FULL-TEXT: Emergency Nursing & Triage NCLEX Practice (40 Questions)

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Emergency Nursing NCLEX Practice Quiz #1 (20 Questions)

Question-1-001

Nurse Ejay is assigned to telephone triage. A client called who was stung by a honeybee and is asking for help. The client reports pain and localized swelling but has no respiratory distress or other symptoms of anaphylactic shock. What is the appropriate initial action that the nurse should direct the client to perform?

  • A. Removing the stinger by scraping it.
  • B. Applying a cold compress.
  • C. Taking an oral antihistamine.
  • D. Calling 911.

Correct Answer: A. Removing the stinger by scraping it.

Since the stinger will continue to release venom into the skin, removing the stinger should be the first action that the nurse should direct to the client. Within the first few minutes after the sting, the stinger should be removed via scraping with a credit card rather than squeezing/tweezing to avoid further venom exposure.

  • Option B: Uncomplicated local reactions can be treated with supportive care (ice packs, NSAIDs/APAP for pain, H1/H2 blocker). Cold compress follows the administration of antihistamine. Large local reactions should also be treated with supportive care along with glucocorticoids (usually a burst course of prednisone 40 to 60 mg per day for 3 to 5 days) to decrease the inflammatory response and improve symptoms.
  • Option C: After removing the stinger, an antihistamine is administered. H1 and H2 antagonists block the effects of histamine decreasing pruritus, erythema, and urticaria. Corticosteroids (prednisone, methylprednisolone, dexamethasone) act to decrease inflammation and immune response to the antigen.
  • Option D: The caller should be further advised about symptoms that require 911 assistance. Systemic reactions (anaphylaxis) are life-threatening and should be managed as such. ABCs first. The airway can be lost within seconds to minutes, so intubate early. As with any anaphylactic reaction, epinephrine, corticosteroids, H1 and H2 antagonists, and intravenous (IV) fluids should be given immediately.

Question-1-002

Nurse Anna is an experienced travel nurse who was recently employed and is assigned to the emergency unit. In her first week of the job, which of the following areas is the most appropriate assignment for her?

  • A. Triage
  • B. Ambulatory section
  • C. Trauma team
  • D. Psychiatric care

Correct Answer: B. Ambulatory section

The ambulatory section deals with clients with relatively stable conditions. The decision of whether or not to delegate or assign is based upon the RN’s judgment concerning the condition of the patient, the competence of all members of the nursing team and the degree of supervision that will be required of the RN if a task is delegated.

  • Option A: The RN delegates only those tasks for which he or she believes the other health care worker has the knowledge and skill to perform, taking into consideration training, cultural competence, experience and facility/agency policies and procedures.
  • Option C: This area should be filled with nurses who are experienced with hospital routines and policies and have the ability to locate equipment immediately. There is both individual accountability and organizational accountability for delegation. Organizational accountability for delegation relates to providing sufficient resources, including sufficient staffing with an appropriate staff mix.
    Option D: Few places are more hectic than a Hospital Emergency Room. Clearly, delegating important nursing tasks is the only plausible way for short-staffed emergency rooms to meet the challenges of providing quality patient care. All decisions related to delegation and assignment are based on the fundamental principles of protection of the health, safety, and welfare of the public.

Question-1-003

A client arrives at the emergency department who suffered multiple injuries from a head-on car collision. Which of the following assessments should take the highest priority to take?

  • A. Unequal pupils
  • B. Irregular pulse
  • C. Ecchymosis in the flank area
  • D. A deviated trachea

Correct Answer: D. A deviated trachea

A deviated trachea is a symptom of tension pneumothorax, which will result in respiratory distress if left untreated. The first question in the ESI triage algorithm for triage nurses asks whether “the patient requires immediate life-saving interventions” or simply “is the patient dying?” The nurse determines this by looking to see if the patient has a patent airway, if the patient is breathing, and if the patient has a pulse.

