Ch. 72: Emergency Nursing

The nurse has commenced a transfusion of fresh frozen plasma (FFP) and notes the client is exhibiting symptoms of a transfusion reaction. After the nurse stops the transfusion, what is the next required action? Remove the peripheral IV line Start a dextrose 5% water infusion Run a normal saline line to keep the vein open Obtain a blood culture from the IV insertion site

Correct response: Run a normal saline line to keep the vein open Explanation: If the nurse suspects a transfusion reaction, the transfusion must be stopped immediately and the nurse's next action is to ensure the normal saline line is running at a rate that permits administration of IV fluids or medications that are required to treat the reaction. The nurse should ensure IV access is maintained. The 'to keep vein open (TKVO) rate allows the nurse to keep the IV client without the potential to cause fluid volume overload. It would be unsafe for the nurse to remove the peripheral IV because continued access is required for urgent IV administration of medications or fluids to treat the reaction. Obtaining a blood culture at the IV site would be necessary if an infection was suspected. This is not required for a transfusion reaction. Normal saline is the solution of choice when transfusing blood products because there is a risk for incompatibility with all other IV solutions.

A client comes to the emergency department after experiencing a wound. Inspection reveals an opening in the skin with distinct edges and whose depth is greater than the length of the wound. The nurse documents this as which type of wound? Laceration Avulsion Stab Patterned

Correct response: Stab Explanation: A stab wound is an incision of the skin with well-defined edges and is typically deeper than long. It is usually caused by a sharp instrument. A laceration is a tear in the skin with irregular edges and vein bridging. An avulsion is manifested as a tearing away of tissue from the supporting structures. A patterned wound takes on the outline of the object causing the wound.

A patient was bitten by a tick 3 months ago and is now having muscle aches as well as joint pain and swelling. The patient is having difficulty with self care and requires assistance with activities of daily living (ADLs). What stage of Lyme disease does the nurse recognize the patient is in? Stage I Stage II Stage III Stage IV

Correct response: Stage III Explanation: Lyme disease has three stages. Stage I presents with a classic "bull's-eye" rash (i.e., erythema migrans) and flulike signs and symptoms that may include chills, fever, myalgia, fatigue, and headache. If antibiotics are not administered, stage II Lyme disease may present within 4 to 10 weeks following the tick bite and may manifest with joint pain, memory loss, poor motor coordination, and meningitis. Stage III can begin anywhere from weeks to more than a year after the bite and has serious long-term chronic sequelae, including arthritis, neuropathy, myalgia, and myocarditis.

A nurse is providing inservice education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step? Collecting semen Performing the pelvic examination Obtaining consent for examination Supporting the client's emotional status

Correct response: Supporting the client's emotional status Explanation: The teaching session is successful when staff members focus first on supporting the client's emotional status. Next, staff members should gain consent to perform the pelvic examination, perform the examination, and collect evidence, such as semen if present.

The intensive care unit nurse is assessing a client who is going to require a peripheral intravenous (PIV) line for fluids. The nurse should consider what information in the client's health history when deciding the site for the PIV? The client has had a mastectomy on the right side The client has hypertension The client has a fluid volume restriction The client has a history of falls

Correct response: The client has had a mastectomy on the right side Explanation: Contraindications to the placement of a PIV line in any specific placement (right vs. left side) will include history of mastectomy, arterial-venous shunt placement, peripherally inserted central catheter (PICC) line placement, thrombus, trauma, and other device placements, such as splints and casts. The nurse will only have the option to start the PIV on a site in the client's left arm if the client has had a ride-sided mastectomy. A history of hypertension does not preclude the client from having a PIV inserted in any specific location. Although fluid requirements are monitored more strictly with clients who are on a fluid volume restriction, this does not influence the placement of the PIV. The nurse should always be aware of the risks of a PIV for a client with a falls history. The tubing can be a tripping hazard, therefore, the client with a falls history who requires a PIV should be closely monitored but this does not preclude the client from having a PIV inserted.

When providing care to a client who has experienced multiple trauma, which of the following would be most important for the nurse to keep in mind? The client is assumed to have a spinal cord injury until proven otherwise. The most lethal injuries are often the most readily apparent. Most multiple trauma victims exhibit evidence of the trauma. Injuries have occurred to at least three distinct organ systems.

Correct response: The client is assumed to have a spinal cord injury until proven otherwise. Explanation: With clients experiencing multiple trauma, the nurse must assume that the client has a spinal cord injury until proven otherwise. Multiple trauma cleints experience life-threatening injuries to at least two distinct organs or organ systems. Evidence of the trauma may be sparse or absent. Additionally, the injury that may seem the least significant may be the most lethal.

