This is the full-text copy of the 40-item quiz Emergency Nursing & Triage Nursing NCLEX Practice Quiz (40 Questions)
Use this page to print a copy of the quiz or export it via PDF.
CREATING PDF. For most modern browsers like Chrome, Safari, Firefox, Edge, you can simply click on File> Print > Save as PDF to create a PDF version of this page.
For more quizzes, please visit Nursing Test Bank and Nursing Practice Questions for Free.
Emergency Nursing NCLEX Practice Quiz #1 (20 Questions)
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.
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.
- Option B: Uncomplicated local reactions can be treated with supportive care (ice packs, NSAIDs/APAP for pain, H1/H2 blocker). Cold compress follows the administration of antihistamine. Large local reactions should also be treated with supportive care along with glucocorticoids (usually a burst course of prednisone 40 to 60 mg per day for 3 to 5 days) to decrease the inflammatory response and improve symptoms.
- Option C: After removing the stinger, an antihistamine is administered. H1 and H2 antagonists block the effects of histamine decreasing pruritus, erythema, and urticaria. Corticosteroids (prednisone, methylprednisolone, dexamethasone) act to decrease inflammation and immune response to the antigen.
- Option D: The caller should be further advised about symptoms that require 911 assistance. Systemic reactions (anaphylaxis) are life-threatening and should be managed as such. ABCs first. The airway can be lost within seconds to minutes, so intubate early. As with any anaphylactic reaction, epinephrine, corticosteroids, H1 and H2 antagonists, and intravenous (IV) fluids should be given immediately.
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 areas is the most appropriate assignment for her?
- A. Triage
- B. Ambulatory section
- C. Trauma team
- D. Psychiatric care
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.
- Option A: The RN delegates only those tasks for which he or she believes the other health care worker has the knowledge and skill to perform, taking into consideration training, cultural competence, experience and facility/agency policies and procedures.
- Option C: This area should be filled with nurses who are experienced with hospital routines and policies and have the ability to locate equipment immediately. There is both individual accountability and organizational accountability for delegation. Organizational accountability for delegation relates to providing sufficient resources, including sufficient staffing with an appropriate staff mix.
Option D: Few places are more hectic than a Hospital Emergency Room. Clearly, delegating important nursing tasks is the only plausible way for short-staffed emergency rooms to meet the challenges of providing quality patient care. All decisions related to delegation and assignment are based on the fundamental principles of protection of the health, safety, and welfare of the public.
A client arrives at the emergency department who suffered multiple injuries from a head-on car collision. Which of the following assessments should take the highest priority to take?
- A. Unequal pupils
- B. Irregular pulse
- C. Ecchymosis in the flank area
- D. A deviated trachea
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 if the patient has a pulse.
- Option A: Another scale used by nurses in the assessment is if the patient is meeting criteria for a true level 1 trauma is the AVPU (alert, verbal, pain, unresponsive) scale. The scale is used to evaluate if the patient had a recent or sudden change in the level of consciousness and needs immediate intervention.
- Option B: The nurse evaluates the patient, checking pulse, rhythm, rate, and airway patency. Is there concern for inadequate oxygenation? Is this person hemodynamically stable? Does the patient need any immediate medication or interventions to replace volume or blood loss? Does this patient have pulselessness, apnea, severe respiratory distress, oxygen saturation below 90, acute mental status changes, or unresponsiveness?
- Option C: If the patient is not categorized as a level 1, the nurse then decides if the patient should wait or not. This is determined by three questions; is the patient in a high-risk situation, confused, lethargic, or disoriented? Or is the patient in severe pain or distress? The high-risk patient is one who could easily deteriorate, one who could have a threat to life, limb, or organ.
Nurse Kelly, a triage nurse, encountered a client who complained of mid-sternal chest pain, dizziness, and diaphoresis. Which of the following nursing actions should take priority?
- A. Administer oxygen therapy via nasal cannula.
- B. Notify the physician.
- C. Complete history taking.
- D. Put the client on ECG monitoring.
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.
- Option B: Patients with non-ST elevation myocardial infarction (NSTEMI) and unstable angina should be admitted for cardiology consultation and workup. Patients with stable angina may be appropriate for outpatient workup.
- Option C: Carefully review the patient’s medical history for cardiac history, coagulopathies, and kidney disease. Ask about family history, especially cardiac, and ask about social histories like drug use and tobacco use.
- Option D: These actions are also appropriate and should be performed immediately. Electrocardiogram (ECG) preferably in the first 10 min of arrival, (consider serial ECGs). Patients with ST-elevation on ECG patients should receive immediate reperfusion therapy either pharmacologic (thrombolytics) or transfer to the catheterization laboratory for percutaneous coronary intervention (PCI).
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. Instruct personnel to don personal protective equipment.
- B. Direct the clients to the cold or clean zone for immediate treatment.
- C. Immediately remove other clients and visitors from the area.
- D. Measure vital signs and auscultate lung sounds.
- E. Direct the clients to the decontamination area.
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.
- Option A: Personnel should don personal protective equipment before assisting with decontamination or assessing the clients. Take precautionary measures to preserve the health and safety of emergency responders working within the Contamination Reduction (Warm) Zone and the Exclusion (Hot) Zone. This includes ensuring responders wear appropriate personal protective equipment (PPE).
- Option B: The clients must undergo decontamination before entering cold or clean areas. In mass casualty incidents, decontamination corridors can be set up that consist of high volume, low-pressure water deluges. Assign personnel to decontamination stations to control and instruct victims when they enter the decontamination area.
- Option C: Decontamination triage is especially important in mass casualty incidents and should not be confused with medical triage. Decontamination triage is the process of determining which victims require decontamination and which do not. Rapidly identifying victims who may not require decontamination can significantly reduce the time and resources needed for mass decontamination.
