NUR 213 Test #1

Following field triaging for a mass casualty incident, which patient arriving in the emergency department will receive the most rapid intervention? A. Patient with a red tag B. Patient with a blue tag C. Patient with a green tag D. Patient with a yellow tag

A

The nurse provides education about emergency nursing for a group of nursing students. The nurse includes which primary purpose for the secondary survey? A. To identify all injuries B. To identify life-threatening conditions C. To perform an initial focused assessment D. To allow for the patient's clinical condition to be categorized

A

The patient receives a prescription for lactated Ringer's IV at a rate of 175 mL/hour. While making initial shift rounds at 0730, the nurse notes that 525 mL is left in the bag. The nurse calculates that the IV solution will be completed at which time? A. 0900 B. 1030 C. 1145 D. 1215

B

The nurse is conducting a secondary survey for a patient involved in a motor vehicle accident. Which initial action does the nurse take after moving the patient's injured extremity? A. Elevate the extremity. B. Immobilize the extremity. C. Assess the pulse of the extremity. D. Apply ice packs to the injured area.

C

Which action by the nurse manager will be best to prepare emergency department staff members to care for victims of emergency and mass casualty incidents (MCIs)? Select all that apply A. Providing staff with articles about best practices for emergency response B. Giving written exams to test staff member's knowledge of emergency response C. Arranging for annual emergency response drills involving all hospital departments D. Supplying all hospital staff with computer apps that describe response to emergencies

C

Which action might have led to increased edema in the tissues surrounding chemical burns after a factory explosion?

Lowering burned limbs below the heart

Yellow Tag

Major injuries that are not yet life threatening and can wait for treatment

Conscious client with a flail chest What tag would this patient be?

Red Tag

For a client experiencing the emergent phase secondary to serious burns involving a large surface of the skin, which action is the nurse's priority during this phase?

Restoring fluid volume

Which instruction would the nurse provide to a group of parents with small children to promote safety and prevent injury?

Turn pot handles away from edges. Install smoke detectors in the house. Lock medication away in a safe place. Place child safety latches on cabinets. Verify water temperature before baths.

A client in the second (acute) phase of burn recovery may exhibit an increase in which value?

Urinary output

Which statement regarding interventions for clients with inhalation burns indicates a nurse needs further education?

"'I would immediately calculate the burned surface area with the rule of nines."

Which injured children will be given a yellow tag by first responders at a school bus crash? Select all that apply. A. Achild with a broken leg B. A child with minor scrapes C. A child in respiratory distress D. A child with a bruised and swollen arm E. A child complaining of abdominal pains F. A child who is drowsy and has a head wound

A, D

After the nurse has triaged patients at an emergency scene that involved multiple patients, which patients must be transported immediately to the hospital? Select all that apply. Some correct answers were not selected A. A patient with an amputated leg B. A patient who does not have a pulse C. A patient with an injured broken arm D. A patient who is crying and vomiting blood E. A patient with chest pain and shortness of breath F. A patient who is nonresponsive and has a blunt chest wound

A, D, E

Which action will the nurse take first when a patient who reports feeling ill after having skin contamination with an unknown dry powder arrives in the emergency department? A. Obtain the patient's vital signs. B. Don personal protective equipment. C. Use a dry brush to remove the powder. D. Notify local law enforcement officials.

B

A nurse is working at a health care facility in which there is a threat of flooding and an internal disaster plan has been activated. Which of the following clients should the nurse evacuate first? A. A client receiving platelets for late stage leukemia B. A client who has a saline lock with chest pain C.A client receiving antibiotic IV therapy and wound vacuum care D. A client who has a casted arm and balanced suspension traction on a lower extremity

C

A patient is admitted to the emergency department after falling from a roof. To which assessment finding does the nurse assign the highest priority? A. Pale, moist skin B. Pain on inspiration C. Asymmetrical chest movement D. Laceration on a lower extremity

C

Which action will the nurse take first when victims who were exposed to radioactive dust arrive in the emergency department? A. Obtain patient's vital signs. B. Complete the primary survey. C. Start decontamination procedures. D. Ask victims about their medical history.

C

A patient arrives in the emergency department reporting severe chest pain and difficulty breathing. Which is the priority nursing action? A. Determine a medical diagnosis. B. Perform an electrocardiogram (ECG). C. Perform a brief neurologic examination. D. Provide oxygenation via a non-rebreather mask.

D

Which type of burn or injury may cause a client to have a cervical spine injury?

