Unit 3: Trauma
During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient has an unobstructed airway. Which action should the nurse take next? a. Palpate extremities for bilateral pulses. b. Observe the patient's respiratory effort. c. Check the patient's level of consciousness. d. Examine the patient for any external bleeding.
ANS: B Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient's breathing. The other actions are also part of the initial survey but assessment of breathing should be done immediately after assessing for airway patency.
A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should a. obtain a complete set of vital signs. b. obtain a Glasgow Coma Scale score. c. attach an electrocardiogram monitor. d. ask about chronic medical conditions.
ANS: B The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the secondary survey.
The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed? a. A large air leak in the water-seal chamber b. 400 mL of blood in the collection chamber c. Complaint of pain with each deep inspiration d. Subcutaneous emphysema at the insertion site
ANS: B The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. An air leak would be expected immediately after chest tube placement for a pneumothorax. Initially, brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax. A small amount of subcutaneous air is harmless and will be reabsorbed.
An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action should the nurse take? a. Clamp the chest tube in two places. b. Administer the prescribed morphine. c. Milk the chest tube to remove any clots. d. Assist the patient with incentive spirometry.
ANS: B Treat the pain. The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy. Milking or stripping chest tubes is no longer recommended because these practices can dangerously increase intrapleural pressures and damage lung tissues. Position tubing so that drainage flows freely to negate need for milking or stripping. An air leak is expected in the initial postoperative period after thoracotomy. Clamping the chest tube is not indicated and may lead to dangerous development of a tension pneumothorax.
After a motorcycle accident, a patient arrives in the emergency department with severe swelling of the left lower leg. Which action will the nurse take first? a. Elevate the leg on 2 pillows. c. Assess leg pulses and sensation. b. Apply a compression bandage. d. Place ice packs on the lower leg.
ANS: C The initial action by the nurse will be to assess circulation to the leg and observe for any evidence of injury such as fractures or dislocations. After the initial assessment, the other actions may be appropriate based on what is observed during the assessment.
The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment? a. A patient with no pedal pulses b. A patient with an open femur fracture c. A patient with bleeding facial lacerations d. A patient with paradoxical chest movement
ANS: D Most immediate deaths from trauma occur because of problems with ventilation, so the patient with paradoxical chest movements should be treated first. Face and head fractures can obstruct the airway, but the patient with facial injuries only has lacerations. The other two patients also need rapid intervention but do not have airway or breathing problems
The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective? a. "I am going to buy a rib binder to wear during the day." b. "I can take shallow breaths to prevent my chest from hurting." c. "I should plan on taking the pain pills only at bedtime so I can sleep." d. "I will use the incentive spirometer every hour or two during the day."
ANS: D Prevention of the complications of atelectasis and pneumonia is a priority after rib fracture. This can be ensured by deep breathing and coughing. Use of a rib binder, shallow breathing, and taking pain medications only at night are likely to result in atelectasis
When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient? a. Emergency pericardiocentesis c. Bronchodilator administration b. Stabilization of the chest wall d. Chest tube connected to suction
ANS: D The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage to suction. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient's clinical manifestations are not consistent with these problems.
A 47-yr-old man who was lost in the mountains for 2 days is admitted to the emergency department with cold exposure and a core body temperature of 86.6ºF (30.3ºC). Which nursing action is most important? 1.Administer warmed IV fluids. 2.Position patient under a radiant heat lamp. 3.Place an air-filled warming blanket on the patient. 4.Immerse the extremities in a water bath (102° to 108°F [38.9° to 42.2°C]).
1 A patient with a core body temperature of 86.6ºF (30.3ºC) has moderate hypothermia. Active core rewarming is used for moderate to severe hypothermia and includes administration of warmed IV fluids (109.4ºF [43ºC]). Patients with moderate to severe hypothermia should have the core warmed before the extremities to prevent after drop (or further drop in core temperature). This occurs when cold peripheral blood returns to the central circulation. Use passive or active external rewarming for mild hypothermia. Active external rewarming involves fluid-filled warming blankets or radiant heat lamps. Immersion of extremities in a water bath is indicated for frostbite.
