WEEKEND CLASS 3

EVENING CLASS 1

EVENING CLASS 2

CRASH COURSE

FAST TRACK

1. The nurse is assigned to care for four *1/1

clients. In planning client rounds, which
client would the nurse assess first?

A postoperative client preparing for discharge

with a new medication

A client requiring daily dressing changes of a

recent surgical incision

A client scheduled for a chest x-ray after

insertion of a nasogastric tube

A client with asthma who requested a

breathing treatment during the previous
shift
 2. The nurse employed in an emergency *1/1
department is assigned to triage clients
coming to the emergency department for
treatment on the evening shift. The nurse
would assign priority to which client?

A client complaining of muscle aches, a

headache, and history of seizures

A client who twisted their ankle when

rollerblading and is requesting medication for
pain

A client with a minor laceration on the index

finger sustained while cutting an eggplant
Management
RIOM
> MI : I
A client with chest pain who states that
Doctor
they just ate pizza that was made with a
very spicy sauce

3. The nurse has received the assignment *1/1

for the dayshift. After making initial
rounds and checking all of the assigned
clients, which client would the nurse plan
to care for first?

A client who is ambulatory, demonstrating

steady gait

A postoperative client who has just received an

opioid pain medication

A client scheduled for physical therapy for the

first crutch-walking session

A client with a white blood cell count of

14,000 mm3 and a temperature of 38.4° C sign of
Infection
Normal NBC :
4 5 k to 11k
.
 -
4. The client is admitted into the *···/1
emergency department with diaphoresis,
pale clammy skin, and BP of 90/70. Hy povolemic
Shock
Which intervention should the nurse
implement first?

O Start an IV with an 18-gauge catheter.

Administer intravenous dopamine infusion. secondary

Obtain arterial blood gases (ABGs). secondary

Insert an indwelling urinary catheter. secondary

Walang mga tamang sagot

5. The client has recently experienced a *0/1

myocardial infarction. Which action by
the nurse helps prevent cardiogenic
shock?

Monitor the client's telemetry.

Turn the client every 2 hours. bedsores/pressure ukers

Administer oxygen via nasal cannula.

Place the client in the Trendelenburg

position. Hypovolemic

Tamang sagot

Administer oxygen via nasal cannula.

 6. The triage nurse in a large trauma *0/1
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?

SAFETY FIRST !!

A. Triage the clients and send them to the

appropriate areas.

B. Thoroughly wash the clients with soap and

water and then rinse.

C. Remove the clients’ clothing and have them

shower.

D. Assume the clients have been

decontaminated at the plant.

Tamang sagot

C. Remove the clients’ clothing and have them

shower.

7. According to the North Atlantic Treaty *1/1

Organization (NATO) triage system,
which situation is considered a level
red?

A. Injuries are extensive and chances of

survival are unlikely.

B. Injuries are minor and treatment can be

delayed hours to days.

C. Injuries are significant but can wait hours

without threat to life or limb.

D. Injuries are life-threatening but

survivable with available interventions.
8. The nurse in a disaster is triaging the *1/1
following clients. Which client should be
triaged as an Expectant Category and
color black?

A. The alert client diagnosed with a sucking

chest wound.

B. The unresponsive client diagnosed with

a head injury.

C. The client diagnosed with an abdominal

wound and stable vital signs.

D. The client diagnosed with a sprained ankle

which may be fractured.

9. The father of a child brought to the *1/1

emergency department is yelling at the
staff and obviously intoxicated. Which
approach should the nurse take with the
father?

A. Talk to the father in a calm and low

voice.

B. Tell the father to wait in the waiting room.

C. Notify the child's mother to come to the ED.

D. Call the police department to come and

arrest him.
 10. The nurse is providing first aid to a *1/1
victim of a poisonous snake bite. Which
intervention should be the
nurse’s first action?

A. Apply a tourniquet to the affected limb.

B. Cut an “X” across the bite and suck out the

venom.

C. Administer a corticosteroid medication.

D. Have the client lie still and remove

constrictive items.

11. In conducting a primary survey on a *0/1

trauma patient, which of the following is
considered one of the priority elements
of the primary survey?

a. Complete set of vital signs

b. Palpation and auscultation of the abdomen

c. Brief neurologic assessment

d. Initiation of pulse oximetry.

Tamang sagot

c. Brief neurologic assessment

 12. A 56-year-old patient presents in *0/1
triage with left-sided chest pain,
diaphoresis and dizziness. This patient
should be prioritized into which
category?

