1.

Regular oral hygiene is an essential intervention for the client who

has had a stroke. Which of the following nursing measures is
inappropriate when providing oral hygiene?

1. Placing the client on the back with a small pillow under the head.
2. Keeping portable suctioning equipment at the bedside.
3. Opening the client’s mouth with a padded tongue blade.
4. Cleaning the client’s mouth and teeth with a toothbrush.

2. A 78-year-old client is admitted to the emergency department with

numbness and weakness of the left arm and slurred speech. Which
nursing intervention is a priority?

1. Prepare to administer recombinant tissue plasminogen activator (rt-PA).

2. Discuss the precipitating factors that caused the symptoms.
3. Schedule for A STAT computer tomography (CT) scan of the head.
4. Notify the speech pathologist for an emergency consult.

3. A client arrives in the emergency department with an ischemic stroke

and receives tissue plasminogen activator (t-PA) administration. Which
is the priority nursing assessment?

1. Current medications.
2. Complete physical and history.
3. Time of onset of current stroke.
4. Upcoming surgical procedures.

4. During the first 24 hours after thrombolytic therapy for ischemic

stroke, the primary goal is to control the client’s:

1. Pulse
2. Respirations
3. Blood pressure
4. Temperature

5. What is a priority nursing assessment in the first 24 hours after

admission of the client with a thrombotic stroke?

1. Cholesterol level
2. Pupil size and pupillary response
3. Bowel sounds
4. Echocardiogram

6. What is the expected outcome of thrombolytic drug therapy?

1. Increased vascular permeability.

2. Vasoconstriction.
3. Dissolved emboli.
4. Prevention of hemorrhage

7. The client diagnosed with atrial fibrillation has experienced a

transient ischemic attack (TIA). Which medication would the nurse
anticipate being ordered for the client on discharge?

1. An oral anticoagulant medication.

2. A beta-blocker medication.
3. An anti-hyperuricemic medication.
4. A thrombolytic medication.

8. Which client would the nurse identify as being most at risk for
experiencing a CVA?

1. A 55-year-old African American male.

2. An 84-year-old Japanese female.
3. A 67-year-old Caucasian male.
4. A 39-year-old pregnant female.

9. Which assessment data would indicate to the nurse that the client
would be at risk for a hemorrhagic stroke?

1. A blood glucose level of 480 mg/dl.

2. A right-sided carotid bruit.
3. A blood pressure of 220/120 mmHg.
4. The presence of bronchogenic carcinoma.

10. The nurse and unlicensed assistive personnel (UAP) are caring for a
client with right-sided paralysis. Which action by the UAP requires the
nurse to intervene?

1. The assistant places a gait belt around the client’s waist prior to ambulating.
2. The assistant places the client on the back with the client’s head to the side.
3. The assistant places her hand under the client’s right axilla to help him/her
move up in bed.
4. The assistant praises the client for attempting to perform ADL’s
independently.

Answers and Rationale

1. Answer: 1. Placing the client on the back with a small pillow under
the head.

A helpless client should be positioned on the side, not on the back. This lateral
positionhelps secretions escape from the throat and mouth, minimizing the risk
of aspiration.
  Option B: It may be necessary to suction, so having suction equipment
at the bedside is necessary.
 Option C: Padded tongue blades are safe to use.
 Option D: A toothbrush is appropriate to use.

2. Answer: 3. Schedule for A STAT computer tomography (CT) scan of

the head.

A CT scan will determine if the client is having a stroke or has a brain tumor or
another neurological disorder. This would also determine if it is a hemorrhagic
or ischemic accident and guide the treatment because only an ischemic stroke
can use rt-PA. This would make (1) not the priority since if a stroke was
determined to be hemorrhagic, rt-PA is contraindicated.

 Option A: rt-PA is contraindicated.

 Options B and D: Discuss the precipitating factors for teaching would
not be a priority and slurred speech would as indicate interference for
teaching. Referring the client for speech therapy would be an
intervention after the CVA emergency treatment is administered
according to protocol.

3. Answer: 3. Time of onset of current stroke.

The time of onset of a stroke to t-PA administration is critical. Administration

within 3 hours has better outcomes.

 Option A: Current medications are relevant, but the onset of current

stroke takes priority.
 Option B: A complete history is not possible in emergency care.
 Option D: Upcoming surgical procedures will need to be delay if t-PA is
administered.

4. Answer: 3. Blood pressure

Controlling the blood pressure is critical because an intracerebral hemorrhage is
the major adverse effect of thrombolytic therapy. Blood pressure should be
maintained according to physician and is specific to the client’s ischemic tissue
needs and risks ofbleeding from treatment. Other vital signs are monitored, but
the priority is blood pressure.

5. Answer: 2. Pupil size and pupillary response

It is crucial to monitor the pupil size and pupillary response to indicate changes
around the cranial nerves.

 Option A: Cholesterol level is an assessment to be addressed for long-

term healthy lifestyle rehabilitation.
 Option C: Bowel sounds need to be assessed because an ileus
or constipation can develop, but is not a priority in the first 24 hours.
 Option D: An echocardiogram is not needed for the client with a
thrombotic stroke.

6. Answer: 3. Dissolved emboli.

Thrombolytic therapy is used to dissolve emboli and reestablish cerebral

perfusion.

7. Answer: 1. An oral anticoagulant medication.

Thrombi form secondary to atrial fibrillation. Therefore, an anticoagulant would

be anticipated to prevent thrombi formation; and oral (warfarin [Coumadin]) at
discharge versus intravenous.

 Option B: Beta blockers slow the heart rate and lower the blood
pressure.
 Option C: Anti-hyperuricemic medication is given to clients with gout.
  Option D: Thrombolytic medication might have been given at initial
presentation but would not be a drug prescribed at discharge.

8. Answer: 1. A 55-year-old African American male.

African Americans have twice the rate of CVA’s as Caucasians; males are more
likely to have strokes than females except in advanced years.

 Option B: Oriental’s have a lower risk, possibly due to their high

omega-3 fatty acids.
 Option D: Pregnancy is a minimal risk factor for CVA.

9. Answer: 3. A blood pressure of 220/120 mmHg.

Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a

ruptured blood vessel in the cranium.

 Option A: High blood glucose levels could predispose a patient to

ischemic stroke, but not hemorrhagic.
 Option B: Bruit in the carotid artery would predispose a client to an
embolic or ischemic stroke.
 Option D: Cancer is not a precursor to stroke.

10. Answer: 3. The assistant places her hand under the client’s right
axilla to help him/her move up in bed.

This action is inappropriate and would require intervention by the nurse because
pulling on a flaccid shoulder joint could cause shoulder dislocation; as always
use a lift sheet for the client and nurse safety.

Options A, B, and D: All the other actions are appropriate.

