Chapter 67: Emergency Nursing

A family member brings a client to the ED following an apparent oxycodone overdose. The client is experiencing severe respiratory depression. Which medication will the nurse administer?

Naloxone hydrochloride

Which medication reverses severe respiratory depression and coma?

Naloxone hydrochloride

A triage nurse in the ED determines that a patient with dyspnea and dehydration is not in a life-threatening situation. What triage category will the nurse choose?

Urgent

Which solid organ is most frequently injured in a penetrating trauma?

liver

The nurse is caring for a client in the ED following a sexual assault. The client is hysterical and crying. The client states, "I know I'm pregnant now, maybe I have HIV. Why did this happen to me?" Which is the best response by the nurse?

"Let's talk about this. Do you want me to call a support person?"

Which of the following statements would most lead a nurse to suspect that a patient is experiencing food poisoning?

"My brother got sick like me after eating the same food."

Permanent brain injury or death will occur within which time frame secondary to hypoxia?

3 to 5 minutes

A patient with frostbite to both lower extremities from exposure to the elements is preparing to have rewarming of the extremities. What intervention should the nurse provide prior to the procedure?

Administer an analgesic as ordered.

The nurse is caring for a client in the ED with frostbite to the left hand. During the rewarming process of the hand, the nurse should perform which action?

Administer analgesic medications as ordered

A homeless client presents to the ED. Upon assessment, the client is experiencing hypothermia. The nurse will plan to complete which priority intervention during the rewarming process?

Attach a cardiac monitor

Which term refers to injuries that occur when a person is caught between objects, run over by a moving vehicle, or compressed by machinery?

Crush injuries

A high school football player is brought to the emergency department after collapsing at practice in extremely hot and humid weather. Which of the following would lead the nurse to suspect that the client is experiencing heat stroke?

Delirium

The nurse has come on shift to find that a client newly admitted to the ICU is confused and persistently trying to get out of bed despite being comforted and re-oriented by the nurse. The client begins to pull on the peripheral intravenous line in the hand and speaking in non-sensical terms. The client's history indicates a sudden onset of neurological symptoms after developing a bacterial infection. The nurse anticipates providing care for which health problem?

Delirium

A nurse is preparing to assist with a gastric lavage for a client who has ingested an unknown poison and is obtunded. To ensure that the tube reaches the stomach, the nurse would measure the distance from the bridge of the nose to which of the following?

Ear lobe and then to the xiphoid process

A client is being cared for in the ED. The client is assigned to the triage category of "urgent." How often must the nurse reassess the client?

Every 30 minutes

After inserting an oropharyngeal airway, which of the following indicates that the airway is properly positioned?

Flange is at the client's lips.

A nurse is providing care to a client who is a victim of trauma resulting from injuries sustained in a convenience store robbery. The client has been stabbed numerous times in the abdomen and chest. His shirt is bloody and torn. Which of the following would be most appropriate when collecting forensic evidence?

Hanging up any damp or wet clothing to dry before securing

A client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later, the nurse identifies which finding as an early sign of shock?

Increasing heart rate

A nurse is completing her annual cardiopulmonary resuscitation training. The class instructor tells her that a client has fallen off a ladder and is lying on his back; he is unconscious and isn't breathing. What maneuver should the nurse use to open his airway?

Jaw-thrust

A patient arrives at the emergency department after sustaining a gunshot wound to the abdomen. When assessing the patient, the nurse pays particular attention to which of the following?

Liver

An 83-year-old client is brought in by ambulance from a long-term care facility. The client's symptoms are weakness, lethargy, incontinence, and a change in mental status. The nurse knows that emergencies in older adults may be more difficult to manage for what reason?

Older adults may have an altered response to treatment.

A nurse is providing an in-service program for fellow emergency nurses about hypothermia and rewarming methods used. The nurse determines that the presentation was successful when the group identifies which of the following as a passive active rewarming method?

Over-the-bed heaters

A family member brings a patient to the emergency department. The family member states, "I think he overdosed on heroin." Which of the following would the nurse expect to assess?

Pinpoint pupils

A nurse is establishing a patient's airway. Which action would the nurse perform first?

Repositioning the patient's head

Which laboratory study is used to detect pancreatic injury?

Serum amylase

A nurse is providing in-service education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step?

Supporting the client's emotional status

The nurse in the hospital emergency department is assessing a patient who fell while intoxicated with alcohol. The nurse is using the Clinical Institute Withdrawal Assessment-Alcohol (CIWA-A) scale to assess the patient's need for a benzodiazepine medication. In order to assess for auditory disturbances, which question should the nurse ask the patient?

