Lewis-Chapter 69: Nursing Management Emergency, Terrorism, and Disaster Nursing NEW

When planning the response to the potential use of smallpox as an agent of terrorism, the emergency department (ED) nurse-manager will plan to obtain sufficient quantities of a. blood. b. vaccine. c. atropine. d. antibiotics.

B Smallpox infection can be prevented or ameliorated by the administration of vaccine given rapidly after exposure. The other interventions would be helpful for other agents of terrorism but not for smallpox.

When a patient is admitted to the emergency department after a submersion injury, which assessment will the nurse obtain first? a. Apical pulse b. Lung sounds c. Body temperature d. Level of consciousness

B The priority assessment data are how well the patient is oxygenating, so lung sounds should be assessed first. The other data also will be collected rapidly but are not as essential as the lung sounds.

An unresponsive 78-year-old is admitted to the emergency department (ED) 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 initially will plan to a. administer an aspirin rectal suppository. b. start O2 at 6 L/min with a nasal cannula. c. apply wet sheets and a fan to the patient. d. infuse lactated Ringer's solution at 1000 mL/hr.

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

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

A 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 also are part of the initial survey but assessment of breathing should be done immediately after assessing for airway patency.

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

A 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 diagnosis of intraabdominal bleeding.

A patient arrives in the emergency department (ED) a few hours after taking "20 to 30" acetaminophen (Tylenol) tablets. Which action will the nurse plan to take? a. Give N-acetylcysteine (Mucomyst). b. Discuss the use of chelation therapy. c. Have the patient drink large amounts of water. d. Administer oxygen using a non-rebreather mask.

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.

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. have sympathomimetic drugs available.

A Rewarming can produce dysrhythmias, so the patient should be monitored and treated if necessary. Urinary catheterization and endotracheal intubation are not needed for rewarming. Sympathomimetic drugs tend to stimulate the heart and increase the risk for fatal dysrhythmias such as ventricular fibrillation.

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.

A 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 done after the decontamination is completed.

When assessing a patient admitted to the emergency department (ED) 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. "Is someone at home hurting you?" b. "You should not return to your home." c. "Would you like to see a social worker?" d. "I have to report this abuse to the police."

A 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.

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. assess the patient's current vital signs. b. obtain a clean-catch urine for urinalysis. c. tell the patient that it may be several hours before being seen by the doctor. d. ask the health care provider to order an analgesic medication for the patient.

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 needed, but vital signs will provide the nurse with the data needed to determine this. The health care provider will not order a medication before assessing the patient.

The following actions are part of the routine 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? a. Remove the patient's rings. b. Place ice packs on both hands. c. Apply calamine lotion to any itching areas. d. Give diphenhydramine (Benadryl) 100 mg PO.

A The patient's rings should be removed first because it might not be possible to remove them if swelling develops. The other orders also should be implemented as rapidly as possible after the nurse has removed the jewelry.

Following an earthquake, patients are triaged by emergency medical personnel and are transported to the hospital. Which of these patients 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 yellow tag d. A patient with a green tag

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.

After resuscitation, a patient who had a cardiac arrest is nonresponsive to commands and therapeutic hypothermia is prescribed. Which action will the nurse include in the plan of care? a. Rapidly infuse cold normal saline. b. Avoid the use of sedative medications. c. Check neurologic status every 30 minutes. d. Rewarm if temperature is >91° F (32.8° C).

A When therapeutic hypothermia is used postresuscitation, cold normal saline is infused to rapidly lower body temperature to 89.6° F to 93.2° F (32° C to 34° C). Since hypothermia will decrease brain activity, neurologic assessment every 30 minutes is not needed. Sedative medications are administered during therapeutic hypothermia.

