EMERGENCY NURSING CARE 1.

You are the charge nurse in an emergency department (ED) and must assign two staff members to cover the triage area. Which team is the most appropriate for this assignment? a. An advanced practice nurse and an e perienced !"#$!%# b. An e perienced !"#$!%# and an ine perienced &# c. An experienced RN and an inexperienced RN d. An e perienced &# and a nursing assistant '. You are wor(ing in the triage area of an ED) and four patients approach the triage des( at the same time. !ist the order in which you wi** assess these patients.BADC a. An ambu*atory) da+ed ',-year-o*d ma*e with a bandaged head wound b. An irritab*e infant with a fever) petechiae) and nucha* rigidity c. A .,-year-o*d /ogger with a twisted an(*e) having peda* pu*se and no deformity d. A ,0-year-o*d fema*e with moderate abdomina* pain and occasiona* vomiting 11111) 11111) 11111) 1111 .. 2n conducting a primary survey on a trauma patient) which of the fo**owing is considered one of the priority e*ements of the primary survey? a. 3omp*ete set of vita* signs b. "a*pation and auscu*tation of the abdomen c. Brief neurologic assessmen d. 2nitiation of pu*se o imetry 4. A ,5-year-o*d patient presents in triage with *eft-sided chest pain) diaphoresis) and di++iness. 6his patient shou*d be prioriti+ed into which category? a. 7igh urgent b. 8rgent c. #on-urgent d. Emergen ,. 6he physician has ordered coo*ing measures for a chi*d with fever who is *i(e*y to be discharged when the temperature comes down. Which of the fo**owing wou*d be appropriate to de*egate to the nursing assistant? a. Assis !e c!ild o remo"e ou er clo !ing. b. Advise the parent to use acetaminophen instead of aspirin. c. E p*ain the need for coo* f*uids. d. "repare and administer a tepid bath. 5. 2t is the summer season) and patients with signs and symptoms of heat-re*ated i**ness present in the ED. Which patient needs attention first? a. An e*der*y person comp*ains of di++iness and syncope after standing in the sun for severa* hours to view a parade b. A marathon runner comp*ains of severe *eg cramps and nausea. 6achycardia) diaphoresis) pa**or) and wea(ness are observed. c. A previous*y hea*thy homema(er reports bro(en air conditioner for days. 6achypnea) hypotension) fatigue) and profuse diaphoresis are observed. d. A !omeless person# poor !is orian# presen s $i ! al ered men al s a us# poor muscle coordina ion# and !o # dr%# as!en s&in. Dura ion of exposure is un&no$n. 9. You respond to a ca** for he*p from the ED waiting room. 6here is an e*der*y patient *ying on the f*oor. !ist the order for the actions that you must perform. :DA3E a. "erform the chin *ift or /aw thrust maneuver. b. Estab*ish unresponsiveness. c. 2nitiate cardiopu*monary resuscitation (3"&). d. 3a** for he*p and activate the code team. e. 2nstruct a nursing assistant to get the crash cart. ;. 6he emergency medica* service (E<=) has transported a patient with severe chest pain. As the patient is being transferred to the emergency stretcher) you note unresponsiveness) cessation of breathing) and no pa*pab*e pu*se. Which tas( is appropriate to de*egate to the nursing assistant? a. C!es compressions b. :ag-va*ve mas( venti*ation c. Assisting with ora* intubation d. "*acing the defibri**ator pads >. An an ious '4-year-o*d co**ege student comp*ains of ting*ing sensations) pa*pitations) and chest tightness. Deep) rapid breathing and carpa* spasms are noted. What priority nursing action shou*d you ta(e? a. #otify the physician immediate*y. b. Administer supp*ementa* o ygen. c. 'a"e !e s uden (rea !e in o a paper (ag. d. ?btain an order for an an io*ytic medication. 10.An e perienced trave*ing nurse has been assigned to wor( in the ED@ however) this is the nurseAs first wee( on the /ob. Which area of the ED is the most appropriate assignment for the nurse? a. 6rauma team b. 6riage c. Am(ula or% or fa s rac& clinic d. "ediatric medicine team

