Ch 72 - emergency
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? a) 24 hours from the last dose b) 8 p.m. c) 11:00 p.m. d) Stat
11:00 p.m. 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.
When assessing a client with suspected carbon monoxide poisoning, which finding would be least reliable? a) Headache b) Palpitations c) Confusion d) Cherry red skin color
Cherry red skin color 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.
Which of the following triage categories refers to life-threatening or potentially life-threatening injury or illness requiring immediate treatment? a) Emergent b) Nonacute c) Immediate d) Urgent
Emergent The patient triaged as emergent must be seen immediately. The triage category of urgent refers to minor illness or injury needing first-aid-level treatment. The triage category of immediate refers to non-acute, non-life threatening injury or illness.
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? a) Refusal to lie flat b) Forceful coughing c) High-pitched noise on inhalation d) Wheezing between coughs
High-pitched noise on inhalation 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 providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate? a) Placing sterile cotton between the toes after rewarming b) Restricting ambulation c) Massaging the feet d) Providing an analgesic for pain
Massaging the feet 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 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? a) Lethargy b) Lack of perspiration c) Seizures d) Hypotension
Seizures Serotonin syndrome is manifested by agitation, seizures, hyperthermia, diaphoresis, and hypertension.
Following an earthquake, a client who was rescued from a collapsed building is seen in the emergency department. He has blunt trauma to the thorax and abdomen. The nursing observation that most suggests the client is bleeding is: a) orthostatic hypotension. b) a prolonged partial thromboplastin time (PTT). c) diminished breath sounds. d) a recent history of warfarin (Coumadin) usage.
orthostatic hypotension. Bleeding is a volume-loss problem, which causes a drop in blood pressure. As the bleeding persists and the body's ability to compensate declines, orthostatic hypotension becomes evident. A prolonged PTT and a history of warfarin usage are causes of bleeding but aren't evidence of bleeding. As bleeding persists and the client's level of consciousness declines, breathing will become more shallow and breath sounds will diminish; however, this is a late and unreliable manifestation of bleeding.
The nurse is caring for a patient in the ED following a sexual assault. The patient is hysterical and crying. The patient states, "I know I'm pregnant now, maybe I have HIV; why did this happen to me?" The nurse's best response is which of the following? a) "Do you want to discuss antipregnancy measures?" b) "Do you want the phone number for the National Sexual Assault Hotline?" c) "Would you like us to complete HIV testing?" d) "Let's talk about this; do you want me to call a support person?"
"Let's talk about this; do you want me to call a support person?" The patient 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 patient's emotional trauma, and gather available evidence for possible legal proceedings. Throughout the patient's stay in the ED, the patient's privacy and sensitivity must be respected. The patient may exhibit a wide range of emotional reactions, such as hysteria, stoicism, or feelings of being overwhelmed. Support and caring are crucial.
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? a) Administer an analgesic as ordered. b) Apply a heat lamp. c) Elevate the legs. d) Massage the extremities.
Administer an analgesic as ordered. 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 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? a) Immobilize the area to control blood loss. b) Elevate the injured part. c) Apply firm pressure over the involved area or artery. d) Apply a tourniquet.
Apply firm pressure over the involved area or artery. 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.
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? a) Establishing a patent airway b) Assessing neurologic function c) Applying electrocardiogram electrodes d) Providing adequate ventilation
Applying electrocardiogram electrodes 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.
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? a) Notify the rape crisis team. b) Notify the client's family. c) Notify the physician of her findings immediately. d) Attend to the client's physiological needs.
Attend to the client's physiological needs. 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.
Which of the following phases of psychological reaction to rape is characterized by fear and flashbacks? a) Heightened anxiety phase b) Reorganization phase c) Denial phase d) Acute disorganization phase
Heightened anxiety phase During the heightened anxiety phase, the patient 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 patients never fully recover from rape trauma.
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? a) Dilution with water or milk b) Administration of activated charcoal c) Induced vomiting d) Gastric lavage
Induced vomiting 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.
Which of the following solutions should the nurse anticipate for fluid replacement in the male patient? a) Lactated Ringer's solution b) Hypertonic saline c) Type O negative blood d) Dextrose 5% in water
Lactated Ringer's solution Replacement fluids may include isotonic electrolyte solutions and blood component therapy. O negative blood is prepared for emergency use in women of childbearing age.Dextrose 5% in water should not be used to replace fluids in hypovolemic patients. Hypertonic saline is used only to treat severe symptomatic hyponatremia and should be used only in intensive care units.
