lacharity chapter 21

The nurse is working in the triage area of an emergency department, and the following four clients approach the triage desk at the same time. List the order in which the nurse will assess these clients. 1. An ambulatory, dazed 25 year old man with a bandaged head wound. 2. An irritable newborn with a fever, petechiae, and nuchal rigidity. 3. A 35 year old jogger with a twisted ankle who has a pedal pulse and no deformity. 4. A 50 year old woman with moderate abdominal pain and occasional vomiting.

2, 1, 4, 3 Rationale: An irritable newborn with fever and petechiae should be further assessed for other signs of meningitis. The client with the head wound needs additional assessment bc of the risk for incr ICP. The client with moderate abd pain is in discomfort, but her condition is not unstable at this point. For the ankle injury, medical evaluation could be delayed for 24-48 hrs if necessary but the client should receive the appropriate first aid.

identify the 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 LOC 4. visually inspect for gross deformities, bleeding and obvious injuries 5. note the color, presence of moisture, and temperature of the skin 6. check VS, including pulse and respirations

2, 3, 4, 5, 6

The nurse responds to a call for help from the emergency department waiting room. An older adult client is lying on the floor. List the order in which the nurse must carry out the following actions: 1. Perform the chin lift or jaw thrust maneuver 2. Establish responsiveness 3. Initiate CPR 4. Call for help and activate the code team 5. Instruct UAP to get the crash cart

2, 4, 1, 3, 5 Rationale: 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. A pocket mask or bag-valve mask is used to deliver rescue breaths. 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 code team arrived.

A client presents to triage with fever, myalgia, severe headache, abd pain, vomiting, diarrhea, and unexplained bruising that started after returning from Africa. The triage nurse suspects, but is unsure, that the client may have Ebola. What should the nurse do first? 1. Delay any additional assessment or questioning and don full PPE. 2. Isolate the client in a private room and initiate standard, contact, and droplet precautions. 3. Direct all clients and staff out of the triage area and call the infection control department. 4. Continue assessment and questioning to determine the likelihood of exposure to Ebola.

2. Isolate the client in a private room and initiate standard, contact, and droplet precautions. Rationale: The pt can be taken out of isolation at any time if the HCP determines that the client does not have Ebola, but in the meantime, isolation precautions protect others. After the client is in isolation, the nurse's next actions are based on the activity of the client. If the client needs immediate assistance, the nurse would alert the HCP and charge nurse. Selected team members would don PPE, and care would be initiated. The infection control department would be notified ASAP so that system-wide measures can be activated as needed.

the nurse is caring for a client with frostbite to the fact. 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 to 115 degrees 5. monitor for compartment syndrome

3, 2, 4, 1, 5

a client involved in a one-car rollover comes in with multiple injuries. list in order or priority the interventions that must be initiated for this client. 1. secure 2 large bore IV lines and infuse NS 2. use the chin lift or jaw thrust manruver to open airway 3. assess for spontaneous respirations 4. give supplemental oxygen via mask 5. obtain a full set of VS 6. remove or cut away the client's clothing

3, 2, 4, 1, 5, 6

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.

3, 4, 2, 5, 1

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 EKG monitoring 2. Notify the ED HCP 3. Administer O2 via nasal cannula 4. Draw blood and establish IV access

3. Administer O2 via nasal cannula Rationale: The priority goal is to incr myocardial oxygenation. The other actions are also appropriate and should be done immediately after administering O2

The client's blood alcohol level is 0.45%. Based on this information, what is the priority nursing concept that underlies emergency medical and nursing interventions for this client? 1. Cognition 2. Addiction 3. Gas exchange 4. Functional ability

3. Gas exchange At a blood alcohol level of 0.45%, the client would demonstrate respiratory depression, stupor, and coma.

A healthy but anxious 24-year old college student reports tingling sensations, palpitations, and sore chest muscles. Deep, rapid breathing and carpal spasms are noted. What priority action should the nurse take? 1. Notify the HCP immediately 2. Administer supplemental O2 3. Have the student breathe into a paper bag 4. Obtain an order for an anxiolytic medication

3. Have the student breathe into a paper bag

When a primary survey of a trauma client is conducted, what is one of the priority actions that would be performed first? 1. Obtain a complete set of vital signs 2. Palpate and auscultate the abd 3. Perform a brief neurological assessment 4. Check the pulse oximetry reading

3. Perform a brief neurological assessment Rationale: Brief neurologic assessment to determine level of consciousness and pupil reaction and pupil reaction is part of the primary survey. Measuring vital signs, assessing the abd, checking pulse oximetry readings are considered part of the secondary survey

An ED clinical nurse specialist is training staff in how to don and doff PPE when caring for clients with infections, such as Ebola. Which staff member has demonstrated the most grievous error during the practice session? 1. Triage nurse forgets to perform hand hygiene before donning PPE. 2. UAP performs self-inspection; then begins to doff PPE 3. HCP forgets to wipe shoes with disinfectant after doffing shoe covers 4. Emergency med tech doffs both pairs of gloves first

4. Emergency med tech doffs both pairs of gloves first Rationale: All are errors, but removing both pairs of gloves puts the ET at most risk because the outer surfaces of the remaining PPE are considered contaminated.

