Emergency Department Prep U

A client comes to the emergency department with a suspected airway obstruction. The emergency department team prepares to manage the client as if he has a complete airway obstruction based on which of the following? Forceful coughing Wheezing between coughs High-pitched noise on inhalation Refusal to lie flat

High-pitched noise on inhalation

A patient brought to the ED by the rescue squad after getting off a plane at the airport is complaining of severe joint pain, numbness, and an inability to move the arms. The patient was on a diving vacation and went for a last dive this morning before flying home. What is a priority action by the nurse? Ensure a patent airway and that the patient is receiving 100% oxygen. Send the patient for a chest x-ray. Send the patient to the hyperbaric chamber. Draw labs for a chemistry panel.

Ensure a patent airway and that the patient is receiving 100% oxygen.

The nurse is caring for a client in the ED following a sexual assault. The client is hysterical and crying. The client states, "I know I'm pregnant now, maybe I have HIV. Why did this happen to me?" Which is the best response by the nurse? "Let's talk about this. Do you want me to call a support person?" "Do you want to discuss antipregnancy measures?" "Do you want the phone number for the National Sexual Assault Hotline?" "Would you like us to complete HIV testing?"

"Let's talk about this. Do you want me to call a support person?"

The nurse is caring for an intensive care unit client who has died with family members at the bedside. The death was sudden and unexpected resulting from a car accident that took place three days ago. The family is upset and the client's partner, crying loudly, yells, "How did this happen? We were just about to celebrate his birthday. He can't be gone!" The family member continues to cry inconsolably. How should the nurse respond? " I will get you some medication that will help you feel more calm." "He has passed on to a better place now." "It is important to face the reality that he is gone." "We did everything we could possibly do to try to save his life."

"We did everything we could possibly do to try to save his life."

A patient with frostbite to both lower extremities from exposure to the elements is preparing to have rewarming of the extremities. What intervention should the nurse provide prior to the procedure? Administer an analgesic as ordered. Massage the extremities. Elevate the legs. Apply a heat lamp.

Administer an analgesic as ordered.

The nurse is caring for a client in the ED with frostbite to the left hand. During the rewarming process of the hand, the nurse should perform which action? Administer analgesic medications as ordered. Keep the hand in the circulating bath for 1 hour. Rupture any hemorrhagic blebs that are noted. Have the client complete active range-of-motion exercises.

Administer analgesic medications as ordered.

The nurse received a patient from a motor vehicle accident who is hemorrhaging from a femoral wound. What is the initial nursing action for the control of the hemorrhage? Apply a tourniquet. Apply firm pressure over the involved area or artery. Elevate the injured part. Immobilize the area to control blood loss.

Apply firm pressure over the involved area or artery.

A female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing interventions should be provided? (Select all that apply.) Have the patient shower or wash the perineal area before the examination. Assess and document any bruises and lacerations. Record a history of the event, using the patient's own words. Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police. Ensure that the police are present when the examination is performed.

Assess and document any bruises and lacerations. Record a history of the event, using the patient's own words. Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police.

Which term refers to injuries that occur when a person is caught between objects, run over by a moving vehicle, or compressed by machinery? Blunt trauma Penetrating abdominal injuries Intra-abdominal injuries Crush injuries

Crush injuries

The nurse has come on shift to find that a client newly admitted to the ICU is confused and persistently trying to get out of bed despite being comforted and re-oriented by the nurse. The client begins to pull on the peripheral intravenous line in the hand and speaking in non-sensical terms. The client's history indicates a sudden onset of neurological symptoms after developing a bacterial infection. The nurse anticipates providing care for which health problem? Delirium Pain Anxiety Fever

Delirium

The nurse is conducting a secondary survey on a client in the ED. Which action is completed during the secondary survey? Diagnostic and laboratory testing Assessment of peripheral pulses Establishing a patent airway Undressing the client

Diagnostic and laboratory testing

A client is brought to the emergency department by ambulance. The client is seriously ill and unconscious. No family or friends are present. Which of the following would be most appropriate to do? Document the client's condition and absence of friends or family for obtaining consent to treatment. Check the client's record for the name of a family member to call to allow care to be provided. Ask the ambulance team for information about the client's family to ensure informed consent. Explain to the client that care is going to be provided because he is seriously ill.

Document the client's condition and absence of friends or family for obtaining consent to treatment.

