TEST BANK For Emergency Care, 14th Edition by Daniel
Limmer, Michael F. O'Keefe
An emergency room nurse assesses a client who has been raped. With which health
care team member should the nurse collaborate when planning this clients care?
a. Emergency medicine physician
b. Case manager
c. Forensic nurse examiner
d. Psychiatric crisis nurse - ANSWER:ANS: C
All other members of the health care team listed may be used in the management of
this clients 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 clients spouse arrives at the emergency department. Which action
should the nurse take first?
a. Request that the clients 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 clients spouse to the hospitals crisis team. - ANSWER: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.
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 - ANSWER:ANS: 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. - ANSWER:ANS: 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,
and 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 - ANSWER:ANS: 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
d. Level IV Located in large teaching hospitals and provides a full continuum of
trauma care for all clients - ANSWER:ANS: B
Level I trauma centers are usually located in large teaching hospital systems and
provide a full continuum of trauma care for all clients. Both Level II and Level III
facilities are usually located in community hospitals. These trauma centers provide
care for most clients and transport to Level I centers when client needs exceed
resource capabilities. Level IV trauma centers are usually located in rural and remote
areas. These centers provide basic care, stabilization, and advanced life support
while transfer arrangements to higher-level trauma centers are made.
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.
b. Insert a large-bore intravenous line.
c. Place the client on a cardiac monitor.
d. Assess for the best neurologic response. - ANSWER:ANS: A
The highest-priority intervention in the primary survey is to establish that the client
is breathing adequately. Even though this client has an oxygen mask on, he or she
may not be breathing, or may be breathing inadequately with the device in place.
A trauma client with multiple open wounds is brought to the emergency department
in cardiac arrest. Which action should the nurse take prior to providing advanced
cardiac life support?
a. Contact the on-call orthopedic surgeon.
b. Don personal protective equipment.
c. Notify the Rapid Response Team.
d. Obtain a complete history from the paramedic. - ANSWER:ANS: B
Nurses must recognize and plan for a high risk of contamination with blood and body
fluids when engaging in trauma resuscitation. Standard Precautions should be taken
in all resuscitation situations and at other times when exposure to blood and body
fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye
protection, a facemask, a surgical cap, and shoe covers.
Limmer, Michael F. O'Keefe
An emergency room nurse assesses a client who has been raped. With which health
care team member should the nurse collaborate when planning this clients care?
a. Emergency medicine physician
b. Case manager
c. Forensic nurse examiner
d. Psychiatric crisis nurse - ANSWER:ANS: C
All other members of the health care team listed may be used in the management of
this clients 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 clients spouse arrives at the emergency department. Which action
should the nurse take first?
a. Request that the clients 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 clients spouse to the hospitals crisis team. - ANSWER: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.
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 - ANSWER:ANS: 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. - ANSWER:ANS: 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,
and 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 - ANSWER:ANS: 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
d. Level IV Located in large teaching hospitals and provides a full continuum of
trauma care for all clients - ANSWER:ANS: B
Level I trauma centers are usually located in large teaching hospital systems and
provide a full continuum of trauma care for all clients. Both Level II and Level III
facilities are usually located in community hospitals. These trauma centers provide
care for most clients and transport to Level I centers when client needs exceed
resource capabilities. Level IV trauma centers are usually located in rural and remote
areas. These centers provide basic care, stabilization, and advanced life support
while transfer arrangements to higher-level trauma centers are made.
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.
b. Insert a large-bore intravenous line.
c. Place the client on a cardiac monitor.
d. Assess for the best neurologic response. - ANSWER:ANS: A
The highest-priority intervention in the primary survey is to establish that the client
is breathing adequately. Even though this client has an oxygen mask on, he or she
may not be breathing, or may be breathing inadequately with the device in place.
A trauma client with multiple open wounds is brought to the emergency department
in cardiac arrest. Which action should the nurse take prior to providing advanced
cardiac life support?
a. Contact the on-call orthopedic surgeon.
b. Don personal protective equipment.
c. Notify the Rapid Response Team.
d. Obtain a complete history from the paramedic. - ANSWER:ANS: B
Nurses must recognize and plan for a high risk of contamination with blood and body
fluids when engaging in trauma resuscitation. Standard Precautions should be taken
in all resuscitation situations and at other times when exposure to blood and body
fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye
protection, a facemask, a surgical cap, and shoe covers.
