Answer & Rationale Steven, an Athletic 20-Year-Old College Student, Suffered a Fractured Shoul

Sample Nursing Examinations - Answer & Rationale

Steven, an athletic 20-year-old college student, suffered a fractured shoulder and sprained wrist in a fall at a ski resort.

In developing Steven's care plan following surgery, which of the following typical problems would you anticipate?

A. He will undergo an alteration in self-concept.

B. He will experience anxiety as a result of flashbacks about the skiing accident.

C. He will have impaired mobility caused by immobilization of upper extremity.

D. There will be abnormal tissue perfusion caused by swelling.

If you use both the information provided and your understanding of surgical needs following reduction of a fracture, the only problem that would normally occur is impaired mobility. In analyzing data you would first attempt to recall and understand typical scenarios or patterns of needs that commonly occur. Validate your problem definition by incorporating specialized data or individualized signs and symptoms presented by your client. These specialized data should be accompanied by a statement of cause. For example, if you note that Steven's fingertips are cold and pitting edema is forming on the back of the hand, your analytic statement might be option D, abnormal tissue perfusion caused by swelling. An accurate analysis of data provides a valid and useful framework for planning patient care.

Jean Thomas is a 25-year-old secretary admitted to the emergency room with diaphoresis, hyperventilation, palpitations, and trembling. Jean tells the nurse that she has been "very upset and nervous" over a poor employment evaluation. A tentative diagnosis of acute anxiety episode is made.

Which of the following acid-base imbalances would likely occur as a result of Jean's hyperventilation?

A. Respiratory acidosis

B. Respiratory alkalosis

C. Metabolic acidosis

D. Metabolic alkalosis

The intended response is B, since hyperventilation will cause an increased loss of CO2,

Mrs. Durham is recovering from a colon resection for removal of a malignant mass in the large bowel. Following breakfast one morning, she told the nurse, "I'm tired of waiting, I want my bath now. You're never here when I need you."

Which of the following responses by the nurse is most appropriate?

A. What do you mean, I'm never here? I spent all three hours with you yesterday, Mrs. Durham.

B. I'm sorry you've been waiting Mrs. Durham. Let's get you comfortable now and I'll be back in twenty minutes to give you a bath.

C. I'm doing my best, Mrs. Durham. You know I have three other patients to take care of today, besides you.

D. I must see Mrs. Jones right now, Mrs. Durham. She's really sick today. I'll be back as soon as I can.

The only appropriate response is option B. Acknowledge her feelings and give her a clear, factual response to her concern. Never challenge a patient's statements and don't be defensive (option C). Do not reprimand the patient unnecessarily or talk about the needs of the other patients ( options C and D). In this case you did not need to know a lot about colon resections to answer this question. You did need to have skill in basic communication and human interaction.

Brian, aged 4 years, is sitting in the pediatric day room with Michael, another patient. He suddenly realizes that he has wet his pants and runs to the nurse, crying.

The most appropriate initial response by the nurse is:

A. Why, Brian, what happened? Why did you wet your pants?

B. You know better than this, Brian; next time you'll get a good spanking.

C. Let's take off those wet pants, Brian, and put on something dry so you'll be more comfortable.

D. Wait until I tell Michael what you did. Aren't you ashamed of yourself?

Several relevant principles come into play in this item in selecting the correct answer. A very basic principle is, "The nurse shows respect for the individual in treating human responses to actual or potential health problems." In other words, focus on treating the patient with respect first and then attempt to modify wrong behavior. This principle shows an acceptable standard of nursing action. The intended response is C.

Margaret O'Hara, a 30-year-old known diabetic, is brought to the emergency department by ambulance. The paramedic team reports symptoms of apparent hyperglycemia. Stat blood glucose is 640.

The nurse is aware that excess serum glucose acts to draw fluids osmotically with resultant polyuria. In addition to increased urinary output, the nurse should expect to observe which of the following sets of symptoms in Margaret?

A. Polydipsia, diaphoresis, bradycardia

B. Thirst, dry mucous membranes, hot dry skin

C. Hypotension, bounding pulse, headache

D. Nervousness, rapid respirations, diarrhea

The intended response is B, because these are all symptoms associated with the dehydration that occurs in hyperglycemia. Although polydypsia is expected (response A), diaphoresis does not occur in the body's effort to compensate by holding back fluid. The patient would experience tachycardia as a cardiac compensatory mechanism, causing a rapid, thready pulse. Headache and nervousness (responses C and D) are symptoms associated with hypoglycemia.

Molly Flannery is a 67-year-old female with chronic congestive heart failure and hypertension. She is being evaluated for complaints of muscular weakness and general fatigue.

Molly's serum electrolyte studies reveal a K+ level of 2.9. Which of the following medications taken by the patient at home contributed most to her hypokalemic state?

A. Digoxin, .125 mg, PO, daily

B. Lasix, 80 mg, PO, daily

C. Aldomet, 250 mg, PO, tid

D. Aspirin, 10 grains, bid

The intended response is B, since Lasix, in addition to its diuretic action, also wastes K+ by increasing urinary excretion. Digoxin, response A, contributes to K+ loss by enhancing urinary output, but Lasix is much more directly related to the development of hypokalemia. Response C is an anti-hypertensive that is not related to K+ loss. Response D, aspirin, may have been prescribed as myocardial infarction prophylaxis, and is not related to K+ loss.

Mr. Robert Bacchus is a 63-year-old retired business executive who comes to the emergency room with complaints of dyspnea, shortness of breath, and chest pain radiating to the left arm.

The nurse caring for Mr. Bacchus should implement which of the following actions FIRST?

A. Administer prescribed pain medication

B.. Apply oxygen per nasal cannula as ordered

C. Assess vital signs

D. Apply electrocardiogram electrodes to the patient's chest

The intended response is C, since vital sign assessment will provide baseline data of vital cardiac and respiratory function, which will then serve as a guideline for diagnosis and therapy measures.

Loberta Jackson, a 21-year-old college student, is admitted to a medical unit with diagnosis of uncontrolled diabetes, acute hypoglycemic reaction.

Loberta explains to the admitting nurse that she had been feeling "sick to my stomach, like I was coming down with the flu" for the past 48 hours. She has continued to take her usual daily dosage of insulin. Noting that Loberta has been admitted with a blood-glucose value of 46, which of the following assessment questions would provide the most valuable information about Loberta's status?

A.. "Have you been under a great deal of stress lately, Loberta?"

