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REMAR- Priority Practice Questions & Answers Already Graded A+, Exams of Advanced Education

The nurse on a pediatric unit has received report on four clients. The nurse should first plan to assess which client first? A. A 9 years old, has a fracture of the radial bone and is reporting pain rated 8 on a pain scale of 0 to 10. B. A 5 years old with a history of asthma and has a peak expiratory flow rate of 83% C. A 3 years old client with a temperature of 99.7 and a blood pressure of 70/45. D. A 7 years old with ulcerative colitis and has had 16 blood tinged stools in the last 24 hours. - CORRECT ANSWER-C. The child experiencing fever and hypotension should be seen first, they are at the highest risk in this situation for hypovolemic shock; the average blood pressure for a toddler is 92/56. The child with asthma is not acutely ill at this time; pain is expected with a bone fracture, management of pain is important but does not take priority; ulcerative colitis is expected to produce 10 - 20 bloody stools per day, this is not the priority in this situation.

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2024/2025

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REMAR- Priority Practice
The nurse on a pediatric unit has received report on four clients. The nurse should first
plan to assess which client first?
A. A 9 years old, has a fracture of the radial bone and is reporting pain rated 8 on a pain
scale of 0 to 10.
B. A 5 years old with a history of asthma and has a peak expiratory flow rate of 83%
C. A 3 years old client with a temperature of 99.7 and a blood pressure of 70/45.
D. A 7 years old with ulcerative colitis and has had 16 blood tinged stools in the last 24
hours. - CORRECT ANSWER-C.
The child experiencing fever and hypotension should be seen first, they are at the
highest risk in this situation for hypovolemic shock; the average blood pressure for a
toddler is 92/56. The child with asthma is not acutely ill at this time; pain is expected
with a bone fracture, management of pain is important
but does not take priority; ulcerative colitis is expected to produce 10 - 20 bloody stools
per day, this is not the priority in this situation.
A nurse is working triage during an external disaster. When assessing adequate
breathing in a patient, she should look for which of the following?
A. Look for chest rise.
B. Listen for air exchange.
C. Feel for abdominal movement.
D. All of the above. - CORRECT ANSWER-D
All of the techniques should be utilized in the field. Nurse should observe the rise and
fall of the chest (inspiration and expiration) - this counts as one breath;
The respirations should be counted for a full minute in order to have an accurate
recording. Air exchange should be recorded. Note the pattern of breathing and the
depth of the breaths while feeling for abdominal movement.
The nurse has received 4 clients from a house fire. Which patient should she see first?
A. The client who is unconscious, pulseless, and has dilated pupils.
B. The client who has the tibia bone protruding through the skin and is in severe pain.
C. The client who has soot on the face and the nares and is coughing.
D. The client who has third degree burns of the left foot and is crying. - CORRECT
ANSWER-C
The client with soot on the face and nose may have a potential airway problem. After a
disaster clients are seen in order of priority. Those with life threatening injuries who are
likely to survive are seen first. Those that require immediate care, who can be evaluated
within 2 hours, are seen next. Next are clients who could wait hours to days before
treatment.
A nurse is working an external disaster scene. He knows to reduce the anxiety of a
victim he can:
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REMAR- Priority Practice

The nurse on a pediatric unit has received report on four clients. The nurse should first plan to assess which client first? A. A 9 years old, has a fracture of the radial bone and is reporting pain rated 8 on a pain scale of 0 to 10. B. A 5 years old with a history of asthma and has a peak expiratory flow rate of 83% C. A 3 years old client with a temperature of 99.7 and a blood pressure of 70/45. D. A 7 years old with ulcerative colitis and has had 16 blood tinged stools in the last 24 hours. - CORRECT ANSWER-C. The child experiencing fever and hypotension should be seen first, they are at the highest risk in this situation for hypovolemic shock; the average blood pressure for a toddler is 92/56. The child with asthma is not acutely ill at this time; pain is expected with a bone fracture, management of pain is important but does not take priority; ulcerative colitis is expected to produce 10 - 20 bloody stools per day, this is not the priority in this situation. A nurse is working triage during an external disaster. When assessing adequate breathing in a patient, she should look for which of the following? A. Look for chest rise. B. Listen for air exchange. C. Feel for abdominal movement. D. All of the above. - CORRECT ANSWER-D All of the techniques should be utilized in the field. Nurse should observe the rise and fall of the chest (inspiration and expiration) - this counts as one breath; The respirations should be counted for a full minute in order to have an accurate recording. Air exchange should be recorded. Note the pattern of breathing and the depth of the breaths while feeling for abdominal movement. The nurse has received 4 clients from a house fire. Which patient should she see first? A. The client who is unconscious, pulseless, and has dilated pupils. B. The client who has the tibia bone protruding through the skin and is in severe pain. C. The client who has soot on the face and the nares and is coughing. D. The client who has third degree burns of the left foot and is crying. - CORRECT ANSWER-C The client with soot on the face and nose may have a potential airway problem. After a disaster clients are seen in order of priority. Those with life threatening injuries who are likely to survive are seen first. Those that require immediate care, who can be evaluated within 2 hours, are seen next. Next are clients who could wait hours to days before treatment. A nurse is working an external disaster scene. He knows to reduce the anxiety of a victim he can:

A. Talk with them as he does a head-to-toe assessment. B. Tell them an ambulance is coming, even if it is a disaster situation where there won't be one arriving. C. Tell them to be quiet. D. Tell the client that he is scared too. - CORRECT ANSWER-A Nurses take an active role in reducing stress and anxiety. By speaking with the client during the assessment it is a distraction which may be therapeutic. The nurse should not lie to the client or focus on their own fears when giving care. There was a ruptured gas line and explosion at a large medical clinic. The nurse is assigned to triage. Which patient should she see first? A. A school aged boy standing in the middle of the room. Pale, shaking, and crying out loud. No obvious injuries. B. A teenage boy in shorts with blistered reddened skin covering both legs. No evidence of burns above the legs. Alert and talking but has severe pain. C. A young woman, obviously very pregnant. Complains of shortness of breath. RR 38, shallow, strained. Skin pale, cool and dry, capillary perfusion > 2 seconds. D. A disheveled adult male, poorly groomed. Wandering around without purpose, mumbling. Some scratches and abrasions are noted, but no obvious injury. No breathing difficulties. He tells you his name and where he lives, but speech is bizarre. - CORRECT ANSWER-C A young woman, obviously very pregnant. Complains of shortness of breath. RR 38, shallow, strained. This client has increased respirations and the airway issue is priority over the other clients. A charge nursing working on a cardiac unit notices a nurse staggering down the hall. The nurse has slurred speech, sweating, and has white powder under both nares. What is the priority action of the nurse? A. Notify the hospital supervisor. B. Ask the nurse if she has used any illegal substances. C. Complete an incident report. D. Reassign the nurse's patients to other staff. - CORRECT ANSWER-D. The priority in this situation is client safety. The nurse should be relieved of their assigned clients since these behaviors suggest that the nurse may be impaired; the charge nurse should not confront the other nurse. Instead, a clear factual description of the situation should be documented then reported to the nursing supervisor. A nurse is working in the emergency room. She has 4 patients which should she see first? A. A 79 year old female arrives at the ER with her right arm in a sling. She states she was walking out to get her mail when she tripped on an uneven sidewalk and fell onto her right side. She denies hitting her head or losing consciousness. She has a positive radial pulse in the right arm, there is some deformity noted.

D. The youngest victim - CORRECT ANSWER-C When nurses are in the external field they should initially do a brief visual survey to check the safety of the location. Immediately after that triage should begin with the nearest victim.