emergency nursing

A patient who has deep human bite wounds on the left hand is being treated in the urgent care center. Which action will the nurse plan to take?

Teach the patient the reason for the use of prophylactic antibiotics.

A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center?

Level II—located within community hospitals and provides care to most injured clients

An elderly client who has fallen from a roof is transported to the emergency department by ambulance. The client was unconscious at the scene but is conscious on arrival and is triaged as urgent. What is the priority assessment the nurse includes during the primary survey of the patient?

Neurologic status

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?

Observe the patient's respiratory effort.

A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. What should the nurse do during the primary survey of the patient?

Check a Glasgow Coma Scale score.

A nurse is triaging clients in the emergency department (ED). Which client would the nurse prioritize to receive care first?

A 45 year old reporting chest pain and diaphoresis

A nurse is triaging clients in the emergency department. Which client would the nurse classify as "nonurgent?"

A 62 year old with a simple fracture of the left arm

A nurse is triaging clients in the emergency department. Which client would be considered "urgent"?

A 75-year-old female with a cough and a temperature of 102° F (38.9° C)

On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, and blood pressure 106/66 mm Hg. What action would the nurse take?

Start an intravenous line and infuse 0.9% saline solution.

A client presents to the emergency department after prolonged exposure to the cold. The client is difficult to arouse and speech is incoherent. What action would the nurse take first?

Administer warmed intravenous fluids to the client.

What is the primary goal of a triage system used by the nurse with clients presenting to the emergency department?

Determine the acuity of the client's condition to determine priority of care.

During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next?

Start normal saline fluid infusion with a large-bore IV line.

Which finding indicates that the nurse should discontinue active rewarming of a patient admitted with hypothermia?

The core temperature is 94° F (34.4° C).

When assessing an older patient admitted to the emergency department (ED) with a broken arm and facial bruises, the nurse observes several additional bruises in various stages of healing. Which statement or question by the nurse should be first?

"Do you feel safe at home?"

A nurse teaches a community health class about water safety. Which statement by a participant indicates that additional teaching is needed?

"I can go swimming all by myself because I am a certified lifeguard."

A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). Which patient statement indicates to the nurse that discharge teaching has been effective?

"I need to drink extra fluids when working outside in hot weather."

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. What should the nurse anticipate giving?

TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap)

An emergency department (ED) case manager is consulted for a client who is homeless. Which intervention would the case manager provide?

Provide referrals to subsidized community-based health clinics.

Which interventions will the nurse plan for a comatose patient who will have targeted temperature management/therapeutic hypothermia? (Select all that apply.)

-Assist with endotracheal intubation. -Insert an indwelling urinary catheter. -Begin continuous cardiac monitoring.

An emergency department nurse is triaging victims of a multi-casualty event. Which client would receive care first?

A 26-year-old male who has pale, cool, clammy skin

An emergency department nurse is caring for a client who has died from a suspected homicide. Which action does the nurse take?

Communicate the client's death to the family in a simple and concrete manner.

A primary health care provider prescribes diazepam to a client who was bitten by a black widow spider. The client asks, "What is this medication for?" How does the nurse respond?

· "It will relieve your muscle rigidity and spasms."

The nurse is teaching participants in a family-oriented community center ways to prevent their older relatives and friends from getting heat-related illnesses. What information does the nurse include? (Select all that apply.)

· Take cool baths or showers after outdoor activities. · Check on the older adult daily in hot weather. · Drink plenty of liquids throughout the day.

A nurse plans care for a client admitted with a snakebite to the right leg. With whom would the nurse collaborate?

· The poison control center

A nurse is caring for clients in a busy emergency department. What actions would the nurse take to ensure client and staff safety? (Select all that apply.)

· Use two identifiers before each intervention and before mediation administration. · Attempt de-escalation strategies for clients who demonstrate aggressive behaviors. · Search the belongings of clients with altered mental status to gain essential medical information. · Use facility policy identification procedures for "Jane/John Doe" clients. · Check clients for a medical alert bracelets or necklaces.

An emergency department nurse is caring for a client who is homeless. Which action would the nurse take to gain the client's trust?

Listen to the client's concerns and needs.

