Unit 1: Emergency and Trauma Nursing, Common Environmental Emergencies, Emergency and Disaster Preparedness, Critically Ill Patients with Respiratory Problems

A client is ordered heparin 5000 units at 7 AM. The heparin is provided in a vial labeled 20,000 units per mL. How much does the nurse administer? ______ mL

ANS: 0.25 5000 units/20,000 units × 1 mL = 0.25 mL

A nurse is making initial rounds on assigned clients at the beginning of the shift. One client is receiving a heparin infusion at 5 mL/hr. The nurse notes that 25,000 units of heparin are mixed in 250 mL of solution. How many units per hour is the client receiving? __________ units/hr

ANS: 500 25,000 units/250 mL = X units/hr/(5 mL/hr) 250X = 125,000 X = 500 units/hr

The nurse is assessing clients on site at a multi-vehicle accident. Triage clients in the order they should receive care. (Place in order of priority.) a. A 50-year-old with chest trauma and difficulty breathing b. A mother frantically looking for her 6-year-old son c. An 8-year-old with a broken leg in his father's arms d. A 60-year-old with facial lacerations and confusion e. A pulseless male with a penetrating head wound

ANS: a, d, b, c, e Clients should be prioritized with ABCs and emergent, urgent, and nonurgent status. The client with chest trauma and difficulty breathing is the priority because no clients have an airway problem, and this is the only client with a breathing problem. The client with confusion should be seen next. Confusion can be caused by lack of oxygen to the brain due to a circulation problem. The pulseless client with a penetrating head wound is seen last because there are multiple clients to be seen, and care for this client would be futile. The client with a broken leg is nonurgent and can wait. The mother looking for her son should be seen third. Finding the child is urgent to identify potential injuries.

In what sequence would a client move through the process of admission to disposition in emergency care? (Place in order of priority.) a. Client is transported to the medical-surgical floor. b. Emergency department (ED) nurse gives a report on the client. c. Paramedics arrive and start IV access. d. Nurse and other health care provider(s) perform assessment. e. Emergency medical technicians (EMTs) provide oxygen and vital sign monitoring. f. Laboratory technician obtains blood specimens.

ANS: e, c, d, f, b, a When clients are in an emergency situation, EMTs arrive on the scene first. EMTs apply oxygen and obtain vital signs to determine a baseline for further care. EMTs can provide basic life support measures and can assess ABCs. Second on the scene are paramedics. Starting IV access and performing advanced life support is within the paramedic's scope of practice. The client is then transported to an ED, where nurses and other health care providers perform an initial assessment. Laboratory technicians are notified and appropriate blood specimens are obtained for diagnostic testing. When the client is stable, the ED nurse gives report to the medical-surgical unit nurse, and the client is finally transferred to an inpatient room.

It is determined that a client has a large pulmonary embolism (PE). Fibrinolytic therapy is initiated. What is the nurse's priority action? a. Monitor the client's oxygenation. b. Teach the client about potential side effects. c. Monitor the IV insertion site. d. Monitor for bleeding.

ANS: A Airway and breathing are the top priority. The nurse would also need to monitor for bleeding when administering fibrinolytic therapy, and would monitor the IV site as well. Teaching the client is also a need, however. Oxygenation is the highest priority.

The nurse is teaching a wilderness survival class. Which statement by a participant indicates that additional teaching is needed? a. "If I get too cold, I can have some brandy to help me get warmed up." b. "My climbing partner should let me know right away if my nose turns white." c. "If my partner can't think straight, we should descend to a lower altitude." d. "It is okay to feel a little short of breath when I am climbing, but not at rest."

ANS: A Alcohol will increase the risk of cold-related injuries and should be avoided. The other options all show good understanding of the education.

The nurse is working with a paramedic who just finished assisting at the scene of a school shooting where several students were killed. Which statement by the nurse is most therapeutic? a. "Would you like to talk about what happened?" b. "Surely the department will give you the day off tomorrow." c. "At least the gunman was taken into custody." d. "Let's just sit here for a while quietly."

ANS: A Allowing staff members to ventilate their feelings about the incident can facilitate recovery and effective coping afterward. The other choices do not facilitate open communication because the nurse is not providing the opportunity for the paramedic to talk.

The nurse is caring for a client who had a near-drowning incident in a lake. Which action will the nurse take to monitor for possible complications? a. Assess the client's temperature every 4 hours. b. Check the client's blood glucose level before meals. c. Assess the client's bowel sounds three times daily. d. Check the client's skin for petechiae daily.

ANS: A Chemicals, algae, microbes, sand, and mud found in lake water put the client at risk for developing a lung infection. The client's temperature should be assessed every 4 hours. A near-drowning victim will not be at risk for glucose or bowel complications. Assessing for petechiae is not necessary

The nurse working at a first aid booth during a summer marathon sees several runners. Which runner should be seen first? A runner who: a. Has fallen several times b. Is fatigued c. Thinks he has the flu d. Has tachypnea

ANS: A Hot, dry skin, tachycardia, tachypnea, and hypotension are signs of heat stroke. A marathon runner who has fallen several times may have a thermal injury to the brain, causing loss of coordination. Mental status changes from thermal injury to the brain include confusion, bizarre behavior, seizures, and even coma. The nurse should prioritize the client with potential thermal brain injury over the other clients.

While on a camping trip, the nurse provides care for a camper who was bitten by a black widow spider. What is the priority action of the nurse? a. Apply ice to the site of the bite. b. Apply a loose tourniquet to the limb. c. Give acetaminophen (Tylenol) for pain. d. Cover the camper with a warm blanket.

ANS: A Ice inhibits the action of neurotoxin and should be the first intervention provided to a client bitten by a black widow spider. A tourniquet should not be used because it impairs arterial blood flow. Tylenol and covering the camper do not treat the neurotoxic effect of the black widow spider's bite.

Carlos, RN is caring for an intubated patient with an endotracheal tube and on a mechanical ventilator. The client is able to make sounds. What is the nurse's first action? a. Check cuff inflation on the endotracheal tube. b. Listen carefully to the client. c. Call the health care provider. d. Auscultate the lungs.

ANS: A If the client has the cuff on the endotracheal tube inflated, the cuff should prevent air from going around the cuff and through the vocal cords. If the client can talk with the cuff inflated, the cuff probably has a leak, causing it to become deflated and allowing air to pass through. The risk is that the client will not receive the prescribed tidal volume.

The nurse is caring for a client who is receiving mechanical ventilation accompanied by positive end-expiratory pressure (PEEP). What assessment findings require immediate intervention? a. Blood pressure drop from 110/90 mm Hg to 80/50 mm/Hg b. Pulse oximetry value of 96% c. Arterial blood gas (ABG): pH, 7.40; PaO2, 80 mm Hg; PaCO2, 45 mm Hg; HCO3-, 26 mEq/L d. Urinary output of 30 mL/hr

ANS: A Increased intrathoracic pressure can inhibit blood return to the heart and cause decreased cardiac output. This manifests with a drop in blood pressure. The pulse oximetry reading, ABGs, and urinary output are all normal.

A hospital has "stood down" from a mass casualty disaster. The staff have rested and eaten. Which action by the nursing supervisor takes priority? a. Restocking the emergency department (ED) b. Making rounds on each unit to check staffing c. Determining which staff can go home d. Planning a critical incident stress debriefing

ANS: A Inventorying and stocking the ED are high-priority actions because the usual flow of emergency clients may not be lessened in the wake of a disaster. Supplies may be low or exhausted, and it would be vital to resupply the area. Rounding on inpatient units, determining the staff who can be relieved, and planning a debriefing are certainly important items, but they do not take priority over getting the ED ready for more clients.

A client presents to the emergency department after prolonged exposure to the cold. The client is shivering, has slurred speech, and is slow to respond to questions. Which treatment will the nurse prepare for this client? a. Dry clothing and warm blankets b. Administration of warmed IV fluids c. Peritoneal lavage with warmed normal saline d. Continuous arteriovenous rewarming

ANS: A Mild hypothermia is manifested by shivering, slurred speech, poor muscular coordination, and impaired cognitive abilities. Mild hypothermia may be treated with dry clothing and warm blankets. Rewarming should occur slowly by removing wet clothing and providing dry warm blankets first. Other treatments are secondary and should be used to treat moderate to severe hypothermia.

A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention by the nurse is most beneficial? a. Offer the family choices as appropriate and possible. b. Call the hospital chaplain to stay with the family. c. Do not allow visiting of the victims until the bodies are prepared. d. Provide privacy for law enforcement to interview the family.

ANS: A Offering choices when appropriate and when possible gives some personal control back to individuals. The family may or may not want the assistance of religious personnel; the nurse should assess for this before calling anyone. Visiting procedures should take into account the needs of the family. The family may appreciate privacy, but this is not as helpful as allowing choices when the family is able to make them.

The nurse is triaging clients in the emergency department (ED). Which is true about the presentation of client symptoms? a. Older adults frequently have symptoms that are vague or less specific. b. Young adults present with nonspecific symptoms for serious illnesses. c. Diagnosing children's symptoms often keeps them in the ED longer. d. Symptoms of confusion always represent neurologic disorders.

