6

triage

The purpose of mass casualty incident (or disaster) triage is to do the greatest good for the greatest number with the resources at that time. Disaster triage uses START - Simple Triage and Rapid Transport. It makes a rapid (<1 minute) assessment looking at circulation, respirations, and mental status to determine a category for a client. Another accepted methodology under the same concept is SALT (Sort, Assess, Life-saving interventions, Treatment/transport). "Red," which goes first for definitive care, is a client with a life-threatening injury who is likely to survive if receiving prompt treatment (<60 minutes). This includes compromise to airway, breathing, and circulation. "Yellow," or second to go, can wait 1-2 hours without loss of life or limb. "Green" is considered the "walking wounded," who can wait indefinitely. In a disaster, there is a 4th category, "black," which indicates the client is unlikely to survive given the severity of injuries, level of available care, or both. The nurse should care for the clients in the following order: Client 4 with an inhalation injury is a priority. Progressive edema is a risk, especially in a client with stridor. Prophylactic intubation would be expected. Client 2 is at risk for hypothermia. Body heat loss can increase with wet clothing or cold water immersion. Drying the client to prevent further heat loss and the inherent complications is easily done and should stabilize the client. Untreated hypothermia can cause decreased cerebral metabolism, cardiac dysrhythmias, renal effects, hemoconcentration, and coagulopathies. Client 3's lack of insulin is important but not an emergency. Failure to take insulin will result in hyperglycemia, which is concerning but will not cause serious pathology with a 2-hour delay. Client 1 has 72% full-thickness or 3rd-degree burns. There is extensive life-threatening injury and a poor prognosis even in the best circumstances. In this case, the limited resources should not be spent on the client who is not expected to survive.

The nurse reviews an elderly client's medication administration record and identifies which prescriptions as having the potential for injury in the elderly? Select all that apply. 1. Amitriptyline 2. Chlorpheniramine 3. Docusate 4. Donepezil 5. Lorazepam

1 2 5 Polypharmacy and physiologic changes associated with aging (eg, decreased renal and hepatic function, orthostatic hypotension, decreased visual acuity, balance and gait problems) place the elderly at increased risk of adverse drug effects. The Beers criteria provide a list that classifies potentially harmful drugs to avoid or administer with caution in the elderly due to the high incidence of drug-induced toxicity, cognitive dysfunction, and falls. Some commonly used medications in this list include antipsychotics, anticholinergics, antihistamines, antihypertensives, benzodiazepines, diuretics, opioids, and sliding insulin scales. Amitriptyline (Elavil) is a tricyclic antidepressant used to treat depression and neuropathic pain; its anticholinergic properties may cause dry mouth, constipation, blurred vision, and dysrhythmias (Option 1). Chlorpheniramine (ChlorTrimeton) is a sedating histamine H1 antagonist used to treat allergy symptoms. Increased central nervous system effects (eg, drowsiness, dizziness) may occur due to its reduced clearance in the elderly (Option 2). Lorazepam (Ativan) is a benzodiazepine with a long half-life (10-17 hours). Side effects include drowsiness, dizziness, ataxia, and confusion (Option 5). (Option 3) Docusate is a stool softener and does not increase risk of injury in the elderly. (Option 4) Donepezil (Aricept) is an acetylcholinesterase inhibitor used to treat Alzheimer dementia. It does not place the elderly at increased risk of adverse effects.

A nurse is teaching home management to a client newly diagnosed with severe psoriasis. Which client statement indicates that further teaching is needed? 1. "Exposure to sunlight will worsen my psoriasis." 2. "I should avoid drinking alcohol." 3. "I should use moisturizing creams frequently." 4. "Stress can worsen psoriasis."

