Block 10 Module 9 Iggy Questions: ED/Trauma/Burns

B Airway is the priority, followed by breathing (pulse oximetry) and circulation (IVs and direct pressure).

A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority? a. Apply direct pressure to the bleeding. b. Ensure the client has a patent airway. c. Obtain a pulse oximetry reading d. Start two large-bore IV catheters.

B Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions would be taken in all resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers. It is not known if this client has orthopedic injuries. The Rapid Response Team is not needed in the ED. A complete history is needed but the staff's protection comes first.

A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action would the nurse take prior to providing advanced cardiac life support? a. Contact the on-call orthopedic surgeon. b. Don personal protective equipment. c. Notify the Rapid Response Team. d. Obtain a complete history from the paramedic.

C The client with pale, cool, clammy skin may be in shock and needs immediate medical attention. The mother does not have injuries and so would be the lowest priority. The other two people need medical attention soon, but not at the expense of a person in shock.

An emergency department nurse is triaging victims of a multi-casualty event. Which client would receive care first? a. A 30-year-old distraught mother holding her crying child b. A 65-year-old conscious male with a head laceration c. A 26-year-old male who has pale, cool, clammy skin d. A 48 year old with a simple fracture of the lower leg

A High glucose readings are common in shock, and best outcomes are the result of treating them and maintaining glucose readings in the range of 140 to 180 mg/dL (7.7 to 10 mmol/L. Medications and IV solutions may raise blood glucose levels, but this is not the most accurate answer. The stress of the illness has not "made" the client diabetic.

A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL (11.6 mmol/L). The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best? a. "High glucose is common in shock and needs to be treated." b. "Some of the medications we are giving are to raise blood sugar." c. "The IV solution has lots of glucose, which raises blood sugar." d. "The stress of this illness has made your spouse a diabetic."

B As part of the primary survey, the nurse would ensure that the client does not have any life-threatening problem by assessing the ABCs first. If there are not major problems, then the nurse could attend to the injured extremity.

A client is admitted to the emergency department with a fractured femur resulting from a motor vehicle crash. What the nurse's priority action? a. Keep the client warm and comfortable. b. Assess airway, breathing, and circulation. c. Maintain the client in a supine position. d. Immobilize the injured extremity with a splint.

A, B, D, E The AP can bring the client warm blankets, reorient the client as needed to decrease anxiety, and sit with the client for reassurance. If the nurse assesses the client is safely able to swallow, small amounts of fluids would be allowed. Massaging the legs is not recommended as this can dislodge any clots present, which may lead to pulmonary embolism.

A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the assistive personnel (AP)? (Select all that apply.) a. Bringing the client warm blankets b. Giving the client hot tea to drink c. Massaging the client's painful legs d. Reorienting the client as needed e. Sitting with the client for reassurance

A Normal cognitive function is a good indicator that the client is receiving the benefits of norepinephrine. The brain is very sensitive to changes in oxygenation and perfusion. Norepinephrine can cause chest pain as an adverse reaction, so the absence of chest pain is good but does not indicate therapeutic effect. The IV site is normal. The urine output is normal, but only minimally so.

A client is receiving norepinephrine for shock. What assessment finding best indicates a therapeutic effect from this drug? a. Alert and oriented, answering questions b. Client denies chest pain or chest pressure c. IV site without redness or swelling d. Urine output of 30 mL/hr for 2 hours

B Moderate hypothermia manifests with muscle weakness, increased loss of coordination, acute confusion, apathy, incoherence, stupor, and impaired clotting. Moderate hypothermia is treated by core rewarming methods, which include administration of warm IV fluids; heated oxygen; and heated peritoneal, pleural, gastric, or bladder lavage. The client's trunk would be warmed prior to the extremities to prevent peripheral vasodilation. Extracorporeal warming with cardiopulmonary bypass or hemodialysis is a treatment for severe hypothermia.

A client presents to the emergency department after prolonged exposure to the cold. The client is difficult to arouse and speech is incoherent. What action would the nurse take first? a. Reposition the client into a prone position. b. Administer warmed intravenous fluids to the client. c. Wrap the client's extremities in warm blankets. d. Initiate extracorporeal rewarming via hemodialysis.

A The client is experiencing respiratory distress which could be due to pulmonary embolus, fat embolism syndrome, or anxiety. Regardless of the cause, the nurse would place the client in a sitting position first and then perform additional assessment. Oxygen would likely be needed, especially if the client's oxygen saturation was under 95%.

