Chapter 67: Emergency Nursing
A client in the critical care unit is being prepared for insertion of an intra-aortic balloon pump. When teaching the client about the device, which information would the nurse most likely include? "The device will work whenever your heart beat gets irregular." "The balloon inflates when your heart contracts." "The device will decrease the work your heart needs to do to pump." "The device will be inserted through an artery in your neck."
"The device will decrease the work your heart needs to do to pump." A balloon in placed in the descending aorta via a femoral artery. The balloon can be alternately inflated and deflated. It is programmed to inflate during diastole, which pushes blood back toward the cardiac muscle itself, as well as toward the brain. It deflates just before the ejection phase of systole and acts as a vacuum that pulls blood into the aorta with less effort from the left ventricle. An IABP essentially decreases the workload of the heart, allowing the heart muscle to rest and recover while improving organ perfusion. The machine itself can be programmed to assist with every heartbeat or every second, third, or fourth alternate beat, depending upon client requirements.
A nurse is using the Richmond Agitation-Sedation Scale to assess a client's anxiety level. The nurse notes that the client is drowsy and is able to maintain eye contact to the nurse's voice for about 15 to 20 seconds. The nurse would document which score for the client? +1 -1 -2 0
-1 A score of -1 is used for a client who is drowsy, not fully alert, but has sustained eye-opening or eye contact to voice for more than 10 seconds. A restless, anxious, but nonaggressive client would be given a score of +1. A client who is alert and calm would be given a score of 0. A client who is lightly sedated but briefly awakens with eye contact to voice for less than 10 seconds would be given a score of -2.
A client suspected of acetaminophen (Tylenol) toxicity reports that he ingested the medication at 7 p.m. At what time should the nurse anticipate laboratory tests to assess the acetaminophen level? 8 p.m. Stat 24 hours from the last dose 11:00 p.m.
11:00 p.m. The duration of action of acetaminophen ranges from 3 to 5 hours. Its half-life ranges from 1 to 3 hours. At least 4 hours should pass between the last dose and laboratory assessment of the acetaminophen level.
Permanent brain injury or death will occur within which time frame secondary to hypoxia? 1 to 2 minutes 3 to 5 minutes 6 to 8 minutes 9 to 10 minutes
3 to 5 minutes If the airway is completely obstructed, permanent brain injury or death will occur within 3 to 5 minutes secondary to hypoxia. Air movement is absent in the presence of complete airway obstruction. Oxygen saturation of the blood decreases rapidly because obstruction of the airway prevents air from entering the lungs. Oxygen deficit occurs in the brain, resulting in unconsciousness, with death following rapidly. The other time frames are incorrect.
The nurse is administering 100% oxygen to a patient with carbon monoxide poisoning and obtains a carboxyhemoglobin level. Which level would the nurse interpret as indicating that oxygen therapy can be discontinued? 4% 9% 7% 6%
4% Oxygen is administered until the carboxyhemoglobin level is less than 5%.
A critical care nurse is assessing a client's plasma lactate concentration. Which result would lead the nurse to suspect that the client is experiencing lactic acidosis? 4.0 mEq/L 4.7 mEq/L 2.9 mEq/L 3.3 mEq/L
4.7 mEq/L The lactic acid level represents the end product of anaerobic metabolism used by the body during times of insufficient oxygen supply. Lactic acidosis is generally considered to be present if the plasma lactate concentration is greater than 4 to 5 mEq/L.
The nurse is caring for a client in the ED with frostbite to the left hand. During the rewarming process of the hand, the nurse should perform which action? Have the client complete active range-of-motion exercises. Rupture any hemorrhagic blebs that are noted. Administer analgesic medications as ordered. Keep the hand in the circulating bath for 1 hour.
Administer analgesic medications as ordered. During rewarming, an analgesic for pain is administered as prescribed because the rewarming process may be very painful. Frozen extremities are usually placed in a 37°C to 40°C (98.6°F to 104°F) circulating bath for 30- to 40-minute spans. This treatment is repeated until circulation is effectively restored. Hemorrhagic blebs, which may develop 1 hour to a few days after rewarming, are left intact and unruptured. Nonhemorrhagic blisters are debrided to decrease the inflammatory mediators found in the blister fluid. After rewarming, hourly active motion of any affected digits is encouraged to promote maximal restoration of function and to prevent contractures.
The nurse is providing care for a client who is experiencing alcohol withdrawal. The client reports, "I cannot fall or stay asleep." The nurse observes that the client is agitated, having difficulty falling asleep and crying uncontrollably, with confused speech and a tachycardic pulse. Which intervention should the nurse implement first? Administer lorazepam as ordered by the health care provider Assess the client for suicidal and homicidal ideation Encourage the client to use deep breathing Ask a family member to remain with the client
Administer lorazepam as ordered by the health care provider Clients with alcohol withdrawal syndrome show signs of anxiety, uncontrollable fear, tremor, irritability, agitation, insomnia, and incontinence. They are talkative and preoccupied and experience visual, tactile, olfactory, and auditory hallucinations that often are terrifying. Autonomic overactivity occurs and is evidenced by tachycardia, dilated pupils, and profuse perspiration. Usually, all vital signs are elevated in the alcoholic toxic state. The goals of management are to give adequate sedation and support to allow the client to rest and recover without danger of injury or peripheral vascular collapse. A sufficient dosage of a benzodiazepine medication such as lorazepam should be administered to establish and maintain sedation, which reduces agitation, prevents exhaustion, prevents seizures, and promotes sleep. Although the alternate answer options should be included in the client's care, the nurse's first action should be to treat the presenting symptoms. Once the client is calm, the nurse can assess for the risk to harm self or others. The nurse can also support the client in managing anxiety by encouraging deep breathing. If a family member is present, the nurse can ask him or her to stay at the bedside to support the client and ensure safety as the client experiences withdrawal symptoms.
The nurse received a patient from a motor vehicle accident who is hemorrhaging from a femoral wound. What is the initial nursing action for the control of the hemorrhage? Apply a tourniquet. Immobilize the area to control blood loss. Elevate the injured part. Apply firm pressure over the involved area or artery.
