1. A nurse is preparing an in-service for an annual skills fair at a community medical facility about fire
safety. Place the steps in the order in which they should be performed in the case of a fire emergency.
(Move the steps into the box on the right, placing them in the selected order of performance. Use all the
steps.)
A. Pull the fire alarm.
B. Confine the fire.
C. Extinguish the fire.
D. Rescue the clients. - ANSWER The correct order for responding to a fire emergency is typically
referred to as "RACE," which stands for:
R. Rescue the clients.
A. Activate the fire alarm (pull the fire alarm).
C. Confine the fire.
E. Extinguish the fire.
2. A nurse is administering nasal decongestant drops for a client. Which of the following actions should
the nurse take?
A. Tell the client to blow her nose gently before the instillation.
,B. Assist the client to a side-lying position.
C. Hold the dropper 2 cm (1 in) above the naris.
D. Instruct the client to stay in the same position for 2 min. - ANSWER A. Tell the client to blow her nose
gently before the instillation.
Rationale: Prior to instillation, the nurse should instruct the client to blow her nose gently. This action
will help remove any secretions or crusts that could interfere with the distribution and absorption of
the medication.
3. A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions.
Which of the following actions should the nurse take?
A. Suction two to three times with a 60-second pause between passes.
B. Perform chest physiotherapy prior to suctioning.
C. Lubricate the suction catheter tip with sterile saline.
D. Hyperventilate the client on 100% oxygen prior to suctioning. - ANSWER A. Suction two to three
times with a 60-second pause between passes.
Rationale: Copious secretions may require several passes of the suction catheter. An interval of 60
seconds should be allowed between passes to prevent hypoxia.
,4. A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is
the priority nursing action?
A. Administer vitamin K.
B. Dry the skin.
C. Administer eye prophylaxis.
D. Place an identification bracelet. - ANSWER B. Dry the skin.
Rationale: The newborn should be thoroughly dried, covered with a warm blanket, placed on the
mother's abdomen, and a cap applied to the newborn's head to prevent cold stress. The newborn
responds to the cooler environment by increasing his respiratory rate, which can lead to respiratory
distress. Based on Maslow's hierarchy of needs, this is the most important nursing
action after securing the airway.
5. A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured
mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the
following actions is the priority for the nurse to take?
A. Prevent aspiration.
B. Ensure adequate nutrition.
C. Promote oral hygiene.
D. Relieve the client's pain. - ANSWER A. Prevent aspiration.
, Rationale: When using the airway, breathing, circulation approach to client care, the nurse should
determine that the priority goal is to prevent the client from aspirating. Because the client's jaws are
wired together, aspiration of emesis is a possibility. Therefore, the client should be given medication for
nausea, and wire cutters should be kept at the bedside in case of vomiting
6. A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires
mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that
this medication is for which of the following purposes?
A. Decrease chest wall compliance.
B. Suppress respiratory effort.
C. Induce sedation.
D. Decrease respiratory secretions. - ANSWER B. Suppress respiratory effort
Rationale: Neuromuscular blocking agents, such as pancuronium, induce paralysis and suppress the
client's respiratory efforts to the point of apnea, allowing the mechanical ventilator to take over the
work of breathing for the client. This therapy is especially helpful for a client who has ARDS and poor
lung compliance.
7. A nurse is providing teaching to a client who has emphysema and a new prescription for theophylline.
Which of the following instructions should the nurse provide?
A. Consume a high-protein diet.
B. Administer the medication with food.
safety. Place the steps in the order in which they should be performed in the case of a fire emergency.
(Move the steps into the box on the right, placing them in the selected order of performance. Use all the
steps.)
A. Pull the fire alarm.
B. Confine the fire.
C. Extinguish the fire.
D. Rescue the clients. - ANSWER The correct order for responding to a fire emergency is typically
referred to as "RACE," which stands for:
R. Rescue the clients.
A. Activate the fire alarm (pull the fire alarm).
C. Confine the fire.
E. Extinguish the fire.
2. A nurse is administering nasal decongestant drops for a client. Which of the following actions should
the nurse take?
A. Tell the client to blow her nose gently before the instillation.
,B. Assist the client to a side-lying position.
C. Hold the dropper 2 cm (1 in) above the naris.
D. Instruct the client to stay in the same position for 2 min. - ANSWER A. Tell the client to blow her nose
gently before the instillation.
Rationale: Prior to instillation, the nurse should instruct the client to blow her nose gently. This action
will help remove any secretions or crusts that could interfere with the distribution and absorption of
the medication.
3. A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions.
Which of the following actions should the nurse take?
A. Suction two to three times with a 60-second pause between passes.
B. Perform chest physiotherapy prior to suctioning.
C. Lubricate the suction catheter tip with sterile saline.
D. Hyperventilate the client on 100% oxygen prior to suctioning. - ANSWER A. Suction two to three
times with a 60-second pause between passes.
Rationale: Copious secretions may require several passes of the suction catheter. An interval of 60
seconds should be allowed between passes to prevent hypoxia.
,4. A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is
the priority nursing action?
A. Administer vitamin K.
B. Dry the skin.
C. Administer eye prophylaxis.
D. Place an identification bracelet. - ANSWER B. Dry the skin.
Rationale: The newborn should be thoroughly dried, covered with a warm blanket, placed on the
mother's abdomen, and a cap applied to the newborn's head to prevent cold stress. The newborn
responds to the cooler environment by increasing his respiratory rate, which can lead to respiratory
distress. Based on Maslow's hierarchy of needs, this is the most important nursing
action after securing the airway.
5. A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured
mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the
following actions is the priority for the nurse to take?
A. Prevent aspiration.
B. Ensure adequate nutrition.
C. Promote oral hygiene.
D. Relieve the client's pain. - ANSWER A. Prevent aspiration.
, Rationale: When using the airway, breathing, circulation approach to client care, the nurse should
determine that the priority goal is to prevent the client from aspirating. Because the client's jaws are
wired together, aspiration of emesis is a possibility. Therefore, the client should be given medication for
nausea, and wire cutters should be kept at the bedside in case of vomiting
6. A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires
mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that
this medication is for which of the following purposes?
A. Decrease chest wall compliance.
B. Suppress respiratory effort.
C. Induce sedation.
D. Decrease respiratory secretions. - ANSWER B. Suppress respiratory effort
Rationale: Neuromuscular blocking agents, such as pancuronium, induce paralysis and suppress the
client's respiratory efforts to the point of apnea, allowing the mechanical ventilator to take over the
work of breathing for the client. This therapy is especially helpful for a client who has ARDS and poor
lung compliance.
7. A nurse is providing teaching to a client who has emphysema and a new prescription for theophylline.
Which of the following instructions should the nurse provide?
A. Consume a high-protein diet.
B. Administer the medication with food.
