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  Lewis: Medical-Surgical Nursing, 7 th  Edition Test Bank Chapter 69: Nursing Management: Emergency and Disaster Nursing MULTIPLE CHICE 1.Four ictims o! an automo i#e crash are rought y am u#ance to the emergency department $emergency department%. The triage nurse determines that the ictim &ho has the highest priority !or treatment is the one &itha.seere #eeding o! !acia# and head #acerations.  .an open !emur !racture &ith pro!use #eeding.c.a sucking chest &ound.d.a sence o! periphera# pu#ses. Correct !nswer: C ationale:  Most immediate deaths !rom trauma occur ecause o! pro #ems &ith enti#ation' so the patient &ith a sucking chest &ound shou#d e treated !irst. Face and head !ractures can o struct the air&ay' ut the patient &ith !acia# in(uries has #acerations on#y. The other t&o patients a#so need rapid interention ut do not hae air&ay or reathing pro #ems. Cogniti#e Le#el:  )pp#ication Te$t e%erence:  p. 1*+, Nursing Process:  )ssessment NCLE&:  -hysio#ogica# ntegrity+.) triage nurse in a usy emergency department assesses a patient &ho comp#ains o! 6/10 a domina# pain and states'  had a temperature o! 102.63 F $20.,3 C% at home.4 The nurse5s !irst action shou#d e toa.te## the patient that it may e seera# hours e!ore eing seen y the doctor.  .assess the patient5s current ita# signs.c.o tain a c#eancatch urine !or urina#ysis.d.ask the hea#th care proider to order a nonopioid ana#gesic medication !or the patient. Correct !nswer: B ationale:  The patient5s pain and statement a out an e#eated temperature indicate that the nurse shou#d o tain ita# signs e!ore deciding ho& rapid#y the patient shou#d e seen y the hea#th care proider. ) urina#ysis may e needed' ut ita# signs &i## proide the nurse &ith more use!u# data !or triage. The hea#th care proider &i## not order a medication e!ore assessing the patient. Cogniti#e Le#el:  )pp#ication Te$t e%erence:  pp. 1*++1*+, Nursing Process:  )ssessment NCLE&:  -hysio#ogica# ntegrity,.During the primary assessment o! a trauma ictim' the nurse determines that the patient has a patent air&ay. The ne7t assessment y the nurse shou#d e toa.check the patient5s #ee# o! consciousness.  .e7amine the patient !or any e7terna# #eeding.c.o sere the patient5s respiratory e!!ort.d.pa#pate !or the presence o! periphera# pu#ses. Correct !nswer: C ationale:  Een &ith a patent air&ay' patients can hae other pro #ems that compromise enti#ation' so the ne7t action is to assess the patient5s   reathing. The other actions are a#so part o! the initia# surey ut are not accomp#ished as rapid#y as the assessment o! reathing. Cogniti#e Le#el:  )pp#ication Te$t e%erence:  p. 1*+, Nursing Process:  )ssessment NCLE&:  -hysio#ogica# ntegrity2.During the primary assessment o! a patient &ith mu#tip#e trauma' the nurse o seres that the patient5s right peda# pu#ses are a sent and the #eg is s&o##en. The nurse5s !irst action shou#d e toa.initiate isotonic !#uid in!usion through t&o #arge ore 8 #ines.  .send #ood to the #a !or a comp#ete #ood count $CBC%.c.!inish the air&ay' reathing' circu#ation' disa i#ity surey.d.assess !urther !or a cause o! the decreased circu#ation. Correct !nswer: ) ationale:  The assessment data indicate that the patient may hae arteria# trauma and hemorrhage. hen a possi #y #i!ethreatening in(ury is !ound during the primary surey' the nurse shou#d immediate#y start interentions e!ore proceeding &ith the surey. )#though a CBC is indicated' administration o! 8 !#uids shou#d e started !irst. Comp#etion o! the primary surey and !urther assessment shou#d e comp#eted a!ter the 8 !