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A patient is brought to the hospital in cardiac arrest by emergency personnel who are performing
resuscitation. The spouse arrives as the patient is taken into a treatment room and asks to stay with the
patient. The nurse should
a. have the spouse wait outside the treatment room with a designated staff member to provide
emotional support.
b. bring the spouse into the room and ensure him or her that a member of the team will explain the care
given and answer questions.
c. explain that the presence of family members is distracting to staff and might impair the resuscitation
efforts.
d. advise the spouse that if the resuscitation effort is unsuccessful, the memories may have an adverse
impact on grieving. - CORRECT ANSWER-Correct Answer: B
Rationale: Family members and patients report benefits from family presence during resuscitation
efforts, so the nurse should try to accommodate the spouse. Having the spouse wait outside the room is
not as supportive to the spouse or patient. It would be inappropriate to imply that the spouse's
presence would have adverse consequences for the patient. Family members do not report problems
with grieving caused by being present during resuscitation efforts.
, Four victims of an automobile crash are brought by ambulance to the emergency department. The
triage nurse determines that the victim who has the highest priority for treatment is the one with
a. severe bleeding of facial and head lacerations.
b. an open femur fracture with profuse bleeding.
c. a sucking chest wound.
d. absence of peripheral pulses. - CORRECT ANSWER-Correct Answer: C
Rationale: Most immediate deaths from trauma occur because of problems with ventilation, so the
patient with a sucking chest wound should be treated first. Face and head fractures can obstruct the
airway, but the patient with facial injuries has lacerations only. The other two patients also need rapid
intervention but do not have airway or breathing problems.
A triage nurse in a busy emergency department assesses a patient who complains of 6/10 abdominal
pain and states, "I had a temperature of 104.6º F (40.3º C) at home." The nurse's first action should be
to
a. tell the patient that it may be several hours before being seen by the doctor.
b. assess the patient's current vital signs.
c. obtain a clean-catch urine for urinalysis.
d. ask the health care provider to order a nonopioid analgesic medication for the patient. -
CORRECT ANSWER-Correct Answer: B
Rationale: The patient's pain and statement about an elevated temperature indicate that the nurse
should obtain vital signs before deciding how rapidly the patient should be seen by the health care
provider. A urinalysis may be needed, but vital signs will provide the nurse with more useful data for
triage. The health care provider will not order a medication before assessing the patient.
During the primary assessment of a trauma victim, the nurse determines that the patient has a patent
airway. The next assessment by the nurse should be to
a. check the patient's level of consciousness.
b. examine the patient for any external bleeding.
c. observe the patient's respiratory effort.
d. palpate for the presence of peripheral pulses. - CORRECT ANSWER-Correct Answer: C
Rationale: Even with a patent airway, patients can have other problems that compromise ventilation, so
the next action is to assess the patient's breathing. The other actions are also part of the initial survey
but are not accomplished as rapidly as the assessment of breathing.