Emergency Nursing Practice Questions

The client in a code is now diagnosed with ventricular bigeminy. The HCP orders a lidocaine drip at 3 mg/min. The lidocaine comes prepackaged with 2 grams of lidocaine in 500 mL of D5W. At which rate will the nurse set the infusion pump?

Answer: 45 mL/hr The test taker could remember the mnemonic, which is "For 1 mg, 2 mg, 3 mg, 4 mg the rate is 15 mL, 30 mL, 45 mL, 60 mL." If the test taker has not memorized it, it is too late to figure it out in an emergency situation. But for math purposes: First determine the number of milligrams of lidocaine in the 500 mL of D5W: 2 g × 1,000 mg = 2,000 mg per 500 mL Then determine how many milligrams per milliliters: 2,000 mg ÷ 500 mL = ÷ mg/mL Then find out how many milliliters must be infused per minute to give the ordered dose of 3 mg/min. In algebraic terms: 4 mg : 1 mL = 3 mg : x mL Cross multiply and divide: x = 3/4 or 0.75 The number of milliliters to be infused in a minute is 3/4 mL or 0.75. The infusion pump is set at an hourly rate, so multiply 3/4 by 60 minutes: 3/4 × 60 = 45 The pump should be set at 45 mL/hr to infuse 3 mg/min. TEST-TAKING HINT: The test taker must be familiar with basic nursing math and become comfortable with the equations the test taker uses to compute dosage calculations.

The charge nurse is making assignments. Which client should be assigned to the most experienced nurse? 1. The client diagnosed with a snake bite receiving antivenin. 2. The client who swallowed a lye preparation and is being discharged. 3. The angry client following a failed suicide attempt. 4. The client requiring skin grafting after a chemical spill.

Answer: 1 1. Before administering antivenin, the affected body part must be measured. The infusion is begun slowly and increased after 10 minutes. The affected part is measured every 30 to 60 minutes after the infusion and for 48 hours to detect symptoms of compartment syndrome (edema, loss of pulse, increased pain, and paresthesias). Allergic reactions to the antivenin are not uncommon and are usually the result of a too-rapid infusion of the antivenin. The most experienced nurse should be assigned to this client. 2. This client is beyond critical danger and is being discharged, so a less-experienced nurse could care for this client. 3. This client has many needs, but anger is not a priority over a physiological need. 4. A less-experienced nurse could care for this client. TEST-TAKING HINT: The test taker can rule out options "2" and "3" because of the discharge information and psychosocial versus physiological problem.

Which situation requires the emergency department manager to schedule and conduct a Critical Incident Stress Management (CISM)? 1. Caring for a 2-year-old child who died from severe physical abuse. 2. Performing unsuccessful CPR on a middle-aged male executive. 3. Responding to a 22-victim bus accident with no apparent fatalities. 4. Being required to work 16 hours without taking a break.

Answer: 1 1. CISM is an approach to preventing and treating the emotional trauma affecting emergency responders as a consequence of their job. Performing CPR and treating a young child affects the emergency personnel psychologically, and the death increases the traumatic experience. 2. Caring for this type of client is an expected part of the job. If the nurse finds this traumatic enough to require a CISM, then the nurse should probably leave the emergency department. 3. This requires an intense time for triaging and caring for the victims, but without fatalities, this should not be as traumatic for the staff. 4. This is a dangerous practice because medication errors and other mistakes may occur as a result of fatigue, but this is not a traumatic situation. TEST-TAKING HINT: The test taker should examine the words "critical," "incident," and "stress." Each option should be examined to determine which is the most traumatic. Needless deaths of children are psychologically traumatic.

The client abused as a child is diagnosed with post-traumatic stress disorder (PTSD). Which intervention should the nurse implement when the client is resting? 1. Call the client's name to awaken him or her, but don't touch the client. 2. Touch the client gently to let him or her know you are in the room. 3. Enter the room as quietly as possible to not disturb the client. 4. Do not allow the client to be awakened at all when sleeping.

Answer: 1 1. Clients diagnosed with PTSD are easily startled and can react violently if awakened from sleep by being touched. 2. Touching the client can cause the client to become afraid, to feel under attack, and to react violently. The nurse should not touch a sleeping client diagnosed with PTSD. 3. If the client awakes with the nurse in the room, the client could become fearful and react to the fear. 4. There may be times when the nurse must awaken the client to determine if the client is physically stable. TEST-TAKING HINT: Option "4" can be eliminated because of the absolute statement "at all." Options "2" and "3" can be eliminated if the test taker thinks of how it feels to be startled when perceiving another person around him or her when the test taker was not aware of the other person's presence.

Which statement explains the scientific rationale for having emergency suction equipment available during resuscitation efforts? 1. Gastric distention can occur as a result of ventilation. 2. It is needed to assist when intubating the client. 3. This equipment will ensure a patent airway. 4. It keeps the vomitus away from the healthcare provider.

Answer: 1 1. Gastric distention occurs from over ventilating clients. When compressions are performed, the pressure will cause vomiting, which may cause aspiration into the lungs. 2. The HCP does not require suctioning equipment to intubate. 3. Nothing ensures a patent airway, except a correctly inserted endotracheal tube, and suction is needed to clear the airway. 4. Suction equipment is for the client's needs, not the HCP's needs. TEST-TAKING HINT: Option "4" could be eliminated because the equipment is for the client, not for the nurse or HCPs. The word "ensures" in option "3" is an absolute word, so the test taker should be cautious before selecting this option.

The health-care facility has been notified an alleged inhalation anthrax exposure has occurred at the local post office. Which category of personal protective equipment (PPE) should the response team wear? 1. Level A. 2. Level B. 3. Level C. 4. Level D.

Answer: 1 1. Level A protection is worn when the highest level of respiratory, skin, eye, and mucous membrane protection is required. In this situation of possible inhalation of anthrax, such protection is required. 2. Level B protection is similar to Level A protection, but it is used when a lesser level of skin and eye protection is needed. 3. Level C protection requires an air-purified respirator (APR), which uses filters or absorbent materials to remove harmful substances. 4. Level D is basically the work uniform. TEST-TAKING HINT: If the test taker were totally unaware of the correct answer, then the choice should be either option "1" or option "4" because these are at either end of the spectrum. This gives the test taker a 50/50 chance of selecting the correct answer, instead of a 25% chance.

The nurse working in a homeless shelter identifies an adolescent female acting sexually aggressive toward some of the males in the shelter. Which is the most common cause for this behavior? 1. The client is acting in a learned behavior pattern to get attention. 2. The client had to leave home because of promiscuous behavior. 3. The client has a psychiatric disorder called nymphomania. 4. The client is a prostitute and is trying to get customers.

Answer: 1 1. Research suggests at least 67% of runaways or homeless adolescents have been abused in the home. This represents a learned behavior pattern getting the female adolescent attention. 2. One reason adolescents of both sexes run away from home is abuse in the home. Nothing in the stem indicates the client was turned out of the home for any behavior. 3. This has the nurse medically diagnosing the client. 4. This is a judgmental statement. TEST-TAKING HINT: The test taker should not read into the question or choose an option allowing the nurse to function outside the scope of practice. Option "2" is assuming facts not in the stem, and option "3" is asking the nurse to make a medical diagnosis.

The registered nurse (RN) and an unlicensed assistive personnel (UAP) are caring for a group of clients on a medical floor. Which action by the UAP warrants intervention by the RN? 1. The UAP places a urine specimen in a biohazard bag in the hallway. 2. The UAP uses the alcohol foam hand cleanser after removing gloves. 3. The UAP puts soiled linen in a plastic bag in the client's room. 4. The UAP obtains a disposable stethoscope for a client in an isolation room.

Answer: 1 1. Specimens should be put into biohazard bags before leaving the client's room. 2. This is the appropriate way to clean hands and does not warrant intervention. 3. This is the appropriate way to dispose of soiled linens and does not warrant intervention. 4. Taking a stethoscope from a client in isolation to another room is a violation of infection-control principles. TEST-TAKING HINT: This is an "except" question. The stem is asking which action warrants intervention; therefore, the test taker must select the option indicating an inappropriate action by the unlicensed assistive personnel.

Which situation warrants the nurse obtaining information from a material safety data sheet (MSDS)? 1. The custodian spilled a chemical solvent in the hallway. 2. A visitor slipped and fell on the floor that had just been mopped. 3. A bottle of antineoplastic agent broke on the client's floor. 4. The nurse was stuck with a contaminated needle in the client's room.

Answer: 1 1. The MSDS provides chemical information regarding specific agents, health information, and spill information for a variety of chemicals. It is required for every chemical found in the hospital. 2. This situation requires an occurrence or accident report. 3. Any facility administering antineoplastic agents (medications used to treat cancer) is required to have specific chemotherapy spill kits available and a policy and procedure included; in this situation, the nurse already knows the chemical involved. 4. This requires a hospital variance report and notifying the employee health or infection-control nurse. TEST-TAKING HINT: If the test taker were not aware of an MSDS, the name tells the test taker to look for content in the answer options addressing materials; therefore, options "2" and "4" could be eliminated as possible answers.

Which health-care team member referral should be made by the nurse when a code is being conducted on a client in a community hospital? 1. The hospital chaplain. 2. The social worker. 3. The respiratory therapist. 4. The director of nurses.

