Community Health Diaster Nursing Prioritization
ABCDEFGHI
A Airway B Breathing C Circulation D Disability (neurologic status) E Expose (remove clothing, keep the patient warm) F Full set of vital signs G Give comfort measures H History/Head-to-Toe assessment I Inspect posterior surfaces
A patient arrives at the emergency department after being bitten by a poisonous snake. Initially, the nurse will plan to a. start a large-bore IV line. b. administer analgesics. c. draw blood for laboratory testing. d. administer tetanus prophylaxis.
Correct Answer: A Rationale: Because hypovolemic shock and hemolysis can occur with snakebite, it is important to be able to administer large amounts of IV fluids rapidly. Analgesic administration, drawing blood, and administration of tetanus prophylaxis can be accomplished later. Cognitive Level: Application Text Reference: p. 1836 Nursing Process: Implementation NCLEX: Physiological Integrity
When preparing to rewarm a patient with hypothermia, the nurse will plan to a. attach a cardiac monitor. b. insert a urinary catheter. c. assist with endotracheal intubation. d. keep inotropic drugs available.
Correct Answer: A Rationale: Rewarming can produce dysrhythmias, so the patient should be monitored and treated if necessary. Urinary catheterization and endotracheal intubation are not needed for rewarming. Cardiac inotropes tend to stimulate the heart and increase the risk for fatal dysrhythmias such as ventricular fibrillation. Cognitive Level: Application Text Reference: pp. 1831-1832 Nursing Process: Planning NCLEX: Physiological Integrity
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.
Correct Answer: 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. Cognitive Level: Application Text Reference: pp. 1822-1824 Nursing Process: Implementation NCLEX: Physiological Integrity
A 67-year-old patient who has fallen from a ladder is transported to the emergency department by ambulance. The patient is unconscious on arrival and accompanied by family members. During the primary survey of the patient, the nurse should a. assess the patient's vital signs. b. obtain a Glasgow Coma Scale score. c. attach a cardiac ECG monitor. d. ask about chronic medical conditions.
Correct Answer: B Rationale: The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the secondary survey. Cognitive Level: Application Text Reference: p. 1824 Nursing Process: Assessment NCLEX: Physiological Integrity
A 77-year-old patient is brought into the emergency department unconscious and with a core temperature of 89° F (31.6° C). During rewarming measures, the nurse determines that the goals of treatment are being met when the patient a. has a core temperature of 95° F (35° C). b. shivers involuntarily to raise body temperature. c. regains consciousness. d. has a blood pH within normal limits.
Correct Answer: A Rationale: The improvement in the patient's body temperature is the best indication that the goals of rewarming are being met. Shivering, improvement in level of consciousness (LOC), and normalization of pH all might confirm that the patient's condition is improving, but they are not as clear as the elevation in temperature. Cognitive Level: Application Text Reference: p. 1831 Nursing Process: Evaluation NCLEX: Physiological
A patient arrives in the emergency department after exposure to radioactive dust. Which action should the nurse take first? a. Place the patient in a shower. b. Obtain the patient's vital signs. c. Determine the type of radioactive agent. d. Obtain a baseline complete blood count.
Correct Answer: A Rationale: The initial action should be to protect staff members and decrease the patient's exposure to the radioactive agent by decontamination. The other actions can be accomplished after the decontamination is completed. Cognitive Level: Application Text Reference: p. 1840 Nursing Process: Implementation NCLEX: Physiological Integrity
A patient is admitted to the emergency department with multiple bruises of the face and arms and an obvious deformity of the right upper arm. A friend accompanying the patient tells the nurse that the patient's spouse was responsible for the injuries. The nurse's role in this patient's care is a. to inform the patient of safe houses and other options. b. to encourage the friend to have the patient report the abuse. c. to notify the local law enforcement agency. d. limited to the treatment of the patient's injuries.
Correct Answer: A Rationale: The nurse's role includes informing victims of domestic violence about options and safe housing. The nurse should speak directly to the patient about the option of reporting the abuse to the police (after further assessment of the patient). A competent adult patient is responsible for reporting abuse to the police. The nurse is responsible for assessing for domestic violence and making appropriate referrals in addition to providing care for the physical injuries. Cognitive Level: Comprehension Text Reference: p. 1838 Nursing Process: Implementation NCLEX: Physiological Integrity
An unresponsive 78-year-old patient is admitted to the emergency department in a coma during a summer heat wave. The patient's core temperature is 106.2° F (41.2° C), blood pressure (BP) 86/52, and pulse 102. The nurse will plan to a. apply wet sheets and a fan to the patient. b. administer an acetaminophen (Tylenol) suppository. c. start O2 at 6 L/min with a nasal cannula. d. infuse lactated Ringer's solution at 1000 ml/hr.
