ch 68 Emergency Patient Care

Which is a clinical manifestation of a low dose of amitriptyline poisoning? 1 Hypertension 2 Renal damage 3 Abdominal pain 4 Respiratory depression

1 Amitriptyline in low doses causes hypertension, which indicates a high blood pressure. Nonsteroidal antiinflammatory drugs can cause an abnormality in renal function and stomach upset, leading to abdominal pain. Amitriptyline consumption in high doses results in respiratory distress and depression.

A patient is admitted to the emergency department with a traumatic head injury. What is an appropriate nursing action during the primary survey? 1 Using the Glasgow Coma Scale 2 Removing the patient's clothing 3 Obtaining a portable chest x-ray exam 4 Monitoring the electrocardiogram (ECG) for heart rate and rhythm

1 During the primary survey, the Glasgow Coma Scale is used to assess the degree of disability. It determines the patient's response to verbal and/or painful stimuli to assess the level of consciousness. In the secondary survey, the nurse uses a portable x-ray to check for any displacement of endotracheal or gastric tubes if any are inserted into the patient. The patient's clothing is later removed for a thorough physical assessment. An electrocardiogram (ECG) monitors the heart rate and rhythm as part of the secondary survey when the patient requires life-saving interventions

Which guideline for the assessment of intimate partner violence (IPV) should the emergency nurse follow? 1 Patients should be screened routinely for family and IPV. 2 Patients whom the nurse deems high risk should be assessed for IPV. 3 All female patients and patients under 18 should be assessed for IPV. 4 Patients should be assessed for IPV provided corroborating evidence exists.

1 In the emergency department, the nurse needs to screen for family and IPV. Routine screening for this risk factor is required. Such assessment should not be limited to female, high-risk, or young patients, and evidence need not be present to screen for the problem.

The nurse creates a plan of care for a patient with frostbite of the hands. What is the most desirable outcome for the patient? 1 Brisk capillary refill 2 Adequate dietary intake 3 Balanced fluid intake and output 4 Blood pressure within normal limits

1 The major dysfunction with frostbite is impaired circulation. Therefore measures to promote and maintain adequate circulation are the highest priority. This includes assessment of the nail beds for capillary refill. A good appetite, a balanced fluid intake and output, and normal blood pressure are not direct indicators in the treatment of frostbite.

A patient fell through the ice on a pond near his farm and is admitted to the emergency department with somnolence. Vital signs are blood pressure (BP) 82 mm Hg systolic with Doppler, respirations 9 breaths/minute, and core temperature of 90 o F (32.2 o C). The nurse should anticipate which intervention? 1 Active core rewarming 2 Immersion in a hot bath 3 Rehydration and massage 4 Passive external rewarming

1 Active internal or core rewarming is used for moderate to severe hypothermia and involves the application of heat directly to the core. Immersion in a hot bath, rehydration, and massage are not appropriate interventions in the treatment of severe hypothermia. Passive rewarming is used in mild hypothermia. Topics

What is a factor that contributes to cold-related injuries? 1 Age 2 Obesity 3 Dehydration 4 Physical exertion

1 Age Age is a contributing factor to cold-related injuries. Older adults are more vulnerable to cold related injuries because of low body fat, low energy reserves, preexisting chronic illness, and use of medicines that can alter the response mechanism in an event of adverse environmental conditions. Obesity is associated with poor heat tolerance; hence obese people are at an increased risk of heat disorders in a hot and humid environment. Dehydration reduces the body's ability to sweat and maintain a normal temperature. Physical exertion generates heat; hence, any strenuous activity leads to heat stress.

Which part of the assessment will the nurse address during the secondary survey of a patient in triage? 1 Assess patient allergies 2 Patency of the patient's airway 3 Neurologic status and level of consciousness 4 Presence or absence of breath sound and quality of breathing

1 Assess patient allergies Patient allergies are assessed during secondary survey. Airway, breathing, circulation, and a brief neurologic assessment are components of the primary survey that is done to identify life-threatening conditions.

After stabilization of a trauma victim's airway, breathing, and circulation, what is the nurse's next priority action? 1 Assessing neurologic status 2 Obtaining a complete history 3 Examining the extremities for fractures 4 Performing an abdominal assessment

1 Assessing neurologic status Standard trauma care includes assessing and stabilizing the ABCs (airway, breathing, and circulation), followed by a neurologic assessment and care. This includes stabilizing the cervical spine. Obtaining a complete history, performing an abdominal assessment, and examining the extremities for fractures are done after assessment of the airway, breathing, circulation, and neurologic status. The abdominal assessment and examination of the extremities are part of the head-to-toe survey.

