Nurselabs Emergency Nursing and Triage Flashcards
(39 cards)
A 15-year-old male client was sent to the emergency unit following a small laceration on the forehead. The client says that he can’t move his legs. Upon assessment, respiratory rate of 20, strong pulses, and capillary refill time of less than 2 seconds. Which triage category would this client be assigned to?
A. Red
B. Black
C. Yellow
D. Green
E. White
C. Yellow
The client is possibly suffering from a spinal injury but otherwise, has a stable status and can communicate so the appropriate tag is yellow. If individuals can breathe spontaneously, follow simple commands, and have distal pulses with a normal capillary refill, they are tagged delayed and given the code yellow.
Nurse Kelly, a triage nurse encountered a client who complained of mid-sternal chest pain, dizziness, and diaphoresis. Which of the following nursing action should take priority?
A. Administer oxygen therapy via nasal cannula
B. Notify the physician
C. Complete history taking
D. Put the client on ECG monitoring
A. Administer oxygen therapy via nasal cannula.
The priority goal is to increase myocardial oxygenation. Place the patient on a cardiac monitor, establish intravascular access (IV) access, give 162 mg to 325 mg chewable aspirin, clopidogrel, or ticagrelor (unless bypass surgery is imminent), control pain and consider oxygen (O2) therapy.
A 5-year-old client was admitted to the emergency unit due to the ingestion of an unknown amount of chewable vitamins for children at an unknown time. Upon assessment, the child is alert and with no symptoms. Which of the following information should be reported to the physician immediately?
A. The child was nauseated and vomited once at home
B. The child has been treated several times for toxic substance ingestion
C. The vitamin that was ingested contains iron
D. The child has been treated multiple times for injuries caused by accidents
C. The vitamin that was ingested contains iron.
Iron is a toxic substance that can lead to massive hemorrhage, shock, coma, and kidney failure. Iron poisoning is one of the most common toxic ingestion and one of the most deadly among children. Failure to diagnose and treat iron poisoning can have serious consequences including multi-organ failure and death.
You are assessing a patient who has sustained a cat bite to the left hand. The cat is up-to-date immunizations. The date of the patient’s last tetanus shot is unknown. Which of the following is the priority nursing diagnosis?
A. Impaired Skin Integrity related to puncture wounds
B. Ineffective Health Maintenance related to immunization status
C. Risk for Infection related to organisms specific to cat bites
D. Risk for Impaired Mobility related to potential tendon damage
C. Risk for Infection related to organisms specific to cat bites.
Cat’s mouths contain a virulent organism, Pasteurella multocida, that can lead to septic arthritis or bacteremia. Infections resulting from bites of all animal species are poly-microbial with aerobic and anaerobic bacteria; dogs and cats have an oral flora of Pasteurella, Staph, and Strep most commonly. In cat bites and scratches, Bartonella infections are an additional concern.
A client arrived at the emergency department after suffering multiple physical injuries including a fractured pelvis from a vehicular accident. Upon assessment, the client is incoherent, pale, and diaphoretic. With vital signs as follows: temperature of 97°F (36.11° C), blood pressure of 60/40 mm Hg, heart rate of 143 beats/minute, and a respiratory rate of 30 breaths/minute. The client is mostly suffering from which of the following shock?
A. Distributive
B. Hypovolemic
C. Obstructive
D. Cardiogenic
B. Hypovolemic
Hypovolemic shock occurs when the volume of the circulatory system is too depleted to allow adequate circulation to the tissues of the body. A fractured pelvis will lose about one liter of blood hence symptoms such as hypotension, tachycardia, and tachypnea will occur. If left untreated, these patients can develop ischemic injury of vital organs, leading to multi-system organ failure.
A client was brought to the ED due to an abdominal trauma caused by a motorcycle accident. During the assessment, the client complains of epigastric pain and back pain. Which of the following is true regarding the diagnosis of pancreatic injury?
A. Redness and bruising may indicate the site of the injury in blunt trauma
B. The client is symptom-free during the early post-injury period
C. Signs of peritoneal irritation may indicate pancreatic injury
D. All of the above
D. All of the above
Blunt injury resulting from vehicular accidents could cause pancreatic injury. Redness, bruising in the flank and severe peritoneal irritation are signs of a pancreatic injury. The client is usually pain-free during the early post-injury period, hence a comprehensive assessment and monitoring should be done.
