Chapter 72: Emergency Nursing

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? Counselling Defusing Debriefing Follow up

Debriefing Explanation: After serious events, critical incident stress management (CISM) is necessary to critique individual and group performance and to facilitate healthy coping. Optimally, this may consist of three steps: defusing, debriefing, and follow-up. Debriefing typically occurs 1 to 10 days after the critical incident. Debriefing sessions follow a format similar to the initial defusing session; however, during these sessions, participating staff are encouraged to discuss their feelings about the incident and are reassured that their negative reactions and feelings are normal and that their negative feelings will diminish over time. Defusing occurs immediately after the critical incident. During this session, affected staff are encouraged to discuss their feelings about the incident and are given contact information so that they may talk to someone if they have disturbing symptoms (e.g., sleeplessness, excessive worry). Follow-up may occur after the debriefing session is completed for those participants who have persistent negative symptoms and may consist of continued individual or group counseling and therapy. Counseling or group therapy would typically occur outside the context of the stress-inducing environment. Individuals may require private counseling versus group counseling. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Caring for Emergency Personnel, p. 2159.

A client is brought to the emergency department after being involved in a motor vehicle collision. Which of the following would lead the nurse to suspect internal bleeding? Bradycardia Rising blood pressure Delayed capillary refill Pale pink dry skin

Delayed capillary refill Explanation: If a client exhibits tachycardia, falling blood pressure, thirst, apprehension, cool moist skin, or delayed capillary refill, internal bleeding should be suspected. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Hemorrhage, p. 2165.

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 Pain Anxiety Fever

Delirium Explanation: Delirium is a confused state that has a sudden onset and can last hours to days or weeks; it is characterized by hyperactivity and has the potential to be reversible. The client who quickly becomes confused and agitated while attempting to pull out IV lines and get out of bed is experiencing delirium. The nurse caring for this client should anticipate the need to provide close monitoring to prevent injury. Although clients can experience a high level of stress with both pain and anxiety, which often accompany one another, these problems do not cause confusion and disorientation. Nursing interventions would be aimed at reducing pain and anxiety with the use of medications and other non-pharmacological interventions that enhance client comfort. Although fever can accompany delirium, it does not produce confusion and disorientation on its own. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Alcohol Withdrawal Syndrome/ Delirium Tremens, p. 2185.

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 Assessment of peripheral pulses Establishing a patent airway Undressing the client

Diagnostic and laboratory testing Explanation: Diagnostic and laboratory testing is completed during the secondary survey, along with a complete health history, a head-to-toe assessment, insertion or application of monitoring devices, splinting of suspected fractures, cleansing, closure, and dressing of wounds, and performance of other necessary interventions based on the client's condition. The other interventions are completed during the primary survey. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, p. 2162.

A client is brought to the emergency department by ambulance. The client is seriously ill and unconscious. No family or friends are present. Which of the following would be most appropriate to do? Document the client's condition and absence of friends or family for obtaining consent to treatment. Check the client's record for the name of a family member to call to allow care to be provided. Ask the ambulance team for information about the client's family to ensure informed consent. Explain to the client that care is going to be provided because he is seriously ill.

Document the client's condition and absence of friends or family for obtaining consent to treatment. Explanation: Consent is needed to examine and treat a client unless he or she is unconscious or in critical condition and unable to make decisions. In this situation, the client is unconscious and no friends or family are around to provide consent to treatment. The nurse should document this fact and provide care. Checking the client's record and asking the ambulance team for information would waste valuable time. Explaining to the client that care will be provided is appropriate even though the client is unconscious, but documentation is essential. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Documentation of Consent and Privacy, p. 2157.

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 Chin and then to the xiphoid process Ear lobe and then to the umbilicus Chin and then to the umbilicus

Ear lobe and then to the xiphoid process Explanation: The nurse measures the tube from the bridge of the nose to the xiphoid process to ensure that the tube reaches the stomach on insertion.

A client presents to the ED reporting choking on a chicken bone. The client is breathing spontaneously. The nurse applies oxygen and suspects a partial airway obstruction. Which action should the nurse do next? Encourage the client to cough forcefully. Insert a nasopharyngeal airway. Prepare the client for a bronchoscopy. Insert an oropharyngeal airway.

Encourage the client to cough forcefully. Explanation: If the client can breathe and cough spontaneously, a partial obstruction should be suspected. The client is encouraged to cough forcefully and to persist with spontaneous coughing and breathing efforts as long as good air exchange exists. There may be some wheezing between coughs. If the client demonstrates a weak, ineffective cough, a high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis, the client should be managed as if there were complete airway obstruction. If the client is unconscious, inspection of the oropharynx may reveal the offending object. X-ray study, laryngoscopy, or bronchoscopy also may be performed. There is no indication that an artificial airway is indicated. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, p. 2163.

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. Send the patient for a chest x-ray. Send the patient to the hyperbaric chamber. Draw labs for a chemistry panel.

Ensure a patent airway and that the patient is receiving 100% oxygen. Explanation: Decompression sickness, also known as "the bends," occurs in patients who have engaged in diving (lake/ocean diving), high-altitude flying, or flying in commercial aircraft within 24 hours after diving. Signs and symptoms include joint or extremity pain, numbness, hypesthesia, and loss of range of motion. A patent airway and adequate ventilation are established before all other interventions, as described previously, and 100% oxygen is administered throughout treatment and transport. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Decompression Sickness, p. 2175.

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 15 minutes Every 30 minutes Every 60 minutes Every 120 minutes

Every 30 minutes Explanation: Clients assigned to the resuscitation category must receive continuous nursing surveillance, those in the emergent category must be reassessed at least every 15 minutes, clients in the urgent category must be reassessed at least every 30 minutes, those in the less urgent category must be reassessed at least every 60 minutes, and those in the nonurgent category must be reassessed at least every 120 minutes. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, p. 2161.

A patient has undergone a diagnostic peritoneal lavage. The nurse interprets which result as indicating a positive test? Red blood cell count of 50,000/mm3 White blood cell count of 300/mm3 Absence of bile Evidence of feces

Evidence of feces Explanation: A diagnostic peritoneal lavage is considered positive if there is bile, feces, or food in the specimen, a red blood cell count greater than 100,000/mm3, and a white blood cell count greater than 500/mm3. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Intraperitoneal Injury, p. 2170.