11.A tearfu* parent brings a chi*d to the ED for ta(ing an un(nown amount of chi*drenAs chewab*e vitamins at an un(nown time. 6he chi*d is current*y a*ert and asymptomatic. What information shou*d be immediate*y reported to the physician? a. )!e inges ed c!ildren*s c!e$a(le "i amins con ain iron. b. 6he chi*d has been treated severa* times for ingestion of to ic substances. c. 6he chi*d has been treated severa* times for accidenta* in/uries. d. 6he chi*d was nauseated and vomited once at home. 1'.2n caring for a victim of se ua* assau*t) which tas( is most appropriate for an !"#$!%#? a. Assess immediate emotiona* state and physica* in/uries b. 3o**ect hair samp*es) sa*iva swabs) and scrapings beneath fingernai*s. c. +ro"ide emo ional suppor and suppor i"e communica ion. d. Ensure that the Bchain of custodyC is maintained. 1..You are caring for a victim of frostbite to the feet. "*ace the fo**owing interventions in the correct order. CBDA a. App*y a *oose) steri*e) bu*(y dressing. b. Dive pain medication. c. &emove the victim from the co*d environment. d. 2mmerse the feet in warm water 100o E to 10,o E (40.5o 3 to 45.1o 3) 11111) 11111) 11111) 11111 14.A patient sustains an amputation of the first and second digits in a chainsaw accident. Which tas( shou*d be de*egated to the !"#$!%#? a. Dent*y c*eanse the amputated digits with :etadine so*ution. b. "*ace the amputated digits direct*y into ice s*urry. c. ,rap !e ampu a ed digi s in s erile gau-e mois ened $i ! saline. d. =tore the amputated digits in a so*ution of steri*e norma* sa*ine. 1,.A .5-year-o*d patient with a history of sei+ures and medication comp*iance of phenytoin (Di*antin) and carbama+epine (6egreto*) is brought to the ED by the <= personne* for repetitive sei+ure activity that started 4, minutes prior to arriva*. You anticipate that the physician wi** order which drug for status epi*epticus? a. "? phenytoin and carbama+epine (. I. lora-epam /A i"an0 c. 2% carbama+epam d. 2% magnesium su*fate 15.You are preparing a chi*d for 2% conscious sedation prior to repair of a facia* *aceration. What information shou*d you immediate*y report to the physician? a. 6he parent is unsure about the chi*dAs tetanus immuni+ation status. b. 6he chi*d is upset and pu**s out the 2%. c. )!e paren declines !e I. conscious seda ion. d. 6he parent wants information about the 2% conscious sedation. 19.An into icated patient presents with s*urred speech) mi*d confusion) and uncooperative behavior. 6he patient is a poor historian but admits to Bdrin(ing a few on the wee(end.C What is the priority nursing action for this patient? a. ?btain an order for a b*ood a*coho* *eve*. b. 3ontact the fami*y to obtain additiona* history and base*ine information. c. Administer na*o one (#arcan) ' F 4 mg as ordered. d. Adminis er I. fluid suppor $i ! supplemen al !iamine as ordered. 1;.When an une pected death occurs in the ED) which of the fo**owing tas(s is most appropriate to de*egate to the nursing assistant? a. Escort the fami*y to a p*ace of privacy. b. Do with the organ donor specia*ist to ta*( to the fami*y. c. Assis $i ! pos mor em care. d. Assist the fami*y to co**ect be*ongings. 1>.Eo**owing emergency endotrachea* intubation) you must verify tube p*acement and secure the tube. !ist in order the steps that are reGuired to perform this function? CDBA a. ?btain an order for a chest -ray to document tube p*acement. b. =ecure the tube in p*ace. c. Auscu*tate the chest during assisted venti*ation. d. 3onfirm that the breath sounds are eGua* and bi*atera*. 