Lacharity Chapter 20: Emergencies & Disasters

You are caring for a client with multiple injuries sustained during a head-on car collision. Which assessment finding takes priority? 1. A deviated trachea 2. Unequal pupils 3. Ecchymosis in the flank area 4. Irregular apical pulse

Ans: 1 A deviated trachea is a symptom of tension pneumothorax, which will result in respiratory arrest if not corrected. All of the other symptoms need to be addressed, but are of lower priority. Focus: Prioritization

You are assessing a client who has sustained a cat bite to the left hand. The cat's immunizations are up to date. The date of the client's last tetanus shot is unknown. Which is the priority nursing diagnosis? 1. Risk for Infection related to organisms specific to cat bites 2. Impaired Skin Integrity related to puncture wounds 3. Ineffective Health Maintenance related to immunization status 4. Risk for Impaired Physical Mobility related to potential tendon damage

Ans: 1 Cats' mouths contain a virulent organism, Pasteurella multocida, that can lead to septic arthritis or bacteremia. Appropriate first aid would include rigorous washing of the wound site with soap and water to combat infection. There is also a risk for tendon damage due to deep puncture wounds, but this is usually evaluated by an orthopedic surgeon after initial emergency care is started. A tetanus shot can be given before discharge. Focus: Prioritization

You are giving discharge instructions to a woman who has been treated for contusions and bruises sustained during an episode of domestic violence. What is your priority intervention for this client? 1. Arrange transportation to a safe house. 2. Make a referral to a counselor. 3. Advise the client about contacting the police. 4. Make an appointment to follow up on the injuries.

Ans: 1 Safety is a priority for this client, and she should not return to a place where violence could recur. The other options are important for the long-term management of this case. Focus: Prioritization

A man, with a known history of alcohol abuse, has been in police custody for 48 hours. Initially, anxiety, sweating, and tremors were noted. Now, disorientation, hallucination, and hyperreactivity are observed. The medical diagnosis is delirium tremens. What is the priority nursing diagnosis? 1. Risk for Injury related to seizures 2. Risk for Other-Directed Violence related to hallucinations 3. Risk for Situational Low Self-Esteem related to police custody 4. Risk for Imbalanced Nutrition: Less than Body Requirements related to chronic alcohol abuse

Ans: 1 The client demonstrates neurologic hyperreactivity and is on the verge of a seizure. Client safety is the priority. The client needs medications such as chlordiazepoxide (Librium) to decrease neurologic irritability and phenytoin (Dilantin) for seizures. Thiamine and haloperidol (Haldol) may also be ordered to address the other problems. The other diagnoses are pertinent but less urgent. Focus: Prioritization

The emergency medical service team has transported a client with severe chest pain. As the client is being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and no palpable pulse. Which task is appropriate to delegate to the UAP? 1. Performing chest compressions 2. Initiating bag-valve mask ventilation 3. Assisting with oral intubation 4. Placing the defibrillator pads

Ans: 1 UAPs are trained in basic cardiac life support and can perform chest compressions. The use of the bag-valve mask requires practice, and usually a respiratory therapist will perform this function. The nurse or the respiratory therapist should provide assistance as needed during intubation. The defibrillator pads are clearly marked; however, placement should be done by the RN or physician because of the potential for skin damage and electrical arcing. Focus: Delegation

The LPN/LVN is performing care for a client who sustained an amputation of the first and second digits in a chainsaw accident. Which actions would require immediate intervention by the supervising RN? (Select all that apply.) 1. Gently cleansing the amputated digits and the hand with a povidone-iodine (Betadine)/normal saline solution 2. Cleansing the amputated digits and placing them directly into an ice slurry 3. Wrapping the cleansed digits in saline-moistened gauze, sealing them in a plastic bag, and placing them in an ice slurry 4. Cleansing the digits with sterile normal saline and placing them in a sterile cup with sterile normal saline 5. Placing the amputated digits in the correct anatomic position and then wrapping the hand and digits with sterile gauze.

