Introduction > Medical Surgical
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Total Questions : 13
Showing 13 questions, Sign in for moreA nurse is teaching a first aid class to a group of high school students. The nurse asks one of the students to demonstrate how to perform abdominal thrusts (Heimlich maneuver) on a choking victim. Which of the following actions by the student indicates a need for further instruction?
Explanation
Choice A Reason: This action is correct because it positions the student behind the victim and allows him to perform abdominal thrusts.
Choice B Reason: This action is correct because it places the fist above the navel and below the xiphoid process, where the thrusts can dislodge the object.
Choice C Reason: This action is correct because it pulls the fist inward and upward, creating a strong pressure in the abdomen that can expel the object.
Choice D Reason: This action is incorrect because it does not recognize the need to change the intervention if the victim becomes unconscious. The student repeats the thrusts until the object is expelled or the victim becomes unconscious. This action indicates a need for further instruction because if the victim becomes unconscious, the student should lower them to the ground, call 911, and start CPR.
A nurse is providing first aid to a client who has a puncture wound on his foot from stepping on a nail. The nurse cleans the wound with soap and water and applies a sterile dressing. The nurse should also advise the client to:
Explanation
Choice A Reason: This advice is not specific to a puncture wound. Taking ibuprofen for pain relief may be helpful, but it is not a priority intervention.
Choice B Reason: This advice is incorrect because soaking the foot in warm water can increase the risk of infection and delay healing.
Choice C Reason: This advice is correct because getting a tetanus booster shot if needed can prevent tetanus, a serious bacterial infection that affects the nervous system.
Choice D Reason: This advice is incorrect because avoiding wearing shoes until the wound heals can expose the wound to dirt and bacteria and cause more complications.
A nurse is providing first aid to a client who has a nosebleed. The nurse should instruct the client to:
Explanation
Choice A Reason: This action is incorrect because tilting the head back can cause blood to go down the throat and increase the risk of choking or vomiting.
Choice B Reason: This action is correct because tilting the head forward and pinching the nostrils together helps to stop the bleeding and prevent blood from going down the throat.
Choice C Reason: This action is incorrect because blowing the nose forcefully can dislodge any clots and worsen the bleeding, and applying ice to the bridge of the nose may not be effective.
Choice D Reason: This action is incorrect because breathing through the mouth can dry out the nasal passages and delay healing, and applying pressure to the upper lip may not be effective.
A nurse is providing first aid to a client who has a sprained ankle. The nurse should apply which of the following interventions?
Explanation
Choice A Reason: This choice is correct because rest, ice, compression, and elevation (RICE) helps to reduce swelling, pain, and inflammation of a sprained ankle.
Choice B Reason: This choice is incorrect because heat, massage, exercise, and immobilization (HMEI) can increase swelling, pain, and inflammation of a sprained ankle.
Choice C Reason: This choice is incorrect because flexion, extension, rotation, and stabilization (FERS) can cause further damage to a sprained ankle.
Choice D Reason: This choice is incorrect because traction, reduction, splinting, and alignment (TRSA) are not indicated for a sprained ankle.
A nurse is providing first aid to a client who has been bitten by a dog. The nurse should take which of the following actions? (Select all that apply.)
Explanation
Choice A Reason: This choice is correct because washing the wound with soap and water helps to remove dirt and bacteria and prevent infection.
Choice B Reason: This choice is incorrect because applying an antibiotic ointment to the wound may not be necessary or effective for a dog bite wound.
Choice C Reason: This choice is correct because covering the wound with a sterile dressing helps to protect it from further contamination and injury.
Choice D Reason: This choice is correct because reporting the incident to the local health department helps to track and prevent rabies transmission.
Choice E Reason: This choice is incorrect because administering rabies vaccine to the client may not be indicated or available for a dog bite wound.
A nurse is providing first aid to a client who has a head injury from falling off a ladder. The nurse should monitor the client for signs of increased intracranial pressure (ICP), such as:
Explanation
Choice A Reason: This choice is correct because headache is caused by pressure on pain-sensitive structures in the brain.
Choice B Reason: This choice is correct because dilated pupils are caused by pressure on cranial nerves that control eye movement and pupil size.
Choice C Reason: This choice is correct because slurred speech is caused by pressure on areas of the brain that control language and speech.
Choice D Reason: This choice is correct because it includes all of the signs of increased intracranial pressure (ICP) as described in the text.
A nurse is providing first aid to a client who has a sprained ankle from playing soccer. The nurse should apply which of the following interventions?
Explanation
Choice A Reason: This choice is correct because rest, ice, compression, and elevation (RICE) helps to reduce swelling, pain, and inflammation of a sprained ankle.
Choice B Reason: This choice is incorrect because heat, massage, exercise, and immobilization (HMEI) can increase swelling, pain, and inflammation of a sprained ankle.
Choice C Reason: This choice is incorrect because flexion, extension, rotation, and stabilization (FERS) can cause further damage to a sprained ankle.
Choice D Reason: This choice is incorrect because traction, reduction, splinting, and alignment (TRSA) are not indicated for a sprained ankle.
A nurse is providing first aid to a client who has been stung by a bee and has a history of severe allergic reactions. The nurse should monitor the client for signs of anaphylaxis, such as: (Select all that apply.)
Explanation
Choice A Reason: This choice is correct because difficulty breathing is caused by swelling of the airways or bronchospasm that restricts airflow.
