Question

A nurse finds a 60-year-old client with diabetes unconscious on the floor next to the bed during morning rounds. Which intervention takes priority?

Answer 1

Correct Answers:

Establish a patent airway and assess respirations.

Rationale :

✨ An unconscious client must first be assessed using the airway, breathing, circulation (ABC) priority framework because loss of airway patency can rapidly become fatal.

✨ Establishing a patent airway and assessing respirations determines whether the client is ventilating adequately and whether immediate respiratory support is required.

✨ Although the client has diabetes and could have severe hypoglycemia, glucose correction cannot take priority over an obstructed airway or absent respirations.

✨ Once airway and breathing are stabilized, the nurse should rapidly assess the blood glucose level and treat hypoglycemia according to findings.

✨ This intervention therefore takes priority because oxygenation and ventilation are essential for immediate survival.

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Answer 2

Correct Answers:

Minimize interruptions in chest compressions to less than 10 seconds.

Rationale :

✳️ High-quality CPR requires continuous, effective chest compressions to maintain coronary and cerebral perfusion during cardiac arrest.

✳️ Interruptions should be limited to less than 10 seconds whenever possible because blood flow rapidly decreases when compressions stop.

✳️ Adult compressions should be performed at a rate of approximately 100 to 120/min with adequate depth and complete chest recoil.

✳️ Rescuers should minimize pauses for ventilation, rhythm checks, defibrillation preparation, and other procedures.

✳️ Keeping interruptions brief therefore directly improves the quality and effectiveness of CPR.

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Answer 3

Correct Answers:

Provide support and education to the patient's family.

Rationale :

💎 Hospice care focuses on comfort, symptom management, dignity, and quality of life for clients with terminal illness.

💎 Nurses provide extensive education and emotional support to family members, helping them understand the dying process and how to provide comfort.

💎 Hospice nursing also includes pain and symptom management, communication with the interdisciplinary team, and support for anticipatory grief.

💎 Family members may require teaching about medications, nutrition changes, respiratory changes, and expected signs of approaching death.

💎 Providing family support and education is therefore a central responsibility of the hospice nurse.

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Answer 4

Correct Answers:

Level 1 trauma center

Rationale :

⚽ A 15-foot fall with loss of consciousness and new bilateral leg paralysis and sensory loss indicates major multisystem trauma with possible spinal cord injury.

⚽ A Level 1 trauma center provides the highest level of comprehensive trauma care, including immediate availability of specialized surgeons and advanced diagnostic resources.

⚽ The client may require emergency neurosurgical, orthopedic, critical-care, and trauma interventions.

⚽ Rapid access to definitive care is essential because spinal cord compression, hemorrhage, and other traumatic injuries can progress quickly.

⚽ A Level 1 trauma center is therefore the most appropriate destination for this high-acuity trauma patient.

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Answer 5

Correct Answers:

Cheyne-Stokes respirations with periods of apnea.

Rationale :

🎯 Cheyne-Stokes respirations consist of a cyclic pattern in which respirations gradually increase in depth and then decrease, followed by a period of apnea.

🎯 This respiratory pattern commonly occurs near the end of life as neurologic control of breathing becomes less stable.

🎯 The pattern can appear alarming to family members but does not necessarily indicate that the dying client is experiencing distress.

🎯 The nurse should provide reassurance and continue comfort-focused assessment and positioning.

🎯 The described waxing-and-waning respirations followed by apnea therefore clearly identify Cheyne-Stokes breathing.

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Answer 6

Correct Order:

Order : 1 : No answer text available
Order : 2 : No answer text available
Order : 3 : No answer text available
Order : 4 : No answer text available

Rationale :

🧿 The first priority in trauma is airway, because airway obstruction can cause death within minutes.

🧿 After ensuring airway patency, the nurse assesses breathing, including whether both sides of the chest expand equally, because a penetrating chest injury can cause pneumothorax or hemothorax.

🧿 The next priority is circulation and hemorrhage control, so pressure is applied to the chest wound as appropriate while monitoring for worsening respiratory compromise.

🧿 After airway, breathing, and circulation are addressed, the nurse evaluates neurologic status using the Glasgow Coma Scale, which represents the disability portion of the primary trauma survey.

🧿 This sequence follows the trauma priority framework of A-B-C-D: airway, breathing, circulation, disability.

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Answer 7

Correct Answers:

934

Rationale :

➡️Formula

✔️Parkland formula = 4 mL × weight (kg) × TBSA burned (%)

✔️38 lb ÷ 2.2 = 17.3 kg

✔️3Both lower extremities in a young child ≈ 27% TBSA

✔️4 mL × 17.3 kg × 27 = 1,868.4 mL in 24 hr

✔️1,868.4 mL ÷ 2

➡️ 934.2 mL → 934 mL during first 8 hr

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Answer 8

Correct Answers:

Pneumothorax

Rationale :

✨ Absent left-sided chest expansion after blunt chest trauma strongly suggests that the affected lung is not expanding normally.

✨ A pneumothorax occurs when air enters the pleural space and disrupts the negative pressure needed to keep the lung expanded.

✨ The client’s shortness of breath and unilateral chest movement are classic findings of impaired ventilation on the injured side.

✨ Additional findings can include decreased or absent breath sounds, chest pain, tachypnea, and worsening oxygenation.

