Emergency Nursing

Emergency
I. Cardiac Arrest
A. Adult/child/infant CPR
1. Definition of ages
a. adult and older child (15 and older)
b. child – 1 to 14 years
c. infant – less than 1 year
. Assess res!onsi"eness
a. sha#e gently
b. shout $are you o#ay%$
&. 'f unres!onsi"e( acti"ate the e)ergency res!onse syste)
a. if hy!o*ic arrest call e)ergency res!onse syste)
after )inutes of CPR
b. if child or infant call after )inutes of CPR unless
sudden +itnessed arrest call e)ergency res!onse
syste) first
4. Call for a defibrillator
5. Position the client to a resuscitation !osition( if no e"idence
of trau)a (if trau)a( see section ''' of this lesson)
,. -!en the air+ay
a. head tilt.chin lift
b. /a+ thrust (if trau)a is e"ident or s!inal in/ury
sus!ected)
0. Assess for breathing1 loo#( listen and feel
a. if breathing( !osition in a reco"ery !osition
b. if not breathing( gi"e rescue breaths at 1
second/breath
c. assess if breaths go into lungs by chest )o"e)ent
d. if air does not go in( re!osition air+ay (see 24
abo"e)
e. if air still does not go in( chec# for foreign body
i. abdo)inal thrust for adults( older child and
child (3ei)lich )aneu"er)
ii. bac# blo+s and chest thrusts for infants
iii. do not !roceed until air+ay and rescue
breathing is established
iv. no blind finger s+ee!s
f. +hen air+ay is clear( chec# for !resence of a !ulse
i. chec# !ulse for 14 seconds or less
ii. adult or older child – chec# carotid
iii. child – chec# carotid or fe)oral
i". infant – brachial or fe)oral
g. begin chest co)!ressions if !ulse is absent or in
child/infant if heart rate is 5 ,4 +ith signs of !oor
!erfusion
i. be sure client is on a fir) surface
ii. hand !osition is critical
• adult/older child – center of chest
bet+een ni!!les6 t+o hands +ith
heel of one hand and the other hand
on to!
• child – center of chest bet+een
ni!!les6 one hand or t+o hands +ith
use of the heel(s) of the hands
• infant – /ust belo+ the ni!!le line6
one rescuer . t+o fingers or t+o
rescuers – t+o thu)bs encircling
hands around chest
iii. co)!ression de!th
• adults/older child . 1.5 to inches
• child/infants – 1/& to 1/ the de!th of
the chest
iv. co)!ression rate 144 co)!ressions !er
)inute for all ages
". 7P893 3ARD( P893 :A9;< for chest
co)!ressions
"i. allo+ chest recoil
"ii. )ini)i=e interru!tions in chest co)!ression
– #ee! at 14 seconds or less
"iii. co)!ressions."entilation ratios
• adult/child – &41 >&4 co)!ressions
to breaths? for one or t+o rescuers
• child or infant –
 one rescuers &41 (&4
co)!ressions to breaths)
 t+o rescuers 151 (&4
co)!ressions to breaths)
h. a!!ly )onitor or defibrillator +hen a"ailable
i. reassess cardio!ul)onary status after e"ery fi"e
cycles of co)!ressions to "entilations
/. continue until AC@9 !ro"iders ta#e o"er or the
client starts to )o"e
#. differences for lay !ersons
i. lay rescuers do not need to assess for !ulse
or signs of circulation for an unres!onsi"e
"icti)
ii. lay rescuers do not need to !ro"ide rescue
breathing +ithout chest co)!ressions
II. Early defibrillation
 'n adults( the arrhyth)ia )ost correctable is "entricular fibrillation
if treated !ro)!tly
 Aefore starting CPR for "entricular fibrillation( call for hel!
''. 9hoc# . see the discussion of shoc# in Cardio"ascular
'''. ;rau)a Care
A. Air+ay +ith si)ultaneous cer"ical s!ine i))obili=ation
1. Bust use /a+ thrust
. Do not use head.tilt chin.lift1 it could in/ure nec#
A. Areathing
1. @oo#( listen and feel for res!irations
. :ollo+ CPR !rocedure
C. Circulation
1. Assess !ulses
a. carotid !ulse1 AP at least ,4
b. fe)oral !ulse1 AP at least 04
c. radial !ulse1 AP at least C4
. 9to! any acti"e( "isible bleeding by a!!lying direct !ressure
&. After initial assess)ent( start t+o large.bore 'Ds
D. Disability1 brief neurological e*a)
1. @e"el of consciousness
. Pu!il res!onse to light
&. Ability to )o"e e*tre)ities
4. Ability to )o"e against resistance
E. E*!ose
1. 8ndress client
. 'ns!ect for in/uries or defor)ities
:. :ahrenheit
1. ;a#e te)!erature
. Baintain +ar)th
a. +ar) blan#ets
b. +ar)ing lights
F. Fet "itals
1. Pulse
. Res!iratory rate
&. Alood !ressure
3. 3istory and head.to.toe full assess)ent
1. 3o+ did in/ury occur . )echanis) of in/ury
. ClientGs )edical history
&. :ull body syste) assess)ent
'. 'ns!ect the bac#
1. Roll the client o"er . log roll +ith hel!
. 'ns!ect for in/uries or defor)ities
CPR
• Early defibrillation is the #ey to successful resuscitation for )any adults.
• Continually reassess during CPR to see if the client regains a !ulse or begins
breathing. Reassess to see that the chest )o"es and !ulses are !al!able during
CPR.
SHOCK
• 'n shoc#( the first hour of treat)ent is )ost critical. Early detection is #ey.
• ;here are different +ays to categori=e shoc#. Aasically( shoc# !resents three
!otential !roble)s1
1. Hot enough fluid in the blood "essels (hy!o"ole)ia) -R
. :luid has )o"ed outside the "essels( so cannot be !u)!ed to the organs
(distributi"e) -R
&. 3eart cannot !u)! fluid that is !resent (cardiogenic)
Shock and Temerat!re
• 'n se!tic shoc#( the s#in and body te)!erature )ay increase. 'n other shoc#
states( body and s#in te)!erature +ill decrease.
Shock and Heart Signs
• Early stages of shoc# acti"ate the sy)!athetic ner"ous syste). 9o in early
stages( the client +ill not al+ays be hy!otensi"e.
• Aradycardia is a "ery late sign in shoc#.
• Another late sign is cardiac arrhyth)ia (other than sinus tachycardia).
Arrhyth)ias reflect less !erfusion of the coronary arteries and )yocarditis.
• As the )yocardiu) recei"es less !erfusion( heart !u)!s less.
• Aecause less blood !erfuses the brain( le"el of consciousness dro!s.
Shock and "rinary O!t!t
• A"erage adult urinary out!ut is 4.5 to 1.4 )l/#g/hr. @ess than &4 )l/hour reflects
decreased renal blood flo+. Acute renal failure can result.
Shock and Resiration
• As blood flo+ to lungs decreases( less gas e*change +ill occur.
• Ihen tissues recei"e less o*ygen( they !roduce )ore lactate and )etabolic
acidosis sets in. Betabolic acidosis increases ris# of cardiac arrhyth)ias.
• :or a client in shoc#( body cells recei"e less o*ygen and nutrients. ;hus
treat)ent ai)s at increasing both a"ailable o*ygen and "olu)e of blood in
"essels (unless the heart has failed).
• Bedications can i)!ro"e tone of blood "essels (inotro!es) or treat the cause of
shoc# (corticosteroids( antibiotics).
• Ihen treating a trau)a client( you )ust Juic#ly assess A#Cs. After you #no+
the client is breathing and has a !ulse( "ital signs can +ait +hile you sto! any
bleeding and start other inter"entions (such as starting 'Ds). DonGt rely only on
the "ital sign nu)bers.
Head and Sine In$!ry
• 'f client has head in/ury( the )ost i)!ortant assess)ent is le"el of
consciousness6 ne*t is !u!il res!onse to light. Changes in "itals are "ery late
sign.
• Iith trau)a clients( assu)e s!ine is in/ured until !ro"en other+ise. Ihile you
o!en the air+ay( you )ust #ee! cer"ical s!ine i))obile.
Nursing Board Exam Review Questions in Emergency
1. A nurse from medical-surgical unit is asked to work on the
orthopedic unit. The medical-surgical nurse has no
orthopedic nursing experience. Which client should be
assigned to the medical-surgical nurse?
d) a client who had a total hip replacement 2
days ago and needs blood glucose monitoring
a nurse from medical-surgical unit foated to the orthopedic
unit should be given clients with stable condition, and those
whose care are similar to her training and experience. A
client who is -da! postop is more likel! to be on stable
condition. And the medical-surgical unit nurse is competent
in monitoring blood glucose.
2. The nurse plans care for a client undergoing a colposcop!.
Which of the following actions should the nurse take "rst?
b) assist with silver nitrate application to the
cervix to control bleeding
the priorit! nursing action when caring for a client who will
undergo colposcop! is to assist in controlling potential
bleeding b! appl!ing silver nitrate to the cervix.
. A nurse is caring for four clients and is preparing to do her
initial rounds. Which client should the nurse assess "rst?
b) a client with tracheostomy and copious
secretions
- a patient with problem of the airwa! should be given
highest priorit!. A#$ is a priorit!.
!. A nurse enters a room and "nds a client l!ing on the foor.
Which action should the nurse perform "rst?
b) establish whether the client is responsive
- assessing for responsiveness is the "rst nursing action
when performing $%&.
