Lesson 8-H: Medical Emergencies
The nurse is caring for a client with a medical history of peripheral artery disease, hypertension and smoking. The client reports severe pain in the right lower leg that started very suddenly and did not get better after receiving an analgesic. What action should the nurse take first? A. Check the client's pedal pulse. B. Offer the client an ice pack for the pain. C. Notify the health care provider. D. Administer an additional dose of the analgesic.
Correct Answer: A Rationale: Peripheral artery disease (PAD) refers to excessive plaque buildup in the arterial walls. Excessive plaque buildup, due to atherosclerosis, can have an impact on perfusion to limbs and is associated with high levels of morbidity and mortality. The client is exhibiting symptoms of an acute arterial obstruction. This obstruction usually causes severe pain, loss of pulses and skin color changes. The nurse should follow the nursing process and first collect more data. Based on the data collected (e.g., an absent pulse) the nurse should notify health care provider right away because this would signal a medical emergency. Ice would be contraindicated as that would further reduce tissue perfusion to the leg.
The nurse is caring for a client who suddenly develops slurred speech and a facial droop. What diagnostic test would the nurse expect to be performed first? A. Computerized tomography scan B. Echocardiogram C. Chest X-ray D. Arterial blood gas
Correct Answer: A Rationale: The client's symptoms are indicative of an acute stroke. The nurse would anticipate that a non-contrast computerized tomography (CT) of the head will be done first because time is of the essence with an acute stroke. The other tests may or may not be indicated for this client.
The nurse in a long-term care facility is caring for an 89-year-old client with atrial fibrillation and a history of multiple falls. The client's medications include amiodarone, atorvastatin, baby aspirin and metoprolol. Which new finding should be of greatest concern to the nurse? A. Right-sided facial droop B. SpO2 of 89% on room air C. Heart rate of 106 D. Bibasilar crackles
Correct Answer: A Rationale: The most concerning finding would be the development of a right-sided facial droop. The client with atrial fibrillation is at increased risk of stroke, and this client's listed medications do not include an anticoagulant, typically prescribed to prevent a stroke. Given the finding of frequent falls, it is possible that the client is not on a stronger anticoagulant, such as warfarin, due to an increased risk of intracranial hemorrhage after a fall. A SpO2 of 89% on room air, a heart rate of 106 and crackles on auscultation are all concerning findings, but the possibility of a stroke should be of the greatest concern to the nurse.
The nurse enters the room of an adult client in cardiac arrest with cardiopulmonary resuscitation already in progress. The client's bedside telemetry monitor shows ventricular fibrillation. What should the nurse do next? A. Assist with preparing the client for defibrillation. B. Quickly leave the room and notify the client's next-of-kin. C. Assist with the insertion of a large-bore IV catheter. D. Prepare to administer two rescue breaths.
Correct Answer: A Rationale: Ventricular fibrillation (V-Fib) is a life-threatening dysrhythmia that requires immediate defibrillation to attempt to restore a viable cardiac rhythm. V-Fib will cause death within minutes due to the complete lack of cardiac output and tissue perfusion. The other actions should be implemented after defibrillation has been performed or attempted.
The nurse is beginning a shift caring for a group of adult clients on a neurological unit in an acute care hospital. Which client should the nurse see first? A. A client admitted with a transient ischemic attack, who has a bubble study echocardiogram ordered B. A client admitted several hours ago with a subdural hematoma due to an unwitnessed fall at home C. A client admitted two days ago with an ischemic stroke who has a blood pressure of 158/64 D. A client admitted with hepatic encephalopathy who has an elevated ammonia level
Correct Answer: B Rationale: After an unwitnessed fall, the nurse must consider the possibility of head injury. Due to the elevated risk for worsening bleeding and increased intracranial pressure because of the fall and pre-existing head injury, the client with a subdural hematoma should be seen first. A blood pressure of 158/64 in a client with an ischemic stroke would not represent an urgent situation, and an elevated ammonia level would not be unexpected for a client with hepatic encephalopathy. While the results of an echocardiogram with a bubble study would be relevant to the care of client with a transient ischemic attack (TIA), this client is not showing signs of a worsening condition requiring urgent assessment.
An off-duty nurse arrives at a park and is told by a bystander that a child is choking and needs assistance. The bystander has already called 911. The nurse observes an approximately 8-year-old child with cyanosis and an inability to breathe who remains conscious and standing. What should the nurse do next? A. Check the child's carotid pulse. B. Stand behind the child and administer abdominal thrusts. C. Instruct the child to lay down and begin CPR. D. Deliver two rescue breaths.
