NU 456 Prioritization EAQ

Prevention The primary priority for decreasing the risk for morbidity and mortality is prevention. Treatment and surgical therapy are secondary priorities. Rehabilitation is a tertiary priority.

Which intervention is the primary priority for decreasing a client's risk for morbidity and mortality? Treatment Prevention Rehabilitation Surgical therapy

Functional nursing The functional method of delivering care works well in emergency and disaster situations. Each care provider knows the expectations of the assigned role and completes the tasks quickly and efficiently. Team nursing, primary nursing, and client-centered nursing delivery systems are not supported by evidence as working well in emergency situations.

Which nursing care delivery system works well in emergency situations that necessitate prioritization of care? Team nursing Primary nursing Functional nursing Client-centered nursing

Red Clients who have a red tag should be provided with immediate care because red tags are given to clients who are in life-threatening situations. A black tag is given to clients who are expected to die or are already dead. Green tags are given to clients who can wait a short time for care. A yellow tag is given to clients in nonurgent situations.

In a mass casualty event, clients with which color tag would be provided with immediate care based on priority? Red Black Green Yellow

Airway Airway is assessed first in a client with severe trauma because inadequate oxygen supply can lead to brain injury that can progress to anoxic brain death. Disability is assessed after the vital signs are assessed. Breathing is assessed after the airway is assessed and cleared. Circulation is assessed after effective breathing is ensured.

Which assessment would the nurse perform first for a client with severe trauma? Airway Disability Breathing Circulation

Bachelor's degree registered nurse According to the Model for Differentiated Nursing Practice, the bachelor's degree registered nurse is the entry-level nurse who is most prepared for prioritization of client care. Licensed practical nurses, diploma nurses, and associate's degree nurses are managed at the bedside by the bachelor's degree registered nurse.

According to the Model for Differentiated Nursing Practice, which entry-level nurse is most prepared for prioritization of client care? Licensed practical nurse Diploma registered nurse Associate's degree registered nurse Bachelor's degree registered nurse

Class III Class III clients are considered "walking wounded" and are classified under the nonurgent category. Class I or emergent clients are identified with a red tag. Class II clients can wait a short time for care but have serious injuries that require near-term treatment. Class IV clients are expected to die or are dead and are issued a black tag.

Which class of clients during a mass casualty situation would the nurse refer to as the "walking wounded"? Class I Class II Class III Class IV

Chews tobacco Multiple sex partners History of alcohol abuse for 5 years Tobacco, alcohol, and human papilloma virus (HPV) are the major causes of neck cancer. The nurse would counsel the client who chews tobacco and educate regarding the importance of oral hygiene. The nurse would advise the client to stop chewing tobacco to reduce the risk of head and neck cancer. The nurse would educate the client with multiple sex partners about protecting against HPV, which is a risk factor for cancer. The nurse would place a high priority on health promotion in a client with a history of alcohol abuse for 5 years because it is 1 of the major risk factors for head and neck cancer. The client should use condoms when having sex with potentially infectious partners to prevent HPV infections that can lead to head and neck cancer. A client should maintain proper oral hygiene by brushing her or his teeth regularly with a soft-bristle brush and flossing.

Which client activities warrant the highest priority for education about health promotion to prevent head and neck cancer? Select all that apply. One, some, or all responses may be correct. Chews tobacco Multiple sex partners Uses condoms when having sex History of alcohol abuse for 5 years Brushes with a soft-bristle toothbrush

Client A with an airway obstruction has an immediate threat to life and the condition is considered emergent, which meets the criteria for class 1. Client B with extensive full-thickness burns should be triaged under class 4 because the client with this condition is expected to die. Client C with open fractures implies a major injury that requires treatment and is considered urgent. This client is triaged under class 2. Client D with a closed fracture and abrasions indicates a minor injury that does not require immediate treatment and is triaged under class 3. Test-Taking Tip: Key words or phrases in the question stem such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. No real absolutes exist in life; however, every rule has its exceptions, so answer with care.

Which client would be treated first? A B C D

Client D Client D with chest trauma who is coughing up blood and experiencing difficulty breathing should be cared for first. Client A with cardiomyopathy and swelling of the lower extremities and weight gain can be treated later because the client can wait for treatment. Client B with peripheral artery disease can be treated after treating the clients with emergency conditions because this client can wait for treatment. Client C with an aortic aneurysm and chest pain with difficulty breathing can be cared for after client D because there is no sign that the aneurysm has ruptured.

