1. 1. The nurse is triaging four clients injured in a train derailment. Which client should
receive priority treatment?
A. A 42-year-old with dyspnea and chest asymmetry
B. A 17-year-old with a fractured arm
C. A 4-year-old with facial lacerations
D. A 30-year-old with blunt abdominal trauma
2. Direct pressure to a deep laceration on the client’s lower leg has failed to stop the
bleeding. The nurse’s next action should be to:
A. Place a tourniquet proximal to the laceration.
B. Elevate the leg above the level of the heart.
C. Cover the laceration and apply an ice compress.
D. Apply pressure to the femoral artery.
3. A pediatric client is admitted after ingesting a bottle of vitamins with iron.
Emergency care would include treatment with:
A. Acetylcysteine
B. Deferoxamine
C. Calcium disodium acetate
D. British antilewisite
4. The nurse is preparing to administer Ringer’s Lactate to a client with hypovolemic
shock. Which intervention is important in helping to stabilize the client’s condition?
A. Warming the intravenous fluids
B. Determining whether the client can take oral fluids
C. Checking for the strength of pedal pulses
D. Obtaining the specific gravity of the urine
5. The emergency room staff is practicing for its annual disaster drill. According to
disaster triage, which of the following four clients would be cared for last?
A. A client with a pneumothorax
B. A client with 70% TBSA full thickness burns
C. A client with fractures of the tibia and fibula
D. A client with smoke inhalation injuries
6. An unresponsive client is admitted to the emergency room with a history of
diabetes mellitus. The client’s skin is cold and clammy, and the blood pressure
reading is 82/56. The first step in emergency treatment of the client’s symptoms
would be:

2. A. Checking the client’s blood sugar
B. Administering intravenous dextrose
C. Intubation and ventilator support
D. Administering regular insulin
7. A client with a history of severe depression has been brought to the emergency
room with an overdose of barbiturates. The nurse should pay careful attention to
the client’s:
A. Urinary output
B. Respirations
C. Temperature
D. Verbal responsiveness
8. A client is to receive antivenin following a snake bite. Before administering the
antivenin, the nurse should give priority to:
A. Administering a local anesthetic
B. Checking for an allergic response
C. Administering an anxiolytic
D. Withholding fluids for 6–8 hours
9. The nurse is caring for a client following a radiation accident. The client is
determined to have incorporation. The nurse knows that the client will:
A. Not need any medical treatment for radiation exposure
B. Have damage to the bones, kidneys, liver, and thyroid
C. Experience only erythema and desquamation
D. Not be radioactive because the radiation passes through the body
10. The emergency staff has undergone intensive training in the care of clients with
suspected anthrax. The staff understands that the suggested drug for treating
anthrax is:
A. Ancef (cefazolin sodium)
B. Cipro (ciprofloxacin)
C. Kantrex (kanamycin)
D. Garamycin (gentamicin)
Answer Rationales
1. Answer A is correct. Following the ABCDs of basic emergency care, the client with

3. dyspnea and asymmetrical chest should be cared for first because these
symptoms are associated with flail chest. Answer D is incorrect because he should
be cared for second because of the likelihood of organ damage and bleeding.
Answer B is incorrect because he should be cared for after the client with
abdominal trauma. Answer C is incorrect because he should receive care last
because his injuries are less severe.
2. Answer B is correct. If bleeding does not subside with direct pressure, the nurse
should elevate the extremity above the level of the heart. Answers A and D are
done only if other measures are ineffective, so they are incorrect. Answer C would
slow the bleeding but will not stop it, so it’s incorrect.
3. Answer B is correct. Deferoxamine is the antidote for iron poisoning. Answer A is
the antidote for acetaminophen overdose, making it wrong. Answers C and D are
antidotes for lead poisoning, so they are wrong.
