national agency, not a federal agency. 2. Most cities and all states have an OEM, which coordinates the disaster relief efforts at the state and local levels. 3. **Federal resources include organizations such as DHHS and the Depart- ment of Justice. Each of these federal departments oversees hundreds of agencies, including the American Red Cross, which respond to disasters.** 4. MMRS teams are local teams located in cities deemed to be possible terrorist targets.

Question 44

Which situation requires the emergency department manager to schedule and conduct a Critical Incident Stress Management (CISM)? 1. Caring for a two (2)-year-old child who died from severe physical abuse. 2. Performing CPR on a middle-aged male executive who died. 3. Responding to a 22-victim bus accident with no apparent fatalities. 4. Being required to work 16 hours without taking a break.

Answer 44

1. **CISM is an approach to preventing and treating the emotional trauma affecting emergency responders as a consequence of their job. Performing CPR and treating a young child affects the emergency personnel psychologically, and the death increases the traumatic experience.** 2. Caring for this type of client is an expected part of the job. If the nurse finds this traumatic enough to require a CISM, then the nurse should probably leave the emergency department. 3. This requires an intense time for triaging and caring for the victims, but without fatalities this should not be as traumatic for the staff. 4. This is a dangerous practice because medication errors and other mistakes may occur as a result of fatigue, but this is not a traumatic situation.

Question 45

During a disaster, a local news reporter comes to the emergency department requesting information about the victims. Which action is most appropriate for the nurse to implement? 1. Have security escort the reporter off the premises. 2. Direct the reporter to the disaster command post. 3. Tell the reporter this is a violation of HIPAA. 4. Request the reporter to stay out of the way.

Answer 45

1. The media have an obligation to report the news and can play a significant positive role in communication, but communica- tion should come from only one source— the disaster command center. 2. **Emergency operations plans will have a designated disaster plan coordinator. All public information should be routed through this person.** 3. Client confidentiality must be maintained, but the best action is for the nurse to help the reporter get to the appropriate area for information. 4. This allows the reporter to stay in the emergency room, which is inappropriate.

Question 46

The triage nurse has placed a disaster tag on the client. Which action warrants immediate intervention by the nurse? 1. The nurse documents the tag number in the disaster log. 2. The unlicensed assistive personnel documents vital signs on the tag. 3. The health-care provider removes the tag to examine the limb. 4. The LPN securely attaches the tag to the client’s foot.

Answer 46

1. This is the correct procedure when tagging a client and does not warrant intervention. 2. Vital signs should be documented on the tag. The tag takes the place of the client’s chart, so this does not warrant intervention. 3. **The tag should never be removed from the client until the disaster is over or the client is admitted and the tag becomes a part of the client’s record. The HCP needs to be informed immediately of the action.** 4. The tag can be attached to any part of the client’s body.

Question 47

The father of a child brought to the emergency department is yelling at the staff and obviously intoxicated. Which approach should the nurse take with the father? 1. Talk to the father in a calm and low voice. 2. Tell the father to wait in the waiting room. 3. Notify the child’s mother to come to the ED. 4. Call the police department to come and arrest him.

Answer 47

1. **This will help diffuse the escalating situation and attempt to keep the father calm.** 2. Sending the father to the waiting room does not help his behavior and could possibly make his behavior worse; loud and obnoxious behavior can become violent. 3. This will not help the current situation and could make it worse because the nurse doesn’t know the home situation. 4. The nurse should notify hospital security before calling the police department.

Question 48

A gang war has resulted in 12 young males being brought to the emergency department. Which action by the nurse is priority when a gang member points a gun at a rival gang member in the trauma room? 1. Attempt to talk to the person who has the gun. 2. Explain to the person the police are coming. 3. Stand between the client and the man with the gun. 4. Get out of the line of fire and protect self.

