Chapter 72: Emergency Nursing

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Which triage category refers to life-threatening or potentially
life-threatening injury or illness requiring immediate treatment?

a. Immediate Emergent
b. Non acute
c.Emergent
d. Urgent
Which phase of the psychological reaction to rape is characterized
by fear and flashbacks?

a. Heightened anxiety phase Heightened anxiety phase

b. Reorganization phase
c. Acute disorganization phase
d.Denial phase
A nurse is providing an in-service program for fellow emergency
nurses about hypothermia and rewarming methods used. The Over-the-bed heaters
nurse determines that the presentation was successful when the Explanation:
group identifies which of the following as a passive-active rewarm- Passive active rewarming uses over-the-bed heaters to the ex-
ing method? tremities and increases blood flow to the acidotic, anaerobic ex-
tremities. Cardiopulmonary bypass and warm humidified oxygen
a. Over-the-bed heaters by ventilator are examples of active core (internal) rewarming
b. Warmed humidified oxygen by ventilator methods. Forced warm air blankets are examples of active exter-
c. Forced warm air blankets nal rewarming methods.
d. Cardiopulmonary bypass
A client arrives at the emergency department and is experiencing
a severe allergic reaction to a bee sting. The client received treat- "Brightly colored clothes help to ward off bees."
ment and is being discharged. Which client statement indicates Explanation:
that additional teaching about exposure prevention is needed? To prevent insect stings, the client should avoid wearing brightly
colored clothing because it attracts bees. The client should wear
a. "I should always wear something on my feet when I'm outside." covering on the feet and avoid going barefoot because yellow
b. "If a bee comes near me, I should stay still." jackets nest and pollinate on the ground. Staying still or motionless
c. "Brightly colored clothes help to ward off bees." reduces the likelihood of being stung. Perfumes and scented
d. "I need to avoid using perfumes and scented soaps when I'm soaps attract bees and should be avoided.
going outside."
A patient is brought to the emergency department and diagnosed
Diving in an ocean
with decompression sickness. The nurse interprets this as indi-
Explanation:
cating that the patient most likely has been involved with which of
Decompression sickness occurs when patients have engaged in
the following?
diving in a lake or ocean or high-altitude flying or flying in a
commercial aircraft within 24 hours of diving. Swimming in a lake
a. Diving in an ocean
could lead to a near-drowing episode. Running a race in hot humid
b. Running a race in hot humid weather
weather would increase a person's risk for heat stroke. Working in
c. Working in a chemical plant
a chemical plant would increase the risk for chemical burns.
d. Swimming in a lake
Show acceptance of the body by touching it, giving the family
Which guideline is appropriate for a nurse to implement while
permission to touch.
helping family members cope with the sudden death of a loved
Explanation:
one?
The nurse should encourage the family to view and touch the
body if they wish, since this action helps the family to integrate the
a. Show acceptance of the body by touching it, giving the family
loss. The nurse should avoid using euphemisms such as "passed
permission to touch.
on." The nurse should avoid giving sedation to family members,
b. Inform the family that the client has passed on.
because this may mask or delay the grieving process. The nurse
c. Provide details of the factors attendant to the sudden death.
should avoid volunteering unnecessary information (e.g., client
d. Obtain orders for sedation for family members.
was drinking at the time of the accident).
The nurse is caring for a victim of a sexual assault. The client is Heightened anxiety phase
fearful and experiencing flashbacks. The nurse recognizes that the Explanation:
client is experiencing which phase of the psychological reaction During the heightened anxiety phase, the client demonstrates
to rape? anxiety, hyperalertness, and psychosomatic reactions, in addi-
tion to fear and flashbacks. The acute disorganization phase is
a. Reorganization phase characterized by shock, disbelief, guilt, humiliation, and anger.
b. Denial phase The denial phase is characterized by an unwillingness to talk.
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 Chapter 72: Emergency Nursing
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c. Heightened anxiety phase The reorganization phase occurs when the incident is put into
d.Acute disorganization phase perspective. Some clients never fully recover from rape trauma.
Administer analgesic medications as ordered.
Explanation:
During rewarming, an analgesic for pain is administered as pre-
The nurse is caring for a client in the ED with frostbite to the left
scribed because the rewarming process may be very painful.
hand. During the rewarming process of the hand, the nurse should
Frozen extremities are usually placed in a 37°C to 40°C (98.6°F to
perform which action?
104°F) circulating bath for 30- to 40-minute spans. This treatment
is repeated until circulation is effectively restored. Hemorrhagic
a. Administer analgesic medications as ordered.
blebs, which may develop 1 hour to a few days after rewarming, are
b. Rupture any hemorrhagic blebs that are noted.
left intact and unruptured. Nonhemorrhagic blisters are debrided
c. Keep the hand in the circulating bath for 1 hour.
to decrease the inflammatory mediators found in the blister fluid.
d. Have the client complete active range-of-motion exercises.
After rewarming, hourly active motion of any affected digits is
encouraged to promote maximal restoration of function and to
prevent contractures.
The nurse is administering antivenin to a patient who was bitten Measure the circumference of the arm.
on the arm by a poisonous snake. What intervention provided by Explanation:
the nurse is required prior to the procedure and every 15 minutes Before administering antivenin and every 15 minutes thereafter,
after? the circumference of the affected part is measured. Premedication
with diphenhydramine (Benadryl) or cimetidine (Tagamet) may
a. Measure the circumference of the arm. be indicated, because these antihistamines may decrease the
b.Administer diphenhydramine (Benadryl). allergic response to antivenin. Antivenin is administered as an IV
c. Assess peripheral pulses. infusion whenever possible, although intramuscular administration
d. Administer cimetidine (Tagamet). can be used.