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

ANS: C, A, B, D The highest priority is to assess the 21-year-old patient for airway obstruction, which is the most life-threatening injury. The 74-year-old patient may have chest pain from cardiac ischemia and should be assessed and have diagnostic testing for this pain. The 43-year-old patient may have abdominal trauma or bleeding and should be seen next to assess circulatory status. The 37-year-old appears to have a possible fracture of the left leg and should be seen soon, but this patient has the least life-threatening injury. DIF: Cognitive Level: Analyze (analysis) REF: 1676 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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? a. Use tweezers to remove any remaining ticks. b. Check the vital signs, including temperature. c. Give doxycycline (Vibramycin) 100 mg orally. d. Obtain information about recent outdoor activities.

ANS: A Because neurotoxic venom is released as long as the tick is attached to the patient, the initial action should be to remove any ticks using tweezers or forceps. The other actions are also appropriate, but the priority is to minimize venom release. DIF: Cognitive Level: Apply (application) REF: 1697 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A 20-year-old 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 (Mucomyst). 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. DIF: Cognitive Level: Understand (comprehension) REF: 1689 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

When planning the response to the potential use of smallpox as an agent of terrorism, the emergency department (ED) nurse manager will plan to obtain adequate quantities of a. vaccine. b. atropine. c. antibiotics. d. whole blood.

ANS: A Smallpox infection can be prevented or ameliorated by the administration of vaccine given rapidly after exposure. The other interventions would be helpful for other agents of terrorism but not for smallpox. DIF: Cognitive Level: Understand (comprehension) REF: 1690 TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

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 is most appropriate? a. "Do you feel safe in your home?" b. "You should not return to your home." c. "Would you like to see a social worker?" d. "I need to report my concerns to the police."

ANS: A 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. A social worker may be appropriate once further assessment is completed. DIF: Cognitive Level: Apply (application) REF: 1682 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

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

ANS: A The patient's pain and statement about an elevated temperature indicate that the nurse should obtain vital signs before deciding how rapidly the patient should be seen by the health care provider. A urinalysis may be appropriate, but this would be done after the vital signs are taken. The nurse will not give acetaminophen before confirming a current temperature elevation. DIF: Cognitive Level: Apply (application) REF: 1675-1676 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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? a. Remove the patient's rings. b. Apply ice packs to both hands. c. Apply calamine lotion to any itching areas. d. Give diphenhydramine (Benadryl) 50 mg PO.

ANS: A 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. DIF: Cognitive Level: Apply (application) REF: 1687 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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

ANS: A The priority intervention is to cool the patient. Antipyretics are not effective in decreasing temperature in heat stroke, and 100% oxygen should be given, which requires a high flow rate through a non-rebreather mask. An older patient would be at risk for developing complications such as pulmonary edema if given fluids at 1000 mL/hr. DIF: Cognitive Level: Apply (application) REF: 1683 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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

ANS: A The red tag indicates a patient with a life-threatening injury requiring rapid treatment. The other tags indicate patients with less urgent injuries or those who are likely to die. DIF: Cognitive Level: Remember (knowledge) REF: 1692 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

After the return of spontaneous circulation following the resuscitation of a patient who had a cardiac arrest, therapeutic hypothermia is ordered. Which action will the nurse include in the plan of care? a. Apply external cooling device. b. Check mental status every 15 minutes. c. Avoid the use of sedative medications. d. Rewarm if temperature is <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 needed at this stage. Sedative medications are administered during therapeutic hypothermia. DIF: Cognitive Level: Apply (application) REF: 1681 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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

ANS: A, B, C Cooling can produce dysrhythmias, so the patient's heart rhythm should be continuously monitored and dysrhythmias treated if necessary. Bladder catheterization and endotracheal intubation are needed during cooling. Sympathomimetic drugs tend to stimulate the heart and increase the risk for fatal dysrhythmias such as ventricular fibrillation. Patients receiving therapeutic hypothermia are comatose or do not follow commands so restraints are not indicated. DIF: Cognitive Level: Apply (application) REF: 1681 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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

ANS: B 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) REF: 1676 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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 diagnosis of intraabdominal bleeding. DIF: Cognitive Level: Apply (application) REF: 1678 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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

ANS: B 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: Apply (application) REF: 1689 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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. ask about chronic medical conditions. d. attach a cardiac electrocardiogram monitor.

