You are the charge nurse in an emergency department (ED) and must assign two staff members to cover the triage area. Which team is the most appropriate for this assignment? Show 3. An experienced RN and an inexperienced RN You are working in the triage area of an ED, and four patients approach the triage desk at the same time. List the order in which you will assess these patients. 2,1,4,3 In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? 3. Brief neurologic assessment 4. A 56-year-old patient presents in triage with left-sided chest pain, diaphoresis, and dizziness. This patient should be prioritized into which category? The physician has ordered cooling measures for a child with fever who is likely to be discharged when the temperature comes down. Which of the following would be appropriate to delegate to the nursing assistant? 1) Assist the child to remove outer clothing. It is the summer season, and patients with signs and symptoms of heat-related illness present in the ED. Which patient needs attention first? 4) A homeless person, poor historian, presents with altered mental status, poor muscle coordination, and hot, dry, ashen skin. Duration of exposure is unknown. You respond to a call for help from the ED waiting room. There is an elderly patient lying on the floor. List the order for the actions that you must perform. 2, 4, 1, 3, 5 2. Establish unresponsiveness. The emergency medical service (EMS) has transported a patient with severe chest pain. As the patient is being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and no palpable pulse. Which task is appropriate to delegate to the nursing assistant? An anxious 24-year-old college student complains of tingling sensations, palpitations, and chest tightness. Deep, rapid breathing and carpal spasms are noted. What priority nursing action should you take? 3. Have the student breathe into a paper bag. An experienced traveling nurse has been assigned to work in the ED; however, this is the nurse's first week on the job. Which area of the ED is the most appropriate assignment for this nurse? 3. Ambulatory or fast track clinic A tearful parent brings a child to the ED for taking an unknown amount of children's chewable vitamins at an unknown time. The child is currently alert and asymptomatic. What information should be immediately reported to the physician? 1. The ingested children's chewable vitamins contain iron. 11. In caring for a victim of sexual assault, which task is most appropriate for an LPN/LVN? 3. Provide emotional support and supportive communication 12. You are caring for a victim of frostbite to the feet. Place the following interventions in the correct order. 3,2,4,1 3. Remove the victim from the cold environment. 14. A patient sustains an amputation of the first and second digits in a chainsaw accident. Which task should be delegated to the LPN/LVN? 3. Wrap the amputated digits in sterile gauze moistened with saline. A 36-year-old patient with a history of seizures and medication compliance of phenytoin (Dilan¬tin) and carbamazepine (Tegretol) is brought to the ED by the EMS personnel for repetitive seizure activity that started 45 minutes prior to arrival. You anticipate that the physician will order which drug for status epilepticus? You are preparing a child for IV conscious sedation prior to repair of a facial laceration. What infor¬mation should you immediately report to the physician? In relation to submersion injuries, which task is most appropriate to delegate to an LPN/LVN 4. Monitor an asymptomatic near-drowning victim. An intoxicated patient presents with slurred speech, mild confusion, and uncooperative behavior. The patient is a poor historian but admits to "drinking a few on the weekend. What is the priority nursing action for this patient? 4. Administer IV fluid support with supplemental thiamine as ordered. When an unexpected death occurs in the ED, which of the following tasks is most appropriate to delegate to the nursing assistant 3. Assist with postmortem care. Following emergency endotracheal intubation, you must verify tube placement and secure the tube. 3,4,2,1 1. A client who presents to the emergency room with vision loss would be classified in which triage category? A. Nonurgent B. Urgent C. Emergent D. Severe 2. During a disaster situation following a tornado a client is found to have a head injury with a decreased level of consiousness and is hypoxic. Which triage category would this client be assigned to? A. Black B. Green C. Yellow D. Red 3. Which best describes the meaning of the word "triage"? A. Assembling B. Dispersing C. Labeling D. Sorting 4. Which of these injuries is an example of what would be categorized as a Green Priority during triage in a disaster situation? A. Psychological disorders B. Spinal cord injury C. Burns over 10% of the body D. Radiation exposure A. Psychological disorders Which is the best example of a natural disaster? A. Terrorism B. Building collapse C. Flooding D. Train crash Which is a common injury seen following a tornado? A. Drownings B. Insect bites C. Gastrointestinal illnesses D. Multiple fractures 3. Which of these is not classified as a Category A biologic agent? A. Anthrax B. Botulism C. Hantavirus D. Smallpox 4. Which disease can be contracted through human contact with infected rabbits, deer, or other wildlife? A. Tularemia B. Smallpox C. Botulism D. Tuberculosis Serum T4 concentration is an effective indicator of thyroid function. How are serum T 4 levels affected in hyperthyroidism? Some manifestations are specific for certain endocrine disorders. Match the following manifestation with the appropriate endocrine disorder: Tremors. Some manifestations are specific for certain endocrine disorders. Match the following manifestation with the appropriate endocrine disorder: Tachycardia. Some manifestations are specific for certain endocrine disorders. Match the following manifestation with the appropriate endocrine disorder: Hirsutism (excessive body hair). 