- Option D: Set up or assign an area or building as a safe refuge/observation area for victims who do not require medical attention. Here they can be monitored for a delayed outbreak of symptoms or indications of residual contamination.
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.
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.”
- Option B: The RN may delegate components of care, but does not delegate the nursing process itself. The practice of pervasive functions of assessment, planning, evaluation, and nursing judgment cannot be delegated. 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.
- Option C: A licensed nurse should take responsibility for the other tasks to help the family begin the grieving process. The RN delegates only those tasks for which he or she believes the other health care worker has the knowledge and skill to perform, taking into consideration training, cultural competence, experience, and facility/agency policies and procedures.
- Option D: In cases of questionable death, belongings may be retained for evidence, so the chain of custody would have to be maintained. The registered nurse individualized communication regarding the delegation to the nursing assistive personnel and client situation and the communication should be clear, concise, correct, and complete. The registered nurse verifies comprehension with the nursing assistive personnel and that the assistant accepts the delegation and the responsibility that accompanies it.
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. Prepare and administer a tepid sponge bath.
- B. Explain the need for giving cool fluids.
- C. Assist the child in removing outer clothing.
- D. Advise the parent to use acetaminophen (Tylenol) instead of aspirin.
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.
- Option A: Tepid baths are not usually given because of the possibility of shivering and rebound. Registered nurses who assign, delegate and/or provide nursing care to clients and groups of clients must report all significant changes that occur in terms of the client and their condition. For example, a significant change in a client’s laboratory values requires that the registered nurse report this to the nurse’s supervisor and doctor.
- Option B: Explaining is a teaching function only appropriate for a registered nurse. The staff members’ levels of education, knowledge, past experiences, skills, abilities, and competencies are also evaluated and matched with the needs of all of the patients in the group of patients that will be cared for.
- Option D: Advising is a teaching function that is the responsibility of the registered nurse. Delegation should be done according to the differentiated practice for each of the staff members. A patient care technician, a certified nursing assistant, a licensed practical nurse, an associate degree registered nurse and a bachelor’s degree registered nurse should not be delegated to the same aspects of nursing care.
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. The child suddenly pulls out the IV.
- B. The parent is not sure regarding the child’s tetanus immunization status.
- C. The parent wants information about the IV conscious sedation.
- D. The parent’s refusal of the administration of the IV sedation.
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.
- Option A: The RN can reestablish the IV access. Parents’ views might, at least in some circumstances, influence whether or not treatment would be in a child’s best interests. Nurses and doctors are able to administer fluid directly into the veins using IV therapy. IV therapy is a relatively simple process that can be performed by nurses, but there are serious complications associated with it.
- Option B: Tetanus status can be addressed later. Tetanus immunization is part of the DTaP (diphtheria, tetanus, and acellular pertussis) vaccinations. Kids usually get: a series of four doses of DTaP vaccine before 2 years of age. another dose at 4–6 years of age.
- Option C: The RN can provide information about conscious sedation. Identifying teachable moments in clinical practice is an effective way to increase workplace learning with all nurses playing a role, not just nurse educators.
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 impalpable pulse. Which of the following tasks 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
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).
- Option A: Due to the nature of critical care patients it is inevitable that nurses working in this setting will be called on to assist with tracheal intubation. This assistant role requires a high degree of knowledge and skills in order for the intubation procedure to be executed smoothly.
- Option B: The defibrillator pads are clearly marked; however placement should be done by the RN or physician because of the potential for skin damage and electrical arcing. Most hospital nurses will be trained in advisory defibrillation, while a few will be trained in manual defibrillation.
- Option C: The use of the bag valve mask requires practice, and usually a respiratory therapist will perform the function. Bag-valve-mask ventilation can be done with one person or two, but two-person BVM ventilation is easier and more effective because a tight seal must be achieved and this usually requires two hands on the mask.
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
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.
- Option A: The policies against violence in the workplace must be developed by management and employee representatives, including the health and safety committee or representative, and union, if present.
- Option B: Administrative practices may also include education and training for employees. This education and training would include not only information about the workplace’s policy and process to respond to incidents, but may also include how to respond to an incident of violence (e.g., emergency response, when to contact security or police, etc.).
- Option C: Preventive measures generally fall into three categories, workplace design, administrative practices and work practices. All employees should know how to respond to customers or members of the public who may be angry or frustrated, such as how to de-escalate a conflict.
- A. Cleansing the amputated digits and placing them directly into an ice slurry.
- B. Wrapping the cleansed digits in saline-moistened gauze, sealing in a plastic container, and placing it in icy water.
- C. Gently cleansing the amputated digits and the hand with povidone-iodine.
- D. Cleansing the digits with sterile normal saline and placing it in a sterile cup with sterile normal saline.
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.
- Option A: 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.
- Option C: Based on these characteristics and the total client needs for the group of clients that the registered nurse is responsible and accountable for, the registered nurse determines and analyzes all of the health care needs for a group of clients; the registered nurse delegates care that matches the skills of the person that the nurse is delegating to..
- Option D: The job of the registered nurse is far from done after client care has been delegated to members of the nursing team. The delegated care must be followed up on and the staff members have to be supervised as they deliver care. The registered nurse remains responsible for and accountable for the quality, appropriateness, completeness, and timeliness of all of the care that is delivered.
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. Examine the client’s visual acuity
- B. Patch the eye
- C. Use restasis (Allergan) drops in the eye
- D. Flush the eye repeatedly using sterile normal saline
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.
- Option A: After irrigation, visual acuity then is assessed. Irrigation should continue until the pH of the eye is between 7.0 to 7.4 and remains within this range for at least 30 minutes after the irrigation has been discontinued.