Choice B Reason: This choice is correct because swelling of face, lips, tongue, or throat is caused by fluid accumulation in the tissues that can block the airway.
Choice C Reason: This choice is correct because hives or itching are caused by histamine release that triggers an inflammatory response in the skin.
Choice D Reason: This choice is correct because nausea or vomiting are caused by histamine release that affects the gastrointestinal tract.
Choice E Reason: This choice is correct because dizziness or fainting are caused by low blood pressure or reduced blood flow to the brain.
A nurse is using an AED on a child who has ventricular fibrillation. The nurse should use which of the following types of AED pads?
Explanation
Choice A Reason: This choice is incorrect because adult pads are too large for a child's chest and may deliver too much electricity, which can damage the heart.
Choice B Reason: This choice is correct because child pads are specially designed for children between 1 and 8 years old and deliver a lower dose of electricity than adult pads.
Choice C Reason: This choice is incorrect because infant pads are too small for a child's chest and may not deliver enough electricity, which can fail to restart the heart.
Choice D Reason: This choice is incorrect because using any pads may not be appropriate or effective for a child's chest size and heart condition.
A nurse is providing CPR to an infant who has no pulse and is not breathing. The nurse should give two breaths by:
Explanation
Choice A Reason: This choice is incorrect because pinching the nose shut may obstruct the airway or cause air leakage.
Choice B Reason: This choice is correct because opening the mouth and sealing the mouth over both mouth and nose allows the nurse to deliver adequate ventilation to an infant's small airway.
Choice C Reason: This choice is incorrect because opening both mouth and nose may cause air leakage or reduce the pressure of ventilation.
Choice D Reason: This choice is incorrect because pinching both mouth and nose shut may obstruct the airway or cause trauma to the tissues.
A nurse is caring for a client who has an abdominal stab wound. The nurse notes that there is bright red blood spurting from the wound site. Which of the following actions should the nurse take? (Select all that apply.)
Explanation
Choice A Reason: Applying direct pressure over the wound site with a sterile gauze pad can help control the bleeding by compressing the blood vessels. This is an appropriate action for arterial bleeding, which is bright red and spurts from a wound.
Choice B Reason: Elevating the client's legs above the level of the heart can help increase venous return and cardiac output, but it is not recommended for abdominal injuries, as it can increase intra-abdominal pressure and worsen bleeding or organ damage.
Choice C Reason: Applying ice packs around the wound site can help reduce inflammation and pain, but it is not recommended for bleeding wounds, as it can cause vasoconstriction and impair blood flow to the injured area.
Choice D Reason: Covering the wound site with an occlusive dressing can help prevent air from entering the abdominal cavity and causing a pneumoperitoneum, which can impair breathing and circulation. This is an appropriate action for penetrating wounds, such as stab wounds.
Choice E Reason: Checking the client's distal pulses frequently can help monitor the perfusion of the extremities and detect signs of shock or compartment syndrome. Shock is a condition in which there is inadequate tissue perfusion due to blood loss or other causes. Compartment syndrome is a condition in which there is increased pressure within a muscle compartment due to swelling or bleeding, which can compromise blood flow and nerve function.
A nurse is caring for a client who has a pressure ulcer on the sacrum. The nurse observes that the wound has yellow slough, red granulation tissue, and black eschar. The nurse should use which of the following types of dressings to debride the wound?
Explanation
Choice A Reason: Hydrogel dressings are water-based gels that provide moisture and hydration to the wound bed. They are suitable for wounds that are dry and have minimal drainage, such as partial-thickness burns or radiation injuries.
Choice B Reason: Foam dressings are soft, absorbent pads that provide cushioning and insulation to the wound bed. They are suitable for wounds that have moderate to heavy drainage, such as venous ulcers or surgical wounds.
Choice C Reason: Alginate dressings are fiber-based dressings that form a gel when in contact with wound exudate. They are suitable for wounds that have heavy drainage or bleeding, such as diabetic ulcers or arterial ulcers.
Choice D Reason: Enzymatic dressings are topical agents that contain enzymes that break down necrotic tissue and slough in the wound bed. They are suitable for wounds that have mixed necrotic and viable tissue, such as pressure ulcers with yellow slough, red granulation tissue, and black eschar.
A nurse is caring for a client who has a surgical wound on the abdomen. The nurse notes that the wound edges are separated and there is pink, shiny tissue protruding from the wound. The nurse should document this finding as which of the following types of wound dehiscence?
Explanation
Choice A Reason: Partial-thickness wound dehiscence is a type of wound dehiscence in which the wound edges separate but only involve the epidermis and dermis layers of the skin. The wound bed is usually moist and red, but there is no organ protrusion.
Choice B Reason: Full-thickness wound dehiscence is a type of wound dehiscence in which the wound edges separate and involve all layers of the skin and underlying tissues. The wound bed may have granulation tissue or necrotic tissue, but there is no organ protrusion.
Choice C Reason: Evisceration is a type of wound dehiscence in which the wound edges separate and the visceral organs protrude from the wound. This is a medical emergency that requires immediate intervention to prevent organ damage and infection.
Choice D Reason: Infection is not a type of wound dehiscence, but it can be a cause or a complication of wound dehiscence. Signs of infection include fever, pain, swelling, redness, warmth, pus, or foul odor.
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