11111) 11111) 11111) 11111 '0.A teenager arrives by private car. 7e is a*ert and ambu*atory) but this shirt and pants are covered with b*ood. 7e and his hysterica* friends are ye**ing and trying to e p*ain that that they were goofing around and he got po(ed in the abdomen with a stic(. Which of the fo**owing comments shou*d be given first consideration? a. B6here was a *ot of b*ood and we used three bandages.C (. 1'e pulled !e s ic& ou # 2us no$# (ecause i $as !ur ing !im.3 c. B6he stic( was rea**y dirty and covered with mud.C d. B7eAs a diabetic) so he needs attention right away.C '1.A prisoner) with a (nown history of a*coho* abuse) has been in po*ice custody for 4; hours. 2nitia**y) an iety) sweating) and tremors were noted. #ow) disorientation) ha**ucination) and hyper-reactivity are observed. 6he medica* diagnosis is de*irium tremens. What is the priority nursing diagnosis? a. Ris& for In2ur% rela ed o sei-ures b. &is( for ?ther-Directed %io*ence re*ated to ha**ucinations c. &is( for =ituationa* !ow =e*f-esteem re*ated to po*ice custody d. &is( for #utritiona* Deficit re*ated to chronic a*coho* abuse

''.You are assigned to te*ephone triage. A patient who was stung by a common honey bee ca**s for advice) reports pain and *oca*i+ed swe**ing) but denies any respiratory distress or other systemic signs of anaphy*a is. What is the action that you shou*d direct the ca**er to perform? a. 3a** >11. (. Remo"e !e s inger (% scraping. c. App*y a coo* compress. d. 6a(e an ora* antihistamine. '..2n re*ation to submersion in/uries) which tas( is most appropriate to de*egate to an !"#$!%#? a. 6a*( to a community group about water safety issues. b. =tabi*i+e the cervica* spine for an unconscious drowning victim. c. &emove wet c*othing and cover the victim with a warm b*an(et. d. Moni or an as%mp oma ic near4dro$ning "ic im. '4.You are assessing a patient who has sustained a cat bite to the *eft hand. 6he cat is up-to-date immuni+ations. 6he date of the patientAs *ast tetanus shot is un(nown. Which of the fo**owing is the priority nursing diagnosis? a. Ris& for Infec ion rela ed o organisms specific o ca (i es b. 2mpaired =(in 2ntegrity re*ated to puncture wounds c. 2neffective 7ea*th <aintenance re*ated to immuni+ation status d. &is( for 2mpaired <obi*ity re*ated to potentia* tendon damage ',.6hese patients present to the ED comp*aining of acute abdomina* pain. "rioriti+e them in order of severity. DBCA a. A .,-year-o*d ma*e comp*aining of severe) intermittent cramps with three episodes of watery diarrhea) ' hours after eating b. A 11-year-o*d boy with a *ow-grade fever) *eft *ower Guadrant tenderness) nausea) and anore ia for the past ' days c. A 40-year-o*d fema*e with moderate *eft upper Guadrant pain) vomiting sma** amounts of ye**ow bi*e) and worsening symptoms over the past wee( d. A ,5-year-o*d ma*e with a pu*sating abdomina* mass and sudden onset of pressure-*i(e pain in the abdomen and f*an( within the past hour 11111) 11111) 11111) 11111 '5.6he nursing manager decides to form a committee to address the issue of vio*ence against ED personne*. Which combination of emp*oyees is best suited to fu*fi** this assignment? a. ED p!%sicians and c!arge nurses b. E perienced &#s and e perienced paramedics c. &#s) !"#$!%#s) and nursing assistants d. At *east one representative from each group of ED personne* '9.2n a mu*tip*e-trauma victim) which assessment finding signa*s the most serious and *ife-threatening condition? a. A de"ia ed rac!ea b. Dross deformity in a *ower e tremity c. Decreased bowe* sounds d. 7ematuria ';.A patient in a one-car ro**over presents with mu*tip*e in/uries. "rioriti+e the interventions that must be initiated for this patient. CBDAE5G a. =ecure$start two *arge-bore 2%s with norma* sa*ine b. 8se the chin *ift or /aw thrust method to open the airway. c. Assess for spontaneous respirations d. Dive supp*ementa* o ygen per mas(. e. ?btain a fu** set of vita* signs. f. &emove patientAs c*othing. g. 2nsert a Eo*ey catheter if not contraindicated. 