NUR417 Exam 3 Questions With Complete Solutions
A patient who has experienced blunt abdominal trauma during a
motor vehicle collision is complaining of increasing abdominal
pain. The nurse will plan to teach the patient about the purpose
of
a. peritoneal lavage.
b. abdominal ultrasonography.
c. nasogastric (NG) tube placement.
d. magnetic resonance imaging (MRI).
ANS: B
For patients who are at risk for intraabdominal bleeding, focused
abdominal ultrasonography is the preferred method to assess for
intraperitoneal bleeding. An MRI would not be used. Peritoneal
lavage is an alternative, but it is more invasive. An NG tube
would not be helpful in the diagnosis of intraabdominal
bleeding.
DIF: Cognitive Level: Apply (application)
A patient with hypotension and an elevated temperature after
working outside on a hot day is treated in the emergency
department (ED). The nurse determines that discharge teaching
has been effective when the patient makes which statement?
a. "I'll take salt tablets when I work outdoors in the summer."
b. "I should take acetaminophen (Tylenol) if I start to feel too
warm."
c. "I need to drink extra fluids when working outside in hot
,weather."
d. "I'll move to a cool environment if I notice that I'm feeling
confused"
ANS: C
Oral fluids and electrolyte replacement solutions such as sports
drinks help replace fluid and electrolytes lost when exercising in
hot weather. Salt tablets are not recommended because of the
risks of gastric irritation and hypernatremia. Antipyretic drugs
are not effective in lowering body temperature elevations caused
by excessive exposure to heat. A patient who is confused is
likely to have more severe hyperthermia and will be unable to
remember to take appropriate action.
DIF: Cognitive Level: Apply (application)
A 22-yr-old patient who experienced a drowning accident in a
local pool, but now is awake and breathing spontaneously, is
admitted for observation. Which assessment will be most
important for the nurse to take during the observation period?
a. Auscultate heart sounds. c. Auscultate breath sounds.
b. Palpate peripheral pulses. d. Check mental orientation.
ANS: C
Because pulmonary edema is a common complication after
drowning, the nurse should assess the breath sounds frequently.
The other information also will be obtained by the nurse, but it
is not as pertinent to the patient's admission diagnosis.
DIF: Cognitive Level: Analyze (analysis)
,When rewarming a patient who arrived in the emergency
department (ED) with a temperature of 87° F (30.6° C), which
finding indicates that the nurse should discontinue active
rewarming?
a. The patient begins to shiver.
b. The BP decreases to 86/42 mm Hg.
c. The patient develops atrial fibrillation.
d. The core temperature is 94° F (34.4° C).
ANS: D
A core temperature of at least 89.6° F to 93.2° F (32° C to 34°
C) indicates that sufficient rewarming has occurred.
Dysrhythmias, hypotension, and shivering may occur during
rewarming, and should be treated but are not an indication to
stop rewarming the patient.
DIF: Cognitive Level: Apply (application)
When assessing an older patient admitted to the emergency
department (ED) with a broken arm and facial bruises, the nurse
observes several additional bruises in various stages of healing.
Which statement or question by the nurse should be first?
a. "You should not go home."
b. "Do you feel safe at home?"
c. "Would you like to see a social worker?"
d. "I need to report my concerns to the police."
ANS: B
The nurse's initial response should be to further assess the
patient's situation. Telling the patient not to return home may be
, an option once further assessment is done. A social worker or
police report may be appropriate once further assessment is
completed.
DIF: Cognitive Level: Analyze (analysis)
A triage nurse in a busy emergency department (ED) assesses a
patient who complains of 7/10 abdominal pain and states, "I had
a temperature of 103.9° F (39.9° C) at home." The nurse's first
action should be to
a. assess the patient's current vital signs.
b. give acetaminophen (Tylenol) per agency protocol.
c. ask the patient to provide a clean-catch urine for urinalysis.
d. tell the patient that it will be 1 to 2 hours before seeing a
health care provider.
ANS: A
The patient's pain and statement about an elevated temperature
indicate that the nurse should obtain vital signs before deciding
how rapidly the patient should be seen by the health care
provider. A urinalysis may be appropriate, but this would be
done after the vital signs are taken. The nurse will not give
acetaminophen before confirming a current temperature
elevation.
DIF: Cognitive Level: Analyze (analysis)
The emergency department (ED) triage nurse is assessing four
victims involved in a motor vehicle collision. Which patient has
the highest priority for treatment?
