MSII Prep U Ch. 72 Emergency Nursing

A nurse is caring for a client who is experiencing alcohol withdrawal. Which statement best indicates that the client understands the need for long-term treatment?

The client agrees to detoxification, rehabilitation, and participation in an aftercare program. Detoxification, rehabilitation, and participation in an aftercare program are the only options that address the client's long-term treatment needs. Supportive counseling, family involvement, and support-group participation are important aspects of the treatment process, but they don't address the client's need for long-term treatment.

Which of the following triage categories refers to life-threatening or potentially life-threatening injury or illness requiring immediate treatment?

Emergent The patient triaged as emergent must be seen immediately. The triage category of urgent refers to minor illness or injury needing first-aid-level treatment. The triage category of immediate refers to non-acute, non-life threatening injury or illness.

Which triage category would a patient that requires simple first aid or basic primary care?

Fast track Fast track patients require simple first aid or basic primary care and may be treated in the ED or safely referred to a clinic or physician's office. Urgent patients have serious health problems that are not immediately life threatening. They must be seen within 1 hour. Emergent patients have the highest priority, their conditions are life threatening and they must be seen immediately. Nonurgent patients have episodic illness that can be addressed within 24 hours without increased morbidity.

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

Heightened anxiety phase During the heightened anxiety phase, the patient demonstrates anxiety, hyperalertness, and psychosomatic reactions, in addition to fear and flashbacks. The acute disorganization phase is characterized by shock, disbelief, guilt, humiliation, and anger. The denial phase is characterized by an unwillingness to talk. The reorganization phase occurs when the incident is put into perspective. Some patients never fully recover from rape trauma.

A client is brought to the emergency department by ambulance. The client is seriously ill and unconscious. No family or friends are present. Which of the following would be most appropriate to do?

Document the client's condition and absence of friends or family for obtaining consent to treatment. Consent is needed to examine and treat a client unless he or she is unconscious or in critical condition and unable to make decisions. In this situation, the client is unconscious and no friends or family are around to provide consent to treatment. The nurse should document this fact and provide care. Checking the client's record and asking the ambulance team for information would waste valuable time. Explaining to the client that care will be provided is appropriate even though the client is unconscious, but documentation is essential.

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 Examples of penetrating trauma include gunshot wounds and stab wounds. Motor vehicle crashes, falls, and being struck with a baseball bat are examples of blunt trauma.

The nurse is caring for a victim of a sexual assault. The patient is fearful and experiencing flashbacks. The nurse recognizes that the patient is experiencing which of the following phases of the psychological reaction to rape?

Heightened anxiety phase During the heightened anxiety phase, the patient demonstrates anxiety, hyperalertness, and psychosomatic reactions, in addition to fear and flashbacks. The acute disorganization phase is characterized by shock, disbelief, guilt, humiliation, and anger. The denial phase is characterized by an unwillingness to talk. The reorganization phase occurs when the incident is put into perspective. Some patients never fully recover from rape trauma.

The nurse is conducting a secondary survey on a patient in the ED. Which of the following is completed during the secondary survey?

Diagnostic and laboratory testing During the secondary survey, diagnostic and laboratory testing is completed. The other interventions are completed during the primary survey.

The nurse is caring for a patient in the ED with frostbite to the left hand. During the rewarming process of the hand, the nurse should perform which of the following actions?

Administer analgesic medications as ordered. During rewarming, an analgesic for pain is administered as prescribed because the rewarming process may be very painful. Frozen extremities are usually placed in a 37°C to 40°C (98.6°F to 104°F) circulating bath for 30- to 40-minute spans. This treatment is repeated until circulation is effectively restored. Hemorrhagic blebs, which may develop 1 hour to a few days after rewarming, are left intact and unruptured. Nonhemorrhagic blisters are debrided to decrease the inflammatory mediators found in the blister fluid. After rewarming, hourly active motion of any affected digits is encouraged to promote maximal restoration of function and to prevent contractures.

The nurse is caring for a patient in the ED following a sexual assault. The patient is hysterical and crying. The patient states, "I know I'm pregnant now, maybe I have HIV; why did this happen to me?" The nurse's best response is which of the following?

"Let's talk about this; do you want me to call a support person?" The patient should be reassured that anxiety is natural and asked whether a support person may be called. The goals of management are to provide support, reduce the patient's emotional trauma, and gather available evidence for possible legal proceedings. Throughout the patient's stay in the ED, the patient's privacy and sensitivity must be respected. The patient may exhibit a wide range of emotional reactions, such as hysteria, stoicism, or feelings of being overwhelmed. Support and caring are crucial.

Which laboratory study is used to detect pancreatic injury?

Serum amylase Serum amylase analysis is done to detect increasing levels, which suggest pancreatic injury or perforation of the GI tract. A white blood cell count is done to detect an elevation. A urinalysis is done to detect hematuria. A hemoglobin and hematocrit is done to evaluate trends reflecting the presence or absence of bleeding.

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 When performing abdominal thrusts, the nurse would place the thumb side of one fist against the client's abdomen in the midline slighlty above the umbilicus and well below the xiphoid process, grasping the fist with the other hand. Then the nurse would press the fist into the client's abdomen with a quick inward and upward thrust such that each new thrust should be a separate and distinct maneuver. The unconscious client is positioned on the back. The client who is conscious should be standing or sitting.

A client arrives at the emergency department and is experiencing a severe allergic reacton 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." To prevent insect stings, the client should avoid wearing brightly colored clothing because it attracts bees. The client should wear covering on the feet and avoid going barefoot because yellow jackets nest and pollinate on the ground. Staying still or motionless reduces the likelihood of being stung. Perfumes and scented soaps attract bees and should be avoided.

A patient is brought to the emergency department and diagnosed with decompression sickness. The nurse interprets this as indicating that the patient most likely has been involved with which of the following?

Diving in an ocean Decompression sickness occurs when patients have engaged in diving in a lake or ocean or high-altitude flying or flying in a commercial aircraft within 24 hours of diving. Swimming in a lake could lead to a near-drowing episode. Running a race in hot humid weather would increase a person's risk for heat stroke. Working in a chemical plant would increase the risk for chemical burns.

Which of the following solid organs is most frequently injured in a penetrating trauma?

Liver The most frequently injured solid organ in a penetrating trauma is the liver.

A male patient presents to the ED with a stab wound to the abdomen following an assault. It is suspected that the patient has an injury to his pancreas. Which of the following laboratory studies is used to detect pancreatic injury?

Serum amylase Serum amylase analysis is done to detect increasing levels, which suggests pancreatic injury or perforation of the GI tract. A white blood cell count is done to detect an elevation. A urinalysis is done to detect hematuria. A hemoglobin and hematocrit test is done to evaluate trends reflecting the presence or absence of bleeding.

A homeless patient presents to the ED. Upon assessment, the patient is experiencing hypothermia. The nurse will plan to complete which of the following priority interventions during the rewarming process?

Attach a cardiac monitor. During the rewarming process continuous electrocardiograph (ECG) monitoring is performed, because cold-induced myocardial irritability leads to conduction disturbances, especially ventricular fibrillation. A urinary catheter should be inserted to monitor urinary output; however, ECG monitoring is the priority. There is no indication for endotracheal intubation. Inotropic medications are contraindicated, as they can stimulate the heart and increase the risk for fatal dysrhythmias, such as ventricular fibrillation.

A patient is admitted to the ED after a near-drowning accident. The patient is diagnosed with saltwater aspiration. The nurse will observe the patient for several hours to monitor for symptoms of which of the following?

Pulmonary edema Resultant pathophysiologic changes and pulmonary injury depend on the type of fluid (fresh or salt water) and the volume aspirated. Freshwater aspiration results in a loss of surfactant and, therefore, an inability to expand the lungs. Saltwater aspiration leads to pulmonary edema from the osmotic effects of the salt within the lungs. If a person survives submersion, acute respiratory distress syndrome (ARDS), resulting in hypoxia, hypercarbia, and respiratory or metabolic acidosis, can occur. The patient would experience hypernatremia. Hypothermia and head injury may be associated with near drowning, but would be apparent at the time of admission and would not develop after several hours.

