The College of Maasin “Nisi Dominus Frustra” College of Nursing and Allied Health Sciences NCM 106-Emergency Nursing
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1. Michael works as a triage nurse, and four clients arrive at the emergency department at the same time. List the order in which he will assess these clients from first to last. 1. A 50-year-old female with moderate abdominal pain and occasional vomiting. 2. A 35-year-old jogger with a twisted ankle, having a pedal pulse and no deformity. 3. An ambulatory dazed 25-year-old male with a bandaged head wound. 4. An irritable infant with a fever, petechiae, and nuchal rigidity. A. 1, 2, 3, 4 B. 2, 1, 3, 4 C. 4, 3, 1, 2 D. 3, 4, 2, 1 Answer: C. 4, 3, 1, 2 An irritable infant with fever and petechiae should be further assessed for other meningeal signs. The patient with the head wound needs additional history and assessment for intracranial pressure. The patient with moderate abdominal pain is uncomfortable, but not unstable at this point. For the ankle injury, a medical evaluation can be delayed 24 – 48 hours if necessary. 2. In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? A. Initiation of pulse oximetry. B. Complete set of vital signs. C. Client’s allergy history. D. Brief neurologic assessment. 2. Answer: D. Brief neurologic assessment. A brief neurologic assessment to determine the level of consciousness and pupil reaction is part of the primary survey. Vital signs, client’s allergy, and initiation of pulse oximetry are considered part of the secondary survey. 3. A 65-year-old patient arrived at the triage area with complaints of diaphoresis, dizziness, and left-sided chest pain. This patient should be prioritized into which category? A. Non-urgent. B. Urgent. C. Emergent. D. High urgent. 3. Answer: C. Emergent.Chest pain is considered an emergent priority, which is defined as potentially life-threatening. Option B: Clients with urgent priority need treatment within 2 hours of triage (e.g. kidney stones). Option A: Non-urgent conditions can wait for hours or even days. Option D: High urgent is not commonly used; however, in 5-tier triage systems, High urgent patients fall between emergent and urgent in terms of the time elapsing prior to treatment. 4. You respond to a call for help from the ED waiting room. There is an elderly patient lying on the floor. List the order for the actions that you must perform.
1. Call for help and activate the code team. 2. Instruct a nursing assistant to get the emergency cart. 3. Initiate cardiopulmonary resuscitation (CPR). 4. Perform the chin lift or jaw thrust maneuver. 5. Establish unresponsiveness.
A. 5, 2, 4, 3, 1 B. 1, 5, 2, 4, 3 C. 1, 2, 5, 4, 3 D. 5, 1, 4, 3, 2
4. Answer: D. 5, 1, 4, 3, 2 Establish unresponsiveness first. (The patient may have fallen and sustained a minor injury.) If the patient is unresponsive, get help and have someone initiate the code. Performing the chin lift or jaw thrust maneuver opens the airway. The nurse is then responsible for starting CPR. CPR should not be interrupted until the patient recovers or it is determined that heroic efforts have been exhausted. A crash cart should be at the site when the code team arrives; however, basic CPR can be effectively performed until the team arrives. 5. In caring for a victim of sexual assault, which task is most appropriate for an LPN/LVN? A. Provide emotional support and supportive communication. B. Assess immediate emotional state and physical injuries. C. Ensure that the “chain of custody” is maintained. D. Collect hair samples, saliva swabs, and scrapings beneath fingernails. Answer: A. Provide emotional support and supportive communication.The LPN/LVN is able to listen and provide emotional support for her patients.Options B, C, and D: The other tasks are the responsibility of an RN or, if available, a SANE (sexual assault nurse examiner) who has received training to assess, collect and safeguard evidence, and care for these victims. 6. Following an emergency endotracheal intubation, nurses must verify tube placement and secure the tube. List in order the steps that are required to perform this function?
1. Obtain an order for a chest x-ray to document tube placement. 2. Confirm that the breath sounds are equal and bilateral. 3. Auscultate the chest during assisted ventilation. 4. Secure the tube in place.