Answer: 1 1. The chaplain should be called to help address the client's family or significant others. A small community hospital does not have a 24-hour on-duty pastoral service. A chaplain is part of the code team in large medical center hospitals. 2. The social worker does not need to be notified of a code. 3. The respiratory therapist responds to the code automatically without a referral. The respiratory therapist is part of the code team, and one is on duty 24 hours a day, even in a small community hospital. 4. The director of nurses does not need to be notified of codes, but possibly the house supervisor should be notified. TEST-TAKING HINT: The test taker must know the roles of the multidisciplinary health-care team to make appropriate referrals. The words "community hospital" are an important phrase to help determine the correct answer.

The nurse is preparing to administer medications to a newly admitted client with a hemoglobin of 5.3 g/mL. Which medication should the nurse administer first? Diagnosis: GI Bleed - Normal Saline 1,000 mL (150 mL per hour) continuous - Packed red blood cells (2 units); administer over 2 hours each unit - Furosemide 40 mg between units - Diphenhydramine 50 mg IVP before each unit of PRBCs 1. Normal saline. 2. Packed red blood cells unit #1. 3. Furosemide. 4. Diphenhydramine.

Answer: 1 1. The normal saline can be initiated to maintain the client's circulatory status while the packed red blood cells (PRBCs) are cross-matched. 2. The PRBCs are the third order to initiate. 3. Furosemide is not to be administered until after the client has received the first unit of PRBCs. 4. Diphenhydramine is the second order to initiate because it is to be administered before the PRBCs. TEST-TAKING HINT: After looking at all the options, the test taker should select the option that best addresses the entire situation. This client has perfusion and hematological regulation issues.

The nurse is working at a facility where a client diagnosed with Ebola has been admitted. Which action should the nurse take? 1. Consult the nurse manager regarding the infection-control standards to follow. 2. Resign immediately and leave the facility. 3. Watch the television news reports to identify which station has the client. 4. Participate in a news report about the quality of care provided at the hospital.

Answer: 1 1. The nurse should not panic but follow the infection-control procedures as guided by the Centers for Disease Control (CDC). 2. This is not a professional response to a public health issue. The best action the nurse can take is to follow the procedure and remain calm. 3. Television news reports are frequently inaccurate and biased. 4. The nurse should not discuss hospital situations in a public venue; rather, the nurse should refer the news reporter to the Public Relations Officer for the hospital. TEST-TAKING HINT: After looking at all the options, the test taker should select the option that best assesses the entire situation, which is the following of policy. There will be a tendency for mass hysteria to occur in the community, but the CDC has plans for this type of emergency.

The male client presents to the emergency department stating he vomited a "large" amount of bright red blood. Which should the RN implement first? 1. Start an intravenous line with an 18-gauge needle. 2. Have the UAP take the client's vital signs. 3. Ask the client to provide a stool specimen for blood. 4. Send the client to radiology for an abdominal CT scan.

Answer: 1 1. The nurse should start an intravenous line with a large-bore needle to administer fluids and blood if needed. This client may need a rapid replacement of fluid volume. 2. The nurse must assess the client to determine if the client is stable or unstable before being able to delegate this task to a UAP. 3. This will be done, but not first. 4. The nurse must assess the client to determine if the client is stable or unstable before allowing the client to go to the radiology department. TEST-TAKING HINT: The nurse should initiate an IV because in an emergency, this, followed with rapid fluid replacement, can stabilize an unstable client. Then the nurse must determine if the client is stable before delegating activities or allowing the client to leave the ED.

Which is the primary goal of the ED nurse in caring for a poison ingestion client? 1. Remove or inactivate the poison before it is absorbed. 2. Provide long-term supportive care to prevent organ damage. 3. Administer an antidote to increase the effects of the poison. 4. Implement treatment prolonging the elimination of the poison.

Answer: 1 1. The primary goal for the ED nurse is to stop the action of the poison and then maintain organ functioning. 2. ED nurses do not provide long-term care. 3. Antidotes are administered to neutralize the effects of poisons, not to increase the effects. 4. Treatment is implemented to hasten the elimination of the poison. TEST-TAKING HINT: The test taker should read each option carefully. ED nurse and "long-term care" don't match. Increasing the effects and prolonging the elimination of the poison is damaging to the client.

A vat of chemicals spilled onto the client. Which action should the occupational health nurse implement first? 1. Have the client stand under a shower while removing all clothes. 2. Check the material safety data sheets for the antidote. 3. Administer oxygen by nasal cannula. 4. Collect a sample of the chemicals in the vat for analysis.

Answer: 1 1. The skin should be immediately drenched with water from a hose or shower. A constant stream of water is applied. Time should not be lost by removing the clothes first and then proceeding to rinse with water. If a dry powder form of white phosphorus or lye spilled onto the client, it is brushed off and then the client is placed under the shower. 2. The first action is to remove the poison from the client's skin and prevent further damage. 3. If the client becomes dyspneic, the nurse administers oxygen while waiting for the paramedics. 4. The vat should be labeled as to the chemical contents per Occupational Safety and Health Administration (OSHA) regulations, but if not, the nurse must determine which chemicals are in the vat so the HCP can treat the client appropriately. TEST-TAKING HINT: Usually, oxygen is a priority, but in this scenario, the client has dangerous chemicals on the skin. The stem did not tell the test taker the respirations were a problem. It is important not to read into a question.

The client is admitted into the emergency department with diaphoresis, pale clammy skin, and BP of 90/70. Which intervention should the nurse implement first? 1. Start an IV with an 18-gauge catheter. 2. Administer intravenous dopamine infusion. 3. Obtain arterial blood gases (ABGs). 4. Insert an indwelling urinary catheter.

Answer: 1 1. There are many types of shock, but the one common intervention that should be done first in all types of shock is to establish an intravenous line with a large-bore catheter. The low blood pressure and cold, clammy skin indicate shock. 2. This blood pressure does not require dopamine; fluid resuscitation is first. 3. The client may need ABGs monitored, but this is not the first intervention. 4. An indwelling catheter may need to be inserted for accurate measurement of output, but it is not the first intervention. TEST-TAKING HINT: This question asks for the first intervention, which means all options may be appropriate interventions for the client, but only one should be implemented first. Remember: When the client is in distress, do not assess.

The CPR instructor is discussing an automated external defibrillator (AED) during class. Which statement best describes an AED? 1. It analyzes the rhythm and shocks the client diagnosed with ventricular fibrillation. 2. The client will be able to have synchronized cardioversion with the AED. 3. It will keep the health-care provider informed of the client's oxygen level. 4. The AED will perform cardiac compressions on the client.

Answer: 1 1. This is the correct statement explaining what an AED does when used in a code. 2. The defibrillator on the crash cart must be used to perform synchronized cardioversion. 3. This is the explanation for a pulse oximeter. 4. This is not the function of the AED. TEST-TAKING HINT: The test taker must know the equipment to be able to answer this question. The test taker may be able to eliminate options based on knowledge of what other equipment does.

The father of a child brought to the emergency department is yelling at the staff and obviously intoxicated. Which approach should the nurse take with the father? 1. Talk to the father in a calm and low voice. 2. Tell the father to wait in the waiting room. 3. Notify the child's mother to come to the ED. 4. Call the police department to come and arrest him.

Answer: 1 1. This will help diffuse the escalating situation and attempt to keep the father calm. 2. Sending the father to the waiting room does not help his behavior and could possibly make his behavior worse; loud and obnoxious behavior can become violent. 3. This will not help the current situation and could make it worse because the nurse doesn't know the home situation. 4. The nurse should notify hospital security before calling the police department. TEST-TAKING HINT: The rule concerning dealing with anger is to address the client directly and defuse the situation. There is only one option addressing this rule, option "1."

Which cultural issues should the nurse consider when caring for clients during a bioterrorism attack? Select all that apply. 1. Language difficulties. 2. Religious practices. 3. Prayer times for the people. 4. Rituals for handling the dead. 5. Keeping the family in the designated area.

Answer: 1, 2, 3, 4 1. Language difficulties can increase fear and frustration on the part of the client. 2. Some religions have specific practices related to medical treatments, hygiene, and diet, and these should be honored if at all possible. 3. Prayers in times of grief and disaster are important to an individual and actually can have a calming effect on the situation. 4. Caring for the dead is as important as caring for the living based on religious beliefs. 5. For purposes of organization, this may be needed, but it is not addressing cultural sensitivity and, in some instances, may violate the cultural needs of the client and the family. TEST-TAKING HINT: The stem asks the test taker to address cultural needs, and these client needs must be addressed in a bioterrorism attack or with an individual in the hospital. The test taker should select options addressing cultural needs. Dishonoring cultural needs can increase the client's anxiety and increase problems for the health-care team.

The client diagnosed with hypovolemic shock has a BP of 100/60. Fifteen minutes later the BP is 88/64. How much narrowing of the client's pulse pressure has occurred between the two readings?

Answer: 16 mmHg pulse pressure The pulse pressure is the systolic BP minus the diastolic BP. 100 - 60 = 40 mmHg pulse pressure in first BP reading 88 - 64 = 24 mmHg pulse pressure in second reading 40 - 24 = 16 mmHg pulse pressure narrowing. A narrowing or decreased pulse pressure is an earlier indicator of shock than a decrease in systolic blood pressure. TEST-TAKING HINT: If the test taker is not aware of how to obtain a pulse pressure, the only numbers provided in the stem are systolic and diastolic blood pressures. The test taker should do something with the numbers.

The nurse in an outpatient rehabilitation facility is working with convicted child abusers. Which characteristics should the nurse expect to observe in the abusers? Select all that apply. 1. The abuser calls the child a liar. 2. The abuser has a tendency toward violence. 3. The abuser exhibits a high self-esteem. 4. The abuser is unable to admit the need for help. 5. The abuser was spoiled as a child.

