Ch 67: Emergency nursing

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

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

A high school football player is brought to the emergency department after collapsing at practice in extremely hot and humid weather. Which of the following would lead the nurse to suspect that the client is experiencing heat stroke?

Delirium Explanation: Manifestations of heat stroke include a temperature of 105 degrees F or greater (40.5 degrees C or greater), anhidrosis (absence of sweating), central nervous system dysfunction (bizarre behavior, delirium, confusion, or coma), hot, dry skin, tachycardia, tachypnea, and hypotension.

The nurse is conducting a secondary survey on a client in the ED. Which action is completed during the secondary survey?

Diagnostic and laboratory testing Explanation: Diagnostic and laboratory testing is completed during the secondary survey, along with a complete health history, a head-to-toe assessment, insertion or application of monitoring devices, splinting of suspected fractures, cleansing, closure, and dressing of wounds, and performance of other necessary interventions based on the client's condition. The other interventions are completed during the primary survey.

A client is brought to the emergency department by ambulance. The client is seriously ill and unconscious. No family or friends are present. Which of the following would be most appropriate to do?

Document the client's condition and absence of friends or family for obtaining consent to treatment. Explanation: Consent is needed to examine and treat a client unless he or she is unconscious or in critical condition and unable to make decisions. In this situation, the client is unconscious and no friends or family are around to provide consent to treatment. The nurse should document this fact and provide care. Checking the client's record and asking the ambulance team for information would waste valuable time. Explaining to the client that care will be provided is appropriate even though the client is unconscious, but documentation is essential.

A nurse is preparing to assist with a gastric lavage for a client who has ingested an unknown poison and is obtunded. To ensure that the tube reaches the stomach, the nurse would measure the distance from the bridge of the nose to which of the following?

Ear lobe and then to the xiphoid process Explanation: The nurse measures the tube from the bridge of the nose to the xiphoid process to ensure that the tube reaches the stomach on insertion.

The nurse is caring for a client in the intensive care unit and while reviewing the client's history, the nurse notes the client had a King laryngeal tube inserted to begin ventilation. The nurse recognizes this intervention was required for which reason?

Emergency response personnel performed this intervention outside the hospital. Explanation: If the client is not hospitalized and cannot be intubated in the field, emergency medical personnel may insert a King laryngeal tube, which rapidly provides pharyngeal ventilation. When the tube is inserted into the trachea, it functions like an endotracheal tube. An oversized airway would not be the rationale for the use of a King tube. This is a temporary life-saving intervention used by first responders. Once admitted to hospital and stabilized, a different type of endotracheal tube would be considered. Laryngeal edema and hemorrhage into the neck are two emergency conditions in which intubation may not be an option. In this case, the nurse would note in the client's history that an emergency cricothyroidotomy (cricothyroid membrane puncture) was performed to establish an airway.

A client presents to the ED reporting choking on a chicken bone. The client is breathing spontaneously. The nurse applies oxygen and suspects a partial airway obstruction. Which action should the nurse do next?

Encourage the client to cough forcefully. Explanation: If the client can breathe and cough spontaneously, a partial obstruction should be suspected. The client is encouraged to cough forcefully and to persist with spontaneous coughing and breathing efforts as long as good air exchange exists. There may be some wheezing between coughs. If the client demonstrates a weak, ineffective cough, a high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis, the client should be managed as if there were complete airway obstruction. If the client is unconscious, inspection of the oropharynx may reveal the offending object. X-ray study, laryngoscopy, or bronchoscopy also may be performed. There is no indication that an artificial airway is indicated.

A patient brought to the ED by the rescue squad after getting off a plane at the airport is complaining of severe joint pain, numbness, and an inability to move the arms. The patient was on a diving vacation and went for a last dive this morning before flying home. What is a priority action by the nurse?

Ensure a patent airway and that the patient is receiving 100% oxygen. Explanation: Decompression sickness, also known as "the bends," occurs in patients who have engaged in diving (lake/ocean diving), high-altitude flying, or flying in commercial aircraft within 24 hours after diving. Signs and symptoms include joint or extremity pain, numbness, hypesthesia, and loss of range of motion. A patent airway and adequate ventilation are established before all other interventions, as described previously, and 100% oxygen is administered throughout treatment and transport.

A client is brought to the ED by friends. The friends tell the nurse that the client was using cocaine at a party. On arrival to the ED the client is in visible distress with an axillary temperature of 40.1ºC (104.2°F). What would be the priority nursing action for this client?

Ensure airway and ventilation. Explanation: Although all of the listed actions may be necessary for this client's care, the priority is to establish a patent airway and adequate ventilation.

A 6-year-old is admitted to the ED after being rescued from a pond after falling through the ice while ice skating. What action should the nurse perform while rewarming the client?

Ensuring continuous ECG monitoring Explanation: A hypothermic client requires continuous ECG monitoring and assessment of core temperatures with an esophageal probe, bladder, or rectal thermometer. Massage is not performed and bronchodilators would normally be insufficient to meet the client's respiratory needs.

A nurse is caring for a patient with multiple injuries and performs the following. Place these actions in the order in which the nurse would perform them. Use all options.

Establish airway and ventilation Control hemorrhage Prevent and treat shock Assess for head and neck injuries Assess for abdomen, back, and extremity injuries Splint fractures Explanation: When providing care to a patient with multiple injuries, the nurse would first establish airway and ventilation, then control hemorrhage, prevent and treat hypovolemic shock, and assess for head and neck injuries. Then the nurse would evaluate for other injuries including re-assessing the head, neck, and chest and assessing the abdomen, back, and extremities. Then the nurse would splint fractures and, lastly, perform a more thorough and ongoing examination and assessment.

Medical and nursing interventions for patients who present with multiple injuries follow a sequence of treatment priorities. Which of the following is the first priority of care?

Establish an airway. Explanation: The immediate intervention is to always manage the airway and breathing first; controlling hemorrhage is the second priority, followed by preventing and treating hypovolemic shock.

A patient has undergone a diagnostic peritoneal lavage. The nurse interprets which result as indicating a positive test?

Evidence of feces Explanation: A diagnostic peritoneal lavage is considered positive if there is bile, feces, or food in the specimen, a red blood cell count greater than 100,000/mm3, and a white blood cell count greater than 500/mm3.

The nurse is caring for a client with diabetes who requires a peripheral intravenous (PIV) line for antibiotic administration and to treat dehydration. The nurse must avoid inserting which type of PIV?

Foot Explanation: PIV lines should rarely be used in the foot for various reasons. They limit the client's ability to ambulate and tend to occlude easily. These types of IVs should never be used in clients with diabetes due to the risk that the client has neuropathy and cannot feel injury caused by the IV catheter. IV lines in the forearm and hands are acceptable and are commonly used sites. These sites would be safe to use for a client with diabetes. The upper arm is a site of choice for the insertion of a peripherally inserted central line (PICC) not a PIV line. Although, this site would not be an option for a PIV line, it would be safe for use in a client with diabetes if warranted.

Nursing students are reviewing the categories of intra-abdominal injuries. The students demonstrate understanding of the information when they identify which of the following as examples of penetrating trauma? Select all that apply.

Gunshot wound Knife-stab wound

A nurse is working as a camp nurse during the summer. A camp counselor comes to the clinic after receiving a snakebite on the arm. What is the first action by the nurse?

Have the patient lie down and place the arm below the level of the heart. Explanation: Initial first aid at the site of the snakebite includes having the person lie down, removing constrictive items such as rings, providing warmth, cleansing the wound, covering the wound with a light sterile dressing, and immobilizing the injured body part below the level of the heart. Airway, breathing, and circulation are the priorities of care. Ice, incision and suction, or a tourniquet is not applied.

A client is brought to the emergency department with injuries obtained from a motor vehicle crash. Which action will the nurse take during the secondary survey of the client? Select all that apply.

Head-to-toe assessment Results of laboratory tests History of the current event Splinting of suspected fractures Explanation: A systematic approach to effectively establishing and treating health priorities is the primary survey/secondary survey approach. Actions when completing the secondary survey include completing a head-to-toe assessment, reviewing the results of laboratory tests, collecting information about the current event, and splinting any suspected fractures. Maintenance of the airway occurs during the primary survey.

Which phase of the psychological reaction to rape is characterized by fear and flashbacks?

Heightened anxiety phase Explanation: During the heightened anxiety phase, the client demonstrates anxiety, hyperalertness, and psychosomatic reactions, in addition to fear and flashbacks. The acute disorganization phase is characterized by shock, disbelief, guilt, humiliation, and anger. The denial phase is characterized by an unwillingness to talk. The reorganization phase occurs when the incident is put into perspective. Some clients never fully recover from rape trauma.

A client comes to the emergency department with a suspected airway obstruction. The emergency department team prepares to manage the client as if he has a complete airway obstruction based on which of the following?

High-pitched noise on inhalation Explanation: A client who demonstrates a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis should be managed as if he or she has a complete airway obstruction. Forceful coughing, wheezing between coughs, and a refusal to lie flat suggest a partial airway obstruction that can be managed as such.

A nurse is caring for a client who has arrived at the emergency department in shock. The nurse intervenes based on the knowledge that which of the following is the most common cause of shock?

Hypovolemia Explanation: Types of shock include cardiogenic, neurogenic, anaphylactic, and septic. Of these, the most common cause is hypovolemia.

A backcountry skier has been airlifted to the ED after becoming lost and developing hypothermia and frostbite. How should the nurse best manage the client's frostbite?

Immerse affected extremities in water slightly above normal body temperature. Explanation: Frozen extremities are usually placed in a 37°C to 40°C (98.6°F to 104°F) circulating bath for 30- to 40-minute spans. To avoid further mechanical injury, the body part is not handled. Massage is contraindicated.

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

Increasing heart rate Explanation: Early in shock, heart rate increases. Inadequate tissue perfusion causes pale, cool, clammy skin (not pale, warm, dry skin). In the early stages of shock, the client's heart rate will become elevated above normal. In early shock the client's blood pressure will remain normal, but as shock progresses the mechanisms that regulate blood pressure will not be able to compensate.