B. "Were you having difficulty sleeping after this illness started?"

C. "Have you eaten anything in the past 48 hours?"

D. "Did you take any medications for this illness other than your insulin?"

The intended response is C, because it is highly probable that Loberta, feeling "sick to her stomach," has not taken in adequate foods and fluids, and coupled with taking her usual dosage of daily insulin, has brought about an acute hypoglycemic reaction. (Higher than normal circulating levels of insulin with insufficient food intake of essential nutrients will result in acute decreased blood-glucose levels). Response A, focusing on increased stress, would more than likely stimulate a hyperglycemic reaction, since stress causes elevations of blood glucose. Response D, focusing on other medications the patient has taken, would probably not trigger a hypoglycemic reaction. Response B is unrelated to her present status.

Jerry is a 32-year-old white male. He has been married for 10 months, and he and his wife, Sue, are expecting their first child in 6 months. Prior to marrying Sue, Jerry was sexually active and nonmonogamous. He has been sexually active since the age of 18. Recently Jerry has complained of persistent dry cough, night sweats, and a temperature over 100?F. Although Jerry is concerned about his weight and watches his diet, he has lost 15 pounds without even trying. Upon assessing Jerry, he admits to having had sexual intercourse with prostitutes, both male and female, during the last 10 years.

Jerry's symptoms of elevated temperature, chills, and dry cough are probably related to which undiagnosed condition?

A. Alteration in tissue perfusion

B. An infection, etiology unknown

C. Indigestion from too frequent traveling

D. Lack of knowledge related to frequent travel

The intended response is B. Classic signs and symptoms of infection are fever, chills, loss of appetite, generalized myalgias, or localized pain and discomfort. The dry cough that Jerry experiences can be associated with the system of involvement. Pulmonary etiology should be assessed and evaluated.

Mrs. Brown's husband was admitted to the emergency room in delirium tremens (DTs). This admission is his third visit in 2 weeks. While waiting to see her husband, Mrs. Brown said to the nurse, "What in the world can I do to help Joe get over this drinking problem?"

The best initial response for the nurse is:

A. Don't feel guilty, Mrs. Brown; I know this must be difficult for you.

B. Let's go into the lounge so we can talk more about your concern, Mrs. Brown.

C. You need to convince Joe to seek professional help, Mrs. Brown.

D. How long has your husband been drinking, Mrs. Brown?

If you chose Option A, you are reading into the question and adding a factor that was not provided-- that Mrs. Brown is feeling guilty. Perhaps you know of someone who did feel guilty in a situation like this, or perhaps you thought she should feel guilty. Because this background statement does not tell you how Mrs. Brown feels, you can't make this assumption (option A).

Option C is incorrect because you don't have enough information about the situation to offer this advice. You should be in the assessment or data collection phase of the nursing process. Option D is not the best choice because it focuses on Mr. Brown's problem and channels the interaction specifically, rather than encouraging Mrs. Brown to express her concerns. Since Mrs. Brown is concerned about what she can do to help her husband, the correct response is one that first encourages her to verbalize how she is feeling (option B).

Amy Stevens is a 17-year-old student admitted for evaluation of lower abdominal pain. She tells the nurse, "I wish my friends would come to visit me. I don't like being here alone."

Which of the following would be the most appropriate response of the nurse?

A. "You sound very lonely. Shall I stay with your for awhile?"

B. "I'm sure your friends will come to see you soon."

C. "It's a little too early for visiting hours. You'll have to wait until this afternoon."

D. "It's hard to be alone. Would you like me to stay with you?"

The intended response is D, since this response acknowledges the patient's feelings and offers support. Response A tends to catastrophize the patient's situation by saying "you must be very lonely." Response B provides false reassurance because the nurse has no real way of knowing if in fact friends will come to visit Amy. Finally, C is incorrect because it provides only a factual response and does not attend to the feeling tone of Amy's remarks.

Patty Daniels is a 25-year-old white female, pregnant with her first child. She is being seen in the obstetrical clinic for her first prenatal visit.

Patty tells the nurse, "I drank a glass of wine at a party before I found out that I was pregnant. I'm worried that I might have hurt the baby." Based on an understanding of alcohol use in pregnancy, which of the following responses is the most appropriate?

A. "We don't really know how much alcohol is too much during pregnancy. Don't drink anymore and try not to worry about it."

B. "As long as your drinking is moderate, I wouldn't worry about it. There were plenty of healthy babies born to drinking mothers before they ever discovered fetal alcohol syndrome."

C. "An occasional drink shouldn't hurt the baby. Research has shown that the risk to the fetus increases as the amount and frequency of alcohol consumption increases."

D. "I can understand why you're so upset, but an occasional drink shouldn't hurt the baby."

The correct response is C. This patient needs two things from the nurse: information about alcohol use in pregnancy and reassurance about the potential risk to her own baby. Alcohol is a known teratogenic substance, but it is unclear how much alcohol it takes and at what point in development to adversely affect the fetus. Research has shown that the incidence of fetal alcohol syndrome and related disorders increases as the amount and frequency of alcohol consumption increase. An occasional drink should not harm the fetus. C is the correct response because it is the only answer that offers reassurance and accurate information without catastrophizing the situation.

Kelly Jones, aged 3 years, is brought to the emergency room by her mother following an accidental ingestion of acetaminophen. When questioned, Mrs. Jones states that she believes that Kelly ingested approximately 20 tablets. She further states that she believes that the ingestion occurred within the last hour.

Immediately upon arrival in the emergency room the nurse should:

A. Assess vital signs

B. Administer O2

C. Start IV fluids

D. Perform an arterial puncture for blood gases

A is the correct response. The establishment of baseline vital signs should always be done first. Although hyperventilation and resultant respiratory alkalosis is the most obvious clinical manifestation, acetaminophen does not exert its peak effect until 2 to 4 hours following ingestion. Performing an arterial puncture for blood-gas analysis will be important, but it is not the first thing that the nurse should do. There is no indication at this time for the administration of O2 or IV fluids.