". A nurse preceptor is working with a new nurse and notes
that the new nurse is reluctant to delegate tasks to members
of the care team. The nurse preceptor recogni'es that this
reluctance most likel! is due to(
d) lac# o$ trust in the team members
lack of trust is the most common reason for reluctance in
delegating tasks among members of the team.
%. A nurse is working in an emergenc! department and
receives a client after a radiologic incident. Which task is a
priorit! for the nurse to do "rst?
b) decontaminate an open wound on the client&s
thigh
decontaminating an open wound is the "rst priorit! when
caring for a client after a radiologic incident. This minimi'es
absorption of radiation in the client)s bod!.
'. The nurse plans care for a client in the post-anesthesia
care unit. Which assessment should the nurse make "rst?
a) respiratory status
assessing respirator! status is the "rst priorit! when caring
for a client in the post-anensthesia care unit. A#$ is a
priorit!.
(. A nurse in the clinic is reviewing the diet of a *-!ear old
female who reports several months of intermittent
abdominal pain, abdominal bloating, and fatulence. Which is
a priorit! for the nurse to counsel the client to avoid in her
diet?
b) broccoli
- broccoli is gas forming. This should be avoided in clients
experiencing fatulence.
). A nurse is developing the care plan for a client after
bariatric surger! for morbid obesit!. The nurse includes
which of the following on the care plan as the priorit!
complication to prevent?
b) wound in$ection
wound infection is the most common complication among
obese clients who had undergone surger!. This is due to poor
blood suppl! in the adipose tissues. Therefore, there is
decreased ox!gen suppl! and diminished suppl! of
protective cells in the areas.
1*. A client presents to the emergenc! room with d!spnea,
chest pain, and s!ncope. The nurse assesses the client and
notes that the client is pale and diaphoretic with blood
pressure +,-./, respiration 0. The client is anxious, fearing
death. Which action should the nurse take "rst?
promotion of ade1uate ox!genation is most vital to life.
Therefore, this should be given highest priorit! b! the nurse
for a client with d!spnea, chest pain, and s!ncope. d)
administer oxygen per nasal cannula
11. A nurse in a long term facilit! is planning care for an
elderl! client with confusion. Which action should the nurse
take "rst?
a) sit the client in a geriatric chair with an activity
12. The nurse is providing care in the emergenc!
department to the client with chest pain. Which action is
most important for the nurse to do "rst?
b) administer oxygen via nasal cannula
1. A nurse arrives on the scene of a multi-motor vehicle
accident. The nurse determines that which of the following
clients should be seen "rst?
a) + !( year old male who is pale, diaphoretic and
reporting chest pain and shortness o$ breath
1!. A child reports to the camp nurse)s o2ce after stepping
on a bee. The child has pain, er!thema, and edema of the
lower aspect of the left foot. As the nurse is observing the
foot, the child sa!s, 34 feel like m! throat is getting tight.3
The "rst action the nurse should take is(
d) remove the stinger $rom the $oot
1". A nurse is working on a poison control hot-line and gets
a call from a mother who reports her child has apparentl!
taken part of a bottle of adult acetaminophen capsules. The
priorit! action for the nurse to take "rst is(
d) instruct the mother on how to administer syrup o$
ipecac
acetaminophen is non-corrosive. Therefore, inducing
vomiting b! administering s!rup of ipecac is appropriate
management in case of acetaminophen overdose or
poisoning.
1%. A nurse receives a 5/-month old child with a fracture of
the left femur on the pediatric unit. Which action is
important for the nurse to take "rst?
a6 call for a social worker to meet with the famil!
b6 check the child)s blood pressure, then pulse, respiration,
and temperature
c6 administer pain medication
d) spea# with the parents about how the $racture
occurred
1'. A nurse on the cardiac unit is caring for four clients and
is preparing to do initial rounds. Which client should the
nurse assess "rst?
a6 a client scheduled for cardiac ultrasound this morning
b6 a client with s!ncope being discharged toda!
c) a client with chronic bronchitis on nasal oxygen
d6 a client with a diabetic foot ulcer that needs a dressing
change
1(. A nurse enters a room and "nds l!ing face down on the
foor, bleeding from a gash in the head. Which action should
the nurse perform "rst?
a) determine level o$ consciousness
b6 push the call button for help
c6 turn the client face up to assess
d6 go out in the hall to get the nursing assistant to sta! with
the client while the nurse calls the ph!sician
1). A nurse is working on the night shift with a nursing
assistant. The nursing assistant comes to the nurse stating
that the other nurse working on the unit is not assessing a
client with abdominal pain despite multiple re1uests. Which
of the following actions b! the nurse is best?
a6 ask the other nurse if she needs an! help
b6 assess the client, and let the other nurse know what
should be done
c6 ask the client if he is satis"ed with his care
d) contact the nursing supervisor to address the
situation
2*. The nurse is reviewing immuni'ations with the caregiver
of a 7 !ear old client with a histor! of cerebral vascular
disease. The caregiver learns that which immuni'ation is a
priorit! for the client?
a6 hepatitis A vaccine
b6 l!me disease vaccine
c6 hepatitis # vaccine
d) pneumococccal vaccine
21. A nurse delegates administration of an enema to a
nursing assistant. The nurse should intervene if the nursing
assistant 8-6
a6 advances the catheter , inches into the anal canal
b6 hangs the enema bag 5 to 5* inches above the anus
c6 lubricates , to 9 inches of the catheter tip
d) positions the client on the right side with head
slightly elevated
the appropriate position of the client during enema
administration is left lateral position to facilitate fow of
solution b! gravit!. Therefore, the action of the $:A in
choices no. , needs to be corrected.
22. A nurse is reviewing with a nursing assistant the care
assignment for a client. Which of the following statements if
made b! the nurse regarding care of a client with crutches is
most appropriate?
b) ambulate the client without weight bearing
every ! hours the length o$ the hall and bac#
2. The home care nurse has four phone calls to answer.
Which phone call should the home care nurse respond to
"rst?
d) the wi$e o$ a client with chronic heart disease
who reports her husband is coughing $rothy, white
secretions and became con$used during the night
the situation indicates development of pulmonar! edema in
the client with chronic heart disease. This serious
complication is a priorit!.
2!. A nurse arrives on the scene of an apartment "re. Which
of the following clients does the nurse attend to "rst?
d) a 2(-year old woman who has burns on the
$ace and nec# and reports di.culty swallowing
burns on the face and neck involves obstruction of airwa!
due to smoke inhalation. Airwa! is a priorit!.
2". A female college student reports to the student health
center ver! distressed after waking up in a male student)s
restroom and not remembering what happened to the night
before. The "rst action the nurse should take is(
d) provide a /uiet, private area to use $or initial
assessment o$ the client
this situation indicates possible rape of the client. %roviding
ps!chosocial support and ensuring privac! for initial
assessment of the client is most appropriate initial action.
2%. A nurse recentl! started working in a hospital that
emplo!s unlicensed assistant personnel 8;A%6. Which of the
following are essential to e<ective delegation?
a) give the 0+1 written instructions $or assignments
b) ma#e $re/uent wal#ing rounds to assess clients
c) delegate tas#s based on the experience o$ the 0+1
d) ta#e $re/uent mini-reports $rom the 0+1
e) have the 0+1 repeat instructions
$) explain unexpected outcomes o$ delegated tas#s to
the 0+1
2'. A nurse is teaching a class regarding lead poisoning in
children to student nurses. The nursing students learn to
target which priorit! group of children for screening?
c) those who live in low-income $amilies
lead poisoning is common in old houses 8built in 5+9/)s6, and
in places with unsanitar! conditions including soil, dust,
vehicles using leaded gas. These factors are common among
low-income families.
2(. A nurse is attending an 4n-service training class on
delegation. The nurse learns that proper delegation can
involve which of the following? =elect all that appl!
a) giving authority
b6 delegating nursing process
c) delegating tas#s
d6 delegating accountabilit!
e) delegating responsibility
f6 giving orders
2). When developing the plan of care for a client with
suicidal ideation, which of the following would the nurse
anticipate as the priorit!?
d)2a$ety
*. A client in earl! labor is receiving ox!tocin. When
observing late decelerations in the fetal heart rate, the nurse
should "rst(
d) 3iscontinue the oxytocin in$usion
- the infusion should be stopped because it is placing the
fetus in danger.
1. A nurse emplo!ed in an emergenc! department is
assigned to triage clients arriving to the emergenc! room for
treatment on the evening shift. The nurse should assign
highest priorit! to which of the following clients?
a6 a client complaining of muscle aches, a headache, and
malaise
b6 a client who twisted her ankle when she fell while
rollerblading
c6 a client with a minor laceration on the index "nger
sustained while cutting an eggplant
d) a client with chest pain who states that he 4ust ate
pi55a that was made with a very spicy sauce
2. The &: is planning the client assignments for the da!.
Which of the following is the most appropriate assignment
for the nursing assistant?
a6 a client re1uiring colostom! irrigation
b6 a client receiving continuous tube feedings
c) a client who re/uires urine specimen collections
d6 a client with di2cult! swallowing foods and fuids
. The &: emplo!ed in a long-term care facilit! is planning
assignments for the clients on a nursing unit. The &: needs
to assign four clients and has a licensed practical
8vocational6 nurse and three nursing assistants on a nursing
team. Which of the following clients would the nurse most
appropriatel! assign to the licensed practical 8vocational6
nurse?
a6 the client who re1uires a bed bath
b6 an older client re1uiring fre1uent ambulation
c6 a client who re1uires a ,-hour urine collection
d) a client with an abdominal wound re/uiring wound
irrigations and dressing changes every hours
!. The &: has received the assignment for the da! shift.
