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Question 1 of 25
1. Question
1 point(s)After exposure to hot weather and sun, clients with signs and symptoms of heat-related ailment rush to the Emergency Department (ED). Sort clients into those who need critical attention and those with less serious conditions.
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An elderly traffic enforcer who complains of dizziness and syncope after standing under the heat of the sun for several hours to perform his job.
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A comparatively healthy housewife who states that the air conditioner has been down for 5 days and who exhibits hypotension, tachypnea, profuse diaphoresis, and fatigue.
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An abandoned person who is a teacher; has altered mental state, weak muscle movement, hot, dry, pale skin; and whose duration of heat exposure is unknown.
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A sportsman who complains of severe leg cramps and nausea, and displays paleness, tachycardia, weakness, and diaphoresis.
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Question 2 of 25
2. Question
1 point(s)The ambulance has transported a man with severe chest pain. As the man is being transferred to the emergency stretcher, the nurse assessed the following: unresponsiveness, cessation of breathing, and absence of palpable pulse. Which of the following tasks is proper to assign to the nursing assistant?
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Question 3 of 25
3. Question
1 point(s)A high school student comes in the triage area alert and ambulatory, and his uniform is soaked with blood. He and his classmates are sounding, “We were running around outside the school and he got hit in the abdomen with a stick!” Which statement should be a priority?
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Question 4 of 25
4. Question
1 point(s)A mother is so worried that her son took an unknown amount of children’s chewable vitamins at an unknown time. While in the ED, the child is alert and asymptomatic. What information should be directly stated to the physician?
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Question 5 of 25
5. Question
1 point(s)Several clients arrive in the ED with the same complaint of abdominal pain. Designate them for care in order of the severity of their condition.
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A 12-year-old girl with a low-grade fever, anorexia, nausea, and right lower quadrant tenderness for the past 2 days.
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A 25-year-old woman complaining of dizziness and severe left lower quadrant pain who states she is probably pregnant.
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A 42-year-old woman with moderate right upper quadrant pain who has vomited little amounts of yellow bile and whose symptoms have worsened over the past week.
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A 53-year-old man who experiences discomforting mid-epigastric pain that is worse between meals and during the night.
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A 68-year-old man with a pulsating abdominal mass and sudden onset of “tearing” pain in the abdomen and flank within the past hour.
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A 38-year-old man complaining of severe occasional cramps with three episodes of watery diarrhea hours after meal.
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Question 6 of 25
6. Question
1 point(s)The newly hired nurse is in his first week on the job in the ED. He used to be a traveling nurse for 5 years. Which area in his present job is the most appropriate assignment for him?
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Question 7 of 25
7. Question
1 point(s)A client with multiple injuries is rushed to the ED after a head-on car collision. Which assessment finding takes priority?
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Question 8 of 25
8. Question
1 point(s)Several people were killed and injured in a recent industrial explosion. The victims are being interviewed and assessed by the nurses for possible psychiatric crises. Which client has the greatest risk for posttraumatic distress disorder?
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Question 9 of 25
9. Question
1 point(s)When several areas of a daycare center collapsed due to an earthquake, children, especially injured ones, were brought to the ED. As a competent nurse, you know that children will be more predisposed to which of the following? Select all that apply.
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Question 10 of 25
10. Question
1 point(s)What is regarded as one of the priority actions that must be accomplished when a primary assessment of a trauma client is conveyed?
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Question 11 of 25
11. Question
1 point(s)Prior to oral defense, a 21-year-old nursing student goes straight to the clinic due to tingling sensations, palpitations, and chest tightness. Deep, rapid breathing and carpal spasms are also observed. What is the nursing priority action for this situation?
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Question 12 of 25
12. Question
1 point(s)The nurse is assigned to a small rural community hospital. Six clients have arrived at the ED because the local church is caught on deadly fire. More affected residents are expected to arrive soon and it is the only hospital in the nearby area. Arrange the following six clients in the order in which they should obtain medical attention utilizing disaster triage principles.
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A 19-year-old anxious girl with a crushed leg that is very swollen and has tachycardia.
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A 50-year-old man in full cardiac arrest who has been receiving CPR continuously for the past 30 minutes.
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A firefighter who is exhibiting combative behavior and has respiratory stridor.
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A 5-year-old child with respiratory distress and burns over more than 70% of the anterior body.
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A 62-year-old grandmother with full-thickness burns to the hands and forearms.
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An 11-year-old boy wheezing and heavily labored breathing unrelieved by an asthma inhaler.
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Question 13 of 25
13. Question
1 point(s)Identify the five most important elements in conducting disaster triage for multiple victims. Select all that apply.
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Question 14 of 25
14. Question
1 point(s)A group of passengers enters the ED with complaints of cough, tightness in the throat, and extreme periorbital swelling. There is a strong odor exuding from their clothes. They report exposure to a “gas bomb” that was placed in the bus terminal. What is the priority action?
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Question 15 of 25
15. Question
1 point(s)A drunk driver has been in the police station for 48 hours. During the first hours, he had tremors and was feeling anxious and sweaty. Currently, he is experiencing disorientation, hallucination, and hyperactivity. It was noted that the client has a history of alcohol abuse. What is the priority nursing diagnosis?
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Question 16 of 25
16. Question
1 point(s)During a class discussion, the 50-year-old professor suddenly feels left-sided chest pain, dizziness, and diaphoresis. What is the priority action when he arrives in the ED triage area?
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Question 17 of 25
17. Question
1 point(s)A child with fever has been admitted to the ED for several hours. Cooling measures are ordered by the physician in order for the client’s temperature to come down. Which task would be appropriate to delegate to the nursing assistant?
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Question 18 of 25
18. Question
1 point(s)A traveler’s feet suddenly become pale, turn red, and feel very cold. In just 30 minutes, the affected part became prickly and numb. Place the following interventions in the correct order for a client with frostbite.
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Remove the client from the cold environment
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Monitor for compartment syndrome
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Administer pain medication
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Apply loose, sterile, bulky dressing
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Immerse the feet in warm water of 105°F to 115°F (40.6°C to 46.1°C)
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Question 19 of 25
19. Question
1 point(s)An elderly maintenance staff is lying on the floor and the ED nurse responds to a call for help. List the order in which the nurse must carry out the following actions.
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Call for help and activate the code team
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Perform the chin lift or jaw thrust maneuver
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Establish unresponsiveness
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Initiate cardiopulmonary resuscitation (CPR)
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Instruct the nurse assistant to get the crash cart
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Question 20 of 25
20. Question
1 point(s)Which task is most appropriate to assign to the nursing assistant when an instantaneous death transpires in the ED? Select all that apply.
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Question 21 of 25
21. Question
1 point(s)During the shift of a triage nurse in the Emergency Department (ED), the following clients arrive. Which client needs the most rapid response to protect other clients in the ED from infection?
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Question 22 of 25
22. Question
1 point(s)The nurse is assigned to a client who has a draining sacral wound infected by MRSA. Which personal protective equipment (PPE) will the nurse plan to use in preparing to change the linens of the client? Select all that apply.
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Question 23 of 25
23. Question
1 point(s)Which action will the nurse take to most effectively reduce the incidence of hospital-related urinary tract infections (UTI)?
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Question 24 of 25
24. Question
1 point(s)A 90-year-old client is confined to the unit for two weeks. He has been receiving antibiotics for more than a week and tells that he is having frequent watery stools. Which action will you take first?
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Question 25 of 25
25. Question
1 point(s)The nurse is assigned to a client with meningococcal meningitis. Which information about the client is the best indicator that the nurse can discontinue droplet precautions?
CorrectIncorrect