Chapter 72: Emergency Nursing

Nursing students are reviewing information about endotracheal intubation. They demonstrate understanding of the information when they identify which of the following as a reason for this procedure? Select all that apply. a) Allow connection to a manual resuscitation bag b) Facilitate removal of an upper airway obstruction c) Prevent aspiration into the lungs d) Establish an airway for ventilation e) Decrease tracheobronchial secretions

a) Allow connection to a manual resuscitation bag c) Prevent aspiration into the lungs d) Establish an airway for ventilation Endotracheal intubation is indicated to establish an airway for a patient who cannot be adequately ventilated with an oropharyngeal airway, bypass an upper airway obstruction, prevent aspiration, permit connection to a resuscitation bag or mechanical ventilator, or facilitate removal of tracheobronchial secretions.

A client with a history of allergies comes to the emergency department. The nurse suspects anaphylaxis based on which of the following? Select all that apply. a) Facial angioedema b) Pallor c) Chest tightness d) Increasing blood pressure e) Localized itching

a) Facial angioedema b) Pallor c) Chest tightness e) Localized itching Manifestations suggesting anaphylaxis include chest tightness, generalized itching, pallor, massive facial angioedema, tachycardia or bradycardia, and decreasing blood pressure (as a result of peripheral vascular collapse).

A nurse is working as a camp nurse during the summer. A camp counselor comes to the clinic after receiving a snakebite on the arm. What is the first action by the nurse? a) Have the patient lie down and place the arm below the level of the heart. b) Apply ice to the area. c) Make an incision and suck the venom out. d) Apply a tourniquet to the arm above the bite.

a) Have the patient lie down and place the arm below the level of the heart. Initial first aid at the site of the snakebite includes having the person lie down, removing constrictive items such as rings, providing warmth, cleansing the wound, covering the wound with a light sterile dressing, and immobilizing the injured body part below the level of the heart. Airway, breathing, and circulation are the priorities of care. Ice, incision and suction, or a tourniquet is not applied.

A nurse is providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate? a) Massaging the feet b) Restricting ambulation c) Providing an analgesic for pain d) Placing sterile cotton between the toes after rewarming

a) Massaging the feet For a client with frostbite, massaging the affected body part is contraindicated. Analgesia is given for pain during the rewarming process because it can be very painful. Ambulation would be restricted. Once rewarmed, sterile gauze or cotton is placed between the affected toes to prevent maceration.

A nurse who is a member of an emergency response team anticipates that several patients with airway obstruction may need a cricothyroidotomy. For which of the following patients would this procedure be appropriate? Select all that apply. a) Patient with extensive facial trauma b) Patient with a lumbar spine injury c) Patient with laryngeal edema secondary to anaphylaxis d) Patient with an obstructed larynx e) Patient who is bleeding from the chest

a) Patient with extensive facial trauma c) Patient with laryngeal edema secondary to anaphylaxis d) Patient with an obstructed larynx Cricothyroidotomy is used in emergencies when endotracheal intubation is either not possible or contraindicated. Examples include airway obstruction from extensive maxillofacial trauma, cervical spine injury, laryngospasm, laryngeal edema after an allergic reaction or extubation, hemorrhage into neck tissue, and obstruction of the larynx.

Which of the following triage categories refers to life-threatening or potentially life-threatening injury or illness requiring immediate treatment? a) Nonacute b) Emergent c) Urgent d) Immediate

b) Emergent The patient triaged as emergent must be seen immediately. The triage category of urgent refers to minor illness or injury needing first-aid-level treatment. The triage category of immediate refers to non-acute, non-life threatening injury or illness.

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) Evidence of feces c) Absence of bile d) White blood cell count of 300/mm3

b) 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.

What is the most frequently injured solid organ in a penetrating trauma? a) Pancreas b) Liver c) Brain d) Lungs

b) Liver The most frequently injured solid organ in a penetrating trauma is the liver.

When preparing to perform abdominal thrusts on a client with an airway obstruction, which of the following would be most appropriate? a) Using a sequence of four thrusts, each progressing in intensity b) Positioning the hands in the midline slightly above the umbilicus c) Placing the thumb side of one hand at the xiphoid process d) Having the conscious client lie down

b) Positioning the hands in the midline slightly above the umbilicus When performing abdominal thrusts, the nurse would place the thumb side of one fist against the client's abdomen in the midline slighlty above the umbilicus and well below the xiphoid process, grasping the fist with the other hand. Then the nurse would press the fist into the client's abdomen with a quick inward and upward thrust such that each new thrust should be a separate and distinct maneuver. The unconscious client is positioned on the back. The client who is conscious should be standing or sitting.