An 18-yr-old man who fell through the ice on a pond near his farm was admitted to the emergency department with somnolence. Vital signs are blood pressure of 82 mm Hg systolic with Doppler, respirations of 9 breaths/min, and core temperature of 90°F (32.2°C). The nurse should anticipate which intervention? 1.Active core rewarming 2.Immersion in a hot bath 3.Rehydration and massage 4.Passive external rewarming
1 Active internal or core rewarming is used for moderate to severe hypothermia and involves the application of heat directly to the core. Immersion in a hot bath, rehydration, and massage are not appropriate interventions in the treatment of severe hypothermia. Passive rewarming is used in mild hypothermia.
The nurse is providing immediate postprocedure care to a client who had a thoracentesis to relieve a tension pneumothorax that resulted from rib fractures. The goal is that the client will exhibit normal respiratory functioning, and the nurse provides instructions to assist the client with this goal. Which client statement indicates that further instruction is needed? 1."I will lie on the affected side for an hour." 2."I can expect a chest x-ray exam to be done shortly." 3."I will let you know at once if I have trouble breathing." 4."I will notify you if I feel a crackling sensation in my chest."
1 After the procedure the client usually is turned onto the unaffected side for 1 hour to facilitate lung expansion. Tachypnea, dyspnea, cyanosis, retractions, or diminished breath sounds, which may indicate pneumothorax, should be reported to the primary health care provider. A chest x-ray may be performed to evaluate the degree of lung reexpansion or pneumothorax. Subcutaneous emphysema (crepitus) may follow this procedure because air in the pleural cavity leaks into subcutaneous tissues. The involved tissues feel like lumpy paper and crackle when palpated (crepitus). Usually subcutaneous emphysema causes no problems unless it is increasing and constricting vital organs, such as the trachea.
A client experienced an open pneumothorax (sucking wound), which has been covered with an occlusive dressing. The client begins to experience severe dyspnea, and the blood pressure begins to fall. The nurse should first perform which action? 1.Remove the dressing. 2.Reinforce the dressing. 3.Call the primary health care provider (PHCP). 4.Measure oxygen saturation by oximetry.
1 Placement of a dressing over a chest wound could convert an open pneumothorax to a closed (tension) pneumothorax. This may result in a sudden decline in respiratory status, mediastinal shift with twisting of the great vessels, and circulatory compromise. If clinical changes occur, the nurse should remove the dressing immediately, allowing air to escape. Therefore, reinforcing the dressing is an incorrect action. The nurse would measure oxygen saturation by oximetry and would call the PHCP, but these would not be the first actions in this situation.
A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition? 1.Right pneumothorax 2.Pulmonary embolism 3.Displaced endotracheal tube 4.Acute respiratory distress syndrome
1 Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left mainstem bronchi.
The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance? 1.Respiratory acidosis from inadequate ventilation 2.Respiratory alkalosis from anxiety and hyperventilation 3.Metabolic acidosis from calcium loss due to broken bones 4.Metabolic alkalosis from taking analgesics containing base products
1 Respiratory acidosis is most often caused by hypoventilation. The client with broken ribs will have difficulty with breathing adequately and is at risk for hypoventilation and resultant respiratory acidosis. The remaining options are incorrect. Respiratory alkalosis is associated with hyperventilation. There are no data in the question that indicate calcium loss or that the client is taking analgesics containing base products.
A patient with a gunshot wound to the right side of the chest arrives in the emergency department exhibiting severe shortness of breath with decreased breath sounds on the right side of the chest. Which action should the nurse take immediately? 1.Cover the chest wound with a nonporous dressing taped on three sides. 2.Pack the chest wound with sterile saline soaked gauze and tape securely. 3.Stabilize the chest wall with tape and initiate positive pressure ventilation. 4.Apply a pressure dressing over the wound to prevent excessive loss of blood.