1. "Exposure to sunlight will worsen my psoriasis." Psoriasis is a chronic autoimmune disease that causes a rapid turnover of epidermal cells. Characteristic silver plaques on reddened skin may be found bilaterally on the elbows, knees, scalp, lower back, and/or buttocks. The goal of therapy is to slow epidermal turnover, heal lesions, and control exacerbations. There is no cure for psoriasis; disease management includes avoidance of triggers (eg, stress, trauma, infection), topical therapy (eg, corticosteroids, moisturizers), phototherapy (eg, ultraviolet light), and systemic medications, including cytotoxic (eg, methotrexate) and biologic (eg, infliximab) agents (Options 3 and 4). The client should avoid alcohol as it can worsen psoriasis (Option 2). In addition, the liver, kidneys, and bone marrow are specifically affected by the systemic medications commonly used to control psoriasis. (Option 1) Exposure to ultraviolet light (eg, phototherapy, sunlight) can help slow epidermal turnover and decrease exacerbations; however, there is a greater long-term risk of skin cancer. Therefore, frequent skin examinations by a health care provider are important.

A client is able to partially bear weight and follow the nurse's instructions. Which would be the most appropriate method for the nurse to use to safely transfer this client? 1. 1-person stand and pivot with gait belt and walker 2. 1-person standby assist with walker 3. 2-person motorized stand-assist lift 4. 2-person stand and pivot with gait belt and walker

1. 1-person stand and pivot with gait belt and walker

The nurse on the step-down cardiothoracic unit receives the change-of-shift hand-off report. Which client should the nurse assess first? 1. 2 days postabdominal aortic aneurysm repair with a pedal pulse decreased from baseline 2. 2 days postcoronary bypass graft surgery with a white blood cell count of 18,000/mm3 (18.0 × 109/L) 3. Cardiomyopathy with an ejection fraction of 25% and dyspnea on exertion 4. Pneumothorax with a chest tube to negative suction and subcutaneous emphysema

1. 2 days postabdominal aortic aneurysm repair with a pedal pulse decreased from baseline The nurse should assess the pulses (eg, femoral, posterior tibial, dorsalis pedis) and skin color and temperature of the lower extremities in the client with the abdominal aortic aneurysm (AAA) repair first. Pulses can be absent for 4-12 hours after surgery due to vasospasm. However, a pedal pulse decreased from the client's baseline or an absent pulse with a painful, cool, or mottled extremity 2 days postoperative can indicate the presence of an arterial or graft occlusion. This client's condition poses the greatest threat to survival.

The nurse assesses 4 clients. Which assessment finding requires the nurse's priority action? 1. 26-year-old with splenectomy reports a headache and chills 2. 40-year-old with immune thrombocytopenic purpura has petechiae on the arms 3. 60-year-old with marked anemia reports shortness of breath when ambulating 4. 68-year-old with polycythemia vera has a hematocrit of 66% (0.66)

1. 26-year-old with splenectomy reports a headache and chills The spleen is part of the immune system and functions as a filter to purify the blood and remove specific microorganisms that cause infections (eg, pneumococcal pneumonia, meningococcal meningitis). Overwhelming postsplenectomy bacterial infection or rapid-onset sepsis are major lifelong complications in a client without a functioning spleen. A minor infection can quickly become life-threatening, and so any indicator of infection such as a low-grade fever, chills, or headache needs immediate intervention (eg, cultures, imaging, antibiotic therapy). Therefore, the client with the splenectomy who is reporting headache and chills requires immediate action.

A licensed practical nurse is discussing some client findings with the registered nurse (RN). Which client would be the priority for the RN to assess? 1. 72-year-old client with pneumonia who is receiving intravenous fluids and has a new S3 heart sound 2. Client on metoprolol for hypertension with pulse of 54/min and blood pressure of 154/82 mm Hg 3. Client who is 8 hours postoperative hip arthroplasty with 205 mL drainage in the suction drain 4. Client with 345 mL gastric residual volume aspirated from a PEG tube before an enteral feed

