Emergency Nursing Practice 79 Questions with Verified Answers,100% CORRECT

Emergency Nursing Practice 79 Questions with Verified Answers The client diagnosed with hypovolemic shock has a BP of 100/60. Fifteen minutes later the BP is 88/64. How much narrowing of the client's pulse pressure has occurred between the two readings? - CORRECT ANSWER Answer: 16 mmHg pulse pressure The pulse pressure is the systolic BP minus the diastolic BP. 100 - 60 = 40 mmHg pulse pressure in first BP reading 88 - 64 = 24 mmHg pulse pressure in second reading 40 - 24 = 16 mmHg pulse pressure narrowing. A narrowing or decreased pulse pressure is an earlier indicator of shock than a decrease in systolic blood pressure. TEST-TAKING HINT: If the test taker is not aware of how to obtain a pulse pressure, the only numbers provided in the stem are systolic and diastolic blood pressures. The test taker should do something with the numbers. The client is admitted into the emergency department with diaphoresis, pale clammy skin, and BP of 90/70. Which intervention should the nurse implement first? 1. Start an IV with an 18-gauge catheter. 2. Administer intravenous dopamine infusion. 3. Obtain arterial blood gases (ABGs). 4. Insert an indwelling urinary catheter. - CORRECT ANSWER Answer: 1 1. There are many types of shock, but the one common intervention that should be done first in all types of shock is to establish an intravenous line with a large-bore catheter. The low blood pressure and cold, clammy skin indicate shock. 2. This blood pressure does not require dopamine; fluid resuscitation is first. 3. The client may need ABGs monitored, but this is not the first intervention. 4. An indwelling catheter may need to be inserted for accurate measurement of output, but it is not the first intervention. TEST-TAKING HINT: This question asks for the first intervention, which means all options may be appropriate interventions for the client, but only one should be implemented first. Remember: When the client is in distress, do not assess. The nurse is caring for a client diagnosed with septic shock. Which assessment data warrant immediate intervention by the nurse? 1. Vital signs T 100.4°F, P 104, R 26, and BP 102/60. 2. A white blood cell count of 18,000/mm^3. 3. Urinary output of 90 mL in the last 4 hours. 4. The client reports being thirsty. - CORRECT ANSWER Answer: 3 1. These vital signs are expected in a client diagnosed with septic shock. 2. An elevated WBC count indicates an infection, which is the definition of sepsis. 3. The client must have a urinary output of at least 30 mL/hr, so 90 mL in the last 4 hours indicates impaired renal perfusion, which is a sign of worsening shock. 4. The client being thirsty is not an uncommon issue for a client diagnosed with septic shock. This warrants immediate intervention. TEST-TAKING HINT: The words "warrant immediate intervention" mean the nurse must do something, which frequently can be notifying the HCP. Any client diagnosed with shock will have clinical manifestations requiring the nurse to intervene. In this question, the test taker must determine priority and which data require immediate intervention. The client diagnosed with septicemia has the following health-care provider (HCP) orders. Which HCP order has the highest priority? 1. Provide clear liquid diet. 2. Initiate IV antibiotic therapy. 3. Obtain a STAT chest x-ray. 4. Perform hourly glucometer checks. - CORRECT ANSWER Answer: 2 1. The client's diet is not a priority when transcribing orders. 2. An IV antibiotic is the priority medication for the client diagnosed with an infection, which is the definition of sepsis—a systemic bacterial infection of the blood. A new order for an IV antibiotic should be implemented within 1 hour of receiving the order. 3. Diagnostic tests are important but not priority over intervening in a potentially life-threatening situation such as septic shock. 4. There is no indication in the stem of the question that this client has diabetes, and glucose levels are not associated with clinical manifestations of septicemia. TEST-TAKING HINT: Remember, if the test taker can rule out two answers—options "1" and "4"—and cannot determine the right answer between options "2" and "3," select the option directly affecting or treating the client, which is antibiotics. Diagnostic tests do not treat the client. The client is diagnosed with neurogenic shock. Which clinical manifestations should the nurse assess in this client? Select all that apply. 1. Cool, moist skin. 2. Bradycardia. 3. Wheezing. 4. Decreased bowel sounds. 5. Hypotension. - CORRECT ANSWER Answer: 2, 5 1. The client diagnosed with neurogenic shock will have dry, warm skin, rather than cool, moist skin, as seen in hypovolemic shock. 2. The client will have bradycardia instead of tachycardia, which is seen in other forms of shock. 3. Wheezing is associated with anaphylactic shock. 4. Decreased bowel sounds occur in the hyper-dynamic phase of septic shock. 5. Hypotension is a clinical manifestation of most types of shock. TEST-TAKING HINT: The test taker should identify the body system the question is addressing. In this case, neuro- indicates the question relates to the neurological system. With this information only, the test taker could possibly rule out option "4," which refers to the gastrointestinal system, and option "3," which refers to the respiratory system. Although bradycardia is in the cardiac system, the pulse rate is controlled by the brain. The nurse in the emergency department administered an intramuscular antibiotic in the left ventrogluteal muscle to the client diagnosed with pneumonia being discharged home. Which intervention should the nurse implement? 1. Ask the client about drug allergies. 2. Obtain a sterile sputum specimen. 3. Have the client wait for 30 minutes. 4. Place a warm washcloth on the client's left hip. - CORRECT ANSWER Answer: 3 1. It is too late to ask the client about drug allergies because the medication has already been administered. 2. Obtaining a specimen after the antibiotic has been initiated will skew the culture and sensitivity results. It must be obtained before the antibiotic is started. 3. Anytime a nurse administers a medication for the first time, the client should be observed for a possible anaphylactic reaction, especially with antibiotics. 4. The client is being discharged, and the nurse can encourage the client to do this at home, but it is not appropriate to do in the emergency department. TEST-TAKING HINT: The test taker must be observant of information in the stem. The nurse has already administered the medication, and checking for allergies after the fact will not affect the client's outcome. This is a violation of the five rights; this medication cannot be the right medication if the client is allergic to it. The nurse caring for a client diagnosed with sepsis writes the client diagnosis of "alteration in comfort R/T chills and fever." Which intervention should be included in the plan of care? 1. Ambulate the client in the hallway every shift. 2. Monitor urinalysis, creatinine level, and BUN level. 3. Apply sequential compression devices to the lower extremities. 4. Administer an antipyretic medication every 4 hours PRN. - CORRECT ANSWER Answer: 4 1. Ambulating the client in the hall will not address the etiology of the client's chills and fever; in fact, this could increase the client's discomfort. 2. Monitoring these laboratory data does not address the etiology of the client's diagnosis. 3. Sequential compression devices help prevent deep vein thrombosis. 4. Antipyretic medication will help decrease the client's fever, which directly addresses the etiology of the client's nursing diagnosis. TEST-TAKING HINT: The test taker must know the problem "alteration in comfort" is addressed by the goal and the interventions address the etiology, which is "chills and fever." The registered nurse (RN) and an unlicensed assistive personnel (UAP) are caring for a group of clients on a medical floor. Which action by the UAP warrants intervention by the RN? 1. The UAP places a urine specimen in a biohazard bag in the hallway. 