200 EAQ Questions

After a bus accident, five clients are admitted to an emergency department. Which client does the nurse think should be seen first? 1 Client in cardiac arrest 2 Client with abdominal pain 3 Client with closed extremity trauma 4 Client with chest pain resulting from ischemia

1 Client in cardiac arrest The client in cardiac arrest is triaged under emergency severity index 1 (ESI-1) and should be seen immediately because the condition is severe. The client with abdominal pain is triaged as ESI-3 and is seen within up to 1 hour. The client with closed extremity trauma could be delayed and is assigned ESI-4. The client with chest pain resulting from ischemia is triaged as ESI-2. This client should be seen by the healthcare provider within 10 minutes but not immediately as should the client with cardiac arrest.

What should be included in an organization's policy for hand hygiene? Select all that apply. 1 Wash hands before applying sterile gloves 2Wash hands before touching a client's personal items 3 Wash with either soap and water or alcohol-based hand rub (ABHR) before client contact 4 Wash with soap and water when hands visibly soiled with blood 5 Wash with alcohol-based hand rub (ABHR) if hands are not visibly soiled

1 Wash hands before applying sterile gloves 3 Wash with either soap and water or alcohol-based hand rub (ABHR) before client contact 4 Wash with soap and water when hands visibly soiled with blood 5 Wash with alcohol-based hand rub (ABHR) if hands are not visibly soiled

The nurse is assessing a client brought to the emergency department after a bomb blast. What are the steps in order in which the nurse prioritizes care to the client? - Monitoring blood pressure and pulse rate - Establishing a patent airway - Covering the client with a blanket - Protecting the cervical spine by maintaining alignment - Evaluating client's level of consciousness - Assessing breath sounds and respiratory effort

1.Establishing a patent airway 2.Protecting the cervical spine by maintaining alignment 3.Assessing breath sounds and respiratory effort 4.Monitoring blood pressure and pulse rate 5.Evaluating client's level of consciousness 6.Covering the client with a blanket Establishing a patent airway by positioning and suctioning is the first action done by the nurse while caring for a traumatized client. Next, the cervical spine is protected by maintaining the proper alignment. Then, breath sounds and respiratory effort are assessed. After ensuring that the airway is cleared, blood pressure and pulse rate are monitored. Next, level of consciousness is evaluated using the Glasgow Coma Scale. Covering the client with a blanket is given the last priority.

A client with facial trauma is admitted to the emergency department. The client has dyspnea, cyanosis, and external bleeding. What is the correct order of nursing interventions that should be performed in this situation? - Measure client's level of consciousness. - Administer supplemental oxygen. - Apply direct pressure with a sterile dressing. - Remove the client's clothing to perform a thorough physical examination. - Perform jaw-thrust maneuver.

1.Perform jaw-thrust maneuver. 2.Administer supplemental oxygen. 3.Apply direct pressure with a sterile dressing. 4.Measure client's level of consciousness. 5.Remove the client's clothing to perform a thorough physical examination. Facial trauma can obstruct the airway and cause respiratory compromise. Therefore opening the airway using jaw-thrust maneuver is priority for this client. Once the airway is opened, adequate ventilation should be ensured by administering supplemental oxygen. After ensuring the airway patency, circulation should be assessed and direct pressure applied with a sterile dressing on the bleeding site. After ensuring respiration and circulation, the client's level of consciousness should be determined. Then all clothing should be removed to perform thorough physical assessment.

After a train derailment disaster, five clients are admitted to the emergency department. Which order should the nurse triage based on the clients' conditions, from the most to the least urgent? 1 Client with minor burns 2 Client with multiple trauma 3 Client with simple laceration 4 Client with gynecological disorder 5 Client with overdose and bradypnea

5 Client with overdose and bradypnea 2 Client with multiple trauma 4 Client with gynecological disorder 3 Client with simple laceration 1 Client with minor burns A client who has overdosed and has bradypnea is categorized under emergency severity index 1 (ESI-1), which indicates that the life or organ threat to the client is clear and the client needs to be seen immediately. The client with multiple trauma is triaged as ESI-2, which indicates that the client's condition is likely to be life threatening; he or she should receive treatment within 10 minutes. The client with a gynecological disorder who is triaged under ESI-3, which indicates that the life threat to the client is unlikely, can be seen after 1 hour. A client with simple lacerations is categorized as ESI level 4, showing no threat to life and the assessment could be delayed. A client with minor burns categorized under ESI level 5 with no threat to life could have treatment delayed.