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When assessing a patient who has suffered a burn injury the nurse classifies the burn as a deep partial-thickness burn. What is this observation most likely based upon?
- A. Painful reddened skin
- B. Charred skin with milky-white areas
- C. Erythema and blisters
- D. Erythema pain and swelling
Correct Answer: C
Rationale: With deep partial-thickness burns, blister formation may be seen with erythema.
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While on break in the hospital cafeteria a nurse witnesses her pregnant coworker start to choke. The coworker is conscious but unable to breathe. Where should the nurse administer thrusts?
- A. Below the navel
- B. The chest
- C. At the xiphoid process
- D. The upper back
Correct Answer: B
Rationale: If the victim is pregnant or obese, chest thrusts are acceptable instead of abdominal thrusts. To provide chest thrusts, the nurse should place his or her hands in the same position that is used for chest compressions during CPR.
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 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.
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.
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.