Title RECALLS 13 - NP4 - KEY ✅

C. “Patient says he will sue the surgeon and the hospital if the operation turns out to be a failure.” D. “Patient says he feels sharp and stabbing pain in the abdominal area.” 24. The attending physician writes an order of Do Not Resuscitate (DNR) on a patient who is seriously ill. Which of the following is a responsibility of Nurse Rose? Nurse Rose should ________ 1) Carry out the order in the event the patient experiences sudden need for CPR 2) Determine if there is a living will on the medical record of the patient 3) Consult the policies and procedures of the Institution if she feels such DNR order is contrary to the patient’s or family’s wishes. 4) Refer to the Ethics Committee of the Institution the DNR order to determine appropriateness of the order. A. 2 & 3 B. 1 & 3 C. 3 & 4 D. 1 & 2 25. The physician orders a dose of medication to be given to a patient before undergoing surgery. Nurse Rose is aware that the dose is too high for the patient. She tries to locate the physician to check the order but the physician is not available. Which of the following is the MOST appropriate action Nurse Rose will take to ensure the safety of the patient? A. Notify the nurse supervisor immediately B. Administer half of the dose of the medication ordered. C. Administer the medication as ordered. D. Withhold the medication. 26-30. Situation. The charge nurse in the Emergency Department calls for a crisis meeting to review principles in mass casualty to enhance preparedness and improve emergency quality care. 26. Which of the following statements is NOT TRUE about emergency preparedness? A. Hospitals should have an emergency preparedness plan that is tested through drills or actual participation. B. Generally, hospital employees participate seriously in emergency drills. C. Emergency preparedness training and drills are standard functions of emergency departments of hospitals. D. Drills must involve the participation and collaboration of the community. 27. The charge nurse explains that mass casualty incidents are due to events such as the following EXCEPT: A. Earthquakes B. Severe weather phenomena. C. Lightning strikes. D. Transportation disasters. 28. The charge nurse reiterates the importance of using a disaster triage tag system. Clients that have been “green-tagged” are those ________. A. With injuries of closed fracture, sprains, contusions and abrasions. B. Who are expected to die or are dead already. 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. 3 | Page
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 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? 4 | Page