1. Clients with chronic illnesses are more likely to get pneumonia when which of the following situations
is present?

1. Dehydration

2. Group living

3. Malnutrition

4. Severe periodontal disease

2. Which of the following pathophysiological mechanisms that occurs in the lung parenchyma allows
pneumonia to develop?

1. Atelectasis

2. Bronchiectasis

3. Effusion

4. Inflammation

3. Which of the following organisms most commonly causes community-acquired pneumonia in adults?

1. Haemiphilus influenzae

2. Klebsiella pneumoniae

3. Streptococcus pneumoniae

4. Staphylococcus aureus

4. An elderly client with pneumonia may appear with which of the following symptoms first?

1. Altered mental status and dehydration

2. Fever and chills

3. Hemoptysis and dyspnea

4. Pleuritic chest pain and cough

5. When auscultating the chest of a client with pneumonia, the nurse would expect to hear which of the
following sounds over areas of consolidation?

1. Bronchial

2. Bronchovesicular

3. Tubular

4. Vesicular

6. A diagnosis of pneumonia is typically achieved by which of the following diagnostic tests?

1. ABG analysis

2. Chest x-ray

3. Blood cultures

4. sputum culture and sensitivity

7. A client with pneumonia develops dyspnea with a respiratory rate of 32 breaths/minute and difficulty
expelling his secretions. The nurse auscultates his lung fields and hears bronchial sounds in the left
lower lobe. The nurse determines that the client requires which of the following treatments first?

1. Antibiotics

2. Bed rest

3. Oxygen

4. Nutritional intake

8. A client has been treated with antibiotic therapy for right lower-lobe pneumonia for 10 days and will
be discharged today. Which of the following physical findings would lead the nurse to believe it is
appropriate to discharge this client?
1. Continued dyspnea

2. Fever of 102*F

3. Respiratory rate of 32 breaths/minute

4. Vesicular breath sounds in right base

9. The right forearm of a client who had a purified protein derivative (PPD) test for tuberculosis is
reddened and raised about 3mm where the test was given. This PPD would be read as having which of
the following results?

1. Indeterminate

2. Needs to be redone

3. Negative

4. Positive

10. A client with primary TB infection can expect to develop which of the following conditions?

1. Active TB within 2 weeks

2. Active TB within 1 month

3. A fever that requires hospitalization

4. A positive skin test

11. A client was infected with TB 10 years ago but never developed the disease. He’s now being treated
for cancer. The client begins to develop signs of TB. This is known as which of the following types of
infection?

1. Active infection

2. Primary infection

3. Superinfection

4. Tertiary infection
12. A client has active TB. Which of the following symptoms will he exhibit?

1. Chest and lower back pain

2. Chills, fever, night sweats, and hemoptysis

3. Fever of more than 104*F and nausea

4. Headache and photophobia

13. Which of the following diagnostic tests is definitive for TB?

1. Chest x-ray

2. Mantoux test

3. Sputum culture

4. Tuberculin test

14. A client with a positive Mantoux test result will be sent for a chest x-ray. For which of the following
reasons is this done?

1. To confirm the diagnosis

2. To determine if a repeat skin test is needed

3. To determine the extent of the lesions

4. To determine if this is a primary or secondary infection

15. A chest x-ray should a client’s lungs to be clear. His Mantoux test is positive, with a 10mm if
induration. His previous test was negative. These test results are possible because:

1. He had TB in the past and no longer has it.

2. He was successfully treated for TB, but skin tests always stay positive.

3. He’s a “seroconverter”, meaning the TB has gotten to his bloodstream.

4. He’s a “tuberculin converter,” which means he has been infected with TB since his last skin test.

16. A client with a positive skin test for TB isn’t showing signs of active disease. To help prevent the
development of active TB, the client should be treated with isoniazid, 300 mg daily, for how long?

1. 10 to 14 days

2. 2 to 4 weeks

3. 3 to 6 months

4. 9 to 12 months

17. A client with a productive cough, chills, and night sweats is suspected of having active TB. The
physician should take which of the following actions?

1. Admit him to the hospital in respiratory isolation

2. Prescribe isoniazid and tell him to go home and rest

3. Give a tuberculin test and tell him to come back in 48 hours and have it read.

4. Give a prescription for isoniazid, 300 mg daily for 2 weeks, and send him home.

18. A client is diagnosed with active TB and started on triple antibiotic therapy. What signs and
symptoms would the client show if therapy is inadequate?

1. Decreased shortness of breath

2. Improved chest x-ray

3. Nonproductive cough

4. Positive acid-fast bacilli in a sputum sample after 2 months of treatment.

19. A client diagnosed with active TB would be hospitalized primarily for which of the following
reasons?

1. To evaluate his condition

2. To determine his compliance

3. To prevent spread of the disease

4. To determine the need for antibiotic therapy.

20. A high level of oxygen exerts which of the following effects on the lung?

1. Improves oxygen uptake

2. Increases carbon dioxide levels

3. Stabilizes carbon dioxide levels

4. Reduces amount of functional alveolar surface area

21. A 24-year-old client comes into the clinic complaining of right-sided chest pain and shortness of
breath. He reports that it started suddenly. The assessment should include which of the following
interventions?

1. Auscultation of breath sounds

2. Chest x-ray

3. Echocardiogram

4. Electrocardiogram (ECG)

22. A client with shortness of breath has decreased to absent breath sounds on the right side, from the
apex to the base. Which of the following conditions would best explain this?

1. Acute asthma

2. Chronic bronchitis

3. Pneumonia

4. Spontaneous pneumothorax

23. Which of the following treatments would the nurse expect for a client with a spontaneous
pneumothorax?
1. Antibiotics

2. Bronchodilators

3. Chest tube placement

4. Hyperbaric chamber

24. Which of the following methods is the best way to confirm the diagnosis of a pneumothorax?

1. Auscultate breath sounds

2. Have the client use an incentive spirometer

3. Take a chest x-ray

4. stick a needle in the area of decreased breath sounds

25. A pulse oximetry gives what type of information about the client?

1. Amount of carbon dioxide in the blood

2. Amount of oxygen in the blood

3. Percentage of hemoglobin carrying oxygen

4. Respiratory rate

26. What effect does hemoglobin amount have on oxygenation status?

1. No effect

2. More hemoglobin reduces the client’s respiratory rate

3. Low hemoglobin levels cause reduces oxygen-carrying capacity

4. Low hemoglobin levels cause increased oxygen-carrying capacity.

27. Which of the following statements best explains how opening up collapsed alveoli improves
oxygenation?
1. Alveoli need oxygen to live

2. Alveoli have no effect on oxygenation

3. Collapsed alveoli increase oxygen demand

4. Gaseous exchange occurs in the alveolar membrane.

28. Continuous positive airway pressure (CPAP) can be provided through an oxygen mask to improve
oxygenation in hypoxic patients by which of the following methods?