Answer: 1, 2, 4 1. Frequently child abusers will deny the child's reports of abuse and say the child is a habitual liar. 2. Child abusers believe violence is an acceptable way to reduce tension. They tend to have a low tolerance for frustration and have poor impulse control. 3. Child abusers have a tendency toward feelings of helplessness and hopelessness. 4. Child abusers tend to blame the child for the abuse and not admit the problem is their own. 5. The child abuser may have been abused as a child, but there is no evidence of the child abuser being spoiled as a child. TEST-TAKING HINT: This is an alternative-type question. The test taker should examine each option carefully to determine if it could be a correct answer. Option "3" could be eliminated because of the adjective "high," and "5" could be eliminated because of the adjective "spoiled."

The nurse is teaching a class about rape prevention to a group of women at a community center. Which information are common myths about rape? Select all that apply. 1. Raped women asked for it by dressing provocatively. 2. If a woman says no, it is a come on and she really does not mean it. 3. Rape is an attempt to exert power and control over the client. 4. All victims of sexual assault are women; men can't be raped. 5. A person cannot be raped by their legal spouse.

Answer: 1, 2, 4, 5 1. This is a myth believed by some people. Many individuals are raped, ranging in age from infants to people in their 90s of all gender identities, and sexual orientations. No one asks to be raped. 2. If a person says I am not interested in any type of sexual activity, it means "no" and therefore, anything else is forced and is rape. "No" means "no." It is considered rape if a prostitute says "no." 3. Rape is an act of violence motivated by the rapist desiring to overpower and control the victim. 4. This is a myth. Men and children can be victims of rape. Sexual arousal and orgasm do not imply consent; it may be a pathological response to stimulation. 5. This is a myth. Sexual assault can occur between spouses and partners. TEST-TAKING HINT: This question asks about myths or widely held false beliefs. Only one option is a true statement about rape.

The nurse is teaching a class on disaster preparedness. Which are components of an emergency operations plan (EOP)? Select all that apply. 1. A plan for practice drills. 2. A deactivation response. 3. A plan for internal communication only. 4. A preincident response. 5. A security plan.

Answer: 1, 2, 5 1. Practice drills allow for troubleshooting any issues before a real-life incident occurs. 2. A deactivation response is important so resources are not overused, and the facility can then get back to daily activities and routine care. 3. Communication between the facility and external resources and an internal communication plan are critical. 4. In a postincident response, it is important to include a critique and debriefing for all parties involved; a preincident response is a plan itself. Be sure to read adjectives closely. 5. A coordinated security plan involving facility and community agencies is the key to controlling an otherwise chaotic situation. TEST-TAKING HINT: The test taker must notice adjectives such as "only" in option "3" and "preincident" in option "4." These words make these options incorrect. This question requires the test taker to select more than one option as the correct answer.

The charge nurse has been notified that a disaster has occurred and that all possible clients should be discharged so the floor can receive the casualties. Which clients can be discharged? Select all that apply. 1. The 13-year-old client scheduled for a tonsillectomy. 2. The 42-year-old client scheduled for an abdominal aorta aneurysm dissection. 3. The 76-year-old client diagnosed with a pulmonary embolus with 2.9 INR. 4. The 80-year-old client refusing to assist in activities of daily living. 5. The 30-year-old client diagnosed with a small bowel obstruction.

Answer: 1, 3, 4 1. The 13-year-old is having elective surgery and could be rescheduled. 2. Abdominal aortic aneurysm surgeries are not scheduled until the aneurysm is at least 7 cm and at risk for rupture. This client should not be discharged. 3. This client is on oral medication and the INR is in therapeutic range; this client could be discharged. 4. Not wanting to care for oneself is not a valid reason to remain in the hospital. 5. A small bowel obstruction can compromise the blood supply to the bowel tissue. This is a life-threatening situation. The client should not be discharged. TEST-TAKING HINT: After looking at all the options, the test taker should select the options that best assess the entire situation. Option "1" describes an elective surgery and could be postponed. The client described in option "3" is on oral medication, warfarin (Coumadin), with an INR that is within the therapeutic range. The client in option "4" has a psychosocial issue, and this does not warrant remaining in the hospital.

The RN and a UAP are caring for clients in a medical unit. Which nursing task can be delegated to the UAP? Select all that apply. 1. Obtaining the intake and output of a client diagnosed with food poisoning. 2. Performing a dressing change on the client diagnosed with a chemical burn. 3. Assisting a client overdosed on morphine to the bedside commode. 4. Helping a client diagnosed with carbon monoxide poisoning turn, cough, and deep breathe. 5. Giving activated charcoal to a client with acetaminophen poisoning.

Answer: 1, 3, 4 1. UAPs can obtain intake and outputs, but evaluating the information is the nurse's responsibility. 2. This is a sterile dressing change and should not be delegated. 3. A UAP can assist clients in getting up to the bedside commode as long as the UAP is knowledgeable about body mechanics. 4. The UAP can assist a client in turning and asking the client to cough and deep breathe. 5. The UAP cannot administer medications to clients. This should not be delegated. TEST-TAKING HINT: The task requiring knowledge of sterile technique is the one the nurse should perform. Any task requiring specialized knowledge or nursing judgment cannot be delegated.

The client has ingested the remaining amount of a bottle of analgesic medication. The medication comes 500 mg per capsule. Two doses of two capsules each have been used by another member of the family. The bottle originally had 250 capsules. How many milligrams of medication did the client take?

Answer: 123,000 mg of analgesic medication were consumed. The container originally contained 250 capsules. Two doses of two capsules each were removed. 2 × 2 = 4. 250 capsules - 4 capsules= 246 capsules remaining. Each capsule contains 500 mg. 246 capsules × 500 mg = 123,000 mg of medication consumed. TEST-TAKING HINT: The test taker must not overlook a step in the problem. On the NCLEX-RN®, the test taker should check answers with the drop-down calculator.

Which equipment must be immediately brought to the client's bedside when a code is called for a client diagnosed with a cardiac arrest? 1. A ventilator. 2. A crash cart. 3. A gurney. 4. Portable oxygen.

Answer: 2 1. A ventilator is not kept on the medical-surgical floors and is not routinely brought to the bedside. The client is manually ventilated until arriving in the intensive care unit. 2. The crash cart is the mobile unit with the defibrillator and all the medications and supplies needed to conduct a code. 3. The gurney, a stretcher, may be needed when the client is being transferred to another unit, but it is not an immediate need, and in some hospitals, the client is transferred in the bed. 4. Oxygen is available in the room and portable oxygen is on the crash cart, so it doesn't need to be brought separately. TEST-TAKING HINT: This is knowledge the test taker must have. The crash cart is the primary piece of equipment, and in most facilities there is a person assigned to bring the crash cart to the client's bedside.

Activated charcoal has been ordered for a client after ingesting a full bottle of acetaminophen. Which statements explain the rationale for using activated charcoal? 1. Activated charcoal adheres to gastric mucosa to prevent absorption. 2. Activated charcoal binds with drugs to reduce systemic absorption. 3. Activated charcoal irritates gastric lining to induce vomiting of drugs. 4. Activated charcoal irrigates the stomach to be removed by suction.

Answer: 2 1. Activated charcoal does not adhere to the gastric mucosa; it binds to the drug or toxin. 2. Activated charcoal binds to drugs or toxins in the body, reducing systemic absorption. It is the most frequently used method of gastrointestinal decontamination. 3. A client may occasionally vomit when given activated charcoal, but this is not the scientific rationale for the administration. Ipecac can be given to induce vomiting but is not commonly used today. 4. Gastric lavage can be performed to flush the stomach, and the fluid is removed by suction but not activated charcoal. TEST-TAKING HINT: This is a knowledge-based question. The test taker should have knowledge of the actions of medications administered for a drug overdose.

The older male client is admitted to the medical unit with a diagnosis of dementia. The client is 74 inches tall and weighs 54.5 kg. The client lives with his son and daughter-in-law, and both work outside the house. Which referral is most important for the nurse to implement? 1. Adult Protective Services. 2. Social worker. 3. Medicare ombudsman. 4. Dietitian.

Answer: 2 1. Adult Protective Services should be called only if it is determined willful neglect or abuse of the client is occurring. 2. The nurse should arrange for the social worker to see the client and family to determine if some arrangements could be made to provide for the client's safety and for the client to be provided with nutritious meals while the adult children are at work. A long-term care facility or adult day care may be needed. 3. The Medicare ombudsman is a person representing a Medicare client in a long-term care facility. 4. The dietitian could see this client to determine eating preferences (74 inches = 6 foot 2 inches and 54.5 kg = 120 pounds), but the most appropriate intervention is safety. TEST-TAKING HINT: The question asks for the test taker to determine a priority intervention. The client is diagnosed with senile dementia and is being left alone for hours of the day. Safety is a priority.

The older female client diagnosed with vertebral fractures and self-medicating with ibuprofen presents to the emergency department (ED) reporting abdominal pain, is pale and clammy, and has a P of 110 and a BP of 92/60. Which type of shock should the nurse suspect? 1. Cardiogenic shock. 2. Hypovolemic shock. 3. Neurogenic shock. 4. Septic shock.

