Deck 16: Care of Patients Experiencing Urgent Alterations in Health

Question 1

When administering first aid in emergency situations, the nurse must first survey victims for severity of injuries. What term correctly describes this process?

A) The Good Samaritan law
B) An emergency interview
C) Triage
D) Taking vital signs

Answer 1

Triage

Question 2

A patient with multiple serious injuries sustained in a motorcycle accident is lying beside his wrecked motorcycle unconscious and bleeding when the rescuer arrives at the scene. What will be the rescuer's priority action?

A) Assessing blood loss
B) Assessing respiratory status
C) Obtaining vital signs
D) Organizing laypeople at the scene

Answer 2

Assessing respiratory status

Question 3

CPR has been initiated at an accident site. When can CPR be terminated?

A) Victim is clinically dead
B) Victim is brain dead
C) Paramedics arrive
D) Rescuer perceives CPR is futile

Answer 3

Paramedics arrive

Question 4

When other methods have failed to stop the bleeding and the victim's life is in danger, the rescuer at the scene applies a tourniquet to a young woman's leg above the knee. What is another step that is essential for the rescuer to follow?

A) Never release the tourniquet
B) Wrap the tourniquet around the limb twice
C) Mark the patient with a "T"
D) Leave the limb elevated

Question 5

A machinist visits the industrial nurse's clinic with a deep laceration of the thigh. What should be the nurse's first action?

A) Splint the thigh and apply tape to approximate the edges
B) Apply ice and a pressure dressing to the thigh
C) Give a tetanus booster injection
D) Wash the laceration with an antiseptic

Question 6

The patient arrived at the emergency department in pain and bleeding profusely with the following vital signs: BP 80/54, P 102, RR 22. What does the nurse recognize that these symptoms indicate?

A) Inadequate perfusion
B) Circulatory shock
C) Massive vasodilation
D) Heart failure

Question 7

A nurse assesses an accident victim who has bright red blood spurting from a laceration on his right forearm. Where will the nurse apply pressure after applying direct pressure and elevating the limb?

A) Right subclavian artery
B) Right radial artery
C) Right ulnar artery
D) Right brachial artery

Question 8

A patient arrives in the emergency department with a sucking wound to the left chest. What is the first action the nurse should take?

A) Place several layers of gauze dressing over the wound
B) Place the patient in a supine position
C) Cover the wound with an airtight dressing taped on three sides
D) Turn the patient to the left side

Question 9

The nurse is attempting to control bleeding in a patient with a profusely bleeding scalp wound. What is the most effective initial treatment of this bleeding?

A) Elevate the head
B) Apply direct pressure
C) Apply an ice pack
D) Apply indirect pressure

Question 10

A nurse is assessing victims in an emergency situation. What will the nurse assess for first?

A) Hemorrhage
B) Fractures
C) Mobility
D) Abnormal breathing

Question 11

When a patient suddenly experiences respiratory difficulty in the cafeteria, the nurse begins assessment for foreign body airway obstruction. What is the most appropriate question to ask the victim?

A) "What did you swallow?"
B) "Are you choking?"
C) "Are you OK?"
D) "Can I help you?"

Question 12

The nurse determines clinical death and initiates CPR immediately. How long is resuscitation considered possible?

A) If cardiopulmonary arrest has existed for no more 2 minutes
B) If cardiopulmonary arrest has existed for no more 3 minutes
C) If cardiopulmonary arrest has existed for no more 4 minutes
D) If cardiopulmonary arrest has existed for no more 5 minutes

Question 13

The nurse is assessing a patient who is severely bleeding and at risk for hypovolemic shock. What can the nurse anticipate?

A) Slow, labored breathing
B) Hot, flushed skin
C) Edematous extremities
D) Weak, thready pulse

Question 14

When assessing the adult victim for pulselessness, the CPR rescuer should palpate the most reliable and accessible pulse. Which pulse will be palpated?

A) Radial
B) Brachial
C) Carotid
D) Femoral

Question 15

The Good Samaritan law will protect all people who offer assistance. What is necessary for this protection?

A) A license
B) The person acts prudently
C) Licensed supervision
D) The patient improves

Question 16

The worried mother of an accident victim asks the nurse how much circulating blood an average adult male is supposed to have.What will the nurse reply?

A) 8 pints
B) 10 pints
C) 12 pints
D) 14 pints

Question 17

The nurse is teaching a patient with epistaxis about the best way to control bleeding. What information will the nurse relay to this patient?

