NSG 233 Final Exam (Herzing University) –
Questions With Expert Solutions
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Terms in this set (123)
Primary Survey (ABCs + DE)
A nurse arrives at the scene of a B) Perform a jaw-thrust maneuver
motor vehicle crash and finds an
unconscious patient lying supine. The Rationale: Snoring respirations indicate partial airway
patient has snoring respirations. What obstruction, likely from the tongue falling back. In a
is the nurse's FIRST action? trauma patient, use the jaw-thrust maneuver to open
the airway while maintaining cervical spine
A) Insert an oropharyngeal airway protection. This is the least invasive intervention and
B) Perform a jaw-thrust maneuver should be attempted first before inserting artificial
C) Begin suctioning the airway airways.
D) Prepare for endotracheal
intubation
A stroke patient is comatose and at C) Either oropharyngeal or nasopharyngeal airway
risk for airway obstruction. Which
airway adjunct should the nurse Rationale: An oropharyngeal airway in a comatose
anticipate using? patient may prevent the tongue from falling back and
obstructing the airway and provide access for
A) Nasopharyngeal airway only suctioning. Alternatively, a nasopharyngeal airway
B) Oropharyngeal airway only may be used to provide airway protection and
C) Either oropharyngeal or access. Both are appropriate for maintaining airway
nasopharyngeal airway patency in unconscious patients.
D) Immediate endotracheal intubation
,A patient with a laryngectomy has B) 10 seconds
thick, blood-tinged secretions. The
nurse prepares to suction via the Rationale: Limit each suctioning pass to 10 seconds
tracheostomy. What is the maximum or less to prevent hypoxemia. Always
time for each suctioning pass? hyperoxygenate the patient before and after each
suctioning pass. Monitor SpO₂ and vital signs closely
A) 5 seconds during the procedure, and stop immediately if the
B) 10 seconds patient does not tolerate suctioning.
C) 15 seconds
D) 20 seconds
Which patient requires a C) Patient requiring an artificial airway for a
tracheostomy for prolonged airway prolonged time
management?
Rationale: When an artificial airway is needed for a
A) Patient needing mechanical prolonged time, a tracheostomy may be done. This is
ventilation for 24 hours more comfortable for long-term use than
B) Patient with temporary airway endotracheal intubation and reduces complications
edema C) Patient requiring an artificial associated with prolonged intubation.
airway for a prolonged time
D) Patient with mild respiratory
distress
A nurse is performing a primary survey B) Paradoxical chest wall movement
on a trauma patient. Which respiratory
assessment finding requires Rationale: Paradoxical or asymmetric chest wall
IMMEDIATE intervention? movement is a sign of a life-threatening breathing
problem such as flail chest. This finding, along with
A) Respiratory rate of 22 breaths/min dyspnea, decreased or absent breath sounds on the
B) Paradoxical chest wall movement affected side, visible wounds to the chest wall,
C) Decreased breath sounds at the cyanosis, tachycardia, and hypotension indicates
lung bases severe compromise to ventilation requiring
D) Use of accessory muscles during immediate intervention.
breathing
,A patient arrives at the ED after a B) Administer high-flow oxygen (100%) via
stabbing injury to the chest. The nurse nonrebreather mask
notes absent breath sounds on the
right side, severe dyspnea, and Rationale: Every critically injured or ill patient has
hypotension. What is the priority increased metabolic and oxygen demand and should
intervention? receive supplemental oxygen. Give high-flow oxygen
(100%) via a nonrebreather mask and monitor the
A) Obtain a stat chest x-ray patient's response. The patient's symptoms suggest
B) Administer high-flow oxygen (100%) tension pneumothorax, but oxygen administration is
via nonrebreather mask the immediate priority while preparing for definitive
C) Position the patient in high Fowler's treatment (needle decompression or chest tube).
D) Prepare for chest tube insertion
During the breathing assessment, the B) Chest symmetry and movement
nurse observes a respiratory rate of 26
breaths/min with decreased breath Rationale: When assessing breathing, evaluate
sounds on the right side. The patient respiratory rate, depth, and symmetry of chest wall
has visible chest trauma. What should movement. Asymmetric chest wall movement
the nurse assess NEXT? combined with decreased breath sounds on the
affected side may indicate pneumothorax,
A) Pain level hemothorax, or flail chest requiring immediate
B) Chest symmetry and movement intervention.
C) Oxygen saturation
D) Blood pressure
A nurse is performing a primary survey B) Establish the patient's level of consciousness
on a trauma patient in the emergency
department. Which action should the Rationale: The ABCDE approach begins with A =
nurse take FIRST? Alertness and Airway. The patient's alertness level is
crucial for choosing appropriate airway interventions.
