Question 1

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

Accepted Answer

B

Question 2

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?

Accepted Answer

The charge nurse is responsible for managing the unit's patient flow, coordinating resources, and delegating tasks to the nursing staff during a crisis situation such as a sudden influx of patients. They will prioritize care and ensure that patients receive treatment in a timely and effective manner. The nurse supervisor may also be involved in support, but the charge nurse is typically the primary point of contact for staffing and patient care decisions. The licensed practical nurse and unlicensed assistive personnel may be involved in providing direct patient care, but they are not responsible for managing the flow of patients on the unit.

Question 3

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?

Accepted Answer

The symptoms of hypotension, jugular distension, and tracheal deviation suggest a tension pneumothorax, which is a medical emergency caused by air collecting in the pleural space and exerting pressure on the lung and surrounding structures. This can lead to compression of the heart and great vessels, causing the symptoms described. Hemorrhage and hypovolemic shock may also cause hypotension, but they would not typically cause jugular distension or tracheal deviation. Compensatory shock occurs when the body attempts to compensate for a decreased cardiac output, but it would not cause the specific symptoms described.

Question 4

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

Accepted Answer

During a secondary survey, the focus is on a more detailed assessment and addressing the needs of the patient and their family. Assigning a nurse to support family members is appropriate as it helps address their concerns and provides emotional support.

Question 5

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

Accepted Answer

Chest pain and diaphoresis are both indicators of a potentially life-threatening condition, such as a heart attack. This patient would be the top priority in the three-tiered triage system.

Question 6

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

Accepted Answer

The answer of Which are the priority nursing actions after...

Question 7

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?

Accepted Answer

Taking vital signs is within the scope of practice for a UAP and can be safely delegated by the RN. Administration of medications and wound care should only be performed by licensed healthcare professionals, and discharge teaching requires a higher level of education and training.

Question 8

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

Accepted Answer

The answer of Which assessment data indicates the patient is...

Question 9

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

Accepted Answer

The team leader is responsible for prioritizing patient care in the team nursing approach. They coordinate and delegate tasks to other members of the team, ensuring that patient needs are met in a timely and efficient manner. The charge nurse may also have some responsibility in prioritizing patient care but their role is primarily focused on overall management of the unit. Licensed practical nurses and unlicensed assistive personnel may assist in providing patient care but do not have the authority to prioritize care.

Question 10

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

Accepted Answer

Preserving the chain of evidence is critical in gunshot wound cases as it can help in the investigation and prosecution of the perpetrator. The nurse should avoid interfering with any potential evidence and notify the appropriate authorities to handle the situation. A and C are inappropriate and potentially dangerous as it is not the nurse's role to investigate or handle weapons. B may be necessary but is not the most critical concern in this situation.

Question 11

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?

Accepted Answer

Breathing is the top priority during the primary survey in an emergency assessment, and having suction available is a critical nursing action to maintain a clear airway. Assessing pupil size and reactivity, immobilizing deformities, and obtaining blood samples are important but are not the priority action for breathing during the primary survey.

Question 12

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

Accepted Answer

Setting priorities is the essential nursing skill for the triage process in the emergency department. Triage is the process of determining the priority of patients' treatments based on their medical condition and urgency. The nurse must be able to identify which patients require immediate care and prioritize their treatments accordingly. Evaluating care, formulating diagnoses, and implementing interventions are also important nursing skills, but they are not specific to the triage process.

Question 13

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

Accepted Answer

The fact that the patient is able to move all four extremities independently, feed themselves, and participate in a partial bath indicates that they have regained function and independence as a result of successful interventions. The other options do not necessarily indicate success in treating neck injuries. Urine output and restfulness can be affected by a variety of factors, and being unable to move independently in bed may indicate ongoing motor dysfunction.

Question 14

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

Accepted Answer

Counting respiratory rate is the appropriate action during the breathing assessment, as it is a vital sign that provides important information about the patient's respiratory status. Assessing for edema, checking for foreign bodies, and monitoring for respiratory distress are also important nursing actions but are not specific to the breathing assessment during the primary survey.

Question 15

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?

Accepted Answer

Determining drug allergies is the priority nursing action during the health history portion of the assessment, as this information is essential in determining appropriate treatment and medication administration during the emergency. Noting the general appearance, examining the neck for stiffness, and auscultating for heart and lung sounds are important components of the assessment, but they are not as urgent as determining drug allergies.

Question 16

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?

Accepted Answer

Magnetic resonance imaging (MRI) is the most appropriate diagnostic test for spinal cord injuries as it provides detailed visualization of soft tissues, which is necessary in identifying the location and extent of the damage. CT scan and X-ray can provide valuable information but are not as effective in visualizing soft tissues. Ultrasound is not generally used for diagnosing spinal cord injuries.

Question 17

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

Accepted Answer

The patient with unstable vital signs and chest pain would require priority care as this could potentially be a cardiac emergency. The other patients also require care, but their conditions are less urgent.

Question 18

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?

Accepted Answer

Turning the patient at least every two hours helps to prevent pressure ulcers and other integumentary complications by redistributing pressure on the skin. Active and passive exercises (A) promote cardiovascular and respiratory health, while coughing, deep breathing, and incentive spirometry (B) prevent respiratory complications. However, neither of these interventions specifically targets integumentary complications. Assisting with turning every eight hours (D) may not be frequent enough to prevent pressure ulcers and other skin breakdown.

Question 19

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

Accepted Answer

A patient with possible asthma presenting with dyspnea is a potential emergency and should be prioritized as such. Chest pain and fractures can also be serious, but in this scenario, the patient with asthma has the potential to rapidly deteriorate and require urgent intervention. The older adult with a hip fracture in pain would also be a priority, but may not require immediate intervention as the patient with asthma.

Question 20

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

Accepted Answer

Assisting the patient to deep breathe and cough every two hours is important to prevent respiratory complications such as atelectasis and pneumonia, which are common in patients recovering from thoracic injuries. While monitoring urine output, assessing vital signs, and performing passive range of motion to all extremities are also important interventions, they are not the priority in this case.

Quiz 70: Emergency,trauma,and Environmental Injuries