The nurse is caring for a client suffering from carbon monoxide poisoning. The nurse will expect the client to exhibit which manifestation?

Intoxication Explanation: A client suffering from carbon monoxide poisoning appears intoxicated (from cerebral hypoxia). Other signs and symptoms include headache, muscular weakness, palpitation, dizziness, and mental confusion. The skin coloring in the client with carbon monoxide poisoning can range from pink to cherry red to cyanotic and pale and is not a reliable diagnostic sign.

A patient arrives at the emergency department after sustaining a gunshot wound to the abdomen. When assessing the patient, the nurse pays particular attention to which of the following?

Liver Explanation: Penetrating abdominal injuries, such as from a gunshot wound, are serious and result in a high incidence of injury to hollow and solid organs. Although any organs can be injured, the liver is the most frequently injured solid organ. The small bowel is a frequently injured hollow organ. Thus, of the options shown, the nurse would assess the liver area most closely.

Which solid organ is most frequently injured in a penetrating trauma?

Liver Explanation: The most frequently injured solid organ in a penetrating trauma is the liver because of its size and anterior placement in the right upper quadrant of the abdomen.

A nurse is providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate?

Massaging the feet Explanation: For a client with frostbite, massaging the affected body part is contraindicated. Analgesia is given for pain during the rewarming process because it can be very painful. Ambulation would be restricted. Once rewarmed, sterile gauze or cotton is placed between the affected toes to prevent maceration.

A client presents to the ED after an unsuccessful suicide attempt. The client is diagnosed with an acetaminophen overdose. The nurse anticipates the administration of which medication?

N-acetylcysteine Explanation: Treatment of acetaminophen overdose includes administration of N-acetylcysteine. Flumazenil is administered in the treatment of nonbarbiturate sedative overdoses. Naloxone is administered in the treatment of narcotic overdoses. Diazepam may be administered to treat uncontrolled hyperactivity in the client with a hallucinogen overdose.

Which medication reverses severe respiratory depression and coma?

Naloxone hydrochloride Explanation: Naloxone hydrochloride, a narcotic antagonist, reverses respiratory depression and coma. Diazepam is a benzodiazepine. Flumazenil is a benzodiazepine antagonist. N-acetylcysteine is used for acetaminophen toxicity.

The nurse is caring for a client with known myocardial ischemia. The client will be getting up to ambulate for the first time in three days after being on bedrest since admission to the intensive care unit. Which medication should the nurse administer before the client ambulates?

Nitroglycerin Explanation: Nitroglycerin is indicated for use in clients who experience angina pectoris as a result of myocardial ischemia. The medication acts by decreasing blood pressure and causing arterial vasodilation permitting blood flow into the myocardium. Nitroglycerin should be given prior to any anticipated physical exertion that is likely to bring on chest pain from vasoconstriction. Vasopressin is a vasoactive medication administered to increase blood pressure in cases where clients have diabetes insipidus, a gastrointestinal bleed or in cases of septic shock. Norepinephrine raises blood pressure and is indicated for use in emergencies such as cardiac arrest or for hypovolemia. Dobutamine increased heart contractility and blood pressure to improve stroke volume in clients with congestive heart failure.

A client presents to the ED following a chemical burn. The client identifies the source of the burn as white phosphorus. The nurse knows that treatment will include

No application of water to the burn. Explanation: Water should not be applied to burns from lye or white phosphorus because of the potential for an explosion or for deepening of the burn. All evidence of these chemicals should be brushed off the client before any flushing occurs.

An 83-year-old client is brought in by ambulance from a long-term care facility. The client's symptoms are weakness, lethargy, incontinence, and a change in mental status. The nurse knows that emergencies in older adults may be more difficult to manage for what reason?

Older adults may have an altered response to treatment. Explanation: Emergencies in this age group may be more difficult to manage because elderly clients may have an atypical presentation, an altered response to treatment, a greater risk of developing complications, or a combination of these factors. The elderly client may perceive the emergency as a crisis signaling the end of an independent lifestyle or even resulting in death. Stigmatization and nonadherence to treatment are not commonly noted. Older adults do not necessarily have difficulty giving a health history.

A client is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the health care provider will perform which of the following actions?

Perform endotracheal intubation. Explanation: Endotracheal tubes are used in cases when the client cannot be ventilated with an oropharyngeal airway, which is used in clients who are breathing spontaneously. The jaw thrust maneuver does not establish an airway and cricothyroidotomy would be performed as a last resort.

A nurse is providing care to a client in the emergency department and walks into the hallway to get equipment. All of a sudden, gunshots are heard. Which of the following would be the nurse's priority?

Protecting himself or herself Explanation: If gunfire occurs in the emergency department, self-protection is the priority. Security officers and police must gain control of the situation first and then care is provided to the injured.

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

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

A client is admitted to the ED complaining of abdominal pain. Further assessment of the abdomen reveals signs of peritoneal irritation. What assessment findings would corroborate this diagnosis? Select all that apply.

Rebound tenderness Changes in bowel sounds Muscular rigidity Explanation: Signs of peritoneal irritation include abdominal distention, involuntary guarding, tenderness, pain, muscular rigidity, or rebound tenderness along with changes in bowel sounds. Diarrhea and ascites are not signs of peritoneal irritation.

The nurse observes that the family members of a client who was injured in an accident are blaming each other for the circumstances leading up to the accident. The nurse appropriately lets the family members express their feelings of responsibility, while explaining that there was probably little they could do to prevent the injury. In what stage of crisis is this family?

Remorse and guilt Explanation: Remorse and guilt are natural processes of the stages of a crisis and should be facilitated for the family members to process the crisis. The family's sense of blame and responsibility are more suggestive of guilt than anger, grief, or anxiety.

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

Repositioning the patient's head Explanation: Establishing an airway may be as simple as repositioning the patient's head to prevent the tongue from obstructing the pharynx. Subsequent measures would include abdominal thrusts to dislodge a foreign body, head-tilt chin-lift or jaw-thrust maneuver, or insertion of an artificial airway.

The nurse in an intensive care unit is assigned to two clients. One of the clients has just passed away. The deceased client's family members have arrived to be at the client's bedside. Despite wanting to support the client's family, the nurse is must assess the other client's vital signs every 15 minutes, because the client is receiving a blood transfusion. In this situation, what is the nurse's best action?

Request that the pastor be present to support the family at the client bedside Explanation: The death of a family member in the intensive care unit is a difficult and often time-consuming process. If nurses are unable to spend much time with grieving client's family, it is imperative to find the family alternate help: a colleague with more experience with grieving clients, a pastor, a social worker, hospital volunteers, family, or friends. It would be best if the nurse requests a pastor be available to the family in advance of their arrival to the deceased client's bedside. Much of the pastor's role in hospital settings is to support grieving families; therefore, the pastor would have more time to be with the family during this difficult time. The blood transfusion in the intensive care unit is not within the scope of practice for the licensed practical/vocational nurse. The nurse cannot delegate the monitoring of blood products to this health care provider. The intensive care unit is a busy environment and as difficult as it is for the assigned nurse to remain with the deceased client, it would be even more difficult for a nurse with a full assignment to take on the support role for the family. Explaining to the family that the unit is busy demonstrates a lack of empathy and would be countertherapeutic communication. It would not be appropriate to explain this to the family.

The emergency nurse is preparing to triage a group of four clients who have presented to the emergency department (ED) and arrived at the same time.

Requires Immediate Intervention 46-year-old male client who presents with suspected broken leg as a result of motor vehicle crash (MVC) 22-year-old female client who presents with left quadrant abdominal pain and moderate vaginal bleeding with clots 52-year-old female client who presents with severe back pain of recent onset Can wait to be seen 25-year-old male client who presents with a small laceration on the left upper arm The concept of triage is to "sort" clients into groups based on acuity, and determine which clients should be seen/treated first. The 46-year-old male client with a suspected fractured leg should be seen immediately. A fracture can lead to further complications such as development of a fat embolism, which can be fatal. Stabilization and surgical intervention are needed. The 22-year-old female client needs to be seen immediately because they may be experiencing a tubal pregnancy, ovarian problem, or a miscarriage. Determination of the source of the bleeding and the etiology of the abdominal pain must be identified. The 52-year-old female client experiencing severe back pain should be seen immediately because female clients present with atypical presentations related to cardiac issues. This client may be experiencing a cardiac event, and the client should be seen immediately to determine if this is cardiac in nature. The 25-year-old male client presenting with a small laceration on the left upper arm does not require immediate attention and can be classified as nonurgent.

A nurse is performing triage at the scene of a building collapse and is using a five-level triage system. Place the categories below in the proper order from most to least immediate.

Resuscitation Emergent Urgent Less urgent Nonurgent Explanation: The five-level system of triage classifies patients as follows: resuscitation (need immediate treatment to prevent death); emergent (may deteriorate rapidly and develop a major life-threatening situation or require time-sensitive treatment); urgent (need two or more resources to provide care and conditions are not life-threatening); less urgent (need only one resource for needs and condition is not life-threatening); and nonurgent (require no resources for care with no life-threatening condition).

The nurse has commenced a transfusion of fresh frozen plasma (FFP) and notes the client is exhibiting symptoms of a transfusion reaction. After the nurse stops the transfusion, what is the next required action?

Run a normal saline line to keep the vein open Explanation: If the nurse suspects a transfusion reaction, the transfusion must be stopped immediately and the nurse's next action is to ensure the normal saline line is running at a rate that permits administration of IV fluids or medications that are required to treat the reaction. The nurse should ensure IV access is maintained. The "to keep vein open" (TKVO) rate allows the nurse to keep the IV client without the potential to cause fluid volume overload. It would be unsafe for the nurse to remove the peripheral IV because continued access is required for urgent IV administration of medications or fluids to treat the reaction. Obtaining a blood culture at the IV site would be necessary if an infection was suspected. This is not required for a transfusion reaction. Normal saline is the solution of choice when transfusing blood products because there is a risk for incompatibility with all other IV solutions.

