Question 1

A community health nurse is providing an educational session on childhood poisoning at a local school. The topic of the discussion is preventive measures to avoid accidental poisoning. The nurse includes instructions that if an accidental poisoning occurs to immediately:

Accepted Answer

Calling the poison control center is the immediate and appropriate action to take in the event of an accidental poisoning, as they can provide specific advice on what to do next based on the substance involved.

Question 2

A nurse is conducting a basic life support (BLS) recertification class and is discussing automated external defibrillation (AED) when a member of the class asks the nurse to identify the correct location for the placement of conductive gel pads to treat ventricular fibrillation. The nurse correctly responds with:

Accepted Answer

The correct placement for AED pads when treating ventricular fibrillation is one pad under the right clavicle and the other to the left of the nipple in the midaxillary line. This positioning allows for optimal electrical conduction through the heart.

Question 3

The nurse is initiating one-rescuer cardiopulmonary resuscitation (CPR) on an adult client. After ventilating the client, the nurse places the hands in which of the following positions to begin chest compressions?

Accepted Answer

The correct hand placement for chest compressions during CPR on an adult is on the lower half of the sternum. This location ensures that the force of the compressions is directed at the heart, between the breasts, without putting pressure on the ribs or the upper abdomen, which could cause harm.

Question 4

A nurse walking in a downtown business area witnesses a worker fall from a ladder. The nurse rushes to the victim, who is unresponsive. The nurse then opens the victim's airway by using the:

Accepted Answer

The answer of A nurse walking in a downtown business...

Question 5

The nurse notes that a 5-year-old child is choking but is awake and alert at this time. As the nurse rushes to aid the child, the nurse plans to place the hands between which of the following landmarks to do the abdominal thrust maneuver?

Accepted Answer

The correct hand placement for performing the abdominal thrust maneuver (Heimlich maneuver) on a child or adult is between the umbilicus (belly button) and the xiphoid process (the lower part of the sternum). This positioning targets the diaphragm to create enough pressure to expel the foreign object causing the choking.

Question 6

The nurse employed in the pediatric unit working on the 11 PM to 7 AM shift finds an infant unresponsive and without respirations or a pulse. After opening the airway and initiating ventilation, the nurse delivers chest compressions at a minimum rate of:

Accepted Answer

For infants, the recommended rate for chest compressions is at least 100 times per minute, according to CPR guidelines.

Question 7

A nurse is undergoing annual recertification in basic life support (BLS). The BLS instructor asks the nurse to identify the most appropriate pulse point to use when determining pulselessness on an infant. The nurse undergoing recertification replies that the correct pulse point is:

Accepted Answer

For infants, the brachial pulse is the most appropriate pulse point to check when determining pulselessness, as it is more accessible and reliable in this age group compared to other pulse points.

Question 8

An automatic external defibrillator (AED) interprets that the rhythm of a pulseless client is ventricular fibrillation. The nurse takes which of the following actions next?

Accepted Answer

In the case of ventricular fibrillation, the immediate action after the AED interprets the rhythm is to ensure safety (ordering personnel away from the client), charge the machine, and then depress the discharge buttons to deliver a shock. This is the correct sequence of actions to attempt to restore a normal heart rhythm. Performing CPR for 1 minute before defibrillation (A), administering rescue breathing during defibrillation (B), and immediately pushing the discharge buttons without ensuring safety (C) are not the recommended actions according to resuscitation guidelines.

Question 9

The client has been defibrillated unsuccessfully three times using an automatic external defibrillator (AED). The nurse determines that which of the following actions should be taken next?

Accepted Answer

Current guidelines recommend performing CPR for 2 minutes (not 1 minute as stated in the question, but D is the closest to the recommended practice among the options provided), assessing the patient, and then considering further defibrillation attempts if necessary. Continuous CPR is crucial for maintaining blood flow to the heart and brain until a normal heart rhythm can be restored.

Question 10

The nurse has completed four cycles of compressions after beginning cardiopulmonary resuscitation (CPR) on a hospitalized adult client. At this time, the nurse should:

Accepted Answer

Continuing CPR is essential until advanced life support can take over, the person shows signs of life, or a healthcare professional with the authority to do so calls off the resuscitation effort.

