QUIZ 1
Administer oxygen therapy via nasal
1. Nurse Ejay is assigned to a telephone
triage. A client called who was stung by
a honeybee and is asking for help. The
client reports of pain and localized
swelling but has no respiratory distress
or other symptoms of anaphylactic
shock. What is the appropriate initial
action that the nurse should direct the
client to perform?
A. Removing the stinger by scraping it.
B. Applying a cold compress.
C. Taking an oral antihistamine.
D. Calling the 911.
2. Nurse Anna is an experienced travel
nurse who was recently employed and is
assigned in the emergency unit. In her
first week of the job, which of the
following area is the most appropriate
assignment for her?
A. Triage.
B. Ambulatory section.
C. Trauma team.
D. Psychiatric care
3. A client arrives at the emergency
department who suffered multiple
injuries from a head-on car collision.
Which of the following assessment
should take the highest priority to take?
A. Irregular pulse.
B. Ecchymosis in the flank area.
C. A deviated trachea.
D. Unequal pupils.
4. Nurse Kelly, a triage nurse
encountered a client who complaints of
mid-sternal chest pain, dizziness, and
diaphoresis. Which of the following
nursing action should take priority?
A. Complete history taking.
B. Put the client on ECG monitoring.
C. Notify the physician.
D.
cannula.
5. A group of people arrived at the
emergency unit by a private car with
complaints of periorbital swelling,
cough, and tightness in the throat.
There is a strong odor emanating from
their clothes. They report exposure to a
“gas bomb” that was set off in the
house. What is the priority action?
A. Direct the clients to the decontamination
area.
B. Direct the clients to the cold or clean zone
for immediate treatment.
C. Measure vital signs and auscultate lung
sounds.
D. Immediately remove other clients and
visitors from the area.
E. Instruct personnel to don personal
protective equipment.
6. When an unexpected death occurs in
the emergency department, which task
is the most appropriate to delegate to
a nursing assistant?
A. Help the family to collect belongings.
B. Assisting with postmortem care.
C. Facilitate meeting between the family and
the organ donor specialist.
D. Escorting the family to a place of privacy.
7. The physician has ordered cooling
measures for a child with a fever who is
likely to be discharged when the
temperature comes down. Which task
would be appropriate to delegate to a
nursing assistant?
A. Prepare and administer a tepid sponge
bath.
B. Explain the need for giving cool fluids.
C. Assist the child in removing outer
clothing.
D. Advise the parent to use acetaminophen
(Tylenol) instead of aspirin.
8. You are preparing a child for IV
conscious sedation before the repair of
a facial laceration. What information
should you report immediately to the
physician?
A. The parent wants information about the
IV conscious sedation.
B. The parent is not sure regarding the
child’s tetanus immunization status.
C. The child suddenly pulls out the IV.
D. The parent’s refusal of the administration
of the IV sedation.
9. The emergency medical service has
transported a client with severe
chest pain. As the client is being
transferred to the emergency stretcher,
you note unresponsiveness, cessation of
breathing, and unpalpable pulse. Which
of the following task is appropriate to
delegate to the nursing assistant?
A. Assisting with the intubation.
B. Placing the defibrillator pads.
C. Doing chest compressions.
D. Initiating bag valve mask ventilation.
10. The nursing manager decides to
form a committee to address the issue
of violence against ED personnel. Which
combination of employees would be
best suited to fulfill this assignment?
A. RNs, LPNs, and nursing assistants.
B. At least one representative from each
group of ED personnel.
C. Experienced RNs and experienced
paramedics.
D. ED physicians and charge nurses.
11. A client suffered an amputation of
the first and second digits in a chainsaw
accident. Which task should be
delegated to an LPN/LVN?
A. Cleansing the amputated digits and
placing them directly into an ice slurry.
B. Cleansing the digits with sterile normal
saline and placing in a sterile cup with
sterile normal saline.
C. Gently cleansing the amputated digits and
the hand with povidone-iodine.
D. Wrapping the cleansed digits in saline-
moistened gauze, sealing in a plastic
