Prep U CH 67 Emergency Nursing

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

Stomach

Large intestine

Kidneys

Liver

Explanation:

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.

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?

Swimming in a lake

Diving in an ocean

Running a race in hot humid weather

Working in a chemical plant

Diving in an ocean

Explanation:

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.

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?

Laceration

Avulsion

Stab

Patterned

Stab

Explanation:

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 6-year-old is admitted to the ED after being rescued from a pond after falling through the ice while ice skating. What action should the nurse perform while rewarming the client?

Assessing the client's oral temperature frequently

Ensuring continuous ECG monitoring

Massaging the client's skin surfaces to promote circulation Administering bronchodilators by nebulizer

Ensuring continuous ECG monitoring

Explanation:

A hypothermic client requires continuous ECG monitoring and assessment of core temperatures with an esophageal probe, bladder, or rectal thermometer.

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

Applying antimicrobial ointment

Administering tetanus prophylaxis

Covering the area with a sterile dressing

Rinsing the area with copious amounts of water

Rinsing the area with copious amounts of water

Explanation:

The priority for any chemical burn is to immediately drench the area with running water, unless the chemical is lye or white phosphorus, which should be brushed off the patient.

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

Tissue tearing away from supporting structures

Incision of the skin with well-defined edges, usually long rather than deep

Skin tear with irregular edges and vein bridging

Denuded skin

Tissue tearing away from supporting structures

Explanation:

An avulsion is described as a tearing away of tissue from supporting structures.

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.

Check the client's record for the name of a family member to call to allow care to be provided.

Ask the ambulance team for information about the client's family to ensure informed consent.

Explain to the client that care is going to be provided because he is seriously ill.

Document the client's condition and absence of friends or family for obtaining consent to treatment.

Explanation:

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.

A client is brought to the emergency department with injuries obtained from a motor vehicle crash. Which action will the nurse take during the secondary survey of the client? Select all that apply.

Maintenance of airway

Head-to-toe assessment

Results of laboratory tests

History of the current event

Splinting of suspected fractures

Head-to-toe assessment

Results of laboratory tests

History of the current event

Splinting of suspected fractures

Explanation:

A systematic approach to effectively establishing and treating health priorities is the primary survey/secondary survey approach. Actions when completing the secondary survey include completing a head-to-toe assessment, reviewing the results of laboratory tests, collecting information about the current event, and splinting any suspected fractures.

An 83-year-old client is brought in by ambulance from a long-term care facility. The client's symptoms are weakness, lethargy, incontinence, and a change in mental status. The nurse knows that emergencies in older adults may be more difficult to manage for what reason?

Older adults may have an altered response to treatment.

Older adults are often reluctant to adhere to prescribed treatment.

Older adults have difficulty giving a health history.

Older adults often stigmatize their peers who use the ED.

Older adults may have an altered response to treatment.

Explanation:

Emergencies in this age group may be more difficult to manage because elderly clients may have an atypical presentation, an altered response to treatment, a greater risk of developing complications, or a combination of these factors.

The nurse has received a client into care who was admitted with a heroin overdose. The client has a 5-year history of illicit substance use with cocaine, heroine and oxycodone. The client develops a sudden onset of wheezing, restlessness and a cough that produces a frothy, pink sputum. The nurse suspects the client has most likely developed which complication of opioid overdose?

Pulmonary edema

Pneumonia

Congestive heart failure

Panic attack

Pulmonary edema

Explanation:

The nurse should suspect the client has developed pulmonary edema, which is frequently seen in clients who abuse/overdose on narcotics. Many drugs — ranging from illegal drugs such as heroin and cocaine to aspirin — are known to cause noncardiogenic pulmonary edema. Pneumonia is not the likely cause given the sudden onset of respiratory symptoms accompanied but coughing up the pink frothy sputum. The client's history of illicit substance use and now overdose on these drugs should lead the nurse to suspect pulmonary edema is the cause of the sudden onset of these symptoms over congestive heart failure, in which clients have a more gradual onset of respiratory issues.

A client is brought to the ED by friends. The friends tell the nurse that the client was using cocaine at a party. On arrival to the ED the client is in visible distress with an axillary temperature of 40.1ºC (104.2°F). What would be the priority nursing action for this client?