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) REF: 1676 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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

ANS: B The priority assessment relates to ABCs (airway, breathing, circulation) and how well the patient is oxygenating, so breath sounds should be assessed first. The other data will also be collected rapidly but are not as essential as the breath sounds. DIF: Cognitive Level: Apply (application) REF: 1685 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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

ANS: C Although many family members and patients report benefits from family presence during resuscitation efforts, the nurse's initial action should be to determine the preference of these family members. The other actions may be appropriate, but this will depend on what is learned when assessing family preferences. DIF: Cognitive Level: Apply (application) REF: 1679 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

A 28-year-old 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? a. Prepare to administer rabies immune globulin (BayRab). b. Assist the health care provider with suturing of the bite wounds. c. Teach the patient the reason for the use of prophylactic antibiotics. d. Keep the wounds dry until the health care provider can assess them.

ANS: C Because human bites of the hand frequently become infected, prophylactic antibiotics are usually prescribed to prevent infection. To minimize infection, deep bite wounds on the extremities are left open. Rabies immune globulin might be used after an animal bite. Initial treatment of bite wounds includes copious irrigation to help clean out contaminants and microorganisms. DIF: Cognitive Level: Apply (application) REF: 1688 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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

ANS: C Because pulmonary edema is a common complication after near drowning, the nurse should assess the breath sounds frequently. The other information also will be obtained by the nurse, but it is not as pertinent to the patient's admission diagnosis. DIF: Cognitive Level: Apply (application) REF: 1686 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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

ANS: C Electrolyte solutions such as sports drinks help replace fluid and electrolytes lost when exercising in hot weather. Salt tablets are not recommended because of the risks of gastric irritation and hypernatremia. Antipyretic medications are not effective in lowering body temperature elevations caused by excessive exposure to heat. A patient who is confused is likely to have more severe hyperthermia and will be unable to remember to take appropriate action. DIF: Cognitive Level: Apply (application) REF: 1682 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

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

ANS: C, D, E Experienced LPN/LVNs have the education and scope of practice to implement hypothermia measures (e.g., cooling blanket, temperature probe) and administer medications under the supervision of a registered nurse (RN). Assessment of neurologic status and monitoring the heart rhythm require RN-level education and scope of practice and should be done by the RN. DIF: Cognitive Level: Apply (application) REF: 15-16 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

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

ANS: D A core temperature of 89.6° F to 93.2° F (32° C to 34° C) indicates that sufficient rewarming has occurred. Dysrhythmias, hypotension, and shivering may occur during rewarming and should be treated but are not an indication to stop rewarming the patient. DIF: Cognitive Level: Apply (application) REF: 1686 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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

ANS: D For an adult with no previous tetanus immunizations, TIG and Tdap are recommended. The other immunizations are not sufficient for this patient. DIF: Cognitive Level: Apply (application) REF: 1681 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

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 paradoxic chest movements.

ANS: D Most immediate deaths from trauma occur because of problems with ventilation, so the patient with paradoxic 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: Apply (application) REF: 1676 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

A patient who is unconscious after a fall from a ladder is transported to the emergency department by family members. During the primary survey of the patient, the nurse should a. assess the patient's vital signs. b. attach a cardiac electrocardiogram (ECG) monitor. c. obtain a Glasgow Coma Scale score. d. ask about chronic medical conditions.

C The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the secondary survey.

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

ANS: D The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a possibly life-threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey. Although a complete blood count is indicated, administration of IV fluids should be started first. Completion of the primary survey and further assessment should be completed after the IV fluids are initiated. DIF: Cognitive Level: Apply (application) REF: 1676 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A 54-year-old patient arrives in the emergency department (ED) after exposure to powdered lime at work. Which action should the nurse take first? a. Obtain the patient's vital signs. b. Obtain a baseline complete blood count. c. Decontaminate the patient by showering with water. d. Brush off any visible powder on the skin and clothing.