11111) 11111) 11111) 11111) 1111) 1111) 1111 '>.2n the wor( setting) what is your primary responsibi*ity in preparing for disaster management that inc*udes natura* disasters or bioterrorism incidents? a. 6no$ledge of !e agenc%*s emergenc% response plan b. Awareness of the signs and symptoms for potentia* agnets of bioterrorism c. Hnow*edge of how and what to report to the 3D3 d. Ethica* decision-ma(ing about e posing se*f to potentia**y *etha* substances .0.You are giving discharge instructions to a woman who has been treated for contusions and bruises sustained during an episode of domestic vio*ence. What is your priority intervention for this patient? a. )ranspor a ion arrangemen s o a safe !ouse b. &eferra* to a counse*or c. Advise about contacting the po*ice d. Eo**ow-up appointment for in/uries Answers I &ationa*e 1. AnswerJ 3 F 6riage reGuires at *east one e perienced &#. "airing an e perienced &# with ine perienced &# provides opportunities for mentoring. Advanced practice nurses are Gua*ified to perform triage@ however) their services are usua**y reGuired in other areas of the ED. An !"#$!%# is not Gua*ified to perform the initia* patient assessment or decision ma(ing. "airing an e perienced &# with a nursing assistant is the second best option) because the assistant can obtain vita* signs and assist in transporting.

'. AnswerJ :) A) D) 3 F An irritab*e infant with fever and petechiae shou*d be further assessed for other meningea* signs. 6he patient with the head wound needs additiona* history and assessment for intracrania* pressure. 6he patient with moderate abdomina* pain is uncomfortab*e) but not unstab*e at this point. Eor the an(*e in/ury) medica* eva*uation can be de*ayed '4 F 4; hours if necessary. .. AnswerJ 3 F A brief neuro*ogic assessment to determine *eve* of consciousness and pupi* reaction is part of the primary survey. %ita* signs) assessment of the abdomen) and initiation of pu*se o imetry are considered part of the secondary survey. 4. AnswerJ D F 3hest pain is considered an emergent priority) which is defined as potentia**y *ife-threatening. "atients with urgent priority need treatment within ' hours of triage (e.g. (idney stones). #on-urgent conditions can wait for hours or even days. (7igh urgent is not common*y used@ however) in ,-tier triage systems) 7igh urgent patients fa** between emergent and urgent in terms of the time *apsing prior to treatment). ,. AnswerJ A F 6he nursing assistant can assist with the remova* of the outer c*othing) which a**ows the heat to dissipate from the chi*dAs s(in. Advising and e p*aining are teaching functions that are the responsibi*ity of the &#. 6epid baths are not usua**y performed because of potentia* for rebound and shivering. 5. AnswerJ D F 6he home*ess person has symptoms of heat stro(e) a medica* emergency) which increases ris( for brain damage. E*der*y patients are at ris( for heat syncope and shou*d be educated to rest in coo* area and avoid future simi*ar situations. 6he runner is having heat crams) which can be managed with rest and f*uids. 6he housewife is e periencing heat e haustion) and management inc*udes f*uids (2% or parentera*) and coo*ing measures. 6he prognosis for recovery is good. 9. AnswerJ :) D) A) 3) E F Estab*ish unresponsiveness first. (6he patient may have fa**en and sustained a minor in/ury.) 2f the patient is unresponsive) get he*p and have someone initiate the code. "erforming the chin *ift or /aw thrust maneuver opens the airway. 6he nurse is then responsib*e for starting 3"&. 