Nokea
A burn patient is brought into the emergency department with the following burns: half of the front torso entire left arm and front of left leg. The nurse should record that the patient has a __% burn.
- A. 27
- B. 25
- C. 50
- D. 43
Correct Answer: A
Rationale: Half of the front torso = 9, entire left arm = 9, front of the left leg = 9.
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When a patient suddenly experiences respiratory difficulty in the cafeteria the nurse begins assessment for foreign-body airway obstruction. What is the most appropriate question to ask the victim?
- A. What did you swallow?
- B. Are you choking?
- C. Are you OK?
- D. Can I help you?
Correct Answer: B
Rationale: With complete airway obstruction, the victim cannot speak. Ask, 'Are you choking?' With this question the nurse pinpoints the problem and can perform the Heimlich maneuver with no wasted time.
CPR has been initiated on an adult patient. How will the nurse confirm the effectiveness of CPR?
- A. Assessing an EKG pattern with each compression
- B. Assessing a palpable carotid pulse during each compression
- C. Assuring a compression depth of to 2 in
- D. Observing pupils that change from pinpoint to dilated
Correct Answer: B
Rationale: During effective CPR, a carotid pulse is palpable during each compression.
A patient arrives in the emergency department with a sucking wound to the left chest. What is the first action the nurse should take?
- A. Place several layers of gauze dressing over the wound.
- B. Place the patient in a supine position.
- C. Cover the wound with an airtight dressing taped on three sides.
- D. Turn the patient to the left side.
Correct Answer: C
Rationale: Sucking chest wounds should be dressed with a flutter dressing so that air can escape the pleural space, but no more air can be sucked in.
A machinist visits the industrial nurse's clinic with a deep laceration of the thigh. What should be the nurse's first action?
- A. Splint the thigh and apply tape to approximate the edges.
- B. Apply ice and a pressure dressing to the thigh.
- C. Give a tetanus booster injection.
- D. Wash the laceration with an antiseptic.
Correct Answer: D
Rationale: Lacerations should be cleaned thoroughly and bandaged to approximate the edges.
A visitor in the hospital slips and falls. The patient's arm appears dislocated and the visitor is unable to move it. What is the first action the nurse should implement?
- A. Apply cold packs.
- B. Check range of motion.
- C. Splint the arm.
- D. Apply an Ace bandage.
Correct Answer: C
Rationale: The nurse should splint the arm where it lies and not attempt to move or rearrange the limb.