1. 72-year-old client with pneumonia who is receiving intravenous fluids and has a new S3 heart sound ' An S3 sound is made when blood from the atrium is pumped into a noncompliant ventricle. S3 is heard after S2 (ventricular gallop). It can present as a normal finding in young adults. In older clients, S3 is a significant finding as it often indicates heart failure or volume overload. This client may be receiving excessive IV fluids that are causing volume overload. (Option 2) The normal heart rate is 60-100/min; however, the client's medications and baseline numbers need to be assessed when analyzing vital signs. A heart rate of 54/min in a client on beta blockers (eg, metoprolol, atenolol, propranolol) is not the priority to assess unless signs of decreased cardiac output are evident. The nurse should discuss this client's medication regimen with the health care provider as the blood pressure remains elevated. (Option 3) An output of 205 mL in the first 8 hours after hip arthroplasty is an expected finding due to the highly vascular nature of the hip. Drainage is considered excessive if there is >250 mL in the first 8 hours. (Option 4) Enteral feeds may need to be adjusted if high residual volumes (>250 mL) continue due to the high risk of aspiration, but this client would not be a priority over one with possible new-onset heart failure.

A client in the postoperative period after an open reduction and internal fixation of a left wrist fracture reports constant, severe arm pain that is unrelieved by prescribed morphine administered 30 minutes ago. The client's nail beds appear dusky. What are the nurse's appropriate actions? Select all that apply. 1. Apply a heating pad and encourage range-of-motion exercises 2. Assess the temperature and movement of the fingers 3. Elevate the arm on pillows above the heart level 4. Notify the health care provider 5. Reassure client, document findings, and reassess in 1 hour

2 4 Compartment syndrome, a serious postoperative complication, is caused by decreased blood flow to the tissue distal to the injury. This results from either decreased compartment size (restrictive dressings/splints/casts) or increased pressure within the compartment (bleeding, inflammation, and edema). Earliest symptoms may include pain or numbness that is unrelieved by medication. Subsequent findings include diminished/lost pulses, pallor, coolness, swelling, decreased movement, and cyanosis. Failure to treat this condition can lead to loss of limb function, paralysis, and tissue necrosis. The nurse should assess neurovascular status and report to the health care provider immediately (Options 2 and 4). Removing tight bandages/casts and fasciotomy (surgery) are required to relieve the pressure.

A client with cancer pain is prescribed oxycodone. Which teaching is most essential to help prevent long-term complications? 1. Teach the client how to assess blood pressure daily 2. Teach the client how to prevent constipation 3. Teach the client how to prevent itching 4. Teach the client how to prevent nausea

2. Teach the client how to prevent constipation Oxycodone is a morphine-like opioid medication. Opioid medications bind to opioid receptors in the intestine, which slows peristalsis and increases water absorption, leading to constipation. Constipation is an almost universally expected side effect from opioid medications. Clients will not develop tolerance to this side effect. Although clients with idiopathic chronic constipation are not commonly advised to take laxatives, opioid-induced constipation is treated with simultaneous use of senna (stimulant) and docusate (stool softener).

Which prescriptions for these clients does the nurse question? Select all that apply. 1. Client with Clostridium difficile colitis, prescribed vancomycin 125 mg PO 2. Client with diabetes and elevated mealtime glucose, prescribed lispro insulin scale 6 units subcutaneously 3. Client with gastrointestinal bleed and nasogastric tube, prescribed pantoprazole 40 mg intravenous 4. Client with hypertension and blood pressure (BP) 94/40 mm Hg, prescribed metoprolol succinate SR 50 mg PO 5. Client with otitis media and penicillin allergy, prescribed ampicillin 500 mg PO