After making initial rounds and checking all of the assigned
clients, which client will the &: plan to care for "rst?
a6 A client who is ambulator!
b6 a client scheduled for ph!sical therap! at 5%>
c) a client with a $ever who is diaphoretic and restless
d6 a postoperative client who has ?ust received pain and
medication
". The nurse is assigned to care for four clients. 4n planning
client rounds, which client should the nurse assess "rst?
a6 a client scheduled for a chest x-ra!
b6 a client re1uiring dail! dressing changes
c6 a postoperative client preparing for discharge
d) a client receiving oxygen via nasal cannula who
had di.culty breathing during the previous shi$t
%. The nurse is giving a bed bath to an assigned client
when a nursing assistant enters the client)s room and tells
the nurse that another assigned client is in pain and needs
pain medication. The appropriate nursing action is which of
the following?
a6 "nish the bed bath and then administer the pain
medication to the other client
b6 ask the nursing assistant to "nd out when the last pain
medication was given to the client
c6 ask the nursing assistant to tell the client in pain that
medication will be administered as soon as the bed bath is
complete
d) cover the client, raise the side rails, tell the client
that you will return shortly, and administer the pain
medication to the other client
'. A nurse is preparing to obtain an arterial blood gas
specimen from a client and plans to preform the Allen)s Test
on the client. Arrange in order of priorit! the steps for
performing Allen)s test. 8@etter A is the "rst step and letter A
is the last step.
a) document the 6ndings
b) explain the procedure to the client
c) release pressure $rom the ulnar artery
d) apply pressure over the ulnar and radial arteries
e) as# the client to open and close the hand
repeatedly
$) assess the color o$ the extremity distal to the
pressure point
The AllenBs test is performed before obtaining an arterial
blood specimen from the radial arter! to determine the
presence of collateral circulation and the ade1uac! of the
ulnar arter!. Aailure to determine the presence of ade1uate
collateral circulation could result in severe ischemic in?ur! to
the hand if damage to the radial arter! occurs with arterial
puncture. The nurse "rst would explain the procedure to the
client. To perform the test, the nurse applies direct pressure
over the clientBs ulnar and radial arteries simultaneousl!.
While appl!ing pressure, the nurse asks the client to open
and close the hand repeatedl!C the hand should blanch. The
nurse then releases pressure from the ulnar arter! while
compressing the radial arter! and assesses the color of the
extremit! distal to the pressure point. 4f pinkness fails to
return within . seconds, the ulnar arter! is insu2cient,
indicating that the radial arter! should not be used for
obtaining a blood specimen. Ainall!, the nurse documents
the "ndings.
(. A nurse is monitoring a client receiving parenteral
nutrition. The client suddenl! develops respirator! distress,
d!spnea, and chest pain, and the nurse suspects air
embolism. Arrange the actions that the nurse would take in
order of priorit! 8@etter A is the "rst action and letter A is the
last action6.
a) administer oxygen
b) contact the physician
c) document the occurrence
d) ta#e the client&s vital signs
e) clamp the intravenous catheter
$) position the client in le$t trendelenburg position
4f air embolism is suspected, the nurse would "rst clamp the
intravenous catheter to prevent the embolism from traveling
through the heart to the pulmonar! s!stem. The nurse would
next place the client in a left side-l!ing position with the
head lower than the feet 8to trap air in right side of the
heart6. The nurse would notif! the ph!sician and administer
ox!gen as prescribed. The nurse would monitor the client
closel! and take the clientBs vital signs. Ainall!, the nurse
documents the occurrence.
). A client has 5@ bag of 9D dextrose in /.+D sodium
chloride hung at 0%>. The nurse making rounds at 0(,9%>
"nds that the client is complaining of pounding headache
and is d!spneic, experiencing chills, and apprehensive, with
an increased pulse rate. The intravenous 84E6 bag has ,// ml
remaining. The nurse should take which of the following
action "rst?
b) slow the 78 in$usion
c6 sit the client up in bed
d6 remove the 4E catheter
The clientBs s!mptoms are compatible with circulator!
overload. This ma! be veri"ed b! noting that .// m@ has
infused in the course of ,9 minutes. The "rst action of the
nurse is to slow the infusion. Fther actions ma! follow in
rapid se1uence. The nurse ma! elevate the head of the bed
to aid the clientBs breathing, if necessar!. The nurse also
noti"es the ph!sician immediatel!. The 4E catheter is not
removedC it ma! be needed once the complication has been
resolved.
!*. The nurse determines that he client is having a
transfusion reaction. After the nurse stops the transfusion,
which action should immediatel! be taken next?
b) run normal saline at a #eep vein open rate
c6 run a solution of 9D dextrose in water
d6 obtain a culture of the tip of the catheter device removed
from the client
!2. A nurse on the da! shift walks into a client)s room and
"nds the client unresponsive. The client is not breathing and
does not have a pulse, and the nurse immediatel! calls out
for help. The next nursing action is which of the following?
a) open the airway
b6 give the client ox!gen
c6 start chest compressions
d6 ventilate with a mouth-to-mask device
!!. A nurse receives a telephone call from the post-
anesthesia care unit stating that a client is being transferred
to the surgical unit. The nurse plans to do which of the
following "rst on arrival of the client?
a) assess the patency o$ the airway
b6 check tubes or drains for patenc!
c6 check the dressing to assess for bleeding
d6 assess the vital signs to compare with preoperative
measurements.
!". A nurse is caring for a pregnant client with preeclampsia.
The nurse prepares a plan of care for the client and
documents in the plan that if the client progresses for
preeclampsia to eclampsia, the nurse)s "rst action should be
to(
a6 administer ox!gen b! face mask
b) clear and maintain an open airway
c6 administer magnesium sulfate intravenousl!
d6 assess the blood pressure and fetal heart rate
- The immediate care during a sei'ure 8eclampsia6 is to
ensure a patent airwa!. Fptions A, $, and G are actions that
follow or are implemented after the sei'ure has ceased.
!%. A labor and deliver! room nurse has ?ust received report
on four clients. The nurse should assess which client "rst?
a6 a primiparous client in the active stage of labor
b6 a multiparous client who was admitted for induction of
labor
c6 a client who is not contracting, but has suspected
premature rupture
d6 a client who has ?ust received an 4E loading dose of
magnesium sulfate to stop preterm labor
!'. A nurse in a newborn nurser! receives a telephone call
to prepare for the admission of a ,0-week gestation newborn
infant with Apgar scores of 5 and ,. 4n planning for admission
of this infant, the nurse)s highest priorit! should be to(
a6 turn on the apnea and cardiorespirator! monitors
b6 connect the resuscitation bag to the ox!gen outlet
c6 set up the intravenous line with 9D dextrose in water
d) set the radiant warmer control temperature at
%."9 :)'.%;)
!(. A nurse is caring for a newborn infant with spina bi"da
8m!elomeningocele6 who is scheduled for surgical closure of
the sac. 4n the preoperative period, the priorit! nursing
diagnosis would be risk for(
a) in$ection
b6 aspiration
c6 activit! intolerance
d6 altered growth and development
!). After a tonsillectom!, a child begins to vomit bright red
blood. The initial nursing action is to(
a6 notif! the ph!sician
b) turn the child to the side
c6 maintain an :%F status
d6 administer the prescribed antiemetic
"*. The nurse manager is planning the clinical assignments
for the da! and avoids assigning which sta< member to the
client with herpes 'oster?
a6 the nurse who never had rubeola
b6 the nurse who never had mumps
c) the nurse who never had chic#enpox
d6 the nurse who never had german measles
"1. A client with a wound infection and osteom!elitis is to
receive h!perbaric ox!gen therap!. Guring the therap!, the
nurse implements which priorit! intervention?
a6 maintains an intravenous access
b) ensures that oxygen is being delivered
c6 administers sedation to prevent claustrophobia
d6 provides emotional support to the client)s famil!
"2. A nurse is caring for a client who had an orthopedic
in?ur! of the leg re1uiring surger! and application of a cast.
%ostoperativel!, which nursing assessment is of highest
priorit!?
a6 monitoring of heel breakdown
b6 monitoring of bladder distention
c6 monitoring of extremit! shortening
d) monitoring $or loss o$ blanching ability o$ toe
nailbeds
With cast application, concern for compartment s!ndrome
development is of the highest priorit!. 4f postsurgical edema
compromises circulation, the client will demonstrate
numbness, tingling, loss of blanching of toenail beds, and
pain that will not be relieved b! opioids. Although bladder
distention, extremit! lengthening or shortening, or heel
breakdown can occur, these complications are not
potentiall! life-threatening complications.
". A nurse hears the alarm sound on the telemetr! monitor,
looks at the monitor, and notes that a client is in ventricular
tach!cardia. The nurse rushes to the client)s room. ;pon
reaching the client)s bedside, the nurse would take which
action "rst?
a6 call a code
b6 prepare for cardioversion
c6 prepare to de"brillate the client
d) chec# the client&s level o$ consciousness
"!. A nurse has ?ust "nished assisting the ph!sician in
placing a central intravenous 84E6 line. Which of the following
is a priorit! nursing intervention after central line insertion?
a) prepare the client $or a chest radiograph
A ma?or risk associated with central line placement is the
possibilit! of a pneumothorax developing from an accidental
puncture of the lung. Assessing the results of a chest
radiograph is one of the best methods to determine if this
complication has occurred and to verif! catheter tip
placement before initiating intravenous 84E6 therap!. A
temperature elevation related to central line insertion would
not likel! occur immediatel! after placement. @abeling the
dressing site is important but is not the priorit!. Although #%
assessment is alwa!s important in assessing a client)s status
after an invasive procedure, fuid volume overload is not a
c9oncern until 4E fuids are started.
