Professional Documents
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EMERGENCY
Text Mode Text version of the exam
1. You are the charge nurse in an emergency department (ED) and must assign two staff
members to cover the triage area. Which team is the most appropriate for this assignment?
An advanced practice nurse and an experienced LPN/LVN
An experienced LPN/LVN and an inexperienced RN
An experienced RN and an inexperienced RN
An experienced RN and a nursing assistant
2. You are working in the triage area of an ED, and four patients approach the triage desk at the
same time. List the order in which you will assess these patients.
An ambulatory, dazed 25-year-old male with a bandaged head wound
An irritable infant with a fever, petechiae, and nuchal rigidity
A 35-year-old jogger with a twisted ankle, having pedal pulse and no
deformity
A 50-year-old female with moderate abdominal pain and occasional
vomiting
_____, _____, _____, _____
3. In conducting a primary survey on a trauma patient, which of the following is considered one
of the priority elements of the primary survey?
Complete set of vital signs
Palpation and auscultation of the abdomen
Brief neurologic assessment
Initiation of pulse oximetry
4. A 56-year-old patient presents in triage with left-sided chest pain, diaphoresis, and dizziness.
This patient should be prioritized into which category?
High urgent
Urgent
Non-urgent
Emergent
5. The physician has ordered cooling measures for a child with fever who is likely to be
discharged when the temperature comes down. Which of the following would be appropriate to
delegate to the nursing assistant?
Assist the child to remove outer clothing.
Advise the parent to use acetaminophen instead of aspirin.
Explain the need for cool fluids.
Prepare and administer a tepid bath.
6. It is the summer season, and patients with signs and symptoms of heat-related illness present
in the ED. Which patient needs attention first?
An elderly person complains of dizziness and syncope after standing in the
sun for several hours to view a parade
A marathon runner complains of severe leg cramps and nausea.
Tachycardia, diaphoresis, pallor, and weakness are observed.
A previously healthy homemaker reports broken air conditioner for days.
Tachypnea, hypotension, fatigue, and profuse diaphoresis are observed.
A homeless person, poor historian, presents with altered mental status,
poor muscle coordination, and hot, dry, ashen skin. Duration of exposure is
unknown.
7. 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.
Perform the chin lift or jaw thrust maneuver.
Establish unresponsiveness.
Initiate cardiopulmonary resuscitation (CPR).
Call for help and activate the code team.
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23.In relation to submersion injuries, which task is most appropriate to delegate to an LPN/LVN?
Talk to a community group about water safety issues.
Stabilize the cervical spine for an unconscious drowning victim.
Remove wet clothing and cover the victim with a warm blanket.
Monitor an asymptomatic near-drowning victim.
24.You are assessing a patient who has sustained a cat bite to the left hand. The cat is up-todate immunizations. The date of the patients last tetanus shot is unknown. Which of the
following is the priority nursing diagnosis?
Risk for Infection related to organisms specific to cat bites
Impaired Skin Integrity related to puncture wounds
Ineffective Health Maintenance related to immunization status
Risk for Impaired Mobility related to potential tendon damage
25.These patients present to the ED complaining of acute abdominal pain. Prioritize them in
order of severity.
A 35-year-old male complaining of severe, intermittent cramps with three
episodes of watery diarrhea, 2 hours after eating
A 11-year-old boy with a low-grade fever, left lower quadrant tenderness,
nausea, and anorexia for the past 2 days
A 40-year-old female with moderate left upper quadrant pain, vomiting
small amounts of yellow bile, and worsening symptoms over the past week
A 56-year-old male with a pulsating abdominal mass and sudden onset of
pressure-like pain in the abdomen and flank within the past hour
_____, _____, _____, _____
26.The nursing manager decides to form a committee to address the issue of violence against
ED personnel. Which combination of employees is best suited to fulfill this assignment?
ED physicians and charge nurses
Experienced RNs and experienced paramedics
RNs, LPN/LVNs, and nursing assistants
At least one representative from each group of ED personnel
27.In a multiple-trauma victim, which assessment finding signals the most serious and lifethreatening condition?
A deviated trachea
Gross deformity in a lower extremity
Decreased bowel sounds
Hematuria
28.A patient in a one-car rollover presents with multiple injuries. Prioritize the interventions that
must be initiated for this patient.
Secure/start two large-bore IVs with normal saline
Use the chin lift or jaw thrust method to open the airway.
Assess for spontaneous respirations
Give supplemental oxygen per mask.
Obtain a full set of vital signs.
Remove patients clothing.
Insert a Foley catheter if not contraindicated.
_____, _____, _____, _____, ____, ____, ____
29.In the work setting, what is your primary responsibility in preparing for disaster management
that includes natural disasters or bioterrorism incidents?
Knowledge of the agencys emergency response plan
Awareness of the signs and symptoms for potential agnets of bioterrorism
Knowledge of how and what to report to the CDC
Ethical decision-making about exposing self to potentially lethal substances
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30.You are giving discharge instructions to a woman who has been treated for contusions and
bruises sustained during an episode of domestic violence. What is your priority intervention for
this patient?
