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During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next? A. palpate extremities for bilateral pulses B. Observe the patients respiratory effort C. Check the pt.'s level of consciousness D. Examine the pt. for any external bleeding - Correct Answer B During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal pulse is absent and the leg is swollen. Which action will the nurse take next? A. Send blood to the lab for complete blood count B. Assess further for a cause of the decreased circulation C. Finish the airway, breathing, circulation, disability survey.
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D. Start normal saline fluid infusion with a large-bore IV line. - Correct Answer D After the return of spontaneous circulation following the resuscitation of a patient who had cardiac arrest, therapeutic hypothermia is ordered. Which action will the nurse include in the plan of care? A. Apply external cooling device B. Check mental status every 15 minutes C. Avoid the use of sedative medications D. Rewarm if temperature is <91 - Correct Answer A A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should
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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) - Correct Answer B A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the ED. The nurse determines that discharge teaching has been effective when the patient makes which statement? A. I will take salt tablets when I work outdoors in the summer B. I should take acetaminophen (Tylenol) if I start to feel too warm
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C. I should drink sports drinks when working outside in hot weather D. I will move to a cool environment if I notice that I am feeling confused - Correct Answer C A 22 year old patient who experienced a near 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 take during the observation period? A. Auscultate heart sounds B. Palpate peripheral pulses C. Auscultate breath sounds D. Check pupil reaction to light - Correct Answer C
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When assessing an older patient admitted to the 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 is most appropriate? A. Do you feel safe in your home? B. You should not return to your home C. would you like to see a social worker? D. I need to report my concerns to the police - Correct Answer A A 20 year old patient arrives in the ED several hours after taking 25 to 30 acetaminophen (Tylenol) tablets. Which action will the nurse plan to take? A. Give N-acetylcysteine (Mucomyst) B. Discuss the use of chelation therapy
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C. Start oxygen using a non-rebreather mask D. Have the patient drink large amounts of water - Correct Answer A A triage nurse in a busy ED assesses a patient who complains of 7/10 abdominal pain and states, I had a temperature of 103.9 at home. The nurses first action should be to A. Assess the patients 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 1 to 2 hours before being seen by the doctor - Correct Answer A The ED triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment?
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Gastric lavage and administration of activated charcoal are ordered for an unconscious patient who has been admitted to the Ed after ingesting 30 lorazepam (Ativan) tablets. Which 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 - Correct Answer B A 54 year old patient arrives in the ED after exposure to powdered line at work. Which action should the nurse take first? A. Obtain the patients vital signs B. Obtain a baseline complete blood count C. Decontaminate the patient by showering with water
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D. Brush off any visible powder on the skin and clothing - Correct Answer D An unresponsive 79 year old is admitted to the ED during. summer heat wave. The patients core temperature is 105.4 F, BP 88/50, and pulse 112. The nurse initially will plan to A. Apply wet sheets and a fan to the patient B. Provide O2 at 6 L/min with a nasal cannula C. Start lactated Ringers solution at 1000 mL/hr D. Give acetaminophen (Tylenol) rectal suppository - Correct Answer A A patient is admitted to the ED after falling through the ice while ice skating. Which assessment will the nurse obtain first? A. Heart rate B. Breath sounds
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B. Ask the family to wait outside the patients room with a designated staff member to provide emotional support C. Ask the family members about whether they would prefer to remain in the patients room or wait outside the room D. Te - Correct Answer C A 28 year old patient who has deep human bite wounds on the left hand is being treated in the urgent care center. Which action will the nurse plan to take? A. Prepare to administer rabies immune globulin B. Assist the health care provider with suturing of the bite wounds C. Teach the patient the reason for the use of prophylactic antibiotics D. Keep the wounds dry until the health care provider can assess them - Correct Answer C
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The urgent care center portal for tick bites includes the following actions. Which action will the nurse take first when caring for a patient with a tick bite? A. Use tweezers to remove any remaining ticks B. Check the vital signs, including temperature C. Give doxycycline (Vibramycin) 100 mg orally D. Obtain information about recent outdoor activities - Correct Answer A To determine whether there is a delay in impulse conduction through the atria, the nurse will measure the duration of the patients A. P wave B. Q wave C. P-R interval
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A. 15 to 20 B. 20 to 40 C. 40 to 60 D. 60 to 100 - Correct Answer C The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, P-R interval not measurable, ventricular rate 162, R-R interval regular and QRS complex wide and distorted, QRS duration 0.18 second. The nurse interprets the patients cardiac rhythm as A. Atrial flutter B. Sinus tachycardia C. Ventricular fibrillation D. Ventricular tachycardia - Correct Answer D
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The nurse notes that a patients cardiac monitoring shows that every other beat is earlier than expected, has no visible P wave, and has a QRS complex that is wide and bizarre in shape. How will the nurse document the rhythm? A. Ventricular couplets B. Ventricular bigeminy C. Ventricular R-on-T phenomenon D. Multifocal premature ventricular contractions - Correct Answer B A patient has a normal cardiac rhythm and a heart rate of 72 beats/minutre. The nurse determines that the P-R interval is 0.24 seconds. The most appropriate intervention by the nurse would be to A. Notify the healthcare provider immediately B. Give atropine per agency dysthymia protocol
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After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the medication has been effective? A. Increase in the patients heart rate B. Increase in the strength of peripheral pulses C. Decrease in premature atrial contractions D. Decrease in premature ventricular contractions - Correct Answer A A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. The priority teaching needed for this patient would include information about A. Anticoagulant therapy B. Permanent pacemenrs C. Electrical cardio version
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D. IV adenosine - Correct Answer A Which information will the nurse include when teaching a patient who is scheduled for radio frequency catheter ablation for treatment of atrial flutter? A. The procedure will prevent or minimize the risk for sudden cardia death B. The procedure will use cold therapy to stop the formation of the flutter waves C. The procedure will use electrical energy to destroy areas of the conduction system D. The procedure will stimulate the growth of new conduction pathways between the atria - Correct Answer C
