CHN Flashcards
You are 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 LPN/LVN
An experienced LPN/LVN and an inexperienced RN
An experienced RN and an inexperienced RN
An experienced RN and a nursing assistant
ANSWER C –Triage requires at least one experienced RN. Pairing an experienced RN with inexperienced RN provides opportunities for mentoring. Advanced practice nurses are qualified to perform triage; however, their services are usually required in other areas of the ED. An LPN/LVN is not qualified to perform the initial patient assessment or decision making. Pairing an experienced RN with a nursing assistant is the second best option, because the assistant can obtain vital signs and assist in transporting.
You are working in the triage area of an ED, and four patients approach the triage desk at the same time. List the order in which you will assess these patients.
An ambulatory, dazed 25-year-old male with a bandaged head wound
An irritable infant with a fever, petechiae, and nuchal rigidity
A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity
A 50-year-old female with moderate abdominal pain and occasional vomiting
ANSWER B, A, D, C
–An irritable infant with fever and petechiae should be further assessed for other meningeal signs. The patient with the head wound needs additional history and assessment for intracranial pressure. The patient with moderate abdominal pain is uncomfortable, but not unstable at this point. For the ankle injury, medical evaluation can be delayed 24 – 48 hours if necessary.
In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey?
Complete set of vital signs
Palpation and auscultation of the abdomen
Brief neurologic assessment
Initiation of pulse oximetry
ANSWER C
–A brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary survey. Vital signs, assessment of the abdomen, and initiation of pulse oximetry are considered part of the secondary survey.
A 56-year-old patient presents in triage with left-sided chest pain, diaphoresis, and dizziness. This patient should be prioritized into which category?
High urgent
Urgent
Non-urgent
Emergent
ANSWER D
–Chest pain is considered an emergent priority, which is defined as potentially life-threatening. Patients with urgent priority need treatment within 2 hours of triage (e.g. kidney stones). Non-urgent conditions can wait for hours or even days. (High urgent is not commonly used; however, in 5-tier triage systems, High urgent patients fall between emergent and urgent in terms of the time lapsing prior to treatment).
The physician has ordered cooling measures for a child with fever who is likely to be discharged when the temperature comes down. Which of the following would be appropriate to delegate to the nursing assistant?
Assist the child to remove outer clothing.
Advise the parent to use acetaminophen instead of aspirin.
Explain the need for cool fluids.
Prepare and administer a tepid bath.
ANSWER A
–The nursing assistant can assist with the removal of the outer clothing, which allows the heat to dissipate from the child’s skin. Advising and
explaining are teaching functions that are the responsibility of the RN. Tepid baths are not usually performed because of potential for rebound and shivering.
It is the summer season, and patients with signs and symptoms of heat-related illness present in the ED. Which patient needs attention first?
An elderly person complains of dizziness and syncope after standing in the sun for several hours to view a parade
A marathon runner complains of severe leg cramps and nausea. Tachycardia, diaphoresis, pallor, and weakness are observed.
A previously healthy homemaker reports broken air conditioner for days. Tachypnea, hypotension, fatigue, and profuse diaphoresis are observed.
A homeless person, poor historian, presents with altered mental status, poor muscle coordination, and hot, dry, ashen skin. Duration of exposure is unknown.
ANSWER D
–The homeless person has symptoms of heat stroke, a medical emergency, which increases risk for brain damage. Elderly patients are at risk for
heat syncope and should be educated to rest in cool area and avoid future similar situations. The runner is having heat crams, which can be managed with rest and fluids. The housewife is experiencing heat exhaustion, and management includes fluids (IV or parenteral) and cooling measures. The prognosis for recovery is good.
You respond to a call for help from the ED waiting room. There is an elderly patient lying on the floor. List the order for the actions that you must perform.
Perform the chin lift or jaw thrust maneuver.
Establish unresponsiveness.
Initiate cardiopulmonary resuscitation (CPR).
Call for help and activate the code team.
Instruct a nursing assistant to get the crash cart.
ANSWER B, D, A, C, E
–Establish unresponsiveness first. (The patient may have fallen and sustained a minor injury.) If the patient is unresponsive, get help and have someone initiate the code. Performing the chin lift or jaw thrust maneuver opens the airway. The nurse is then responsible for starting CPR. CPR should not be interrupted until the patient recovers or it is determined that 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 team arrives.
the emergency medical service (EMS) has transported a patient with severe chest pain. As the patient is being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and no palpable pulse. Which task is appropriate to delegate to the nursing assistant?
Chest compressions
Bag-valve mask ventilation
Assisting with oral intubation
Placing the defibrillator pads
ANSWER A
–Nursing assistants 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 PRN assistance during intubation. The defibrillator pads are clearly marked; however, placement should be done by the RN or physician because of the potential for skin damage and electrical arcing.
An anxious 24-year-old college student complains of tingling sensations, palpitations, and chest tightness. Deep, rapid breathing and carpal spasms are noted. What priority nursing action should you take?
Notify the physician immediately.
Administer supplemental oxygen.
Have the student breathe into a paper bag.
Obtain an order for an anxiolytic medication.
ANSWER C
–The patient 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 and medication may be needed if other causes are identified.
10.An experienced traveling nurse has been assigned to work in the ED; however, this is the nurse’s first week on the job. Which area of the ED is the most
appropriate assignment for the nurse?
Trauma team
Triage
Ambulatory or fats track clinic
Pediatric medicine team
ANSWER C –The fast track clinic will deal with relatively stable patients. Triage, trauma, and pediatric medicine should be staffed with experienced nurses who know the hospital routines and policies and can rapidly locate equipment.
A tearful parent brings a child to the ED for taking an unknown amount of children’s chewable vitamins at an unknown time. The child is currently alert and asymptomatic. What information should be immediately reported to the physician?
The ingested children’s chewable vitamins contain iron.
The child has been treated several times for ingestion of toxic substances.
The child has been treated several times for accidental injuries.
The child was nauseated and vomited once at home.
ANSWER A –Iron is a toxic substance that can lead to massive hemorrhage, coma, shock, and hepatic failure. Deferoxame is an antidote that can be used for severe cases of iron poisoning. Other information needs additional investigation, but will not change the immediate diagnostic testing or treatment plan.
In caring for a victim of sexual assault, which task is most appropriate for an LPN/LVN?
Assess immediate emotional state and physical injuries
Collect hair samples, saliva swabs, and scrapings beneath fingernails.
Provide emotional support and supportive communication.
Ensure that the “chain of custody” is maintained.
ANSWER C
–The LPN/LVN is able to listen and provide emotional support for her patients. The other tasks are the responsibility of an RN or, if available, a SANE (sexual assault nurse examiner) who has received training to assess, collect and safeguard evidence, and care for these victims.
You are caring for a victim of frostbite to the feet. Place the following interventions in the correct order.
Apply a loose, sterile, bulky dressing.
Give pain medication.
Remove the victim from the cold environment.
Immerse the feet in warm water 100o F to 105o F (40.6o C to 46.1o C)
ANSWER C, B, D, A
–The victim should be removed from the cold environment first, and then the rewarming process can be initiated. It will be painful, so give pain medication prior to immersing the feet in warmed water.
A patient sustains an amputation of the first and second digits in a chainsaw accident. Which task should be delegated to the LPN/LVN?
Gently cleanse the amputated digits with Betadine solution.
Place the amputated digits directly into ice slurry.
Wrap the amputated digits in sterile gauze moistened with saline.
Store the amputated digits in a solution of sterile normal saline
ANSWER C
–The only correct intervention is C. the digits should be gently cleansed with normal saline, wrapped in sterile gauze moistened with saline, and placed in a plastic bag or container. The container is then placed on ice.
A 36-year-old patient with a history of seizures and medication compliance of phenytoin (Dilantin) and carbamazepine (Tegretol) is brought to the ED by the MS personnel for repetitive seizure activity that started 45 minutes prior to arrival. You anticipate that the physician will order which drug for status epilepticus?
PO phenytoin and carbamazepine
IV lorazepam (Ativan)
IV carbamazepam
IV magnesium sulfate
ANSWER B
–IV Lorazepam (Ativan) is the drug of choice for status epilepticus. Tegretol is used in the management of generalized tonic-clonic, absence or mixed type seizures, but it does not come in an IV form. PO (per os) medications are inappropriate for this emergency situation. Magnesium sulfate is given to control seizures in toxemia of pregnancy.