Ans: 1, 2, 4, 5 The only correct intervention is to gently cleanse the digits with normal saline, wrap them in sterile gauze moistened with saline, and place them in a plastic bag or container. The container is then placed on ice. Focus: Supervision, knowledge

A client is admitted through the ED for treatment of a strangulated intestinal obstruction with perforation. What interventions do you anticipate for this emergency condition? (Select all that apply.) 1. Preparation for surgery 2. Barium enema examination 3. Nasogastric (NG) tube insertion 4. Abdominal radiography 5. IV fluid administration 6. IV administration of broad-spectrum antibiotics 7. Morphine via a client-controlled analgesia device

Ans: 1, 3, 4, 5, 6 Strangulated intestinal obstruction is a surgical emergency. The NG tube is for decompression of the intestine. Abdominal radiography is the most useful diagnostic aid. IV fluids are needed to maintain fluid and electrolyte balance and allow IV delivery of medication. IV broad-spectrum antibiotics are usually ordered. Pain medications are likely to be withheld during the initial period to prevent masking of peritonitis or perforation. In addition, morphine slows gastric motility. A barium enema examination is not ordered if perforation is suspected. Focus: Prioritization

A group of people arrive at the ED by private car reporting extreme periorbital swelling, cough, and tightness in the throat. There is a strong odor emanating from their clothes. They report exposure to a "gas bomb" that was set off in their house. What is the priority action? 1. Measure vital signs and listen to lung sounds. 2. Direct the clients to the decontamination area. 3. Instruct clients to don personal protective equipment. 4. Direct the clients to the cold or clean zone for immediate treatment.

Ans: 2 Decontamination in a specified area is the priority. Performing assessments delays decontamination and does not protect the total environment. These clients do not need to don personal protective equipment (PPE); however, personnel should don PPE before assisting with decontamination or assessing the clients. The clients must undergo decontamination before entering cold or clean areas. Focus: Prioritization

You notify the ED physician about a client who reports abdominal pain, nausea and vomiting, and fever. The abdomen is distended, rigid, and boardlike, and there is rebound tenderness. Later you see an order for discharge and a follow-up appointment in the morning. You reexamine the client and the symptoms seem worse. What should you do first? 1. Contact the nursing supervisor and express your concerns. 2. Express your findings and concerns to the physician. 3. Discharge the client, but stress the importance of follow-up. 4. Follow the physician's orders and write an incident report.

Ans: 2 First try to express your concerns to the physician. The ED can be very hectic, and the ED staff should work as a team and watch out for each other as well as the clients. If the physician refuses to consider your concerns, then you may have to contact the nursing supervisor or write an incident report. This client has the signs of peritonitis. If the client dies or suffers a poor outcome, you are as liable as the physician if you fail to intervene. Focus: Prioritization

You are assigned to telephone triage. A client who was just stung by a common honeybee calls for advice. The client reports pain and localized swelling but has no respiratory distress or other systemic signs of anaphylaxis. What is the first action that you should direct the caller to perform? 1. Call 911. 2. Remove the stinger by scraping. 3. Apply a cool compress. 4. Take an oral antihistamine.

Ans: 2 The stinger will continue to release venom into the skin, so prompt removal of the stinger is advised. Cool compresses and antihistamines can follow. The caller should be further advised about symptoms that require 911 assistance. Focus: Prioritization

You are working in the triage area of an ED, and the following four clients approach the triage desk at the same time. List the order in which you will assess these clients. 1. Ambulatory, dazed 25-year-old man with a bandaged head wound 2. Irritable infant with a fever, petechiae, and nuchal rigidity 3. 35-year-old jogger with a twisted ankle who has a pedal pulse and no deformity 4. 50-year-old woman with moderate abdominal pain and occasional vomiting _____, _____, _____, _____

Ans: 2, 1, 4, 3 An irritable infant with fever and petechiae should be further assessed for other signs of meningitis. The client with the head wound needs additional history taking and assessment for intracranial pressure. The client with moderate abdominal pain is in discomfort, but her condition is not unstable at this point. For the ankle injury, medical evaluation could be delayed up to 24 to 48 hours if necessary, but the client should receive the appropriate first aid. Focus: Prioritization