Electrical burns

Which information will the nurse share with a client who sustained a burn and asks, "What is the difference between my full-thickness and deep partial-thickness burns?"

Full-thickness burns extend into the subcutaneous tissue; deep partial-thickness burns extend through the epidermis and involve only part of the dermis

Adult female with wrist fracture What tag would this patient be?

Green Tag

Which laboratory result would the nurse check to evaluate a client's fluid loss from extensive burns?

Hematocrit

Which health concern would be the nurse's highest priority to monitor after the removal of clothing from a client with burn trauma?

Hypothermia

Red Tag

Life threatening injuries with a high chance of survival RR greater than 30 RR less than 30 with a cap refill of greater than 2 seconds

Green Tag

Minor injuries May be ambulatory Not life threatening and does not need immediate attention

Black Tag

Not expected to live

Which complication is the client at high risk for when sepsis has developed after severe burn injuries?

Paralytic ileus

Which immediate nursing intervention is most appropriate for the client with an eye injury from exposure to a chemical blast?

Performing ocular irrigation

A conscious adult with RR 42, cap refill less tan 2 sec What tag would this patient be?

Red Tag

Adult male, scattered lacerations, confused, unable to follow commands, and ambulatory What tag would this patient be?

Red Tag

Which type of burns would the nurse assessing burn injuries identify on fire survivors with pink to cherry-red skin with blisters?

Second-degree burns

Which complication will it prevented administering a histamine H 2 antagonist to a client who has extensive burns?

Stress ulcer

Which example will the nurse use to describe occupational hazards for burn injuries when teaching a safety class on burns?

Tar Power lines Fertilizers

Which primary short-term outcome established by the nurse and client will be added to the care plan when caring for a client who sustained a partial-thickness burn to the lower leg accounting for 5% of the total body surface area 1 day ago?

The client's pain will remain at 2 or less on a scale of 0 to 10

Which clinical finding would the nurse anticipate during the acute phase of burn recovery?

Unstable vital signs

Which area is most important for the nurse to assess for fluid balance in a client with full-thickness burns of the anterior trunk and thigh when monitoring fluid balance during the first 2 to 3 days after the burn?

Urinary output every hour

Adult male, ambulatory with scattered lacerations What tag would this patient be?

Green Tag

Which information would the nurse recall when caring for a client who has a diagnosis of partial-thickness burns?

Partial-thickness burns are often painful, reddened, and have blisters.

Scenario: Place an "X" next to the patients) that can be safely discharged (either to home or another facility) during a disaster. The patient with chest pain receiving nitro and heparin drip The patient receiving IV Cephalexin for cellulitis of the right lower leg The patient scheduled for carpel tunnel surgery The patient receiving a blood transfusion due to a Gl bleed

Patient receiving IV Cephalexin Patient scheduled for carpel tunnel surgery

Which condition in a client with burn injuries from a chemical plant explosion requires immediate surgical intervention based on priority?

Visible thrombosed vessels

Scenario: A fire is occurring in the basement cafeteria of a 136 bed, two story nursing home. Place the patients in the order which they should be evacuated. -650 lb bariatric patient on the 2nd floor requires maximum assistance to transfer -48 year old receiving physical therapy ambulation for total knee replacement -75 year old with dementia and is wheelchair dependent

48 year old, 75 year old, 650 lb bariatric patient

A patient is admitted to the emergency department with a traumatic head injury. Which action does the nurse take during the primary survey? A. Uses the Glasgow Coma Scale B. Removes the patient's clothing C. Obtains a portable chest x-ray exam D. Monitors the electrocardiogram (ECG) for heart rate and rhythm

A

Which of the following clients will require immediate care during a disaster triage? A. The client who has a punctured femoral artery B. The client who displays multiple limb fractures C. The client who has a red rash over the abdomen D. The client who reports severe flank pain radiating to the groin

A

Which part of the assessment does the nurse address during the secondary survey of a patient in triage? A. Allergies B. Patency of the patient's airway C. Neurologic status and level of consciousness D. Presence or absence of breath sounds

A

A nurse is assisting with disaster triage following a bomb explosion in a bus station. Which of the following clients should the nurse identify as being the highest priority? A. An unconscious adult who has a large head wound. Absent respirations and cap refill >2 seconds. B. A conscious adult with full thickness burns on lower legs; RR is >30/min, cap refill <2 sec C. An unconscious infant with no visible injuries; no respirations and no pulse D. A conscious adult wearing a diabetic medic bracelet; RR <30/min; cap refill <2 sec.

