Chapter 21

The nurse is working in the triage area of an emergency department, and the following four clients approach the triage desk at the same time. List the order in which the nurse will assess these clients. 1. An ambulatory, dazed 25-year-old man with a bandaged head wound 2. An irritable newborn with a fever, petechiae, and nuchal rigidity 3. A 35-year-old jogger with a twisted ankle who has a pedal pulse and no deformity 4. A 50-year-old woman with moderate abdominal pain and occasional vomiting

2. An irritable newborn with a fever, petechiae, and nuchal rigidity 1. An ambulatory, dazed 25-year-old man with a bandaged head wound 4. A 50-year-old woman with moderate abdominal pain and occasional vomiting 3. A 35-year-old jogger with a twisted ankle who has a pedal pulse and no deformity

40. Identify the five most critical elements in performing disaster triage for multiple victims. 1. Obtain past medical and surgical histories. 2. Check airway, breathing, and circulation. 3. Assess the level of consciousness. 4. Visually inspect for gross deformities, bleeding, and obvious injuries. 5. Note the color, presence of moisture, and temperature of the skin. 6. Check vital signs, including pulse and respirations.

2. Check airway, breathing, and circulation. 3. Assess the level of consciousness. 4. Visually inspect for gross deformities, bleeding, and obvious injuries. 5. Note the color, presence of moisture, and temperature of the skin. 6. Check vital signs, including pulse and respirations.

38. A newly hired emergency department (ED) clinical nurse specialist (CNS) is reviewing the hospital's disaster plan and finds that it has not been reviewed or revised for 3 years. Which finding will be most important for the CNS to address related to the status of the disaster plan? 1. Stockpiles of antibiotics and resuscitation equipment may be depleted. 2. Current staff is unlikely to have training and practice in using the plan. 3. Resources within and outside of the hospital are likely to have changed. 4. Surrounding communities are at increased risk for technologic disasters.

2. Current staff is unlikely to have training and practice in using the plan.

A group of people arrive at the emergency department by private car. They all have extreme periorbital swelling, coughing, and tightness in the throat. There is a strong odor emanating from their clothes. They report exposure to a "gas bomb" that was set off in their house. What is the priority action? 1. Measure vital signs and listen to lung sounds. 2. Direct clients to the decontamination area. 3. Alert security about possible terrorism activity. 4. Direct clients to cold or clean zones for immediate treatment.

2. Direct clients to the decontamination area.

The nurse responds to a call for help from the emergency department waiting room. An older adult client is lying on the floor. List the order in which the nurse must carry out the following actions. 1. Perform the chin lift or jaw thrust maneuver. 2. Establish unresponsiveness. 3 Initiate cardiopulmonary resuscitation (CPR). 4. Call for help and activate the code team. 5. Instruct unlicensed assistive personnel to get the crash cart.

2. Establish unresponsiveness. 4. Call for help and activate the code team. 1. Perform the chin lift or jaw thrust maneuver. 3 Initiate cardiopulmonary resuscitation (CPR). 5. Instruct unlicensed assistive personnel to get the crash cart.

The nurse notifies the emergency department (ED) health care provider (HCP) about a client who reports abdominal pain, nausea and vomiting, and fever. The abdomen is distended, rigid, and boardlike, and there is rebound tenderness. Later the nurse sees that the client is to be discharged with a follow-up appointment in the morning. The nurse reexamines the client and the symptoms seem worse. What should the nurse do first? 1. Contact the nursing supervisor and express concerns. 2. Express findings and concerns to the HCP. 3. Discharge the client but stress the importance of follow-up. 4. Follow the discharge orders and write an incident report.

2. Express findings and concerns to the HCP.

A young woman is brought to the emergency department (ED) by emergency medical services (EMS). EMS reports they were called because the woman has been depressed and threatening to commit suicide. On arrival to the ED, the woman is confused; her speech is slurred, and there is vomit on her clothes. EMS found several empty prescription bottles at the house. What are the priority interventions for this client? 1. Identify toxic substances by history and analysis of blood, urine, and gastric contents. 2. Initiate supportive care, such as checking airway and giving oxygen and IV fluids. 3. Reduce absorption by giving activated charcoal or performing gastric lavage. 4. Promote poison removal using drugs to facilitate excretion or by starting hemodialysis.

