Page 211 - Saunders Comprehensive Review For NCLEX-RN

numbers (Box 7-14).
2. The nurse needs to be familiar with the triage system of the health
care agency.
3. When caring for a client who has died, the nurse needs to
recognize the importance of family and cultural and religious
rituals and provide support to loved ones.
4. Organ donation procedures of the health care agency need to be
addressed if appropriate.

Think survivability. If you are the first responder to a scene of a disaster, such

as a train crash, a priority victim is one whose life can be saved.

I. Client assessment in the emergency department

1. Primary assessment
a. The purpose of primary assessment is to identify any
client problem that poses an immediate or potential
threat to life.
b. The nurse gathers information primarily through
objective data and, on finding any abnormalities,
immediately initiates interventions.
c. The nurse uses the ABCs—airway, breathing, and
circulation—as a guide in assessing a client’s needs
and assesses a client who has sustained a traumatic
injury for signs of a head injury or cervical spine
injury. If CPR needs to be initiated, use CAB—
compressions, airway, breathing—as the priority
guideline.
d. Agonal breathing does not provide effective
respiration and ventilation and indicates a need for
ventilatory support.
e. Only central pulses, such as the carotid or femoral
pulses, should be used to assess circulation; they
should be checked for at least 5 seconds but no longer
than 10 seconds so as to not delay chest compressions.
2. Secondary assessment
a. The nurse performs secondary assessment after the
primary assessment and after treatment for any
primary problems identified.
b. Secondary assessment identifies any other life-
threatening problems that a client might be
experiencing.
c. 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.

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