Multi-Client Priority Flashcards

Question 1

Q

What is the order for assessing clients?

Answer

A

Assess clients with immediate complications first such as unconscious, airway, breathing, and circulatory issues (ABCs)
Then see clients with expected and moderate to severe pain
See psychosocial clients that are upset next
Lastly, see clients with expected or normal symptoms of a condition that are not immediate concerns

Question 2

Q

What type of clients are discharged first?

Answer

A

Discharge stable clients that are not having any complications first.

Question 3

Q

What are the ABCs?

Answer

A

Airway, Breathing, Circulation

Clients with these complications are a high priority for being seen. Chest pain and stroke symptoms are usually a higher priority than shortness of breath.

Question 4

Q

Immediate Complication

Unconscious clients are completely dependent on caregivers. What is the priority concern?

Answer

A

Make sure unconscious clients have an airway.

Question 5

Q

Immediate Complication

At what Glasgow coma score is the client typically intubated?

Answer

A

“Less than 8, intubate”

8 indicates a coma.

Question 6

Q

Immediate Complication

Why do burns have a high risk of airway problems?

Answer

A

Smoke inhalation

Always assess the airway first and give oxygen.

Question 7

Q

Immediate Complication

What is a pneumothorax?

Answer

A

A pneumothorax is a collapsed lung with air in the pleural space.

It is caused by trauma. The client will get chest tubes.

Question 8

Q

Immediate Complication

What is an anaphylactic reaction?

Answer

A

An anaphylactic reaction is an overactive response of the immune system to substances that can cause a rash or severe difficulty with breathing.

Question 9

Q

Immediate Complication

What are the steps if a client has an anaphylactic reaction?

Answer

A

assess respiration status and maintain a patent airway
call HCP and rapid response team
give oxygen
start an IV and give normal saline
prepare to give diphenhydramine and epinephrine
possible intubation and ventilator
document the event

Question 10

Q

Immediate Complication

What is the immediate action if the tracheostomy tube dislodges?

Answer

A

extend neck and open the tissues of the stoma
pull the retention sutures to spread the opening
use a tracheal dilator to hold the stoma open

Question 11

Q

Immediate Complication

What is the immediate action if the tracheostomy tube falls out within the first 72 hours?

Answer

A

If the tracheostomy tube falls out within the first 72 hours:

manually resuscitate using an Ambu bag and call the HCP.

Question 12

Q

Immediate Complication

What is an air embolism?

Answer

A

An air embolism is when air goes into the client’s IV and goes to the lungs.

Place the client in Trendelenburg position.

Question 13

Q

Immediate Complication

What is a major complication from the fracture of a large bone?

Answer

A

A fat embolism occurs when a large bone such as a femur or pelvis gets fractured.

A fat embolism is a fat blob that gets released into the bloodstream and can go to the lungs causing respiratory distress.

Question 14

Q

Immediate Complication

What is flail chest?

Answer

A

Flail chest occurs when a segment of the rib cage breaks due to trauma and becomes detached from the rest of the chest wall.

There can also be rib fractures.

Question 15

Q

Immediate Complication

What is pulmonary edema?

Answer

A

Pulmonary edema is when fluid gets backed up into the lungs.

It can be caused by left-sided heart failure, kidney failure or liver failure.

Question 16

Q

Immediate Complication

What is hypoxia?

Answer

A

Hypoxia: pulse oximetry reading < 95%.

Give oxygen.

Question 17

Q

Immediate Complication

What is acute respiratory failure (ARF)?

Answer

A

Acute respiratory failure is when there is not enough oxygen to get to the lungs or alveoli (air sacs) and CO₂ builds up in the blood.

The client becomes hypoxic and hypercapnic.

Question 18

Q

Immediate Complication

What is a pulmonary embolism?

Answer

A

A pulmonary embolism is when a blood clot goes to the lungs.

It is usually caused by a DVT.

Question 19

Q

Immediate Complication

What is acute respiratory distress syndrome (ARDS)?

Answer

A

ARDS is a form of ARF that causes inflammation and fluid to build up in the alveoli. The client is unable to get enough oxygen.

The client will be intubated and placed on a ventilator.

Question 20

Q

Immediate Complication

What is a pneumothorax?

Answer

A

A pneumothorax is a collapsed lung with air in the pleural space.

It is caused by trauma. The client will get chest tubes.

Question 21

Q

Immediate Complication

What is Guillain-Barre Syndrome?

Answer

A

Guillain-Barre Syndrome occurs after an infection where the immune system overacts and destroys the myelin sheath (the part that connects nerves).

