Emergency Nursing & Triage PROMETRIC 2022 Practice (Part 2: 20 Questions)

Correct Answer: A. (Brief neurologic assessment). A brief neurologic assessment to determine the level of consciousness and pupil reaction is part of the primary survey. Once the patient is stabilized, a neurologic examination should be conducted. CT scan is the diagnostic modality of choice in the initial evaluation of patients with head trauma.

Correct Answer: C. (Emergent). Chest pain is considered an emergent priority, which is defined as potentially life-threatening. If the nurse can accurately diagnose the patient with these criteria and mark as a Level 1 trauma patient, the patient will need immediate life-saving therapy. Immediate physician involvement in the care of the patient is critical and is one of the differences between level 1 and level 2 patient designations.

Correct Answer: A. (Provide emotional support and supportive communication). The LPN/LVN is able to listen and provide emotional support for her patients. 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: B. (“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. Surgery is often required; impaled objects are secured in place so that they do not move and they should only be removed in an operating room.

Correct Answer: A. (Risk for Injury related to seizures). The client shows neurologic hyperactivity and is on the verge of a seizure. Seizures can recur, though rarely lead to status epilepticus. Uncharacteristic signs of seizure activity should warrant further workup. 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 other problems.

Correct Answer: C. (Monitor an asymptomatic near-drowning victim). The asymptomatic patient is currently stable but should be observed for delayed pulmonary edema, cerebral edema, or pneumonia. Appropriate decisions relating to the successful assignment of care are accurately based on the needs of the patient, the skills of the staff, the staffs’ position description or job descriptions, the employing facility’s policies and procedures, and legal aspects of care such as the states’ legal scopes of practice for nurses, nursing assistants and other members of the nursing team.

Correct Answer: C. (Risk for Infection related to organisms specific to cat bites). Cat’s mouths contain a virulent organism, Pasteurella multocida, that can lead to septic arthritis or bacteremia. Infections resulting from bites of all animal species are poly-microbial with aerobic and anaerobic bacteria; dogs and cats have an oral flora of Pasteurella, Staph, and Strep most commonly. In cat bites and scratches, Bartonella infections are an additional concern.

Correct Answer: D. (Lorazepam (Ativan) IV). IV Lorazepam (Ativan) is the drug of choice for status epilepticus. Benzodiazepines are the antiepileptic drug of choice for emergent control. Lorazepam is preferred because of its rapid onset of action and is dosed at 0.1 mg/kg IV. No more than 2 mg should be administered per minute.

Correct Answer: B. (Hypovolemic) Hypovolemic shock occurs when the volume of the circulatory system is too depleted to allow adequate circulation to the tissues of the body. A fractured pelvis will lose about one liter of blood hence symptoms such as hypotension, tachycardia, and tachypnea will occur. If left untreated, these patients can develop ischemic injury of vital organs, leading to multi-system organ failure.

Correct Answer: D. Burkholderia pseudomallei (Melioidosis). Burkholderia pseudomallei (Melioidosis) belongs to the category B priority pathogen. These agents are moderately easy to be transmitted and can result in moderate morbidity rates. Melioidosis is endemic to southeast Asia and northern Australia but has also occurred in South America, Central America, Africa, and the Middle East. Melioidosis may present in an acute form with an incubation period of one day to three weeks. However, latent melioidosis may not present for decades. Melioidosis often infects those with underlying risk factors such as diabetes, kidney disease, alcohol abuse, and thalassemia, although healthy patients may also contract the disease.

Correct Answer: C. (Yellow). The client is possibly suffering from a spinal injury but otherwise, has a stable status and can communicate so the appropriate tag is yellow. If individuals can breathe spontaneously, follow simple commands, and have distal pulses with a normal capillary refill, they are tagged delayed and given the code yellow.

Correct Answer: C. (“We’ll need to keep you for further assessment; you may develop blood clots.”) Paroxysmal supraventricular tachycardia (PSVT) is characterized by episodes of rapid heart rate that occur periodically and stop on their own. PSVT decreases cardiac output and can result in a thrombus. These clots could turn into an embolus, which could eventually lead to a stroke. Treatment of PSVT in a patient is dependent on the type of rhythm present on the electrocardiogram and the patient’s hemodynamic stability.

Correct Answer: D. (All of the above). Blunt injury resulting from vehicular accidents could cause pancreatic injury. Redness, bruising in the flank and severe peritoneal irritation are signs of a pancreatic injury. The client is usually pain-free during the early post-injury period, hence a comprehensive assessment and monitoring should be done.

Correct Answer: D. (“What direction did the bullet enter into the body?”) The entry point and direction of the bullet will predict the injuries of the client. In gunshot wounds, due to the high-intensity kinetic energy of the bullet, the pathway is often unpredictable in nature as well as the internal organs that may be affected. The most common organs injured are the small and large bowel at 50% and 40%, respectively.

Correct Answer: C. (Immobilize the cervical area). Clients with suspected or possible cervical spine injury must have their neck immobilized until formal assessment occurs. Maintain cervical spine spinal immobilization and minimize neck movement particularly during transport. Beware that absence of neurologic findings does not eliminate the possibility of spinal cord injury.

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: 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. (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: 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.