Chapter 68: Emergency and Disaster Nursing Lewis: Medical-Surgical Nursing, 10th Edition ?'s

A male patient with multiple injuries is brought to the ED by ambulance. He has had his airway stabilized and is breathing on his own. The ED nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding? A) Absence of bruising at contusion sites B) Rapid pulse and decreased capillary refill C) Increased BP with narrowed pulse pressure D) Sudden diaphoresis

B Feedback: The nurse would anticipate that the pulse would increase and BP would decrease. Urine output would also decrease. An absence of bruising and the presence of diaphoresis would not suggest internal hemorrhage.

An emergency room nurse assesses a client who has been raped. With which health care team member should the nurse collaborate when planning this client's care? a. Emergency medicine physician b. Case manager c. Forensic nurse examiner d. Psychiatric crisis nurse

C All other members of the health care team listed may be used in the management of this client's care. However, the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing with the victim of an assault.

A nurse is triaging clients in the emergency department. Which client should be considered urgent? a. A 20-year-old female with a chest stab wound and tachycardia b. A 45-year-old homeless man with a skin rash and sore throat c. A 75-year-old female with a cough and a temperature of 102 F d. A 50-year-old male with new-onset confusion and slurred speech

C A client with a cough and a temperature of 102 F is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. The client with a chest stab wound and tachycardia and the client with new-onset confusion and slurred speech should be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent.

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

C A client with signs and symptoms of tuberculosis or other airborne pathogens should be placed in a negative-pressure room to prevent contamination of staff, clients & family members in the crowded emergency department.

An emergency department (ED) case manager is consulted for a client who is homeless. Which intervention should the case manager provide? a. Communicate client needs and restrictions to support staff. b. Prescribe low-cost antibiotics to treat community-acquired infection. c. Provide referrals to subsidized community-based health clinics. d. Offer counseling for substance abuse and mental health disorders.

C Case management interventions include facilitating referrals to primary care providers who are accepting new clients or to subsidized community-based health clinics for clients or families in need of routine services. The ED nurse is accountable for communicating pertinent staff considerations, client needs, and restrictions to support staff (e.g., physical limitations, isolation precautions) to ensure that ongoing client and staff safety issues are addressed. The ED physician prescribes medications and treatments. The psychiatric nurse team evaluates clients with emotional behaviors or mental illness and facilitates the follow-up treatment plan, including possible admission to an appropriate psychiatric facility.

An emergency department nurse is caring for a client who is homeless. Which action should the nurse take to gain the clients trust? a. Speak in a quiet and monotone voice. b. Avoid eye contact with the client. c. Listen to the client's concerns and needs. d. Ask security to store the client's belongings.

C ~ To demonstrate behaviors that promote trust with homeless clients, the emergency room nurse should make eye contact (if culturally appropriate), speak calmly, avoid any prejudicial or stereotypical remarks, show genuine care and concern by listening, and follow through on promises. The nurse should also respect the client's belongings and personal space.

A workplace explosion has left a 40-year-old man burned over 65% of his body. His burns are second and third-degree burns, but he is conscious. How would this person be triaged? A. Green B. Yellow C. Red D. Black

D Feedback: The purpose of triaging in a disaster is to do the greatest good for the greatest number of people. The patient would be triaged as black due to the unlikelihood of survival. Persons triaged as green, yellow, or red have a higher chance of recovery.

A patient with multiple trauma is brought to the ED by ambulance after a fall while rock climbing. What is a responsibility of the ED nurse in this patients care? A) Intubating the patient B) Notifying family members C) Ensuring IV access D) Delivering specimens to the laboratory

C

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

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

A patient is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the physician will perform which of the following actions? A) Insert an oropharyngeal airway. B) Perform the jaw thrust maneuver. C) Perform endotracheal intubation. D) Perform a cricothyroidotomy.

C Feedback: Endotracheal tubes are used in cases when the patient cannot be ventilated with an oropharyngeal airway, which is used in patients who are breathing spontaneously. The jaw thrust maneuver does not establish an airway and cricothyroidotomy would be performed as a last resort.