The nurse is caring for a patient in the ED who is breathing but unconscious. In order to avoid an upper airway obstruction, the nurse is inserting an oropharyngeal airway. How would the nurse insert the airway?

Upside down and then rotated 180 degrees The nurse should insert the oropharyngeal airway with the tip facing up toward the roof of the mouth until it passes the uvula and then rotate the tip 180 degrees so that the tip is pointed down toward the pharynx. This displaces the tongue anteriorly, and the patient then breathes through and around the airway.

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. During rewarming, an analgesic for pain is administered as prescribed, because the rewarming process may be very painful. To avoid further mechanical injury, the body part is not handled. Massage is contraindicated.

What is a common source of airway obstruction in an unconscious client?

The tongue In an unconscious client, the muscles controlling the tongue commonly relax, causing the tongue to obstruct the airway. When this situation occurs, the nurse should use the head-tilt, chin-lift maneuver to cause the tongue to fall back into place. If she suspects the client has a neck injury she must perform the jaw-thrust maneuver.

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 If a neck or spine injury is suspected, the jaw-thrust maneuver should be used to open the client's airway. To perform this maneuver, the nurse should position herself at the client's head and rest her thumbs on his lower jaw, near the corners of his mouth. She should then grasp the angles of his lower jaw with her fingers and lift the jaw forward. The head tilt-chin lift maneuver is used to open the airway when a neck or spine injury isn't suspected. To perform this maneuver the nurse places two fingers on the chin and lifts while pushing down on the forehead with the other hand. The abdominal thrust is used to relieve severe or complete airway obstruction caused by a foreign body. The Seldinger maneuver is a method of percutaneous introduction of a catheter into a vessel.

A nurse is caring for a client who has arrived at the emergency department in shock. The nurse intervenes based on the knowledge that which of the following is the most common cause of shock?

Hypovolemia Types of shock include cardiogenic, neurogenic, anaphylactic, and septic. Of these, the most common cause is hypovolemia.

A client comes to the emergency department after experiencing a wound. Inspection reveals an opening in the skin with distinct edges and whose depth is greater than the length of the wound. The nurse documents this as which type of wound?

Stab A stab wound is an incision of the skin with well-defined edges and is typically deeper than long. It is usually caused by a sharp instrument. A laceration is a tear in the skin with irregular edges and vein bridging. An avulsion is manifested as a tearing away of tissue from the supporting structures. A patterned wound takes on the outline of the object causing the wound.

A nurse working in an emergency department is responsible for determining the severity of the patients' problems and how fast each needs to be seen. The nurse is implementing which of the following?

Triage The nurse is performing triage, which sorts patients into groups based on the severity of their health problems and the immediacy with which these problems need to be treated. Referral involves communicating with other health care delivery service providers to assist the patient with meeting his or her needs. Discharge planning involves actions to get the patient ready to leave the facility. Crisis intervention involves actions to alleviate the high level of stress and to promote effective coping with challenging life events.

A patient who has accidentally ingested toilet bowel cleaner is brought to the emergency department. Which action would NOT be appropriate for the nurse to implement?

Induced vomiting Vomiting is never induced after ingestion of caustic substances (acid or alkaline) such as toilet bowl cleaner because the substance is corrosive to the tissues. Appropriate actions include dilution with milk or water, gastric lavage, and administration of activated charcoal.

A patient working in a chemical facility sustains a chemical burn to his arms. The chemical involved was white phosphorus. Which of the following would be the priority nursing action?

Brushing off all traces of the chemical from the patient's skin For a chemical burn involving lye or white phosphorous, all evidence of the chemical should be brushed off the patient before any flushing occurs. These chemicals, if exposed to water, have the potential for exploding or for deepening the burn. Covering the burn area or applying ice is an inappropriate action.

A patient present to the ED following a work-related injury to the left hand. The patient has an avulsion of the left ring finger. Which of the following correctly describes an avulsion?

Tearing away of tissue from supporting structures An avulsion is described as a tearing away of tissue from supporting structures. A laceration is a skin tear with irregular edges and vein bridging. Abrasion is denuded skin. A cut is an incision of the skin with well-defined edges, usually longer than deep.

A female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing interventions should be provided? (Select all that apply.)

Assess and document any bruises and lacerations. Record a history of the event, using the patient's own words. Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police. A history is obtained only if the patient has not already talked to a police officer, social worker, or crisis intervention worker. The patient should not be asked to repeat the history. Any history of the event that is obtained should be recorded in the patient's own words. The patient is asked whether he or she has bathed, douched, brushed his or her teeth, changed clothes, urinated, or defecated since the attack, because these actions may alter interpretation of subsequent findings. Each item of clothing is placed in a separate paper bag. The bags are labeled and given to appropriate law enforcement authorities. The patient is examined (from head to toe) for injuries, especially injuries to the head, neck, breasts, thighs, back, and buttocks. The exam focuses on external evidence of trauma (bruises, contusions, lacerations, stab wounds).

A patient was bitten by a tick 3 months ago and is now having muscle aches as well as joint pain and swelling. The patient is having difficulty with self care and requires assistance with activities of daily living (ADLs). What stage of Lyme disease does the nurse recognize the patient is in?

Stage III Lyme disease has three stages. Stage I presents with a classic "bull's-eye" rash (i.e., erythema migrans) and flulike signs and symptoms that may include chills, fever, myalgia, fatigue, and headache. If antibiotics are not administered, stage II Lyme disease may present within 4 to 10 weeks following the tick bite and may manifest with joint pain, memory loss, poor motor coordination, and meningitis. Stage III can begin anywhere from weeks to more than a year after the bite and has serious long-term chronic sequelae, including arthritis, neuropathy, myalgia, and myocarditis.

A nurse is providing inservice education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step?

Supporting the client's emotional status The teaching session is successful when staff members focus first on supporting the client's emotional status. Next, staff members should gain consent to perform the pelvic examination, perform the examination, and collect evidence, such as semen if present.

Which category of triage encompasses patients with serious health problems that are not immediately life threatening?

Urgent Urgent patients have serous health problems that not immediately life threatening. They must be seen within 1 hour. Emergent patients have the highest priority with conditions are life threatening and they must be seen immediately. Nonurgent patients have episodic illness that can be addressed within 24 hours without increased morbidity. Fast track patients require simple first aid or basic primary care and may be treated in the ED or safely referred to a clinic or physician's office.

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

3 to 5 minutes If the airway is completely obstructed, permanent brain injury or death will occur within 3 to 5 minutes secondary to hypoxia. Air movement is absent in the presence of complete airway obstruction. Oxygen saturation of the blood decreases rapidly because obstruction of the airway prevents entry of air into the lungs. Oxygen deficit occurs in the brain, resulting in unconsciousness, with death following rapidly. The other timeframes are incorrect.

A nurse is providing care to a client in the emergency department and walks into the hallway to get equipment. All of a sudden, gunshots are heard. Which of the following would be the nurse's priority?

Protecting himself or herself If gunfire occurs in the emergency department, self-protection is the priority. Security officers and police must gain control of the situation first and then care is provided to the injured.

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 For a client with frostbite, massaging the affected body part is contraindicated. Analgesia is given for pain during the rewarming process because it can be very painful. Ambulation would be restricted. Once rewarmed, sterile gauze or cotton is placed between the affected toes to prevent maceration.

A nurse is preparing to assist with a gastric lavage for a client who has ingested an unknown poison and is obtunded. To ensure that the tube reaches the stomach, the nurse would measure the distance from the bridge of the nose to which of the following?

Xiphoid process The nurse measures the tube from the bridge of the nose to the xiphoid process to ensure that the tube reaches the stomach on insertion.

When assessing a client with suspected carbon monoxide poisoning, which finding would be least reliable?

Cherry red skin color Skin color can range from pink or cherry-red to cyanotic and pale is not a reliable sign. In clients with carbon monoxide poisoning, central nervous system signs such as headache and confusion predominate. Palpitations also may occur.