1. The mask provides 100% oxygen to the client.

2. The mask provides continuous air that the client can breathe.

3. The mask provides pressurized oxygen so the client can breathe more easily.

4. The mask provides pressurized at the end of expiration to open collapsed alveoli.

29. Which of the following best describes pleural effusion?

1. The collapse of alveoli

2. The collapse of bronchiole

3. The fluid in the alveolar space

4. The accumulation of fluid between the linings of the pleural space.

30. If a pleural effusion develops, which of the following actions best describes how the fluid can be
removed from the pleural space and proper lung status restored?

1. Inserting a chest tube

2. Performing thoracentesis

3. Performing paracentesis

4. Allowing the pleural effusion to drain by itself.

31. A comatose client needs a nasopharyngeal airway for suctioning. After the airway is inserted, he
gags and coughs. Which action should the nurse take?

1. Remove the airway and insert a shorter one.

2. Reposition the airway.

3. Leave the airway in place until the client gets used to it.

4. Remove the airway and attempt suctioning without it.

32. An 87-year-old client requires long-term ventilator therapy. He has a tracheostomy in place and
requires frequent suctioning. Which of the following techniques is correct?

1. Using intermittent suction while advancing the catheter.

2. Using continuous suction while withdrawing the catheter.

3. Using intermittent suction while withdrawing the catheter.

4. Using continuous suction while advancing the catheter.

33. A client’s ABG analysis reveals a pH of 7.18, PaCO2 of 72 mm Hg, PaO2 of 77 mm Hg, and HCO3- of
24 mEq/L. What do these values indicate?

1. Metabolic acidosis

2. Respiratory alkalosis

3. Metabolic alkalosis

4. Respiratory acidosis

34. A police officer brings in a homeless client to the ER. A chest x-ray suggests he has TB. The physician
orders an intradermal injection of 5 tuberculin units/0.1 ml of tuberculin purified derivative. Which
needle is appropriate for this injection?

1. 5/8” to ½” 25G to 27G needle.

2. 1” to 3” 20G to 25G needle.

3. ½” to 3/8” 26 or 27G needle.

4. 1” 20G needle.

35. A 76-year old client is admitted for elective knee surgery. Physical examination reveals shallow
respirations but no signs of respiratory distress. Which of the following is a normal physiologic change
related to aging?

1. Increased elastic recoil of the lungs

2. Increased number of functional capillaries in the alveoli

3. Decreased residual volume

4. Decreased vital capacity.

36. A 79-year-old client is admitted with pneumonia. Which nursing diagnosis should take priority?

1. Acute pain related to lung expansion secondary to lung infection

2. Risk for imbalanced fluid volume related to increased insensible fluid losses secondary to fever.

3. Anxiety related to dyspnea and chest pain.

4. Ineffective airway clearance related to retained secretions.

37. A community health nurse is conducting an educational session with community members regarding
TB. The nurse tells the group that one of the first symptoms associated with TB is:

1. A bloody, productive cough

2. A cough with the expectoration of mucoid sputum

3. Chest pain

4. Dyspnea

38. A nurse evaluates the blood theophylline level of a client receiving aminophylline (theophylline) by
intravenous infusion. The nurse would determine that a therapeutic blood level exists if which of the
following were noted in the laboratory report?
1. 5 mcg/mL

2. 15 mcg/mL

3. 25 mcg/mL

4. 30 mcg/mL

39. Isoniazid (INH) and rifampin (Rifadin) have been prescribed for a client with TB. A nurse reviews the
medical record of the client. Which of the following, if noted in the client’s history, would require
physician notification?

1. Heart disease

2. Allergy to penicillin

3. Hepatitis B

4. Rheumatic fever

40. A client is experiencing confusion and tremors is admitted to a nursing unit. An initial ABG report
indicates that the PaCO2 level is 72 mm Hg, whereas the PaO2 level is 64 mm Hg. A nurse interprets that
the client is most likely experiencing:

1. Carbon monoxide poisoning

2. Carbon dioxide narcosis

3. Respiratory alkalosis

4. Metabolic acidosis

41. A client who is HIV+ has had a PPD skin test. The nurse notes a 7-mm area of induration at the site
of the skin test. The nurse interprets the results as:

1. Positive

2. Negative

3. Inconclusive
4. The need for repeat testing.

42. A nurse is caring for a client diagnosed with TB. Which assessment, if made by the nurse, would not
be consistent with the usual clinical presentation of TB and may indicate the development of a
concurrent problem?

1. Nonproductive or productive cough

2. Anorexia and weight loss

3. Chills and night sweats

4. High-grade fever

43. A nurse is teaching a client with TB about dietary elements that should be increased in the diet. The
nurse suggests that the client increase intake of:

1. Meats and citrus fruits

2. Grains and broccoli

3. Eggs and spinach

4. Potatoes and fish

44. Which of the following would be priority assessment data to gather from a client who has been
diagnosed with pneumonia? Select all that apply.

1. Auscultation of breath sounds

2. Auscultation of bowel sounds

3. Presence of chest pain.

4. Presence of peripheral edema

5. Color of nail beds

45. A client with pneumonia has a temperature of 102.6*F (39.2*C), is diaphoretic, and has a productive
cough. The nurse should include which of the following measures in the plan of care?
1. Position changes q4h

2. Nasotracheal suctioning to clear secretions

3. Frequent linen changes

4. Frequent offering of a bedpan.

46. The cyanosis that accompanies bacterial pneumonia is primarily caused by which of the following?

1. Decreased cardiac output

2. Pleural effusion

3. Inadequate peripheral circulation

4. Decreased oxygenation of the blood.

47. Which of the following mental status changes may occur when a client with pneumonia is first
experiencing hypoxia?

1. Coma

2. Apathy

3. Irritability

4. Depression

48. A client with pneumonia has a temperature ranging between 101* and 102*F and periods of
diaphoresis. Based on this information, which of the following nursing interventions would be a priority?

1. Maintain complete bedrest

2. Administer oxygen therapy

3. Provide frequent linen changes.

4. Provide fluid intake of 3 L/day

49. Which of the following would be an appropriate expected outcome for an elderly client recovering
from bacterial pneumonia?

1. A respiratory rate of 25 to 30 breaths per minute

2. The ability to perform ADL’s without dyspnea

3. A maximum loss of 5 to 10 pounds of body weight

4. Chest pain that is minimized by splinting the ribcage.

50. Which of the following symptoms is common in clients with TB?

1. Weight loss

2. Increased appetite

3. Dyspnea on exertion

4. Mental status changes

51. The nurse obtains a sputum specimen from a client with suspected TB for laboratory study. Which
of the following laboratory techniques is most commonly used to identify tubercle bacilli in sputum?

