Chapter 66 My Nursing Test Banks

Osborn,_2e
Chapter 66

Question 1

Type: MCSA

The prehospital nurse is screening several people injured in a store robbery. Of those injured, the nurse should encourage which one to seek additional care at the nearest emergency department?

1. Male in his mid-20s who had several light boxes of products fall on him while the robbers ran through the store

2. Teenage female who took cover under a shelving unit and sustained a scratch on her arm

3. Middle-age female who crouched down in a corner of the room and strained her knee

4. Elderly male who was briefly unconscious

Correct Answer: 4

Rationale 1: Because this patient is young and the boxes were light, emergency care will probably not be needed.

Rationale 2: This teenager sustained only a minor injury that could be treated at the scene. She should be referred to her primary care physician for follow-up if necessary.

Rationale 3: A knee strain can likely be managed at home or through follow-up with her personal primary care physician.

Rationale 4: An older patient who was briefly unconscious may have suffered a cardiac or neurologic event, or may have simply fainted. The patient should be evaluated for the reason for the unconsciousness.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-2

Question 2

Type: MCSA

The nurse provides care in a hospital in an inner-city with a large immigrant population. How can the nurse provide the most culturally competent care?

1. Approach the care of every patient in the same manner.

2. Plan to attend educational programs to understand ethnic differences in health values.

3. Discuss with the supervisor the types of patients for whom the nurse feels prepared to provide care.

4. Realize that the best care is standardized care.

Correct Answer: 2

Rationale 1: The nurse should not approach the care of every patient in the same manner but should consider cultural differences.

Rationale 2: There are challenges with providing care to a diverse population. To provide the best culturally sensitive care, the nurse should attend education programs to understand ethnic differences in health values.

Rationale 3: The nurse should provide quality care for all patients, not discuss preferred types of patients with the supervisor.

Rationale 4: The best care is not standardized but rather is individualized.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 66-1

Question 3

Type: MCSA

A paramedic was asked by family members to take a patient complaining of chest pain to the local hospital. However, the patient is being

taken to a hospital that is farther away and harder for the family to reach. The decision to take the patient to a different hospital is the result of which factor?

1. The patient does not have sufficient insurance.

2. The paramedic did not understand the request.

3. The emergency department at the local hospital would not accept the patient.

4. The patient was taken to the care center that provides the optimal care for the problem.

Correct Answer: 4

Rationale 1: The paramedic may or may not be aware of the type of insurance the patient has.

Rationale 2: There is no evidence that the family did not make their wishes known.

Rationale 3: Because of the Emergency Medical Transport and Active Labor Act, the local hospital would not refuse to see the patient.

Rationale 4: One of the Institute of Medicine recommendations for emergency care in the United States is to transport patients to the care center that can provide the optimal care for the patient.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-3

Question 4

Type: MCSA

The nurse assessing a patient who walked into the emergency department decides the patient is in no acute distress. Which patient condition would support the nurses decision?

1. Limping and walking with the assistance of a possible family member or friend

2. Gasping for breath and holding a bloody tissue to the nose

3. Ambulating, breathing without difficulty, possible right arm/shoulder pain because holding arm bent and close to body

4. Calling for help while limping with the use of a cane

Correct Answer: 3

Rationale 1: This patient has an obvious sign of illness or injury.

Rationale 2: This patient has an obvious sign of illness or injury that could progress to a more serious condition such as airway occlusion.

Rationale 3: Of the individuals described, the patient who is able to ambulate, breathe without difficulty, but might have right arm/shoulder discomfort would be the one with the least amount of distress.

Rationale 4: Limping and calling for help indicate the need for immediate assessment.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 66-3

Question 5

Type: MCSA

The nurse works in an emergency department (ED) that implements the spot check triage system. Which activity will the nurse triaging patients perform?

1. Starting intravenous access lines

2. Applying cardiac monitoring leads on patients

3. Determining patients urgency for care

4. Drawing serum laboratory samples

Correct Answer: 3

Rationale 1: IV lines are typically started once the patient is admitted to the ED.

Rationale 2: Cardiac monitor leads are typically applied after the patient is admitted to the ED.

Rationale 3: The purpose and goals of triage include early and brief patient assessment, determination of the patients urgency for care, and documentation of findings.