A. 1, 2, 3, 4 B. 4, 3, 2, 1 C. 3, 2, 4, 1 D. 4, 1, 2, 3 Answer: C. 3, 2, 4, 1Auscultating and confirming equal bilateral breath sounds should be performed in rapid succession. If the sounds are not equal or if the sounds are heard over the mid-epigastric area, tube placement must be corrected immediately. Securing the tube is appropriate while waiting for the x-ray study. 7. A 15-year-old male client arrives at the emergency department. He is conscious, coherent and ambulatory, but his shirt and pants are covered with blood. He and his hysterical friends are yelling and trying to explain that they were goofing around and he got poked in the abdomen with a stick. Which of the following comments should be given first consideration? A. “He’s a diabetic, so he needs attention right away.” B. “There was a lot of blood and we used three bandages.” C. “The stick was really dirty and covered with mud.” D. “He pulled the stick out, just now, because it was hurting him.” Answer: D. “He pulled the stick out, just now, because it was hurting him.”An impaled object may be providing a tamponade effect, and removal can precipitate sudden hemodynamic decompensation. Additional history including a more definitive description of the blood loss, depth of penetration, and medical history should be obtained. Other information, such as the dirt on the stick or history of diabetes, is important in the overall treatment.Options A and C: Other information, such as the dirt on the stick or history of diabetes, is important in the overall treatment plan, but can be addressed later. 8. A prisoner, with a known history of alcohol abuse, has been in police custody for 48 hours. Initially, anxiety, sweating, and tremors were noted. Now, disorientation, hallucination, and hyper-reactivity are observed. The medical diagnosis is delirium tremens. What is the priority nursing diagnosis? A. Risk for Situational Low Self-esteem related to police custody. B. Risk for Nutritional Deficit related to chronic alcohol abuse. C. Risk for Injury related to seizures. D. Risk for Other-Directed Violence related to hallucinations. Answer: C. Risk for Injury related to seizures.The client shows neurologic hyperactivity and is on the verge of a seizure. Patient safety is the priority. The patient needs chlordiazepoxide (Librium) to decrease neurologic irritability and phenytoin (Dilantin) for seizures. Thiamine and haloperidol (Haldol) will also be ordered to address the other problems.Options A, B, and D: The other diagnoses are pertinent but not as immediate.
9. In relation to submersion injuries, which task is most appropriate to delegate to an LPN/LVN? A. Talk to a community group about water safety issues. B. Stabilize the cervical spine for an unconscious drowning victim. C. Remove wet clothing and cover the victim with a warm blanket. D. Monitor an asymptomatic near-drowning victim. The asymptomatic patient is currently stable but should be observed for delayed pulmonary edema, cerebral edema, or pneumonia.Options A and B: Teaching and care of critical patients are an RN responsibility.Option C: Removing clothing can be delegated to a nursing assistant. 10. You are assessing a patient who has sustained a cat bite to the left hand. The cat is up-to-date immunizations. The date of the patient’s last tetanus shot is unknown. Which of the following is the priority nursing diagnosis? A. Risk for Impaired Mobility related to potential tendon damage. B. Risk for Infection related to organisms specific to cat bites. C. Ineffective Health Maintenance related to immunization status. D. Impaired Skin Integrity related to puncture wounds. Answer: B. Risk for Infection related to organisms specific to cat bites.Cat’s mouths contain a virulent organism, Pasteurella multocida, that can lead to septic arthritis or bacteremia.Options A and D: There is also a risk for tendon damage due to deep puncture wounds. These wounds are usually not sutured.Option C: A tetanus shot can be given before discharge. 11. A client in a one-car rollover presents with multiple injuries. Prioritize the interventions that must be initiated for this patient.
1. Assess for spontaneous respirations. 2. Give supplemental oxygen per mask. 3. Insert a Foley catheter if not contraindicated. 4. Obtain a full set of vital signs. 5. Remove patient’s clothing. 6. Secure/start two large-bore IVs with normal saline. 7. Use the chin lift or jaw thrust method to open the airway.
