Chapter 69: Nursing Management: Emergency, Terrorism, and Disaster Nursing My Nursing Test Banks

Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 69: Nursing Management: Emergency, Terrorism, and Disaster Nursing

Test Bank

MULTIPLE CHOICE

1. During the primary assessment of a trauma victim, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next?

a.

Observe the patients respiratory effort.

b.

Check the patients level of consciousness.

c.

Palpate extremities for capillary refill time.

d.

Examine the patient for any external bleeding.

ANS: A

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

DIF: Cognitive Level: Application REF: 1769-1771

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

2. During the primary survey of a patient with multiple traumatic injuries, the nurse observes that the patients right pedal pulses are absent and the leg is swollen. Which of these actions will the nurse take next?

a.

Assess further for a cause of the decreased circulation.

b.

Send blood to the lab for a complete blood count (CBC).

c.

Finish the airway, breathing, circulation, disability survey.

d.

Initiate isotonic fluid infusion through two large-bore IV lines.

ANS: D

The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a possibly life-threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey. Although a CBC 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.

DIF: Cognitive Level: Application REF: 1769-1771

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

3. After resuscitation, a patient who had a cardiac arrest is nonresponsive to commands and therapeutic hypothermia is prescribed. Which action will the nurse include in the plan of care?

a.

Rapidly infuse cold normal saline.

b.

Avoid the use of sedative medications.

c.

Check neurologic status every 30 minutes.

d.

Rewarm if temperature is >91 F (32.8 C).

ANS: A

When therapeutic hypothermia is used postresuscitation, cold normal saline is infused to rapidly lower body temperature to 89.6 F to 93.2 F (32 C to 34 C). Since hypothermia will decrease brain activity, neurologic assessment every 30 minutes is not needed. Sedative medications are administered during therapeutic hypothermia.

DIF: Cognitive Level: Application REF: 1773-1774 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

4. A patient who is unconscious after a fall from a ladder is transported to the emergency department by family members. During the primary survey of the patient, the nurse should

a.

assess the patients vital signs.

b.

attach a cardiac electrocardiogram (ECG) monitor.

c.

obtain a Glasgow Coma Scale score.

d.

ask about chronic medical conditions.

ANS: C

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

DIF: Cognitive Level: Application REF: 1769-1771

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

5. An 18-year-old is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the right hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. The nurse will anticipate administration of

a.

tetanus-diphtheria toxoid (Td) only.

b.

tetanus immunoglobulin (TIG) only.

c.

TIG and tetanus-diphtheria toxoid (Td).

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.

DIF: Cognitive Level: Application REF: 1773-1774 TOP: Nursing Process: Planning

MSC: NCLEX: Health Promotion and Maintenance

6. A patient who has experienced blunt abdominal trauma during a car accident is complaining of increasing abdominal pain. The nurse will plan to teach the patient about the purpose of

a.

ultrasonography.

b.

peritoneal lavage.

c.

nasogastric (NG) tube placement.

d.

magnetic resonance imaging (MRI).

ANS: A

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 diagnosis of intraabdominal bleeding.

DIF: Cognitive Level: Application REF: 1773 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

7. A patient with hypotension and temperature elevation after doing yard work on a hot day is treated in the ED. After the nurse has completed discharge teaching, which statement by the patient indicates that the teaching has been effective?

a.

I will 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 should have sports drinks when exercising outside in hot weather.

d.

I will get into a cool environment if I notice that I am feeling confused.

ANS: C

Electrolyte 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 medications 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.

DIF: Cognitive Level: Application REF: 1775-1776 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

8. When preparing to rewarm a patient with hypothermia, the nurse will plan to

a.

attach a cardiac monitor.

b.

insert a urinary catheter.

c.

assist with endotracheal intubation.

d.

have sympathomimetic drugs available.

ANS: A

Rewarming can produce dysrhythmias, so the patient should be monitored and treated if necessary. Urinary catheterization and endotracheal intubation are not needed for rewarming. Sympathomimetic drugs tend to stimulate the heart and increase the risk for fatal dysrhythmias such as ventricular fibrillation.