2. Initiate supportive care, such as checking airway and giving oxygen and IV fluids.

A client presents to triage with fever, myalgia, severe headache, abdominal pain, vomiting, diarrhea, and unexplained bruising that started after returning from Africa. The triage nurse suspects, but is unsure, that the client may have Ebola. What should the nurse do first? 1. Delay any additional assessment or questioning and don full personal protective equipment. 2. Isolate the client in a private room and initiate standard, contact, and droplet precautions. 3. Direct all clients and staff out of the triage area and call the infection control department. 4. Continue assessment and questioning to determine the likelihood of exposure to Ebola.

2. Isolate the client in a private room and initiate standard, contact, and droplet precautions.

The following clients come to the emergency department triage desk reporting acute abdominal pain. Which client has the most severe condition? 1. A 35-year-old man reporting severe intermittent cramps with three episodes of watery diarrhea 2 hours after eating 2. An 11-year-old boy with a low-grade fever, right lower quadrant tenderness, nausea, and anorexia for the past 2 days 3. A 23-year-old woman reporting dizziness and severe left lower quadrant pain who states she is possibly pregnant 4. A 50-year-old woman who reports gnawing midepigastric pain that is worse between meals and during the night

3. A 23-year-old woman reporting dizziness and severe left lower quadrant pain who states she is possibly pregnant

A 56-year-old client comes to the triage area with left-sided chest pain, diaphoresis, and dizziness. What is the priority action? 1. Initiate continuous electrocardiographic monitoring. 2. Notify the emergency department health care provider. 3. Administer oxygen via nasal cannula. 4. Draw blood and establish IV access.

3. Administer oxygen via nasal cannula.

An experienced traveling nurse has been assigned to work in the emergency department (ED); however, this is the nurse's first week on the job. Which area of the ED is the most appropriate assignment for this nurse? 1. Trauma team 2. Triage 3. Ambulatory or fast-track clinic 4. Pediatric medicine team

3. Ambulatory or fast-track clinic

32. A client involved in a one-car rollover comes in with multiple injuries. List in order of priority the interventions that must be initiated for this client. 1. Place large bore IVs 2. Use the chin lift or jaw thrust maneuver to open the airway. 3. Assess for spontaneous respirations. 4. Give supplemental oxygen via mask. 5. Obtain a full set of vital sign measurements. 6. Remove or cut away the client's clothing.

3. Assess for spontaneous respirations. 2. Use the chin lift or jaw thrust maneuver to open the airway. 4. Give supplemental oxygen via mask. 1. large bore IVS 5. Obtain a full set of vital sign measurements. 6. Remove or cut away the client's clothing.

When an unexpected death occurs in the emergency department, which task is most appropriate to delegate to the unlicensed assistive personnel (UAP)? 1. Escorting the family to a place of privacy 2. Accompanying organ donor specialist to talk to family 3. Assisting with postmortem care 4. Helping the family to collect belongings

3. Assisting with postmortem care

The LPN/LVN is performing care for a client who sustained an amputation of the first and second digits in a chainsaw accident. What instructions would the RN give to the LPN/LVN? 1. Clean the amputated digits and the hand with a povidone-iodine and normal saline solution; then wrap with gauze. 2. Clean the amputated digits, wrap them in gauze, and place cleansed digits directly into an ice slurry. 3. Clean the amputated digits with saline, wrap in moist gauze, seal in a plastic bag, and place in ice slurry. 4. Clean the digits with sterile normal saline and submerge the digits in sterile normal saline in a sterile cup.

3. Clean the amputated digits with saline, wrap in moist gauze, seal in a plastic bag, and place in ice slurry.

The client's blood alcohol level is 0.45%. Based on this information, what is the priority nursing concept that underlies emergency medical and nursing interventions for this client? 1. Cognition 2. Addiction 3. Gas exchange 4. Functional ability

3. Gas exchange

A healthy but anxious 24-year-old college student reports tingling sensations, palpitations, and sore chest muscles. Deep, rapid breathing and carpal spasms are noted. What priority action should the nurse take? 1. Notify the health care provider immediately. 2. Administer supplemental oxygen. 3. Have the student breathe into a paper bag. 4. Obtain an order for an anxiolytic medication.

