Chapter 70

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? 1) Having suction available 2) Assessing pupil size and reactivity 3) Immobilizing any obvious deformities 4) Obtaining blood samples for type and crossmatch

ANS: 1 Feedback 1 The priority nursing actions related to breathing when conducting a primary survey during an emergency assessment include having suction available and giving supplemental oxygen. 2 Assessing pupil size and reactivity is an appropriate nursing action during the brief neurological assessment. 3 Immobilization of any obvious deformities is a nursing action appropriate in response to data obtained during the disability portion of the assessment. 4 Obtaining blood samples for a type and crossmatch is a nursing action appropriate in response to data obtained during the circulation portion of the assessment.

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) 1) Clear the airway 2) Protect the cervical spine 3) Perform chest compressions 4) Provide supplemental oxygen

ANS: 1243 Feedback: The first step the nurse takes when providing care to a trauma patient is to clear the airway. The second step is to protect the cervical spine. The third step is to provide supplemental oxygen. The fourth step is to perform chest compressions.

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) 1) A patient with a leg laceration requiring sutures 2) A patient with abdominal pain rated as a 7 on a numeric pain scale 3) A patient who has multiple trauma due to a motor vehicle accident 4) A patient who took an overdose of opioids with a respiratory rate of eight breaths per minute

ANS: 4321 Feedback: When using the Five-Level Emergency Severity Index (ESI), an ESI-1 is the highest priority while an ESI-5 is the lowest priority. The patient who took an overdose of opioids and is experiencing bradypnea (respiratory rate of less than 10 breaths per minute) is the priority at ESI-1. The patient who has multiple trauma due to a motor vehicle accident is an ESI-2. The patient with abdominal pain rated as a 7 using the numeric pain scale is an ESI-3. A patient with a leg laceration requiring sutures is an ESI-4.

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? 1) Charge nurse 2) Nurse supervisor 3) Licensed practical nurse 4) Unlicensed assistive personnel

ANS: 1 Feedback 1 A charge nurse coordinates care and assignments and may ultimately be the only person familiar with all the needs of any individual patient; therefore, it is this member of the team that will prioritize care for the patients who are being admitted. 2 The nurse supervisor may be in charge of assigning the trauma patients to individual units. 3 The licensed practical nurse will receive a patient assignment on the unit but will not prioritize care for the unit. 4 The unlicensed assistive personnel will be delegated tasks by other members of the nursing team.

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? 1) Determining drug allergies 2) Noting the general appearance 3) Examining the neck for stiffness 4) Auscultating for heart and lung sounds

ANS: 1 Feedback 1 The priority nursing action during the health history portion of the assessment is to determine drug allergies. 2 Noting the general appearance, examining the neck for stiffness, and auscultating for heart and lung sounds are actions that occur during the head-to-toe physical assessment, not the health history. 3 Noting the general appearance, examining the neck for stiffness, and auscultating for heart and lung sounds are actions that occur during the head-to-toe physical assessment, not the health history. 4 Noting the general appearance, examining the neck for stiffness, and auscultating for heart and lung sounds are actions that occur during the head-to-toe physical assessment, not the health history

Which are the priority nursing actions after the completion of the secondary survey when providing care for a trauma patient with a penetrating wound? 1) Documenting the patient's care 2) Formulating the patient's plan of care 3) Reassessing the patient's level of consciousness 4) Transferring the patient to the general medical unit

ANS: 1 Feedback 1 The priority nursing actions after completion of the secondary survey during the emergency assessment include documenting all patient care and administering tetanus prophylaxis. 2 Formulating the patient's plan of care, reassessing level of consciousness, and transferring the patient to the general medical unit are nursing actions implemented once the patient is stable. 3 Formulating the patient's plan of care, reassessing level of consciousness, and transferring the patient to the general medical unit are nursing actions implemented once the patient is stable. 4 Formulating the patient's plan of care, reassessing level of consciousness, and transferring the patient to the general medical unit are nursing actions implemented once the patient is stable.

Which member of the health-care team, when using the team nursing approach, is responsible for prioritizing patient care? 1) Team leader 2) Charge nurse 3) Licensed practical nurse 4) Unlicensed assistive personnel

ANS: 1 Feedback 1 When using the team nursing approach, the team leader, who is a registered nurse, is responsible for coordinating a group of licensed and unlicensed personnel to provide patient care to a small group of patients, including the prioritization of patient care. 2 The charge nurse is responsible for assigning team members to each team leader. 3 The licensed practical nurse and the unlicensed assistive personnel will receive their assigned tasks and patient care from the team leader. 4 The licensed practical nurse and the unlicensed assistive personnel will receive their assigned tasks and patient care from the team leader

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? 1) Taking vital signs 2) Providing wound care 3) Conducting discharge teaching 4) Administering oral medications

ANS: 1 Feedback 1 When working in an environment that uses the functional model of nursing, each team member will be delegated tasks for a group of patients by the team leader, the RN. The RN will delegate taking vital signs to the UAP. 2 One of the LPNs can provide wound care. 3 Typically, the RN is the member of the team who will conduct discharge teaching. 4 An LPN is able to administer oral medications.

