Emergency and Trauma Nursing. Which statement given by the nurse would indicate the need for further education?
A. “Common reasons for emergency room admission include headache and fever.”
B. “Some clients use the emergency room as a clinic.”
C. “The emergency room does not provide services to the uninsured.”
D. “The typical emergency room can appear chaotic.”
Rationale C. The emergency room must provide services to any client, regardless of their financial status. All the other distractors are confirmed in the emergency room environment.
Which population would most likely go to the emergency room to treat a temperature and a sore throat?
A. Older adults
Rationale D. The emergency room serves as an important safety net for ill or injured clients but lack access to primary health care. Especially vulnerable populations include the underinsured and uninsured.
Assessment findings reveal that a client has been raped. Which health care team member will be most helpful in planning this client’s care in the emergency room?
A. Emergency medicine physician
B. Case manager
C. Forensic nurse examiner
D. Psychiatric crisis nurse
Rationale C., All the other members of the health care team listed may manage this client’s care. However, the forensic nurse examiner is educated to obtain client histories, collect evidence dealing with the assault, and offer the counseling and follow-up needed when dealing with the victim of an assault.
On admission to the emergency department, a client states that he feels like killing himself. When planning this client’s care, the nurse needs to coordinate with which health care team member?
A. Case manager
B. Forensic nurse examiner
D. Psychiatric crisis nurse
Rationale D. The psychiatric crisis nurse team interacts with clients and families in crisis. This health care team member can offer valuable expertise to the emergency health care team, including the case manager and physician.
When taking the client’s medical history, what is the first question the nurse will ask to reduce the error potential in the emergency room?
a. “What medications do you take?”
b. “What year were you born?”
c. “Who is your contact person?”
d. “Who is your primary health care provider?”
Rationale A. A significant risk for all clients who enter the emergency room is the potential for medical errors or adverse events, particularly those associated with medication administration. All the other distractors are questions asked in the assessment of the client but are not as important as knowing what medications the client is taking.
The emergency room nurse is assigned an older adult client who is confused and agitated. Which intervention should be included in the nurse’s plan of care?
A. Administers a sedative medication
B. Asks a family member to stay with the client.
C. Uses a Posey vest to prevent the client from climbing out of the stretcher
D. Places the client in front of the nurses’ station.
Rationale B. Older adults who are confused are at increased risks for falls. Fall prevention includes measures such as side rails up, reorientation, call light in reach and, in some cases, asking the family member, significant other, or sitter to stay with the client to prevent falls.
An emergency room nurse is transferring a client to the medical-surgical unit. What is the essential core competency needed in this situation?
Rationale B. The emergency nurse wants to be able to assess, evaluate, and carry out multitasking. However, these competencies have already been carried out in the early phases of emergency room admission. When a client is ready to be transferred out of the emergency room, communication with staff nurses from the inpatient units is essential. This report should be a concise but comprehensive report of the client’s emergency department experience.
What would the emergency room nurse consider the significant purpose of advanced cardiac life support (ACLS) certification?
A. Learning the concepts of multitasking.
B. Becoming an expert in pediatric resuscitation
C. Demonstrating competence in adult emergencies
D. Demonstrating basic first aid skills
Rationale C. Certification marks the successful completion of a particular course of study and nursing specialty. The ACLS course builds on essential cardiac life support (BCLS) content to include special resuscitation situations in the adult population.
The emergency room nurse is caring for the following clients. Which client does the nurse prioritize to see first?
A. Blood pressure 100/60 mm Hg, right wrist painful and swollen.
B. Complaining of chest pain and diaphoresis
C. Complaining of difficulty swallowing and nausea
D. Respiratory rate of 28/min and temperature of 101° F
Rationale B. A client experiencing chest pain and diaphoresis would be classified as emergent and triaged immediately to a treatment room in the emergency department.
The nurse needs to triage clients. A client with which complaint would be considered as nonurgent?
A. Chest pain and diaphoresis
B. Decreased breath sounds and coughing up yellow secretions.
C. Left arm fractured.
D. Sore throat and a temperature of 102° F
Rationale C. A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration.
A client has been injured in a stabbing incident. The assessment reveals the following data: Blood pressure: 80/60 mm Hg Heart rate: 130 beats/min Respiratory rate: 35/min Bleeding from stabbing wound site Client is lethargic based on this assessment data. What would be the most appropriate level trauma center?
A. Level I
B. Level II
C. Level III
D. Level IV
Rationale A. The level I trauma center can provide a full continuum of care for all client areas. Level II can provide care to most injured clients, but given the extent of his injuries, a class I center would be better if it is available. Both levels III and IV can stabilize significant injuries, but transport to a higher level center is preferred when possible.
The emergency medical technicians (EMTs) arrive with an unresponsive client with an oxygen mask in place at the emergency room. What will the nurse do first?
A. Assesses that the client is breathing
B. adequately. Places a large-bore intravenous line
C. Places the client on a cardiac monitor
D. Takes a blood pressure reading
Rationale A. The highest priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he may not be breathing or living inadequately with the device in place.