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EMERGENCY NURSING POST TEST

Name: __________________________________________________________SCORE: ________

Instructions: Shade appropriate box corresponding your best answer.

1. You are in the cafeteria when you hear a patient cry out from one of the small
dining room. You enter the room and find the patient, wearing a hospital gown
and arm band, collapsed on the floor. An anxious relative is nearby. What
should be your first step in the BLS sequence of action?
a. check for breathing
b. check for signs of circulation
c. Check for responsiveness
d. Open the airway

2. While at work you discover someone lying unconscious in the hallway. You
first establish that the victim is unresponsive. Which of the following is the
correct sequence of actions for you to take?
a. phone the emergency response number, check for signs of circulation,
open the airway, then give rescue breaths if needed
b. open the airway, give rescue breaths if needed, check for signs of
circulation then phone emergency number if no signs of circulation
c. phone Emergency response number, open the airway, give rescue
breaths if needed, then check for signs of circulation
d. give rescue breaths, check for signs of circulation, phone E!, then
begin chest compressions

3. You are treating a victim of cardiac arrest with an AED, you have powered on
the AED, attached the AED electrode pads, and pushed the ANALYZE button.
The AED has charged and gives the “shock indicated” message. Your next
step is to
a. Push the SHOCK button
b. Clear the victim and ensure that no one is touching the patient
c. Press ANALYZE
d. Check pulse

4. You are assessing a 42-year-old woman and note that she has a pulse,
although it is weak. But her face has turned blue and she is not breathing.
Your next step is to
a. Attach the AED and start the SHOCK cycle
b. Attach the AED and press ANALYZE
c. Open the airway and initiate rescue breathing
d. Attach the AED and monitor the victim’s rhythm

5. A 20 year-old responsive man is clutching his throat and cannot speak,


breath, or cough. You ask if he is choking and he nods yes. You ask if he can
speak and he shakes his head no. You should
a. Give back blows
b. Phone emergency number
c. Give abdominal thrust immediately
d. Open his airway and check the throat

6. You are performing rescue breathing for an infant with respiratory arrest. You
ensure that you are delivering proper rescue breath by
a. Observing a change in the victims color
b. Checking the victim regularly for signs of circulation
c. Seeing the victim’s chest rise during rescue breathing
d. Checking the airway frequently

7. You are in the clinic, and a mother walks in carrying her infant in her arms.
She says, “I think he stopped breathing on the way here.” What should be
your priority?
a. Opening the airway
b. Checking for signs of breathing
c. Checking for unresponsiveness
d. Checking for signs of circulation
8. A 32-year-old woman becomes unresponsive at a restaurant. Her companions
say that she suddenly stopped talking, clutched her throat with both her
hands, turned blue, and collapsed. You should first
a. Let someone phone Emergency number
b. Check the pulse
c. Attempt ventilation
d. Perform finger sweep

9. You are a care provider called to the scene of an emergency. Upon arrival you
find a 65-year-old man lying unresponsive on the floor. The victim’s wife says
that she thinks a loose dental appliance fell back his throat and that he
couldn’t speak before he became unresponsive. You perform head-tilt chin lift,
attempt a rescue breath, and note a complete inability to get the chest to rise.
You should
a. Perform a pulse check
b. Perform a finger sweep
c. Perform up to 5 abdominal thrusts
d. Reposition the head, reopen the airways, and try to ventilate again

10. When performing Heimlich maneuver on a conscious victim, the rescuer


delivers inward and upward thrusts specifically:
a. Above the umbilicus
b. Below the Xiphoid process and above the umbilicus
c. At the level of the Xiphoid process
d. Over the victim’s midabdominal area

11. A man driving has met an accident and sustained multiple injuries in the head,
back, and legs. The nurse should
a. Open the airway using the head tilt and jaw thrust
b. Assess cardiac function
c. Maintain control of hemorrhage
d. Assume that there is a cervical injury

12. For which of the following would the nurse prioritize after a multiple bus
collision?
a. a 12 year-old child with fracture of the right fibula and complains of
severe pain
b. a 16 year-old female with laceration on the Left arm
c. a 24-year-old male with a head wound
d. a 22 year old female with a RR of 24 with no radial pulse

13. Which of the following do not indicate severe choking in a 6 month old infant?
a. Poor or no air exchange
b. Weak, ineffective cough or no cough at all
c. Wheeze between cough
d. High pitched noise or no sound at all

14. Which of the following if perform by a new RN in the use of AED indicates
further training?
a. Using the AED if the patient have No response, breathing and pulse
b. Attaching one of the patch to the victim’s bare chest on the Upper
right side, R breastbone, below collar bone
c. Shaving the hairs before application of the patch
d. Placing patch at least 1-2 inches to the side of a pacemaker

