MSS Ch 15: Emergency Nursing Comprehensive Exam

Question 1

The ED nurse is caring for a client diagnosed with multiple rib fractures. Which data should the nurse include in the assessment?

1. Level of orientation to time and place.
2. Current use and last dose of medication.
3. Symmetrical movement of the chest.
4. Time of last meal the client ate.

Answer 1

1. Orientation to person, place, and time should be assessed on all clients, but this information will not provide specific information about the chest trauma.
2. Current use of all medication and the last doses should be assessed for all clients.
3. When a client suffers from multiple rib fractures, the client has an increased risk for flail chest. The nurse should assess the client for paradoxical chest wall movement and, if respiratory distress is present, for pallor and cyanosis.
4. The time of this last meal is important if the client were to have surgery or intubation planned. A nutritional assessment should be performed on all clients.

Question 2

The nurse is caring for a client in the ED with abdominal trauma who has had peritoneal lavage. Which intervention should the nurse include in the plan of care? 1. Assess for the presence of blood, bile, or feces.

2. Palpate the client for bilateral femoral pulses.
3. Perform Leopold’s maneuver every eight (8) hours.
4. Collect information on the client’s dietary history.

Answer 2

1. A diagnostic peritoneal lavage is per- formed to assess the presence of blood, bile, and feces from internal bleeding induced by injury. If any of these are present, surgery should be considered to explore the extent of damage and repair of the injury.
2. Palpating the client’s peripheral pulses indi- cates blood flow to the extremities. Femoral pulses are not necessarily assessed if all distal pulses are strong.
3. Leopold’s maneuver is performed on pregnant clients to assess the position of the fetus.
4. Dietary history is information which is assessed, but not in an emergency situation. Assessments need to be efficient and direct to eliminate any time-wasting activities.

Question 3

The elderly client is brought to the ED complaining of cramps, headache, and weakness after working outside in the sun. The telemetry shows sinus tachycardia. Which intervention should the nurse implement?

1. Determine if the client is experiencing any thirst.
2. Administer D5W intravenously at 250 mL/hr.
3. Maintain a cool environment to promote rest.
4. Withhold the client’s oral intake.

Answer 3

1. Elderly clients lose the defense mechanism of increased thirst with dehydration. This does not accurately indicate fluid deficit.
2. An intravenous fluid should be administered, but the solution should correct fluid and electrolyte imbalances. D5W does not replace electrolytes lost, and 250 mL/hr could place the client at risk for heart fail- ure if the body cannot adjust rapidly to the fluid replacement.
3. The nurse should encourage the client to rest and should maintain a cool environment to assist the client to recover from heat exhaustion. The elderly are more susceptible to this condition.
4. 4. If the client can tolerate oral fluids, the client should be encouraged to drink fluids to replace electrolytes lost in excessive

Question 4

The ED nurse is caring for a client who suffered a near-drowning. Which expected outcome should the nurse include in the plan of care for this client?

1. Maintain the client’s cardiac function.
2. Promote a continued decrease in lung surfactant.
3. Warm rapidly to minimize the effects of hypothermia.
4. Keep the oxygen saturation level above 93%.

Answer 4

1. An expected outcome is a desired occur- rence, not a common event. Tachycardia is a common manifestation of a near-drowning event, but it is not desired. A combination of physiological changes, hypothermia, and hypoxia put the client at risk for life-threatening cardiac rhythms.
2. Any near-drowning causes a decrease in alveolar surfactant, which results in alveolar collapse. A decrease in surfactant is not the desired outcome.
3. The client needs to be rewarmed slowly to reduce the influx of metabolites. These metabolites, including lactic acid, remain in the extremities.
4. The oxygen level needs to be main- tained greater than 93%. The client needs as much support as necessary for this. Mechanical ventilation with peak end-expiratory pressure (PEEP) and high oxygen levels may be needed to achieve this goal.

Question 5

The nurse is assessing the client who suffered a near-drowning event. Which data require immediate intervention?

1. The onset of pink, frothy sputum.
2. An oral temperature of 97 ̊F.
3. An alcohol level of 100 mg/dL.
4. A heart rate of 100 beats/min.

