An emergency room nurse is performing secondary triage on clients transported from the scene of a chemical spill. After caring for the clients, the EMS workers complained of nausea and dizziness. Which immediate interventions need to be taken by the triage nurse? SELECT ALL THAT APPLY
Continue with the triage process.
Evacuate the emergency department.
Place the client in a private room.
Treat the client after contaminated items are removed.
Send the client and EMS crew to decontamination.
Correct Answer : B,E
Choice A reason: Continuing with the triage process is not an immediate intervention that needs to be taken by the triage nurse, as it may expose more people to the chemical hazard and worsen the situation. The triage nurse should stop the triage process and alert the emergency department staff and management about the potential contamination. The triage nurse should also follow the facility's emergency preparedness plan and protocols for dealing with chemical spills.
Choice B reason: Evacuating the emergency department is an immediate intervention that needs to be taken by the triage nurse, as it helps to protect the safety and health of the staff, clients, and visitors. The triage nurse should assist with evacuating everyone from the emergency department to a safe and designated area, away from the source of contamination. The triage nurse should also ensure that everyone is accounted for and that no one re-enters the emergency department until it is cleared by the authorities.
Choice C reason: Placing the client in a private room is not an immediate intervention that needs to be taken by the triage nurse, as it may not prevent the spread of contamination or provide adequate care to the client. The client who have been exposed to a chemical spill should not be moved to another area of the facility, as they may contaminate other people or surfaces along the way. The client should be kept in a separate and isolated area until they are decontaminated and assessed.
Choice D reason: Treating the client after contaminated items are removed is not an immediate intervention that needs to be taken by the triage nurse, as it may delay or compromise the care of the client. The client who has been exposed to a chemical spill should be treated as soon as possible, as some chemicals can cause serious or irreversible damage to the skin, eyes, lungs, or other organs. The triage nurse should provide basic life support measures, such as airway management, oxygen therapy, or bleeding control while wearing appropriate personal protective equipment (PPE). The triage nurse should also remove any contaminated clothing or jewelry from the client and place them in a sealed bag.
Choice E reason: Sending the client and EMS crew to decontamination is an immediate intervention that needs to be taken by the triage nurse, as it helps to remove or neutralize any harmful chemicals from their skin, hair, or clothing. The triage nurse should direct or escort the client and EMS crew to a designated decontamination area or unit, where they will undergo a thorough washing process with water and soap or other solutions. The triage nurse should also monitor their vital signs and symptoms during and after decontamination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Monitoring vital signs and neurological status frequently is a priority intervention for a client who has experienced a hemorrhagic stroke, as it helps to detect any changes in the client's condition and guide appropriate treatment. Hemorrhagic stroke is a medical emergency that occurs when a blood vessel in the brain ruptures and causes bleeding into the brain tissue. This can lead to increased intracranial pressure, cerebral edema, and brain damage. Therefore, the nurse should monitor the client's blood pressure, pulse, respiration, temperature, level of consciousness, pupil reaction, motor function, and sensory function frequently and report any abnormalities to the health care provider.
Choice B reason: Maintaining strict bed rest to minimize cerebral blood flow is not a priority intervention for a client who has experienced a hemorrhagic stroke, as it may not prevent further bleeding or improve the client's outcome. In fact, strict bed rest may increase the risk of complications such as deep vein thrombosis, pulmonary embolism, pneumonia, pressure ulcers, and muscle atrophy. The nurse should follow the health care provider's orders regarding the client's activity level and position. The nurse should also provide adequate hydration, nutrition, skincare, and comfort measures to the client.
Choice C reason: Administering anticoagulant medications as prescribed is not a priority intervention for a client who has experienced a hemorrhagic stroke, as it may worsen the bleeding and increase the risk of intracranial hemorrhage. Anticoagulant medications are used to prevent or treat ischemic stroke, which is caused by a blood clot that blocks a blood vessel in the brain. However, anticoagulant medications are contraindicated in hemorrhagic stroke, as they interfere with the blood's ability to clot and stop the bleeding. The nurse should avoid giving any medications that may affect coagulation or platelet function to the client unless ordered by the health care provider.
Choice D reason: Assisting the client with active range of motion exercises is not a priority intervention for a client who has experienced a hemorrhagic stroke, as it may not improve the client's neurological function or prevent complications. Active range of motion exercises are performed by the client with or without assistance from the nurse to maintain joint mobility and muscle strength. However, these exercises are not indicated in the acute phase of hemorrhagic stroke, as they may increase intracranial pressure or cause pain or discomfort to the client. The nurse should consult with the physical therapist before initiating any exercise program for the client.
Correct Answer is A
Explanation
Choice A reason: Monitoring vital signs and neurological status frequently is a priority intervention for a client who has experienced a hemorrhagic stroke, as it helps to detect any changes in the client's condition and guide appropriate treatment. Hemorrhagic stroke is a medical emergency that occurs when a blood vessel in the brain ruptures and causes bleeding into the brain tissue. This can lead to increased intracranial pressure, cerebral edema, and brain damage. Therefore, the nurse should monitor the client's blood pressure, pulse, respiration, temperature, level of consciousness, pupil reaction, motor function, and sensory function frequently and report any abnormalities to the health care provider.
Choice B reason: Maintaining strict bed rest to minimize cerebral blood flow is not a priority intervention for a client who has experienced a hemorrhagic stroke, as it may not prevent further bleeding or improve the client's outcome. In fact, strict bed rest may increase the risk of complications such as deep vein thrombosis, pulmonary embolism, pneumonia, pressure ulcers, and muscle atrophy. The nurse should follow the health care provider's orders regarding the client's activity level and position. The nurse should also provide adequate hydration, nutrition, skin care, and comfort measures to the client.
Choice C reason: Administering anticoagulant medications as prescribed is not a priority intervention for a client who has experienced a hemorrhagic stroke, as it may worsen the bleeding and increase the risk of intracranial hemorrhage. Anticoagulant medications are used to prevent or treat ischemic stroke, which is caused by a blood clot that blocks a blood vessel in the brain. However, anticoagulant medications are contraindicated in hemorrhagic stroke, as they interfere with the blood's ability to clot and stop the bleeding. The nurse should avoid giving any medications that may affect coagulation or platelet function to the client unless ordered by the health care provider.
Choice D reason: Assisting the client with active range of motion exercises is not a priority intervention for a client who has experienced a hemorrhagic stroke, as it may not improve the client's neurological function or prevent complications. Active range of motion exercises are performed by the client with or without assistance from the nurse to maintain joint mobility and muscle strength. However, these exercises are not indicated in the acute phase of hemorrhagic stroke, as they may increase intracranial pressure or cause pain or discomfort to the client. The nurse should consult with the physical therapist before initiating any exercise program for the client.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today