NS 2 QUIZ CHN & EDN
1. During the primary assessment of a victim of a motor vehicle collision, the nurse determines that
the patient has an unobstructed airway. Which action should the nurse take next?
A. Palpate extremities for bilateral pulses.
B. Observe the patient's respiratory effort.
C. Check the patient's level of consciousness.
D. Examine the patient for any external bleeding.
ANSWER B. Even with a patent airway, patients can have other problems that compromise
ventilation, so the next action is to assess the patient's breathing. The other actions are also part of
the initial survey but assessment of breathing should be done immediately after assessing for airway
patency.
2. During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's
left pedal and posterior tibial pulses are absent and the entire leg is swollen. Which action will the
nurse take next?
A. Send blood to the lab for a complete blood count.
B. Assess further for a cause of the decreased circulation.
C. Finish the airway, breathing, circulation, disability survey.
D. Start normal saline fluid infusion with a large-bore IV line.
ANSWER D. The assessment data indicate that the patient may have arterial trauma and
hemorrhage. When a possibly life threatening injury is found during the primary survey, the nurse
should immediately start interventions before proceeding with the survey. Although a complete
blood count is indicated, administration of IV fluids should be started first. Completion of the
primary survey and further assessment should be completed after the IV fluids are initiated.
3. After the return of spontaneous circulation following the resuscitation of a patient who had a
cardiac arrest, therapeutic hypothermia is ordered. Which action will the nurse include in the plan of
care?
A. Initiate cooling per protocol.
B. Avoid the use of sedative drugs.
C. Check mental status every 15 minutes.
D. Rewarm if temperature is below 91° F (32.8°C).
ANSWER A- When therapeutic hypothermia is used post resuscitation, external cooling devices or
cold normal saline infusions are used to rapidly lower body temperature to 89.6° F to 93.2° F (32° C
to 34° C). Because hypothermia will decrease brain activity, assessing mental status every 15
minutes is not done at this stage. Sedative drugs are given during therapeutic hypothermia.
,4. When assessing an older patient admitted to the emergency department (ED) with a broken arm
and facial bruises, the nurse observes several additional bruises in various stages of healing. Which
statement or question by the nurse should be first?
A. "You should not go home."
B. "Do you feel safe at home?"
C. "Would you like to see a social worker?"
D. "I need to report my concerns to the police."
ANSWER B- The nurse's initial response should be to further assess the patient's situation. Telling
the patient not to return home may be an option once further assessment is done. A social worker
or police report may be appropriate once further assessment is completed.
5. A patient arrives in the emergency department (ED) several hours after taking "25 to 30"
acetaminophen (Tylenol) tablets. Which action will the nurse plan to take?
A. Give N-acetylcysteine.
B. Discuss the use of chelation therapy.
C. Start oxygen using a non-rebreather mask.
D. Have the patient drink large amounts of water.
ANSWER A- N-acetylcysteine is the recommended treatment to prevent liver damage after
acetaminophen overdose. The other actions might be used for other types of poisoning, but they
will not be appropriate for a patient with acetaminophen poisoning.
6. The following interventions are part of the emergency department (ED) protocol for a patient who
has been admitted with multiple bee stings to the hands. Which action should the nurse take first?
A. Remove the patient's rings.
B. Apply ice packs to both hands.
C. Apply calamine lotion to itching areas.
D. Give diphenhydramine (Benadryl) 50 mg PO.
ANSWER A- The patient's rings should be removed first because it might not be possible to remove
them if swelling develops. The other orders should also be implemented as rapidly as possible after
the nurse has removed the jewelry.
7. A patient who sustains a severe pulmonary contusion as a result of a motor vehicle crash should be
expected to have
A. steady, substernal pain and no radiographic changes.
B. hypotension and muffled breath sounds.
C. local areas of wheezing and radiographic changes.
, D. neck vein distention and diminished breath sounds on the affected side.
