EMERGENCY NURSING COMPREHENSIVE EXAMINATION

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. 22. The client with a temperature of 94˚F is being treated in the ED. Which intervention should the nurse implement to directly elevate the client's temperature? 1. Remove the client's clothing. 2. Place a warm air blanket over the client. 3. Have the client change into a hospital gown. 4. Raise the temperature in the room.

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1. The ED nurse is caring for a client diagnosed with multiple rib fractures. Which data should the nurse include in the assessment? 1. Level of orientation to time and place. 2. Current use and last dose of medication. 3. Symmetrical movement of the chest. 4. Time of last meal the client ate.

1,2,4

10. The occupational health nurse is called to the scene of a traumatic amputation of a finger. Which intervention should the nurse implement prior to sending the client to the ED? Select all that apply. 1. Rinse the amputated finger with sterile normal saline. 2. Place the amputated finger in a sealed and watertight plastic bag. 3. Place the amputated finger into iced saline solution. 4. Wrap the amputated finger in saline-moistened gauze dressings. 5. Replace the amputated finger on the hand and wrap with gauze.

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11. The nurse is teaching the client home care instructions for a reimplanted finger after a traumatic amputation. Which information should the nurse include the teaching? 1. Perform range-of-motion exercises weekly. 2. Smoking may be resumed if it does not cause nausea. 3. Protect the finger and be careful not to reinjure the finger. 4. An elevated temperature is the only reason to call the HCP.

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12. The ED nurse is caring for a client diagnosed with frostbite of the feet. Which intervention should the nurse implement? 1. Massage the feet vigorously. 2. Soak the feet in warm water. 3. Apply a heating pad to feet. 4. Apply petroleum jelly to feet.

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13. A student reports to the school nurse with complaints of stinging and burning from a wasp sting. Which intervention should the nurse implement? 1. Grasp the stinger and pull it out. 2. Apply a warm, moist soak to the area. 3. Cleanse the site with alcohol. 4. Apply an ice pack to the site.

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14. The ED nurse is caring for a client who had a severe allergic reaction to a bee sting. Which discharge instructions should the nurse discuss with the client? 1. Instruct the client to wear a medical identification bracelet. 2. Apply corticosteroid cream to the site to prevent anaphylaxis. 3. Administer epinephrine 1:10,000 intravenously every three (3) minutes. 4. Teach the client to avoid attracting insects by wearing bright colors.

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15. The ED nurse is caring for a client with fractured pelvis and bladder trauma secondary to a motor-vehicle accident. Which data are most important for the nurse to assess? 1. Monitor the creatinine and BUN. 2. Check urine output hourly. 3. Note the amount and color of the urine. 4. Assess for bladder distention.

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16. The school nurse is caring for a child with a deep laceration. Which intervention should the nurse implement first? 1. Clean with saline solution. 2. Apply direct pressure. 3. Don nonsterile gloves. 4. Notify the child's parents.

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17. The ED receives a client involved in a motor-vehicle accident. The nurse notes a large hematoma on the right flank. Which intervention should the nurse implement first? 1. Insert an indwelling urinary catheter. 2. Take the vital signs every 15 minutes. 3. Monitor the skin turgor every hour. 4. Mark the edges of the bruised area.

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18. Which expected outcome is priority for the nurse who is caring for a client with chest trauma from a gunshot injury? 1. The client will have an absence of pain. 2. The client will maintain a BP of 90/60. 3. The client will have symmetrical chest expansion. 4. The client will maintain urine output of 30 mL/hr.

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19. Which problem is most appropriate for the nurse to identify for the client experiencing renal trauma? 1. Infection of the renal tract. 2. Ineffective tissue perfusion. 3. Alteration in skin integrity. 4. Alteration in temperature.

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2. The nurse is caring for a client in the ED with abdominal trauma who has had peritoneal lavage. Which intervention should the nurse include in the plan of care? 1. Assess for the presence of blood, bile, or feces. 2. Palpate the client for bilateral femoral pulses. 3. Perform Leopold's maneuver every eight (8) hours. 4. Collect information on the client's dietary history.