Monitor cardiovascular effects.

Administer antipyretics.

Ensure airway and ventilation.

Prevent seizure activity.

Ensure airway and ventilation.

Explanation:

Although all of the listed actions may be necessary for this client's care, the priority is to establish a patent airway and adequate ventilation.

Which solid organ is most frequently injured in a penetrating trauma?

Lung

Liver

Pancreas

Brain

Liver

Explanation:

The most frequently injured solid organ in a penetrating trauma is the liver because of its size and anterior placement in the right upper quadrant of the abdomen.

A client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later, the nurse identifies which finding as an early sign of shock?

Increasing heart rate

Pale, warm, dry skin

Heart rate of 70 beats/minute

Elevated blood pressure

Increasing heart rate

Explanation:

Early in shock, heart rate increases. Inadequate tissue perfusion causes pale, cool, clammy skin (not pale, warm, dry skin). In the early stages of shock, the client's heart rate will become elevated above normal. In early shock the client's blood pressure will remain normal, but as shock progresses the mechanisms that regulate blood pressure will not be able to compensate.

The nurse has come on shift to find that a client newly admitted to the ICU is confused and persistently trying to get out of bed despite being comforted and re-oriented by the nurse. The client begins to pull on the peripheral intravenous line in the hand and speaking in non-sensical terms. The client's history indicates a sudden onset of neurological symptoms after developing a bacterial infection. The nurse anticipates providing care for which health problem?

Delirium

Pain

Anxiety

Fever

Delirium

Explanation:

Delirium is a confused state that has a sudden onset and can last hours to days or weeks; it is characterized by hyperactivity and has the potential to be reversible. The client who quickly becomes confused and agitated while attempting to pull out IV lines and get out of bed is experiencing delirium. The nurse caring for this client should anticipate the need to provide close monitoring to prevent injury.

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?

Anaphylaxis

Sepsis

Hypovolemia

Cardiac dysfunction

Hypovolemia

Explanation:

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

A client is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the health care provider will perform which of the following actions?

Insert an oropharyngeal airway.

Perform the jaw thrust maneuver.

Perform endotracheal intubation.

Perform a cricothyroidotomy.

Perform endotracheal intubation.

Explanation:

Endotracheal tubes are used in cases when the client cannot be ventilated with an oropharyngeal airway, which is used in clients who are breathing spontaneously.

The nurse educator is explaining the difference between indications for nasopharyngeal airway insertion versus endotracheal intubation. Which responses from learners indicate correct reasons for the use of endotracheal tubes in clients? Select all that apply.

To support ventilation in a client with basal skull trauma

To provide airway support to a client with facial trauma

To bypass an upper airway obstruction

To support connecting to mechanical ventilation

To facilitate removal of tracheobronchial secretions

To bypass an upper airway obstruction

To support connecting to mechanical ventilation

To facilitate removal of tracheobronchial secretions

Explanation:

Endotracheal intubation is indicated to establish an airway for a client who cannot be adequately ventilated with an oropharyngeal or nasopharyngeal airway, bypass an upper airway obstruction, prevent aspiration, permit connection of the client to a resuscitation bag or mechanical ventilator, or facilitate the removal of tracheobronchial secretions.

When providing care to a client who has experienced multiple trauma, which of the following would be most important for the nurse to keep in mind?

The client is assumed to have a spinal cord injury until proven otherwise.

The most lethal injuries are often the most readily apparent.

Most multiple trauma victims exhibit evidence of the trauma. Injuries have occurred to at least three distinct organ systems.

The client is assumed to have a spinal cord injury until proven otherwise.

Explanation:

With clients experiencing multiple trauma, the nurse must assume that the client has a spinal cord injury until proven otherwise. Multiple trauma clients experience life-threatening injuries to at least two distinct organs or organ systems.

Which medication reverses severe respiratory depression and coma?

Naloxone hydrochloride

Diazepam

Flumazenil

N-acetylcysteine

Naloxone hydrochloride

Explanation:

Naloxone hydrochloride, a narcotic antagonist, reverses respiratory depression and coma.

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

Collecting semen

Performing the pelvic examination

Obtaining consent for examination

Supporting the client's emotional status

Supporting the client's emotional status

Explanation:

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.

