STRESS: TRAUMA Unit 3 Semester 4 PBSC

SEAT BEALT INJURIES

*Can cause contusions or abrasion *Strap too high→ internal trauma to neck *Waist belt worn too high→ damage to abdominal organs, also has the potential for injuring the fetus in the pregnant client

Which information will the nurse teach seniors at a community recreation center about ways to prevent fractures? a. Tack down scatter rugs in the home. b. Expect most falls to happen outside the home. c. Buy shoes that provide good support and are comfortable to wear. d. Get instruction in range-of-motion exercises from a physical therapist.

ANS: C Comfortable shoes with good support will help decrease the risk for falls. Scatter rugs should be eliminated, not just tacked down. Activities of daily living provide range of motion exercise; these do not need to be taught by a physical therapist. Falls inside the home are responsible for many injuries.

Electronic Fetal Monitoring (EFM)

-Reflects fetal cardiac responses to hypoxia and hypoperfusion and helps to assess maternal status after a trauma.

A client was brought to the emergency department after suffering a closed head injury and lacerations around the face due to a hit-run accident. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessment findings if observed after few hours, should be reported to the physician immediately? a. Bleeding around the lacerations. b. Withdrawal of the client in response to painful stimuli. c. Bruises and minimal edema of the eyelids. d. Drainage of a clear fluid from the client's nose.

ANS:

Assessment findings suggestive of peritonitis include (select all that apply) a. rebound tenderness. b. a soft, distended abdomen. c. dull, intermittent abdominal pain. d. shallow respirations with bradypnea. e. observing that the patient is lying still.

ANS: A, E -rebound tenderness. -observing that the patient is lying still.

A patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first? a. Heart rate b. Breath sounds c. Body temperature d. Level of consciousness

ANS: B (Primary Survey: Breathing) The priority assessment relates to ABCs (airway, breathing, circulation) and how well the patient is oxygenating, so breath sounds should be assessed first. The other data will also be collected rapidly but are not as essential as the breath sounds.

Which patient requires the most rapid assessment and care by the emergency department nurse? a. The patient with hemochromatosis who reports abdominal pain b. The patient with peritonitis who has a temperature of 101.8° F c. The patient with thrombocytopenia who has oozing gums after a tooth extraction d. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours.

ANS: B A peritonitis patient with a fever is at risk for rapidly developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed.

OB TRAUMA Which assessment would be important for a 6-hour-old infant who has bruising over the cheeks from a forceps birth? a. Presence of newborn reflexes b. Symmetry of facial movements c. Caput and molding of the head d. Anterior and posterior fontanels

ANS: B Following a forceps birth, the infant may have ecchymoses and facial nerve injury. Facial asymmetry suggests facial nerve damage. Changes in newborn reflexes, presence of caput and molding, and changes in the anterior and posterior fontanels are not risks associated with trauma to the infant's face

A patient is receiving positive pressure mechanical ventilation and has a chest tube. When assessing the water seal chamber what do you expect to find? a. The water in the chamber will increase during inspiration and decrease during expiration. b. There will be continuous bubbling noted in the chamber. c. The water in the chamber will decrease during inspiration and increase during expiration. d. The water in the chamber will not move.

ANS: C

Glascow Coma Scale (GCS)

A neurological scaled used to determine the level of consciousness of a patient.

HEAD TRAUMA Causes

Causes -Motor vehicle accident -Fall greater than 20 ft -Child abuse (shaken baby) Imaging • CT scan or MRI: show evidence of bleeding, bruising, or swelling

HEAD TRAUMA HEMATOMA (3) Types

EPIDURAL *Epidural- Most Deadly *Medical emergency! High bleeding & rapid *DEATH from ^ ICP - Classic sign: Loss of consciousness - Followed by brief alertness (STAY with & -Monitor client who passed out and then woke up again. Subdural Subarachnoid

What is the priority assessment for a client in C spine after a fall?

Obtain Glasgow Coma Scale score.

In Primary Survey (CIRCULATION) If ABSENT pedal pulse:

Start NS fluid infusion w large bore IV line.(Risk compartment syndrome if fx) *Prolonged cap refill could be a sx compartment syndrome

PERIOTINITIS TREATMENT

*Broad spectrum ABX given (until culture report comes back): tx 1st bc fatal if treatment delayed *NG tube to suction -Decompresses stomach to decrease gastric motility (in peritonitis you are building up gastric acid but it has nowhere to go d/t paralytic ileus) *IV fluids (Corrects hypovolemia) Isotonic *Pain (Manage w/ PCA pump) Analgestics *Surgical Treatments (remove infected material, correct cause) Excision esp if appendix involved. Resection. of intestines done w or w/o anastomosis. Fecal diversion. created w extensive sepsis.

PRIMARY SURVEY (ABCDE) CIRCULATION

*Control bleeding w/ direct pressure -Sterile dressing then pressure dressing -Obtain blood samples for typing (determine ABO & RH group) *Assess pulses (carotid/apical & peripheral/femoral) *Assess Cap refill (Compartment Fx) *Assess Skin color *Insert large bore IV catheter & start aggressive fluid resuscitation (Either LR or NS) -For upper extremity (unless contraindicated)

After change-of-shift report, which patient should the nurse assess first? a. Patient with a repaired mandibular fracture who is complaining of facial pain b. Patient with an unrepaired intracapsular left hip fracture whose leg is externally rotated c. Patient with an unrepaired Colles' fracture who has right wrist swelling and deformity d. Patient with repaired right femoral shaft fracture who is complaining of tightness in the calf

ANS: D (Primary Survey: Circulation) (Second Survey: Extremities) Calf swelling after a femoral shaft fracture suggests hemorrhage and risk for compartment syndrome. The nurse should assess the patient rapidly and then notify the health care provider. The other patients have symptoms that are typical for their injuries but do not require immediate intervention

SECONDARY SURVEY (SAMPLE) PELVIS/PERINEUM ASSESSMENTS

*Check if soft tissue injury (pain upon light palpation of pelvis may indicate Fx) -Look for bladder distension -Ability to void *Inspect perineum for injury

Chest Tube REMOVAL

-Gather supplies needed which will include petroleum gauze dressing per physician preference. -Place in Semi-Fowler's position. -Have the pt take deep breath, exhale, and bear down during removal of the tube. -Pre-medicate prior to removal as ordered by the physician.

Hemothorax

* BLOOD in pleural space (Lung is not able to expand do to surrounding blood) *Caused by -Chest trauma -Lung tumor -PE

Flail Chest

*Caused by: Fractures of ribs (portion of the chest caves in) *Gives instability to the chest *S/Sx : -Paradoxical breathing

In Primary Survey (BREATHING) look for:

*Dyspnea *Cyanosis *Paradoxical or *Asymmetrical chest wall movements *Decreased/Absent breath sounds affected area. *Visible wound to chest wall *Hypotension *Tachycardia

The nurse is assessing a client with a laryngeal trauma. This client presents with hemoptysis, aphonia, hoarseness, dyspnea, and subcutaneous emphysema. Which condition of the client stands first in the priority list? a. Dyspnea b. Aphonia c. Hoarseness d. Subcutaneous emphysema

ANS: A (Primary Survery: Airway) Bleeding from the airway, aphonia, hoarseness, and subcutaneous emphysema are the clinical manifestations of laryngeal trauma. Maintaining a patent airway is a priority; therefore, dyspnea should be corrected to prevent life-threatening consequences. Aphonia is of moderate priority and can be corrected by clearing the throat. Hoarseness can be cleared slowly since it does not threaten the client's life. Subcutaneous emphysema is of moderate priority since it does not affect the client's life directly.

OB TRAUMA The nurse assesses the amniotic fluid. Which characteristic presents the lowest risk of fetal complications? a. Bloody b. Clear with bits of vernix caseosa c. Green and thick d. Yellow and cloudy with foul odor

ANS: B Amniotic fluid should be clear and may include bits of vernix caseosa, the creamy white fetal skin lubricant. Green fluid indicates that the fetus passed meconium before birth. The newborn may need extra respiratory suctioning at birth if the fluid is heavily stained with meconium. Cloudy, yellowish, strong-smelling, or foul-smelling fluid suggests infection. Bloody fluid may indicate partial placental separation.

Which finding in a patient with a Colles' fracture of the left wrist is most important to communicate immediately to the health care provider? a. Swelling is noted around the wrist. b. The patient is reporting severe pain. c. The wrist has a deformed appearance. d. Capillary refill to the fingers is prolonged.

ANS: D (Primary Survey: Circulation) Swelling, pain, and deformity are common findings with a Colles' fracture. Prolonged capillary refill indicates decreased circulation and risk for ischemia. This is not an expected finding and should be immediately reported.

THERMOREGULATION

Process of maintaining an internal temperature within a tolerable range.

OB TRAUMA EMERGENCY: RELIEF OF FOREIGH BODY AIRWAY OBSTRUCTION

Unable to SPEAK/COUGH: Perform chest thrust (Stand behind, place arms under armpits to encircle chest, press backward w/ quick thrust until foreign body expelled Becomes UNCONSIOUS Support her to group, activate EMS and begin CPR **NOTE: Unconscious pregnant women increase risk for regurgitation of gastric content & aspiration when head position LOWER than STOMACH or if applied ABDOMINAL PRESSURE

Chest Tube used for:

• After thoracic surgery * During cardiac surgery (drain fluid from around the heart) - Spontaneous pneumothorax • Pneumothorax • Hemothorax - Pleural effusion • Empyema (infection)

In Primary Survey (AIRWAY) look for Signs or Compromised Airway:

*Dyspnea *Inability to vocalize. *Foreign in airway *Trauma face/neck

OB TRAUMA BLUNT TRAUMA *If mom survives placental abruption is most common cause of fetal death *If impact force fractures moms' pelvis: Fetus skull fx -Evaluation: fetal skull fracture or intracranial hemorrhage

*Mostly d/t MVC *Evaluate ALL pregnant victims for sx of: Placental abruption even minor blunt Abd trauma BLUNT TRAUMA TYPES Acceleration Moving Object Deceleration Sudden stop forces Shearing (Tear) Moving in opposite direction create tears Compression (Crushing) *Uterine rupture = RARE -Assoc: direct blow w substantial force -Traumatic uterine rupture almost always results fetal death & sometimes mom deaths

A patient came in with abdominal pain and is lying still and has shallow breathing. The nurse will monitor for a. Abdominal distention b. Projectile vomiting c. Leukemia d. Placenta previa

ANS: A

When preparing to cool a patient who is comatose and is to begin therapeutic hypothermia, which intervention will the nurse plan to do (select all that apply)? a. Assist with endotracheal intubation. b. Insert an indwelling urinary catheter. c. Begin continuous cardiac monitoring. d. Obtain an order to restrain the patient. e. Prepare to give sympathomimetic drugs.

ANS: A, B, C Cooling can produce dysrhythmias, so the patient's heart rhythm should be continuously monitored, and dysrhythmias treated if necessary. Bladder catheterization and endotracheal intubation are needed during cooling. Sympathomimetic drugs tend to stimulate the heart and increase the risk for fatal dysrhythmias such as ventricular fibrillation. Patients receiving therapeutic hypothermia are comatose or do not follow commands, so restraints are not indicated.

The nurse practicing in the perinatal setting should promote kangaroo care regardless of an infant's gestational age. This intervention: a. is adopted from classical British nursing traditions. b. helps infants with motor and central nervous system impairment. c. helps infants to interact directly with their parents and enhances their temperature regulation. d. gets infants ready for breastfeeding.

ANS: C Kangaroo care is skin-to-skin holding in which the infant, dressed only in a diaper, is placed directly on the parent's bare chest and then covered. The procedure helps infants interact with their parents and regulates their temperature, among other developmental benefits.

During the assessment, the nurse should be looking for additional symptoms diagnostic of peritonitis, which include: a. Abdominal rigidity b. Diminished peristalsis. c. Leukocytosis d. All of the above.

ANS: D

A nurse is preparing for an unconscious client with a head injury to be transferred from the emergency department to a neurologic trauma unit. Which nursing action is the priority? a. Notifying the receiving unit of the transfer. b. Having the client's records ready for the transfer c. Verifying that the family has been notified of the transfer d. Checking that a bag-valve mask is available during the transfer

ANS: D (Primary Survey: Airway) Checking that a bag-valve mask is available during the transfer is vital in case of respiratory distress; increased intracranial pressure compresses the brainstem, which contains the medulla, the respiratory center. Notifying the receiving unit of the transfer is important but not of primary urgency; the respiratory status is the priority. Having the client's records ready for the transfer is important but not of primary urgency; the respiratory status is the priority. Verifying that the family has been notified of the transfer is important but not of primary urgency; the respiratory status is the priority.

