ER

Nurse Ejay is assigned to a telephone triage. A client called who was stung by a honeybee and is asking for help. The client reports of pain and localized swelling but has no respiratory distress or other symptoms of anaphylactic shock. What is the appropriate initial action that the nurse should direct the client to perform?

A client arrives at the emergency department who suffered multiple injuries from a head-on car collision. Which of the following assessment should take the highest priority to take?

Nurse Kelly, a triage nurse encountered a client who complaints of mid-sternal chest pain, dizziness, and diaphoresis. Which of the
following nursing action should take priority?

The following clients come at the emergency department complaining of acute abdominal pain. Prioritize them for care in order of the severity of the conditions.
1. A 27-year-old woman complaining of lightheadedness and severe sharp left lower quadrant pain who reports she is possibly pregnant.
2. A 43-year-old woman with moderate right upper quadrant pain who has vomited small amounts of yellow bile and whose symptoms have worsened over the week.
3. A 15-year-old boy with a low-grade fever, right lower quadrant pain, vomiting, nausea, and loss of appetite for the past few days.
4. A 57-year-old woman who complains of a sore throat and gnawing midepigastric pain that is worse between meals and during the night.
5. A 59-year-old man with a pulsating abdominal mass and sudden onset of persistent abdominal or back pain, which can be described as a tearing sensation within the past hour.

The following clients are presented with signs and symptoms of heat-related illness. Which of them needs to be attended first?

An anxious female client complains of chest tightness, tingling sensations, and palpitations. Deep, rapid breathing, and carpal spasms are noted. Which of the following priority action should the nurse do first?

You’re working as a triage nurse during a disaster situation. Based on the triage color code tags placed on each of the wounded, which tag color represents the wounded who have the highest priority of being treated first?

A catastrophic disaster has occurred 5 miles from the hospital you are working in. The hospital’s disaster plan is activated and the wounded are brought to the hospital. You’re helping triage the survivors. One of the wounded is able to walk around and has minor lacerations on the arms, hands, chest, and legs. You would place what color tag on this survivor?

A 57 year old African American male presents to your Emergency Department at 2200 complaining of chest pain that began at dinner and has lasted for over two hours. He has a prior history of hypertension for which he is on lisinopril 40mg PO daily and he smokes 1/2 pack a day. He weighs 240 lbs and is 5’6”. He is accompanied by his worried wife and his occupation is a business executive. He did try to take two Tums at dinner but it didn’t relieve his chest pain. His pain is an 8/10 and is radiating up his sternum. It is intermittent and activity makes it worse. He was brought directly back into your ED bay and his vital signs are 170/90, heart rate of 98, respirations 27, 97% pulse oximetry on room air, and temperature of 98.9 degrees F.