PRELIMS

Question 1

The emergency department team is performing cardiopulmonary resuscitation on a client when the client’s spouse arrives at the emergency department. What should the nurse do next?

a. Request that the client’s spouse sit in the waiting room.
b. Ask the spouse if he wishes to be present during the resuscitation.
c. Suggest that the spouse begin to pray for the client.
d. Refer the client’s spouse to the hospital’s crisis team.

Answer 1

ANS: B
If resuscitation efforts are still under way when the family arrives, one or two family members may be given the opportunity to be present during lifesaving procedures. The other options do not give the spouse the opportunity to be present for the client or to begin to have closure.

Question 2

The emergency department nurse is assigned an older adult client who is confused and agitated. Which intervention should the nurse include in the client’s plan of care?

a. Administer a sedative medication.
b. Ask a family member to stay with the client.
c. Use restraints to prevent the client from falling.
d. Place the client in a wheelchair at the nurses’ station.

Answer 2

ANS: B
Older adults who are confused are at increased risks for falls. Fall prevention includes measures such as siderails up, reorientation, call light in reach, and, in some cases, asking the family member, significant other, or sitter to stay with the client to prevent falls.

Question 3

An emergency department nurse is transferring a client to the medical-surgical unit. What is the most important nursing intervention in this situation?

a. Triage the client to determine the urgency of care.
b. Clearly communicate client data to the unit nurse.
c. Evaluate the need for ongoing medical treatment.
d. Perform a thorough assessment of the client.

Answer 3

ANS: B
The emergency nurse needs to be able to triage, assess, and evaluate. However, these steps have already been carried out in the early phases of the emergency department (ED) admission. When a client is ready to be transferred from the ED, communication with staff nurses from the inpatient units is essential. This report should be a concise but comprehensive report of the client’s ED experience.

Question 4

A nurse is triaging clients in the emergency department. Which client complaint would the triage nurse classify as nonurgent?

a. Chest pain and diaphoresis
b. Decreased breath sounds due to chest trauma
c. Left arm fracture with palpable radial pulses
d. Sore throat and a temperature of 104° F

Answer 4

ANS: C
A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration. The client with an arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent.

Question 5

The nurse is triaging clients in the emergency department. Which client should be considered urgent?

a. 20-year-old female with a chest stab wound and tachycardia
b. 45 year-old homeless man with a skin rash and sore throat
c. 75-year-old female with a cough and of temperature of 102° F
d. 50-year-old male with new-onset confusion and slurred speech

Answer 5

ANS: C
A client with a cough and a temperature of 102° F is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. Clients with a chest stab wound and tachycardia, and with new-onset confusion and slurred speech, should be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent.

Question 6

An unresponsive client with poor ventilator effort and a pulse rate of 120 beats/min arrives at the emergency department. What should the nurse do first?

a. Place the client on a non-rebreather mask.
b. Begin bag-valve-mask ventilation.
c. Initiate cardiopulmonary resuscitation.
d. Prepare for chest tube insertion.

Answer 6

B

Question 7

The emergency department (ED) nurse is assigned to triage clients. What is the purpose of triage?

a. Treat clients on a first-come, first-serve basis.
b. Identify and treat clients with low acuity first.
c. Prioritize clients based on illness severity.
d. Determine health needs from a complete assessment.

Answer 7

C

Question 8

Which interventions will be performed during the primary survey for a trauma client? (Select all that apply.)

a. Removing wet clothing
b. Splinting open fractures
c. Initiating IV fluids
d. Endotracheal intubation
e. Foley catheterization
f. Needle decompression
g. Laceration repair

Answer 8

A C D F

Question 9

A nurse sees a patient get struck by lightning during a thunder storm on a golf course. What should be the FIRST action by the nurse?

1. Check breathing and circulation.
2. Look for entrance and exit wounds.
3. Cover the patient to prevent heat loss.
4. Move the patient indoors to a dry place.
5. Get the patient up off the ground.

Answer 9

1

Question 10

A patient, experiencing a burn that is pale and waxy with large flat blisters, asks the nurse about the severity of the burn and how long it will take to heal. With which of the following should the nurse respond to this patient?

1. The wound is a deep partial-thickness burn, and will take more than three weeks to heal.
2. The wound is a partial-thickness burn, and could take up to two weeks to heal.
3. The wound is a superficial burn, and will take up to three weeks to heal.
4. The wound is a full-thickness burn and will take one to two weeks to heal.
5. Wound healing is individualized.

Answer 10

1

Question 11

A patient has a scald burn on the arm that is bright red, moist, and has several blisters. The nurse would classify this burn as which of the following?
Select all that apply.

1. a superficial partial-thickness burn
2. a thermal burn
3. a superficial burn
4. a deep partial-thickness burn
5. a full-thickness burn

Answer 11

1, 2

Question 12

A patient is brought to the emergency department with the following burn injuries: a blistered and reddened anterior trunk, reddened lower back, and pale, waxy anterior right arm. Calculate the extent of the burn injury (TBSA) using the rule of nines

Answer 12

Correct Answer: 22.5
Rationale : The anterior trunk has superficial partial-thickness burns and is calculated in TBSA as 18%. The arm has a deep partial-thickness burn and is calculated as 4.5%. The burn on the lower back is superficial and is not calculated in TBSA.

Question 13

A 25-year-old patient is admitted with partial-thickness injuries over 20% of the total body surface area involving both lower legs. The nurse would classify this injury as being which of the following?

1. a moderate burn
2. a minor burn
3. a major burn
4. a severe burn
5. an intermediate burn

Answer 13

1

Question 14

A patient has sustained a partial-thickness injury of 28% of total body surface area (TBSA) and full-thickness injury of 30% or greater of TBSA. How should the nurse classify this burn injury?

