Exam (elaborations)
Chapter 16 Care of Patients Experiencing Urgent Alterations in Health
- Course
- Nursing
- Institution
- Western Piedmont Community College
Chapter 16 Care of Patients Experiencing Urgent Alterations in Health
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Chapter 16: Care of Patients Experiencing Urgent Alterations in HealthMULTIPLE CHOICE
1. When administering first aid in emergency situations, the nurse must first survey victims for
severity of injuries. What term correctly describes this process?
a. The Good Samaritan law
b. An emergency interview
c. Triage
d. Taking vital signs
ANS: C
This process of patient classification is called triage.
PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 414
OBJ: 1 TOP: First aid KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
2. The Good Samaritan law will protect all people who offer assistance. What is necessary for
this protection?
a. A license
b. The person acts prudently
c. Licensed supervision
d. The patient improves
ANS: B
The Good Samaritan law will protect any person who follows a prudent course of action.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 415
OBJ: 2 TOP: Good Samaritan law KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
3. A nurse is assessing victims in an emergency situation. What will the nurse assess for first?
a. Hemorrhage
b. Fractures
c. Mobility
d. Abnormal breathing
ANS: D
A life-threatening situation of the highest priority is arrested or abnormal breathing.
PTS: 1 DIF: Cognitive Level: Application REF: Page 415
OBJ: 1 TOP: ABC of assessment
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
4. CPR has been initiated at an accident site. When can CPR be terminated?
a. Victim is clinically dead
b. Victim is brain dead
c. Paramedics arrive
d. Rescuer perceives CPR is futile
, ANS: C
There is a moral obligation to continue CPR once it has been initiated unless the rescuer is
exhausted and cannot continue, trained medical personnel take over CPR, or a licensed
physician pronounces the victim dead.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 416
OBJ: 4 TOP: Cardiopulmonary resuscitation (CPR)
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
5. The nurse determines clinical death and initiates CPR immediately. How long is resuscitation
considered possible?
a. If cardiopulmonary arrest has existed for no more 2 minutes
b. If cardiopulmonary arrest has existed for no more 3 minutes
c. If cardiopulmonary arrest has existed for no more 4 minutes
d. If cardiopulmonary arrest has existed for no more 5 minutes
ANS: C
CPR can reverse clinical death if initiated before 4 minutes.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 416
OBJ: 3 TOP: Cardiopulmonary resuscitation (CPR)
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
6. When assessing the adult victim for pulselessness, the CPR rescuer should palpate the most
reliable and accessible pulse. Which pulse will be palpated?
a. Radial
b. Brachial
c. Carotid
d. Femoral
ANS: C
When assessing the adult victim for pulselessness, the most reliable and accessible pulse is the
carotid.
PTS: 1 DIF: Cognitive Level: Application REF: Page 417
OBJ: 4 TOP: Cardiopulmonary resuscitation (CPR)
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
7. When a patient suddenly experiences respiratory difficulty in the cafeteria, the nurse begins
assessment for foreign body airway obstruction. What is the most appropriate question to ask
the victim?
a. "What did you swallow?"
b. "Are you choking?"
c. "Are you OK?"
d. "Can I help you?"
ANS: B
With complete airway obstruction, the victim cannot s peak. Ask, ―Are you choking? ‖ With
this question the nurse pinpoints the problem and can perform the Heimlich maneuver with no
wasted time.
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