4. Answer A is correct. Warming the intravenous fluid helps to prevent further stress
on the vascular system. Thirst is a sign of hypovolemia; however, oral fluids alone
will not meet the fluid needs of the client in hypovolemic shock, so answer B is
incorrect. Answers C and D are wrong because they can be used for baseline
information but will not help stabilize the client.
5. Answer B is correct. The client with 70% TBSA burns would be classified as an
emergent client. In disaster triage, emergent clients, code black, are cared for last
because they require the greatest expenditure of resources. Answers A and D are
examples of immediate clients and are assigned as code red, so they are wrong.
These clients are cared for first because they can survive with limited
interventions. Answer C is wrong because it is an example of a delayed client,
code yellow. These clients have significant injuries that require medical care.
6. Answer A is correct. The client has symptoms of insulin shock and the first step is
to check the client’s blood sugar. If indicated, the client should be treated with
intravenous dextrose. Answer B is wrong because it is not the first step the nurse
should take. Answer C is wrong because it does not apply to the client’s
symptoms. Answer D is wrong because it would be used for diabetic ketoacidosis,
not insulin shock.
7. Answer B is correct. Barbiturate overdose results in central nervous system
depression, which leads to respiratory failure. Answers A and C are important to
the client’s overall condition but are not specific to the question, so they are
incorrect. The use of barbiturates results in slow, slurred speech, so answer D is
expected, and therefore incorrect.
8. Answer B is correct. The nurse should perform the skin or eye test before
administering antivenin. Answers A and D are unnecessary and therefore
incorrect. Answer C would help calm the client but is not a priority before giving
the antivenin, making it incorrect.
9. Answer B is correct. The client with incorporation radiation injuries requires
immediate medical treatment. Most of the damage occurs to the bones, kidneys,
liver, and thyroid. Answers A, C, and D refer to external irradiation, so they are

4. wrong.
10. Answer B is correct. Cipro (ciprofloxacin) is the drug of choice for treating anthrax.
Answers A, C, and D are not used to treat anthrax, so they are incorrect.
1. An elderly female client presents to the ED with complaints of chest pain and a history of angina. After the
initial triage, what would be the next appropriate interventions?
a. cardiac monitor, oxygen, and sublingual nitroglycerin
b. cardiac monitor, sublingual nitroglycerin, and Foley catheter
c. cardiac monitor, IV, oxygen, and sublingual nitroglycerin
d. oxygen, sublingual nitroglycerin, and Foley catheter
2. A 7-year-old child is brought to the emergency department after multiple bee stings about 30 minutes
previously. He complains of itching, swollen lips, and difficulty breathing. Wheezing and stridor are heard.
What is the most immediate treatment required?
a. epinephrine 0.1 mg intramuscularly
b. intravenous corticosteroid
c. intravenous antihistamine
d. broad-spectrum antibiotic
3. After an auto accident, x-rays of the patient's leg show a transverse fracture of the midfemur with several
bone fragments surrounding the fracture site. The skin of the leg is intact. This type fracture is called:
a. compression fracture
b. comminuted fracture
c. avulsion fracture
d. open fracture
4. A cancer patient is seen in the emergency department with high fevers and malaise for 2 days. She
received chemotherapy about 10 days ago. Her physical exam is not revealing but her temperature is 103°F.
A CBC shows a hemoglobin of 10 g/dL, WBC 4000 with 10% polys, 5% bands, 70% lymphs, 10% monos, and
5% other white or unidentified cells. Platelets are 60,000/mm3. Which of the following is NOT immediately
appropriate?
a. blood cultures from different sites
b. electrolytes, liver and renal function tests
c. eask if she has been receiving granulocyte colony-stimulating factor (G-CSF)
d. white blood cell transfusion
5. Which statement best describes acute respiratory distress syndrome (ARDS)?
a. ARDS is caused by trauma only.
b. ARDS is sudden, progressive, and severe.
c. ARDS is caused by an illness only.
d. ARDS never results in lung scarring.
