RNSG 2514 Exam 5 - COMPLETED

A victim of a house fire is brought to the emergency department for burn treatment. What assessment finding indicates that the patient may have an inhalation injury?

1) Coughing

2) Soot on the face

3) Singed facial hair

4) Heart rate 98 bpm

3) Singed facial hair

FEEDBACK: Patients with an inhalation injury may present with singed facial hair.

The nurse is caring for a patient with 50% total body surface area burns. Which finding indicates that burn shock is resolving?

1) Heart rate 112 bpm

2) Respirations 24 per minute

3) Blood pressure 90/60 mm Hg

4) Urine output 800 mL over 2 hours

4) Urine output 800 mL over 2 hours

FEEDBACK: In the postburn shock phase, which begins 24 to 48 hours after injury, the capillaries begin to regain integrity. Burn shock slowly begins to resolve, and the fluid gradually returns to the intravascular space. Urinary output continues to increase secondary to patient diuresis.

A victim of a car fire is confused, dizzy, and nauseated. What diagnostic test should be done to determine if this patient is experiencing carbon monoxide poisoning?

1) Chest x-ray

2) Bronchoscopy

3) Pulse oximeter

4) Carboxyhemoglobin level

4) Carboxyhemoglobin level

FEEDBACK: Because carbon monoxide binds to the hemoglobin molecule with an affinity 200 times greater than that of oxygen, tissue hypoxia results when carbon monoxide levels are above normal. Carboxyhemoglobin levels will detect the amount of carbon monoxide in the patient.

A patient is admitted for a suspected inhalation injury. What should the nurse emphasize when caring for this patient?

1) Increase oral fluids

2) Turn in bed every two hours

3) Monitor strict intake and output

4) Deep breathing and coughing every hour

4) Deep breathing and coughing every hour

FEEDDBACK: Deep breathing and coughing should be done every hour to assist with airway clearance

and mobilization of secretions.

The nurse is caring for a patient who sustained electrical burns. Why should the nurse monitor this patient for compartment syndrome?

1) Potential for undiagnosed injuries

2) Injuries from being thrown bruise soft tissue

3) Electrical current alters integrity of blood vessels

4) Fluid seeps from intravascular spaces into the interstitium

4) Fluid seeps from intravascular spaces into the interstitium

FEEDBACK: Pulses are closely monitored in all affected extremities for the first 48 hours postinjury in order to assess for the potential development of compartment syndrome. As fluid seeps from the intravascular spaces into the interstitium, pressure within the tissues continues to rise and confines swelling inside muscle compartments.

The nurse is preparing an educational tool to instruct community members on burn prevention. What should the nurse include as the most common injury in children under age 5?

1) Scald

2) Flame

3) Chemical

4) Carbon monoxide poisoning

1) Scald

FEEDBACK: Scald injuries are most prevalent in children under the age of 5.

A patient with 55% total body surface area burned received two-thirds of the required fluid resuscitation. For which potential problem should the nurse prepare to provide care to this patient?

1) Increased zone of stasis

2) Increased zone of hyperemia

3) Increased zone of coagulation

4) Decreased zone of coagulation

3) Increased zone of coagulation

FEEDBACK: The zone of stasis immediately surrounds the zone of coagulation and is characterized by damaged cells and impaired circulation. It is this area of the burn that is most at risk

for conversion if the patient does not receive adequate Resuscitation. Improper resuscitation or under-resuscitation may cause the burn to become deeper because of limited blood flow, causing the zone of stasis to convert into the zone of coagulation.

A patient comes into the emergency room seeking treatment for radiation burns. What should be considered prior to providing care to this patient?

1) Pathway of flow through the body

2) Duration of contact with the agent

3) Type, dose, and length of exposure

4) Temperature to which the skin is heated

3) Type, dose, and length of exposure

FEEDBACK: The severity of a radiation burn is dependent upon the type, dose, and length of exposure.

It is documented that a patient has superficial partial-thickness burns over both anterior lower arms. What should the nurse expect when assessing this patient?

1) Dry with no blisters

2) Waxy appearance and cherry red in color

3) Dry leathery appearance and pale or brown in color

4) Open or closed blisters, mild edema, easily blanches

4) Open or closed blisters, mild edema, easily blanches

FEEDBACK: A superficial partial-thickness burn has blisters that may be closed or open and weeping; pink or red; mild edema; and blanches easily.

A patient has full-thickness burns over 30% of total body surface area. Which intervention will least likely provide comfort initially to this patient?

1) Elevate injured extremities

2) Medicate for pain around the clock

3) Apply medicated ointment to all areas

4) Elevate the head of the bed 30 degrees

2) Medicate for pain around the clock

FEEDBACK: A full-thickness burn involves destruction of the epidermis, the dermis, and portions of the subcutaneous tissue. All epidermal and dermal structures are destroyed including hair follicles, sweat glands, and nerve endings. As a result of the extensive damage to the nerve endings, full-thickness burns are insensate to palpation and often are not painful. Pain medication would be least likely to provide comfort to this patient initially.

A patient with several deep partial-thickness burns asks how long it will take for the burn to heal. What should the nurse respond to this patient?

1) "More than two weeks."

2) "Within one to two weeks."

3) "Within 24 to 72 hours."

4) "You will need skin grafts."

1) "More than two weeks."

FEEDBACK: The majority of deep partial-thickness burns take more than two weeks to heal.

The nurse is assisting with the secondary survey of a patient with 50% total body surface area electrical burns. Which test would be a priority for this patient?

1) Chest x-ray

2) Bronchoscopy

3) CT scan of the head

4) 12-lead electrocardiogram

4) 12-lead electrocardiogram

FEEDBACK: A 12-lead electrocardiogram is indicated for an electrical injury.

The nurse is caring for a patient with 45% total body surface area thermal burns. Which laboratory value change would be expected?

1) Increased pH

2) Increased sodium

3) Increased potassium

4) Decreased hematocrit

3) Increased potassium

FEEDBACK: Hyperkalemia is expected because of massive cellular trauma causing the release of potassium into extracellular fluid.

A patient recovering from deep and full thickness burns is nauseated. Which medication should the nurse provide to help this patient?

