Chapter 16, Care of Patients Experiencing Urgent Alterations in Health

A patient calls an after-hours clinic for advice on how to treat a conscious victim for frostbite. The nurse gives the caller instructions on caring for the affected part. The caller then asks the nurse if drinking alcohol will be helpful. What is the best response the nurse can give?

"Alcohol may cause the core temperature to drop further." If the victim of frostbite is conscious, warm fluids may be offered. Alcohol should never be given because of the vasodilatory effect on the vessels; it can cause the central core temperature to drop further. Alcohol should not be given in any quantity or at any temperature. If the alcohol is given after the temperature has increased, it can cause the temperature to decrease, which can be detrimental to the patient.

A burn patient is being discharged home from the pediatric unit. After discharge instructions about care of a full-thickness (third-degree) burn are given, the mother asks if an antiseptic or ointment can be applied to the burned areas. How should the nurse advise the mother?

"Antiseptics or ointments may interfere with medical treatment." It is not appropriate to apply antiseptics, ointments, sprays, or creams to the burn because they may potentially interfere with medical treatment and cause further complications. Loose sterile dressings can be applied to the burn area.

The nursing instructor is teaching nursing students about giving mouth-to-mouth ventilation to a patient who has normal pulse. Which statement made by the nursing student needs correction?

"You should initiate one breath every 15 seconds." The statement made by the nursing student that needs correction is that there should be one breath every 15 seconds. When the patient has normal pulse, the nurse should provide one breath every six to eight seconds to restore the patient's breathing capability. Giving the patient one breath every 15 seconds is inadequate as it amounts to only 4 breaths per minute, which further promotes hypoxia. Tilting the head and chin helps provide effective mouth-to-mouth ventilation. If the initial attempt fails, the nurse should adjust the position of the head and chin and continue to try to provide ventilation to the patient. The nurse should take a deep breath and give two full breaths to the patient lasting one second each. This practice helps deliver an adequate amount of oxygen to the patient.

A care plan for a patient with full-thickness (third-degree) burns is being developed. Place the following problems in the order of priority.

1. Gas exchange. 2. Fluid and electrolyte imbalance. 3. Infection. 4. Pain. Full-thickness burns involve destruction of the skin and underlying tissues including, fat, muscle, and bone. Capillaries become permeable, and there is a shift of plasma into interstitial spaces, resulting in edema and blistering. An airway is established before the edema occurs. Gas exchange is the first problem that should be addressed. The larger the burn, the greater the shift causing fluid and electrolyte imbalance. Because of the edema and fluid shift, fluid and electrolyte imbalance is the next priority. Hypovolemic shock and infection are common complications. Infection is the next priority that the nurse must address. Many victims do not complain of pain because the nerve endings are severely burned, so it is the last priority on the problem list.

The nurse is palpating the carotid pulse in a patient during a cardiac arrest. What is the proper order of the steps that the nurse should follow?

1. Place the patient in supine position. 2. Put a hand on the patient's forehead. 3. Locate the thyroid cartilage. 4. Slide the fingers on the side of the neck. Monitoring the carotid pulse is the most reliable and accessible method of determining pulselessness. The nurse should place the patient in a supine position, maintaining the head-tilt position with one hand resting on the patient's forehead. With two or three fingers of the other hand, the nurse should locate the thyroid cartilage of the patient. The nurse should then gently slide the fingers into the groove between the trachea and muscles on the side of the neck until feeling the carotid pulse.

In performing chest compressions on a child, the breastbone is compressed to the depth of:

1½ inches. The chest is compressed with the heel of one hand at a depth of 1½ inches at 100 times per minute; ½ inch is not a deep enough compression for a child. Two inches is too deep a compression for a child; 2½ inches is too deep a compression for a child.

A nurse is caring for an adult patient with severe burns covering the face, anterior of the chest, and anterior and posterior of both arms. According to the rule of nines, what percentage of this patient's body is burned?

40.5%. According to the rule of nines, the face equals 4.5%, the anterior chest equals 18%, and the anterior and posterior of both arms equal 18% for a total of 40.5%.

