Emergency and Nursing Prioritization Scenarios

Front

Who would the cardiac nurse take care of first? A client with: atrial fibrillation on warfarin sodium therapy with an INR of 4.0 and PT of 30 seconds, new onset of atrial fibrillation, nonadherent with hypertension medication, admitted with a blood pressure of 210/104 and reporting a headache, an inferior wall MI, discharged to cardiac rehabilitation, threatening to sign out against medical advice (AMA), with heart failure, whose dopamine drip infiltrated in the right wrist

Back

with heart failure, whose dopamine drip infiltrated in the right wrist

Front

The unit secretary on the orthopedic unit reports that four clients are asking for the nurse. Who should be seen first: The client with Buck's traction, reporting muscle spasms; in a leg cast, reporting pain that is unrelieved by the medicine; one day post-external fixation insertion, who has wetness at the pin sites; in a cervical halter, asking for pain medication?

Back

in a leg cast, reporting pain that is unrelieved by the medicine

Front

Bus accident victims are brought to the Emergency Department (ED). Who should be addressed first? A 54-year old client with an irregular heartbeat, A 24-year old client with high-pitched inspiration, A 72-year old client with a strong cough and mucus expectoration, A 35-year old client with a regular heartbeat of 140

Back

A 24-year old client with high-pitched inspiration

Front

A client diagnosed with hoarding disorder is referred to the psychiatric home health nurse after a call from her adult children. After determining that the client is hoarding, the nurse's initial action would be to:

Back

help the client and family determine safety and health risks that need to be addressed

Front

What is the primary intervention for a client in an Addisonian crisis?

Back

Place the client on a cardiac monitor

Front

A charge nurse comes on duty to the medical unit at change of shift and finds the unit personnel involved in an emergency situation with a client. The nurse should:

Back

make assessment rounds on other clients on the unit

Front

A client, who had a prostatectomy earlier that day, reports abdominal pain. The initial action of the nurse is to:

Back

Check patency of the catheter

Front

The most valuable action that nurses can take when emergency triage involves a dirty bomb is to first:

Back

protect themselves

Front

Which client would receive the highest priority from the triage nurse in the Emergency Department? A 68-year old client reporting a headache, left sided numbness and tingling that started one hour ago. VS BP 166/78, P 60, RR 18, SaO2 96%, A 36-year old client reporting sharp abdominal pain, nausea, and vomiting that started 2 hrs ago. Her VS BP 172/96, P 96, RR 22, SaO2 98%, A 7-year old child with pain and deformity of the right arm after a football injury. His VS BP 102/74, P 100, RR 22, SaO2 93%, A 17-year old adolescent experiencing an asthma attack. She stated that she used her albuterol home nebulizer twice before coming to the ED. VS BP 118/68, P 118, RR 20, SaO2 95%

Back

A 68-year old client reporting a headache, left sided numbness and tingling that started one hour ago. VS BP 166/78, P 60, RR 18, SaO2 96%

Front

A severely burned client is admitted and an infusion of a large amount of fluid is ordered. After starting the infusion, it would be most important for the nurse to: assess vital signs, auscultate the lungs, evaluate urine output, check the level of consciousness

Back

evaluate urine output