CM IV, EXAM 1 CHAPTERS 8, 9, 10,
1.) A patient who attempted suicide being treated in the ED is accompanied by his mother, father,
and brother. When planning the nursing care of this family, the nurse should perform which of
the following action?
a. Ensure that the family receives appropriate crisis intervention services
2.) A patient is admitted to the ED with an apparent overdose of IV heroin. After stabilizing the
patient’s cardiopulmonary status, the nurse should prepare to perform what intervention?
a. Administer naloxone hydrochloride (Narcan).
3.) The ED nurse admitting a patient with a history of depression is screening the patient for suicide
risk. What assessment question should the nurse ask when screening the patient?
a. Have you ever thought about taking your own life?
4.) An ED nurse is triaging patients according to the Emergency Severity Index (ESI). When assigning
patients to a triage level, the nurse will consider the patients acuity as well as what other variable?
a. The resources that the patient is likely to require
5.) A patient who has been exposed to anthrax is being treated in the local hospital. The nurse
should prioritize what health assessments?
a. Assessment of respiratory status
6.) While developing an emergency operations plan (EOP), the committee is discussing the
components of the EOP. During the post-incident response of an emergency operations plan,
what activity will take place?
a) Conducting a critique and debriefing for all involved in the incident
7.) Emergency department (ED) staff members have been trained to follow steps that will decrease
the risk of secondary exposure to a chemical. When conducting decontamination, staff members
should remove the patients clothing and then perform what action?
a. Rinse the patient with water.
8.) An industrial site has experienced a radiation leak and workers who have been potentially
affected are en-route to the hospital. To minimize the risks of contaminating the hospital,
managers should perform what action?
a. Establish a triage outside the hospital.
9.) A hospitals emergency operations plan has been enacted following an industrial accident. While
one nurse performs the initial triage, what should other emergency medical services personnel
do?
a. Perform life-saving measures.
, 10.) A nurse is triaging patients after a chemical leak at a nearby fertilizer factory. The guiding
principle of this activity is what?
a. Doing the greatest good for the greatest number of people
11.)A nurse is triaging clients in the emergency department. Which client should the nurse classify as
nonurgent?
a. A 62-year-old with a simple fracture of the left arm
12.)The complex care provided during an emergency requires interdisciplinary collaboration. Which
interdisciplinary team members are paired with the correct responsibilities? (Select all that apply.)
a. Psychiatric crisis nurse Interacts with clients and families when sudden illness, serious injury,
or death of a loved one may cause a crisis
e. Paramedic Provides prehospital advanced life support, including cardiac monitoring, advanced
airway management, and medication administration
13.)A nurse assesses a client recently bitten by a coral snake. Which assessment is the priority?
a. Respiratory rate and depth
14.)Emergency medical technicians arrive at the emergency department with an unresponsive client
who has an oxygen mask in place. Which action should the nurse take first?
a. Assess that the client is breathing adequately
15.) The nurse in the emergency department is performing an assessment on a client who sustained
a right finger laceration from a fishhook while fishing. The nurse asks the client which priority
question?
a. “When did you receive your last tetanus immunization?”
16.) A client is brought to the emergency department by the police after having seriously lacerated
both wrists. The initial action that the nurse should take is which step?
a. Assess and treat the wound sites
17.) ***With a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should
identify a decrease in which of the following findings as an indication of adequate fluid strength?
(Question got blurred out)
18.) A nurse is assisting with disaster triage following a bomb explosion in a bus station. Which of the
following clients should the nurse identify as being the highest priority?
a. A conscious adult with second degree burns on both lower legs
19.) 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 patient?
a. Ensuring continuous ECG monitoring
,20.) A nurse enters a client’s room and sees that ashes from a cigarette are beginning to ignite trash
in a waste basket. Which of the following actions should the nurse take first?
a. Rescue the client from immediate danger
21.) A client is admitted to the emergency department with complaints of severe radiating chest
pain, and a myocardial infarction is suspected the nurse immediately applies oxygen to the client
and plans to take which action first?
a. Call the laboratory to prescribe stat blood work
b. Notify the coronary care unit to inform them that the client will need admission
c. Obtain a 12-lead ECG
d. Call radiology to prescribe a chest radiograph
22.) A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to
a client. Which of the following actions should the nurse take first?
a. Wash the area of the puncture thoroughly with soap and water.