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

4. Homeless person displays altered mental status, poor muscle coordination, and hot, dry, ashen skin; duration of heat exposure is unknown. Rationale: The homeless person has sx of heat stroke, a medical emergency that incr the risk for brain damage. The older adult client is at risk for heat syncope and should be educated to rest in a cool area and avoid future situations. The runner is having heat cramps, which can be managed with rest and fluids. The housewife is experiencing heat exhaustion, and management includes fluids and cooling measures.

according to the joint commission, hospitals are required to form emergency management committees to periodically exercise the disaster operations plan. hospital administration has selected various HCPs to join the committee. members from which other key departments should be included? select all that apply. 1. security and communications 2. nursing and unlicensed assistive personnel 3. laboratory and diagnostic services 4. medical and information technology 5. maintenance and engineering 6. physical therapy and occupational therapy

1, 2, 3, 4, 5

A client reports the emergency department with reports of nausea, vomiting, colicky abdominal pain, fever, and tachycardia. The healthcare provider informed the nurse that the client probably has a strangulated intestinal obstruction with perforation. What diagnostic testing and interventions does the nurse anticipate for this emergency condition? Select all that apply. 1. Preparation for surgery 2. Barium enema examination 3. Nasogastric tube insertion 4. Abdominal radiography 5. IV fluid administration 6. IV administration of broad spectrum antibiotics

1, 3, 4, 5, 6

the nurse is 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, with 1 being the first to receive attention and 6 being the last to receive attention.

1. 12 year old child 2. firefighter 3. teenager with crushed leg 4. 60 year old 5. 3 year old 6. 52 year old

Emergency medical services has transported a client with severe chest pain. As the client is being transferred to the emergency stretcher, the nurse notes 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

1. Performing chest compressions Rationale: UAPs are trained in basic cardiac life support and can perform chest compressions. The rest require training/experience/practice.

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?

Ambulatory or fast-track clinic

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?

An experienced RN and an inexperienced RN

When an unexpected death occurs in the ED, which task is most appropriate to delegate to the UAP?

Assisting with postmortem care

In the care of a client who has experienced sexual assault, which task is most appropriate for an LPN/LVN to perform?

Providing emotional support and supportive communication

a confused client admits to frequently drinking alcohol. the ED HCP makes a preliminary diagnosis or wernicke encephalopathy. which medication does the nurse anticipate that the HCP will prescribe initially?

Thiamine IV

the following clients come to the ED triage desk reporting acute abdominal pain. which client has the most severe condition?

a 23 year old woman reporting dizziness and severe left lower quadrant pain who states she is possibly pregnant

the nurse is caring for a client with multiple injuries sustained during a head-on car collision. which assessment finding takes priority?

a deviated trachea

the nurse is assigned to telephone triage. a client who was just stung by a common honeybee calls for advice. which question would the nurse ask first?

are you having any facial swelling, wheezing or shortness of breath?

the nurse is caring for a client who is on the cardiac monitor because of these symptoms: syncope, dizziness, and intermittent episodes of palpitations. below is a display of what the nurse sees on the cardiac monitor. what should the nurse do first?

assess the client and take VS

the nurse 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?

at least one person from all ED groups

after emergency endotracheal intubation, the health care team and the nurse must verify tube placement before securing the tube. what is the most accurate bedside assessment that can be performed immediately after the tube is placed?

check exhaled carbon dioxide levels with capnography

The LPN/LVN is performing care for a client who sustained an amputation of the first and second digits in a chainsaw accident. What instructions would the RN give to the lpn/lvn?

clean the amputated digits with saline, wrap in moist gauze, seal in a plastic bag, and place in ice slurry

a newly hired ED clinical nurse specialist is reviewing the hospital's disaster plan and finds that it has not been reviewed or revised for 3 years. which finding will be most important for CNS to address related to the status of the disaster plan?

current staff is unlikely to have training and practice in using the plan

a group of people arrive at the ED by private car. they all have extreme periorbital swelling, coughing 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?

direct clients to the decontamination area

The nurse is giving discharge instructions to a client who has been treated for contusions and bruises sustained during an episode of domestic violence. what is the priority intervention for this client?

encourage the client to go to a safe home

the nurse notifies the ED HCP 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 the nurse sees that the client is to be discharged with a follow-up appointment in the morning. what should the nurse do first?

express findings and concern to HCP

a young woman is brought to the ED by EMS. EMS reports they were called because the woman has been depressed and threatening to commit suicide. on arrival to the ED, the woman is confused. her speech is slurred and there is vomit on her clothes. EMS found several empty prescription bottles at the house. what are the priority interventions for this client?

initiate supportive care, such as checking airway and giving oxygen and IV fluids

The victim of heatstroke arrives in the ED. his skin is hot and dry. his body temperature is 105. he is confused and demonstrates bizarre behavior. his bp is 85/60, pulse 130, and respirations 40. which task should be assigned to an experienced LPN/LVN?

insert an indwelling urinary drainage catheter

in the work setting, what is the nurse's primary responsibility in preparing for management of disasters, including natural disasters and bioterrorism incidents?

knowing the agency's emergency response plan

tetanus immunizations are routinely administered during childhood and in the emergency department for clients who sustain wounds. although the incidence of tetanus has decreased, there is still a danger. which client represents the group that is most vulnerable for risks?

older adults who lives alone sustained a minor cut while cleaning the basement

the nurse is 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 PTSD, related to the incident?

person who was injured and trapped for several hours before rescue

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 concept to consider in planning interventions for this emergency situation?

safety

a newly graduated nurse overhears a senior emergency department nurse making a sarcastic remarks toward a medical student and refusing to help the student find the equipment for a nonemergent client procedure. what should the new nurse do first?

step in and offer to assist the medical student because the other nurse is unwilling

the nurse is 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. what is the priority concern?

treating infection specific to cat bites

the nurse and a group of friends are at the lake. suddenly someone says "look across the lake! it looks like someone might be drowning out there!" what is the nurses first action?

use a pair of binoculars and look across the lake