Nursing Board Exam Review Questions in MSN Part 9/10

1. Among the following, which client is autotransfusion possible? a. Client with AIDS b. Client with ruptured bowel c. Client who is in danger of cardiac arrest d. Client with wound infection

2. Which of the following is not a sign of thromboembolism? a. Edema b. Swelling c. Redness d. Coolness

3. Nurse Becky is caring for client who begins to experience seizure while in bed. Which action should the nurse implement to prevent aspiration? a. Position the client on the side with head flexed forward b. Elevate the head c. Use tongue depressor between teeth d. Loosen restrictive clothing

4. A client has undergone bone biopsy. Which nursing action should the nurse provide after the procedure? a. Administer analgesics via IM b. Monitor vital signs c. Monitor the site for bleeding, swelling and hematoma formation d. Keep area in neutral position

5. A client is suffering from low back pain. Which of the following exercises will strengthen the lower back muscle of the client? a. Tennis b. Basketball c. Diving d. Swimming

6. A client with peptic ulcer is being assessed by the nurse for gastrointestinal perforation. The nurse should monitor for: a. (+) guaiac stool test b. Slow, strong pulse c. Sudden, severe abdominal pain d. Increased bowel sounds

7. A client has undergone surgery for retinal detachment. Which of the following goal should be prioritized? a. Prevent an increase intraocular pressure b. Alleviate pain c. Maintain darkened room d. Promote low-sodium diet

8. A Client with glaucoma has been prescribed with miotics. The nurse is aware that miotics is for: a. Constricting pupil b. Relaxing ciliary muscle c. Constricting intraocular vessel d. Paralyzing ciliary muscle

9. When suctioning an unconscious client, which nursing intervention should the nurse prioritize in maintaining cerebral perfusion? a. Administer diuretics b. Administer analgesics c. Provide hygiene d. Hyperoxygenate before and after suctioning

10. When discussing breathing exercises with a postoperative client, Nurse Hazel should include which of the following teaching? a. Short frequent breaths b. Exhale with mouth open c. Exercise twice a day d. Place hand on the abdomen and feel it rise 1.Answer: C.

Rationale: Autotransfusion is acceptable for the client who is in danger of cardiac arrest.

2.Answer: D.

Rationale: The client with thromboembolism does not have coolness.

3.Answer: A.

Rationale: Positioning the client on one side with head flexed forward allows the tongue to fall forward and facilitates drainage secretions therefore prevents aspiration.

4.Answer: C.

Rationale: Nursing care after bone biopsy includes close monitoring of the punctured site for bleeding, swelling and hematoma formation.

5.Answer: D.

Rationale: Walking and swimming are very helpful in strengthening back muscles for the client suffering from lower back pain.

6.Answer: C.

Rationale: Sudden, severe abdominal pain is the most indicative sign of perforation. When perforation of an ulcer occurs, the nurse maybe unable to hear bowel sounds at all.

7.Answer: A.

Rationale: After surgery to correct a detached retina, prevention of increased intraocular pressure is the priority goal.

8.Answer: A. Rationale: Miotic agent constricts the pupil and contracts ciliary muscle. These effects widen the filtration angle and permit increased out flow of aqueous humor.

9.Answer: D.

Rationale: It is a priority to hyperoxygenate the client before and after suctioning to prevent hypoxia and to maintain cerebral perfusion.

10.Answer: D.

Rationale: Abdominal breathing improves lungs expansion.

1. Louie, with burns over 35% of the body, complains of chilling. In promoting the client͛s comfort, the nurse should:

a. Maintain room humidity below 40%

b. Place top sheet on the client

c. Limit the occurrence of drafts

d. Keep room temperature at 80 degrees

2. Nurse Trish is aware that temporary heterograft (pig skin) is used to treat burns because this graft will:

a. Relieve pain and promote rapid epithelialization

b. Be sutured in place for better adherence

c. Debride necrotic epithelium

d. Concurrently used with topical antimicrobials

3. Mark has multiple abrasions and a laceration to the trunk and all four extremities says, ͞I can͛t eat all this food͟. The food that the nurse should suggest to be eaten first should be:

a. Meat loaf and coffee

b. Meat loaf and strawberries c. Tomato soup and apple pie d. Tomato soup and buttered bread

4. Tony returns form surgery with permanent colostomy. During the first 24 hours the colostomy does not drain. The nurse should be aware that: a. Proper functioning of nasogastric suction b. Presurgical decrease in fluid intake c. Absence of gastrointestinal motility d. Intestinal edema following surgery

5. When teaching a client about the signs of colorectal cancer, Nurse Trish stresses that the most common complaint of persons with colorectal cancer is: a. Abdominal pain b. Hemorrhoids c. Change in caliber of stools d. Change in bowel habits

6. Louis develops peritonitis and sepsis after surgical repair of ruptures diverticulum. The nurse in charge should expect an assessment of the client to reveal: a. Tachycardia b. Abdominal rigidity c. Bradycardia d. Increased bowel sounds

7. Immediately after liver biopsy, the client is placed on the right side, the nurse is aware that that this position should be maintained because it will: a. Help stop bleeding if any occurs b. Reduce the fluid trapped in the biliary ducts c. Position with greatest comfort d. Promote circulating blood volume

8. Tony has diagnosed with hepatitis A. The information from the health history that is most likely linked to hepatitis A is: a. Exposed with arsenic compounds at work b. Working as local plumber c. Working at hemodialysis clinic d. Dish washer in restaurants

9. Nurse Trish is aware that the laboratory test result that most likely would indicate acute pancreatitis is an elevated: a. Serum bilirubin level b. Serum amylase level c. Potassium level d. Sodium level

10. Dr. Marquez orders serum electrolytes. To determine the effect of persistent vomiting, Nurse Trish should be most concerned with monitoring the: a. Chloride and sodium levels b. Phosphate and calcium levels c. Protein and magnesium levels d. Sulfate and bicarbonate levels1.Answer: C.

Rationale: A Client with burns is very sensitive to temperature changes because heat is loss in the burn areas.

2.Answer: A.

Rationale: The graft covers the nerve endings, which reduces pain and provides framework for granulation

3.Answer: B.

Rationale: Meat provides proteins and the fruit proteins vitamin C that both promote wound healing.

4.Answer: C.

Rationale: This is primarily caused by the trauma of intestinal manipulation and the depressive effects anesthetics and analgesics.

5.Answer: D.

Rationale: Constipation, diarrhea, and/or constipation alternating with diarrhea are the most common symptoms of colorectal cancer.

6.Answer: B.

Rationale: With increased intraabdominal pressure, the abdominal wall will become tender and rigid.

7.Answer: A. rationale: Pressure applied in the puncture site indicates that a biliary vessel was puncture which is a common complication after liver biopsy.

8.Answer: B.

Rationale: Hepatitis A is primarily spread via fecal-oral route. Sewage polluted water may harbor the virus.

9.Answer: B. Rationale: Amylase concentration is high in the pancreas and is elevated in the serum when the pancreas becomes acutely inflamed and also it distinguishes pancreatitis from other acute abdominal problems.

10.Answer: A.

Rationale:Sodium, which is concerned with the regulation of extracellular fluid volume, it is lost with vomiting. Chloride, which balances cations in the extracellular compartments, is also lost with vomiting, because sodium and chloride are parallel electrolytes, hyponatremia will accompany.