A nurse is establishing a patient's airway. Which action would the nurse perform first? a) Using the jaw-thrust maneuver b) Repositioning the patient's head c) Inserting an artificial airway d) Giving abdominal thrusts

b) Repositioning the patient's head Establishing an airway may be as simple as repositioning the patient's head to prevent the tongue from obstructing the pharynx. Subsequent measures would include abdominal thrusts to dislodge a foreign body, head-tilt chin-lift or jaw-thrust manuever, or insertion of an artificial airway.

A finger sweep is only to be used in which patient population? a) Child b) Unconscious adult c) Adolescent d) Conscious adult

b) Unconscious adult A finger sweep should be used only in the unconscious adult patient. This action draws the tongue away from the back of the throat and away from the foreign body that may be lodged there. A finger sweep should not be done on a conscious adult, child, or adolescent.

The nurse is caring for a patient in the ED who is breathing but unconscious. In order to avoid an upper airway obstruction, the nurse is inserting an oropharyngeal airway. How would the nurse insert the airway? a) With the convex portion facing upward b) Upside down and then rotated 180 degrees c) With the concave portion touching the posterior pharynx d) At an angle of 90 degrees

b) Upside down and then rotated 180 degrees The nurse should insert the oropharyngeal airway with the tip facing up toward the roof of the mouth until it passes the uvula and then rotate the tip 180 degrees so that the tip is pointed down toward the pharynx. This displaces the tongue anteriorly, and the patient then breathes through and around the airway.

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) Stat c) 11:00 p.m. d) 8 p.m.

c) 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.

Permanent brain injury or death will occur within which timeframe secondary to hypoxia? a) 9 to 10 minutes b) 1 to 2 minutes c) 3 to 5 minutes d) 6 to 8 minutes

c) 3 to 5 minutes If the airway is completely obstructed, permanent brain injury or death will occur within 3 to 5 minutes secondary to hypoxia. Air movement is absent in the presence of complete airway obstruction. Oxygen saturation of the blood decreases rapidly because obstruction of the airway prevents entry of air into the lungs. Oxygen deficit occurs in the brain, resulting in unconsciousness, with death following rapidly. The other timeframes are incorrect.

After inserting an oropharyngeal airway, the nurse determines that it is in the proper position when the flange is located at which position? a) At the level of the patient's epiglottis b) Directly in front of the patient's teeth c) Approximately at the patient's lips d) Just below the tip of the patient's nose

c) Approximately at the patient's lips When an oropharyngeal airway is properly inserted, the tip is in the hypopharynx and the flange is approximately at the patient's lips.

A 40-year-old female patient is admitted to the ED with facial bruises and a broken right wrist. Upon further assessment, the nurse notes multiple bruises in various stages of healing. Which of the following is the nurse's best course of action? a) Contacting the local police and report the suspected abuse b) Providing the patient with information about local shelters c) Asking the patient if someone is abusing her d) Asking the patient how she obtained the various bruises

c) Asking the patient if someone is abusing her The priority is to ask the patient if someone is harming/abusing her, and proceed as the situation dictates. Nurses must be mindful that competent adults are free to accept or refuse the help that is offered to them. Some patients insist on remaining in the home environment where the abuse or neglect is occurring. The wishes of patients who are competent and not cognitively impaired should be respected. However, all possible alternatives, available resources, and safety plans should be explored with the patient. Mandatory reporting laws in most states require health care workers to report suspected child abuse or abuse of older adults to an official agency, usually Adult (or Child) Protective Services. All that is required for reporting is the suspicion of abuse; the health care worker is not required to prove abuse or neglect.

A patient presents to the ED complaining of choking on a chicken bone. The patient is breathing spontaneously. The nurse applies oxygen and suspects a partial airway obstruction. Which of the following should the nurse do next? a) Prepare the patient for a bronchoscopy. b) Insert a nasopharyngeal airway. c) Encourage the patient to cough forcefully. d) Insert an oropharyngeal airway.

c) Encourage the patient to cough forcefully. If the patient can breathe and cough spontaneously, a partial obstruction should be suspected. The patient is encouraged to cough forcefully and to persist with spontaneous coughing and breathing efforts as long as good air exchange exists. There may be some wheezing between coughs. If the patient demonstrates a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis, the patient should be managed as if there were complete airway obstruction. If the person is unconscious, inspection of the oropharynx may reveal the offending object. X-ray study, laryngoscopy, or bronchoscopy also may be performed. There is no indication that an artificial airway is indicated.

