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Unit 8- IGGY Concepts of Emergency and Trauma Nursing
Terms in this set (40)
Which first action would the triage nurse take for a client who comes to the ED with blurred vision, difficulty speaking, left extremity weakness, and difficulty walking?
A. Send the client immediately for a head CT scan.
B. Notify the ED health care provider.
C. Delegate the assistive personnel (AP) to stay with the client.
D. Categorize the client as emergent.
Which information would the ED nurse be sure to include in a Situation, Background, Assessment, Recommendation (SBAR) report to be given to the medical nurse regarding a client admitted for bacterial meningitis? Select all that apply.
A. "Client is currently alert and oriented × 2; speech is clear but rambling."
B. "Client is very demanding and has used call bell repeatedly in the ED."
C. "IV normal saline is infusing into the left anterior forearm."
D. "Client has received the first dose of IV ceftriaxone at 07:00 a.m."
E. "Client reports severe headache with high fever which started 4 days ago."
F. "Lumbar puncture results are pending, but meningococcal meningitis is suspected."
G. "Client has male characteristics but prefers to be called Ms. Jenny Jones."
H. "Cardiac monitor shows normal sinus rhythm with occasional PAC."
What is the nurse's best response when a client with a sprained ankle complains that several clients who arrived later have been admitted before him or her?
A. "I understand your frustration, but please sit down and wait until we call you."
B. "We must attend to the clients who are unstable with life-threatening conditions first."
C. "This is a system problem and if you wish to complain, I can call a supervisor."
D. "Other clients have problems more serious than yours."
Which are among the most common reasons that clients seek care in the ED? Select all that apply.
A. Chest pain
B. Breathing problems
C. Vaccinations and shots
D. Injuries such as falls in older adults
What is the ED nurse's best response when the surgical nurse answers the phone and says, "You people always dump admissions on us during shift change"?
A. "I apologize for the timing. How much time do you need for shift change?"
B. "I apologize. We just now received this bed assignment."
C. "I'm sorry. I realize you are busy, but we are busy too."
D. "I'm also trying to finish a hand-off report. Should I call the supervisor?"
Which are vulnerable populations that often seek care in the ED? Select all that apply.
A. Clients with substance use problems
B. Clients who are pregnant
C. Clients with mental health needs
D. Clients who are older adults
E. Clients with small children
F. Clients who are poor
For which situation would the ED nurse, who is working alone, in triage activate the panic button?
A. Emergency medical services call on their way to the ED with a client in full arrest.
B. Several clients who have been in the waiting room for a long time begin to complain.
C. The line for clients waiting to be triaged becomes overwhelmingly long.
D. A person walks in and starts threatening the registration staff with a weapon.
Which strategies would the ED nurse use to conduct an interview with a client who has been verbally aggressive for the past couple of hours? Select all that apply.
A. Sit at eye level with the client in a secluded room.
B. Attempt de-escalating strategies before harm is done.
C. Notify security and supervisory staff of the situation.
D. Conduct the interview near the door in a quiet room.
E. Ask the family members to sit in while the interview is completed.
F. Request a security guard to stand by the client during the interview.
What is the first priority concern for nurses providing care for homeless clients in the ED setting?
A. Assessing for substance use problems
B. Providing clients with adequate nutrition
C. Attending to their needs for personal safety
D. Referring to social services related to economic hardship
Which actions would the nurse use to promote trust with a homeless client? Select all that apply.
A. Make eye contact.
B. Speak calmly.
C. Be patient.
D. Show care by listening.
E. Instruct the client at all times.
F. Follow through on promises.
Which statement would the nurse use first when giving a hand-off report to the next shift nurse using the SBAR method?
A. "The client's vital signs are T 98.6oF (37oC), HR 80/min, RR 16/min, BP 160/80 mm Hg."
B. "The client is a 65-year-old who came to the ED for a severe headache."
C. "The client is very uncomfortable and we should get him admitted as soon as possible." D. "The client has a history of hypertension but stopped taking medications 3 months ago."
What is the best procedure for client identification when caring for an unconscious admission with no known identification or family, and the ED nurse must administer a medication to the client?
A. The client is designated as John/Jane Doe (based on gender) and the nurse uses two unique identifiers.
B. Emergent conditions prevent identification, so the nurse gives the medication as prescribed.
C. The nurse administers the medication, and identification of the client is made as soon as possible.
D. The nurse validates the order with another nurse and both verify that the client is unidentified.
For which client is the forensic nurse examiner most likely to be consulted?