Answer 48

1. This puts the nurse in a dangerous position and might cause the death of the nurse. 2. This will escalate the situation. 3. This is a dangerous position for the nurse to put himself or herself in. 4. **Self-protection is priority; the nurse is not required to be injured in the line of duty.**

Question 49

The parents bring their toddler to the ED in a panic. The parents state the child had been playing in the kitchen and got into some cleaning agents and swallowed an unknown quantity of the agents. Which health-care agency should the nurse contact at this time? 1. Child Protective Services (CPS). 2. The local police department. 3. The Department of Health. 4. The Poison Control Center.

Answer 49

1. CPS should be contacted only if the nurse suspects an intentional administration of the poison, but at this time determining which poison the child has swallowed and the antidote is the priority. 2. The local police department is only noti- fied if the nurse suspects child abuse. 3. The Department of Health does not need to be notified. 4. **The Poison Control Center can assist the nurse in identifying which chemical has been ingested by the child and the antidote.**

Question 50

Which is the primary goal of the ED nurse in caring for a client who has ingested poison? 1. Remove or inactivate the poison before it is absorbed. 2. Provide long-term supportive care to prevent organ damage. 3. Administer an antidote to increase the effects of the poison. 4. Implement treatment prolonging the elimination of the poison.

Answer 50

1. **The primary goal for the ED nurse is to stop the action of the poison and then maintain organ functioning.** 2. ED nurses do not provide long-term care. 3. Antidotes are administered to neutralize the effects of poisons, not to increase the effects. 4. Treatment is implemented to hasten the elimination of the poison.

Question 51

The client has ingested a corrosive solution containing lye. Which intervention should the nurse implement? 1. Administer syrup of ipecac to induce vomiting. 2. Insert a nasogastric tube and connect to wall suction. 3. Assess for airway compromise. 4. Immediately administer water or milk.

Answer 51

1. Vomiting is never induced in clients who have ingested corrosive alkaline substances or petroleum distillates. More damage can occur to the esophagus and pharynx. 2. A gastric lavage may be done but not by inserting an NGT and attaching it to wall suction. 3. **Airway edema or obstruction can occur as a result of the burning action of corrosive substances.** 4. Water or milk may be administered to dilute the substance if the airway is not compromised.

Question 52

The male client was found in a parked car with the motor running. The paramedic brought the client to the ED with complaints of a headache, nausea, and dizziness and the client is unable to recall his name or address. On assessment, the nurse notes the buccal mucosa is a cherry-red color. Which intervention should the nurse implement first? 1. Check the client’s oxygenation level with a pulse oximeter. 2. Apply oxygen via nasal cannula at 100%. 3. Obtain a psychiatric consult to determine if this was a suicide attempt. 4. Prepare the client for transfer to a facility with a hyperbaric chamber.

Answer 52

1. These are signs and symptoms of carbon monoxide poisoning. Pulse oximetry is not a valid test because the hemoglobin is sat- urated with the carbon monoxide and a false high reading is being obtained. 2. **These are signs and symptoms of carbon monoxide poisoning. Symptoms include skin color from a cherry red to cyanotic and pale, headache, muscular weakness, palpitations, dizziness, and confusion and can progress rapidly to coma and death. Oxygen should be administered 100% at hyperbaric or atmospheric pressures to reverse hypoxia and accelerate elimination of the carbon monoxide.** 3. This may be done, but it is not the first action. 4. This may need to be done, but getting oxygen to the brain is first.

Question 53

A gastric lavage has been ordered for a client who is comatose and who ingested a full bottle of acetaminophen, a nonnarcotic analgesic. Which intervention should be included in the procedure? Select all that apply. 1. Place the client on the left side with the head 15 degrees lower than the body. 2. Insert a small-bore feeding tube into the naris. 3. Have standby suction available. 4. Withdraw stomach contents and then instill an irrigating solution. 5. Send samples of the stomach contents to the lab for analysis.