ANSWER C. local areas of wheezing and radiographic changes. - In a pulmonary contusion, blood
extravasates into the lung tissue, causing alveolar and interstitial edema. This may cause localized
wheezing and may be evident on radiograph, though usually 12 or more hours after the event.
8. A tearful parent brings a child to the ED for taking an unknown amount of children's chewable
vitamins at an unknown time. The child is currently alert and asymptomatic. What information
should be immediately reported to the physician?
A. The ingested children's chewable vitamins contain iron.
B. The child has been treated several times for ingestion of toxic substances.
C. The child has been treated several times for accidental injuries.
D. The child was nauseated and vomited once at home
ANSWER A- Iron is a toxic substance that can lead to massive hemorrhage, coma, shock, and hepatic
failure. Deferoxamine is an antidote that can be used for severe cases of iron poisoning. Other
information needs additional investigation, but will not change the immediate diagnostic testing or
treatment plan.
9. A teenager arrives by private car. He is alert and ambulatory, but this shirt and pants are covered
with blood. He and his hysterical friends are yelling and trying to explain that 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. "There was a lot of blood and we used three bandages."
B. "He pulled the stick out, just now, because it was hurting him."
C. "The stick was really dirty and covered with mud."
D. "He's a diabetic, so he needs attention right away."
ANSWER B- 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 plan, but can
be addressed later.
10. A triage nurse in a busy emergency department assesses a patient who complains of 6/10
abdominal pain and states, "I had a temperature of 104.6º F (40.3º C) at home." The nurse's first
action should be to
a. tell the patient that it may be several hours before being seen by the doctor.
b. assess the patient's current vital signs.
c. obtain a clean-catch urine for urinalysis.
d. ask the health care provider to order a nonopioid analgesic medication for the patient.
ANSWER B Rationale: The patient's pain and statement about an elevated temperature indicate that
the nurse should obtain vital signs before deciding how rapidly the patient should be seen by the
health care provider. A urinalysis may be needed, but vital signs will provide the nurse with more
1. During the primary assessment of a victim of a motor vehicle collision, the nurse determines that
the patient has an unobstructed airway. Which action should the nurse take next?
A. Palpate extremities for bilateral pulses.
B. Observe the patient's respiratory effort.
C. Check the patient's level of consciousness.
D. Examine the patient for any external bleeding.
ANSWER B. Even with a patent airway, patients can have other problems that compromise
ventilation, so the next action is to assess the patient's breathing. The other actions are also part of
the initial survey but assessment of breathing should be done immediately after assessing for airway
patency.
2. During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's
left pedal and posterior tibial pulses are absent and the entire leg is swollen. Which action will the
nurse take next?
A. Send blood to the lab for a complete blood count.
B. Assess further for a cause of the decreased circulation.
C. Finish the airway, breathing, circulation, disability survey.
D. Start normal saline fluid infusion with a large-bore IV line.
ANSWER D. The assessment data indicate that the patient may have arterial trauma and
hemorrhage. When a possibly life threatening injury is found during the primary survey, the nurse
should immediately start interventions before proceeding with the survey. Although a complete
blood count is indicated, administration of IV fluids should be started first. Completion of the
primary survey and further assessment should be completed after the IV fluids are initiated.
3. After the return of spontaneous circulation following the resuscitation of a patient who had a
cardiac arrest, therapeutic hypothermia is ordered. Which action will the nurse include in the plan of
care?
A. Initiate cooling per protocol.
B. Avoid the use of sedative drugs.
C. Check mental status every 15 minutes.
D. Rewarm if temperature is below 91° F (32.8°C).
ANSWER A- When therapeutic hypothermia is used post resuscitation, external cooling devices or
cold normal saline infusions are used to rapidly lower body temperature to 89.6° F to 93.2° F (32° C
to 34° C). Because hypothermia will decrease brain activity, assessing mental status every 15
minutes is not done at this stage. Sedative drugs are given during therapeutic hypothermia.
