med-surg chapter 11 – Flashcards
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While the nurse is visiting the community pool, an adult swimmer is pulled out of the pool, unconscious and cyanotic. What is the priority action of the nurse?
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Give two rescue breaths.
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The nurse working at a first aid booth during a summer marathon sees several runners. Which runner should be seen first? A runner who:
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Has fallen several times
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The nurse is working at a first aid booth for a spring training game on a hot day. A spectator comes in, reporting that he is not feeling well. Vital signs are temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, and blood pressure 106/66 mm Hg. He trips over his feet as the nurse leads him to a cot. What is the priority action of the nurse?
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Sponge the victim with cool water and remove his shirt.
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The emergency department nurse assesses a client in extreme pain with an apparent snakebite of the leg. Vital signs are stable. What is the priority action of the nurse?
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Apply an immobilization splint.
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The nurse is teaching a wilderness survival class. Which statement by a participant indicates that additional teaching is needed?
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"If I get too cold, I can have some brandy to help me get warmed up."
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A community nurse assesses a client, who has an allergy to bees, after a bee sting. The client's lips are swollen, and wheezes are audible. What is the priority action of the nurse?
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Administer an EpiPen from the first aid kit and call 911.
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While on a camping trip, the nurse provides care for a camper who was bitten by a black widow spider. What is the priority action of the nurse?
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Apply ice to the site of the bite.
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A client presents to the emergency department after prolonged exposure to the cold. The client is shivering, has slurred speech, and is slow to respond to questions. Which treatment will the nurse prepare for this client?
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Dry clothing and warm blankets
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The emergency department nurse assesses a middle-aged mountain climber who reports headache, nausea, vomiting, and "feeling winded." What is the nurse's priority intervention?
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Administer acetazolamide (Diamox).
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A nurse is at the scene of a lightning strike during a thunderstorm. Which is the priority action of the nurse?
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Move victims and first aid responders to a sheltered area.
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On a hot, humid day, several clients present to the emergency department with symptoms of heat exposure. Which client will be treated first? A client who:
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Is anxious and confused
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The nurse is teaching a community health class about water safety. Which statement by a participant indicates that additional teaching is needed?
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"I can go swimming all by myself because I am a certified lifeguard."
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The nurse is assessing a client recently bitten by a coral snake. Which assessment is the priority?
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Respiratory rate and depth
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The nurse is teaching a client with severe allergies how to prevent bug bites. Which statement by the client indicates that additional teaching is needed?
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"I will wear sandals whenever I go outside."
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The nurse is planning care for a client admitted with a snakebite to the right leg. With whom should the nurse collaborate?
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The regional poison control center
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The nurse is caring for a client who had a near-drowning incident in a lake. Which action will the nurse take to monitor for possible complications?
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Assess the client's temperature every 4 hours.
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The nurse is working in the emergency department on a hot, humid day, when a hiker is brought in after collapsing. The hiker is confused and tachycardic with a temperature of 105.6° F (40.9° C). Which IV solution and medication will the nurse have ready for the client?
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Normal saline and lorazepam (Ativan)
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The nurse is assessing a client admitted with a brown recluse spider bite. What priority assessment should the nurse perform?
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Obtain the client's temperature.
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The nurse is providing emergency care to a client with frostbite. Which intervention is performed first?
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Rewarm the affected area in a 104° F water bath.
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The nurse is caring for a drowning victim after resuscitation. What focused assessment will the nurse perform to identify complications from drowning?
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Auscultation of lungs
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The nurse is assessing a group of clients. Which clients are at greater risk for hypothermia or frostbite? (Select all that apply.)
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*A young man who has just consumed six martinis *An older man who smokes a pack of cigarettes a day *A young woman who is anorexic *A young woman who is diabetic
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The nurse is providing health education at a community center. Which instructions should the nurse include in teaching about prevention of lightning injuries during a storm? (Select all that apply.)
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*Seek shelter inside a building or vehicle. *Do not take a bath or shower. *Turn off the television. *Put down golf clubs or gardening tools.
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An emergency department nurse moves to a new city, where heat-related illnesses are common. Which clients should the nurse anticipate as at higher risk for heat-related illness? (Select all that apply.)
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*Homeless individuals *Illicit drug users *Older adults
