Plan de emergencias

The nurse on the medical-surgical unit is walking in the hallway and observes a fire. Which of the following actions should the nurse take first?

•   1. Activate the fire alarm.  

•   2. Close all the doors on the unit.  

•   3. Remove clients from the immediate area.  

•   4. Obtain the appropriate fire extinguisher.  

Answer explanation

Fires in health care facilities can be particularly dangerous because of the presence of certain substances (eg, oxygen) and because clients often cannot remove themselves from the danger.  The nurse should respond quickly and efficiently to fire emergencies by following proper fire safety guidelines.  The RACE mnemonic is helpful to recall the appropriate order for fire safety guidelines in inpatient settings:

Rescue (eg, remove) all clients from immediate danger (eg, immediate area) and evacuate them to a safe area (Option 3).

Activate the fire alarm.

Contain or Confine the fire by closing all doors where the fire is located.

Extinguish small fires using a fire extinguisher or Evacuate the area if a large fire is present.

(Options 1, 2, and 4)  The nurse should activate the fire alarm, close all doors on the unit, and obtain the appropriate fire extinguisher after first rescuing clients in immediate danger.

An unconscious client is brought to the emergency department by the paramedics after being hit by a car.  An emergency craniotomy is required.  The client has no identification.  What action should be taken next?

•   1. Contact the national database to see if the client has a healthcare proxy  

•   2. Contact the police to help identify the client and locate family members  

•   3. Obtain a court order for the client's surgical procedure  

•   4. Transport the client to the operating room under implied consent  

Answer explanation

Implied consent in emergency situations includes the following criteria:

There is an emergency
Treatment is required to protect the client's health
It is impractical to obtain consent
It is believed that the client would want treatment if able to consent
In this case, it would be assumed that the client would want life-saving surgery; the health care provider should proceed.

(Option 1)  This client's name is not known and there is no national database of healthcare proxy names/power of attorney.

(Option 2)  This should also be done but results may not be obtained in a timely manner.  The client needs immediate surgery and this should proceed with the client as a "John Doe" (placeholder name) in the meantime.

(Option 3)  This would cause considerable delay.  Court orders are used for protective custody to take control of the care of a minor when the adult parent is refusing necessary life-saving care.

A nurse is making a home visit when a fire starts in the client's kitchen trash can.  The client has a fire extinguisher.  The nurse should take which actions to properly operate the fire extinguisher?  Select all that apply.

•  1. Aim the nozzle at the base of the fire

•  2. Pull out the pin on the handle

•  3. Shake the canister prior to use

•  4. Squeeze the handle to spray

•  5. Sweep the spray from side to side

Answer explanation

A small fire can quickly become very dangerous.  During an emergency situation, such as a fire, anxiety can narrow a person's focus, causing hesitation or difficulty in responding to the situation, especially when operation of unfamiliar equipment (eg, fire extinguisher) is involved.  The mnemonic PASS is often used to help people remember the steps used in operating a fire extinguisher:

P – Pull the pin on the handle to release the extinguisher's locking mechanism
A – Aim the spray at the base of the fire
S – Squeeze the handle to release the contents/extinguishing agent
S – Sweep the spray from side to side until the fire is extinguished
(Option 3)  The extinguisher does not need to be shaken before use, and doing so would delay extinguishing the fire.

Multiple clients have been brought to the emergency department after being struck by lightning during a severe thunderstorm.

 Which of the following clients should the nurse prioritize? The client who

• A.is unresponsive and is laying on their back

• B.has paralysis on both lower extremities

• C.is confused and cannot remember their name or why they are in the emergency department

• D.experienced a massive electrical current discharge to their body

Answer explanation

Choice D is correct. The nurse should prioritize the care of this client. The most lethal initial effect of a massive electrical current discharge is cardiac arrest. Severe lightning injuries can cause cardiac arrest due to the cardiopulmonary and central nervous system being profoundly affected by lightning injuries. The nurse should initiate resuscitation measures by immediate airway and ventilatory management, chest compressions, and other life support interventions as needed.

Choice A is incorrect. Clients with a moderate lightning injury may be comatose or experience paralysis or confusion. Although these are serious injuries needing medical attention, the nurse would need to prioritize a client with a severe lightning injury.

Choice B is incorrect. Clients with a moderate lightning injury may experience paralysis, confusion, or be comatose. Although these are serious injuries needing medical attention, the nurse would need to prioritize a client with a severe lightning injury.

