TDH Flashcards
(32 cards)
Patient Rara was rushed to the ER of Lorma Hospital because of a wound due to injury, you were assigned to that station. As a student nurse, you were correct
if you stated that the description of a wound is/are, except? SATA
A. Wounds are injuries that break the skin or other body tissues
B. They include cuts, scrapes, scratches, and punctured skin
C. A wound is also a disruption to the integrity of the skin that leaves the body vulnerable to pain and infection.
D. Minor wounds usually aren’t serious, but it is not important to clean them
D. Minor wounds usually aren’t serious, but it is not important to clean them
You were the student nurse assigned to the ER, and you noticed that the patient had a wound. You classified this as an “EXTERNAL” type of wound. What are the types of external wounds? SATA
A. Non-penetrating wounds
B. Penetration wounds
C. Miscellaneous wounds
D. Penetrating wounds
A. Non-penetrating wounds
C. Miscellaneous wounds
D. Penetrating wounds
In the Emergency Department, a patient needs advanced wound care. As a student nurse, what action will benefit the patient?
A. Get Plenty of Rest
B. Avoid Aspirin Products
C. Patient Assessment and Vital Signs Monitoring
D. Apply Ice for Bruising or Swelling
C. Patient Assessment and Vital Signs Monitoring
In the Emergency Department there is a patient who needs Basic wound care. As a student nurse, what action will benefit the patient?
A. Apply Direct Pressure to Stop Bleeding
B. Debridement
C. Antibiotic Therapy
D. Provide Aspirin products
A. Apply Direct Pressure to Stop Bleeding
Patient Harashora was rushed to the ER, where you were assigned. Your Head Nurse instructed you to perform basic wound care. How will you wash and disinfect the wound? SATA
A. Rinse the wound with clean water or sterile saline
B. Gently clean around the wound with mild soap
C. Disinfect using a mild antiseptic solution or alcohol swabs.
D. Gently clean the wound directly with mild soap
A. Rinse the wound with clean water or sterile saline
B. Gently clean around the wound with mild soap
C. Disinfect using a mild antiseptic solution or alcohol swabs.
- The student nurse in the ER department is observing the patient’s wound. He is right when he identifies what are the types of Miscellaneous wounds? SATA
A. Thermal wounds
B. Chemical wounds
C. Bites and Stings
D. Electrical wounds
A. Thermal wounds
B. Chemical wounds
C. Bites and Stings
D. Electrical wounds
Nurse Ejay is assigned to telephone triage. A client called who was stung by a honeybee and is asking for help. The client reports pain and localized swelling but has no respiratory distress or other symptoms of anaphylactic shock. What is the appropriate initial action that the nurse should direct the client to perform?
A. Removing the stinger by scraping it
B. Applying a cold compress
C. Taking an oral antihistamine
D. Calling 911
A. Removing the stinger by scraping it
Nurse Anna is an experienced travel nurse who was recently employed and is assigned to the emergency unit. In her first week of the job, which of the following areas is the most appropriate assignment for her?
A. Triage
B. Ambulatory section
C. Trauma team
D. Psychiatric care
A. Triage
This term is used for those who need to be treated right away to stop their illness from getting worse.
A. Urgent
B. Resuscitation
C. Emergency
D. Semi-Urgent
C. Emergency
A client arrives at the emergency department who suffered multiple injuries from a head-on car collision. Which of the following assessment should take the highest priority?
A. Unequal pupils
B. Irregular pulse
C. Ecchymosis in the flank area
D. A deviated trachea
D. A deviated trachea
Nurse Rara performs his duties and responsibilities with the use of his knowledge of the right conduct and right nursing practices. What ethical principle did he
perform?
A. Justice
B. Fidelity
C. Autonomy
D. Veracity
C. Autonomy
It is designated for conditions that are life-threatening and need urgent care.
A. Urgent
B. Resuscitation
C. Semi-Urgent
D. Emergency
B. Resuscitation
Which of the following are the principles of Emergency Nursing? SATA
A. Ensure an open airway and provide sufficient ventilation
B. Perform surgical procedures independently
C. Keep wounds clean and protected
D. Provide immediate action to treat the patient
A. Ensure an open airway and provide
C. Keep wounds clean and protected
The emergency department (ED) nurse is caring for the following clients. Which client does the nurse prioritize to see first?