What are the clinical manifestations of superficial frostbite? 1 Blisters 2 Hot, dry skin 3 Low muscle skill 4 Profuse sweating

1 Blisters Patients with superficial frostbite injury experience blister formation within a few hours after the injury. The physiologic changes with heatstroke include hot, dry, and ashen-looking skin. With heatstroke, the nervous system is affected, lessening muscle skill and coordination. Neurologic symptoms are indicative of thermal injuries to the brain. Heat exhaustion leads to profuse sweating due to extended exposure to heat for long hours.

Which statement refers to frostbite? 1 Condition of tissue damage due to freezing 2 Condition of deficiency of oxygen in the tissues 3 Condition of abnormally low core body temperature 4 Condition caused by overexposure to high temperature

1 Condition of tissue damage due to freezing Frostbite is a cold-related injury caused by exposure to extreme weather. The body tissues freeze, which results in formation of ice crystals in the tissues and cells. Patients with hypoxia experience a fall in oxygen levels, which results in symptoms of inadequate oxygenation. Hypothermia occurs when the core body temperature falls abnormally low after the body is exposed to freezing temperatures. Heatstroke is caused by prolonged exposure to extremely high temperatures

Which are nursing interventions provided specifically by sexual assault nurse examiners (SANEs)? Select all that apply. 1 Providing expert emergency care 2 Providing emotional support to victims 3 Collecting and documenting evidence 4 Screening the victim for family violence 5 Informing victims about their legal rights

1 Providing expert emergency care 3 Collecting and documenting evidence The emergency department nurses are encouraged to become certified sexual assault nurse examiners (SANEs). The SANE provides expert emergency care to the assault victims and collects and documents evidence of the assault. Non-SANE staff may provide emotional support, inform victims about their legal rights, and screen the victim for family violence.

Which part of the body is most vulnerable to frostbite in a superficial injury? 1 Skin 2 Bone 3 Muscle 4 Tendon

1 Skin In a superficial frostbite, the surface of the skin is affected. The appearance of the skin varies from waxy pale to blue to mottled in color. Dark-skinned persons run a higher risk, making them more prone to frostbite. In deep frostbite, the bones, muscles, and tendons are involved in the freezing process. The patient experiences loss of sensation on does not respond to touch.

Which is the focus area in the treatment of submersion injuries? 1 Correcting fluid imbalances 2 Rewarming when hypothermia is present 3 Freezing the injured tissues by submersion 4 Prevention of a further drop in body temperature

1 The primary focus area in the treatment of submersion injury is correction of fluid imbalances. Fluid imbalance is corrected when the gas exchange is improved by way of mechanical ventilation and positive airway pressure. Submersion injuries cause acute respiratory distress that requires ventilation and oxygenation for treatment, not rewarming. Frostbite causes the freezing of tissues, which doesn't occur in a submersion injury. There is no drop in body temperate during submersion injury; hence treatment focuses on physiologic function.

The patient has a prescription for 0.9% normal saline intravenous (IV) at a rate of 75 mL/hour. The IV tubing has a drop factor of 10 gtts/mL. At how many drops per minute should the nurse regulate the flow of the IV solution? 1 13 gtt/minute 2 21 gtt/minute 3 25 gtt/minute 4 31 gtt/minute

1 13 gtt/minute Use the following formula to calculate the rate of IV solutions: Volume multiplied by drop factor divided by time (in minutes). Multiply 75 by 10 to yield 750 and divide this by 60 to yield 12.5, or 13 gtt/minute (because the nurse cannot count a fraction of a drop).

Which factors predispose an individual to heat stress? 1 Opioid 2 Alcohol 3 Inability to swim 4 Adequate clothing

2 Alcohol affects the body's ability to regulate temperature, and hence, should be avoided, because it increases the sensation of warmth. Opioids suppress shivering and hence body temperature is regulated and so they do not lead to heat stress. The inability to swim can cause a submersion injury and is not a heat-related injury. Wearing adequate clothing suitable for the weather as well as wearing clothes that do not interfere with perspiration reduce heat stress.

