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The emergency department team is performing cardiopulmonary resuscitation on a client when the clients spouse arrives at the emergency department. Which action should the nurse take first?
- A. Request that the clients spouse ask in the waiting room.
- B. Ask the spouse if he wishes to be present during the resuscitation.
- C. Suggest that the spouse begin to pray for the client.
- D. Suggest that the spouse begin to pray for the client.
Correct Answer: B
Rationale: Allowing the spouse to be present during resuscitation respects their need for closure and emotional support, making it the priority action.
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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.
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.
A nurse in evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center?
- A. Level I Located within remote areas and provides advanced life support within resource capabilities
- B. Level II Located within remote areas and provides advanced life support within resource capabilities
- C. Level III Located in rural communities and provides only basic care to clients
- D. Level IV Located in large trauma hospitals and provides a full continuum of trauma care for all clients
Correct Answer: B
Rationale: Level II trauma centers provide advanced life support and transfer clients to Level I centers when needed, unlike Level I, which are in large hospitals, or Level IV, which provide basic care in rural areas.
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 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.