A. 1, 7, 2, 6, 4, 5, 3 B. 7, 1, 4, 2, 3, 5, 6 C. 4, 1, 5, 7, 6, 3, 2 D. 5, 4, 1, 7, 2, 6, 3 Answer: A. 1, 7, 2, 6, 4, 5, 3.For multiple trauma victims, a lot of interventions will occur simultaneously as team members assist in the resuscitation. Methods to open the airway such as the chin lift or jaw thrust can be used simultaneously while assessing for spontaneous respirations. However, airway and oxygenation are a priority. Starting IVs for fluid resuscitation is part of supporting circulation. (EMS will usually establish at least one IV in the field.) Nursing assistants can be directed to take vitals and remove clothing. Foley catheter is necessary to closely monitor output. 12. A 36-year-old patient with a history of seizures and medication compliance of phenytoin (Dilantin) and carbamazepine (Tegretol) is brought to the ED by the MS personnel for repetitive seizure activity that started 45 minutes prior to arrival. You anticipate that the physician will order which drug for status epilepticus? A. Lorazepam (Ativan) IV. B. Magnesium sulfate IV. C. Carbamazepine (Tegretol) IV. D. Phenytoin and Carbamazepine PO. Answer: A. Lorazepam (Ativan) IV.IV Lorazepam (Ativan) is the drug of choice for status epilepticus.Option B: Magnesium sulfate is given to control seizures in toxemia of pregnancy.Option C: Tegretol is used in the management of generalized tonic-clonic, absence or mixed type seizures, but it does not come in an IV form.Option D: PO (per os) medications are inappropriate for this emergency situation.
13. A client arrived at the emergency department after suffering multiple physical injuries including a fractured pelvis from a vehicular accident. Upon assessment, the client is incoherent, pale, and diaphoretic. With vital signs as follows: temperature of 97°F (36.11° C), blood pressure of 60/40 mm Hg, heart rate of 143 beats/minute, and a respiratory rate of 30 breaths/minute. The client is mostly suffering from which of the following shock? A. Cardiogenic. B. Distributive. C. Hypovolemic. D. Obstructive. Answer: C. Hypovolemic.Hypovolemic shock occurs when the volume of the circulatory system is too depleted to allow adequate circulation to the tissues of the body. A fractured pelvis will lose about one liter of blood hence symptoms such as hypotension, tachycardia, and tachypnea will occur.Option A: Causes of cardiogenic include massive myocardial infarction or other cause of primary cardiac (pump) failure. Option B: Distributive shock results from a relative inadequate intravascular volume caused by arterial or venous vasodilation.Option D: Obstructive shock is a form of shock associated with physical obstruction of the major vessels or the heart itself. 14. An ER nurse is handling a 50-year-old woman complaining of dizziness and palpitations that occur from time to time. ECG confirms the diagnosis of paroxysmal supraventricular tachycardia. The client seems worried about it. Which of the following is an appropriate response of the nurse? A. “You can be discharged now; this is a probable sign of anxiety.” B. “You have to stay here for a few hours to undergo blood tests to rule out myocardial infarction.” C. “We’ll need to keep you for further assessment; you may develop blood clots.” D. “The physician will prescribe you blood-thinning medications to lessen the episodes of palpitations.” Answer: C. “You have to stay to undergo an electrophysiology study as per doctor’s advice.”Paroxysmal supraventricular tachycardia (PSVT) is characterized by episodes of rapid heart rate that occurs periodically and stops on its own. PSVT decreases the cardiac output and can result to a thrombus. These clots could turn into an embolus, which could eventually lead to a stroke. 15. A client was brought to the ED due to an abdominal trauma caused by a motorcycle accident. During the assessment, the client complains of epigastric pain and back pain. Which of the following is true regarding the diagnosis of pancreatic injury? A. Redness and bruising may indicate the site of the injury in blunt trauma. B. The client is symptom-free during the early post-injury period. C. Signs of peritoneal irritation may indicate pancreatic injury. D. All of the above. Answer: D. All of the above.Blunt injury resulting from vehicular accidents could cause pancreatic injury. Redness, bruising in the flank and severe peritoneal irritation are signs of a pancreatic injury. The client is usually pain-free during the early post-injury period, hence a comprehensive assessment and monitoring should be done. 16. A 20-year-old male client was brought to the emergency department with a gunshot wound to the chest. In obtaining a history of the incident to determine possible injuries, the nurse should ask which of the following? A. “What was the initial first aid done?” B. “Where did the incident happen?” C. “What direction did the bullet enter into the body?” D. “How long ago did the incident occur?” Answer: C. “What direction did the bullet enter into the body?”The entry point and direction of the bullet will predict the involve injuries of the client.Options A, B, and D: The other information is not as useful in determining which diagnostic studies and care are needed immediately. 17. When attending a client with a head and neck trauma following a vehicular accident, the nurse’s initial action is to? A. Do oral and nasal suctioning. B. Provide oxygen therapy. C. Initiate intravenous access. D. Immobilize the cervical area.
