Nursing NUR408 Exam 4 – SATA (Select All That Apply) Practice Questions and Answers Study
Guide
B, C, D
To ensure client and staff safety, nurses should use two identifiers per The Joint Commissions
National Patient Safety Goals; follow the hospitals security plan, including de-escalation
strategies for people who demonstrate aggressive or violent tendencies; and search belongings
to identify essential medical information. Nurses should also use standard fall prevention
interventions, including leaving stretchers in the lowest position with rails up, and isolating
clients who present with signs and symptoms of contagious infectious disorders. - ✔✔A nurse
is caring for clients in a busy emergency department. Which actions should the nurse take to
ensure client and staff safety? (Select all that apply.)
a. Leave the stretcher in the lowest position with rails down so that the client can access the
bathroom.
b. Use two identifiers before each intervention and before mediation administration.
c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors.
d. Search the belongings of clients with altered mental status to gain essential medical
information.
e. Isolate clients who have immune suppression disorders to prevent hospital-acquired
infections.
A, B, E
Hand-off communication should be comprehensive so that the receiving nurse can continue
care for the client fluidly. Communication should be concise and should include only the most
essential information for a safe transition in care. Hand-off communication should include the
clients situation (reason for being in the ED), brief medical history, assessment and diagnostic
findings, Transmission-Based Precautions needed, interventions provided, and response to
those interventions - ✔✔An emergency department (ED) nurse is preparing to transfer a client
, to the trauma intensive care unit. Which information should the nurse include in the nurse-to-
nurse hand-off report? (Select all that apply.)
a. Mechanism of injury
b. Diagnostic test results
c. Immunizations
d. List of home medications
e. Isolation precautions
B, C, E, F
The primary survey for a trauma client organizes the approach to the client so that life-
threatening injuries are rapidly identified and managed. The primary survey is based on the
standard mnemonic ABC, with an added D and E: Airway and cervical spine control; Breathing;
Circulation; Disability; and Exposure. After the completion of primary diagnostic and laboratory
studies, and the insertion of gastric and urinary tubes, the secondary survey (a complete head-
to-toe assessment) can be carried out. - ✔✔An emergency room nurse is caring for a trauma
client. Which interventions should the nurse perform during the primary survey? (Select all that
apply.)
a. Foley catheterization
b. Needle decompression
c. Initiating IV fluids
d. Splinting open fractures
e. Endotracheal intubation
f. Removing wet clothing
g. Laceration repair
A, E
Guide
B, C, D
To ensure client and staff safety, nurses should use two identifiers per The Joint Commissions
National Patient Safety Goals; follow the hospitals security plan, including de-escalation
strategies for people who demonstrate aggressive or violent tendencies; and search belongings
to identify essential medical information. Nurses should also use standard fall prevention
interventions, including leaving stretchers in the lowest position with rails up, and isolating
clients who present with signs and symptoms of contagious infectious disorders. - ✔✔A nurse
is caring for clients in a busy emergency department. Which actions should the nurse take to
ensure client and staff safety? (Select all that apply.)
a. Leave the stretcher in the lowest position with rails down so that the client can access the
bathroom.
b. Use two identifiers before each intervention and before mediation administration.
c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors.
d. Search the belongings of clients with altered mental status to gain essential medical
information.
e. Isolate clients who have immune suppression disorders to prevent hospital-acquired
infections.
A, B, E
Hand-off communication should be comprehensive so that the receiving nurse can continue
care for the client fluidly. Communication should be concise and should include only the most
essential information for a safe transition in care. Hand-off communication should include the
clients situation (reason for being in the ED), brief medical history, assessment and diagnostic
findings, Transmission-Based Precautions needed, interventions provided, and response to
those interventions - ✔✔An emergency department (ED) nurse is preparing to transfer a client
, to the trauma intensive care unit. Which information should the nurse include in the nurse-to-
nurse hand-off report? (Select all that apply.)
a. Mechanism of injury
b. Diagnostic test results
c. Immunizations
d. List of home medications
e. Isolation precautions
B, C, E, F
The primary survey for a trauma client organizes the approach to the client so that life-
threatening injuries are rapidly identified and managed. The primary survey is based on the
standard mnemonic ABC, with an added D and E: Airway and cervical spine control; Breathing;
Circulation; Disability; and Exposure. After the completion of primary diagnostic and laboratory
studies, and the insertion of gastric and urinary tubes, the secondary survey (a complete head-
to-toe assessment) can be carried out. - ✔✔An emergency room nurse is caring for a trauma
client. Which interventions should the nurse perform during the primary survey? (Select all that
apply.)
a. Foley catheterization
b. Needle decompression
c. Initiating IV fluids
d. Splinting open fractures
e. Endotracheal intubation
f. Removing wet clothing
g. Laceration repair
A, E
