Exam (elaborations)
Complex Adult Health- Exam 1/109 Q’s and A’s
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- Complex Adult Health-
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- Complex Adult Health-
Complex Adult Health- Exam 1/109 Q’s and A’s
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Complex Adult Health- Exam1/109 Q’s and A’s
1. 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 - -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.
DIF: Understanding/Comprehension REF: 118
KEY: Interdisciplinary team| emergency nursing
MSC: Integrated Process: Nursing Process: Planning
NOT: Client Needs Category: Safe and Effective Care Environment:
Management of Care
-2. 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. - -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.
DIF: Applying/Application REF: 126
KEY: Death| emergency nursing MSC: Integrated Process: Caring
NOT: Client Needs Category: Psychosocial Integrity
-3. 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 - -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.
DIF: Applying/Application REF: 129
KEY: Triage| emergency nursing
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment:
Management of Care
-4. 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. - -ANS: C
A client with signs and symptoms of tuberculosis or other airborne pathogens
should be placed in a negativepressure room to prevent contamination of
staff, clients, and family members in the crowded emergency
department.
DIF: Applying/Application REF: 120
KEY: Infection control| Transmission-Based Precautions| emergency nursing|
staff safety
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety
and Infection Control
-5. 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 - -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.
DIF: Applying/Application REF: 123
KEY: Triage| emergency nursing
,MSC: Integrated Process: Nursing Process: Planning
NOT: Client Needs Category: Safe and Effective Care Environment:
Management of Care
-6. 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 - -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.
DIF: Remembering/Knowledge REF: 127
KEY: Trauma center| emergency nursing
MSC: Integrated Process: Nursing Process: Planning
NOT: Client Needs Category: Safe and Effective Care Environment:
Management of Care
-7. 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. - -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.
Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional
Collaborative Care 9e 51
, DIF: Applying/Application REF: 128
KEY: Primary survey| emergency nursing
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment:
Management of Care
-8. 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. - -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.
DIF: Applying/Application REF: 128
KEY: Infection control| Standard Precautions| emergency nursing| staff safety
MSC: Integrated Process: Nursing Process: Planning
NOT: Client Needs Category: Safe and Effective Care Environment: Safety
and Infection Control
-9. A nurse is triaging clients in the emergency department. Which client
should be considered urgent?
a. A 20-year-old female with a chest stab wound and tachycardia
b. A 45-year-old homeless man with a skin rash and sore throat
c. A 75-year-old female with a cough and a temperature of 102 F
d. A 50-year-old male with new-onset confusion and slurred speech - -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. The
client with a chest stab wound and
tachycardia and the client 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.
DIF: Applying/Application REF: 124
KEY: Triage| emergency nursing
MSC: Integrated Process: Nursing Process: Planning
NOT: Client Needs Category: Safe and Effective Care Environment:
Management of Care
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