Chapter 73
1. The prehospital nurse is screening victims of a store robbery that resulted in several people
being injured. Of those injured, the nurse should encourage which of the following to seek
additional care at the nearest emergency department?
1. Elderly male who was knocked unconscious
2. Teenage female who took cover under a shelving unit
3. Middle-age female who crouched down in a corner of the room
4. Male in his mid-20s who had several light boxes of products fall on him while the robbers
ran through the store
Answer: Elderly male patient who was knocked unconscious
Rationale:
The patient who will most likely need to be seen in the emergency department is the elderly
male who was knocked unconscious. The female teenager, middle-age female, and male in
his mid-20s did not experience any injuries needing further evaluation or stabilization.
2. The nurse provides care in an inner-city hospital with a large immigrant population. In
order to provide the most culturally competent care, the nurse should:
1. Plan to attend educational programs to understand ethnic differences in health values.
2. Discuss with the supervisor the types of patients for whom the nurse feels prepared to
provide care.
3. Approach the care of every patient in the same manner.
4. Realize that the best care is standardized care.
Answer: Plan to attend educational programs to understand ethic differences in health values.
Rationale:
There are challenges with providing care to a diverse population. To provide the best
culturally sensitive care, the nurse should plan to attend education programs to understand
ethnic differences in health values. The nurse should provide quality care for all patients, not
discuss preferred types of patients with the supervisor. Because there are cultural differences
in client behavior and in expectations of health care providers, the nurse should not approach
the care of every patient in the same manner; the best care is not standardized but rather is
individualized.
3. The ambulance driver 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:
1. The patient being taken to the care center that provides the optimal care for the problem.
2. The patient not having sufficient insurance.
3. The ambulance driver not understanding the request.
4. The emergency department at the local hospital not accepting the patient to be seen.
Answer: The patient being taken to the care center that provides the optimal care for the
problem.
Rationale:
One of the National Guidelines actions for emergency care in the United States is to transport
patients to the care center that can provide the optimal care for the patient. The ambulance
driver may or may not be aware of the patient’s insurance. The ambulance driver may or may
not have heard the request. The local hospital would not refuse to see the patient because of
the Emergency Medical Transport and Active Labor Act.
4. The nurse assessing a patient who walked into the emergency department decides the
patient is in no acute distress. Which of the following did the nurse assess in this patient?
1. Able to ambulate, breathing without difficulty, possible right arm/shoulder pain because
holding arm bent and close to body
2. Limping and walking with the assistance of a possible family member or friend
3. Gasping for breath and holding a bloody tissue next to nose
4. Calling for help while limping with the use of a cane
Answer: Able to ambulate, breathing without difficulty, possible right arm/shoulder pain
because holding arm bent and close to body
Rationale:
Triage begins with an “across the room” assessment and takes into consideration the primary
assessment components of airway, breathing, circulation, and disability. 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. The other
patients would have more distress or disability and would need faster intervention.
5. The nurse in the emergency department is currently triaging patients. Which of the
following activities will this nurse be performing?
1. Determining the patients’ urgency for care
2. Drawing serum laboratory samples
3. Starting intravenous access lines
4. Applying cardiac monitoring leads on patients
Answer: Determining the patients’ urgency for care
Rationale:
The purpose and goals of triage include early and brief patient assessment, determination of
the patients’ urgency for care, and documentation of findings. The triage nurse will most
likely not be drawing blood, starting intravenous lines, or applying cardiac monitoring leads
on patients.
6. The nurse in the emergency department is deciding where to place patients in the various
cubicles to be seen by the health care provider. This nurse later talks with one patient about
the fall he sustained from his motorcycle and if he is able to move all four extremities
independently. The nurse is demonstrating:
1. The goals of triage.
2. Standards of practice for an emergency department.
3. Hospital-identified policies and procedures.
4. Evidence-based practice.
Answer: The goals of triage.
Rationale:
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. There is not
enough information to know if the nurse is following the standards of practice or policies and
procedures for the hospital, or if the nurse is implementing evidence-based practice.
7. A patient, assigned as nonurgent in the emergency department, begins to have shortness of
breath and is dizzy. Which of the following should be done to assist this patient?
1. Immediately reassess and assign the category of emergent
2. Immediately reassess and assign the category of resuscitation
3. Immediately reassess and assign the category of urgent
4. Remind the individual to be patient and wait to be seen
Answer: Immediately reassess and assign the category of emergent
Rationale:
Even when 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
should be immediately reassessed and assigned the category of emergent because he has an
immediately life-threatening problem. The patient does not need resuscitation. An urgent
patient will need to wait a bit longer; this patient must be treated immediately. The patient
should not be scolded for needing help but rather be reassessed, assigned another category,
and treated immediately.
8. A patient, arriving by ambulance into the emergency department, is having respirations
provided by a paramedic using a breathing bag. The nurse realizes this patient’s triage level
would be:
1. Resuscitative.
2. Emergent.
3. Urgent.
4. Nonurgent.
Answer: Resuscitative.
Rationale:
A patient assigned as resuscitative means that resuscitative interventions must be
implemented immediately. The status of emergent means the patient has an immediate lifethreatening problem. A patient assigned as urgent means the patient can wait a little longer
but should be seen as soon as possible. The patient assigned as nonurgent means the patient is
stable enough to wait for care.
9. 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 of the following nonurgent patients should be seen and treated
first?