A patient is brought into the emergency center by an ambulance after a motor vehicle accident. The patient is anxious and coughing up bright red blood. In addition, the nurse notes neck vein distention, asymmetrical chest expansion, and a deviated trachea. Based on the patient's clinical presentation, what medical concern should the nurse suspect?

A collapsed lung. Chest wounds are extremely dangerous and necessitate immediate medical attention. In many chest wounds air or blood escapes into the pleural space and has the potential to cause an increase in pressure, resulting in collapse of lung tissue. The patient has sharp pain at the site and labored breathing. Asymmetrical chest expansion, coughing up blood, cyanosis, a sucking or hissing sound, neck vein distention, anxiety, and tracheal deviation may be present. Emphysema and lung cancer are associated with smoking, not trauma. A crushed trachea would not result in asymmetrical chest expansion or neck vein distention.

The nurse is assessing a baby under the age of 12 months who is choking on a piece of candy. The nurse did not find the candy in the baby's mouth. Which technique should the nurse use to alleviate choking in the baby?

A combination of back blows and chest thrusts. A chest thrust , if performed alone, is not helpful to remove the aspirated object from the baby's airway (mouth). The nurse should use a combination of back blows and chest thrusts to remove the object stuck in the baby's mouth. Performing chest thrusts in the prone position is not possible. Abdominal thrusts in the supine position can cause severe injury in the child and are not a preferred technique for children. If the object is visible, the nurse can use the blind sweep technique. Because the object is not visible in this case, the nurse should not perform this technique.

Following an assessment, the primary health care provider concludes that the patient is in a irreversible coma. What clinical features should the nurse expect to find in the patient? Select all that apply.

Absence of reflex activity Absence of respiration Presence of heart beat An irreversible coma can also be called brain death. Absence of reflex activity, body movements and respiration are the clinical features that indicate brain death. The heart continues to beat even if the brain is dead; therefore, the absence of a heartbeat does not indicate brain death. The presence of a dilated and fixed pupil indicates the condition of irreversible coma; therefore, the presence of constricted pupils is not an indication of brain death.

A patient is bitten on the ankle by a poisonous snake. What actions would the nurse do to save the patient? Select all that apply.

Administer a suitable prophylactic antibiotic. Remove the restrictive clothing in case of swelling. Remove the poison with the help of a suction device. Administering a prophylactic antibiotic helps prevent any infection that occurs due to a snake bite. In case of swelling, any restrictive clothing should be removed to avoid pressure being applied on the site of injury. If a suction device is available, sucking out the poison would prevent the poison from spreading to other parts of the body. Keeping the injured part above the heart level is not advisable, because it increases the blood circulation and facilitates the poison entering the bloodstream. The wound should be washed with soap water if the wound is caused by the bite of a rabid animal. It is not advisable in the case of a snake bite.

A patient had a closed fracture of the arm. What is the immediate intervention of the nurse?

Apply a triangular bandage. The triangular bandage, as the name indicates, is a triangular piece of cloth that is useful in the case of bone injuries (fractures). In this case, the nurse can use a triangular bandage to immobilize the bone and prevent further injury to the arm. A compress bandage is useful to treat bleeding, as with open compound fractures. In this case, this bandage cannot be used because the arm has a closed fracture. In this case, a gauze bandage cannot be used, because it is used as a part of wound dressing or while applying pressure. The arm fracture requires that the limb be kept in position until medical assistance arrives. Hence, pressure cannot be applied. A butterfly bandage is used to keep the wound closed in the case of deep cuts that require stitches; closed fractures do not involve external wounds and therefore, a butterfly bandage is not used for closed fractures.

A patient arrives at the emergency room (ER) with a penetrating sucking chest wound. The nurse expects that the patient is experiencing a pneumothorax. What should the nurse do first to increase patient safety?

Apply an airtight dressing. If there is a sucking chest wound, the nurse should apply an airtight dressing. Any available material is acceptable—gauze, plastic wrap, clothing, or a hand. The vital signs should be taken, the doctor located, and the patient medicated, but the dressing should be applied first because a pneumothorax can become a tension thorax if air continues to enter the open wound. Sometimes the fourth side will have to be untaped to allow air to escape. This will be assessed further once the airtight dressing is in place.

