Study Guide

What is the priority focus of prehospital care for a client with a chemical injury burn? A. Decontamination B. Fluid balance C. Airway control D. Preventing infection

A

Which factors increase the risk of complications from a burn injury in an older adult client? Select all that apply. A. Slower healing time B. Thinner skin C. Increased inflammatory response D. Increased pulmonary compliance E. Medical conditions such as diabetes F. Increased immune response

A,B,E

Which are priorities of care when providing care for a client with a burn injury during the emergent phase? Select all that apply. A. Securing the airway B. Maintaining nutrition status C. Supporting circulation and perfusion D. Maintaining body temperature E. Keeping client comfortable with analgesics F. Psychosocial adjustment

A,C,D,E

The nurse is caring for a client with a burn injury who is receiving silver sulfadiazine (Silvadene) to the burn wounds. Which best describes the goal of topical antimicrobials? A. Reduction of bacterial growth in the wound and prevention of systemic sepsis B. Prevention of cross-contamination from other clients in the unit C. Enhanced cell growth D. Reduced need for a skin graft

A. Reduction of bacterial growth in the wound and prevention of systemic sepsis Topical antimicrobials such as silver sulfadiazine are an important intervention for infection prevention in burn wounds. Topical antimicrobials such as silver sulfadiazine do not prevent cross-contamination from other clients in the unit. They do not enhance cell growth, nor do they minimize the need the need for a skin graft.

Which factors indicate that a client's burn wounds are becoming infected? (Select all that apply.) A. Dry, crusty granulation tissue B. Elevated blood pressure C. Hypoglycemia D. Edema of the skin around the wound E. Tachycardia

A., D., E. Pale, boggy, dry, or crusted granulation tissue is a sign of infection, as is swelling or edema of the skin around the wound. Tachycardia is a systemic sign of infection. Hypotension, not elevated blood pressure, and hyperglycemia, not hypoglycemia, are systemic signs of infection.

While on a camping trip, a nurse cares for an adult client who had a drowning incident in a lake and is experiencing agonal breathing with a palpable pulse. What action would the nurse take first? a. Deliver rescue breaths. b. Wrap the client in dry blankets. c. Assess for signs of bleeding. d. Check for a carotid pulse.

ANS: A In this emergency situation, the nurse immediately initiates airway clearance and ventilator support measures, including delivering rescue breaths.

A nurse teaches a community health class about water safety. Which statement by a participant indicates that additional teaching is needed? a. "I can go swimming all by myself because I am a certified lifeguard." b. "I cannot leave my toddler alone in the bathtub for even a minute." c. "I will appoint one adult to supervise the pool at all times during a party." d. "I will make sure that there is a phone near my pool in case of an emergency."

ANS: A People would never swim alone, regardless of lifeguard status. The other statements indicate good understanding of the teaching.

A primary health care provider prescribes a rewarming bath for a client who presents with Grade 3 frostbite. What action would the nurse take prior to starting this treatment? a. Administer intravenous morphine. b. Wrap the limb with a compression dressing. c. Massage the frostbitten areas. d. Assess the limb for compartment syndrome.

ANS: A Rapid rewarming in a water bath is recommended for all instances of partial-thickness and full-thickness frostbite. Patients experience severe pain during the rewarming process and nurses would administer intravenous analgesics.

8. A nurse wants to become involved in community disaster preparedness and is interested in helping set up and staff first aid stations or community acute care centers in the event of a disaster. Which organization is the best fit for this nurse's interests? a. The Medical Reserve Corps b. The National Guard c. The health department d. A Disaster Medical Assistance Team

ANS: A The Medical Reserve Corps (MRC) consists of volunteer medical and public health care professionals who support the community during times of need. They may help staff hospitals, establish first aid stations or special needs shelters, or set up acute care centers in the community. The National Guard often performs search and rescue operations and law enforcement. The health department focuses on communicable disease tracking, treatment, and prevention. A Disaster Medical Assistance Team is deployed to a disaster area for up to 72 hours, providing many types of relief services.

