EMERGENCY NURSING & TRIAGE 2 | This is the last part of this quiz series about emergency nursing. Please review the rationales and read our reviewer to maximize your learning!
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In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey?
A. Brief neurologic assessment
B. Client's allergy history
C. Initiation of pulse oximetry
D. Complete set of vital signs
Question 1 Explanation:
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.
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?
D. High urgent
Question 2 Explanation:
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.
In caring for a victim of sexual assault, which task is most appropriate for an LPN/LVN?
A. Provide emotional support and supportive communication
B. Assess immediate emotional state and physical injuries
C. Ensure that the “chain of custody” is maintained
D. Collect hair samples, saliva swabs, and scrapings beneath fingernails
Question 3 Explanation:
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.
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?
A. “The stick was really dirty and covered with mud.”
B. “He pulled the stick out, just now, because it was hurting him.”
C. “He’s a diabetic, so he needs attention right away.”
D. “There was a lot of blood and we used three bandages.”
Question 4 Explanation:
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.
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?
A. Risk for Injury related to seizures
B. Risk for Situational Low Self-esteem related to police custody
C. Risk for Nutritional Deficit related to chronic alcohol abuse
D. Risk for Other-Directed Violence related to hallucinations
Question 5 Explanation:
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.
In relation to submersion injuries, which task is most appropriate to delegate to an LPN/LVN?
A. Stabilize the cervical spine for an unconscious drowning victim
B. Talk to a community group about water safety issues
C. Monitor an asymptomatic near-drowning victim
D. Remove wet clothing and cover the victim with a warm blanket
Question 6 Explanation:
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.
You are assessing a patient who has sustained a cat bite to the left hand. The cat is up-to-date immunizations. The date of the patient’s last tetanus shot is unknown. Which of the following is the priority nursing diagnosis?
A. Impaired Skin Integrity related to puncture wounds
B. Ineffective Health Maintenance related to immunization status
C. Risk for Infection related to organisms specific to cat bites
D. Risk for Impaired Mobility related to potential tendon damage
Question 7 Explanation:
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.
A 33-year-old patient with a history of seizures and medication compliance of phenytoin (Dilantin) and carbamazepine (Tegretol) is brought to the ED by the MS personnel for repetitive seizure activity that started 45 minutes prior to arrival. You anticipate that the physician will order which drug for status epilepticus?
A. Phenytoin and Carbamazepine PO
B. Carbamazepine (Tegretol) IV
C. Magnesium sulfate IV
D. Lorazepam (Ativan) IV
Question 8 Explanation:
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.
A client arrived at the emergency department after suffering multiple physical injuries including a fractured pelvis from a vehicular accident. Upon assessment, the client is incoherent, pale, and diaphoretic. With vital signs as follows: temperature of 97°F (36.11° C), blood pressure of 60/40 mm Hg, heart rate of 143 beats/minute, and a respiratory rate of 30 breaths/minute. The client is mostly suffering from which of the following shock?
Question 9 Explanation:
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.
Cole is an emergency nurse who encountered a patient who is a suspected carrier of a biologic agent. Which of these if found in the patient is not classified as a Category A biologic agent?
A. Bacillus anthracis (anthrax)
B. Francisella tularensis (tularemia)
C. Clostridium botulinum toxin (botulism)
D. Burkholderia pseudomallei (Melioidosis)
E. Yersinia petis (plague)
Question 10 Explanation:
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.
A 15-year-old male client was sent to the emergency unit following a small laceration on the forehead. The client says that he can’t move his legs. Upon assessment, respiratory rate of 20, strong pulses, and capillary refill time of less than 2 seconds. Which triage category would this client be assigned to?
Question 11 Explanation:
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.
An ER nurse is handling a 50-year-old woman complaining of dizziness and palpitations that occur from time to time. ECG confirms the diagnosis of paroxysmal supraventricular tachycardia. The client seems worried about it. Which of the following is an appropriate response of the nurse?
A. “You can be discharged now; this is a probable sign of anxiety.”
B. “The physician will prescribe you blood-thinning medications to lessen the episodes of palpitations.”
C. “We’ll need to keep you for further assessment; you may develop blood clots.”
D. "You have to stay here for a few hours to undergo blood tests to rule out myocardial infarction.”
Question 12 Explanation:
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.
A client was brought to the ED due to an abdominal trauma caused by a motorcycle accident. During the assessment, the client complains of epigastric pain and back pain. Which of the following is true regarding the diagnosis of pancreatic injury?
A. Redness and bruising may indicate the site of the injury in blunt trauma
B. The client is symptom-free during the early post-injury period
C. Signs of peritoneal irritation may indicate pancreatic injury
D. All of the above
Question 13 Explanation:
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.
A 20-year-old male client was brought to the emergency department with a gunshot wound to the chest. In obtaining a history of the incident to determine possible injuries, the nurse should ask which of the following?
A. "How long ago did the incident occur?"
B. "What was the initial first aid done?"
C. "Where did the incident happen?"
D. "What direction did the bullet enter into the body?"
Question 14 Explanation:
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.
When attending a client with a head and neck trauma following a vehicular accident, the nurse’s initial action is to?
A. Provide oxygen therapy
B. Initiate intravenous access
C. Immobilize the cervical area
D. Do oral and nasal suctioning
Question 15 Explanation:
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.
Nurse Ejay 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. Removing the stinger by scraping it
B. Applying a cold compress
C. Taking an oral antihistamine
D. Calling 911
Question 16 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.
When an unexpected death occurs in the emergency department, which task is the most appropriate to delegate to a nursing assistant?
A. Assisting with postmortem care
B. Facilitate meetings between the family and the organ donor specialist
C. Escorting the family to a place of privacy
D. Help the family to collect belongings
Question 17 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.”
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. Assisting with the intubation
B. Placing the defibrillator pads
C. Doing chest compressions
D. Initiating bag valve mask ventilation
Question 18 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).
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. ED physicians and charge nurses
B. RNs, LPNs, and nursing assistants
C. Experienced RNs and experienced paramedics
D. At least one representative from each group of ED personnel
Question 19 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.
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. Drainage of a clear fluid from the client's nose
B. Withdrawal of the client in response to painful stimuli
C. Bruises and minimal edema of the eyelids
D. Bleeding around the lacerations
Question 20 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.
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