Apply firm pressure over the involved area or artery. Direct, firm pressure is applied over the bleeding area or the involved artery at a site that is proximal to the wound (Fig. 72-3). Most bleeding can be stopped or at least controlled by application of direct pressure. Otherwise, unchecked arterial bleeding results in death. A firm pressure dressing is applied, and the injured part is elevated to stop venous and capillary bleeding, if possible. If the injured area is an extremity, the extremity is immobilized to control blood loss. A tourniquet is applied to an extremity only as a last resort when the external hemorrhage cannot be controlled in any other way and immediate surgery is not feasible.
A patient is brought to the ED by a friend, who states that a tree fell on the patient's leg and crushed it while they were cutting firewood. What priority actions should the nurse perform? (Select all that apply.) Elevating the site to limit the accumulation of fluid in the interstitial spaces Performing a fasciotomy Splinting the wound in a position of rest to prevent motion Inserting an indwelling catheter Applying a clean dressing to protect the wound
Applying a clean dressing to protect the wound Elevating the site to limit the accumulation of fluid in the interstitial spaces Splinting the wound in a position of rest to prevent motion Major soft tissue injuries are dressed and splinted promptly to control bleeding and pain. If an extremity is injured, it is elevated to relieve swelling and pressure.
As part of an emergency department team, an emergency nurse is conducting a secondary survey on a client. Which of the following would the nurse include? Establishing a patent airway Applying electrocardiogram electrodes Providing adequate ventilation Assessing neurologic function
Applying electrocardiogram electrodes A secondary survey is completed after the primary survey priorities of airway, breathing, circulation, and disability have been addressed. Applying electrocardiogram electrodes would be a component of the secondary survey. Establishing a patent airway, providing adequate ventilation, and determining neurologic disability by assessing neurologic function are components of the primary survey.
A nurse is providing care to the family of a client who was brought to the emergency department and suddenly died. Which of the following would be appropriate for the nurse to do? Select all that apply. Talk with the family about the client having "passed on." Ask the family if they would like to view the body. Allow the family to express their emotions freely. Provide a private place for the family to be together. Provide sedation to family members as needed.
Ask the family if they would like to view the body. Provide a private place for the family to be together. Allow the family to express their emotions freely. When providing care to a family experiencing the sudden death of a member, the nurse would take the relatives to a private place where they can be together to grieve. In addition, the nurse would encourage the family to view the body if they wish and allow members to support each other and express their emotions freely. Euphemisms such as "passing on" or "going to a better place" should be avoided. Sedation is avoided because it may mask or delay the grieving process, which is necessary to achieve emotional equilibrium and prevent prolonged depression.
The ED staff work collaboratively and follow the ABCDE method to establish and treat health priorities effectively in a client experiencing a trauma. Which action is completed by the nurse when implementing the "D" element of this method? Assessing the client's Glasgow Coma Scale score Providing cervical spine protection Managing hypothermia Undressing the client quickly
Assessing the client's Glasgow Coma Scale score The primary survey focuses on stabilizing life-threatening conditions. The ED staff work collaboratively and follow the ABCDE (airway, breathing, circulation, disability, exposure) method. While implementing the D element, the nurse determines neurologic disability by assessing neurologic function using the Glasgow Coma Scale and performing a motor and sensory evaluation of the spine. A quick neurologic assessment may be performed using the AVPU mnemonic: A, alert: is the client alert and responsive? V, verbal: does the client respond to verbal stimuli? P, pain: does the client respond only to painful stimuli? U, unresponsive: is the client unresponsive to all stimuli, including pain? The other interventions are not included in this element of the primary survey.
A homeless client presents to the ED. Upon assessment, the client is experiencing hypothermia. The nurse will plan to complete which priority intervention during the rewarming process? Assist with endotracheal intubation Attach a cardiac monitor Insert a Foley urinary catheter Administer inotropic drugs
Attach a cardiac monitor Continuous electrocardiograph (ECG) monitoring is performed during the rewarming process because cold-induced myocardial irritability leads to conduction disturbances, especially ventricular fibrillation. A urinary catheter should be inserted to monitor urinary output; however, ECG monitoring is the priority. There is no indication for endotracheal intubation. Inotropic medications are contraindicated because they can stimulate the heart and increase the risk for fatal dysrhythmias, such as ventricular fibrillation.
The nurse is caring for a client who is agitated and confused. The client is persistently trying to get out of bed and attempted to remove the peripheral IV. The nurse has attempted to re-orient the client; however, this was not effective in de-escalating the client's agitation. The client yells, "I am going to punch you in the face!" What is the nurse's next action? Move out of the client's view Administer antipsychotic medication Apply physical restraints Call security personnel to assist
Call security personnel to assist Clients at risk for harming staff members require specific interventions. It is important to first notification of security and administration of the potential for violence. Although medication and physical restraints maybe required, the nurse will not be able to carry out these interventions in a safe manner independently. The nurse should first call for security personnel to assist, all other interventions can be carried out with the support of trained staff. When a client is agitated and has the potential to be violent, they should not be left unattended. Moving out of the client's view can lead to further agitation for the client and increase the risk for escalating to violence.
A client with a history of allergies comes to the emergency department. The nurse suspects anaphylaxis based on which of the following? Select all that apply. Facial angioedema Increasing blood pressure Generalized itching Chest tightness Pallor
Chest tightness Generalized itching Pallor Facial angioedema Manifestations suggesting anaphylaxis include chest tightness, generalized itching, pallor, massive facial angioedema, tachycardia or bradycardia, and decreasing blood pressure (as a result of peripheral vascular collapse).
A patient with a history of major depressive disorder is brought to the emergency department by a friend, who reports that the patient took an overdose of prescribed amitriptyline. Which of the following findings would the nurse expect to assess? Select all that apply. Visual hallucinations Hypothermia Tachycardia Hypoactive reflexes Clonus
Clonus Tachycardia Visual hallucinations Amitriptyline is a tricyclic antidepressant. In cases of overdose, the patient would likely experience tachycardia, hypotension, confusion, visual hallucinations, clonus, tremors, hyperactive reflexes, seizures, blurred vision, flushing, and hyperthermia.