  • Option A: Another scale used by nurses in the assessment is if the patient is meeting criteria for a true level 1 trauma is the AVPU (alert, verbal, pain, unresponsive) scale. The scale is used to evaluate if the patient had a recent or sudden change in the level of consciousness and needs immediate intervention.
  • Option B: The nurse evaluates the patient, checking pulse, rhythm, rate, and airway patency. Is there concern for inadequate oxygenation? Is this person hemodynamically stable? Does the patient need any immediate medication or interventions to replace volume or blood loss? Does this patient have pulselessness, apnea, severe respiratory distress, oxygen saturation below 90, acute mental status changes, or unresponsiveness?
  • Option C: If the patient is not categorized as a level 1, the nurse then decides if the patient should wait or not. This is determined by three questions; is the patient in a high-risk situation, confused, lethargic, or disoriented? Or is the patient in severe pain or distress? The high-risk patient is one who could easily deteriorate, one who could have a threat to life, limb, or organ.

Question-1-004

Nurse Kelly, a triage nurse, encountered a client who complained of mid-sternal chest pain, dizziness, and diaphoresis. Which of the following nursing actions should take priority?

  • A. Administer oxygen therapy via nasal cannula.
  • B. Notify the physician.
  • C. Complete history taking.
  • D. Put the client on ECG monitoring.

Correct Answer: A. Administer oxygen therapy via nasal cannula.

The priority goal is to increase myocardial oxygenation. Place the patient on a cardiac monitor, establish intravascular access (IV) access, give 162 mg to 325 mg chewable aspirin, clopidogrel, or ticagrelor (unless bypass surgery is imminent), control pain and consider oxygen (O2) therapy.

  • Option B: Patients with non-ST elevation myocardial infarction (NSTEMI) and unstable angina should be admitted for cardiology consultation and workup. Patients with stable angina may be appropriate for outpatient workup.
  • Option C: Carefully review the patient’s medical history for cardiac history, coagulopathies, and kidney disease. Ask about family history, especially cardiac, and ask about social histories like drug use and tobacco use.
  • Option D: These actions are also appropriate and should be performed immediately. Electrocardiogram (ECG) preferably in the first 10 min of arrival, (consider serial ECGs). Patients with ST-elevation on ECG patients should receive immediate reperfusion therapy either pharmacologic (thrombolytics) or transfer to the catheterization laboratory for percutaneous coronary intervention (PCI).

Question-1-005

A group of people arrived at the emergency unit by a private car with complaints of periorbital swelling, cough, and tightness in the throat. There is a strong odor emanating from their clothes. They report exposure to a “gas bomb” that was set off in the house. What is the priority action?

  • A. Instruct personnel to don personal protective equipment.
  • B. Direct the clients to the cold or clean zone for immediate treatment.
  • C. Immediately remove other clients and visitors from the area.
  • D. Measure vital signs and auscultate lung sounds.
  • E. Direct the clients to the decontamination area.

Correct Answer: E. Direct the clients to the decontamination area.

Decontamination in a specified area is the priority. The decontamination and support areas are established within the Warm Zone, also referred to as the Contamination Reduction Zone. Decontamination involves thorough washing to remove contaminants.

  • Option A: Personnel should don personal protective equipment before assisting with decontamination or assessing the clients. Take precautionary measures to preserve the health and safety of emergency responders working within the Contamination Reduction (Warm) Zone and the Exclusion (Hot) Zone. This includes ensuring responders wear appropriate personal protective equipment (PPE).
  • Option B: The clients must undergo decontamination before entering cold or clean areas. In mass casualty incidents, decontamination corridors can be set up that consist of high volume, low-pressure water deluges. Assign personnel to decontamination stations to control and instruct victims when they enter the decontamination area.
  • Option C: Decontamination triage is especially important in mass casualty incidents and should not be confused with medical triage. Decontamination triage is the process of determining which victims require decontamination and which do not. Rapidly identifying victims who may not require decontamination can significantly reduce the time and resources needed for mass decontamination.
  • Option D: Set up or assign an area or building as a safe refuge/observation area for victims who do not require medical attention. Here they can be monitored for a delayed outbreak of symptoms or indications of residual contamination.

Question-1-006

When an unexpected death occurs in the emergency department, which task is the most appropriate to delegate to a nursing assistant?