SECONDARY SURVEY (SAMPLE) HEAD, NECK, FACE ASSESSMENTS

Asses: Gaze, Bruising, Specific Bruises *Battles sx: bruise behind ears→ found w/ fx of posterior base of the skull *Raccoon eye: periorbital ecchymosis → fx of frontal base of the skull *CSF leakage -Clear drainage from nose or ears creates yellow halo on white paper or gauze *Airway obstruction -Assess movement of mouth -Check trachea for shift from midline & neck mobility or pain (To know whether have pneumothorax or whether have fx of cervical vertebrae)

Cognitive Appraisal Theory (Theory of emotions)

States that a person's evaluative judgment (or appraisal) of a situation, event or object determines or contributes to his/her emotional response to it.

OB TRAUMA Risks Factors: MVC, Falls, IPV, Assault, Suicide attempt

Trauma effects on pregnancy influenced by: - Length of gestation -Type/severity trauma - Degree of disruption of uterine & fetal physiologic features Fetal death: -Death of mother -Shock of mother -Disruption of the placenta -Direct injury to fetus Maternal Death -Major cause is Head injury If not Pregnant ask: - LMP (last menstrual prd) / Always →HCG: -Need to know if pt is pregnant -Many don't think they are or aren't far along. -Trauma can cause major damage to fetus

A 58-yr-old patient with blunt abdominal trauma from a motor vehicle crash undergoes peritoneal lavage. If the lavage returns brown fecal drainage, which action will the nurse plan to take next? a. Auscultate the bowel sounds. b. Prepare the patient for surgery. c. Check the patient's oral temperature. d. Obtain information about the accident.

ANS: B Return of brown drainage and fecal material suggests perforation of the bowel and the need for immediate surgery. Auscultation of bowel sounds, checking the temperature, and obtaining information about the accident are appropriate actions, but the priority is to prepare to send the patient for emergency surgery.

CHEST TRAUMA "Cardiac" & Thoracic Injuries Cardiac Trauma: Blunt cardiac injury is blunt chest trauma that causes contusion of myocardial muscle, rupture of a cardiac chamber, or disruption of a heart valve. * Sometimes a blow to the anterior chest wall causes cardiac arrest without any structural lesion (commotio cordis)

Blunt: cause Shearing compression, Lacerations or Internal structures in Thorax Penetration: Results in visible injury; Easier to detect Open Pneumothorax: chest wall penetrated, outside air enter pleural space. Closed Pneumothorax: chest wall intact (fx rib) *Cardiac Tamponade (Pericardial) *Flail Chest *Pneumothorax: -Tension -Open -Closed (Spontaneous & Iatrogenic) *Hemopneumothorax *Hemothorax

HEAD TRAUMA Manifestations IICP/ HEMATOMA 3 TYPES

Early signs Agitation Restlessness/irritability Change in LOC Decreased Mental Status Sudden Vomiting "Emesis" W/O Nausea Late signs Seizures Posturing (decorticate & decerebrate) Cushing triad Imaging

ABDOMINAL COMPARTMENT SYNDROME (ACS) Complication of BLUNT Abdominal Trauma MANIFESTATIONS & NURSING CARE

Manifestations: -Tense/distended abdomen -Sx of hypovolemic shock (tachycardia, hypotension) *ACS can lead to tissue necrosis (risk for infection) → Assess V/S frequently. -WBC -Pain level -Bowel sounds -Abdominal discoloration, distension, firmness

CHILDREN TRAUMA

*Head injury: most common pediatric trauma *Thoracic injuries: high mortality rate (RF) Increased risk for trauma r/t problems d/t: -High RR: more vulnerable to noxious agents -Less fluid reserve (susceptible to dehydration) -Less circulating volume: takes smaller amounts of blood loss to cause hypovolemic shock compared to adults) -Smaller airways -Infants under 3 (nose breathers)

Hemopneumothorax

*BLOOD & AIR in the pleural space *Treatment: -2 chest tubes inserted (large tube 36-40F) ; are connected to Y connector & then to a pleural drainage system.

Complications of BLUNT Abdominal Trauma

*ABDOMINAL COMPARTMENT SYNDROME *Must be treated soon→ high mortality rate *HEMORRHAGE: If hemorrhage is suspected a Focused Sonography Test (FAST) -Helps determine cause of hemorrhage. -Done at the bedside

KB

-Evaluate transplacental hemorrhage. -Identify fetal-to-maternal bleeding, usually after a trauma. -Indicates hemorrhage of fetal blood thru placenta in mom's circulation -Detects fetal RBC's in maternal circulation

A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (on 0 to 10 scale) "whenever I take a deep breath." Which action will the nurse take next? a. Auscultate for breath sounds. b. Administer the PRN morphine. c. Have the patient cough forcefully. d. Notify the patient's health care provider.

ANS: A The patient's statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub and decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider.

PERIOTINITIS Complications of PENETRATING Abdominal Trauma DEFINE/CAUSES/COMPLICATIONS *Life threatening inflammation of the epithelial lining of the abdominal cavity known as the peritoneum *Bacteria spillage into peritoneal cavity *Not just caused by penetrating injuries (can occur in medical procedure if bowel is perforated)

PRIMARY CAUSE: -Blood-borne & Genital tract organisms -Cirrhosis w/ ascites SECONDARY CAUSE (common): -Appendicitis w/ rupture -Blunt or penetrating abdominal trauma -Diverticulitis w/ rupture -Ischemic bowel disorders -Pancreatitis -Perforated intestine, peptic ulcer -Peritoneal dialysis -Postop (breakage of anastomosis) Complications: Shock (septicemia/hypovolemia) Sepsis Intraabdominal abscess formation Paralytic ileus ARDS

Cardiac Tamponade "Pericardial Tamponade"

*Collection of FLUID or BLOOD in the pericardial sac (inhibits heart from filling adequately) -Results in compression or obstruction of the heart (Aorta, Pulmonary Arteries) *Leads to obstructive shock *Massive internal bleeding * RX → Immediate crack chest & explore for leak and attempt to tie off (if possible) *S/Sx: -Muffled heart sounds -Sx of decreased CO/SV (HTN, JVD...cyanosis) *Beck's Triad: -Hypotension -JVD -Muffled heart sounds *Emergent; must be treated w/ pericardiocentesis Pericardial tap (pericardiocentesis): -Fluid will be clear or straw colored -(+) Glucose present

BLUNT TRAUMA

*Force that doesn't leave open wound *Commonly occurs with motor vehicle crashes or falls -Abdominal blunt trauma Retro peritoneal hemorrhage (Cullen, Gray Turner) -Thoracic Trauma: Pulmonary contusion can be life threatening Suspect cases of thoracic injury, Esp after blunt acceleration or deceleration trauma (MVA)

Chest Tube Nursing Considerations

•Always keep drainage system BELOW chest • NEVER strip the tubing * NEVER clamp the tubing *EDUCATE to do Valsalva maneuver (Deep breath, exhale, and bear down) when the HCP is removing the chest tube • MONITOR: Color & quantity of the drainage in the drainage collection chamber every • Lung sounds • Insertion site *REPORT bright red blood (dark red is expected)

OB TRAUMA PREGNANT WOMEN DIAGNOSTIC TEST/MANIFESTATIONS Acidosis develops quicker in pregnant than nonpregnant. Circulating blood volume increase 40-50% in gestation-Pregnant women can tolerate 1000-mL blood loss readily w/o demonstrating clinical sx Careful monitor fetal status assists greatly in maternal assessment: fetal monitor tracing works as "oximeter" of internal maternal well-being

* PT / PTT *Type & CROSSMATCH *BICARB / LACTATE levels *KLEIHAVER-BETKS test (KB) *Pregnant normally Hypervolemic & Hyperdynamic state -10th wk: slight ↑ pulse rate, SV, CO (1.5 L/min) -Hypervolemia: allows maternal circulation to compensate for gradual loss of blood volume up 30% & acute blood loss of 10-15% -Fetal compromise w/ maternal blood loss if 15-30% *Ultrasonography & CT scan: Likelihood of intraabdominal bleeding *EFM (Electronic Fetal Monitoring): Initiate soon after woman is stable *Radiographic exam: If woman sustained serious injuries

OB TRAUMA PREGNANT WOMEN Trauma During Pregnancy, Increases incidence of ● Preterm labor & birth ● Placental abruption ● Fetal or neonatal death Ask if any preggo complications prior to injury ...Inspect: -Perineum (Vag bleeding / amniotic fluid) -Vaginal Open? (Crowning or fetal presentation) -Observe shape & contour of ABD (A change indicates uterine rupture or concealed hemorrhage)

**Priorities after trauma: Resuscitate & Stabilize her condition 1st and then fetal needs 1. Initial priority: Immediate stabilize women (best way to ensure fetal stability) 2. Determine MOI (MECHANISM OF INJURY) 3. Administer vasopressors (Constriction: norepinephrine, epinephrine) -Preggos have decreased tolerance for hypoxia & apnea d/t decreased o2 reserve. *AVOID Drugs to treat maternal hypotension bc may reduce uterine blood which would reduce oxygen delivery to the fetus. 4. Fetal monitoring: if fetus is > 20 wks gestation & is continued for at least 4 hrs, Dr should consult early for a pt w/ serious trauma or sx of pregnancy complications: -Abnormal fetal HR -Vaginal bleeding -Contractions *Exploratory laparotomy: penetrating wound (gunshot- organ damage) *Cesarean Section: -If mom in cardiac arrest r/t trauma -Perimortem Cesarean Birth performed after 4 mins of resuscitative efforts if no evidence of a maternal pulse

Tension Pneumothorax *Medical emergency→ causes decrease in CO (d/t compressed vena cava from excess air)

*AIR enters but not escape: intrathoracic pressure increases lung collapses causing shift of mediastinum toward the unaffected side decreasing its expansion *Result of rapid accumulations of air in pleural space (d/t either an open or a closed pneumothorax) *If not treated: will go into SHOCK *Needle decompression: immediately (allows escape of some air into the atmosphere) -Followed by chest tube insertion *Manifestations: -Dyspnea -Marked Tachycardia -Tracheal deviation -Dec/Absent breath sounds in affected area -(JVD) Neck vein distention -Hypotension -Cyanosis -Profuse diaphoresis.

Pneumothorax

*AIR enters the pleural cavity which disrupts the pressure within *Atmospheric air causes positive pressure within space....results in collapse of the lung

Open Pneumothorax *Traumatic in nature: immediate interventions transport to OR

*AIR enters the pleural through a chest wall wound or d/t trauma Manifestations *Penetrating chest wound "Sucking chest wound" (air moves freely between pleural space & atmosphere....suck noise hear movement of air back/forth) Causes: -Gunshot wounds -Stab wounds -Rib fractures -Surgical thoracotomy *Emergency treatment: -Cover the wound w/ occlusive dressing that's secured on 3 sides (vent dressing) -Open heart: cardiac massage (last effort to save life)

PLEURAL DRAINAGE 3rd COMPARTMENT (SUCTION CONTROL CHAMBER)

*Amount of suction applied is regulated by amount of water in this chamber (Not by amount of suction applied to the system) *NORMAL: continuous bubbling in this chamber ......over time this water can evaporate so monitor! -Continue to monitor the collection device. *Typically filled with 20 cm of water

PENETRATING TRAUMA

*Causes an open wound Gunshot May cause internal damage d/t velocity of bullet & bc many types of bullets ricochet off organs or bones and move throughout body leaving fragments. Stabbing: Leave knife in place until can go to surgery -Abdominal Penetrating Trauma -Thoracic Trauma: Pneumothorax or Hemothorax: can result d/t Penetrating wounds into chest (steering wheel or loose article)

PLEURAL DRAINAGE 2nd COMPARTMENT ( WATER-SEAL CHAMBER) If the water stops fluctuating, this could mean: 1. The lung has re-expand 2. The tubing is kinked Tidaling = GOOD (rise & fall with each breath) Excessive continuous bubbling = BAD in the water seal chamber

*Has 2 cm of WATER (acts as one-way valve) *AIR enters from 1st compartment "collection chamber" & bubbles up thru the water. *Bubbling in chamber? Intrathoracic pressure is ABOVE atmospheric pressure (goal: have pressure return to normal) Pneumothorax: initially brisk bubbling seen...also may see bubbling during exhalation, coughing, sneezing (ok to see intermittent bubbling).... NOT NORMAL: continuous bubbling (AIR LEAK!!) Tidaling (fluctuation of the water): -Reflects intrapleural pressure changes during interm-156spiration & expiration -Gradual reduction & eventual cessation of tidaling expected as lung re expands. -Sudden cessation of tidaling? may be occluded chest tube -NO tidaling in water seal chamber? Either lung re expanded or kink in the tube.