The nurse is providing care to a client who will be ambulating for the first time after being extubated. The client tells the nurse, "I don't want to do this today. It's too soon and I am afraid I am not strong enough." What intervention should the nurse implement first for the client's fear of falling? Explore possible causes of the client's fear Evaluate the client for cognitive impairment Allow the client to remain on bedrest Clear the area around the bed

Explore possible causes of the client's fear Explanation: The client is exhibiting a fear of falling. For a client who has not mobilized in days due to mechanical ventilation and other medication interventions in the intensive care unit (ICU), ICU-acquired weakness is a reality. The client's concerns should be addressed by exploring the possible reasons for the fear of falling first. The client may be experiencing pain, dizziness or self-doubt. By identifying this cause, the nurse will be able to formulate the next action. The risk for falls is not due to cognitive impairment. This is evident in that the client is aware of current limitations and as a result is fearful. Preventative and rehabilitative measures to counter ICU-acquired weakness generally include early identification and treatment of potential causes of multiple organ failure (in particular severe sepsis and septic shock), avoiding unnecessary deep sedation and hyperglycemia, promotion of early mobilization, and thoughtful decisions regarding the risks versus benefits of corticosteroids. For these reasons, the client should not be encouraged to continue to have bedrest. Although the nurse should ensure the area around the bed is free of clutter to prevent a fall, this does not address the client's anxiety related to the fear of falling. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Injury Prevention, p. 2168.

A patient arrives at the emergency department after taking more than 20 lorazepam tablets. Which of the following would the nurse anticipate that the patient would be given to reverse the effects of the drug? Naloxone Flumazenil Diazepam N-acetylcysteine

Flumazenil Explanation: Lorazepam is a nonbarbiturate sedative whose effects are reversed with flumazenil. Naloxone is used to reverse the effects of opioids. Diazepam is used to treat seizures associated with drug overdose. It would not be used here, because it is in the same class as lorazepam and concurrent administration would add to the patient's overdose state. N-acetylcysteine is the antidote for acetaminophen toxicity. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Table 72-1, p. 2182.

The nurse is caring for a client with diabetes who requires a peripheral intravenous (PIV) line for antibiotic administration and to treat dehydration. The nurse must avoid inserting which type of PIV? Forearm Hand Foot Upper arm

Foot Explanation: PIV lines should rarely be used in the foot for various reasons. They limit the client's ability to ambulate and tend to occlude easily. These types of IVs should never be used in clients with diabetes due to the risk that the client has neuropathy and cannot feel injury caused by the IV catheter. IV lines in the forearm and hands are acceptable and are commonly used sites. These sites would be safe to use for a client with diabetes. The upper arm is a site of choice for the insertion of a peripherally inserted central line (PICC) not a PIV line. Although, this site would not be an option for a PIV line, it would be safe for use in a client with diabetes if warranted. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Fluid Replacement, p. 2165.

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 Motor-vehicle crash Fall from a roof Being struck with a baseball bat

Gunshot wound Knife-stab wound Examples of penetrating trauma include gunshot wounds and stab wounds. Motor vehicle crashes, falls, and being struck with a baseball bat are examples of blunt trauma. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Intra-Abdominal Injuries, p. 2169.

A nurse is working as a camp nurse during the summer. A camp counselor comes to the clinic after receiving a snakebite on the arm. What is the first action by the nurse? Apply ice to the area. Apply a tourniquet to the arm above the bite. Have the patient lie down and place the arm below the level of the heart. Make an incision and suck the venom out.

Have the patient lie down and place the arm below the level of the heart. Explanation: Initial first aid at the site of the snakebite includes having the person lie down, removing constrictive items such as rings, providing warmth, cleansing the wound, covering the wound with a light sterile dressing, and immobilizing the injured body part below the level of the heart. Airway, breathing, and circulation are the priorities of care. Ice, incision and suction, or a tourniquet is not applied. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Snakebites, p. 2176.

A client is brought to the emergency department with injuries obtained from a motor vehicle crash. Which action will the nurse take during the secondary survey of the client? Select all that apply. Maintenance of airway Head-to-toe assessment Results of laboratory tests History of the current event Splinting of suspected fractures

Head-to-toe assessment Results of laboratory tests History of the current event Splinting of suspected fractures A systematic approach to effectively establishing and treating health priorities is the primary survey/secondary survey approach. Actions when completing the secondary survey include completing a head-to-toe assessment, reviewing the results of laboratory tests, collecting information about the current event, and splinting any suspected fractures. Maintenance of the airway occurs during the primary survey.

Which phase of the psychological reaction to rape is characterized by fear and flashbacks? Heightened anxiety phase Acute disorganization phase Denial phase Reorganization phase

Heightened anxiety phase Explanation: During the heightened anxiety phase, the client demonstrates anxiety, hyperalertness, and psychosomatic reactions, in addition to fear and flashbacks. The acute disorganization phase is characterized by shock, disbelief, guilt, humiliation, and anger. The denial phase is characterized by an unwillingness to talk. The reorganization phase occurs when the incident is put into perspective. Some clients never fully recover from rape trauma. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, p. 2188.

A client comes to the emergency department with a suspected airway obstruction. The emergency department team prepares to manage the client as if he has a complete airway obstruction based on which of the following? Forceful coughing Wheezing between coughs High-pitched noise on inhalation Refusal to lie flat

High-pitched noise on inhalation Explanation: A client who demonstrates a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis should be managed as if he or she has a complete airway obstruction. Forceful coughing, wheezing between coughs, and a refusal to lie flat suggest a partial airway obstruction that can be managed as such. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Management, p. 2163.

A nurse is caring for a client who has arrived at the emergency department in shock. The nurse intervenes based on the knowledge that which of the following is the most common cause of shock? Anaphylaxis Sepsis Hypovolemia Cardiac dysfunction

Hypovolemia Explanation: Types of shock include cardiogenic, neurogenic, anaphylactic, and septic. Of these, the most common cause is hypovolemia. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Hypovolemic Shock, p. 2167.

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? Anaphylactic Hypovolemic Neurogenic Cardiogenic

Hypovolemic Explanation: The underlying cause of shock (hypovolemic, cardiogenic, neurogenic, anaphylactic, or septic) must be determined. Of these, hypovolemia is the most common cause. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Hypovolemic Shock, p. 2167.