A patient is suspected to have Lyme disease. The nurse recalls that the causative organism of the disease is what? 1 Rickettsia rickettsii 2 Borrelia burgdorferi 3 Pasteurella multocida 4 Staphylococcus aureus

2 Borrelia burgdorferi is the organism that causes Lyme disease. Rickettsia rickettsii causes Rocky Mountain spotted fever. Pasteurella multocida is a parasite that lives in the mouths of cats and dogs. It causes septic arthritis, osteomyelitis, and tenosynovitis in the patient. Staphylococcus aureus causes pneumonia.

Which effect does the nurse anticipate in a patient who has ingested contaminated freshwater during a submersion injury? 1 Extreme thirst 2 Pulmonary edema 3 Muscle contractions 4 Altered mental status

2 In a submersion injury, the victim of near-drowning accident aspirates freshwater that is usually contaminated with chlorine, mud, or algae. The end result is acute respiratory distress causing pulmonary edema. Extreme thirst is experienced during heat exhaustion caused by hyperthermia. Strenuous activity in a hot and humid environment causes severe muscle contractions in the exerted muscles. Altered mental status is a result of cerebral edema caused by direct thermal injury to the brain in a heatstroke.

During the physical examination of a patient, the nurse finds that the patient has subcutaneous emphysema, absence of "Raccoon eyes," and negative Battle's sign. What does the nurse conclude from these findings? 1 The patient has a risk of compartment syndrome. 2 The patient has a risk of laryngotracheal disruption. 3 The patient has a fracture at the base of the frontal portion of the skull. 4 The patient has a fracture at the base of the posterior portion of the skull.

2 Subcutaneous emphysema occurs from an accumulation of air under the subcutaneous tissue present over the chest wall. Subcutaneous emphysema may cause trauma to the organs in the chest region, resulting in laryngotracheal disruption. Compartment syndrome is caused by the accumulation of fluids in the lower limbs. If a patient has "Raccoon eyes" then the nurse would suspect that the patient has a fracture at the base of the frontal portion of the skull. If the patient has Battle's sign, then it indicates that the patient has a fracture at the base of the posterior portion of the skull.

The nurse assesses a patient with ischemia and chest pain. The patient should be assigned what Emergency Severity Index (ESI) rating? 1 ESI-1 2 ESI-2 3 ESI-3 4 ESI-4

2 The ESI is a five-level triage system that integrates the illness symptoms and severity with resource utilization to prioritize patient care in an emergency situation. The ESI for a patient with ischemia and chest pain is rated as a 2, because the patient's vital functions would be threatened if he or she were not treated. The patient should be seen by the health care provider within 10 minutes in order to provide effective treatment. The ESI will be 1 for the patient who has cardiac arrest or who has unstable vital signs. The ESI will be 3 for the patient with abdominal pain. The ESI will be 4 if the patient has simple laceration or cystitis.

A nurse obtains a medical history from a patient that is admitted to the emergency department, using the mnemonic AMPLE to gather what patient information? Select all that apply. 1 Blood pressure 2 Allergies to food 3 Medication history 4 Full set of vital signs 5 Tetanus immunization

2 Allergies to food 3 Medication history 5 Tetanus immunization During the secondary survey, the nurse obtains details of the illness, length of time since the incident has occurred, treatment provided, the patient's response, and level of consciousness. The mnemonic AMPLE is a mnemonic that prompts the nurse to ask about A, allergies to drugs, food, latex, environment; M, medication history; P, past health history, tetanus, immunization; L, last meal; and E, events or environmental factors leading to the illness. The nurse checks vital signs and blood pressure at the start of the secondary survey prior to the assessment of health history.

Which instruction should the nurse give to a patient to avoid cold-related injuries? 1 Leave the head uncovered. 2 Dress in layers for cold weather. 3 Consume alcohol-based drinks. 4 Reduce consumption of carbohydrates.

2 Dress in layers for cold weather Cold-related injuries can be prevented by wearing adequate clothes suitable for the climate and environmental temperature. The head should be also covered to protect the extremities from being affected. Alcohol is extremely harmful in a cold climate because it causes peripheral vasodilation. Individuals should increase consumption of foods high in carbohydrates to gain extra calories useful in generating internal warmth during cold.