Answer: 2 1. Cardiogenic shock occurs when the heart's ability to contract and pump blood is impaired and the supply of oxygen to the heart and tissues is inadequate, such as occurs in myocardial infarction or valvular damage. 2. This client's clinical manifestations make the nurse suspect the client is losing blood, which leads to hypovolemic shock, which is the most common type of shock and is characterized by decreased intravascular volume. The client's taking of ibuprofen, an NSAID, puts her at risk for hemorrhage because NSAIDs inhibit prostaglandin production in the stomach, which increases the risk of developing ulcers, which can erode the stomach lining and lead to hemorrhaging. 3. In neurogenic shock, vasodilation occurs as a result of a loss of sympathetic tone. It can result from the depressant action of medication or lack of glucose. 4. Septic shock is a type of circulatory shock caused by widespread infection. TEST-TAKING HINT: The test taker must look at the clinical manifestations and realize this client is in shock. Tachycardia and hypotension with clammy skin indicate shock. The additional information in the stem describes a particular medication, an NSAID, which can cause a peptic ulcer.

The client presents to the ED with acute vomiting after eating at a fast-food restaurant. There has not been any diarrhea. The nurse suspects botulism poisoning. Which nursing problem is the highest priority for this client? 1. Fluid volume loss. 2. Risk for respiratory paralysis. 3. Abdominal pain. 4. Anxiety.

Answer: 2 1. Fluid volume loss is a concern because of the potential for the client to go into hypovolemic shock, but this is not a priority over the airway. 2. Clients diagnosed with botulism are at risk for respiratory paralysis, and this is the priority problem. 3. The client will be in pain and pain is a priority, but it does not come before airway and fluid volume. 4. The client may be anxious, but a psychosocial problem usually can be ranked after a physiological one in priority. TEST-TAKING HINT: Maslow's hierarchy of needs lists the airway as the highest priority.

The nurse is discharging a client diagnosed with accidental carbon monoxide poisoning. Which statement made by the client indicates the need for further teaching? 1. "I should install carbon monoxide detectors in my home." 2. "Having a natural bright red color to my lips is good." 3. "You cannot smell carbon monoxide, so it can be difficult to detect." 4. "I should have my furnace checked for leaks before turning it on."

Answer: 2 1. Installing carbon monoxide detectors in the home is a recommended safety measure. 2. The lips should not be bright red or blue. This indicates saturation of the hemoglobin with carbon monoxide. This client needs more instruction. 3. Because carbon monoxide is colorless and odorless, it can be dangerous. It is detected with special detectors. 4. One of the major causes of accidental carbon monoxide poisoning is a faulty furnace. TEST-TAKING HINT: Three options, "1," "3," and "4" are about protecting the home and keeping the client from inhaling carbon monoxide. If the test taker did not know the answer, a good choice is the different option.

The nurse in the emergency department has admitted five clients in the last 2 hours with reports of fever and gastrointestinal distress. Which question is most appropriate for the nurse to ask each client to determine if there is a bioterrorism threat? 1. "Do you work or live near any large power lines?" 2. "Where were you immediately before you got sick?" 3. "Can you write down everything you ate today?" 4. "What other health problems do you have?"

Answer: 2 1. Power lines are not typical sources of biological terrorism, which is what these symptoms represent. 2. The nurse should take note of any unusual illness for the time of year or clusters of clients coming from a single geographical location, all exhibiting clinical manifestations of possible biological terrorism. 3. This might be appropriate for gastroenteritis secondary to food poisoning but is not the nurse's first thought to determine a biological threat. The nurse must determine if the clients have anything in common. 4. This is important information to obtain for all clients but is not pertinent to determine a biological threat. TEST-TAKING HINT: Option "4" is a question the nurse asks all clients; therefore, the test taker should eliminate it based on the specific question. Power lines are electrical, and most bioterrorism threats involve chemical or biological threats, so option "1" can be eliminated.

Which clinical manifestations should the nurse assess in the client exposed to the anthrax bacillus via the skin? 1. A scabby, clear fluid-filled vesicle. 2. Edema, pruritus, and a 2-mm ulcerated vesicle. 3. Irregular brownish-pink spots around the hairline. 4. Tiny purple spots flush with the surface of the skin.

Answer: 2 1. Scabby, clear fluid-filled vesicles are characteristic of chickenpox. 2. Exposure to anthrax bacilli via the skin results in skin lesions, which cause edema with pruritus and the formation of macules or papules, which ulcerate, forming a 1- to 3-mm vesicle. Then a painless eschar develops, which falls off in 1 to 2 weeks. 3. Irregular brownish-pink spots around the hairline are characteristic of rubella. 4. Tiny purple spots flush with the skin surface are petechiae. TEST-TAKING HINT: This is a knowledge-based question. The test taker should try to determine which disease or condition each answer option describes to rule out the incorrect answers.

A chemical exposure has just occurred at an airport. An off-duty nurse, knowledgeable about biochemical agents, is giving directions to the travelers. Which direction should the nurse provide to the travelers? 1. Hold their breath as much as possible. 2. Stand up to avoid heavy exposure. 3. Lie down to stay under the exposure. 4. Attempt to breathe through their clothing.

Answer: 2 1. The absence of breathing is death, and this is neither a viable option nor a sensible recommendation to terrified people. 2. Standing up will avoid heavy exposure because the chemical will sink toward the floor or ground. 3. Staying below the level of the smoke is the instruction for a fire. 4. Breathing through the clothing, which is probably contaminated with the chemical, will not provide protection from the chemical entering the lung. TEST-TAKING HINT: If the test taker does not know the answer, the test taker should realize options "1" and "4" address breathing and options "2" and "3" address positioning, and one set of options should be eliminated, narrowing the choice to one out of two options.

The triage nurse is working in the emergency department. Which client should be assessed first? 1. The 10-year-old child whose dad thinks the child's leg is broken. 2. The 45-year-old male clutching his chest and diaphoretic. 3. The 58-year-old female reporting a headache and seeing spots. 4. The 25-year-old male with a hunting knife wound on the hand.

Answer: 2 1. The child needs an x-ray to confirm the fracture, but the client is stable and does not have a life-threatening problem. 2. The triage nurse should see this client first because these are symptoms of a myocardial infarction, which is potentially life-threatening. 3. These are symptoms of a migraine headache and are not life-threatening. 4. A laceration on the hand is a priority, but not over a client having a myocardial infarction. TEST-TAKING HINT: The test taker should evaluate each option on a scale of 1 to 10, with 1 being the least critical client and 10 being life-threatening. Option "2" rates a score of 10.

The client diagnosed with septicemia has the following health-care provider (HCP) orders. Which HCP order has the highest priority? 1. Provide clear liquid diet. 2. Initiate IV antibiotic therapy. 3. Obtain a STAT chest x-ray. 4. Perform hourly glucometer checks.

Answer: 2 1. The client's diet is not a priority when transcribing orders. 2. An IV antibiotic is the priority medication for the client diagnosed with an infection, which is the definition of sepsis—a systemic bacterial infection of the blood. A new order for an IV antibiotic should be implemented within 1 hour of receiving the order. 3. Diagnostic tests are important but not priority over intervening in a potentially life-threatening situation such as septic shock. 4. There is no indication in the stem of the question that this client has diabetes, and glucose levels are not associated with clinical manifestations of septicemia. TEST-TAKING HINT: Remember, if the test taker can rule out two answers—options "1" and "4"—and cannot determine the right answer between options "2" and "3," select the option directly affecting or treating the client, which is antibiotics. Diagnostic tests do not treat the client.

During a disaster, a local news reporter comes to the emergency department requesting information about the victims. Which action is most appropriate for the nurse to implement? 1. Have security escort the reporter off the premises. 2. Direct the reporter to the disaster command post. 3. Tell the reporter this is a violation of HIPAA. 4. Request the reporter to stay out of the way.

Answer: 2 1. The media have an obligation to report the news and can play a significant positive role in communication, but communication should come from only one source—the disaster command center. 2. EOPs will have a designated disaster plan coordinator. All public information should be routed through this person. 3. Client confidentiality must be maintained, but the best action is for the nurse to help the reporter get to the appropriate area for information. 4. This allows the reporter to stay in the emergency department, which is inappropriate. TEST-TAKING HINT: The nurse should address the situation with the reporter and provide access for the information. Options "1," "3," and "4" do not help the reporter get accurate information.

The nurse writes a nursing diagnosis of "risk for injury as a result of physical abuse by spouse" for a client. Which is an appropriate goal for this client? 1. The client will learn not to trust anyone. 2. The client will admit the abuse is happening and get help. 3. The client will discuss the nurse's suspicions with the spouse. 4. The client will choose to stay with the spouse.

Answer: 2 1. The nurse should attempt to develop a relationship in which the client feels they can trust the nurse (people of all gender identities are abused by significant others). 2. The first step in helping an abused client is to get the client to admit the abuse is happening. 3. This could cause the abuse to escalate. 4. This is what the nurse is trying to get the client to avoid. TEST-TAKING HINT: Option "1" could be eliminated because it is the opposite of what the nurse tries to establish in a nurse-client relationship. Option "4" places the client in harm's way.

The nurse is caring for a client diagnosed with shock. The client has hypotension, decreased urine output, and cool, pale skin. Which stage of shock is the client experiencing? 1. The refractory stage. 2. The compensatory stage. 3. The initial stage. 4. The progressive stage.

Answer: 2 1. The refractory stage is the last and irreversible phase of shock, characterized by multi-system organ failure, coma, and death. 2. In the compensatory stage of shock, the heart rate and respiratory rate are increased, but the skin may be cold and clammy and urinary output may be decreased. The client exhibits restlessness and confusion. 3. In the initial stage of shock the client can have no clinical manifestations or very subtle findings. 4. The progressive stage of shock is characterized by hypotension, lethargy, weak pulses, and respiratory and metabolic acidosis. TEST-TAKING HINT: There are some questions the test taker must know; they are called knowledge-based questions. The stages of shock are important for the nurse to recognize.