- Option B: Patching the eye is not part of the first-line treatment of a chemical splash. Irrigation should be gentle, and care should be taken to avoid direct irrigation to the cornea to prevent further injury. Use of a commercial irrigation lens such as a Morgan lens may be helpful.
- Option C: Restasis (Allergan) drops are used to treat dry eyes. A topical anesthetic such as tetracaine can be applied directly to the eye, or 10 mL of 1% lidocaine can be added to a liter of irrigating fluid, taking care not to reach a toxic dose if copious irrigation is required.
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 a 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.
Correct Answer: A. Drainage of a clear fluid from the client’s nose.
Clear drainage from the client’s nose indicates that there is a leakage of CSF and should be reported to the physician immediately. Symptoms of CSF leaks include a constant dripping of clear fluid from the nose, severe headaches and meningitis. Leaks of CSF are usually caused by blunt trauma to the head and/or ears or prior sinonasal surgery.
- Option B: This reflex protects humans against tissue necrosis from contact with noxious stimuli such as pain or heat. It can occur in either the upper or lower limbs. Specifically, the withdrawal reflex mediates the flexion of the limb that comes into contact with the noxious stimuli; it also inhibits the extensors of that same limb.
- Option C: A good history concerning the mechanism of injury is important. Follow advanced trauma life support protocol and perform primary, secondary, and tertiary surveys. Once the patient is stabilized, a neurologic examination should be conducted.
- Option D: Primary injury includes injury upon the initial impact that causes displacement of the brain due to direct impact, rapid acceleration-deceleration, or penetration. These injuries may cause contusions, hematomas, or axonal injuries.
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. The child was nauseated and vomited once at home.
- B. The child has been treated several times for toxic substance ingestion.
- C. The vitamin that was ingested contains iron.
- D. The child has been treated multiple times for injuries caused by accidents.
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.
- Option A: During the first stage (0.5 to 6 hours), the patient mainly exhibits gastrointestinal (GI) symptoms including abdominal pain, vomiting, diarrhea, hematemesis, and hematochezia. The second stage (6 to 24 hours) represents an apparent recovery phase, as the patient’s GI symptoms may resolve despite toxic amounts of iron absorption.
- Option B: Patients who have GI symptoms that resolve after a short period of time and have normal vital signs require supportive care and an observation period, as it may represent the second stage of iron toxicity. Patients who remain asymptomatic 4 to 6 hours after ingestion or those who have not ingested a potentially toxic amount do not require any treatment for iron toxicity.
- Option D: This information needs further investigation but will not change the immediate diagnostic testing or treatment plan. Patients who have GI symptoms that resolve after a short period of time and have normal vital signs require supportive care and an observation period, as it may represent the second stage of iron toxicity.
The following clients come to the emergency department complaining of acute abdominal pain. Prioritize them for care in order of the severity of the conditions.
- A 59-year-old man with a pulsating abdominal mass and sudden onset of persistent abdominal or back pain, which can be described as a tearing sensation within the past hour.
- A 27-year-old woman complaining of lightheadedness and severe sharp left lower quadrant pain who reports she is possibly pregnant.
- A 15-year-old boy with a low-grade fever, right lower quadrant pain, vomiting, nausea, and loss of appetite for the past few days.
- A 43-year-old woman with moderate right upper quadrant pain who has vomited small amounts of yellow bile and whose symptoms have worsened over the week.
- A 57-year-old woman who complains of a sore throat and gnawing midepigastric pain that is worse between meals and during the night.
The correct order is shown above.
- The client with a pulsating mass has an abdominal aneurysm that may rupture and he may decompensate easily. An abdominal aortic aneurysm is a life-threatening condition that requires monitoring or treatment depending upon the size of the aneurysm and/or symptomatology.
- The woman with lower left quadrant pain is at risk for a life-threatening ectopic pregnancy. An ectopic pregnancy occurs when fetal tissue implants outside of the uterus or attaches to an abnormal or scarred portion of the uterus. Ectopic pregnancies carry high rates of morbidity and mortality if not recognized and treated promptly.
- The 15-year-old boy needs evaluation to rule out appendicitis. It should be considered in any patient with acute abdominal pain without a prior appendectomy. The diagnosis must be made as quickly as possible because with time, the rate of rupture increases.
- The woman with vomiting needs evaluation for gallbladder problems, which appear to be worsening. Disruption of the gallbladder’s normal physiology can result in a significant medical burden. Over 20 million Americans suffer from gallbladder disease and cholecystectomy is one of the most common surgeries performed.
- Lastly, the woman with mid-epigastric pain is suffering from an ulcer, but follow-up diagnostic testing can be scheduled with a primary care provider. It is important to understand this disease process is both preventable and treatable. Patients may be treated differently depending on the etiology of their gastric ulcer.
The following clients are presented with signs and symptoms of heat-related illness. Which of them needs to be attended first?
- A. A relatively healthy homemaker who reports that the air conditioner has been broken for days and who manifests fatigue, hypotension, tachypnea, and profuse sweating.
- B. An elderly person who complains of dizziness and syncope after standing in the sun for several hours to view a parade.
- 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.
- D. A marathon runner who complains of severe leg cramps and nausea, and manifests weakness, pallor, diaphoresis, and tachycardia.
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.
- Option A: The homemaker is experiencing heat exhaustion, which can be managed by fluids and cooling measures. It is important to differentiate where the patient is on the heat illness continuum. The signs and symptoms of heat exhaustion may present similarly include cramping, fatigue, dizziness, nausea, vomiting, headache. If progression to end-organ damage occurs it then becomes heat injury.
- Option B: The elderly client is at risk for heat syncope and should be advised to rest in a cool area and avoid similar situations. Heat syncope is the temporary, self-limited dizziness, weakness, or loss of consciousness during prolonged standing or positional changes in a hot environment, including physical activity. The thinking is that it is due to a combination of dehydration, pooling of blood in the venous system, decreased cardiac filling, and low blood pressure, which leads to decreased cerebral blood flow.