Correct Answer: A Rationale: 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-rebreathing mask. An older patient would be at risk for developing complications such as pulmonary edema if given fluids at 1000 ml/hr. Cognitive Level: Application Text Reference: pp. 1829-1830 Nursing Process: Planning NCLEX: Physiological Integrity
These four patients arrive in the emergency department after a motor-vehicle crash. In which order should they been assessed? a. A 22-year-old with fractures of the face and jaw b. A 30-year-old with a misaligned right leg c. A 45-year-old complaining of 6/10 abdominal pain d. A 72-year-old with palpitations and chest pain
Correct Answer: A, D, C, B Rationale: The highest priority is to assess the 22-year-old patient for airway obstruction, which is the most life-threatening injury. The 72-year-old patient may have chest pain from cardiac ischemia and should be assessed and have diagnostic testing for this pains. The 45-year-old patient may have abdominal trauma or bleeding and should be seen next to assess circulatory status. The 30-year-old appears to have a possible fracture of the right leg and should be seen soon, but this patient has the least life-threatening injury Cognitive Level: Application Text Reference: pp. 1822-1825 Nursing Process: Assessment NCLEX: Physiological Integrity .
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.
Correct Answer: 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. Cognitive Level: Application Text Reference: pp. 1825-1826 Nursing Process: Implementation NCLEX: Psychosocial Integrity
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.
Correct Answer: 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. Cognitive Level: Application Text Reference: p. 1827 Nursing Process: Planning NCLEX: Physiological Integrity
A patient is admitted to the emergency department after a near-drowning accident in a local lake. The patient received rescue breathing at the site and now has spontaneous respirations. The nurse will observe the patient for several hours to monitor for symptoms of a. hypernatremia. b. pulmonary edema. c. hypothermia. d. head injury.
Correct Answer: B Rationale: Pulmonary edema is a common complication after a near-drowning incident. Hypernatremia would not occur in a freshwater submersion. Hypothermia and head injury may be associated with near-drowning but would be apparent at the time of admission and would not develop after several hours. Cognitive Level: Application Text Reference: p. 1832 Nursing Process: Implementation NCLEX: Physiological Integrity
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?"
Correct Answer: 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. Cognitive Level: Application Text Reference: pp. 1825-1826 Nursing Process: Assessment NCLEX: Physiological Integrity
A triage nurse in a busy emergency department assesses a patient who complains of 6/10 abdominal pain and states, "I had a temperature of 104.6º F (40.3º C) at home." The nurse's first action should be to a. tell the patient that it may be several hours before being seen by the doctor. b. assess the patient's current vital signs. c. obtain a clean-catch urine for urinalysis. d. ask the health care provider to order a nonopioid analgesic medication for the patient.
Correct Answer: B Rationale: 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 needed, but vital signs will provide the nurse with more useful data for triage. The health care provider will not order a medication before assessing the patient. Cognitive Level: Application Text Reference: pp. 1822-1823 Nursing Process: Assessment NCLEX: Physiological Integrity
When a patient is admitted to the emergency department after a submersion injury, which assessment will the nurse obtain first? a. Lung sounds b. Oxygen saturation c. Body temperature d. Apical pulse
Correct Answer: B Rationale: The priority assessment data are how well the patient is oxygenating, so O2 saturation should be obtained first because this measure gives the most direct information. The other data will also be collected rapidly but are not as essential as the O2 saturation. Cognitive Level: Application Text Reference: pp. 1832-1833 Nursing Process: Assessment NCLEX: Physiological Integrity
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.
Correct Answer: 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. Cognitive Level: Application Text Reference: p. 1823 Nursing Process: Implementation NCLEX: Physiological Integrity
When rewarming a patient who arrived in the emergency department with a temperature of 87° F, which assessment indicates that rewarming should be stopped? a. The patient develops atrial fibrillation. b. The BP decreases to 85/40 mm Hg. c. The core temperature is 95.2° F. d. The axillary temperature reaches 96° F.