4 5 The nurse would question the prescriptions for the following clients: Client with hypertension and BP 94/40 mm Hg, prescribed metoprolol succinate SR (Toprol-XL) 50 mg PO: This client's mean arterial pressure (MAP) is only 58 mm Hg ({[2x diastolic] + systolic} ÷ 3). A MAP >60-65 mm Hg is necessary to perfuse the vital organs (eg, brain, coronary arteries, kidneys). Toprol-XL is a long-acting beta blocker and will continue to drop the client's BP over a 24-hour period. Client with otitis media and penicillin allergy prescribed ampicillin 500 mg PO: Ampicillin is classified as a penicillin antibiotic and is contraindicated in clients with a penicillin allergy. (Option 1) C difficile colitis is treated with metronidazole or vancomycin, depending on severity and number of relapses. Vancomycin is typically given orally in this situation, unlike other nonintestinal infections in which IV is the standard route. There is no reason to question this prescription. (Option 2) A sliding insulin (correction) scale is used to prescribe rapid-acting lispro (Humalog) to control postprandial hyperglycemia. The nurse would not question this prescription. (Option 3) Proton pump inhibitors (eg, pantoprazole, omeprazole) are prescribed for gastroesophageal reflux disease, and ulcer treatment and prophylaxis. The IV preparation is administered when the oral route is contraindicated. The nurse would not question this prescription.

The nurse prepares to administer intravenous albumin to a client with severe liver disease who has a low serum albumin level of 1.5 g/dL (15 g/L). Which characteristic finding associated with hypoalbuminemia should the nurse anticipate assessing? 1. Altered mental status 2. Easy bruising 3. Loss of body hair 4. Pitting edema

4. Pitting edema Oncotic pressure (or colloid osmotic pressure) is a form of osmotic pressure exerted by plasma proteins (albumin) in the blood that pulls water into the circulatory system. Albumin (normal: 3.5-5.0 g/dL [35-50 g/L]) is a large plasma protein that remains in the vascular compartment. Albumin plays a role in maintaining intravascular oncotic pressure and prevents fluid from leaking out of the vessels. Clients with severe liver disease can develop hypoalbuminemia because the liver manufactures albumin, and damaged hepatocytes are unable to synthesize it. When serum albumin is low, oncotic pressure decreases and fluid leaks from the intravascular compartment into the interstitial spaces, causing pitting edema of the lower extremities, periorbital edema, and ascites (Option 4). (Options 1, 2, and 3) Altered mental status, easy bruising, and loss of body hair are manifestations of liver disease, not hypoalbuminemia. Altered mental status (hepatic encephalopathy) is due to elevated serum ammonia levels. Easy bruising is caused by an inability to produce prothrombin and other clotting factors. Loss of body hair is due to altered hormone metabolism.

The nurse reviews the most current laboratory results for assigned clients. Which finding is the highest priority for the nurse to report to the health care provider? 1. CD4+ cell count of 500/mm3 (0.5 × 109/L) in a client with oral candidiasis and HIV who is receiving fluconazole orally 2. Hemoglobin A1C of 7.3% in a client with community-acquired pneumonia and type 2 diabetes who is receiving IV levofloxacin 3. Platelet count of 148,000/mm3 (148 × 109/L) in a client with a venous thrombosis who is receiving a continuous heparin infusion 4. Serum glucose of 68 mg/dL (3.8 mmol/L) in a client with radiation enteritis who is receiving total parenteral nutrition