container, and placing it in an ice.
12. A client arrives in the emergency
unit and reports that a concentrated
household cleaner was splashed in both
eyes. Which of the following nursing
actions is a priority?
A. Use Restasis (Allergan) drops in the eye.
B. Flush the eye repeatedly using
sterile normal saline.
C. Examine the client’s visual acuity.
D. Patch the eye.
13. A client was brought to the
emergency department after suffering a
closed head injury and lacerations
around the face due to a hit-run
accident. The client is unconscious and
has minimal response to noxious
stimuli. Which of the following
assessment findings if observed after
few hours, should be reported to the
physician immediately?
A. Bleeding around the lacerations.
B. Withdrawal of the client in response to
painful stimuli.
C. Bruises and minimal edema of the eyelids.
D. Drainage of a clear fluid from the client’s
nose.
14. A 5-year-old client was admitted to
the emergency unit due to ingestion of
unknown amount of chewable vitamins
for children at an unknown time. Upon
assessment, the child is alert and with
no symptoms. Which of the following
information should be reported to the
physician immediately?
A. The child has been treated multiple times
for injuries caused by accidents.
B. The vitamin that was ingested contains
iron.
C. The child was nauseated and vomited
once at home.
D. The child has been treated several times
for toxic substance ingestion.
15. The following clients come at the
emergency department complaining of
acute abdominal pain. Prioritize them
for care in order of the severity of the
conditions.
 1. A 27-year-old woman
complaining of lightheadedness and
severe sharp left lower
quadrant pain who reports she is
possibly pregnant.
 2. A 43-year-old woman with
moderate right upper quadrant pain
who has vomited small amounts of
yellow bile and whose symptoms
have worsened over the week.
 3. A 15-year-old boy with a low-
grade fever, right lower quadrant
pain, vomiting, nausea, and loss of
appetite for the past few days.
 4. A 57-year-old woman who
complains of a sore throat and
gnawing midepigastric pain that is
worse between meals and during
the night.
 5. A 59-year-old man with a
pulsating abdominal mass and
sudden onset of persistent
abdominal or back pain, which can
be described as a tearing sensation
within the past hour.
A. 2,5,3,4,1
B. 3,1,4,5,2
C. 5,1,3,2,4
D. 2,5,1,4,3
16. The following clients are presented
with signs and symptoms of heat-
related illness. Which of them needs to
be attended first?
A. A relatively healthy homemaker who
reports that the air conditioner has been
broken for days and who
manifest fatigue, hypotension, tachypnea,
and profuse sweating.
B. An elderly person who complains of
dizziness and syncope after standing in the
sun for several hours to view a parade.
C. A homeless person who is a poor
historian; has altered mental status,
poor musclecoordination, and hot, dry ashen
skin; and whose duration of heat exposure is
unknown.
D. A marathon runner who complains of
severe leg cramps and nausea, and
manifests weakness, pallor, diaphoresis, and
tachycardia.
17. An anxious female client complains
of chest tightness, tingling sensations,
and palpitations. Deep, rapid breathing,
and carpal spasms are noted. Which of
the following priority action should the
nurse do first?
A. Provide oxygen therapy.
B. Notify the physician immediately.
C. Administer anxiolytic medication as
ordered.
D. Have the client breathe into a brown
paper bag.
18. An intoxicated client comes into the
emergency unit with an uncooperative
behavior, mild confusion, and with
slurred speech. The client is unable to
provide a good history but he verbalizes
that he has been drinking a lot. Which of
the following is a priority action of the
nurse?
A. Administer IV fluid incorporated with
Vitamin B1 as ordered.
B. Administer Naloxone (Narcan) 4 mg as
ordered.
C. Contact the family to get information of
the client.
D. Obtain an order for the determination
of blood alcohol level.
19. A nurse is providing discharge
instruction to a woman who has been
treated for contusions and bruises due
to a domestic violence. What is the
priority intervention for this client?
A. Making a referral to a counselor.
B. Making an appointment to follow up on
the injuries.
C. Advising the client about contacting the
police.
D. Arranging transportation to a safe house.

20. In the work setting, what is the

primary responsibility of the nurse in
preparation for disaster management,
that includes natural disasters and
bioterrorism incidents?

A. Being aware of the signs and symptoms of

potential agents of bioterrorism.
B. Making ethical decisions regarding
exposing self to potentially lethal
substances.
C. Being aware of the agency’s emergency
response plan.
D. Being aware of what and how to report to
the Centers for Disease Control and
Prevention.
ANSWERS AND RATIONALE
1. Answer: A. Removing the stinger by
scraping it.
Since the stinger will continue to release
venom into the skin, removing the stinger
should be the first action that the nurse
should direct to the client.
 Options B and C: After removing
the stinger, Antihistamine and cold
compress follow.
 Option D: The caller should be
further advised about symptoms
that require 911 assistance.
2. Answer: B. Ambulatory section.
The ambulatory section deals with clients
with relatively stable conditions.
 Options A, C, and D: These areas
should be filled with nurses who are
experienced with hospital routines
and policies and has the ability to
locate equipment immediately.
3. Answer: C. A deviated trachea.
A deviated trachea is a symptom of
tension pneumothorax, which will result in
respiratory distress if left untreated.
4. Answer: D. Administer oxygen
therapy via nasal cannula.
The priority goal is to increase myocardial
oxygenation.
 Options A, B, and C: These actions
are also appropriate and should be
performed immediately.
5. Answer: A. Direct the clients to the
decontamination area.
Decontamination in a specified area is the
priority.
 Option B: The clients must undergo
decontamination before entering
cold or clean areas.
 Options C and D: Performing
assessments and moving others
delays contamination and does not
protect the total environment.
 Option E: Personnel should don
personal protective equipment
before assisting with
decontamination or assessing the
clients.
6. Answer: B. Assisting with
postmortem care.
Postmortem care requires some turning,
cleaning, lifting, and so on, and the nursing
assistant is able to assist with these duties.
 Option A: In cases of questionable
death, belongings may be retained
for evidence, so the chain of
custody would have to be
maintained.
 Options C and D: A licensed nurse
should take responsibility for the
other tasks to help the family begin
the grieving process.
7. Answer: C. Assist the child in
removing outer clothing.
The nursing assistant can help with the
removal of outer clothing, which allows the
heat to dissipate from the child’s skin.
 Option A: Tepid baths are not
usually given because of the
possibility of shivering and
rebound.
 Options B and D: Explaining and
Advising are teaching functions that
are a responsibility of the
registered nurse.
8. Answer: D. The parent’s refusal of the
administration of the IV sedation.
The refusal of the parents is an absolute
contraindication; therefore the physician
must be notified.
 Options A and C: The RN can
reestablish the IV access and
provide information about
conscious sedation.
 Option B: Tetanus status can be
addressed later.
9. Answer: C. Doing chest compressions.
Performing chest compressions are within
the training of a nurse assistant.
 Option A: The use of the bag valve
mask requires practice, and usually
a respiratory therapist will perform
the function.
 Option B: The defibrillator pads are
clearly marked; however placement
should be done by the RN or
physician because of the potential
for skin damage and electrical
arcing.
10. Answer: B. At least one
representative from each group of ED
personnel.
At least one representative from each group
of ED personnel should be included because
all employees are potential targets for
violence in the ED.
11. Answer: D. Wrapping the cleansed
digits in saline-moistened gauze,
sealing in a plastic container, and
placing it in an ice.
12. Answer: B. Flush the eye repeatedly
using sterile normal saline.
Initial emergency action during a chemical
splash to the eye includes immediate
continuous irrigation of the affected eye with
normal saline.
 Option A: Restasis (Allergan) drops
are used to treat dry eyes.
 Option C: Patching the eye is not
part of the first line treatment of a
chemical splash.
 Option D: After irrigation, visual
acuity then is assessed.
13. Answer: D. Drainage of a clear fluid
from the client’s nose.
Clear drainage from the client’s nose
indicates that there is a leakage of CSF and
should be reported to the physician
immediately.
14. Answer: B. The vitamin that was
ingested contains iron.
Iron is a toxic substance that can lead to
massive hemorrhage, shock, coma,
and kidney failure.
 Options A, C, and D: These
information needs further
investigation but will not change
the immediate diagnostic testing or
treatment plan.
15. Answer: C. 5,1,3,2,4
The client with a pulsating mass has an
abdominal aneurysm that may rupture and
he may decompensate easily. The woman
with lower left quadrant pain is at risk for a
life-threatening ectopic pregnancy. The 15-
year-old boy needs evaluation to rule
out appendicitis. The woman with vomiting
needs evaluation for gallbladder problems,
which appear to be worsening. Lastly, the
woman with mid epigastric pain is suffering
from an ulcer, but follow-up diagnostic
testing can be scheduled with a primary care
provider.
16. Answer: C. A homeless person who
is a poor historian; has altered mental
status, poor muscle coordination, and
hot, dry ashen skin; and whose duration
of heat exposure is unknown.
the management but should not
delay the immediate treatment.
19. Answer: D. Arranging transportation
to a safe house.

