what must the Emergency Room Nurse do FIRST?

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Adult Health Med Surg Nursing Test Banks Questions

Question 1 of 9

what must the Emergency Room Nurse do FIRST?

Correct Answer: B

Rationale: When a patient arrives in the emergency room, the nurse's first priority is to assess the patient's airway, breathing, and circulation, following the ABCs of emergency care. In this scenario, positioning the patient with the head lower than the extremities ensures proper blood flow to vital organs, especially the brain. This position helps to maintain perfusion to the brain and prevent complications such as hypotension and shock. Once the patient's position is optimized, the nurse can proceed with further interventions such as starting an intravenous line, stopping bleeding, and requesting laboratory examinations as needed.

Question 2 of 9

The group was observant as to the activities taking place in the delivery room. One of the activities involved social processes, which can be better explored. Which of the following qualitative research method should be used?

Correct Answer: A

Rationale: Grounded theory is a qualitative research method that focuses on generating theory from data rather than testing pre-existing theories. In this scenario, where the goal is to explore social processes observed in the delivery room activities, grounded theory would be the most appropriate method. This method allows researchers to systematically collect and analyze data in order to develop theoretical explanations for social phenomena. By using grounded theory, researchers can explore the interactions, behaviors, and social processes at play in the delivery room in a structured and systematic way, thereby gaining insights into these phenomena through an inductive approach.

Question 3 of 9

Baby Sharon was placed on phototherapy. What precaution should Nurses Juvy observe?

Correct Answer: A

Rationale: When a baby is placed on phototherapy, especially for treating jaundice, it is crucial for the nurses to put sunglasses on the newborn to protect their eyes. Phototherapy involves exposing the baby's skin to certain types of light to help break down the bilirubin causing the jaundice. However, this light can be harmful to the baby's sensitive eyes, potentially leading to eye damage or other eye-related issues if not protected adequately. Therefore, placing sunglasses on the newborn is a necessary precaution to ensure the safety and well-being of the baby's eyes during the treatment.

Question 4 of 9

Considering the pain assessment scale (1, is the least pain and 5 is the most painful) Mrs. P described her pain in the scale of 5, you expect that the doctor will order which of the following pain medication?

Correct Answer: B

Rationale: When a patient describes their pain as a 5 on the pain assessment scale, it indicates severe pain and the need for a strong pain medication. Morphine Sulphate is a potent opioid analgesic that is commonly used to manage severe pain, such as in cases where the pain is rated as 5. Meperidine HCl (Demerol) is another opioid analgesic, but it is not as commonly used due to its side effect profile and potential for toxicity. Fentanyl (Duragesic) is also a potent opioid analgesic that can be used for severe pain, but morphine is often preferred in this situation. Acetaminophen (Tylenol) is a milder pain reliever and is not typically sufficient for pain described at a level of 5 on the pain scale.

Question 5 of 9

The nurse educator Adalynn reviewed the risk factors for postpartum hemorrhage for the mothers. Which of the following factors IS NOT included ____?

Correct Answer: D

Rationale: Postpartum hemorrhage (PPH) is a significant complication after childbirth. The risk factors for PPH that are typically included in the list are uterine atony, overdistended uterus (e.g., multiple gestation or polyhydramnios), and ruptured uterus. Retroversion of the uterus is not a known risk factor for PPH. Retroversion refers to the position of the uterus, where it is tilted back towards the rectum. While retroverted uterus can sometimes lead to other issues or complications during pregnancy, it is not directly associated with an increased risk of postpartum hemorrhage.

Question 6 of 9

A patient presents with acute onset of severe headache, visual disturbances, and altered mental status. Imaging reveals a tumor compressing the optic chiasm. Which of the following neurological conditions is most likely responsible for these symptoms?

Correct Answer: C

Rationale: Pituitary adenoma is the most likely neurological condition responsible for the described symptoms of acute onset severe headache, visual disturbances, and altered mental status when a tumor is found compressing the optic chiasm. Pituitary adenomas are benign tumors arising from the pituitary gland located at the base of the brain. As the tumor grows, it can compress nearby structures such as the optic chiasm, leading to visual disturbances (due to pressure on the optic nerves), severe headache (due to increased intracranial pressure), and altered mental status (due to effects on nearby brain structures).

Question 7 of 9

Right after endorsement and during the rounds, the incoming nurse observes that the IV fluid is at 800 cc level and not 400cc, as endorsed. What is the CORRECT information that she will chart?

Correct Answer: C

Rationale: The correct information that the incoming nurse should chart is that she received 800 cc of IV fluid. It is crucial for the charting to accurately reflect the actual situation to provide an accurate record for the patient's care. In this scenario, the discrepancy between the endorsed amount (400 cc) and the observed amount (800 cc) should be documented to ensure transparency and continuity of care. This deviation from the expected amount should be clearly recorded for proper monitoring and evaluation of the patient's condition.

Question 8 of 9

During a support group meeting, Nurse Donato, in a teasing manner, has made several provocative remarks about your appearance and behavior as a group leader. Select your MOST appropriate response.

Correct Answer: D

Rationale: Choosing option D, "Donato, what you are saying is inappropriate," is the most appropriate response in this situation. It directly addresses Nurse Donato's behavior without escalating the situation or being overly confrontational. By calmly pointing out that the remarks are inappropriate, you are setting a boundary and letting Nurse Donato know that such behavior is not acceptable in a professional setting. This response also signals to the rest of the group that you are aware of the inappropriate comments and are taking action to address them. It is important to address such behavior professionally and assertively to maintain a respectful and supportive environment during the support group meeting.

Question 9 of 9

A patient with advanced cancer experiences dyspnea and anxiety during episodes of breathlessness. Which intervention should the palliative nurse prioritize to address the patient's symptoms?

Correct Answer: C

Rationale: Opioid medications are considered the first-line pharmacological treatment for dyspnea in palliative care patients with advanced cancer. Opioids help relieve dyspnea by reducing respiratory drive and the sensation of breathlessness, providing effective symptom management. In this case, addressing the patient's dyspnea with opioid medications would likely also help alleviate their anxiety related to breathlessness. Administering oxygen therapy (choice A) may not be effective at relieving dyspnea in this situation, as dyspnea in advanced cancer patients is often not primarily due to low oxygen levels. Teaching pursed-lip breathing techniques (choice B) and referring the patient to a respiratory therapist for breathing exercises (choice D) may be helpful complementary interventions, but opioid medications should be the priority for symptom management.

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