Triage/EMTALA
What distance from the hospital are we responsible to respond to in case of visitor or staff injury or illness?
250 yards
Kehr's sign is indicative of
Ruptured spleen
The earliest sign of neurological deterioration and increasing ICP is
Change in level of consciousness
The earliest sign of impending respiratory failure is
Restlessness
A patient has epistaxis, what position should you instruct them to assume?
Upright with the head forward
The nurse's primary goal in triage is
Immediate and brief assessment to assign an ESI
Hypotension and bright red emesis are expected findings in what type of GI bleed
Upper
A patient's GCS is 7 this indicates what level of severity head injury?
Severe head injury
A patient experiencing cardiac tamponade and hypotension require
Pericardiocentesis
The most important finding in suspected abuse cases is
An injury that does not match the patient history
A patient who presents to the ED being transcutaneously paced by EMS for bradycardia is an ESI level
1
A 35 F presents to the ED with suspected placental abruption. The nursing priorities include
Establish large bore IV access, obtain labs including cross and match, notify provider immediately
What is a classic sign/symptom of meningococcal meningitis
Nuchal rigidity
Fever
A patient presents with chest pain upon deep respiration, relieved by sitting forward. They are most likely experiencing
Pericarditis
A patient involved in a motor vehicle accident presents to the ED in respiratory distress. You auscultate bowel sounds in the pt's chest, you suspect
Ruptured diaphragm
A coworker experiences a needlestick while performing phlebotomy, their ESI score is
2
A 34 week pregnant female presents with HTN, pitting edema, and 3+ protein in her urine, you suspect which diagnosis?
Pre-eclampsia
When your patient is having a tonic clonic seizure your nursing priority is
What is the first line vasopressor in a patient in septic shock following fluid resuscitation?
Levophed
Early signs of alcohol withdrawal include
Anxiety and restlessness
When a patient’s condition requires emergency transport to a tertiary care center, the action by the sending institution which most effectively meets the needs of the patient and family include which of the following?
Explain the patient’s condition and the risks and benefits of transfer
What is a modification employed during CPR for a pregnant woman?
Left sided positioning with left lateral uterine displacement
The most effective initial intervention to de-escalate a verbally agitated patient is
Place the patient in a quiet and safe room, activate a Code Grey
PaCO2 level of 65 mm Hg is indicative of
Acute respiratory failure
Traumatic amputated parts should be
Wrapped with sterile gauze moistened in normal saline