Final Exam 205
A nurse is caring for a client who has lung cancer and is dying. Which prescription
should the nurse question?
a.
Morphine 10 mg sublingual every 6 hours PRN for pain level greater than 5
b.
Albuterol (Proventil) metered dose inhaler every 4 hours PRN for wheezes
c.
Atropine solution 1% sublingual every 4 hours PRN for excessive oral secretions
d.
Sodium biphosphate (Fleet) enema once a day PRN for impacted stool – answer A
The spouse of a dying client states that she is concerned that her husband is choking to
death. What is the nurse's best response?
a.
"Do not worry. The choking sound is normal during the dying process."
b.
"I will administer more morphine to keep your husband comfortable."
c.
"I can ask the respiratory therapist to suction secretions out through his nose."
d.
"I will have another nurse assist me to turn your husband on his side." - answerD
The emergency department team is performing cardiopulmonary resuscitation on a
client when the client's spouse arrives at the emergency department. What should the
nurse do next?
a.
Request that the client's spouse sit in the waiting room.
b.
Ask the spouse if he wishes to be present during the resuscitation.
c.
Suggest that the spouse begin to pray for the client.
d.
Refer the client's spouse to the hospital's crisis team. - answerB
The nurse has been assigned the role of triage nurse after a weather-related disaster.
What is the priority action of the nurse?
a.
Call in additional staff to assist with care of the victims.
b.
Splint fractures and clean and dress lacerations.
c.
,Perform a rapid assessment of clients to determine priority of care.
d.
Provide psychological support to staff and family members. - answerC
An industrial accident has occurred near the hospital, and many victims are brought to
the emergency department (ED) for treatment of their injuries. The nurse triages the
victim with which injury with a red tag?
a.
Dislocated right hip and an open fracture of the right lower leg
b.
Large contusion to the forehead and a bloody nose
c.
Closed fracture of the right clavicle and arm numbness
d.
Multiple fractured ribs and shortness of breath - answerD
An accident has occurred near the hospital, and a victim is brought to the emergency
department with severe chest pain, a pulse of 120 beats/min, blood pressure of 100/60
mm Hg, and a respiratory rate of 28 breaths/min. The nurse assesses shortness of
breath and diaphoresis. Which color tag does the nurse use when triaging this client?
a.
Red
b.
Yellow
c.
Green
d.
Black - answerA
A nursing instructor is debriefing students who participated in a community-wide
disaster drill. Several students are upset with the black-tagged triage category. Which
statement by the nursing instructor is best?
a.
"To do the greatest good for the greatest number of people, it is necessary to sacrifice
some."
b.
"Not everyone will survive a disaster, so it is best to identify those people early and
move on."
c.
"In a disaster, extensive resources are not used for one person at the expense of many
others."
d.
"With black tags, volunteers can identify those who are dying and can give them comfort
care." - answerC
,A community disaster has occurred and the hospital's emergency department (ED) has
efficiently triaged, treated, and transferred most clients to appropriate units. The hospital
incident command officer wants to "stand down" from the emergency plan. Which
question by the nursing supervisor is most beneficial at this time?
a.
"Are you sure no more victims are coming into the ED?"
b.
"Do all other areas of the hospital have the supplies and personnel they need now?"
c.
"Have all ED staff had the chance to eat and rest recently?"
d.
"Are all other incident command officers and house supervisors in agreement with you?"
- answerB
The triage nurse is assessing a client who has been brought to the emergency
department (ED) by emergency medical services (EMS) following a mass casualty
incident. Which assessment questions are used to determine the appropriate triage
category for the client? (Select all that apply.)
a.
"Can you wiggle your toes?"
b.
"Are you having any difficulty breathing?"
c.
"Are you allergic to any medications?"
d.
"Does your family know that you are here?"
e.
"Can you tell me what day it is?"
f.
"Do you have any abdominal or back pain?" - answerA, B, E, F
A nurse is triaging clients in the emergency department. Which client complaint would
the triage nurse classify as nonurgent?
a.
Chest pain and diaphoresis
b.
Decreased breath sounds due to chest trauma
c.
Left arm fracture with palpable radial pulses
d.
Sore throat and a temperature of 104° F - answerC
The nurse is triaging clients in the emergency department. Which client should be
considered urgent?
a.
20-year-old female with a chest stab wound and tachycardia
, b.
45 year-old homeless man with a skin rash and sore throat
c.
75-year-old female with a cough and of temperature of 102° F
d.
50-year-old male with new-onset confusion and slurred speech - answerC
The nurse is triaging clients in the emergency department (ED). Which is true about the
presentation of client symptoms?
a.
Older adults frequently have symptoms that are vague or less specific.
b.
Young adults present with nonspecific symptoms for serious illnesses.
c.
Diagnosing children's symptoms often keeps them in the ED longer.
d.
Symptoms of confusion always represent neurologic disorders. - answerA
The emergency department (ED) nurse is assigned to triage clients. What is the
purpose of triage?
a.
Treat clients on a first-come, first-serve basis.
b.
Identify and treat clients with low acuity first.
c.
Prioritize clients based on illness severity.
d.
Determine health needs from a complete assessment. - answerC
A client has been injured in a stabbing incident. Assessment reveals the following:
Blood pressure: 80/60 mm Hg
Heart rate: 140 beats/min
Respiratory rate: 35 breaths/min
Bleeding from stabbing wound site
Client is lethargic
Based on these assessment data, to which trauma center should the nurse ensure
transport of the client?
a.
Level I
b.
Level II
c.
Level III
d.