23.) A nurse is helping to triage a group of clients at a mass casualty incident who were involved in
an explosion at a local factory. Which of the following clients should the nurse tag to be the
priority for care?
a. A client who has a piece of wood punctured into the chest wall and has an audible
hissing sound coming from the wound site
24.) An emergency department nurse is transferring a client to the medical-surgical unit. What is the
most important nursing intervention in this situation?
a. Clearly communicate client data to the unit nurse
25.) A nurse suspects anaphylaxis when caring for a client following the initial administration of an
oral antibiotic. Which of the following is the priority intervention?
a. Count the Respiratory rate
26.) An emergency department nurse is caring for a patient who had been taking in the mountains
for the past 2 days. What are the most important indicators that a patient is experiencing high-
altitude pulmonary edema (HAPE)? (NOT SURE IF I GOT THIS RIGHT)
a. Confusion
b. Ataxia
c. Decreased level of consciousness
d. Crackles in both lung fields
e. Persistent dry cough
27.) A nursing is caring for a client who develops and airway obstruction from a foreign body but
remains conscious. Which of the following actions should the nurse take first?
a. Administer the abdominal thrust maneuver
, 28.) The nurse in trauma unit has received report on a client who has multiple injuries following a
motor vehicle crash. Which of the following actions should the nurse plan to take first?
a. Evaluate chest expansion
29.) A nurse is triaging clients following a mass casualty event. Which of the following clients should
the nurse assess first?
a. A client who has severe respiratory stridor and a deviated trachea
30.) A patient is admitted with a thermal injury, the mechanism of injury that this patient would
most likely experience would be which of the following?
a. Fire
31.) An ER assesses a patient who has been raped, with which health care team would the nurse
collaborate with while planning this patient care
a. Forensic nurse
32.)A spouse of a patient admitted with a gunshot wound ask the nurse when her husband will be
discharged so that they could resume their life together. With which should the nurse respond to
the spouse?
a. "Right now, there is no way of knowing how soon your husband can return to his
previous life."
33.)The patient is admitted with possible head and spinal injuries after falling from a ladder, the
diagnostic test that will identify the extent of injuries
a. MRI
34.)How can a nurse assist disaster victim to cope with their experiences?
a. Refer to hospital chaplain
b. Active listening
c. Assist to debrief
d. Give emotional outlet
35.)A client presents to the ER after prolonged exposure to the cold, the client is shivering, has
slurred speech and is slow to respond to questions, what treatment would the nurse provide for
this client?
a. Administer warmed intravenous fluids to the client.
36.)An Elderly patient fell and hit their head was transported by ambulance, was unconscious at the
scene but is conscious on arrival, triage is urgent, what is the priority assessment the nurse
includes during the primary survey of the patient?
a. Neurological status?
1.) A patient who attempted suicide being treated in the ED is accompanied by his mother, father,
and brother. When planning the nursing care of this family, the nurse should perform which of
the following action?
a. Ensure that the family receives appropriate crisis intervention services
2.) A patient is admitted to the ED with an apparent overdose of IV heroin. After stabilizing the
patient’s cardiopulmonary status, the nurse should prepare to perform what intervention?
a. Administer naloxone hydrochloride (Narcan).
3.) The ED nurse admitting a patient with a history of depression is screening the patient for suicide
risk. What assessment question should the nurse ask when screening the patient?
a. Have you ever thought about taking your own life?
4.) An ED nurse is triaging patients according to the Emergency Severity Index (ESI). When assigning
patients to a triage level, the nurse will consider the patients acuity as well as what other variable?
a. The resources that the patient is likely to require
5.) A patient who has been exposed to anthrax is being treated in the local hospital. The nurse
should prioritize what health assessments?
a. Assessment of respiratory status
6.) While developing an emergency operations plan (EOP), the committee is discussing the
components of the EOP. During the post-incident response of an emergency operations plan,
what activity will take place?
a) Conducting a critique and debriefing for all involved in the incident
7.) Emergency department (ED) staff members have been trained to follow steps that will decrease
the risk of secondary exposure to a chemical. When conducting decontamination, staff members
should remove the patients clothing and then perform what action?
a. Rinse the patient with water.
8.) An industrial site has experienced a radiation leak and workers who have been potentially
affected are en-route to the hospital. To minimize the risks of contaminating the hospital,
managers should perform what action?
a. Establish a triage outside the hospital.
9.) A hospitals emergency operations plan has been enacted following an industrial accident. While
one nurse performs the initial triage, what should other emergency medical services personnel
do?
a. Perform life-saving measures.