An emergency department nurse cares for a middle-age mountain climber who is confused, ataxic, and exhibits impaired judgement. After administering oxygen, which intervention would the nurse implement next? a. Administer dexamethasone. b. Complete a mini mental state examination. c. Prepare the client for computed tomography of the brain. d. Request a psychiatric consult.

ANS: A The client is exhibiting signs of mountain sickness and high-altitude cerebral edema (HACE). Dexamethasone reduces cerebral edema by acting as an anti-inflammatory in the central nervous system. The other interventions will not specifically treat HACE, although a thorough mental status exam would be performed.

11. A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention should the nurse complete first? a. Provide a calm location for the family to cope and discuss needs. b. Call the hospital chaplain to stay with the family and pray for the deceased. c. Do not allow visiting of the victims until the bodies are prepared. d. Provide privacy for law enforcement to interview the family.

ANS: A The nurse should first provide emotional support by encouraging relaxation, listening to the family's needs, and offering choices when appropriate and possible to give some personal control back to individuals. The family may or may not want the assistance of religious personnel; the nurse should assess for this before calling anyone. Visiting procedures should take into account the needs of the family. The family may want to see the victim immediately and do not want to wait until the body can be prepared. The nurse should assess the family's needs before assuming the body needs to be prepared first. The family may appreciate privacy, but this is not as important as assessing the family's needs.

9. A nurse wants to become part of a Disaster Medical Assistance Team (DMAT) but is concerned about maintaining licensure in several different states. Which statement best addresses these concerns? a. "Deployed DMAT providers are federal employees, so their licenses are good in all 50 states." b. "The government has a program for quick licensure activation wherever you are deployed." c. "During a time of crisis, licensure issues would not be the government's priority concern." d. "If you are deployed, you will be issued a temporary license in the state in which you are working."

ANS: A When deployed, DMAT health care providers are acting as agents of the federal government, and so are considered federal employees. Thus their licenses are valid in all 50 states. Licensure is an issue that the government would be concerned with, but no programs for temporary licensure or rapid activation are available.

A client resuscitated after drowning is admitted to the emergency department. What assessment findings does the nurse recognize as symptoms of a drowning? (Select all that apply.) a. Bilateral crackles b. Bradycardia c. Cyanosis of the lips d. Hypotension e. Flushed, diaphoretic skin

ANS: A, B, C, D Drowning victims will exhibit signs of pulmonary edema which includes crackles in one or both lungs, persistent dry cough, and cyanosis of the lips and/or nail beds. The diving reflex as a response to asphyxia produces bradycardia, signs of decreased cardiac output with hypotension, and vasoconstriction of vessels in the intestine, skeletal muscles, and kidneys.

A nurse prepares to administer a blood transfusion to a client, and checks the blood label with a second registered nurse using the International Society of Blood Transfusion (ISBT) universal bar-coding system to ensure the right blood for the right client. Which components must be present on the blood label in bar code and in eye-readable format? (Select all that apply.) a. Unique facility identifier b. Lot number related to the donor c. Name of the client receiving blood d. ABO group and Rh type of the donor e. Blood type of the client receiving blood f. Signature line for 2-person verification

ANS: A, B, D The ISBT universal bar-coding system includes four components: (1) the unique facility identifier, (2) the lot number relating to the donor, (3) the product code, and (4) the ABO group and Rh type of the donor. Positive identification by two qualified health care providers is essential although automated bar coding is acceptable in some care areas. However, a signature line is not required on the blood label.