ABDOMINAL COMPARTMENT SYNDROME (ACS) Complication of BLUNT Abdominal Trauma DEFINE/PATHO

*High pressure in Abd cavity → caused by edema of organs &/or bleeding of abdomen. -As more fluids fills the abdomen, the diaphragm is unable to allow for adequate lung expansion. can lead to respiratory failure -Decrease in CO (secondary to increased intra-abdominal pressure and compression of inferior vena cava) -Hypoperfusion begins to occur to abdominal organs (kidneys...big problem)

PRIMARY SURVEY (ABCDE) BREATHING

*Intact unobstructed airway doesn't guarantee adequate ventilation/ gas exchange -Observe RR effort (rising/falling) -Listen/feel air movement (nose/mouth) *100% O2 non rebreathing mask (If difficulty breathing) *CPR w 2 breathes. *Prepare Intubation (If Severe RR distress or arrest, agonal breathes) *Prepare Needles thoracostomy/Chest tube (After attempt to ventilate w bag valve mask 100%; absent breathes)

ABDOMINAL BLUNT TRAUMA

*MVC or falls *Consider ALL Abd trauma: to have intra-abdominal injuries until proven otherwise -Sometimes external wounds are not present (difficult to detect) -Intoxication, Head injury, or Spinal cord injuries make Abdomen assessment unreliable bc pt will experience diminished/absent pain & guarding may not be present -Bullet: most common follow by stabs -Fetus: more likely than mom to be serious injured Retro peritoneal hemorrhage -Cullen's (ecchymosis around umbilicus ) -Gray turner (ecchymosis around flank)

Chest Tube INSERTION

*Position w/ arm raised above head on affected side to expose midaxillary area *Elevate HOB 30- 60 degrees (when possible) *Cleanse area w/ antiseptic solution. *After procedure: Cover w/ occlusive dressing (petroleum -airtight- gauze)

ABDOMINAL PENETRATING TRAUMA

*Profuse bleeding in abdomen can be caused by injury to intra-abdominal vessels & to a solid organ (diaphragm, spleen, liver, pancreas, kidney) *Hollow organs: stomach, gallbladder, large & small intestine, and bladder in general do not bleed significantly **Penetrating wound to the abdomen can result in peritonitis

Chest Tubes and Pleural Drainage

*Purpose: inserted into the pleural space to: -Remove air or fluid or -Help re-expand the lung *Vary in size from 12F- 40F -Small (12F to 24F) → drain air -Medium (24F to 36F)→ drain fluid -Large (36F to 40F) → drain blood...Large tube would be used in Hemopneumothorax

PLEURAL DRAINAGE 1ST COMPARTMENT (COLLECTION CHAMBER)

*Receives FLUID & AIR from pleural or mediastinal space *Drained fluid: stays in this chamber while.. *Expelled air: vents to the 2nd second compartment *Monitor what's coming out ...typically < 100cc/hr (may see about 100cc initially) ...record regularly

PRIMARY SURVEY (ABCDE) DISABILITY

*Suspect cervical spine trauma if face, head, or neck trauma, or significant upper chest injuries → 1st Action: Place C-collar *Identify deformities (ROM) -Immobile? Splint -ORIF: risk for infection when open *Rapid neuro exam: AVPU & GCS -Unconscious? Assess pupils for size, shape, equality, reactivity. -Sudden confusion? Check O2 saturation

OLDER ADULTS TRAUMA

*Trauma r/t changes: reaction time, balance, coordination, sensory motor function (Falls, Fractures, Soft tissue injuries) *Falls can be d/t syncope -Is it neurological in nature or cardiac in nature? work up will be different. CONCERNS: *Chronic Dx Status: Poly pharmaceutical *Limited Physiological Reserve -Cardiopulmonary -Neurologic -Osteoporosis & Decreased muscle mass *Shock is difficult to Dx

PRIMARY SURVEY (ABCDE) EXPOSURE/ENVIRONMENT

*Undress fully to assess (may cut off clothes & check for injuries). *Hard to detect: Turn on side, inspect all areas. *Look for: Foreign objects, Evisceration of bowels, Hemorrhaging *Check sx of prolonged heat or cold exposure *ER arrival: environment is safe/warm *Prevent heat loss by recovering pt up: -Warming blankets -Overhead warmers -Warmed IV fluids *Hold C-Spine but do log-roll in order to check back

PERIOTINITIS Lab Findings/MANIFESTATIONS *Dx primarly on manifestations -Increased WBC -Electrolytes -Abdominal xray & ultrasounds -CT scan -MRI

*WBC w/ differential (up to 20k w/ HIGH neutrophil count) *Hgb/HCT: INCREASED (d/t hemoconcentration from 3rd spacing) *Electrolytes alter *K, Na, Cl" ABDOMEN: -Pain, Hard, Distended -Diminished/Decreased bowel sounds. -Tender over affected area (universal sx) -Rebound tenderness Muscular rigidity or spasms Fever Tachycardia (Increase pulse rate d/t fever) Tachypnea N/V (d/t pain & decreased peristalsis) Lying still or shallow breathing (movement makes pain worse)

OB TRAUMA After a mobile car collision, the pregnant patient is being evaluated at the ED. What will assessments the nurse does to check that the fetus is alive within the uterus?

- Progesterone levels -Transvaginal ultrasounds -Human chorionic gonadotropin (hCG) measurement

PRIMARY SURVEY (ABCDE) AIRWAY

-Airway open: allow O2 & expel CO2 *Head-tilt chin lift w/o extending neck (Jaw Thrust Maneuver) *Check or remove obstructions (Suction) *Cervical spine stabilization and/or immobilization *Dr/Respiratory team decide to intubate -Place 100% O2 ambu or bag valve pre procedure

SECONDARY SURVEY (SAMPLE) EXTREMITIES ASSESSMENTS

-Assess pulses (peripheral) -Assess fracture &/or compartment syndrome, *Calf swelling after a femoral shaft fracture suggests hemorrhage and risk for compartment syndrome. -Signs of external injury, pain, crepitus, etc If strain: Elevate above heart to reduce swelling Inspect Posterior Surfaces: -Logroll & inspect, palpate back for deformity, bleeding, lacerations, bruising *Changes in bowel or bladder function indicate possible spinal cord compression and should be reported immediately!

SECONDARY SURVEY (SAMPLE) CHEST ASSESSMENTS

-Check Breathing effort, Lung sounds -Signs of Pneumothorax, or Flail chest, or Rib fx (use of accessory) *Check Abdomen & flank (pain/rigid/distend) *Obtain 12 lead ECG & chest x ray *Stabilize impaled objects→ DO NOT remove until Dr attends injury (often require pt to be in OR) *Changes in Bowel/Bladder, Bowel sounds & Superficial Bleeding evidence -Focused Abdominal sonography for trauma (AKA: FAST): if increasing Abd pain after trauma "MVA" -Check If Retroperitoneal Bleeding suspected (typically not clear/visible. It's kind of in the back of the abdomen)

In Primary Survey Order of assessments for TRAUMA:

1) Immobilize cervical spine if not done at site and ensure there is a patent airway 2) Assess to see if breathing effectively and if he needs assistance 3) Evaluate circulation & determine if any acute blood loss 4) Complete quick neuro exam of the LOC and motor function 5) Completely undress the pt to visualize eternal causes of injury

OB TRAUMA EMERGENCY: CARDIOPULMONARY RESUSCITATION FOR PREGNANT WOMAN

1. Determine unresponsive & absent or abnormal breathing *Open airway head tilt-chin lift maneuver (Hyperextension of neck AVOID, instead jaw thrust to establish airway in trauma victim) *Deliver breathes (face mask or bag mask device) 2. Activate EMS, get AED 3. Check pulse 4. Position *Flat, firm surface w. uterus lateral w/ a wedge (under hip) or place lateral position. 5. Begin chest compressions if absent pulse *Start chest compression at 100/mins......Push hard & fast! -End of each compression allow chest to recoil (re-expand) completely -May do slightly higher on sternum if uterus enlarged to display diaphragm into higher position *After 5 cycles of 30 compressions + 2 breathes (2 min): 6. Check pulse (no pulse= continue CPR)

PERIOTINITIS INTERVENTIONS

1. Establish IV access: for Replacement fluids (loss in peritoneal cavity) & to access for antibiotic therapy. -Culture, Give ABX 1st before results *Position knees flex: Increase comfort/decrease pain *Analgestics *Sedatives to relieve anxiety. *Fluid I/O, Electrolyte status monitor (to determine replacement therapy) *V/S (BP) monitor Frequently *Antiemetics administer to decrease N/V & prevent further fluid/electrolyte losses. *Place NPO status. *NG tube to decrease gastric distention and further leakage of bowel contents into the peritoneum. *Low-FiO2 administer if needed. *Drainage monitoring: monitor and record post op

PRIMARY SURVEY (ABCDE) life threatening problems are identified and treated...PRIORITIES are ABCs IF UNRESPONSIVE: CAB!! *Circulation, Airway, Breathing

A: AIRWAY (Patency...If block: hypoxia) -Jaw Thrust Maneuver -Suction -Cervical spine stabilize &/or immobilize *Decide to intubate: 100% O2 ambu or bag B: BREATHING (RR depth & patten) -RR effort (rising/falling) *100% O2 non rebreathing mask *CPR w 2 breathes. *Intubation *Needles thoracostomy/Chest tube C: CIRCULATION (Hypovolemia...Heart & Brain circulation is critical) *Control bleeding *Pulses, Cap refill, Skin color *Large bore IV & Fluid resuscitate (LR/NS) D: DISABILITY (LOC & Motor, Pain) *C-collar *Deformities (ROM) *Neuro: AVPU & GCS E: EXPOSURE/ENVIRONMENT (Undress, External injuries) -Inspect ALL areas. -Foreign objects, Evisceration bowels, Hemorrhaging *Prolonged heat or cold exposure *Hold C-Spine

Match symptoms to probable treatment 1. Paradoxical breathing 2. Tachycardia, absent breath sounds over left lung 3. Muffled heart sounds, HTN, neck vein distention a. stabilize chest wall b. chest tube insertion c. pericardiocentesis:

ANS: 1.A 2. B 3. C 1. Flail chest: stabilize chest wall 2. Cardiac tamponade: pericardiocentesis 3. Pneumothorax: chest tube insertion

A client with facial trauma is admitted to the emergency department. The client has dyspnea, cyanosis, and external bleeding. What is the correct order of nursing interventions that should be performed in this situation? a. Apply direct pressure with a sterile dressing. b. Perform jaw-thrust maneuver. c. Measure client's level of consciousness. d. Remove clothing, perform thorough physical examination. e. Administer supplemental oxygen.

ANS: 1.B 2.E 3.A 4.C 5.D 1. Perform jaw-thrust maneuver. 2. Administer supplemental oxygen. 3. Apply direct pressure with a sterile dressing. 4. Measure client's level of consciousness. 5. Remove the client's clothing to perform a thorough physical examination. Facial trauma can obstruct the airway and cause respiratory compromise. Therefore, opening the airway using jaw-thrust maneuver is priority for this client. Once the airway is opened, adequate ventilation should be ensured by administering supplemental oxygen. After ensuring the airway patency, circulation should be assessed, and direct pressure applied with a sterile dressing on the bleeding site. After ensuring respiration and circulation, the client's level of consciousness should be determined. Then all clothing should be removed to perform thorough physical assessment

OB TRAUMA Because most pregnant women continue their usual activities, trauma remains a common complication during pregnancy. Approximately 30,000 women in the United States experience treatable injuries related to trauma each year. As a result of the physiologic alterations that accompany pregnancy, special considerations for mother and fetus are necessary when trauma occurs. Match the maternal system adaptation in pregnancy with the clinical response to trauma: a. Increased oxygen consumption b. Increased heart rate c. Decreased gastric motility. d. Displacement of abdominal viscera e. Increase in clotting factors 1. Decreased placental perfusion in supine position 2. Increased risk of thrombus formation 3. Altered pain referral 4. Increased risk of acidosis 5. Increased risk of aspiration

ANS: 1.B 2.E 3.D 4.A 5.C 1. Decreased placental perfusion in supine position: Increased heart rate 2. Increased risk of thrombus formation: Increase in clotting factors 3. Altered pain referral: Displacement of abdominal viscera 4. Increased risk of acidosis: Increased oxygen consumption 5. Increased risk of aspiration: Decreased gastric motility

A client is recovering from head trauma. The nurse notices that their GCS of 15 was over 2 hours ago, but now the GCS score of 14. What is the nurse's first action? a. Report to the provider immediately b. Administer a large bore IV. c. Lower the patient's head below heart level. d. Document finding and continue to monitor.