High urgent

Urgent

Non-urgent

Emergent

Tamang sagot

Emergent

13. It is the summer season, and patients *1/1

with signs and symptoms of heat-related
illness present in the ED. Which patient
needs attention first?

a. An elderly person complains of dizziness

and syncope after standing in the sun for
several hours to view a parade.

b. A marathon runner complains of severe leg

cramps and nausea. Tachycardia, diaphoresis,
pallor and weakness are observed.

c. A previously healthy homemaker reports

broken airconditioner for days. Tachypnea,
hypotension, fatigue and profuse diaphoresis
are observed

d. A homeless person, poor historian,

presents with altered mental status, poor
muscle coordination and hot, dry ashen
skin. Duration of exposure is unknown.
 14. An anxious 24-year-old college *1/1
student complains of tingling sensations,
palpitations, and chest tightness. Deep,
rapid breathing and carpal spasms are
noted. What priority nursing action
should you take?
Hyperventilation off Anxiety

Notify the physician immediately.

Administer supplemental oxygen.

Have the student breathe into a paper bag. carbon

~ Dioxide

Obtain an order for an anxiolytic medication

15. A teenager arrives by a private car. *0/1

He is alert and ambulatory, but this shirt
and pants are covered with blood. He and
his hysterical friends are yelling and
trying to explain that they were goofing
around and he got poked in the abdomen
with a stick. Which of the following
comments should be given first
consideration?

a. "There was a lot of blood and we used

three bandages."

b. "He pulled the stick out, just now, because it

was hurting him." circulation

C. "The stick was really dirty and covered with

mud." infection

d. "He's a diabetic, so he needs attention right

away." secondary

Tamang sagot

b. "He pulled the stick out, just now, because it

was hurting him."
 16. These patients present to the ED *0/1
complaining of acute abdominal pain.
Who among these pt will be your
outmost priority?

a. A 35-year-old male complaining of severe,

intermittent cramps with three episodes of
watery diarrhea, 2 hours after eating.

b. An 11-year-old boy with a low-grade

fever, left lower quadrant tenderness,
nausea and anorexia for the past 2 days.

c. A 40-year-old female with moderate left

upper quadrant pain, vomiting small amounts
of yellow bile, and worsening symptoms over
the past week.

d. A 56-year-old male with a pulsating

abdominal mass and sudden onset of pressure-
like-pain in the abdomen and flank within the
past hour.

Tamang sagot

d. A 56-year-old male with a pulsating

abdominal mass and sudden onset of pressure-
like-pain in the abdomen and flank within the
past hour.

17. In a multiple-trauma victim, which *1/1

assessment finding signals the most
serious and life-threatening condition?

A deviated trachea

Gross deformity in a lower extremity.

Decreased bowel sounds.

Hematuria
 18. A triage nurse is talking to a patient *1/1
when the patient begins choking on his
lunch. The patient is coughing forcefully.
What should the nurse do?

A) Stand him up and perform the abdominal

thrust maneuver from behind.

B) Lay him down, straddle him, and perform

the abdominal thrust maneuver.

C) Leave him to get assistance.

D) Stay with him and encourage him, but

not intervene at this time.

19. A 6-year-old is admitted to the ED *0/1

after being rescued from a pond after
falling through the ice while ice skating.
What action should the nurse perform
while rewarming the patient?

A. Assessing the patients oral temperature

frequently

B. Ensuring continuous ECG monitoring

C. Massaging the patients skin surfaces to

promote circulation

D. Administering bronchodilators by nebulizer

Tamang sagot

B. Ensuring continuous ECG monitoring

20. A male patient with multiple injuries *1/1
is brought to the ED by ambulance. He
has had his airway stabilized and is
breathing on his own. The ED nurse does
not see any active bleeding, but should
suspect internal hemorrhage based on
what finding?

Absence of bruising at contusion sites

Rapid pulse and decreased capillary refill

compensatory mechanism

Increased BP with narrowed pulse pressure

Sudden diaphoresis

21. A patient is brought to the ER in an *1/1

unconscious state. The physician notes
that the patient is in need of emergency
surgery. No family members are present,
and the patient does not have
identification. What action by the nurse
is most important regarding consent for
treatment?

Ask the social worker to come and sign the

consent.

Contact the police to obtain the patients

identity.

Obtain a court order to treat the patient.

Clearly document LOC and health status

on the patient’s chart.
 22. A patient is experiencing respiratory *1/1
insufficiency and cannot maintain
spontaneous respirations. The nurse
suspects that the physician will perform
which of the following actions?