  • A. Assisting with postmortem care.
  • B. Facilitate meetings between the family and the organ donor specialist.
  • C. Escorting the family to a place of privacy.
  • D. Help the family to collect belongings.

Correct Answer: A. Assisting with postmortem care.

Postmortem care requires some turning, cleaning, lifting, and so on, and the nursing assistant is able to assist with these duties. The use of NAPs increasingly demands registered nurses to delegate patient care tasks according to the principles of the ANA. These principles define nursing delegation as the “transfer of responsibility for the performance of an activity from one individual to another while retaining accountability for the outcome.”

  • Option B: The RN may delegate components of care, but does not delegate the nursing process itself. The practice of pervasive functions of assessment, planning, evaluation, and nursing judgment cannot be delegated. The decision of whether or not to delegate or assign is based upon the RN’s judgment concerning the condition of the patient, the competence of all members of the nursing team, and the degree of supervision that will be required of the RN if a task is delegated.
  • Option C: A licensed nurse should take responsibility for the other tasks to help the family begin the grieving process. The RN delegates only those tasks for which he or she believes the other health care worker has the knowledge and skill to perform, taking into consideration training, cultural competence, experience, and facility/agency policies and procedures.
  • Option D: In cases of questionable death, belongings may be retained for evidence, so the chain of custody would have to be maintained. The registered nurse individualized communication regarding the delegation to the nursing assistive personnel and client situation and the communication should be clear, concise, correct, and complete. The registered nurse verifies comprehension with the nursing assistive personnel and that the assistant accepts the delegation and the responsibility that accompanies it.

Question-1-007

The physician has ordered cooling measures for a child with a fever who is likely to be discharged when the temperature comes down. Which task would be appropriate to delegate to a nursing assistant?

  • A. Prepare and administer a tepid sponge bath.
  • B. Explain the need for giving cool fluids.
  • C. Assist the child in removing outer clothing.
  • D. Advise the parent to use acetaminophen (Tylenol) instead of aspirin.

Correct Answer: C. Assist the child in removing outer clothing.

The nursing assistant can help with the removal of outer clothing, which allows the heat to dissipate from the child’s skin. The client is the center of care. The needs of the client must be competently met with the knowledge, skills and abilities of the staff to meet these needs. In other words, the nurse who delegates aspects of care to other members of the nursing team must balance the needs of the client with the abilities of those to which the nurse is delegating tasks and aspects of care, among other things such as the scopes of practice and the policies and procedures within the particular healthcare facility.

  • Option A: Tepid baths are not usually given because of the possibility of shivering and rebound. Registered nurses who assign, delegate and/or provide nursing care to clients and groups of clients must report all significant changes that occur in terms of the client and their condition. For example, a significant change in a client’s laboratory values requires that the registered nurse report this to the nurse’s supervisor and doctor.
  • Option B: Explaining is a teaching function only appropriate for a registered nurse. The staff members’ levels of education, knowledge, past experiences, skills, abilities, and competencies are also evaluated and matched with the needs of all of the patients in the group of patients that will be cared for.
  • Option D: Advising is a teaching function that is the responsibility of the registered nurse. Delegation should be done according to the differentiated practice for each of the staff members. A patient care technician, a certified nursing assistant, a licensed practical nurse, an associate degree registered nurse and a bachelor’s degree registered nurse should not be delegated to the same aspects of nursing care.

Question-1-008

You are preparing a child for IV conscious sedation before the repair of a facial laceration. What information should you report immediately to the physician?

  • A. The child suddenly pulls out the IV.
  • B. The parent is not sure regarding the child’s tetanus immunization status.
  • C. The parent wants information about the IV conscious sedation.
  • D. The parent’s refusal of the administration of the IV sedation.

Correct Answer: D. The parent’s refusal of the administration of the IV sedation.

The refusal of the parents is an absolute contraindication; therefore the physician must be notified. But the autonomy of parents is very obviously different from the autonomy of patients to make decisions for themselves. While adult patients are generally thought to have an absolute right to refuse medical treatment for themselves, we don’t usually think that parents can refuse all medical treatment for their children.

