A
A nurse cares for a dying patient. Which manifestation of dying does the nurse treat first?
a. Anorexia
b. Pain
c. Nausea
d. Hair loss
Only symptoms that cause distress for a dying patient should be treated. Such symptoms include pain, nausea and vomiting, dyspnea, and agitation. These problems interfere with the patient’s comfort. Even when symptoms, such as anorexia or hair loss, disturb the family, they should be treated only if the patient is distressed by their presence. The nurse should treat the patient’s pain first.
PTS: 1 DIF: Cognitive Level: Applying KEY: End-of-life care | advance directives
MSC: Integrated Process: Caring NOT: Patient Needs Category: Psychosocial Integrity
A patient tells the nurse that even though it has been 4 months since her sister’s death, she frequently finds herself crying uncontrollably. How does the nurse respond?
a. “Most people move on within a few months. You should see a grief counselor.”
b. “Whenever you start to cry, distract yourself from thoughts of your sister.”
c. “You should try not to cry. I’m sure your sister is in a better place now.”
d. “Your feelings are completely normal and may continue for a long time.”
ANS: D
Frequent crying is not an abnormal response. The nurse should let the patient know that this is normal and okay. Although the patient may benefit from talking with a grief counselor, it is not unusual for her to still be grieving after a few months. The other responses are not as therapeutic because they justify or minimize the patient’s response.
PTS: 1 DIF: Cognitive Level: Applying KEY: End-of-life care | coping
MSC: Integrated Process: Caring
A nurse teaches a patient who is considering being admitted to hospice. Which statement does the nurse include in this patient’s teaching?
a. “Hospice admission has specific criteria. You may not be a viable candidate, so we will look at alternative plans for your discharge.”
b. “Hospice care focuses on a holistic approach to health care. It is not designed to hasten death, but rather to relieve symptoms.”
c. “Hospice care will not help with your symptoms of depression. I will refer you to the facility’s counseling services instead.”
d. “You seem to be experiencing some difficulty with this stage of the grieving process. Let’s talk about your feelings.”
ANS: B
As both a philosophy and a system of care, hospice care uses an interdisciplinary approach to assess and address the holistic needs of patients and families to facilitate quality of life and a peaceful death. This holistic approach neither hastens nor postpones death but provides relief of symptoms experienced by the dying patient.
PTS: 1 DIF: Cognitive Level: Applying
KEY: End-of-life care | palliative/hospice care
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Psychosocial Integrity
A nurse discusses inpatient hospice with a patient and the patient’s family. A family member expresses concern that her loved one will receive only custodial care. How will the nurse respond?
a. “The goal of palliative care is to provide the greatest degree of comfort possible and help the dying person enjoy whatever time is left.”
b. “Palliative care will release you from the burden of having to care for someone in the home. It does not mean that curative treatment will stop.”
c. “A palliative care facility is like a nursing home and costs less than a hospital because only pain medications are given.”
d. “Your relative is unaware of her surroundings and will not notice the difference between her home and a palliative care facility.”
ANS: A
Palliative care provides an increased level of personal care designed to manage symptom distress. The focus is on pain control and helping the relative die with dignity.
PTS: 1 DIF: Cognitive Level: Understanding
KEY: End-of-life care | palliative/hospice care MSC: Integrated Process: Caring
NOT: Patient Needs: Psychosocial Integrity
An emergency room nurse is triaging victims of a multi-casualty event. Which patient would receive care first?
a. A 30-year-old distraught mother holding her crying child
b. A 65-year-old conscious male with a head laceration
c. A 26-year-old male who has pale, cool, clammy skin
d. A 48-year-old with a simple fracture of the lower leg
ANS: C
The patient with pale, cool, clammy skin may be in shock and needs immediate medical attention. The mother does not have injuries and so would be the lowest priority. The other two people need medical attention soon, but not at the expense of a person in shock.