The nurse receives a call that a victim of a bomb blast is being brought to the emergency care unit. What should be the first intervention followed by the nurse while caring for the patient?

Assess the patient for any life-threatening problems. While caring for a patient in an emergency situation, the first priority of nurse should be to assess any life-threatening problems in the patient. This helps the nurse know if they need to provide cardiopulmonary resuscitation to the patient and restore vital signs. External and internal bleeding can be assessed later. The nurse needs to alert the emergency medical technician for assistance after assessing the patient. The nurse should collect the patient's medical history from the family after stabilizing the heart rate and respiration.

A patient comes into the emergency department with an open wound on the right leg. There is a large piece of tissue missing, leaving the tendon and muscles exposed. This is an example of which type of open wound?

Avulsion. An avulsion is a torn piece of tissue that results in a section being completely removed or left hanging by a flap. Underlying bones, tendons, or muscles may be exposed. A laceration is a wound that has jagged, irregular edges caused by auto accidents or injury involving blunt objects or heavy machinery. An incision is a smoothly divided wound made by sharp instruments. A puncture is a piercing wound of the skin caused by knives, nails, wood, glass, or other objects that penetrate the skin.

An infant is choking on a marble. What technique should the nurse instruct the babysitter to use for removing the object?

Back blows and chest thrusts. If the nurse is assisting a child who has aspirated a foreign body, the nurse may treat the child in a similar manner as an adult. Blind finger sweeps should never be used because it is possible to cause the foreign body to become lodged within the airway. The nurse or rescuer should use a combination of back blows and chest thrusts, keeping the head lower than the trunk. Breath blows are not a term that applies to CPR, finger sweeps are not recommended unless the object is visible on inspection of the mouth, and the Valsalva maneuver is the act of straining, which increases thoracic pressure and stimulates the vagus nerve.

On entering the room of a female patient, the nurse assesses her to be unresponsive and not breathing and to have no pulse. The nurse immediately calls for assistance. What is the next nursing action?

Begin chest compressions. The nurse should begin compressions. A primary health care provider being called falls in the area of calling for assistance, which has already been done. Oxygen may be provided at some point but would not be the next nursing action. Reassessment of the airway may occur after compressions have been started or once assistance arrives.

The nurse is placing a patient in an arm sling. Which action of the nurse would enable venous return from the hand and forearm and also facilitate drainage of edema?

Bending arm with slightly elevated elbow. Placing the arm in an arm sling helps to bend the arm to facilitate venous return, and elevating the elbow would facilitate drainage of edema. Placing the arm close to the chest would establish a proper position for arm sling. Placing the apex of sling's triangle behind the elbow of the injured arm facilitates usefulness of the sling. Tying the bandage connecting the neck and uninjured side would help to prevent pressure on the cervical spine.

A child has accidentally consumed floor cleaner. What actions would the nurse take? Select all that apply.

Call poison control center. Ask for the substance container. Treat shock manifestations. Calling the poison control center enables the nurse to provide better care before the medical provider arrives. Asking for the substance container in order to check for the contents listed on the container is a useful action, because it helps identify the chemical nature of the ingested substance(s). This will help provide the proper treatment, based on the chemicals ingested. The victim may be in shock; the necessary steps should be taken to treat the patient. Specific antidote administration should be done only after consulting the primary health care provider. Inducing vomiting with ipecac is not advisable because it may lead to other complications, such as persistent vomiting, lethargy and diarrhea. Because ipecac is a prescription drug, it should be used only with the advice of a primary health care provider.

A mother calls her friend who is a nurse and says that her child has ingested furniture polish. What should the nurse tell the mother to do?

Call the Poison Control Center. The mother should call the Poison Control Center immediately to receive instructions regarding to what to do. Taking the child to the emergency room or calling 911 for an ambulance would not be the first intervention because it could delay treatment. The mother should not give ipecac until instructed to do so by Poison Control. Vomiting may not be the appropriate action for this type of poisoning.

A patient accidentally steps on an iron nail which pierces deep into the foot. What immediate action should the nurse perform?