The health care team in an intensive care unit have experienced a critical incident in which a young client died unexpectedly and the client's father physically attacked the senior physician treating the client. The client's father was arrested and escorted from the intensive care unit by police, against his will and in handcuffs. A critical incident stress management (CISM) staff meeting held 3 days after the incident took place. What would be the purpose for that meeting? Debriefing Follow up Counselling Defusing
Debriefing After serious events, critical incident stress management (CISM) is necessary to critique individual and group performance and to facilitate healthy coping. Optimally, this may consist of three steps: defusing, debriefing, and follow-up. Debriefing typically occurs 1 to 10 days after the critical incident. Debriefing sessions follow a format similar to the initial defusing session; however, during these sessions, participating staff are encouraged to discuss their feelings about the incident and are reassured that their negative reactions and feelings are normal and that their negative feelings will diminish over time. Defusing occurs immediately after the critical incident. During this session, affected staff are encouraged to discuss their feelings about the incident and are given contact information so that they may talk to someone if they have disturbing symptoms (e.g., sleeplessness, excessive worry). Follow-up may occur after the debriefing session is completed for those participants who have persistent negative symptoms and may consist of continued individual or group counseling and therapy. Counseling or group therapy would typically occur outside the context of the stress-inducing environment. Individuals may require private counseling versus group counseling.
A client is brought to the emergency department after being involved in a motor vehicle collision. Which of the following would lead the nurse to suspect internal bleeding? Delayed capillary refill Rising blood pressure Bradycardia Pale pink dry skin
Delayed capillary refill If a client exhibits tachycardia, falling blood pressure, thirst, apprehension, cool moist skin, or delayed capillary refill, internal bleeding should be suspected.
A high school football player is brought to the emergency department after collapsing at practice in extremely hot and humid weather. Which of the following would lead the nurse to suspect that the client is experiencing heat stroke? Diaphoresis Bradycardia Temperature of 101 degrees F (38 degrees C) Delirium
Delirium Manifestations of heat stroke include a temperature of 105 degrees F or greater (40.5 degrees C or greater), anhidrosis (absence of sweating), central nervous system dysfunction (bizarre behavior, delirium, confusion, or coma), hot, dry skin, tachycardia, tachypnea, and hypotension.
The nurse is conducting a secondary survey on a client in the ED. Which action is completed during the secondary survey? Establishing a patent airway Undressing the client Assessment of peripheral pulses Diagnostic and laboratory testing
Diagnostic and laboratory testing Diagnostic and laboratory testing is completed during the secondary survey, along with a complete health history, a head-to-toe assessment, insertion or application of monitoring devices, splinting of suspected fractures, cleansing, closure, and dressing of wounds, and performance of other necessary interventions based on the client's condition. The other interventions are completed during the primary survey.
A patient is brought to the emergency department and diagnosed with decompression sickness. The nurse interprets this as indicating that the patient most likely has been involved with which of the following? Swimming in a lake Running a race in hot humid weather Working in a chemical plant Diving in an ocean
Diving in an ocean Decompression sickness occurs when patients have engaged in diving in a lake or ocean or high-altitude flying or flying in a commercial aircraft within 24 hours of diving. Swimming in a lake could lead to a near-drowning episode. Running a race in hot humid weather would increase a person's risk for heat stroke. Working in a chemical plant would increase the risk for chemical burns.
A client presents to the ED reporting choking on a chicken bone. The client is breathing spontaneously. The nurse applies oxygen and suspects a partial airway obstruction. Which action should the nurse do next? Encourage the client to cough forcefully. Insert a nasopharyngeal airway. Insert an oropharyngeal airway. Prepare the client for a bronchoscopy.
Encourage the client to cough forcefully. If the client can breathe and cough spontaneously, a partial obstruction should be suspected. The client is encouraged to cough forcefully and to persist with spontaneous coughing and breathing efforts as long as good air exchange exists. There may be some wheezing between coughs. If the client demonstrates a weak, ineffective cough, a high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis, the client should be managed as if there were complete airway obstruction. If the client is unconscious, inspection of the oropharynx may reveal the offending object. X-ray study, laryngoscopy, or bronchoscopy also may be performed. There is no indication that an artificial airway is indicated.
A patient brought to the ED by the rescue squad after getting off a plane at the airport is complaining of severe joint pain, numbness, and an inability to move the arms. The patient was on a diving vacation and went for a last dive this morning before flying home. What is a priority action by the nurse? Send the patient to the hyperbaric chamber. Draw labs for a chemistry panel. Ensure a patent airway and that the patient is receiving 100% oxygen. Send the patient for a chest x-ray.
Ensure a patent airway and that the patient is receiving 100% oxygen. Decompression sickness, also known as "the bends," occurs in patients who have engaged in diving (lake/ocean diving), high-altitude flying, or flying in commercial aircraft within 24 hours after diving. Signs and symptoms include joint or extremity pain, numbness, hypesthesia, and loss of range of motion. A patent airway and adequate ventilation are established before all other interventions, as described previously, and 100% oxygen is administered throughout treatment and transport.
A patient has undergone a diagnostic peritoneal lavage. The nurse interprets which result as indicating a positive test? Absence of bile Red blood cell count of 50,000/mm3 White blood cell count of 300/mm3 Evidence of feces
Evidence of feces A diagnostic peritoneal lavage is considered positive if there is bile, feces, or food in the specimen, a red blood cell count greater than 100,000/mm3, and a white blood cell count greater than 500/mm3.
