Nurselabs Emergency Nursing and Triage

Question 1

A 15-year-old male client was sent to the emergency unit following a small laceration on the forehead. The client says that he can’t move his legs. Upon assessment, respiratory rate of 20, strong pulses, and capillary refill time of less than 2 seconds. Which triage category would this client be assigned to?

A. Red
B. Black
C. Yellow
D. Green
E. White

Answer 1

C. Yellow

The client is possibly suffering from a spinal injury but otherwise, has a stable status and can communicate so the appropriate tag is yellow. If individuals can breathe spontaneously, follow simple commands, and have distal pulses with a normal capillary refill, they are tagged delayed and given the code yellow.

Question 2

Nurse Kelly, a triage nurse encountered a client who complained of mid-sternal chest pain, dizziness, and diaphoresis. Which of the following nursing action should take priority?

A. Administer oxygen therapy via nasal cannula
B. Notify the physician
C. Complete history taking
D. Put the client on ECG monitoring

Answer 2

A. Administer oxygen therapy via nasal cannula.

The priority goal is to increase myocardial oxygenation. Place the patient on a cardiac monitor, establish intravascular access (IV) access, give 162 mg to 325 mg chewable aspirin, clopidogrel, or ticagrelor (unless bypass surgery is imminent), control pain and consider oxygen (O2) therapy.

Question 3

A 5-year-old client was admitted to the emergency unit due to the ingestion of an unknown amount of chewable vitamins for children at an unknown time. Upon assessment, the child is alert and with no symptoms. Which of the following information should be reported to the physician immediately?

A. The child was nauseated and vomited once at home
B. The child has been treated several times for toxic substance ingestion
C. The vitamin that was ingested contains iron
D. The child has been treated multiple times for injuries caused by accidents

Answer 3

C. The vitamin that was ingested contains iron.

Iron is a toxic substance that can lead to massive hemorrhage, shock, coma, and kidney failure. Iron poisoning is one of the most common toxic ingestion and one of the most deadly among children. Failure to diagnose and treat iron poisoning can have serious consequences including multi-organ failure and death.

Question 4

You are assessing a patient who has sustained a cat bite to the left hand. The cat is up-to-date immunizations. The date of the patient’s last tetanus shot is unknown. Which of the following is the priority nursing diagnosis?

A. Impaired Skin Integrity related to puncture wounds
B. Ineffective Health Maintenance related to immunization status
C. Risk for Infection related to organisms specific to cat bites
D. Risk for Impaired Mobility related to potential tendon damage

Answer 4

C. Risk for Infection related to organisms specific to cat bites.

Cat’s mouths contain a virulent organism, Pasteurella multocida, that can lead to septic arthritis or bacteremia. Infections resulting from bites of all animal species are poly-microbial with aerobic and anaerobic bacteria; dogs and cats have an oral flora of Pasteurella, Staph, and Strep most commonly. In cat bites and scratches, Bartonella infections are an additional concern.

Question 5

A client arrived at the emergency department after suffering multiple physical injuries including a fractured pelvis from a vehicular accident. Upon assessment, the client is incoherent, pale, and diaphoretic. With vital signs as follows: temperature of 97°F (36.11° C), blood pressure of 60/40 mm Hg, heart rate of 143 beats/minute, and a respiratory rate of 30 breaths/minute. The client is mostly suffering from which of the following shock?

A. Distributive
B. Hypovolemic
C. Obstructive
D. Cardiogenic

Answer 5

B. Hypovolemic

Hypovolemic shock occurs when the volume of the circulatory system is too depleted to allow adequate circulation to the tissues of the body. A fractured pelvis will lose about one liter of blood hence symptoms such as hypotension, tachycardia, and tachypnea will occur. If left untreated, these patients can develop ischemic injury of vital organs, leading to multi-system organ failure.

Question 6

A client was brought to the ED due to an abdominal trauma caused by a motorcycle accident. During the assessment, the client complains of epigastric pain and back pain. Which of the following is true regarding the diagnosis of pancreatic injury?

