module 7/8 AD3

A client arrives in the emergency department after ingesting 8 g of acetaminophen. What is the most important questions for the nurse to ask? Select all that apply.

"Do you feel like you have a fever?" "What time did you take the medication?

A nurse is performing triage in the emergency department. Which client should the nurse see first?

32-yr-old client with drug overdose who is unresponsive with a poor respiratory effort

A teenager fell through the ice on a pond near his farm and was admitted to the emergency department with somnolence. Vital signs are blood pressure of 82 mm Hg systolic with Doppler, respirations of 9 breaths/min, and core temperature of 90°F (32.2°C). The nurse should anticipate which intervention?

Active core rewarming

A teenage client has been admitted to the emergency department after ingesting an entire bottle of chewable multivitamins in a suicide attempt. What is the appropriate nursing intervention?

Administration of activated charcoal

Which of the following is not included in the interprofessional care of the client who has sustained a submersion injury?

Aggressive suctioning of the lungs for water removal

The nursing educator is reviewing the signs and symptoms of heat stroke with a group of nurses who provide care in a desert region. The educator should describe what sign or symptom?

Anhidrosis

A client is being treated for bites that she suffered during an assault. After the bites have been examined and documented by a forensic examiner, what is the appropriate nursing action?

Assess the patient's immunization history.

Which assessment parameter will the nurse address during the secondary survey of a client in triage?

BP & HR

A client has been involved in a motor vehicle accident and has multiple injuries. After establishing an airway and adequate ventilation, the healthcare team should prioritize what aspect of care?

Control the client's hemorrhage.

A backcountry skier has been airlifted to the ED after becoming lost and developing hypothermia and frostbite. How should the nurse best manage the patient's frostbite?

Immerse affected extremities in water slightly above normal body temperature.

A client has been involved in a motor vehicle accident and sustained blunt trauma to the abdomen. What nursing action would be most appropriate for this client?

Immobilize the client on a backboard.

A nurse in the emergency department is working triage. Which assessment findings would indicate immediate care is required?

Inability to swallow and move the left arm

Assessment of a client during the primary survey indicates delayed capillary refill of the extremities. He cannot explain the events before admission to the ED. Which action should the nurse take immediately?

Initiate pulse oximetry by placing the probe on the client's index finger.

Three days after experiencing a series of tick bites, a client presents to the emergency department. Which manifestation would indicate the client is experiencing tick paralysis?

Respiratory distress

Students are having an end of the semester party, which includes drinking alcohol, having snacks, and swimming. A student was found floating in the pool. Which action by first responders is most important?

Securing the airway and providing ventilation

The emergency department (ED) nurse is triaging clients according to the Emergency Severity Index (ESI). When assigning clients to a triage level, the nurse will consider the clients' acuity as well as what other variable?

The resources that the client is likely to require

The nurse is preparing to admit clients who have been the victim of a blast injury. The nurse should expect to treat a large number of clients who have experienced what type of injury?

Tympanic membrane rupture

Which of the following accurately describes a mass casualty incident (MCI)?

a man-made or natural event or disaster that overwhelms a community's ability to respond with existing resources

Which client should the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined below? The client with

blunt chest trauma with some difficulty breathing.

A moderate to severe reactions to a hymenopteran sting may require intramuscular or intravenous antihistamine administration.

correct

An obvious threat to life or organ places the client at the emergency severity index (ESI) level 1.

correct

Cat bites result in a greater incidence of infection than with dog bites.

correct

An alert client is admitted to the ED after ingesting bleach. What is appropriate nursing intervention?

gastric lavage

The triage nurse is working in the ED. A homeless person is admitted during a blizzard with complaints of being unable to feel his feet and lower legs. Core temperature is noted at 33.2°C (91.8°F). The client is intoxicated with alcohol at the time of admission and is visibly malnourished. What is the triage nurse's priority in the care of this client? Addressing the client's

hypothermia

A primary and secondary survey is the approach used for all emergency department clients.

incorrect

Rabies prophylaxis is only required following wild animal bites.

incorrect

While taking a class on emergency and disaster nursing, a student learns that there is a vaccine that is approved by the food and drug administration for anthrax?

true

The Emergency Severity Index (ESI) is a triage system incorporating concepts of illness severity and resource utilization to determine which client should be treated first.

correct

The client who has ingested an acid or alkali material may present with dysphagia and excessive salivation.

correct

The secondary survey begins after addressing each step of the primary survey and starting any lifesaving interventions.

correct

Treatment of the client with submersion injury includes administration or osmotic or loop diuretics.

correct

In the secondary survey (H, I), the 'I' refers to 'inspect all anterior surfaces'.

incorrect

It is only necessary to immobilize the cervical spine in a person who has experienced a submersion injury if they dove into the water.

incorrect

When a client is admitted with a potential poisoning and has dry substances on the skin, they should be immediately washed away.

incorrect

When assessing the client's level of alertness during the primary survey, a simple mnemonic to remember is AVPU: A = alert, V = responsive to voice, P = responsive to physical stimulus, and U = unresponsive

incorrect

An 82-year-old client is brought in by ambulance from a long-term care facility. The client's symptoms are weakness, lethargy, incontinence, and a change in mental status. The nurse knows that emergencies in older adults may be more difficult to manage. Why would this be true?

Older adults may have an altered response to treatment.

A client has been brought to the emergency department (ED) with multiple trauma after a motor vehicle accident. After immediate threats to life have been addressed, the nurse and trauma team should take what action?

Perform a rapid physical assessment.

The patient has been part of a community emergency response team (CERT) for a tropical storm in Dallas with temperatures near 100°F (37.7°C) for the past 2 weeks. When assessing the client, the nurse finds hypotension, body temperature of 104°F (40°C), dry and ashen skin, and neurologic symptoms. What treatments should the nurse anticipate? Select all that apply.

Provide cool IV fluids Administer 100% oxygen

At any point during the primary survey, if identify life-threatening conditions are identified, start interventions immediately, before moving to the next step of the survey.

correct

In the client with uncontrolled external hemorrhage, the usual ABC assessment format may be reprioritized to <C>ABC for hemorrhage control.

correct

In the secondary survey (H, I), the 'H' refers to 'history' and 'head-to-toe assessment'.

correct

Persons who have experienced a submersion injury and aspirated water may develop pulmonary edema.

correct