Call the primary health care provider. If an iron nail pierces the foot, it causes internal tissue damage and sepsis. The nurse should call the primary health care provider immediately. Removing the nail may cause a further increase in bleeding and may lead to an internal infection. Giving a tetanus booster may be considered as a follow-up treatment for such injuries. Because the wound is caused by a metal object, it may lead to sepsis. The nurse should instruct the patient about the symptoms after a proper treatment has been given to the patient.

An intoxicated patient arrives at an urgent care health facility. The patient becomes agitated, excited, and belligerent. What attitude should the nurse use in approaching this patient?

Calm and supportive. An intoxicated patient should never be left alone. A calm, supportive, nonjudgmental approach is best when a victim is agitated or excited. An agitated patient should not be ignored, confronted aggressively, or indirectly approached because these could potentially cause the patient to become more belligerent.

The nurse working at a health care center receives a patient with full-thickness burns. The nurse calls the specialty hospital and expects the medical help to arrive in 15 minutes. What should the nurse do while the medical help arrives?

Cover the wounds with loose sterile dressing. Full-thickness burns may result in large surface area exposed to the external environment, which further increases the risk of infection. Therefore, the burnt area should be covered with loose sterile dressing, which will allow the drainage of fluid and also protect it from contamination. Cold compress can cause hypothermia and should be avoided. Blisters should not be intentionally broken as it may increase the risk of infection. Antiseptics may interfere with the assessment of wound. Therefore, antiseptics should not be applied on the burnt area.

The nursing student is caring for a patient who has severe injuries. The nursing student placed the patient in the supine position, provided tight bandages, administered analgesic drugs, and provided emotional support. Which intervention of the nursing student needs to be corrected?

Dressing the patient with tight bandages. The patient should be provided loose and comfortable clothing for more comfort. It is necessary to place the patient in the supine position to establish airway and provide proper breathing. Emotional support is required for a patient who is usually anxious and restless due to shock. Analgesic drugs are administered to patients who are in pain, based on the prescription of the primary health care provider.

From the following list, what are the events that require cardiopulmonary resuscitation (CPR)? Select all that apply.

Drowning Asphyxiation Sudden infant death syndrome Events that require the rescuer to assess the ABCs of cardiopulmonary resuscitation and initiate necessary interventions include cardiac arrest, drowning, electrical shock, anaphylactic reaction, asphyxiation, drug overdose, and sudden infant death syndrome. CPR may not always be required with hypothermia or heatstroke.

While caring for a patient with a fractured forelimb and continuous bleeding, the nurse places a clean cloth and applies firm pressure on the site of the bleeding. Then the nurse secures a bandage and adds an additional layer of cloth, but does not remove bandage kept previously. Finally, the nurse raises patient's hand above heart. Which action of the nurse may harm the patient?

Elevation of the arm. As the patient has a fracture on arm, elevating the arm above the heart may cause exaggeration of the condition so it should be avoided. The nurse should retain the bandage and only the primary healthcare provider should remove it while providing further treatment. Further cloth is applied, when the bandage gets saturated with blood. This action may not cause any harm to the patient. Applying direct pressure helps to decrease the flow of blood.

Older adults are at risk for drug overdose. What is the main physiologic change of aging that can lead to overdose?

Eyesight. The main physiologic change that may contribute to overdose is eyesight. Changes leading to decreased vision lead to taking the medication inappropriately. Older adults with hearing loss, chronic weakness, or an impaired sense of smell may still be able to read the labels of their medications to take them appropriately.

Following a head injury, an unconscious patient is being transported to a health care center. In which position does the nurse place the patient?

Flat position without disruption The patient is suffering from a head injury; positioning the patient in a flat or supine position, without any disturbance, is the most desirable alternative. Both positions prevent the occurrence of shock. A Flat position with legs elevated is not suitable because this increases blood flow to vital organs of the body and results in excessive bleeding. Trendelenberg's position is not suitable, as it causes blood to flow more towards the head, resulting in excessive bleeding. In this case, elevating the shoulder and head may cause severe discomfort in the patient, as the injured part could move due to displacement in position.

A nurse arrives on an accident scene and quickly recognizes that an individual is going into shock. How should the nurse position the patient?