A client who had a surgical fractured femur repair reports new-onset shortness of breath and increased respirations. What is the nurse's first action? a. Place the client in a high-Fowler position. b. Document the client's oxygen saturation level. c. Start oxygen therapy at 2 L/min via nasal cannula. d. Contact the primary health care provider.

D The pelvis is very vascular and close to major organs. Injury to the pelvis can cause integral damage that may manifest as blood in the urine (hematuria) or stool. The nurse would also assess for signs of hemorrhage and hypovolemic shock, which include hypotension and tachycardia. Diarrhea and infection are not common complications of a pelvic fracture.

A nurse assesses a client with a pelvic fracture. Which assessment finding would the nurse identify as a complication of this injury? a. Hypertension b. Diarrhea c. Infection d. Hematuria

A The client is at high risk for a fat embolism syndrome and pulmonary embolus. Although these complications are life-threatening emergencies, the nurse would administer oxygen first and then notify the primary health care provider. Oxygen administration can reduce the risk for cerebral damage from hypoxia. Pain medication most likely would not cause the client to be restless.

A nurse assesses an older adult who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless with an oxygen saturation of 88%. Which action would the nurse take first? a. Administer oxygen via nasal cannula. b. Re-position to a semi-Fowler position. c. Increase the intravenous flow rate. d. Assess response to pain medication.

A Skeletal traction pins or screws are surgically inserted into the bone to aid in bone alignment. As a last resort, traction can be used to relieve pain, decrease muscle spasm, and prevent or correct deformity and tissue damage. These are not primary purposes of skeletal traction.

A nurse cares for a client placed in skeletal traction. The client asks, "What is the primary purpose of this type of traction?" How would the nurse respond? a. "Skeletal traction will assist in realigning your fractured bone." b. "This treatment will prevent future complications and back pain." c. "Traction decreases muscle spasms that occur with a fracture." d. "This type of traction minimizes damage as a result of fracture treatment."

B The client with numbness and/or tingling of the extremity may be displaying the first signs of acute compartment syndrome. This is an acute problem that requires immediate intervention because of possible decreased circulation. Moderate pain and swelling is an expected assessment after a fracture. These findings can be treated with comfort measures. Being cold can be treated with additional blankets or by increasing the temperature of the room.

A nurse cares for a client with a recently fractured tibia. Which assessment would alert the nurse to take immediate action? a. Pain of 4 on a scale of 0-10 b. Numbness in the extremity c. Swollen extremity at the injury site d. Feeling cold while lying in bed

C This client has several indicators of sepsis with systemic inflammatory response. The nurse would notify the primary health care provider immediately. Documentation needs to be thorough but does not take priority. The client may appreciate warm blankets, but comfort measures do not take priority. The client may need insulin if blood glucose is being regulated tightly.

A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3 (3.8 × 109/L), blood glucose level 198 mg/dL (11 mmol/L), and temperature 96.2° F (35.6° C). What action by the nurse takes priority? a. Document the findings in the client's chart. b. Give the client warmed blankets for comfort. c. Notify the primary health care provider immediately. d. Prepare to administer insulin per sliding scale.

B Urine output changes are a sensitive early indicator of shock. The nurse would delegate emptying the urinary catheter and measuring output to the AP as a baseline for hourly urine output measurements. The AP cannot assess for pain. Repositioning may or may not be effective for decreasing restlessness, but does not take priority over physical assessments. Reassurance is a therapeutic nursing action, but the nurse needs to do more in this situation.

A nurse is caring for a client after surgery who is restless and apprehensive. The assistive personnel (AP) reports the vital signs and the nurse sees that they are only slightly different from previous readings. What action does the nurse delegate next to the AP? a. Assess the client for pain or discomfort. b. Measure urine output from the catheter. c. Reposition the client to the side. d. Stay with the client and reassure him or her.

B Lower blood volume will decrease MAP. The other answers are not accurate.

A nurse is caring for a client who suffered massive blood loss after trauma. How does the nurse correlate the blood loss with the client's mean arterial pressure (MAP)? a. It causes vasoconstriction and increased MAP. b. Lower blood volume lowers MAP. c. There is no direct correlation to MAP. d. It raises cardiac output and MAP.

A A client's medical alert bracelet or any other jewelry would be removed from the fractured arm before the affected extremity swells. Immobilization, positioning, and dressing should occur after the bracelet is removed.