Identify the five most critical elements in performing disaster triage for multiple victims. 1. Obtain past medical and surgical histories. 2. Check airway, breathing, and circulation. 3. Assess the level of consciousness. 4. Visually inspect for gross deformities, bleeding, and obvious injuries. 5. Note color, presence of moisture, and temperature of the skin. 6. Obtain a history of allergies to food or medicine. 7. Check vital signs, including pulse and respirations. 8. Obtain a list of current medications. 9. Inquire about the last tetanus shot. _____, _____, _____, _____, _____

Ans: 2, 3, 4, 5, 7 These would be appropriate for disaster triage. The other items are important and would be addressed when the staff has time and resources to collect the additional information. (Note: During nondisaster situations, it would be appropriate to include all items.) Focus: Prioritization

You respond to a call for help from the ED waiting room. An elderly client is lying on the floor. List the order in which you must carry out the following actions. 1. Perform the chin lift or jaw thrust maneuver. 2. Establish unresponsiveness. 3. Initiate cardiopulmonary resuscitation (CPR). 4. Call for help and activate the code team. 5. Instruct a UAP to get the crash cart. _____, _____, _____, _____, _____

Ans: 2, 4, 1, 3, 5 Establish unresponsiveness first. (The client may have fallen and sustained a minor injury.) If the client is unresponsive, get help and activate the code team. Performing the chin lift or jaw thrust maneuver opens the airway. The nurse is then responsible for starting CPR. (Use a pocket mask or bag-valve mask.) CPR should not be interrupted until the client recovers or it is determined that all heroic efforts have been exhausted. A crash cart should be at the site when the code team arrives; however, basic CPR can be effectively performed until the team is present. Focus: Prioritization

When a primary survey of a trauma client is conducted, what is considered one of the priority actions? 1. Obtain a complete set of vital sign measurements. 2. Palpate and auscultate the abdomen. 3. Perform a brief neurologic assessment. 4. Check the pulse oximetry reading.

Ans: 3 A brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary survey. Measuring vital signs, assessing the abdomen, and checking pulse oximetry readings are considered part of the secondary survey. Focus: Prioritization

In the care of a client who has experienced sexual assault, which task is most appropriate for an LPN/LVN to perform? 1. Assessing immediate emotional state and physical injuries 2. Collecting hair samples, saliva specimens, and scrapings beneath fingernails 3. Providing emotional support and supportive communication 4. Ensuring that the chain of custody of evidence is maintained

Ans: 3 An LPN/LVN is able to listen and provide emotional support for clients. The other tasks are the responsibility of an RN or, if available, a sexual assault nurse examiner who has received training in assessing, collecting, and safeguarding evidence, and caring for assault victims. Focus: Delegation

When an unexpected death occurs in the ED, which task is most appropriate to delegate to the UAP? 1. Escorting the family to a place of privacy 2. Going with the organ donor specialist to talk to the family 3. Assisting with postmortem care 4. Helping the family to collect belongings

Ans: 3 Postmortem care requires some turning, cleaning, lifting, and so on, and the UAP is able to assist with these duties. The RN should take responsibility for the other tasks to help the family begin the grieving process. In cases of questionable death, belongings may be retained for evidence, so the chain of custody would have to be maintained. Focus: Delegation

An anxious 24-year-old college student reports tingling sensations, palpitations, and sore chest muscles. Deep, rapid breathing and carpal spasms are noted. What priority nursing action should you take? 1. Notify the physician immediately. 2. Administer supplemental oxygen. 3. Have the student breathe into a paper bag. 4. Obtain an order for an anxiolytic medication.