Flat with legs elevated. It is essential to treat shock immediately. Priority interventions include establishing an airway, controlling bleeding if present, and positioning the patient supine with the legs elevated slightly above the head. Prone is lying face down, side-lying does not raise the legs, and the Fowler position raises the head higher than the legs and is not appropriate for shock.

A nurse provides care for a patient in an emergency situation on the roadside. The patient survived but was left with a minor deformity. The patient is angry and files a lawsuit against the nurse. Which law will protect the nurse from legal liability?

Good Samaritan laws. Good Samaritan laws give legal protection for those giving first aid in an emergency situation. Civil law is a suit involving citizens, malpractice refers to bad practice and is not a true law, and nurse practice acts guide nursing practice.

A child's x-ray report shows a bend and cracks in the bone of the left leg. What type of fracture should the nurse identify this condition as?

Green stick fracture A bend and cracks in the bone represents an incomplete breakage in the bone. An incomplete break in the bone is also called a green stick fracture. This type of fracture is more common in children because their bones are more pliable. Shattering of the bone into two or more pieces or fragments is called a communicated fracture. In an impacted fracture, the bone ends may jam together. This type of fracture mostly occurs due to trauma. Fracture to the vertebrae as a result of pressure can be considered a compressed fracture.

An elderly patient was admitted to a large medical surgical unit as a result of an accidental overdose of a cardiac drug. Which intervention would increase patient safety related to accidental ingestion?

Have a person organize the drugs in a medication box for a week. Older adults are sometimes the victims of accidental overdose because poor eyesight leads to ingestion of the wrong medication and confusion leads to accidentally repeating a dose of medication. Placing the medications in one bottle significantly increases the possibility of a medication error. Medications should be clearly marked with large lettering. Distinguishing the cardiac drugs from all of the other medications will not help the patient remember when and if medication was taken.

A young child is experiencing a nosebleed that is uncontrollable. What intervention should the nurse implement for this condition?

Have the patient lean forward, and apply pressure to the nose. The victim experiencing a nosebleed should be kept quiet in a sitting position leaning forward, or if not possible, supine with the head and shoulders elevated. The thumb and forefinger should be used to apply pressure for 10 to 15 minutes before releasing, and an ice compress should be applied. The child should sit upright or, if lying flat, should have the shoulders and head elevated. The child should not hyperextend the neck but should bring it forward. Finally, the child should not be turned on the side.

A patient in the waiting room collapses. The nurse assesses the patient and determines that the airway may be blocked. What technique should the nurse use to open the airway?

Head-tilt/chin-lift. The nurse ensures that the patient's airway is open via the head-tilt/chin-lift. A log roll is used to align the body during movement. Abdominal thrusts and chest compressions are not used to open an airway during cardiopulmonary resuscitation.

A trauma patient has ingested a combination of drugs. The patient is being monitored for complications. Which alteration is likely to occur?

Hypoventilation. The nurse should obtain as much information as possible about the drug ingested. The nurse must perform an assessment of the victim's mental status and vital signs. It is possible for a victim of substance abuse to go into respiratory arrest quickly, resulting in slow respirations. An increase in heart rate, temperature, and blood pressure can occur, but it is very common for patients to go into respiratory arrest after ingesting drugs.

The nurse is teaching CPR to a group of LPN students. The nurse briefs the students about conditions when the nurses should avoid giving CPR to the patient. Under which conditions should one avoid giving CPR? Select all that apply.

If the nurse is exhausted If the nurse is in an unsafe place If the patient is able to breathe Once the nurse starts performing cardiopulmonary resuscitation (CPR ), it is necessary to continue it till the patient is able to breathe. If the nurse is exhausted while performing CPR, then it is necessary to stop because the nurse may suffer from shortness of breath. An unsafe place increases the risk of infection and injury; so CPR should be immediately stopped and the patient should be evacuated from there. CPR should be resumed after the patient is moved to a safe place. CPR should be stopped after the patient recovers and breathes properly without any assistance. The nurse should motivate the students to not be scared and confused while giving CPR because it is an important life-saving measure.

A nurse is caring for a patient with a suspected fracture of his right arm. What is the most appropriate nursing action?

