NUR445 Exam 4
Study online at https://quizlet.com/_hjdetl
1. A nurse is assisting with triaging clients following an explosion. Which of the
following clients should the nurse identify as the highest priority?: A conscious adult
client who has second-degree burns on both lower legs; respiratory rate is > 30/min
2. A charge nurse is discussing the phases of community response to disaster
with nursing staff. Which of the following statements indicates an understand-
ing of the heroic phase of disaster response?: "Personnel are willing to work in dangerous
conditions to provide assistance."
3. A nurse is assessing an adolescent who experienced blunt trauma to the
abdomen. Which of the following findings is the nurse's priority?: Blood pressure
92/50 mm Hg
4. A nurse is caring for a client who experienced an open, right femur fracture
following a motor-vehicle crash.: the client is most likely experiencing compartment syndrome. Bc
increased edema/ restriction by a cast or splint. five Ps: pain, pallor, pulselessness, paresthesia, and paralysis. medica
emergency. loosen the dressing to the splint, assess the client's peripheral pulses. A pulse volume recorder may be
necessary. monitor neurovascular function, any changes indicate progression of compartment syndrome. monitor/
treat pain using prescribed opioids.
5. A nurse is reviewing treatment protocols for clients exposed to bioterrorism
agents. For which of the following agents should the nurse plan to administer
a vaccine following exposure?: Smallpox
6. Which of the following are potential signs or symptoms of internal bleeding
caused by a brown recluse spider bite?: Internal bleeding, abdominal pain, black/ tarry stools,
bloody/ dark urine, chest pain/SOB.
Skin rash, itching, headache, dizziness, joint pain/ swelling, numbness/ tingling, fever / chills are not typically associated
with internal bleeding from a spider bite.
7. A nurse is preparing a response protocol for botulism as a bioterrorism
agent. The nurse should prepare the protocol based on which of the following
information? (Select all that apply.): can produce paralysis 12 -72 hr following exposure. neurotoxin
- causes flaccid paralysis within hours of exposure. Notify cdc if even a single case is suspected. primarily acquired
through ingestion of a contaminated food source. Vomiting and diarrhea are expected findings. Botulism is NOT found
in castor beans. Ricin, rather than botulism, is a toxin found in castor beans.
, NUR445 Exam 4
Study online at https://quizlet.com/_hjdetl
8. A nurse is caring for a client who has burns to his face, ears, and eyelids. The
nurse should identify which of the following is the priority finding to report to
the provider?: Difficulty swallowing
9. A nurse in an emergency department is caring for a client who has a sucking
chest wound resulting from a gunshot. The client has a blood pressure of
100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min.
Which of the following actions should the nurse take?: Administer oxygen via nasal cannula.
10. A community health nurse is teaching a group of community members
about natural disasters. Which of the following information about natural
disasters should the nurse include in the teaching?: They are geological or meteorological
occurrences.
11. A nurse is among the first responders to a mass-casualty incident and does
not know what type of personal protective equipment (PPE) is needed. Which of
the following actions should the nurse take?: Choose the highest level of protection equipment
available.
12. A public health nurse is teaching a group of nurses about smallpox. Which
of the following statements by one of the nurses indicates understanding of
the teaching?: "Unlike chickenpox, the vesicles of smallpox are more abundant on the face."
13. A nurse is admitting a client who sustained severe burn injuries. The nurse
refers to the rule of nines to determine the total body surface area of the burn
injury. What percentage of body surface area should the nurse estimate the
client has burned?: 54%
14. Which of the following are potential indications for spinal immobilization in
clients?: Spinal immobilization is indicated in clients with suspected spinal cord injury and loss of consciousness
as these conditions may be associated with spinal injury. Simple fractures of extremities, acute myocardial infarction,
asthma exacerbation, severe allergic reactions, and acute appendicitis do not require spinal immobilization unless there
is suspicion of associated spinal injury.