Answer 5

1. The onset of pinky, frothy sputum indicates the client is experiencing pulmonary edema. This needs to be treated to prevent further decline in this client.
2. An oral temperature of 97 ̊F is in the lower level of within normal limits.
3. A blood alcohol of 100 mg/dL is an eleva- tion but should not be considered priority over pulmonary edema. Treatments for elevations in toxicology levels can be considered after the client is stable.
4. A heart rate of 100 beats/min is tachycardia but not at a critical level. The nurse needs to follow the ABCs of treatment: A is for airway, B is for breathing, and C is for cir- culation. Pulmonary edema interferes with breathing.

Question 6

A nurse is at the lake when a person nearly drowns. The nurse determines the client is breathing spontaneously. Which data should the nurse assess next?

1. Possibility of drug use.
2. Spinal cord injury.
3. Level of confusion.
4. Amount of alcohol.

Answer 6

1. The use of drugs can alter the treatment of and recovery from the near-drowning event. This is information needed, but it is not priority at this time.
2. An injury of the spinal cord should be con- sidered and the spine should be assessed, but after the client has been stabilized. The nurse does not complete an assessment of a potential spinal injury before assessing oxygenation status.
3. The nurse should assess the victim for hypoxia. Signs and symptoms of hypoxia include confusion or irritability and alterations in level of consciousness, such as lethargy.
4. The amount of alcohol ingestion will affect the treatment, but this is not a higher priority than oxygenation.

Question 7

The ED nurse is caring for a male client admitted with carbon monoxide poisoning. Which intervention requires the nurse to notify the Rapid Response Team?

1. The client has expectorated black sputum.
2. The client reports trying to kill himself.
3. The client’s pulse oximeter reading is 94%.
4. The client has stridor and reports dizziness.

Answer 7

1. The client diagnosed with carbon monoxide poisoning frequently has black sputum from inhaling soot, so the RRT does not need to be notified.
2. The client admitting to attempting suicide requires the client being placed on one (1)-to-one (1) suicide precautions and psychological counseling.
3. A pulse oximeter reading of 94% indicates the client is being well oxygenated and does not require notifying the RRT.
4. Stridor or dizziness indicates an occlu- sion of the airway, which is a medical emergency. The RRT is called when the client is experiencing a decline but is still breathing.

Question 8

The ED nurse is working triage. Which client should be triaged first?

1. A client who has multiple injuries from a motor-vehicle accident.
2. A client complaining of epigastric pain and nausea after eating.
3. An elderly client who fell and fractured the left femoral neck.
4. The client suffering from a migraine headache and nausea.

Answer 8

1. Injuries from a motor-vehicle accident can be life threatening. This client should be assessed first to rule out respiratory difficulties and hemorrhage.
2. Epigastric pain with nausea after eating sounds like gallbladder disease. Pain has high priority but not over breathing and hemorrhage.
3. Elderly clients have special fluid and electrolyte issues after a fall. The cause of the fall may be cardiac, but the question does not indicate this.
4. Migraine headaches are painful experi- ences, but they do not have a higher priority than breathing and hemorrhage.

Question 9

The nurse is providing discharge teaching for the client with intermaxillary wiring to repair a fractured mandible. Which statement by the client indicates teaching has been effective?

1. Iced alcoholic drinks may be consumed by using a straw.
2. Only one (1) food item should be consumed at one (1) time.
3. Carbonated sodas should be limited to two (2) daily.
4. Teeth can be brushed after tenderness and edema subside.

Answer 9

1. Alcoholic beverages should be avoided to prevent nausea and vomiting. The client should be taught where and how to cut wires if vomiting occurs.
2. A combination of foods should be blended into a milk shake and consumed to maintain caloric intake and promote nutrition.
3. Carbonated sodas can cause foam in the back of the throat and may induce vomiting.
4. Hygiene is helpful in healing. The mouth should be rinsed and an irrigation device should be used frequently. Gentle brushing and rinsing the mouth after each meal and at bedtime can begin after edema and tenderness subside.

Question 10

The occupational health nurse is called to the scene of a traumatic amputation of a finger. Which intervention should the nurse implement prior to sending the client to the ED? Select all that apply.

1. Rinse the amputated finger with sterile normal saline.
2. Place the amputated finger in a sealed and watertight plastic bag.
3. Place the amputated finger into iced saline solution.
4. Wrap the amputated finger in saline-moistened gauze dressings. 5. Replace the amputated finger on the hand and wrap with gauze.

