Primary Survey and Prioritization

A nurse is triaging clients in the emergency department (ED). Which client would the nurse prioritize to receive care first? a. A 22 year old with a painful and swollen right wrist b. A 45 year old reporting chest pain and diaphoresis c. A 60 year old reporting difficulty swallowing and nausea d. An 81 year old, respiratory rate 28 breaths/min and temperature of 101° F (38.8°

ANS: B A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable

AVPU

Alert, Verbal, Pain, Unresponsive

Glasgow Coma Scale (GCS)

Eye opening: Spontaneous = 4 to voice =3 to pain = 2 none= 1 VERBAL RESPONSE Oriented = 5 Confused = 4 Inappropriate words =3 Incomprehensible sounds= 2 None = 1 MOTOR RESPONSE Obeys commands = 6 Localizes pain = 5 Withdraws = 4 Flexion = 3 Extension = 2 None= 1 A low score of 3 indicates a client who is totally unresponsive, and a high score of 15 indicates a client who is within normal limits neurologically.

What is the primary goal of a triage system used by the nurse with clients presenting to the emergency department? a. Determine the acuity of the client's condition to determine priority of care. b. Assess the status of the airway, breathing, circulation, or presence of deficits. c. Determine whether the client is responsive enough to provide needed information. d. Evaluate the emergency department's resources to adequately treat the patient.

ANS: A ED triage is an organized system for sorting and classifying clients into priority levels depending on illness or injury severity. The primary goal of the triage system is to facilitate the ED nurse's ability to prioritize care according to the acuity of the patient, having the clients with the more severe illness or injury seen first. Airway, breathing, and circulation are part of the primary survey. Determining responsiveness is done during the disability phase of the primary survey and is not the primary goal. Evaluating the ED's resources is also not a goal of triage.

A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action would the nurse take prior to providing advanced cardiac life support? a. Contact the on-call orthopedic surgeon. b. Don personal protective equipment. c. Notify the Rapid Response Team. d. Obtain a complete history from the paramedic.

ANS: B Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions would be taken in all resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers. It is not known if this client has orthopedic injuries. The Rapid Response Team is not needed in the ED. A complete history is needed but the staff's protection comes first

An emergency department nurse is caring for a trauma patient. Which interventions does the nurse perform during the primary survey? (Select all that apply.) a. Foley catheterization b. Needle decompression c. Initiating IV fluids d. Splinting open fractures e. Endotracheal intubation f. Removing wet clothing g. Laceration repair

ANS: B, C, E, F The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic ABC, with an added D and E: Airway and cervical spinal motion restriction; Breathing; Circulation; Disability; and Exposure. After the completion of primary diagnostic and laboratory studies, and the insertion of gastric and urinary tubes, the secondary survey (a complete head-to-toe assessment) can be carried out.

An emergency department nurse is triaging victims of a multi-casualty event. Which client would receive care first? a. A 30-year-old distraught mother holding her crying child b. A 65-year-old conscious male with a head laceration c. A 26-year-old male who has pale, cool, clammy skin d. A 48 year old with a simple fracture of the lower leg

ANS: C The client with pale, cool, clammy skin may be in shock and needs immediate medical attention. The mother does not have injuries and so would be the lowest priority. The other two people need medical attention soon, but not at the expense of a person in shock

While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action would the nurse take first? a. Apply oxygen via nasal cannula. b. Administer intravenous 0.9% saline solution. c. Transfer the client to a negative-pressure room. d. Obtain a sputum culture and sensitivity.

ANS: C A client with signs and symptoms of tuberculosis or other airborne pathogens would be placed in a negative-pressure room to prevent contamination of staff, clients, and family members in the crowded emergency department. The client may or may not need oxygen or an IV. A sputum culture would be obtained but is not the priority.

Q1- A 21-year-old male client was in a motorcycle accident but was wearing a helmet. He is admitted to the emergency department with a possible traumatic brain injury (TBI). Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. Case study

The first priority for the nurse is to assess ___Airway ___1__Breathing, and Circulation____ Breathing, Airway, Motor Response, Vital signs, Circulation. After these assessments are performed and the client is stabilized, the most important parameter for the nurse to monitor is the client's __level of consciousness____ . Sensory response, Vital Signs, Cognitive level, level of consciousness, Motor response. The nurse assesses changes in behavior such as __Confusion___ and ___Agitation.__and Restlessness_ with/ hypoxia Restlessness, Hallucinations, Paranoia, Confusion, Agitation.

