Question 1

The emergency department (ED)triage nurse is assessing four victims involved in a motor vehicle collision.Which patient has the highest priority for treatment?

Accepted Answer

Most immediate deaths from trauma occur because of problems with ventilation,so the patient with paradoxic chest movements should be treated first.Face and head fractures can obstruct the airway,but the patient with facial injuries only has lacerations.The other two patients also need rapid intervention but do not have airway or breathing problems.

Question 2

Gastric lavage and administration of activated charcoal are ordered for an unconscious patient who has been admitted to the emergency department (ED)after ingesting 30 lorazepam (Ativan)tablets.Which action should the nurse plan to do first?

Accepted Answer

In an unresponsive patient,intubation is done before gastric lavage and activated charcoal administration to prevent aspiration.The other actions will be implemented after intubation.

Question 3

During the primary assessment of a victim of a motor vehicle collision,the nurse determines that the patient is breathing and has an unobstructed airway.Which action should the nurse take next?

Accepted Answer

Even with a patent airway,patients can have other problems that compromise ventilation,so the next action is to assess the patient's breathing.The other actions are also part of the initial survey but assessment of breathing should be done immediately after assessing for airway patency.

Question 4

Following an earthquake,patients are triaged by emergency medical personnel and are transported to the emergency department (ED).Which patient will the nurse need to assess first?

Accepted Answer

The red tag indicates a patient with a life-threatening injury requiring rapid treatment.The other tags indicate patients with less urgent injuries or those who are likely to die.

Question 5

A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel.During the primary survey of the patient,the nurse should

Accepted Answer

The Glasgow Coma Scale is included when assessing for disability during the primary survey.The other information is part of the secondary survey.

Question 6

A patient who has experienced blunt abdominal trauma during a motor vehicle collision is complaining of increasing abdominal pain.The nurse will plan to teach the patient about the purpose of

Accepted Answer

For patients who are at risk for intraabdominal bleeding,focused abdominal ultrasonography is the preferred method to assess for intraperitoneal bleeding.An MRI would not be used.Peritoneal lavage is an alternative,but it is more invasive.An NG tube would not be helpful in diagnosis of intraabdominal bleeding.

Question 7

When planning the response to the potential use of smallpox as an agent of terrorism,the emergency department (ED)nurse manager will plan to obtain adequate quantities of

Accepted Answer

Smallpox infection can be prevented or ameliorated by the administration of vaccine given rapidly after exposure.The other interventions would be helpful for other agents of terrorism but not for smallpox.

Question 8

A 19-year-old is brought to the emergency department (ED)with multiple lacerations and tissue avulsion of the left hand.When asked about tetanus immunization,the patient denies having any previous vaccinations.The nurse will anticipate giving

Accepted Answer

For an adult with no previous tetanus immunizations,TIG and Tdap are recommended.The other immunizations are not sufficient for this patient.

Question 9

An unresponsive 79-year-old is admitted to the emergency department (ED)during a summer heat wave.The patient's core temperature is 105.4° F (40.8° C),blood pressure (BP)88/50,and pulse 112.The nurse initially will plan to

Accepted Answer

The priority intervention is to cool the patient.Antipyretics are not effective in decreasing temperature in heat stroke,and 100% oxygen should be given,which requires a high flow rate through a non-rebreather mask.An older patient would be at risk for developing complications such as pulmonary edema if given fluids at 1000 mL/hr.

Question 10

A 22-year-old patient who experienced a near drowning accident in a local pool,but now is awake and breathing spontaneously,is admitted for observation.Which assessment will be most important for the nurse to take during the observation period?

Accepted Answer

Because pulmonary edema is a common complication after near drowning,the nurse should assess the breath sounds frequently.The other information also will be obtained by the nurse,but it is not as pertinent to the patient's admission diagnosis.

Question 11

The following interventions are part of the emergency department (ED)protocol for a patient who has been admitted with multiple bee stings to the hands.Which action should the nurse take first?

Accepted Answer

The patient's rings should be removed first because it might not be possible to remove them if swelling develops.The other orders should also be implemented as rapidly as possible after the nurse has removed the jewelry.

Question 12

A 20-year-old patient arrives in the emergency department (ED)several hours after taking "25 to 30" acetaminophen (Tylenol)tablets.Which action will the nurse plan to take?

Accepted Answer

N-acetylcysteine is the recommended treatment to prevent liver damage after acetaminophen overdose.The other actions might be used for other types of poisoning,but they will not be appropriate for a patient with acetaminophen poisoning.

Question 13

A patient is admitted to the emergency department (ED)after falling through the ice while ice skating.Which assessment will the nurse obtain first?

Accepted Answer

The priority assessment relates to ABCs (airway,breathing,circulation)and how well the patient is oxygenating,so breath sounds should be assessed first.The other data will also be collected rapidly but are not as essential as the breath sounds.

Question 14

After the return of spontaneous circulation following the resuscitation of a patient who had a cardiac arrest,therapeutic hypothermia is ordered.Which action will the nurse include in the plan of care?

Accepted Answer

When therapeutic hypothermia is used postresuscitation,external cooling devices or cold normal saline infusions are used to rapidly lower body temperature to 89.6° F to 93.2° F (32° C to 34° C).Because hypothermia will decrease brain activity,assessing mental status every 15 minutes is not needed at this stage.Sedative medications are administered during therapeutic hypothermia.