"". A nurse reviews the assessment data of a client
admitted to the hospital with a diagnosis of anxiet!. The
nurse assigns priorit! to which assessment "nding?
b) 6st clenched and pounding table
Anxiet! can lead to behavior that is harmful to the client and
others. 4f safet! is threatened, this is the priorit!. Tearfulness,
withdrawal, isolation, and elevated vital signs are abnormal
"ndings. However, these "ndings are not life-threatening,
although the! should be monitored. After the client)s mental
status is addressed and the client)s safet! is ensured, the
nurse should attend to the elevated vital signs.
"%. A client is being brought into the emergenc! department
after su<ering a head in?ur!. The "rst action b! the nurse is
to determine the client)s(
a6 level of consciousness
b6 pulse and blood pressure
c) respiratory rate and depth
d6 abilit! to move extremities
"'. A nurse is caring for a client scheduled for an
arthroscop!. The nurse develops a postoperative plan of care
and includes which priorit! nursing action in the plan?
a6 monitor intake and output
b6 assess the tissue at the surgical site
c) monitor the area $or numbness or tingling
d6 assess the complete blood cell count results
"(. A nurse is performing an assessment on a client who
has a suspected spinal cord in?ur!. Which of the following is
the priorit! nursing assessment?
a6 pain level
b6 mobilit! level
c) respiratory status
d6 pupillar! response
"). A 9-!ear old male client is seen in the ph!sician)s o2ce
for a ph!sical examination after experiencing unusual fatigue
over the last several weeks. The client)s height is 9 feet, *
inches, and his weight is / pounds. Eital signs are(
temperature +*A orall!, pulse *. beats per minute, and
respirations 5* breaths per minute. The blood pressure 8#%6
is 5*,-5// mmHg. &andom blood sugar glucose is 5 mg?
d@. Which of the following 1uestions should the nurse ask the
client "rst?
a6 do !ou exercise regularl!?
b6 are !ou considering tr!ing to lose weight?
c) is there a history o$ diabetes mellitus in your
$amily<
d6 when was the last time !ou had !our blood pressure
checked?
%*. A client admitted to the nursing unit from the
emergenc! department has a spinal cord in?ur! at the level
of the fourth cervical vertebra 8$-,6. Which assessment
should the nurse perform "rst when admitting the client to
the nursing unit?
a) listen to breath sounds
b6 observe for d!skinesias
c6 take the client)s temperature
d6 assess extremit! muscle strength
%1. A client received a thermal burn caused b! the
inhalation of steam. The client)s mouth is edematous and the
nurse notes blisters in the client)s mouth. The nurse "rst
assesses which priorit! item8s6?
a6 neurological status
b6 level of consciousness
c6 temperature via the rectal route
d) respiratory status and lung sounds
%2. A registered nurse 8&:6 is planning the assignments for
the da! and is leading a team composed of a licensed
practical nurse 8@%:6 and a nursing assistant 8:A6. The nurse
assigns which client to the @%:
a6 client with dementia
b6 a 5-da! postoperative mastectom! client
c6 a client who re1uires some assistance with bathing
d) a client who re/uires some assistance with
ambulation
%. A client re1uests pain medication and the nurse
administers a ventrogluteal intramuscular in?ection. After
administration of the in?ection, the nurse does which of the
following "rst?
a6 washes the hands
b6 removes the gloves
c) applies gentle pressure to the in4ection site
d6 places the s!ringe in the secure, puncture-resistant
needle box container
%!. A registered nurse is delegating activities to the nursing
sta<. Which activit! is least appropriate for the nursing
assistant?
a6 collecting a urine specimen from a client
b6 obtaining fre1uent oral temperatures on a client
c6 accompan!ing a man being discharged
d) assisting a postcardiac catheteri5ation client who
needs to lie =at to eat lunch
%". A nurse is planning the client assignments for the shift.
Which client would the nurse assign to the nursing assistant?
a6 a client re1uiring dressing changes
b6 a client re1uiring fre1uent ambulation
c6 a client on a bowel management program re1uiring rectal
suppositories and a dail! enema
d) a client with diabetes mellitus re/uiring daily
insulin and rein$orcement o$ dietary measures
%%. A client tells the home care nurse of a personal decision
to refuse external cardiac resuscitation measures. Which of
the following is the most appropriate initial nursing action?
a) noti$y the physician o$ the client&s re/uest
b6 discuss the client)s re1uest with the client)s famil!
c6 document the client)s re1uest in the home care nursing
care plan
d6 conduct a client conference with the home care sta< to
share the client)s re1uest
%'. A nurse is caring for a client who is going to have an
arthrogram using a contrast medium. Which preprocedure
assessment would be of highest priorit!?
a) allergy to iodine or shell6sh
b6 whether the client wishes to void before the procedure
c6 abilit! of the client to remain still during the procedure
d6 whether the client has an! remaining 1uestions about the
procedure
%(. A registered nurse 8&:6 asks a licensed practical nurse
8@%:6 to change the colostom! bag on a client. The @%: tells
the &: that although attendance at the hospital in-service
was completed regarding this procedure, the @%: has never
performed a colostom! bag change on a client. The
appropriate action b! the &: is to(
a) per$orm the procedure with the >1N
b6 re1uest that the @%: observe another @%: perform the
procedure
c6 ask the @%: to review the materials from the in-service
before performing the procedure
d6 instruct the @%: to review the procedure in the hospital
manual and take the written procedure into the client)s room
for reference
%). A nurse working on a medical nursing unit during an
external disaster is called to assist with care for clients
coming into the emergenc! department. ;sing principles of
triage, the nurse initiates immediate care for a client with
which of the following in?uries?
a6 fractured tibia
b6 penetrating abdominal in?ur!
c) bright red bleeding $rom a nec# wound
d6 open massive head in?ur! to deep coma
'*. A nurse working on an adult nursing unit is told to review
the client census to determine which client could be
discharged if there are a large number of admissions from a
newl! declared disaster. The nurse determines that the client
with which of the following problems would need to remain
hospitali'ed?
a6 laparoscopic cholec!stectom!
b6 fractured hip, pinned 9 da!s ago
c6 diabetes mellitus with blood glucose at 5*/ mg-d@
d) ongoing ventricular dysrhythmias while receiving
procainamide :1rocanbid)
'1. A nurse is called to a client)s room b! another nurse.
When the nurse arrives at the room, she discovers that a "re
has occurred in the client)s wastebasket. The "rst nurse
removed the client from the room. What is the second
nurse)s next action?
a6 con"ne the "re
b6 evacuate the unit
c6 extinguish the "re
d) activate the 6re alarm
&emember the acron!m &A$I 8i.e., rescue, alarm, con"ne,
extinguish6 to set priorities if a "re occurs. 4n this situation,
the client has been rescued from the immediate vicinit! of
the "re. The next action is to activate the "re alarm.
'2. A client with t!pe diabetes mellitus is being discharge
from the hospital after an occurrence of h!pergl!cemic
h!perosmolar nonketotic s!ndrome 8HH:=6. The nurse
develops a discharge teaching plan for the client and
identi"es which of the following as a priorit!?
a6 exercise routines
b6 controlling dietar! intake
c6 keeping follow-up appointments
d) monitoring $or signs o$ dehydration
'. A client is receiving intralipids 8fat emulsion6
intravenousl! at home, and the client)s spouse manages the
infusion. The health care nurse makes a visit and discusses
potential adverse reactions and the side e<ects of the
therap! with the client and the spouse. After the discussion,
the nurse expects the spouse to verbali'e that, in case of
suspected adverse reaction, the priorit! action is to(
a) stop the in$usion
b6 contact the nurse
c6 take the client)s blood pressure
d6 contact the local area emergenc! response team
'!. The nurse caring for a client who is d!ing formulates a
nursing diagnosis of Aear and identi"es appropriate nursing
interventions. Arom the following list of nursing
interventions, which intervention should the nurse
implement "rst?
a6 help the client express fears
b6 assess the nature of the client)s fear
c6 help the client identif! coping mechanisms that were
successful in the past
d) document verbal and nonverbal expressions o$ $ear
and other signi6cant data
'". A nurse reviews the preoperative teaching plan for a
client scheduled for a radical neck dissection. When
implementing the plan, the nurse initiall! focuses on(
a6 the "nancial status of the client
b6 postoperative communication techni1ues
c6 information given to the client b! the surgeon
d) the client&s support system and coping behaviors
'%. A nurse in a rehabilitation center is planning the client
assignments for the da!. Which client would the nurse assign
to the nursing assistant?
a) a client on strict bedrest $or whom a 2!-hour urine
specimen is being collected
b6 a client scheduled for transfer to the hospital for coronar!
arter! b!pass surger!
c6 a client scheduled for transfer to the hospital for an
invasive diagnostic procedure
d6 a client who is going through rehabilitation after
undergoing a below-the-knee amputation 8#JA6
''. A client has received electroconvulsive therap! 8I$T6. 4n
the post-treatment area and upon the client)s awakening,
the nurse will perform which intervention "rst?
a6 assist the client from the stretcher to a wheelchair
b) orient the client and monitor the client&s vital signs
c6 o<er the client fre1uent reassurance and repeat
orientation statements
d6 check for a gag refex and then encourage the client to
eat breakfast and resume activit!
