Title: ASN 210 Week 6 Post Quiz (Remotely Proctored)
Course: 16SP-ASN-210-GH1A1-ADV NUR THROUGH LIFESPAN I > Section: Week 6

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Q: 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?
- Apply oxygen via nasal cannula.
- Administer intravenous 0.9% saline solution.
- Transfer the client to a negative-pressure room.
- Obtain a sputum culture and sensitivity.
A: Transfer the client to a negative-pressure room.
If right: A client with signs and symptoms of tuberculosis or other airborne pathogens should be placed in a negative-pressure room to prevent contamination of staff, clients, and family members in the crowded emergency department.
If wrong: A client with signs and symptoms of tuberculosis or other airborne pathogens should be placed in a negative-pressure room to prevent contamination of staff, clients, and family members in the crowded emergency department.

Q: The emergency department team is performing cardiopulmonary resuscitation on a client when the client’s spouse arrives at the emergency department. Which action should the nurse take first?
- Request that the client’s spouse sit in the waiting room.
- Ask the spouse if he wishes to be present during the resuscitation.
- Suggest that the spouse begin to pray for the client.
- Refer the client’s spouse to the hospital’s crisis team.
A: Ask the spouse if he wishes to be present during the resuscitation.
If right: If resuscitation efforts are still under way when the family arrives, one or two family members may be given the opportunity to be present during lifesaving procedures. The other options do not give the spouse the opportunity to be present for the client or to begin to have closure.
If wrong: If resuscitation efforts are still under way when the family arrives, one or two family members may be given the opportunity to be present during lifesaving procedures. The other options do not give the spouse the opportunity to be present for the client or to begin to have closure.

Q: The complex care provided during an emergency requires interdisciplinary collaboration. Which interdisciplinary team members are paired with the correct responsibilities?<i> </i><b>(Select all that apply.)</b>
- Psychiatric crisis nurse – Interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis
- Forensic nurse examiner – Performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources
- Triage nurse – Provides basic life support interventions such as oxygen, basic wound care, splinting, spinal immobilization, and monitoring of vital signs
- Emergency medical technician – Obtains client histories, collects evidence, and offers counseling and follow-up care for victims of rape, child abuse, and domestic violence
- Paramedic – Provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration
A: Psychiatric crisis nurse – Interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis; Paramedic – Provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration
If right: The psychiatric crisis nurse evaluates clients with emotional behaviors or mental illness and facilitates follow-up treatment plans. The psychiatric crisis nurse also works with clients and families when experiencing a crisis. Paramedics are advanced life support providers who can perform advanced techniques that may include cardiac monitoring, advanced airway management and intubation, establishing IV access, and administering drugs en route to the emergency department. The forensic nurse examiner is trained to recognize evidence of abuse and to intervene on the client’s behalf. The forensic nurse examiner will obtain client histories, collect evidence, and offer counseling and follow-up care for victims of rape, child abuse, and domestic violence. The triage nurse performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources. The emergency medical technician is usually the first caregiver and provides basic life support and transportation to the emergency department.
If wrong: The psychiatric crisis nurse evaluates clients with emotional behaviors or mental illness and facilitates follow-up treatment plans. The psychiatric crisis nurse also works with clients and families when experiencing a crisis. Paramedics are advanced life support providers who can perform advanced techniques that may include cardiac monitoring, advanced airway management and intubation, establishing IV access, and administering drugs en route to the emergency department. The forensic nurse examiner is trained to recognize evidence of abuse and to intervene on the client’s behalf. The forensic nurse examiner will obtain client histories, collect evidence, and offer counseling and follow-up care for victims of rape, child abuse, and domestic violence. The triage nurse performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources. The emergency medical technician is usually the first caregiver and provides basic life support and transportation to the emergency department.

