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Flashcards in NCLEX Emergency and Disaster Nursing Deck (26)
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1

During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient has an unobstructed airway. Which action should the nurse take next?
a. Palpate extremities for bilateral pulses.
b. Observe the patient’s respiratory effort.
c. Check the patient’s level of consciousness.
d. Examine the patient for any external bleeding.

ANS: B
Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient’s breathing. The other actions are also part of the initial survey, but assessment of breathing should be done immediately after assessing for airway patency.

2

During the primary survey of a patient with severe leg trauma, the nurse observes that the patient’s left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next?
a. Send blood to the lab for a complete blood count.
b. Assess further for a cause of the decreased circulation.
c. Finish the airway, breathing, circulation, disability survey.
d. Start normal saline fluid infusion with a large-bore IV line.

ANS: D
The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a life-threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey. Although a complete blood count is indicated, administration of IV fluids should be started first. Completion of the primary survey and further assessment should be completed after the IV fluids are initiated.

3

After the return of spontaneous circulation following the resuscitation of a patient who had a cardiac arrest, therapeutic hypothermia is prescribed. Which action will the nurse include in the plan of care?
a. Initiate cooling per protocol.
b. Avoid the use of sedative drugs.
c. Check mental status every 15 minutes.
d. Rewarm if temperature is below 91° F (32.8° C)

ANS: A
When therapeutic hypothermia is used postresuscitation, external cooling devices or cold normal saline infusions are used to rapidly lower body temperature to 89.6° to 93.2° F (32° to 34° C). Because hypothermia will decrease brain activity, assessing mental status every 15 minutes is not done at this stage. Sedative drugs are given during therapeutic hypothermia.

4

A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. What should the nurse do during the primary survey of the patient?
a. Obtain a complete set of vital signs.
b. Check a Glasgow Coma Scale score.
c. Attach an electrocardiogram monitor.
d. Ask about chronic medical conditions.

ANS: B
The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the secondary survey

5

A 19-yr-old patient is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the left hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. What should the nurse anticipate giving?
a. Tetanus immunoglobulin (TIG) only
b. TIG and tetanus-diphtheria toxoid (Td)
c. Tetanus-diphtheria toxoid and pertussis vaccine (Tdap) only
d. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap)

ANS: D
For an adult with no previous tetanus immunizations, TIG and Tdap are recommended. The other immunizations are not sufficient for this patient.

6

A patient who has experienced blunt abdominal trauma during a motor vehicle collision reports increasing abdominal pain. What topic will the nurse plan to teach the patient?
a. Peritoneal lavage
b. Abdominal ultrasonography
c. Nasogastric (NG) tube placement
d. Magnetic resonance imaging (MRI)

ANS: B
For patients who are at risk for intraabdominal bleeding, focused abdominal ultrasonography is the preferred method to assess for intraperitoneal bleeding. An MRI would not be used. Peritoneal lavage is an alternative, but it is more invasive. An NG tube would not be helpful in the diagnosis of intraabdominal bleeding

7

A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). Which patient statement indicates to the nurse that discharge teaching has been effective?
a. “I’ll take salt tablets when I work outdoors in the summer.”
b. “I should take acetaminophen (Tylenol) if I start to feel too warm.”
c. “I need to drink extra fluids when working outside in hot weather.”
d. “I’ll move to a cool environment if I notice that I’m feeling confused”

ANS: C
Oral fluids and electrolyte replacement solutions such as sports drinks help replace fluid and electrolytes lost when exercising in hot weather. Salt tablets are not recommended because of the risks of gastric irritation and hypernatremia. Antipyretic drugs are not effective in lowering body temperature elevations caused by excessive exposure to heat. A patient who is confused is likely to have more severe hyperthermia and will be unable to remember to take appropriate action

8

A 22-yr-old patient who experienced a drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period?
a. Auscultate heart sounds.
b. Palpate peripheral pulses.
c. Check mental orientation.
d. Auscultate breath sound

ANS: D
Because pulmonary edema is a common complication after drowning, the nurse should assess the breath sounds frequently. The other information also will be obtained by the nurse, but it is not as pertinent to the patient’s admission diagnosis

9

When requested to plan the response to the potential use of smallpox as a biological weapon, what should the emergency department (ED) nurse manager expect to obtain?
a. Vaccine
b. Atropine
c. Antibiotics
d. Whole blood

ANS: A
Smallpox infection can be prevented or ameliorated by the administration of vaccine given rapidly after exposure. The other interventions would be helpful for other agents of terrorism but not for smallpox

10

Which finding indicates that the nurse should discontinue active rewarming of a patient admitted with hypothermia?
a. The patient begins to shiver.
b. The BP decreases to 86/42 mm Hg.
c. The patient develops atrial fibrillation.
d. The core temperature is 94° F (34.4° C).

