Answers and Rationals for Emergency and Prioritization

 Answers and Rationals for Emergency and Prioritization
01 Answer. d
Rational: The first action of the nurse is to assess the patency of the airway and respiratory function. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. If the airway is not patent, the nurse must take immediate measures for the survival of the client. Options a, b, and c are all nursing actions that should be performed after a patent airway has been established.

02.  Answer .c
Rational:The next nursing action would be to open the airway. Ventilation cannot be initiated unless the airway is opened. Chest compressions are started after opening the airway and initiating ventilation. Oxygen may be helpful at some point, but the airway is opened first.

03  Answer .a
Rational:The immediate care during a seizure (eclampsia) is to ensure a patent airway. Options b, c, and d are actions that follow or are implemented after the seizure has ceased.


04. Answer: a
Rational:The priority nursing action for a patient arriving at the ED in distress is always assessment of vital signs. This indicates the extent of physical compromise and provides a baseline by which to plan further assessment and treatment. A thorough medical history, including onset of symptoms, will be necessary and it is likely that an electrocardiogram will be performed as well, but these are not the first priority. Similarly, chest exam with auscultation may offer useful information after vital signs are assessed.

05. Answer: d
Rational: Emergency treatment following a chemical splash to the eye includes immediate irrigation with normal saline. The irrigation should be continued for at least 10 minutes. Fluorescein drops are used to check for scratches on the cornea due to their fluorescent properties and are not part of the initial care of a chemical splash, nor is patching the eye. Following irrigation, visual acuity will be assessed.


06. Answer: d
Rational: Following triage, an x-ray should be performed to rule out fracture. Ice, not heat, should be applied to a recent sports injury. An elastic bandage may be applied and pain medication given once fracture has been excluded.

07. Answer: b
Rational: Acetaminophen in even modestly large doses can cause serious liver damage that may result in death. Immediate evaluation of liver function is indicated with consideration of N-acetylcysteine administration as an antidote. Tinnitus is associated with aspirin overdose, not acetaminophen. Diarrhea and hypertension are not associated with acetaminophen.

08. Answer: d
Rational: The patient may be experiencing an anaphylactic reaction. The most urgent action is to maintain an airway, particularly with visible oral swelling, followed by the administration of epinephrine by subcutaneous injection. The physician will see the patient as soon as possible with the above actions underway. Oral diphenhydramine is indicated for mild allergic reactions and is not appropriate for anaphylaxis.

09 Answer .d
Rational: assessing for responsiveness is the first nursing action when performing CPR.

10) Answer. a
Rational: promotion of adequate oxygenation is most vital to life. Therefore, this should be given highest priority by the nurse for a client with dyspnea, chest pain, and syncope.


11 Answer .c
Rational: administration of oxygen is a priority nursing action in a client with chest pain. The primary reason for chest pain is inadequate myocardial oxygenation.