C. Forensic nurse examiner

NURSIG NCLEX Emergency & Trauma

• 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?

• Emergency medicine physician
• Case manager
• Forensic nurse examiner

D. Psychiatric crisis nurse:

Answer C

~ 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.

• The emergency department team is performing cardiopulmonary resuscitation on a client

when the client's spouse arrives at the emergency department. Which action should the nurse take first?

• Request that the client's spouse sit in the waiting room.
• Ask the spouse if he wishes to be present during the resuscitation.
• Suggest that the spouse begin to pray for the client.

D. Refer the client's spouse to the hospitals crisis team.:

Answer 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 30-year-old distraught mother holding her crying child
• A 65-year-old conscious male with a head laceration
• 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

~ 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?

• Apply oxygen via nasal cannula.
• Administer intravenous 0.9% saline solution.
• Transfer the client to a negative-pressure room.

D. Obtain a sputum culture and sensitivity.:

Answer 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 & 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 22-year-old with a painful and swollen right wrist
• A 45-year-old reporting chest pain and diaphoresis
• A 60-year-old reporting difficulty swallowing and nausea
• An 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101 F:

Answer 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?

• Level I Located within remote areas and provides advanced life support within

resource capabilities

• Level II Located within community hospitals and provides care to most injured clients
• Level III Located in rural communities and provides only basic care to clients
• Level IV Located in large teaching hospitals and provides a full continuum of trauma

care for all clients:

Answer 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?

• Assess that the client is breathing adequately.
• Insert a large-bore intravenous line.
• Place the client on a cardiac monitor.

D. Assess for the best neurologic response.:

Answer 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?

• Contact the on-call orthopedic surgeon.
• Don personal protective equipment.
• Notify the Rapid Response Team.

D. Obtain a complete history from the paramedic.:

Answer 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.

• A nurse is triaging clients in the emergency department.Which client should be

considered urgent?

• A 20-year-old female with a chest stab wound and tachycardia
• A 45-year-old homeless man with a skin rash and sore throat
• 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 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.

• An emergency department nurse is caring for a client who has died from a suspected

homicide. Which action should the nurse take?

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

Answer D

~ When dealing with client's 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.

• An emergency department (ED) case manager is consulted for a client who is homeless.

Which intervention should the case manager provide?

• Communicate client needs and restrictions to support staff.
• Prescribe low-cost antibiotics to treat community-acquired infection.
• Provide referrals to subsidized community-based health clinics.

D. Offer counseling for substance abuse and mental health disorders.:

Answer C