An emergency department nurse moves to a new city where heat-related illnesses are common. Which clients does the nurse anticipate being at highest risk for heat-related illnesses? (Select all that apply.) a. Homeless individuals b. People with substance abuse disorders c. Caucasians d. Hockey players e. Older adults f. Obese individuals

ANS: A, B, E, F Some of the most vulnerable, at-risk populations for heat-related illness include older adults; people who work outside, such as construction and agricultural workers; homeless people; people who abuse substances; outdoor athletes (recreational and professional); and members of the military who are stationed in countries with hot climates (e.g., Iraq, Afghanistan). Hockey is generally a cold-air game whether played indoors or outdoors and wouldn't have as much risk for heat-related illness as other sports.

1. Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies the clients with which injuries with yellow tags? (Select all that apply.) a. Partial-thickness burns covering both legs b. Open fractures of both legs with absent pedal pulses c. Neck injury and numbness of both legs d. Small pieces of shrapnel embedded in both eyes e. Head injury and difficult to arouse f. Bruising and pain in the right lower abdomen

ANS: A, C, D, F Clients with burns, spine injuries, eye injuries, and stable abdominal injuries should be treated within 30 minutes to 2 hours, and therefore should be identified with yellow tags. The client with the open fractures and the client with the head injury would be classified as urgent with red tags.

Which assessment findings would indicate to the nurse that a client has suffered from a heat stroke? (Select all that apply.) a. Confusion and bizarre behavior b. Headache and fatigue c. Hypotension d. Presence of perspiration e. Tachycardia and tachypnea f. Body temperature more than 104° F (40° C)

ANS: A, C, E, F Signs and symptoms of heat stroke include as elevated body temperature (above 104° F [40° C]), mental status changes such as confusion and decreasing level of consciousness, hypotension, tachycardia, and tachypnea. Perspiration is an inconsistent finding.

2. A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? (Select all that apply.) a. A 35-year-old female with severe chest pain: red tag b. A 42-year-old male with full-thickness body burns: green tag c. A 55-year-old female with a scalp laceration: black tag d. A 60-year-old male with an open fracture with distal pulses: yellow tag e. An 88-year-old male with shortness of breath and chest bruises: green tag

ANS: A, D Red-tagged clients need immediate care due to life-threatening injuries. A client with severe chest pain would receive a red tag. Yellow-tagged clients have major injuries that should be treated within 30 minutes to 2 hours. A client with an open fracture with distal pulses would receive a yellow tag. The client with full-thickness body burns would receive a black tag. The client with a scalp laceration would receive a green tag, and the client with shortness of breath would receive a red tag

A nurse is in charge of a first-aid tent at an all-day outdoor sports event on a hot and humid day. A participant comes to the tent reporting a headache, weakness, and nausea. What actions would the nurse take? (Select all that apply.) a. Have the client lie down in a cool place. b. Force fluids with large quantities of plain water. c. Administer acetaminophen and send home. d. Apply cold packs to neck, arm pits, and groin. e. Encourage drinking a sports drink. f. Remove all clothing and cover with a towel.

ANS: A, D, E Heat exhaustion manifests as flulike symptoms with headache, weakness, nausea, and/or vomiting. Treatment includes stopping the activity, moving to a cool place, and using cooling measures such as cold packs, cool water soaks, or fanning while spraying cool water on skin. Sodium deficits may occur from drinking plain water, so sports drinks or an oral rehydration therapy solution would be provided. The nurse would remove constrictive clothing only.

An emergency department nurse plans care for a client who is admitted with heat stroke. Which interventions does the nurse include in this patient's plan of care? (Select all that apply.) a. Administer oxygen via mask or nasal cannula. b. Administer ibuprofen, an antipyretic medication. c. Apply cooling techniques until core body temperature is less than 101° F (38.3° C). d. Infuse 0.9% sodium chloride via a large-bore intravenous cannula. e. Obtain baseline serum electrolytes and cardiac enzymes. f. Insert an indwelling urinary catheter for urine output measurements.

ANS: A, D, E Heat stroke is a medical emergency. Oxygen therapy and intravenous fluids would be provided, and baseline laboratory tests would be performed as quickly as possible. Urinary output is measured via an indwelling urinary catheter. The client would be cooled until core body temperature is reduced to 102° F (38.9° C). Antipyretics would not be administered.