The nurse is providing care to a client who will be ambulating for the first time after being extubated. The client tells the nurse, "I don't want to do this today. It's too soon and I am afraid I am not strong enough." What intervention should the nurse implement first for the client's fear of falling? Explore possible causes of the client's fear Evaluate the client for cognitive impairment Allow the client to remain on bedrest Clear the area around the bed
Explore possible causes of the client's fear The client is exhibiting a fear of falling. For a client who has not mobilized in days due to mechanical ventilation and other medication interventions in the intensive care unit (ICU), ICU-acquired weakness is a reality. The client's concerns should be addressed by exploring the possible reasons for the fear of falling first. The client may be experiencing pain, dizziness or self-doubt. By identifying this cause, the nurse will be able to formulate the next action. The risk for falls is not due to cognitive impairment. This is evident in that the client is aware of current limitations and as a result is fearful. Preventative and rehabilitative measures to counter ICU-acquired weakness generally include early identification and treatment of potential causes of multiple organ failure (in particular severe sepsis and septic shock), avoiding unnecessary deep sedation and hyperglycemia, promotion of early mobilization, and thoughtful decisions regarding the risks versus benefits of corticosteroids. For these reasons, the client should not be encouraged to continue to have bedrest. Although the nurse should ensure the area around the bed is free of clutter to prevent a fall, this does not address the client's anxiety related to the fear of falling.
A patient arrives at the emergency department after taking more than 20 lorazepam tablets. Which of the following would the nurse anticipate that the patient would be given to reverse the effects of the drug? Diazepam Naloxone N-acetylcysteine Flumazenil
Flumazenil Lorazepam is a nonbarbiturate sedative whose effects are reversed with flumazenil. Naloxone is used to reverse the effects of opioids. Diazepam is used to treat seizures associated with drug overdose. It would not be used here, because it is in the same class as lorazepam and concurrent administration would add to the patient's overdose state. N-acetylcysteine is the antidote for acetaminophen toxicity.
The nurse is caring for a client with diabetes who requires a peripheral intravenous (PIV) line for antibiotic administration and to treat dehydration. The nurse must avoid inserting which type of PIV? Foot Hand Forearm Upper arm
Foot PIV lines should rarely be used in the foot for various reasons. They limit the client's ability to ambulate and tend to occlude easily. These types of IVs should never be used in clients with diabetes due to the risk that the client has neuropathy and cannot feel injury caused by the IV catheter. IV lines in the forearm and hands are acceptable and are commonly used sites. These sites would be safe to use for a client with diabetes. The upper arm is a site of choice for the insertion of a peripherally inserted central line (PICC) not a PIV line. Although, this site would not be an option for a PIV line, it would be safe for use in a client with diabetes if warranted.
A client is brought to the emergency department after being locked outside of her house in the frigid weather for several hours. What finding leads the nurse to suspect the client has sustained frostbite of the hand? Hand is cool with pale nailbeds Hand is insensitive to touch Hand appears pink with some white spotting Hand is soft to palpation
Hand is insensitive to touch Indicators of frostbite include an extremity that is hard, cold, and insensitive to touch and appears white or mottled blue-white. A hand that is pink, soft, or cool with pale nailbeds is not indicative of frostbite.
A nurse is working as a camp nurse during the summer. A camp counselor comes to the clinic after receiving a snakebite on the arm. What is the first action by the nurse? Apply ice to the area. Make an incision and suck the venom out. Apply a tourniquet to the arm above the bite. Have the patient lie down and place the arm below the level of the heart.
Have the patient lie down and place the arm below the level of the heart. Initial first aid at the site of the snakebite includes having the person lie down, removing constrictive items such as rings, providing warmth, cleansing the wound, covering the wound with a light sterile dressing, and immobilizing the injured body part below the level of the heart. Airway, breathing, and circulation are the priorities of care. Ice, incision and suction, or a tourniquet is not applied.
The nurse is caring for a victim of a sexual assault. The client is fearful and experiencing flashbacks. The nurse recognizes that the client is experiencing which phase of the psychological reaction to rape? Heightened anxiety phase Reorganization phase Acute disorganization phase Denial phase
Heightened anxiety phase During the heightened anxiety phase, the client demonstrates anxiety, hyperalertness, and psychosomatic reactions, in addition to fear and flashbacks. The acute disorganization phase is characterized by shock, disbelief, guilt, humiliation, and anger. The denial phase is characterized by an unwillingness to talk. The reorganization phase occurs when the incident is put into perspective. Some clients never fully recover from rape trauma.
A client comes to the emergency department with a suspected airway obstruction. The emergency department team prepares to manage the client as if he has a complete airway obstruction based on which of the following? Wheezing between coughs Refusal to lie flat Forceful coughing High-pitched noise on inhalation
High-pitched noise on inhalation A client who demonstrates a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis should be managed as if he or she has a complete airway obstruction. Forceful coughing, wheezing between coughs, and a refusal to lie flat suggest a partial airway obstruction that can be managed as such.
A client has sustained multiple injuries from a gunshot wound while hunting in cold winter weather. The client has waited several hours for rescue and is transported in a helicopter to the emergency department. The nurse recognizes what additional factors are associated with increased mortality for this client? Hypothermia, acidosis, and coagulopathy Comorbidities, location of injury, and gravitational forces Time of injury, hyperhidrosis, and thermal changes Venous insufficiency, barometric changes, and fatigue
Hypothermia, acidosis, and coagulopathy Major trauma can cause hypothermia, acidosis, and coagulopathy, sometimes called the "triad of death" because each of these factors is associated with increased mortality. In this case the client was exposed to cold weather for several hours. The client had a gunshot wound that caused bleeding. Coagulopathy likely occurs immediately after massive trauma and shock. As the client with trauma perfusion worsens, lactic acid rapidly accumulates in the tissues, which ultimately results in severe metabolic acidosis. Thermal changes, gravitational forces, barometric changes, and fatigue are all related to stresses of flight, but they are not directly related to an increased mortality. Comorbidities, time, and location of injury can contribute to the client's survivability but are paired with choices that do not. Venous insufficiency and hyperhidrosis (excessive sweating) are not directly linked to this event.
A nurse is caring for a client who has arrived at the emergency department in shock. The nurse intervenes based on the knowledge that which of the following is the most common cause of shock? Sepsis Cardiac dysfunction Anaphylaxis Hypovolemia
Hypovolemia Types of shock include cardiogenic, neurogenic, anaphylactic, and septic. Of these, the most common cause is hypovolemia.