ANS: D The initial action should be to protect staff members and decrease the patient's exposure to the toxin by decontamination. Patients exposed to powdered lime should not be showered; instead any/all visible powder should be brushed off. The other actions can be done after the decontamination is completed. DIF: Cognitive Level: Apply (application) REF: 1690 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse provides information to a patient who was exposed to anthrax by inhalation. The nurse determines the teaching has been successful if the patient makes which statement? A. "Anthrax can be spread by person-to-person contact." B. "It is not necessary to receive the anthrax vaccine." C. "An antibiotic will be prescribed for 2 months." D. "Antibiotics are only indicated for an active infection."

Answer: C. "An antibiotic will be prescribed for 2 months." Rationale: Postexposure prophylaxis includes a 60-day course of antibiotics. Ciprofloxacin (Cipro) is the treatment of choice. Anthrax is not spread by person-to-person contact; anthrax is spread by direct contact with the bacteria and its spores. The patient may receive the anthrax vaccine (three doses); if vaccinated, the course of antibiotic therapy is reduced to 30 days. Antibiotics are indicated after exposure to inhaled anthrax. Ch. 69

Which patient should the nurse prepare to transfer to a regional burn center? A. A 53-year-old patient with a chemical burn to the anterior chest and neck B. A 25-year-old pregnant patient with a carboxyhemoglobin level of 1.5% C. A 42-year-old patient who is scheduled for skin grafting of a burn wound D. A 39-year-old patient with a partial-thickness burn to the right upper arm

Answer: A. A 53-year-old patient with a chemical burn to the anterior chest and neck Rationale: The American Burn Association (ABA) has established referral criteria to determine which burn injuries should be treated in burn centers where specialized facilities and personnel are available to handle this type of trauma (see Table 25-3). Patients with chemical burns should be referred to a burn center. A normal serum carboxyhemoglobin level for nonsmokers is 0% to 1.5% and for smokers is 4% to 9%. Skin grafting for burn wound management is not a criteria for a referral to a burn center. Partial-thickness burns greater than 10% total body surface area (TBSA) should be referred to a burn center; a burn to the right upper arm is 4% TBSA. Ch. 25

The nurse is caring for a 71 kg patient during the first 12 hours after a thermal burn injury. Which outcomes if observed by the nurse would indicate adequate fluid resuscitation (select all that apply)? A. Heart rate is 94 beats/minute. B. Mean arterial pressure is 54 mm Hg. C. Urine output is 46 mL/hour. D. Urine specific gravity is 1.040. E. Systolic blood pressure 88 mm Hg

Answer: A. Heart rate is 94 beats/minute. C. Urine output is 46 mL/hour. Rationale: Assessment of the adequacy of fluid resuscitation is best made using either urine output or cardiac factors. Urine output should be 0.5 to 1 mL/kg/hr (or 75 to 100 mL/hr for an electrical burn patient with evidence of hemoglobinuria/myoglobinuria). Cardiac factors include a mean arterial pressure (MAP) greater than 65 mm Hg, systolic blood pressure (BP) greater than 90 mm Hg, heart rate less than 120 beats/minute. Normal range for urine specific gravity is 1.003 to 1.030. Ch. 25

A nurse manager educates the emergency department staff about their roles during a disaster with mass casualties. Which primary responsibility should the nurse manager discuss with the staff? A. Learn the hospital emergency response plan. B. Report acts of violence to security personnel. C. Contact the American Red Cross for assistance. D. Notify local, state, and national authorities.

