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N450 Assessment 2-Questions with Correct Answers/Verified/ Latest Update 2024/2025 $10.49   Add to cart

Exam (elaborations)

N450 Assessment 2-Questions with Correct Answers/Verified/ Latest Update 2024/2025

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  • Course
  • N450
  • Institution
  • N450

ED Triage -️️Process of quickly sorting patients and assigning right resources in the right place and right time ESI 1 -️️Unstable ESI 2 -️️Threatened ESI 3-5 -️️Stable ABCDE -️️Airway Breathing Circulation Disability Exposure/Environment

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  • August 2, 2024
  • 24
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers
  • N450
  • N450
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MikeHarris
N450 Assessment 2-Questions with Correct Answers/Verified/ Latest
Update 2024/2025
ED Triage - ✔️✔️Process of quickly sorting patients and assigning right resources in the right place
and right time



ESI 1 - ✔️✔️Unstable



ESI 2 - ✔️✔️Threatened



ESI 3-5 - ✔️✔️Stable



ABCDE - ✔️✔️Airway

Breathing

Circulation

Disability

Exposure/Environment



Nursing Interventions for Alertness/Airway - ✔️✔️Control Bleeding

Open airway

Jaw thrust

Suction airway

Nasal/Oral airway or intubation

Cervical Spine immobilization



Nursing Interventions for Breathing - ✔️✔️Administer O2

Intubate

Suction



Alertness/Airway Assessment - ✔️✔️Assess:

Catastrophic external bleeding

LOC

,Respiratory distress

Patency: Foreign objects/loose teeth



Breathing Assessment - ✔️✔️Ventilation

Use of accessory muscles

Respiratory rate

Color of skin

Auscultate lungs

JVD and trachea position



Airflow does not ensure adequate.... - ✔️✔️ventilation



Circulation Assessment - ✔️✔️Palpate carotid or femoral

Pulse rate and quality

Skin color, temp, dry/moist

Capillary refill

BP



Nursing Interventions for Circulation - ✔️✔️CPR/ACLS

Prep for central venous access

Administer IV fluids/blood products

Control bleeding



If patient is hypotensive insert ______ large bore IVs, and start 0.9% normal saline or lactated
ringers - ✔️✔️two



Disability Assessment - ✔️✔️LOC w/ Glasgow Coma Scale

Pupils



Glasgow Coma Scale - ✔️✔️Eye opening 4

Verbal response 5

, Motor response 6



GCS 8 or less - ✔️✔️severe brain injury



GCS 9-12 - ✔️✔️moderate brain injury



GCS 13-15 - ✔️✔️mild head injury



Exposure/Environment Assessment - ✔️✔️Remove clothing for complete assessment



Nursing Interventions for Exposure/Environment - ✔️✔️Prevent heat loss by keeping patient
covered or infusing warmed IV fluids

Stabilize impaled objects

Protect patient's privacy



DO NOT remove _________ objects - ✔️✔️impaled



Facilitate Adjunctive Monitoring/Family Presence Assessment - ✔️✔️Evaluate VS and POx

Discuss family preference for involvement during invasive procedures and/or CPR



Nursing Interventions for Family Presence - ✔️✔️Monitor VS

Establish healthcare team



Secondary Survey - ✔️✔️head to toe assessment starting at head.

Touch, smell, looking all areas.



SAMPLE - ✔️✔️Symptoms

Allergies

Medications

Pertinent history

Last meal or intake

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