The nurse is caring for a client who is being prepared for the placement of a central intravenous line. The nurse recognizes this client requires this type of intravenous access for which reason? client will require intravenous access for three days The client requires total parenteral nutrition The client requires infusion of intravenous antibiotics The client requires infusion of a dextrose 5% water (D5W)

Correct response: The client requires total parenteral nutrition Explanation: For a patient who requires total parenteral nutrition (TPN), a central intravenous line is required due to the length of time the client will require the infusion as well as the nature of the solution itself. A large vein is required to safely infuse TPN. For this reason, a central line is needed. A peripheral intravenous line is safe to used when IV access is required under six days. Beyond this time, either a new peripheral IV will need to be inserted. If it is known in advance that IV treatment will last beyond six days, the client's health care provider will order the placement of a central intravenous line. Intravenous antibiotics can be administered peripherally unless the course is longer than six days. D5W is an intravenous solution that can be administered either peripherally or centrally. The nature of this IV solution would not determine which type of IV access the client requires.

A client present to the ED following a work-related injury to the left hand. The client has an avulsion of the left ring finger. Which correctly describes an avulsion? Tissue tearing away from supporting structures Incision of the skin with well-defined edges, usually long rather than deep Skin tear with irregular edges and vein bridging Denuded skin

Correct response: Tissue tearing away from supporting structures Explanation: An avulsion is described as a tearing away of tissue from supporting structures. A laceration is a skin tear with irregular edges and vein bridging. Abrasion is denuded skin. A cut is an incision of the skin with well-defined edges, usually long rather than deep.

The nurse is caring for a patient in the ED who is breathing but unconscious. In order to avoid an upper airway obstruction, the nurse is inserting an oropharyngeal airway. How would the nurse insert the airway? At an angle of 90 degrees Upside down and then rotated 180 degrees With the concave portion touching the posterior pharynx With the convex portion facing upward

Correct response: Upside down and then rotated 180 degrees Explanation: The nurse should insert the oropharyngeal airway with the tip facing up toward the roof of the mouth until it passes the uvula and then rotate the tip 180 degrees so that the tip is pointed down toward the pharynx. This displaces the tongue anteriorly, and the patient then breathes through and around the airway.

The nurse in the hospital emergency department is assessing a patient who fell while intoxicated with alcohol. The nurse is using the Clinical Institute Withdrawal Assessment-Alcohol (CIWA-A) scale to assess the patient's need for a benzodiazipine medication. In order to assess for auditory disturbances, which question should the nurse ask the patient? "Are you hearing anything that is disturbing you?" "Are you experiencing any burning or numbness?" "Are you finding the light is too harsh or bothering your eyes?" "Does it feel like there is a tight band around your head?"

Correct response: "Are you hearing anything that is disturbing you?" Explanation: The Clinical Institute Withdrawal Assessment-Alcohol (CIWA-A) scale is used in the assessment of alcohol withdrawal. The patient's score on this scale helps determine the level of intervention that is required to support safe, withdrawal from alcohol. Assessing for auditory disturbances is one subsection on the scale. In order to effectively assess for this symptom, the nurse should ask the patient if they are hearing anything that is disturbing. By asking the patient if they are experiencing any numbness or burning would help to assess for tactile disturbances. By asking the patient if the light is bothering their eyes would support the assessment for visual disturbances. Asking the patient if it feels like there is a tight band around their head would help determine if the patient has a headache or fullness of the head. These are all symptom items that are measured by this scale.

A client arrives at the emergency department and is experiencing a severe allergic reacton to a bee sting. The client received treatment and is being discharged. Which client statement indicates that additional teaching about exposure prevention is needed? I should always wear something on my feet when I'm outside." "Brightly colored clothes help to ward off bees." "If a bee comes near me, I should stay still." "I need to avoid using perfumes and scented soaps when I'm going outside."

Correct response: "Brightly colored clothes help to ward off bees." Explanation: To prevent insect stings, the client should avoid wearing brightly colored clothing because it attracts bees. The client should wear covering on the feet and avoid going barefoot because yellow jackets nest and pollinate on the ground. Staying still or motionless reduces the likelihood of being stung. Perfumes and scented soaps attract bees and should be avoided.

The nurse is caring for a client in the ED following a sexual assault. The client is hysterical and crying. The client states, "I know I'm pregnant now, maybe I have HIV. Why did this happen to me?" Which is the best response by the nurse? "Let's talk about this. Do you want me to call a support person?" "Do you want to discuss antipregnancy measures?" "Do you want the phone number for the National Sexual Assault Hotline?" "Would you like us to complete HIV testing?"

Correct response: "Let's talk about this. Do you want me to call a support person?" Explanation: The client should be reassured that anxiety is natural and asked whether a support person may be called. The goals of management are to provide support, reduce the client's emotional trauma, and gather available evidence for possible legal proceedings. Throughout the client's stay in the ED, the client's privacy and sensitivity must be respected. The client may exhibit a wide range of emotional reactions, such as hysteria, stoicism, or feelings of being overwhelmed. Support and caring are crucial.

The nurse is caring for an intensive care unit client who has died with family members at the bedside. The death was sudden and unexpected resulting from a car accident that took place three days ago. The family is upset and the client's partner, crying loudly, yells, "How did this happen? We were just about to celebrate his birthday. He can't be gone!" The family member continues to cry inconsolably. How should the nurse respond? " I will get you some medication that will help you feel more calm." "He has passed on to a better place now." "It is important to face the reality that he is gone." "We did everything we could possibly do to try to save his life."