- Option D: The runner is experiencing heat cramps, which can be managed with fluid and rest. Heat cramps: include involuntary spasmodic contractions of large muscle groups as opposed to an isolated muscle spasm/cramp that can also occur during or after exertion. This condition is due to a relative deficiency of sodium, potassium, chloride, or magnesium. Other symptoms may include nausea, vomiting, fatigue, weakness, sweating, and tachycardia.
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 actions should the nurse do first?
- A. Provide oxygen therapy.
- B. Notify the physician immediately.
- C. Administer anxiolytic medication as ordered.
- D. Have the client breathe into a brown paper bag.
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.
- Option A: Acute anxiety may require treatment with a benzodiazepine. Chronic anxiety treatment consists of psychotherapy, pharmacotherapy, or a combination of both. Anxiety disorders appear to be caused by an interaction of biopsychosocial factors. Genetic vulnerability interacts with situations that are stressful or traumatic to produce clinically significant syndromes.
- Option B: Anxiety is one of the most common psychiatric disorders but the true prevalence is not known as many people do not seek help or clinicians fail to make the diagnosis. Anxiety is one of the most common psychiatric disorders in the general population. Specific phobia is the most common with a 12-month prevalence rate of 12.1%. Social anxiety disorder is the next most common, with a 12-month prevalence rate of 7.4%.
- Option C: Selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), benzodiazepines, tricyclic antidepressants, mild tranquilizers, and beta-blockers treat anxiety disorders.
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. Administer IV fluid incorporated with Vitamin B1 as ordered.
- B. Administer Naloxone (Narcan) 4 mg as ordered.
- C. Contact the family to get information about the client.
- D. Obtain an order for the determination of blood alcohol level.
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.
- Option B: Multiple drug abuse is not uncommon; however, there is currently nothing to suggest an opiate overdose that requires the administration of naloxone. Naloxone is indicated for the treatment of opioid toxicity, specifically to reverse respiratory depression from opioid use. It is useful in accidental or intentional overdose and acute or chronic toxicity.
- Option C: Teens and young adults are at higher risk for binge drinking, which can cause alcohol poisoning. Binge drinking is a pattern of drinking that raises the blood alcohol level within a short period of time. Though it varies from person to person, binge drinking is usually defined as four drinks for women and five drinks for men in a two-hour period.
- Option D: Additional information or the results of the blood alcohol testing are part of the management but should not delay the immediate treatment. A blood alcohol test may be used to find out if the patient has alcohol poisoning, a life-threatening condition that happens when your blood alcohol level gets very high. Alcohol poisoning can seriously affect basic body functions, including breathing, heart rate, and temperature.
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. Arranging transportation to a safe house.
- B. Advising the client about contacting the police.
- C. Making an appointment to follow up on the injuries.
- D. Making a referral to a counselor.
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.
- Option B: If the patient does not want to go to a shelter, provide telephone numbers for domestic violence or crisis hotlines and support services for potential later use. Provide the patient with instructions but be mindful that written materials may pose a danger once the patient returns home.
- Option C: Without proper social service and mental health intervention, all forms of abuse can be recurrent and escalating problems, and the prognosis for recovery is poor. Without treatment, domestic and family violence usually recurs and escalates in both frequency and severity.
- Option D: These are important for the long-term management of this case. Health professionals provide an opportunity for victims of domestic violence to obtain help. Of those injured by domestic violence, over 75% continue to experience abuse. Over half of battered women who attempt suicide will try again; often they are successful with the second attempt.
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. Being aware of the signs and symptoms of potential agents of bioterrorism.
- B. Making ethical decisions regarding exposing self to potentially lethal substances.
- C. Being aware of the agency’s emergency response plan.
- D. Being aware of what and how to report to the Centers for Disease Control and Prevention.
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.
- Option A: Planning/Prevention focuses on providing protection from disasters on both the domestic and international levels in an attempt to limit the loss of life and reduce the financial impact of disaster response. Planning includes care, evacuation, and environmental planning and response standards.
- Option B: Risk Assessment identifies high priority and vulnerability areas and directs mitigation efforts. The goal of risk assessment is the identification of the possible disasters that challenge the area including both internal and external disasters, collecting resource inventory, identifying a facility or region’s vulnerabilities based on location and resources, and generating a priorities list.
- Option D: The Centers for Disease Control and Prevention (CDC) provides education and information regarding specific disaster types, including infectious diseases, chemical and radiation exposure, and natural disaster or weather-related incidents.
Emergency Nursing NCLEX Practice Quiz #2 (20 Questions)
Michael works as a triage nurse, and four clients arrive at the emergency department at the same time. List the order in which he will assess these clients from first to last.
- An irritable infant with a fever, petechiae, and nuchal rigidity
- An ambulatory dazed 25-year-old male with a bandaged head wound
- A 50-year-old female with moderate abdominal pain and occasional vomiting
- A 35-year-old jogger with a twisted ankle, having a pedal pulse, and no deformity
The correct order is shown above.
- An irritable infant with fever and petechiae should be further assessed for other meningeal signs. Meningitis is a life-threatening disorder that is most often caused by bacteria or viruses. Before the era of antibiotics, the condition was universally fatal. Nevertheless, even with great innovations in healthcare, the condition still carries a mortality rate of close to 25%.
- The patient with the head wound needs additional history and assessment for intracranial pressure. Traumatic brain injury (TBI) due to head trauma is a common presentation in emergency departments and usually accounts for more than one million visits annually. It is a common cause of death and disability among children and adults.