Correct Answer: B Rationale: For a conscious choking victim, according to basic life support (BLS) guidelines by the American Heart Association (AHA), the next action by the nurse should be to perform abdominal thrusts (i.e., the Heimlich Maneuver) to attempt to clear the airway obstruction. Attempting to deliver rescue breaths or checking the carotid pulse of a conscious choking victim would not be indicated. If the child were to become unconscious, then chest compressions should be initiated.
The off-duty nurse is helping to administer first aid following a mass casualty incident in the community. Emergency medical personnel at the scene have started to triage victims, using a common, color-tagging system. Which tag color usually indicates the highest priority for a victim to receive care? A. Yellow B. Red C. Green D. Black
Correct Answer: B Rationale: In a mass casualty incident (MCI), first responders often use a color-tagging system to facilitate rapid triage of victims. Generally speaking, a green tag would indicate minor injuries, a yellow tag would indicate more significant but not expected to be life-threatening injuries, a red tag would indicate life-threatening injuries, and a black tag would identify a victim who has died, is near death or has the lowest chance for survival. Victims assigned a red tag are the highest priority for care and transport to the nearest hospital.
A postoperative client following a thyroidectomy suddenly develops difficulty breathing, stridor and an increase in swelling of the anterior neck area. What should the nurse do first? A. Ask the charge nurse to come see the client immediately. B. Activate the hospital's emergency or rapid response system. C. Place a heart monitor on the client and observe for dysrhythmias. D. Check the client's blood pressure and heart rate.
Correct Answer: B Rationale: The client is demonstrating clinical manifestations of an airway obstruction related to bleeding and/or swelling following the thyroidectomy. This is a life-threatening, medical emergency and the nurse's first action should be to activate the hospital's emergency or rapid response system. It is possible that the client will need an emergency surgical airway intervention, such as a tracheostomy, to maintain a patent airway.
A client with a known large abdominal aortic aneurysm develops a sudden change in level of consciousness and tachycardia. The client's blood pressure is 72/48. What should the nurse do first? A. Conduct a complete head-to-toe physical assessment. B. Activate the hospital's emergency response team. C. Obtain a 12-lead electrocardiogram. D. Page the client's health care provider.
Correct Answer: B Rationale: The client is exhibiting signs and symptoms of an abdominal aortic aneurysm (AAA) rupture. The nurse's first action should be to activate the hospital's emergency response team, as this client needs immediate advanced care. The nurse is anticipating the need for rapid action and surgical intervention to avoid the death of the client. While notifying the client's health care provider and obtaining a 12-lead electrocardiogram (ECG) may be needed, activating the emergency response team should be done first. Similarly, the nurse does not have time complete a head-to-toe physical assessment before activating the emergency response team.
An adult client who has been experiencing a seizure for approximately 15 minutes is brought to the emergency department by private vehicle. Which intervention should the nurse implement first? A. Administer levetiracetam intravenously. B. Administer lorazepam intravenously. C. Obtain a STAT electroencephalogram. D. Obtain a STAT 12-lead electrocardiogram.
Correct Answer: B Rationale: This client is experiencing status epilepticus and is in immediate need of medication to stop the seizure. Of the provided options, the highest priority would be to administer the intravenous (IV) lorazepam to stop the seizure. While levetiracetam, an anticonvulsant, may be indicated for the client, lorazepam, a benzodiazepine, would be administered first in an attempt to stop the seizure quickly. An electroencephalogram (EEG) is an important test when evaluating for seizures, but it would not be highest priority at this time. A 12-lead electrocardiogram (ECG) may be part of a more general diagnostic work-up for many clients, but it would be a lower priority than stopping the seizures.
The home health care nurse is caring for a client who has epilepsy. While the nurse is providing care, the client has a seizure. Which intervention would be most appropriate to prevent an injury to the client? A. Asking the client to state where they are B. Loosening clothing around the waist C. Lowering the client to the ground D. Placing a pillow under the client's head
Correct Answer: C Rationale: Epilepsy is a disorder that involves two or more unprovoked seizures. A seizure is an abnormal discharge of electrical activity in the brain which can cause alterations in motor function, sensation, consciousness, behavior and autonomic function. During a seizure, clients may suddenly lose consciousness and fall to the ground, increasing their risk of breaking a bone or suffering a head injury. The most appropriate intervention at this time is to prevent further injury by lowering the client to the ground and placing them in the recovery position to prevent aspiration. Clothing should be loosened around the neck, not the waist, to ensure a patent airway. Once the client is more awake, the nurse can reoriented them to their surroundings.