ANS: D
A core temperature of at least 89.6° to 93.2° F (32° to 34° C) indicates that sufficient rewarming has occurred. Dysrhythmias, hypotension, and shivering may occur during rewarming, and should be treated but are not an indication to stop rewarming the patient.

11

When assessing an older patient admitted to the emergency department (ED) with a broken arm and facial bruises, the nurse observes several additional bruises in various stages of healing. Which statement or question by the nurse should be first?
a. “You should not go home.”
b. “Do you feel safe at home?”
c. “Would you like to see a social worker?”
d. “I need to report my concerns to the police.”

ANS: B
The nurse’s initial response should be to further assess the patient’s situation. Telling the patient not to return home may be an option once further assessment is done. A social worker or police report may be appropriate once further assessment is completed.

12

A patient arrives in the emergency department (ED) several hours after taking “25 to 30” acetaminophen (Tylenol) tablets. Which action will the nurse plan to take?
a. Give N-acetylcysteine.
b. Discuss the use of chelation therapy.
c. Start oxygen using a non-rebreather mask.
d. Have the patient drink large amounts of water.

ANS: A
N-acetylcysteine is the recommended treatment to prevent liver damage after acetaminophen overdose. The other actions might be used for other types of poisoning, but they will not be appropriate for a patient with acetaminophen poisoning.

13

A triage nurse in a busy emergency department (ED) assesses a patient who reports 7/10 abdominal pain and states, “I had a temperature of 103.9° F (39.9° C) at home.” What should be the nurse’s first action?
a. Give acetaminophen (Tylenol).
b. Assess the patient’s current vital signs.
c. Ask the patient to provide a clean-catch urine for urinalysis.
d. Tell the patient that it may be 1 to 2 hours before seeing a health care provider

ANS: B
The patient’s pain and statement about an elevated temperature indicate that the nurse should obtain vital signs before deciding how rapidly the health care provider should see the patient. A urinalysis may be appropriate, but this would be done after the vital signs are taken. The nurse will not give acetaminophen before confirming a current temperature elevation.

14

The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment?
a. A patient with no pedal pulses
b. A patient with an open femur fracture
c. A patient with paradoxical chest motion
d. A patient with bleeding facial lacerations

ANS: C
Most immediate deaths from trauma occur because of problems with ventilation, so the patient with paradoxical chest movements should be treated first. Face and head fractures can obstruct the airway, but the patient with facial injuries only has lacerations. The other two patients also need rapid intervention but do not have airway or breathing problems

15

The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?
a. Apply ice packs to both hands.
b. Attempt to remove the patient’s rings.
c. Apply calamine lotion to itching areas.
d. Give diphenhydramine (Benadryl) 50 mg PO.

ANS: B
The patient’s rings should be removed first because it might not be possible to remove them if swelling develops. The other actions should also be implemented as rapidly as possible after the nurse has removed the jewelry.

16

Gastric lavage and administration of activated charcoal are prescribed for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action should the nurse plan to do first?
a. Insert a large-bore orogastric tube.
b. Assist with intubation of the patient.
c. Prepare a 60-mL syringe with saline.
d. Give first dose of activated charcoal.

ANS: B
In an unresponsive patient, intubation is done before gastric lavage and activated charcoal administration to prevent aspiration. The other actions will be implemented after intubation

17

A patient arrives in the emergency department (ED) after topical exposure to powdered lime at work. Which action should the nurse take first?
a. Obtain the patient’s vital signs.
b. Obtain a baseline complete blood count.
c. Brush visible powder from the skin and clothing.
d. Decontaminate the patient by showering with water.

ANS: C
The initial action should be to protect staff members and decrease the patient’s exposure to the toxin by decontamination. Patients exposed to powdered lime should not be showered; instead, any and all visible powder should be brushed off. The other actions can be done after the decontamination is completed.

18

An unresponsive 79-yr-old patient is admitted to the emergency department (ED) during a summer heat wave. The patient’s core temperature is 105.4° F (40.8° C), blood pressure (BP) is 88/50 mm Hg, and pulse is 112 beats/min. What action should the nurse plan to take?
a. Apply wet sheets and a fan to the patient.
b. Provide O2 at 2 L/min with a nasal cannula.
c. Start lactated Ringer’s solution at 1000 mL/hr.
d. Give acetaminophen (Tylenol) rectal suppository

ANS: A
The priority intervention is to cool the patient. Antipyretics are not effective in decreasing temperature in heat stroke and 100% O2 should be given, which requires a high flowrate through a non-rebreather mask. An older patient would be at risk for developing complications such as pulmonary edema if given fluids at 1000 mL/hr.

19

An unresponsive patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first?
a. Pulse
b. Heart rhythm
c. Breath sounds
d. Body temperature

ANS: A
The priority assessment in an unresponsive patient relates to CAB (circulation, airway, breathing) so a pulse check should be performed first. While assessing the pulse, the nurse should look for signs of breathing. The other data will also be collected rapidly but are not as essential as determining if there is a pulse.