Answer 10

1. The amputated finger and all tissue should be rinsed with sterile normal saline to remove dirt and sent to the ED with the client.
2. Place the finger and all tissue in a watertight, sealed plastic bag to prevent loss and contamination.
3. The finger or other tissue should not be placed on ice or in saline solution because this will cause severe damage to the tissue cells.
4. The finger should be wrapped in gauze moistened with sterile normal saline.
5. The finger should not be replaced on the hand and wrapped with gauze in the field. The surgeon will determine if reattach- ment is possible.

Question 11

The nurse is teaching the client home care instructions for a reimplanted finger after a traumatic amputation. Which information should the nurse include the teaching? 1. Perform range-of-motion exercises weekly.

2. Smoking may be resumed if it does not cause nausea.
3. Protect the finger and be careful not to reinjure the finger.
4. An elevated temperature is the only reason to call the HCP.

Answer 11

1. Exercises should be performed several times each day, not weekly.
2. Smoking causes vasoconstriction, which will compromise the implanted finger’s survival.
3. The client should take extra care to protect the finger from injury. The peripheral nerves protecting the finger require months to regenerate.
4. The client needs to report any signs of rejection of the finger, such as infection or impaired circulation, not just an elevated temperature.

Question 12

The ED nurse is caring for a client diagnosed with frostbite of the feet. Which intervention should the nurse implement?

1. Massage the feet vigorously.
2. Soak the feet in warm water.
3. Apply a heating pad to feet.
4. Apply petroleum jelly to feet.

Answer 12

1. Massaging or rubbing tissue with frostbite will cause further damage.
2. Soaking the feet in a warm bath of 107 ̊F causes rapid continuous rewarming.
3. Heating pads are not used to rewarm tissue with frostbite. Heating pads can cause tissue damage from burns, especially in tissue with impaired sensation.
4. Petroleum jelly does not affect the temperature of the tissue.

Question 13

A student reports to the school nurse with complaints of stinging and burning from a wasp sting. Which intervention should the nurse implement?

1. Grasp the stinger and pull it out.
2. Apply a warm, moist soak to the area.
3. Cleanse the site with alcohol.
4. Apply an ice pack to the site.

Answer 13

1. The stinger should not be grasped because the wasp’s venom sac may release more toxin. The stinger should be scraped in the opposite direction.
2. Warmth increases the blood flow, which will increase the edema.
3. The site should be cleaned with soap and water, not alcohol.
4. The nurse should apply an ice pack to the site. The cold will decrease the blood flow and sensation. The ice should be applied intermittently.

Question 14

The ED nurse is caring for a client who had a severe allergic reaction to a bee sting. Which discharge instructions should the nurse discuss with the client?

1. Instruct the client to wear a medical identification bracelet.
2. Apply corticosteroid cream to the site to prevent anaphylaxis.
3. Administer epinephrine 1:10,000 intravenously every three (3) minutes.
4. Teach the client to avoid attracting insects by wearing bright colors.

Answer 14

1. Clients who have severe reactions to insect stings should wear identifying bracelets to provide information. If the client is unconscious, the bracelet can alert the health-care provider so treatment can be started.
2. Corticosteroid creams treat local reactions, not systemic ones.
3. Epinephrine 1:10,000 is administered intravenously during a code situation or for a severe anaphylactic reaction to an allergen. This client is being discharged and may need an EpiPen to carry at all times, but not IV epinephrine.
4. Bright-colored clothing attracts insects. Clients who are allergic to insect stings should learn how to avoid them to de- crease the risk. Flowery-smelling perfumes and lotions should also be avoided.

Question 15

The ED nurse is caring for a client with fractured pelvis and bladder trauma secondary to a motor-vehicle accident. Which data are most important for the nurse to assess?

1. Monitor the creatinine and BUN.
2. Check urine output hourly.
3. Note the amount and color of the urine.
4. Assess for bladder distention.

Answer 15

1. The creatinine and BUN assess kidney function, but the nurse should assess blad- der function by checking the amount and color of the urine.
2. Checking the urine output hourly is appropriate data to assess but not the most important for a client with bladder trauma.
3. The amount and color of urine assists with diagnosing the extent of injury. Color of the urine indicates the presence of blood. The amount indicates whether the urine is contained throughout the pathway from bladder to urinary meatus.
4. The nurse should not palpate a client with bladder trauma because it could cause fur- ther damage.a

Question 16

The school nurse is caring for a child with a deep laceration. Which intervention should the nurse implement first?

