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Naam: ____________________ Datum: ____________
1.Makkelijk
In the ABC framework, which finding is mainly a breathing problem?
AStridor caused by a swollen throat
BShallow breaths with an SpO₂ of 85% on room air
CHeart rate 150/min with a low blood pressure and cold skin
DA blood glucose of 60 mg/dL (3,3 mmol/L)
2.Makkelijk
What does the Morse Fall Scale measure?
AA patient’s skin integrity
BA patient’s pain level
CA patient’s risk of falling
DA patient’s nutrition status
3.Makkelijk
In mass-casualty triage, what does a yellow tag usually mean?
ADeceased or not expected to survive
BImmediate: life-threatening injuries that are survivable with quick care
CMinor: the walking wounded
DDelayed: serious injuries, but care can safely wait a little
4.Gemiddeld
A nasogastric tube has just been placed for feeding. What must happen before the first feed is given?
AThe feed is started slowly to see if the patient coughs
BThe tube is flushed with a large volume of water
CPlacement is confirmed by an approved method
DThe patient is asked if the tube feels comfortable
5.Gemiddeld
A patient has a blood pressure of 210/120 mmHg. Which finding would make this a hypertensive emergency?
ANew chest pain or confusion suggesting organ damage
BA history of high blood pressure for ten years
CMild anxiety about the high reading on the monitor
DForgetting to take the blood pressure tablet this morning
6.Gemiddeld
A nurse teaches a patient who uses home oxygen. Which statement shows a need for further teaching?
A“I will put up no-smoking signs at the front door and in my room.”
B“My husband can smoke in my room if the window is open.”
C“I will not use oil-based creams on my face.”
D“I will keep the oxygen away from the gas stove.”
7.Moeilijk
An RN has five patients and a nursing assistant. One patient has just become short of breath. Which task should the RN delegate so that the RN can go to that patient?
AExplaining the new diagnosis to the breathless patient’s family
BGiving the breathless patient’s IV furosemide
CAssessing the breathless patient’s lung sounds
DMorning vital signs on the four stable patients
8.Moeilijk
A patient with a severe asthma attack had a PaCO₂ of 32 mmHg (4,3 kPa) on arrival. An hour later it is 46 mmHg (6,1 kPa), and the patient seems tired. What does this suggest?
ARespiratory muscle fatigue with possible impending respiratory failure
BThe patient is hyperventilating even more than before and needs calming
CA laboratory error that should be ignored
DThe asthma is improving, because the PaCO₂ is now near normal
Antwoordenblad
1. B · Shallow breaths with an SpO₂ of 85% on room air
2. C · A patient’s risk of falling
3. D · Delayed: serious injuries, but care can safely wait a little
4. C · Placement is confirmed by an approved method
5. A · New chest pain or confusion suggesting organ damage
6. B · “My husband can smoke in my room if the window is open.”
7. D · Morning vital signs on the four stable patients
8. A · Respiratory muscle fatigue with possible impending respiratory failure
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