Deck 82: Management of Clients in the Emergency Department

Question 1

For children who need crystalloid fluid resuscitation, the formula is altered to

A) 20 ml/kg bolus.
B) 20 ml/kg/hour.
C) 40 ml/kg bolus
D) 40 ml/kg/hour.

Answer 1

20 ml/kg bolus.

Question 2

A nurse is preparing to administer 150 mg of intravenous phenytoin to a client with seizure activity. After diluting the medication with the supplied diluent, the nurse will infuse the medication over a period of

A) 1 minute.
B) 2 minutes.
C) 3 minutes.
D) 4 minutes.

Answer 2

3 minutes.

Question 3

A client with a chest injury develops respiratory distress, distended jugular neck veins, and tracheal deviation. The nurse anticipates the client will receive immediate

A) chest tube insertion.
B) chest x-ray.
C) intubation.
D) needle thoracotomy.

Answer 3

needle thoracotomy.

Question 4

The ED triage nurse identifies the client who can have treatment delayed for a few hours as the client with a

A) avulsed (knocked-out) tooth.
B) broken finger.
C) head injury from a fall.
D) large laceration that needs suturing.

Question 5

A 7-year-old child is brought to the emergency department complaining of arm pain after falling off a swing at school. The child rates the pain as an 8 on a scale of 1-10. The best response by the nurse to this information is to

A) assume the child is too young to verbalize how much pain he/she is in.
B) give the child a narcotic pain medication.
C) obtain further information about the pain using an age-appropriate tool.
D) send the parents to the waiting room to see if the child "gets better" without them.

Question 6

The nurse clarifies that the law specifies that an ED client cannot be transferred to another facility until the client is stable. "Stable" is interpreted to mean that the client

A) has a blood pressure of at least 90/50 mm Hg.
B) has been evaluated by a physician.
C) is conscious and able to provide necessary information.
D) is not likely to deteriorate during transfer.

Question 7

When a client is brought to the ED with chemical injury to the left eye, the nurse would irrigate the eye with normal saline, a minimum of

A) 250 ml.
B) 500 ml.
C) 1000 ml.
D) 2000 ml.

Question 8

After stabilizing a trauma victim's airway, breathing, and circulation, the next item for the ED nurse to assess is

A) abdomen.
B) broken bones.
C) integument.
D) neurologic status.

Question 9

The nurse is caring for a 100-kg client who sustained a burn injury over 50% of total body surface area (TBSA). How much fluid should this client receive in the first 8 hours?

A)
B)
C)
D)

Question 10

A teenage girl brings her newborn baby wrapped in a bloody T-shirt into the ED and says she intends to leave the baby there. The nurse should

A) call the police.
B) initiate admission to the pediatric unit.
C) notify social services.
D) restrain the mother.

Question 11

A client is brought to the ED with a suspected neck injury. The nurse should

A) adjust the table to sit the client upright.
B) apply a hard cervical collar to the nuchal area.
C) check for full range of motion of the head.
D) place a rolled towel under the client's neck.

Question 12

A young man is admitted to the ED after sustaining a gunshot wound and dies within a short time. To prepare the body before the family's viewing, the nurse should

A) remove all clothing in order to give it to the family.
B) remove all tubes and instruments used in treatment.
C) wash the body thoroughly.
D) wrap all clothing already removed and place it in a paper bag.

Question 13

A client admitted to the ED exhibits raccoon eyes and Battle's sign. The nurse interprets that these manifestations are compatible with

A) basilar skull fracture.
B) extreme fatigue and sensory deprivation.
C) opiate overdose or poisoning.
D) subarachnoid hemorrhage.

Question 14

When a client is admitted to the ED with respiratory distress and rapid-sequence induction (RSI) is needed to intubate the client, the nurse should first

A) apply nasal oxygen.
B) establish intravenous (IV) access.
C) hyperventilate with 50% oxygen.
D) insert a nasogastric tube.

Question 15

The nurse explains to the family of a client with a spinal cord injury that IV methylprednisolone will reduce

A) pain.
B) possibility of seizure.
C) muscle spasms.
D) spinal cord edema.

Question 16

A client is brought to the emergency department (ED) in critical condition after a car crash. The client's family is distraught. To best help this family, the ED nurse should first

A) assist the family to make phone calls to other family members.
B) call the hospital chaplain or social worker to be with the family.
C) help the family understand the reality of the situation.
D) tell the family they must stay in the waiting room until they calm down.

Question 17

The nurse is caring for a client brought to the ED after suffering amputation of a toe. The nurse should take care to avoid

A) cleansing the stump area with normal saline.
B) placing the toe directly on ice.
C) placing the wrapped toe in a plastic bag.
D) wrapping the toe in sterile gauze moistened with saline.

Question 18

A client is brought to the emergency department complaining of severe chest pain. The triage nurse assigns this client the triage category of

A) emergent.
B) non-urgent.
C) urgent.
D) vital.

Question 19

A client has died from very disfiguring injuries received in an automobile accident. When the family arrives moments later, the nurse relays the news to the family and then should (Select all that apply)

A) allow the family to be alone to grieve.
B) give information related to the extent of the fatal injuries.
C) help the family to focus on decisions requiring immediate attention.
D) tell the family that it is best not to view the body.

Question 20

An unconscious client is brought to the emergency department (ED) by ambulance following a car accident. Without a family member to give informed consent, the nurse should

A) begin treatment of the client under the doctrine of implied emergency consent.
B) have a hospital administrator sign the consent form.
C) request the physician to sign the consent form.
D) wait until a family member is contacted before treating the client.