Nokea
A nurse in triaging clients in the emergency department (ED). Which client should the nurse prioritize to receive care first.
- A. A 22-year-old with a painful and swollen right wrist
- B. A 45-year-old reporting chest pain and diaphoresis
- C. A 45-year-old with a pain and a 28 breaths/min and a temperature of 101 F
- D. An 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101 F
Correct Answer: B
Rationale: Chest pain and diaphoresis suggest a potential cardiac emergency, which is life-threatening and requires immediate attention.
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An emergency department nurse is caring for a client who has died from a suspected homicide. Which action should the nurse take?
- A. Knows all tubes and wires in preparation for the medical examiner.
- B. Listens the number of people in the client's family trauma.
- C. Consult the bereavement committee to follow up with the grieving family.
- D. Communicate the clients death to the family in a simple and concrete manner.
Correct Answer: D
Rationale: Clear and simple communication minimizes confusion during a crisis, making it the priority action when informing the family of the client's death.
Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action should the nurse take first?
- A. Assess that the client is breathing adequately.
- B. Insert a large-bore intravenous line.
- C. Place the client rate in a cardiac monitor.
- D. Assess for the best neurologic response.
Correct Answer: A
Rationale: Ensuring adequate breathing is the highest priority in the primary survey, as it directly impacts survival.
While staging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of a tuberculosis. Which action should the nurse take first?
- A. Apply oxygen via nasal cannula.
- B. Administer intravenous 0.5% saline solution.
- C. Transfer the client to a negative-pressure room.
- D. Obtain a sputum culture and sensitivity.
Correct Answer: C
Rationale: Placing the client in a negative-pressure room prevents the spread of airborne pathogens like tuberculosis, prioritizing staff and patient safety.
An emergency department (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.
Correct Answer: C
Rationale: Providing referrals to subsidized clinics addresses the client's ongoing healthcare needs, which is within the case manager's role.
A nurse is triaging clients in the emergency department. Which client should be considered urgent?
- A. A 20-year-old female with a chest stab wound and tachycardia
- B. A 20-year-old female with a chest stab wound and tachycardia
- C. A 70-year-old female with a cough and a temperature of 102 F
- D. A 50-year-old male with chest pain, confusion, and slurred speech.
Correct Answer: C
Rationale: A cough and fever of 102 F indicate a risk of deterioration, making this client urgent, though clients with stab wounds or neurological symptoms are emergent.