4. Serum glucose of 68 mg/dL (3.8 mmol/L) in a client with radiation enteritis who is receiving total parenteral nutrition The American Society for Parenteral and Enteral Support (ASPEN) recommends 140-180 mg/dL (7.8-10.0 mmol/L) as the target range for glucose control in clients receiving nutritional support. Hypoglycemia (serum glucose <70 mg/dL [3.9 mmol/L]) can be due to slowing the rate of the infusion. Although it occurs less frequently in clients receiving total parenteral nutrition (TPN) than hyperglycemia (serum glucose >180 mg/dL [10.0 mmol/L]) does, hypoglycemia can lead to life-threatening complications (eg, seizures, nervous system dysfunction). Therefore, the serum glucose of 68 mg/dL (3.8 mmol/L) is the laboratory finding of highest priority for the nurse to report to the health care provider (HCP). (Option 1) A CD4+ cell count of 500/mm3 (0.5 × 109/L) in a client with HIV who is receiving oral fluconazole (Diflucan) to treat oral candidiasis is within normal limits (500-1,200/mm3 [0.5-1.2 × 109/L]) and does not need to be reported to the HCP. (Option 2) A hemoglobin A1C (HbA1c) of 7.3% in a client with type 2 diabetes who is receiving IV levofloxacin to treat pneumonia is not exceptionally high; the recommended goal is <7%. A bacterial infection causes physiologic stress and increased serum glucose. This increases insulin requirements but would not affect the current HbA1c level, as it reflects glucose control over a 2-3 month period. Therefore, this finding is not the highest priority for the nurse to report to the HCP. (Option 3) Heparin can lead to thrombocytopenia. However, a platelet count of 148,000/mm3 (148 × 109/L) is just below normal limits (150,000-400,000/mm3 [150-400 × 109/L]). Therefore, this finding does not need to be reported to the HCP.

A 65-year-old client has been hospitalized for 2 weeks with diabetic gastroparesis. While preparing to administer the daily dose of IV metoclopramide to this client, the nurse assesses for which symptom that may indicate a serious adverse effect of this medication? 1. Bradycardia 2. Diarrhea 3. Frequent burping 4. Unusual movements

4. Unusual movements Metoclopramide is an antiemetic and/or prokinetic agent that promotes gastrointestinal motility and gastric emptying. It is commonly used to treat nausea/vomiting and gastroparesis. This medication can cause tardive dyskinesia (TD), a condition characterized by unusual uncontrollable movements of the arms, legs, head, face, or entire body. Examples include protruding and twisting tongue movements, lip smacking, torticollis, and "piano-playing" finger movements. TD is irreversible in many cases, and the risk for developing metoclopramide-induced TD is greater with advanced age, long-term therapy, and high drug doses.

The nurse is preparing to administer the fourth dose of IV vancomycin to a client. Which set of laboratory values would alert the nurse to hold the vancomycin and notify the health care provider? 1. Vancomycin trough 10 mg/L (6.9 µmol/L), creatinine 1.1 mg/dL (97.2 µmol/L), BUN 6 mg/dL (2.1 mmol/L) 2. Vancomycin trough 14 mg/L (9.7 µmol/L), creatinine 1.2 mg/dL (106.1 µmol/L), BUN 10 mg/dL (3.6 mmol/L) 3. Vancomycin trough 18 mg/L (12.4 µmol/L), creatinine 0.6 mg/dL (53 µmol/L), BUN 18 mg/dL (6.4 mmol/L) 4. Vancomycin trough 23 mg/L (15.9 µmol/L), creatinine 1.5 mg/dL (132.6 µmol/L), BUN 24 mg/dL (8.6 mmol/L)

4. Vancomycin trough 23 mg/L (15.9 µmol/L), creatinine 1.5 mg/dL (132.6 µmol/L), BUN 24 mg/dL (8.6 mmol/L) Vancomycin (Vancocin) is a potent antibiotic used to treat gram-positive bacterial infections (eg, Staphylococcus aureus, Clostridium difficile). To lower the risk of dose-related nephrotoxicity, especially in clients with renal impairment and those who are >60 years of age, serum vancomycin trough levels should be monitored to assess for therapeutic range (10-20 mg/L [6.9-13.8 µmol/L]). A vancomycin trough level above the normal range and/or elevated creatinine and blood urea nitrogen (BUN) values should be reported to the health care provider (HCP) as this may indicate nephrotoxicity. (Options 1, 2, and 3) Normal laboratory values do not need to be reported to the HCP. Baseline and ongoing monitoring for normal levels of creatinine (0.6-1.3 mg/dL [53-115 µmol/L]) and BUN (6-20 mg/dL [2.1-7.1 mmol/L]) are necessary in clients receiving vancomycin.