Nurs 4 - Mod 17: ER/Disaster EAQ's

Which nursing intervention would be included in the exposure and environmental control assessment component of the primary survey in the emergency department? 1 Securing the forehead to a backboard 2 Keeping the patient warm with blankets 3 Reassessing the level of consciousness 4 Periodically performing a neurologic examination

2 - Keeping the patient warm with blankets In the Exposure or Environmental Control step, the patient's clothes are removed for a thorough physical assessment. Once the patient is exposed, warming blankets, overhead warmers, and warmed IV fluids are used to limit heat loss, prevent hypothermia, and maintain privacy. A brief pain assessment is conducted under the disability step during primary survey to periodically reassess pain using standardized pain scale. The patient's forehead is secured to the backboard to achieve cervical spine stabilization and/or immobilization. A neurologic examination is a measure of the degree of disability, done to assess the patient's level of consciousness.

The nurse is caring for a patient with superficial frostbite on the nose, fingers, and toes. What interventions should the nurse perform? Select all that apply. 1 Massage the injured area. 2 Use warm soaks for the face. 3 Use a heavy blanket to keep the patient warm. 4 Apply a sterile dressing following debridement. 5 Immerse toes and fingers in a water bath at 98.6° to 104° F.

2 - Use warm soaks for the face. 4 - Apply a sterile dressing following debridement. 5 - Immerse toes and fingers in a water bath at 98.6° to 104° F. The nurse should use warm soaks for the face. Blisters that form within a few hours should be debrided and covered with a sterile dressing. The affected toes and fingers should be immersed in a water bath at 98.6° to 104° F. The frostbitten area should be handled carefully; massaging causes damage to the tissues. The nurse should avoid using heavy blankets for the patient because they could cause friction and sloughing of damaged tissue.

What is the appropriate nursing action in the initial treatment for animal and human bites? 1 Close puncture wounds. 2 Leave facial wounds open. 3 Do not administer analgesic. 4 Administer tetanus prophylaxis.

4 - Administer tetanus prophylaxis. Initially, the nurse administers tetanus prophylaxis to counter any risk associated with tetanus infection from the bite. Punctured wounds should be left open. All cuts and lacerations should be loosely sutured. A facial wound requires an initial closure. Analgesics are administered to provide relief from pain.

A land slide occurs, injuring a group of people. Victims who are moaning and clearly in pain are still at the scene. How long will the rescue nurse assess each victim before placing the appropriate triage tag? 1 15 seconds 2 30 seconds 3 One minute 4 Five minutes

1 - 15 seconds The rescue worker should take 15 seconds to quickly make an assessment to determine the triage level. Thirty seconds, one minute, and five minutes are too long for triage purposes.

In the event of a mass casualty, prioritized medical care is provided based on the triage of victims using colored tags. Which patient receives immediate intervention? 1 A patient with a red tag 2 A patient with a blue tag 3 A patient with a green tag 4 A patient with a yellow tag

1 - A patient with a red tag When a mass casualty incident occurs, the victims are triaged according to color-coded tags. These colored tags are used to designate both the seriousness of the injury and the likelihood of a patient's survival. Red indicates a life-threatening injury, such as shock that requires immediate intervention. Blue indicates those who are expected to die due to a massive head trauma. Green is for minor injuries like sprains, and yellow is for urgent, but not life-threatening injuries like open fractures. In general, two-thirds of patients are tagged green or yellow, and the remaining are tagged red, blue, or black.

Which part of the assessment will the nurse address during the secondary survey of a patient in triage? 1 Assess patient allergies 2 Patency of the patient's airway 3 Neurologic status and level of consciousness 4 Presence or absence of breath sound and quality of breathing

1 - Assess patient allergies Patient allergies are assessed during secondary survey. Airway, breathing, circulation, and a brief neurologic assessment are components of the primary survey that is done to identify life-threatening conditions.

What are the clinical manifestations of superficial frostbite? 1 Blisters 2 Hot, dry skin 3 Low muscle skill 4 Profuse sweating

1 - Blisters Patients with superficial frostbite injury experience blister formation within a few hours after the injury. The physiologic changes with heatstroke include hot, dry, and ashen-looking skin. With heatstroke, the nervous system is affected, lessening muscle skill and coordination. Neurologic symptoms are indicative of thermal injuries to the brain. Heat exhaustion leads to profuse sweating due to extended exposure to heat for long hours.