A patient brought to the ED by the rescue squad after getting off a plane at the airport is complaining of severe joint pain, numbness, and an inability to move the arms. The patient was on a diving vacation and went for a last dive this morning before flying home. What is a priority action by the nurse? a) Send the patient for a chest x-ray. b) Draw labs for a chemistry panel. c) Ensure a patent airway and that the patient is receiving 100% oxygen. d) Send the patient to the hyperbaric chamber.

c) Ensure a patent airway and that the patient is receiving 100% oxygen. Decompression sickness, also known as "the bends," occurs in patients who have engaged in diving (lake/ocean diving), high-altitude flying, or flying in commercial aircraft within 24 hours after diving. Signs and symptoms include joint or extremity pain, numbness, hypesthesia, and loss of range of motion. A patent airway and adequate ventilation are established before all other interventions, as described previously, and 100% oxygen is administered throughout treatment and transport.

A is patient being cared for in the ED. The patient is assigned to the triage category of "urgent." How often must the nurse reassess the patient? a) Every 120 minutes b) Every 60 minutes c) Every 30 minutes d) Every 15 minutes

c) Every 30 minutes Patients assigned to the resuscitation category must receive continuous nursing surveillance, those in the emergent category must be reassessed at least every 15 minutes, patients in the urgent category must be reassessed at least every 30 minutes, patients in the less urgent category must be reassessed at least every 60 minutes, and those in the nonurgent category must be reassessed at least every 120 minutes.

A person suffering from carbon monoxide poisoning would exhibit which of the following manifestations? a) Hyperactivity b) Cherry red skin coloring c) Intoxication d) Severe hypertension

c) Intoxication A person suffering from carbon monoxide poisoning appears intoxicated (from cerebral hypoxia). Other signs and symptoms include headache, muscular weakness, palpitation, dizziness, and mental confusion. The skin coloring in the patient with carbon monoxide poisoning can range from pink to cherry red to cyanotic and pale and is not a reliable diagnostic sign.

A nurse is providing care to a client in the emergency department and walks into the hallway to get equipment. All of a sudden, gunshots are heard. Which of the following would be the nurse's priority? a) Gaining control of the situation b) Securing the area c) Protecting himself or herself d) Providing care to the injured

c) Protecting himself or herself If gunfire occurs in the emergency department, self-protection is the priority. Security officers and police must gain control of the situation first and then care is provided to the injured.

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.) a) Performing a fasciotomy b) Inserting an indwelling catheter c) Splinting the wound in a position of rest to prevent motion d) Elevating the site to limit the accumulation of fluid in the interstitial spaces e) Applying a clean dressing to protect the wound

c) Splinting the wound in a position of rest to prevent motion d) Elevating the site to limit the accumulation of fluid in the interstitial spaces e) Applying a clean dressing to protect the wound 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.

A patient was bitten by a tick 3 months ago and is now having muscle aches as well as joint pain and swelling. The patient is having difficulty with self care and requires assistance with activities of daily living (ADLs). What stage of Lyme disease does the nurse recognize the patient is in? a) Stage II b) Stage IV c) Stage III d) Stage I

c) Stage III Lyme disease has three stages. Stage I presents with a classic "bull's-eye" rash (i.e., erythema migrans) and flulike signs and symptoms that may include chills, fever, myalgia, fatigue, and headache. If antibiotics are not administered, stage II Lyme disease may present within 4 to 10 weeks following the tick bite and may manifest with joint pain, memory loss, poor motor coordination, and meningitis. Stage III can begin anywhere from weeks to more than a year after the bite and has serious long-term chronic sequelae, including arthritis, neuropathy, myalgia, and myocarditis.

A patient working in a chemical facility sustains a chemical burn to his arms. The chemical involved was white phosphorus. Which of the following would be the priority nursing action? a) Dousing the area with large amounts of water b) Applying ice to the burned area c) Covering the burned area to prevent further spread d) Brushing off all traces of the chemical from the patient's skin

d) Brushing off all traces of the chemical from the patient's skin For a chemical burn involving lye or white phosphorous, all evidence of the chemical should be brushed off the patient before any flushing occurs. These chemicals, if exposed to water, have the potential for exploding or for deepening the burn. Covering the burn area or applying ice is an inappropriate action.

