ANSWERS|LATEST!!!!!2025/2026|GUARANTEED
An indwelling urinary catheter is ordered for a patient who has sustained a straddle injury to
his external genitalia. Before catheter insertion, the nurse should assess the patient for:
1. penile tenderness.
2. scrotal or penile swelling.
3. blood at the urinary meatus.
4. the ability to void spontaneously. - ANSWER 3. blood at the urinary meatus.
When assessing a trauma patient with blood at the urinary meatus, it is important to know
that this is a sign of a possible pelvic fracture and that a urinary drainage catheter insertion
is contraindicated. Penile tenderness and scrotal or penile swelling are expected complaints
after the described trauma, but alone they are not a contraindication for a urinary drainage
catheter insertion. The ability to void spontaneously is not an indication or contraindication
for the insertion of a urinary drainage catheter.
Trauma Nursing Core Course, 8th ed. 2020, pg. 154
Emergency Nursing Core Curriculum, 7th ed. 2018, pg. 520
The MOST beneficial action of morphine in the treatment of pulmonary edema is to:
1. decrease preload.
2. decrease cardiac reserve.
3. increase systemic vascular resistance.
1
,4. increase oxygen consumption. - ANSWER Morphine sulfate has several beneficial
effects in the patient experiencing pulmonary edema, particularly pulmonary edema due to
heart failure. Morphine reduces pain and anxiety but, most importantly, by increasing
venous capacitance (through vasodilation), less blood is delivered to the lungs.
Emergency Nursing Core Curriculum, 7th ed. 2018, pg. 171
Sheehy's Emergency Nursing: Principles and Practice, 7th ed. 2020, pg. 223
An elderly woman presents with vague complaints of abdominal pain. The patient states
that the people she lives with are stealing from her. The nurse should:
1. call the family to discuss the situation.
2. arrange for protective custody of the patient.
3. assess the patient for signs of neglect and maltreatment.
4. obtain consent for evaluation by social services. - ANSWER 3. assess the patient for
signs of neglect and maltreatment.
Maltreatment of the elderly cannot be assessed quickly or easily from a cluster of signs and
vague presenting symptoms. Keen awareness when performing the physical examination is
essential to identify elder abuse.
Emergency Nursing Core Curriculum, 7th ed. 2018, pg. 40-41
A patient who has a long-leg cast has pain out of proportion to the injury and decreased
sensation in the affected leg. Urinalysis reveals myoglobinemia. These findings MOST likely
indicate:
1. fat emboli.
2. nerve laceration.
2
,3. compartment syndrome.
4. deep vein thrombosis. - ANSWER 3. compartment syndrome.
Characteristic signs of compartment syndrome are pain out of proportion of the extent of
the injury and decreased sensation. Muscle damage due to compression/damage of the
muscle releases myoglobin, which will be evident in the urinalysis.
Trauma Nursing Core Course, 8th ed. 2020, pg. 196-198
A 14-year-old patient whose airway is obstructed is conscious and unable to speak. The
nurse should FIRST:
1. remove the obstruction with Magill forceps.
2. administer back blows.
3. administer abdominal thrusts.
4. encourage the patient to cough. - ANSWER 3. administer abdominal thrusts.
The American Heart Association recommends performing abdominal thrusts for a conscious
choking patient; this should generate enough pressure to force the foreign body out of the
trachea. Back blows are reserved for infant choking victims, and, without proper
visualization, the Magill forceps are likely to force the blockage deeper. If the patient is
obstructed, there will not be an effective cough.
Pediatric Advanced Life Support (2015), pg. 135
Chronic arterial insufficiency of the lower extremities is characterized by:
1. pitting edema.
2. bounding pedal pulses.
3.dilated tortuous veins.
3
, 4. intermittent claudication. - ANSWER 4. intermittent claudication.
Claudication is caused by poor tissue perfusion or ischemia due to gradual enlargement of
atheromatous plaques.
Emergency Nursing Core Curriculum, 7th ed. 2018, pg. 177-178
To assess pronator drift, the nurse should instruct the patient to:
1. "hold both arms straight out with your eyes closed."
2. "touch your finger to your nose, alternating your right and left hands."
3. "slide the left heel of your foot down your right shin."
4. "smile and show me your teeth." - ANSWER 1. "hold both arms straight out with
your eyes closed."
Pronator drift is an assessment parameter used to determine arm weakness potentially
caused by stroke. Both arms are held out straight while the nurse assesses for drift or the
patient's inability to hold one or both arms in place.
AACN Core Curriculum for High Acuity, Progressive and Critical Care Nursing, 7th ed. 2018,
pg. 348
A patient who has been in a motorcycle crash is awake, alert, and oriented, but complains of
severe neck pain. Shortly after arrival, the patient experiences respiratory arrest.
Appropriate INITIAL management of the airway should consist of
1. endotracheal intubation.
2. administration of oxygen by a nasal cannula.
3. jaw-thrust maneuver and ventilation with a bag-mask device.