15. A nurse is performing triage for a group of clients following a mass casualty
incident (MCI). Which of the following clients should the nurse plan to care for
first?: A client experiencing a tension pneumothorax
16. When should a client with rib fractures use the incentive spirometer?: Every 1
hour while awake
Study online at https://quizlet.com/_hjdetl
1. A nurse is assisting with triaging clients following an explosion. Which of the
following clients should the nurse identify as the highest priority?: A conscious adult
client who has second-degree burns on both lower legs; respiratory rate is > 30/min
2. A charge nurse is discussing the phases of community response to disaster
with nursing staff. Which of the following statements indicates an understand-
ing of the heroic phase of disaster response?: "Personnel are willing to work in dangerous
conditions to provide assistance."
3. A nurse is assessing an adolescent who experienced blunt trauma to the
abdomen. Which of the following findings is the nurse's priority?: Blood pressure
92/50 mm Hg
4. A nurse is caring for a client who experienced an open, right femur fracture
following a motor-vehicle crash.: the client is most likely experiencing compartment syndrome. Bc
increased edema/ restriction by a cast or splint. five Ps: pain, pallor, pulselessness, paresthesia, and paralysis. medica
emergency. loosen the dressing to the splint, assess the client's peripheral pulses. A pulse volume recorder may be
necessary. monitor neurovascular function, any changes indicate progression of compartment syndrome. monitor/
treat pain using prescribed opioids.
5. A nurse is reviewing treatment protocols for clients exposed to bioterrorism
agents. For which of the following agents should the nurse plan to administer
a vaccine following exposure?: Smallpox
6. Which of the following are potential signs or symptoms of internal bleeding
caused by a brown recluse spider bite?: Internal bleeding, abdominal pain, black/ tarry stools,
bloody/ dark urine, chest pain/SOB.
Skin rash, itching, headache, dizziness, joint pain/ swelling, numbness/ tingling, fever / chills are not typically associated
with internal bleeding from a spider bite.
7. A nurse is preparing a response protocol for botulism as a bioterrorism
agent. The nurse should prepare the protocol based on which of the following
information? (Select all that apply.): can produce paralysis 12 -72 hr following exposure. neurotoxin
- causes flaccid paralysis within hours of exposure. Notify cdc if even a single case is suspected. primarily acquired
through ingestion of a contaminated food source. Vomiting and diarrhea are expected findings. Botulism is NOT found
in castor beans. Ricin, rather than botulism, is a toxin found in castor beans.
, NUR445 Exam 4
Study online at https://quizlet.com/_hjdetl
8. A nurse is caring for a client who has burns to his face, ears, and eyelids. The
nurse should identify which of the following is the priority finding to report to
the provider?: Difficulty swallowing
9. A nurse in an emergency department is caring for a client who has a sucking
chest wound resulting from a gunshot. The client has a blood pressure of
100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min.
Which of the following actions should the nurse take?: Administer oxygen via nasal cannula.
10. A community health nurse is teaching a group of community members
about natural disasters. Which of the following information about natural
disasters should the nurse include in the teaching?: They are geological or meteorological
occurrences.
11. A nurse is among the first responders to a mass-casualty incident and does
not know what type of personal protective equipment (PPE) is needed. Which of
the following actions should the nurse take?: Choose the highest level of protection equipment
available.
12. A public health nurse is teaching a group of nurses about smallpox. Which
of the following statements by one of the nurses indicates understanding of
the teaching?: "Unlike chickenpox, the vesicles of smallpox are more abundant on the face."
13. A nurse is admitting a client who sustained severe burn injuries. The nurse
refers to the rule of nines to determine the total body surface area of the burn
injury. What percentage of body surface area should the nurse estimate the
client has burned?: 54%
14. Which of the following are potential indications for spinal immobilization in
clients?: Spinal immobilization is indicated in clients with suspected spinal cord injury and loss of consciousness
as these conditions may be associated with spinal injury. Simple fractures of extremities, acute myocardial infarction,
asthma exacerbation, severe allergic reactions, and acute appendicitis do not require spinal immobilization unless there
is suspicion of associated spinal injury.
15. A nurse is performing triage for a group of clients following a mass casualty
incident (MCI). Which of the following clients should the nurse plan to care for
first?: A client experiencing a tension pneumothorax
16. When should a client with rib fractures use the incentive spirometer?: Every 1
hour while awake
