ATI- MED SURG PROCTORED PRACTICE QUESTIONS & ANSWERS (Chapter 2 to 8) (NEWEST, 100% CORRECT)

Chapter2: Emergency Nursing Principles and Management 1. What are the five level system of triage? a. Level 1: Resuscitation b. Level 2: Emergent c. Level 3: Urgent d. Level 4: Less urgent e. Level 5: Nonurgent 2. Resuscitation requires what? a. Immediate treatment to prevent death 3. What is required for nonurgent triage (level 5)? a. Non life threatening condition requiring simple evaluation and care management 4. What is the standard precaution for primary survey during triage? a. Gloves b. Gowns c. Eye protection d. Face masks e. Shoe covers f. ABCDE  guides the primary survey 5. What is the ABCDE principle? a. Airway/Cervical Spine  brain injury/death = 3-5 min. if airway not patent. b. Breathing  assess presence & effectiveness of breathing. c. Circulation d. Disability e. Exposure 6. How to implement airway for patients who is unresponsive without suspicious of trauma? a. Airway opened  head tilt, chin lift maneuver 7. How to implement airway for patients who is unresponsive WITH suspicious trauma? a. Airway opened  modified jaw thrust maneuver 8. How is the modified jaw thrust maneuver performed? a. Nurse place both hands on either side of the client’s head. Locate the connection between maxilla and mandible. Lift the jaw superiorly while maintaining alignment of the cervical spine. 9. During triage, what mask is given to patient who are spontaneously breathing? a. Non-breather mask with 100% O2 source 10. What does the breathing assessment include? a. Auscultation of breath sounds b. Observation of chest expansion and respiratory effort c. Notation of rate and depth of respiration d. Identification of chest trauma e. Assessment of tracheal position f. Assessment of JVD 11. How to assess for circulation? a. Nurse assess HR, BP, peripheral pulses, and capillary refill for adequate perfusion. 12. What are the precursor to shock that nurses need to be aware of? a. Cardiac arrest b. Myocardial dysfunction c. Hemorrhage 13. What are some interventions that is geared toward restoring effective circulation? a. CPR b. Assess for external bleeding. c. Hemorrhage control d. Obtain IV access using large-bore IV catheters inserted into the antecubital fossa of both arms, unless there is obvious injury to the extremity. e. Infuse isotonic IV fluids such as Lactated Ringer’s & 0.9% NaCl &/or Blood products. 14. What is shock? a. Body response to inadequate tissue perfusion and oxygenation. It manifests with an increase HR, hypotension and result in tissue ischemia and necrosis. 15. What are some intervention that can alleviate shock? a. Administer oxygen b. Apply pressure to obvious bleeding c. Elevate lower extremities to shunt blood to vital organs d. Administer IV fluids and blood products e. Monitor VS f. Remain with client and provide reassurance and support for anxiety. 16. What is the D portion of the ABCDE protocol during triage? a. Disability  quick assessment to determine clients LOC b. Ex: AVPU (Alert, Response to Voice, Responsive to pain, Unresponsive), GCS 17. What is the E portion of the ABCDE protocol during triage? a. Exposure 18. What is the primary concern during the exposure phase during triage? a. Hypothermia  pt. core temperature 35 degree Celsius (95-degree F.) or less. i. Why hypothermia for trauma patients? Exposure, un-warmed oxygen, cold IV fluids 19. What can hypothermia eventually lead to? a. Coma, hypoxemia, and acidosis 20. What is a contraindication in the first 6-8 hours after the bite (poisoning)? a. Ice b. Tourniquets c. Heparin d. Corticosteroids 21. Antivenom is effective when? a. Within 4-12 hour and is based on type and severity of a snake bite 22. What is considered cardiac emergency? a. Cardiac arrest b. V. Fib c. Pulseless V. tach. d. V. Asystole e. Pulseless electrical activity (PEA) 23. What is a cardiac arrest? a. Sudden cessation of cardiac function causes most commonly by V. fib. or V. sys. 24. What is Ventricular fibrillation? a. Fluttering of the ventricles causing LOC, pulselessness, no breathing. Requires collaborative care to defibrillate immediately using ACLS protocol. 25. What is pulseless V. tach.? a. Irritable firing of ectopic ventricular beats at a rate of 140 to 180/min. b. Pt. overtime become unconscious and deteriorate into V. fib. 26. What is v. asystole? a. Complete absence of electrical activity and ventricular mvmt of heart. b. Pt. complete cardiac arrest  requires implementation of BLS/ACLS protocol. 27. What is pulseless electrical activity (PEA)? a. Rhythm appears to have electrical activity but is not sufficient to stimulate effective cardiac contractions and requires implementation of BLS/ACLS protocol 28. What are the most common causes of pulseless electrical activity? 29. What is an Alpha-1 Receptor site? a. Activation of receptors in the arterioles of skin, viscera, mucous membranes, veins  vasoconstriction 30. What is Beta-1 Receptor site? a. Heart stimulation leads to increased HR, increased myocardial contractility, increased rate of conduction through the AV node b. Activation of receptors in the kidney  release of renin 31. What is a Beta-2 receptor site? a. Bronchial stimulation  bronchodilation b. Activation of receptors in uterine smooth muscle  relaxation c. Activation of receptors in the liver  breakdown of glycogen into glucose d. Skeletal muscle receptor activation  muscle contraction  tremors 32. What is a dopamine receptor site? a. Activation of receptors in the kidney  renal blood vessels to dilate. 33. What is the AHA ACLS protocol for VF or pulseless VT? a. Initiate CPR BLS b. Defibrillate c. IV access d. Administer IV  antidysrhythmic medication  epi. & vasopressin e. Amioda...

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