Emergency

The nurse is caring for a client who has just been intubated and started on mechanical ventilation in the intensive care unit. The nurse recognizes that it is possible to inadvertently intubate the right lung only. What nursing assessment and monitoring is required to determine if this complication has occurred? Select all that apply. A) Monitor for both high and low pressure alarms B) Mark the endotracheal tube at the corner of the mouth and nose C) Re-set the ventilator rate as needed D) Apply suctioning to clear the airway E) Auscultate both sides of the chest

A, B, E

A nurse who is a member of an emergency response team anticipates that several patients with airway obstruction may need a cricothyroidotomy. For which of the following patients would this procedure be appropriate? Select all that apply. A) Patient with an obstructed larynx B) Patient who is bleeding from the chest C) Patient with laryngeal edema secondary to anaphylaxis D) Patient with extensive facial trauma E) Patient with a lumbar spine injury

A, C, D

A patient with a history of major depressive disorder is brought to the emergency department by a friend, who reports that the patient took an overdose of prescribed amitriptyline. Which of the following findings would the nurse expect to assess? Select all that apply. A) Tachycardia B) Hypoactive reflexes C) Visual hallucinations D) Clonus E) Hypothermia

A, C, D

The nurse educator is explaining the difference between indications for nasopharyngeal airway insertion versus endotracheal intubation. Which responses from learners indicate correct reasons for the use of endotracheal tubes in clients? Select all that apply. A) To support ventilation in a client with basal skull trauma B) To provide airway support to a client with facial trauma C) To support connecting to mechanical ventilation D) To facilitate removal of tracheobronchial secretions E) To bypass an upper airway obstruction

A, C, D

A patient is brought to the emergency department following an overdose of a selective serotonin reuptake inhibitor (SSRI). While assessing the patient, the nurse suspects that the patient may be developing serotonin syndrome based on which of the following? A) Lack of perspiration B) Hypotension C) Lethargy D) Seizures

D) Seizures

Which data is important for the nurse to record while assessing the client with an open wound? A) Time and place of the injury B) Degree of movement and range of motion C) Vital signs D) Time when the client last received a tetanus immunization

D) Time when the client last received a tetanus immunization

The nurse is caring for a patient in the ED who is breathing but unconscious. In order to avoid an upper airway obstruction, the nurse is inserting an oropharyngeal airway. How would the nurse insert the airway? A) At an angle of 90 degrees B) With the convex portion facing upward C) With the concave portion touching the posterior pharynx D) Upside down and then rotated 180 degrees

D) Upside down and then rotated 180 degrees

A client suspected of acetaminophen (Tylenol) toxicity reports that he ingested the medication at 7 p.m. At what time should the nurse anticipate laboratory tests to assess the acetaminophen level? A) 24 hours from the last dose B) 11:00 p.m. C) Stat D) 8 p.m.

B) 11:00 p.m.

A nurse is providing care to the family of a client who was brought to the emergency department and suddenly died. Which of the following would be appropriate for the nurse to do? Select all that apply. A) Talk with the family about the client having "passed on." B) Provide sedation to family members as needed. C) Ask the family if they would like to view the body. D) Provide a private place for the family to be together. E) Allow the family to express their emotions freely.

C, D, E

Several clients in the emergency department are being categorized by the triage nurse. Which client will the nurse place in the urgent category? A) A 54-year-old client with a history of diabetes presenting with anemia and abdominal pain B) A 60-year-old client presenting with chest pain and ST elevation on electrocardiogram C) A 24-year-old client with multiple gunshot wounds to the chest, arms, and legs D) A 56-year-old client with a cut to the left hand that requires wound debridement and stitches

A

A 13-year-old is being admitted to the ED after falling from a roof and sustaining blunt abdominal injuries. To assess for internal injury in the client's peritoneum, the nurse should anticipate what diagnostic test? A) Computed tomography (CT) scan B) Radiograph C) Barium swallow D) Complete blood count (CBC)

A) Computed tomography (CT) scan

The nurse is caring for a client with diabetes who requires a peripheral intravenous (PIV) line for antibiotic administration and to treat dehydration. The nurse must avoid inserting which type of PIV? A) foot B) upper arm C) forearm D) hand