Q: 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?
- Assess that the client is breathing adequately.
- Insert a large-bore intravenous line.
- Place the client on a cardiac monitor.
- Assess for the best neurologic response.
A: Assess that the client is breathing adequately.
If right: The highest-priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he or she may not be breathing, or may be breathing inadequately with the device in place.
If wrong: The highest-priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he or she may not be breathing, or may be breathing inadequately with the device in place.

Q: An emergency room nurse is triaging victims of a multi-casualty event. Which client should receive care first?
- A 30-year-old distraught mother holding her crying child
- A 65-year-old conscious male with a head laceration
- A 26-year-old male who has pale, cool, clammy skin
- A 48-year-old with a simple fracture of the lower leg
A: A 26-year-old male who has pale, cool, clammy skin
If right: The client with pale, cool, clammy skin is in shock and needs immediate medical attention. The mother does not have injuries and so would be the lowest priority. The other two people need medical attention soon, but not at the expense of a person in shock.
If wrong: The client with pale, cool, clammy skin is in shock and needs immediate medical attention. The mother does not have injuries and so would be the lowest priority. The other two people need medical attention soon, but not at the expense of a person in shock.

Q: An emergency room nurse is caring for a trauma client. Which interventions should the nurse perform during the primary survey? <b>(Select all that apply.)</b>
- Foley catheterization
- Needle decompression
- Initiating IV fluids
- Splinting open fractures
- Endotracheal intubation
- Removing wet clothing
- Laceration repair
A: Needle decompression; Initiating IV fluids; Endotracheal intubation; Removing wet clothing
If right: The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic <i>ABC,</i> with an added <i>D</i> and <i>E:</i> <i>A</i>irway and cervical spine control; <i>B</i>reathing; <i>C</i>irculation; <i>D</i>isability; and <i>E</i>xposure. After the completion of primary diagnostic and laboratory studies, and the insertion of gastric and urinary tubes, the secondary survey (a complete head-to-toe assessment) can be carried out.
If wrong: The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic <i>ABC,</i> with an added <i>D</i> and <i>E:</i> <i>A</i>irway and cervical spine control; <i>B</i>reathing; <i>C</i>irculation; <i>D</i>isability; and <i>E</i>xposure. After the completion of primary diagnostic and laboratory studies, and the insertion of gastric and urinary tubes, the secondary survey (a complete head-to-toe assessment) can be carried out.

Q: An emergency room nurse assesses a client who has been raped. With which health care team member should the nurse collaborate when planning this client’s care?
- Emergency medicine physician
- Case manager
- Forensic nurse examiner
- Psychiatric crisis nurse
A: Forensic nurse examiner
If right: All other members of the health care team listed may be used in the management of this client’s care. However, the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing with the victim of an assault.
If wrong: All other members of the health care team listed may be used in the management of this client’s care. However, the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing with the victim of an assault.

Q: While on a camping trip, a nurse cares for an adult client who had a drowning incident in a lake and is experiencing agonal breathing with a palpable pulse. Which action should the nurse take first?
- Deliver rescue breaths.
- Wrap the client in dry blankets.
- Assess for signs of bleeding.
- Check for a carotid pulse.
A: Deliver rescue breaths.
If right: In this emergency situation, the nurse should immediately initiate airway clearance and ventilator support measures, including delivering rescue breaths.
If wrong: In this emergency situation, the nurse should immediately initiate airway clearance and ventilator support measures, including delivering rescue breaths.

Q: 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?
- Elevate the site and notify the person’s next of kin.
- Remove the stinger with tweezers and encourage rest.
- Administer diphenhydramine (Benadryl) and apply ice.
- Administer an EpiPen from the first aid kit and call 911.
A: Administer an EpiPen from the first aid kit and call 911.
If right: The client’s swollen lips indicate that anaphylaxis may be developing, and this is a medical emergency. 911 should be called immediately, and the client transported to the emergency department as quickly as possible. If an EpiPen is available, it should be administered at the first sign of an anaphylactic reaction. The other answers do not provide adequate interventions to treat airway obstruction due to anaphylaxis.
If wrong: The client’s swollen lips indicate that anaphylaxis may be developing, and this is a medical emergency. 911 should be called immediately, and the client transported to the emergency department as quickly as possible. If an EpiPen is available, it should be administered at the first sign of an anaphylactic reaction. The other answers do not provide adequate interventions to treat airway obstruction due to anaphylaxis.