The adolescent female comes to the school nurse of an intermediate school and tells the nurse she thinks she is pregnant. During the interview, the client states her father is the baby's father. Which intervention should the nurse implement first? 1. Complete a rape kit. 2. Notify Child Protective Services. 3. Call the parents to come to the school. 4. Arrange for the client to go to a free clinic.

Answer: 2 1. The school nurse is not a Sexual Assault Nurse Examiner (SANE) nurse, and this child thinks she is pregnant, suggesting the abuse has been occurring for a period of time or at least in some months past. The child should be taken to a hospital for examination. 2. Child Protective Services should be notified to protect the child from further abuse and to initiate charges against the father. An intermediate school nurse cares for children in the fourth, fifth, sixth, or seventh grades, depending on the school district. 3. This action brings the abuser to the school. 4. Sending the child to a free clinic does not negate the nurse's responsibility to report suspected child abuse. TEST-TAKING HINT: All 50 states require the nurse to report suspected child abuse. CPS is the advocate to notify. Nurses in a school clinic do not have the appropriate facilities to perform rape examinations. Option "4" does not address the abuse.

The male client was found in a parked car with the motor running. The paramedic brought the client to the ED with reports of a headache, nausea, and dizziness and the client is unable to recall his name or address. On assessment, the nurse notes the buccal mucosa is a cherry red color. Which intervention should the nurse implement first? 1. Check the client's oxygenation level with a pulse oximeter. 2. Apply oxygen via nasal cannula at 100%. 3. Obtain a psychiatric consult to determine if this was a suicide attempt. 4. Prepare the client for transfer to a facility with a hyperbaric chamber.

Answer: 2 1. These are clinical manifestations of carbon monoxide poisoning. Pulse oximetry is not a valid test because the hemoglobin is saturated with the carbon monoxide and a false high reading is being obtained. 2. These are clinical manifestations of carbon monoxide poisoning. Symptoms include skin color from a cherry red to cyanotic and pale, headache, muscular weakness, palpitations, dizziness, and confusion and can progress rapidly to coma and death. Oxygen should be administered 100% at hyperbaric or atmospheric pressures to reverse hypoxia and accelerate the elimination of the carbon monoxide. 3. This may be done, but it is not the first action. 4. This may need to be done, but getting oxygen to the brain is first. TEST-TAKING HINT: Three of the four options concern oxygenation. The test taker must then decide which of the three has the highest priority.

The 84-year-old female client is admitted with multiple burn marks on the torso and under the breasts along with contusions in various stages of healing. When questioned by the nurse, the woman denies any problems have occurred. The woman lives with her son and does the housework. Which is the most probable reason the woman denies being abused? 1. There has not been any abuse to report. 2. The client is ashamed to admit to being abused. 3. The client has Alzheimer's disease and can't remember. 4. The client fell on a hike.

Answer: 2 1. This client has signs of ongoing abuse such as multiple burns and contusions in different stages of healing. 2. Often older clients are ashamed to report abuse because they raised the abuser and feel responsible for their child becoming an abuser. The elder parent may feel financially dependent on the child or be afraid of being placed in a long-term care facility. Forty-seven states have Adult Protective Services (APS) created by the states to protect older citizens. 3. There is no evidence provided in the stem that the client is not mentally competent, and there is evidence in the stem of physical abuse. This client is performing activities of daily living. 4. The client may have fallen and sustained contusions, but burn marks would not result from a fall. TEST-TAKING HINT: The test taker could eliminate options "1," "3," and "4" by examining the stem and noting the physical abuse occurring and by the fact the client is functioning by performing activities of daily living.

The nurse in a disaster is triaging the following clients. Which client should be triaged as an Expectant Category and color black? 1. The alert client diagnosed with a sucking chest wound. 2. The unresponsive client diagnosed with a head injury. 3. The client diagnosed with an abdominal wound and stable vital signs. 4. The client diagnosed with a sprained ankle which may be fractured.

Answer: 2 1. This client should be classified as an Immediate Category and the color red. If not treated STAT, a tension pneumothorax will occur. 2. This client has a very poor prognosis, and even with treatment, survival is unlikely. This client is classified as a black tag and an Expectant Category. 3. This client should be classified as an Observation Category and the color yellow. This client receives treatment after the casualties requiring immediate treatment are treated. 4. This client is a Wait Category and the color green. This client can wait for days for treatment. TEST-TAKING HINT: If the test taker did not know the definition of the categories, looking at the word "black," which has a connotation of death, and the word "expectant" might lead the test taker to select the worst-case scenario.

The nurse is teaching a class on bioterrorism to first responders and is discussing PPE. Which statements are important for the nurse to share with the participants? Select all that apply. 1. Health-care facilities should keep masks at entry doors. 2. The respondent should be trained in the proper use of PPE. 3. No single combination of PPE protects against all hazards. 4. The CDC has divided PPE into levels of protection. 5. PPE should be properly fitted to each respondent.

Answer: 2, 3, 4, 5 1. Masks are kept at designated areas, not at every entry door. 2. This is a true statement, but in an emergency situation, the respondent should use the equipment even if not trained. 3. The HCPs are not guaranteed absolute protection, even with all the training and protective equipment. This is the most important information individuals wearing protective equipment should know because all other procedures should be followed at all times. 4. The CDC has divided PPE into different levels based on exposure risk. 5. Properly fitted PPE increases the protection from exposure to biological agents. TEST-TAKING HINT: There are very few questions where the test taker should select an option with the word "all." Option "3" is stating this is not an "always" situation. The test taker should not automatically assume it is not a possible answer until understanding the context.

The client is diagnosed with neurogenic shock. Which clinical manifestations should the nurse assess in this client? Select all that apply. 1. Cool, moist skin. 2. Bradycardia. 3. Wheezing. 4. Decreased bowel sounds. 5. Hypotension.

Answer: 2, 5 1. The client diagnosed with neurogenic shock will have dry, warm skin, rather than cool, moist skin, as seen in hypovolemic shock. 2. The client will have bradycardia instead of tachycardia, which is seen in other forms of shock. 3. Wheezing is associated with anaphylactic shock. 4. Decreased bowel sounds occur in the hyper-dynamic phase of septic shock. 5. Hypotension is a clinical manifestation of most types of shock. TEST-TAKING HINT: The test taker should identify the body system the question is addressing. In this case, neuro- indicates the question relates to the neurological system. With this information only, the test taker could possibly rule out option "4," which refers to the gastrointestinal system, and option "3," which refers to the respiratory system. Although bradycardia is in the cardiac system, the pulse rate is controlled by the brain.

The nurse is caring for a client diagnosed with the prodromal phase of radiation exposure. Which clinical manifestations should the nurse assess in the client? 1. Anemia, leukopenia, and thrombocytopenia. 2. Sudden fever, chills, and enlarged lymph nodes. 3. Nausea, vomiting, and diarrhea. 4. Flaccid paralysis, diplopia, and dysphagia.

Answer: 3 1. Anemia, leukopenia, and thrombocytopenia, signs of bone marrow depression, are clinical manifestations the client experiences in the manifest illness stage of radiation exposure, which occurs from 72 hours to years after exposure. The client is usually asymptomatic in the prodromal phase of radiation exposure. 2. Sudden fever, chills, and enlarged lymph nodes are clinical manifestations of bubonic plague. 3. The prodromal stage (presenting symptoms) of radiation exposure occurs 48 to 72 hours after exposure, and the clinical manifestations are nausea, vomiting, diarrhea, anorexia, and fatigue. Clinical manifestations of higher exposures of radiation include fever, respiratory distress, and coma. 4. These are clinical manifestations of inhalation botulism. TEST-TAKING HINT: If the test taker knows the definition of "prodromal," which is an early sign of a developing condition or disease (prodrom is Greek for "running before"), then the option with vague and nonspecific clinical manifestations should be selected as the correct answer.

The nurse is caring for clients on a medical floor. Which client is most likely to experience sudden cardiac death? 1. The 84-year-old client exhibiting uncontrolled atrial fibrillation. 2. The 60-year-old client exhibiting asymptomatic sinus bradycardia. 3. The 53-year-old client exhibiting ventricular fibrillation. 4. The 65-year-old client exhibiting supraventricular tachycardia.

Answer: 3 1. Atrial fibrillation is not a life-threatening dysrhythmia; it is chronic. 2. Asymptomatic sinus bradycardia may be normal for the client, especially for athletes or long-distance runners. 3. Ventricular fibrillation is the most common dysrhythmia associated with sudden cardiac death. 4. "Supraventricular" means "above the ventricle." The atrium is above the ventricle, and atrial dysrhythmias are not life-threatening. TEST-TAKING HINT: The test taker should know the left ventricle is responsible for pumping blood to the body (heart muscle and brain) and could eliminate options "1" and "4" as correct answers. The word "asymptomatic" should cause the test taker to eliminate option "2" as the correct answer.

The triage nurse in a large trauma center has been notified of an explosion in a major chemical manufacturing plant. Which action should the nurse implement first when the clients arrive at the emergency department? 1. Triage the clients and send them to the appropriate areas. 2. Thoroughly wash the clients with soap and water and then rinse. 3. Remove the clients' clothing and have them shower. 4. Assume the clients have been decontaminated at the plant.

