Chapter 21 - Prioritization, Delegation, and Assignment

When a primary survey of a trauma client is conducted, what is one of the *priority* actions that would be performed *first*? •Obtain a complete set of vital sign measurements •Palpate and auscultate the abdomen •Perform a brief neurologic assessment •Check the pulse oximetry reading

•Perform a brief neurologic assessment •A brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary survey. Measuring vital signs, assessing the abdomen, and checking pulse oximetry readings are considered part of the secondary survey.

The nurse manager decides to form a committee to address the issue of violence against emergency department (ED) personnel. Which combination of employees would be *best* suited to fulfill this assignment? •ED physicians and charge nurses •Experienced RNs and experienced paramedics •RNs, LPNs/LVNs, and unlicensed assistive personnel •At least one person from all ED groups

•At least one person from all ED groups •At least one representative from each group should be included because all employees are potential targets for violence in the ED.

Emergency medical services has transported a client with severe chest pain. As the client is being transferred to the emergency stretcher, the nurse notes unresponsiveness, cessation of breathing, and no palpable pulse. Which task is appropriate to delegate to the unlicensed assistive personnel (UAP)? •Performing chest compressions •Initiating bag-valve mask ventilation •Assisting with oral intubation •Placing the defibrillator pads

•Performing chest compressions

A man with a known history of alcohol abuse has been in police custody for 48 hours. Initially, anxiety, sweating, and tremors were noted. Now disorientation, hallucination, and hyperreactivity are observed. The medical diagnosis is delirium tremens. What is the *priority* nursing concept to consider in planning interventions for this emergency condition? •Safety •Psychosis •Thermoregulation •Addiction

•Safety •The client demonstrates neurologic hyperreactivity and is on the verge of a seizure. Client safety is the priority. The client needs medications such as chlordiazepoxide to decrease neurologic irritability and phenytoin for seizures. Thiamine is given to correct underlying nutritional deficiency, and haloperidol may be prescribed for the psychotic symptoms.

The nurse is talking to a group of people about an industrial explosion in which many people were killed or injured. Which individual has the *greatest* risk for psychiatric difficulties, such as post-traumatic stress disorder, related to the incident? •Individual who repeatedly watched television coverage of the event •Person who recently learned that her son was killed in the incident •Individual who witnessed the death of a co-worker during the explosion •Person who was injured and trapped for several hours before rescue

•Person who was injured and trapped for several hours before rescue •Any of these people may need or benefit from psychiatric counseling. Obviously, there will be variations in previous coping skills and support systems; however, a person who experienced a threat to his or her own life is at the greatest risk for psychiatric problems after a disaster incident.

A confused client admits to frequently drinking alcohol. The emergency department health care provider (HCP) makes a preliminary diagnosis of Wernicke encephalopathy. Which medication does the nurse anticipate that the HCP will prescribe *initially*? •Glucagon IV •Naltrexone IM •Thiamine IV •Naloxone IV

•Thiamine IV •Wernicke encephalopathy is caused by a thiamine deficiency and manifests as confusion, nystagmus, and abnormal ocular movements. It can be reversed with thiamine. IV glucagon is given if change of mental status is caused by severe hypoglycemia. Naltrexone is used to decrease the craving for alcohol. Naloxone is used to reverse opioid overdose.

When an unexpected death occurs in the emergency department, which task is *most* appropriate to delegate to the unlicensed assistive personnel (UAP)? •Escorting the family to a place of privacy •Accompanying organ donor specialist to talk to family •Assisting with postmortem care •Helping the family to collect belongings

•Assisting with postmortem care •Postmortem care requires some turning, cleaning, lifting, and so on, and the UAP is able to assist with these duties. The RN should take responsibility for the other tasks to help the family begin the grieving process. In cases of questionable death, belongings may be retained for evidence, so the chain of custody would have to be maintained.