The client has had a mastectomy on the right side
Explanation:
Contraindications to the placement of a PIV line in any specific
placement (right vs. left side) will include history of mastecto-
The intensive care unit nurse is assessing a client who is going my, arterial-venous shunt placement, peripherally inserted cen-
to require a peripheral intravenous (PIV) line for fluids. The nurse tral catheter (PICC) line placement, thrombus, trauma, and other
should consider what information in the client's health history device placements, such as splints and casts. The nurse will only
when deciding the site for the PIV? have the option to start the PIV on a site in the client's left arm if the
client has had a ride-sided mastectomy. A history of hypertension
a. The client has a fluid volume restriction does not preclude the client from having a PIV inserted in any
b. The client has hypertension specific location. Although fluid requirements are monitored more
c. The client has had a mastectomy on the right side strictly with clients who are on a fluid volume restriction, this does
d. The client has a history of falls not influence the placement of the PIV. The nurse should always
be aware of the risks of a PIV for a client with a falls history. The
tubing can be a tripping hazard, therefore, the client with a falls
history who requires a PIV should be closely monitored but this
does not preclude the client from having a PIV inserted.
The tongue
What is a common source of airway obstruction in an unconscious
Explanation:
client?
In an unconscious client, the muscles controlling the tongue com-
monly relax, causing the tongue to obstruct the airway. When
a. A foreign object
this situation occurs, the nurse should use the head-tilt, chin-lift
b. The tongue
maneuver to cause the tongue to fall back into place. If she sus-
c. edema
pects the client has a neck injury she must perform the jaw-thrust
d. Saliva or mucus
maneuver.
Jaw-thrust
A nurse is completing her annual cardiopulmonary resuscitation Explanation:
training. The class instructor tells her that a client has fallen off If a neck or spine injury is suspected, the jaw-thrust maneuver
a ladder and is lying on his back; he is unconscious and isn't should be used to open the client's airway. To perform this ma-
breathing. What maneuver should the nurse use to open his neuver, the nurse should position herself at the client's head and
airway? rest her thumbs on his lower jaw, near the corners of his mouth.
She should then grasp the angles of his lower jaw with her fingers
a. Jaw-thrust and lift the jaw forward. The head tilt-chin lift maneuver is used to
b. Abdominal thrust open the airway when a neck or spine injury isn't suspected. To
c. Seldinger perform this maneuver the nurse places two fingers on the chin
d. Head tilt-chin lift and lifts while pushing down on the forehead with the other hand.
The abdominal thrust is used to relieve severe or complete airway
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 Chapter 72: Emergency Nursing
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obstruction caused by a foreign body. The Seldinger maneuver is
a method of percutaneous introduction of a catheter into a vessel.
Which medication reverses severe respiratory depression and
Naloxone hydrochloride
coma?
Explanation:
Naloxone hydrochloride, a narcotic antagonist, reverses respi-
a. Flumazenil
ratory depression and coma. Diazepam is a benzodiazepine.
b. N-acetylcysteine
Flumazenilis a benzodiazepine antagonist. N-acetylcysteine is
c. Diazepam
used for acetaminophen toxicity.
d. Naloxone hydrochloride
Positioning the hands in the midline slightly above the umbilicus
When preparing to perform abdominal thrusts on a client with an Explanation:
airway obstruction, which of the following would be most appro- When performing abdominal thrusts, the nurse would place the
priate? thumb side of one fist against the client's abdomen in the midline
slighlty above the umbilicus and well below the xiphoid process,
a. Having the conscious client lie down grasping the fist with the other hand. Then the nurse would press
b. Using a sequence of four thrusts, each progressing in intensity the fist into the client's abdomen with a quick inward and upward
c. Placing the thumb side of one hand at the xiphoid process thrust such that each new thrust should be a separate and distinct
d. Positioning the hands in the midline slightly above the umbilicus maneuver. The unconscious client is positioned on the back. The
client who is conscious should be standing or sitting.
A nurse is providing care to an older adult client who has frostbite Massaging the feet
of the feet. Which action would be least appropriate? Explanation:
For a client with frostbite, massaging the affected body part is
a. Massaging the feet contraindicated. Analgesia is given for pain during the rewarm-
b. Placing sterile cotton between the toes after rewarming ing process because it can be very painful. Ambulation would
c. Restricting ambulation be restricted. Once rewarmed, sterile gauze or cotton is placed
d. Providing an analgesic for pain between the affected toes to prevent maceration.
A nurse is preparing to assist with a gastric lavage for a client
who has ingested an unknown poison and is obtunded. To ensure
that the tube reaches the stomach, the nurse would measure the Xiphoid process
distance from the bridge of the nose to which of the following? Explanation:
The nurse measures the tube from the bridge of the nose to the
a. Umbilicus xiphoid process to ensure that the tube reaches the stomach on
b. Ear lobe insertion.
c. Xiphoid process
d. Chin
A nurse is assessing a patient who is suspected of having a partial
Spontaneous coughing
airway obstruction. Which of the following would the nurse expect
Explanation:
to find?
If a patient can breathe and cough spontaneously, a partial airway
obstruction should be suspected. If the patient demonstrates a
a. Severe respiratory distress
weak, ineffective cough, high-pitched noise while inhaling, in-
b. High-pitched noises on inhalation
creased respiratory difficulty, or cyanosis, the patient should be
c. Spontaneous coughing
managed as if there were a complete airway obstruction.
d. Cyanosis
"We did everything we could possibly do to try to save his life."
