An infant was brought to the emergency department with fever and respiratory distress. During the primary assessment, the nurse observed nasal flaring, nasal secretions, retractions, and coughing, so the patient’s nares were suctioned and high-flow oxygen was initiated. During the secondary assessment, the nurse observes that the patient’s breathing has become irregular and peripheral oxygen […]

An infant is brought to the emergency department with coughing and respiratory distress. In obtaining the history as part of the secondary assessment, the nurse determines that the patient has not received a pertussis vaccination. Suddenly, the patient moves from respiratory distress to respiratory failure. What step should the nurse take next? A. Don appropriate […]

Asking the patient’s perspective on the patient-provider relationship, is an example of (choose only one answer): • Clinical excellency according to Hanyok (2012) • A process that takes a fair amount of time, and is really not that important in the big picture • A routine and common practice where a clinician asks a series […]

An adolescent who was hit in the head by a baseball bat is brought to the emergency department. The patient has no history of loss of consciousness, and the nurse observes a large hematoma to the right occipital area with no other injuries. During the secondary assessment, the nurse observes that the patient opens the […]

A nurse obtains information about a preschooler who has had four seizures at home in the past 2 days. The patient is healthy except for the seizure disorder but had been seizure-free for 11 months and has had no hospital stays, surgeries, allergies, or recent illnesses or injuries. The patient’s immunizations are up to date, […]

The primary assessment has been completed on a preadolescent who fell 15 feet down from a tree. During the secondary assessment, the nurse observes that the patient has chest tenderness, as well as back and neck pain. What should the nurse’s next action be? A. Send for cervical spinal imaging. B. Place the patient on […]

Mrs. Huerta says her son Henry, who is in the 5th grade, was recently screened for hearing at his school, and she shows you a document that supports that fact. Henry’s hearing checked out fine. According to the Texas Health Steps Periodicity Schedule, 10-year-old Henry is due for his audiometric screening. Do you perform the […]

An infant is brought to the ED with a fever and respiratory distress. The PAT reveals that the infant is sleepy and tachypneic, with nasal flaring and retractions. During the airway assessment, the nurse observes nasal flaring, nasal secretions, retractions, and coughing. What is the appropriate initial intervention? A. Open the airway with a head-tilt […]

The intensive care unit nurse has just received report from the ED nurse regarding a 7-year-old patient who was involved in a car crash. Based on the report, the patient’s cervical spine was cleared in the ED. The patient remains on the long backboard that was placed under the back on arrival to the ED. […]

A family brings a young infant to the ED, stating that the infant has had an axillary temperature up to 38.9°C (102°F) at home and has a “funny rash.” The patient has vomitus coming from the mouth. What should the nurse’s first action be? A. Auscultate breath sounds. B. Obtain an accurate weight. C. Undress […]