emergency and critical care
When a nurse responds to an in-hospital emergency with visible active bleeding, the priority sequence according to the HABC method is:
. Hemorrhage, Airway, Breathing, Circulation
The primary purpose of the initial nursing admission assessment is to
Establish a baseline and identify actual or potential health problems
Which age-related physiological change in older adults increases the risk of falls?
Decreased proprioception and slower reaction time
The first link in the chain of infection is
Infectious agent
The FAST acronym is used to assess for stroke. "A" stands for:
Arm weakness
The phrase “head-to-toe, treat as you go” means the nurse should:
. Address life-threatening problems immediately as they are discovered during assessment
The correct sequence for abdominal assessment is:
Palpation, percussion, auscultation, inspection
An older adult patient is taking five different medications daily. This situation is best described as:
Polypharmacy
According to standard infection control guidelines, hand hygiene should be performed:
Before and after every patient contact and after touching contaminated surfaces
Muscle strength is graded on a 0–5 scale. A patient who can move the limb against gravity but not against resistance receives which grade?
3/5
Which of the following are early signs of internal hemorrhage?
Tachycardia, Narrowing pulse pressure, and Restlessness or altered mental status
Absent bowel sounds in all four quadrants for 5 minutes most likely indicate:
Paralytic ileus or bowel obstruction
A hospitalized older adult suddenly becomes confused, agitated, and has fluctuating attention over the past 6 hours. This presentation is most consistent with:
Delirium
Which of the following are components of standard precautions? (Select all that apply)
A. Hand hygiene
B. Use of PPE when anticipating contact with body fluids
C. Safe injection practices
D. Respiratory hygiene/cough etiquette
E. Airborne isolation for all patients
A. Hand hygiene
B. Use of PPE when anticipating contact with body fluids
C. Safe injection practices
D. Respiratory hygiene/cough etiquette
The nurse suspects compartment syndrome in a patient with a casted leg when which finding is present?
Severe pain unrelieved by opioids and paresthesia
In a patient with suspected cervical spine injury after a fall, the correct initial airway maneuver is:
Jaw thrust with manual in-line stabilization
Which findings are included in a basic neurological assessment? select all
A. Glasgow Coma Scale
B. Pupil size and reactivity
C. Motor strength and movement
D. Orientation to person, place, and time
E. Blood glucose level
A. Glasgow Coma Scale
B. Pupil size and reactivity
C. Motor strength and movement
D. Orientation to person, place, and time
To promote patient safety upon admission, the nurse should:
Place the bed in the lowest position with wheels locked
A patient with active tuberculosis requires which type of transmission-based precautions?
Airborne precautions
Passive range-of-motion (PROM) exercises are performed when the patient:
Is unable to move the joint themselves due to weakness or paralysis
During a seizure, the nurse's first priority action is to:
Protect the patient’s head and turn them to the side
Which breath sound is normally heard over the peripheral lung fields?
Vesicular
Which interventions are part of effective discharge teaching? (Select all that apply)
A. Using teach-back method to confirm understanding
B. Providing written instructions at a 6th-grade reading level
C. Including family or caregivers when appropriate
D. Reviewing medications, follow-up appointments, and warning signs
A. Using teach-back method to confirm understanding
B. Providing written instructions at a 6th-grade reading level
C. Including family or caregivers when appropriate
D. Reviewing medications, follow-up appointments, and warning signs
When caring for a patient on contact precautions for MRSA, the nurse should:
Establish a baseline and identify actual or potential health problems
The most reliable method to confirm correct nasogastric tube placement before initial use is:
Checking pH of aspirate (≤5.5) and obtaining chest X-ray