Emergency Triage Practice Questions

Thirty people are injured in a train derailment. Which client should be transported to the hospital first? 1. A 20-year-old who is unresponsive and has a high injury to his spinal cord. 2. An 80-year-old who has a compound fracture of the arm. 3. A 10-year-old with a laceration on his leg. 4. A 25-year-old with a sucking chest wound.

4 During a disaster, the nurse must make difficult decisions about which persons to treat first. The guidelines for triage offer general priorities for immediate, delayed, minimal, and expectant care. The client with a sucking chest wound needs immediate attention and will likely survive. The 80-year-old is classified as delayed; emergency response personnel can immobilize the fracture and cover the wound. The 10-year-old has minimal injuries and can wait to be treated. The client with a spinal cord injury is not likely to survive and should not be among the first to be transported to the health care facility.

The nurse is the first responder at the scene of a 6-car crash on a highway. Which victim should the nurse attend to first? 1. A victim experiencing dyspnea 2. A victim experiencing confusion 3. A victim experiencing tachycardia 4. A victim experiencing intense pain

1 A victim experiencing dyspnea The client experiencing dyspnea is the priority. Needs related to maintaining a patent airway are always the priority. The victims experiencing confusion, tachycardia, and intense pain would be assessed following stabilization of the client with an airway problem.

An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event? a. Ask ED staff to discharge clients from the medical-surgical units in order to make room for critically injured victims. b. Call additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in. c. Inform the incident commander at the mass casualty scene about how many victims may be handled by the ED. d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims.

D The ED charge nurse should direct additional nursing staff to help care for current ED clients while the ED staff prepares to receive mass casualty victims; however, they should not be assigned to the most critically ill or injured clients. The house supervisor and unit directors would collaborate to discharge stable clients. The hospital incident commander is responsible for mobilizing resources and would have the responsibility for calling in staff. The medical command physician would be the person best able to communicate with on-scene personnel regarding the ability to take more clients.

A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at a nurse when dinner is served late. How should the nurse respond? a. Do you need something for pain right now? b. Please stop yelling. I brought dinner as soon as I could. c. I suggest that you get control of yourself. d. You seem upset. I have time to talk if you'd like.

D Clients should be allowed to ventilate their feelings of anger and despair after a catastrophic event. The nurse establishes rapport through active listening and honest communication and by recognizing cues that the client wishes to talk. Asking whether the client is in pain as the first response closes the door to open communication and limits the clients options. Simply telling the client to stop yelling and to gain control does nothing to promote therapeutic communication.

Which cultural issues should the nurse consider when caring for clients during a bioterrorism attack? Select all that apply. 1. Language difficulties. 2. Religious practices. 3. Prayer times for the people. 4. Rituals for handling the dead. 5. Keeping the family in the designated area.

1, 2, 3, 4 1. Language difficulties can increase fear and frustration on the part of the client. 2. Some religions have specific practices related to medical treatments, hygiene, and diet, and these should be honored if at all possible. 3. Prayers in time of grief and disaster are important to an individual and actually can have a calming affect on the situation. 4. Caring for the dead is as important as caring for the living based on religious beliefs. 5. For purposes of organization this may be needed, but it is not addressing cultural sensitivity and in some instances may violate cultural needs of the client and the family.

An explosion at a chemical plant produces flames and smoke. More than 20 persons have burn injuries. Which victims should be transported to a burn center? Select all that apply. 1. The victim with chemical spills on both arms. 2. The victim with third-degree burns of both legs. 3. The victim with first-degree burns of both hands. 4. The victim in respiratory distress. 5. The victim who inhaled smoke.

1, 2, 4, 5. Victims with chemical burns, second- and third-degree burns over more than 20% of their body surface area, and those with inhalation injuries should be transported to a burn center. The victim with first-degree burns of the hands can be treated with first aid on the scene and referred to a health care facility

Which situation requires the emergency department manager to schedule and conduct a Critical Incident Stress Management (CISM)? 1. Caring for a two (2)-year-old child who died from severe physical abuse. 2. Performing CPR on a middle-aged male executive who died. 3. Responding to a 22-victim bus accident with no apparent fatalities. 4. Being required to work 16 hours without taking a break.

1. CISM is an approach to preventing and treating the emotional trauma affecting emergency responders as a consequence of their job. Performing CPR and treating a young child affects the emergency personnel psychologically, and the death increases the traumatic experience. 2. Caring for this type of client is an expected part of the job. If the nurse finds this traumatic enough to require a CISM, then the nurse should probably leave the emergency department. 3. This requires an intense time for triaging and caring for the victims, but without fatalities this should not be as traumatic for the staff. 4. This is a dangerous practice because medication errors and other mistakes may occur as a result of fatigue, but this is not a traumatic situation.

A chemical exposure has just occurred at an airport. An off-duty nurse, knowledgeable about biochemical agents, is giving directions to the travelers. Which direction should the nurse provide to the travelers? 1. Hold their breath as much as possible. 2. Stand up to avoid heavy exposure. 3. Lie down to stay under the exposure. 4. Attempt to breathe through their clothing.

2 Standing up will avoid heavy exposure because the chemical will sink toward the floor or ground. 1. The absence of breathing is death, and this is neither a viable option nor a sensible recommendation to terrified people. 3. Staying below the level of the smoke is the instruction for a fire. 4. Breathing through the clothing, which is probably contaminated with the chemical, will not provide protection from the chemical entering the lung.

The nurse in charge of a nursing unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply. 1. A client with chest pain 2. A client with a Holter monitor 3. A client receiving oral antibiotics 4. A client experiencing sinus rhythm 5. A client newly diagnosed with atrial fibrillation 6. A client experiencing third-degree heart block who requires a pacemaker

2,3,4 Clients should be medically stable if discharged and should be able to manage their condition at home. A client experiencing chest pain could be having a myocardial infarction and needs frequent monitoring. A client newly diagnosed with atrial fibrillation requires medication and monitoring to stabilize the condition. A client in third-degree heart block is considered unstable, especially if the client needs a pacemaker.