  • Option A: The RN can reestablish the IV access. Parents’ views might, at least in some circumstances, influence whether or not treatment would be in a child’s best interests. Nurses and doctors are able to administer fluid directly into the veins using IV therapy. IV therapy is a relatively simple process that can be performed by nurses, but there are serious complications associated with it.
  • Option B: Tetanus status can be addressed later. Tetanus immunization is part of the DTaP (diphtheria, tetanus, and acellular pertussis) vaccinations. Kids usually get: a series of four doses of DTaP vaccine before 2 years of age. another dose at 4–6 years of age.
  • Option C: The RN can provide information about conscious sedation. Identifying teachable moments in clinical practice is an effective way to increase workplace learning with all nurses playing a role, not just nurse educators.

Question-1-009

The emergency medical service has transported a client with severe chest pain. As the client is being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and impalpable pulse. Which of the following tasks is appropriate to delegate to the nursing assistant?

  • A. Assisting with the intubation
  • B. Placing the defibrillator pads
  • C. Doing chest compressions
  • D. Initiating bag valve mask ventilation

Correct Answer: C. Doing chest compressions.

Performing chest compressions are within the training of a nurse assistant. Every good certified nursing assistant should be proficient at cardiopulmonary resuscitation (CPR). Basic Life Support (BLS) certification is the widely-used term for any form of CPR certification and is required for all Registered Nurses (RN) and Certified Nursing Assistants (CNA).

  • Option A: Due to the nature of critical care patients it is inevitable that nurses working in this setting will be called on to assist with tracheal intubation. This assistant role requires a high degree of knowledge and skills in order for the intubation procedure to be executed smoothly.
  • Option B: The defibrillator pads are clearly marked; however placement should be done by the RN or physician because of the potential for skin damage and electrical arcing. Most hospital nurses will be trained in advisory defibrillation, while a few will be trained in manual defibrillation.
  • Option C: The use of the bag valve mask requires practice, and usually a respiratory therapist will perform the function. Bag-valve-mask ventilation can be done with one person or two, but two-person BVM ventilation is easier and more effective because a tight seal must be achieved and this usually requires two hands on the mask.

Question-1-010

The nursing manager decides to form a committee to address the issue of violence against ED personnel. Which combination of employees would be best suited to fulfill this assignment?

  • A. ED physicians and charge nurses
  • B. RNs, LPNs, and nursing assistants
  • C. Experienced RNs and experienced paramedics
  • D. At least one representative from each group of ED personnel

Correct Answer: D. At least one representative from each group of ED personnel.

At least one representative from each group of ED personnel should be included because all employees are potential targets for violence in the ED. The diversity of the group should also be considered and assure that each department or each employee is represented. 

  • Option A: The policies against violence in the workplace must be developed by management and employee representatives, including the health and safety committee or representative, and union, if present.
  • Option B: Administrative practices may also include education and training for employees. This education and training would include not only information about the workplace’s policy and process to respond to incidents, but may also include how to respond to an incident of violence (e.g., emergency response, when to contact security or police, etc.).
  • Option C: Preventive measures generally fall into three categories, workplace design, administrative practices and work practices. All employees should know how to respond to customers or members of the public who may be angry or frustrated, such as how to de-escalate a conflict.

Question-1-011

A client suffered an amputation of the first and second digits in a chainsaw accident. Which task should be delegated to an LPN/LVN?

  • A. Cleansing the amputated digits and placing them directly into an ice slurry.
  • B. Wrapping the cleansed digits in saline-moistened gauze, sealing in a plastic container, and placing it in icy water.
  • C. Gently cleansing the amputated digits and the hand with povidone-iodine.
  • D. Cleansing the digits with sterile normal saline and placing it in a sterile cup with sterile normal saline.

Correct Answer: B. Wrapping the cleansed digits in saline-moistened gauze, sealing in a plastic container, and placing it in icy water.

Once a finger amputation has occurred, ischemic tolerance times are 12 hours if warm and up to 24 hours if cold. For more proximal amputations, these times are halved. The amputated part should be covered in a normal saline-soaked gauze, sealed in a plastic bag, and submerged in icy water with no direct contact with ice. If there is direct contact with ice, it could result in tissue damage and render the amputated part non-viable. 

