Chap 72 Emergency Nursing

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.

Correct response: Resuscitation Emergent Urgent Nonurgent Minor

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?

Q30min

An acutely ill patient has had a pulmonary artery catheter (PAC) placed and the critical care nurse is closely monitoring the data that the PAC provides. When documenting the patient's mean arterial pressure, the nurse understands that this value represents:

The average arterial blood pressure throughout the patient's cardiac cycle

Which triage category refers to life-threatening or potentially life-threatening injury or illness requiring immediate treatment?

You Selected: Urgent Correct response: Emergent Explanation: The client 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 nonacute, non-life-threatening injury or illness.

A client has a gaping wound on his forearm that is bleeding profusely. Applying pressure to which pressure point would be most helpful?

brachial

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

unconscious adult

A woman is brought to the emergency department by her husband, who reports that his wife "accidentally fell down a flight of steps and broke her arm." The patient is very quiet and withdrawn. During the examination, inspection reveals numerous bruises at different stages of healing over the patient's legs, arms, and abdomen. The nurse suspects abuse. Which of the following questions would be most appropriate for the nurse to use to gather additional information?

"I've noticed several bruises here and there. Can you tell me what happened?"

You are a pediatric nurse practitioner working in a walk-in clinic. A young mother comes to the clinic with her two-year-old because the child has a swollen arm. While you are taking a history, the mother tells you the child "got stung by a bee yesterday." You examine the child and find only a localized reaction to the bee venom. How would you explain the swelling in the arm to the mother?

"The swelling is caused by a localized reaction to the bee venom. It will go away in a few days."

A patient is brought to the emergency department. Assessment reveals that the patient is lethargic and diaphoretic and complaining of right upper quandrant 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?

10,500mg 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.

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.

Ask the patient questions that can be answered with a nod or a shake of the head.

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

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?

Correct response: 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 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

For a patient who is experiencing multiple injuries, which sequence of medical or nursing management would the nurse identify as a priority?

Establish an airway, control hemorrhage, prevent hypovolemic shock, assess for head injuries.

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 acetaminiophen toxicity.

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

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.

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 patient in a cold-water bath Explanation: For the patient 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 patient'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 patient in a cold-water bath is the optimal method for cooling (if available). Hydration would be with lactated Ringer's solution. There is no indication for intubation. Administration of sodium supplements is indicated for the treatment of heat cramps.

Which solution should the nurse use to replace lost fluids in a client with signs and symptoms of shock due ot hemmorhaging?

LR

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

A family member brings a patient to the emergency department. The family member states, "I think he overdosed on heroin." Which of the following would the nurse expect to assess?

Pinpoint pupils Explanation: Signs of an acute overdose of heroin, an opioid, include pinpoint pupils, marked respiratory depression, descreased blood pressure, stupor progressing to coma, seizures, and pulmonary edema. Flushed face typically reflects a barbiturate overdose.

When preparing to perform abdominal thrusts on a client with an airway obstruction, which of the following would be most appropriate?

Positioning the hands in the midline slightly above the umbilicus

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

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.)

Splinting the wound in a position of rest to prevent motion Elevating the site to limit the accumulation of fluid in the interstitial spaces Applying a clean dressing to protect the wound

A nurse is providing inservice 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

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.

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

confusion

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

evidence of feces

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

heightened anxiety phase

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

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

A nurse is monitoring a client diagnosed with Lyme disease. Which finding would suggest that the disease is in the early stages?

red macule or papule

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

urgent

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

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?"

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) Allow connection to a manual resuscitation bag c) Prevent aspiration into the lungs d) 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.

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?

You Selected: Assessing neurologic function Correct response: 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.

Which of the following statements would most lead a nurse to suspect that a patient is experiencing food poisoning?

"My brother got sick like me after eating the same food."

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?

measure circumference of arm

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 water to burn

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

liver

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

reposition head

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

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?

You Selected: Forced warm air blankets Correct response: 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 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 analesic

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

cherry red skin

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 cap refill

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

dx and lab tests

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.

knife gunshot

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 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.

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

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 knife

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 3