A 24-year-old is brought to the emergency department with multiple lacerations and tissue avulsion of the right hand after catching the hand in a produce conveyor belt. When asked about tetanus immunization, the patient says, "I've never had any vaccinations." The nurse will anticipate administration of tetanus a. immunoglobulin. b. and diphtheria toxoid. c. immunoglobulin, tetanus-diphtheria toxoid, and pertussis vaccine. d. immunoglobulin and tetanus-diphtheria toxoid.

C Rationale: For a patient with unknown immunization status, the tetanus immune globulin is administered along with the Tdap (since the patient has not had pertussis vaccine previously). The other immunizations are not sufficient for this patient.

Four victims of an automobile crash are brought by ambulance to the emergency department. The triage nurse determines that the victim who has the highest priority for treatment is the one with a. severe bleeding of facial and head lacerations. b. an open femur fracture with profuse bleeding. c. a sucking chest wound. d. absence of peripheral pulses.

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

A patient has been brought to the ED with multiple trauma after a motor vehicle accident. After immediate threats to life have been addressed, the nurse and trauma team should take what action? A) Perform a rapid physical assessment. B) Initiate health education. C) Perform diagnostic imaging. D) Establish the circumstances of the accident.

A Feedback: Once immediate threats to life have been corrected, a rapid physical examination is done to identify injuries and priorities of treatment. Health education is initiated later in the care process and diagnostic imaging would take place after a rapid physical assessment. It is not the care teams responsibility to determine the circumstances of the accident.

A patient with a history of major depression is brought to the ED by her parents. Which of the following nursing actions is most appropriate? A) Noting that symptoms of physical illness are not relevant to the current diagnosis B) Asking the patient if she has ever thought about taking her own life C) Conducting interviews in a brief and direct manner D) Arranging for the patient to spend time alone to consider her feelings

: B Feedback: Establishing if the patient has suicidal thoughts or intents helps identify the level of depression and intervention. Physical symptoms are relevant and should be explored. Allow the patient to express feelings, and conduct the interview at a comfortable pace for the patient. Never leave the patient alone, because suicide is usually committed in solitude.

A patient is admitted to the ED with suspected alcohol intoxication. The ED nurse is aware of the need to assess for conditions that can mimic acute alcohol intoxication. In light of this need, the nurse should perform what action? A) Check the patients blood glucose level. B) Assess for a documented history of major depression. C) Determine whether the patient has ingested a corrosive substance. D) Arrange for assessment of serum potassium levels.

A Feedback: Hypoglycemia can mimic alcohol intoxication and should be assessed in a patient suspected of alcohol intoxication. Potassium imbalances, depression, and poison ingestion are not noted to mimic the characteristic signs and symptoms of alcohol intoxication.

A hospitals emergency operations plan has been enacted following an industrial accident. While one nurse performs the initial triage, what should other emergency medical services personnel do? A. Perform life-saving measures. B. Classify patients according to acuity. C. Provide health promotion education. D. Modify the emergency operations plan.

A Feedback: In an emergency, patients are immediately tagged and transported or given life-saving interventions. One person performs the initial triage while other emergency medical services (EMS) personnel perform lifesaving measures and transport patients. Health promotion is not a priority during the acute stage of the crisis. Classifying patients is the task of the triage nurse. EMS personnel prioritize life-saving measures; they do not modify the operations plan.

Which patient should the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined below? A) A patient with a blunt chest trauma with some difficulty breathing B) A patient with a sore neck who was immobilized in the field on a backboard with a cervical collar C) A patient with a possible fractured tibia with adequate pedal pulses D) A patient with an acute onset of confusion

A Feedback: The patient with blunt chest trauma possibly has a compromised airway. Establishment and maintenance of a patent airway and adequate ventilation is prioritized over other health problems, including skeletal injuries and changes in cognition.

During the primary assessment of a patient with multiple trauma, the nurse observes that the patient's right pedal pulses are absent and the leg is swollen. The nurse's first action should be to a. initiate isotonic fluid infusion through two large-bore IV lines. b. send blood to the lab for a complete blood count (CBC). c. finish the airway, breathing, circulation, disability survey. d. assess further for a cause of the decreased circulation.

A Rationale: 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 CBC 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.

