The physician notes that an unconscious patient brought to the emergency room needs emergency surgery. No family members are present, and the patient does not have identification. Which of the following actions by the nurse is most important regarding obtaining consent to examine and treat the pati...
The physician notes that an unconscious patient brought to the emergency room needs
emergency surgery. No family members are present, and the patient does not have
identification. Which of the following actions by the nurse is most important regarding
obtaining consent to examine and treat the patient?
A) Ask the social worker to come and sign the consent.
B) Contact the police to obtain the patient's identity.
C) Obtain a court order to treat the patient.
D) Document in the patient's chart the level of consciousness and health status of
patient. - CORRECT-ANSWER-D
Feedback: When a patient is unconscious and in critical condition, the level of
consciousness and health status of the patient should be documented so that treatment
can be quickly administered when consent cannot be obtained by usual routes.
The most appropriate nursing diagnosis for a patient who has difficulty maintaining a
patent airway due to hemorrhage in the oral cavity would be:
A) Ineffective airway clearance
B) Impaired swallowing
C) Risk for trauma
D) Ineffective individual coping - CORRECT-ANSWER-A
A patient who has broken his femur presents to the emergency department with the
following signs and symptoms: cool, moist skin, increased heart rate, and falling blood
pressure. The nurse suspects the patient is experiencing:
A) Low blood glucose
B) High blood glucose
C) Hemorrhage
D) Fluid volume excess - CORRECT-ANSWER-C
Which of the following injuries would take highest priority if demonstrated by the patient
entering the emergency department?
A) Open fracture of the femur
B) Laceration of the forearm
C) Stabbing to the chest
D) Traumatic amputation of foot - CORRECT-ANSWER-C
A patient enters the emergency department with a gunshot wound to the abdomen. The
most common hollow organ injured in this way is the:
A) Liver
B) Small bowel
C) Stomach
D) Large bowel - CORRECT-ANSWER-B
,To assess for internal injury in the peritoneum of a patient who has sustained blunt
abdominal injuries in a fall, the most effective diagnostic test is a:
A) Radiograph
B) Computed tomography (CT) scan
C) Complete blood count
D) Barium swallow - CORRECT-ANSWER-B
After immediate threats to life have been corrected in a patient with multiple trauma, the
nurse and trauma team will:
A) Perform a rapid physical assessment
B) Splint fractures
C) Perform a thorough physical examination
D) Establish the patient's age - CORRECT-ANSWER-A
A male patient with multiple injuries has had his airway stabilized and is breathing on his
own. The nurse does not see any bleeding but suspects internal hemorrhage when the
patient:
A) Complains of pain at wound sites
B) Has increased pulse rate
C) Has increased blood pressure
D) Has increased urine output - CORRECT-ANSWER-B
The nurse caring for a patient with suspected alcohol intoxication assesses for which
condition that can mimic acute alcohol intoxication?
A) Hypoglycemia
B) Hyperglycemia
C) Hyponatremia
D) Hypokalemia - CORRECT-ANSWER-A
When treating a patient with alcohol withdrawal syndrome, to minimize the potential for
hallucinations the nurse should:
A) Place the patient in a room with roommates.
B) Turn the lights to low illumination.
C) Close the closet doors.
D) Leave the television on at all times. - CORRECT-ANSWER-C
A client is admitted to the ED after being involved in a MVC. The client has multiple
injuries. After establishing an airway and adequate ventilation, the ED team should
prioritize what aspect of care?
A) Control the client's hemorrhage
B) Assess for cognitive effects of the injury
C) Splint the client's fractures
D) Assess the client's neurologic status - CORRECT-ANSWER-A
, A client is brought to the ED by friends. The friends tell the nurse that the client was
using cocaine at a part. On arrival to the ED the client is in visible distress with an
axillary temperature of 104.2. What would be the priority nursing action for this client?
A) Monitor cardiovascular effects
B) Administer antipyretics
C) Ensure airway and ventilation
D) Prevent seizure activity - CORRECT-ANSWER-C
The nurse is caring for a client admitted with a drug overdose. What is the nurse's
priority responsibility in caring for this client?
A) Support the client's respiratory and cardiovascular function
B) Provide for the safety of the client
C) Enhance clearance of the offending agent
D) Ensure the safety of the staff - CORRECT-ANSWER-A
A client is admitted to the ED with an apparent overdose of IV heroin. After stabilizing
the client's cardiopulmonary status, the nurse should prepare to perform what
intervention?
A) Administer a bolus of lactated Ringer's
B) Administer naloxone hydrochloride
C) Insert an indwelling urinary catheter
D) Perform a focused neurologic assessment - CORRECT-ANSWER-B
A client is being treated for bites suffered during an assault. After the bites have been
examined by the HCP, the nurse should do what prior to wound care?
A. Apply gauze soaked with chlorhexidine
B. Document the wounds by photograph
C. Administer a hepatitis B vaccination
D. Assess the client's immunization history - CORRECT-ANSWER-B
A workplace explosion has produced over 100 injuries, including a 40-year-old-man with
full thickness burns over 75% of his body. Despite his injuries, the man is conscious.
During a mass casualty incident (MCI) how would this person be triaged?
A) Green
B) Yellow
C) Red
D) Black - CORRECT-ANSWER-D
A client who has been exposed to anthrax is being treated in the local hospital. The
nurse should prioritize what health assessments?
A) Integumentary assessment
B) Assessment for signs of hemorrhage
C) Neurologic assessment
D) Assessment of respiratory status - CORRECT-ANSWER-D
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