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

Administer analgesic medications as ordered.

Keep the hand in the circulating bath for 1 hour.

Rupture any hemorrhagic blebs that are noted.

Have the client complete active range-of-motion exercises.

Administer analgesic medications as ordered.

Explanation:

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.

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

"I should always wear something on my feet when I'm outside." "Brightly colored clothes help to ward off bees."

"If a bee comes near me, I should stay still."

"I need to avoid using perfumes and scented soaps when I'm going outside."

"Brightly colored clothes help to ward off bees."

Explanation:

To prevent insect stings, the client should avoid wearing brightly colored clothing because it attracts bees.

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

pulmonary edema.

hypothermia.

hyponatremia.

head injury.

pulmonary edema.

Explanation:

Resultant pathophysiologic changes and pulmonary injury depend on the type of fluid (fresh or salt water) and the volume aspirated. Freshwater aspiration results in a loss of surfactant and therefore an inability to expand the lungs. Saltwater aspiration leads to pulmonary edema from the osmotic effects of the salt within the lungs. If a person survives submersion, acute respiratory distress syndrome, resulting in hypoxia, hypercarbia, and respiratory or metabolic acidosis, can occur. The client would experience hypernatremia.

The nurse received a patient from a motor vehicle accident who is hemorrhaging from a femoral wound. What is the initial nursing action for the control of the hemorrhage?

Apply a tourniquet.

Apply firm pressure over the involved area or artery.

Elevate the injured part.

Immobilize the area to control blood loss.

Apply firm pressure over the involved area or artery.

Explanation:

Direct, firm pressure is applied over the bleeding area or the involved artery at a site that is proximal to the wound (Fig. 72-3). Most bleeding can be stopped or at least controlled by application of direct pressure. Otherwise, unchecked arterial bleeding results in death. A firm pressure dressing is applied, and the injured part is elevated to stop venous and capillary bleeding, if possible. If the injured area is an extremity, the extremity is immobilized to control blood loss.

A 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?

Dilution with water or milk

Gastric lavage

Administration of activated charcoal

Induced vomiting

Induced vomiting

Explanation:

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 client is admitted to the ED after being involved in a motor vehicle accident. The client has multiple injuries. After establishing an airway and adequate ventilation, the ED team should prioritize what aspect of care?

Control the client's hemorrhage.

Assess for cognitive effects of the injury.

Splint the client's fractures.

Assess the client's neurologic status.

Control the client's hemorrhage.

Explanation:

After establishing airway and ventilation, the team should evaluate and restore cardiac output by controlling hemorrhage. This must precede neurologic assessments and treatment of skeletal injuries.

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

Red blood cell count of 50,000/mm3

White blood cell count of 300/mm3

Absence of bile

Evidence of feces

Evidence of feces

Explanation:

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.

A client is admitted to the ED with suspected alcohol intoxication. The ED nurse is aware of the need to assess for conditions that can mimic acute alcohol intoxication. In light of this need, the nurse should perform what action?

Check the client's blood glucose level.

Assess for a documented history of major depression.

Determine whether the client has ingested a corrosive substance. Arrange for assessment of serum potassium levels.

Check the client's blood glucose level.

Explanation:

Hypoglycemia can mimic alcohol intoxication and should be assessed in a client suspected of alcohol intoxication.

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.)

Have the patient shower or wash the perineal area before the examination.

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.

Ensure that the police are present when the examination is performed.

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 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.

Send the patient for a chest x-ray.

Send the patient to the hyperbaric chamber.

Draw labs for a chemistry panel.

Ensure a patent airway and that the patient is receiving 100% oxygen.

Explanation:

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 patient is brought to the emergency department. Assessment reveals that the patient is lethargic and diaphoretic and complaining of right upper quadrant pain. Acetaminophen toxicity is suspected and an acetaminophen level is drawn. Which result would the nurse interpret as indicating toxicity for the patient if he weighs 70 kg?

6300 mg

7700 mg

9100 mg

10,500 mg

10,500 mg

Explanation:

An acetaminophen level greater than or equal to 140 mg/kg would be considered toxic. For a patient weighing 70 kg, the toxic level would be 9800 mg. A level of 10,500 mg would be greater, thus indicating toxicity.

