Question 1

A homeless person is brought to the emergency department after having been found asleep on a park bench under a layer of snow.He has a rectal temperature of 95$\degree$ F.Which additional symptoms should the nurse anticipate?

Accepted Answer

Hypothermia, indicated by a body temperature of 95°F, leads to decreased metabolic and physiological functions. This results in decreased heart and respiratory rates, and decreased blood pressure, as the body conserves energy in response to the cold.

Question 2

A patient comes to the emergency department with an evisceration after a knife attack.What is the best nursing intervention related to the exposed bowel?

Accepted Answer

The best nursing intervention related to the exposed bowel in a patient with evisceration is to cover the bowel with a moist saline dressing. This will help to prevent dehydration and proteolysis and maintain a moist environment, which is essential for viability of the exposed bowel. The nurse should also monitor the patient for signs of shock and ensure that the patient is kept warm and comfortable. The nurse should not attempt to replace the bowel into the abdominal cavity as this may lead to further injury and complications. The use of a sandbag is also not indicated as it may cause pressure and further damage to the exposed bowel. Placing the patient in a high Fowler position may be appropriate for comfort and to aid in breathing, but it will not help to address the evisceration.

Question 3

An accident victim comes to the emergency department with an open chest wound.What should the nurse apply to the wound?

Accepted Answer

An open chest wound should be covered with a vented dressing that is taped on three sides. This allows air to escape from the chest cavity, preventing tension pneumothorax, but prevents air from being drawn into the chest with inhalation.

Question 4

Which condition may complicate the assessment of an older adult patient with a suspected head injury?

Accepted Answer

The answer of Which condition may complicate the assessment of...

Question 5

A child is brought to the emergency department with several deep dog bites on her legs.After cleaning the wounds, what should the nurse be primarily concerned with ascertaining?

Accepted Answer

The nurse's primary concern after cleaning the wounds should be to determine the child's tetanus inoculation status. This is important because dog bites can introduce bacteria into the body that can cause tetanus. The other options are also important, but not as immediate a concern as ensuring that the child is protected against tetanus.

Question 6

What is the initial intervention for an unconscious patient who is not breathing according to one-person CPR principles, as taught and practiced by professional nurses?

Accepted Answer

The answer of What is the initial intervention for an...

Question 7

What instructions should the nurse provide for immediate treatment for epistaxis?

Accepted Answer

Leaning forward while sitting prevents blood from going down the throat, which can cause choking or nausea. Pinching the nose helps to stop the bleeding. This position and action are recommended for treating epistaxis (nosebleeds).

Question 8

A patient visits the industrial nurse after an accident on the factory floor, which has amputated three toes.What is the most effective nursing intervention for the amputated toes?

Accepted Answer

The most effective nursing intervention for amputated parts is to wrap them in saline-moistened gauze, place them in a waterproof container or plastic bag, and then place that container or bag in a container of ice or cold saline. This method helps preserve the tissue without causing further damage from direct contact with ice.

Question 9

Six hours after a beach picnic on a hot afternoon, a young man enters the emergency department with nausea and vomiting, headache, and diarrhea.On interview, the patient says that he ate potato salad and tuna fish sandwiches.What should the nurse suspect is the causative organism for these symptoms?

Accepted Answer

Staphylococcus aureus is known for producing enterotoxins that can cause rapid onset food poisoning, characterized by nausea, vomiting, and diarrhea. These symptoms can develop quickly, often within hours of consuming contaminated food, such as improperly stored potato salad and tuna fish sandwiches at a picnic.

Question 10

A patient is present with signs of severe airway obstruction.What term accurately describes the high-pitched noise the patient is exhibiting with inhalation?

Accepted Answer

Stridor is a high-pitched, harsh sound that is heard during inhalation when there is a partial obstruction of the trachea or larynx, indicating severe airway obstruction. Tachypnea refers to rapid breathing, wheezing is a whistling sound heard during expiration, and rhonchi are low-pitched, snoring or rattling sounds heard during inspiration or expiration.

Question 11

While ambulating, a patient gasps and drops to the floor unconscious with no pulse or respiration.When is the nurse aware that brain cells begin to die?

Accepted Answer

Brain cells begin to die approximately 4 to 6 minutes after the heart stops beating due to lack of oxygen.

Question 12

A nurse who is assisting victims of an automobile collision has already placed a towel secured with a belt on a bleeding leg wound.What action should the nurse take when the towel becomes saturated?

Accepted Answer

Reinforcing the towel with additional material, such as the victim's jacket, helps to apply more pressure to the wound, which can aid in controlling the bleeding without removing the initial layer that is directly applying pressure to the wound site. Removing the towel could disrupt clot formation and exacerbate bleeding.