Explanation:
The nurse is caring for an intensive care unit client who has died In order to help the family cope with the sudden death of their
with family members at the bedside. The death was sudden and loved one, it is helpful for the nurse to explain that the care team
unexpected resulting from a car accident that took place three employed all medical interventions possible to try to save the
days ago. The family is upset and the client's partner, crying loudly, client's life. With the support of other members of the health care
yells, "How did this happen? We were just about to celebrate his team, the nurse can take the time to explain what life saving
birthday. He can't be gone!" The family member continues to cry treatments were rendered. The nurse should avoid giving sedation
inconsolably. How should the nurse respond? to family members; this may mask or delay the grieving process,
which is necessary to achieve emotional equilibrium and to pre-
a." I will get you some medication that will help you feel more vent prolonged depression. It is important that the nurse avoid
calm." using euphemisms such as "passed on." Instead the nurse should
b."It is important to face the reality that he is gone." show the family that he or she cares by touching, and offering
c. "He has passed on to a better place now." coffee, water, and the services of a chaplain. The nurse should
d. "We did everything we could possibly do to try to save his life." encourage the family to express emotion including events leading
up to the event that led to the client's death. The nurse should not
challenge initial feelings of anger or denial.

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 Chapter 72: Emergency Nursing
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Delirium
The nurse has come on shift to find that a client newly admitted Explanation:
to the ICU is confused and persistently trying to get out of bed Delirium is a confused state that has a sudden onset and can last
despite being comforted and re-oriented by the nurse. The client hours to days or weeks; it is characterized by hyperactivity and
begins to pull on the peripheral intravenous line in the hand and has the potential to be reversible. The client who quickly becomes
speaking in non-sensical terms. The client's history indicates a confused and agitated while attempting to pull out IV lines and get
sudden onset of neurological symptoms after developing a bacte- out of bed is experiencing delirium. The nurse caring for this client
rial infection. The nurse anticipates providing care for which health should anticipate the need to provide close monitoring to prevent
problem? injury. Although clients can experience a high level of stress with
both pain and anxiety, which often accompany one another, these
a.Fever problems do not cause confusion and disorientation. Nursing in-
b. Delirium terventions would be aimed at reducing pain and anxiety with the
c. Pain use of medications and other non-pharmacological interventions
d. Anxiety that enhance client comfort. Although fever can accompany delir-
ium, it does not produce confusion and disorientation on its own.
Explore possible causes of the client's fear
Explanation:
The client is exhibiting a fear of falling. For a client who has
not mobilized in days due to mechanical ventilation and other
medication interventions in the intensive care unit (ICU), ICU-ac-
quired weakness is a reality. The client's concerns should be
The nurse is providing care to a client who will be ambulating for addressed by exploring the possible reasons for the fear of falling
the first time after being extubated. The client tells the nurse, "I first. The client may be experiencing pain, dizziness or self-doubt.
don't want to do this today. It's too soon and I am afraid I am not By identifying this cause, the nurse will be able to formulate the
strong enough." What intervention should the nurse implement next action. The risk for falls is not due to cognitive impairment.
first for the client's fear of falling? This is evident in that the client is aware of current limitations
and as a result is fearful. Preventative and rehabilitative mea-
a. Clear the area around the bed sures to counter ICU-acquired weakness generally include early
b. Evaluate the client for cognitive impairment identification and treatment of potential causes of multiple organ
c. Explore possible causes of the client's fear failure (in particular severe sepsis and septic shock), avoiding un-
d. Allow the client to remain on bedrest necessary deep sedation and hyperglycemia, promotion of early
mobilization, and thoughtful decisions regarding the risks versus
benefits of corticosteroids. For these reasons, the client should not
be encouraged to continue to have bedrest. Although the nurse
should ensure the area around the bed is free of clutter to prevent
a fall, this does not address the client's anxiety related to the fear
of falling.
A nurse is caring for a client who is experiencing alcohol withdraw-
The client agrees to detoxification, rehabilitation, and participation
al. Which statement best indicates that the client understands the
in an aftercare program.
need for long-term treatment?
Explanation:
Detoxification, rehabilitation, and participation in an aftercare pro-
a. The client agrees to attend supportive counseling
gram are the only options that address the client's long-term
b. The client agrees to ongoing participation in one or more sup-
treatment needs. Supportive counseling, family involvement, and
port groups.
support-group participation are important aspects of the treatment
c. The client agrees to detoxification, rehabilitation, and participa-
process, but they don't address the client's need for long-term
tion in an aftercare program.
treatment.
d. The client agrees to involve his family in psychotherapy.
N-acetylcysteine
Acetaminophen overdose is treated with administration of which
Explanation:
medication?
Treatment of acetaminophen overdose includes administration
of N-acetylcysteine. Flumazenil is administered in the treatment
a. Diazepam
of nonbarbiturate sedative overdoses. Naloxone is administered
b. Naloxone
in the treatment of narcotic overdoses. Diazepam may be ad-
c. Flumazenil
ministered to treat uncontrolled hyperactivity in the client with a
d. N-acetylcysteine
hallucinogen overdose.
A client has a gaping wound on his forearm that is bleeding Brachial
profusely. Applying pressure to which pressure point would be Explanation:
most helpful? The pressure point at the brachial artery would be most ap-
propriate because this site is proximal to the bleeding site. The
a. Subclavian femoral pressure point would be useful for bleeding in the lower
b. Femoral extremities. The radial pressure point would be appropriate for
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c. Radial bleeding in the wrist and hands. The subclavian pressure point
d. Brachial would be used for bleeding in the upper anterior chest area.