1 The patient has a sucking chest wound (open pneumothorax). Air enters the pleural space through the chest wall during inspiration. Emergency treatment consists of covering the wound with an occlusive dressing that is secured on three sides. During inspiration, the dressing pulls against the wound, preventing air from entering the pleural space. During expiration, the dressing is pushed out and air escapes through the wound and from under the dressing.
Which assessment parameter will the nurse address during the secondary survey of a patient in triage? 1.Blood pressure and heart rate 2.Patency of the patient's airway 3.Neurologic status and level of consciousness 4.Presence or absence of breath sound and quality of breathing
1 Vital signs are considered to be a part of the secondary survey in the triage process. Airway, breathing, circulation, and a brief neurologic assessment are components of the primary survey that is done to identify life-threatening
The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate? 1.Do nothing because this is an expected finding. 2.Check for an air leak because the bubbling should be intermittent. 3.Increase the suction pressure so that the bubbling becomes vigorous. 4.Clamp the chest tube and notify the primary health care provider immediately.
2 Fluctuation with inspiration and expiration, not continuous bubbling, should be noted in the water seal chamber. Intermittent bubbling may be noted if the client has a known pneumothorax, but this should decrease as time goes on and as the pneumothorax begins to resolve. Therefore, the nurse should check for an air leak. If a wet chest drainage system is used, bubbling would be continuous in the suction control chamber and not intermittent. In a dry system, there is no bubbling. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system; in addition, increasing the suction can be harmful and is not done without a specific prescription to do so if using a wet system. Dry systems will allow for only a certain amount of suction to be applied; an orange bellow will appear in the suction window, indicating that the proper amount of suction has been applied. Chest tubes should be clamped only with a primary health care provider's prescription.
A nurse in the emergency department is working triage. Which patient assessment findings would indicate immediate care is required? 1.Shortened and externally rotated leg 2.Inability to swallow and move the left arm 3.Warm, edematous, reddened and painful calf 4.Yellow sputum and pain with deep inspiration
2 Inability to swallow and move the left arm suggests the patient is experiencing a stroke. A CT scan is indicated within 25 minutes of arrival to determine ischemic versus hemorrhagic origin, which will delineate available treatments. The warm, edematous, reddened and painful calf suggests deep vein thrombosis. Although not an immediate threat, there is a risk of pulmonary emboli. A shortened and externally rotated leg suggests a hip fracture. A patient with yellow sputum and pain with deep inspiration suggest a pneumonia that may require hospitalization or could be treated as an outpatient.
The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client? 1.A low respiratory rate 2.Diminished breath sounds 3.The presence of a barrel chest 4.A sucking sound at the site of injury
2 This client has sustained a blunt or closed-chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyper-resonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.
Students are having an end of the semester party, which includes drinking alcohol, having snacks, and swimming. A student was found floating in the pool. Which action by first responders is most important? 1.Immobilizing the cervical spine 2.Evacuating water from the lungs 3.Securing the airway and providing ventilation 4.Establishing IV access and infusing warmed fluids
3 Aggressive resuscitation efforts (e.g., airway and ventilation management), especially in the prehospital phase, improve survival of drowning victims. Initial evaluation involves assessment of airway, cervical spine, breathing, and circulation. Treatment of submersion injuries focuses on correcting hypoxia and fluid imbalances, supporting basic physiologic functions, and rewarming when hypothermia is present. Most drowning victims do not aspirate any liquid due to laryngospasm.
A nurse teaches the emergency department staff about their roles during a mass casualty incident. Which primary responsibility is expected of all licensed and unlicensed health care staff? 1.Notify local, state, and national authorities. 2.Assist security personnel to patrol the area. 3.Learn the hospital emergency response plan. 4.Contact the American Red Cross for assistance.
