Chapter 72 Emergency Nursing Prep U

The ED staff work collaboratively and follow the ABCDE method to establish and treat health priorities in a trauma patient effectively. Which of the following actions is completed by the nurse when implementing the "D" element of this method?

Assessing the patient's Glasgow Coma Scale 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 a motor and sensory evaluation of the spine. A quick neurologic assessment may be performed using the AVPU mnemonic: A, alert: is the patient alert and responsive? V, verbal: does the patient respond to verbal stimuli? P, pain: does the patient respond only to painful stimuli? U, unresponsive: is the patient unresponsive to all stimuli, including pain? The other interventions are not included in this element of the primary survey.

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? You Selected: Urgent

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.

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?

Jaw-thrust 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.

A family member brings a patient to the ED following an apparent oxycodone (OxyContin) overdose. The patient is experiencing severe respiratory depression. Which of the following medications will the nurse administer?

Naloxone hydrochloride (Narcan) Narcan, a narcotic antagonist, reverses respiratory depression and coma. Romazicon is a benzodiazepine antagonist. Valium is a benzodiazepine. Mucomyst is used for acetaminophen toxicity.

A nurse working in an emergency department is responsible for determining the severity of the patients' problems and how fast each needs to be seen. The nurse is implementing which of the following?

Triage The nurse is performing triage, which sorts patients into groups based on the severity of their health problems and the immediacy with which these problems need to be treated. Referral involves communicating with other health care delivery service providers to assist the patient with meeting his or her needs. Discharge planning involves actions to get the patient ready to leave the facility. Crisis intervention involves actions to alleviate the high level of stress and to promote effective coping with challenging life events.

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

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.

What is a common source of airway obstruction in an unconscious client?

The tongue 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 finger sweep is only to be used in which patient population?

Unconscious adult A finger sweep should be used only in the unconscious adult patient. This action draws the tongue away from the back of the throat and away from the foreign body that may be lodged there. A finger sweep should not be done on a conscious adult, child, or adolescent.

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?

Upside down and then rotated 180 degrees 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.

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?

Urgent 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.

Which category of triage encompasses patients with serious health problems that are not immediately life threatening?

Urgent Urgent patients have serous health problems that not immediately life threatening. They must be seen within 1 hour. Emergent patients have the highest priority with conditions are life threatening and they must be seen immediately. Nonurgent patients have episodic illness that can be addressed within 24 hours without increased morbidity. Fast track patients 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.

Permanent brain injury or death will occur within which time frame secondary to hypoxia? You Selected: 3 to 5 minutes

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.

Permanent brain injury or death will occur within which timeframe secondary to hypoxia?

3 to 5 minutes 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 entry of air into the lungs. Oxygen deficit occurs in the brain, resulting in unconsciousness, with death following rapidly. The other timeframes are incorrect.

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?

4% Oxygen is administered until the carboxyhemoglobin level is less than 5%.

A nurse is performing a primary survey on a patient. Place the following steps in the order in which the nurse would perform them

A primary survey follows the ABCD sequence: airway, breathing, circulation, and disability. First, the nurse establishes a patent airway by repositioning the head, using the head-tilt, chin-lift or jaw-thrust maneuver, or inserting an airway. Next, the nurse provides adequate ventilations and then evaluates and restores cardiac output, which includes assessing pulses. Lastly, the nurse determines neurologic disability by assessing neurologic function using the Glasgow Coma Scale.

After inserting an oropharyngeal airway, the nurse determines that it is in the proper position when the flange is located at which position?

Approximately at the patient's lips When an oropharyngeal airway is properly inserted, the tip is in the hypopharynx and the flange is approximately at the patient's lips.

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.

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. 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 patient working in a chemical facility sustains a chemical burn to his arms. The chemical involved was white phosphorus. Which of the following would be the priority nursing action?

Brushing off all traces of the chemical from the patient's skin For a chemical burn involving lye or white phosphorous, all evidence of the chemical should be brushed off the patient before any flushing occurs. These chemicals, if exposed to water, have the potential for exploding or for deepening the burn. Covering the burn area or applying ice is an inappropriate action.

A patient presents to the ED following a motor vehicle collision. The patient is suspected of having internal hemorrhage. The nurse assesses the patient for signs and symptoms of shock. Signs and symptoms of shock include which of the following? Select all that apply.

Cool, moist skin Decreasing blood pressure Increasing heart rate Delayed capillary refill 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.

A client is brought to the emergency department after being involved in a motor vehicle collision. Which of the following would lead the nurse to suspect internal bleeding?

Delayed capillary refill If a client exhibits tachycardia, falling blood pressure, thirst, apprehension, cool moist skin, or delayed capillary refill, internal bleeding should be suspected.

The nurse is conducting a secondary survey on a patient in the ED. Which of the following is completed during the secondary survey?

Diagnostic and laboratory testing During the secondary survey, diagnostic and laboratory testing is completed. The other interventions are completed during the primary survey.

Which of the following triage categories refers to life-threatening or potentially life-threatening injury or illness requiring immediate treatment?

Emergent The patient 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 non-acute, non-life threatening injury or illness.

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?

Hypovolemia 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?

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

Which of the following solutions should the nurse anticipate for fluid replacement in the male patient?

Lactated Ringer's solution Replacement fluids may include isotonic electrolyte solutions 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 patients. Hypertonic saline is used only to treat severe symptomatic hyponatremia and should be used only in intensive care units.

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? You Selected: 4%

Oxygen is administered until the carboxyhemoglobin level is less than 5%.

When preparing to perform abdominal thrusts on a client with an airway obstruction, which of the following would be most appropriate?

Positioning the hands in the midline slightly above the umbilicus 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.

A patient is hemorrhaging from an open wound on his leg. The nurse implements care using the following steps. Place them in the order in which the nurse would perform them. Use all options.

Provide firm direct pressure Apply a pressure dressing Elevate the leg Immobilize the leg When a patient is hemorrhaging from a leg wound, first the nurse would apply direct firm pressure to control the bleeding. Next, the nurse would apply a pressure dressing, and elevate the injured area to stop venous and capillary bleeding if possible. Then, the area is immobilized to control blood loss.

A nurse is establishing a patient's airway. Which action would the nurse perform first?

Repositioning the patient's head 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.

A patient is brought to the emergency department following an overdose of a selective serotonin reuptake inhibitor (SSRI). While assessing the patient, the nurse suspects that the patient may be developing serotonin syndrome based on which of the following?

Seizures Serotonin syndrome is manifested by agitation, seizures, hyperthermia, diaphoresis, and hypertension.

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. 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 client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later, the nurse identifies which finding as an early sign of shock? You Selected: Confusion

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). An above-normal heart rate is a late sign of shock. A urine output of 30 ml/hour is within normal limits.

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? You Selected: Jaw-thrust

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 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 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. You Selected: Delayed capillary refill Decreasing blood pressure Cool, moist skin Increasing heart rate

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.

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.

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.