A car accident involves four vehicles on a remote highway. The nearest emergency department is 15 minutes away. Which victim should be transported by helicopter to the nearest hospital? 1. A 10-year-old with a simple fracture of the femur who is crying and cannot find his parents. 2. Middle-aged woman with cold, clammy skin and a heart rate of 120 bpm who is unconscious. 3. Middle-aged man with severe asthma and a heart rate of 120 bpm who is having difficulty breathing. 4. A 70-year-old man with a severe headache who is conscious.

2. The middle-aged woman is likely in shock. She is classified as a triage level I, requiring immediate care. The child with moderate trauma is classified as triage level III (urgent and should be treated within 30 minutes). The man with asthma and the man with the severe headache are classified as triage level II (emergent) and can be transported by ambulance and reach the hospital within 15 minutes.

The nurse in the emergency department is triaging the following victims of an airplane crash. Prioritize the clients in the order in which they should be treated. 1. A 75-year-old with a 2-inch (5.1-cm) laceration to the left forearm. 2. A 22-year-old with a 2-inch (5.1-cm) laceration to the left temple, slightly confused. 3. A 14-year-old with a 2-inch (5.1-cm) laceration to chin, history of asthma, respirations 26, audible wheezing. 4. A 22-year-old female, 36 weeks pregnant with contractions every 10 to 15 minutes.

3, 2, 4, 1 The 14-year-old with asthma needs immediate, lifesaving interventions for the wheezing and should be seen first. The 22-year-old who is confused should be seen next to assess for head injury; the location of the laceration could indicate a significant blunt force traumatic injury. The pregnant female requires assessment but is not urgent unless other symptoms appear. The 75-year-old is nonurgent and can wait safely for several hours.

The triage nurse has placed a disaster tag on the client. Which action warrants immediate intervention by the nurse? 1. The nurse documents the tag number in the disaster log. 2. The unlicensed assistive personnel documents vital signs on the tag. 3. The health-care provider removes the tag to examine the limb. 4. The LPN securely attaches the tag to the client's foot.

3. The tag should never be removed from the client until the disaster is over or the client is admitted and the tag becomes a part of the client's record. The HCP needs to be informed immediately of the action. 1. This is the correct procedure when tagging a client and does not warrant intervention. 2. Vital signs should be documented on the tag. The tag takes the place of the client's chart, so this does not warrant intervention. 4. The tag can be attached to any part of the client's body.

The nurse is teaching a class on bioterrorism. Which statement is the scientific rationale for designating a specific area for decontamination? 1. Showers and privacy can be provided to the client in this area. 2. This area isolates the clients who have been exposed to the agent. 3. It provides a centralized area for stocking the needed supplies. 4. It prevents secondary contamination to the health-care providers.

4 Avoiding cross-contamination is a priority for personnel and equipment— the fewer the number of people exposed, the safer the community and area. 1. This is not a rationale; this is a statement of what is done at the area. 2. This separates the clients until decontamination occurs, but the question is asking for the scientific rationale. 3. This is false statement—the supplies should not be kept in the decontamination area.

Which statement best describes the role of the medical-surgical nurse during a disaster? 1. The nurse may be assigned to ride in the ambulance. 2. The nurse may be assigned as a first assistant in the operating room. 3. The nurse may be assigned to crowd control. 4. The nurse may be assigned to the emergency department.

4. New settings and atypical roles for nurses may be required during disasters; medical-surgical nurses can provide first aid and may be required to work in unfamiliar settings. 1. The nurse should not leave the hospital area; the nurse must wait for the casualties to come to the facility. 2. This is a position requiring knowledge of instruments and procedures not common to the medical-surgical floor. 3. The people in this area are usually chaplains or social workers, not direct client care personnel. In a disaster, direct care personnel cannot be spared for this duty.

The nurse is assessing the client who has recently returned from a 2-month mission in Africa with smallpox. What type of respiratory protection is appropriate for the staff? 1.N95 particulate respirator. 2.Double-layered surgical mask. 3.Surgical mask with eye shield. 4.No respiratory protection is needed

1 Any type of blistering lesion, such as smallpox, requires extreme care to prevent exposure. Transmission-based precautions for smallpox includes airborne, droplet, and contact precautions. The N95 mask filters at least 95% of airborne particles. To prevent exposure through the respiratory tract, the N95 mask must be fitted and worn properly.

The nurse in the hospital emergency department is notified by emergency medical services that several victims who survived a plane crash will be transported to the hospital. Victims are suffering from cold exposure because the plane plummeted and was submerged in a local river. What is the initial action of the nurse? 1. Call the nursing supervisor to activate the agency disaster plan. 2. Supply the triage rooms with bottles of sterile water and normal saline. 3. Call the intensive care unit to request that nurses be sent to the emergency department. 4. Call the laundry department, and ask the department to send as many warm blankets as possible to the emergency department.

1 Call the nursing supervisor to activate the agency disaster plan. In an external disaster, many people may be brought to the emergency department for treatment. The initial nursing action must be to activate the disaster plan. Although options 2, 3, and 4 may be additional measures that the nurse would take, the initial action would be to activate the disaster plan.

A middle-aged man collapses in the emergency department waiting room. The triage nurse should first: 1. Gently shake the victim and ask him to state his name. 2. Perform the chin-tilt to open the victim's airway. 3. Feel for any air movement from the victim's nose or mouth. 4. Watch the victim's chest for respirations.

1 Calling the victim's name and gently shaking the victim is used to establish unresponsiveness. The head-tilt, chin-lift maneuver is used to open the victim's airway. Feeling for any air movement from the victim's nose or mouth indicates whether the victim is breathing on his own. The rescuer can watch the victim's chest for respirations to see if the victim is breathing.

The client has expired secondary to smallpox. Which information about funeral arrangements is most important for the nurse to provide to the client's family? 1. The client should be cremated. 2. Suggest an open casket funeral. 3. Bury the client within 24 hours. 4. Notify the public health department.