The signs and symptoms manifested by the Safety is a priority for this client and she
homeless person indicate that a should not return to a place where violence
heat stroke is happening, a medical could recur.
emergency, which can lead to brain damage.
 Options A, B, and C: These are
 Option A: The homemaker is important for the long-term
experiencing heat exhaustion, management of this case.
which can be managed by fluids
and cooling measures. 20. Answer: C. Being aware of the
 Option B: The elderly client is at agency’s emergency response plan.
risk for heat syncope and should be
advised to rest in a cool area and
In disasters preparedness, the nurse should
avoid similar situations.
know the emergency response plan. This
 Option D: The runner is
gives guidance that includes the roles of the
experiencing heat cramps, which
team members, responsibilities and
can be managed with fluid and rest.
mechanism of reporting.
17. Answer: D. Have the client breathe
into a brown paper bag.

The client is suffering from hyperventilation

secondary from anxiety, the initial action is
to let the client breathe in a paper bag that
will allow the rebreathing of carbon dioxide.

18. Answer: A. Administer IV fluid

incorporated with Vitamin B1 as
ordered.

The client has symptoms of alcohol abuse

and there is a risk for Wernicke syndrome,
which is caused by a deficiency in Vitamin B.

 Option B: Multiple drug abuse is not

uncommon; however, there is
currently nothing to suggest an
opiate overdose that requires the
administration of naloxone.
 Options C and D: Additional
information or the results of
the blood alcohol testing are part of
QUIZ 2
1. Michael works as a triage nurse, and
four clients arrive at the emergency
department at the same time. List the
order in which he will assess these
clients from first to last.
 1. A 50-year-old female with
moderate abdominal pain and
occasional vomiting.
 2. A 35-year-old jogger with a
twisted ankle, having a pedal pulse
and no deformity.
 3. An ambulatory dazed 25-year-
old male with a bandaged head
wound.
 4. An irritable infant with a fever,
petechiae, and nuchal rigidity.
A. 1, 2, 3, 4
B. 2, 1, 3, 4
C. 4, 3, 1, 2
D. 3, 4, 2, 1
2. In conducting a primary survey on a
trauma patient, which of the following is
considered one of the priority elements
of the primary survey?
A. Initiation of pulse oximetry.
B. Complete set of vital signs.
C. Client’s allergy history.
D. Brief neurologic assessment.
3. A 65-year-old patient arrived at the
triage area with complaints of
diaphoresis, dizziness, and left-sided
chest pain. This patient should be
prioritized into which category?
A. Non-urgent.
B. Urgent.
C. Emergent.
D. High urgent.
4. You respond to a call for help from
the ED waiting room. There is an elderly
patient lying on the floor. List the order
for the actions that you must perform.
 1. Call for help and activate the
code team.
 2. Instruct a nursing assistant to
get the emergency cart.
 3. Initiate cardiopulmonary
resuscitation (CPR).
 4. Perform the chin lift or jaw
thrust maneuver.
 5. Establish unresponsiveness.
A. 5, 2, 4, 3, 1
B. 1, 5, 2, 4, 3
C. 1, 2, 5, 4, 3
D. 5, 1, 4, 3, 2
5. In caring for a victim of sexual
assault, which task is most appropriate
for an LPN/LVN?