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

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

Which guideline is appropriate for a nurse to implement while helping family members cope with the sudden death of a loved one?

Show acceptance of the body by touching it, giving the family permission to touch. Explanation: The nurse should encourage the family to view and touch the body if they wish, since this action helps the family to integrate the loss. The nurse should avoid using euphemisms such as "passed on." The nurse should avoid giving sedation to family members, because this may mask or delay the grieving process. The nurse should avoid volunteering unnecessary information (e.g., client was drinking at the time of the accident).

A client comes to the emergency department after experiencing a wound. Inspection reveals an opening in the skin with distinct edges and whose depth is greater than the length of the wound. The nurse documents this as which type of wound?

Stab Explanation: A stab wound is an incision of the skin with well-defined edges and is typically deeper than long. It is usually caused by a sharp instrument. A laceration is a tear in the skin with irregular edges and vein bridging. An avulsion is manifested as a tearing away of tissue from the supporting structures. A patterned wound takes on the outline of the object causing the wound.

A client is admitted to the emergency department after sustaining a penetrating injury to the abdomen. Which of the following would the nurse identify as a possible cause?

Stabbing with a knife Explanation: Penetrating abdominal injuries are ones involving an opening into the abdomen, such as those that occur with a gunshot or stabbing. Blunt injuries usually occur with motor vehicle crashes, falls, and explosions.

A patient was bitten by a tick 3 months ago and is now having muscle aches as well as joint pain and swelling. The patient is having difficulty with self care and requires assistance with activities of daily living (ADLs). What stage of Lyme disease does the nurse recognize the patient is in?

Stage III Explanation: Lyme disease has three stages. Stage I presents with a classic "bull's-eye" rash (i.e., erythema migrans) and flulike signs and symptoms that may include chills, fever, myalgia, fatigue, and headache. If antibiotics are not administered, stage II Lyme disease may present within 4 to 10 weeks following the tick bite and may manifest with joint pain, memory loss, poor motor coordination, and meningitis. Stage III can begin anywhere from weeks to more than a year after the bite and has serious long-term chronic sequelae, including arthritis, neuropathy, myalgia, and myocarditis.

A triage nurse is talking to a client when the client begins choking on his lunch. The client is coughing forcefully. What should the nurse do?

Stay with him and encourage him, but not intervene at this time. Explanation: If the client is coughing, he should be able to dislodge the object or cause a complete obstruction. If complete obstruction occurs, the nurse should perform the abdominal thrust maneuver with the client standing. If the client is unconscious, the nurse should lay the client down. A nurse should never leave a choking client alone.

A nurse is providing in-service education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step?

Supporting the client's emotional status Explanation: The teaching session is successful when staff members focus first on supporting the client's emotional status. Next, staff members should gain consent to perform the pelvic examination, perform the examination, and collect evidence, such as semen if present.

A patient in the emergency department is bleeding profusely from numerous large and deep lacerations on the top of his head, right side of his face, and forehead. The nurse determines the need to apply pressure at the appropriate pressure point. The nurse would use which of the following pressure points?

Temple pic Explanation: The location of the injuries and site of bleeding determine which pressure point to use. In this case, the patient's bleeding is proximal to the temporal artery; therefore, pressure should be applied to this area, as shown in option A. If the patient was bleeding from the lower portion of the face, pressure would be applied to the facial artery, as in option B. The carotid artery would be used to control bleeding proximal to that area. The subclavian artery would be used to control bleeding proximal to it, such as the lower neck and shoulder area.

The nurse is caring for a client in the intensive care unit who is recovering from trauma as a result of a motor vehicle accident that claimed the life of the client's friend. While the nurse is performing a dressing change on the client's surgical wound, the client states, "I don't deserve to live. I have just been thinking about ending it all." As the nurse assesses the client's imminent risk for suicide, what contributing factors need to be considered? Select all that apply.

The client attempted suicide as a teenager. The client's maternal uncle committed suicide. The client had a close relationship to the accident victim. Explanation: When assessing a client's suicide risk, it is very important to first determine whether the client has a previous history of suicide attempts. Having a suicide-attempt history increases the risk that the client will attempt to end his or her life if experiencing suicidal thoughts. Having a family member who has committed suicide increases the risk that the client will follow through with a suicide attempt. Family support mitigates the risk that the client will follow through with a suicide attempt if the client is experiencing hopeless thoughts. Having a close relationship with the victim in the car accident indicates the client is experiencing grief and loss and may increase the risk of suicide. If the client is unable to ambulate unassisted, this decreases the client's means to access to be able to follow through with a suicide attempt.

When reviewing the results of a client's lumbar puncture, a nurse notes a glucose level of 32 mg/dl. What does this result suggest to the nurse?

The client may have bacterial meningitis. Explanation: The normal glucose level for CSF ranges from 50 mg/dl to 75 mg/dl. The client's reduced glucose level may indicate a condition such as bacterial meningitis. The client's glucose level doesn't indicate diabetes mellitus. A decreased serum (not CSF) glucose level indicates hypoglycemia.

The nurse is caring for a client who is being prepared for the placement of a central intravenous line. The nurse recognizes this client requires this type of intravenous access for which reason?

The client requires total parenteral nutrition Explanation: For a patient who requires total parenteral nutrition (TPN), a central intravenous line is required due to the length of time the client will require the infusion as well as the nature of the solution itself. A large vein is required to safely infuse TPN. For this reason, a central line is needed. A peripheral intravenous line is safe to used when IV access is required under six days. Beyond this time, either a new peripheral IV will need to be inserted. If it is known in advance that IV treatment will last beyond six days, the client's health care provider will order the placement of a central intravenous line. Intravenous antibiotics can be administered peripherally unless the course is longer than six days. D5W is an intravenous solution that can be administered either peripherally or centrally. The nature of this IV solution would not determine which type of IV access the client requires.

The nurse is caring for a client with right ventricular heart failure. The nurse understands hypervolemia will have what effect on the client's heart?

The client's myocardial oxygen requirements will be higher Explanation: Clients with heart failure are typically hypervolemic and as a result this increases the cardiac preload. An increased fluid volume increases the stroke volume, ventricular work and myocardial oxygen requirements. Vasodilation can be a potential cause for decreased preload and afterload, not increased preload as in this case. This client would experience vasoconstriction due to the increase volume with each stroke.

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

The tongue Explanation: In an unconscious client, the muscles controlling the tongue commonly relax, causing the tongue to obstruct the airway. When this situation occurs, the nurse should use the head-tilt, chin-lift maneuver to cause the tongue to fall back into place. If she suspects the client has a neck injury she must perform the jaw-thrust maneuver.

A client present to the ED following a work-related injury to the left hand. The client has an avulsion of the left ring finger. Which correctly describes an avulsion?

Tissue tearing away from supporting structures Explanation: An avulsion is described as a tearing away of tissue from supporting structures. A laceration is a skin tear with irregular edges and vein bridging. Abrasion is denuded skin. A cut is an incision of the skin with well-defined edges, usually long rather than deep.

The nurse is caring for a patient in the ED who is breathing but unconscious. In order to avoid an upper airway obstruction, the nurse is inserting an oropharyngeal airway. How would the nurse insert the airway?

Upside down and then rotated 180 degrees Explanation: The nurse should insert the oropharyngeal airway with the tip facing up toward the roof of the mouth until it passes the uvula and then rotate the tip 180 degrees so that the tip is pointed down toward the pharynx. This displaces the tongue anteriorly, and the patient then breathes through and around the airway.

A triage nurse in the ED determines that a patient with dyspnea and dehydration is not in a life-threatening situation. What triage category will the nurse choose?

Urgent Explanation: A basic and widely used triage system that had been in use for many years utilized three categories: emergent, urgent, and nonurgent. In this system, emergent patients had the highest priority, urgent patients had serious health problems but not immediately life-threatening ones, and nonurgent patients had episodic illnesses.

A client presents to the ED with serious health problems that are not immediately life threatening. The nurse will correctly triage the client into which category?

Urgent Explanation: Clients triaged as urgent have serious health problems that are not immediately life threatening. They must be seen within 1 hour. The emergent category is for clients who have the highest priority conditions that are life-threatening and they must be seen immediately. Nonurgent is for clients who have episodic illness that can be addressed within 24 hours without increased morbidity. Clients in the less urgent category must be reassessed at least every 60 minutes and do not have serious health problems.

A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's:

blood pressure. Explanation: With adequate fluid replacement, fluid volume in the intravascular space expands, raising the client's blood pressure. The hemoglobin level reflects red blood cell concentration, not overall fluid status. Temperature and heart rate aren't directly related to fluid status.

An 85-year-old client is admitted to the ED. Heat stroke is suspected. The client's core temperature is 106.2°F (41.2°C), blood pressure (BP) 90/60 mm Hg, and pulse 102 bpm. The nurse understands that the primary treatment measure for the client will include

immersion of the client in a cold-water bath. Explanation: For the client with heat stroke, simultaneous treatment focuses on stabilizing oxygenation using the CABs (circulation, airway, and breathing; formerly called the ABCs) of basic life support. This includes establishing IV access for fluid administration. After the client's clothing is removed, the core (internal) temperature is reduced to 39°C (102°F) as rapidly as possible, preferably within 1 hour. One or more of the following methods may be used as prescribed: cool sheets and towels or continuous sponging with cool water; ice applied to the neck, groin, chest, and axillae while spraying with tepid water; and cooling blankets. Immersion of the client in a cold-water bath is the optimal method for cooling (if available). Hydration would be with lactated Ringer solution. There is no indication for intubation. Administration of sodium supplements is indicated for the treatment of heat cramps.