The triage nurse is working in the ED. A homeless person is admitted during a blizzard with complaints of being unable to feel his feet and lower legs. Core temperature is noted at 33.2C (91.8F). The patient is intoxicated with alcohol at the time of admission and is visibly malnourished. What is the triage nurses priority in the care of this patient? A) Addressing the patients hypothermia B) Addressing the patients frostbite in his lower extremities C) Addressing the patients alcohol intoxication D) Addressing the patients malnutrition

A Feedback: The patient may also have frostbite, but hypothermia takes precedence in treatment because it is systemic rather than localized. The alcohol abuse and the alteration in nutrition do not take precedence over the treatment of hypothermia because both problems are a less acute threat to the patients survival

The nurse is caring for a patient admitted with a drug overdose. What is the nurses priority responsibility in caring for this patient? A) Support the patients respiratory and cardiovascular function. B) Provide for the safety of the patient. C) Enhance clearance of the offending agent. D) Ensure the safety of the staff.

A Feedback: Treatment goals for a patient with a drug overdose are to support the respiratory and cardiovascular functions, to enhance clearance of the agent, and to provide for safety of the patient and staff. Of these responsibilities, however, support of vital physiologic function is a priority.

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

A The highest-priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he or she may not be breathing, or may be breathing inadequately with the device in place.

An emergency department (ED) nurse is preparing to transfer a client to the trauma intensive care unit. Which information should the nurse include in the nurse-to-nurse hand-off report? (SATA) a. Mechanism of injury b. Diagnostic test results c. Immunizations d. List of home medications e. Isolation precautions

A, B, E Hand-off communication should be comprehensive so that the receiving nurse can continue care for the client fluidly. Communication should be concise and should include only the most essential information for a safe transition in care. Hand-off communication should include the clients situation (reason for being in the ED), brief medical history, assessment and diagnostic findings, Transmission-Based Precautions needed, interventions provided, and response to those interventions.

The complex care provided during an emergency requires interdisciplinary collaboration. Which interdisciplinary team members are paired with the correct responsibilities? (SATA) a. Psychiatric crisis nurse Interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis b. Forensic nurse examiner Performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources c. Triage nurse Provides basic life support interventions such as oxygen, basic wound care, splinting, spinal immobilization, and monitoring of vital signs d. Emergency medical technician Obtains client histories, collects evidence, and offers counseling and follow-up care for victims of rape, child abuse, and domestic violence e. Paramedic Provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration

A, E The psychiatric crisis nurse evaluates clients with emotional behaviors or mental illness and facilitates follow-up treatment plans. The psychiatric crisis nurse also works with clients and families when experiencing a crisis. Paramedics are advanced life support providers who can perform advanced techniques that may include cardiac monitoring, advanced airway management and intubation, establishing IV access, and administering drugs en route to the emergency department. The forensic nurse examiner is trained to recognize evidence of abuse and to intervene on the clients behalf. The forensic nurse examiner will obtain client histories, collect evidence, and offer counseling and follow-up care for victims of rape, child abuse, and domestic violence. The triage nurse performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources. The emergency medical technician is usually the first caregiver and provides basic life support and transportation to the emergency department.

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-yr-old patient with palpitations and chest pain b. A 43-yr-old patient complaining of 7/10 abdominal pain c. A 21-yr-old patient with multiple fractures of the face and jaw d. A 37-yr-old patient with a misaligned lower left leg with intact pulses

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

Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires immediate action by the nurse? a. Only continuous IV opioids have been ordered. b. The patient does not respond to verbal stimulation. c. There is no cough or gag when the patient is suctioned. d. The patient's oxygen saturation fluctuates between 90% to 93%.

ANS: A Because neuromuscular blockade is extremely anxiety provoking, it is essential that patients who are receiving neuromuscular blockade receive concurrent sedation and analgesia. Absence of response to stimuli is expected in patients receiving neuromuscular blockade. The oxygen saturation is adequate.

While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen saturation (SpO2) from 94% to 88%. Which action should the nurse take next? a. Increase the oxygen flow rate. b. Suction the patient's oropharynx. c. Instruct the patient to cough and deep breathe. d. Help the patient to sit in a more upright position.

ANS: A Increasing oxygen flow rate will usually improve oxygen saturation in patients with ventilation-perfusion mismatch, as occurs with pulmonary embolism. Because the problem is with perfusion, actions that improve ventilation, such as deep breathing and coughing, sitting upright, and suctioning, are not likely to improve oxygenation.