Which nursing intervention would be appropriate when caring for a client who has sustained an electrical burn? a. Applying ice to the burned area b. Flushing the burn area with large amounts of water c. Monitoring the client with cardiac telemetry d. Preparing to administer the chemical antidote

2. Eddie, 40 years old, is brought to the emergency room after the crash of his private plane. He has suffered multiple crushing wounds of the chest, abdomen and legs. It is feared his leg may have to be amputated.

When Eddie arrives in the emergency room, the assessment that assume the greatest priority are: a. Level of consciousness and pupil size b. Abdominal contusions and other wounds c. Pain, Respiratory rate and blood pressure d. Quality of respirations and presence of pulses.

3. An emergency treatment for an acute asthmatic attack is Adrenaline 1:1000 given hypodermically. This is given to: a. increase BP b. decrease mucosal swelling c. relax the bronchial smooth muscle d. decrease bronchial secretions

4. Intervention for a pt. who has swallowed a Muriatic Acid includes all of the following except

a. administering an irritant that will stimulate vomiting

b. aspirating secretions from the pharynx if respirations are affected

c. neutralizing the chemical

d. washing the esophagus with large volumes of water via gastric lavage

5. John, 16 years old, is brought to the ER after a vehicular accident. He is pronounced dead on arrival. When his parents arrive at the hospital, the nurse should:

a. ask them to stay in the waiting area until she can spend time alone with them

b. speak to both parents together and encourage them to support each other and express their emotions freely

c. Speak to one parent at a time so that each can ventilate feelings of loss without upsetting the other

d. ask the MD to medicate the parents so they can stay calm to deal with their son͛s death.

6. A nurse is eating in the hospital cafeteria when a toddler at a nearby table chokes on a piece of food and appears slightly blue. The appropriate initial action should be to

a. Begin mouth to mouth resuscitation

b. Give the child water to help in swallowing

c. Perform 5 abdominal thrusts

d. Call for the emergency response team

7. A client is admitted from the emergency department with severe-pain and edema in the right foot. His diagnosis is gouty arthritis. When developing a plan of care, which action would have the highest priority?

a. Apply hot compresses to the affected joints. b. Stress the importance of maintaining good posture to prevent deformities. c. Administer salicylates to minimize the inflammatory reaction.

d. Ensure an intake of at least 3000 ml of fluid per day.

8. The Heimlich maneuver (abdominal thrust), for acute airway obstruction, attempts to: a. Force air out of the lungs b. Increase systemic circulation c. Induce emptying of the stomach d. Put pressure on the apex of the heart

9. A nurse is performing CPR on an adult patient. When performing chest compressions, the nurse understands the correct hand placement is located over the a. upper half of the sternum b. upper third of the sternum c. lower half of the sternum d. lower third of the sternum

10. John, 16 years old, is brought to the ER after a vehicular accident. He is pronounced dead on arrival. When his parents arrive at the hospital, the nurse should: a. ask them to stay in the waiting area until she can spend time alone with them b. speak to both parents together and encourage them to support each other and express their emotions freely c. Speak to one parent at a time so that each can ventilate feelings of loss without upsetting the other d. ask the MD to medicate the parents so they can stay calm to deal with their son͛s death.

Click here to View the Correct Answers and Rational(ANSWER KEY)

1. Answer: C

Rationale: Because of the effects of the electrical current on the cardiovascular system, all clients experiencing electrical burns should be placed on a cardiac monitor. Applying ice is inappropriate for any type of burn. Only chemical burns should be flushed with large amounts of water. Chemical antidotes may be used for chemical burns for which an antidote has been identified.

2. Answer: D

Rationale: Respiratory and cardiovascular functions are essential for oxygenation. These are top priorities to trauma management. Basic life functions must be maintained or reestablished

3. Answer: C

Rationale: Acute asthmatic attack is characterized by severe bronchospasm which can be relieved by the immediate administration of bronchodilators. Adrenaline or Epinephrine is an adrenergic agent that causes bronchial dilation by relaxing the bronchial smooth muscles.

4. Answer: A

Rationale: Swallowing of corrosive substances causes severe irritation and tissue destruction of the mucous membrane of the GI tract. Measures are taken to immediately remove the toxin or reduce its absorption. For corrosive poison ingestion, such as in muriatic acid where burn or perforation of the mucosa may occur, gastric emptying procedure is immediately instituted, This includes gastric lavage and the administration of activated charcoal to absorb the poison. Administering an irritant with the concomitant vomiting to remove the swallowed poison will further cause irritation and damage to the mucosal lining of the digestive tract. Vomiting is only indicated when non-corrosive poison is swallowed.

5. Answer: B

Rationale: Sudden death of a family member creates a state of shock on the family. They go into a stage of denial and anger in their grieving. Assisting them with information they need to know, answering their questions and listening to them will provide the needed support for them to move on and be of support to one another.

6. Answer: C Rationale: Perform 5 abdominal thrusts. At this age, the most effective way to clear the airway of food is to perform abdominal thrusts.

7. Answer: D

Rationale: Ensure an intake of at least 3000 ml of fluid per day. Gouty arthritis is a metabolic disease marked by urate deposits that cause painful arthritic joints. The patient should be urged to increase his fluid intake to prevent the development of urinary uric acid stones.

8. Answer: A

Rationale: The Heimlich maneuver is used to assist a person choking on a foreign object. The pressure from the thrusts lifts the diaphragm, forces air out of the lungs and creates an artificial cough that expels the aspirated material.

9. Answer: C

Rationale: The exact and safe location to do cardiac compression is the lower half of the sternum. Doing it at the lower third of the sternum may cause gastric compression which can lead to a possible aspiration.

10. Answer: B

Nursing Board Exam Review Questions in MSN Part 7/10

1. During the initial postoperative period of the client͛s stoma. The nurse evaluates which of the following observations should be reported immediately to the physician? a. Stoma is dark red to purple b. Stoma is oozes a small amount of blood

c. Stoma is lightly edematous

d. Stoma does not expel stool

2. Kate which has diagnosed with ulcerative colitis is following physician͛s order for bed rest with bathroom privileges. What is the rationale for this activity restriction? a. Prevent injury b. Promote rest and comfort c. Reduce intestinal peristalsis d. Conserve energy

3. Nurse KC should regularly assess the client͛s ability to metabolize the total parenteral nutrition (TPN) solution adequately by monitoring the client for which of the following signs: a. Hyperglycemia b. Hypoglycemia c. Hypertension d. Elevate blood urea nitrogen concentration

4. A female client has an acute pancreatitis. Which of the following signs and symptoms the nurse would expect to see? a. Constipation b. Hypertension c. Ascites d. Jaundice

