Practice Questions 2

Question 1

Four victims of an automobile crash are brought by ambulance to the emergency department. The triage nurse determines that the victim who has the highest priority for treatment is the one with
a. severe bleeding of facial and head lacerations.
b. an open femur fracture with profuse bleeding.
c. a sucking chest wound.
d. absence of peripheral pulses.

Answer 1

Correct Answer: C
Rationale: Most immediate deaths from trauma occur because of problems with ventilation. so the patient with a sucking chest wound should be treated first. Face and head fractures can obstruct the airway, but the patient with facial injuries has lacerations only. The other two patients also need rapid intervention but do not have airway or breathing problems.

Question 2

A triage nurse in a busy emergency department assesses a patient who complains of 6/1O abdominal pain and states, “I had a temperature of 104.6° F (40.3° C) at home.” The nurse’s first action should be to
a. tell the patient that it may be several hours before being seen by the doctor.
b. assess the patient’s current vital signs.
c. obtain a clean-catch urine for urinalysis.
d. ask the health care provider to order a nonopioid analgesic medication for the patient.

Answer 2

Correct Answer: B
Rationale: The patient’s pain and statement about an elevated temperature indicate that the nurse should obtain vital signs before deciding how rapidly the patient should be seen by the health care provider. A urinalysis may be needed, but vital signs will provide the nurse with more useful data for triage. The health care provider will not order a medication before assessing the patient.

Question 3

During the primary assessment of a trauma victim, the nurse determines that the patient has a patent airway. The next assessment by the nurse should be to
a. check the patient’s level of consciousness.
b. examine the patient for any external bleeding.
c. observe the patient’s respiratory effort.
d. palpate for the presence of peripheral pulses.

Answer 3

Correct Answer: C
Rationale: Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient’s breathing. The other actions are also part of the initial survey but are not accomplished as rapidly as the assessment of breathing.

Question 4

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During the primary assessment of a patient with multiple trauma, the nurse observes that the patient’s right pedal pulses are absent and the leg is swollen. The nurse’s first action should be to
a. initiate isotonic fluid infusion through two large-bore IV lines.
b. send blood to the lab for a complete blood count (CBC).
c. finish the airway, breathing, circulation, disability survey.
d. assess further for a cause of the decreased circulation.

Answer 4

Correct Answer: A
Rationale: The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a possibly life-threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey. Although a CBC is indicated, administration of IV fluids should be started first. Completion of the primary survey and further assessment should be completed after the IV fluids are initiated.

Question 5

When caring for a patient with head and neck trauma after a motorcycle accident. the emergency department nurse’s first action should be to
a. suction the mouth and oropharynx.
b. immobilize the cervical spine.
c. administer supplemental oxygen.
d. obtain venous access.

Answer 5

Correct Answer: B
Rationale: When there is a risk of spinal cord injury, the nurse’s initial action is immobilization of the cervical spine during positioning of the head and neck for airway
administration, and venous access are also necessary after the cervical spine is protected by immobilization.

Question 6

A patient has been brought to the emergency department with a gunshot wound to the abdomen. In obtaining a history of the incident to determine possible injuries, the nurse asks
a. “Where did the incident occur?”
b. “What direction did the bullet enter the body?”
c. “How long ago did the incident happen?”
d. “What emergency care was started at the scene?”

Answer 6

Correct Answer: B
Rationale: The entry point and direction of the bullet will help to predict the type of injuries the patient has. The other information is not as useful in determining which diagnostic studies and care are needed immediately.

Question 7

A 67-year-old patient who has fallen from a ladder is transported to the emergency department by ambulance. The patient is unconscious on arrival and accompanied by family members. During the primary survey of the patient, the nurse should
a. assess a full set of vital signs.
b. obtain a Glasgow Coma Scale score.
c. attach a cardiac ECG monitor.
d. ask about chronic medical conditions.

Answer 7

Correct Answer: B
Rationale: The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the secondary survey.

Question 8

A 24-year-old is brought to the emergency department with multiple lacerations and tissue avulsion of the right hand after catching the hand in a produce conveyor belt. When asked about tetanus immunization, the patient says, ‘‘I’ve never had any vaccinations.” The nurse will anticipate administration of tetanus
a. immunoglobulin.
b. and diphtheria toxoid.
c. immunoglobulin, tetanus-diphtheria toxoid, and pertussis vaccine.
d. immunoglobulin and tetanus-diphtheria toxoid.

Answer 8

Correct Answer: C
Rationale: For a patient with unknown immunization status, the tetanus immune globulin is administered along with the Tdap (since the patient has not had pertussis vaccine previously). The other immunizations are not sufficient for this patient.

Question 9

A patient has experienced blunt abdominal trauma from a motor vehicle accident. The nurse should explain to the patient the purpose of
a. magnetic resonance imaging (MRI).
b. ultrasonography.
c. peritoneal lavage.
d. nasogastric (NG) tube placement.

Answer 9

Correct Answer: B
Rationale: If intra-abdominal bleeding is suspected, focused abdominal ultrasonography is obtained to look for lavage is an alternative, but it is more invasive. An NG tube would not be helpful in diagnosis of intra-abdominal bleeding.

Question 10

A patient is brought to the hospital in cardiac arrest by emergency personnel who are performing resuscitation. The spouse arrives as the patient is taken Into a treatment room and asks to stay with the patient. The nurse should

a. have the spouse wait outside the treatment room with a designated staff member to provide emotional support.
b. bring the spouse into the room and ensure him or her that a member of the team will explain the care given and answer questions.
c. explain that the presence of family members is distracting to staff and might impair the resuscitation efforts.
d. advise the spouse that if the resuscitation effort is unsuccessful, the memories may have an adverse impact on grieving.

Answer 10

Correct Answer: B
Rationale: Family members and patients report benefits from family presence during resuscitation efforts, so the nurse should try to accommodate the spouse. Having the spouse wait outside the room is not as supportive to the spouse or patient. It would be inappropriate to imply that the spouse’s presence would have adverse consequences for the patient. Family members do not report problems with grieving caused by being present during resuscitation efforts.

