h h h
180-QuestionhhwithhAnswersh&hRationales
Questionh1hofh180
H
Ahnursehishprovidinghanhin service
abouthclienthevacuationhduringhahfire.hWhichhofhthehfollowinghclientshshouldhthehnursehevacuateh
first?
A. Ahclienthwhohishambulatoryhandhreceivinghoxygen.
B. Ahclienthwhohuseshahwheelchairhandhishconfused.
C. Ahclienthwhohishbedriddenhandhwearshahhearinghaid.
D.hAhclienthwhohhashahfracturehandhishinhbalancehsuspensionhtraction.
CorrecthAnswerh&hRationale:
Answer:hD.hUsinghRACEhprinciples,hthehclienthinhbalancehsuspensionhtractionhcannothself-
evacuatehandhrequireshspecialhequipment.hTheyharehthehmosthdependenthandhhighesthpriorityhforhevacuationhplanning.h
Ambulatoryhclientshandhthosehwithhhearinghaidshcanhself-evacuatehwithhdirection.
,Question 2 of 180
Ahnursehinhanhemergencyhdepartmenthishassessinghahtoddlerhwhohaccidentallyhingestedhlead.hW
hichhofhthehfollowinghfindingshshouldhthehnursehexpect?
A.hCognitivehimpairment
B.hCoughing
C.hHemoptysis
D.hExcessivehdrooling
CorrecthAnswerh&hRationale:
Answer:hA.hLeadhpoisoninghprimarilyhaffectshthehcentralhnervoushsystem,hcausinghcognitivehimpairment,hdevelopmen
talhdelays,hlearninghdifficulties,handhbehavioralhchanges.hTheseharehthehhallmarkhneurologicalhmanifestationshofhpediat
richleadhtoxicity.
,Question 3 of 180
Ahnursehinhthehemergencyhdepartmenthishassessinghahclienthwhohhashstatushasthmaticus.hThehn
ursehshouldhexpecthwhichhofhthehfollowinghfindings?
A.hIncreasehinhpeakhexpiratoryhratehflow
B.hEpigastrichpain
C.hDistendedhneckhveins
D. Bradycardia
CorrecthAnswerh&hRationale:
Answer:hC.hStatushasthmaticushcauseshseverehairhtrappinghandhincreasedhintrathoracichpressure,hwhichhimpedeshve
noushreturnhandhresultshinhdistendedhneckhveins.hPeakhexpiratoryhflowhishdecreasedh(nothincreased).hTachycardia,hnoth
bradycardia,hishexpected.
, Question 4 of 180
Ahchargehnursehishassigninghclienthcarehtaskshforhthehupcominghshift.hWhichhofhthehfollowinghtas
kshshouldhthehchargehnursehassignhtohanhassistivehpersonnelh(AP)?
A. Performinghahthoracentesis
B. Insertinghanhendotrachealhtube
C.hObtaininghbloodhcultureshfromhahcentralhcatheter
D.hInsertinghanhepiduralhcatheter
CorrecthAnswerh&hRationale:
Answer:hC.hObtaininghbloodhcultureshfromhahcentralhcatheterhishwithinhthehscopehofhahtrainedhAPhunderhnursehsupervisi
on.hThoracentesis,hEThtubehinsertion,handhepiduralhcatheterhinsertionharehinvasivehprocedureshrequiringhadvancedhclini
calhskillshthathcannothbehdelegatedhtohanhAP.