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 Pale, warm, dry skin Heart rate of 70 beats/minute Elevated blood pressure

Increasing heart rate Explanation: Early in shock, heart rate increases. Inadequate tissue perfusion causes pale, cool, clammy skin (not pale, warm, dry skin). In the early stages of shock, the client's heart rate will become elevated above normal. In early shock the client's blood pressure will remain normal, but as shock progresses the mechanisms that regulate blood pressure will not be able to compensate. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Hemorrhage, p. 2165.

A patient who has accidentally ingested toilet bowel cleaner is brought to the emergency department. Which action would NOT be appropriate for the nurse to implement? Dilution with water or milk Gastric lavage Administration of activated charcoal Induced vomiting

Induced vomiting Explanation: Vomiting is never induced after ingestion of caustic substances (acid or alkaline) such as toilet bowl cleaner because the substance is corrosive to the tissues. Appropriate actions include dilution with milk or water, gastric lavage, and administration of activated charcoal. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Ingested (Swallowed) Poisons, p. 2178.

A client suffering from carbon monoxide poisoning would exhibit which manifestation? Severe hypertension Hyperactivity Intoxication Cherry red skin coloring

Intoxication Explanation: A client suffering from carbon monoxide poisoning appears intoxicated (from cerebral hypoxia). Other signs and symptoms include headache, muscular weakness, palpitation, dizziness, and mental confusion. The skin coloring in the client with carbon monoxide poisoning can range from pink to cherry red to cyanotic and pale and is not a reliable diagnostic sign. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, p. 2179.

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? Neck tilt-head lift Jaw-thrust Abdominal thrust Seldinger

Jaw-thrust Explanation: If a neck or spine injury is suspected, the jaw-thrust maneuver should be used to open the client's airway. To perform this maneuver, the nurse should position herself at the client's head and rest her thumbs on his lower jaw, near the corners of his mouth. She should then grasp the angles of his lower jaw with her fingers and lift the jaw forward. The head tilt-chin lift maneuver is used to open the airway when a neck or spine injury isn't suspected. To perform this maneuver the nurse places two fingers on the chin and lifts while pushing down on the forehead with the other hand. The abdominal thrust is used to relieve severe or complete airway obstruction caused by a foreign body. The Seldinger maneuver is a method of percutaneous introduction of a catheter into a vessel. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Establishing an Airway, p. 2163.

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 Stomach Large intestine Kidneys

Liver Explanation: Penetrating abdominal injuries, such as from a gunshot wound, are serious and result in a high incidence of injury to hollow and solid organs. Although any organs can be injured, the liver is the most frequently injured solid organ. The small bowel is a frequently injured hollow organ. Thus, of the options shown, the nurse would assess the liver area most closely. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Intra-Abdominal Injuries, p. 2169.

A nurse is providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate? Providing an analgesic for pain Massaging the feet Restricting ambulation Placing sterile cotton between the toes after rewarming

Massaging the feet Explanation: For a client with frostbite, massaging the affected body part is contraindicated. Analgesia is given for pain during the rewarming process because it can be very painful. Ambulation would be restricted. Once rewarmed, sterile gauze or cotton is placed between the affected toes to prevent maceration. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Frostbite, p. 2173.

The nurse is administering antivenin to a patient who was bitten on the arm by a venomous snake. What intervention provided by the nurse is required prior to the procedure and every 15 minutes after? Administer diphenhydramine (Benadryl). Administer cimetidine (Tagamet). Measure the circumference of the arm. Assess peripheral pulses.

Measure the circumference of the arm. Explanation: Before administering antivenin and every 15 minutes thereafter, the circumference of the affected part is measured. Premedication with diphenhydramine (Benadryl) or cimetidine (Tagamet) may be indicated, because these antihistamines may decrease the allergic response to antivenin. Antivenin is administered as an IV infusion whenever possible, although intramuscular administration can be used. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Snakebites, p. 2176.

A client presents to the ED after an unsuccessful suicide attempt. The client is diagnosed with an acetaminophen overdose. The nurse anticipates the administration of which medication? N-acetylcysteine Flumazenil Naloxone Diazepam

N-acetylcysteine Explanation: Treatment of acetaminophen overdose includes administration of N-acetylcysteine. Flumazenil is administered in the treatment of nonbarbiturate sedative overdoses. Naloxone is administered in the treatment of narcotic overdoses. Diazepam may be administered to treat uncontrolled hyperactivity in the client with a hallucinogen overdose. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Table 72-1, p. 2184.

The nurse is caring for a client with known myocardial ischemia. The client will be getting up to ambulate for the first time in three days after being on bedrest since admission to the intensive care unit. Which medication should the nurse administer before the client ambulates? Nitroglycerin Vasopressin Norepinephrine Dobutamine

Nitroglycerin Explanation: Nitroglycerin is indicated for use in clients who experience angina pectoris as a result of myocardial ischemia. The medication acts by decreasing blood pressure and causing arterial vasodilation permitting blood flow into the myocardium. Nitroglycerin should be given prior to any anticipated physical exertion that is likely to bring on chest pain from vasoconstriction. Vasopressin is a vasoactive medication administered to increase blood pressure in cases where clients have diabetes insipidus, a gastrointestinal bleed or in cases of septic shock. Norepinephrine raises blood pressure and is indicated for use in emergencies such as cardiac arrest or for hypovolemia. Dobutamine increased heart contractility and blood pressure to improve stroke volume in clients with congestive heart failure.

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 immediately drenching the skin with running water from a shower, hose, or faucet. alternately applying water and ice to the burn. No application of water to the burn. washing off the chemical using warm water, then flushing the skin with cool water.

No application of water to the burn. Explanation: Water should not be applied to burns from lye or white phosphorus because of the potential for an explosion or for deepening of the burn. All evidence of these chemicals should be brushed off the client before any flushing occurs. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, p. 2179.

A nurse who is a member of an emergency response team anticipates that several patients with airway obstruction may need a cricothyroidotomy. For which of the following patients would this procedure be appropriate? Select all that apply. Patient with extensive facial trauma Patient with a lumbar spine injury Patient with laryngeal edema secondary to anaphylaxis Patient who is bleeding from the chest Patient with an obstructed larynx

Patient with extensive facial trauma Patient with laryngeal edema secondary to anaphylaxis Patient with an obstructed larynx Cricothyroidotomy is used in emergencies when endotracheal intubation is either not possible or contraindicated. Examples include airway obstruction from extensive maxillofacial trauma, cervical spine injury, laryngospasm, laryngeal edema after an allergic reaction or extubation, hemorrhage into neck tissue, and obstruction of the larynx. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Cricothyroidotomy (Cricothyroid Membrane Puncture), p. 2165.