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. 1) Airway maintenance 2) Obtaining medical history 3) Ventilation assistance 4) Hemorrhage control 5) Hypothermia prevention

ANS: 1, 3, 4, 5 Feedback 1. This is correct. Clinical priorities for the treatment of gunshot wound are the following: maintain airway and assist ventilation as necessary, control hemorrhage, prevent hypothermia. Also necessary is a rapid, recurrent assessment of the patient's neurological status, as well as prevention of infection. 2. This is incorrect. While obtaining the patient's medical history is important, this action would not be priority and would take place after the priority assessment and treatment. Once the safety of the patient is assured, then the nurse will manage the patient's emotional state and obtain the medical history. 3. This is correct. Clinical priorities for the treatment of gunshot wound are the following: maintain airway and assist ventilation as necessary, control hemorrhage, prevent hypothermia. Also necessary is a rapid, recurrent assessment of the patient's neurological status, as well as prevention of infection. 4. This is correct. Clinical priorities for the treatment of gunshot wound are the following: maintain airway and assist ventilation as necessary, control hemorrhage, prevent hypothermia. Also necessary is a rapid, recurrent assessment of the patient's neurological status, as well as prevention of infection. 5. This is correct. Clinical priorities for the treatment of gunshot wound are the following: maintain airway and assist ventilation as necessary, control hemorrhage, prevent hypothermia. Also necessary is a rapid, recurrent assessment of the patient's neurological status, as well as prevention of infection.

Which are the top priorities when conducting a primary patient survey during the emergency assessment? Select all that apply. 1) Airway 2) Disability 3) Breathing 4) Circulation 5) Cervical spine

ANS: 1, 5 Feedback 1. This is correct. Airway and stabilization of the cervical spine are the top priorities when conducting a primary patient survey during the emergency assessment. 2. This is incorrect. The nurse will then focus on breathing, circulation, and disability. 3. This is incorrect. The nurse will then focus on breathing, circulation, and disability. 4. This is incorrect. The nurse will then focus on breathing, circulation, and disability. 5. This is correct. Airway and stabilization of the cervical spine are the top priorities when conducting a primary patient survey during the emergency assessment.

Which is a potentially life-threatening condition found during the primary triage survey that would necessitate priority nursing care? 1) Cystitis 2) Concussion 3) Lacerated arm 4) Fractured femur

ANS: 2 Feedback 1 Cystitis, a lacerated arm, and a fractured femur would not necessitate priority nursing care. 2 A concussion, which is a type of head injury, is a potentially life-threatening condition found during the primary triage survey that would necessitate priority nursing care. 3 Cystitis, a lacerated arm, and a fractured femur would not necessitate priority nursing care. 4 Cystitis, a lacerated arm, and a fractured femur would not necessitate priority nursing care.

Which is the essential nursing skill for the triage process in the emergency department? 1) Evaluating care 2) Setting priorities 3) Formulating diagnoses 4) Implementing interventions

ANS: 2 Feedback 1 Evaluating care, formulating diagnoses, and implementing interventions are all nursing skills used in the emergency department; however, these are not essential during the triage process. 2 Setting priorities is an essential nursing skill for the triage, or assessment, process that occurs in the emergency department. 3 Evaluating care, formulating diagnoses, and implementing interventions are all nursing skills used in the emergency department; however, these are not essential during the triage process. 4 Evaluating care, formulating diagnoses, and implementing interventions are all nursing skills used in the emergency department; however, these are not essential during the triage process.

Which treatment should the nurse prepare to administer when providing care to a toddler who presents after an accidental overdose of aspirin? 1) Gastric lavage 2) Activated charcoal 3) Peritoneal dialysis 4) Vitamin D injection

ANS: 2 Feedback 1 Gastric lavage will not remove concentrations of aspirin. 2 The nurse would prepare to administer activated charcoal to the client and repeat every four hours, if needed, for a client with active bowel sounds. 3 Hemodialysis, not peritoneal dialysis, is a treatment that may be prescribed for a client who presents with an overdose of aspirin. 4 Vitamin K, not D, is administered to assist with clotting.

