ATI Care of Patients
with Common Environmental Emergencies, Questions and Answers with Explanations,
100% Correct, Download to Score A
Test Bank
MULTIPLE CHOICE
1. 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?
a. Begin
chest compressions.
b. Move from
the pool area.
c. Give two
rescue breaths.
d. Check for
a carotid pulse.
ANS: C
The highest priority is to maintain ventilatory support until
the victim can breathe on his or her own. The other options are important, but
maintaining the airway and breathing are always priority.
DIF: Cognitive Level: Application/Applying or higher REF:
N/A
TOP: Client Needs Category: Physiological Integrity (Physiological
Adaptation—Medical Emergencies) MSC: Integrated Process: Nursing Process
(Implementation)
2. The nurse working at a first aid booth during a summer
marathon sees several runners. Which runner should be seen first? A runner who:
a. Has
fallen several times
b. Is
fatigued
c. Thinks
he has the flu
d. Has
tachypnea
ANS: A
Hot, dry skin, tachycardia, tachypnea, and hypotension are
signs of heat stroke. A marathon runner who has fallen several times may have a
thermal injury to the brain, causing loss of coordination. Mental status
changes from thermal injury to the brain include confusion, bizarre behavior,
seizures, and even coma. The nurse should prioritize the client with potential
thermal brain injury over the other clients.
DIF: Cognitive Level: Application/Applying or higher REF:
N/A
TOP: Client Needs Category: Physiological Integrity
(Physiological Adaptation—Medical Emergencies) MSC: Integrated Process: Nursing
Process (Planning)
3. 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?
a. Encourage
drinking of cool water or sports drinks.
b. Sponge
the victim with cool water and remove his shirt.
c. Administer
Tylenol (acetaminophen), 650 mg orally.
d. Encourage
rest, and reassess in 15 minutes.
ANS: B
The spectator shows signs of heat stroke, which is a medical
emergency. The spectator should be transported to the emergency department as
quickly as possible. The nurse should take actions to lower his body
temperature in the meantime by removing his shirt and sponging his body with
cool water. Lowering body temperature by drinking cool fluids or taking
acetaminophen is not as effective in an emergency situation. The client needs
to be cooled quickly and is a priority for treatment.
DIF: Cognitive Level: Application/Applying or higher REF:
N/A
TOP: Client Needs Category: Physiological Integrity
(Physiological Adaptation—Medical Emergencies) MSC: Integrated Process: Nursing
Process (Implementation)
4. 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?
a. Call the
regional poison control center.
b. Administer
IV pain medication.
c. Place a
tourniquet around the leg.
d. Apply an
immobilization splint.
ANS: D
Treatment involves immobilization to minimize the spread of
venom. A tourniquet should not be used because it impairs arterial blood flow.
Pain medication should be administered and collaboration with the regional poison
control center begun after the leg is immobilized.
DIF: Cognitive Level: Application/Applying or higher REF:
N/A
TOP: Client Needs Category: Physiological Integrity
(Physiological Adaptation—Medical Emergencies) MSC: Integrated Process: Nursing
Process (Implementation)
5. The nurse is teaching a wilderness survival class. Which
statement by a participant indicates that additional teaching is needed?
a. “If I get
too cold, I can have some brandy to help me get warmed up.”
b. “My
climbing partner should let me know right away if my nose turns white.”
c. “If my
partner can’t think straight, we should descend to a lower altitude.”
d. “It is
okay to feel a little short of breath when I am climbing, but not at rest.”
ANS: A
Alcohol will increase the risk of cold-related injuries and
should be avoided. The other options all show good understanding of the
education.
DIF: Cognitive Level: Application/Applying or higher REF:
N/A
TOP: Client Needs Category: Health Promotion and Maintenance
(Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
6. 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?
a. Elevate
the site and notify the client’s next of kin.
b. Remove
the stinger with tweezers and encourage rest.
c. Administer
diphenhydramine (Benadryl) and apply ice.
d. Administer
an EpiPen from the first aid kit and call 911.