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

Motor-vehicle crash

Fall from a roof

Being struck with a baseball bat

Gunshot wound

Knife-stab wound

Explanation:

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.

Which of the following statements would most lead a nurse to suspect that a patient is experiencing food poisoning?

"I've been feeling sick to my stomach for about 3 or 4 days now." "The food I ate seemed to look and taste like it should."

"My brother got sick like me after eating the same food."

"I have a pain in my left side, down low near my groin."

"My brother got sick like me after eating the same food."

Explanation:

The statement about the patient's brother also being sick after eating the same food suggests food poisoning.

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?

Bradycardia

Rising blood pressure

Delayed capillary refill

Pale pink dry skin

Delayed capillary refill

Explanation:

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

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

Inserting an indwelling catheter

Splinting the wound in a position of rest to prevent motion

Performing a fasciotomy

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

Explanation:

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 client is brought to the ED by family members who tell the nurse that the client has been exhibiting paranoid, agitated behavior. What should the nurse do when interacting with this client?

Keep the client in a confined space.

Use therapeutic touch appropriately.

Give the client honest answers about likely treatment.

Attempt to convince the client that his or her fears are unfounded.

Give the client honest answers about likely treatment.

Explanation:

The nurse should offer appropriate and honest explanations in order to foster rapport and trust.

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

1 to 2 minutes

3 to 5 minutes

6 to 8 minutes

9 to 10 minutes

3 to 5 minutes

Explanation:

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

The nurse is caring for a client who is being prepared for the placement of a central intravenous line. The nurse recognizes this client requires this type of intravenous access for which reason?

The client will require intravenous access for three days

The client requires total parenteral nutrition

The client requires infusion of intravenous antibiotics

The client requires infusion of a dextrose 5% water (D5W)

The client requires total parenteral nutrition

Explanation:

For a patient who requires total parenteral nutrition (TPN), a central intravenous line is required due to the length of time the client will require the infusion as well as the nature of the solution itself. A large vein is required to safely infuse TPN. For this reason, a central line is needed.

Several clients in the emergency department are being categorized by the triage nurse. Which client will the nurse place in the urgent category?

A 24-year-old client with multiple gunshot wounds to the chest, arms, and legs

A 54-year-old client with a history of diabetes presenting with anemia and abdominal pain

A 56-year-old client with a cut to the left hand that requires wound debridement and stitches

A 60-year-old client presenting with chest pain and ST elevation on electrocardiogram

A 54-year-old client with a history of diabetes presenting with anemia and abdominal pain

Explanation:

A basic and widely used triage system utilizes three categories: emergent, urgent, and nonurgent. In this system emergent patients have the highest priority, urgent patients had serious health problems but not immediately life-threatening ones, and nonurgent patients had episodic illnesses. The client with diabetes presenting with anemia and abdominal pain would be the most likely candidate considered as urgent because they have serious health problems but not immediately and obviously life-threatening ones.

The nurse has commenced a transfusion of fresh frozen plasma (FFP) and notes the client is exhibiting symptoms of a transfusion reaction. After the nurse stops the transfusion, what is the next required action?

Remove the peripheral IV line

Start a dextrose 5% water infusion

Run a normal saline line to keep the vein open

Obtain a blood culture from the IV insertion site

Run a normal saline line to keep the vein open

Explanation:

If the nurse suspects a transfusion reaction, the transfusion must be stopped immediately and the nurse's next action is to ensure the normal saline line is running at a rate that permits administration of IV fluids or medications that are required to treat the reaction. The nurse should ensure IV access is maintained. The "to keep vein open" (TKVO) rate allows the nurse to keep the IV client without the potential to cause fluid volume overload. It would be unsafe for the nurse to remove the peripheral IV because continued access is required for urgent IV administration of medications or fluids to treat the reaction.

A client with depression and behavioral changes is transferred from a local assisted living center to the emergency department. The nurse notes that the client cries out when she approaches. When the nurse gains the client's confidence and performs an assessment, the nurse notes bruising of the labia and a lateral laceration in the perineal area. When the nurse asks the client about the injury, the client shakes her head and begins to cry "don't tell, don't tell." The nurse suspects sexual abuse. How should the nurse proceed?

