NUR 254 Nursing Role in Crisis Review
Questions and Correct Answers
What are the priority emergency measures for all patients? ✅- safety is the first priority
- preplanning to ensure security and a safe environment
- close observation of patient and family members in event that they respond to stress
with physical violence
How does triage work in the ED? ✅triage sorts patients by hierarchy based on severity
of health problems and the immediacy with which these problems must be treated
(quickly assess, treat and move them)
What are the 5 levels of triage in the ED? ✅1 - resuscitation
2 - emergent
3 - urgent
4 - less urgent
5 - non urgent
What is the resuscitation level of triage? ✅1:1 care, suicide risk, cardiac arrest, post
code, TPA
What is the emergent level of triage? ✅Q15 assessment; stroke, chest pain, acute
asthma attack, ARD, MI, sepsis, head injury, spinal cord injury, hypotensive shock,
rectal bleeds, gunshot wounds, airway blockage, waterbroke with moderate bleeding
What is the urgent level of triage? ✅Q30 assessment; stable GI bleed, ABD pain, high
fever with cough
What is the less urgent level of triage? ✅Q60 assess; minor cuts or lacerations, UTI
What is the non urgent level of triage? ✅Q2H; episodic or chronic illness, could wait to
see PCP
What is involved in a primary survey? ✅A - airway
B- breathing
C- circulation
D - disability
E - exposure
What is involved in a secondary survey? ✅- health history
- head-to-toe assessment
- diagnostic and lab testing
, - monitoring devices
- splinting
- wound care
- other interventions
What are the signs and symptoms of hemorrhage? ✅- stab wounds have defined
edges and are deep and wide
- hypotension, weak peripheral pulses, tachycardia, clammy skin, delayed cap refill,
fatigue, weakness
- low H/H, low RBC, low COP
What are the priorities for hemorrhage? ✅- control the bleeding (internal and external)
- fluid replacement
- assessment changes monitoring
How can we control hemorrhage in external injuries? ✅- tourniquet and apply pressure
(write the time the tourniquet is placed to prevent tissue damage)
What are the priorities of care for the patient with multiple traumas? ✅- requires a team
approach
- determine the extent of the injuries and establish priorities of treatment
- assume cervical spine injury
- injuries interfering with vital physiologic function have highest priority
Why are abdominal injuries so severe? ✅they can cause massive life-threatening
blood loss into the abdominal cavity
What are the signs and symptoms of an intra-abdominal injury? ✅- firm board-like
abdomen, tender abdomen, hypoactive or absent bowel sounds, hypotension,
tachycardia, black or tarry stools
- referred pain from liver, spleen or intraperitoneal injury (get an abdominal CT asap!)
What are the priorities for a patient with an intra-abdominal injury? ✅- they would be
emergent
- ensure ABC, immobilize the cervical spine
- packed RBC and maybe platelets, IVF
- monitor H/H and lactic acid levels to determine acidosis
- may require NG for decompression, prophylactic abx, exploratory surgery, hold oral
fluids,
- if viscera protruding: cover with sterile, moist saline dressing and call MD if theres any
color changes
What are complications of intra-abdominal injuries? ✅- shock
- hemorrhage
- loss of bowel function