20

Following an earthquake, patients are triaged by emergency medical personnel and transported to the emergency department (ED). Which patient will the nurse need to assess first?
a. A patient with a red tag
b. A patient with a blue tag
c. A patient with a black tag
d. A patient with a yellow tag

ANS: A
The red tag indicates a patient with a life-threatening injury requiring rapid treatment. The other tags indicate patients with less urgent injuries or those who are likely to die.

21

Family members are in the patient’s room when the patient has a cardiac arrest and the staff start resuscitation measures. Which action should the nurse take next?
a. Keep the family in the room and assign a staff member to explain the care given and answer questions.
b. Ask the family to wait outside the patient’s room with a staff member to provide emotional support.
c. Ask the family members whether they would prefer to remain in the patient’s room or wait outside the room.
d. Tell the family members that patients are comforted by having family members present during resuscitation efforts.

ANS: C
Although many family members and patients report benefits from family presence during resuscitation efforts, the nurse’s initial action should be to determine the preference of these family members. The other actions may be appropriate, but this will depend on what is learned when assessing family preferences.

22

A patient who has deep human bite wounds on the left hand is being treated in the urgent care center. Which action will the nurse plan to take?
a. Prepare to administer rabies immune globulin.
b. Assist the health care provider with suturing the wounds.
c. Teach the patient the reason for the use of prophylactic antibiotics.
d. Keep the wounds dry until the health care provider can assess them.

ANS: C
Because human bites of the hand frequently become infected, prophylactic antibiotics are usually prescribed to prevent infection. To minimize infection, deep bite wounds on the extremities are left open. Rabies immune globulin might be used after an animal bite. Initial treatment of bite wounds includes copious irrigation to help clean out contaminants and microorganisms.

23

The urgent care center protocol for tick bites includes the following actions. Which action will the nurse take first when caring for a patient with a tick bite?
a. Use tweezers to remove any remaining ticks.
b. Check the vital signs, including temperature.
c. Give doxycycline (Vibramycin) 100 mg orally.
d. Obtain information about recent outdoor activities

ANS: A
Because neurotoxic venom is released as long as the tick is attached to the patient, the initial action should be to remove any ticks using tweezers or forceps. The other actions are also appropriate, but the priority is to minimize venom release.

24

Which interventions will the nurse plan for a comatose patient who will have targeted temperature management/therapeutic hypothermia? (Select all that apply.)
a. Assist with endotracheal intubation.
b. Insert an indwelling urinary catheter.
c. Begin continuous cardiac monitoring.
d. Prepare to give sympathomimetic drugs.
e. Obtain a prescription for patient restraints.

ANS: A, B, C
Cooling can produce dysrhythmias, so the patient’s heart rhythm should be continuously monitored, and dysrhythmias treated if necessary. Bladder catheterization and endotracheal intubation are needed during cooling. Sympathomimetic drugs tend to stimulate the heart and increase the risk for fatal dysrhythmias such as ventricular fibrillation. Patients receiving therapeutic hypothermia are comatose, so restraints are not indicated.

25

The emergency department (ED) nurse is starting targeted temperature management/therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed
practical/vocational nurse (LPN/VN)? (Select all that apply.)
a. Insert a urinary catheter to drainage.
b. Continuously monitor heart rhythm.
c. Assess neurologic status every 2 hours.
d. Place cooling blankets above and below patient.
e. Attach rectal temperature probe to cooling blanket control panel

ANS: A, D, E
Experienced LPN/VNs have the education and scope of practice to implement hypothermia measures (e.g., cooling blanket, temperature probe) and insert a urinary catheter under the supervision of a registered nurse (RN). Assessment of neurologic status and monitoring the heart rhythm require RN-level education and scope of practice and should be done by the RN.

26

The following four patients arrive in the emergency department (ED) after a motor vehicle collision. In which order should the nurse assess them? (Put a comma and a space between each answer choice [A, B, C, D, E].)
a. A 43-yr-old patient reporting 7/10 abdominal pain
b. A 74-yr-old patient with palpitations and chest pain
c. A 21-yr-old patient with multiple fractures of the face and jaw
d. A 37-yr-old patient with a misaligned lower leg and intact pulses

ANS:
C, B, A, D
The highest priority is to assess the 21-yr-old patient for airway obstruction, which is the most life-threatening injury. The 74-yr-old patient may have chest pain from cardiac ischemia and should be assessed and have diagnostic testing for this pain. The 43-yr-old patient may have abdominal trauma or bleeding and should be seen next to assess circulatory status. The 37-yr-old patient appears to have a possible fracture of the left leg and should be seen soon, but this patient has the least life threatening injury.