A. Provide emotional support and supportive
communication.
B. Assess immediate emotional state and
physical injuries.
C. Ensure that the “chain of custody” is
maintained.
D. Collect hair samples, saliva swabs, and
scrapings beneath fingernails.
6. You are caring for a client with a
frostbite on the feet. Place the following
interventions in the correct order.
 1. Immerse the feet in warm water
100° F to 105° F (40.6º C to 46.1°
C).
 2. Remove the victim from the cold
environment.
 3. Monitor for signs of compartment
syndrome.
 4. Apply a loose, sterile, bulky
dressing.
 5. Administer a pain medication.
A. 5, 2, 1, 3, 4
B. 2, 5, 1, 4, 3
C. 2, 1, 5, 3, 4
D. 3, 2, 1, 4, 5
7. Following an emergency endotracheal
intubation, nurses must verify tube
placement and secure the tube. List in
order the steps that are required to
perform this function?
 1. Obtain an order for a chest x-ray
to document tube placement.
 2. Confirm that the breath sounds
are equal and bilateral.
 3. Auscultate the chest during
assisted ventilation.
 4. Secure the tube in place.
A. 1, 2, 3, 4
B. 4, 3, 2, 1
C. 3, 2, 4, 1
D. 4, 1, 2, 3
8. A 15-year-old male client arrives at
the emergency department. He is
conscious, coherent and ambulatory,
but his shirt and pants are covered
with blood. He and his hysterical friends
are yelling and trying to explain that
they were goofing around and he got
poked in the abdomen with a stick.
Which of the following comments should
be given first consideration?
A. “He’s a diabetic, so he needs attention
right away.”
B. “There was a lot of blood and we used
three bandages.”
C. “The stick was really dirty and covered
with mud.”
D. “He pulled the stick out, just now,
because it was hurting him.”
9. A prisoner, with a known history of
alcohol abuse, has been in police
custody for 48 hours. Initially, anxiety,
sweating, and tremors were noted.
Now, disorientation, hallucination, and
hyper-reactivity are observed. The
medical diagnosis is delirium tremens.
What is the priority nursing diagnosis?
A. Risk for Situational Low Self-esteem
related to police custody.
B. Risk for Nutritional Deficit related to
chronic alcohol abuse.
C. Risk for Injury related to seizures.
D. Risk for Other-Directed Violence related to
hallucinations.
10. In relation to submersion injuries,
which task is most appropriate to
delegate to an LPN/LVN?
A. Talk to a community group about water
safety issues.
B. Stabilize the cervical spine for an
unconscious drowning victim.
C. Remove wet clothing and cover the victim
with a warm blanket.
D. Monitor an asymptomatic near-drowning
victim.
11. You are assessing a patient who has
sustained a cat bite to the left hand. The
cat is up-to-date immunizations. The
date of the patient’s last tetanus shot is
unknown. Which of the following is the
priority nursing diagnosis?
A. Risk for Impaired Mobility related to
potential tendon damage.
B. Risk for Infection related to organisms
specific to cat bites.
C. Ineffective Health Maintenance related to
immunization status.
D. Impaired Skin Integrity related to
puncture wounds.
12. A client in a one-car rollover
presents with multiple injuries.
Prioritize the interventions that must be
initiated for this patient.
 1. Assess for spontaneous
respirations.