A patient in the emergency department is bleeding profusely from numerous large and deep lacerations on the top of his head, right side of his face, and forehead. The nurse determines the need to apply pressure at the appropriate pressure point. The nurse would use which of the following pressure points?

Image of finger on the right side near the head The location of the injuries and site of bleeding determine which pressure point to use. In this case, the patient's bleeding is proximal to the temporal artery; therefore, pressure should be applied to this area, as shown in option A. If the patient was bleeding from the lower portion of the face, pressure would be applied to the facial artery, as in option B. The carotid artery would be used to control bleeding proximal to that area. The subclavian artery would be used to control bleeding proximal to it, such as the lower neck and shoulder area.

A patient arrives at the emergency department after sustaining a gunshot wound to the abdomen. When assessing the patient, the nurse pays particular attention to which of the following?

Liver Penetrating abdominal injuries, such as from a gunshot wound, are serious and result in a high incidence of injury to hollow and solid organs. Although any organs can be injured, the liver is the most frequently injured solid organ. The small bowel is a frequently injured hollow organ. Thus, of the options shown, the nurse would assess the liver area most closely.

A patient brought to the ED by the rescue squad after getting off a plane at the airport is complaining of severe joint pain, numbness, and an inability to move the arms. The patient was on a diving vacation and went for a last dive this morning before flying home. What is a priority action by the nurse?

Ensure a patent airway and that the patient is receiving 100% oxygen. Decompression sickness, also known as "the bends," occurs in patients who have engaged in diving (lake/ocean diving), high-altitude flying, or flying in commercial aircraft within 24 hours after diving. Signs and symptoms include joint or extremity pain, numbness, hypesthesia, and loss of range of motion. A patent airway and adequate ventilation are established before all other interventions, as described previously, and 100% oxygen is administered throughout treatment and transport.

A client is brought to the emergency department after being involved in a motor vehicle collision. Which of the following would lead the nurse to suspect internal bleeding?

Delayed capillary refill If a client exhibits tachycardia, falling blood pressure, thirst, apprehension, cool moist skin, or delayed capillary refill, internal bleeding should be suspected.

A high school football player is brought to the emergency department after collapsing at practice in extremely hot and humid weather. Which of the following would lead the nurse to suspect that the client is experiencing heat stroke?

Delirium Manifestations of heat stroke include a temperature of 105 degrees F or greater (40.5 degrees C or greater), anhidrosis (absence of sweating), central nervous system dysfunction (bizarre behavior, delirium, confusion, or coma), hot, dry skin, tachycardia, tachypnea, and hypotension.

A nurse is providing care to the family of a client who was brought to the emergency department and suddenly died. Which of the following would be appropriate for the nurse to do? Select all that apply.

Ask the family if they would like to view the body. Provide a private place for the family to be together. Allow the family to express their emotions freely. When providing care to a family experiencing the sudden death of a member, the nurse would take the relatives to a private place where they can be together to grieve. In addition, the nurse would encourage the family to view the body if they wish and allow members to support each other and express their emotions freely. Euphemisms such as "passing on" or "going to a better place" should be avoided. Sedation is avoided because it may mask or delay the grieving process, which is necessary to achieve emotional equilibrium and prevent prolonged depression.

A patient is hemorrhaging from an open wound on his leg. The nurse implements care using the following steps. Place them in the order in which the nurse would perform them. Use all options.

Provide firm direct pressure Apply a pressure dressing Elevate the leg Immobilize the leg When a patient is hemorrhaging from a leg wound, first the nurse would apply direct firm pressure to control the bleeding. Next, the nurse would apply a pressure dressing, and elevate the injured area to stop venous and capillary bleeding if possible. Then, the area is immobilized to control blood loss.

A patient is brought to the emergency department after being locked outside of her house in the frigid weather for several hours. The nurse suspects that the patient has sustained frostbite of her hand based on which of the following findings?

Hand that is insensitive to touch Indicators of frostbite include an extremity that is hard, cold, and insensitive to touch and appears white or mottled blue-white.

An 85-year-old patient is admitted to the ED. Heat stroke is suspected. The patient's core temperature is 106.2°F (41.2°C), blood pressure (BP) 90/60 mm Hg, and pulse 102 bpm. The nurse understands that the primary treatment measure for the patient will include which of the following?

Immersion of the patient in a cold-water bath For the patient with heat stroke, simultaneous treatment focuses on stabilizing oxygenation using the CABs (circulation, airway, and breathing) (formerly called the ABCs) of basic life support. This includes establishing IV access for fluid administration. After the patient's clothing is removed, the core (internal) temperature is reduced to 39°C (102°F) as rapidly as possible, preferably within 1 hour. One or more of the following methods may be used as prescribed: Cool sheets and towels or continuous sponging with cool water; ice applied to the neck, groin, chest, and axillae while spraying with tepid water; and cooling blankets. Immersion of the patient in a cold-water bath is the optimal method for cooling (if available). Hydration would be with lactated Ringer's solution. There is no indication for intubation. Administration of sodium supplements is indicated for the treatment of heat cramps.

A patient presents to the ED following a motor vehicle collision. The patient is suspected of having internal hemorrhage. The nurse assesses the patient for signs and symptoms of shock. Signs and symptoms of shock include which of the following? Select all that apply.

Cool, moist skin Decreasing blood pressure Increasing heart rate Delayed capillary refill Signs and symptoms of shock include cool, moist skin (resulting from poor peripheral perfusion), decreasing blood pressure, increasing heart rate, delayed capillary refill, and decreasing urine volume.

Which of the following solutions should the nurse anticipate for fluid replacement in the male patient?

Lactated Ringer's solution Replacement fluids may include isotonic electrolyte solutions and blood component therapy. O negative blood is prepared for emergency use in women of childbearing age.Dextrose 5% in water should not be used to replace fluids in hypovolemic patients. Hypertonic saline is used only to treat severe symptomatic hyponatremia and should be used only in intensive care units.

A nurse is assessing a patient who is suspected of having a partial airway obstruction. Which of the following would the nurse expect to find?

Spontaneous coughing If a patient can breathe and cough spontaneously, a partial airway obstruction should be suspected. If the patient demonstrates a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis, the patient should be managed as if there were a complete airway obstruction

A nurse who is a member of an emergency response team anticipates that several patients with airway obstruction may need a cricothyroidotomy. For which of the following patients would this procedure be appropriate? Select all that apply.

Patient with extensive facial trauma Patient with an obstructed larynx Patient with laryngeal edema secondary to anaphylaxis Cricothyroidotomy is used in emergencies when endotracheal intubation is either not possible or contraindicated. Examples include airway obstruction from extensive maxillofacial trauma, cervical spine injury, laryngospasm, laryngeal edema after an allergic reaction or extubation, hemorrhage into neck tissue, and obstruction of the larynx.

A woman is brought to the emergency department by her husband, who reports that his wife "accidentally fell down a flight of steps and broke her arm." The patient is very quiet and withdrawn. During the examination, inspection reveals numerous bruises at different stages of healing over the patient's legs, arms, and abdomen. The nurse suspects abuse. Which of the following questions would be most appropriate for the nurse to use to gather additional information?

"I've noticed several bruises here and there. Can you tell me what happened?" Approaching the subject of abuse requires a nonthreatening approach that allows the patient to feel comfortable and trusting of the nurse. Therapeutic communication techniques with skillful interviewing are key. Acknowledging the evidence of the bruises and then asking the patient about them is a broad opening statement that allows the patient to direct the response. It also is nonthreatening to the patient and facilitates the development of trust. Questioning the patient about her husband "beating her" indicates that the nurse already assumes this to be the case. It is threatening to the patient and may add to her anxiety and fear levels. Asking the patient if she really fell down the stairs can sound accusatory. The patient may believe the nurse is implying that the patient is lying, which would be nontherapeutic. Although it is true that the husband has no right to abuse his wife, telling the patient this and offering to call the police can be too overwhelming for her at this time.