PTS: 1 DIF: Cognitive Level: Applying KEY: Triage | emergency nursing
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
A nurse is triaging patients in the emergency department (ED). Which patient would the nurse prioritize to receive care first?
a. A 22-year-old with a painful and swollen right wrist
b. A 45-year-old reporting chest pain and diaphoresis
c. A 60-year-old reporting difficulty swallowing and nausea
d. An 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101 F (38.8 C)
ANS: B
A patient experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other patients are more stable.
PTS: 1 DIF: Cognitive Level: Applying KEY: Triage | emergency nursing
MSC: Integrated Process: Nursing Process/Planning
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center?
a. Level I—located within remote areas and provides advanced life support within resource capabilities
b. Level II—located within community hospitals and provides care to most injured patients
c. Level III—located in rural communities and provides only basic care to patients
d. Level IV—located in large teaching hospitals and provides a full continuum of trauma care for all patients
ANS: B
Level I trauma centers are usually located in large teaching hospital systems and provide a full continuum of trauma care for all patients. Both Level II and Level III facilities are usually located in community hospitals. These trauma centers provide care for most patients and transport to Level I centers when patient needs exceed resource capabilities. Level IV trauma centers are usually located in rural and remote areas. These centers provide basic care, stabilization, and advanced life support while transfer arrangements to higher level trauma centers are made.
PTS: 1 DIF: Cognitive Level: Remembering KEY: Trauma center | emergency nursing
MSC: Integrated Process: Nursing Process/Planning
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
Emergency medical technicians arrive at the emergency department with an unresponsive patient who has an oxygen mask in place. Which action would the nurse take first?
a. Assess that the patient is breathing adequately.
b. Insert a large-bore intravenous line.
c. Place the patient on a cardiac monitor.
d. Assess for the best neurologic response.
ANS: A
After establishing an airway, the highest priority intervention in the primary survey is to establish that the patient is breathing adequately. Even though this patient has an oxygen mask on, he or she may not be breathing, or may be breathing inadequately with the device in place. Inserting an IV line and placing the patient on a monitor would come after ensuring a patent airway and effective breathing.
PTS: 1 DIF: Cognitive Level: Applying KEY: Primary survey | emergency nursing
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
A nurse is triaging patients in the emergency department. Which patient would be considered “urgent”?
a. A 20-year-old female with a chest stab wound and tachycardia
b. A 45-year-old homeless man with a skin rash and sore throat
c. A 75-year-old female with a cough and a temperature of 102 F (38.9 C)
d. A 50-year-old male with new-onset confusion and slurred speech
ANS: C
A patient with a cough and a temperature of 102 F (38.9 C) is urgent. This patient is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. The patient with a chest stab wound and tachycardia and the patient with new-onset confusion and slurred speech should be triaged as emergent. The patient with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent.
PTS: 1 DIF: Cognitive Level: Applying KEY: Triage | emergency nursing
MSC: Integrated Process: Nursing Process/Planning
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
A nurse is triaging patients in the emergency department. Which patient would the nurse classify as “nonurgent?”
a. A 44-year-old with chest pain and diaphoresis
b. A 50-year-old with chest trauma and absent breath sounds
c. A 62-year-old with a simple fracture of the left arm
d. A 79-year-old with a temperature of 104 F (40.0 C)
ANS: C
A patient in a nonurgent category can tolerate waiting several hours for healthcare services without a significant risk of clinical deterioration. The patient with a simple arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent. The patient with chest pain and diaphoresis and the patient with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The patient with a high fever may be stable now but also has a risk of deterioration.
