RATED ANSWERS
An ED nurse is caring for a client who has died from a suspected homicide. Which action should
the nurse take?
A. remove all tubes and wires in preparation for the medical examiner
B. limit the number of visitors to minimize the family's trauma
C. consult the bereavement committee to follow up with the grieving family
D. communicate the client's death to the family in a simple and concrete manner D
An ED case manager is consulted for a client who is homeless. Which intervention should the
case manager provide?
A. communicate client needs and restrictions to support staff
B. prescribe low-cost antibiotics to treat community-acquired infection
C. provide referrals to subsidized community-based health clinics
D. offer counseling for substance abuse and mental health disorders C
An ED nurse is caring for a client who is homeless. Which action should the nurse take to gain
the client's trust?
A. speak in a quiet and monotone voice.
B. avoid eye contact with the client
C. listen to the client's concerns and needs
D. ask security to store the client's belongings C
,A nurse is triaging clients in the ED. Which client should the nurse classify as nonurgent?
A. 44 year old with chest pain and diaphoresis
B. 50 year old with chest trauma and absent breath sounds
C. 62 year old with a simple fracture of the left arm
D. 79 year old with a temperature of 104* F C
A nurse is caring for clients in a busy ED. Which actions should the nurse take to ensure client
and staff safety? (SATA)
A. leave the stretcher in the lowest position with rails down so that the client can access the
bathroom
B. use 2 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 B, C, D
An ED nurse is preparing to transfer a client to the trauma ICU. Which information should the
nurse include in the nurse-to-nurse hand-off report? (SATA)
A. mechanism of injury
B. diagnostic test results
C. immunizations
,D. list of home medications
E. isolation precautions A, B, E
An ED nurse is caring for a trauma client. Which interventions should the nurse perform during
the primary survey? (SATA)
A. foley cath
B. needle decompression
C. initiating IV fluids
D. splinting open fractures
E. endotracheal intubation
F. removing wet clothing
G. laceration repair B, C, E, F
The complex care provided during an emergency requires interdisciplinary collaboration. Which
interdisciplinary team members are paired with the correct responsibilities? (Select all that
apply.)
a. Psychiatric crisis nurse - Interacts with clients and families when sudden illness, serious
injury, or death of a loved one may cause a crisis
b. Forensic nurse examiner - Performs rapid assessments to ensure clients with the highest
acuity receive the quickest evaluation, treatment, and prioritization of resources
c. Triage nurse - Provides basic life support interventions such as oxygen, basic wound care,
splinting, spinal immobilization, and monitoring of vital signs
, d. Emergency medical technician - Obtains client histories, collects evidence, and offers
counseling and follow-up care for victims of rape, child abuse, and domestic violence
e. Paramedic - Provides prehospital advanced life support, including cardiac mon A, E
A nurse prepares to discharge an older adult client home from the ED. Which actions should the
nurse take to prevent future ED visits? (SATA)
A. provide medical supplies to the family
B. consult a home health agency
C. encourage participation in community activities
D. screen for depression and suicide
E. complete a functional assessment D, E
Total Body Surface Area - Rule of nine Front of head - 4 1/2 %
Back of head - 4 1/2 %
Front of Torso - 18%
Back of Torso - 18%
Genitals - 1%
Front of arms - 4 1/2%
Back of arms - 4 1/2%
Front of legs - 9%
Back of legs - 9%