A nurse in the emergency department is assessing a client who is unresponsive. The client's partner states, "He was pulling weeds in the yard and slumped to the ground." Which of the following techniques should the nurse use to open the client's airway? A. Head-tilt, chin-lift B. Modified jaw thrust C. Hyperextension of the head D. Flexion of the head

A. CORRECT: The nurse should open the client's airway by the head-tilt, chin-lift because the client is unresponsive without suspicion of trauma. B. The nurse should not open the client's airway with the modified jaw thrust because this method is used for a client who is unresponsive with suspected traumatic neck injury. C. The nurse should not open the client's airway with hyperextension of the head because hyperextension of the head can close off the airway and cause injury. D. The nurse should not open the client's airway with flexion of the head because flexion of the head does not open the airway.

A nurse in the emergency department is caring for a client who fell through the ice on a pond and is unresponsive and breathing slowly. Which of the following actions should the nurse take? (Select all that apply.) A. Remove wet clothing. B. Maintain normal room temperature. C. Apply warm blankets. D. Use a rapid rewarming water of 40º to 42º C (104º to 108º F). E. Infuse warmed IV fluids

A. CORRECT: This is an appropriate action by the nurse because the body temperature can rise more quickly when heat is applied to dry skin. B. The nurse should increase the temperature of the room to help return the client to a normal body temperature. C. CORRECT: This is an appropriate action by the nurse because the client's body temperature can rise more quickly when warm blankets are applied. D. CORRECT: This is an appropriate action by the nurse because the client's body temperature can rise more quickly when a rapid rewarming bath water of 40º to 42º C (104º to 108º F) is used to warm the client's body and preserve tissues. E. CORRECT: This is an appropriate action by the nurse because the client's body temperature can rise more quickly when warmed IV fluids are infused.

A nurse is reviewing the common emergency management protocol for clients who have asystole. Which of the following actions should the nurse plan to take during this cardiac emergency? A. Perform defibrillation. B. Prepare for transcutaneous pacing. C. Administer IV epinephrine. D. Elevate the client's lower extremities

A. Defibrillation is not indicated for asystole, because this is not considered a shockable cardiac rhythm. B. Transcutaneous pacing is not indicated for the treatment of asystole. C. CORRECT: Administering epinephrine during asystole is an appropriate action by the nurse because it increases heart rate, improves cardiac output, and promotes bronchodilation. D. Elevating the client's lower extremities is indicated for the treatment of a client who is in shock, rather than asystole.

A nurse on a medical-surgical unit is caring for a group of clients. The nurse should notify the rapid response team for which of the following clients? A. Client who has a pressure injury of the right heel whose blood glucose is 300 mg/dL B. Client who reports right calf pain and shortness of breath C. Client who has blood on a pressure dressing in the femoral area following a cardiac catheterization D. Client who has dark red coloration of left toes and absent pedal pulse

A. The nurse should notify the provider. The situation does not indicate the beginning of a rapid decline in the client's condition. B. CORRECT: The nurse should identify that the client is at risk for respiratory arrest due to a possible embolism. The nurse should call the rapid response team because the manifestations can indicate the beginning of a rapid decline in the client's condition. C. This assessment does not indicate the beginning of a rapid decline in the client's condition at this time. The nurse should reassess the client and notify the provider if the bleeding increases. D. The nurse should notify the provider. The situation does not indicate the beginning of a rapid decline in the client's condition.

A nurse is caring for a client who has ingested a toxic agent. Which of the following actions should the nurse plan to take? (Select all that apply.) A. Induce vomiting. B. Instill activated charcoal. C. Perform a gastric lavage with aspiration. D. Administer syrup of ipecac. E. Infuse IV fluids.

A. Vomiting places the client at risk for aspiration. B. CORRECT: This is an appropriate action by the nurse because activated charcoal adsorbs toxic substances, and the charcoal does not pass into the bloodstream. C. CORRECT: This is an appropriate action by the nurse because gastric lavage with aspiration removes the toxic substance when the instilled fluid is suctioned from the gastrointestinal tract. D. Administering syrup of ipecac is not recommended because it induces vomiting, which increases the client's risk for aspiration. E. CORRECT: This is an appropriate action by the nurse because intravenous fluids help dilute the toxic substances in the bloodstream and promote elimination from the body through the kidneys

