Emergency Room NCLEX q's. Trusted Study Materials for All Testing Exams

ANS: B Older adults who are confused are at increased risks for falls. Fall prevention includes measures such as siderails up, reorientation, call light in reach, and, in some cases, asking the family member, significant other, or sitter to stay with the client to prevent falls. An emergency department nurse is transferring a client to the medical-surgical unit. What is the most important nursing intervention in this situation? a. Triage the client to determine the urgency of care. b. Clearly communicate client data to the unit nurse. c. Evaluate the need for ongoing medical treatment. d. Perform a thorough assessment of the client. ANS: B The emergency nurse needs to be able to triage, assess, and evaluate. However, these steps have already been carried out in the early phases of the emergency department (ED) admission. When a client is ready to be transferred from the ED, communication with staff nurses from the inpatient units is essential. This report should be a concise but comprehensive report of the client's ED experience. The nurse manager is assessing current demographics of the facility's emergency department (ED) clients. Which population would most likely present to the ED for treatment of a temperature and a sore throat? a. Older adults b. Immunocompromised people c. Pediatric clients d. Underinsured people ANS: D The ED serves as an important safety net for clients who are ill or injured but lack access to basic health care. Especially vulnerable populations include the underinsured and the uninsured, who may have nowhere else to go for health care. The emergency department (ED) nurse is caring for the following clients. Which client does the nurse prioritize to see first? a. 22-year-old with a painful and swollen right wrist b. 45-year-old reporting chest pain and diaphoresis c. 60-year-old reporting difficulty swallowing and nausea d. 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101° F ANS: B A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable. A nurse is triaging clients in the emergency department. Which client complaint would the triage nurse classify as nonurgent? a. Chest pain and diaphoresis b. Decreased breath sounds due to chest trauma c. Left arm fracture with palpable radial pulses d. Sore throat and a temperature of 104° F ANS: C A client in a nonurgent category can tolerate waiting several hours for health care