Exam 2 practice questions

1. While assessing a client in the emergency department, the nurse identifies that the client has been raped. Which health care team member should the nurse collaborate with when planning this client’s care?

a. Pastoral care
b. Case manager
c. Forensic nurse examiner
d. Law enforcement


2. On admission to the emergency department, a client states that he feels like killing himself. When planning this client’s care, it is most important for the nurse to coordinate with which member of the health care team?

a. Case manager
b. Forensic nurse examiner
c. Law enforcement
d. Psychiatric crisis nurse


3. 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.


4. 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.


5. 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 medical-surgical unit nurse.
c. Evaluate the need for ongoing medical treatment.
d. Perform a thorough assessment of the client.


6. The nurse manager is assessing current demographics of the facility’s emergency department (ED) clients. Which population would most likely present to the ED for treatment of a temperature and a sore throat?

a. Older adults
b. Immunocompromised people
c. Pediatric clients
d. Underinsured people


7. The emergency department (ED) nurse is caring for the following clients. Which client does the nurse prioritize to see first?

a. 22-year-old with a painful and swollen right wrist
b. 45-year-old reporting severe chest pain and diaphoresis
c. 60-year-old reporting nausea
d. 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101° F


8. 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


9. The emergency medical technicians (EMTs) arrive at the emergency department with an unresponsive client with an oxygen mask in place. What will the nurse do 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 best neurologic response


10. A client arrives at the emergency department following a motor vehicle collision. The client is not awake and is being bagged with a bag-valve-mask by paramedics. The client has sustained obvious injuries to the head and face, as well as an open right femur fracture that is bleeding profusely. What will the nurse do first?

a. Splint the right lower extremity.
b. Apply direct pressure to the leg.
c. Assess for a patent airway.
d. Start two large-bore IVs.


11. The nurse is providing care for a client admitted for suicidal precautions. What priority intervention should the nurse implement first?

a. Administer prescribed anti-anxiety drugs.
b. Decrease the noise level and the harsh lighting.
c. Remove oxygen tubing from the room.
d. Set firm behavioral limits.


12. A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. What should the nurse do before 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.


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

a. 20-year-old female with a leg 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


14. A client in the emergency department has died from a suspected homicide. What is the nurse’s priority intervention?

a. Remove all tubes and wires in preparation for the medical examiner.
b. Limit the number of visitors to minimize the family’s trauma.
c. Consult the bereavement committee to follow up with the grieving family.
d. Communicate the client’s death to the family in a simple and concrete manner.


15. A new nurse is orienting to the emergency department (ED). Which statement made by the nurse would indicate the need for further education by the preceptor?

a. “Only emergency medicine physician coordinates care with all levels of the emergency health care team.”
b. “Emergency departments have specialized teams that deal with high-risk populations of patients.”
c. “Many older adults seek emergency services when they are ill because they do not want to bother their primary health care provider.”
d. “Emergency departments are responsible for public health surveillance and emergency disaster preparedness.”


16. An unresponsive client with poor ventilatory 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.


17. The nurse is triaging clients in the emergency department (ED). Which is true about the presentation of client symptoms?

a. Older adults frequently have symptoms that are vague or less specific.
b. Young adults present with nonspecific symptoms for serious illnesses.
c. Diagnosing children’s symptoms often keeps them in the ED longer.
d. Symptoms of confusion always represent neurologic disorders.


18. 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.


19. The nurse is caring for a homeless client and consults the emergency department (ED) case manager. What can the ED case manager do for this client?

a. Communicate client needs and restrictions to support staff.
b. Prescribe low-cost antibiotics to treat community-acquired infection.
c. Provide referrals to subsidized community-based health clinics.
d. Offer counseling for substance abuse and mental health disorders.