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 Hyperventilation Hypertension Flushed face

Pinpoint pupils Explanation: Signs of an acute overdose of heroin, an opioid, include pinpoint pupils, marked respiratory depression, decreased blood pressure, stupor progressing to coma, seizures, and pulmonary edema. Flushed face typically reflects a barbiturate overdose. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Table 72-1, p. 2181.

When preparing to perform abdominal thrusts on a client with an airway obstruction, which of the following would be most appropriate? Having the conscious client lie down Placing the thumb side of one hand at the xiphoid process Positioning the hands in the midline slightly above the umbilicus Using a sequence of four thrusts, each progressing in intensity

Positioning the hands in the midline slightly above the umbilicus Explanation: When performing abdominal thrusts, the nurse would place the thumb side of one fist against the client's abdomen in the midline slightly above the umbilicus and well below the xiphoid process, grasping the fist with the other hand. Then the nurse would press the fist into the client's abdomen with a quick inward and upward thrust such that each new thrust should be a separate and distinct maneuver. The unconscious client is positioned on the back. The client who is conscious should be standing or sitting. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Management, p. 2163.

A nurse is providing care to a client in the emergency department and walks into the hallway to get equipment. All of a sudden, gunshots are heard. Which of the following would be the nurse's priority? Protecting himself or herself Securing the area Gaining control of the situation Providing care to the injured

Protecting himself or herself Explanation: If gunfire occurs in the emergency department, self-protection is the priority. Security officers and police must gain control of the situation first and then care is provided to the injured. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Violence in the Emergency Department, p. 2158.

The nurse has received a client into care who was admitted with a heroin overdose. The client has a 5-year history of illicit substance use with cocaine, heroine and oxycodone. The client develops a sudden onset of wheezing, restlessness and a cough that produces a frothy, pink sputum. The nurse suspects the client has most likely developed which complication of opioid overdose? Pulmonary edema Pneumonia Congestive heart failure Panic attack

Pulmonary edema Explanation: The nurse should suspect the client has developed pulmonary edema, which is frequently seen in clients who abuse/overdose on narcotics. Many drugs — ranging from illegal drugs such as heroin and cocaine to aspirin — are known to cause noncardiogenic pulmonary edema. Pneumonia is not the likely cause given the sudden onset of respiratory symptoms accompanied but coughing up the pink frothy sputum. The client's history of illicit substance use and now overdose on these drugs should lead the nurse to suspect pulmonary edema is the cause of the sudden onset of these symptoms over congestive heart failure, in which clients have a more gradual onset of respiratory issues. Although a panic attack can manifest in shortness or breath and restlessness, the client would not be wheezing or producing blood tinged sputum with a cough. Panic attacks do, however, have a sudden onset and can cause the client chest pain and a sense of doom. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Substance Abuse: Table 72-1 Emergency Management of Patients With Drug Overdose, p. 2181.

A nurse is establishing a patient's airway. Which action would the nurse perform first? Giving abdominal thrusts Using the jaw-thrust maneuver Inserting an artificial airway Repositioning the patient's head

Repositioning the patient's head Explanation: Establishing an airway may be as simple as repositioning the patient's head to prevent the tongue from obstructing the pharynx. Subsequent measures would include abdominal thrusts to dislodge a foreign body, head-tilt chin-lift or jaw-thrust maneuver, or insertion of an artificial airway. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Establishing an Airway, p. 2163.

A nurse is performing triage at the scene of a building collapse and is using a five-level triage system. Place the categories below in the proper order from most to least immediate.

Resuscitation Emergent Urgent Less urgent Nonurgent The five-level system of triage classifies patients as follows: resuscitation (need immediate treatment to prevent death); emergent (may deteriorate rapidly and develop a major life-threatening situation or require time-sensitive treatment); urgent (need two or more resources to provide care and conditions are not life-threatening); less urgent (need only one resource for needs and condition is not life-threatening); and nonurgent (require no resources for care with no life-threatening condition).

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? Applying antimicrobial ointment Administering tetanus prophylaxis Covering the area with a sterile dressing Rinsing the area with copious amounts of water

Rinsing the area with copious amounts of water Explanation: The priority for any chemical burn is to immediately drench the area with running water, unless the chemical is lye or white phosphorus, which should be brushed off the patient. Antimicrobial ointments, sterile dressings, and tetanus prophylaxis are measures instituted later in the course of treatment, depending on the characteristics of the chemical agent and the size and location of the burn. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Skin Contamination Poisoning (Chemical Burns), p. 2179.

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? Remove the peripheral IV line Start a dextrose 5% water infusion Run a normal saline line to keep the vein open Obtain a blood culture from the IV insertion site

Run a normal saline line to keep the vein open Explanation: If the nurse suspects a transfusion reaction, the transfusion must be stopped immediately and the nurse's next action is to ensure the normal saline line is running at a rate that permits administration of IV fluids or medications that are required to treat the reaction. The nurse should ensure IV access is maintained. The "to keep vein open" (TKVO) rate allows the nurse to keep the IV client without the potential to cause fluid volume overload. It would be unsafe for the nurse to remove the peripheral IV because continued access is required for urgent IV administration of medications or fluids to treat the reaction. Obtaining a blood culture at the IV site would be necessary if an infection was suspected. This is not required for a transfusion reaction. Normal saline is the solution of choice when transfusing blood products because there is a risk for incompatibility with all other IV solutions. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Fluid Replacement, p. 2165.

A patient is brought to the emergency department following an overdose of a selective serotonin reuptake inhibitor (SSRI). While assessing the patient, the nurse suspects that the patient may be developing serotonin syndrome based on which of the following? Hypotension Seizures Lack of perspiration Lethargy

Seizures Explanation: Serotonin syndrome is manifested by agitation, seizures, hyperthermia, diaphoresis, and hypertension. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Table 72-1, p. 2184.

A client presents to the ED with a stab wound to the abdomen following an assault. It is suspected that the client has an injury to the pancreas. Which laboratory study is used to detect pancreatic injury? White blood cell count Serum amylase Urinalysis Hemoglobin and hematocrit

Serum amylase Explanation: Serum amylase is analyzed to detect increasing levels, which suggests pancreatic injury or perforation of the gastrointestinal tract. A white blood cell count is done to detect an elevation. Urinalysis is done to detect hematuria. A hemoglobin and hematocrit test is done to evaluate trends reflecting the presence or absence of bleeding.

