RPN Emergency Response 3 — Questions and Answers
Question 1: A patient presents with a Glasgow Coma Scale (GCS) score of 8. The nurse correctly interprets this as:
- Mild traumatic brain injury
- Moderate traumatic brain injury
- Severe traumatic brain injury (Correct answer)
- Normal neurological function
Correct answer: Severe traumatic brain injury
A GCS score of 8 or below indicates severe traumatic brain injury and typically necessitates intubation to protect the airway.
Question 2: During CPR, the nurse notes the cardiac monitor shows ventricular fibrillation. The MOST appropriate next action is:
- Administer 1 mg epinephrine IV push
- Deliver a synchronized cardioversion at 100 J
- Deliver an unsynchronized defibrillation shock (Correct answer)
- Administer amiodarone 300 mg IV push
Correct answer: Deliver an unsynchronized defibrillation shock
Ventricular fibrillation is a shockable rhythm requiring immediate unsynchronized defibrillation as the first intervention.
Question 3: A patient is brought in after a house fire with suspected carbon monoxide poisoning. The pulse oximetry reads 99%. The nurse should:
- Reassure the patient that oxygen saturation is normal
- Apply 100% high-flow oxygen via nonrebreather mask regardless of SpO2 (Correct answer)
- Obtain an arterial blood gas to verify oxygenation
- Administer supplemental oxygen at 2 L/min via nasal cannula
Correct answer: Apply 100% high-flow oxygen via nonrebreather mask regardless of SpO2
Pulse oximetry cannot differentiate carboxyhemoglobin from oxyhemoglobin, so CO-poisoned patients must receive 100% O2 to accelerate CO elimination.
Question 4: A nurse is caring for a trauma patient who develops Beck's triad (hypotension, muffled heart sounds, and jugular venous distension). The nurse should suspect:
- Tension pneumothorax
- Cardiac tamponade (Correct answer)
- Pulmonary embolism
- Aortic dissection
Correct answer: Cardiac tamponade
Beck's triad is the classic presentation of cardiac tamponade caused by fluid accumulation in the pericardial sac compressing the heart.
Question 5: A patient presents with epistaxis that has not stopped despite 20 minutes of direct pressure. The nurse anticipates which intervention?
- Application of ice to the forehead
- Nasal packing with vasoconstrictive agents (Correct answer)
- Immediate surgical ligation
- Administration of protamine sulfate
Correct answer: Nasal packing with vasoconstrictive agents
Persistent epistaxis unresponsive to direct pressure is treated with anterior nasal packing, often with vasoconstricting agents like oxymetazoline-soaked gauze.
Question 6: A nurse assesses a burn patient and determines the burns cover the entire anterior trunk and both anterior arms. Using the Rule of Nines, what is the total body surface area (TBSA) burned?
- 18%
- 27% (Correct answer)
- 36%
- 45%
Correct answer: 27%
Anterior trunk = 18%, anterior surface of each arm = 4.5% each (9% total), giving 18% + 9% = 27% TBSA.
Question 7: A patient with a suspected spinal cord injury is immobilized on a long backboard. After assessment, the nurse's priority is to:
- Maintain supine position on the backboard indefinitely
- Remove the backboard as soon as a complete spinal injury is ruled out (Correct answer)
- Keep the patient on the board until surgical consult is obtained
- Place the patient in the Trendelenburg position to improve perfusion
Correct answer: Remove the backboard as soon as a complete spinal injury is ruled out
Long backboards cause pressure injuries and respiratory compromise, so patients should be removed from the board as soon as spinal injury is clinically cleared.
RPN Emergency Response 3
A patient presents with a Glasgow Coma Scale (GCS) score of 8.
The nurse correctly interprets this as: