Observe the patient's respiratory effort.
rationale:
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 also are part of the initial survey bu
During the primary assessment of a trauma victim, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next?
Initiate isotonic fluid infusion through two large-bore IV lines.
rationale:
The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a possibly life-threatening injury is found during the primary survey, the nurse shoul
During the primary survey of a patient with multiple traumatic injuries, the nurse observes that the patient's right pedal pulses are absent and the leg is swollen. Which of these actions will the nurse take next?
Rapidly infuse cold normal saline.
rationale:
When therapeutic hypothermia is used postresuscitation, cold normal saline is infused to rapidly lower body temperature to 89.6� F to 93.2� F (32� C to 34� C). Since hypothermia will decrease brain activity, n
After resuscitation, a patient who had a cardiac arrest is nonresponsive to commands and therapeutic hypothermia is prescribed. Which action will the nurse include in the plan of care?
obtain a Glasgow Coma Scale score.
rationale:
The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the secondary survey.
A patient who is unconscious after a fall from a ladder is transported to the emergency department by family members. During the primary survey of the patient, the nurse should _____________
TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap).
rationale:
For an adult with no previous tetanus immunizations, TIG and Tdap are recommended. The other immunizations are not sufficient for this patient.
An 18-year-old is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the right hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. The nurse will anticipate administratio
ultrasonography.
rationale:
For patients who are at risk for intraabdominal bleeding, focused abdominal ultrasonography is the preferred method to assess for intraperitoneal bleeding. An MRI would not be used. Peritoneal lavage is an alternative, but it i
A patient who has experienced blunt abdominal trauma during a car accident is complaining of increasing abdominal pain. The nurse will plan to teach the patient about the purpose of ______________
I should have sports drinks when exercising outside in hot weather."
rationale:
Electrolyte solutions such as sports drinks help replace fluid and electrolytes lost when exercising in hot weather. Salt tablets are not recommended because of the risks of
A patient with hypotension and temperature elevation after doing yard work on a hot day is treated in the ED. After the nurse has completed discharge teaching, which statement by the patient indicates that the teaching has been effective?
attach a cardiac monitor.
rationale:
Rewarming can produce dysrhythmias, so the patient should be monitored and treated if necessary. Urinary catheterization and endotracheal intubation are not needed for rewarming. Sympathomimetic drugs tend to stimulate
When preparing to rewarm a patient with hypothermia, the nurse will plan to _____________
Auscultate breath sounds.
rationale:
Since pulmonary edema is a common complication after near drowning, the nurse should assess the breath sounds frequently. The other information also will be collected by the nurse, but it is not as pertinent to the pat
A patient who experienced a near drowning accident in a local lake, but now is awake and breathing spontaneously, is admitted for observation. Which action will be most important for the nurse to take during the observation period?
vaccine.
rationale:
Smallpox infection can be prevented or ameliorated by the administration of vaccine given rapidly after exposure. The other interventions would be helpful for other agents of terrorism but not for smallpox.
When planning the response to the potential use of smallpox as an agent of terrorism, the emergency department (ED) nurse-manager will plan to obtain sufficient quantities of ______________
The core temperature is 94� F (34.4� C).
rationale:
A core temperature of 89.6� F to 93.2� F (32� C to 34� C) indicates that sufficient rewarming has occurred. Dysrhythmias, hypotension, and shivering may occur during rewarming and should be treated but a
When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87� F, which assessment indicates that the nurse should discontinue the rewarming?
Is someone at home hurting you?"
rationale:
The nurse's initial response should be to further assess the patient's situation. Telling the patient not to return home may be an option once further assessment is done. The patient, not the nurse, is responsi
When assessing a patient admitted to the emergency department (ED) with a broken arm and facial bruises, the nurse notes multiple additional bruises in various stages of healing. Which statement or question by the nurse is most appropriate?
Give N-acetylcysteine (Mucomyst).
rationale:
N-acetylcysteine is the recommended treatment to prevent liver damage after acetaminophen overdose. The other actions might be used for other types of poisoning, but they will not be appropriate for a patient w
A patient arrives in the emergency department (ED) a few hours after taking "20 to 30" acetaminophen (Tylenol) tablets. Which action will the nurse plan to take?
assess the patient's current vital signs.
rationale:
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 uri
A triage nurse in a busy emergency department assesses a patient who complains of 6/10 abdominal pain and states, "I had a temperature of 104.6� F (40.3� C) at home." The nurse's first action should be to ______________
A patient with a sucking chest wound
rationale:
Most immediate deaths from trauma occur because of problems with ventilation, so the patient with a sucking chest wound should be treated first. Face and head fractures can obstruct the airway, but the patie
The emergency department (ED) triage nurse is assessing four victims of an automobile accident. Which patient has the highest priority for treatment?
Remove the patient's rings.
rationale:
The patient's rings should be removed first because it might not be possible to remove them if swelling develops. The other orders also should be implemented as rapidly as possible after the nurse has removed the jew
The following actions are part of the routine emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?
Assist with intubation of the patient.
rationale:
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.
Gastric lavage and administration of activated charcoal are prescribed for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 diazepam (Valium) tablets. Which action will the nurse plan to take first?
Place the patient in a shower.
rationale:
The initial action should be to protect staff members and decrease the patient's exposure to the radioactive agent by decontamination. The other actions can be done after the decontamination is completed.
A patient arrives in the emergency department after exposure to radioactive dust. Which action should the nurse take first?
apply wet sheets and a fan to the patient.
rationale:
The priority intervention is to cool the patient. Antipyretics are not effective in decreasing temperature in heat stroke, and 100% oxygen should be given, which requires a high flow rate through a non
An unresponsive 78-year-old is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 106.2� F (41.2� C), blood pressure (BP) 86/52, and pulse 102. The nurse initially will plan to _____________
Lung sounds
rationale:
The priority assessment data are how well the patient is oxygenating, so lung sounds should be assessed first. The other data also will be collected rapidly but are not as essential as the lung sounds.
When a patient is admitted to the emergency department after a submersion injury, which assessment will the nurse obtain first?
A patient with a red tag
rationale:
The red tag indicates a patient with a life-threatening injury requiring rapid treatment. The other tags indicate patients with less urgent injuries or those who are likely to die.
Following an earthquake, patients are triaged by emergency medical personnel and are transported to the hospital. Which of these patients will the nurse need to assess first?
Ask the family members about whether they would prefer to remain in the patient room or wait outside the room.
rationale:
Although many family members and patients report benefits from family presence during resuscitation efforts, the nurse's initial acti
A patient's family members are in the patient room when the patient has a cardiac arrest and emergency personnel start resuscitation measures. Which action is best for the nurse to take initially?
c) A 22-year-old with multiple fractures of the face and jaw
a) A 72-year-old with palpitations and chest pain
b) A 45-year-old complaining of 6/10 abdominal pain
d) A 30-year-old with a misaligned right leg with intact pulses
rationale:
The highest prior
These four patients arrive in the emergency department after a motor vehicle crash. In which order should they be assessed?