Certified Emergency Nurse (CEN) Answer Key
1. Answer: C
A cardiac monitor, oxygen, and an IV should be in place for anyone complaining of chest pain and before
administering nitroglycerin, especially in an elderly client, who may develop hypotension quickly. When a client does

5. not respond to sublingual nitroglycerin, it indicates possible unstable angina and may require other interventions to
relieve the pain.
2. Answer: A
The clinical picture of this patient is that of an anaphylactic reaction to bee stings which is potentially life-threatening.
The onset of symptoms within 1 hour after exposure to the allergen is particularly worrisome as are the laryngeal and
pulmonary signs. The airway must be established with intubation often necessary; high-flow oxygen, cardiac
monitoring, and intravenous fluids are basics. Epinephrine given intramuscularly is the most rapidly acting agent and
should be given as soon as possible after the diagnosis of anaphylaxis and every 5 to 15 minutes thereafter as
needed. Steroids and antihistamines are slower acting than epinephrine but are often given to alleviate itching,
angioedema, and hives. There is no indication for antibiotics in this clinical situation unless further signs and
symptoms develop.
3. Answer: B
A fracture is a break or disruption in a bone, generally divided into closed (no break in the skin) and open (protrusion
of the bone through the skin). Fractures may take different anatomic patterns, depending on the bone location, the
nature of the trauma and the bone density (may be diminished with osteoporosis). Compression fractures are most
common in the spine in which a fracture of one or more vertebral bodies leads to a collapse of the spine at that
location. An avulsion fracture reflects a forceful contraction of muscle mass, which pulls a bone fragment to break
away at the tendon's insertion site. This type of fracture is often seen with severe joint strains. This patient has a
comminuted fracture in which the trauma causes more than two separated portions of the bone. Often, several small
bony fragments are seen at the site of the break.
4. Answer: D
This patient has fever and neutropenia after chemotherapy. Neutropenia is defined as an absolute neutrophil count
(ANC) under 1000/mm3, and a severe neutropenia less than 500/mm3 is particularly dangerous. These patients must
be worked up quickly and antibiotic and possibly additional therapy started as soon as possible since the situation
may be life-threatening. While myelosuppressive drugs differ in the length of time between administration and the
nadir of the ANC, 10 to 14 days is typical. Multiple cultures from different possible sites of origin for sepsis must be
done along with chest x-ray and other imaging as indicated by examination. Broad-spectrum antibiotics, such as
ceftazidime or imipenem/cilastatin, should be started after cultures are obtained. She should be asked if she has
been receiving G-CSF (Neupogen, Neulasta). WBC transfusions are rarely used today since they have a very short
shelf life, do not last long in the circulation, and may cause allergic reactions.
5. Answer: B
ARDS is sudden, progressive, and severe, and can even lead to death.
1. A patient arrives at the emergency department complaining of mid-sternal chest pain. Which of the
following nursing action should take priority?
A. A complete history with emphasis on preceding events.
B. An electrocardiogram.
C. Careful assessment of vital signs.
D. Chest exam with auscultation.
2. A patient has been hospitalized with pneumonia and is about to be discharged. A nurse provides
discharge instructions to a patient and his family. Which misunderstanding by the family indicates the nee
for more detailed information?
A. The patient may resume normal home activities as tolerated but should avoid physical exertion and get
adequate rest.
B. The patient should resume a normal diet with emphasis on nutritious, healthy foods.

6. C. The patient may discontinue the prescribed course of oral antibiotics once the symptoms have completely
resolved.
D. The patient should continue use of the incentive spirometer to keep airways open and free of secretions.
3. A nurse is caring for an elderly Vietnamese patient in the terminal stages of lung cancer. Many family
members are in the room around the clock performing unusual rituals and bringing ethnic foods. Which o
the following actions should the nurse take?
