Deck 71: Nursing Management: Emergency Care Situations

Question 1

The patient has been diagnosed with Rocky Mountain spotted fever.When teaching the patient about his diagnosis,the nurse tells him that the incubation period for this disease is how long?

A) 24 to 48 hours
B) 3 to 5 days
C) 4 to 20 days
D) 1 to 2 months

Answer 1

4 to 20 days

Question 2

When completing the secondary survey,the nurse knows that the E in EFGHI represents which one of the following?

A) Evaluating vital signs
B) Exposure and environmental control
C) Environmental scan
D) Effect of immediate treatment

Answer 2

Exposure and environmental control

Question 3

During the primary assessment of a trauma victim,the nurse determines that the patient has a patent airway.What is the next assessment the nurse should make?

A) The patient's level of consciousness
B) Observation for external bleeding
C) The status of the patient's respiration
D) The rate and character of the patient's carotid or femoral pulses

Answer 3

The status of the patient's respiration

Question 4

A construction worker is treated in the emergency department in the summer with heat cramps accompanied by nausea,weakness,and profuse diaphoresis.The nurse determines that discharge teaching regarding the prevention of another episode of heat cramps has been effective when the patient gives which of the following responses?

A) "I will take salt tablets when I work outdoors in the summer."
B) "I should double my water intake when the weather gets hot."
C) "I should drink commercially prepared electrolyte solutions when the weather is warm."
D) "If I notice swelling of my hands and feet,I should get into a cool environment for a while."

Question 5

A 58-year-old woman is brought to the hospital in cardiac arrest by emergency personnel who are performing resuscitation of the patient.The husband arrives as the patient is taken into a treatment room and asks to stay with his wife.What should the nurse do?

A) Insist that he wait outside the room while resuscitation is being performed.
B) Allow him to be present,and ensure that a member of the team explains the care given and answer his questions.
C) Explain that it would be better if he did not experience the resuscitation effort because he might not understand it.
D) Advise him that if his wife is not resuscitated,the resuscitation scene is not the last memory of her he would like to have.

Question 6

An 82-year-old woman is admitted to the emergency department in a coma after a neighbour found her during a summer heat wave in her stifling apartment,which has no air conditioning.Assessment findings include hot,dry skin;temperature 41.2°C;blood pressure 86/52 mm Hg;and pulse 102 beats/min.The nurse initiates care for the patient,with the knowledge that which of the following treatments will be the initial treatment to include?

A) Application of wet sheets and fans
B) Rectal administration of antipyretics
C) Rapid,large-volume fluid resuscitation with lactated Ringer's solution
D) IV administration of lidocaine (Xylocaine)to prevent cardiac dysrhythmias

Question 7

Which assessment finding would the nurse anticipate with a patient who is hypothermic?

A) Hyperventilation
B) Hypertension
C) Tachycardia
D) Fixed,dilated pupils

Question 8

To prevent ventricular fibrillation during treatment of a patient with hypothermia,the nurse plans to carry out which of the following actions?

A) Monitor cardiac activity.
B) Have defibrillation equipment readily available.
C) Avoid moving and stimulating the patient as much as possible.
D) Encourage oral fluids to decrease the hematocrit and sludging of the blood.

Question 9

A 77-year-old woman wandered away from her home during the winter and was found unconscious in a field by a search team 24 hours later.On arrival at the emergency department,her core temperature is 31.6°C.During rewarming measures,the nurse determines that the goals of treatment are being met when which of the following responses is observed in the patient?

A) Regains consciousness
B) Has a blood pH within normal limits
C) Has a core temperature of 33.9°C
D) Shivers involuntarily to raise body temperature

Question 10

What is included in emergency interventions for a victim with upper torso injuries or face,head,or neck trauma?

A) Suctioning to clear the airway
B) Immobilization of the cervical spine
C) Administration of supplemental oxygen
D) Ensuring venous access with at least two large-bore IV lines

Question 11

According to the Canadian Emergency Department Triage and Acuity Scale,what is the time to physician assessment for a patient assessed at level III?

A) Immediate
B) 15 minutes
C) 30 minutes
D) 60 minutes

Question 12

During the primary assessment of a trauma victim,the nurse observes that the patient's right pedal pulses are absent and the leg is swollen.What is the nurse's priority action?

A) Initiate two large-bore intravenous (IV)lines with isotonic fluids.
B) Administer 100% oxygen with a nonrebreather mask.
C) Complete the primary assessment before initiating any treatments.
D) Expose the patient to further assess for a cause of the decreased peripheral circulation.

Question 13

A young woman is admitted to the emergency department after experiencing submersion at a local lake.She received rescue breathing at the site and now has spontaneous respirations.The nurse tells the patient that she will need to be observed for some time,primarily because she may yet experience which of the following complications?

A) Hypernatremia
B) Pulmonary edema
C) Respiratory acidosis
D) Signs of head injury

Question 14

Four victims of an automobile accident are brought by ambulance to the emergency department.Based on the principles of triage,which of the following signs does the nurse determine has the highest priority for treatment?

A) A sucking chest wound
B) Absence of peripheral pulses
C) Severe bleeding of facial and head lacerations
D) An open fracture of the femur with profuse bleeding

Question 15

A patient has experienced blunt abdominal trauma from a motor vehicle accident.Which of the following diagnostic tests does the nurse know is a noninvasive method of determining the presence of intra-abdominal bleeding?

A) Magnetic resonance imaging
B) Ultrasonography
C) Peritoneal lavage
D) Auscultation of bowel sounds in the chest

Question 16

Which of the following is a cause of a life-threatening condition that the nurse identifies during the primary survey?

A) Pneumonia
B) Controlled hemorrhage
C) Hyperthermia
D) Flail chest with pulmonary contusion

Question 17

A migrant field worker is brought to the emergency department after he caught his right hand in a produce conveyer belt.His hand has multiple lacerations,and he has tissue avulsion of the right palm.On questioning,he does not know about his tetanus prophylaxis status.Which of the following drug regimens does the nurse anticipate administering?

A) Tetanus immunoglobulin
B) Tetanus and diphtheria toxoid
C) Tetanus-diphtheria toxoid and tetanus immune globulin
D) Tetanus immune globulin and two doses of tetanus and diphtheria toxoid

Question 18

During immediate care of a victim of a bite or sting to the hands or fingers,it is most important for the nurse to carry out which of the following actions?

A) Elevate the affected extremity.
B) Scrub the wound with an antibacterial solution.
C) Apply ice to the site with ice water or ice packs.
D) Remove rings and watches from the affected extremity.

Question 19

A 72-year-old man has fallen from a ladder and is transported to the emergency department by ambulance.He is unconscious on arrival and accompanied by his wife and son.During the primary survey of the patient,what should the nurse do?

A) Obtain the patient's vital signs.
B) Calculate a Glasgow Coma Scale (GCS)score.
C) Examine the neck for rigidity or stiffness.
D) Determine whether he has underlying medical conditions.