,4. When assessing an older patient admitted to the emergency department (ED) with a broken arm
and facial bruises, the nurse observes several additional bruises in various stages of healing. Which
statement or question by the nurse should be first?
A. "You should not go home."
B. "Do you feel safe at home?"
C. "Would you like to see a social worker?"
D. "I need to report my concerns to the police."
ANSWER B- The nurse's initial response should be to further assess the patient's situation. Telling
the patient not to return home may be an option once further assessment is done. A social worker
or police report may be appropriate once further assessment is completed.
5. A patient arrives in the emergency department (ED) several hours after taking "25 to 30"
acetaminophen (Tylenol) tablets. Which action will the nurse plan to take?
A. Give N-acetylcysteine.
B. Discuss the use of chelation therapy.
C. Start oxygen using a non-rebreather mask.
D. Have the patient drink large amounts of water.
ANSWER A- N-acetylcysteine is the recommended treatment to prevent liver damage after
acetaminophen overdose. The other actions might be used for other types of poisoning, but they
will not be appropriate for a patient with acetaminophen poisoning.
6. The following interventions are part of the emergency department (ED) protocol for a patient who
has been admitted with multiple bee stings to the hands. Which action should the nurse take first?
A. Remove the patient's rings.
B. Apply ice packs to both hands.
C. Apply calamine lotion to itching areas.
D. Give diphenhydramine (Benadryl) 50 mg PO.
ANSWER A- The patient's rings should be removed first because it might not be possible to remove
them if swelling develops. The other orders should also be implemented as rapidly as possible after
the nurse has removed the jewelry.
7. A patient who sustains a severe pulmonary contusion as a result of a motor vehicle crash should be
expected to have
A. steady, substernal pain and no radiographic changes.
B. hypotension and muffled breath sounds.
C. local areas of wheezing and radiographic changes.
, D. neck vein distention and diminished breath sounds on the affected side.
ANSWER C. local areas of wheezing and radiographic changes. - In a pulmonary contusion, blood
extravasates into the lung tissue, causing alveolar and interstitial edema. This may cause localized
wheezing and may be evident on radiograph, though usually 12 or more hours after the event.
8. A tearful parent brings a child to the ED for taking an unknown amount of children's chewable
vitamins at an unknown time. The child is currently alert and asymptomatic. What information
should be immediately reported to the physician?
A. The ingested children's chewable vitamins contain iron.
B. The child has been treated several times for ingestion of toxic substances.
C. The child has been treated several times for accidental injuries.
D. The child was nauseated and vomited once at home
ANSWER A- Iron is a toxic substance that can lead to massive hemorrhage, coma, shock, and hepatic
failure. Deferoxamine is an antidote that can be used for severe cases of iron poisoning. Other
information needs additional investigation, but will not change the immediate diagnostic testing or
treatment plan.
9. A teenager arrives by private car. He is alert and ambulatory, but this shirt and pants are covered
with blood. He and his hysterical friends are yelling and trying to explain that 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. "There was a lot of blood and we used three bandages."
B. "He pulled the stick out, just now, because it was hurting him."
C. "The stick was really dirty and covered with mud."
D. "He's a diabetic, so he needs attention right away."
ANSWER B- 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 plan, but can
be addressed later.
10. A triage nurse in a busy emergency department assesses a patient who complains of 6/10
abdominal pain and states, "I had a temperature of 104.6º F (40.3º C) at home." The nurse's first
action should be to
a. tell the patient that it may be several hours before being seen by the doctor.
b. assess the patient's current vital signs.
c. obtain a clean-catch urine for urinalysis.
d. ask the health care provider to order a nonopioid analgesic medication for the patient.
ANSWER B Rationale: The patient's pain and statement about an elevated temperature indicate that
the nurse should obtain vital signs before deciding how rapidly the patient should be seen by the
health care provider. A urinalysis may be needed, but vital signs will provide the nurse with more