Level IV - answerA
A nurse is caring for a client who has lung cancer and is dying. Which prescription
should the nurse question?
a.
Morphine 10 mg sublingual every 6 hours PRN for pain level greater than 5
b.
Albuterol (Proventil) metered dose inhaler every 4 hours PRN for wheezes
c.
Atropine solution 1% sublingual every 4 hours PRN for excessive oral secretions
d.
Sodium biphosphate (Fleet) enema once a day PRN for impacted stool – answer A
The spouse of a dying client states that she is concerned that her husband is choking to
death. What is the nurse's best response?
a.
"Do not worry. The choking sound is normal during the dying process."
b.
"I will administer more morphine to keep your husband comfortable."
c.
"I can ask the respiratory therapist to suction secretions out through his nose."
d.
"I will have another nurse assist me to turn your husband on his side." - answerD
The emergency department team is performing cardiopulmonary resuscitation on a
client when the client's spouse arrives at the emergency department. What should the
nurse do next?
a.
Request that the client's spouse sit in the waiting room.
b.
Ask the spouse if he wishes to be present during the resuscitation.
c.
Suggest that the spouse begin to pray for the client.
d.
Refer the client's spouse to the hospital's crisis team. - answerB
The nurse has been assigned the role of triage nurse after a weather-related disaster.
What is the priority action of the nurse?
a.
Call in additional staff to assist with care of the victims.
b.
Splint fractures and clean and dress lacerations.
c.
,Perform a rapid assessment of clients to determine priority of care.
d.
Provide psychological support to staff and family members. - answerC
An industrial accident has occurred near the hospital, and many victims are brought to
the emergency department (ED) for treatment of their injuries. The nurse triages the
victim with which injury with a red tag?
a.
Dislocated right hip and an open fracture of the right lower leg
b.
Large contusion to the forehead and a bloody nose
c.
Closed fracture of the right clavicle and arm numbness
d.
Multiple fractured ribs and shortness of breath - answerD
An accident has occurred near the hospital, and a victim is brought to the emergency
department with severe chest pain, a pulse of 120 beats/min, blood pressure of 100/60
mm Hg, and a respiratory rate of 28 breaths/min. The nurse assesses shortness of
breath and diaphoresis. Which color tag does the nurse use when triaging this client?
a.
Red
b.
Yellow
c.
Green
d.
Black - answerA
A nursing instructor is debriefing students who participated in a community-wide
disaster drill. Several students are upset with the black-tagged triage category. Which
statement by the nursing instructor is best?
a.
"To do the greatest good for the greatest number of people, it is necessary to sacrifice
some."
b.
"Not everyone will survive a disaster, so it is best to identify those people early and
move on."
c.
"In a disaster, extensive resources are not used for one person at the expense of many
others."
d.
"With black tags, volunteers can identify those who are dying and can give them comfort
care." - answerC
,A community disaster has occurred and the hospital's emergency department (ED) has
efficiently triaged, treated, and transferred most clients to appropriate units. The hospital
incident command officer wants to "stand down" from the emergency plan. Which
question by the nursing supervisor is most beneficial at this time?
a.
"Are you sure no more victims are coming into the ED?"
b.
"Do all other areas of the hospital have the supplies and personnel they need now?"
c.
"Have all ED staff had the chance to eat and rest recently?"
d.
"Are all other incident command officers and house supervisors in agreement with you?"
- answerB
The triage nurse is assessing a client who has been brought to the emergency
department (ED) by emergency medical services (EMS) following a mass casualty
incident. Which assessment questions are used to determine the appropriate triage
category for the client? (Select all that apply.)
a.
"Can you wiggle your toes?"
b.
"Are you having any difficulty breathing?"
c.
"Are you allergic to any medications?"
d.
"Does your family know that you are here?"
e.
"Can you tell me what day it is?"
f.
"Do you have any abdominal or back pain?" - answerA, B, E, F
A nurse is triaging clients in the emergency department. Which client complaint would
the triage nurse classify as nonurgent?
a.
Chest pain and diaphoresis
b.
Decreased breath sounds due to chest trauma
c.
Left arm fracture with palpable radial pulses
d.
Sore throat and a temperature of 104° F - answerC
The nurse is triaging clients in the emergency department. Which client should be
considered urgent?
a.
20-year-old female with a chest stab wound and tachycardia
, b.
45 year-old homeless man with a skin rash and sore throat
c.
75-year-old female with a cough and of temperature of 102° F
d.
50-year-old male with new-onset confusion and slurred speech - answerC
The nurse is triaging clients in the emergency department (ED). Which is true about the
presentation of client symptoms?
a.
Older adults frequently have symptoms that are vague or less specific.
b.
Young adults present with nonspecific symptoms for serious illnesses.
c.
Diagnosing children's symptoms often keeps them in the ED longer.
d.
Symptoms of confusion always represent neurologic disorders. - answerA
The emergency department (ED) nurse is assigned to triage clients. What is the
purpose of triage?
a.
Treat clients on a first-come, first-serve basis.
b.
Identify and treat clients with low acuity first.
c.
Prioritize clients based on illness severity.
d.
Determine health needs from a complete assessment. - answerC
A client has been injured in a stabbing incident. Assessment reveals the following:
Blood pressure: 80/60 mm Hg
Heart rate: 140 beats/min
Respiratory rate: 35 breaths/min
Bleeding from stabbing wound site
Client is lethargic
Based on these assessment data, to which trauma center should the nurse ensure
transport of the client?
a.
Level I
b.
Level II
c.
Level III
d.
Level IV - answerA