1

20. The nurse is discharging a client from the ED with a sutured laceration on the right knee. Which information is most important for the nurse to obtain? 1. The date of the client's last tetanus injection. 2. The name of the client's regular health-care provider. 3. Explain the sutures must be removed in 10 to 14 days. 4. Determine if the client has any drug or food allergies.

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21. The nurse working in an outpatient clinic is caring for a client who is experiencing epistaxis. Which intervention should the nurse implement first? 1. Take the client's blood pressure in both arms. 2. Hold the nose with thumb and finger for 15 minutes. 3. Have the client sit with the head tilted back and hold a tissue. 4. Prepare to administer silver nitrate, a cauterizing agent, with a packing applicator

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23. The ED nurse is caring for the client who has taken an overdose of cocaine. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Evaluate the airway and breathing. 2. Monitor the rate of intravenous fluids. 3. Place the cardiac monitor on the client. 4. Transfer the client to the intensive care unit.

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24. The client has been brought to the ED by ambulance following a motor-vehicle accident with a flail chest, an intravenous line, and a Heimlich valve. Which intervention should the nurse implement first? 1. Start a large-bore intravenous access. 2. Request a portable chest x-ray. 3. Prepare to insert chest tubes. 4. Assess the cardiac rhythm on the monitor.

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25. The ED nurse is completing the initial assessment on a client who becomes unresponsive. Which intervention should the nurse implement first? 1. Assess the rate and site of the intravenous fluid. 2. Administer an ampule of sodium bicarbonate. 3. Assess the cardiac rhythm shown on the monitor. 4. Prepare to cardiovert the client into sinus rhythm.

4,2,3,1,5

26. The ED nurse is caring for a female client with a greenstick fracture of the left forearm and multiple contusions on the face, arms, trunk, and legs. The significant other is in the treatment area with the client. Which nursing interventions should the nurse implement? List in order of priority. 1. Determine if the client has a plan for safety. 2. Assess the pulse, temperature, and capillary refill of the left wrist and hand. 3. Ask the client if she feels safe in her own home. 4. Request the significant other wait in the waiting room during the examination. 5. Notify the social worker to consult on the case.

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3. The elderly client is brought to the ED complaining of cramps, headache, and weakness after working outside in the sun. The telemetry shows sinus tachycardia. Which intervention should the nurse implement? 1. Determine if the client is experiencing any thirst. 2. Administer D5W intravenously at 250 mL/hr. 3. Maintain a cool environment to promote rest. 4. Withhold the client's oral intake.

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4. The ED nurse is caring for a client who suffered a near-drowning. Which expected outcome should the nurse include in the plan of care for this client? 1. Maintain the client's cardiac function. 2. Promote a continued decrease in lung surfactant. 3. Warm rapidly to minimize the effects of hypothermia. 4. Keep the oxygen saturation level above 93%.

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5. The nurse is assessing the client who suffered a near-drowning event. Which data require immediate intervention? 1. The onset of pink, frothy sputum. 2. An oral temperature of 97˚F. 3. An alcohol level of 100 mg/dL. 4. A heart rate of 100 beats/min.

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6. A nurse is at the lake when a person nearly drowns. The nurse determines the client is breathing spontaneously. Which data should the nurse assess next? 1. Possibility of drug use. 2. Spinal cord injury. 3. Level of confusion. 4. Amount of alcohol.

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7. The ED nurse is caring for a male client admitted with carbon monoxide poisoning. Which intervention requires the nurse to notify the Rapid Response Team? 1. The client has expectorated black sputum. 2. The client reports trying to kill himself. 3. The client's pulse oximeter reading is 94%. 4. The client has stridor and reports dizziness.

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8. The ED nurse is working triage. Which client should be triaged first? 1. A client who has multiple injuries from a motor-vehicle accident. 2. A client complaining of epigastric pain and nausea after eating. 3. An elderly client who fell and fractured the left femoral neck. 4. The client suffering from a migraine headache and nausea.

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9. The nurse is providing discharge teaching for the client with intermaxillary wiring to repair a fractured mandible. Which statement by the client indicates teaching has been effective? 1. Iced alcoholic drinks may be consumed by using a straw. 2. Only one (1) food item should be consumed at one (1) time. 3. Carbonated sodas should be limited to two (2) daily. 4. Teeth can be brushed after tenderness and edema subside.