Emergency Nursing Management | NCLEX Quiz 163

1. A client arrived at the emergency department after suffering multiple physical injuries including a fractured pelvis from a vehicular accident. Upon assessment. the client is incoherent. pale. and diaphoretic. With vital signs as follows: temperature of 97°F (36.11° C). blood pressure of 60/40 mm Hg. heart rate of 143 beats/minute. and a respiratory rate of 30 breaths/minute. The client is mostly suffering from which of the following shock?

Cardiogenic.

Distributive.

Hypovolemic.

Obstructive.

Hypovolemic shock occurs when the volume of the circulatory system is too depleted to allow adequate circulation to the tissues of the body. A fractured pelvis will lose about one liter of blood hence symptoms such as hypotension. tachycardia. and tachypnea will occur.Option A: Causes of cardiogenic include massive myocardial infarction or other cause of primary cardiac (pump) failure.Option B: Distributive shock results from a relative inadequate intravascular volume caused by arterial or venous vasodilation.Option D: Obstructive shock is a form of shock associated with physical obstruction of the major vessels or the heart itself.

Explanation

Hypovolemic shock occurs when the volume of the circulatory system is too depleted to allow adequate circulation to the tissues of the body. A fractured pelvis will lose about one liter of blood hence symptoms such as hypotension. tachycardia. and tachypnea will occur.Option A: Causes of cardiogenic include massive myocardial infarction or other cause of primary cardiac (pump) failure.Option B: Distributive shock results from a relative inadequate intravascular volume caused by arterial or venous vasodilation.Option D: Obstructive shock is a form of shock associated with physical obstruction of the major vessels or the heart itself.

2. You are assessing a patient who has sustained a cat bite to the left hand. The cat is up-to-date immunizations. The date of the patient's last tetanus shot is unknown. Which of the following is the priority nursing diagnosis?

Risk for Impaired Mobility related to potential tendon damage.

Risk for Infection related to organisms specific to cat bites.

Ineffective Health Maintenance related to immunization status.

Impaired Skin Integrity related to puncture wounds.

Cat’s mouths contain a virulent organism. Pasteurella multocida. that can lead to septic arthritis or bacteremia.Options A and D: There is also a risk for tendon damage due to deep puncture wounds. These wounds are usually not sutured.Option C: A tetanus shot can be given before discharge.

Explanation

Cat’s mouths contain a virulent organism. Pasteurella multocida. that can lead to septic arthritis or bacteremia.Options A and D: There is also a risk for tendon damage due to deep puncture wounds. These wounds are usually not sutured.Option C: A tetanus shot can be given before discharge.

3. A client was brought to the ED due to an abdominal trauma caused by a motorcycle accident. During the assessment. the client complains of epigastric pain and back pain. Which of the following is true regarding the diagnosis of pancreatic injury?

Redness and bruising may indicate the site of the injury in blunt trauma.

The client is symptom-free during the early post-injury period.

Signs of peritoneal irritation may indicate pancreatic injury.

All of the above.

Blunt injury resulting from vehicular accidents could cause pancreatic injury. Redness. bruising in the flank and severe peritoneal irritation are signs of a pancreatic injury. The client is usually pain-free during the early post-injury period. hence a comprehensive assessment and monitoring should be done.

Explanation

Blunt injury resulting from vehicular accidents could cause pancreatic injury. Redness. bruising in the flank and severe peritoneal irritation are signs of a pancreatic injury. The client is usually pain-free during the early post-injury period. hence a comprehensive assessment and monitoring should be done.

4. When attending a client with a head and neck trauma following a vehicular accident. the nurse's initial action is to?

Do oral and nasal suctioning.

Provide oxygen therapy.

Initiate intravenous access.

Immobilize the cervical area.

Clients with suspected or possible cervical spine injury must have their neck immobilized until formal assessment occurs.Options A. B. and C: Suctioning. oxygen therapy. and intravenous access are also done after the cervical spine is immobilize.

Explanation

Clients with suspected or possible cervical spine injury must have their neck immobilized until formal assessment occurs.Options A. B. and C: Suctioning. oxygen therapy. and intravenous access are also done after the cervical spine is immobilize.

5. A client in a one-car rollover presents with multiple injuries. Prioritize the interventions that must be initiated for this patient.(1. Assess for spontaneous respirations.2. Give supplemental oxygen per mask.3. Insert a Foley catheter if not contraindicated.4. Obtain a full set of vital signs.5. Remove patient's clothing.6. Secure/start two large-bore IVs with normal saline.7. Use the chin lift or jaw thrust method to open the airway.)