A nurse is caring for a client with diabetes mellitus who has fractured her arm. Which action would the nurse take first? a. Remove the medical alert bracelet from the fractured arm. b. Immobilize the arm by splinting the fractured site. c. Place the client in a supine position with a warm blanket. d. Cover any open areas with a sterile dressing.

B A lactate level of 5.4 mg/dL (6 mmol/L) is high and is indicative of possible shock. A creatinine level of 0.9 mg/dL (68.6 mcmol/L) is normal. A sodium level of 150 mEq/L (150 mmol/L) is slightly high but does not need to be communicated. A white blood cell count of 11,000/mm3 (11 × 109/L) is slightly high but is not as critical as the lactate level.

A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to communicate with the primary health care provider? a. Creatinine: 0.9 mg/dL (68.6 mcmol/L) b. Lactate: 5.4 mg/dL (6 mmol/L) c. Sodium: 150 mEq/L (150 mmol/L) d. White blood cell count: 11,000/mm3 (11 × 109/L)

D Deep vein thrombosis (DVT) as a complication with bone fractures occurs more often when fractures are sustained in the lower extremities and the client has additional risk factors for thrombus formation. Other risk factors include obesity, smoking, oral contraceptives, previous thrombus events, advanced age, venous stasis, and heart disease. The other clients do not have additional risk factors for DVT

A nurse is caring for several clients with fractures. Which client would the nurse identify as being at the highest risk for developing deep vein thrombosis? a. An 18-year-old male athlete with a fractured clavicle b. A 36-year-old female with type 2 diabetes and fractured ribs c. A 55-year-old female prescribed ibuprofen for osteoarthritis d. A 74-year-old male who smokes and has a fractured pelvis

A, D, E Heat exhaustion manifests as flulike symptoms with headache, weakness, nausea, and/or vomiting. Treatment includes stopping the activity, moving to a cool place, and using cooling measures such as cold packs, cool water soaks, or fanning while spraying cool water on skin. Sodium deficits may occur from drinking plain water, so sports drinks or an oral rehydration therapy solution would be provided. The nurse would remove constrictive clothing only.

A nurse is in charge of a first-aid tent at an all-day outdoor sports event on a hot and humid day. A participant comes to the tent reporting a headache, weakness, and nausea. What actions would the nurse take? (Select all that apply.) a. Have the client lie down in a cool place. b. Force fluids with large quantities of plain water. c. Administer acetaminophen and send home. d. Apply cold packs to neck, arm pits, and groin. e. Encourage drinking a sports drink. f. Remove all clothing and cover with a towel.

B A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable.

A nurse is triaging clients in the emergency department (ED). Which client would the nurse prioritize to receive care first? a. A 22 year old with a painful and swollen right wrist b. A 45 year old reporting chest pain and diaphoresis c. A 60 year old reporting difficulty swallowing and nausea d. An 81 year old, respiratory rate 28 breaths/min and temperature of 101° F (38.8° C)

C A client with a cough and a temperature of 102° F (38.9° C) is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. The client with a chest stab wound and tachycardia and the client with new-onset confusion and slurred speech would be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent.

A nurse is triaging clients in the emergency department. Which client would be considered "urgent"? a. A 20-year-old female with a chest stab wound and tachycardia b. A 45-year-old homeless man with a skin rash and sore throat c. A 75-year-old female with a cough and a temperature of 102° F (38.9° C) d. A 50-year-old male with new-onset confusion and slurred speech

C A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with a simple arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration.

A nurse is triaging clients in the emergency department. Which client would the nurse classify as "nonurgent?" a. A 44 year old with chest pain and diaphoresis b. A 50 year old with chest trauma and absent breath sounds c. A 62 year old with a simple fracture of the left arm d. A 79 year old with a temperature of 104° F (40.0° C)

D This client has a MEWS score of 7 (RR: 0, P: 3, SBP: 1, LOC: 1, Temperature: 1, UO: 1). Scores above 5 are associated with a high risk of death and ICU admission. The most important action for the nurse is to notify the Rapid Response Team so that timely interventions can be initiated. The client most likely will be transferred to the ICU, but an order is required. Monitoring the client every 30 minutes is appropriate, but the nurse needs to obtain care for the client. The charge nurse is a valuable resource, but the best action is to notify the Rapid Response Team.

