Emergency Nursing Practice Exam Latest Update

Emergency Nursing Practice 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: 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: 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: 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. During the primary assessment of a patient with multiple trauma, the nurse observes that the patient's right pedal pulses are absent and the leg is swollen. The nurse's first action should be to a. initiate isotonic fluid infusion through two large-bore IV lines. b. send blood to the lab for a complete blood count (CBC). c. finish the airway, breathing, circulation, disability survey. d. assess further for a cause of the decreased circulation. - Correct Answer: A