Insert an oropharyngeal airway.

Perform the jaw thrust maneuver.

Perform endotracheal intubation.

Perform a cricothyroidotomy.

23. A patient is admitted to the ED after *0/1

being involved in a motor vehicle
accident. The patient has multiple
injuries. After establishing an airway and
adequate ventilation, the ED team should
prioritize what aspect of care?

Control the patients hemorrhage.

Assess for cognitive effects of the injury.

Splint the patient’s fractures.

Assess the patient’s neurologic status.

Tamang sagot

Control the patients hemorrhage.

 24. The triage nurse is working in the *1/1
ED. A homeless person is admitted
during a blizzard with complaints of
being unable to feel his feet and lower
legs. Core temperature is noted at 33.2C
(91.8F). The patient is intoxicated with
alcohol at the time of admission and is
visibly malnourished. What is the triage
nurses priority in the care of this patient?

A) Addressing the patients hypothermia

B) Addressing the patients frostbite in his

lower extremities

C) Addressing the patients alcohol intoxication

D) Addressing the patients malnutrition

25. A patient is verbally abusive and is *0/1

fighting the staff in the ED, but appears
medically stable. The decision is made to
place the patient in restraints. What
action should the nurse perform when the
patient is restrained?

A) Frequently assess the patients skin integrity.

B) Inform the patient that he is likely to be

charged with assault.

C) Avoid interacting with the patient until the

restraints are removed.

D) Take the opportunity to perform a full

physical assessment.

Tamang sagot

A) Frequently assess the patients skin integrity.

 26. An ED nurse is triaging patients *1/1
according to the Emergency Severity
Index (ESI). When assigning patients to
a triage level, the nurse will consider the
patients acuity as well as what other
variable?

A) The likelihood of a repeat visit to the ED in

the next 7 days

B) The resources that the patient is likely to

require

C) The patients or insurers ability to pay for

care

D) Whether the patient is known to ED staff

from previous visits

27. Circulation must be restored within *0/1

four minutes of cardio pulmonary arrest
because

A. Irreversible kidney failure develops

B. Blood begins to coagulate

C. Lungs begin to fill with fluid

D. Brain cells begin to die

Tamang sagot

D. Brain cells begin to die

 28. The nurse witnessed a motor vehicle *0/1
accident that injured four people, all of
which have a decreased level of
consciousness. After an initial
assessment of each individual's
condition, the nurse determines which
should be treated first?

A. A 25-year-old woman hemorrhaging from a

right thigh laceration

B. A 20-year-old man complaining of

immobility in arms and legs

C. A 35 year-old man with clear fluid

leaking from his nose

D. A 30 year old woman with paradoxical chest

movement

Tamang sagot

D. A 30 year old woman with paradoxical chest

movement

29. Grabbing the throat with one or both *1/1

hands as a universal sign for:

A. Heart attack

B. Choking

C. Danger

D. Loss of consciousness
 30. All of the following are important *1/1
teaching points to prevent heat
exhaustion except:

A. Avoid strenuous activities in high

temperature or humidity

B. Increase fluid intake

C. Wear heavy clothing to absorb

perspiration

D. Take frequent rest breaks

31. Skin is red, hot, and dry perspiration *0/1

is absent

A. Heat stroke

B. Heat exhaustion

C. Hyperthermia

D. Hypothermia

Tamang sagot

A. Heat stroke

32. What is the danger of too rapid *1/1

rewarming as treatment for a patient with
severe hypothermia?

A. Cardiac dysrhythmias

B. Heat stroke

C. Tingling and numbness

D. Muscle cramps
 33. In an adult, what amount of blood *1/1
loss results in hypovolemic shock?

A. 30 mL or more

B. 1 pint or more

C. 1 L or more

D. 10 L or more

34. Immediate treatment for external *1/1

bleeding is

A. Application of ice

B. Evaluate the site of bleeding

C. Direct continuous pressure

d. Checking vital signs

35. While triaging clients in a crowded *0/1

emergency department, a nurse assesses
a client who presents with symptoms of
tuberculosis. Which action should the
nurse take first?

a. Apply oxygen via nasal cannula.

b. Administer intravenous 0.9% saline solution.

c. Transfer the client to a negative-pressure

room.

d. Obtain a sputum culture and sensitivity.