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? Laceration Avulsion Stab Patterned

Stab Explanation: A stab wound is an incision of the skin with well-defined edges and is typically deeper than long. It is usually caused by a sharp instrument. A laceration is a tear in the skin with irregular edges and vein bridging. An avulsion is manifested as a tearing away of tissue from the supporting structures. A patterned wound takes on the outline of the object causing the wound. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Intra-Abdominal Injuries, p. 2169.

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 I Stage II Stage III Stage IV

Stage III Explanation: Lyme disease has three stages. Stage I presents with a classic "bull's-eye" rash (i.e., erythema migrans) and flulike signs and symptoms that may include chills, fever, myalgia, fatigue, and headache. If antibiotics are not administered, stage II Lyme disease may present within 4 to 10 weeks following the tick bite and may manifest with joint pain, memory loss, poor motor coordination, and meningitis. Stage III can begin anywhere from weeks to more than a year after the bite and has serious long-term chronic sequelae, including arthritis, neuropathy, myalgia, and myocarditis. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Tick Bites, p. 2178.

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? Collecting semen Performing the pelvic examination Obtaining consent for examination Supporting the client's emotional status

Supporting the client's emotional status Explanation: The teaching session is successful when staff members focus first on supporting the client's emotional status. Next, staff members should gain consent to perform the pelvic examination, perform the examination, and collect evidence, such as semen if present. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Assessment and Diagnostic Findings, p. 2188.

The nurse is caring for a client in the intensive care unit who is recovering from trauma as a result of a motor vehicle accident that claimed the life of the client's friend. While the nurse is performing a dressing change on the client's surgical wound, the client states, "I don't deserve to live. I have just been thinking about ending it all." As the nurse assesses the client's imminent risk for suicide, what contributing factors need to be considered? Select all that apply. The client attempted suicide as a teenager. The client's maternal uncle committed suicide. The client's parents visit on a daily basis. The client had a close relationship to the accident victim. The client is not able to ambulate unassisted.

The client attempted suicide as a teenager. The client's maternal uncle committed suicide. The client had a close relationship to the accident victim. When assessing a client's suicide risk, it is very important to first determine whether the client has a previous history of suicide attempts. Having a suicide-attempt history increases the risk that the client will attempt to end his or her life if experiencing suicidal thoughts. Having a family member who has committed suicide increases the risk that the client will follow through with a suicide attempt. Family support mitigates the risk that the client will follow through with a suicide attempt if the client is experiencing hopeless thoughts. Having a close relationship with the victim in the car accident indicates the client is experiencing grief and loss and may increase the risk of suicide. If the client is unable to ambulate unassisted, this decreases the client's means to access to be able to follow through with a suicide attempt. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Patients Who Are Suicidal, p. 2190.

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 will require intravenous access for three days The client requires total parenteral nutrition The client requires infusion of intravenous antibiotics The client requires infusion of a dextrose 5% water (D5W)

The client requires total parenteral nutrition Explanation: For a patient who requires total parenteral nutrition (TPN), a central intravenous line is required due to the length of time the client will require the infusion as well as the nature of the solution itself. A large vein is required to safely infuse TPN. For this reason, a central line is needed. A peripheral intravenous line is safe to used when IV access is required under six days. Beyond this time, either a new peripheral IV will need to be inserted. If it is known in advance that IV treatment will last beyond six days, the client's health care provider will order the placement of a central intravenous line. Intravenous antibiotics can be administered peripherally unless the course is longer than six days. D5W is an intravenous solution that can be administered either peripherally or centrally. The nature of this IV solution would not determine which type of IV access the client requires.

The nurse is caring for a client with right ventricular heart failure. The nurse understands hypervolemia will have what effect on the client's heart? The client's myocardial oxygen requirements will be higher The client's stroke volume will be decreased The client's ventricles will not have to work as hard The client's will experience systemic vasodilation

The client's myocardial oxygen requirements will be higher Explanation: Clients with heart failure are typically hypervolemic and as a result this increases the cardiac preload. An increased fluid volume increases the stroke volume, ventricular work and myocardial oxygen requirements. Vasodilation can be a potential cause for decreased preload and afterload, not increased preload as in this case. This client would experience vasoconstriction due to the increase volume with each stroke.

What is a common source of airway obstruction in an unconscious client? A foreign object Saliva or mucus The tongue Edema

The tongue Explanation: In an unconscious client, the muscles controlling the tongue commonly relax, causing the tongue to obstruct the airway. When this situation occurs, the nurse should use the head-tilt, chin-lift maneuver to cause the tongue to fall back into place. If she suspects the client has a neck injury she must perform the jaw-thrust maneuver. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Establishing an Airway, p. 2163.

A client present to the ED following a work-related injury to the left hand. The client has an avulsion of the left ring finger. Which correctly describes an avulsion? Tissue tearing away from supporting structures Incision of the skin with well-defined edges, usually long rather than deep Skin tear with irregular edges and vein bridging Denuded skin

Tissue tearing away from supporting structures Explanation: An avulsion is described as a tearing away of tissue from supporting structures. A laceration is a skin tear with irregular edges and vein bridging. Abrasion is denuded skin. A cut is an incision of the skin with well-defined edges, usually long rather than deep. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Chart 72-4, p. 2167.

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? Referral Triage Discharge planning Crisis intervention

Triage Explanation: The nurse is performing triage, which sorts patients into groups based on the severity of their health problems and the immediacy with which these problems need to be treated. Referral involves communicating with other health care delivery service providers to assist the patient with meeting his or her needs. Discharge planning involves actions to get the patient ready to leave the facility. Crisis intervention involves actions to alleviate the high level of stress and to promote effective coping with challenging life events. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Triage, p. 2161.

A finger sweep is only to be used in which client population? Conscious adult Unconscious adult Child Adolescent

Unconscious adult Explanation: A finger sweep should be used only in the unconscious adult client. This action draws the tongue away from the back of the throat and away from any foreign body that may be lodged there. A finger sweep should not be done on a conscious adult, child, or adolescent. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, p. 2163.