Ans: 3 The client is hyperventilating secondary to anxiety, and breathing into a paper bag will allow rebreathing of carbon dioxide. Also, encouraging slow breathing will help. Other treatments such as oxygen administration and medication may be needed if other causes are identified. Focus: Prioritization

An experienced traveling nurse has been assigned to work in the ED; however, this is the nurse's first week on the job. Which area of the ED is the most appropriate assignment for this nurse? 1. Trauma team 2. Triage 3. Ambulatory or fast-track clinic 4. Pediatric medicine team

Ans: 3 The fast-track clinic deals with clients in relatively stable condition. The triage, trauma, and pediatric medicine areas should be staffed with experienced nurses who know the hospital routines and policies and can rapidly locate equipment. Focus: Assignment

A 56-year-old client comes to the triage area with left-sided chest pain, diaphoresis, and dizziness. What is the priority action? 1. Initiate continuous electrocardiographic monitoring. 2. Notify the ED physician. 3. Administer oxygen via nasal cannula. 4. Establish IV access.

Ans: 3 The priority goal is to increase myocardial oxygenation. The other actions are also appropriate and should be performed immediately after administering oxygen. Focus: Prioritization

You are the charge nurse in an emergency department (ED) and must assign two staff members to cover the triage area. Which team is the most appropriate for this assignment? 1. An advanced practice nurse and an experienced LPN/LVN 2. An experienced LPN/LVN and an inexperienced RN 3. An experienced RN and an inexperienced RN 4. An experienced RN and an experienced UAP

Ans: 3 Triage requires at least one experienced RN. Pairing an experienced RN with an inexperienced RN provides opportunities for mentoring. Advanced practice nurses are qualified to perform triage; however, their services are usually required in other areas of the ED. An LPN/LVN is not qualified to perform the initial client assessment or decision making. Pairing an experienced RN with an experienced UAP is the second best option, because the UAP can measure vital signs and assist in transporting. Focus: Assignment

You are caring for a client with frostbite to the feet. Place the following interventions in the correct order. 1. Apply a loose, sterile, bulky dressing. 2. Give pain medication. 3. Remove the client from the cold environment. 4. Immerse the feet in warm water of 105° F to 115° F (40.6° C to 46.1° C). 5. Monitor for compartment syndrome. _____, _____, _____, _____, _____

Ans: 3, 2, 4, 1, 5 The client should be removed from the cold environment first, then the rewarming process can be initiated. It will be painful, so pain medication should be given before immersing the feet in warm water. A loose, sterile, bulky bandage should be applied to the area after warming to protect the feet. The client should be monitored for compartment syndrome every hour after initial treatment. Focus: Prioritization

A client involved in a one-car rollover comes in with multiple injuries. List in order of priority the interventions that must be initiated for this client. 1. Secure two large-bore IV lines and infuse normal saline. 2. Use the chin lift or jaw thrust maneuver to open the airway. 3. Assess for spontaneous respirations. 4. Give supplemental oxygen via mask. 5. Obtain a full set of vital sign measurements. 6. Remove the client's clothing. 7. Insert a Foley catheter if not contraindicated. _____, _____, _____, _____, _____, _____, _____

Ans: 3, 2, 4, 1, 5, 6, 7 For a trauma client with multiple injuries, many interventions will occur simultaneously as team members assist in the resuscitation. Assessing for spontaneous respirations, performing techniques to open the airway such as chin lift or jaw thrust, and applying oxygen may occur simultaneously. However, in the nursing process, recall that first you must assess, then you intervene. Opening the airway must precede the administration of oxygen because, if the airway is closed, the oxygen cannot enter the air passages. Starting IV lines for fluid resuscitation is part of supporting circulation. (Emergency medical service personnel will usually establish at least one IV line in the field.) UAPs can be directed to measure vital signs and remove clothing. Insertion of a Foley catheter is necessary for close monitoring of output. Focus: Prioritization

Emergency and ambulatory care nurses are among the first health care workers to encounter victims of a bioterrorist attack. List in order of priority the actions that should be taken by ED staff in the event of a biochemical incident. 1. Report to the public health department or CDC per protocol. 2. Decontaminate the affected individuals in a separate area. 3. Protect the environment for the safety of personnel and nonaffected clients. 4. Don personal protective equipment. 5. Perform triage according to protocol. _____, _____, _____, _____, _____

