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RN LASALLE ACHIEVE STUDY GUIDE TEST MAP EXAM 3 GET a A+ ON YOUR EXAM $20.49   Add to cart

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RN LASALLE ACHIEVE STUDY GUIDE TEST MAP EXAM 3 GET a A+ ON YOUR EXAM

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TEST MAP ADULT HEALTH 2 LASALLE BSN,RN EXAM 3

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  • October 30, 2024
  • 17
  • 2024/2025
  • Exam (elaborations)
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Emergency Nursing & Trauma
1. What systems are used for triage in the emergency department?
Triage: used to sort patients into groups based on the severity of their health problems
and the immediacy with which these problems must be treated; used for rapid
assessment and decision-making preferably in less than 5 minutes
Three Category Scale
 Categorizes patients as emergent, urgent, or nonurgent

Emergency Severity Index
 Assigns patients into 5 levels based on acuity and resource need
o Level 1- resuscitation
o Level 2- emergent
o Level 3- urgent
o Level 4- less urgent
o Level 5- nonurgent

Canadian Triage & Acute Scale
 Assigns patients into 5 levels and includes time parameters for how frequently
patients are reassessed
o Level 1- resuscitation + continuous nursing surveillance
o Level 2- emergent + reassessed every 15 minutes
o Level 3- urgent + reassessed every 30 minutes
o Level 4- less urgent + reassessed every 60 minutes
o Level 5- nonurgent + reassessed every 120 minutes

Triage Bypass
 Moves patient directly to an open bed in the ED to reduce waiting times
 Receiving nurse performs initial assessment & vital signs

Team Triage
 Triage nurse works with a physician or APN within the triage area
 Can move patients to diagnostics and possible discharge without fully admission
to the ED

,2. What are the components (assessment and interventions) of the primary and
secondary survey?
Primary Assessment
 Focuses on stabilizing life/limb threatening conditions; rapid assessment
o Airway- ensure airway is patent
o Breathing- provide adequate ventilation
o Circulation-restore cardiac output, control hemorrhage, prevent & treat
shock
o Disability- assess neurologic function using the Glascow Coma Scale or
AVPU mnemonic
 Alert
 Verbal responsiveness
 Pain responsiveness
 Unresponsive
o Exposure- undress to assess any wounds or areas of injury

Secondary Assessment
 A more throughout assessment that focuses on diagnosis & treatment
 Health history
 Head-to-toe assessment
 Diagnostics & lab testing
 Monitoring devices
 Splinting fractures
 Wound care

3. What methods should the nurse utilize to determine neurologic function in a client
who experienced a trauma?
Glascow Coma Scale
 Assesses neurological status in acute medical or trauma patients
 Contains 3 components
o Eye opening response
o Verbal response
o Motor response
 A sore of ≤ 8 indicates a comatose state

, 4. What are the different causes and types of traumas?
Trauma: an intentional or unintentional wound or injury inflicted on the body from a
mechanism against which the body cannot protect itself
Multiple Trauma: a single catastrophic event that causes life-threatening injuries to at
least two distinct organs or organ systems
 Triad of mortality
o Hypothermia
o Metabolic acidosis
o Coagulopathy
Types
 Blunt- injury of the body by forceful impact, falls, or physical attack with a dull
object
 Penetrating- involves an object or surface piercing the skin, causing an open
wound

Management
 Establish airway and ventilation
 Control hemorrhage
 Prevent and treat hypovolemic shock
 Assess for head & neck injuries
 Evaluate for other injuries
 Splint fractures and reassess pulses & neurovascular status (if applicable)
 Perform secondary assessment and diagnostic studies

5. What are the clinical manifestations associated with abdominal trauma?
Assessment & Diagnostic Findings
 Gross injuries
o Bruises, abrasions, or penetrating trauma
 Absent bowel sounds
 Internal hemorrhage
o Blueish discoloration of back and flanks
o Hypotension & other signs of shock
 Intraperitoneal injury
o Tenderness or rebound tenderness
o Guarding
o Abdominal distension/rigidity
o Referred pain

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