'(. A nurse has assisted the ph!sician in placing a central
8subclavian6 catheter. Aollowing the procedure, the nurse
takes which priorit! action?
a) ensures that a chest radiograph is done
b6 obtains a temperature reading to monitor for infection
c6 labels the dressing with the date and time of catheter
insertion
d6 monitor the blood pressure 8#%6 to check for fuid volume
overload
'). A nurse is caring for a hospitali'ed client with a
diagnosis of abruptio placentae. The nurse develops a
nursing care plan and suggests measures to be implemented
in the event of the development of shock. The nurse
documents that the initial nursing action in the event of
shock is which of the following?
a) turn the client onto her side
b6 check the client)s blood pressure
c6 monitor urinar! output
d6 check the client)s heart rate
(*. A nurse is assigned to care for a pregnant client with a
diagnosis of sickle cell anemia. The nurse reviews the plan of
care and notes documentation of four nursing diagnoses.
Which would the nurse select as the priorit!?
a6 activit! intolerance
b6 ine<ective coping
c6 imbalanced nutrition( less than bod! re1uirements
d) de6cient =uid volume
(1. An emergenc! department nurse prepares a client who
sustained a gunshot wound for surger!. The nurse removes
the client)s clothing and places a gown on the client to
prepare the client for the surgical procedure. Which of the
following indicates the appropriate nursing action regarding
the client)s clothing, which is stianed with blood?
a6 discard clothing
b6 give the clothing to the famil! member or signi"cant other
c) place the clothing in a paper bag
d6 place the clothing in a plastic bag and in a locked cabinet
(2. A nurse is assessing a client who has a suspected spinal
cord in?ur!. Which of the following is the priorit! assessment?
a6 pupillar! response
b) respiratory status
c6 mobilit!
d6 pain
(. When delegating a task to a team member, the nurse as
the team leader gives authorit! over the task b!(
a6 o<ering suggestions on how to complete the task
b) waiting $or the team member to report the results
o$ the completed tas#
c6 completing the task for the team member
d6 checking to be sure the task is complete
(!. A nurse is assigned to care for a client with coronar!
arter! disease 8$AG6 who is scheduled fro a cardiac
catheteri'ation. Aollowing the catheteri'ation, the priorit!
nursing action is to assess the(
a) catheter insertion site
b6 temperature
c6 potassium level
d6 urine output
(". A nurse in a da! care center is told that a child with
autism will be attending the center. The nurse collaborates
with the sta< of the da! care center and plans activities that
will meet the child)s needs. The priorit! consideration in
planning activities for the child is to ensure(
a6 social interactions with other children in the same age-
group
b) sa$ety with activities
c6 familiarit! with all activities and providing orientation
throughout the activities
d6 activities that provide verbal stimulation
(%. A nurse emplo!es in a rehabilitation center is planning
the client assignments for the da!. Which client would the
nurse assign to the nursing assistant?
a6 a client who had a below-the-knee amputation
b) a client on a 2!-hour urine collection who is on
strict bedrest
c6 a client scheduled to be transferred to the hospital for
coronar! arter! b!pass surger!
d6 a client scheduled for transfer to the hospital for an
invasive diagnostic procedure
('. The parents of an 5*-month-old child arrive at the
emergenc! department with the child. The child is
unconscious. The ph!sical examination reveals bruises on
the child)s upper arms that resemble grip marks, and the
nurse suspects child abuse. The "rst priorit! of the nurse is
to(
a6 contact the appropriate state o2cials to report the abuse
case
b6 establish a trusting relationship with the parents
c6 secure a safe environment for the child
d) stabili5e the child&s physical condition
((. A nurse is planning care for a client with an obsessive-
compulsive disorder. The nurse would assign the highest
priorit! to which of the following nursing interventions?
a6 educate the client about self-control techni1ues
b) establish a trusting nurse-client relationship
c6 monitor the client for abnormal behavior
d6 encourage participation in dail! self-care and unit
activities
(). A nurse has delegated several nursing tasks to sta<
members. The nurse)s primar! responsibilit! following
delegation of the tasks is to(
b) $ollow up with each sta? member regarding the
per$ormance o$ the tas# and the outcomes related to
implementing the tas#
c6 document that the task was complemented
d6 assign the tasks that were not completed to the next
nursing shift
)*. A client who has had abdominal surger! calls the nurse
and reports that she felt that 3something gave wa!3 in the
abdominal incision. The nurse checks the abdominal incision
and notes the presence of wound dehiscence. The nurse
should take which action "rst?
a6 contact the ph!sician
b6 document the "ndings
c) place the client inlow-$owler&s position and instruct
the client to lie /uietly
d6 cover the abdominal wound with a sterile dressing
moistened with sterile saline solution
)1. A nurse is caring for a client who ?ust returned from the
recover! room after a tonsillectom! and adenoidectom!. The
client is restless and the pulse rate is elevated. The nurse
prepares to continue assessing the client, but the client
begins to vomit large amounts of bright red blood. The
immediate nursing action is to(
a) noti$y the surgeon
b6 continue with the assessment
c6 check the client)s temperature
d6 obtain a fashlight, gau'e, and a curved hemostat
)2. A postoperative client suddenl! develops chest pain and
is experiencing d!spnea and tach!pnea. The nurse suspects
that the client has a pulmonar! embolism and immediatel!
plans to(
a6 ensure that the intravenous 84E6 line is patent
b6 prepare the client for a perfusion scan
c) administer nasal oxygen
d6 place the client on a cardiac monitor
). An older client with a histor! of h!perparath!roidism and
severe osteoporosis is newl! hospitali'ed. The nurse reviews
the plan of care for the client and selects which nursing
diagnosis as the priorit!?
a) ris# $or in4ury
b6 impaired urinar! elimination
c6 risk for constipation
d6 ine<ective health maintenance
)!. A client arrives at the nursing unit following internal
maxillar! "xation 84>A6 surger!. The immediate nursing
action is to(
a6 administer an anti-emetic to prevent vomiting
b) position the client on the side with the head
slightly elevated
c6 place wire cutters at the bedside
d6 connect the nasogastric tube 8:KT6 to allow intermittent
suction
)". A registered nurse is planning the client assignments for
the da!. Which of the following is the appropriate assignment
for the nursing assistant?
a6 a client re1uiring fre1uent vital signs following a cardiac
catheteri'ation
b) a client who re/uires $re/uent ambulation
c6 a client re1uiring wound irrigation
d6 a client receiving continuous tube feedings
)%. A registered nurse 8&:6 emplo!ed in a long-term care
facilit! is planning assignments for the clients on a nursing
unit. The &: needs to assign four clients and has a licensed
practical nurse 8@%:6 and three nursing assistants on a
nursing team. Which of the following clients would the nurse
appropriatel! assign to the @%:?
a6 a client with a right leg amputation who re1uires
assistance with a shower
b6 a client re1uiring a bed bath and fre1uent ambulation with
a walker
c6 a client who re1uires fre1uent temperatures taken
d) a client with a decubitus ulcer that re/uires a
wound irrigation and dressing change
)'. A registered nurse 8&:6 has received the assignment for
the da! shift. After making initial rounds and checking all the
assigned clients, which client will the &: plan to care for
"rst?
a6 a postoperative client with chest tubes who has ?ust
received pain medication
b6 a client scheduled for a chest x-ra! at 55(// A>
c) a client who is scheduled $or surgery at 1@** 1A
d6 a client who is self-care
)(. A nurse is assigned to care for four clients. 4n planning
client rounds, which client would the nurse assess "rst?
a6 a client admitted on the previous shift with a diagnosis of
gastroenteritis
b6 a client in skeletal traction
c) a client attached to a ventilator
d6 a postoperative client preparing for discharge
)). A nurse on the da! shift is assigned to care for four
clients. Aollowing report from the night shift, which client will
the nurse plan to asses "rst?
a6 client scheduled for a cardiac catheteri'ation at 5/(// A>
b6 client newl! diagnosed with diabetes mellitus who is
scheduled for discharge to home
c) client with pulmonary edema who was treated with
$urosemide :>asix) at "@** +A
d6 client scheduled to have an electrocardiogram 8I$K6 at
+(// A>
1**. A registered nurse 8&:6 is planning the client
assignments for the da!. The &: assigns which of the
following clients to the nursing assistant?
a) a client who needs range-o$-motion exercises every
! hours
b6 a client who needs to be catheteri'ed ever! 5 hours
c6 a client who needs to be suctioned as needed 8%&:6
d6 a client who needs a dressing change performed ever! ,
hours
1*1. A registered nurse 8&:6 is implementing a team
nursing approach. The &: has a licensed practical nurse
8@%:6 and a nursing assistant on the team and is planning
the client assignments for the da!. The &: appropriatel!
assigns which of the following clients to the @%:?
a6 a client who needs assistance with grooming
b6 a client who needs fre1uent ambulation
c) a client who needs to be suctioned as needed :1RN)
d6 a client who needs assistance with h!giene measures
1*2. A nurse is planning client assignments. Which of the
following is the least appropriate assignment for the nursing
assistant?
a) assisting a pro$oundly developmentally disabled
child to eat lunch
b6 obtaining fre1uent oral temperatures on a client
c6 accompan!ing a 95-!ear old man, being discharged to
home following a bowel resection
d6 collecting a urine specimen from a 7/-!ear old woman
admitted 0 da!s ago
1*. A nurse is assigned to care for four clients. 4n planning
client rounds, which client would the nurse assess "rst?
a) a client receiving oxygen via nasal cannula who
had di.culty breathing during the previous shi$t
b6 a postoperative client preparing fro discharge
c6 a client scheduled for a chest x-ra!
d6 a client re1uiring dail! dressing changes
1*!. A nurse is planning the client assignments for the shift.