ANS: A

A patient is recovering from a pneumothorax and has a chest tube present. Which of the following is an appropriate finding when assessing the chest tube drainage system? a. Intermittent bubbling may be noted in the water seal chamber. b. 200 cc of drainage per hour is expected during recovery of a pneumothorax. c. The chest tube is positioned at the patient's chest level to facilitate drainage. d. All of these options are appropriate findings

ANS: A

You're assessing a patient who is post-opt from a chest tube insertion. On assessment, you note there is 50 cc of serosanguinous fluid in the drainage chamber, fluctuation of water in the water seal chamber when the patient breathes in and out, and bubbling in the suction control chamber. Which of the following is the most appropriate nursing intervention? a. Document your findings as normal. b. Assess for an air leak due to bubbling noted in the suction chamber. c. Notify the physician about the drainage. d. Milk the tubing to ensure patency of the tubes.

ANS: A

A client presents to the Emergency Department with a head injury received in a fall at home. On admission, the client's Glasgow Coma Scale (GCS) score is 12. Within 20 minutes of arrival, the GCS is 8. What should the nurse do? a. Prepare the client for intubation. b. Lower the head of the bed to 30 degrees. c. Repeat the client's blood pressure reading. d. Turn up the client's IV.

ANS: A "Prepare the client for intubation." The client with a GCS lower than 9 will likely be intubated immediately.

Which parameter does the nurse assess first while assessing a client with severe trauma? a. Airway b. Disability c. Breathing d. Circulation

ANS: A (Primary Survery: Airway) Airway is first assessed in a client with severe trauma because inadequate oxygen supply can lead to brain injury that can progress to anoxic brain death. Disability is assessed after the vital signs are assessed. Breathing is assessed after the airway is assessed and cleared. Circulation is assessed after effective breathing is ensured.

An unresponsive patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first? a. Pulse c. Breath sounds b. Heart rhythm d. Body temperature

ANS: A (Primary Survey: Circulation) The priority assessment in an unresponsive patient relates to CAB (circulation, airway, breathing) so a pulse check should be performed first. While assessing the pulse, the nurse should look for signs of breathing. The other data will also be collected rapidly but are not as essential as determining if there is a pulse.

The nurse should continue to assess for the common complications in Peritonitis which involve: a. Abscess formation. b Respiratory arrest. c. Umbilical hernia. d. Urinary tract infection.

ANS: A Abscess formation

A patient tells the nurse "My doctor thinks my problems with stress relates to the negative way I think about things, and he wants me to learn a new way of thinking." Which response would be in keeping with the doctor's recommendations? a. Teaching the patient to recognize, reconsider, and reframe irrational thoughts. b. Encouraging the patient to imagine being in calming circumstances c. Teaching the patient to use instruments that give feedback about bodily functions d. Provide the patient with a blank journal and guidance about journaling

ANS: A Cognitive reframing focuses on recognizing/correcting maladaptive patterns of thinking that create stress or interfere with coping. Cognitive reframing involves recognizing the habit of thinking about a situation or issue in a fixed, irrational, and unquestioning manner. Helping the patient to recognize and reframe (reword) such thoughts so that they are realistic and accurate promotes coping and reduces stress. Thinking about being in calming circumstances is a form of guided imagery. Instruments that give feedback about bodily functions are used in biofeedback. Journaling is effective for helping to increase self-awareness. However, none of these last three interventions is likely to alter the patient's manner of thinking.

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment could be used to evaluate the effectiveness of the therapies? a. Observe for distended neck veins (JVD) b. Auscultate for crackles in the lungs. c. Palpate for heaves or thrills over the heart. d. Monitor for elevated white blood cell count.

ANS: A Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular venous distention, and right upper-quadrant abdominal tenderness would be expected. Crackles in the lungs are likely to be heard with left-sided heart failure. Findings in cor pulmonale include evidence of right ventricular hypertrophy on electrocardiography and an increase in intensity of the second heart sound. Heaves or thrills are not common with cor pulmonale. WBC elevation might indicate infection but is not expected with cor pulmonale.

The nurse is planning to teach a patient with hypertension how to use relaxation techniques to prevent elevation of BP and HR. The nurse is teaching the patient to control which physiological function? a. Switch from the sympathetic mode of the autonomic nervous system to the parasympathetic mode. b. Alter the internal state by modifying electronic signals related to physiologic processes. c. Replace stress-producing thoughts and activities with daily stress-reducing thoughts and activities. d. Reduce catecholamine production and promote the production of additional beta-endorphins.

ANS: A When the SNS is operative, the individual experiences muscular tension, elevated pulse, BP, and RR. Relaxation is achieved when the SNS is quieted & the PNS is operative. Modifying electronic signals is the basis for biofeedback, a behavioral approach to stress reduction. Altering thinking and activities from more-stressful to less-stressful reflects the cognitive approach to stress management. Reducing catecholamine production is the basis for guided imagery's effectiveness.

A patient who has had open reduction and internal fixation (ORIF) of left lower leg fractures continues to complain of severe pain in the leg 15 minutes after receiving the prescribed IV morphine. Pulses are faintly palpable and the foot is cool to the touch. Which action should the nurse take next? a. Notify the health care provider. b. Assess the incision for redness. c. Reposition the left leg on pillows. d. Check the patient's blood pressure.

ANS: A (Primary Survey: Circulation) (Second Survey: Extremities) The patient's clinical manifestations suggest compartment syndrome and delay in diagnosis and treatment may lead to severe functional impairment. The data do not suggest problems with blood pressure or infection. Elevation of the leg will decrease arterial flow and further reduce perfusion.

A patient undergoes left above-the-knee amputation with an immediate prosthetic fitting. When the patient arrives on the orthopedic unit after surgery, the nurse should a. control the surgical site for hemorrhage. b. remove the prosthesis and wrap the site. c. place the patient in a side-lying position. d. keep the residual limb elevated on a pillow.

ANS: A (Primary Survey: Circulation) The nurse should monitor for postoperative hemorrhage. The prosthesis will not be removed. To avoid flexion contracture of the hip, the leg will not be elevated on a pillow. Unless contraindicated, the patient will be placed in a prone position for 30 minutes several times a day to prevent hip flexion contracture.

OB TRAUMA Which assessment finding is an indication of hemorrhage in the recently delivered postpartum patient? a. Elevated pulse rate b. Elevated blood pressure c. Firm fundus at the midline d. Saturation of two perineal pads in 4 hours

ANS: A An increasing pulse rate is an early sign of excessive blood loss. If the blood volume were diminishing, the blood pressure would decrease.

OB TRAUMA The patient in labor experiences a spontaneous rupture of membranes. Which information related to this event must the nurse include in the patient's record? a. Fetal heart rate b. Pain level c. Test results ensuring that the fluid is not urine d. The patient's understanding of the event

ANS: A Charting related to membrane rupture includes the time, FHR, and character and amount of the fluid. Pain is not associated with this event. When it is obvious that the fluid is amniotic fluid, which is anticipated during labor, it is not necessary to verify this by testing. The patient's understanding of the event would only need to be documented if it presents a problem

The nurse is assessing a patient with abdominal pain. The nurse, who notes that there is ecchymosis around the area of umbilicus, will document this finding as a. Cullen sign. b. Rovsing sign. c. McBurney sign d. Grey-Turner's sign.

ANS: A Cullen sign is ecchymosis around the umbilicus. Rovsing sign occurs when palpation of the left lower quadrant causes pain in the right lower quadrant. Grey Turner's sign is bruising over the flanks. Deep tenderness at McBurney's point (halfway between the umbilicus and the right iliac crest), known as McBurney's sign, is a sign of acute appendicitis.

OB TRAUMA If a woman's fundus is soft 30 minutes after birth, the nurse's first action should be to a. massage the fundus. b. take the blood pressure. c. notify the physician or nurse-midwife. d. place the woman in Trendelenburg position

ANS: A First response should be to massage the fundus to stimulate contraction of the uterus to compress open blood vessels at the placental site, limiting blood loss. The blood pressure is an important assessment to determine the extent of blood loss but is not the top priority. Notification should occur after all nursing measures have been attempted with no favorable results. The Trendelenburg position is contraindicated for this woman at this point. This position would not allow for appropriate vaginal drainage of lochia.

OB TRAUMA Immediately following the forceps-assisted birth of an infant, which action should the nurse implement? a. Assess the infant for signs of trauma. b. Apply a cold pack to the infant's scalp. c. Give the infant prophylactic antibiotics. d. Measure the circumference of the infant's head.

ANS: A Forceps birth can result in local irritation, bruising, or lacerations of the fetal scalp. This would put the infant at risk for cold stress and would be contraindicated. Prophylactic antibiotics are not necessary with a forceps birth. Measuring the circumference of the head is part of the initial nursing assessmen

The nurse thoroughly dries the infant immediately after birth primarily to a. reduce heat loss from evaporation. b. stimulate crying and lung expansion. c. increase blood supply to the hands and feet. d. remove maternal blood from the skin surface.

ANS: A Infants are wet with amniotic fluid and blood at birth, which accelerates evaporative heat loss. Rubbing the infant does stimulate crying but is not the main reason for drying the infant. The main purpose of drying the infant is to prevent heat loss. Drying the infant after birth does not remove all of the maternal blood.

The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider? a. Oxygen saturation is 88%. b. Blood pressure is 145/90 mm Hg. c. Respiratory rate is 22 breaths/minute when lying flat. d. Pain level is 5 (on 0 to 10 scale) with a deep breath.

ANS: A Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 88% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low oxygen saturation is the priority.

A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment? a. Paradoxical chest movement b. Complaint of chest wall pain c. Heart rate of 110 beats/minute d. Large bruised area on the chest

ANS: A Paradoxic chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange.

Which nursing action for a patient who has had right hip arthroplasty can the nurse delegate to experienced unlicensed assistive personnel (UAP)? a. Reposition the patient every 1 to 2 hours. b. Assess for skin irritation on the patient's back. c. Teach the patient quadriceps-setting exercises. d. Determine the patient's pain intensity and tolerance.

ANS: A Repositioning of orthopedic patients is within the scope of practice of UAP (after they have been trained and evaluated in this skill). The other actions should be done by licensed nursing staff members.

A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10 abdominal pain and states, "I had a temperature of 103.9° F (39.9° C) at home." The nurse's first action should be to a. assess the patient's current vital signs. b. give acetaminophen (Tylenol) per agency protocol. c. ask the patient to provide a clean-catch urine for urinalysis. d. tell the patient that it will 1 to 2 hours before being seen by the doctor.

ANS: A The patient's pain and statement about an elevated temperature indicate that the nurse should obtain vital signs before deciding how rapidly the patient should be seen by the health care provider. A urinalysis may be appropriate, but this would be done after the vital signs are taken. The nurse will not give acetaminophen before confirming a current temperature elevation.

An unresponsive 79-year-old is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 105.4° F (40.8° C), blood pressure (BP) 88/50, and pulse 112. The nurse initially will plan to a. apply wet sheets and a fan to the patient. b. provide O2 at 6 L/min with a nasal cannula. c. start lactated Ringer's solution at 1000 mL/hr. d. give acetaminophen (Tylenol) rectal suppository.

ANS: A The priority intervention is to cool the patient. Antipyretics are not effective in decreasing temperature in heat stroke, and 100% oxygen should be given, which requires a high flow rate through a non-rebreather mask. An older patient would be at risk for developing complications such as pulmonary edema if given fluids at 1000 mL/hr.

Following an earthquake, patients are triaged by emergency medical personnel and are transported to the emergency department (ED). Which patient will the nurse need to assess first? a. A patient with a red tag b. A patient with a blue tag c. A patient with a black tag d. A patient with a yellow tag

ANS: A The red tag indicates a patient with a life-threatening injury requiring rapid treatment. The other tags indicate patients with less urgent injuries or those who are likely to die.

A patient is awaiting surgery for acute peritonitis. Which action will the nurse include in the plan of care? a. Position patient with the knees flexed. b. Avoid use of opioids or sedative drugs. c. Offer frequent small sips of clear liquids. d. Assist patient to breathe deeply and cough.

ANS: A There is less peritoneal irritation with the knees flexed, which will help decrease pain. Opioids and sedatives are typically given to control pain and anxiety. Preoperative patients with peritonitis are given IV fluids for hydration. Deep breathing and coughing will increase the patient's discomfort.

The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Document the amount of drainage every eight hours. b. Obtain samples of drainage for culture from the system. c. Assess patient pain level associated with the chest tube. d. Check the water-seal chamber for the correct fluid level.

ANS: A UAP education includes documentation of intake and output. The other actions are within the scope of practice and education of licensed nursing personnel.