According to The Joint Commission, hospitals are required to form emergency management committees to periodically exercise the disaster operations plan. Hospital administration has selected various health care providers (HCPs) to join the committee. Members from which other key departments should be included? *Select all that apply.* •Security and communications •Nursing and unlicensed assistive personnel •Laboratory and diagnostic services •Medical and information technology •Maintenance and engineering •Physical therapy and occupational therapy

•Security and communications •Nursing and unlicensed assistive personnel •Laboratory and diagnostic services •Medical and information technology •Maintenance and engineering •When the disaster plan is activated, the expectation is that a large number of clients will arrive who need triage and various levels of care. Security and communications are essential to the flow of people and information in and out of the facility. HCPs, nurses, and unlicensed assistive personnel are assigned to care for clients. Laboratory and diagnostic services are required for ongoing client care. Accurate records and client tracking is essential during a disaster. Maintenance and engineering are responsible for the ongoing integrity of the facility's structure. In fact, all hospital personnel are needed in the immediate period after a disaster, but members of departments such as quality improvement, physical therapy, volunteer services, and occupational therapy are less likely to be performing their usual functions.

The nurse is assessing a client who has sustained a cat bite to the left hand. The cat's immunizations are up to date. The date of the client's last tetanus shot is unknown. What is the *priority* concern? •Treating infection specific to cat bites •Suturing the puncture wounds •Administering tetanus vaccine •Maintaining mobility of finger joints

•Treating infection specific to cat bites •Cats' mouths contain a virulent organism, Pasteurella multocida, which can lead to septic arthritis or bacteremia. Appropriate first aid includes rigorous washing of the wound site with soap and water to combat infection. Puncture wounds, especially those caused by bites, are usually not sutured. There is also a risk for tendon damage and loss of joint mobility caused by deep puncture wounds, but an orthopedic surgeon would be consulted after initial emergency care is started. A tetanus shot can be given before discharge.

The nurse is assigned to telephone triage. A client who was just stung by a common honeybee calls for advice. Which question would the nurse ask first? •"Is this the first time you have been stung by a bee or wasp?" •"Do you have access to and know how to use an epinephrine autoinjector?" •"What type of first aid measures have you tried?" •"Are you having any facial swelling, wheezing, or shortness of breath?"

•"Are you having any facial swelling, wheezing, or shortness of breath?" •First, the nurse would try determine if the client is having a severe allergic reaction to the bee sting. Facial swelling, wheezing, or shortness of breath can rapidly progress to a life-threatening airway obstruction. If these signs and symptoms are occurring, the nurse would instruct the client to call 911 and to use the epinephrine autoinjector if it is available. If the client is not having a life-threatening reaction, the nurse could ask other questions to determine appropriate interventions.

The nurse is working in a small rural community hospital. There is a fire in a local church, and six injured clients have arrived at the hospital. Many others are expected to arrive soon, and other hospitals are 5 hours away. Using disaster triage principles, place the following six clients in the order in which they should receive medical attention, with 1 being the first to receive attention and 6 being the last to receive attention. •A 52-year-old man in full cardiac arrest who has been receiving cardiopulmonary resuscitation (CPR) continuously for the past 60 minutes •A firefighter who is showing combative behavior and has respiratory stridor •A 60-year-old woman with full-thickness burns to the hands and forearms •A teenager with a crushed leg that is very swollen; he is anxious and has tachycardia •A 3-year-old child with respiratory distress and burns over more than 70% of the anterior body •A 12-year-old child with wheezing and very labored respirations unrelieved by an asthma inhaler

•A 12-year-old child with wheezing and very labored respirations unrelieved by an asthma inhaler •A firefighter who is showing combative behavior and has respiratory stridor •A teenager with a crushed leg that is very swollen; he is anxious and has tachycardia •A 60-year-old woman with full-thickness burns to the hands and forearms •A 3-year-old child with respiratory distress and burns over more than 70% of the anterior body •A 52-year-old man in full cardiac arrest who has been receiving cardiopulmonary resuscitation (CPR) continuously for the past 60 minutes •Treat the 12-year-old child with asthma first by initiating an albuterol treatment. This action is quick to initiate, and the child or parent can be instructed to hold the apparatus while the nurse attends to other clients. The firefighter is in greater respiratory distress than the 12-year-old child; however, managing a strong combative client is difficult and time consuming (e.g., the 12-year-old could die if too much time is spent trying to control the firefighter). Attend to the teenager with a crush injury next. Anxiety and tachycardia may be caused by pain or stress; however, the swelling suggests hemorrhage. Next attend to the woman with burns on the forearms by providing dressings and pain management. The child with burns over more than 70% of the anterior body should be given comfort measures; however, the prognosis is very poor. The prognosis for the client in cardiac arrest is also very poor because CPR efforts have been prolonged.