A. Redness and bruising may indicate the site of the injury in blunt trauma
B. The client is symptom-free during the early post-injury period
C. Signs of peritoneal irritation may indicate pancreatic injury
D. All of the above

Answer 6

D. All of the above

Blunt injury resulting from vehicular accidents could cause pancreatic injury. Redness, bruising in the flank and severe peritoneal irritation are signs of a pancreatic injury. The client is usually pain-free during the early post-injury period, hence a comprehensive assessment and monitoring should be done.

Question 7

Nurse Anna is an experienced travel nurse who was recently employed and is assigned to the emergency unit. In her first week of the job, which of the following area is the most appropriate assignment for her?

A. Triage
B. Ambulatory section
C. Trauma team
D. Psychiatric care

Answer 7

B. Ambulatory section

The ambulatory section deals with clients with relatively stable conditions. The decision of whether or not to delegate or assign is based upon the RN’s judgment concerning the condition of the patient, the competence of all members of the nursing team and the degree of supervision that will be required of the RN if a task is delegated.

Question 8

Cole is an emergency nurse who encountered a patient who is a suspected carrier of a biologic agent. Which of these if found in the patient is not classified as a Category A biologic agent?

A. Bacillus anthracis (anthrax)
B. Francisella tularensis (tularemia)
C. Clostridium botulinum toxin (botulism)
D. Burkholderia pseudomallei (Melioidosis)
E. Yersinia petis (plague)

Answer 8

D. Burkholderia pseudomallei (Melioidosis)

Burkholderia pseudomallei (Melioidosis) belongs to the category B priority pathogen. These agents are moderately easy to be transmitted and can result in moderate morbidity rates. Melioidosis is endemic to southeast Asia and northern Australia but has also occurred in South America, Central America, Africa, and the Middle East. Melioidosis may present in an acute form with an incubation period of one day to three weeks. However, latent melioidosis may not present for decades. Melioidosis often infects those with underlying risk factors such as diabetes, kidney disease, alcohol abuse, and thalassemia, although healthy patients may also contract the disease.

Question 9

A prisoner, with a known history of alcohol abuse, has been in police custody for 48 hours. Initially, anxiety, sweating, and tremors were noted. Now, disorientation, hallucination, and hyper-reactivity are observed. The medical diagnosis is delirium tremens. What is the priority nursing diagnosis?

A. Risk for Injury related to seizures
B. Risk for Situational Low Self-esteem related to police custody
C. Risk for Nutritional Deficit related to chronic alcohol abuse
D. Risk for Other-Directed Violence related to hallucinations

Answer 9

A. Risk for Injury related to seizures.

The client shows neurologic hyperactivity and is on the verge of a seizure. Seizures can recur, though rarely lead to status epilepticus. Uncharacteristic signs of seizure activity should warrant further workup. Patient safety is the priority. The patient needs chlordiazepoxide (Librium) to decrease neurologic irritability and phenytoin (Dilantin) for seizures. Thiamine and haloperidol (Haldol) will also be ordered to address other problems.

Question 10

When attending a client with a head and neck trauma following a vehicular accident, the nurse’s initial action is to?

A. Provide oxygen therapy
B. Initiate intravenous access
C. Immobilize the cervical area
D. Do oral and nasal suctioning

Answer 10

C. Immobilize the cervical area

Clients with suspected or possible cervical spine injury must have their neck immobilized until formal assessment occurs. Maintain cervical spine spinal immobilization and minimize neck movement particularly during transport. Beware that absence of neurologic findings does not eliminate the possibility of spinal cord injury.

Question 11

Following an emergency endotracheal intubation, nurses must verify tube placement and secure the tube. List in order the steps that are required to perform this function?

