RN Introduction to Critical Care and
Emergency Nursing Assessment
A newly licensed nurse working in the ED is learning about the Emergency Medical Treatment and Active
Labor Act. During a current disaster, the ED is transferring some patients to another facility prior to the
patients being stabilized. Which statement by the nurse manager explains this to the newly licensed
nurse? - Answer --A provision of EMTALA permits the transfer of patients before they are completely
stabilized.
An ED nurse is reporting on a patient who is being transferred to ICU. Which of the following sets of
people are responsible for the transfer report? - Answer --The ED nurse and the ICU nurse
A nurse is caring for a patient admitted to the ED following an injury. The nurse demonstrates concern
and involves the patient's family in decision making. Which of the following outcomes is the nurse's
primary goal from this interaction? - Answer --Creating a trusting relationship
A nurse is caring for a patient who was admitted to the ED by ambulance. the patients BP is 110/62, HR
is 100 bpm, and Resp is 28/min. Which of the following represents how the nurse should perform the
"D" portion of the ABCDE assessment? - Answer --The nurse should check alertness and response to
voice and pain
A nurse is caring for a group of patients in the ED who were exposed to a chemical spill at their work. A
student nurse asks the charge nurse where to find the info about safety regarding the chemical spill.
Where should the charge nurse instruct the student nurse to find more info about a chemical spill in the
workplace? - Answer --Look up the Safety Data Sheets (SDS0 on the hospital WiFi network.
, A newly licensed nurse is providing care to a patient admitted to the ED who is experiencing heroin
toxicity. The patient becomes violent and strikes the nurse. The nurse speaks with the manager about
violence in the ED. Which of the following statements represents how the nurse manager should
respond to the nurse? - Answer --Patients may fear the possible outcome of their clinical situation,
leading to stress
A nurse is caring for a 30 year old patient who experience sexual assault 2 days ago. Which of the
following is the most important to ask the patient? - Answer --Do you know if you were exposed to HIV
A preceptor in CCU is orienting a new nurse to the code chart. The preceptor communicates to the new
nurse that the code charts should be checked at which of the following intervals? - Answer --Every 24
hours
A triage nurse is evaluating a patient who reports taking anticoagulation medication and arrived at the
ED with bleeding from both nares, which slowed after applying direct pressure to the nose. Which of the
following Emergency Severity Index (ESI) levels should the nurse assign to this patient? - Answer --ESI
level 2
A nurse in the ED is triaging a patient who is accompanied by an individual that refuses to leave the
patient alone with the nurse. While assessing the patient, the nurse notes an unusual tattoo on the
patients inner thigh, as well as multiple bruises near the groin and lower abdomen. the nurse should
consider that the client may need further evaluation for which of the following? - Answer --Potential
human trafficking
A nurse is triaging patients in the ED using the three-tiered triaging system. Which of the following
patients should the nurse place in the delayed category? - Answer --A patient is reporting generalized
abdominal pain, nausea, vomiting, and diarrhea for 3 days. Findings indicate the VS are stable and the
patient has no comorbidities and is taking no medications.
A nurse is caring for a patient in the ED who will most likely not survive. The patients family member
asks for an update. Which of the following is the best response by the nurse? - Answer --Work with the
provider to frequently update the family on the status of the patient in a compassionate way.
Emergency Nursing Assessment
A newly licensed nurse working in the ED is learning about the Emergency Medical Treatment and Active
Labor Act. During a current disaster, the ED is transferring some patients to another facility prior to the
patients being stabilized. Which statement by the nurse manager explains this to the newly licensed
nurse? - Answer --A provision of EMTALA permits the transfer of patients before they are completely
stabilized.
An ED nurse is reporting on a patient who is being transferred to ICU. Which of the following sets of
people are responsible for the transfer report? - Answer --The ED nurse and the ICU nurse
A nurse is caring for a patient admitted to the ED following an injury. The nurse demonstrates concern
and involves the patient's family in decision making. Which of the following outcomes is the nurse's
primary goal from this interaction? - Answer --Creating a trusting relationship
A nurse is caring for a patient who was admitted to the ED by ambulance. the patients BP is 110/62, HR
is 100 bpm, and Resp is 28/min. Which of the following represents how the nurse should perform the
"D" portion of the ABCDE assessment? - Answer --The nurse should check alertness and response to
voice and pain
A nurse is caring for a group of patients in the ED who were exposed to a chemical spill at their work. A
student nurse asks the charge nurse where to find the info about safety regarding the chemical spill.
Where should the charge nurse instruct the student nurse to find more info about a chemical spill in the
workplace? - Answer --Look up the Safety Data Sheets (SDS0 on the hospital WiFi network.
, A newly licensed nurse is providing care to a patient admitted to the ED who is experiencing heroin
toxicity. The patient becomes violent and strikes the nurse. The nurse speaks with the manager about
violence in the ED. Which of the following statements represents how the nurse manager should
respond to the nurse? - Answer --Patients may fear the possible outcome of their clinical situation,
leading to stress
A nurse is caring for a 30 year old patient who experience sexual assault 2 days ago. Which of the
following is the most important to ask the patient? - Answer --Do you know if you were exposed to HIV
A preceptor in CCU is orienting a new nurse to the code chart. The preceptor communicates to the new
nurse that the code charts should be checked at which of the following intervals? - Answer --Every 24
hours
A triage nurse is evaluating a patient who reports taking anticoagulation medication and arrived at the
ED with bleeding from both nares, which slowed after applying direct pressure to the nose. Which of the
following Emergency Severity Index (ESI) levels should the nurse assign to this patient? - Answer --ESI
level 2
A nurse in the ED is triaging a patient who is accompanied by an individual that refuses to leave the
patient alone with the nurse. While assessing the patient, the nurse notes an unusual tattoo on the
patients inner thigh, as well as multiple bruises near the groin and lower abdomen. the nurse should
consider that the client may need further evaluation for which of the following? - Answer --Potential
human trafficking
A nurse is triaging patients in the ED using the three-tiered triaging system. Which of the following
patients should the nurse place in the delayed category? - Answer --A patient is reporting generalized
abdominal pain, nausea, vomiting, and diarrhea for 3 days. Findings indicate the VS are stable and the
patient has no comorbidities and is taking no medications.
A nurse is caring for a patient in the ED who will most likely not survive. The patients family member
asks for an update. Which of the following is the best response by the nurse? - Answer --Work with the
provider to frequently update the family on the status of the patient in a compassionate way.