1. Acid-fast staining

2. Sensitivity testing

3. Agglutination testing

4. Dark-field illumination

52. Which of the following antituberculous drugs can cause damage to the eighth cranial nerve?

1. Streptomycin

2. Isoniazid

3. Para-aminosalicylic acid

4. Ethambutol hydrochloride
53. The client experiencing eighth cranial nerve damage will most likely report which of the following
symptoms?

1. Vertigo

2. Facial paralysis

3. Impaired vision

4. Difficulty swallowing

54. Which of the following family members exposed to TB would be at highest risk for contracting the
disease?

1. 45-year-old mother

2. 17-year-old daughter

3. 8-year-old son

4. 76-year-old grandmother

55. The nurse is teaching a client who has been diagnosed with TB how to avoid spreading the disease
to family members. Which statement(s) by the client indicate(s) that he has understood the nurses
instructions? Select all that apply.

1. “I will need to dispose of my old clothing when I return home.”

2. “I should always cover my mouth and nose when sneezing.”

3. “It is important that I isolate myself from family when possible.”

4. “I should use paper tissues to cough in and dispose of them properly.”

5. “I can use regular plate and utensils whenever I eat.”

56. A client has a positive reaction to the PPD test. The nurse correctly interprets this reaction to mean
that the client has:
1. Active TB

2. Had contact with Mycobacterium tuberculosis

3. Developed a resistance to tubercle bacilli

4. Developed passive immunity to TB.

57. INH treatment is associated with the development of peripheral neuropathies. Which of the
following interventions would the nurse teach the client to help prevent this complication?

1. Adhere to a low cholesterol diet

2. Supplement the diet with pyridoxine (vitamin B6)

3. Get extra rest

4. Avoid excessive sun exposure.

58. The nurse should include which of the following instructions when developing a teaching plan for
clients receiving INH and rifampin for treatment for TB?

1. Take the medication with antacids

2. Double the dosage if a drug dose is forgotten

3. Increase intake of dairy products

4. Limit alcohol intake

59. The public health nurse is providing follow-up care to a client with TB who does not regularly take
his medication. Which nursing action would be most appropriate for this client?

1. Ask the client’s spouse to supervise the daily administration of the medications.

2. Visit the clinic weekly to ask him whether he is taking his medications regularly.

3. Notify the physician of the client’s non-compliance and request a different prescription.

4. Remind the client that TB can be fatal if not taken properly.

60. The Causative agent of Tuberculosis is said to be:

1. Mycobacterium Tuberculosis

2. Hansen’s Bacilli

3. Bacillus Anthracis

4. Group A Beta Hemolytic Streptococcus

Answers and Rationale

1. Answer: 2. Group living

Clients with chronic illnesses generally have poor immune systems. Often, residing in group living
situations increases the chance of disease transmission.

2. Answer: 4. Inflammation

The common feature of all type of pneumonia is an inflammatory pulmonary response to the offending
organism or agent. Atelectasis and bronchiectasis indicate a collapse of a portion of the airway that
doesn’t occur in pneumonia. An effusion is an accumulation of excess pleural fluid in the pleural space,
which may be a secondary response to pneumonia.

3. Answer: 3. Streptococcus pneumoniae

Pneumococcal or streptococcal pneumonia, caused by streptococcus pneumoniae, is the most common

cause of community-acquired pneumonia. H. influenzae is the most common cause of infection in
children. Klebsiella species is the most common gram-negative organism found in the hospital setting.
Staphylococcus aureus is the most common cause of hospital-acquired pneumonia.

4. Answer: 1. Altered mental status and dehydration

Fever, chills, hemoptysis, dyspnea, cough, and pleuritic chest pain are common symptoms of
pneumonia, but elderly clients may first appear with only an altered mental status and dehydration due
to a blunted immune response.
5. Answer: 1. Bronchial

Chest auscultation reveals bronchial breath sounds over areas of consolidation. Bronchovesicular are
normal over midlobe lung regions, tubular sounds are commonly heard over large airways, and vesicular
breath sounds are commonly heard in the bases of the lung fields.

6. Answer: 4. sputum culture and sensitivity

Sputum C & S is the best way to identify the organism causing the pneumonia. Chest x-ray will show the
area of lung consolidation. ABG analysis will determine the extent of hypoxia present due to the
pneumonia, and blood cultures will help determine if the infection is systemic.

7. Answer: 3. Oxygen

The client is having difficulty breathing and is probably becoming hypoxic. As an emergency measure,
the nurse can provide oxygen without waiting for a physicians order. Antibiotics may be warranted, but
this isn’t a nursing decision. The client should be maintained on bedrest if he is dyspneic to minimize his
oxygen demands, but providing additional will deal more immediately with his problem. The client will
need nutritional support, but while dyspneic, he may be unable to spare the energy needed to eat and
at the same time maintain adequate oxygenation.

8. Answer: 4. Vesicular breath sounds in right base

If the client still has pneumonia, the breath sounds in the right base will be bronchial, not the normal
vesicular breath sounds. If the client still has dyspnea, fever, and increased respiratory rate, he should
be examined by the physician before discharge because he may have another source of infection or still
have pneumonia.

9. Answer: 3. Negative

This test would be classed as negative. A 5 mm raised area would be a positive result if a client was HIV+
or had recent close contact with someone diagnosed with TB. Indeterminate isn’t a term used to
describe results of a PPD test. If the PPD is reddened and raised 10mm or more, it’s considered positive
according to the CDC.

10. Answer: 4. A positive skin test

A primary TB infection occurs when the bacillus has successfully invaded the entire body after entering
through the lungs. At this point, the bacilli are walled off and skin tests read positive. However, all but
infants and immunosuppressed people will remain asymptomatic. The general population has a 10% risk
of developing active TB over their lifetime, in many cases because of a break in the body’s immune
defenses. The active stage shows the classic symptoms of TB: fever, hemoptysis, and night sweats.

11. Answer: 1. Active infection

Some people carry dormant TB infections that may develop into active disease. In addition, primary sites
of infection containing TB bacilli may remain inactive for years and then activate when the client’s
resistance is lowered, as when a client is being treated for cancer. There’s no such thing as tertiary
infection, and superinfection doesn’t apply in this case.

12. Answer: 2. Chills, fever, night sweats, and hemoptysis

Typical signs and symptoms are chills, fever, night sweats, and hemoptysis. Chest pain may be present
from coughing, but isn’t usual. Clients with TB typically have low-grade fevers, not higher than 102*F.
Nausea, headache, and photophobia aren’t usual TB symptoms.

13. Answer: 3. Sputum culture

The sputum culture for Mycobacterium tuberculosis is the only method of confirming the diagnosis.
Lesions in the lung may not be big enough to be seen on x-ray. Skin tests may be falsely positive or
falsely negative.