A nurse on the general medical-surgical unit is caring for a client in shock and assesses the following: Respiratory rate: 10 breaths/min Pulse: 136 beats/min Blood pressure: 92/78 mm Hg Level of consciousness: responds to voice Temperature: 101.5° F (38.5° C) Urine output for the last 2 hours: 40 mL/hr. What action by the nurse is best? a. Transfer the client to the Intensive Care Unit. b. Continue monitoring every 30 minutes. c. Notify the unit charge nurse immediately. d. Call the Rapid Response Team.

D To decrease the risk for infection in a client with skeletal traction or external fixation, the nurse would provide routine pin care and assess for signs and symptoms of infection at the pin sites every shift.

A nurse plans care for a client who has an external fixator on the lower leg. Which intervention would the nurse include in the plan of care to decrease the client's risk for infection? a. Washing the frame of the fixator once a day b. Releasing fixator tension for 30 minutes twice a day c. Avoiding moving the extremity by holding the fixator d. Scheduling for pin care to be provided every shift

A, B, D Postoperative care for a client who has ORIF of the hip includes elevating the client's heels off the bed and re-positioning every 2 hours to prevent pressure and skin breakdown. It also includes ambulating the client on the first postoperative day, and using pillows or an abduction pillow to prevent subluxation of the hip. The nurse would teach the client to use the patient-controlled analgesia pump, but the nurse would never push the button for the client.

A nurse plans care for a client who is recovering from open reduction and internal fixation (ORIF) surgery for a right hip fracture. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) a. Elevate heels off the bed with a pillow. b. Ambulate the client on the first postoperative day. c. Push the client's patient-controlled analgesia button. d. Re-position the client every 2 hours. e. Use pillows to encourage subluxation of the hip.

A, B, E External fixation is a system in which pins or wires are inserted through the skin and bone and then connected to a ridged external frame. With external fixation, blood loss is less than with internal fixation, but the risk for infection is much higher. The device allows early ambulation and exercise, maintains alignment, stabilizes the fracture site, and promotes healing. The device does not increase blood supply to the tissues. The nurse would assess for distal circulation, movement, and sensation, which can be disturbed by fracture injuries and treatments.

A nurse teaches a client with a fractured tibia about external fixation. Which advantages of external fixation for the immobilization of fractures would the nurse share with the client? (Select all that apply.) a. It leads to minimal blood loss. b. It allows for early ambulation. c. It decreases the risk of infection. d. It increases blood supply to tissues. e. It promotes healing.

D The client with a healing fracture needs supplements of vitamins B and C and a high-protein, high-calorie diet. Milk for calcium supplementation and vitamin C supplementation is appropriate. Meat would increase protein in the diet that is necessary for bone healing. Fish, a sandwich, and vegetable lasagna would provide less protein.

After teaching a client with a fractured humerus, the nurse assesses the client's understanding. Which dietary choice demonstrates that the client correctly understands the nutrition needed to assist in healing the fracture? a. Baked fish with orange juice and a vitamin D supplement b. Bacon, lettuce, and tomato sandwich with a vitamin B supplement c. Vegetable lasagna with a green salad and a vitamin A supplement d. Roast beef with low-fat milk and a vitamin C supplement

C The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. Injuries from this type of fall have a high risk for cervical spine injuries. In addition, with the loss of consciousness at the scene the client would be at risk for head trauma. A full set of vital signs is obtained as part of the secondary survey. The cardiac rhythm is important but not specifically related to this client's presentation. Client history would be obtained as able.

An elderly client who has fallen from a roof is transported to the emergency department by ambulance. The client was unconscious at the scene but is conscious on arrival and is triaged as urgent. What is the priority assessment the nurse includes during the primary survey of the patient? a. A full set of vital signs b. Cardiac rhythm c. Neurologic status d. Client history

B, C, E, F The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic ABC, with an added D and E: Airway and cervical spinal motion restriction; Breathing; Circulation; Disability; and Exposure. After the completion of primary diagnostic and laboratory studies, and the insertion of gastric and urinary tubes, the secondary survey (a complete head-to-toe assessment) can be carried out.

An emergency department nurse is caring for a trauma patient. Which interventions does the nurse perform during the primary survey? (Select all that apply.) a. Foley catheterization b. Needle decompression c. Initiating IV fluids d. Splinting open fractures e. Endotracheal intubation f. Removing wet clothing g. Laceration repair

A, D, E Heat stroke is a medical emergency. Oxygen therapy and intravenous fluids would be provided, and baseline laboratory tests would be performed as quickly as possible. Urinary output is measured via an indwelling urinary catheter. The client would be cooled until core body temperature is reduced to 102° F (38.9° C). Antipyretics would not be administered.

