Republic of the Philippines

University of Northern Philippines

Tamag, Vigan City
2700 Ilocos Sur

College Of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP#09177148749, 09175785986

In Partial Fulfillment

of the

Requirements of the Course

Related Learning Experience Duty

at

Ilocos Sur Provincial Hospital- Gabriela Silang

EMERGENCY DEPARTMENT

Presented to:
Mr. Greggie Talingdan, RN
Clinical Instructor

Presented by:
Rhose Angel B. Azur
BSN 4E
 Republic of the Philippines
University of Northern Philippines
Tamag, Vigan City
2700 Ilocos Sur

College Of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP#09177148749, 09175785986

Questions and answers with rationale

1. A patient is brought to the ED by ambulance with a gunshot wound to the abdomen. The nurse
knows that the most common hollow organ injured in this type of injury is what?
A) Liver
B) Small bowel
C) Stomach
D) Large bowel

ANS: B
Rationale: Penetrating abdominal wounds have a high incidence of injury to hollow organs,
especially the small bowel. The liver is also injured frequently, but it is a solid organ

2. A patient has been brought to the ED with multiple trauma after a motor vehicle accident. After
immediate threats to life have been addressed, the nurse and trauma team should take what
action?

A) Perform a rapid physical assessment.

B) Initiate health education.
C) Perform diagnostic imaging.
D) Establish the circumstances of the accident

ANS: A
Feedback: Once immediate threats to life have been corrected, a rapid physical examination is
done to identify injuries and priorities of treatment. Health education is initiated later in the care
process and diagnostic imaging would take place after a rapid physical assessment. It is not the
care team's responsibility to determine the circumstances of the accident.

3. Which patient should the nurse prioritize as needing emergent treatment, assuming no other
injuries are present except the ones outlined below?

A) A patient with a blunt chest trauma with some

difficulty breathing
B) A patient with a sore neck who was immobilized in
 Republic of the Philippines
University of Northern Philippines
Tamag, Vigan City
2700 Ilocos Sur

College Of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP#09177148749, 09175785986

the field on a backboard with a cervical collar

C) A patient with a possible fractured tibia with
adequate pedal pulses
D) A patient with an acute onset of confusion

ANS: A
Feedback: The patient with blunt chest trauma possibly has a compromised airway. Establishment
and maintenance of a patent airway and adequate ventilation is prioritized over other health
problems, including skeletal injuries and changes in cognition.

4. The nurse observes that the family members of a patient who was injured in an accident are
blaming each other for the circumstances leading up to the accident. The nurse appropriately lets
the family members express their feelings of responsibility, while explaining that there was
probably little they could do to prevent the injury. In what stage of crisis is this family?
A) Anxiety and denial
B) Remorse and guilt
C) Anger
D) Grief

ANS: B
Feedback: Remorse and guilt are natural processes of the stages of a crisis and should be
facilitated for the family members to process the crisis. The family's sense of blame and
responsibility are more suggestive of guilt than anger, grief, or anxiety.

5. An emergency room nurse is triaging victims of a multi- casualty event. Which client should
receive care first?
a. A 30-year-old distraught mother holding her crying child
b. A 65-year-old conscious male with a head laceration
c. A 26-year-old male who has pale, cool, clammy skin
d. A 48-year-old with a simple fracture of the lower leg

C ~ The client with pale, cool, clammy skin is in shock and needs immediate medical attention.
The mother does not have injuries and so would be the lowest priority. The other two people need
medical attention soon, but not at the expense of a person in shock.
 Republic of the Philippines
University of Northern Philippines
Tamag, Vigan City
2700 Ilocos Sur

College Of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP#09177148749, 09175785986

6. While triaging clients in a crowded emergency department, a nurse assesses a client who presents
with symptoms of tuberculosis. Which action should the nurse take first?
a. Apply oxygen via nasal cannula.
b. Administer intravenous 0.9% saline solution.
c. Transfer the client to a negative-pressure room.
d. Obtain a sputum culture and sensitivity.

