Chapter 08: Concepts of Emergency and Trauma Nursing Flashcards
An emergency room nurse assesses a client who has been raped. With which health care team member
should the nurse collaborate when planning this clients care?
Forensic nurse examiner
The emergency department team is performing cardiopulmonary resuscitation on a client when the clients spouse arrives at the emergency department. Which action should the nurse take first?
Ask the spouse if he wishes to be present during the resuscitation
If resuscitation efforts are still under way when the family arrives, one or two family members may be given
the opportunity to be present during lifesaving procedures
An emergency room nurse is triaging victims of a multi-casualty event. Which client should receive care first?
a. A 30-year-old distraught mother holding her crying child
b. A 65-year-old conscious male with a head laceration
c. A 26-year-old male who has pale, cool, clammy skin
d. A 48-year-old with a simple fracture of the lower leg
A 26-year-old male who has pale, cool, clammy skin
The client with pale, cool, clammy skin is in shock and needs immediate medical attention.
While triaging clients in a crowded emergency department, a nurse assesses a client who presents with
symptoms of tuberculosis. Which action should the nurse take first?
Transfer the client to a negative-pressure room
A client with signs and symptoms of tuberculosis or other airborne pathogens should be placed in a negativepressure
room to prevent contamination of staff, clients, and family members in the crowded emergency
department
A nurse is triaging clients in the emergency department (ED). Which client should the nurse prioritize to
receive care first?
a. A 22-year-old with a painful and swollen right wrist
b. A 45-year-old reporting chest pain and diaphoresis
c. A 60-year-old reporting difficulty swallowing and nausea
d. An 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101 F
A 45-year-old reporting chest pain and diaphoresis
A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED.
A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center?
a. Level I Located within remote areas and provides advanced life support within resource capabilities
b. Level II Located within community hospitals and provides care to most injured clients
c. Level III Located in rural communities and provides only basic care to clients
d. Level IV Located in large teaching hospitals and provides a full continuum of trauma care for all clients
Level II Located within community hospitals and provides care to most injured clients
Level I trauma centers are usually located in large teaching hospital systems and provide a full continuum of trauma care for all clients. Both Level II and Level III facilities are usually located in community hospitals.
These trauma centers provide care for most clients and transport to Level I centers when client needs exceed resource capabilities. Level IV trauma centers are usually located in rural and remote areas. These centers provide basic care, stabilization, and advanced life support while transfer arrangements to higher-level trauma
centers are made.
Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action should the nurse take first?
Assess that the client is breathing adequately
The highest-priority intervention in the primary survey is to establish that the client is breathing adequately.
A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action should the nurse take prior to providing advanced cardiac life support?
Don personal protective equipment
Nurses must recognize and plan for a high risk of contamination with blood and body fluids when engaging in trauma resuscitation. Standard Precautions should be taken in all resuscitation situations and at other times
when exposure to blood and body fluids is likely. Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers.
A nurse is triaging clients in the emergency department. Which client should be considered urgent?
a. A 20-year-old female with a chest stab wound and tachycardia
b. A 45-year-old homeless man with a skin rash and sore throat
c. A 75-year-old female with a cough and a temperature of 102 F
d. A 50-year-old male with new-onset confusion and slurred speech
A 75-year-old female with a cough and a temperature of 102 F
A client with a cough and a temperature of 102 F is urgent. This client is at risk for deterioration and needs to be seen quickly, but is not in an immediately life-threatening situation
An emergency department nurse is caring for a client who has died from a suspected homicide. Which action should the nurse take?
Communicate the clients death to the family in a simple and concrete manner.
Communicate the clients death to the family in a simple and concrete manner.
A nurse is triaging clients in the emergency department. Which client should the nurse classify as
nonurgent?
a. A 44-year-old with chest pain and diaphoresis
b. A 50-year-old with chest trauma and absent breath sounds
c. A 62-year-old with a simple fracture of the left arm
d. A 79-year-old with a temperature of 104 F
A 62-year-old with a simple fracture of the left arm
A client in a nonurgent category can tolerate waiting several hours for health care services without a significant risk of clinical deterioration.
A nurse is caring for clients in a busy emergency department. Which actions should the nurse take to ensure client and staff safety (Multiple Response)
SAUC
Use two identifiers before each intervention and before mediation administration.
Attempt de-escalation strategies for clients who demonstrate aggressive behaviors.
Search the belongings of clients with altered mental status to gain essential medical information.
Use facility policy identification procedures for “Jane/John Doe” clients.
Check clients for a medical alert bracelets or necklaces.
Best practices for client and staff safety in the emergency department include leaving beds in the lowest position with side rails up,
using two unique identifiers for medications and procedures, using de-escalation strategies for clients or visitors showing hostile or
aggressive behaviors, searching the belongings of confused clients for medical information, using facility identification systems for
Jane/John Doe clients, observing for medical alert jewelry, and using security staff as needed.
An emergency department (ED) nurse is preparing to transfer a client to the trauma intensive care unit. Which information should the nurse include in the nurse-to-nurse hand-off report? (Multiple Response)
SLIM
Mechanism of injury
Diagnostic test results
Isolation precautions
Safety concerns
Hand-off communication should be comprehensive so that the receiving nurse can continue care for the client fluidly. Communication should be concise and should include only the most essential information for a safe transition in care. Hand-off communication should include the clients situation (reason for being in the ED), brief medical history, assessment and diagnostic findings, Transmission-Based Precautions needed, interventions provided, and response to those interventions.
An emergency room nurse is caring for a trauma client. Which interventions should the nurse perform during the primary survey?
REIN
Needle decompression
Initiating IV fluids
Endotracheal intubation
Removing wet clothing
The primary survey for a trauma client organizes the approach to the client so that life-threatening injuries are rapidly identified and managed. The primary survey is based on the standard mnemonic ABC, with an added D and E: Airway and cervical spine control; Breathing; Circulation; Disability; and Exposure. After the
completion of primary diagnostic and laboratory studies, and the insertion of gastric and urinary tubes, the secondary survey (a complete head-to-toe assessment) can be carried out.
The complex care provided during an emergency requires interdisciplinary collaboration. Which interdisciplinary team members are paired with the correct responsibilities? (Select all that apply.)
a. Psychiatric crisis nurse Interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis
b. Forensic nurse examiner Performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources
c. Triage nurse Provides basic life support interventions such as oxygen, basic wound care, splinting, spinal immobilization, and monitoring of vital signs
d. Emergency medical technician Obtains client histories, collects evidence, and offers counseling and followup care for victims of rape, child abuse, and domestic violence
e. Paramedic Provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration
Psychiatric crisis nurse Interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis
Paramedic Provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration
The psychiatric crisis nurse evaluates clients with emotional behaviors or mental illness and facilitates followup
treatment plans. The psychiatric crisis nurse also works with clients and families when experiencing a crisis.
Paramedics are advanced life support providers who can perform advanced techniques that may include
cardiac monitoring, advanced airway management and intubation, establishing IV access, and administering drugs en route to the emergency department. The forensic nurse examiner is trained to recognize evidence of abuse and to intervene on the clients behalf. The forensic nurse examiner will obtain client histories, collect
evidence, and offer counseling and follow-up care for victims of rape, child abuse, and domestic violence. The triage nurse performs rapid assessments to ensure clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of resources. The emergency medical technician is usually the first caregiver and provides basic life support and transportation to the emergency department