A. Restrict visiting hours and ask the family to limit visitors to two at a time.
B. Notify visitors with a sign on the door that the patient is limited to clear fluids only with no solid food allowed
C. If possible, keep the other bed in the room unassigned to provide privacy and comfort to the family.
D. Contact the physician to report the unusual rituals and activities.
4. The charge nurse on the cardiac unit is planning assignments for the day. Which of the following is the
most appropriate assignment for the float nurse that has been reassigned from labor and delivery?
A. A one-week postoperative coronary bypass patient, who is being evaluated for placement of a pacemaker prio
to discharge.
B. A suspected myocardial infarction patient on telemetry, just admitted from the Emergency Department and
scheduled for an angiogram.
C. A patient with unstable angina being closely monitored for pain and medication titration.
D. A post-operative valve replacement patient who was recently admitted to the unit because all surgical beds
were filled.
5. A newly diagnosed 8-year-old child with type I diabetes mellitus and his mother are receiving diabetes
education prior to discharge. The physician has prescribed Glucagon for emergency use. The mother asks
the purpose of this medication. Which of the following statements by the nurse is correct?
A. Glucagon enhances the effect of insulin in case the blood sugar remains high one hour after injection.
B. Glucagon treats hypoglycemia resulting from insulin overdose.
C. Glucagon treats lipoatrophy from insulin injections.
D. Glucagon prolongs the effect of insulin, allowing fewer injections.
6. A patient on the cardiac telemetry unit unexpectedly goes into ventricular fibrillation. The advanced
cardiac life support team prepares to defibrillate. Which of the following choices indicates the correct
placement of the conductive gel pads?
A. The left clavicle and right lower sternum.
B. Right of midline below the bottom rib and the left shoulder.
C. The upper and lower halves of the sternum.
D. The right side of the sternum just below the clavicle and left of the precordium.
7. The nurse performs an initial abdominal assessment on a patient newly admitted for abdominal pain.
The nurse hears what she describes as "clicks and gurgles in all four quadrants" as well as "swishing or
buzzing sound heard in one or two quadrants." Which of the following statements is correct?
A. The frequency and intensity of bowel sounds varies depending on the phase of digestion.
B. In the presence of intestinal obstruction, bowel sounds will be louder and higher pitched.
C. A swishing or buzzing sound may represent the turbulent blood flow of a bruit and is not normal.
D. All of the above.

7. 8. A patient arrives in the emergency department and reports splashing concentrated household cleaner in
his eye. Which of the following nursing actions is a priority?
A. Irrigate the eye repeatedly with normal saline solution.
B. Place fluorescein drops in the eye.
C. Patch the eye.
D. Test visual acuity.
9. A nurse is caring for a patient who has had hip replacement. The nurse should be most concerned about
which of the following findings?
A. Complaints of pain during repositioning.
B. Scant bloody discharge on the surgical dressing.
C. Complaints of pain following physical therapy.
D. Temperature of 101.8 F (38.7 C).
10. A child is admitted to the hospital with an uncontrolled seizure disorder. The admitting physician writ
orders for actions to be taken in the event of a seizure. Which of the following actions would NOT be
included?
A. Notify the physician.
B. Restrain the patient's limbs.
C. Position the patient on his/her side with the head flexed forward.
D. Administer rectal diazepam.
11. Emergency department triage is an important nursing function. A nurse working the evening shift is
presented with four patients at the same time. Which of the following patients should be assigned the
highest priority?
A. A patient with low-grade fever, headache, and myalgias for the past 72 hours.
B. A patient who is unable to bear weight on the left foot, with swelling and bruising following a running
accident.
C. A patient with abdominal and chest pain following a large, spicy meal.
D. A child with a one-inch bleeding laceration on the chin but otherwise well after falling while jumping on his
bed.
12. A patient is admitted to the hospital with a calcium level of 6.0 mg/dL. Which of the following symptom
would you NOT expect to see in this patient?
A. Numbness in hands and feet.
B. Muscle cramping.
C. Hypoactive bowel sounds.
D. Positive Chvostek's sign.
13. A nurse cares for a patient who has a nasogastric tube attached to low suction because of a suspected
bowel obstruction. Which of the following arterial blood gas results might be expected in this patient?