3 All health care providers must be prepared for a mass casualty incident. The priority responsibility is to know the agency's emergency response plan
A patient is admitted to the emergency department after a motor vehicle crash with suspected abdominal trauma. What assessment finding by the nurse is of highest priority? 1.Nausea and vomiting 2.Hyperactive bowel sounds 3.Firmly distended abdomen 4.Abrasions on all extremities
3 Clinical manifestations of abdominal trauma are guarding and splinting of the abdominal wall; a hard, distended abdomen (indicating possible intraabdominal bleeding); decreased or absent bowel sounds; contusions, abrasions, or bruising over the abdomen; abdominal pain; pain over the scapula; hematemesis or hematuria; and signs of hypovolemic shock (tachycardia and decreased blood pressure).
A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? 1.Cyanosis 2.Hypotension 3.Paradoxical chest movement 4.Dyspnea, especially on exhalation
3 Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest.
The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective? 1.Muffled heart sounds 2.Client reports dyspnea 3.A rise in blood pressure 4.Jugular venous distention
3 Following pericardiocentesis, the client usually expresses immediate relief. Heart sounds are no longer muffled or distant and blood pressure increases. Distended neck veins are a sign of increased venous pressure, which occurs with cardiac tamponade.
The nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. The nurse immediately applies sterile gauze over the chest tube insertion site. Which is the nurse's next action? 1.Replace the chest tube system. 2.Obtain a pulse oximetry reading. 3.Call the primary health care provider. 4.Place the client in a Trendelenburg's position.
3 If the chest drainage system is dislodged from the insertion site, the nurse immediately applies sterile gauze over the site and calls the primary health care provider. The nurse would maintain the client in an upright position. A new chest tube system may be attached if the tube requires insertion, but this would not be the next action. Pulse oximetry readings would assist in determining the client's respiratory status, but the priority action would be to call the health care provider in this emergency situation.
One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing actions? 1.Water-seal chamber has 5 cm of water. 2.No new drainage in collection chamber 3.Chest tube with a loose-fitting dressing 4.Small pneumothorax at CT insertion site
3 If the dressing at the CT insertion site is loose, an air leak will occur and will need to be sealed. The water-seal chamber usually has 2 cm of water, but having more water will not contribute to an air leak, and it should not be drained from the CDS. No new drainage does not indicate an air leak but may indicate the CT is no longer needed. If there is a pneumothorax, the chest tube should remove the air.
A client is diagnosed with a rib fracture and asks the nurse why strapping of the ribs is not being done. Which response by the nurse is most appropriate? 1."Strapping is useful only if the ribs are fractured in several places at once." 2."That's a good idea. I'll ask the primary health care provider for a prescription for the needed supplies." 3."That isn't done because people often would develop pneumonia from the constricting effect on the lungs." 4."That might help you to breathe better, but this facility does not carry the necessary supplies in the stockroom. When you get home, you can purchase them at the medical supply store."
3 Strapping of the ribs has a constricting effect on the ribs and on deep breathing and can actually increase the risk of atelectasis and pneumonia. Therefore, options 1, 2, and 4 are incorrect.
A client who has just suffered a large flail chest is experiencing severe pain and dyspnea. The client's central venous pressure (CVP) is rising, and the arterial blood pressure is falling. Which condition should the nurse interpret that the client is experiencing? 1.Fat embolism 2.Mediastinal shift 3.Mediastinal flutter 4.Hypovolemic shock
3 The client with severe flail chest will have significant paradoxical chest movement. This causes the mediastinal structures to swing back and forth with respiration. This movement can affect hemodynamics. Specifically, the client's CVP rises, the filling of the right side of the heart is impaired, and the arterial blood pressure falls. This is referred to as mediastinal flutter. The client with fat embolism experiences chest pain and dyspnea, but this condition occurs as a complication of a bone fracture. Mediastinal shift is a condition in which the structures of the mediastinum shift or move to the opposite side of the chest cavity; this may be caused by a pleural effusion or tension pneumothorax. In hypovolemic shock, the blood pressure falls and the pulse rises; this occurs following hemorrhage.
