Which nursing care delivery system works well in emergency situations that necessitate prioritization of care quizlet?

After exposure to hot weather and sun, clients with signs and symptoms of heat-related ailment rush to the Emergency Department (ED). Sort clients into those who need critical attention to those with less serious condition.
1. An abandoned person who is a teacher; has altered mental state, weak muscle movement, hot, dry, pale skin; and whose duration of heat exposure is unknown
2. An elderly traffic enforcer who complains of dizziness and syncope after standing under the heat of the sun for several hours to perform his job
3. A comparatively healthy housewife who states that the air conditioner has been down for 5 days and who exhibits hypotension, tachypnea, profuse diaphoresis, and fatigue
4. A sportsman who complains of severe leg cramps and nausea, and displays paleness, tachycardia, weakness, and diaphoresis.
A. 4, 3, 2, 1
B. 1, 2, 4, 3
C. 1, 4, 2, 3
D. 4, 1, 3, 2

Several clients arrive in the ED with the same complaint of abdominal pain. Designate them for care in order of the severity of their condition.
1. A 12-year-old girl with a low-grade fever, anorexia, nausea, and right lower quadrant tenderness for the past 2 days
2. A 25-year-old woman complaining of dizziness and severe left lower quadrant pain who states she is probably pregnant
3. A 38-year-old man complaining of severe occasional cramps with three episodes of watery diarrhea hours after meal
4. A 42-year-old woman with moderate right upper quadrant pain who has vomited little amounts of yellow bile and whose symptoms have worsened over the past week
5. A 53-year-old man who experiences discomforting mid-epigastric pain that is worse between meals and during the night
6. A 68-year-old man with a pulsating abdominal mass and sudden onset of "tearing" pain in the abdomen and flank within the past hour
a) 2, 6, 4, 1, 5, 3
b) 6, 2, 4, 1, 3, 5
c) 2, 6, 1, 4, 5, 3
d) 6, 2, 1, 4, 3, 5

d) the RN assesses the client, checks the client's surgical notes, and gathers additional data before calling the surgeon

The RN must not depend exclusively on the judgment of an LPN because the RN is responsible for supervising those to whom client care has been delegated. The client has recently had surgery, and there is the potential for complications, which may be signaled by alterations in vital signs and respiratory status. An analgesic may be needed, but in order to make that determination, the RN must have more information. A call to the surgeon may be warranted, but the RN has insufficient data at this time. In order to provide the client with the degree of care required, the nurse must assess the client, gather additional information, and analyze that information before notifying the surgeon.

D. Fluid​ Volume: Excess

​Rationale: Compensatory mechanisms are activated in heart​ failure, specifically neuroendocrine responses. The cascade of decreased cardiac output and decreased renal perfusion stimulates the​ renin-angiotensin system, which stimulates the release of aldosterone from the adrenal cortex and ADH from the posterior pituitary. ANP and BNP are released and blood flow is redistributed to the heart and brain. As a​ result, there is salt and water retention by the kidneys and water excretion is​ inhibited, causing pulmonary​ congestion, renal vasoconstriction and decreased renal​ perfusion, and increased preload and afterload. According to​ Maslow's Hierarchy of​ Needs, oxygenation is the priority need for a client in stage IV heart​ failure, and therefore Fluid​ Volume: Excess is the priority​ diagnosis, since oxygenation is compromised with fluid overload in the lungs. The second one would be Cardiac​ Output,
Decreased​,
then Activity Intolerance and ​Knowledge,
Deficient.
​(NANDA-I ©​ 2014)

also known as performance improvement, quality improvement focuses on processes or systems that significantly contribute to client safety and effective client care outcomes. Criteria are used to monitor outcomes of care and to determine the need for change to improve the quality of care. Quality improvement processes or systems may be named quality assurance, continuous quality management, or continuous quality improvement. When quality improvement is part of the philosophy of health care agency, every staff member becomes involved in ways to improve client care and outcomes. A restrospective ('looking back') audit is an evaluation method used to inspect the med record after the client's discharge for documentation of compliance with the standards. a concurrent (at the same time) audit is an evaluation method used to inspect compliance of nurses with predetermined standards and criteria while the nurses are providing care during the client's stay. Peer review is a process in which nurses employed in an organization evaluate the quality of nursing care delivered to the client. The quality improvement process is similar to the nursing process and involves an interprofessional approach. An outcome describes the most positive response to care; comparision of client responses to the expected outcomes indicates whether the interventions are effective, whether the client responses to the expected outcomes indicates whether the interventions are effective, whether the client has progressed, how well standards are met, and whether changes are necessary. The nurse is responsible for recognizing trends in nursing practice, identifying recurrent problems, reporting these problems, and initiating opportunities to improve the quality of care.
Quality improvement processes improve the quality of care delivery to clients and the safety of health care agencies.