Which risk factor predisposes an individual to submersion injury? 1 Hyperthermia 2 Inability to swim 3 Child pampering 4 Alcohol abstinence

2 The primary condition that predisposes an individual to submersion injury is the inability to swim. Hyperthermia is a condition experienced due to elevated core body temperature, leading to heat stress. Neglect exposes a child to injuries, especially in instances when the child is left unattended near a swimming pool. Alcohol intoxication causes peripheral vasodilation leading to cold-related injuries.

Which characteristics confirm deep frostbite? Select all that apply. 1 The skin feels tingly. 2 The skin appears white. 3 The skin is insensitive to touch. 4 The skin feels crunchy and frozen. 5 The skin shows signs of gangrene.

2 The skin appears white. 3 The skin is insensitive to touch. Deep frostbite affects the layers of the skin. The skin texture is white, hard, and does not respond to touch. The signs and symptoms of superficial frostbite include tingling, numbness, and burning sensation on the skin. With deep frostbite, the affected area will gradually become gangrenous, but does not appear so right away. The surface of the skin feels crunchy and frozen to the touch with superficial frostbite.

What finding indicates mild hypothermia? 1 Body temperature of 84° F (28.8ºC) 2 Body temperature of 86° to 93.2ºF, (32º to 34ºC) 3 Body temperature of 93.2º to 98.6º F, (34º to 35ºC) 4 Body temperature of 99.6º to 105.8ºF (37.5º to 41ºC)

3 Assessment findings in hypothermia are variable and depend on the core body temperature of the patient. In mild hypothermia, the patient experiences shivers and reports a body temperature between 93.2 and 96.8 oF. In moderate hypothermia, the shivering diminishes or disappears and the body temperature is maintained between 86 and 93.2 oF. Severe hypothermia is a life-threatening situation when the body temperature is at or below 86 o. At 86 o F, the patient appears dead.

What differentiates heatstroke from heat exhaustion? 1 Fatigue 2 Perspiration 3 Mental status 4 Core body temperature

3 In heat exhaustion, the core temperature of a patient is 99.6° to 104° F, and that of a patient with heat stroke is greater than 104° F. Extended exposure to heat leads to heat stress characterized by fatigue and weakness, which occurs during heatstroke and heat exhaustion. Heatstroke patients sweat profusely; however, increased sweating in heat exhaustion eventually causes the sweat glands to stop working, leading to absence of perspiration. The mental status of the patient is affected in heatstroke as well as in heat exhaustion as a result of thermal injury to the brain.

The nurse assesses that a patient who sustained a severe trauma injury has asymmetric chest wall movement and no breath sounds on the left side of the chest. Which treatment strategy will help to alleviate the patient's symptoms? 1 Administering mannitol 2 Administering chlorpromazine 3 Applying a bag valve mask (BVM) 4 Infusing warmed intravenous fluids

3 When a patient has asymmetric chest wall movement and no breath sounds on one side of the chest, it indicates that the patient has a flail chest or a pneumothorax. This means the patient may have respiratory distress. Therefore the nurse should provide ventilation to the patient by using a bag valve mask for effective treatment. Mannitol is a diuretic, which helps to reduce cerebral edema but will not alleviate the symptoms of abnormal breathing. Warmed intravenous (IV) fluids will help treat hypothermia in a patient who has frostbite. This intervention does not help to provide adequate breathing to this patient. Chlorpromazine helps to reduce shivering in a patient who has heat stroke. It does not help to alleviate abnormal breath sounds and chest movements.

A parent brings a child to the emergency department with a bee sting. The child has nausea, feels faint, and is having difficulty breathing. Which of the following health care provider's prescriptions should the nurse implement first? 1 Applying cool compresses to the upper right arm 2 Elevating the right arm above the level of the heart 3 Administering 0.4 mg epinephrine subcutaneously 4 Administering 25 mg diphenhydramine by mouth (PO)

3 Administering 0.4 mg epinephrine subcutaneously Removing the stinger with tweezers may have caused additional venom to be released into the body. This would increase the severity of the reaction, as seen with the nausea, syncope, and breathing difficulties. Therefore the priority intervention would be to administer epinephrine to treat the reaction. Cool compresses, administering diphenhydramine, and elevating the arm are all appropriate treatments if the reaction is mild, that is, stinging, swelling, headache, and so forth.