3. Have the student breathe into a paper bag

A victim of heat stroke arrives in the emergency department. His skin is hot and dry; his body temperature is 105°F (40.6°C). He is confused and demonstrates bizarre behavior. His blood pressure is 85/60 mm Hg, pulse 130 beats/min, and respirations are 40 breaths/min. Which task should be assigned to an experienced LPN/LVN? 1. Insert a rectal probe to measure core body temperature. 2. Administer aspirin or another antipyretic. 3. Insert an indwelling urinary drainage catheter. 4. Assess respiratory effort, hemodynamics, and mental status.

3. Insert an indwelling urinary drainage catheter.

Tetanus immunizations are routinely administered during childhood and in the emergency department (ED) for clients who sustain wounds. Although the incidence of tetanus has decreased, there is still a danger. Which client represents the group that is most vulnerable for risk? 1. Child who helps with the farm work sustained scratches while feeding the animals 2. Newborn infant delivered in the emergency department; mother had no prenatal care 3. Older adult who lives alone sustained a minor cut while cleaning the basement 4. Young adult who works in an auto repair shop sustained a deep cut on a metal edge

3. Older adult who lives alone sustained a minor cut while cleaning the basement

When a primary survey of a trauma client is conducted, what is one of the priority actions that would be performed first? 1. Obtain a complete set of vital sign measurements. 2. Palpate and auscultate the abdomen. 3. Perform a brief neurologic assessment. 4. Check the pulse oximetry reading.

3. Perform a brief neurologic assessment.

36. Emergency and ambulatory care nurses are among the first health care workers to encounter victims of a bioterrorist attack. List in order of priority the actions that should be taken by emergency department staff in the event of a biochemical incident. 1. Report to public health department or Centers for Disease Control and Prevention per protocol. 2. Decontaminate the affected individuals in a separate area. 3. Protect the environment for the safety of personnel and nonaffected clients. 4. Don personal protective equipment. 5. Perform triage according to protocol.

3. Protect the environment for the safety of personnel and nonaffected clients. 4. Don personal protective equipment. 2. Decontaminate the affected individuals in a separate area. 5. Perform triage according to protocol. 1. Report to public health department or Centers for Disease Control and Prevention per protocol.

In the care of a client who has experienced sexual assault, which task is most appropriate for an LPN/LVN to perform? 1. Assessing immediate emotional state and physical injuries 2. Collecting hair samples, saliva specimens, and scrapings beneath fingernails 3. Providing emotional support and supportive communication 4. Ensuring that the chain of custody of evidence is maintained

3. Providing emotional support and supportive communication

The nurse is caring for a client with frostbite to the feet. Place the following interventions in the correct order. 1. Apply a loose, sterile, bulky dressing. 2. Give pain medication. 3. Remove the client from the cold environment. 4. Immerse the feet in warm water of 105° to 115°F (40.6° to 46.1°C). 5. Monitor for compartment syndrome.

3. Remove the client from the cold environment. 2. Give pain medication. 4. Immerse the feet in warm water of 105° to 115°F (40.6° to 46.1°C). 1. Apply a loose, sterile, bulky dressing. 5. Monitor for compartment syndrome.

. A confused client admits to frequently drinking alcohol. The emergency department health care provider (HCP) makes a preliminary diagnosis of Wernicke encephalopathy. Which medication does the nurse anticipate that the HCP will prescribe initially? 1. Glucagon IV 2. Naltrexone IM 3. Thiamine IV 4. Naloxone IV

3. Thiamine IV

The nurse is assigned to telephone triage. A client who was just stung by a common honeybee calls for advice. Which question would the nurse ask first? 1. "Is this the first time you have been stung by a bee or wasp?" 2. "Do you have access to and know how to use an epinephrine autoinjector?" 3. "What type of first aid measures have you tried?" 4. "Are you having any facial swelling, wheezing, or shortness of breath?"

4. "Are you having any facial swelling, wheezing, or shortness of breath?"