  • Option A: The client is the center of care. The needs of the client must be competently met with the knowledge, skills and abilities of the staff to meet these needs. In other words, the nurse who delegates aspects of care to other members of the nursing team must balance the needs of the client with the abilities of those to which the nurse is delegating tasks and aspects of care, among other things such as the scopes of practice and the policies and procedures within the particular healthcare facility.
  • Option C: Based on these characteristics and the total client needs for the group of clients that the registered nurse is responsible and accountable for, the registered nurse determines and analyzes all of the health care needs for a group of clients; the registered nurse delegates care that matches the skills of the person that the nurse is delegating to..
  • Option D: The job of the registered nurse is far from done after client care has been delegated to members of the nursing team. The delegated care must be followed up on and the staff members have to be supervised as they deliver care. The registered nurse remains responsible for and accountable for the quality, appropriateness, completeness, and timeliness of all of the care that is delivered.

Question-1-012

A client arrives in the emergency unit and reports that a concentrated household cleaner was splashed in both eyes. Which of the following nursing actions is a priority?

  • A. Examine the client’s visual acuity
  • B. Patch the eye
  • C. Use restasis (Allergan) drops in the eye
  • D. Flush the eye repeatedly using sterile normal saline

Correct Answer: D. Flush the eye repeatedly using sterile normal saline.

Initial emergency action during a chemical splash to the eye includes immediate continuous irrigation of the affected eye with normal saline. Immediate irrigation with copious amounts of an isotonic solution as described previously is the mainstay of treatment for chemical burns. Never use any substance to neutralize chemical exposure as the exothermic reaction can lead to secondary thermal injuries.

  • Option A: After irrigation, visual acuity then is assessed. Irrigation should continue until the pH of the eye is between 7.0 to 7.4 and remains within this range for at least 30 minutes after the irrigation has been discontinued.
  • Option B: Patching the eye is not part of the first-line treatment of a chemical splash. Irrigation should be gentle, and care should be taken to avoid direct irrigation to the cornea to prevent further injury. Use of a commercial irrigation lens such as a Morgan lens may be helpful.
  • Option C: Restasis (Allergan) drops are used to treat dry eyes. A topical anesthetic such as tetracaine can be applied directly to the eye, or 10 mL of 1% lidocaine can be added to a liter of irrigating fluid, taking care not to reach a toxic dose if copious irrigation is required.

Question-1-013

A client was brought to the emergency department after suffering a closed head injury and lacerations around the face due to a hit-run accident. The client is unconscious and has a minimal response to noxious stimuli. Which of the following assessment findings, if observed after a few hours, should be reported to the physician immediately?

  • A. Drainage of a clear fluid from the client’s nose.
  • B. Withdrawal of the client in response to painful stimuli.
  • C. Bruises and minimal edema of the eyelids.
  • D. Bleeding around the lacerations.

Correct Answer: A. Drainage of a clear fluid from the client’s nose.

Clear drainage from the client’s nose indicates that there is a leakage of CSF and should be reported to the physician immediately. Symptoms of CSF leaks include a constant dripping of clear fluid from the nose, severe headaches and meningitis. Leaks of CSF are usually caused by blunt trauma to the head and/or ears or prior sinonasal surgery. 

  • Option B: This reflex protects humans against tissue necrosis from contact with noxious stimuli such as pain or heat. It can occur in either the upper or lower limbs. Specifically, the withdrawal reflex mediates the flexion of the limb that comes into contact with the noxious stimuli; it also inhibits the extensors of that same limb.
  • Option C: A good history concerning the mechanism of injury is important. Follow advanced trauma life support protocol and perform primary, secondary, and tertiary surveys. Once the patient is stabilized, a neurologic examination should be conducted.
  • Option D: Primary injury includes injury upon the initial impact that causes displacement of the brain due to direct impact, rapid acceleration-deceleration, or penetration. These injuries may cause contusions, hematomas, or axonal injuries.

Question-1-014

A 5-year-old client was admitted to the emergency unit due to the ingestion of an unknown amount of chewable vitamins for children at an unknown time. Upon assessment, the child is alert and with no symptoms. Which of the following information should be reported to the physician immediately?

