Chapter 72: Emergency Nursing (Working)

A client arrives at the emergency department and is experiencing a severe allergic reaction to a bee sting. The client received treatment and is being discharged. Which client statement indicates that additional teaching about exposure prevention is needed?

"Brightly colored clothes help to ward off bees."

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?"

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."

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

Emergent

A nurse is providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate?

Massaging the feet

Acetaminophen overdose is treated with administration of which medication?

N-acetylcysteine (Mucomyst)

Which medication reverses severe respiratory depression and coma?

Naloxone hydrochloride (Narcan)

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 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 an analgesic as ordered.

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?

Administer analgesic medications as ordered.

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

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

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?

High-pitched noise on inhalation

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

Intoxication

A nurse is providing an educational program for a group of occupational health nurses working in chemical facilities. Which of the following would the nurse include as the priority in the case of a chemical burn?

Rinsing the area with copious amounts of water

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.

Gunshot wound Knife-stab wound

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.

The nurse is caring for a client with right ventricular heart failure. The nurse understands hypervolemia will have what effect on the client's heart?

The client's myocardial oxygen requirements will be higher

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?

Jaw-thrust Explanation: 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.