- The patient with moderate abdominal pain is uncomfortable, but not unstable at this point. An acute abdomen is a condition that demands urgent attention and treatment. The acute abdomen may be caused by an infection, inflammation, vascular occlusion, or obstruction. The patient will usually present with sudden onset of abdominal pain with associated nausea or vomiting.
- For the ankle injury, a medical evaluation can be delayed 24 – 48 hours if necessary. Acute ankle sprains are commonly seen in both primary care practices and emergency departments and can result in significant short-term morbidity, recurrent injuries, and functional instability. Appropriate initial evaluation and treatment can decrease the likelihood of these complications.
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
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.
- Option B: Primary injury includes injury upon the initial impact that causes displacement of the brain due to direct impact, rapid acceleration-deceleration, or penetration. These injuries may cause contusions, hematomas, or axonal injuries.
- Option C: Identify any condition which might compromise the airway, such as pneumothorax. The cervical spine should be maintained in-line during intubation. Nasotracheal intubation should be avoided in patients with facial trauma or basilar skull fracture.
- Option D: Vital signs are considered part of the secondary survey. Avoid hypotension. Normal blood pressure may not be adequate to maintain adequate flow and CPP if ICP is elevated. Isolated head trauma usually does not cause hypotension. Look for another cause if the patient is in shock.
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?
- A. Non-urgent
- B. Urgent
- C. Emergent
- D. High urgent
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.
- Option A: Non-urgent conditions can wait for hours or even days. If the patient meets a certain group of discriminators, he or she is categorized into an urgency category that ranges from immediate to non-urgent.
- Option B: Clients with urgent priority need treatment within 2 hours of triage (e.g. kidney stones). If the patient is not categorized as a level 1, the nurse then decides if the patient should wait or not. This is determined by three questions; is the patient in a high-risk situation, confused, lethargic, or disoriented? Or is the patient in severe pain or distress?
- Option D: High urgency is not commonly used; however, in 5-tier triage systems, High urgent patients fall between emergent and urgent in terms of the time elapsing prior to treatment. The urgency categorization is tied to a maximum waiting time, with the immediate maximum waiting time being 0 minutes, very urgent is 10 minutes max. Urgent waiting time is maxed at 60 minutes, standard 120 minutes, and non-urgent waiting time is maxed at 240 minutes.
You respond to a call for help from the ED waiting room. There is an elderly patient lying on the floor. List the order for the actions that you must perform.
- Establish unresponsiveness
- Call for help and activate the code team
- Perform the chin lift or jaw thrust maneuver
- Initiate cardiopulmonary resuscitation (CPR)
- Instruct a nursing assistant to get the emergency cart
The correct order is shown above.
- Establish unresponsiveness first. (The patient may have fallen and sustained a minor injury.) The Code Blue will follow the AHA/HSFC ACLS/PALS guidelines. It is recommended all members have current ACLS/PALS training and certification.
- If the patient is unresponsive, get help, and have someone initiate the code. Any individual may call a code blue and certified staff will initiate BLS and AED if available, until relieved by the Code Blue team.
- Performing the chin lift or jaw thrust maneuver opens the airway. Staff trained in the use of the LifePak 20 Automatic External Defibrillator (AED) function, may initiate AED use prior to the arrival of the Code Blue Team.
- The nurse is then responsible for starting CPR. CPR should not be interrupted until the patient recovers or it is determined that heroic efforts have been exhausted. The Emergency Medical System (EMS) will be activated for all areas in the hospital not covered by the Code Blue team, as well as all arrests occurring outside the building. If the team is not able to transport the Code Blue Cart to the scene, the team will provide Basic Life Support (BLS) until EMS arrives.
- A crash cart should be at the site when the code team arrives; however, basic CPR can be effectively performed until the team arrives. The units where the Code Blue carts are located are only responsible for transporting the cart to the unit where a Code Blue has been called.
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.
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.
- Option B: Among the tasks that CANNOT be legally and appropriately delegated to nonprofessional, unlicensed assistive nursing personnel, such as nursing assistants, patient care technicians, and personal care aides, include assessments, nursing diagnosis, establishing expected outcomes, evaluating care and any and all other tasks and aspects of care including but not limited to those that entail sterile technique, critical thinking, professional judgment, and professional knowledge.
- Option C: Part of supervision entails the ongoing evaluation of staff’s ability by the registered nurse to perform assigned tasks using direct observations and with indirect observations of patient safety, the quality of the care provided, the appropriateness of care provided, and the timeliness of care provided.
- Option D: Scopes of practice are also considered prior to the assignment of care. All states have scopes of practice for advanced nurse practitioners, registered nurses, licensed practical nurses, and unlicensed assistive personnel like nursing assistants and patient care technicians.
You are caring for a client with frostbite on the feet. Place the following interventions in the correct order.
- Remove the victim from the cold environment.
- Administer pain medication.
- Immerse the feet in warm water 100° F to 105° F (40.6º C to 46.1° C).
- Apply a loose, sterile, bulky dressing.
- Monitor for signs of compartment syndrome.
The correct order is shown above.
Frostbite, also known as freezing cold injury, is tissue damage that occurs due to cold exposure, occurring at temperatures below zero degrees celsius. The victim should be removed from the cold environment first, and then the rewarming process can be initiated. It will be painful, so give pain medication prior to immersing the feet in warmed water.
- Patients should have protection from further injury by covering exposed areas. Remove patients from the wind. Remove wet clothing and replace it with dry clothing. Avoid vigorous rubbing as this can cause further damage.
- NSAIDS (ibuprofen) are indicated for controlling pain and preventing further inflammation, but stronger analgesics including narcotics may be necessary to achieve pain control. Frequent re-examination for sensation should accompany rewarming.
- The care of patients with frostbite begins with rewarming in the field if there is no anticipation of refreezing, as thaw-refreezing may worsen injuries. In-hospital management includes warm water baths, approximately 40-42 degrees C. Patients with systemic hypothermia should be managed by raising core temperature above 35 degrees C using warm IV fluids, and this should precede warming of the affected extremity.
