DUE 1 6 ED Rationales - The emergency department nurse receives report from EMS regarding a client in PDF

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The emergency department nurse receives report from EMS regarding a client in an overturned vehicle who has been missing for the last 24 hours. They have started a 20 gauge IV to the left antecubital with normal saline running at 125 mLs/hr. The client is alive and conscious with full thickness bur...

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The emergency department nurse receives report from EMS regarding a client in an overturned vehicle who has been missing for the last 24 hours. They have started a 20 gauge IV to the left antecubital with normal saline running at 125 mLs/hr. The client is alive and conscious with full thickness burns on the left posterior and anterior leg, left anterior and posterior arm, face and chest. The client weighs 125 pounds. ●

[What is the TBSA burned?] ○ Posterior and anterior leg = 9% + 9% = 18% ○ Left anterior and posterior arm = 4.5 (x2) = 9% ○ Face = 4.5 % ○ Chest = 18% ○ Total surface area 49.5% ● [What is the weight in kilograms?] ○ 125lbs/2.2lbs/kg= 56.8kg ● [How much fluid will the client be given for the first 8 hours?] ○ 49.5 (4) = 198 ○ 198 * 56.8 = 11,246.4 mL ○ 11,246.4/2 = 5,623.3 mL in the first 8 hrs ● [What rate will the pump be set for the first 8 hours?] ○ 5,623.3 / 8 = 703 mL/hr ● [How much fluid will the client receive for the second phase of fluid resuscitation?] ○ 5,623.3 in the second 16 hrs ● [What rate will the pump be set for the second phase of fluid resuscitation?] ○ 5,623.3/16hr = 351 ml/hr Question 1 A client arrives in the emergency department reporting pain and immobility of the right shoulder. The client reports a history of recurrent dislocations of the same shoulder. Which additional signs or symptoms would the nurse assess for a dislocation injury? 1. Bone fragments protruding from the skin 2. Deviation in length of the extremity 3. Muscle atrophy with weakness 4. Mottled skin discoloration Rationale: An open or displaced fracture typically has bone fragments protruding from the skin which would not indicate a dislocation. Muscle atrophy and mottled skin discoloration would also not be present in a dislocation. When a dislocation occurs there typically is a deviation in the length of the extremity (Ignatavicius, 2018, p. 1032) Question 2 Which client should be triaged as urgent? 1. A 44-year-old with a dislocated elbow 2. A 35-year-old with chest pain and diaphoresis 3. An 85-year-old with new-onset confusion and blood pressure grossly elevated compared to his usual 4. A 65-year-old with redness and swelling on the forearm associated with a bee sting Rationale: Urgent patients include those who are experiencing rashes, strains, sprains, colds, and simple fractures. Chest pain and new-onset confusion would be triaged emergent and these patients are experiencing life threatening conditions (Ignatavicius, 2018, p. 124). Question 3 During a shift report, the nurse learns that a new client was admitted for an inhalation injury. Auscultation of the lungs has revealed wheezing over the mainstem bronchi since admission. During the nurse’s assessment of the client, the wheezing sounds are now absent. What is the nurse’s next priority action? 1. Document these findings because they indicate that the client is improving 2. Assess for respiratory distress because of potential airway obstruction

[Type here] 3. 4.

Obtain an order to discontinue oxygen therapy because it is no longer needed Encourage the use of incentive spirometry to prevent atelectasis

Rationale: For a patient who experienced an inhalation injury the inflammation that occurs could cause rapid airway obstruction causing a blockage of air through the narrowed airways. This is indicated by a sudden disappearance in breath sounds (Ignatavicius, 2018, p. 490). All of the other options would not be indicated here because of the high change that this patient is in respiratory distress.