The nurse is caring for a patient in the ED who is breathing but unconscious. In order to avoid an upper airway obstruction, the nurse is inserting an oropharyngeal airway. How would the nurse insert the airway? At an angle of 90 degrees Upside down and then rotated 180 degrees With the concave portion touching the posterior pharynx With the convex portion facing upward

Upside down and then rotated 180 degrees Explanation: The nurse should insert the oropharyngeal airway with the tip facing up toward the roof of the mouth until it passes the uvula and then rotate the tip 180 degrees so that the tip is pointed down toward the pharynx. This displaces the tongue anteriorly, and the patient then breathes through and around the airway. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Chart 72-3, p. 2164.

Which category of triage encompasses clients with serious health problems that are not immediately life threatening? Emergent Urgent Nonurgent Psychological support

Urgent Explanation: Urgent clients have serious health problems that not immediately life threatening. They must be seen within 1 hour. Emergent clients have the highest priority with life-threatening conditions and they must be seen immediately. Nonurgent clients have episodic illness that can be addressed within 24 hours without increased morbidity. Fast-track clients require simple first aid or basic primary care and may be treated in the ED or safely referred to a clinic or physician's office. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, p. 2161.

A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's: blood pressure. hemoglobin level. temperature. heart rate.

blood pressure. Explanation: With adequate fluid replacement, fluid volume in the intravascular space expands, raising the client's blood pressure. The hemoglobin level reflects red blood cell concentration, not overall fluid status. Temperature and heart rate aren't directly related to fluid status. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Hypovolemic Shock, p. 2167.

Following a motor vehicle collision, a client is brought to the ED for evaluation and treatment. The client is being assessed for intra-abdominal injuries. The client reports severe left shoulder pain (pain score of 10 on a 1 to 10 scale). The nurse suspects injury to the spleen. liver. gallbladder. large intestine.

spleen. Explanation: The location of pain can indicate certain types of intra-abdominal injuries. Pain in the left shoulder is common in a client with bleeding from a ruptured spleen, whereas pain in the right shoulder can result from laceration of the liver. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Quality and Safety Nursing Alert, p. 2170.

A client arrives at the emergency department and is experiencing a severe allergic reaction to a bee sting. The client received treatment and is being discharged. Which client statement indicates that additional teaching about exposure prevention is needed? "I should always wear something on my feet when I'm outside." "Brightly colored clothes help to ward off bees." "If a bee comes near me, I should stay still." "I need to avoid using perfumes and scented soaps when I'm going outside."

"Brightly colored clothes help to ward off bees." Explanation: To prevent insect stings, the client should avoid wearing brightly colored clothing because it attracts bees. The client should wear covering on the feet and avoid going barefoot because yellow jackets nest and pollinate on the ground. Staying still or motionless reduces the likelihood of being stung. Perfumes and scented soaps attract bees and should be avoided.

A nurse is providing wound care to a patient who arrived at the emergency department after being hit by flying glass from a broken window. The nurse asks the patient about his last tetanus shot. Which statement would indicate to the nurse that the patient needs a tetanus booster? "I just had a tetanus shot last year when I cut my foot on a piece of metal." "It must be at least 6 or 7 years since I had one." "My last tetanus shot was 2 1/2 years ago during a check-up." "I had one last month after I was injured at work."

"It must be at least 6 or 7 years since I had one." Explanation: Tetanus prophylaxis is administered as prescribed, based on the condition of the wound and the patient's immunization status. If the patient's last tetanus booster was administered more than 5 years ago, or if the patient's immunization status is unknown, he or she requires a tetanus booster. Thus, the patient's statement about it being at least 6 or 7 years would indicate to the nurse that the patient needs a booster immunization. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Delayed Primary Closure, p. 2167.

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?" "Do you want to discuss antipregnancy measures?" "Do you want the phone number for the National Sexual Assault Hotline?" "Would you like us to complete HIV testing?"

"Let's talk about this. Do you want me to call a support person?" Explanation: The client should be reassured that anxiety is natural and asked whether a support person may be called. The goals of management are to provide support, reduce the client's emotional trauma, and gather available evidence for possible legal proceedings. Throughout the client's stay in the ED, the client's privacy and sensitivity must be respected. The client may exhibit a wide range of emotional reactions, such as hysteria, stoicism, or feelings of being overwhelmed. Support and caring are crucial. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, p. 2188.

Permanent brain injury or death will occur within which time frame secondary to hypoxia? 1 to 2 minutes 3 to 5 minutes 6 to 8 minutes 9 to 10 minutes

3 to 5 minutes Explanation: If the airway is completely obstructed, permanent brain injury or death will occur within 3 to 5 minutes secondary to hypoxia. Air movement is absent in the presence of complete airway obstruction. Oxygen saturation of the blood decreases rapidly because obstruction of the airway prevents air from entering the lungs. Oxygen deficit occurs in the brain, resulting in unconsciousness, with death following rapidly. The other time frames are incorrect. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, p. 2163.

The nurse is administering 100% oxygen to a patient with carbon monoxide poisoning and obtains a carboxyhemoglobin level. Which level would the nurse interpret as indicating that oxygen therapy can be discontinued? 9% 7% 6% 4%

4% Explanation: Oxygen is administered until the carboxyhemoglobin level is less than 5%. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Management, p. 2179.

Several clients in the emergency department are being categorized by the triage nurse. Which client will the nurse place in the urgent category? A 24-year-old client with multiple gunshot wounds to the chest, arms, and legs A 54-year-old client with a history of diabetes presenting with anemia and abdominal pain A 56-year-old client with a cut to the left hand that requires wound debridement and stitches A 60-year-old client presenting with chest pain and ST elevation on electrocardiogram

A 54-year-old client with a history of diabetes presenting with anemia and abdominal pain Explanation: A basic and widely used triage system utilizes three categories: emergent, urgent, and nonurgent. In this system emergent patients have the highest priority, urgent patients had serious health problems but not immediately life-threatening ones, and nonurgent patients had episodic illnesses.The client with multiple gunshot wounds to the chest and the client with chest pain and ST elevations (Indicator of a myocardial infarction) would be considered emergent patients because without intervention they have a high likelihood of death. The client needing stitches would be considered non-urgent since their chance of losing their hand was not an issue and they only needed stitches and cleaning. The client with diabetes presenting with anemia and abdominal pain would be the most likely candidate considered as urgent because they have serious health problems but not immediately and obviously life-threatening ones.

The client arrives at the emergency department and has experienced frostbite to the right hand. Which of the following would the nurse note on assessment of the client's hand? A pink, edematous hand. A fiery red skin with edema in the nail beds. Black fingertips surrounded by an erythematous rash. A white color to the skin, which is insensitive to touch.

