[Osborn] chapter 73

Learning Outcomes [Number and Title]

Learning Outcome
Explain the practice of emergency nursing.
Learning Outcome
Differentiate among the various components of the triage
process and determine each components relevance.
Learning Outcome
Compare and contrast patient priority categories.
Learning Outcome
Explain the legal issues related to the practice of emergency
nursing.
Learning Outcome
Describe preparation for emergency nursing practice.

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

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.
2.
3.
4.

Elderly male who was knocked unconscious

Teenage female who took cover under a shelving unit
Middle-age female who crouched down in a corner of the room
Male in his mid-20s who had several light boxes of products fall on him while the
robbers ran through the store

Correct 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.
Cognitive Level: Analysis
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

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.
Correct 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.
Cognitive Level: Application
Nursing Process: Planning
Client Need: Safe, Effective Care Environment
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

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.
Correct 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 patients 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.
Cognitive Level: Analysis
Nursing Process: Implementation
Client Need: Safe, Effective Care Environment
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

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
Correct 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.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

5. The nurse in the emergency department is currently triaging patients. Which of the
following activities will this nurse be performing?
1.
2.
3.
4.

Determining the patients urgency for care

Drawing serum laboratory samples
Starting intravenous access lines
Applying cardiac monitoring leads on patients

Correct 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.
Cognitive Level: Analysis
Nursing Process: Implementation
Client Need: Safe, Effective Care Environment
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

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.
2.
3.
4.

The goals of triage.

Standards of practice for an emergency department.
Hospital-identified policies and procedures.
Evidence-based practice.

Correct 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.
Cognitive Level: Analysis
Nursing Process: Implementation
Client Need: Safe, Effective Care Environment
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

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.
2.
3.
4.

Immediately reassess and assign the category of emergent

Immediately reassess and assign the category of resuscitation
Immediately reassess and assign the category of urgent
Remind the individual to be patient and wait to be seen

Correct 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.
Cognitive Level: Analysis
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

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 patients triage
level would be:
1.
2.
3.
4.

Resuscitative.
Emergent.
Urgent.
Nonurgent.

Correct 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
life-threatening 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.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

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
Correct 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.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

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.
Correct 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 patients 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.
Cognitive Level: Analysis
Nursing Process: Implementation
Client Need: Safe, Effective Care Environment
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

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 patients consent for resuscitative treatment would be
considered:
1.
2.
3.
4.

Implied.
Informed.
Expected.
Blanket.

Correct 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.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Safe, Effective Care Environment
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

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.
2.
3.
4.

Allow the clothing to dry and then place in a paper bag; label appropriately.
Place the clothing in a plastic bag; document the time it was collected.
Secure the clothing on a wire hanger; label appropriately.
Drape the clothing over a chair in the room; provide to law enforcement officials
when they arrive.

Correct 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.
Cognitive Level: Application
Nursing Process: Implementation
Client Need: Safe, Effective Care Environment
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

13. The nurse, who has worked for 8 years on an adult medicalsurgical 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.
2.
3.
4.

Emergency pediatric and obstetrical nursing care

Neurological emergencies with the elderly
Basic cardiac life support
Managing the care of four or five patients simultaneously

Correct Answer: Emergency pediatric and obstetrical nursing care

Rationale: The nurse has provided care to adult medicalsurgical 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 medicalsurgical 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.
Cognitive Level: Analysis
Nursing Process: Planning
Client Need: Safe, Effective Care Environment
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

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.
Correct 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 patients understanding. Instructing the family on the use and referring them to
the Internet for any questions is inappropriate.
Cognitive Level: Application
Nursing Process: Implementation
Client Need: Safe, Effective Care Environment
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

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.
2.
3.
4.

Bicycles and Helmets: Friends for Life!

Get Out and Walk!
Clean House: Eliminate Winter Pathogens Just in Time for Spring!
Recycle Your Clothing: Help a Friend in Need!

Correct 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.
Cognitive Level: Application
Nursing Process: Planning
Client Need: Health Promotion and Maintenance
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.