Emergency Nursing Management NCLEX Quiz

1. A client arrives in the emergency unit and reports that a concentrated household cleaner was splashed in both eyes. Which of the following nursing actions is a priority?

Use Restasis (Allergan) drops in the eye.

Flush the eye repeatedly using sterile normal saline.

Examine the client’s visual acuity.

Patch the eye.

The priority nursing action in this situation is to flush the eye repeatedly using sterile normal saline. This is because the client has been exposed to a concentrated household cleaner in both eyes, which can cause severe damage to the eyes. Flushing the eyes with sterile normal saline helps to dilute and remove the chemical from the eyes, reducing the risk of further injury. It is important to do this as soon as possible to minimize potential damage and protect the client's vision.

Explanation

The priority nursing action in this situation is to flush the eye repeatedly using sterile normal saline. This is because the client has been exposed to a concentrated household cleaner in both eyes, which can cause severe damage to the eyes. Flushing the eyes with sterile normal saline helps to dilute and remove the chemical from the eyes, reducing the risk of further injury. It is important to do this as soon as possible to minimize potential damage and protect the client's vision.

2. A client who had a hit-run accident was brought to the emergency department after suffering a closed head injury and lacerations around the face. The client is unconscious and has a minimal response to noxious stimuli. Which of the following assessment findings if observed, after a few hours should be reported to the physician immediately?

Bleeding around the lacerations.

Withdrawal of the client in response to painful stimuli.

Bruises and minimal edema of the eyelids.

Drainage of a clear fluid from the client’s nose.

Drainage of a clear fluid from the client's nose is a concerning finding after a head injury. This could indicate a cerebrospinal fluid (CSF) leak, which is a serious complication. CSF leakage can lead to infection and other complications, and immediate medical attention is required to prevent further damage.

Explanation

Drainage of a clear fluid from the client's nose is a concerning finding after a head injury. This could indicate a cerebrospinal fluid (CSF) leak, which is a serious complication. CSF leakage can lead to infection and other complications, and immediate medical attention is required to prevent further damage.

3. A client suffered an amputation of the first and second digits in a chainsaw accident. Which task should be delegated to an LPN/LVN?

Cleansing the amputated digits and placing them directly into an ice slurry.

Cleansing the digits with sterile normal saline and placing in a sterile cup with sterile normal saline.

Gently cleansing the amputated digits and the hand with povidone-iodine.

Wrapping the cleansed digits in saline-moistened gauze. sealing in a plastic container and placing it in a block of ice.

The correct answer is to wrap the cleansed digits in saline-moistened gauze, seal them in a plastic container, and place them in a block of ice. This task can be delegated to an LPN/LVN because it involves basic wound care and preservation techniques. The LPN/LVN can safely perform this task under the supervision of a registered nurse or physician. Cleansing the amputated digits and placing them directly into an ice slurry or cleansing the digits with sterile normal saline and placing them in a sterile cup with sterile normal saline may not provide adequate protection and preservation. Gently cleansing the amputated digits and the hand with povidone-iodine is not recommended as it can cause tissue damage.

Explanation

The correct answer is to wrap the cleansed digits in saline-moistened gauze, seal them in a plastic container, and place them in a block of ice. This task can be delegated to an LPN/LVN because it involves basic wound care and preservation techniques. The LPN/LVN can safely perform this task under the supervision of a registered nurse or physician. Cleansing the amputated digits and placing them directly into an ice slurry or cleansing the digits with sterile normal saline and placing them in a sterile cup with sterile normal saline may not provide adequate protection and preservation. Gently cleansing the amputated digits and the hand with povidone-iodine is not recommended as it can cause tissue damage.

4.

A 5-year-old client was admitted to the emergency unit due to ingestion of an unknown amount of chewable vitamins for children at an unknown time. Upon assessment, the child is alert and with no symptoms. Which of the following information should be reported to the physician immediately?

The child has been treated multiple times for injuries caused by accidents.

The vitamin that was ingested contains iron.

The child was nauseated and vomited once at home.

The child has been treated several times for toxic substance ingestion.

The presence of iron in the ingested vitamin is important to report to the physician immediately because iron overdose can be very dangerous, especially in children. Iron toxicity can lead to severe symptoms such as abdominal pain, vomiting, diarrhea, and even organ failure. It is important for the physician to be aware of this information in order to assess and provide appropriate treatment for the child.