ANS: A Older adults present with symptoms that often are different or less specific than those of younger adults. For example, increasing weakness, fatigue, and confusion may be the only admission concerns. These vague symptoms can be caused by serious illness, such as an acute myocardial infarction (MI), urinary tract infection, or pneumonia. Diagnosing older adults often keeps them in the ED for extended periods of time

The nurse is teaching a community health class about water safety. Which statement by a participant indicates that additional teaching is needed? a. "I can go swimming all by myself because I am a certified lifeguard." b. "I cannot leave my toddler alone in the bathtub for even a minute." c. "I will appoint one adult to supervise the pool at all times during a party." d. "I will make sure that there is a phone near my pool in case of an emergency."

ANS: A People should never swim alone, regardless of lifeguard status. The other statements indicate good understanding of the teaching.

A client admitted with respiratory difficulty and decreased oxygen saturation keeps pulling off the oxygen mask. What action does the nurse take? a. Stays with the client and replaces the oxygen mask b. Asks the client's spouse to hold the oxygen mask in place c. Restrains the client per facility policy d. Contacts the health care provider and requests sedation

ANS: A Restlessness and confusion are clinical manifestations of hypoxemia. It is important that the nurse stay with the client, ensure that the oxygen is maintained, and attempt to calm the client. Because of the client's restlessness, the nurse cannot delegate care to the spouse. Requesting a sedative might adversely affect the client's respiratory status further. Restraining the client could increase restlessness and increase oxygen demand.

The hospital administration has arranged for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation? a. "You are free to express your feelings; whatever is said here stays here." b. "Let's determine what we can do better the next time we have this situation." c. "This session is only for nursing and medical staff, not for ancillary personnel." d. "Let's pass around the written policy compliance form for everyone."

ANS: A Strict confidentiality during stress debriefing is essential so that staff members can feel comfortable sharing their feelings, which should be accepted unconditionally. Brainstorming improvements and discussing policies would occur during an administrative review. Any employee present during a mass casualty situation is eligible for critical incident stress management services.

A client has been injured in a stabbing incident. Assessment reveals the following: Blood pressure: 80/60 mm Hg Heart rate: 140 beats/min Respiratory rate: 35 breaths/min Bleeding from stabbing wound site Client is lethargic Based on these assessment data, to which trauma center should the nurse ensure transport of the client? a. Level I b. Level II c. Level III d. Level IV

ANS: A The Level I trauma center is able to provide a full continuum of care for all client areas. Level II can provide care to most injured clients, but given the extent of his injuries, a Level I center would be better if it is available. Both Levels III and IV can stabilize major injuries, but transport to a higher-level center is preferred, when possible.

A nurse wants to become involved in community disaster preparedness and is interested in helping set up and staff first aid stations or community acute care centers in the event of a disaster. Which organization is the best fit for this nurse's interests? a. The Medical Reserve Corps b. The National Guard c. The Health Department d. A Disaster Medical Assistance Team

ANS: A The Medical Reserve Corps (MRC) consists of volunteer medical and public health care professionals who support the community during times of need. They may help staff hospitals, establish first aid stations or special needs shelters, or set up acute care centers in the community. The National Guard often performs search and rescue operations and law enforcement. The Health Department focuses on communicable disease tracking, treatment, and prevention. A Disaster Medical Assistance Team is deployed to a disaster area for up to 72 hours, providing many types of relief services.

An accident has occurred near the hospital, and a victim is brought to the emergency department with severe chest pain, a pulse of 120 beats/min, blood pressure of 100/60 mm Hg, and a respiratory rate of 28 breaths/min. The nurse assesses shortness of breath and diaphoresis. Which color tag does the nurse use when triaging this client? a. Red b. Yellow c. Green d. Black

ANS: A The client in the emergent triage category has a condition that may post an immediate threat to life or limb and is given the highest priority. Clients who should be treated emergently receive a red tag. Yellow tags signify major but stable injuries that can wait 30 minutes to 2 hours for definitive care. Green tags designate "walking wounded" who can wait longer than 2 hours to receive care. Black tags are used to designate those who are dead or who are expected to die.

What is the best way for the nurse to communicate with a client who is intubated and is receiving mechanical ventilation? a. Ask the client to point to words on a board. b. Ask the client to blink for "yes" and "no." c. Have the client mouth words slowly. d. Teach the client some simple sign language.

ANS: A The nurse should have the client point to words on a board to communicate needs. The endotracheal tube is positioned and placement is maintained with tape or some other type of appliance. Asking the client to move his or her mouth and lips could result in possible extubation. Communication is limited and could be misunderstood with blinking. Teaching the client sign language, even simple, would be an involved and unrealistic goal.

A hospital is receiving large numbers of casualties from a disaster. Which clients does the supervisor identify as appropriate for discharge or transfer to another facility? (Select all that apply.) a. Client who had open reduction and internal fixation of a femur fracture 3 days ago b. Client who had a colostomy 4 days ago and whose daughter is a registered nurse c. Client admitted last night with community-acquired pneumonia d. Infant admitted 2 days ago for fever of unknown origin e. Client in the medical decision unit for evaluation of chest pain

ANS: A, B The client with the femur fracture could be transferred to a rehabilitation facility and the RN could provide care and teaching to her father. The newly admitted client with pneumonia would not be a good choice because culture results are not yet available and antibiotics have not been administered long enough. Also, the infant has not been in the hospital long enough for cultures to return for a definitive diagnosis. The client in the medical decision unit should be identified for dismissal if diagnostic testing reveals a noncardiac source of chest pain.

A client admitted for difficulty breathing becomes worse. Which assessment findings indicate that the client has developed acute respiratory distress syndrome (ARDS)? (Select all that apply.) a. Oxygen administered at 100%, PaO2 60 b. Increased dyspnea c. Anxiety d. Chest pain e. Pitting pedal edema f. Clubbing of fingertips

ANS: A, B, C A client who is developing ARDS presents with a decrease in oxygen despite an increase in the fraction of inspired oxygen. Increased dyspnea goes along with the increased hypoxemia, as does anxiety. Chest pain is not specific to ARDS; although chest pain can occur with ARDS, it occurs with many other conditions as well. Pitting edema would not be an assessment factor that confirms ARDS. Clubbing occurs in chronic, not acute, respiratory conditions.

A wing of a hospital is on fire. Which actions by the nurse promote safe evacuation of clients? (Select all that apply.) a. Direct ambulatory clients on where to go to be safe. b. Use ambulatory clients to help push clients in wheelchairs. c. Use oxygen tanks for all clients who are on oxygen. d. Manually ventilate clients who are on ventilators. e. Move bedridden clients in their beds if possible.

ANS: A, B, D, E Ambulatory clients can evacuate themselves with direction or could be used to help push wheelchair-bound clients. Clients on ventilators need to be removed from the ventilator and "bagged" until evacuated, then they can be put back on the ventilator if one is available. Bedridden clients should be moved in their beds or on stretchers, or carried if needed. Any client who can breathe without oxygen should have it removed for the evacuation because oxygen is an accelerant.

The nurse is discharging an older adult client home from the emergency department (ED) after an acute episode of angina. What should the nurse do to ensure client safety upon discharge? (Select all that apply.) a. Reconcile the client's prescription and over-the-counter medications b. Screen the client for functional and cognitive abilities, as well as risk for falls c. Consult physical therapy to organize for home health services d. Arrange for the client's car keys to be taken to prevent an accident e. Review discharge instructions with the client and a family member

ANS: A, B, E Before discharge, the nurse should ensure that the client's prescription and over-the-counter medications are evaluated to determine whether the drug regimen should be continued. Discharge education should be provided to the client and a significant other or family member. To prevent future ED visits, screen older adults per agency policy for functional assessment, cognitive assessment, and risk for falls. Case management should be consulted to organize home health services. The nurse should emphasize safety when driving but cannot organize to take the client's keys away.

The emergency department (ED) nurse is preparing to transfer a client to the critical care unit. What information should the nurse include in the nurse-to-nurse hand-off report? (Select all that apply.) a. Allergies b. Vital signs c. Immunizations d. Marital status e. Isolation precautions

ANS: A, B, E Hand-off communication should be comprehensive so that the nurse can continue care for the client fluidly. Communication should be concise and should include only the most essential information for a safe transition in care. Hand-off communication should include the client's situation (reason for being in the ED), brief medical history, assessment and diagnostic findings, transmission-based precautions needed, interventions provided, and response to those interventions.

An emergency department nurse moves to a new city, where heat-related illnesses are common. Which clients should the nurse anticipate as at higher risk for heat-related illness? (Select all that apply.) a. Homeless individuals b. Illicit drug users c. Whites d. Hockey players e. Older adults

ANS: A, B, E Some of the most vulnerable, at-risk populations for heat-related illness include older adults; blacks (more than whites); people who work outside, such as construction and agricultural workers (more men than women); homeless people; illicit drug users (especially cocaine users); outdoor athletes (recreational and professional); and members of the military who are stationed in countries with hot climates (e.g., Iraq, Afghanistan).