An emergency department nurse plans care for a client who is admitted with heat stroke. Which interventions does the nurse include in this patient's plan of care? (Select all that apply.) a. Administer oxygen via mask or nasal cannula. b. Administer ibuprofen, an antipyretic medication. c. Apply cooling techniques until core body temperature is less than 101° F (38.3° C). d. Infuse 0.9% sodium chloride via a large-bore intravenous cannula. e. Obtain baseline serum electrolytes and cardiac enzymes. f. Insert an indwelling urinary catheter for urine output measurements.

A After establishing an airway, the highest priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he or she may not be breathing, or may be breathing inadequately with the device in place. Inserting an IV line and placing the client on a monitor would come after ensuring a patent airway and effective breathing.

Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action would the nurse take first? a. Assess that the client is breathing adequately. b. Insert a large-bore intravenous line. c. Place the client on a cardiac monitor. d. Assess for the best neurologic response.

B, C, D, E, F All of the choices are correct except that the client should stay in a flat supine position immediately after the procedure.

The nurse is caring for a client who just had a kyphoplasty. What nursing care is needed for the client at this time? (Select all that apply.) a. Place the client in a prone position to prevent pressure on the surgical area. b. Apply an ice pack to the surgical area to help relieve pain. c. Assess the client's pain level to compare it with pain before the procedure. d. Take vital signs, including oxygen saturation, frequently. e. Monitor for complications such as bleeding or shortness of breath. f. Perform frequent neurologic assessments and report major changes.

B The client demonstrates signs of heat stroke. This is a medical emergency and priority care includes oxygen therapy, IV infusion with 0.9% saline solution, insertion of a urinary catheter, and aggressive interventions to cool the patient, including external cooling and internal cooling methods. Oral hydration would not be appropriate for a client who has symptoms of heat stroke because oral fluids would not provide necessary rapid rehydration, and the confused client would be at risk for aspiration. Acetaminophen would not decrease this patient's temperature or improve the patient's symptoms. The client needs immediate medical treatment; therefore, rest and reassessing in 15 minutes are inappropriate.

On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, and blood pressure 106/66 mm Hg. What action would the nurse take? a. Encourage the client to drink cool water or sports drinks. b. Start an intravenous line and infuse 0.9% saline solution. c. Administer acetaminophen (Tylenol) 650 mg orally. d. Encourage rest and reassess in 15 minutes.

B, C, E With a pelvic fracture, internal organ damage may result in bleeding and hypovolemic shock. The nurse monitors the client's heart rate, blood pressure, urine output, skin color, and level of consciousness frequently to detect assess for shock. It is important to monitor the urine for blood to assess whether the urinary system has been damaged with the pelvic fracture. Changes in temperature and pupil reactions are not directly associated with hypovolemic shock. Temperature changes are usually associated with hypo- or hyperthermia or infectious processes. Pupillary changes occur with brain injuries, bleeds, or strokes.

The nurse assesses a client who is admitted with a pelvic fracture. Which assessments would the nurse monitor to prevent or detect a complication of this injury? (Select all that apply.) a. Temperature b. Urinary output c. Blood pressure d. Pupil reaction e. Skin color

A, C, D, E Assessing and identifying clients at risk for shock is probably the most critical action the nurse can take to prevent shock from occurring. Proper hand hygiene, using aseptic technique, and removing IV lines and catheters are also important actions to prevent shock. Monitoring laboratory values does not prevent shock but can indicate a change. Limiting the client's visitors is not a caring action. The nurse would ensure they perform proper hand hygiene on entering and leaving the room and that visitors are not ill themselves.

The nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility of the clients developing shock? (Select all that apply.) a. Assessing and identifying clients at risk b. Monitoring the daily white blood cell count c. Performing proper hand hygiene d. Removing invasive lines as soon as possible e. Using aseptic technique during procedures f. Limiting the client's visitors until more stable

A, B, C, D, F Immobility, decreased thirst response, diminished immune response, malnutrition, and use of diuretics can place the older adult at higher risk of developing shock. Overhydration is not a common risk factor for shock.