The nurse is talking with a client during a home health visit. The client states, "my right arm and right leg are beginning to feel heavy." The nurse notices the client is having trouble speaking and has stopped moving the right side of their face. What action the nurse should take first? A. Ask the client if they have a headache. B. Document the onset of symptoms in the medical record. C. Call 911. D. Take the client's vital signs.
Correct Answer: C Rationale: The client is exhibiting signs of an acute stroke. A stroke is caused by a disruption in the normal blood supply to the brain. A stroke is a medical emergency. The nurse in the home health setting should call 911 first. While waiting for emergency medical help to arrive, the nurse should gather additional data by obtaining vital signs and evaluating the client's neurological status. The data should be recorded in the medical record.
The nurse is reviewing vital signs documented in the electronic health record for a group of clients. Based on this data, which client should the nurse see first? A. A client diagnosed with atrial fibrillation who has a heart rate of 110 beats per minute. B. A client diagnosed with mitral valve insufficiency who has a blood pressure of 152/88. C. A client diagnosed with heart failure who has a SpO2 of 82%. D. A client diagnosed with infective endocarditis who has a temperature of 101.8 °F (39° C).
Correct Answer: C Rationale: The nurse should see the client with heart failure and a SpO2 of 82% first. The client with heart failure could be experiencing life-threatening pulmonary edema, and the SpO2 of 82% indicates dangerously low oxygenation. An elevated temperature in a client with infective endocarditis is a clinically significant but not unexpected finding. A heart rate of 110 beats per minute in a client with atrial fibrillation is concerning, but it does not reflect the same life-threatening clinical finding as the low SpO2 in the client with heart failure. While elevated and of concern, a blood pressure of 152/88 is not as high of a priority for the nurse to address as a dangerously low oxygen level.
A client presents to the emergency department with a prolonged asthma attack that did not resolve after the client used a metered-dosed inhaler at home. Which medication should the nurse plan to administer first for this client? A. Oral prednisone B. Intravenous azithromycin C. Nebulized albuterol D. Fluticasone inhaler
Correct Answer: C Rationale: The nurse would anticipate that nebulized albuterol would be given first in this situation to address the acute asthma attack through bronchodilation. While oral prednisone may be used in the treatment of this client, it would be given after administration of an inhaled B2-adrenergic agonist like albuterol. There is no information provided that would indicate antibiotic therapy is needed for the client. A fluticasone inhaler may be part of long-term asthma management for this client, but is not recommended as a rescue treatment for acute asthma attacks.
An off-duty nurse witnesses a person collapse in a grocery store, and the individual is now unresponsive. Multiple bystanders are present. What should the nurse do first? A. Run to get the store's automated external defibrillator. B. Begin chest compressions. C. Check for a carotid pulse and instruct a bystander to call 911. D. Deliver two rescue breaths.
Correct Answer: C Rationale: The off-duty nurse's first action when encountering this unresponsive individual who just collapsed should be to check for a pulse and to ensure the activation of 911 emergency response. While chest compressions may very well be needed, the nurse should first check for a carotid pulse. If a carotid pulse cannot be palpated in this unresponsive individual, cardiopulmonary resuscitation (CPR) chest compressions should be initiated. An automated external defibrillator (AED) should be incorporated into the response once it is available. However, the nurse should stay with the victim, begin CPR and assign the task of obtaining the AED to someone else at the scene.
An adult client in the waiting room of an outpatient clinic is found to have become unresponsive. Their carotid pulse cannot be palpated. Emergency medical services have been requested by calling 911. What should the nurse do next? A. Use a jaw-thrust maneuver to open the client's airway. B. Deliver two rescue breaths. C. Wait for the emergency medical services technicians to arrive. D. Begin chest compressions.
Correct Answer: D Rationale: According to basic life support (BLS) guidelines by the American Heart Association (AHA), chest compressions are the next step in initiating cardiopulmonary resuscitation (CPR) for an unresponsive client in whom a carotid pulse cannot be palpated. After the initial round of 30 chest compressions, the nurse should open the client's airway with a head tilt-chin lift maneuver (or a jaw-thrust maneuver if spinal cord injury is suspected) and deliver two breaths. It would not be appropriate to wait to start CPR until emergency medical services technicians arrive because immediate action is needed.