The nurse is conducting a primary survey during the emergency assessment. Which nursing action is appropriate during the breathing assessment? 1) Assessing for edema 2) Counting respiratory rate 3) Checking for foreign bodies 4) Monitoring for respiratory distress

ANS: 2 Feedback 1 Nursing actions that are appropriate when conducting a primary survey during the airway assessment include assessing for edema, checking for foreign bodies, and monitoring for respiratory distress. 2 Counting the respiratory rate is a nursing action appropriate during the breathing assessment. 3 Nursing actions that are appropriate when conducting a primary survey during the airway assessment include assessing for edema, checking for foreign bodies, and monitoring for respiratory distress. 4 Nursing actions that are appropriate when conducting a primary survey during the airway assessment include assessing for edema, checking for foreign bodies, and monitoring for respiratory distress.

Which observation indicates that interventions provided to a patient with neck injuries from a motor vehicle crash have been successful? 1) Urine is clear and odorless from indwelling catheter 2) Moves all four extremities independently, feeds self, and participates in partial bath 3) Unable to move independently in bed 4) Rests in bed with lights and television turned off

ANS: 2 Feedback 1 The other observations indicate that the patient is not yet recovered from the injuries or that interventions for the injuries have not yet been successful. The patient who is in bed with the lights and television turned off might need additional psychosocial support. 2 The patient sustained neck injuries from a motor vehicle accident. With these types of injuries, there is a risk for paralysis. Evidence that interventions have been successful for this patient includes moving all four extremities independently, feeding self, and participating in partial bath care. This means the patient has mobility, which is a successful outcome. 3 The other observations indicate that the patient is not yet recovered from the injuries or that interventions for the injuries have not yet been successful. The patient who is in bed with the lights and television turned off might need additional psychosocial support. 4 The other observations indicate that the patient is not yet recovered from the injuries or that interventions for the injuries have not yet been successful. The patient who is in bed with the lights and television turned off might need additional psychosocial support.

Which is the priority nursing action when providing care to a patient with a penetrating abdominal wound? 1) Assessing bowel sounds 2) Stabilizing the impaled object 3) Administering prescribed pain medication 4) Scheduling a CT scan to determine retroperitoneal bleeding

ANS: 2 Feedback 1 While assessing bowel sounds, administering pain medication, and scheduling a CT scan to determine retroperitoneal bleeding are important interventions, these are not the priorities in this situation. 2 The priority nursing action when providing care to a patient with a penetrating abdominal wound is to stabilize the impaled object to prevent further injury. 3 While assessing bowel sounds, administering pain medication, and scheduling a CT scan to determine retroperitoneal bleeding are important interventions, these are not the priorities in this situation. 4 While assessing bowel sounds, administering pain medication, and scheduling a CT scan to determine retroperitoneal bleeding are important interventions, these are not the priorities in this situation.

Which nursing actions are appropriate during the primary survey of the emergency assessment process? Select all that apply. 1) Inserting a nasogastric tube 2) Immobilizing the cervical spine 3) Arranging for diagnostic studies 4) Preparing for chest tube insertion 5) Applying direct pressure to a wound

ANS: 2, 4, 5 Feedback 1. This is incorrect. The secondary survey begins after addressing each step of the primary survey and starting any lifesaving interventions. The secondary survey is a brief, systematic process that aims to identify all injuries. Nursing actions appropriate during the secondary, not primary, survey include inserting a nasogastric tube and arranging for diagnostic studies. 2. This is correct. The primary survey focuses on airway, breathing, circulation (ABC), disability, and exposure or environmental control. It aims to identify life-threatening conditions so that appropriate interventions can be started. Nursing actions that are appropriate during the primary survey include immobilizing the cervical spine, preparing for chest tube insertion, and applying direct pressure to a wound. 3. This is incorrect. The secondary survey begins after addressing each step of the primary survey and starting any lifesaving interventions. The secondary survey is a brief, systematic process that aims to identify all injuries. Nursing actions appropriate during the secondary, not primary, survey include inserting a nasogastric tube and arranging for diagnostic studies. 4. This is correct. The primary survey focuses on airway, breathing, circulation (ABC), disability, and exposure or environmental control. It aims to identify life-threatening conditions so that appropriate interventions can be started. Nursing actions that are appropriate during the primary survey include immobilizing the cervical spine, preparing for chest tube insertion, and applying direct pressure to a wound. 5. This is correct. The primary survey focuses on airway, breathing, circulation (ABC), disability, and exposure or environmental control. It aims to identify life-threatening conditions so that appropriate interventions can be started. Nursing actions that are appropriate during the primary survey include immobilizing the cervical spine, preparing for chest tube insertion, and applying direct pressure to a wound.

