Emergency/Trauma Nursing

Nurse Ejay is assigned to telephone triage. A patient called who was stung by a honeybee and is asking for help. The patient reports pain and localized swelling but has no respiratory distress or other symptoms of anaphylactic shock. What is the appropriate initial action that the nurse should direct the patient to perform?

• remove the stinger by scraping it

• apply a cold compress

• take an oral antihistamine

• call 911

Answer explanation

Since the stinger will continue to release venom into the skin, removing the stinger should be the first action that the nurse should direct to the client. Within the first few minutes after the sting, the stinger should be removed via scraping with a credit card rather than squeezing/tweezing to avoid further venom exposure.

A client arrives at the emergency department who suffered multiple injuries from a head-on car collision. Which of the following assessment should take the highest priority to take?

• unequal pupils

• irregular pulse

• ecchymosis in the flank area

• deviated trachea

Answer explanation

A deviated trachea is a symptom of tension pneumothorax, which will result in respiratory distress if left untreated. The first question in the ESI triage algorithm for triage nurses asks whether “the patient requires immediate life-saving interventions” or simply “is the patient dying?” The nurse determines this by looking to see if the patient has a patent airway, if the patient is breathing, and does the patient has a pulse.

A triage nurse encountered a patient who complained of mid-sternal chest pain, dizziness, and diaphoresis. Which of the following nursing action should take priority?

• administer oxygen via nasal cannula

• notify the physician

• complete history taking

• put the patient on ECG monitoring

A group of people arrived at the emergency unit by a private car with complaints of periorbital swelling, cough, and tightness in the throat. There is a strong odor emanating from their clothes. They report exposure to a “gas bomb” that was set off in the house. What is the priority action?

• Instruct personnel to don personal protective equipment

• Direct the patients to the cold or clean zone for immediate treatment

• Immediately remove other patients and visitors from the area

• Measure vital signs and auscultate lung sounds

• Direct the patients to the decontamination area

Answer explanation

Decontamination in a specified area is the priority. The decontamination and support areas are established within the Warm Zone, also referred to as the Contamination Reduction Zone. Decontamination involves thorough washing to remove contaminants.

When an unexpected death occurs in the emergency department, which task is the most appropriate to delegate to a nursing assistant?

• assist with postmortem care

• facilitate meetings between family and organ donor specialist

• escort the family to a place of privacy

• help the family collect belongings

Answer explanation

Postmortem care requires some turning, cleaning, lifting, and so on, and the nursing assistant is able to assist with these duties. The use of NAPs increasingly demands registered nurses to delegate patient care tasks according to the principles of the ANA. These principles define nursing delegation as the “transfer of responsibility for the performance of an activity from one individual to another while retaining accountability for the outcome.”

The physician has ordered cooling measures for a child with a fever who is likely to be discharged when the temperature comes down. Which task would be appropriate to delegate to a nursing assistant?

• prepare and administer a sponge bath

• explain the need for giving cool fluids

• assist the child in removing outer clothing

• advise the parent to administer acetaminophen instead of aspirin

Answer explanation

The nursing assistant can help with the removal of outer clothing, which allows the heat to dissipate from the child’s skin. The client is the center of care. The needs of the client must be competently met with the knowledge, skills and abilities of the staff to meet these needs. In other words, the nurse who delegates aspects of care to other members of the nursing team must balance the needs of the client with the abilities of those to which the nurse is delegating tasks and aspects of care, among other things such as the scopes of practice and the policies and procedures within the particular healthcare facility.

You are preparing a child for IV conscious sedation before the repair of a facial laceration. What information should you report immediately to the physician?

• The child suddenly pulls out the IV

• The parent is not sure regarding the child's tetanus immunization status

• The parent wants information about the IV conscious sedation

• The parent's refusal of the administration of the IV sedation

Answer explanation

The refusal of the parents is an absolute contraindication; therefore the physician must be notified. But the autonomy of parents is very obviously different from the autonomy of patients to make decisions for themselves. While adult patients are generally thought to have an absolute right to refuse medical treatment for themselves, we don’t usually think that parents can refuse all medical treatment for their children.

The emergency medical service has transported a client with severe chest pain. As the client is being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and unpalpable pulse. Which of the following task is appropriate to delegate to the nursing assistant?

• assist with intubation

• place the defibrillator pads

• doing chest compressions

• initate bag valve mask ventilation

Answer explanation

Performing chest compressions are within the training of a nurse assistant. Every good certified nursing assistant should be proficient at cardiopulmonary resuscitation (CPR). Basic Life Support (BLS) certification is the widely-used term for any form of CPR certification and is required for all Registered Nurses (RN) and Certified Nursing Assistants (CNA).

You’re working as a triage nurse during a disaster situation. Based on the triage color code tags placed on each of the wounded, which tag color represents the wounded who have the highest priority of being treated first?*

• green

• yellow

• red

• black

A catastrophic disaster has occurred 5 miles from the hospital you are working in. The hospital’s disaster plan is activated and the wounded are brought to the hospital. You’re helping triage the survivors. One of the wounded is able to walk around and has minor lacerations on the arms, hands, chest, and legs. You would place what color tag on this survivor?

• red

• yellow

• green

• black