The triage nurse is assessing a client who has been brought to the emergency department (ED) by emergency medical services (EMS) following a mass casualty incident. Which assessment questions are used to determine the appropriate triage category for the client? (Select all that apply.) a. "Can you wiggle your toes?" b. "Are you having any difficulty breathing?" c. "Are you allergic to any medications?" d. "Does your family know that you are here?" e. "Can you tell me what day it is?" f. "Do you have any abdominal or back pain?"

ANS: A, B, E, F The triage nurse should assess for possible spinal cord injury, shortness of breath, abdominal or back pain, and disorientation when the client is brought to the ED. Determining allergies, although important, does not assist in categorizing clients, nor does inquiring about the client's family.

Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies clients with which injuries with yellow tags? (Select all that apply.) a. Partial-thickness burns covering both legs b. Open fractures of both legs with absent pedal pulses c. Neck injury and numbness of both legs d. Small pieces of shrapnel embedded in both eyes e. Head injury and difficult to arouse f. Bruising and pain in the right lower abdomen

ANS: A, C, D, F Clients with burns, spine injuries, eye injuries, and stable abdominal injuries should be treated within 30 minutes to 2 hours, and therefore should be identified with yellow tags. The client with the open fracture and the client with the head injury would be classified as urgent with red tags.

Which interventions will be performed during the primary survey for a trauma client? (Select all that apply.) a. Removing wet clothing b. Splinting open fractures c. Initiating IV fluids d. Endotracheal intubation e. Foley catheterization f. Needle decompression g. Laceration repair

ANS: A, C, D, F The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic ABC, with an added D and E: A, airway and cervical spine control; B, breathing; C, circulation; D, disability; and E, exposure. After completion of primary diagnostic studies and laboratory studies, and insertion of gastric and urinary tubes, the secondary survey, a complete head-to-toe assessment, can be carried out.

The nurse is providing health education at a community center. Which instructions should the nurse include in teaching about prevention of lightning injuries during a storm? (Select all that apply.) a. Seek shelter inside a building or vehicle. b. Seek shelter under a tall tree. c. Do not take a bath or shower. d. Turn off the television. e. Remove body piercings. f. Put down golf clubs or gardening tools.

ANS: A, C, D, F When you hear thunder, seek shelter in a safe area such as a building or an enclosed vehicle. Electrical equipment such as TVs and stereos should be turned off. Stay away from plumbing and water, and metal objects. Do not stand under an isolated tall tree or a structure such as a flagpole. Body piercings will not increase a person's chances of being struck by lightning.

The nurse is caring for a client on a ventilator when the high-pressure alarm sounds. What actions are most appropriate? (Select all that apply.) a. Assess the tubing for kinks. b. Assess whether the tubing has become disconnected. c. Determine the need for suctioning. d. Call the health care provider. e. Call the Rapid Response Team. f. Auscultate the client's lungs.

ANS: A, C, F Reasons for a high-pressure alarm include water or a kink impeding airflow or mucus in the airway. The nurse first should assess the client and determine whether he or she needs to be suctioned; then the nurse should auscultate the lungs. The nurse also should assess the tubing for kinks. The high-pressure alarm sounding would not be a reason to call the health care provider or the Rapid Response Team. If the tubing became disconnected, the low-pressure alarm would sound.

The nurse is caring for a client with a high risk for pulmonary embolism (PE). Which prevention measures does the nurse add to the client's care plan? (Select all that apply.) a. Use antiembolism stockings. b. Massage calf muscles per client request. c. Maintain supine position with the legs flat. d. Turn every 2 hours if client is in bed. e. Refrain from active range-of-motion exercises.

ANS: A, D Both antiembolism stockings (or sequential pressure devices) and a turning schedule can help prevent venous thromboembolism, which can lead to PE. Massaging the calves is discouraged because this can cause a clot to break loose and travel to the lungs. Legs should be elevated when in bed, and the client should perform active range of motion (ROM) if able. If the client is unable to perform active ROM, the nurse should provide passive ROM.

The nurse working with survivors of a disaster wants to assess them for post-traumatic stress disorder. For which clients does the nurse perform further assessment before administering the Impact of Event Scale-Revised? (Select all that apply.) a. Older adult survivor with minor injuries b. Woman who lost both her children c. Middle-aged victim with multiple medical problems d. Young adult who had serious orthopedic injuries e. Older adolescent who had a traumatic brain injury

ANS: A, E The Impact of Event Scale-Revised tool should not be used with people who have short-term memory loss, so the nurse should assess the older adult survivor and the client with the brain injury for this problem before administering the tool. The other clients do not have medical issues that would preclude use of this tool.

The ED nurse is caring for the following patients. Which does the nurse prioritize to see first? a. 22-year-old with a painful and swollen right wrist b. 45-year-old reporting chest pain and diaphoresis c. 60-year-old reporting difficulty swallowing and nausea d. 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101° F

ANS: B A patient experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable.

A client is receiving follow-up care after surviving a tornado. The client reports insomnia and the nurse notes that the client jumped as the nurse entered the room. Which action by the nurse is most appropriate? a. Document findings on the client's chart and inform the physician. b. Perform additional assessments for post-traumatic stress disorder. c. Educate the client on nonpharmaceutical methods to promote sleep. d. Plan to initiate a referral to a psychologist experienced in survivor issues.

ANS: B An individual may experience physical symptoms as a normal response to profound grief or loss, particularly after a traumatic incident. Manifestations such as insomnia, being startled easily, having flashbacks, or feelings of numbness may indicate post-traumatic stress disorder, and the nurse should first assess for this problem. The nurse should document assessment findings, but only after performing a more thorough assessment. A referral may be necessary, but the nurse does not have enough information yet to initiate it. If assessment reveals that methods to assist with sleep would be helpful, the nurse could provide that education.

An unresponsive client with poor ventilator effort and a pulse rate of 120 beats/min arrives at the emergency department. What should the nurse do first? a. Place the client on a non-rebreather mask. b. Begin bag-valve-mask ventilation. c. Initiate cardiopulmonary resuscitation. d. Prepare for chest tube insertion.

ANS: B Apneic clients and those with poor ventilatory effort need bag-valve-mask (BVM) ventilation for support until endotracheal intubation is performed and a mechanical ventilator is used. A non-rebreather mask would be appropriate only if the client had adequate spontaneous ventilation. Cardiopulmonary resuscitation is necessary only if the client is pulseless. Chest tubes are inserted for decompression and pneumothorax.

A community disaster has occurred and the hospital's emergency department (ED) has efficiently triaged, treated, and transferred most clients to appropriate units. The hospital incident command officer wants to "stand down" from the emergency plan. Which question by the nursing supervisor is most beneficial at this time? a. "Are you sure no more victims are coming into the ED?" b. "Do all other areas of the hospital have the supplies and personnel they need now?" c. "Have all ED staff had the chance to eat and rest recently?" d. "Are all other incident command officers and house supervisors in agreement with you?"

ANS: B Before "standing down," the incident command officer ensures that the needs of the other hospital departments have been taken care of because they may still be stressed and may need continued support to keep functioning. Many more "walking wounded" victims may present to the ED; that number may not be predictable. Giving staff the chance to eat and rest is important, but all areas of the facility need that too. Although agreement among incident officers is important, it is not the priority concern before standing down.

The nurse is caring for a client with a ventilation/perfusion mismatch who is receiving mechanical ventilation. Which intervention is a priority for this client? a. Administering antibiotics every 6 hours b. Positioning the client with the "good lung dependent" c. Making sure that the pilot balloon line on the endotracheal tube is deflated d. Ensuring that the client is able to speak clearly

ANS: B Clients who are being mechanically ventilated are experiencing a problem in that their normal ventilation is not adequate. The recommended position for clients who have one lung more affected by a problem than the other lung is to place the "good lung down," keeping the healthier lung dependent to the less healthy lung. Such positioning allows gravity to keep more blood in the lower lung (healthier lung) and better ventilation in the upper lung, thus helping a ventilation/perfusion mismatch. Antibiotics are not prescribed for this disorder. The pilot balloon line should be inflated to ensure that the cuff is inflated, keeping the endotracheal tube in place and directing ventilated air into the lungs. The client with an endotracheal tube that is nonfenestrated, with the cuff inflated, will not be able to speak. Communication is addressed in other ways.

The ED team is performing cardiopulmonary resuscitation on a patient when the client's spouse arrives at the emergency department. What should the nurse do next? a. Request that the client's spouse sit in the waiting room. b. Ask the spouse if he wishes to be present during the resuscitation. c. Suggest that the spouse begin to pray for the client. d. Refer the client's spouse to the hospital's crisis team.

ANS: B If resuscitation efforts are still under way when the family arrives, one or two family members may be given the opportunity to be present during lifesaving procedures. The other options do not give the spouse the opportunity to be present for the client or to begin to have closure.

