Emergency Nursing Procedures and Assessments, Exams of Nursing

Download Emergency Nursing Procedures and Assessments and more Exams Nursing in PDF only on Docsity! TNCC ENA 9th Edition PreTest Graded A+ A patient arrives at the emergency department by private vehicle after sustaining an injury to the right lower extremity while using a saw. There is a large gaping wound to the right thigh area with significant bleeding. What is the priority intervention? A. Elevate the extremity to the level of the heart B. Initiate direct pressure C. Apply a tourniquet D. Cover the open wound with sterile saline dressings - ANSWER-B. Initiate direct pressure Rationale: The first step inn controlling any bleeding is application of direct pressure. A patient fell two weeks ago, striking their head. Today, the patient presented with a persistent headache and nausea and was diagnosed with a small subdural hematoma. The patient has been in the ED for 24 hours awaiting an inpatient bed. The night shift nurse reports the patient has been anxious, restless, shaky, and vomited twice during the night. The patient states they couldn't sleep because a young child kept coming into the room. What is the most likely cause for these signs and symptoms? A. Increased intracranial pressure B. Alcohol withdrawal C. Rhabdomyolysis D. Pulmonary embolus - ANSWER-B. Alcohol withdrawal Rationale: Alcohol withdrawal is a common delayed condition because symptoms are difficult to identify early. Signs include autonomic hyperactivity, hand tremors, nausea or vomiting, psychomotor agitation, anxiety, insomnia, transient hallucinations, or seizures. A patient involved in a MVC has sustained a fracture to the second rib of the anterior left chest. Which concurrent injury is most commonly associated with this fracture? A. Blunt cardiac injury B. Brachial plexus injury C. Pneumothorax D. Hemothorax - ANSWER-B. Brachial plexus injury Rationale: First and second rib fractures are most commonly associated with great vessel, head and spinal cord, and brachial plexus injuries. A patient with a spinal cord injury at C5 is being cared for in the emergency department while awaiting transport to a trauma center. Which of the following represents the highest priority for ongoing assessment and management for this patient? A. Maintain adequate respiratory status B. Administer balanced resuscitation fluid C. Perform serial assessments of neurologic function D. Maintain core temperature - ANSWER-A. Maintain adequate respiratory status Rationale: Spinal cord injuries at C3 to C5 can cause the loss of phrenic nerve function, resulting in a paralyzed diaphragm and inability to breathe. Maintenance of respiratory function is the highest priority. A trauma nurse cared for a child with devastating burns two weeks ago. The nurse called in sick for a couple of days and is now back working on the team. Which of the following would indicate this nurse is coping well? A. They are talking about taking the emergency nursing certification exam B. They keep requesting to be assigned to the walk-in/ambulatory area C. They are impatient and snap at their coworkers D. They are thinking about transferring out of the emergency department - ANSWER-A. They are talking about taking the emergency nursing certification exam Rationale: This is an indication the nurse is taking positive steps to advance their own practice, a sign of resilience. B indicates the nurse is still not ready to return to their previous level of engagement in their job. C shows signs of burnout, irritability and frustration. D shows decreased satisfaction with the job, a sign of burnout. An adult patient with a knife injury to the neck has an intact airway and is hemodynamically stable. They complain of difficulty swallowing and speaking. In the primary survey, further assessment is indicated next for which of the following conditions? A. Damage to the cervical spine B. An expanding pneumothorax C. Laceration of the carotid artery D. Injury of the thyroid gland - ANSWER-A. Damage to the cervical spine Rationale: Penetrating neck trauma may include concurrent injuries to the cervical spine and cord, airway, or vascular neck structures. With an intact airway and hemodynamic stability, the other common concurrent injury is to the cervical spine. Following a bomb explosion, fragmentation injuries from the bomb or objects in the environment are examples of which phase of injury? A. Primary B. Secondary C. Tertiary D. Quaternary - ANSWER-B. Secondary Rationale: The secondary phase of a blast results from flying debris, projectiles, and bomb fragments causing lacerations or penetrating injuries. B. Supine C. Reverse Trendelenburg D. Right lateral recumbent - ANSWER-C. Reverse Trendelenburg Rationale: The reverse Trendelenburg position will benefit both airway maintenance and work of breathing in the obese patient. What is the leading cause of preventable death for the trauma patient in the prehospital environment? A. Airway compromise B. Ineffective ventilation C. Secondary head injury D. Uncontrolled external hemorrhage - ANSWER-D. Uncontrolled external hemorrhage Rationale: Uncontrolled external hemorrhage is the leading cause of preventable death after injury in the prehospital environment; assessment to identify uncontrolled external hemorrhage is key to the initial assessment process, beginning with the general impression. What technique is most appropriate when obtaining a history from a patient who has experienced a sexual assault? A. Sitting next to the patient B. Ensuring the patient answers all the questions C. Asking for information only related to the assault D. Applying active listening - ANSWER-D. Applying active listening Rationale: Therapeutic communication techniques such as active listening decrease unintentional distress during the interaction. Which of following accurately describes ventilation principles associated with use of bag-mask device for an adult? A. Compress the bag-mask device at a rate of one breath every 6 seconds B. Delivers 100% oxygen C. Squeeze the bag-mask device completely for each breath D. Maintain the oxygen saturation levels between 92% and 94% - ANSWER-A. Compress the bag-mask device at a rate of one breath every 6 seconds Rationale: If breathing is ineffective for an adult, assist ventilations by compressing the bag-mask device at a rate of one breath every 6 seconds. Which of the following is considered a cornerstone of a high-performance trauma team? A. Individual goals B. Use of TeamSTEPPS C. Identification of a single decision maker D. Effective communication - ANSWER-D. Effective communication Rationale: Skilled communication, cooperation, and coordination are the cornerstones of high-performance and high-quality trauma care. While performing an assessment on a 13-month-old involved in a motor vehicle collision, the nurse identifies which of the following findings from the patient as a sign of possible altered mental status? A. Sunken fontanel B. Crying, but consolable C. Spontaneous movement of arms and legs D. Cooperation with the assessment - ANSWER-D. Cooperation with the assessment Rationale: An alert older infant or toddler will recognize their caregiver, be cautious of strangers, and may not respond to commands or cooperate, which are normal.