A male patient is brought into the emergency department with multiple stab wounds to the legs, one stab wound to the left abdomen, and gang tattoos on both arms. He refused to identify his attacker and then loses consciousness. Police identify him as the assailant in the fatal stabbing of another man. What is the nurse's priority? 1.Guard locked access doors. 2.Maintain patient safety from revenge. 3.Maintain personal and work place safety. 4.Attain open patient airway and breathing
3 The nurse's priority is to maintain personal and work place safety. Violence can erupt in the emergency department when treating gang members if the rival gang seeks revenge, or the patient's gang members seek to protect the patient with their presence. Staff members can be victims of that violence, so they should maintain a safe work environment by seeking law enforcement and security assistance in maintaining safety for the staff and the patient. ABCs are the usual priority, but this situation does not show any problem with the patient's airway or breathing.
Which clinical manifestations of a tension pneumothorax should be of immediate concern to the nurse? Select all that apply. 1.Bradypnea 2.Flattened neck veins 3.Decreased cardiac output 4.Hyperresonance to percussion 5.Tracheal deviation to the opposite side
3,4,5 Tension pneumothorax is the rapid accumulation of air in the pleural space. This causes extremely high intrapleural pressures, resulting in tension on the heart and great vessels. This can cause decreased cardiac output (tachycardia, hypotension), hyperresonance on percussion, and a tracheal shift away from the affected side. Bradypnea and flattened neck veins are incorrect because the client would have tachypnea and distended neck veins.
The nurse is assessing the functioning of a chest tube drainage system in a client with a chest injury who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. 1.Excessive bubbling in the water seal chamber 2.Vigorous bubbling in the suction control chamber 3.Drainage system maintained below the client's chest 4.50 mL of drainage in the drainage collection chamber 5.Occlusive dressing in place over the chest tube insertion site 6.Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation
3,5,6 The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure; it may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has re-expanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 mL/hr is considered excessive and requires notification of the surgeon. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.
The nurse caring for a client who has a pneumothorax notes continuous bubbling in the water seal chamber of the client's closed chest drainage system. How should the nurse interpret this finding? 1.The drainage chamber is full. 2.The pneumothorax is resolving. 3.The suction chamber system is shut off. 4.There is an air leak somewhere in the system.
4 Continuous bubbling through both inspiration and expiration indicates that there is air leaking into the system. A resolving pneumothorax or a full drainage chamber would not cause bubbling with respiration in the water seal chamber. Shutting off the suction to the system stops bubbling in the suction control chamber but does not affect the water seal chamber.
The nurse witnesses an accident whereby a pedestrian is hit by an automobile. The nurse stops at the scene and assesses the victim. The nurse notes that the victim is responsive and has suffered trauma to the thorax resulting in a flail chest involving at least 3 ribs. What is the nurse's priority action for this victim? 1.Assist the victim to sit up. 2.Remove the victim's shirt. 3.Turn the victim onto the side opposite the flail chest. 4.Apply firm but gentle pressure with the hands to the flail segment.
4 If flail chest is present, the nurse applies firm but gentle pressure to the flail segments of the ribs to stabilize the chest wall, which will ultimately help the victim's respiratory status. The nurse does not move an injured client for fear of worsening an undetected spinal injury. Removing the victim's shirt is of no value in this situation and could in fact result in chilling the victim, which is counterproductive. Injured clients should be kept warm until help arrives at the scene.
A mass casualty incident was identified on a nearby freeway. Which patient would likely be designated "red" during triage at the site? 1.An individual who is distraught at the violence of the incident 2.An individual who has experienced an open arm fracture from falling debris 3.An individual who is not expected to survive a crushing head and neck wound 4.An individual whose femoral artery has been severed and is bleeding profusely
4 Red indicates a life-threatening injury requiring immediate intervention, such as severe bleeding. Emotional trauma would not warrant a "red" designation, and a fracture would likely be deemed "yellow," urgent but not life threatening. Those not expected to survive are categorized "blue." "Black" identifies the dead.
