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
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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