1. An emergency department (ED) nurse is preparing to transfer a client to the trauma intensive care unit. Which information should the nurse include in the nurse-to-nurse hand-off report? (Select all that apply.)

2. Diagnostic test results

3. Immunizations

4. List of home medications e. Isolation precautions ANS: A, B, E

Hand-off communication should be comprehensive so that the receiving nurse can continue care for the client fluidly. Communication should be concise and should include only the most essential information for a safe transition in care. Hand-off communication should include the client’s situation (reason for being in the ED), brief medical history, assessment and diagnostic findings, Transmission-Based Precautions needed,

interventions provided, and response to those interventions.

2. Primary goal of triage by the nurse in the emergency department with Emergency Department patients?

1. Other choice

2. Determine acuity of conditions and establish/prioritize care

3. Other choice

4. Assess ABC’s and deficits

The correct answer is B; D is incorrect because the D in ABCDE stands for disability not deficits

3. An emergency room nurse is triaging victims of a multi-casualty event. Which client should receive care first?

1. A 30-year-old distraught mother holding her crying child

2. A 65-year-old conscious male with a head laceration

3. A 26-year-old male who has pale, cool, clammy skin

4. A 48-year-old with a simple fracture of the lower leg ANS: 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.

4. An emergency room nurse assesses a client who has been raped. With which health care team member should the nurse collaborate when planning this clients care?

1. Emergency medicine physician

2. Case manager

3. Forensic nurse examiner

4. Psychiatric crisis nurse ANS: C

All other members of the health care team listed may be used in the management of this client’s care. However, the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault and can offer the counseling and follow-up needed when dealing with the victim of an assault.

5. The complex care provided during an emergency requires interdisciplinary collaboration. Which interdisciplinary team members are paired with the correct responsibilities? (Select all that apply.)

1. Psychiatric crisis nurse Interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis

2. Forensic nurse examiner Performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources

3. Triage nurse Provides basic life support interventions such as oxygen, basic wound care, splinting, spinal immobilization, and monitoring of vital signs

4. Emergency medical technician Obtains client histories, collects evidence, and offers counseling and follow- up care for victims of rape, child abuse, and domestic violence