The following clients come to the emergency department triage desk reporting acute abdominal pain. Which client has the *most* severe condition? •A 35-year-old man reporting severe intermittent cramps with three episodes of watery diarrhea 2 hours after eating •An 11-year-old boy with a low-grade fever, right lower quadrant tenderness, nausea, and anorexia for the past 2 days •A 23-year-old woman reporting dizziness and severe left lower quadrant pain who states she is possibly pregnant •A 50-year-old woman who reports gnawing midepigastric pain that is worse between meals and during the night

•A 23-year-old woman reporting dizziness and severe left lower quadrant pain who states she is possibly pregnant •The woman with lower left quadrant pain is at risk for ectopic pregnancy. This is a life-threatening condition. The 11-year-old boy needs evaluation to rule out appendicitis. The 35-year-old man has food poisoning, which is usually self-limiting. The woman with midepigastric pain may have an ulcer, but follow-up diagnostic testing and teaching of lifestyle modification can be scheduled with the primary care provider.

The nurse is caring for a client with multiple injuries sustained during a head-on car collision. Which assessment finding takes *priority*? •A deviated trachea •Unequal pupils •Ecchymosis in the flank area •Irregular apical pulse

•A deviated trachea •A deviated trachea is a symptom of tension pneumothorax, which will result in respiratory arrest if not corrected. All of the other symptoms are potentially serious but are of lower priority.

A 56-year-old client comes to the triage area with left-sided chest pain, diaphoresis, and dizziness. What is the *priority* action? •Initiate continuous electrocardiographic monitoring •Notify the emergency department health care provider •Administer oxygen via nasal cannula •Draw blood and establish IV access

•Administer oxygen via nasal cannula •The priority goal is to increase myocardial oxygenation. The other actions are also appropriate and should be performed immediately after administering oxygen.

An experienced traveling nurse has been assigned to work in the emergency department (ED); however, this is the nurse's first week on the job. Which area of the ED is the *most* appropriate assignment for this nurse? •Trauma team •Triage •Ambulatory or fast-track clinic •Pediatric medicine team

•Ambulatory or fast-track clinic •The fast-track clinic deals with clients in relatively stable condition. The triage, trauma, and pediatric medicine areas should be staffed with experienced nurses who know the hospital routines and policies and can rapidly locate equipment.

The charge nurse in an emergency department (ED) and must assign two staff members to cover the triage area. Which team is the *most* appropriate for this assignment? •An advanced practice nurse and an experienced RN •An experienced LPN/LVN and an inexperienced RN •An experienced RN and an inexperienced RN •An experienced RN and an experienced unlicensed assistive personnel (UAP)

•An advanced practice nurse and an experienced RN •Triage requires at least one experienced RN. Advanced practice nurses can perform medical screening exams, and this expedites treatment and decreases overall time spent in the ED. Pairing an experienced RN with an inexperienced RN provides opportunities for mentoring. This would be the second-best choice. Pairing an experienced RN with an experienced UAP is an option if licensed staff is unavailable because the UAP can measure vital signs and assist in transporting. An LPN/LVN is not qualified to perform the initial client assessment or decision making, and the expertise of the LPN/LVN could be used elsewhere in a busy ED.

The nurse is working in the triage area of an emergency department, and the following four clients approach the triage desk at the same time. List the order in which the nurse will assess these clients. •An ambulatory, dazed 25-year-old man with a bandaged head wound •An irritable newborn with a fever, petechiae, and nuchal rigidity •A 35-year-old jogger with a twisted ankle who has a pedal pulse and no deformity •A 50-year-old woman with moderate abdominal pain and occasional vomiting

•An irritable newborn with a fever, petechiae, and nuchal rigidity •An ambulatory, dazed 25-year-old man with a bandaged head wound •A 50-year-old woman with moderate abdominal pain and occasional vomiting •A 35-year-old jogger with a twisted ankle who has a pedal pulse and no deformity •An irritable newborn with fever and petechiae should be further assessed for other signs of meningitis. The client with the head wound needs additional assessment because of the risk for increased intracranial pressure. The client with moderate abdominal pain is in discomfort, but her condition is not unstable at this point. For the ankle injury, medical evaluation could be delayed for 24 to 48 hours if necessary, but the client should receive the appropriate first aid.