The nurse manager decides to form a committee to address the issue of violence against emergency department (ED) personnel. Which combination of employees would be best suited to fulfill this assignment? 1. ED physicians and charge nurses 2. Experienced RNs and experienced paramedics 3. RNs, LPNs/LVNs, and unlicensed assistive personnel 4. At least one person from all ED groups

4. At least one person from all ED groups

24. After emergency endotracheal intubation, the health care team and the nurse must verify tube placement before securing the tube. What is the most accurate bedside assessment that can be performed immediately after the tube is placed? 1. Visualize the movement of the thoracic cage. 2. Auscultate the chest during assisted ventilation. 3. Confirm that the breath sounds are equal and bilateral. 4. Check exhaled carbon dioxide levels with capnography.

4. Check exhaled carbon dioxide levels with capnography.

An emergency department clinical nurse specialist is training staff in how to don and doff personal protective equipment (PPE) when caring for clients with infections, such as Ebola. Which staff member has demonstrated the most grievous error during the practice session? 1. Triage nurse forgets to perform hand hygiene before donning PPE. 2. Unlicensed assistive personnel performs self-inspection; then begins to doff PPE. 3. Health care provider forgets to wipe shoes with disinfectant after doffing shoe covers. 4. Emergency medical technician doffs both pairs of gloves first.

4. Emergency medical technician doffs both pairs of gloves first.

It is the summer season, and clients with signs and symptoms of heat-related illness come to the emergency department. Which client needs attention first? 1. Older adult reports dizziness and syncope after standing in the sun for several hours to view a parade 2. Marathon runner reports severe leg cramps and nausea and shows tachycardia, diaphoresis, pallor, and weakness 3. Healthy homemaker reports that air conditioner has been broken for days; she has tachypnea, hypotension, fatigue, and profuse diaphoresis 4. Homeless person displays altered mental status, poor muscle coordination, and hot, dry, ashen skin; duration of heat exposure is unknown

4. Homeless person displays altered mental status, poor muscle coordination, and hot, dry, ashen skin; duration of heat exposure is unknown

The nurse is talking to a group of people about an industrial explosion in which many people were killed or injured. Which individual has the greatest risk for psychiatric difficulties, such as post-traumatic stress disorder, related to the incident? 1. Individual who repeatedly watched television coverage of the event 2. Person who recently learned that her son was killed in the incident 3. Individual who witnessed the death of a co-worker during the explosion 4. Person who was injured and trapped for several hours before rescue

4. Person who was injured and trapped for several hours before rescue

The nurse and group of friends are at the lake. Suddenly, someone says, "Look across the lake! It looks like someone might be drowning out there!" What is the nurse's first action? 1. Determine who is the strongest swimmer in the group. 2. Direct someone to locate a cell phone and call 911. 3. Find a boat, raft, or some type of flotation device. 4. Use a pair of binoculars and look across the lake.

4. Use a pair of binoculars and look across the lake.

The nurse is caring for a client with multiple injuries sustained during a head-on car collision. Which assessment finding takes priority? 1. A deviated trachea 2. Unequal pupils 3. Ecchymosis in the flank area 4. Irregular apical pulse

1. A deviated trachea

The charge nurse in an emergency department (ED) and must assign two staff members to cover the triage area. Which team is the most appropriate for this assignment? 1. An advanced practice nurse and an experienced RN 2. An experienced LPN/LVN and an inexperienced RN 3. An experienced RN and an inexperienced RN 4. An experienced RN and an experienced unlicensed assistive personnel (UAP)

1. An advanced practice nurse and an experienced RN

The nurse is giving discharge instructions to a woman who has been treated for contusions and bruises sustained during an episode of domestic violence. What is the priority intervention for this client? 1. Encourage client to go to a safe house. 2. Make a referral to a counselor. 3. Advise the client about contacting the police. 4. Make an appointment to follow up on the injuries.