1. 7. 2. 6. 4. 5. 3

7. 1. 4. 2. 3. 5. 6

4. 1. 5. 7. 6. 3. 2

5. 4. 1. 7. 2. 6. 3

For multiple trauma victims. a lot of interventions will occur simultaneously as team members assist in the resuscitation. Methods to open the airway such as the chin lift or jaw thrust can be used simultaneously while assessing for spontaneous respirations. However. airway and oxygenation are a priority. Starting IVs for fluid resuscitation is part of supporting circulation. (EMS will usually establish at least one IV in the field.) Nursing assistants can be directed to take vitals and remove clothing. Foley catheter is necessary to closely monitor output.

Explanation

For multiple trauma victims. a lot of interventions will occur simultaneously as team members assist in the resuscitation. Methods to open the airway such as the chin lift or jaw thrust can be used simultaneously while assessing for spontaneous respirations. However. airway and oxygenation are a priority. Starting IVs for fluid resuscitation is part of supporting circulation. (EMS will usually establish at least one IV in the field.) Nursing assistants can be directed to take vitals and remove clothing. Foley catheter is necessary to closely monitor output.

6. A 36-year-old patient with a history of seizures and medication compliance of phenytoin (Dilantin) and carbamazepine (Tegretol) is brought to the ED by the MS personnel for repetitive seizure activity that started 45 minutes prior to arrival. You anticipate that the physician will order which drug for status epilepticus?

Lorazepam (Ativan) IV.

Magnesium sulfate IV.

Carbamazepine (Tegretol) IV.

Phenytoin and Carbamazepine PO.

IV Lorazepam (Ativan) is the drug of choice for status epilepticus.Option B: Magnesium sulfate is given to control seizures in toxemia of pregnancy.Option C: Tegretol is used in the management of generalized tonic-clonic. absence or mixed type seizures. but it does not come in an IV form.Option D: PO (per os) medications are inappropriate for this emergency situation.

Explanation

IV Lorazepam (Ativan) is the drug of choice for status epilepticus.Option B: Magnesium sulfate is given to control seizures in toxemia of pregnancy.Option C: Tegretol is used in the management of generalized tonic-clonic. absence or mixed type seizures. but it does not come in an IV form.Option D: PO (per os) medications are inappropriate for this emergency situation.

7. A 15-year-old male client was sent to the emergency unit following a small laceration on the forehead. The client says that he can't move his legs. Upon assessment. respiratory rate of 20. strong pulses. and capillary refill time of less than 2 seconds. Which triage category would this client be assigned to?

Black.

Green.

Red.

Yellow.

The client is possibly suffering from a spinal injury but otherwise. has a stable status and can communicate so the appropriate tag is YELLOW.

Explanation

The client is possibly suffering from a spinal injury but otherwise. has a stable status and can communicate so the appropriate tag is YELLOW.

8. A 20-year-old male client was brought to the emergency department with a gunshot wound to the chest. In obtaining a history of the incident to determine possible injuries. the nurse should ask which of the following?

“What was the initial first aid done?”

“Where did the incident happen?”

“What direction did the bullet enter into the body?”

“How long ago did the incident occur?”

The entry point and direction of the bullet will predict the involve injuries of the client.Options A. B. and D: The other information is not as useful in determining which diagnostic studies and care are needed immediately.

Explanation

The entry point and direction of the bullet will predict the involve injuries of the client.Options A. B. and D: The other information is not as useful in determining which diagnostic studies and care are needed immediately.

9. An ER nurse is handling a 50-year-old woman complaining of dizziness and palpitations that occur from time to time. ECG confirms the diagnosis of paroxysmal supraventricular tachycardia. The client seems worried about it. Which of the following is an appropriate response of the nurse?

“You can be discharged now; this is a probable sign of anxiety.”

“You have to stay here for a few hours to undergo blood tests to rule out myocardial infarction.”

“We’ll need to keep you for further assessment; you may develop blood clots.”

“The physician will prescribe you blood-thinning medications to lessen the episodes of palpitations.”

Paroxysmal supraventricular tachycardia (PSVT) is characterized by episodes of rapid heart rate that occurs periodically and stops on its own. PSVT decreases the cardiac output and can result to a thrombus. These clots could turn into an embolus. which could eventually lead to a stroke.

Explanation

Paroxysmal supraventricular tachycardia (PSVT) is characterized by episodes of rapid heart rate that occurs periodically and stops on its own. PSVT decreases the cardiac output and can result to a thrombus. These clots could turn into an embolus. which could eventually lead to a stroke.

10. Which of these is not classified as a Category A biologic agent?

Staphylococcus enterotoxin B (SEB).

Clostridium botulinum toxin (botulism).

Bacillus anthracis (anthrax).

Francisella tularensis (tularemia).

Staphylococcus enterotoxin B (SEB) belongs to the category B priority pathogen.

Explanation

Staphylococcus enterotoxin B (SEB) belongs to the category B priority pathogen.