A. 81-year-old. with a respiratory rate of 28 breaths/min and a temperature of 101° F.
B. 45-year-old reporting chest pain and diaphoresis.
C. 60-year-old reporting difficulty swallowing and nausea
CLINICAL TEACHING PLAN: EMERGENCY ROOM
D. 22-year-old with a painful and swollen right wrist.
A. 81-year-old. with a respiratory rate of 28 breaths/min and a temperature of 101° F.
What percentage of ER visits are for true emergencies?
A. 50%
B. 20%
C. 30%
D. 10%
C. 30%
Which triage level would a patient with a head injury who is conscious but not vomiting fall under?
A. Semi-Urgent
B. Urgent
C. Non-Urgent
D. Emergency
A. Semi-Urgent
Nurse Kelly, a triage nurse encountered a client who complained of mid-sternal chest pain, dizziness, and diaphoresis. Which of the following nursing action should take priority?
A. Administer oxygen therapy via nasal cannula
B. Notify the physician
C. Complete history taking
D. Put the client on ECG monitoring
A. Administer oxygen therapy via nasal cannula
Georgy is experiencing a burn that is pale and waxy with large flat blisters, and asks the nurse about the severity of the burn and how long it will take to heal. With which of the following should the nurse respond to this patient?
A. The wound is a deep partial-thickness burn, and will take more than three weeks to heal.
B. The wound is a partial-thickness burn, and could take up to two weeks to heal.
C. The wound is a superficial burn, and will take up to three weeks to heal.
D. The wound is a full-thickness burn and will take one to two weeks to heal.
A. The wound is a deep partial-thickness burn, and will take more than three weeks to heal.
Nurse Badet is triaging clients in the emergency department. Which client complaint would the triage nurse classify as nonurgent?
A. Chest pain and diaphoresis
B. Decreased breath sounds due to chest trauma
C. Left arm fracture with palpable radial pulses
D. Sore throat and a temperature of 104° F
C. Left arm fracture with palpable radial pulses
Nurse Badet is triaging clients in the emergency department. Which client complaint would the triage nurse classify as nonurgent?
A. Chest pain and diaphoresis
B. Decreased breath sounds due to chest trauma
C. Left arm fracture with palpable radial pulses
D. Sore throat and a temperature of 104° F
C. Left arm fracture with palpable radial pulses
Bogart arrives at the emergency department with an electrical burn. What assessment questions should the nurse ask in determining the possible severity of
the burn injury? Select all that apply.
A. What type of current was involved?
B. How long was the patient in contact with the current?
C. Where was the patient when the burn occurred?
D. How much voltage was involved?
E. What was the point of contact with the current?
A. What type of current was involved?
B. How long was the patient in contact with the current?
D. How much voltage was involved?
In order for the nurse to correctly classify a burn injury, which of the following does the nurse need to assess? Select all that apply.
A. the depth of the burn
B. extent of burns on the body
C. the causative agent and the duration of exposure.
D. location of burns on the body
E. the time that the burn occurred
A. the depth of the burn
B. extent of burns on the body
C. the causative agent and the duration of exposure.
D. location of burns on the body
Paul is a 54-year-old widower with a history of chronic obstructive pulmonary disease and was rushed to the emergency department with increasing shortness
of breath, pyrexia, and a productive cough with yellow-green sputum. He has difficulty communicating because of his inability to complete a sentence. One of his
sons, Jacob, says he has been unwell for three days. Upon examination, crackles and wheezes can be heard in the lower lobes; he has tachycardia and a
bounding pulse. Measurement of arterial blood gas shows pH 7.3, PaCO2 68 mm Hg, HCO3 28 mmol/L, and PaO2 60 mm Hg. How would you interpret this?
Respiratory Acidosis, Partially Compensated
George, an elementary student, was rushed to the hospital due to vomiting and a decreased level of consciousness. The patient displays slow and deep
(Kussmaul breathing), and he is lethargic and irritable in response to stimulation. He appears to be dehydrated—his eyes are sunken and mucous membranes are
dry—and he has a two-week history of polydipsia, polyuria, and weight loss. Measurement of arterial blood gas shows pH 7.0, PaO2 90 mm Hg, PaCO2 23 mm
Hg, and HCO3 12 mmol/L; other results are Na+ 126 mmol/L, K+ 5 mmol/L, and Cl- 95 mmol/L. What is your assessment?
Metabolic Acidosis, Partially, Compensated
