Chapter 72: Emergency nursing

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

A client presents 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

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?

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

3 to 5 minutes

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

Crush Injuries

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

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

Emergent

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

Fast track

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

Heightened anxiety phase

An 85 year old client is admitted to the ED. Heat stroke is suspected. The client's core temperature is 106.2 degree Fahrenheit, 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.

Which solution should the nurse use to replace lost fluids in a client?

Lactated Ringer Solution

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

Liver

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

Acetaminophen overdose is treated with administration of which medication?

N-acetylcysteine

Which medication reverses severe respiratory depression and coma?

Naloxone Hydrochloride

A family member brings a client to the ED following an apparent oxycodone overdose. The client is experiencing sever respiratory depression. Which medication will the nurse administer?

Naloxone hydrochloride

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

Which laboratory study is used to detect pancreatic injury?

Serum amylase

Following a motor vehicle collision, a client is brought to the ED for evaluation and treatment. THe client is being assessed for intro-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

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

Time when the client last received a tetanus immunization

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

Unconscious Adult

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

Urgent

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

Administer analgesic medications as ordered.

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

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

Do not apply water to the burn

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

The nurse is caring for a victim of 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

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

Intoxication

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

Intoxication

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

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

Urgent

The Ed staff 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 (disability)

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 rewarding process?

Attach a cardiac monitor

A client presents to the ED following a motor vehicle Allison. The client is suspected of having internal hemorrhage. The nurse assess the client for signs and symptoms of shock. Which are signs and symptoms of shock?

Cool, moist skin Delayed capillary refill Decreasing blood pressure Increasing heart rate

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

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.