A client involved in a one-car rollover comes in with multiple injuries. List in order of priority the interventions that must be initiated for this client. •Secure two large-bore IV lines and infuse normal saline •Use the chin lift or jaw thrust maneuver to open the airway •Assess for spontaneous respirations •Give supplemental oxygen via mask •Obtain a full set of vital sign measurements •Remove or cut away the client's clothing's

•Assess for spontaneous respirations •Use the chin lift or jaw thrust maneuver to open the airway •Give supplemental oxygen via mask •Secure two large-bore IV lines and infuse normal saline •Obtain a full set of vital sign measurements •Remove or cut away the client's clothing •For a trauma client with multiple injuries, many interventions (e.g., assessing for spontaneous respirations, performing techniques to open the airway such as chin lift or jaw thrust, and applying oxygen) may occur simultaneously as team members assist in the resuscitation A quick assessment of respiratory status precedes intervention. Opening the airway must precede the administration of oxygen because, if the airway is closed, the oxygen cannot enter the air passages. Starting IV lines for fluid resuscitation is part of supporting circulation. (Emergency medical service personnel will usually establish at least one IV line in the field.) Unlicensed assistive personnel can be directed to obtain and report vital signs and remove or cut away clothing.

The nurse is caring for a client who is on the cardiac monitor because of these symptoms: syncope, dizziness, and intermittent episodes of palpitations. The nurse sees (occasional premature ventricular contractions) on the cardiac monitor. What should the nurse do first? •Call the Rapid Response Team •Obtain the automated external defibrillator •Assess the client and take vital signs •Check the adherence of the gel pads on the chest

•Assess the client and take vital signs •The nurse recognizes that the monitor is showing sinus rhythm with occasional premature ventricular contractions (PVCs). The client is likely to be alert and in no distress. Sometimes people do report the subjective sensation of "skipped beats." The nurse would ask the client about subjective symptoms and assess for any signs of decreased cardiac output or problems related to decreased perfusion. The nurse would continue to observe the client. Increase in frequency or duration of PVCs can precede ventricular tachycardia or dysthymias.

Identify the five most critical elements in performing disaster triage for multiple victims. •Obtain past medical and surgical histories •Check airway, breathing, and circulation •Assess the level of consciousness •Visually inspect for gross deformities, bleeding, and obvious injuries •Note the color, presence of moisture, and temperature of the skin •Check vital signs, including pulse and respirations

•Check airway, breathing, and circulation •Assess the level of consciousness •Visually inspect for gross deformities, bleeding, and obvious injuries •Note the color, presence of moisture, and temperature of the skin •Check vital signs, including pulse and respirations •Quickly assessing respiratory effort, level of consciousness, obvious injuries, appearance of skin (indicative of peripheral perfusion), and vital signs are appropriate for disaster triage. Other information, such as medical and surgical history, medication history, support systems, and last tetanus booster, would be collected when the staff has more time and resources.

After emergency endotracheal intubation, the health care team and the nurse must verify tube placement before securing the tube. What is the most accurate bedside assessment that can be performed *immediately* after the tube is placed? •Visualize the movement of the thoracic cage •Auscultate the chest during assisted ventilation •Confirm that the breath sounds are equal and bilateral •Check exhaled carbon dioxide levels with capnography

•Check exhaled carbon dioxide levels with capnography •Checking exhaled carbon dioxide levels is the most accurate way of immediately verifying placement. Observing chest movements and auscultating and confirming equal bilateral breath sounds are considered less accurate. (Note to student: Possibly, you may see the health care team auscultating the chest; this is a long-time practice that is quick to perform and doesn't harm the client if used in conjunction with other verification methods.) Radiographic study will verify and document correct placement.

The LPN/LVN is performing care for a client who sustained an amputation of the first and second digits in a chainsaw accident. What instructions would the RN give to the LPN/LVN? •Clean the amputated digits and the hand with a povidone-iodine and normal saline solution; then wrap with gauze •Clean the amputated digits, wrap them in gauze, and place cleansed digits directly into an ice slurry •Clean the amputated digits with saline, wrap in moist gauze, seal in a plastic bag, and place in ice slurry •Clean the digits with sterile normal saline and submerge the digits in sterile normal saline in a sterile cup

•Clean the amputated digits with saline, wrap in moist gauze, seal in a plastic bag, and place in ice slurry •The correct intervention is to gently cleanse the digits with normal saline, wrap them in sterile gauze moistened with saline, and place them in a plastic bag or container. The container is then placed in an ice slurry.

