Chapter 8 ER

A client has been injured in a stabbing incident. Assessment reveals the following: Blood pressure: 80/60 mm Hg Heart rate: 140 beats/min Respiratory rate: 35 breaths/min Bleeding from stabbing wound site Client is lethargic Based on these assessment data, to which trauma center should the nurse ensure transport of the client? a. Level I b. Level II c. Level III d. Level IV

A

A new nurse is orienting to the emergency department (ED). Which statement made by the nurse would indicate the need for further education by the preceptor? a. "The emergency medicine physician coordinates care with all levels of the emergency health care team." b. "Emergency departments have specialized teams that deal with high-risk populations of patients." c. "Many older adults seek emergency services when they are ill because they do not want to bother their primary health care provider." d. "Emergency departments are responsible for public health surveillance and emergency disaster preparedness."

A

The emergency medical technicians (EMTs) arrive at the emergency department with an unresponsive client with an oxygen mask in place. What will the nurse do 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 best neurologic response

A

The nurse is triaging clients in the emergency department (ED). Which is true about the presentation of client symptoms? a. Older adults frequently have symptoms that are vague or less specific. b. Young adults present with nonspecific symptoms for serious illnesses. c. Diagnosing children's symptoms often keeps them in the ED longer. d. Symptoms of confusion always represent neurologic disorders.

A

The emergency department (ED) nurse is preparing to transfer a client to the critical care unit. What information should the nurse include in the nurse-to-nurse hand-off report? (Select all that apply.) a. Allergies b. Vital signs c. Immunizations d. Marital status e. Isolation precautions

A, B, E

The nurse is discharging an older adult client home from the emergency department (ED) after an acute episode of angina. What should the nurse do to ensure client safety upon discharge? (Select all that apply.) a. Reconcile the client's prescription and over-the-counter medications b. Screen the client for functional and cognitive abilities, as well as risk for falls c. Consult physical therapy to organize for home health services d. Arrange for the client's car keys to be taken to prevent an accident e. Review discharge instructions with the client and a family member

A, B, E

Which interventions will be performed during the primary survey for a trauma client? (Select all that apply.) a. Removing wet clothing b. Splinting open fractures c. Initiating IV fluids d. Endotracheal intubation e. Foley catheterization f. Needle decompression g. Laceration repair

A, C, D, F

An emergency department nurse is transferring a client to the medical-surgical unit. What is the most important nursing intervention in this situation? a. Triage the client to determine the urgency of care. b. Clearly communicate client data to the unit nurse. c. Evaluate the need for ongoing medical treatment. d. Perform a thorough assessment of the client.

B

An unresponsive client with poor ventilator effort and a pulse rate of 120 beats/min arrives at the emergency department. What should the nurse do first? a. Place the client on a non-rebreather mask. b. Begin bag-valve-mask ventilation. c. Initiate cardiopulmonary resuscitation. d. Prepare for chest tube insertion.

B

The emergency department (ED) nurse is caring for the following clients. Which client does the nurse prioritize to see first? a. 22-year-old with a painful and swollen right wrist b. 45-year-old reporting chest pain and diaphoresis c. 60-year-old reporting difficulty swallowing and nausea d. 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101° F

B

The emergency department nurse is assigned an older adult client who is confused and agitated. Which intervention should the nurse include in the client's plan of care? a. Administer a sedative medication. b. Ask a family member to stay with the client. c. Use restraints to prevent the client from falling. d. Place the client in a wheelchair at the nurses' station.

B

The emergency department team is performing cardiopulmonary resuscitation on a client when the client's spouse arrives at the emergency department. What should the nurse do next? a. Request that the client's spouse sit in the waiting room. b. Ask the spouse if he wishes to be present during the resuscitation. c. Suggest that the spouse begin to pray for the client. d. Refer the client's spouse to the hospital's crisis team.

B

The emergency department (ED) nurse is assigned to triage clients. What is the purpose of triage? a. Treat clients on a first-come, first-serve basis. b. Identify and treat clients with low acuity first. c. Prioritize clients based on illness severity. d. Determine health needs from a complete assessment.

C

A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. What should the nurse do before 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.

B

A client arrives at the emergency department following a motor vehicle collision. The client is not awake and is being bagged with a bag-valve-mask by paramedics. The client has sustained obvious injuries to the head and face, as well as an open right femur fracture that is bleeding profusely. What will the nurse do first? a. Splint the right lower extremity. b. Apply direct pressure to the leg. c. Assess for a patent airway. d. Start two large-bore IVs.

C

A nurse is triaging clients in the emergency department. Which client complaint would the triage nurse classify as nonurgent? a. Chest pain and diaphoresis b. Decreased breath sounds due to chest trauma c. Left arm fracture with palpable radial pulses d. Sore throat and a temperature of 104° F

C

The nurse is caring for a homeless client and consults the emergency department (ED) case manager. What can the ED case manager do for this client? 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.

C

The nurse is providing care for a client admitted for suicidal precautions. What priority intervention should the nurse implement first? a. Administer prescribed anti-anxiety drugs. b. Decrease the noise level and the harsh lighting. c. Remove oxygen tubing from the room. d. Set firm behavioral limits.

C

The nurse is triaging clients in the emergency department. Which client should be considered urgent? a. 20-year-old female with a chest stab wound and tachycardia b. 45 year-old homeless man with a skin rash and sore throat c. 75-year-old female with a cough and of temperature of 102° F d. 50-year-old male with new-onset confusion and slurred speech

C

While assessing a client in the emergency department, the nurse identifies that the client has been raped. Which health care team member should the nurse collaborate with when planning this client's care? a. Emergency medicine physician b. Case manager c. Forensic nurse examiner d. Psychiatric crisis nurse

C

A client in the emergency department has died from a suspected homicide. What is the nurse's priority intervention? 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.

D

On admission to the emergency department, a client states that he feels like killing himself. When planning this client's care, it is most important for the nurse to coordinate with which member of the health care team? a. Case manager b. Forensic nurse examiner c. Physician d. Psychiatric crisis nurse

D

The nurse manager is assessing current demographics of the facility's emergency department (ED) clients. Which population would most likely present to the ED for treatment of a temperature and a sore throat? a. Older adults b. Immunocompromised people c. Pediatric clients d. Underinsured people

D