Correct response: "We did everything we could possibly do to try to save his life." Explanation: In order to help the family cope with the sudden death of their loved one, it is helpful for the nurse to explain that the care team employed all medical interventions possible to try to save the client's life. With the support of other members of the health care team, the nurse can take the time to explain what life saving treatments were rendered. The nurse should avoid giving sedation to family members; this may mask or delay the grieving process, which is necessary to achieve emotional equilibrium and to prevent prolonged depression. It is important that the nurse avoid using euphemisms such as "passed on." Instead the nurse should show the family that he or she cares by touching, and offering coffee, water, and the services of a chaplain. The nurse should encourage the family to express emotion including events leading up to the event that led to the client's death. The nurse should not challenge initial feelings of anger or denial.

The nurse is administering 100% oxygen to a patient with carbon monoxide poisoning and obtains a carboxyhemoglobin level. Which level would the nurse interpret as indicating that oxygen therapy can be discontinued? 9% 7% 6% 4%

Correct response: 4% Explanation: Oxygen is administered until the carboxyhemoglobin level is less than 5%.

A patient with frostbite to both lower extremities from exposure to the elements is preparing to have rewarming of the extremities. What intervention should the nurse provide prior to the procedure? Administer an analgesic as ordered. Massage the extremities. Elevate the legs. Apply a heat lamp.

Correct response: Administer an analgesic as ordered. Explanation: During rewarming, an analgesic for pain is administered as prescribed, because the rewarming process may be very painful. To avoid further mechanical injury, the body part is not handled. Massage is contraindicated.

The nurse is caring for a client in the ED with frostbite to the left hand. During the rewarming process of the hand, the nurse should perform which action? Administer analgesic medications as ordered. Keep the hand in the circulating bath for 1 hour. Rupture any hemorrhagic blebs that are noted. Have the client complete active range-of-motion exercises.

Correct response: Administer analgesic medications as ordered. Explanation: During rewarming, an analgesic for pain is administered as prescribed because the rewarming process may be very painful. Frozen extremities are usually placed in a 37°C to 40°C (98.6°F to 104°F) circulating bath for 30- to 40-minute spans. This treatment is repeated until circulation is effectively restored. Hemorrhagic blebs, which may develop 1 hour to a few days after rewarming, are left intact and unruptured. Nonhemorrhagic blisters are debrided to decrease the inflammatory mediators found in the blister fluid. After rewarming, hourly active motion of any affected digits is encouraged to promote maximal restoration of function and to prevent contractures.

The nurse received a patient from a motor vehicle accident who is hemorrhaging from a femoral wound. What is the initial nursing action for the control of the hemorrhage? Apply a tourniquet. Apply firm pressure over the involved area or artery. Elevate the injured part. Immobilize the area to control blood loss.

Correct response: Apply firm pressure over the involved area or artery. Explanation: Direct, firm pressure is applied over the bleeding area or the involved artery at a site that is proximal to the wound (Fig. 72-3). Most bleeding can be stopped or at least controlled by application of direct pressure. Otherwise, unchecked arterial bleeding results in death. A firm pressure dressing is applied, and the injured part is elevated to stop venous and capillary bleeding, if possible. If the injured area is an extremity, the extremity is immobilized to control blood loss. A tourniquet is applied to an extremity only as a last resort when the external hemorrhage cannot be controlled in any other way and immediate surgery is not feasible.

A patient is brought to the ED by a friend, who states that a tree fell on the patient's leg and crushed it while they were cutting firewood. What priority actions should the nurse perform? (Select all that apply.) Applying a clean dressing to protect the wound Elevating the site to limit the accumulation of fluid in the interstitial spaces Inserting an indwelling catheter Splinting the wound in a position of rest to prevent motion Performing a fasciotomy

Correct response: Applying a clean dressing to protect the wound Elevating the site to limit the accumulation of fluid in the interstitial spaces Splinting the wound in a position of rest to prevent motion Explanation: Major soft tissue injuries are dressed and splinted promptly to control bleeding and pain. If an extremity is injured, it is elevated to relieve swelling and pressure.

A nurse is providing care to the family of a client who was brought to the emergency department and suddenly died. Which of the following would be appropriate for the nurse to do? Select all that apply. Talk with the family about the client having "passed on." Provide sedation to family members as needed. Ask the family if they would like to view the body. Provide a private place for the family to be together. Allow the family to express their emotions freely.

Correct response: Ask the family if they would like to view the body. Provide a private place for the family to be together. Allow the family to express their emotions freely. Explanation: When providing care to a family experiencing the sudden death of a member, the nurse would take the relatives to a private place where they can be together to grieve. In addition, the nurse would encourage the family to view the body if they wish and allow members to support each other and express their emotions freely. Euphemisms such as "passing on" or "going to a better place" should be avoided. Sedation is avoided because it may mask or delay the grieving process, which is necessary to achieve emotional equilibrium and prevent prolonged depression.

A female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing interventions should be provided? (Select all that apply.) Have the patient shower or wash the perineal area before the examination. Assess and document any bruises and lacerations. Record a history of the event, using the patient's own words. Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police. Ensure that the police are present when the examination is performed.