A newly hired emergency department (ED) clinical nurse specialist (CNS) is reviewing the hospital's disaster plan and finds that it has not been reviewed or revised for 3 years. Which finding will be *most* important for the CNS to address related to the status of the disaster plan? •Stockpiles of antibiotics and resuscitation equipment may be depleted •Current staff is unlikely to have training and practice in using the plan •Resources within and outside of the hospital are likely to have changed •Surrounding communities are at increased risk for technologic disasters

•Current staff is unlikely to have training and practice in using the plan •The ED CNS would be most concerned that the staff has not had any training or practice opportunities for at least the past 3 years because training staff members is the direct responsibility of the CNS. The Joint Commission recommends biannual training practice and rehearsal; training exercises also provide data that can be used to revise and update the plan. The CNS should also alert hospital administration about the need to inventory stockpiles, to conduct an internal and external resource analysis, and to contact public health officials about increased risk in surrounding communities.

A group of people arrive at the emergency department by private car. They all have extreme periorbital swelling, coughing, and tightness in the throat. There is a strong odor emanating from their clothes. They report exposure to a "gas bomb" that was set off in their house. What is the *priority* action? •Measure vital signs and listen to lung sounds •Direct clients to the decontamination area •Alert security about possible terrorism activity •Direct clients to cold or clean zones for immediate treatment

•Direct clients to the decontamination area •Decontamination in a specified area is the priority. Performing assessments delays decontamination and does not protect the total environment. Personnel should don personal protective equipment before assisting with decontamination or assessing the clients. The clients must undergo decontamination before entering cold or clean areas. The nurse should notify the charge nurse or nurse manager about communicating with security regarding potential terrorist activities.

An emergency department clinical nurse specialist is training staff in how to don and doff personal protective equipment (PPE) when caring for clients with infections, such as Ebola. Which staff member has demonstrated the *most* grievous error during the practice session? •Triage nurse forgets to perform hand hygiene before donning PPE •Unlicensed assistive personnel performs self-inspection; then begins to doff PPE •Health care provider forgets to wipe shoes with disinfectant after doffing shoe covers •Emergency medical technician doffs both pairs of gloves first

•Emergency medical technician doffs both pairs of gloves first •All team members have made errors, but removing both pairs of gloves puts the emergency medical technician at the greatest risk because the outer surfaces of the remaining PPE are considered contaminated. According to the latest recommendations from the Centers for Disease Control and Prevention, the flow of donning is as follows: hand hygiene, inner gloves, shoe covers, gown, N95 respirator, hood, outer gloves, face shield, inspection (by self and trained observer), range of motion, and hand hygiene. The flow of doffing is inspection (by self and trained observer), hand hygiene, remove shoe covers, remove outer gloves, inspect inner gloves, remove face shield, hand hygiene, remove hood, hand hygiene, remove gown, hand hygiene, remove inner gloves, hand hygiene, apply new gloves, remove n95 respirator, hand hygiene, disinfect shoes, hand hygiene, remove gloves, hand hygiene, and inspection (by self and trained observer).

The nurse is giving discharge instructions to a woman who has been treated for contusions and bruises sustained during an episode of domestic violence. What is the *priority* intervention for this client? •Encourage client to go to a safe house •Make a referral to a counselor •Advise the client about contacting the police •Make an appointment to follow up on the injuries

•Encourage client to go to a safe house •Safety is a priority for this client, and she should not return to a place where violence could recur. The other options are important for the long-term management of this case.

The nurse responds to a call for help from the emergency department waiting room. An older adult client is lying on the floor. List the order in which the nurse must carry out the following actions. •Perform the chin lift or jaw thrust maneuver •Establish unresponsiveness •Initiate cardiopulmonary resuscitation (CPR) •Call for help and activate the code team •Instruct unlicensed assistive personnel to get the crash cart

•Establish unresponsiveness •Call for help and activate the code team •Perform the chin lift or jaw thrust maneuver •Initiate cardiopulmonary resuscitation (CPR) •Instruct unlicensed assistive personnel to get the crash cart •Establish unresponsiveness first. (The client may have fallen and sustained a minor injury.) If the client is unresponsive, get help and activate the code team. Performing the chin lift or jaw thrust maneuver opens the airway. The nurse is then responsible for starting CPR. A pocket mask or bag-valve mask is used to deliver rescue breaths. CPR should not be interrupted until the client recovers or it is determined that all heroic efforts have been exhausted. A crash cart should be at the site when the code team arrives; however, basic CPR can be effectively performed until the code team arrives.