PTS: 1 DIF: Cognitive Level: Applying KEY: Triage | emergency nursing
MSC: Integrated Process: Nursing Process/Planning
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
An elderly patient who has fallen from a roof is transported to the emergency department by ambulance. The patient was unconscious at the scene but is conscious on arrival and is triaged as urgent. What is the priority assessment the nurse includes during the primary survey of the patient?
a. A full set of vital signs
b. Cardiac rhythm
c. Neurological status
d. Patient history
ANS: C
The primary survey for a trauma patient organizes the approach to the patient so that life-threatening injuries are rapidly identified and managed. Injuries from this type of fall have a high risk for cervical spine injuries. In addition, with the loss of consciousness at the scene the patient would be at risk for head trauma. A full set of vital signs is obtained as part of the secondary survey. The cardiac rhythm is important but not specifically related to this patient’s presentation. Patient history would be obtained as able.
PTS: 1 DIF: Cognitive Level: Applying KEY: Triage | emergency nursing
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
A hospital responds to a local mass casualty event. What action would the nurse supervisor take to prevent staff post-traumatic stress disorder during a mass casualty event?
a. Provide water and healthy snacks for energy throughout the event.
b. Schedule 16-hour shifts to allow for greater rest between shifts.
c. Encourage counseling upon deactivation of the emergency response plan.
d. Assign staff to different roles and units within the medical facility.
ANS: A
To prevent staff post-traumatic stress disorder during a mass casualty event, the nurses should use available counseling, encourage and support coworkers, monitor each other’s stress level and performance, take breaks when needed, talk about feelings with staff and managers, and drink plenty of water and eat healthy snacks for energy. Nurses should also keep in touch with family, friends, and significant others, and not work for more than 12 hours per day. Encouraging counseling upon deactivation of the plan, or after the emergency response is over, does not prevent stress during the casualty event. Assigning staff to unfamiliar roles or units may increase situational stress and is not an approach to prevent post-traumatic stress disorder.
PTS: 1 DIF: Cognitive Level: Remembering KEY: Post-traumatic stress disorder
MSC: Integrated Process: Communication and Documentation
NOT: Patient Needs Category: Safe and Effective Care Environment: Safety and Infection Control
A nurse is field-triaging patients after an industrial accident. Which patient condition would the nurse triage with a red tag?
a. Dislocated right hip and an open fracture of the right lower leg
b. Large contusion to the forehead and a bloody nose
c. Closed fracture of the right clavicle and arm numbness
d. Multiple fractured ribs and shortness of breath
ANS: D
Patients who have an immediate threat to life are given the highest priority, are placed in the emergent or class I category, and are given a red triage tag. The patient with multiple rib fractures and shortness of breath most likely has developed a pneumothorax, which may be fatal if not treated immediately. The patient with the hip and leg problem and the patient with the clavicle fracture would be classified as class II; these major but stable injuries can wait for 30 minutes to 2 hours for definitive care. The patient with facial wounds would be considered the “walking wounded” and classified as nonurgent.
PTS: 1 DIF: Cognitive Level: Analyzing KEY: Triage | emergency nursing
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
An emergency department (ED) charge nurse prepares to receive patients from a mass casualty within the community. What is the role of this nurse during the event?
a. Ask ED staff to discharge patients from the medical-surgical units in order to make room for critically injured victims.
b. Call additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in.
c. Inform the incident commander at the mass casualty scene about how many victims may be handled by the ED.
d. Direct medical-surgical and critical care nurses to assist with patients currently in the ED while emergency staff prepare to receive the mass casualty victims.
ANS: D
The ED charge nurse should direct additional nursing staff to help care for current ED patients while the ED staff prepares to receive mass casualty victims; however, they should not be assigned to the most critically ill or injured patients. The house supervisor and unit directors would collaborate to discharge stable patients. The hospital incident commander is responsible for mobilizing resources and would have the responsibility for calling in staff. The medical command physician would be the person best able to communicate with on-scene personnel regarding the ability to take more patients.
PTS: 1 DIF: Cognitive Level: Applying KEY: Emergency nursing
MSC: Integrated Process: Nursing Process/Planning
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
The nurse is caring for a patient with an acute burn injury. What action would the nurse take to prevent infection by autocontamination?
a. Use a disposable blood pressure cuff to avoid sharing with other patients.
b. Change gloves between wound care on different parts of the patient’s body.
c. Use the closed method of burn wound management for all wound care.
d. Advocate for proper and consistent handwashing by all members of the staff.
