Ch 72 - emergency
Tx goals for poison
-Remove or inactivate the poison before it is absorbed -Provide supportive care in maintaining vital organ systems -Administer specific antidotes -Implement tx to hasten the elimination of the poison
If there is no pulse even after you try to reposition the client what do you do?
1. CALL DOC 2. Rapid total body assessment 3. transfer pt to OR for arteriography and possible arterial repair 4. If doesnt work then amputation
Priority Management in Patients With Multiple Injuries
1. Establish airway and ventilation 2. Control hemmorhage 3. PRevent and treat hypovlemic shock 4. Assess for head and neck injury 5. Evaluate for other injures 6. Splint fractures then reassess pulses and neurovascular status 7. Perorm a more thorough assessment; diagnostic studies
Steps for fractures
1. handle body part gently 2.cut off clothes 3. Assess 4 pain, swelling and circulatory disturbances 4. Assess for ecchymosis, tenderness, creptitation
A client suspected of acetaminophen (Tylenol) toxicity reports that he ingested the medication at 7 p.m. At what time should the nurse anticipate laboratory tests to assess the acetaminophen level? a) 24 hours from the last dose b) 8 p.m. c) 11:00 p.m. d) Stat
11:00 p.m. The duration of action of acetaminophen ranges from 3 to 5 hours. Its half-life ranges from 1 to 3 hours. At least 4 hours should pass between the last dose and laboratory assessment of the acetaminophen level.
A gastric lavage has been ordered for a client who is comatose and who ingested a full bottle of acetaminophen, a nonnarcotic analgesic. Which should be included in the procedure? Select all that apply. 1. Place the client on the left side with the head 15 degrees lower than the body. 2. Insert a small bore feeding tube into the nare. 3. Have standby suction available. 4. Withdraw all stomach contents and then instill an irrigating solution. 5. Send samples of the stomach contents to the lab for analysis.
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The nurse is discharging a client diagnosed with accidental carbon monoxide poisoning. Which statement made by the client indicates the need for further teaching? 1. "I should install carbon monoxide detectors in my home." 2. "Having a natural bright-red color to my lips is good." 3. "You cannot smell carbon monoxide, so it can be difficult to detect." 4. "I should have my furnace checked for leaks before turning it on."
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The nurse received a patient from a motor vehicle accident who is hemorrhaging from a femoral wound. What is the initial nursing action for the control of the hemorrhage? a) Immobilize the area to control blood loss. b) Elevate the injured part. c) Apply firm pressure over the involved area or artery. d) Apply a tourniquet.
Apply firm pressure over the involved area or artery. Direct, firm pressure is applied over the bleeding area or the involved artery at a site that is proximal to the wound (Fig. 72-3). Most bleeding can be stopped or at least controlled by application of direct pressure. Otherwise, unchecked arterial bleeding results in death. A firm pressure dressing is applied, and the injured part is elevated to stop venous and capillary bleeding, if possible. If the injured area is an extremity, the extremity is immobilized to control blood loss. A tourniquet is applied to an extremity only as a last resort when the external hemorrhage cannot be controlled in any other way and immediate surgery is not feasible.
A patient is brought to the ED by a friend, who states that a tree fell on the patient's leg and crushed it while they were cutting firewood. What priority actions should the nurse perform? (Select all that apply.) Performing a fasciotomy Splinting the wound in a position of rest to prevent motion Inserting an indwelling catheter Elevating the site to limit the accumulation of fluid in the interstitial spaces Applying a clean dressing to protect the wound
Applying a clean dressing to protect the wound Elevating the site to limit the accumulation of fluid in the interstitial spaces Splinting the wound in a position of rest to prevent motion Explanation: Major soft tissue injuries are dressed and splinted promptly to control bleeding and pain. If an extremity is injured, it is elevated to relieve swelling and pressure.
As part of an emergency department team, an emergency nurse is conducting a secondary survey on a client. Which of the following would the nurse include? a) Establishing a patent airway b) Assessing neurologic function c) Applying electrocardiogram electrodes d) Providing adequate ventilation
Applying electrocardiogram electrodes A secondary survey is completed after the primary survey priorities of airway, breathing, circulation, and disability have been addressed. Applying electrocardiogram electrodes would be a component of the secondary survey. Establishing a patent airway, providing adequate ventilation, and determining neurologic disability by assessing neurologic function are components of the primary survey.
When assessing a client with suspected carbon monoxide poisoning, which finding would be least reliable? a) Headache b) Palpitations c) Confusion d) Cherry red skin color
Cherry red skin color Skin color can range from pink or cherry-red to cyanotic and pale is not a reliable sign. In clients with carbon monoxide poisoning, central nervous system signs such as headache and confusion predominate. Palpitations also may occur.