Explanation

The presence of iron in the ingested vitamin is important to report to the physician immediately because iron overdose can be very dangerous, especially in children. Iron toxicity can lead to severe symptoms such as abdominal pain, vomiting, diarrhea, and even organ failure. It is important for the physician to be aware of this information in order to assess and provide appropriate treatment for the child.

5. What is the primary responsibility of the nurse in preparation for disaster management?

Being aware of the signs and symptoms of potential agents of bioterrorism.

Making ethical decisions regarding exposing self to potentially lethal substances.

Being aware of the agency’s emergency response plan.

Being aware of what and how to report to the Centers for Disease Control and Prevention.

The primary responsibility of a nurse in preparation for disaster management is to be aware of the agency's emergency response plan. This involves understanding the specific protocols and procedures that need to be followed in the event of a disaster. By being familiar with the emergency response plan, nurses can effectively coordinate and provide appropriate care to patients during a crisis. This responsibility takes precedence over other tasks such as recognizing signs and symptoms of potential bioterrorism agents, making ethical decisions, or reporting to the Centers for Disease Control and Prevention.

Explanation

The primary responsibility of a nurse in preparation for disaster management is to be aware of the agency's emergency response plan. This involves understanding the specific protocols and procedures that need to be followed in the event of a disaster. By being familiar with the emergency response plan, nurses can effectively coordinate and provide appropriate care to patients during a crisis. This responsibility takes precedence over other tasks such as recognizing signs and symptoms of potential bioterrorism agents, making ethical decisions, or reporting to the Centers for Disease Control and Prevention.

6. The following clients come to the emergency department complaining of acute abdominal pain. Prioritize them for care in order of the severity of the conditions. 1. A 27-year-old woman complaining of lightheadedness and severe sharp left lower quadrant pain who reports she is possibly pregnant.2. A 43-year-old woman with moderate right upper quadrant pain who has vomited small amounts of yellow bile and whose symptoms have worsened over the week.3. A 15-year-old boy with a low-grade fever. right lower quadrant pain. vomiting. nausea. and loss of appetite for the past few days.4. A 57-year-old woman who complains of a sore throat and gnawing mid-epigastric pain that is worse between meals and during the night.5. A 59-year-old man with a pulsating abdominal mass and sudden onset of persistent abdominal or back pain. which can be described as a tearing sensation within the past hour.

2.5.3.4.1

3.1.4.5.2

5.1.3.2.4

2.5.1.4.3

The correct order of prioritizing the clients for care based on the severity of their conditions is 5.1.3.2.4. The 59-year-old man with a pulsating abdominal mass and sudden onset of persistent abdominal or back pain is prioritized first as this could be indicative of an abdominal aortic aneurysm, a life-threatening condition requiring immediate attention. The 27-year-old woman with lightheadedness and severe sharp left lower quadrant pain, possibly pregnant, is next as she may have an ectopic pregnancy or ovarian torsion, which also require urgent evaluation. The 15-year-old boy with right lower quadrant pain, vomiting, fever, nausea, and loss of appetite is prioritized third as these symptoms could indicate appendicitis. The 43-year-old woman with moderate right upper quadrant pain and vomiting bile is fourth as she may have gallbladder disease. Lastly, the 57-year-old woman with a sore throat and gnawing mid-epigastric pain is prioritized last as her symptoms are less severe and could be indicative of acid reflux or gastritis.

Explanation

The correct order of prioritizing the clients for care based on the severity of their conditions is 5.1.3.2.4. The 59-year-old man with a pulsating abdominal mass and sudden onset of persistent abdominal or back pain is prioritized first as this could be indicative of an abdominal aortic aneurysm, a life-threatening condition requiring immediate attention. The 27-year-old woman with lightheadedness and severe sharp left lower quadrant pain, possibly pregnant, is next as she may have an ectopic pregnancy or ovarian torsion, which also require urgent evaluation. The 15-year-old boy with right lower quadrant pain, vomiting, fever, nausea, and loss of appetite is prioritized third as these symptoms could indicate appendicitis. The 43-year-old woman with moderate right upper quadrant pain and vomiting bile is fourth as she may have gallbladder disease. Lastly, the 57-year-old woman with a sore throat and gnawing mid-epigastric pain is prioritized last as her symptoms are less severe and could be indicative of acid reflux or gastritis.

