Michael, a triage nurse, must assess four clients who have arrived at the emergency department at the same time. He will assess them in the following order: 1) a 50-year-old female with abdominal pain and vomiting, 2) a 35-year-old jogger with a twisted ankle, 3) an ambulatory 25-year-old male with a head wound, and 4) an infant with fever, petechiae, and neck stiffness. When conducting an assessment of a trauma patient, a brief neurologic assessment is considered a priority element of the primary survey. A 65-year-old patient who arrived with chest pain, sweating, and dizziness should be prioritized in the emergent
Michael, a triage nurse, must assess four clients who have arrived at the emergency department at the same time. He will assess them in the following order: 1) a 50-year-old female with abdominal pain and vomiting, 2) a 35-year-old jogger with a twisted ankle, 3) an ambulatory 25-year-old male with a head wound, and 4) an infant with fever, petechiae, and neck stiffness. When conducting an assessment of a trauma patient, a brief neurologic assessment is considered a priority element of the primary survey. A 65-year-old patient who arrived with chest pain, sweating, and dizziness should be prioritized in the emergent
Michael, a triage nurse, must assess four clients who have arrived at the emergency department at the same time. He will assess them in the following order: 1) a 50-year-old female with abdominal pain and vomiting, 2) a 35-year-old jogger with a twisted ankle, 3) an ambulatory 25-year-old male with a head wound, and 4) an infant with fever, petechiae, and neck stiffness. When conducting an assessment of a trauma patient, a brief neurologic assessment is considered a priority element of the primary survey. A 65-year-old patient who arrived with chest pain, sweating, and dizziness should be prioritized in the emergent
• Michael works as a triage nurse, and four clients arrive at the
emergency department at the same time. List the order in
which he will assess these clients from first to last. • 1. A 50-year-old female with moderate abdominal pain and occasional vomiting. • 2. A 35-year-old jogger with a twisted ankle, having a pedal pulse and no deformity. • 3. An ambulatory dazed 25-year-old male with a bandaged head wound. • 4. An irritable infant with a fever, petechiae, and nuchal rigidity. • In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? • A • Initiation of pulse oximetry. • B • Complete set of vital signs. • C • Client's allergy history. • D • Brief neurologic assessment. • A 65-year-old patient arrived at the triage area with complaints of diaphoresis, dizziness, and left-sided chest pain. This patient should be prioritized into which category? • A.Non-urgent. • B. Urgent. • C. Emergent. • D. High urgent • 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. 1. Call for help and activate the code team. 2. Instruct a nursing assistant to get the emergency cart. 3. Initiate cardiopulmonary resuscitation (CPR). 4. Perform the chin lift or jaw thrust maneuver. 5. Establish unresponsiveness. • A. 5, 2, 4, 3, 1 • B. 1, 5, 2, 4, 3 • C. 1, 2, 5, 4, 3 • D. 5, 1, 4, 3, 2 • You are caring for a client with a frostbite on the feet. Place the following interventions in the correct order.1. Immerse the feet in warm water 100° F to 105° F (40.6º C to 46.1° C). 2. Remove the victim from the cold environment. 3. Monitor for signs of compartment syndrome. 4. Apply a loose, sterile, bulky dressing. 5. Administer a pain medication. • A. 5, 2, 1, 3, 4 • B. 2, 5, 1, 4, 3 • C. 2, 1, 5, 3, 4 • D. 3, 2, 1, 4, 5 • Following an emergency endotracheal intubation, nurses must verify tube placement and secure the tube. List in order the steps that are required to perform this function?1. Obtain an order for a chest x-ray to document tube placement. • 2. Confirm that the breath sounds are equal and bilateral. • 3. Auscultate the chest during assisted ventilation. • 4. Secure the tube in place. • A • 1, 2, 3, 4 • B • 4, 3, 2, 1 • C • 3, 2, 4, 1 • D • 4, 1, 2, 3 • 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? • A • Lorazepam (Ativan) IV. • B • Magnesium sulfate IV. • C • Carbamazepine (Tegretol) IV. • D • Phenytoin and Carbamazepine PO • A client arrived at the emergency department after suffering multiple physical injuries including a fractured pelvis from a vehicular accident. Upon assessment, the client is incoherent, pale, and diaphoretic. With vital signs as follows: temperature of 97°F (36.11° C), blood pressure of 60/40 mm Hg, heart rate of 143 beats/minute, and a respiratory rate of 30 breaths/minute. The client is mostly suffering from which of the following shock? • A. Cardiogenic. • B. Distributive. • C. Hypovolemic. • D. Obstructive • A 15-year-old male client was sent to the emergency unit following a small laceration on the forehead. The client says that he can’t move his legs. Upon assessment, respiratory rate of 20, strong pulses, and capillary refill time of less than 2 seconds. Which triage category would this client be assigned to? • A. Black. • B. Green. • C. Red. • D • Yellow.