After the return of spontaneous circulation following the resuscitation of a patient who had a cardiac arrest, therapeutic hypothermia is ordered. Which action will the nurse include in the plan of care? a. Apply external cooling device per protocol. b. Check mental status every 15 minutes. c. Avoid the use of sedative medications. d. Rewarm if temperature is

ANS: A When therapeutic hypothermia is used post resuscitation, external cooling devices or cold normal saline infusions are used to rapidly lower body temperature to 89.6° F to 93.2° F (32° C to 34° C). Because hypothermia will decrease brain activity, assessing mental status every 15 minutes is not needed at this stage. Sedative medications are administered during therapeutic hypothermia.

The nurse notes new onset confusion in an older patient who is normally alert and oriented. In which order should the nurse take the following actions?(Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain the O2 saturation. b. Check the patient's pulse rate. c. Document the change in status. d. Notify the health care provider.

ANS: A, B, D, C Assessment for physiologic causes of new onset confusion such as pneumonia, infection, or perfusion problems should be the first action by the nurse. Airway and oxygenation should be assessed first, then circulation. After assessing the patient, the nurse should notify the health care provider. Finally, documentation of the assessments and care should be done.

The nurse is caring for a client who was just admitted to the hospital with the diagnosis of head trauma. Which clinical indicators should the nurse consider as evidence of increasing intracranial pressure? Select all that apply. a. Vomiting b. Irritability c. Hypotension d. Increased respirations e. Decreased level of consciousness

ANS: A, B, E Anorexia, nausea, and vomiting occur because of pressure on the brain. Increasing pressure on the vital centers in the brain and irritation of cerebral tissue result in irritability and seizures. Increased intracranial pressure disrupts neurons and neurotransmitters, resulting in faulty impulse transmission and an altered level of consciousness. The blood pressure will be increased, not decreased, because of pressure on the vital centers in the brain. Also, the pulse pressure increases. Pressure on the respiratory center in the medulla results in a decreased, not increased, respiratory rate. As the intracranial pressure increases, the client may exhibit Cheyne-Stokes respirations.

Which are the priority nursing actions after the completion of the secondary survey when providing care for a trauma client with a penetrating wound? Select all that apply. a. Documenting the client's care b. Formulating the client's plan of care c. Reassessing the client's level of consciousness d. Administering tetanus prophylaxis to the client e. Transferring the client to the general medical unit

ANS: A, D The priority nursing actions after completion of the secondary survey during the emergency assessment include documenting all client care and administering tetanus prophylaxis. Formulating the client's plan of care, reassessing level of consciousness, and transferring the client to the general medical unit are nursing actions implemented once the client is stable

The charge nurse in the intensive care unit is making client assignments. Which client should the charge nurse assign to the graduate nurse who has just finished the 3-month orientation? a. The client with an abnormal peritoneal resection who has a colostomy. b. The client diagnosed with pneumonia who has acute respiratory distress syndrome. c. The client with a head injury developing disseminated intravascular coagulation. d. The client admitted with a gunshot wound who has an H&H of 7 and 2

ANS: A. This is major surgery but has a predictable course with no complications identified in the stem and a colostomy is expected with this type of surgery. The graduate nurse could be assigned this patient.

A patient with a chest tube has no fluctuation of water in the water seal chamber. What could be the cause of this? a. This is an expected finding. b. The lung may have re-expanded or there is a kink in the system. c. The system is broken and needs to be replaced. d. There is an air leak in the tubing.

ANS: B

What type of chest tube system does this statement describe? This chest drainage system has no water column to control suction but uses a suction monitor bellow that balances the wall suction and you can adjust water suction pressure using the rotary suction dial on the side of the system. It allows for higher suction pressure levels, has no bubbling sounds, and water does not evaporate from it as with other systems. a. Mediastinal chest tube system b. Dry suction chest tube system c. Wet suction chest tube system d. Dry-Wet suction chest tube system

ANS: B

While helping a patient with a chest tube reposition in the bed, the chest tube becomes dislodged. What is your immediate nursing intervention? a. Stay with the patient and monitor their vital signs while another nurse notifies the physician. b. Place a sterile dressing over the site and tape it on three sides and notify the physician. c. Attempt to re-insert the tube. d. Keep the site open to air and notify the physician.

ANS: B

Which action will the urgent care nurse take for a patient with a possible knee meniscus injury? a. Encourage bed rest for 24 to 48 hours. b. Apply an immobilizer to the affected leg. c. Avoid palpation or movement of the knee. d. Administer intravenous opioids for pain management.

ANS: B (Primary Survey: Disability) A knee immobilizer may be used for several days after a meniscus injury to stabilize the knee and minimize pain. Patients are encouraged to ambulate with crutches. The knee is assessed by flexing, internally rotating, and extending the knee (McMurray's test)

A patient who has experienced blunt abdominal trauma during a motor vehicle collision is complaining of increasing abdominal pain. The nurse will plan to teach the patient about the purpose of a. peritoneal lavage. b. abdominal ultrasonography. c. nasogastric (NG) tube placement. d. magnetic resonance imaging (MRI).

ANS: B For patients who are at risk for intra abdominal bleeding, focused abdominal ultrasonography is the preferred method to assess for intraperitoneal bleeding. An MRI would not be used. Peritoneal lavage is an alternative, but it is more invasive. An NG tube would not be helpful in diagnosis of intra abdominal bleeding.

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? a. A 23-yr-old patient with cystic fibrosis who has pulmonary function testing scheduled b. A 46-yr-old patient on bed rest who is complaining of sudden onset of shortness of breath c. A 77-yr-old patient with tuberculosis (TB) who has four medications due in 15 minutes d. A 35-yr-old patient who was admitted with pneumonia and has a temperature of 100.2° F (37.8° C)

ANS: B Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism and requires immediate assessment and action such as O2 administration. The other patients should also be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration.

OB TRAUMA Which intervention does the nurse implement for a patient immediately after a severe abdominal trauma? a. Prep the patient for cesarean birth. b. Send the patient for pelvic computed tomography (CT) scanning. c. Provide fluids to the patient as part of the protocol for ultrasound examination. d. Prepare to administer Rho(D) immunoglobulin

ANS: B Pelvic CT scanning helps visualize extraperitoneal and retroperitoneal structures and the genitourinary tract. The nurse needs to prepare the patient for cesarean birth if there is no evidence of a maternal pulse. Ultrasound examination is not as effective as electronic fetal monitoring for determining placental abruption in the patient after the trauma. Therefore the nurse prepares the patient for a CT scan after a severe abdominal trauma. The nurse needs to administer Rho(D) immunoglobulin in an Rh-negative pregnant trauma patient. This helps protect the patient from isoimmunization.

OB TRAUMA A pregnant patient is at risk for cardiac arrest as a result of profound hypovolemia after a trauma. Which action does the nurse take? a. Assesses airway, breathing, and pulse rate. b. Administers warmed crystalloid solutions. c. Administers calcium gluconate intravenously d. Obtains a prescription for magnesium sulfate.

ANS: B The nurse administers warmed crystalloid solutions foterm-149r massive fluid resuscitation in the patient who has profound hypovolemia after a trauma. The nurse needs to assess the airway, breathing, and pulse in a patient after a convulsion so that prompt actions can be taken to stabilize the patient. The nurse administers calcium gluconate as an antidote to a patient who has magnesium toxicity. The nurse may administer magnesium sulfate for the treatment of eclamptic seizures in a patient with preeclampsia

An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action should the nurse take? a. Clamp the chest tube in two places to check for the origin of the air leak. b. Administer the prescribed morphine. Set up the patient-controlled analgesia (PCA). c. Milk the chest tube to remove any clots. d. Assist the patient with incentive spirometry. e. Assist the patient to deep breathe, cough.

ANS: B Treat the pain. The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy. Milking or stripping chest tubes is no longer recommended because these practices can dangerously increase intrapleural pressures and damage lung tissues. Position tubing so that drainage flows freely to negate need for milking or stripping. An air leak is expected in the initial postoperative period after thoracotomy. Clamping the chest tube is not indicated and may lead to dangerous development of a tension pneumothorax.

A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should. a. obtain a complete set of vital signs. b. obtain a Glasgow Coma Scale score. c. attach an electrocardiogram monitor. d. ask about chronic medical conditions.

ANS: B (CABD) (Primary Survey: Disability) The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the secondary survey.

Gastric lavage and administration of activated charcoal are ordered for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which action should the nurse plan to do first? a. Insert a large-bore orogastric tube. b. Assist with intubation of the patient. c. Prepare a 60-mL syringe with saline. d. Give first dose of activated charcoal.

ANS: B (Primary Survery: Airway) In an unresponsive patient, intubation is done before gastric lavage and activated charcoal administration to prevent aspiration. The other actions will be implemented after intubation.

.After being hospitalized for 3 days with a right femur fracture, a patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" Which action should the nurse take first? a. Stay with the patient and offer reassurance. b. Administer prescribed PRN O2 at 4 L/min. c. Check the patient's legs for swelling or tenderness. d. Notify the health care provider about the symptoms.

ANS: B (Primary Survery: Airway) The patient's clinical manifestations and history are consistent with a pulmonary embolism, and the nurse's first action should be to ensure adequate oxygenation.

During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next? a. Palpate extremities for bilateral pulses. b. Observe the patient's respiratory effort. c. Check the patient's level of consciousness. d. Examine the patient for any external bleeding.

ANS: B (Primary Survey: Breathing) Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient's breathing. The other actions are also part of the initial survey but assessment of breathing should be done immediately after assessing for airway patency

A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which nursing assessment finding indicates a potential complication of the fracture? a. The patient states the pelvis feels unstable. b. Abdomen is distended and bowel sounds are absent. c. The patient complains of pelvic pain with palpation. d. Ecchymoses are visible across the abdomen and hips.

ANS: B (Secondary: Pelvic) The abdominal distention and absent bowel sounds may be due to complications of pelvic fractures such as paralytic ileus or hemorrhage or trauma to the bladder, urethra, or colon. Pelvic instability, abdominal pain with palpation, and abdominal bruising would be expected with this type of injury.

A 33-yr-old male patient with a gunshot wound to the abdomen undergoes surgery, and a loop colostomy. Which information will be included in patient teaching? a. Stool will be expelled from both stomas. b. This type of colostomy is usually temporary. c. Soft, formed stool can be expected as drainage. d. Irrigations can regulate drainage from the stomas.

ANS: B A loop, or double-barrel stoma, is usually temporary. Stool will be expelled from the proximal stoma only. The stool from the transverse colon will be liquid and regulation through irrigations will not be possible.

A patient is admitted to the emergency department with a left femur fracture. Which information obtained by the nurse is most important to report to the health care provider? a. Ecchymosis of the left thigh b. Complaints of severe thigh pain c. Slow capillary refill of the left foot d. Outward pointing toes on the left foot

ANS: C (Primary Survey: Circulation) Prolonged capillary refill may indicate complications such as compartment syndrome. The other findings are typical with a left femur fracture.

Which nursing intervention will be included in the plan of care after a patient with a right femur fracture has a hip spica cast applied? a. Avoid placing the patient in prone position. b. Ask the patient about abdominal discomfort. c. Discuss remaining on bed rest for several weeks. d. Use the cast support bar to reposition the patient.

ANS: B Assessment of bowel sounds, abdominal pain, and nausea and vomiting will detect the development of abdominal cast syndrome. To avoid breakage, the cast support bar should not be used for repositioning. After the cast dries, the patient can begin ambulating with the assistance of physical therapy personnel and may be turned to the prone position.

A patient in the emergency department has just been diagnosed with peritonitis caused by a ruptured diverticulum. Which prescribed intervention will the nurse implement first? a. Insert a urinary catheter to drainage. b. Infuse metronidazole (Flagyl) 500 mg IV. c. Send the patient for a computerized tomography scan. d. Place a nasogastric (NG) tube to intermittent low suction

ANS: B Because peritonitis can be fatal if treatment is delayed, the initial action should be to start antibiotic therapy (after any ordered cultures are obtained). The other actions can be done after antibiotic therapy is initiated.

A patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take? a. Position the patient so that the left chest is dependent. b. Tape a nonporous dressing on three sides over the chest wound. c. Cover the sucking chest wound firmly with an occlusive dressing. d. Keep the head of the patients bed at no more than 30 degrees elevation.

ANS: B The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the left side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30 to 45 degrees to facilitate breathing.

The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed? a. A large air leak in the water-seal chamber b. 400 mL of blood in the collection chamber c. Complaint of pain with each deep inspiration d. Subcutaneous emphysema at the insertion site

ANS: B The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. An air leak would be expected immediately after chest tube placement for a pneumothorax. Initially, brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax. A small amount of subcutaneous air is harmless and will be reabsorbed.

The nurse develops a plan of care to prevent aspiration in a high-risk patient. Which nursing action will be most effective? a. Turn and reposition immobile patients at least every 2 hours. b. Place patients with altered consciousness in side-lying positions. c. Monitor for respiratory symptoms in patients who are immunosuppressed. d. Insert nasogastric tube for feedings for patients with swallowing problems.