Correct response: Assess and document any bruises and lacerations. Record a history of the event, using the patient's own words. Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police. Explanation: A history is obtained only if the patient has not already talked to a police officer, social worker, or crisis intervention worker. The patient should not be asked to repeat the history. Any history of the event that is obtained should be recorded in the patient's own words. The patient is asked whether he or she has bathed, douched, brushed his or her teeth, changed clothes, urinated, or defecated since the attack, because these actions may alter interpretation of subsequent findings. Each item of clothing is placed in a separate paper bag. The bags are labeled and given to appropriate law enforcement authorities. The patient is examined (from head to toe) for injuries, especially injuries to the head, neck, breasts, thighs, back, and buttocks. The exam focuses on external evidence of trauma (bruises, contusions, lacerations, stab wounds).

The ED staff work collaboratively and follow the ABCDE method to establish and treat health priorities effectively in a client experiencing a trauma. Which action is completed by the nurse when implementing the "D" element of this method? Assessing the client's Glasgow Coma Scale score Managing hypothermia Providing cervical spine protection Undressing the client quickly

Correct response: Assessing the client's Glasgow Coma Scale score Explanation: The primary survey focuses on stabilizing life-threatening conditions. The ED staff work collaboratively and follow the ABCDE (airway, breathing, circulation, disability, exposure) method. While implementing the D element, the nurse determines neurologic disability by assessing neurologic function using the Glasgow Coma Scale and performing a motor and sensory evaluation of the spine. A quick neurologic assessment may be performed using the AVPU mnemonic: A, alert: is the client alert and responsive? V, verbal: does the client respond to verbal stimuli? P, pain: does the client respond only to painful stimuli? U, unresponsive: is the client unresponsive to all stimuli, including pain? The other interventions are not included in this element of the primary survey.

A homeless client presents to the ED. Upon assessment, the client is experiencing hypothermia. The nurse will plan to complete which priority intervention during the rewarming process? Attach a cardiac monitor Insert a Foley urinary catheter Assist with endotracheal intubation Administer inotropic drugs

Correct response: Attach a cardiac monitor Explanation: Continuous electrocardiograph (ECG) monitoring is performed during the rewarming process because cold-induced myocardial irritability leads to conduction disturbances, especially ventricular fibrillation. A urinary catheter should be inserted to monitor urinary output; however, ECG monitoring is the priority. There is no indication for endotracheal intubation. Inotropic medications are contraindicated because they can stimulate the heart and increase the risk for fatal dysrhythmias, such as ventricular fibrillation.

A client has a gaping wound on his forearm that is bleeding profusely. Applying pressure to which pressure point would be most helpful? Brachial Femoral Radial Subclavian

Correct response: Brachial Explanation: The pressure point at the brachial artery would be most appropriate because this site is proximal to the bleeding site. The femoral pressure point would be useful for bleeding in the lower extremities. The radial pressure point would be appropriate for bleeding in the wrist and hands. The subclavian pressure point would be used for bleeding in the upper anterior chest area.

A client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later, the nurse identifies which finding as an early sign of shock? Confusion Pale, warm, dry skin Heart rate of 70 beats/minute Elevated blood pressure

Correct response: Confusion Explanation: Early in shock, inadequate perfusion leads to anaerobic metabolism, which causes metabolic acidosis. As the respiratory rate increases to compensate, the client's carbon dioxide level decreases, causing alkalosis and subsequent confusion and combativeness. Inadequate tissue perfusion causes pale, cool, clammy skin (not pale, warm, dry skin). In the early stages of shock, the client's heart rate will become elevated above normal. In early shock the client's blood pressure will remain normal, but as shock progresses the mechanisms that regulate blood pressure will not be able to compensate.

A client presents to the ED following a motor vehicle collision. The client is suspected of having internal hemorrhage. The nurse assesses the client for signs and symptoms of shock. Which are signs and symptoms of shock? Select all that apply. Cool, moist skin Decreasing blood pressure Increasing heart rate Delayed capillary refill Increasing urine volume

Correct response: Cool, moist skin Decreasing blood pressure Increasing heart rate Delayed capillary refill Explanation: Signs and symptoms of shock include cool, moist skin (resulting from poor peripheral perfusion), decreasing blood pressure, increasing heart rate, delayed capillary refill, and decreasing urine volume.

The nurse has come on shift to find that a client newly admitted to the ICU is confused and persistently trying to get out of bed despite being comforted and re-oriented by the nurse. The client begins to pull on the peripheral intravenous line in the hand and speaking in non-sensical terms. The client's history indicates a sudden onset of neurological symptoms after developing a bacterial infection. The nurse anticipates providing care for which health problem? Delirium Pain Anxiety Fever

Correct response: Delirium Explanation: Delirium is a confused state that has a sudden onset and can last hours to days or weeks; it is characterized by hyperactivity and has the potential to be reversible. The client who quickly becomes confused and agitated while attempting to pull out IV lines and get out of bed is experiencing delirium. The nurse caring for this client should anticipate the need to provide close monitoring to prevent injury. Although clients can experience a high level of stress with both pain and anxiety, which often accompany one another, these problems do not cause confusion and disorientation. Nursing interventions would be aimed at reducing pain and anxiety with the use of medications and other non-pharmacological interventions that enhance client comfort. Although fever can accompany delirium, it does not produce confusion and disorientation on its own.

