Correct Answers
A 4-year-old is brought to Emergency by his parents, who report he
swallowed a small toy. What symptom suggests complete airway
obstruction by a foreign body?
A. Gagging
B. Coughing
C. Inability to speak
D. Rapid respirations - 🧠 ANSWER ✔✔C. Inability to speak
The adult client is newly admitted to the ward following surgery. Which
assessment finding should be the RN's priority?
A.The surgical site dressing has a scant amount of bright red blood.
,B.The client is sleeping but easily arouses when touched.
C.The client's respirations are 6 to 8 breaths per minute.
D.The client's blood pressure is 100/68 mm Hg. - 🧠 ANSWER ✔✔C. The
client's respirations are 6 to 8 breaths per minute.
The nurse is caring for a client who had a total hip replacement four days
ago. Which assessment requires the nurse's immediate attention?
A."I have bad pain in my lower leg"
B."I just can't 'catch my breath"
C. "I have to use the bedpan to pee at least every hour."
D. "The pain medication is not working today." - 🧠 ANSWER ✔✔B. "I just
can't 'catch my breath"
There has been a train derailment and four people are injured. Which
patient should the RN see first?
A.Client who is 20 years of age who has unequal pupils and is tachypneic
B.Client who is 80 years old complaining of a "racing heart" and has a
laceration on his arm
C.Client who is 10 years old with a swollen wrist
,D.Client who is 25 years old with an open chest wall wound - 🧠 ANSWER
✔✔D. Client who is 25 years old with an open chest wall wound
Because of open-chest wall wound = at risk for pneumothorax or
hemothorax = life-threatening.
The client just returned to the nursing unit following surgery. Which
observation by the RN requires the most immediate intervention?
A. The client is sleepy
B. The client coughed up blood-tinged sputum
C. Oxygen saturation level is 82%
D. Jackson-Pratt wound drain is half full - 🧠 ANSWER ✔✔C. Oxygen
saturation level is 82%
At 0730 hours, the oncoming RN is planning care for four clients. Which
client should the RN plan to assess first?
A.The 23-year-old client with cystic fibrosis who has pulmonary function
tests scheduled in ten minutes
B.The 35-year-old client admitted the previous day with bacterial
pneumonia and now has a temperature of 39.4oC
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, C.The 46-year-old client who had a chest tube removed an hour ago and
now has dyspnea
D.The 77-year-old client with tuberculosis who has four anti-tubercular
medications due at 08:00 hours - 🧠 ANSWER ✔✔C. The 46-year-old client
who had a chest tube removed an hour ago and now has dyspnea
What is the purpose of the ABCDE approach? - 🧠 ANSWER ✔✔To provide
life-saving treatment
To break down complex clinical situations into more manageable parts
To serve as an assessment and treatment algorithm
To establish common situational awareness among all treatment providers
To buy time to establish a final diagnosis and treatment (identifies priority
needs and guides nursing practice)
Can be initiated without any equipment and more advanced interventions
can be applied on arrival of emergency medical services, in a clinic, or at
the hospital.
Assessments should be repeated until the patient is stable, regularly,
and/or at any sign of deterioration.