Answer: A. Learn the hospital emergency response plan. Rationale: All health care providers need to be prepared for a mass casualty incident; the priority responsibility is to know the agency's emergency response plan. Ch. 69

The nurse is planning to change the dressing covering a deep partial-thickness burn of the right lower leg. Which prescribed medication should the nurse administer 30 minutes before the scheduled dressing change? A. zolpidem (Ambien) B. morphine sulfate C. sertraline (Zoloft) D. enoxaparin (Lovenox)

Answer: B. morphine sulfate Rationale: Deep partial-thickness burns result in severe pain related to nerve injury. The nurse should plan to administer analgesics before the dressing change to promote patient comfort. Morphine sulfate is a common opioid used for pain control. Sedative/hypnotics and antidepressant agents can also be given with analgesics to control the anxiety, insomnia, and/or depression that patients may experience. Zolpidem promotes sleep; sertraline is an antidepressant; and enoxaparin is an anticoagulant. Ch. 25

The nurse is caring for a patient who sustained a deep partial thickness burn to the anterior chest area. Which statement would be appropriate for the nurse to include when documenting the appearance of this type of burn? ]A. Skin is hard with a dry, waxy white appearance with visible venous patterns. B. Skin blanches with pressure and is red with delayed blister formation. C. Skin is red and shiny with the presence of clear fluid-filled blisters. D. Skin is charred and leathery with visible muscles, tendons, and bones

Answer: C. Skin is red and shiny with the presence of clear fluid-filled blisters. Rationale: Deep partial thickness burns have fluid-filled vesicles that are red and shiny; may appear wet (if vesicles have ruptured); and mild to moderate edema may be present. Deep partial thickness burns result in severe pain related to nerve injury. Superficial partial thickness burns are red and blanch with pressure; pain and mild edema are present. Superficial partial thickness burns may have vesicles that appear 24 hours after the burn injury. Full-thickness burns are dry, waxy white, leathery, or hard; thrombosed vessels may be visible. Full-thickness burns result in an insensitivity to pain because of nerve destruction, and there may be involvement of muscles, tendons, and bones. Ch. 25

A patient arrives in the emergency department after ingesting 8 g of acetaminophen (Tylenol). Which question is most important for the nurse to ask? A. Have you tried to commit suicide before? B. Do you feel like you have a fever? C. What time did you take the Tylenol? D. Are you experiencing any abdominal pain?

Answer: C. What time did you take the Tylenol? Rationale: Acetaminophen will bind to activated charcoal and pass through the gastrointestinal tract without being absorbed. Activated charcoal is most effective if administered within 1 hour of ingestion of acetaminophen and other select poisons. Ch. 69

The nurse is providing emergent care for a patient with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. Which action should the nurse take first? A. Assist the patient to a high Fowler's position. B. Teach the patient deep breathing exercises. C. Allow the patient to verbalize feelings. D. Administer 100% humidified oxygen.

Answer: D. Administer 100% humidified oxygen. Rationale: Carbon monoxide (CO) poisoning may occur in house fires; CO displaces oxygen on the hemoglobin molecule resulting in hypoxia. High levels of CO in the blood result in a skin color that is described as cherry red. Hypoxia may cause anxious behaviors and altered mental status. Emergency treatment for inhalation injury and CO poisoning includes the immediate administration of 100% humidified oxygen. The other interventions are appropriate for inhalation injury but are not as emergent as oxygen administration. Ch. 25

A patient is admitted to the emergency department with cold exposure and a core body temperature of 86.6o F (30.3o C). Which action is most appropriate for the nurse to take? A. Immerse the extremities in a water bath (102° to 108° F) [38.9° to 42.2° C]) B. Place an air-filled warming blanket on the patient. C. Position patient under a radiant heat lamp. D. Administer warmed intravenous (IV) fluids.

Answer: D. Administer warmed intravenous (IV) fluids. Rationale: A patient with a core body temperature of 86.6o F (30.3o C) has moderate hypothermia. Active core rewarming is used for moderate to severe hypothermia and includes administration of warmed IV fluids (109.4° F [43° C]). Patients with moderate to severe hypothermia should have the core warmed before the extremities to prevent after drop (or further drop in core temperature). This occurs when cold peripheral blood returns to the central circulation. Use passive or active external rewarming for mild hypothermia. Active external rewarming involves fluid-filled warming blankets or radiant heat lamps. Immersion of extremities in a water bath is indicated for frostbite. Ch. 69

A nurse is performing triage in the emergency department. Which patient should the nurse see first? A. 18-year-old patient with type 1 diabetes mellitus who has a 4-cm laceration on right leg. B. 32-year-old patient with drug overdose who is unresponsive with poor respiratory effort. C. 56-year-old patient with substernal chest pain who is diaphoretic with shortness of breath. D. 78-year-old patient with right hip fracture who is confused; blood pressure is 98/62 mm Hg.