Question 13

A nurse follows the protocol of SAMPLE when speaking to a victim of a fall in the parking lot of the hospital.What does the P stand for?

Accepted Answer

The P in SAMPLE stands for past illnesses. It is important for the nurse to know the patient's medical history as it can provide useful information for proper treatment and care.

Question 14

What will the nurse giving discharge instructions to a patient who is severely allergic to insect stings caution the patient to do?

Accepted Answer

Obtaining an emergency treatment kit is crucial for a patient who is severely allergic to insect stings. This kit should contain medications such as epinephrine to treat anaphylaxis in case of a sting. The other choices, such as wearing bright colors, applying perfume, or dressing in sleeveless garments do not provide effective protection or prevention against insect stings and can actually increase the risk of being stung.

Question 15

While at the local pool on an extremely hot day, a nurse is called on to care for a woman who has evidently developed heat exhaustion.What is the initial nursing care for this person?

Accepted Answer

The first step in caring for someone with heat exhaustion is removing them from the hot environment and into a cooler location. This can be an air-conditioned building or just a shaded area. Vital signs can be obtained after the patient has been moved and assessed. Giving ice water or covering with a wet towel can also be helpful, but the priority is to get them out of the hot environment.

Question 16

A nurse comes upon a traffic accident where injured, unconscious people are lying on the highway.What should the nurse be aware of regarding the sanctioning of first-aid interventions in this scenario?

Accepted Answer

The Good Samaritan Law provides legal protection for individuals who provide reasonable assistance to those who are injured or in danger, without expectation of compensation, by shielding them from liability for any harm that may occur during the course of their actions. This law would apply to the nurse in this scenario who is providing first aid interventions to the injured individuals on the highway. The Emergency Care Doctrine applies to medical providers who are providing emergency care in a hospital setting and is not relevant in this scenario. The Fifth Amendment pertains to the right against self-incrimination and is not applicable in this scenario. The Liability Protection against Malpractice Act may provide protection to healthcare providers in certain circumstances, but is not applicable in this scenario where the nurse is providing first-aid interventions on the highway.

Question 17

A mother brings in her 2-year-old who has ingested gasoline 1 hour earlier.What should the nurse implement following the initial assessment?

Accepted Answer

Ingestion of gasoline is considered a medical emergency and can cause severe harm to the body. As such, the best choice in this scenario is to prepare to administer bowel lavage and cathartics. This will involve flushing the patient's system with large amounts of fluid to remove any remaining gasoline from the GI tract. Other interventions, such as syrup of ipecac or turning the patient on their stomach to induce vomiting, are no longer recommended in this situation as they can cause further harm to the patient. Milk of Magnesia may be used in some cases to help promote bowel movements, but it is not the best choice for this specific scenario.

Question 18

A patient is admitted to the emergency department after having been bitten on the hand by a black widow spider.Which nursing intervention should the nurse initiate?

Accepted Answer

Black widow spider bites can cause severe muscle cramps and spasms, including in the muscles used for breathing, so the nurse should monitor for respiratory distress. Wrapping the hand in a warm compress, seating the patient upright in a chair, and elevating the patient's hand above his or her heart are not appropriate interventions for a black widow spider bite.

Question 19

A nurse is called on to assist a neighbor who needs first aid.What should the nurse know is the legal responsibility for this action?

Accepted Answer

As a nurse, it is important to understand that even when providing first aid outside of the hospital setting, there is still a legal responsibility to provide care that is consistent with the standard of care provided by other nurses in the same community with the same credentials. This means that the nurse should not perform any aid skill that is outside of their scope of practice and could be held accountable for any harm caused to the individual being treated.

Question 20

Standing in a fast-food line, the person in front, while munching on a cookie, begins to cough heavily, takes deep inspirations, and waves his arms around wildly.What should be the nurse's first action?

Accepted Answer

The person is coughing and taking deep inspirations, indicating that air is still being exchanged. This suggests that the airway is not completely blocked, and immediate aggressive interventions like rescue breathing, chest compressions, or abdominal thrusts are not necessary at this point. The best course of action is to monitor the situation and encourage the person to continue coughing to try to dislodge the obstruction themselves.

Quiz 63: First Aid, Emergency Care, and Disaster Management

A homeless person is brought to the emergency department after having been found asleep on a park bench under a layer of snow.He has a rectal temperature of 95 $\degree$ F.Which additional symptoms should the nurse anticipate?

A patient comes to the emergency department with an evisceration after a knife attack.What is the best nursing intervention related to the exposed bowel?

An accident victim comes to the emergency department with an open chest wound.What should the nurse apply to the wound?

Which condition may complicate the assessment of an older adult patient with a suspected head injury?