ANS: B The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk.

A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure? a. Start a peripheral IV line to administer the necessary sedative drugs. b. Position the patient sitting upright on the edge of the bed and leaning forward. c. Obtain a large collection device to hold 2 to 3 liters of pleural fluid at one time. d. Remove the water pitcher and remind the patient not to eat or drink anything for 6 hours.

ANS: B When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious. Usually only 1000 to 1200 mL of pleural fluid is removed at one time. Rapid removal of a large volume can result in hypotension, hypoxemia, or pulmonary edema.

Which action should the nurse take to monitor the effects of an acute stressor on a hospitalized patient? (Select all that apply.) a. Assess for bradycardia. b. Ask about epigastric pain. c. Observe for increased appetite. d. Check for elevated blood glucose levels. e. Monitor for a decrease in respiratory rate.

ANS: B, C, D - Ask about epigastric pain. - Observe for increased appetite. -Check for elevated blood glucose levels. Physiologic changes associated with the acute stress response can cause changes in appetite, increased gastric acid secretion, and elevation of blood glucose levels. Stress causes an increase in the respiratory and heart rates.

A patient is about to have their chest tube removed by the physician. As the nurse assisting with the removal, which of the following actions will you perform? Select-all-that-apply: a.. Educate the patient how to take a deep breath out and inhale rapidly while the tube in being removed. b. Gather supplies needed which will include a petroleum gauze dressing per physician preference. c. Place the patient in Semi-Fowler's position. d. Have the patient take a deep breath, exhale, and bear down during removal of the tube. e. Pre-medicate prior to removal as ordered by the physician. F. Place the patient is prone position after removal.

ANS: B, C, D, E -Gather supplies needed which will include petroleum gauze dressing per physician preference. -Place the patient in Semi-Fowler's position. -Have the patient take a deep breath, exhale, and bear down during removal of the tube. -Pre-medicate prior to removal as ordered by the physician.

The nurse is working with a patient who is in a situational crisis after recently losing her spouse after a lengthy illness. The patient shares that she would like to sell her home and move to another state now that her spouse has passed away. Which of the following interventions would be considered a priority for this patient? (Select all that apply.) a. Notify the provider to evaluate for antidepressant therapy. b. Suggest the patient to consider a support group for widows. c. Suggest the patient to learn stress reduction breathing exercises. d. Suggest that the patient take prescribed antianxiety medications. e. Assist the patient in identifying support systems. f. Notify the provider to evaluate the need for antianxiety medications.

ANS: B, C, E Stress prevention management involves counseling, education, and implementation of techniques to manage problem-oriented and emotion-oriented stress. To prevent physical symptoms, relaxation and deep breathing are effective and individuals can learn to prevent the stress response through cognitive behavioral strategies. Medications are not indicated for patients with known stressors unless the stress is prolonged, or the patient has ineffective coping mechanisms.

Which interventions should be performed in the birth room to facilitate thermoregulation of the newborn? (Select all that apply.) a. Place the infant covered with blankets in the radiant warmer. b. Dry the infant off with sterile towels. c. Place stockinette cap on infant's head. d. Bathe the newborn within 30 minutes of birth. e. Remove wet linen as needed.

ANS: B, C, E Following birth, the newborn is at risk for hypothermia. Therefore nursing interventions are aimed at maintaining warmth. Drying the infant off, in addition to maintaining warmth, helps stimulate crying and lung expansion, which helps in the transition period following birth. Placing a cap on the infant's head helps prevent heat loss. Removal of wet linens helps minimize further heat loss caused by exposure. Newborns should not be covered while in a radiant warmer with blankets because this will impede birth of heat transfer. Bathing a newborn should be delayed for at least a few hours so that the newborn temperature can stabilize during the transition period.

When giving home care instructions to a patient who has comminuted left forearm fractures and a long-arm cast, which information should the nurse include? a. Keep the left shoulder elevated on a pillow or cushion. b. Avoid nonsteroidal antiinflammatory drugs (NSAIDs). c. Call the health care provider for numbness of the hand. d. Keep the hand immobile to prevent soft tissue swelling.

ANS: C (Second Survey: Extremities) Increased swelling or numbness may indicate increased pressure at the injury, and the health care provider should be notified immediately to avoid damage to nerves and other tissues. The patient should be encouraged to move the joints above and below the cast to avoid stiffness. There is no need to elevate the shoulder, although the forearm should be elevated to reduce swelling. NSAIDs are appropriate to treat mild to moderate pain after a fracture.

OB TRAUMA A pregnant woman arrives for evaluation of her symptoms, which includes abdominal trauma followed by a missed period, adnexal fullness, tenderness, and dark red vaginal bleeding. On examination the nurse notices an ecchymotic blueness around the womans umbilicus and recognizes this assessment finding as: a. Normal integumentary changes associated with pregnancy. b. Turners sign associated with appendicitis. c. Cullens sign associated with a ruptured ectopic pregnancy. d. Chadwicks sign associated with early pregnancy.

ANS: C Cullen's sign, the blue ecchymosis seen in the umbilical area, indicates hematoperitoneum associated with an undiagnosed ruptured intraabdominal ectopic pregnancy. Linea nigra on the abdomen is the normal integumentary change associated with pregnancy. It manifests as a brown, pigmented, vertical line on the lower abdomen. Turners sign is ecchymosis in the flank area, often associated with pancreatitis. Chadwick's sign is the blue-purple color of the cervix that may be seen during or around the eighth week of pregnancy

OB TRAUMA The nurse observes a patient with blunt abdominal trauma has maternal HYPOtension which has decreased uterine and fetal perfusion. What does the nurse need to assess further to understand the maternal status? a. D-Dimer b. Kleihauer-Betke (KB) test c. Electronic fetal monitoring d. Electrocardiogram reading

ANS: C Electronic fetal monitoring reflects fetal cardiac responses to hypoxia and hypoperfusion and helps to assess maternal status after a trauma. The D-dimer blood test is used to rule out the presence of a thrombus. The KB test is used to evaluate transplacental hemorrhage. Electrocardiogram reading is more useful to assess the cardiac functions in nonpregnant cardiac patients.

The nurse has assessed four primigravid clients in the prenatal clinic. Which of the women would the nurse refer to the nurse midwife for further assessment? a.10 weeks' gestation, complains of fatigue with nausea and vomiting. b. 26 weeks' gestation, complains of ankle edema and chloasma. c. 32 weeks' gestation, complains of epigastric pain and facial edema. d. 37 weeks' gestation, complains of bleeding gums and urinary frequency

ANS: C Epigastric pain and facial edema are NOT normal. This client should be referred to the nurse midwife. The nurse must be prepared to identify clients with symptoms that are unexpected. This question requires the test taker to differentiate between normal signs and symptoms of pregnancy at a variety of gestational ages and those that could indicate a serious complication of pregnancy.

OB TRAUMA At 37 weeks of gestation, the patient is in a severe automobile crash where her abdomen was hit by the steering wheel and her seat belt. What actions would the emergency room nurse expect to perform upon the patient's arrival at the hospital? a. Stay with the patient, assure a patent airway is present, and keep the patient as calm as possible. b. Move the patient's skirt to determine if any vaginal bleeding is present, find out who to call, and monitor the level of consciousness. c. Assess the patient's vital signs, determine location and severity of pain, and establish continual fetal heart rate monitoring. d. Obtain arterial blood gases, obtain a hemoglobin and hematocrit, and oxygen saturation rate.

ANS: C Full assessment of the patient and her fetus are essential and include vital signs, continual fetal heart rate monitoring, determining the location and severity of pain, whether any vaginal bleeding is dark red or bright red, and the status of the abdomen, which would be expected to be rigid or "board like." Staying with the patient, assuring a patent airway is present, and keeping the patient as calm as possible would be appropriate at the crash site before the arrival of emergency medical services (EMS). The current status of the patient and fetus are the priority. The health care provider would prescribe the arterial blood gases and other laboratory work after the patient is assessed and stabilized.

A patient has not been sleeping well because he is worried about losing his job and not being able to support his family. The nurse takes the patient's vital signs and notes a pulse rate of 112 beats/min, respirations are 26 breaths/min, and his blood pressure is 166/88 instead his usual 110-120/76-84 range. Which nursing intervention or recommendation should be used first? a. Go to sleep 30 to 60 minutes earlier each night to increase rest. b. Relax by spending more time playing with his pet dog. c. Slow and deepen breathing via use of a positive, repeated word. d. Consider that a new job might be better than his present one.

ANS: C He is responding to stress with increased arousal of the SNS , as evident in his elevated v/s. These will have a negative effect on his health and increase his perception of being anxious and stressed. Stimulating the PNS (Benson's relaxation response) will counter the sympathetic nervous system's arousal, normalizing these v/s changes and reducing the physiologic demands stress is placing on his body. Other options do not address his physiologic response pattern as directly or immediately.

A patient who had been complaining of intolerable stress at work has demonstrated the ability to use progressive muscle relaxation and deep breathing techniques. He will return to the clinic for follow-up evaluation in 2 weeks. Which data will best suggest that the patient is successfully using these techniques to cope more effectively with stress? a. The patient's wife reports that he spends more time sitting quietly at home. b. He reports that his appetite, mood, and energy levels are all good. c. His systolic blood pressure has gone from the 140s to the 120s (mm Hg). d. He reports that he feels better and that things are not bothering him as much.

ANS: C Objective measures tend to be the most reliable means of gauging progress. In this case, the patient's elevated blood pressure, an indication of the body's physiologic response to stress, has diminished. The wife's observations regarding his activity level are subjective, and his sitting quietly could reflect his having given up rather than improved. Appetite, mood, and energy levels are also subjective reports that do not necessarily reflect physiologic changes from stress and may not reflect improved coping with stress.

Where in the health history should the nurse describe all details related to the chief complaint? a. Past history b. Chief complaint c. Present illness d. Review of systems

ANS: C The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. The focus of the present illness is on all factors relevant to the main problem, even if they have disappeared or changed during the onset, interval, and present. Past history refers to information that relates to previous aspects of the child's health, not to the current problem. The chief complaint is the specific reason for the child's visit to the clinic, office, or hospital. It does not contain the narrative portion describing the onset and progression. The review of systems is a specific review of each body system.

OB TRAUMA A blunt abdominal trauma causes fetal hemorrhage in a pregnant patient. The nurse finds that the patient is Rh negative. What action does the nurse take? a. Initiate magnesium sulfate per protocol. b. Administer oxytocin (pitocin). c. Administer prescribed Rho (D) immunoglobulin. d. Prepare the patient for magnetic resonance imaging (MRI).

ANS: C The nurse administers the prescribed Rho(D) immunoglobulin to the patient to protect the patient from isoimmunization. The nurse needs to obtain a prescription for magnesium sulfate if there are eclamptic seizures in a patient with preeclampsia. Oxytocin (Pitocin) is administered to prevent bleeding after birth or the evacuation of the uterus. Magnetic resonance imaging (MRI) is used to assess injuries in a patient after trauma

After a motorcycle accident, a patient arrives in the emergency department with severe swelling of the left lower leg. Which action will the nurse take first? a. Elevate the leg on 2 pillows. b. Apply a compression bandage. c. Assess leg pulses and sensation d. Place ice packs on the lower leg.

ANS: C (Primary Survey: Circulation) The initial action by the nurse will be to assess circulation to the leg and observe for any evidence of injury such as fractures or dislocations. After the initial assessment, the other actions may be appropriate based on what is observed during the assessment.

The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy. Which information should the nurse include about the patient's postoperative care? a. Positioning on the right side b. Bed rest for the first 24 hours c. Frequent use of an incentive spirometer d. Chest tube placement with continuous drainage

ANS: C Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To promote gas exchange, patients after pneumonectomy are positioned on the surgical side. Early mobilization decreases the risk for postoperative complications such as pneumonia and deep vein thrombosis. In a pneumonectomy, chest tubes may or may not be placed in the space from which the lung was removed. If a chest tube is used, it is clamped and only released by the surgeon to adjust the volume of serosanguineous fluid that will fill the space vacated by the lung. If the cavity overfills, it could compress the remaining lung and compromise the cardiovascular and pulmonary function. Daily chest x-rays can be used to assess the volume and space.

When a patient arrives in the emergency department with a facial fracture, which action will the nurse take first? a. Assess for nasal bleeding and pain. b. Apply ice to the face to reduce swelling. c. Use a cervical collar to stabilize the spine. d. Check the patient's alertness and orientation.

ANS: C (Primary Survery: Airway) Patients who have facial fractures are at risk for cervical spine injury, and should be treated as if they have a cervical spine injury until this is ruled out. The other actions are also necessary, but the most important action is to prevent cervical spine injury.

