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NUR 265 UNIT 9,10 AND 11 QUESTIONS AND RATIONALES (1)-4 EXAM 2024/2025
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NUR 265 UNIT 9,10 AND 11 QUESTIONS AND RATIONALES (1)-4 EXAM 2024/2025
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NUR 265 UNIT 9,10 AND 11 QUESTIONS AND RATIONALES(1)-4 EXAM 2024/2025
, NUR 265 Practice units 9,10 and 11
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. An emergency room nurse is triaging victims of a multi-casualty event.
Which client should receive care first?
a. A 30-year-old distraught mother holding her crying child
b. A 65-year-old conscious male with a head laceration
c. A 26-year-old male who has pale, cool, clammy skin
d. A 48-year-old with a simple fracture of the lower leg
2. While triaging clients in a crowded emergency department, a nurse assesses a
client who presents with symptoms of tuberculosis. Which action should the nurse take first?
a. Apply oxygen via nasal cannula.
b. Administer intravenous 0.9% saline solution.
c. Transfer the client to a negative-pressure room.
d. Obtain a sputum culture and sensitivity.
3. A nurse is triaging clients in the emergency department (ED). Which client
should the nurse prioritize to receive care first?
a. A 22-year-old with a painful and swollen right wrist
b. A 45-year-old reporting chest pain and diaphoresis
c. A 60-year-old reporting difficulty swallowing and nausea
d. An 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101°
F
4. Emergency medical technicians arrive at the emergency department with an
unresponsive client who has an oxygen mask in place. Which action should the nurse take
first?
a. Assess that the client is breathing adequately.
b. Insert a large-bore intravenous line.
c. Place the client on a cardiac monitor.
d. Assess for the best neurologic response.
5. A trauma client with multiple open wounds is brought to the emergency
department in cardiac arrest. Which action should the nurse take prior to providing advanced
cardiac life support?
a. Contact the on-call orthopedic surgeon.
b. Don personal protective equipment.
c. Notify the Rapid Response Team.
d. Obtain a complete history from the paramedic.
6. A nurse is triaging clients in the emergency department. Which client should
be considered “urgent”?
a. A 20-year-old female with a chest stab wound and tachycardia
b. A 45-year-old homeless man with a skin rash and sore throat
, c. A 75-year-old female with a cough and a temperature of 102° F
d. A 50-year-old male with new-onset confusion and slurred speech
7. An emergency department nurse is caring for a client who has died from
a suspected homicide. Which action should the nurse take?
a. Remove all tubes and wires in preparation for the medical examiner.
b. Limit the number of visitors to minimize the family’s trauma.
c. Consult the bereavement committee to follow up with the grieving family.
d. Communicate the client’s death to the family in a simple and concrete manner.
8. An emergency department (ED) case manager is consulted for a client who
is homeless. Which intervention should the case manager provide?
a. Communicate client needs and restrictions to support staff.
b. Prescribe low-cost antibiotics to treat community-acquired infection.
c. Provide referrals to subsidized community-based health clinics.
d. Offer counseling for substance abuse and mental health disorders.
9. On a hot humid day, an emergency department nurse is caring for a client who is
confused and has these vital signs: temperature 104.1° F (40.1° C), pulse 132 beats/min, respira-
tions 26 breaths/min, blood pressure 106/66 mm Hg. Which action should the nurse take?
a. Encourage the client to drink cool water or sports drinks.
b. Start an intravenous line and infuse 0.9% saline solution.
c. Administer acetaminophen (Tylenol) 650 mg orally.
d. Encourage rest and re-assess in 15 minutes.
10. While at a public park, a nurse encounters a person immediately after a bee sting.
The person’s lips are swollen, and wheezes are audible. Which action should the nurse take
first?
a. Elevate the site and notify the person’s next of kin.
b. Remove the stinger with tweezers and encourage rest.
c. Administer diphenhydramine (Benadryl) and apply ice.
d. Administer an EpiPen from the first aid kit and call 911.
11. A client presents to the emergency department after prolonged exposure to the
cold. The client is difficult to arouse and speech is incoherent. Which action should the nurse take
first?
a. Reposition the client into a prone position.
b. Administer warmed intravenous fluids to the client.
c. Wrap the client’s extremities in warm blankets.
d. Initiate extracorporeal rewarming via hemodialysis.
12. An emergency department nurse cares for a middle-aged mountain climber who
is confused and exhibits bizarre behaviors. After administering oxygen, which priority
intervention should the nurse implement?
a. Administer dexamethasone (Decadron).
b. Complete a mini–mental state examination.
c. Prepare the client for computed tomography of the brain.
, d. Request a psychiatric consult.
17. After teaching a client how to prevent altitude-related illnesses, a nurse assesses the
client’s understanding. Which statement indicates the client needs additional teaching?
a. “If my climbing partner can’t think straight, we should descend to a lower altitude.”
b. “I will ask my provider about medications to help prevent acute mountain
sickness.”
c. “My partner and I will plan to sleep at a higher elevation to acclimate more
quickly.”
d. “I will drink plenty of fluids to stay hydrated while on the mountain.”
18. A hospital responds to a local mass casualty event. Which action should the
nurse supervisor take to prevent staff post-traumatic stress disorder during a mass casualty
event?
a. Provide water and healthy snacks for energy throughout the event.
b. Schedule 16-hour shifts to allow for greater rest between shifts.
c. Encourage counseling upon deactivation of the emergency response plan.
d. Assign staff to different roles and units within the medical facility.
19. A nurse is field-triaging clients after an industrial accident. Which client
condition should the nurse triage with a red tag?
a. Dislocated right hip and an open fracture of the right lower leg
b. Large contusion to the forehead and a bloody nose
c. Closed fracture of the right clavicle and arm numbness
d. Multiple fractured ribs and shortness of breath
20. An emergency department (ED) charge nurse prepares to receive clients from
a mass casualty within the community. What is the role of this nurse during the event?
a. Ask ED staff to discharge clients from the medical-surgical units in order to make
room for critically injured victims.
b. Call additional medical-surgical and critical care nursing staff to come to the
hospital to assist when victims are brought in.
c. Inform the incident commander at the mass casualty scene about how many victims
may be handled by the ED.
d. Direct medical-surgical and critical care nurses to assist with clients currently in the
ED while emergency staff prepare to receive the mass casualty victims.
21. The hospital administration arranges for critical incident stress debriefing for
the staff after a mass casualty incident. Which statement by the debriefing team leader is most
appropriate for this situation?
a. “You are free to express your feelings; whatever is said here stays here.”
b. “Let’s evaluate what went wrong and develop policies for future incidents.”
c. “This session is only for nursing and medical staff, not for ancillary personnel.”
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