1. Auscultate the chest during assisted ventilation
2. Obtain an order for a chest x-ray to document tube placement
3. Secure the tube in place
4. Confirm that the breath sounds are equal and bilateral

Answer 11

1, 4, 3, 2

Question 12

A client suffered an amputation of the first and second digits in a chainsaw accident. Which task should be delegated to an LPN/LVN?

A. Cleansing the amputated digits and placing them directly into an ice slurry
B. Wrapping the cleansed digits in saline-moistened gauze, sealing in a plastic container, and placing it in icy water
C. Gently cleansing the amputated digits and the hand with povidone-iodine
D. Cleansing the digits with sterile normal saline and placing it in a sterile cup with sterile normal saline

Answer 12

B. Wrapping the cleansed digits in saline-moistened gauze, sealing in a plastic container, and placing it in icy water.

Once a finger amputation has occurred, ischemic tolerance times are 12 hours if warm and up to 24 hours if cold. For more proximal amputations, these times are halved. The amputated part should be covered in a normal saline-soaked gauze, sealed in a plastic bag, and submerged in icy water with no direct contact with ice. If there is direct contact with ice, it could result in tissue damage and render the amputated part non-viable.

Question 13

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.

1. Initiate cardiopulmonary resuscitation (CPR)
2. Establish unresponsiveness
3. Call for help and activate the code team
4. Perform the chin lift or jaw thrust maneuver
5. Instruct a nursing assistant to get the emergency cart

Answer 13

2, 3, 4, 1, 5

Question 14

The following clients are presented with signs and symptoms of heat-related illness. Which of them needs to be attended first?

A. A relatively healthy homemaker who reports that the air conditioner has been broken for days and who manifest fatigue, hypotension, tachypnea, and profuse sweating.
B. An elderly person who complains of dizziness and syncope after standing in the sun for several hours to view a parade.
C. A homeless person who is a poor historian; has altered mental status, poor muscle coordination, and hot, dry ashen skin; and whose duration of heat exposure is unknown.
D. A marathon runner who complains of severe leg cramps and nausea, and manifests weakness, pallor, diaphoresis, and tachycardia.

Answer 14

C. A homeless person who is a poor historian; has altered mental status, poor muscle coordination, and hot, dry ashen skin; and whose duration of heat exposure is unknown.

The signs and symptoms manifested by the homeless person indicate that a heat stroke is happening, a medical emergency, which can lead to brain damage. Also, there must be clinical signs of central nervous system dysfunction that may include ataxia, delirium, or seizures, in the setting of exposure to hot weather or strenuous physical exertion. Patients who present with heat stroke typically have vital sign abnormalities to include an elevated core body temperature, sinus tachycardia, tachypnea, a widened pulse pressure, and a quarter of patients will be hypotensive.

Question 15

An intoxicated client comes into the emergency unit with uncooperative behavior, mild confusion, and slurred speech. The client is unable to provide a good history but he verbalizes that he has been drinking a lot. Which of the following is a priority action of the nurse?

A. Administer IV fluid incorporated with Vitamin B1 as ordered
B. Administer Naloxone (Narcan) 4 mg as ordered
C. Contact the family to get information about the client
D. Obtain an order for the determination of blood alcohol level

Answer 15

A. Administer IV fluid incorporated with Vitamin B1 as ordered.

The client has symptoms of alcohol abuse and there is a risk for Wernicke syndrome, which is caused by a deficiency in Vitamin B. Thiamine deficiency (vitamin B1) is common in patients with alcohol dependence. Cognitive impairments may be an early consequence of thiamine deficiency. Wernicke’s encephalopathy is underdiagnosed and undertreated.

Question 16

A nurse is providing discharge instructions to a woman who has been treated for contusions and bruises due to domestic violence. What is the priority intervention for this client?

A. Arranging transportation to a safe house
B. Advising the client about contacting the police
C. Making an appointment to follow up on the injuries
D. Making a referral to a counselor

Answer 16

A. Arranging transportation to a safe house.

Safety is a priority for this client and she should not return to a place where violence could recur. Make sure a safe environment is provided. Offer shelter options, legal services, counseling, and facilitate such referral.