ANS: B
Autocontamination is the transfer of microorganisms from one area to another area of the same patient’s body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between performing wound care on different parts of the patient’s body can prevent autocontamination.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Infection control | Standard Precautions
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Safe and Effective Care Environment: Safety and Infection Control
An emergency room nurse assesses a patient who was rescued from a home fire. The patient suddenly develops a loud, brassy cough. What action would the nurse take first?
a. Apply oxygen and continuous pulse oximetry.
b. Provide small quantities of ice chips and sips of water.
c. Request a prescription for an antitussive medication.
d. Ask the respiratory therapist to provide humidified air.
ANS: A
Brassy cough and wheezing are some of the signs seen with inhalation injury. The first action by the nurse is to give the patient oxygen. Patients with possible inhalation injury also need continuous pulse oximetry. Ice chips and humidified room air will not help the problem, and antitussives are not warranted.
PTS: 1 DIF: Cognitive Level: Applying KEY: Respiratory distress/failure
MSC: Integrated Process: Nursing Process/Analysis
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
66. ANS: C
A nurse prepares to administer intravenous cimetidine (Tagamet), a histamine H2 receptor antagonist, to a patient who has a new burn injury. The patient asks, “Why am I taking this medication?” How would the nurse respond?
a. “Tagamet stimulates intestinal movement so you can eat more.”
b. “It improves fluid retention, which helps prevent hypovolemic shock.”
c. “It helps prevent stomach ulcers, which are common after burns.”
d. “Tagamet protects the kidney from damage caused by dehydration.”
ANS: C
Ulcerative gastrointestinal disease (Curling’s ulcer) may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and a decreased mucosal barrier. This process occurs because of the sympathetic nervous system stress response. Cimetidine is a histamine2 blocker and inhibits the production and release of hydrochloric acid. Cimetidine does not affect intestinal movement and does not prevent hypovolemic shock or kidney damage.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Medication | patient education | peptic ulcer disease prophylaxis
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
A nurse cares for a patient with a burn injury who presents with drooling and difficulty swallowing. What action would the nurse take first?
a. Assess the level of consciousness and pupillary reactions.
b. Ascertain the time food or liquid was last consumed.
c. Auscultate breath sounds over the trachea and bronchi.
d. Measure abdominal girth and auscultate bowel sounds.
ANS: C
Inhalation injuries are present in 7% of patients admitted to burn centers. Drooling and difficulty swallowing can mean that the patient is about to lose his or her airway because of this injury. Absence of breath sounds over the trachea and bronchi indicates impending airway obstruction and demands immediate intubation. Knowing the level of consciousness is important in assessing oxygenation to the brain. Ascertaining the time of last food intake is important in case intubation is necessary (the nurse will be more alert for signs of aspiration). However, assessing for air exchange is the most important intervention at this time. Measuring abdominal girth is not relevant in this situation.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Medical emergency | respiratory distress/failure
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
A nurse receives new prescriptions for a patient with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The patient’s urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription would the nurse question?
a. Increase intravenous fluids by 100 mL/hr.
b. Administer furosemide (Lasix) 40 mg IV push.
c. Continue to monitor urine output hourly.
d. Draw blood for serum electrolytes STAT.
ANS: B
The plan of care for a patient with a burn includes fluid and electrolyte resuscitation. Furosemide would be inappropriate to administer. Postburn fluid needs are calculated initially by using a standardized formula such as the Parkland formula. However, needs vary among patients, and the final fluid volume needed is adjusted to maintain hourly urine output at 0.5 mL/kg/hr. Based on this patient’s inadequate urine output, fluids need to be increased, urine output needs to be monitored hourly, and electrolytes would be evaluated to ensure that appropriate fluids are being infused.
