Ch 16 Care of Patient Experiencing Alterations in Health

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Questions and Answers

What is the term used to describe the process of classifying patients according to the severity of their injuries?

An emergency interview

The Good Samaritan law

Taking vital signs

Triage (correct)

What action must a person take to be protected under the Good Samaritan law?

Act prudently (correct)

Have a medical license

Have licensed supervision

Ensure patient improvement

When assessing victims in an emergency situation, what should the nurse assess for first?

Abnormal breathing (correct)

Hemorrhage

Fractures

Mobility

Under which circumstances can CPR be terminated?

Paramedics arrive Signup and view all the answers

Which of the following best describes the primary focus of triage in an emergency situation?

Classifying severity of injuries Signup and view all the answers

What does the Good Samaritan law generally aim to protect?

Untrained bystanders offering assistance Signup and view all the answers

In emergency care, which assessment is considered a priority to maintain life?

Critical functions like breathing Signup and view all the answers

What is the primary goal of the nurse during the initial assessment of a patient in an emergency?

Identify life-threatening conditions Signup and view all the answers

When performing CPR, which condition is an indicator for potentially stopping the procedure?

Emergency services arrive Signup and view all the answers

What is the purpose of asking, 'Are you choking?'

To determine if the Heimlich maneuver is required Signup and view all the answers

What do the vital signs indicate with a BP of 80/54, P 102, and RR 22?

Inadequate perfusion Signup and view all the answers

How can the nurse confirm the effectiveness of CPR?

By assessing a palpable carotid pulse Signup and view all the answers

What should the rescuer's priority action be upon arriving at an accident scene?

Assessing respiratory status Signup and view all the answers

What does circulatory shock commonly result from?

Inadequate blood circulation Signup and view all the answers

What is the expected depth of compressions during CPR for adults?

2 to 2.4 inches Signup and view all the answers

In the case of chest pain and bleeding, what does a BP of 80/54 indicate?

Potential hypovolemic shock Signup and view all the answers

Which of the following is NOT an indicator of effective CPR?

Application of an automated external defibrillator (AED) Signup and view all the answers

What should the rescuer primarily focus on when a patient has multiple serious injuries?

Assessing airway and breathing Signup and view all the answers

What is a common cause for a patient to enter circulatory shock?

Severe blood loss Signup and view all the answers

What is the most effective initial treatment for bleeding?

Apply direct pressure Signup and view all the answers

What should a rescuer do once a tourniquet has been applied?

Never release the tourniquet Signup and view all the answers

What is the best way to control bleeding in a patient with epistaxis?

Place ice on the nose and pinch the nostrils Signup and view all the answers

What does foul, black, tarry stool indicate in a patient?

Melena Signup and view all the answers

Which of the following is NOT an effective way to control bleeding?

Leaving the patient in a supine position Signup and view all the answers

What is an enhancement procedure when applying a tourniquet?

Wrap the tourniquet twice around the limb Signup and view all the answers

In managing epistaxis, how should the patient position themselves?

Lean forward Signup and view all the answers

If a patient is experiencing hemoptysis, what does this indicate?

Bloody sputum Signup and view all the answers

What action is crucial during the application of a tourniquet?

Never release the tourniquet Signup and view all the answers

What does continuous bloody vomit indicate?

Hematemesis Signup and view all the answers

What does the 'C' in the acronym RICE stand for in the care of a sprain?

Compression Signup and view all the answers

During CPR on an infant, how much should the breastbone be depressed?

One-third of the chest diameter Signup and view all the answers

Which of the following is NOT a component of the RICE acronym for treating a sprain?

Activation Signup and view all the answers

In what situation is the acronym RICE primarily applied?

Sprains and strains Signup and view all the answers

What is the primary purpose of the 'Ice' component in RICE?

To reduce swelling Signup and view all the answers

What is a critical step to perform during CPR on an infant?

Depressing the breastbone at the correct depth Signup and view all the answers

What is the nurse's first action for a patient with a deep laceration of the thigh?

Wash the laceration with an antiseptic. Signup and view all the answers

What should the nurse do first when a patient's lower chest is punctured with a knife still in place?

Immobilize the knife with dressings and tape. Signup and view all the answers

What is the first action for a patient with a sucking wound to the left chest?

Cover the wound with an airtight dressing taped on three sides. Signup and view all the answers

In the case of a deep laceration, what is an incorrect first action for the nurse to take?

Apply a tourniquet to stop bleeding. Signup and view all the answers

If a knife is embedded in a chest wound, what should not be done immediately?

Remove the knife to clean the wound. Signup and view all the answers

When managing a patient with a sucking chest wound, what is an inappropriate action?

Covering the wound with a non-occlusive dressing. Signup and view all the answers

For a laceration, which of the following should not be performed as a first action?

Start applying a pressure dressing. Signup and view all the answers

What is the primary goal when handling chest wounds with embedded objects?

Prevent further injury and immobilize the object. Signup and view all the answers

What is the correct technique for dressing a sucking chest wound?

Apply an occlusive dressing taped on three sides. Signup and view all the answers

In the case of a deep thigh laceration, what immediate priority should the nurse recognize?

Control any bleeding present. Signup and view all the answers

Study Notes

Emergency Care

Triage is the process of classifying patients based on the severity of their injuries, prioritizing care based on need.
Good Samaritan Laws protect individuals who offer assistance in emergencies, as long as their actions are prudent.
ABCs of Assessment: In emergency situations, prioritize:
- Airway: Ensure a clear airway for breathing.
- Breathing: Assess the patient's breathing pattern for any abnormalities.
- Circulation: Check for signs of adequate blood flow.
CPR (Cardiopulmonary Resuscitation): Can be terminated when:
- CPR is deemed futile
- Paramedics arrive.
Heimlich Maneuver: Used for choking victims, involves applying upward pressure on the abdomen.
Shock: Occurs when the circulatory system fails to provide sufficient blood flow, indicated by vital signs like decreased blood pressure, increased heart rate, and rapid breathing.
Effective CPR: Should result in a palpable carotid pulse during each compression.
Control of Bleeding: The most effective treatment is to provide direct pressure to the bleeding site.
Tourniquet Use: Should only be used as a last resort for severe bleeding, and should never be released once in place.
Epistaxis (Nosebleed): Controlled by applying pressure to both nostrils and applying ice to the nose.
Melena: A sign of internal bleeding, characterized by the passage of foul, black, tarry stool.
Wounds:
- Deep lacerations should be cleaned thoroughly and bandaged.
- Objects impaled in wounds should be stabilized, not removed.
- Sucking chest wounds should be covered with an airtight dressing.
Sprains: Managed by using the RICE method: Rest, Ice, Compression, and Elevation.

CPR

Two-person CPR: One person performs compressions while the other provides breaths.
Infant CPR: Compressions are performed on the breastbone, depressing it one-third the chest diameter.

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Description

Test your knowledge on essential emergency care practices such as triage, CPR, and the Heimlich Maneuver. This quiz covers important concepts including Good Samaritan laws and the ABCs of assessment, aiming to enhance your preparedness in emergency situations.