Nur 235 Test 2 UPDATED ACTUAL Questions and CORRECT Answers
1. A client arrives with severe respiratory distress and a. ESI-1 is reserved for patients
absent pulses. According to the Emergency Severity in imminent danger of dying,
Index (ESI), what is the triage category? requiring immediate life-sav-
a. ESI-1 ing intervention.
b. ESI-2
c. ESI-3
d. ESI-4
2. During a disaster drill, a patient with GCS of 5 and d. A GCS of 5 indicates severe
no response to pain should be placed in which brain injury with minimal sur-
triage category? vival chance; in mass casualty
a. Green triage, this is "expectant/black
b. Yellow tag"
c. Red
d. Black
3. Which if the following patients should be classified b. ESI-2 identifies patients at
as ESI-2? high risk who should not wait
a. A stable patient with ankle sprain (e.g., chest pain with ACS
b. A patient with chest pain and diaphoresis symptoms)
c. A patient requesting a work note
d. A child with a scraped knee
4. The primary survey in emergency care follows a. The primary survey uses
which sequence? ABCDEFG: Airway, Breathing,
a. A-B-C-D-E-F-G Circulation, Disability, Expo-
b. A-I-M sure, Full set of vitals, Get re-
c. H-I-J suscitation adjuncts
d. PQRST
5. Which step belongs to the secondary survey?
a. Establishing airway
, b. Checking exposure c. Secondary survey (HIJ) fo-
c. History and head-to-toe exam cuses on history, head-to-toe
d. Providing oxygen assessment, and interventions
6. A runner collapses after intense exercise in the b. Heat exhaustion presents
heat. He is pale, diaphoretic, tachycardic, and nau- with prolonged exposure, pro-
seous. What condition is most likely? fuse sweating, tachycardia, and
a. Heat cramps mild confusion
b. Heat exhaustion
c. Heatstroke
d. Hypothermia
7. Which intervention is the priority for a patient with a. Heatstroke requires rapid
heatstroke? cooling to prevent cerebral
a. Apply ice packs to the axilla and groin edema and death
b. Encourage oral hydration
c. Place patient in Trendelenburg position
d. Provide warm blankets
8. True or False: Patients with heat cramps should re- False. They should avoid the
turn to the same activity within 1 hour if symptoms activity for at least 12 hours.
resolve.
9. A patient with heatstroke begins shivering during c. Shivering increases core
immersion cooling. Which intervention is best? temperature; benzodiazepines
a. Continue cooling without changes may be used to suppress it
b. Administer IV dantolene
c. Administer IV benzodiazepines as ordered
d. Cover the patient with heavy blankets
10. Which lab result is most concerning in heatstroke? c. Rhabdomyolysis from mus-
a. Sodium 140 mEq/L cle breakdown can cause renal
b. Creatinine 1.0 mg/dL failure
, c. CK elevated
d. Hemoglobin 13 g/dL
11. A hiker presents with pale, waxy fingertips that feel b. Superficial frostbite
crunchy. What is this?
a. Deep frostbite
b. Superficial frostbite
c. Mild hypothermia
d. Gangrene
12. Which action is contraindicated for frostbite? c. Massage the attected area
a. Immerse in warm water 99-102 degrees F
b. Remove jewelry
c. Massage the affected area
d. Apply sterile dressing
13. Select all that apply: Deep frostbite care includes: a, b, c, d
a. Elevating extremity after rewarming
b. Administering IV analgesia
c. Tetanus prophylaxis
d. Possible amputation
e. Vigorous massage of tissue
14. Which temperature defines hypothermia? b. <95
a. <98.6
b. <95
c. <90
d. <100
15. A hypothermic patient has core temp 85 degrees F, b. Moderate
rigidity, and bradycardia. What stage is this?
a. Mild
b. Moderate
1. A client arrives with severe respiratory distress and a. ESI-1 is reserved for patients
absent pulses. According to the Emergency Severity in imminent danger of dying,
Index (ESI), what is the triage category? requiring immediate life-sav-
a. ESI-1 ing intervention.
b. ESI-2
c. ESI-3
d. ESI-4
2. During a disaster drill, a patient with GCS of 5 and d. A GCS of 5 indicates severe
no response to pain should be placed in which brain injury with minimal sur-
triage category? vival chance; in mass casualty
a. Green triage, this is "expectant/black
b. Yellow tag"
c. Red
d. Black
3. Which if the following patients should be classified b. ESI-2 identifies patients at
as ESI-2? high risk who should not wait
a. A stable patient with ankle sprain (e.g., chest pain with ACS
b. A patient with chest pain and diaphoresis symptoms)
c. A patient requesting a work note
d. A child with a scraped knee
4. The primary survey in emergency care follows a. The primary survey uses
which sequence? ABCDEFG: Airway, Breathing,
a. A-B-C-D-E-F-G Circulation, Disability, Expo-
b. A-I-M sure, Full set of vitals, Get re-
c. H-I-J suscitation adjuncts
d. PQRST
5. Which step belongs to the secondary survey?
a. Establishing airway
, b. Checking exposure c. Secondary survey (HIJ) fo-
c. History and head-to-toe exam cuses on history, head-to-toe
d. Providing oxygen assessment, and interventions
6. A runner collapses after intense exercise in the b. Heat exhaustion presents
heat. He is pale, diaphoretic, tachycardic, and nau- with prolonged exposure, pro-
seous. What condition is most likely? fuse sweating, tachycardia, and
a. Heat cramps mild confusion
b. Heat exhaustion
c. Heatstroke
d. Hypothermia
7. Which intervention is the priority for a patient with a. Heatstroke requires rapid
heatstroke? cooling to prevent cerebral
a. Apply ice packs to the axilla and groin edema and death
b. Encourage oral hydration
c. Place patient in Trendelenburg position
d. Provide warm blankets
8. True or False: Patients with heat cramps should re- False. They should avoid the
turn to the same activity within 1 hour if symptoms activity for at least 12 hours.
resolve.
9. A patient with heatstroke begins shivering during c. Shivering increases core
immersion cooling. Which intervention is best? temperature; benzodiazepines
a. Continue cooling without changes may be used to suppress it
b. Administer IV dantolene
c. Administer IV benzodiazepines as ordered
d. Cover the patient with heavy blankets
10. Which lab result is most concerning in heatstroke? c. Rhabdomyolysis from mus-
a. Sodium 140 mEq/L cle breakdown can cause renal
b. Creatinine 1.0 mg/dL failure
, c. CK elevated
d. Hemoglobin 13 g/dL
11. A hiker presents with pale, waxy fingertips that feel b. Superficial frostbite
crunchy. What is this?
a. Deep frostbite
b. Superficial frostbite
c. Mild hypothermia
d. Gangrene
12. Which action is contraindicated for frostbite? c. Massage the attected area
a. Immerse in warm water 99-102 degrees F
b. Remove jewelry
c. Massage the affected area
d. Apply sterile dressing
13. Select all that apply: Deep frostbite care includes: a, b, c, d
a. Elevating extremity after rewarming
b. Administering IV analgesia
c. Tetanus prophylaxis
d. Possible amputation
e. Vigorous massage of tissue
14. Which temperature defines hypothermia? b. <95
a. <98.6
b. <95
c. <90
d. <100
15. A hypothermic patient has core temp 85 degrees F, b. Moderate
rigidity, and bradycardia. What stage is this?
a. Mild
b. Moderate