Which event is defined as requiring a rapid and skilled medical response that existing resources can manage easily? 1 Emergency 2 First responder 3 Hazardous conditions 4 Mass casualty incident

1 - Emergency An emergency is defined as an event that requires a rapid and skilled medical response that existing resources can manage easily. A mass casualty incident is an event that overwhelms community resources. A hazardous condition is variable; it may be handled well by local resources, but it can also take complex materials and special staff to manage. A first responder is a person who arrives first to a scene to care for victims until medical professionals arrive.

A patient has been admitted to the emergency department after ingesting an entire bottle of chewable multivitamins in a suicide attempt. The nurse should anticipate which intervention? 1 Induced vomiting 2 Whole bowel irrigation 3 Administration of activated charcoal 4 Administration of fresh frozen plasma

3 - Administration of activated charcoal Among the most common treatments for poisoning is the administration of activated charcoal. Induced vomiting typically is not indicated, and there is no need for plasma administration. Whole bowel irrigation may be used as an adjunct therapy later in treatment, but the use of activated charcoal is central to the treatment of poisonings.

The patient has been part of a community emergency response team (CERT) for a tropical storm where it has been 100 oF (37.7 oC) or more for the last two weeks. With assessment, the nurse finds hypotension, body temperature of 104 oF (40 oC), dry and ashen skin, and neurologic symptoms. What treatments should the National Disaster Medical System (NDMS) nurse anticipate? Select all that apply. 1 Administer 100% O2 2 Immerse in an ice bath 3 Administer cool intravenous (IV) fluids 4 Cover the patient to prevent chilling 5 Administer acetaminophen (Tylenol)

1 - Administer 100% O2 3 - Administer cool intravenous (IV) fluids The patient is experiencing heatstroke. Treatment focuses first on stabilizing the patient's airway, breathing, and circulation (ABCs) and rapidly reducing the core temperature. Administration of 100% O2 compensates for the patient's hypermetabolic state. Cooling the body with IV fluids is effective. Immersion in an ice bath will cause shivers that increase core temperature, so a cool water bath should be used for conductive cooling. Removing the clothing, covering the patient with wet sheets, and placing the patient in front of a fan will cause evaporative cooling. Excessive covers will not be used. Acetaminophen will not be effective because the increase in temperature is not related to infection.

The nurse creates a plan of care for a patient with frostbite of the hands. What is the most desirable outcome for the patient? 1 Brisk capillary refill 2 Adequate dietary intake 3 Balanced fluid intake and output 4 Blood pressure within normal limits

1 - Brisk capillary refill The major dysfunction with frostbite is impaired circulation. Therefore measures to promote and maintain adequate circulation are the highest priority. This includes assessment of the nail beds for capillary refill. A good appetite, a balanced fluid intake and output, and normal blood pressure are not direct indicators in the treatment of frostbite.

A nurse is administering cool fluids to a patient admitted to the hospital due to heatstroke. Which actions should the nurse take to avoid any complications? 1 Control shivering. 2 Administer antipyretics. 3 Keep the patient clothed. 4 Cover the patient with warm sheets.

1 - Control shivering. The nurse should keep shivering under control. The heat produced by the muscles involved in the shivering activity leads to an increase in the core body temperature. Antipyretics can be administered to lower the body temperature but since the increase in temperature is not due to infection, these drugs are not effective in this case. In the event of a heatstroke, the nurse should remove any tight or layered clothing that covers most of the patient's skin. After removing the outer clothes, the patient should be wrapped in wet sheets to cool down the body.

A mass casualty incident (MCI) overwhelms a community's ability to respond with existing resources, and it requires assistance from resources outside of the affected community. Which are examples of MCIs that would require outside resources? Select all that apply. 1 Hurricane 2 Terrorist attack with anthrax 3 Terrorist attack with phosgene gas 4 Multi-vehicle crash with five vehicles 5 Multiple gunshot victims of gang violence

1 - Hurricane 2 - Terrorist attack with anthrax 3 - Terrorist attack with phosgene gas An MCI is a man-made or natural event or disaster that overwhelms a community's ability to respond with existing resources. A hurricane is an MCI. Anthrax is a man-made biologic agent most commonly associated with terrorist attacks and is considered an MCI. A terrorist attack involving phosgene gas, which is a man-made chemical gas, is considered an MCI. A multi-vehicle crash is considered an emergency that a community's existing resources can manage; therefore, it is not an MCI. Similarly, a community's hospitals will likely be able to handle treating multiple gunshot victims.

