Page 206 - Saunders Comprehensive Review For NCLEX-RN

(assessment is first) to prioritize. Also consider the acuity level of clients
when applying these guidelines. If cardiopulmonary resuscitation (CPR)
needs to be initiated, use CAB—compressions, airway, breathing—as
the priority guideline.

Priority Nursing Actions

Assessing a Group of Clients in Order of Priority
The nurse is assigned to the following clients. The order of priority in
assessing the clients is as follows:
1. A client with heart failure who has a 4-lb weight gain since
yesterday and is experiencing shortness of breath
2. A 24-hour postoperative client who had a wedge resection of the
lung and has a closed chest tube drainage system
3. A client admitted to the hospital for observation who has absent
bowel sounds
4. A client who is undergoing surgery for a hysterectomy on the
following day

References

Potter et al. (2017), pp. 284-285
Zerwekh, Zerwekh Garneau (2015), pp. 511, 514.

XVIII. Disasters and Emergency Response Planning

A. Description
1. A disaster is any human-made or natural event that
causes destruction and devastation that cannot be
alleviated without assistance (Box 7-11).
2. Internal disasters are disasters that occur within a
health care agency (e.g., health care agency fire,
structural collapse, radiation spill), whereas external
disasters are disasters that occur outside the health
care agency (e.g., mass transit accident that could
send hundreds of victims to emergency departments).
3. A multicasualty event involves a limited number of
victims or casualties and can be managed by a
hospital with available resources; a mass casualty
event involves a number of casualties that exceeds the
resource capabilities of the hospital, and is also
known as a disaster.
4. An emergency response plan is a formal plan of action
for coordinating the response of the health care
agency staff in the event of a disaster in the health
care agency or surrounding community.
B. American Red Cross (ARC)
1. The ARC has been given authority by the federal
government to provide disaster relief.
2. All ARC disaster relief assistance is free, and local
offices are located across the United States.

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