Nokea
A nurse is assessing victims in an emergency situation. What will the nurse assess for first?
- A. Hemorrhage
- B. Fractures
- C. Mobility
- D. Abnormal breathing
Correct Answer: D
Rationale: A life-threatening situation of the highest priority is arrested or abnormal breathing.
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The patient's lower chest has been punctured with a knife that is still in place. What should the nurse's first action be?
- A. Remove the knife.
- B. Apply an airtight dressing over the wound.
- C. Place the patient in a modified Trendelenburg's position.
- D. Immobilize the knife with dressings and tape.
Correct Answer: D
Rationale: When the patient's lower chest has been punctured with the weapon still in place, the nurse should immobilize the weapon with dressings and tape.
A patient is admitted to the hospital after receiving a blow to the head. The patient begins to show signs of shock. How should the patient be positioned?
- A. With the head lower than the body
- B. Flat with the legs elevated
- C. Flat on the back
- D. In a side-lying position
Correct Answer: C
Rationale: If head injuries are suspected, the victim must be kept flat.
The nurse determines clinical death and initiates CPR immediately. How long is resuscitation considered possible?
- A. If cardiopulmonary arrest has existed for no more 2 minutes
- B. If cardiopulmonary arrest has existed for no more 3 minutes
- C. If cardiopulmonary arrest has existed for no more 4 minutes
- D. If cardiopulmonary arrest has existed for no more 5 minutes
Correct Answer: C
Rationale: CPR can reverse clinical death if initiated before 4 minutes.
The nurse is assessing a patient who is severely bleeding and at risk for hypovolemic shock. What can the nurse anticipate?
- A. Slow labored breathing
- B. Hot flushed skin
- C. Edematous extremities
- D. Weak thready pulse
Correct Answer: D
Rationale: The pulse becomes weak and thready with hypovolemic shock.
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.