B

The nurse is providing support for the family of a patient who died immediately after arrival in the emergency department. Which intervention by the nurse would be most supportive of the family's spiritual needs? A. Quietly escort the family to the hospital chapel and stay with them. B. Ask the family whether they would like a visit from the hospital chaplain, who is nearby. C. Encourage the family to spend time with the loved one to allow them to begin to accept that the death as real. D. Review the patient's medical record to determine religious affiliation and contact the appropriate entity.

B

Which victim of an explosion at an industrial plant would receive a black tag? A. Patient with chest pains after a crushing injury B. Patient with a gaping head wound and no pulse C. Patient with massive bleeding from the lower leg D. Patient with weak, thready pulses and hypotension

B

During the secondary survey for a patient who has been involved in a motor vehicle accident, swelling and ecchymosis of the right foot and ankle are noted. Which action will the nurse take next? A. Apply cold packs to the ankle and foot. B. Elevate the foot and ankle above the heart. C. Check dorsalis pedis and posterior tibial pulses. D. Administer acetaminophen per hospital protocols.

C

The nurse is caring for patients in the emergency department. Which patient does the nurse see first? A. Patient with abdominal pain B. Patient with first-degree burn C. Patient with severe respiratory distress D. Patient with chest pain due to ischemia

C

Which client has second-degree burns? Client: A: Waxy white, dark-brown appearance B: Redness, pain, minimal edema C: Moist blebs, blisters, severe pain D: Dry, leathery eschar, absence of pain

Client C

The nurse provides education to a group of nursing students about emergency care of trauma patients. The nurse describes the circulation component of the primary survey that is performed. The nurse includes which important aspect of this part of the survey? A. Determining the level of consciousness (LOC) by assessing the patient's response to verbal and/or painful stimuli B. Initially checking for peripheral pulses rather than femoral or carotid pulses C. Identifying that capillary refill is delayed when it is longer than 5 seconds D. When evaluating capillary refill in cold environments, recognizing that cold temperature delays refill

D

The nurse is caring for a client with severe burns and determines that the client is at risk for hypovolemic shock. Which physiological finding supports the nurse's conclusion?

Plasma proteins moving out of the intravascular compartment

A client, admitted with full-thickness burns 2 weeks ago, has lost an average of 1 lb (0.5 kg) of weight each day. Which dietary adjustment would the nurse recommend?

Provide high-protein drinks.

Which statement made by the client shows ineffective learning after the nurse has instructed the client about effective ways of reducing burn injury?

"I will set the bathing water temperature below 160°F (71°C)."

First Degree Burn

"superficial" => may have pain & erythema, but epidermis is still intact & adherent

Which response would a nurse give to an older adult client who is brought to the hospital by a family member because of deep partial-thickness burns on the arms and hands who protests being hospitalized and asks, "Why can't I just go home and have my spouse care for me?"?

'You may heal more slowly because of your age, and you may need the special care and equipment available in the hosnital."

3rd & Fourth Degree Burn

-"full-thickness" => extends through entire dermis -Less or no pain; does not blanch; dry/leathery texture; may be white/khaki, black/charred, or cherry red

Second Degree Burn

-"partial-thickness" => involves entire epidermis & some portion of dermis -Superficial partial-thickness extends only into upper level of dermis -VERY painful; cap refill present; appears pink/red, moist; with blisters -Deep partial-thickness extends further, into lower level of dermis -Less painful; may no longer blanch; drier, waxy; more pale

The order you would discharge/relocate/evacuate during a disaster

-Ambulatory clients requiring minimal care should be discharged or relocated first -Clients requiring assistance or the least amount of nursing care should be next -Unstable clients, clients requiring significant amounts of nursing care should not be discharged unless they are in imminent danger, If evacuating these client should be last

Poisoning/Chemicals

-Don't place around other patients -Decontamination first- wear PPE -MSDS -Health care workers at high exposure because of chemo, cleaning agents, etc.