The nurse notifies the emergency department (ED) health care provider (HCP) about a client who reports abdominal pain, nausea and vomiting, and fever. The abdomen is distended, rigid, and boardlike, and there is rebound tenderness. Later the nurse sees that the client is to be discharged with a follow-up appointment in the morning. The nurse reexamines the client and the symptoms seem worse. What should the nurse do *first*? •Contact the nursing supervisor and express concerns •Express findings and concerns to the HCP •Discharge the client but stress the importance of follow-up •Follow the discharge orders and write an incident report

•Express findings and concerns to the HCP •First, the nurse tries to express concerns to the HCP. The ED can be very hectic, and the ED staff should work as a team and watch out for each other as well as the clients. If the HCP refuses to consider concerns, then the nurse may have to contact the nursing supervisor or write an incident report. This client has the signs of peritonitis. If the client dies or has a poor outcome, the nurse is liable for failing to intervene.

The client's blood alcohol level is 0.45%. Based on this information, what is the *priority* nursing concept that underlies emergency medical and nursing interventions for this client? •Cognition •Addiction •Gas exchange •Functional ability

•Gas exchange •At a blood alcohol level of 0.45%, the client would demonstrate respiratory depression, stupor, and coma. At 0.05%, client would display euphoria and decreased inhibitions; at 0.20%, reduced motor skills and slurred speech occur; and at 0.30%, altered perception and double vision occur.

A healthy but anxious 24-year-old college student reports tingling sensations, palpitations, and sore chest muscles. Deep, rapid breathing and carpal spasms are noted. What priority action should the nurse take? •Notify the health care provider immediately •Administer supplemental oxygen •Have the student breathe into a paper bag •Obtain an order for an anxiolytic medication

•Have the student breathe into a paper bag •The client is hyperventilating secondary to anxiety, and breathing into a paper bag will allow rebreathing of carbon dioxide. Also, encouraging slow breathing will help. Other treatments such as oxygen administration and medication may be needed if other causes are identified.

It is the summer season, and clients with signs and symptoms of heat-related illness come to the emergency department. Which client needs attention *first*? •Older adult reports dizziness and syncope after standing in the sun for several hours to view a parade •Marathon runner reports severe leg cramps and nausea and shows tachycardia, diaphoresis, pallor, and weakness •Healthy homemaker reports that air conditioner has been broken for days; she has tachypnea, hypotension, fatigue, and profuse diaphoresis •Homeless person displays altered mental status, poor muscle coordination, and hot, dry, ashen skin; duration of heat exposure is unknown

•Homeless person displays altered mental status, poor muscle coordination, and hot, dry, ashen skin; duration of heat exposure is unknown •The homeless person has symptoms of heat stroke, a medical emergency that increases the risk for brain damage. The older adult client is at risk for heat syncope and should be educated to rest in a cool area and avoid future similar situations. The runner is having heat cramps, which can be managed with rest and fluids. The housewife is experiencing heat exhaustion, and management includes administration of fluids (IV or oral) and cooling measures.

A young woman is brought to the emergency department (ED) by emergency medical services (EMS). EMS reports they were called because the woman has been depressed and threatening to commit suicide. On arrival to the ED, the woman is confused; her speech is slurred, and there is vomit on her clothes. EMS found several empty prescription bottles at the house. What are the *priority* interventions for this client? •Identify toxic substances by history and analysis of blood, urine, and gastric contents •Initiate supportive care, such as checking airway and giving oxygen and IV fluids •Reduce absorption by giving activated charcoal or performing gastric lavage •Promote poison removal using drugs to facilitate excretion or by starting hemodialysis

•Initiate supportive care, such as checking airway and giving oxygen and IV fluids •Maintaining airway, oxygenation, and circulation are the priorities. The other steps are also important in managing clients who have ingested toxic substances.