The nurse is administering 100% oxygen to a patient with carbon monoxide poisoning and obtains a carboxyhemoglobin level. Which level would the nurse interpret as indicating that oxygen therapy can be discontinued?

4% Oxygen is administered until the carboxyhemoglobin level is less than 5%.

A family member brings a patient to the ED following an apparent oxycodone (OxyContin) overdose. The patient is experiencing severe respiratory depression. Which of the following medications will the nurse administer?

Naloxone hydrochloride (Narcan) Narcan, a narcotic antagonist, reverses respiratory depression and coma. Romazicon is a benzodiazepine antagonist. Valium is a benzodiazepine. Mucomyst is used for acetaminophen toxicity.

A patient presents to the ED complaining of choking on a chicken bone. The patient is breathing spontaneously. The nurse applies oxygen and suspects a partial airway obstruction. Which of the following should the nurse do next?

Encourage the patient to cough forcefully. If the patient can breathe and cough spontaneously, a partial obstruction should be suspected. The patient is encouraged to cough forcefully and to persist with spontaneous coughing and breathing efforts as long as good air exchange exists. There may be some wheezing between coughs. If the patient demonstrates a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis, the patient should be managed as if there were complete airway obstruction. If the person is unconscious, inspection of the oropharynx may reveal the offending object. X-ray study, laryngoscopy, or bronchoscopy also may be performed. There is no indication that an artificial airway is indicated.

A triage nurse in the ED determines that a patient with dyspnea and dehydration is not in a life-threatening situation. What triage category will the nurse choose?

Urgent A basic and widely used triage system that had been in use for many years utilized three categories: emergent, urgent, and nonurgent. In this system, emergent patients had the highest priority, urgent patients had serious health problems but not immediately life-threatening ones, and nonurgent patients had episodic illnesses.

A patient is brought to the ED by a friend, who states that a tree fell on the patient's leg and crushed it while they were cutting firewood. What priority actions should the nurse perform? (Select all that apply.)

Applying a clean dressing to protect the wound Elevating the site to limit the accumulation of fluid in the interstitial spaces Splinting the wound in a position of rest to prevent motion Major soft tissue injuries are dressed and splinted promptly to control bleeding and pain. If an extremity is injured, it is elevated to relieve swelling and pressure.

A person suffering from carbon monoxide poisoning would exhibit which of the following manifestations?

Intoxication A person suffering from carbon monoxide poisoning appears intoxicated (from cerebral hypoxia). Other signs and symptoms include headache, muscular weakness, palpitation, dizziness, and mental confusion. The skin coloring in the patient with carbon monoxide poisoning can range from pink to cherry red to cyanotic and pale and is not a reliable diagnostic sign.

A client has a gaping wound on his forearm that is bleeding profusely. Applying pressure to which pressure point would be most helpful?

Brachial The pressure point at the brachial artery would be most appropriate because this site is proximal to the bleeding site. The femoral pressure point would be useful for bleeding in the lower extremities. The radial pressure point would be appropriate for bleeding in the wrist and hands. The subclavian pressure point would be used for bleeding in the upper anterior chest area.

A nurse is establishing a patient's airway. Which action would the nurse perform first?

Repositioning the patient's head Establishing an airway may be as simple as repositioning the patient's head to prevent the tongue from obstructing the pharynx. Subsequent measures would include abdominal thrusts to dislodge a foreign body, head-tilt chin-lift or jaw-thrust manuever, or insertion of an artificial airway.

An emergency nurse has collected evidence from a patient who was shot during a robbery. The nurse is preparing to transfer the evidence to law enforcement. Which of the following would be important for the nurse to include when documenting this transfer? Select all that apply.

Time of the transfer of evidence Date that the evidence was collected Name of the law-enforcement official When transferring evidence to law enforcement, the nurse must document the chain of custody. This includes the information that evidence was transferred to the officer, the officer's name, and the date and time of the transfer. Labels are placed on each item, but this does not need to be documented for the transfer. The names of family members witnessing the transfer also do not need to be documented.

A patient presents to the ED after an unsuccessful suicide attempt. The patient is diagnosed with an acetaminophen overdose. The nurse anticipates the administration of which of the following medications?

N-acetylcysteine (Mucomyst) Treatment of acetaminophen overdose includes administration of N-acetylcysteine (Mucomyst). Flumazenil is administered in the treatment of nonbarbiturate sedative overdoses. Naloxone (Narcan) is administered in the treatment of narcotic overdoses. Diazepam (Valium) may be administered to treat uncontrolled hyperactivity in the patient with a hallucinogen overdose.

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

Unconscious adult A finger sweep should be used only in the unconscious adult patient. This action draws the tongue away from the back of the throat and away from the foreign body that may be lodged there. A finger sweep should not be done on a conscious adult, child, or adolescent.

As part of an emergency department team, an emergency nurse is conducting a secondary survey on a client. Which of the following would the nurse include?

Applying electrocardiogram electrodes A secondary survey is completed after the primary survey priorities of airway, breathing, circulation, and disability have been addressed. Applying electrocardiogram electrodes would be a component of the secondary survey. Establishing a patent airway, providing adequate ventilation, and determining neurologic disability by assessing neurologic function are components of the primary survey.

A patient has undergone a diagnostic peritoneal lavage. The nurse interprets which result as indicating a positive test?

Evidence of feces A diagnostic peritoneal lavage is considered positive if there is bile, feces, or food in the specimen, a red blood cell count greater than 100,000/mm3, and a white blood cell count greater than 500/mm3.

After inserting an oropharyngeal airway, the nurse determines that it is in the proper position when the flange is located at which position?

Approximately at the patient's lips When an oropharyngeal airway is properly inserted, the tip is in the hypopharynx and the flange is approximately at the patient's lips.

A patient with intra-abdominal injuries is brought to the emergency department. Which of the following would most likely alert the nurse to suspect internal bleeding secondary to a ruptured spleen?

Pain in the left shoulder Pain in the left shoulder is common in a patient with bleeding from a ruptured spleen. Pain in the right shoulder is consistent with a laceration of the liver. The spleen is located in the left upper quadrant, not the right. Rebound tenderness and abdominal distention are generalized signs suggesting intraperitoneal injury. Although these generalized signs may accompany a ruptured spleen, they are less specific than pain in the left shoulder.

Nursing students are reviewing information about anaphylactic reactions and their possible causes. The students demonstrate understanding of this information when they identify which of the following as a common cause? Select all that apply.

Insect stings Medications Latex Eggs Shellfish Common causes of anaphylactic reactions include insect stings, medications (eg, penicillin, iodinated-contrast materials), latex, insect stings, eggs, peanuts, and shellfish. Green vegetables typically are not associated with anaphylaxis.

A patient is brought to the emergency department following an overdose of a selective serotonin reuptake inhibitor (SSRI). While assessing the patient, the nurse suspects that the patient may be developing serotonin syndrome based on which of the following?

Seizures Serotonin syndrome is manifested by agitation, seizures, hyperthermia, diaphoresis, and hypertension.

The ED staff work collaboratively and follow the ABCDE method to establish and treat health priorities in a trauma patient effectively. Which of the following actions is completed by the nurse when implementing the "D" element of this method?

Assessing the patient's Glasgow Coma Scale The primary survey focuses on stabilizing life-threatening conditions. The ED staff work collaboratively and follow the ABCDE (airway, breathing, circulation, disability, exposure) method. While implementing the D element, the nurse determines neurologic disability by assessing neurologic function using the Glasgow Coma Scale and a motor and sensory evaluation of the spine. A quick neurologic assessment may be performed using the AVPU mnemonic: A, alert: is the patient alert and responsive? V, verbal: does the patient respond to verbal stimuli? P, pain: does the patient respond only to painful stimuli? U, unresponsive: is the patient unresponsive to all stimuli, including pain? The other interventions are not included in this element of the primary survey.