A. pH 7.52, PCO2 54 mm Hg.
B. pH 7.42, PCO2 40 mm Hg.
C. pH 7.25, PCO2 25 mm Hg.
D. pH 7.38, PCO2 36 mm Hg.

8. 14. A patient is admitted to the hospital for routine elective surgery. Included in the list of current
medications is Coumadin (warfarin) at a high dose. Concerned about the possible effects of the drug,
particularly in a patient scheduled for surgery, the nurse anticipates which of the following actions?
A. Draw a blood sample for prothrombin (PT) and international normalized ratio (INR) level.
B. Administer vitamin K.
C. Draw a blood sample for type and crossmatch and request blood from the blood bank.
D. Cancel the surgery after the patient reports stopping the Coumadin one week previously.
15. The follow lab results are received for a patient. Which of the following results are abnormal? Note:
More than one answer may be correct.
A. Hemoglobin 10.4 g/dL.
B. Total cholesterol 340 mg/dL.
C. Total serum protein 7.0 g/dL.
D. Glycosylated hemoglobin A1C 5.4%.
16. A nurse is performing routine assessment of an IV site in a patient receiving both IV fluids and
medications through the line. Which of the following would indicate the need for discontinuation of the IV
line as the next nursing action?
A. The patient complains of pain on movement.
B. The area proximal to the insertion site is reddened, warm, and painful.
C. The IV solution is infusing too slowly, particularly when the limb is elevated.
D. A hematoma is visible in the area of the IV insertion site.
17. A hospitalized patient has received transfusions of 2 units of blood over the past few hours. A nurse
enters the room to find the patient sitting up in bed, dyspneic and uncomfortable. On assessment, crackles
are heard in the bases of both lungs, probably indicating that the patient is experiencing a complication of
transfusion. Which of the following complications is most likely the cause of the patient's symptoms?
A. Febrile non-hemolytic reaction.
B. Allergic transfusion reaction.
C. Acute hemolytic reaction.
D. Fluid overload.
18. A patient in labor and delivery has just received an amniotomy. Which of the following is correct? Not
More than one answer may be correct.
A. Frequent checks for cervical dilation will be needed after the procedure.
B. Contractions may rapidly become stronger and closer together after the procedure.
C. The FHR (fetal heart rate) will be followed closely after the procedure due to the possibility of cord
compression.
D. The procedure is usually painless and is followed by a gush of amniotic fluid.
19. A nurse is counseling the mother of a newborn infant with hyperbilirubinemia. Which of the following
instructions by the nurse is NOT correct?
A. Continue to breastfeed frequently, at least every 2-4 hours.
B. Follow up with the infant's physician within 72 hours of discharge for a recheck of the serum bilirubin and
exam.
C. Watch for signs of dehydration, including decreased urinary output and changes in skin turgor.

9. D. Keep the baby quiet and swaddled, and place the bassinet in a dimly lit area.
20. A nurse is giving discharge instructions to the parents of a healthy newborn. Which of the following
instructions should the nurse provide regarding car safety and the trip home from the hospital?
A. The infant should be restrained in an infant car seat, properly secured in the back seat in a rear-facing position
B. The infant should be restrained in an infant car seat, properly secured in the front passenger seat.
C. The infant should be restrained in an infant car seat facing forward or rearward in the back seat.
D. For the trip home from the hospital, the parent may sit in the back seat and hold the newborn.
Answers Below
1. Answer: C
The priority nursing action for a patient arriving at the ED in distress is always assessment of vital signs. This
indicates the extent of physical compromise and provides a baseline by which to plan further assessment and
treatment. A thorough medical history, including onset of symptoms, will be necessary and it is likely that an
electrocardiogram will be performed as well, but these are not the first priority. Similarly, chest exam with
auscultation may offer useful information after vital signs are assessed.