15. A child BLS includes the following except:


a. Activating EMS on Unresponsive child victim after a lone rescuer
provides 5 cycles of CPR
b. Starting CPR if PR is 62 with signs of low perfusion
c. Activating EMS on witness child collapsed before a lone rescuer
provides 5 cycles of CPR
d. Providing 5 cycles of CPR before attaching AED
16. You arrive at the side of a victim in respiratory arrest. Another rescuer is
already performing rescue breathing using a pocket mask and tells you that
someone has already phoned the emergency response number. What action
can you take to assist the other rescuer and help reduce the chances of
gastric inflation?
a. Provide pressure on the gastric area
b. Encourage the other rescuer to breathe faster
c. Assist in opening the airway
d. Apply cricoid pressure

17. You are caring at the scene for a woman who fell 20 feet from a rooftop. She
is unresponsive, and you direct bystanders to phone emergency number. Your
next step in the BLS sequence of action should be to
a. Begin chest compressions
b. Check for signs of circulation
c. Perform head tilt-chin lift
d. Perform jaw thrust without head tilt

18. A client is admitted to the emergency room with chest injuries. Which piece of
assessment data would be most helpful in assessing blood loss and deciding
what action the nurse must take?
a. History and mentation since the accident
b. Sex of the victim
c. Time of Injury
d. What was the cause of the injury

19. A child presents to the emergency room with history of ingesting a large
amount of Tylenol. For which of the following would the nurse assess?
a. Dizziness and changes of vision
b. Systolic hypertension and widening pulse pressure
c. Increase in the frequency of urination
d. Pain at the RUQ

20. Teachings in anticipatory guidance were provided by the nurse to a parent


and her toddler. Which would be least appropriate?
a. Label containers
b. Place harmful substances on hanging cabinets
c. Never refer to medicine as candy
d. Lock up kerosene on lower cabinets

21. You are observing a new RN checking for infants pulse during a BLS. You will
not intervene if the new RN checks the
a. Carotid artery
b. Apex of the heart
c. Brachial artery
d. Radial pulse

22. In performing the secondary assessment – head to toe, which of the following
would most likely be a concerned?
a. Capillary refill of less than 3 sec
b. Hearing bronchovesicular sound upon auscultation of the lungs
c. Clear fluid draining the patients ear
d. Ability of the pupils to constrict when strike with light

23. it is a basic knowledge by the emergency nurse that the first step in primary
assessment is:
a. to determine unconsciousness
b. to call for a code
c. to determine if the patient is breathing
d. to determine if the patient is injured

24. An insect bite victim has shown signs of anaphylaxis. Which of the following
interventions will the nurse prioritize?
a. Ventilate the client
b. Administer bronchodilator and Antihistamine
c. Intervene for signs of shock
d. Determine Airway and circulation

25. You are an ER nurse when you ask a student nurse about 2 rescuers CPR on
adult. Which of the following statements made by a student nurse indicates
understanding?
a. “Compression and Ventilation ratio of 30:2 and call for a code after 5
cycles in 2 minutes”
b. “1st rescuer must do the compression while counting up to 30 loudly
while the 2nd rescuer must give 1 breath every 5-6 secs.”
c. “Establish unresponsiveness and call for a code”
d. “1st rescuer must do 30 compressions and 2nd rescuer must give 2
breaths then position the patient in recovery position.”

26. A patient in the ER tells you that her leg is broken. Which of the following is
your initial response?
a. Immobilized the Right leg
b. Call the AP
c. Infused for a possible shock
d. Check the appearance of the leg

27. An ED patient asks you about a contusion of his right thigh. Which of the
following responses is best?
a. “It is a bleeding beneath the skin into the soft tissue”
b. “it is superficial skin loose thru rubbing or scraping the skin over a
rough or even surface”
c. “The accident may have cause you this”
d. “It is a tear in you skin and SQ tissues”

28. You are admitting 4 patients on a night shift. Which of the following patients
you should see first?
a. A patient with asthma with no sounds upon auscultation of the lungs
b. A elderly patient with altered level of consciousness
c. A male client with complains of pain in the lower lumbar area
d. A patient who have R arm and leg paralysis who can’t urinate
29. You are working in the ED when a patient with a head injury was admitted.
Which of the following interventions is correct?
a. Instruct the nursing assistant to stay with the client while you get the
equipment for assessment
b. Stay with the client and call for a code
c. Intervene when the student nurse move the patient as a unit
d. Initiate an IV line @ KVO rate

30. You arrived in a scene in chaos after a bomb explosion. Which of the following
intervention is least appropriate?
a. Take care of a patient with 62% BSA burned
b. Allow all the walking wounded to move out of the scene
c. Tag a patient with Agonal Respirations black
d. Call for someone from the GREEN tag to apply pressure on a patient
with bleeding

31. Which of the following patients in the ED is your priority?


a. A patient with COPD
b. A patient with fracture of the femur and complains of sudden chest
pain
c. A patient with a CRT of 2 secs
d. A patient with a core temperature of 35.4 Celcius

32. A child was found in a frozen river unresponsive, cold to touch and wet. Which
of the following is done initially?
a. Phone emergency number
b. Avoid vertical position
c. Remove the wet clothing
d. Give compressions of 100 per minute