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?

Pulse

A nurse teaches a client who has severe allergies ways to prevent insect bites. Which statements does the nurse include in this client's teaching? (Select all that apply.)

· "Consult an exterminator to control bugs in and around your home." · "Do not swat at insects or wasps." · "Use screens in your windows and doors to prevent flying insects from entering." · "Identify and remove potential nesting sites in your yard."

After teaching a client how to prevent altitude-related illnesses, a nurse assesses the client's understanding. Which statement indicates that the client needs additional teaching?

· "My partner and I will plan to sleep at a higher elevation to acclimate more quickly."

A nurse is teaching a wilderness survival class. Which statements would the nurse include about the prevention of hypothermia and frostbite? (Select all that apply.)

· "Wear synthetic clothing instead of cotton to keep your skin dry." · Wear sunglasses to protect skin and eyes from harmful rays." · "Know your physical limits. Come in out of the cold when limits are reached." · "Change your gloves and socks if they become wet."

A middle-age mountain hiker is admitted to the emergency department exhibiting a cough with pink, frothy sputum and cyanosis of lips and nail beds. What priority action would the nurse implement?

· Administer oxygen via a nonrebreather mask.

An emergency department nurse plans care for a client who is admitted with heat stroke. Which interventions does the nurse include in this patient's plan of care? (Select all that apply.)

· Administer oxygen via mask or nasal cannula. · Infuse 0.9% sodium chloride via a large-bore intravenous cannula. · Obtain baseline serum electrolytes and cardiac enzymes.

A provider prescribes Crotalidae Polyvalent Immune Fab (CroFab) for a client who is admitted after being bitten by a pit viper snake. Which assessment should the nurse complete prior to administering this medication?

· Ask about allergies to pineapple or papaya.

A client resuscitated after drowning is admitted to the emergency department. What assessment findings does the nurse recognize as symptoms of a drowning? (Select all that apply.)

· Bilateral crackles · Bradycardia · Cyanosis of the lips · Hypotension

A client admitted to the emergency department following a lightning strike. What is the priority assessment the nurse focuses on?

· Cardiopulmonary

A nurse assesses a client recently bitten by a coral snake. Which assessment would the nurse complete first?

· Cardiopulmonary status

Which assessment findings would indicate to the nurse that a client has suffered from a heat stroke? (Select all that apply.)

· Confusion and bizarre behavior · Hypotension · Tachycardia and tachypnea · Body temperature more than 104° F (40° C)

An emergency department nurse is caring for a client who had been hiking in the mountains for the past 2 days. What are the most important indicators that a client is experiencing high-altitude pulmonary edema (HAPE)? (Select all that apply.)

· Crackles in both lung fields · Persistent dry cough

While on a camping trip, a nurse cares for an adult client who had a drowning incident in a lake and is experiencing agonal breathing with a palpable pulse. What action would the nurse take first?

· Deliver rescue breaths.

A nurse is in charge of a first-aid tent at an all-day outdoor sports event on a hot and humid day. A participant comes to the tent reporting a headache, weakness, and nausea. What actions would the nurse take? (Select all that apply.)

· Have the client lie down in a cool place. · Apply cold packs to neck, arm pits, and groin. · Encourage drinking a sports drink.

An emergency department nurse moves to a new city where heat-related illnesses are common. Which clients does the nurse anticipate being at highest risk for heat-related illnesses? (Select all that apply.)

· Homeless individuals · People with substance abuse disorders · Older adults · Obese individuals

An emergency department (ED) nurse is preparing to transfer a client to the trauma intensive care unit. Which information would the nurse include in the nurse-to-nurse hand-off report? (Select all that apply.)

· Mechanism of injury · Diagnostic test results · Isolation Precautions · Safety concerns

A nurse assesses a client admitted with a brown recluse spider bite. Which assessment does the nurse perform to identify complications of this bite?

· Monitor the client's temperature every 4 hours.

An emergency department nurse is caring for a trauma patient. Which interventions does the nurse perform during the primary survey? (Select all that apply.)

· Needle decompression · Initiating IV fluids · Endotracheal intubation · Removing wet clothing

The complex care provided during an emergency requires interprofessional collaboration. Which team members are paired with the correct responsibilities? (Select all that apply.)