14. Answer: 3. To determine the extent of the lesions

If the lesions are large enough, the chest x-ray will show their presence in the lungs. Sputum culture
confirms the diagnosis. There can be false-positive and false-negative skin test results. A chest x-ray
can’t determine if this is a primary or secondary infection.

15. Answer: 4. He’s a “tuberculin converter,” which means he has been infected with TB since his last
skin test.

A tuberculin converter’s skin test will be positive, meaning he has been exposed to an infected with TB
and now has a cell-mediated immune response to the skin test. The client’s blood and x-ray results may
stay negative. It doesn’t mean the infection has advanced to the active stage. Because his x-ray is
negative, he should be monitored every 6 months to see if he develops changes in his x-ray or
pulmonary examination. Being a seroconverter doesn’t mean the TB has gotten into his bloodstream; it
means it can be detected by a blood test.

16. Answer: 4. 9 to 12 months

Because of the increased incidence of resistant strains of TB, the disease must be treated for up to 24
months in some cases, but treatment typically lasts for 9-12 months. Isoniazid is the most common
medication used for the treatment of TB, but other antibiotics are added to the regimen to obtain the
best results.

17. Answer: 1. Admit him to the hospital in respiratory isolation

The client is showing s/s of active TB and because of a productive cough is highly contagious. He should
be admitted to the hospital, placed in respiratory isolation, and three sputum cultures should be
obtained to confirm the diagnosis. He would most likely be given isoniazid and two or three other
antitubercular antibiotics until the diagnosis is confirmed, then isolation and treatment would continue
if the cultures were positive for TB. After 7 to 10 days, three more consecutive sputum cultures will be
obtained. If they’re negative, he would be considered non-contagious and may be sent home, although
he’ll continue to take the antitubercular drugs for 9 to 12 months.

18. Answer: 4. Positive acid-fast bacilli in a sputum sample after 2 months of treatment.

Continuing to have acid-fast bacilli in the sputum after 2 months indicated continued infection.
19. Answer: 3. To prevent spread of the disease

The client with active TB is highly contagious until three consecutive sputum cultures are negative, so
he’s put in respiratory isolation in the hospital.

20. Answer: 4. Reduces amount of functional alveolar surface area

Oxygen toxicity causes direct pulmonary trauma, reducing the amount of alveolar surface area available
for gaseous exchange, which results in increased carbon dioxide levels and decreased oxygen uptake.

21. Answer: 1. Auscultation of breath sounds

Because the client is short of breath, listening to breath sounds is a good idea. He may need a chest x-
ray and an ECG, but a physician must order these tests. Unless a cardiac source for the client’s pain is
identified, he won’t need an echocardiogram.

22. Answer: 4. Spontaneous pneumothorax

A spontaneous pneumothorax occurs when the client’s lung collapses, causing an acute decrease in the
amount of functional lung used in oxygenation. The sudden collapse was the cause of his chest pain and
shortness of breath. An asthma attack would show wheezing breath sounds, and bronchitis would have
rhonchi. Pneumonia would have bronchial breath sounds over the area of consolidation.

23. Answer: 3. Chest tube placement

The only way to re-expand the lung is to place a chest tube on the right side so the air in the pleural
space can be removed and the lung re-expanded.

24. Answer: 3. Take a chest x-ray

A chest x-ray will show the area of collapsed lung if pneumothorax is present as well as the volume of air
in the pleural space. Listening to breath sounds won’t confirm a diagnosis. An IS is used to encourage
deep breathing. A needle thoracostomy is done only in an emergency and only by someone trained to
do it.

25. Answer: 3. Percentage of hemoglobin carrying oxygen

The pulse oximeter determines the percentage of hemoglobin carrying oxygen. This doesn’t ensure that
the oxygen being carried through the bloodstream is actually being taken up by the tissue.

26. Answer: 3. Low hemoglobin levels cause reduces oxygen-carrying capacity

Hemoglobin carries oxygen to all tissues in the body. If the hemoglobin level is low, the amount of
oxygen-carrying capacity is also low. More hemoglobin will increase oxygen-carrying capacity and thus
increase the total amount of oxygen available in the blood. If the client has been tachypneic during
exertion, or even at rest, because oxygen demand is higher than the available oxygen content, then an
increase in hemoglobin may decrease the respiratory rate to normal levels.

27. Answer: 4. Gaseous exchange occurs in the alveolar membrane.

Gaseous exchange occurs in the alveolar membrane, so if the alveoli collapse, no exchange occurs,
Collapsed alveoli receive oxygen, as well as other nutrients, from the bloodstream. Collapsed alveoli
have no effect on oxygen demand, though by decreasing the surface area available for gas exchange,
they decrease oxygenation of the blood.

28. Answer: 3. The mask provides pressurized oxygen so the client can breathe more easily.

The mask provides pressurized oxygen continuously through both inspiration and expiration. The mask
can be set to deliver any amount of oxygen needed. By providing the client with pressurized oxygen, the
client has less resistance to overcome in taking his next breath, making it easier to breathe. Pressurized
oxygen delivered at the end of expiration is positive end-expiratory pressure (PEEP), not continuous
positive airway pressure.

29. Answer: 4. The accumulation of fluid between the linings of the pleural space.
The pleural fluid normally seeps continually into the pleural space from the capillaries lining the parietal
pleura and is reabsorbed by the visceral pleural capillaries and lymphatics. Any condition that interferes
with either the secretion or drainage of this fluid will lead to a pleural effusion.

30. Answer: 2. Performing thoracentesis

Performing thoracentesis is used to remove excess pleural fluid. The fluid is then analyzed to determine
if it’s transudative or exudative. Transudates are substances that have passed through a membrane and
usually occur in low protein states. Exudates are substances that have escaped from blood vessels. They
contain an accumulation of cells and have a high specific gravity and a high lactate dehydrogenase level.
Exudates usually occur in response to a malignancy, infection, or inflammatory process. A chest tube is
rarely necessary because the amount of fluid typically isn’t large enough to warrant such a measure.
Pleural effusions can’t drain by themselves.

31. Answer: 1. Remove the airway and insert a shorter one.

If a client gags or coughs after nasopharyngeal airway placement, the tube may be too long. The nurse
should remove it and insert a shorter one. Simply repositioning the airway won’t solve the problem. The
client won’t get used to the tube because it’s the wrong size. Suctioning without a nasopharyngeal
airway causes trauma to the natural airway.

32. Answer: 3. Using intermittent suction while withdrawing the catheter.

Intermittent suction should be applied during catheter withdrawal. To prevent hypoxia, suctioning
shouldn’t last more than 10-seconds at a time. Suction shouldn’t be applied while the catheter is being
advanced.

33. Answer: 4. Respiratory acidosis

34. Answer: 3. ½” to 3/8” 26 or 27G needle.

Intradermal injections like those used in TN skin tests are administered in small volumes (usually 0.5 ml
or less) into the outer skin layers to produce a local effect. A TB syringe with a ½” to 3/8” 26G or 27G
needle should be inserted about 1/8” below the epidermis.
35. Answer: 4. Decreased vital capacity.