A) foot

The nurse is providing care to a client who was brought to hospital with a opioid overdose. The nurse should expect to include which immediate interventions in the care of this client? Select all that apply. A) Monitor naloxone intravenous infusion B) Assess the client using the CIWA-A scale C) Apply warming blankets to client D) Assess respiratory rate every 4 to 6 hours E) Ensure the head of the bed remains elevated

A, E

The nurse is providing care for a client who is experiencing alcohol withdrawal. The client reports, "I cannot fall or stay asleep." The nurse observes that the client is agitated, having difficulty falling asleep and crying uncontrollably, with confused speech and a tachycardic pulse. Which intervention should the nurse implement first? A) Assess the client for suicidal and homicidal ideation B) Administer lorazepam as ordered by the health care provider C) Ask a family member to remain with the client D) Encourage the client to use deep breathing

B) Administer lorazepam as ordered by the health care provider

The nurse is caring for a client who sustained a gunshot wound from a drive-by shooting. Which action will the nurse take to protect the chain of evidence? Select all that apply. A) In the event of death, document any tubes or lines before removal. B) Hang wet clothing until dried, then label and give to law enforcement. C) Photograph any wounds twice, and one photograph should include a reference ruler. D) The nurse would summarize any statements made by the client and anyone present. E) Place each piece of the client's clothing in seperate paper bags.

B, C, E

A high school football player is brought to the emergency department after collapsing at practice in extremely hot and humid weather. Which of the following would lead the nurse to suspect that the client is experiencing heat stroke? A) Temperature of 101 degrees F (38 degrees C) B) Diaphoresis C) Delirium D) Bradycardia

C) Delirium

The nurse is caring for a client with known myocardial ischemia. The client will be getting up to ambulate for the first time in three days after being on bedrest since admission to the intensive care unit. Which medication should the nurse administer before the client ambulates? A) Norepinephrine B) Dobutamine C) Nitroglycerin D) Vasopressin

C) Nitroglycerin

A patient is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the physician will perform which of the following actions? A) Insert an oropharyngeal airway. B) Perform the jaw thrust maneuver. C) Perform endotracheal intubation. D) Perform a cricothyroidotomy.

C) Perform endotracheal intubation.

A finger sweep is only to be used in which client population? A) Adolescent B) Child C) Conscious adult D) Unconscious adult

D) Unconscious adult

A client is brought to the emergency department with injuries obtained from a motor vehicle crash. Which action will the nurse take during the secondary survey of the client? Select all that apply. A) Splinting of suspected fractures B) History of the current event C) Results of laboratory tests D) Maintenance of airway E) Head-to-toe assessment

A, B, C, E

A patient is admitted to the ED with suspected alcohol intoxication. The ED nurse is aware of the need to assess for conditions that can mimic acute alcohol intoxication. In light of this need, the nurse should perform what action? A) Check the patient's blood glucose level. B) Assess for a documented history of major depression. C) Determine whether the patient has ingested a corrosive substance. D) Arrange for assessment of serum potassium levels.

A) Check the patient's blood glucose level.

The nurse is conducting a secondary survey on a client in the ED. Which action is completed during the secondary survey? A) Diagnostic and laboratory testing B) Undressing the client C) Assessment o periphrral pulses D) Establishing a patent airway

A) Diagnostic and laboratory testing

A client is admitted to the ED complaining of abdominal pain. Further assessment of the abdomen reveals signs of peritoneal irritation. What assessment findings would corroborate this diagnosis? Select all that apply. A) Copious diarrhea B) Rebound tenderness C) Changes in bowel sounds D) Ascites E) Muscular rigidity

B, C, E

A nurse is establishing a patient's airway. Which action would the nurse perform first? A) Inserting an artificial airway B) Giving abdominal thrusts C) Using the jaw-thrust maneuver D) Repositioning the patient's head

D) Repositioning the patient's head

A nurse is caring for a client who has been the victim of sexual assault. The nurse documents that the client appears to be in a state of shock, verbalizing fear, guilt, and humiliation. What phase of rape trauma syndrome is this client most likely experiencing? A) Reorganization phase B) Heightened anxiety phase C) Denial phase D) Acute disorganization phase