- Apply a loose, bulky dressing to prevent infection. As with burn patients, particular care to prevent infections and dehydration should be a priority. Overly aggressive surgical debridement may remove skin that is otherwise viable, so complete rewarming should be achieved before surgical debridement.
- Signs of compartment syndrome (edema, pulselessness, extreme pain) should prompt urgent surgery. Delayed amputation (up to 6 weeks following injury) until the determination of tissue viability may prevent surgical morbidity from unnecessary procedures.
Following an emergency endotracheal intubation, nurses must verify tube placement and secure the tube. List in order the steps that are required to perform this function.
- Auscultate the chest during assisted ventilation.
- Confirm that the breath sounds are equal and bilateral.
- Secure the tube in place.
- Obtain an order for a chest x-ray to document tube placement.
The correct order is shown above.
Auscultating and confirming equal bilateral breath sounds should be performed in rapid succession. If the sounds are not equal or if the sounds are heard over the mid-epigastric area, tube placement must be corrected immediately. Securing the tube is appropriate while waiting for the x-ray study.
- 1 and 2: After placing the endotracheal tube, it is essential to confirm its placement in the trachea and position proximal to the carina. The physician should auscultate for symmetric bilateral breath sounds, and the absence of breath sounds over the stomach.
- 3. After confirmation of breath sounds, the nurse may secure the tube in place. After the endotracheal tube is passed through the vocal cords, the cuff is inflated using a 5 cc or 10 cc syringe filled with air. The stylet is removed, and the proximal end of the endotracheal tube is connected to the carbon dioxide monitor and the ventilation device.
- 4. A post-intubation chest x-ray confirms the location of the endotracheal tube’s distal tip 2 to 4 cm proximal to the carina and rules out mainstem bronchus intubation. To avoid an unrecognized misplaced endotracheal tube, immediate confirmation of the tube position should take place.
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.”
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.
- Option A: Penetrating trauma often causes damage to internal organs resulting in shock and infection. The severity depends on the body organs involved, the characteristics of the object, and the amount of energy transmitted.
- Option C: Other information, such as a history of diabetes, is important in the overall treatment plan, but can be addressed later. The indications for surgical intervention include a patient with hemodynamic instability, development of peritoneal findings such as involuntary guarding, point tenderness or rebound tenderness, and diffuse abdominal pain that does not resolve.
- Option D: These injuries may be life-threatening because abdominal organs bleed profusely. If the pancreas is injured, further injury occurs from autodigestion. Injuries of the liver often present in shock because the liver tissue has a large blood supply.
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
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.
- Option B: Delirium tremens occur in chronic alcohol abusers who abruptly discontinue alcohol use, often as early as 48 hours. The initial minor withdrawal symptoms are characterized by anxiety, insomnia, palpitations, headache, and gastrointestinal symptoms. These symptoms usually occur as early as 6 hours after cessation of alcohol use. More than 50% of those with a history of alcohol abuse can exhibit alcohol withdrawal symptoms at discontinuing or decreasing their alcohol use.
- Option C: If withdrawal symptoms remain untreated, this can typically lead to DT. Additional evaluation of a patient with DT involves identifying electrolyte, nutrition, and fluid abnormalities. Most of these patients present with severe dehydration (up to 10 L fluid deficit) and severe electrolyte abnormalities, including hypoglycemia and severe hypomagnesemia and hypophosphatemia.
- Option D: After 12 hours, minor withdrawal symptoms can progress to alcohol hallucinosis, a condition characterized by visual hallucinations. It can typically resolve in 24 to 48 hours, and may also be associated with auditory and tactile hallucinations.
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.
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.
- Option A: The care of critical patients is an RN’s responsibility. Some needs require high levels of professional judgment and skill, and other patient needs are somewhat routine and without the need for high levels of professional judgment and skill. Based on these characteristics and the total client needs for the group of clients that the registered nurse is responsible and accountable for, the registered nurse determines and analyzes all of the health care needs for a group of clients; the registered nurse delegates care that matches the skills of the person that the nurse is delegating to.
- Option B: Teaching is an RN’s responsibility. Among the tasks that CANNOT be legally and appropriately delegated to nonprofessional, unlicensed assistive nursing personnel, such as nursing assistants, patient care technicians, and personal care aides, include assessments, nursing diagnosis, establishing expected outcomes, evaluating care, and any and all other tasks and aspects of care including but not limited to those that entail sterile technique, critical thinking, professional judgment, and professional knowledge.
- Option D: Removing clothing can be delegated to a nursing assistant. The staff members’ levels of education, knowledge, past experiences, skills, abilities, and competencies are also evaluated and matched with the needs of all of the patients in the group of patients that will be cared for.
You are assessing a patient who has sustained a cat bite to the left hand. The cat has 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
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.
- Option A: The initial injury is the result of the physical trauma of teeth puncturing and/or tearing soft tissue, and in the case of some dog bites, blunt force breaking bones. Cat bites are narrow and deep as the animal rarely pulls or shakes its head, simply biting and holding. Because the cat bite wound is deep and narrow, it is much more likely to seal itself relatively quickly, providing an anaerobic environment for the inoculated bacteria as well as initially appearing less consequential and prolonging time to seeking medical care.
- Option B: A tetanus shot can be given before discharge. The patient’s TDaP status should be updated if necessary. Patients should be encouraged to get an updated tetanus vaccination. The prognosis for most animal bites is excellent. However, it is essential to know that, on average, about 30 to 50 people die from dog bites each year.
- Option D: There is also a risk for tendon damage due to deep puncture wounds. Cat bites deeper than superficial need thorough irrigation under local anesthesia and the wound left open. The patient should be discharged with a week’s course of amoxicillin-clavulanate and given strict wound care precautions.
