Welcome to your NCLEX reviewer and practice questions quiz about Emergency Nursing and Triage. Test your competence in emergency nursing in this nursing test bank. Emergency Nursing & Triage NCLEX Practice QuizIn this section are the practice problems and questions for emergency nursing and triage NCLEX practice quiz. In this nursing test bank, there are 40 practice questions divided into two parts. Please check out also our reviewer for emergency nursing below. Quizzes included in this guide are: Want a full copy? If you want to print a copy of this quiz, please visit FULL TEXT: Emergency Nursing & Triage NCLEX Practice Quiz (40 Questions) Quiz guidelines:
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Emergency Nursing Reviewer“Emergency!” The very event that is linked to drama and hysteria. The word emerge in emergency, and an emergency suddenly emerges — it happens all of a sudden, at any time to anyone, and anywhere. The person, specifically the nurse who responds at the scene in the emergency department or on the medical-surgical unit, faces the ultimate challenge of their nursing skills. In this medical setting, you plan a solution for a short period of time, and there is no room for error. Emergency
Emergency Nursing
Emergency Medical Services
1. Emergency Medical Technician (EMT). Also known as an ambulance technician, is a health professional that provides emergency medical services. EMTs are most commonly found working in ambulances. They are also the most common type of providers in all of EMS. 2. Emergency Medical Technician Intermediates (EMTI). EMTIs are next to EMTs. Intermediates maintain a critical skill set that can often be life-saving to those involved in accidents, emergencies, and complicated procedures. 3. Emergency Medical Technician Paramedics (EMTP). EMTPs are the highest level of EMTs. Paramedics are advanced providers of emergency medical care and are highly educated in anatomy and physiology, cardiology, medications, and medical procedures. Four Basic Steps for Emergencies 1. Know your facility. It is important to know what emergency resources are available in each location and the equipment’s placement, such as overhead sprinkler systems, fire extinguishers, and defibrillators. Healthcare providers, especially nurses, should know where the E-carts and E-kits are placed in the hospital setting. They need to be available to providers very easily. 2. Know the proper scope of your emergency care. The nurse should know their role, accountability, and responsibility when dealing with emergencies. The nurse is responsible for the following:
Primary and Secondary Assessment
3. Know your patients. Nurses are responsible for identifying if the patient is in an emergency and recognizing patients’ symptoms, taking measures within their scope of practice to administer medications, providing other measures for symptom alleviation, and collaborating with other professionals to optimize patients’ comfort and families’ understanding and adaptation. 4. Stay prepared. Preparing for unexpected occurrences is only part of the equation. Being fast, ready, and accurate for an emergency also involves practicing good mental health strategies that can develop one’s level of competency in the event of a crisis. Emergency Equipment, Drugs, and Procedures.
Guidelines for giving emergency care 1. Getting Started A. Planning of action. B. Gathering of materials needed. 2. Emergency Action Principles A. Survey the scene. First, survey the scene for any possible hazards. Stop. Look. Listen. Feel. Safety first! B. Perform Primary Assessment. If the area appears safe, check the victim for life-threatening conditions such as: I. Assess for ABC.
C. Call for help. After checking the victim, call for help. Remain calm, and be prepared to describe the situation and the exact location where responders are needed. Also, contact local site security and emergency response. D. Perform Secondary Assessment. The main focus of the secondary assessment is to explore specific medical conditions the patient may have. I. Neurologic Assessment
Glasgow Coma Scale
Four grades are starting with the most severe: 1. No opening of the eye2. Eye opening in response to pain stimulus. A peripheral pain stimulus, such as squeezing the lunula area of the person’s fingernail, is more effective than a central stimulus, such as a trapezius squeeze, due to a grimacing effect.3. Eye opening to speech. Not to be confused with the awakening of a sleeping person; such people receive a score of 4, not 3. 4. Eyes opening spontaneously Five grades are starting with the most severe: 1. No verbal response2. Incomprehensible sounds. Moaning but no words.3. Inappropriate words. Random or exclamatory articulated speech, but no conversational exchange. Speaks words but no sentences. 4. Confused. The person responds to questions coherently, but there is some disorientation and confusion. 5. Oriented. The person responds coherently and appropriately to questions such as their name and age, where they are and why, the year, month, etc. There are six grades: 1. No motor response2. Decerebrate posturing accentuated by pain (extensor response: adduction of the arm, internal rotation of the shoulder, pronation of forearm and extension at the elbow, flexion of wrist and fingers, leg extension, plantar flexion of the foot)3. Decorticate posturing accentuated by pain (flexor response: internal rotation of the shoulder, flexion of forearm and wrist with a clenched fist, leg extension, plantar flexion of the foot) 4. Withdrawal from pain (absence of abnormal posturing; unable to lift hand past chin with supraorbital pain but does pull away when nail bed is pinched) 5. Localizes to pain (purposeful movements towards painful stimuli; e.g., brings a hand up beyond chin when supraorbital pressure applied)6. Obeys commands (the person does simple things as asked)
II. History
III. Pain Assessment. OPQRST is a useful mnemonic used by EMTs, paramedics, nurses, medical assistants, and other allied health professionals to learn about the patient’s pain complaint.