Which of the following clients would the nurse appropriatel!
assign to the nursing assistant?
a6 a client re1uiring twice -dail! dr! dressing changes
b) a client re/uiring $re/uent ambulation with a
wal#er
c6 a client on a bowel management program re1uiring rectal
suppositories and a dail! enema
d6 a client with diabetes mellitus re1uiring dail! insulin and
reinforcement of dietar! measures
1*". A client with a spinal cord in?ur! develops a severe,
pounding headache. The client is diaphoretic, h!pertensive,
and brad!cardic and complains of nausea and nasal
congestion. The nurse determines that the client is
experiencing autonomic h!perrefexia 8autonomic
d!srefexia6. Which action would the nurse take "rst?
a6 notif! the ph!sician
b6 document the "ndings
c6 perform a rectal examination
d) place the client in a sitting position
Nursing Board Exam Review Questions in Emergency
$ompiled b! La!cesar
5. The nurse is teaching a class on biological warfare. Which
information should the nurse include in the presentation?
a. $ontaminated water is the onl! source of transmission of biological
agents.
b. Eaccines are available and being prepared to counteract biological
agents.
c. #iological weapons are less of a threat than chemical agents.
d. #iological weapons are easil! obtained and result in signi"cant
mortalit!.
+nswer@ 3 &ationale( #ecause of the variet! of agents, the means of
transmission, and lethalit! of the agents, biological weapons, including
anthrax, smallpox, and plague, is especiall! dangerous.
. Which signs- s!mptoms would the nurse assess in the client who has
been exposed to the anthrax bacillus via the skin?
a. A scabb!, clear fuid-"lled vesicle.
b. Idema, pruritus, and a -mm ulcerated vesicle.
c. 4rregular brownish-pink spots around the hairline.
d. Tin! purple spots fush with the surface of the skin.
+nswer@ B &ationale( Ixposure to anthrax bacilli via the skin results in
skin lesions, which cause edema with pruritus and the formation of
macules or papules that ulcerate, forming a 5-0 mm vesicle. Then a
painless eschar develops, which falls o< in one 856 to weeks.
0. The client has expired secondar! to smallpox. Which information
about funeral arrangements is most important for the nurse to provide
to the clientBs famil!?
a. The client must be cremated.
b. =uggest an open casket funeral.
c. #ur! the client within , hours.
d. :otif! the public health department.
+nswer@ + &ationale( $remation is recommended because the virus
can sta! alive in the scabs of the bod! for 50 !ears.
,. A chemical exposure has ?ust occurred at an airport. An o<-dut!
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. =tand up to avoid heav! exposure.
c. @ie down to sta! under the exposure.
d. Attempt to breathe through their clothing.
+nswer@ B &ationale( =tanding up will avoid heav! exposure the
chemical will sink toward the foor or ground.
9. The nurse is caring for a client in the prodromal phase of radiation
exposure. Which signs-s!mptoms would the nurse assess in the client?
a. Anemia, leukopenia, and thromboc!topenia.
b. =udden fever, chills, and enlarged l!mph nodes.
c. :ausea, vomiting, and diarrhea.
d. Alaccid paral!sis, diplopia, and d!sphagia.
+nswer@ 9 &ationale( The prodromal phase 8presenting s!mptoms6 of
radiation exposure occurs ,*-7hours after exposure and the
signs-s!mptoms are nausea, vomiting, diarrhea, anorexia, and fatigue.
Higher exposures of radiation signs-s!mptoms include fever,
respirator! distress, and excitabilit!.
.. The o<-dut! nurse hears on the television of a bioterrorism act in the
communit!. Which action should the nurse take "rst?
a. 4mmediatel! report to the hospital emergenc! room.
b. $all the American &ed $ross to "nd out where to go.
c. %ack a bag and prepare to sta! at the hospital.
d. Aollow the nurseBs hospital polic! for responding.
.. +nswer@ 3 &ationale( The nurse should follow the hospitalBs polic!.
>an! times nurses will sta! at home until decisions are made as to
where the emplo!ees should report.
7. Which situation would warrant the nurse obtaining information from
a material safet! datasheet 8>=G=6?
a. The custodian spilled a chemical solvent in the hallwa!.
b. A visitor slipped and fell on the foor that had ?ust been mopped.
c. A bottle of antineoplastic agent broke on the clientBs foor.
d. The nurse was stuck with a contaminated needle in the clientBs
room.
7. +nswer@ + &ationale( The >=G= provides chemical information
regarding speci"c agents, health information, and spill information for
a variet! of chemicals. 4t is re1uired for ever! chemical that is found in
the hospital.
*. The triage nurse is working in the emergenc! department. Which
client should be assessed "rst?
a. The 5/-!ear-old child whose dad thinks the childBs leg is broken.
b. The ,9-!ear-old male who is diaphoretic and clutching his chest.
c. The 9*-!ear-old female complaining of a headache and seeing spots.
d. The 9-!ear- old male who cut his hand with a hunting knife.
*. +nswer@ B &ationale( The triage nurse should see this client "rst
because these are s!mptms of a m!ocardial infarction, which
potentiall! life is threatening.
+. According to the :orth Atlantic Treat! Frgani'ation 8:ATF6 triage
s!stem, which situation would be considered a level red 8%riorit! 56?
a. 4n?uries are extensive and chances of survival are unlikel!.
b. 4n?uries are minor and treatment can be dela!ed hours to da!s.
c. 4n?uries are signi"cant but can wait hours without threat to life or
limb.
d. 4n?uries are life threatening but survivable with minimal
interventions.
+nswer@ 3 &ationale( This is called the immediate categor!.
4ndividuals in this group can progress rapidl! to expectant if treatment
is dela!ed.
5/. Which statement best describes the role of the medical-surgical
nurse during a disaster?
a. The nurse ma! be assigned to ride in the ambulance.
b. The nurse ma! be assigned as a "rst assistant in the operating
room.
c. The nurse ma! be assigned to crowd control.
d. The nurse ma! be assigned to the emergenc! department
+nswer@ 3 &ationale( :ew settings and at!pical roles for nurses ma!
be re1uired during disastersC medical-M surgical nurses can provide "rst
aid and be re1uired to work in unfamiliar settings.
55. Which intervention is the most important for the nurse to
implement when performing mouth-to- mouth resuscitation on a client
who has pulse less ventricular "brillation?
a. %erform the ?aw thrust maneuver to open the airwa!.
b. ;se the mouth to cover the clientBs mouth and nose.
c. 4nsert an oral airwa! prior to performing mouth to mouth.
d. ;se a pocket mouth shield to cover clientBs mouth.
Answer: D Rationale: Nurses should protect themselves against possible communicable
disease, such as HIV, hepatitis, or any types of sexually transmitted disease.
5. The nurse is teaching $%& to a class. Which statement best
explains the de"nition of sudden cardiac death?
a. $ardiac death occurs after being removed from a mechanical
ventilator.
b. $ardiac death is the time that the ph!sician o2ciall! declares the
client dead.
c. $ardiac death occurs within one 856 hour of the onset of
cardiovascular s!mptoms.
d. The death is caused b! m!ocardial ischemia resulting from coronar!
arter! disease.
Answer: C Rationale: Unexpected death occurring ithin! hour of the onset of
cardiovascular symptoms is the definition of sudden cardiac death.
50. Which statement explains the scienti"c rationale for having
emergenc! suction e1uipment available during resuscitation e<orts?
a. Kastric distention can occur as a result of ventilation.
b. 4t is needed to assist when intubating the client.
c. This e1uipment will ensure a patent airwa!.
d. 4t keeps the vomitus awa! from the health-care provider.
Answer: A Rationale: "astric distention occurs from over ventilating clients. #hen
compressions are performed, the pressure ill cause vomiting that could be aspirated into
the lungs.
5,. Which e1uipment must be immediatel! brought to the clientBs
bedside when a code is called for a client who has experienced a
cardiac arrest?
a. A ventilator.
b. A crash cart.
c. A gurne!.
d. %ortable ox!gen.
Answer: B Rationale: $he crash cart is the mobile unit that has the defibrillator and all
the medications and supplies needed to conduct a code
59. The nursing administrator responds to a code situation. When
assessing the situation, which role must the administrator ensure is
performed for legal purposes and continuit! of care of the client?
a. A person is ventilating with an ambu bag.
b. A person is performing chest compressions correctl!.
c. A person is administering medications as ordered.
d. A person is keeping an accurate record of the code.
Answer: D Rationale: $he chart is a legal document and the code must be documented in
the chart and provide information that may be needed in the intensive care unit.
5.. The nurse in the emergenc! department has admitted "ve 896
clients in the last two 86 hours with complaints of fever and
gastrointestinal distress. Which 1uestion would be most appropriate for
the nurse to ask each client to determine if there is a bioterrorism
threat?
a. NGo !ou work or live near an! large power lines?O
b. NWhere were !ou immediatel! before !ou got sickO?
c. N$an !ou write down ever!thing !ou ate toda!?O
d. NWhat other health problems do !ou have?O
Answer: B Rationale: $he nurse should ta%e note of any unusual illness for the time of
year or clusters of clients coming from a single geographical location ho all exhibit
signs&symptoms of possible biological terrorism.
57. The health-care facilit! has been noti"ed that an alleged inhalation
anthrax exposure has occurred at the local post o2ce. Which categor!
of personal protective e1uipment 8%%I6 would the response team wear?
a. @evel A
b. @evel #
c. @evel $
d. @evel G
Answer: A Rationale: 'evel ( protection is orn hen the highest level of respiratory,
s%in, eye, and mucous membrane protection is re)uired. In this situation of possible
inhalation of anthrax, such protection is re)uired
5*. The nurse is teaching a class on bioterrorism and is discussing
personal protective e1uipment 8%%I6. Which statement is the most
important fact that must be shared with the participants?
a. Health-care facilities should keep masks at entr! doors.
b. The respondent should be trained in the proper use of %%I.
c. :o single combination of %%I protects against all ha'ards.
d. The I%A has divided %%I into four levels of protection
Answer: C Rationale: $he health* care providers are not guaranteed absolute protects.
