Principles of Emergency Nursing final
True or False: The American Association of Critical Care Nurses is the association that represents Emergency Department nurses in the United States.
False
True or False: The pulse rate is considered subjective assessment data.
False
True or False: The second step of determining the need for emergent care is checking for circulation.
False
True or False: The triage nurse is not held legally responsible for his/her care decisions?
False
Who was considered one of the first emergency nurses?
Florence Nightengale
Which client should be deemed urgent by the triage nurse?
Fractured tibia and fibula.
Which client should the triage nurse deem emergent?
Head injury
What is the purpose of the primary survey?
Identify a pneumothorax.
The main purpose of triage is to____.
Identify those needing resuscitation and emergent care immediately.
A client from a different culture request that he be allowed to kneel on his prayer mat every afternoon at 5 PM. What should the hospital consider at this point?
If the staff can reasonably accommodate this request.
One of the positive benefits of "going vertical" was which result?
Increased patient satisfaction
A client has been exposed to the flu at work and now has symptoms of fever and muscle aches. The triage nurse suspects the client has the flu also. What should the nurse do before sending him back to wait in the waiting room?
Instruct the client to wear a surgical mask while waiting for treatment.
A client has a Glasgow Score of 6. The nurse should prepare for what intervention?
Intubation
What is the role of the Emergency Department (ED) Nurse Manager?
Meet with administration about plans for expanding the ED staff
In the article, "What works: An ED Goes Vertical to Improve Pt. Flow and Satisfaction," what did the nurses do to reduce wait times?
Move clients to a set of recliners where they will wait for their pending results. This frees up needed beds for sicker patients.
Who is responsible to perform triage?
Nurse
According to the article, "Emergency Nursing, A specialty unlike any other," the Emergency Department nurse must have which of the following?
Patience and empathy
Which of the following would be considered a specialty Emergency Department?
Pediatric Emergency Department
A 22-yr-old female is admitted in a comatose state to the Emergency Department after a biking accident. What action should the x-ray staff take to protect a fetus?
Place a lead apron over the abdomen of the client
During the ABC assessment of the primary survey, the physician determines that the airway is swollen from smoke inhalation. What action should the nurse take next?
Prepare to assist the physician to intubate the client
What is the role of the Emergency Department (ED) physician in the ED?
Provide care and treatment plans for clients with urgent conditions
What is the main purpose of an Emergency Department?
Provide lifesaving care for clients with a severe illness of injury
A client tells the triage nurse that he just returned from working overseas where there is an outbreak of rubella. The nurse should do which of the following next?
Put a surgical mask on the patient
The triage nurse has determined that the client has a nonurgent condition and sits the client back in the waiting room. If the client is still in the waiting room after one hour what should the nurse do?
Recheck the client's vital signs.
A client tells the nurse that he was in a car accident, but the police weren't notified. What should the nurse do at this time?
Report it to the police for investigation
While assessing the circulation during the primary survey, the nurse notes that the pulse is 120 beats per minute. What action should the nurse take next?
Report to the physician immediately
What is the role of the Emergency Department (ED) Technician?
Restocking the ED rooms with supplies
The Emergency Department has 8 rooms. Room A is a critical care room, Room B is a gynecological room, Room C is a pediatric room, Room D is an orthopedic room, and Rooms E-H are general treatment rooms. A client is admitted with a gunshot wound to the chest. What room should the client be placed in?
Room A
The Emergency Department has 8 rooms. Room A is a critical care room, Room B is a gynecological room, Room C is a pediatric room, Room D is an orthopedic room, and Rooms E-H are general treatment rooms. A client is admitted with pregnancy and vaginal bleeding. What room should the client be placed in?
Room B
The Emergency Department has 8 rooms. Room A is a critical care room, Room B is a gynecological room, Room C is a pediatric room, Room D is an orthopedic room, and Rooms E-H are general treatment rooms. A client complains of abdominal pain and vomiting, what room should the client be placed in?
Room E
At which point should the head-to-toe assessment be performed?
Secondary survey
What can cause an obstructed airway?
Small coin
The client's culture uses Medicine Men for healing. The client requests that a Medicine Man be allowed to order all her medications and treatments. What answer should the staff give her at this time?