D) Acute disorganization phase

Acetaminophen overdose is treated with administration of which medication? A) N-acetylcysteine B) Diazepam C) Naloxone D) Flumazenil

A) N-acetylcysteine

A nurse is providing wound care to a patient who arrived at the emergency department after being hit by flying glass from a broken window. The nurse asks the patient about his last tetanus shot. Which statement would indicate to the nurse that the patient needs a tetanus booster? A) "It must be at least 6 or 7 years since I had one." B) "My last tetanus shot was 2 1/2 years ago during a check-up." C) "I had one last month after I was injured at work." D) "I just had a tetanus shot last year when I cut my foot on a piece of metal."

A) "It must be at least 6 or 7 years since I had one."

A patient is admitted to the ED after being involved in a motor vehicle accident. The patient has multiple injuries. After establishing an airway and adequate ventilation, theED team should prioritize what aspect of care? A) Control the patient's hemorrhage. B) Assess for cognitive effects of the injury. C) Splint the patient's fractures. D) Assess the patient's neurologic status.

A) Control the patient's hemorrhage.

Which statement reflects the nursing management of the client with a white phosphorus chemical burn? A) Do not apply water to the burn B) Wash off the chemical using warm water, then flush the skin with cool water C) Alternate applications of water and ice to the burn D) Immediately drench the skin with running water from a shower, hose, or faucet

A) Do not apply water to the burn

The nurse is caring for a client in the intensive care unit and while reviewing the client's history, the nurse notes the client had a King laryngeal tube inserted to begin ventilation. The nurse recognizes this intervention was required for which reason? A) Emergency response personnel performed this intervention outside the hospital. B) Laryngeal edema prevented placement of an endotracheal tube. C) The client was hemorrhaging into the neck. D) The client's airway is oversized requiring a specialized endotracheal tube.

A) Emergency response personnel performed this intervention outside the hospital.

A patient presents to the ED complaining of choking on a chicken bone. The patient is breathing spontaneously. The nurse applies oxygen and suspects a partial airway obstruction. Which of the following should the nurse do next? A) Encourage the patient to cough forcefully. B) Prepare the patient for a bronchoscopy. C) Insert a nasopharyngeal airway. D) Insert an oropharyngeal airway.

A) Encourage the patient to cough forcefully.

A patient has undergone a diagnostic peritoneal lavage. The nurse interprets which result as indicating a positive test? A) Evidence of feces B) White blood cell count of 300/mm3 C) Absence of bile D) Red blood cell count of 50,000/mm3

A) Evidence of feces

In which triage category would the nurse include a client who requires simple first aid or basic primary care? A) Fast track B) Nonurgent C) Emergent D) Urgent

A) Fast track

A nurse is providing care to a client who is a victim of trauma resulting from injuries sustained in a convenience store robbery. The client has been stabbed numerous times in the abdomen and chest. His shirt is bloody and torn. Which of the following would be most appropriate when collecting forensic evidence? A) Hanging up any damp or wet clothing to dry before securing B) Placing the law enforcement officer's name on the secured clothing for pick up C) Placing the client's clothing in a plastic bag D) Cutting away clothing through the tears or holes

A) Hanging up any damp or wet clothing to dry before securing

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? A) Heightened anxiety phase B) Acute disorganization phase C) Denial phase D) Reorganization phase

A) 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? A) Hypovolemia B) Sepsis C) Cardiac dysfunction D) Anaphylaxis

A) Hypovolemia

A backcountry skier has been airlifted to the ED after becoming lost and developing hypothermia and frostbite. How should the nurse best manage the client's frostbite? A) Immerse affected extremities in water slightly above normal body temperature. B) Immerse the patient's frostbitten extremities in the warmest water the patient can tolerate. C) Gently massage the patient's frozen extremities in between water baths. D) Perform passive range-of-motion exercises of the affected extremities to promote circulation.

A) Immerse affected extremities in water slightly above normal body temperature.