2. The UAP uses the alcohol foam hand cleanser after removing gloves. 3. The UAP puts soiled linen in a plastic bag in the client's room. 4. The UAP obtains a disposable stethoscope for a client in an isolation room. - CORRECT ANSWER Answer: 1 1. Specimens should be put into biohazard bags before leaving the client's room. 2. This is the appropriate way to clean hands and does not warrant intervention. 3. This is the appropriate way to dispose of soiled linens and does not warrant intervention. 4. Taking a stethoscope from a client in isolation to another room is a violation of infection-control principles. TEST-TAKING HINT: This is an "except" question. The stem is asking which action warrants intervention; therefore, the test taker must select the option indicating an inappropriate action by the unlicensed assistive personnel. The older female client diagnosed with vertebral fractures and self-medicating with ibuprofen presents to the emergency department (ED) reporting abdominal pain, is pale and clammy, and has a P of 110 and a BP of 92/60. Which type of shock should the nurse suspect? 1. Cardiogenic shock. 2. Hypovolemic shock. 3. Neurogenic shock. 4. Septic shock. - CORRECT ANSWER Answer: 2 1. Cardiogenic shock occurs when the heart's ability to contract and pump blood is impaired and the supply of oxygen to the heart and tissues is inadequate, such as occurs in myocardial infarction or valvular damage. 2. This client's clinical manifestations make the nurse suspect the client is losing blood, which leads to hypovolemic shock, which is the most common type of shock and is characterized by decreased intravascular volume. The client's taking of ibuprofen, an NSAID, puts her at risk for hemorrhage because NSAIDs inhibit prostaglandin production in the stomach, which increases the risk of developing ulcers, which can erode the stomach lining and lead to hemorrhaging. 3. In neurogenic shock, vasodilation occurs as a result of a loss of sympathetic tone. It can result from the depressant action of medication or lack of glucose. 4. Septic shock is a type of circulatory shock caused by widespread infection. TEST-TAKING HINT: The test taker must look at the clinical manifestations and realize this client is in shock. Tachycardia and hypotension with clammy skin indicate shock. The additional information in the stem describes a particular medication, an NSAID, which can cause a peptic ulcer. The client has recently experienced a myocardial infarction. Which action by the nurse helps prevent cardiogenic shock? 1. Monitor the client's telemetry. 2. Turn the client every 2 hours. 3. Administer oxygen via nasal cannula. 4. Place the client in the Trendelenburg position. - CORRECT ANSWER Answer: 3 1. Monitoring the telemetry will not prevent cardiogenic shock. It might help identify changes in the hemodynamics of the heart, but it does not prevent anything from occurring. 2. Turning the client every 2 hours will help prevent pressure injuries, but it will do nothing to prevent cardiogenic shock. 3. Promoting adequate oxygenation of the heart muscle and decreasing the cardiac workload can prevent cardiogenic shock. 4. Placing the client's head below the heart will not prevent cardiogenic shock. This position can be used when a client is in hypovolemic shock. TEST-TAKING HINT: If the test taker has no idea what the correct answer is, the test taker should apply Maslow's hierarchy of needs, which states oxygenation is most important. The test taker must know positions the client may be put in during different disorders and diseases. The client diagnosed with septicemia is receiving a broad-spectrum antibiotic. Which laboratory data require the nurse to notify the HCP? 1. The client's potassium level is 3.8 mEq/L. 2. The urine culture indicates high sensitivity to the antibiotic. 3. The client's pulse oximeter reading is 94%. 4. The culture and sensitivity is resistant to the client's antibiotic. - CORRECT ANSWER Answer: 4 1. This is a normal potassium level (3.5 to 5.5 mEq/L); therefore, the nurse does not need to notify the HCP. 2. A culture result showing a high sensitivity to an antibiotic indicates this is the antibiotic the client should be receiving. 3. A pulse oximeter reading of greater than 93% indicates the client is adequately oxygenated. 4. A sensitivity report indicating resistance to the antibiotic being administered indicates the medication the client is receiving is not appropriate for the treatment of the infectious organism, and the HCP needs to be notified so the antibiotic can be changed. TEST-TAKING HINT: The keywords in option "2" are "high sensitivity," and this should make the test taker think this is a good thing. In option "4," the word "resistant" indicates something wrong with the antibiotic and the need for intervention. The nurse is caring for a client diagnosed with shock. The client has hypotension, decreased urine output, and cool, pale skin. Which stage of shock is the client experiencing? 1. The refractory stage. 2. The compensatory stage. 3. The initial stage. 4. The progressive stage. - CORRECT ANSWER Answer: 2 1. The refractory stage is the last and irreversible phase of shock, characterized by multi-system organ failure, coma, and death. 2. In the compensatory stage of shock, the heart rate and respiratory rate are increased, but the skin may be cold and clammy and urinary output may be decreased. The client exhibits restlessness and confusion. 3. In the initial stage of shock the client can have no clinical manifestations or very subtle findings. 4. The progressive stage of shock is characterized by hypotension, lethargy, weak pulses, and respiratory and metabolic acidosis. TEST-TAKING HINT: There are some questions the test taker must know; they are called knowledge-based questions. The stages of shock are important for the nurse to recognize. The nurse in the emergency department has admitted five clients in the last 2 hours with reports of fever and gastrointestinal distress. Which question is most appropriate for the nurse to ask each client to determine if there is a bioterrorism threat? 1. "Do you work or live near any large power lines?" 2. "Where were you immediately before you got sick?" 3. "Can you write down everything you ate today?" 4. "What other health problems do you have?" - CORRECT ANSWER Answer: 2 1. Power lines are not typical sources of biological terrorism, which is what these symptoms represent. 2. The nurse should take note of any unusual illness for the time of year or clusters of clients coming from a single geographical location, all exhibiting clinical manifestations of possible biological terrorism. 3. This might be appropriate for gastroenteritis secondary to food poisoning but is not the nurse's first thought to determine a biological threat. The nurse must determine if the clients have anything in common. 4. This is important information to obtain for all clients but is not pertinent to determine a biological threat. TEST-TAKING HINT: Option "4" is a question the nurse asks all clients; therefore, the test taker should eliminate it based on the specific question. Power lines are electrical, and most bioterrorism threats involve chemical or biological threats, so option "1" can be eliminated. The health-care facility has been notified an alleged inhalation anthrax exposure has occurred at the local post office. Which category of personal protective equipment (PPE) should the response team wear? 1. Level A. 2. Level B. 3. Level C. 4. Level D. - CORRECT ANSWER Answer: 1 1. Level A protection is worn when the highest level of respiratory, skin, eye, and mucous membrane protection is required. In this situation of possible inhalation of anthrax, such protection is required. 