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MSII Prep U Ch. 72 Emergency Nursing - Subjecto.com

MSII Prep U Ch. 72 Emergency Nursing

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A nurse is caring for a client who is experiencing alcohol withdrawal. Which statement best indicates that the client understands the need for long-term treatment?

The client agrees to detoxification, rehabilitation, and participation in an aftercare program. Detoxification, rehabilitation, and participation in an aftercare program are the only options that address the client’s long-term treatment needs. Supportive counseling, family involvement, and support-group participation are important aspects of the treatment process, but they don’t address the client’s need for long-term treatment.

Which of the following triage categories refers to life-threatening or potentially life-threatening injury or illness requiring immediate treatment?

Emergent The patient triaged as emergent must be seen immediately. The triage category of urgent refers to minor illness or injury needing first-aid-level treatment. The triage category of immediate refers to non-acute, non-life threatening injury or illness.

Which triage category would a patient that requires simple first aid or basic primary care?

Fast track Fast track patients require simple first aid or basic primary care and may be treated in the ED or safely referred to a clinic or physician’s office. Urgent patients have serious health problems that are not immediately life threatening. They must be seen within 1 hour. Emergent patients have the highest priority, their conditions are life threatening and they must be seen immediately. Nonurgent patients have episodic illness that can be addressed within 24 hours without increased morbidity.

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

Heightened anxiety phase During the heightened anxiety phase, the patient demonstrates anxiety, hyperalertness, and psychosomatic reactions, in addition to fear and flashbacks. The acute disorganization phase is characterized by shock, disbelief, guilt, humiliation, and anger. The denial phase is characterized by an unwillingness to talk. The reorganization phase occurs when the incident is put into perspective. Some patients never fully recover from rape trauma.

A client is brought to the emergency department by ambulance. The client is seriously ill and unconscious. No family or friends are present. Which of the following would be most appropriate to do?

Document the client’s condition and absence of friends or family for obtaining consent to treatment. Consent is needed to examine and treat a client unless he or she is unconscious or in critical condition and unable to make decisions. In this situation, the client is unconscious and no friends or family are around to provide consent to treatment. The nurse should document this fact and provide care. Checking the client’s record and asking the ambulance team for information would waste valuable time. Explaining to the client that care will be provided is appropriate even though the client is unconscious, but documentation is essential.

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 Examples of penetrating trauma include gunshot wounds and stab wounds. Motor vehicle crashes, falls, and being struck with a baseball bat are examples of blunt trauma.

The nurse is caring for a victim of a sexual assault. The patient is fearful and experiencing flashbacks. The nurse recognizes that the patient is experiencing which of the following phases of the psychological reaction to rape?

Heightened anxiety phase During the heightened anxiety phase, the patient demonstrates anxiety, hyperalertness, and psychosomatic reactions, in addition to fear and flashbacks. The acute disorganization phase is characterized by shock, disbelief, guilt, humiliation, and anger. The denial phase is characterized by an unwillingness to talk. The reorganization phase occurs when the incident is put into perspective. Some patients never fully recover from rape trauma.

The nurse is conducting a secondary survey on a patient in the ED. Which of the following is completed during the secondary survey?

Diagnostic and laboratory testing During the secondary survey, diagnostic and laboratory testing is completed. The other interventions are completed during the primary survey.

The nurse is caring for a patient in the ED with frostbite to the left hand. During the rewarming process of the hand, the nurse should perform which of the following actions?

Administer analgesic medications as ordered. During rewarming, an analgesic for pain is administered as prescribed because the rewarming process may be very painful. Frozen extremities are usually placed in a 37°C to 40°C (98.6°F to 104°F) circulating bath for 30- to 40-minute spans. This treatment is repeated until circulation is effectively restored. Hemorrhagic blebs, which may develop 1 hour to a few days after rewarming, are left intact and unruptured. Nonhemorrhagic blisters are debrided to decrease the inflammatory mediators found in the blister fluid. After rewarming, hourly active motion of any affected digits is encouraged to promote maximal restoration of function and to prevent contractures.

The nurse is caring for a patient in the ED following a sexual assault. The patient is hysterical and crying. The patient states, "I know I’m pregnant now, maybe I have HIV; why did this happen to me?" The nurse’s best response is which of the following?

"Let’s talk about this; do you want me to call a support person?" The patient should be reassured that anxiety is natural and asked whether a support person may be called. The goals of management are to provide support, reduce the patient’s emotional trauma, and gather available evidence for possible legal proceedings. Throughout the patient’s stay in the ED, the patient’s privacy and sensitivity must be respected. The patient may exhibit a wide range of emotional reactions, such as hysteria, stoicism, or feelings of being overwhelmed. Support and caring are crucial.

Which laboratory study is used to detect pancreatic injury?

Serum amylase Serum amylase analysis is done to detect increasing levels, which suggest pancreatic injury or perforation of the GI tract. A white blood cell count is done to detect an elevation. A urinalysis is done to detect hematuria. A hemoglobin and hematocrit is done to evaluate trends reflecting the presence or absence of bleeding.

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 When performing abdominal thrusts, the nurse would place the thumb side of one fist against the client’s abdomen in the midline slighlty above the umbilicus and well below the xiphoid process, grasping the fist with the other hand. Then the nurse would press the fist into the client’s abdomen with a quick inward and upward thrust such that each new thrust should be a separate and distinct maneuver. The unconscious client is positioned on the back. The client who is conscious should be standing or sitting.

A client arrives at the emergency department and is experiencing a severe allergic reacton 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." To prevent insect stings, the client should avoid wearing brightly colored clothing because it attracts bees. The client should wear covering on the feet and avoid going barefoot because yellow jackets nest and pollinate on the ground. Staying still or motionless reduces the likelihood of being stung. Perfumes and scented soaps attract bees and should be avoided.

A patient is brought to the emergency department and diagnosed with decompression sickness. The nurse interprets this as indicating that the patient most likely has been involved with which of the following?

Diving in an ocean Decompression sickness occurs when patients have engaged in diving in a lake or ocean or high-altitude flying or flying in a commercial aircraft within 24 hours of diving. Swimming in a lake could lead to a near-drowing episode. Running a race in hot humid weather would increase a person’s risk for heat stroke. Working in a chemical plant would increase the risk for chemical burns.

Which of the following solid organs is most frequently injured in a penetrating trauma?

Liver The most frequently injured solid organ in a penetrating trauma is the liver.

A male patient presents to the ED with a stab wound to the abdomen following an assault. It is suspected that the patient has an injury to his pancreas. Which of the following laboratory studies is used to detect pancreatic injury?

Serum amylase Serum amylase analysis is done to detect increasing levels, which suggests pancreatic injury or perforation of the GI tract. A white blood cell count is done to detect an elevation. A urinalysis is done to detect hematuria. A hemoglobin and hematocrit test is done to evaluate trends reflecting the presence or absence of bleeding.

A homeless patient presents to the ED. Upon assessment, the patient is experiencing hypothermia. The nurse will plan to complete which of the following priority interventions during the rewarming process?

Attach a cardiac monitor. During the rewarming process continuous electrocardiograph (ECG) monitoring is performed, because cold-induced myocardial irritability leads to conduction disturbances, especially ventricular fibrillation. A urinary catheter should be inserted to monitor urinary output; however, ECG monitoring is the priority. There is no indication for endotracheal intubation. Inotropic medications are contraindicated, as they can stimulate the heart and increase the risk for fatal dysrhythmias, such as ventricular fibrillation.

A patient is admitted to the ED after a near-drowning accident. The patient is diagnosed with saltwater aspiration. The nurse will observe the patient for several hours to monitor for symptoms of which of the following?

Pulmonary edema Resultant pathophysiologic changes and pulmonary injury depend on the type of fluid (fresh or salt water) and the volume aspirated. Freshwater aspiration results in a loss of surfactant and, therefore, an inability to expand the lungs. Saltwater aspiration leads to pulmonary edema from the osmotic effects of the salt within the lungs. If a person survives submersion, acute respiratory distress syndrome (ARDS), resulting in hypoxia, hypercarbia, and respiratory or metabolic acidosis, can occur. The patient would experience hypernatremia. Hypothermia and head injury may be associated with near drowning, but would be apparent at the time of admission and would not develop after several hours.