Notify the physician of her findings immediately.

Attend to the client's physiological needs.

Notify the client's family.

Notify the rape crisis team.

Attend to the client's physiological needs.

Explanation:

The nurse should attend to the client's immediate physiological needs, including physical safety. Next, the nurse can notify the physician and the rape crisis team. The family should be notified if the client consents, but not until the rape investigation is complete.

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.

Talk with the family about the client having "passed on."

Provide sedation to family members as needed.

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.

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.

Explanation:

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.

The nurse is caring for an intensive care unit client who has died with family members at the bedside. The death was sudden and unexpected resulting from a car accident that took place three days ago. The family is upset and the client's partner, crying loudly, yells, "How did this happen? We were just about to celebrate his birthday. He can't be gone!" The family member continues to cry inconsolably. How should the nurse respond?

" I will get you some medication that will help you feel more calm."

"He has passed on to a better place now."

"It is important to face the reality that he is gone."

"We did everything we could possibly do to try to save his life."

"We did everything we could possibly do to try to save his life."

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 I

Stage II

Stage III

Stage IV

Stage III

Explanation:

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.

The nurse is caring for a client with diabetes who requires a peripheral intravenous (PIV) line for antibiotic administration and to treat dehydration. The nurse must avoid inserting which type of PIV?

Forearm

Hand

Foot

Upper arm

Foot

Explanation:

PIV lines should rarely be used in the foot for various reasons. They limit the client's ability to ambulate and tend to occlude easily. These types of IVs should never be used in clients with diabetes due to the risk that the client has neuropathy and cannot feel injury caused by the IV catheter.

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

Protecting themselves

Securing the area

Gaining control of the situation

Providing care to the injured

Protecting themselves

Explanation:

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 triage nurse determines that a client with non-life-threatening injuries requires imaging studies and moderate sedation. The triage nurse would document this client as which of the following?

Resuscitation

Emergent

Urgent

Nonurgent

Urgent

Explanation:

Clients who have non-life-threatening conditions but require two or more resources to provide their care would be classified as urgent. In this situation, the client would be considered urgent because he requires imaging studies (one resource) and moderate sedation (a two-resource procedure).

A client presents to the ED with serious health problems that are not immediately life threatening. The nurse will correctly triage the client into which category?

Emergent

Urgent

Nonurgent

Psychological support

Urgent

Explanation:

Clients triaged as urgent have serious health problems that are not immediately life threatening. They must be seen within 1 hour. The emergent category is for clients who have the highest priority conditions that are life-threatening and they must be seen immediately.

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

Emergent

Urgent

Nonurgent

Psychological support

Urgent

Explanation:

Urgent clients have serious health problems that not immediately life threatening. They must be seen within 1 hour. Emergent clients have the highest priority with life-threatening conditions and they must be seen immediately.

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?

Establishing a patent airway

Providing adequate ventilation

Assessing neurologic function

Applying electrocardiogram electrodes

Applying electrocardiogram electrodes

Explanation:

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.

The nurse observes that the family members of a client who was injured in an accident are blaming each other for the circumstances leading up to the accident. The nurse appropriately lets the family members express their feelings of responsibility, while explaining that there was probably little they could do to prevent the injury. In what stage of crisis is this family?

Anxiety and denial

Remorse and guilt

Anger

Grief

Remorse and guilt

Explanation:

Remorse and guilt are natural processes of the stages of a crisis and should be facilitated for the family members to process the crisis. The family's sense of blame and responsibility are more suggestive of guilt than anger, grief, or anxiety.

The health care team in an intensive care unit have experienced a critical incident in which a young client died unexpectedly and the client's father physically attacked the senior physician treating the client. The client's father was arrested and escorted from the intensive care unit by police, against his will and in handcuffs. A critical incident stress management (CISM) staff meeting held 3 days after the incident took place. What would be the purpose for that meeting?