Q: 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?
- “You are free to express your feelings; whatever is said here stays here.”
- “Let’s evaluate what went wrong and develop policies for future incidents.”
- “This session is only for nursing and medical staff, not for ancillary personnel.”
- “Let’s pass around the written policy compliance form for everyone.”
A: “You are free to express your feelings; whatever is said here stays here.”
If right: Strict confidentiality during stress debriefing is essential so that staff members can feel comfortable sharing their feelings, which should be accepted unconditionally. Brainstorming improvements and discussing policies would occur during an administrative review. Any employee present during a mass casualty situation is eligible for critical incident stress management services.
If wrong: Strict confidentiality during stress debriefing is essential so that staff members can feel comfortable sharing their feelings, which should be accepted unconditionally. Brainstorming improvements and discussing policies would occur during an administrative review. Any employee present during a mass casualty situation is eligible for critical incident stress management services.

Q: 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, respirations 26 breaths/min, blood pressure 106/66 mm Hg. Which action should the nurse take?
- Encourage the client to drink cool water or sports drinks.
- Start an intravenous line and infuse 0.9% saline solution.
- Administer acetaminophen (Tylenol) 650 mg orally.
- Encourage rest and re-assess in 15 minutes.
A: Start an intravenous line and infuse 0.9% saline solution.
If right: The client demonstrates signs of heat stroke. This is a medical emergency and priority care includes oxygen therapy, IV infusion with 0.9% saline solution, insertion of a urinary catheter, and aggressive interventions to cool the client, including external cooling and internal cooling methods. Oral hydration would not be appropriate for a client who has symptoms of heat stroke because oral fluids would not provide necessary rapid rehydration, and the confused client would be at risk for aspiration. Acetaminophen would not decrease this client’s temperature or improve the client’s symptoms. The client needs immediate medical treatment; therefore, rest and re-assessing in 15 minutes is inappropriate.
If wrong: The client demonstrates signs of heat stroke. This is a medical emergency and priority care includes oxygen therapy, IV infusion with 0.9% saline solution, insertion of a urinary catheter, and aggressive interventions to cool the client, including external cooling and internal cooling methods. Oral hydration would not be appropriate for a client who has symptoms of heat stroke because oral fluids would not provide necessary rapid rehydration, and the confused client would be at risk for aspiration. Acetaminophen would not decrease this client’s temperature or improve the client’s symptoms. The client needs immediate medical treatment; therefore, rest and re-assessing in 15 minutes is inappropriate.

Q: Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies the clients with which injuries with yellow tags? <b>(Select all that apply.)</b>
- Partial-thickness burns covering both legs
- Open fractures of both legs with absent pedal pulses
- Neck injury and numbness of both legs
- Small pieces of shrapnel embedded in both eyes
- Head injury and difficult to arouse
- Bruising and pain in the right lower abdomen
A: Partial-thickness burns covering both legs; Neck injury and numbness of both legs; Small pieces of shrapnel embedded in both eyes; Bruising and pain in the right lower abdomen
If right: Clients with burns, spine injuries, eye injuries, and stable abdominal injuries should be treated within 30 minutes to 2 hours, and therefore should be identified with yellow tags. The client with the open fractures and the client with the head injury would be classified as urgent with red tags.
If wrong: Clients with burns, spine injuries, eye injuries, and stable abdominal injuries should be treated within 30 minutes to 2 hours, and therefore should be identified with yellow tags. The client with the open fractures and the client with the head injury would be classified as urgent with red tags.