A) Place ice on the nose and pinch the nostrils
B) Maintain a flat position
C) Pack nostrils with cotton
D) Lean backward

Question 18

A farm worker who has been kicked in the stomach by a mule passes a foul, black, tarry stool. What is this called?

A) Loose stool
B) Melena
C) Hematuria
D) Hemoptysis

Question 19

CPR has been initiated on an adult patient. How will the nurse confirm the effectiveness of CPR?

A) Assessing an EKG pattern with each compression
B) Assessing a palpable carotid pulse during each compression
C) Assuring a compression depth of $1 \frac { 1 } { 2 }$ to 2 inches
D) Observing pupils that change from pinpoint to dilated

Question 20

The patient's lower chest has been punctured with a knife that is still in place. What should the nurse's first action be?

A) Remove the knife
B) Apply an airtight dressing over the wound
C) Place the patient in a modified Trendelenburg position
D) Immobilize the knife with dressings and tape

Question 21

A patient has been stung by a bee and is brought to the emergency department. The nurse observes the sting site and identifies that the stinger is still in the skin. What action should the nurse take?

A) Remove it with sterile tweezers
B) Soak the area with a cold compress
C) Scrape the stinger with the side of a knife
D) Squeeze the surrounding tissue to expel the stinger

Question 22

A burn patient is brought into the emergency department with the following burns: half of the front torso, entire left arm, and front of left leg. The nurse should record that the patient has a ______% burn.

Question 23

The nurse is assisting a victim of an accident who requires bandaging of the right lower extremity. What should the nurse do when applying the bandage?

A) Use sterile material
B) Leave the toes exposed
C) Bandage the extremity tightly
D) Bend the knee after bandaging

Question 24

While on break in the hospital cafeteria a nurse witnesses her pregnant co-worker start to choke. The co-worker is conscious, but unable to breathe. Where should the nurse administer thrusts?

A) Below the navel
B) The chest
C) At the xiphoid process
D) The upper back

Question 25

If a spinal injury is suspected, before the rescuer starts CPR, the trachea should be opened with a _______ _______ maneuver.

Question 26

A patient is admitted to the hospital after receiving a blow to the head. The patient begins to show signs of shock. How should the patient be positioned?

A) With the head lower than the body
B) Flat with the legs elevated
C) Flat on the back
D) In a side-lying position

Question 27

A visitor in the hospital slips and falls. The patient's arm appears dislocated and the visitor is unable to move it. What is the first action the nurse should implement?

A) Apply cold packs
B) Check range of motion
C) Splint the arm
D) Apply an Ace bandage

Question 28

When performing CPR on an infant, the breastbone is depressed approximately ____ to ____ inch(es).

Question 29

The patient is brought to the emergency department after having fractured an arm 12 hours ago. The arm is very edematous from the fingers to the elbow, and the patient cannot move it. What should be the initial action of the nurse?

A) Test range of motion
B) Take the vital signs
C) Place ice packs on the arm
D) Check fingers for capillary refill

Question 30

When assessing a patient who has suffered a burn injury, the nurse classifies the burn as a deep partial-thickness burn. What is this observation most likely based upon?

A) Painful reddened skin
B) Charred skin with milky-white areas
C) Erythema and blisters
D) Erythema, pain, and swelling

Question 31

When two nurses perform two-person CPR, there should be _____ slow breaths for every _____ compressions.

Question 32

The acronym RICE directs the nurse in the care of a sprain. The "C" in the acronym stands for ________.

Question 33

The nurse arrives on the scene of a fire. What is the first thing the nurse will do for a burn victim?

A) Apply dressings
B) Cover with a blanket
C) Cool the burn immediately
D) Apply topical ointment

Question 34

When treating an infant choking on a foreign body, the nurse should use a combination of ______ _________ and chest thrusts.

Question 35

The patient is admitted to the emergency department, having suffered frostbite to the hands, which are grayish-white in color. What action should the nurse implement when attempting to warm the hands?

A) Have the patient rub the hands together briskly
B) Wipe the hands vigorously with a warm towel
C) Run tepid water over the hands to warm slowly
D) Wrap the hands in hot, moist towels

Question 36

The patient with heat stroke has been undressed and treated with cold packs and a fan. The patient's temperature is now down to 101.2° F. The patient starts to shiver. What action should the emergency department nurse take?

A) Raise the head of the bed
B) Offer warm liquids
C) Remove cold packs and fan
D) Continue with cooling interventions

Question 37

A patient who had taken a poisonous substance is brought to the emergency department. What is the first action the nurse should take?

A) Give syrup of ipecac
B) Contact the poison control center
C) Give milk to coat the stomach
D) Observe for symptoms