Which client would the nurse care for first based on priority of condition and findings? Client A Client B Client C Client D

Black The disaster triage tag system categorizes triage priority by color. The clients who are expected to die after a disaster are marked with a black tag. The clients who have an immediate threat to life and need emergency treatment are marked with a red tag. The clients who have minor injuries that do not require immediate treatment are marked with a green tag. The clients who have major injuries and require treatment are marked with a yellow tag. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

Which color tag is used for a client who is expected to die after a disaster with mass casualties? Red Black Green Yellow

Team The hallmark of team nursing is "care through others," which was designed as an adaptation to functional nursing. Primary nursing is an adaptation to the case method. Case management is the process of coordinating health care by planning, facilitating, and evaluating interventions across levels of care to achieve measurable cost and quality outcomes. Differentiated practice consists of models of care delivery that are differentiated by level of education, expected clinical skills or competencies, job descriptions, pay scales, and participation in decision-making. Test-Taking Tip: Multiple-choice questions can be challenging, because students think they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

Which delivery system was developed to provide care through others as an adaptation to functional nursing? Team Primary Case management Differentiated practice

Increase in cost One disadvantage when using the primary nursing model to implement client care is an increase in overall cost. The primary nursing model enhances autonomy and increases holistic care and rapport between the nurse and the client.

Which disadvantage is associated with the primary nursing model for implementing client care? Increase in cost Loss of autonomy Lack of holistic care Decrease in client rapport

Drowning In case of drowning, the nurse would deliver abdominal and chest thrusts only if needed to clear an airway obstruction but should not be concerned with getting the water out. To treat frostbite, the nurse would thaw the frozen part in a water bath at a temperature range of 104°F to 108°F. For treatment of mild hypothermia, the client needs to be sheltered from the cold environment, have all wet clothing removed, and undergo passive or active external rewarming. As an initial care of lightening injury, the nurse would perform spinal immobilization with priority attention to stabilization of airway-breathing-circulation through standard basic and advanced life support measures.

Which environmental emergency requires the nurse to administer priority emergency abdominal and chest thrusts to clear a client's airway obstruction? Frostbite Drowning Hypothermia Lightening injury

Plan of care The associate nurse provides care using the plan of care developed by the primary nurse. The nurse's notes and primary health care provider's prescriptions will not provide adequate information to provide client care. The charge nurse will not provide direction for client care within primary nursing.

Which guide would the associate nurse use to provide client care within the primary nursing delivery model? Plan of care Nurse's notes Primary health care provider's prescriptions Direction from the charge nurse

Registered nurse (RN) The RN is responsible for providing intravenous medications to clients. The RN has knowledge of medication administration via all routes. Nursing managers are able to provide intravenous medications but may not be available at all times. PCAs are unlicensed professionals and are unable to provide intravenous medications. UNP are not eligible to provide medications to clients; they can provide assistance in monitoring clients. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

Which health care team member is considered the priority person to provide medications to the client receiving intravenous therapy? Registered nurse (RN) Nursing manager Patient-care associate (PCA) Unlicensed nursing personnel (UNP)

Immobilizing the affected extremity using a splint The priority nursing intervention for a client bitten by a snake is to immobilize the affected extremity using a splint because this may limit the spread of venom. The affected area should not be sucked because it will further harm the client. Alcohol should not be offered because it can cause the venom to spread through vasodilation. Applying ice to the affected area is ineffective and may worsen the client's condition.

Which intervention is the highest priority prehospital intervention for a client bitten by a snake? Sucking the venom out of the bitten area Offering alcohol to the client Applying ice to the affected area Immobilizing the affected extremity using a splint

Pericarditis Pericarditis is a late effect of radiation therapy on the heart. Trismus is a late effect of radiation therapy on the head and neck. Lymphedema is a late effect of radiation therapy on the chest wall of the client. Pulmonary fibrosis is a late effect of radiation therapy on the lungs of the client.

Which late effect of radiation therapy on the heart would the nurse monitor as a priority? Trismus Pericarditis Lymphedema Pulmonary fibrosis

ESI-4 Clients who are triaged as an ESI-4 are the clients with minor injuries. These clients are given lowest priority when large numbers of clients are cared for in the emergency department. Clients who require immediate care are triaged in ESI-1, and they are given first priority. Clients in ESI-2 can be cared for after the care of the clients in ESI-1. Clients in ESI-3 should be cared for within an hour.

Which level of emergency severity index (ESI) would be considered the lowest priority in the emergency department? ESI-1 ESI-2 ESI-3 ESI-4

Sertraline A client with severe cramps, backache, and a migraine with anxiety and mood swings likely has premenstrual syndrome (PMS). Selective serotonin reuptake inhibitors (SSRIs) such as sertraline are effective in relieving the symptoms of severe PMS. Buspirone is useful only to relieve anxiety in the client with PMS. Ibuprofen is used to reduce physiological symptoms. Diuretics such as spironolactone are effective in reducing fluid overload.