Question 11

The nurse is teaching cardiopulmonary resuscitation (CPR) to a group of lay persons. Which of the following behaviors by one of the participants would indicate the need for further review?

Accepted Answer

Letting the fingers rest on the chest can interfere with effective chest compressions and may cause injury, indicating a need for further review.

Question 12

The client with a perforated gastric ulcer who is scheduled for emergency surgery cannot sign the operative consent form because of sedation with opioid analgesics. The nurse takes which priority action?

Accepted Answer

If the client is unable to sign due to sedation, a telephone consent from a family member is appropriate, provided it is witnessed by two persons to ensure legality and ethical standards are maintained.

Question 13

The preoperative client expresses anxietyto the nurse about the upcoming surgery. Which of the following statements by the nurse is most likely to stimulate further discussion between the client and the nurse?

Accepted Answer

This statement invites the client to share their understanding and concerns, facilitating further discussion and addressing specific anxieties.

Question 14

The nurse is preparing the client for transfer to the operating room (OR). The nurse should take which of the following actions first?

Accepted Answer

Ensuring that the client has voided is important to prevent discomfort during surgery and to reduce the risk of bladder injury.

Question 15

The nurse is assigned to assist in caring for a client who recently returned from the operating room (OR). On data collection, the nurse notes that the client's vital signs are blood pressure (BP), 118/70 mm Hg; pulse, 91 beats/min; and respirations, 16 breaths/min. Preoperative vital signs were BP, 132/88 mm Hg; pulse, 74 beats/min; and respirations, 20 breaths/min. Which of the following actions should the nurse plan to take first?

Accepted Answer

The nurse should first recheck the vital signs in 15 minutes to determine if the changes are persistent or if they stabilize, as fluctuations can occur postoperatively.

Question 16

The nurse has just reassessed the condition of the postoperative client who was admitted 1 hour ago to the surgical unit. The nurse monitors which of the following parameters during the next hour most carefully?

Accepted Answer

Urinary output of 20 mL/hr is significantly below the normal range (typically 0.5 mL/kg/hr for adults), indicating potential postoperative complications such as inadequate fluid volume or kidney function issues, which requires careful monitoring.

Question 17

The client is admitted to the surgical unit postoperatively with a wound drain (Jackson-Pratt) in place. Which of the following correctly describes the primary purpose of a Jackson-Pratt?

Accepted Answer

The primary purpose of a Jackson-Pratt drain is to assist in the evacuation of fluid and blood from the surgical wound, which helps in reducing swelling and promoting healing.

Question 18

When performing a surgical dressing change of a client's abdominal dressing, the nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The priority nursing action at this time is to:

Accepted Answer

The priority nursing action when there is an increase in drainage and separation of the incision line with visible underlying tissue is to apply a sterile dressing soaked with normal saline. This maintains a moist wound environment, which is essential for wound healing, and protects the wound from further contamination.

Question 19

The nurse is reviewing the physician's prescription sheet for the preoperative client, which states that the client must be NPO after midnight. The nurse should clarify which of the following medications should be given to the client and not withheld?

Accepted Answer

Atenolol (Tenormin) is a beta-blocker used to manage hypertension and other cardiovascular conditions. It is crucial to continue beta-blockers even on the day of surgery to avoid withdrawal symptoms and maintain blood pressure control, unless specifically advised otherwise by the physician or anesthesiologist.

Question 20

The client who underwent preadmission testing prior to a surgical procedure had serum laboratory studies drawn, including complete blood count, electrolytes, coagulation studies, and creatinine. Which of the following laboratory results should be reported to the surgeon immediately?

Accepted Answer

A hemoglobin level of 8.9 g/dL is significantly low and indicates anemia, which could affect the patient's ability to tolerate surgery and recover properly. This should be reported to the surgeon immediately for further assessment and possible treatment before proceeding with the surgery.

Quiz 3: Fundamentals and Issues of Nursing