A high school football player is brought to the emergency department after collapsing at practice in extremely hot and humid weather. Which of the following would lead the nurse to suspect that the client is experiencing heat stroke? Temperature of 101 degrees F (38 degrees C) Diaphoresis Delirium Bradycardia

Correct response: Delirium Explanation: Manifestations of heat stroke include a temperature of 105 degrees F or greater (40.5 degrees C or greater), anhidrosis (absence of sweating), central nervous system dysfunction (bizarre behavior, delirium, confusion, or coma), hot, dry skin, tachycardia, tachypnea, and hypotension.

The nurse is conducting a secondary survey on a client in the ED. Which action is completed during the secondary survey? Diagnostic and laboratory testing Assessment of peripheral pulses Establishing a patent airway Undressing the client

Correct response: Diagnostic and laboratory testing Explanation: Diagnostic and laboratory testing is completed during the secondary survey, along with a complete health history, a head-to-toe assessment, insertion or application of monitoring devices, splinting of suspected fractures, cleansing, closure, and dressing of wounds, and performance of other necessary interventions based on the client's condition. The other interventions are completed during the primary survey.

A client is brought to the emergency department by ambulance. The client is seriously ill and unconscious. No family or friends are present. Which of the following would be most appropriate to do? Document the client's condition and absence of friends or family for obtaining consent to treatment. Check the client's record for the name of a family member to call to allow care to be provided. Ask the ambulance team for information about the client's family to ensure informed consent. Explain to the client that care is going to be provided because he is seriously ill.

Correct response: Document the client's condition and absence of friends or family for obtaining consent to treatment. Explanation: Consent is needed to examine and treat a client unless he or she is unconscious or in critical condition and unable to make decisions. In this situation, the client is unconscious and no friends or family are around to provide consent to treatment. The nurse should document this fact and provide care. Checking the client's record and asking the ambulance team for information would waste valuable time. Explaining to the client that care will be provided is appropriate even though the client is unconscious, but documentation is essential.

A nurse is preparing to assist with a gastric lavage for a client who has ingested an unknown poison and is obtunded. To ensure that the tube reaches the stomach, the nurse would measure the distance from the bridge of the nose to which of the following? Ear lobe and then to the xiphoid process Chin and then to the xiphoid process Ear lobe and then to the umbilicus Chin and then to the umbilicus

Correct response: Ear lobe and then to the xiphoid process Explanation: The nurse measures the tube from the bridge of the nose to the xiphoid process to ensure that the tube reaches the stomach on insertion.

A client presents to the ED reporting choking on a chicken bone. The client is breathing spontaneously. The nurse applies oxygen and suspects a partial airway obstruction. Which action should the nurse do next? Encourage the client to cough forcefully. Insert a nasopharyngeal airway. Prepare the client for a bronchoscopy. Insert an oropharyngeal airway.

Correct response: Encourage the client to cough forcefully. Explanation: If the client can breathe and cough spontaneously, a partial obstruction should be suspected. The client is encouraged to cough forcefully and to persist with spontaneous coughing and breathing efforts as long as good air exchange exists. There may be some wheezing between coughs. If the client demonstrates a weak, ineffective cough, a high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis, the client should be managed as if there were complete airway obstruction. If the client is unconscious, inspection of the oropharynx may reveal the offending object. X-ray study, laryngoscopy, or bronchoscopy also may be performed. There is no indication that an artificial airway is indicated.

A patient brought to the ED by the rescue squad after getting off a plane at the airport is complaining of severe joint pain, numbness, and an inability to move the arms. The patient was on a diving vacation and went for a last dive this morning before flying home. What is a priority action by the nurse? Ensure a patent airway and that the patient is receiving 100% oxygen. Send the patient for a chest x-ray. Send the patient to the hyperbaric chamber. Draw labs for a chemistry panel.

Correct response: Ensure a patent airway and that the patient is receiving 100% oxygen. Explanation: Decompression sickness, also known as "the bends," occurs in patients who have engaged in diving (lake/ocean diving), high-altitude flying, or flying in commercial aircraft within 24 hours after diving. Signs and symptoms include joint or extremity pain, numbness, hypesthesia, and loss of range of motion. A patent airway and adequate ventilation are established before all other interventions, as described previously, and 100% oxygen is administered throughout treatment and transport.

Medical and nursing interventions for patients who present with multiple injuries follow a sequence of treatment priorities. Which of the following is the first priority of care? Establish an airway. Prevent hypovolemic shock. Assess for head and neck injuries. Control hemorrhage.

Correct response: Establish an airway. Explanation: The immediate intervention is to always manage the airway and breathing first; controlling hemorrhage is the second priority, followed by preventing and treating hypovolemic shock.

The nurse in the ED is triaging patients during the shift. What does the nurse know is the first priority in treating any patient in the ED? Controlling hemorrhage. Establishing an airway. Obtaining consent for treatment. Restoring cardiac output.