Which medication would the nurse expect to be prescribed first to reduce the symptoms of a female client who has severe cramping, pain, backache, and a migraine headache and presents with anxiety and mood swings? Sertraline Buspirone Ibuprofen Spironolactone

Maintaining a patent airway The nurse should assess, ensure, and maintain a patent airway first in a client with neck trauma. The nurse then may palpate the skin near the esophagus to assess crepitus, which indicates an injury to the esophagus. After ensuring airway patency, the nurse should assess for bleeding or impending shock. The nurse should also perform a neurological assessment for mental status, sensory level, and motor function, which holds a medium priority.

Which nursing intervention has the highest priority for a client who was in a motor bike accident and has a severe neck injury? Assessing for crepitus Assessing for bleeding Maintaining a patent airway Performing neurological assessment

Chest pain and diaphoresis The three-tiered triage system in an emergency department includes emergent, urgent, and nonurgent levels in which care should be provided to the clients accordingly. The client with chest pain and diaphoresis has a life-threatening situation and requires immediate intervention. The client with bruises and superficial lacerations and the client with severe pain resulting from a displaced tendon have urgent situations but can wait for some time. Clients with complex lacerations but with moderate hemorrhage have an urgent situation but can be treated even after some time because there is no life-threatening problem.

Which of four clients in a pediatric unit of a health care facility would the nurse provide immediate care for first? Chest pain and diaphoresis Bruises and superficial lacerations Severe pain as a result of displaced tendons Complex lacerations associated with moderate hemorrhage

Implementation Implementation is the fourth phase of the strategic planning process, which specifies the plan for action and is executed in order of priority. Identification of strategies is the third phase of the strategic planning process, which involves identifying major issues, establishing goals, and developing strategies to meet the goals. Review of the mission statement, philosophy, goals, and objectives is the second phase of the strategic planning process, which reflects the purpose and direction of the health care organization or department. Assessment of the external, internal, and organizational environment is the first phase of the strategic planning process, which assesses the external environment for planning a process.

Which phase of the strategic planning process executes a specific action plan according to order of priority? Implementation Identification of strategies Review of mission statement, philosophy, goals, and objectives Assessment of the external, internal, and organizational environment

Administer 100% oxygen (O2). Prepare for endotracheal intubation Stop all inhalation anesthetic agents. The client should be ventilated with 100% O2 using the highest possible flow rate when malignant hyperthermia is evident. The nurse would prepare the client for endotracheal intubation. All inhalation anesthetic agents should be stopped immediately because the client's condition may worsen. The core body temperature should be monitored on an ongoing basis. An indwelling urinary catheter is inserted to monitor urine output, which is part of ongoing monitoring.

Which priority interventions would the nurse follow when caring for a client with malignant hyperthermia? Select all that apply. One, some, or all responses may be correct. Administer 100% oxygen (O2). Prepare for endotracheal intubation Monitor the core body temperature. Stop all inhalation anesthetic agents. Insert an indwelling urinary catheter

Integrate care with cost-effective approaches. The goal of case management is to provide cost-effective care through integration of clinical services in combination with financial services. Maximizing the skill level of all care providers is a feature of team nursing. Eliminating the need for UAP is a feature of primary nursing. Ensuring all resources for client care are located within a geographical location is a feature of client-focused care.

Which statement describes the goal of case management? Maximize the skill level of all care providers. Integrate care with cost-effective approaches. Eliminate the need for unlicensed assistive personnel (UAP). Ensure all resources for client care are located within a geographical location.

"I should assess for a decreased depth of ventilation in respiratory alkalosis." "I should assess for a decreased rate of ventilation in respiratory alkalosis." The nurse would assess for increased rate of ventilation and increased depth of ventilation in respiratory alkalosis. It is imperative that the nurse check for decreased respiratory effort associated with skeletal muscle weakness in metabolic alkalosis. Assessing for a decreased rate of ventilation and a decreased depth of ventilation are not appropriate in alkalosis and demonstrate the need for further learning about alkalosis. Test-Taking Tip: When a question stem asks for statements by a client or student nurse that would indicate the need for further teaching or learning, the question is asking you to pick out the incorrect or wrong response(s), which would require further teaching or learning. Read questions carefully to determine if they are asking you to find the correct answers or the answers that require further client or student nurse teaching or learning.