A client is admitted to the ED after a near-drowning accident. The client is diagnosed with saltwater aspiration. The nurse will observe the client for several hours to monitor for symptoms of

pulmonary edema. Explanation: Resultant pathophysiologic changes and pulmonary injury depend on the type of fluid (fresh or salt water) and the volume aspirated. Freshwater aspiration results in a loss of surfactant and therefore an inability to expand the lungs. Saltwater aspiration leads to pulmonary edema from the osmotic effects of the salt within the lungs. If a person survives submersion, acute respiratory distress syndrome, resulting in hypoxia, hypercarbia, and respiratory or metabolic acidosis, can occur. The client would experience hypernatremia. Hypothermia and head injury may be associated with near drowning but would be apparent at the time of admission and would not develop after several hours.

The nurse is caring for a client in the ED following a sexual assault. The client is hysterical and crying. The client states, "I know I'm pregnant now, maybe I have HIV. Why did this happen to me?" Which is the best response by the nurse?

"Let's talk about this. Do you want me to call a support person?" Explanation: The client should be reassured that anxiety is natural and asked whether a support person may be called. The goals of management are to provide support, reduce the client's emotional trauma, and gather available evidence for possible legal proceedings. Throughout the client's stay in the ED, the client's privacy and sensitivity must be respected. The client may exhibit a wide range of emotional reactions, such as hysteria, stoicism, or feelings of being overwhelmed. Support and caring are crucial.

The nurse is caring for an intensive care unit client who has died with family members at the bedside. The death was sudden and unexpected resulting from a car accident that took place three days ago. The family is upset and the client's partner, crying loudly, yells, "How did this happen? We were just about to celebrate his birthday. He can't be gone!" The family member continues to cry inconsolably. How should the nurse respond?

"We did everything we could possibly do to try to save his life." Explanation: In order to help the family cope with the sudden death of their loved one, it is helpful for the nurse to explain that the care team employed all medical interventions possible to try to save the client's life. With the support of other members of the health care team, the nurse can take the time to explain what life saving treatments were rendered. The nurse should avoid giving sedation to family members; this may mask or delay the grieving process, which is necessary to achieve emotional equilibrium and to prevent prolonged depression. It is important that the nurse avoid using euphemisms such as "passed on." Instead the nurse should show the family that he or she cares by touching, and offering coffee, water, and the services of a chaplain. The nurse should encourage the family to express emotion including events leading up to the event that led to the client's death. The nurse should not challenge initial feelings of anger or denial.

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

3 to 5 minutes Explanation: If the airway is completely obstructed, permanent brain injury or death will occur within 3 to 5 minutes secondary to hypoxia. Air movement is absent in the presence of complete airway obstruction. Oxygen saturation of the blood decreases rapidly because obstruction of the airway prevents air from entering the lungs. Oxygen deficit occurs in the brain, resulting in unconsciousness, with death following rapidly. The other time frames are incorrect.

The nurse is administering 100% oxygen to a patient with carbon monoxide poisoning and obtains a carboxyhemoglobin level. Which level would the nurse interpret as indicating that oxygen therapy can be discontinued?

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

Several clients in the emergency department are being categorized by the triage nurse. Which client will the nurse place in the urgent category?

A 54-year-old client with a history of diabetes presenting with anemia and abdominal pain Explanation: A basic and widely used triage system utilizes three categories: emergent, urgent, and nonurgent. In this system emergent patients have the highest priority, urgent patients had serious health problems but not immediately life-threatening ones, and nonurgent patients had episodic illnesses.The client with multiple gunshot wounds to the chest and the client with chest pain and ST elevations (Indicator of a myocardial infarction) would be considered emergent patients because without intervention they have a high likelihood of death. The client needing stitches would be considered non-urgent since their chance of losing their hand was not an issue and they only needed stitches and cleaning. The client with diabetes presenting with anemia and abdominal pain would be the most likely candidate considered as urgent because they have serious health problems but not immediately and obviously life-threatening ones.

The nurse is caring for a client in the ED with frostbite to the left hand. During the rewarming process of the hand, the nurse should perform which action?

Administer analgesic medications as ordered. Explanation: During rewarming, an analgesic for pain is administered as prescribed because the rewarming process may be very painful. Frozen extremities are usually placed in a 37°C to 40°C (98.6°F to 104°F) circulating bath for 30- to 40-minute spans. This treatment is repeated until circulation is effectively restored. Hemorrhagic blebs, which may develop 1 hour to a few days after rewarming, are left intact and unruptured. Nonhemorrhagic blisters are debrided to decrease the inflammatory mediators found in the blister fluid. After rewarming, hourly active motion of any affected digits is encouraged to promote maximal restoration of function and to prevent contractures.

The nurse received a patient from a motor vehicle accident who is hemorrhaging from a femoral wound. What is the initial nursing action for the control of the hemorrhage?

Apply firm pressure over the involved area or artery. Explanation: Direct, firm pressure is applied over the bleeding area or the involved artery at a site that is proximal to the wound (Fig. 72-3). Most bleeding can be stopped or at least controlled by application of direct pressure. Otherwise, unchecked arterial bleeding results in death. A firm pressure dressing is applied, and the injured part is elevated to stop venous and capillary bleeding, if possible. If the injured area is an extremity, the extremity is immobilized to control blood loss. A tourniquet is applied to an extremity only as a last resort when the external hemorrhage cannot be controlled in any other way and immediate surgery is not feasible.

A patient is brought to the ED by a friend, who states that a tree fell on the patient's leg and crushed it while they were cutting firewood. What priority actions should the nurse perform? (Select all that apply.)

Applying a clean dressing to protect the wound Elevating the site to limit the accumulation of fluid in the interstitial spaces Splinting the wound in a position of rest to prevent motion Explanation: Major soft tissue injuries are dressed and splinted promptly to control bleeding and pain. If an extremity is injured, it is elevated to relieve swelling and pressure.

As part of an emergency department team, an emergency nurse is conducting a secondary survey on a client. Which of the following would the nurse include?

Applying electrocardiogram electrodes Explanation: A secondary survey is completed after the primary survey priorities of airway, breathing, circulation, and disability have been addressed. Applying electrocardiogram electrodes would be a component of the secondary survey. Establishing a patent airway, providing adequate ventilation, and determining neurologic disability by assessing neurologic function are components of the primary survey.

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

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

A client is brought to the emergency department with abdominal and pelvic injuries caused by a motor vehicle crash. Which action will the nurse take when the client is prescribed to have an indwelling catheter inserted?

Ask if the rectal examination has been done prior to inserting the catheter. Explanation: A focused genitourinary examination, which typically includes a rectal and/or vaginal examination, is performed to determine any injury to the pelvis, bladder, urethra, vaginal, or intestinal wall. In the male client, a prostate gland issue discovered during a rectal examination indicates a potential urethra injury. A digital vaginal examination is performed on female clients to determine if there is an open pelvic fracture that has torn the vagina. To decompress the bladder and monitor urine output in a client with a genitourinary injury, an indwelling catheter is inserted after a rectal examination has been completed. Urethra catheterization is contraindicated when a possible urethra injury is present. Urology consultation and further evaluation of the urethra is required prior to any insertion. A bladder scan, urodynamic testing, and putting the client on a bedpan are not warranted since the placement of a urinary cathether is primarily for decompression not retention. Urodynamic testing are procedures that typically reveal how well the bladder sphincters and urethra store and release urine.

A nurse is providing care to the family of a client who was brought to the emergency department and suddenly died. Which of the following would be appropriate for the nurse to do? Select all that apply.

Ask the family if they would like to view the body. Provide a private place for the family to be together. Allow the family to express their emotions freely. Explanation: When providing care to a family experiencing the sudden death of a member, the nurse would take the relatives to a private place where they can be together to grieve. In addition, the nurse would encourage the family to view the body if they wish and allow members to support each other and express their emotions freely. Euphemisms such as "passing on" or "going to a better place" should be avoided. Sedation is avoided because it may mask or delay the grieving process, which is necessary to achieve emotional equilibrium and prevent prolonged depression.

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

Assessing the client's Glasgow Coma Scale score Explanation: The primary survey focuses on stabilizing life-threatening conditions. The ED staff work collaboratively and follow the ABCDE (airway, breathing, circulation, disability, exposure) method. While implementing the D element, the nurse determines neurologic disability by assessing neurologic function using the Glasgow Coma Scale and performing a motor and sensory evaluation of the spine. A quick neurologic assessment may be performed using the AVPU mnemonic: A, alert: is the client alert and responsive? V, verbal: does the client respond to verbal stimuli? P, pain: does the client respond only to painful stimuli? U, unresponsive: is the client unresponsive to all stimuli, including pain? The other interventions are not included in this element of the primary survey.

A homeless client presents to the ED. Upon assessment, the client is experiencing hypothermia. The nurse will plan to complete which priority intervention during the rewarming process?

Attach a cardiac monitor Explanation: Continuous electrocardiograph (ECG) monitoring is performed during the rewarming process because cold-induced myocardial irritability leads to conduction disturbances, especially ventricular fibrillation. A urinary catheter should be inserted to monitor urinary output; however, ECG monitoring is the priority. There is no indication for endotracheal intubation. Inotropic medications are contraindicated because they can stimulate the heart and increase the risk for fatal dysrhythmias, such as ventricular fibrillation.

A client with depression and behavioral changes is transferred from a local assisted living center to the emergency department. The nurse notes that the client cries out when she approaches. When the nurse gains the client's confidence and performs an assessment, the nurse notes bruising of the labia and a lateral laceration in the perineal area. When the nurse asks the client about the injury, the client shakes her head and begins to cry "don't tell, don't tell." The nurse suspects sexual abuse. How should the nurse proceed?

Attend to the client's physiological needs. Explanation: The nurse should attend to the client's immediate physiological needs, including physical safety. Next, the nurse can notify the physician and the rape crisis team. The family should be notified if the client consents, but not until the rape investigation is complete.

The nurse is caring for a client who has just been intubated and started on mechanical ventilation in the intensive care unit. The nurse recognizes that it is possible to inadvertently intubate the right lung only. What nursing assessment and monitoring is required to determine if this complication has occurred? Select all that apply.