"Are you hearing anything that is disturbing you?"

A client is brought to the emergency department with severe hemorrhage requiring massive blood replacement. The nurse warms the blood in a commercial warmer based on the understanding that infusion of large amounts of blood could result in which of the following?

Cardiac arrest

A client is admitted to the ED with suspected alcohol intoxication. The ED nurse is aware of the need to assess for conditions that can mimic acute alcohol intoxication. In light of this need, the nurse should perform what action?

Check the client's blood glucose level.

A client presents to the ED following a chemical burn. The client identifies the source of the burn as white phosphorus. The nurse knows that treatment will include

No application of water to the burn.

A nurse working in an emergency department is responsible for determining the severity of the patients' problems and how fast each needs to be seen. The nurse is implementing which of the following?

Triage

A client presents to the ED with serious health problems that are not immediately life threatening. The nurse will correctly triage the client into which category?

Urgent

Which category of triage encompasses clients with serious health problems that are not immediately life threatening?

urgent

A triage nurse is talking to a client when the client begins choking on his lunch. The client is coughing forcefully. What should the nurse do?

Stay with him and encourage him, but not intervene at this time.

A nurse providing care to a client in the critical care unit implements interventions to reduce the client's pain. The nurse implements these measures based on the understanding that they will help to achieve which result?

lessen the body's stress response

Acetaminophen overdose is treated with administration of which medication?

N-acetylcysteine

When preparing to perform abdominal thrusts on a client with an airway obstruction, which of the following would be most appropriate?

Positioning the hands in the midline slightly above the umbilicus

A client is admitted to the ED after a near-drowning accident. The client is diagnosed with saltwater aspiration. The nurse will observe the client for several hours to monitor for symptoms of

pulmonary edema.

The nurse received a patient from a motor vehicle accident who is hemorrhaging from a femoral wound. What is the initial nursing action for the control of the hemorrhage?

Apply firm pressure over the involved area or artery.

The nurse is caring for an intensive care unit client who has died with family members at the bedside. The death was sudden and unexpected resulting from a car accident that took place three days ago. The family is upset and the client's partner, crying loudly, yells, "How did this happen? We were just about to celebrate his birthday. He can't be gone!" The family member continues to cry inconsolably. How should the nurse respond?

"We did everything we could possibly do to try to save his life."

The nurse is caring for a client in the ED with frostbite to the left hand. During the rewarming process of the hand, the nurse should perform which action?

Administer analgesic medications as ordered.

the nurse in the ED is triaging patients during the shift. What does the nurse know is the first priority in treating any patient in the ED?

Establishing an airway.

A client comes to the emergency department after experiencing a wound. Inspection reveals an opening in the skin with distinct edges and whose depth is greater than the length of the wound. The nurse documents this as which type of wound?

Stab

When providing care to a client who has experienced multiple trauma, which of the following would be most important for the nurse to keep in mind?

The client is assumed to have a spinal cord injury until proven otherwise.

The nurse is caring for a client who is being prepared for the placement of a central intravenous line. The nurse recognizes this client requires this type of intravenous access for which reason?

The client requires total parenteral nutrition

The ED staff work collaboratively and follow the ABCDE method to establish and treat health priorities effectively in a client experiencing a trauma. Which action is completed by the nurse when implementing the "D" element of this method?

Assessing the client's Glasgow Coma Scale score

The nurse is conducting a secondary survey on a client in the ED. Which action is completed during the secondary survey?

Diagnostic and laboratory testing

A patient is brought to the emergency department and diagnosed with decompression sickness. The nurse interprets this as indicating that the patient most likely has been involved with which of the following?

Diving in an ocean

A nurse is caring for a client who is experiencing alcohol withdrawal. Which statement best indicates that the client understands the need for long-term treatment?

The client agrees to detoxification, rehabilitation, and participation in an aftercare program.

The emergency nurse is preparing to triage a group of four clients who have presented to the emergency department (ED) and arrived at the same time. For each client, determine based on the system of triage if the client requires immediate intervention or can wait to be seen. 46-year-old male client who presents with suspected broken leg as a result of motor vehicle crash (MVC) 22-year-old female client who presents with left quadrant abdominal pain and moderate vaginal bleeding with clots 25-year-old male client who presents with a small laceration on the left upper arm 52-year-old female client who presents with severe back pain of recent onset

46 year old - immediate intervention 22 year old- immediate intervention 25 year old- can wait 52 year old - immediate intervention

A patient is brought to the ED by a friend, who states that a tree fell on the patient's leg and crushed it while they were cutting firewood. What priority actions should the nurse perform? (Select all that apply.)