Answer 53

1. **The client should be placed on the left side, which allows the gastric contents to pool in the stomach and decreases passage of fluid into the duodenum during lavage. After the placement of the orogastric tube, the head is lowered to facilitate removal of the gastric contents.** 2. A large-bore tube is placed through the mouth into the stomach of a client who is comatose and an endotracheal tube is in- serted into the airway prior to beginning lavage to prevent aspiration. 3. **Standby suction is an emergency measure to prevent aspiration in case the client vomits.** 4. **Removing stomach contents before beginning the lavage helps to prevent overdistention of the stomach and aspiration.** 5. **Samples of the first two (2) lavage washings should be sent to the laboratory to be analyzed for chemical compounds.**

Question 54

A vat of chemicals spilled onto the client. Which action should the occupational health nurse implement first? 1. Have the client stand under a shower while removing all clothes. 2. Check the material safety data sheets for the antidote. 3. Administer oxygen by nasal cannula. 4. Collect a sample of the chemicals in the vat for analysis.

Answer 54

1. **The skin should be immediately drenched with water from a hose or shower. A constant stream of water is applied. Time should not be lost by re- moving the clothes first and then proceeding to rinsing with water. If a dry powder form of white phosphorus or lye spilled onto the client, it is brushed off and then the client is placed under the shower.** 2. The first action is to remove the poison from the client’s skin and prevent further damage. 3. If the client becomes dyspneic, the nurse administers oxygen while waiting for the paramedics. 4. The vat should be labeled as to the chemi- cal contents per Occupational Safety and Health Administration (OSHA) regula- tions, but if not, then the nurse must determine which chemicals are in the vat so the HCP can treat the client appropriately.

Question 55

The client presents to the ED with acute vomiting after eating at a fast-food restaurant. There has not been any diarrhea. The nurse suspects botulism poisoning. Which nursing problem is the highest priority for this client? 1. Fluid volume loss. 2. Risk for respiratory paralysis. 3. Abdominal pain. 4. Anxiety.

Answer 55

1. Fluid volume loss is a concern because of the potential for the client to go into hypovolemic shock, but this is not priority over airway. 2. **Clients with botulism are at risk for respiratory paralysis, and this is the priority problem.** 3. The client will be in pain and pain is a priority, but it does not come before airway and fluid volume. 4. The client may be anxious, but a psy- chosocial problem usually can be ranked after a physiological one in priority.

Question 56

The client has ingested the remaining amount of a bottle of analgesic medication. The medication comes 500 mg per capsule. Two (2) doses of two (2) capsules each have been used by another member of the family. The bottle originally had 250 capsules. How many mg of medication did the client take? \_\_\_\_\_\_\_

Answer 56

**123,000 mg of analgesic medication were consumed.** The container originally contained 250 capsules. Two (2) doses of two (2) capsules each were removed. 2×2=4 250 capsules 􏰀 4 capsules = 246 capsules remaining Each capsule contains 500 mg. 246 capsules × 500 mg = 123,000 mg of medication consumed

Question 57

The nurse is providing first aid to a victim of a poisonous snake bite. Which intervention should be the nurse’s first action? 1. Apply a tourniquet to the affected limb. 2. Cut an “X” across the bite and suck out the venom. 3. Administer a corticosteroid medication. 4. Have the client lie still and remove constrictive items.

Answer 57

1. Although this is seen as a first action in old television westerns, it is not a recommended action for clients who have been bitten by a snake. This action will cause further damage to the tissue by restricting blood flow to the tissue. 2. This is an action seen in classic television programs and movies from the 1950s and 1960s, but this is not the current treat- ment for snakebite. If this is done, the res- cuer will suck the venom into the rescuer’s mouth and possibly be poisoned. 3. Corticosteroid medications are contraindi- cated in the first six (6) to eight (8) hours after the bite because they might interfere with antibody production and hinder the action of the antivenin. 4. **The client should lie down, all restrictive items such as rings should be removed, the wound should be cleansed and covered with a sterile dressing, the affected body part should be immobilized, and the client should be kept warm.**

Question 58

The nurse is discharging a client diagnosed with accidental carbon monoxide poisoning. Which statement made by the client indicates the need for further teaching? 1. “I should install carbon monoxide detectors in my home.” 2. “Having a natural bright-red color to my lips is good.” 3. “You cannot smell carbon monoxide, so it can be difficult to detect.” 4. “I should have my furnace checked for leaks before turning it on.”