4 Foundations of Emergency Management Program

-Mitigation/ Prevention -Preparation -Response -Recovery

Five patients are brought to the emergency department (ED) from a fire at a nearby chemical plant. In which order does the nurse treat the patients? -Patient with multiple trauma and burns to the lower extremities -Patient experiencing cardiac arrest -Patient with a closed fracture of the tibia -Patient who reports abdominal pain -Patient with minor burn to the arm

-Patient experiencing cardiac arrest -Patient with multiple trauma and burns to the lower extremities -Patient who reports abdominal pain -Patient with a closed fracture of the tibia -Patient with minor burn to the arm

In which order will the emergency department (ED) staff prioritize the assessment and care for these patients who have been transported by ambulance to the ED after a mass casualty incident (MCI)? -Patient with a deviated trachea and rib fractures -Non responsive patient with a blunt head wound -Patient with a BP of 70/30 mm Hg -Patient complaining of abdominal pain -Patient with multiple superficial wounds

-Patient with a deviated trachea and rib fractures -Patient with BP of 70/30 mm Hg -Patient complaining of abdominal pain -Patient with multiple superficial wounds -Non responsive patient with a blunt head wound

Which situations will be classified as mass casualty incidents (MCIs? Select all that apply. A. Hurricane B. Terrorist attack with anthrax C. Bombing incident at a theatre D. Multi-vehicle crash with five vehicles E. Multiple gunshot victims of gang violence

A, B, C

Primary Survey

ABC Stabilize patient

Secondary Survey

After stabilization Any secondary injuries Full set of vital signs Head to toe assessment Patient interview/history

Which client who sustained injuries in an accidental fire would be provided with immediate care based on priority?

Client with burns to the head

Child with no pulse, no respirations What tag would this patient be?

Black Tag

Unconscious elderly adult wit agonal respirations What tag would this patient be?

Black Tag

Which example is associated with third spacing in a burn injury?

Blister formation

The nurse evaluates the condition of a client with burns of the upper body. Which assessment findings indicate potential respiratory obstruction?

Brassy cough Singed nasal hair Dark mucous membranes

Which assessment finding would the nurse expect to see in a client admitted to the hospital because of electrical burns?

Burn odor Leathery skin Cardiac arrest

A 10-year-old child sustained burns of the extremities in a house fire. During assessment of the child, which clinical finding would be of concern to the nurse?

Burns around the mouth

Which priority nursing intervention would the nurse implement for a client with electric burns?

Check airway-breathing-circulation

Which color tag will the nurse use for a patient at a mass casualty incident who reports severe pain and has an open fracture to the leg with BP 160/90 mmHg and pulse 90 beats min? A. Red B. Blue C. Green D. Yellow

D

A nurse is triaging clients after a local disaster. Which of the following clients should the nurse recommend discharging first? A. a client with a large hematoma over the left eyebrow and is reporting a headache. B. a client who has a contusion to the right upper abdominal quadrant and is reporting pain. C. A client who has a suspected fracture of the right wrist and has limited movement. D. A client who has pain in the left ankle with mild swelling.

D

After a mailroom worker is exposed to anthrax, which treatment will the emergency department nurse anticipate? A. Inject subcutaneous epinephrine. B. Induce vomiting and administer antidote. C. Give immediate immune globulin administration. D. Start antibiotic administration to prevent infection.

D

Considering Good Samaritan Laws, which statement is correct about the responsibility of a nurse who observes a two-vehicle accident while driving home from work? A. As a health care provider, the nurse must provide care at the scene. B. The nurse must report to the first responders before providing assistance. C. The nurse can choose to avoid caring for inebriated victims of the accident. D. After assisting the victims, the nurse must not leave until trained responders arrive.

D

Following a terrorist attack with multiple victims, which color tag will the nurse give to a patient who is able to walk, reports wrist pain, and has no obvious deformities? A. Red tag B. Blue tag C. Black tag D. Green tag

D

The nurse is conducting a primary survey in an emergency department. Which is the purpose of the survey? A. To assess whether the patient has any threat to life B. To determine the priority for treatment for patients who are in the emergency department C. To evaluate whether the resources in the emergency department are adequate to treat the patient D. To evaluate the status of airway, breathing, circulation, disability, and exposure and environmental control

D

Which classification would the nurse use to describe burns that are painful, mottled red, weeping, and edematous?

Deep partial-thickness

Which assessment has the highestpriority when providing care for a client with a burn in the emergent stage?

Extent of burn

Which type of burn would the nurse suspect in a client admitted with a burn injury that has erythema and mild swelling?

First degree burn

For a client admitted to the hospital with partial- and full-thickness burns of the chest and face obtained while attempting to extinguish a brush fire, which concern would the nurse establish as a priority?

Inadequate gas exchange caused by smoke inhalation

When providing care for a client during the first few hours after admission to the burn unit with full-thickness burns of the trunk and head, which goal is the nurse's priority during the emergent phase of this injury?

Managing fluid loss