The ED RN is assigned an older adult patient who is confused and agitated. Which intervention should the nurse include in the client's plan of care? a. Administer a sedative medication. b. Ask a family member to stay with the client. c. Use restraints to prevent the client from falling. d. Place the client in a wheelchair at the nurses' station.

ANS: B Older adults who are confused are at increased risks for falls. Fall prevention includes measures such as siderails up, reorientation, call light in reach, and, in some cases, asking the family member, significant other, or sitter to stay with the client to prevent falls.

The nurse is providing emergency care to a client with frostbite. Which intervention is performed first? a. Wrap the affected area in a warm, dry blanket to rewarm. b. Rewarm the affected area in a 104° F water bath. c. Elevate the affected area above the heart to decrease tissue edema. d. Use a splint to immobilize the affected area.

ANS: B Rewarming of the client with frostbite must occur first. Rapid rewarming in a water bath at a temperature of 104° F is preferable. If a warm bath is not available, warm wet towels can be used, but not warm dry blankets. After rewarming the affected area, elevate and apply an immobilization splint.

An emergency department nurse is transferring a client to the med surg unit. What is the most important nursing intervention in this situation? a. Triage the client to determine the urgency of care. b. Clearly communicate client data to the unit nurse. c. Evaluate the need for ongoing medical treatment. d. Perform a thorough assessment of the client.

ANS: B The emergency nurse needs to be able to triage, assess, and evaluate. However, these steps have already been carried out in the early phases of the emergency department (ED) admission. When a client is ready to be transferred from the ED, communication with staff nurses from the inpatient units is essential. This report should be a concise but comprehensive report of the client's ED experience.

A client is admitted to the emergency department several hours after a motor vehicle crash. The car's driver-side airbag was activated during the accident. Which assessment requires the nurse's immediate intervention? a. Disorientation b. Hemoptysis c. Pulse oximetry reading of 94% d. Chest pain with movement

ANS: B The nurse should be concerned about possible pulmonary contusion. Interstitial hemorrhage accompanies pulmonary contusion. Bleeding may not be evident at the initial injury, but the client develops hemoptysis and decreased breath sounds up to several hours after injury as bleeding into the alveoli or airways occurs. The pulse oximetry reading is within normal limits and chest pain is expected with movement after chest trauma. Disorientation needs to be investigated, but does not take priority over a breathing problem.

The pilot balloon on the endotracheal tube of a client being mechanically ventilated is deflated. What is the nurse's priority action? a. Nothing; this is required during ventilation. b. Inflate the cuff using minimal leak technique. c. Call the Rapid Response Team. d. Increase the tidal volume.

ANS: B The pilot balloon indicates whether the endotracheal tube cuff is inflated or deflated. A deflated balloon means that the cuff is also deflated and a seal is no longer present around the tube to prevent air from escaping. Thus, some of the air being moved into the client's airway by the ventilator is escaping through the client's trachea before it reaches the lower airways and alveoli. The nurse should inflate the cuff. Calling the Rapid Response Team is not necessary, and increasing tidal volume will not improve oxygenation if the cuff is leaking.

The nurse is working at a first aid booth for a spring training game on a hot day. A spectator comes in, reporting that he is not feeling well. Vital signs are temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, and blood pressure 106/66 mm Hg. He trips over his feet as the nurse leads him to a cot. What is the priority action of the nurse? a. Encourage drinking of cool water or sports drinks. b. Sponge the victim with cool water and remove his shirt. c. Administer Tylenol (acetaminophen), 650 mg orally. d. Encourage rest, and reassess in 15 minutes.

ANS: B The spectator shows signs of heat stroke, which is a medical emergency. The spectator should be transported to the emergency department as quickly as possible. The nurse should take actions to lower his body temperature in the meantime by removing his shirt and sponging his body with cool water. Lowering body temperature by drinking cool fluids or taking acetaminophen is not as effective in an emergency situation. The client needs to be cooled quickly and is a priority for treatment.

The nurse is caring for a client with a pulmonary embolus who also has right-sided heart failure. Which symptom will the nurse need to intervene for immediately? a. Respiratory rate of 28 breaths/min b. Urinary output of 10 mL/hr c. Heart rate of 100 beats/min d. Dry cough

ANS: B Urinary output is very low; this could indicate that the client has decreased cardiac output. The nurse will need to intervene and notify the health care provider. A respiratory rate that is slightly elevated is expected in this condition. Likewise, a heart rate that is a little higher is expected in this situation. A dry cough is also commonly found with pulmonary embolus.

A nursing administrator is reviewing a hospital's disaster planning. The administrator evaluates the plan that addresses which component as being the best? a. Internal disasters such as fires or power outages b. All possible catastrophes in the community c. The Joint Commission's assessment of possible disasters d. Responses to all types of weather-related emergencies

ANS: B When The Joint Commission-accredited health care facilities are planning disaster preparedness programs, they need to take an "all-hazards approach" (versus planning by strict guidelines) and to plan for all credible threats to the community that could result in a disaster. This means planning for all events that could conceivably happen in that geographic area, including possible weather events. Planning only for internal disasters is too limited and does not account for weather- or terrorist-related threats. The Joint Commission does not assess what disasters are possible in the areas that accredited hospitals serve.

A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. What should the nurse do before providing advanced cardiac life support? a. Contact the on-call orthopedic surgeon. b. Don personal protective equipment. c. Notify the Rapid Response Team. d. Obtain a complete history from the paramedic.

ANS: B Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions should be taken in all resuscitation situations and at other times when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers.

A large number of victims arrive at the emergency department after a bus is hit by a train. Which interventions are performed immediately for red-tagged victims? (Select all that apply.) a. Splinting a closed tibial fracture b. Intubating a cyanotic client in respiratory distress c. Initiating IV fluids for a client with a blood pressure of 96/60 mm Hg and a pulse of 144 beats/min d. Attaching an external pacemaker for a client with a heart rate of 44 beats/min e. Performing postmortem care for a client who has just died f. Removing glass that is embedded in a client's arm

ANS: B, C, D Priority interventions are those that must be performed to save the client's life, including intubation, IV fluid replacement for shock, and pacemaker placement. Splinting a fracture and removing glass from a client's arm can wait until after life-threatening injuries are cared for. Postmortem care would wait until after all clients have been cared for.

Which clients are at highest risk for pulmonary embolism (PE)? (Select all that apply) a. Middle-aged client awaiting surgery b. Older adult with a 20-pack-year history of smoking c. Client who has been on bedrest for 3 weeks d. Obese client who has elevated platelets e. Middle-aged client with diabetes mellitus type 1 f. Older adult who has just had abdominal surgery

ANS: B, C, D, F Older adults, especially those with chronic lung problems, are at higher risk for pulmonary embolism. Prolonged bedrest is also a risk factor, as are abdominal surgery and smoking. Because platelets are involved in the clotting process, elevated platelets may contribute to increased clotting. Diabetes and waiting for surgery are not known risk factors.

Which symptoms in a client assist the nurse in confirming the diagnosis of pulmonary embolus (PE)? (Select all that apply.) a. Wheezes throughout lung fields b. Hemoptysis c. Sharp chest pain d. Flattened neck veins e. Hypotension f. Pitting edema

ANS: B, C, E Hemoptysis, sharp chest pain, and hypotension all may be caused by pulmonary embolism and the pulmonary hypertension that results. Rather than wheezes, crackles usually occur along with a dry cough.

A nurse is triaging clients in the emergency department. Which client complaint would the triage nurse classify as nonurgent? a. Chest pain and diaphoresis b. Decreased breath sounds due to chest trauma c. Left arm fracture with palpable radial pulses d. Sore throat and a temperature of 104° F

ANS: C A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration. The client with an arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent.

The nurse is caring for a drowning victim after resuscitation. What focused assessment will the nurse perform to identify complications from drowning? a. Palpation of abdominal cavity b. Inspection of skin color c. Auscultation of lungs d. Palpation of pulse strength

ANS: C Auscultation of the lungs will assist the nurse to identify complications from drowning, including pulmonary infection and acute respiratory distress syndrome (ARDS). All other assessments are important, but the nurse must focus on the respiratory system as most likely to demonstrate complications.

The nurse assesses a client admitted for chest trauma who reports dyspnea. The nurse finds tracheal deviation and a pulse oximetry reading of 86%. What is the nurse's priority intervention? a. Notify the health care provider and document the symptoms. b. Intubate the client and prepare for mechanical ventilation. c. Administer oxygen and prepare for chest tube insertion. d. Administer an intermittent positive-pressure breathing treatment.

ANS: C Blunt chest trauma can cause an air leak into the thoracic cavity, collapsing the lung on the side with the air leak (pneumothorax). More air enters the pleural space with each breath, increasing intrathoracic pressure on the affected side, moving the trachea to the unaffected side, and leading to decreased cardiac output. This condition (tension pneumothorax) is life threatening without intervention. The client will need oxygen administration right away and a chest tube inserted.