Reduction in VC is a normal physiologic change in the older adult. Other normal physiologic changes
include decreased elastic recoil of the lungs, fewer functional capillaries in the alveoli, and an increase is
residual volume.

36. Answer: 4. Ineffective airway clearance related to retained secretions.

Pneumonia is an acute infection of the lung parenchyma. The inflammatory reaction may cause an
outpouring of exudate into the alveolar spaces, leading to an ineffective airway clearance related to
retained secretions.

37. Answer: 2. A cough with the expectoration of mucoid sputum

One of the first pulmonary symptoms includes a slight cough with the expectoration of mucoid sputum.

38. Answer: 2. 15 mcg/mL

The therapeutic theophylline blood level range from 10-20 mcg/mL.

39. Answer: 3. Hepatitis B

Isoniazid and rifampin are contraindicated in clients with acute liver disease or a history of hepatic
injury.

40. Answer: 2. Carbon dioxide narcosis

Carbon dioxide narcosis is a condition that results from extreme hypercapnia, with carbon dioxide levels
in excess of 70 mm Hg. The client experiences symptoms such as confusion and tremors, which may
progress to convulsions and possible coma.
41. Answer: 1. Positive

The client with HIV+ status is considered to have positive results on PPD skin test with an area greater
than 5-mm of induration. The client with HIV is immunosuppressed, making a smaller area of induration
positive for this type of client.

42. Answer: 4. High-grade fever

The client with TB usually experiences cough (non-productive or productive), fatigue, anorexia, weight
loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a
low-grade fever.

43. Answer: 1. Meats and citrus fruits

The nurse teaches the client with TB to increase intake of protein, iron, and vitamin C.

44. Answer: 1, 3, 5.

A respiratory assessment, which includes auscultating breath sounds and assessing the color of the nail
beds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an
important respiratory assessment as chest pain can interfere with the client’s ability to breathe deeply.
Auscultating bowel sounds and assessing for peripheral edema may be appropriate assessments, but
these are not priority assessments for the patient with pneumonia.

45. Answer: 3. Frequent linen changes

Frequent linen changes are appropriate for this client because of diaphoresis. Diaphoresis produces
general discomfort. The client should be kept dry to promote comfort. Position changes need to be done
every 2 hours. Nasotracheal suctioning is not indicated with the client’s productive cough. Frequent
offering of a bedpan is not indicated by the data provided in this scenario.

46. Answer: 4. Decreased oxygenation of the blood.

A client with pneumonia has less lung surface available for the diffusion of gases because of the
inflammatory pulmonary response that creates lung exudate and results in reduced oxygenation of the
blood. The client becomes cyanotic because blood is not adequately oxygenated in the lungs before it
enters the peripheral circulation.

47. Answer: 3. Irritability

Clients who are experiencing hypoxia characteristically exhibit irritability, restlessness, or anxiety as
initial mental status changes. As the hypoxia becomes more pronounced, the client may become
confused and combative. Coma is a late clinical manifestation of hypoxia. Apathy and depression are not
symptoms of hypoxia.

48. Answer: 4. Provide fluid intake of 3 L/day

A fluid intake of at least 3 L/day should be provided to replace any fluid loss occurring as a result the
fever and diaphoresis; this is a high-priority intervention.

49. Answer: 2. The ability to perform ADL’s without dyspnea

An expected outcome for a client recovering from pneumonia would be the ability to perform ADL’s
without experiencing dyspnea. A respiratory rate of 25 to 30 breaths/minute indicates the client is
experiencing tachypnea, which would not be expected on recovery. A weight loss of 5-10 pounds is
undesirable; the expected outcome would be to maintain normal weight. A client who is recovering
from pneumonia should experience decreased or no chest pain.

50. Answer: 1. Weight loss

TB typically produces anorexia and weight loss. Other signs and symptoms may include fatigue, low-
grade fever, and night sweats.

51. Answer: 1. Acid-fast staining

The most commonly used technique to identify tubercle bacilli is acid-fast staining. The bacilli have a
waxy surface, which makes them difficult to stain in the lab. However, once they are stained, the stain is
resistant to removal, even with acids. Therefore, tubercle bacilli are often called acid-fast bacilli.

52. Answer: 1. Streptomycin

Streptomycin is an aminoglycoside, and eight cranial nerve damage (ototoxicity) is a common side effect
from aminoglycosides.

53. Answer: 1. Vertigo

The eighth cranial nerve is the vestibulocochlear nerve, which is responsible for hearing and equilibrium.
Streptomycin can damage this nerve.

54. Answer: 4. 76-year-old grandmother

Elderly persons are believed to be at higher risk for contracting TB because of decreased
immunocompetence. Other high-risk populations in the US include the urban poor, AIDS, and minority
groups.

55. Answer: 2, 4, 5.

56. Answer: 2. Had contact with Mycobacterium tuberculosis

A positive PPD test indicates that the client has been exposed to tubercle bacilli. Exposure does not
necessarily mean that active disease exists.

57. Answer: 2. Supplement the diet with pyridoxine (vitamin B6)

INH competes with the available vitamin B6 in the body and leaves the client at risk for development of
neuropathies related to vitamin deficiency. Supplemental vitamin B6 is routinely prescribed.
58. Answer: 4. Limit alcohol intake

INH and rifampin are hepatotoxic drugs. Clients should be warned to limit intake of alcohol during drug
therapy. Both drugs should be taken on an empty stomach. If antacids are needed for GI distress, they
should be taken 1 hour before or 2 hours after these drugs are administered. Clients should not double
the dosage of these drugs because of their potential toxicity. Clients taking INH should avoid foods that
are rich in tyramine, such as cheese and dairy products, or they may develop hypertension.

59. Answer: 1. Ask the client’s spouse to supervise the daily administration of the medications.

Directly observed therapy (DOT) can be implemented with clients who are not compliant with drug
therapy. In DOT, a responsible person, who may be a family member or a health care provider, observes
the client taking the medication. Visiting the client, changing the prescription, or threatening the client
will not ensure compliance if the client will not or cannot follow the prescribed treatment.

60. Answer: 1. Mycobacterium Tuberculosis

1. Nurse Ejay is assigned to a telephone triage. A client called who was

stung by a honeybee and is asking for help. The client reports of pain
and localized swelling but has no respiratory distress or other
symptoms of anaphylactic shock. What is the appropriate initial action
that the nurse should direct the client to perform?