Question 17

An ER nurse is handling a 50-year-old woman complaining of dizziness and palpitations that occur from time to time. ECG confirms the diagnosis of paroxysmal supraventricular tachycardia. The client seems worried about it. Which of the following is an appropriate response of the nurse?

A. “You can be discharged now; this is a probable sign of anxiety.”
B. “The physician will prescribe you blood-thinning medications to lessen the episodes of palpitations.”
C. “We’ll need to keep you for further assessment; you may develop blood clots.”
D. “You have to stay here for a few hours to undergo blood tests to rule out myocardial infarction.”

Answer 17

C. “We’ll need to keep you for further assessment; you may develop blood clots.”

Paroxysmal supraventricular tachycardia (PSVT) is characterized by episodes of rapid heart rate that occur periodically and stop on their own. PSVT decreases cardiac output and can result in a thrombus. These clots could turn into an embolus, which could eventually lead to a stroke. Treatment of PSVT in a patient is dependent on the type of rhythm present on the electrocardiogram and the patient’s hemodynamic stability.

Question 18

The emergency medical service has transported a client with severe chest pain. As the client is being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and unpalpable pulse. Which of the following task is appropriate to delegate to the nursing assistant?

A. Assisting with the intubation
B. Placing the defibrillator pads
C. Doing chest compressions
D. Initiating bag valve mask ventilation

Answer 18

C. Doing chest compressions.

Performing chest compressions are within the training of a nurse assistant. Every good certified nursing assistant should be proficient at cardiopulmonary resuscitation (CPR). Basic Life Support (BLS) certification is the widely-used term for any form of CPR certification and is required for all Registered Nurses (RN) and Certified Nursing Assistants (CNA).

Question 19

Michael works as a triage nurse, and four clients arrive at the emergency department at the same time. List the order in which he will assess these clients from first to last.

1. A 35-year-old jogger with a twisted ankle, having a pedal pulse, and no deformity
2. A 50-year-old female with moderate abdominal pain and occasional vomiting
3. An irritable infant with a fever, petechiae, and nuchal rigidity
4. An ambulatory dazed 25-year-old male with a bandaged head wound

Answer 19

3, 4, 2, 1

Question 20

In the work setting, what is the primary responsibility of the nurse in preparation for disaster management, that includes natural disasters and bioterrorism incidents?

A. Being aware of the signs and symptoms of potential agents of bioterrorism
B. Making ethical decisions regarding exposing self to potentially lethal substances
C. Being aware of the agency’s emergency response plan
D. Being aware of what and how to report to the Centers for Disease Control and Prevention

Answer 20

C. Being aware of the agency’s emergency response plan.

In disaster preparedness, the nurse should know the emergency response plan. This gives guidance that includes the roles of the team members, responsibilities, and mechanisms of reporting. Emergency preparedness encompasses diverse fields within the hospital and regional settings. Planning membership groups should address key aspects across these fields including but not limited to: public safety, facilities, logistics, pharmacy, transportation, clinical patient care, non-clinical patient care, media/public relations, communications, radiation, infection control, and administration.

Question 21

A 20-year-old male client was brought to the emergency department with a gunshot wound to the chest. In obtaining a history of the incident to determine possible injuries, the nurse should ask which of the following?

A. “How long ago did the incident occur?”
B. “What was the initial first aid done?”
C. “Where did the incident happen?”
D. “What direction did the bullet enter into the body?”

Answer 21

D. “What direction did the bullet enter into the body?”

The entry point and direction of the bullet will predict the injuries of the client. In gunshot wounds, due to the high-intensity kinetic energy of the bullet, the pathway is often unpredictable in nature as well as the internal organs that may be affected. The most common organs injured are the small and large bowel at 50% and 40%, respectively.