The nurse is caring for a homeless client and consults the emergency department (ED) case manager. What can the ED case manager do for this client? a. Communicate client needs and restrictions to support staff. b. Prescribe low-cost antibiotics to treat community-acquired infection. c. Provide referrals to subsidized community-based health clinics. d. Offer counseling for substance abuse and mental health disorders.

ANS: C Case management interventions include facilitating referrals to primary care providers who are accepting new clients or to subsidized community-based health clinics for clients or families in need of routine services. The ED nurse is accountable for communicating pertinent staff considerations, client needs, and restrictions to support staff (e.g., physical limitations, isolation precautions) to ensure that ongoing client and staff safety issues are addressed. The ED physician prescribes medications and treatments. The psychiatric nurse team evaluates clients with emotional behaviors or mental illness and facilitates the follow-up treatment plan, including possible admission to an appropriate psychiatric facility.

A nursing instructor is debriefing students who participated in a community-wide disaster drill. Several students are upset with the black-tagged triage category. Which statement by the nursing instructor is best? a. "To do the greatest good for the greatest number of people, it is necessary to sacrifice some." b. "Not everyone will survive a disaster, so it is best to identify those people early and move on." c. "In a disaster, extensive resources are not used for one person at the expense of many others." d. "With black tags, volunteers can identify those who are dying and can give them comfort care."

ANS: C In a disaster, military style triage is used; this approach identifies the dead or expectant dead with black tags. This practice helps to maintain the goal of triage, which is doing the most good for the most people. Precious resources are not used for those with overwhelming critical injury or illness, so that they can be allocated to others who have a reasonable expectation of survival. Clients are not "sacrificed." Telling students to move on after identifying the expectant dead belittles their feelings and does not provide an adequate explanation. Clients are not black-tagged to allow volunteers to give comfort care.

The nurse is assessing a client recently bitten by a coral snake. Which assessment is the priority? a. Peripheral edema and swelling b. Evaluation of clotting times c. Respiratory rate and depth d. Electrocardiogram rhythm

ANS: C Manifestations of coral snake envenomation are the result of its neurotoxic properties. The physiologic effect is to block neurotransmission, which produces ascending paralysis, reduced perception of pain, and, ultimately, respiratory paralysis. The nurse should monitor for respiratory rate and depth. Severe swelling and clotting problems do not occur with coral snakes but do occur with pit viper snakes. Electrocardiogram rhythm is not affected by neurotoxins.

A client has been treated in the emergency department after a tornado and is awaiting discharge instructions. This client is close to losing control, although other family members are attempting to calm him down. Which response by the nurse is most helpful? a. Call security and have them standing by in case they are needed. b. Instruct the person to leave the area until he can calm down. c. Offer the client the choice of waiting in the treatment room or the waiting room. d. Ask the family to help move the client out of the treatment area.

ANS: C Offering people choices often is a good way to get them to focus on something other than their distress. Calling security and telling the person to leave might escalate the situation, although if all other methods fail, the safety of staff, clients, and other visitors takes priority. Asking the family to help move the client puts him in a difficult position and may end up causing them injury.

The Susy, RN is caring for a client with acute respiratory distress syndrome (ARDS) on mechanical ventilation and positive end-expiratory pressure (PEEP). The alarm sounds, indicating decreased pressure in the system. What is the Susy's best action? a. Change the client's position. b. Suction the client. c. Assess lung sounds. d. Turn off the pressure alarm.

ANS: C One of the biggest risks in the client with ARDS on mechanical ventilation with PEEP is tension pneumothorax. The nurse needs to assess lung sounds hourly. The alarms on a ventilator should never be turned off. If the client needed to be suctioned, the high-pressure alarm would sound. Changing the client's position would not change the pressure needed to administer a breath.

A client states, "At night, I usually need to sleep propped up on two pillows in the chair, but now it seems I need three pillows." What is the nurse's best response? a. "You should try to rest more during the day." b. "You should try to lie flat for short periods of time." c. "You need to stay in the hospital for further evaluation." d. "You can take medication at night so you can sleep."

ANS: C Orthopnea is the sensation of dyspnea or breathlessness in the supine position. Clients feel that they cannot catch their breath in the supine position and must rest or sleep in a semi-sitting position by placing pillows behind their backs or by using a reclining chair. The degree of breathlessness can be measured roughly by the number of pillows needed to make the client less dyspneic (e.g., one-pillow orthopnea, two-pillow orthopnea). With a client who has chronic respiratory problems, a minor increase in dyspnea may indicate a severe respiratory problem. Respiratory failure is a high risk. This client needs to stay in the hospital to be evaluated more completely. The client should not be instructed to try to lie flat, or to take a sleeping pill.

The emergency department (ED) is expecting a large number of casualties after a bridge collapse. Which is a priority consideration for the ED leadership when activating the disaster plan? a. Responding paramedics and rescue personnel will notify the ED about exactly how many victims to expect. b. Responding paramedics and rescue personnel will triage all victims at the bridge collapse site before bringing them to the ED. c. The ED may receive many unexpected victims with minor injuries from the bridge collapse. d. Victims who have been contaminated with gasoline will be decontaminated by rescue personnel before arriving at the ED.

ANS: C Paramedics may not note all the "walking wounded" to give the ED an accurate count of victims to expect because these people might evacuate themselves from the accident scene without being seen by paramedics or rescue personnel. They may then secure their own transportation to the hospital and could overwhelm an ED that is already handling many severely injured victims who have been brought in by emergency medical services (EMS).

The nurse assesses a client who has a hemothorax and a chest tube inserted on the right side. What finding requires immediate attention? a. Pain at the chest tube insertion site b. Fluctuation in the water seal chamber with breathing c. Puffiness of the skin around the chest tube insertion site and a crackling feeling d. Dullness to percussion on the affected side

ANS: C Puffiness of the skin around the chest tube and a crackling feeling indicate subcutaneous emphysema, or air leaking into the tissue around the insertion site. This must be addressed immediately. A hemothorax involves bleeding into the thoracic cavity and decreased lung inflation on the affected side, resulting in duller and less resonant percussion notes. Pain at the insertion site, fluctuation in the water seal, and dullness to percussion are all expected.

The nurse is working in the emergency department on a hot, humid day, when a hiker is brought in after collapsing. The hiker is confused and tachycardic with a temperature of 105.6° F (40.9° C). Which IV solution and medication will the nurse have ready for the client? a. Normal saline and methylprednisolone (Solu-Medrol) b. Lactated Ringer's solution and morphine sulfate c. Normal saline and lorazepam (Ativan) d. Dextrose 5% and diphenhydramine (Benadry)

ANS: C The client has heat stroke and is at risk for developing seizures, so the nurse should be prepared to administer lorazepam (Ativan) as needed. The optimal solution for clients with heat stroke is IV normal saline. Ringer's lactate solution cannot be used because the liver is unable to metabolize lactate during hyperthermia. Methylprednisolone and diphenhydramine would not be used to treat heat stroke.

The nurse auscultates the lungs of a client on mechanical ventilation and hears vesicular breath sounds throughout the right side but decreased sounds on the left side of the chest. What is the nurse's best action? a. Turn the client to the right side. b. Elevate the head of the bed. c. Assess placement of the endotracheal (ET) tube. d. Suction the client.

ANS: C The endotracheal tube is more likely to slip into the right mainstem bronchus, leading to the breath sounds described. The nurse should assess placement of the ET tube by assessing where the markings are, making sure it is taped, and confirming equal breath sounds bilaterally. If it is believed that the tube has slipped into the right mainstem bronchus, the health care provider should order a chest x-ray and reposition the tube.

The nurse is providing care for a client admitted for suicidal precautions. What priority intervention should the nurse implement first? a. Administer prescribed anti-anxiety drugs. b. Decrease the noise level and the harsh lighting. c. Remove oxygen tubing from the room. d. Set firm behavioral limits.

ANS: C The first priority in caring for a mentally ill client is providing a safe environment. This would include removing any item that the client could use to harm himself or herself (or others). All the other interventions can be used in providing a therapeutic environment. However, they are not as imperative as the safety of the client and staff.

While the nurse is visiting the community pool, an adult swimmer is pulled out of the pool, unconscious and cyanotic. What is the priority action of the nurse? a. Begin chest compressions. b. Move from the pool area. c. Give two rescue breaths. d. Check for a carotid pulse.

ANS: C The highest priority is to maintain ventilatory support until the victim can breathe on his or her own. The other options are important, but maintaining the airway and breathing are always priority.

A young man comes into the foyer of the hospital and says that he has a container of anthrax, which he opens and pours on the floor. Which is the priority action for the nurse who first comes upon the scene? a. Don a protective gown, mask, and goggles. b. Escort the man to the decontamination room. c. Begin to evacuate the immediate area. d. Notify the local health department of a biohazard situation.

ANS: C The highest priority is to remove people from immediate danger, so the nurse should evacuate the immediate area and prevent injury to those near the spill. Donning personal protective equipment would probably take the nurse away from the scene to obtain the equipment and would not help protect those in immediate danger. The man may need to be escorted to a decontamination area after people are removed from the scene. Reporting the incident to the health department should be done after the scene is secured and could be delegated to someone else.

