ch 70 Emergency, Trauma, and Environmental Injuries
Charge nurse
A medical-surgical unit is expecting a large volume of patient admissions after a train derailment. Which member of the nursing care team will prioritize care for the unit?
Assist the patient in turning at least every two hours
A nurse is developing a plan of care for a patient with traumatic injuries from a motor vehicle crash. Which nursing intervention does the nurse include in the plan of care to reduce the risk of integumentary complications?
MRI
A patient is brought into the emergency department after being assaulted. It is suspected that the patient has a spinal cord injury. Which diagnostic test does the nurse anticipate based on the data collected?
Tension pneumothorax
A patient recovering from a motor vehicle crash develops hypotension and jugular distension with a tracheal deviation. Based on this data, which should the nurse suspect occurred?
A school-age patient with asthma presenting with dyspnea
The emergency department nurse is triaging patients. Which patient should be prioritized?
Having suction available
The nurse is conducting a primary survey during an emergency assessment. Which is the priority nursing action related to breathing in response to this assessment?
Counting respiratory rate
The nurse is conducting a primary survey during the emergency assessment. Which nursing action is appropriate during the breathing assessment?
Determining drug allergies
The nurse is conducting a secondary survey as part of the emergency assessment. Which is the priority nursing action during the health history portion of the assessment?
-Clear the airway -Protect the cervical spine -Provide supplemental oxygen -Perform chest compressions
The nurse is providing care to a trauma patient. What is the correct order of steps the nurse will implement when providing care to this patient? Select all that apply. (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234
- A patient who took an overdose of opioids with a respiratory rate of eight breaths per minute -A patient who has multiple trauma due to a motor vehicle accident -A patient with abdominal pain rated as a 7 on a numeric pain scale -A patient with a leg laceration requiring sutures
The nurse is providing care to several patients in the emergency department. In which order should the nurse assess and provide care to the patients? (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234)
A patient with chest pain and diaphoresis
The nurse is providing care to several patients in the emergency department. Which patient is the priority when using the three-tiered triage system?
An adult patient with unstable vital signs and chest pain
The nurse is providing care to several patients in the emergency department. Which patient would require priority care from the nurse?
Taking vital signs
The registered nurse (RN) is the team leader for a group of patients using the functional model of nursing. The team of nurses includes two licensed practical nurses (LPNs) and an unlicensed assistive personnel (UAP). Which task will the RN delegate to the UAP?
Preserve the chain of evidence
What should the nurse do to assist a patient brought to the emergency department as a victim of a gunshot wound?
-Airway maintenance -Ventilation assistance -Hemorrhage control -Hypothermia prevention
What would the nurse working in the emergency department identify as clinical priorities for the treatment of a patient with a gunshot wound? Select all that apply
Documenting the patient's care
Which are the priority nursing actions after the completion of the secondary survey when providing care for a trauma patient with a penetrating wound?
-Airway -Cervical spine
Which are the top priorities when conducting a primary patient survey during the emergency assessment? Select all that apply
Ecchymosis
Which assessment data indicates the patient is experiencing a late symptom associated with chronic aspirin overdose?
Agonal breaths
Which assessment data related to the patient's airway would indicate the need for priority intervention by the nurse?
Assist to deep breathe and cough every two hours
Which intervention would be a priority when providing care to a patient recovering from thoracic injuries sustained from a motor vehicle crash?
Concussion
Which is a potentially life-threatening condition found during the primary triage survey that would necessitate priority nursing care?
Setting priorities
Which is the essential nursing skill for the triage process in the emergency department?
Stabilizing the impaled object
Which is the priority nursing action when providing care to a patient with a penetrating abdominal wound?
Team leader
Which member of the health-care team, when using the team nursing approach, is responsible for prioritizing patient care?
Assigning a nurse to support family members
Which nursing action is appropriate when conducting a secondary survey during the emergency assessment?
-Immobilizing the cervical spine -Preparing for chest tube insertion -Applying direct pressure to a wound
Which nursing actions are appropriate during the primary survey of the emergency assessment process? Select all that apply
Moves all four extremities independently, feeds self, and participates in partial bath
Which observation indicates that interventions provided to a patient with neck injuries from a motor vehicle crash have been successful?
Activated charcoal
Which treatment should the nurse prepare to administer when providing care to a toddler who presents after an accidental overdose of aspirin?