IV. General Appearance. Gait, unusual skin markings, affect, posture, skin color. V. Head to toe Assessment. Establishing a good assessment would, later on, provide a more accurate diagnosis, planning, and better interventions and evaluation. That’s why it’s important to have a good and strong assessment. VI. Diagnostic Tests. A diagnostic procedure is an examination to identify an individual’s specific areas of weakness and strength to determine a condition, disease, or illness. E. Diagnosis. Nursing diagnoses represent the nurse’s clinical judgment about actual or potential health problems/life processes occurring with the individual, family, group, or community. F. Management. The nurse implements the nursing care plan, performing the determined interventions that were selected to help meet the goals/outcomes that were established. G. Evaluation. The nurse evaluates the progress toward the goals/outcomes identified in the previous phases. If progress towards the goal is slow, or if regression has occurred, the nurse must change the care plan accordingly. H. Client Disposition. Understanding the patient’s readmission risk stratification, the needs of the patient upon discharge, and the ability of the receiving facility to meet those needs all have a role in the patient’s well-being and can help prevent readmission. I. Documentation. The entire process is recorded or documented to inform all members of the health care team. 3. Golden Rules of Emergency Care
Triage Triage
Purpose:
Descriptions of a few Emergency Nurse roles: Triage Nurse
ED Charge Nurse
Trauma Nurse
Code Nurse
Disaster Response or Emergency Preparedness Nurse
Critical-Care Transport (CCT) Nurse (Ambulance)
Burn Center Nurse
Emergency Department Triage System (Three-Tier System) EMERGENT (RED)
URGENT (YELLOW)
NONURGENT (GREEN)
NO CATEGORY or BLACK CATEGORY
Cardiopulmonary Resuscitation (CPR) Cardiopulmonary Resuscitation (CPR) incorporates rescue breathing with chest compression to circulate oxygen around the body while anticipating further emergency help. CPR does not normally restart a person’s heart, but it can save many lives when combined with early emergency help, early defibrillation, and early advanced hospital care. Ribs may be broken during CPR, but this is preferable to dying. Basic Life Support (BLS)
Elements of Basic Life Support (BLS)
Four Age Categories in Basic Life Support (BLS)
Procedures in Doing Cardiopulmonary Resuscitation (CPR) https://www.redcross.org/take-a-class/cpr/performing-cpr/cpr-steps Before Giving CPR 1. Check the scene and the person. Ensure the scene is safe, then tap the person on the shoulder and shout “Are you OK?” to ensure that the person needs help.2. Call 911 for assistance. If it’s evident that the person needs help, call (or ask a bystander to call) 911, then send someone to get an AED. (If an AED is unavailable, or there is no bystander to access it, stay with the victim, call 911 and begin administering assistance.)3. Open the airway. With the person lying on their back, tilt the head back slightly to lift the chin. 4. Check for breathing. Listen carefully, for no more than 10 seconds, for sounds of breathing. (Occasional gasping sounds do not equate to breathing.) If there is no breathing, begin CPR. CPR Steps according to Red Cross 1. Push hard, push fast. Place your hands, one on top of the other, in the middle of the chest. Use your body weight to help you administer compressions at least 2 inches deep and delivered at a rate of at least 100 compressions per minute.2. Deliver rescue breaths. With the person’s head tilted back slightly and the chin lifted, pinch the nose shut and place your mouth over the person’s mouth to make a complete seal. Blow into the person’s mouth to make the chest rise. Deliver two rescue breaths, then continue compressions.Note: If the chest does not rise with the initial rescue breath, re-tilt the head before delivering the second breath. If the chest doesn’t rise with the second breath, the person may be choking. After each subsequent set of 30 chest compressions, and before attempting breaths, look for an object and, if seen, remove it. 3. Continue CPR steps. Keep performing chest compressions and breathing cycles g until the person exhibits signs of life, such as breathing, an AED becomes available, or EMS or a trained medical responder arrives on the scene. Note: End the cycles if the scene becomes unsafe or you cannot perform CPR due to exhaustion. Automated External Defibrillation (AED)
Two Types of Machine 1. Monophasic. Monophasic AEDs are devices that emit a type of shock. It sends an electrical current in a single direction from one side of the chest to an electrode on the other side. 2. Biphasic. Biphasic waveform defibrillators utilize bidirectional current flow as opposed to monophasic AED, where the current flows are in one direction. Contraindications: While it’s important to know when to use a defibrillator, it’s just as important to know when not to use a defibrillator.
Advanced Cardiac Life Support (ACLS)
Criteria for Not Starting Cardiac Life Support
Terminating BLS in Out-of-Hospital Setting
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