A client in a one-car rollover presents with multiple injuries. Prioritize the interventions that must be initiated for this patient.
- Assess for spontaneous respirations.
- Use the chin lift or jaw thrust method to open the airway.
- Give supplemental oxygen per mask.
- Secure/start two large-bore IVs with normal saline.
- Obtain a full set of vital signs.
- Remove the patient’s clothing.
- Insert a Foley catheter if not contraindicated.
The correct order is shown above.
For multiple trauma victims, a lot of interventions will occur simultaneously as team members assist in the resuscitation. Methods to open the airway such as the chin lift or jaw thrust can be used simultaneously while assessing for spontaneous respirations. However, airway and oxygenation are a priority. Starting IVs for fluid resuscitation is part of supporting circulation. (EMS will usually establish at least one IV in the field.) Nursing assistants can be directed to take vitals and remove clothing. A Foley catheter is necessary to closely monitor output.
- Assessing the conscious patient’s airway starts with talking to the patient. Ask the patient their name to see if they respond clearly and appropriately. This will help assess the patency of the airway. Airway evaluation also includes a visual inspection of the patient. Look for signs of respiratory distress, listen for stridor, inspect the face, oral cavity, and neck, as well as palpate the patient’s neck and face.
- Once the airway is secured or maintained by the patient, breathing and ventilation should be assessed. This involves visual inspection of the patient’s chest, looking for injury. Look for paradoxical chest movement, which indicates flail chest, penetrating injury, or tracheal deviation. Auscultate the lungs listening for decreased breath sounds.
- Evaluate the patient’s oxygen saturation and give supplemental oxygen per mask. If the patient has signs of tension pneumothorax, immediate needle decompression or chest thoracostomy should be performed. Ultrasound or x-ray imaging of the chest should be considered as an adjunct to the physical exam.
- In patients with shock, isotonic intravenous fluids can be initially administered, but blood products are preferred in a 1 to 1 to 1 ratio of red blood cells to plasma to platelets for patients with ongoing fluid requirements and concerns for hemorrhage. Establishing adequate IV access in trauma patients is also of critical importance. Two large-bore peripheral IVs, or functioning intraosseous access, should be established early in the evaluation period.
- Emergency medical services (EMS) should provide information including mechanism of injury, patient vital signs, obvious injury, current interventions, and patient’s age and sex if available. After receiving this information, the healthcare team members should begin thinking of possible injuries that may be a threat to the patient’s life.
- The fifth and final step of the primary survey includes removing all clothing to assess for signs of injury such as gunshot wounds, stab wounds, abrasions, lacerations, ecchymosis, or any other traumatic findings. During this stage, it is important to remember to keep the patient warm as hypothermia can lead to multiorgan failure.
- Evaluate the patient’s rectum as well as a genitourinary exam. Evaluate the patient’s genitals looking for any bleeding, ecchymosis, or lacerations. Foley catheter may be placed as an adjunct but should be avoided without further evaluation if blood is noted at the meatus.
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
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.
- Option A: PO (per os) medications are inappropriate for this emergency situation. Intravenous administration is preferred, but benzodiazepines can be administered via the intramuscular, rectal, nasal, or buccal route if vascular access is not available.
- Option B: Tegretol is used in the management of generalized tonic-clonic, absence or mixed type seizures, but it does not come in an IV form. Carbamazepine is used to manage and treat epilepsy, trigeminal neuralgia, and acute manic and mixed episodes in bipolar I disorder. Indications for epilepsy are specifically for partial seizures with complex symptomatology (psychomotor, temporal lobe), generalized tonic seizures (grand mal), and mixed seizure patterns.
- Option C: Magnesium sulfate is given to control seizures in toxemia of pregnancy. If eclampsia is suspected, intravenous magnesium sulfate is the antiepileptic drug of choice. Delivery of the fetus is the definitive treatment of eclampsia.
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 the following shock?
- A. Distributive
- B. Hypovolemic
- C. Obstructive
- D. Cardiogenic
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.
- Option A: Distributive shock results from a relative inadequate intravascular volume caused by arterial or venous vasodilation. In distributive shock, systemic vasodilation leads to decreased blood flow to the brain, heart, and kidneys damaging vital organs. Additionally, fluid leaks from the capillaries into the surrounding tissues, further complicating the clinical picture. further complicating the clinical picture.
- Option C: An obstructive shock is a form of shock associated with physical obstruction of the major vessels of the heart itself. Obstructive shock is a less common, but important cause of shock in critically ill infants and children. It is caused by mechanical obstruction of blood flow to and/or from the heart and causes can include tension pneumothorax, cardiac tamponade, pulmonary embolism, or cardiac defects resulting in left-sided outflow tract obstruction.
- Option D: Causes of cardiogenic include massive myocardial infarction or other causes of primary cardiac (pump) failure. Cardiogenic shock is a primary cardiac disorder characterized by a low cardiac output state of circulatory failure that results in end-organ hypoperfusion and tissue hypoxia. Clinical criteria include a systolic blood pressure of less than or equal to 90 mm Hg for greater than or equal to 30 minutes or support to maintain systolic blood pressure less than or equal to 90 mm Hg and urine output less than or equal to 30 mL/hr or cool extremities.
Cole is an emergency nurse who encounters a patient who is a suspected carrier of a biological 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 pestis (plague)
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.
- Option A: Although B. anthracis is generally an environmentally-stable and ubiquitous organism in nature, it has also been recognized as a potential pathogen that could be used as a biological weapon. Anthrax is categorized as a category A priority pathogen by the Centers for Disease Control and Prevention because it is potentially capable of being disseminated as a bioweapon.