Immobilizing by splinting the bone as is. The nurse should not attempt to realign the bone, but should immobilize it as is. Circulation needs to be assessed below the injury and any bleeding stopped.

A car accident victim was ejected from the car. It has been determined that his airway needs to be opened. What is the most appropriate method for the rescuer to use?

Jaw-thrust/chin-lift. If a neck injury is suspected, the jaw-thrust/chin-lift is used. If neck injury is suspected, the head-tilt/chin-lift produces hyperextension of the neck and could cause complications. A flexed position is an inappropriate position to open an airway.

While performing first aid to a patient with a penetrating chest wound, the nurse observes the signs and symptoms of pneumothorax. What is the best intervention to address this complication?

Leave one side of the dressing untaped for air to escape. If the signs and symptoms of pneumothorax are observed, then one side of the dressing should be left untaped. Tight taping of the dressing may cause respiratory distress. Intake of any liquids during this time may cause aspiration and should be avoided. Removal of an object may cause an escape of fluids into the plural space and increase the bleeding. The nurse should not remove the object.

A public health nurse is training a group of citizens on administering cardiopulmonary resuscitation (CPR). What information, if given by the participants, indicates that they understand when the CPR should be discontinued? Select all that apply.

Licensed personnel arrive. The rescuer cannot continue An automated external defibrillator is available. Once started, CPR should not be stopped unless the patient is responsive, licensed medical personnel arrive on the scene, an automated external device is available, or the rescuer is unable to continue. Broken bones and vomiting may occur doing CPR.

A nurse is assessing a patient in the early stage of shock. What signs should the nurse expect to find to support a medical diagnosis of early stage of shock? Select all that apply.

Oliguria Tachypnea Hypotension Altered level of consciousness During shock the skin is cool and clammy, the patient loses consciousness, and the patient may experience an increase in the heart rate (tachycardia) and pulse (tachypnea). Urinary output decreases (oliguria), and the blood pressure goes down (hypotension). The heart rate increases, not decreases, and the skin is not warm but cool and clammy. Bradycardia may occur, but it is usually in the late stages of shock.

A patient with a diagnosis of drug overdose is brought into a health care facility. While the nurse is starting a heparin lock, the patient begins to have a seizure. What is the nurse's priority?

Patient safety. Victims must be protected from self-injury during a seizure or hallucinations by removing potential harmful objects from the patient's vicinity. The patient's safety is essential. Obtaining the medical history, determining allergies, and securing an intravenous access are essential, but preventing injury is the priority.

A patient experienced a severe strain to the wrist. Ice has been prescribed for the area by the primary health care provider. How should the nurse instruct the patient to apply the ice?

Place a bag of ice in a thin towel. Ice is applied, but not directly to the skin, for 48 hours after an injury for 15 to 20 minutes at a time. The ice can be placed in a thin wrapping such as a towel so that the ice is not placed directly on the skin. Applying the ice directly to the strained area or placing the limb into an ice bucket until pain subsides are contraindicated because the skin is at risk for injury from direct contact.

A skier falls on the slopes and injures a leg. Once the bleeding is controlled, the nurse places a bandage on the injury. Which action is essential for the nurse to implement before applying the bandage?

Place the leg in a functional position. The nurse should control the bleeding before applying the bandage. The nurse should always bandage the part in the aligned position. The leg may be elevated after the bandage has been applied, massaging the calf may dislodge a clot, and heat is not indicated at this point.

A nurse is assisting a patient on the phone to perform cardiopulmonary resuscitation (CPR). How should the nurse instruct the caller to palpate the pulse?

Place three fingers in the groove between the throat and the neck. To determine the absence of a pulse, the carotid pulse is the most reliable and accessible. The position of the head should be maintained, and the nurse slides three fingers into the groove between the trachea and the muscles on the side of the neck. The nurse should use terms that a layperson can understand. Therefore telling the patient to place the fingers in the groove between the throat and the neck can guide the patient to locate the carotid artery. The carotid artery is located on the side of the neck; therefore it is incorrect to instruct the caller to touch under the chin, the inside of the thigh, or the elbow.

A hunter has been bitten by a snake and is brought to the emergency room. Which measures should the nurse implement? Select all that apply.

