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A. Removing the stinger by scraping it. A. Direct the clients to the decontamination
B. Applying a cold compress. area.
C. Taking an oral antihistamine. B. Direct the clients to the cold or clean zone
D. Calling the 911. for immediate treatment.
C. Measure vital signs and auscultate lung
sounds.
2. Nurse Anna is an experienced travel
D. Immediately remove other clients and
nurse who was recently employed and is
visitors from the area.
assigned in the emergency unit. In her
E. Instruct personnel to don personal
first week of the job, which of the
protective equipment.
following area is the most appropriate
assignment for her?
6. When an unexpected death occurs in
the emergency department, which task
A. Triage.
is the most appropriate to delegate to
B. Ambulatory section.
a nursing assistant?
C. Trauma team.
D. Psychiatric care
A. Help the family to collect belongings.
B. Assisting with postmortem care.
3. A client arrives at the emergency
C. Facilitate meeting between the family and
department who suffered multiple
the organ donor specialist.
injuries from a head-on car collision.
D. Escorting the family to a place of privacy.
Which of the following assessment
should take the highest priority to take?
7. The physician has ordered cooling
measures for a child with a fever who is
A. Irregular pulse.
likely to be discharged when the
B. Ecchymosis in the flank area.
temperature comes down. Which task
C. A deviated trachea.
would be appropriate to delegate to a
D. Unequal pupils.
nursing assistant?
The priority goal is to increase myocardial The nursing assistant can help with the
oxygenation. removal of outer clothing, which allows the
heat to dissipate from the child’s skin.
Options A, B, and C: These actions
are also appropriate and should be Option A: Tepid baths are not
performed immediately. usually given because of the
possibility of shivering and
rebound.
Options B and D: Explaining and
Advising are teaching functions that
are a responsibility of the
registered nurse.
8. Answer: D. The parent’s refusal of the continuous irrigation of the affected eye with
administration of the IV sedation. normal saline.
9. Answer: C. Doing chest compressions. Clear drainage from the client’s nose
indicates that there is a leakage of CSF and
should be reported to the physician
Performing chest compressions are within
immediately.
the training of a nurse assistant.
The signs and symptoms manifested by the Safety is a priority for this client and she
homeless person indicate that a should not return to a place where violence
heat stroke is happening, a medical could recur.
emergency, which can lead to brain damage.
Options A, B, and C: These are
Option A: The homemaker is important for the long-term
experiencing heat exhaustion, management of this case.
which can be managed by fluids
and cooling measures. 20. Answer: C. Being aware of the
Option B: The elderly client is at agency’s emergency response plan.
risk for heat syncope and should be
advised to rest in a cool area and
In disasters preparedness, the nurse should
avoid similar situations.
know the emergency response plan. This
Option D: The runner is
gives guidance that includes the roles of the
experiencing heat cramps, which
team members, responsibilities and
can be managed with fluid and rest.
mechanism of reporting.
17. Answer: D. Have the client breathe
into a brown paper bag.
Below are the answers and rationale for the Establish unresponsiveness first. (The
questions above. If you think the answers patient may have fallen and sustained a
are wrong, please comment below. minor injury.) If the patient is unresponsive,
get help and have someone initiate the code.
1. Answer: C. 4, 3, 1, 2 Performing the chin lift or jaw thrust
maneuver opens the airway. The nurse is
then responsible for starting CPR. CPR
An irritable infant with fever and petechiae should not be interrupted until the patient
should be further assessed for other recovers or it is determined that heroic
meningeal signs. The patient with the head efforts have been exhausted. A crash cart
wound needs additional history and should be at the site when the code team
assessment for intracranial pressure. The arrives; however, basic CPR can be
patient with moderate abdominal pain is effectively performed until the team arrives.
uncomfortable, but not unstable at this
point. For the ankle injury, a medical
evaluation can be delayed 24 – 48 hours if 5. Answer: A. Provide emotional support
necessary. and supportive communication.
Chest pain is considered an emergent The victim should be removed from the cold
priority, which is defined as potentially life- environment first, and then the rewarming
threatening. process can be initiated. It will be painful, so
give pain medication prior to immersing the
Option B: Clients with urgent feet in a warmed water.
priority need treatment within 2
hours of triage 7. Answer: C. 3, 2, 4, 1
(e.g. kidney stones).
Option A: Non-urgent conditions
can wait for hours or even days. Auscultating and confirming equal bilateral
Option D: High urgent is not breath sounds should be performed in rapid
commonly used; however, in 5-tier succession. If the sounds are not equal or if
triage systems, High urgent the sounds are heard over the mid-epigastric
patients fall between emergent and area, tube placement must be corrected
urgent in terms of the time elapsing immediately. Securing the tube is
prior to treatment. appropriate while waiting for the x-ray
study.
8. Answer: D. “He pulled the stick out, 11. Answer: B. Risk for Infection related
just now, because it was hurting him.” to organisms specific to cat bites.
Hypovolemic shock occurs when the volume Blunt injury resulting from vehicular
of the circulatory system is too depleted to accidents could cause pancreatic injury.
allow adequate circulation to the tissues of Redness, bruising in the flank and severe
the body. A fractured pelvis will lose about peritoneal irritation are signs of a pancreatic
one liter of blood hence symptoms such injury. The client is usually pain-free during
as hypotension, tachycardia, and tachypnea the early post-injury period, hence a
will occur. comprehensive assessment and monitoring
should be done.
Option A: Causes
of cardiogenic include 19. Answer: C. “What direction did the
massive myocardial infarction or bullet enter into the body?”
other cause of primary cardiac
(pump) failure.
The entry point and direction of the bullet
Option B: Distributive shock results
will predict the involve injuries of the client.
from a relative inadequate
intravascular volume caused by
arterial or venous vasodilation. Options A, B, and D: The other
Option D: Obstructive shock is a information is not as useful in
form of shock associated with determining which diagnostic
physical obstruction of the major studies and care are needed
vessels or the heart itself. immediately.