1) Ranitidine (Zantac)

2) Esomeprazole (Nexium)

3) Metoclopramide (Reglan)

4) Polyethylene glycol (Miralax)

3) Metoclopramide (Reglan)

FEEDBACK: Metoclopramide (Reglan) promotes stomach emptying and decreases nausea.

The nurse is evaluating care provided to a patient with burns during the emergent phase. Which data indicates that additional fluid resuscitation is required?

1) Blood pH 7.39

2) Heart rate 112 bpm

3) Blood pressure 110/60 mm Hg

4) Central venous pressure 2 mm Hg

4) Central venous pressure 2 mm Hg

FEEDBACK: Indications of adequate fluid resuscitation include a central venous pressure between 5- 10 mm Hg. A pressure of 2 mm Hg indicates fluid volume deficit. More fluid would be indicated.

A patient with deep partial-thickness wounds is receiving enzymatic debridement. What assessment made by the nurse would indicate that wound care treatment has been successful?

1) Gray wound bed

2) Separation of eschar

3) Development of eschar

4) Presence of purulent exudate

2) Separation of eschar

FEEDBACK: Enzymatic debridement involves the application of a proteolytic ointment that hastens eschar separation.

A patient recovering from full-thickness burns rates pain as a 9 on a scale of 0 to 10 when hydrotherapy is performed. For which type of pain should this patient be treated?

1) Referred

2) Procedural

3) Background

4) Breakthrough

2) Procedural

FEEDBACK: Procedural pain is associated with therapeutic activities such as wound care and physical therapy.

The nurse is caring for a patient with 70% total body surface area chemical burns. Which approach should the nurse anticipate to meet this patient's nutritional needs?

1) Parenteral nutrition

2) Duodenal tube feedings

3) Nasogastric tube feedings

4) Six small high-calorie meals per day

2) Duodenal tube feedings

FEEDBACK: In large burn injuries, longer nutritional support is required, and placement of a duodenal feeding tube is often recommended to help prevent aspiration and allow for feeding up to and during procedures.

A patient recovering from 25% total body surface area burns has a low-grade fever. What should the nurse do to reduce this patient's risk of developing an infection?

1) Follow contact precautions

2) Implement protective isolation

3) Use sterile technique for all dressing changes

4) Administer prophylactic antibiotics as prescribed

1) Follow contact precautions

FEEDBACK: Cross-contamination among burn patients is common, and as a result, isolation guidelines are widespread practices among burn centers. Contact precautions may be used when entering all patient rooms.

The nurse is evaluating nutritional teaching provided to a patient recovering from 24% total body surface area burns. Which information indicates that teaching has been effective?

1) Weight loss 3 kg

2) Serum protein level 7.1 g/dL

3) Serum albumin level 2.8 g/dL

4) +1 pitting edema of lower extremities

2) Serum protein level 7.1 g/dL

FEEDBACK: A normal serum protein level is 6.4 to 8.3 g/dL.

A patient with 35% total body surface area burns is in the rehabilitative phase of care. Which approach should be used to reduce the risk of developing contractures?

1) Apply splints

2) Physical therapy two hours a day

3) Passive range of motion exercises

4) Occupational therapy one hour every other day

1) Apply splints

FEEDBACK: Splinting is the most common method used to help prevent the formation of contractures.

A patient is ending the first year of recovery after having burns to both legs. Which observation indicates that the patient needs to be encouraged to wear the pressure garment?

1) Skin warm and moist

2) Pedal pulses present but faint

3) Scattered areas of scarring noted

4) Nonpitting edema of both ankles

3) Scattered areas of scarring noted

FEEDBACK: Specialty pressure garments are intended to provide continuous and uniform pressure over the area of burn to prevent hypertrophic scarring. These garments are to be worn 23 hours a day for up to a year or more after injury in some patients. The presence of scarring indicates the garment has not been worn consistently.

An 11-year-old child received burns over both upper and lower arms, both hands, anterior upper and lower legs, anterior chest, and the neck. Using the following as a guide, what is this child's total body surface area burned?

1) 30 %

2) 42 %

3) 57 %

4) 65 %

4) 65 %

FEEDBACK: Select the percentage burn column for 10-14-year-old. The neck is 2; the anterior trunk is 13; the right upper arm is 4; the right lower arm is 3; the left upper arm is 4; the left lower arm is 3; the right hand is 2.5; the left hand is 2.5; the right thigh is 9; the left thigh is 9; the right lower leg is 6.5; and the left lower leg is 6.5. The total body surface area burned is 65%. The other answer choices are miscalculations or incorrect use of the graphic provided.

The nurse is caring for a patient who sustained chemical burns. What would have caused these injuries? Select all that apply.

1) Lime

2) Gasoline

3) Bleach

4) Fabric softener

5) Hydrofluoric acid

1) Lime

2) Gasoline

3) Bleach

5) Hydrofluoric acid

FEEDBACK:

1. Lime can cause a chemical burn.

2. Gasoline can cause a chemical burn.

3. Bleach can cause a chemical burn.

4. Fabric softener is not identified as causing a chemical burn.

5. Hydrofluoric acid can cause a chemical burn.

The school nurse is preparing material for National Fire Prevention week. What information should be added to the classroom posters? Select all that apply.

1) Never leave a burning candle unattended.

2) Set heating pads on "low" when sleeping.

3) Keep a flashlight and telephone near the bed.

4) Check smoke alarm batteries every six months.

5) Never use the oven as a method to warm the home.

1) Never leave a burning candle unattended.

3) Keep a flashlight and telephone near the bed.

4) Check smoke alarm batteries every six months.

5) Never use the oven as a method to warm the home.

FEEDBACK:

1. To prevent fires, never leave a burning candle unattended.

2. To prevent fires, never use a heating pad during sleep.

3. To respond to a fire, keep a flashlight and telephone near the bed.

4. To prevent fires, check smoke alarm batteries every 6 months.

5. To prevent fires, never use the oven as a method to warm the home.

A patient is diagnosed with several superficial partial-thickness burns. What treatment would be indicated for this patient? Select all that apply.