The client gets ascending paralysis, eventually affecting the respiratory muscles.

Question 22

Q

Immediate Complication

What is a seizure?

Answer

A

A seizure is a sudden, uncontrolled electrical disturbance in the brain. It can cause changes in behavior, movements or feelings, and in levels of consciousness.

Epilepsy is a seizure disorder of two or more seizures or a tendency to have recurrent seizures.

Question 23

Q

Immediate Complication

What is an intracerebral hemorrhage?

Answer

A

An intracerebral hemorrhage is when a blood vessel within the brain has ruptured.

It can occur from a traumatic brain injury (TBI) or cerebral aneurysm.

Question 24

Q

Immediate Complication

What is a stroke?

Answer

A

A stroke is when the brain does not get enough oxygen either caused by bleeding or a blood clot.

Question 25

Q

Immediate Complication

What is a hypertensive crisis?

Answer

A

A hypertensive crisis is blood pressure greater than 200/120.

It not controlled, it can cause a hypertensive stroke.

Question 26

Q

Immediate Complication

What is angina?

Answer

A

Angina is chest pain caused by inadequate myocardial blood and oxygen supply.

Give OANM: oxygen, aspirin, nitroglycerin, and morphine.

Question 27

Q

Immediate Complication

What is an aortic aneurysm?

Answer

A

An aortic aneurysm is stretching of the arterial wall in the abdomen.

If it ruptures the client will experience pain, difficulty breathing and signs of shock.

Question 28

Q

Immediate Complication

What is cardiogenic shock?

Answer

A

Cardiogenic shock is low blood pressure caused by damage to the heart that impairs pumping ability.

It can be from myocardial infarction, tamponade, or heart failure.

Question 29

Q

Immediate Complication

What is asystole?

Answer

A

Asystole is a fatal dysrhythmia:

start CPR
epinephrine
NO defibrillation

Question 30

Q

Immediate Complication

What is ventricular tachycardia?

Answer

A

Pulseless V-tach
- CPR
- defibrillate
- epinephrine
- amiodarone (or lidocaine)
With a pulse
- amiodarone (or lidocaine)

Question 31

Q

Immediate Complication

What is ventricular fibrillation?

Answer

A

“defib the V-fib”
CPR
epinephrine
amiodarone (or lidocaine)

Question 32

Q

Immediate Complication

What is a myocardial infarction?

Answer

A

A myocardial infarction is a fatal heart condition:

give “OANM”
- oxygen
- aspirin
- nitroglycerin
- morphine
“clot busters” if caused by a clot
- T-PA
cardiac catheterization if caused by plaque

Question 33

Q

Immediate Complication

What is supraventricular tachycardia?

Answer

A

Supraventricular tachycardia can be a fatal dysrhythmia:

vagal maneuvers (carotid sinus massage, beardown/Valsalva)
cardiovert with adenosine

Question 34

Q

Immediate Complication

What is a heart block?

Answer

A

typically less than 60 beats per minute
have an elongated PR interval
will receive atropine if showing symptoms
if atropine doesn’t work, client will either get cardioversion or a pacemaker.

Question 35

Q

Immediate Complication

What is an Addisonian crisis?

Answer

A

An Addisonian crisis can cause severe fluid and electrolyte imbalances.

It is caused by stress, infection, trauma, or abrupt discontinuation of steroids.

Question 36

Q

Immediate Complication

What is a myxedema coma?

Answer

A

Myxedema coma is when the client has extremely low metabolism and goes into a coma.

Question 37

Q

Immediate Complication

What is a thyroid storm?

Answer

A

A thyroid storm is when the client has an extremely high metabolism and can get elevated temperature, blood pressure, seizures and then a coma.

Question 38

Q

Immediate Complication

What is hyperosmolar hyperglycemic syndrome (HHS) and diabetic ketone acidosis (DKA)?

Answer

A

HHS and DKA are extremely high blood sugar.

If not treated the client can go into a coma.

Question 39

Q

Immediate Complication

What is compartment syndrome?

Answer

A

Compartment syndrome is when there is too much pressure in a cast or enclosed space due to edema.

The client will either get a fasciotomy (cut the skin open) or the cast will be cut off.

Question 40

Q

Immediate Complication

What is hemorrhage?

Answer

A

Hemorrhage is severe bleeding that causes the client to go into hypovolemic shock.

The client gets a very low blood pressure and tachycardia.

Question 41

Q

Immediate Complication

What major complications can occur with fluid and electrolyte imbalances?