The nurse educator is providing orientation to a group of nurses newly hired to an intensive care unit. The group of nurses are correct in stating which is the most common type of shock managed in critical care? Neurogenic Hypovolemic Anaphylactic Cardiogenic
Hypovolemic The underlying cause of shock (hypovolemic, cardiogenic, neurogenic, anaphylactic, or septic) must be determined. Of these, hypovolemia is the most common cause.
A nurse is completing her annual cardiopulmonary resuscitation training. The class instructor tells her that a client has fallen off a ladder and is lying on his back; he is unconscious and isn't breathing. What maneuver should the nurse use to open his airway? Abdominal thrust Seldinger Jaw-thrust Neck tilt-head lift
Jaw-thrust If a neck or spine injury is suspected, the jaw-thrust maneuver should be used to open the client's airway. To perform this maneuver, the nurse should position herself at the client's head and rest her thumbs on his lower jaw, near the corners of his mouth. She should then grasp the angles of his lower jaw with her fingers and lift the jaw forward. The head tilt-chin lift maneuver is used to open the airway when a neck or spine injury isn't suspected. To perform this maneuver the nurse places two fingers on the chin and lifts while pushing down on the forehead with the other hand. The abdominal thrust is used to relieve severe or complete airway obstruction caused by a foreign body. The Seldinger maneuver is a method of percutaneous introduction of a catheter into a vessel.
A female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing interventions should be provided? (Select all that apply.) Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police. Ensure that the police are present when the examination is performed. Assess and document any bruises and lacerations. Record a history of the event, using the patient's own words. Have the patient shower or wash the perineal area before the examination.
Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police. Assess and document any bruises and lacerations. Record a history of the event, using the patient's own words. A history is obtained only if the patient has not already talked to a police officer, social worker, or crisis intervention worker. The patient should not be asked to repeat the history. Any history of the event that is obtained should be recorded in the patient's own words. The patient is asked whether he or she has bathed, douched, brushed his or her teeth, changed clothes, urinated, or defecated since the attack, because these actions may alter interpretation of subsequent findings. Each item of clothing is placed in a separate paper bag. The bags are labeled and given to appropriate law enforcement authorities. The patient is examined (from head to toe) for injuries, especially injuries to the head, neck, breasts, thighs, back, and buttocks. The exam focuses on external evidence of trauma (bruises, contusions, lacerations, stab wounds).
The nurse is administering antivenin to a patient who was bitten on the arm by a venomous snake. What intervention provided by the nurse is required prior to the procedure and every 15 minutes after? Administer diphenhydramine (Benadryl). Administer cimetidine (Tagamet). Assess peripheral pulses. Measure the circumference of the arm.
Measure the circumference of the arm. Before administering antivenin and every 15 minutes thereafter, the circumference of the affected part is measured. Premedication with diphenhydramine (Benadryl) or cimetidine (Tagamet) may be indicated, because these antihistamines may decrease the allergic response to antivenin. Antivenin is administered as an IV infusion whenever possible, although intramuscular administration can be used.
A client presents to the ED after an unsuccessful suicide attempt. The client is diagnosed with an acetaminophen overdose. The nurse anticipates the administration of which medication? Naloxone Flumazenil Diazepam N-acetylcysteine
N-acetylcysteine Treatment of acetaminophen overdose includes administration of N-acetylcysteine. Flumazenil is administered in the treatment of nonbarbiturate sedative overdoses. Naloxone is administered in the treatment of narcotic overdoses. Diazepam may be administered to treat uncontrolled hyperactivity in the client with a hallucinogen overdose.
Which medication reverses severe respiratory depression and coma? Diazepam Flumazenil N-acetylcysteine Naloxone hydrochloride
Naloxone hydrochloride Naloxone hydrochloride, a narcotic antagonist, reverses respiratory depression and coma. Diazepam is a benzodiazepine. Flumazenil is a benzodiazepine antagonist. N-acetylcysteine is used for acetaminophen toxicity.
The nurse is caring for a client with known myocardial ischemia. The client will be getting up to ambulate for the first time in three days after being on bedrest since admission to the intensive care unit. Which medication should the nurse administer before the client ambulates? Dobutamine Vasopressin Norepinephrine Nitroglycerin
Nitroglycerin Nitroglycerin is indicated for use in clients who experience angina pectoris as a result of myocardial ischemia. The medication acts by decreasing blood pressure and causing arterial vasodilation permitting blood flow into the myocardium. Nitroglycerin should be given prior to any anticipated physical exertion that is likely to bring on chest pain from vasoconstriction. Vasopressin is a vasoactive medication administered to increase blood pressure in cases where clients have diabetes insipidus, a gastrointestinal bleed or in cases of septic shock. Norepinephrine raises blood pressure and is indicated for use in emergencies such as cardiac arrest or for hypovolemia. Dobutamine increased heart contractility and blood pressure to improve stroke volume in clients with congestive heart failure.
A client presents to the ED following a chemical burn. The client identifies the source of the burn as white phosphorus. The nurse knows that treatment will include immediately drenching the skin with running water from a shower, hose, or faucet. No application of water to the burn. alternately applying water and ice to the burn. washing off the chemical using warm water, then flushing the skin with cool water.
No application of water to the burn. Water should not be applied to burns from lye or white phosphorus because of the potential for an explosion or for deepening of the burn. All evidence of these chemicals should be brushed off the client before any flushing occurs.
A nurse who is a member of an emergency response team anticipates that several patients with airway obstruction may need a cricothyroidotomy. For which of the following patients would this procedure be appropriate? Select all that apply. Patient with an obstructed larynx Patient with a lumbar spine injury Patient with laryngeal edema secondary to anaphylaxis Patient who is bleeding from the chest Patient with extensive facial trauma
Patient with extensive facial trauma Patient with laryngeal edema secondary to anaphylaxis Patient with an obstructed larynx Cricothyroidotomy is used in emergencies when endotracheal intubation is either not possible or contraindicated. Examples include airway obstruction from extensive maxillofacial trauma, cervical spine injury, laryngospasm, laryngeal edema after an allergic reaction or extubation, hemorrhage into neck tissue, and obstruction of the larynx.