$he nurse should ta%e note of any unusual illness for the time of year or clusters of
clients coming from a single geographical location ho all exhibit signs&symptoms of
possible biological terrorism.ion, even ith all the training and protective e)uipment.
5+. The nurse is teaching a class on bioterrorism. What is the scienti"c
rationale for designating a speci"c area for decontamination?
a. =howers and privac! can be provided to the client in this area.
b. This area isolates the clients who have been exposed to the agent.
c. 4t provides a centrali'ed area for stocking the needed supplies.
d. 4t prevents secondar! contamination to the health-care providers.
Answer: D Rationale: (voiding cross contamination is a priority for personnel and
e)uipment the feer number of people exposed, the safer the community and area
/. The triage nurse in a large trauma center has been noti"ed of an
explosion in a ma?or chemical manufacturing plant. Which action
should the nurse implement "rst when the clientBs arrive at the
emergenc! department?
a. Triage the clients and send them to the appropriate areas.
b. Thoroughl! wash the clients with soap and water and then rinse.
c. &emove the client+s clothing and have them shoer.
d. (ssume the clients have been decontaminated at the plant.
Answer: C Rationale: $his is the first step. ,epending on the type of exposure, this step
alone can remove a large portion of exposure.
-!. $he nurse is planning a program for clients at a health fair regarding the prevention
and early detection of cancer of the pancreas. #hich self*care activity should the nurse
teach that is an example of primary nursing care.
a. /onitor for elevated blood glucose at random intervals.
b. Inspect the s%in and sclera of the eyes for a yello tint
c. 'imit meat in the diet and eat a diet that is lo in fats.
d. Instruct the client ith hyperglycemia about insulin in0ections.
Answer: C Rationale: 'imiting the inta%e of meat and fats in the diet ould be an
example of primary interventions. Ris% factors for the development of cancer of the
pancreas are cigarette smo%ing and eating a high*fat diet that is high in animal protein.
1y changing these behaviors the client could possibly prevent the development of cancer
of the pancreas. 2ther ris% factors include genetic predisposition and exposure to
industrial chemicals.
--. $he client diagnosed ith cancer of the pancreas is being discharged to start
chemotherapy in the H34+s office. #hich statement made by the client indicates the
client understands. $he discharge instructions.
a. 5I ill have to see the H34 every day for six 678 ee%s for my treatments.9
b. 5I should rite don all my )uestions so I can as% them hen I see the H34.9
c. 5I am sure that this is not going to be a serious problem for me to deal ith.9
d. 5$he nurse ill give me an in0ection in my leg and I ill get to go home.9
Answer: B Rationale: $he most important person in the treatment of the cancer is the
client. Research has proved that the more involved a client becomes in his or her care, the
better the prognosis. 3lients should have a chance to as% all the )uestions that they
-:. $he nurse caring for a client diagnosed ith cancer of the pancreas rites the
collaborative problem of 9 altered nutrition.;9 #hich intervention should the nurse
include in the plan of care.
a. 3ontinuous feedings via 4<" tube.
b. Have the family bring in foods from home.
c. (ssess for food preferences.
d. Refer to the dietitian.
Answer: D Rationale: ( collaborative intervention ould be to refer to the nutrition
expert, the dietitian.
-=. $he client is ta%en to the emergency department ith an in0ury to the left arm. #hich
action should the nurse ta%e first.
a. (ssess the nail beds for capillary refill time.
b. Remove the client+s clothing from the arm.
c. 3all radiology for a >$($ x*ray of the extremity.
d. 4repare the client for the application of a cast.
Answer: A Rationale: $he nurse should assess the nail beds for the capillary refill time.
( prolonged time 6greater than three seconds8 indicates impaired circulation to the
extremity.
-?. $he nurse finds the client unresponsive on the floor of the bathroom. #hich action
should the nurse implement first.
a. 3hec% the client for breathing.
b. (ssess the carotid artery for a pulse.
c. >ha%e the client and shout.
d. 3all a code via the bathroom call light.
Answer: C Rationale: $his is the first intervention the nurse should implement after
finding the client unresponsive on the floor.
-7. #hich behavior by the unlicensed assistive personnel ho is performing cardiac
compressions on an adult client during a code arrants immediate intervention by the
nurse.
a. Has one hand on the loer half of the sternum above the xiphoid process.
b. 4erforms cardiac compressions and allos for rescue breathing.
c. ,epresses the sternum @.? to one 6!8 inch during compressions.
d. Re)uests to be relieved from performing compressions because of exhaustion.
7. Answer: C Rationale: $he sternum should be depressed !.? to - inches during
compressions to ensure ade)uate circulation of blood to the bodyA therefore, the nurse
needs to correct the assistant.
-B. #hich is the most important intervention for the nurse to implement hen
participating in a code.
a. <levate the arm after administering medication.
b. /aintain sterile techni)ue throughout the code.
c. $reat the client+s signs&symptomsA do not atch the monitor.
d. 1e sure to provide accurate documentation of hat happened in the code.
Answer: C Rationale: $his is the most important intervention. $he nurse should alays
treat the client based on the nurse+s assessment and data from the monitorsA an
intervention should not be based on data from the monitors ithout the nurse+s
assessment.
-C. $he 34R instructor is explaining hat an automated external defibrillator
6(<,8 does to students in a 34R class. #hich statement best describes an (<,.
a. It analyDes the rhythm and shoc%s the client in ventricular fibrillation.
b. $he client ill be able to have synchroniDed cardio version ith the (<,.
c. It ill %eep the health*care provider informed of the client+s oxygen level.
d. $he (<, ill perform cardiac compressions on the client.
Answer: A Rationale: $his is the correct statement explaining hat an (<, does hen
used in a code
-E. $he nurse is caring for clients on a medical floor. #hich client is most li%ely to
experience sudden cardiac death.
a. $he C=* year*old client exhibiting uncontrolled atrial fibrillation.
b. $he 7@*year*old client exhibiting asymptomatic sinus bradycardia.
c. $he ?:*year*old client exhibiting ventricular fibrillation.
d. $he 7?* year*old client exhibiting supra ventricular tachycardia.
Answer: C Rationale: Ventricular fibrillation is the most common dysrhythmia
associated ith >udden cardiac deathA ventricular fibrillation is responsible for 7?F to
C?F of sudden cardiac deaths.
:@. #hich health*care team member referral should be made hen a code is being
conducted on a client in a community hospital.
a. $he hospital chaplain.
b. $he social or%er.
c. $he respiratory therapist.
d. $he director of nurses.
Answer: A Rationale: $he chaplain should be called to help address the client+s family or
significant others. ( small community hospital ould not have a-=*hour on*duty pastoral
service.
:!. ( client ith multiple in0ury folloing a vehicular accident is transferred to the
critical care unit. He begins to complain of increased abdominal pain in the left upper
)uadrant. ( ruptured spleen is diagnosed and he is scheduled for emergency splenectomy.
In preparing the client for surgery, the nurse should emphasiDe in his teaching plan the:
a. 3omplete safety of the procedure
b. <xpectation of postoperative bleeding
c. Ris% of the procedure ith his other in0uries
d. 4resence of abdominal drains for several days after surgery
Answer: D Rationale: 4resence of abdominal drains for several days after surgery. ,rains
are usually inserted into the splenic bed to facilitate removal of fluid in the area that could
lead to abscess formation.
-
:-. (fter you managed to stabiliDe the respiratory function of your burn patient, your next
goal is to prevent this you have to replace the lost fluid and electrolytes. In starting fluid
replacement therapy, the total volume and rate of IV fluid replacement are gauged by the
patient+s response and by the patient+s response and by the resuscitation formula. In
determining the ade)uacy of fluid resuscitation, it is essential for you to monitor the:
a. urine output
b. blood pressure
c. intracranial pressure
d. cardiac output
Answer: A Rationale: to establish the sufficiency of fluid resuscitation, urine output
totals an index of renal perfusion. Urine output totals an index of renal perfusion, urine
output totals of :@*?@ ml&hour have been used as resuscitation goals. 2ther indicators of
ade)uate fluid replacement are systolic blood pressure exceeding !@@ mmHg, a pulse rate
less than!!@ beats&min or both.
::. Gou are a nurse in the emergency department and it is during the shift that /r. 3$ is
admitted in the area due to a fractured s%ull from a motor accident. Gou scheduled him
for surgery under hich classification.
a. Urgent
b. <mergent
c. Re)uired
d. <lective
Answer: B Rationale: <mergent surgery is performed, immediately ithout delay to
maintain life, limb or organ, remove damage and stop bleeding. Urgent surgery re)uires
prompt attention and is done fe hours but ithin -= to =C hours. Re)uired surgery is
done ithin a fe ee%s as surgery is important. <lective surgery is scheduled and done
at the convenience of client as failure to have surgery is not catastrophic. 2ptional
surgeries are done by preference only.
:=. 'uc%y as in a vehicular accident here he sustained in0ury to his left an%le. In the
<mergency room, you noticed anxious he loo%s. Gou establish rapport ith him and to
reduce his anxiety, you initially:
a. Identify yourself and state your purpose in being ith the client
b. $a%e him to the radiology section for x*ray of affected extremity
c. $al% to the physician for an order of valium
d. ,o inspection and palpation to chec% extent of his in0uries
Answer: A Rationale: Introducing self initiates the nurse*patient interaction, relationship
and the purpose of being ith the client. $his prevents confusion and let the client %no
hat to expect, thereby reducing anxiety.
