NCLEX-PN

Chapter 2: Quiz & Answer Key 1. The nurse prepares to administer docusate sodium and perform a client’s daily dressing change. The fire alarm suddenly begins sounding. Which is the next action by the nurse? A.​ Change the dressing quickly and hold the medication. B.​ Administer the medication and postpone the dressing change. C.​ Respond to the alarm and postpone client care. D.​ Ask other nurses on the unit whether it is a real fire or a drill. Correct Response : C Explanation : When a fire alarm sounds, the nurse should follow the RACE response protocol . The RACE acronym represents the following steps: R emove, A larm/Alert, C onfine, E xtinguish/Evacuate. During this time, the nurse should delay any non-life-saving procedures, such as client care or routine tasks like changing dressings and administering docusate sodium for constipation. The immediate focus should be on responding to the alarm as directed, as this is crucial for learning emergency plans in case of a drill and ensuring the safety of both themselves and the clients in case of a real fire. Prioritizing the response to the alarm is essential for everyone's safety, especially when the nurse is engaged in routine care rather than emergency actions. (See Disaster Planning: Fire Prevention ) 2. The LPN discovers an unconscious 8-year-old in the bathroom. She does a quick assessment and discovers he is not breathing and does not have a pulse. The LPN is alone and does not have quick access to a call button. What should she do first? A.​ Give 2 minutes of CPR at a compression-ventilation ratio of 15:2. Then, look for help and an AED, and return and resume CPR. B.​ Look for help and an AED, then give 2 minutes of CPR at a compression-ventilation ratio of 30:2. C.​ Look for help and an AED, then give 1 minute of CPR at a compression-ventilation ratio of 15:2. D.​ Give 2 minutes of CPR at a compression-ventilation ratio of 30:2. Then, look for help and an AED, and return and resume CPR. Correct Response : D Explanation : According to the current American Heart Association (AHA) Guidelines, if alone, you should do CPR on an unconscious infant or child (up to puberty) for two minutes at a compression-ventilation ratio of 30:2, then seek help and look for an AED. In two-person CPR, a compression-ventilation ratio of 15:2 is utilized. When asking questions, don't forget to think about characterizing words like first, next, before, and after. Even if the other answer options can be relevant to the question, they signal that there

is only one right response. (See Cardiopulmonary Resuscitation ) 3. Which of the following is considered an internal disaster? A.​ A tornado that has touched down on the healthcare facility B.​ A severe cyclone that has destroyed nearby homes C.​ A massive train accident that brings victims to your facility D.​ An act of bioterrorism in a nearby factory

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