When preparing to perform abdominal thrusts on a client with an airway obstruction, which of the following would be most appropriate? Using a sequence of four thrusts, each progressing in intensity Having the conscious client lie down Positioning the hands in the midline slightly above the umbilicus Placing the thumb side of one hand at the xiphoid process
Positioning the hands in the midline slightly above the umbilicus When performing abdominal thrusts, the nurse would place the thumb side of one fist against the client's abdomen in the midline slightly above the umbilicus and well below the xiphoid process, grasping the fist with the other hand. Then the nurse would press the fist into the client's abdomen with a quick inward and upward thrust such that each new thrust should be a separate and distinct maneuver. The unconscious client is positioned on the back. The client who is conscious should be standing or sitting.
A nurse is providing care to a client in the emergency department and walks into the hallway to get equipment. All of a sudden, gunshots are heard. Which of the following would be the nurse's priority? Providing care to the injured Securing the area Gaining control of the situation Protecting himself or herself
Protecting himself or herself If gunfire occurs in the emergency department, self-protection is the priority. Security officers and police must gain control of the situation first and then care is provided to the injured
The nurse has received a client into care who was admitted with a heroin overdose. The client has a 5-year history of illicit substance use with cocaine, heroine and oxycodone. The client develops a sudden onset of wheezing, restlessness and a cough that produces a frothy, pink sputum. The nurse suspects the client has most likely developed which complication of opioid overdose? Pulmonary edema Congestive heart failure Panic attack Pneumonia
Pulmonary edema The nurse should suspect the client has developed pulmonary edema, which is frequently seen in clients who abuse/overdose on narcotics. Many drugs — ranging from illegal drugs such as heroin and cocaine to aspirin — are known to cause noncardiogenic pulmonary edema. Pneumonia is not the likely cause given the sudden onset of respiratory symptoms accompanied but coughing up the pink frothy sputum. The client's history of illicit substance use and now overdose on these drugs should lead the nurse to suspect pulmonary edema is the cause of the sudden onset of these symptoms over congestive heart failure, in which clients have a more gradual onset of respiratory issues. Although a panic attack can manifest in shortness or breath and restlessness, the client would not be wheezing or producing blood tinged sputum with a cough. Panic attacks do, however, have a sudden onset and can cause the client chest pain and a sense of doom.
A nurse is establishing a patient's airway. Which action would the nurse perform first? Inserting an artificial airway Repositioning the patient's head Giving abdominal thrusts Using the jaw-thrust maneuver
Repositioning the patient's head Establishing an airway may be as simple as repositioning the patient's head to prevent the tongue from obstructing the pharynx. Subsequent measures would include abdominal thrusts to dislodge a foreign body, head-tilt chin-lift or jaw-thrust maneuver, or insertion of an artificial airway.
The nurse is caring for a 21-year-old client with a diagnoses of brain death due to injuries sustained in a snowboarding accident. The family has chosen to remove life support measures to allow the client's death. Upon hearing the family's decision, what is the nurse's first action? Provide family members with PRN sedation Request senior medical staff discuss organ donation Ask the family if the client had advanced directives Assess for interrupted family processes
Request senior medical staff discuss organ donation Clients who meet the criteria for past health and current diagnosis of brain death are eligible to donate organs to those on the various transplant lists. This places nurses in a difficult position at times due to their simultaneous obligations to care for a particular client and the family while informing organ donation services of a potential donor. When the diagnosis of brain death is made, it is usually up to the senior medical staff and organ procurement services to approach the family about the possibility of organ donation. The nurse's next best action is to request a senior physician speak to the family in a timely manner so organs can be harvested and made available as needed. Advance directives are typically in place for clients who are older and for whom death may be expected. In this case, the client is young and death is unexpected, advanced directives are not likely and this question would be inappropriate. Although the nurse should assess for interrupted family process, this is not the nurse's initial action after hearing the family has decided to remove life support. This nursing assessment goes beyond acute care and into the provision of community health services which the family will need throughout their grieving process.
The nurse in an intensive care unit is assigned to two clients. One of the clients has just passed away. The deceased client's family members have arrived to be at the client's bedside. Despite wanting to support the client's family, the nurse is must assess the other client's vital signs every 15 minutes, because the client is receiving a blood transfusion. In this situation, what is the nurse's best action? Request that the pastor be present to support the family at the client bedside Hand off care of the other client to another nurse Delegate the blood transfusion to the licensed practical/vocational nurse Explain to the family it is a busy time on the unit but someone will be with them soon
Request that the pastor be present to support the family at the client bedside The death of a family member in the intensive care unit is a difficult and often time-consuming process. If nurses are unable to spend much time with grieving client's family, it is imperative to find the family alternate help: a colleague with more experience with grieving clients, a pastor, a social worker, hospital volunteers, family, or friends. It would be best if the nurse requests a pastor be available to the family in advance of their arrival to the deceased client's bedside. Much of the pastor's role in hospital settings is to support grieving families; therefore, the pastor would have more time to be with the family during this difficult time. The blood transfusion in the intensive care unit is not within the scope of practice for the licensed practical/vocational nurse. The nurse cannot delegate the monitoring of blood products to this health care provider. The intensive care unit is a busy environment and as difficult as it is for the assigned nurse to remain with the deceased client, it would be even more difficult for a nurse with a full assignment to take on the support role for the family. Explaining to the family that the unit is busy demonstrates a lack of empathy and would be countertherapeutic communication. It would not be appropriate to explain this to the family.
A nurse is performing triage at the scene of a building collapse and is using a five-level triage system. Place the categories below in the proper order from most to least immediate.
Resuscitation Emergent Urgent Less urgent Nonurgent The five-level system of triage classifies patients as follows: resuscitation (need immediate treatment to prevent death); emergent (may deteriorate rapidly and develop a major life-threatening situation or require time-sensitive treatment); urgent (need two or more resources to provide care and conditions are not life-threatening); less urgent (need only one resource for needs and condition is not life-threatening); and nonurgent (require no resources for care with no life-threatening condition).