1 Cremation is recommended because the virus can stay alive in the scabs of the body for 13 years. 2. An open casket might allow for the spread of the virus to the general public; therefore, the nurse should not make this suggestion. The nurse should not tell the client's family how to make funeral arrangement for viewing. 3. Burying the body quickly is the second best option for safety of the funeral home personnel and anyone who could come in contact with the body. The quicker the burial, the safer the situation (if the family refuses cremation). 4. The hospital, not the client's family, must notify the public health department.

A client is brought to the emergency room via ambulance accompanied by her sister. The sister states, "She was playing cards with us and had a seizure. Then she had another seizure just as the first one was stopping, so I called the ambulance." The client is currently not demonstrating any seizure activity, her eyes are closed, and she does not respond to commands. Which intervention should the nurse implement first? 1. Make sure suction equipment is set up bedside. 2. Draw blood for a phenytoin (Dilantin) level. 3. Assess the client's vital signs. 4. Prepare the client for a head computed tomography (CT).

1 Following a seizure (postictal stage), the client will most likely be tired and want to sleep. Maintaining the airway is the priority; the nurse should verify that suction equipment is available in case the client aspirates or chokes. Assessing vital signs and obtaining a Dilantin level are both appropriate actions by the nurse, but assuring safety is the first priority. There is no indication of a need to obtain a head CT at this time.

Which situation warrants the nurse obtaining information from a material safety data sheet (MSDS)? 1. The custodian spilled a chemical solvent in the hallway. 2. A visitor slipped and fell on the floor that had just been mopped. 3. A bottle of antineoplastic agent broke on the client's floor. 4. The nurse was stuck with a contaminated needle in the client's room.

1 The MSDS provides chemical information regarding specific agents, health information, and spill information for a variety of chemicals. It is required for every chemical found in the hospital. 2. This situation requires an occurrence or accident report. 3. Any facility administering antineoplastic agents (medications used to treat cancer) is required to have specific chemotherapy spill kits available and a policy and procedure included; in this situation the nurse already knows the chemical involved. 4. This requires a hospital variance report and notifying the employee health or infection control nurse.

3. A client is brought to the emergency department with abdominal trauma following an automobile accident. The vital signs are as follows: HR 132, RR 28, BP 84/58, temp 97.0°F (36.1°C), and oxygen saturation 89% on room air. Which of the following prescriptions from the health care provider should the nurse implement first? 1. Administer 1 L 0.9% normal saline IV. 2. Draw a complete blood count (CBC) with hematocrit and hemoglobin. 3. Obtain an abdominal x-ray. 4. Insert an indwelling urinary catheter.

1 The client is demonstrating vital signs consistent with fluid volume deficit, likely due to bleeding and/or hypovolemic shock as a result of the automobile accident. The client will need intravenous fluid volume replacement using an isotonic fluid (eg, 0.9% normal saline) to expand or replace blood volume and normalize vital signs. The other prescriptions can be implemented once the intravenous fluids have been initiated.

The father of a child brought to the emergency department is yelling at the staff and obviously intoxicated. Which approach should the nurse take with the father? 1. Talk to the father in a calm and low voice. 2. Tell the father to wait in the waiting room. 3. Notify the child's mother to come to the ED. 4. Call the police department to come and arrest him.

1 This will help diffuse the escalating situation and attempt to keep the father calm. 2. Sending the father to the waiting room does not help his behavior and could possibly make his behavior worse; loud and obnoxious behavior can become violent. 3. This will not help the current situation and could make it worse because the nurse doesn't know the home situation. 4. The nurse should notify hospital security before calling the police department.

An airplane crash results in mass casualties. The nurse is directing personnel to tag all victims. Which information should be placed on the tag? Select all that apply. 1. Triage priority. 2. Identifying information when possible (such as name, age, and address). 3. Medications and treatments administered. 4. Presence of jewelry. 5. Next of kin.

1, 2, 3. Tracking victims of disasters is important for casualty planning and management. All victims should receive a tag, securely attached, that indicates the triage priority, any available identifying information, and what care, if any, has been given along with time and date. Tag information should be recorded in a disaster log and used to track victims and inform families. It is not necessary to document the presence of jewelry or next of kin.

A small airplane crashes in a neighborhood of 10 houses. One of the victims appears to have a cervical spine injury. What should first aid for this victim include? Select all that apply. 1. Establish an airway with the jaw-thrust maneuver. 2. Immobilize the spine. 3. Logroll the victim to a side-lying position. 4. Elevate the feet 6 inches (15.2 cm). 5. Place a cervical collar around the neck

1, 2. The victim of a neck injury should be immobilized and moved as little as possible. It is also important to ensure an open airway; this can be accomplished with the jaw-thrust maneuver, which does not require tilting the head. The victim should not be rolled to a side-lying position nor have his feet elevated. Both actions can cause additional injury to the spinal cord. Placing a cervical collar causes movement of the spinal column and should not be done as a first-aid measure

The community health nurse is preparing to teach personnel and family preparedness for disasters to a group of parents of school-age children. Which items should the nurse plan to include in disaster preparedness? Select all that apply. 1. Flashlight 2. Supply of batteries 3. Battery-operated radio 4. Extra pair of eyeglasses 5. 4-week supply of water 6. 4-week supply of nonperishable food

1,2,3,4 Options 1, 2, 3, and 4 should be identified as items to have on hand as part of disaster preparedness. A 3-day supply of water is recommended (1 gallon per client per day). Similarly, a 3-day supply of nonperishable food is recommended. A 4-week supply of water and food is unnecessary and not recommended.

The nurse is teaching a class on disaster preparedness. Which are components of an Emergency Operations Plan (EOP)? Select all that apply. 1. A plan for practice drills. 2. A deactivation response. 3. A plan for internal communication only. 4. A pre-incident response. 5. A security plan.

1,2,5 1. Practice drills allow for troubleshooting any issues before a real-life incident occurs. 2. A deactivation response is important so resources are not overused, and the facility can then get back to daily activities and routine care. 3. Communication between the facility and external resources and an internal communication plan are critical. 4. A postincident response is important to include a critique and debriefing for all parties involved; a pre-incident response is the plan itself. Be sure to read adjectives closely. 5. A coordinated security plan involving facility and community agencies is the key to controlling an otherwise chaotic situation.