Correct Answer: C Rationale: A core temperature of 95° F is an indication that sufficient rewarming has occurred. Dysrhythmias and hypotension may occur during rewarming and should be treated but are not an indication to stop rewarming the patient. The patient's core temperature, rather than the axillary temperature, is used to determine the success of rewarming procedures. Cognitive Level: Application Text Reference: p. 1831 Nursing Process: Assessment NCLEX: Physiological Integrity
An unconscious patient is admitted to the emergency department 45 minutes after ingesting approximately 30 diazepam (Valium) tablets. The health care provider prescribes gastric lavage. The first action the nurse will plan when implementing the order is to a. position the patient on his or her side. b. insert a large-bore nasogastric tube. c. assist the health care provider to intubate the patient. d. prepare a 60-ml syringe with saline.
Correct Answer: C Rationale: An unconscious patient cannot protect the airway and is at risk for aspiration during gastric lavage, so intubation is done before starting the lavage. Positioning the patient on his or her side will decrease the risk for aspiration, but the patient will need to be supine for intubation. An orogastric tube is used for gastric lavage. The saline will be injected after the intubation. Cognitive Level: Application Text Reference: p. 1837 Nursing Process: Planning NCLEX: Safe and Effective Care Environment
During the summer, a patient with heat cramps is treated in the emergency department. The nurse determines that discharge teaching regarding the prevention of another episode of heat cramps has been effective when the patient states, a. "I will take salt tablets when I work outdoors in the summer." b. "I should double my water intake when the weather gets warm." c. "I should have sports drinks when exercising outside in hot weather." d. "I will get into a cool environment if I notice that I am feeling confused."
Correct Answer: C Rationale: 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. It is not necessary to double one's water intake simply when the weather is warm. A patient who is confused is likely to have more severe hyperthermia and will be unable to remember to take appropriate action. Cognitive Level: Application Text Reference: pp. 1829-1830 Nursing Process: Evaluation NCLEX: Physiological Integrity
During the primary assessment of a trauma victim, the nurse determines that the patient has a patent airway. The next assessment by the nurse should be to a. check the patient's level of consciousness. b. examine the patient for any external bleeding. c. observe the patient's respiratory effort. d. palpate for the presence of peripheral pulses.
Correct Answer: C Rationale: 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 are not accomplished as rapidly as the assessment of breathing. Cognitive Level: Application Text Reference: p. 1823 Nursing Process: Assessment NCLEX: Physiological Integrity
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.
Correct Answer: 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. Cognitive Level: Application Text Reference: p. 1828 Nursing Process: Planning NCLEX: Health Promotion and Maintenance
Four victims of an automobile crash are brought by ambulance to the emergency department (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.
Correct Answer: 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. Cognitive Level: Application Text Reference: p. 1823 Nursing Process: Assessment NCLEX: Physiological Integrity
When planning the response to the potential use of smallpox as a biologic weapon, the emergency department manager will focus on obtaining sufficient quantities of a. blood. b. antibiotics. c. vaccine. d. antitoxin.
Correct Answer: C Rationale: Smallpox infection can be prevented or ameliorated by the administration of vaccine given rapidly after exposure. The other interventions would be helpful for other biologic weapons, but not for smallpox. Cognitive Level: Comprehension Text Reference: pp. 1838-1839 Nursing Process: Planning NCLEX: Physiological Integrity
When assessing a patient admitted to the emergency department with a broken arm and facial bruises, the nurse notes multiple additional bruises in various stages of healing. Which statement or question by the nurse is most appropriate? a. "You should not return to your home." b. "I have to report this abuse to the police." c. "Would you like to see a social worker?" d. "Is someone at home hurting you?"
Correct Answer: D Rationale: The nurse's initial response should be to further assess the patient's situation. Telling the patient not to return home may be an option once further assessment is done. The patient, not the nurse, is responsible for reporting the abuse. A social worker may be appropriate once further assessment is completed. Cognitive Level: Application Text Reference: p. 1838 Nursing Process: Implementation NCLEX: Physiological Integrity
All of the following actions are needed for a patient admitted with multiple bee stings to the hands. Which one will the nurse accomplish first? a. Give diphenhydramine (Benadryl) 100 mg po. b. Apply calamine lotion to any itching areas. c. Place ice packs on both hands. d. Remove the patient's rings.
Correct Answer: D Rationale: The patient's rings should be removed first because it might not be possible to remove them if swelling develops. The other orders should also be implemented as rapidly as possible after the nurse has removed the jewelry. Cognitive Level: Application Text Reference: p. 1834 Nursing Process: Implementation NCLEX: Physiological Integrity