Question 1

For children who need crystalloid fluid resuscitation, the formula is altered to

Accepted Answer

Fluid resuscitation in a child is delivered in 20 ml/kg boluses.

Question 2

A nurse is preparing to administer 150 mg of intravenous phenytoin to a client with seizure activity. After diluting the medication with the supplied diluent, the nurse will infuse the medication over a period of

Accepted Answer

Phenytoin must be diluted and infused at a rate of less than 50 mg/minute.

Question 3

A client with a chest injury develops respiratory distress, distended jugular neck veins, and tracheal deviation. The nurse anticipates the client will receive immediate

Accepted Answer

These signs and symptoms are consistent with a tension pneumothorax. The immediate treatment is insertion of a large-bore IV catheter into the anterior chest wall at the second intercostal space, mid-clavicular line. A chest tube may be indicated after emergent treatment, and a chest x-ray will be ordered, but they should not delay the life-saving treatment. Intubation may be needed depending on the client's ability to ventilate and oxygenate post thoracotomy.

Question 4

The ED triage nurse identifies the client who can have treatment delayed for a few hours as the client with a

Accepted Answer

This client requires treatment, but life/limb/vision is not threatened if care cannot be provided within 1 to 2 hours. The other injuries would require more rapid care to prevent future problems or possible complications.

Question 5

A 7-year-old child is brought to the emergency department complaining of arm pain after falling off a swing at school. The child rates the pain as an 8 on a scale of 1-10. The best response by the nurse to this information is to

Accepted Answer

Clients in pain need a thorough pain assessment using the PQRST mnemonic. Children should be assessed using an age-appropriate tool such as the Faces scale. However, any score at 7 or above needs to be considered high risk, evaluated, and then treated appropriately.

Question 6

The nurse clarifies that the law specifies that an ED client cannot be transferred to another facility until the client is stable. "Stable" is interpreted to mean that the client

Accepted Answer

"Stable" means that the client's condition will not deteriorate during the transfer to another facility.

Question 7

When a client is brought to the ED with chemical injury to the left eye, the nurse would irrigate the eye with normal saline, a minimum of

Accepted Answer

For exposure to harmful chemicals, the eye must be irrigated with a minimum of 1 L of normal saline.

Question 8

After stabilizing a trauma victim's airway, breathing, and circulation, the next item for the ED nurse to assess is

Accepted Answer

Once it is determined that the client's airway, breathing, and circulation (ABC) status is satisfactory, the secondary assessment is performed to identify any other non-life-threatening problems the client may be experiencing. The secondary assessment includes the following elements: neurologic assessment, history, pain, general overview, and focused assessment.

Question 9

The nurse is caring for a 100-kg client who sustained a burn injury over 50% of total body surface area (TBSA). How much fluid should this client receive in the first 8 hours?

Accepted Answer

Fluid resuscitation for burned clients is based on the formula 2-4 ml/kg/TBSA. The number used for TBSA is the whole number, not the decimal equivalent (i.e., in this case use 50, not 0.5). Half of the volume must be infused within the first 8 hours post-burn.

Question 10

A teenage girl brings her newborn baby wrapped in a bloody T-shirt into the ED and says she intends to leave the baby there. The nurse should

Accepted Answer

People may voluntarily abandon newborns in the care of an ED in many states, which will notify social services, who will take the child into their custody.

Question 11

A client is brought to the ED with a suspected neck injury. The nurse should

Accepted Answer

When there is a suspected neck injury the head should be manually stabilized. Apply a hard cervical collar, place on a spinal board, and place immobilizing devices for the head and neck. The other three options may make a spinal cord injury, if present, worse.

Question 12

A young man is admitted to the ED after sustaining a gunshot wound and dies within a short time. To prepare the body before the family's viewing, the nurse should

Accepted Answer

Tips for preserving evidence in the ED: minimally handle the body of a deceased person; place wet clothing in individual paper bags (do not use plastic bags, as wet clothes can "sweat," thereby destroying evidence); and collect the client's personal items. Tubes should not be removed as this client will have an autopsy and they need to be present for that procedure. Washing the body thoroughly may destroy evidence.

Question 13

A client admitted to the ED exhibits raccoon eyes and Battle's sign. The nurse interprets that these manifestations are compatible with

Accepted Answer

Bruising of the face, eyes (raccoon eyes), or mastoid process (Battle's sign) or a bluish hue to the tympanic membrane can indicate a recent head injury and an associated basilar skull fracture.

Question 14

When a client is admitted to the ED with respiratory distress and rapid-sequence induction (RSI) is needed to intubate the client, the nurse should first

Accepted Answer

RSI involves (1) establishing venous access, (2) hyperventilating the client with 100% oxygen, and (3) administering an IV general barbiturate or anesthetic medication.

Question 15

The nurse explains to the family of a client with a spinal cord injury that IV methylprednisolone will reduce

Accepted Answer

Administration of high-dose IV steroids such as methylprednisolone may be considered to reduce cord edema. It has no action on pain, seizures, or muscle spasms.

Question 16

A client is brought to the emergency department (ED) in critical condition after a car crash. The client's family is distraught. To best help this family, the ED nurse should first

Accepted Answer

The family needs a clear understanding of their loved one's condition before proceeding on to calling other family members and perhaps giving them incorrect information. Having a good understanding of the situation can also help the family calm down. A chaplain or social worker can be an effective adjunct, but the ED nurse is primarily responsible for providing information to the family. Making the family stay in the waiting room until they calm down may actually increase their agitation, although it is acceptable to give them guidelines for behaviors.

Question 17

The nurse is caring for a client brought to the ED after suffering amputation of a toe. The nurse should take care to avoid

Accepted Answer

The stump is cleansed with normal saline. The amputated part is wrapped in sterile gauze moistened with normal saline. It is then placed in a plastic bag or container, and the plastic bag or container is placed on ice. The amputated part should never be placed directly on ice because freezing of the tissues will result.

Question 18

A client is brought to the emergency department complaining of severe chest pain. The triage nurse assigns this client the triage category of

Accepted Answer

In the emergent category, the client must be treated immediately; otherwise, life/limb/vision is threatened. The client having chest pain must be evaluated immediately for a myocardial infarction. The non-urgent client has no time restrictions on treatment. The urgent client does not have a threat to life/limb/vision and care can be provided within 1-2 hours. "Vital" is not a triage classification.

Question 19

A client has died from very disfiguring injuries received in an automobile accident. When the family arrives moments later, the nurse relays the news to the family and then should (Select all that apply)

Accepted Answer

When death occurs, the ED nurse and physician have important roles in informing the family: provide the family with an explanation of the course of events related to the death; offer the family an opportunity to view the body if desired; help the family focus on decisions requiring immediate attention; and provide community agency referral as needed.

Question 20

An unconscious client is brought to the emergency department (ED) by ambulance following a car accident. Without a family member to give informed consent, the nurse should

Accepted Answer

When a client is unable to give consent or is unconscious, emergency treatment can be provided under the doctrine of implied consent, which assumes that the client would consent to treatment to prevent death or disability if the client were so able.

Quiz 82: Management of Clients in the Emergency Department