Mariah Shaina Sanchez BSN-3a1 1.

The emergency medical service (EMS) has transported a patient with severe chest pain. As the patient is being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and no palpable pulse. Which task is appropriate to delegate to the nursing assistant? a. Chest compressions b. Bag-valve mask ventilation c. Assisting with oral intubation d. Placing the defibrillator pads
ANSWER A Nursing assistants are trained in basic cardiac life support and can perform chest compressions. The use of the bag-valve mask requires practice and usually a respiratory therapist will perform this function. The nurse or the respiratory therapist should provide PRN assistance during intubation. The defibrillator pads are clearly marked; however, placement should be done by the RN or physician because of the potential for skin damage and electrical arcing.

2. You are preparing a child for IV conscious sedation prior to repair of a facial laceration. What information should you immediately report to the physician? a. The parent is unsure about the childs tetanus immunization status. b. The child is upset and pulls out the IV. c. The parent declines the IV conscious sedation. d. The parent wants information about the IV conscious sedation.
ANSWER C Parent refusal is an absolute contraindication; therefore, the physician must be notified. Tetanus status can be addressed later. The RN can restart the IV and provide information about conscious sedation; if the parent still notsatisfied, the physician can give more information. 3. An anxious 24-year-old college student complains of tingling sensations, palpitations, and

chest tightness. Deep, rapid breathing and carpal spasms are noted. What priority nursing action should you take? a. Notify the physician immediately. b. Administer supplemental oxygen. c. Have the student breathe into a paper bag. d. Obtain an order for an anxiolytic medication.
ANSWER C The patient is hyperventilating secondary to anxiety, and breathing into a paper bag will allow rebreathing of carbon dioxide. Also, encouraging slow breathing will help. Other treatments such as oxygen and medication may be needed if other causes are identified

4. Halfway through the administration of blood, the female client complains of lumbar pain. After stopping the infusion Nurse Hazel should: a. Increase the flow of normal saline b. Assess the pain further c. Notify the blood bank d. Obtain vital signs.
A. The blood must be stopped at once, and then normal saline should be infused to keep the line patent and maintain blood volume
ANSWER

Situation: Larry was admitted at Manila Doctor's Hospital because of a second-degree burn wound. 5. Before debriding a second-degree burn wound in the left lower leg, the nurse should do which of the following? a. Apply Lindane (Kwell) to the affected area b. Medicate the client with narcotic analgesic c. Administer acylovir (Zovirax) IV d. Apply a topical antimicrobial ointment
Answer B. Medicate the client with narcotic analgesic 6. Larrys anterior trunk, both front upper extremities, both lower extremities sustained second

and third degree burn. Estimate the total percentage of body surface area burned using the Rule of Nines. a. 60% b.63% c. 62% d. 61%
Answer B. 63% 7. The nurse is caring for a client who is receiving IV fluids, Which observation the nurse makes

best indicates that the IV has infiltrated? a. Pain at the site b. A change in flow rate c. Coldness around the insertion site d. Redness around the insertion site

ANSWER C. Coldness around the insertion site 8. A clients nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which

action related to the fluid management should be delegated to a nursing assistant? a. Administer IV fluids as prescribed by the physician. b. Provide straws and offer fluids between meals. c. Develop plan for added fluid intake over 24 hours d. Teach family members to assist client with fluid intake
ANSWER B The nursing assistant can reinforce additional fluild intake once it is part of the care plan. Administering IV fluids, developing plans, and teaching families require additional education and skills that are within the scope of practice for the RN. 9. The client also has the nursing diagnosis Decreased Cardiac Output related to decrease plasma

volume. Which finding on assessment supports this nursing diagnosis? a. Flattened neck veins when client is in supine position b. Full and bounding pedal and post-tibial pulses c. Pitting edema located in feet, ankles, and calves d. Shallow respirations with crackles on auscultation
ANSWER A Normally, neck veins are distended when the client is in the supine position. The veins flatten as the client moves to a sitting position. The other three responses are characteristic of Excess Fluid Volume.