A patient has been hospitalized with iron toxicity. Which medication does the nurse suspect will be prescribed? 1 Etomidate 2 Midazolam 3 Deferoxamine 4 Succinylcholine

3 Deferoxamine Deferoxamine is a chelating agent that binds with excess iron in the blood and reduces the symptoms of iron toxicity. Midazolam is a sedative medication that causes central nervous system depression. Etomidate is an anesthetic agent. Succinylcholine is a neuromuscular blocking agent. Midazolam, etomidate and succinylcholine cause bronchodilation and reduce the risk of aspiration in a patient who is undergoing rapid-sequence intubation.

A patient is brought to the emergency unit of the hospital with a compound fracture of the radius. How should the nurse rate the patient as per the Emergency Severity Index (ESI)? 1 ESI-1 2 ESI-2 3 ESI-3 4 ESI-4

3 ESI-3 The nurse should rate the patient with a compound fracture of the radius with ESI-3. The patient is stable and can be attended by a health care provider within an hour. A patient rated as ESI-1 would be unstable and in need of immediate attention, as in the case of a patient with cardiac arrest. A patient rated as ESI-2 has a threat to the stability of vital functions and needs continuous monitoring, as in the case of a patient with chest pain. A patient rated as ESI-4 is stable and may need simple procedures or diagnostic study, as in the case of a patient with cystitis.

The nurse is caring for patients in the emergency room. Which patient does the nurse see first? 1 Patient with abdominal pain 2 Patient with first-degree burn 3 Patient with severe respiratory distress 4 Patient with chest pain due to ischemia

3 Patient with severe respiratory distress The Emergency Severity Index (ESI) is a five level triage system used to critically analyze the priority of patient care. ESI indicates that patients with severe respiratory distress, cardiac arrest, and intubated trauma patients are prioritized for treatment (ESI-1). Patients with abdominal pain are given third preference (ESI-3). Patients with minor burns such as first-degree burns are given the last preference (ESI-5). Patients with chest pain likely due to ischemia are given second preference (ESI-2).

After completing a full set of vital signs on a patient who was injured severely in a motor-vehicle accident, the nurse begins to insert a Foley catheter per the health care provider's prescription. Which of the following would warrant the nurse to notify the health care provider? 1 Priapism 2 Rectal bleeding 3 Perineal ecchymosis 4 Abdominal distention

3 Perineal ecchymosis The nurse would not want to insert a Foley catheter if the patient has blood at the urinary meatus, scrotal hematoma, or perineal ecchymosis, because these are signs of possible damage to the urinary tract, and the Foley catheter could possibly cause additional damage. A Foley catheter may still be inserted in a patient experiencing priapism. Abdominal distention and rectal bleeding do not affect the urinary tr

A patient seeks treatment following a cat bite. The nurse recognizes that the bite may result in which condition? 1 Tick paralysis 2 Lyme disease 3 Tenosynovitis 4 Immersion syndrome

3 Tenosynovitis Cat bites cause deep puncture wounds that can damage tendons and joint capsules, resulting in tenosynovitis. Dog ticks or wood ticks may cause tick paralysis. Lyme disease is a tick-borne disease that is caused by a tick infected with Borrelia burgdorferi. Immersion syndrome is caused when an individual immerses in cold water for a long time.

A patient is admitted to the emergency department after falling from a roof. To which assessment finding should the nurse assign the highest priority? 1 Pale, moist skin 2 Pain on inspiration 3 Asymmetrical chest movement 4 Laceration on a lower extremity

3 Asymmetrical chest movement Prioritization of care for this patient follows an initial assessment of airway, breathing, circulation, and neurologic status. In a traumatic injury, ribs may be fractured and detached from the chest wall, resulting in asymmetric chest movement. This may compromise respiratory status and indicate a pneumothorax or other internal injuries. After identification of asymmetric chest movement, pain on inspiration would be evaluated as part of the respiratory assessment. After the breathing and respiratory issues are assessed, pale, moist skin and lower extremity lacerations may be evaluated as part of the circulatory assessment.

Which substance is absorbed by activated charcoal? 1 Lithium 2 Cyanide 3 Boric acid 4 Ethylene glycol

4 Activated charcoal absorbs acids and ethylene glycol. Activated charcoal does not alkylate substances such as lithium and cyanide. Activated charcoal does not absorb weakly acidic substances such as boric acid.