Answer: B. 32-year-old patient with drug overdose who is unresponsive with poor respiratory effort. Rationale: Patient with drug overdose is unstable and needs to be seen immediately. Patient with chest pain (possible myocardial infarction) should be seen second. Patient with hip fracture should be seen third. Patient with laceration is the most stable and should be seen last. Ch. 69

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.

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 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.

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.

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's family members are in the patient room when the patient has a cardiac arrest and emergency personnel start resuscitation measures. Which action is best for the nurse to take initially? a. Have the family wait outside the patient room with a designated staff member to provide emotional support. b. Keep the family in the room and assign a member of the team to explain the care given and answer questions. c. Ask the family members about whether they would prefer to remain in the patient room or wait outside the room. d. Advise the family members that patients are comforted by having family members present during resuscitation efforts.

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

A patient with hypotension and temperature elevation after doing yard work on a hot day is treated in the ED. After the nurse has completed discharge teaching, which statement by the patient indicates that the teaching has been effective? a. "I will take salt tablets when I work outdoors in the summer." b. "I should take acetaminophen (Tylenol) if I start to feel too warm." c. "I should 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."

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

The emergency department (ED) triage nurse is assessing four victims of an automobile accident. Which patient has the highest priority for treatment? a. A patient with absent pedal pulses b. A patient with an open femur fracture c. A patient with a sucking chest wound d. A patient with bleeding of facial lacerations

C 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 who experienced a near drowning accident in a local lake, but now is awake and breathing spontaneously, is admitted for observation. Which action will be most important for the nurse to take during the observation period? a. Listen to heart sounds. b. Palpate peripheral pulses. c. Auscultate breath sounds. d. Check pupil reaction to light.

C Since pulmonary edema is a common complication after near drowning, the nurse should assess the breath sounds frequently. The other information also will be collected by the nurse, but it is not as pertinent to the patient's admission diagnosis.

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 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 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.

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 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.

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.

These four patients arrive in the emergency department after a motor vehicle crash. In which order should they be assessed? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. A 72-year-old with palpitations and chest pain b. A 45-year-old complaining of 6/10 abdominal pain c. A 22-year-old with multiple fractures of the face and jaw d. A 30-year-old with a misaligned right leg with intact pulses

C, A, B, D 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 pain. 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.

When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87° F, which assessment indicates that the nurse should discontinue the rewarming? a. The patient stops shivering. b. The BP decreases to 85/40 mm Hg. c. The patient develops atrial fibrillation. d. The core temperature is 94° F (34.4° C).

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

An 18-year-old is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the right hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. The nurse will anticipate administration of a. tetanus-diphtheria toxoid (Td) only. b. tetanus immunoglobulin (TIG) only. c. TIG and tetanus-diphtheria toxoid (Td). d. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap).

D For an adult with no previous tetanus immunizations, TIG and Tdap are recommended. The other immunizations are not sufficient for this patient.

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 diazepam (Valium) tablets. Which action will the nurse plan to take first? a. Administer activated charcoal. b. Insert a large-bore orogastric tube. c. Prepare a 60-mL syringe with saline. d. Assist with intubation of the patient.

D 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.

During the primary survey of a patient with multiple traumatic injuries, the nurse observes that the patient's right pedal pulses are absent and the leg is swollen. Which of these actions will the nurse take next? a. Assess further for a cause of the decreased circulation. b. Send blood to the lab for a complete blood count (CBC). c. Finish the airway, breathing, circulation, disability survey. d. Initiate isotonic fluid infusion through two large-bore IV lines.

D 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.

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.