10. The physician has written the following orders for the client with Excess Fluid volume. The

clients morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time? a. Weight client every morning. b. Maintain accurate intake and output. c. Restrict fluid to 1500 mL per day d. Administer furosemide (Lasix) 40 mg IV push
ANSWER D Bilateral moist crackles indicate fluid-filled alveoli, which interferes with gas exchange. Furosemide is a potent loop diuretic that will help mobilize the fluid in the lungs. The other orders are important but not urgent. 11. The clients potassium level is 6.7 mEq/L. Which intervention should you delegate to the

student nurse under your supervision?

a. Administer Kayexalate 15 g orally b. Administer spironolactone 25 mg orally c. Assess WCG strip for tall T waves d. Administer potassium 10 mEq orally
ANSWER A The clients potassium level is high (normal range 3.5-5.0). Kayexalate removes potassium from the body through the gastrointestinal system. Spironolactone is a potassium-sparing diuretic that may cause the clients potassium level to go even higher. The nursing student may not have the skill to assess ECG strips and this should be done by the RN. 12. You are preparing to discharge a client whose calcium level was low but is now just slightly

within the normal range (9-10.5 mg/dL). Which statement by the client indicates the need for additional teaching? a. I will call my doctor if I experience muscle twitching or seizures. b. I will make sure to take my vitamin D with my calcium each day. c. I will take my calcium pill every morning before breakfast. d. I will avoid dairy products, broccoli, and spinach when I eat.
ANSWER D Clients with low calcium levels should be encouraged to consume dairy products, seafood, nuts, broccoli, and spinach. Which are all good sources of dietary calcium. 13. A client with respiratory failure is receiving mechanical ventilation and continues to produce

ABG results indicating respiratory acidosis. Which action should you expect to correct this problem? a. Increase the ventilator rate from 6 to 10 per minute b. Decrease the ventilator rate from 10 to 6 per minute c. Increase the oxygen concentration fro 30% to 40% d. Decrease the oxygen concentration fro 40% to 30%
ANSWER A the blood gas component responsible for respiratory acidosis is CO2 (Carbon dioxide). Increasing the ventilator rate will blow off more CO2 and decrease the acidosis. Changes in the oxygen setting may improve oxygenation but will not affect respiratory acidosis. 15. The nursing assistant reports to you that a client seems very anxious and that vital signs

included a respiratory rate of 38 per minute. Which acid-base imbalance should you suspect? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

ANSWER B The client is most likely hyperventilating and blowing off CO2. This decrease in CO2 will lead to an increase in pH, causing respiratory alkalosis. Respiratory acidosis results from respiratory depression and retained CO2. Metabolic acidosis and alkalosis result from problems related to renal acid-base control. 16. A client has a nasogastric tube connected to intermittent wall suction. The student nurse asks

why the clients respiratory rate has increased. What your best response? a. Its common for clients with uncomfortable procedures such as nasogastric tubes to have a higher rate to breathing. b. The client may have a metabolic alkalosis due to the NG suctioning and the increased respiratory rate is a compensatory mechanism. c. Whenever a client develops a respiratory acid-base problem, increasing the respiratory rate helps correct the problem. d. The client is hyperventilating because of anxiety and we will have to stay alert for development of a respiratory acidosis.
ANSWER B Nasogastric suctioning can result in a decrease in acid components and metabolic alkalosis. The clients increase in rate and depth of ventilation is an attempt to compensate by blowing off CO2. the first response maybe true but does not address all the components of the question. The third and fourth answers are inaccurate.

17. The newly admitted client has a large burned area on the right arm. The burned area appears

red, has blisters, and is very painful. How should this injury be categorized? A. Superficial B. Partial-thickness superficial C. Partial-thickness deep D. Full thickness
ANSWER B The characteristics of the wound meet the criteria for a superficial partialthickness injury (color that is pink or red; blisters; pain present and high). 18. Which vitamin deficiency is most likely to be a long-term consequence of a full-thickness

burn injury? A. Vitamin A B. Vitamin B C. Vitamin C D. Vitamin D ANSWER D Skin exposed to sunlight activates vitamin D. Partial-thickness burns reduce the activation of vitamin D. Activation of vitamin D is lost completely in fullthickness burns.

19. The burned client is ordered to receive intravenous cimetidine, an H2 histamine blocking agent, during the emergent phase. When the client's family asks why this drug is being given, what is the nurses best response? A. To increase the urine output and prevent kidney damage. B. To stimulate intestinal movement and prevent abdominal bloating. C. To decrease hydrochloric acid production in the stomach and prevent ulcers. D. To inhibit loss of fluid from the circulatory system and prevent hypovolemic shock. ANSWER C Ulcerative gastrointestinal disease may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and decreased mucosal barrier. Cimetidine inhibits the production and release of hydrochloric acid. 20. At what point after a burn injury should the nurse be most alert for the complication of hypokalemia? A. Immediately following the injury B. During the fluid shift C. During fluid remobilization D. During the late acute phase ANSWER C Hypokalemia is most likely to occur during the fluid remobilization period as a result of dilution, potassium movement back into the cells, and increased potassium excreted into the urine with the greatly increased urine output.