Which core body temperature readings confirm hyperthermia? 1 86° to 93.2° F (32ºC to 34ºC) 2 93.2° to 96.8° F (34ºC to 36ºC) 3 Less than or equal to 86° F (32ºC) 4 99.6° to 105.8° F (37.5 ºC to 41ºC)

4 Hyperthermia indicates an elevated core body temperature. Heat exhaustion causes hyperthermia and is indicated when the core body temperature is at 99.6° F to 105.8° F. Hypothermia in a patient indicates low core body temperature. Mild hypothermia is reported at 93.2° F to 96.8° F, moderate hypothermia at 86° F to 93.2°F, and severe hypothermia is less than or equal to 86° F

Which medication is useful in the treatment of a sting by an African honey bee? 1 Mannitol 2 Ceftriaxone 3 Chlorpromazine 4 Diphenhydramine

4 Stings by African honey bees cause a severe reaction that requires intramuscular or intravenous antihistamines such as diphenhydramine. Mannitol is widely used in the treatment of cerebral edema in patients with submersion injuries. Ceftriaxone is a medication recommended for treatment of symptoms arising in the later stages of Lyme disease. Chlorpromazine is used to control shivering in a hypothermic patient.

An elderly patient is being discharged from the hospital after treatment for heat cramps sustained during a strenuous workout. What should the nurse emphasize during discharge teaching? 1 Stay outdoors 2 Do not use salt tablets 3 Drink caffeinated drinks 4 Avoid intense activity for at least 12 hours

4 The nurse should instruct the patient not to exercise or do any strenuous or intense activity for at least 12 hours after discharge. The patient should stay indoors in a cool, low-humidity environment. Salt intake should be encouraged to increase the low sodium level. Caffeinated drinks should be avoided, because they cause dehydration.

Which drug controls shivering in a patient being treated for hyperthermia? 1 Mannitol 2 Analgesia 3 Antihistamine 4 Chlorpromazine

4 Treatment of a patient with hyperthermia focuses on lowering the core body temperature. Chlorpromazine intravenously (IV) administered is the preferred drug used to control shivering in instances when aggressive temperature reduction measures are required. Mannitol is widely used in treatment of cerebral edema in patients with submersion injuries. IV analgesia is used in the treatment of cold injuries. Antihistamines are administered IV to relieve different types of allergies and reactions.

Which is the most significant problem related to dog bites of children? 1 Rashes 2 Paralysis 3 Heart disease 4 Destruction of skin

4 Animal bites pose a greater risk to children. Facial bites are common in children and are often caused by the dog owned by the victim. The most significant problem that arises is destruction of skin, which may lead to tearing of multiple layers of tissue under the skin. The bite may cause a simple wound or may be a serious puncture wound; hence there is no occurrence of a rash on the affected area. Paralysis is caused by reaction to tick-borne disease. Heart disease is a result of pulmonary complications in an event of respiratory distress.

The nurse identifies that a patient is at an increased risk for frostbite if the patient has what condition? Select all that apply. 1 Abdominal pain 2 Hyperthyroidism 3 Urinary retention 4 Diabetes mellitus 5 Peripheral vascular disease

4 Diabetes mellitus 5 Peripheral vascular disease Increased blood glucose levels and decreased blood supply to the peripheral tissue impair tissue integrity and increase the risk of frostbite. Therefore a person with diabetes mellitus and peripheral vascular disease has a higher risk of frostbite. Abdominal pain, an increase in thyroid hormone levels, or decreased urine outflow do not impair tissue integrity, so these conditions do not increase the risk of frostbite.

During the primary survey of a trauma victim, it is determined that a patient has a patent airway. What is the priority nursing action? 1 Measure the blood pressure 2 Assess for external bleeding 3 Palpate the pulse for quality and rate 4 Examine the chest for signs of breathing

4 Examine the chest for signs of breathing Even with a patent airway, patients can have other problems that compromise ventilation; the next action is to examine the chest to assess the patient's breathing. The nurse measures the blood pressure to check for any abnormalities; however, this check is not the top priority. The patient should be checked for any external bleeding and for any irregular pulses, but these actions are not the top priority.

During the primary survey the nurse observes a patient exhibit paradoxical movement of the chest wall during respiration. What actions does the nurse take? Select all that apply. 1 Open the airway. 2 Insert the endotracheal tube. 3 Use the jaw-thrust maneuver. 4 Give supplemental oxygen therapy. 5 Ventilate with bag-valve-mask with 100% oxygen.