:?. $he client diagnosed ith a mild concussion is being discharged from the <mergency
department. #hich discharge instruction should the nurse teach the client+s significant
other.
a. (a%en then client every to hours.
b. /onitor for increased intracranial pressure.
c. 2bserve fre)uently for hypervigilance.
d. 2ffer the client food every three to four hours.
Answer: A Rationale: (a%ening the client every - hours allos the identification of
headache, diDDiness, and lethargy, irritability, and anxietyHall signs of post*concussion
>yndrome that ould arrant the significant others ta%ing the client bac% to the
emergency department
:7. $he client diagnosed ith (ddison+s disease is admitted to the emergency department
after a day at the la%e. $he client is lethargic, forgetful, and ea%. #hich intervention
should be the emergency department nurse+s first action.
a. >tart an IV ith an !C*gauge needle and infuse N> rapidly.
b. Have the client ait in the aiting room until a bed is available.
c. 4erform a complete head*to* toe assessment.
d. 3ollect urinalysis and blood samples for a 313 and calcium level.
Answer: A Rationale: $his client has been exposed to ind and sun at the la%e during the
hours prior to being admitted to the emergency department. $his predisposes the client to
dehydration and an (ddisonian crisis. Rapid IV fluid replacement is necessary.
:B. $he nurse caring for a client diagnosed ith cancer of the pancreas rites the nursing
diagnosis of Iris% for altered s%in integrity related to pruritus.; #hich interventions
should the nurse implement.
a. (ssess tissue turgor.
b. (pply antifungal creams.
c. /onitor bony prominences for brea%don.
d. Have the client %eep the fingernails short.
Answer: D Rationale: Jeeping the fingernails short ill reduce the chance of brea%s in
the s%in from scratching.
:C. $he client diagnosed ith cancer of the head of the pancreas is to 6-8 days post
pancreas to duodenectomy 6#hipple+s procedure8. #hich nursing problem has the
highest priority.
a. (nticipatory grieving.
b. Kluid volume imbalance.
c. (cute incisional pain.
d. (ltered nutrition.
Answer: B Rationale: $his is a ma0or abdominal surgery, and there are massive fluid
volume shifts that occur hen this type of trauma is experienced by the body.
/aintaining the circulatory system ithout overloading it re)uires extremely close
monitoring.

:E. $he client is diagnosed ith cancer of the head of the pancreas. #hen assessing the
patient.
#hich signs and symptoms ould the nurse expect to find.
a. 3lay*colored stools and dar% urine.
b. Night seats and fever.
c. 'eft loer abdominal cramps and tenesmus.
d. Nausea and coffee*ground emesis.
Answer: A Rationale: $he client ill have 0aundice, clay*colored stools, and tea* colored
urine resulting from bloc%age of the bile drainage.
=@. $he client admitted to rule out pancreatic islet tumors complains of feeling ea%,
sha%y, and seaty. #hich should be the first intervention implemented by the nurse.
a. >tart an IV ith ,?#.
b. Notify the health* care provider.
c. 4erform a bedside glucose chec%.
d. "ive the client some orange 0uice.
Answer: C Rationale: $hese are symptoms of an insulin reaction 6hypoglycemia8. (
bedside glucose chec% should be done. 4ancreatic islet tumors can produce
hyperinsulinemia or hypoglycemia.
=!. #hich nursing intervention ould be appropriate hen caring for a client ho has
sustained an electrical burn.
a. (pplying ice to the burned area
b. Klushing the burn area ith large amounts of ater
c. /onitoring the client ith cardiac telemetry
d. 4reparing to administer the chemical antidote
Answer: C Rationale: 1ecause of the effects of the electrical current on the
cardiovascular system, all clients experiencing electrical burns should be placed on a
cardiac monitor. (pplying ice is inappropriate for any type of burn. 2nly chemical burns
should be flushed ith large amounts of ater. 3hemical antidotes may be used for
chemical burns for hich an antidote has been identified.
=-. <ddie, =@ years old, is brought to the emergency room after the crash of his private
plane. He has suffered multiple crushing ounds of the chest, abdomen and legs. It is
feared his leg may have to be amputated. #hen <ddie arrives in the emergency room, the
assessments that assume the greatest priority are:
a. 'evel of consciousness and pupil siDe
b. (bdominal contusions and other ounds
c. 4ain, Respiratory rate and blood pressured.
d. Luality of respirations and presence of pulses.
Answer: D Rationale: Respiratory and cardiovascular functions are essential for
oxygenation.
$hese are top priorities to trauma management. 1asic life functions must maintained or
reestablished
=:. (n emergency treatment for an acute asthmatic attac% is (drenaline !:!@@@ given
hypodermically. $his is given to:
a. increase 14
b. decrease mucosal selling
c. relax the bronchial smooth muscle
d. decrease bronchial secretions
Answer: C Rationale: (cute asthmatic attac% is characteriDed by severe bronchospasm
hich can be relieved by the immediate administration of bronchodilators. (drenaline or
<pinephrine is an adrenergic agent that causes bronchial dilation by relaxing the
bronchial smooth muscles.
==. Intervention for a pt. ho has salloed a /uriatic (cid includes all of the folloing
except:
a. administering an irritant that ill stimulate vomiting
b. aspirating secretions from the pharynx if respirations are affected
c. neutraliDing the chemical
d. ashing the esophagus ith large volumes of ater via gastric lavage
Answer: A Rationale: >alloing of corrosive substances causes severe irritation and
tissue destruction of the mucous membrane of the "I tract. /easures are ta%en to
immediately remove the toxin or reduce its absorption. Kor corrosive poison ingestion,
such as in muriatic acid here burn or perforation of the mucosa may occur, gastric
emptying procedure is immediately instituted, $his includes gastric lavage and the
administration of activated charcoal to absorb the poison. (dministering an irritant ith
the concomitant vomiting to remove the salloed poison ill further cause irritation
and damage to the mucosal lining of the digestive tract. Vomiting is only indicated hen
non*corrosive poison is salloed
=?. Mohn, !7 years old, is brought to the <R after a vehicular accident. He is pronounced
dead on arrival. #hen his parents arrive at the hospital, the nurse should:
a. (s% them to stay in the aiting area until she can spend time alone ith them
b. >pea% to both parents together and encourage them to support each other and express
their emotions freely
c. >pea% to one parent at a time so that each can ventilate feelings of loss ithout
upsetting the other
d. (s% the /, to medicate the parents so they can stay calm to deal ith their son+s
death.
Answer: B Rationale: >udden death of a family member creates a state of shoc% on the
family. $hey go into a stage of denial and anger in their grieving. (ssisting them ith
information they need to %no, ansering their )uestions and listening to them ill
provide the needed support for them to move on and be of support to one another.
=7. ( nurse is eating in the hospital cafeteria hen a toddler at a nearby table cho%es on a
piece of food and appears slightly blue. $he appropriate initial action should be to
a. 1egin mouth to mouth resuscitation
b. "ive the child ater to help in salloing
c. 4erform ? abdominal thrusts
d. 3all for the emergency response team
Answer: C Rationale: 4erform ? abdominal thrusts. (t this age, the most effective ay
to clear the airay of food is to perform abdominal thrusts.
=B. ( client is admitted from the emergency department ith severe*pain and edema in
the right foot. His diagnosis is gouty arthritis. #hen developing a plan of care, hich
action ould have the highest priority.
a. (pply hot compresses to the affected 0oints.
b. >tress the importance of maintaining good posture to prevent deformities.
c. (dminister salicylates to minimiDe the inflammatory reaction.
d. <nsure an inta%e of at least :@@@ ml of fluid per day.
Answer: D Rationale: <nsure an inta%e of at least :@@@ ml of fluid per day. "outy
arthritis is a metabolic disease mar%ed by urate deposits that cause painful arthritic 0oints.
$he patient should be urged to increase his fluid inta%e to prevent the development of
urinary uric acid stones.
=C. $he Heimlich maneuver 6abdominal thrust8, for acute airay obstruction, attempts to:
a. Korce air out of the lungs
b. Increase systemic circulation
c. Induce emptying of the stomach
d. 4ut pressure on the apex of the heart
Answer: A Rationale: $he Heimlich maneuver is used to assist a person cho%ing on a
foreign ob0ect. $he pressure from the thrusts lifts the diaphragm, forces air out of the
lungs and creates an artificial cough that expels the aspirated material.
=E. ( nurse is performing 34R on an adult patient. #hen performing chest compressions,
the nurse understands the correct hand placement is located over the
a. upper half of the sternum
b. Upper third of the sternum
c. loer half of the sternum
d. loer third of the sternum
Answer: C Rationale: $he exact and safe location to do cardiac compression is the loer
half of the sternum. ,oing it at the loer third of the sternum may cause gastric
compression hich can lead to a possible aspiration.
?@. Mohn, !7 years old, is brought to the <R after a vehicular accident. He is pronounced
dead on arrival. #hen his parents arrive at the hospital, the nurse should:
a. as% them to stay in the aiting area until she can spend time alone ith them
b. spea% to both parents together and encourage them to support each other and express
their emotions freely
c. >pea% to one parent at a time so that each can ventilate feelings of loss ithout
upsetting the other
d. as% the /, to medicate the parents so they can stay calm to deal ith their son+s death.
Answer: B Rationale: >udden death of a family member creates a state of shoc% on the
family. $hey go into a stage of denial and anger in their grieving. (ssisting them ith
information they need to %no, ansering their )uestions and listening to them ill
provide the needed support for them to move on and be of support to one another