Chapter 10: Concepts of Emergency and Trauma Nursing

A new nurse is orienting to the emergency department (ED). Which statement made by the nurse would indicate the need for further education by the preceptor?

"The emergency medicine physician coordinates care with all levels of the emergency health care team."

The nurse is assessing clients on site at a multi-vehicle accident. Triage clients in the order they should receive care. (Place in order of priority.)

- A 50-year-old with chest trauma and difficulty breathing - A 60-year-old with facial lacerations and confusion - A mother frantically looking for her 6-year-old son - An 8-year-old with a broken leg in his father's arms - A pulseless male with a penetrating head wound

The emergency department (ED) nurse is preparing to transfer a client to the critical care unit. What information should the nurse include in the nurse-to-nurse hand-off report? (Select all that apply.)

- Allergies - Vital signs - Isolation precautions

In what sequence would a client move through the process of admission to disposition in emergency care? (Place in order of priority.)

- Emergency medical technicians (EMTs) provide oxygen and vital sign monitoring. - Paramedics arrive and start IV access. - Nurse and other health care provider(s) perform assessment. - Laboratory technician obtains blood specimens. -

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

- Mechanism of injury - Diagnostic test results - Isolation Precautions - Safety concerns

An emergency department nurse is caring for a trauma patient. Which interventions does the nurse perform during the primary survey? (Select all that apply.)

- Needle decompression - Initiating IV fluids - Endotracheal intubation - Removing wet clothing

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

- Psychiatric crisis nurse—interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis - Paramedic—provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration

The nurse is discharging an older adult client home from the emergency department (ED) after an acute episode of angina. What should the nurse do to ensure client safety upon discharge? (Select all that apply.)

- Reconcile the client's prescription and over-the-counter medications - Screen the client for functional and cognitive abilities, as well as risk for falls - Review discharge instructions with the client and a family member

Which interventions will be performed during the primary survey for a trauma client? (Select all that apply.)

- Removing wet clothing - Initiating IV fluids - Endotracheal intubation - Needle decompression

A nurse prepares to discharge an older adult client home from the emergency department (ED). What actions does the nurse take to prevent future ED visits? (Select all that apply.)

- Screen for depression and suicide. - Complete a functional assessment.

A nurse is caring for clients in a busy emergency department. What actions would the nurse take to ensure client and staff safety? (Select all that apply.)

- 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. - Use facility policy identification procedures for "Jane/John Doe" clients. - Check clients for a medical alert bracelets or necklaces.

The emergency department (ED) nurse is caring for the following clients. Which client does the nurse prioritize to see first?

45-year-old reporting chest pain and diaphoresis

The nurse is triaging clients in the emergency department. Which client should be considered urgent?

75-year-old female with a cough and of temperature of 102° F

An emergency department nurse is triaging victims of a multi-casualty event. Which client would receive care first?

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

A nurse is triaging clients in the emergency department (ED). Which client would the nurse prioritize to receive care first?

A 45 year old reporting chest pain and diaphoresis

A nurse is triaging clients in the emergency department. Which client would the nurse classify as "nonurgent?"

A 62 year old with a simple fracture of the left arm

A nurse is triaging clients in the emergency department. Which client would be considered "urgent"?

A 75-year-old female with a cough and a temperature of 102° F (38.9° C)

The emergency department nurse is assigned an older adult client who is confused and agitated. Which intervention should the nurse include in the client's plan of care?

Ask a family member to stay with the client.

The emergency department team is performing cardiopulmonary resuscitation on a client when the client's spouse arrives. Which action would the nurse take first?

Ask the spouse if he or she wishes to be present during the resuscitation.

The emergency department team is performing cardiopulmonary resuscitation on a client when the client's spouse arrives at the emergency department. What should the nurse do next?

Ask the spouse if he wishes to be present during the resuscitation.

A client arrives at the emergency department following a motor vehicle collision. The client is not awake and is being bagged with a bag-valve-mask by paramedics. The client has sustained obvious injuries to the head and face, as well as an open right femur fracture that is bleeding profusely. What will the nurse do first?

Assess for a patent airway.

The emergency medical technicians (EMTs) arrive at the emergency department with an unresponsive client with an oxygen mask in place. What will the nurse do first?

Assess that the client is breathing adequately

Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action would the nurse take first?

Assess that the client is breathing adequately.

An unresponsive client with poor ventilator effort and a pulse rate of 120 beats/min arrives at the emergency department. What should the nurse do first?

Begin bag-valve-mask ventilation.

An emergency department nurse is transferring a client to the medical-surgical unit. What is the most important nursing intervention in this situation?

Clearly communicate client data to the unit nurse.

A client in the emergency department has died from a suspected homicide. What is the nurse's priority intervention?

Communicate the client's death to the family in a simple and concrete manner.

An emergency department nurse is caring for a client who has died from a suspected homicide. Which action does the nurse take?

Communicate the client's death to the family in a simple and concrete manner.

What is the primary goal of a triage system used by the nurse with clients presenting to the emergency department?

Determine the acuity of the client's condition to determine priority of care.

A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. What should the nurse do before providing advanced cardiac life support?

Don personal protective equipment.

A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action would the nurse take prior to providing advanced cardiac life support?

Don personal protective equipment.

An emergency department nurse assesses a client who has been raped. With which health care team member would the nurse collaborate when planning this client's care?

Forensic nurse examiner

A nurse is triaging clients in the emergency department. Which client complaint would the triage nurse classify as nonurgent?

Left arm fracture with palpable radial pulses

A client has been injured in a stabbing incident. Assessment reveals the following:Blood pressure: 80/60 mm HgHeart rate: 140 beats/minRespiratory rate: 35 breaths/minBleeding from stabbing wound siteClient is lethargicBased on these assessment data, to which trauma center should the nurse ensure transport of the client?

Level I

A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center?

Level II—located within community hospitals and provides care to most injured clients

An emergency department nurse is caring for a client who is homeless. Which action would the nurse take to gain the client's trust?

Listen to the client's concerns and needs.

An elderly client who has fallen from a roof is transported to the emergency department by ambulance. The client was unconscious at the scene but is conscious on arrival and is triaged as urgent. What is the priority assessment the nurse includes during the primary survey of the patient?

Neurologic status

The nurse is triaging clients in the emergency department (ED). Which is true about the presentation of client symptoms?

Older adults frequently have symptoms that are vague or less specific.

The emergency department (ED) nurse is assigned to triage clients. What is the purpose of triage?

Prioritize clients based on illness severity.

An emergency department (ED) case manager is consulted for a client who is homeless. Which intervention would the case manager provide?

Provide referrals to subsidized community-based health clinics.

The nurse is caring for a homeless client and consults the emergency department (ED) case manager. What can the ED case manager do for this client?

Provide referrals to subsidized community-based health clinics.

On admission to the emergency department, a client states that he feels like killing himself. When planning this client's care, it is most important for the nurse to coordinate with which member of the health care team?

Psychiatric crisis nurse

The nurse is providing care for a client admitted for suicidal precautions. What priority intervention should the nurse implement first?

Remove oxygen tubing from the room.

While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action would the nurse take first?

Transfer the client to a negative-pressure room.

The nurse manager is assessing current demographics of the facility's emergency department (ED) clients. Which population would most likely present to the ED for treatment of a temperature and a sore throat?

Underinsured people