Chapter 21: Emergencies and Disasters Flashcards
A client presents to triage with fever, myalgia, severe headache, abdominal pain, vomiting, diarrhea, and unexplained bruising that started after returning from Africa. The triage nurse suspects, but is unsure, that the client may have Ebola. What should the nurse do first?
- Delay any additional assessment or questioning and don full personal protective equipment.
- Isolate the client in a private room and initiate standard, contact, and droplet precautions.
- Direct all clients and staff out of the triage area and call the infection control department.
- Continue assessment and questioning to determine the likelihood of exposure to Ebola.
Ans: 2
First, the nurse would isolate the client and initiate standard, contact, and droplet precautions. The person can be taken out of isolation at any time if the health care provider (HCP) determines that the client does not have Ebola, but in the meantime, isolation precautions protect others. After the client is in isolation, the nurse’s next actions are based on the acuity of the client. If the client needs immediate assistance, the nurse would alert the HCP and charge nurse. Selected team members would don personal protective equipment, and care would be initiated. The infection control department should be notified as soon as possible so that system-wide measures can be activated as needed. Focus: Prioritization; Test Taking Tip: Safety is one of the concepts that is used to identify priorities. In this case, recognize that the safety priority is for other people and the environment.
An emergency department clinical nurse specialist is training staff in how to don and doff personal protective equipment (PPE) when caring for clients with infections, such as Ebola. Which staff member has demonstrated the most grievous error during the practice session?
- Triage nurse forgets to perform hand hygiene before donning PPE.
- Unlicensed assistive personnel performs self-inspection; then begins to doff PPE.
- Health care provider forgets to wipe shoes with disinfectant after doffing shoe covers.
- Emergency medical technician doffs both pairs of gloves first.
Ans: 4
All team members have made errors, but removing both pairs of gloves puts the emergency medical technician at the greatest risk because the outer surfaces of the remaining PPE are considered contaminated. According to the latest recommendations from the Centers for Disease Control and Prevention, the flow of donning is as follows: hand hygiene, inner gloves, shoe covers, gown, N95 respirator, hood, outer gloves, face shield, inspection (by self and trained observer), range of motion, and hand hygiene. The flow of doffing is inspection (by self and trained observer), hand hygiene, remove shoe covers, remove outer gloves, inspect inner gloves, remove face shield, hand hygiene, remove hood, hand hygiene, remove gown, hand hygiene, remove inner gloves, hand hygiene, apply new gloves, remove n95 respirator, hand hygiene, disinfect shoes, hand hygiene, remove gloves, hand hygiene, and inspection (by self and trained observer). Focus: Supervision.
The charge nurse in an emergency department (ED) and must assign two staff members to cover the triage area. Which team is the most appropriate for this assignment?
- An advanced practice nurse and an experienced RN
- An experienced LPN/LVN and an inexperienced RN
- An experienced RN and an inexperienced RN
- An experienced RN and an experienced unlicensed assistive personnel (UAP)
Ans: 1
Triage requires at least one experienced RN. Advanced practice nurses can perform medical screening exams, and this expedites treatment and decreases overall time spent in the ED. Pairing an experienced RN with an inexperienced RN provides opportunities for mentoring. This would be the second-best choice. Pairing an experienced RN with an experienced UAP is an option if licensed staff is unavailable because the UAP can measure vital signs and assist in transporting. An LPN/LVN is not qualified to perform the initial client assessment or decision making, and the expertise of the LPN/LVN could be used elsewhere in a busy ED. Focus: Assignment.
The nurse is working in the triage area of an emergency department, and the following four clients approach the triage desk at the same time. List the order in which the nurse will assess these clients.
- An ambulatory, dazed 25-year-old man with a bandaged head wound
- An irritable newborn with a fever, petechiae, and nuchal rigidity
- A 35-year-old jogger with a twisted ankle who has a pedal pulse and no deformity
- A 50-year-old woman with moderate abdominal pain and occasional vomiting
Ans: 2, 1, 4, 3
An irritable newborn with fever and petechiae should be further assessed for other signs of meningitis. The client with the head wound needs additional assessment because of the risk for increased intracranial pressure. The client with moderate abdominal pain is in discomfort, but her condition is not unstable at this point. For the ankle injury, medical evaluation could be delayed for 24 to 48 hours if necessary, but the client should receive the appropriate first aid. Focus: Prioritization; Test Taking Tip: Use knowledge of growth and development and remember that newborns have immature immune systems that are readily overwhelmed by infection. Any temperature elevation in a neonate is considered a life-threatening emergency.
When a primary survey of a trauma client is conducted, what is one of the priority actions that would be performed first?
- Obtain a complete set of vital sign measurements.
- Palpate and auscultate the abdomen.
- Perform a brief neurologic assessment.
- Check the pulse oximetry reading.
Ans: 3
A brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary survey. Measuring vital signs, assessing the abdomen, and checking pulse oximetry readings are considered part of the secondary survey. Focus: Prioritization.
A 56-year-old client comes to the triage area with left-sided chest pain, diaphoresis, and dizziness. What is the priority action?
- Initiate continuous electrocardiographic monitoring.
- Notify the emergency department health care provider. 3. Administer oxygen via nasal cannula.
- Draw blood and establish IV access.
Ans: 3
The priority goal is to increase myocardial oxygenation. The other actions are also appropriate and should be performed immediately after administering oxygen. Focus: Prioritization; Test Taking Tip: Remember to use the ABCs (airway, breathing, and circulation) in determining priorities. This is especially important when the client is in critical distress.
The client’s blood alcohol level is 0.45%. Based on this information, what is the priority nursing concept that underlies emergency medical and nursing interventions for this client?
- Cognition
- Addiction
- Gas exchange
- Functional ability
Ans: 3
At a blood alcohol level of 0.45%, the client would demonstrate respiratory depression, stupor, and coma. At 0.05%, client would display euphoria and decreased inhibitions; at 0.20%, reduced motor skills and slurred speech occur; and at 0.30%, altered perception and double vision occur. Focus: Prioritization.
A client comes to the emergency department and reports nausea, vomiting, colicky abdominal pain, fever, and tachycardia. The health care provider informs the nurse that the client probably has a strangulated intestinal obstruction with perforation. What diagnostic testing and interventions does the nurse anticipate for this emergency condition? Select all that apply.
- Preparation for surgery
- Barium enema examination
- Nasogastric (NG) tube insertion
- Abdominal radiography
- IV fluid administration
- IV administration of broad-spectrum antibiotics
Ans: 1, 3, 4, 5, 6
Strangulated intestinal obstruction is a surgical emergency. The NG tube is for decompression of the intestine. Abdominal radiography is the most useful diagnostic aid. IV fluids are needed to maintain fluid and electrolyte balance. IV broad-spectrum antibiotics are usually ordered. A barium enema examination is not ordered if perforation is suspected. Focus: Prioritization.
It is the summer season, and clients with signs and symptoms of heat-related illness come to the emergency department. Which client needs attention first?
- Older adult reports dizziness and syncope after standing in the sun for several hours to view a parade
- Marathon runner reports severe leg cramps and nausea and shows tachycardia, diaphoresis, pallor, and weakness
- Healthy homemaker reports that air conditioner has been broken for days; she has tachypnea, hypotension, fatigue, and profuse diaphoresis
- Homeless person displays altered mental status, poor muscle coordination, and hot, dry, ashen skin; duration of heat exposure is unknown
Ans: 4
The homeless person has symptoms of heat stroke, a medical emergency that increases the risk for brain damage. The older adult client is at risk for heat syncope and should be educated to rest in a cool area and avoid future similar situations. The runner is having heat cramps, which can be managed with rest and fluids. The housewife is experiencing heat exhaustion, and management includes administration of fluids (IV or oral) and cooling measures. Focus: Prioritization.
The nurse responds to a call for help from the emergency department waiting room. An older adult client is lying on the floor. List the order in which the nurse must carry out the following actions.
- Perform the chin lift or jaw thrust maneuver.
- Establish unresponsiveness.
- Initiate cardiopulmonary resuscitation (CPR).
- Call for help and activate the code team.
- Instruct unlicensed assistive personnel to get the crash cart.
Ans: 2, 4, 1, 3, 5
Establish unresponsiveness first. (The client may have fallen and sustained a minor injury.) If the client is unresponsive, get help and activate the code team. Performing the chin lift or jaw thrust maneuver opens the airway. The nurse is then responsible for starting CPR. A pocket mask or bag-valve mask is used to deliver rescue breaths. CPR should not be interrupted until the client recovers or it is determined that all heroic efforts have been exhausted. A crash cart should be at the site when the code team arrives; however, basic CPR can be effectively performed until the code team arrives. Focus: Prioritization.
