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OTHER 1. The nurse is assessing clients on site at a multi-vehicle accident. Triage clients in the order they should receive care. (Place in order of priority.) a. A 50-year-old with chest trauma and difficulty breathing b. A mother frantically looking for her 6-year-old son c. An 8-year-old with a broken leg in his father's arms d. A 60-year-old with facial lacerations and confusion e. A pulseless male with a penetrating head wound

ANS: a, d, b, c, e Clients should be prioritized with ABCs and emergent, urgent, and nonurgent status. The client with chest trauma and difficulty breathing is the priority because no clients have an airway problem, and this is the only client with a breathing problem. The client with confusion should be seen next. Confusion can be caused by lack of oxygen to the brain due to a circulation problem. The pulseless client with a penetrating head wound is seen last because there are multiple clients to be seen, and care for this client would be futile. The client with a broken leg is nonurgent and can wait. The mother looking for her son should be seen third. Finding the child is urgent to identify potential injuries. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities) MSC: Integrated Process: Nursing Process (Assessment)

2. In what sequence would a client move through the process of admission to disposition in emergency care? (Place in order of priority.) a. Client is transported to the medical-surgical floor. b. Emergency department (ED) nurse gives a report on the client. c. Paramedics arrive and start IV access. d. Nurse and other health care provider(s) perform assessment. e. Emergency medical technicians (EMTs) provide oxygen and vital sign monitoring. f. Laboratory technician obtains blood specimens.

ANS: e, c, d, f, b, a When clients are in an emergency situation, EMTs arrive on the scene first. EMTs apply oxygen and obtain vital signs to determine a baseline for further care. EMTs can provide basic life support measures and can assess ABCs. Second on the scene are paramedics. Starting IV access and performing advanced life support is within the paramedic's scope of practice. The client is then transported to an ED, where nurses and other health care providers perform an initial assessment. Laboratory technicians are notified and appropriate blood specimens are obtained for diagnostic testing. When the client is stable, the ED nurse gives report to the medical-surgical unit nurse, and the client is finally transferred to an inpatient room. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC: Integrated Process: Nursing Process (Implementation)

18. 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.

ANS: A Older adults present with symptoms that often are different or less specific than those of younger adults. For example, increasing weakness, fatigue, and confusion may be the only admission concerns. These vague symptoms can be caused by serious illness, such as an acute myocardial infarction (MI), urinary tract infection, or pneumonia. Diagnosing older adults often keeps them in the ED for extended periods of time. DIF: Cognitive Level: Knowledge/Remembering REF: p. 126 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment)

9. 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

ANS: A The Level I trauma center is able to provide a full continuum of care for all client areas. Level II can provide care to most injured clients, but given the extent of his injuries, a Level I center would be better if it is available. Both Levels III and IV can stabilize major injuries, but transport to a higher-level center is preferred, when possible. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Continuity of Care) MSC: Integrated Process: Nursing Process (Assessment)

16. 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."

ANS: A The emergency nurse is one member of the large interdisciplinary team that provides care for clients in the ED. A collaborative team approach to emergency care is considered a standard of practice. In this setting, the nurse coordinates care with all levels of health care team providers, from prehospital emergency medical services (EMS) personnel to physicians, hospital technicians, and professional and ancillary staff. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with Interdisciplinary Team) MSC: Integrated Process: Communication and Documentation

10. 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

ANS: A 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 may not be breathing, or he may be breathing inadequately with the device in place. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities) MSC: Integrated Process: Nursing Process (Assessment)

2. 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

ANS: A, B, E Before discharge, the nurse should ensure that the client's prescription and over-the-counter medications are evaluated to determine whether the drug regimen should be continued. Discharge education should be provided to the client and a significant other or family member. To prevent future ED visits, screen older adults per agency policy for functional assessment, cognitive assessment, and risk for falls. Case management should be consulted to organize home health services. The nurse should emphasize safety when driving but cannot organize to take the client's keys away. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Continuity of Care) MSC: Integrated Process: Teaching/Learning

MULTIPLE RESPONSE 1. 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

ANS: A, B, E Hand-off communication should be comprehensive so that the nurse can continue care for the client fluidly. Communication should be concise and should include only the most essential information for a safe transition in care. Hand-off communication should include the client's situation (reason for being in the ED), brief medical history, assessment and diagnostic findings, transmission-based precautions needed, interventions provided, and response to those interventions. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Continuity of Care) MSC: Integrated Process: Communication and Documentation

3. 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

ANS: A, C, D, F The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic ABC, with an added D and E: A, airway and cervical spine control; B, breathing; C, circulation; D, disability; and E, exposure. After completion of primary diagnostic studies and laboratory studies, and insertion of gastric and urinary tubes, the secondary survey, a complete head-to-toe assessment, can be carried out. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC: Integrated Process: Nursing Process (Implementation)

7. 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

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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities) MSC: Integrated Process: Nursing Process (Assessment)

17. 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.

