done before gastric lavage and activatedcharcoal administration to preventaspiration.

The other actions will

beimplemented after intubation.department (ED) after ingesting 30diazepam (Valium) tablets. Whichaction will the
nurse plan to takefirst?Place the patient in a shower.rationale:The initial action should be to protect staff members
and decrease the patient'sexposure to the radioactive agent bydecontamination. The other actions can bedone after
the decontamination iscompleted.A patient arrives in the emergencydepartment after exposure toradioactive dust.
Which action shouldthe nurse take first?apply wet sheets and a fan to the patient.rationale:The priority intervention
is to cool thepatient. Antipyretics are not effective indecreasing temperature in heat stroke, and100% oxygen should
be given, whichrequires a high flow rate through a non-rebreather mask. An older patient would beat risk for
developing complications suchas pulmonary edema if given fluids at 1000mL/hr.An unresponsive 78-year-old
isadmitted to the emergencydepartment (ED) during a summerheat wave. The patient's coretemperature is 106.2° F
(41.2° C),blood pressure (BP) 86/52, and pulse102. The nurse initially will plan to_____________Lung
soundsrationale:The priority assessment data are how wellthe patient is oxygenating, so lung soundsshould be
assessed first. The other dataalso will be collected rapidly but are not asessential as the lung sounds.When a patient
is admitted to theemergency department after asubmersion injury, which assessmentwill the nurse obtain first?A
patient with a red tagrationale:The red tag indicates a patient with a life-Following an earthquake, patientsare triaged
by emergency medicalpersonnel and are transported to thehospital. Which of these patients will
threatening injury requiring rapidtreatment. The other tags indicate patientswith less urgent injuries or those who
arelikely to die.the nurse need to assess first?Ask the family members about whetherthey would prefer to remain in
the patientroom or wait outside the room.rationale:Although many family members andpatients report benefits from
familypresence during resuscitation efforts, thenurse's initial action should be todetermine the preference of these
familymembers. The other actions may beappropriate, but this will depend on what islearned when assessing family
preferences.A patient's family members are in thepatient room when the patient has acardiac arrest and
emergencypersonnel start resuscitationmeasures. Which action is best forthe nurse to take initially?c) A 22-year-old
with multiple fractures of the face and jawa) A 72-year-old with palpitations andchest painb) A 45-year-old
complaining of 6/10abdominal paind) A 30-year-old with a misaligned rightleg with intact pulsesrationale:The
highest priority is to assess the 22-year-old patient for airway obstruction,which is the most life-threatening
injury.The 72-year-old patient may have chestpain from cardiac ischemia and should beassessed and have diagnostic
testing forthis pain. The 45-year-old patient mayhave abdominal trauma or bleeding andshould be seen next to
assess circulatorystatus. The 30-year-old appears to have apossible fracture of the right leg andshould be seen soon,
but this patient hasThese four patients arrive in theemergency department after a motorvehicle crash. In which order
shouldthey be assessed?
the least life-threatening injury.