Question 11

An emergency room nurse assesses a client who has been raped. With which health care team member should the nurse collaborate when planning this client’s care?

a. Emergency medicine physician
b. Case manager
c. Forensic nurse examiner
d. Psychiatric crisis nurse

Answer 11

ANS: C -All other members of the health care team listed may be used in the management of this client’s care.
However, the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing with the victim of an assault.

Question 12

The emergency department team is performing cardiopulmonary resuscitation on a client when the client’s spouse arrives at the emergency department. Which action should the nurse take first?

a. Request that the client’s spouse sit In the waiting room.
b. Ask the spouse if he wishes to be present during
the resuscitation.
c. Suggest that the spouse begin to pray for the client.
d. Refer the client’s spouse to the hospitals crisis team.

Answer 12

ANS: B - If resuscitatlon efforts are still under way when the family arrives, one or two family members may be given the opportunity to be present during lifesaving procedures. The other options do not give the spouse the opportunity to be present for the client or to begin to have closure.

Question 13

An emergency room nurse is triaging victims of a multi­ casualty event. Which client should receive care first?

a. A 30-year-old distraught mother holding her crying child
b. A 65-year-old conscious male with a head laceration
c. A 26-year-old male who has pale, cool, clammy skin
d. A 48-year-old with a simple fracture of the lower leg

Answer 13

C - The client with pale, cool, clammy skin Is in shock and needs immediate medical attention. The mother does not have injuries and so would be the lowest priority. The other two people need medical attention soon, but not at the expense of a person in shock.

Question 14

While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action should the nurse take first?

a. Apply oxygen via nasal cannula.
b. Administer intravenous 0.9% saline solution.
c. Transfer the client to a negative-pressure room.
d. Obtain a sputum culture and sensitivity.

Answer 14

ANS: C - A client with signs and symptoms of tuberculosis or other airborne pathogens should be placed in a negative­ pressure room to prevent contamination of staff, clients & family members in the crowded emergency department.

Question 15

A nurse is triaging clients in the emergency department (ED). Which client should the nurse prioritize to receive care first?

a. A 22-year-old with a painful and swollen right wrist
b. A 45-year-old reporting chest pain and diaphoresis
c. A 60-year-old reporting difficulty swallowing and nausea
d. An 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101 F

Answer 15

B - A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable.

Question 16

A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center?

a. Level I Located within remote areas and provides advanced life support within resource capabilities
b. Level II Located within community hospitals and provides care to most Injured clients
c. Level Ill Located in rural communities and provides only basic care to clients
d. Level IV Located in large teaching hospitals and provides a full continuum of trauma care for all clients

Answer 16

ANS: B - Level I trauma centers are usually located in large teaching hospital systems and provide a full continuum of trauma care for all clients. Both Level II and Level Ill facilities are usually located in community hospitals. These trauma centers provide care for most clients and transport to Level I centers when client needs exceed resource capabilities. Level IV trauma centers are usually located in rural and remote areas. These centers provide basic care, stabilization, and advanced life support while transfer arrangements to higher-level trauma centers are made.

Question 17

Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action should the nurse take first?

a. Assess that the client is breathing adequately.
b. Insert a large-bore intravenous line.
c. Place the client on a cardiac monitor.
d. Assess for the best neurologic response.

Answer 17

A - The highest-priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he or she may not be breathing, or may be breathing inadequately with the device in place.

Question 18

A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action should the nurse take prior to providing advanced cardiac life support?

a. Contact the on-call orthopedic surgeon.
b. Don personal protective equipment.
c. Notify the Rapid Response Team.
d. Obtain a complete history from the paramedic.

Answer 18

B - Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions should be taken in all resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection. a facemask. a surgical cap, and shoe covers.

Question 19

A nurse is triaging clients in the emergency department. Which client should be considered urgent?

a. A 20-year-old female with a chest stab wound and tachycardia
b. A 45-year-old homeless man with a skin rash and sore throat
c. A 75-year-old female with a cough and a
temperature of 102 F
d. A 50-year-old male with new-onset confusion and slurred speech

Answer 19

C - A client with a cough and a temperature of 102 F is urgent. This client is at risk for deterioration and needs to be seen quickly, but Is not in an immediately life-threatening situation. The client with a chest stab wound and tachycardia and the client with new-onset confusion and slurred speech should be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent.

Question 20

An emergency department nurse is caring for a client who has died from a suspected homicide. Which action should the nurse take?
a. Remove all tubes and wires in preparation for the medical examiner.
b.
Limit the number of visitors to minimize the family’s trauma.
c. Consult the bereavement committee to follow up with the grieving family.
d. Communicate the client’s death to the family in a simple and concrete manner.

Answer 20

ANS: D - When dealing with client’s and families in crisis, communicate in a simple and concrete manner to minimize confusion. Tubes must remain in place for the medical examiner. Family should be allowed to view the body.
Offering to call for additional family support during the crisis is suggested. The bereavement committee should be consulted, but this is not the priority at this time.

Question 21

An emergency department (ED) case manager is consulted for a client who is homeless. Which intervention should the case manager provide?

a. Communicate client needs and restrictions to support staff.
b. Prescribe low-cost antibiotics to treat community­ acquired infection.
c. Provide referrals to subsidized community-based health clinics.
d. Offer counseling for substance abuse and mental health disorders.

Answer 21

C - Case management interventions include facilitating referrals to primary care providers who are accepting new clients or to subsidized community-based health clinics for clients or families in need of routine services. The ED nurse is accountable for communicating pertinent staff considerations, client needs, and restrictions to support staff (e.g., physical limitations, isolation precautions) to ensure that ongoing client and staff safety issues are addressed.
The ED physician prescribes medications and treatments. The psychiatric nurse team evaluates clients with emotional behaviors or mental illness and facilitates the follow-up treatment plan, including possible admission to an appropriate psychiatric facility.