The nurse on a postpartum nursing unit is receiving report about a client who had a normal spontaneous vaginal delivery the night before. The client has been passing golf ball-sized clots on her peri-pad for the last few hours. The client's most recent blood pressure is 88/56, and her heart rate is 118. The nurse enters the client's room and notices blood oozing from her intravenous insertion site. Which action should the nurse take first? A. Perform peri-care and change the client's peri-pad. B. Encourage breastfeeding to promote uterine contractions. C. Palpate and massage the client's uterus. D. Notify the client's health care provider.
Correct Answer: D Rationale: After a normal spontaneous vaginal delivery (NSVD), it is normal for a client to have vaginal bleeding on their peri-pad. Postpartum hemorrhage (PPH) is defined as blood loss greater than or equal to 500 mL after birth. If a patient is saturating more than one peri-pad in an hour or passing several large clots, the patient could be experiencing PPH. This is an obstetric emergency. Signs and symptoms of PPH include dizziness, hypotension, tachycardia, large clots passed vaginally and heavy bleeding on the peri-pad. PPH can progress to a life-threatening condition called disseminated intravascular coagulation (DIC). This can occur after an injury or childbirth. Proteins in the blood that form blood clots travel to the injury site to help stop bleeding. If these proteins become abnormally overactive throughout the body, DIC can ensue. Small blood clots form in blood vessels throughout the body, and can clog the vessels and cut off the normal blood supply to the organs. Signs and symptoms of DIC include severe bleeding, oozing from puncture sites, hypotension, tachycardia, dizziness and hypoxia. The nurse should suspect DIC and should notify the primary health care provider (HCP) immediately. Nursing measures to monitor and control normal postpartum uterine bleeding can include uterine massage, breastfeeding and peri-care. The client in this scenario may be experiencing a medical emergency (e.g., DIC), therefore the nurse should first notify the HCP.
The nurse is participating in a disaster simulation that involves a school bus accident. The nurse is assigned to care for the following four clients in a rural hospital's emergency department. Which client should the nurse see first? A. The client with a third degree burn to the arm B. The client with multiple facial abrasions C. The client with an open humerus fracture D. The client with a penetrating abdominal wound
Correct Answer: D Rationale: Part of a nurse's role is being a part of disaster management and assisting in client care throughout all aspects of health care delivery. To better prepare nurses for disaster situations, simulation is a method used to evaluate preparedness. The nurse needs to be able to respond to disasters in the community and keep clients safe. Answering this specific scenario requires the application of survival potential priority setting frameworks. A client with a penetrating abdominal wound should be seen first because a penetrating injury usually causes internal injuries, such as bleeding, which can quickly lead to death.
An adult client arrives at the clinic after being stung by a bee. The nurse notes that the client is having difficulty breathing, is audibly wheezing and has swollen lips. What is the nurse's highest priority? A. Obtain a home medication list. B. Obtain an arterial blood gas. C. Administer a bronchodilator. D. Administer epinephrine.
Correct Answer: D Rationale: The client's condition indicates the high likelihood of a life-threatening anaphylactic reaction to a bee sting, with an obstructed airway due to bronchoconstriction and a high potential for hypoxemia. While obtaining a home medication list and obtaining arterial blood gases may be part of the care provided to the client, the highest priority is to administer epinephrine. Epinephrine is a critical drug in the treatment of anaphylaxis. Relieving the vasoconstriction effects on bronchial muscles with epinephrine could be life-saving in this situation. A bronchodilator may also be prescribed, but not before epinephrine has been administered.
The off-duty nurse witnesses a motor vehicle accident and is concerned that the driver of the automobile may be injured. What should the nurse do first? A. Check the driver's respiratory rate. B. Check the driver's pulse. C. Minimize movement of the driver's cervical spine. D. Consider scene safety to prevent further injury.
Correct Answer: D Rationale: When attempting to render aid after a motor vehicle collision, it is critically important that the responder first consider scene safety. Responders should assess the scene for risks to safety to prevent further injury to themselves, the victim and other motorists on the road. Minimizing the movement of the driver's cervical spine, checking the driver's pulse and checking the driver's respiratory rate may all be indicated in the scenario, but scene safety should be considered first.