A. Client who accidentally received a large dose of opioid medication
B. Older adult client who died under mysterious circumstances in the ED
C. Client who was injured by a police officer while resisting arrest
D. Client who was gang-raped by a group of fraternity students
Which ED clients, who are currently on stretchers and waiting for discharge or transfer to an inpatient bed, are at greatest risk for falls? Select all that apply.
A. Young client with heavy vaginal bleeding secondary to a miscarriage
B. Client with chronic pain who received 10 mg oxycodone orally for myalgia
C. Middle-aged adult with severe nausea and vomiting and frequent watery stool over 3 days
D. Opioid-naïve teenager with a fracture who received morphine sulfate 3 mg IV for pain
E. Old adult client with acute dementia secondary to an infection
F. Younger adult with gastroesophageal reflux disease.
Which actions are within the scope of practice for an emergency medical technician (EMT) as a prehospital care provider? Select all that apply.
A. Cardiac monitoring
B. Oxygen application
C. Endotracheal intubation
E. Establishing IV lines
F. Basic life support (CPR)
What type of personal protective equipment (PPE) or attire would the nurse wear to provide care for a motor vehicle crash victim with severe chest trauma who is coughing up blood and has a crush injury to the right leg?
A. No PPE is needed because the nurse is only recording and not giving direct care.
B. The client situation must be assessed before determining what type of PPE would be worn.
C. Gloves only, but handwashing is required before and after all emergency care.
D. Impervious cover gown, gloves, eye protection, face mask, cap, and shoe covers are required.
Which intervention in the ED is least likely to be covered by a standing protocol for the nurses when the health care provider is not readily available?
A. Insert a peripheral IV line with normal saline at 125 mL/hr.
B. Give 50% dextrose IV push for low blood sugar.
C. Ventilate with bag-valve-mask at 100% oxygen and intubate client.
D. Initiate pulse oximetry monitoring and start oxygen therapy.
Which client would the triage nurse categorize as urgent?
A. 35-year-old with chest pain and diaphoresis
B. 44-year-old with a dislocated elbow
C. 65-year-old with redness and swelling on the forearm due to a bee sting
D. 83-year-old with new confusion and very elevated blood pressure compared with his baseline
Which instruction would the nurse give to the assistive personnel (AP) after giving a client with a migraine headache medication for the pain?
A. Check the client frequently to make sure of arousal and that the headache is not getting worse.
B. Wait 45 minutes and then assess the client to find out if the pain has been relieved.
C. Help the client out of bed, sit them up slowly and dangle the feet, then assist them to stand.
D. Ask the client if they need a ride home and if so, call a family member to arrange for client pickup.
Which technique would the nurse use to estimate the systolic blood pressure for a client who was transported to the ED on a stretcher in a resuscitation situation?
A. Place the client on a cardiac monitor and count heart rate.
B. Palpate the client for the presence of a radial pulse.
C. Check the client for the presence of capillary refill.
D. Apply and use an automated blood pressure cuff.
Which actions would the nurse take to prevent harm from the risk of injuries to clients in the ED? Select all that apply.
A. Keep rails up on the stretcher.
B. Keep the stretcher at a level for easy client access by staff.
C. Frequently reorient any client who is confused.
D. Ask a family member to remain with a confused client.
E. Allow family members to escort client to the bathroom.
F. Reposition any client who is at risk for skin breakdown every 1 to 2 hours.
What does the nurse expect will be the appearance of a client when the hand-off report states that the client has a Glasgow Coma Scale of 3?
A. Client will withdraw from painful stimuli.
B. Client will be completely unresponsive.
C. Client will open eyes spontaneously.
D. Client will moan but speech will be incoherent.
Which actions would the nurse take to reduce the potential for medical errors or adverse events in the ED? Select all that apply.
A. Contact the family by phone to get an accurate medical history.
B. Look for a medical alert necklace or bracelet when a client has altered mental status.
C. Perform a two-person search of belongings looking for a medication list or containers.
D. Search among belongings for the name of the client's health care provider or pharmacy.
E. Try to find out the name of the person who provides in-home care for the client.
F. Check client's belongings for drugs or drug paraphernalia as well as weapons.
Which priority question must the nurse be sure to ask the paramedics when an older adult is brought to the ED alert, but with lower left leg swelling and deformity and an air splint in place?
A. "What time was the air splint applied?"
B. "Does the client normally walk independently?"
C. "How did the client describe the level of pain?"
D. "What was the mechanism of injury?"
When the nurse collaborates with the ED health care provider, which procedures must he or she be prepared to assist with? Select all that apply.