The nurse is providing care to several patients in the emergency department. Which patient would require priority care from the nurse? 1) An adult patient with an ankle sprain 2) An infant with a rash of unknown origin 3) An adult patient with unstable vital signs and chest pain 4) A pediatric patient with multiple fractures following a motor vehicle accident

ANS: 3 Feedback 1 An adult patient with an ankle sprain and an infant with a rash of unknown origin are both classified as nonurgent. 2 An adult patient with an ankle sprain and an infant with a rash of unknown origin are both classified as nonurgent. 3 An adult patient with unstable vital signs would receive priority care based on the threetiered triage system due to emergent, or life-threatening, injury. 4 A pediatric patient with multiple fractures following a motor vehicle accident is classified as an urgent patient.

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? 1) Provide active or passive exercises at least once every eight hours 2) Encourage coughing, deep breathing, and incentive spirometry 3) Assist the patient in turning at least every two hours 4) Assist the patient in turning at least every eight hours

ANS: 3 Feedback 1 Encouraging exercise improves muscle tone, and encouraging coughing and deep breathing reduces the risk of respiratory complications, but neither helps reduce the risk of integumentary complications. 2 Encouraging exercise improves muscle tone, and encouraging coughing and deep breathing reduces the risk of respiratory complications, but neither helps reduce the risk of integumentary complications. 3 Assisting the patient to turn at least every two hours is the most appropriate intervention for the nurse to include in the plan of care to reduce the risk of integumentary complications. 4 Turning the patient every eight hours will not reduce the risk of integumentary complications.

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? 1) Computed tomography (CT) scan 2) X-ray 3) Ultrasound 4) Magnetic resonance imaging (MRI)

ANS: 4 Feedback 1 A computed tomography (CT) scan is performed if internal bleeding is suspected. 2 An x-ray will be performed for potential broken or fractured bones. 3 An ultrasound is performed if internal bleeding is suspected. 4 An MRI will be performed if there is a risk for spinal cord injuries, injuries to the muscles, or abdominal injuries.

The emergency department nurse is triaging patients. Which patient should be prioritized? 1) An adult patient experiencing mild chest pain 2) An adolescent patient with a possible fractured wrist 3) An older adult patient with a hip fracture who is in pain 4) A school-age patient with asthma presenting with dyspnea

ANS: 4 Feedback 1 An adult patient experiencing mild chest pain would be an ESI-2. 2 An adolescent patient with a possible wrist fracture would be an ESI-4. 3 An older adult patient with a hip fracture who is experiencing pain would be an ESI-3. 4 According to the Five-Level Emergency Severity Index (ESI), a patient experiencing severe respiratory distress such as the school-age patient with asthma who is having difficulty breathing (dyspnea) would receive priority care as an ESI-1.

What should the nurse do to assist a patient brought to the emergency department as a victim of a gunshot wound? 1) Ask the patient who shot him 2) Bathe the patient and provide a clean gown 3) Ask the patient where the weapon is 4) Preserve the chain of evidence

ANS: 4 Feedback 1 Because the majority of gunshot wounds require an investigation by law enforcement, nurses working in emergency departments and trauma centers should be familiar with their agency's protocols for maintaining evidence required by law enforcement. Often, law enforcement does not want the victim's hands or the area around the victim's wounds cleansed. Clothes and personal items are often wanted as evidence. The nurse should not bathe the patient and provide a clean gown. The nurse should not ask the patient who shot him or where the weapon is. The nurse should preserve the chain of evidence. 2 Because the majority of gunshot wounds require an investigation by law enforcement, nurses working in emergency departments and trauma centers should be familiar with their agency's protocols for maintaining evidence required by law enforcement. Often, law enforcement does not want the victim's hands or the area around the victim's wounds cleansed. Clothes and personal items are often wanted as evidence. The nurse should not bathe the patient and provide a clean gown. The nurse should not ask the patient who shot him or where the weapon is. The nurse should preserve the chain of evidence. 3 Because the majority of gunshot wounds require an investigation by law enforcement, nurses working in emergency departments and trauma centers should be familiar with their agency's protocols for maintaining evidence required by law enforcement. Often, law enforcement does not want the victim's hands or the area around the victim's wounds cleansed. Clothes and personal items are often wanted as evidence. The nurse should not bathe the patient and provide a clean gown. The nurse should not ask the patient who shot him or where the weapon is. The nurse should preserve the chain of evidence. 4 Because the majority of gunshot wounds require an investigation by law enforcement, nurses working in emergency departments and trauma centers should be familiar with their agency's protocols for maintaining evidence required by law enforcement. Often, law enforcement does not want the victim's hands or the area around the victim's wounds cleansed. Clothes and personal items are often wanted as evidence. The nurse should not bathe the patient and provide a clean gown. The nurse should not ask the patient who shot him or where the weapon is. The nurse should preserve the chain of evidence.