A nurse is teaching a wilderness survival class. Which statements would the nurse include about the prevention of hypothermia and frostbite? (Select all that apply.) a. "Wear synthetic clothing instead of cotton to keep your skin dry." b. "Drink plenty of fluids. Brandy can be used to keep your body warm." c. "Remove your hat when exercising to prevent overheating." d. "Wear sunglasses to protect skin and eyes from harmful rays." e. "Know your physical limits. Come in out of the cold when limits are reached." f. "Change your gloves and socks if they become wet."

ANS: A, D, E, F To prevent hypothermia and frostbite, the nurse would teach patients to wear synthetic clothing (which moves moisture away from the body and dries quickly), layer clothing, and a hat, facemask, sunscreen, and sunglasses. The client would also be taught to drink plenty of fluids, but to avoid alcohol when participating in winter activities. Clients need to know their physical limits and come in out of the cold when these limits have been reached. Wet clothing contributes to heat loss so clients would be taught to change any clothing that becomes wet.

A primary health care provider prescribes diazepam to a client who was bitten by a black widow spider. The client asks, "What is this medication for?" How does the nurse respond? a. "This medication is an antivenom for this type of bite." b. "It will relieve your muscle rigidity and spasms." c. "It prevents respiratory difficulty from excessive secretions." d. "This medication will prevent respiratory failure."

ANS: B Black widow spider venom can produce muscle rigidity and spasms, which are treated with the muscle relaxant, diazepam. It does not prevent respiratory difficulty or failure nor is it antivenom.

A nurse plans care for a client admitted with a snakebite to the right leg. With whom would the nurse collaborate? a. The facility's neurologist b. The poison control center c. The physical therapy department d. A herpetologist (snake specialist)

ANS: B For the client with a snakebite, the nurse would contact the regional poison control center immediately for specific advice on antivenom administration and client management.

A client presents to the emergency department after prolonged exposure to the cold. The client is difficult to arouse and speech is incoherent. What action would the nurse take first? a. Reposition the client into a prone position. b. Administer warmed intravenous fluids to the client. c. Wrap the client's extremities in warm blankets. d. Initiate extracorporeal rewarming via hemodialysis.

ANS: B Moderate hypothermia manifests with muscle weakness, increased loss of coordination, acute confusion, apathy, incoherence, stupor, and impaired clotting. Moderate hypothermia is treated by core rewarming methods, which include administration of warm IV fluids; heated oxygen; and heated peritoneal, pleural, gastric, or bladder lavage. The client's trunk would be warmed prior to the extremities to prevent peripheral vasodilation. Extracorporeal warming with cardiopulmonary bypass or hemodialysis is a treatment for severe hypothermia.

On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, and blood pressure 106/66 mm Hg. What action would the nurse take? a. Encourage the client to drink cool water or sports drinks. b. Start an intravenous line and infuse 0.9% saline solution. c. Administer acetaminophen (Tylenol) 650 mg orally. d. Encourage rest and reassess in 15 minutes.

ANS: B The client demonstrates signs of heat stroke. This is a medical emergency and priority care includes oxygen therapy, IV infusion with 0.9% saline solution, insertion of a urinary catheter, and aggressive interventions to cool the patient, including external cooling and internal cooling methods. Oral hydration would not be appropriate for a client who has symptoms of heat stroke because oral fluids would not provide necessary rapid rehydration, and the confused client would be at risk for aspiration. Acetaminophen would not decrease this patient's temperature or improve the patient's symptoms. The client needs immediate medical treatment; therefore, rest and reassessing in 15 minutes are inappropriate.