25. Some manifestations are specific for certain endocrine disorders. Match the following manifestation with the appropriate endocrine disorder: Exophthalmos (bulging eyes). Some manifestations are specific for certain endocrine disorders. Match the following manifestation with the appropriate endocrine disorder: Buffalo hump and moon facies. Some manifestations are specific for certain endocrine disorders. Match the following manifestation with the appropriate endocrine disorder: Constipation. 28. Some manifestations are specific for certain endocrine disorders. Match the following manifestation with the appropriate endocrine disorder: Diarrhea. Some manifestations are specific for certain endocrine disorders. Match the following manifestation with the appropriate endocrine disorder: Dry, brittle hair. Why is iodine therapy prescribed for Graves' disease? 4. Which of the following disorders is characterized by an excessive secretion of TH? 5. Hyperthyroidism is characterized by which of the following? The major complications of Graves' disease are: A. exophthalmos, heart disease, and thyroid storm. 7. Which of the following is a major medication used to control hypothyroidism? 8. In the treatment of hyperthyroidism and to prevent urolithiasis, acidification is used to: Indicate whether the following sign or symptom is more closely associated with hyperthyroidism or hypothyroidism: Lethargy and apathy. Indicate whether the following sign or symptom is more closely associated with hyperthyroidism or hypothyroidism: Exophthalmos. Indicate whether the following sign or symptom is more closely associated with hyperthyroidism or hypothyroidism: Thick, brittle nails. 22. Indicate whether the following sign or symptom is more closely associated with hyperthyroidism or hypothyroidism: Weight loss. Indicate whether the following sign or symptom is more closely associated with hyperthyroidism or hypothyroidism: Warm, smooth skin. Indicate whether the following sign or symptom is more closely associated with hyperthyroidism or hypothyroidism: Profuse sweating. Indicate whether the following sign or symptom is more closely associated with hyperthyroidism or hypothyroidism: Emotional instability. How are burn injuries categorized? C. By the mechanism of injury 2. Which category of burn injury is the least common? 3. What is the leading cause of burn injury? Regarding the medical management in the emergent phase of a burn injury, clients with moderate burns: B. can usually be managed on an inpatient basis at the receiving hospital. 9. What factors influence burn severity? D. All of the above are correct. Where is the IV access site for a client with extensive burns or a limited peripheral IV? D. Any of the above would be appropriate. Which is not recommended in wound care? 12. Which of the following is not an appropriate method of wound care? D. All of the above are appropriate. 13. Which management strategy in the acute phase of burn injuries concentrates on the maintenance of adequate nutrition? B. Providing metabolic support 15. What type of debridement involves the application of commercially prepared proteolytic and fibrinolytic substances? 17. Autograft procedures can be performed by applying the autografts in what two ways? In the administration of an antidiuretic hormone, the nurse would recognize that which medication could be easily self-administered by a client? [Hint] 1. Desmopressin (DDAVP) Desmopressin (DDAVP) is available as a nasal spray and can be easily self-administered by a client Myxedema, which includes fatigue, general weakness, and muscle cramps is a symptom of which endocrine disorder? Which drugs cause increased risk for peptic ulcers, decreased wound healing, and increased capillary fragility? 1. Glucocorticoids Glucocorticoids can cause increased risk for peptic ulcers, decreased wound healing, and increased capillary fragility. Which disease is characterized by increased body metabolism, tachycardia, increased body temperature and anxiety? Grave's disease 2. Grave's disease is characterized by all of the symptoms In the administration of Hydrocortisone (Aeroseb-HC, Alphadern, Cetacort), it is vital that the nurse recognize that this drug may mask which symptoms? Signs and symptoms of infection When hydrocortisone use is discontinued, the nurse must recognize the possibility of what side effect, if this drug is stopped abruptly? A client who is taking Levothyroxine (Synthroid) begins to develop weight loss, diarrhea and intolerance. The nurse should be aware that this might be an indication of what hormonal condition? Which organ is responsible for secreting chemicals called releasing factors? What precautions should a client who is receiving radioactive iodine be made aware of? Avoid close contact with children or pregnant women for 1 week after administration of drug In the administration of an antithyroid drug such as Propacil, the nurse must be aware that the client may be at risk for the development of which skin condition? Jaundice The nurse needs to be aware of the risk of developing the skin condition called jaundice The client asks how too much calcium could be dangerous. The nurse explains that hypercalcemia could cause cardiac dysrhythmias. Calcium ions influence the excitability of all neurons. Whenever calcium concentrations are too high, sodium permeability decreases across cell membranes. This is a dangerous state because nerve conduction depends on the proper influx of sodium into cells The nurse completing a