2. Level B protection is similar to Level A protection, but it is used when a lesser level of skin and eye protection is needed. 3. Level C protection requires an air-purified respirator (APR), which uses filters or absorbent materials to remove harmful substances. 4. Level D is basically the work uniform. TEST-TAKING HINT: If the test taker were totally unaware of the correct answer, then the choice should be either option "1" or option "4" because these are at either end of the spectrum. This gives the test taker a 50/50 chance of selecting the correct answer, instead of a 25% chance. The nurse is teaching a class on bioterrorism to first responders and is discussing PPE. Which statements are important for the nurse to share with the participants? Select all that apply. 1. Health-care facilities should keep masks at entry doors. 2. The respondent should be trained in the proper use of PPE. 3. No single combination of PPE protects against all hazards. 4. The CDC has divided PPE into levels of protection. 5. PPE should be properly fitted to each respondent. - CORRECT ANSWER Answer: 2, 3, 4, 5 1. Masks are kept at designated areas, not at every entry door. 2. This is a true statement, but in an emergency situation, the respondent should use the equipment even if not trained. 3. The HCPs are not guaranteed absolute protection, even with all the training and protective equipment. This is the most important information individuals wearing protective equipment should know because all other procedures should be followed at all times. 4. The CDC has divided PPE into different levels based on exposure risk. 5. Properly fitted PPE increases the protection from exposure to biological agents. TEST-TAKING HINT: There are very few questions where the test taker should select an option with the word "all." Option "3" is stating this is not an "always" situation. The test taker should not automatically assume it is not a possible answer until understanding the context. The nurse is teaching a class on bioterrorism. Which statement is the scientific rationale for designating a specific area for decontamination? 1. Showers and privacy can be provided to the client in this area. 2. This area isolates the clients exposed to the agent. 3. It provides a centralized area for stocking the needed supplies. 4. It prevents secondary contamination to the health-care providers. - CORRECT ANSWER Answer: 4 1. This is not a rationale; this is a statement of what is done in the area. 2. This separates the clients until decontamination occurs, but the question is asking for the scientific rationale. 3. This is a false statement—the supplies should not be kept in the decontamination area. 4. Avoiding cross-contamination is a priority for personnel and equipment—the fewer the number of people exposed, the safer the community and area. TEST-TAKING HINT: Options "1" and "2" are not rationales. The triage nurse in a large trauma center has been notified of an explosion in a major chemical manufacturing plant. Which action should the nurse implement first when the clients arrive at the emergency department? 1. Triage the clients and send them to the appropriate areas. 2. Thoroughly wash the clients with soap and water and then rinse. 3. Remove the clients' clothing and have them shower. 4. Assume the clients have been decontaminated at the plant. - CORRECT ANSWER Answer: 3 1. In most situations, this is the first step, but with a potential chemical or biological exposure, the first step must be the safety of the hospital; therefore, the client must be decontaminated. 2. This is the second step in the decontamination process. 3. This is the first step. Depending on the type of exposure, this step alone can remove a large portion of the exposure. 4. This assumption could cost many people in the hospital staff, as well as clients, their lives. TEST-TAKING HINT: If the test taker wants to select option "4" as the correct answer, the test taker should be careful—assumptions are dangerous. The test taker may want to choose option "1" because it involves assessment, but exposure to a chemical agent should be considered distress and an action should be implemented first. The nurse is teaching a class on biological warfare. Which information should the nurse include in the presentation? 1. Contaminated water is the only source of transmission of biological agents. 2. Vaccines are available and being prepared to counteract all biological agents. 3. Biological weapons are less of a threat than chemical agents. 4. Biological weapons are easily obtained and result in significant mortality. - CORRECT ANSWER Answer: 4 1. Sources of biological agents include inhalation, insects, animals, and people. 2. Vaccines are not available to counteract all biological agents. 3. Because of the vast range of agents, biological weapons are more of a threat. A biological agent could be released in one city and affect people in other cities thousands of miles away. 4. Because of the variety of agents, the means of transmission, and the lethality of the agents, biological weapons, including anthrax, smallpox, and plague, are especially dangerous. TEST-TAKING HINT: Answer option "1" should be eliminated because of the word "only." Even if the test taker has little knowledge of biological warfare, knowledge of the human body suggests a wide range of ways biological agents could be transmitted. Which clinical manifestations should the nurse assess in the client exposed to the anthrax bacillus via the skin? 1. A scabby, clear fluid-filled vesicle. 2. Edema, pruritus, and a 2-mm ulcerated vesicle. 3. Irregular brownish-pink spots around the hairline. 4. Tiny purple spots flush with the surface of the skin. - CORRECT ANSWER Answer: 2 1. Scabby, clear fluid-filled vesicles are characteristic of chickenpox. 2. Exposure to anthrax bacilli via the skin results in skin lesions, which cause edema with pruritus and the formation of macules or papules, which ulcerate, forming a 1- to 3-mm vesicle. Then a painless eschar develops, which falls off in 1 to 2 weeks. 3. Irregular brownish-pink spots around the hairline are characteristic of rubella. 4. Tiny purple spots flush with the skin surface are petechiae. TEST-TAKING HINT: This is a knowledge-based question. The test taker should try to determine which disease or condition each answer option describes to rule out the incorrect answers. The client asks the nurse about the smallpox vaccine. Which information should the nurse provide to the client? Select all that apply. 1. The client should get the vaccine for prevention from the health department. 2. The client should get the vaccine only after the smallpox rash has developed. 3. The smallpox vaccine can help if given less than a week after exposure to the virus. 4. Health officials have enough smallpox vaccine to vaccinate everyone in the United States. 5. The client should avoid travel to countries with smallpox outbreaks. - CORRECT ANSWER Answer: 3, 4 1. The smallpox vaccine is not available to the general public because smallpox has been eradicated and the virus no longer exists in nature. 2. Once the smallpox rash has developed, the vaccine does not provide protection from the disease. 3. If given within 7 days of being exposed to the smallpox virus, the vaccine can provide some protection from the disease. 4. Health officials have enough smallpox vaccine to vaccinate every person in the United States if an outbreak were to occur. 5. Smallpox is eradicated and the virus no longer exists in nature. TEST-TAKING HINT: This is a knowledge-based question. The test taker should try to determine which answer options to select based on knowledge of immunizations. A chemical exposure has just occurred at an airport. An off-duty nurse, knowledgeable about biochemical agents, is giving directions to the travelers. Which direction should the nurse provide to the travelers? 1. Hold their breath as much as possible. 2. Stand up to avoid heavy exposure. 