A nurse assesses a client recently bitten by a coral snake. Which assessment would the nurse complete first? a. Unilateral peripheral swelling b. Clotting times c. Cardiopulmonary status d. Electrocardiogram rhythm

ANS: C Signs and symptoms of coral snake envenomation are the result of its neurotoxic properties. The physiologic effect is to block neurotransmission, which produces ascending paralysis, reduced perception of pain, and, ultimately, respiratory paralysis. The nurse would monitor for respiratory rate and depth. Severe swelling and clotting problems do not occur with coral snakes but do occur with pit viper snakes. Electrocardiogram rhythm is not affected by neurotoxins.

A middle-age mountain hiker is admitted to the emergency department exhibiting a cough with pink, frothy sputum and cyanosis of lips and nail beds. What priority action would the nurse implement? a. Administer acetazolamide. b. Administer oxygen via a nonrebreather mask. c. Complete a thorough pulmonary assessment. d. Obtain arterial blood gas (ABG) specimen for analysis.

ANS: B The client is exhibiting signs of AMS with high-altitude pulmonary edema (HAPE). Cyanosis indicates hypoxia and must be treated immediately. A complete pulmonary assessment and ABG analysis are indicated but the priority is oxygen administration. Acetazolamide is used to prevent AMS.

The nurse is teaching participants in a family-oriented community center ways to prevent their older relatives and friends from getting heat-related illnesses. What information does the nurse include? (Select all that apply.) a. Use sunscreen with an SPF of at least 15 when outdoors. b. Take cool baths or showers after outdoor activities. c. Check on the older adult daily in hot weather. d. Drink plenty of liquids throughout the day. e. Wear light-colored, snugly-fitting clothing to wick sweat away.

ANS: B, C, D To best prevent heat-related illnesses, the nurse would teach individuals to use sunscreen with at least an SPF of 30 for both UVA and UVB rays, to shower or bathe in cool water after being outdoors to reduce body heat, to remain hydrated, and to wear light-colored, loose-fitting clothes. Families and friends should check older adults at least twice a day during a heat wave; however, this may not prevent heat-related illness but could catch it quickly and limit its severity.

4. A hospital prepares for a mass casualty event. Which functions are correctly paired with the personnel role? (Select all that apply.) a. Paramedic - Decides the number, acuity, and resource needs of clients b. Hospital incident commander - Assumes overall leadership for implementing the emergency plan c. Public information officer - Provides advanced life support during transportation to the hospital d. Triage officer - Rapidly evaluates each client to determine priorities for treatment e. Medical command physician - Serves as a liaison between the health care facility and the media

ANS: B, D The hospital incident commander assumes overall leadership for implementing the emergency plan. The triage officer rapidly evaluates each client to determine priorities for treatment. The paramedic provides advanced life support during transportation to the hospital. 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. Students

3. A hospital prepares to receive large numbers of casualties from a community disaster. Which clients should the nurse identify as appropriate for discharge or transfer to another facility? (Select all that apply.) a. Older adult in the medical decision unit for evaluation of chest pain b. Client who had open reduction and internal fixation of a femur fracture 3 days ago c. Client admitted last night with community-acquired pneumonia d. Infant who has a fever of unknown origin e. Client on the medical unit for wound care

ANS: B, E The client with the femur fracture could be transferred to a rehabilitation facility, and the client on the medical unit for wound care should be transferred home with home health or to a long-term care facility for ongoing wound care. The client in the medical decision unit should be identified for dismissal if diagnostic testing reveals a noncardiac source of chest pain. The newly admitted client with pneumonia would not be a good choice because culture results are not yet available and antibiotics have not been administered long enough. The infant does not have a definitive diagnosis.

7. A nurse cares for clients during a community-wide disaster drill. Once of the clients asks, "Why are the individuals with black tags not receiving any care?" How should the nurse respond? a. "To do the greatest good for the greatest number of people, it is necessary to sacrifice some." b. "Not everyone will survive a disaster, so it is best to identify those people early and move on." c. "In a disaster, extensive resources are not used for one person at the expense of many others." d. "With black tags, volunteers can identify those who are dying and can give them comfort care."

