Emergency Nursing & Triage PROMETRIC 2022 Practice (Part 1: 20 Questions)

Correct Answer: A. (Removing the stinger by scraping it). 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. Within the first few minutes after the sting, the stinger should be removed via scraping with a credit card rather than squeezing/tweezing to avoid further venom exposure.

Correct Answer: B. (Ambulatory section). The ambulatory section deals with clients with relatively stable conditions. The decision of whether or not to delegate or assign is based upon the RN’s judgment concerning the condition of the patient, the competence of all members of the nursing team and the degree of supervision that will be required of the RN if a task is delegated.

Correct Answer: D. (A deviated trachea). A deviated trachea is a symptom of tension pneumothorax, which will result in respiratory distress if left untreated. The first question in the ESI triage algorithm for triage nurses asks whether “the patient requires immediate life-saving interventions” or simply “is the patient dying?” The nurse determines this by looking to see if the patient has a patent airway, if the patient is breathing, and does the patient has a pulse.

Correct Answer: A. (Administer oxygen therapy via nasal cannula). The priority goal is to increase myocardial oxygenation. Place the patient on a cardiac monitor, establish intravascular access (IV) access, give 162 mg to 325 mg chewable aspirin, clopidogrel, or ticagrelor (unless bypass surgery is imminent), control pain and consider oxygen (O2) therapy.

Correct Answer: E. (Direct the clients to the decontamination area). Decontamination in a specified area is the priority. The decontamination and support areas are established within the Warm Zone, also referred to as the Contamination Reduction Zone. Decontamination involves thorough washing to remove contaminants.

Correct Answer: A. (Assisting with postmortem care). Postmortem care requires some turning, cleaning, lifting, and so on, and the nursing assistant is able to assist with these duties. The use of NAPs increasingly demands registered nurses to delegate patient care tasks according to the principles of the ANA. These principles define nursing delegation as the “transfer of responsibility for the performance of an activity from one individual to another while retaining accountability for the outcome.”

Correct Answer: C. (Assist the child in removing outer clothing). The nursing assistant can help with the removal of outer clothing, which allows the heat to dissipate from the child’s skin. The client is the center of care. The needs of the client must be competently met with the knowledge, skills and abilities of the staff to meet these needs. In other words, the nurse who delegates aspects of care to other members of the nursing team must balance the needs of the client with the abilities of those to which the nurse is delegating tasks and aspects of care, among other things such as the scopes of practice and the policies and procedures within the particular healthcare facility.

Correct Answer: D. (The parent’s refusal of the administration of the IV sedation). The refusal of the parents is an absolute contraindication; therefore the physician must be notified. But the autonomy of parents is very obviously different from the autonomy of patients to make decisions for themselves. While adult patients are generally thought to have an absolute right to refuse medical treatment for themselves, we don’t usually think that parents can refuse all medical treatment for their children.

Correct Answer: C. (Doing chest compressions). Performing chest compressions are within the training of a nurse assistant. Every good certified nursing assistant should be proficient at cardiopulmonary resuscitation (CPR). Basic Life Support (BLS) certification is the widely-used term for any form of CPR certification and is required for all Registered Nurses (RN) and Certified Nursing Assistants (CNA).

Correct Answer: D. (At least one representative from each group of ED personnel). At least one representative from each group of ED personnel should be included because all employees are potential targets for violence in the ED. The diversity of the group should also be considered and assure that each department or each employee is represented.

Correct Answer: B. (Wrapping the cleansed digits in saline-moistened gauze, sealing in a plastic container, and placing it in icy water). Once a finger amputation has occurred, ischemic tolerance times are 12 hours if warm and up to 24 hours if cold. For more proximal amputations, these times are halved. The amputated part should be covered in a normal saline-soaked gauze, sealed in a plastic bag, and submerged in icy water with no direct contact with ice. If there is direct contact with ice, it could result in tissue damage and render the amputated part non-viable.

Correct Answer: D. (Flush the eye repeatedly using sterile normal saline). Initial emergency action during a chemical splash to the eye includes immediate continuous irrigation of the affected eye with normal saline. Immediate irrigation with copious amounts of an isotonic solution as described previously is the mainstay of treatment for chemical burns. Never use any substance to neutralize chemical exposure as the exothermic reaction can lead to secondary thermal injuries.

Correct Answer: A. (Drainage of a clear fluid from the client’s nose). Option A: Clear drainage from the client’s nose indicates that there is a leakage of CSF and should be reported to the physician immediately.

Correct Answer: C. (The vitamin that was ingested contains iron). Iron is a toxic substance that can lead to massive hemorrhage, shock, coma, and kidney failure. Iron poisoning is one of the most common toxic ingestion and one of the most deadly among children. Failure to diagnose and treat iron poisoning can have serious consequences including multi-organ failure and death.

Correct Answer: C. (A homeless person who is a poor historian; has altered mental status, poor muscle coordination, and hot, dry ashen skin; and whose duration of heat exposure is unknown). The signs and symptoms manifested by the homeless person indicate that a heat stroke is happening, a medical emergency, which can lead to brain damage. Also, there must be clinical signs of central nervous system dysfunction that may include ataxia, delirium, or seizures, in the setting of exposure to hot weather or strenuous physical exertion. Patients who present with heat stroke typically have vital sign abnormalities to include an elevated core body temperature, sinus tachycardia, tachypnea, a widened pulse pressure, and a quarter of patients will be hypotensive.

Correct Answer: D. (Have the client breathe into a brown paper bag). The client is suffering from hyperventilation secondary to anxiety, the initial action is to let the client breathe in a paper bag that will allow the rebreathing of carbon dioxide. The idea behind breathing into a paper bag or mask is that rebreathing exhaled air helps the body put CO2 back into the blood.

Correct Answer: A. (Administer IV fluid incorporated with Vitamin B1 as ordered). The client has symptoms of alcohol abuse and there is a risk for Wernicke syndrome, which is caused by a deficiency in Vitamin B. Thiamine deficiency (vitamin B1) is common in patients with alcohol dependence. Cognitive impairments may be an early consequence of thiamine deficiency. Wernicke’s encephalopathy is underdiagnosed and undertreated.

Correct Answer: A. (Arranging transportation to a safe house). Safety is a priority for this client and she should not return to a place where violence could recur. Make sure a safe environment is provided. Offer shelter options, legal services, counseling, and facilitate such referral.

Correct Answer: A. (Arranging transportation to a safe house). Safety is a priority for this client and she should not return to a place where violence could recur. Make sure a safe environment is provided. Offer shelter options, legal services, counseling, and facilitate such referral.

Correct Answer: C. (Being aware of the agency’s emergency response plan). In disaster preparedness, the nurse should know the emergency response plan. This gives guidance that includes the roles of the team members, responsibilities, and mechanisms of reporting. Emergency preparedness encompasses diverse fields within the hospital and regional settings. Planning membership groups should address key aspects across these fields including but not limited to: public safety, facilities, logistics, pharmacy, transportation, clinical patient care, non-clinical patient care, media/public relations, communications, radiation, infection control, and administration.