Nursing students are reviewing the categories of intra-abdominal
injuries. The students demonstrate understanding of the infor-
mation when they identify which of the following as examples of Gunshot wound
penetrating trauma? Select all that apply. Knife-stab wound
Explanation:
a. Being struck with a baseball bat Examples of penetrating trauma include gunshot wounds and
b. Motor-vehicle crash stab wounds. Motor vehicle crashes, falls, and being struck with
c. Gunshot wound a baseball bat are examples of blunt trauma.
d. Knife-stab wound
e. Fall from a roof
A patient who has accidentally ingested toilet bowel cleaner is
Induced vomiting
brought to the emergency department. Which action would NOT
Explanation:
be appropriate for the nurse to implement?
Vomiting is never induced after ingestion of caustic substances
(acid or alkaline) such as toilet bowl cleaner because the sub-
a. Gastric lavage
stance is corrosive to the tissues. Appropriate actions include
b. Induced vomiting
dilution with milk or water, gastric lavage, and administration of
c. Dilution with water or milk
activated charcoal.
d. Administration of activated charcoal
Which solid organ is most frequently injured in a penetrating
trauma? Liver
Explanation:
a. Lung The most frequently injured solid organ in a penetrating trauma is
b. Pancreas the liver because of its size and anterior placement in the right
c. Brain upper quadrant of the abdomen.
d. Liver
Assessing the client's Glasgow Coma Scale score
Explanation:
The primary survey focuses on stabilizing life-threatening con-
The ED staff work collaboratively and follow the ABCDE method
ditions. The ED staff work collaboratively and follow the ABCDE
to establish and treat health priorities effectively in a client expe-
(airway, breathing, circulation, disability, exposure) method. While
riencing a trauma. Which action is completed by the nurse when
implementing the D element, the nurse determines neurologic
implementing the "D" element of this method?
disability by assessing neurologic function using the Glasgow
Coma Scale and performing a motor and sensory evaluation of
a. Providing cervical spine protection
the spine. A quick neurologic assessment may be performed using
b. Assessing the client's Glasgow Coma Scale score
the AVPU mnemonic: A, alert: is the client alert and responsive? V,
c. Managing hypothermia
verbal: does the client respond to verbal stimuli? P, pain: does the
d. Undressing the client quickly
client respond only to painful stimuli? U, unresponsive: is the client
unresponsive to all stimuli, including pain? The other interventions
are not included in this element of the primary survey.
A client present to the ED following a work-related injury to the
left hand. The client has an avulsion of the left ring finger. Which
Tissue tearing away from supporting structures
correctly describes an avulsion?
Explanation:
An avulsion is described as a tearing away of tissue from support-
a. Tissue tearing away from supporting structures
ing structures. A laceration is a skin tear with irregular edges and
b. Incision of the skin with well-defined edges, usually long rather
vein bridging. Abrasion is denuded skin. A cut is an incision of the
than deep
skin with well-defined edges, usually long rather than deep.
c. Denuded skin
d. Skin tear with irregular edges and vein bridging
A patient with frostbite to both lower extremities from exposure to
the elements is preparing to have rewarming of the extremities.
Administer an analgesic as ordered.
What intervention should the nurse provide prior to the proce-
Explanation:
dure?
During rewarming, an analgesic for pain is administered as pre-
scribed, because the rewarming process may be very painful.
a. Administer an analgesic as ordered.
To avoid further mechanical injury, the body part is not handled.
b. Elevate the legs.
Massage is contraindicated.
c. Massage the extremities.
d. Apply a heat lamp.

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 Chapter 72: Emergency Nursing
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Prothrombin time (PTT)
Explanation:
Prothrombin time (PTT) is assessed in the blood work to identify
coagulopathy or presence of chemically induced anticoagulation.
The nurse in an intensive care unit is caring for a client who
This client is receiving heparin, an intravenous medication that
requires blood work to assess for changes in blood coagulation
helps to prevent the formation of clots; therefore, the PTT must
due to heparin therapy. Which test should the nurse expect to see
be monitored regularly to ensure the medication remains within
prescribed for this value to be assessed?
the therapeutic range. The client's white blood cell (WBC) reflects
a count of this blood component to detect elevation of these cells,
a. Arterial blood gas (ABG)
which is related to increased physiological stress. Typically this
b. Prothrombin time (PTT)
stress is infection, but it can also increase when there is trauma.
c. White blood cell (WBC)
Lactate would be drawn with the blood work to determine acidosis
d. Lactate
and need for continued resuscitation. Arterial blood gas (ABG)
is evaluated to determine pH for the presence of acidosis, the
base deficit for resuscitation evaluation, and ventilation parame-
ters (PaCO2, PaO2).
Hypovolemia
A nurse is caring for a client who has arrived at the emergency de-
Explanation:
partment in shock. The nurse intervenes based on the knowledge
Types of shock include cardiogenic, neurogenic, anaphylactic, and
that which of the following is the most common cause of shock?
septic. Of these, the most common cause is hypovolemia.
Stab
Explanation:
A client comes to the emergency department after experiencing A stab wound is an incision of the skin with well-defined edges
a wound. Inspection reveals an opening in the skin with distinct and is typically deeper than long. It is usually caused by a sharp
edges and whose depth is greater than the length of the wound. instrument. A laceration is a tear in the skin with irregular edges
The nurse documents this as which type of wound? and vein bridging. An avulsion is manifested as a tearing away of
tissue from the supporting structures. A patterned wound takes on
the outline of the object causing the wound.
Rinsing the area with copious amounts of water
Explanation:
The priority for any chemical burn is to immediately drench the
A nurse is providing an educational program for a group of occu-
area with running water, unless the chemical is lye or white phos-
pational health nurses working in chemical facilities. Which of the
phorus, which should be brushed off the patient. Antimicrobial
following would the nurse include as the priority in the case of a
ointments, sterile dressings, and tetanus prophylaxis are mea-
chemical burn?
sures instituted later in the course of treatment, depending on the
characteristics of the chemical agent and the size and location of
the burn.