The nurse is caring for a patient in the ED who is breathing but unconscious. In order to avoid an upper airway obstruction, the nurse is inserting an oropharyngeal airway. How would the nurse insert the airway?

Upside down and then rotated 180 degrees The nurse should insert the oropharyngeal airway with the tip facing up toward the roof of the mouth until it passes the uvula and then rotate the tip 180 degrees so that the tip is pointed down toward the pharynx. This displaces the tongue anteriorly, and the patient then breathes through and around the airway.

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. During rewarming, an analgesic for pain is administered as prescribed, because the rewarming process may be very painful. To avoid further mechanical injury, the body part is not handled. Massage is contraindicated.

What is a common source of airway obstruction in an unconscious client?

The tongue In an unconscious client, the muscles controlling the tongue commonly relax, causing the tongue to obstruct the airway. When this situation occurs, the nurse should use the head-tilt, chin-lift maneuver to cause the tongue to fall back into place. If she suspects the client has a neck injury she must perform the jaw-thrust maneuver.

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 If a neck or spine injury is suspected, the jaw-thrust maneuver should be used to open the client’s airway. To perform this maneuver, the nurse should position herself at the client’s head and rest her thumbs on his lower jaw, near the corners of his mouth. She should then grasp the angles of his lower jaw with her fingers and lift the jaw forward. The head tilt-chin lift maneuver is used to open the airway when a neck or spine injury isn’t suspected. To perform this maneuver the nurse places two fingers on the chin and lifts while pushing down on the forehead with the other hand. The abdominal thrust is used to relieve severe or complete airway obstruction caused by a foreign body. The Seldinger maneuver is a method of percutaneous introduction of a catheter into a vessel.

A nurse is caring for a client who has arrived at the emergency department in shock. The nurse intervenes based on the knowledge that which of the following is the most common cause of shock?

Hypovolemia Types of shock include cardiogenic, neurogenic, anaphylactic, and septic. Of these, the most common cause is hypovolemia.

A client comes to the emergency department after experiencing a wound. Inspection reveals an opening in the skin with distinct edges and whose depth is greater than the length of the wound. The nurse documents this as which type of wound?

Stab A stab wound is an incision of the skin with well-defined edges and is typically deeper than long. It is usually caused by a sharp instrument. A laceration is a tear in the skin with irregular edges and vein bridging. An avulsion is manifested as a tearing away of tissue from the supporting structures. A patterned wound takes on the outline of the object causing the wound.

A nurse working in an emergency department is responsible for determining the severity of the patients’ problems and how fast each needs to be seen. The nurse is implementing which of the following?

Triage The nurse is performing triage, which sorts patients into groups based on the severity of their health problems and the immediacy with which these problems need to be treated. Referral involves communicating with other health care delivery service providers to assist the patient with meeting his or her needs. Discharge planning involves actions to get the patient ready to leave the facility. Crisis intervention involves actions to alleviate the high level of stress and to promote effective coping with challenging life events.

A patient who has accidentally ingested toilet bowel cleaner is brought to the emergency department. Which action would NOT be appropriate for the nurse to implement?

Induced vomiting Vomiting is never induced after ingestion of caustic substances (acid or alkaline) such as toilet bowl cleaner because the substance is corrosive to the tissues. Appropriate actions include dilution with milk or water, gastric lavage, and administration of activated charcoal.

A patient working in a chemical facility sustains a chemical burn to his arms. The chemical involved was white phosphorus. Which of the following would be the priority nursing action?

Brushing off all traces of the chemical from the patient’s skin For a chemical burn involving lye or white phosphorous, all evidence of the chemical should be brushed off the patient before any flushing occurs. These chemicals, if exposed to water, have the potential for exploding or for deepening the burn. Covering the burn area or applying ice is an inappropriate action.

A patient present to the ED following a work-related injury to the left hand. The patient has an avulsion of the left ring finger. Which of the following correctly describes an avulsion?

Tearing away of tissue from supporting structures An avulsion is described as a tearing away of tissue from supporting structures. A laceration is a skin tear with irregular edges and vein bridging. Abrasion is denuded skin. A cut is an incision of the skin with well-defined edges, usually longer than deep.

A female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing interventions should be provided? (Select all that apply.)

Assess and document any bruises and lacerations. Record a history of the event, using the patient’s own words. Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police. A history is obtained only if the patient has not already talked to a police officer, social worker, or crisis intervention worker. The patient should not be asked to repeat the history. Any history of the event that is obtained should be recorded in the patient’s own words. The patient is asked whether he or she has bathed, douched, brushed his or her teeth, changed clothes, urinated, or defecated since the attack, because these actions may alter interpretation of subsequent findings. Each item of clothing is placed in a separate paper bag. The bags are labeled and given to appropriate law enforcement authorities. The patient is examined (from head to toe) for injuries, especially injuries to the head, neck, breasts, thighs, back, and buttocks. The exam focuses on external evidence of trauma (bruises, contusions, lacerations, stab wounds).

A patient was bitten by a tick 3 months ago and is now having muscle aches as well as joint pain and swelling. The patient is having difficulty with self care and requires assistance with activities of daily living (ADLs). What stage of Lyme disease does the nurse recognize the patient is in?

Stage III Lyme disease has three stages. Stage I presents with a classic "bull’s-eye" rash (i.e., erythema migrans) and flulike signs and symptoms that may include chills, fever, myalgia, fatigue, and headache. If antibiotics are not administered, stage II Lyme disease may present within 4 to 10 weeks following the tick bite and may manifest with joint pain, memory loss, poor motor coordination, and meningitis. Stage III can begin anywhere from weeks to more than a year after the bite and has serious long-term chronic sequelae, including arthritis, neuropathy, myalgia, and myocarditis.

A nurse is providing inservice education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step?

Supporting the client’s emotional status The teaching session is successful when staff members focus first on supporting the client’s emotional status. Next, staff members should gain consent to perform the pelvic examination, perform the examination, and collect evidence, such as semen if present.

Which category of triage encompasses patients with serious health problems that are not immediately life threatening?

Urgent Urgent patients have serous health problems that not immediately life threatening. They must be seen within 1 hour. Emergent patients have the highest priority with conditions are life threatening and they must be seen immediately. Nonurgent patients have episodic illness that can be addressed within 24 hours without increased morbidity. Fast track patients require simple first aid or basic primary care and may be treated in the ED or safely referred to a clinic or physician’s office.

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

3 to 5 minutes If the airway is completely obstructed, permanent brain injury or death will occur within 3 to 5 minutes secondary to hypoxia. Air movement is absent in the presence of complete airway obstruction. Oxygen saturation of the blood decreases rapidly because obstruction of the airway prevents entry of air into the lungs. Oxygen deficit occurs in the brain, resulting in unconsciousness, with death following rapidly. The other timeframes are incorrect.

A nurse is providing care to a client in the emergency department and walks into the hallway to get equipment. All of a sudden, gunshots are heard. Which of the following would be the nurse’s priority?

Protecting himself or herself If gunfire occurs in the emergency department, self-protection is the priority. Security officers and police must gain control of the situation first and then care is provided to the injured.

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 For a client with frostbite, massaging the affected body part is contraindicated. Analgesia is given for pain during the rewarming process because it can be very painful. Ambulation would be restricted. Once rewarmed, sterile gauze or cotton is placed between the affected toes to prevent maceration.

A nurse is preparing to assist with a gastric lavage for a client who has ingested an unknown poison and is obtunded. To ensure that the tube reaches the stomach, the nurse would measure the distance from the bridge of the nose to which of the following?

Xiphoid process The nurse measures the tube from the bridge of the nose to the xiphoid process to ensure that the tube reaches the stomach on insertion.

When assessing a client with suspected carbon monoxide poisoning, which finding would be least reliable?