Answer: D. Immobilize the cervical area.Clients with suspected or possible cervical spine injury must have their neck immobilized until formal assessment occurs.Options A, B, and C: Suctioning, oxygen therapy, and intravenous access are also done after the cervical spine is immobilize. 18. Nurse Ejay is assigned to a telephone triage. A client called who was stung by a honeybee and is asking for help. The
client reports of pain and localized swelling but has no respiratory distress or other symptoms of anaphylactic shock. What is the appropriate initial action that the nurse should direct the client to perform? A. Removing the stinger by scraping it. B. Applying a cold compress. C. Taking an oral antihistamine. D. Calling the 911. Answer: A. Removing the stinger by scraping it. Since the stinger will continue to release venom into the skin, removing the stinger should be the first action that the nurse should direct to the client. Options B and C: After removing the stinger, Antihistamine and cold compress follow. Option D: The caller should be further advised about symptoms that require 911 assistance. 19. A client arrives at the emergency department who suffered multiple injuries from a head-on car collision. Which of the following assessment should take the highest priority to take? A. Irregular pulse. B. Ecchymosis in the flank area. C. A deviated trachea. D. Unequal pupils. Answer: C. A deviated trachea.A deviated trachea is a symptom of tension pneumothorax, which will result in respiratory distress if left untreated. 20. Nurse Kelly, a triage nurse encountered a client who complaints of mid-sternal chest pain, dizziness, and diaphoresis. Which of the following nursing action should take priority? A. Complete history taking. B. Put the client on ECG monitoring. C. Notify the physician. D. Administer oxygen therapy via nasal cannula. Answer: D. Administer oxygen therapy via nasal cannula.The priority goal is to increase myocardial oxygenation.Options A, B, and C: These actions are also appropriate and should be performed immediately. 21. A group of people arrived at the emergency unit by a private car with complaints of periorbital swelling, cough, and tightness in the throat. There is a strong odor emanating from their clothes. They report exposure to a “gas bomb” that was set off in the house. What is the priority action? A. Direct the clients to the decontamination area. B. Direct the clients to the cold or clean zone for immediate treatment. C. Measure vital signs and auscultate lung sounds. D. Immediately remove other clients and visitors from the area. E. Instruct personnel to don personal protective equipment. Answer: A. Direct the clients to the decontamination area.Decontamination in a specified area is the priority.Option B: The clients must undergo decontamination before entering cold or clean areas. Options C and D: Performing assessments and moving others delays contamination and does not protect the total environment.
Option E: Personnel should don personal protective equipment before assisting with decontamination or assessing the clients. 22. When an unexpected death occurs in the emergency department, which task is the most appropriate to delegate to a nursing assistant? A. Help the family to collect belongings. B. Assisting with postmortem care. C. Facilitate meeting between the family and the organ donor specialist. D. Escorting the family to a place of privacy. Answer: B. Assisting with postmortem care.Postmortem care requires some turning, cleaning, lifting, and so on, and the nursing assistant is able to assist with these duties.