Nurse Anna is an experienced travel nurse who was recently employed and is assigned to the emergency unit. In her first week of the job, which of the following area is the most appropriate assignment for her?
A. Triage
B. Ambulatory section
C. Trauma team
D. Psychiatric care
B. Ambulatory section
The ambulatory section deals with clients with relatively stable conditions. The decision of whether or not to delegate or assign is based upon the RN’s judgment concerning the condition of the patient, the competence of all members of the nursing team and the degree of supervision that will be required of the RN if a task is delegated.
Cole is an emergency nurse who encountered a patient who is a suspected carrier of a biologic agent. Which of these if found in the patient is not classified as a Category A biologic agent?
A. Bacillus anthracis (anthrax)
B. Francisella tularensis (tularemia)
C. Clostridium botulinum toxin (botulism)
D. Burkholderia pseudomallei (Melioidosis)
E. Yersinia petis (plague)
D. Burkholderia pseudomallei (Melioidosis)
Burkholderia pseudomallei (Melioidosis) belongs to the category B priority pathogen. These agents are moderately easy to be transmitted and can result in moderate morbidity rates. Melioidosis is endemic to southeast Asia and northern Australia but has also occurred in South America, Central America, Africa, and the Middle East. Melioidosis may present in an acute form with an incubation period of one day to three weeks. However, latent melioidosis may not present for decades. Melioidosis often infects those with underlying risk factors such as diabetes, kidney disease, alcohol abuse, and thalassemia, although healthy patients may also contract the disease.
A prisoner, with a known history of alcohol abuse, has been in police custody for 48 hours. Initially, anxiety, sweating, and tremors were noted. Now, disorientation, hallucination, and hyper-reactivity are observed. The medical diagnosis is delirium tremens. What is the priority nursing diagnosis?
A. Risk for Injury related to seizures
B. Risk for Situational Low Self-esteem related to police custody
C. Risk for Nutritional Deficit related to chronic alcohol abuse
D. Risk for Other-Directed Violence related to hallucinations
A. Risk for Injury related to seizures.
The client shows neurologic hyperactivity and is on the verge of a seizure. Seizures can recur, though rarely lead to status epilepticus. Uncharacteristic signs of seizure activity should warrant further workup. Patient safety is the priority. The patient needs chlordiazepoxide (Librium) to decrease neurologic irritability and phenytoin (Dilantin) for seizures. Thiamine and haloperidol (Haldol) will also be ordered to address other problems.
When attending a client with a head and neck trauma following a vehicular accident, the nurse’s initial action is to?
A. Provide oxygen therapy
B. Initiate intravenous access
C. Immobilize the cervical area
D. Do oral and nasal suctioning
C. Immobilize the cervical area
Clients with suspected or possible cervical spine injury must have their neck immobilized until formal assessment occurs. Maintain cervical spine spinal immobilization and minimize neck movement particularly during transport. Beware that absence of neurologic findings does not eliminate the possibility of spinal cord injury.
Following an emergency endotracheal intubation, nurses must verify tube placement and secure the tube. List in order the steps that are required to perform this function?
- Auscultate the chest during assisted ventilation
- Obtain an order for a chest x-ray to document tube placement
- Secure the tube in place
- Confirm that the breath sounds are equal and bilateral
1, 4, 3, 2
A client suffered an amputation of the first and second digits in a chainsaw accident. Which task should be delegated to an LPN/LVN?
A. Cleansing the amputated digits and placing them directly into an ice slurry
B. Wrapping the cleansed digits in saline-moistened gauze, sealing in a plastic container, and placing it in icy water
C. Gently cleansing the amputated digits and the hand with povidone-iodine
D. Cleansing the digits with sterile normal saline and placing it in a sterile cup with sterile normal saline
B. Wrapping the cleansed digits in saline-moistened gauze, sealing in a plastic container, and placing it in icy water.
Once a finger amputation has occurred, ischemic tolerance times are 12 hours if warm and up to 24 hours if cold. For more proximal amputations, these times are halved. The amputated part should be covered in a normal saline-soaked gauze, sealed in a plastic bag, and submerged in icy water with no direct contact with ice. If there is direct contact with ice, it could result in tissue damage and render the amputated part non-viable.