 2. Give supplemental oxygen per
mask.
 3. Insert a Foley catheter if not
contraindicated.
 4. Obtain a full set of vital signs.
 5. Remove patient’s clothing.
 6. Secure/start two large-bore IVs
with normal saline.
 7. Use the chin lift or jaw thrust
method to open the airway.
A. 1, 7, 2, 6, 4, 5, 3
B. 7, 1, 4, 2, 3, 5, 6
C. 4, 1, 5, 7, 6, 3, 2
D. 5, 4, 1, 7, 2, 6, 3
13. A 36-year-old patient with a history
of seizures and medication compliance
of phenytoin (Dilantin)
and carbamazepine (Tegretol) is
brought to the ED by the MS personnel
for repetitive seizure activity that
started 45 minutes prior to arrival. You
anticipate that the physician will order
which drug for status epilepticus?
A. Lorazepam (Ativan) IV.
B. Magnesium sulfate IV.
C. Carbamazepine (Tegretol) IV.
D. Phenytoin and Carbamazepine PO.
14. A client arrived at the emergency
department after suffering multiple
physical injuries including a fractured
pelvis from a vehicular accident. Upon
assessment, the client is incoherent,
pale, and diaphoretic. With vital signs as
follows: temperature of 97°F (36.11°
C), blood pressure of 60/40 mm Hg,
heart rate of 143 beats/minute, and a
respiratory rate of 30 breaths/minute.
The client is mostly suffering from
which of the following shock?
A. Cardiogenic.
B. Distributive.
C. Hypovolemic.
D. Obstructive.
15. Which of these is not classified as a
Category A biologic agent?
A. Staphylococcus enterotoxin B (SEB).
B. Clostridium botulinum toxin (botulism).
C. Bacillus anthracis (anthrax).
D. Francisella tularensis (tularemia).
16. A 15-year-old male client was sent
to the emergency unit following a small
laceration on the forehead. The client
says that he can’t move his legs. Upon
assessment, respiratory rate of 20,
strong pulses, and capillary refill time of
less than 2 seconds. Which triage
category would this client be assigned
to?
A. Black.
B. Green.
C. Red.
D. Yellow.
17. An ER nurse is handling a 50-year-
old woman complaining of dizziness and
palpitations that occur from time to
time. ECG confirms the diagnosis of
paroxysmal supraventricular
tachycardia. The client seems worried
about it. Which of the following is an
appropriate response of the nurse?
A. “You can be discharged now; this is a
probable sign of anxiety.”
B. “You have to stay here for a few hours to
undergo blood tests to rule out myocardial
infarction.”
C. “We’ll need to keep you for further
assessment; you may develop blood clots.”
D. “The physician will prescribe you blood-
thinning medications to lessen the episodes
of palpitations.”
18. A client was brought to the ED due
to an abdominal trauma caused by a
motorcycle accident. During the
assessment, the client complains of
epigastric pain and back pain. Which of
the following is true regarding the
diagnosis of pancreatic injury?
A. Redness and bruising may indicate the
site of the injury in blunt trauma.
B. The client is symptom-free during the
early post-injury period.
C. Signs of peritoneal irritation may indicate
pancreatic injury.
D. All of the above.
19. A 20-year-old male client was
brought to the emergency department
with a gunshot wound to the chest. In
obtaining a history of the incident to
determine possible injuries, the nurse
should ask which of the following?