Applying a clean dressing to protect the wound Elevating the site to limit the accumulation of fluid in the interstitial spaces Splinting the wound in a position of rest to prevent motionone

After inserting an oropharyngeal airway, the nurse determines that it is in the proper position when the flange is located at which position?

Approximately at the patient's lips

A nurse is providing care to the family of a client who was brought to the emergency department and suddenly died. Which of the following would be appropriate for the nurse to do? Select all that apply.

Ask the family if they would like to view the body. Provide a private place for the family to be together. Allow the family to express their emotions freely.

A female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing interventions should be provided? (Select all that apply.)

Assess and document any bruises and lacerations. Record a history of the event, using the patient's own words. Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police.

The nurse is caring for a client who is agitated and confused. The client is persistently trying to get out of bed and attempted to remove the peripheral IV. The nurse has attempted to re-orient the client; however, this was not effective in de-escalating the client's agitation. The client yells, "I am going to punch you in the face!" What is the nurse's next action?

Call security personnel to assist

A client presents to the ED following a motor vehicle collision. The client is suspected of having internal hemorrhage. The nurse assesses the client for signs and symptoms of shock. Which are signs and symptoms of shock? Select all that apply.

Cool, moist skin Decreasing blood pressure Increasing heart rate Delayed capillary refill

A 6-year-old is admitted to the ED after being rescued from a pond after falling through the ice while ice skating. What action should the nurse perform while rewarming the client?

Ensuring continuous ECG monitoring

A nurse is caring for a patient with multiple injuries and performs the following. Place these actions in the order in which the nurse would perform them. Use all options.

Establish airway and ventilation Control hemorrhage Prevent and treat shock Assess for head and neck injuries Assess for abdomen, back, and extremity injuries Splint fractures

A home health nurse is visiting a 74-year-old client with Alzheimer's disease. During the visit, the nurse notes bruising on the client's upper arms, and the client is more withdrawn than normal. The client is unable to communicate effectively because of his disease progression. The nurse suspects elder abuse. What is the nurse's responsibility in this situation?

Report the suspicion to the local agency on aging within 24 hours of the visit.

A nurse is providing an educational program for a group of occupational health nurses working in chemical facilities. Which of the following would the nurse include as the priority in the case of a chemical burn?

Rinsing the area with copious amounts of water

Nursing students are reviewing the categories of intra-abdominal injuries. The students demonstrate understanding of the information when they identify which of the following as examples of penetrating trauma? Select all that apply.

Gunshot wound Knife-stab wound

The health care team in an intensive care unit have experienced a critical incident in which a young client died unexpectedly and the client's father physically attacked the senior physician treating the client. The client's father was arrested and escorted from the intensive care unit by police, against his will and in handcuffs. A critical incident stress management (CISM) staff meeting held 3 days after the incident took place. What would be the purpose for that meeting?

Debriefing

A patient brought to the ED by the rescue squad after getting off a plane at the airport is complaining of severe joint pain, numbness, and an inability to move the arms. The patient was on a diving vacation and went for a last dive this morning before flying home. What is a priority action by the nurse?

Ensure a patent airway and that the patient is receiving 100% oxygen.

A client is brought to the ED by friends. The friends tell the nurse that the client was using cocaine at a party. On arrival to the ED the client is in visible distress with an axillary temperature of 40.1ºC (104.2°F). What would be the priority nursing action for this client?

Ensure airway and ventilation.

The nurse is caring for a victim of a sexual assault. The client is fearful and experiencing flashbacks. The nurse recognizes that the client is experiencing which phase of the psychological reaction to rape?

Heightened anxiety phase

The nurse educator is providing orientation to a group of nurses newly hired to an intensive care unit. The group of nurses are correct in stating which is the most common type of shock managed in critical care?

Hypovolemic

The nurse has commenced a transfusion of fresh frozen plasma (FFP) and notes the client is exhibiting symptoms of a transfusion reaction. After the nurse stops the transfusion, what is the next required action?

Run a normal saline line to keep the vein open

A patient was bitten by a tick 3 months ago and is now having muscle aches as well as joint pain and swelling. The patient is having difficulty with self care and requires assistance with activities of daily living (ADLs). What stage of Lyme disease does the nurse recognize the patient is in?

Stage III

The nurse educator is explaining the difference between indications for nasopharyngeal airway insertion versus endotracheal intubation. Which responses from learners indicate correct reasons for the use of endotracheal tubes in clients? Select all that apply.

To bypass an upper airway obstruction To support connecting to mechanical ventilation To facilitate removal of tracheobronchial secretions