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The nurse is caring for a client in the ED with abdominal trauma who has had peritoneal lavage. Which intervention should the nurse include in the plan of care?
- A. Assess for the presence of blood, bile, or feces.
- B. Palpate the client for bilateral femoral pulses.
- C. Perform Leopold’s maneuver every eight (8) hours.
- D. Collect information on the client’s dietary history.
Correct Answer: A
Rationale: Peritoneal lavage detects blood, bile, or feces, indicating internal injury. Femoral pulses, Leopold’s maneuver (pregnancy), and diet history are irrelevant.
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Which intervention is the most important for the intensive care unit nurse to implement when performing mouth-to-mouth resuscitation on a client who has pulseless ventricular fibrillation?
- A. Perform the jaw thrust maneuver to open the airway.
- B. Use the mouth to cover the client’s mouth and nose.
- C. Insert an oral airway prior to performing mouth to mouth.
- D. Use a pocket mouth shield to cover the client’s mouth.
Correct Answer: A
Rationale: The jaw thrust opens the airway without neck manipulation, critical in suspected trauma or codes. Covering mouth and nose, oral airways, and shields are secondary or less safe.
The ED nurse is caring for a female client with a greenstick fracture of the left forearm and multiple contusions on the face, arms, trunk, and legs. The significant other is in the treatment area with the client. Which nursing interventions should the nurse implement? List in order of priority.
- A. Determine if the client has a plan for safety.
- B. Assess the pulse, temperature, and capillary refill of the left wrist and hand.
- C. Ask the client if she feels safe in her own home.
- D. Request the significant other wait in the waiting room during the examination.
- E. Notify the social worker to consult on the case.
Correct Answer: D,C,A,B,E
Rationale: 1) Request significant other to wait (ensures private assessment); 2) Ask about safety (screens for abuse); 3) Plan for safety (addresses immediate risk); 4) Assess limb (ensures circulation); 5) Notify social worker (coordinates support).
The ED nurse is working triage. Which client should be triaged first?
- A. A client who has multiple injuries from a motor-vehicle accident.
- B. A client complaining of epigastric pain and nausea after eating.
- C. An elderly client who fell and fractured the left femoral neck.
- D. The client suffering from a migraine headache and nausea.
Correct Answer: A
Rationale: Multiple trauma from an MVA suggests life-threatening injuries, requiring immediate triage. Epigastric pain, fractures, and migraines are less urgent.
The ED nurse is caring for the client who has taken an overdose of cocaine. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Evaluate the airway and breathing.
- B. Monitor the rate of intravenous fluids.
- C. Place the cardiac monitor on the client.
- D. Transfer the client to the intensive care unit.
Correct Answer: C
Rationale: Placing a cardiac monitor is a technical task delegable to UAPs. Airway evaluation, IV monitoring, and transfers require nursing judgment.
The ED receives a client involved in a motor-vehicle accident. The nurse notes a large hematoma on the right flank. Which intervention should the nurse implement first?
- A. Insert an indwelling urinary catheter.
- B. Take the vital signs every 15 minutes.
- C. Monitor the skin turgor every hour.
- D. Mark the edges of the bruised area.
Correct Answer: B
Rationale: Frequent vital signs assess for hypovolemia from potential internal bleeding (flank hematoma suggests renal or retroperitoneal injury). Catheter, skin turgor, and marking are secondary.