"My brother got sick like me after eating the same food."
Explanation:
The statement about the patient's brother also being sick after
eating the same food suggests food poisoning. Feeling sick to the
Which of the following statements would most lead a nurse to stomach for 3 to 4 days could indicate various problems, not just
suspect that a patient is experiencing food poisoning? food poisoning. Food tasting or looking fine does not really indi-
cate anything definitive about the patient's condition. Most foods
causing bacterial poisoning do not have unusual odor or taste. A
pain in the left groin area is more suggestive of appendicitis, not
food poisoning.
Serum amylase
Explanation:
A client presents to the ED with a stab wound to the abdomen Serum amylase is analyzed to detect increasing levels, which sug-
following an assault. It is suspected that the client has an injury to gests pancreatic injury or perforation of the gastrointestinal tract.
the pancreas. Which laboratory study is used to detect pancreatic A white blood cell count is done to detect an elevation. Urinalysis
injury? is done to detect hematuria. A hemoglobin and hematocrit test
is done to evaluate trends reflecting the presence or absence of
bleeding.
pulmonary edema.
Explanation:
Resultant pathophysiologic changes and pulmonary injury de-
pend on the type of fluid (fresh or salt water) and the volume
aspirated. Freshwater aspiration results in a loss of surfactant and
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therefore an inability to expand the lungs. Saltwater aspiration
leads to pulmonary edema from the osmotic effects of the salt
within the lungs. If a person survives submersion, acute respi-
A client is admitted to the ED after a near-drowning accident.
ratory distress syndrome, resulting in hypoxia, hypercarbia, and
The client is diagnosed with saltwater aspiration. The nurse will
respiratory or metabolic acidosis, can occur. The client would
observe the client for several hours to monitor for symptoms of
experience hypernatremia. Hypothermia and head injury may be
associated with near drowning but would be apparent at the time
of admission and would not develop after several hours.
"Let's talk about this. Do you want me to call a support person?"
Explanation:
The client should be reassured that anxiety is natural and asked
The nurse is caring for a client in the ED following a sexual assault. whether a support person may be called. The goals of manage-
The client is hysterical and crying. The client states, "I know I'm ment are to provide support, reduce the client's emotional trau-
pregnant now, maybe I have HIV. Why did this happen to me?" ma, and gather available evidence for possible legal proceedings.
Which is the best response by the nurse? Throughout the client's stay in the ED, the client's privacy and
sensitivity must be respected. The client may exhibit a wide range
of emotional reactions, such as hysteria, stoicism, or feelings of
being overwhelmed. Support and caring are crucial.
The client has had a mastectomy on the right side
Explanation:
Contraindications to the placement of a PIV line in any specific
placement (right vs. left side) will include history of mastecto-
my, arterial-venous shunt placement, peripherally inserted cen-
tral catheter (PICC) line placement, thrombus, trauma, and other
device placements, such as splints and casts. The nurse will only
The intensive care unit nurse is assessing a client who is going
have the option to start the PIV on a site in the client's left arm if the
to require a peripheral intravenous (PIV) line for fluids. The nurse
client has had a ride-sided mastectomy. A history of hypertension
should consider what information in the client's health history
does not preclude the client from having a PIV inserted in any
when deciding the site for the PIV?
specific location. Although fluid requirements are monitored more
strictly with clients who are on a fluid volume restriction, this does
not influence the placement of the PIV. The nurse should always
be aware of the risks of a PIV for a client with a falls history. The
tubing can be a tripping hazard, therefore, the client with a falls
history who requires a PIV should be closely monitored but this
does not preclude the client from having a PIV inserted.
Foot
Explanation:
PIV lines should rarely be used in the foot for various reasons.
They limit the client's ability to ambulate and tend to occlude easily.
These types of IVs should never be used in clients with diabetes
The nurse is caring for a client with diabetes who requires a
due to the risk that the client has neuropathy and cannot feel injury
peripheral intravenous (PIV) line for antibiotic administration and
caused by the IV catheter. IV lines in the forearm and hands are
to treat dehydration. The nurse must avoid inserting which type of
acceptable and are commonly used sites. These sites would be
PIV?
safe to use for a client with diabetes. The upper arm is a site
of choice for the insertion of a peripherally inserted central line
(PICC) not a PIV line. Although, this site would not be an option
for a PIV line, it would be safe for use in a client with diabetes if
warranted.

Pulmonary edema
Explanation:
The nurse should suspect the client has developed pulmonary
edema, which is frequently seen in clients who abuse/overdose on
The nurse has received a client into care who was admitted
narcotics. Many drugs — ranging from illegal drugs such as heroin
with a heroin overdose. The client has a 5-year history of illicit
and cocaine to aspirin — are known to cause noncardiogenic
substance use with cocaine, heroine and oxycodone. The client
pulmonary edema. Pneumonia is not the likely cause given the
develops a sudden onset of wheezing, restlessness and a cough
sudden onset of respiratory symptoms accompanied but coughing
that produces a frothy, pink sputum. The nurse suspects the client
up the pink frothy sputum. The client's history of illicit substance
has most likely developed which complication of opioid overdose?
use and now overdose on these drugs should lead the nurse to
suspect pulmonary edema is the cause of the sudden onset of
these symptoms over congestive heart failure, in which clients
have a more gradual onset of respiratory issues. Although a panic
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attack can manifest in shortness or breath and restlessness, the
client would not be wheezing or producing blood tinged sputum
with a cough. Panic attacks do, however, have a sudden onset and
can cause the client chest pain and a sense of doom.