Question 22

An emergency department nurse is caring for a client who is homeless. Which action should the nurse take to gain the clients trust?

a. Speak in a quiet and monotone voice.
b. Avoid eye contact with the client.
c. Listen to the client’s concerns and needs.
d. Ask security to store the client’s belongings.

Answer 22

ANS: C - To demonstrate behaviors that promote trust with homeless clients, the emergency room nurse should make eye contact (if culturally appropriate), speak calmly, avoid any prejudicial or stereotypical remarks. show genuine care and concern by listening, and follow through on promises. The nurse should also respect the client’s belongings and personal space.

Question 23

A nurse is triaging clients in the emergency department. Which client should the nurse classify as nonurgent?

a. A 44-year-old with chest pain and diaphoresis
b. A 50-year-old with chest trauma and absent breath sounds
c. A 62-year-old with a simple fracture of the left arm
d. A 79-year-old with a temperature of 104 F

Answer 23

ANS: c - A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with a simple arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration.

Question 24

A nurse is caring for clients in a busy emergency department. Which actions should the nurse take to ensure client and staff safety? (SATA)

a. Leave the stretcher in the lowest position with rails down so that the client can access the bathroom.
b. Use two identifiers before each Intervention and before mediation administration.
c. Attempt de-escalation strategies for clients who
demonstrate aggressive behaviors.
d. Search the belongings of clients with altered mental status to gain essential medical information.
e. Isolate clients who have immune suppression disorders to prevent hospital-acquired infections.

Answer 24

ANS: B, C, D - To ensure client and staff safety, nurses should use two identifiers per The Joint Commissions National Patient Safety Goals; follow the hospitals security plan, including de-escalation strategies for people who demonstrate aggressive or violent tendencies; and search belongings to identify essential medical information. Nurses should also use standard fall prevention interventions, including leaving stretchers in the lowest position with rails up, and isolating clients who present with signs and symptoms of contagious infectious disorders.

Question 25

An emergency department (ED) nurse is preparing to transfer a client to the trauma intensive care unit. Which information should the nurse include in the nurse-to-nurse hand-off report? (SATA)

a. Mechanism of injury
b. Diagnostic test results
c. Immunizations
d. List of home medications
e. Isolation precautions

Answer 25

ANS: A, B, E - Hand-off communication should be comprehensive so that the receiving nurse can continue care for the client fluidly. Communication should be concise and should include only the most essential information for a safe transition in care. Hand-off communication should include the clients situation (reason for being in the ED), brief medical history, assessment and diagnostic findings, Transmission­ Based Precautions needed, interventions provided, and response to those interventions.

Question 26

An emergency room nurse is caring for a trauma client. Which interventions should the nurse perform during the primary survey? (SATA)

a. Foley catheterization
b. Needle decompression
c. Initiating IV fluids
d. Splinting open fractures
e. Endotracheal intubation
f. Removing wet clothing
g. Laceration repair

Answer 26

ANS: B, C, E, F ~ The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic ABC, with an added D and E: Airway and cervical spine control; Breathing; Circulation; Disability; and Exposure. After the completion of primary diagnostic and laboratory studies, and the insertion of gastric and urinary tubes, the secondary survey (a complete head-to-toe assessment) can be carried out.

Question 27

The complex care provided during an emergency requires interdisciplinary collaboration. Which interdisciplinary team members are paired with the correct responsibilities? (SATA)

a. Psychiatric crisis nurse Interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis
b. Forensic nurse examiner Performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources
c. Triage nurse Provides basic life support interventions such as oxygen, basic wound care, splinting, spinal immobilization, and monitoring of vital signs
d. Emergency medical technician Obtains client
histories, collects evidence, and offers counselling and follow-up care for victims of rape, child abuse, and domestic violence
e. Paramedic Provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration

Answer 27

ANS: A, E - The psychiatric crisis nurse evaluates clients with emotional behaviors or mental illness and facilitates follow-up treatment plans. The psychiatric crisis nurse also works with clients and families when experiencing a crisis. Paramedics are advanced life support providers who can perform advanced techniques that may include cardiac monitoring, advanced airway management and intubation, establishing IV access, and administering drugs en route to the emergency department. The forensic nurse examiner is trained to recognize evidence of abuse and to intervene on the clients behalf. The forensic nurse examiner will obtain client histories, collect evidence, and offer counselling and follow-up care for victims of rape, child abuse, and domestic violence. The triage nurse performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources. The emergency medical technician is usually the first caregiver and provides basic life support and transportation to the emergency department.

Question 28

A nurse prepares to discharge an older adult client home from t.he emergency department (ED). Which actions should the nurse take to prevent future ED visits? (SATA)

a. Provide medical supplies to the family.
b. Consult a home health agency.
c. Encourage participation in community activities.
d. Screen for depression and suicide.
e. Complete a functional assessment.

Answer 28

ANS: D, E ~ Due to the high rate of suicide among older adults, a nurse should assess all older adults for depression and suicide. The nurse should also screen older adults for functional assessment, cognitive assessment, and risk for falls to prevent future ED visits

Question 29

The client diagnosed with hypovolemic shock has a BP of 100/60. Fifteen minutes later the BP is 88/64. How much narrowing of the client’s pulse pressure has occurred between the two readings?

Answer 29

Answer: 16 mmHg pulse pressure

The pulse pressure is the systolic BP minus the diastolic BP. 100 - 60 = 40 mmHg pulse pressure in first BP reading
88 - 64 = 24 mmHg pulse pressure in second reading
40 - 24 = 16 mmHg pulse pressure narrowing.
A narrowing or decreased pulse pressure is an ear1ier indicator of shock than a decrease in systolic blood pressure.

TEST-TAKING HINT: If the test taker is not aware of how to obtain a pulse pressure, the only numbers provided in the stem are systolic and diastolic blood pressures. The test taker should do something with the numbers.

Question 30

The client is admitted into the emergency department with diaphoresis, pale clammy skin, and BP of 90/70. Which intervention should the nurse implement first?

a) Start an IV with an 18-gauge catheter.
b) Administer intravenous dopamine infusion.
c) Obtain arterial blood gases (ABGs).
d) Insert an indwelling urinary catheter.