Remove restrictive clothing. Assess the patient for shock. Emergency care for bites from reptiles such as snakes includes restricting movement of the affected limb and keeping it below the level of the heart, as well as removing restrictive clothing and jewelry. The patient must be monitored for shock. The toxins are not generally suctioned in the emergency room. This intervention may have been attempted by the patient. This is not a nursing intervention. Exercise should not be done, and the extremity should be below the level of the heart.

A patient arrives at the hospital with a serious strain of the left ankle. What measures should the nurse implement?

Rest the limb, apply ice, compress, and elevate. In the treatment of sprains and strains, the nurse should remember the acronym RICE: rest the limb, apply ice to the limb, apply a compression bandage or ACE bandage, elevate above the level of the heart. There is no indication the patient needs therapy; ice is applied to reduce the swelling, and then heat. Finally the extremity is elevated after ice and bandages have been applied.

The nurse is assisting an accident victim who is conscious. What should be the first nursing intervention?

Seek the patient's permission before administering first aid. If the patient is conscious, the nurse is obliged to seek verbal permission even in an emergency situation. This is the moral and legal responsibility of the nurse. Any emergency requires first aid to be provided immediately. The patient's demographic data should be documented. However, it is not an immediate intervention. Documentation can be done once the patient is stabilized. The nurse should initiate first aid and continue to care for the patient until an expert is available to assist.

A patient is brought to the health care center with history of falling while playing football. The nurse suspects of the patient's shoulder to be dislocated. Which is the best nursing intervention until the patient is diagnosed and shifted to a specialty center?

Splint the joint. Dislocation usually happens after a fall or a blow. In case of shoulder dislocation, the joint should be splinted to prevent any movements of the joint. Movements of the dislocated joint can be painful and may worsen the dislocation. The dislocated joint should not be reduced as it can cause soft tissue injury. The joint should not be elevated because it can tear the fragile soft tissues. Cold packs rather than hot packs should be applied to reduce the edema.

The nurse instructor is teaching a group of students about the necessary interventions that are to be taken while treating wounds. Which statement by the student indicates the need for further teaching?

Tetanus toxoid should be administered for every 12 years. Tetanus toxoid is an active immunizing agent that is used for the treatment and prevention of infection. It has to be administered every 10 years to maintain immunity in the patient. A cold compress is applied along with the padding to relieve pain. Tetanus is used as a general treatment in any kind of wound treatment, whether open or closed. The patient may undergo shock due to injury so the nurse should monitor the patient from time to time.

During a clinical session, the nurse educator positions the patient with the head slightly tilted. The instructor places one hand on the patient's forehead and slides two fingers of the other hand into the groove between the trachea and neck. What do the nursing students understand from these actions?

The nurse educator is determining the carotid pulse of the patient. During the assessment of a patient, the nurse should determine the carotid pulse. This helps to find out whether the patient has a pulse or if external cardiac compression is required. The carotid pulse can be determined by slightly tilting the patient's head and placing one hand on the forehead. The two fingers of the other hand should be placed in the groove between the trachea and neck. The pulse of the patient can be found by slighting palpating the area. If the nurse were providing head massage, the nurse would not place the finger of other hand in the groove between trachea and neck. The presence of tonsils cannot be determined by recommending throat culture to the patient. Laryngitis is characterized by inflammation in the throat and can be detected by laboratory finding, not by physical assessment.

A graduate nurse in training receives a patient with frostbite to the big toe. Which action requires immediate correction by the preceptor training the graduate nurse?

The nurse is rubbing the toe. The nurse should refrain from rubbing the part because friction can bruise and damage underlying tissue. Wrapping the frostbitten part in the warm towels, placing the area in a whirlpool of water, and applying several blankets are appropriate interventions for the nurse to implement for the frostbitten part.

The nurse asks the primary health care provider if a patient has a risk of vasodilatory shock. Which observations did the nurse make to spark this suspicion?

The patient has hypothermia. A patient who has undergone shock usually has a cool and clammy skin that may develop into hypothermia. A patient who is at a risk of vasodilatory shock does not have polyuria. Such patients usually develop oliguria due to decreased circulation of fluids resulting in decreased urine output. The patient has an increased pulse rate. Therefore, the patient may be at risk of tachycardia or a heart rate of more than 100. The patient may not be at risk of bradycardia (reduced heart rate). The patient with low oxygenation may not develop vasodilatory shock.