, 10.) A nurse is triaging patients after a chemical leak at a nearby fertilizer factory. The guiding
principle of this activity is what?
a. Doing the greatest good for the greatest number of people
11.)A nurse is triaging clients in the emergency department. Which client should the nurse classify as
nonurgent?
a. A 62-year-old with a simple fracture of the left arm
12.)The complex care provided during an emergency requires interdisciplinary collaboration. Which
interdisciplinary team members are paired with the correct responsibilities? (Select all that apply.)
a. Psychiatric crisis nurse Interacts with clients and families when sudden illness, serious injury,
or death of a loved one may cause a crisis
e. Paramedic Provides prehospital advanced life support, including cardiac monitoring, advanced
airway management, and medication administration
13.)A nurse assesses a client recently bitten by a coral snake. Which assessment is the priority?
a. Respiratory rate and depth
14.)Emergency medical technicians arrive at the emergency department with an unresponsive client
who has an oxygen mask in place. Which action should the nurse take first?
a. Assess that the client is breathing adequately
15.) The nurse in the emergency department is performing an assessment on a client who sustained
a right finger laceration from a fishhook while fishing. The nurse asks the client which priority
question?
a. “When did you receive your last tetanus immunization?”
16.) A client is brought to the emergency department by the police after having seriously lacerated
both wrists. The initial action that the nurse should take is which step?
a. Assess and treat the wound sites
17.) ***With a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should
identify a decrease in which of the following findings as an indication of adequate fluid strength?
(Question got blurred out)
18.) A nurse is assisting with disaster triage following a bomb explosion in a bus station. Which of the
following clients should the nurse identify as being the highest priority?
a. A conscious adult with second degree burns on both lower legs
19.) 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 patient?
a. Ensuring continuous ECG monitoring
,20.) A nurse enters a client’s room and sees that ashes from a cigarette are beginning to ignite trash
in a waste basket. Which of the following actions should the nurse take first?
a. Rescue the client from immediate danger
21.) A client is admitted to the emergency department with complaints of severe radiating chest
pain, and a myocardial infarction is suspected the nurse immediately applies oxygen to the client
and plans to take which action first?
a. Call the laboratory to prescribe stat blood work
b. Notify the coronary care unit to inform them that the client will need admission
c. Obtain a 12-lead ECG
d. Call radiology to prescribe a chest radiograph
22.) A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to
a client. Which of the following actions should the nurse take first?
a. Wash the area of the puncture thoroughly with soap and water.
23.) A nurse is helping to triage a group of clients at a mass casualty incident who were involved in
an explosion at a local factory. Which of the following clients should the nurse tag to be the
priority for care?
a. A client who has a piece of wood punctured into the chest wall and has an audible
hissing sound coming from the wound site
24.) An emergency department nurse is transferring a client to the medical-surgical unit. What is the
most important nursing intervention in this situation?
a. Clearly communicate client data to the unit nurse
25.) A nurse suspects anaphylaxis when caring for a client following the initial administration of an
oral antibiotic. Which of the following is the priority intervention?
a. Count the Respiratory rate
26.) An emergency department nurse is caring for a patient who had been taking in the mountains
for the past 2 days. What are the most important indicators that a patient is experiencing high-
altitude pulmonary edema (HAPE)? (NOT SURE IF I GOT THIS RIGHT)
a. Confusion
b. Ataxia
c. Decreased level of consciousness
d. Crackles in both lung fields
e. Persistent dry cough
27.) A nursing is caring for a client who develops and airway obstruction from a foreign body but
remains conscious. Which of the following actions should the nurse take first?
a. Administer the abdominal thrust maneuver
, 28.) The nurse in trauma unit has received report on a client who has multiple injuries following a
motor vehicle crash. Which of the following actions should the nurse plan to take first?
a. Evaluate chest expansion
29.) A nurse is triaging clients following a mass casualty event. Which of the following clients should
the nurse assess first?
a. A client who has severe respiratory stridor and a deviated trachea
30.) A patient is admitted with a thermal injury, the mechanism of injury that this patient would
most likely experience would be which of the following?
a. Fire
31.) An ER assesses a patient who has been raped, with which health care team would the nurse
collaborate with while planning this patient care
a. Forensic nurse
32.)A spouse of a patient admitted with a gunshot wound ask the nurse when her husband will be
discharged so that they could resume their life together. With which should the nurse respond to
the spouse?
a. "Right now, there is no way of knowing how soon your husband can return to his
previous life."
33.)The patient is admitted with possible head and spinal injuries after falling from a ladder, the
diagnostic test that will identify the extent of injuries
a. MRI
34.)How can a nurse assist disaster victim to cope with their experiences?
a. Refer to hospital chaplain
b. Active listening
c. Assist to debrief
d. Give emotional outlet
35.)A client presents to the ER after prolonged exposure to the cold, the client is shivering, has
slurred speech and is slow to respond to questions, what treatment would the nurse provide for
this client?
a. Administer warmed intravenous fluids to the client.
36.)An Elderly patient fell and hit their head was transported by ambulance, was unconscious at the
scene but is conscious on arrival, triage is urgent, what is the priority assessment the nurse
includes during the primary survey of the patient?
a. Neurological status?