You respond to a call for help from the ED waiting room. There is an elderly patient lying on the floor. List the order for the actions that you must perform.
- Initiate cardiopulmonary resuscitation (CPR)
- Establish unresponsiveness
- Call for help and activate the code team
- Perform the chin lift or jaw thrust maneuver
- Instruct a nursing assistant to get the emergency cart
2, 3, 4, 1, 5
The following clients are presented with signs and symptoms of heat-related illness. Which of them needs to be attended first?
A. A relatively healthy homemaker who reports that the air conditioner has been broken for days and who manifest fatigue, hypotension, tachypnea, and profuse sweating.
B. An elderly person who complains of dizziness and syncope after standing in the sun for several hours to view a parade.
C. A homeless person who is a poor historian; has altered mental status, poor muscle coordination, and hot, dry ashen skin; and whose duration of heat exposure is unknown.
D. A marathon runner who complains of severe leg cramps and nausea, and manifests weakness, pallor, diaphoresis, and tachycardia.
C. A homeless person who is a poor historian; has altered mental status, poor muscle coordination, and hot, dry ashen skin; and whose duration of heat exposure is unknown.
The signs and symptoms manifested by the homeless person indicate that a heat stroke is happening, a medical emergency, which can lead to brain damage. Also, there must be clinical signs of central nervous system dysfunction that may include ataxia, delirium, or seizures, in the setting of exposure to hot weather or strenuous physical exertion. Patients who present with heat stroke typically have vital sign abnormalities to include an elevated core body temperature, sinus tachycardia, tachypnea, a widened pulse pressure, and a quarter of patients will be hypotensive.
An intoxicated client comes into the emergency unit with uncooperative behavior, mild confusion, and slurred speech. The client is unable to provide a good history but he verbalizes that he has been drinking a lot. Which of the following is a priority action of the nurse?
A. Administer IV fluid incorporated with Vitamin B1 as ordered
B. Administer Naloxone (Narcan) 4 mg as ordered
C. Contact the family to get information about the client
D. Obtain an order for the determination of blood alcohol level
A. Administer IV fluid incorporated with Vitamin B1 as ordered.
The client has symptoms of alcohol abuse and there is a risk for Wernicke syndrome, which is caused by a deficiency in Vitamin B. Thiamine deficiency (vitamin B1) is common in patients with alcohol dependence. Cognitive impairments may be an early consequence of thiamine deficiency. Wernicke’s encephalopathy is underdiagnosed and undertreated.
A nurse is providing discharge instructions to a woman who has been treated for contusions and bruises due to domestic violence. What is the priority intervention for this client?
A. Arranging transportation to a safe house
B. Advising the client about contacting the police
C. Making an appointment to follow up on the injuries
D. Making a referral to a counselor
A. Arranging transportation to a safe house.
Safety is a priority for this client and she should not return to a place where violence could recur. Make sure a safe environment is provided. Offer shelter options, legal services, counseling, and facilitate such referral.
An ER nurse is handling a 50-year-old woman complaining of dizziness and palpitations that occur from time to time. ECG confirms the diagnosis of paroxysmal supraventricular tachycardia. The client seems worried about it. Which of the following is an appropriate response of the nurse?
A. “You can be discharged now; this is a probable sign of anxiety.”
B. “The physician will prescribe you blood-thinning medications to lessen the episodes of palpitations.”
C. “We’ll need to keep you for further assessment; you may develop blood clots.”
D. “You have to stay here for a few hours to undergo blood tests to rule out myocardial infarction.”
C. “We’ll need to keep you for further assessment; you may develop blood clots.”
Paroxysmal supraventricular tachycardia (PSVT) is characterized by episodes of rapid heart rate that occur periodically and stop on their own. PSVT decreases cardiac output and can result in a thrombus. These clots could turn into an embolus, which could eventually lead to a stroke. Treatment of PSVT in a patient is dependent on the type of rhythm present on the electrocardiogram and the patient’s hemodynamic stability.
The emergency medical service has transported a client with severe chest pain. As the client is being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and unpalpable pulse. Which of the following task is appropriate to delegate to the nursing assistant?