1. major
2. moderate
3. minor
4. superficial
5. intermediate

Answer 14

1

Question 15

A 70-year-old patient has experienced a sunburn over much of the body. What self-care technique is MOST important to emphasize to an older adult in dealing with the effects of the sunburn?

1. increasing fluid intake
2. applying mild lotions
3. taking mild analgesics
4. maintaining warmth
5. using sunscreen

Answer 15

1

Question 16

A patient is being evaluated after experiencing severe burns to his torso and upper extremities. The nurse notes edema at the burned areas. Which of the following best describes the underlying cause for this assessment finding?

1. inability of the damaged capillaries to maintain fluids in the cell walls
2. reduced vascular permeability at the site of the burned area
3. decreased osmotic pressure in the burned tissue
4. increased fluids in the extracellular compartment
5. the IV fluid being administered too quickly

Answer 16

1

Question 17

When monitoring the vital signs of the patient who has experienced a major burn injury, the nurse assesses a heart rate of 112 and a temperature of 99.9° F. Which of the following best describes the findings?

1. These values are normal for the patient’s post-burn injury condition.
2. The patient is demonstrating manifestations consistent with the onset of an infection.
3. The patient is demonstrating manifestations consistent with an electrolyte imbalance.
4. The patient is demonstrating manifestations consistent with renal failure.
5. The patient is demonstrating manifestations of fluid volume overload.

Answer 17

1

Question 18

A patient is scheduled for surgery to graft a burn injury on the arm. Which of the following statements should the nurse include when instructing the patient prior to the procedure?

1. “You will begin to perform exercises to promote flexibility and reduce contractures after five days.”
2. “You will need to report any itching, as it might signal infection.”
3. “Performing the procedure near the end of the hospitalization will reduce the incidence of infection and improve success of the procedure.”
4. “The procedure will be performed in your room.”
5. “You will need to be in protective isolation for several weeks after the graft is performed.”

Answer 18

1

Question 19

A patient is admitted to the emergency department with deep partial-thickness burns over 35 % of the body. What IV solution will be started initially?

1. warmed lactated Ringer’s solution
2. dextrose 5% with saline solution
3. dextrose 5% with water
4. normal saline solution
5. 0.45% saline solution

Answer 19

1

Question 20

Using the modified Brooke formula, calculate the amount of intravenous solution that will be administered in the first 8 hours for a patient with 40% TBSA and weighs 52 kg.

Answer 20

Correct Answer: 2080 mL
Rationale : The modified Brooke formula is 2 mL × total kg of body weight × % TBSA. In this situation, 2 mL × 52 kg × 40 = 4160 mL. One-half is given over the first eight hours, or 2080 mL.

Question 21

A patient is coming into the emergency department with third-degree burns over 25% of his body. The nurse should prepare which of the following solutions for intravenous infusion for this patient?

1. warmed lactated Ringer’s
2. 5% dextrose in water
3. 5% dextrose in 0.45 normal saline
4. 5% dextrose in normal saline

Answer 21

1

Question 22

A patient is brought to the ED by ambulance with a gunshot wound to the abdomen. The nurse knows that the most common hollow organ injured in this type of injury is what?

A) Liver
B) Small bowel
C) Stomach
D) Large bowel

Answer 22

B

Question 23

A patient has been brought to the ED with multiple trauma after a motor vehicle accident. After immediate threats to life have been addressed, the nurse and trauma team should take what action?

A) Perform a rapid physical assessment.
B) Initiate health education.
C) Perform diagnostic imaging.
D) Establish the circumstances of the accident.

Answer 23

A

Question 24

A patient is brought to the ED by ambulance after swallowing highly acidic toilet bowl cleaner 2 hours earlier. The patient is alert and oriented. What is the care teams most appropriate treatment?

A) Administering syrup of ipecac
B) Performing a gastric lavage
C) Giving milk to drink
D) Referring to psychiatry

Answer 24

C

Question 25

A triage nurse is talking to a patient when the patient begins choking on his lunch. The patient is coughing forcefully. What should the nurse do?

A) Stand him up and perform the abdominal thrust maneuver from behind.
B) Lay him down, straddle him, and perform the abdominal thrust maneuver.
C) Leave him to get assistance.
D) Stay with him and encourage him, but not intervene at this time.

Answer 25

D

Question 26

An obtunded patient is admitted to the ED after ingesting bleach. The nurse should prepare to assist with what intervention?

A) Prompt administration of an antidote
B) Gastric lavage
C) Administration of activated charcoal
D) Helping the patient drink large amounts of water

Answer 26

D

Question 27

A 6-year-old is admitted to the ED after being rescued from a pond after falling through the ice while ice skating. What action should the nurse perform while rewarming the patient?

A) Assessing the patients oral temperature frequently

B) Ensuring continuous ECG monitoring

C) Massaging the patients skin surfaces to promote circulation

D) Administering bronchodilators by nebulizer

Answer 27

B

Question 28

male patient with multiple injuries is brought to the ED by ambulance. He has had his airway stabilized and is breathing on his own. The ED nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding?

A) Absence of bruising at contusion sites

B) Rapid pulse and decreased capillary refill

C) Increased BP with narrowed pulse pressure

D) Sudden diaphoresis - 1355

Answer 28

B

Question 29

A patient is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the physician will perform which of the following actions?

A) Insert an oropharyngeal airway.
B) Perform the jaw thrust maneuver.
C) Perform endotracheal intubation.
D) Perform a cricothyroidotomy.

Answer 29

C

Question 30

A patient with a fractured femur presenting to the ED exhibits cool, moist skin, increased heart rate, and falling BP. The care team should consider the possibility of what complication of the patients injuries?

A) Myocardial infarction
B) Hypoglycemia
C) Hemorrhage
D) Peritonitis

Answer 30

C