Exam A

Question 1

Caring for a client who was admitted due to hypovolemic shock from hemorrhage suffered during a plane crash. Initially administer which of the following fluids?

Answer 1

0.9% normal saline

Question 2

Which of the following clients should the nurse consider as having the highest priority?

Answer 2

a 56 year old who is diaphoretic with substernal chest pain

Question 3

The nurse is working in the ED. While performing an assessment, someone comes in and points a gun at the patient and yess, “I told you i was going to kill you if you harmed my daughter in any way!” What should the nurse do?

Answer 3

Get out of the line of fire and protect self

Question 4

What is the most therapeutic response to a family’s request to view the body of their loved one who died in a plane crash?

Answer 4

“I’ll see what I can arrange so you can see and spend time with your loved one”

Question 5

Which situation would most likely indicate a critical incident stress management staff meeting by the nurse manager of the ED?

Answer 5

Death of a 4 month old from a plane crash

Question 6

The ICU nurse is monitoring a patient in shock who is receiving rapid IV infusions for fluid resuscitation. The patient is experiencing SOB, decreasing pulse pressure, absent bowel sounds and oliguria. The nurse suspects what?

Answer 6

Abdominal compartment syndrome

Question 7

The nurse in the ED is receiving a client after a plane crash. The client is complaining of severe abdominal pain, has cool, diaphoretic skin, tachycardia, hypotension, and is extremely anxious. The nurse notes a large hematoma on the left flank. What is the priority?

Answer 7

Start an IV with a large bore angiocath

Question 8

To assist the survivors in understanding heat exhaustion, which manifestations should the nurse include in the teaching?

Answer 8

-headache
-syncope
-diaphoresis

Question 9

Patient has experienced an overdose of heparin. To manage adverse reactions from the antidote, which of the following actions should the nurse take?

Answer 9

Have equipment and personnel ready for possible resuscitation

Question 10

Which of the following interventions is appropriate for the nurse to implement when caring for a client who has experienced frostbite?

Answer 10

soak the feet in warm water

Question 11

A client needs sutures placed for lacerations on their arms and legs. Which piece of information is most important?

Answer 11

date of the client’s last tetanus toxoid vaccination

Question 12

A patient is diagnosed with hypothermia. Which complication would you monitor for in rewarming?

Answer 12

ventricular fibrillation

Question 13

A patient with a diagnosis of decompression sickness is being monitored by a nurse. Which of the following interventions would be appropriate to prevent complications?

Answer 13

insert a nasogastric tube and attach to low suction

Question 14

The ED nurse has a client from a nonfatal drowning event. Which assessment data concerns you?

Answer 14

The onset of pink, frothy sputum

Question 15

The nurse is teaching a class on Lyme disease. Which of the following should be included in the presentation?

Answer 15

Wear tight, light-colored clothing when hiking or hunting

Question 16

Preparing to administer IV potassium chloride to a client with severe hypokalemia from a heat stroke. Which of the following nursing actions is appropriate?

Answer 16

Verifying adequate urine output

Question 17

An ED nurse is treating a 3-year-old who has ingested a corrosive substance during a crash. Which of the following actions takes priority?

Answer 17

Assess for airway obstruction

Question 18

A client with carbon monoxide poisoning is confused and complaining of dizziness, nausea, headache, and has a cherry red color to their lips. Which intervention is a priority?

Answer 18

Assess carboxyhemoglobin levels

Question 19

What is the antidote for acetaminophen overdose?

Answer 19

Acetylcysteine

Question 20

You have given lorazepam IV for agitation and hallucinations. What is appropriate to initiate?

Answer 20

Vital signs every 30 mintues

Question 21

You suspect that the client in the ER is a victim of abuse. The partner is present, what could you do? SATA

Answer 21

-assess perfusion at the injury site
-request that the partner leave the room
-give the client the local shelter number

Question 22

Who would you see first?

Answer 22

A woman who has been raped

Question 23

A client on an anticoagulant agrees to take medication to prevent STI’s. Which of the prophylactic medications might cause a possible interaction?

Answer 23

Ceftriaxone

Question 24

Client with psychosis is brought to the ER in full-blown meltdown. What is your immediate goal?

Answer 24

Gain control of the situation

Question 25

What indicates a tension pneumothorax?

Answer 25

tracheal shift & central cyanosis

Question 26

Which information describes a tension pneumothorax?

Answer 26

Allows air into the pleural space that cannot escape

Question 27

Which client is at risk for a spontaneous pneumothorax?

Answer 27

A chronic, emphysema patient

Question 28

You are setting up a PCA with morphine. You program a lockout into the pump. Which piece of education is important for the client?

Answer 28

We have to monitor respiratory status and sedation levels

Question 29

What indicates that your client might be experiencing rhabdomyolysis as a complication?

Answer 29

Myalgia muscle weakness dark urine

Question 30

Your patient returns from surgery with a cast. They are complaining of pain, tightness, and trouble moving their toes. What could a complication be?

Answer 30

compartment syndrome

Question 31

Patient has the following vitals: BP 100/70, pulse 110, R 24, T 97.5, and cool, clammy skin. Which action take priority?

Answer 31

establish large bore IV

Question 32

Which statement is true about shock?

Answer 32

in the compensatory stage, a client can become uncooperative and combative

Question 33

Which data would cause you to call the HCP if your client was septic?

Answer 33

urine output of 50mL over the last 2 hours

Question 34

Your patient has suspected sepsis. Which order has a priority?

Answer 34

obtain blood cultures

Question 35

What is the major concern when caring for a patient with hypovolemic shock?

Answer 35

fluid resuscitation

Question 36

We suspect a flail chest. Which findings do you expect? SATA

Answer 36

-atelectasis -paradoxical chest movement -respiratory acidosis

Question 37

Patient profile: T 97.2 P 108 BP 99/60 O2 89% cool, clammy skin, confused, lethargic, 85 years old What do you suspect?

Answer 37

septic shock

Question 38

Spinal cord injury at c-4. Monitor for neurogenic shock signs and symptoms: SATA

Answer 38

-hypotension -elevated temperature -cool, moist skin -lower extremity redness and swelling

Question 39

Anaphylactic shock response to a bee sting. What do we give first?

Answer 39

Epinephrine

Question 40

What is an early symptom of multi-organ dysfunction syndrome?

Answer 40

dyspnea

Question 41

Patient is receiving norepinephrine and now has an area of extravasation in the IV site. Stop the infusion and do what next?

Answer 41

infuse cortisone

Question 42

What is the therapeutic effect of phenylephrine?

Answer 42

bronchodilation and relaxation of airways