Question 1

An unresponsive older-adult client is admitted to the emergency department (ED) during a summer heat wave. The client's core temperature is 41.2°C (106.1°F), blood pressure (BP) 86/52, and pulse 102. Which of the following actions should the nurse implement initially?

Accepted Answer

The priority intervention is to cool the client. Antipyretics are not effective in decreasing temperature in heat stroke, and 100% oxygen should be given, which requires a high flow rate through a non-rebreather mask. An older client would be at risk for developing complications such as pulmonary edema if given fluids at 1 000 mL/hour.

Question 2

The nurse is admitting a client to the emergency department after a submersion injury. Which of the following assessments is priority?

Accepted Answer

The priority assessment data are how well the client is oxygenating, so lung sounds should be assessed first. The other data also will be collected rapidly but are not as essential as the lung sounds.

Question 3

The nurse is assessing a client admitted to the emergency department (ED) with a broken arm and facial bruises and notes multiple additional bruises in various stages of healing. Which of the following responses by the nurse is most appropriate?

Accepted Answer

The nurse's initial response should be to further assess the client's situation. Telling the client not to return home may be an option once further assessment is done. The client, not the nurse, is responsible for reporting the abuse. A social worker may be appropriate once further assessment is completed.

Question 4

The triage nurse is assessing four victims of an automobile accident. Which of the following clients has the highest priority for treatment?

Accepted Answer

Most immediate deaths from trauma occur because of problems with ventilation, so the client with a sucking chest wound should be treated first. Face and head fractures can obstruct the airway, but the client with facial injuries has lacerations only. The other two clients also need rapid intervention but do not have airway or breathing problems.

Question 5

The following actions are part of the routine emergency department (ED) protocol for a client who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?

Accepted Answer

The client's rings should be removed first because it might not be possible to remove them if swelling develops. The other orders also should be implemented as rapidly as possible after the nurse has removed the jewellery.

Question 6

A triage nurse is assessing a client who complains of 6/10 abdominal pain and states, "I had a temperature of 40.3°C (104.5°F) at home." Which of the following actions should the nurse implement first?

Accepted Answer

The client's pain and statement about an elevated temperature indicate that the nurse should obtain vital signs before deciding how rapidly the client should be seen by the health care provider. A urinalysis may be needed, but vital signs will provide the nurse with the data needed to determine this. The health care provider will not order a medication before assessing the client.

Question 7

The nurse is preparing to rewarm a client with hypothermia. Which of the following actions should the nurse implement?

Accepted Answer

Rewarming can produce dysrhythmias, so the client should be monitored and treated if necessary. Urinary catheterization and endotracheal intubation are not needed for rewarming. Sympathomimetic drugs tend to stimulate the heart and increase the risk for fatal dysrhythmias such as ventricular fibrillation.

Question 8

The nurse is caring for a client with hypotension and temperature elevation after doing yard work on a hot day and is being treated in the emergency department. After the nurse has completed discharge teaching, which of the following client statements indicates that the teaching has been effective?

Accepted Answer

Electrolyte solutions such as sports drinks help replace fluid and electrolytes lost when exercising in hot weather. Salt tablets are not recommended because of the risks of gastric irritation and hypernatremia. Antipyretic medications are not effective in lowering body temperature elevations caused by excessive exposure to heat. A client who is confused is likely to have more severe hyperthermia and will be unable to remember to take appropriate action.

Question 9

The nurse is conducting a primary survey of a client with multiple traumatic injuries and observes that the client's right pedal pulses are absent and the leg is swollen. Which of the following actions will the nurse take next?

Accepted Answer

The assessment data indicate that the client may have arterial trauma and hemorrhage. When a possibly life-threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey. Although a CBC is indicated, administration of IV fluids should be started first. Completion of the primary survey and further assessment should be completed after the IV fluids are initiated.

Question 10

The nurse is conducting a primary assessment of a trauma victim and determines that the client is breathing and has an unobstructed airway. Which of the following actions should the nurse take next?

