ANSWERS AND RATIONALES

EXAM CODE HAAD10

1. Answer: C
Rationale: Nausea is one of the common complaints of a patient after
receiving general anesthesia. But this complaint could be aggravated by
gastric distention especially in a patient who has undergone abdominal
surgery. Insertion of the NGT helps relieve the problem. Checking on the
patency of the NGT for any obstruction will help the nurse determine the
cause of the problem and institute the necessary intervention.

2. Answer: D
Drains are usually inserted into the splenic bed to facilitate removal of
fluid in the area that could lead to abscess formation.

3. Answer: C
Rationale: The nurse’s priority at this time is to alleviate the chest pain
of the client. Obtaining chest radiograph, ECG and blood work are all
important and can be done after administering morphine.

4. Answer: B
Rationale: There are many possible causes for a childhood seizure. These
include fever, central nervous system conditions, trauma, metabolic
alterations and idiopathic

5. Answer: B
Rationale: Croup is an upper airway obstruction and the signs and
symptoms are because of difficulty getting air past the upper airway.
Wheezing is found with Asthma, decreased aeration in lung fields is found
with Pneumonia. Shallow respirations are unlikely; the child may exhibit
retractions, but not shallow respirations.

6. Answer: B
Rationale: This patient is suffering from frostbite, due to prolonged
exposure to sub-freezing temperatures without proper protection.
Frostbite is a condition in which there is trauma to the tissues without
actual freezing of tissue fluids. Exposed areas of the body such as
hands, feet, earlobes, etc. are all subject to this. The affected part
becomes hard, cold, and is not sensitive to touch, and mottled bluish-
white in color. The aim of nursing care is to restore normal temperature
and circulation to the part.

7. Answer: A
Rationale: When dealing with an emergency, the ABCs — airway,
breathing, and circulation — are the priorities and must be maintained
first. Blood pressure, neurological, and neurovascular assessments are
important, but in this case, airway is the priority.

8. Answer: B
Rationale: Infection is a priority for all types of burns. Airway is a
priority only for burns to the face and neck. Pain is a second priority
for 1st and 2nd degree burns. Fluid and electrolyte balance is a second
priority for 3rd and 4th degree burns [no pain because nerve endings are
damaged].

9. Answer: C
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Rationale: Regardless of the cause, the priority in an emergency situation

is the ABCs — airway, breathing, and circulation; thus, the priority would
be to provide support for breathing and circulation. Eliminating the drug
from the body is important, but only after respiratory and cardiovascular
support is provided.

10. Answer: B
Rationale: The client is probably experiencing autonomic hyperreflexia, a
medical emergency usually triggered by a distended bladder; a distended
bowel or pain also may lead to autonomic hyperreflexia

11. Answer: C
Rationale: Because of the effects of the electrical current on the
cardiovascular system, all clients experiencing electrical burns should be
placed on a cardiac monitor. Applying ice is inappropriate for any type of
burn. Only chemical burns should be flushed with large amounts of water.
Chemical antidotes may be used for chemical burns for which an antidote
has been identified.

12. Answer: D
Rationale: Respiratory and cardiovascular functions are essential for
oxygenation. These are top priorities to trauma management. Basic life
functions must be maintained or reestablished

13. Answer: C
Rationale: Acute asthmatic attack is characterized by severe
bronchospasm which can be relieved by the immediate administration of
bronchodilators. Adrenaline or Epinephrine is an adrenergic agent that
causes bronchial dilation by relaxing the bronchial smooth muscles.

14. Answer: A
Rationale: Swallowing of corrosive substances causes severe irritation and
tissue destruction of the mucous membrane of the GI tract. Measures are
taken to immediately remove the toxin or reduce its absorption. For
corrosive poison ingestion, such as in muriatic acid where burn or
perforation of the mucosa may occur, gastric emptying procedure is
immediately instituted, This includes gastric lavage and the administration
of activated charcoal to absorb the poison. Administering an irritant with
the concomitant vomiting to remove the swallowed poison will further
cause irritation and damage to the mucosal lining of the digestive tract.
Vomiting is only indicated when non-corrosive poison is swallowed.

15. Answer: B
Rationale: Sudden death of a family member creates a state of shock on
the family. They go into a stage of denial and anger in their grieving.
Assisting them with information they need to know, answering their
questions and listening to them will provide the needed support for them
to move on and be of support to one another.

16. Answer: C
Rationale: Perform 5 abdominal thrusts. At this age, the most effective
way to clear the airway of food is to perform abdominal thrusts.

17. Answer: D
Rationale: Ensure an intake of at least 3000 ml of fluid per day. Gouty
arthritis is a metabolic disease marked by urate deposits that cause
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painful arthritic joints. The patient should be urged to increase his fluid
intake to prevent the development of urinary uric acid stones.

