lewiss medical surgical nursing assessment and management of clinical problems testbank
the following four patients arrive in the emergency department ed after a motor vehicle collision in whi
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Testbank-for-lewis-medical-surgical-nursing-11th-edition-by-harding-all-chapters-1-68| Complete Guide Newest Version Correct Test bank Questions and answers with explanations
LEWIS’S MEDICAL SURGICAL NURSING 11TH EDITION HARDING TEST BANK
TEST BANK FOR LEWIS’S MEDICAL SURGICAL NURSING 11TH EDITION HARDING CHAPTER 1-68|COMPLETE GUIDE-2022
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b. Assess neurologic status every 2 hours.
c. Give acetaminophen (Tylenol) 650 mg.
d. Place cooling blankets above and below patient.
e. Attach rectal temperature probe to cooling blanket control panel.
ANS: C, D, E
Experienced LPN/LVNs have the education and scope of practice to implement hypothermia
measures (e.g., cooling blanket, temperature probe) and administer medications under the
supervision of a registered nurse (RN). Assessment of neurologic status and monitoring the
heart rhythm require RN-level education and scope of practice and should be done by the RN.
DIF: Cognitive Level: Apply (application) REF: 1634
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
OTHER
1. The following four patients arrive in the emergency department (ED) after a motor vehicle
collision. In which order should the nurse assess them? (Put a comma and a space between
each answer choice [A, B, C, D, E].)
a. A 74-yr-old patient with palpitations and chest pain
b. A 43-yr-old patient complaining of 7/10 abdominal pain
c. A 21-yr-old patient with multiple fractures of the face and jaw
d. A 37-yr-old patient with a misaligned lower left leg with intact pulses
ANS:
C, A, B, D
The highest priority is to assess the 21-yr-old patient for airway obstruction, which is the most
life-threatening injury. The 74-yr-old patient may have chest pain from cardiac ischemia and
should be assessed and have diagnostic testing for this pain. The 43-yr-old patient may have
abdominal trauma or bleeding and should be seen next to assess circulatory status. The
37-yr-old patient appears to have a possible fracture of the left leg and should be seen soon,
but this patient has the least life-threatening injury.
, Because human bites of the hand frequently become infected, prophylactic antibiotics are
usually prescribed to prevent infection. To minimize infection, deep bite wounds on the
extremities are left open. Rabies immune globulin might be used after an animal bite. Initial
treatment of bite wounds includes copious irrigation to help clean out contaminants and
microorganisms.
23. The urgent care center protocol 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.
ANS: A
Because neurotoxic venom is released as long as the tick is attached to the patient, the initial
action should be to remove any ticks using tweezers or forceps. The other actions are also
appropriate, but the priority is to minimize venom release.
1. Which interventions will the nurse plan for a comatose patient who is to begin therapeutic
hypothermia (select all that apply)?
a. Assist with endotracheal intubation.
b. Insert an indwelling urinary catheter.
c. Begin continuous cardiac monitoring.
d. Obtain an order to restrain the patient.
e. Prepare to give sympathomimetic drugs.
ANS: A, B, C
Cooling can produce dysrhythmias, so the patient’s heart rhythm should be continuously
monitored and dysrhythmias treated if necessary. Bladder catheterization and endotracheal
intubation are needed during cooling. Sympathomimetic drugs tend to stimulate the heart and
increase the risk for fatal dysrhythmias such as ventricular fibrillation. Patients receiving
therapeutic hypothermia are comatose or do not follow commands so restraints are not
indicated.
2. The emergency department (ED) nurse is starting therapeutic hypothermia in a patient who
has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be
delegated to an experienced licensed practical/vocational nurse (LPN/LVN) (select all that
apply)?
a. Continuously monitor heart rhythm.
, The priority assessment in an unresponsive patient relates to CAB (circulation, airway,
breathing) so a pulse check should be performed first. While assessing the pulse, the nurse
should look for signs of breathing. The other data will also be collected rapidly but are not as
essential as determining if there is a pulse.
20. Following an earthquake, patients are triaged by emergency medical personnel and
transported to the emergency department (ED). Which patient will the nurse need to assess
first?
a. A patient with a red tag c. A patient with a black tag
b. A patient with a blue tag d. A patient with a yellow tag
ANS: A
The red tag indicates a patient with a life-threatening injury requiring rapid treatment. The
other tags indicate patients with less urgent injuries or those who are likely to die.
DIF: Cognitive Level: Remember (knowledge) REF: 1646
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
21. Family members are in the patient’s room when the patient has a cardiac arrest and the staff
start resuscitation measures. Which action should the nurse take next?
a. Keep the family in the room and assign a staff member to explain the care given
and answer questions.
b. Ask the family to wait outside the patient’s room with a designated staff member
to provide emotional support.
c. Ask the family members whether they would prefer to remain in the patient’s room
or wait outside the room.
d. Tell the family members that patients are comforted by having family members
present during resuscitation efforts.
ANS: C
Although many family members and patients report benefits from family presence during
resuscitation efforts, the nurse’s initial action should be to determine the preference of these
family members. The other actions may be appropriate, but this will depend on what is
learned when assessing family preferences.
22. A 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 (BayRab).
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.
ANS: C
, d. Give first dose of activated charcoal.
ANS: B
In an unresponsive patient, intubation is done before gastric lavage and activated charcoal
administration to prevent aspiration. The other actions will be implemented after intubation.
17. A patient arrives in the emergency department (ED) after topical exposure to powdered lime
at work. Which action should the nurse take first?
a. Obtain the patient’s vital signs.
b. Obtain a baseline complete blood count.
c. Decontaminate the patient by showering with water.
d. Brush off any visible powder on the skin and clothing.
ANS: D
The initial action should be to protect staff members and decrease the patient’s exposure to the
toxin by decontamination. Patients exposed to powdered lime should not be showered;
instead, any and all visible powder should be brushed off. The other actions can be done after
the decontamination is completed.
18. An unresponsive 79-yr-old patient is admitted to the emergency department (ED) during a
summer heat wave. The patient’s core temperature is 105.4° F (40.8° C), blood pressure (BP)
is 88/50 mm Hg, and pulse is 112 beats/min. The nurse will plan to
a. apply wet sheets and a fan to the patient.
b. provide O2 at 2 L/min with a nasal cannula.
c. start lactated Ringer’s solution at 1000 mL/hr.
d. give acetaminophen (Tylenol) rectal suppository.
ANS: A
The priority intervention is to cool the patient. Antipyretics are not effective in decreasing
temperature in heat stroke and 100% O2 should be given, which requires a high flow rate
through a non-rebreather mask. An older patient would be at risk for developing
complications such as pulmonary edema if given fluids at 1000 mL/hr.
19. An unresponsive patient is admitted to the emergency department (ED) after falling through
the ice while ice skating. Which assessment will the nurse obtain first?
a. Pulse c. Breath sounds
b. Heart rhythm d. Body temperature
ANS: A
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