Thirty-two children are brought to the emergency department after a school bus accident. Two children were killed along with the three people in the car that caused the crash. Before the victims arrive, in addition to ensuring that the hospital staff are prepared for the emergency, which step should the nurse anticipate carrying out? 1. Calling the nearest crisis response team. 2. Alerting the news media. 3. Notifying the hospital volunteer office. 4. Calling the school to inform teachers of the accident.

1. The children and their families are at risk for experiencing a crisis. Disaster teams are available for crisis intervention in such emergencies. Usually the news media monitors emergency radio frequencies and most likely are aware of the accident already. Although volunteers may help in some ways, they are not responsible for crisis intervention. Calling the school might be done, but the emergency issues take precedence.

Several clients who work in the same building are brought to the emergency department. They all have fever, headache, a rash over the entire body, and abdominal pain with vomiting and diarrhea. Upon initial assessment, the nurse finds that each client has low blood pressure and has developed petechiae in the area where the blood pressure cuff was inflated. Which isolation precautions should the nurse initiate? 1. Contact isolation with double-gloving and shoe covers. 2. Respiratory isolation with positive pressure rooms. 3. Enteric precautions. 4. Reverse isolation.

1. The nurse should institute treatment for hemorrhagic fever viruses, including contact isolation with double-gloving and shoe covers, strict hand hygiene, and protective eyewear. The nurse should start respiratory isolation with negative pressure rooms, not positive pressure rooms. Enteric precautions are not needed because the virus is spread by droplet and contact. Reverse isolation protects the client; in this situation, the health care team also needs protection.

Three hours ago, a client was thrown From a car into a ditch, and he is now admitted to the emergency department in a stable condition with vital signs within normal limits, alert and oriented with good coloring and an open fracture of the right tibia. For which signs and symptoms should the nurse be especially alert? 1. Hemorrhage. 2. Infection. 3. Deformity. 4. Shock.

2 Because of the degree of contamination of the open fracture and the time that has passed since the accident, the risk of infection is very high. Therefore, the nurse should be especially alert for signs and symptoms of possible existing infection or early signs of infections, such as debris in the wound site, temperature abnormalities, results of laboratory studies (such as complete blood cell count and wound culture and sensitivities), or heat or redness around or in the wound. Because the client's vital signs and cardiovascular status are stable at this time, hemorrhage is not the primary concern. The client is talking coherently at this point, so his mentation does not suggest that he is in shock. However, assessment for signs and symptoms of hemorrhage and shock would certainly be ongoing. The fracture would be corrected by surgery as soon as possible, thereby minimizing the risk of deformity.

A client is admitted to the emergency department with a full-thickness burn to the right arm. Upon assessment, the arm is edematous, fingers are mottled, and radial pulse is now absent. The client states that the pain is 8 on a scale of 1 to 10. The nurse should: 1. Administer morphine sulfate IV push for the severe pain. 2. Call the physician to report the loss of the radial pulse. 3. Continue to assess the arm every hour for any additional changes. 4. Instruct the client to exercise his fingers and wrist.

2 Circulation can be impaired by circumferential burns and edema, causing compartment syndrome. Early recognition and treatment of impaired blood supply is key. The physician should be informed since an escharotomy (incision through full-thickness eschar) is frequently performed to restore circulation. Pain management is important for burn clients, but restoration of circulation is the priority. Assessments should be performed more frequently. Exercise will not restore the obstructed circulation.

Which signs/symptoms should the nurse assess in the client who has been exposed to the anthrax bacillus via the skin? 1. A scabby, clear fluid-filled vesicle. 2. Edema, pruritus, and a 2-mm ulcerated vesicle. 3. Irregular brownish-pink spots around the hairline. 4. Tiny purple spots flush with the surface of the skin.

2 Exposure to anthrax bacilli via the skin results in skin lesions, which cause edema with pruritus and the formation of macules or papules which ulcerate, forming a one (1)- to (3)-mm vesicle. Then a painless eschar develops, which falls off in one (1) to two (2) weeks. 1. Scabby, clear fluid-filled vesicles are characteristic of chickenpox. 3. Irregular brownish-pink spots around the hairline are characteristic of rubella. 4. Tiny purple spots flush with the skin surface are petechiae.

An apartment fire spreads to seven apartment units. Victims suffer burns, minor injuries, and broken bones from jumping from windows. Which client should be transported first? 1. A woman who is 5 months pregnant with no apparent injuries. 2. A middle-aged man with no injuries who has rapid respirations and coughs. 3. A 10-year-old with a simple fracture of the humerus who is in severe pain. 4. A 20-year-old with first-degree burns on her hands and forearms.

2 The man with respiratory distress and coughing should be transported first because he is probably experiencing smoke inhalation. The pregnant woman is not in imminent danger or likely to have a precipitous delivery. The 10-year-old is not at risk for infection and could be treated in an outpatient facility. First-degree burns are considered less urgent.

The nurse in the emergency department has admitted five (5) clients in the last two (2) hours with complaints of fever and gastrointestinal distress. Which question is most appropriate for the nurse to ask each client to determine if there is a bioterrorism threat? 1. "Do you work or live near any large power lines?" 2. "Where were you immediately before you got sick?" 3. "Can you write down everything you ate today?" 4. "What other health problems do you have?"

2 The nurse should take note of any unusual illness for the time of year or clusters of clients coming from a single geographical location who all exhibit signs/symptoms of possible biological terrorism. 1. Power lines are not typical sources of biological terrorism, which is what these symptoms represent. 3. This might be appropriate for gastroenteritis secondary to food poisoning but is not the nurse's first thought to determine a biological threat. The nurse must determine if the clients have anything in common. 4. This is important information to obtain for all clients but is not pertinent to determine a biological threat.

The triage nurse is working in the emergency department. Which client should be assessed first? 1. The 10-year-old child whose dad thinks the child's leg is broken. 2. The 45-year-old male who is diaphoretic and clutching his chest. 3. The 58-year-old female complaining of a headache and seeing spots. 4. The 25-year-old male who cut his hand with a hunting knife.