should be factual, accurate, current, complete, and organized. Reports should include essential background info, subjective data, objective data, any changes in the client's status, client problems, treatments and procedures, medication administration, client teaching, dischare planning, family information, the client's response to treatments and procedures, and the client's priority needs

identify tasks, obligations, and activities and write them down. Organize the work day; identify which tasks must be completed in specified time frames. Prioritize client needs according to importance. Anticipate the needs of the day and provide time for unexpected and unplanned tasks that may arise. Focus on beginning the daily tasks, working on the most important first while keeping goals in mind. Look at the final goal for the day, which helps in the breakdown of tasks into manageable parts. Begin client rounds at the beginning of the shift, collecting data o each assigned client. Delegate tasks when appropriate. Keep a daily hour-by-hour log to assist in providing structure to the tasks that must be accomplished, and cross tasks off the list as they are accomplished. Use health care agency resources wisely, anticipating resource needs, and gather the necessary supplies before beginning the task. Organize paperwork and continuously document task completion and necessary client data throughout the day (i.e., documentation should be concurrent with completioins of a task or oberservation of pertinent client data). At the end of the day, evaluate the effectiveness of time management.

review the problems of each client. Review nursing diagnoses. Determine which client problems are most urgent based on basic needs, the client's changing or unstable status, and complexity of the client's problems. Anticipate the time that it may take to care for the priority needs of the clients. Combine activities, if possible, to resolve more than one problem at a time. Involve the client in his or her care as much as possible.
Use the ABCs-airway, breathing, and circulation-, Maslow's Hierarchy of Nees theory, and the steps of the nursing process (assessment is first) to prioritize. If cardio pulmonary resuscitation (CPR) needs to be initiated, use CAB-circulation, airway, and breathing-as the priority guideline.

the federal emergency management agency (FEMA) identifies four disaster management phases: mitigation, preparedness, response, and recovery.
mitigation encompassesthe following: actions or measures that can prevent the occurrence of a disaster or reduce the damaging effects of a disaster. Determination of the community hazards and community risks (actual and potential threats) before a disaster occurs. Awareness of abailable community resources and community health personnel to facilitate mobilization of activities and minimize chaos and confusion if a disaster occurs. Determination of the resoiurces available for care to infants, older adults, disabled individuals, and individuals with chronic health problems.
Preparedness encompasses the following: Plans for rescue, evacuation, and caring for disaster victims. Plans for training disaster personnel and gathering resoiurces, equipment, and other materials needed for dealing with the disaster. Identification of specific responsibilities for various emergency response personnel. Establishment of a community emergency response plan and an effective public communication system. Development of an emergency emdical system and a plan for activation. Verification of proper functioning of emergency equipment. Collection of anticipatory provisions and creation of a location for providing food, water, clothing, shelter, other supplies, and needed medicine
INventory of supplies on aregular basis and replenishment of outdated supplies. Practice of community emergency response plans (mock dissaster chlls)
response encompasses the foolowing: putting disaster planning services into action and the actions taken to save lives and prvent further damage. Primary concerns include safety, physical health, and mental health of victims and members of the disster response team.
Recovery encompasses the following: actions taken to return to a normal situation after the disaster. Preventing debilitating effects and restoring peronal, econmic, and environmental health and stability to the commuity

personal and professional preparedness
Make personal and family preparations (plan a meeting place for family members, identify where to go if evacuation is necessary, determine when and how to turn off water, gas, and electricity at main switches, locate the safe spots in the home for each type of disaster, have on hand needed pet supplies including a leash).
be aware of the disaste rplan at the place of employiment and in the community. maintain certification is disaster training and in cardiopulmonary resuscitation. Participate in mock disaster drills, including a bomb threat drill. Prepare professional emergency response items, such as a copy of nursing lecense, personal health care equipment such as a copy of nursing license, personal health care equipment such as a stethoscope, case, warm clothing, record-keeping materials, and other nursing care supplies.

primary assessment: the purpose of primary assessment is to identify any client problem that poses an immediate or potential threat to life. The nurse gathers info primarily thru objective data and, on finding any abnormalities, immediately initiates interventions. The nurse uses the ABCs-airway, breathing, and circulation-as a guide in assesssing a client's needs and assesses a client who has sustained a traumatic injury for signs of a head injury or cervical spine injury; CAB-circulation, airway, and breathing-is used if CPR needs to be initiated.
secondary assessment: the nurse performs secondary assessment after the primary assessment and after tretment for any primary problems identified. Secondary assessment identifies any other life-threatening problems that a client might be experiencing.
The nurse obtains subjective and objective data, including a history, general overview, vital sign measurements, neurological assessment, pain assessment, and complete or focused physical assessment.