Auscultate both sides of the chest Mark the endotracheal tube at the corner of the mouth and nose Monitor for both high and low pressure alarms Explanation: It is important to remember that the right main bronchus is wider, shorter, and more vertical than the left. This physiologic difference may lead to inadvertent intubation of the right lung only. It is essential to listen to both sides of the chest for bilateral breath sounds, mark the correct endotracheal tube (ETT) placement at lip or nares, and monitor for high- and low-pressure alarms. Although suctioning the airway to remove secretions is an essential part of the nurse's responsibility when caring for a ventilated client, this action will not help the nurse determine if the tube has been placed only into the right lung only. The ventilator settings are determined by the client's primary health provider and any changes would require an order. These settings are specific to the client's individualized needs. Despite this, the re-setting the ventilator would not help determine incorrect placement of the endotracheal tube.

When assessing a client with suspected carbon monoxide poisoning, which finding would be least reliable?

Cherry red skin color Explanation: Skin color can range from pink or cherry-red to cyanotic and pale is not a reliable sign. In clients with carbon monoxide poisoning, central nervous system signs such as headache and confusion predominate. Palpitations also may occur.

A client is admitted to the ED after being involved in a motor vehicle accident. The client has multiple injuries. After establishing an airway and adequate ventilation, the ED team should prioritize what aspect of care?

Control the client's hemorrhage. Explanation: After establishing airway and ventilation, the team should evaluate and restore cardiac output by controlling hemorrhage. This must precede neurologic assessments and treatment of skeletal injuries.

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

Cool, moist skin Decreasing blood pressure Increasing heart rate Delayed capillary refill Explanation: Signs and symptoms of shock include cool, moist skin (resulting from poor peripheral perfusion), decreasing blood pressure, increasing heart rate, delayed capillary refill, and decreasing urine volume.

A client arrives at the emergency department and is experiencing a severe allergic reaction to a bee sting. The client received treatment and is being discharged. Which client statement indicates that additional teaching about exposure prevention is needed?

"Brightly colored clothes help to ward off bees." Explanation: To prevent insect stings, the client should avoid wearing brightly colored clothing because it attracts bees. The client should wear covering on the feet and avoid going barefoot because yellow jackets nest and pollinate on the ground. Staying still or motionless reduces the likelihood of being stung. Perfumes and scented soaps attract bees and should be avoided.

A patient is brought to the emergency department. Assessment reveals that the patient is lethargic and diaphoretic and complaining of right upper quadrant pain. Acetaminophen toxicity is suspected and an acetaminophen level is drawn. Which result would the nurse interpret as indicating toxicity for the patient if he weighs 70 kg?

10,500 mg Explanation: An acetaminophen level greater than or equal to 140 mg/kg would be considered toxic. For a patient weighing 70 kg, the toxic level would be 9800 mg. A level of 10,500 mg would be greater, thus indicating toxicity.

A client suspected of acetaminophen (Tylenol) toxicity reports that he ingested the medication at 7 p.m. At what time should the nurse anticipate laboratory tests to assess the acetaminophen level?

11:00 p.m. Explanation: The duration of action of acetaminophen ranges from 3 to 5 hours. Its half-life ranges from 1 to 3 hours. At least 4 hours should pass between the last dose and laboratory assessment of the acetaminophen level.

A nurse is caring for a client who has been the victim of sexual assault. The nurse documents that the client appears to be in a state of shock, verbalizing fear, guilt, and humiliation. What phase of rape trauma syndrome is this client most likely experiencing?

Acute disorganization phase Explanation: The acute disorganization phase may manifest as an expressed state in which shock, disbelief, fear, guilt, humiliation, anger, and other such emotions are encountered. These varied responses to the assault are not associated with a denial, heightened anxiety, or reorganization phase.

A patient with frostbite to both lower extremities from exposure to the elements is preparing to have rewarming of the extremities. What intervention should the nurse provide prior to the procedure?

Administer an analgesic as ordered. Explanation: During rewarming, an analgesic for pain is administered as prescribed, because the rewarming process may be very painful. To avoid further mechanical injury, the body part is not handled. Massage is contraindicated.

The nurse is providing care for a client who is experiencing alcohol withdrawal. The client reports, "I cannot fall or stay asleep." The nurse observes that the client is agitated, having difficulty falling asleep and crying uncontrollably, with confused speech and a tachycardic pulse. Which intervention should the nurse implement first?

Administer lorazepam as ordered by the health care provider Explanation: Clients with alcohol withdrawal syndrome show signs of anxiety, uncontrollable fear, tremor, irritability, agitation, insomnia, and incontinence. They are talkative and preoccupied and experience visual, tactile, olfactory, and auditory hallucinations that often are terrifying. Autonomic overactivity occurs and is evidenced by tachycardia, dilated pupils, and profuse perspiration. Usually, all vital signs are elevated in the alcoholic toxic state. The goals of management are to give adequate sedation and support to allow the client to rest and recover without danger of injury or peripheral vascular collapse. A sufficient dosage of a benzodiazepine medication such as lorazepam should be administered to establish and maintain sedation, which reduces agitation, prevents exhaustion, prevents seizures, and promotes sleep. Although the alternate answer options should be included in the client's care, the nurse's first action should be to treat the presenting symptoms. Once the client is calm, the nurse can assess for the risk to harm self or others. The nurse can also support the client in managing anxiety by encouraging deep breathing. If a family member is present, the nurse can ask him or her to stay at the bedside to support the client and ensure safety as the client experiences withdrawal symptoms.

A 40-year-old client is admitted to the ED with facial bruises and a broken right wrist. Upon further assessment, the nurse notes multiple bruises in various stages of healing. Which is the best course of action by the nurse?

Asking the client whether they are experiencing abuse Explanation: The priority is to ask the client whether they are experiencing abuse, then proceed as the situation dictates. It is important to use interviewing techniques that are likely to elicit accurate information. Since many people experiencing abuse are afraid to disclose, an open-ended question asking how the bruises occurred is less appropriate than a question that asks directly about abuse, such as "I see that you have many bruises. Has someone hurt you?" or "You have several injuries. Is there anyone that you're afraid of?" These more direct questions supply some of the words the client can use to discuss abuse if it is occurring. Nurses must be mindful that competent adults are free to accept or refuse help that is offered. Some clients insist on remaining in the home environment where the abuse or neglect is occurring. The wishes of clients who are competent and not cognitively impaired should be respected. However, all possible alternatives, available resources, and safety plans should be explored with the client. Mandatory reporting laws in most states require health care workers to report suspected child abuse or abuse of older adults to an official agency, usually Adult (or Child) Protective Services. All that is required for reporting is the suspicion of abuse; the health care worker is not required to prove abuse or neglect.

A female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing interventions should be provided? (Select all that apply.)

Assess and document any bruises and lacerations. Record a history of the event, using the patient's own words. Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police. Explanation: A history is obtained only if the patient has not already talked to a police officer, social worker, or crisis intervention worker. The patient should not be asked to repeat the history. Any history of the event that is obtained should be recorded in the patient's own words. The patient is asked whether he or she has bathed, douched, brushed his or her teeth, changed clothes, urinated, or defecated since the attack, because these actions may alter interpretation of subsequent findings. Each item of clothing is placed in a separate paper bag. The bags are labeled and given to appropriate law enforcement authorities. The patient is examined (from head to toe) for injuries, especially injuries to the head, neck, breasts, thighs, back, and buttocks. The exam focuses on external evidence of trauma (bruises, contusions, lacerations, stab wounds).

The nurse is admitting a patient with a penetrating abdominal injury from a knife wound. What should the nursing measures for a penetrating abdominal injury include? (Select all that apply.)

Assessing for manifestations of hemorrhage Covering any protruding viscera with sterile dressings soaked in normal saline solution Looking for any associated chest injuries Irrigating the wound with normal saline and a syringe Explanation: Hemorrhage frequently accompanies abdominal injury, especially if the liver or spleen has been traumatized. Therefore, the patient is assessed continuously for signs and symptoms of external and internal bleeding. If abdominal viscera protrude, the area is covered with sterile, moist saline dressings to keep the viscera from drying. Stab wounds should be irrigated with normal saline.

A client with a history of allergies comes to the emergency department. The nurse suspects anaphylaxis based on which of the following? Select all that apply.

Chest tightness Generalized itching Pallor Facial angioedema Explanation: Manifestations suggesting anaphylaxis include chest tightness, generalized itching, pallor, massive facial angioedema, tachycardia or bradycardia, and decreasing blood pressure (as a result of peripheral vascular collapse).

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

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

A client is admitted to the ED with suspected alcohol intoxication. The ED nurse is aware of the need to assess for conditions that can mimic acute alcohol intoxication. In light of this need, the nurse should perform what action?

Check the client's blood glucose level. Explanation: Hypoglycemia can mimic alcohol intoxication and should be assessed in a client suspected of alcohol intoxication. Potassium imbalances, depression, and poison ingestion are not noted to mimic the characteristic signs and symptoms of alcohol intoxication.

The nurse is caring for a client who is agitated and confused. The client is persistently trying to get out of bed and attempted to remove the peripheral IV. The nurse has attempted to re-orient the client; however, this was not effective in de-escalating the client's agitation. The client yells, "I am going to punch you in the face!" What is the nurse's next action?

Call security personnel to assist Explanation: Clients at risk for harming staff members require specific interventions. It is important to first notification of security and administration of the potential for violence. Although medication and physical restraints maybe required, the nurse will not be able to carry out these interventions in a safe manner independently. The nurse should first call for security personnel to assist, all other interventions can be carried out with the support of trained staff. When a client is agitated and has the potential to be violent, they should not be left unattended. Moving out of the client's view can lead to further agitation for the client and increase the risk for escalating to violence.

A client is brought to the emergency department with severe hemorrhage requiring massive blood replacement. The nurse warms the blood in a commercial warmer based on the understanding that infusion of large amounts of blood could result in which of the following?