#uids are initiated. Cogniti#e Le#el:  )pp#ication Te$t e%erence:  pp. 1*++1*+2 Nursing Process:  mp#ementation NCLE&:  -hysio#ogica# ntegrity Copyright  +00; y Mos y' nc.' an a!!i#iate o! E#seier nc.  <.hen caring !or a patient &ith head and neck trauma a!ter a motorcyc#e accident' the emergency department nurse5s !irst action shou#d e toa.suction the mouth and oropharyn7.  .immo i#i=e the cerica# spine.c.administer supp#ementa# o7ygen.d.o tain enous access. Correct !nswer: B ationale:  hen there is a risk o! spina# cord in(ury' the nurse5s initia# action is immo i#i=ation o! the cerica# spine during positioning o! the head and neck !or air&ay management. >uctioning' supp#ementa# o7ygen administration' and enous access are a#so necessary a!ter the cerica# spine is protected y immo i#i=ation. Cogniti#e Le#el:  )pp#ication Te$t e%erence:  p. 1*+, Nursing Process:  mp#ementation NCLE&:  -hysio#ogica# ntegrity6.) patient has een rought to the emergency department &ith a gunshot &ound to the a domen. n o taining a history o! the incident to determine possi #e in(uries' the nurse asksa.here did the incident occur?4  .hat direction did the u##et enter the ody?4c.@o& #ong ago did the incident happen?4d.hat emergency care &as started at the scene?4 Correct !nswer: B ationale:  The entry point and direction o! the u##et &i## he#p to predict the type o! in(uries the patient has. The other in!ormation is not as use!u# in determining &hich diagnostic studies and care are needed immediate#y. Cogniti#e Le#el:  )pp#ication Te$t e%erence:  pp. 1*+<1*+6 Nursing Process:  )ssessment NCLE&:  -hysio#ogica# ntegrity;.) 6;yearo#d patient &ho has !a##en !rom a #adder is transported to the emergency department y am u#ance. The patient is unconscious on arria# and accompanied y !ami#y mem ers. During the primary surey o! the patient' the nurse shou#da.assess the patient5s ita# signs.  .o tain a A#asgo& Coma >ca#e score.c.attach a cardiac ECA monitor.d.ask a out chronic medica# conditions. Correct !nswer: B ationale:  The A#asgo& Coma >ca#e is inc#uded &hen assessing !or disa i#ity during the primary surey. The other in!ormation is part o! the secondary surey. Cogniti#e Le#el:  )pp#ication Te$t e%erence:  p. 1*+2 Nursing Process:  )ssessment NCLE&:  -hysio#ogica# ntegrity*.) +2yearo#d is rought to the emergency department &ith mu#tip#e #acerations and tissue au#sion o! the right hand a!ter catching the handin a produce coneyor e#t. hen asked a out tetanus immuni=ation' the patient says' 5e neer had any accinations.4 The nurse &i## anticipate administration o! tetanusa.immunog#o u#in.  .and diphtheria to7oid.c.immunog#o u#in' tetanusdiphtheria to7oid' and pertussis accine.d.immunog#o u#in and tetanusdiphtheria to7oid. Correct !nswer: C ationale:  For a patient &ith unkno&n immuni=ation status' the tetanus immune g#o u#in is administered a#ong &ith the Tdap $since the patient has not had pertussis accine preious#y%. The other immuni=ations are not su!!icient !or this patient. Cogniti#e Le#el:  )pp#ication Te$t e%erence:  p. 1*+* Nursing Process:  -#anning NCLE&:  @ea#th -romotion and Maintenance9.) patient has e7perienced #unt a domina# trauma !rom a motor ehic#e accident. The nurse shou#d e7p#ain to the patient the purpose o! a.magnetic resonance imaging $M%.  .u#trasonography.c.peritonea# #aage.d.nasogastric $NA% tu e p#acement. Copyright  +00; y Mos y' nc.' an a!!i#iate o! E#seier nc.  