18. Answer: A
Rationale: The Heimlich maneuver is used to assist a person choking on a
foreign object. The pressure from the thrusts lifts the diaphragm, forces
air out of the lungs and creates an artificial cough that expels the
aspirated material.

19. Answer: C
Rationale: The exact and safe location to do cardiac compression is the
lower half of the sternum. Doing it at the lower third of the sternum
may cause gastric compression which can lead to a possible aspiration.

20. Answer: B
Rationale: Sudden death of a family member creates a state of shock on
the family. They go into a stage of denial and anger in their grieving.
Assisting them with information they need to know, answering their
questions and listening to them will provide the needed support for them
to move on and be of support to one another.

21. Answer: D
Rationale: Presence of abdominal drains for several days after surgery
Drains are usually inserted into the splenic bed to facilitate removal of
fluid in the area that could lead to abscess formation.

22. Answer: A
Rationale: to establish the sufficiency of fluid resuscitation, urine output
totals an index of renal perfusion. Urine output totals an index of renal
perfusion, urine output totals of 30-50 ml/hour have been used as
resuscitation goals. Other indicators of adequate fluid replacement are
systolic blood pressure exceeding 100 mmHg, a pulse rate less than110
beats/min or both.

23. Answer: B
Rationale: Emergent surgery is performed, immediately without delay to
maintain life, limb or organ, remove damage and stop bleeding. Urgent
surgery requires prompt attention and is done few hours but within 24 to
48 hours. Required surgery is done within a few weeks as surgery is
important. Elective surgery is scheduled and done at the convenience of
client as failure to have surgery is not catastrophic. Optional surgeries
are done by preference only.

24. Answer: A
Rationale: Introducing self initiates the nurse-patient interaction,
relationship and the purpose of being with the client. This prevents
confusion and let the client know what to expect, thereby reducing
anxiety.
25. Answer: A
Rationale: Awakening the client every 2 hours allows the identification of
headache, dizziness, lethargy, irritability, and anxiety—all signs of post-
concussion syndrome—that would warrant the significant other’s taking the
client back to the emergency department.

26. Answer: A
Rationale: This client has been exposed to wind and sun at the lake
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during the hours prior to being admitted to the emergency department.

This predisposes the client to dehydration and an Addisonian crisis. Rapid
IV fluid replacement is necessary.

27. Answer: D
Rationale: Keeping the fingernails short will reduce the chance of breaks
in the skin from scratching.

28. Answer: B
Rationale: This is a major abdominal surgery, and there are massive fluid
volume shifts that occur when this type of trauma is experienced by the
body. Maintaining the circulatory system without overloading it requires
extremely close monitoring.

29. Answer: A
Rationale: The client will have jaundice, clay-colored stools, and tea-
colored urine resulting from blockage of the bile drainage.

30. Answer: C
Rationale: These are symptoms of an insulin reaction (hypoglycemia). A
bedside glucose check should be done. Pancreatic islet tumors can produce
hyperinsulinemia or hypoglycemia.

31. Answer: C
Rationale: Limiting the intake of meat and fats in the diet would be an
example of primary interventions. Risk factors for the development of
cancer of the pancreas are cigarette smoking and eating a high-fat diet
that is high in animal protein. By changing these behaviors the client
could possibly prevent the development of cancer of the pancreas. Other
risk factors include genetic predisposition and exposure to industrial
chemicals.

32. Answer: B
Rationale: The most important person in the treatment of the cancer is
the client. Research has proved that the more involved a client becomes
in his or her care, the better the prognosis. Clients should have a chance
to ask all the questions that they have.

33. Answer: D
Rationale: A collaborative intervention would be to refer to the nutrition
expert, the dietitian.

34. Answer: A
Rationale: The nurse should assess the nail beds for the capillary refill
time. A prolonged time (greater than three seconds) indicates impaired
circulation to the extremity.

35. Answer: C
Rationale: This is the first intervention the nurse should implement after
finding the client unresponsive on the floor.

36. Answer: C
Rationale: 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 assistant.
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37. Answer: C
Rationale: 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.

38. Answer: A
Rationale: This is the correct statement explaining what an AED does
when used in a code.

39. Answer: C
Rationale: Ventricular fibrillation is the most common dysrhythmia
associated with sudden cardiac death; ventricular fibrillation is responsible
for 65% to 85% of sudden cardiac deaths.

40. Answer: A
Rationale: The chaplain should be called to help address the client’s
family or significant others.
A small community hospital would not have a 24-hour on-duty pastoral
service.

41. Answer: D
Rationale: Nurses should protect themselves against possible communicable
disease, such as HIV, hepatitis, or any types of sexually transmitted
disease.

