chapter 21

A 22-year-old patient who experienced a drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period?

Auscultate breath sounds. Because pulmonary edema is a common complication after drowning, the nurse should assess the breath sounds frequently.

An unresponsive patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first?

Pulse The priority assessment in an unresponsive patient relates to CAB (circulation, airway, breathing) so a pulse check should be performed first.

Following an earthquake, patients are triaged by emergency medical personnel and transported to the emergency department (ED). Which color tag indicates that the nurse needs to assess that patient first?

Red The red tag indicates a patient with a life-threatening injury requiring rapid treatment.

During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next?

Start normal saline fluid infusion with two large-bore IV lines. The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a life-threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey.

A 19-year-old patient presents to the emergency department (ED) with multiple lacerations and tissue avulsion of the left hand. The patient denies having any previous vaccinations. What would the nurse anticipate administering?

TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap) For an adult with no previous tetanus immunizations, TIG and Tdap are recommended.

A patient who has deep human bite wounds on the left hand is being treated in the urgent care center. Which action will the nurse plan to take?

Teach the patient about the use of prophylactic antibiotics Because human bites of the hand frequently become infected, prophylactic antibiotics are usually prescribed to prevent infection.

When assessing an older patient admitted to the emergency department (ED) with a broken arm and facial bruises, the nurse observes several additional bruises in various stages of healing. Which statement or question would the nurse provide first?

"Do you feel safe at home?" The nurse's initial response should be to further assess the patient's situation.

A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). Which patient statement indicates to the nurse that discharge teaching has been effective?

"I need to drink extra fluids when working outside in hot weather." Water and oral electrolyte replacement solutions such as sports drinks help replace fluid and electrolytes lost when exercising in hot weather.

The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient requires the most immediate treatment?

A patient with paradoxical chest motion Most immediate deaths from trauma occur because of problems with ventilation, so the patient with paradoxical chest movements should be treated first.

Which interventions will the nurse plan for a comatose patient who will have targeted temperature management/therapeutic hypothermia? (Select all that apply.)

A. Assist with endotracheal intubation. b. Insert an indwelling urinary catheter. c. Begin continuous cardiac monitoring. Cooling can produce dysrhythmias, so the patient's heart rhythm would be continuously monitored, and dysrhythmias treated if necessary. Bladder catheterization and endotracheal intubation are needed during cooling.

A triage nurse in a busy emergency department (ED) assesses a patient who reports 7/10 abdominal pain and states, "I had a temperature of 103.9F (39.9C) at home." Which action would the nurse take first?

Assess the patient's current vital signs. The patient's pain and statement about an elevated temperature indicate that the nurse should obtain vital signs before deciding how rapidly the health care provider should see the patient.

The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action would the nurse take first?

Attempt to remove the patient's rings The patient's rings should be removed first because it might not be possible to remove them if swelling develops.

A patient who experienced blunt abdominal trauma during a motor vehicle collision reports increasing abdominal pain. For which procedure would the nurse expect to prepare the patient?

Abdominal ultrasonography For patients who are at risk for intraabdominal bleeding, focused abdominal ultrasonography is the preferred method to assess for intraperitoneal bleeding.

A patient arrives in the emergency department (ED) several hours after taking "25 to 30" acetaminophen (Tylenol) tablets. Which action will the nurse plan to take?

Administer N-acetylcysteine. N-acetylcysteine is a recommended treatment to prevent liver damage after acetaminophen overdose.

An unresponsive 79-year-old patient is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 105.4F (40.8C), blood pressure (BP) is 88/50 mm Hg, and pulse is 112 beats/min. Which action would the nurse plan to take?

Apply wet sheets and a fan to the patient The priority intervention is to cool the patient. Antipyretics are not effective in decreasing temperature in heat stroke and 100% O2 would be given, which requires a high flow rate through a non-rebreather mask.

Family members are in the patient's room when the patient has a cardiac arrest and the staff start resuscitation measures. Which action would the nurse take first?

Ask the family members whether they would prefer to remain in the patient's room or wait outside the room. Although many family members and patients report benefits from family presence during resuscitation efforts, the nurse's initial action would be to determine the preference of these family members.

A patient arrives in the emergency department (ED) after topical exposure to powdered lime at work. Which action would the nurse take first?

Brush visible powder from the skin and clothing. The initial action would be to protect staff members and decrease the patient's exposure to toxin by decontamination.

A patient who had a cardiac arrest has been resuscitated and therapeutic hypothermia is prescribed. Which action will the nurse include in the plan of care?

Initiate protocol for temperature management. Therapeutic hypothermia, also called targeted temperature management (TTM), uses external cooling devices or cold normal saline infusions to rapidly lower body temperature to 89.6 to 93.2F (32 to 34C).

The emergency department (ED) nurse is starting targeted temperature management/therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/VN)? (Select all that apply.)

Insert a urinary catheter to drainage. Place cooling blankets above and below patient. Attach rectal temperature probe to cooling blanket control panel. Experienced LPN/VNs have the education and scope of practice to implement hypothermia measures (e.g., cooling blanket, temperature probe) and insert a urinary catheter under the supervision of a registered nurse (RN). A

The nurse is doing the primary survey of an adult who was in a motor vehicle collision. After the nurse determines that the patient has an unobstructed airway, which action would the nurse take next?

Observe the patient's respiratory effort. Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient's breathing.

Which finding indicates that the nurse should discontinue active rewarming of a patient admitted with hypothermia?

The core temperature is 94F (34.4C) The nurse would discontinue active rewarming once the patient's core temperature reaches 90 to 95F (32.2 to 35C).

Gastric lavage and administration of activated charcoal are prescribed for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action would the nurse plan to take first? a.

Assist with endotracheal intubation. In an unresponsive patient, endotracheal intubation is done before gastric lavage and activated charcoal administration to prevent aspiration. The other actions will be implemented after intubation.

A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. Which action would the nurse complete during the primary survey of the patient?

Check a Glasgow Coma Scale score The Glasgow Coma Scale is included when assessing for disability during the primary survey.

The urgent care center protocol for tick bites includes the following actions. Which action will the nurse take first when caring for a patient with a tick bite?

Use tweezers to remove any remaining ticks. Because neurotoxic venom is released as long as the tick is attached to the patient, the initial action would be to remove any ticks using tweezers or forceps.

The emergency department (ED) nurse is requested to plan for a response to the potential use of smallpox as a biological weapon. Which resource would the nurse recommend be obtained?

Vaccine Smallpox infection can be prevented or ameliorated by the administration of a vaccine given rapidly after exposure.