5. A client is suspected to develop tetany after a subtotal thyroidectomy. Which of the following symptoms might indicate tetany? a. Tingling in the fingers

b. Pain in hands and feet

c. Tension on the suture lines

d. Bleeding on the back of the dressing

6. A 58 year old woman has newly diagnosed with hypothyroidism. The nurse is aware that the signs and symptoms of hypothyroidism include: a. Diarrhea b. Vomiting c. Tachycardia d. Weight gain

7. A client has undergone for an ileal conduit, the nurse in charge should closely monitor the client for occurrence of which of the following complications related to pelvic surgery? a. Ascites b. Thrombophlebitis c. Inguinal hernia d. Peritonitis

8. Dr. Marquez is about to defibrillate a client in ventricular fibrillation and says in a loud voice ͞clear͟. What should be the action of the nurse? a. Places conductive gel pads for defibrillation on the client͛s chest b. Turn off the mechanical ventilator c. Shuts off the client͛s IV infusion d. Steps away from the bed and make sure all others have done the same

9. A client has been diagnosed with glomerulonephritis complains of thirst. The nurse should offer: a. Juice

b. Ginger ale

c. Milk shake

d. Hard candy

10. A client with acute renal failure is aware that the most serious complication of this condition is:

a. Constipation

b. Anemia

c. Infection

d. Platelet dysfunction

Nursing Board Exam Review Questions in MSN Part 7/10

(ANSWER KEY)

1.Answer: A.

Rationale: Dark red to purple stoma indicates inadequate blood supply.

2.Answer: C.

Rationale: The rationale for activity restriction is to help reduce the hypermotility of the colon.

3.Answer: A.

Rationale: During Total Parenteral Nutrition (TPN) administration, the client should be monitored regularly for hyperglycemia.

4.Answer: D.

Rationale: Jaundice may be present in acute pancreatitis owing to obstruction of the biliary duct.

5.Answer: A.

Rationale: Tetany may occur after thyroidectomy if the parathyroid glands are accidentally injured or removed.

6.Answer: D.

Rationale: Typical signs of hypothyroidism includes weight gain, fatigue, decreased energy, apathy, brittle nails, dry skin, cold intolerance, constipation and numbness.

7.Answer: B.

Rationale: After a pelvic surgery, there is an increased chance of thrombophlebitits owing to the pelvic manipulation that can interfere with circulation and promote venous stasis.

8.Answer: D.

Rationale: For the safety of all personnel, if the defibrillator paddles are being discharged, all personnel must stand back and be clear of all the contact with the client or the client͛s bed.

9.Answer: D.

Rationale: Hard candy will relieve thirst and increase carbohydrates but does not supply extra fluid.

10.Answer: C.

Rationale: Infection is responsible for one third of the traumatic or surgically induced death of clients with renal failure as well as medical induced acute renal failure (ARF) ursing Board Exam Review Questions in MSN Part 8/10

1. Nurse Karen is caring for clients in the OR. The nurse is aware that the last physiologic function that the client loss during the induction of anesthesia is: a. Consciousness b. Gag reflex c. Respiratory movement

d. Corneal reflex

2. The nurse is assessing a client with pleural effusion. The nurse expect to find:

a. Deviation of the trachea towards the involved side

b. Reduced or absent of breath sounds at the base of the lung c. Moist crackles at the posterior of the lungs d. Increased resonance with percussion of the involved area

3. A client admitted with newly diagnosed with Hodgkin͛s disease. Which of the following would the nurse expect the client to report? a. Lymph node pain b. Weight gain c. Night sweats d. Headache

4. A client has suffered from fall and sustained a leg injury. Which appropriate question would the nurse ask the client to help determine if the injury caused fracture? a. ͞Is the pain sharp and continuous?͟ b. ͞Is the pain dull ache?͟ c. ͞Does the discomfort feel like a cramp?͟ d. ͞Does the pain feel like the muscle was stretched?͟

5. The Nurse is assessing the client͛s casted extremity for signs of infection. Which of the following findings is indicative of infection? a. Edema b. Weak distal pulse c. Coolness of the skin

d. Presence of ͞hot spot͟ on the cast

6. Nurse Rhia is performing an otoscopic examination on a female client with a suspected diagnosis of mastoiditis. Nurse Rhia would expect to note which of the following if this disorder is present?

a. Transparent tympanic membrane

b. Thick and immobile tympanic membrane

c. Pearly colored tympanic membrane

d. Mobile tympanic membrane

7. Nurse Jocelyn is caring for a client with nasogastric tube that is attached to low suction. Nurse Jocelyn assesses the client for symptoms of which acid-base disorder?

a. Respiratory alkalosis

b. Respiratory acidosis

c. Metabolic acidosis

d. Metabolic alkalosis

8. A male adult client has undergone a lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis. Which of the following values should be negative if the CSF is normal? a. Red blood cells b. White blood cells c. Insulin d. Protein

9. A client is suspected of developing diabetes insipidus. Which of the following is the most effective assessment? a. Taking vital signs every 4 hours b. Monitoring blood glucose c. Assessing ABG values every other day d. Measuring urine output hourly

10. A 58 year old client is suffering from acute phase of rheumatoid arthritis. Which of the following would the nurse in charge identify as the lowest priority of the plan of care? a. Prevent joint deformity b. Maintaining usual ways of accomplishing task c. Relieving pain d. Preserving joint function

Nursing Board Exam Review Questions in MSN Part 8/10

(ANSWER KEY)

1.Answer: C.

Rationale: There is no respiratory movement in stage 4 of anesthesia, prior to this stage, respiration is depressed but present.

2.Answer: B.

Rationale: Compression of the lung by fluid that accumulates at the base of the lungs reduces expansion and air exchange.

3.Answer: C.

Rationale: Assessment of a client with Hodgkin͛s disease most often reveals enlarged, painless lymph node, fever, malaise and night sweats.

4.Answer: A.

Rationale: Fractured pain is generally described as sharp, continuous, and increasing in frequency.

5.Answer: D.

Rationale: Signs and symptoms of infection under a casted area include odor or purulent drainage and the presence of ͞hot spot͟ which are areas on the cast that are warmer than the others.

6.Answer: B.

Rationale: Otoscopic examnation in a client with mastoiditis reveals a dull, red, thick and immobile tymphanic membrane with or without perforation.

7.Answer: D.

Rationale: Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis because of the loss of hydrochloric acid which is a potent acid in the body.

8.Answer: A.

Rationale: The adult with normal cerebrospinal fluid has no red blood cells.

9.Answer: D.

Rationale: Measuring the urine output to detect excess amount and checking the specific gravity of urine samples to determine urine concentration are appropriate measures to determine the onset of diabetes insipidus.

10.Answer: B.