  • A. The child was nauseated and vomited once at home.
  • B. The child has been treated several times for toxic substance ingestion.
  • C. The vitamin that was ingested contains iron.
  • D. The child has been treated multiple times for injuries caused by accidents.

Correct Answer: C. The vitamin that was ingested contains iron.

Iron is a toxic substance that can lead to massive hemorrhage, shock, coma, and kidney failure. Iron poisoning is one of the most common toxic ingestion and one of the most deadly among children. Failure to diagnose and treat iron poisoning can have serious consequences including multi-organ failure and death.

  • Option A: During the first stage (0.5 to 6 hours), the patient mainly exhibits gastrointestinal (GI) symptoms including abdominal pain, vomiting, diarrhea, hematemesis, and hematochezia. The second stage (6 to 24 hours) represents an apparent recovery phase, as the patient’s GI symptoms may resolve despite toxic amounts of iron absorption.
  • Option B: Patients who have GI symptoms that resolve after a short period of time and have normal vital signs require supportive care and an observation period, as it may represent the second stage of iron toxicity. Patients who remain asymptomatic 4 to 6 hours after ingestion or those who have not ingested a potentially toxic amount do not require any treatment for iron toxicity.
  • Option D: This information needs further investigation but will not change the immediate diagnostic testing or treatment plan. Patients who have GI symptoms that resolve after a short period of time and have normal vital signs require supportive care and an observation period, as it may represent the second stage of iron toxicity.

Question-1-015

The following clients come to the emergency department complaining of acute abdominal pain. Prioritize them for care in order of the severity of the conditions.

  1. A 59-year-old man with a pulsating abdominal mass and sudden onset of persistent abdominal or back pain, which can be described as a tearing sensation within the past hour.
  2. A 27-year-old woman complaining of lightheadedness and severe sharp left lower quadrant pain who reports she is possibly pregnant.
  3. A 15-year-old boy with a low-grade fever, right lower quadrant pain, vomiting, nausea, and loss of appetite for the past few days.
  4. A 43-year-old woman with moderate right upper quadrant pain who has vomited small amounts of yellow bile and whose symptoms have worsened over the week.
  5. A 57-year-old woman who complains of a sore throat and gnawing midepigastric pain that is worse between meals and during the night.

The correct order is shown above.

Rationale:

  1. The client with a pulsating mass has an abdominal aneurysm that may rupture and he may decompensate easily. An abdominal aortic aneurysm is a life-threatening condition that requires monitoring or treatment depending upon the size of the aneurysm and/or symptomatology.
  2. The woman with lower left quadrant pain is at risk for a life-threatening ectopic pregnancy. An ectopic pregnancy occurs when fetal tissue implants outside of the uterus or attaches to an abnormal or scarred portion of the uterus. Ectopic pregnancies carry high rates of morbidity and mortality if not recognized and treated promptly.
  3. The 15-year-old boy needs evaluation to rule out appendicitis. It should be considered in any patient with acute abdominal pain without a prior appendectomy. The diagnosis must be made as quickly as possible because with time, the rate of rupture increases.
  4. The woman with vomiting needs evaluation for gallbladder problems, which appear to be worsening. Disruption of the gallbladder’s normal physiology can result in a significant medical burden. Over 20 million Americans suffer from gallbladder disease and cholecystectomy is one of the most common surgeries performed.
  5. Lastly, the woman with mid-epigastric pain is suffering from an ulcer, but follow-up diagnostic testing can be scheduled with a primary care provider. It is important to understand this disease process is both preventable and treatable. Patients may be treated differently depending on the etiology of their gastric ulcer.

Question-1-016

The following clients are presented with signs and symptoms of heat-related illness. Which of them needs to be attended first?

  • A. A relatively healthy homemaker who reports that the air conditioner has been broken for days and who manifests fatigue, hypotension, tachypnea, and profuse sweating.
  • B. An elderly person who complains of dizziness and syncope after standing in the sun for several hours to view a parade.
  • C. A homeless person who is a poor historian; has altered mental status, poor muscle coordination, and hot, dry ashen skin; and whose duration of heat exposure is unknown.
  • D. A marathon runner who complains of severe leg cramps and nausea, and manifests weakness, pallor, diaphoresis, and tachycardia.

