advance nursing review

The nurse is assigned to a telephone triage a client called who was stung by a honeybee and is asking for help the client reports pain in 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?

Removing the stinger by scraping it

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 Deviated trachea

a group of people arrive at the emergency unit by a private car which complaints of preorbital swelling, cough and tightness in the throat. There is a strong odor emanating from their clothes they report exposure to a gas bomb that was set off in the house what are the priority actions (select all that apply?)

Direct clients to the decontamination area

Immediately remove other clients and visitors from the area

Instruct personnel to don personal protective equipment

The nursing manager decides to form a committee to address the issue of violence against ED personnel, which combination of employees would be best suited to fulfill this assignment

at least one representative from each group of ED personnel

a client suffered an amputation of the first and second digits in a chainsaw accident which task is appropriate

wrapping the cleanse digits in saline, moist and gauze, sealing in a plastic container and placing it in ice

a client arrives in the emergency unit and reports that a concentrated household cleaner was splashed in both eyes, which of the following nursing actions is a priority

Flush the eye repeatedly using sterile, normal saline

a client was brought to the emergency department after suffering a closed head injury and lacerations around the face due to a hit-and-run accident. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessment findings if observed after few hours should be reported to the physician immediately?

Drainage of a clear fluid from the client nose

a five-year-old client was admitted to emergency unit due to injection of unknown amount of chewable vitamins for children at an unknown time upon assessment, the child is alert and with no symptoms, which of the following information should be reported to the physician immediately?

The vitamin that was ingested contains iron

The following clients are presented with signs and symptoms of heat related illness, which of them needs to be attended first?

a homeless person who is a poor historian has altered mental status poor muscle coordination and hot, dry action skin and hose duration of heat exposure is unknown

an anxious female client complains of chest tightness, tingling sensations and palpitations, deep rapid breathing, and carpal spasms are noted which of the following priority actions should the nurse do first

Have the client breathe into a brown paper bag

A Intoxicated client comes into the emergency unit with uncooperative behavior, mild confusion with slurred speech the client is unable to provide a good history, but he verbalizes that he has been drinking a lot. Which of the following is a priority action of the nurse.

administer IV fluids Incorporated with vitamin B1 one is ordered

in the work setting what is the priority responsibility of the nurse in preparation for disaster management that includes natural disasters and bioterrorism incidents?

being aware of the agencies emergency response plan

The nurse is assessing a client who lost a large volume of blood from a laceration, which finding would indicate that the client is in shock

Rapid thready pulse

Which action is a priority for the nurse to take for a client with second-degree burns who has singed and sooty nasal hair

Monitor respiratory status

The nurse is caringfor a client who is bleeding from the radial artery and has lost a large volume of blood. The nurse is applying pressure to the radial artery and has the arm elevated, but the wound continues to bleed. What should the nurse do next?

apply pressure to the brachial artery

a client is a victim of a stab wound to the abdomen he has bow loops protruding through the abdominal wall, the nurse should first

Cover the exposed intestines with sailine soaked gauze

a nurse arrived on the scene of a motor vehicle accident. She finds a driver unconscious and bleeding from a head wound the nurses first action should be?

Ensure the patient has a patent airway

a 24 year-old client enters the ED with a screwdriver protruding from his left flank. The nurse should.

Tether the screwdriver in place to eliminate shifting

a man comes to the ED with complaints of food poisoning after a picnic that afternoon which food was the probable cause of his problem

tuna salad

a client is seen in the ED with an open sucking chest wound from a stray bullet that hit her the first action the nurse should take is

Put a flutter gauze dressing on the wound

The client comes into the ED after a motor vehicle accident where he was not wearing his seatbelt the client’s exhibiting paradoxical breathing. The nurse knows that this is a unique pattern of breathing associated with

Fail chest

a 38-year-old male patient presents to the ED after collapsing at a marathon. He has an oral temperature of 103.6. The nurse should

Encourage him to drink, cold sips, and place him near a fan

The nurse is working as a triage nurse during a disaster situation. Based on the triage color code tag placed on each of the wounded which color represents the wounded who of the highest priority of being treated first.

Red

Well triage in the wound from a disaster the nurse noticed that one of the wound is not breathing radio pulse is absent and capillary refill is 2 seconds and does not respond to the nurses commands. What color tag is assigned

Black

The wounded victim is unable to walk as a respiratory rate of 19 capillary refill of one second and able to obey your commands, the wounded victim is assigned what tag color?

Yellow