Chapter 68: Emergency and Disaster
Nursing Lewis: Medical-Surgical
Nursing, 10th Edition,
During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient has an unobstructed airway. Which action should the nurse take next?
- Palpate extremities for bilateral pulses.
- Observe the patient's respiratory effort.
- Check the patient's level of consciousness.
d. Examine the patient for any external bleeding. - ✔✔ANS: B
Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient's breathing. The other actions are also part of the initial survey but assessment of breathing should be done immediately after assessing for airway patency.
DIF: Cognitive Level: Apply (application)
A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should
- obtain a complete set of vital signs.
- obtain a Glasgow Coma Scale score.
- attach an electrocardiogram monitor.
d. ask about chronic medical conditions. - ✔✔ANS: B
The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the secondary survey.
DIF: Cognitive Level: Apply (application)
A 22-yr-old patient who experienced a drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period? 1 / 3
- Auscultate heart sounds. c. Auscultate breath sounds.
b. Palpate peripheral pulses. d. Check mental orientation. - ✔✔ANS: C
Because pulmonary edema is a common complication after drowning, the nurse should assess the breath sounds frequently. The other information also will be obtained by the nurse, but it is not as pertinent to the patient's admission diagnosis.
DIF: Cognitive Level: Analyze (analysis)
A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10 abdominal pain and states, "I had a temperature of 103.9° F (39.9° C) at home." The nurse's first action should be to
- assess the patient's current vital signs.
- give acetaminophen (Tylenol) per agency protocol.
- ask the patient to provide a clean-catch urine for urinalysis.
- tell the patient that it will be 1 to 2 hours before seeing a health care provider. - ✔✔ANS: A
The patient's pain and statement about an elevated temperature indicate that the nurse should obtain vital signs before deciding how rapidly the patient should be seen by the health care provider. A urinalysis may be appropriate, but this would be done after the vital signs are taken. The nurse will not give acetaminophen before confirming a current temperature elevation.
DIF: Cognitive Level: Analyze (analysis)
The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment?
- A patient with no pedal pulses
- A patient with an open femur fracture
- A patient with bleeding facial lacerations
d. A patient with paradoxical chest movement - ✔✔ANS: D
Most immediate deaths from trauma occur because of problems with ventilation, so the patient with paradoxical chest movements should be treated first. Face and head fractures can obstruct the airway, but the patient with facial injuries only has lacerations. The other two patients also need rapid intervention but do not have airway or breathing problems. 2 / 3
DIF: Cognitive Level: Analyze (analysis)
Gastric lavage and administration of activated charcoal are ordered for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action should the nurse plan to do first?
- Insert a large-bore orogastric tube.
- Assist with intubation of the patient.
- Prepare a 60-mL syringe with saline.
d. Give first dose of activated charcoal. - ✔✔ANS: B
In an unresponsive patient, intubation is done before gastric lavage and activated charcoal administration to prevent aspiration. The other actions will be implemented after intubation.
DIF: Cognitive Level: Analyze (analysis)
An unresponsive patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first?
- Pulse c. Breath sounds
b. Heart rhythm d. Body temperature - ✔✔ANS: A
The priority assessment in an unresponsive patient relates to CAB (circulation, airway, breathing) so a pulse check should be performed first. While assessing the pulse, the nurse should look for signs of breathing. The other data will also be collected rapidly but are not as essential as determining if there is a pulse.
DIF: Cognitive Level: Apply (application)
The emergency department (ED) nurse is starting therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/LVN) (select all that apply)?
- Continuously monitor heart rhythm.
- Assess neurologic status every 2 hours.
- Give acetaminophen (Tylenol) 650 mg.
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