2 The triage nurse should see this client first because these are symptoms of a myocardial infarction, which is potentially life threatening. 1. The child needs an x-ray to confirm the fracture, but the client is stable and does not have a life-threatening problem. 3. These are symptoms of a migraine headache and are not life threatening. 4. A laceration on the hand is priority, but not over a client having a myocardial infarction.

Several clients come to the emergency department with suspected contamination by the Ebola virus. What should the nurse do? Select all that apply. 1. Call in extra staff to assist with the possibility of more clients with the same condition. 2. Isolate all the suspected clients in the emergency department in one area. 3. Call housekeeping for diluted household bleach. 4. Restrict visitors from the emergency department. 5. Quarantine all contacts.

2, 3, 4 The nurse should isolate all the suspected clients in the emergency department in one area and restrict visitors from the emergency department to minimize exposure to others. The nurse should also obtain diluted household bleach (1:100) to decontaminate areas suspected of coming in contact with the virus. There is no indication at this time that extra staff is needed, so the nurse should not call in extra staff, to minimize exposure to health care workers. It is not necessary to quarantine contacts until a diagnosis is confirmed. In addition, it is the role of the public health officer to issue the quarantine if needed.

A client has been admitted to the emergency department diagnosed with food poisoning following an outdoor picnic. The nurse should do which of the following? Select all that apply. 1. Tell the family to discard contaminated food. 2. Collect specimens for laboratory examination. 3. Assess vital signs. 4. Initiate support for the respiratory system. 5. Monitor fluid and electrolyte status. 6. Provide antiemetics, as prescribed.

2, 3, 4, 5, 6. Food poisoning is a sudden illness that occurs after ingestion of contaminated food or drink. The nurse should first assess vital signs and then ensure that the client is not in respiratory distress, because death from respiratory paralysis can occur with botulism, fish poisoning, and other food poisonings. Measures to control nausea are important to prevent vomiting, which could exacerbate fluid and electrolyte imbalance. Because large volumes of electrolytes and water are lost by vomiting and diarrhea, fluid and electrolyte status needs to be continuously monitored. The key to treatment is determining the source and type of food poisoning. If possible, rather than discarding the food, the suspected food should be brought to the medical facility and a history obtained from the client or family.

The nurse is triaging victims of an earthquake who were removed from a building when the earthquake occurred. Which of the following victims should be classified as red? Select all that apply. 1. A 10-year-old male with crushing chest wound, tachypnea with labored breathing, unconscious, impaled object in forehead. 2. A 49-year-old male with crushing chest pain radiating to the jaw, is diaphoretic, nauseated, and has an open fracture of the left wrist. 3. A 75-year-old female with obvious fracture of the femur, absent pedal pulses on the affected side; heart rate 110, respirations 34, skin diaphoretic; awake/alert, states pain is 10 on a scale of 1 to 10. 4. A 32-year-old female who is unconscious, 3-inch (7.6-cm) laceration to her forehead, ecchymosis behind the ears, respiratory rate 10/shallow; radial pulse is weak/thread/ rapid; no breath sounds on the right side.

2, 3. The client with crushing chest pain has an acute cardiac condition and can have a successful outcome if immediate interventions are initiated. The client with the open fracture could be stabilized and is not a significant factor in triage in a mass casualty incident. The client with a displaced femur fracture can also be classified as immediate because the fracture can impair circulation. There are also signs of shock and severe pain. All conditions can improve with interventions. In a mass casualty incident, the goal is to do the greatest good for the greatest number—which sometimes means that limited resources are not allocated to the very critically injured that have a very low probability of survival. The other two clients are categorized as "black"/expectant because of their critical injuries and the unavailability of advance trauma care.

The nurse in charge of a nursing unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Select the clients who can be safely discharged. Select all that apply. 1. A client with dyspnea 2. A client experiencing sinus rhythm 3. A client receiving oral anticoagulants 4. A client with chronic atrial fibrillation 5. A client experiencing third-degree heart block 6. A client who has not voided since before surgery

2,3,4 Clients should be medically stable if discharged and should be able to manage their condition at home independently, with family assistance, or with community services. The client in option 2 is stable because sinus rhythm is a normal finding. Oral anticoagulants can be taken at home as long as the client understands how to take the medication and is provided with education about the medication. The client in option 4 can be discharged because the client's condition is chronic, not acute. The client experiencing dyspnea is not considered stable. The client experiencing third-degree heart block is considered unstable and will most likely need a pacemaker insertion. Clients should not be discharged after surgery until they have voided.

The nurse in charge of a nursing unit is asked to select those hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply. 1. The client with heart failure (HF) who has bilateral rhonchi 2. The client who 24 hours earlier gave birth to her second child by caesarean delivery 3. The 48-hour postoperative client who has undergone an ileostomy because of ulcerative colitis 4. The client with peritonitis caused by a ruptured appendix who is febrile with a temperature of 102°F (38.9°C) 5. The 2-day postoperative client who has undergone total knee replacement and is ambulating with a walker 6. The 3-day postoperative client who has undergone coronary artery bypass grafting and is ready for rehabilitation

2,3,5,6 The client who remains febrile with peritonitis and the client who has continuing rhonchi with heart failure need to be monitored on an ongoing basis. The remaining clients could be cared for at home with the help of a home health care nurse.

The nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the nurse attend to first? 1. A pregnant woman who exclaims, "My baby is not moving." 2. A child who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!" 3. A young child standing next to an adult family member who is screaming, "I want my mommy!" 4. An older victim who is sitting next to her husband sobbing, "My husband is dead. My husband is dead."

2. A child who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!" Priority nursing care in disaster situations needs to be delivered to the living and not the dead. The child who is bleeding badly is the priority. The bleeding could be from an arterial vessel; if the bleeding is not stopped, the child is at risk for shock and death. The pregnant client is the next priority, but the absence of fetal movement may or may not be indicative of fetal demise. The young child is with a family member and is safe at this time. The older victim will need comfort measures; there is no information indicating she is physically hurt.