Correct Answer: C. A homeless person who is a poor historian; has altered mental status, poor muscle coordination, and hot, dry ashen skin; and whose duration of heat exposure is unknown.

The signs and symptoms manifested by the homeless person indicate that a heat stroke is happening, a medical emergency, which can lead to brain damage. Also, there must be clinical signs of central nervous system dysfunction that may include ataxia, delirium, or seizures, in the setting of exposure to hot weather or strenuous physical exertion. Patients who present with heat stroke typically have vital sign abnormalities to include an elevated core body temperature, sinus tachycardia, tachypnea, a widened pulse pressure, and a quarter of patients will be hypotensive.

  • Option A: The homemaker is experiencing heat exhaustion, which can be managed by fluids and cooling measures. It is important to differentiate where the patient is on the heat illness continuum. The signs and symptoms of heat exhaustion may present similarly include cramping, fatigue, dizziness, nausea, vomiting, headache. If progression to end-organ damage occurs it then becomes heat injury.
  • Option B: The elderly client is at risk for heat syncope and should be advised to rest in a cool area and avoid similar situations. Heat syncope is the temporary, self-limited dizziness, weakness, or loss of consciousness during prolonged standing or positional changes in a hot environment, including physical activity. The thinking is that it is due to a combination of dehydration, pooling of blood in the venous system, decreased cardiac filling, and low blood pressure, which leads to decreased cerebral blood flow.
  • Option D: The runner is experiencing heat cramps, which can be managed with fluid and rest. Heat cramps: include involuntary spasmodic contractions of large muscle groups as opposed to an isolated muscle spasm/cramp that can also occur during or after exertion. This condition is due to a relative deficiency of sodium, potassium, chloride, or magnesium. Other symptoms may include nausea, vomiting, fatigue, weakness, sweating, and tachycardia.

Question-1-017

An anxious female client complains of chest tightness, tingling sensations, and palpitations. Deep, rapid breathing, and carpal spasms are noted. Which of the following priority actions should the nurse do first?

  • A. Provide oxygen therapy.
  • B. Notify the physician immediately.
  • C. Administer anxiolytic medication as ordered.
  • D. Have the client breathe into a brown paper bag.

Correct Answer: D. Have the client breathe into a brown paper bag

The client is suffering from hyperventilation secondary to anxiety, the initial action is to let the client breathe in a paper bag that will allow the rebreathing of carbon dioxide. The idea behind breathing into a paper bag or mask is that rebreathing exhaled air helps the body put CO2 back into the blood.

  • Option A: Acute anxiety may require treatment with a benzodiazepine. Chronic anxiety treatment consists of psychotherapy, pharmacotherapy, or a combination of both. Anxiety disorders appear to be caused by an interaction of biopsychosocial factors. Genetic vulnerability interacts with situations that are stressful or traumatic to produce clinically significant syndromes.
  • Option B: Anxiety is one of the most common psychiatric disorders but the true prevalence is not known as many people do not seek help or clinicians fail to make the diagnosis. Anxiety is one of the most common psychiatric disorders in the general population. Specific phobia is the most common with a 12-month prevalence rate of 12.1%. Social anxiety disorder is the next most common, with a 12-month prevalence rate of 7.4%.
  • Option C: Selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), benzodiazepines, tricyclic antidepressants, mild tranquilizers, and beta-blockers treat anxiety disorders.

Question-1-018

An intoxicated client comes into the emergency unit with uncooperative behavior, mild confusion, and slurred speech. The client is unable to provide a good history but he verbalizes that he has been drinking a lot. Which of the following is a priority action of the nurse?

  • A. Administer IV fluid incorporated with Vitamin B1 as ordered.
  • B. Administer Naloxone (Narcan) 4 mg as ordered.
  • C. Contact the family to get information about the client.
  • D. Obtain an order for the determination of blood alcohol level.

Correct Answer: A. Administer IV fluid incorporated with Vitamin B1 as ordered.

