1. What color is the sun?

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NUR 213 JSCC

• What color is the sun?

Answer Yellow

• A nurse is triaging patients in the ED. Which pt should be seen first?
• A 22 y/o with a painful swollen right wrist?
• A 45 y/o reporting chest pain and diaphoresis?
• A 60 y/o reporting difficulty swallowing and nausea?
• An 81 y/o with a 101.5F temp and RR of 28/min?

Answer

• A 45 y/o reporting chest pain and diaphoresis

All others are stable

• EMTs arrive in the ED with an unresponsive pt with an oxygen mask. Which action should

nurse take first?

• Assess the client is breathing properly
• Insert a large bore IV catheter
• Place client on cardiac monitor
• Assess neurological response

Answer

• The highest priority is to make sure client is breathing adequately. Although oxygen mask is in

place, the pt may not be breathing, or breathing inadequately

• An ED nurse is caring for a trauma pt. Which interventions should the nurse perform during

the primary survey? SATA

• Foley catheter
• Needle decompression (to stabilize pneumothorax) 3 Initiating IV fluids
• Splinting open fracture
• Endotracheal intubation
• Removing wet clothing
• Laceration repair

Answer 2, 3, 5, 6 all part of primary

• The physician has ordered lab work for a client with suspected dissem- inated intravascular

coagulation (DIC). Which lab finding would provide a definitive diagnosis of DIC?

• Elevated ESR
• Prolonged clotting time
• Presence of fibrin split compound 1 / 2

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• Elevated WBC

Answer

• Presence of fibrin split compound is definitive. Elevated ESR incorrect because not

inflammatory. Clotting is not prolonged, it is gone. Elevated WBC incorrect because DIC is not an infection.

• The nurse is caring for a client 7 days post-burn injury with 60% body surface area

involved. The nursing care of this client would primarily focus on

• Meticulous infection-control measures
• Fluid-replacement evaluation

• Psychological adjustment to the wound
• Measurement and application of a pressure garment

Answer Answer A is correct. The main cause of death after the immediate post-burn time frame is sepsis; therefore, preventing infection is a priority for this time period. Answer B would be emphasized earlier, and answer D requires a healed wound before it can be implemented. Answer C would be a necessary intervention during care, but it is not the primary focus

• A client is admitted to the emergency room with multiple injuries. What is the proper

sequence for managing the client?

• Assess for head injuries, control hemorrhage, establish an airway, prevent hypovolemic

shock

• Control hemorrhage, prevent hypovolemic shock, establish an airway, as- sess for head

injuries

• Establish an airway, control hemorrhage, prevent hypovolemic shock, as- sess for head

injuries

• Prevent hypovolemic shock, assess for head injuries, establish an airway, control

hemorrhage

Answer C is correct. Using the ABCD approach to the client with multiple trauma the nurse in the ER would

establish an airway, determine whether the client is breathing, check circulation (control hemorrhage), and check for deficits (head injuries). Answers A, B, and D are incorrect because they are not in the appropriate sequence for maintaining life

• The nurse is caring for a client post-myocardial infarction on the cardiac unit. The client is

exhibiting symptoms of shock. Which clinical manifestation is the best indicator that the shock is cardiogenic rather than anaphylactic?

1. BP 90/60

• Chest pain
• Anxiety
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