A. Removing the stinger by scraping it.

B. Applying a cold compress.
C. Taking an oral antihistamine.
D. Calling the 911.

2. Nurse Anna is an experienced travel nurse who was recently

employed and is assigned in the emergency unit. In her first week of
the job, which of the following area is the most appropriate assignment
for her?
A. Triage.
B. Ambulatory section.
C. Trauma team.
D. Psychiatric care

3. A client arrives at the emergency department who suffered multiple

injuries from a head-on car collision. Which of the following assessment
should take the highest priority to take?

A. Irregular pulse.
B. Ecchymosis in the flank area.
C. A deviated trachea.
D. Unequal pupils.

4. Nurse Kelly, a triage nurse encountered a client who complaints of

mid-sternal chest pain, dizziness, and diaphoresis. Which of the
following nursing action should take priority?

A. Complete history taking.

B. Put the client on ECG monitoring.
C. Notify the physician.
D. Administer oxygen therapy via nasal cannula.

5. A group of people arrived at the emergency unit by a private car with

complaints of periorbital swelling, cough, and tightness in the throat.
There is a strong odor emanating from their clothes. They report
exposure to a “gas bomb” that was set off in the house. What is the
priority action?

A. Direct the clients to the decontamination area.

B. Direct the clients to the cold or clean zone for immediate treatment.
C. Measure vital signs and auscultate lung sounds.
D. Immediately remove other clients and visitors from the area.
E. Instruct personnel to don personal protective equipment.

6. When an unexpected death occurs in the emergency department,

which task is the most appropriate to delegate to a nursing assistant?

A. Help the family to collect belongings.

B. Assisting with postmortem care.
C. Facilitate meeting between the family and the organ donor specialist.
D. Escorting the family to a place of privacy.

7. The physician has ordered cooling measures for a child with

a fever who is likely to be discharged when the temperature comes
down. Which task would be appropriate to delegate to a nursing
assistant?

A. Prepare and administer a tepid sponge bath.

B. Explain the need for giving cool fluids.
C. Assist the child in removing outer clothing.
D. Advise the parent to use acetaminophen (Tylenol) instead of aspirin.

8. You are preparing a child for IV conscious sedation before the repair
of a facial laceration. What information should you report immediately
to the physician?

A. The parent wants information about the IV conscious sedation.

B. The parent is not sure regarding the child’s tetanus immunization status.
C. The child suddenly pulls out the IV.
D. The parent’s refusal of the administration of the IV sedation.

9. The emergency medical service has transported a client with severe

chest pain. As the client is being transferred to the emergency
stretcher, you note unresponsiveness, cessation of breathing, and
unpalpable pulse. Which of the following task is appropriate to delegate
to the nursing assistant?

A. Assisting with the intubation.

B. Placing the defibrillator pads.
C. Doing chest compressions.
D. Initiating bag valve mask ventilation.

10. The nursing manager decides to form a committee to address the

issue of violence against ED personnel. Which combination of
employees would be best suited to fulfill this assignment?

A. RNs, LPNs, and nursing assistants.

B. At least one representative from each group of ED personnel.
C. Experienced RNs and experienced paramedics.
D. ED physicians and charge nurses.

11. A client suffered an amputation of the first and second digits in a

chainsaw accident. Which task should be delegated to an LPN/LVN?

A. Cleansing the amputated digits and placing them directly into an ice slurry.
B. Cleansing the digits with sterile normal saline and placing in a sterile cup with
sterile normal saline.
C. Gently cleansing the amputated digits and the hand with povidone-iodine.
D. Wrapping the cleansed digits in saline-moistened gauze, sealing in a plastic
container, and placing it in an ice.

12. A client arrives in the emergency unit and reports that a

concentrated household cleaner was splashed in both eyes. Which of
the following nursing actions is a priority?

A. Use Restasis (Allergan) drops in the eye.

B. Flush the eye repeatedly using sterile normal saline.
C. Examine the client’s visual acuity.
D. Patch the eye.

13. A client was brought to the emergency department after suffering a

closed head injury and lacerations around the face due to a hit-run
accident. The client is unconscious and has minimal response to
noxious stimuli. Which of the following assessment findings if observed
after few hours, should be reported to the physician immediately?

A. Bleeding around the lacerations.

B. Withdrawal of the client in response to painful stimuli.
C. Bruises and minimal edema of the eyelids.
D. Drainage of a clear fluid from the client’s nose.

14. A 5-year-old client was admitted to the emergency unit due to

ingestion of unknown amount of chewable vitamins for children at an
unknown time. Upon assessment, the child is alert and with no
symptoms. Which of the following information should be reported to
the physician immediately?

A. The child has been treated multiple times for injuries caused by accidents.
B. The vitamin that was ingested contains iron.
C. The child was nauseated and vomited once at home.
D. The child has been treated several times for toxic substance ingestion.

15. The following clients come at the emergency department

complaining of acute abdominal pain. Prioritize them for care in order
of the severity of the conditions.

 1. A 27-year-old woman complaining of lightheadedness and severe

sharp left lower quadrant pain who reports she is possibly pregnant.
  2. A 43-year-old woman with moderate right upper quadrant pain who
has vomited small amounts of yellow bile and whose symptoms have
worsened over the week.
 3. A 15-year-old boy with a low-grade fever, right lower quadrant pain,
vomiting, nausea, and loss of appetite for the past few days.
 4. A 57-year-old woman who complains of a sore throat and gnawing
midepigastric pain that is worse between meals and during the night.
 5. A 59-year-old man with a pulsating abdominal mass and sudden
onset of persistent abdominal or back pain, which can be described as
a tearing sensation within the past hour.

A. 2,5,3,4,1
B. 3,1,4,5,2
C. 5,1,3,2,4
D. 2,5,1,4,3

16. The following clients are presented with signs and symptoms of
heat-related illness. Which of them needs to be attended first?

A. A relatively healthy homemaker who reports that the air conditioner has been
broken for days and who manifest fatigue, hypotension, tachypnea, and profuse
sweating.
B. An elderly person who complains of dizziness and syncope after standing in
the sun for several hours to view a parade.
C. A homeless person who is a poor historian; has altered mental status,
poor musclecoordination, and hot, dry ashen skin; and whose duration of heat
exposure is unknown.
D. A marathon runner who complains of severe leg cramps and nausea, and
manifests weakness, pallor, diaphoresis, and tachycardia.

17. An anxious female client complains of chest tightness, tingling

sensations, and palpitations. Deep, rapid breathing, and carpal spasms
are noted. Which of the following priority action should the nurse do
first?

A. Provide oxygen therapy.

B. Notify the physician immediately.
C. Administer anxiolytic medication as ordered.
D. Have the client breathe into a brown paper bag.

18. An intoxicated client comes into the emergency unit with an

uncooperative behavior, mild confusion, and with slurred speech. The
client is unable to provide a good history but he verbalizes that he has
been drinking a lot. Which of the following is a priority action of the
nurse?