physical exam on a child diagnosed with osteomalacia would expect to find bowlegs and a pigeon breast. Osteomalacia, referred to as rickets in children, is a disorder characterized by softening of bones without alteration of basic bone structure. Classic signs of rickets in children include bowlegs and a pigeon breast. The client's calcium level is reported as 5.6 mg/dL. The nurse should assess the client for muscle spasms. Normal serum calcium level is 8.5-11.5 mg/dL. Signs of hypocalcemia include seizures, muscle spasms, facial twitching, and paresthesias. The nurse cautions the client receiving Calcium Gluconate to avoid adding foods such as nuts, legumes and tofu to the diet. The rationale for this instruction is that these foods, rich in zinc, may decrease calcium absorption. Consuming food rich in zinc may decrease calcium absorption. Teach clients to avoid zinc-rich roods such as nuts, legumes, seeds, sprouts, and tofu. A client in the health department asks what purpose the pituitary gland serves. The nurse plans to provide the client information based on the knowledge that the function of the pituitary gland is which of the following? [Hint] 2. The pituitary gland serves as the body's "master gland" because its hormones regulate many body functions. The pituitary gland is the body's master gland because its hormones regulate many body functions. The anterior pituitary secretes the growth hormone (GH), prolactin (PRL), thyroid stimulating hormone (TSH), adrenocorticotropic hormone (ACTH), gonadotropin hormones, follicle-stimulating hormone (FSH) and luteinizing hormone (LH). The posterior
pituitary secretes the antidiuretic hormone (ADH) and oxytocin. When implementing a teaching session on endocrine disorders to a group of nurses, the nurse educator explains that which of the following endocrine glands is responsible for increasing metabolism and for growth and development in children? A nurse is formulating a plan of care for a male client admitted with pancreatitis. In establishing teaching information for the client, the nurse will explain to the client the function of the pancreas includes which of the following? 4. Secretes hormones such as insulin necessary for carbohydrate metabolism A nurse, teaching a group of clients with endocrine disorders, is evaluating their understanding of the teaching session. Which of the following statements made by one of the clients indicates an understanding regarding negative feedback and hormone regulation? 1. "When my body detects a change in hormone levels, the hormones adjust secretion to maintain stable levels." A nurse is performing a routine health screening on a 42-year-old female who reports that her necklaces seem to be tighter around her neck and that her neck appears swollen to her. Which of the following identifies the nurse's most appropriate action at this time? 2. Assess the client's thyroid gland A nurse is providing preventive health teaching to a 40-year-old, obese African-American female with a family history of diabetes. The nurse educates the client that which of the following of the identified risk factors is modifiable? A nurse assessing the thyroid gland while performing a physical assessment is performing the technique correctly when which of the following is demonstrated? 1. Standing behind the client and placing fingers on either side of the trachea below the thyroid cartilage A nurse, assessing a client, knows that which of the following symptoms would cause the suspicion that the client has hyperthyroidism? 3. Exophthalmos (protruding eyes) An advance practice nurse is performing a physical assessment on a client suspected of having an endocrine disorder. During testing of stereognosis in the client, the nurse implements which of the following? Place a rubber band in the client's hand and ask to the client to identify the object Stereognosis is the ability to identify an object merely by touch. The use of rubber bands, buttons, cotton balls or other common items are recommended. The pinprick tests pain; the cold water tests temperature; and the tuning fork tests vibration. An elderly client in the physician's office complains of changes in memory and ability to concentrate, as well as a change in hair texture. Which of the following represents the most appropriate response to the client? 1. "I will inform the physician and she may want to run some lab tests on you." Which client should the nurse assess first?The nurse receives report on 4 assigned clients. Which client should the nurse assess first? 37% of people answered this question correctly. The nurse should first assess the client showing symptoms of a deep venous thrombosis (DVT) (eg, unilateral edema , warmth, redness , tenderness on palpation).
Which of the following clients should the ED nurse in triage immediately prioritize for assessment and care?The highest priority should be clients who have potentially life-threatening problems or conditions that need immediate stabilization, including victims of trauma, individuals in severe respiratory distress, and those with chest pain, acute neuro deficits, chemical splashes to the eyes, or limb amputations.
Which client would the nurse assess first after a shift report?Which client should the nurse on the vascular unit assess first after receiving the shift report? The client with an above the knee amputation who needs a full body lift to get in the wheelchair. The charge nurse of a long-term care facility is making assignments.
In which order should clients receive care based on triage tag color quizlet?Red-tagged clients have major injuries, black-tagged clients are expected and allowed to die, and yellow-tagged clients have major injuries.
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