A victim of heat stroke arrives in the emergency department. His skin is hot and dry; his body temperature is 105°F (40.6°C). He is confused and demonstrates bizarre behavior. His blood pressure is 85/60 mm Hg, pulse 130 beats/min, and respirations are 40 breaths/min. Which task should be assigned to an experienced LPN/LVN? •Insert a rectal probe to measure core body temperature •Administer aspirin or another antipyretic •Insert an indwelling urinary drainage catheter •Assess respiratory effort, hemodynamics, and mental status

•Insert an indwelling urinary drainage catheter •Inserting an indwelling urinary catheter is within the scope of practice of an experienced LPN/LVN. Experienced unlicensed assistive personnel should be directed to insert the rectal probe to monitor the core temperature. Initial assessment of new clients and critically ill clients should be performed by the RN. Aspirin and other antipyretics are not given because they won't work to decrease the body temperature and may be harmful. The care of this client would also include arterial blood gases; possible endotracheal intubation; IV fluids; blood for electrolytes, cardiac and liver enzymes, and complete blood count; muscle relaxants (benzodiazepines) if the client begins to shiver; monitoring urine output and specific gravity to determine fluid needs; cooling interventions; and discontinuing cooling interventions when core body temperature is reduced to 102°F (38.9°C).

A client presents to triage with fever, myalgia, severe headache, abdominal pain, vomiting, diarrhea, and unexplained bruising that started after returning from Africa. The triage nurse suspects, but is unsure, that the client may have Ebola. What should the nurse do *first*? •Delay any additional assessment or questioning and don full personal protective equipment •Isolate the client in a private room and initiate standard, contact, and droplet precautions •Direct all clients and staff out of the triage area and call the infection control department •Continue assessment and questioning to determine the likelihood of exposure to Ebola

•Isolate the client in a private room and initiate standard, contact, and droplet precautions •First, the nurse would isolate the client and initiate standard, contact, and droplet precautions. The person can be taken out of isolation at any time if the health care provider (HCP) determines that the client does not have Ebola, but in the meantime, isolation precautions protect others. After the client is in isolation, the nurse's next actions are based on the acuity of the client. If the client needs immediate assistance, the nurse would alert the HCP and charge nurse. Selected team members would don personal protective equipment, and care would be initiated. The infection control department should be notified as soon as possible so that system-wide measures can be activated as needed.

In the work setting, what is the nurse's *primary* responsibility in preparing for management of disasters, including natural disasters and bioterrorism incidents? •Knowing the agency's emergency response plan •Being aware of the signs and symptoms of potential agents of bioterrorism •Knowing how and what to report to the Centers for Disease Control and Prevention •Making ethical decisions about exposing self to potentially lethal substances

•Knowing the agency's emergency response plan •In preparing for disasters, the RN should be aware of the emergency response plan. The plan gives guidance that includes the roles of team members, responsibilities, and mechanisms of reporting. Signs and symptoms of exposure to many agents will mimic common complaints, such as flulike symptoms. Discussions with colleagues and supervisors may help the individual nurse to sort through ethical dilemmas related to potential danger to self.

Tetanus immunizations are routinely administered during childhood and in the emergency department (ED) for clients who sustain wounds. Although the incidence of tetanus has decreased, there is still a danger. Which client represents the group that is *most* vulnerable for risk? •Child who helps with the farm work sustained scratches while feeding the animals •Newborn infant delivered in the emergency department; mother had no prenatal care •Older adult who lives alone sustained a minor cut while cleaning the basement •Young adult who works in an auto repair shop sustained a deep cut on a metal edge

•Older adult who lives alone sustained a minor cut while cleaning the basement •Older adults are the most likely to be nonvaccinated or undervaccinated. Tetanus usually occurs when a minor wound gets contaminated by wood, metal, or other organic material. In addition, most people would not seek medical treatment for minor wounds. Farm work offers many opportunities for injuries, but most children are usually immunized before entering elementary school (the nurse should always ask). Persons with deep cuts from industrial accidents are more likely to present to the ED for treatment. Neonatal tetanus is more likely to occur in underdeveloped countries related to poor hygienic conditions during birth.

A client comes to the emergency department and reports nausea, vomiting, colicky abdominal pain, fever, and tachycardia. The health care provider informs the nurse that the client probably has a strangulated intestinal obstruction with perforation. What diagnostic testing and interventions does the nurse anticipate for this emergency condition? *Select all that apply.* •Preparation for surgery •Barium enema examination •Nasogastric (NG) tube insertion •Abdominal radiography •IV fluid administration •IV administration of broad-spectrum antibiotics

•Preparation for surgery •Nasogastric (NG) tube insertion •Abdominal radiography •IV administration of broad-spectrum antibiotics •Strangulated intestinal obstruction is a surgical emergency. The NG tube is for decompression of the intestine. Abdominal radiography is the most useful diagnostic aid. IV fluids are needed to maintain fluid and electrolyte balance. IV broad-spectrum antibiotics are usually ordered. A barium enema examination is not ordered if perforation is suspected.