Answer: 3 1. In most situations, this is the first step, but with a potential chemical or biological exposure, the first step must be the safety of the hospital; therefore, the client must be decontaminated. 2. This is the second step in the decontamination process. 3. This is the first step. Depending on the type of exposure, this step alone can remove a large portion of the exposure. 4. This assumption could cost many people in the hospital staff, as well as clients, their lives. TEST-TAKING HINT: If the test taker wants to select option "4" as the correct answer, the test taker should be careful—assumptions are dangerous. The test taker may want to choose option "1" because it involves assessment, but exposure to a chemical agent should be considered distress and an action should be implemented first.

The nurse in the emergency department administered an intramuscular antibiotic in the left ventrogluteal muscle to the client diagnosed with pneumonia being discharged home. Which intervention should the nurse implement? 1. Ask the client about drug allergies. 2. Obtain a sterile sputum specimen. 3. Have the client wait for 30 minutes. 4. Place a warm washcloth on the client's left hip.

Answer: 3 1. It is too late to ask the client about drug allergies because the medication has already been administered. 2. Obtaining a specimen after the antibiotic has been initiated will skew the culture and sensitivity results. It must be obtained before the antibiotic is started. 3. Anytime a nurse administers a medication for the first time, the client should be observed for a possible anaphylactic reaction, especially with antibiotics. 4. The client is being discharged, and the nurse can encourage the client to do this at home, but it is not appropriate to do in the emergency department. TEST-TAKING HINT: The test taker must be observant of information in the stem. The nurse has already administered the medication, and checking for allergies after the fact will not affect the client's outcome. This is a violation of the five rights; this medication cannot be the right medication if the client is allergic to it.

The client has recently experienced a myocardial infarction. Which action by the nurse helps prevent cardiogenic shock? 1. Monitor the client's telemetry. 2. Turn the client every 2 hours. 3. Administer oxygen via nasal cannula. 4. Place the client in the Trendelenburg position.

Answer: 3 1. Monitoring the telemetry will not prevent cardiogenic shock. It might help identify changes in the hemodynamics of the heart, but it does not prevent anything from occurring. 2. Turning the client every 2 hours will help prevent pressure injuries, but it will do nothing to prevent cardiogenic shock. 3. Promoting adequate oxygenation of the heart muscle and decreasing the cardiac workload can prevent cardiogenic shock. 4. Placing the client's head below the heart will not prevent cardiogenic shock. This position can be used when a client is in hypovolemic shock. TEST-TAKING HINT: If the test taker has no idea what the correct answer is, the test taker should apply Maslow's hierarchy of needs, which states oxygenation is most important. The test taker must know positions the client may be put in during different disorders and diseases.

The charge nurse of the medical-surgical unit secured the crash cart during the code. Which intervention should the charge nurse implement first after transferring the client to the intensive care unit? 1. Reassign the clients on the floor because one is now gone. 2. Call the family of the code client and let them know of the transfer. 3. Make sure the crash cart is restocked. 4. Hold a unit meeting to determine if anything could have been done differently during the code.

Answer: 3 1. The charge nurse would not reassign the clients in the middle of the shift. If the nurse caring for the client has time, then the nurse can assist the other staff. 2. The HCP should notify the family of the client's arrest and current bed assignment. 3. The charge nurse must maintain a culture of readiness for any emergency. The crash cart must be checked and restocked for a future emergency. 4. A unit meeting can be held when the crash cart has been restocked and the floor has settled down, but it is not the priority. TEST-TAKING HINT: After looking at all the options, the test taker should select the option that best cares for the remaining clients on the unit.

The nurse is responding to a disaster call from home following a multivehicle motor-vehicle accident. Which action should the nurse take first? 1. Go to the emergency department to triage the clients coming in. 2. Assist the charge nurse to identify discharge-able clients. 3. Report to the command center for assignment. 4. Pack a bag to be able to stay until the emergency is over.

Answer: 3 1. The nurse should wait to be assigned when responding to a disaster; even if the nurse works in the emergency department, the nurse may be assigned to a different area for the disaster. 2. The nurse should not assume where to be best utilized during a disaster. The command center administrative nurse will determine where the greatest need exists. 3. The command center administrative nurse will determine where the greatest need exists. The nurse reports there to receive assignments. 4. The nurse should not delay responding to the hospital to pack a bag. TEST-TAKING HINT: After looking at all the options, the test taker should think, "How will I know where the greatest need is?" The answer is to ask for instructions, not assume the answer.

The nurse is caring for a client diagnosed with septic shock. Which assessment data warrant immediate intervention by the nurse? 1. Vital signs T 100.4°F, P 104, R 26, and BP 102/60. 2. A white blood cell count of 18,000/mm^3. 3. Urinary output of 90 mL in the last 4 hours. 4. The client reports being thirsty.

Answer: 3 1. These vital signs are expected in a client diagnosed with septic shock. 2. An elevated WBC count indicates an infection, which is the definition of sepsis. 3. The client must have a urinary output of at least 30 mL/hr, so 90 mL in the last 4 hours indicates impaired renal perfusion, which is a sign of worsening shock. 4. The client being thirsty is not an uncommon issue for a client diagnosed with septic shock. This warrants immediate intervention. TEST-TAKING HINT: The words "warrant immediate intervention" mean the nurse must do something, which frequently can be notifying the HCP. Any client diagnosed with shock will have clinical manifestations requiring the nurse to intervene. In this question, the test taker must determine priority and which data require immediate intervention.

The UAP is performing cardiac compressions on an adult client during a code. Which behavior warrants immediate intervention by the RN? 1. The UAP has hand placement on the lower half of the sternum. 2. The UAP performs cardiac compressions and allows for rescue breathing. 3. The UAP depresses the sternum 0.5 to 1 inch during compressions. 4. The UAP asks to be relieved from performing compressions because of exhaustion.

Answer: 3 1. This hand position will help prevent positioning the hand over the xiphoid process, which can break the ribs and lacerate the liver during compressions. 2. This is the correct two-rescuer CPR; therefore, no intervention is needed. 3. The sternum should be depressed 1.5 to 2 inches during compressions to ensure adequate circulation of blood to the body; therefore, the nurse needs to correct the UAP. 4. The UAP should request another HCP to perform compressions when exhausted. TEST-TAKING HINT: The test taker must select which option is an incorrect procedure for cardiac compressions.

Which intervention is most important for the nurse to implement when participating in a code? 1. Elevate the arm after administering medication. 2. Maintain sterile technique throughout the code. 3. Treat the client's clinical manifestations; do not treat the monitor. 4. Provide accurate documentation of what happened during the code.

Answer: 3 1. This is an appropriate intervention, but it is not the most important. 2. Sterile technique should be maintained as much as possible, but the nurse can treat a live body with an infection without using sterile technique; however, the nurse cannot treat a dead body without an infection. 3. This is the most important intervention. The nurse should always treat the client based on the nurse's assessment and data from the monitors; an intervention should not be based on data from the monitors without the nurse's assessment. 4. Documentation is important but not a priority over treating the client. TEST-TAKING HINT: The phrase "most important" in the stem is the key to answering this question. All four options are appropriate interventions for the question, but only one is the most important. The test taker should remember to always select the option directly affecting the client, and this may mean not selecting an assessment intervention when the client is in distress.

The nurse is teaching CPR to a class. Which statement best explains the definition of sudden cardiac death? 1. Cardiac death occurs after being removed from a mechanical ventilator. 2. Cardiac death is the time the HCP officially declares the client dead. 3. Cardiac death occurs within 1 hour of the onset of cardiovascular symptoms. 4. The death is caused by myocardial ischemia resulting from coronary artery disease.

Answer: 3 1. This is not the definition of sudden cardiac death; this is sometimes known as "pulling the plug" on clients diagnosed as brain dead. 2. This is not the definition of sudden cardiac death. 3. Unexpected death occurring within 1 hour of the onset of cardiovascular symptoms is the definition of sudden cardiac death. 4. This is not the definition of sudden cardiac death. TEST-TAKING HINT: If the test taker relates the word "sudden" in the stem with "unexpected," the best answer is option "3." The test taker must be aware of adjectives and adverbs.

The nurse finds the client unresponsive on the floor of the bathroom. Which action should the nurse implement first? 1. Check the client for breathing. 2. Assess the carotid artery for a pulse. 3. Shake the client and shout. 4. Notify the rapid response team.

Answer: 3 1. This is not the first intervention based on the answer options available in this question. 2. This is not the first intervention based on the options available in this question. 3. This is the first intervention the nurse should implement after finding the client unresponsive on the floor. 4. The rapid response team is called if the client is breathing; a code would be called if the client were not breathing. TEST-TAKING HINT: Options "1," "2," and "3" are all assessment interventions, which is the first step in the nursing process. Of these three possible options, the test taker should select the intervention easiest and fastest to determine if the client is alert, which is to shake and shout at the client.

The triage nurse has placed a disaster tag on the client. Which action warrants immediate intervention by the nurse? 1. The nurse documents the tag number in the disaster log. 2. The unlicensed assistive personnel documents vital signs on the tag. 3. The health-care provider removes the tag to examine the limb. 4. The licensed practical nurse securely attaches the tag to the client's foot.

Answer: 3 1. This is the correct procedure when tagging a client and does not warrant intervention. 2. Vital signs should be documented on the tag. The tag takes the place of the client's EHR, so this does not warrant intervention. 3. The tag should never be removed from the client until the disaster is over or the client is admitted and the tag becomes a part of the client's record. 4. The tag can be attached to any part of the client's body. TEST-TAKING HINT: This question is asking the test taker to identify an incorrect option for the situation. Sometimes asking which action is appropriate helps identify the correct answer.