Rationale: The nurse should focus more on developing less stressful ways of accomplishing routine task.

Nursing Board Exam Review Questions in Emergency Part 4/20

1. The nurse is planning a program for clients at a health fair regarding the prevention and early detection of cancer of the pancreas. Which self-care activity should the nurse teach that is an example of primary nursing care? a. Monitor for elevated blood glucose at random intervals. b. Inspect the skin and sclera of the eyes for a yellow tint. c. Limit meat in the diet and eat a diet that is low in fats. d. Instruct the client with hyperglycemia about insulin injections.

2. The client diagnosed with cancer of the pancreas is being discharged to start chemotherapy in the HCP͛s office. Which statement made by the client indicates the client understands the discharge instructions? a. ͞I will have to see the HCP every day for six (6) weeks for my treatments.͟ b. ͞I should write down all my questions so I can ask them when I see the HCP.͟ c. ͞I am sure that this is not going to be a serious problem for me to deal with.͟ d. ͞The nurse will give me an injection in my leg and I will get to go home.͟

3. The nurse caring for a client diagnosed with cancer of the pancreas writes the collaborative problem of ͞altered nutrition.͟ Which intervention should the nurse include in the plan of care? a. Continuous feedings via PEG tube. b. Have the family bring in foods from home. c. Assess for food preferences. d. Refer to the dietitian.

4. The client is taken to the emergency department with an injury to the left arm. Which action should the nurse take first? a. Assess the nail beds for capillary refill time. b. Remove the client͛s clothing from the arm. c. Call radiology for a STAT x-ray of the extremity. d. Prepare the client for the application of a cast.

5. The nurse finds the client unresponsive on the floor of the bathroom. Which action should the nurse implement first? a. Check the client for breathing. b. Assess the carotid artery for a pulse. c. Shake the client and shout. d. Call a code via the bathroom call light.

6. Which behavior by the unlicensed assistive personnel who is performing cardiac compressions on an adult client during a code warrants immediate intervention by the nurse? a. Has one hand on the lower half of the sternum above the xiphoid process. b. Performs cardiac compressions and allows for rescue breathing. c. Depresses the sternum 0.5 to one (1) inch during compressions. d. Requests to be relieved from performing compressions because of exhaustion.

7. Which is the most important intervention for the nurse to implement when participating in a code? a. Elevate the arm after administering medication. b. Maintain sterile technique throughout the code. c. Treat the client͛s signs/symptoms; do not watch the monitor. d. Be sure to provide accurate documentation of what happened in the code.

8. The CPR instructor is explaining what an automated external defibrillator (AED) does to students in a CPR class. Which statement best describes an AED? a. It analyzes the rhythm and shocks the client in ventricular fibrillation. b. The client will be able to have synchronized cardioversion with the AED. c. It will keep the health-care provider informed of the client͛s oxygen level. d. The AED will perform cardiac compressions on the client.

9. The nurse is caring for clients on a medical floor. Which client is most likely to experience sudden cardiac death? a. The 84-year-old client exhibiting uncontrolled atrial fibrillation. b. The 60-year-old client exhibiting asymptomatic sinus bradycardia. c. The 53-year-old client exhibiting ventricular fibrillation. d. The 65-year-old client exhibiting supraventricular tachycardia.

10. Which health-care team member referral should be made when a code is being conducted on a client in a community hospital? a. The hospital chaplain. b. The social worker. c. The respiratory therapist. d. The director of nurses.

Nursing Board Exam Review Questions in Emergency Part 4/20

(ANSWER KEY)

1. Answer: C

Rationale: Limiting the intake of meat and fats in the diet would be an example of primary interventions. Risk factors for the development of cancer of the pancreas are cigarette smoking and eating a high-fat diet that is high in animal protein. By changing these behaviors the client could possibly prevent the development of cancer of the pancreas. Other risk factors include genetic predisposition and exposure to industrial chemicals.

2. Answer: B Rationale: The most important person in the treatment of the cancer is the client. Research has proved that the more involved a client becomes in his or her care, the better the prognosis. Clients should have a chance to ask all the questions that they have.

3. Answer: D

Rationale: A collaborative intervention would be to refer to the nutrition expert, the dietitian.

4. Answer: A

Rationale: The nurse should assess the nail beds for the capillary refill time. A prolonged time (greater than three seconds) indicates impaired circulation to the extremity.

5. Answer: C

Rationale: This is the first intervention the nurse should implement after finding the client unresponsive on the floor.

6. Answer: C

Rationale: The sternum should be depressed 1.5 to 2 inches during compressions to ensure adequate circulation of blood to the body; therefore, the nurse needs to correct the assistant.

7. Answer: C

Rationale: This is the most important intervention.

The nurse should always treat the client based on the nurse͛s assessment and data from the monitors; an intervention should not be based on data from the monitors without the nurse͛s assessment.

8. Answer: A

Rationale: This is the correct statement explaining what an AED does when used in a code.

9. Answer: C Rationale: Ventricular fibrillation is the most common dysrhythmia associated with sudden cardiac death; ventricular fibrillation is responsible for 65% to 85% of sudden cardiac deaths.

10. Answer: A

Rationale: The chaplain should be called to help address the client͛s family or significant others.

A small community hospital would not have a 24-hour on-duty pastoral service.

Nursing Board Exam Review Questions in Emergency Part 3/20

1. A client with multiple injury following a vehicular accident is transferred to the critical care unit. He begins to complain of increased abdominal pain in the left upper quadrant. A ruptured spleen is diagnosed and he is scheduled for emergency splenectomy. In preparing the client for surgery, the nurse should emphasize in his teaching plan the:

a. Complete safety of the procedure

b. Expectation of postoperative bleeding

c. Risk of the procedure with his other injuries

d. Presence of abdominal drains for several days after surgery

2. After you managed to stabilize the respiratory function of your burn patient, your next goal is to prevent this you have to replace the lost fluid and electrolytes. In starting fluid replacement therapy, the total volume and rate of IV fluid repalcement are gauged by the patient͛s response and by the patient͛s response and by the resuscitation formula. In determining the adequacy of fluid resuscitation, it is essential for you to monitor the:

a. urine output

b. blood pressure

c. intracranial pressure

d. cardiac output

3. You are a nurse in the emergency department and it is during the shift that Mr. CT is admitted in the area due to a fractured skull from a motor accident. You scheduled him for surgery under which classification?

a. Urgent

b. Emergent

c. Required

d. Elective

4. Lucky was in a vehicular acccident where he sustained injury to his left ankle. In the Emergency room, you noticed anxious he looks. You establish rapport with him and to reduce his anxiety, you initially:

a. Identify yourself and state your purpose in being with the client

b. Take him to the radiology section for x-ray of affected extremity

c. Talk to the physician for an order of valium

d. Do inspection and palpation to check extent of his injuries

5. The client diagnosed with a mild concussion is being discharged from the emergency department. Which discharge instruction should the nurse teach the client͛s significant other? a. Awaken the client every two hours. b. Monitor for increased intracranial pressure. c. Observe frequently for hypervigilance. d. Offer the client food every three to four hours.