ANS: B Apneic clients and those with poor ventilatory effort need bag-valve-mask (BVM) ventilation for support until endotracheal intubation is performed and a mechanical ventilator is used. A non-rebreather mask would be appropriate only if the client had adequate spontaneous ventilation. Cardiopulmonary resuscitation is necessary only if the client is pulseless. Chest tubes are inserted for decompression and pneumothorax. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC: Integrated Process: Nursing Process (Implementation)

3. 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.

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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Crisis Intervention) MSC: Integrated Process: Caring

13. 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.

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 should 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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard Precautions/Transmission-Based Precautions/Surgical Asepsis) MSC: Integrated Process: Nursing Process (Planning)

4. 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.

ANS: B Older adults who are confused are at increased risks for falls. Fall prevention includes measures such as siderails up, reorientation, call light in reach, and, in some cases, asking the family member, significant other, or sitter to stay with the client to prevent falls. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention) MSC: Integrated Process: Nursing Process (Planning)

5. 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.

ANS: B The emergency nurse needs to be able to triage, assess, and evaluate. However, these steps have already been carried out in the early phases of the emergency department (ED) admission. When a client is ready to be transferred from the ED, communication with staff nurses from the inpatient units is essential. This report should be a concise but comprehensive report of the client's ED experience. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Continuity of Care) MSC: Integrated Process: Communication and Documentation

14. 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

ANS: C A client with a cough and a temperature of 102° F is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. Clients with a chest stab wound and tachycardia, and with new-onset confusion and slurred speech, should 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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities) MSC: Integrated Process: Nursing Process (Planning)

Multiple Choice 1. aww

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. DIF: Cognitive Level: Comprehension/Understanding REF: p. 122 TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with Interdisciplinary Team) MSC: Integrated Process: Nursing Process (Planning)

20. 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.

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 physician 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. DIF: Cognitive Level: Knowledge/Remembering REF: p. 129 TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with Interdisciplinary Team) MSC: Integrated Process: Nursing Process (Planning)

19. 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.

ANS: C ED triage is an organized system for sorting or classifying clients into priority levels, depending on illness or injury severity. The key concept is that clients who present to the ED with the greatest acuity needs receive the quickest evaluation, treatment, and prioritized resource utilization. A person with a lower-acuity problem may wait longer in the ED because the higher-acuity client is moved to the "head of the line." DIF: Cognitive Level: Knowledge/Remembering REF: p. 127 TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities) MSC: Integrated Process: Nursing Process (Assessment)

12. 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.

ANS: C The first priority in caring for a mentally ill client is providing a safe environment. This would include removing any item that the client could use to harm himself or herself (or others). All the other interventions can be used in providing a therapeutic environment. However, they are not as imperative as the safety of the client and staff. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention) MSC: Integrated Process: Nursing Process (Implementation)

11. 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.

ANS: C The highest-priority intervention in the primary survey is to establish a patent airway. Without an adequate airway to supply oxygen to the cells, a cerebral injury could progress to anoxic brain death. After an airway is established, resuscitation may continue to B for breathing and C for circulation assessment. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities) MSC: Integrated Process: Nursing Process (Assessment)

6. 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

ANS: D The ED serves as an important safety net for clients who are ill or injured but lack access to basic health care. Especially vulnerable populations include the underinsured and the uninsured, who may have nowhere else to go for health care. DIF: Cognitive Level: Comprehension/Understanding REF: p. 122 TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Continuity of Care) MSC: Integrated Process: Communication and Documentation

2. 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

ANS: D The psychiatric crisis nurse interacts with clients and families in crisis. This health care team member can offer valuable expertise to the emergency health care team, which also includes the case manager and the physician. DIF: Cognitive Level: Comprehension/Understanding REF: p. 122 TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with Interdisciplinary Team) MSC: Integrated Process: Nursing Process (Planning)

15. 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.

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 should be allowed to view the body. Offering to call for additional family support during the crisis is suggested. The bereavement committee should be consulted, but this is not the priority at this time. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Psychosocial Integrity (Grief and Loss) MSC: Integrated Process: Caring