PTS: 1 DIF: Cognitive Level: Applying KEY: Intravenous fluids | medication
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A nurse reviews the laboratory results for a patient who was burned 24 hours ago. Which laboratory result would the nurse report to the healthcare provider immediately?
a. Arterial pH: 7.32
b. Hematocrit: 52%
c. Serum potassium: 6.5 mEq/L (6.5 mmol/L)
d. Serum sodium: 131 mEq/L (131 mmol/L)
ANS: C
The serum potassium level is changed to the degree that serious life-threatening responses could result. With such a rapid rise in potassium level, the patient is at high risk for experiencing severe cardiac dysrhythmias and death. All the other findings are abnormal but do not show the same degree of severity; they would be expected in the emergent phase after a burn injury.
PTS: 1 DIF: Cognitive Level: Applying KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process/Analysis
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
A nurse assesses a patient who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. What action would the nurse take next?
a. Administer furosemide (Lasix).
b. Perform chest physiotherapy.
c. Document and reassess in an hour.
d. Place the patient in an upright position.
ANS: D
Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the patient in an upright position can relieve lung congestion immediately before other measures can be carried out. Although Lasix may be used to treat pulmonary edema in patients who are fluid overloaded, a patient with a burn injury will lose a significant amount of fluid through the broken skin; therefore, Lasix would not be appropriate. Chest physiotherapy will not get rid of fluid.
PTS: 1 DIF: Cognitive Level: Applying KEY: Respiratory distress/failure
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
A nurse uses the rule of nines to assess a patient with burn injuries to the entire back region and left arm. How would the nurse document the percentage of the patient’s body that sustained burns?
a. 9%
b. 18%
c. 27%
d. 36%
ANS: C
According to the rule of nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the patient received burns to the back (18%) and one arm (9%), totaling 27% of the body.
PTS: 1 DIF: Cognitive Level: Applying KEY: Skin lesions/wounds
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A nurse assesses a patient admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding would alert the nurse to a potential complication?
a. Partial pressure of arterial oxygen (PaO2) of 80 mm Hg
b. Urine output of 20 mL/hr
c. Productive cough with white pulmonary secretions
d. Core temperature of 100.6 F (38 C)
ANS: B
A significant loss of fluid occurs with burn injuries, and fluids must be replaced to maintain hemodynamics. If fluid replacement is not adequate, the patient may become hypotensive and have decreased perfusion of organs, including the brain and kidneys. A low urine output is an indication of poor kidney perfusion. The other manifestations are not complications of burn injuries.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Intravenous fluids | vascular perfusion
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
The nurse gets the hand-off report on four patients. Which patient would the nurse assess first?
a. Patient with a blood pressure change of 128/74 to 110/88 mm Hg
b. Patient with oxygen saturation unchanged at 94%
c. Patient with a pulse change of 100 to 88 beats/min
d. Patient with urine output of 40 mL/hr for the last 2 hours
ANS: A
This patient has a falling systolic blood pressure, rising diastolic blood pressure, and narrowing pulse pressure, all of which may be indications of the progressive stage of shock. The nurse would assess this patient first. The patient with the unchanged oxygen saturation is stable at this point. Although the patient with a change in pulse has a slower rate, it is not an indicator of shock since the pulse is still within the normal range; it may indicate that the patient’s pain or anxiety has been relieved, or he or she is sleeping or relaxing. A urine output of 40 mL/hr is only slightly above the normal range, which is 30 mL/hr.
PTS: 1 DIF: Cognitive Level: Analyzing
KEY: Shock | perfusion | nursing assessment
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
A patient arrives in the emergency department after being in a car crash with fatalities. The patient has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority?
a. Apply direct pressure to the bleeding.
b. Ensure that the patient has a patent airway.
c. Obtain consent for emergency surgery.
d. Start two large-bore IV catheters.
ANS: B
Airway is the priority, followed by breathing and circulation (IVs and direct pressure). Obtaining consent is done by the physician.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Critical rescue | shock | primary survey
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care