6. The client diagnosed with Addison͛s disease is admitted to the emergency department after a day at the lake. The client is lethargic, forgetful, and weak. Which intervention should be the emergency department nurse͛s first action? a. Start an IV with an 18-gauge needle and infuse NS rapidly. b. Have the client wait in the waiting room until a bed is available. c. Perform a complete head-to-toe assessment. d. Collect urinalysis and blood samples for a CBC and calcium level.

7. The nurse caring for a client diagnosed with cancer of the pancreas writes the nursing diagnosis of ͞risk for altered skin integrity related to pruritus.͟ Which interventions should the nurse implement?

a. Assess tissue turgor.

b. Apply antifungal creams.

c. Monitor bony prominences for breakdown.

d. Have the client keep the fingernails short.

8. The client diagnosed with cancer of the head of the pancreas is two (2) days postpancreatoduodenectomy (Whipple͛s procedure). Which nursing problem has the highest priority?

a. Anticipatory grieving.

b. Fluid volume imbalance.

c. Acute incisional pain.

d. Altered nutrition.

9. The client is diagnosed with cancer of the head of the pancreas. When assessing the patient, which signs and symptoms would the nurse expect to find?

a. Clay-colored stools and dark urine.

b. Night sweats and fever.

c. Left lower abdominal cramps and tenesmus.

d. Nausea and coffee-ground emesis.

10. The client admitted to rule out pancreatic islet tumors complains of feeling weak, shaky, and sweaty. Which should be the first intervention implemented by the nurse?

a. Start an IV with D5W.

b. Notify the health-care provider. c. Perform a bedside glucose check. d. Give the client some orange juice. Nursing Board Exam Review Questions in Emergency Part 5/20

1. Which intervention is the most important for the nurse to implement when performing mouth-to- mouth resuscitation on a client who has pulseless ventricular fibrillation? a. Perform the jaw thrust maneuver to open the airway. b. Use the mouth to cover the client͛s mouth and nose. c. Insert an oral airway prior to performing mouth to mouth. d. Use a pocket mouth shield to cover client͛s mouth.

2. The nurse is teaching CPR to a class. Which statement best explains the definition of sudden cardiac death? a. Cardiac death occurs after being removed from a mechanical ventilator. b. Cardiac death is the time that the physician officially declares the client dead. c. Cardiac death occurs within one (1) hour of the onset of cardiovascular symptoms. d. The death is caused by myocardial ischemia resulting from coronary artery disease.

3. Which statement explains the scientific rationale for having emergency suction equipment available during resuscitation efforts? a. Gastric distention can occur as a result of ventilation. b. It is needed to assist when intubating the client. c. This equipment will ensure a patent airway. d. It keeps the vomitus away from the health-care provider.

4. Which equipment must be immediately brought to the client͛s bedside when a code is called for a client who has experienced a cardiac arrest? a. A ventilator. b. A crash cart.

c. A gurney.

d. Portable oxygen.

5. The nursing administrator responds to a code situation. When assessing the situation, which role must the administrator ensure is performed for legal purposes and continuity of care of the client? a. A person is ventilating with an ambu bag. b. A person is performing chest compressions correctly.

c. A person is administering medications as ordered.

d. A person is keeping an accurate record of the code.

6. The nurse in the emergency department has admitted five (5) clients in the last two (2) hours with complaints of fever and gastrointestinal distress. Which question would be most appropriate for the nurse to ask each client to determine if there is a bioterrorism threat?

a. ͞Do you work or live near any large power lines?͟

b. ͞Where were you immediately before you got sick?͟

c. ͞Can you write down everything you ate today?͟

d. ͞What other health problems do you have?͟

7. The health-care facility has been notified that an alleged inhalation anthrax exposure has occurred at the local post office. Which category of personal protective equipment (PPE) would the response team wear? a. Level A b. Level B c. Level C d. Level D

8. The nurse is teaching a class on bioterrorism and is discussing personal protective equipment (PPE). Which statement is the most important fact that must be shared with the participants? a. Health-care facilities should keep masks at entry doors. b. The respondent should be trained in the proper use of PPE. c. No single combination of PPE protects against all hazards. d. The EPA has divided PPE into four levels of protection

9. The nurse is teaching a class on bioterrorism. What is the scientific rationale for designating a specific area for decontamination? a. Showers and privacy can be provided to the client in this area. b. This area isolates the clients who have been exposed to the agent. c. It provides a centralized area for stocking the needed supplies. d. It prevents secondary contamination to the health-care providers.

10. The triage nurse in a large trauma center has been notified of an explosion in a major chemical manufacturing plant. Which action should the nurse implement first when the clients arrive at the emergency department? a. Triage the clients and send them to the appropriate areas. b. Thoroughly wash the clients with soap and water and then rinse. c. Remove the clients͛ clothing and have them shower. d. Assume the clients have been decontaminated at the plantNursing Board Exam Review Questions in Emergency Part 5/20

(ANSWER KEY)

1. Answer: D

Rationale: Nurses should protect themselves against possible communicable disease, such as HIV, hepatitis, or any types of sexually transmitted disease.

2. Answer: C

Rationale: Unexpected death occurring within1 hour of the onset of cardiovascular symptoms is the definition of sudden cardiac death.

3. Answer: A

Rationale: Gastric distention occurs from overventilating clients. When compressions are performed, the pressure will cause vomiting that could be aspirated into the lungs.

4. Answer: B

Rationale: The crash cart is the mobile unit that has the defibrillator and all the medications and supplies needed to conduct a code.

5. Answer: D

Rationale: The chart is a legal document and the code must be documented in the chart and provide information that may be needed in the intensive care unit.

6. Answer: B

Rationale: The nurse should take note of any unusual illness for the time of year or clusters of clients coming from a single geographical location who all exhibit signs/symptoms of possible biological terrorism.

7. Answer: A

Rationale: Level A protection is worn when the highest level of respiratory, skin, eye, and mucous membrane protection is required.

In this situation of possible inhalation of anthrax, such protection is required.

8. Answer: C

Rationale: The health-care providers are not guaranteed absolute protects. The nurse should take note of any unusual illness for the time of year or clusters of clients coming from a single geographical location who all exhibit signs/symptoms of possible biological terrorism.ion, even with all the training and protective equipment.