DIF: Cognitive Level: Application REF: 1776-1778 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

9. A patient who experienced a near drowning accident in a local lake, but now is awake and breathing spontaneously, is admitted for observation. Which action will be most important for the nurse to take during the observation period?

a.

Listen to heart sounds.

b.

Palpate peripheral pulses.

c.

Auscultate breath sounds.

d.

Check pupil reaction to light.

ANS: C

Since pulmonary edema is a common complication after near drowning, the nurse should assess the breath sounds frequently. The other information also will be collected by the nurse, but it is not as pertinent to the patients admission diagnosis.

DIF: Cognitive Level: Application REF: 1778-1880

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

10. When planning the response to the potential use of smallpox as an agent of terrorism, the emergency department (ED) nurse-manager will plan to obtain sufficient quantities of

a.

blood.

b.

vaccine.

c.

atropine.

d.

antibiotics.

ANS: B

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.

DIF: Cognitive Level: Comprehension REF: 1783-1784 TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

11. When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87 F, which assessment indicates that the nurse should discontinue the rewarming?

a.

The patient stops shivering.

b.

The BP decreases to 85/40 mm Hg.

c.

The patient develops atrial fibrillation.

d.

The core temperature is 94 F (34.4 C).

ANS: D

A core temperature of 89.6 F to 93.2 F (32 C 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.

DIF: Cognitive Level: Application REF: 1778-1779

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

12. When assessing a patient admitted to the emergency department (ED) with a broken arm and facial bruises, the nurse notes multiple additional bruises in various stages of healing. Which statement or question by the nurse is most appropriate?

a.

Is someone at home hurting you?

b.

You should not return to your home.

c.

Would you like to see a social worker?

d.

I have to report this abuse to the police.

ANS: A

The nurses initial response should be to further assess the patients situation. Telling the patient not to return home may be an option once further assessment is done. The patient, not the nurse, is responsible for reporting the abuse. A social worker may be appropriate once further assessment is completed.

DIF: Cognitive Level: Application REF: 1782-1783

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

13. A patient arrives in the emergency department (ED) a few hours after taking 20 to 30 acetaminophen (Tylenol) tablets. Which action will the nurse plan to take?

a.

Give N-acetylcysteine (Mucomyst).

b.

Discuss the use of chelation therapy.

c.

Have the patient drink large amounts of water.

d.

Administer oxygen using a non-rebreather mask.

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.

DIF: Cognitive Level: Comprehension REF: 1781-1782 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

14. A triage nurse in a busy emergency department assesses a patient who complains of 6/10 abdominal pain and states, I had a temperature of 104.6 F (40.3 C) at home. The nurses first action should be to

a.

assess the patients current vital signs.

b.

obtain a clean-catch urine for urinalysis.

c.

tell the patient that it may be several hours before being seen by the doctor.

d.

ask the health care provider to order an analgesic medication for the patient.

ANS: A

The patients pain and statement about an elevated temperature indicate that the nurse should obtain vital signs before deciding how rapidly the patient should be seen by the health care provider. A urinalysis may be needed, but vital signs will provide the nurse with the data needed to determine this. The health care provider will not order a medication before assessing the patient.

DIF: Cognitive Level: Application REF: 1770-1771

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

15. The emergency department (ED) triage nurse is assessing four victims of an automobile accident. Which patient has the highest priority for treatment?

a.

A patient with absent pedal pulses

b.

A patient with an open femur fracture

c.

A patient with a sucking chest wound

d.

A patient with bleeding of facial lacerations

ANS: C

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

DIF: Cognitive Level: Application REF: 1768 | 1769-1771

OBJ: Special Questions: Multiple Patients

TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

16. The following actions are part of the routine 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.

Remove the patients rings.

b.

Place ice packs on both hands.

c.

Apply calamine lotion to any itching areas.

d.