The nurse in a disaster is triaging the following clients. Which client should be triaged as an Expectant Category, Priority 4, and color black? 1. The client with a sucking chest wound who is alert. 2. The client with a head injury who is unresponsive. 3. The client with an abdominal wound and stable vital signs. 4. The client with a sprained ankle which may be fractured.

2. This client has a very poor prognosis, and even with treatment, survival is unlikely. 1. This client should be classified as an Immediate Category, Priority 1, and color red. If not treated STAT, a tension pneumothorax will occur. 3. This client should be classified as a Delayed Category, Priority 2, and color yellow. This client receives treatment after the casualties requiring immediate treatment are treated. 4. This client is a Minimal Category, Priority 3, and color green. This client can wait days for treatment.

Which client should the emergency department triage nurse classify as emergent? 1. A client with a displaced fracture who is crying 2. A client with a simple laceration and soft tissue injury 3. A client with crushing substernal pain who is short of breath 4. A client with a temperature of 101°F (38.3°C) with a productive cough

3 A client with crushing substernal pain who is short of breath A triage method commonly used in the emergency department consists of 3 categories: emergent, urgent, and nonurgent. The emergent category implies that a condition exists that poses an immediate threat to life or limb. An example of a client who fits into this category is the client experiencing crushing substernal pain who is short of breath. The urgent category indicates that the client should be treated quickly but that an immediate threat to life does not exist at the moment. The client with a displaced fracture who is crying and the client with a temperature of 101°F (38.3°C) and a productive cough would fit into this category. The nonurgent category indicates that the client can generally tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with a simple laceration and soft tissue injury would fit into this category.

The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first? 1. A victim experiencing excruciating pain 2. A victim experiencing moderate anxiety 3. A victim experiencing airway obstruction 4. A victim experiencing altered level of consciousness

3 A victim experiencing airway obstruction Client needs related to maintaining a patent airway are always the priority. Therefore, the nurse would attend to the victim experiencing airway obstruction first. Care to the other victims follows.

The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first? 1. A middle-aged man with 1 foot trapped under the wreckage 2. A crying teenager who is holding pressure on an arm laceration 3. A young woman who appears dazed and confused and is shivering 4. A screaming middle-aged woman looking frantically for her husband

3 A young woman who appears dazed and confused and is shivering The young woman is demonstrating classic signs of shock, possibly from a closed head injury. Initial management of a client displaying signs of shock includes management of airway, breathing, and circulation. Initial treatment includes keeping the client warm. Oxygenation and intravenous fluids will be needed immediately to stabilize and maintain tissue perfusion. A first responder would be unlikely to be able to release a foot trapped under wreckage without help. The teenager is already applying pressure to the arm and is more likely to be able to maintain self-care until help arrives. Assisting a client with search and rescue would only be feasible once help arrives. Therefore, the nurse should attend to the client with the priority needs and the greatest potential of survival.

The nurse from a medical unit is called to assist with care for clients coming into the hospital emergency department during an external disaster. Using principles of triage during a disaster, the nurse should attend to the client with which problem first? 1. Fractured tibia 2. Penetrating abdominal injury 3. Bright red bleeding from a neck wound 4. Open massive head injury in deep coma

3 Bright red bleeding from a neck wound The client with arterial bleeding from a neck wound is in immediate need of treatment to save the client's life. This client is classified as such and would wear a color tag of red from the triage process. The client with a penetrating abdominal injury would be tagged yellow and classified as "delayed," requiring intervention within 30 to 60 minutes. A green or "minimal" designation would be given to the client with a fractured tibia, who requires intervention but who can provide self-care if needed. A designation of expectant is applied to the client with massive head or other injuries and minimal chance of survival; the corresponding color code is black in the triage process. Such clients receive supportive care and pain management but are given definitive treatment last.

The nurse is teaching a class on bioterrorism and is discussing personal protective equipment (PPE). Which statement is the most important fact for the nurse to share with the participants? 1. Health-care facilities should keep masks at entry doors. 2. The respondent should be trained in the proper use of PPE. 3. No single combination of PPE protects against all hazards. 4. The EPA has divided PPE into four levels of protection.

3 The health-care providers are not guaranteed absolute protection, even with all the training and protective equipment. This is the most important information individuals wearing protective equipment should know because all other procedures should be followed at all times. 1. Masks are kept at designated areas, not at every entry door. 2. This is a true statement, but it is not the most important information; in an emergency situation, the respondent should use the equipment even if not trained. 4. This is a true statement, but it is not the most important statement.

The triage nurse in a large trauma center has been notified of an explosion in a major chemical manufacturing plant. Which action should the nurse implement first when the clients arrive at the emergency department? 1. Triage the clients and send them to the appropriate areas. 2. Thoroughly wash the clients with soap and water and then rinse. 3. Remove the clients' clothing and have them shower. 4. Assume the clients have been decontaminated at the plant.

3 This is the first step. Depending on the type of exposure, this step alone can remove a large portion of exposure. 1. In most situations this is the first step, but with a potential chemical or biological exposure, the first step must be the safety of the hospital; therefore, the client must be decontaminated. 2. This is the second step in the decontamination process. 4. This assumption could cost many people in the hospital staff, as well as clients, their lives.

The nurse is teaching a class on biological warfare. Which information should the nurse include in the presentation? 1. Contaminated water is the only source of transmission of biological agents. 2. Vaccines are available and being prepared to counteract biological agents. 3. Biological weapons are less of a threat than chemical agents. 4. Biological weapons are easily obtained and result in significant mortality.

4 Because of the variety of agents, the means of transmission, and lethality of the agents, biological weapons, including anthrax, smallpox, and plague, are especially dangerous. 1. Sources of biological agents include inhalation, insects, animals, and people. 2. The only known vaccine against a possible bioterrorism agent is the smallpox vaccine, which is not available in quantities sufficient to inoculate the public. 3. Because of the vast range of agents, biological weapons are more of a threat. A biological agent could be released in one city and affect people in other cities thousands of miles away.

Proper hand placement for chest compressions during cardiopulmonary resuscitation (CPR) is essential to reduce the risk of which complication? 1. Gastrointestinal bleeding. 2. Myocardial infarction. 3. Emesis. 4. Rib fracture.

