OH NO, WHAT FIRST
This tag is considered the "walking wounded".
What is the green tag under mass casualty
When planning care for clients who have burn injuries
What is the nurse will need to separate and sort clients based on burn severity
True or false: When an unconscious patient comes in to the ER, medical personnel need permission before starting treatment.
False
A man who is homeless enters the emergency department seeking health care. The healthcare provider indicates that the client needs to be transferred to the city hospital for care before assessing the client. This action is most likely a violation of which of the following laws?
Emergency Medical Treatment and Active Labor Act (EMTALA)
Occurs in the ED where the ED triage nurse categorizes the clients using the three- or five-tier tools
What is secondary triage
A nurse cares for a dying patient. Which manifestation of dying does the nurse treat first?
a. Anorexia
b. Pain
c. Nausea
d. Hair loss
Pain
Severe burns can result in shock due to fluid shifts out of
what is the intravascular compartment
A patient arrives in the emergency department after being in a car crash with fatalities. The patient has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority?
a. Apply direct pressure to the bleeding.
b. Ensure that the patient has a patent airway.
c. Obtain consent for emergency surgery.
d. Start two large-bore IV catheters.
B
Airway is the priority, followed by breathing and circulation (IVs and direct pressure). Obtaining consent is done by the physician.
A fast-paced, crowded environment that can be stressful.
What is the Emergency Department (ED)
Occurs when the client exits the ED and is moved into the ICU or operating room
What is tertiary triage
A nurse is field-triaging patients after an industrial accident. Which patient condition would the nurse triage with a red tag?
a. Dislocated right hip and an open fracture of the right lower leg
b. Large contusion to the forehead and a bloody nose
c. Closed fracture of the right clavicle and arm numbness
d. Multiple fractured ribs and shortness of breath
Patients who have an immediate threat to life are given the highest priority, are placed in the emergent or class I category, and are given a red triage tag. The patient with multiple rib fractures and shortness of breath most likely has developed a pneumothorax, which may be fatal if not treated immediately. The patient with the hip and leg problem and the patient with the clavicle fracture would be classified as class II; these major but stable injuries can wait for 30 minutes to 2 hours for definitive care. The patient with facial wounds would be considered the “walking wounded” and classified as nonurgent.
If the client has burns greater than 15% of TBSA, the client will require
What is intravenous fluid resuscitation
Critical care nurses must be competent in
What is clinical judgment, teamwork and collaboration, clinical skills, and communication
The three-tiered tool identifies clients based on the following.
What is:
Occurs in the field where health care providers treat clients at the scene and prioritize clients for evacuation to the ED or to a Trauma Unit
What is primary triage
A nurse reviews the laboratory results for a patient who was burned 24 hours ago. Which laboratory result would the nurse report to the healthcare provider immediately?
a. Arterial pH: 7.32
b. Hematocrit: 52%
c. Serum potassium: 6.5 mEq/L (6.5 mmol/L)
d. Serum sodium: 131 mEq/L (131 mmol/L)
The serum potassium level is changed to the degree that serious life-threatening responses could result. With such a rapid rise in potassium level, the patient is at high risk for experiencing severe cardiac dysrhythmias and death. All the other findings are abnormal but do not show the same degree of severity; they would be expected in the emergent phase after a burn injury.
An emergency room nurse assesses a patient who was rescued from a home fire. The patient suddenly develops a loud cough and shortness of breath and wheezing. What action would the nurse take first?
a. Apply oxygen and continuous pulse oximetry.
b. Provide small quantities of ice chips and sips of water.
c. Request a prescription for an antitussive medication.
d. Ask the respiratory therapist to provide humidified air.
A
Brassy cough and wheezing are some of the signs seen with inhalation injury. The first action by the nurse is to give the patient oxygen. Patients with possible inhalation injury also need continuous pulse oximetry. Ice chips and humidified room air will not help the problem, and antitussives are not warranted.
A nurse assesses a patient admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding would alert the nurse to a potential complication?
a. O2 Saturation of 95%
b. Urine output of 20 mL/hr
c. Productive cough with white pulmonary secretions
d. Core temperature of 100.6 F (38 C)
B
A significant loss of fluid occurs with burn injuries, and fluids must be replaced to maintain hemodynamics. If fluid replacement is not adequate, the patient may become hypotensive and have decreased perfusion of organs, including the brain and kidneys. A low urine output is an indication of poor kidney perfusion.
Levels and descriptions of the Emergency Severity Index (ESI)
What is
Level 1-Resuscitation needed
Level 2-High risk situation
Level 3-Two or more resources needed
Level 4-One resource needed
Level 5-No resources needed
Nurses have a primary role in responding to and helping communities in the event of a disaster. Therefore, nurses need to
What is learn disaster communication, triage, and disaster treatment skills
An emergency room nurse is triaging victims of a multi-casualty event. Which patient would receive care first?
a. A 30-year-old distraught mother holding her crying child
b. A 65-year-old conscious male with a head laceration
c. A 26-year-old male who has pale, cool, clammy skin
d. A 48-year-old with a simple fracture of the lower leg
C
The patient with pale, cool, clammy skin may be in shock and needs immediate medical attention. The mother does not have injuries and so would be the lowest priority. The other two people need medical attention soon, but not at the expense of a person in shock.
Clients with moderate burns will need immediate
What are laboratory studies to determine their fluid-volume status, IV access with Lactated Ringers solution, and pain management.
It can increase a patient's risk for a more severe illness or death.
What is deteriorate
ABCDE assessment performed in the ED to assess for life-threatening injuries.
What is primary survey
A disaster triage system that is frequently used is the Sort, Assess, Life-saving Interventions, Treatment, and Transportation (SALT) algorithm. During this process, triage tags are implemented as part of the client tracking, which includes
What are