A child is brought to the emergency department with several deep dog bites on her legs.After cleaning the wounds, what should the nurse be primarily concerned with ascertaining?

What is the initial intervention for an unconscious patient who is not breathing according to one-person CPR principles, as taught and practiced by professional nurses?

What instructions should the nurse provide for immediate treatment for epistaxis?

A patient visits the industrial nurse after an accident on the factory floor, which has amputated three toes.What is the most effective nursing intervention for the amputated toes?

Six hours after a beach picnic on a hot afternoon, a young man enters the emergency department with nausea and vomiting, headache, and diarrhea.On interview, the patient says that he ate potato salad and tuna fish sandwiches.What should the nurse suspect is the causative organism for these symptoms?

A patient is present with signs of severe airway obstruction.What term accurately describes the high-pitched noise the patient is exhibiting with inhalation?

While ambulating, a patient gasps and drops to the floor unconscious with no pulse or respiration.When is the nurse aware that brain cells begin to die?

A nurse who is assisting victims of an automobile collision has already placed a towel secured with a belt on a bleeding leg wound.What action should the nurse take when the towel becomes saturated?

A nurse follows the protocol of SAMPLE when speaking to a victim of a fall in the parking lot of the hospital.What does the P stand for?

What will the nurse giving discharge instructions to a patient who is severely allergic to insect stings caution the patient to do?

While at the local pool on an extremely hot day, a nurse is called on to care for a woman who has evidently developed heat exhaustion.What is the initial nursing care for this person?

A nurse comes upon a traffic accident where injured, unconscious people are lying on the highway.What should the nurse be aware of regarding the sanctioning of first-aid interventions in this scenario?

A mother brings in her 2-year-old who has ingested gasoline 1 hour earlier.What should the nurse implement following the initial assessment?

A patient is admitted to the emergency department after having been bitten on the hand by a black widow spider.Which nursing intervention should the nurse initiate?

A nurse is called on to assist a neighbor who needs first aid.What should the nurse know is the legal responsibility for this action?

Standing in a fast-food line, the person in front, while munching on a cookie, begins to cough heavily, takes deep inspirations, and waves his arms around wildly.What should be the nurse's first action?

Quiz 63: First Aid, Emergency Care, and Disaster Management

A homeless person is brought to the emergency department after having been found asleep on a park bench under a layer of snow.He has a rectal temperature of 95 °\degree° F.Which additional symptoms should the nurse anticipate?

A patient comes to the emergency department with an evisceration after a knife attack.What is the best nursing intervention related to the exposed bowel?

An accident victim comes to the emergency department with an open chest wound.What should the nurse apply to the wound?

Which condition may complicate the assessment of an older adult patient with a suspected head injury?

A child is brought to the emergency department with several deep dog bites on her legs.After cleaning the wounds, what should the nurse be primarily concerned with ascertaining?

What is the initial intervention for an unconscious patient who is not breathing according to one-person CPR principles, as taught and practiced by professional nurses?

What instructions should the nurse provide for immediate treatment for epistaxis?

A patient visits the industrial nurse after an accident on the factory floor, which has amputated three toes.What is the most effective nursing intervention for the amputated toes?

A patient is present with signs of severe airway obstruction.What term accurately describes the high-pitched noise the patient is exhibiting with inhalation?

While ambulating, a patient gasps and drops to the floor unconscious with no pulse or respiration.When is the nurse aware that brain cells begin to die?

A nurse who is assisting victims of an automobile collision has already placed a towel secured with a belt on a bleeding leg wound.What action should the nurse take when the towel becomes saturated?

A nurse follows the protocol of SAMPLE when speaking to a victim of a fall in the parking lot of the hospital.What does the P stand for?

What will the nurse giving discharge instructions to a patient who is severely allergic to insect stings caution the patient to do?

While at the local pool on an extremely hot day, a nurse is called on to care for a woman who has evidently developed heat exhaustion.What is the initial nursing care for this person?

A nurse comes upon a traffic accident where injured, unconscious people are lying on the highway.What should the nurse be aware of regarding the sanctioning of first-aid interventions in this scenario?

A mother brings in her 2-year-old who has ingested gasoline 1 hour earlier.What should the nurse implement following the initial assessment?

A patient is admitted to the emergency department after having been bitten on the hand by a black widow spider.Which nursing intervention should the nurse initiate?

A nurse is called on to assist a neighbor who needs first aid.What should the nurse know is the legal responsibility for this action?

Standing in a fast-food line, the person in front, while munching on a cookie, begins to cough heavily, takes deep inspirations, and waves his arms around wildly.What should be the nurse's first action?

A homeless person is brought to the emergency department after having been found asleep on a park bench under a layer of snow.He has a rectal temperature of 95 $\degree$ F.Which additional symptoms should the nurse anticipate?