1) Apply bacitracin ointment

2) Cover with a nonadherent bandage

3) Apply mafenide acetate 10% cream

4) Wash with antiseptic soap and warm water

5) Apply collagenase and cover with roll gauze

1) Apply bacitracin ointment

2) Cover with a nonadherent bandage

4) Wash with antiseptic soap and warm water

FEEDBACK:

1. Care of a superficial partial-thickness burn includes applying bacitracin ointment.

2. Care of a superficial partial-thickness burn includes covering with nonadherent bandage.

3. Mafenide acetate 10% cream is used to treat full-thickness burns.

4. A superficial partial-thickness burn is to be washed with antiseptic soap and warm water.

5. An enzymatic cream like collagenase is used for full-thickness burn wound care.

A patient has been recovering for 18 months from burns that affected 60% total body surface area. For which problems should the nurse anticipate providing continuing care to this patient? Select all that apply.

1) Anxiety

2) Depression

3) Spiritual distress

4) Body image disorder

5) Post-traumatic stress disorder (PTSD)

1) Anxiety

2) Depression

4) Body image disorder

5) Post-traumatic stress disorder (PTSD)

FEEDBACK:

1. The burn patient may endure many psychological and emotional challenges throughout his or

her lengthy course of treatment and recovery. The patient may experience anxiety.

2. The burn patient may endure many psychological and emotional challenges throughout his or

her lengthy course of treatment and recovery. The patient may experience depression.

3. Spiritual distress is not specifically identified as a potential problem for a patient recovering

from burns.

4. The burn patient may endure many psychological and emotional challenges throughout his or

her lengthy course of treatment and recovery. The patient may experience body image

disorder.

5. The burn patient may endure many psychological and emotional challenges throughout his or

her lengthy course of treatment and recovery. The patient may experience post-traumatic

stress disorder (PTSD).

A patient weighing 187 lbs. has 38% total body surface area burns. Using the Parkland formula, how much fluid should this patient receive over the first eight hours after the burn occurred? Record your answer as a whole number.

6460 mL

FEEDBACK:

First calculate the patient's weight in kg by dividing the weight in lbs. by 2.2 or 187/2.2 = 85 kg. Next use the formula 4 mL x kg of body weight x TBSA % to calculate the total fluid amount needed. For this patient that would be 4 mL x 85 x 38 = 12,920 mL. Since one-half of the total fluid amount should be provided in the first 8 hours, divide the total amount of fluid by 2 or 12,920/2 = 6460 mL. The patient should receive 6460 mL of fluid in the first 8 hours after the burn injury.

A patient is recovering from surgery to repair a third-degree strain. What needs to be emphasized to the patient about postoperative care?

1) Elevate the extremity

2) Rest the extremity for up to 72 hours

3) Apply ice to the area three to five times day

4) Immobilize the extremity for four to six weeks

4) Immobilize the extremity for four to six weeks

FEEDBACK: Postoperative treatment forstrains and sprainsinvolves immobilization of the affected

extremity for four to six weeks.

A patient is treated for a second-degree sprain. Which patient statement indicates that teaching about care has been ineffective?

1) "I should apply ice."

2) "I should elevate my leg."

3) "I should expect the leg to feel numb."

4) "I should take pain medication as directed."

3) "I should expect the leg to feel numb."

FEEDBACK: Numbness could indicate neurovascular compromise and should be reported.

A 70-year-old patient is diagnosed with a low energy fracture. What most likely caused this injury to occur?

1) A fall

2) Contact sport

3) Bicycle accident

4) Motor vehicle collision

1) A fall

FEEDBACK: Fractures in people 65 or older are generally caused by low-energy trauma such as falls.

A patient has an injury where one side of the bone is bent and the other is fractured. How should the nurse document this fracture?

1) Spiral

2) Oblique

3) Greenstick

4) Comminuted

3) Greenstick

FEEDBACK: A greenstick fracture is an incomplete disruption where one side of the bone is bent and

the other is fractured.

A patient with Paget's disease is demonstrating manifestations of a fracture. What diagnostic test should be ordered to confirm if a fracture has occurred?

1) X-ray

2) Bone scan

3) Myelogram

4) Angiogram

2) Bone scan

FEEDBACK: If a chronic illness is suspected as having a major role in the injury, a bone scan may be

needed to confirm the diagnosis.

While playing tennis a patient fell and fractured the right elbow. For which treatment should the nurse prepare this patient?

1) Cast

2) Splint

3) External fixator

4) Pressure dressing

1) Cast

FEEDBACK: An elbow fracture is immobilized with a cast.

A patient recovering from surgery to repair a fractured femur is experiencing extreme pain and pulselessness. What should the nurse expect to be prescribed for this patient?

1) Fasciotomy

2) Limb CT scan

3) Intravenous fluids

4) Anticoagulant therapy

1) Fasciotomy

FEEDBACK: Once compartment syndrome is suspected, the provider will often remove the cast or perform a fasciotomy to immediately relieve the compartment pressure.

A patient recovering from surgery to repair a fractured hip is placed on skin traction. Which finding indicates that the traction is being effective?

1) Strong peripheral pulses

2) Reduction in muscle spasms

3) Improved mobility of the foot

4) Reduction of lower extremity edema

2) Reduction in muscle spasms

FEEDBACK: Skin traction is applied to relieve muscle spasms.

A patient with peripheral vascular disease has a non-healing leg wound. Which observation indicates that the patient is at risk for an elective amputation?

1) Mutilation of soft tissue

2) Development of gangrene

3) Crushed lower extremity bone

4) Severed blood vessels and nerves

2) Development of gangrene

FEEDBACK: Elective amputations are caused by disease that alters perfusion. Cell death causes necrotic tissue to form. The wound acts as a portal for an infection that can lead to gangrene.

A patient recovering from a traumatic amputation is experiencing phantom limb pain. What should the nurse expect to be included in the treatment plan for this patient?

1) Gabapentin

2) Rigid splint

3) Ice compresses

4) Elevate stump on a pillow

1) Gabapentin

FEEDBACK: The administration of antidepressant and anticonvulsant medications such as gabapentin has demonstrated effectiveness in treating phantom limb pain.

During a home visit the nurse suspects that a patient recovering from an amputation is not complying with prescribed postoperative care. What observation caused the nurse to make this clinical determination?