Answer 58

1. Installing carbon monoxide detectors in the home is a recommended safety measure. 2. **The lips should be pink, not bright red or blue. This indicates a saturation of the hemoglobin with carbon monoxide. This client needs more instruction.** 3. Because carbon monoxide is colorless and odorless, it can be dangerous. It is detected with special detectors. 4. One of the major causes of accidental carbon monoxide poisoning is a faulty furnace.

Question 59

The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a medical unit. Which nursing task cannot be delegated to the UAP? 1. Obtaining the intake and output on a client diagnosed with food poisoning. 2. Performing a dressing change on the client with a chemical burn. 3. Assisting a client who overdosed on morphine to the bedside commode. 4. Help a client with carbon monoxide poisoning turn, cough, and deep breathe.

Answer 59

1. UAPs can obtain intake and outputs, but evaluating the information is the nurse’s responsibility. 2. **This is a sterile dressing change and should not be delegated.** 3. A UAP can assist clients to get up to the bedside commode as long as the 4. UAP is knowledgeable about body mechanics. The UAP can assist a client to turn and ask the client to cough and deep breathe.

Question 60

The charge nurse is making assignments. Which client should be assigned to the most experienced nurse? 1. The client diagnosed with a snake bite who is receiving antivenin. 2. The client who swallowed a lye preparation and is being discharged. 3. The client who is angry the suicide attempt did not work. 4. The client who required skin grafting after a chemical spill.

Answer 60

1. **Before administering antivenin, the affected body part must be measured, and it is remeasured every 15 minutes during a four (4)- to six (6)-hour procedure. The infusion is begun slowly and increased after 10 minutes. The affected part is measured every 30 to 60 minutes after the infusion and for 48 hours to detect symptoms of compartment syndrome (edema, loss of pulse, increased pain, and paresthesias). Allergic reactions to the antivenin are not uncommon and are usually the result of a too-rapid infusion of the antivenin. The most experienced nurse should be assigned this client.** 2. This client is beyond critical danger and is being discharged, so a less experienced nurse could care for this client. 3. This client has many needs, but anger is not a priority over a physiological need. 4. A less experienced nurse could care for this client.

Question 61

The female client presents to the emergency department with facial lacerations and contusions. The spouse will not leave the room during the assessment interview. Which intervention should be the nurse’s first action? 1. Call the security guard to escort the spouse away. 2. Discuss the injuries while the spouse is in the room. 3. Tell the spouse the police will want to talk to him. 4. Escort the client to the bathroom for a urine specimen.

Answer 61

1. This action could cause the spouse to become violent. The security personnel should not attempt to remove the spouse unless the client wishes them to do so. 2. Injuries resulting from spousal abuse should be discussed without the abuser present. 3. This may or may not be true. The client will have to prosecute, and many times the abused client will not do so. The client may feel responsible for the abuse, or may fear for her children’s lives or for her own, or there may be a financial hold the spouse has over the client. Battered woman syndrome has many facets. 4. **By escorting the client to a bathroom for any reason, the nurse can get the client to a safe area out of the hearing of the spouse. This is the most innocu- ous way to get the client alone.**

Question 62

The elderly male client is admitted to the medical unit with a diagnosis of senile dementia. The client is 74 inches tall and weighs 54.5 kg. The client lives with his son and daughter-in-law, both of whom work outside the house. Which referral is most important for the nurse to implement? 1. Adult Protective Services. 2. Social worker. 3. Medicare ombudsman. 4. Dietitian.

Answer 62

1. Adult protective services should be called only if it is determined willful neglect or abuse of the client is occurring. 2. **The nurse should arrange for the social worker to see the client and family to determine if some arrangements could be made to provide for the client’s safety and for the client to be provided with nutritious meals while the adult children are at work. A long-term care facility or adult day care may be needed.** 3. The Medicare ombudsman is a person who represents a Medicare client in a long-term care facility. 4. The dietitian could see this client to determine eating preferences (74 inches = 6 foot 2 inches and 54.5 kg = 120 pounds), but the most appropriate intervention is safety.