Answer 30

Answer: 1

• There are many types of shock, but the one common intervention that should be done first in all types of shock is to establish an intravenous line with a large-bore catheter. The low blood pressure and cold, clammy skin indicate shock.
• This blood pressure does not require dopamine; fluid resuscitation is first.
• The client may need ABGs monitored, but this is not the first Intervention.
• An indwelling catheter may need to be inserted for accurate measurement of output, but it is not the first intervention.

TEST-TAKING HINT: This question asks for the first Intervention, which means all options may be appropriate Interventions for the cllent, but only one should be Implemented first Remember: When the client is in distress, do not assess.

Question 31

The nurse is caring for a client diagnosed with septic shock. Which assessment data warrant
immediate intervention by the nurse?

a) Vital signs T 100.4°F, P 104, R 26, and BP 102/60.
b)
A white blood cell count of 18,000/mm”3.
c) Urinary output of 90 ml in the last 4 hours.
d) The client reports being thirsty.

Answer 31

Answer: 3

• These vital signs are expected in a client diagnosed with septic shock.
• An elevated WBC count indicates an infection, which is the definition of sepsis.
• The client must have a urinary output of at least 30 ml/hr, so 90 mL in the last 4 hours indicates impaired renal perfusion, which is a sign of worsening shock.
• The client being thirsty is not an uncommon issue for a client diagnosed with septic shock. This warrants immediate intervention.

TEST-TAKING HINT: The words “warrant immediate intervention” mean the nurse must do something, which frequently can be notifying the HCP. Any client diagnosed with shock will have clinical manifestations requiring the nurse to intervene. In this question, the test taker must determine priority and which data require immediate intervention.

Question 32

The client diagnosed with septicemia has the following health-care provider (HCP) orders. Which HCP order has the highest priority?

a) Provide clear liquid diet.
b) Initiate IV antibiotic therapy.
c) Obtain a STAT chest x-ray.
d) Perform hourly glucometer checks.

Answer 32

Answer: 2

• The client’s diet is not a priority when transcribing orders.
• An IV antibiotic is the priority medication for the client diagnosed with an infection, which is the definition of sepsis-a systemic bacterial infection of the blood. A new order for an IV antibiotic should be implemented within 1 hour of receiving the order.
• Diagnostic tests are important but not priority over intervening in a potentially life-threatening situation such as septic shock.
• There is no indication in the stem of the question
  that this client has diabetes, and glucose levels are not associated with clinical manifestations of septicemia.

TEST-TAKING HINT: Remember, if the test taker can rule out two answers-options “1” and “4”-and cannot determine the right answer between options “2” and “3,” select the option directly affecting or treating the client, which is antibiotics. Diagnostic tests do not treat the client.

Question 33

The client is diagnosed with neurogenic shock. Which clinical manifestations should the nurse assess in this client? Select all that apply.

a) Cool, moist skin.
b) Bradycardia.
c) Wheez.ing.
d) Decreased bowel sounds.
e) Hypotension.

Answer 33

Answer: 2, 5

• The client diagnosed with neurogenic shock will have dry, warm skin, rather than cool, moist skin, as seen in hypovolemic shock.
• The client will have bradycardia instead of tachycardia, which is seen in other forms of shock.
• Wheezing is associated with anaphylactic shock.
• Decreased bowel sounds occur in the hyper­ dynamic phase of septic shock.
• Hypotension is a clinical manifestation of most types of shock.

TEST-TAKING HINT: The test taker should identify the body system the question is addressing. In this case, neuro­ indicates the question relates to the neurological system.
With this information only, the test taker could possibly rule out option “4,” which refers to the gastrointestinal system, and option “3,” which refers to the respiratory system.
Although bradycardia is in the cardiac system, the pulse rate is controlled by the brain.

Question 34

The nurse in the emergency department administered an intramuscular antibiotic in the left ventrogluteal muscle to the client diagnosed with pneumonia being discharged home. Which intervention should the nurse implement?

a) Ask the client about drug allergies.
b) Obtain a sterile sputum specimen.
c) Have the client wait for 30 minutes.
d) Place a warm washcloth on the client’s left hip.

Answer 34

Answer: 3

• It is too late to ask the client about drug allergies because the medication has already been administered.
• Obtaining a specimen after the antibiotic has been
  initiated will skew the culture and sensitivity results. It must be obtained before the antibiotic is started.
• Anytime a nurse administers a medication for the first time, the client should be observed for a possible anaphylactic reaction, especially with antibiotics.
• The client is being discharged, and the nurse can encourage the client to do this at home. but it is not appropriate to do in the emergency department.

TEST-TAKING HINT: The test taker must be observant of information in the stem. The nurse has already administered the medication, and checking for allergies after the fact will not affect the client’s outcome. This is a violation of the five rights; this medication cannot be the right medication if the client is allergic to it.

Question 35

The nurse caring for a client diagnosed with sepsis writes the client diagnosis of “alteration in comfort R/T chills and fever.” Which intervention should be included in the plan of care?

a) Ambulate the client in the hallway every shift.
b) Monitor urinalysis, creatinine level, and BUN level.
c) Apply sequential compression devices to the lower extremities.
d) Administer an antipyretic medication every 4 hours PRN.

Answer 35

Answer: 4

• Ambulating the client in the hall will not address the etiology of the client’s chills and fever; In fact, this could increase the client’s discomfort.
• Monitoring these laboratory data does not address the etiology of the client’s diagnosis.
• Sequential compression devices help prevent deep vein thrombosis.
• Antipyretic medication will help decrease the client’s fever, which directly addresses the etiology of the client’s nursing diagnosis.

TEST-TAKING HINT: The test taker must know the problem “alteration in c.omfort” is addressed by the goal and the interventions address the etiology, which is “chills and fever.”

Question 36

The registered nurse (RN) and an unlicensed assistive personnel (UAP) are caring for a group of clients on a medical floor. Which action by the UAP warrants intervention by the RN?

a) The UAP places a urine specimen in a biohazard bag in the hallway.
b) The UAP uses the alcohol foam hand cleanser after removing gloves.
c) The UAP puts soiled linen in a plastic bag in the client’s room.
d) The UAP obtains a disposable stethoscope for a
client in an isolation room.

