RN Introduction to Critical Care and Emergency Nursing Assessment
A nurse is caring for a group of patients in the ED who were exposed to a chemical spill at their work. A student nurse asks the charge nurse where to find the info about safety regarding the chemical spill. Where should the charge nurse instruct the student nurse to find more info about a chemical spill in the workplace?
Look up the Safety Data Sheets (SDS0 on the hospital WiFi network.
A newly licensed nurse is providing care to a patient admitted to the ED who is experiencing heroin toxicity. The patient becomes violent and strikes the nurse. The nurse speaks with the manager about violence in the ED. Which of the following statements represents how the nurse manager should respond to the nurse?
Patients may fear the possible outcome of their clinical situation, leading to stress
A nurse is caring for a patient who is 1 day postop and is currently receiving ventilation. The nurse is organizing staff to move the patient to a chair. the patients family asks why it is necessary to move the patient. Which statement best represents how the nurse should respond?
Patients must be ambulated as early as possible so they can keep their muscle strength
A nurse in the ED is triaging a patient who is accompanied by an individual that refuses to leave the patient alone with the nurse. While assessing the patient, the nurse notes an unusual tattoo on the patients inner thigh, as well as multiple bruises near the groin and lower abdomen. the nurse should consider that the client may need further evaluation for which of the following?
Potential human trafficking
A nurse is caring for a patient who has a terminal illness whose life support equipment is scheduled to be removed. Which of the following actions should the nurse take first?
Prepare in advance how to discuss the situation with the family
An ED nurse is preparing for a pandemic disaster situations that requires more PPE than what is avail. Which of the following elements of resource allocation would be most appropriate for the nurse to implement?
Reusing
An ED nurse is reporting on a patient who is being transferred to ICU. Which of the following sets of people are responsible for the transfer report?
The ED nurse and the ICU nurse
A nurse turns of lights in an older patients room every night. Which of the following is the basis for the nurses intervention?
The nurse is implementing this strategy to prevent the development of delirium in the patient.
A nurse is caring for a patient who was admitted to the Med Surg unit via the ED 1 week ago following a head injury. Upon further review the patient was DX with a hip fracture. While the nurse was providing D/C instructions, the patient began to report left wrist pain. Follow up xrays were obtained and the patient was D/C with a cast for a wrist fracture. Which of the following describes the process performed by nurse during discharge?
The nurse performed a tertiary survey
A nurse is caring for a patient who was admitted to the ED by ambulance. the patients BP is 110/62, HR is 100 bpm, and Resp is 28/min. Which of the following represents how the nurse should perform the "D" portion of the ABCDE assessment?
The nurse should check alertness and response to voice and pain
Next Gen A nurse is caring for a patient who is receiving mechanical ventilation. Complete the following sentence. The nurse should first____________, based upon the patients__________?
The nurse should first POSTPONE AMBULATION, based upon the patients BLOOD PRESSURE
A new nurse assigned to the critical care unit is caring for a patient who requires immediate IV access. the nurse does not have the skills, so they ask a colleague to insert the IV line. Which question should the nurse consider?
What knowledge can I improve upon
A nurse is caring for a patient in the ED who will most likely not survive. The patients family member asks for an update. Which of the following is the best response by the nurse?
Work with the provider to frequently update the family on the status of the patient in a compassionate way.
Next Gen A nurse is caring for a 16 year old patient who presented to the ED with a companion. Click to highlight the findings that require immediate follow up.
- Their companion answers most of the questions. - The patient has bruising to both arms and to their neck. -The companion refuses to allow the nurse to ambulate the patient to the restroom, insists doing it themselves. -Oxygen Sat 96% on RA - Oxygen Sat 94% on RA - Xray of bilateral upper extremities: Multiple healing fractures with a hairline fracture noted to the right 4th rib
A nurse is triaging patients in the ED using the three-tiered triaging system. Which of the following patients should the nurse place in the delayed category?
A patient is reporting generalized abdominal pain, nausea, vomiting, and diarrhea for 3 days. Findings indicate the VS are stable and the patient has no comorbidities and is taking no medications.
A newly licensed nurse working in the ED is learning about the Emergency Medical Treatment and Active Labor Act. During a current disaster, the ED is transferring some patients to another facility prior to the patients being stabilized. Which statement by the nurse manager explains this to the newly licensed nurse?
A provision of EMTALA permits the transfer of patients before they are completely stabilized.
A nurse is preparing to D/C a patient who was treated for injuries related to sexual assault. Which of the following is the most important action for the nurse to take before the patient leaves the facility?
Ask the patient if they wish to return to their home
A nurse is caring for a patient in the ED who reports a HX of MI. Which of the following findings is most concerning?
Chest pain unrelieved by nitroglycerine
A nurse is caring for a patient admitted to the ED following an injury. The nurse demonstrates concern and involves the patient's family in decision making. Which of the following outcomes is the nurse's primary goal from this interaction?
Creating a trusting relationship
An ED nurse is providing care for a patient during a chemical disaster situation. The patient is A/O and can walk and follow commands. Which of the following is the priority action the nurse should take?
Direct the patient to the decontamination area.
A nurse is caring for a 30 year old patient who experience sexual assault 2 days ago. Which of the following is the most important to ask the patient?
Do you know if you were exposed to HIV
Next Gen A nurse is caring for a patient who has suffered significant burns in a house fire. Specify if each intervention is INDICATED, CONTRAINDICATED, or UNRELATED.
Droplet Isolation - UNRELATED Ambulate in the hallway- CONTRAINDICATION Indwelling Urinary Catheter- INDICATED Mechanical ventilation- INDICATED Gastric intubation- INDICATED
A triage nurse is evaluating a patient who reports taking anticoagulation medication and arrived at the ED with bleeding from both nares, which slowed after applying direct pressure to the nose. Which of the following Emergency Severity Index (ESI) levels should the nurse assign to this patient?
ESI level 2
A preceptor in CCU is orienting a new nurse to the code chart. The preceptor communicates to the new nurse that the code charts should be checked at which of the following intervals?
Every 24 hours
A new nurse is working in the ED is caring for a patient who has been sexually assaulted. Which of the following reasons is the most frequently cited for not reporting sexual assaults?
Fear of being stigmatized