33. You are a geriatric nurse in a nursing home when you found an elderly on his
bed unresponsive and no breathing and circulation. Which of the following
interventions should be avoided?
a. Transffering the patient to the floor if the patient is lying on a soft
mattress
b. Instructing your co nurse to call your supervisor to call for a code and
get the AED
c. Compressing the chest @ 100 per minute
d. Providing breaths @ 1 sec/ breath
34. A student nurse asks you about the jump start system. Which of the following
statements is inappropriate?
a. Allow all the walking wounded to move to an area
b. If the victim is breathing with RR of 23 and with palpable pulse, TAG
YELLOW if unresponsive
c. A victim with a RR of 46 is TAG RED
d. It is a pediatric START system”

35. In the START system, the Triage nurse must not


a. eliminate all Green wounded in the prioritization
b. tag a victim BLACK if he/she is no longer breathing
c. triage patients without radial pulse RED
d. triage patients who can follow verbal commands YELLOW
36. A nurse in the ED reviews the principles in responding for a choking infant.
Which of the following statements indicates further research?
a. Holding the infant prone, with the head slightly lower than the chest
b. Delivering 5 back slaps with heel of the fingers in between the
shoulder blades
c. The infant will be turned as a unit after the 5 back slaps for chest
thrust in the same location as the chest compressions
d. Stop when the infant is unresponsive

37. In giving CPR for a child you must:


a. Compress at a rate of 100 per 2 minutes
b. Give 2 breaths of 2 secs each
c. Give a compression-ventilation ratio of 15:2 for 2 rescuer
d. Use 2 thumb encircling technique

38. A client treated for an episode of hyperthermia is being discharged to home


from the ED. The nurse determines that the client needs reinforcements of the
discharge instructions if the client states intentions to:
a. Stay in the cool environment when possible
b. Increase fluid intake for the next 24 hours
c. Monitor voiding for adequacy of urine output
d. Resume full activity level immediately

39. All of the following indicates discontinuation of CPR for an adult except
a. Scene becomes unsafe
b. An AED is ready in use
c. You are too exhausted to continue
d. Activating EMS and getting AED

40. You found an unresponsive child with no breathing and pulse of 85. You will:
a. Give 2 rescue breath every 3-5 secs
b. Initiate 100 compressions per minute
c. Give 1 rescue breath every 3-5 secs
d. Phone emergency number before starting CPR
41. Which of the following positions best describe decorticate posturing?
a. Neck extended, arms extended and pronated, feet plantar flexed
b. Arms close to sides, elbows and wrists flexed, legs extended
c. In prone position with arms and knees sharply flexed
d. In supine position, spine extended, legs extended

42. The nurse is caring for a client admitted to the emergency department after
taking an overdose of morphine sulphate (MS Contrin). The nurse should give
priority to monitoring the client for:
a. Decreased urinary output

b. Nausea and vomiting

c. Respiratory Depression

d. Increased blood pressure

43. The nurse is rendering first aid at the scene of a motor vehicle accident.
Before moving a client with an apparent fracture of lower leg, the nurse
should give priority to:

a. Removing the client’s shoes to see whether there is trauma to the foot

b. Immobilizing the extremity by splinting the joint above and below the
fracture

c. Keeping the client in a semi-sitting position

d. Checking the neurovascular status of the area distal to the fracture

44. Which of the following clients falls into the category of Emergent care?

a. A client admitted with a simple fracture of the arm

b. A client admitted with abdominal pain

c. A client admitted with chest pain, dyspnea, and diaphoresis

d. A client admitted with a cough and temp of 101 * F

45. A client is admitted with protruding abdominal organs after being stabbed
repeatedly. Emergency care should include:

a. Applying a sterile saline soaked dressing

b. Covering the area with a dry sterile dressing

c. Applying a clear nonadherent dressing

d. Leaving the are open for easier assessment

46. The nurse is triaging four clients injured in a train derailment. Which client
should receive priority treatment?

a. A 42-year-old with dyspnea and chest asymmetry

b. A 17-year-old with fractured arm


c. A 4-year-old with facial lacerations

d. A 30-year-old with blunt abdominal trauma

47. Direct pressure to a deep laceration on the client’s lower leg has failed to stop
the bleeding. The nurse’s next action should be able to:

a. Place a tourniquet proximal to the laceration

b. Elevate the leg above the level of the heart

c. Cover the laceration and apply an ice compress

d. Apply pressure to the femoral artery

48. A pediatric a client is admitted after ingesting a bottle of vitamins with iron.
Emergency care would include treatment with:

a. Acetylcysteine

b. Deferoxamine

c. Calcium disodium acetate

d. Calcium gluconate

49. The ER staff nurse is practicing for its annual disaster drill. According to
disaster triage, which of the following four clients would be cared for last?

a. A client with pneumothorax

b. A client with 70% TBSA full thickness burns

c. A client with fractures of the tibia and fibula

d. A client with smoke inhalation injuries

50. According to the Monroe – Kellie Hypothesis, if a patient has an increase in


CSF, then he/she should compensate by having a(n):

a. Increase in blood viscosity

b. Decrease in blood volume

c. Increase in brain volume

d. Increase in Blood pressure

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