Which statement made by a student nurse indicates the need for further learning about assessing for respiratory system manifestations of alkalosis? Select all that apply. One, some, or all responses may be correct. "I should assess for an increased rate of ventilation in respiratory alkalosis." "I should assess for a decreased depth of ventilation in respiratory alkalosis." "I should assess for a decreased rate of ventilation in respiratory alkalosis." "I should assess for an increased depth of ventilation in respiratory alkalosis." "I should assess for a decreased respiratory effort associated with skeletal muscle weakness in metabolic alkalosis."

"I should compare the mental status of the client with that of the family statement." "I should compare the mental status of the client with the statement provided in the health record of the client." When the nurse compares the mental status with that of the family statement, it comes under the assessment of the client. Comparing mental status with the family statement does not mean assessing the client's history. The nurse is assessing the client, not the client's history when a comparison is made between the mental status of the client and the statement provided in the health record of the client. Assessing the client for drugs, chronic health problems, and acute health problems along with other risk factors for an acid-base imbalance helps obtain the client's history. Asking the client to list all the drugs, especially the diuretics and the antacids, helps the nurse assess the client's history of acid-base imbalance. The nurse asking for recall of all the liquid taken during the past 24 hours helps assess the history of the client. Test-Taking Tip: When a question stem asks for statements by a client or student nurse that would indicate the need for further teaching or learning, the question is asking you to pick out the incorrect or wrong response(s), which would require further teaching or learning. Read questions carefully to determine if they are asking you to find the correct answers or the answers that require further client or student nurse teaching or learning.

Which statements indicate the student nurse needs further teaching about how to gather history data for a client experiencing acid-base imbalance? Select all that apply. One, some, or all responses may be correct. "I should assess for drugs, chronic health problems, and acute health problems." "I should ask the client to list all the medications, especially the diuretics and the antacids." "I should compare the mental status of the client with that of the family statement." "I should ask the client to recall all the liquids that have been taken by the client in the past 24 hours." "I should compare the mental status of the client with the statement provided in the health record of the client."

"I should lower the extremity of the client." "I should apply warm compresses to stabilize the clot." "I should stop the infusion, but keep the short peripheral catheter in place." It is essential that the nurse elevate the extremities of the client. The nurse would always use cold compresses, not warm, to stabilize the clot in case of thrombosis. The nurse would use a low-dose thrombolytic agent that can help in lysing the clot. The nurse would stop the infusion and would remove the short peripheral catheter rather than keeping it in place. It is imperative for the nurse to use cold compresses to decrease the blood flow in case of thrombosis. Test-Taking Tip: When a question stem asks for statements by a client or student nurse that would indicate the need for further teaching or learning, the question is asking you to pick out the incorrect or wrong response(s), which would require further teaching or learning. Read questions carefully to determine if they are asking you to find the correct answers or the answers that require further client or student nurse teaching or learning.

Which statements made by a student nurse would a registered nurse need to correct about emergency treatment procedures for the local complication of intravenous therapy involving thrombosis? Select all that apply. One, some, or all responses may be correct. "I should lower the extremity of the client." "I should apply warm compresses to stabilize the clot." "I should apply cold compresses to decrease the blood flow." "I should use low-dose thrombolytic agent that can lyse the clot." "I should stop the infusion but keep the short peripheral catheter in place."

Interprofessional education Interprofessional education and collaboration are important and have a positive effect on the outcomes of client care, communication, and collaboration, which is increasingly important as the complexity of health care increases. The care models of primary nursing, client-focused care, and community-based transitional programs do not have the same effect as interprofessional education and collaboration on outcomes, communication, and collaboration.

Which strategy was designed to improve client outcomes, communication, and collaboration among all health care providers? Primary nursing Client-focused care Interprofessional education Community-based transitional program

Developmental needs Developmental needs and long-term care needs are low priority when prioritizing care because they are not an immediate threat to health. Potential needs in care are intermediate priority because they are best addressed before complications follow. Needs related to survival and safety are the highest priority because these are an immediate threat to client health.

Which type of needs would be placed as a low priority in the prioritization of client care? Developmental needs Potential needs in care Needs related to survival Needs that affect safety

Triage officer The triage officer determines the priorities for treatment in an emergency preparedness and emergency response plan. The public information officer serves as a liaison between the health care facility and the media. The medical command physician decides the number, acuity, and resource needs of clients. The hospital incident commander assumes overall leadership for implementing the emergency plan.

Which personnel can determine priorities for treatment in an emergency response plan? Triage officer Public information officer Medical command physician Hospital incident commander

Each team member's strengths Team nursing uses the strengths of each caregiver. This should be a priority when making client assignments. The length of the work shift, number of clients to assign, and amount of time needed to provide care are not as important when assigning clients to team members.

