Nokea
A nurse is caring for clients in a busy emergency department. Which actions should the nurse take to ensure client and staff safety? (Select all that apply.)
- A. Leave the stretcher in the lowest position with rails down so that the client can access the bathroom.
- B. Use two identifiers before each intervention and before medication administration.
- C. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors.
- D. Place clients with infectious diseases in isolation rooms.
- E. Ensure all sharps are disposed of in puncture-resistant containers.
Correct Answer: B,C,D,E
Rationale: Leaving the stretcher with rails down poses a fall risk, so it is incorrect. Using two identifiers ensures correct patient identification, de-escalation promotes safety with aggressive clients, isolation prevents disease spread, and proper sharps disposal reduces injury risk.
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An emergency room nurse assesses a client who has been raped. With which health care team member should the nurse collaborate, when planning this clients care?
- A. Emergency medicine physician
- B. Case manager
- C. Forensic nurse examiner
- D. Psychiatric crisis nurse
Correct Answer: C
Rationale: The forensic nurse examiner is educated to obtain client histories, collect evidence related to the assault, and provide counseling and follow-up care, making them the most appropriate team member for this situation.
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.
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.
A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action should the nurse take prior to providing advanced cardiac life support?
- A. Consult the or medical orthopedic surgeon.
- B. Does personal protective equipment.
- C. Notify the Rapid Response Team.
- D. Obtain a complete history from the paramedic.
Correct Answer: B
Rationale: Wearing personal protective equipment is critical to prevent contamination from blood and body fluids during emergency resuscitation.
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.