ANS: C In a disaster, military-style triage is used; this approach identifies the dead or expectant dead with black tags. This practice helps to maintain the goal of triage, which is doing the most good for the most people. Precious resources are not used for those with overwhelming critical injury or illness, so that they can be allocated to others who have a reasonable expectation of survival. Clients are not "sacrificed." Telling students to move on after identifying the expectant dead belittles their feelings and does not provide an adequate explanation. Clients are not black-tagged to allow volunteers to give comfort care.

After teaching a client how to prevent altitude-related illnesses, a nurse assesses the client's understanding. Which statement indicates that the client needs additional teaching? a. "If my climbing partner can't think straight, we should descend to a lower altitude." b. "I will ask my primary health care provider about medications to help prevent acute mountain sickness." c. "My partner and I will plan to sleep at a higher elevation to acclimate more quickly." d. "I will drink plenty of fluids to stay hydrated while on the mountain."

ANS: C Teaching to prevent altitude-related illness would include descending when symptoms start, staying hydrated, and taking acetazolamide, which is commonly used to prevent and treat acute mountain sickness. The nurse would teach the client to sleep at a lower elevation.

15. An elderly client who has fallen from a roof is transported to the emergency department by ambulance. The client was unconscious at the scene but is conscious on arrival and is triaged as urgent. What is the priority assessment the nurse includes during the primary survey of the patient? a. A full set of vital signs b. Cardiac rhythm c. Neurologic status d. Client history

ANS: C The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. Injuries from this type of fall have a high risk for cervical spine injuries. In addition, with the loss of consciousness at the scene the client would be at risk for head trauma. A full set of vital signs is obtained as part of the secondary survey. The cardiac rhythm is important but not specifically related to this client's presentation. Client history would be obtained as able.

12. An emergency department charge nurse notes an increase in sick calls and bickering among the staff after a week with multiple trauma incidents. Which action should the nurse take? a. Organize a pizza party for each shift. b. Remind the staff of the facility's sick-leave policy. c. Arrange for critical incident stress debriefing. d. Talk individually with staff members.

ANS: C The staff may be suffering from critical incident stress and needs to have a debriefing by the critical incident stress management team to prevent the consequences of long-term, unabated stress. Speaking with staff members individually does not provide the same level of support as a group debriefing. Organizing a party and revisiting the sick-leave policy may be helpful, but are not as important and beneficial as a debriefing.

An emergency department nurse is caring for a client who had been hiking in the mountains for the past 2 days. What are the most important indicators that a client is experiencing high-altitude pulmonary edema (HAPE)? (Select all that apply.) a. Ataxia b. Confusion c. Crackles in both lung fields d. Decreased level of consciousness e. Persistent dry cough f. Reports "feeling hung over"

ANS: C, E Signs and symptoms of high-altitude pulmonary edema (HAPE) include poor exercise tolerance, prolonged recovery time after exertion, fatigue, and weakness that progresses to a persistent dry cough and cyanosis of lips and nail beds. Crackles may be auscultated in one or both lung fields. A late sign of HAPE is pink, frothy sputum. Ataxia and confusion or decreased level of consciousness are seen in HACE—high-altitude cerebral edema. Acute mountain sickness produces a syndrome similar to an alcohol-induced hangover.

3. A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag? a. Dislocated right hip and an open fracture of the right lower leg b. Large contusion to the forehead and a bloody nose c. Closed fracture of the right clavicle and arm numbness d. Multiple fractured ribs and shortness of breath

ANS: D Clients who have an immediate threat to life are given the highest priority, are placed in the emergent or class I category, and are given a red triage tag. The client with multiple rib fractures and shortness of breath most likely has developed a pneumothorax, which may be fatal if not treated immediately. The client with the hip and leg problem and the client with the clavicle fracture would be classified as class II; these major but stable injuries can wait 30 minutes to 2 hours for definitive care. The client with facial wounds would be considered the "walking wounded" and classified as nonurgent.