3. Lie down to stay under the exposure. 4. Attempt to breathe through their clothing. - CORRECT ANSWER Answer: 2 1. The absence of breathing is death, and this is neither a viable option nor a sensible recommendation to terrified people. 2. Standing up will avoid heavy exposure because the chemical will sink toward the floor or ground. 3. Staying below the level of the smoke is the instruction for a fire. 4. Breathing through the clothing, which is probably contaminated with the chemical, will not provide protection from the chemical entering the lung. TEST-TAKING HINT: If the test taker does not know the answer, the test taker should realize options "1" and "4" address breathing and options "2" and "3" address positioning, and one set of options should be eliminated, narrowing the choice to one out of two options. The nurse is caring for a client diagnosed with the prodromal phase of radiation exposure. Which clinical manifestations should the nurse assess in the client? 1. Anemia, leukopenia, and thrombocytopenia. 2. Sudden fever, chills, and enlarged lymph nodes. 3. Nausea, vomiting, and diarrhea. 4. Flaccid paralysis, diplopia, and dysphagia. - CORRECT ANSWER Answer: 3 1. Anemia, leukopenia, and thrombocytopenia, signs of bone marrow depression, are clinical manifestations the client experiences in the manifest illness stage of radiation exposure, which occurs from 72 hours to years after exposure. The client is usually asymptomatic in the prodromal phase of radiation exposure. 2. Sudden fever, chills, and enlarged lymph nodes are clinical manifestations of bubonic plague. 3. The prodromal stage (presenting symptoms) of radiation exposure occurs 48 to 72 hours after exposure, and the clinical manifestations are nausea, vomiting, diarrhea, anorexia, and fatigue. Clinical manifestations of higher exposures of radiation include fever, respiratory distress, and coma. 4. These are clinical manifestations of inhalation botulism. TEST-TAKING HINT: If the test taker knows the definition of "prodromal," which is an early sign of a developing condition or disease (prodrom is Greek for "running before"), then the option with vague and nonspecific clinical manifestations should be selected as the correct answer. Which cultural issues should the nurse consider when caring for clients during a bioterrorism attack? Select all that apply. 1. Language difficulties. 2. Religious practices. 3. Prayer times for the people. 4. Rituals for handling the dead. 5. Keeping the family in the designated area. - CORRECT ANSWER Answer: 1, 2, 3, 4 1. Language difficulties can increase fear and frustration on the part of the client. 2. Some religions have specific practices related to medical treatments, hygiene, and diet, and these should be honored if at all possible. 3. Prayers in times of grief and disaster are important to an individual and actually can have a calming effect on the situation. 4. Caring for the dead is as important as caring for the living based on religious beliefs. 5. For purposes of organization, this may be needed, but it is not addressing cultural sensitivity and, in some instances, may violate the cultural needs of the client and the family. TEST-TAKING HINT: The stem asks the test taker to address cultural needs, and these client needs must be addressed in a bioterrorism attack or with an individual in the hospital. The test taker should select options addressing cultural needs. Dishonoring cultural needs can increase the client's anxiety and increase problems for the health-care team. The off-duty nurse hears on the television of a bioterrorism act in the community. Which action should the nurse take first? 1. Immediately report to the hospital emergency department. 2. Call the American Red Cross to find out where to go. 3. Pack a bag and prepare to stay at the hospital. 4. Follow the nurse's hospital policy for responding. - CORRECT ANSWER Answer: 4 1. Many hospital procedures mandate off-duty nurses should not report immediately to the hospital, so relief is available for initial responders. 2. The nurse's first responsibility is to the facility of employment, not the community. 3. This is a good action to take when the nurse is notified of the next action. For example, if the hospital is quarantined, the nurse may not report for days. 4. The nurse should follow the hospital's policy. Often nurses will stay at home until decisions are made as to where the employees should report. TEST-TAKING HINT: After looking at all the options, the test taker should select the option that best assesses the entire situation, which is following policy. There will be a tendency for mass hysteria to occur in the community, but following the terrorist attack on 9/11/2001, all hospitals and communities are now required by Homeland Security to have a disaster preparedness plan in place. The best action the nurse can take is to follow the procedure and remain calm. The nurse finds the client unresponsive on the floor of the bathroom. Which action should the nurse implement first? 1. Check the client for breathing. 2. Assess the carotid artery for a pulse. 3. Shake the client and shout. 4. Notify the rapid response team. - CORRECT ANSWER Answer: 3 1. This is not the first intervention based on the answer options available in this question. 2. This is not the first intervention based on the options available in this question. 3. This is the first intervention the nurse should implement after finding the client unresponsive on the floor. 4. The rapid response team is called if the client is breathing; a code would be called if the client were not breathing. TEST-TAKING HINT: Options "1," "2," and "3" are all assessment interventions, which is the first step in the nursing process. Of these three possible options, the test taker should select the intervention easiest and fastest to determine if the client is alert, which is to shake and shout at the client. The UAP is performing cardiac compressions on an adult client during a code. Which behavior warrants immediate intervention by the RN? 1. The UAP has hand placement on the lower half of the sternum. 2. The UAP performs cardiac compressions and allows for rescue breathing. 3. The UAP depresses the sternum 0.5 to 1 inch during compressions. 4. The UAP asks to be relieved from performing compressions because of exhaustion. - CORRECT ANSWER Answer: 3 1. This hand position will help prevent positioning the hand over the xiphoid process, which can break the ribs and lacerate the liver during compressions. 2. This is the correct two-rescuer CPR; therefore, no intervention is needed. 3. The sternum should be depressed 1.5 to 2 inches during compressions to ensure adequate circulation of blood to the body; therefore, the nurse needs to correct the UAP. 4. The UAP should request another HCP to perform compressions when exhausted. TEST-TAKING HINT: The test taker must select which option is an incorrect procedure for cardiac compressions. Which intervention is most important for the nurse to implement when participating in a code? 1. Elevate the arm after administering medication. 2. Maintain sterile technique throughout the code. 3. Treat the client's clinical manifestations; do not treat the monitor. 4. Provide accurate documentation of what happened during the code. - CORRECT ANSWER Answer: 3 1. This is an appropriate intervention, but it is not the most important. 2. Sterile technique should be maintained as much as possible, but the nurse can treat a live body with an infection without using sterile technique; however, the nurse cannot treat a dead body without an infection. 3. This is the most important intervention. The nurse should always treat the client based on the nurse's assessment and data from the monitors; an intervention should not be based on data from the monitors without the nurse's assessment. 