Answer 36

Answer: 1

• Specimens should be put into biohazard bags before leaving the client’s room.
• This is the appropriate way to clean hands and does not warrant intervention.
• This is the appropriate way to dispose of soiled linens and does not warrant intervention.
• Taking a stethoscope from a client in isolation to another room is a violation of infection-control principles.

TEST-TAKING HINT: This is an “except” question. The stem is asking which action warrants intervention; therefore, the test taker must select the option indicating an inappropriate action by the unlicensed assistive personnel.

Question 37

The older female client diagnosed with vertebral fractures and self-medicating with ibuprofen presents to the emergency department (ED) reporting abdominal pain, is pale and clammy, and has a P of 110 and a BP of 92/60. Which type of shock should the nurse suspect?

a) Cardiogenic shock.
b) Hypovolemic shock.
c) Neurogenic shock.
d) Septic shock.

Answer 37

Answer: 2

• Cardiogenic shock occurs when the heart’s ability to contract and pump blood is impaired and the supply L3 of oxygen to the heart and tissues is inadequate, such as occurs in myocardial infarction or valvular damage.
• This client’s clinical manifestations make the nurse suspect the client is losing blood, which leads to hypovolemic shock. which is the most common type of shock and is characterized by decreased intravascular volume. The client’s taking of ibuprofen, an NSAID, puts her at risk for hemorrhage because NSAIDs inhibit prostaglandin production in the stomach, which increases the risk of developing ulcers, which can erode the stomach lining and lead to hemorrhaging.
• In neurogenic shock, vasodilation occurs as a result of a loss of sympathetic tone. It can result from the depressant action of medication or lack of glucose.
• Septic shock is a type of circulatory shock caused
  by widespread infection.

TEST-TAKING HINT: The test taker must look at the clinical manifestations and realize this client is in shock. Tachycardia and hypotension with clammy skin indicate shock. The additional information in the stem describes a particular medication, an NSAID, which can cause a peptic ulcer.

Question 38

The client has recently experienced a myocardial infarction. Which action by the nurse helps prevent cardiogenic shock?

a) Monitor the client’s telemetry.
b) Tum the client every 2 hours.
c) Administer oxygen via nasal cannula.
d) Place the client in the Trendelenburg position.

Answer 38

Answer: 3

• Monitoring the telemetry will not prevent cardiogenic shock. It might help identify changes in the hemodynamics of the heart, but it does not prevent
  anything from occurring.
• Tuming the client every 2 hours will help prevent pressure injuries, but it will do nothing to prevent cardiogenic shock.
• Promoting adequate oxygenation of the heart
  muscle and decreasing the cardiac workload can prevent cardiogenic shock.
• Placing the client’s head below the heart will not
  prevent cardiogenic shock. This position can be used when a client is in hypovolemic shock.

TEST-TAKING HINT: If the test taker has no idea what the correct answer is, the test taker should apply Maslow’s hierarchy of needs, which states oxygenation is most important. The test taker must know positions the client may be put in during different disorders and diseases.

Question 39

The client diagnosed with septicemia is receiving a broad-spectrum antibiotic. Which laboratory data require the nurse to notify the HCP?

a) The client’s potassium level is 3.8 mEq/L.
b) The urine culture indicates high sensitivity to the antibiotic.
c) The client’s pulse oximeter reading is 94%.
d) The culture and sensitivity is resistant to the client’s antibiotic.

Answer 39

Answer: 4

• This is a normal potassium level (3.5 to 5.5 mEq/L); therefore, the nurse does not need to notify the HCP.
• A culture result showing a high sensitivity to an antibiotic indicates this is the antibiotic the client
  should be receiving.
• A pulse oximeter reading of greater than 93% indicates the client is adequately oxygenated.
• A sensitivity report indicating resistance to the antibiotic being administered indicates the
  medication the client is receiving is not appropriate for the treatment of the infectious organism, and the HCP needs to be notified so the antibiotic can be changed.

TEST-TAKING HINT: The keywords in option “2” are “high sensitivity,” and this should make the test taker think this is a good thing. In option “4,” the word “resistant” Indicates something wrong with the antibiotic and the need for intervention.

Question 41

The nurse in the emergency department has admitted five clients in the last 2 hours with reports of fever and gastrointestinal distress. Which question is most appropriate for the nurse to ask each client to determine if there is a bioterrorism threat?

a) “Do you work or live near any large power lines?”
b) “Where were you immediately before you got sick?”
c) “Can you write down everything you ate today?”
d) “What other health problems do you have?”

Answer 41

Answer: 2
* Power lines are not typical sources of biological terrorism, which is what these symptoms represent.
* The nurse should take note of any unusual illness for the time of year or clusters of clients coming from a single geographical location, all exhibiting clinical manifestations of possible biological terrorism.
* This might be appropriate for gastroenteritis secondary to food poisoning but is not the nurse’s first thought to determine a biological threat. The nurse must determine if the clients have anything in common.
* This is important information to obtain for all clients but is not pertinent to determine a biological threat.

TEST-TAKING HINT: Option “4” is a question the nurse asks all clients; therefore, the test taker should eliminate it based on the specific question. Power lines are electrical, and most bioterrorism threats involve chemical or biological threats, so option “1” can be eliminated.

Question 42

The health-care facility has been notified an alleged inhalation anthrax exposure has occurred at the local post office. Which category of personal protective equipment (PPE) should the response team wear?

a) LevelA.
b) Level B.
c) Level C.
d) Level D.

Answer 42

Answer: 1
* Level A protection is worn when the highest level of respiratory, skin, eye, and mucous membrane protection is required. In this situation of possible inhalation of anthrax, such protection is required.
* Level B protection is similar to Level A protection, but it is used when a lesser level of skin and eye protection is needed.
* Level c protection requires an air-purified respirator
(APR), which uses filters or absorbent materials to remove harmful substances.
* Level D is basically the work uniform.