The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding? 1.Slow, deep respirations 2.Rapid, deep respirations 3.Paradoxical respirations 4.Pain, especially with inspiration
4 Rib fractures result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest.
The following four patients arrive in the emergency department (ED) after a motor vehicle collision. In which order should the nurse assess them? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. A 74-yr-old patient with palpitations and chest pain b. A 43-yr-old patient complaining of 7/10 abdominal pain c. A 21-yr-old patient with multiple fractures of the face and jaw d. A 37-yr-old patient with a misaligned lower left leg with intact pulses
ANS: C, A, B, D The highest priority is to assess the 21-yr-old patient for airway obstruction, which is the most life-threatening injury. The 74-yr-old patient may have chest pain from cardiac ischemia and should be assessed and have diagnostic testing for this pain. The 43-yr-old patient may have abdominal trauma or bleeding and should be seen next to assess circulatory status. The 37-yr-old patient appears to have a possible fracture of the left leg and should be seen soon, but this patient has the least life-threatening injury.
The nurse is assessing a patient with abdominal pain. The nurse, who notes that there is ecchymosis around the area of umbilicus, will document this finding as a. Cullen sign. c. McBurney sign. b. Rovsing sign. d. Grey-Turner's sign.
ANS: A Cullen sign is ecchymosis around the umbilicus. Rovsing sign occurs when palpation of the left lower quadrant causes pain in the right lower quadrant. Grey Turner's sign is bruising over the flanks. Deep tenderness at McBurney's point (halfway between the umbilicus and the right iliac crest), known as McBurney's sign, is a sign of acute appendicitis.
The nurse is caring for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider? a. O2 saturation is 88%. b. Blood pressure is 155/90 mm Hg. c. Pain level is 5 (on 0 to 10 scale) with a deep breath. d. Respiratory rate is 24 breaths/minute when lying flat.
ANS: A O2 saturation would be expected to improve after a thoracentesis. A saturation of 88% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low O2 saturation is the priority.
A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment? a. Paradoxical chest movement c. Heart rate of 110 beats/minute b. Complaint of chest wall pain d. Large bruised area on the chest
ANS: A Paradoxical chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange.
A patient is awaiting surgery for acute peritonitis. Which action will the nurse include in the plan of care? a. Position patient with the knees flexed. b. Avoid use of opioids or sedative drugs. c. Offer frequent small sips of clear liquids. d. Assist patient to breathe deeply and cough.
ANS: A There is less peritoneal irritation with the knees flexed, which will help decrease pain. Opioids and sedatives are typically given to control pain and anxiety. Preoperative patients with peritonitis are given IV fluids for hydration. Deep breathing and coughing will increase the patient's discomfort.
A patient in the emergency department has just been diagnosed with peritonitis caused by a ruptured diverticulum. Which prescribed intervention will the nurse implement first? a. Insert a urinary catheter to drainage. b. Infuse metronidazole (Flagyl) 500 mg IV. c. Send the patient for a computerized tomography scan. d. Place a nasogastric (NG) tube to intermittent low suction.
ANS: B Because peritonitis can be fatal if treatment is delayed, the initial action should be to start antibiotic therapy (after any ordered cultures are obtained). The other actions can be done after antibiotic therapy is initiated.
A patient who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is appropriate? a. Adjust the dial on the wall regulator. b. Continue to monitor the collection device. c. Document the presence of a large air leak. d. Notify the surgeon of a possible pneumothorax.
ANS: B Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction pressure. The amount of suction applied is regulated by the amount of water in this chamber and not by the amount of suction applied to the system.
A patient who has experienced blunt abdominal trauma during a motor vehicle collision is complaining of increasing abdominal pain. The nurse will plan to teach the patient about the purpose of a. peritoneal lavage. b. abdominal ultrasonography. c. nasogastric (NG) tube placement. d. magnetic resonance imaging (MRI).