Rationale 4: Drawing serum for laboratory samples is generally done after admission to the ED.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-2

Question 6

Type: MCSA

A nurse working in the emergency department (ED) decides which cubicles to place patients in to be seen by the health care provider. The nurse talks with one patient about the fall he sustained from his motorcycle and whether he is able to move all four extremities independently. What part of the role of the emergency department nurse is this nurse fulfilling?

1. Triage

2. Referral to hospital-identified policies and procedures

3. Following physician orders for admitting a patient

4. Following evidence-based practice

Correct Answer: 1

Rationale 1: The goals of triage include early and brief patient assessment, assignment of patients to the appropriate care area, and initiation of diagnostic and therapeutic interventions.

Rationale 2: The ED nurse must make on-the-spot decisions about how to prioritize care. There is insufficient time to refer to policy and procedures with each decision.

Rationale 3: The nurse is making an independent nursing judgment regarding which patient has the most urgent need to be seen and which cubicle provides the correct equipment and access.

Rationale 4: As there is no information about where this patient was placed based on the nurses assessment, it is not possible to tell if evidence-based care was considered.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-2

Question 7

Type: MCSA

A patient, assigned the category of nonurgent in the emergency department, begins to have shortness of breath and is dizzy. What should be done to assist this patient?

1. Immediately reassess the patient and assign the category of urgent.

2. Immediately reassess the patient and assign the category of resuscitation.

3. Remind the individual to be patient and wait to be seen.

4. Immediately reassess the patient and assign the category of emergent.

Correct Answer: 4

Rationale 1: An urgent patient will need to wait a bit longer; this patient must be treated immediately.

Rationale 2: The patient does not need resuscitation.

Rationale 3: The patient should not be scolded for needing help.

Rationale 4: After patients have been assigned a triage category their condition might change, so patients who are waiting to be seen should be reassessed at regular intervals. This patient has an immediately life-threatening problem.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-2

Question 8

Type: MCSA

A patient arrives by ambulance to the emergency department. A paramedic is administering a breathing bag to help with the patients respirations. Which triage level will the nurse assign?

1. Nonurgent

2. Resuscitative

3. Emergent

4. Urgent

Correct Answer: 2

Rationale 1: A patient in the nonurgent category is stable enough to wait for care.

Rationale 2: For a patient in the resuscitative category, resuscitative interventions must be implemented immediately. This patient is already receiving resuscitative measures.

Rationale 3: The status of emergent means the patient has an immediate life-threatening problem but is not imminently dying.

Rationale 4: A patient in the urgent category can wait a little longer but should be seen as soon as possible.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 66-2

Question 9

Type: MCSA

The nurse is reviewing the current status of patients who have been waiting in the emergency department for several hours. At the time of first arrival, each of the patients was identified as nonurgent. Which nonurgent patient should be seen and treated first?

1. Male child holding left arm in sling, fingers and wrist intact to sensation, motion, and pulse

2. Female with swollen ankle, leg elevated, ice pack currently applied, pulse present

3. Elderly male whose swollen hand now is slightly blue-tinged with a faint pulse

4. Adolescent male with bruised right eye, ice pack applied, no further bleeding from nose

Correct Answer: 3

Rationale 1: This patient remains stable and is not the current priority patient.

Rationale 2: This patient remains stable and is not the current priority patient.

Rationale 3: The nurse needs to reprioritize the patients who were all identified at first as nonurgent. At this time, the elderly male has the most dramatic status change.

Rationale 4: This patient remains stable and is not the current priority patient.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 66-1

Question 10

Type: MCSA

A patient without health insurance comes to the emergency department limping and dripping blood from a head wound. Which intervention should be performed first with this patient?

1. Tell the patient that there are no orthopedic doctors available and that the hospital in the next town will be better able to help him.

2. Determine the patients triage level, examine, and treat as needed.

3. Have the patient sign in and provide method of payment for services.

4. Tell the patient that he will have to go to the emergency room at a hospital that treats people who do not have health insurance.

Correct Answer: 2

Rationale 1: The patient should not be told that because the hospital does not have the resources to provide the care he needs, he will have to go to a hospital in another town.

Rationale 2: According to the Emergency Medical Treatment and Active Labor Act, no patient can be turned away from care for financial reasons. Although the patient does not have health insurance, he should be triaged, examined, and treated.

