Emergency & Triage Flashcards
primary survey–ABCDE
ABCDE
-airway
-breathing
-circulation
-disability
-exposure
what are the most significant signs of shock
-altered mental status
-delayed capillary refill, longer than 3 secs
Anthrax
1st stage = Flu like symptoms (HA, vomiting)
2nd stage = Respiratory distress
(stridor, cyanosis, hypoxia, diaphoresis, hypotension, and shock.)
Primary Survey
Breathing
**Administer high-flow O2 via a nonrebreather mask (100%)
For life-threatening conditions
Bag-valve-mask (BVM) ventilation with 100% O2
Needle decompression
Intubation
Breathing
Assess for dyspnea, cyanosis EXAMparadoxic/asymmetric chest wall movement, decreased/absent breath sounds, visible wound to chest wall, cyanosis, tachycardia, hypotension
**visible wound to chest, put a clean saline gauze, until you bring the pt. inside the hospital
Primary Survey - Circulation
Check for central pulse
Assess for signs of shock
Mental status
Check for delayed capillary refill
Insert 2 large-bore IV catheters
Initiate aggressive fluid resuscitation using normal saline or lactated Ringer’s solution
Hypothermic pt. - Risk of rewarming
Rewarm core before extremities
Risks of rewarming
Afterdrop
**Hypotension
Dysrhythmias
#Exam#Discontinue rewarming once core temperature reaches## 89.6º to 93.2º F (32º to 34º C)
Stings
Hymenopteran stings
Remove stinger
ExamDon’t use tweezers
**Remove jewelry and restrictive clothing
A patient arrives in the emergency department (ED) after topical exposure to powdered lime at work. Which action should the nurse take first?
a. Obtain the patient’s vital signs.
b. Obtain a baseline complete blood count.
c. Decontaminate the patient by showering with water.
d. Brush off any visible powder on the skin and clothing.
ANS: D
The initial action should be to protect staff members and decrease the patient’s exposure to the toxin by decontamination. Patients exposed to powdered lime should not be showered; instead, any and all visible powder should be brushed off. The other actions can be done after the decontamination is completed.
identified on a nearby freeway. Which patient would likely be designated “red” during triage at the site?
A. An individual who is distraught at the violence of the incident
B. An individual who has experienced an open arm fracture from falling debris
C. An individual who is not expected to survive a crushing head and neck wound
D. An individual whose femoral artery has been severed and is bleeding profusely
D. An individual whose femoral artery has been severed and is bleeding profusely
Red indicates a life-threatening injury requiring immediate intervention, such as severe bleeding. Emotional trauma would not warrant a “red” designation, and a fracture would likely be deemed “yellow,” urgent but not life threatening. Those not expected to survive are categorized “blue.” “Black” identifies the dead.
Three days after experiencing a series of tick bites, a patient presents to the emergency department. Which manifestation would indicate the patient is experiencing tick paralysis?
A. Respiratory distress
B. Aggression and frequent falls
C. Decreased level of consciousness
D. Fever and necrosis at the bite sites
A. Respiratory distress
A classic manifestation of tick paralysis is flaccid ascending paralysis, which develops over 1 to 2 days. Without tick removal, the patient dies as respiratory muscles become paralyzed. Aggression, decreased level of consciousness, fever, and necrosis at the bite sites are not characteristic of the problem.
Triaging Primary and Secondary Survey
The Glasgow Coma Scale is included when assessing for disability during the primary survey.
Primary - ABC, LOC, GCS
Secondary - Vital Signs
Active core rewarming
Administer warmed IV fluids.
Active internal or core rewarming is used for moderate to severe hypothermia and involves the application of heat directly to the core. Immersion in a hot bath, rehydration, and massage are not appropriate interventions in the treatment of severe hypothermia. Passive rewarming is used in mild hypothermia.
With acetaminophen question to ask
B. “What time did you take the medication?”
Acetaminophen will bind to activated charcoal and pass through the gastrointestinal tract without being absorbed. Activated charcoal is most effective if administered within 1 hour of ingestion of acetaminophen and other select poisons.
The patient has been part of a community emergency response team (CERT) for a tropical storm in Dallas with temperatures near 100°F (37.7°C) for the past 2 weeks. When assessing the patient, the nurse finds hypotension, body temperature of 104°F (40°C), dry and ashen skin, and neurologic symptoms. What treatments should the nurse anticipate (select all that apply.)?
Select all that apply.
