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NUR 213 ( LATEST 2024 / 2025 ) TEST 4 CH.2 | GRADED A+ SOLVED 100% CORRECT
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NUR 213 ( LATEST 2024 / 2025 ) TEST 4 CH.2 | GRADED A+ SOLVED 100% CORRECT
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NUR 213 Test 4 Ch.21. An emergency room nurse assesses a client who has been raped. With which health care
team member should the nurse collaborate when planning this client's care?
a. Emergency medicine physician
b. Case manager
c. Forensic nurse examiner
d. Psychiatric crisis nurse
Answer
c. Forensic nurse examiner
All other members of the health care team listed may be used in the management of this client's
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.
2. The emergency department team is performing cardiopulmonary resuscita- tion on a client
when the client's spouse arrives at the emergency department. Which action should the nurse take
first?
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.
Answer
b. Ask the spouse if he wishes to be present during the resuscitation.
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.
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
Answer
c. A 26-year-old male who has pale, cool, clammy skin
The client with pale, cool, clammy skin is in shock and needs immediate medical attention. The
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,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.
4. While triaging clients in a crowded emergency department, a nurse as- sesses 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
c. Transfer the client to a nega- tive-pressure room.
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.
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
Answer
b. A 45-year-old reporting chest pain and diaphoresis
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.
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
Answer
b. Level II - Located within community hospitals and provides care to most injured clients
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
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,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.
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.
Answer
a. Assess that the client is breathing adequately.
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.
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.
Answer
b. Don personal protective equipment.
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.
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
Answer
c. A 75-year-old female with a cough and a temperature of 102° F
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, 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.
10. An emergency department nurse is caring for a client who has died from a suspected
homicide. Which action should the nurse take?
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.
Answer
d. Communicate the client's death to the family in a simple and concrete manner.
When dealing with clients and families in crisis, communicate in a simple and concrete manner
to minimize confusion. Tubes must remain in place for the medical examiner. Family should be
allowed to view the body. Offering to call for additional family support during the crisis is
suggested. The bereavement committee should be consulted, but this is not the priority at this
time.
11. An emergency department (ED) case manager is consulted for a client who is homeless.
Which intervention should the case manager provide?
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.
Answer
c. Pro- vide referrals to subsidized community-based health clinics.
Case management interventions include facilitating referrals to primary care providers who are
accepting new clients or to subsidized community-based health clinics for clients or families in
need of routine services. The ED nurse is accountable for communicating pertinent staff
considerations, client needs, and restrictions to support staff (e.g., physical limitations, isolation
precautions) to ensure that ongoing client and staff safety issues are addressed. The ED
physician prescribes medica- tions and treatments. The psychiatric nurse team evaluates clients
with emotional behaviors or mental illness and facilitates the follow-up treatment plan,
including possible admission to an appropriate psychiatric facility.
12. An emergency department nurse is caring for a client who is homeless. Which action
should the nurse take to gain the client's trust?
a. Speak in a quiet and monotone voice.
b. Avoid eye contact with the client.
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