Ans: 3, 4, 2, 5, 1 The first priority is to protect personnel, unaffected clients, bystanders, and the facility. Personal protective gear should be donned before victims are assessed or treated. Decontamination of victims in a separate area is followed by triage and treatment. The incident should be reported according to protocol as information about the number of people involved, history, and signs and symptoms becomes available. Focus: Prioritization

You are talking to a group of people about an industrial explosion in which many people were killed or injured. Which individual has the greatest risk for psychiatric difficulties, such as post-traumatic stress disorder, related to the incident? 1. Individual who repeatedly watched television coverage of the event 2. Person who recently learned that her son was killed in the incident 3. Individual who witnessed the death of a co-worker during the explosion 4. Person who was injured and trapped for several hours before rescue

Ans: 4 Any of these people may need or benefit from psychiatric counseling. Obviously, there will be variations in previous coping skills and support systems; however, a person who experienced a threat to his or her own life is at the greatest risk for psychiatric problems following a disaster incident. Focus: Prioritization

The nursing manager decides to form a committee to address the issue of violence against ED personnel. Which combination of employees would be best suited to fulfill this assignment? 1. ED physicians and charge nurses 2. Experienced RNs and experienced paramedics 3. RNs, LPNs/LVNs, and UAPs 4. At least one representative from each group of ED personnel

Ans: 4 At least one representative from each group should be included, because all employees are potential targets for violence in the ED. Focus: Assignment

An intoxicated client comes in with slurred speech, mild confusion, and uncooperative behavior. The client cannot provide a good history but admits to "drinking a few on the weekend." What is the priority nursing action for this client? 1. Obtain an order for determining blood alcohol level. 2. Contact the family to obtain additional history and baseline information. 3. Administer naloxone (Narcan) 2 to 4 mg as ordered. 4. Administer IV fluid with supplemental thiamine as ordered.

Ans: 4 The client has symptoms of alcohol abuse and there is a risk for Wernicke-Korsakoff syndrome, which is caused by a thiamine deficiency. Multiple drug abuse is not uncommon; however, the primary concern with an opiate overdose is respiratory depression, and the client does not show any respiratory distress or alterations in respiratory pattern. Additional information or the results of the blood alcohol testing are part of the total treatment plan but should not delay the immediate treatment. Focus: Prioritization

It is the summer season, and clients with signs and symptoms of heat-related illness come to the ED. Which client needs attention first? 1. Elderly person with reports of dizziness and syncope after standing in the sun for several hours to view a parade 2. Marathon runner who reports severe leg cramps and nausea, and shows tachycardia, diaphoresis, pallor, and weakness 3. Relatively healthy homemaker who reports that the air conditioner has been broken for days and who manifests tachypnea, hypotension, fatigue, and profuse diaphoresis 4. Homeless person with altered mental status, poor muscle coordination, and hot, dry, ashen skin; and whose duration of heat exposure is unknown

Ans: 4 The homeless person has symptoms of heat stroke, a medical emergency that increases the risk for brain damage. The elderly client is at risk for heat syncope and should be educated to rest in a cool area and avoid future similar situations. The runner is having heat cramps, which can be managed with rest and fluids. The housewife is experiencing heat exhaustion, and management includes administration of fluids (IV or oral) and cooling measures. Focus: Prioritization

The following clients come to the ED reporting acute abdominal pain. Prioritize them for care in order of the severity of their conditions. 1. 35-year-old man reporting severe intermittent cramps with three episodes of watery diarrhea 2 hours after eating 2. 11-year-old boy with a low-grade fever, right lower quadrant tenderness, nausea, and anorexia for the past 2 days 3. 40-year-old woman with moderate right upper quadrant pain who has vomited small amounts of yellow bile and whose symptoms have worsened over the past week 4. 65-year-old man with a pulsating abdominal mass and sudden onset of "tearing" pain in the abdomen and flank within the past hour 5. 23-year-old woman reporting dizziness and severe left lower quadrant pain who states she is possibly pregnant 6. 50-year-old woman who reports gnawing midepigastric pain that is worse between meals and during the night _____, _____, _____, _____, _____, _____