4. Documentation is important but not a priority over treating the client. TEST-TAKING HINT: The phrase "most important" in the stem is the key to answering this question. All four options are appropriate interventions for the question, but only one is the most important. The test taker should remember to always select the option directly affecting the client, and this may mean not selecting an assessment intervention when the client is in distress. The CPR instructor is discussing an automated external defibrillator (AED) during class. Which statement best describes an AED? 1. It analyzes the rhythm and shocks the client diagnosed with ventricular fibrillation. 2. The client will be able to have synchronized cardioversion with the AED. 3. It will keep the health-care provider informed of the client's oxygen level. 4. The AED will perform cardiac compressions on the client. - CORRECT ANSWER Answer: 1 1. This is the correct statement explaining what an AED does when used in a code. 2. The defibrillator on the crash cart must be used to perform synchronized cardioversion. 3. This is the explanation for a pulse oximeter. 4. This is not the function of the AED. TEST-TAKING HINT: The test taker must know the equipment to be able to answer this question. The test taker may be able to eliminate options based on knowledge of what other equipment does. The nurse is caring for clients on a medical floor. Which client is most likely to experience sudden cardiac death? 1. The 84-year-old client exhibiting uncontrolled atrial fibrillation. 2. The 60-year-old client exhibiting asymptomatic sinus bradycardia. 3. The 53-year-old client exhibiting ventricular fibrillation. 4. The 65-year-old client exhibiting supraventricular tachycardia. - CORRECT ANSWER Answer: 3 1. Atrial fibrillation is not a life-threatening dysrhythmia; it is chronic. 2. Asymptomatic sinus bradycardia may be normal for the client, especially for athletes or long-distance runners. 3. Ventricular fibrillation is the most common dysrhythmia associated with sudden cardiac death. 4. "Supraventricular" means "above the ventricle." The atrium is above the ventricle, and atrial dysrhythmias are not life-threatening. TEST-TAKING HINT: The test taker should know the left ventricle is responsible for pumping blood to the body (heart muscle and brain) and could eliminate options "1" and "4" as correct answers. The word "asymptomatic" should cause the test taker to eliminate option "2" as the correct answer. Which health-care team member referral should be made by the nurse when a code is being conducted on a client in a community hospital? 1. The hospital chaplain. 2. The social worker. 3. The respiratory therapist. 4. The director of nurses. - CORRECT ANSWER Answer: 1 1. The chaplain should be called to help address the client's family or significant others. A small community hospital does not have a 24-hour on-duty pastoral service. A chaplain is part of the code team in large medical center hospitals. 2. The social worker does not need to be notified of a code. 3. The respiratory therapist responds to the code automatically without a referral. The respiratory therapist is part of the code team, and one is on duty 24 hours a day, even in a small community hospital. 4. The director of nurses does not need to be notified of codes, but possibly the house supervisor should be notified. TEST-TAKING HINT: The test taker must know the roles of the multidisciplinary health-care team to make appropriate referrals. The words "community hospital" are an important phrase to help determine the correct answer. Which intervention is the most important for the intensive care unit nurse to implement when performing mouth-to-mouth resuscitation on a client diagnosed with pulseless ventricular fibrillation? 1. Perform the jaw thrust maneuver to open the airway. 2. Use the mouth to cover the client's mouth and nose. 3. Insert an oral airway before performing mouth to mouth. 4. Use a pocket mouth shield to cover the client's mouth. - CORRECT ANSWER Answer: 4 1. A jaw thrust is used for a possible fractured neck. The nurse should use the head-tilt, chin-lift maneuver to open the airway. 2. The nurse should cover the client's mouth and nose with the nurse's mouth when giving mouth-to-mouth resuscitation to an infant but not when giving mouth-to-mouth resuscitation to an adult. According to the American Heart Association 2010 Guidelines, mouth to mouth is only performed with a barrier device in place to protect the rescuer. 3. An oral airway is not mandatory to do effective breathing; therefore, it is not the most important intervention. 4. Nurses should protect themselves against possible communicable diseases, such as HIV and hepatitis, and should be protected if the client vomits during CPR. TEST-TAKING HINT: Unless the stem provides an age for the client, the client is an adult client; therefore, the test taker could eliminate option "2" because it is for an infant. The nurse is teaching CPR to a class. Which statement best explains the definition of sudden cardiac death? 1. Cardiac death occurs after being removed from a mechanical ventilator. 2. Cardiac death is the time the HCP officially declares the client dead. 3. Cardiac death occurs within 1 hour of the onset of cardiovascular symptoms. 4. The death is caused by myocardial ischemia resulting from coronary artery disease. - CORRECT ANSWER Answer: 3 1. This is not the definition of sudden cardiac death; this is sometimes known as "pulling the plug" on clients diagnosed as brain dead. 2. This is not the definition of sudden cardiac death. 3. Unexpected death occurring within 1 hour of the onset of cardiovascular symptoms is the definition of sudden cardiac death. 4. This is not the definition of sudden cardiac death. TEST-TAKING HINT: If the test taker relates the word "sudden" in the stem with "unexpected," the best answer is option "3." The test taker must be aware of adjectives and adverbs. Which statement explains the scientific rationale for having emergency suction equipment available during resuscitation efforts? 1. Gastric distention can occur as a result of ventilation. 2. It is needed to assist when intubating the client. 3. This equipment will ensure a patent airway. 4. It keeps the vomitus away from the healthcare provider. - CORRECT ANSWER Answer: 1 1. Gastric distention occurs from over ventilating clients. When compressions are performed, the pressure will cause vomiting, which may cause aspiration into the lungs. 2. The HCP does not require suctioning equipment to intubate. 3. Nothing ensures a patent airway, except a correctly inserted endotracheal tube, and suction is needed to clear the airway. 4. Suction equipment is for the client's needs, not the HCP's needs. TEST-TAKING HINT: Option "4" could be eliminated because the equipment is for the client, not for the nurse or HCPs. The word "ensures" in option "3" is an absolute word, so the test taker should be cautious before selecting this option. Which equipment must be immediately brought to the client's bedside when a code is called for a client diagnosed with a cardiac arrest? 1. A ventilator. 2. A crash cart. 3. A gurney. 4. Portable oxygen. - CORRECT ANSWER Answer: 2 1. A ventilator is not kept on the medical-surgical floors and is not routinely brought to the bedside. The client is manually ventilated until arriving in the intensive care unit. 2. The crash cart is the mobile unit with the defibrillator and all the medications and supplies needed to conduct a code. 3. The gurney, a stretcher, may be needed when the client is being transferred to another unit, but it is not an immediate need, and in some hospitals, the client is transferred in the bed. 4. Oxygen is available in the room and portable oxygen is on the crash cart, so it doesn't need to be brought separately. TEST-TAKING HINT: This is knowledge the test taker must have. The crash cart is the primary piece of equipment, and in most facilities there is a person assigned to bring the crash cart to the client's bedside. The nursing administrator responds to a code situation. When assessing the situation, which role must the administrator ensure is performed for legal purposes and continuity of care of the client? 