Cardiac arrest Explanation: Blood must be warmed in a commercial blood warmer because administration of large amounts of blood that has been refrigerated has a core cooling effect that may lead to cardiac arrest and coagulopathy. Hyperthermia, hemolytic transfusion reaction, or fluid overload is not the concern.

A nurse is preparing an in-service education program about emergency nursing to a group of newly hired nurses who will be working in the emergency department. When describing the current status of visits to the emergency department, which of the following would the nurse include in the presentation?

Clients with Medicaid use the emergency department more often than clients with private health insurance. Explanation: According to the most recent survey, clients with Medicaid use emergency departments more often than clients with private health insurance, Medicare, or self-pay. More than 15.5% of clients arrived at the emergency department by ambulance, leaving the majority of clients arriving by other means. Injuries account for almost one-half of all emergency department visits. The average emergency department waiting time before being seen by a health care provider for definitive treatment is approximately 2.4 hours.

A 13-year-old is being admitted to the ED after falling from a roof and sustaining blunt abdominal injuries. To assess for internal injury in the client's peritoneum, the nurse should anticipate what diagnostic test?

Computed tomography (CT) scan Explanation: CT scan of the abdomen, diagnostic peritoneal lavage, and abdominal ultrasound are appropriate diagnostic tools to assess intra-abdominal injuries. X-rays do not yield sufficient data and a CBC would not reveal the presence of intraperitoneal injury.

Which term refers to injuries that occur when a person is caught between objects, run over by a moving vehicle, or compressed by machinery?

Crush injuries Explanation: Crush injuries are those that occur when a person is caught between objects, run over by a moving vehicle, or compressed by machinery. Blunt trauma is commonly associated with extra-abdominal injuries to the chest, head, or extremities. Penetrating abdominal injuries include those such as gunshot wounds and stab wounds. Intra-abdominal injuries are categorized as penetrating and blunt trauma.

After inserting an oropharyngeal airway, which of the following indicates that the airway is properly positioned?

Flange is at the client's lips. Explanation: An oropharyngeal airway is properly positioned when the distal end is in the hypopharynx and the flange is approximately at the client's lips. Air moving through the airway may or may not indicate proper placement. An oropharyngeal airway is inserted so that the tongue is displaced anteriorly.

The health care team in an intensive care unit have experienced a critical incident in which a young client died unexpectedly and the client's father physically attacked the senior physician treating the client. The client's father was arrested and escorted from the intensive care unit by police, against his will and in handcuffs. A critical incident stress management (CISM) staff meeting held 3 days after the incident took place. What would be the purpose for that meeting?

Debriefing Explanation: After serious events, critical incident stress management (CISM) is necessary to critique individual and group performance and to facilitate healthy coping. Optimally, this may consist of three steps: defusing, debriefing, and follow-up. Debriefing typically occurs 1 to 10 days after the critical incident. Debriefing sessions follow a format similar to the initial defusing session; however, during these sessions, participating staff are encouraged to discuss their feelings about the incident and are reassured that their negative reactions and feelings are normal and that their negative feelings will diminish over time. Defusing occurs immediately after the critical incident. During this session, affected staff are encouraged to discuss their feelings about the incident and are given contact information so that they may talk to someone if they have disturbing symptoms (e.g., sleeplessness, excessive worry). Follow-up may occur after the debriefing session is completed for those participants who have persistent negative symptoms and may consist of continued individual or group counseling and therapy. Counseling or group therapy would typically occur outside the context of the stress-inducing environment. Individuals may require private counseling versus group counseling.

Which statement reflects the nursing management of the client with a white phosphorus chemical burn?

Do not apply water to the burn Explanation: Water should not be applied to burns from lye or white phosphorus because of the potential for an explosion or deepening of the burn.

A client is brought to the emergency department after being involved in a motor vehicle collision. Which of the following would lead the nurse to suspect internal bleeding?The nurse is providing care to a client who was brought to hospital with a opioid overdose. The nurse should expect to include which immediate interventions in the care of this client? Select all that apply.

Ensure the head of the bed remains elevated Monitor naloxone intravenous infusion Explanation: Interventions in the urgent care of a client who has overdosed on an opioid narcotic focuses on reversal of the effects of the narcotic agent and supporting oxygenation. The nurse should ensure the client has the head of the bed elevated to aid respirations and monitor the intravenous infusion of naloxone, an opioid narcotic reversal agent. Applying a warming blanket to a client in this state should not be considered an immediate intervention as the blanket may interfere with the nurse's ability watch respirations closely. This may also risk causing the client hyperthermia. The CIWA-A scale would be appropriate in assessing withdrawal from alcohol. Respirations need to be assessed more closely than every 4 to 6 hours when immediate, more urgent care is being provided to prevent respiratory depression.

The nurse is providing care to a client who was brought to hospital with a opioid overdose. The nurse should expect to include which immediate interventions in the care of this client? Select all that apply.

Ensure the head of the bed remains elevated Monitor naloxone intravenous infusion Explanation: Interventions in the urgent care of a client who has overdosed on an opioid narcotic focuses on reversal of the effects of the narcotic agent and supporting oxygenation. The nurse should ensure the client has the head of the bed elevated to aid respirations and monitor the intravenous infusion of naloxone, an opioid narcotic reversal agent. Applying a warming blanket to a client in this state should not be considered an immediate intervention as the blanket may interfere with the nurse's ability watch respirations closely. This may also risk causing the client hyperthermia. The CIWA-A scale would be appropriate in assessing withdrawal from alcohol. Respirations need to be assessed more closely than every 4 to 6 hours when immediate, more urgent care is being provided to prevent respiratory depression.

The nurse is assigned to a client admitted to the ICU from the emergency department. The client sustained multiple injuries from a motor vehicle accident. When reviewing the client chart, the notes indicate the client's emergency care was managed in what sequence of steps?

Establish airway and start ventilation Application of pressure to control abdominal bleeding Start peripheral intravenous insertion and infusion of fluids Assess for head and neck injuries Examine client for additional injuries to the body Reassess pulses and neurovascular status Explanation: The goals of treatment are to determine the extent of injuries and to establish priorities of treatment. Any injury interfering with a vital physiologic function (e.g., airway, breathing, circulation) is an immediate threat to life and has the highest priority for immediate treatment. Essential lifesaving procedures are performed simultaneously by the emergency team. Establishing the airway and performing ventilation is necessary to support airway and breathing. Hypovolemic shock is prevented by applying pressure to bleeding sites and initiating a peripheral IV and immediate start of infusion of intravenous fluids. As soon as the client is resuscitated, clothes are removed or cut off and a rapid physical assessment is performed. The physical assessment should prioritize head and neck injuries and then injuries over the rest of the body. Ongoing examination, assessment and diagnostic evaluation are necessary. The health care team will continue to assess vascular and neurological status as these can change quickly.

A nurse is performing a primary survey of a client brought to the emergency department. Which of the following would the nurse include? Select all that apply.

Establishing airway patency Providing adequate ventilation Assessing neurologic function Explanation: The primary survey addresses airway, breathing, circulation, and disability. The nurse would establish a patent airway, provide adequate ventilation, evaluate and restore cardiac output, and determine neurologic disability by assessing neurologic function. Obtaining a complete health history and applying monitoring devices are activities involved with the secondary survey.

The nurse in the ED is triaging patients during the shift. What does the nurse know is the first priority in treating any patient in the ED?

Establishing an airway. Explanation: The primary survey focuses on stabilizing life-threatening conditions. The ED staff work collaboratively and follow the ABCDE (airway, breathing, circulation, disability, exposure) method. The first priority is always to establish a patent airway.

A client is being cared for in the ED. The client is assigned to the triage category of "urgent." How often must the nurse reassess the client?

Every 30 minutes Explanation: Clients assigned to the resuscitation category must receive continuous nursing surveillance, those in the emergent category must be reassessed at least every 15 minutes, clients in the urgent category must be reassessed at least every 30 minutes, those in the less urgent category must be reassessed at least every 60 minutes, and those in the nonurgent category must be reassessed at least every 120 minutes.

In which triage category would the nurse include a client who requires simple first aid or basic primary care?

Fast track Explanation: Fast-track clients require simple first aid or basic primary care and may be treated in the ED or safely referred to a clinic or physician's office. Urgent clients have serious health problems that are not immediately life threatening. They must be seen within 1 hour. Emergent clients have the highest priority, their conditions are life threatening, and they must be seen immediately. Nonurgent clients have episodic illnesses that can be addressed within 24 hours without increased morbidity.

A patient arrives at the emergency department after taking more than 20 lorazepam tablets. Which of the following would the nurse anticipate that the patient would be given to reverse the effects of the drug?

Flumazenil Explanation: Lorazepam is a nonbarbiturate sedative whose effects are reversed with flumazenil. Naloxone is used to reverse the effects of opioids. Diazepam is used to treat seizures associated with drug overdose. It would not be used here, because it is in the same class as lorazepam and concurrent administration would add to the patient's overdose state. N-acetylcysteine is the antidote for acetaminophen toxicity.

A client is brought to the ED by family members who tell the nurse that the client has been exhibiting paranoid, agitated behavior. What should the nurse do when interacting with this client?

Give the client honest answers about likely treatment. Explanation: The nurse should offer appropriate and honest explanations in order to foster rapport and trust. Confinement is likely to cause escalation, as is touching the client. The nurse should not normally engage in trying to convince the client that his or her fears are unjustified, as this can also cause escalation.

The nurse is caring for a client who sustained a gunshot wound from a drive-by shooting. Which action will the nurse take to protect the chain of evidence? Select all that apply.

