Adult health 4 medical emergencies
A child is admitted to the emergency department and diagnosed with a suspected ruptured appendix. The parents are anxious about the child's condition and ask the nurse what to expect for immediate treatment. What is the best response by the nurse?
"We will be preparing your child for emergency surgery."
After receiving a dose of penicillin, a client develops dyspnea and hypotension. The nurse suspects the client is experiencing anaphylactic shock. What should the nurse do first? Establish intravenous access. Administer epinephrine. Administer albuterol (salbutamol). Provide respiratory support with bag-valve mask.
Administer epinephrine.
The nurse is caring for a lethargic but arousable preschooler who is a victim of a near-drowning accident. What should the nurse do first? Administer oxygen. Institute rewarming. Prepare for intubation. Start an intravenous (IV) infusion.
Administer oxygen
A multigravid client in active labor at term suddenly sits up and says, "I can't breathe! My chest hurts really bad!" The client's skin begins to turn a dusky gray color. After calling for assistance, the nurse should take which action next? Administer oxygen by face mask. Begin cardiopulmonary resuscitation. Administer intravenous oxytocin. Obtain an prescription for intravenous fibrinogen.
Administer oxygen by face mask.
A client in the emergency department reports squeezing substernal pain that radiates to the left shoulder and jaw. The client also reports nausea, diaphoresis, and shortness of breath. What is the nurse's priority action?
Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin.
A client who had abdominal surgery 4 days ago reports that "something gave way" during a sneeze. The nurse observes a wound evisceration. What should the nurse do next?
Apply a sterile, moist dressing.
An occupational nurse is called to treat an employee who experienced a finger injury on a piece of equipment. When the nurse arrives, it is discovered that the finger tip was cut off at the first digit and is bleeding profusely. What should be the nurse's first action?
Apply direct pressure to the finger with a clean, dry cloth.
Parents bring a preschool-age client to the emergency department with suspected ingestion of an unknown toxic substance. What intervention should the nurse perform first?
Assess the child's vital signs and neurological status.
The nurse assesses an 8-month-old infant for a possible head injury after a fall of about 3 feet. The child is awake, alert, and crying. Vital signs are within normal limits. What action should the nurse take next?
Assess the infant's pupillary responses.
A nurse notices a client lying on the floor at the bottom of the stairs. The client's alert and oriented and states that they fell down several stairs. The client denies pain other than in their arm, which is swollen and appears deformed. After calling for help, what should the nurse do?
Immobilize the client's arm.
A 10-year-old child falls, injures the left shoulder, and is taken to the emergency department. While the client waits to be seen by the health care provider, what intervention should the nurse perform first?
Keep the child in a comfortable position and apply ice to the injured shoulder.
The nurse is caring for a client who is in active labor. The client states, "I think my water just broke!" The fetal heart rate shows a prolonged variable deceleration to 80 beats per minute. The nurse performs a sterile vaginal exam and feels a pulsating cord in the vaginal canal. What are the nurse's priority interventions at this time? Select all that apply. Insert an indwelling catheter to empty the client's bladder. Move the client's bed into Trendelenburg position. Have the client's family call for help. Keep fingers in the vagina to keep pressure off of the cord. Have the anesthetist insert an epidural for pain control. Clip any hair from the surgical site.
Move the client's bed into Trendelenburg position. Have the client's family call for help. Keep fingers in the vagina to keep pressure off of the cord.
A 4-month-old infant has been carried into the emergency department after falling off the parents' bed and hitting the head on the floor. What should the nurse do first? Move the family to an area where an assessment can be completed and call for a health care provider. Notify the supervisor that an operating room is needed because the health care provider will want to insert a ventriculoperitoneal (VP) shunt. Assess the infant's vital signs in the triage area and instruct the family to wait until their names are called. Call child protective services because of suspected child endangerment.
Move the family to an area where an assessment can be completed and call for a health care provider.
A client has chest pain rated at 8 on a 10-point visual analog scale and is receiving intravenous nitroglycerin. The 12-lead electrocardiogram reveals ST elevation in the inferior leads, and troponin levels are elevated. What should the nurse do first?
Notify the health care provider.
The nurse discovers that a young client has been given a dose of morphine four times the dose prescribed. What is the priority action of the nurse? Monitor the client's respiratory rate for 5 minutes. Follow the facility policy for reporting of the error. Obtain naloxone and assess the need for administration. Bring emergency resuscitation equipment to the child's room.
Obtain naloxone and assess the need for administration.
A nurse is standing next to a person eating fried shrimp at a parade. Suddenly, the person clutches the throat and is unable to speak, cough, or breathe. The nurse asks if the person is choking, and the person nods yes. What action should the nurse take next?
Perform the Heimlich maneuver
The nurse is giving rescue breaths to a client who just had a cardiac arrest while a team member performs chest compressions. The chest wall fails to rise after the team has been performing cardiopulmonary resuscitation for 30 seconds. What should the nurse do next?
Reposition the airway.
A nurse is helping a client who is suspected of choking. When should the nurse perform the Heimlich maneuver?