Answer

A

Severe fluid and electrolyte imbalances can cause life-threatening complications such as:

dysrhythmias
seizures
respiratory depression
coma

Question 42

Q

Immediate Complication

What is septic shock?

Answer

A

Septic shock is a systemic infection throughout the entire body.

It can cause very low blood pressure and tachycardia.

Question 43

Q

Immediate Complication

What is peritonitis?

Answer

A

Peritonitis is when the bowel perforates causing infection and eventually septic shock if not treated.

The client gets a rigid, hard abdomen.

Question 44

Q

Immediate Complication

What is acute angle-closure glaucoma?

Answer

A

Acute angle-closure glaucoma is sudden eye pain and possible nausea and vomiting, resulting in blindness.

The client will receive antiglaucoma meds to lower the pressure.

Question 45

Q

Immediate Complication

What are the interventions if a client has a penetrating object in the eye such as sharp metal?

Answer

A

DO NOT remove the object
cover the eye with a cup and tape in place
no bending, no straining
surgery to remove object

Question 46

Q

Immediate Complication

What is the intervention if a client gets chemicals splashed in the eye?

Answer

A

flush eyes with water for at least 15 to 20 minutes

Question 47

Q

Immediate Complication

What is an acid-base imbalance?

Answer

A

An acid-base imbalance is a circulation or breathing issue where the client has a high risk of death if it becomes severe.

Question 48

Q

Immediate Complication

What is autonomic dysreflexia?

Answer

A

Autonomic dysreflexia is when the client with a spinal injury overreacts to stimuli such as unable to urinate or have a bowel movement.

It can cause a hypertensive crisis if it becomes severe.

Question 49

Q

Immediate Complication

What is a myasthenic crisis and cholinergic crisis?

Answer

A

A myasthenic crisis and cholinergic crisis is when the client with myasthenia crisis does not get the correct amount of medicine at the correct time.

This causes muscle weakness and respiratory muscle weakness if not treated.

myasthenic crisis is undermedicated
cholinergic crisis is overmedicated

Question 50

Q

Immediate Complication

What life-threatening condition are clients at risk for after a head injury, stroke or brain surgery?

Answer

A

Increased intracranial pressure (ICP)

Increased pressure in the brain due to edema.

Question 51

Q

Immediate Complication

What are Steven’s Johnson syndrome and toxic epidermal necrolysis?

Answer

A

Steven’s Johnson syndrome and toxic epidermal necrolysis are really bad adverse reactions of many meds that cause a severe rash all over the body.

Always let the HCP know if you notice a rash, especially after the client starts a new med.

Question 52

Q

Immediate Complication

What is wound dehiscence and evisceration?

Answer

A

Dehiscence is when the surgical incision opens.
Evisceration is when the abdominal organ comes out of the incision.

Immediate intervention is to put a sterile, saline-soaked dressing over site.

Question 53

Q

Immediate Complication

What are life-threatening signs and symptoms of a blood transfusion reaction?

Answer

A

respiratory distress, dyspnea, dizziness, shortness of breath
chills, diaphoresis
back or chest pain

Antibodies are attacking the red blood cells causing decreased oxygen.

Question 54

Q

Immediate Complication

What are the steps if there’s a reaction to a blood transfusion?

Answer

A

FIRST: stop the blood transfusion
change out the tubing, but keep the IV line in
start a new bag of normal saline, 0.9%
tell the HCP and blood bank
return the blood and tubing to the blood bank
stay with the client
may have to give epinephrine for severe symptoms such as difficulty breathing

Question 55

Q

Immediate Complication

What is suicide?

Answer

A

Suicide is a psychological disorder when the client wants to kill themselves.

It is an emergency and someone needs to stay with the client at all times.

Question 56

Q

Immediate Complication

What is done if the chest tube comes out of the client’s chest wall?

Answer

A

Pinch the opening shut and apply an occlusive sterile dressing taped on 3 sides.

Question 57

Q

Immediate Complication

When should the HCP be notified about chest tubes?

Answer

A

drainage is >70 - 100 mL/hour
drainage suddenly becomes bright red or increases in the amount
chest tube comes out of client

Question 58

Q

Immediate Complication

What should be kept at the bedside for a client with chest tubes?

Answer

A

a clamp
- to check for leaks
sterile occlusive dressing
- in case the tube comes out of the client
a bottle of sterile water
- in case the tube comes out of the CDU

Question 59

Q

Immediate Complication

What is the immediate intervention if the chest tube drainage system breaks or cracks?