12. A patient arrives in the emergency department (ED) several hours after taking "25 to 30" acetaminophen (Tylenol) tablets. Which action will the nurse plan to take? a. Give N-acetylcysteine. b. Discuss the use of chelation therapy. c. Start oxygen using a non-rebreather mask. d. Have the patient drink large amounts of water.

ANS: A N-acetylcysteine is the recommended treatment to prevent liver damage after acetaminophen overdose. The other actions might be used for other types of poisoning, but they will not be appropriate for a patient with acetaminophen poisoning.

A nurse is caring for an obese patient with right lower lobe pneumonia. Which position will be best to improve gas exchange? a. On the left side b. On the right side c. In the tripod position d. In the high-Fowler's position

ANS: A The patient should be positioned with the "good" lung in the dependent position to improve the match between ventilation and perfusion. The obese patient's abdomen will limit respiratory excursion when sitting in the high-Fowler's or tripod positions.

DELTE13. 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 be 1 to 2 hours before seeing a health care provider.

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.

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 be 1 to 2 hours before seeing a health care provider.

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. DIF: Cognitive Level: Analyze (analysis)

The nurse reviews the electronic medical record for a patient scheduled for a total hip replacement. Which assessment data shown in the accompanying figure increase the patient's risk for respiratory complications after surgery? a. Albumin level and recent weight loss b. Mild confusion and recent weight loss c. Age and recent arthroscopic procedure. d. Anemia and recent arthroscopic procedure

ANS: A The patient's recent weight loss and low protein stores indicate possible muscle weakness, which make it more difficult for an older patient to recover from the effects of general anesthesia and immobility associated with the hip surgery. The other information will also be noted by the nurse but does not place the patient at higher risk for respiratory failure.

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 b. Heart rhythm c. Breath sounds d. Body temperature

ANS: A 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. DIF: Cognitive Level: Apply (application)

20. Following an earthquake, patients are triaged by emergency medical personnel and 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.

3. 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. Initiate cooling per protocol. b. Avoid the use of sedative drugs. c. Check mental status every 15 minutes. d. Rewarm if temperature is below 91° F (32.8° C).

ANS: A When therapeutic hypothermia is used postresuscitation, 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 done at this stage. Sedative drugs are given during therapeutic hypothermia.

1. During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient 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 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.

During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient 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 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. DIF: Cognitive Level: Apply (application)

6. 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 intraabdominal 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 the diagnosis of intraabdominal bleeding.

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 prescribed 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 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. DIF: Cognitive Level: Analyze (analysis)

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 The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the secondary survey. DIF: Cognitive Level: Apply (application)

The oxygen saturation (SpO2) for a patient with left lower lobe pneumonia is 90%. The patient has rhonchi, a weak cough effort, and complains of fatigue. Which action is a priority for the nurse to take? a. Position the patient on the left side. b. Assist the patient with staged coughing. c. Place a humidifier in the patient's room. d. Schedule a 2-hour rest period for the patient.

ANS: B The patient's assessment indicates that assisted coughing is needed to help remove secretions, which will improve oxygenation. A 2-hour rest period at this time may allow the oxygen saturation to drop further. Humidification will not be helpful unless the secretions can be mobilized. Positioning on the left side may cause a further decrease in oxygen saturation because perfusion will be directed more toward the more poorly ventilated lung.

A patient with respiratory failure has a respiratory rate of 6 breaths/minute and an oxygen saturation (SpO2) of 88%. The patient is increasingly lethargic. Which intervention will the nurse anticipate? a. Administration of 100% oxygen by non-rebreather mask b. Endotracheal intubation and positive pressure ventilation c. Insertion of a mini-tracheostomy with frequent suctioning d. Initiation of continuous positive pressure ventilation (CPAP)

ANS: B The patient's lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation with ventilator-controlled respiratory rate. Administration of high flow oxygen will not be helpful because the patient's respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate removal of secretions, but it will not improve the patient's respiratory rate or oxygenation. CPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange.

A 22-yr-old patient who experienced a 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. c. Auscultate breath sounds. b. Palpate peripheral pulses. d. Check mental orientation.