A nurse is caring for a patient with multiple injuries and performs the following. Place these actions in the order in which the nurse would perform them. Use all option Assess for abdomen, back, and extremity injuries Splint fractures Establish airway and ventilation Assess for head and neck injuries Control hemorrhage Prevent and treat shock

Establish airway and ventilation Control hemorrhage Prevent and treat shock Assess for head and neck injuries Assess for abdomen, back, and extremity injuries Splint fractures

The nurse is providing care to a client who will be ambulating for the first time after being extubated. The client tells the nurse, "I don't want to do this today. It's too soon and I am afraid I am not strong enough." What intervention should the nurse implement first for the client's fear of falling? Explore possible causes of the client's fear Evaluate the client for cognitive impairment Allow the client to remain on bedrest Clear the area around the bed

Explore possible causes of the client's fear

The nurse is caring for a victim of a sexual assault. The client is fearful and experiencing flashbacks. The nurse recognizes that the client is experiencing which phase of the psychological reaction to rape? Heightened anxiety phase Acute disorganization phase Denial phase Reorganization phase

Heightened anxiety phase

A nurse is caring for a client who has arrived at the emergency department in shock. The nurse intervenes based on the knowledge that which of the following is the most common cause of shock? Anaphylaxis Sepsis Hypovolemia Cardiac dysfunction

Hypovolemia

A patient who has accidentally ingested toilet bowel cleaner is brought to the emergency department. Which action would NOT be appropriate for the nurse to implement? Dilution with water or milk Gastric lavage Administration of activated charcoal Induced vomiting

Induced vomiting

A nurse is completing her annual cardiopulmonary resuscitation training. The class instructor tells her that a client has fallen off a ladder and is lying on his back; he is unconscious and isn't breathing. What maneuver should the nurse use to open his airway? Head tilt-chin lift Jaw-thrust Abdominal thrust Seldinger

Jaw-thrust

A client presents to the ED after an unsuccessful suicide attempt. The client is diagnosed with an acetaminophen overdose. The nurse anticipates the administration of which medication? N-acetylcysteine Flumazenil Naloxone Diazepam

N-acetylcysteine

A patient is hemorrhaging from an open wound on his leg. The nurse implements care using the following steps. Place them in the order in which the nurse would perform them. Use all options. Immobilize the leg Apply a pressure dressing Provide firm direct pressure Elevate the leg

Provide firm direct pressure Apply a pressure dressing Elevate the leg Immobilize the leg

A client comes to the emergency department after experiencing a wound. Inspection reveals an opening in the skin with distinct edges and whose depth is greater than the length of the wound. The nurse documents this as which type of wound? Laceration Avulsion Stab Patterned

Stab

A nurse is providing inservice education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step? Collecting semen Performing the pelvic examination Obtaining consent for examination Supporting the client's emotional status

Supporting the client's emotional status

The intensive care unit nurse is assessing a client who is going to require a peripheral intravenous (PIV) line for fluids. The nurse should consider what information in the client's health history when deciding the site for the PIV? The client has had a mastectomy on the right side The client has hypertension The client has a fluid volume restriction The client has a history of falls

The client has had a mastectomy on the right side

What is a common source of airway obstruction in an unconscious client? A foreign object Saliva or mucus The tongue Edema

The tongue

A client present to the ED following a work-related injury to the left hand. The client has an avulsion of the left ring finger. Which correctly describes an avulsion? Tissue tearing away from supporting structures Incision of the skin with well-defined edges, usually long rather than deep Skin tear with irregular edges and vein bridging Denuded skin

Tissue tearing away from supporting structures

Which category of triage encompasses clients with serious health problems that are not immediately life threatening? Emergent Urgent Nonurgent Psychological support

Urgent

A patient arrives at the emergency department after sustaining a gunshot wound to the abdomen. When assessing the patient, the nurse pays particular attention to which of the following? Liver Stomach Large intestine Kidneys

liver

A client is admitted to the ED after a near-drowning accident. The client is diagnosed with saltwater aspiration. The nurse will observe the client for several hours to monitor for symptoms of pulmonary edema. hypothermia. hyponatremia. head injury.

pulmonary edema.

Which phase of the psychological reaction to rape is characterized by fear and flashbacks? Heightened anxiety phase Acute disorganization phase Denial phase Reorganization phase

Heightened anxiety phase

The nurse is preparing to transfer a client from the ICU to a medical unit in the hospital. To ensure consistent communication regarding the client's care needs to the receiving unit, in what sequence of steps should the nurse organize the report? Obtain the client's health record State the client's admission date and current diagnosis Provide a brief statement of current concerns Give the client's pertinent medical history Give recommendations for what needs to be done for the client Provide the most recent vital signs and assessment findings

Obtain the client's health record State the client's admission date and current diagnosis Provide a brief statement of current concerns Give the client's pertinent medical history Provide the most recent vital signs and assessment findings Give recommendations for what needs to be done for the client