Title RECALLS 13 - NP4 - SC ✅

C. With major injuries such as open fractures and large wounds. D. Experiencing hemorrhagic shock that requires immediate treatment. 29. The term NBC means nuclear, biological and chemical weapons of mass destruction. Which of the following is an example of biologic terrorism agents? A. Vaccine B. Nerve agent antidotes C. Anthrax D. Neoplastic agents 30. The charge nurse emphasizes the overall goal in a disaster situation which is ___. A. Saving as many lives as possible B. Using a disaster triage system that categorizes triage priority by color and number. C. Calling all emergency medical service providers from the hospital to attend the needs of the victims. D. Doing the greatest good for the greatest number of people. 31-35. Situation. The nurse in the emergency department performs initial assessment on clients brought to the department. The following questions pertain to assessment and nursing interventions. 31. The nurse assesses a trauma client in pain who refuses pain medication. Which of the following alternative methods to manage pain can the nurse use or recommend? 1) Positioning/Splinting 2) Application of heat and cold 3) Non-therapeutic touch 4) Guided imagery 5) Humor A. 1, 2, 3 & 5 B. 2, 4 & 5 C. 1, 2, 3, 4 & 5 D. 1, 2 & 5 32. The nurse assesses circulation of an adult trauma victim by palpating a central pulse. Which of the arteries will the nurse palpate? A. Apical artery B. Brachial artery C. Femoral artery D. Popliteal artery 33. The nurse performs complete spinal immobilization. The procedure includes the following actions EXCEPT _____. A. Placing the client on the backboard B. Placing a small pillow on the head. C. Application of a rigid cervical collar. D. Immobilization of the head and neck. 34. In inspecting a client’s airway, the nurse should observe the following, EXCEPT: A. Tongue obstructing the airway B. Foreign objects that may have been lodged. C. Loose teeth or dentures. D. Condition of the tonsils. 35. The correct sequence of the primary assessment of trauma clients is ____. 1)Open and inspect the client's airway while initiating or maintaining cervical spine protection. 2)Palpate a central pulse for strength and rate. 3)Conduct a brief neurologic assessment to determine the degree of disability as measured by the client’s level of consciousness. 4)Remove clothing so that all injuries can be quickly identified. 5)Assess for spontaneous breathing. A. 2, 5, 1, 3 & 4 B. 1, 2, 3, 4 & 5 C. 1, 3, 2 & 5 D. 1, 5, 2, 3 & 4 36-40. Situation. A 38 year old female trauma victim is brought to the emergency department of X hospital. 36. The trauma client has a blood type of AB+. Which type of blood will the client need? A. AB- B. AB+ C. Any type D. O+ only 37. Nurse Pau continues to monitor the condition of the trauma client. The client is in hypovolemic shock. Which of the following types of blood products should Nurse Pau prepare? A. Platelets B. Packed red blood cells C. Plasma D. Whole blood 38. Nurse Pau admits the client. What factors will assist the nurse in determining the classification of a trauma client? 1) Site the injury 2) Speed of the vehicle 3) Height of fall 4) Mechanism of injury A. 2 & 4 B. 1, 2, 3, & 4 C. 1 & 3 D. 1, 2 & 4 39. The trauma client manifests a deviated trachea, jugular vein distention, and cyanosis. Nurse Pau realizes that the trauma client is MOST likely demonstrating? A. Tension pneumothorax B. Cervical spine injury C. Blunt trauma to the chest D. Acceleration-deceleration injury 40. The physician assesses the trauma client using the Champion Revised Scoring System. Nurse Pau understands that the elements of this scoring system are which of the following: 1) Diastolic Blood Pressure 2) Systolic Blood Pressure 3) Heart Rate 4) Glasgow Coma Scale 5) Respiratory Rate A. 2, 4 & 5 B. 2, 3, 4 & 5 C. 1, 3 & 5 D. 1, 2, 3, 4 & 5 41-50. Situation. The nurse assists in the care of a 20-year old male client needing blood transfusion. The attending physician writes an order of blood transfusion of 250 cc of packed red cells after blood cross matching. 41. Before infusing the blood, the nurse assesses the client’s ________. A. Vital signs B. Mental state C. Skin color D. Hemoglobin and hematocrit levels 42. The nurse takes the temperature of the client. The temperature registers 390C. Based on this finding, the nurse should: A. Administer an antihistamine and transfuse the blood. B. Start the blood transfusion as ordered. C. Withhold the blood transfusion and notify the physician. D. Give tepid sponge bath and wait for the temperature to go down then transfuse the blood. 43. Which of the following nursing interventions should have the HIGHEST priority when caring for a client receiving blood transfusion? A. Regulate the drops accurately. B. Instruct the client to notify the nurse if the client experiences itchiness, headache or difficulty of breathing. C. Document the blood type, time transfusion started, and vital signs taken. D. Inform the client that the transfusion may last for one and a half to two hours. 44. The nurse administers the blood and starts the transfusion at 20 – 25 drops per minute. The nurse observes for a transfusion reaction which usually occurs during the _____ minutes after transfusion. A. 15 minutes B. 45 minutes C. 5 minutes D. 30 minutes 3 | Page