A. Assisting with the intubation
B. Placing the defibrillator pads
C. Doing chest compressions
D. Initiating bag valve mask ventilation
C. Doing chest compressions.
Performing chest compressions are within the training of a nurse assistant. Every good certified nursing assistant should be proficient at cardiopulmonary resuscitation (CPR). Basic Life Support (BLS) certification is the widely-used term for any form of CPR certification and is required for all Registered Nurses (RN) and Certified Nursing Assistants (CNA).
Michael works as a triage nurse, and four clients arrive at the emergency department at the same time. List the order in which he will assess these clients from first to last.
- A 35-year-old jogger with a twisted ankle, having a pedal pulse, and no deformity
- A 50-year-old female with moderate abdominal pain and occasional vomiting
- An irritable infant with a fever, petechiae, and nuchal rigidity
- An ambulatory dazed 25-year-old male with a bandaged head wound
3, 4, 2, 1
In the work setting, what is the primary responsibility of the nurse in preparation for disaster management, that includes natural disasters and bioterrorism incidents?
A. Being aware of the signs and symptoms of potential agents of bioterrorism
B. Making ethical decisions regarding exposing self to potentially lethal substances
C. Being aware of the agency’s emergency response plan
D. Being aware of what and how to report to the Centers for Disease Control and Prevention
C. Being aware of the agency’s emergency response plan.
In disaster preparedness, the nurse should know the emergency response plan. This gives guidance that includes the roles of the team members, responsibilities, and mechanisms of reporting. Emergency preparedness encompasses diverse fields within the hospital and regional settings. Planning membership groups should address key aspects across these fields including but not limited to: public safety, facilities, logistics, pharmacy, transportation, clinical patient care, non-clinical patient care, media/public relations, communications, radiation, infection control, and administration.
A 20-year-old male client was brought to the emergency department with a gunshot wound to the chest. In obtaining a history of the incident to determine possible injuries, the nurse should ask which of the following?
A. “How long ago did the incident occur?”
B. “What was the initial first aid done?”
C. “Where did the incident happen?”
D. “What direction did the bullet enter into the body?”
D. “What direction did the bullet enter into the body?”
The entry point and direction of the bullet will predict the injuries of the client. In gunshot wounds, due to the high-intensity kinetic energy of the bullet, the pathway is often unpredictable in nature as well as the internal organs that may be affected. The most common organs injured are the small and large bowel at 50% and 40%, respectively.
A client arrives in the emergency unit and reports that a concentrated household cleaner was splashed in both eyes. Which of the following nursing actions is a priority?
A. Examine the client’s visual acuity
B. Patch the eye
C. Use Restasis (Allergan) drops in the eye
D. Flush the eye repeatedly using sterile normal saline
D. Flush the eye repeatedly using sterile normal saline.
Initial emergency action during a chemical splash to the eye includes immediate continuous irrigation of the affected eye with normal saline. Immediate irrigation with copious amounts of an isotonic solution as described previously is the mainstay of treatment for chemical burns. Never use any substance to neutralize chemical exposure as the exothermic reaction can lead to secondary thermal injuries.
A 33-year-old patient with a history of seizures and medication compliance of phenytoin (Dilantin) and carbamazepine (Tegretol) is brought to the ED by the MS personnel for repetitive seizure activity that started 45 minutes prior to arrival. You anticipate that the physician will order which drug for status epilepticus?
A. Phenytoin and Carbamazepine PO
B. Carbamazepine (Tegretol) IV
C. Magnesium sulfate IV
D. Lorazepam (Ativan) IV
D. Lorazepam (Ativan) IV.
IV Lorazepam (Ativan) is the drug of choice for status epilepticus. Benzodiazepines are the antiepileptic drug of choice for emergent control. Lorazepam is preferred because of its rapid onset of action and is dosed at 0.1 mg/kg IV. No more than 2 mg should be administered per minute.
A client was brought to the emergency department after suffering a closed head injury and lacerations around the face due to a hit-run accident. The client is unconscious and has a minimal response to noxious stimuli. Which of the following assessment findings if observed after few hours, should be reported to the physician immediately?
A. Drainage of a clear fluid from the client’s nose
B. Withdrawal of the client in response to painful stimuli
C. Bruises and minimal edema of the eyelids
D. Bleeding around the lacerations
A. Drainage of a clear fluid from the client’s nose
Clear drainage from the client’s nose indicates that there is a leakage of CSF and should be reported to the physician immediately.