A) Assess for breath sounds bilaterally Use the AVPU mnemonic (Alert, responsive to Voice,
B) Establish the patient's level of responsive to Pain, Unresponsive) to quickly assess
consciousness level of consciousness while simultaneously
C) Check for a carotid pulse assessing airway patency.
D) Apply a cervical collar
, A patient in respiratory distress can B) Moderate to severe dyspnea
only say 2-3 words before pausing to
breathe. What does this finding Rationale: The ability to speak is related to the
indicate? severity of dyspnea. "2-word" or "3-word" dyspnea
indicates the patient can only say 2-3 words before
A) Mild respiratory distress pausing to breathe, signifying moderate to severe
B) Moderate to severe dyspnea respiratory distress requiring immediate intervention.
C) Impending respiratory arrest
D) Normal breathing pattern
A nurse assesses a trauma patient and B) Insert two large-bore (14- to 16-gauge) IV
finds a weak, thready carotid pulse at catheters
130 bpm, cool and mottled skin, and
delayed capillary refill of 5 seconds. Rationale: This addresses C = Circulation and Control
What is the priority nursing action? of Hemorrhage. The patient shows signs of shock
(tachycardia, altered skin perfusion, delayed capillary
A) Apply warm blankets to the patient refill >3 seconds). Priority is establishing vascular
B) Insert two large-bore (14- to 16- access with 2 large-bore IV catheters in the upper
gauge) IV catheters extremities to begin aggressive fluid resuscitation
C) Obtain a full set of vital signs with normal saline or lactated Ringer's solution.
D) Assess for internal bleeding
sources
When assessing circulation during the B) Check for a femoral or carotid pulse
primary survey, the nurse finds no
peripheral pulses in the patient's Rationale: Peripheral pulses may be absent due to
extremities. What should the nurse do direct injury or vasoconstriction, not necessarily
NEXT? cardiac arrest. The nurse should assess central pulses
(femoral or carotid) to determine if circulation is
A) Document absent peripheral pulses present before taking further action.
and notify the provider
B) Check for a femoral or carotid
pulse C) Begin chest compressions
immediately
D) Elevate the patient's legs
Questions With Expert Solutions
Save Groups
Terms in this set (123)
Primary Survey (ABCs + DE)
A nurse arrives at the scene of a B) Perform a jaw-thrust maneuver
motor vehicle crash and finds an
unconscious patient lying supine. The Rationale: Snoring respirations indicate partial airway
patient has snoring respirations. What obstruction, likely from the tongue falling back. In a
is the nurse's FIRST action? trauma patient, use the jaw-thrust maneuver to open
the airway while maintaining cervical spine
A) Insert an oropharyngeal airway protection. This is the least invasive intervention and
B) Perform a jaw-thrust maneuver should be attempted first before inserting artificial
C) Begin suctioning the airway airways.
D) Prepare for endotracheal
intubation
A stroke patient is comatose and at C) Either oropharyngeal or nasopharyngeal airway
risk for airway obstruction. Which
airway adjunct should the nurse Rationale: An oropharyngeal airway in a comatose
anticipate using? patient may prevent the tongue from falling back and
obstructing the airway and provide access for
A) Nasopharyngeal airway only suctioning. Alternatively, a nasopharyngeal airway
B) Oropharyngeal airway only may be used to provide airway protection and
C) Either oropharyngeal or access. Both are appropriate for maintaining airway
nasopharyngeal airway patency in unconscious patients.
D) Immediate endotracheal intubation
,A patient with a laryngectomy has B) 10 seconds
thick, blood-tinged secretions. The
nurse prepares to suction via the Rationale: Limit each suctioning pass to 10 seconds
tracheostomy. What is the maximum or less to prevent hypoxemia. Always
time for each suctioning pass? hyperoxygenate the patient before and after each
suctioning pass. Monitor SpO₂ and vital signs closely
A) 5 seconds during the procedure, and stop immediately if the
B) 10 seconds patient does not tolerate suctioning.
C) 15 seconds
D) 20 seconds
Which patient requires a C) Patient requiring an artificial airway for a
tracheostomy for prolonged airway prolonged time
management?