A patient presents to the ED following a motor vehicle collision. The patient is suspected of having internal hemorrhage. The nurse assesses the patient for signs and symptoms of shock. Signs and symptoms of shock include which of the following? Select all that apply. A. Increasing urine volume B. Decreasing blood pressure C. Increasing heart rate D. Delayed capillary refill E. Cool, moist skin
Cool, moist skin Decreasing blood pressure Increasing heart rate Delayed capillary refill Explanation: Signs and symptoms of shock include cool, moist skin (resulting from poor peripheral perfusion), decreasing blood pressure, increasing heart rate, delayed capillary refill, and decreasing urine volume
A client has a gaping wound on his forearm that is bleeding profusely. Applying pressure to which pressure point would be most helpful? Femoral Brachial Radial Subclavian
Correct response: Brachial Explanation: The pressure point at the brachial artery would be most appropriate because this site is proximal to the bleeding site. The femoral pressure point would be useful for bleeding in the lower extremities. The radial pressure point would be appropriate for bleeding in the wrist and hands. The subclavian pressure point would be used for bleeding in the upper anterior chest area.
A family member brings a patient to the emergency department. The family member states, "I think he overdosed on heroin." Which of the following would the nurse expect to assess? Flushed face Pinpoint pupils Hypertension Hyperventilation
Correct response: Pinpoint pupils Explanation: Signs of an acute overdose of heroin, an opioid, include pinpoint pupils, marked respiratory depression, descreased blood pressure, stupor progressing to coma, seizures, and pulmonary edema. Flushed face typically reflects a barbiturate overdose.
A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's: heart rate. blood pressure. temperature. hemoglobin level.
Correct response:blood pressure. Explanation:With adequate fluid replacement, fluid volume in the intravascular space expands, raising the client's blood pressure. The hemoglobin level reflects red blood cell concentration, not overall fluid status. Temperature and heart rate aren't directly related to fluid status.
A client is brought to the emergency department by ambulance. The client is seriously ill and unconscious. No family or friends are present. Which of the following would be most appropriate to do? a) Ask the ambulance team for information about the client's family to ensure informed consent. b) Document the client's condition and absence of friends or family for obtaining consent to treatment. c) Explain to the client that care is going to be provided because he is seriously ill. d) Check the client's record for the name of a family member to call to allow care to be provided.
Document the client's condition and absence of friends or family for obtaining consent to treatment. Consent is needed to examine and treat a client unless he or she is unconscious or in critical condition and unable to make decisions. In this situation, the client is unconscious and no friends or family are around to provide consent to treatment. The nurse should document this fact and provide care. Checking the client's record and asking the ambulance team for information would waste valuable time. Explaining to the client that care will be provided is appropriate even though the client is unconscious, but documentation is essential.
A patient has undergone a diagnostic peritoneal lavage. The nurse interprets which result as indicating a positive test? a) Red blood cell count of 50,000/mm3 b) Absence of bile c) White blood cell count of 300/mm3 d) Evidence of feces
Evidence of feces A diagnostic peritoneal lavage is considered positive if there is bile, feces, or food in the specimen, a red blood cell count greater than 100,000/mm3, and a white blood cell count greater than 500/mm3.
A patient who has accidentally ingested toilet bowel cleaner is brought to the emergency department. Which action would NOT be appropriate for the nurse to implement? a) Administration of activated charcoal b) Dilution with water or milk c) Induced vomiting d) Gastric lavage
Induced vomiting Vomiting is never induced after ingestion of caustic substances (acid or alkaline) such as toilet bowl cleaner because the substance is corrosive to the tissues. Appropriate actions include dilution with milk or water, gastric lavage, and administration of activated charcoal.
A patient who has accidentally ingested toilet bowel cleaner is brought to the emergency department. Which action would NOT be appropriate for the nurse to implement? a) Dilution with water or milk b) Administration of activated charcoal c) Induced vomiting d) Gastric lavage
Induced vomiting Vomiting is never induced after ingestion of caustic substances (acid or alkaline) such as toilet bowl cleaner because the substance is corrosive to the tissues. Appropriate actions include dilution with milk or water, gastric lavage, and administration of activated charcoal.
Which of the following solutions should the nurse anticipate for fluid replacement in the male patient? a) Lactated Ringer's solution b) Hypertonic saline c) Type O negative blood d) Dextrose 5% in water
Lactated Ringer's solution Replacement fluids may include isotonic electrolyte solutions and blood component therapy. O negative blood is prepared for emergency use in women of childbearing age.Dextrose 5% in water should not be used to replace fluids in hypovolemic patients. Hypertonic saline is used only to treat severe symptomatic hyponatremia and should be used only in intensive care units.
Acetaminophen overdose is treated with the administration of which of the following medications? a) Flumazenil (Romazicon) b) Diazepam (Valium) c) Naloxone (Narcan) d) N-acetylcysteine (Mucomyst)
N-acetylcysteine (Mucomyst) Treatment of acetaminophen overdose includes administration of N-acetylcysteine (Mucomyst). Flumazenil is administered in the treatment of nonbarbiturate sedative overdoses. Naloxone (Narcan) is administered in the treatment of narcotic overdoses. Diazepam (Valium) may be administered to treat uncontrolled hyperactivity in the patient with a hallucinogen overdose.
