Emergency Nursing Management | NCLEX Quiz 162

1. Michael works as a triage nurse. and four clients arrive at the emergency department at the same time. List the order in which he will assess these clients from first to last.(1. A 50-year-old female with moderate abdominal pain and occasional vomiting.2. A 35-year-old jogger with a twisted ankle. having a pedal pulse and no deformity.3. An ambulatory dazed 25-year-old male with a bandaged head wound.4. An irritable infant with a fever. petechiae. and nuchal rigidity.)

1. 2. 3. 4

2. 1. 3. 4

4. 3. 1. 2

3. 4. 2. 1

An irritable infant with fever and petechiae should be further assessed for other meningeal signs. The patient with the head wound needs additional history and assessment for intracranial pressure. The patient with moderate abdominal pain is uncomfortable. but not unstable at this point. For the ankle injury. a medical evaluation can be delayed 24 – 48 hours if necessary.

Explanation

An irritable infant with fever and petechiae should be further assessed for other meningeal signs. The patient with the head wound needs additional history and assessment for intracranial pressure. The patient with moderate abdominal pain is uncomfortable. but not unstable at this point. For the ankle injury. a medical evaluation can be delayed 24 – 48 hours if necessary.

2. A 65-year-old patient arrived at the triage area with complaints of diaphoresis. dizziness. and left-sided chest pain. This patient should be prioritized into which category?

Non-urgent.

Urgent.

Emergent.

High urgent.

Chest pain is considered an emergent priority. which is defined as potentially life-threatening.Option B: Clients with urgent priority need treatment within 2 hours of triage (e.g. kidney stones).Option A: Non-urgent conditions can wait for hours or even days.Option D: High urgent is not commonly used; however. in 5-tier triage systems. High urgent patients fall between emergent and urgent in terms of the time elapsing prior to treatment.

Explanation

Chest pain is considered an emergent priority. which is defined as potentially life-threatening.Option B: Clients with urgent priority need treatment within 2 hours of triage (e.g. kidney stones).Option A: Non-urgent conditions can wait for hours or even days.Option D: High urgent is not commonly used; however. in 5-tier triage systems. High urgent patients fall between emergent and urgent in terms of the time elapsing prior to treatment.

3. In conducting a primary survey on a trauma patient. which of the following is considered one of the priority elements of the primary survey?

Initiation of pulse oximetry.

Complete set of vital signs.

Client’s allergy history.

Brief neurologic assessment.

A brief neurologic assessment to determine the level of consciousness and pupil reaction is part of the primary survey. Vital signs. client’s allergy. and initiation of pulse oximetry are considered part of the secondary survey.

Explanation

A brief neurologic assessment to determine the level of consciousness and pupil reaction is part of the primary survey. Vital signs. client’s allergy. and initiation of pulse oximetry are considered part of the secondary survey.

4. A 15-year-old male client arrives at the emergency department. He is conscious. coherent and ambulatory. but his shirt and pants are covered with blood. He and his hysterical friends are yelling and trying to explain that they were goofing around and he got poked in the abdomen with a stick. Which of the following comments should be given first consideration?

“He’s a diabetic. so he needs attention right away.”

“There was a lot of blood and we used three bandages.”

“The stick was really dirty and covered with mud.”

“He pulled the stick out. just now. because it was hurting him.”

An impaled object may be providing a tamponade effect. and removal can precipitate sudden hemodynamic decompensation. Additional history including a more definitive description of the blood loss. depth of penetration. and medical history should be obtained. Other information. such as the dirt on the stick or history of diabetes. is important in the overall treatment.Options A and C: Other information. such as the dirt on the stick or history of diabetes. is important in the overall treatment plan. but can be addressed later.

Explanation

An impaled object may be providing a tamponade effect. and removal can precipitate sudden hemodynamic decompensation. Additional history including a more definitive description of the blood loss. depth of penetration. and medical history should be obtained. Other information. such as the dirt on the stick or history of diabetes. is important in the overall treatment.Options A and C: Other information. such as the dirt on the stick or history of diabetes. is important in the overall treatment plan. but can be addressed later.

5. You respond to a call for help from the ED waiting room. There is an elderly patient lying on the floor. List the order for the actions that you must perform.(1. Call for help and activate the code team.2. Instruct a nursing assistant to get the emergency cart.3. Initiate cardiopulmonary resuscitation (CPR).4. Perform the chin lift or jaw thrust maneuver.5. Establish unresponsiveness.)

5. 2. 4. 3. 1

1. 5. 2. 4. 3

1. 2. 5. 4. 3

5. 1. 4. 3. 2

Establish unresponsiveness first. (The patient may have fallen and sustained a minor injury.) If the patient is unresponsive. get help and have someone initiate the code. Performing the chin lift or jaw thrust maneuver opens the airway. The nurse is then responsible for starting CPR. CPR should not be interrupted until the patient recovers or it is determined that heroic efforts have been exhausted. A crash cart should be at the site when the code team arrives; however. basic CPR can be effectively performed until the team arrives.