· Psychiatric crisis nurse—interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis · Paramedic—provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration

A nurse prepares to discharge an older adult client home from the emergency department (ED). What actions does the nurse take to prevent future ED visits? (Select all that apply.)

· Screen for depression and suicide. · Complete a functional assessment.

The emergency department (ED) nurse is starting targeted temperature management/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/VN)? (Select all that apply.)

-Insert a urinary catheter to drainage. -Place cooling blankets above and below patient. -Attach rectal temperature probe to cooling blanket control panel.

A nurse is providing health education at a community center. Which instructions does the nurse include in teaching about prevention of lightning injuries during a storm? (Select all that apply.)

· Seek shelter inside a building or vehicle. ·Do not take a bath or shower. ·Turn off the television. ·Put down golf clubs or gardening tools.

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 patient with a red tag 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.

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 patient with paradoxical chest motion 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.

After the return of spontaneous circulation following the resuscitation of a patient who had a cardiac arrest, therapeutic hypothermia is prescribed. Which action will the nurse include in the plan of care?

Initiate cooling per protocol.

A primary health care provider prescribes a rewarming bath for a client who presents with Grade 3 frostbite. What action would the nurse take prior to starting this treatment?

Administer intravenous morphine.

A patient who has experienced blunt abdominal trauma during a motor vehicle collision reports increasing abdominal pain. What topic will the nurse plan to teach the patient?

Abdominal ultrasonography

While at a public park, a nurse encounters a person immediately after a bee sting. The person's lips are swollen, and wheezes are audible. What action would the nurse take first?

Administer an epinephrine autoinjector and call 911.

An emergency department nurse cares for a middle-age mountain climber who is confused, ataxic, and exhibits impaired judgement. After administering oxygen, which intervention would the nurse implement next?

Administer dexamethasone.

The emergency department team is performing cardiopulmonary resuscitation on a client when the client's spouse arrives. Which action would the nurse take first?

Ask the spouse if he or she wishes to be present during the resuscitation.

Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action would the nurse take first?

Assess that the client is breathing adequately.

An unresponsive 79-yr-old patient is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 105.4° F (40.8° C), blood pressure (BP) is 88/50 mm Hg, and pulse is 112 beats/min. What action should the nurse plan to take?

Apply wet sheets and a fan to the patient.

Family members are in the patient's room when the patient has a cardiac arrest and the staff start resuscitation measures. Which action should the nurse take next?

Ask the family members whether they would prefer to remain in the patient's room or wait outside the room.

A triage nurse in a busy emergency department (ED) assesses a patient who reports 7/10 abdominal pain and states, "I had a temperature of 103.9° F (39.9° C) at home." What should be the nurse's first action?

Assess the patient's current vital signs.

Gastric lavage and administration of activated charcoal are prescribed 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?

Assist with intubation of the patient. In an unresponsive patient, intubation is done before gastric lavage and activated charcoal administration to prevent aspiration

The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?

Attempt to remove the patient's rings.

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?

Auscultate breath sounds.

A patient arrives in the emergency department (ED) after topical exposure to powdered lime at work. Which action should the nurse take first?

Brush visible powder from the skin and clothing.

A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action would the nurse take prior to providing advanced cardiac life support?

Don personal protective equipment.

An emergency department nurse assesses a client admitted after a lightning strike. The client is awake but somewhat confused. Which assessment would the nurse complete first?

Electrocardiogram (ECG)

An emergency department nurse assesses a client who has been raped. With which health care team member would the nurse collaborate when planning this client's care?

Forensic nurse examiner

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?

Give N-acetylcysteine. N-acetylcysteine is the recommended treatment to prevent liver damage after acetaminophen overdose.

While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action would the nurse take first?

Transfer the client to a negative-pressure room.

The urgent care center protocol for tick bites includes the following actions. Which action will the nurse take first when caring for a patient with a tick bite?

Use tweezers to remove any remaining ticks.

When requested to plan the response to the potential use of smallpox as a biological weapon, what should the emergency department (ED) nurse manager expect to obtain?

Vaccine