9. Answer: D

Rationale: Avoiding cross contamination is a priority for personnel and equipmentͶthe fewer number of people exposed, the safer the community and area.

10. Answer: C

Rationale: This is the first step. Depending on the type of exposure, this step alone can remove a large portion of exposure. Nursing Board Exam Review Questions in Emergency Part 6/20

1. The nurse is teaching a class on biological warfare. Which information should the nurse include in the presentation? a. Contaminated water is the only source of transmission of biological agents. b. Vaccines are available and being prepared to counteract biological agents. c. Biological weapons are less of a threat than chemical agents. d. Biological weapons are easily obtained and result in significant mortality.

2. Which signs/symptoms would the nurse assess in the client who has been exposed to the anthrax bacillus via the skin? a. A scabby, clear fluidʹfilled vesicle. b. Edema, pruritus, and a 2-mm ulcerated vesicle. c. Irregular brownish-pink spots around the hairline. d. Tiny purple spots flush with the surface of the skin.

3. The client has expired secondary to smallpox. Which information about funeral arrangements is most important for the nurse to provide to the client͛s family? a. The client must be cremated. b. Suggest an open casket funeral.

c. Bury the client within 24 hours.

d. Notify the public health department.

4. A chemical exposure has just occurred at an airport. An off-duty nurse, knowledgeable about biochemical agents, is giving directions to the travelers. Which direction should the nurse provide to the travelers? a. Hold their breath as much as possible. b. Stand up to avoid heavy exposure. c. Lie down to stay under the exposure. d. Attempt to breathe through their clothing.

5. The nurse is caring for a client in the prodromal phase of radiation exposure. Which signs/symptoms would the nurse assess in the client? a. Anemia, leukopenia, and thrombocytopenia. b. Sudden fever, chills, and enlarged lymph nodes. c. Nausea, vomiting, and diarrhea. d. Flaccid paralysis, diplopia, and dysphagia.

6. The off-duty nurse hears on the television of a bioterrorism act in the community.

Which action should the nurse take first? a. Immediately report to the hospital emergency room. b. Call the American Red Cross to find out where to go. c. Pack a bag and prepare to stay at the hospital. d. Follow the nurse͛s hospital policy for responding.

7. Which situation would warrant the nurse obtaining information from a material safety data sheet (MSDS)?

a. The custodian spilled a chemical solvent in the hallway.

b. A visitor slipped and fell on the floor that had just been mopped.

c. A bottle of antineoplastic agent broke on the client͛s floor.

d. The nurse was stuck with a contaminated needle in the client͛s room.

8. The triage nurse is working in the emergency department. Which client should be assessed first?

a. The 10-year-old child whose dad thinks the child͛s leg is broken.

b. The 45-year-old male who is diaphoretic and clutching his chest.

c. The 58-year-old female complaining of a headache and seeing spots. d. The 25-year-old male who cut his hand with a hunting knife.

9. According to the North Atlantic Treaty Organization (NATO) triage system, which situation would be considered a level red (Priority 1)? a. Injuries are extensive and chances of survival are unlikely.

b. Injuries are minor and treatment can be delayed hours to days. c. Injuries are significant but can wait hours without threat to life or limb.

d. Injuries are life threatening but survivable with minimal interventions.

10. Which statement best describes the role of the medical-surgical nurse during a disaster?

a. The nurse may be assigned to ride in the ambulance.

b. The nurse may be assigned as a first assistant in the operating room.

c. The nurse may be assigned to crowd control.

d. The nurse may be assigned to the emergency department.

Nursing Board Exam Review Questions in Emergency Part 6/20

6. The off-duty nurse hears on the television of a bioterrorism act in the community.

7. Which situation would warrant the nurse obtaining information from a material safety data sheet (MSDS)? a. The custodian spilled a chemical solvent in the hallway. b. A visitor slipped and fell on the floor that had just been mopped. c. A bottle of antineoplastic agent broke on the client͛s floor. d. The nurse was stuck with a contaminated needle in the client͛s room.

8. The triage nurse is working in the emergency department. Which client should be assessed first? a. The 10-year-old child whose dad thinks the child͛s leg is broken.

b. The 45-year-old male who is diaphoretic and clutching his chest.

c. The 58-year-old female complaining of a headache and seeing spots. d. The 25-year-old male who cut his hand with a hunting knife.

b. Injuries are minor and treatment can be delayed hours to days. c. Injuries are significant but can wait hours without threat to life or limb.

d. Injuries are life threatening but survivable with minimal interventions.

10. Which statement best describes the role of the medical-surgical nurse during a disaster?

a. The nurse may be assigned to ride in the ambulance.

b. The nurse may be assigned as a first assistant in the operating room.

c. The nurse may be assigned to crowd control.

d. The nurse may be assigned to the emergency department.

Nursing Board Exam Review Questions in Emergency Part 6/20

(ANSWER KEY)

1. Answer: D

Rationale: Because of the variety of agents, the means of transmission, and lethality of the agents, biological weapons, including anthrax, smallpox, and plague, is especially dangerous.

2. Answer: B Rationale: Exposure to anthrax bacilli via the skin results in skin lesions, which cause edema with pruritus and the formation of macules or papules that ulcerate, forming a 1-3 mm vesicle. Then a painless eschar develops, which falls off in one (1) to 2 weeks.

3. Answer: A

Rationale: Cremation is recommended because the virus can stay alive in the scabs of the body for 13 years.

4. Answer: B

Rationale: Standing up will avoid heavy exposure the chemical will sink toward the floor or ground.

5. Answer: C

Rationale: The prodromal phase (presenting symptoms) of radiation exposure occurs 48ʹ72 hours after exposure and the signs/symptoms are nausea, vomiting, diarrhea, anorexia, and fatigue. Higher exposures of radiation signs/symptoms include fever, respiratory distress, and excitability.

6. Answer: D

Rationale: The nurse should follow the hospital͛s policy. Many times nurses will stay at home until decisions are made as to where the employees should report.

7. Answer: A

Rationale: The MSDS provides chemical information regarding specific agents, health information, and spill information for a variety of chemicals. It is required for every chemical that is found in the hospital.

8. Answer: B

Rationale: The triage nurse should see this client first because these are symptoms of a myocardial infarction, which potentially life is threatening.

9. Answer: D Rationale: This is called the immediate category. Individuals in this group can progress rapidly to expectant if treatment is delayed.

10. Answer: D

Rationale: New settings and atypical roles for nurses may be required during disasters; medical-surgical nurses can provide first aid and be required to work in unfamiliar settings.