Question 4 The nurse is caring for several clients on an orthopedic trauma unit. Which conditions pose a high risk for the development of acute compartment syndrome? (Select all that apply.) 1. Lower legs caught between the bumpers of two cars 2. Massive infiltration of IV fluid into forearm 3. Bivalve cast on lower leg 4. Multiple insect bites to lower legs 5. Daily use of oral contraceptives 6. Severe burns to the upper extremities Rationale: The cause of acute compartment syndrome are classified into two different categories: external and internal pressure. External pressure includes tight, bulky dressing and casts. Internal pressure causes fluid or blood flow in the compartment and accumulates. Other common causes of acute compartment syndrome include crush injuries or overuse injuries, extensive insect bites or snakebites, or massive infiltration of IV fluids (Ignatavicius, 2018, p. 1033). Bivalve cast on lower leg and oral use of contraceptives could not be considered a high risk for acute compartment syndrome. Question 5 The emergency department trauma team is preparing to receive a motor vehicle crash victim with severe chest trauma who is coughing up blood and has a crush injury to the right leg. What type of personal protective equipment (PPE) does the nurse who is assigned to do the recording put on? 1. No PPE is necessary because the nurse is only recording and not giving direct care 2. Gloves only, but handwashing is required before and after all emergency care 3. Gown, gloves, eye protection, face mask, cap, and shoe covers 4. Client situation must first be assessed before determining what PPE to wear Rationale: When a nurse is in the ED it is important to ensure that standard precautions are in place during all resuscitation procedures. This is because of the high risk that there will be contimationan with blood and bodily fluids which is why the other 3 options are not correct. The proper PPE necessary when there is a patient coming in with large amount of blood include gown, gloves, eye protection, face mask, cap and shoe covers (Ignatavicius, 2018, p. 129). Question 6 Which client should be triaged as emergent? 1. A 56-year-old man with severe unilateral back pain and previous history of kidney stones 2. A 23-year-old woman with severe abdominal pain, positive home pregnancy test, and BP 80/40 mmHg 3. A 6-year-old with a temperature of 101 F and flu-like symptoms 4. A 10-year-old girl with vomiting, diarrhea, and abdominal cramps onset 4 hours after eating fish Rationale: A patient is triaged as urgent when they are experiencing respiratory distress, chest pain, stroke, active bleeding, and unstable vital signs (Ignatavicius, 2018, p. 124).The 23-year-old’s blood pressure of 80/40 which is unstable and could be due to an active bleed. Because she is also pregnant, we are

[Type here] worried about active bleeding and low blood pressure because those two combined could lead to and/or indicate a complication. Question 7 Which intervention would be addressed during the primary survey? 1. Insert a urinary catheter 2. Establish patent airway 3. Stabilize a fracture 4. Insert a nasogastric tube Rationale: When a nurse implements the primary survey, they are assessing the patient’s A,B,C,D, and E which indicate airway, breathing, circulation, disabilities, and exposure (Ignatavicius, 2018, p. 129-130). This is used when a patient comes in as urgent in order to get a quick understanding of the patient’s condition and prevent the patient from deteriorating even more. Insertion of a catheter, stabilizing a fracture, and inserting an NG tube are all a part of the secondary survey (Ignatavicius, 2018, p. 130). Question 8 The nurse is caring for a client with a head injury whose Glasgow Coma Scale (GCS) score is 3. This score indicates the client is most likely to do what? 1. Withdraw from painful stimuli 2. Open eyes spontaneously 3. Moan with incoherent speech 4. Present as totally unresponsive Rationale: For a patient who has a glasgow coma scale of 3 it illustrates that this specific patient is demonstrating the following characteristics: 1. No eye movement = 1 point 2. No verbal response = 1 point 3. No motor response = 1 point Due to the above, this patient is totally unresponsive (Ignatavicius, 2018, p. 130). Question 9 A client comes to the emergency department for gastric distress, vomiting large amounts of dark brown emesis, and passing small amounts of bright red blood rectally. Which preexisting health condition is most likely to be a factor in determining triage classification? 1. History of diabetes mellitus 2. History of anticoagulant use 3. History of high blood pressure 4. History of recent alcohol intoxication Rationale: For a patient with a history of anticoagulant use, their body has a decreased ability to clot and stop bleeding from occurring. Because of this reason, this specific patient would be triaged as emergent because they are actively bleeding and they are at a higher risk for hypovolemic shock due to the anticoagulant usage (Ignatavicius, 2018, p. 124).

References (2019). Adult medical-surgical – RN edition 11.0. Assessment Technology Institute, LLC.

[Type here] Ignatavicius, D.,Workman, L., Blair, M., Rebar, C., & Winkelman, C. (2016). Medical surgical nursing: Patient-centered collaborative care (9th) St. Louis, MO: Saunders/Elsevier....