A counselor on a camping trip begins to experience a body temperature of 102.9, nausea, vomiting, and hot, dry skin. A camp nurse suspects the counselor is experiencing a heat stroke. The nurse will follow the protocol and hydrate the victim with 125 mL every 15 minutes. How much fluid in ounces will the patient get over the next 3 hours? Record your answer using a whole number. _____ ounces of fluid

The patient should receive 125 ml/15 min. 125 mL × 12 = 1500 mL 30 mL:1 ounce::1500 mL: x ounces x = 50 ounces

An emergency room triage nurse answers the call of a frantic family member. The caller tells the nurse that the victim has been stabbed and blood is flowing out rapidly. What should the nurse instruct the caller to do?

Use a towel and place firm pressure on the wound. The most effective general treatment for bleeding is applying direct pressure over the bleeding site. The cleanest material or dressing should be applied over the site with a gloved hand. Therefore the nurse should instruct the caller to apply direct pressure. CPR may be needed but is not indicated at this time. The nurse can notify the ambulance, and the rescuer may talk to the patient, but the direct pressure must applied first to stop the bleeding or the patient will die.

A patient sustains a first-degree burn after being splashed with hot water. What effective treatment should the nurse provide? Select all that apply.

Use cold compress to reduce pain. Apply a sterile dressing on burn. When hot water is spilled on the skin, it causes first degree burns. Using a cold compress can reduce the pain caused by the burn. A sterile dressing should be applied to the burn to prevent any further infection. Soaking the burned area with ice water is to be avoided, because it may cause further damage to the tissue by causing frostbite. Oral rehydration therapy is advisable in the case of second- and third-degree burns, because these burns may result in fluid loss. As first-degree burns result in erythema and pain but not blisters, application of antiseptic solution is not necessary.

The nurse is performing cardio pulmonary resuscitation (CPR) on an unconscious patient who was involved in motor vehicle accident. While assessing the patient, the nurse suspects neck and cervical spine injuries. What does the nurse do to ensure that the patient's airway is open?

Use the jaw-thrust maneuver to open the patient's airway. The jaw-thrust maneuver is an effective airway technique, particularly in patients with cervical spine injuries. The nurse should use the jaw-thrust maneuver without tilting the patient's head to open the airway, because the patient has neck and cervical injuries. CPR should not be used in conjunction with AED; the nurse should stop CPR before using the AED. Hyperextension of the patient's neck may aggravate the patient's cervical spinal injury. The nurse should not hyperextend the patient's neck to manage the airway. The head-tilt or chin-lift maneuver can be used in the case of a patient with a cervical spine injury; however, it should not be used if a neck injury is suspected.

A geriatric patient fell unconscious due to an airway obstruction. The nurse laid the patient in the supine position, performed a blind finger sweep, and tried to remove the object obstructing the airway. The nurse then knelt near the patient's thigh and placed a fist on the abdomen to perform abdominal thrusts. After the object was ejected, the nurse performed cardiopulmonary resuscitation (CPR). Which action of the nurse needs to be rectified?

Using a blind finger sweep to remove the object obstructing the airway. The patient is already unconscious. Therefore, the object is unlikely to be in the mouth, which means performing a blind finger sweep is not needed. It is necessary to lay the person in the supine position to promote breathing and to perform CPR. While performing abdominal thrusts, the nurse should place the heel of the hands and not the fist on the patient's abdomen. If the patient is unable to breathe properly even after the object is removed, then it is necessary to perform CPR.

A patient falls from a bike and sustains abrasions on both legs. How should the nurse provide effective treatment to the patient?

Wash the abrasions with saline. Skin abrasions are to be irrigated with normal saline. This procedure helps in the effective removal of debris and microorganisms. Antiseptics should not be used, because they can cause skin irritation and delay the healing process. Using povidone for irrigating the abrasion is not advisable because it may cause tissue necrosis. The abrasions should be washed from inside to outside in order to prevent the abrasions from contracting an infection.