In the team nursing model, which is a priority consideration when the team leader is assigning clients to team members? Length of the work shift Number of clients to assign Each team member's strengths Amount of time needed to provide care

B The client with an HbA1c percentage level of less than 7%, fasting plasma glucose above 126 mg/dL, and 2-hour plasma glucose greater than 200 mg/dL indicates diabetes mellitus. Client B has increased values for A1c percentage, fasting plasma glucose, and 2-hour plasma glucose. Client B should be treated first. Clients A, C, and D have normal values for diabetes mellitus and therefore can be treated after client B.

The client with which laboratory values should be treated first during a diabetes mellitus campaign? A B C D

Hypokalemia In case of hypokalemia, the nurse would assess the respiratory status of the client every 2 hours. In case of hyperkalemia, the nurse would notify the health care team if the heart rate falls below 60 beats per minute or T waves become spiked. In case of hyponatremia, the nurse would be aware of muscle weakness in the client and immediately check respiratory effectiveness. In case of hypernatremia, the nurse would assess the client hourly for excessive losses of fluid, sodium, or potassium.

The nurse would assess the respiratory status of the client at 2-hour intervals as a safety priority for which condition affecting the client? Hypokalemia Hyperkalemia Hyponatremia Hypernatremia

Client D Client D is hemorrhaging; this should be the priority for treatment because waiting to treat the client can lead to total blood loss and death. Client A has a simple fracture, which requires a nonurgent level of care and can wait for several hours for treatment. Client B has renal colic, which is not a life-threatening situation. Client C has pneumonia, for which treatment can be delayed.

Which client would be given care first based on condition? Client A Client B Client C Client D

Safely rescuing the client The emergency care for a drowning client is focused on safe rescue of the victim. O2 is administered after the client is brought to a safe area. Gastric contents are prevented from aspiration after the client is safely removed from the water. Cardiopulmonary resuscitation is performed after the client is rescued.

Which consideration is made first when providing emergency care for a drowning client? Administering oxygen (O2) Safely rescuing the client Preventing aspiration of gastric contents Performing cardiopulmonary resuscitation

"The client's Trousseau sign would be positive." "The client would be suffering from paresthesias." "The client would show signs of anxiety and irritability." If clients suffer from the alkalosis, central nervous system activity increases, which manifests as paresthesias, positive Trousseau sign, anxiety, and irritability. The Chvostek sign would also be positive, not negative.

Which statements by the student nurse are accurate about the manifestation of alkalosis in the central nervous system? Select all that apply. One, some, or all responses may be correct. "The client's Chvostek sign would be negative." "The client's Trousseau sign would be positive." "The client would be suffering from paresthesias." "The client would show signs of anxiety and irritability." "The client's central nervous system should have decreased activity."

Primary nurse When using an adapted case method of care delivery, known as primary nursing, it is the primary nurse who is responsible for 24-hour client care. The charge nurse, associated nurse, and LPN will all help provide client care when the primary nurse is not available.

Which team member is responsible for 24-hour client care when using an adapted case method? Charge nurse Primary nurse Associate nurse Licensed practical nurse (LPN)

Reliability In the Transforming Care at the Bedside model, reliability is a theme that ensures the care provided for moderately sick clients who are hospitalized is safe, reliable, effective, and equitable. Validity, cost-effectiveness, and evidence-based practice are not themes within the design of Transforming Care at the Bedside.

Which theme is part of the design of "Transforming Care at the Bedside"? Validity Reliability Cost-effectiveness Evidence-based practic

Opportunities to attend clinical care conferences to discuss client care needs In Magnet® hospitals, staff have autonomy and control over nursing practice. This would include attending care conferences to discuss client care needs. Salaries planned according to education level and assignments made according to years of experience would be expected in an environment with differentiated nursing practice. There is no care delivery method that uses physician input for annual performance appraisals.

The nurse working at a Magnet® organization can expect which treatment? Salaries that are planned according to education level Physicians that provide input for annual performance appraisals Assignments that are made according to years of experience Opportunities to attend clinical care conferences to discuss client care needs

Client C Client C reporting with shock is identified with a red tag, indicating an immediate threat to life. The client with massive head trauma is labeled with a black tag, which indicates the client is deceased or is expected to die, so treatment will not be provided to maximize resources to save the most clients possible. The client reporting with an open fracture with distal pulse is triaged as class 3, in which the treatment is considered urgent but less so than for a red-tagged client. Strains and contusions are minor injuries and are considered nonurgent; client D should be triaged as class 3.