ANS: C ~ A client with signs and symptoms of tuberculosis or other airborne pathogens should
be placed in a negative-pressure room to prevent contamination of staff, clients & family
members in the crowded emergency department.

7. A nurse is 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 60-year-old reporting difficulty swallowing and nausea
d. An 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101 F

ANS: B ~ A client experiencing chest pain and diaphoresis would be classified as emergent and
would be triaged immediately to a treatment room in the ED. The other clients are more stable.

8. A nurse is 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 community hospitals and provides care to most injured clients
c. Level III Located in rural communities and provides only basic care to clients
d. Level IV Located in large teaching hospitals and provides a full continuum of trauma
care for all clients

ANS: B ~ Level I trauma centers are usually located in large teaching hospital systems and
provide a full continuum of trauma care for all clients. Both Level II and Level III facilities are
usually located in community hospitals. These trauma centers provide care for most clients and
 Republic of the Philippines
University of Northern Philippines
Tamag, Vigan City
2700 Ilocos Sur

College Of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP#09177148749, 09175785986

transport to Level centers when client needs exceed resource capabilities. Level IV trauma centers
are usually located in rural and remote areas. These centers provide basic care,
stabilization, and advanced life support while transfer arrangements to higher-level trauma
centers are made.

9. Emergency medical technicians arrive at the emergency department with an unresponsive client
who has an oxygen mask in place. Which action should the nurse take first?
a. Assess that the client is breathing adequately.
b. Insert a large-bore intravenous line.
c. Place the client on a cardiac monitor.
d. Assess for the best neurologic response.

ANS: A ~ The highest-priority intervention in the primary survey is to establish that the client is
breathing adequately. Even though this client has an oxygen mask on, he or she may not be
breathing, or may be breathing inadequately with the device in place.

10. A trauma client with multiple open wounds is brought to the emergency department in cardiac
arrest. Which action should the nurse take prior to providing advanced cardiac life
support?
a. Contact the on-call orthopedic surgeon.
b. Don personal protective equipment.
c. Notify the Rapid Response Team.
d. Obtain a complete history from the paramedic.

ANS: B ~ Nurses must recognize and plan for a high risk of contamination with blood and body
fluids when engaging in trauma resuscitation. Standard Precautions should be taken in all
resuscitation situations and at other times when exposure to blood and body fluids is likely.
Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical
cap, and shoe covers.

11. 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 45-year-old homeless man with a skin rash and sore throat
 Republic of the Philippines
University of Northern Philippines
Tamag, Vigan City
2700 Ilocos Sur

College Of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP#09177148749, 09175785986

c. A 75-year-old female with a cough and a temperature of 102 F

d. A 50-year-old male with new-onset confusion and slurred speech

ANS: C ~ A client with a cough and a temperature of 102 F is urgent. This client is at risk for
deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation.
The client with a chest stab wound and tachycardia and the client with new-onset confusion and
slurred speech should be triaged as emergent. The client with a skin rash and a sore throat is not
at risk for deterioration and would be triaged as nonurgent.

12. A patient is brought to the ER in an unconscious state. The physician notes that the patient is in
need of emergency surgery. No family members are present, and the patient does not have
identification. What action by the nurse is most important regarding consent for treatment?
A) Ask the social worker to come and sign the consent.
B) Contact the police to obtain the patients identity.
C) Obtain a court order to treat the patient.
D) Clearly document LOC and health status on the
patients chart.

ANS D
Feedback: When patients are unconscious and in criticac condition, the condition and situation
should be documented to administer treatment quickly and timely when no consent can be
obtained by usual routes. A social worker is not asked to sign the consent. Finding the patients
identity is not a priority. Obtaining a court order would take too long.

13. A patient is experiencing respiratory insufficiency and cannot maintain spontaneous respirations.
The nurse suspects that the physician will perform which of the following actions?
A) Insert an oropharyngeal airway.
B) Perform the jaw thrust maneuver.
C) Perform endotracheal intubation.
D) Perform a cricothyroidotomy.

