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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.
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When assessing a patient who has suffered a burn injury the nurse classifies the burn as a deep partial-thickness burn. What is this observation most likely based upon?
- A. Painful reddened skin
- B. Charred skin with milky-white areas
- C. Erythema and blisters
- D. Erythema pain and swelling
Correct Answer: C
Rationale: With deep partial-thickness burns, blister formation may be seen with erythema.
While on break in the hospital cafeteria a nurse witnesses her pregnant coworker start to choke. The coworker is conscious but unable to breathe. Where should the nurse administer thrusts?
- A. Below the navel
- B. The chest
- C. At the xiphoid process
- D. The upper back
Correct Answer: B
Rationale: If the victim is pregnant or obese, chest thrusts are acceptable instead of abdominal thrusts. To provide chest thrusts, the nurse should place his or her hands in the same position that is used for chest compressions during CPR.
A patient has been stung by a bee and is brought to the emergency department. The nurse observes the sting site and identifies that the stinger is still in the skin. What action should the nurse take?
- A. Remove it with sterile tweezers.
- B. Soak the area with a cold compress.
- C. Scrape the stinger with the side of a knife.
- D. Squeeze the surrounding tissue to expel the stinger.
Correct Answer: C
Rationale: The stinger should be removed with the side of a knife by scraping to avoid forcing more venom into the skin.
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.
When other methods have failed to stop the bleeding and the victim's life is in danger the rescuer at the scene applies a tourniquet to a young woman's leg above the knee. What is another step that is essential for the rescuer to follow?
- A. Never release the tourniquet.
- B. Wrap the tourniquet around the limb twice.
- C. Mark the patient with a "T."
- D. Leave the limb elevated.
Correct Answer: A
Rationale: A tourniquet must never be released once it is in place. All other options are enhancements to the procedure of the tourniquet application, but not essential.