"No, he is not recognized as a health care provider, but he can be allowed to provide suggestions regarding your care."
When assessing the client's chief complaint, the nurse should ask the client_______________.
"What is the problem today?"
A client cut his leg while walking in the woods. He has a two inch laceration without any bleeding. It is most important to ask the client which question?
"When was your last tetanus immunization?"
A client states she was raped. The nurse must help the HCP complete which intervention during the exam?
Collect body fluids and other evidence of a possible assault.
The Emergency Department (ED) nurse must be which of the following in order to care for the diverse population of clients in the ED?
Culturally Competent
True or False: The nurse can give the Forensic Evidence Collection kit to another nurse to hide in a drawer at the desk.
False
True or False: The nurse should place all bedding and clothing in the Forensic Evidence Collection assault kit while they are still damp to preserve the body fluids.
False
True or False: A woman calls the ED stating that her husband was in the ED last night and she needs the results of his medical tests. Since she is the next-of-kin, the nurse can give her the results over the phone.
False
True or False: A client having a heart attack should be seen by the Nurse Practitioner.
False
True or False: A client who is deaf does not need a medical interpreter.
False
True or False: A family member can be considered a medical interpreter.
False
True or False: According to the disaster triage model, the yellow color means they must be seen immediately
False
True or False: Clients that have committed a serious crime are not allowed to be treated in the Emergency Department.
False
A mother brings in her ten-year-old to the ED with a complaint that her throat has been sore. What additional questions should be asked by the triage nurse to assess for any symptoms that may be associated with the chief complaint? Select All That Apply.
"Has she had any fever in the last 24 hours?" "What medications have you given her at home for her throat?" "Does she have any history of medical illnesses like diabetes or asthma?"
Which clients can give consent? Select All That Apply.
40-yr-old client with a history of depression Parents of a 12-yr-old
What assessment finding would require chest tubes to be inserted?
A deviated trachea
True or False: Four clients present to the triage nurse at the same time: a client who states he is having trouble breathing; a client who states that his blood glucose is 60 mg/dL; a client who states that he needs a prescription refill; a client who states that she has a bladder infection. The nurse would be correct to assess the client with a blood glucose of 60 m/dL first.
False
True or False: In the Leah Curtin article she said that nurses should not be able to refuse a flu immunization and, if they do, they should be fired.
False
What is the role of the Emergency Department staff nurse?
Administer medication
Which of the following requires mandatory reporting to a designated agency by the hospital?
An animal bite.
The triage nurse is assessing a client with a possible sprain injury to the ankle. What interventions could the nurse take to reduce the pain and swelling of this injury?
Apply an ice pack
A client is brought by ambulance to the ED after a farming accident. He is actively bleeding from an injury to his right groin. What action should the nurse take next?
Apply pressure to the site of bleeding
To keep the client from being chilled after the clothes have been removed, the nurse should take which action?
Apply warm blankets and infuse fluids through a fluid warmer
A client states that he has had chest pain for several days that seems to be getting worse. What information should the nurse collect to help determine his risk of an acute myocardial infarction?
Ask the client, "Do you have a history of cardiac disease?"
In the SAMPLE mnemonic, what does the L stand for?
Asking questions about last meal and last tetanus
A client is brought to the triage nurse after he injured his leg. The client states, "I think I broke my leg playing football." What assessment is most important to do at this time?
Assess for pulses below the level of the injury
While performing the primary survey, which step is second?
Assessing the breathing
A client has died, what should the RN do at this time regarding organ donation?
Call the supervisor to report the death
A client tells the triage nurse he is experiencing severe abdominal pain. To assess the client's pain, what should the nurse ask the client at this time?
Can you rate your pain on a scale of 0-10 with zero being no pain and ten being the worst pain?"
Which of the following is an example of implied consent?
Client who is unconscious and needs a lifesaving surgery.
Four clients have been brought to the ED after a gang fight. Which client should be seen by the ED team first?
Client with a respiratory rate of 6 breaths per minute
What is the purpose of the disability assessment during the primary survey?
Determine neurological injuries that could cause death
When would disaster triage by used?