The nurse is caring for a client suffering from carbon monoxide poisoning. The nurse will expect the client to exhibit which manifestation? A) Intoxication B) Hyperactivity C) Cherry red skin coloring D) Severe hypertension

A) Intoxication

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? A) N-acetylcysteine B) Flumazenil C) Naloxone D) Diazepam

A) N-acetylcysteine

A nurse is providing an in-service program for fellow emergency nurses about hypothermia and rewarming methods used. The nurse determines that the presentation was successful when the group identifies which of the following as a passive active rewarming method? A) Over-the-bed heaters B) Warmed humidified oxygen by ventilator C) Forced warm air blankets D) Cardiopulmonary bypass

A) Over-the-bed heaters

The nurse in an intensive care unit is assigned to two clients. One of the clients has just passed away. The deceased client's family members have arrived to be at the client's bedside. Despite wanting to support the client's family, the nurse is must assess the other client's vital signs every 15 minutes, because the client is receiving a blood transfusion. In this situation, what is the nurse's best action? A) Request that the pastor be present to support the family at the client bedside B) Explain to the family it is a busy time on the unit but someone will be with them soon C) Hand off care of the other client to another nurse D) Delegate the blood transfusion to the licensed practical/vocational nurse

A) Request that the pastor be present to support the family at the client bedside

A triage nurse is talking to a client when the client begins choking on his lunch. The client is coughing forcefully. What should the nurse do? A) Stay with him and encourage him, but not intervene at this time. B) Leave him to get assistance. C) Lay him down, straddle him, and perform the abdominal thrust maneuver. D) Stand him up and perform the abdominal thrust maneuver from behind.

A) Stay with him and encourage him, but not intervene at this time.

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? A) The client has had a mastectomy on the right side B) The client has hypertension C) The client has a fluid volume restriction D) The client has a history of falls

A) The client has had a mastectomy on the right side

The nurse is caring for a client with right ventricular heart failure. The nurse understands hypervolemia will have what effect on the client's heart? A) The client's myocardial oxygen requirements will be higher B) The client's will experience systemic vasodilation C) The client's ventricles will not have to work as hard D) The client's stroke volume will be decreased

A) The client's myocardial oxygen requirements will be higher

An 85-year-old client is admitted to the ED. Heat stroke is suspected. The client's core temperature is 106.2°F (41.2°C), blood pressure (BP) 90/60 mm Hg, and pulse 102 bpm. The nurse understands that the primary treatment measure for the client will include A) immersion of the client in a cold-water bath. B) endotracheal intubation with mechanical ventilation. C) administration of sodium supplements. D) IV hydration with normal saline solution.

A) immersion of the client in a cold-water bath.

A nurse is providing care to a client in the emergency department and walks into the hallway to get equipment. All of a sudden, gunshots are heard. Which of the following would be the nurse's priority? A) protecting him or herself B) securing the area C) gaining control of the situation D) Providing care to the injured

A) protecting him or herself

A nurse is providing care to a client in the critical care unit who is experiencing altered mental status. The nurse uses the mnemonic AEIOUTIPS to address the possible causes. When applying the T portion of the mnemonic, which cause would the nurse identify as a possibility? Select all that apply. A) trauma B) temperature C) thyroid dysfunction D) transient ischemic attack E) tachypnea

A, B

Nursing students are reviewing the categories of intra-abdominal injuries. The students demonstrate understanding of the information when they identify which of the following as examples of penetrating trauma? Select all that apply. A) Gunshot wound B) Knife-stab wound C) Motor-vehicle crash D) Fall from a roof E) Being struck with a baseball bat

A, B

A client with a history of allergies comes to the emergency department. The nurse suspects anaphylaxis based on which of the following? Select all that apply. A) Generalized itching B) Facial angioedema C) Pallor D) Chest tightness E) Increasing blood pressure

A, B, C, D

The nurse is caring for a client in the intensive care unit who is recovering from trauma as a result of a motor vehicle accident that claimed the life of the client's friend. While the nurse is performing a dressing change on the client's surgical wound, the client states, "I don't deserve to live. I have just been thinking about ending it all." As the nurse assesses the client's imminent risk for suicide, what contributing factors need to be considered? Select all that apply. A) The client attempted suicide as a teenager. B) The client's maternal uncle committed suicide. C) The client's parents visit on a daily basis. D) The client had a close relationship to the accident victim. E) The client is not able to ambulate unassisted.