1. A person is ventilating with an Ambu bag. 2. A person is performing chest compressions correctly. 3. A person is administering medications as ordered. 4. A person is keeping an accurate record of the code. - CORRECT ANSWER Answer: 4 1. This is providing immediate direct care to the client and is not performed for legal purposes. 2. The key to answering the question is "legal," and direct care is not performed for legal purposes. 3. This is providing immediate direct care to the client and is not performed for legal purposes. This is an occasion where someone else is allowed to document another nurse's medication administration. 4. The EHR is a legal document, and the code must be documented in the EHR and provide the information needed in the intensive care unit. TEST-TAKING HINT: Answer options "1," "2," and "3" have the nurse providing direct hands-on care. Option "4" is the only option addressing documentation and should be selected as the correct answer because it is different. The client in a code is now diagnosed with ventricular bigeminy. The HCP orders a lidocaine drip at 3 mg/min. The lidocaine comes prepackaged with 2 grams of lidocaine in 500 mL of D5W. At which rate will the nurse set the infusion pump? - CORRECT ANSWER Answer: 45 mL/hr The test taker could remember the mnemonic, which is "For 1 mg, 2 mg, 3 mg, 4 mg the rate is 15 mL, 30 mL, 45 mL, 60 mL." If the test taker has not memorized it, it is too late to figure it out in an emergency situation. But for math purposes: First determine the number of milligrams of lidocaine in the 500 mL of D5W: 2 g × 1,000 mg = 2,000 mg per 500 mL Then determine how many milligrams per milliliters: 2,000 mg ÷ 500 mL = ÷ mg/mL Then find out how many milliliters must be infused per minute to give the ordered dose of 3 mg/min. In algebraic terms: 4 mg : 1 mL = 3 mg : x mL Cross multiply and divide: x = 3/4 or 0.75 The number of milliliters to be infused in a minute is 3/4 mL or 0.75. The infusion pump is set at an hourly rate, so multiply 3/4 by 60 minutes: 3/4 × 60 = 45 The pump should be set at 45 mL/hr to infuse 3 mg/min. TEST-TAKING HINT: The test taker must be familiar with basic nursing math and become comfortable with the equations the test taker uses to compute dosage calculations. Which situation warrants the nurse obtaining information from a material safety data sheet (MSDS)? 1. The custodian spilled a chemical solvent in the hallway. 2. A visitor slipped and fell on the floor that had just been mopped. 3. A bottle of antineoplastic agent broke on the client's floor. 4. The nurse was stuck with a contaminated needle in the client's room. - CORRECT ANSWER Answer: 1 1. The MSDS provides chemical information regarding specific agents, health information, and spill information for a variety of chemicals. It is required for every chemical found in the hospital. 2. This situation requires an occurrence or accident report. 3. Any facility administering antineoplastic agents (medications used to treat cancer) is required to have specific chemotherapy spill kits available and a policy and procedure included; in this situation, the nurse already knows the chemical involved. 4. This requires a hospital variance report and notifying the employee health or infection-control nurse. TEST-TAKING HINT: If the test taker were not aware of an MSDS, the name tells the test taker to look for content in the answer options addressing materials; therefore, options "2" and "4" could be eliminated as possible answers. The triage nurse is working in the emergency department. Which client should be assessed first? 1. The 10-year-old child whose dad thinks the child's leg is broken. 2. The 45-year-old male clutching his chest and diaphoretic. 3. The 58-year-old female reporting a headache and seeing spots. 4. The 25-year-old male with a hunting knife wound on the hand. - CORRECT ANSWER Answer: 2 1. The child needs an x-ray to confirm the fracture, but the client is stable and does not have a life-threatening problem. 2. The triage nurse should see this client first because these are symptoms of a myocardial infarction, which is potentially life-threatening. 3. These are symptoms of a migraine headache and are not life-threatening. 4. A laceration on the hand is a priority, but not over a client having a myocardial infarction. TEST-TAKING HINT: The test taker should evaluate each option on a scale of 1 to 10, with 1 being the least critical client and 10 being life-threatening. Option "2" rates a score of 10. The nurse is teaching a class on disaster preparedness. Which are components of an emergency operations plan (EOP)? Select all that apply. 1. A plan for practice drills. 2. A deactivation response. 3. A plan for internal communication only. 4. A preincident response. 5. A security plan. - CORRECT ANSWER Answer: 1, 2, 5 1. Practice drills allow for troubleshooting any issues before a real-life incident occurs. 2. A deactivation response is important so resources are not overused, and the facility can then get back to daily activities and routine care. 3. Communication between the facility and external resources and an internal communication plan are critical. 4. In a postincident response, it is important to include a critique and debriefing for all parties involved; a preincident response is a plan itself. Be sure to read adjectives closely. 5. A coordinated security plan involving facility and community agencies is the key to controlling an otherwise chaotic situation. TEST-TAKING HINT: The test taker must notice adjectives such as "only" in option "3" and "preincident" in option "4." These words make these options incorrect. This question requires the test taker to select more than one option as the correct answer. According to the North Atlantic Treaty Organization (NATO) triage system, which situation is considered a level red? 1. Injuries are extensive and chances of survival are unlikely. 2. Injuries are minor and treatment can be delayed hours to days. 3. Injuries are significant but can wait hours without threat to life or limb. 4. Injuries are life-threatening but survivable with available interventions. - CORRECT ANSWER Answer: 4 1. This describes injuries color-coded black and is called the Expectant Category. It is used for the deceased or those with extensive, unsurvivable injuries 2. This is a description of injuries color-coded green and is called the Wait Category. These clients are walking wounded. 3. These injuries are color-coded yellow and are in the Observation Category. 4. This is called the Immediate Category. Individuals in this group can progress rapidly to Expectant if treatment is delayed. TEST-TAKING HINT: This is basically a knowledge-based question, but often the color "red" indicates a high priority. Which statement best describes the role of the medical-surgical nurse during a disaster? 1. The nurse may be assigned to ride in the ambulance. 2. The nurse may be assigned as a first assistant in the operating room. 3. The nurse may be assigned to crowd control. 4. The nurse may be assigned to the emergency department. - CORRECT ANSWER Answer: 4 1. The nurse should not leave the hospital area; the nurse must wait for the casualties to come to the facility. 2. This is a position requiring knowledge of instruments and procedures not common to the medical-surgical floor. 3. The people in this area are usually chaplains or social workers, not direct client care personnel. In a disaster, direct care personnel cannot be spared for this duty. 4. New settings and atypical roles for nurses may be required during disasters; medical-surgical nurses can provide first aid and may be required to work in unfamiliar settings. TEST-TAKING HINT: The test taker should look at traditional nursing roles requiring nursing expertise and eliminate crowd control or riding in an ambulance. The nurse in a disaster is triaging the following clients. Which client should be triaged as an Expectant Category and color black? 