A white color to the skin, which is insensitive to touch.

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 a tourniquet. Apply firm pressure over the involved area or artery. Elevate the injured part. Immobilize the area to control blood loss.

Apply firm pressure over the involved area or artery. Explanation: Direct, firm pressure is applied over the bleeding area or the involved artery at a site that is proximal to the wound (Fig. 72-3). Most bleeding can be stopped or at least controlled by application of direct pressure. Otherwise, unchecked arterial bleeding results in death. A firm pressure dressing is applied, and the injured part is elevated to stop venous and capillary bleeding, if possible. If the injured area is an extremity, the extremity is immobilized to control blood loss. A tourniquet is applied to an extremity only as a last resort when the external hemorrhage cannot be controlled in any other way and immediate surgery is not feasible. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Control of External Hemorrhage, p. 2166.

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 Inserting an indwelling catheter Splinting the wound in a position of rest to prevent motion Performing a fasciotomy

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 motion Major soft tissue injuries are dressed and splinted promptly to control bleeding and pain. If an extremity is injured, it is elevated to relieve swelling and pressure. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Assess and Intervene, p. 2162.

As part of an emergency department team, an emergency nurse is conducting a secondary survey on a client. Which of the following would the nurse include? Establishing a patent airway Providing adequate ventilation Assessing neurologic function Applying electrocardiogram electrodes

Applying electrocardiogram electrodes Explanation: A secondary survey is completed after the primary survey priorities of airway, breathing, circulation, and disability have been addressed. Applying electrocardiogram electrodes would be a component of the secondary survey. Establishing a patent airway, providing adequate ventilation, and determining neurologic disability by assessing neurologic function are components of the primary survey. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Triage, p. 2162.

After inserting an oropharyngeal airway, the nurse determines that it is in the proper position when the flange is located at which position? Just below the tip of the patient's nose Approximately at the patient's lips Directly in front of the patient's teeth At the level of the patient's epiglottis

Approximately at the patient's lips Explanation: When an oropharyngeal airway is properly inserted, the tip is in the hypopharynx and the flange is approximately at the patient's lips. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Chart 72-3, p. 2164.

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. Talk with the family about the client having "passed on." Provide sedation to family members as needed. 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.

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. When providing care to a family experiencing the sudden death of a member, the nurse would take the relatives to a private place where they can be together to grieve. In addition, the nurse would encourage the family to view the body if they wish and allow members to support each other and express their emotions freely. Euphemisms such as "passing on" or "going to a better place" should be avoided. Sedation is avoided because it may mask or delay the grieving process, which is necessary to achieve emotional equilibrium and prevent prolonged depression. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Chart 72-2, p. 2159.

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.) Have the patient shower or wash the perineal area before the examination. 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. Ensure that the police are present when the examination is performed.

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. A history is obtained only if the patient has not already talked to a police officer, social worker, or crisis intervention worker. The patient should not be asked to repeat the history. Any history of the event that is obtained should be recorded in the patient's own words. The patient is asked whether he or she has bathed, douched, brushed his or her teeth, changed clothes, urinated, or defecated since the attack, because these actions may alter interpretation of subsequent findings. Each item of clothing is placed in a separate paper bag. The bags are labeled and given to appropriate law enforcement authorities. The patient is examined (from head to toe) for injuries, especially injuries to the head, neck, breasts, thighs, back, and buttocks. The exam focuses on external evidence of trauma (bruises, contusions, lacerations, stab wounds). Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Assessment and Diagnostic Findings, pp. 2188-2189.

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 Managing hypothermia Providing cervical spine protection Undressing the client quickly

Assessing the client's Glasgow Coma Scale score Explanation: The primary survey focuses on stabilizing life-threatening conditions. The ED staff work collaboratively and follow the ABCDE (airway, breathing, circulation, disability, exposure) method. While implementing the D element, the nurse determines neurologic disability by assessing neurologic function using the Glasgow Coma Scale and performing a motor and sensory evaluation of the spine. A quick neurologic assessment may be performed using the AVPU mnemonic: A, alert: is the client alert and responsive? V, verbal: does the client respond to verbal stimuli? P, pain: does the client respond only to painful stimuli? U, unresponsive: is the client unresponsive to all stimuli, including pain? The other interventions are not included in this element of the primary survey. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, p. 2162.

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 Insert a Foley urinary catheter Assist with endotracheal intubation Administer inotropic drugs

Attach a cardiac monitor Explanation: Continuous electrocardiograph (ECG) monitoring is performed during the rewarming process because cold-induced myocardial irritability leads to conduction disturbances, especially ventricular fibrillation. A urinary catheter should be inserted to monitor urinary output; however, ECG monitoring is the priority. There is no indication for endotracheal intubation. Inotropic medications are contraindicated because they can stimulate the heart and increase the risk for fatal dysrhythmias, such as ventricular fibrillation. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, p. 2174.

The nurse is caring for a client who has just been intubated and started on mechanical ventilation in the intensive care unit. The nurse recognizes that it is possible to inadvertently intubate the right lung only. What nursing assessment and monitoring is required to determine if this complication has occurred? Select all that apply. Auscultate both sides of the chest Mark the endotracheal tube at the corner of the mouth and nose Monitor for both high and low pressure alarms Apply suctioning to clear the airway Re-set the ventilator rate as needed

Auscultate both sides of the chest Mark the endotracheal tube at the corner of the mouth and nose Monitor for both high and low pressure alarms It is important to remember that the right main bronchus is wider, shorter, and more vertical than the left. This physiologic difference may lead to inadvertent intubation of the right lung only. It is essential to listen to both sides of the chest for bilateral breath sounds, mark the correct endotracheal tube (ETT) placement at lip or nares, and monitor for high- and low-pressure alarms. Although suctioning the airway to remove secretions is an essential part of the nurse's responsibility when caring for a ventilated client, this action will not help the nurse determine if the tube has been placed only into the right lung only. The ventilator settings are determined by the client's primary health provider and any changes would require an order. These settings are specific to the client's individualized needs. Despite this, the re-setting the ventilator would not help determine incorrect placement of the endotracheal tube.

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 Administer antipsychotic medication Apply physical restraints Move out of the client's view

Call security personnel to assist Explanation: Clients at risk for harming staff members require specific interventions. It is important to first notification of security and administration of the potential for violence. Although medication and physical restraints maybe required, the nurse will not be able to carry out these interventions in a safe manner independently. The nurse should first call for security personnel to assist, all other interventions can be carried out with the support of trained staff. When a client is agitated and has the potential to be violent, they should not be left unattended. Moving out of the client's view can lead to further agitation for the client and increase the risk for escalating to violence. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Patients Who Are Overactive, p. 2190.