Which client condition would require the highest priority for treatment among four clients admitted at the same time under mass casualty conditions? Client A Client B Client C Client D

Client with a healing wound being monitored for infection Client with diabetes requiring education for newly prescribed insulin Client with deep vein thrombosis being monitored for impairment of peripheral tissue perfusion Client 8 hours postoperative thyroidectomy being monitored for possible complications Client with cancer in need of education concerning prescribed home chemotherapy regimen Intermediate priority needs are nonemergent, nonthreatening actual or potential needs. Clients who are at risk for infection, who need education on new medications, who are at risk for postoperative complications, or who are at risk for perfusion problems because of current diagnoses would all be classified as having intermediate priority needs.

Which client would be classified as having intermediate priority needs? Select all that apply. One, some, or all responses may be correct. Client with a healing wound being monitored for infection Client with diabetes requiring education for newly prescribed insulin Client with deep vein thrombosis being monitored for impairment of peripheral tissue perfusion Client 8 hours postoperative thyroidectomy being monitored for possible complications Client with cancer in need of education concerning prescribed home chemotherapy regimen

Total client care The premise of the total client care model (also known as the case method) is that one nurse provides total care for one client during the entire work period. In primary nursing, the primary nurse is accountable for the clients' care 24 hours a day from admission through discharge. In the team model, an RN is a team leader who coordinates a group of licensed and unlicensed personnel to provide care to a small group of clients. In the functional model, each licensed and unlicensed staff member performs specific tasks for a large group of clients.

Which nursing care delivery model is used if the nurse provides care to the same client for the entire work period? Primary Total client care Team Functional

Crotalidae polyvalent immune fab (CroFab) CroFab is used for treating a victim bitten by a North American pit viper as a part of hospital care. Diazepam is a muscle relaxant used for the treatment of black widow spider bite. Epinephrine is used as a nursing priority for bees and wasps sting. Acetaminophen is used for the treatment of fever related to scorpion bite.

Which medication would be used as a nursing priority to treat the client bitten by a snake that belongs to the class of North American pit vipers? Diazepam Epinephrine Acetaminophen Crotalidae polyvalent immune fab (CroFab)

Setting priorities Setting priorities is an essential nursing skill for the triage, or assessment, process that occurs in the ED. Evaluating care, formulating diagnoses, and implementing interventions are all nursing skills used in the ED; however, these are not essential during the triage process.

Which nursing skill is essential for the triage process in the emergency department (ED)? Evaluating care Setting priorities Formulating diagnoses Implementing interventions

Major injuries with yellow tag A yellow tag is given to clients with emergency situations such as having major injuries and open fractures that do not need treatment for 30 minutes to 2 hours. The client with major injuries should be provided with a yellow tag. Clients with closed fractures and minor injuries should be provided with a green tag, which indicates a nonemergent situation. Clients with open fractures should be provided with a yellow tag.

Which triage tag and client condition pair is appropriate? Closed fractures with red tag Minor injuries with black tag Major injuries with yellow tag Open fractures with green tag

Client A Client A is an older adult who presents with a bounding pulse rate because of fluid overload in the body. Care should be prioritized in this client because the condition of the client indicates increasing fluid overload and needs immediate treatment. Vital signs should be monitored properly to identify other associated risks. Client B has pale skin with pitting edema, so this client should be given second priority for treatment and an oxygen mask or nasal cannula should be provided. Client C can be given medications to relieve the headache resulting from fluid overload. Client D should be given nutritional therapy to treat fluid overload.

Care of which client admitted with fluid overload would be considered a priority requiring immediate care based on age and condition? Client A Client B Client C Client D

Green Green-tagged clients have minor injuries that can be managed in a delayed fashion, and they can evacuate themselves from the mass casualty scene and leave by private vehicle. They are termed the "walking wounded" clients. Red-tagged clients need immediate intervention because they have an immediate threat to life. Black-tagged clients are those who are dead or considered about to die. Yellow-tagged clients also have major injuries that need treatment within 30 minutes to 2 hours and are not considered "walking wounded" clients.

Clients with which color triage tag are often referred to as the "walking wounded" in a mass casualty scene? Red Black Green Yellow

Within 10 minutes Multiple traumas are considered a level 2 on the emergency severity index (ESI) and require treatment within 10 minutes. Life-threatening and organ-threatening conditions such as cardiac arrest and severe respiratory distress need immediate treatment within 5 minutes. Abdominal pain, gynecological disorders, and hip fracture in elderly require treatment within 1 hour after the incident. Treatment for minor burns, colds, and other minor conditions may be delayed to within 2 days.

