EMERGENCY NURSING & TRIAGE 1 | Welcome to the first part of your quiz about emergency nursing. If you have trouble with the questions, why not read our reviewer first (see below) to refresh your memory.
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Question 1 |
Nurse Fatimah 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 that the nurse should direct the client to perform?
A | A. Removing the stinger by scraping it |
B | B. Applying a cold compress |
C | C. Taking an oral antihistamine |
D | D. Calling 911 |
Question 1 Explanation:
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.
Question 2 |
Nurse Anna is an experienced travel nurse who was recently employed and is assigned to the emergency unit. In her first week of the job, which of the following area is the most appropriate assignment for her?
A | A. Triage |
B | B. Ambulatory section |
C | C. Trauma team |
D | D. Psychiatric care |
Question 2 Explanation:
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.
Question 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?
A | A. Unequal pupils |
B | B. Irregular pulse |
C | C. Ecchymosis in the flank area |
D | D. A deviated trachea |
Question 3 Explanation:
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.
Question 4 |
Nurse Ahmad, 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?
A | A. Administer oxygen therapy via nasal cannula |
B | B. Notify the physician |
C | C. Complete history taking |
D | D. Put the client on ECG monitoring |
Question 4 Explanation:
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.
Question 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?
A | A. Instruct personnel to don personal protective equipment |
B | B. Direct the clients to the cold or clean zone for immediate treatment |
C | C. Immediately remove other clients and visitors from the area |
D | D. Measure vital signs and auscultate lung sounds
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E | E. Direct the clients to the decontamination area |
Question 5 Explanation:
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.
Question 6 |
When an unexpected death occurs in the emergency department, which task is the most appropriate to delegate to a nursing assistant?
A | A. Assisting with postmortem care
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B | B. Facilitate meetings between the family and the organ donor specialist
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C | C. Escorting the family to a place of privacy
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D | D. Help the family to collect belongings |
Question 6 Explanation:
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.”
Question 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?
A | A. Prepare and administer a tepid sponge bath |
B | B. Explain the need for giving cool fluids
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C | C. Assist the child in removing outer clothing
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D | D. Advise the parent to use acetaminophen (Tylenol) instead of aspirin |
Question 7 Explanation:
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.
Question 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?
A | A. The child suddenly pulls out the IV
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B | B. The parent is not sure regarding the child's tetanus immunization status
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C | C. The parent wants information about the IV conscious sedation
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D | D. The parent's refusal of the administration of the IV sedation |
Question 8 Explanation:
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.
Question 9 |
The emergency medical service has transported a client with severe chest pain. As 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?
A | A. Assisting with the intubation
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B | B. Placing the defibrillator pads
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C | C. Doing chest compressions
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D | D. Initiating bag valve mask ventilation |
Question 9 Explanation:
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).
Question 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?
A | A. ED physicians and charge nurses
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B | B. RNs, LPNs, and nursing assistants
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C | C. Experienced RNs and experienced paramedics
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D | D. At least one representative from each group of ED personnel |
Question 10 Explanation:
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.
Question 11 |
A client suffered an amputation of the first and second digits in a chainsaw accident. Which task should be delegated to an LPN/LVN?
A | A. Cleansing the amputated digits and placing them directly into an ice slurry
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B | B. Wrapping the cleansed digits in saline-moistened gauze, sealing in a plastic container, and placing it in icy water
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C | C. Gently cleansing the amputated digits and the hand with povidone-iodine
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D | D. Cleansing the digits with sterile normal saline and placing it in a sterile cup with sterile normal saline |
Question 11 Explanation:
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.
Question 12 |
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?
A | A. Examine the client's visual acuity
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B | B. Patch the eye
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C | C. Use Restasis (Allergan) drops in the eye
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D | D. Flush the eye repeatedly using sterile normal saline |
Question 12 Explanation:
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.
Question 13 |
A client was brought to the emergency department after suffering a closed head injury and lacerations around the face due to a hit-run accident. The client is unconscious and has a minimal response to noxious stimuli. Which of the following assessment findings if observed after few hours, should be reported to the physician immediately?
A | A. Drainage of a clear fluid from the client's nose
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B | B. Withdrawal of the client in response to painful stimuli
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C | C. Bruises and minimal edema of the eyelids
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D | D. Bleeding around the lacerations |
Question 13 Explanation:
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.
Question 14 |
A 5-year-old client was admitted to the emergency unit due to the 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?
A | A. The child was nauseated and vomited once at home
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B | B. The child has been treated several times for toxic substance ingestion
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C | C. The vitamin that was ingested contains iron
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D | D. The child has been treated multiple times for injuries caused by accidents |
Question 14 Explanation:
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.
Question 15 |
The following clients are presented with signs and symptoms of heat-related illness. Which of them needs to be attended first?
A | A. A relatively healthy homemaker who reports that the air conditioner has been broken for days and who manifest fatigue, hypotension, tachypnea, and profuse sweating.
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B | B. An elderly person who complains of dizziness and syncope after standing in the sun for several hours to view a parade.
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C | 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.
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D | D. A marathon runner who complains of severe leg cramps and nausea, and manifests weakness, pallor, diaphoresis, and tachycardia. |
Question 15 Explanation:
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.
Question 16 |
An anxious female client complains of chest tightness, tingling sensations, and palpitations. Deep, rapid breathing, and carpal spasms are noted. Which of the following priority action should the nurse do first?
A | A. Provide oxygen therapy
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B | B. Notify the physician immediately
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C | C. Administer anxiolytic medication as ordered
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D | D. Have the client breathe into a brown paper bag |
Question 16 Explanation:
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.
Question 17 |
An intoxicated client comes into the emergency unit with uncooperative behavior, mild confusion, and slurred speech. The client is unable to provide a good history but he verbalizes that he has been drinking a lot. Which of the following is a priority action of the nurse?
A | A. Administer IV fluid incorporated with Vitamin B1 as ordered
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B | B. Administer Naloxone (Narcan) 4 mg as ordered
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C | C. Contact the family to get information about the client
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D | D. Obtain an order for the determination of blood alcohol level |
Question 17 Explanation:
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.
Question 18 |
A nurse is providing discharge instructions to a woman who has been treated for contusions and bruises due to domestic violence. What is the priority intervention for this client?
A | A. Arranging transportation to a safe house
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B | B. Advising the client about contacting the police
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C | C. Making an appointment to follow up on the injuries
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D | D. Making a referral to a counselor |
Question 18 Explanation:
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.
Question 19 |
A nurse is providing discharge instructions to a woman who has been treated for contusions and bruises due to domestic violence. What is the priority intervention for this client?
A | A. Arranging transportation to a safe house
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B | B. Advising the client about contacting the police
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C | C. Making an appointment to follow up on the injuries
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D | D. Making a referral to a counselor |
Question 19 Explanation:
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.
Question 20 |
In the work setting, what is the primary responsibility of the nurse in preparation for disaster management, that includes natural disasters and bioterrorism incidents?
A | A. Being aware of the signs and symptoms of potential agents of bioterrorism
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B | B. Making ethical decisions regarding exposing self to potentially lethal substances
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C | C. Being aware of the agency's emergency response plan
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D | D. Being aware of what and how to report to the Centers for Disease Control and Prevention |
Question 20 Explanation:
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.
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