Counselling

Defusing

Debriefing

Follow up

Debriefing

Explanation:

After serious events, critical incident stress management (CISM) is necessary to critique individual and group performance and to facilitate healthy coping. Optimally, this may consist of three steps: defusing, debriefing, and follow-up. Debriefing typically occurs 1 to 10 days after the critical incident. Debriefing sessions follow a format similar to the initial defusing session; however, during these sessions, participating staff are encouraged to discuss their feelings about the incident and are reassured that their negative reactions and feelings are normal and that their negative feelings will diminish over time.

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.

1Provide firm direct pressure

2Apply a pressure dressing

3Elevate the leg

4Immobilize the leg

Provide firm direct pressure

Apply a pressure dressing

Elevate the leg

Immobilize the leg

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

Encourage the client to cough forcefully.

Insert a nasopharyngeal airway.

Prepare the client for a bronchoscopy.

Insert an oropharyngeal airway.

Encourage the client to cough forcefully.

Explanation:

If the client can breathe and cough spontaneously, a partial obstruction should be suspected. The client 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.

Which of the following would the nurse identify as indicating that a client is experiencing a complete airway obstruction? Select all that apply.

Inability to speak

Clutching of the neck

Stridor

Spontaneous coughing

Cyanosis

Inability to speak

Clutching of the neck

Stridor

Cyanosis

Explanation:

Manifestations of a complete airway obstruction include the inability to speak, breathe, or cough; clutching the neck; inspiratory and expiratory stridor; and cyanosis (a late sign). If the client can cough spontaneously, then a partial airway obstruction is most likely.

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 a lumbar spine injury

Patient with laryngeal edema secondary to anaphylaxis

Patient who is bleeding from the chest

Patient with an obstructed larynx

Patient with extensive facial trauma

Patient with laryngeal edema secondary to anaphylaxis

Patient with an obstructed larynx

Explanation:

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 client undergoes a total abdominal hysterectomy. When assessing the client 10 hours later, the nurse identifies which finding as an early sign of shock?

Increasing heart rate

Pale, warm, dry skin

Heart rate of 70 beats/minute

Elevated blood pressure

Increasing heart rate

Explanation:

Early in shock, heart rate increases. Inadequate tissue perfusion causes pale, cool, clammy skin (not pale, warm, dry skin). In the early stages of shock, the client's heart rate will become elevated above normal. In early shock the client's blood pressure will remain normal, but as shock progresses the mechanisms that regulate blood pressure will not be able to compensate.

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?

Delayed

Emergent

Immediate

Urgent

Urgent

Explanation:

A basic and widely used triage system that had been in use for many years utilized three categories: emergent, urgent, and nonurgent.

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

Assessing the client's Glasgow Coma Scale score

Managing hypothermia

Providing cervical spine protection

Undressing the client quickly

Assessing the client's Glasgow Coma Scale score

Explanation:

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 performing a motor and sensory evaluation of the spine.

The nurse is assigned to a client admitted to the ICU from the emergency department. The client sustained multiple injuries from a motor vehicle accident. When reviewing the client chart, the notes indicate the client's emergency care was managed in what sequence of steps?

1Establish airway and start ventilation

2Application of pressure to control abdominal bleeding

3Start peripheral intravenous insertion and infusion of fluids

4Assess for head and neck injuries

5Examine client for additional injuries to the body

6Reassess pulses and neurovascular status

Establish airway and start ventilation

Application of pressure to control abdominal bleeding

Start peripheral intravenous insertion and infusion of fluids

Assess for head and neck injuries

Examine client for additional injuries to the body

Reassess pulses and neurovascular status

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?

9%

7%

6%

4%

4%

Explanation:

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

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?

Temperature of 101 degrees F (38 degrees C)

Diaphoresis

Delirium

Bradycardia

Delirium

Explanation:

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 suspects an older adult is experiencing heat stroke based on which assessment findings? Select all that apply.

Temperature 105 degrees F (40.6 degrees C)

Lack of sweating

Increased thirst

Weakness

Delirium

Bradypnea

Temperature 105 degrees F (40.6 degrees C)

Lack of sweating

Delirium

Explanation:

A patient with heat stroke typically exhibits a temperature of 105 degrees F (40.6 degrees C) or higher; profound central nervous system dysfunction; hot, dry skin; anhidrosis (absence of sweating); tachypnea; hypotension; and tachycardia. Increased thirst and weakness would suggest heat exhaustion.