NUR417 Exam 3 Questions With Complete Solutions
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. A patient with no pedal pulses
b. A patient with an open femur fracture
c. A patient with bleeding facial lacerations
d. A patient with paradoxical chest movement
ANS: D
Most immediate deaths from trauma occur because of problems
with ventilation, so the patient with paradoxical chest
movements should be treated first. Face and head fractures can
obstruct the airway, but the patient with facial injuries only has
lacerations. The other two patients also need rapid intervention
but do not have airway or breathing problems.
DIF: Cognitive Level: Analyze (analysis)
The following interventions are part of the emergency
department (ED) protocol for a patient who has been admitted
with multiple bee stings to the hands. Which action should the
nurse take first?
a. Remove the patient's rings.
b. Apply ice packs to both hands.
c. Apply calamine lotion to itching areas.
d. Give diphenhydramine (Benadryl) 50 mg PO.
ANS: A
The patient's rings should be removed first because it might not
be possible to remove them if swelling develops. The other
, orders should also be implemented as rapidly as possible after
the nurse has removed the jewelry.
DIF: Cognitive Level: Analyze (analysis)
Gastric lavage and administration of activated charcoal are
ordered for an unconscious patient who has been admitted to the
emergency department (ED) after ingesting 30 lorazepam
(Ativan) tablets. Which prescribed action should the nurse plan
to do first?
a. Insert a large-bore orogastric tube.
b. Assist with intubation of the patient.
c. Prepare a 60-mL syringe with saline.
d. Give first dose of activated charcoal.
ANS: B
In an unresponsive patient, intubation is done before gastric
lavage and activated charcoal administration to prevent
aspiration. The other actions will be implemented after
intubation.
DIF: Cognitive Level: Analyze (analysis)
A patient arrives in the emergency department (ED) after topical
exposure to powdered lime at work. Which action should the
nurse take first?
a. Obtain the patient's vital signs.
b. Obtain a baseline complete blood count.
c. Decontaminate the patient by showering with water.
d. Brush off any visible powder on the skin and clothing.
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. A patient with no pedal pulses
b. A patient with an open femur fracture
c. A patient with bleeding facial lacerations
d. A patient with paradoxical chest movement
ANS: D
Most immediate deaths from trauma occur because of problems
with ventilation, so the patient with paradoxical chest
movements should be treated first. Face and head fractures can
obstruct the airway, but the patient with facial injuries only has
lacerations. The other two patients also need rapid intervention
but do not have airway or breathing problems.
DIF: Cognitive Level: Analyze (analysis)
The following interventions are part of the emergency
department (ED) protocol for a patient who has been admitted
with multiple bee stings to the hands. Which action should the
nurse take first?
a. Remove the patient's rings.
b. Apply ice packs to both hands.
c. Apply calamine lotion to itching areas.
d. Give diphenhydramine (Benadryl) 50 mg PO.
ANS: A
The patient's rings should be removed first because it might not
be possible to remove them if swelling develops. The other
, orders should also be implemented as rapidly as possible after
the nurse has removed the jewelry.
DIF: Cognitive Level: Analyze (analysis)
Gastric lavage and administration of activated charcoal are
ordered for an unconscious patient who has been admitted to the
emergency department (ED) after ingesting 30 lorazepam
(Ativan) tablets. Which prescribed action should the nurse plan
to do first?
a. Insert a large-bore orogastric tube.
b. Assist with intubation of the patient.
c. Prepare a 60-mL syringe with saline.
d. Give first dose of activated charcoal.
ANS: B
In an unresponsive patient, intubation is done before gastric
lavage and activated charcoal administration to prevent
aspiration. The other actions will be implemented after
intubation.
DIF: Cognitive Level: Analyze (analysis)
A patient arrives in the emergency department (ED) after topical
exposure to powdered lime at work. Which action should the
nurse take first?
a. Obtain the patient's vital signs.
b. Obtain a baseline complete blood count.
c. Decontaminate the patient by showering with water.
d. Brush off any visible powder on the skin and clothing.