Sometimes the CDU falls over and breaks.

Answer

A

Put the chest tube in a bottle of sterile water to act as a water seal so air doesn’t go into the client.

Question 60

Q

Immediate Complication

In what order should clients be evacuated during a fire?

Answer

A

evacuate clients who can walk first
evacuate clients in wheelchairs next
evacuate bedridden clients last

Question 61

Q

Immediate Complication

What are 3 adverse effects (reactions) of medications?

Answer

A

anaphylactic shock or difficulty breathing
rash
significant changes in vital signs or level of consciousness

Notify the HCP immediately.

Question 62

Q

Immediate Complication

What is delirium tremens?

Answer

A

Delirium tremens is withdrawal of alcohol that occurs 48 - 72 hours after stopping alcohol.

Question 63

Q

Immediate Complication

What should the nurse do immediately if a client is being violent?

Answer

A

approach the client calmly and communicate with a calm and clear tone of voice
maintain a safe distance away from client
maintain a non-aggressive posture
listen actively and acknowledge anger
determine what their need is
call security if client does not calm down

Question 64

Q

Immediate Complication

What is serotonin syndrome?

Answer

A

Serotonin syndrome is when a client’s serotonin level increases to dangerous levels.

It is caused by taking too many sedatives at once.

Answer 65

A

Neuroleptic malignant syndrome is a rare and fatal reaction to antipsychotics.

Answer 66

A

A positive/abnormal result indicates a bad finding and that late decelerations of the fetal heart rate were noted.

Late decelerations are never a good finding.

Answer 67

A

Disseminated intravascular coagulation is a serious bleeding and clotting complication in a pregnant client with eclampsia, placenta abruptio, a dead fetus, placenta retention or infection.

The clotting factors are becoming over or underactivated.

Answer 68

A

HELLP syndrome is a condition that can cause severe bleeding in a pregnant client.

The cause is not known but associated with gestational hypertension and preeclampsia.

Answer 69

A

Eclampsia is the onset of seizures for a pregnant client with preeclampsia.

Answer 70

A

put mom in Trendelenburg position
give oxygen 8-10 liters by mask
give IV fluids
blood transfusion if needed
prepare for cesarean delivery

Answer 71

A

A prolapsed umbilical cord is when the umbilical cord drops through the open cervix into the vagina ahead of the baby.

The cord can then become trapped against the baby’s body during delivery.

Answer 72

A

Abruptio placenta is when the placenta has separated off the uterine wall.

Answer 73

A

Amniotic fluid embolism is when there is an escape of amniotic fluid into maternal circulation which can lead to respiratory failure and bleeding.

Answer 74

A

fetal heart rate is < 110 or > 160 beats/minute
meconium-stained amniotic fluids
fetal hypo or hyperactivity
severe variable or late decelerations

Answer 75

A

Late decelerations caused by placenta compression.

There is a gradual decrease in fetal heart rate. The lowest heart rate occurs after the contraction peak.

Answer 76

A

Bleeding and Infection

Answer 77

A

Hemorrhage is:

> than 1 pad per hour or
one pad that gets saturated within 15 minutes

Answer 78

A

Vaginal delivery: > 500 mL after delivery
Cesarean delivery: > 1000 mL after delivery

Answer 79

A

Respiratory distress syndrome is caused by the newborn unable to produce enough surfactant. It can occur in preterm infants.

Surfactant helps open up the lungs to breathe better.

Answer 80

A

Pathological jaundice is an increase in bilirubin and yellowing of the skin. It is caused by a hemolytic disease such as Rh incompatibility or liver disease.

It occurs before 24 hours and is a serious life-threatening condition.

Answer 81

A

Meconium aspiration syndrome is when meconium gets into the lungs and causes respiratory distress and/or pneumonia.

Answer 82

A

hold infant face down with head lower than feet
support head and jaw
give 5 back slaps
then put baby face up and give 5 chest thrusts
repeat until obstruction clears

Click HERE for a video on infant CPR and Choking treatment.

Answer 83

A

check for pulse with brachial artery
use 2 fingers or 2 thumbs for chest compressions
go down 1 1/2 inches (2 cm) for compressions

1 rescuer: 30 compressions then 2 breaths
2 rescuers: 15 compressions and then 2 breaths

Click HERE for a video on infant CPR and choking treatment.

Answer 84

A

Esophageal atresia and tracheoesophageal fistula is when the esophagus forms an unnatural connection with the trachea causing food to enter the airway.