Chapter 72 Emergency Nursing ; Hinkle: Brunner & Suddarth's Textbook of MedicalSurgical Nursing, Fourteenth Edition PREPU LEVEL 7 TEST BANK

A nurse is performing triage at the scene of a building collapse and is using a five-level triage system. Place the categories below in the proper order from most to least immediate. a. Urgent b. Resuscitation c. Emergent d. Nonurgent e. Less urgent ANSWER: b. Resuscitation c. Emergent a. Urgent e. Less urgent d. Nonurgent A nurse is providing in-service education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step? a. Collecting semen b. Performing the pelvic examination c. Obtaining consent for examination d. Supporting the client's emotional status ANSWER: d. Supporting the client's emotional status The teaching session is successful when staff members focus first on supporting the client's emotional status. Next, staff members should gain consent to perform the pelvic examination, perform the examination, and collect evidence, such as semen if present. A nurse is preparing to assist with a gastric lavage for a client who has ingested an unknown poison and is obtunded. To ensure that the tube reaches the stomach, the nurse would measure the distance from the bridge of the nose to which of the following? a. Ear lobe and then to the xiphoid process b. Chin and then to the xiphoid process c. Ear lobe and then to the umbilicus d. Chin and then to the umbilicus ANSWER: a. Ear lobe and then to the xiphoid process The nurse measures the tube from the bridge of the nose to the xiphoid process to ensure that the tube reaches the stomach on insertion. The nurse educator is providing orientation to a group of nurses newly hired to an intensive care unit. The group of nurses are correct in stating which is the most common type of shock managed in critical care? a. Anaphylactic b. Hypovolemic c. Neurogenic d. Cardiogenic ANSWER: b. Hypovolemic The underlying cause of shock (hypovolemic, cardiogenic, neurogenic, anaphylactic, or septic) must be determined. Of these, hypovolemia is the most common cause. Nursing students are reviewing the categories of intra-abdominal injuries. The students demonstrate understanding of the information when they identify which of the following as examples of penetrating trauma? Select all that apply. a. Gunshot wound b. Knife-stab wound c. Motor-vehicle crash d. Fall from a roof E. Being struck with a baseball ba