The victim cannot speak due to airway obstruction.
A visitor sitting in a chair in the waiting room is found unconscious with spontaneous breathing. Which action should the nurse take as the priority?
^Attempt to arouse and identify the visitor. ^Call the rapid response team. Place the visitor on the floor. Ask other visitors in the hallway what happened.
The nurse is caring for a client who is experiencing an allergic reaction. Which action(s) should the nurse take? Select all that apply.
^Notify the rapid response team. ^Assess the client's breathing pattern. ^Document the client's response to treatment. ^Notify the health care provider. Monitor for a decrease in edema.
A client is admitted to the emergency department with sudden onset of chest pain. Which prescription(s) should the nurse implement immediately? Select all that apply.
^Provide oxygen. ^Administer nitroglycerin. ^Administer aspirin. Insert a Foley catheter. ^Administer morphine. Administer acetaminophen
A nurse is assigned to care for a client with chest pain in the intensive care unit. The client is reading a book when the nurse observes a flat line on the monitor and the alarm rings. What is the nurse's priority intervention at this time? calling the resuscitation team defibrillating the client delivering a precordial thump assessing the client
assessing the client
The nurse is performing the Heimlich maneuver on a conscious adult victim. What landmark should the nurse use to deliver the inward and upward thrusts?
below the xiphoid process and above the umbilicus
A nurse performs cardiopulmonary resuscitation (CPR) for 2 minutes on an infant without calling for assistance. In reassessing the infant after 2 minutes of CPR, the nurse finds the infant still isn't breathing and has no pulse. The nurse should then: resume CPR beginning with breaths. reposition the infant. resume CPR beginning with chest compressions. call for assistance.
call for assistance.
A child has ingested a bottle of over-the-counter medication and is brought into the emergency department by the parents. The nurse expedites rapid first aid for poisoning by immediately accessing what resource?
contacting the Poison Control Center by phone
An adolescent is brought to the hospital emergency department in a state of unconsciousness after having swallowed "a bottle of pain pills" 45 minutes earlier. The pills are identified as oxycodone. A suicide note is found that asks for forgiveness. Which measure should the nurse be prepared to carry out when this client is admitted? forcing fluids giving a diuretic inducing vomiting giving naloxone IV
giving naloxone IV
The nurses teaches the parents of an infant how to perform back slaps to dislodge a foreign body. What should the nurse tell the parents to use to deliver the blows?
heel of the hand
A child is in the emergency department with suspected epiglottitis and has been ordered an X-ray to confirm the diagnosis. The nurse would prepare the child for X-ray by which methods? in radiology, transported by wheelchair, accompanied by a nurse in radiology, transported by stretcher, accompanied by a nurse in surgery, by portable X-ray in the emergency department, by portable X-ray
in the emergency department, by portable X-ray
The nurse is admitting a client diagnosed with diabetic ketoacidosis (DKA). What is the nurse's priority intervention? subcutaneous glucagon administration transfusion of whole blood glucocorticoid administration intravenous insulin
intravenous insulin
A client has been diagnosed with an acute episode of angle-closure glaucoma. The client asks the nurse what will be done. What should the nurse tell the client about this health problem?
is a medical emergency that can rapidly lead to blindness.
A client has been diagnosed with an acute episode of angle-closure glaucoma. The client asks the nurse what will be done. What should the nurse tell the client about this health problem? frequently resolves without treatment. is typically treated with sustained bed rest. is a medical emergency that can rapidly lead to blindness. is most commonly treated with steroid therapy.
is a medical emergency that can rapidly lead to blindness.
A client is reporting shortness of breath. The nurse finds the client's assessment includes dyspnea, diaphoresis, and slight confusion. Concerned that the client may have an air embolism, how should the nurse position the client? left side in the deep Trendelenburg position right side in the deep Trendelenburg position left side in semi-Fowler's position in the semi-Fowler's position
left side in the deep Trendelenburg position
Which intervention is the most critical for a client with myxedema coma? administering an oral dose of levothyroxine warming the client with a warming blanket measuring and recording accurate intake and output maintaining a patent airway
maintaining a patent airway
18-year-old college student presents to the emergency department with a severe headache and onset of bizarre behavior that started approximately five hours ago. Client is oriented to person, but not place or time. Physical assessment includes petechiae. Oral temperature is 104° F (40° C). HR: 128/bpm. RR: 24/min, O2: 95% on room air. Lumbar puncture ordered. Client is being evaluated for bacterial meningitis. What is the most important action by the nurse? prepare this client for endotracheal intubation administer the meningitis vaccination per order administer an analgesic per order obtaining I.V. access in preparation of antibiotic administration
obtaining I.V. access in preparation of antibiotic administration
A 4-year-old child is having a sickle cell crisis. The initial nursing intervention should be to
provide oral and IV fluids
A 4-year-old child is having a sickle cell crisis. The initial nursing intervention should be to place ice packs on the client's painful joints. administer antibiotics. provide oral and IV fluids. administer folic acid supplements.
provide oral and IV fluids.