Question 63

The nurse working in a homeless shelter identifies an adolescent female sexually aggressive toward some of the males in the shelter. Which is the most common cause for this behavior? 1. The client is acting in a learned behavior pattern to get attention. 2. The client had to leave home because of promiscuous behavior. 3. The client has a psychiatric disorder called nymphomania. 4. The client is a prostitute and is trying to get customers.

Answer 63

1. **Research suggests at least 67% of adolescents who are runaways or homeless have been abused in the home. This represents a learned behavior pattern getting the female adolescent attention.** 2. One reason adolescents of both sexes run away from home is abuse in the home. Nothing in the stem indicates the client was turned out of the home for any behavior. 3. This has the nurse medically diagnosing the client. 4. This is a judgmental statement.

Question 64

The adolescent female comes to the school nurse of an intermediate school and tells the nurse she thinks she is pregnant. During the interview, the client states her father is the baby’s father. Which intervention should the nurse implement first? 1. Complete a rape kit. 2. Notify Child Protective Services 3. Call the parents to come to the school. 4. Arrange for the client to go to a free clinic.

Answer 64

1. The school nurse is not a Sexual Assault Nurse Examiner (SANE) nurse, and this child thinks she is pregnant, suggesting the abuse has been occurring for a period of time or at least in some months past. The child should be taken to a hospital for examination. 2. **Child Protective Services should be notified to protect the child from further abuse and to initiate charges against the father. An intermediate school nurse cares for children in the 4th, 5th, 6th, or 7th grades, depending on the school district.** 3. This action brings the abuser to the school. 4. Sending the child to a free clinic does not negate the nurse’s responsibility to report suspected child abuse.

Question 65

The nurse in an outpatient rehabilitation facility is working with convicted child abusers. Which characteristics should the nurse expect to observe in the abusers? Select all that apply. 1. The abuser calls the child a liar. 2. The abuser has a tendency toward violence. 3. The abuser exhibits a high self-esteem. 4. The abuser is unable to admit the need for help. 5. The abuser was spoiled as a child.

Answer 65

1. **Frequently child abusers will deny the child’s reports of abuse and say the child is a habitual liar.** 2. **Child abusers believe violence is an acceptable way to reduce tension. They tend to have a low tolerance for frustration and have poor impulse control.** 3. Child abusers have a tendency toward feelings of helplessness and hopelessness. 4. **Child abusers tend to blame the child for the abuse and not admit the problem is their own.** 5. The child abuser may have been abused as a child, but there is no evidence of the child abuser being spoiled as a child.

Question 66

The nurse is teaching a class about rape prevention to a group of women at a community center. Which information is not a myth about rape? 1. Women who are raped asked for it by dressing provocatively. 2. If a woman says no, it is a come on and she really does not mean it. 3. Rape is an attempt to exert power and control over the client. 4. All victims of sexual assault are women; men can’t be raped.

Answer 66

1. This is a myth believed by some people. Many individuals are raped, ranging in age from infants to the 90s, male and female, heterosexuals and homosexuals. No one asks to be raped. 2. If a person says he or she is not interested in any type of sexual activity, it means “no” and anything else is forced and it is rape. “No” means “no.” It is considered rape if a prostitute says “no.” 3. **Rape is an act of violence motivated by the rapist desiring to overpower and control the victim.** 4. Men and children can be victims of rape. Sexual arousal and orgasm do not imply consent; it may be a pathological response to stimulation.

Question 67

The nurse working in the emergency department is admitting a 34-year-old female client for one of multiple admissions for spousal abuse. The client has refused to leave her husband or to press charges against him. Which action should the nurse implement? 1. Insist the woman press charges this time. 2. Treat the wounds and do nothing else. 3. Tell the woman her husband could kill her. 4. Give the woman the number of a woman’s shelter.