42. Answer: C
Rationale: Unexpected death occurring within1 hour of the onset of
cardiovascular symptoms is the definition of sudden cardiac death.

43. Answer: A
Rationale: Gastric distention occurs from overventilating clients. When
compressions are performed, the pressure will cause vomiting that could
be aspirated into the lungs.

44. Answer: B
Rationale: The crash cart is the mobile unit that has the defibrillator
and all the medications and supplies needed to conduct a code.

45. Answer: D
Rationale: The chart is a legal document and the code must be
documented in the chart and provide information that may be needed in
the intensive care unit.

46. Answer: B
Rationale: The nurse should take note of any unusual illness for the time
of year or clusters of clients coming from a single geographical location
who all exhibit signs/symptoms of possible biological terrorism.

47. Answer: A
Rationale: 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.

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48. Answer: C
Rationale: The health-care providers are not guaranteed absolute protects.
The nurse should take note of any unusual illness for the time of year or
clusters of clients coming from a single geographical location who all
exhibit signs/symptoms of possible biological terrorism.ion, even with all
the training and protective equipment.

49. Answer: D
Rationale: Avoiding cross contamination is a priority for personnel and
equipment—the fewer number of people exposed, the safer the community
and area.

50. Answer: C
Rationale: This is the first step. Depending on the type of exposure, this
step alone can remove a large portion of exposure.

51. Answer: D
Rationale: Because of the variety of agents, the means of transmission,
and lethality of the agents, biological weapons, including anthrax,
smallpox, and plague, is especially dangerous.

52. Answer: B
Rationale: Exposure to anthrax bacilli via the skin results in skin lesions,
which cause edema with pruritus and the formation of macules or papules
that ulcerate, forming a 1-3 mm vesicle. Then a painless eschar develops,
which falls off in one (1) to 2 weeks.

53. Answer: A
Rationale: Cremation is recommended because the virus can stay alive in
the scabs of the body for 13 years.
54. Answer: B
Rationale: Standing up will avoid heavy exposure the chemical will sink
toward the floor or ground.

55. Answer: C
Rationale: The prodromal phase (presenting symptoms) of radiation
exposure occurs 48–72 hours after exposure and the signs/symptoms are
nausea, vomiting, diarrhea, anorexia, and fatigue. Higher exposures of
radiation signs/symptoms include fever, respiratory distress, and
excitability.
56. Answer: D
Rationale: The nurse should follow the hospital’s policy. Many times
nurses will stay at home until decisions are made as to where the
employees should report.

57. Answer: A
Rationale: The MSDS provides chemical information regarding specific
agents, health information, and spill information for a variety of
chemicals. It is required for every chemical that is found in the hospital.

58. Answer: B
Rationale: The triage nurse should see this client first because these are
symptoms of a myocar- dial infarction, which potentially life is
threatening.

59. Answer: D
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Rationale: This is called the immediate category. Individuals in this group

can progress rapidly to expectant if treatment is delayed.

60. Answer: D
Rationale: New settings and atypical roles for nurses may be required
during disasters; medical-surgical nurses can provide first aid and be
required to work in unfamiliar settings.

61. Answer: B
Rationale: This client has a very poor prognosis, and even with treatment,
survival is unlikely.

62. Answer: C
Rationale: Federal resources include organizations such as DHHS and the
Department of Justice. Each of these federal departments oversees
hundreds of agencies, including the American Red Cross, that respond to
disasters.

63. Answer: A
Rationale: CISM is an approach to preventing and treating the emotional
trauma that can affect 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.

64. Answer: B
Rationale: Emergency operations plans will always have a designated
disaster plan coordinator.
All public information should be routed through this person.

65. Answer: C
Rationale: 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. The HCP needs to be informed immediately of the
action.

66. Answer: A
Rationale: This will help diffuse the escalating situation and attempt to
keep the father calm.

67. Answer: D
Rationale: Self-protection is priority, and the nurse is not required to be
injured in the line of duty.

68. Answer: D
Rationale: The Poison Control Center can assist the nurse in identifying
which chemical has been ingested by the child and the antidote.

69. Answer: A
Rationale: The primary goal for the ED nurse is to stop the action of the
poison and then maintain organ functioning.

70. Answer: C
Rationale: Airway edema or obstruction can occur as a result of the
burning action of corrosive substances.

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71. Answer: B
Rationale: These are signs and symptoms 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 elimination of the carbon monoxide.

72. Answer: A
Rationale: 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 and then proceeding to rinsing with
water.
If the person has a dry powder form of white phosphorus or lye, it is
brushed off and then the client is placed under the shower.