Give diphenhydramine (Benadryl) 100 mg PO.

ANS: A

The patients rings should be removed first because it might not be possible to remove them if swelling develops. The other orders also should be implemented as rapidly as possible after the nurse has removed the jewelry.

DIF: Cognitive Level: Application REF: 1779-1781

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

17. 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 diazepam (Valium) tablets. Which action will the nurse plan to take first?

a.

Administer activated charcoal.

b.

Insert a large-bore orogastric tube.

c.

Prepare a 60-mL syringe with saline.

d.

Assist with intubation of the patient.

ANS: D

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.

DIF: Cognitive Level: Application REF: 1781-1782

OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

18. A patient arrives in the emergency department after exposure to radioactive dust. Which action should the nurse take first?

a.

Place the patient in a shower.

b.

Obtain the patients vital signs.

c.

Determine the type of radioactive agent.

d.

Obtain a baseline complete blood count.

ANS: A

The initial action should be to protect staff members and decrease the patients exposure to the radioactive agent by decontamination. The other actions can be done after the decontamination is completed.

DIF: Cognitive Level: Application REF: 1783 | 1785

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

19. An unresponsive 78-year-old is admitted to the emergency department (ED) during a summer heat wave. The patients core temperature is 106.2 F (41.2 C), blood pressure (BP) 86/52, and pulse 102. The nurse initially will plan to

a.

administer an aspirin rectal suppository.

b.

start O2 at 6 L/min with a nasal cannula.

c.

apply wet sheets and a fan to the patient.

d.

infuse lactated Ringers solution at 1000 mL/hr.

ANS: C

The priority intervention is to cool the patient. Antipyretics are not effective in decreasing temperature in heat stroke, and 100% oxygen should be given, which requires a high flow rate 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.

DIF: Cognitive Level: Application REF: 1775-1776

OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

20. When a patient is admitted to the emergency department after a submersion injury, which assessment will the nurse obtain first?

a.

Apical pulse

b.

Lung sounds

c.

Body temperature

d.

Level of consciousness

ANS: B

The priority assessment data are how well the patient is oxygenating, so lung sounds should be assessed first. The other data also will be collected rapidly but are not as essential as the lung sounds.

DIF: Cognitive Level: Application REF: 1770 | 1779

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

21. Following an earthquake, patients are triaged by emergency medical personnel and are transported to the hospital. Which of these patients 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 yellow tag

d.

A patient with a green 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.

DIF: Cognitive Level: Knowledge REF: 1785-1786

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Safe and Effective Care Environment

22. A patients family members are in the patient room when the patient has a cardiac arrest and emergency personnel start resuscitation measures. Which action is best for the nurse to take initially?

a.

Have the family wait outside the patient room with a designated staff member to provide emotional support.

b.

Keep the family in the room and assign a member of the team to explain the care given and answer questions.

c.

Ask the family members about whether they would prefer to remain in the patient room or wait outside the room.

d.

Advise 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 nurses 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.

DIF: Cognitive Level: Application REF: 1771-1772

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Psychosocial Integrity

COMPLETION

1. These four patients arrive in the emergency department after a motor vehicle crash. In which order should they be assessed? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________

a. A 72-year-old with palpitations and chest pain

b. A 45-year-old complaining of 6/10 abdominal pain

c. A 22-year-old with multiple fractures of the face and jaw

d. A 30-year-old with a misaligned right leg with intact pulses

ANS:

C, A, B, D

The highest priority is to assess the 22-year-old patient for airway obstruction, which is the most life-threatening injury. The 72-year-old patient may have chest pain from cardiac ischemia and should be assessed and have diagnostic testing for this pain. The 45-year-old patient may have abdominal trauma or bleeding and should be seen next to assess circulatory status. The 30-year-old appears to have a possible fracture of the right leg and should be seen soon, but this patient has the least life-threatening injury.

DIF: Cognitive Level: Analysis REF: 1768

OBJ: Special Questions: Alternate Item Format, Multiple Patients

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

Leave a Reply