Cherry red skin color Skin color can range from pink or cherry-red to cyanotic and pale is not a reliable sign. In clients with carbon monoxide poisoning, central nervous system signs such as headache and confusion predominate. Palpitations also may occur.

A patient in the emergency department is bleeding profusely from numerous large and deep lacerations on the top of his head, right side of his face, and forehead. The nurse determines the need to apply pressure at the appropriate pressure point. The nurse would use which of the following pressure points?

Image of finger on the right side near the head The location of the injuries and site of bleeding determine which pressure point to use. In this case, the patient’s bleeding is proximal to the temporal artery; therefore, pressure should be applied to this area, as shown in option A. If the patient was bleeding from the lower portion of the face, pressure would be applied to the facial artery, as in option B. The carotid artery would be used to control bleeding proximal to that area. The subclavian artery would be used to control bleeding proximal to it, such as the lower neck and shoulder area.

A patient arrives at the emergency department after sustaining a gunshot wound to the abdomen. When assessing the patient, the nurse pays particular attention to which of the following?

Liver Penetrating abdominal injuries, such as from a gunshot wound, are serious and result in a high incidence of injury to hollow and solid organs. Although any organs can be injured, the liver is the most frequently injured solid organ. The small bowel is a frequently injured hollow organ. Thus, of the options shown, the nurse would assess the liver area most closely.

A patient brought to the ED by the rescue squad after getting off a plane at the airport is complaining of severe joint pain, numbness, and an inability to move the arms. The patient was on a diving vacation and went for a last dive this morning before flying home. What is a priority action by the nurse?

Ensure a patent airway and that the patient is receiving 100% oxygen. Decompression sickness, also known as "the bends," occurs in patients who have engaged in diving (lake/ocean diving), high-altitude flying, or flying in commercial aircraft within 24 hours after diving. Signs and symptoms include joint or extremity pain, numbness, hypesthesia, and loss of range of motion. A patent airway and adequate ventilation are established before all other interventions, as described previously, and 100% oxygen is administered throughout treatment and transport.

A client is brought to the emergency department after being involved in a motor vehicle collision. Which of the following would lead the nurse to suspect internal bleeding?

Delayed capillary refill If a client exhibits tachycardia, falling blood pressure, thirst, apprehension, cool moist skin, or delayed capillary refill, internal bleeding should be suspected.

A high school football player is brought to the emergency department after collapsing at practice in extremely hot and humid weather. Which of the following would lead the nurse to suspect that the client is experiencing heat stroke?

Delirium Manifestations of heat stroke include a temperature of 105 degrees F or greater (40.5 degrees C or greater), anhidrosis (absence of sweating), central nervous system dysfunction (bizarre behavior, delirium, confusion, or coma), hot, dry skin, tachycardia, tachypnea, and hypotension.

A nurse is providing care to the family of a client who was brought to the emergency department and suddenly died. Which of the following would be appropriate for the nurse to do? Select all that apply.

Ask the family if they would like to view the body. Provide a private place for the family to be together. Allow the family to express their emotions freely. When providing care to a family experiencing the sudden death of a member, the nurse would take the relatives to a private place where they can be together to grieve. In addition, the nurse would encourage the family to view the body if they wish and allow members to support each other and express their emotions freely. Euphemisms such as "passing on" or "going to a better place" should be avoided. Sedation is avoided because it may mask or delay the grieving process, which is necessary to achieve emotional equilibrium and prevent prolonged depression.

A patient is hemorrhaging from an open wound on his leg. The nurse implements care using the following steps. Place them in the order in which the nurse would perform them. Use all options.

Provide firm direct pressure Apply a pressure dressing Elevate the leg Immobilize the leg When a patient is hemorrhaging from a leg wound, first the nurse would apply direct firm pressure to control the bleeding. Next, the nurse would apply a pressure dressing, and elevate the injured area to stop venous and capillary bleeding if possible. Then, the area is immobilized to control blood loss.

A patient is brought to the emergency department after being locked outside of her house in the frigid weather for several hours. The nurse suspects that the patient has sustained frostbite of her hand based on which of the following findings?

Hand that is insensitive to touch Indicators of frostbite include an extremity that is hard, cold, and insensitive to touch and appears white or mottled blue-white.

An 85-year-old patient is admitted to the ED. Heat stroke is suspected. The patient’s core temperature is 106.2°F (41.2°C), blood pressure (BP) 90/60 mm Hg, and pulse 102 bpm. The nurse understands that the primary treatment measure for the patient will include which of the following?

Immersion of the patient in a cold-water bath For the patient with heat stroke, simultaneous treatment focuses on stabilizing oxygenation using the CABs (circulation, airway, and breathing) (formerly called the ABCs) of basic life support. This includes establishing IV access for fluid administration. After the patient’s clothing is removed, the core (internal) temperature is reduced to 39°C (102°F) as rapidly as possible, preferably within 1 hour. One or more of the following methods may be used as prescribed: Cool sheets and towels or continuous sponging with cool water; ice applied to the neck, groin, chest, and axillae while spraying with tepid water; and cooling blankets. Immersion of the patient in a cold-water bath is the optimal method for cooling (if available). Hydration would be with lactated Ringer’s solution. There is no indication for intubation. Administration of sodium supplements is indicated for the treatment of heat cramps.

A patient presents to the ED following a motor vehicle collision. The patient is suspected of having internal hemorrhage. The nurse assesses the patient for signs and symptoms of shock. Signs and symptoms of shock include which of the following? Select all that apply.

Cool, moist skin Decreasing blood pressure Increasing heart rate Delayed capillary refill Signs and symptoms of shock include cool, moist skin (resulting from poor peripheral perfusion), decreasing blood pressure, increasing heart rate, delayed capillary refill, and decreasing urine volume.

Which of the following solutions should the nurse anticipate for fluid replacement in the male patient?

Lactated Ringer’s solution Replacement fluids may include isotonic electrolyte solutions and blood component therapy. O negative blood is prepared for emergency use in women of childbearing age.Dextrose 5% in water should not be used to replace fluids in hypovolemic patients. Hypertonic saline is used only to treat severe symptomatic hyponatremia and should be used only in intensive care units.

A nurse is assessing a patient who is suspected of having a partial airway obstruction. Which of the following would the nurse expect to find?

Spontaneous coughing If a patient can breathe and cough spontaneously, a partial airway obstruction should be suspected. If the patient demonstrates a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis, the patient should be managed as if there were a complete airway obstruction

A nurse who is a member of an emergency response team anticipates that several patients with airway obstruction may need a cricothyroidotomy. For which of the following patients would this procedure be appropriate? Select all that apply.

Patient with extensive facial trauma Patient with an obstructed larynx Patient with laryngeal edema secondary to anaphylaxis Cricothyroidotomy is used in emergencies when endotracheal intubation is either not possible or contraindicated. Examples include airway obstruction from extensive maxillofacial trauma, cervical spine injury, laryngospasm, laryngeal edema after an allergic reaction or extubation, hemorrhage into neck tissue, and obstruction of the larynx.

A woman is brought to the emergency department by her husband, who reports that his wife "accidentally fell down a flight of steps and broke her arm." The patient is very quiet and withdrawn. During the examination, inspection reveals numerous bruises at different stages of healing over the patient’s legs, arms, and abdomen. The nurse suspects abuse. Which of the following questions would be most appropriate for the nurse to use to gather additional information?

"I’ve noticed several bruises here and there. Can you tell me what happened?" Approaching the subject of abuse requires a nonthreatening approach that allows the patient to feel comfortable and trusting of the nurse. Therapeutic communication techniques with skillful interviewing are key. Acknowledging the evidence of the bruises and then asking the patient about them is a broad opening statement that allows the patient to direct the response. It also is nonthreatening to the patient and facilitates the development of trust. Questioning the patient about her husband "beating her" indicates that the nurse already assumes this to be the case. It is threatening to the patient and may add to her anxiety and fear levels. Asking the patient if she really fell down the stairs can sound accusatory. The patient may believe the nurse is implying that the patient is lying, which would be nontherapeutic. Although it is true that the husband has no right to abuse his wife, telling the patient this and offering to call the police can be too overwhelming for her at this time.