A client arrives at the emergency department following a motor vehicle collision. The client is not awake and is being bagged with a bag-valve-mask by paramedics. The client has sustained obvious injuries to the head and face, as well as an open right femur fracture that is bleeding profusely. What will the nurse do first? a. Splint the right lower extremity. b. Apply direct pressure to the leg. c. Assess for a patent airway. d. Start two large-bore IVs.

ANS: C The highest-priority intervention in the primary survey is to establish a patent airway. Without an adequate airway to supply oxygen to the cells, a cerebral injury could progress to anoxic brain death. After an airway is established, resuscitation may continue to B for breathing and C for circulation assessment.

The nurse is caring for several on the respiratory floor. Which patient does the nurse assess most carefully for the development of acute respiratory distress syndrome (ARDS)? a. Older adult with COPD b. Middle-aged client receiving a blood transfusion c. Older adult who has aspirated his tube feeding d. Young adult with a broken leg from a motorcycle accident

ANS: C The older adult who has aspirated a tube feeding is at high risk and should be assessed closely for the possibility of ARDS. A client with COPD and a middle-aged client with no other risk factors are not at as high a risk for ARDS. The client who has a broken leg from an accident is not at high risk.

An emergency department (ED) supervisor has noted an increase in sick calls and bickering among the ED staff after a week with multiple trauma incidents. What action by the supervisor is most helpful? a. Organize a pizza party for each shift. b. Remind staff of facility sick-leave policy. c. Arrange critical incident stress debriefing. d. Talk individually with staff members.

ANS: C The staff may be suffering from critical incident stress and needs to have a debriefing by the critical incident stress management team to prevent the consequences of long-term, unabated stress. The other interventions may be helpful as well but are not as important as a debriefing.

The nurse is caring for a client whose wife just died in an accident. The client says to the nurse, "I can't believe that my wife is gone and I am left to raise my children all by myself." Which response by the nurse is most appropriate? a. "Please accept my sympathy for your loss." b. "I can call the hospital chaplain if you wish." c. "You sound anxious about being a single parent." d. "At least your children still have you in their lives."

ANS: C Therapeutic communication includes active listening and honesty. This statement demonstrates that the nurse recognizes the client's distress and has provided an opening for discussion. Extending sympathy and offering to call the chaplain do not give the client the opportunity to discuss feelings. Stating that the children still have one parent discounts the client's feelings and situation.

The nurse assesses a client who suffered chest trauma and finds that the left chest sucks in during inhalation and out during exhalation. The client's oxygen saturation has dropped from 94% to 86%. What is the priority action by the nurse? a. Encourage the client to take deep, controlled breaths. b. Document findings and continue to monitor the client. c. Notify the health care provider and prepare for intubation. d. Stabilize the chest wall with rib binders.

ANS: C This client has a flail chest characterized by paradoxical chest wall motion. With the oxygen saturation dropping, the client is at high risk for respiratory failure and needs to be intubated. Deep-breathing exercises are not enough at this point. Rib binders are not used anymore because they limit chest wall expansion and were used only for simple rib fractures.

The nurse is prioritizing care for a client on a ventilator. What are essential nursing interventions for this client? (Select all that apply.) a. Change the settings in accordance with provider orders. b. Modify the settings for weaning the client. c. Assess the reasons for alarms. d. Compare the ventilator settings with ordered settings. e. Assess the water level in the humidifier. f. Change the ventilator tubing according to hospital policy.

ANS: C, D, E The nurse should assess the client when an alarm sounds and should intervene accordingly. The nurse should also check the settings to make sure they are correct and should evaluate the water level to make sure the humidifier does not go dry. The nurse would not be responsible for changing ventilator settings, weaning the client, or changing the ventilator tubing.

A client with a large pulmonary embolism is receiving alteplase (Activase). The nurse notes frank red blood in the Foley catheter drainage bag. What is the nurse's first action? a. Irrigate the Foley. b. Administer an antibiotic. c. Clamp the Foley. d. Notify the health care provider.

ANS: D Alteplase is a fibrinolytic agent that dissolves formed clots. The drug has an impact on clots outside the pulmonary embolism, and the client is at great risk for hemorrhage and shock. The nurse should realize the potential for a severe problem and should call the health care provider immediately for orders. The other actions would not be appropriate first actions in this situation.

A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at the nurse when dinner is served late. What is the nurse's best response? a. "Do you need something for pain right now?" b. "Please stop yelling. I brought dinner as soon as I could." c. "I suggest that you get control of yourself." d. "You seem upset. I have time to talk if you like."

ANS: D Clients should be allowed to ventilate their feelings of anger and despair after a catastrophic event. The nurse establishes rapport through active listening and honest communication and by recognizing cues that the client wishes to talk. Asking whether the client is in pain as the first response closes the door to open communication and limits the client's options. Simply telling the client to gain control does nothing to promote therapeutic communication.

An industrial accident has occurred near the hospital, and many victims are brought to the emergency department (ED) for treatment of their injuries. The nurse triages the victim with which injury with a red tag? a. Dislocated right hip and an open fracture of the right lower leg b. Large contusion to the forehead and a bloody nose c. Closed fracture of the right clavicle and arm numbness d. Multiple fractured ribs and shortness of breath

ANS: D Clients who have an immediate threat to life are given the highest priority, are placed in the emergent or class I category, and are given a red triage tag. The client with multiple rib fractures and shortness of breath most likely has developed a pneumothorax, which may be fatal if not treated immediately. The client with the hip and leg problem and the client with the clavicle fracture would be classified as class II; these major but stable injuries can wait 30 minutes to 2 hours for definitive care. The client with facial wounds would be considered the "walking wounded" and classified as nonurgent.

The nurse is assessing a client admitted with a brown recluse spider bite. What priority assessment should the nurse perform? a. Ask the client about pruritus at the bite site. b. Inspect for a bluish purple vesicle. c. Assess for redness and swelling. d. Obtain the client's temperature.

ANS: D Fever and chills indicate systemic toxicity, which can lead to hemolytic reactions, renal failure, pulmonary edema, cardiovascular collapse, and death. Assessing for a fever should be the nurse's priority. All other symptoms are normal for a brown recluse bite. These should be assessed, but they do not provide information about complications from the bite and therefore are not the priority.

The client receiving mechanical ventilation has become more restless over the course of the shift. Which is the nurse's first action? a. Sedate the client. b. Call the health care provider. c. Assess the client for pain. d. Assess the client's oxygenation.

ANS: D Increasing restlessness in a client being mechanically ventilated may mean that the client is not receiving sufficient oxygen. It can also be a manifestation of pain. When in doubt, determining the adequacy of ventilation has the highest priority. The nurse would not sedate the client until the cause of the restlessness has been addressed. The nurse would call the provider if the cause could not be determined and addressed, or if the client's status deteriorated.

On a hot, humid day, several clients present to the emergency department with symptoms of heat exposure. Which client will be treated first? A client who: a. Has normal mental status and flu-like symptoms b. Is diaphoretic with nausea and vomiting c. Is hypotensive and tachycardic d. Is anxious and confused

ANS: D Normal mental status, flu-like symptoms, diaphoresis, nausea and vomiting, hypotension, and tachycardia all are symptoms of heat exhaustion. The differentiating symptom between heat exhaustion and exertional heat stroke is the presence of mental status changes, which indicate thermal injury to the brain and represent an emergency situation.

The nurse manager is assessing current demographics of the facility's ED patients. Which population would most likely present to the ED for treatment of a temperature and a sore throat? a. Older adults b. Immunocompromised people c. Pediatric clients d. Underinsured people

ANS: D The ED serves as an important safety net for clients who are ill or injured but lack access to basic health care. Especially vulnerable populations include the underinsured and the uninsured, who may have nowhere else to go for health care.

The nurse is caring for a client receiving heparin and warfarin therapy for a pulmonary embolus. The client's international normalized ratio (INR) is 2.0. What is the nurse's best action? a. Increase the heparin dose. b. Increase the warfarin dose. c. Continue the current therapy. d. Discontinue the heparin.

ANS: D The client who is being treated for pulmonary embolism usually continues on heparin and warfarin until the INR reaches a therapeutic level between 2 and 3. Heparin can then be discontinued because warfarin is therapeutic.

Elmo, RN caring for a client who has been intubated and placed on a ventilator for treatment of acute respiratory distress syndrome (ARDS). What is the nurse's priority action? a. Assess hemoglobin. b. Administer ferrous sulfate. c. Assess muscle strength. d. Consult with the registered dietitian.

ANS: D The client who is intubated needs nutrition delivered via enteral tube feeding. If nutrition is ignored, the client's respiratory status can deteriorate, because respiratory muscle function can deteriorate.

Which assessment finding requires the nurse's immediate action? a. Being intubated for 4 days b. Uneven breath sounds c. Wheezing on auscultation d. Having the endotracheal (ET) tube taped to the lower jaw

ANS: D The endotracheal tube can be taped to the upper lip but should never be taped to the lower jaw because the lower jaw moves too much. The other clients need to be assessed by the nurse, but the one with the ET tube taped to the jaw requires immediate action.

