Medical Surgical Nursing Patient Centered Collaborative Care, 7th Edition by Donna D. – Test Bank

Chapter 11: Care of Patients with Common Environmental Emergencies
Test Bank

MULTIPLE CHOICE

1. While the nurse is visiting the community pool, an adult swimmer is pulled out of the pool, unconscious and cyanotic. What is the priority action of the nurse?
a. Begin chest compressions.
b. Move from the pool area.
c. Give two rescue breaths.
d. Check for a carotid pulse.

ANS: C
The highest priority is to maintain ventilatory support until the victim can breathe on his or her own. The other options are important, but maintaining the airway and breathing are always priority.

DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC: Integrated Process: Nursing Process (Implementation)

2. The nurse working at a first aid booth during a summer marathon sees several runners. Which runner should be seen first? A runner who:
a. Has fallen several times
b. Is fatigued
c. Thinks he has the flu
d. Has tachypnea

ANS: A
Hot, dry skin, tachycardia, tachypnea, and hypotension are signs of heat stroke. A marathon runner who has fallen several times may have a thermal injury to the brain, causing loss of coordination. Mental status changes from thermal injury to the brain include confusion, bizarre behavior, seizures, and even coma. The nurse should prioritize the client with potential thermal brain injury over the other clients.

DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC: Integrated Process: Nursing Process (Planning)

3. The nurse is working at a first aid booth for a spring training game on a hot day. A spectator comes in, reporting that he is not feeling well. Vital signs are temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, and blood pressure 106/66 mm Hg. He trips over his feet as the nurse leads him to a cot. What is the priority action of the nurse?
a. Encourage drinking of cool water or sports drinks.
b. Sponge the victim with cool water and remove his shirt.
c. Administer Tylenol (acetaminophen), 650 mg orally.
d. Encourage rest, and reassess in 15 minutes.

ANS: B
The spectator shows signs of heat stroke, which is a medical emergency. The spectator should be transported to the emergency department as quickly as possible. The nurse should take actions to lower his body temperature in the meantime by removing his shirt and sponging his body with cool water. Lowering body temperature by drinking cool fluids or taking acetaminophen is not as effective in an emergency situation. The client needs to be cooled quickly and is a priority for treatment.

DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC: Integrated Process: Nursing Process (Implementation)

4. The emergency department nurse assesses a client in extreme pain with an apparent snakebite of the leg. Vital signs are stable. What is the priority action of the nurse?
a. Call the regional poison control center.
b. Administer IV pain medication.
c. Place a tourniquet around the leg.
d. Apply an immobilization splint.

ANS: D
Treatment involves immobilization to minimize the spread of venom. A tourniquet should not be used because it impairs arterial blood flow. Pain medication should be administered and collaboration with the regional poison control center begun after the leg is immobilized.

DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC: Integrated Process: Nursing Process (Implementation)

5. The nurse is teaching a wilderness survival class. Which statement by a participant indicates that additional teaching is needed?
a. “If I get too cold, I can have some brandy to help me get warmed up.”
b. “My climbing partner should let me know right away if my nose turns white.”
c. “If my partner can’t think straight, we should descend to a lower altitude.”
d. “It is okay to feel a little short of breath when I am climbing, but not at rest.”

ANS: A
Alcohol will increase the risk of cold-related injuries and should be avoided. The other options all show good understanding of the education.

DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning

6. A community nurse assesses a client, who has an allergy to bees, after a bee sting. The client’s lips are swollen, and wheezes are audible. What is the priority action of the nurse?
a. Elevate the site and notify the client’s next of kin.
b. Remove the stinger with tweezers and encourage rest.
c. Administer diphenhydramine (Benadryl) and apply ice.
d. Administer an EpiPen from the first aid kit and call 911.

ANS: D
The student’s swollen lips indicate that anaphylaxis may be developing, and this is a medical emergency. 911 should be called immediately, and the client transported to the emergency department as quickly as possible. If an EpiPen is available, it should be administered at the first sign of an anaphylactic reaction. The other answers do not provide adequate interventions to treat airway obstruction due to anaphylaxis.

DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC: Integrated Process: Nursing Process (Implementation)

7. While on a camping trip, the nurse provides care for a camper who was bitten by a black widow spider. What is the priority action of the nurse?
a. Apply ice to the site of the bite.
b. Apply a loose tourniquet to the limb.
c. Give acetaminophen (Tylenol) for pain.
d. Cover the camper with a warm blanket.

ANS: A
Ice inhibits the action of neurotoxin and should be the first intervention provided to a client bitten by a black widow spider. A tourniquet should not be used because it impairs arterial blood flow. Tylenol and covering the camper do not treat the neurotoxic effect of the black widow spider’s bite.

DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC: Integrated Process: Nursing Process (Implementation)

8. A client presents to the emergency department after prolonged exposure to the cold. The client is shivering, has slurred speech, and is slow to respond to questions. Which treatment will the nurse prepare for this client?
a. Dry clothing and warm blankets
b. Administration of warmed IV fluids
c. Peritoneal lavage with warmed normal saline
d. Continuous arteriovenous rewarming

ANS: A
Mild hypothermia is manifested by shivering, slurred speech, poor muscular coordination, and impaired cognitive abilities. Mild hypothermia may be treated with dry clothing and warm blankets. Rewarming should occur slowly by removing wet clothing and providing dry warm blankets first. Other treatments are secondary and should be used to treat moderate to severe hypothermia.

DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Planning)

9. The emergency department nurse assesses a middle-aged mountain climber who reports headache, nausea, vomiting, and “feeling winded.” What is the nurse’s priority intervention?
a. Administer acetazolamide (Diamox).
b. Administer prochlorperazine (Compazine).
c. Perform a neurologic assessment.
d. Assess for bowel sounds.

ANS: A
The client is exhibiting signs of mountain sickness. Acetazolamide (Diamox, Apo-Acetazolamide) is used to prevent and treat acute mountain sickness. The other interventions will not treat mountain sickness.

DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Planning)

10. A nurse is at the scene of a lightning strike during a thunderstorm. Which is the priority action of the nurse?
a. Make sure that victims are not electrically charged.
b. Assess victims for second- and third-degree burns.
c. Start emergency resuscitation on anyone not breathing.
d. Move victims and first aid responders to a sheltered area.

ANS: D
Victims of a lightning strike are not electrically charged afterward. Cardiopulmonary resuscitation (CPR) should be started once victims and first aid responders are in a sheltered area, because the thunderstorm presents a continued threat of lightning strikes.

DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC: Integrated Process: Nursing Process (Implementation)