Which federal agency is a resource for the nurse volunteering at the American Red Cross on a committee to prepare the community for any type of disaster? 1. The Joint Commission (JC). 2. Office of Emergency Management (OEM). 3. Department of Health and Human Services (HHS). 4. Metro Medical Response Systems (MMRS).

Answer: 3 1. This organization mandates all health-care facilities to have an emergency operations plan, but it is a national agency, not a federal agency. 2. Most cities and all states have an OEM, which coordinates the disaster relief efforts at the state and local levels. 3. Federal resources include organizations such as the HHS, Federal Emergency Management Agency (FEMA), and the Department of Justice. The American Red Cross provides disaster relief alongside these federal departments. 4. MMRS teams are local teams located in cities deemed to be possible terrorist targets. TEST-TAKING HINT: The question asks for a federal agency. The word "metro" means "local"; therefore, option "4" could be eliminated. All HCPs should be aware of the role of The Joint Commission in the hospital, so the test taker could eliminate option "1."

The emergency department nurse writes the problem of "ineffective coping" for a client who was raped. Which intervention should the nurse implement? 1. Encourage the client to take the "morning-after" pill. 2. Allow the client to admit guilt for causing the rape. 3. Provide a list of rape crisis counselors. 4. Discuss reporting the case to the police.

Answer: 3 1. This plan for the client to take RU 486, or the "morning-after" pill, prevents pregnancy from occurring, but it does not directly address coping skills. 2. The client may talk about "what if I had not done ...," but the client is not guilty of causing the rape. 3. The client should be provided the phone number of a rape crisis counseling center or counselor to help the client deal with the psychological effects of having been raped. 4. This is a legal issue. TEST-TAKING HINT: The test taker should read the stem "ineffective coping" and eliminate the physiological problem in option "1" and the legal problem in option "4."

The client has ingested a corrosive solution containing lye. Which intervention should the nurse implement? 1. Administer syrup of ipecac to induce vomiting. 2. Insert a nasogastric tube and connect to wall suction. 3. Assess for airway compromise. 4. Immediately administer water or milk.

Answer: 3 1. Vomiting is never induced in clients after ingesting corrosive alkaline substances or petroleum distillates. More damage can occur to the esophagus and pharynx. 2. Gastric lavage may be done (very rare) but not by inserting an NGT and attaching it to wall suction. 3. Airway edema or obstruction can occur as a result of the burning action of corrosive substances. 4. Water or milk may be administered to dilute the substance if the airway is not compromised. TEST-TAKING HINT: This is an emergency situation. If the test taker did not know the answer, Maslow's hierarchy of needs puts the airway first.

The client asks the nurse about the smallpox vaccine. Which information should the nurse provide to the client? Select all that apply. 1. The client should get the vaccine for prevention from the health department. 2. The client should get the vaccine only after the smallpox rash has developed. 3. The smallpox vaccine can help if given less than a week after exposure to the virus. 4. Health officials have enough smallpox vaccine to vaccinate everyone in the United States. 5. The client should avoid travel to countries with smallpox outbreaks.

Answer: 3, 4 1. The smallpox vaccine is not available to the general public because smallpox has been eradicated and the virus no longer exists in nature. 2. Once the smallpox rash has developed, the vaccine does not provide protection from the disease. 3. If given within 7 days of being exposed to the smallpox virus, the vaccine can provide some protection from the disease. 4. Health officials have enough smallpox vaccine to vaccinate every person in the United States if an outbreak were to occur. 5. Smallpox is eradicated and the virus no longer exists in nature. TEST-TAKING HINT: This is a knowledge-based question. The test taker should try to determine which answer options to select based on knowledge of immunizations.

Which intervention is the most important for the intensive care unit nurse to implement when performing mouth-to-mouth resuscitation on a client diagnosed with pulseless ventricular fibrillation? 1. Perform the jaw thrust maneuver to open the airway. 2. Use the mouth to cover the client's mouth and nose. 3. Insert an oral airway before performing mouth to mouth. 4. Use a pocket mouth shield to cover the client's mouth.

Answer: 4 1. A jaw thrust is used for a possible fractured neck. The nurse should use the head-tilt, chin-lift maneuver to open the airway. 2. The nurse should cover the client's mouth and nose with the nurse's mouth when giving mouth-to-mouth resuscitation to an infant but not when giving mouth-to-mouth resuscitation to an adult. According to the American Heart Association 2010 Guidelines, mouth to mouth is only performed with a barrier device in place to protect the rescuer. 3. An oral airway is not mandatory to do effective breathing; therefore, it is not the most important intervention. 4. Nurses should protect themselves against possible communicable diseases, such as HIV and hepatitis, and should be protected if the client vomits during CPR. TEST-TAKING HINT: Unless the stem provides an age for the client, the client is an adult client; therefore, the test taker could eliminate option "2" because it is for an infant.

The nurse is providing first aid to a victim of a poisonous snake bite. Which intervention should be the nurse's first action? 1. Apply a tourniquet to the affected limb. 2. Cut an "X" across the bite and suck out the venom. 3. Administer a corticosteroid medication. 4. Have the client lie still and remove constrictive items.

Answer: 4 1. Although this is seen as the first action in old television westerns, it is not a recommended action for clients been bitten by a snake. This action will cause further damage to the tissue by restricting blood flow to the tissue. 2. This is an action seen in classic television programs and movies from the 1950s and 1960s, but this is not the current treatment for snakebite. If this is done, the rescuer will suck the venom into the rescuer's mouth and possibly be poisoned. 3. Corticosteroid medications are contraindicated in the first 6 to 8 hours after the bite because they might interfere with antibody production and hinder the action of the antivenin. 4. The client should lie down, all restrictive items such as rings should be removed, the wound should be cleaned and covered with a sterile dressing, the affected body part should be immobilized, and the client should be kept warm. TEST-TAKING HINT: The test taker should not jump to what is depicted in the mass media as the correct answer. Both options "1" and "2" have answers portrayed in the media as the correct method of caring for snake bite. This should give the test taker a clue: If both options cannot be right, then both are probably wrong.

The nurse caring for a client diagnosed with sepsis writes the client diagnosis of "alteration in comfort R/T chills and fever." Which intervention should be included in the plan of care? 1. Ambulate the client in the hallway every shift. 2. Monitor urinalysis, creatinine level, and BUN level. 3. Apply sequential compression devices to the lower extremities. 4. Administer an antipyretic medication every 4 hours PRN.

Answer: 4 1. Ambulating the client in the hall will not address the etiology of the client's chills and fever; in fact, this could increase the client's discomfort. 2. Monitoring these laboratory data does not address the etiology of the client's diagnosis. 3. Sequential compression devices help prevent deep vein thrombosis. 4. Antipyretic medication will help decrease the client's fever, which directly addresses the etiology of the client's nursing diagnosis. TEST-TAKING HINT: The test taker must know the problem "alteration in comfort" is addressed by the goal and the interventions address the etiology, which is "chills and fever."

The parents bring their toddler to the ED in a panic. The parents state the child had been playing in the kitchen and got into some cleaning agents and swallowed an unknown quantity of the agents. Which health-care agency should the nurse contact at this time? 1. Child Protective Services (CPS). 2. The local police department. 3. The Department of Health. 4. The Poison Control Center.

Answer: 4 1. CPS should be contacted only if the nurse suspects an intentional administration of the poison, but at this time, determining which poison the child has swallowed and the antidote is the priority. 2. The local police department is only notified if the nurse suspects child abuse. 3. The Department of Health does not need to be notified. 4. The Poison Control Center can assist the nurse in identifying which chemical has been ingested by the child and the antidote. TEST-TAKING HINT: The test taker should analyze each option to determine what information could be obtained. Then the test taker should put this information in order of priority. Even if the nurse suspects child abuse, the priority is to help the child immediately.

The off-duty nurse hears on the television of a bioterrorism act in the community. Which action should the nurse take first? 1. Immediately report to the hospital emergency department. 2. Call the American Red Cross to find out where to go. 3. Pack a bag and prepare to stay at the hospital. 4. Follow the nurse's hospital policy for responding.

Answer: 4 1. Many hospital procedures mandate off-duty nurses should not report immediately to the hospital, so relief is available for initial responders. 2. The nurse's first responsibility is to the facility of employment, not the community. 3. This is a good action to take when the nurse is notified of the next action. For example, if the hospital is quarantined, the nurse may not report for days. 4. The nurse should follow the hospital's policy. Often nurses will stay at home until decisions are made as to where the employees should report. TEST-TAKING HINT: After looking at all the options, the test taker should select the option that best assesses the entire situation, which is following policy. There will be a tendency for mass hysteria to occur in the community, but following the terrorist attack on 9/11/2001, all hospitals and communities are now required by Homeland Security to have a disaster preparedness plan in place. The best action the nurse can take is to follow the procedure and remain calm.

The nurse is teaching a class on bioterrorism. Which statement is the scientific rationale for designating a specific area for decontamination? 1. Showers and privacy can be provided to the client in this area. 2. This area isolates the clients exposed to the agent. 3. It provides a centralized area for stocking the needed supplies. 4. It prevents secondary contamination to the health-care providers.

Answer: 4 1. This is not a rationale; this is a statement of what is done in the area. 2. This separates the clients until decontamination occurs, but the question is asking for the scientific rationale. 3. This is a false statement—the supplies should not be kept in the decontamination area. 4. Avoiding cross-contamination is a priority for personnel and equipment—the fewer the number of people exposed, the safer the community and area. TEST-TAKING HINT: Options "1" and "2" are not rationales.