ANS: C Because pulmonary edema is a common complication after 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. DIF: Cognitive Level: Analyze (analysis)

The emergency department (ED) nurse is starting 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. Assess neurologic status every 2 hours. c. Give acetaminophen (Tylenol) 650 mg. d. Place cooling blankets above and below patient. e. Attach rectal temperature probe 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. DIF: Cognitive Level: Apply (application)

5. A 19-yr-old patient 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 For an adult with no previous tetanus immunizations, TIG and Tdap are recommended. The other immunizations are not sufficient for this patient.

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 movement

ANS: D Most immediate deaths from trauma occur because of problems with 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. DIF: Cognitive Level: Analyze (analysis)

A patient is brought to the hospital in cardiac arrest by emergency personnel who are performing resuscitation. The spouse arrives as the patient is taken into a treatment room and asks to stay with the patient. The nurse should a. have the spouse wait outside the treatment room with a designated staff member to provide emotional support. b. bring the spouse into the room and ensure him or her that a member of the team will explain the care given and answer questions. c. explain that the presence of family members is distracting to staff and might impair the resuscitation efforts. d. advise the spouse that if the resuscitation effort is unsuccessful, the memories may have an adverse impact on grieving.

B Rationale: Family members and patients report benefits from family presence during resuscitation efforts, so the nurse should try to accommodate the spouse. Having the spouse wait outside the room is not as supportive to the spouse or patient. It would be inappropriate to imply that the spouse's presence would have adverse consequences for the patient. Family members do not report problems with grieving caused by being present during resuscitation efforts.

A patient has experienced blunt abdominal trauma from a motor vehicle accident. The nurse should explain to the patient the purpose of a. magnetic resonance imaging (MRI). b. ultrasonography. c. peritoneal lavage. d. nasogastric (NG) tube placement.

B Rationale: If intra-abdominal bleeding is suspected, focused abdominal ultrasonography is obtained to look for intraperitoneal bleeding. 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.

A patient has been brought to the emergency department with a gunshot wound to the abdomen. In obtaining a history of the incident to determine possible injuries, the nurse asks a. "Where did the incident occur?" b. "What direction did the bullet enter the body?" c. "How long ago did the incident happen?" d. "What emergency care was started at the scene?"

B Rationale: The entry point and direction of the bullet will help to predict the type of injuries the patient has. The other information is not as useful in determining which diagnostic studies and care are needed immediately.

When caring for a patient with head and neck trauma after a motorcycle accident, the emergency department nurse's first action should be to a. suction the mouth and oropharynx. b. immobilize the cervical spine. c. administer supplemental oxygen. d. obtain venous access.

B Rationale: When there is a risk of spinal cord injury, the nurse's initial action is immobilization of the cervical spine during positioning of the head and neck for airway management. Suctioning, supplemental oxygen administration, and venous access are also necessary after the cervical spine is protected by immobilization.

A 13-year-old is being admitted to the ED after falling from a roof and sustaining blunt abdominal injuries. To assess for internal injury in the patients peritoneum, the nurse should anticipate what diagnostic test? A) Radiograph B) Computed tomography (CT) scan C) Complete blood count (CBC) D) Barium swallow

B Feedback: CT scan of the abdomen, diagnostic peritoneal lavage, and abdominal ultrasound are appropriate diagnostic tools to assess intra-abdominal injuries. X-rays do not yield sufficient data and a CBC would not reveal the presence of intraperitoneal injury.

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

B Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions should be taken in all resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers.

The emergency department team is performing cardiopulmonary resuscitation on a client when the client's spouse arrives at the emergency department. Which action should the nurse take first? a. Request that the client's spouse sit in the waiting room. b. Ask the spouse if he wishes to be present during the resuscitation. c. Suggest that the spouse begin to pray for the client. d. Refer the client's spouse to the hospitals crisis team.

B If resuscitation efforts are still under way when the family arrives, one or two family members may be given the opportunity to be present during lifesaving procedures. The other options do not give the spouse the opportunity to be present for the client or to begin to have closure.