Question 15

A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED).The nurse determines that discharge teaching has been effective when the patient makes which statement?

Accepted Answer

Electrolyte solutions such as sports drinks help replace fluid and electrolytes lost when exercising in hot weather.Salt tablets are not recommended because of the risks of gastric irritation and hypernatremia.Antipyretic medications are not effective in lowering body temperature elevations caused by excessive exposure to heat.A patient who is confused is likely to have more severe hyperthermia and will be unable to remember to take appropriate action.

Question 16

A triage nurse in a busy emergency department (ED)assesses a patient who complains of 7/10 abdominal pain and states,"I had a temperature of 103.9° F (39.9° C)at home." The nurse's first action should be to

Accepted Answer

The patient's pain and statement about an elevated temperature indicate that the nurse should obtain vital signs before deciding how rapidly the patient should be seen by the health care provider.A urinalysis may be appropriate,but this would be done after the vital signs are taken.The nurse will not give acetaminophen before confirming a current temperature elevation.

Question 17

When assessing an older patient admitted to the emergency department (ED)with a broken arm and facial bruises,the nurse observes several additional bruises in various stages of healing.Which statement or question by the nurse is most appropriate?

Accepted Answer

The nurse's initial response should be to further assess the patient's situation.Telling the patient not to return home may be an option once further assessment is done.A social worker may be appropriate once further assessment is completed.

Question 18

When rewarming a patient who arrived in the emergency department (ED)with a temperature of 87° F (30.6° C),which assessment indicates that the nurse should discontinue active rewarming?

Accepted Answer

A core temperature of 89.6° F to 93.2° F (32° C to 34° C)indicates that sufficient rewarming has occurred.Dysrhythmias,hypotension,and shivering may occur during rewarming and should be treated but are not an indication to stop rewarming the patient.

Question 19

During the primary survey of a patient with severe leg trauma,the nurse observes that the patient's left pedal pulse is absent and the leg is swollen.Which action will the nurse take next?

Accepted Answer

The assessment data indicate that the patient may have arterial trauma and hemorrhage.When a possibly life-threatening injury is found during the primary survey,the nurse should immediately start interventions before proceeding with the survey.Although a complete blood count is indicated,administration of IV fluids should be started first.Completion of the primary survey and further assessment should be completed after the IV fluids are initiated.

Question 20

A 54-year-old patient arrives in the emergency department (ED)after exposure to powdered lime at work.Which action should the nurse take first?

Accepted Answer

The initial action should be to protect staff members and decrease the patient's exposure to the toxin by decontamination.Patients exposed to powdered lime should not be showered; instead any/all visible powder should be brushed off.The other actions can be done after the decontamination is completed.

Quiz 65: Nursing Management: Emergency Care Situations

The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision.Which patient has the highest priority for treatment?

Gastric lavage and administration of activated charcoal are ordered for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets.Which action should the nurse plan to do first?

During the primary assessment of a victim of a motor vehicle collision,the nurse determines that the patient is breathing and has an unobstructed airway.Which action should the nurse take next?

Following an earthquake,patients are triaged by emergency medical personnel and are transported to the emergency department (ED) .Which patient will the nurse need to assess first?

A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel.During the primary survey of the patient,the nurse should

A patient who has experienced blunt abdominal trauma during a motor vehicle collision is complaining of increasing abdominal pain.The nurse will plan to teach the patient about the purpose of

When planning the response to the potential use of smallpox as an agent of terrorism,the emergency department (ED) nurse manager will plan to obtain adequate quantities of

A 19-year-old is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the left hand.When asked about tetanus immunization,the patient denies having any previous vaccinations.The nurse will anticipate giving

An unresponsive 79-year-old is admitted to the emergency department (ED) during a summer heat wave.The patient's core temperature is 105.4° F (40.8° C) ,blood pressure (BP) 88/50,and pulse 112.The nurse initially will plan to

A 22-year-old patient who experienced a near drowning accident in a local pool,but now is awake and breathing spontaneously,is admitted for observation.Which assessment will be most important for the nurse to take during the observation period?

The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands.Which action should the nurse take first?

A 20-year-old patient arrives in the emergency department (ED) several hours after taking "25 to 30" acetaminophen (Tylenol) tablets.Which action will the nurse plan to take?

A patient is admitted to the emergency department (ED) after falling through the ice while ice skating.Which assessment will the nurse obtain first?

After the return of spontaneous circulation following the resuscitation of a patient who had a cardiac arrest,therapeutic hypothermia is ordered.Which action will the nurse include in the plan of care?

A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED) .The nurse determines that discharge teaching has been effective when the patient makes which statement?

A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10 abdominal pain and states,"I had a temperature of 103.9° F (39.9° C) at home." The nurse's first action should be to

When assessing an older patient admitted to the emergency department (ED) with a broken arm and facial bruises,the nurse observes several additional bruises in various stages of healing.Which statement or question by the nurse is most appropriate?

When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87° F (30.6° C) ,which assessment indicates that the nurse should discontinue active rewarming?

During the primary survey of a patient with severe leg trauma,the nurse observes that the patient's left pedal pulse is absent and the leg is swollen.Which action will the nurse take next?

A 54-year-old patient arrives in the emergency department (ED) after exposure to powdered lime at work.Which action should the nurse take first?