Hang wet clothing until dried, then label and give to law enforcement. Place each piece of the client's clothing in seperate paper bags. Photograph any wounds twice, and one photograph should include a reference ruler. Explanation: When clothing is removed from the client who has experienced trauma, the nurse must be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing if criminal activity is suspected. Each piece of clothing should be placed in an individual paper bag. Plastic bags are not used because they retain moisture. Moisture may promote mold and mildew formation which can destroy evidence. If the clothing is wet, it should be hung to dry. If a police officer is present to collect clothing or any other items from the client, each item is labeled and the transfer of custody to the officer, the officer's name, the date, and the time are documented. In the event of death, all tubes and lines must remain in place and sent with the client to the medical examiner. These measures ensure that the chain of custody has been maintained for the evidence to be valid and useful for legal purposes. Photographs of wounds or clothing are essential and should include a reference ruler in one photo and another without the ruler. Documentation should also include any statements made by the patient in the client's own words, and surrounded by quotation marks.The nurse should not summarize the statements for fear of losing important data and/or for any misinterpretation. Clear documentation assist the judicial process and helps to identify the the activities that occurred in the emergency department

A nurse is providing care to a client who is a victim of trauma resulting from injuries sustained in a convenience store robbery. The client has been stabbed numerous times in the abdomen and chest. His shirt is bloody and torn. Which of the following would be most appropriate when collecting forensic evidence?

Hanging up any damp or wet clothing to dry before securing Explanation: When collecting forensic evidence, the nurse should remove the client's clothing, being careful not to cut through or disrupt any tears, holes, blood stains or dirt present on the clothing. Each piece of clothing is put into a separate paper bag and labeled. If the clothing is wet or damp, it should be hung to dry. If a police officer is present to collect clothing or any other items from the client, each bag is labeled with the client's name, and the transfer of custody to the officer, the officer's name, date, and time are documented.

A nurse is providing initial first-aid care to a patient who was bitten by a snake. Place the following actions in the order in which the nurse would perform them. Use all options.

Have the patient lie down Remove constricting clothing Provide warmth Clean the wound Cover the wound with a light sterile dressing Immobilize the injury below the level of the heart Explanation: Initial first aid for a snake bite includes having the person lie down, removing constrictive items, providing warmth, cleaning the wound, covering the wound with a light and sterile dressing, and immobilizing the injured body part below the level of the heart.

The nurse is caring for a victim of a sexual assault. The client is fearful and experiencing flashbacks. The nurse recognizes that the client is experiencing which phase of the psychological reaction to rape?

Heightened anxiety phase Explanation: During the heightened anxiety phase, the client demonstrates anxiety, hyperalertness, and psychosomatic reactions, in addition to fear and flashbacks. The acute disorganization phase is characterized by shock, disbelief, guilt, humiliation, and anger. The denial phase is characterized by an unwillingness to talk. The reorganization phase occurs when the incident is put into perspective. Some clients never fully recover from rape trauma.

Which of the following would the nurse identify as indicating that a client is experiencing a complete airway obstruction? Select all that apply.

Inability to speak Clutching of the neck Stridor Cyanosis Explanation: Manifestations of a complete airway obstruction include the inability to speak, breathe, or cough; clutching the neck; inspiratory and expiratory stridor; and cyanosis (a late sign). If the client can cough spontaneously, then a partial airway obstruction is most likely.

A patient who has accidentally ingested toilet bowel cleaner is brought to the emergency department. Which action would NOT be appropriate for the nurse to implement?

Induced vomiting Explanation: Vomiting is never induced after ingestion of caustic substances (acid or alkaline) such as toilet bowl cleaner because the substance is corrosive to the tissues. Appropriate actions include dilution with milk or water, gastric lavage, and administration of activated charcoal.

Nursing students are reviewing information about anaphylactic reactions and their possible causes. The students demonstrate understanding of this information when they identify which of the following as a common cause? Select all that apply.

Insect stings Medications Latex Eggs Shellfish Explanation: Common causes of anaphylactic reactions include insect stings, medications (e.g., penicillin, iodinated-contrast materials), latex, insect stings, eggs, peanuts, and shellfish. Green vegetables typically are not associated with anaphylaxis.

A client suffering from carbon monoxide poisoning would exhibit which manifestation?

Intoxication Explanation: A client suffering from carbon monoxide poisoning appears intoxicated (from cerebral hypoxia). Other signs and symptoms include headache, muscular weakness, palpitation, dizziness, and mental confusion. The skin coloring in the client with carbon monoxide poisoning can range from pink to cherry red to cyanotic and pale and is not a reliable diagnostic sign.

An emergency nurse has collected evidence from a patient who was shot during a robbery. The nurse is preparing to transfer the evidence to law enforcement. Which of the following would be important for the nurse to include when documenting this transfer? Select all that apply.

Name of the law-enforcement official Date that the evidence was collected Time of the transfer of evidence Explanation: When transferring evidence to law enforcement, the nurse must document the chain of custody. This includes the information that evidence was transferred to the officer, the officer's name, and the date and time of the transfer. Labels are placed on each item, but this does not need to be documented for the transfer. The names of family members witnessing the transfer also do not need to be documented.

The nurse is preparing to transfer a client from the ICU to a medical unit in the hospital. To ensure consistent communication regarding the client's care needs to the receiving unit, in what sequence of steps should the nurse organize the report?

Obtain the client's health record State the client's admission date and current diagnosis Provide a brief statement of current concerns Give the client's pertinent medical history Provide the most recent vital signs and assessment findings Give recommendations for what needs to be done for the client Explanation: When using the SBAR tool for consistent communication in health care settings, the nurse should organize sharing information about the client by including what the receiving unit needs to know about the (S)ituation, (B)ackground, (A)ssessment and (R)ecommendations. The nurse should first have the chart in hand before making the phone call, and be sure they can readily communicate all the following: Briefly state the issue or problem: what it is, when it happened (or how it started) and how severe it is. Give the signs and symptoms that cause concern. The nurse should then provide the date of admission and current medical diagnoses. Next, the nurse must give most recent vital signs and any recent changes in the systems assessment. For example, the nurse may need to communicate that the client had become constipated over the past 24 hours. Finally, it is important for the nurse to provide recommendations about what actions are need to be taken in the client's care. The nurse should state what they think should be done to address any identified client problems.

A nurse is providing an in-service program for fellow emergency nurses about hypothermia and rewarming methods used. The nurse determines that the presentation was successful when the group identifies which of the following as a passive active rewarming method?

Over-the-bed heaters Explanation: Passive active rewarming uses over-the-bed heaters to the extremities and increases blood flow to the acidotic, anaerobic extremities. Cardiopulmonary bypass and warm humidified oxygen by ventilator are examples of active core (internal) rewarming methods. Forced warm air blankets are examples of active external rewarming methods.

A patient with intra-abdominal injuries is brought to the emergency department. Which of the following would most likely alert the nurse to suspect internal bleeding secondary to a ruptured spleen?

Pain in the left shoulder Explanation: Pain in the left shoulder is common in a patient with bleeding from a ruptured spleen. Pain in the right shoulder is consistent with a laceration of the liver. The spleen is located in the left upper quadrant, not the right. Rebound tenderness and abdominal distention are generalized signs suggesting intraperitoneal injury. Although these generalized signs may accompany a ruptured spleen, they are less specific than pain in the left shoulder.

A nurse who is a member of an emergency response team anticipates that several patients with airway obstruction may need a cricothyroidotomy. For which of the following patients would this procedure be appropriate? Select all that apply.

Patient with extensive facial trauma Patient with laryngeal edema secondary to anaphylaxis Patient with an obstructed larynx Explanation: Cricothyroidotomy is used in emergencies when endotracheal intubation is either not possible or contraindicated. Examples include airway obstruction from extensive maxillofacial trauma, cervical spine injury, laryngospasm, laryngeal edema after an allergic reaction or extubation, hemorrhage into neck tissue, and obstruction of the larynx.

The nurse is providing care for a client who was admitted to the intensive care unit after suffering cardiovascular collapse secondary to a methamphetamine overdose. The client is semi-conscious and has a nasopharyngeal in place. The nurse anticipates this client may require which interventions? Select all that apply.

Provide airway support and ventilation Minimize lights and noise disturbances Administer antipsychotic medication Follow the unit seizure protocol Explanation: Anticipated interventions for client who have experienced cardiovascular collapse secondary to overdose with methamphetamines include prioritizing airway support, ventilation, cardiac monitoring and intravenous access. The nurse should attempt to provide a calm environment that is as private as possible. Lights and noise disturbances should be kept to a minimum because external stimulation can produce overactivity and overstimulation. Due to the hallucinations and/or delusions that can be caused by the illicit substance overdose, the client may require antipsychotic medication such as haloperidol. Clients can experience seizures after illicit substance overdose and withdrawal. The nurse should anticipate the need to employ a seizure protocol in accordance with unit policy. Clients with methamphetamine overdoses experience hypertension and hyperthermia. Warming the client potentiates amphetamine toxicity.

The nurse has received a client into care who was admitted with a heroin overdose. The client has a 5-year history of illicit substance use with cocaine, heroine and oxycodone. The client develops a sudden onset of wheezing, restlessness and a cough that produces a frothy, pink sputum. The nurse suspects the client has most likely developed which complication of opioid overdose?

Pulmonary edema Explanation: The nurse should suspect the client has developed pulmonary edema, which is frequently seen in clients who abuse/overdose on narcotics. Many drugs — ranging from illegal drugs such as heroin and cocaine to aspirin — are known to cause noncardiogenic pulmonary edema. Pneumonia is not the likely cause given the sudden onset of respiratory symptoms accompanied but coughing up the pink frothy sputum. The client's history of illicit substance use and now overdose on these drugs should lead the nurse to suspect pulmonary edema is the cause of the sudden onset of these symptoms over congestive heart failure, in which clients have a more gradual onset of respiratory issues. Although a panic attack can manifest in shortness or breath and restlessness, the client would not be wheezing or producing blood tinged sputum with a cough. Panic attacks do, however, have a sudden onset and can cause the client chest pain and a sense of doom.