ANS: C
 Republic of the Philippines
University of Northern Philippines
Tamag, Vigan City
2700 Ilocos Sur

College Of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP#09177148749, 09175785986

Feedback: Endotracheal tubes are used in cases when the patient cannot be ventilated with an
oropharyngeal airway, which is used in patients who are breathing spontaneously. The jaw thrust
maneuver does not establish an airway and cricothyroidotomy would be performed as a last
resort.

14. A patient is brought by friends to the ED after being involved in a motor vehicle accident. The
patient sustained blunt trauma to the abdomen. What nursing action would be most appropriate
for this patient?
A) Ambulate the patient to expel flatus. B) Place the
patient in a high Fowlers position.
B) Immobilize the patient on a backboard.
C) Place the patient in a left lateral position.

ANS: C
Feedback: When admitted for blunt trauma, patients must be immobilized until spinal injury is
ruled out. Ambulation, side- lying, and upright positioning would be contraindicated until spinal
injury is ruled out.

15. A backcountry skier has been airlifted to the ED after becoming lost and developing hypothermia
and frostbite. How should the nurse best manage the patients frostbite?
A) Immerse affected extremities in water slightly above normal body temperature.
B) Immerse the patients frostbitten extremities in the warmest water the patient can
tolerate.
C) Gently massage the patients frozen extremities in between water baths.
D) Perform passive range-of-motion exercises of the affected extremities to promote
circulation.

ANS: A
Feedback: Frozen extremities are usually placed in a 37C to 40C (98.6F to 104F) circulating bath
for 30- to 40- minute spans. To avoid further mechanical injury, the body part is not handled.
Massage is contraindicated.
 Republic of the Philippines
University of Northern Philippines
Tamag, Vigan City
2700 Ilocos Sur

College Of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP#09177148749, 09175785986

16. A patient with a fractured femur presenting to the ED exhibits cool, moist skin, increased heart
rate, and falling BP. The care team should consider the possibility of what complication of the
patients injuries?
A) Myocardial infarction
B) Hypoglycemia
C) Hemorrhage
D) Peritonitis

ANS: C
Feedback: The signs and symptoms the patient is experiencing suggest a volume deficit from an
internal bleed. That the symptoms follow an acute injury suggests hemorrhage rather than
myocardial infarction or hypoglycemia. Peritonitis would be an unlikely result of a femoral
fracture.

17. A patient is admitted to the ED complaining of abdominal pain. Further assessment of the
abdomen reveals signs of peritoneal irritation. What assessment findings would
corroborate this diagnosis? Select all that apply.
A) Ascites
B) Rebound tenderness
C) Changes in bowel sounds
D) Muscular rigidity
E) Copious diarrhea

ANS: B, C, D
Feedback: Signs of peritoneal irritation include abdominal distention, involuntary guarding,
tenderness, pain, muscular rigidity, or rebound tenderness along with changes in bowel
sounds. Diarrhea and ascites are not signs of peritoneal irritation.

18. A patient is admitted to the ED after being involved in a motor vehicle accident. The patient has
multiple injuries. After establishing an airway and adequate ventilation, the ED team should
prioritize what aspect of care?
A) Control the patients hemorrhage.
B) Assess for cognitive effects of the injury.
C) Splint the patients fractures.
 Republic of the Philippines
University of Northern Philippines
Tamag, Vigan City
2700 Ilocos Sur

College Of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP#09177148749, 09175785986

D) Assess the patients neurologic status.

ANS: A
Feedback: After establishing airway and ventilation, the team should evaluate and restore cardiac
output by controlling hemorrhage. This must precede neurologic assessments and treatment of
skeletal injuries.

19. A patient with multiple trauma is brought to the ED by ambulance after a fall while rock
climbing. What is a responsibility of the ED nurse in this patients care?
A) Intubating the patient
B) Notifying family members
C) Ensuring IV access
D) Delivering specimens to the laboratory

ANS: C
Feedback: ED nursing responsibilities include ensuring airway and IV access. Nurses are not
normally responsible for notifying family members. Nurses collect specimens, but are not
responsible for their delivery. Physicians or other team members with specialized training
intubate the patient

20. A patient has been brought to the ED after suffering genitourinary trauma in an assault. Initial
assessment reveals that the patients bladder is distended. What is the nurses most appropriate
action?
A) Withhold fluids from the patient.
B) Perform intermittent urinary catheterization.
C) Insert a narrow-gauge indwelling urinary catheter.
D) Await orders following the urologists assessment.