The nurse is administering 100% oxygen to a patient with carbon monoxide poisoning and obtains a carboxyhemoglobin level. Which level would the nurse interpret as indicating that oxygen therapy can be discontinued?

4% Oxygen is administered until the carboxyhemoglobin level is less than 5%.

A family member brings a patient to the ED following an apparent oxycodone (OxyContin) overdose. The patient is experiencing severe respiratory depression. Which of the following medications will the nurse administer?

Naloxone hydrochloride (Narcan) Narcan, a narcotic antagonist, reverses respiratory depression and coma. Romazicon is a benzodiazepine antagonist. Valium is a benzodiazepine. Mucomyst is used for acetaminophen toxicity.

A patient presents to the ED complaining of choking on a chicken bone. The patient is breathing spontaneously. The nurse applies oxygen and suspects a partial airway obstruction. Which of the following should the nurse do next?

Encourage the patient to cough forcefully. If the patient can breathe and cough spontaneously, a partial obstruction should be suspected. The patient is encouraged to cough forcefully and to persist with spontaneous coughing and breathing efforts as long as good air exchange exists. There may be some wheezing between coughs. If the patient demonstrates a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis, the patient should be managed as if there were complete airway obstruction. If the person is unconscious, inspection of the oropharynx may reveal the offending object. X-ray study, laryngoscopy, or bronchoscopy also may be performed. There is no indication that an artificial airway is indicated.

A triage nurse in the ED determines that a patient with dyspnea and dehydration is not in a life-threatening situation. What triage category will the nurse choose?

Urgent A basic and widely used triage system that had been in use for many years utilized three categories: emergent, urgent, and nonurgent. In this system, emergent patients had the highest priority, urgent patients had serious health problems but not immediately life-threatening ones, and nonurgent patients had episodic illnesses.

A patient is brought to the ED by a friend, who states that a tree fell on the patient’s leg and crushed it while they were cutting firewood. What priority actions should the nurse perform? (Select all that apply.)

Applying a clean dressing to protect the wound Elevating the site to limit the accumulation of fluid in the interstitial spaces Splinting the wound in a position of rest to prevent motion Major soft tissue injuries are dressed and splinted promptly to control bleeding and pain. If an extremity is injured, it is elevated to relieve swelling and pressure.

A person suffering from carbon monoxide poisoning would exhibit which of the following manifestations?

Intoxication A person suffering from carbon monoxide poisoning appears intoxicated (from cerebral hypoxia). Other signs and symptoms include headache, muscular weakness, palpitation, dizziness, and mental confusion. The skin coloring in the patient with carbon monoxide poisoning can range from pink to cherry red to cyanotic and pale and is not a reliable diagnostic sign.

A client has a gaping wound on his forearm that is bleeding profusely. Applying pressure to which pressure point would be most helpful?

Brachial The pressure point at the brachial artery would be most appropriate because this site is proximal to the bleeding site. The femoral pressure point would be useful for bleeding in the lower extremities. The radial pressure point would be appropriate for bleeding in the wrist and hands. The subclavian pressure point would be used for bleeding in the upper anterior chest area.

A nurse is establishing a patient’s airway. Which action would the nurse perform first?

Repositioning the patient’s head Establishing an airway may be as simple as repositioning the patient’s head to prevent the tongue from obstructing the pharynx. Subsequent measures would include abdominal thrusts to dislodge a foreign body, head-tilt chin-lift or jaw-thrust manuever, or insertion of an artificial airway.

An emergency nurse has collected evidence from a patient who was shot during a robbery. The nurse is preparing to transfer the evidence to law enforcement. Which of the following would be important for the nurse to include when documenting this transfer? Select all that apply.

Time of the transfer of evidence Date that the evidence was collected Name of the law-enforcement official When transferring evidence to law enforcement, the nurse must document the chain of custody. This includes the information that evidence was transferred to the officer, the officer’s name, and the date and time of the transfer. Labels are placed on each item, but this does not need to be documented for the transfer. The names of family members witnessing the transfer also do not need to be documented.

A patient presents to the ED after an unsuccessful suicide attempt. The patient is diagnosed with an acetaminophen overdose. The nurse anticipates the administration of which of the following medications?

N-acetylcysteine (Mucomyst) Treatment of acetaminophen overdose includes administration of N-acetylcysteine (Mucomyst). Flumazenil is administered in the treatment of nonbarbiturate sedative overdoses. Naloxone (Narcan) is administered in the treatment of narcotic overdoses. Diazepam (Valium) may be administered to treat uncontrolled hyperactivity in the patient with a hallucinogen overdose.

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

Unconscious adult A finger sweep should be used only in the unconscious adult patient. This action draws the tongue away from the back of the throat and away from the foreign body that may be lodged there. A finger sweep should not be done on a conscious adult, child, or adolescent.

As part of an emergency department team, an emergency nurse is conducting a secondary survey on a client. Which of the following would the nurse include?

Applying electrocardiogram electrodes A secondary survey is completed after the primary survey priorities of airway, breathing, circulation, and disability have been addressed. Applying electrocardiogram electrodes would be a component of the secondary survey. Establishing a patent airway, providing adequate ventilation, and determining neurologic disability by assessing neurologic function are components of the primary survey.

A patient has undergone a diagnostic peritoneal lavage. The nurse interprets which result as indicating a positive test?

Evidence of feces A diagnostic peritoneal lavage is considered positive if there is bile, feces, or food in the specimen, a red blood cell count greater than 100,000/mm3, and a white blood cell count greater than 500/mm3.

After inserting an oropharyngeal airway, the nurse determines that it is in the proper position when the flange is located at which position?

Approximately at the patient’s lips When an oropharyngeal airway is properly inserted, the tip is in the hypopharynx and the flange is approximately at the patient’s lips.

A patient with intra-abdominal injuries is brought to the emergency department. Which of the following would most likely alert the nurse to suspect internal bleeding secondary to a ruptured spleen?

Pain in the left shoulder Pain in the left shoulder is common in a patient with bleeding from a ruptured spleen. Pain in the right shoulder is consistent with a laceration of the liver. The spleen is located in the left upper quadrant, not the right. Rebound tenderness and abdominal distention are generalized signs suggesting intraperitoneal injury. Although these generalized signs may accompany a ruptured spleen, they are less specific than pain in the left shoulder.

Nursing students are reviewing information about anaphylactic reactions and their possible causes. The students demonstrate understanding of this information when they identify which of the following as a common cause? Select all that apply.

Insect stings Medications Latex Eggs Shellfish Common causes of anaphylactic reactions include insect stings, medications (eg, penicillin, iodinated-contrast materials), latex, insect stings, eggs, peanuts, and shellfish. Green vegetables typically are not associated with anaphylaxis.

A patient is brought to the emergency department following an overdose of a selective serotonin reuptake inhibitor (SSRI). While assessing the patient, the nurse suspects that the patient may be developing serotonin syndrome based on which of the following?

Seizures Serotonin syndrome is manifested by agitation, seizures, hyperthermia, diaphoresis, and hypertension.

The ED staff work collaboratively and follow the ABCDE method to establish and treat health priorities in a trauma patient effectively. Which of the following actions is completed by the nurse when implementing the "D" element of this method?

Assessing the patient’s Glasgow Coma Scale The primary survey focuses on stabilizing life-threatening conditions. The ED staff work collaboratively and follow the ABCDE (airway, breathing, circulation, disability, exposure) method. While implementing the D element, the nurse determines neurologic disability by assessing neurologic function using the Glasgow Coma Scale and a motor and sensory evaluation of the spine. A quick neurologic assessment may be performed using the AVPU mnemonic: A, alert: is the patient alert and responsive? V, verbal: does the patient respond to verbal stimuli? P, pain: does the patient respond only to painful stimuli? U, unresponsive: is the patient unresponsive to all stimuli, including pain? The other interventions are not included in this element of the primary survey.

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