A client is brought to the emergency department with suspected genitourinary injury. The nurse prepares the client for insertion of an indwelling urinary catheter for bladder decompression and urine output monitoring. The nurse reviews the client's medical record to ensure that which of the following has been completed?

Rectal examination Explanation: In a client with a suspected genitourinary injury, an indwelling urinary catheter is inserted for bladder decompression and urine output monitoring only after a rectal examination has been completed. Computed tomography or bladder ultrasound are not necessary. A diagnostic peritoneal lavage is a backup procedure for evaluating intraperitoneal injury.

The nurse is caring for a 21-year-old client with a diagnoses of brain death due to injuries sustained in a snowboarding accident. The family has chosen to remove life support measures to allow the client's death. Upon hearing the family's decision, what is the nurse's first action?

Request senior medical staff discuss organ donation Explanation: Clients who meet the criteria for past health and current diagnosis of brain death are eligible to donate organs to those on the various transplant lists. This places nurses in a difficult position at times due to their simultaneous obligations to care for a particular client and the family while informing organ donation services of a potential donor. When the diagnosis of brain death is made, it is usually up to the senior medical staff and organ procurement services to approach the family about the possibility of organ donation. The nurse's next best action is to request a senior physician speak to the family in a timely manner so organs can be harvested and made available as needed. Advance directives are typically in place for clients who are older and for whom death may be expected. In this case, the client is young and death is unexpected, advanced directives are not likely and this question would be inappropriate. Although the nurse should assess for interrupted family process, this is not the nurse's initial action after hearing the family has decided to remove life support. This nursing assessment goes beyond acute care and into the provision of community health services which the family will need throughout their grieving process.

A nurse is providing an educational program for a group of occupational health nurses working in chemical facilities. Which of the following would the nurse include as the priority in the case of a chemical burn?

Rinsing the area with copious amounts of water Explanation: The priority for any chemical burn is to immediately drench the area with running water, unless the chemical is lye or white phosphorus, which should be brushed off the patient. Antimicrobial ointments, sterile dressings, and tetanus prophylaxis are measures instituted later in the course of treatment, depending on the characteristics of the chemical agent and the size and location of the burn.

A client presents to the ED with a stab wound to the abdomen following an assault. It is suspected that the client has an injury to the pancreas. Which laboratory study is used to detect pancreatic injury?

Serum amylase Explanation: Serum amylase is analyzed to detect increasing levels, which suggests pancreatic injury or perforation of the gastrointestinal tract. A white blood cell count is done to detect an elevation. Urinalysis is done to detect hematuria. A hemoglobin and hematocrit test is done to evaluate trends reflecting the presence or absence of bleeding.

An adolescent is brought to the ED after a vehicular accident and is pronounced dead on arrival (DOA). When the parents arrive at the hospital, what is the priority action by the nurse?

Speak to both parents together and encourage them to support each other and express their emotions freely. Explanation: The nurse should take the family to a private place and talk to the family together so that they can grieve together and hear the information given together. The nurse should encourage family members to support each other and to express emotions freely (grief, loss, anger, helplessness, tears, disbelief). The nurse should avoid giving sedation to family members; this may mask or delay the grieving process, which is necessary to achieve emotional equilibrium and to prevent prolonged depression.

A nurse is assessing a patient who is suspected of having a partial airway obstruction. Which of the following would the nurse expect to find?

Spontaneous coughing Explanation: If a patient can breathe and cough spontaneously, a partial airway obstruction should be suspected. If the patient demonstrates a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis, the patient should be managed as if there were a complete airway obstruction.

The nurse is monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs) for impaired tissue oxygenation resulting from hemorrhage. After 15 minutes of the transfusion, the nurse notes the client has a fever and shortness of breath. Place in order the steps the nurse should take in response to these findings. Use all options.

Stop the transfusion Ensure the normal saline IV line is open Assess need for airway support Check full vital signs Notify the physician Intervene for any signs and symptoms as appropriate Explanation: The client is experiencing an immunological transfusion reaction which will only become worse as the transfusion proceeds. The nurse's first action is to stop the transfusion. A normal saline line is always made available prior to commencing a transfusion of any blood product to promote flushing and allowing for the immediate administration of any IV medications that may be required to manage the signs and symptoms resulting from the transfusion reaction. Airway, circulation and breathing are a top priority in transfusion reactions. The client is experiencing shortness of breath which can progress to respiratory distress if not managed. The nurse must assess airway and work of breathing to determine if oxygen, repositioning or other respiratory interventions are required. The nurse must assess a full set of vital signs to determine other systemic effects caused by the transfusion. It is possible to see variations of vital signs such as hyper- and hypotension, tachycardia, fever and increased respiratory rate. Any change in the vital signs requires an intervention. This should be completed prior to contacting the physician as it is important to have this information readily available to collaborate with the physician for next steps in the client's care. The nurse must notify the physician to obtain any additional orders for interventions that may be individualized based on the client's overall clinical situation. The nurse is responsible for intervening for any other signs or symptoms such as administering antihistamines or antipyretic medications.

A patient with a history of major depressive disorder is brought to the emergency department by a friend, who reports that the patient took an overdose of prescribed amitriptyline. Which of the following findings would the nurse expect to assess? Select all that apply.

Tachycardia Visual Hallucinations Clonus Explanation: Amitriptyline is a tricyclic antidepressant. In cases of overdose, the patient would likely experience tachycardia, hypotension, confusion, visual hallucinations, clonus, tremors, hyperactive reflexes, seizures, blurred vision, flushing, and hyperthermia.

A nurse suspects an older adult is experiencing heat stroke based on which assessment findings? Select all that apply.

Temperature 105 degrees F (40.6 degrees C) Lack of sweating D Explanation: A patient with heat stroke typically exhibits a temperature of 105 degrees F (40.6 degrees C) or higher; profound central nervous system dysfunction; hot, dry skin; anhidrosis (absence of sweating); tachypnea; hypotension; and tachycardia. Increased thirst and weakness would suggest heat exhaustion.

A nurse is caring for a client who is experiencing alcohol withdrawal. Which statement best indicates that the client understands the need for long-term treatment?

The client agrees to detoxification, rehabilitation, and participation in an aftercare program. Explanation: Detoxification, rehabilitation, and participation in an aftercare program are the only options that address the client's long-term treatment needs. Supportive counseling, family involvement, and support-group participation are important aspects of the treatment process, but they don't address the client's need for long-term treatment.

Which data is important for the nurse to record while assessing the client with an open wound?The nurse is caring for a client with right ventricular heart failure. The nurse understands hypervolemia will have what effect on the client's heart?

The client's myocardial oxygen requirements will be higher Explanation: Clients with heart failure are typically hypervolemic and as a result this increases the cardiac preload. An increased fluid volume increases the stroke volume, ventricular work and myocardial oxygen requirements. Vasodilation can be a potential cause for decreased preload and afterload, not increased preload as in this case. This client would experience vasoconstriction due to the increase volume with each stroke.

Which data is important for the nurse to record while assessing the client with an open wound?

Time when the client last received a tetanus immunization Explanation: If the client has an open wound, the nurse ascertains when the client last received a tetanus immunization. This vital information helps assess the risk of infection in a client with an open wound. The assessment begins with measuring the client's vital signs. It is important to ascertain the time and place of injury with the degree of movement and range of motion in all cases, not just in the case of an open wound.

The nurse educator is explaining the difference between indications for nasopharyngeal airway insertion versus endotracheal intubation. Which responses from learners indicate correct reasons for the use of endotracheal tubes in clients? Select all that apply.

To bypass an upper airway obstruction To support connecting to mechanical ventilation To facilitate removal of tracheobronchial secretions Explanation: Endotracheal intubation is indicated to establish an airway for a client who cannot be adequately ventilated with an oropharyngeal or nasopharyngeal airway, bypass an upper airway obstruction, prevent aspiration, permit connection of the client to a resuscitation bag or mechanical ventilator, or facilitate the removal of tracheobronchial secretions. In the case of potential facial trauma or basal skull fracture, the nasopharyngeal airway should not be used because it could enter the brain cavity instead of the pharynx.

A finger sweep is only to be used in which client population?

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

A triage nurse determines that a client with non-life-threatening injuries requires imaging studies and moderate sedation. The triage nurse would document this client as which of the following?

Urgent Explanation: Clients who have non-life-threatening conditions but require two or more resources to provide their care would be classified as urgent. In this situation, the client would be considered urgent because he requires imaging studies (one resource) and moderate sedation (a two-resource procedure). Clients in the resuscitation category need treatment immediately to prevent death. Clients in the emergent category may deteriorate rapidly and develop a major life-threatening situation or may require time-sensitive treatment. Clients in the nonurgent category have non-life-threatening conditions and likely need only one resource to provide for their needs.

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

Urgent Explanation: Urgent clients have serious health problems that not immediately life threatening. They must be seen within 1 hour. Emergent clients have the highest priority with life-threatening conditions and they must be seen immediately. Nonurgent clients have episodic illness that can be addressed within 24 hours without increased morbidity. Fast-track clients require simple first aid or basic primary care and may be treated in the ED or safely referred to a clinic or physician's office.

Following a motor vehicle collision, a client is brought to the ED for evaluation and treatment. The client is being assessed for intra-abdominal injuries. The client reports severe left shoulder pain (pain score of 10 on a 1 to 10 scale). The nurse suspects injury to the

spleen. Explanation: The location of pain can indicate certain types of intra-abdominal injuries. Pain in the left shoulder is common in a client with bleeding from a ruptured spleen, whereas pain in the right shoulder can result from laceration of the liver.

A nurse is providing care to a client in the critical care unit who is experiencing altered mental status. The nurse uses the mnemonic AEIOUTIPS to address the possible causes. When applying the T portion of the mnemonic, which cause would the nurse identify as a possibility? Select all that apply.

trauma temperature Explanation: When applying the T portion of the mnemonic, the nurse would identify trauma and temperature as possible causes of altered mental status. Thyroid dysfunction, TIA or tachypnea are not part of the mnemonic.