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Nursing Emergencies
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The patient is bleeding profusely from his left leg and the nurse decides to use pressure point control over an artery. The nurse should apply pressure over which artery?
left femoral artery
What level of spinal injury includes a high risk of respiratory complications?
C5 or above
The head injury patient is opening his eyes spontaneously, disoriented to time and place, and withdrawing from painful stimuli. The Glasgow coma score would be documented as
12
An area of the rib cage sucks in with respiration and pushes out with expiration. What type of chest injury is this?
Flail chest
How is pericardial tamponade treated?
pericardiocentesis (to relieve the pressure inside the pericardial sac)
The nurse is providing first aid to the patient with a fracture. How should the nurse position the extremity for splinting?
The extremity should be splinted in the position that it lies.
The nurse suspects a joint injury and implements RICE. What does the E stand for in RICE?
Elevation. Elevate the extremity above the level of the heart.
In tension pneumothorax, the structures in the trachea will be pushed toward which side? (affected or unaffected)
unaffected
What technique should be used to move the victim with possible spinal injury?
log roll (by trained professionals)
Which of the following is an early sign of increased intracranial pressure? Decorticate posturing Nonreactive pupils Drowsiness Unresponsive
drowsiness
What is the maximum score on the Glasgow Coma Scale?
15
The head injury patient is at risk of increased intracranial pressure. How should the patient be positioned?
Elevate the head of the bed and position the head midline
True or False? If the puncture wound does not bleed, the injury is not significant.
False. Puncture wounds are deceiving because it is impossible to see which structures might be damaged deeper in the wound.
The trauma victim has an amputated finger. Should the finger be placed in a bag of ice?
No. Place the finger in a sealed bag on top of the ice.
How often should an individual receive a tetanus booster?
Every 10 years
A car accident victim has an object impaled in his arm. Should the nurse remove the object before transport?
No
The patient suffered an avulsion in an accident. Can the physician suture this wound type closed?
No (the edges cannot be approximated)
The elderly client lost her balance and the nurse attempted to catch her. What type of injury might have occurred where the nurse grabbed her arm?
skin tear
The patient has scraped away outer layers of skin in a bicycle accident. This is referred to as an
abrasion
If an individual fell but attempted to "break the fall," where on the body are additional injuries most likely to occur?
hands and knees
The patient has a stab wound. Would this be considered a blunt trauma or penetrating trauma?
penetrating trauma
Which type of shock is caused by excessive vasodilation?
distributive shock (Examples: anaphylaxis or sepsis)
What type of shock is caused by the heart's inability to effectively pump blood?
cardiogenic
The nurse is caring for a patient with an anaphylactic response to a bee sting. The patient used an epi pen. What other two classes of medications might be used for allergic reactions?
antihistamines and corticosteroids
The patient's circulation is evaluated by blanching the nail beds and watching for blood return. How long many seconds is the normal capillary refill?
No more than 3 seconds
The patient presents to the emergency room with difficulty breathing, itching in the chest, and stridor. What should the nurse suspect?
anaphylaxis (severe allergic reaction)
Which of the following is NOT important in the emergency treatment of shock? Administer oxygen Administer IV fluids Provide a healthy diet Assess vital signs
Provide a healthy diet (patient should be NPO)
The patient is bleeding from a laceration on the hand. The nurse applies direct pressure. What he/she do next to control the bleeding?
Elevate above the level of the heart
What is the second step in the primary survey?
B: Breathing
True or False? Trauma victims should be treated as having a spinal injury until proven otherwise.
True
During which part of the primary survey should the nurse look for a medic alert bracelet or ID?
E: Exposure
Which part of the primary survey includes placement of an endotracheal tube (if necessary)?
A: Airway
What causes hypovolemic shock?
decreased blood volume (blood loss)
What type of shock is anaphylaxis?
distributive shock
The nurse is caring for a patient at high risk for shock. Which vital sign typically shows signs of shock first?
heart rate
The nurse is caring for a trauma victim. The abdomen is firm and tender, and the patient's blood pressure is low. The nurse should suspect
intra-abdominal bleeding
The nurse completes ABCDE in an emergency. The next step is a rapid head to toe assessment. This is referred to as the
secondary survey
The patient collapsed but did not suffer any trauma. What technique should the nurse use to open the airway?
head tilt chin lift
The patient responds when you apply periorbital pressure. This is documented as "response to ____________" in the nurse's note.
pain
What does the C stand for in the primary survey?
Circulation
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