A, B, D

A client presents to the ED following a motor vehicle collision. The client is suspected of having internal hemorrhage. The nurse assesses the client for signs and symptoms of shock. Which are signs and symptoms of shock? Select all that apply. A) Decreasing blood pressure B) Increasing heart rate C) Increasing urine volume D) Delayed capillary refill E) Cool, moist skin

A, B, D, E

Which of the following would the nurse identify as indicating that a client is experiencing a complete airway obstruction? Select all that apply. A) Clutching of the neck B) Cyanosis C) Spontaneous coughing D) Inability to speak E) Stridor

A, B, D, E

A patient is brought to the ED by a friend, who states that a tree fell on the patient's leg and crushed it while they were cutting firewood. What priority actions should the nurse perform? (Select all that apply.) A) Elevating the site to limit the accumulation of fluid in the interstitial spaces B) Splinting the wound in a position of rest to prevent motion C) Performing a fasciotomy D) Inserting an indwelling catheter E) Applying a clean dressing to protect the wound

A, B, E

The nurse is admitting a patient with a penetrating abdominal injury from a knife wound. What should the nursing measures for a penetrating abdominal injury include? (Select all that apply.) A) Covering any protruding viscera with sterile dressings soaked in normal saline solution B) Exploring the abdominal wound with a gloved finger C) Assessing for manifestations of hemorrhage D) Looking for any associated chest injuries E) Irrigating the wound with normal saline and a syringe

A, C, D, E

The nurse is providing care for a client who was admitted to the intensive care unit after suffering cardiovascular collapse secondary to a methamphetamine overdose. The client is semi-conscious and has a nasopharyngeal in place. The nurse anticipates this client may require which interventions? Select all that apply. A) Follow the unit seizure protocol B) Apply warming blankets C) Provide airway support and ventilation D) Administer antipsychotic medication E) Minimize lights and noise disturbances

A, C, D, E

A nurse suspects an older adult is experiencing heat stroke based on which assessment findings? Select all that apply. A) Delirium B) Weakness C) Bradypnea D) Temperature 105 degrees F (40.6 degrees C) E) Increased thirst F) Lack of sweating

A, D, F

The ED staff work collaboratively and follow the ABCDE method to establish and treat health priorities effectively in a client experiencing a trauma. Which action is completed by the nurse when implementing the "D" element of this method? A) Providing cervical spine protection B) Assessing the client's Glasgow Coma Scale score C) Managing hypothermia D) Undressing the client quickly

B) Assessing the client's Glasgow Coma Scale score

A patient working in a chemical facility sustains a chemical burn to his arms. The chemical involved was white phosphorus. Which of the following would be the priority nursing action? A) Dousing the area with large amounts of water B) Brushing off all traces of the chemical from the patient's skin C) Covering the burned area to prevent further spread D) Applying ice to the burned area

B) Brushing off all traces of the chemical from the patient's skin

When assessing a client with suspected carbon monoxide poisoning, which finding would be least reliable? A) Palpitations B) Cherry red skin color C) Confusion D) Headache

B) Cherry red skin color

The health care team in an intensive care unit have experienced a critical incident in which a young client died unexpectedly and the client's father physically attacked the senior physician treating the client. The client's father was arrested and escorted from the intensive care unit by police, against his will and in handcuffs. A critical incident stress management (CISM) staff meeting held 3 days after the incident took place. What would be the purpose for that meeting? A) Counselling B) Debriefing C) Defusing D) Follow up

B) Debriefing

A 6-year-old is admitted to the ED after being rescued from a pond after falling through the ice while ice skating. What action should the nurse perform while rewarming the patient? A) Assessing the patients oral temperature frequently B) Ensuring continuous ECG monitoring C) Massaging the patients skin surfaces to promote circulation D) Administering bronchodilators by nebulizer

B) Ensuring continuous ECG monitoring

The nurse in the ED is triaging patients during the shift. What does the nurse know is the first priority in treating any patient in the ED? A) Controlling hemorrhage. B) Establishing an airway. C) Restoring cardiac output. D) Obtaining consent for treatment.