1. Elderly male whose swollen hand now is slightly blue-tinged with a faint pulse
2. Female with swollen ankle, leg elevated, ice pack currently applied, pulse present
3. Adolescent male with bruised right eye, ice pack applied, no further bleeding from nose
4. Male child holding left arm in sling, fingers and wrist intact to sensation, motion, and pulse
Answer: Elderly male whose swollen hand is now slightly blue-tinged with a faint pulse.
Rationale:
The nurse needs to reprioritize the patients who were all identified at first as being nonurgent.
At this time, the elderly male has the most dramatic status change in that his hand is turning
blue and he is losing a pulse to the limb. This patient should be seen first. The other three
patients remain stable and remain nonurgent.
10. A patient without health insurance comes into the emergency department limping and
dripping blood from a head wound. Which of the following should be done first with this
patient?
1. Determine triage level and examine and treat as needed.
2. Have the patient sign in and provide method of payment for services.
3. 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.
4. Tell the patient that there are no orthopedic doctors available to help him and tell him that
the hospital in the next town will be better able to help him.
Answer: Determine triage level and examine and treat as needed.
Rationale:
According to the Emergency Medical Treatment and Active Labor Act, no patient can be
turned away from care for financial reasons. The patient does not have health insurance;
however, the patient should be triaged, examined, and treated. The patient is in obvious
distress, and the hospital cannot delay appropriate medical screening or treatment to inquire
about the patient’s ability to pay for services. The patient should not be told to go to another
hospital nor should the patient be told that because the hospital does not have the capabilities
to provide the care that he needs, such as an orthopedic health care provider, he will have to
go to a hospital in another town.
11. When a patient came to the emergency department, he signed 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 realizes
that the patient’s consent for resuscitative treatment would be considered:
1. Implied.
2. Informed.
3. Expected.
4. Blanket.
Answer: Implied.
Rationale:
Implied consent allows for treatment in an emergency situation that is based on the premise
that if the patient were able to, he would have given permission for treatment. Informed
consent involves the patient stating that he has full understanding of a procedure, including
risks, and is competent to give consent. Blanket consent is what the patient signed upon
entering the emergency department and is a general consent agreement used for evaluation
and treatment. Expected is not a type of consent.
12. The nurse is collecting evidence of sexual assault from a female patient. Which of the
following should the nurse do with damp clothing?
1. Allow the clothing to dry and then place in a paper bag; label appropriately.
2. Place the clothing in a plastic bag; document the time it was collected.
3. Secure the clothing on a wire hanger; label appropriately.
4. Drape the clothing over a chair in the room; provide to law enforcement officials when
they arrive.
Answer: Allow the clothing to dry and then place in a paper bag; label appropriately.
Rationale:
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. The clothing should not be secured on a wire hanger nor draped over a
chair to be picked up later by law enforcement officials.
13. The nurse, who has worked for 8 years on an adult medical−surgical unit, is transferring
to become an emergency room nurse. Which of the following types of training will this nurse
most likely need to become proficient in providing emergency nursing care?
1. Emergency pediatric and obstetrical nursing care
2. Neurological emergencies with the elderly
3. Basic cardiac life support
4. Managing the care of four or five patients simultaneously
Answer: Emergency pediatric and obstetrical nursing care
Rationale:
The nurse has provided care to adult medical−surgical patients for 8 years. This nurse will not
need training on neurological emergencies with the elderly. This nurse will most likely
already have basic cardiac life-support training. Because the nurse has worked on a
medical−surgical unit, the care of four or five patients simultaneously might have been the
norm. This nurse will need training on patient populations of which she has had minimal
exposure, such as pediatrics and obstetrics.
14. The nurse is discharging a patient from the emergency department. The patient will need
to walk with crutches for a sprained ankle. Which of the following should the nurse do to
ensure that the patient will safely use the crutches at home?
1. Demonstrate the use of the crutches and ask for a return demonstration before discharge.
2. Provide a written handout on the use of crutches.
3. Demonstrate the use of the crutches while the patient observes from the wheelchair.
4. Instruct the family member on the use of the crutches and suggest he or she access the
Internet for any questions.
Answer: Demonstrate the use of the crutches and ask for a return demonstration before
discharge.
Rationale:
Discharge instructions are a large portion of the care emergency nurses provide. The best way
for the nurse to assess if the patient understands the instructions provided about crutch use
would be for the nurse to demonstrate the use and then ask the patient to return the
demonstration. A written handout on the use of crutches might not be enough for the patient.
Demonstrating the use without a return demonstration will not assess the patient’s
understanding. Instructing the family on the use and referring them to the Internet for any
questions is inappropriate.
15. The emergency department nurses are planning a community education program during
Summer Safety Week at the hospital. Which of the following should be included in this
program?
1. Bicycles and Helmets: Friends for Life!
2. Get Out and Walk!
3. Clean House: Eliminate Winter Pathogens Just in Time for Spring!
4. Recycle Your Clothing: Help a Friend in Need!
Answer: Bicycles and Helmets: Friends for Life!
Rationale:
One role of the emergency room nurse is to participate in injury and disease prevention
education. The nurses who are planning a community education program for Summer Safety
Week should include a topic that has to do with a summer activity and safety. The best
selection would be to include Bicycles and Helmets: Friends for Life! The other topics would
focus on fitness (walking), environmental cleanliness (eliminate pathogens), and community
support (donate recycled clothing) and are not specifically focused on injury prevention.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