23. The physician has ordered cooling measures for a child with a fever who is likely to be discharged when the temperature comes down. Which task would be appropriate to delegate to a nursing assistant? A. Prepare and administer a tepid sponge bath. B. Explain the need for giving cool fluids. C. Assist the child in removing outer clothing. D. Advise the parent to use acetaminophen (Tylenol) instead of aspirin. Option A: Tepid baths are not usually given because of the possibility of shivering and rebound. Options B and D: Explaining and Advising are teaching functions that are a responsibility of the registered nurse. 24. You are preparing a child for IV conscious sedation before the repair of a facial laceration. What information should you report immediately to the physician? A. The parent wants information about the IV conscious sedation. B. The parent is not sure regarding the child’s tetanus immunization status. C. The child suddenly pulls out the IV. D. The parent’s refusal of the administration of the IV sedation. Answer: D. The parent’s refusal of the administration of the IV sedation.The refusal of the parents is an absolute contraindication; therefore the physician must be notified.Options A and C: The RN can reestablish the IV access and provide information about conscious sedation. Option B: Tetanus status can be addressed later. 25. The emergency medical service has transported a client with severe chest pain. As the client is being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and unpalpable pulse. Which of the following task is appropriate to delegate to the nursing assistant? A. Assisting with the intubation. B. Placing the defibrillator pads. C. Doing chest compressions. D. Initiating bag valve mask ventilation. C. Doing chest compressions. Performing chest compressions are within the training of a nurse assistant.Option A: The use of the bag valve mask requires practice, and usually a respiratory therapist will perform the function. Option B: The defibrillator pads are clearly marked; however placement should be done by the RN or physician because of the potential for skin damage and electrical arcing.
26. A client suffered an amputation of the first and second digits in a chainsaw accident. Which task should be delegated to an LPN/LVN? A. Cleansing the amputated digits and placing them directly into an ice slurry. B. Cleansing the digits with sterile normal saline and placing in a sterile cup with sterile normal saline. C. Gently cleansing the amputated digits and the hand with povidone-iodine. D. Wrapping the cleansed digits in saline-moistened gauze, sealing in a plastic container, and placing it in an ice. Answer: D. Wrapping the cleansed digits in saline-moistened gauze, sealing in a plastic container, and placing it in an ice. 27. A client arrives in the emergency unit and reports that a concentrated household cleaner was splashed in both eyes. Which of the following nursing actions is a priority? A. Use Restasis (Allergan) drops in the eye. B. Flush the eye repeatedly using sterile normal saline. C. Examine the client’s visual acuity. D. Patch the eye. Answer: B. Flush the eye repeatedly using sterile normal saline.Initial emergency action during a chemical splash to the eye includes immediate continuous irrigation of the affected eye with normal saline.
28. A client was brought to the emergency department after suffering a closed head injury and lacerations around the face due to a hit-run accident. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessment findings if observed after few hours, should be reported to the physician immediately? A. Bleeding around the lacerations. B. Withdrawal of the client in response to painful stimuli. C. Bruises and minimal edema of the eyelids. D. Drainage of a clear fluid from the client’s nose. Answer: D. Drainage of a clear fluid from the client’s nose.Clear drainage from the client’s nose indicates that there is a leakage of CSF and should be reported to the physician immediately.
28. A 5-year-old client was admitted to the emergency unit due to ingestion of unknown amount of chewable vitamins for children at an unknown time. Upon assessment, the child is alert and with no symptoms. Which of the following information should be reported to the physician immediately? A. The child has been treated multiple times for injuries caused by accidents. B. The vitamin that was ingested contains iron. C. The child was nauseated and vomited once at home. D. The child has been treated several times for toxic substance ingestion. Answer: B. The vitamin that was ingested contains iron.Iron is a toxic substance that can lead to massive hemorrhage, shock, coma, and kidney failure.Options A, C, and D: These information needs further investigation but will not change the immediate diagnostic testing or treatment plan. 29. The following clients come at the emergency department complaining of acute abdominal pain. Prioritize them for care in order of the severity of the conditions. 1. A 27-year-old woman complaining of lightheadedness and severe sharp left lower quadrant pain who reports she is possibly pregnant. 2. A 43-year-old woman with moderate right upper quadrant pain who has vomited small amounts of yellow bile and whose symptoms have worsened over the week.