Correct response: Establishing an airway. Explanation: The primary survey focuses on stabilizing life-threatening conditions. The ED staff work collaboratively and follow the ABCDE (airway, breathing, circulation, disability, exposure) method. The first priority is always to establish a patent airway.

A client is being cared for in the ED. The client is assigned to the triage category of "urgent." How often must the nurse reassess the client? 15 minutes Every 30 minutes Every 60 minutes Every 120 minutes

Correct response: Every 30 minutes Explanation: Clients assigned to the resuscitation category must receive continuous nursing surveillance, those in the emergent category must be reassessed at least every 15 minutes, clients in the urgent category must be reassessed at least every 30 minutes, those in the less urgent category must be reassessed at least every 60 minutes, and those in the nonurgent category must be reassessed at least every 120 minutes.

After inserting an oropharyngeal airway, which of the following indicates that the airway is properly positioned? Distal end is in the pharynx. Flange is at the client's lips. Air is moving through the airway. Tongue lies on top of the airway.

Correct response: Flange is at the client's lips. Explanation: An oropharyngeal airway is properly positioned when the distal end is in the hypopharynx and the flange is approximately at the client's lips. Air moving through the airway may or may not indicate proper placement. An oropharyngeal airway is inserted so that the tongue is displaced anteriorly.

Nursing students are reviewing the categories of intra-abdominal injuries. The students demonstrate understanding of the information when they identify which of the following as examples of penetrating trauma? Select all that apply. Gunshot wound Knife-stab wound Motor-vehicle crash Fall from a roof Being struck with a baseball bat

Correct response: Gunshot wound Knife-stab wound Explanation: Examples of penetrating trauma include gunshot wounds and stab wounds. Motor vehicle crashes, falls, and being struck with a baseball bat are examples of blunt trauma.

The nurse is caring for a victim of a sexual assault. The client is fearful and experiencing flashbacks. The nurse recognizes that the client is experiencing which phase of the psychological reaction to rape? Heightened anxiety phase Acute disorganization phase Denial phase Reorganization phase

Correct response: Heightened anxiety phase Explanation: During the heightened anxiety phase, the client demonstrates anxiety, hyperalertness, and psychosomatic reactions, in addition to fear and flashbacks. The acute disorganization phase is characterized by shock, disbelief, guilt, humiliation, and anger. The denial phase is characterized by an unwillingness to talk. The reorganization phase occurs when the incident is put into perspective. Some clients never fully recover from rape trauma.

A nurse is caring for a client who has arrived at the emergency department in shock. The nurse intervenes based on the knowledge that which of the following is the most common cause of shock? Anaphylaxis Sepsis Hypovolemia Cardiac dysfunction

Correct response: Hypovolemia Explanation: Types of shock include cardiogenic, neurogenic, anaphylactic, and septic. Of these, the most common cause is hypovolemia.

The nurse educator is providing orientation to a group of nurses newly hired to an intensive care unit. The group of nurses are correct in stating which is the most common type of shock managed in critical care? Anaphylactic Hypovolemic Neurogenic Cardiogenic

Correct response: Hypovolemic Explanation: The underlying cause of shock (hypovolemic, cardiogenic, neurogenic, anaphylactic, or septic) must be determined. Of these, hypovolemia is the most common cause.

A patient who has accidentally ingested toilet bowel cleaner is brought to the emergency department. Which action would NOT be appropriate for the nurse to implement? Dilution with water or milk Gastric lavage Administration of activated charcoal Induced vomiting

Correct response: Induced vomiting Explanation: Vomiting is never induced after ingestion of caustic substances (acid or alkaline) such as toilet bowl cleaner because the substance is corrosive to the tissues. Appropriate actions include dilution with milk or water, gastric lavage, and administration of activated charcoal.

A nurse is completing her annual cardiopulmonary resuscitation training. The class instructor tells her that a client has fallen off a ladder and is lying on his back; he is unconscious and isn't breathing. What maneuver should the nurse use to open his airway? Head tilt-chin lift Jaw-thrust Abdominal thrust Seldinger

Correct response: Jaw-thrust Explanation: If a neck or spine injury is suspected, the jaw-thrust maneuver should be used to open the client's airway. To perform this maneuver, the nurse should position herself at the client's head and rest her thumbs on his lower jaw, near the corners of his mouth. She should then grasp the angles of his lower jaw with her fingers and lift the jaw forward. The head tilt-chin lift maneuver is used to open the airway when a neck or spine injury isn't suspected. To perform this maneuver the nurse places two fingers on the chin and lifts while pushing down on the forehead with the other hand. The abdominal thrust is used to relieve severe or complete airway obstruction caused by a foreign body. The Seldinger maneuver is a method of percutaneous introduction of a catheter into a vessel.