TEST-TAKING HINT: If the test taker were totally unaware of the correct answer. then the choice should be either option “1* or option “4” because these are at either end of the spectrum. This gives the test taker a 50/50 chance of selecting the correct answer, instead of a 25% chance.

Question 43

The nurse is teaching a class on bioterrorism to first responders and is discussing PPE. Which statements are important for the nurse to share with the participants? Select all that apply.

a) Health-care facilities should keep masks at entry doors.
b) The respondent should be trained in the proper use of PPE.
c) No single combination of PPE protects against all hazards.
d) The CDC has divided PPE into levels of protection.
e) PPE should be properly fitted to each respondent.

Answer 43

Answer: 2, 3, 4, 5
*
Masks are kept at designated areas, not at every entry door.
* This is a true statement, but in an emergency situation, the respondent should use the equipment even if not trained.
* The HCPs are not guaranteed absolute protection, even with all the training and protective equipment. This is the most important information individuals wearing protective equipment should know because all other procedures should be followed at all times.
* The CDC has divided PPE into different levels based on exposure risk.
* Properly fitted PPE increases the protection from exposure to biological agents.

TEST-TAKING HINT: There are very few questions where the test taker should select an option with the word “all.” Option “3” is stating this is not an “always” situation. The test taker should not automatically assume it is not a possible answer until understanding the context.

Question 44

The nurse is teaching a class on bioterrorism. Which statement is the scientific rationale for designating a specific area for decontamination?

a) Showers and privacy can be provided to the client in this area.
b) This area isolates the clients exposed to the agent.
c) It provides a centralized area for stocking the needed supplies.
d) It prevents secondary contamination to the health­ care providers.

Answer 44

Answer: 4

• This is not a rationale; this is a statement of what is done in the area.
• This separates the clients until decontamination occurs, but the question Is asking for the scientific rationale.
• This is a false statement-the supplies should not be kept in the decontamination area.
• Avoiding cross-contamination is a priority for personnel and equipment-the fewer the number of people exposed, the safer the community and area.

TEST-TAKING HINT Options “1” and “2” are not rationales.

Question 45

The triage nurse in a large trauma center has been notified of an explosion in a major chemical manufacturing plant. Which action should the nurse implement first when the clients arrive at the emergency department?

a) Triage the clients and send them to the appropriate areas.
b) Thoroughly wash the clients with soap and water and then rinse.
c) Remove the clients’ clothing and have them shower.
d) Assume the clients have been decontaminated at the plant.

Answer 45

Answer: 3

• In most situations, this is the first step, but with a potential chemical or biological exposure, the first step must be the safety of the hospital; therefore, the client must be decontaminated.
• This is the second step in the decontamination process.
• This Is the first step. Depending on the type of exposure, this step alone can remove a large portion of the exposure.
• This assumption could cost many people in the hospital staff, as well as clients, their lives.

TEST-TAKING HINT: If the test taker wants to select option “4” as the correct answer, the test taker should be careful-assumptions are dangerous. The test taker may want to choose option “1” because it involves assessment, but exposure to a chemical agent should be considered distress and an action should be implemented first.

Question 46

The nurse is teaching a class on biological warfare. Which information should the nurse include in the presentation?

a) Contaminated water is the only source of transmission of biological agents.
b) Vaccines are available and being prepared to counteract all biological agents.
c) Biological weapons are less of a threat than chemical agents.
d) Biological weapons are easily obtained and result in
significant mortality.

Answer 46

Answer: 4

• Sources of biological agents include inhalation, insects, animals, and people.
• Vaccines are not available to counteract all biological agents.
• Because of the vast range of agents, biological weapons are more of a threat. A biological agent could be released in one city and affect people In other cities thousands of miles away.
• Because of the variety of agents, the means of transmission, and the lethality of the agents, biological weapons, including anthrax, smallpox, and plague, are especially dangerous.

TEST-TAKING HINT: Answer option “1” should be eliminated because of the word “only.” Even if the test taker has little knowledge of biological warfare, knowledge of the human body suggests a wide range of ways biological agents could be transmitted.

Question 47

Which clinical manifestations should the nurse assess in the client exposed to the anthrax bacillus via the skin?

a) A scabby, clear fluid-filled vesicle.
b) Edema, pruritus, and a 2-mm ulcerated vesicle.
c) Irregular brownish-pink spots around the hairline.
d) liny purple spots flush with the surface of the skin.

Answer 47

Answer: 2

• Scabby, clear fluid-filled vesicles are characteristic of chickenpox.
• Exposure to anthrax bacllll via the skin results In skin leslons, which cause edema with prurltus and the formation of macules or papules, which ulcerate, forming a 1- to 3-mm vesicle. Then a painless eschar develops, which falls off in 1 to 2 weeks.
• Irregular brownish-pink spots around the hairline are characteristic of rubella.
• Tiny purple spots flush with the skin surface are petechiae.

TEST-TAKING HINT: This is a knowledge-based question. The test taker should try to determine which disease or condition each answer option describes to rule out the incorrect answers.

Question 48

The client asks the nurse about the smallpox vaccine.
Which information should the nurse provide to the client? Select all that apply.

a) The client should get the vaccine for prevention from the health department.
b) The client should get the vaccine only after the smallpox rash has developed.
c) The smallpox vaccine can help if given less than a week after exposure to the virus.
d) Health officials have enough smallpox vaccine to vaccinate everyone in the United States.
e) The client should avoid travel to countries with smallpox outbreaks.

Answer 48

Answer: 3, 4

• The smallpox vaccine is not available to the general public because smallpox has been eradicated and the virus no longer exists in nature.
• Once the smallpox rash has developed, the vaccine
  does not provide protection from the disease.
• If given within 7 days of being exposed to the smallpox virus, the vaccine can provide some protection from the disease.
• Health offlclals have enough smallpox vaccine to vaccinate every person In the United States If an outbreak were to occur.
• Smallpox is eradicated and the virus no longer exists in nature.