3. A 15-year-old boy with a low-grade fever, right lower quadrant pain, vomiting, nausea, and loss of appetite for the past few days. 4. A 57-year-old woman who complains of a sore throat and gnawing midepigastric pain that is worse between meals and during the night. 5. A 59-year-old man with a pulsating abdominal mass and sudden onset of persistent abdominal or back pain, which can be described as a tearing sensation within the past hour. A. 2,5,3,4,1 B. 3,1,4,5,2 C. 5,1,3,2,4 D. 2,5,1,4,3 Answer: C. 5,1,3,2,4.The client with a pulsating mass has an abdominal aneurysm that may rupture and he may decompensate easily. The woman with lower left quadrant pain is at risk for a life-threatening ectopic pregnancy. The 15-year-old boy needs evaluation to rule out appendicitis. The woman with vomiting needs evaluation for gallbladder problems, which appear to be worsening. Lastly, the woman with mid epigastric pain is suffering from an ulcer, but follow-up diagnostic testing can be scheduled with a primary care provider.
30. The following clients are presented with signs and symptoms of heat-related illness. Which of them needs to be attended first? A. A relatively healthy homemaker who reports that the air conditioner has been broken for days and who manifest fatigue, hypotension, tachypnea, and profuse sweating. B. An elderly person who complains of dizziness and syncope after standing in the sun for several hours to view a parade. C. A homeless person who is a poor historian; has altered mental status, poor muscle coordination, and hot, dry ashen skin; and whose duration of heat exposure is unknown. D. A marathon runner who complains of severe leg cramps and nausea, and manifests weakness, pallor, diaphoresis, and tachycardia. Answer: C. A homeless person who is a poor historian; has altered mental status, poor muscle coordination, and hot, dry ashen skin; and whose duration of heat exposure is unknown.The signs and symptoms manifested by the homeless person indicate that a heat stroke is happening, a medical emergency, which can lead to brain damage.Option A: The homemaker is experiencing heat exhaustion, which can be managed by fluids and cooling measures.Option B: The elderly client is at risk for heat syncope and should be advised to rest in a cool area and avoid similar situations.Option D: The runner is experiencing heat cramps, which can be managed with fluid and rest. 31. An anxious female client complains of chest tightness, tingling sensations, and palpitations. Deep, rapid breathing, and carpal spasms are noted. Which of the following priority action should the nurse do first? A. Provide oxygen therapy. B. Notify the physician immediately. C. Administer anxiolytic medication as ordered. D. Have the client breathe into a brown paper bag. Answer: D. Have the client breathe into a brown paper bag.The client is suffering from hyperventilation secondary from anxiety, the initial action is to let the client breathe in a paper bag that will allow the rebreathing of carbon dioxide.
32. An intoxicated client comes into the emergency unit with an uncooperative behavior, mild confusion, and with slurred speech. The client is unable to provide a good history but he verbalizes that he has been drinking a lot. Which of the following is a priority action of the nurse? A. Administer IV fluid incorporated with Vitamin B1 as ordered. B. Administer Naloxone (Narcan) 4 mg as ordered.
C. Contact the family to get information of the client. D. Obtain an order for the determination of blood alcohol level. Answer: A. Administer IV fluid incorporated with Vitamin B1 as ordered.The client has symptoms of alcohol abuse and there is a risk for Wernicke syndrome, which is caused by a deficiency in Vitamin B. Option B: Multiple drug abuse is not uncommon; however, there is currently nothing to suggest an opiate overdose that requires the administration of naloxone. Options C and D: Additional information or the results of the blood alcohol testing are part of the management but should not delay the immediate treatment. 34. A nurse is providing discharge instruction to a woman who has been treated for contusions and bruises due to a domestic violence. What is the priority intervention for this client? A. Making a referral to a counselor. B. Making an appointment to follow up on the injuries. C. Advising the client about contacting the police. D. Arranging transportation to a safe house. Answer: D. Arranging transportation to a safe house.Safety is a priority for this client and she should not return to a place where violence could recur.