4 Give supplemental oxygen therapy. 5 Ventilate with bag-valve-mask with 100% oxygen. When a patient exhibits paradoxical movement of the chest wall during respiration, supplemental oxygen should be given through an appropriate delivery system. If the respiration is inadequate or absent, the patient should be ventilated using a bag-valve mask with 100 percent oxygen. When airway patency is absent, the airway should be opened. An endotracheal tube is inserted when there is no airway patency. Intubation is performed if there is respiratory distress and the patient cannot breathe. The jaw-thrust maneuver is performed to prevent obstructing the airway.

A patient arrives in the emergency department reporting severe chest pain and difficulty breathing. What is the priority nursing action? 1 Determine a medical diagnosis. 2 Perform an electrocardiogram (ECG). 3 Perform a brief neurologic examination. 4 Provide oxygenation via non-rebreather mask.

4 Provide oxygenation via non-rebreather mask. Initiating an intervention to reverse or prevent a crisis should take priority. Chest pain indicates oxygen deprivation, and providing oxygen is a priority. A medical diagnosis is determined later to recognize the cause of symptoms. Although it is important to obtain an ECG, the patient must have the airway needs met first. A neurologic exam can be performed after other interventions are initiated.

A nurse is conducting a primary survey in an emergency department. What is the purpose of the survey? 1 To assess whether the patient has any threat to life 2 To determine the priority for treatment for patients who are in the emergency department 3 To evaluate whether the resources in the emergency department are adequate to treat the patient 4 To evaluate the status of airway, breathing, circulation, disability and exposure and environmental control

4 To evaluate the status of airway, breathing, circulation, disability and exposure and environmental control The primary survey in an emergency assessment focuses on airway, breathing, circulation (ABC), disability, and exposure or environmental control. It aims to identify life-threatening conditions so that appropriate interventions can be started. The initial focused assessment prior to a primary survey determines the presence of actual or potential threats to life. Determining the priority for treatment is triaging. Patients are evaluated to decide whether they meet the criteria for ESI (Emergency Severity Index), thereby determining the number of resources required for the treatment.

While assessing an unresponsive apneic spinal cord injury patient, the nurse understands the need to open the airway with the jaw thrust maneuver and apply a cervical collar. What intervention would be the priority for the nurse to complete next? 1 Inserting an intravenous line 2 Assessing skin color, temperature, and moisture 3 Determining the patient's level of consciousness 4 Ventilating with a bag-valve mask at 100% oxygen

4 Ventilating with a bag-valve mask at 100% oxygen Ventilating with the bag-valve mask at 100% oxygen would be the priority, because breathing is the priority after the airway has been stabilized. The nurse would not assess skin color, temperature, and moisture or insert an intravenous line until after the patient's airway and breathing have been assessed and treated, because this is part of the circulation assessment or treatment. The patient's level of consciousness has been determined already; he or she is unresponsive.

A client arrives with blunt chest trauma, The nurse prioritizes which assessment

ABCs

To improve oxygenation in the client with flail chest the nurse will take which action

Administer NSAIDS (No binders, RIBS are impedening ventilation, reducing pain helps ventilation)

Which client should be triaged first in the ED?

Child having a seizure

A client with abdominal trauma has ecchymosis near the umbilicus, The RN documents this findings as

Cullen's sign

If a client is high risk and should not wait to be seen, What is the ESI

ESI 2

C presents to ED with Stroke symptoms, the client will be classified which ESI level

ESI 2 Pt cannot wait, but they need to be seen within 10 min. As long as there are no respiratory distress

A ED client requires a CXR, Vital signs are stable. Which ESI level is appropriate for this client

ESI 4 chest xray is 1 resource

A new trauma patient arrives and the nurses observes a hard, distended abdomen What test is anticipated?

FAST internal bleeding

A client has 3 consecutive rib fractures impacting 2 segments of each rib. This describes what condition

Flail chest

Which of the following is considered a resource within the ESI system

IV medication

Which assessment is part of the secondary survey in trauma?

Log rolling to inspect posterior surface

Which resuscitation aide will best assist in monitoring for GI bleed

NG tube decompression GI

A C chest tube dislodges, which action should the nurse take

Place the distal end of the chest tube in sterile water

Which clinical manifestations suggests tension pneumothorax?

Tracheal deviation to unaffected side

In a client with a suspected cervical injury the nurse should perform which action

Use Jaw-thrust method to open airway

C in ED has Absent breath sounds, dyspnea and hyperresonance to percussion. The RN suspects

pneumothorax