1) Suture line pink and slightly edematous

2) Evidence of a developing hip contracture

3) Stump wrapped with a compression bandage

4) Taking opioid medication every 8 to 10 hours

2) Evidence of a developing hip contracture

FEEDBACK: A developing hip contracture indicates that the patient is not complying with postoperative exercises and actions to prevent the development of a contracture.

A patient seeks medical treatment for a meniscus injury. What assessment finding would suggest a reason this injury occurred?

1) History of chronic joint disease

2) Participation in cycling or golf

3) Intake of sufficient water and protein

4) Use of nonsteroidal anti-inflammatory drugs (NSAIDs)

1) History of chronic joint disease

FEEDBACK: Chronic joint diseases are risk factors for a meniscus injury.

A patient sustained a meniscus injury several months ago and did not seek medical attention. What is this patient at risk of developing?

1) Tendonitis

2) Fractured patella

3) Dependent edema

4) Permanent joint damage

4) Permanent joint damage

FEEDBACK: If left untreated, meniscus tears can lead to permanent joint damage.

The nurse suspects that while playing basketball a patient sustained a meniscus tear. What information did the nurse use to make this decision?

1) Knee pops when bent

2) Weak peripheral pulses

3) Reduced muscle tone of the thigh

4) Calf cramping with the knees bent

1) Knee pops when bent

FEEDBACK: The diagnosis of meniscus injuries is based upon physical examination using either the McMurray's or Steinman's test in which the knee is supported and flexed while the lower leg is rotated internally and externally. A positive result is indicated when either test reveals an audible/palpable "click."

The nurse notes that a patient recovering from surgery to repair a torn meniscus has a blood pressure of 158/90 mm Hg. This finding would suggest that the nurse also assess the patient for which condition?

1) Pain

2) Edema

3) Infection

4) Hemorrhage

1) Pain

FEEDBACK: Hypertension may indicate increased pain.

The nurse is preparing a teaching tool for a community health program. What should the nurse include as a risk factor for the development of carpal tunnel syndrome (CTS)?

1) Male gender

2) Age less than 20

3) Plays musical instruments

4) Works as a marketing manager

3) Plays musical instruments

FEEDBACK: Higher occurrences are noted in patients who have jobs requiring repetitive motions of the hands such as musicians.

The nurse suspects that a patient is developing carpal tunnel syndrome (CTS). What finding caused the nurse to make this clinical determination?

1) Reduced radial pulses

2) Fingers cool to touch

3) Capillary refill > 3 seconds

4) Hand tingling during the night

4) Hand tingling during the night

FEEDBACK: In CTS inflammation compresses the median nerve causing sharp pain, numbness, and tingling of the hand. Symptoms initially occur intermittently at night, then progress if not treated.

A patient with bilateral carpal tunnel syndrome (CTS) does not want to have surgery. What is this patient at risk for developing?

1) Infection

2) Chronic pain

3) Further nerve injury

4) Hematoma formation

2) Chronic pain

FEEDBACK: Untreated CTS can lead to chronic pain.

The nurse requests an occupational therapy consultation for a patient with bilateral carpal tunnel syndrome. What is the reason for this consultation?

1) Evaluate the work area

2) Instruct on hand exercises

3) Instruct on the use of splints

4) Review the action of NSAIDs

1) Evaluate the work area

FEEDBACK: An occupational therapist can evaluate the work area and make recommendations for modifications to eliminate causative factors.

The nurse is reviewing postoperative instructions with a patient recovering from carpal tunnel syndrome (CTS) surgery. Which statement indicates that additional teaching would be required?

1) "I should take the pain medication as prescribed."

2) "I should expect my hand to feel numb for a few weeks."

3) "I should perform hand exercises as directed by the therapist."

4) "I should stop any activity that causes hand numbness or pain."

2) "I should expect my hand to feel numb for a few weeks."

FEEDBACK: The patient should report any worsening symptoms to the health-care provider.

The nurse is reviewing statistics about the frequency of anterior cruciate ligament (ACL) tears. What increases the risk of experiencing this type of injury? Select all that apply.

1) Knee torque

2) Less knee flexibility

3) Practicing ice skating

4) Performing gymnastics

5) Less muscular strength

1) Knee torque

2) Less knee flexibility

4) Performing gymnastics

5) Less muscular strength

FEEDBACK:

1. A great degree of knee torque increases the risk of an ACL injury.

2. Less knee flexibility increases the risk of an ACL injury.

3. The frequency of ankle sprains can be ranked highest among the sport of ice skating.

4. An ACL injury occurs most frequently in sports that involve twisting and jumping like gymnastics.

5. Less muscular strength increases the risk for an ACL injury.

A patient is diagnosed with a third-degree sprain. What should the nurse expect to assess in this patient? Select all that apply.

1) Edema

2) Severe pain

3) Ecchymosis

4) Inability to ambulate

5) Altered ability to ambulate

1) Edema

2) Severe pain

3) Ecchymosis

4) Inability to ambulate

FEEDBACK:

1. Symptoms of a third-degree sprain include edema.

2. Symptoms of a third-degree sprain include severe pain.

3. Symptoms of a third-degree sprain include ecchymosis.

4. Third-degree or severe sprains include the complete tearing of a ligament, which renders the patient unable to ambulate because of joint instability.

5. Symptoms of a second-degree sprain include an altered ability to ambulate.

The nurse suspects that a patient with an injured ankle is experiencing neurovascular compromise. What did the nurse assess to come to this conclusion? Select all that apply.

1) Pain

2) Pressure

3) Paralysis

4) Peristalsis

5) Pulselessness

1) Pain

2) Pressure

3) Paralysis

5) Pulselessness

FEEDBACK:

1. Symptoms of neurovascular compromise include pain.

2. Symptoms of neurovascular compromise include pressure.

3. Symptoms of neurovascular compromise include paralysis.

4. Peristalsis is not a symptom of neurovascular compromise.

5. Symptoms of neurovascular compromise include pulselessness.

A victim of a motor vehicle crash has a partially severed lowered extremity. What emergency care does this patient need? Select all that apply.