A. Administer IV fluid incorporated with Vitamin B1 as ordered.

B. Administer Naloxone (Narcan) 4 mg as ordered.
C. Contact the family to get information of the client.
D. Obtain an order for the determination of blood alcohol level.

19. A nurse is providing discharge instruction to a woman who has been

treated for contusions and bruises due to a domestic violence. What is
the priority intervention for this client?

A. Making a referral to a counselor.

B. Making an appointment to follow up on the injuries.
C. Advising the client about contacting the police.
D. Arranging transportation to a safe house.

20. In the work setting, what is the primary responsibility of the nurse
in preparation for disaster management, that includes natural disasters
and bioterrorism incidents?
A. Being aware of the signs and symptoms of potential agents of bioterrorism.
B. Making ethical decisions regarding exposing self to potentially lethal
substances.
C. Being aware of the agency’s emergency response plan.
D. Being aware of what and how to report to the Centers for Disease Control
and Prevention.

Answers and Rationale

Here are the answers and rationale for the NCLEX quiz.

1. Answer: A. Removing the stinger by scraping it.

Since the stinger will continue to release venom into the skin, removing the
stinger should be the first action that the nurse should direct to the client.

 Options B and C: After removing the stinger, Antihistamine and cold

compress follow.
 Option D: The caller should be further advised about symptoms that
require 911 assistance.

2. Answer: B. Ambulatory section.

The ambulatory section deals with clients with relatively stable conditions.

 Options A, C, and D: These areas should be filled with nurses who are
experienced with hospital routines and policies and has the ability to
locate equipment immediately.

3. Answer: C. A deviated trachea.

A deviated trachea is a symptom of tension pneumothorax, which will result in

respiratory distress if left untreated.
4. Answer: D. Administer oxygen therapy via nasal cannula.

The priority goal is to increase myocardial oxygenation.

 Options A, B, and C: These actions are also appropriate and should be

performed immediately.

5. Answer: A. Direct the clients to the decontamination area.

Decontamination in a specified area is the priority.

 Option B: The clients must undergo decontamination before entering

cold or clean areas.
 Options C and D: Performing assessments and moving others delays
contamination and does not protect the total environment.
 Option E: Personnel should don personal protective equipment before
assisting with decontamination or assessing the clients.

6. Answer: B. Assisting with postmortem care.

Postmortem care requires some turning, cleaning, lifting, and so on, and the
nursing assistant is able to assist with these duties.

 Option A: In cases of questionable death, belongings may be retained

for evidence, so the chain of custody would have to be maintained.
 Options C and D: A licensed nurse should take responsibility for the
other tasks to help the family begin the grieving process.

7. Answer: C. Assist the child in removing outer clothing.

The nursing assistant can help with the removal of outer clothing, which allows
the heat to dissipate from the child’s skin.
  Option A: Tepid baths are not usually given because of the possibility
of shivering and rebound.
 Options B and D: Explaining and Advising are teaching functions that
are a responsibility of the registered nurse.

8. Answer: D. The parent’s refusal of the administration of the IV

sedation.

The refusal of the parents is an absolute contraindication; therefore the

physician must be notified.

 Options A and C: The RN can reestablish the IV access and provide

information about conscious sedation.
 Option B: Tetanus status can be addressed later.

9. Answer: C. Doing chest compressions.

Performing chest compressions are within the training of a nurse assistant.

 Option A: The use of the bag valve mask requires practice, and usually
a respiratory therapist will perform the function.
 Option B: The defibrillator pads are clearly marked; however
placement should be done by the RN or physician because of the
potential for skin damage and electrical arcing.

10. Answer: B. At least one representative from each group of ED

personnel.

At least one representative from each group of ED personnel should be included

because all employees are potential targets for violence in the ED.

11. Answer: D. Wrapping the cleansed digits in saline-moistened gauze,

sealing in a plastic container, and placing it in an ice.
12. Answer: B. Flush the eye repeatedly using sterile normal saline.

Initial emergency action during a chemical splash to the eye includes immediate
continuous irrigation of the affected eye with normal saline.

 Option A: Restasis (Allergan) drops are used to treat dry eyes.

 Option C: Patching the eye is not part of the first line treatment of a
chemical splash.
 Option D: After irrigation, visual acuity then is assessed.

13. Answer: D. Drainage of a clear fluid from the client’s nose.

Clear drainage from the client’s nose indicates that there is a leakage of CSF
and should be reported to the physician immediately.

14. Answer: B. The vitamin that was ingested contains iron.

Iron is a toxic substance that can lead to massive hemorrhage, shock, coma,
andkidney failure.

 Options A, C, and D: These information needs further investigation but

will not change the immediate diagnostic testing or treatment plan.

15. Answer: C. 5,1,3,2,4

The client with a pulsating mass has an abdominal aneurysm that may rupture
and he may decompensate easily. The woman with lower left quadrant pain is
at risk for a life-threatening ectopic pregnancy. The 15-year-old boy needs
evaluation to rule outappendicitis. The woman with vomiting needs evaluation
for gallbladder problems, which appear to be worsening. Lastly, the woman with
mid epigastric pain is suffering from anulcer, but follow-up diagnostic testing
can be scheduled with a primary care provider.
16. Answer: C. A homeless person who is a poor historian; has altered
mental status, poor muscle coordination, and hot, dry ashen skin; and
whose duration of heat exposure is unknown.

The signs and symptoms manifested by the homeless person indicate that a
heatstroke is happening, a medical emergency, which can lead to brain damage.

 Option A: The homemaker is experiencing heat exhaustion, which can

be managed by fluids and cooling measures.
 Option B: The elderly client is at risk for heat syncope and should be
advised to rest in a cool area and avoid similar situations.
 Option D: The runner is experiencing heat cramps, which can be
managed with fluid and rest.

17. Answer: D. Have the client breathe into a brown paper bag.

The client is suffering from hyperventilation secondary from anxiety, the initial
action is to let the client breathe in a paper bag that will allow the rebreathing
of carbon dioxide.

18. Answer: A. Administer IV fluid incorporated with Vitamin B1 as

ordered.

The client has symptoms of alcohol abuse and there is a risk for Wernicke
syndrome, which is caused by a deficiency in Vitamin B.

 Option B: Multiple drug abuse is not uncommon; however, there is

currently nothing to suggest an opiate overdose that requires the
administration of naloxone.
 Options C and D: Additional information or the results of the blood
alcohol testing are part of the management but should not delay the
immediate treatment.
19. Answer: D. Arranging transportation to a safe house.

Safety is a priority for this client and she should not return to a place where
violence could recur.

 Options A, B, and C: These are important for the long-term

management of this case.

20. Answer: C. Being aware of the agency’s emergency response plan.

In disasters preparedness, the nurse should know the emergency response

plan. This gives guidance that includes the roles of the team members,
responsibilities and mechanism of reporting.