3"& shou*d not be interrupted unti* the patient recovers or it is determined that heroic efforts have been e hausted. A crash cart shou*d be at the site when the code team arrives@ however) basic 3"& can be effective*y performed unti* the team arrives. ;. AnswerJ A F #ursing assistants are trained in basic cardiac *ife support and can perform chest compressions. 6he use of the bagva*ve mas( reGuires practice and usua**y a respiratory therapist wi** perform this function. 6he nurse or the respiratory therapist shou*d provide "&# assistance during intubation. 6he defibri**ator pads are c*ear*y mar(ed@ however) p*acement shou*d be done by the &# or physician because of the potentia* for s(in damage and e*ectrica* arcing. >. AnswerJ 3 F 6he patient is hyperventi*ating secondary to an iety) and breathing into a paper bag wi** a**ow rebreathing of carbon dio ide. A*so) encouraging s*ow breathing wi** he*p. ?ther treatments such as o ygen and medication may be needed if other causes are identified. 10. AnswerJ 3 F 6he fast trac( c*inic wi** dea* with re*ative*y stab*e patients. 6riage) trauma) and pediatric medicine shou*d be staffed with e perienced nurses who (now the hospita* routines and po*icies and can rapid*y *ocate eGuipment. 11. AnswerJ A F 2ron is a to ic substance that can *ead to massive hemorrhage) coma) shoc() and hepatic fai*ure. Defero ame is an antidote that can be used for severe cases of iron poisoning. ?ther information needs additiona* investigation) but wi** not change the immediate diagnostic testing or treatment p*an. 1'. AnswerJ 3 F 6he !"#$!%# is ab*e to *isten and provide emotiona* support for her patients. 6he other tas(s are the responsibi*ity of an &# or) if avai*ab*e) a =A#E (se ua* assau*t nurse e aminer) who has received training to assess) co**ect and safeguard evidence) and care for these victims. 1.. AnswerJ 3) :) D) A F 6he victim shou*d be removed from the co*d environment first) and then the rewarming process can be initiated. 2t wi** be painfu*) so give pain medication prior to immersing the feet in warmed water. 14. AnswerJ 3 F 6he on*y correct intervention is 3. the digits shou*d be gent*y c*eansed with norma* sa*ine) wrapped in steri*e gau+e moistened with sa*ine) and p*aced in a p*astic bag or container. 6he container is then p*aced on ice. 1,. AnswerJ : F 2% !ora+epam (Ativan) is the drug of choice for status epi*epticus. 6egreto* is used in the management of genera*i+ed tonic-c*onic) absence or mi ed type sei+ures) but it does not come in an 2% form. "? (per os) medications are inappropriate for this emergency situation. <agnesium su*fate is given to contro* sei+ures in to emia of pregnancy. 15. AnswerJ 3 F "arent refusa* is an abso*ute contraindication@ therefore) the physician must be notified. 6etanus status can be addressed *ater. 6he &# can restart the 2% and provide information about conscious sedation@ if the parent sti** notsatisfied) the physician can give more information. 19. AnswerJ D F 6he patient presents with symptoms of a*coho* abuse and there is a ris( for Wernic(eAs syndrome) which is caused by a thiamine deficiency. <u*tip*es drug abuse is not uncommon@ however) there is nothing in the Guestion that suggests an opiate overdose that reGuires na*o one. Additiona* information or the resu*ts of the b*ood a*coho* *eve* are part of the tota* treatment p*an but shou*d not de*ay the immediate treatment. 1;. AnswerJ 3 F "ostmortem care reGuires some turning) c*eaning) *ifting) etc.) and the nursing assistant is ab*e to assist with these duties. 6he &# shou*d ta(e responsibi*ity for the other tas(s to he*p the fami*y begin the grieving process. 2n cases of Guestionab*e death) be*ongings may be retained for evidence) so the chain of custody wou*d have to be maintained. 