Question 22

A client arrives in the emergency unit and reports that a concentrated household cleaner was splashed in both eyes. Which of the following nursing actions is a priority?

A. Examine the client’s visual acuity
B. Patch the eye
C. Use Restasis (Allergan) drops in the eye
D. Flush the eye repeatedly using sterile normal saline

Answer 22

D. Flush the eye repeatedly using sterile normal saline.

Initial emergency action during a chemical splash to the eye includes immediate continuous irrigation of the affected eye with normal saline. Immediate irrigation with copious amounts of an isotonic solution as described previously is the mainstay of treatment for chemical burns. Never use any substance to neutralize chemical exposure as the exothermic reaction can lead to secondary thermal injuries.

Question 23

A 33-year-old patient with a history of seizures and medication compliance of phenytoin (Dilantin) and carbamazepine (Tegretol) is brought to the ED by the MS personnel for repetitive seizure activity that started 45 minutes prior to arrival. You anticipate that the physician will order which drug for status epilepticus?

A. Phenytoin and Carbamazepine PO
B. Carbamazepine (Tegretol) IV
C. Magnesium sulfate IV
D. Lorazepam (Ativan) IV

Answer 23

D. Lorazepam (Ativan) IV.

IV Lorazepam (Ativan) is the drug of choice for status epilepticus. Benzodiazepines are the antiepileptic drug of choice for emergent control. Lorazepam is preferred because of its rapid onset of action and is dosed at 0.1 mg/kg IV. No more than 2 mg should be administered per minute.

Question 24

A client was brought to the emergency department after suffering a closed head injury and lacerations around the face due to a hit-run accident. The client is unconscious and has a minimal response to noxious stimuli. Which of the following assessment findings if observed after few hours, should be reported to the physician immediately?

A. Drainage of a clear fluid from the client’s nose
B. Withdrawal of the client in response to painful stimuli
C. Bruises and minimal edema of the eyelids
D. Bleeding around the lacerations

Answer 24

A. Drainage of a clear fluid from the client’s nose

Clear drainage from the client’s nose indicates that there is a leakage of CSF and should be reported to the physician immediately.

Question 25

The following clients come to the emergency department complaining of acute abdominal pain. Prioritize them for care in order of the severity of the conditions.

1. A 59-year-old man with a pulsating abdominal mass and sudden onset of persistent abdominal or back pain, which can be described as a tearing sensation within the past hour.
2. A 57-year-old woman who complains of a sore throat and gnawing midepigastric pain that is worse between meals and during the night.
3. A 15-year-old boy with a low-grade fever, right lower quadrant pain, vomiting, nausea, and loss of appetite for the past few days.
4. A 27-year-old woman complaining of lightheadedness and severe sharp left lower quadrant pain who reports she is possibly pregnant.
5. A 43-year-old woman with moderate right upper quadrant pain who has vomited small amounts of yellow bile and whose symptoms have worsened over the week.

Answer 25

1, 4, 3, 5, 2

Question 26

In caring for a victim of sexual assault, which task is most appropriate for an LPN/LVN?

A. Provide emotional support and supportive communication
B. Assess immediate emotional state and physical injuries
C. Ensure that the “chain of custody” is maintained
D. Collect hair samples, saliva swabs, and scrapings beneath fingernails

Answer 26

A. Provide emotional support and supportive communication

The LPN/LVN is able to listen and provide emotional support for her patients. The client is the center of care. The needs of the client must be competently met with the knowledge, skills, and abilities of the staff to meet these needs. In other words, the nurse who delegates aspects of care to other members of the nursing team must balance the needs of the client with the abilities of those to which the nurse is delegating tasks and aspects of care, among other things such as the scopes of practice and the policies and procedures within the particular healthcare facility.

Question 27

A group of people arrived at the emergency unit by a private car with complaints of periorbital swelling, cough, and tightness in the throat. There is a strong odor emanating from their clothes. They report exposure to a “gas bomb” that was set off in the house. What is the priority action?