The second day after admission with a fractured pelvis, a patient suddenly develops confusion. Which action should the nurse take first? a. Take the blood pressure. b. Assess patient orientation. c. Check the O2 saturation. d. Observe for facial asymmetry

ANS: C (Primary Survery: Airway) The patient's history and clinical manifestations suggest a fat embolism. The most important assessment is oxygenation. The other actions are also appropriate but will be done after the nurse assesses O2 saturation.

Based on the information in the accompanying figure obtained for a patient in the emergency room, which action will the nurse take first? - Age 23 years -Reports severe right lower leg pain -Reports feeling short of breath -Bone protruding from right lower leg -WBC 9400/µL; Hgb 11.6 g/dL - Right leg x-ray; right tibial fractur a. Administer the prescribed morphine 4 mg IV. b. Contact the operating room to schedule surgery. c. Check the patient's O2 saturation using pulse oximetry. d. Ask the patient about the date of the last tetanus immunization.

ANS: C (Primary Survey: Airway) Because fat embolism can occur with tibial fracture, the nurse's first action should be to check the patient's O2 saturation. The other actions are also appropriate but not as important at this time as obtaining the patient's O2 saturation.

A 22-year-old patient who experienced a near drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period? a. Auscultate heart sounds. b. Palpate peripheral pulses. c. Auscultate breath sounds. d. Check pupil reaction to light.

ANS: C (Primary Survey: Breathing) Because pulmonary edema is a common complication after near drowning, the nurse should assess the breath sounds frequently. The other information also will be obtained by the nurse, but it is not as pertinent to the patient's admission diagnosis.

A pedestrian who was hit by a car is admitted to the emergency department with possible right lower leg fractures. The initial action by the nurse should be to a. elevate the right leg. c. assess the pedal pulses. b. splint the lower leg. d. verify tetanus immunization.

ANS: C (Primary Survey: Circulation) The initial nursing action should be assessment of the neurovascular condition of the injured leg. After assessment, the nurse may need to splint and elevate the leg based on the assessment data. Information about tetanus immunizations should be obtained if there is an open wound.

A patient arrived at the emergency department after tripping over a rug and falling at home. Which finding is most important for the nurse to communicate to the health care provider? a. There is bruising at the shoulder area. b. The patient reports arm and shoulder pain. c. The right arm appears shorter than the left. d. There is decreased shoulder range of motion.

ANS: C (Primary Survey: Disability) A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. Bruising, pain, and decreased range of motion should also be reported, but these do not indicate emergent treatment is needed to preserve function.

A 26-yr-old woman is being evaluated for vomiting and abdominal pain. Which question from the nurse will be most useful in determining the cause of the patient's symptoms? a. "What type of foods do you eat?" b. "Is it possible that you are pregnant?" c. "Can you tell me more about the pain?" d. "What is your usual elimination pattern?"

ANS: C A complete description of the pain provides clues about the cause of the problem. Although the nurse should ask whether the patient is pregnant to determine whether the patient might have an ectopic pregnancy and before any radiology studies are done, this information is not the most useful in determining the cause of the pain. The usual diet and elimination patterns are less helpful in determining the reason for the patient's symptoms.

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first? a. Assist the patient to sit upright in a chair. b. Splint the patients chest during coughing. c. Medicate the patient with prescribed morphine. d. Observe the patient use the incentive spirometer.

ANS: C A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance but should be done after the morphine is given.

Family members are in the patient's room when the patient has a cardiac arrest and the staff start resuscitation measures. Which action should the nurse take next? a. Keep the family in the room and assign a staff member to explain the care given and answer questions. b. Ask the family to wait outside the patient's room with a designated staff member to provide emotional support. c. Ask the family members whether they would prefer to remain in the patient's room or wait outside the room. d. Tell the family members that patients are comforted by having family members present during resuscitation efforts

ANS: C Although many family members and patients report benefits from family presence during resuscitation efforts, the nurse's initial action should be to determine the preference of these family members. The other actions may be appropriate, but this will depend on what is learned when assessing family preferences

A 71-yr-old patient had an abdominal-perineal resection for colon cancer. Which nursing action is most important to include in the plan of care for the day after surgery? a. Teach about a low-residue diet. b. Monitor output from the stoma. c. Assess the perineal drainage and incision. d. Encourage acceptance of the colostomy stoma

ANS: C Because the perineal wound is at high risk for infection (Risk for peritonitis), the initial care is focused on assessment and care of this wound.

A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction control chamber of the collection device. Which action by the nurse is most appropriate? a. Document the presence of a large air leak. b. Notify the surgeon of a possible pneumothorax. c. Take no further action with the collection device. (Continue to monitor the collection device.) d. Adjust the dial on the wall regulator to decrease suction.

ANS: C Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction pressure. The amount of suction applied is regulated by the amount of water in this chamber and not by the amount of suction applied to the system.

A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). The nurse determines that discharge teaching has been effective when the patient makes which statement? a. "I will take salt tablets when I work outdoors in the summer." b. "I should take acetaminophen (Tylenol) if I start to feel too warm." c. "I should drink sports drinks when working outside in hot weather." d. "I will move to a cool environment if I notice that I am feeling confused."

ANS: C Electrolyte solutions such as sports drinks help replace fluid and electrolytes lost when exercising in hot weather. Salt tablets are not recommended because of the risks of gastric irritation and hypernatremia. Antipyretic medications are not effective in lowering body temperature elevations caused by excessive exposure to heat. A patient who is confused is likely to have more severe hyperthermia and will be unable to remember to take appropriate action

A 19-yr-old woman is brought to the emergency department with a knife handle protruding from her abdomen. During the initial assessment of the patient, the nurse should a. remove the knife and assess the wound. b. determine the presence of Rovsing sign. c. check for circulation and tissue perfusion. d. insert a urinary catheter and assess for hematuria

ANS: C The initial assessment is focused on determining whether the patient has hypovolemic shock. The knife should not be removed until the patient is in surgery, where bleeding can be controlled. Rovsing sign is assessed in the patient with suspected appendicitis. Assessment for bladder trauma is not part of the initial assessment.

A patient is admitted to the emergency department with peritonitis that has severe abdominal pain and rebound tenderness. Vital signs include temperature 102°F (38.3°C), pulse 120 beats/min, respirations 32 breaths/min, and blood pressure (BP) 82/54 mm Hg. Which prescribed intervention should the nurse implement first? a. Administer IV ketorolac 15 mg for pain relief. b. Draw a blood sample for a complete blood count (CBC). c. Infuse a liter of lactated Ringer's solution over 30 minutes. d. Send the patient for an abdominal computed tomography (CT) scan

ANS: C The priority for this patient is to treat the patient's hypovolemic shock with fluid infusion. The other actions should be implemented after starting the fluid infusion

Which care activity for a patient with a paralytic ileus is appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)? a. Auscultation for bowel sounds b. Nasogastric (NG) tube irrigation c. Applying petroleum jelly to the lips d. Assessment of the nares for irritation

ANS: C UAP education and scope of practice include patient hygiene such as oral care. The other actions require education and scope of practice appropriate to the RN.

The following four patients arrive in the emergency department (ED) after a motor vehicle collision. In which order should the nurse assess them? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. A 74-year-old with palpitations and chest pain b. A 43-year-old complaining of 7/10 abdominal pain c. A 21-year-old with multiple fractures of the face and jaw d. A 37-year-old with a misaligned left leg with intact pulses

ANS: C, A, B, D The highest priority is to assess the 21-year-old patient for airway obstruction, which is the most life-threatening injury. The 74-year-old patient may have chest pain from cardiac ischemia and should be assessed and have diagnostic testing for this pain. The 43-year-old patient may have abdominal trauma or bleeding and should be seen next to assess circulatory status. The 37-year old appears to have a possible fracture of the left leg and should be seen soon, but this patient has the least life-threatening injury.

Which question from the nurse would help determine if a patient's abdominal pain might indicate peritonitis? Select all that apply. a. "Have you been passing a lot of gas?" b. "What foods affect your bowel patterns?" c. "Do you have any abdominal distention?" d. "How long have you had abdominal pain?"

ANS: C, D

In which order will the nurse take these actions when caring for a patient in the emergency department with a right leg fracture after a motor vehicle crash? (Put a comma and a space between each answer choice [A, B, C, D, E, F].) a. Obtain x-rays. b. Check pedal pulses. c. Assess lung sounds. d. Take blood pressure. e. Apply splint to the leg. f. Administer tetanus prophylaxis.

ANS: C, D, B, E, A, F (Primary Survey ABCDE) 1. Assess lung sounds. 2. Take blood pressure. 3. Check pedal pulses. 4. Apply splint to the leg. 5. Obtain x-rays. 6. Administer tetanus prophylaxis. The initial actions should be to ensure adequate airway, breathing, and circulation. This should be followed by checking the neurovascular condition of the leg (before and after splint application). Application of a splint to immobilize the leg should be done before sending the patient for x-ray examination. The tetanus prophylaxis is the least urgent of the actions.

The emergency department (ED) nurse is initiating therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/LVN) (select all that apply)? a. Continuously monitor heart rhythm. b. Check neurologic status every 2 hours. c. Place cooling blankets above and below patient. d. Give acetaminophen (Tylenol) 650 mg per nasogastric tube. e. Insert rectal temperature probe and attach to cooling blanket control panel.

ANS: C, D, E Experienced LPN/LVNs have the education and scope of practice to implement hypothermia measures (e.g., cooling blanket, temperature probe) and administer medications under the supervision of a registered nurse (RN). Assessment of neurologic status and monitoring the heart rhythm require RN-level education and scope of practice and should be done by the RN.

The nurse is providing care to a patient with a chest tube. On assessment of the drainage system, she notes continuous bubbling in the water seal chamber and oscillation. Which of the following is the correct nursing intervention for this type of finding? a. Reposition the patient because the tubing is kinked. b. Continue to monitor the drainage system. c. Increase the suction to the drainage system until the bubbling stops. d. Check the drainage system for an air leak.

ANS: D

The patient calls on the call light to tell you something is wrong with his chest tube. When you arrive to the room you note that the drainage system has fallen on its side and is leaking drainage onto the floor from a crack in the system. What is your next PRIORITY? a. Place the patient in supine position and clamp the tubing. b Notify the physician immediately. c. Disconnect the drainage system and get a new one. d. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.

ANS: D

A client is admitted with head trauma after a fall. The client is being prepared for a supratentorial craniotomy with burr holes, and an intravenous infusion of mannitol is instituted. The nurse concludes that this medication primarily is given to do what? a. Lower blood pressure b. Prevent hypoglycemia c. Increase cardiac output d. Decrease fluid in the brain

ANS: D Osmotic diuretics remove excessive cerebrospinal fluid (CSF), reducing intracranial pressure. Osmotic diuretics increase, not decrease, the blood pressure by increasing the fluid in the intravascular compartment. Osmotic diuretics do not directly influence blood glucose levels. Although there is an increase in cardiac output when the vascular bed expands as CSF is removed, it is not the primary purpose for administering the medication.

A client is admitted with traumatic injuries after a tornado. While performing resuscitation during the primary survey, the nurse notices a compromised airway. Which nursing intervention would be of most benefit to the client? a. Preparing for chest decompression if needed b. Monitoring vital signs, especially blood pressure and pulse c. Preventing hypothermia using blankets and heating devices d. Preparing for endotracheal intubation and mechanical ventilation

ANS: D (Primary Survery: Airway) Preparing for endotracheal intubation and mechanical ventilation ensures airway patency during the primary survey in order to reduce the severity of airway compromise. Preparing for chest decompression is done during the primary survey when there are no breath sounds. Monitoring vital signs, especially blood pressure and pulse, is performed to assess circulatory disorders. Preventing hypothermia using blankets and heating devices is done during the exposure assessment.

CHILDREN TRAUMA The nurse must assess a child's capillary refilling time. This can be accomplished by: a. inspecting the chest. b. auscultating the heart. c. palpating the apical pulse. d. palpating the skin to produce a slight blanching.

ANS: D (Primary Survey: Circulation) Capillary refilling time is assessed by pressing lightly on the skin to produce blanching and then noting the amount of time it takes for the blanched area to refill. Inspecting the chest, auscultating the heart, and palpating the apical pulse will not provide an assessment of capillary filling time.

A client is admitted to the unit with a crushed chest, abdominal trauma, a probable head injury, and multiple fractures. The nurse should provide what initial emergency care? a. Start an intravenous (IV) line, get blood for typing and crossmatching, and obtain a history b. Assess vital signs, obtain a history, and arrange for emergency x-ray films c. Conduct a thorough physical assessment, assess vital signs, and cover open wounds d. Assess vital signs, control accessible bleeding, and determine the presence of critical injuries

ANS: D A thorough physical assessment is too time-consuming initially; open wounds can be covered at a later time. Initial rapid assessment will determine priorities of care and subsequent actions. IV therapy and transfusions will be prescribed, but baseline data are needed to assess the client's present condition and the significance of future responses. Although important, obtaining a history and x-ray films can be postponed until bleeding is controlled and injuries are assessed.

