Perioperitive Care +Pain, Blood Adm, Basic Life Support, Emergency, Disaster, Prioritizing, Triage, Safety

The nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department. The nurse should assign priority to which client?

-A client complaining of muscle aches, a headache, and malaise -A client who twisted her ankle when she fell while in-line skating -A client with a minor laceration on the index finger sustained while cutting an eggplant -A client with chest pain who states that he just ate pizza that was made with a very spicy sauce (correct)

A client who is receiving a blood transfusion rings the call bell for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. How should the nurse correctly interpret these findings?

1.Bacteremia 2.Fluid overload 3.Hypovolemic shock 4.Transfusion reaction (correct) The signs and symptoms exhibited by the client are consistent with a transfusion reaction. With bacteremia, the client would have a fever, which is not part of the clinical picture presented. With fluid (circulatory) overload, the client would have crackles in addition to dyspnea. There is no correlation between the signs mentioned in the question and hypovolemic shock. The signs identified in the question are indicative of an allergic reaction, which is one type of blood transfusion reaction.

A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which area?

1.The pharmacy 2.The laboratory 3.The blood bank (correct) 4.The risk-management department The nurse prepares to return the blood transfusion bag containing any remaining blood to the blood bank. This allows the blood bank to complete any follow-up testing procedures that are needed after a transfusion reaction has been documented. The remaining options are incorrect.

The nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to check which item?

1.Vital signs (correct) 2.Skin color 3.Oxygen saturation 4.Latest hematocrit level A change in the vital signs may indicate that a transfusion reaction is occurring. The nurse assesses the client's vital signs before the procedure to obtain a baseline every 15 minutes for the first half hour after beginning the transfusion and every half hour thereafter. Skin color, oxygen saturation, and most recent hematocrit may be checked but are not the most important.

A change in the vital signs may indicate that a transfusion reaction is occurring. The nurse assesses the client's vital signs before the procedure to obtain a baseline every ___ minutes for the first ___ hour after beginning the transfusion and every half hour thereafter. Skin color, oxygen saturation, and most recent hematocrit may be checked but are not the most important.

A change in the vital signs may indicate that a transfusion reaction is occurring. The nurse assesses the client's vital signs before the procedure to obtain a baseline every 15 minutes for the first half hour after beginning the transfusion and every half hour thereafter. Skin color, oxygen saturation, and most recent hematocrit may be checked but are not the most important.

The nurse is recording a nursing hands-off (end-of-shift) report for a client. Which information needs to be included?

As-needed medications given that shift

The nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department. The nurse should assign priority to which client?

In an emergency department, triage involves classifying clients according to their need for care, and it includes establishing priorities of care. The type of illness, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress, cardiac arrest, limb amputation, or acute neurological deficits and those who sustained a chemical splash to the eyes are classified as emergent, and these clients are the number 1 priority. Clients with conditions such as simple fractures, asthma without respiratory distress, fever, hypertension, abdominal pain, or renal stones have urgent needs, and these clients are classified as the number 2 priority. Clients with conditions such as minor lacerations, sprains, or cold symptoms are classified as nonurgent, and they are the number 3 priority.

The nurse is educating a new nurse about mass casualty events (disasters). Which statement by the new nurse indicates a need for further teaching? Select all that apply.

Mass casualty events, also known as disasters, overwhelm local medical capabilities and may require the collaboration of multiple agencies and health care facilities to handle the crises. This type of event can occur in the health care facility or outside of it. Fights in the emergency department are not termed mass casualty events but are agency security and local enforcement issues. Mass casualty events almost always require an increase in staffing to ensure safe patient care.

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse check first?

The airway is always a priority, and the nurse first checks the client on a ventilator etc -A client on a ventilator (correct)) -A client in skeletal traction -A postoperative client preparing for discharge -A client admitted on the previous shift who has a diagnosis of gastroenteritis

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse collect data from first?

The airway is always a priority, and the nurse would attend to the client who has been experiencing an airway problem first. The clients described in options 1, 2, and 3 would have intermediate priority. -A client scheduled for a chest x-ray -A client requiring daily dressing changes -A postoperative client preparing for discharge -A client receiving oxygen who is having difficulty breathing (correct)

The nurse is recording a nursing hands-off (end-of-shift) report for a client. Which information needs to be included?

The nursing hands-off (end-of-shift) report needs to be an efficient and accurate account of the client's condition during the last shift. It needs to include pertinent information about the client, such as tests and treatments; as-needed medications given or therapies performed during the past 24 hours, including the client's response to them; changes in the client's condition; scheduled tests and treatments; current problems; and any other special concerns. It is not necessary to include the total number of medications given or a list of all the tests and treatments that the client has had since admission. Only significant vital signs need to be included.

The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100° F orally. The nurse reports the finding to the registered nurse (RN) and anticipates that which action will take place?

i