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? Hyperthermia Hemolytic transfusion reaction Cardiac arrest Fluid overload

Cardiac arrest Explanation: Blood must be warmed in a commercial blood warmer because administration of large amounts of blood that has been refrigerated has a core cooling effect that may lead to cardiac arrest and coagulopathy. Hyperthermia, hemolytic transfusion reaction, or fluid overload is not the concern. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Quality and Safety Nursing Alert, p. 2166.

When assessing a client with suspected carbon monoxide poisoning, which finding would be least reliable? Cherry red skin color Headache Confusion Palpitations

Cherry red skin color Explanation: Skin color can range from pink or cherry-red to cyanotic and pale is not a reliable sign. In clients with carbon monoxide poisoning, central nervous system signs such as headache and confusion predominate. Palpitations also may occur. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Clinical Manifestations, p. 2179.

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 Increasing urine volume

Cool, moist skin Decreasing blood pressure Increasing heart rate Delayed capillary refill Signs and symptoms of shock include cool, moist skin (resulting from poor peripheral perfusion), decreasing blood pressure, increasing heart rate, delayed capillary refill, and decreasing urine volume. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, p. 2165.

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?" "Are you experiencing any burning or numbness?" "Are you finding the light is too harsh or bothering your eyes?" "Does it feel like there is a tight band around your head?"

"Are you hearing anything that is disturbing you?" Explanation: The Clinical Institute Withdrawal Assessment-Alcohol (CIWA-A) scale is used in the assessment of alcohol withdrawal. The patient's score on this scale helps determine the level of intervention that is required to support safe, withdrawal from alcohol. Assessing for auditory disturbances is one subsection on the scale. In order to effectively assess for this symptom, the nurse should ask the patient if they are hearing anything that is disturbing. By asking the patient if they are experiencing any numbness or burning would help to assess for tactile disturbances. By asking the patient if the light is bothering their eyes would support the assessment for visual disturbances. Asking the patient if it feels like there is a tight band around their head would help determine if the patient has a headache or fullness of the head. These are all symptom items that are measured by this scale. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Alcohol Withdrawal Syndrome/ Delirium Tremens, p. 2185.

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. Massage the extremities. Elevate the legs. Apply a heat lamp. TAKE ANOTHER QUIZ

Administer an analgesic as ordered. Explanation: During rewarming, an analgesic for pain is administered as prescribed, because the rewarming process may be very painful. To avoid further mechanical injury, the body part is not handled. Massage is contraindicated. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Frostbite, p. 2173.

The nurse is providing care for a client who is experiencing alcohol withdrawal. The client reports, "I cannot fall or stay asleep." The nurse observes that the client is agitated, having difficulty falling asleep and crying uncontrollably, with confused speech and a tachycardic pulse. Which intervention should the nurse implement first? Assess the client for suicidal and homicidal ideation Ask a family member to remain with the client Encourage the client to use deep breathing Administer lorazepam as ordered by the health care provider

Administer lorazepam as ordered by the health care provider Explanation: Clients with alcohol withdrawal syndrome show signs of anxiety, uncontrollable fear, tremor, irritability, agitation, insomnia, and incontinence. They are talkative and preoccupied and experience visual, tactile, olfactory, and auditory hallucinations that often are terrifying. Autonomic overactivity occurs and is evidenced by tachycardia, dilated pupils, and profuse perspiration. Usually, all vital signs are elevated in the alcoholic toxic state. The goals of management are to give adequate sedation and support to allow the client to rest and recover without danger of injury or peripheral vascular collapse. A sufficient dosage of a benzodiazepine medication such as lorazepam should be administered to establish and maintain sedation, which reduces agitation, prevents exhaustion, prevents seizures, and promotes sleep. Although the alternate answer options should be included in the client's care, the nurse's first action should be to treat the presenting symptoms. Once the client is calm, the nurse can assess for the risk to harm self or others. The nurse can also support the client in managing anxiety by encouraging deep breathing. If a family member is present, the nurse can ask him or her to stay at the bedside to support the client and ensure safety as the client experiences withdrawal symptoms. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Alcohol Withdrawal Syndrome/ Delirium Tremens, p. 2185.

A nurse is performing a primary survey of a client brought to the emergency department. Which of the following would the nurse include? Select all that apply. Obtaining a complete health history Establishing airway patency Applying monitoring devices Providing adequate ventilation Assessing neurologic function

Establishing airway patency Providing adequate ventilation Assessing neurologic function The primary survey addresses airway, breathing, circulation, and disability. The nurse would establish a patent airway, provide adequate ventilation, evaluate and restore cardiac output, and determine neurologic disability by assessing neurologic function. Obtaining a complete health history and applying monitoring devices are activities involved with the secondary survey. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Assess and Intervene, p. 2162.

Which guideline is appropriate for a nurse to implement while helping family members cope with the sudden death of a loved one? Inform the family that the client has passed on. Obtain orders for sedation for family members. Show acceptance of the body by touching it, giving the family permission to touch. Provide details of the factors attendant to the sudden death.

Show acceptance of the body by touching it, giving the family permission to touch. Explanation: The nurse should encourage the family to view and touch the body if they wish, since this action helps the family to integrate the loss. The nurse should avoid using euphemisms such as "passed on." The nurse should avoid giving sedation to family members, because this may mask or delay the grieving process. The nurse should avoid volunteering unnecessary information (e.g., client was drinking at the time of the accident). Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, Chart 72-2, p. 2159.

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. hypothermia. hyponatremia. head injury.

pulmonary edema. Explanation: Resultant pathophysiologic changes and pulmonary injury depend on the type of fluid (fresh or salt water) and the volume aspirated. Freshwater aspiration results in a loss of surfactant and therefore an inability to expand the lungs. Saltwater aspiration leads to pulmonary edema from the osmotic effects of the salt within the lungs. If a person survives submersion, acute respiratory distress syndrome, resulting in hypoxia, hypercarbia, and respiratory or metabolic acidosis, can occur. The client would experience hypernatremia. Hypothermia and head injury may be associated with near drowning but would be apparent at the time of admission and would not develop after several hours. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 72: Emergency Nursing, pp. 2174-2175.