Lewis: Emergency and Disaster Nursing Flashcards
During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next?
Observe the patients respiratory effort.
Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is
to assess the patients breathing
During the primary survey of a patient with severe leg trauma, the nurse observes that the patients left pedal
pulse is absent and the leg is swollen. Which action will the nurse take next?
Start normal saline fluid infusion with a large-bore IV line
The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a possibly lifethreatening
injury is found during the primary survey, the nurse should immediately start interventions before
proceeding with the survey.
After the return of spontaneous circulation following the resuscitation of a patient who had a cardiac arrest, therapeutic hypothermia is ordered. Which action will the nurse include in the plan of care?
Apply external cooling device
When therapeutic hypothermia is used postresuscitation, external cooling devices or cold normal saline
infusions are used to rapidly lower body temperature to 89.6 F to 93.2 F (32 C to 34 C).
A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should
obtain a Glasgow Coma Scale score.
The Glasgow Coma Scale is included when assessing for disability during the primary survey
A 19-year-old is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of
the left hand. When asked about tetanus immunization, the patient denies having any previous vaccinations.
The nurse will anticipate giving
TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap).
For an adult with no previous tetanus immunizations, TIG and Tdap are recommended
A patient who has experienced blunt abdominal trauma during a motor vehicle collision is complaining of
increasing abdominal pain. The nurse will plan to teach the patient about the purpose of
abdominal ultrasonography.
For patients who are at risk for intraabdominal bleeding, focused abdominal ultrasonography is the preferred
method to assess for intraperitoneal bleeding
A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). The nurse determines that discharge teaching has been effective when the patient makes which statement?
I should drink sports drinks when working outside in hot weather
Electrolyte solutions such as sports drinks help replace fluid and electrolytes lost when exercising in hot
weather.
A 22-year-old patient who experienced a near drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period?
Auscultate breath sounds.
Because pulmonary edema is a common complication after near drowning, the nurse should assess the breath
sounds frequently.
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 adequate quantities of
vaccine.
Smallpox infection can be prevented or ameliorated by the administration of vaccine given rapidly after
exposure.
When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87 F (30.6 C), which assessment indicates that the nurse should discontinue active rewarming?
The core temperature is 94 F (34.4 C).
A core temperature of 89.6 F to 93.2 F (32 C to 34 C) indicates that sufficient rewarming has occurred.
When assessing an older patient admitted to the emergency department (ED) with a broken arm and facial
bruises, the nurse observes several additional bruises in various stages of healing. Which statement or question by the nurse is most appropriate?
Do you feel safe in your home?
The nurses initial response should be to further assess the patients situation
A 20-year-old patient arrives in the emergency department (ED) several hours after taking 25 to 30
acetaminophen (Tylenol) tablets. Which action will the nurse plan to take?
Give N-acetylcysteine (Mucomyst).
N-acetylcysteine is the recommended treatment to prevent liver damage after acetaminophen overdose
A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10 abdominal pain and states, I had a temperature of 103.9 F (39.9 C) at home. The nurses first action should be to
assess the patients current vital signs.
The patients 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
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 patient with paradoxic chest movements
Most immediate deaths from trauma occur because of problems with ventilation, so the patient with paradoxic
chest movements should be treated first.
The following interventions are part of the 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?
Remove the patients rings
The patients rings should be removed first because it might not be possible to remove them if swelling develops