73. Answer: B
Rationale: Clients with botulism are at risk for respiratory paralysis, and
this is the priority problem.

74. Answer: D
Rationale: The client should lie down, all restrictive items such as rings
should be removed, the wound should be cleansed and covered with a
sterile dressing, the affected body part should be immobilized, and the
client should be kept warm.

75. Answer: B
Rationale: The lips should be pink, not bright red or blue. This indicates
a saturation of the hemoglobin with carbon monoxide. This client needs
more instruction.

76. Answer: B
Rationale: This is a sterile dressing change and should not be delegated.

77. Answer: A
Rationale: Before administering antivenin, the affected body part must be
measured and remeasured every 15 minutes during a 4- to 6-hour
procedure. The infusion is begun slowly and increased after 10 minutes.
The affected part is measured every 30–60 minutes after the infusion and
for 48 hours to detect symptoms of compartment syndrome (swelling, loss
of pulse, increased pain, and paresthesias). Allergic reactions to the
antivenin are not uncommon and are usually the result of a too-rapid
infusion of the antivenin. The most experienced nurse should be assigned
this client.

78. Answer: A
Rationale: There are many type 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. This client has
signs and symptoms of shock, and the narrowing pulse pressure indicates
the client is getting worse.

79. Answer: C
Rationale: The client must have a urinary output of at least 30 mL/hr, so
90 mL in the last four (4) hours indicates impaired renal perfusion, which
is a sign of worsening shock and warrants immediate intervention.
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80. Answer: B
Rationale: An IV antibiotic is the priority medication for the client 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 one (1) hour of receiving
the order.

81. Answer: B
Rationale: The client will have bradycardia instead of tachycardia, which
is seen in other forms of shock.

82. Answer: C
Rationale: Any time a nurse administers a medication for the first time,
the client should be observed for a possible anaphylactic reaction,
especially with antibiotics.
83. Answer: D
Rationale: Antipyretic medication will help decrease the client’s fever,
which directly addresses the etiology of the client’s nursing diagnosis.

84. Answer: A
Rationale: Specimens should be put into biohazard bags prior to leaving
the client’s room.

85. Answer: B
Rationale: This client’s signs/symptoms would 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 NSAID medications 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.

86. Answer: C
Rationale: Promoting adequate oxygenation of the heart muscle and
decreasing the cardiac workload can prevent cardiogenic shock.

87. Answer: D
Rationale: A sensitivity report that indicates a resistance to the antibiotic
being given 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 that the antibiotic can be changed.

88. Answer: A
Rationale: The hypodynamic phase is the last and irreversible phase of
septic shock, characterized by low cardiac output with vasoconstriction.
It reflects the body’s effort to compensate for hypovolemia caused by the
loss of intravascular volume through the capillaries.

89. Answer: D
Rationale: By escorting the client to a bathroom for any reason, the
nurse can get the client to a safe area out of the hearing of the spouse.
This is the most innocuous way to get the client alone.

90. Answer: B
Rationale: The nurse should arrange for the social worker to see the
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client and family to determine if some arrangements could be made to

provide for the client’s safety and for the client to be provided with
nutritious meals while the adult children are at work. A long-term care
facility or adult day care may be needed.

91. Answer: A
Rationale: Research suggests that at least 67% of adolescents who are
runaways or homeless have been abused in the home. This represents a
learned behavior pattern that gets the female adolescent attention.

92. Answer: B
Rationale: Child Protective Services should be notified to protect the child
from further abuse and to initiate charges against the father. An
intermediate school nurse would be caring for children in the 4th, 5th,
6th, or 7th grades, depending on the school district.

93. Answer: C
Rationale: Rape is an act of violence motivated by the rapist desires to
overpower and control the victim.

94. Answer: D
Rationale: The nurse should help the client to devise a plan for safety by
giving the client the number of a safe house or a woman’s shelter.

95. Answer: B
Rationale: Many times the elderly are ashamed to report abuse because
they raised the abuser and feel responsible that their child became an
abuser. The elder parent may feel financially dependent on the child or
be afraid of being placed in a long-term care facility. Forty-seven states
have Adult Protective
Services (APS) created by the states to protect elder citizens.

96. Answer: D
Rationale: This statement assesses the abused client’s safety (or a plan
for safety).

97. Answer: A
Rationale: Clients diagnosed with PTSD are easily startled and can react
violently if awakened from sleep by being touched.

98. Answer: C
Rationale: The client should be provided the phone number of a rape
crisis counseling center or counselor to help the client deal with the
psychological feelings of being raped.

99. Answer: B
Rationale: The first step in helping a client who has been abused is to
get the client to admit that the abuse is happening.

100. Answer: C
Rationale: When a client suffers from multiple rib fractures, the client
has an increased risk for flail chest. The nurse should assess the client
for paradoxical chest wall movement and, if respiratory distress is
present forpallor and cyanosis.

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