The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what factors would the nurse assess? (Select all that apply.) a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition e. Overhydration f. Use of diuretics

A This client has a falling systolic blood pressure, rising diastolic blood pressure, and narrowing pulse pressure, all of which may be indications of worsening perfusion status and possible shock. The nurse would assess this client first. The client with the unchanged oxygen saturation is stable at this point. Although the client with a change in pulse has a slower rate, it is not an indicator of shock since the pulse is still within the normal range; it may indicate that the client's pain or anxiety has been relieved, or he or she is sleeping or relaxing. A urine output of 40 mL/hr is above the normal range, which is 30 mL/hr.

The nurse gets the hand-off report on four clients. Which client would the nurse assess first? a. Client with a blood pressure change of 128/74 to 110/88 mm Hg b. Client with oxygen saturation unchanged at 94% c. Client with a pulse change of 100 to 88 beats/min d. Client with urine output of 40 mL/hr for the last 2 hours

C The primary health care provider should be notified to examine the client and determine the source of the drainage. The nurse's assessment should be documented, but that is not the most important action.

The nurse is caring for a client who had a closed reduction of the left arm and notes a large wet area of drainage on the cast. What action is the most important? a. Cut off the old cast. b. Document the assessment. c. Notify the primary health care provider. d. Wrap the cast with gauze.

A, C, D, E The client who experiences a sports injury should be managed using the RICE treatment plan. Rest, ice, compression, and elevation are all appropriate. Heat would increase swelling and probably pain. An x-ray would be obtained to determine if one or more fractures are present. Opioids may not be needed depending on the nature of the injury.

The nurse is caring for a client who recently sustained a sports injury to his right leg. What nursing interventions are appropriate for this client? (Select all that apply.) a. Immobilize the right leg. b. Apply heat immediately after the injury. c. Use compression to support the leg. d. Obtain an x-ray to detect possible fracture. e. Elevate the right leg to decrease swelling. f. Administer an opioid every 4 to 6 hours.

A, B, C, E, F Within the first hour of suspecting severe sepsis, the nurse would draw (or facilitate) serum lactate levels, obtain blood cultures (or other cultures), administer antibiotics (after the cultures have been obtained), begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L. and administer vasopressors if hypotensive during or after fluid resuscitation to maintain a mean arterial pressure ≥ 65 mm Hg. Initiating hemodynamic monitoring would be done after these "bundle" measures have been accomplished.

The nurse is caring for a client with suspected septic shock. What does the nurse prepare to do within 1 hour of the client being identified as possibly having sepsis? (Select all that apply.) a. Administer antibiotics. b. Draw serum lactate levels. c. Infuse vasopressors. d. Measure central venous pressure. e. Obtain blood cultures. f. Administer rapid bolus of IV crystalloids.

B, C, D To best prevent heat-related illnesses, the nurse would teach individuals to use sunscreen with at least an SPF of 30 for both UVA and UVB rays, to shower or bathe in cool water after being outdoors to reduce body heat, to remain hydrated, and to wear light-colored, loose-fitting clothes. Families and friends should check older adults at least twice a day during a heat wave; however, this may not prevent heat-related illness but could catch it quickly and limit its severity.

The nurse is teaching participants in a family-oriented community center ways to prevent their older relatives and friends from getting heat-related illnesses. What information does the nurse include? (Select all that apply.) a. Use sunscreen with an SPF of at least 15 when outdoors. b. Take cool baths or showers after outdoor activities. c. Check on the older adult daily in hot weather. d. Drink plenty of liquids throughout the day. e. Wear light-colored, snugly-fitting clothing to wick sweat away.

A,C The common signs and symptoms of shock, no matter the cause, are directly related to the effects of anaerobic metabolism and hypotension. Hyperglycemia, impaired renal function, and increased perfusion are not the cause of common signs and symptoms of shock.

The nurse studying shock understands that the common signs and symptoms of this condition are directly related to which problems? (Select all that apply.) a. Anaerobic metabolism b. Hyperglycemia c. Hypotension d. Impaired renal perfusion e. Increased systemic perfusion

b. Uncontrolled external bleeding CAB for hemorrhage

What is the one exception to the ABCDE primary survey? a. Total cardiac and respiratory arrest b. Uncontrolled external bleeding c. Fifty percent total body surface burns d. Client with HIV and active AIDs

A ED triage is an organized system for sorting and classifying clients into priority levels depending on illness or injury severity. The primary goal of the triage system is to facilitate the ED nurse's ability to prioritize care according to the acuity of the patient, having the clients with the more severe illness or injury seen first. Airway, breathing, and circulation are part of the primary survey. Determining responsiveness is done during the disability phase of the primary survey and is not the primary goal. Evaluating the ED's resources is also not a goal of triage.