4. An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event? a. Ask ED staff to discharge clients from the medical-surgical units in order to make room for critically injured victims. b. Call additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in. c. Inform the incident commander at the mass casualty scene about how many victims may be handled by the ED. d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims.

ANS: D The ED charge nurse should direct additional nursing staff to help care for current ED clients while the ED staff prepares to receive mass casualty victims; however, they should not be assigned to the most critically ill or injured clients. The house supervisor and unit directors would collaborate to discharge stable clients. The hospital incident commander is responsible for mobilizing resources and would have the responsibility for calling in staff. The medical command physician would be the person best able to communicate with on-scene personnel regarding the ability to take more clients.

What priority complication would the nurse suspect when assessing a client with an electrical burn that has an entrance wound on the right shoulder and an exit wound through the left side ribs? A. Kidney failure B. Cardiac dysrhythmias C. Gastrointestinal ileus D. Fractured ribs

B

Which is the best action for the nurse to take prior to changing the dressing of a client with a burn injury? A. Allow the client to rest and nap for an hour. B. Give pain medication 30 minutes prior to dressing change. C. Instruct the AP to give the client a complete bath. D. Leave the wound open to air for 30 minutes.

B

A nursing student is caring for a client with open-wound burns. Which nursing interventions does the nursing student provide for this client? (Select all that apply.) A. Provides cushions and rugs for comfort B. Performs frequent handwashing C. Places plants in the client's room D. Performs gloved dressing changes E. Uses disposable dishes

B., D., E. Handwashing is the most effective technique for preventing infection. Gloves should be worn when changing dressings to reduce the risk for infection. Equipment is not shared with other clients to prevent the risk for infection. Disposable items (e.g., pillows, dishes) are used as much as possible. Cushions and rugs are difficult to clean and may harbor organisms, and so are not provided. To avoid exposure to Pseudomonas, having plants or flowers in the room is prohibited.

What would be the nurse's best action when a client with a burn injury develops a brassy cough, increased difficulty swallowing, and progressive hoarseness? A. Place the client on continuous pulse oximetry. B. Instruct the AP to check vital signs every 30 minutes. C. Activate the Rapid Response Team. D. Establish a second IV access.

C

7. Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action would the nurse take first? a. Assess that the client is breathing adequately. b. Insert a large-bore intravenous line. c. Place the client on a cardiac monitor. d. Assess for the best neurologic response.

a. Assess that the client is breathing adequately. After establishing an airway, the highest priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he or she may not be breathing, or may be breathing inadequately with the device in place. Inserting an IV line and placing the client on a monitor would come after ensuring a patent airway and effective breathing.

14. What is the primary goal of a triage system used by the nurse with clients presenting to the emergency department? a. Determine the acuity of the client's condition to determine priority of care. b. Assess the status of the airway, breathing, circulation, or presence of deficits. c. Determine whether the client is responsive enough to provide needed information. d. Evaluate the emergency department's resources to adequately treat the patient.

a. Determine the acuity of the client's condition to determine priority of care. ED triage is an organized system for sorting and classifying clients into priority levels depending on illness or injury severity. The primary goal of the triage system is to facilitate the ED nurse's ability to prioritize care according to the acuity of the patient, having the clients with the more severe illness or injury seen first. Airway, breathing, and circulation are part of the primary survey. Determining responsiveness is done during the disability phase of the primary survey and is not the primary goal. Evaluating the ED's resources is also not a goal of triage.

5. A nurse is triaging clients in the emergency department (ED). Which client would the nurse prioritize to receive care first?a. A 22 year old with a painful and swollen right wristb. A 45 year old reporting chest pain and diaphoresisc. A 60 year old reporting difficulty swallowing and nausead. An 81 year old, respiratory rate 28 breaths/min and temperature of 101° F (38.8°C)

b. A 45 year old reporting chest pain and diaphoresis A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable.