During a plane crash with over 100 victims
A client presents to the Emergency Department with a compliant of a sprained ankle. The nurse would be correct to ask which healthcare provider to see the client?
Emergency Department Nurse Practitioner
A client presents to the Emergency Department with a compliant of an earache. The nurse would be correct to ask which healthcare provider to treat the client?
Emergency Department Nurse Practitioner
A client is transported by ambulance to the Emergency Department with a stab wound to the chest. The nurse would be correct to ask which healthcare provider to see the client?
Emergency Department Physician
The Emergency Department Physician needs help setting up a suture tray. Which staff member would be best to assign this task?
Emergency Department Technician
The Emergency Department is at increased risk for lawsuits because they take care of victims of crime?
False
The nurse is responsible to explain the surgical procedure and get the patient's written signature on the form.
False
True or False: EMTALA is a federal law that protects the privacy of sexual assault clients.
False
The ED is preparing to transfer a client for neurosurgery which is a service they don't provide. The client has been stabilized. What additional requirement must be met before the client can be transferred?
The ED HCP has a physician at the receiving hospital that agrees to take the client as his/her patient.
A female Muslim client presents to the Emergency Nursing with a complaint of abdominal pain. The Muslim client requests a female nurse. The Emergency Department is very busy and all of the female nurses are caring for other clients. This client should be assigned to which nurse.
The client must be assigned to a female nurse because of their cultural restrictions.
According to the article, "Emergency Nursing, A specialty unlike any other," the Emergency Department is a microcosm of what?
The community it serves
A client presents to the ED with a complaint of vomiting blood and dizziness. What rule must the hospital follow regarding EMTALA?
The hospital can't refuse the client care based on the ability to pay.
According to EMTALA, when can a client be refused care?
The hospital can't refuse to evaluate any client based on ability to pay
A hospital is on diversion. What is the best explanation for diversion?
The hospital is full and doesn't have the staff or beds to provide care to other emergency clients
What is the purpose of cutting off all the client's clothes after a trauma?
To be able to identify hidden injuries
When would Social Services be needed in the Emergency Department?
To help a client who was a victim of domestic violent find shelter
The nurse is assisting with performing the primary survey on a client who was in a motor vehicle accident. The nurse places his hand on the client's forehead. What is the purpose of this action?
To prevent the client from moving the head and neck
Triage is a French word that means ____.
To sort
What does the word "triage" mean?
To sort
One of the greatest ways that the science of Emergency Medicine has evolved is through which event?
Treatment of injuries on the military battlefield
True or False: A client has tested positive for a sexually transmitted disease. The hospital must report this to the appropriate state agency.
True
True or False: A medical screening is any test or evaluation necessary to determine if the client has an emergency condition.
True
True or False: Discharge teaching must be delayed if the client is intoxicated and alone,
True
True or False: The Living Will is a document that lists the treatments the client does and does not want at the end of life.
True
True or False: A client who states she is two months pregnant tells the triage nurse she has been having vaginal bleeding for the last twelve hours. The priority question that should be asked at this time is, "how many pads have you soaked in the last hour?
True
True or False: A nurse is responsible to help collect and preserve forensic evidence from a victim when a crime has been committed.
True
True or False: Flight Nurses can perform advanced procedures to save a client's life at the scene of an accident.
True
True or False: In the Leah Curtin article, "Conscience, legalism, and the clash of rights," she argues that nurses should have a right to refuse to participate in certain types of care based on their moral beliefs and conscience objections.
True
True or False: Nurses who work the Emergency Department need to have Advanced Cardiac Life Support (ACLS) training.
True
True or False: The Emergency Department treats all clients of all ages.
True
True or False: The best location for the Emergency Department in the hospital is on the ground floor to allow for access to ambulance transport.
True
True or False: The client states that his stomach hurts is considered subjective data.
True
True or False: The nurse should assess the airway before assessing for adequate breathing.
True
True or False: The universal sign of choking is grabbing the throat.
True
Which of the following is the most common diagnosis seen in the Emergency Departments across the United States?
Upper Respiratory Infections
A client states the following to the triage nurse, "I have felt like I was going to faint all day when I stand up or move." This statement is an example of the
chief complaint