✨ The nurse should recognize this as a potentially life-threatening thoracic injury that requires rapid respiratory assessment and treatment.

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Answer 9

Correct Answers:

30 compressions to 2 breaths

Rationale :

✳️ For adult CPR with two rescuers, the correct compression-to-ventilation ratio remains 30 compressions to 2 breaths when an advanced airway is not in place.

✳️ High-quality CPR requires compressions at approximately 100 to 120/min with adequate depth and full chest recoil.

✳️ The rescuers should minimize interruptions in compressions because sustained blood flow is essential for cerebral and coronary perfusion.

✳️ Two breaths are delivered after every 30 compressions, with each breath given just enough to produce visible chest rise.

✳️ This ratio therefore provides the appropriate balance between circulation and ventilation during adult basic life support.

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Answer 10

Correct Answers:

Bargaining

Rationale :

💎 Bargaining occurs when a person attempts to negotiate, make promises, or perform certain actions in hopes of changing an unavoidable outcome.

💎 The statement about donating money every day in exchange for the spouse being cured reflects a classic “if I do this, maybe this will happen” pattern.

💎 Bargaining can also be accompanied by guilt and thoughts about what the person could have done differently.

💎 This stage is part of the emotional response to impending loss and may alternate with other grief reactions rather than occurring in a fixed sequence.

💎 The client’s statement therefore most clearly demonstrates bargaining.

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QLexNursing

1 :
A nurse finds a 60-year-old client with diabetes unconscious on the floor next to the bed during morning rounds. Which intervention takes priority?

2 :
A triage nurse finds an adult client in the emergency department parking lot who has no pulse and is not breathing. Staff immediately begin cardiopulmonary resuscitation (CPR). Which action maintains high-quality CPR?

3 :
The nurse is preparing to join a hospice care team. Which responsibility does the nurse expect to perform?

4 :
A client falls 15 feet from a ladder and loses consciousness for approximately 90 seconds. On arrival, the client reports an inability to move or feel both legs. Which facility provides the most appropriate level of care?

5 :
A hospice patient has respirations that gradually increase and decrease in depth, followed by periods of apnea. Which respiratory pattern does the nurse identify?

6 :
An off-duty nurse assists a man who has been stabbed in the right chest with a knife. The scene is safe. Place the nursing actions in the order they are performed.

8 :
A patient arrives at the emergency department after an unrestrained motor vehicle crash (MVC). The patient reports striking the steering wheel and has shortness of breath with absent left-sided chest expansion. Which condition does the nurse suspect?

9 :
Two nurses begin CPR on an adult client who has no pulse and is not breathing. Which compression-to-ventilation ratio is appropriate?

10 :
Patient data.

Answer Options

QLexNursing

1 : A nurse finds a 60-year-old client with diabetes unconscious on the floor next to the bed during morning rounds. Which intervention takes priority?

2 : A triage nurse finds an adult client in the emergency department parking lot who has no pulse and is not breathing. Staff immediately begin cardiopulmonary resuscitation (CPR). Which action maintains high-quality CPR?

3 : The nurse is preparing to join a hospice care team. Which responsibility does the nurse expect to perform?

4 : A client falls 15 feet from a ladder and loses consciousness for approximately 90 seconds. On arrival, the client reports an inability to move or feel both legs. Which facility provides the most appropriate level of care?

5 : A hospice patient has respirations that gradually increase and decrease in depth, followed by periods of apnea. Which respiratory pattern does the nurse identify?

6 : An off-duty nurse assists a man who has been stabbed in the right chest with a knife. The scene is safe. Place the nursing actions in the order they are performed.

8 : A patient arrives at the emergency department after an unrestrained motor vehicle crash (MVC). The patient reports striking the steering wheel and has shortness of breath with absent left-sided chest expansion. Which condition does the nurse suspect?

9 : Two nurses begin CPR on an adult client who has no pulse and is not breathing. Which compression-to-ventilation ratio is appropriate?

10 : Patient data.

Answer Options

1 :
A nurse finds a 60-year-old client with diabetes unconscious on the floor next to the bed during morning rounds. Which intervention takes priority?

2 :
A triage nurse finds an adult client in the emergency department parking lot who has no pulse and is not breathing. Staff immediately begin cardiopulmonary resuscitation (CPR). Which action maintains high-quality CPR?

3 :
The nurse is preparing to join a hospice care team. Which responsibility does the nurse expect to perform?

4 :
A client falls 15 feet from a ladder and loses consciousness for approximately 90 seconds. On arrival, the client reports an inability to move or feel both legs. Which facility provides the most appropriate level of care?

5 :
A hospice patient has respirations that gradually increase and decrease in depth, followed by periods of apnea. Which respiratory pattern does the nurse identify?

6 :
An off-duty nurse assists a man who has been stabbed in the right chest with a knife. The scene is safe. Place the nursing actions in the order they are performed.

8 :
A patient arrives at the emergency department after an unrestrained motor vehicle crash (MVC). The patient reports striking the steering wheel and has shortness of breath with absent left-sided chest expansion. Which condition does the nurse suspect?

9 :
Two nurses begin CPR on an adult client who has no pulse and is not breathing. Which compression-to-ventilation ratio is appropriate?

10 :
Patient data.