Correct !nswer: B ationale:  ! intraa domina# #eeding is suspected' !ocused a domina# u#trasonography is o tained to #ook !or intraperitonea# #eeding. M &ou#d not e used. -eritonea# #aage is an a#ternatie' ut it is more inasie. )n NA tu e &ou#d not e he#p!u# in diagnosis o! intraa domina#   #eeding. Cogniti#e Le#el:  )pp#ication Te$t e%erence:  p. 1*+; Nursing Process:  -#anning NCLE&:  -hysio#ogica# ntegrity10.) patient is rought to the hospita# in cardiac arrest y emergency personne# &ho are per!orming resuscitation. The spouse arries as the  patient is taken into a treatment room and asks to stay &ith the patient. The nurse shou#da.hae the spouse &ait outside the treatment room &ith a designated sta!! mem er to proide emotiona# support.  . ring the spouse into the room and ensure him or her that a mem er o! the team &i## e7p#ain the care gien and ans&er uestions.c.e7p#ain that the presence o! !ami#y mem ers is distracting to sta!! and might impair the resuscitation e!!orts.d.adise the spouse that i! the resuscitation e!!ort is unsuccess!u#' the memories may hae an aderse impact on grieing. Correct !nswer: B ationale:  Fami#y mem ers and patients report ene!its !rom !ami#y presence during resuscitation e!!orts' so the nurse shou#d try to accommodate the spouse. @aing the spouse &ait outside the room is not as supportie to the spouse or patient. t &ou#d e inappropriate to imp#y that the spouse5s presence &ou#d hae aderse conseuences !or the patient. Fami#y mem ers do not report pro #ems &ith grieing caused   y eing present during resuscitation e!!orts. Cogniti#e Le#el:  )pp#ication Te$t e%erence:  pp. 1*+<1*+6 Nursing Process:  mp#ementation NCLE&:  -sychosocia# ntegrity11.During the summer' a patient &ith heat cramps is treated in the emergency department. The nurse determines that discharge teaching regarding the preention o! another episode o! heat cramps has een e!!ectie &hen the patient states'a. &i## take sa#t ta #ets &hen  &ork outdoors in the summer.4  . shou#d dou #e my &ater intake &hen the &eather gets &arm.4c. shou#d hae sports drinks &hen e7ercising outside in hot &eather.4d. &i## get into a coo# enironment i!  notice that  am !ee#ing con!used.4 Correct !nswer: C ationale:  E#ectro#yte so#utions such as sports drinks he#p rep#ace !#uid and e#ectro#ytes #ost &hen e7ercising in hot &eather. >a#t ta #ets are not recommended ecause o! the risks o! gastric irritation and hypernatremia. t is not necessary to dou #e one5s &ater intake simp#y &hen the &eather is &arm. ) patient &ho is con!used is #ike#y to hae more seere hyperthermia and &i## e una #e to remem er to take appropriate action. Cogniti#e Le#el:  )pp#ication Te$t e%erence:  pp. 1*+91*,0 Nursing Process:  Ea#uation NCLE&:  -hysio#ogica# ntegrity1+.)n unresponsie ;*yearo#d patient is admitted to the emergency department in a coma during a summer heat &ae. The patient5s core temperature is 106.+ F $21.+ C%' #ood pressure $B-% *6/<+' and pu#se 10+. The nurse &i## p#an toa.app#y &et sheets and a !an to the patient.  .administer an acetaminophen $Ty#eno#% suppository.c.start  +  at 6 /min &ith a nasa# cannu#a.d.in!use #actated inger5s so#ution at 1000 m#/hr. Correct !nswer: ) ationale:  The priority interention is to coo# the patient. )ntipyretics are not e!!ectie in decreasing temperature in heat stroke' and 100G o7ygen shou#d e gien' &hich reuires a high !#o& rate through a nonre reathing mask. )n o#der patient &ou#d e at risk !or dee#oping comp#ications such as pu#monary edema i! gien !#uids at 1000 m#/hr. Cogniti#e Le#el:  )pp#ication Te$t e%erence:  pp. 1*+91*,0 Nursing Process:  -#anning NCLE&:  -hysio#ogica# ntegrity1,.) ;;yearo#d patient is rought into the emergency department unconscious and &ith a core temperature o! *9 F $,1.6 C%. During re&arming measures' the nurse determines that the goa#s o! treatment are eing met &hen the patienta.has a core temperature o! 9< F $,< C%.  .shiers ino#untari#y to raise ody temperature.c.regains consciousness.d.has a #ood p@ &ithin norma# #imits. Correct !nswer: ) ationale:  The improement in the patient5s ody temperature is the est indication that the goa#s o! re&arming are eing met. >hiering' improement in #ee# o! consciousness $C%' and norma#i=ation o! p@ a## might con!irm that the patient5s condition is improing' ut they are not as c#ear as the e#eation in temperature. Copyright  +00; y Mos y' nc.' an a!!i#iate o! E#seier nc.  Cogniti#e Le#el:  )pp#ication Te$t e%erence:  p. 1*,1 Nursing Process:  Ea#uation NCLE&:  -hysio#ogica# ntegrity12.hen preparing to re&arm a patient &ith hypothermia' the nurse &i## p#an toa.attach a cardiac monitor.  .insert a urinary catheter.c.assist &ith endotrachea# intu ation.d.keep inotropic drugs aai#a #e. Correct !nswer: ) ationale:  e&arming can produce dysrhythmias' so the patient shou#d e monitored and treated i! necessary. Hrinary catheteri=ation and endotrachea# intu ation are not needed !or re&arming. Cardiac inotropes tend to stimu#ate the heart and increase the risk !or !ata# dysrhythmias such as entricu#ar !i ri##ation. Cogniti#e Le#el:  )pp#ication Te$t e%erence:  pp. 1*,11*,+ Nursing Process:  -#anning NCLE&:  -hysio#ogica# ntegrity1<.) patient is admitted to the emergency department a!ter a neardro&ning accident in a #oca# #ake. The patient receied rescue reathing at the site and no& has spontaneous respirations. The nurse &i## o sere the patient !or seera# hours to monitor !or symptoms o! a.hypernatremia.  .pu#monary edema.c.hypothermia.d.head in(ury. Correct !nswer: B ationale:  -u#monary edema is a common comp#ication a!ter a neardro&ning incident. @ypernatremia &ou#d not occur in a !resh&ater su mersion. @ypothermia and head in(ury may e associated &ith neardro&ning ut &ou#d e apparent at the time o! admission and &ou#d not dee#op a!ter seera# hours. Cogniti#e Le#el:  )pp#ication Te$t e%erence:  p. 1*,+ Nursing Process:  mp#ementation NCLE&:  -hysio#ogica# ntegrity16.)## o! the !o##o&ing actions are needed !or a patient admitted &ith mu#tip#e ee stings to the hands. hich one &i## the nurse accomp#ish !irst?a.Aie diphenhydramine $Benadry#% 100 mg po.  .)pp#y ca#amine #otion to any itching areas.c.-#ace ice packs on oth hands.d.emoe the patient5s rings. Correct !nswer: D ationale:  The patient5s rings shou#d e remoed !irst ecause it might not e possi #e to remoe them i! s&e##ing dee#ops. The other orders shou#d a#so e imp#emented as rapid#y as possi #e a!ter the nurse has remoed the (e&e#ry. Cogniti#e Le#el:  )pp#ication Te$t e%erence:  p. 1*,2 Nursing Process:  mp#ementation NCLE&:  -hysio#ogica# ntegrity1;.)n unconscious patient is admitted to the emergency department 2< minutes a!ter ingesting appro7imate#y ,0 dia=epam $8a#ium% ta #ets. The hea#th care proider prescri es gastric #aage. The !irst action the nurse &i## p#an &hen imp#ementing the order is toa.position the patient on his or her side.  .insert a #arge ore nasogastric tu e.c.assist the hea#th care proider to intu ate the patient.d.prepare a 60m# syringe &ith sa#ine. Correct !nswer: C ationale:  )n unconscious patient cannot protect the air&ay and is at risk !or aspiration during gastric #aage' so intu ation is done e!ore starting the #aage. -ositioning the patient on his or her side &i## decrease the risk !or aspiration' ut the patient &i## need to e supine !or intu ation. )n orogastric tu e is used !or gastric #aage. The sa#ine &i## e in(ected a!ter the intu ation. Cogniti#e Le#el:  )pp#ication Te$t e%erence:  p. 1*,; Nursing Process:  -#anning NCLE&:  >a!e and E!!ectie Care Enironment Copyright  +00; y Mos y' nc.' an a!!i#iate o! E#seier nc.
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