The client has symptoms of alcohol abuse and there is a risk for Wernicke syndrome, which is caused by a deficiency in Vitamin B. Thiamine deficiency (vitamin B1) is common in patients with alcohol dependence. Cognitive impairments may be an early consequence of thiamine deficiency. Wernicke’s encephalopathy is underdiagnosed and undertreated.

  • Option B: Multiple drug abuse is not uncommon; however, there is currently nothing to suggest an opiate overdose that requires the administration of naloxone. Naloxone is indicated for the treatment of opioid toxicity, specifically to reverse respiratory depression from opioid use. It is useful in accidental or intentional overdose and acute or chronic toxicity.
  • Option C: Teens and young adults are at higher risk for binge drinking, which can cause alcohol poisoning. Binge drinking is a pattern of drinking that raises the blood alcohol level within a short period of time. Though it varies from person to person, binge drinking is usually defined as four drinks for women and five drinks for men in a two-hour period.
  • Option D: Additional information or the results of the blood alcohol testing are part of the management but should not delay the immediate treatment. A blood alcohol test may be used to find out if the patient has alcohol poisoning, a life-threatening condition that happens when your blood alcohol level gets very high. Alcohol poisoning can seriously affect basic body functions, including breathing, heart rate, and temperature.

Question-1-019

A nurse is providing discharge instructions to a woman who has been treated for contusions and bruises due to domestic violence. What is the priority intervention for this client?

  • A. Arranging transportation to a safe house.
  • B. Advising the client about contacting the police.
  • C. Making an appointment to follow up on the injuries.
  • D. Making a referral to a counselor.

Correct Answer: A. Arranging transportation to a safe house.

Safety is a priority for this client and she should not return to a place where violence could recur. Make sure a safe environment is provided. Offer shelter options, legal services, counseling, and facilitate such referral.

  • Option B: If the patient does not want to go to a shelter, provide telephone numbers for domestic violence or crisis hotlines and support services for potential later use. Provide the patient with instructions but be mindful that written materials may pose a danger once the patient returns home.
  • Option C: Without proper social service and mental health intervention, all forms of abuse can be recurrent and escalating problems, and the prognosis for recovery is poor. Without treatment, domestic and family violence usually recurs and escalates in both frequency and severity.
  • Option D: These are important for the long-term management of this case. Health professionals provide an opportunity for victims of domestic violence to obtain help. Of those injured by domestic violence, over 75% continue to experience abuse. Over half of battered women who attempt suicide will try again; often they are successful with the second attempt.

Question-1-020

In the work setting, what is the primary responsibility of the nurse in preparation for disaster management, that includes natural disasters and bioterrorism incidents?

  • A. Being aware of the signs and symptoms of potential agents of bioterrorism.
  • B. Making ethical decisions regarding exposing self to potentially lethal substances.
  • C. Being aware of the agency’s emergency response plan.
  • D. Being aware of what and how to report to the Centers for Disease Control and Prevention.

Correct Answer: C. Being aware of the agency’s emergency response plan.

In disaster preparedness, the nurse should know the emergency response plan. This gives guidance that includes the roles of the team members, responsibilities, and mechanisms of reporting. Emergency preparedness encompasses diverse fields within the hospital and regional settings. Planning membership groups should address key aspects across these fields including but not limited to: public safety, facilities, logistics, pharmacy, transportation, clinical patient care, non-clinical patient care, media/public relations, communications, radiation, infection control, and administration.

  • Option A: Planning/Prevention focuses on providing protection from disasters on both the domestic and international levels in an attempt to limit the loss of life and reduce the financial impact of disaster response. Planning includes care, evacuation, and environmental planning and response standards.
  • Option B: Risk Assessment identifies high priority and vulnerability areas and directs mitigation efforts. The goal of risk assessment is the identification of the possible disasters that challenge the area including both internal and external disasters, collecting resource inventory, identifying a facility or region’s vulnerabilities based on location and resources, and generating a priorities list.
  • Option D: The Centers for Disease Control and Prevention (CDC) provides education and information regarding specific disaster types, including infectious diseases, chemical and radiation exposure, and natural disaster or weather-related incidents.
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