Rationale 3: The patient is in obvious distress, and the hospital cannot delay appropriate medical screening or treatment to inquire about the patients ability to pay for services.

Rationale 4: The patient should not be told to go to another hospital.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-3

Question 11

Type: MCSA

A patient comes to the emergency department and signs a general consent for treatment. While waiting to be seen, the patient experiences cardiac arrest and is subsequently resuscitated, stabilized, and admitted to the intensive care unit. The emergency nurse acted on which type of consent?

1. Implied

2. Blanket

3. Expected

4. Informed

Correct Answer: 1

Rationale 1: Implied consent allows for treatment in an emergency situation. It is based on the premise that if the patient were able to, he or she would give permission for treatment.

Rationale 2: Blanket consent is what the patient signed upon entering the emergency department; it is a general consent agreement used for evaluation and treatment. If more invasive tests are needed, additional consent is necessary.

Rationale 3: Expected does not describe a type of consent.

Rationale 4: Informed consent involves the patient stating that he or she has full understanding of a procedure, including risks, and is competent to give consent.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 66-4

Question 12

Type: MCSA

The nurse is collecting evidence of sexual assault from a female patient. What should the nurse do with damp clothing?

1. Place the clothing in a plastic bag and document the time it was collected.

2. Drape the clothing over a chair in the room and give it to law enforcement officers when they arrive.

3. Allow the clothing to dry, place it in a paper bag, and label it appropriately.

4. Secure the clothing on a wire hanger and label it appropriately.

Correct Answer: 3

Rationale 1: Evidence should be placed in a paper bag.

Rationale 2: The clothing should not be draped over a chair to be picked up later by law enforcement officers.

Rationale 3: Nurses who collect and preserve evidence and the chain of custody must remember that evidence that is wet should always be dried before packaging. Evidence should always be placed in a paper bag.

Rationale 4: The clothing should not be secured on a wire hanger.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-4

Question 13

Type: MCSA

The nurse has worked for 8 years on an adult medical-surgical unit and is transferring to become an emergency department nurse. Which type of training will this nurse most likely need to become proficient in providing emergency nursing care?

1. Pediatric and obstetric nursing care

2. Managing the care of four or five patients simultaneously

3. Basic cardiac life support

4. Neurologic emergencies with the elderly

Correct Answer: 1

Rationale 1: The nurse will need training related to patient populations with which she or he has had minimal experience, such as pediatrics and obstetrics.

Rationale 2: A nurse who has worked on a medical-surgical unit probably has experience caring for four or five patients simultaneously.

Rationale 3: The nurse probably already has basic cardiac life-support training.

Rationale 4: The nurse has provided care to adult medical-surgical patients for 8 years. This nurse will not need training in neurologic emergencies with the elderly.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 66-5

Question 14

Type: MCSA

The nurse is discharging a patient from the emergency department. The patient will need to walk with crutches for a sprained ankle. What should the nurse do to ensure that the patient will safely use the crutches at home?

1. Instruct a family member on the use of the crutches and suggest that he or she access the Internet for any questions.

2. Demonstrate the use of the crutches while the patient observes from the wheelchair.

3. Demonstrate the use of the crutches and ask for a return demonstration before discharge.

4. Provide a written handout on the use of crutches.

Correct Answer: 3

Rationale 1: Instructing the family on the use of crutches and referring them to the Internet for any questions is inappropriate.

Rationale 2: Demonstrating the use without a return demonstration will not assess the patients understanding.

Rationale 3: Discharge instructions are an important part of the care emergency nurses provide. The best way for the nurse to assess if the patient understands the instructions about crutch use would be for the nurse to demonstrate and then ask the patient to return the demonstration.

Rationale 4: A written handout might not be enough for the patient. It also does not ensure that instructions are understood.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-1

Question 15

Type: MCSA

The emergency department (ED) nurses are planning a community education program during Summer Safety Week at the hospital. Including which topic in this program would support the Emergency Nurses Association (ENA) initiatives?

1. Clean House: Eliminate Winter Pathogens Just in Time for Spring!

2. Bicycles and Helmets: Friends for Life!

3. Recycle Your Clothing: Help a Friend in Need!

4. Get Out and Walk!

Correct Answer: 2

Rationale 1: Environmental cleanliness is not specifically focused on injury prevention.