A patient who has experienced blunt abdominal trauma during a
motor vehicle collision is complaining of increasing abdominal
pain. The nurse will plan to teach the patient about the purpose
of
a. peritoneal lavage.
b. abdominal ultrasonography.
c. nasogastric (NG) tube placement.
d. magnetic resonance imaging (MRI).
ANS: B
For patients who are at risk for intraabdominal bleeding, focused
abdominal ultrasonography is the preferred method to assess for
intraperitoneal bleeding. An MRI would not be used. Peritoneal
lavage is an alternative, but it is more invasive. An NG tube
would not be helpful in the diagnosis of intraabdominal
bleeding.
DIF: Cognitive Level: Apply (application)
A patient with hypotension and an elevated temperature after
working outside on a hot day is treated in the emergency
department (ED). The nurse determines that discharge teaching
has been effective when the patient makes which statement?
a. "I'll take salt tablets when I work outdoors in the summer."
b. "I should take acetaminophen (Tylenol) if I start to feel too
warm."
c. "I need to drink extra fluids when working outside in hot
,weather."
d. "I'll move to a cool environment if I notice that I'm feeling
confused"
ANS: C
Oral fluids and electrolyte replacement solutions such as sports
drinks help replace fluid and electrolytes lost when exercising in
hot weather. Salt tablets are not recommended because of the
risks of gastric irritation and hypernatremia. Antipyretic drugs
are not effective in lowering body temperature elevations caused
by excessive exposure to heat. A patient who is confused is
likely to have more severe hyperthermia and will be unable to
remember to take appropriate action.
DIF: Cognitive Level: Apply (application)
A 22-yr-old patient who experienced a drowning accident in a
local pool, but now is awake and breathing spontaneously, is
admitted for observation. Which assessment will be most
important for the nurse to take during the observation period?
a. Auscultate heart sounds. c. Auscultate breath sounds.
b. Palpate peripheral pulses. d. Check mental orientation.
ANS: C
Because pulmonary edema is a common complication after
drowning, the nurse should assess the breath sounds frequently.
The other information also will be obtained by the nurse, but it
is not as pertinent to the patient's admission diagnosis.
DIF: Cognitive Level: Analyze (analysis)
,When rewarming a patient who arrived in the emergency
department (ED) with a temperature of 87° F (30.6° C), which
finding indicates that the nurse should discontinue active
rewarming?
a. The patient begins to shiver.
b. The BP decreases to 86/42 mm Hg.
c. The patient develops atrial fibrillation.
d. The core temperature is 94° F (34.4° C).
ANS: D
A core temperature of at least 89.6° F to 93.2° F (32° C to 34°
C) indicates that sufficient rewarming has occurred.
Dysrhythmias, hypotension, and shivering may occur during
rewarming, and should be treated but are not an indication to
stop rewarming the patient.
DIF: Cognitive Level: Apply (application)
When assessing an older patient admitted to the emergency
department (ED) with a broken arm and facial bruises, the nurse
observes several additional bruises in various stages of healing.
Which statement or question by the nurse should be first?
a. "You should not go home."
b. "Do you feel safe at home?"
c. "Would you like to see a social worker?"
d. "I need to report my concerns to the police."
ANS: B
The nurse's initial response should be to further assess the
patient's situation. Telling the patient not to return home may be
, an option once further assessment is done. A social worker or
police report may be appropriate once further assessment is
completed.
DIF: Cognitive Level: Analyze (analysis)
A triage nurse in a busy emergency department (ED) assesses a
patient who complains of 7/10 abdominal pain and states, "I had
a temperature of 103.9° F (39.9° C) at home." The nurse's first
action should be to
a. assess the patient's current vital signs.
b. give acetaminophen (Tylenol) per agency protocol.
c. ask the patient to provide a clean-catch urine for urinalysis.
d. tell the patient that it will be 1 to 2 hours before seeing a
health care provider.
ANS: A
The patient's pain and statement about an elevated temperature
indicate that the nurse should obtain vital signs before deciding
how rapidly the patient should be seen by the health care
provider. A urinalysis may be appropriate, but this would be
done after the vital signs are taken. The nurse will not give
acetaminophen before confirming a current temperature
elevation.
DIF: Cognitive Level: Analyze (analysis)
The emergency department (ED) triage nurse is assessing four
victims involved in a motor vehicle collision. Which patient has
the highest priority for treatment?