Delegate the right task to the right delegatee. Be familiar with the experience of the delegatees, their scopes of practice, their job descriptions, agency policy and procedures, and the state nurse practice act; Provide clear directions about the task and ensure that the delegatee understands the expectations; determine the degree of supervision that may be required; provide the delegatee with the authority to complete the task; provide a dealing for completion of the task; evaluate the outcomes of care that has been delegated; provide feedback to the delegatee regarding his/her performance
In general, a license vocl nurse can perform not only the tasks that a nursing assistant can perform but also certain invasive tasks, such as dressing changes, suctioning, urinary catheterization, and medication administration (oral, subcutaneous, intramuscular, and selected piggyback meds), according to the education and job description of the LVN. THe LVN can also review teaching plans with the client that were initiated by the RN.
A RN can perform the tasks that a LVN can perform and is responsible for assessment and planning care, initiating teaching, and administering meds intravenously.

the nurse and the client mutually rank the client's needs in order of importance based on teh client's preferences and expectations, safety, and physical and psychological needs. What the client sees as his or her priority needs may be different from what the nurse sees as the priority needs. Priorities are classified as high, intermediate, or low. CLient needs that are life-threatening or that could result in harm to the client if they are left untreated are high priorities. Nonemergency and non-life-threatening client needs are intermediate priorities; client needs that are not related directly to the client's illness or prognosis are low priorities. When providing care, the nurse needs to decide which needs or problems require immediate action and which ones could be delayed until a later tiem b/c they are not urgent; the nurse considers client problems that involve actual or life-threatening concerns before potential health-threatening concerns. When prioritizing care, the nurse must consider time constraints and available resources. Problems identified as important by the client must be given high priority. The nurse can use the ABCs-airway, breathing and circulaiton- as a guide when determining priorities; client needs related to maintaining a patent airway are always the priority. If the nurse determines that CPR is necessary, then the nurse uses CAB-circulation, airway, and breathing-as a guide to prioritize actions.
the nurse can use Maslow's Hierarcy of Nees theory as a guide to determine priorities and identify the levels of physiological needs, safety, love and belonging, self-esteem, and self-actualizationl. (Basic needs are met before moving to other needs in the hierarchy.) The nurse can use the steps of the nursing process as a guide to determine priorities, remembering that data collection is the first step of the nursing processs.

accidents involving release of radioactive material
dam failures resulting in flooding
hazardous substance accidents such as pollution, chem spills, or toxic gas leads
mass transportation accidents
resources shortages such as food, water, and electricity
structural collapse, fire, or explosions
Terrorist attacks such as bombing, riots, and bioterrorism

natural disasters: blizzards, communicable disease epidemics, cyclones, droughts, earthquakes, floods, forest fires, hailstorms, hurricanes, landslides, mudslides, tidal waves (tsunami), tornadoes, volcanic eruptions

Plan a meeting place for family members. Identify where to go if an evacuation is necessary. Determine when and how to turn off water, gas, and electricity at main switches. Locate the safe spots in the home for each type of disaster. Replace stored water supply every 3 months and stored food supply every 6 months. Include the following supplies:
a 3 day supply of water ( 1 gallon per person per day)
a 3 day supply of nonperishable food
clothing and blankets
first-aid kit
adequate supply of prescription med
battery operated radio
flashlight and batterires
credit card, cash, or traveler's checks
extra set of car keys and a full tank of gas in the car
sanitation supplies for washing, toileting, and disposing of trash
extra pair of eyeglasses
special items for infants, older adults, or disabled individuals
items needed for a pet such as food, water, and leash
important documents in a waterproof case

Emergent (Red): Priority 1 (Highest): This classification is assigned to clients who have life-threatening injuries and need immediate attention and continuous evaluationi but have a high probability for survival when stabilized. Such clients include trauma victims, clients with chest pain, clients with severe respiratory distress or cardiac arrest, clients with limb amputation, clients with acute neurological deficits, and clients who have sustained chemical splashes to the eyes.

Urgent (Yellow): Priority 2: this classification is assigned to clients who require treatment and whose injuries have complications that are not life-threatening, provided that they are treated within 1 to 2 hours. These clients require continuous evaluation every 30 to 60 minutes threreafter. Such clients include clients with a simple fracture, asthma without respiratory distress, fever, htn, abdominal pain, or a renal stone.

nonurgent (Green): Priority 3: this classification is assigned to clients with local injuries who do not have immediate complications and who can wait several hours for medical treatment. These clients require evaluation every 1 to 2 hours thereafter.
Such clients include clients with conditions such as minor laceration, sprain, or cold symptoms.
NOte: Some triage systems include tagging a client "black" if the victim is dead or who soon will be deceased b/c of severe injuries; these are victims who would not benefit from any care b/c of the severity of their injuries

Which nursing skill is essential for the triage process in the emergency department Ed?

Which client would the nurse prioritize when triaging clients in the emergency department?

Which would the nurse consider to be an example of a potential internal disaster quizlet?

Which tag is suitable for a client with high priority during a disaster with mass casualties quizlet?