Accepted Answer

Even with a patent airway, clients can have other problems that compromise ventilation, so the next action is to assess the client's breathing. The evaluation of airway patency and the effectiveness of breathing always assume highest priority. The other actions also are part of the initial survey but assessment of breathing should be done immediately after assessing for airway patency.

Question 11

A client arrives in the emergency department (ED) a few hours after taking "20-30" acetaminophen (Tylenol) tablets. Which of the following actions will the nurse plan to take?

Accepted Answer

N-acetylcysteine is the recommended treatment to prevent liver damage after acetaminophen overdose. The other actions might be used for other types of poisoning, but they will not be appropriate for a client with acetaminophen poisoning.

Question 12

After spending the previous weekend camping out with some friends, a client arrives at the emergency department and is diagnosed with flaccid ascending paralysis. Based upon this information, the nurse concludes that the client has been bitten by whichofthefollowing?

Accepted Answer

Tick paralysis occurs 5-7 days after exposure to the wood or dog tick. Classic symptoms are flaccid ascending paralysis, which develops over 1-2 days. Without tick removal, the client dies as respiratory muscles become paralyzed. Tick removal leads to return of muscle movement, usually within 48-72 hours.

Question 13

Gastric lavage and administration of activated charcoal are prescribed for an unconscious client who has been admitted to the emergency department (ED) after ingesting 30 diazepam tablets. Which of the following actions will the nurse plan to take first?

Accepted Answer

In an unresponsive client, intubation is done before gastric lavage and activated charcoal administration to prevent aspiration. The other actions will be implemented after intubation.

Question 14

The nurse is assessing a client who is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the right hand. When asked about tetanus immunization, the client denies having any previous vaccinations. Which of the following should the nurse anticipate administering to the client?

Accepted Answer

For an adult with no previous tetanus immunizations, TIG and TD are recommended. The other immunizations are not sufficient for this client.

Question 15

The nurse is caring for a client who has experienced blunt abdominal trauma during a car accident and has increasing abdominal pain. Which of the following diagnostic tests should the nurse prepare the client for?

Accepted Answer

For clients who are at risk for intra-abdominal bleeding, focused abdominal ultrasonography is the preferred method to assess for intraperitoneal bleeding-focused abdominal sonography for trauma (FAST). An MRI would not be used. Peritoneal lavage is an alternative, but it is more invasive. An x-ray would not be helpful in diagnosis of intra-abdominal bleeding.

Question 16

The nurse is assessing a client with hypothermia. Which of the following assessments should the nurse expect to find?

Accepted Answer

A client with hypothermia will have bradycardia. The other symptoms a client with hypothermia may have are hypotension, blue or white extremities, and hypoventilation.

Question 17

The nurse is caring for a client that has sustained a black widow spider bite. Which of the following times should the nurse be aware of that the symptoms usually peak?

Accepted Answer

After a spider bite symptoms will peak in 2-3 hours.

Question 18

The nurse is observing a client who experienced a near drowning accident in a local lake, but now is awake and breathing spontaneously. Which of the following actions will be most important for the nurse to take during the observation period?

Accepted Answer

Since pulmonary edema is a common delayed complication after near drowning, the nurse should assess the breath sounds frequently. The other information also will be collected by the nurse, but it is not as pertinent to the client's admission diagnosis.

Question 19

Aclient who is unconscious after a fall from a ladder is transported to the emergency department by family members. During the primary survey of the client, which of the following actions should the nurse implement?

Accepted Answer

The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the secondary survey.

Question 20

The nurse is rewarming a client who arrived in the emergency department (ED) with a temperature of 29°C (84.2°F) and no audible pulse. Which of the following temperatures should the nurse rewarm the client to, prior to a pronouncement of death?

Accepted Answer

Every effort is made to warm the client to at least 32°C (89.6°F) before the person is pronounced dead. The cause of death is usually refractory ventricular fibrillation.

Quiz 71: Nursing Management Emergency Care Situations

An unresponsive older-adult client is admitted to the emergency department (ED) during a summer heat wave. The client's core temperature is 41.2°C (106.1°F) , blood pressure (BP) 86/52, and pulse 102. Which of the following actions should the nurse implement initially?