Emergency and ambulatory care nurses are among the first health care workers to encounter victims of a bioterrorist attack. List in order of priority the actions that should be taken by emergency department staff in the event of a biochemical incident. •Report to public health department or Centers for Disease Control and Prevention per protocol •Decontaminate the affected individuals in a separate area •Protect the environment for the safety of personnel and nonaffected clients •Don personal protective equipment •Perform triage according to protocol

•Protect the environment for the safety of personnel and nonaffected clients •Don personal protective equipment •Decontaminate the affected individuals in a separate area •Perform triage according to protocol •Report to public health department or Centers for Disease Control and Prevention per protocol •The first priority is to protect personnel, unaffected clients, bystanders, and the facility. Personal protective gear should be donned by staff before victims are assessed or treated. Decontamination of victims in a separate area is followed by triage and treatment. The incident should be reported according to protocol as information about the number of people involved, history, and signs and symptoms becomes available.

In the care of a client who has experienced sexual assault, which task is *most* appropriate for an LPN/LVN to perform? •Assessing immediate emotional state and physical injuries •Collecting hair samples, saliva specimens, and scrapings beneath fingernails •Providing emotional support and supportive communication •Ensuring that the chain of custody of evidence is maintained

•Providing emotional support and supportive communication •An LPN/LVN is able to listen and provide emotional support for clients. The other tasks are the responsibility of an RN, or preferably, a sexual assault nurse examiner who has received training in assessing, collecting, and safeguarding evidence, and caring for assault victims.

The nurse is caring for a client with frostbite to the feet. Place the following interventions in the correct order. •Apply a loose, sterile, bulky dressing •Give pain medication •Remove the client from the cold environment •Immerse the feet in warm water of 105° to 115°F (40.6° to 46.1°C) •Monitor for compartment syndrome

•Remove the client from the cold environment •Give pain medication •Immerse the feet in warm water of 105° to 115°F (40.6° to 46.1°C) •Apply a loose, sterile, bulky dressing •Monitor for compartment syndrome •The client should be removed from the cold environment first. The rewarming process will be painful, so pain medication should be given before immersing the feet in warm water. A loose, sterile, bulky bandage should be applied to the area after warming to protect the feet. The client should be monitored for compartment syndrome every hour after initial treatment.

A newly graduated nurse overhears a senior emergency department nurse making sarcastic remarks toward a medical student and refusing to help the student find the equipment for a nonemergent client procedure. What should the new nurse do *first*? •Step in and offer to assist the medical student because the other nurse is unwilling •Confront the senior nurse and indicate that an apology is the right thing to do •Observe the situation and then report behaviors of both parties to the charge nurse •Watch and observe the dynamics; the scenario is probably typical of unit norms

•Step in and offer to assist the medical student because the other nurse is unwilling •First, the new nurse steps in and takes action to protect and address the needs of the vulnerable persons: the medical student who is being bullied and the client who needs the procedure. The next step would be to take the senior nurse aside and discuss the behaviors and how those behaviors impact team moral and overall client care. It is difficult to approach someone who is more senior, but the new nurse can use "I" statements, which are less accusatory. For example, "I overheard the interaction with the medical student. I stepped into help him, because I felt uncomfortable. I was wondering how you felt." Observing the dynamics of the scenario is appropriate, and those observations can be shared with the charge nurse or unit manager so that steps can be taken to create a climate of interprofessional collaboration.

The nurse and group of friends are at the lake. Suddenly, someone says, "Look across the lake! It looks like someone might be drowning out there!" What is the nurse's *first* action? •Determine who is the strongest swimmer in the group •Direct someone to locate a cell phone and call 911 •Find a boat, raft, or some type of flotation device •Use a pair of binoculars and look across the lake

•Use a pair of binoculars and look across the lake •First, the nurse would gather as much data as possible. In this case, the number of potential victims; distance from shore; hazards or barriers that may affect rescue (e.g., water temperature, roughness of waves, wind, or lightning); and resources available to victim(s) or rescuers (e.g., boat, pier, closer rescuers). These data can be reported to the 911 dispatcher and used to decide whether a rescue attempt is reasonably safe for the nurse and the bystanders.