A nurse is providing an educational program for a group of occupational health nurses working in chemical facilities. Which of the following would the nurse include as the priority in the case of a chemical burn? Rinsing the area with copious amounts of water Administering tetanus prophylaxis Covering the area with a sterile dressing Applying antimicrobial ointment
Rinsing the area with copious amounts of water The priority for any chemical burn is to immediately drench the area with running water, unless the chemical is lye or white phosphorus, which should be brushed off the patient. Antimicrobial ointments, sterile dressings, and tetanus prophylaxis are measures instituted later in the course of treatment, depending on the characteristics of the chemical agent and the size and location of the burn.
The nurse has commenced a transfusion of fresh frozen plasma (FFP) and notes the client is exhibiting symptoms of a transfusion reaction. After the nurse stops the transfusion, what is the next required action? Start a dextrose 5% water infusion Remove the peripheral IV line Obtain a blood culture from the IV insertion site Run a normal saline line to keep the vein open
Run a normal saline line to keep the vein open If the nurse suspects a transfusion reaction, the transfusion must be stopped immediately and the nurse's next action is to ensure the normal saline line is running at a rate that permits administration of IV fluids or medications that are required to treat the reaction. The nurse should ensure IV access is maintained. The "to keep vein open" (TKVO) rate allows the nurse to keep the IV client without the potential to cause fluid volume overload. It would be unsafe for the nurse to remove the peripheral IV because continued access is required for urgent IV administration of medications or fluids to treat the reaction. Obtaining a blood culture at the IV site would be necessary if an infection was suspected. This is not required for a transfusion reaction. Normal saline is the solution of choice when transfusing blood products because there is a risk for incompatibility with all other IV solutions.
A client comes to the emergency department after experiencing a wound. Inspection reveals an opening in the skin with distinct edges and whose depth is greater than the length of the wound. The nurse documents this as which type of wound? Stab Patterned Avulsion Laceration
Stab A stab wound is an incision of the skin with well-defined edges and is typically deeper than long. It is usually caused by a sharp instrument. A laceration is a tear in the skin with irregular edges and vein bridging. An avulsion is manifested as a tearing away of tissue from the supporting structures. A patterned wound takes on the outline of the object causing the wound.
A patient was bitten by a tick 3 months ago and is now having muscle aches as well as joint pain and swelling. The patient is having difficulty with self care and requires assistance with activities of daily living (ADLs). What stage of Lyme disease does the nurse recognize the patient is in? Stage I Stage IV Stage II Stage III
Stage III Lyme disease has three stages. Stage I presents with a classic "bull's-eye" rash (i.e., erythema migrans) and flulike signs and symptoms that may include chills, fever, myalgia, fatigue, and headache. If antibiotics are not administered, stage II Lyme disease may present within 4 to 10 weeks following the tick bite and may manifest with joint pain, memory loss, poor motor coordination, and meningitis. Stage III can begin anywhere from weeks to more than a year after the bite and has serious long-term chronic sequelae, including arthritis, neuropathy, myalgia, and myocarditis.
A nurse is providing in-service education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step? Performing the pelvic examination Obtaining consent for examination Collecting semen Supporting the client's emotional status
Supporting the client's emotional status The teaching session is successful when staff members focus first on supporting the client's emotional status. Next, staff members should gain consent to perform the pelvic examination, perform the examination, and collect evidence, such as semen if present.
The nurse is caring for a client who is being prepared for the placement of a central intravenous line. The nurse recognizes this client requires this type of intravenous access for which reason? The client requires infusion of a dextrose 5% water (D5W) The client will require intravenous access for three days The client requires infusion of intravenous antibiotics The client requires total parenteral nutrition
The client requires total parenteral nutrition For a patient who requires total parenteral nutrition (TPN), a central intravenous line is required due to the length of time the client will require the infusion as well as the nature of the solution itself. A large vein is required to safely infuse TPN. For this reason, a central line is needed. A peripheral intravenous line is safe to used when IV access is required under six days. Beyond this time, either a new peripheral IV will need to be inserted. If it is known in advance that IV treatment will last beyond six days, the client's health care provider will order the placement of a central intravenous line. Intravenous antibiotics can be administered peripherally unless the course is longer than six days. D5W is an intravenous solution that can be administered either peripherally or centrally. The nature of this IV solution would not determine which type of IV access the client requires.
A patient in the emergency department is bleeding profusely from numerous large and deep lacerations on the top of his head, right side of his face, and forehead. The nurse determines the need to apply pressure at the appropriate pressure point. The nurse would use which of the following pressure points?
The location of the injuries and site of bleeding determine which pressure point to use. In this case, the patient's bleeding is proximal to the temporal artery; therefore, pressure should be applied to this area, as shown in option A. If the patient was bleeding from the lower portion of the face, pressure would be applied to the facial artery, as in option B. The carotid artery would be used to control bleeding proximal to that area. The subclavian artery would be used to control bleeding proximal to it, such as the lower neck and shoulder area.
What is a common source of airway obstruction in an unconscious client? Edema Saliva or mucus The tongue A foreign object
The tongue In an unconscious client, the muscles controlling the tongue commonly relax, causing the tongue to obstruct the airway. When this situation occurs, the nurse should use the head-tilt, chin-lift maneuver to cause the tongue to fall back into place. If she suspects the client has a neck injury she must perform the jaw-thrust maneuver.
A finger sweep is only to be used in which client population? Child Adolescent Unconscious adult Conscious adult
Unconscious adult A finger sweep should be used only in the unconscious adult client. This action draws the tongue away from the back of the throat and away from any foreign body that may be lodged there. A finger sweep should not be done on a conscious adult, child, or adolescent.
A triage nurse in the ED determines that a patient with dyspnea and dehydration is not in a life-threatening situation. What triage category will the nurse choose? Immediate Urgent Emergent Delayed
Urgent A basic and widely used triage system that had been in use for many years utilized three categories: emergent, urgent, and nonurgent. In this system, emergent patients had the highest priority, urgent patients had serious health problems but not immediately life-threatening ones, and nonurgent patients had episodic illnesses.
