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An emergency room nurse assesses a client who has been raped. With which health
care team member should the nurse collaborate when planning this client's care?
a. Emergency medicine physician
b. Case manager
c. Forensic nurse examiner
d. Psychiatric crisis nurse -ANSWERS-C ~ All other members of the health care team
listed may be used in the management of this client's care. However, the forensic nurse
examiner is educated to obtain client histories and collect evidence dealing with the
assault, and can offer the counseling and follow-up needed when dealing with the victim
of an assault.
The emergency department team is performing cardiopulmonary resuscitation on a
client when the client's spouse arrives at the emergency department. Which action
should the nurse take first?
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 hospitals crisis team. -ANSWERS-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.
An emergency room nurse is triaging victims of a multi-casualty event. Which client
should receive care first?
a. A 30-year-old distraught mother holding her crying child
, b. A 65-year-old conscious male with a head laceration
c. A 26-year-old male who has pale, cool, clammy skin
d. A 48-year-old with a simple fracture of the lower leg -ANSWERS-C ~ The client with
pale, cool, clammy skin is in shock and needs immediate medical attention. The mother
does not have injuries and so would be the lowest priority. The other two people need
medical attention soon, but not at the expense of a person in shock.
While triaging clients in a crowded emergency department, a nurse assesses a client
who presents with symptoms of tuberculosis. Which action should the nurse take first?
a. Apply oxygen via nasal cannula.
b. Administer intravenous 0.9% saline solution.
c. Transfer the client to a negative-pressure room.
d. Obtain a sputum culture and sensitivity. -ANSWERS-C ~ A client with signs and
symptoms of tuberculosis or other airborne pathogens should be placed in a negative-
pressure room to prevent contamination of staff, clients & family members in the
crowded emergency department.
A nurse is triaging clients in the emergency department (ED). Which client should the
nurse prioritize to receive care first?
a. A 22-year-old with a painful and swollen right wrist
b. A 45-year-old reporting chest pain and diaphoresis
c. A 60-year-old reporting difficulty swallowing and nausea
d. An 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101 F -
ANSWERS-B ~ A client experiencing chest pain and diaphoresis would be classified as
emergent and would be triaged immediately to a treatment room in the ED. The other
clients are more stable.
A nurse is evaluating levels and functions of trauma centers. Which function is
appropriately paired with the level of the trauma center?
a. Level I Located within remote areas and provides advanced life support within
resource capabilities
b. Level II Located within community hospitals and provides care to most injured clients
c. Level III Located in rural communities and provides only basic care to clients