EMERGENCY NURSING Comprehensive
Examination Questions With Answers| Latest
Update
The ED nurse is caring for a client diagnosed with multiple rib fractures. Which
data should the nurse include in the assessment?
1. Level of orientation to time and place.
2. Current use and last dose of medication.
3. Symmetrical movement of the chest.
4. Time of last meal the client ate.
3
1. Orientation to person, place, and time
should be assessed on all clients, but this
information will not provide specific
information about the chest trauma.
2. Current use of all medication and the last
doses should be assessed for all clients.
**3. When a client suffers from multiple rib
fractures, the client has an increased risk
for flail chest. The nurse should assess
the client for paradoxical chest wall
,movement and, if respiratory distress is
present, for pallor and cyanosis.**
4. The time of this last meal is important if
the client were to have surgery or intubation
planned. A nutritional assessment
should be performed on all clients.
The nurse is caring for a client in the ED with abdominal trauma who has had
peritoneal lavage. Which intervention should the nurse include in the plan of
care
1. Assess for the presence of blood, bile, or feces.
2. Palpate the client for bilateral femoral pulses.
3. Perform Leopold's maneuver every eight (8) hours.
4. Collect information on the client's dietary history.
1
**1. A diagnostic peritoneal lavage is performed
to assess the presence of blood,
bile, and feces from internal bleeding
induced by injury. If any of these are
present, surgery should be considered to
explore the extent of damage and repair
,of the injury.**
2. Palpating the client's peripheral pulses indicates
blood flow to the extremities. Femoral
pulses are not necessarily assessed if all
distal pulses are strong.
3. Leopold's maneuver is performed on
pregnant clients to assess the position
of the fetus.
4. Dietary history is information which is
assessed, but not in an emergency situation.
Assessments need to be efficient and direct
to eliminate any time-wasting activities.
The elderly client is brought to the ED complaining of cramps, headache, and
weakness after working outside in the sun. The telemetry shows sinus
tachycardia.
Which intervention should the nurse implement?
1. Determine if the client is experiencing any thirst.
2. Administer D5W intravenously at 250 mL/hr.
3. Maintain a cool environment to promote rest.
4. Withhold the client's oral intake.
3
, 1. Elderly clients lose the defense mechanism
of increased thirst with dehydration. This
does not accurately indicate fluid deficit.
2. An intravenous fluid should be administered,
but the solution should correct fluid
and electrolyte imbalances. D5W does not
replace electrolytes lost, and 250 mL/hr
could place the client at risk for heart failure
if the body cannot adjust rapidly to the
fluid replacement.
**3. The nurse should encourage the client
to rest and should maintain a cool environment
to assist the client to recover
from heat exhaustion. The elderly are
more susceptible to this condition.**
4. If the client can tolerate oral fluids, the
client should be encouraged to drink fluids
to replace electrolytes lost in excessive
sweating.
Examination Questions With Answers| Latest
Update
The ED nurse is caring for a client diagnosed with multiple rib fractures. Which
data should the nurse include in the assessment?
1. Level of orientation to time and place.
2. Current use and last dose of medication.
3. Symmetrical movement of the chest.
4. Time of last meal the client ate.
3
1. Orientation to person, place, and time
should be assessed on all clients, but this
information will not provide specific
information about the chest trauma.
2. Current use of all medication and the last
doses should be assessed for all clients.
**3. When a client suffers from multiple rib
fractures, the client has an increased risk
for flail chest. The nurse should assess
the client for paradoxical chest wall
,movement and, if respiratory distress is
present, for pallor and cyanosis.**
4. The time of this last meal is important if
the client were to have surgery or intubation
planned. A nutritional assessment
should be performed on all clients.
The nurse is caring for a client in the ED with abdominal trauma who has had
peritoneal lavage. Which intervention should the nurse include in the plan of
care
1. Assess for the presence of blood, bile, or feces.
2. Palpate the client for bilateral femoral pulses.
3. Perform Leopold's maneuver every eight (8) hours.
4. Collect information on the client's dietary history.
1
**1. A diagnostic peritoneal lavage is performed
to assess the presence of blood,
bile, and feces from internal bleeding
induced by injury. If any of these are
present, surgery should be considered to
explore the extent of damage and repair
,of the injury.**
2. Palpating the client's peripheral pulses indicates
blood flow to the extremities. Femoral
pulses are not necessarily assessed if all
distal pulses are strong.
3. Leopold's maneuver is performed on
pregnant clients to assess the position
of the fetus.
4. Dietary history is information which is
assessed, but not in an emergency situation.
Assessments need to be efficient and direct
to eliminate any time-wasting activities.
The elderly client is brought to the ED complaining of cramps, headache, and
weakness after working outside in the sun. The telemetry shows sinus
tachycardia.
Which intervention should the nurse implement?
1. Determine if the client is experiencing any thirst.
2. Administer D5W intravenously at 250 mL/hr.
3. Maintain a cool environment to promote rest.
4. Withhold the client's oral intake.
3
, 1. Elderly clients lose the defense mechanism
of increased thirst with dehydration. This
does not accurately indicate fluid deficit.
2. An intravenous fluid should be administered,
but the solution should correct fluid
and electrolyte imbalances. D5W does not
replace electrolytes lost, and 250 mL/hr
could place the client at risk for heart failure
if the body cannot adjust rapidly to the
fluid replacement.
**3. The nurse should encourage the client
to rest and should maintain a cool environment
to assist the client to recover
from heat exhaustion. The elderly are
more susceptible to this condition.**
4. If the client can tolerate oral fluids, the
client should be encouraged to drink fluids
to replace electrolytes lost in excessive
sweating.