Tamang sagot

c. Transfer the client to a negative-pressure

room.
36. Emergency medical technicians *1/1
arrive at the emergency department with
an unresponsive client who has an
oxygen mask in place. Which action
should the nurse take first?

a. Assess that the client is breathing

adequately.

b. Insert a large-bore intravenous line.

c. Place the client on a cardiac monitor.

d. Assess for the best neurologic response.

37. A nurse is triaging clients in the *1/1

emergency department. Which client
should be considered urgent?

a. A 20-year-old female with a chest stab

wound and tachycardia

b. A 45-year-old homeless man with a skin rash

and sore throat

c. A 75-year-old female with a cough and a

temperature of 38.8˚c

d. A 50-year-old male with new-onset

confusion and slurred speech
 38. A nurse is triaging clients in the *1/1
emergency department. Which client
should the nurse classify as nonurgent?

a. A 44-year-old with chest pain and

diaphoresis

b. A 50-year-old with chest trauma and absent

breath sounds

c. A 62-year-old with a simple fracture of

the left arm

d. A 79-year-old with a temperature of 104 F

39. A 67-year-old patient who has fallen *0/1

from a ladder is transported to the
emergency department by ambulance.
The patient is unconscious on arrival and
accompanied by family members. During
the primary survey of the patient, the
nurse should

a. assess a full set of vital signs.

b. obtain a Glasgow Coma Scale score.

c. attach a cardiac ECG monitor.

d. ask about chronic medical conditions.

Tamang sagot

b. obtain a Glasgow Coma Scale score.

 40. Placement of a nasogastric tube (NG) *0/1
is contraindicated during emergency care
when the patient has a possible

A) Inhalation injury.

B) Head or facial trauma.

C) Intra-abdominal bleeding.

D) Cervical spine fracture.

Tamang sagot

B) Head or facial trauma.

41. A nurse is providing an in-service *1/1

program for fellow emergency nurses
about hypothermia and rewarming
methods used. The nurse determines that
the presentation was successful when the
group identifies which of the following
as a passive-active rewarming method?

a. Over-the-bed heaters

b. Warmed humidified oxygen by ventilator

c. Forced warm air blankets

d. Cardiopulmonary bypass
42. The nurse is administering antivenin *1/1
to a patient who was bitten on the arm by
a poisonous snake. What intervention
provided by the nurse is required prior to
the procedure and every 15 minutes
after?

a. Measure the circumference of the arm.

b. Administer diphenhydramine (Benadryl).

c. Assess peripheral pulses.

d. Administer cimetidine (Tagamet).

43. What is a common source of airway *1/1

obstruction in an unconscious client?

a. A foreign object

b. The tongue

c. edema

d. Saliva or mucus
44. A nurse is completing her annual *1/1
cardiopulmonary resuscitation training.
The class instructor tells her that a client
has fallen off a ladder and is lying on his
back; he is unconscious and isn't
breathing. What maneuver should the
nurse use to open his airway?

a. Jaw-thrust

b. Abdominal thrust

c. Seldinger

d. Head tilt-chin lift

45. A nurse is assessing a patient who is *1/1

suspected of having a partial airway
obstruction. Which of the following
would the nurse expect to find?

a. Severe respiratory distress

b. High-pitched noises on inhalation

c. Spontaneous coughing

d. Cyanosis
46. A client has a gaping wound on his *1/1
forearm that is bleeding profusely.
Applying pressure to which pressure
point would be most helpful?

a. Subclavian

b. Femoral

c. Radial

d. Brachial

47. A nurse is caring for a client who has *1/1

arrived at the emergency department in
shock. The nurse intervenes based on the
knowledge that which of the following is
the most common cause of shock?

MI

Infection

Anaphylaxis

Hypovolemia
48. Which solution should the nurse use *1/1
to replace lost fluids in a client with
signs and symptoms of shock due to
hemorrhaging?

Plain Normal Saline Solution

Lactated Ringers

D5 Water

D5 IMB

49. An 85-year-old client is admitted to *1/1

the ED. Heat stroke is suspected. The
client's core temperature is 106.2°F
(41.2°C), blood pressure (BP) 90/60 mm
Hg, and pulse 102 bpm. The nurse
understands that the primary treatment
and optimal method for cooling measure
is

Remove pt’s clothing

Cool sheets and towels: continuous sponging

Cooling blankets

Immersion of the pt in a cold water bath

 50. A nurse is establishing a patient's *1/1
airway. Which action would the nurse
perform first?

OPA or NPA

Endotracheal Intubation

Head tilt/Chin lift

Reposition pt’s head

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