1. Clean with saline solution.
2. Apply direct pressure.
3. Don nonsterile gloves.
4. Notify the child’s parents.

Answer 16

1. The laceration should be cleaned well to prevent infection. A sterile saline solution or water should be used. This is done after donning nonsterile gloves and applying pressure.
2. The nurse should apply direct pressure to a deep laceration to stop the bleeding after donning nonsterile gloves.
3. The nurse must follow Standard Precautions in the school nurse setting by donning nonsterile gloves prior to caring for the client.
4. The school nurse must notify the parents but not prior to taking care of the client.

Question 17

The ED receives a client involved in a motor-vehicle accident. The nurse notes a large hematoma on the right flank. Which intervention should the nurse implement first?

1. Insert an indwelling urinary catheter.
2. Take the vital signs every 15 minutes.
3. Monitor the skin turgor every hour.
4. Mark the edges of the bruised area.

Answer 17

1. Inserting an indwelling catheter may cause further injury. Until the extent of injury is determined, prevention of further damage should have high priority.
2. Vital signs should be taken frequently to assess for covert bleeding. The hematoma in the flank area may indicate the presence of trauma to the kidney. Because of the large amount of blood flow through the kidney, hemorrhage is a high risk.
3. Assessing skin turgor is important in determining the fluid balance, but it is not higher priority than monitoring vital signs.
4. The nurse could mark the bruised area to better assess if the hematoma is enlarging, but this is not the first intervention.

Question 18

Which expected outcome is priority for the nurse who is caring for a client with chest trauma from a gunshot injury?

1. The client will have an absence of pain.
2. The client will maintain a BP of 90/60.
3. The client will have symmetrical chest expansion.
4. The client will maintain urine output of 30 mL/hr.

Answer 18

1. Pain management is a goal for clients. At this time in the care of this client, it is not realistic to expect no pain.
2. Maintaining homeostasis is an appropriate outcome, but the priority is to maintain respiratory status. Remember Maslow’s hierarchy of needs.
3. Symmetrical chest expansion indicates the client’s lungs have not collapsed and air is being exchanged. This is the client’s priority outcome.
4. A urine output of 30 mL/hr indicates the tissues are being adequately perfused and is an indicator of kidney functioning. Kidney function is important but is not a priority over respiratory status in a client with a gunshot wound.

Question 19

Which problem is most appropriate for the nurse to identify for the client experiencing renal trauma?

1. Infection of the renal tract.
2. Ineffective tissue perfusion.
3. Alteration in skin integrity.
4. Alteration in temperature.

Answer 19

1. A potential for infection is an appropri- ate nursing diagnosis, but there is no indication of infection from this question.
2. Bleeding results in an impairment of tissue perfusion. Because of the large amount of blood flow through the renal system, bleeding is a major problem.
3. Skin integrity is not necessarily an issue in trauma. There is no indication from the question the skin is not intact.
4. An alteration in temperature is not a problem for this client unless infection occurs. This intervention is not indicated at this time.

Question 20

The nurse is discharging a client from the ED with a sutured laceration on the right knee. Which information is most important for the nurse to obtain?

1. The date of the client’s last tetanus injection.
2. The name of the client’s regular health-care provider.
3. Explain the sutures must be removed in 10 to 14 days. 4. Determine if the client has any drug or food allergies.

Answer 20

1. Any client who has not had a tetanus injection within five (5) years will need to receive an injection as prophylaxis.
2. The nurse may need to determine if the usual HCP can remove the sutures or the client should return to the ED for suture removal, but this is not the most important information.
3. This information is important to teach the client, but preventing tetanus (lockjaw) is priority.
4. This client has been treated, so it is too late to determine if the client has allergies.

Question 21

The nurse working in an outpatient clinic is caring for a client who is experiencing epistaxis. Which intervention should the nurse implement first?

1. Take the client’s blood pressure in both arms.
2. Hold the nose with thumb and finger for 15 minutes.
3. Have the client sit with the head tilted back and hold a tissue.
4. Prepare to administer silver nitrate, a cauterizing agent, with a packing applicator.