A. Lumbar puncture
B. Wound closure by suturing
C. Chest tube insertion
E. Central line insertion
Which is the most essential component of the emergency nurse's skill base?
B. Establishing IV access
C. Interpreting cardiac monitor rhythms
D. Providing pain relief
Which nursing action would be incorrect when a client is likely to be the subject of a forensic investigation?
A. Nurse declines to give information to friends of the deceased client.
B. Nurse invites the family to spend time with the deceased client.
C. Nurse gives the client's clothes and belongings to the family of the deceased.
D. Nurse leaves intravenous lines and indwelling tubes in place.
Which clients would the triage nurse classify as emergent, needing to be seem immediately? Select all that apply.
A. Client with crushing substernal chest pain and shortness of breath
B. Client with a generalized skin rash who had shellfish for dinner yesterday
C. Client with active hemorrhage after a motor vehicle crash
D. Client with back pain and hematuria with a history of kidney stones
E. Client with a dislocated shoulder
F. Client with dysuria from a long-term care facility
What would the nurse do first when the provider has written a discharge order for an older adult client who cannot walk independently and has no family?
A. Speak with the provider about the client's self-care abilities.
B. Consult social services for nursing home placement.
C. Ask the client if a friend could come to the hospital.
D. Obtain a taxi voucher for the client.
What would the ED nurse do when a family arrives and wants to see the client, after death due to multiple injuries from an aggravated assault?
A. Remove any tubes and debris that are near the client's face, then cover the rest of the body with a blanket.
B. Explain what the family will see, dim the lights, leave the client's face exposed, and cover the rest of the body with a blanket.
C. Suggest that the family could spend time with their loved one at the morgue after the medical examiner is finished.
D. Explain that viewing the body would be too traumatic because all the tubes must remain in place for the forensic exam.
What is the best way for the emergency health care provider and nurse to inform a family that their family member has died of extensive injuries despite resuscitation efforts?
A. "We're sorry to inform you that your loved one died due to extensive injuries."
B. "We did everything we could but your loved one expired."
C. "Your loved one never woke up, but we are sure that they passed without discomfort."
D. "We want to extend our sympathies because your loved one is not with us anymore."
Which actions would the ED nurse expect to perform as a member of the ED bereavement committee?
A. Assign a staff nurse to sit with the family during resuscitation efforts for the client.
B. Provide grief counseling and group support for nurses who care for dying clients.
C. Attend funerals, send sympathy cards and make follow-up calls to the family.
D. Advocate that one or two family members be allowed at the bedside during resuscitation.
Which injuries would the ED nurse categorize as intentional injuries? Select all that apply.
A. Motor vehicle crash
C. Fracture due to fall
When would the nurse working in a large urban hospital most likely refer to the ED's automated electronic tracking system?
A. When seeking complete records of previous admissions for a client
B. When needing a medication for a client that should have come from the pharmacy
C. When desiring to know if the client's CT scan has been completed
D. When believing the client frequently visits the ED for opioids prescriptions
What is the most important action for the ED nurse to take for a client admitted with repeated kicks to the abdomen, and for whom testing currently reveals no life-threatening damage?
A. Assign vital signs every 4 hours to the assistive personnel (AP).
B. Place the client in a quiet place to assure he or she can rest.
C. Initiate serial abdominal assessments every hour.
D. Administer pain medication in a timely manner.
What is the primary focus for client care at a Level III trauma center?
A. Offer advanced life support in rural or remote areas
B. Provide care for majority of injured clients; may not meet needs of complex multisystem injury management
C. Focus on initial injury stabilization and emergent client transfer
D. Regional resource facility capable of providing leadership and total collaborative care for every aspect of injury
Which are the key elements when the nurse performs a primary survey on a client brought into the emergency department? Select all that apply.
A. Airway/cervical spine
F. Functional ability
What is the one exception to the ABCDE primary survey?
A. Total cardiac and respiratory arrest
B. Uncontrolled external bleeding
C. Fifty percent total body surface burns
D. Client with HIV and active AIDS (HIV-III)
What important information does the Disability (D) portion of the primary survey provide for the emergency department staff?
A. A rapid baseline assessment of the neurological status of the client
B. A look at the client's body searching for additional injuries
C. An estimate of the likelihood that the client will need to be intubated
D. An estimate of blood loss during the injuries that led to admission
Which signs of trafficking would the ED nurse watch for when interviewing and assessing an 18-year-old? Select all that apply.
A. Headache and dizziness
B. Missing patches of hair
C. Vaginal or rectal trauma
D. Smiling and friendly
E. Burns and bruises
F. Unusual tattooing
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