Rationale 2: One role of the ED nurse is to participate in injury and disease prevention education. These nurses should include a topic related to a summer activity, such as bicycle riding, and related safety issues.

Rationale 3: Community support through recycling clothing is not focused on injury prevention.

Rationale 4: Fitness by walking is not specifically focused on injury prevention.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 66-1

Question 16

Type: MCMA

A nurse who is considering transfer to the emergency department (ED) asks, How is ED nursing different from what I have been doing? How would the experienced ED nurse answer this question?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. It is episodic.

2. We focus on primary care.

3. Most of what we do is acute care or critical care.

4. ED nurses provide care to patients of all ages.

5. Most of the time we are providing care to patients without a medical diagnosis.

Correct Answer: 1,3,4,5

Rationale 1: ED nurses do not provide care for long periods or through the course of an illness. They provide care during a short episode, and the patient is either admitted or dismissed.

Rationale 2: ED care can be primary, secondary, or tertiary.

Rationale 3: The care provided in the ED is generally acute or critical care.

Rationale 4: Patients seen in the ED are of all ages.

Rationale 5: At least initially, most ED patients do not have a medical diagnosis and are being seen to determine what is wrong.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 66-1

Question 17

Type: MCSA

A patient from another country is brought to the emergency department (ED) after sustaining a serious leg wound. The ED nurse asks how the wound would be treated in the patients country of origin. The nurse is practicing which part of the ABCDE Diversity Practice Model?

1. A or assumptions

2. B or beliefs

3. C or communication

4. D or diversity

Correct Answer: 4

Rationale 1: Assumption is the act of taking for granted or supposing that a thought or idea about a group is true. This nurse is not assuming how care would be provided, but has asked for information.

Rationale 2: Beliefs are shared ideas about how a group operates. The nurse is asking for information rather than acting on beliefs.

Rationale 3: Communication is the two-way sharing of information that results in an understanding between receiver and sender. This is not the purpose of the nurses inquiry.

Rationale 4: Diversity is the way in which people differ and the effect that these differences have on health perception and health care. The nurses question is an attempt to understand that diversity.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-1

Question 18

Type: MCMA

Which patient statement would the nurse evaluate as reflecting the current trend in use of the emergency department?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. I had to wait for 3 hours to be seen for my head cold.

2. My dad had to stay in the ED overnight until a bed was available in the intensive care unit.

3. I wanted to go to an ED across town, but they arent accepting any ambulance patients right now.

4. The lady in the office told me I should go somewhere else for care, but I am just too sick.

5. The waiting room is packed with people who are sneezing and coughing.

Correct Answer: 1,2,3,5

Rationale 1: Wait times are lengthening as more patients are using the ED for primary care.

Rationale 2: Critically ill patients are sometimes boarded in the ED while awaiting a bed in a specialty unit.

Rationale 3: EDs have become so overwhelmed that they periodically have to go on divert status to allow staff to provide care to the patients already admitted to the ED.

Rationale 4: According to the Emergency Medical Transport and Active Labor Act, people who present to the ED for care cannot be turned away.

Rationale 5: Waiting rooms are often crowded with people who do not need emergency care but have nowhere else to turn.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 66-1

Question 19

Type: MCMA

Which characteristics of the emergency department (ED) would the nurse cite as causing long waits and overcrowded conditions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. We are open 24 hours a day and 7 days a week.

2. So many of our patients dont have any insurance.

3. We cannot turn people away even if they dont have an emergent condition.

4. Patients dont want to wait at the doctors office and they think they can be seen here faster.

5. We have such a large population of older people in our community.

Correct Answer: 1,2,3

Rationale 1: The 24-hour accessibility of the ED is attractive to patients who require medical services after hours.

Rationale 2: People who do not have insurance usually cannot afford private health care and go to the ED instead.

Rationale 3: Open access and the prohibition against turning patients away have increased the numbers of patients in the ED.

Rationale 4: Typically the wait times in the ED are much longer for nonurgent illnesses.

