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NUR213 JSCC: Questions & Correct Solutions
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NUR213 JSCC: Questions & Correct SolutionsWhat color is the sun? - RIGHT Yellow
A nurse is triaging patients in the ED. Which pt should be seen first?
1. A 22 y/o with a painful swollen right wrist?
2. A 45 y/o reporting chest pain and diaphoresis?
3. A 60 y/o reporting difficulty swallowing and nausea?
4. An 81 y/o with a 101.5F temp and RR of 28/min? - RIGHT 2. 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?
1. Assess the client is breathing properly
2. Insert a large bore IV catheter
3. Place client on cardiac monitor
4. Assess neurological response - RIGHT 1. 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
1. Foley catheter
2. Needle decompression (to stabilize pneumothorax)
3 Initiating IV fluids
4. Splinting open fracture
5. Endotracheal intubation
6. Removing wet clothing
7. Laceration repair - RIGHT 2, 3, 5, 6 all part of primary
The physician has ordered lab work for a client with suspected disseminated
intravascular coagulation (DIC). Which lab finding would provide a definitive
diagnosis of DIC?
1. Elevated ESR
2. Prolonged clotting time
3. Presence of fibrin split compound
, 4. Elevated WBC - RIGHT 3. 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:
1. Meticulous infection-control measures
2. Fluid-replacement evaluation
3. Psychological adjustment to the wound
4. Measurement and application of a pressure garment - RIGHT 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?
1. Assess for head injuries, control hemorrhage, establish an airway, prevent
hypovolemic shock
2. Control hemorrhage, prevent hypovolemic shock, establish an airway,
assess for head injuries
3. Establish an airway, control hemorrhage, prevent hypovolemic shock,
assess for head injuries
4. Prevent hypovolemic shock, assess for head injuries, establish an airway,
control hemorrhage - RIGHT 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
2. Chest pain
3. Anxiety
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