1. The alert client diagnosed with a sucking chest wound. 2. The unresponsive client diagnosed with a head injury. 3. The client diagnosed with an abdominal wound and stable vital signs. 4. The client diagnosed with a sprained ankle which may be fractured. - CORRECT ANSWER Answer: 2 1. This client should be classified as an Immediate Category and the color red. If not treated STAT, a tension pneumothorax will occur. 2. This client has a very poor prognosis, and even with treatment, survival is unlikely. This client is classified as a black tag and an Expectant Category. 3. This client should be classified as an Observation Category and the color yellow. This client receives treatment after the casualties requiring immediate treatment are treated. 4. This client is a Wait Category and the color green. This client can wait for days for treatment. TEST-TAKING HINT: If the test taker did not know the definition of the categories, looking at the word "black," which has a connotation of death, and the word "expectant" might lead the test taker to select the worst-case scenario. Which federal agency is a resource for the nurse volunteering at the American Red Cross on a committee to prepare the community for any type of disaster? 1. The Joint Commission (JC). 2. Office of Emergency Management (OEM). 3. Department of Health and Human Services (HHS). 4. Metro Medical Response Systems (MMRS). - CORRECT ANSWER Answer: 3 1. This organization mandates all health-care facilities to have an emergency operations plan, but it is a national agency, not a federal agency. 2. Most cities and all states have an OEM, which coordinates the disaster relief efforts at the state and local levels. 3. Federal resources include organizations such as the HHS, Federal Emergency Management Agency (FEMA), and the Department of Justice. The American Red Cross provides disaster relief alongside these federal departments. 4. MMRS teams are local teams located in cities deemed to be possible terrorist targets. TEST-TAKING HINT: The question asks for a federal agency. The word "metro" means "local"; therefore, option "4" could be eliminated. All HCPs should be aware of the role of The Joint Commission in the hospital, so the test taker could eliminate option "1." Which situation requires the emergency department manager to schedule and conduct a Critical Incident Stress Management (CISM)? 1. Caring for a 2-year-old child who died from severe physical abuse. 2. Performing unsuccessful CPR on a middle-aged male executive. 3. Responding to a 22-victim bus accident with no apparent fatalities. 4. Being required to work 16 hours without taking a break. - CORRECT ANSWER Answer: 1 1. CISM is an approach to preventing and treating the emotional trauma affecting emergency responders as a consequence of their job. Performing CPR and treating a young child affects the emergency personnel psychologically, and the death increases the traumatic experience. 2. Caring for this type of client is an expected part of the job. If the nurse finds this traumatic enough to require a CISM, then the nurse should probably leave the emergency department. 3. This requires an intense time for triaging and caring for the victims, but without fatalities, this should not be as traumatic for the staff. 4. This is a dangerous practice because medication errors and other mistakes may occur as a result of fatigue, but this is not a traumatic situation. TEST-TAKING HINT: The test taker should examine the words "critical," "incident," and "stress." Each option should be examined to determine which is the most traumatic. Needless deaths of children are psychologically traumatic. During a disaster, a local news reporter comes to the emergency department requesting information about the victims. Which action is most appropriate for the nurse to implement? 1. Have security escort the reporter off the premises. 2. Direct the reporter to the disaster command post. 3. Tell the reporter this is a violation of HIPAA. 4. Request the reporter to stay out of the way. - CORRECT ANSWER Answer: 2 1. The media have an obligation to report the news and can play a significant positive role in communication, but communication should come from only one source—the disaster command center. 2. EOPs will have a designated disaster plan coordinator. All public information should be routed through this person. 3. Client confidentiality must be maintained, but the best action is for the nurse to help the reporter get to the appropriate area for information. 4. This allows the reporter to stay in the emergency department, which is inappropriate. TEST-TAKING HINT: The nurse should address the situation with the reporter and provide access for the information. Options "1," "3," and "4" do not help the reporter get accurate information. The triage nurse has placed a disaster tag on the client. Which action warrants immediate intervention by the nurse? 1. The nurse documents the tag number in the disaster log. 2. The unlicensed assistive personnel documents vital signs on the tag. 3. The health-care provider removes the tag to examine the limb. 4. The licensed practical nurse securely attaches the tag to the client's foot. - CORRECT ANSWER Answer: 3 1. This is the correct procedure when tagging a client and does not warrant intervention. 2. Vital signs should be documented on the tag. The tag takes the place of the client's EHR, so this does not warrant intervention. 3. The tag should never be removed from the client until the disaster is over or the client is admitted and the tag becomes a part of the client's record. 4. The tag can be attached to any part of the client's body. TEST-TAKING HINT: This question is asking the test taker to identify an incorrect option for the situation. Sometimes asking which action is appropriate helps identify the correct answer. The father of a child brought to the emergency department is yelling at the staff and obviously intoxicated. Which approach should the nurse take with the father? 1. Talk to the father in a calm and low voice. 2. Tell the father to wait in the waiting room. 3. Notify the child's mother to come to the ED. 4. Call the police department to come and arrest him. - CORRECT ANSWER Answer: 1 1. This will help diffuse the escalating situation and attempt to keep the father calm. 2. Sending the father to the waiting room does not help his behavior and could possibly make his behavior worse; loud and obnoxious behavior can become violent. 3. This will not help the current situation and could make it worse because the nurse doesn't know the home situation. 4. The nurse should notify hospital security before calling the police department. TEST-TAKING HINT: The rule concerning dealing with anger is to address the client directly and defuse the situation. There is only one option addressing this rule, option "1." A gang war has resulted in 12 young males being brought to the emergency department. Which action by the nurse is a priority when a gang member points a gun at a rival gang member in the trauma room? 1. Attempt to talk to the person with the gun. 2. Explain to the person the police are coming. 3. Stand between the client and the man with the gun. 4. Get out of the line of fire and protect self. - CORRECT ANSWER Answer: 4 1. This puts the nurse in a dangerous position and might cause the death of the nurse. 2. This will escalate the situation. 3. This is a dangerous position for the nurse to be put in. 4. Self-protection is a priority; the nurse is not required to be injured in the line of duty. TEST-TAKING HINT: Self-protection is a priority. There is no advantage to protecting others if the caregivers are also injured. The only option protecting the nurse is to get out of the line of fire. The parents bring their toddler to the ED in a panic. The parents state the child had been playing in the kitchen and got into some cleaning agents and swallowed an unknown quantity of the agents. Which health-care agency should the nurse contact at this time? 1. Child Protective Services (CPS). 