Rationale 5: Fully one third of all ED visits are by people less than 25 years old, so it is hard to prove that overuse by the older population has caused overcrowding.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 66-1

Question 20

Type: MCMA

Which statements by an emergency department nurse reflect poor compliance with the A portion of the diversity practice model?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. If patients are going to live in the U.S., they should at least attempt to learn English.

2. Her clothes are dirty, so I bet she doesnt have any insurance.

3. This patient is weird. He has all kinds of marks on his skin and says they will make him feel better.

4. You know how it is with these young mothers; they never follow instructions on how to prevent their kids from getting ear infections.

5. Oh no, another old man with influenza. You take care of him. They all stink.

Correct Answer: 2,4,5

Rationale 1: This statement violates the C or communication portion of the model.

Rationale 2: This is a violation of the A or assumptions part of the model. The nurse should not assume that dirty clothing equates to having no insurance.

Rationale 3: These marks may be a form of cultural ritual for healing. The nurse should attempt to understand the ritual rather than classifying the patient as weird. This violates the D or diversity component of the model.

Rationale 4: This nurse has grouped all young mothers together as unable to follow instructions. This violates the A or assumptions portion of the model.

Rationale 5: This nurse has grouped all old men as smelling bad. This is an assumption regarding older people and violates the A or assumptions part of the model.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-1

Question 21

Type: MCMA

A hospital nurse administrator is working to help the emergency department meet the Institute of Medicine (IOM) recommendations for emergency care. Which initiatives should be included in this work?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Funding for a new pediatric coordinator position in the ED

2. Revision of the ED physical layout to improve patient flow

3. Decreasing the number of standards that affect the operation of the ED

4. Advocating for payment for all ED care provided

5. Development of a clinical decision unit

Correct Answer: 1,2,4,5

Rationale 1: The IOM recommends that a pediatric coordinator be hired to ensure that appropriate equipment, training, and services are provided concerning children.

Rationale 2: The IOM recommends that tools from other disciplines such as engineering and operations research be used to improve patient flow.

Rationale 3: The IOM advocates the development of well-defined standards and performance improvement measures.

Rationale 4: The IOM supports measures that would ensure that hospitals are reimbursed for all care delivered in the ED.

Rationale 5: A clinical decision unit is a short-stay unit where patients are admitted until a decision is made about the best course of treatment. Use of these units would reduce the numbers of patients who are boarded or kept for long periods in the ED.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 66-1

Question 22

Type: MCSA

A patient has returned to the emergency department (ED) numerous times over the past 3 months. The patient has newly diagnosed diabetes and cannot afford testing supplies. Which ED nurse referral is indicated?

1. Nurse educator

2. Emergency nurse practitioner (ENP)

3. Emergency clinical nurse specialist (ECNS)

4. Case manager

Correct Answer: 4

Rationale 1: The nurse educator may discuss the need for testing with the patient, but is not the best resource for this situation.

Rationale 2: The ENP may provide diabetes-specific care for this patient, but is not the best resource for the current situation.

Rationale 3: The ECNS may support provision of excellent care for the patient, but is not the best resource for the current situation.

Rationale 4: This patient requires the services of a case manager who can interact with other departments and agencies to assist the patient in obtaining necessary supplies.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-1

Question 23

Type: MCSA

The nurse manager makes a quick visit with patients in the emergency department (ED) waiting area. The manager is concerned about one patient who was originally assigned nonurgent status, even though there is no specific change from the triage assessment. What action should the manager take?

1. Check on the patient in another 15 minutes.

2. Tell the admittance clerk to keep an eye on the patient.

3. Change the triage tag to urgent and admit the patient to the ED.

4. Blame the concern on the number of patients still waiting to be seen.

Correct Answer: 3

Rationale 1: The manager should not wait 15 minutes for another assessment.

Rationale 2: The admittance clerk is not a nurse and should not be placed in this position.

Rationale 3: The nurses intuition may be correct that this patient is sicker than the assessment indicates. The nurse should act on this sixth sense.

Rationale 4: The nurse should not dismiss this concern.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 66-3

Question 24

Type: MCMA

Nursing administrators are trying to decide if they want a traffic director, spot check, or comprehensive form of triage in the emergency department. What information should be considered when making this decision?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. All forms will require employment of a registered nurse.

