BOOKLET CODE : 011 71. A nurse working at post anesthesia care unit recognized tachycardia immediately after surgery. The nurse recognized it as the earliest indicator and shock. What is the primary responsibility of the nurse? (A) Administer anti pain and continue as usual (B) Re-assess the patient and identify the cause (C) Check vital sign and report to the physician (D) Document findings and wait for 30 minutes 72. A nurse working at central sterilization department received surgical equipments immediately after surgery She was requested to prepare the equipment for the next case. What is the initial activity to be done by the nurse? (C) High level disinfection (A) Decontamination (D) Sterilization (B) Cleaning 73. An emergency patient admitted with chief complaint of sharp chest pain and Thoracentesi:is performed to obtain a specimen of pleural fluid for diagnosis of TBC. The lab result shows drainage purulent , Glucose equal to serum Hevels, increased white blood cells and increased RBC. Which lab result best predict presence of induced pleural effusion of the above case? (A) Drainage appearance (C) RBC level (B) Glucose level (D) WBC level 74. Rescue personnel brought a 19-year-old female patient to the emergency department after a motorcycle crash. She has facial contusion:and lacerations, a fractured stcrnum, three fractured ribs, a hemothorax, a dislocated hip,a fractured pelvis, and multiple minor lacerations. What additional data you need as priority assessment criteria? (C) Body fluid status (A) Airway and breathing (D) Vital sign (B) Consciousness level 75. A 39-year-old male patient was admitted due to motorcycle crash. He has facial contusions and lacerations, a fractured stcrnum , three fractured ribs and hemothorax. Initial findings include sharp pain over chest, an unobstructed airway with absent breath sounds in the right basilar lung field tachypnea with 32 shallow respirations per minute, BP is 94/70 mmHg; skin is cool, bloody and clammy; heart rate is 110 bpm and peripheral pulses are intact. What appropriate nursing intervention should be done first? (C) Initiate IV resuscitation (A) Stop hemorrhage (B) Ventilation support (D) Provide morphine sulphate SUBJECT CODE :01

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$BOOKLET CODE : 011 71. A nurse working at post anesthesia care unit recognized tachycardia immediately after surgery. The nurse recognized it as the earliest indicator and shock. What is the primary responsibility of the nurse? (A) Administer anti pain and continue as usual (B) Re-assess the patient and identify the cause (C) Check vital sign and report to the physician (D) Document findings and wait for 30 minutes 72. A nurse working at central sterilization department received surgical equipments immediately after surgery She was requested to prepare the equipment for the next case. What is the initial activity to be done by the nurse? (C) High level disinfection (A) Decontamination (D) Sterilization (B) Cleaning 73. An emergency patient admitted with chief complaint of sharp chest pain and Thoracentesi:is performed to obtain a specimen of pleural fluid for diagnosis of TBC. The lab result shows drainage purulent , Glucose equal to serum Hevels, increased white blood cells and increased RBC. Which lab result best predict presence of induced pleural effusion of the above case? (A) Drainage appearance (C) RBC level (B) Glucose level (D) WBC level 74. Rescue personnel brought a 19-year-old female patient to the emergency department after a motorcycle crash. She has facial contusion:and lacerations, a fractured stcrnum, three fractured ribs, a hemothorax, a dislocated hip,a fractured pelvis, and multiple minor lacerations. What additional data you need as priority assessment criteria? (C) Body fluid status (A) Airway and breathing (D) Vital sign (B) Consciousness level 75. A 39-year-old male patient was admitted due to motorcycle crash. He has facial contusions and lacerations, a fractured stcrnum , three fractured ribs and hemothorax. Initial findings include sharp pain over chest, an unobstructed airway with absent breath sounds in the right basilar lung field tachypnea with 32 shallow respirations per minute, BP is 94/70 mmHg; skin is cool, bloody and clammy; heart rate is 110 bpm and peripheral pulses are intact. What appropriate nursing intervention should be done first? (C) Initiate IV resuscitation (A) Stop hemorrhage (B) Ventilation support (D) Provide morphine sulphate SUBJECT CODE :01$

BOOKLET CODE : 011 71. A nurse working at post anesthesia care unit recognized tachycardia immediately after surgery. The nurse recognized it as the earliest indicator and shock. What is the primary responsibility of the nurse? (A) Administer anti pain and continue as usual (B) Re-assess the patient and identify the cause (C) Check vital sign and report to the physician (D) Document findings and wait for 30 minutes 72. A nurse working at central sterilization department received surgical equipments immediately after surgery She was requested to prepare the equipment for the next case. What is the initial activity to be done by the nurse? (C) High level disinfection (A) Decontamination (D) Sterilization (B) Cleaning 73. An emergency patient admitted with chief complaint of sharp chest pain and Thoracentesi:is performed to obtain a specimen of pleural fluid for diagnosis of TBC. The lab result shows drainage purulent , Glucose equal to serum Hevels, increased white blood cells and increased RBC. Which lab result best predict presence of induced pleural effusion of the above case? (A) Drainage appearance (C) RBC level (B) Glucose level (D) WBC level 74. Rescue personnel brought a 19-year-old female patient to the emergency department after a motorcycle crash. She has facial contusion:and lacerations, a fractured stcrnum, three fractured ribs, a hemothorax, a dislocated hip,a fractured pelvis, and multiple minor lacerations. What additional data you need as priority assessment criteria? (C) Body fluid status (A) Airway and breathing (D) Vital sign (B) Consciousness level 75. A 39-year-old male patient was admitted due to motorcycle crash. He has facial contusions and lacerations, a fractured stcrnum , three fractured ribs and hemothorax. Initial findings include sharp pain over chest, an unobstructed airway with absent breath sounds in the right basilar lung field tachypnea with 32 shallow respirations per minute, BP is 94/70 mmHg; skin is cool, bloody and clammy; heart rate is 110 bpm and peripheral pulses are intact. What appropriate nursing intervention should be done first? (C) Initiate IV resuscitation (A) Stop hemorrhage (B) Ventilation support (D) Provide morphine sulphate SUBJECT CODE :01

Answer 1

71. (C) Check vital sign and report to the physician Explanation: Tachycardia can be an early indicator of hemorrhage and shock. The nurse's primary responsibility is to assess the patient's vital signs and report any abnormalities to the physician immediately. 72. (A) Decontamination Explanation: The initial activity to be done by the nurse is decontamination. This involves removing any visible debris and contaminants from the surgical equipment before proceeding with cleaning, disinfection, and sterilization. 73. (D) WBC level Explanation: An increased white blood cell (WBC) count in the pleural fluid indicates an infection or inflammation in the pleural space, which is consistent with induced pleural effusion. 74. (A) Airway and breathing Explanation: In a trauma patient with multiple injuries, assessing the airway and breathing is the top priority. Ensuring that the airway is clear and that the patient is breathing adequately is crucial before addressing other assessment criteria. 75. (C) Initiate IV resuscitation Explanation: The patient's vital signs indicate hypovolemic shock due to significant blood loss. The first nursing intervention should be to initiate intravenous (IV) resuscitation to restore blood volume and stabilize the patient's condition.

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