Q: An emergency department nurse plans care for a client who is admitted with heat stroke. Which interventions should the nurse include in this client’s plan of care? <b>(Select all that apply.)</b>
- Administer oxygen via mask or nasal cannula.
- Administer ibuprofen, an antipyretic medication.
- Apply cooling techniques until core body temperature is less than 101°<sup> </sup>F.
- Infuse 0.9% sodium chloride via a large-bore intravenous cannula.
- Obtain baseline serum electrolytes and cardiac enzymes.
A: Administer oxygen via mask or nasal cannula.; Infuse 0.9% sodium chloride via a large-bore intravenous cannula.; Obtain baseline serum electrolytes and cardiac enzymes.
If right: Heat stroke is a medical emergency. Oxygen therapy and intravenous fluids should be provided, and baseline laboratory tests should be performed as quickly as possible. The client should be cooled until core body temperature is reduced to 102° F. Antipyretics should not be administered.
If wrong: Heat stroke is a medical emergency. Oxygen therapy and intravenous fluids should be provided, and baseline laboratory tests should be performed as quickly as possible. The client should be cooled until core body temperature is reduced to 102° F. Antipyretics should not be administered.

Q: An emergency department nurse moves to a new city where heat-related illnesses are common. Which clients does the nurse anticipate being at higher risk for heat-related illnesses? <b>(Select all that apply.)</b>
- Homeless individuals
- Illicit drug users
- White people
- Hockey players
- Older adults
A: Homeless individuals; Illicit drug users; Older adults
If right: Some of the most vulnerable, at-risk populations for heat-related illness include older adults; blacks (more than whites); people who work outside, such as construction and agricultural workers (more men than women); homeless people; illicit drug users (especially cocaine users); outdoor athletes (recreational and professional); and members of the military who are stationed in countries with hot climates (e.g., Iraq, Afghanistan).
If wrong: Some of the most vulnerable, at-risk populations for heat-related illness include older adults; blacks (more than whites); people who work outside, such as construction and agricultural workers (more men than women); homeless people; illicit drug users (especially cocaine users); outdoor athletes (recreational and professional); and members of the military who are stationed in countries with hot climates (e.g., Iraq, Afghanistan).

Q: The student nurse studying shock understands that the common manifestations of this condition are directly related to which problems? <b>(Select all that apply.)</b>
- Anaerobic metabolism
- Hyperglycemia
- Hypotension
- Impaired renal perfusion
- Increased perfusion
A: Anaerobic metabolism; Hypotension
If right: The common manifestations of shock, no matter the cause, are directly related to the effects of anaerobic metabolism and hypotension. Hyperglycemia, impaired renal function, and increased perfusion are not manifestations of shock.
If wrong: The common manifestations of shock, no matter the cause, are directly related to the effects of anaerobic metabolism and hypotension. Hyperglycemia, impaired renal function, and increased perfusion are not manifestations of shock.

Q: The nurse is caring for a client with suspected severe sepsis. What does the nurse prepare to do within 3 hours of the client being identified as being at risk? <b>(Select all that apply.)</b>
- Administer antibiotics.
- Draw serum lactate levels.
- Infuse vasopressors.
- Measure central venous pressure.
- Obtain blood cultures.
A: Administer antibiotics.; Draw serum lactate levels.; Obtain blood cultures.
If right: Within the first 3 hours of suspecting severe sepsis, the nurse should draw (or facilitate) serum lactate levels, obtain blood cultures (or other cultures), and administer antibiotics (after the cultures have been obtained). Infusing vasopressors and measuring central venous pressure are actions that should occur within the first 6 hours.
If wrong: Within the first 3 hours of suspecting severe sepsis, the nurse should draw (or facilitate) serum lactate levels, obtain blood cultures (or other cultures), and administer antibiotics (after the cultures have been obtained). Infusing vasopressors and measuring central venous pressure are actions that should occur within the first 6 hours.