Which term refers to injuries that occur when a person is caught
between objects, run over by a moving vehicle, or compressed by Crush injuries
machinery?
A client is brought to the emergency department by ambulance.
Document the client's condition and absence of friends or family
The client is seriously ill and unconscious. No family or friends are
for obtaining consent to treatment.
present. Which of the following would be most appropriate to do?
When providing care to a client who has experienced multiple
The client is assumed to have a spinal cord injury until proven
trauma, which of the following would be most important for the
otherwise.
nurse to keep in mind?
Establish airway and ventilation
Control hemorrhage
A nurse is caring for a patient with multiple injuries and performs
Prevent and treat shock
the following. Place these actions in the order in which the nurse
Assess for head and neck injuries
would perform them. Use all options.
Assess for abdomen, back, and extremity injuries
Splint fractures
The nurse is caring for a client in the ED with frostbite to the left
hand. During the rewarming process of the hand, the nurse should Administer analgesic medications as ordered.
perform which action?
The nurse received a patient from a motor vehicle accident who
is hemorrhaging from a femoral wound. What is the initial nursing Apply firm pressure over the involved area or artery.
action for the control of the hemorrhage?
Assessing for manifestations of hemorrhage
The nurse is admitting a patient with a penetrating abdominal
Covering any protruding viscera with sterile dressings soaked in
injury from a knife wound. What should the nursing measures for
normal saline solution
a penetrating abdominal injury include? (Select all that apply.)
Looking for any associated chest injuries
Assess and document any bruises and lacerations.
A female patient was sexually assaulted when leaving work. When
Record a history of the event, using the patient's own words.
assisting with the physical examination, what nursing interven-
Label all torn or bloody clothes and place each item in a separate
tions should be provided? (Select all that apply.)
brown bag so that any evidence can be given to the police.
Stage III
Explanation:
Lyme disease has three stages. Stage I presents with a classic
"bull's-eye" rash (i.e., erythema migrans) and flulike signs and
A patient was bitten by a tick 3 months ago and is now having
symptoms that may include chills, fever, myalgia, fatigue, and
muscle aches as well as joint pain and swelling. The patient
headache. If antibiotics are not administered, stage II Lyme dis-
is having difficulty with self care and requires assistance with
ease may present within 4 to 10 weeks following the tick bite and
activities of daily living (ADLs). What stage of Lyme disease does
may manifest with joint pain, memory loss, poor motor coordina-
the nurse recognize the patient is in?
tion, and meningitis. Stage III can begin anywhere from weeks
to more than a year after the bite and has serious long-term
chronic sequelae, including arthritis, neuropathy, myalgia, and
myocarditis.
The nurse in the hospital emergency department is assessing a
patient who fell while intoxicated with alcohol. The nurse is using
the Clinical Institute Withdrawal Assessment-Alcohol (CIWA-A)
"Are you hearing anything that is disturbing you?"
scale to assess the patient's need for a benzodiazipine medica-
tion. In order to assess for auditory disturbances, which question
should the nurse ask the patient?

The nurse has come on shift to find that a client newly admitted
to the ICU is confused and persistently trying to get out of bed
despite being comforted and re-oriented by the nurse. The client
Delirium
begins to pull on the peripheral intravenous line in the hand and
speaking in non-sensical terms. The client's history indicates a
sudden onset of neurological symptoms after developing a bacte-

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 Chapter 72: Emergency Nursing
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rial infection. The nurse anticipates providing care for which health
problem?
The health care team in an intensive care unit have experienced
a critical incident in which a young client died unexpectedly and
the client's father physically attacked the senior physician treating
the client. The client's father was arrested and escorted from the
Debriefing
intensive care unit by police, against his will and in handcuffs. A
critical incident stress management (CISM) staff meeting held 3
days after the incident took place. What would be the purpose for
that meeting?
Which solution should the nurse use to replace lost fluids in a
Lactated Ringer solution
client with signs and symptoms of shock due to hemmorhaging?
Intoxication
Explanation:
A client suffering from carbon monoxide poisoning appears intox-
The nurse is caring for a client suffering from carbon monoxide
icated (from cerebral hypoxia). Other signs and symptoms include
poisoning. The nurse will expect the client to exhibit which mani-
headache, muscular weakness, palpitation, dizziness, and mental
festation?
confusion. The skin coloring in the client with carbon monoxide
poisoning can range from pink to cherry red to cyanotic and pale
and is not a reliable diagnostic sign.
The nurse is conducting a secondary survey on a client in the ED.
Diagnostic and laboratory testing
Which action is completed during the secondary survey?
A homeless client presents to the ED. Upon assessment, the
client is experiencing hypothermia. The nurse will plan to complete Attach a cardiac monitor
which priority intervention during the rewarming process?
A client present to the ED following a work-related injury to the
left hand. The client has an avulsion of the left ring finger. Which Tissue tearing away from supporting structures
correctly describes an avulsion?
A patient brought to the ED by the rescue squad after getting off a
plane at the airport is complaining of severe joint pain, numbness,
Ensure a patent airway and that the patient is receiving 100%
and an inability to move the arms. The patient was on a diving
oxygen.
vacation and went for a last dive this morning before flying home.
What is a priority action by the nurse?
The nurse has commenced a transfusion of fresh frozen plasma
(FFP) and notes the client is exhibiting symptoms of a transfusion
Run a normal saline line to keep the vein open
reaction. After the nurse stops the transfusion, what is the next
required action?