Answer 67

1. The nurse can encourage the client to press charges but has no right to insist. 2. The nurse should treat the wound and may find it frustrating the client will not press charges, but the nurse is obligated to provide the client information to help the client to get to a safe place. 3. The woman is more aware of this fact than the nurse. 4. **The nurse should help the client to devise a plan for safety by giving the client the number of a safe house or a woman’s shelter.**

Question 68

The 84-year-old female client is admitted with multiple burn marks on the torso and under the breasts along with contusions in various stages of healing. When questioned by the nurse, the woman denies any problems have occurred. The woman lives with her son and does the housework. Which is the most probable reason the woman denies being abused? 1. There has not been any abuse to report. 2. The client is ashamed to admit being abused. 3. The client has Alzheimer’s disease and can’t remember. 4. The client has engaged in consensual sex.

Answer 68

1. This client has signs of ongoing abuse such as multiple burns and contusions in different stages of healing. 2. **Many times the elderly are ashamed to report abuse because they raised the abuser and feel responsible for their child becoming an abuser. The elder parent may feel financially dependent on the child or be afraid of being placed in a long-term care facility. Forty-seven states have Adult Protective Services (APS) created by the states to protect elder citizens.** 3. There is no evidence provided in the stem of the client is not being mentally compe- tent, and there is evidence in the stem of physical abuse. This client is performing activities of daily living. 4. Consensual sex does not involve the physical abuse noted in the assessment.

Question 69

Which question is an appropriate interview question for the nurse to use with clients involved in abuse? 1. “I know you are being abused. Can you tell me about it?” 2. “How much does your spouse drink before he hits you?” 3. “What did you do to cause your spouse to get mad?” 4. “Do you have a plan if your partner becomes abusive?”

Answer 69

1. Unless the nurse is being personally abused in the same manner the client is being abused and has seen the abuse tak- ing place, the nurse cannot “know” the client is being abused. 2. Alcohol and drugs are implicated in the abuse of many clients, but not all abusers use alcohol or drugs. 3. This is agreeing with the abuser about the client causing the abuse. 4. **This statement assesses the abused client’s safety (or a plan for safety).**

Question 70

The client who was abused as a child is diagnosed with post-traumatic stress disorder (PTSD). Which intervention should the nurse implement when the client is resting? 1. Call the client’s name to awaken him or her, but don’t touch the client. 2. Touch the client gently to let him or her know you are in the room. 3. Enter the room as quietly as possible to not disturb the client. 4. Do not allow the client to be awakened at all when sleeping.

Answer 70

1. **Clients diagnosed with PTSD are easily startled and can react violently if awakened from sleep by being touched.** 2. Touching the client can cause the client to become afraid, to believe himself or herself to be under attack, and to react violently. The nurse should not touch a sleeping client diagnosed with PTSD. 3. If the client awakes with the nurse in the room, the client could become fearful and react to the fear. 4. There may be times when the nurse must awaken the client to determine if the client is physically stable.

Question 71

The emergency department nurse writes the problem of “ineffective coping” for a client who has been raped. Which intervention should the nurse implement? 1. Encourage the client to take the “morning-after” pill. 2. Allow the client to admit guilt for causing the rape. 3. Provide a list of rape crisis counselors. 4. Discuss reporting the case to the police.

Answer 71

1. This plan for the client to take RU 486, or the “morning-after” pill, prevents preg- nancy from occurring, but it does not di- rectly address coping skills. 2. The client may talk about “what if I had not done...,” but the client is not guilty of causing the rape. 3. **The client should be provided the phone number of a rape crisis counseling center or counselor to help the client deal with the psychological feelings of being raped.** 4. This is a legal issue.

Question 72

The nurse writes a nursing diagnosis of “risk for injury as a result of physical abuse by spouse” for a client. Which is an appropriate goal for this client? 1. The client will learn not to trust anyone. 2. The client will admit the abuse is happening and get help. 3. The client will discuss the nurse’s suspicions with the spouse. 4. The client will choose to stay with the spouse.

Answer 72

1. The nurse should attempt to develop a relationship in which the client feels he or she can trust the nurse (males are abused by significant others too). 2. **The first step in helping a client who has been abused is to get the client to admit the abuse is happening.** 3. This could cause the abuse to escalate. 4. This is what the nurse is trying to get the client to avoid.