Which assessment data related to the patient's airway would indicate the need for priority intervention by the nurse? 1) Eupnea 2) Tachycardia 3) Hypotension 4) Agonal breaths

ANS: 4 Feedback 1 Dyspnea, not eupnea, would indicate the need for priority intervention. This patient is experiencing normal respirations. 2 Tachycardia and hypotension are also priority assessment data that indicate the need for intervention; however, this data indicates circulatory, and not respiratory, compromise. 3 Tachycardia and hypotension are also priority assessment data that indicate the need for intervention; however, this data indicates circulatory, and not respiratory, compromise. 4 Dyspnea, agonal breaths, and an inability to speak are all assessment data that indicate a compromised airway and the need for priority intervention by the nurse.

Which assessment data indicates the patient is experiencing a late symptom associated with chronic aspirin overdose? 1) Emesis 2) Nausea 3) Tinnitus 4) Ecchymosis

ANS: 4 Feedback 1 Emesis, tinnitus, and nausea are all early clinical manifestations of acute aspirin poisoning. 2 Emesis, tinnitus, and nausea are all early clinical manifestations of acute aspirin poisoning. 3 Emesis, tinnitus, and nausea are all early clinical manifestations of acute aspirin poisoning. 4 Ecchymosis is a late symptom associated with a chronic aspirin overdose.

Which nursing action is appropriate when conducting a secondary survey during the emergency assessment? 1) Maintaining privacy 2) Having suction available 3) Giving supplemental oxygen 4) Assigning a nurse to support family members

ANS: 4 Feedback 1 Maintaining privacy, having suction available, and giving supplemental oxygen are all interventions during the primary survey. 2 Maintaining privacy, having suction available, and giving supplemental oxygen are all interventions during the primary survey. 3 Maintaining privacy, having suction available, and giving supplemental oxygen are all interventions during the primary survey. 4 A nursing action that is appropriate during the secondary survey is assigning a nurse, or other team member, to support family members.

Which intervention would be a priority when providing care to a patient recovering from thoracic injuries sustained from a motor vehicle crash? 1) Monitor urine output 2) Assess vital signs 3) Perform passive range of motion to all extremities 4) Assist to deep breathe and cough every two hours

ANS: 4 Feedback 1 Monitoring urine output and assessing vital signs are important but not the priority at this time. 2 Monitoring urine output and assessing vital signs are important but not the priority at this time. 3 The patient may be able to perform active range of motion for all extremities, so this intervention may or may not be indicated. 4 The patient has thoracic injuries and might be reluctant to deep breathe and cough because of pain. The nurse needs to ensure that the patient breathes deeply and coughs every two hours to mobilize secretions and prevent respiratory complications.

The nurse is providing care to several patients in the emergency department. Which patient is the priority when using the three-tiered triage system? 1) A patient with a simple fracture 2) A patient experiencing renal colic 3) A patient with severe abdominal pain 4) A patient with chest pain and diaphoresis

ANS: 4 Feedback 1 The patient with a simple fracture is nonurgent. 2 The patients with renal colic and severe abdominal pain are classified as urgent. 3 The patients with renal colic and severe abdominal pain are classified as urgent. 4 The patient with chest pain and diaphoresis is classified as emergent and would require priority care.

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? 1) Hemorrhage 2) Compensatory shock 3) Hypovolemic shock 4) Tension pneumothorax

ANS: 4 Tracheal deviation and jugular vein distention are not associated with hemorrhage, compensatory shock, or hypovolemic shock. 2 Tracheal deviation and jugular vein distention are not associated with hemorrhage, compensatory shock, or hypovolemic shock. 3 Tracheal deviation and jugular vein distention are not associated with hemorrhage, compensatory shock, or hypovolemic shock. 4 A tension pneumothorax is life threatening and requires immediate intervention. On inspiration, air enters the pleural space, does not escape on expiration, and increases the intrapleural pressure. This pressure collapses the injured lung and shifts the mediastinal contents, compressing the heart, great vessels, trachea, and eventually the uninjured lung.