Which of the following solid organs is most frequently injured in a penetrating trauma? a) Brain b) Liver c) Pancreas d) Lungs
Liver The most frequently injured solid organ in a penetrating trauma is the liver.
The nurse is administering antivenin to a patient who was bitten on the arm by a poisonous snake. What intervention provided by the nurse is required prior to the procedure and every 15 minutes after? a) Assess peripheral pulses. b) Administer cimetidine (Tagamet). c) Administer diphenhydramine (Benadryl). d) Measure the circumference of the arm.
Measure the circumference of the arm. Before administering antivenin and every 15 minutes thereafter, the circumference of the affected part is measured. Premedication with diphenhydramine (Benadryl) or cimetidine (Tagamet) may be indicated, because these antihistamines may decrease the allergic response to antivenin. Antivenin is administered as an IV infusion whenever possible, although intramuscular administration can be used.
A home health nurse is visiting a 74-year-old client with Alzheimer's disease. During the visit, the nurse notes bruising on the client's upper arms, and the client is more withdrawn than normal. The client is unable to communicate effectively because of his disease progression. The nurse suspects elder abuse. What is the nurse's responsibility in this situation? a) Do nothing because the nurse has no proof of wrongdoing. b) Report the suspicion to the local agency on aging within 24 hours of the visit. c) Try to convince the client to report the problem. d) Monitor the situation during subsequent visits.
Report the suspicion to the local agency on aging within 24 hours of the visit. The nurse must report the suspicion to the local agency on aging within 24 hours of the visit. Doing nothing and monitoring the situation during subsequent visits go against the nurse's legal and professional obligation, which is to report suspected abuse when it occurs. The client's disease process prevents him from reporting the problem.
A nurse is establishing a patient's airway. Which action would the nurse perform first? a) Using the jaw-thrust maneuver b) Inserting an artificial airway c) Giving abdominal thrusts d) Repositioning the patient's head
Repositioning the patient's head 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 manuever, or insertion of an artificial airway.
A male patient presents to the ED with a stab wound to the abdomen following an assault. It is suspected that the patient has an injury to his pancreas. Which of the following laboratory studies is used to detect pancreatic injury? a) Urinalysis b) Serum amylase c) White blood cell count d) Hemoglobin and hematocrit
Serum amylase Serum amylase analysis is done to detect increasing levels, which suggests pancreatic injury or perforation of the GI tract. A white blood cell count is done to detect an elevation. A 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? a) Ask them to sit in the waiting room until she can spend time alone with them. b) Speak to one parent at a time in a private setting so that each can ventilate feelings of loss without upsetting the other. c) Speak to both parents together and encourage them to support each other and express their emotions freely. d) Ask the emergency physician to medicate the parents so that they can handle their child's unexpected death quietly and without hysteria.
Speak to both parents together and encourage them to support each other and express their emotions freely. 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 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? a) Stage IV b) Stage II c) Stage I d) Stage III
Stage III 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.
What is a common source of airway obstruction in an unconscious client? a) Edema b) Saliva or mucus c) The tongue d) A foreign object
The tongue 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 finger sweep is only to be used in which patient population? a) Child b) Unconscious adult c) Adolescent d) Conscious adult
Unconscious adult A finger sweep should be used only in the unconscious adult patient. This action draws the tongue away from the back of the throat and away from the foreign body that may be lodged there. A finger sweep should not be done on a conscious adult, child, or adolescent.
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? a) Immediate b) Emergent c) Delayed d) Urgent
Urgent 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.
Nursing students are reviewing information about endotracheal intubation. They demonstrate understanding of the information when they identify which of the following as a reason for this procedure? Select all that apply. a) Decrease tracheobronchial secretions b) Prevent aspiration into the lungs c) Facilitate removal of an upper airway obstruction d) Establish an airway for ventilation e) Allow connection to a manual resuscitation bag
• Allow connection to a manual resuscitation bag • Prevent aspiration into the lungs • Establish an airway for ventilation Endotracheal intubation is indicated to establish an airway for a patient who cannot be adequately ventilated with an oropharyngeal airway, bypass an upper airway obstruction, prevent aspiration, permit connection to a resuscitation bag or mechanical ventilator, or facilitate removal of tracheobronchial secretions
Which of the following triage categories refers to life-threatening or potentially life-threatening injury or illness requiring immediate treatment? a) Nonacute b) Immediate c) Urgent d) Emergent
Emergent The patient triaged as emergent must be seen immediately. The triage category of urgent refers to minor illness or injury needing first-aid-level treatment. The triage category of immediate refers to non-acute, non-life threatening injury or illness.