1. Encourage client to go to a safe house.

In the work setting, what is the nurse's primary responsibility in preparing for management of disasters, including natural disasters and bioterrorism incidents? 1. Knowing the agency's emergency response plan 2. Being aware of the signs and symptoms of potential agents of bioterrorism 3. Knowing how and what to report to the Centers for Disease Control and Prevention 4. Making ethical decisions about exposing self to potentially lethal substances

1. Knowing the agency's emergency response plan

Emergency medical services has transported a client with severe chest pain. As the client is being transferred to the emergency stretcher, the nurse notes unresponsiveness, cessation of breathing, and no palpable pulse. Which task is appropriate to delegate to the unlicensed assistive personnel (UAP)? 1. Performing chest compressions 2. Initiating bag-valve mask ventilation 3. Assisting with oral intubation 4. Placing the defibrillator pads

1. Performing chest compressions

A client comes to the emergency department and reports nausea, vomiting, colicky abdominal pain, fever, and tachycardia. The health care provider informs the nurse that the client probably has a strangulated intestinal obstruction with perforation. What diagnostic testing and interventions does the nurse anticipate for this emergency condition? Select all that apply. 1. Preparation for surgery 2. Barium enema examination 3. Nasogastric (NG) tube insertion 4. Abdominal radiography 5. IV fluid administration 6. IV administration of broad-spectrum antibiotics

1. Preparation for surgery 3. Nasogastric (NG) tube insertion 4. Abdominal radiography 5. IV fluid administration 6. IV administration of broad-spectrum antibiotics

A man with a known history of alcohol abuse has been in police custody for 48 hours. Initially, anxiety, sweating, and tremors were noted. Now disorientation, hallucination, and hyperreactivity are observed. The medical diagnosis is delirium tremens. What is the priority nursing concept to consider in planning interventions for this emergency condition? 1. Safety 2. Psychosis 3. Thermoregulation 4. Addiction

1. Safety

According to The Joint Commission, hospitals are required to form emergency management committees to periodically exercise the disaster operations plan. Hospital administration has selected various health care providers (HCPs) to join the committee. Members from which other key departments should be included? Select all that apply. 1. Security and communications 2. Nursing and unlicensed assistive personnel 3. Laboratory and diagnostic services 4. Medical and information technology 5. Maintenance and engineering 6. Physical therapy and occupational therapy

1. Security and communications 2. Nursing and unlicensed assistive personnel 3. Laboratory and diagnostic services 4. Medical and information technology 5. Maintenance and engineering

A newly graduated nurse overhears a senior emergency department nurse making sarcastic remarks toward a medical student and refusing to help the student find the equipment for a nonemergent client procedure. What should the new nurse do first? 1. Step in and offer to assist the medical student because the other nurse is unwilling. 2. Confront the senior nurse and indicate that an apology is the right thing to do. 3. Observe the situation and then report behaviors of both parties to the charge nurse. 4. Watch and observe the dynamics; the scenario is probably typical of unit norms.

1. Step in and offer to assist the medical student because the other nurse is unwilling.

28. The nurse is assessing a client who has sustained a cat bite to the left hand. The cat's immunizations are up to date. The date of the client's last tetanus shot is unknown. What is the priority concern? 1. Treating infection specific to cat bites 2. Suturing the puncture wounds 3. Administering tetanus vaccine 4. Maintaining mobility of finger joints

1. Treating infection specific to cat bites

The nurse is working in a small rural community hospital. There is a fire in a local church, and six injured clients have arrived at the hospital. Many others are expected to arrive soon, and other hospitals are 5 hours away. Using disaster triage principles, place the following six clients in the order in which they should receive medical attention, with 1 being the first to receive attention and 6 being the last to receive attention. 1. A 52-year-old man in full cardiac arrest who has been receiving cardiopulmonary resuscitation (CPR) continuously for the past 60 minutes 2. A firefighter who is showing combative behavior and has respiratory stridor 3. A 60-year-old woman with full-thickness burns to the hands and forearms 4. A teenager with a crushed leg that is very swollen; he is anxious and has tachycardia 5. A 3-year-old child with respiratory distress and burns over more than 70% of the anterior body 6. A 12-year-old child with wheezing and very labored respirations unrelieved by an asthma inhaler

6. A 12-year-old child with wheezing and very labored respirations unrelieved by an asthma inhaler 2. A firefighter who is showing combative behavior and has respiratory stridor 4. A teenager with a crushed leg that is very swollen; he is anxious and has tachycardia 3. A 60-year-old woman with full-thickness burns to the hands and forearms 5. A 3-year-old child with respiratory distress and burns over more than 70% of the anterior body 1. A 52-year-old man in full cardiac arrest who has been receiving cardiopulmonary resuscitation (CPR) continuously for the past 60 minutes