Choice C is incorrect. Clients who have been struck by lightning who are confused or stunned would be categorized as having a mild lightning injury. Although these are serious injuries needing medical attention, the nurse would need to prioritize a client with a severe lightning injury.

The nurse is caring for a client in the emergency department (ED) who sustained a high-voltage (major) electrical burn.

Which laboratory data should the nurse monitor to determine if the client is experiencing a complication from this injury?

• A.Creatine phosphokinase (CK)

• B.White blood cells

• C.Serum lipase

• D.Serum glucose

Answer explanation

Choice A is correct. Following a major electrical burn, the client is at risk of developing rhabdomyolysis. The muscular damage from a major electrical burn can be determined by obtaining and monitoring the client's CK levels. Additional laboratory studies monitored following a major electrical burn include serum potassium, creatinine and blood urea nitrogen, calcium, creatine phosphokinase (CK), and troponin.

Choice B is incorrect. The client's cardiovascular status is the priority after a major electrical burn. This includes obtaining a 12-lead electrocardiogram, placing the client on a continuous heart monitor, and obtaining serum cardiac enzymes. Monitoring the client's white blood cells is a relevant marker following this injury.

Choice C is incorrect. Monitoring the client's cardiovascular status following a major electrical burn is a priority. Obtaining and monitoring the client's lipase would be necessary if the physician suspected pancreatitis.

Choice D is incorrect. Monitoring the client's serum glucose following a major thermal burn is essential, as hyperglycemia is expected. While this may occur after a major electrical burn, it is not the priority lab to monitor. The nurse needs to monitor the client for cardiovascular collapse and any secondary injury, such as rhabdomyolysis.

The nurse is caring for a client experiencing acute mountain sickness (AMS). The nurse anticipates a prescription for which medication?

• A.Sodium bicarbonate

• B.Acetazolamide

• 
  C.Tamsulosin
  

• D.Dutasteride

Answer explanation

Choice B is correct. Acetazolamide, a carbonic anhydrase inhibitor, is commonly prescribed to prevent or treat AMS. It acts by causing a bicarbonate diuresis, which rids the body of excess fluid and induces metabolic acidosis. The acidotic state increases the respiratory rate and decreases the occurrence of periodic respiration during sleep at night. In this way, it helps clients acclimate faster to a high altitude. By increasing the client's respiratory rate, the client can perfuse more oxygen. It is preferred that this medication be taken 24 hours prior to the ascent.

Choices A, C, and D are incorrect. Sodium bicarbonate is not indicated for AMS. The goal is to create metabolic acidosis by giving the client prescribed acetazolamide, increasing the client's respiratory rate, and increasing oxygen delivery. Tamsulosin and dutasteride are indicated in benign prostatic hyperplasia (BPH) treatment.

A nurse is caring for a client who has come to the emergency department with frostbite to one of their lower extremities.

Which of the following orders by the healthcare provider would the nurse anticipate to treat the client’s frostbite? Select all that apply. 

• A.Apply dry heat with a warming blanket to the lower extremity

• B.Administer a tetanus immunization

• C.Submerge the lower extremity in a rapid rewarming water bath set at 99⁰ F to 102⁰ F (37⁰ C to 39⁰ C)

• D.Report any increasing levels of pain after administering analgesics

• E.Assess hourly for development of compartment syndrome

Answer explanation

Choice C is correct. Frostbite destroys tissue and can cause a deep tetanus-prone wound. For this reason, it is recommended that clients with frostbite receive a tetanus immunization.

Choice D is correct. Submerging the lower extremity in a rapid rewarming water bath set at 99⁰ F to 102⁰ F (37⁰ C to 39⁰ C) is recommended to preserve tissue integrity.

Choice E is correct. Increasing levels of pain reported by the client following the administration of analgesics can be an early sign of compartment syndrome, and should be reported to the healthcare provider immediately.

Choice F is correct. Clients with frostbite should be assessed hourly for compartment syndrome. Compartment syndrome is caused by severe neurovascular impairment and can lead to amputation of the affected limb. Early signs and symptoms of compartment syndrome include increasing pain after analgesics are administered and paresthesia, which is painful tingling and numbness of the affected limb.

Choice A is incorrect. Performing massage on the affected limb is contraindicated because this action can cause further damage to tissue integrity.

Choice B is incorrect. Applying dry heat to the affected limb is contraindicated because this action can cause further damage to tissue integrity.