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? a) Spontaneous coughing b) High-pitched noises on inhalation c) Cyanosis d) Severe respiratory distress
Spontaneous coughing 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.
After inserting an oropharyngeal airway, the nurse determines that it is in the proper position when the flange is located at which position? a) Just below the tip of the patient's nose b) At the level of the patient's epiglottis c) Directly in front of the patient's teeth d) Approximately at the patient's lips
Approximately at the patient's lips When an oropharyngeal airway is properly inserted, the tip is in the hypopharynx and the flange is approximately at the patient's lips.
Acetaminophen overdose is treated with the administration of which of the following medications? a) Flumazenil (Romazicon) b) Diazepam (Valium) c) Naloxone (Narcan) d) N-acetylcysteine (Mucomyst)
N-acetylcysteine (Mucomyst) Treatment of acetaminophen overdose includes administration of N-acetylcysteine (Mucomyst). Flumazenil is administered in the treatment of nonbarbiturate sedative overdoses. Naloxone (Narcan) is administered in the treatment of narcotic overdoses. Diazepam (Valium) may be administered to treat uncontrolled hyperactivity in the patient with a hallucinogen overdose.
A client arrives at the emergency department and is experiencing a severe allergic reacton to a bee sting. The client received treatment and is being discharged. Which client statement indicates that additional teaching about exposure prevention is needed? a) "I need to avoid using perfumes and scented soaps when I'm going outside." b) "If a bee comes near me, I should stay still." c) "I should always wear something on my feet when I'm outside." d) "Brightly colored clothes help to ward off bees."
"Brightly colored clothes help to ward off bees." 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 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. a) Patient with laryngeal edema secondary to anaphylaxis b) Patient with a lumbar spine injury c) Patient with extensive facial trauma d) Patient with an obstructed larynx e) Patient who is bleeding from the chest
• Patient with laryngeal edema secondary to anaphylaxis • Patient with an obstructed larynx • Patient with extensive facial trauma 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.
A patient is brought to the emergency department and diagnosed with decompression sickness. The nurse interprets this as indicating that the patient most likely has been involved with which of the following? a) Diving in an ocean b) Working in a chemical plant c) Running a race in hot humid weather d) Swimming in a lake
Diving in an ocean Decompression sickness occurs when patients have engaged in diving in a lake or ocean or high-altitude flying or flying in a commercial aircraft within 24 hours of diving. Swimming in a lake could lead to a near-drowing episode. Running a race in hot humid weather would increase a person's risk for heat stroke. Working in a chemical plant would increase the risk for chemical burns.
Which triage category would a patient that requires simple first aid or basic primary care? a) Fast track b) Nonurgent c) Urgent d) Emergent
Fast track Fast track patients 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 patients have serious health problems that are not immediately life threatening. They must be seen within 1 hour. Emergent patients have the highest priority, their conditions are life threatening and they must be seen immediately. Nonurgent patients have episodic illness that can be addressed within 24 hours without increased morbidity.
A patient is brought to the emergency department after being locked outside of her house in the frigid weather for several hours. The nurse suspects that the patient has sustained frostbite of her hand based on which of the following findings? a) Hand that is firm to palpation b) Hand that is insensitive to touch c) Hand that is cool with pale nailbeds d) Hand that appears pink with some white spotting
Hand that is insensitive to touch Indicators of frostbite include an extremity that is hard, cold, and insensitive to touch and appears white or mottled blue-white.
Question: 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. 1. Provide warmth 2. Remove constricting clothing 3. Immobilize the injury below the level of the heart 4. Clean the wound 5. Have the patient lie down 6. Cover the wound with a light sterile dressing
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 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.
A nurse is completing her annual cardiopulmonary resuscitation training. The class instructor tells her that a client has fallen off a ladder and is lying on his back; he is unconscious and isn't breathing. What maneuver should the nurse use to open his airway? a) Head tilt-chin lift b) Abdominal thrust c) Seldinger d) Jaw-thrust
Jaw-thrust If a neck or spine injury is suspected, the jaw-thrust maneuver should be used to open the client's airway. To perform this maneuver, the nurse should position herself at the client's head and rest her thumbs on his lower jaw, near the corners of his mouth. She should then grasp the angles of his lower jaw with her fingers and lift the jaw forward. The head tilt-chin lift maneuver is used to open the airway when a neck or spine injury isn't suspected. To perform this maneuver the nurse places two fingers on the chin and lifts while pushing down on the forehead with the other hand. The abdominal thrust is used to relieve severe or complete airway obstruction caused by a foreign body. The Seldinger maneuver is a method of percutaneous introduction of a catheter into a vessel.