A. Instruct personnel to don personal protective equipment
B. Direct the clients to the cold or clean zone for immediate treatment
C. Immediately remove other clients and visitors from the area
D. Measure vital signs and auscultate lung sounds
E. Direct the clients to the decontamination area

Answer 27

E. Direct the clients to the decontamination area.

Decontamination in a specified area is the priority. The decontamination and support areas are established within the Warm Zone, also referred to as the Contamination Reduction Zone. Decontamination involves thorough washing to remove contaminants.

Question 28

In relation to submersion injuries, which task is most appropriate to delegate to an LPN/LVN?

A. Stabilize the cervical spine for an unconscious drowning victim
B. Talk to a community group about water safety issues
C. Monitor an asymptomatic near-drowning victim
D. Remove wet clothing and cover the victim with a warm blanket

Answer 28

C. Monitor an asymptomatic near-drowning victim.

The asymptomatic patient is currently stable but should be observed for delayed pulmonary edema, cerebral edema, or pneumonia. Appropriate decisions relating to the successful assignment of care are accurately based on the needs of the patient, the skills of the staff, the staffs’ position description or job descriptions, the employing facility’s policies and procedures, and legal aspects of care such as the states’ legal scopes of practice for nurses, nursing assistants and other members of the nursing team.

Question 29

Nurse Ejay is assigned to telephone triage. A client called who was stung by a honeybee and is asking for help. The client reports pain and localized swelling but has no respiratory distress or other symptoms of anaphylactic shock. What is the appropriate initial action that the nurse should direct the client to perform?

A. Removing the stinger by scraping it
B. Applying a cold compress
C. Taking an oral antihistamine
D. Calling 911

Answer 29

A. Removing the stinger by scraping it.

Since the stinger will continue to release venom into the skin, removing the stinger should be the first action that the nurse should direct to the client. Within the first few minutes after the sting, the stinger should be removed via scraping with a credit card rather than squeezing/tweezing to avoid further venom exposure.

Question 30

When an unexpected death occurs in the emergency department, which task is the most appropriate to delegate to a nursing assistant?

A. Assisting with postmortem care
B. Facilitate meetings between the family and the organ donor specialist
C. Escorting the family to a place of privacy
D. Help the family to collect belongings

Answer 30

A. Assisting with postmortem care.

Postmortem care requires some turning, cleaning, lifting, and so on, and the nursing assistant is able to assist with these duties. The use of NAPs increasingly demands registered nurses to delegate patient care tasks according to the principles of the ANA. These principles define nursing delegation as the “transfer of responsibility for the performance of an activity from one individual to another while retaining accountability for the outcome.”

Question 31

An anxious female client complains of chest tightness, tingling sensations, and palpitations. Deep, rapid breathing, and carpal spasms are noted. Which of the following priority action should the nurse do first?

A. Provide oxygen therapy
B. Notify the physician immediately
C. Administer anxiolytic medication as ordered
D. Have the client breathe into a brown paper bag

Answer 31

D. Have the client breathe into a brown paper bag

The client is suffering from hyperventilation secondary to anxiety, the initial action is to let the client breathe in a paper bag that will allow the rebreathing of carbon dioxide. The idea behind breathing into a paper bag or mask is that rebreathing exhaled air helps the body put CO2 back into the blood.

Question 32

A 65-year-old patient arrived at the triage area with complaints of diaphoresis, dizziness, and left-sided chest pain. This patient should be prioritized into which category?

A. Non-urgent
B. Urgent
C. Emergent
D. High urgent

Answer 32

C. Emergent

Chest pain is considered an emergent priority, which is defined as potentially life-threatening. If the nurse can accurately diagnose the patient with these criteria and mark as a Level 1 trauma patient, the patient will need immediate life-saving therapy. Immediate physician involvement in the care of the patient is critical and is one of the differences between level 1 and level 2 patient designations.

Question 33

You are caring for a client with frostbite on the feet. Place the following interventions in the correct order.