A patient with dyspnea is becoming very anxious. An arterial blood gas (ABG) shows a PaO2 of 93 mm Hg. How does the nurse best intervene? a. Increase the oxygen. b. Administer an antianxiety medication. c. Administer a bronchodilator. d. Assist with relaxation techniques.

ANS: D The nurse should assess the patient's oxygenation; however, this patiennt's arterial blood gas documents that the his hypoxia has resolved. At this time it is not necessary to increase the oxygen or administer a bronchodilator; both of these interventions would be appropriate if he were hypoxic. The patient with respiratory problems should not take an antianxiety medication as a first-line intervention, because this may decrease the respiratory rate and/or alertness. The best intervention at this time is to assist with relaxation techniques.

The hospital is overwhelmed when caring for victims after an earthquake that occurred 48 hours ago. Which responsibility of the nursing supervisor is most important at this time? a. Assuming leadership for implementation of the hospital emergency plan b. Releasing updates of client conditions to the media c. Converting the physical therapy clinic into a treatment area for the injured d. Arranging relief and coordinating breaks so nursing staff can rest and eat

ANS: D The nursing supervisor should ensure that the staff is not becoming dangerously overtired by working long shifts without food or rest. Overall leadership for implementing the emergency plan and re-designating areas for client care would fall under the job of hospital incident commander. The community relations/public information officer would work with the media.

On admission to the ED, a patient states that he feels like killing himself. When planning this client's care, it is most important for the nurse to coordinate with which member of the health care team? a. Case manager b. Forensic nurse examiner c. Physician d. Psychiatric crisis nurse

ANS: D The psych crisis nurse interacts with patients and families in crisis. This health care team member can offer valuable expertise to the emergency health care team, which also includes the case manager and the physician.

When auscultates the lungs in a client with a respiratory disorder, the nurser hears stridor. What is the best action? a. Have the client use an incentive spirometer. b. Have the client cough and deep breathe. c. Suction the client after auscultating the lower lobes of the lungs. d. Call for the Rapid Response Team.

ANS: D The sound heard is stridor. Stridor on inspiration is caused by laryngospasm or edema and heralds impending airway occlusion. The client's airway is in jeopardy and immediate intervention is necessary. Using the spirometer or coughing and deep breathing will not help the client in this situation. The nurse needs to call the Rapid Response Team.

A community nurse assesses a client, who has an allergy to bees, after a bee sting. The client's lips are swollen, and wheezes are audible. What is the priority action of the nurse? a. Elevate the site and notify the client's next of kin. b. Remove the stinger with tweezers and encourage rest. c. Administer diphenhydramine (Benadryl) and apply ice. d. Administer an EpiPen from the first aid kit and call 911.

ANS: D The student's swollen lips indicate that anaphylaxis may be developing, and this is a medical emergency. 911 should be called immediately, and the client transported to the emergency department as quickly as possible. If an EpiPen is available, it should be administered at the first sign of an anaphylactic reaction. The other answers do not provide adequate interventions to treat airway obstruction due to anaphylaxis.

The nurse is teaching a client with severe allergies how to prevent bug bites. Which statement by the client indicates that additional teaching is needed? a. "I will avoid wearing perfume when I go outside." b. "I will put the picnic food out when we are ready to eat." c. "I will keep my car windows up at all times." d. "I will wear sandals whenever I go outside."

ANS: D Shoes rather than sandals should be worn outside to prevent insect bites. The other statements indicate good understanding of the teaching.

The emergency department nurse assesses a middle-aged mountain climber who reports headache, nausea, vomiting, and "feeling winded." What is the nurse's priority intervention? a. Administer acetazolamide (Diamox). b. Administer prochlorperazine (Compazine). c. Perform a neurologic assessment. d. Assess for bowel sounds.

ANS: A The client is exhibiting signs of mountain sickness. Acetazolamide (Diamox, Apo-Acetazolamide) is used to prevent and treat acute mountain sickness. The other interventions will not treat mountain sickness.

The emergency department nurse manager is explaining concepts of emergency and disaster preparedness to a group of students. Which statement by the nurse manager is most accurate? a. "An internal disaster is something that occurs inside the health care facility." b. "An external disaster occurs when someone not employed here disrupts our operations." c. "A multi-casualty event involves disasters at several different locations." d. "The Joint Commission requires that we participate in a disaster drill once a year."

ANS: A An internal disaster is something that occurs within the health care facility, such as a fire. External disasters, such as a tornado or a hurricane, occur outside the health care facility. A multi-casualty event can be managed with hospital resources. The Joint Commission requires hospitals to participate in two disaster drills a year.

The nurse is caring for a postoperative client who suddenly reports difficulty breathing and sharp chest pain. After notifying the Rapid Response Team, what is the nurse's priority action? a. Elevate the head of the bed and apply oxygen. b. Listen to the client's lung sounds. c. Pull the call bell out of the wall socket. d. Assess the client's pulse oximetry.

ANS: A The client's immediate need is to have oxygen applied. The nurse should then assess the client's pulse oximetry.

A new nurse is orienting to the emergency department (ED). Which statement made by the nurse would indicate the need for further education by the preceptor? a. "The emergency medicine physician coordinates care with all levels of the emergency health care team." b. "Emergency departments have specialized teams that deal with high-risk populations of patients." c. "Many older adults seek emergency services when they are ill because they do not want to bother their primary health care provider." d. "Emergency departments are responsible for public health surveillance and emergency disaster preparedness."

ANS: A The emergency nurse is one member of the large interdisciplinary team that provides care for clients in the ED. A collaborative team approach to emergency care is considered a standard of practice. In this setting, the nurse coordinates care with all levels of health care team providers, from prehospital emergency medical services (EMS) personnel to physicians, hospital technicians, and professional and ancillary staff.

The emergency medical technicians (EMTs) arrive at the emergency department with an unresponsive client with an oxygen mask in place. What will the nurse do first? a. Assess that the client is breathing adequately b. Insert a large-bore intravenous line c. Place the client on a cardiac monitor d. Assess for best neurologic response

ANS: A The highest-priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he may not be breathing, or he may be breathing inadequately with the device in place.

A nursing administrator is evaluating the hospital's response to a recent internal disaster. The administrator assesses that goals for disaster planning have been met when which outcome is assessed? a. The hospital was able to maintain client, staff, and visitor safety during the disaster. b. Supplies were readily available and were transported rapidly where needed. c. The hospital incident command officer successfully utilized ancillary areas for client care. d. All employees followed the chain of command and established policies and procedures.

ANS: A The most important outcome of any internal disaster is maintenance of safety for the hospital's clients, staff, and visitors. Other outcomes listed would be part of a successful disaster response, but are all too narrow to meet this objective.

The nurse is teaching nursing students about personal emergency preparedness. Which statement by a student indicates that further teaching is indicated? a. "I will get a prescription for antibiotics just in case I have to work in an area that has been infected with anthrax." b. "I should keep an extra uniform in my locker in case I get stuck at work." c. "I may be torn between caring for my young daughter and caring for victims at work." d. "I should make plans for my family to evacuate our house in case of tornado or earthquake."

ANS: A The student would have no reason to obtain a prescription for anthrax unless he or she demonstrates clinical evidence of anthrax infection or has been exposed to a substance that tests positive for anthrax. Statements about planning to keep an extra uniform at work, recognizing the moral dilemmas he or she might encounter when working in a disaster situation, and understanding personal preparation for disasters all indicate that the student comprehends information about disaster planning and emergency preparedness.

A nurse wants to become part of a Disaster Medical Assistance Team (DMAT) but is concerned about maintaining licensure in several different states. What statement by the nursing supervisor best addresses these concerns? a. "Deployed DMAT providers are federal employees, so their licenses are good in all 50 states." b. "The government has a program for quick licensure activation wherever you are deployed." c. "During a time of crisis, licensure issues would not be the government's priority concern." d. "If you are deployed, you will be issued a temporary license in the state in which you are working."

ANS: A When deployed, DMAT health care providers are acting as agents of the government, and so are considered federal employees. Thus their licenses are valid in all 50 states. Licensure is an issue that the government would be concerned with, but no programs for temporary licensure or rapid activation are available.

The nurse is assessing a group of clients. Which clients are at greater risk for hypothermia or frostbite? (Select all that apply.) a. A young man who has just consumed six martinis b. A young man with a body mass index (BMI) of 42 c. An older man who smokes a pack of cigarettes a day d. A young woman who is anorexic e. An older woman with hypertension f. A young woman who is diabetic

ANS: A, C, D, F Clients with poor nutrition, fatigue, and multiple chronic illnesses are at greater risk for hypothermia. Clients who smoke, consume alcohol, or have impaired peripheral circulation have a higher incidence of frostbite.