Which solution should the nurse use to replace lost fluids in a client with signs and symptoms of shock due ot hemmorhaging? Lactated Ringer solution Type O negative blood Dextrose 5% in water Hypertonic saline

Correct response: Lactated Ringer solution Explanation: Replacement fluids may include isotonic electrolyte solutions( lactated Ringers, nomoral saline) ,colloids, and blood component therapy. O negative blood is prepared for emergency use in women of childbearing age. Dextrose 5% in water should not be used to replace fluids in hypovolemic clients. Hypertonic saline is used only to treat severe symptomatic hyponatremia and should be used only in intensive care units.

A patient arrives at the emergency department after sustaining a gunshot wound to the abdomen. When assessing the patient, the nurse pays particular attention to which of the following? Liver Stomach Large intestine Kidneys

Correct response: Liver Explanation: Penetrating abdominal injuries, such as from a gunshot wound, are serious and result in a high incidence of injury to hollow and solid organs. Although any organs can be injured, the liver is the most frequently injured solid organ. The small bowel is a frequently injured hollow organ. Thus, of the options shown, the nurse would assess the liver area most closely.

Which solid organ is most frequently injured in a penetrating trauma? Lung Liver Pancreas Brain

Correct response: Liver Explanation: The most frequently injured solid organ in a penetrating trauma is the liver because of its size and anterior placement in the right upper quadrant of the abdomen.

A client presents to the ED after an unsuccessful suicide attempt. The client is diagnosed with an acetaminophen overdose. The nurse anticipates the administration of which medication? N-acetylcysteine Flumazenil Naloxone Diazepam

Correct response: N-acetylcysteine Explanation: Treatment of acetaminophen overdose includes administration of N-acetylcysteine. Flumazenil is administered in the treatment of nonbarbiturate sedative overdoses. Naloxone is administered in the treatment of narcotic overdoses. Diazepam may be administered to treat uncontrolled hyperactivity in the client with a hallucinogen overdose.

Which medication reverses severe respiratory depression and coma? Naloxone hydrochloride Diazepam Flumazenil N-acetylcysteine

Correct response: Naloxone hydrochloride Explanation: Naloxone hydrochloride, a narcotic antagonist, reverses respiratory depression and coma. Diazepam is a benzodiazepine. Flumazenilis a benzodiazepine antagonist. N-acetylcysteine is used for acetaminophen toxicity.

The nurse is caring for a client with known myocardial ischemia. The client will be getting up to ambulate for the first time in three days after being on bedrest since admission to the intensive care unit. Which medication should the nurse administer before the client ambulates? Nitroglycerin Vasopressin Norepinephrine Dobutamine

Correct response: Nitroglycerin Explanation: Nitroglycerin is indicated for use in clients who experience angina pectoris as a result of myocardial ischemia. The medication acts by decreasing blood pressure and causing arterial vasodilation permitting blood flow into the myocardium. Nitroglycerin should be given prior to any anticipated physical exertion that is likely to bring on chest pain from vasoconstriction. Vasopressin is a vasoactive medication administered to increase blood pressure in cases where clients have diabetes insipidus, a gastrointestinal bleed or in cases of septic shock. Norepinephrine raises blood pressure and is indicated for use in emergencies such as cardiac arrest or for hypovolemia. Dobutamine increased heart contractility and blood pressure to improve stroke volume in clients with congestive heart failure.

A nurse who is a member of an emergency response team anticipates that several patients with airway obstruction may need a cricothyroidotomy. For which of the following patients would this procedure be appropriate? Select all that apply. Patient with extensive facial trauma Patient with a lumbar spine injury Patient with laryngeal edema secondary to anaphylaxis Patient who is bleeding from the chest Patient with an obstructed larynx

Correct response: Patient with extensive facial trauma Patient with laryngeal edema secondary to anaphylaxis Patient with an obstructed larynx Explanation: Cricothyroidotomy is used in emergencies when endotracheal intubation is either not possible or contraindicated. Examples include airway obstruction from extensive maxillofacial trauma, cervical spine injury, laryngospasm, laryngeal edema after an allergic reaction or extubation, hemorrhage into neck tissue, and obstruction of the larynx.

When preparing to perform abdominal thrusts on a client with an airway obstruction, which of the following would be most appropriate? Having the conscious client lie down Placing the thumb side of one hand at the xiphoid process Positioning the hands in the midline slightly above the umbilicus Using a sequence of four thrusts, each progressing in intensity

Correct response: Positioning the hands in the midline slightly above the umbilicus Explanation: When performing abdominal thrusts, the nurse would place the thumb side of one fist against the client's abdomen in the midline slighlty above the umbilicus and well below the xiphoid process, grasping the fist with the other hand. Then the nurse would press the fist into the client's abdomen with a quick inward and upward thrust such that each new thrust should be a separate and distinct maneuver. The unconscious client is positioned on the back. The client who is conscious should be standing or sitting.