ANS: D
Feedback: Urethral catheter insertion when a possibleurethral injury is present is contraindicated;
a urology consultation and further evaluation of the urethra are required. The nurse would
withhold fluids, but urologic assessment is the priority.
 Republic of the Philippines
University of Northern Philippines
Tamag, Vigan City
2700 Ilocos Sur

College Of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP#09177148749, 09175785986

21. The triage nurse is working in the ED. A homeless person is admitted during a blizzard with
complaints of being unable to feel his feet and lower legs. Core temperature is noted at 33.2C
(91.8F). The patient is intoxicated with alcohol at the time of admission and is visibly
malnourished. What is the triage nurses priority in the care of this patient?
A) Addressing the patients hypothermia
B) Addressing the patients frostbite in his lower
extremities
C) Addressing the patients alcohol intoxication
D) Addressing the patients malnutrition

ANS: A
Feedback: The patient may also have frostbite, but hypothermia takes precedence in treatment
because it is systemic rather than localized. The alcohol abuse and the alteration in nutrition do
not take precedence over the treatment of hypothermia because both problems are a less
acute threat to the patients survival.

22. A patient is brought to the ED by friends. The friends tell the nurse that the patient was using
cocaine at a party. On arrival to the ED the patient is in visible distress with an axillary
temperature of 40.1C (104.2F). What would be the priority nursing action for this patient?
A) Monitor cardiovascular effects.
B) Administer antipyretics.
C) Ensure airway and ventilation.
D) Prevent seizure activity.

ANS: C
Feedback: Although all of the listed actions may be necessary for this patients care, the priority is
to establish a patent airway and adequate ventilation.

23. A patient admitted to the ED with severe diarrhea and vomiting is subsequently diagnosed with
food poisoning. The nurse caring for this patient assesses for signs and symptoms of fluid and
electrolyte imbalances. For what signs and symptoms would this nurse assess? Select all that
apply.
A) Dysrhythmia
B) Hypothermia
 Republic of the Philippines
University of Northern Philippines
Tamag, Vigan City
2700 Ilocos Sur

College Of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP#09177148749, 09175785986

C) Hypotension
D) Hyperglycemia
E) Delirium

ANS: A, C, E
Feedback: The patient is assessed for signs and symptoms of fluid and electrolyte imbalances,
including lethargy, rapid pulse rate, fever, oliguria, anuria, hypotension, and delirium.
Hyperglycemia and hypothermia are not typically associated with fluid and electrolyte
imbalances.

24. A 23-year-old woman is brought to the ED complaining of stomach cramps, nausea, vomiting,
and diarrhea. The care team suspects food poisoning. What is the key to treatmen in food
poisoning?
A) Administering IV antibiotics
B) Assessing immunization status
C) Determining the source and type of food poisoning
D) Determining if anyone else in the family is ill

ANS: C
Feedback: Determining the source and type of food poisoning is essential to treatment, and is
more important than determining other sick family members. Antibiotics are not normally
indicated and immunizations are not relevant to diagnosis or treatment of food poisoning.

25. Four victims of an automobile crash are brought by ambulance to the emergency department. The
triage nurse determines that the victim who has the highest priority for treatment is the one with
a. severe bleeding of facial and head lacerations.
b. an open femur fracture with profuse bleeding.
c. a sucking chest wound.
d. absence of peripheral pulses.

Correct Answer: C
 Republic of the Philippines
University of Northern Philippines
Tamag, Vigan City
2700 Ilocos Sur

College Of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP#09177148749, 09175785986

Rationale: Most immediate deaths from trauma occur because of problems with ventilation, so
the patient with a sucking chest wound should be treated first. Face and head fractures can
obstruct the airway, but the patient with facial injuries has lacerations only. The other two
patients also need rapid intervention but do not have airway or breathing