4
An indwelling urinary catheter is ordered for a patient who has sustained a straddle injury to
his external genitalia. Before catheter insertion, the nurse should assess the patient for:
1. penile tenderness.
2. scrotal or penile swelling.
3. blood at the urinary meatus.
4. the ability to void spontaneously. - ANSWER 3. blood at the urinary meatus.
When assessing a trauma patient with blood at the urinary meatus, it is important to know
that this is a sign of a possible pelvic fracture and that a urinary drainage catheter insertion
is contraindicated. Penile tenderness and scrotal or penile swelling are expected complaints
after the described trauma, but alone they are not a contraindication for a urinary drainage
catheter insertion. The ability to void spontaneously is not an indication or contraindication
for the insertion of a urinary drainage catheter.
Trauma Nursing Core Course, 8th ed. 2020, pg. 154
Emergency Nursing Core Curriculum, 7th ed. 2018, pg. 520
The MOST beneficial action of morphine in the treatment of pulmonary edema is to:
1. decrease preload.
2. decrease cardiac reserve.
3. increase systemic vascular resistance.
1
,4. increase oxygen consumption. - ANSWER Morphine sulfate has several beneficial
effects in the patient experiencing pulmonary edema, particularly pulmonary edema due to
heart failure. Morphine reduces pain and anxiety but, most importantly, by increasing
venous capacitance (through vasodilation), less blood is delivered to the lungs.
Emergency Nursing Core Curriculum, 7th ed. 2018, pg. 171
Sheehy's Emergency Nursing: Principles and Practice, 7th ed. 2020, pg. 223
An elderly woman presents with vague complaints of abdominal pain. The patient states
that the people she lives with are stealing from her. The nurse should:
1. call the family to discuss the situation.
2. arrange for protective custody of the patient.
3. assess the patient for signs of neglect and maltreatment.
4. obtain consent for evaluation by social services. - ANSWER 3. assess the patient for
signs of neglect and maltreatment.
Maltreatment of the elderly cannot be assessed quickly or easily from a cluster of signs and
vague presenting symptoms. Keen awareness when performing the physical examination is
essential to identify elder abuse.
Emergency Nursing Core Curriculum, 7th ed. 2018, pg. 40-41
A patient who has a long-leg cast has pain out of proportion to the injury and decreased
sensation in the affected leg. Urinalysis reveals myoglobinemia. These findings MOST likely
indicate:
1. fat emboli.
2. nerve laceration.
2
,3. compartment syndrome.
4. deep vein thrombosis. - ANSWER 3. compartment syndrome.
Characteristic signs of compartment syndrome are pain out of proportion of the extent of
the injury and decreased sensation. Muscle damage due to compression/damage of the
muscle releases myoglobin, which will be evident in the urinalysis.
Trauma Nursing Core Course, 8th ed. 2020, pg. 196-198
A 14-year-old patient whose airway is obstructed is conscious and unable to speak. The
nurse should FIRST:
1. remove the obstruction with Magill forceps.
2. administer back blows.
3. administer abdominal thrusts.
4. encourage the patient to cough. - ANSWER 3. administer abdominal thrusts.
The American Heart Association recommends performing abdominal thrusts for a conscious
choking patient; this should generate enough pressure to force the foreign body out of the
trachea. Back blows are reserved for infant choking victims, and, without proper
visualization, the Magill forceps are likely to force the blockage deeper. If the patient is
obstructed, there will not be an effective cough.
Pediatric Advanced Life Support (2015), pg. 135
Chronic arterial insufficiency of the lower extremities is characterized by:
1. pitting edema.
2. bounding pedal pulses.
3.dilated tortuous veins.
3
, 4. intermittent claudication. - ANSWER 4. intermittent claudication.
Claudication is caused by poor tissue perfusion or ischemia due to gradual enlargement of
atheromatous plaques.
Emergency Nursing Core Curriculum, 7th ed. 2018, pg. 177-178
To assess pronator drift, the nurse should instruct the patient to:
1. "hold both arms straight out with your eyes closed."
2. "touch your finger to your nose, alternating your right and left hands."
3. "slide the left heel of your foot down your right shin."
4. "smile and show me your teeth." - ANSWER 1. "hold both arms straight out with
your eyes closed."
Pronator drift is an assessment parameter used to determine arm weakness potentially
caused by stroke. Both arms are held out straight while the nurse assesses for drift or the
patient's inability to hold one or both arms in place.
AACN Core Curriculum for High Acuity, Progressive and Critical Care Nursing, 7th ed. 2018,
pg. 348
A patient who has been in a motorcycle crash is awake, alert, and oriented, but complains of
severe neck pain. Shortly after arrival, the patient experiences respiratory arrest.
Appropriate INITIAL management of the airway should consist of
1. endotracheal intubation.
2. administration of oxygen by a nasal cannula.
3. jaw-thrust maneuver and ventilation with a bag-mask device.
4
