Nokea
A patient arrives in the emergency department with a sucking wound to the left chest. What is the first action the nurse should take?
- A. Place several layers of gauze dressing over the wound.
- B. Place the patient in a supine position.
- C. Cover the wound with an airtight dressing taped on three sides.
- D. Turn the patient to the left side.
Correct Answer: C
Rationale: Sucking chest wounds should be dressed with a flutter dressing so that air can escape the pleural space, but no more air can be sucked in.
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A farm worker who has been kicked in the stomach by a mule passes a foul black tarry stool. What is this called?
- A. Loose stool
- B. Melena
- C. Hematuria
- D. Hemoptysis
Correct Answer: B
Rationale: When internal bleeding occurs, the patient may demonstrate hemoptysis (bloody sputum), hematemesis (bloody vomit), melena (foul black tarry stool), or hematuria (bloody urine).
The Good Samaritan law will protect all people who offer assistance. What is necessary for this protection?
- A. A license
- B. The person acts prudently
- C. Licensed supervision
- D. The patient improves
Correct Answer: B
Rationale: The Good Samaritan law will protect any person who follows a prudent course of action.
A patient with multiple serious injuries sustained in a motorcycle accident is lying beside his wrecked motorcycle unconscious and bleeding when the rescuer arrives at the scene. What will be the rescuer's priority action?
- A. Assessing blood loss
- B. Assessing respiratory status
- C. Obtaining vital signs
- D. Organizing laypeople at the scene
Correct Answer: B
Rationale: Priority intervention is to assess respiratory status.
The patient arrived at the emergency department in pain and bleeding profusely with the following vital signs: BP 80/54 P 102 RR 22. What does the nurse recognize that these symptoms indicate?
- A. Inadequate perfusion
- B. Circulatory shock
- C. Massive vasodilation
- D. Heart failure
Correct Answer: B
Rationale: Shock results from failure of the circulatory system to provide sufficient blood circulation.
A nurse assesses an accident victim who has bright red blood spurting from a laceration on his right forearm. Where will the nurse apply pressure after applying direct pressure and elevating the limb?
- A. Right subclavian artery
- B. Right radial artery
- C. Right ulnar artery
- D. Right brachial artery
Correct Answer: D
Rationale: Arterial bleeding is characterized by the spurting of bright red blood and can be controlled by direct pressure, elevation, and indirect pressure on the appropriate pressure point. The brachial artery is the closest pressure point to the injury.