The nurse is providing care to a client who will be ambulating for
the first time after being extubated. The client tells the nurse, "I
don't want to do this today. It's too soon and I am afraid I am not Explore possible causes of the client's fear
strong enough." What intervention should the nurse implement
first for the client's fear of falling?
A nurse is providing inservice education for staff members about
evidence collection after sexual assault. The educational session
Supporting the client's emotional status
is successful when staff members focus their initial care on which
step?
Which category of triage encompasses clients with serious health
Urgent
problems that are not immediately life threatening?
Permanent brain injury or death will occur within which time frame
3 to 5 minutes
secondary to hypoxia?
A nurse is providing care to a client in the emergency department
and walks into the hallway to get equipment. All of a sudden,
Protecting himself or herself
gunshots are heard. Which of the following would be the nurse's
priority?
As part of an emergency department team, an emergency nurse is
conducting a secondary survey on a client. Which of the following Applying electrocardiogram electrodes
would the nurse include?
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 Chapter 72: Emergency Nursing
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A client is brought to the emergency department after being
involved in a motor vehicle collision. Which of the following would Delayed capillary refill
lead the nurse to suspect internal bleeding?
A nurse is providing care to the family of a client who was brought
Ask the family if they would like to view the body.
to the emergency department and suddenly died. Which of the
Provide a private place for the family to be together.
following would be appropriate for the nurse to do? Select all that
Allow the family to express their emotions freely.
apply.
An 85-year-old client is admitted to the ED. Heat stroke is sus-
pected. The client's core temperature is 106.2°F (41.2°C), blood
pressure (BP) 90/60 mm Hg, and pulse 102 bpm. The nurse immersion of the client in a cold-water bath.
understands that the primary treatment measure for the client will
include
The nurse in the ED is triaging patients during the shift. What does
Establishing an airway.
the nurse know is the first priority in treating any patient in the ED?
The nurse educator is providing orientation to a group of nurses
newly hired to an intensive care unit. The group of nurses are cor-
Hypovolemic
rect in stating which is the most common type of shock managed
in critical care?
After inserting an oropharyngeal airway, the nurse determines that
it is in the proper position when the flange is located at which Approximately at the patient's lips
position?
For a patient who is experiencing multiple injuries, which se-
Establish an airway, control hemorrhage, prevent hypovolemic
quence of medical or nursing management would the nurse iden-
shock, assess for head injuries.
tify as a priority?
A patient arrives at the emergency department after sustaining a
gunshot wound to the abdomen. When assessing the patient, the Liver
nurse pays particular attention to which of the following?
• Patient with laryngeal edema secondary to anaphylaxis
• Patient with an obstructed larynx
• Patient with extensive facial trauma
A nurse who is a member of an emergency response team an-
ticipates that several patients with airway obstruction may need a Cricothyroidotomy is used in emergencies when endotracheal
cricothyroidotomy. For which of the following patients would this intubation is either not possible or contraindicated. Examples
procedure be appropriate? Select all that apply. include airway obstruction from extensive maxillofacial trauma,
cervical spine injury, laryngospasm, laryngeal edema after an
allergic reaction or extubation, hemorrhage into neck tissue, and
obstruction of the larynx.
Nursing students are reviewing information about anaphylactic Medications
reactions and their possible causes. The students demonstrate Latex
understanding of this information when they identify which of the Insect stings
following as a common cause? Select all that apply. Shellfish
A client presents to the ED reporting choking on a chicken bone.
The client is breathing spontaneously. The nurse applies oxygen
Encourage the client to cough forcefully.
and suspects a partial airway obstruction. Which action should the
nurse do next?
The nurse is caring for a client who is being prepared for the
placement of a central intravenous line. The nurse recognizes this The client requires total parenteral nutrition
client requires this type of intravenous access for which reason?
The nurse is administering antivenin to a patient who was bitten
on the arm by a poisonous snake. What intervention provided by
Measure the circumference of the arm.
the nurse is required prior to the procedure and every 15 minutes
after?
A client is brought to the emergency department with severe hem-
orrhage requiring masssive blood replacement. The nurse warms
the blood in a commercial warmer based on the understanding Cardiac arrest
that infusion of large amounts of blood could result in which of the
following?
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 Chapter 72: Emergency Nursing
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A client undergoes a total abdominal hysterectomy. When assess-
ing the client 10 hours later, the nurse identifies which finding as Confusion
an early sign of shock?
A client suspected of acetaminophen (Tylenol) toxicity reports that
he ingested the medication at 7 p.m. At what time should the nurse 11:00 p.m.
anticipate laboratory tests to assess the acetaminophen level?
A high school football player is brought to the emergency de-
partment after collapsing at practice in extremely hot and humid
Delirium
weather. Which of the following would lead the nurse to suspect
that the client is experiencing heat stroke?
When assessing a client with suspected carbon monoxide poi-
Cherry red skin color
soning, which finding would be least reliable?
A patient has undergone a diagnostic peritoneal lavage. The nurse
Evidence of feces
interprets which result as indicating a positive test?
A nurse is establishing a patient's airway. Which action would the
Repositioning the patient's head
nurse perform first?
A patient is brought to the emergency department after being
locked outside of her house in the frigid weather for several hours.
Hand that is insensitive to touch
The nurse suspects that the patient has sustained frostbite of her
hand based on which of the following findings?