How soon should a client with multiple traumas receive treatment according to the five-level emergency severity index (ESI)? Within 2 days Within 1 hour Within 5 minutes Within 10 minutes

Inject epinephrine through the intramuscular route in the mid-portion of the outer thigh. Remove the stinger gently by scraping with a needle. Administer oral liquid diphenhydramine. Establish an intravenous (IV) infusion with normal saline. Basic emergency care for bee and wasp stings includes quick removal of the stinger by scraping with a needle. But in the clients who are allergic to bee sting the foremost care that must be given is administration of epinephrine through the intramuscular route in the mid-portion of the outer thigh. After administering epinephrine, the stinger is gently removed by scraping using a needle. Later, oral liquid diphenhydramine is given. If the client has sustained a serious reaction, IV infusion with normal saline is established.

In which order would the nurse implement interventions for a client who has a history of allergy to bee stings who was brought to the emergency department after a bee sting? Inject epinephrine through the intramuscular route in the mid-portion of the outer thigh. Remove the stinger gently by scraping with a needle. Administer oral liquid diphenhydramine. Establish an intravenous (IV) infusion with normal saline.

1) Prepare to administer supplemental O2 2) Monitor heart function and circulation 3) Start two large-bore intravenous (IV) lines 4) Assess and manage pain 5) Measure the circumference of the bitten extremity every 15 to 30 minutes Recognize the most significant risk to the snakebite victim is airway compromise and respiratory failure. Using ABCs (airway-breathing-circulation-safety), provide supplemental O2 as the first priority, then monitor heart function and circulation. Ensure the client has patent intravenous lines. Assess and manage pain. Monitor the inflammation and swelling on the extremities that were affected by the bite.

In which order would the nurse perform the following actions for a client in the emergency department with a snake bite? Measure the circumference of the bitten extremity every 15 to 30 minutes Prepare to administer supplemental O2 Start two large-bore intravenous (IV) lines Monitor heart function and circulation Assess and manage pain

Stop infusion and remove peripheral venous catheter. Apply a sterile dressing. Elevate the extremity. Use warm or cold compresses according to the solution infiltrated. Insert a new catheter in the opposite extremity. Obtain a study to determine the cause of the problem. Rate the infiltration using the INS Infiltration Scale and document the procedure. To stop infiltration via peripheral venous catheter, the first step of the nurse will involve stopping the infusion and removing the central venous catheter after the identification of the problem. The next step would involve application of sterile dressing if weeping from the tissue occurs. The third step for the nurse is to elevate the extremity. Next, the nurse would use warm or cold compresses according to the solution infiltrated and the organization policy. The fifth step is to insert the new catheter in the opposite extremity. The nurse would then obtain the study to determine the problem causing the infiltration. The final step of the procedure would involve the nurse rating the infiltration using the INS Infiltration Scale and document the procedure. Test-Taking Tip: In this question type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing an action or skill such as those involved in medication administration or device application.

In which order would the nurse treat the infiltration of a nonvesicant intravenous (IV) solution leaking into the extravascular tissue? Stop infusion and remove peripheral venous catheter. Elevate the extremity. Use warm or cold compresses according to the solution infiltrated. Apply a sterile dressing. Insert a new catheter in the opposite extremity. Obtain a study to determine the cause of the problem. Rate the infiltration using the INS Infiltration Scale and document the procedure.

Palpate the BP. Inflate the cuff above the systolic pressure. Deflate the cuff. Note when sounds are first audible on expiration. Identify when sounds are audible on inspiration. Subtract the inspiratory pressure from expiratory pressure. Paradoxical BP is a sign of tamponade in clients with pericarditis. It is important to auscultate the BP in these clients. Initially palpate the BP and then inflate the cuff above the systolic. Then deflate the cuff gradually and note when sounds are first audible on expiration. It is also important to identify when sounds are audible on inspiration. Finally, subtract the inspiratory pressure from the expiratory pressure to determine the paradoxical BP.

Place in the correct order the steps the nurse follows to detect paradoxical blood pressure (BP) in clients with pericarditis. Palpate the BP. Inflate the cuff above the systolic pressure. Deflate the cuff. Note when sounds are first audible on expiration. Identify when sounds are audible on inspiration. Subtract the inspiratory pressure from expiratory pressure.

3 for facial palsy The NIHSS helps in evaluating the effect of an acute stroke and assigns a score based on severity of condition. According to the NIHSS, the score of 3 for facial palsy is given to the client with complete paralysis of 1 or both sides of the face and therefore should be treated first to ensure safety. The client with an NIHSS score of 0 for dysarthria is normal and therefore can be treated last. The client with limb ataxia in the leg and an NIHSS score of 1 can be treated after the client with score 3 for facial palsy is treated. The NIHSS score of 0 for level of consciousness is normal, and this client can be treated after the clients with complete facial paralysis and partial limb ataxia are treated.