Answer 21

1. The nurse should assess the client’s blood pressure but not prior to stopping the bleeding. The most common cause of spontaneous epistaxis is hypertension.
2. Most nosebleeds will stop after applying pressure on the nose between thumb and index finger for 15 minutes.
3. The nurse should position the client with the head tilted forward. This position will prevent the client from swallowing the blood. The blood can be aspirated if the head is tilted back.
4. Most nosebleeds respond to pressure. If pressure for 15 minutes does not stop the bleeding, the health-care provider may need to use electrocautery or silver nitrate. This is performed by the HCP, not the nurse.

Question 22

The client with a temperature of 94 ̊F is being treated in the ED. Which intervention should the nurse implement to directly elevate the client’s temperature?

1. Remove the client’s clothing.
2. Place a warm air blanket over the client.
3. Have the client change into a hospital gown.
4. Raise the temperature in the room.

Answer 22

1. Removing clothing causes further chilling.
2. The warm air blanket blows warm air over the client and is an active warming method.
3. Hospital gowns have openings down the back and can increase chilling.
4. Raising the temperature of the room will not directly raise the client’s temperature.

Question 23

The ED nurse is caring for the client who has taken an overdose of cocaine. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)?

1. Evaluate the airway and breathing.
2. Monitor the rate of intravenous fluids.
3. Place the cardiac monitor on the client.
4. Transfer the client to the intensive care unit.

Answer 23

1. Evaluation of airway and breathing is assessment and cannot be delegated.
2. Monitoring the rate of intravenous fluid is a part of administering a medication. Medication administration cannot be delegated.
3. The UAP can attach leads to the client for the cardiac monitor.
4. The nurse cannot delegate an unstable client to the UAP. A client being transferred to the intensive care unit is unstable.

Question 24

The client has been brought to the ED by ambulance following a motor-vehicle accident with a flail chest, an intravenous line, and a Heimlich valve. Which intervention should the nurse implement first?

1. Start a large-bore intravenous access.
2. Request a portable chest x-ray.
3. Prepare to insert chest tubes.
4. Assess the cardiac rhythm on the monitor.

Answer 24

1. The client already has an intravenous ac- cess; therefore, the nurse would not need to start an intravenous line.
2. A STAT chest x-ray will be done to evalu- ate the extent of the chest trauma, but it is not the first intervention.
3. The client will require a chest tube because the Heimlich valve is only temporary; therefore, the nurse should prepare for this first.
4. Assessing the cardiac rhythm is important, but the client is in distress and needs circulatory support, not further assessment.

Question 25

The ED nurse is completing the initial assessment on a client who becomes unresponsive. Which intervention should the nurse implement first?

1. Assess the rate and site of the intravenous fluid.
2. Administer an ampule of sodium bicarbonate.
3. Assess the cardiac rhythm shown on the monitor.
4. Prepare to cardiovert the client into sinus rhythm.

Answer 25

1. Assessing the site and rate is not the first intervention.
2. Sodium bicarbonate is not administered unless indicated by arterial blood gases.
3. The rhythm on the monitor should be assessed. Many clients who become unresponsive have a lethal rhythm requiring defibrillation immediately.
4. Cardioversion is not appropriate. Defibrillation may be needed.

Question 26

The ED nurse is caring for a female client with a greenstick fracture of the left forearm and multiple contusions on the face, arms, trunk, and legs. The significant other is in the treatment area with the client. Which nursing interventions should the nurse implement? List in order of priority.

1. Determine if the client has a plan for safety.
2. Assess the pulse, temperature, and capillary refill of the left wrist and hand.
3. Ask the client if she feels safe in her own home.
4. Request the significant other wait in the waiting room during the examination.
5. Notify the social worker to consult on the case.

Answer 26

In order of priority: 4, 2, 3, 1, 5.

4. This is done first before any action is taken to decrease suspicions on the part of the significant other. The nurse needs to ask the client questions regarding the injuries and may not get truthful answers with the significant other in the room.
5. The nurse should assess the actual physical problems before assessing the potential abuse situation.
6. This is one of the first questions the nurse should ask to determine if abuse is occurring.
7. The nurse should determine if the client has a plan to escape the violence. The nurse should provide the client with hotline numbers for safe houses.
8. The nurse should refer the client to the social worker for further evaluation and referral needs.