1) Administer antibiotics

2) Prepare for blood transfusions

3) Prepare for emergency surgery

4) Assess for active hemorrhaging

5) Monitor effectiveness of tourniquet

2) Prepare for blood transfusions

3) Prepare for emergency surgery

4) Assess for active hemorrhaging

5) Monitor effectiveness of tourniquet

FEEBACK:

1. Antibiotics are not part of emergency care for a traumatic amputation.

2. To prevent hemorrhagic shock after a traumatic amputation, the patient should be prepared for blood transfusions.

3. The patient with a traumatic amputation should be prepared for emergency surgery.

4. The patient with a traumatic amputation should be assessed for active hemorrhaging.

5. The tourniquet or pressure bandage placed over the site of a traumatic amputation should be assessed for effectiveness.

A patient is diagnosed with a small meniscus tear of the right knee. What should the nurse expect to be prescribed for this patient? Select all that apply.

1) Ice

2) Limited rest

3) Physical therapy for a month

4) Total immobility for several weeks

5) Use of nonsteroidal anti-inflammatory drugs (NSAIDs)

1) Ice

2) Limited rest

5) Use of nonsteroidal anti-inflammatory drugs (NSAIDs)

FEEDBACK:

1. Smaller tears often heal within a few months and are treated with ice.

2. Smaller tears often heal within a few months and are treated with limited rest.

3. Physical therapy would be indicated for a larger meniscus tear requiring surgery.

4. Total immobility and resting of the affected joint is not recommended because it may cause muscle atrophy, stiffness, and further movement problems.

5. Smaller tears often heal within a few months and are treated with NSAIDs.

What should the nurse do to assist a patient brought to the emergency department as a victim of a gunshot wound?

1) Ask the patient who shot him

2) Bathe the patient and provide a clean gown

3) Ask the patient where the weapon is

4) Preserve the chain of evidence

4) Preserve the chain of evidence

FEEDBACK: Because the majority of gunshot wounds require an investigation by law enforcement, nurses working in emergency departments and trauma centers should be familiar with their agency's protocols for maintaining evidence required by law enforcement. Often, law enforcement does not want the victim's hands or the area around the victim's wounds cleansed. Clothes and personal items are often wanted as evidence. The nurse should not bathe the patient and provide a clean gown. The nurse should not ask the patient who shot him or where the weapon is. The nurse should preserve the chain of evidence.

A patient is brought into the emergency department after being assaulted. It is suspected that the patient has a spinal cord injury. Which diagnostic test does the nurse anticipate based on the data collected?

1) Computed tomography (CT) scan

2) X-ray

3) Ultrasound

4) Magnetic resonance imaging (MRI)

4) Magnetic resonance imaging (MRI)

FEEDBACK: An MRI will be performed if there is a risk for spinal cord injuries, injuries to the

muscles, or abdominal injuries.

A patient recovering from a motor vehicle crash develops hypotension and jugular distension with a tracheal deviation. Based on this data, which should the nurse suspect occurred?

1) Hemorrhage

2) Compensatory shock

3) Hypovolemic shock

4) Tension pneumothorax

4) Tension pneumothorax

FEEDBACK: A tension pneumothorax is life threatening and requires immediate intervention. On inspiration, air enters the pleural space, does not escape on expiration, and increases the intrapleural pressure. This pressure collapses the injured lung and shifts the mediastinal contents, compressing the heart, great vessels, trachea, and eventually the uninjured lung.

Which observation indicates that interventions provided to a patient with neck injuries from a motor vehicle crash have been successful?

1) Urine is clear and odorless from indwelling catheter

2) Moves all four extremities independently, feeds self, and participates in partial bath

3) Unable to move independently in bed

4) Rests in bed with lights and television turned off

2) Moves all four extremities independently, feeds self, and participates in partial bath

FEEDBACK: The patient sustained neck injuries from a motor vehicle accident. With these types of injuries, there is a risk for paralysis. Evidence that interventions have been successful for this patient includes moving all four extremities independently, feeding self, and participating in partial bath care. This means the patient has mobility, which is a successful outcome.

Which intervention would be a priority when providing care to a patient recovering from thoracic injuries sustained from a motor vehicle crash?

1) Monitor urine output

2) Assess vital signs

3) Perform passive range of motion to all extremities

4) Assist to deep breathe and cough every two hours

4) Assist to deep breathe and cough every two hours

FEEDBACK: The patient has thoracic injuries and might be reluctant to deep breathe and cough because of pain. The nurse needs to ensure that the patient breathes deeply and coughs every two hours to mobilize secretions and prevent respiratory complications.

A nurse is developing a plan of care for a patient with traumatic injuries from a motor vehicle crash. Which nursing intervention does the nurse include in the plan of care to reduce the risk of integumentary complications?

1) Provide active or passive exercises at least once every eight hours

2) Encourage coughing, deep breathing, and incentive spirometry

3) Assist the patient in turning at least every two hours

4) Assist the patient in turning at least every eight hours

3) Assist the patient in turning at least every two hours

FEEDBACK: Assisting the patient to turn at least every two hours is the most appropriate intervention for the nurse to include in the plan of care to reduce the risk of integumentary complications.

Which assessment data indicates the patient is experiencing a late symptom associated with chronic aspirin overdose?

1) Emesis

2) Nausea

3) Tinnitus

4) Ecchymosis

4) Ecchymosis

FEEDBACK: Ecchymosis is a late symptom associated with a chronic aspirin overdose.

The emergency department nurse is triaging patients. Which patient should be prioritized?

1) An adult patient experiencing mild chest pain

2) An adolescent patient with a possible fractured wrist

3) An older adult patient with a hip fracture who is in pain

4) A school-age patient with asthma presenting with dyspnea

4) A school-age patient with asthma presenting with dyspnea

FEEDBACK: According to the Five-Level Emergency Severity Index (ESI), a patient experiencing severe respiratory distress such as the school age patient with asthma who is having difficulty breathing (dyspnea) would receive priority care as an ESI-1.

The registered nurse (RN) is the team leader for a group of patients using the functional model of nursing. The team of nurses includes two licensed practical nurses (LPNs) and an unlicensed assistive personnel (UAP). Which task will the RN delegate to the UAP?

1) Taking vital signs

2) Providing wound care

3) Conducting discharge teaching

4) Administering oral medications

1) Taking vital signs

FEEDBACK: When working in an environment that uses the functional model of nursing, each team member will be delegated tasks for a group of patients by the team leader, the RN. The RN will delegate taking vital signs to the UAP.