A. Administer 100% O2.
B. Immerse in an ice bath.
C. Administer cool IV fluids.
D. Cover the patient to prevent chilling.
E. Administer acetaminophen (Tylenol).
F. Administer chlorpromazine for shivering.
A, C, F
The patient is experiencing heatstroke. Treatment focuses first on stabilizing the patient’s ABC and rapidly reducing the core temperature. Administration of 100% O2 compensates for the patient’s hypermetabolic state. Cooling the body with IV fluids is effective. Immersion in an ice bath will cause shivers that increase core temperature, so a cool water bath should be used for conductive cooling. Removing the clothing, covering the patient with wet sheets, and placing the patient in front of a fan will cause evaporative cooling. If shivering ensues, treatment with chlorpromazine is indicated. Shivering increases core temperature due to the heat generated by muscle activity. Excessive covers will not be used. Acetaminophen will not be effective because the increase in temperature is not related to infection.
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. A patient with no pedal pulses
b. A patient with an open femur fracture
c. 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.
Unresponsive pt.
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.
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?
a. Pulse
b. Heart rhythm
c. Breath sounds
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.
While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient’s oxygen saturation (SpO2) from 94% to 88%. Which action should the nurse take next?
a.
Increase the oxygen flow rate.
b.
Suction the patient’s oropharynx.
c.
Instruct the patient to cough and deep breathe.
d.
Help the patient to sit in a more upright position.
ANS: A
Increasing oxygen flow rate will usually improve oxygen saturation in patients with ventilation-perfusion mismatch, as occurs with pulmonary embolism. Because the problem is with perfusion, actions that improve ventilation, such as deep breathing and coughing, sitting upright, and suctioning, are not likely to improve oxygenation.
A patient with respiratory failure has a respiratory rate of 6 breaths/minute and an oxygen saturation (SpO2) of 88%. The patient is increasingly lethargic. Which intervention will the nurse anticipate?
a.
Administration of 100% oxygen by non-rebreather mask
b.
Endotracheal intubation and positive pressure ventilation
c.
Insertion of a mini-tracheostomy with frequent suctioning
d.
Initiation of continuous positive pressure ventilation (CPAP)
ANS: B
The patient’s lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation with ventilator-controlled respiratory rate. Administration of high flow oxygen will not be helpful because the patient’s respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate removal of secretions, but it will not improve the patient’s respiratory rate or oxygenation. CPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange.
A nurse is caring for an obese patient with right lower lobe pneumonia. Which position will be best to improve gas exchange?
a.
On the left side
b.
On the right side
c.
In the tripod position
d.
In the high-Fowler’s position
A. Good lung down
The nurse reviews the electronic medical record for a patient scheduled for a total hip replacement. Which assessment data shown in the accompanying figure increase the patient’s risk for respiratory complications after surgery?
a. Albumin level and recent weight loss
b. Mild confusion and recent weight loss
c. Age and recent arthroscopic procedure.
d. Anemia and recent arthroscopic procedure
ANS: A
The patient’s recent weight loss and low protein stores indicate possible muscle weakness, which make it more difficult for an older patient to recover from the effects of general anesthesia and immobility associated with the hip surgery. The other information will also be noted by the nurse but does not place the patient at higher risk for respiratory failure.
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
C
The client with pale, cool, clammy skin is in shock and needs immediate medical attention. The mother does not have injuries and so would be the lowest priority. The other two people need medical attention soon, but not at the expense of a person in shock.
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?
a. Assess that the client is breathing adequately.
b. Insert a large-bore intravenous line.
c. Place the client on a cardiac monitor.
d. Assess for the best neurologic response.
A
The highest-priority intervention in the primary survey is to establish that the client is breathing adequately. Even though this client has an oxygen mask on, he or she may not be breathing, or may be breathing inadequately with the device in place.
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
C
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. The client with a chest stab wound and tachycardia and the client with new-onset confusion and slurred speech should be triaged as emergent. The client with a skin rash and a sore throat is not at risk for deterioration and would be triaged as nonurgent.
injuries is brought to the ED by ambulance. He has had his airway
stabilized and is breathing on his own. The ED nurse does not see any active bleeding, but should
suspect internal hemorrhage based on what finding?
A) Absence of bruising at contusion sites
B) Rapid pulse and decreased capillary refill
C) Increased BP with narrowed pulse pressure
D) Sudden diaphoresis
B
Feedback:
The nurse would anticipate that the pulse would increase and BP would decrease. Urine output would
also decrease. An absence of bruising and the presence of diaphoresis would not suggest internal
hemorrhage.
