Emergency Nursing Priority Test Questions!! Brunner Ch. 71

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@ Emergency Nursing Priority Test Questions!!
Brunner Ch. 71

Intro to the ER

 Who are the clients?
o ANYONE AND EVERYONE
 Teamwork, priorities, high pressure
 Issues: safety, upset families (sometimes they blame HC personnel), potential for violence, high
stress
 PPE (personal protective equipment) is extremely important in this setting
 Coping with death: families, staff, debriefing (may need counselling as nurse due to stress)
 Legal Issues (forensic evidence, documentation) = lawyers are often involved; be aware

Triage

 Sorting out and prioritizing
 Triage is a skill; it takes practice
 “To sort out”. You want to know if the patient’s life or limb is at risk for loss [Prioritize]
 Questions to ask client/family (bullet points – Brunner - 2157-2158)
o Circumstances/baseline data: When did this occur? When did it start? Did client lose
consciousness? Current medications? Allergies? Time of last meal? Last tetanus shot?
 Five levels of triage (some systems use three)
o Resuscitation
 Client is coding coming from an accident
 Gets the most resources
o Emergent
 Highest priority
 Their needs are life threatening and must be seen immediately
 Must be seen RIGHT NOW or they’re going to die
 May not be need resuscitated right now, but they will be if nothing is done soon
 Ex: Hemorrhaging, hypovolemic shock, airway obstruction, arterial bleed)
o Urgent
 Need to be seen within an hour
 Usually need 2 resources
 Ex: Chest pain or SOB; some trauma, but they’re not coding
o Non-urgent
 Will be okay for 24 hours
 May only need 1 resource – ex: test) may need stiches
o Fast-track
 Ex: kids with cold
 Overlaps with nonurgent
o Resources: nurses time, starting IV’s, getting diagnostic studies (CT and MRI), giving
medications
 Test: which patient should you see first!

When you see triage questions on a test, it is still the same priority guidelines: ABC’s

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Assessment: Primary Survey (A,B,C,D)

 A&B: Patent Airway/Breathing
o Protect cervical spine
 Will have C-Collar on until diagnostic studies rule out a spinal cord injury – WE
ALWAYS ASSUME A TRAUMA PATIENT HAS A SPINAL CORD INJURY
until proven otherwise.
 When performing assessment, the client is LOG ROLLED to assess the back of
patient for injuries (keep back and neck in perfect alignment)
o Assess chest injuries immediately after airway
o Oral airway, methods of endotracheal intubation, mechanical ventilation,
cricothyroiotomy (incision in neck to get airway). (The only things discussed on
recording are listed below).
 Jaw thrust is used to open airway when client has trauma. Jaw thrust is a safe
approach to opening the airway of a patient with a suspected spinal cord injury
because it can be accomplished without extending the neck.
 Oral airway: Small plastic airway that is place in the unconscious patient’s mouth
that is used to keep the tongue from falling back and causing airway obstruction.
Side note: if client shows signs “battle signs” (raccoon eyes or bleeding from
ears) you DO NOT USE AN ORAL AIRWAY. These are signs of head injury and
using an oral airway may cause further damage.
 If client is in respiratory failure or if the client is coding, they will have to be
intubated and placed on a ventilator.
 In the event that they cannot get a tube down, a cricothyroidotomy is performed
by Paramedic or Physician, in which an incision is made in the cricothyroid
membrane to establish an airway.
o Assess for adequate ventilation once airway has been established
o Assess for bilateral absent or diminished breath sounds
o Monitor O2 saturation
o Obtaining ABG’s
o If they have a sucking chest wound (puncture wound), they are going to need a chest tube
o Assess for tension pneumothorax
o Frequent vital signs
 C: Circulation
o When a person rolls in, look at if they are bleeding?
o Goals of emergency management: control the bleeding, maintain adequate circulating
blood volume for tissue oxygenation, and prevent shock.
o Control hemorrhage
o Prevent and treat Hypovolemic shock
 Shock S/S: drop in B/P; decreased urine, increased HR; cool, moist skin; anxious
if alert; delayed cap refill
o Risk for cardiac arrest caused by hypovolemia and secondary anoxia.
o A loss of circulating blood results in fluid volume deficit and decreased cardiac output
o Fluid replacement is imperative to maintain circulation
o 2 large gauge IVs need to be started
 Isotonic fluids (NS, LR)