3. An emergency department nurse is caring for a trauma patient. Which interventions does the nurse perform during the primary survey? (Select all that apply.) a. Foley catheterization b. Needle decompression c. Initiating IV fluids d. Splinting open fractures e. Endotracheal intubation f. Removing wet clothing g. Laceration repair

b. Needle decompression c. Initiating IV fluids e. Endotracheal intubation f. Removing wet clothing The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic ABC, with an added D and E: Airway and cervical spinal motion restriction; Breathing; Circulation; Disability; and Exposure. After the completion of primary diagnostic and laboratory studies, and the insertion of gastric and urinary tubes, the secondary survey (a complete head-to-toe assessment) can be carried out.

3. An emergency department nurse is triaging victims of a multi-casualty event. Which client would receive care first? a. A 30-year-old distraught mother holding her crying child b. A 65-year-old conscious male with a head laceration c. A 26-year-old male who has pale, cool, clammy skin d. A 48 year old with a simple fracture of the lower leg

c. A 26-year-old male who has pale, cool, clammy skin The client with pale, cool, clammy skin may be in shock and needs immediate medical attention. The mother does not have injuries and so would be the lowest priority. The other two people need medical attention soon, but not at the expense of a person in shock.

13. A nurse is triaging clients in the emergency department. Which client would the nurse classify as "nonurgent?" a. A 44 year old with chest pain and diaphoresis b. A 50 year old with chest trauma and absent breath sounds c. A 62 year old with a simple fracture of the left arm d. A 79 year old with a temperature of 104°F.(40.0° C)

c. A 62 year old with a simple fracture of the left arm A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with a simple arm fracture and palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and would be considered nonurgent. The client with chest pain and diaphoresis and the client with chest trauma are emergent owing to the potential for clinical deterioration and would be seen immediately. The client with a high fever may be stable now but also has a risk of deterioration.

9. A nurse is triaging clients in the emergency department. Which client would be considered "urgent"?a. A 20-year-old female with a chest stab wound and tachycardiab. A 45-year-old homeless man with a skin rash and sore throatc. A 75-year-old female with a cough and a temperature of 102° F (38.9° C)d. A 50-year-old male with new-onset confusion and slurred speech

c. A 75-year-old female with a cough and a temperature of 102° F (38.9° C) A client with a cough and a temperature of 102° F (38.9° C) is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation. The client with a chest stab wound and tachycardia and the client with new-onset confusion and slurred speech would be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent.

15. An elderly client who has fallen from a roof is transported to the emergency department by ambulance. The client was unconscious at the scene but is conscious on arrival and is triaged as urgent. What is the priority assessment the nurse includes during the primary survey of the patient? a. A full set of vital signs b. Cardiac rhythm c. Neurologic status d. Client history

c. Neurologic status The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. Injuries from this type of fall have a high risk for cervical spine injuries. In addition, with the loss of consciousness at the scene the client would be at risk for head trauma. A full set of vital signs is obtained as part of the secondary survey. The cardiac rhythm is important but not specifically related to this client's presentation. Client history would be obtained as able.

11. An emergency department (ED) case manager is consulted for a client who is homeless. Which intervention would the case manager provide?a. Communicate client needs and restrictions to support staff.b. Prescribe low-cost antibiotics to treat community-acquired infection.c. Provide referrals to subsidized community-based health clinics.d. Offer counseling for substance abuse and mental health disorders.

c. Provide referrals to subsidized community-based health clinics. Case management interventions include facilitating referrals to primary care providers who are accepting new clients or to subsidized community-based health clinics for clients or families in need of routine services. The ED nurse is accountable for communicating pertinent staff considerations, client needs, and restrictions to support staff (e.g., physical limitations, Isolation Precautions) to ensure that ongoing client and staff safety issues are addressed. The ED provider prescribes medications and treatments. The psychiatric nurse team evaluates clients with emotional behaviors or mental illness and facilitates the follow-up treatment plan, including possible admission to an appropriate psychiatric facility.