1.
Nurse Ejay is assigned to telephone triage. A client called who was stung by a honeybee and is asking for help. The client reports pain and localized swelling but has no respiratory distress or other symptoms of anaphylactic shock. What is the appropriate initial action the nurse should direct the client to perform?
Correct Answer
A. Removing the stinger by scraping it.
Explanation
Since the stinger will continue to release venom into the skin, removing the stinger should be the first action that the nurse should direct to the client. Options B and C: After removing the stinger. Antihistamine and cold compress follow. Option D: The caller should be further advised about symptoms that require 911 assistance.
2.
Nurse Anna is an experienced travel nurse who was recently employed and is assigned to the emergency unit. In her first week on the job. Which of the following area is the most appropriate assignment for her?
Correct Answer
B. Ambulatory section.
Explanation
The ambulatory section deals with clients with relatively stable conditions.Options A, C, and D: These areas should be filled with nurses who are experienced with hospital routines and policies and has the ability to locate equipment immediately.
3.
A client arrives at the emergency department who suffered multiple injuries from a head-on car collision. Which of the following assessment should take the highest priority to take?
Correct Answer
C. A deviated trachea.
Explanation
A deviated trachea is a symptom of tension pneumothorax, which will result in respiratory distress if left untreated.
4.
Nurse Kelly. A triage nurse encountered a client who complained of mid-sternal chest pain, dizziness, and diaphoresis. Which of the following nursing action should take priority?
Correct Answer
D. Administer oxygen therapy via nasal cannula.
Explanation
The priority goal is to increase myocardial oxygenation. Options A, B, and C: These actions are also appropriate and should be performed immediately.
5.
A group of people arrived at the emergency unit by a private car with complaints of periorbital swelling, cough, and tightness in the throat. There is a strong odor emanating from their clothes. They report exposure to a “gas bomb” that was set off in the house. What is the priority action?
Correct Answer
A. Direct the clients to the decontamination area.
Explanation
Decontamination in a specified area is the priority. Option B: The clients must undergo decontamination before entering cold or clean areas. Options C and D: Performing assessments and moving others delays contamination and does not protect the total environment.
6.
When an unexpected death occurs in the emergency department, which task is the most appropriate to delegate to a nursing assistant?
Correct Answer
B. Assisting with postmortem care.
Explanation
Postmortem care requires some turning, cleaning, lifting, and so on, and the nursing assistant is able to assist with these duties. Option A: In cases of a questionable death, belongings may be retained for evidence, so the chain of custody would have to be maintained. Options C and D: A licensed nurse should take responsibility for the other tasks to help the family begin the grieving process.
7.
The physician has ordered cooling measures for a child with a fever who is likely to be discharged when the temperature comes down. Which task would be appropriate to delegate to a nursing assistant?
Correct Answer
C. Assist the child in removing outer clothing.
Explanation
The nursing assistant can help with the removal of outer clothing, which allows the heat to dissipate from the child’s skin. Option A: Tepid baths are not usually given because of the possibility of shivering and rebounding. Options B and D: Explaining and Advising are teaching functions that are the responsibility of the registered nurse.
8.
You are preparing a child for IV conscious sedation before the repair of a facial laceration. What information should you report immediately to the physician?
Correct Answer
D. The parent’s refusal of the administration of the IV sedation.
Explanation
The refusal of the parents is an absolute contraindication; therefore, the physician must be notified. Options A and C: The RN can reestablish the IV access and provide information about conscious sedation. Option B: Tetanus status can be addressed later.
9.
The emergency medical service has transported a client with severe chest pain. When the client is being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and unpalpable pulse. Which of the following task is appropriate to delegate to the nursing assistant?
Correct Answer
C. Doing chest compressions.
Explanation
Performing chest compressions are within the training of a nurse assistant. Option A: The use of the bag valve mask requires practice, and usually, a respiratory therapist will perform the function. Option B: The defibrillator pads are clearly marked. However, placement should be done by the RN or physician because of the potential for skin damage and electrical arcing.
10.
The nursing manager decides to form a committee to address the issue of violence against ED personnel. Which combination of employees would be best suited to fulfill this assignment?
Correct Answer
B. At least one representative from each group of ED personnel.
Explanation
At least one representative from each group of ED personnel should be included because all employees are potential targets for violence in the ED.