Chapter 72: Emergency Nursing
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.) Forceful coughing B.) Wheezing between coughs C.) High-pitched noise on inhalation D.) Refusal to lie flat
Answer C.) High-pitched noise on inhalation Rationale: 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 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 - Increasing urine volume
Answer: - Cool, moist skin - Decreasing blood pressure - Increasing heart rate - Delayed capillary refill
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? A.) Administer analgesic medications as ordered. B.) Keep the hand in the circulating bath for 1 hour. C.) Rupture any hemorrhagic blebs that are noted. D.) Have the client complete active range-of-motion exercises.
Answer: A.) Administer analgesic medications as ordered.
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? A.) Attach a cardiac monitor B.) Insert a Foley urinary catheter C.) Assist with endotracheal intubation D.) Administer inotropic drugs
Answer: A.) Attach a cardiac monitor Rationale: 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.
The nurse is conducting a secondary survey on a client in the ED. Which action is completed during the secondary survey? A.) Diagnostic and laboratory testing B.) Assessment of peripheral pulses C.) Establishing a patent airway D.) Undressing the client
Answer: A.) Diagnostic and laboratory testing Rationale: 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? A.) Document the client's condition and absence of friends or family for obtaining consent to treatment. B.) Check the client's record for the name of a family member to call to allow care to be provided. C.) Ask the ambulance team for information about the client's family to ensure informed consent. D.) Explain to the client that care is going to be provided because he is seriously ill.
Answer: A.) Document the client's condition and absence of friends or family for obtaining consent to treatment. Rationale: 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? A.) Ear lobe and then to the xiphoid process B.) Chin and then to the xiphoid process C.) Ear lobe and then to the umbilicus D.) Chin and then to the umbilicus
Answer: A.) Ear lobe and then to the xiphoid process
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? A.) Emergency response personnel performed this intervention outside the hospital. B.) The client's airway is oversized requiring a specialized endotracheal tube. C.) Laryngeal edema prevented placement of an endotracheal tube. D.) The client was hemorrhaging into the neck.
Answer: A.) Emergency response personnel performed this intervention outside the hospital. Rationale: 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 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? A.) Ensure a patent airway and that the patient is receiving 100% oxygen. B.) Send the patient for a chest x-ray. C.) Send the patient to the hyperbaric chamber. D.) Draw labs for a chemistry panel.
Answer: A.) Ensure a patent airway and that the patient is receiving 100% oxygen. Rationale: 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.
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? A.) Establish an airway. B.) Prevent hypovolemic shock. C.) Assess for head and neck injuries. D.) Control hemorrhage.
Answer: A.) Establish an airway. Rationale: 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.
The nurse is providing care to a client who will be ambulating for the first time after being extubated. The client tells the nurse, "I don't want to do this today. It's too soon and I am afraid I am not strong enough." What intervention should the nurse implement first for the client's fear of falling? A.) Explore possible causes of the client's fear B.) Evaluate the client for cognitive impairment C.) Allow the client to remain on bedrest D.) Clear the area around the bed
Answer: A.) Explore possible causes of the client's fear
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? A.) Heightened anxiety phase B.) Acute disorganization phase C.) Denial phase D.) Reorganization phase
Answer: A.) Heightened anxiety phase Rationale: 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 undergoes a total abdominal hysterectomy. When assessing the client 10 hours later, the nurse identifies which finding as an early sign of shock? A.) Increasing heart rate B.) Pale, warm, dry skin C.) Heart rate of 70 beats/minute D.) Elevated blood pressure
Answer: A.) Increasing heart rate
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? A.) Liver B.) Stomach C.) Large intestine D.0 Kidneys
Answer: A.) Liver Rationale: 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.
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? A.) N-acetylcysteine B.) Flumazenil C.) Naloxone D.) Diazepam
Answer: A.) N-acetylcysteine Rationale: 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.
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? A.) Protecting himself or herself B.) Securing the area C.) Gaining control of the situation D.) Providing care to the injured
Answer: A.) Protecting himself or herself Rationale: 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.
The intensive care unit nurse is assessing a client who is going to require a peripheral intravenous (PIV) line for fluids. The nurse should consider what information in the client's health history when deciding the site for the PIV? A.) The client has had a mastectomy on the right side B.) The client has hypertension C.) The client has a fluid volume restriction D.) The client has a history of falls
Answer: A.) The client has had a mastectomy on the right side Rationale: Contraindications to the placement of a PIV line in any specific placement (right vs. left side) will include history of mastectomy, arterial-venous shunt placement, peripherally inserted central catheter (PICC) line placement, thrombus, trauma, and other device placements, such as splints and casts. The nurse will only have the option to start the PIV on a site in the client's left arm if the client has had a ride-sided mastectomy. A history of hypertension does not preclude the client from having a PIV inserted in any specific location. Although fluid requirements are monitored more strictly with clients who are on a fluid volume restriction, this does not influence the placement of the PIV. The nurse should always be aware of the risks of a PIV for a client with a falls history. The tubing can be a tripping hazard, therefore, the client with a falls history who requires a PIV should be closely monitored but this does not preclude the client from having a PIV inserted.
