ch 70 Emergency, Trauma, and Environmental Injuries

Charge nurse

A medical-surgical unit is expecting a large volume of patient admissions after a train derailment. Which member of the nursing care team will prioritize care for the unit?

Assist the patient in turning at least every two hours

A nurse is developing a plan of care for a patient with traumatic injuries from a motor vehicle crash. Which nursing intervention does the nurse include in the plan of care to reduce the risk of integumentary complications?

MRI

A patient is brought into the emergency department after being assaulted. It is suspected that the patient has a spinal cord injury. Which diagnostic test does the nurse anticipate based on the data collected?

Tension pneumothorax

A patient recovering from a motor vehicle crash develops hypotension and jugular distension with a tracheal deviation. Based on this data, which should the nurse suspect occurred?

A school-age patient with asthma presenting with dyspnea

The emergency department nurse is triaging patients. Which patient should be prioritized?

Having suction available

The nurse is conducting a primary survey during an emergency assessment. Which is the priority nursing action related to breathing in response to this assessment?

Counting respiratory rate

The nurse is conducting a primary survey during the emergency assessment. Which nursing action is appropriate during the breathing assessment?

Determining drug allergies

The nurse is conducting a secondary survey as part of the emergency assessment. Which is the priority nursing action during the health history portion of the assessment?

-Clear the airway -Protect the cervical spine -Provide supplemental oxygen -Perform chest compressions

The nurse is providing care to a trauma patient. What is the correct order of steps the nurse will implement when providing care to this patient? Select all that apply. (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234

- A patient who took an overdose of opioids with a respiratory rate of eight breaths per minute -A patient who has multiple trauma due to a motor vehicle accident -A patient with abdominal pain rated as a 7 on a numeric pain scale -A patient with a leg laceration requiring sutures

The nurse is providing care to several patients in the emergency department. In which order should the nurse assess and provide care to the patients? (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234)

A patient with chest pain and diaphoresis

The nurse is providing care to several patients in the emergency department. Which patient is the priority when using the three-tiered triage system?

An adult patient with unstable vital signs and chest pain

The nurse is providing care to several patients in the emergency department. Which patient would require priority care from the nurse?

Taking vital signs

The registered nurse (RN) is the team leader for a group of patients using the functional model of nursing. The team of nurses includes two licensed practical nurses (LPNs) and an unlicensed assistive personnel (UAP). Which task will the RN delegate to the UAP?

Preserve the chain of evidence

What should the nurse do to assist a patient brought to the emergency department as a victim of a gunshot wound?

-Airway maintenance -Ventilation assistance -Hemorrhage control -Hypothermia prevention

What would the nurse working in the emergency department identify as clinical priorities for the treatment of a patient with a gunshot wound? Select all that apply

Documenting the patient's care

Which are the priority nursing actions after the completion of the secondary survey when providing care for a trauma patient with a penetrating wound?

-Airway -Cervical spine

Which are the top priorities when conducting a primary patient survey during the emergency assessment? Select all that apply

Ecchymosis

Which assessment data indicates the patient is experiencing a late symptom associated with chronic aspirin overdose?

Agonal breaths

Which assessment data related to the patient's airway would indicate the need for priority intervention by the nurse?

Assist to deep breathe and cough every two hours

Which intervention would be a priority when providing care to a patient recovering from thoracic injuries sustained from a motor vehicle crash?

Concussion

Which is a potentially life-threatening condition found during the primary triage survey that would necessitate priority nursing care?

Setting priorities

Which is the essential nursing skill for the triage process in the emergency department?

Stabilizing the impaled object

Which is the priority nursing action when providing care to a patient with a penetrating abdominal wound?

Team leader

Which member of the health-care team, when using the team nursing approach, is responsible for prioritizing patient care?

Assigning a nurse to support family members

Which nursing action is appropriate when conducting a secondary survey during the emergency assessment?

-Immobilizing the cervical spine -Preparing for chest tube insertion -Applying direct pressure to a wound

Which nursing actions are appropriate during the primary survey of the emergency assessment process? Select all that apply

Moves all four extremities independently, feeds self, and participates in partial bath

Which observation indicates that interventions provided to a patient with neck injuries from a motor vehicle crash have been successful?

Activated charcoal

Which treatment should the nurse prepare to administer when providing care to a toddler who presents after an accidental overdose of aspirin?