1. An emergency department nurse assesses a client who has been raped. With which health care team member would the nurse collaborate when planning this
... [Show More] client's care?
a. Primary health care provider
b. Case manager
c. Forensic nurse examiner
d. Psychiatric crisis nurse
ANS: C
All other members of the health care team listed may be used in the management of this client's care. However, the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing with the victim of an assault.
2. The emergency department team is performing cardiopulmonary resuscitation on a client when the client's spouse arrives. Which action would the nurse take first?
a. Request that the client's spouse sit in the waiting room. b. Ask the spouse if he or she wishes to be present during the resuscitation.
c. Suggest that the spouse begin to pray for the patient. d. Refer the client's spouse to the hospital's crisis team.
ANS: B
If resuscitation efforts are still under way when the family arrives, one or two family members may be given the opportunity to be present during lifesaving procedures. The other options do not give the spouse the opportunity to be present for the client or to begin to have closure.
3. An emergency department nurse is triaging victims of a multi-casualty event. Which client would receive care first?
a. A 30-year-old distraught mother holding her crying child
b. A 65-year-old conscious male with a head laceration
c. A 26-year-old male who has pale, cool, clammy skin
d. A 48 year old with a simple fracture of the lower leg
ANS: C
The client with pale, cool, clammy skin may be in shock and needs immediate medical attention. The mother does not have injuries and so would be the lowest priority. The other two people need medical attention soon, but not at the expense of a person in shock.
4. While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action would the nurse take first?
a. Apply oxygen via nasal cannula.
b. Administer intravenous 0.9% saline solution.
c. Transfer the client to a negative-pressure room.
d. Obtain a sputum culture and sensitivity.
ANS: C
A client with signs and symptoms of tuberculosis or other airborne pathogens would be placed in a negative-pressure room to prevent contamination of staff, clients, and family members in the crowded emergency department. The client may or may not need oxygen or an IV. A sputum culture would be obtained but is not the priority.
5. A nurse is triaging clients in the emergency department (ED). Which client would the nurse prioritize to receive care first?
a. A 22 year old with a painful and swollen right wrist
b. A 45 year old reporting chest pain and diaphoresis
c. A 60 year old reporting difficulty swallowing and nausea
d. An 81 year old, respiratory rate 28 breaths/min and temperature of 101° F (38.8° C)
ANS: B
A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable
6. A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center?
a. Level I—located within remote areas and provides advanced life support within resource capabilities
b. Level II—located within community hospitals and provides care to most injured clients
c. Level III—located in rural communities and provides only basic care to clients
d. Level IV—located in large teaching hospitals and provides a full continuum of trauma care for all clients
ANS: B
Level I trauma centers are usually located in large teaching hospital systems and provide a full continuum of trauma care for all clients. Both Level II and Level III facilities are usually located in community hospitals. These trauma centers provide care for most clients and transport to Level I centers when client needs exceed resource capabilities. Level IV trauma centers are usually located in rural and remote areas. These centers provide basic care, stabilization, and advanced life support while transfer arrangements to higher level trauma centers are made
7. Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action would the nurse take first?
a. Assess that the client is breathing adequately.
b. Insert a large-bore intravenous line.
c. Place the client on a cardiac monitor.
d. Assess for the best neurologic response.
ANS: A
After establishing an airway, the highest priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he or she may not be breathing, or may be breathing inadequately with the device in place. Inserting an IV line and placing the client on a monitor would come after ensuring a patent airway and effective breathing.
8. A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action would the nurse take prior to providing advanced cardiac life support?
a. Contact the on-call orthopedic surgeon.
b. Don personal protective equipment.
c. Notify the Rapid Response Team.
d. Obtain a complete history from the paramedic.
ANS: B
Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions would be taken in all resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers. It is not known if this client has orthopedic injuries. The Rapid Response Team is not needed in the ED. A complete history is needed but the staff's protection comes first
9. A nurse is triaging clients in the emergency department. Which client would be considered "urgent"?
a. A 20-year-old female with a chest stab wound and tachycardia
b. A 45-year-old homeless man with a skin rash and sore throat
c. A 75-year-old female with a cough and a temperature of 102° F (38.9° C)
d. A 50-year-old male with new-onset confusion and slurred speech
ANS: C
A client with a cough and a temperature of 102° F (38.9° C) is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. The client with a chest stab wound and tachycardia and the client with new-onset confusion and slurred speech would be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent.
10. An emergency department nurse is caring for a client who has died from a suspected homicide. Which action does the nurse take?
a. Remove all tubes and wires in preparation for the medical examiner.
b. Limit the number of visitors to minimize the family's trauma.
c. Consult the bereavement committee to follow up with the grieving family.
d. Communicate the client's death to the family in a simple and concrete manner.
ANS: D
When dealing with clients and families in crisis, communicate in a simple and concrete manner to minimize confusion. Tubes must remain in place for the medical examiner. Family would be allowed to view the body. Offering to call for additional family support during the crisis is suggested. The bereavement committee would be consulted, but this is not the priority at this time.
1. An emergency department (ED) case manager is consulted for a client who is homeless. Which intervention would the case manager provide?
a. Communicate client needs and restrictions to support staff.
b. Prescribe low-cost antibiotics to treat community-acquired infection.
c. Provide referrals to subsidized community-based health clinics.
d. Offer counseling for substance abuse and mental health disorders
ANS: C
Case management interventions include facilitating referrals to primary care providers who are accepting new clients or to subsidized community-based health clinics for clients or families in need of routine services. The ED nurse is accountable for communicating pertinent staff considerations, client needs, and restrictions to support staff (e.g., physical limitations, Isolation Precautions) to ensure that ongoing client and staff safety issues are addressed. The ED provider prescribes medications and treatments. The psychiatric nurse team evaluates clients with emotional behaviors or mental illness and facilitates the follow-up treatment plan, including possible admission to an appropriate psychiatric facility.
12. An emergency department nurse is caring for a client who is homeless. Which action would the nurse take to gain the client's trust?
a. Speak in a quiet and monotone voice.
b. Avoid eye contact with the patient.
c. Listen to the client's concerns and needs.
d. Ask security to store the client's belongings.
ANS: C
To demonstrate behaviors that promote trust with homeless clients, the emergency department nurse makes eye contact (if culturally appropriate), speaks calmly, avoids any prejudicial or stereotypical remarks, shows genuine care and concern by listening, and follows through on promises. The nurse would also respect the client's belongings and personal space.
13. A nurse is triaging clients in the emergency department. Which client would the nurse classify as "nonurgent?"
a. A 44 year old with chest pain and diaphoresis
b. A 50 year old with chest trauma and absent breath sounds
c. A 62 year old with a simple fracture of the left arm
d. A 79 year old with a temperature of 104° F (40.0° C)
ANS: C
A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with a simple arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration. [Show Less]