A nurse is providing care to a client who is a victim of trauma resulting from injuries sustained in a convenience store robbery. The client has been stabbed numerous times in the abdomen and chest. His shirt is bloody and torn. Which of the following would be most appropriate when collecting forensic evidence? a) Cutting away clothing through the tears or holes b) Placing the law enforcement officer's name on the secured clothing for pick up c) Placing the client's clothing in a plastic bag d) Hanging up any damp or wet clothing to dry before securing

d) Hanging up any damp or wet clothing to dry before securing When collecting forensic evidence, the nurse should remove the client's clothing, being careful not to cut through or disrupt any tears, holes, blood stains or dirt present on the clothing. Each piece of clothing is put into a separate paper bag and labeled. If the clothing is wet or damp, it should be hung to dry. If a police officer is present to collect clothing or any other items from the client, each bag is labeled with the client's name, and the transfer of custody to the officer, the officer's name, date, and time are documented

Which of the following phases of psychological reaction to rape is characterized by fear and flashbacks? a) Denial phase b) Acute disorganization phase c) Reorganization phase d) Heightened anxiety phase

d) Heightened anxiety phase During the heightened anxiety phase, the patient demonstrates anxiety, hyperalertness, and psychosomatic reactions, in addition to fear and flashbacks. The acute disorganization phase is characterized by shock, disbelief, guilt, humiliation, and anger. The denial phase is characterized by an unwillingness to talk. The reorganization phase occurs when the incident is put into perspective. Some patients never fully recover from rape trauma.

A nurse is completing her annual cardiopulmonary resuscitation training. The class instructor tells her that a client has fallen off a ladder and is lying on his back; he is unconscious and isn't breathing. What maneuver should the nurse use to open his airway? a) Seldinger b) Head tilt-chin lift c) Abdominal thrust d) Jaw-thrust

d) Jaw-thrust If a neck or spine injury is suspected, the jaw-thrust maneuver should be used to open the client's airway. To perform this maneuver, the nurse should position herself at the client's head and rest her thumbs on his lower jaw, near the corners of his mouth. She should then grasp the angles of his lower jaw with her fingers and lift the jaw forward. The head tilt-chin lift maneuver is used to open the airway when a neck or spine injury isn't suspected. To perform this maneuver the nurse places two fingers on the chin and lifts while pushing down on the forehead with the other hand. The abdominal thrust is used to relieve severe or complete airway obstruction caused by a foreign body. The Seldinger maneuver is a method of percutaneous introduction of a catheter into a vessel.

Which of the following solutions should the nurse anticipate for fluid replacement in the male patient? a) Type O negative blood b) Dextrose 5% in water c) Hypertonic saline d) Lactated Ringer's solution

d) 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.

A patient is admitted to the ED after a near-drowning accident. The patient is diagnosed with saltwater aspiration. The nurse will observe the patient for several hours to monitor for symptoms of which of the following? a) Head injury b) Hyponatremia c) Hypothermia d) Pulmonary edema

d) Pulmonary edema Resultant pathophysiologic changes and pulmonary injury depend on the type of fluid (fresh or salt water) and the volume aspirated. Freshwater aspiration results in a loss of surfactant and, therefore, an inability to expand the lungs. Saltwater aspiration leads to pulmonary edema from the osmotic effects of the salt within the lungs. If a person survives submersion, acute respiratory distress syndrome (ARDS), resulting in hypoxia, hypercarbia, and respiratory or metabolic acidosis, can occur. The patient would experience hypernatremia. Hypothermia and head injury may be associated with near drowning, but would be apparent at the time of admission and would not develop after several hours.

Which of the following guidelines is appropriate to helping family members cope with sudden death? a) Inform the family that the patient has passed on b) Provide details of the factors attendant to the sudden death c) Obtain orders for sedation for family members d) Show acceptance of the body by touching it, giving the family permission to touch

d) Show acceptance of the body by touching it, giving the family permission to touch The nurse should encourage the family to view and touch the body if they wish, since this action helps the family to integrate the loss. The nurse should avoid using euphemisms such as passed on. The nurse should avoid giving sedation to family members, since this may mask or delay the grieving process. The nurse should avoid volunteering unnecessary information (eg, patient was drinking at the time of the accident).