2. Answer: C
It is always critical that patients being discharged from the hospital take prescribed medications as instructed. In
the case of antibiotics, a full course must be completed even after symptoms have resolved to prevent incomplete
eradication of the organism and recurrence of infection. The patient should resume normal activities as tolerated,
as well as a nutritious diet. Continued use of the incentive spirometer after discharge will speed recovery and
improve lung function.
3. Answer: C
When a family member is dying, it is most helpful for nursing staff to provide a culturally sensitive environment
to the degree possible within the hospital routine. In the Vietnamese culture, it is important that the dying be
surrounded by loved ones and not left alone. Traditional rituals and foods are thought to ease the transition to the
next life. When possible, allowing the family privacy for this traditional behavior is best for them and the patient
Answers A, B, and D are incorrect because they create unnecessary conflict with the patient and family.
4. Answer: A
The charge nurse planning assignments must consider the skills of the staff and the needs of the patients. The lab
and delivery nurse who is not experienced with the needs of cardiac patients should be assigned to those with the
least acute needs. The patient who is one-week post-operative and nearing discharge is likely to require routine
care. A new patient admitted with suspected MI and scheduled for angiography would require continuous
assessment as well as coordination of care that is best carried out by experienced staff. The unstable patient
requires staff that can immediately identify symptoms and respond appropriately. A post-operative patient also
requires close monitoring and cardiac experience.
5. Answer: B
Glucagon is given to treat insulin overdose in an unresponsive patient. Following Glucagon administration, the
patient should respond within 15-20 minutes at which time oral carbohydrates should be given. Glucagon reverse
rather than enhances or prolongs the effects of insulin. Lipoatrophy refers to the effect of repeated insulin
injections on subcutaneous fat.
6. Answer: D
One gel pad should be placed to the right of the sternum, just below the clavicle and the other just left of the
precordium, as indicated by the anatomic location of the heart. To defibrillate, the paddles are placed over the
pads. Options A, B, and C are not consistent with the position of the heart and are therefore incorrect responses.
7. Answer: D

10. All of the statements are true. The gurgles and clicks described in the question represent normal bowel sounds,
which vary with the phase of digestion. Intestinal obstruction causes the sounds to intensify as the normal flow is
blocked by the obstruction. The swishing and buzzing sound of turbulent blood flow may be heard in the abdome
in the presence of abdominal aortic aneurism, for example, and should always be considered abnormal.
8. Answer: A
Emergency treatment following a chemical splash to the eye includes immediate irrigation with normal saline. Th
irrigation should be continued for at least 10 minutes. Fluorescein drops are used to check for scratches on the
cornea due to their fluorescent properties and are not part of the initial care of a chemical splash, nor is patching
the eye. Following irrigation, visual acuity will be assessed.
9. Answer: D
Post-surgical nursing assessment after hip replacement should be principally concerned with the risk of
neurovascular complications and the development of infection. A temperature of 101.8 F (38.7 C) postoperativel
is higher than the low grade that is to be expected and should raise concern. Some pain during repositioning and
following physical therapy is to be expected and can be managed with analgesics. A small amount of bloody
drainage on the surgical dressing is a result of normal healing.
10. Answer: B
During a witnessed seizure, nursing actions should focus on securing the patient's safely and curtailing the seizur
Restraining the limbs is not indicated because strong muscle contractions could cause injury. A side-lying positio
with head flexed forward allows for drainage of secretions and prevents the tongue from falling back, blocking th
airway. Rectal diazepam may be a treatment ordered by the physician, who should be notified of the seizure.
11. Answer: C
Emergency triage involves quick patient assessment to prioritize the need for further evaluation and care. Patient
with trauma, chest pain, respiratory distress, or acute neurological changes are always classified number one
priority. Though the patient with chest pain presented in the question recently ate a spicy meal and may be
suffering from heartburn, he also may be having an acute myocardial infarction and require urgent attention. The
patient with fever, headache and muscle aches (classic flu symptoms) should be classified as non-urgent. The
patient with the foot injury may have sustained a sprain or fracture, and the limb should be x-rayed as soon as is
practical, but the damage is unlikely to worsen if there is a delay. The child's chin laceration may need to be
sutured but is also non-urgent.