Emergency medical services has transported a client with severe chest pain. As the client is being transferred to the emergency stretcher, the nurse notes unresponsiveness, cessation of breathing, and no palpable pulse. Which task is appropriate to delegate to the unlicensed assistive personnel (UAP)?
- Performing chest compressions
- Initiating bag-valve mask ventilation
- Assisting with oral intubation
- Placing the defibrillator pads
Ans: 1
UAPs are trained in basic cardiac life support and can perform chest compressions. The use of the bag-valve mask requires practice, and usually a respiratory therapist will perform this function. The nurse or the respiratory therapist should provide assistance as needed during intubation. The defibrillator pads are clearly marked; however, placement should be done by the RN or health care provider because of the potential for skin damage and electrical arcing. Focus: Delegation.
Tetanus immunizations are routinely administered during childhood and in the emergency department (ED) for clients who sustain wounds. Although the incidence of tetanus has decreased, there is still a danger. Which client represents the group that is most vulnerable for risk?
- Child who helps with the farm work sustained scratches while feeding the animals
- Newborn infant delivered in the emergency department; mother had no prenatal care
- Older adult who lives alone sustained a minor cut while cleaning the basement
- Young adult who works in an auto repair shop sustained a deep cut on a metal edge
Ans: 3
Older adults are the most likely to be nonvaccinated or undervaccinated. Tetanus usually occurs when a minor wound gets contaminated by wood, metal, or other organic material. In addition, most people would not seek medical treatment for minor wounds. Farm work offers many opportunities for injuries, but most children are usually immunized before entering elementary school (the nurse should always ask). Persons with deep cuts from industrial accidents are more likely to present to the ED for treatment. Neonatal tetanus is more likely to occur in underdeveloped countries related to poor hygienic conditions during birth. Focus: Prioritization.
A healthy but anxious 24-year-old college student reports tingling sensations, palpitations, and sore chest muscles. Deep, rapid breathing and carpal spasms are noted. What priority action should the nurse take?
- Notify the health care provider immediately.
- Administer supplemental oxygen.
- Have the student breathe into a paper bag.
- Obtain an order for an anxiolytic medication.
Ans: 3
The client is hyperventilating secondary to anxiety, and breathing into a paper bag will allow rebreathing of carbon dioxide. Also, encouraging slow breathing will help. Other treatments such as oxygen administration and medication may be needed if other causes are identified. Focus: Prioritization.
An experienced traveling nurse has been assigned to work in the emergency department (ED); however, this is the nurse’s first week on the job. Which area of the ED is the most appropriate assignment for this nurse?
- Trauma team
- Triage
- Ambulatory or fast-track clinic
- Pediatric medicine team
Ans: 3
The fast-track clinic deals with clients in relatively stable condition. The triage, trauma, and pediatric medicine areas should be staffed with experienced nurses who know the hospital routines and policies and can rapidly locate equipment. Focus: Assignment.
The nurse and group of friends are at the lake. Suddenly, someone says, “Look across the lake! It looks like someone might be drowning out there!” What is the nurse’s first action?
- Determine who is the strongest swimmer in the group. 2. Direct someone to locate a cell phone and call 911.
- Find a boat, raft, or some type of flotation device.
- Use a pair of binoculars and look across the lake.
Ans: 4
First, the nurse would gather as much data as possible. In this case, the number of potential victims; distance from shore; hazards or barriers that may affect rescue (e.g., water temperature, roughness of waves, wind, or lightning); and resources available to victim(s) or rescuers (e.g., boat, pier, closer rescuers). These data can be reported to the 911 dispatcher and used to decide whether a rescue attempt is reasonably safe for the nurse and the bystanders. Focus: Prioritization; Test Taking Tip: The step in the nursing process is assessment. In this case, assess the multiple factors that affect the safety of potential victims and rescuers. This data is then used to weigh harms and benefits.
In the care of a client who has experienced sexual assault, which task is most appropriate for an LPN/LVN to perform?
- Assessing immediate emotional state and physical injuries
- Collecting hair samples, saliva specimens, and scrapings beneath fingernails
- Providing emotional support and supportive communication
- Ensuring that the chain of custody of evidence is maintained
Ans: 3
An LPN/LVN is able to listen and provide emotional support for clients. The other tasks are the responsibility of an RN, or preferably, a sexual assault nurse examiner who has received training in assessing, collecting, and safeguarding evidence, and caring for assault victims. Focus: Assignment.