Q: The nurse gets the hand-off report on four clients. Which client should the nurse assess first?
- Client with a blood pressure change of 128/74 to 110/88 mm Hg
- Client with oxygen saturation unchanged at 94%
- Client with a pulse change of 100 to 88 beats/min
- Client with urine output of 40 mL/hr for the last 2 hours
A: Client with a blood pressure change of 128/74 to 110/88 mm Hg
If right: This client has a falling systolic blood pressure, rising diastolic blood pressure, and narrowing pulse pressure, all of which may be indications of the progressive stage of shock. The nurse should assess this client first. The client with the unchanged oxygen saturation is stable at this point. Although the client with a change in pulse has a slower rate, it is not an indicator of shock since the pulse is still within the normal range; it may indicate the client’s pain or anxiety has been relieved, or he or she is sleeping or relaxing. A urine output of 40 mL/hr is only slightly above the normal range, which is 30 mL/hr.
If wrong: This client has a falling systolic blood pressure, rising diastolic blood pressure, and narrowing pulse pressure, all of which may be indications of the progressive stage of shock. The nurse should assess this client first. The client with the unchanged oxygen saturation is stable at this point. Although the client with a change in pulse has a slower rate, it is not an indicator of shock since the pulse is still within the normal range; it may indicate the client’s pain or anxiety has been relieved, or he or she is sleeping or relaxing. A urine output of 40 mL/hr is only slightly above the normal range, which is 30 mL/hr.

Q: The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what factors would the nurse assess? <b>(Select all that apply.)</b>
- Altered mobility/immobility
- Decreased thirst response
- Diminished immune response
- Malnutrition
- Overhydration
A: Altered mobility/immobility; Decreased thirst response; Diminished immune response; Malnutrition
If right: Immobility, decreased thirst response, diminished immune response, and malnutrition can place the older adult at higher risk of developing shock. Overhydration is not a common risk factor for shock.
If wrong: Immobility, decreased thirst response, diminished immune response, and malnutrition can place the older adult at higher risk of developing shock. Overhydration is not a common risk factor for shock.

Q: The nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility of the clients developing shock? <b>(Select all that apply.)</b>
- Assessing and identifying clients at risk
- Monitoring the daily white blood cell count
- Performing proper hand hygiene
- Removing invasive lines as soon as possible
- Using aseptic technique during procedures
A: Assessing and identifying clients at risk; Performing proper hand hygiene; Removing invasive lines as soon as possible; Using aseptic technique during procedures
If right: Assessing and identifying clients at risk for shock is probably the most critical action the nurse can take to prevent shock from occurring. Proper hand hygiene, using aseptic technique, and removing IV lines and catheters are also important actions to prevent shock. Monitoring laboratory values does not prevent shock but can indicate a change.
If wrong: Assessing and identifying clients at risk for shock is probably the most critical action the nurse can take to prevent shock from occurring. Proper hand hygiene, using aseptic technique, and removing IV lines and catheters are also important actions to prevent shock. Monitoring laboratory values does not prevent shock but can indicate a change.

Q: A student nurse is caring for a client who will be receiving sodium nitroprusside (Nipride) via IV infusion. What action by the student causes the registered nurse to intervene?
- Assessing the IV site before giving the drug
- Obtaining a programmable (“smart”) IV pump
- Removing the IV bag from the brown plastic cover
- Taking and recording a baseline set of vital signs
A: Removing the IV bag from the brown plastic cover
If right: Nitroprusside degrades in the presence of light, so it must be protected by leaving it in the original brown plastic bag when infusing. The other actions are correct, although a “smart” pump is not necessarily required if the facility does not have them available. The drug must be administered via an IV pump, although the programmable pump is preferred for safety.
If wrong: Nitroprusside degrades in the presence of light, so it must be protected by leaving it in the original brown plastic bag when infusing. The other actions are correct, although a “smart” pump is not necessarily required if the facility does not have them available. The drug must be administered via an IV pump, although the programmable pump is preferred for safety.