12. Answer: C
Normal serum calcium is 8.5 - 10 mg/dL. The patient is hypocalcemic. Increased gastric motility, resulting in
hyperactive (not hypoactive) bowel sounds, abdominal cramping and diarrhea is an indication of hypocalcemia.
Numbness in hands and feet and muscle cramps are also signs of hypocalcemia. Positive Chvostek's sign refers to
the sustained twitching of facial muscles following tapping in the area of the cheekbone and is a hallmark of
hypocalcemia.
13. Answer: A
A patient on nasogastric suction is at risk of metabolic alkalosis as a result of loss of hydrochloric acid in gastric
fluid. Of the answers given, only answer A (pH 7.52, PCO2 54 mm Hg) represents alkalosis. Answer B is a
normal blood gas. Answer C represents respiratory acidosis. Answer D is borderline normal with slightly low
PCO2.
14. Answer: A
The effect of Coumadin is to inhibit clotting. The next step is to check the PT and INR to determine the patient's
anticoagulation status and risk of bleeding. Vitamin K is an antidote to Coumadin and may be used in a patient
who is at imminent risk of dangerous bleeding. Preparation for transfusion, as described in option C, is only
indicated in the case of significant blood loss. If lab results indicate an anticoagulation level that would place the
patient at risk of excessive bleeding, the surgeon may choose to delay surgery and discontinue the medication.

11. 15. Answer: A and B
Normal hemoglobin in adults is 12 - 16 g/dL. Total cholesterol levels of 200 mg/dL or below are considered
normal. Total serum protein of 7.0-g/dL and glycosylated hemoglobin A1c of 5.4% are both normal levels.
16. Answer: B
An IV site that is red, warm, painful and swollen indicates that phlebitis has developed and the line should be
discontinued and restarted at another site. Pain on movement should be managed by maneuvers such as splinting
the limb with an IV board or gently shifting the position of the catheter before making a decision to remove the
line. An IV line that is running slowly may simply need flushing or repositioning. A hematoma at the site is likel
a result of minor bleeding at the time of insertion and does not require discontinuation of the line.
17. Answer: D
Fluid overload occurs when then the fluid volume infused over a short period is too great for the vascular system
causing fluid leak into the lungs. Symptoms include dyspnea, rapid respirations, and discomfort as in the patient
described. Febrile non-hemolytic reaction results in fever. Symptoms of allergic transfusion reaction would
include flushing, itching, and a generalized rash. Acute hemolytic reaction may occur when a patient receives
blood that is incompatible with his blood type. It is the most serious adverse transfusion reaction and can cause
shock and death.
18. Answer: B, C, and D
Uterine contractions typically become stronger and occur more closely together following amniotomy. The FHR
assessed immediately after the procedure and followed closely to detect changes that may indicate cord
compression. The procedure itself is painless and results in the quick expulsion of amniotic fluid. Following
amniotomy, cervical checks are minimized because of the risk of infection
19. Answer: D
An infant discharged home with hyperbilirubinemia (newborn jaundice) should be placed in a sunny rather than
dimly lit area with skin exposed to help process the bilirubin. Frequent feedings will help to metabolize the
bilirubin. A recheck of the serum bilirubin and a physical exam within 72 hours will confirm that the level is
falling and the infant is thriving and is well hydrated. Signs of dehydration, including decreased urine output and
skin changes, indicate inadequate fluid intake and will worsen the hyperbilirubinemia.
20. Answer: A
All infants under 1 year of age weighing less than 20 lbs. should be placed in a rear-facing infant car seat secured
properly in the back seat. Infant car seats should never be placed in the front passenger seat. Infants should alway
be placed in an approved car seat during travel, even on that first ride home from the hospital.