NUR255E1.docx - Question 1 2 2 pts A nurse is providing care to an older adult client who has frostbite of the feet Which action would be considered

Question 1 2 / 2 pts A nurse is providing care to an older adult client who has frostbite of the feet. Which action would be considered inppropriate? Placing sterile cotton between the toes after rewarming Massaging the feet For a client with frostbite, massaging the affected body part is contraindicated. Analgesia is given for pain during the rewarming process because it can be very painful. Ambulation would be restricted. Once rewarmed, sterile gauze or cotton is placed between the affected toes to prevent maceration. Providing an analgesic for pain Restricting ambulation Question 2 2 / 2 pts The nurse is caring for a near-drowning victim after resuscitation. What focused assessment will the nurse perform to identify complications from drowning? Auscultation of lungs Auscultation of the lungs will assist the nurse to identify complications from drowning, including pulmonary infection and acute respiratory distress syndrome (ARDS). All other assessments are important, but the nurse must focus on the respiratory system as most likely to demonstrate complications. Palpation of abdominal cavity Inspection of skin color Palpation of pulse strength Question 3 2 / 2 pts A 17 year old male walks into triage stating: My boss won't let me come back to work until I get a note from a doctor. I work in a grocery store stocking shelves. Yesterday I was moving stock and several boxes fell and hit my foot. I'm fine, it doesn't hurt but my boss made me come. There are no obvious signs of trauma to the foot. Vital signs are within normal limits. Vital Signs: Temperature 98.6 Heart rate 68 Respiratory rate 12 Blood pressure 110/68 As the triage nurse what would you categorize this patient using the Emergency Severity Index (ESI) Level 2

Level 3 Level 4 Level 5 Reason is... This patient has no complaints and has no obvious signs of trauma. The patient needs to be seen by a physician or mid level provider, examined and discharged. No resources are needed so the patient meets ESI level 5 criteria. Question 4 2 / 2 pts A client has been exposed to cyanide. Which of the following would the nurse expect to assist in administering? Dimercaprol Lorazepam Sodium thiosulfate Treatment of cyanide exposure involves the use of amyl nitrate, sodium nitrite, and sodium thiosulfate. Atropine is used to treat nerve agent poisoning. Dimercaprol is used to treat systemic toxicity of vesicants. Atropine Incorrect Question 5 0 / 2 pts A 25 year old female present to triage complaining of generalized abdominal cramping with moderate vaginal bleeding, one pad very four hours since she woke up this am. She is 6 weeks pregnant. She denies any localized pain or other complaints. Vital Signs: Temperature 98.6 Heart rate 86 Respiratory rate 16 Blood pressure 120/80 As the triage nurse what would you categorize this patient using the Emergency Severity Index (ESI) Level 5 Level 2 Level 3 Level 4 Reason is... This patient will consume a number of resources including labs, intravenous fluids, an ultrasound and perhaps intravenous analgesics. Her generalized abdominal cramping and