A. “What was the initial first aid done?”

B. “Where did the incident happen?”
C. “What direction did the bullet enter into
the body?”
D. “How long ago did the incident occur?”

20. When attending a client with a head

and neck trauma following a vehicular
accident, the nurse’s initial action is to?

A. Do oral and nasal suctioning.

B. Provide oxygen therapy.
C. Initiate intravenous access.
D. Immobilize the cervical area.
Answers and Rationale
Below are the answers and rationale for the
questions above. If you think the answers
are wrong, please comment below.
1. Answer: C. 4, 3, 1, 2
An irritable infant with fever and petechiae
should be further assessed for other
meningeal signs. The patient with the head
wound needs additional history and
assessment for intracranial pressure. The
patient with moderate abdominal pain is
uncomfortable, but not unstable at this
point. For the ankle injury, a medical
evaluation can be delayed 24 – 48 hours if
necessary.
2. Answer: D. Brief neurologic
assessment.
A brief neurologic assessment to determine
the level of consciousness and pupil reaction
is part of the primary survey. Vital signs,
client’s allergy, and initiation of pulse
oximetry are considered part of the
secondary survey.
3. Answer: C. Emergent.
Chest pain is considered an emergent
priority, which is defined as potentially life-
threatening.
 Option B: Clients with urgent
priority need treatment within 2
hours of triage
(e.g. kidney stones).
 Option A: Non-urgent conditions
can wait for hours or even days.
 Option D: High urgent is not
commonly used; however, in 5-tier
triage systems, High urgent
patients fall between emergent and
urgent in terms of the time elapsing
prior to treatment.
4. Answer: D. 5, 1, 4, 3, 2
Establish unresponsiveness first. (The
patient may have fallen and sustained a
minor injury.) If the patient is unresponsive,
get help and have someone initiate the code.
Performing the chin lift or jaw thrust
maneuver opens the airway. The nurse is
then responsible for starting CPR. CPR
should not be interrupted until the patient
recovers or it is determined that heroic
efforts have been exhausted. A crash cart
should be at the site when the code team
arrives; however, basic CPR can be
effectively performed until the team arrives.
5. Answer: A. Provide emotional support
and supportive communication.
The LPN/LVN is able to listen and provide
emotional support for her patients.
 Options B, C, and D: The other
tasks are the responsibility of an
RN or, if available, a SANE (sexual
assault nurse examiner) who has
received training to assess, collect
and safeguard evidence, and care
for these victims.
6. Answer: B. 2, 5, 1, 4, 3
The victim should be removed from the cold
environment first, and then the rewarming
process can be initiated. It will be painful, so
give pain medication prior to immersing the
feet in a warmed water.
7. Answer: C. 3, 2, 4, 1
Auscultating and confirming equal bilateral
breath sounds should be performed in rapid
succession. If the sounds are not equal or if
the sounds are heard over the mid-epigastric
area, tube placement must be corrected
immediately. Securing the tube is
appropriate while waiting for the x-ray
study.
8. Answer: D. “He pulled the stick out,
just now, because it was hurting him.”
An impaled object may be providing a
tamponade effect, and removal can
precipitate sudden hemodynamic
decompensation. Additional history including
a more definitive description of the blood
loss, depth of penetration, and medical
history should be obtained. Other
information, such as the dirt on the stick or
history of diabetes, is important in the
overall treatment
 Options A and C: Other
information, such as the dirt on the
stick or history of diabetes, is
important in the overall treatment
plan, but can be addressed later.
9. Answer: C. Risk for Injury related to
seizures.
The client shows neurologic hyperactivity
and is on the verge of a seizure. Patient
safety is the priority. The patient needs
chlordiazepoxide (Librium) to decrease
neurologic irritability
and phenytoin (Dilantin) for seizures.
Thiamine and haloperidol(Haldol) will also be
ordered to address the other problems.
 Options A, B, and D: The other
diagnoses are pertinent but not as
immediate.
10. Answer: D. Monitor an
asymptomatic near-drowning victim.
The asymptomatic patient is currently stable
but should be observed for delayed
pulmonary edema, cerebral edema,
or pneumonia.
 Options A and B: Teaching and care
of critical patients are an RN
responsibility.
 Option C: Removing clothing can be
delegated to a nursing assistant.
11. Answer: B. Risk for Infection related
to organisms specific to cat bites.
Cat’s mouths contain a virulent organism,
Pasteurella multocida, that can lead to
septic arthritis or bacteremia.
 Options A and D: There is also a
risk for tendon damage due to deep
puncture wounds. These wounds
are usually not sutured.
 Option C: A tetanus shot can be
given before discharge.
12. Answer: A. 1, 7, 2, 6, 4, 5, 3
For multiple trauma victims, a lot of
interventions will occur simultaneously as
team members assist in the resuscitation.
Methods to open the airway such as the chin
lift or jaw thrust can be used simultaneously
while assessing for spontaneous respirations.
However, airway and oxygenation are a
priority. Starting IVs for fluid resuscitation is
part of supporting circulation. (EMS will
usually establish at least one IV in the field.)
Nursing assistants can be directed to take
vitals and remove clothing. Foley catheter is
necessary to closely monitor output.
13. Answer: A. Lorazepam (Ativan) IV.
IV Lorazepam (Ativan) is the drug of choice
for status epilepticus.
 Option B: Magnesium sulfate is
given to control seizures in toxemia
of pregnancy.
 Option C: Tegretol is used in the
management of generalized tonic-
clonic, absence or mixed type
seizures, but it does not come in an
IV form.
 Option D: PO (per os) medications
are inappropriate for this
emergency situation.
14. Answer: C. Hypovolemic. 18. Answer: D. All of the above