A client with severe respiratory insufficiency becomes short of breath during activities of daily living. Which nursing intervention is best? a. Call the Rapid Response Team. b. Decrease involvement in care until the episode is past. c. Cluster morning activities to provide long rest periods. d. Space out interventions to provide for periods of rest.

ANS: B Clients with shortness of breath and decreased oxygen saturation must be monitored closely. Minimal involvement in activities is required if the client is severely short of breath. The nurse should continue to assess the client and can increase involvement in activities if shortness of breath subsides. The Rapid Response Team is not required. Clustering or spacing of activities does nothing to decrease the client's involvement, which is the cause of shortness of breath.

The nurse is planning care for a client admitted with a snakebite to the right leg. With whom should the nurse collaborate? a. The facility's neurologist b. The regional poison control center c. The physical therapy department d. A herpetologist (snake specialist)

ANS: B Contact the regional poison control center immediately for specific advice on antivenom administration and client management.

A nurse is working at the scene of a catastrophic natural event. Which person does the nurse attend to first? a. Distraught mother looking for her children b. Person walking about with a bleeding head wound c. Supine person with pale, cool, clammy skin d. Child with a deformed lower leg crying in pain

ANS: C The person with pale, cool, clammy skin is in shock and needs immediate medical attention. The mother does not have injuries and so would be the lowest priority. The other two people need medical attention soon, but not at the expense of a person in shock.

The nurse is triaging clients in the emergency department. Which client should be considered urgent? a. 20-year-old female with a chest stab wound and tachycardia b. 45 year-old homeless man with a skin rash and sore throat c. 75-year-old female with a cough and of temperature of 102° F d. 50-year-old male with new-onset confusion and slurred speech

ANS: C A client with a cough and a temperature of 102° F is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. Clients with a chest stab wound and tachycardia, and with new-onset confusion and slurred speech, should be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent.

The pressure reading during inspiration on the ventilator of a client receiving mechanical ventilation is fluctuating widely. What is the nurse's first action? a. Determine whether an air leak is present in the client's endotracheal tube cuff. b. Have the respiratory therapist check the pressure settings. c. Assess the client's oxygenation. d. Manually ventilate the client with a resuscitation bag.

ANS: C A widely fluctuating pressure reading is one indication of inadequate airflow and oxygenation. The nurse's priority is to check the client's oxygenation status. If oxygenation is inadequate, the nurse would assess for a cause while manually ventilating the client and calling for assistance.

While assessing a Suzy in the ED, the Nurse Kelly identifies that the patient has been raped. Which health care team member should the Kelly, RN collaborate with when planning this client's care? a. Emergency medicine physician b. Case manager c. Forensic nurse examiner d. Psychiatric crisis nurse

ANS: C All other members of the health care team listed may be used in the management of this client's care. However, the forensic nurse examiner is educated to obtain client histories and collect evidence dealing with the assault, and can offer the counseling and follow-up needed when dealing with the victim of an assault.

The emergency department (ED) nurse is assigned to triage clients. What is the purpose of triage? a. Treat clients on a first-come, first-serve basis. b. Identify and treat clients with low acuity first. c. Prioritize clients based on illness severity. d. Determine health needs from a complete assessment.

ANS: C ED triage is an organized system for sorting or classifying clients into priority levels, depending on illness or injury severity. The key concept is that clients who present to the ED with the greatest acuity needs receive the quickest evaluation, treatment, and prioritized resource utilization. A person with a lower-acuity problem may wait longer in the ED because the higher-acuity client is moved to the "head of the line."

The nurse has been assigned the role of triage nurse after a weather-related disaster. What is the priority action of the nurse? a. Call in additional staff to assist with care of the victims. b. Splint fractures and clean and dress lacerations. c. Perform a rapid assessment of clients to determine priority of care. d. Provide psychological support to staff and family members.

ANS: C The triage nurse classifies victims of the explosion into priority of care based on illness or injury severity. Calling in additional staff more likely would be done by the hospital incident commander or designee. Physical care is provided to victims after triage occurs. Psychological support should be an ongoing part of the disaster plan but is not included in triage responsibilities; this ensures that the greatest good is provided to the greatest number of people.

The nurse is caring for a client who is taken off a ventilator and placed on continuous positive airway pressure (CPAP). What intervention is most appropriate for this client? a. Administering antianxiety medications PRN b. Administering a medication to help the client sleep c. Telling the client to relax and let the ventilator do the work d. Making sure the client is breathing spontaneously

ANS: D A requirement for using CPAP is that the client will be able to breathe spontaneously. Antianxiety and sleep medications should not be administered to the client during weaning. Telling the client to relax may be helpful in some cases but does not take priority over ensuring the client's ability to breathe spontaneously.

The Nurse Rose notes that each time the mechanical ventilator delivers a breath to a patient with acute respiratory distress syndrome (ARDS), the peak inspiratory pressure alarm sounds. What is the nurse's best intervention? a. Suction the client. b. Perform chest physiotherapy. c. Administer an inhaler. d. Assess the airway.

ANS: D An increase in peak inspiratory pressure (PIP) in the ARDS client is indicative of decreased lung compliance, making it more difficult to ventilate diseased lungs. The nurse first should assess the airway to make sure no sputum is present in the airway and that no kinks are noted in the tubing. The nurse is not able to make changes in the ventilator settings, so an order is needed to increase inspiratory pressure to oxygenate the client. Suctioning or performing chest physical therapy (PT) will not help the client's lung compliance; however, if mucus is impeding the airway, these interventions would be necessary and would be noticed when the airway is assessed. Administering a bronchodilator may help the client; however, an inhaler could not be used by a client on a ventilator.

Which is the priority action for the emergency department charge nurse in the event of a mass casualty situation? a. Directing medical-surgical and case management nurses to assist emergency department (ED) staff with critically injured victims b. Calling additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in c. Informing the incident commander at the mass casualty scene about how many victims may be handled by the ED d. Directing medical-surgical and critical care nurses to assist with clients who are already in the ED while the ED staff prepares to receive the mass casualty victims

ANS: D The ED charge nurse should direct additional nursing staff to help care for current ED clients while the ED staff prepares to receive the mass casualty victims; however, they should not be assigned to the most critically ill or injured clients. The hospital incident commander is responsible for mobilizing resources and would have the responsibility for calling in staff. The medical command physician would be the person best able to communicate with on-scene personnel regarding the ability to take more clients.

The nurse is assessing arterial blood gases (ABGs). The client with which ABG reading requires the nurse's immediate attention? a. pH, 7.32; PaCO2, 55 mm Hg; PaO2, 70 mm Hg b. pH, 7.45; PaCO2, 42 mm Hg; PaO2, 70 mm Hg c. pH, 7.48; PaCO2, 38 mm Hg; PaO2, 60 mm Hg d. pH, 7.55; PaCO2, 32 mm Hg; PaO2, 50 mm Hg

ANS: D This client has the most severe hypoxia and respiratory alkalosis, indicated by low partial pressure of arterial carbon dioxide (PaCO2) values on ABG analysis.

The emergency department nurse assesses a client in extreme pain with an apparent snakebite of the leg. Vital signs are stable. What is the priority action of the nurse? a. Call the regional poison control center. b. Administer IV pain medication. c. Place a tourniquet around the leg. d. Apply an immobilization splint.

ANS: D Treatment involves immobilization to minimize the spread of venom. A tourniquet should not be used because it impairs arterial blood flow. Pain medication should be administered and collaboration with the regional poison control center begun after the leg is immobilized.

A nurse is at the scene of a lightning strike during a thunderstorm. Which is the priority action of the nurse? a. Make sure that victims are not electrically charged. b. Assess victims for second- and third-degree burns. c. Start emergency resuscitation on anyone not breathing. d. Move victims and first aid responders to a sheltered area.

ANS: D Victims of a lightning strike are not electrically charged afterward. Cardiopulmonary resuscitation (CPR) should be started once victims and first aid responders are in a sheltered area, because the thunderstorm presents a continued threat of lightning strikes.

A client is admitted owing to difficulty breathing. The nurse assesses the client's color, lung sounds, and pulse oximetry reading. The pulse oximetry is 90%. What is the nurse's next action? a. Give an intermittent positive-pressure breathing treatment. b. Administer a rescue inhaler. c. Call for a chest x-ray. d. Assess an arterial blood gas.

ANS: D When clients with respiratory problems are assessed, an arterial blood gas is needed for the most accurate assessment of oxygenation. No indications are known for a breathing treatment or an inhaler, nor does the nurse have enough information to know whether a chest x-ray is warranted.

A client in the emergency department has died from a suspected homicide. What is the nurse's priority intervention? a. Remove all tubes and wires in preparation for the medical examiner. b. Limit the number of visitors to minimize the family's trauma. c. Consult the bereavement committee to follow up with the grieving family. d. Communicate the client's death to the family in a simple and concrete manner.

ANS: D When dealing with clients and families in crisis, communicate in a simple and concrete manner to minimize confusion. Tubes must remain in place for the medical examiner. Family should be allowed to view the body. Offering to call for additional family support during the crisis is suggested. The bereavement committee should be consulted, but this is not the priority at this time.