Ans: 4, 5, 2, 3, 1, 6 The client with a pulsating mass has an abdominal aneurysm that may rupture, and he may decompensate suddenly. The woman with lower left quadrant pain is at risk for ectopic pregnancy, which is a life-threatening condition. The 11-year-old boy needs evaluation to rule out appendicitis. The woman with vomiting needs evaluation for gallbladder problems, which appear to be worsening. The 35-year-old man has food poisoning, which is usually self-limiting. The woman with midepigastric pain may have an ulcer, but follow-up diagnostic testing and teaching of lifestyle modification can be scheduled with the primary care provider. Focus: Prioritization

After emergency endotracheal intubation, you must verify tube placement and secure the tube. List in order the steps that are required to perform this function. 1. Obtain an order for a chest radiograph to document tube placement. 2. Secure the tube in place. 3. Auscultate the chest during assisted ventilation. 4. Confirm that the breath sounds are equal and bilateral. 5. Check exhaled carbon dioxide levels. _____, _____, _____, _____, _____

Ans: 5, 3, 4, 2, 1 Checking exhaled carbon dioxide levels is the most accurate way of immediately verifying placement. Auscultating and confirming equal bilateral breath sounds should be performed in rapid succession. If the sounds are not equal or if the sounds are heard over the midepigastric area, tube placement must be corrected immediately. Securing the tube can be performed after these assessments are performed. Finally, radiographic study will verify and document correct placement. Focus: Prioritization

You are working in a small rural community hospital. There is a fire in a local church, and six injured clients have arrived at the hospital. Many others are expected to arrive soon, and other hospitals are 5 hours away. Using disaster triage principles, place the following six clients in the order in which they should receive medical attention. 1. 52-year-old man in full cardiac arrest who has been receiving CPR continuously for the past 60 minutes 2. Firefighter who is showing combative behavior and has respiratory stridor 3. 60-year-old woman with full-thickness burns to the hands and forearms 4. Teenager with a crushed leg that is very swollen who is anxious and has tachycardia 5. 3-year-old child with respiratory distress and burns over more than 70% of the anterior body 6. 12-year-old with wheezing and very labored respirations unrelieved by an asthma inhaler _____, _____, _____, _____, _____, _____

Ans: 6, 2, 4, 3, 5, 1 Treat the 12-year-old with asthma first by initiating an albuterol treatment. This action is quick to initiate, and the child or parent can be instructed to hold the apparatus while you attend to other clients. The firefighter is in greater respiratory distress than the 12-year-old; however, managing a strong combative client is difficult and time consuming (i.e., the 12-year-old could die if you spend too much time trying to control the firefighter). Attend to the teenager with a crush injury next. Anxiety and tachycardia may be caused by pain or stress; however, the swelling suggests hemorrhage. Next attend to the woman with burns on the forearms by providing dressings and pain management. The child with burns over more than 70% of the anterior body should be given comfort measures; however, the prognosis is very poor. The prognosis for the client in cardiac arrest is also very poor, because CPR efforts have been prolonged. Focus: Prioritization

In the work setting, what is your primary responsibility in preparing for management of disasters, including natural disasters and bioterrorism incidents? 1. Knowing the agency's emergency response plan 2. Being aware of the signs and symptoms of potential agents of bioterrorism 3. Knowing how and what to report to the Centers for Disease Control and Prevention (CDC) 4. Making ethical decisions about exposing self to potentially lethal substances

1. gives guidance that includes the roles of team members, responsibilities, and mechanisms of reporting. Signs and symptoms of exposure to many agents will mimic common complaints, such as flulike symptoms. Discussions with colleagues and supervisors may help the individual nurse to sort through ethical dilemmas related to potential danger to self. Focus: Prioritization