Focus on Delegating Prioritizing Triage Disaster

A child arrives at the emergency department experiencing anaphylaxis after being stung by a bee on the right arm. The nurse should first: - Place a tourniquet proximal to the site of the insect sting. Anaphylaxis is a severe immediate hypersensitivity reaction to an excessive release of chemical mediators. Treatment of anaphylaxis must be started immediately, because it may be only a matter of minutes before the child experiences shock. The nurse would immediately take steps to ensure an adequate airway, place a tourniquet just proximal to the site of the insect sting to help confine the allergen, administer epinephrine (medication of choice) as prescribed, administer oxygen, administer corticosteroids and antihistamines as prescribed, keep the child warm and lying flat or with the feet slightly elevated, and start an IV line. A client is brought to the emergency department after a motor vehicle crash in which the client sustained a blunt chest injury when his chest struck the steering wheel. The client is complaining of sharp pain on inspiration and dyspnea. The nurse notes the absence of breath sounds on the affected side. The nurse would immediately: - Place the client in a Semi-Fowler position. The client is exhibiting signs of a closed pneumothorax. If a closed chest injury is suspected, the nurse must immediately place the client in a semi-Fowler position. Because this is a medical emergency, the nurse then notifies the health care provider. A chest x-ray, computed tomography, or ultrasonography would be used to confirm the diagnosis of pneumothorax. Because treatment involves thoracentesis and placement of a chest drainage system, the nurse then prepares a thoracentesis tray and chest drainage equipment. A client is complaining of chest pain, and the nurse notes that the client's skin is cool and clammy. The client is rec