B) Establishing an airway.

A client is being cared for in the ED. The client is assigned to the triage category of "urgent." How often must the nurse reassess the client? A) Every 15 minutes B) Every 30 minutes C) Every 60 minutes D) Every 120 minutes

B) Every 30 minutes

A client presents to the ED following a chemical burn. The client identifies the source of the burn as white phosphorus. The nurse knows that treatment will include A) washing off the chemical using warm water, then flushing the skin with cool water. B) No application of water to the burn. C) immediately drenching the skin with running water from a shower, hose, or faucet. D) alternately applying water and ice to the burn.

B) No application of water to the burn.

When preparing to perform abdominal thrusts on a client with an airway obstruction, which of the following would be most appropriate? A) Using a sequence of four thrusts, each progressing in intensity B) Positioning the hands in the midline slightly above the umbilicus C) Placing the thumb side of one hand at the xiphoid process D) Having the conscious client lie down

B) Positioning the hands in the midline slightly above the umbilicus

The nurse observes that the family members of a patient who was injured in an accident are blaming each other for the circumstances leading up to the accident. The nurse appropriately lets the family members express their feelings of responsibility, while explaining that there was probably little they could do to prevent the injury. In what stage of crisis is this family? A) Anxiety and denial B) Remorse and guilt C) Anger D) Grief

B) Remorse and guilt

A client presents to the ED with a stab wound to the abdomen following an assault. It is suspected that the client has an injury to the pancreas. Which laboratory study is used to detect pancreatic injury? A) White blood cell count B) Serum amylase C) Urinalysis D) Hemoglobin and hematocrit

B) Serum amylase

The nurse is caring for a client who is being prepared for the placement of a central intravenous line. The nurse recognizes this client requires this type of intravenous access for which reason? A) The client will require intravenous access for three days B) The client requires total parenteral nutrition C) The client requires infusion of intravenous antibiotics D) The client requires infusion of a dextrose 5% water (D5W)

B) The client requires total parenteral nutrition

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

B) Urgent

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.) A) Have the patient shower or wash the perineal area before the examination. B) Assess and document any bruises and lacerations. C) Record a history of the event, using the patient's own words. D) 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. E) Ensure that the police are present when the examination is performed.

B, C, D

A nurse is performing a primary survey of a client brought to the emergency department. Which of the following would the nurse include? Select all that apply. A) Applying monitoring devices B) Providing adequate ventilation C) Establishing airway patency D) Obtaining a complete health history E) Assessing neurologic function

B, C, E

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? A. Evaluate the client for cognitive impairment B. Explore possible causes of the client's fear C. Clear the area around the bed D. Allow the client to remain on bedrest

B. Explore possible causes of the client's fear

Which of the following statements would most lead a nurse to suspect that a patient is experiencing food poisoning? A) "I've been feeling sick to my stomach for about 3 or 4 days now." B) "The food I ate seemed to look and taste like it should." C) "My brother got sick like me after eating the same food." C) "I have a pain in my left side, down low near my groin."

C) "My brother got sick like me after eating the same food."

A patient is brought to the emergency department. Assessment reveals that the patient is lethargic and diaphoretic and complaining of right upper quadrant pain. Acetaminophen toxicity is suspected and an acetaminophen level is drawn. Which result would the nurse interpret as indicating toxicity for the patient if he weighs 70 kg? A) 9100 mg B) 7700 mg C) 10,500 mg D) 6300 mg

C) 10,500 mg An acetaminophen level greater than or equal to 140 mg/kg would be considered toxic. For a patient weighing 70 kg, the toxic level would be 9800 mg. A level of 10,500 mg would be greater, thus indicating toxicity.