A patient is admitted to the ED after a near-drowning accident. The patient is diagnosed with saltwater aspiration. The nurse will observe the patient for several hours to monitor for symptoms of which of the following? a) Head injury b) Hyponatremia c) Hypothermia d) Pulmonary edema
Pulmonary edema 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 (ARDS), resulting in hypoxia, hypercarbia, and respiratory or metabolic acidosis, can occur. The patient 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.
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? a) Rectal examination b) Computed tomography scan c) Diagnostic peritoneal lavage d) Bladder ultrasound
Rectal examination 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.
Which of the following guidelines is appropriate to helping family members cope with sudden death? a) Provide details of the factors attendant to the sudden death b) Inform the family that the patient has passed on c) Obtain orders for sedation for family members d) Show acceptance of the body by touching it, giving the family permission to touch
Show acceptance of the body by touching it, giving the family permission to touch 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, since this may mask or delay the grieving process. The nurse should avoid volunteering unnecessary information (eg, patient was drinking at the time of the accident).
Following a motor vehicle collision, a patient is brought to the ED for evaluation and treatment. The patient is being assessed for intra-abdominal injuries. The patient states severe left shoulder pain (pain score of 10 on a 1 to 10 pain scale). The nurse suspects injury to which of the following? a) Large intestines b) Spleen c) Gallbladder d) Liver
Spleen The location of pain can indicate certain types of intra-abdominal injuries. Pain in the left shoulder is common in a patient with bleeding from a ruptured spleen, whereas pain in the right shoulder can result from laceration of the liver.
A patient present to the ED following a work-related injury to the left hand. The patient has an avulsion of the left ring finger. Which of the following correctly describes an avulsion? a) Denuded skin b) Tearing away of tissue from supporting structures c) Incision of the skin with well-defined edges, usually longer than deep d) Skin tear with irregular edges and vein bridging
Tearing away of tissue from supporting structures 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 longer than deep.
A patient presents to the ED with serious health problems that are not immediately life threatening. The nurse will correctly triage the patient into which of the following categories? a) Emergent b) Nonurgent c) Urgent d) Psychological support
Urgent Patients triaged have serious health problems that are not immediately life threatening. They must be seen within 1 hour. The emergent category is for patients who have the highest priority conditions that are life-threatening and they must be seen immediately. Nonurgent is for patients who have episodic illness that can be addressed within 24 hours without increased morbidity. Patients in the less urgent category must be reassessed at least every 60 minutes and do not have serious health problems.
Which category of triage encompasses patients with serious health problems that are not immediately life threatening? a) Nonurgent b) Emergent c) Psychological support d) Urgent
Urgent Urgent patients have serous health problems that not immediately life threatening. They must be seen within 1 hour. Emergent patients have the highest priority with conditions are life threatening and they must be seen immediately. Nonurgent patients have episodic illness that can be addressed within 24 hours without increased morbidity. Fast track patients 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.
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. a) Gunshot wound b) Fall from a roof c) Knife-stab wound d) Motor-vehicle crash e) Being struck with a baseball bat
• Gunshot wound • Knife-stab wound Examples of penetrating trauma include gunshot wounds and stab wounds. Motor vehicle crashes, falls, and being struck with a baseball bat are examples of blunt trauma.
A 40-year-old female patient 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 of the following is the nurse's best course of action? a) Asking the patient how she obtained the various bruises b) Providing the patient with information about local shelters c) Contacting the local police and report the suspected abuse d) Asking the patient if someone is abusing her
Asking the patient if someone is abusing her The priority is to ask the patient if someone is harming/abusing her, and proceed as the situation dictates. Nurses must be mindful that competent adults are free to accept or refuse the help that is offered to them. Some patients insist on remaining in the home environment where the abuse or neglect is occurring. The wishes of patients who are competent and not cognitively impaired should be respected. However, all possible alternatives, available resources, and safety plans should be explored with the patient. 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 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? a) Ask the ambulance team for information about the client's family to ensure informed consent. b) Document the client's condition and absence of friends or family for obtaining consent to treatment. c) Explain to the client that care is going to be provided because he is seriously ill. d) Check the client's record for the name of a family member to call to allow care to be provided.