ANS: B For patients who are at risk for intraabdominal bleeding, focused abdominal ultrasonography is the preferred method to assess for intraperitoneal bleeding. An MRI would not be used. Peritoneal lavage is an alternative, but it is more invasive. An NG tube would not be helpful in the diagnosis of intraabdominal bleeding.
A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure? a. Start a peripheral IV line to administer sedatives. b. Position the patient sitting up on the side of the bed. c. Obtain a collection device to hold 3 liters of pleural fluid. d. Remind the patient not to eat or drink anything for 6 hours.
ANS: B When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious. Usually only 1000 to 1200 mL of pleural fluid is removed at one time. Rapid removal of a large volume can result in hypotension, hypoxemia, or pulmonary edema.
When a patient arrives in the emergency department with a facial fracture, which action will the nurse take first? a. Assess for nasal bleeding and pain. b. Apply ice to the face to reduce swelling. c. Use a cervical collar to stabilize the spine. d. Check the patient's alertness and orientation.
ANS: C Patients who have facial fractures are at risk for cervical spine injury, and should be treated as if they have a cervical spine injury until this is ruled out. The other actions are also necessary, but the most important action is to prevent cervical spine injury.
A 19-yr-old woman is brought to the emergency department with a knife handle protruding from her abdomen. During the initial assessment of the patient, the nurse should a. remove the knife and assess the wound. b. determine the presence of Rovsing sign. c. check for circulation and tissue perfusion. d. insert a urinary catheter and assess for hematuria.
ANS: C The initial assessment is focused on determining whether the patient has hypovolemic shock. The knife should not be removed until the patient is in surgery, where bleeding can be controlled. Rovsing sign is assessed in the patient with suspected appendicitis. Assessment for bladder trauma is not part of the initial assessment.
A patient is admitted to the emergency department with severe abdominal pain and rebound tenderness. Vital signs include temperature 102°F (38.3°C), pulse 120 beats/min, respirations 32 breaths/min, and blood pressure (BP) 82/54 mm Hg. Which prescribed intervention should the nurse implement first? a. Administer IV ketorolac 15 mg for pain relief. b. Draw a blood sample for a complete blood count (CBC). c. Infuse a liter of lactated Ringer's solution over 30 minutes. d. Send the patient for an abdominal computed tomography (CT) scan.
ANS: C The priority for this patient is to treat the patient's hypovolemic shock with fluid infusion. The other actions should be implemented after starting the fluid infusion.
A patient is admitted to the emergency department with an open stab wound to the left chest. What action should the nurse take? a. Keep the head of the patient's bed positioned flat. b. Cover the wound tightly with an occlusive dressing. c. Position the patient so that the left chest is dependent. d. Tape a nonporous dressing on three sides over the wound.
ANS: D The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the left side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30 to 45 degrees to facilitate breathing.
Which patient should the nurse assess first after receiving change-of-shift report? a. A 60-yr-old patient whose new ileostomy has drained 800 mL over the previous 8 hours b. A 50-yr-old patient with familial adenomatous polyposis who has occult blood in the stool c. A 40-yr-old patient with ulcerative colitis who has had six liquid stools in the previous 4 hours d. A 30-yr-old patient who has abdominal distention and an apical heart rate of 136 beats/minute
ANS: D The patient's abdominal distention and tachycardia suggest hypovolemic shock caused by problems such as peritonitis or intestinal obstruction, which will require rapid intervention. The other patients should also be assessed as quickly as possible, but the data do not indicate any life-threatening complications associated with their diagnoses.
After change-of-shift report, which patient should the nurse assess first? a. A 72-yr-old with cor pulmonale who has 4+ bilateral edema in his legs and feet b. A 28-yr-old with a history of a lung transplant and a temperature of 101° F (38.3° C) c. A 40-yr-old with a pleural effusion who is complaining of severe stabbing chest pain d. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion
ANS: D The patient's history and symptoms suggest possible tension pneumothorax, a medical emergency. The other patients also require assessment as soon as possible, but tension pneumothorax will require immediate treatment to avoid death from inadequate cardiac output or hypoxemia.