A medical-surgical unit is expecting a large volume of patient admissions after a train derailment. Which member of the nursing care team will prioritize care for the unit?

1) Charge nurse

2) Nurse supervisor

3) Licensed practical nurse

4) Unlicensed assistive personnel

1) Charge nurse

FEEDBACK: A charge nurse coordinates care and assignments and may ultimately be the only person familiar with all the needs of any individual patient; therefore, it is this member of the team that will prioritize care for the patients who are being admitted.

Which is a potentially life-threatening condition found during the primary triage survey that would necessitate priority nursing care?

1) Cystitis

2) Concussion

3) Lacerated arm

4) Fractured femur

2) Concussion

FEEDBACK: A concussion, which is a type of head injury, is a potentially life-threatening condition found during the primary triage survey that would necessitate priority nursing care.

Which nursing action is appropriate when conducting a secondary survey during the emergency assessment?

1) Maintaining privacy

2) Having suction available

3) Giving supplemental oxygen

4) Assigning a nurse to support family members

4) Assigning a nurse to support family members

FEEDBACK: A nursing action that is appropriate during the secondary survey is assigning a nurse, or other team member, to support family members.

Which member of the health-care team, when using the team nursing approach, is responsible for prioritizing patient care?

1) Team leader

2) Charge nurse

3) Licensed practical nurse

4) Unlicensed assistive personnel

1) Team leader

FEEDBACK: When using the team nursing approach, the team leader, who is a registered nurse, is responsible for coordinating a group of licensed and unlicensed personnel to provide patient care to a small group of patients, including the prioritization of patient care.

The nurse is conducting a primary survey during the emergency assessment. Which nursing action is appropriate during the breathing assessment?

1) Assessing for edema

2) Counting respiratory rate

3) Checking for foreign bodies

4) Monitoring for respiratory distress

2) Counting respiratory rate

FEEDBACK: Counting the respiratory rate is a nursing action appropriate during the breathing assessment.

The nurse is conducting a primary survey during an emergency assessment. Which is the priority nursing action related to breathing in response to this assessment?

1) Having suction available

2) Assessing pupil size and reactivity

3) Immobilizing any obvious deformities

4) Obtaining blood samples for type and crossmatch

1) Having suction available

FEEDBACK: The priority nursing actions related to breathing when conducting a primary survey during an emergency assessment include having suction available and giving supplemental oxygen.

The nurse is conducting a secondary survey as part of the emergency assessment. Which is the priority nursing action during the health history portion of the assessment?

1) Determining drug allergies

2) Noting the general appearance

3) Examining the neck for stiffness

4) Auscultating for heart and lung sounds

1) Determining drug allergies

FEEDBACK: The priority nursing action during the health history portion of the assessment is to determine drug allergies.

Which is the essential nursing skill for the triage process in the emergency department?

1) Evaluating care

2) Setting priorities

3) Formulating diagnoses

4) Implementing interventions

2) Setting priorities

FEEDBACK: Setting priorities is an essential nursing skill for the triage, or assessment, process that occurs in the emergency department.

The nurse is providing care to several patients in the emergency department. Which patient would require priority care from the nurse?

1) An adult patient with an ankle sprain

2) An infant with a rash of unknown origin

3) An adult patient with unstable vital signs and chest pain

4) A pediatric patient with multiple fractures following a motor vehicle accident

3) An adult patient with unstable vital signs and chest pain

FEEDBACK: An adult patient with unstable vital signs would receive priority care based on the three- tiered triage system due to emergent, or life-threatening, injury.

The nurse is providing care to several patients in the emergency department. Which patient is the priority when using the three-tiered triage system?

1) A patient with a simple fracture

2) A patient experiencing renal colic

3) A patient with severe abdominal pain

4) A patient with chest pain and diaphoresis

4) A patient with chest pain and diaphoresis

FEEDBACK: The patient with chest pain and diaphoresis is classified as emergent and would require priority care.

Which are the priority nursing actions after the completion of the secondary survey when providing care for a trauma patient with a penetrating wound?

1) Documenting the patient's care

2) Formulating the patient's plan of care

3) Reassessing the patient's level of consciousness

4) Transferring the patient to the general medical unit

1) Documenting the patient's care

FEEDBACK: The priority nursing actions after completion of the secondary survey during the emergency assessment include documenting all patient care and administering tetanus prophylaxis.

Which is the priority nursing action when providing care to a patient with a penetrating abdominal wound?

1) Assessing bowel sounds

2) Stabilizing the impaled object

3) Administering prescribed pain medication

4) Scheduling a CT scan to determine retroperitoneal bleeding

2) Stabilizing the impaled object

FEEDBACK: The priority nursing action when providing care to a patient with a penetrating abdominal wound is to stabilize the impaled object to prevent further injury.

Which treatment should the nurse prepare to administer when providing care to a toddler who presents after an accidental overdose of aspirin?

1) Gastric lavage

2) Activated charcoal

3) Peritoneal dialysis

4) Vitamin D injection

2) Activated charcoal

FEEDBACK: The nurse would prepare to administer activated charcoal to the client and repeat every four hours, if needed, for a client with active bowel sounds.

Which assessment data related to the patient's airway would indicate the need for priority intervention by the nurse?

1) Eupnea

2) Tachycardia

3) Hypotension

4) Agonal breaths

4) Agonal breaths

FEEDBACK: Dyspnea, agonal breaths, and an inability to speak are all assessment data that indicate a compromised airway and the need for priority intervention by the nurse.

Which nursing actions are appropriate during the primary survey of the emergency assessment process? Select all that apply.

1) Inserting a nasogastric tube

2) Immobilizing the cervical spine

3) Arranging for diagnostic studies

4) Preparing for chest tube insertion

5) Applying direct pressure to a wound

2) Immobilizing the cervical spine

4) Preparing for chest tube insertion

5) Applying direct pressure to a wound

FEEDBACK:

2. This is correct. The primary survey focuses on airway, breathing, circulation (ABC), disability, and exposure or environmental control. It aims to identify life-threatening conditions so that appropriate interventions can be started. Nursing actions that are appropriate during the primary survey include immobilizing the cervical spine, preparing for chest tube insertion, and applying direct pressure to a wound.