What is the primary goal of a triage system used by the nurse with clients presenting to the emergency department? a. Determine the acuity of the client's condition to determine priority of care. b. Assess the status of the airway, breathing, circulation, or presence of deficits. c. Determine whether the client is responsive enough to provide needed information. d. Evaluate the emergency department's resources to adequately treat the patient.

d. Impervious cover gown, gloves, eye protection, face mask, cap, and shoe covers are required

What type of PPE or attire would the nurse wear to provide care for a motor vehicle crash victim with severe chest trauma who is coughing up blood and has a crush injury to the right leg? a. No PPE is needed because the nurse is only recording and not giving direct care b. The client situation must be assessed before determining what type of PPE would be worn c. Gloves only, but handwashing is required before and after all emergency care d. Impervious cover gown, gloves, eye protection, face mask, cap, and shoe covers are required

a. Administer cooled normal saline c. Place client on O2 by nasal cannula e. Insert an indwelling urinary catheter f. Obtain baseline lab tests (e.g. CBC, electrolytes, cardiac enzymes, liver enzymes)

Which are appropriate actions for the nurse to take when a client with a heat stroke has been admitted to the ED? SATA a. Administer cooled normal saline b. Give aspirin or another antipyretic c. Place client on O2 by nasal cannula d. Stop cooling efforts when body temp is 100F e. Insert an indwelling urinary catheter f. Obtain baseline lab tests (e.g. CBC, electrolytes, cardiac enzymes, liver enzymes)

a. Airway/cervical spine b. Breathing c. Circulation d. Disability e. Exposure

Which are the key elements when the nurse performs a primary survey on a client brought into the emergency department? SATA a. Airway/cervical spine b. Breathing c. Circulation d. Disability e. Exposure f. Functional ability

A, C, E, F Signs and symptoms of heat stroke include as elevated body temperature (above 104° F [40° C]), mental status changes such as confusion and decreasing level of consciousness, hypotension, tachycardia, and tachypnea. Perspiration is an inconsistent finding.

Which assessment findings would indicate to the nurse that a client has suffered from a heat stroke? (Select all that apply.) a. Confusion and bizarre behavior b. Headache and fatigue c. Hypotension d. Presence of perspiration e. Tachycardia and tachypnea f. Body temperature more than 104° F (40° C)

b. 44 yr old w/ a dislocated elbow In the 3 tiered system the urgent category includes clients with a new onset of pneumonia (as long as resp failure does not appear imminent), renal colic, complex lacerations not associated with major hemorrhage, displaced fractures or dislocations, and temp greater than 103F. A & D are emergent and C is nonurgent

Which client would the triage nurse categorize as urgent? a. 35 yr old w/ chest pain and diaphoresis b. 44 yr old w/ a dislocated elbow c. 65 yr old w/ redness and swelling on the forearm due to a bee sting d. 83 yr old w/ new confusion and very elevated blood pressure compared with his baseline

a. Client w/ crushing substernal chest pain and shortness of breath c. Client with active hemorrhage after a motor vehicle crash

Which clients would the triage nurse classify as emergent, needing to been immediately? SATA a. Client w/ crushing substernal chest pain and shortness of breath b. Client with a generalized skin rash who had shellfish for dinner yesterday c. Client with active hemorrhage after a motor vehicle crash d. Clients with back pain and hematuria w/ a hx of kidney stones e. Client with a dislocated shoulder f. Client with dysuria from a long term care facility

d. Categorize the client as emergent triage nurse would recognize s/s of stroke and put the pt as emergent and notify provider

Which first action would the triage nurse take for a client who comes to the ED with blurred vision, difficulty speaking, left extremity weakness and difficulty walking? a. Send the client immediately for a head CT scan b. Notify ED health care provider c. Delegate the assistive personnel (AP) to stay with client d. Categorize the client as emergent

A

Which signs and symptoms does the nurse expect when assessing a client admitted to the emergency department with mild hypothermia? a. Shivering, slurred speech, and mental slowness b. Acute confusion, apathy, and incoherence c. Bradycardia, hypotension, and acid-base imbalance d. Bradypnea, ventricular fibrillation, and decreased neurological reflexes