A patient who was recently diagnosed with Preeclampsia is having trouble concentrating. This patient is usually very organized and laid back. Which action should the nurse take? a. Ask the health care provider for a psychiatric referral. b. Administer the PRN sedative medication every 4 hours. c. Suggest the use of a home caregiver to the patient's family. d. Plan to reinforce and repeat teaching about preeclampsia management.

ANS: D Because behavioral responses to stress include temporary changes such as irritability, changes in memory, and poor concentration, patient teaching will need to be repeated. Psychiatric referral or home caregiver referral will not be needed for these expected short-term cognitive changes. Sedation will decrease the patient's ability to learn the necessary information for self-management.

A patient tells the nurse, "I'm told that I should reduce the stress in my life, but I have no idea where to start." Which would be the best initial nursing response? a. "Why not start by learning to meditate? That technique will cover everything." b. "In cases like yours, physical exercise works to elevate mood and reduce anxiety." c. "Reading about stress and how to manage it might be a good place to start." d. "Let's talk about what is going on in your life and then look at possible options."

ANS: D In this case, the nurse lacks information about what stressors the patient is coping with or about what coping skills are already possessed. As a result, further assessment is indicated before potential solutions can be explored. Suggesting further exploration of the stress facing the patient is the only option that involves further assessment rather than suggesting a particular intervention.

The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment? a. A patient with no pedal pulses. b. A patient with an open femur fracture. c. A patient with bleeding facial lacerations. d. A patient with paradoxical chest movements.

ANS: D Most immediate deaths from trauma occur because of problems w ventilation, so the patient with paradoxical chest movements should be treated first. Face and head fractures can obstruct the airway, but the patient with facial injuries only has lacerations. The other two patients also need rapid intervention but do not have airway or breathing problems.

An older patient with a situational crisis presents to the outpatient clinic with a chief complaint of headache and insomnia. In gathering the history, the nurse notes which factors as contributing to this patient's chief complaint? a. The patient is responsible for caring for two school-age grandchildren. b. The patient's daughter works to support the family. c. The patient is being treated for hypertension and is overweight. d. The patient has recently lost her spouse and needed to move in with her daughter.

ANS: D Stress of losing a loved one and having to move are important contributing factors for stress-related symptoms in older people. Caring for children will increase the patient's sense of worth. Being overweight and being treated for hypertension are not the most likely causes of insomnia or headache. The patient's daughter may have added stress due to working, but this should not directly affect the patient.

OB TRAUMA While completing a newborn assessment, the nurse should be aware that the most common birth injury is: a. to the soft tissues. b. caused by forceps gripping the head on delivery. c. fracture of the humerus and femur. d. fracture of the clavicle.

ANS: D The most common birth injury is fracture of the clavicle (collarbone). It usually heals without treatment, although the arm and shoulder may be immobilized for comfort.

A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which action should the nurse take first? a. Administer anticoagulant drug therapy. b. Notify the patient's health care provider. c. Prepare patient for a spiral computed tomography (CT). d. Elevate the head of the bed to a semi-Fowler's position.

ANS: D The patient has symptoms consistent with a pulmonary embolism (PE). Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and O2 is started). A spiral CT may be ordered by the health care provider to identify PE. Anticoagulants may be ordered after confirmation of the diagnosis of PE.

When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient? a. Emergency pericardiocentesis b. Stabilization of the chest wall c. Bronchodilator administration d. Chest tube connected to suction

ANS: D The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage to suction. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient's clinical manifestations are not consistent with these problems.

During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal pulse is absent and the leg is swollen. Which action will the nurse take next? a. Send blood to the lab for a complete blood count. b. Assess further for a cause of the decreased circulation. c. Finish the airway, breathing, circulation, disability survey. d. Start normal saline fluid infusion with a large-bore IV line.

ANS: D (Primary Survey: Circulation) The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a possibly life-threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey. Although a complete blood count is indicated, administration of IV fluids should be started first. Completion of the primary survey and further assessment should be completed after the IV fluids are initiated

A 19-year-old is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the left hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. The nurse will anticipate giving a. tetanus immunoglobulin (TIG) only. b. TIG and tetanus-diphtheria toxoid (Td). c. tetanus-diphtheria toxoid and pertussis vaccine (Tdap) only. d. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap).

ANS: D (Second Survey: Past Illnesses, Imunnization) For an adult with no previous tetanus immunizations, TIG and Tdap are recommended. The other immunizations are not sufficient for this patient.

When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87° F (30.6° C), which assessment indicates that the nurse should discontinue active rewarming? a. The patient begins to shiver. b. The BP decreases to 86/42 mm Hg. c. The patient develops atrial fibrillation. d. The core temperature is 94° F (34.4° C).

ANS: D A core temperature of 89.6° F to 93.2° F (32° C to 34° C) indicates that sufficient rewarming has occurred. Dysrhythmias, hypotension, and shivering may occur during rewarming and should be treated but are not an indication to stop rewarming the patient.

OB TRAUMA To monitor for potential hemorrhage in the patient who has just had a cesarean birth, which action should the recovery room nurse implement? a. Monitor her urinary output. b. Maintain an intravenous infusion at 1 mL/hour. c. Assess the abdominal dressings for drainage. d. Assess the uterus for firmness every 15 minutes.

ANS: D Maintaining contraction of the uterus is important for controlling bleeding from the placental site. Maintaining proper fluid balance will not control hemorrhage. Monitoring urine output is an important assessment, but hemorrhage will first be noted vaginally. Assessing the abdominal dressing is an important assessment to prevent future hemorrhaging from occurring but is not the first priority assessment in the recovery room. *Avoid Prostaglandins if upper uterus surgery or classic C section *Fetal maturity assessment before elective C section

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective? a. I am going to buy a rib binder to wear during the day. b. I can take shallow breaths to prevent my chest from hurting. c. I should plan on taking the pain pills only at bedtime so I can sleep. d. I will use the incentive spirometer every hour or two during the day

ANS: D Prevention of the complications of atelectasis and pneumonia is a priority after rib fracture. This can be ensured by deep breathing and coughing. Use of a rib binder, shallow breathing, and taking pain medications only at night are likely to result in atelectasis.

OB TRAUMA After a forceps-assisted birth, the patient is observed to have continuous bright red lochia and a firm fundus. Which other data would indicate the presence of a potential vaginal wall hematoma? a. Lack of an episiotomy b. Mild, intermittent perineal pain c. Lack of pain in the perineal area d. Edema and discoloration of the labia and perineum

ANS: D The nurse should monitor for edema and discoloration. Using a cold application to the labia and perineum reduces pain by numbing the area and limiting bruising and edema for the first 12 hours. An episiotomy is performed as the fetal head distends the perineum. The pain with vaginal hematoma is severe and constant. The pain associated with vaginal hematoma is severe.

Which patient should the nurse assess first after receiving change-of-shift report? a. A 60-yr-old patient whose new ileostomy has drained 800 mL over the previous 8 hours b. A 50-yr-old patient with familial adenomatous polyposis who has occult blood in the stool c. A 40-yr-old patient with ulcerative colitis who has had six liquid stools in the previous 4 hours d. A 30-yr-old patient who has abdominal distention and an apical heart rate of 136 beats/minute

ANS: D The patient's abdominal distention and tachycardia suggest hypovolemic shock caused by problems such as peritonitis or intestinal obstruction, which will require rapid intervention. The other patients should also be assessed as quickly as possible, but the data do not indicate any life-threatening complications associated with their diagnoses.

When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient? a. Emergency pericardiocentesis b. Stabilization of the chest wall with tape c. Administration of an inhaled bronchodilator d. Insertion of a chest tube with a chest drainage system

ANS: D The patients history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patients clinical manifestations are not consistent with these problems.

After change-of-shift report, which patient should the nurse assess first? a. 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet b. 28-year-old with a history of a lung transplant and a temperature of 101 F (38.3 C) c. 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain d. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion

ANS: D The patients history and symptoms suggest possible tension pneumothorax, a medical emergency. The other patients also require assessment as soon as possible, but tension pneumothorax will require immediate treatment to avoid death from inadequate cardiac output or hypoxemia.

OB TRAUMA Which clinical finding would be an indication to the nurse that the fetus may be compromised? a. Active fetal movements b. Fetal heart rate in the 140s c. Contractions lasting 90 seconds d. Meconium-stained amniotic fluid

ANS: D When fetal oxygen is compromised, relaxation of the rectal sphincter allows passage of meconium into the amniotic fluid. Active fetal movement is an expected occurrence. The expected FHR range is 120 to 160 bpm. The fetus should be able to tolerate contractions lasting 90 seconds if the resting phase is sufficient to allow for a return of adequate blood flow.

BLUNT ABDOMINAL TRAUMA Retro peritoneal hemorrhage: Cullen's vs Gray turner

Cullen's (ecchymosis around umbilicus ) Gray turner (ecchymosis around flank) If hemorrhage is suspected do a Focused sonography test (FAST) to determine the cause of hemorrhage. (Done at the bedside).

Complications of PENETRATING Abdominal Trauma

GI contents may spill in peritoneal cavity→ *Peritonitis: result of infection blood shunted to the Abd resulting in hypovolemia *Third spacing d/t fluid accumulation in peritoneal cavity *Paralytic ileus d/t Intestinal mobility becoming a non essential role. *Hypoperfusion of Kidneys d/t Decreased circulating blood volume, lead to renal failure *Toxins from bacteria may enter bloodstream lead to Septicemia (Septicemia & Renal failure leads to MODS→ death)

TRIAGE system

Identifies & categorizes pts so the most critical are treated first.

Chest Tube DISLOGED Pleural Drainage Chamber DAMAGED

If the tube becomes DISLODGED: -Cover the insertion site with a sterile dressing If the chamber becomes DAMAGED: -Place the tubing in sterile water while waiting for a new system

HEAD TRAUMA Priorities/ Discharge Teaching

PRIORITY *Stabilize cervical spine "C-spine" *Keep body perfect alignment *Assess GCS 15 = highest score 8 = intubate 3 = lowest score Report Decline in GCS score! *Monitor for Increased ICP Discharge Teaching •Return if having difficulty walking "Ataxia" •Adult should stay w patient •No alcohol (vasodilates & brain swells) •NOT necessary for pt to stay awake ALL night

SECONDARY SURVEY (SAMPLE) brief, systematic process that aims to identify all injuries.

S: SYMPTOMS -Assess sx to guide in what may be occurring A: ALLERGIES -Determine allergies M: MEDICATIONS -Assess med list. -On beta blocker? expect to have low HR. -On insulin? glucose lvl may not be optimal P: PAST ILLNESS/IMMUNIZATION P: PREGNANCY -Obtain Hx: preexisting medical &/or psychiatric conditions, hospitalizations/surgeries, smoking, recent drugs/alcohol, tetanus immunization, LMS, baseline mental status L: LAST MEAL/FLUIDS -Last time of meal or fluid intake since may require emergency surgery. -NG to suction: may require to prevent aspiration. E:EVENTS/ENVIRONMENT R/T TO INJURY -Obtain hx in order of event: to determine possibility of injuries not immediately visible *Facilitate family presence *Give comfort measures

Closed Pneumothorax

SPONTANEOUS PNEUMOTHORAX *No external cause (Closed) *Often seen in young men in late teens *Not d/t trauma... (No precipitating event) Causes: Rupture of a bleb (like little cyst on lungs) IATROGENIC PNEMOTHORAX *Occurs infrequently as medical procedure complication (Central line placement; Fine needle thoracentesis) *Closed (bc lung is punctured allowing air from lung to escape into pleural cavity).

General Adaptive Syndrome Model (Reaction Theory)

Stress is the sum of all factors effects that act on the body, w pleasant/unpleasant stressors both equally important. It establishes that an event (or stressor) that threatens an organism's well-being leads to predictably staged process of bodily response. 1. STAGE (ALARM) Upon perceiving stressor, body reacts w autonomic response that activates the SNS (Fight-or-Flight Response) ...mobilizing the body's resources to respond to stressor. 2. STAGE (RESISTENCE) The PNS attenuates the reaction, returning physiological functions to homeostasis while other functions remain hyperactive, ensuring that the body remains alert & ready to respond. 3.STAGE (EXHAUSTION) If the stressor's nature is sufficiently intense or protracted nature, it may exceed body's capacity to compensate, exposing susceptibility to Dz & death.