Transportation arrangements to a safe house
Referral to a counselor
Advise about contacting the police
Follow-up appointment for injuries
Answers
ANSWER C Triage requires at least one experienced RN. Pairing an
experienced RN with inexperienced RN provides opportunities for mentoring.
Advanced practice nurses are qualified to perform triage; however, their services are
usually required in other areas of the ED. An LPN/LVN is not qualified to perform the
initial patient assessment or decision making. Pairing an experienced RN with a
nursing assistant is the second best option, because the assistant can obtain vital
signs and assist in transporting.
ANSWER B, A, D, C An irritable infant with fever and petechiae should
be further assessed for other meningeal signs. The patient with the head wound
needs additional history and assessment for intracranial pressure. The patient with
moderate abdominal pain is uncomfortable, but not unstable at this point. For the
ankle injury, medical evaluation can be delayed 24 48 hours if necessary.
ANSWER C A brief neurologic assessment to determine level of
consciousness and pupil reaction is part of the primary survey. Vital signs,
assessment of the abdomen, and initiation of pulse oximetry are considered part of
the secondary survey.
ANSWER D Chest pain is considered an emergent priority, which is
defined as potentially life-threatening. Patients with urgent priority need treatment
within 2 hours of triage (e.g. kidney stones). Non-urgent conditions can wait for
hours or even days. (High urgent is not commonly used; however, in 5-tier triage
systems, High urgent patients fall between emergent and urgent in terms of the
time lapsing prior to treatment).
ANSWER A The nursing assistant can assist with the removal of the outer
clothing, which allows the heat to dissipate from the childs skin. Advising and
explaining are teaching functions that are the responsibility of the RN. Tepid baths
are not usually performed because of potential for rebound and shivering.
ANSWER D The homeless person has symptoms of heat stroke, a
medical emergency, which increases risk for brain damage. Elderly patients are at
risk for
heat syncope and should be educated to rest in cool area and avoid future similar
situations. The runner is having heat crams, which can be managed with rest and
fluids. The housewife is experiencing heat exhaustion, and management includes
fluids (IV or parenteral) and cooling measures. The prognosis for recovery is good.
ANSWER B, D, A, C, E Establish unresponsiveness first. (The patient
may have fallen and sustained a minor injury.) If the patient is unresponsive, get
help and have someone initiate the code. Performing the chin lift or jaw thrust
maneuver opens the airway. 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. A crash cart should be at the site when the code team
arrives; however, basic CPR can be effectively performed until the team arrives.
ANSWER A Nursing assistants are trained in basic cardiac life support
and can perform chest compressions. The use of the bag-valve mask requires
practice and usually a respiratory therapist will perform this function. The nurse or
the respiratory therapist should provide PRN assistance during intubation. The
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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.
ANSWER C The patient is hyperventilating secondary to anxiety, and
breathing into a paper bag will allow rebreathing of carbon dioxide. Also,
encouraging slow breathing will help. Other treatments such as oxygen and
medication may be needed if other causes are identified.
ANSWER C The fast track clinic will deal with relatively stable patients.
Triage, trauma, and pediatric medicine should be staffed with experienced nurses
who know the hospital routines and policies and can rapidly locate equipment.
ANSWER A Iron is a toxic substance that can lead to massive
hemorrhage, coma, shock, and hepatic failure. Deferoxame is an antidote that can
be used for severe cases of iron poisoning. Other information needs additional
investigation, but will not change the immediate diagnostic testing or treatment
plan.
ANSWER C The LPN/LVN is able to listen and provide emotional support
for her patients. The other tasks are the responsibility of an RN or, if available, a
SANE (sexual assault nurse examiner) who has received training to assess, collect
and safeguard evidence, and care for these victims.
ANSWER C, B, D, A 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.
ANSWER C The only correct intervention is C. the digits should be gently
cleansed with normal saline, wrapped in sterile gauze moistened with saline, and
placed in a plastic bag or container. The container is then placed on ice.
ANSWER B IV Lorazepam (Ativan) is the drug of choice for status
epilepticus. Tegretol is used in the management of generalized tonic-clonic, absence
or mixed type seizures, but it does not come in an IV form. PO (per os) medications
are inappropriate for this emergency situation. Magnesium sulfate is given to control
seizures in toxemia of pregnancy.
ANSWER C Parent refusal is an absolute contraindication; therefore, the
physician must be notified. Tetanus status can be addressed later. The RN can
restart the IV and provide information about conscious sedation; if the parent still
notsatisfied, the physician can give more information.
ANSWER D The patient presents with symptoms of alcohol abuse and
there is a risk for Wernickes syndrome, which is caused by a thiamine deficiency.
Multiples drug abuse is not uncommon; however, there is nothing in the question
that suggests an opiate overdose that requires naloxone. Additional information or
the results of the blood alcohol level are part of the total treatment plan but should
not delay the immediate treatment.
ANSWER C Postmortem care requires some turning, cleaning, lifting, etc.,
and the nursing assistant is able to assist with these duties. The RN should take
responsibility for the other tasks to help the family begin the grieving process. In
cases of questionable death, belongings may be retained for evidence, so the chain
of custody would have to be maintained.
ANSWER C, D, B, A 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.
ANSWER B 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. Other information, such as the dirt on the stick
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