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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.
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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.
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 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.
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.