A 23-year-old sustained a traumatic brain injury received as an unrestrained driver in a motor vehicle crash. On admission a computed tomography (CT) scan revealed a large right subdural hematoma that was successfully addressed during an emergency craniotomy. The client is prescribed 3% saline at 20 mL/hr. intravenously. Item Type: Extended Multiple Response What nursing assessment finding would indicate that the 3% saline therapy has been effective 3 hours post surgery? Select all that apply. Intracranial pressure (ICP): 18mm Hg Heart rate: 50 beats/minute Pupils: equal, round, and reactive to light and accommodation (Perrla) bilaterally Pulse pressure: 70 Urine output: 900 ml/3 hrs. Breath sounds: Clear Opens eyes in response to pain stimulus

ANS Intracranial pressure (ICP): 18mm Hg Pupils: equal, round, and reactive to light and accommodation (Perrla) bilaterally Urine output: 900 ml/3 hrs. Breath sounds: Clear Opens eyes in response to pain stimulus Rationale Pulse pressure = 70 too high —-120/80 Pulse pressure systolic- diastolic Normal pulse pressure = 40 if is greater than 40 is unhealthy ICP= 18- High⇨ goal ICP ＜20 Heart Rate - Low Urine output - too much, breath sound- good Opens eyes in response to pain stimulus- not sure where we start 3% Saline therapy 3% saline order to help decrease SCF when patient increased ICP and improve neurological status for normal person we give 0.9 % saline, that is the BIG shift

Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action would the nurse take first? a. Assess that the client is breathing adequately. b. Insert a large-bore intravenous line. c. Place the client on a cardiac monitor. d. Assess for the best neurologic response

ANS: A After establishing an airway, the highest priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he or she may not be breathing, or may be breathing inadequately with the device in place. Inserting an IV line and placing the client on a monitor would come after ensuring a patent airway and effective breathing.

A client is brought to the emergency department after a car crash. The client has a large piece of glass in the left eye. What action by the nurse takes priority? a. Administer a tetanus booster shot. b. Ensure that the client has a patent airway. c. Prepare to irrigate the client's eye. d. Turn the client on the unaffected side.

ANS: B Airway always comes first. After ensuring a patent airway and providing cervical spine precautions (do not turn the client to the side), the nurse provides other care that may include administering a tetanus shot. The client's eye may or may not be irrigated.

An elderly client who has fallen from a roof is transported to the emergency department by ambulance. The client was unconscious at the scene but is conscious on arrival and is triaged as urgent. What is the priority assessment the nurse includes during the primary survey of the patient? a. A full set of vital signs b. Cardiac rhythm c. Neurologic status d. Client history

ANS: C The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. Injuries from this type of fall have a high risk for cervical spine injuries. In addition, with the loss of consciousness at the scene the client would be at risk for head trauma. A full set of vital signs is obtained as part of the secondary survey. The cardiac rhythm is important but not specifically related to this client's presentation. Client history would be obtained as able.

A nurse is triaging clients in the emergency department. Which client would the nurse classify as "nonurgent?" a. A 44 year old with chest pain and diaphoresis b. A 50 year old with chest trauma and absent breath sounds c. A 62 year old with a simple fracture of the left arm d. A 79 year old with a temperature of 104° F (40.0° C)

ANS: C A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with a simple arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration

Q2-- An 86-year old female presents to her primary health care provider's clinic with a chief complaint of headache. She describes the headache as sudden in onset 4 hours ago, located in the front of the head, and is constant, stabbing, and unrelieved by acetaminophen extra strength 1000 mg. Her daughter attends the appointment with her and informs the nurse that her mother sustained a fall 2 days ago and thinks it is possible she may have hit her head. She noticed periods of confusion since the fall and states that she isn't comfortable leaving her alone since that time. She says the confusion seems to be worsening and she is concerned about an injury from the fall and is concerned for her mother's safety. The physical exam shows ipsilateral dilation of the right pupil. The physician refers her to the emergency department for computed tomography (CT) scan of the brain to rule out subdural hematoma. Upon arrival to the ED, the nurse manages the client based on the head injury. For each action select the order of priority that the action will be implemented on arrival to the ED. Nursing Actions Place in order of priority 1 implement first, 5 last. Stabilize the cervical spine Apply O2 via non-rebreather mask Assess airway, breathing, and circulation Infuse normal saline and lactated Ringer's solution Establish intravenous access with 2 large bore catheter Case study

order 1. Assess airway, breathing, and circulation 2. Stabilize the cervical spine 3. Apply O2 via non-rebreather mask 4. Establish intravenous access with 2 large bore catheters 5. Infuse normal saline and lactated Ringer's solution