4 Proper hand placement during chest compressions is essential to reduce the risk of rib fractures, which may lead to pneumothorax and other internal injuries. Gastrointestinal bleeding and myocardial infarction are generally not considered complications of CPR. Although the victim may vomit during CPR, this is not associated with poor hand placement, but rather with distention of the stomach.

Eight farm workers are admitted to the emergency department after they were splashed with "a couple of chemicals" at work 30 minutes ago. They have watery/itchy eyes, slight cough, diaphoresis, constricted pupils, and are conscious and oriented. Their clothes are wet. What action should the nurse do first? 1. Apply oxygen at 3 L per nasal cannula. 2. Remove their clothing. 3. Begin decontamination shower. 4. Isolate the clients.

4 Safety of the staff and others is the first priority. By isolating the clients, this reduces the chance of contaminating others (secondary contamination). Vital signs can be obtained when it is safe—after protecting staff, patients, and visitors from secondary contamination. Oxygen is not indicated for any of the listed symptoms. Removing clothing is important to prevent further exposure to the client, but must be done in a safe manner to prevent secondary contamination to others. The clients can remove their own clothes and place them in plastic bags. After the safety of the staff and others is addressed, AND the facility is prepared and properly trained staff is ready, the clients can be given a decontamination shower. If the staff is not trained, 911 may be the most appropriate response. Finding out which chemicals were involved is important, but does not take priority over preventing secondary contamination.

A gang war has resulted in 12 young males being brought to the emergency department. Which action by the nurse is priority when a gang member points a gun at a rival gang member in the trauma room? 1. Attempt to talk to the person who has the gun. 2. Explain to the person the police are coming. 3. Stand between the client and the man with the gun. 4. Get out of the line of fire and protect self.

4 Self-protection is priority; the nurse is not required to be injured in the line of duty. 1. This puts the nurse in a dangerous position and might cause the death of the nurse. 2. This will escalate the situation. 3. This is a dangerous position for the nurse to put himself or herself in.

The off-duty nurse hears on the television of a bioterrorism act in the community. Which action should the nurse take first? 1. Immediately report to the hospital emergency room. 2. Call the American Red Cross to find out where to go. 3. Pack a bag and prepare to stay at the hospital. 4. Follow the nurse's hospital policy for responding.

4 The nurse should follow the hospital's policy. Many times nurses will stay at home until decisions are made as to where the employees should report. 1. Many hospital procedures mandate off-duty nurses should not report immediately so relief can be provided for initial responders. 2. The nurse's first responsibility is to the facility of employment, not the community. 3. This is a good action to take when the nurse is notified of the next action. For example, if the hospital is quarantined, the nurse may not report for days.

A client is admitted to the emergency department after being found in a daze walking away from her burning car after an accident. She was not injured in the accident, but the other driver died. She states, "I can't handle it anymore. There's no point to it all." The crisis nurse recommends hospital admission based on the identification of which of the following concerns? 1. The client was walking around in a daze. 2. The client has a lack of knowledge of what to do next. 3. The client is having delusions and is not in touch with reality. 4. The client is expressing helplessness and hopelessness and is a risk for suicide.

4. The client is demonstrating helplessness and hopelessness during a crisis, as evidenced by her statement, "I can't handle it. There is no point to it." Feelings of helplessness and hopelessness are common factors associated with suicidal ideation. Therefore, the client must be hospitalized to ensure safety to herself. There is not sufficient information to know if the client has a lack of knowledge of what to do next. The client is not having delusions, which would be evidenced by statements such as "The devil set my car on fire," not just the inability to think clearly.

According to the North Atlantic Treaty Organization (NATO) triage system, which situation is considered a level red (Priority 1)? 1. Injuries are extensive and chances of survival are unlikely. 2. Injuries are minor and treatment can be delayed hours to days. 3. Injuries are significant but can wait hours without threat to life or limb. 4. Injuries are life threatening but survivable with minimal interventions.

4. This is called the Immediate Category. Individuals in this group can progress rapidly to Expectant if treatment is delayed 1. This describes injures color-coded black or Priority 4 and is called the Expectant Category. 2. This is a description of injuries color-coded green or Priority 3 and is called the Minimal Category. 3. These are injures color-coded yellow or Priority 2 and is called the Delayed Category.

A severe acute respiratory syndrome (SARS) epidemic is suspected in a community of 10,000 people. As clients with SARS are admitted to the hospital, what type of precautions should the nurse institute? 1. Enteric precautions. 2. Hand-washing precautions. 3. Reverse isolation. 4. Standard precautions.

4. Transmission of SARS can be contained by following standard (universal) precautions, which include masks, gowns, eye protection, hand washing, and safe disposal of needles and sharps. The disease is spread by the respiratory, not enteric, route. Hand washing alone is not sufficient to prevent transmission. Reverse isolation (protection of the client) is not sufficient to prevent transmission.

The hospital administration arranges for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation? a. You are free to express your feelings; whatever is said here stays here. b. Lets evaluate what went wrong and develop policies for future incidents. c. This session is only for nursing and medical staff, not for ancillary personnel. d. Lets pass around the written policy compliance form for everyone.

A Strict confidentiality during stress debriefing is essential so that staff members can feel comfortable sharing their feelings, which should be accepted unconditionally. Brainstorming improvements and discussing policies would occur during an administrative review. Any employee present during a mass casualty situation is eligible for critical incident stress management services.

A hospital responds to a local mass casualty event. Which action should the nurse supervisor take to prevent staff post-traumatic stress disorder during a mass casualty event? a. Provide water and healthy snacks for energy throughout the event. b. Schedule 16-hour shifts to allow for greater rest between shifts. c. Encourage counseling upon deactivation of the emergency response plan. d. Assign staff to different roles and units within the medical facility.

A To prevent staff post-traumatic stress disorder during a mass casualty event, the nurses should use available counseling, encourage and support co-workers, monitor each others stress level and performance, take breaks when needed, talk about feelings with staff and managers, and drink plenty of water and eat healthy snacks for energy. Nurses should also keep in touch with family, friends, and significant others, and not work for more than 12 hours per day. Encouraging counseling upon deactivation of the plan, or after the emergency response is over, does not prevent stress during the casualty event. Assigning staff to unfamiliar roles or units may increase situational stress and is not an approach to prevent post-traumatic stress disorder.

Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies the clients with which injuries with yellow tags? Select All That Apply a. Partial-thickness burns covering both legs b. Open fractures of both legs with absent pedal pulses c. Neck injury and numbness of both legs d. Small pieces of shrapnel embedded in both eyes e. Head injury and difficult to arouse f. Bruising and pain in the right lower abdomen

A, C, D, F Clients with burns, spine injuries, eye injuries, and stable abdominal injuries should be treated within 30 minutes to 2 hours, and therefore should be identified with yellow tags. The client with the open fractures and the client with the head injury would be classified as urgent with red tags.

A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified? Select All That Apply a. A 35-year-old female with severe chest pain: red tag b. A 42-year-old male with full-thickness body burns: green tag c. A 55-year-old female with a scalp laceration: black tag d. A 60-year-old male with an open fracture with distal pulses: yellow tag e. An 88-year-old male with shortness of breath and chest bruises: green tag

A, D Red-tagged clients need immediate care due to life-threatening injuries. A client with severe chest pain would receive a red tag. Yellow-tagged clients have major injuries that should be treated within 30 minutes to 2 hours. A client with an open fracture with distal pulses would receive a yellow tag. The client with full-thickness body burns would receive a black tag. The client with a scalp laceration would receive a green tag, and the client with shortness of breath would receive a red tag.

After a hospitals emergency department (ED) has efficiently triaged, treated, and transferred clients from a community disaster to appropriate units, the hospital incident command officer wants to stand down from the emergency plan. Which question should the nursing supervisor ask at this time? a. Are you sure no more victims are coming into the ED? b. Do all areas of the hospital have the supplies and personnel they need? c. Have all ED staff had the chance to eat and rest recently? d. Does the Chief Medical Officer agree this disaster is under control?

B Before standing down, the incident command officer ensures that the needs of the other hospital departments have been taken care of because they may still be stressed and may need continued support to keep functioning. Many more walking wounded victims may present to the ED; that number may not be predictable. Giving staff the chance to eat and rest is important, but all areas of the facility need that too. Although the Chief Medical Officer (CMO) may be involved in the incident, the CMO does not determine when the hospital can stand down.

A hospital prepares for a mass casualty event. Which functions are correctly paired with the personnel role? Select All That Apply a. Paramedic Decides the number, acuity, and resource needs of clients b. Hospital incident commander Assumes overall leadership for implementing the emergency plan c. Public information officer Provides advanced life support during transportation to the hospital d. Triage officer Rapidly evaluates each client to determine priorities for treatment e. Medical command physician Serves as a liaison between the health care facility and the media

B, D The hospital incident commander assumes overall leadership for implementing the emergency plan. The triage officer rapidly evaluates each client to determine priorities for treatment. The paramedic provides advanced life support during transportation to the hospital. The public information officer serves as a liaison between the health care facility and the media. The medical command physician decides the number, acuity, and resource needs of clients.

A hospital prepares to receive large numbers of casualties from a community disaster. Which clients should the nurse identify as appropriate for discharge or transfer to another facility? Select All That Apply a. Older adult in the medical decision unit for evaluation of chest pain b. Client who had open reduction and internal fixation of a femur fracture 3 days ago c. Client admitted last night with community-acquired pneumonia d. Infant who has a fever of unknown origin e. Client on the medical unit for wound care

B, E The client with the femur fracture could be transferred to a rehabilitation facility, and the client on the medical unit for wound care should be transferred home with home health or to a long-term care facility for ongoing wound care. The client in the medical decision unit should be identified for dismissal if diagnostic testing reveals a noncardiac source of chest pain. The newly admitted client with pneumonia would not be a good choice because culture results are not yet available and antibiotics have not been administered long enough. The infant does not have a definitive diagnosis.

A nurse cares for clients during a community-wide disaster drill. Once of the clients asks, "Why are the individuals with black tags not receiving any care?" How should the nurse respond? a. To do the greatest good for the greatest number of people, it is necessary to sacrifice some. b. Not everyone will survive a disaster, so it is best to identify those people early and move on. c. In a disaster, extensive resources are not used for one person at the expense of many others. d. With black tags, volunteers can identify those who are dying and can give them comfort care.

C In a disaster, military-style triage is used; this approach identifies the dead or expectant dead with black tags. This practice helps to maintain the goal of triage, which is doing the most good for the most people. Precious resources are not used for those with overwhelming critical injury or illness, so that they can be allocated to others who have a reasonable expectation of survival. Clients are not sacrificed. Telling students to move on after identifying the expectant dead belittles their feelings and does not provide an adequate explanation. Clients are not black-tagged to allow volunteers to give comfort care.

An emergency department charge nurse notes an increase in sick calls and bickering among the staff after a week with multiple trauma incidents. Which action should the nurse take? a. Organize a pizza party for each shift. b. Remind the staff of the facility's sick-leave policy. c. Arrange for critical incident stress debriefing. d. Talk individually with staff members.

C The staff may be suffering from critical incident stress and needs to have a debriefing by the critical incident stress management team to prevent the consequences of long-term, unabated stress. Speaking with staff members individually does not provide the same level of support as a group debriefing. Organizing a party and revisiting the sick-leave policy may be helpful, but are not as important and beneficial as a debriefing.

A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag? a. Dislocated right hip and an open fracture of the right lower leg b. Large contusion to the forehead and a bloody nose c. Closed fracture of the right clavicle and arm numbness d. Multiple fractured ribs and shortness of breath

D Clients who have an immediate threat to life are given the highest priority, are placed in the emergent or class I category, and are given a red triage tag. The client with multiple rib fractures and shortness of breath most likely has developed a pneumothorax, which may be fatal if not treated immediately. The client with the hip and leg problem and the client with the clavicle fracture would be classified as class II; these major but stable injuries can wait 30 minutes to 2 hours for definitive care. The client with facial wounds would be considered the walking wounded and classified as nonurgent.