1>. AnswerJ 3) D) :) A F Auscu*tating and confirming eGua* bi*atera* breath sounds shou*d be performed in rapid succession. 2f the sounds are not eGua* or if the sounds are heard over the mid-epigastric area) tube p*acement must be corrected immediate*y. =ecuring the tube is appropriate whi*e waiting for the -ray study. '0. AnswerJ : F An impa*ed ob/ect may be providing a tamponade effect) and remova* can precipitate sudden hemodynamic decompensation. Additiona* history inc*uding a more definitive description of the b*ood *oss) depth of penetration) and medica* history shou*d be obtained. ?ther information) such as the dirt on the stic( or history of diabetes) is important in the overa** treatment p*an) but can be addressed *ater. '1. AnswerJ A F 6he patient demonstrates neuro*ogic hyperactivity and is on the verge of a sei+ure. "atient safety is the priority. 6he patient needs ch*ordia+epo ide (!ibrium) to decrease neuro*ogic irritabi*ity and phenytoin (Di*antin) for sei+ures. 6hiamine and ha*operido* (7a*do*) wi** a*so be ordered to address the other prob*ems. 6he other diagnoses are pertinent but not as immediate. ''. AnswerJ : F 6he stinger wi** continue to re*ease venom into the s(in) so prompt remova* of the stinger is advised. 3oo* compresses and antihistamines can fo**ow. 6he ca**er shou*d be further advised about symptoms that reGuire >11 assistance. '.. AnswerJ D F 6he asymptomatic patient is current*y stab*e but shou*d be observed for de*ayed pu*monary edema) cerebra* edema) or pneumonia. 6eaching and care of critica* patients is an &# responsibi*ity. &emoving c*othing can be de*egated to a nursing assistant. '4. AnswerJ A F 3atAs mouths contain a viru*ent organism) "asteure**a mu*tocida) that can *ead to septic arthritis or

bacteremia. 6here is a*so a ris( for tendon damage due to deep puncture wounds. 6hese wounds are usua**y not sutured. A tetanus shot can be given before discharge. ',. AnswerJ D) :) 3) A F 6he patient with a pu*sating mass has an abdomina* aneurysm that may rupture and he may decompensate sudden*y. 6he 11-year-o*d boy needs eva*uation to ru*e out appendicitis. 6he woman needs eva*uation for ga**b*adder prob*ems that appear to be worsening. 6he .,-year-o*d man has food poisoning) which is usua**y se*f-*imiting. '5. AnswerJ D F At *east one representative from each group shou*d be inc*uded because a** emp*oyees are potentia* targets fro vio*ence in the ED. '9. AnswerJ A F A deviated trachea is a symptoms of tension pneumothora . A** of the other symptoms need to be addressed) but are of *esser priority. ';. AnswerJ 3) :) D) A) E) E) D F Eor a mu*tip*e trauma victim) many interventions wi** occur simu*taneous*y as team members assist in the resuscitation. <ethods to open the airway such as the chin *ift or /aw thrust can be used simu*taneous*y whi*e assessing for spontaneous respirations. 7owever) airway and o ygenation are priority. =tarting 2%s for f*uid resuscitation is part of supporting circu*ation. (E<= wi** usua**y estab*ish at *east one 2% in the fie*d.) #ursing assistants can be directed to ta(e vita*s and remove c*othing. Eo*ey catheter is necessary to c*ose*y monitor output. '>. AnswerJ A F 2n preparing for disasters) the &# shou*d be aware of the emergency response p*an. 6he p*an gives guidance that inc*udes ro*es of team members) responsibi*ities) and mechanisms of reporting. =igns and symptoms of many agents wi** mimic common comp*aints) such as f*u-*i(e symptoms. Discussions with co**eagues and supervisors may he*p the individua* nurse to sort through ethica* di*emmas re*ated to potentia* danger to se*f. .0. AnswerJ A F =afety is a priority for this patient) and she shou*d not return to a p*ace where vio*ence cou*d reoccur. 6he other options are important for the *ong term management of this care.