1. Apply a loose, sterile, bulky dressing
2. Immerse the feet in warm water 100° F to 105° F (40.6º C to 46.1° C)
3. Monitor for signs of compartment syndrome
4. Remove the victim from the cold environment.
5. Administer pain medication

Answer 33

4, 5, 2, 1, 3

Question 34

In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey?

A. Brief neurologic assessment
B. Client’s allergy history
C. Initiation of pulse oximetry
D. Complete set of vital signs

Answer 34

A. Brief neurologic assessment

A brief neurologic assessment to determine the level of consciousness and pupil reaction is part of the primary survey. Once the patient is stabilized, a neurologic examination should be conducted. CT scan is the diagnostic modality of choice in the initial evaluation of patients with head trauma.

Question 35

The physician has ordered cooling measures for a child with a fever who is likely to be discharged when the temperature comes down. Which task would be appropriate to delegate to a nursing assistant?

A. Prepare and administer a tepid sponge bath
B. Explain the need for giving cool fluids
C. Assist the child in removing outer clothing
D. Advise the parent to use acetaminophen (Tylenol) instead of aspirin

Answer 35

C. Assist the child in removing outer clothing.

The nursing assistant can help with the removal of outer clothing, which allows the heat to dissipate from the child’s skin. Tepid baths are not usually given because of the possibility of shivering and rebound.

Question 36

A 15-year-old male client arrives at the emergency department. He is conscious, coherent, and ambulatory, but his shirt and pants are covered with blood. He and his hysterical friends are yelling and trying to explain that they were goofing around and he got poked in the abdomen with a stick. Which of the following comments should be given first consideration?

A. “The stick was really dirty and covered with mud.”
B. “He pulled the stick out, just now, because it was hurting him.”
C. “He’s a diabetic, so he needs attention right away.”
D. “There was a lot of blood and we used three bandages.”

Answer 36

“He pulled the stick out, just now, because it was hurting him.”

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. Surgery is often required; impaled objects are secured in place so that they do not move and they should only be removed in an operating room.

Question 37

The nursing manager decides to form a committee to address the issue of violence against ED personnel. Which combination of employees would be best suited to fulfill this assignment?

A. ED physicians and charge nurses
B. RNs, LPNs, and nursing assistants
C. Experienced RNs and experienced paramedics
D. At least one representative from each group of ED personnel

Answer 37

D. At least one representative from each group of ED personnel.

At least one representative from each group of ED personnel should be included because all employees are potential targets for violence in the ED. The diversity of the group should also be considered and assure that each department or each employee is represented.

Question 38

You are preparing a child for IV conscious sedation before the repair of a facial laceration. What information should you report immediately to the physician?

A. The child suddenly pulls out the IV
B. The parent is not sure regarding the child’s tetanus immunization status
C. The parent wants information about the IV conscious sedation
D. The parent’s refusal of the administration of the IV sedation

Answer 38

D. The parent’s refusal of the administration of the IV sedation.

The refusal of the parents is an absolute contraindication; therefore the physician must be notified. But the autonomy of parents is very obviously different from the autonomy of patients to make decisions for themselves. While adult patients are generally thought to have an absolute right to refuse medical treatment for themselves, we don’t usually think that parents can refuse all medical treatment for their children.

Question 39

A client arrives at the emergency department who suffered multiple injuries from a head-on car collision. Which of the following assessment should take the highest priority to take?

A. Unequal pupils
B. Irregular pulse
C. Ecchymosis in the flank area
D. A deviated trachea

Answer 39

D. A deviated trachea

A deviated trachea is a symptom of tension pneumothorax, which will result in respiratory distress if left untreated. The first question in the ESI triage algorithm for triage nurses asks whether “the patient requires immediate life-saving interventions” or simply “is the patient dying?” The nurse determines this by looking to see if the patient has a patent airway, if the patient is breathing, and does the patient has a pulse.