A client presents to the ED with serious health problems that are not immediately life threatening. The nurse will correctly triage the client into which category? Nonurgent Emergent Psychological support Urgent
Urgent Clients triaged as urgent have serious health problems that are not immediately life threatening. They must be seen within 1 hour. The emergent category is for clients who have the highest priority conditions that are life-threatening and they must be seen immediately. Nonurgent is for clients who have episodic illness that can be addressed within 24 hours without increased morbidity. Clients in the less urgent category must be reassessed at least every 60 minutes and do not have serious health problems.
A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's: blood pressure. hemoglobin level. temperature. heart rate.
blood pressure. With adequate fluid replacement, fluid volume in the intravascular space expands, raising the client's blood pressure. The hemoglobin level reflects red blood cell concentration, not overall fluid status. Temperature and heart rate aren't directly related to fluid status.
A critical care nurse is providing care to a client who requires a pacemaker. The client has electrodes placed on the front and side of the chest. The nurse identifies this as which type of pacemaker? epicardial external pacemaker transvenous transthoracic
external pacemaker External pacemakers involve placement of electrodes on the front and side or back of the chest to deliver repeated shocks. Transvenous pacemakers involve placement of a wire into the right ventricle via a central IV catheter. Epicardial pacemaker involves surgical placement of wires into the epicardium to prevent and treat postsurgical conduction defects. Transthoracic cardiac pacemakers involve introduction of a wire into the right ventricle, which is attached to a generator.
A critical care nurse providing care to a client receiving mechanical ventilation identifies that the client is at risk for gastrointestinal bleeding. Which agent would the nurse anticipate administering if prescribed? pantoprazole sucralfate heparin aluminum hydroxide
pantoprazole The incidence of GI bleeding has decreased over the last few decades and is largely due to standard administration of proton pump inhibitors (PPIs, such as pantoprazole) or H2-histamine antagonists. Sucralfate, aluminum hydroxide, and heparin would not be used.
A client in the critical care unit has undergone insertion of a pulmonary artery catheter. When providing care for this client, the nurse would be alert for signs and symptoms of which complication? Select all that apply. increased afterload pneumothorax dysrhythmia increased preload pulmonary artery rupture
pneumothorax dysrhythmia pulmonary artery rupture Complications such as pneumothorax, cardiac dysrhythmias, and pulmonary artery rupture are possible with insertion of a pulmonary artery catheter. Increased preload occurs with increased fluid volume and vasoconstriction; increased afterload occurs with hypovolemia and vasoconstriction.
A client on the unit receiving mechanical ventilation is being prepared to be weaned from the ventilator. When developing this client's plan of care, which ventilator mode would the nurse anticipate using? pressure support high-frequency assist control synchronized intermittent mandatory
pressure support Pressure support ventilation (PSV) is a mode of ventilation in which the client breathes spontaneously but uses additional pressure during inspiration to increase air flow through the ventilator tubing and artificial airway. This decreases the work of breathing caused by a narrowed airway. Clients using pressure support are often in the process of being weaned from the ventilator. Assist control (AC) also delivers a set tidal volume but allows clients to set their own respiratory rate. When they take a breath, they receive the entire preset tidal volume, thus decreasing their work of breathing. High-frequency ventilation (HFV), or oscillating ventilators, deliver very small tidal volumes (from 3 to 6 mL/kg or 50 to 80 mL in a range from 60 to over 200 times per minute). This works on the principle of oxygen diffusion gently pulsating throughout the lungs. Clients on this form of ventilation also require sedation. Synchronized intermittent mandatory ventilation (SIMV) delivers a number of breaths at a preset tidal volume to ensure a minimum number of breaths with an adequate tidal volume. Clients may breathe spontaneously but will receive only the tidal volume they are able to inspire on their own.
Following a motor vehicle collision, a client is brought to the ED for evaluation and treatment. The client is being assessed for intra-abdominal injuries. The client reports severe left shoulder pain (pain score of 10 on a 1 to 10 scale). The nurse suspects injury to the large intestine. gallbladder. spleen. liver.
spleen. The location of pain can indicate certain types of intra-abdominal injuries. Pain in the left shoulder is common in a client with bleeding from a ruptured spleen, whereas pain in the right shoulder can result from laceration of the liver.
A critical care nurse providing care to a client with a cardiac condition is determining the client's cardiac output. Which component would the nurse use to determine this measurement? Select all that apply. stroke volume pulmonary vascular resistance mean arterial pressure cardiac index heart rate
stroke volume heart rate Cardiac output is determined by multiplying the client's stroke volume by heart rate. Cardiac index, pulmonary vascular resistance, and mean arterial pressure are not used to determine cardiac output.
A client in the critical care unit has developed class IV heart failure and is not considered a candidate for transplantation. Based on the nurse's knowledge of treatment, the nurse would anticipate which intervention? ventricular assist device pacemaker vasoactive medication intra-aortic balloon pump
ventricular assist device VADs are reserved for clients who cannot be weaned from maximum volume/inotropic support or the IABP, are awaiting cardiac transplantation, or have class IV heart failure but are not candidates for transplantation. Vasoactive medications, pacemaker, and intra-aortic balloon pump would be used prior to deciding to use a VAD.
A client with a cardiac condition being cared for in the critical care unit is awake and hemodynamically stable. Plans are in progress to transfer the client to the step-down unit. Which intervention would the nurse most likely implement while the client is still in the unit? Select all that apply. arterial line insertion vital sign monitoring oxygen saturation assessment peripheral IV access maintenance cardiac monitoring
vital sign monitoring oxygen saturation assessment cardiac monitoring peripheral IV access maintenance Clients who are expected to do well, but need additional monitoring in case of unexpected complications (e.g., bleeding, dysrhythmias) should have the following interventions readily available in case of emergency: vital sign assessment, oxygen saturation monitoring, cardiac monitoring, and peripheral IV access. Arterial line insertion would be needed for clients who have a medical or surgical issue in which recovery depends on the medical team's provision of more precise monitoring (e.g., heart failure).
