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A bad situation can show special integrity. When to face of a difficult time, only the bravest people could take it easy.
CEN PDF DEMO:
QUESTION NO: 1
Your patient has sustained a burn from cutaneous exposure to lye. The patient received one hour of
irrigation at the site of the injury prior to coming to the emergency department. When you assess the site
what, finding tells you that the burn continues?
A. Eschar
B. Liquefaction necrosis
C. Cherry red, firm tissue
D. Intact blisters
Answer: B
Explanation: Liquefaction necrosis is an indication that the chemical is still burning the patient.
Exposure
to acids or heat causes thick, leathery eschars to form. Thermal injury can lead to cherry red, firm tissue.
Partial-thickness thermal injury leads to intact blisters.
QUESTION NO: 2
You are working in the emergency department and find out that a tornado has hit the local area.
Numerous casualties are being sent to the emergency department. What action should you take at this time?
A. Prepare the triage room.
B. Obtain additional supplies.
C. Activate the agency disaster plan.
D. Call in additional staff.
Answer: C
Explanation: The nurse should activate the agency disaster plan. All the other options may be part of the
disaster plan, but the first priority of the nurse should be to activate the disaster plan. This will cover all the
necessary steps that the will need to take.
QUESTION NO: 3
You are caring for a heart failure patient who suddenly developed symptoms that include shortness of
breath, increased respiratory rate, bilateral crackles and frothy sputum. You have notified the physician
and received orders for the patient. Which activity would be appropriate to delegate to a licensed practical nurse?
A. Start an IV.
B. Check vital signs every 15 minutes.
C. Morphine sulfate 2mg IV push
D. Insert a foley catheter.
Answer: D
Explanation: The RN should delegate the task to the LPN that does not require assessment. Inserting the
foley catheter is the least likely to require immediate assessment. The RN should insert the IV and immediately give IV medications. Vital signs that are taken on a deteriorating patient should be taken by
the RN so that immediate assessment can be made.
QUESTION NO: 4
You are caring for a patient who is becoming more aggressive. He is pacing and agitated. His speech is
becoming rapid and his affect belligerent. What should the nurse's first priority be?
A. Provide safety for the patient and other patients on the unit.
B. Offer the patient a less stimulated area to calm down and gain control.
C. Provide the patients on the unit with a sense of comfort and safety.
D. Assist the staff in caring for the patient in controlled environment.
Answer: A
Explanation: Safety to the patient and other patients on the unit should be the nurse's first priority.
The
patient is showing behavior that is escalating and most likely will hurt himself or some one else if the staff
does not step in immediately. Use Maslow's hierarchy of needs to prioritize which is the most immediate
priority.
QUESTION NO: 5
You are caring for a patient who has been receiving a blood transfusion for the last 30 minutes.
On
assessment, you find the patient to be dyspneic and show bilateral crackles and a heart rate of 110.
Which of the following complications do you suspect the patient is experiencing?
A. Immune response
B. Hypovolemia
C. Fluid overload
D. Polycythemia vera
Answer: C
Explanation: The patient exhibiting these signs and symptoms is most likely going into fluid overload.
Crackles in the lungs would not be associated with the other options. The physician should be notified to
get a diuretic for the patient.
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Updated: May 26, 2022