The client with which National Institutes of Health Stroke Scale (NIHSS) score would be treated first? 0 for dysarthria 1 for limb ataxia 3 for facial palsy 0 for level of consciousness

Redesigning all care areas Cross-training support personnel For client-focused care units, all care areas need to be redesigned and support personnel need to be trained. Additional charge nurses, nurse managers, and creating an all-RN staff are not needed for this care delivery method.

The hospital's board of directors would evaluate cost information about which activities when considering implementing client-focused care delivery for a 300-bed community hospital? Select all that apply. One, some, or all responses may be correct. Training charge nurses Redesigning all care areas Cross-training support personnel Hiring additional nurse managers Hiring an all registered nurse (RN) staff

Airway A of the mnemonic ABCDE stands for airway/cervical spine. B stands for breathing. C stands for circulation. D stands for disability. E stands for exposure. Test-Taking Tip: When a question stem asks for statements by a client or student nurse that would indicate the need for further teaching or learning, the question is asking you to pick out the incorrect or wrong response(s), which would require further teaching or learning. Read questions carefully to determine if they are asking you to find the correct answers or the answers that require further client or student nurse teaching or learning.

Which does the A of the mnemonic ABCDE of primary nursing survey stand for? Airway Allergies Assessment Aspiration

Define how changing a client room item would contribute to cost-effective care. Move the item in the client's room. Determine if moving the item was successful as planned. Identify the steps to implement the change in remaining client rooms. In the rapid cycle change process, the first step is defining the objectives and predicting how the identified change would contribute to a goal, in this case, cost-effective care. In the next step, the do phase, the change occurs; in this case, the item was moved. Then the study phase occurs; in this case, it involves determining if the item that was moved was successful as planned. The final phase is the act phase in which next steps are planned; in this case, the steps are identified to implement the change in the remaining client rooms. Test-Taking Tip: In this question type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing an action or skill such as those involved in medication administration.

The nurse is working in a care area employing the "Transforming Care at the Bedside" program. The nurse wants to use the rapid cycle change process for a unit design issue. In which order would the nurse perform the steps of this process? Define how changing a client room item would contribute to cost-effective care. Move the item in the client's room. Determine if moving the item was successful as planned. Identify the steps to implement the change in remaining client rooms.

Observe for chest wall trauma. Assess breath sounds and respiratory effort. The priorities to check for breathing include observation of the chest wall for trauma and assessment of breath sounds and respiratory effort. Establishment of a patent airway by positioning occurs during the assessment of the airway and cervical spine. Level of consciousness is evaluated to determine mental status of the client. Clothing is removed to perform a complete physical assessment of the client. Test-Taking Tip: If the question asks for an observation or other nursing action in a specific type of assessment, eliminate distractors that are valid nursing observations or valid nursing actions but are not part of the focused assessment referenced in the question stem.

Which are the nurse's priority assessments of the breathing component of a primary survey of a client? Select all that apply. One, some, or all responses may be correct. Observe for chest wall trauma. Establish a patent airway by positioning. Evaluate the client's level of consciousness. Assess breath sounds and respiratory effort. Remove all clothing for a complete physical assessment

Completes the client's plan of care Coordinates care needs with ancillary staff Discusses approaches to improve care responses Actions of a primary nurse include completing the plan of care, coordinating care needs with ancillary staff, and discussing approaches with other care professionals to improve the client's outcomes of care. A primary nurse is not able to provide direct care 24/7; associate nurses will provide the direct care according to plan when the primary nurse is not on duty. Working with the care area budget is an activity of the nurse manager.

Which behaviors indicate that a care provider is functioning as a primary nurse? Select all that apply. One, some, or all responses may be correct. Provides most direct care for this client Completes the client's plan of care Coordinates care needs with ancillary staff Examines and adjusts the care area budget Discusses approaches to improve care responses

Critical path Integrated care pathway Collaborative care pathway Multidisciplinary care pathway Critical path, integrated care pathway, collaborative care pathway, and multidisciplinary care pathway are all terms that are synonymous with critical pathways that the nurse educator can include when presenting information regarding the role of case manager. Plan of care is not synonymous with critical pathways.

Which terms, synonymous with critical pathways, will the nurse educator include in a presentation regarding the role of the case manager? Select all that apply. One, some, or all responses may be correct. Critical path Plan of care Integrated care pathway Collaborative care pathway Multidisciplinary care pathway

Needs that affect safety Needs related to survival and safety are the highest priority because these are an immediate threat to client health. Developmental needs and long-term care needs are low priority when prioritizing care because they are not an immediate threat to health. Potential needs in care are intermediate priority because they are best addressed before complications follow.

Which type of needs would be placed as a high priority in the prioritization of client care? Developmental needs Long-term care needs Potential needs in care Needs that affect safety