4. This is correct. The primary survey focuses on airway, breathing, circulation (ABC), disability, and exposure or environmental control. It aims to identify life-threatening conditions so that appropriate interventions can be started. Nursing actions that are appropriate during the primary survey include immobilizing the cervical spine, preparing for chest tube insertion, and applying direct pressure to a wound.

5. This is correct. The primary survey focuses on airway, breathing, circulation (ABC), disability, and exposure or environmental control. It aims to identify life-threatening conditions so that appropriate interventions can be started. Nursing actions that are appropriate during the primary survey include immobilizing the cervical spine, preparing for chest tube insertion, and applying direct pressure to a wound.

What would the nurse working in the emergency department identify as clinical priorities for the treatment of a patient with a gunshot wound? Select all that apply.

1) Airway maintenance

2) Obtaining medical history

3) Ventilation assistance

4) Hemorrhage control

5) Hypothermia prevention

1) Airway maintenance

3) Ventilation assistance

4) Hemorrhage control

5) Hypothermia prevention

FEEDBACK: This is correct. Clinical priorities for the treatment of gunshot wound are the following: maintain airway and assist ventilation as necessary, control hemorrhage, prevent hypothermia. Also necessary is a rapid, recurrent assessment of the patient's neurological status, as well as prevention of infection.

2. This is incorrect. While obtaining the patient's medical history is important, this action would not be priority and would take place after the priority assessment and treatment. Once the safety of the patient is assured, then the nurse will manage the patient's emotional state and obtain the medical history.

3. This is correct. Clinical priorities for the treatment of gunshot wound are the following: maintain airway and assist ventilation as necessary, control hemorrhage, prevent hypothermia. Also necessary is a rapid, recurrent assessment of the patient's neurological status, as well as prevention of infection.

4. This is correct. Clinical priorities for the treatment of gunshot wound are the following: maintain airway and assist ventilation as necessary, control hemorrhage, prevent hypothermia. Also necessary is a rapid, recurrent assessment of the patient's neurological status, as well as prevention of infection.

5. This is correct. Clinical priorities for the treatment of gunshot wound are the following: maintain airway and assist ventilation as necessary, control hemorrhage, prevent hypothermia. Also necessary is a rapid, recurrent assessment of the patient's neurological status, as well as prevention of infection.

Which are the top priorities when conducting a primary patient survey during the emergency assessment? Select all that apply.

1) Airway

2) Disability

3) Breathing

4) Circulation

5) Cervical spine

1) Airway

5) Cervical spine

FEEDBACK:

1. This is correct. Airway and stabilization of the cervical spine are the top priorities when conducting a primary patient survey during the emergency assessment.

2. Thisis incorrect. The nurse will then focus on breathing, circulation, and disability.

3. This is incorrect. The nurse will then focus on breathing, circulation, and disability.

4. Thisis incorrect. The nurse will then focus on breathing, circulation, and disability.

5. This is correct. Airway and stabilization of the cervical spine are the top priorities when conducting a primary patient survey during the emergency assessment.

The nurse is providing care to several patients in the emergency department. In which order should the nurse assess and provide care to the patients? (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234)

1) A patient with a leg laceration requiring sutures

2) A patient with abdominal pain rated as a 7 on a numeric pain scale

3) A patient who has multiple trauma due to a motor vehicle accident

4) A patient who took an overdose of opioids with a respiratory rate of eight breaths per minute

4, 3, 2, 1

FEEDBACK: When using the Five-Level Emergency Severity Index (ESI), an ESI-1 is the highest priority while an ESI-5 is the lowest priority. The patient who took an overdose of opioids and is experiencing bradypnea (respiratory rate of less than 10 breaths per minute) is the priority at ESI-1. The patient who has multiple trauma due to a motor vehicle accident is an ESI-2. The patient with abdominal pain rated as a 7 using the numeric pain scale is an ESI-3. A patient with a leg laceration requiring sutures is an ESI-4.

The nurse is providing care to a trauma patient. What is the correct order of steps the nurse will implement when providing care to this patient? Select all that apply. (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234)

1) Clear the airway

2) Protect the cervical spine

3) Perform chest compressions

4) Provide supplemental oxygen

1, 2, 4, 3

FEEDBACK: The first step the nurse takes when providing care to a trauma patient is to clear the airway. The second step is to protect the cervical spine. The third step is to provide supplemental oxygen. The fourth step is to perform chest compressions.

Which is the critical factor among health-care professionals, state agencies, and federal agencies to determine when and how to evacuate safely during a natural disaster?

1) Cooperation

2) Classification

3) Collaboration

4) Communication

4) Communication

FEEDBACK: Communication is the critical factor among health-care professionals, state agencies, and federal agencies to determine when and how to evacuate safety during a natural disaster.

A workplace violence prevention plan is often one component of a hospital disaster plan. Which unit assumes priority for implementation and evaluation of this component to the plan?

1) Medical unit

2) Surgical unit

3) Radiology department

4) Emergency department

4) Emergency department

FEEDBACK: The Emergency Nursing Association (ENA) supports comprehensive workplace violence prevention plans to be included as a component of the organizational disaster plan. The ENA recommends that the comprehensive workplace violence prevention plan be implemented and evaluated in every emergency department.

Which is the priority in the preparedness of health-care professionals in any type of disaster plan?

1) Identification of hazards

2) Cooperation with state authorities

3) Collaboration with local authorities

4) Implementation of federal mandates

1) Identification of hazards

FEEDBACK: Identification of hazards is the priority in the preparedness of health-care professionals in any type of disaster plan.

Which treatment for anthrax should be included in the biological agent portion of a disaster plan for terrorist attacks?

1) Antivirals

2) Antitoxins

3) Antibiotics

4) Vaccinations

3) Antibiotics

FEEDBACK: Anthrax is treated effectively with antibiotics if sufficient supplies are available and the organisms are not resistant.

Which medication should be listed as the antidote to a nerve agent in the disaster plan for a terrorist attack?

1) Atropine

2) Dopamine

3) Epinephrine

4) Norepinephrine

1) Atropine

FEEDBACK: Atropine should be listed as the antidote for nerve agent poisoning in the disaster plan for a terrorist attack.