The nurse has received a client into care who was admitted with a heroin overdose. The client has a 5-year history of illicit substance use with cocaine, heroine and oxycodone. The client develops a sudden onset of wheezing, restlessness and a cough that produces a frothy, pink sputum. The nurse suspects the client has most likely developed which complication of opioid overdose? Pulmonary edema Pneumonia Congestive heart failure Panic attack

Correct response: Pulmonary edema Explanation: The nurse should suspect the client has developed pulmonary edema, which is frequently seen in clients who abuse/overdose on narcotics. Many drugs — ranging from illegal drugs such as heroin and cocaine to aspirin — are known to cause noncardiogenic pulmonary edema. Pneumonia is not the likely cause given the sudden onset of respiratory symptoms accompanied but coughing up the pink frothy sputum. The client's history of illicit substance use and now overdose on these drugs should lead the nurse to suspect pulmonary edema is the cause of the sudden onset of these symptoms over congestive heart failure, in which clients have a more gradual onset of respiratory issues. Although a panic attack can manifest in shortness or breath and restlessness, the client would not be wheezing or producing blood tinged sputum with a cough. Panic attacks do, however, have a sudden onset and can cause the client chest pain and a sense of doom.

A nurse is establishing a patient's airway. Which action would the nurse perform first? Giving abdominal thrusts Using the jaw-thrust maneuver Inserting an artificial airway Repositioning the patient's head

Correct response: Repositioning the patient's head Explanation: Establishing an airway may be as simple as repositioning the patient's head to prevent the tongue from obstructing the pharynx. Subsequent measures would include abdominal thrusts to dislodge a foreign body, head-tilt chin-lift or jaw-thrust manuever, or insertion of an artificial airway.

Permanent brain injury or death will occur within which time frame secondary to hypoxia? 1 to 2 minutes 3 to 5 minutes 6 to 8 minutes 9 to 10 minutes

Correct response: 3 to 5 minutes Explanation: If the airway is completely obstructed, permanent brain injury or death will occur within 3 to 5 minutes secondary to hypoxia. Air movement is absent in the presence of complete airway obstruction. Oxygen saturation of the blood decreases rapidly because obstruction of the airway prevents air from entering the lungs. Oxygen deficit occurs in the brain, resulting in unconsciousness, with death following rapidly. The other time frames are incorrect.

Which triage category refers to life-threatening or potentially life-threatening injury or illness requiring immediate treatment? Urgent Immediate Nonacute Emergent

Correct response: Emergent Explanation: The client triaged as emergent must be seen immediately. The triage category of urgent refers to minor illness or injury needing first-aid-level treatment. The triage category of immediate refers to nonacute, non-life-threatening injury or illness.

What is a common source of airway obstruction in an unconscious client? A foreign object Saliva or mucus The tongue Edema

Correct response: The tongue Explanation: In an unconscious client, the muscles controlling the tongue commonly relax, causing the tongue to obstruct the airway. When this situation occurs, the nurse should use the head-tilt, chin-lift maneuver to cause the tongue to fall back into place. If she suspects the client has a neck injury she must perform the jaw-thrust maneuver.

A nurse is providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate? Providing an analgesic for pain Massaging the feet Restricting ambulation Placing sterile cotton between the toes after rewarming

Correct response: Massaging the feet Explanation: For a client with frostbite, massaging the affected body part is contraindicated. Analgesia is given for pain during the rewarming process because it can be very painful. Ambulation would be restricted. Once rewarmed, sterile gauze or cotton is placed between the affected toes to prevent maceration.

A triage nurse in the ED determines that a patient with dyspnea and dehydration is not in a life-threatening situation. What triage category will the nurse choose? Delayed Emergent Immediate Urgent

Correct response: Urgent Explanation: A basic and widely used triage system that had been in use for many years utilized three categories: emergent, urgent, and nonurgent. In this system, emergent patients had the highest priority, urgent patients had serious health problems but not immediately life-threatening ones, and nonurgent patients had episodic illnesses

A client presents to the ED with serious health problems that are not immediately life threatening. The nurse will correctly triage the client into which category? Emergent Urgent Nonurgent Psychological support

Correct response: Urgent Explanation: Clients triaged as urgent have serious health problems that are not immediately life threatening. They must be seen within 1 hour. The emergent category is for clients who have the highest priority conditions that are life-threatening and they must be seen immediately. Nonurgent is for clients who have episodic illness that can be addressed within 24 hours without increased morbidity. Clients in the less urgent category must be reassessed at least every 60 minutes and do not have serious health problems.

Which category of triage encompasses clients with serious health problems that are not immediately life threatening? Emergent Urgent Nonurgent Psychological support

Correct response: Urgent Explanation: Urgent clients have serious health problems that not immediately life threatening. They must be seen within 1 hour. Emergent clients have the highest priority with life-threatening conditions and they must be seen immediately. Nonurgent clients have episodic illness that can be addressed within 24 hours without increased morbidity. Fast-track clients require simple first aid or basic primary care and may be treated in the ED or safely referred to a clinic or physician's office.

Following a motor vehicle collision, a client is brought to the ED for evaluation and treatment. The client is being assessed for intra-abdominal injuries. The client reports severe left shoulder pain (pain score of 10 on a 1 to 10 scale). The nurse suspects injury to the spleen. liver. gallbladder. large intestine.

Correct response: spleen. Explanation: The location of pain can indicate certain types of intra-abdominal injuries. Pain in the left shoulder is common in a client with bleeding from a ruptured spleen, whereas pain in the right shoulder can result from laceration of the liver.