Chapter 10, 11, 12 Iggy's Latest Edition
Test Bank Guaranteed Success.
Which client does the oncoming ED nurse see first when assigned to care for four clients?
A) 21-year-old with a skin rash who has been waiting two hours to see a provider
B) 30-year-old with influenza who has infusing IV fluids and is resting quietly
C) 47-year-old who fell off of a curb resulting in a sprained ankle
D) 56-year-old reporting chest pain and diaphoresis that started 30 minutes prior - Answer D
This client should be seen first since he or she has an emergent condition that could result in
poor outcomes if not treated soon.
What mechanism of injury will the nurse document for a client in a motor vehicle accident
whose airbag deployed when the car struck a tree at 40 miles per hour?
Select all that apply.
A) Blast
B) Blunt
C) Laceration
D) Penetration
E) Acceleration-deceleration - Answer B - E
Blunt trauma has been sustained from the airbag deployment. Acceleration-deceleration
trauma has been sustained from the car striking the tree.
Upon entry to the ED of a client who fell from a roof, what is the nurse's priority action?
A) Place nasal cannula to administer oxygen.
B) Apply pressure to small bleeding wounds.
C) Assess airway and stabilize cervical spine.
, After assessing four clients, which will the triage nurse identify to be seen first in the ED?
A) Client with fever of 101.2F
B) Client who reports slurred speech
C) Client who reports bilateral ear pain
D) Client with urinary burning and frequency - Answer B
According to the three-tiered triage system, clients who present to the ED with the highest
acuity needs receive the quickest evaluation; treatment; and prioritized resource utilization. The
client who reports slurred speech is at the greatest risk for an adverse outcome if he or she is
not seen quickly; therefore, this client would be seen first, followed by the client with fever, and
then the clients with ear pain, and urinary burning and frequency.
What is the nurse's priority action for the unconscious patient who is breathing who has been
brought to the ED?
A) Assess breath sounds and respiratory efforts
B) Establish vascular access with a large-bore catheter
C) Remove clothing to perform a complete physical assessment
D) Evaluate level of consciousness (LOC) using the Glascow Coma Sale (GCS) - Answer A
The highest priority action for an unconscious client who is breathing should follow the ABCDE
acronym. It has been established that the client has an airway ("A"); the next priority is to assess
breathing ("B"). The nurse then will establish vascular access ("C"), evaluate LOC ("D"), and
perform a complete physical assessment ("E")
For which client will the nurse choose to perform SBIRT?
A) Client who continues to use alcohol
B) Client with recurrent asthma admissions
C) Client with infection who did not complete antibiotic therapy
D) Client with a sports injury reporting extreme pain - Answer A
Test Bank Guaranteed Success.
Which client does the oncoming ED nurse see first when assigned to care for four clients?
A) 21-year-old with a skin rash who has been waiting two hours to see a provider
B) 30-year-old with influenza who has infusing IV fluids and is resting quietly
C) 47-year-old who fell off of a curb resulting in a sprained ankle
D) 56-year-old reporting chest pain and diaphoresis that started 30 minutes prior - Answer D
This client should be seen first since he or she has an emergent condition that could result in
poor outcomes if not treated soon.
What mechanism of injury will the nurse document for a client in a motor vehicle accident
whose airbag deployed when the car struck a tree at 40 miles per hour?
Select all that apply.
A) Blast
B) Blunt
C) Laceration
D) Penetration
E) Acceleration-deceleration - Answer B - E
Blunt trauma has been sustained from the airbag deployment. Acceleration-deceleration
trauma has been sustained from the car striking the tree.
Upon entry to the ED of a client who fell from a roof, what is the nurse's priority action?
A) Place nasal cannula to administer oxygen.
B) Apply pressure to small bleeding wounds.
C) Assess airway and stabilize cervical spine.
, After assessing four clients, which will the triage nurse identify to be seen first in the ED?
A) Client with fever of 101.2F
B) Client who reports slurred speech
C) Client who reports bilateral ear pain
D) Client with urinary burning and frequency - Answer B
According to the three-tiered triage system, clients who present to the ED with the highest
acuity needs receive the quickest evaluation; treatment; and prioritized resource utilization. The
client who reports slurred speech is at the greatest risk for an adverse outcome if he or she is
not seen quickly; therefore, this client would be seen first, followed by the client with fever, and
then the clients with ear pain, and urinary burning and frequency.
What is the nurse's priority action for the unconscious patient who is breathing who has been
brought to the ED?
A) Assess breath sounds and respiratory efforts
B) Establish vascular access with a large-bore catheter
C) Remove clothing to perform a complete physical assessment
D) Evaluate level of consciousness (LOC) using the Glascow Coma Sale (GCS) - Answer A
The highest priority action for an unconscious client who is breathing should follow the ABCDE
acronym. It has been established that the client has an airway ("A"); the next priority is to assess
breathing ("B"). The nurse then will establish vascular access ("C"), evaluate LOC ("D"), and
perform a complete physical assessment ("E")
For which client will the nurse choose to perform SBIRT?
A) Client who continues to use alcohol
B) Client with recurrent asthma admissions
C) Client with infection who did not complete antibiotic therapy
D) Client with a sports injury reporting extreme pain - Answer A