Document the client's condition and absence of friends or family for obtaining consent to treatment. 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 patient presents to the ED complaining of choking on a chicken bone. The patient is breathing spontaneously. The nurse applies oxygen and suspects a partial airway obstruction. Which of the following should the nurse do next? a) Encourage the patient to cough forcefully. b) Prepare the patient for a bronchoscopy. c) Insert a nasopharyngeal airway. d) Insert an oropharyngeal airway.
Encourage the patient to cough forcefully. If the patient can breathe and cough spontaneously, a partial obstruction should be suspected. The patient 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 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 complete airway obstruction. If the person 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.
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? a) Controlling hemorrhage. b) Establishing an airway. c) Restoring cardiac output. d) Obtaining consent for treatment.
Establishing an airway. 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 is patient being cared for in the ED. The patient is assigned to the triage category of "urgent." How often must the nurse reassess the patient? a) Every 60 minutes b) Every 30 minutes c) Every 120 minutes d) Every 15 minutes
Every 30 minutes Patients assigned to the resuscitation category must receive continuous nursing surveillance, those in the emergent category must be reassessed at least every 15 minutes, patients in the urgent category must be reassessed at least every 30 minutes, patients 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.
A patient has undergone a diagnostic peritoneal lavage. The nurse interprets which result as indicating a positive test? a) Red blood cell count of 50,000/mm3 b) Absence of bile c) White blood cell count of 300/mm3 d) Evidence of feces
Evidence of feces 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.
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? a) Make an incision and suck the venom out. b) Have the patient lie down and place the arm below the level of the heart. c) Apply ice to the area. d) Apply a tourniquet to the arm above the bite.
Have the patient lie down and place the arm below the level of the heart. 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 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? a) Administration of activated charcoal b) Dilution with water or milk c) Induced vomiting d) Gastric lavage
Induced vomiting 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.
Which category of triage encompasses patients with serious health problems that are not immediately life threatening? a) Psychological support b) Urgent c) Nonurgent d) Emergent
Urgent Urgent patients have serous health problems that not immediately life threatening. They must be seen within 1 hour. Emergent patients have the highest priority with conditions are life threatening and they must be seen immediately. Nonurgent patients have episodic illness that can be addressed within 24 hours without increased morbidity. Fast track patients 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.
A patient presents to the ED following a motor vehicle collision. The patient is suspected of having internal hemorrhage. The nurse assesses the patient for signs and symptoms of shock. Signs and symptoms of shock include which of the following? Select all that apply. a) Decreasing blood pressure b) Increasing urine volume c) Increasing heart rate d) Delayed capillary refill e) Cool, moist skin
• Decreasing blood pressure • Cool, moist skin • Increasing heart rate • Delayed capillary refill 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.
Nursing students are reviewing information about endotracheal intubation. They demonstrate understanding of the information when they identify which of the following as a reason for this procedure? Select all that apply. a) Facilitate removal of an upper airway obstruction b) Allow connection to a manual resuscitation bag c) Decrease tracheobronchial secretions d) Establish an airway for ventilation e) Prevent aspiration into the lungs
• Establish an airway for ventilation • Allow connection to a manual resuscitation bag • Prevent aspiration into the lungs Endotracheal intubation is indicated to establish an airway for a patient who cannot be adequately ventilated with an oropharyngeal airway, bypass an upper airway obstruction, prevent aspiration, permit connection to a resuscitation bag or mechanical ventilator, or facilitate removal of tracheobronchial secretions
Which of the following would the nurse identify as indicating that a client is experiencing a complete airway obstruction? Select all that apply. a) Spontaneous coughing b) Stridor c) Clutching of the neck d) Inability to speak e) Cyanosis
• Inability to speak • Clutching of the neck • Stridor • Cyanosis 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 female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing interventions should be provided? (Select all that apply.) a) Record a history of the event, using the patient's own words. b) Ensure that the police are present when the examination is performed. c) Assess and document any bruises and lacerations. d) 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. e) Have the patient shower or wash the perineal area before the examination.
• 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. • Assess and document any bruises and lacerations. 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).
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. a) Visual hallucinations b) Hypoactive reflexes c) Clonus d) Hypothermia e) Tachycardia
• Tachycardia • Visual hallucinations • Clonus 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.