ANS: D
The student’s swollen lips indicate that anaphylaxis may be
developing, and this is a medical emergency. 911 should be called immediately,
and the client transported to the emergency department as quickly as possible.
If an EpiPen is available, it should be administered at the first sign of an
anaphylactic reaction. The other answers do not provide adequate interventions
to treat airway obstruction due to anaphylaxis.
DIF: Cognitive Level: Application/Applying or higher REF:
N/A
TOP: Client Needs Category: Physiological Integrity
(Physiological Adaptation—Medical Emergencies) MSC: Integrated Process: Nursing
Process (Implementation)
7. 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?
a. Apply ice
to the site of the bite.
b. Apply a
loose tourniquet to the limb.
c. Give
acetaminophen (Tylenol) for pain.
d. Cover the
camper with a warm blanket.
ANS: A
Ice inhibits the action of neurotoxin and should be the
first intervention provided to a client bitten by a black widow spider. A
tourniquet should not be used because it impairs arterial blood flow. Tylenol
and covering the camper do not treat the neurotoxic effect of the black widow
spider’s bite.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity
(Physiological Adaptation—Medical Emergencies) MSC: Integrated Process: Nursing
Process (Implementation)
8. 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?
a. Dry
clothing and warm blankets
b. Administration
of warmed IV fluids
c. Peritoneal
lavage with warmed normal saline
d. Continuous
arteriovenous rewarming
ANS: A
Mild hypothermia is manifested by shivering, slurred speech,
poor muscular coordination, and impaired cognitive abilities. Mild hypothermia
may be treated with dry clothing and warm blankets. Rewarming should occur slowly
by removing wet clothing and providing dry warm blankets first. Other
treatments are secondary and should be used to treat moderate to severe
hypothermia.
DIF: Cognitive Level: Application/Applying or higher REF:
N/A
TOP: Client Needs Category: Physiological Integrity
(Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing
Process (Planning)
9. 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?
a. Administer
acetazolamide (Diamox).
b. Administer
prochlorperazine (Compazine).
c. Perform
a neurologic assessment.
d. Assess
for bowel sounds.
ANS: A
The client is exhibiting signs of mountain sickness.
Acetazolamide (Diamox, Apo-Acetazolamide) is used to prevent and treat acute
mountain sickness. The other interventions will not treat mountain sickness.
DIF: Cognitive Level: Application/Applying or higher REF:
N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological
and Parenteral Therapies—Expected Actions/Outcomes) MSC: Integrated Process:
Nursing Process (Planning)
10. A nurse is at the scene of a lightning strike during a
thunderstorm. Which is the priority action of the nurse?
a. Make sure
that victims are not electrically charged.
b. Assess
victims for second- and third-degree burns.
c. Start
emergency resuscitation on anyone not breathing.
d. Move
victims and first aid responders to a sheltered area.
ANS: D
Victims of a lightning strike are not electrically charged
afterward. Cardiopulmonary resuscitation (CPR) should be started once victims
and first aid responders are in a sheltered area, because the thunderstorm
presents a continued threat of lightning strikes.
DIF: Cognitive Level: Application/Applying or higher REF:
N/A
TOP: Client Needs Category: Physiological Integrity
(Physiological Adaptation—Medical Emergencies) MSC: Integrated Process: Nursing
Process (Implementation)
11. 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:
a. Has
normal mental status and flu-like symptoms
b. Is
diaphoretic with nausea and vomiting
c. Is
hypotensive and tachycardic
d. Is
anxious and confused
ANS: D
Normal mental status, flu-like symptoms, diaphoresis, nausea
and vomiting, hypotension, and tachycardia all are symptoms of heat exhaustion.
The differentiating symptom between heat exhaustion and exertional heat stroke
is the presence of mental status changes, which indicate thermal injury to the
brain and represent an emergency situation.
DIF: Cognitive Level: Application/Applying or higher REF:
N/A
TOP: Client Needs Category: Physiological Integrity
(Physiological Adaptation—Medical Emergencies) MSC: Integrated Process: Nursing
Process (Planning)
Category | ATI |
Release date | 2021-09-14 |
Pages | 11 |
Language | English |
Comments | 0 |
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