ABCDE assessment

In checking a patient's airway, you suspect a spinal cord injury. What maneuver should you use to check for patency

• Head tilt, chin lift

• Move patient's head to the left

• Jaw Thrust

• Pinch nose and wait for patient to grasp for breath throught he mouth

Answer explanation

Jaw thrust is the maneuver used if you suspect spinal cord injury. If no concerns then use head tilt, chin lift

All of the following are audible signs of respiratory distress except for one. Choose which one is not correct.

• Wheezing

• Use of accessory muscles

• Stridor

• Cough

Answer explanation

Use of accessory muscles is a visual sign of respiratory distress

What are the proper steps in taking a client's blood pressure? Select all that apply

• Use a medium sized blood pressure cuff

• Place blood pressure cuff 2 finger breadths above the antecubital fossa

• Ensure the artery index marker is in line with the radial artery

• Check the site for bruises, injuries, signs of infection or fistulas

Answer explanation

The brachial artery should be the one in line with the artery index marker.

Use appropriate cuff size for the patient's arm

In checking Disability which questions should you ask the patient. Choose the correct answer.

• May I ask if you know where you are right now? What do you think is the current date and time?

• Do you have any pain? Which part of your body do you feel pain? Can you score your pain from 0 to 10?

• Do you have any history of diabetes? When was your blood sugar last taken?

• All of the above

Answer explanation

In Disability remember the acronym APBUS

which stands for A - AVCPU, P- pain, B - Blood Sugar, U- Urine, S- Seizures

In checking temperature, select the proper steps to follow. Choose all that apply

• Ensure that the patient is near a heater if they are feeling cold or an AC if they are feeling hot

• I will point the scanner on the patient with a head bandage and dressing

• I will check that the Infrared thermometer is turned on, calibrated and functioning and has been cleaned in the last 24 hours

• None of the above

Answer explanation

We make sure that the patient is not near any device that may affect temperature reading like AC or heaters

We check that the forehead is clear, point the scanner away from the eyes and ensure that the scanner is 2-3 cm away from the forehead