A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center? a. Level I Located within remote areas and provides advanced life support within resource capabilities b. Level II Located within community hospitals and provides care to most injured clients c. Level III Located in rural communities and provides only basic care to clients d. Level IV Located in large teaching hospitals and provides a full continuum of trauma care for all clients

B Level I trauma centers are usually located in large teaching hospital systems and provide a full continuum of trauma care for all clients. Both Level II and Level III facilities are usually located in community hospitals. These trauma centers provide care for most clients and transport to Level I centers when client needs exceed resource capabilities. Level IV trauma centers are usually located in rural and remote areas. These centers provide basic care, stabilization, and advanced life support while transfer arrangements to higher-level trauma centers are made.

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

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

A nurse is caring for clients in a busy emergency department. Which actions should the nurse take to ensure client and staff safety? (SATA) a. Leave the stretcher in the lowest position with rails down so that the client can access the bathroom. b. Use two identifiers before each intervention and before mediation administration. c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors. d. Search the belongings of clients with altered mental status to gain essential medical information. e. Isolate clients who have immune suppression disorders to prevent hospital-acquired infections.c

B, C, D To ensure client and staff safety, nurses should use two identifiers per The Joint Commissions National Patient Safety Goals; follow the hospitals security plan, including de-escalation strategies for people who demonstrate aggressive or violent tendencies; and search belongings to identify essential medical information. Nurses should also use standard fall prevention interventions, including leaving stretchers in the lowest position with rails up, and isolating clients who present with signs and symptoms of contagious infectious disorders.

An emergency room nurse is caring for a trauma client. Which interventions should the nurse perform during the primary survey? (SATA) a. Foley catheterization b. Needle decompression c. Initiating IV fluids d. Splinting open fractures e. Endotracheal intubation f. Removing wet clothing g. Laceration repair

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

A patient is brought to the ED by friends. The friends tell the nurse that the patient was using cocaine at a party. On arrival to the ED the patient is in visible distress with an axillary temperature of 40.1C (104.2F). What would be the priority nursing action for this patient? A) Monitor cardiovascular effects. B) Administer antipyretics. C) Ensure airway and ventilation. D) Prevent seizure activity.

C Feedback: Although all of the listed actions may be necessary for this patients care, the priority is to establish a patent airway and adequate ventilation.

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

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

A patient who has been exposed to anthrax is being treated in the local hospital. The nurse should prioritize what health assessments? A. Integumentary assessment B. Assessment for signs of hemorrhage C. Neurologic assessment D. Assessment of respiratory status

D Feedback: The second stage of anthrax infection by inhalation includes severe respiratory distress, including stridor, cyanosis, hypoxia, diaphoresis, hypotension, and shock. The first stage includes flu-like symptoms. The second stage of infection by inhalation does not include headache, vomiting, or syncope.

A patient is brought to the ER in an unconscious state. The physician notes that the patient is in need of emergency surgery. No family members are present, and the patient does not have identification. What action by the nurse is most important regarding consent for treatment? A) Ask the social worker to come and sign the consent. B) Contact the police to obtain the patients identity. C) Obtain a court order to treat the patient. D) Clearly document LOC and health status on the patients chart.

D Feedback: When patients are unconscious and in critical condition, the condition and situation should be documented to administer treatment quickly and timely when no consent can be obtained by usual routes. A social worker is not asked to sign the consent. Finding the patients identity is not a priority. Obtaining a court order would take too long.

An emergency department nurse is caring for a client who has died from a suspected homicide. Which action should the nurse take? a. Remove all tubes and wires in preparation for the medical examiner. b. Limit the number of visitors to minimize the family's trauma. c. Consult the bereavement committee to follow up with the grieving family. d. Communicate the client's death to the family in a simple and concrete manner.

D When dealing with client's and families in crisis, communicate in a simple and concrete manner to minimize confusion. Tubes must remain in place for the medical examiner. Family should be allowed to view the body. Offering to call for additional family support during the crisis is suggested. The bereavement committee should be consulted, but this is not the priority at this time.

A nurse prepares to discharge an older adult client home from the emergency department (ED). Which actions should the nurse take to prevent future ED visits? (SATA) a. Provide medical supplies to the family. b. Consult a home health agency. c. Encourage participation in community activities. d. Screen for depression and suicide. e. Complete a functional assessment.

D, E Due to the high rate of suicide among older adults, a nurse should assess all older adults for depression and suicide. The nurse should also screen older adults for functional assessment, cognitive assessment, and risk for falls to prevent future ED visits.