- Option B: Francisella tularensis organism is considered a category A biowarfare agent because of its high rate of infectivity, stability in a liquid environment, relative ease of growth, easy spread and ability to cause significant illness and morbidity. Because of its ability to remain viable in the environment, this can also lead to repeat outbreaks and relapses that can last many months. The infection must be reported to the local authorities ASAP.
- Option C: The Centre for Disease Control and Prevention (CDC) has been monitoring cases of botulism in the United States since 1973. From years 2011 through 2015, an average of 162 annual cases were reported. These primarily included infant botulism at 71% to 88%, followed by foodborne botulism, wound botulism, and botulism of unknown origin.
- Option E: This biological agent belongs to Category A. This agent poses the highest risk to national security because they can easily transfer from one person to the other, which can lead to high mortality rates, and necessitate special measures for immediate preparation. Any patient suspected of plague should undergo until cleared. For pneumonic plague, the Centers for Disease Control recommend standard and droplet precautions for 48 hours after the initiation of appropriate antibiotic therapy.
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?
- A. Red
- B. Black
- C. Yellow
- D. Green
- E. White
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.
- Option A: Red tags are for people with life-threatening conditions who need immediate emergency treatment. The rest of the individuals who have poor respirations or cannot protect their airway, have absent or decreased peripheral pulses, and are unable to follow simple commands are tagged immediately and given the color red.
- Option B: Black tags are for deceased people and for those who are not expected to survive due to extensive injuries. Once the “minor” injuries are out of the area, responders should begin to move and triage patients with the RPM acronym; respirations, perfusion, and mental status. This includes making sure the individual has a manual respiration rate that is roughly greater than 30 breaths a minute, peripheral pulses are present with a capillary refill of fewer than 2 seconds, and can follow commands. If a patient has none of these, the patient is declared deceased, given a black tag, and moved to the black-coded area.
- Option D: Green tags are for those people with non-urgent cases and can wait for their turn for assessment and treatment. Anyone who can follow these commands and walk to this area is designated as “minor” and given a green tag to signify minor injury status.
- Option E: White tags are for those with minor injuries that don’t require any medical care. With this method, providers can quickly rule in and rule out individuals who require immediate medical attention, who can wait, and who nothing can be done for.
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.”
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.
- Option A: The patient should not be discharged yet. A significant component of evaluation for a patient who presents with signs and symptoms of PSVT is history and physical exam. These should include vital signs (respiratory rate, blood pressure, temperature, and heart rate), a review of the patient’s medication list, and a 12-lead electrocardiogram.
- Option B: Patients who are hemodynamically stable and have an electrocardiogram that shows a regular rhythm with undetectable P waves, Valsalva maneuvers, carotid sinus massage, or intravenous adenosine might be used to slow the ventricular rate or convert the rhythm into sinus rhythm and thus aid in the diagnosis. If intravenous adenosine does not work, then intravenous or oral calcium channel blockers or beta-blockers should be used.
- Option D: The most common symptoms are dizziness and palpitations. Patients with PSVT and a known history of coronary artery disease may present with a myocardial infarction secondary to the stress on the heart. Patients with PSVT and a known history of heart failure may come in with acute exacerbation.
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
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.
- Option A: Pancreatic injury is hidden in the shadows of coexisting intra abdominal injuries and its inherent retroperitoneal location. Symptoms of radiating epigastric pain to the back, nausea, and vomiting are also seen with the more commonly injured adjacent viscera. An abdominal exam is reported to have a false negative rate of 34% on initial evaluation.
- Option B: Traumatic pancreatitis can be a difficult diagnosis to make and requires meticulous investigation. Damage to the pancreas is not very common and is seldom a solitary insult. As the signs and symptoms are nonspecific, a high index of suspicion is necessary to prevent delayed diagnosis.
- Option C: Other complications include pancreatic pseudocyst which is a circumscribed collection of enzymes, blood, and necrotic tissue. Less frequent complications include peritonitis, intestinal obstruction, and gastrointestinal bleeding. Pancreatic trauma can disrupt the endocrine function for patients as well.
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?”
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.
- Option A: Personnel such as paramedics, police officers, or fire rescue who may have arrived at the scene of the injury may be utilized as sources of essential history regarding the etiology of the injury. This is especially important if the patient has altered mental status and is unable to relay the history of the incident.
- Option B: In penetrating abdominal injury due to a gunshot wound, initial treatment can be paramount for the prognosis and survival of the victim. The most important task for the initial assessment is to assess the airway, breathing, and circulation of the patient and stop the bleeding.
- Option C: The other information is not as useful in determining which diagnostic studies and care are needed immediately. It is beneficial to gather information regarding the events surrounding the injury, including the environment, people involved, allergies, medications, and past medical history of the patient. Information about the caliber of the weapon, the number of shots heard, and any other extenuating circumstances may provide additional valuable information.
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
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.
- Option A: Immediate measures are necessary to maintain breathing and hemodynamic stability, such as oxygen therapy. Hyperbaric oxygen (HBO) therapy has also been shown to exert neuroprotective effects when administered before or after SCI. Experimental studies have revealed various mechanisms that contribute to these neuroprotective effects, including improved spinal cord oxygen tension, decreased apoptosis, reduced inflammation, attenuation of oxidative stress, and improved angiogenesis and autophagy.
- Option B: Rapid infusion as quickly as possible of large volumes of crystalloids to restore blood volume and blood pressure is now the standard treatment for patients with combined traumatic brain injury and hemorrhagic shock. The final goal of fluid management is to optimize the circulatory system to ensure the sufficient delivery of oxygen to organs.
- Option D: Suctioning is also done after the cervical spine is immobilized. Patients with known or suspected cervical spine injury may require emergent intubation for airway protection and ventilatory support or elective intubation for surgery with or without rigid neck stabilization (i.e., halo).