The nurse is teaching a class on biological warfare. Which information should the nurse include in the presentation? 1. Contaminated water is the only source of transmission of biological agents. 2. Vaccines are available and being prepared to counteract all biological agents. 3. Biological weapons are less of a threat than chemical agents. 4. Biological weapons are easily obtained and result in significant mortality.

Answer: 4 1. Sources of biological agents include inhalation, insects, animals, and people. 2. Vaccines are not available to counteract all biological agents. 3. Because of the vast range of agents, biological weapons are more of a threat. A biological agent could be released in one city and affect people in other cities thousands of miles away. 4. Because of the variety of agents, the means of transmission, and the lethality of the agents, biological weapons, including anthrax, smallpox, and plague, are especially dangerous. TEST-TAKING HINT: Answer option "1" should be eliminated because of the word "only." Even if the test taker has little knowledge of biological warfare, knowledge of the human body suggests a wide range of ways biological agents could be transmitted.

The nurse working in the emergency department is admitting a 34-year-old female client for one of multiple admissions for spousal abuse. The client has refused to leave her spouse or to press charges against him. Which action should the nurse implement? 1. Insist the woman press charges this time. 2. Treat the wounds and do nothing else. 3. Tell the woman her spouse could kill her. 4. Give the woman the number of a women's shelter.

Answer: 4 1. The nurse can encourage the client to press charges but has no right to insist. 2. The nurse should treat the wound and may find it frustrating the client will not press charges, but the nurse is obligated to provide the client information to help the client to get to a safe place. 3. The woman is more aware of this fact than the nurse. 4. The nurse should help the client to devise a plan for safety by giving the client the number of a safe house or a women's shelter. TEST-TAKING HINT: The test taker could eliminate option "3" based on common sense; the client lives in an abusive situation and realizes the abuser's potential more than the nurse. Option "2" could be eliminated by the phrase "do nothing else." Option "1" could be eliminated because of the principle of nurses empowering their clients, not overpowering them, which is what has been happening to the client already.

Which statement best describes the role of the medical-surgical nurse during a disaster? 1. The nurse may be assigned to ride in the ambulance. 2. The nurse may be assigned as a first assistant in the operating room. 3. The nurse may be assigned to crowd control. 4. The nurse may be assigned to the emergency department.

Answer: 4 1. The nurse should not leave the hospital area; the nurse must wait for the casualties to come to the facility. 2. This is a position requiring knowledge of instruments and procedures not common to the medical-surgical floor. 3. The people in this area are usually chaplains or social workers, not direct client care personnel. In a disaster, direct care personnel cannot be spared for this duty. 4. New settings and atypical roles for nurses may be required during disasters; medical-surgical nurses can provide first aid and may be required to work in unfamiliar settings. TEST-TAKING HINT: The test taker should look at traditional nursing roles requiring nursing expertise and eliminate crowd control or riding in an ambulance.

The female client presents to the emergency department with facial lacerations and contusions. The spouse will not leave the room during the assessment interview. Which intervention should be the nurse's first action? 1. Call the security guard to escort the spouse away. 2. Discuss the injuries while the spouse is in the room. 3. Tell the spouse the police will want to talk to him. 4. Escort the client to the bathroom for a urine specimen.

Answer: 4 1. This action could cause the spouse to become violent. The security personnel should not attempt to remove the spouse unless the client wishes them to do so. 2. Injuries resulting from spousal abuse should be discussed without the abuser present. 3. This may or may not be true. The client will have to prosecute, and many times the abused client will not do so. The client may feel responsible for the abuse or may fear for her children's lives or for her own, or there may be a financial hold the spouse has over the client. Battered woman syndrome has many facets. 4. By escorting the client to a bathroom for any reason, the nurse can get the client to a safe area out of the hearing of the spouse. This is the most innocuous way to get the client alone. TEST-TAKING HINT: When dealing with a violent person, the nurse should use discretion to avoid the spouse erupting into violence directed against the nurse, client, or others in the emergency department.

According to the North Atlantic Treaty Organization (NATO) triage system, which situation is considered a level red? 1. Injuries are extensive and chances of survival are unlikely. 2. Injuries are minor and treatment can be delayed hours to days. 3. Injuries are significant but can wait hours without threat to life or limb. 4. Injuries are life-threatening but survivable with available interventions.

Answer: 4 1. This describes injuries color-coded black and is called the Expectant Category. It is used for the deceased or those with extensive, unsurvivable injuries 2. This is a description of injuries color-coded green and is called the Wait Category. These clients are walking wounded. 3. These injuries are color-coded yellow and are in the Observation Category. 4. This is called the Immediate Category. Individuals in this group can progress rapidly to Expectant if treatment is delayed. TEST-TAKING HINT: This is basically a knowledge-based question, but often the color "red" indicates a high priority.

The client diagnosed with septicemia is receiving a broad-spectrum antibiotic. Which laboratory data require the nurse to notify the HCP? 1. The client's potassium level is 3.8 mEq/L. 2. The urine culture indicates high sensitivity to the antibiotic. 3. The client's pulse oximeter reading is 94%. 4. The culture and sensitivity is resistant to the client's antibiotic.

Answer: 4 1. This is a normal potassium level (3.5 to 5.5 mEq/L); therefore, the nurse does not need to notify the HCP. 2. A culture result showing a high sensitivity to an antibiotic indicates this is the antibiotic the client should be receiving. 3. A pulse oximeter reading of greater than 93% indicates the client is adequately oxygenated. 4. A sensitivity report indicating resistance to the antibiotic being administered indicates the medication the client is receiving is not appropriate for the treatment of the infectious organism, and the HCP needs to be notified so the antibiotic can be changed. TEST-TAKING HINT: The keywords in option "2" are "high sensitivity," and this should make the test taker think this is a good thing. In option "4," the word "resistant" indicates something wrong with the antibiotic and the need for intervention.

The nursing administrator responds to a code situation. When assessing the situation, which role must the administrator ensure is performed for legal purposes and continuity of care of the client? 1. A person is ventilating with an Ambu bag. 2. A person is performing chest compressions correctly. 3. A person is administering medications as ordered. 4. A person is keeping an accurate record of the code.

Answer: 4 1. This is providing immediate direct care to the client and is not performed for legal purposes. 2. The key to answering the question is "legal," and direct care is not performed for legal purposes. 3. This is providing immediate direct care to the client and is not performed for legal purposes. This is an occasion where someone else is allowed to document another nurse's medication administration. 4. The EHR is a legal document, and the code must be documented in the EHR and provide the information needed in the intensive care unit. TEST-TAKING HINT: Answer options "1," "2," and "3" have the nurse providing direct hands-on care. Option "4" is the only option addressing documentation and should be selected as the correct answer because it is different.

A gang war has resulted in 12 young males being brought to the emergency department. Which action by the nurse is a priority when a gang member points a gun at a rival gang member in the trauma room? 1. Attempt to talk to the person with the gun. 2. Explain to the person the police are coming. 3. Stand between the client and the man with the gun. 4. Get out of the line of fire and protect self.

Answer: 4 1. This puts the nurse in a dangerous position and might cause the death of the nurse. 2. This will escalate the situation. 3. This is a dangerous position for the nurse to be put in. 4. Self-protection is a priority; the nurse is not required to be injured in the line of duty. TEST-TAKING HINT: Self-protection is a priority. There is no advantage to protecting others if the caregivers are also injured. The only option protecting the nurse is to get out of the line of fire.

The nurse is admitting a client with the laboratory results listed. Which priority intervention should the nurse implement first? - WBCs: 25.3 - RBC: 4.8 - Hgb: 10 - Hct: 30% - Platelets: 250 1. Administer the prescribed antibiotic IVPB. 2. Start an intravenous line in the client's left forearm. 3. Perform the admission assessment. 4. Have the laboratory draw blood cultures STAT.

Answer: 4 1. This should be considered a NOW medication but should not be the first intervention because cultures have been ordered. 2. The IV line must be started before the IVPB can be administered, but it is not first. 3. The admission assessment must be completed in a timely manner, but it is actually the last intervention of the four listed. Admission assessments involve a thorough head-to-toe assessment and can take time to complete. 4. The cultures are the priority intervention because the antibiotics should not be administered until the cultures have been drawn. TEST-TAKING HINT: After looking at all the options, the test taker should select the option that best addresses the abnormal laboratory value, which is the high white blood cell (WBC) count. This client has an infection and must be treated as rapidly as possible, but performing cultures first will give the HCP information about the causative agent without skewing the results.

Which question is an appropriate interview question for the nurse to use with clients involved in abuse? 1. "I know you are being abused. Can you tell me about it?" 2. "How much does your spouse drink before he hits you?" 3. "What did you do to cause your spouse to get mad?" 4. "Do you have a plan if your partner becomes abusive?"

Answer: 4 1. Unless the nurse is being personally abused in the same manner the client is being abused and has seen the abuse taking place, the nurse cannot "know" the client is being abused. 2. Alcohol and drugs are implicated in the abuse of many clients, but not all abusers use alcohol or drugs. 3. This is agreeing with the abuser about the client causing the abuse. 4. This statement assesses the abused client's safety (or a plan for safety). TEST-TAKING HINT: Option "3" could be eliminated because it blames the victim. Option "1" can be eliminated because the nurse should not tell the client "I know" unless the nurse has proof or has been in the situation.