The nurse is administering 100% oxygen to a patient with car- 4%
bon monoxide poisoning and obtains a carboxyhemoglobin level. Explanation:
Which level would the nurse interpret as indicating that oxygen Oxygen is administered until the carboxyhemoglobin level is less
therapy can be discontinued? than 5%
A client presents to the ED following a chemical burn. The client
identifies the source of the burn as white phosphorus. The nurse No application of water to the burn.
knows that treatment will include
Following a motor vehicle collision, a client is brought to the ED
for evaluation and treatment. The client is being assessed for
intra-abdominal injuries. The client reports severe left shoulder spleen
pain (pain score of 10 on a 1 to 10 scale). The nurse suspects
injury to the
A triage nurse in the ED determines that a patient with dyspnea
and dehydration is not in a life-threatening situation. What triage Urgent
category will the nurse choose?
Upside down and then rotated 180 degrees

The nurse is caring for a patient in the ED who is breathing but Explanation:
unconscious. In order to avoid an upper airway obstruction, the The nurse should insert the oropharyngeal airway with the tip
nurse is inserting an oropharyngeal airway. How would the nurse facing up toward the roof of the mouth until it passes the uvula
insert the airway? and then rotate the tip 180 degrees so that the tip is pointed down
toward the pharynx. This displaces the tongue anteriorly, and the
patient then breathes through and around the airway.
A patient is brought to the ED by a friend, who states that a tree fell Applying a clean dressing to protect the wound
on the patient's leg and crushed it while they were cutting firewood. Elevating the site to limit the accumulation of fluid in the interstitial
What priority actions should the nurse perform? (Select all that spaces
apply.) Splinting the wound in a position of rest to prevent motion
A nurse is preparing an in-service education program about emer-
gency nursing to a group of newly hired nurses who will be working
Clients with Medicaid use the emergency department more often
in the emergency department. When describing the current status
than clients with private health insurance.
of visits to the emergency department, which of the following
would the nurse include in the presentation?
Stridor
Which of the following would the nurse identify as indicating that
Cyanosis
a client is experiencing a complete airway obstruction? Select all
Clutching of the neck
that apply.
Inability to speak

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 Chapter 72: Emergency Nursing
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A patient is brought to the emergency department. Assessment 10,500 mg
reveals that the patient is lethargic and diaphoretic and com- Explanation:
plaining of right upper quandrant pain. Acetaminophen toxicity is An acetaminophen level greater than or equal to 140 mg/kg would
suspected and an acetaminophen level is drawn. Which result be considered toxic. For a patient weighing 70 kg, the toxic level
would the nurse interpret as indicating toxicity for the patient if he would be 9800 mg. A level of 10,500 mg would be greater, thus
weighs 70 kg? indicating toxicity.
A patient arrives at the emergency department after taking more
than 20 lorazepam tablets. Which of the following would the nurse
Flumazenil
anticipate that the patient would be given to reverse the effects of
the drug?
Resuscitation
A nurse is performing triage at the scene of a building collapse Emergent
and is using a five-level triage system. Place the categories below Urgent
in the proper order from most to least immediate. Nonurgent
Minor
A patient is brought to the emergency department following an
overdose of a selective serotonin reuptake inhibitor (SSRI). While
Seizures
assessing the patient, the nurse suspects that the patient may be
developing serotonin syndrome based on which of the following?
A patient working in a chemical facility sustains a chemical burn
to his arms. The chemical involved was white phosphorus. Which Brushing off all traces of the chemical from the patient's skin
of the following would be the priority nursing action?
A client presents to the ED following a motor vehicle collision. Cool, moist skin
The client is suspected of having internal hemorrhage. The nurse Decreasing blood pressure
assesses the client for signs and symptoms of shock. Which are Delayed capillary refill
signs and symptoms of shock? Select all that apply. Increasing heart rate
A nurse is working as a camp nurse during the summer. A camp
Have the patient lie down and place the arm below the level of the
counselor comes to the clinic after receiving a snakebite on the
heart.
arm. What is the first action by the nurse?
The nurse is providing care for a client who is experiencing alcohol
withdrawal. The client reports, "I cannot fall or stay asleep." The
nurse observes that the client is agitated, having difficulty falling
Administer lorazepam as ordered by the health care provider
asleep and crying uncontrollably, with confused speech and a
tachycardic pulse. Which intervention should the nurse implement
first?
The nurse is caring for a client in the intensive care unit who is
recovering from trauma as a result of a motor vehicle accident that
claimed the life of the client's friend. While the nurse is performing
The client attempted suicide as a teenager.
a dressing change on the client's surgical wound, the client states,
The client's maternal uncle committed suicide.
"I don't deserve to live. I have just been thinking about ending it
The client had a close relationship to the accident victim.
all." As the nurse assesses the client's imminent risk for suicide,
what contributing factors need to be considered? Select all that
apply.
The nurse is caring for a client who is agitated and confused.
The client is persistently trying to get out of bed and attempted to
remove the peripheral IV. The nurse has attempted to re-orient the
Call security personnel to assist
client; however, this was not effective in de-escalating the client's
agitation. The client yells, "I am going to punch you in the face!"
What is the nurse's next action?
Obtain the client's health record
The nurse is preparing to transfer a client from the ICU to a State the client's admission date and current diagnosis
medical unit in the hospital. To ensure consistent communication Provide a brief statement of current concerns
regarding the client's care needs to the receiving unit, in what Give the client's pertinent medical history
sequence of steps should the nurse organize the report? Provide the most recent vital signs and assessment findings
Give recommendations for what needs to be done for the client
The nurse is providing care for a client who was admitted to the in-
Provide airway support and ventilation
tensive care unit after suffering cardiovascular collapse secondary
Minimize lights and noise disturbances
to a methamphetamine overdose. The client is semi-conscious
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 Chapter 72: Emergency Nursing
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and has a nasopharyngeal in place. The nurse anticipates this Administer antipsychotic medication
client may require which interventions? Select all that apply. Follow the unit seizure protocol

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