Title: ASN 210 Week 6 Pre-Quiz (Remotely Proctored)
Course: 16SP-ASN-210-GH1A1-ADV NUR THROUGH LIFESPAN I > Section: Week 6

_147223_111efc7a8fa681edc7c3760cde17b8373

Q: A nurse is caring for clients in a busy emergency department. Which actions should the nurse take to ensure client and staff safety? <b>(Select all that apply.)</b>
- Leave the stretcher in the lowest position with rails down so that the client can access the bathroom.
- Use two identifiers before each intervention and before mediation administration.
- Attempt de-escalation strategies for clients who demonstrate aggressive behaviors.
- Search the belongings of clients with altered mental status to gain essential medical information.
- Isolate clients who have immune suppression disorders to prevent hospital-acquired infections.
A: Use two identifiers before each intervention and before mediation administration.; Attempt de-escalation strategies for clients who demonstrate aggressive behaviors.; Search the belongings of clients with altered mental status to gain essential medical information.
If right: To ensure client and staff safety, nurses should use two identifiers per The Joint Commission’s National Patient Safety Goals; follow the hospital’s security plan, including de-escalation strategies for people who demonstrate aggressive or violent tendencies; and search belongings to identify essential medical information. Nurses should also use standard fall prevention interventions, including leaving stretchers in the lowest position with rails up, and isolating clients who present with signs and symptoms of contagious infectious disorders.
If wrong: To ensure client and staff safety, nurses should use two identifiers per The Joint Commission’s National Patient Safety Goals; follow the hospital’s security plan, including de-escalation strategies for people who demonstrate aggressive or violent tendencies; and search belongings to identify essential medical information. Nurses should also use standard fall prevention interventions, including leaving stretchers in the lowest position with rails up, and isolating clients who present with signs and symptoms of contagious infectious disorders.

Q: A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center?
- Level I – Located within remote areas and provides advanced life support within resource capabilities
- Level II – Located within community hospitals and provides care to most injured clients
- Level III – Located in rural communities and provides only basic care to clients
- Level IV – Located in large teaching hospitals and provides a full continuum of trauma care for all clients
A: Level II – Located within community hospitals and provides care to most injured clients
If right: 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 transport to Level I 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.
If wrong: 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 transport to Level I 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.

Q: A client presents to the emergency department after prolonged exposure to the cold. The client is difficult to arouse and speech is incoherent. Which action should the nurse take first?
- Reposition the client into a prone position.
- Administer warmed intravenous fluids to the client.
- Wrap the client’s extremities in warm blankets.
- Initiate extracorporeal rewarming via hemodialysis.
A: Administer warmed intravenous fluids to the client.
If right: Moderate hypothermia manifests with muscle weakness, increased loss of coordination, acute confusion, apathy, incoherence, stupor, and impaired clotting. Moderate hypothermia should be treated by core rewarming methods, which include administration of warm IV fluids, heated oxygen, and heated peritoneal, pleural, gastric, or bladder lavage, and by positioning the client in a supine position to prevent orthostatic changes. The client’s trunk should be warmed prior to the extremities to prevent peripheral vasodilation. Extracorporeal warming with cardiopulmonary bypass or hemodialysis is a treatment for severe hypothermia.
If wrong: Moderate hypothermia manifests with muscle weakness, increased loss of coordination, acute confusion, apathy, incoherence, stupor, and impaired clotting. Moderate hypothermia should be treated by core rewarming methods, which include administration of warm IV fluids, heated oxygen, and heated peritoneal, pleural, gastric, or bladder lavage, and by positioning the client in a supine position to prevent orthostatic changes. The client’s trunk should be warmed prior to the extremities to prevent peripheral vasodilation. Extracorporeal warming with cardiopulmonary bypass or hemodialysis is a treatment for severe hypothermia.

Q: A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at a nurse when dinner is served late. How should the nurse respond?
- “Do you need something for pain right now?”
- “Please stop yelling. I brought dinner as soon as I could.”
- “I suggest that you get control of yourself.”
- “You seem upset. I have time to talk if you’d like.”
A: “You seem upset. I have time to talk if you’d like.”
If right: Clients should be allowed to ventilate their feelings of anger and despair after a catastrophic event. The nurse establishes rapport through active listening and honest communication and by recognizing cues that the client wishes to talk. Asking whether the client is in pain as the first response closes the door to open communication and limits the client’s options. Simply telling the client to stop yelling and to gain control does nothing to promote therapeutic communication.
If wrong: Clients should be allowed to ventilate their feelings of anger and despair after a catastrophic event. The nurse establishes rapport through active listening and honest communication and by recognizing cues that the client wishes to talk. Asking whether the client is in pain as the first response closes the door to open communication and limits the client’s options. Simply telling the client to stop yelling and to gain control does nothing to promote therapeutic communication.

Q: A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority?
- Apply direct pressure to the bleeding.
- Ensure the client has a patent airway.
- Obtain consent for emergency surgery.
- Start two large-bore IV catheters.
A: Ensure the client has a patent airway.
If right: Airway is the priority, followed by breathing and circulation (IVs and direct pressure). Obtaining consent is done by the physician.
If wrong: Airway is the priority, followed by breathing and circulation (IVs and direct pressure). Obtaining consent is done by the physician.