Explanation

Establish unresponsiveness first. (The patient may have fallen and sustained a minor injury.) If the patient is unresponsive. get help and have someone initiate the code. Performing the chin lift or jaw thrust maneuver opens the airway. The nurse is then responsible for starting CPR. CPR should not be interrupted until the patient recovers or it is determined that heroic efforts have been exhausted. A crash cart should be at the site when the code team arrives; however. basic CPR can be effectively performed until the team arrives.

6. In caring for a victim of sexual assault. which task is most appropriate for an LPN/LVN?

Provide emotional support and supportive communication.

Assess immediate emotional state and physical injuries.

Ensure that the “chain of custody” is maintained.

Collect hair samples. saliva swabs. and scrapings beneath fingernails.

The LPN/LVN is able to listen and provide emotional support for her patients.Options B. C. and D: The other tasks are the responsibility of an RN or. if available. a SANE (sexual assault nurse examiner) who has received training to assess. collect and safeguard evidence. and care for these victims.

Explanation

The LPN/LVN is able to listen and provide emotional support for her patients.Options B. C. and D: The other tasks are the responsibility of an RN or. if available. a SANE (sexual assault nurse examiner) who has received training to assess. collect and safeguard evidence. and care for these victims.

7. A prisoner. with a known history of alcohol abuse. has been in police custody for 48 hours. Initially. anxiety. sweating. and tremors were noted. Now. disorientation. hallucination. and hyper-reactivity are observed. The medical diagnosis is delirium tremens. What is the priority nursing diagnosis?

Risk for Situational Low Self-esteem related to police custody.

Risk for Nutritional Deficit related to chronic alcohol abuse.

Risk for Injury related to seizures.

Risk for Other-Directed Violence related to hallucinations.

The client shows neurologic hyperactivity and is on the verge of a seizure. Patient safety is the priority. The patient needs chlordiazepoxide (Librium) to decrease neurologic irritability and phenytoin (Dilantin) for seizures. Thiamine and haloperidol (Haldol) will also be ordered to address the other problems.Options A. B. and D: The other diagnoses are pertinent but not as immediate.

Explanation

The client shows neurologic hyperactivity and is on the verge of a seizure. Patient safety is the priority. The patient needs chlordiazepoxide (Librium) to decrease neurologic irritability and phenytoin (Dilantin) for seizures. Thiamine and haloperidol (Haldol) will also be ordered to address the other problems.Options A. B. and D: The other diagnoses are pertinent but not as immediate.

8. You are caring for a client with a frostbite on the feet. Place the following interventions in the correct order.(1. Immerse the feet in warm water 100° F to 105° F (40.6? C to 46.1° C).2. Remove the victim from the cold environment.3. Monitor for signs of compartment syndrome.4. Apply a loose. sterile. bulky dressing.5. Administer a pain medication.)

5. 2. 1. 3. 4

2. 5. 1. 4. 3

2. 1. 5. 3. 4

3. 2. 1. 4. 5

The victim should be removed from the cold environment first. and then the rewarming process can be initiated. It will be painful. so give pain medication prior to immersing the feet in a warmed water.

Explanation

The victim should be removed from the cold environment first. and then the rewarming process can be initiated. It will be painful. so give pain medication prior to immersing the feet in a warmed water.

9. Following an emergency endotracheal intubation. nurses must verify tube placement and secure the tube. List in order the steps that are required to perform this function?(1. Obtain an order for a chest x-ray to document tube placement.2. Confirm that the breath sounds are equal and bilateral.3. Auscultate the chest during assisted ventilation.4. Secure the tube in place.)

1. 2. 3. 4

4. 3. 2. 1

3. 2. 4. 1

4. 1. 2. 3

Auscultating and confirming equal bilateral breath sounds should be performed in rapid succession. If the sounds are not equal or if the sounds are heard over the mid-epigastric area. tube placement must be corrected immediately. Securing the tube is appropriate while waiting for the x-ray study.

Explanation

Auscultating and confirming equal bilateral breath sounds should be performed in rapid succession. If the sounds are not equal or if the sounds are heard over the mid-epigastric area. tube placement must be corrected immediately. Securing the tube is appropriate while waiting for the x-ray study.

10. In relation to submersion injuries. which task is most appropriate to delegate to an LPN/LVN?

Talk to a community group about water safety issues.

Stabilize the cervical spine for an unconscious drowning victim.

Remove wet clothing and cover the victim with a warm blanket.

Monitor an asymptomatic near-drowning victim.

The asymptomatic patient is currently stable but should be observed for delayed pulmonary edema. cerebral edema. or pneumonia.Options A and B: Teaching and care of critical patients are an RN responsibility.Option C: Removing clothing can be delegated to a nursing assistant.

Explanation

The asymptomatic patient is currently stable but should be observed for delayed pulmonary edema. cerebral edema. or pneumonia.Options A and B: Teaching and care of critical patients are an RN responsibility.Option C: Removing clothing can be delegated to a nursing assistant.