Rationale: When an artificial airway is needed for a
A) Patient needing mechanical prolonged time, a tracheostomy may be done. This is
ventilation for 24 hours more comfortable for long-term use than
B) Patient with temporary airway endotracheal intubation and reduces complications
edema C) Patient requiring an artificial associated with prolonged intubation.
airway for a prolonged time
D) Patient with mild respiratory
distress
A nurse is performing a primary survey B) Paradoxical chest wall movement
on a trauma patient. Which respiratory
assessment finding requires Rationale: Paradoxical or asymmetric chest wall
IMMEDIATE intervention? movement is a sign of a life-threatening breathing
problem such as flail chest. This finding, along with
A) Respiratory rate of 22 breaths/min dyspnea, decreased or absent breath sounds on the
B) Paradoxical chest wall movement affected side, visible wounds to the chest wall,
C) Decreased breath sounds at the cyanosis, tachycardia, and hypotension indicates
lung bases severe compromise to ventilation requiring
D) Use of accessory muscles during immediate intervention.
breathing
,A patient arrives at the ED after a B) Administer high-flow oxygen (100%) via
stabbing injury to the chest. The nurse nonrebreather mask
notes absent breath sounds on the
right side, severe dyspnea, and Rationale: Every critically injured or ill patient has
hypotension. What is the priority increased metabolic and oxygen demand and should
intervention? receive supplemental oxygen. Give high-flow oxygen
(100%) via a nonrebreather mask and monitor the
A) Obtain a stat chest x-ray patient's response. The patient's symptoms suggest
B) Administer high-flow oxygen (100%) tension pneumothorax, but oxygen administration is
via nonrebreather mask the immediate priority while preparing for definitive
C) Position the patient in high Fowler's treatment (needle decompression or chest tube).
D) Prepare for chest tube insertion
During the breathing assessment, the B) Chest symmetry and movement
nurse observes a respiratory rate of 26
breaths/min with decreased breath Rationale: When assessing breathing, evaluate
sounds on the right side. The patient respiratory rate, depth, and symmetry of chest wall
has visible chest trauma. What should movement. Asymmetric chest wall movement
the nurse assess NEXT? combined with decreased breath sounds on the
affected side may indicate pneumothorax,
A) Pain level hemothorax, or flail chest requiring immediate
B) Chest symmetry and movement intervention.
C) Oxygen saturation
D) Blood pressure
A nurse is performing a primary survey B) Establish the patient's level of consciousness
on a trauma patient in the emergency
department. Which action should the Rationale: The ABCDE approach begins with A =
nurse take FIRST? Alertness and Airway. The patient's alertness level is
crucial for choosing appropriate airway interventions.
A) Assess for breath sounds bilaterally Use the AVPU mnemonic (Alert, responsive to Voice,
B) Establish the patient's level of responsive to Pain, Unresponsive) to quickly assess
consciousness level of consciousness while simultaneously
C) Check for a carotid pulse assessing airway patency.
D) Apply a cervical collar
, A patient in respiratory distress can B) Moderate to severe dyspnea
only say 2-3 words before pausing to
breathe. What does this finding Rationale: The ability to speak is related to the
indicate? severity of dyspnea. "2-word" or "3-word" dyspnea
indicates the patient can only say 2-3 words before
A) Mild respiratory distress pausing to breathe, signifying moderate to severe
B) Moderate to severe dyspnea respiratory distress requiring immediate intervention.
C) Impending respiratory arrest
D) Normal breathing pattern
A nurse assesses a trauma patient and B) Insert two large-bore (14- to 16-gauge) IV
finds a weak, thready carotid pulse at catheters
130 bpm, cool and mottled skin, and
delayed capillary refill of 5 seconds. Rationale: This addresses C = Circulation and Control
What is the priority nursing action? of Hemorrhage. The patient shows signs of shock
(tachycardia, altered skin perfusion, delayed capillary
A) Apply warm blankets to the patient refill >3 seconds). Priority is establishing vascular
B) Insert two large-bore (14- to 16- access with 2 large-bore IV catheters in the upper
gauge) IV catheters extremities to begin aggressive fluid resuscitation
C) Obtain a full set of vital signs with normal saline or lactated Ringer's solution.
D) Assess for internal bleeding
sources
When assessing circulation during the B) Check for a femoral or carotid pulse
primary survey, the nurse finds no
peripheral pulses in the patient's Rationale: Peripheral pulses may be absent due to
extremities. What should the nurse do direct injury or vasoconstriction, not necessarily
NEXT? cardiac arrest. The nurse should assess central pulses
(femoral or carotid) to determine if circulation is
A) Document absent peripheral pulses present before taking further action.
and notify the provider
B) Check for a femoral or carotid
pulse C) Begin chest compressions
immediately
D) Elevate the patient's legs