The nurse is caring for a client who is agitated and confused. The client is persistently trying to get out of bed and attempted to remove the peripheral IV. The nurse has attempted to re-orient the client; however, this was not effective in de-escalating the client's agitation. The client yells, "I am going to punch you in the face!" What is the nurse's next action? A) Administer antipsychotic medication B) Apply physical restraints C) Call security personnel to assist D) Move out of the client's view

C) Call security personnel to assist

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? A) Forceful coughing B) Wheezing between coughs C) High-pitched noise on inhalation D) Refusal to lie flat

C) High-pitched noise on inhalation

A nurse is providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate? A) Placing sterile cotton between the toes after rewarming B) Restricting ambulation C) Massaging the feet D) Providing an analgesic for pain

C) Massaging the feet

The nurse has commenced a transfusion of fresh frozen plasma (FFP) and notes the client is exhibiting symptoms of a transfusion reaction. After the nurse stops the transfusion, what is the next required action? A) Remove the intravenous (IV) line. B) Run a solution of 5% dextrose in water. C) Run normal saline at a keep-vein-open rate. D) Obtain a culture of the tip of the catheter device removed from the client.

C) Run normal saline at a keep-vein-open rate.

A patient was bitten by a tick 3 months ago and is now having muscle aches as well as joint pain and swelling. The patient is having difficulty with self care and requires assistance with activities of daily living (ADLs). What stage of Lyme disease does the nurse recognize the patient is in? A) Stage II B) Stage IV C) Stage III D) Stage I

C) Stage III

A triage nurse determines that a client with non-life-threatening injuries requires imaging studies and moderate sedation. The triage nurse would document this client as which of the following? A) Emergent B) Resuscitation C) Urgent D) Nonurgent

C) Urgent

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? A) pain B) fever C) delirium D) anxiety

C) delirium

An emergency nurse has collected evidence from a patient who was shot during a robbery. The nurse is preparing to transfer the evidence to law enforcement. Which of the following would be important for the nurse to include when documenting this transfer? Select all that apply. A) The labels placed on the collection bags B) Family members who witnessed the transfer C) Name of the law-enforcement official D) Time of the transfer of evidence E) Date that the evidence was collected

C, D, E

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

C. Crush injuries

A client arrives at the emergency department and is experiencing a severe allergic reaction to a bee sting. The client received treatment and is being discharged. Which client statement indicates that additional teaching about exposure prevention is needed? A) "I should always wear something on my feet when I'm outside." B) "If a bee comes near me, I should stay still." C) "I need to avoid using perfumes and scented soaps when I'm going outside." D) "Brightly colored clothes help to ward off bees."

D) "Brightly colored clothes help to ward off bees."

A nurse is providing in-service 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? A) Collecting semen B) Performing the pelvic examination C) Obtaining consent for examination D) Supporting the client's emotional status

D

As part of an emergency department team, an emergency nurse is conducting a secondary survey on a client. Which of the following would the nurse include? A) Providing adequate ventilation B) Assessing neurologic function C) Establishing a patent airway D) Applying electrocardiogram electrodes

D) Applying electrocardiogram electrodes

After inserting an oropharyngeal airway, the nurse determines that it is in the proper position when the flange is located at which position? A) Directly in front of the patient's teeth B) Just below the tip of the patient's nose C) At the level of the patient's epiglottis D) Approximately at the patient's lips

D) Approximately at the patient's lips

A client is brought to the emergency department with abdominal and pelvic injuries caused by a motor vehicle crash. Which action will the nurse take when the client is prescribed to have an indwelling catheter inserted? A) Complete a portable bladder scan before inserting the catheter. B) Review the results of urodynamic testing prior to inserting the catheter. C) Provide the client with a fracture bed pan before inserting the catheter. D) Ask if the rectal examination has been done prior to inserting the catheter.

D) Ask if the rectal examination has been done prior to inserting the catheter.