If there is no pulse in the extremity what do you do?
Repositioning of the extremity to proper alignment is required and then reassess
A patient is brought to the emergency department following an overdose of a selective serotonin reuptake inhibitor (SSRI). While assessing the patient, the nurse suspects that the patient may be developing serotonin syndrome based on which of the following? a) Lethargy b) Lack of perspiration c) Seizures d) Hypotension
Seizures Serotonin syndrome is manifested by agitation, seizures, hyperthermia, diaphoresis, and hypertension.
List the pressure points to control hemorrhage
Temporal, facial, carotid, subclavian, brachial, radial/ulnar, femoral
When providing care to a client who has experienced multiple trauma, which of the following would be most important for the nurse to keep in mind? a. Most multiple trauma victims exhibit evidence of the trauma. b. The most lethal injuries are often the most readily apparent. c. The client is assumed to have a spinal cord injury until proven otherwise. d. Injuries have occurred to at least three distinct organ systems.
The client is assumed to have a spinal cord injury until proven otherwise. Explanation: With clients experiencing multiple trauma, the nurse must assume that the client has a spinal cord injury until proven otherwise. Multiple trauma cleints experience life-threatening injuries to at least two distinct organs or organ systems. Evidence of the trauma may be sparse or absent. Additionally, the injury that may seem the least significant may be the most lethal.
spinal cord compression
Tumor in epidural space of spinal cord; signs include Intense, localized, persistent back pain Motor weakness Sensory paresthesia and loss Change in bladder or bowel function
A triage nurse in the ED determines that a patient with dyspnea and dehydration is not in a life-threatening situation. What triage category will the nurse choose? a) Immediate b) Emergent c) Delayed d) Urgent
Urgent A basic and widely used triage system that had been in use for many years utilized three categories: emergent, urgent, and nonurgent. In this system, emergent patients had the highest priority, urgent patients had serious health problems but not immediately life-threatening ones, and nonurgent patients had episodic illnesses.
what is a hare traction used for
a portable in line traction device may be applied to assist with alignment. If fractured femur is pulseless
Diuresis, dialysis, or hemoperfusion are methods that can be used for what
detoxification of the blood by processing it through an extracorporeal circuit and an adsorbent cartridge containing charcoal or resin, after which the cleansed blood is returned to the patient
what is the main cause of shock
hemorrhage
A nurse is caring for a client who has arrived at the emergency department in shock. The nurse intervenes based on the knowledge that which of the following is the most common cause of shock? Hypovolemia Sepsis Cardiac dysfunction Anaphylaxis
hypovolemia
Risk associated with hemorrhage
o Cardiac arrest caused by hypovolemia
cathartic tx for poison
o the expulsion of liquid stool o Rarely indicated because they can result in severe electrolyte imbalances, diarrhea, and hypovolemia
The nurse has received a client into care who has admitted with heroin overdose. the pt has a 5 yr history of illicit substance use with cocaine, heroine, and oxycodone. the client develops a sudden onset of wheezing, restlessness, and a cough that frothy pink sputum. What is the complication of this overdose?
pulmonary edema
A patient presents to the ED following a motor vehicle collision. The patient is suspected of having internal hemorrhage. The nurse assesses the patient for signs and symptoms of shock. Signs and symptoms of shock include which of the following? Select all that apply. a) Decreasing blood pressure b) Increasing urine volume c) Increasing heart rate d) Delayed capillary refill e) Cool, moist skin
• Decreasing blood pressure • Cool, moist skin • Increasing heart rate • Delayed capillary refill Signs and symptoms of shock include cool, moist skin (resulting from poor peripheral perfusion), decreasing blood pressure, increasing heart rate, delayed capillary refill, and decreasing urine volume.
Hemorrhage Management: Control of external bleeding
• Direct, firm pressure is applied over the bleeding area • Elevation- stops bleeding • Tourniquet applied as LAST RESORT o Applied proximal to the wound o Tag pt. with pencil or tape with "T", location, and time applied
Hemorrhage Management: Control of internal bleeding
• Packed red blood cells administered at a rapid rate • Prep for surgery or pharm therapy • ABGs • Supine position
A patient with a history of major depressive disorder is brought to the emergency department by a friend, who reports that the patient took an overdose of prescribed amitriptyline. Which of the following findings would the nurse expect to assess? Select all that apply. a) Visual hallucinations b) Hypoactive reflexes c) Clonus d) Hypothermia e) Tachycardia
• Tachycardia • Visual hallucinations • Clonus Amitriptyline is a tricyclic antidepressant. In cases of overdose, the patient would likely experience tachycardia, hypotension, confusion, visual hallucinations, clonus, tremors, hyperactive reflexes, seizures, blurred vision, flushing, and hyperthermia.
Hemorrhage Management: Fluid replacement
• Two large-gauge IV catheters are inserted • Blood samples are obtained for analysis, typing, and cross-matching • Replacement fluids: isotonic(e.g., lactated Ringer's, normal saline), colloids, and blood component therapy