Hypovolemic shock occurs when the volume
of the circulatory system is too depleted to
allow adequate circulation to the tissues of
the body. A fractured pelvis will lose about
one liter of blood hence symptoms such
as hypotension, tachycardia, and tachypnea
will occur.
 Option A: Causes
of cardiogenic include
massive myocardial infarction or
other cause of primary cardiac
(pump) failure.
 Option B: Distributive shock results
from a relative inadequate
intravascular volume caused by
arterial or venous vasodilation.
 Option D: Obstructive shock is a
form of shock associated with
physical obstruction of the major
vessels or the heart itself.
Blunt injury resulting from vehicular
accidents could cause pancreatic injury.
Redness, bruising in the flank and severe
peritoneal irritation are signs of a pancreatic
injury. The client is usually pain-free during
the early post-injury period, hence a
comprehensive assessment and monitoring
should be done.
19. Answer: C. “What direction did the
bullet enter into the body?”
The entry point and direction of the bullet
will predict the involve injuries of the client.
 Options A, B, and D: The other
information is not as useful in
determining which diagnostic
studies and care are needed
immediately.

15. Answer: A. Staphylococcus 20. Answer: D. Immobilize the cervical

enterotoxin B (SEB). area.

Staphylococcus enterotoxin B (SEB) belongs Clients with suspected or possible cervical

to the category B priority pathogen. spine injury must have their neck
immobilized until formal assessment occurs.
16. Answer: D. Yellow.
 Options A, B, and C: Suctioning,
oxygen therapy, and intravenous
The client is possibly suffering from a spinal
access are also done after the
injury but otherwise, has a stable status and
cervical spine is immobilize.
can communicate so the appropriate tag is
YELLOW.

17. Answer: C. “You have to stay to

undergo an electrophysiology study as
per doctor’s advice.”

Paroxysmal supraventricular tachycardia

(PSVT) is characterized by episodes of rapid
heart rate that occurs periodically and stops
on its own. PSVT decreases the cardiac
output and can result to a thrombus. These
clots could turn into an embolus, which could
eventually lead to a stroke.
 trauma, septic shock, impaired cardiac function and
dehydration.
The client’s serum potassium level is elevated in acute
renal failure, and the nurse administers sodium QUESTION
polystyrene sulfonate (Kayexalate). This drug acts to
Which of the following abnormal blood values would not be
a. Increase potassium excretion from the colon. improved by dialysis treatment?

b. Release hydrogen ions for sodium ions a. Elevated serum creatinine

c. Increase calcium absorption for potassium ions in the b. Hyperkalemia

colon.
ANSWER c. Decreased hemoglobin

A. Increased potassium excretion from the colon d. Hypernatremia

ANSWER
Kayexalate – cation exchange resin, excrete potassium
through GI tract. In the colon, the sodium of the resin is C. Decreased Hemoglobin
replaced by the potassium
Erythropoeitin stimulation is absent in clients with ARF and is
QUESTION corrected only with weekly administration of the medication
via subcutaneous route.
In the oliguric phase of acute renal failure, the nurse should QUESTION
anticipate the development of which of the following
complications? What is the primary disadvantage of using peritoneal dialysis
for long term management of chronic renal failure?
a. Pulmonary edema
a. The danger of hemorrhage is high
b. Metabolic alkalosis
b. It cannot correct severe imbalances.
c. Hypotension
c. It is a time-consuming method of treatment.
d. Hypokalemia
ANSWER
d. The risk of contracting hepatitis is high.
ANSWER
A. PULMONARY EDEMA.
C. It is a time-consuming method of treatment.
Pulmonary edema can develop during the oliguric phase of
acute renal failure because of decreased urinary output and Dwelling time usually consumes around 8-16-24 hours and
fluid retention. might impede the client to do activities of daily living.
QUESTION

A client developed shock after a severe myocardial infarction

and has now developed renal failure. The client’s family asks
the nurse why the client has developed acute renal failure. The
nurse should base the response on the knowledge that there
was

a. A decrease in the blood flow through kidneys.

b. An obstruction of urine flow from the kidneys.

c. A blood clot formed in the kidneys.

d. Structural damage to the kidney resulting in acute tubular

necrosis.
ANSWER

A. A decrease in the blood flow through the kidneys.

Pre-renal – occur outside of the kidney includes poor

perfusion and decrease in circulating volume resulting from