TEST-TAKING HINT: This Is a knowledge-based question. The test taker should try to determine which answer options to select based on knowledge of Immunizations.

Question 49

A chemical exposure has just occurred at an airport. An off-duty nurse, knowledgeable about biochemical agents, is giving directions to the travelers. Which direction should the nurse provide to the travelers?

a) Hold their breath as much as possible.
b) Stand up to avoid heavy exposure.
c) Lie down to stay under the exposure.
d) Attempt to breathe through their clothing.

Answer 49

Answer: 2

• The absence of breathing Is death, and this is neither a viable option nor a sensible recommendation to terrified people.
• Standing up will avoid heavy exposure because the chemical will sink toward the floor or ground.
• Staying below the level of the smoke is the instruction for a fire.
• Breathing through the clothing, which is probably contaminated with the chemical, will not provide protection from the chemical entering the lung.

TEST-TAKING HINT: If the test taker does not know the answer, the test taker should realize options “1” and “4” address breathing and options “2” and “3” address positioning, and one set of options should be eliminated, narrowing the choice to one out of two options.

Question 50

The nurse is caring for a client diagnosed with the prodromal phase of radiation exposure. Which clinical manifestations should the nurse assess in the client?

a) Anemia, leukopenia, and thrombocytopenia.
b) Sudden fever, chills, and enlarged lymph nodes.
c) Nausea, vomiting, and diarrhea.
d) Flaccid paralysis, diplopia, and dysphagia.

Answer 50

Answer: 3

• Anemia, leukopenia, and thrombocytopenia, signs of bone marrow depression, are clinical manifestations the client experiences in the manifest illness stage of radiation exposure, which occurs from 72 hours to years after exposure. The client is usually asymptomatic in the prodromal phase of radiation exposure.
• Sudden fever, chills, and enlarged lymph nodes are clinical manifestations of bubonic plague.
• The prodromal stage (presenting symptoms} of radiation exposure occurs 48 to 72 hours after exposure, and the clinical manifestations are nausea, vomiting, diarrhea, anorexia, and fatigue. Clinical manifestations of higher exposures of radiation include fever, respiratory distress, and coma.
• These are clinical manifestations of inhalation botulism.

TEST-TAKING HINT: If the test taker knows the definition of “prodromal,” which is an early sign of a developing condition or disease (prodrom is Greek for “running before”), then the option with vague and nonspecific clinical manifestations should be selected as the correct answer.

Question 51

Which cultural issues should the nurse consider when caring for clients during a bioterrorism attack? Select all that apply.

a) Language difficulties.
b) Religious practices.
c) Prayer times for the people.
d) Rituals tor handling the dead.
e) Keeping the family in the designated area.

Answer 51

Answer: 1, 2, 3, 4

• Language difficulties can increase fear and frustration on the part of the client.
• Some religions have specific practices related to medical treatments, hygiene, and diet, and these should be honored if at all possible.
• Prayers in times of grief and disaster are important to an individual and actually can have a calming effect on the situation.
• Caring for the dead is as important as caring for the living based on religious beliefs.
• For purposes of organization, this may be needed, but it is not addressing cultural sensitivity and, in some instances, may violate the cultural needs of the client and the family.

TEST-TAKING HINT: The stem asks the test taker to address cultural needs. and these client needs must be addressed in a bioterrorism attack or with an individual in the hospital. The test taker should select options addressing cultural needs. Dishonoring cultural needs can increase the client’s anxiety and increase problems for the health-care team.

Question 52

The off-duty nurse hears on the television of a bioterrorism act in the community. Which action should the nurse take first?

a) Immediately report to the hospital emergency department.
b) Call the American Red Cross to find out where to go.
c) Pack a bag and prepare to stay at the hospital.
d) Follow the nurse’s hospital policy for responding.

Answer 52

Answer: 4

• Many hospital procedures mandate off-duty nurses should not report immediately to the hospital, so relief is available for initial responders.
• The nurse’s first responsibility is to the facility of employment, not the community.
• This is a good action to take when the nurse is notified of the next action. For example, if the hospital is quarantined, the nurse may not report for days.
• The nurse should follow the hospital’s policy. Often nurses wlll stay at home until decisions are made as to where the employees should report.

TEST-TAKING HINT: After looking at all the options, the test taker should select the option that best assesses the entire situation, which Is following policy. There will be a tendency for mass hysteria to occur in the community, but following the terrorist attack on 9/11/2001, all hospitals and communities are now required by Homeland Security to have a disaster preparedness plan in place. The best action the nurse can take Is to follow the procedure and remain calm.

Question 53

The nurse finds the client unresponsive on the floor of the bathroom. Which action should the nurse implement first?

a) Check the client for breathing.
b) Assess the carotid artery for a pulse.
c) Shake the client and shout.
d) Notify the rapid response team.

Answer 53

Answer: 3

• This is not the first intervention based on the answer options available in this question.
• This is not the first intervention based on the options available in this question.
• This is the first intervention the nurse should implement after finding the client unresponsive on the floor.
• The rapid response team is called if the client is
  breathing; a code would be called if the client were not breathing.

TEST-TAKING HINT: Options “1,” “2,” and “3” are all assessment interventions, which is the first step in the nursing process. Of these three possible options, the test taker should select the intervention easiest and fastest to determine if the client is alert, which is to shake and shout at the client.

Question 54

The UAP is performing cardiac compressions on an adult client during a code. Which behavior warrants
Immediate intervention by the RN?

a) The UAP has hand placement on the lower half of the sternum.
b) The UAP performs cardiac compressions and allows for rescue breathing.
c) The UAP depresses the sternum 0.5 to 1 inch during compressions.
d) The UAP asks to be relieved from performing compressions because of exhaustion.

Answer 54

Answer: 3

• This hand position will help prevent positioning the hand over the xiphoid process, which can break the ribs and lacerate the liver during compressions.
• This is the correct two-rescuer CPR; therefore, no intervention is needed.
• The sternum should be depressed 1.5 to 2
  Inches during compressions to ensure adequate circulation of blood to the body; therefore, the nurse needs to correct the UAP.
• The UAP should request another HCP to perform compressions when exhausted.