2. The local police department. 3. The Department of Health. 4. The Poison Control Center. - CORRECT ANSWER Answer: 4 1. CPS should be contacted only if the nurse suspects an intentional administration of the poison, but at this time, determining which poison the child has swallowed and the antidote is the priority. 2. The local police department is only notified if the nurse suspects child abuse. 3. The Department of Health does not need to be notified. 4. The Poison Control Center can assist the nurse in identifying which chemical has been ingested by the child and the antidote. TEST-TAKING HINT: The test taker should analyze each option to determine what information could be obtained. Then the test taker should put this information in order of priority. Even if the nurse suspects child abuse, the priority is to help the child immediately. Which is the primary goal of the ED nurse in caring for a poison ingestion client? 1. Remove or inactivate the poison before it is absorbed. 2. Provide long-term supportive care to prevent organ damage. 3. Administer an antidote to increase the effects of the poison. 4. Implement treatment prolonging the elimination of the poison. - CORRECT ANSWER Answer: 1 1. The primary goal for the ED nurse is to stop the action of the poison and then maintain organ functioning. 2. ED nurses do not provide long-term care. 3. Antidotes are administered to neutralize the effects of poisons, not to increase the effects. 4. Treatment is implemented to hasten the elimination of the poison. TEST-TAKING HINT: The test taker should read each option carefully. ED nurse and "long-term care" don't match. Increasing the effects and prolonging the elimination of the poison is damaging to the client. The client has ingested a corrosive solution containing lye. Which intervention should the nurse implement? 1. Administer syrup of ipecac to induce vomiting. 2. Insert a nasogastric tube and connect to wall suction. 3. Assess for airway compromise. 4. Immediately administer water or milk. - CORRECT ANSWER Answer: 3 1. Vomiting is never induced in clients after ingesting corrosive alkaline substances or petroleum distillates. More damage can occur to the esophagus and pharynx. 2. Gastric lavage may be done (very rare) but not by inserting an NGT and attaching it to wall suction. 3. Airway edema or obstruction can occur as a result of the burning action of corrosive substances. 4. Water or milk may be administered to dilute the substance if the airway is not compromised. TEST-TAKING HINT: This is an emergency situation. If the test taker did not know the answer, Maslow's hierarchy of needs puts the airway first. The male client was found in a parked car with the motor running. The paramedic brought the client to the ED with reports of a headache, nausea, and dizziness and the client is unable to recall his name or address. On assessment, the nurse notes the buccal mucosa is a cherry red color. Which intervention should the nurse implement first? 1. Check the client's oxygenation level with a pulse oximeter. 2. Apply oxygen via nasal cannula at 100%. 3. Obtain a psychiatric consult to determine if this was a suicide attempt. 4. Prepare the client for transfer to a facility with a hyperbaric chamber. - CORRECT ANSWER Answer: 2 1. These are clinical manifestations of carbon monoxide poisoning. Pulse oximetry is not a valid test because the hemoglobin is saturated with the carbon monoxide and a false high reading is being obtained. 2. These are clinical manifestations of carbon monoxide poisoning. Symptoms include skin color from a cherry red to cyanotic and pale, headache, muscular weakness, palpitations, dizziness, and confusion and can progress rapidly to coma and death. Oxygen should be administered 100% at hyperbaric or atmospheric pressures to reverse hypoxia and accelerate the elimination of the carbon monoxide. 3. This may be done, but it is not the first action. 4. This may need to be done, but getting oxygen to the brain is first. TEST-TAKING HINT: Three of the four options concern oxygenation. The test taker must then decide which of the three has the highest priority. Activated charcoal has been ordered for a client after ingesting a full bottle of acetaminophen. Which statements explain the rationale for using activated charcoal? 1. Activated charcoal adheres to gastric mucosa to prevent absorption. 2. Activated charcoal binds with drugs to reduce systemic absorption. 3. Activated charcoal irritates gastric lining to induce vomiting of drugs. 4. Activated charcoal irrigates the stomach to be removed by suction. - CORRECT ANSWER Answer: 2 1. Activated charcoal does not adhere to the gastric mucosa; it binds to the drug or toxin. 2. Activated charcoal binds to drugs or toxins in the body, reducing systemic absorption. It is the most frequently used method of gastrointestinal decontamination. 3. A client may occasionally vomit when given activated charcoal, but this is not the scientific rationale for the administration. Ipecac can be given to induce vomiting but is not commonly used today. 4. Gastric lavage can be performed to flush the stomach, and the fluid is removed by suction but not activated charcoal. TEST-TAKING HINT: This is a knowledge-based question. The test taker should have knowledge of the actions of medications administered for a drug overdose. A vat of chemicals spilled onto the client. Which action should the occupational health nurse implement first? 1. Have the client stand under a shower while removing all clothes. 2. Check the material safety data sheets for the antidote. 3. Administer oxygen by nasal cannula. 4. Collect a sample of the chemicals in the vat for analysis. - CORRECT ANSWER Answer: 1 1. The skin should be immediately drenched with water from a hose or shower. A constant stream of water is applied. Time should not be lost by removing the clothes first and then proceeding to rinse with water. If a dry powder form of white phosphorus or lye spilled onto the client, it is brushed off and then the client is placed under the shower. 2. The first action is to remove the poison from the client's skin and prevent further damage. 3. If the client becomes dyspneic, the nurse administers oxygen while waiting for the paramedics. 4. The vat should be labeled as to the chemical contents per Occupational Safety and Health Administration (OSHA) regulations, but if not, the nurse must determine which chemicals are in the vat so the HCP can treat the client appropriately. TEST-TAKING HINT: Usually, oxygen is a priority, but in this scenario, the client has dangerous chemicals on the skin. The stem did not tell the test taker the respirations were a problem. It is important not to read into a question. The client presents to the ED with acute vomiting after eating at a fast-food restaurant. There has not been any diarrhea. The nurse suspects botulism poisoning. Which nursing problem is the highest priority for this client? 1. Fluid volume loss. 2. Risk for respiratory paralysis. 3. Abdominal pain. 4. Anxiety. - CORRECT ANSWER Answer: 2 1. Fluid volume loss is a concern because of the potential for the client to go into hypovolemic shock, but this is not a priority over the airway. 2. Clients diagnosed with botulism are at risk for respiratory paralysis, and this is the priority problem. 3. The client will be in pain and pain is a priority, but it does not come before airway and fluid volume. 4. The client may be anxious, but a psychosocial problem usually can be ranked after a physiological one in priority. TEST-TAKING HINT: Maslow's hierarchy of needs lists the airway as the highest priority. The client has ingested