20. The emergency department (ED) nurse is preparing to transfer a client to the critical care unit. What information should the nurse include in the nurse-to-nurse hand-off report? (Select all that apply.)

a. Allergies
b. Vital signs
c. Occupation
d. Marital status
e. Isolation precautions

a, b, e

21. The nurse is discharging an older adult client home from the emergency department (ED) after an acute episode of angina. What should the nurse do to ensure client safety upon discharge? (Select all that apply.)

a. Reconcile the client’s prescription and over-the-counter medications
b. Screen the client for functional and cognitive abilities, as well as risk for falls
c. Consult physical therapy to organize for nutrition services
d. Arrange for the client’s car keys to be taken to prevent an accident
e. Review discharge instructions with the client and a family member

a, b, e

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

a. Removing wet clothing
b. Casting open fractures
c. Initiating IV fluids
d. Endotracheal intubation
e. Foley catheterization

a, c, d

23. The nurse is assessing clients on site at a multi-vehicle accident. Triage clients in the order they should receive care. (Place in order of priority.)
a. A 50-year-old with chest trauma and difficulty breathing
b. A mother frantically looking for her 6-year-old son
c. An 8-year-old with a broken leg in his father’s arms
d. A 60-year-old with facial lacerations and confusion
e. A pulseless male with a penetrating head wound

24. The nurse assesses a client with a below-knee amputation. Which assessment of the skin flap requires immediate action?

a. Pink and warm to the touch
b. Pale and cool to the touch
c. Dark pink and dry to the touch
d. Pink and slightly moist to the touch


25. A client who has had an above-knee amputation of the right leg reports pain in the right foot. Which priority medication does the nurse administer?

a. IV morphine
b. 650 mg of acetaminophen
c. Beta-blocker
d. 600 mg of ibuprofen


27. The patient suffuerd from a fracuted femur, which of the following would you tell the nursing assistant to report immediatley?

a. The patient complains of pain
b. The patient appers confused
c. The patients blood pressure is 136/88
d. The patient voided using the bed pan


28. After change of shift report, which patient should the nurse assess first?

a. A 42 year old patient with carpel tunnel syndrome who complained of pain
b. A 64 year old patient with osteoperosis who is waiting for discharge
c. A 28 year old patient with a fracture complaining that the cast is too tight
d. A 56 year old patient with a leg amputation complaing of phantom pain


29. A patient with a fractue of the right ankel has a nursing diagnosis of impaired physical mobility, as charge nurse you observe a new graduate nurse preform all of these interventions. For which action should you intervene.

a. Encourages the LNA to go from a lying to a standing position
b. Administer pain medication prior to doing exercises
c. Explains to the family of the patient the exercise program
d. Reminds patient of correct use of crutches


30. A charge nurse assigns the nursing care of a pateint who is one day post operative after a left below the knee amputation to an experienced LPN who will function under your supervision. When you instruct the LPN what will you descibe as the major focus for care today?

a. To attain pain control for phantom pain
b. To monitor for signs of sufficient tissue perfusion
c. To assist the patient to ambulate as soon as possible
d. To elevate the risidual limb the the patinet is supine


31. A patient with a right above the knee amputation has phantom limb pain. And asks why? Whats your best response.

a. Phantom limb pain is not explained or predicted by any one theory
b. Phantom limp pain because your body thinks your limb is still present.
c. Phantom limb pain will not interfere with you activities of daily living.
d. Phantom limb pain is not real pain but remembered pain.


32. During morning care a patient with a below the knee amputation asks the nursing assistant about the prosthesis how should you instruct the nursing assistant to respond?

a. You should get the prosthesis so that you can walk again
b. Wait and ask your doctor that question the next time he comes in.
c. Its too soon to be thinking about getting a prosthesis
d. Ill ask the nurse to come in and discuss this with you


33. During an assesment with a patinet with fracures of the medial ulna and the radius you found all of the following data. Which assesment finding should you report to the physician immediatley.

a. The patient reports of pressure and pain
b. The cast is in place and is dry and intact
c. The skin is pink and warm to touch
d. The patient can move all fingers and toes


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