A 40-year-old client is admitted to the ED with facial bruises and a broken right wrist. Upon further assessment, the nurse notes multiple bruises in various stages of healing. Which is the best course of action by the nurse? A) Providing the client with information about local shelters B) Contacting the local police and reporting the suspected abuse C) Asking the client how the various bruises were obtained D) Asking the client whether they are experiencing abuse

D) Asking the client whether they are experiencing abuse

A client with depression and behavioral changes is transferred from a local assisted living center to the emergency department. The nurse notes that the client cries out when she approaches. When the nurse gains the client's confidence and performs an assessment, the nurse notes bruising of the labia and a lateral laceration in the perineal area. When the nurse asks the client about the injury, the client shakes her head and begins to cry "don't tell, don't tell." The nurse suspects sexual abuse. How should the nurse proceed? A) Notify the rape crisis team. B) Notify the client's family. C) Notify the physician of her findings immediately. D) Attend to the client's physiological needs.

D) Attend to the client's physiological needs.

A client is brought to the emergency department with severe hemorrhage requiring massive blood replacement. The nurse warms the blood in a commercial warmer based on the understanding that infusion of large amounts of blood could result in which of the following? A) Fluid overload B) Hyperthermia C) Hemolytic transfusion reaction D) Cardiac arrest

D) Cardiac arrest

A nurse is preparing an in-service education program about emergency nursing to a group of newly hired nurses who will be working in the emergency department. When describing the current status of visits to the emergency department, which of the following would the nurse include in the presentation? A) Clients, on average wait about a hour before being seen by a health care provider. B) Heart attacks and stroke account for most of the visits to the emergency department. C) The majority of clients arriving at the emergency department arrive by ambulance. D) Clients with Medicaid use the emergency department more often than clients with private health insurance.

D) Clients with Medicaid use the emergency department more often than clients with private health insurance.

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? A) Check the client's record for the name of a family member to call to allow care to be provided. B) Ask the ambulance team for information about the client's family to ensure informed consent. C) Explain to the client that care is going to be provided because he is seriously ill. D) Document the client's condition and absence of friends or family for obtaining consent to treatment.

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

A patient arrives at the emergency department after taking more than 20 lorazepam tablets. Which of the following would the nurse anticipate that the patient would be given to reverse the effects of the drug? A) Diazepam B) Naloxone C) N-acetylcysteine D) Flumazenil

D) Flumazenil

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

D) Heightened anxiety phase

The nurse is administering antivenin to a patient who was bitten on the arm by a venomous snake. What intervention provided by the nurse is required prior to the procedure and every 15 minutes after? A) Administer diphenhydramine (Benadryl). B) Administer cimetidine (Tagamet). C) Assess peripheral pulses. D) Measure the circumference of the arm.

D) Measure the circumference of the arm.

The nurse in an intensive care unit is caring for a client who requires blood work to assess for changes in blood coagulation due to heparin therapy. Which test should the nurse expect to see prescribed for this value to be assessed? A) White blood cell (WBC) B) Lactate C) Arterial blood gas (ABG) D) Prothrombin time (PTT)

D) Prothrombin time (PTT)

The nurse is caring for a 21-year-old client with a diagnoses of brain death due to injuries sustained in a snowboarding accident. The family has chosen to remove life support measures to allow the client's death. Upon hearing the family's decision, what is the nurse's first action? A) Ask the family if the client had advanced directives B) Provide family members with PRN sedation C) Assess for interrupted family processes D) Request senior medical staff discuss organ donation

D) Request senior medical staff discuss organ donation

Following a motor vehicle collision, a patient is brought to the ED for evaluation and treatment. The patient is being assessed for intra-abdominal injuries. The patient states severe left shoulder pain (pain score of 10 on a 1 to 10 pain scale). The nurse suspects injury to which of the following? A) Gallbladder B) Large intestines C) Liver D) Spleen

D) Spleen

A nurse is assessing a patient who is suspected of having a partial airway obstruction. Which of the following would the nurse expect to find? A) Cyanosis B) High-pitched noises on inhalation C) Severe respiratory distress D) Spontaneous coughing

D) Spontaneous coughing

Following an earthquake, a client who was rescued from a collapsed building is seen in the emergency department. He has blunt trauma to the thorax and abdomen. The nursing observation that most suggests the client is bleeding is: A) diminished breath sounds. B) a recent history of warfarin (Coumadin) usage. C) a prolonged partial thromboplastin time (PTT). D) orthostatic hypotension.

D) orthostatic hypotension.