45. The client receiving blood transfusion begins to wheeze on respiration, itch and observes that his skin becomes flushed with hives. The nurse recognizes these signs as characteristic of what type of reaction? A. Bacterial B. Hemolytic C. Allergic D. Systemic 46-50. Situation. Nurse Olan works the day shift in the female medical unit. Nurse Olan is aware that when caring for clients, the nursing process can be an effective tool for communication. 46. Nurse Olan understands that the MOST important aspect of communication is to_____ A. Observe the facial expressions of your patients. B. Clarify the statements made. C. Listen to what is being said. D. Restate the words you hear from the client. 47. Which of the following activities will Olan consider to validate effectiveness of a nurse-client communication? A. Assessment of the physician. B. Feedback from the client. C. Adaptation of the client to physiologic changes. D. Conference with the members of the health team. 48. Nurse Olan formulates nursing diagnoses for her clients. She knows that a nursing diagnosis represents the: A. Prepared plan of care. B. Actual nursing interventions carried out. C. Nursing judgments about the health of her patients. D. Actual or potential health problems of her patients. 49. Nurse Olan collects data and begins to develop a trust relationship with her clients. This activity is what aspect of the nursing process? A. Evaluation B. Implementation C. Planning D. Assessment 50. Nurse Olan understands that the nursing process is a scientific method and a proven form for: A. Problem solving B. Health education C. Oral communication D. Cost containment 51-55. Situation. The nurse assists in the care of female clients. Jaira is a 35 year old woman with hyponatremia. According to the client she is taking diuretic medications. 51. Which of the following statements is TRUE about hyponatremia? A. Hyponatremia from diuretic use may produce small quantities of urine. B. Hyponatremia occurs because of excess fluid volume diluting the potassium. C. A serum sodium level determined above 135 mEq/L indicates hyponatremia. D. Hyponatremia from diuretic use may produce large quantities of urine. 52. In assessing the client, the nurse should focus on which part of the following? The ______: A. Spiritual state of the client B. Physical signs and symptoms C. Diagnostic to be done on the client D. Mental status of the client Ratio: Hyponatremia could cause seizures. 53. The nurse writes a nursing diagnosis. Which of the following is appropriate? A. Disturbed thought processes B. Decreased cardiac output C. Activity intolerance D. Ineffective breathing pattern 54. The client has a serum sodium level of 115 mEq/L. a priority nursing intervention is for the nurse to: A. Give frequent oral care B. Take precautions for occurrence of seizures C. Monitor cardiac rhythm D. Take the vital signs every two hours 55. The nurse is much aware that a client receiving D5W at 100 ml/hr. is MOST at risk for developing which of the following conditions? A. Hyponatremia B. Fluid volume excess C. Hypernatremia D. Fluid volume deficit 56-60. Situation. Nurse Frances assists in the care of female patients with coronary artery disease (CAD). She schedules time to educate these groups of women about CAD. 56. A correct statement about CAD in women is that _____: A. Hormone Replacement Therapy is recommended for prevention of coronary artery disease. B. Women develop CAD earlier than men. C. The genetic component for CAD is weak. D. The rate of women having CAD is steadily rising while it is declining in men. 57. Research indicates that a woman with CAD needs to exercise to decrease the risk of having CAD. Which of the following exercises is recommended? A. Light to moderate exercise for 30 minutes 5x a week. B. Light exercises (walking) 20 minutes 3x a week. C. Aggressive exercise for 30 minutes 3x a week D. Moderate exercise for 20 minutes 5x a week. 58. Nurse Frances gives information about blood pressure in women. Which of the following statements is correct? A. Hypertension doesn’t affect CAD risk as women age. B. Low blood pressure is twice as common as oral contraceptive users. C. Twenty percent of women have hypertension before menopause. D. Weight, age, and oral contraceptive use affect blood pressure. 59. Nurse Frances explains that stress can be managed by which of the following: A. An individual has low and constant stress B. An individual has high stress level and low control C. An individual has high control and low stress level D. Stress is controlled over short periods. 60. Nurse Frances explains that stress can be managed by which of the following: A. Socializing with other patients with similar disease B. Taking in prescribed medications to relieve you of stress. C. Finding spiritual meaning in what you are experiencing D. Reflecting on your condition and accepting it. 61-65. Situation. The nurse assists in the care of a female client, 45 years old admitted for severe pain related to cancer. 61. In relieving pain related to cancer, which of the following nursing actions is MOST appropriate? A. Keep the room well-lighted so that the nurse can assess the client thoroughly. B. Allow the client to stay in one position to prevent the occurrence of pain. C. Apply heat or cold in the areas that are painful as prescribed by the physician. D. Place a hand bedroll behind the client’s back. 62. The client has a tunneled epidural catheter to control pain. The catheter site should be assessed every shift by the nurse on duty. Which of the following signs indicate catheter migration or tissue trauma? A. Bright red bleeding under the dressing. B. Catheter insertion site is red, swollen with purulent discharges. C. Bright red bleeding and fluid collecting under the dressing with loss of pain control. D. Bright red bleeding and fluid collecting under the dressing. 63. If catheter becomes disconnected from the tubing, the nurse should use which of the following solutions to clean the tubing or connectors: 4 | Page