2. All forms will include evaluation of the patient.

3. Both spot check and comprehensive triage nurses order lab or radiographs according to established protocol.

4. A comprehensive triage plan results in patients receiving pain medications earlier.

5. Both the spot check and comprehensive triage nurses assign urgency categories.

Correct Answer: 4,5

Rationale 1: The traffic director form of triage can be performed by a nonnurse.

Rationale 2: The traffic director does not evaluate the patient but only records chief complaints.

Rationale 3: Comprehensive triage nurses order some interventions; spot check triage nurses do not.

Rationale 4: The nurse providing comprehensive triage can administer pain medication.

Rationale 5: In both types of triage, urgency categories are assigned. This is not true of traffic director triage.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 66-2

Question 25

Type: MCMA

The emergency department (ED) nurse is using the CIAMPEDS mnemonic to triage an 8-year-old patient. Which questions would the nurse ask?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. C: What is the chief complaint?

2. I: Has the child been exposed to anything requiring isolation?

3. P: What do you think is the problem?

4. E: Has the patient ever had these symptoms before today?

5. D: Has the patients diet or appetite changed?

Correct Answer: 1,2,3,5

Rationale 1: The C of the mnemonic represents chief complaint.

Rationale 2: The I of the mnemonic is related to isolation or immunizations.

Rationale 3: The P of the mnemonic represents the parents or caregivers impression of the patients problem.

Rationale 4: The E in the mnemonic represents the events surrounding the illness or injury.

Rationale 5: The D in the mnemonic represents diet or diapers, signifying output.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 66-3

Question 26

Type: MCSA

Workmen preparing to paint have set up equipment near the emergency department entrance and have taken down all the signage. What is the primary reason the nurse manager is concerned when this is mentioned in the shift report?

1. Inappropriate signage can result in loss of federal funding.

2. Patients and families may get lost if signs are not present.

3. Fumes from paint can impair the breathing ability of patients with lung disorders.

4. The presence of painting equipment is a fall hazard for patients and nurses.

Correct Answer: 1

Rationale 1: The Emergency Medical Treatment and Active Labor Act (EMTALA) requires posting of signs to advise patients of their rights to emergency treatment. Violation of this posting law can result in loss of federal funding.

Rationale 2: Patients and families may get lost, but this is not the primary reason the manager is upset.

Rationale 3: The manager may be concerned about fumes, but this is not the primary concern.

Rationale 4: The equipment is near the entrance, not in the entrance, so the workmen have taken appropriate precautions to prevent injury.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-1

Question 27

Type: MCMA

A patient is being transferred from the emergency department to another hospital. The nurse would expect which conditions to be documented before this transfer occurs?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The current facility does not have the capacity to provide the needed care.

2. The medical benefits of the transfer outweigh the risks of transfer.

3. A medical screening exam has been conducted.

4. No physician with admitting privileges at the current hospital will assume the care of the patient.

5. The appropriate level of care must be provided during the transfer.

Correct Answer: 1,2,3,5

Rationale 1: Transfers from the ED require documentation that the current facility cannot provide the care needed.

Rationale 2: There must be documentation that the risks of transfer are not as great as the expected benefits.

Rationale 3: The current hospital must verify that a medical screening exam has been done.

Rationale 4: There is no need to document that no physician at the current hospital will assume the patients care. If the patient needs care and transfer is not indicated, a physician must be assigned to the patients care.

Rationale 5: The patient must have care during the transfer that is assessed to be adequate and appropriate.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 66-4

Question 28

Type: MCMA

The patient signed a consent for treatment when admitted to the emergency department. This consent would allow which procedures?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Vital signs

2. Drawing lab work

3. Endoscopy

4. X-rays without contrast

5. Medication administration

Correct Answer: 1,2,4,5

Rationale 1: The blanket consent would allow for evaluation such as vital signs.

Rationale 2: Evaluative tests such as lab work are covered by the blanket consent.

Rationale 3: Endoscopy is an invasive procedure that may require conscious sedation. Additional consent is required.

Rationale 4: The blanket consent allows plain x-rays to be taken.

Rationale 5: The blanket consent allows for administration of medication.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 66-4

Question 29

Type: MCSA

A patient being cared for in the emergency department (ED) will require endoscopy to remove a foreign object from the esophagus. Whose responsibility is it to obtain informed consent for this procedure?

Leave a Reply