Which is the priority nursing action to include in a disaster plan for the radioactive dust and smoke that can cause illness from a radiologic dispersal device (RDD)?

1) Covering the nose

2) Protecting the eyes

3) Decontaminating the skin

4) Administering prophylactic antibiotics

1) Covering the nose

FEEDBACK: The priority nursing action to protect against the radioactive dust and smoke that can cause illness from an RDD is covering the nose and the mouth to decrease the risk for inhalation.

Which health-care team member is a first responder when an emergency or mass casualty incident (MCI) occurs?

1) Fireman

2) Police officer

3) Critical care nurse

4) Unlicensed assistive personnel

3) Critical care nurse

FEEDBACK: Critical care nurses are often considered emergency medical personnel that respond to emergency or MCIs.

Which situation does not cover nurses who respond to a mass casualty incident (MCI) for malpractice or negligent lawsuits under the Good Samaritan Act?

1) Terrorist act

2) Neighborhood fire

3) Roadside car accident

4) High school sporting event

1) Terrorist act

FEEDBACK: When terrorist acts occur, nurses are often required to go to an assigned site to offer aid. When this occurs, the nurse is not covered from malpractice or negligent lawsuits.

The nurse is a first responder for a health-care organization for a mass casualty incident. Which injury would the nurse tag as yellow during the triage process?

1) Ankle sprain

2) Hypovolemic shock

3) Open femur fracture

4) Massive head trauma

3) Open femur fracture

FEEDBACK: When using a triage tag system, an open femur fracture is an urgent but not life- threatening injury that would be tagged as yellow.

Which amount of time is appropriate for nurse to spend triaging each patient during a mass casualty incident?

1) Less than 10 seconds

2) Less than 15 seconds

3) Less than 30 seconds

4) Less than 60 seconds

2) Less than 15 seconds

FEEDBACK: Triage of victims of an emergency or an MCI must be conducted in less than 15 seconds. The other time frames, 10 seconds, 30 seconds, and 60 seconds, are not accurate.

The nurse is helping devise a training plan to familiarize health-care providers with emergency response procedures. Which training measure is most effective to adequately prepare the trainees?

1) Drills

2) Tabletop exercises

3) Access to the policy

4) Computer simulations

1) Drills

FEEDBACK: Hospital disaster drills are priority training measures to familiarize health-care providers with emergency response procedure.

The nurse is a member of the critical incident stress management unit that looks to meet the psychosocial needs of first responders after a mass casualty incident. Which action by the nurse is appropriate when conducting a session?

1) Arranging group discussion

2) Administering anti-anxiety medication

3) Scheduling individual therapy appointments

4) Documenting individual responses to the session

1) Arranging group discussion

FEEDBACK: Many hospitals and DMATs have a critical incident stress management unit, which arranges group discussions to allow participants to share and validate their feelings and emotions about the experience. This is important for emotional recovery.

Which type of event can often be handled by an individual hospital disaster plan without collaboration with other systems?

1) A motor vehicle accident involving five cars

2) A tornado destroying 50 homes and businesses

3) An act of terrorism injuring and kills hundreds of people

4) A hurricane causing flooding, displacing thousands of people

1) A motor vehicle accident involving five cars

FEEDBACK: A multi-casualty event, such as a motor vehicle accident involving five cars, is an event that can often be handled with the implementation of an individual hospital disaster plan without collaboration with other systems.

Which organization in the United States mandates ongoing disaster preparedness for hospitals?

1) The Joint Commission (TJC)

2) The local government

3) The state government

4) The Occupational Safety and Health Administration (OSHA)

1) The Joint Commission (TJC)

FEEDBACK: In the United States, The Joint Commission mandates that hospitals have an emergency preparedness plan that is tested through drills or actual participation in a real event at least twice yearly.

A nurse manager is a member of the emergency response planning team for a hospital located in the Rocky Mountains. Which type of natural disaster will the nurse manager recommend be included in their hospital disaster plan?

1) Tornado

2) Hurricane

3) Avalanche

4) Earthquake

3) Avalanche

FEEDBACK: Disaster drills are ideally planned based on a risk assessment or vulnerability analysis that identifies the events most likely to occur in a particular community. For a hospital

in the Rocky Mountains, there is a significant risk for an avalanche. The nurse manager will, therefore, recommend that avalanche planning be included in the hospital disaster plan.

The nurse manager is reviewing the hospital disaster plan with other members of the committee. Which is the minimum number of disaster drills the committee must plan and implement each year?

1) Two

2) Three

3) Four

4) Five

1) Two

FEEDBACK: While it is appropriate to have more than the minimum number of disaster drills each year, the minimum that must be implemented per The Joint Commission (TJC) requirements is twice per calendar year.

The nurse administrator for a long-term care facility is implementing a disaster response plan for staff and residents. Which staff member statements indicate correct understanding of the plan?

1) "We have to implement annual drills."

2) "Nursing homes are not required to have a plan."

3) "Our facility is held to the same standards as hospital facilities."

4) "This is an important component to receive insurance payments for care."

1) "We have to implement annual drills."

FEEDBACK: Hospitals are not the only health-care agencies that are required to practice disaster drills. Long-term care (LTC) facilities are also mandated to have annual drills to prepare for mass casualty events. Part of the response plan must include a method for evacuation of residents from the facility in a timely and safe manner.

Which public health risk became a major focus for hospitals after the September 11, 2001 terrorist attacks?

1) Anthrax exposure

2) Multi-casualty incidents

3) Mass casualty incidents (MCI)

4) Weapons of mass destruction (WMD)

4) Weapons of mass destruction (WMD)

FEEDBACK: Weapons of mass destruction (WMD) rapidly became a focus of public health risk after the terrorist attacks that occurred on September 11, 2001.

The nurse is conducting triage under mass casualty conditions. Which tag should the nurse use for a patient who is experiencing hypovolemic shock due to a penetrating wound?

1) Red

2) Black

3) Green

4) Yellow

1) Red

FEEDBACK: The nurse would use a red tag for a patient who has injuries that are an immediate threat to life, such as hypovolemic shock, during mass casualty conditions.