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? A.) Tissue tearing away from supporting structures B.) Incision of the skin with well-defined edges, usually long rather than deep C.) Skin tear with irregular edges and vein bridging D.) Denuded skin
Answer: A.) Tissue tearing away from supporting structures Rationale: 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.
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 A.) pulmonary edema. B.) hypothermia. C.) hyponatremia. D.) head injury.
Answer: A.) pulmonary edema. Rationale: 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.
Permanent brain injury or death will occur within which time frame secondary to hypoxia? A.) 1 to 2 minutes B.) 3 to 5 minutes C.) 6 to 8 minutes D.) 9 to 10 minutes
Answer: B.) 3 to 5 minutes Rationale: 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 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.) Apply a tourniquet. B.) Apply firm pressure over the involved area or artery. C.) Elevate the injured part. D.) Immobilize the area to control blood loss.
Answer: B.) Apply firm pressure over the involved area or artery. Rationale: 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.
The nurse educator is providing orientation to a group of nurses newly hired to an intensive care unit. The group of nurses are correct in stating which is the most common type of shock managed in critical care? A.) Anaphylactic B.) Hypovolemic C.) Neurogenic D.) Cardiogenic
Answer: B.) Hypovolemic
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.) Neck tilt-head lift B.) Jaw-thrust C.) Abdominal thrust D.) Seldinger
Answer: B.) Jaw-thrust Rationale: 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 nurse is providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate? A.) Providing an analgesic for pain B.) Massaging the feet C.) Restricting ambulation D.) Placing sterile cotton between the toes after rewarming
Answer: B.) Massaging the feet Rationale: 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.
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? A.) The client will require intravenous access for three days B.) The client requires total parenteral nutrition C.) The client requires infusion of intravenous antibiotics D.) The client requires infusion of a dextrose 5% water (D5W)
Answer: B.) The client requires total parenteral nutrition Rationale: 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.
Which category of triage encompasses clients with serious health problems that are not immediately life threatening? A.) Emergent B.) Urgent C.) Nonurgent D.) Psychological support
Answer: B.) Urgent Rationale: 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.
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? A.) Bradycardia B.) Rising blood pressure C.) Delayed capillary refill D.) Pale pink dry skin
Answer: C.) Delayed capillary refill Rationale: If a client exhibits tachycardia, falling blood pressure, thirst, apprehension, cool moist skin, or delayed capillary refill, internal bleeding should be suspected.
Which statement reflects the nursing management of the client with a white phosphorus chemical burn? A.) Immediately drench the skin with running water from a shower, hose, or faucet B.) Alternate applications of water and ice to the burn C.) Do not apply water to the burn D.) Wash off the chemical using warm water, then flush the skin with cool water
Answer: C.) Do not apply water to the burn Rationale: Water should not be applied to burns from lye or white phosphorus because of the potential for an explosion or deepening of the burn.
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? A.) Forearm B.) Hand C.) Foot D.) Upper arm
Answer: C.) Foot Rationale: 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.
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.) Monitor the situation during subsequent visits. C.) Report the suspicion to the local agency on aging within 24 hours of the visit. D.) Try to convince the client to report the problem.
Answer: C.) Report the suspicion to the local agency on aging within 24 hours of the visit. Rationale: 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 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? A.) Laceration B.) Avulsion C.) Stab D.) Patterned
Answer: C.) Stab Rationale: 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 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 I B.) Stage II C.) Stage III D.) Stage IV
Answer: C.) Stage III Rationale: 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.) A foreign object B.) Saliva or mucus C.) The tongue D.) Edema
Answer: C.) The tongue
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? A.) 9% B.) 7% C.) 6% D.) 4%
Answer: D.) 4% Rationale: Oxygen is administered until the carboxyhemoglobin level is less than 5%.
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.) Gastric lavage C.) Administration of activated charcoal D.) Induced vomiting
Answer: D.) Induced vomiting Rationale: 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.
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? A.) Contusion of the right upper quadrant B.) Rebound abdominal tenderness C.) Abdominal distention D.) Pain in the left shoulder
Answer: D.) Pain in the left shoulder Rationale: 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 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? A.) Collecting semen B.) Performing the pelvic examination C.) Obtaining consent for examination D.) Supporting the client's emotional status
Answer: D.) Supporting the client's emotional status
When preparing to perform abdominal thrusts on a client with an airway obstruction, which of the following would be most appropriate? A.) Having the conscious client lie down B.) Placing the thumb side of one hand at the xiphoid process C.) Positioning the hands in the midline slightly above the umbilicus D.) Using a sequence of four thrusts, each progressing in intensity
Answer; C.) Positioning the hands in the midline slightly above the umbilicus Rationale: When performing abdominal thrusts, the nurse would place the thumb side of one fist against the client's abdomen in the midline slightly above the umbilicus and well below the xiphoid process, grasping the fist with the other hand. Then the nurse would press the fist into the client's abdomen with a quick inward and upward thrust such that each new thrust should be a separate and distinct maneuver. The unconscious client is positioned on the back. The client who is conscious should be standing or sitting.