TEST-TAKING HINT: The test taker must select which option Is an Incorrect procedure for cardiac compressions.

Question 55

Which intervention is most important for the nurse to implement when participating in a code?

a) Elevate the arm after administering medication.
b) Maintain sterile technique throughout the code.
c) Treat the client’s clinical manifestations; do not treat the monitor.
d) Provide accurate documentation of what happened during the code.

Answer 55

Answer: 3
* This is an appropriate intervention, but it is not the most important.
* Sterile technique should be maintained as much as possible, but the nurse can treat a live body with an infection without using sterile technique; however, the nurse cannot treat a dead body without an infection.
* This is the most important intervention. The nurse should always treat the client based on the nurse’s assessment and data from the monitors; an intervention should not be based on data from the monitors without the nurse’s assessment.
* Documentation is important but not a priority over treating the client.

TEST-TAKING HINT: The phrase “most important” in the stem is the key to answering this question. All four options are appropriate interventions for the question, but only one is the most important. The test taker should remember to always select the option directly affecting the client, and this may mean not selecting an assessment intervention when the client is in distress.

Question 56

The CPR instructor is discussing an automated external defibrillator (AED) during class. Which statement best describes an AED?

a) It analyzes the rhythm and shocks the client diagnosed with ventricular fibrillation.
b) The client will be able to have synchronized cardioversion with the AED.
c) It will keep the health-care provider informed of the client’s oxygen level.
d) The AED will perform cardiac compressions on the client.

Answer 56

Answer: 1

• This is the correct statement explaining what an AED does when used in a code.
• The defibrillator on the crash cart must be used to
  perform synchronized cardioversion.
• This is the explanation for a pulse oximeter.
• This is not the function of the AED.

TEST-TAKING HINT: The test taker must know the equipment to be able to answer this question. The test taker may be able to eliminate options based on knowledge of what other equipment does.

Question 57

The nurse is caring for clients on a medical floor. Which client is most likely to experience sudden cardiac death?

a) The 84-year-old client exhibiting uncontrolled atrial fibrillation.
b) The 60-year-old client exhibiting asymptomatic
sinus bradycardia.
c) The 53-year-old client exhibiting ventricular fibrillation.
d) The 65-year-old client exhibiting supraventricular tachycardia.

Answer 57

Answer: 3

• Atrial fibrillation is not a life-threatening dysrhythmia; it is chronic.
• Asymptomatic sinus bradycardia may be normal for the client, especially for athletes or long-distance runners.
• Ventricular fibrillation is the most common dysrhythmia associated with sudden cardiac death.
• MSupraventricular” means “above the ventricle.” The atrium is above the ventricle, and atrial dysrhythmias are not life-threatening.

TEST-TAKING HINT: The test taker should know the left ventricle is responsible for pumping blood to the body (heart muscle and brain) and could eliminate options “1” and “4” as correct answers. The word “asymptomatic” should cause the test taker to eliminate option “2” as the correct answer.

Question 58

Which health-care team member referral should be made by the nurse when a code is being conducted on a client in a community hospital?

a) The hospital chaplain.
b) The social worker.
c) The respiratory therapist.
d) The director of nurses.

Answer 58

Answer: 1

• The chaplain should be called to help address the client’s family or significant others. A small community hospital does not have a 24-hour on­ duty pastoral service. A chaplain is part of the code team in large medical center hospitals.
• The social worker does not need to be notified of a code.
• The respiratory therapist responds to the code automatically without a referral. The respiratory therapist is part of the code team, and one is on duty 24 hours a day, even in a small community hospital.
• The director of nurses does not need to be notified of codes, but possibly the house supervisor should be notified.

TEST-TAKING HINT: The test taker must know the roles of the multidisciplinary health-care team to make appropriate referrals. The words “community hospi1al” are an important phrase to help determine the correct answer.

Question 59

Which intervention is the most Important for the intensive care unit nurse to implement when performing mouth-to-mouth resuscitation on a client diagnosed with pulseless ventricular fibrillation?

a) Perform the jaw thrust maneuver to open the airway.
b) Use the mouth to cover the client’s mouth and nose.
c) Insert an oral airway before performing mouth to mouth.
d) Use a pocket mouth shield to cover the client’s mouth.

Answer 59

Answer: 4
* A jaw thrust is used for a possible fractured neck. The nurse should use the head-tilt, chin-lift maneuver to open the airway.
* The nurse should cover the client’s mouth and nose with the nurse’s mouth when giving mouth-to-mouth resuscitation to an infant but not when giving
mouth-to-mouth resuscitation to an adult. According
to the American Heart Association 2010 Guidelines, mouth to mouth is only performed with a barrier device in place to protect the rescuer.
* An oral airway is not mandatory to do effective breathing; therefore, it is not the most important intervention.
* Nurses should protect themselves against possible communicable diseases, such as HIV and hepatitis, and should be protected if the client vomits during CPR.

TEST-TAKING HINT: Unless the stem provides an age for the client, the client is an adult client; therefore, the test taker could eliminate option “2” because it is for an infant.

Question 60

The nurse is teaching CPR to a class. Which statement best explains the definition of sudden cardiac death?

a) Cardiac death occurs after being removed from a mechanical ventilator.
b) Cardiac death is the time the HCP officially declares the client dead.
c) Cardiac death occurs within 1 hour of the onset of cardiovascular symptoms.
d) The death is caused by myocardial ischemia resulting from coronary artery disease.

Answer 60

Answer: 3

• This is not the definition of sudden cardiac death; this is sometimes known as “pulling the plug” on clients diagnosed as brain dead.
• This is not the definition of sudden cardiac death.
• Unexpected death occurring within 1 hour of the onset of cardiovascular symptoms is the definition of sudden cardiac death.
• This is not the definition of sudden cardiac death.

TEST-TAKING HINT If the test taker relates the word “sudden” in the stem with “unexpected,” the best answer is option “3.” The test taker must be aware of adjectives and adverbs.