7. The following clients are presented with signs and symptoms of heat-related illness. Can you tell which patient should be attended first?

A relatively healthy homemaker who reports that the air conditioner has been broken for days and who manifest fatigue. hypotension. tachypnea. and profuse sweating.

An old-age person who complains of dizziness and syncope after standing in the sun for several hours to view a parade.

A homeless person who is a poor historian and has altered mental status.

A marathon runner who complains of severe leg cramps and nausea.

The homeless person who is a poor historian and has altered mental status should be attended to first. Altered mental status can be a sign of a more serious condition, such as heat stroke, which requires immediate medical attention. Additionally, being a poor historian means that the person may not be able to accurately communicate their symptoms or medical history, making it even more important to prioritize their care.

Explanation

The homeless person who is a poor historian and has altered mental status should be attended to first. Altered mental status can be a sign of a more serious condition, such as heat stroke, which requires immediate medical attention. Additionally, being a poor historian means that the person may not be able to accurately communicate their symptoms or medical history, making it even more important to prioritize their care.

8. An anxious female client complains of chest tightness. The following symptoms are observed in her- tingling sensations, palpitations, deep and rapid breathing, and carpal spasms. Which of the following priority action should the nurse do first?

Provide oxygen therapy.

Notify the physician immediately.

Administer anxiolytic medication as ordered.

Have the client breathe into a brown paper bag.

The correct answer is to have the client breathe into a brown paper bag. This is the priority action because the client is experiencing symptoms of hyperventilation, which can lead to respiratory alkalosis. Breathing into a brown paper bag helps to rebreathe carbon dioxide, which can help to restore normal blood pH levels. Oxygen therapy may not be necessary as the client is already breathing rapidly. Notifying the physician and administering anxiolytic medication can be done after the client's breathing is stabilized.

Explanation

The correct answer is to have the client breathe into a brown paper bag. This is the priority action because the client is experiencing symptoms of hyperventilation, which can lead to respiratory alkalosis. Breathing into a brown paper bag helps to rebreathe carbon dioxide, which can help to restore normal blood pH levels. Oxygen therapy may not be necessary as the client is already breathing rapidly. Notifying the physician and administering anxiolytic medication can be done after the client's breathing is stabilized.

9. A nurse is providing discharge instruction to a woman who has been treated for contusions and bruises due to domestic violence. What do you think should be the priority intervention for this client?

Making a referral to a counselor.

Making an appointment to follow up on the injuries.

Advising the client about contacting the police.

Arranging transportation to a safe house.

Arranging transportation to a safe house should be the priority intervention for this client because it ensures the immediate safety and protection of the woman who has been treated for contusions and bruises due to domestic violence. By providing transportation to a safe house, the nurse can help remove the woman from the dangerous environment and provide her with a secure place to stay, away from the abuser. This intervention addresses the immediate physical safety concerns of the client and is crucial in preventing further harm.

Explanation

Arranging transportation to a safe house should be the priority intervention for this client because it ensures the immediate safety and protection of the woman who has been treated for contusions and bruises due to domestic violence. By providing transportation to a safe house, the nurse can help remove the woman from the dangerous environment and provide her with a secure place to stay, away from the abuser. This intervention addresses the immediate physical safety concerns of the client and is crucial in preventing further harm.

10. A client is being discharged today after undergoing autografting. What should the nurse include in the discharge instructions?

Refrain from using splints.

Avoid smoking.

Exposed the site to sunlight.

Encourage weight-bearing exercise.

The nurse should include in the discharge instructions to refrain from using splints. After undergoing autografting, the client's skin graft needs to be protected and allowed to heal properly. Using splints can put pressure on the graft site and disrupt the healing process. Therefore, it is important for the client to avoid using splints to ensure successful healing and recovery.

Explanation

The nurse should include in the discharge instructions to refrain from using splints. After undergoing autografting, the client's skin graft needs to be protected and allowed to heal properly. Using splints can put pressure on the graft site and disrupt the healing process. Therefore, it is important for the client to avoid using splints to ensure successful healing and recovery.