Which guideline for the assessment of intimate partner violence (IPV) should the emergency nurse follow? 1 Patients should be screened routinely for family and IPV. 2 Patients whom the nurse deems high risk should be assessed for IPV. 3 All female patients and patients under 18 should be assessed for IPV. 4 Patients should be assessed for IPV provided corroborating evidence exists.

1 - Patients should be screened routinely for family and IPV. In the emergency department, the nurse needs to screen for family and IPV. Routine screening for this risk factor is required. Such assessment should not be limited to female, high-risk, or young patients, and evidence need not be present to screen for the problem.

A nurse is conducting an assessment of a patient in the emergency room after a violent attack. The patient is unwilling to share what happened. What can the nurse do to help the patient be more comfortable talking about the event? 1 Provide a private space for the patient. 2 Keep the door of the patient's room open. 3 Have the patient's family come into the room. 4 Turn on bright lights to help the patient see better.

1 - Provide a private space for the patient. The nurse can help the patient be more comfortable talking about a violent event by providing a private space. The patient may not want to talk about it in front of his or her family. The door to the patient's room should be closed for privacy. The lights should be dim to help the patient relax.

Which part of the body is most vulnerable to frostbite in a superficial injury? 1 Skin 2 Bone 3 Muscle 4 Tendon

1 - Skin In a superficial frostbite, the surface of the skin is affected. The appearance of the skin varies from waxy pale to blue to mottled in color. Dark-skinned persons run a higher risk, making them more prone to frostbite. In deep frostbite, the bones, muscles, and tendons are involved in the freezing process. The patient experiences loss of sensation on does not respond to touch.

Four patients are admitted to the emergency department. According to the triage system, the nurse should provide treatment to the patients in what order? 1. A patient with a one-inch bleeding laceration on the chin 2. A small child experiencing a cough and runny nose for a week 3. A pregnant woman that reports abdominal pain and occasional vomiting 4. An elderly patient that presents with acute chest pain and respiratory distress

1. - An elderly patient that presents with acute chest pain and respiratory distress 2. - A pregnant woman that reports abdominal pain and occasional vomiting 3. - A patient with a one-inch bleeding laceration on the chin 4. - A small child experiencing a cough and runny nose for a week The emergency triage system identifies and categorizes patients so that the most critical are treated first. An elderly patient with acute chest pain and respiratory distress is classified as the number one priority because the vital signs are unstable and there is an obvious threat to the patient's life. A pregnant woman will be seen next because, even though she has abdominal pain and occasional vomiting, there is no evidence of unstable vital signs. The chin laceration of the patient may need to be sutured but the patient's injury is nonurgent and can be delayed. Finally, a patient with a cough and runny nose for a week is classified as nonurgent and would be treated last.

A patient has arrived in the emergency department after surviving a hurricane. The primary survey focuses on which priority assessment of this patient? 1 Difficulty breathing 2 Tracheal deviation 3 Severe abdominal pain 4 Hemorrhage to the lower left leg

2 - Tracheal deviation The primary survey focuses on airway, breathing, and circulation (ABCs), then disability and exposure. Tracheal deviation involves the airway and is the priority assessment in the primary survey since this poses the most immediate threat to the patient's life. Difficulty breathing is the second priority and may be due to tracheal deviation. Hemorrhage to the lower left leg is the third priority. Severe abdominal pain is assessed after the ABCs.

A patient telephones the emergency department and says to the triage nurse, "I have a tick stuck to my leg. What should I do?" Which instruction by the nurse is most appropriate? 1 "Bathe with a topical lice shampoo immediately." 2 "Carefully remove the tick with tweezers and inspect the site." 3 "Burn the tick and then apply some petroleum jelly to the bite." 4 "Make an appointment with your primary health care provider in two days if the tick is still there."

2 - "Carefully remove the tick with tweezers and inspect the site." As a means of preventing the various diseases caused by tick bites, the tick should be carefully removed immediately with tweezers. The longer the tick remains, the greater the chance that it will transmit a disease such as Lyme disease or Rocky Mountain spotted fever. Bathing with lice shampoo and burning the tick and then applying petroleum jelly are not effective methods of tick removal. Once the tick is removed, the site should be assessed for redness, edema, or other signs of infection; if any of these is present, it should be reported to the patient's primary healthcare provider. The patient should not wait two days to remove the tick.

An explosion at a large industrial plant has left many injured. Which victim should receive a black tag? 1 A patient with chest pains after a crushing injury 2 A patient with a gaping head wound and no pulse 3 A patient with a bleeding leg after a stabbing injury 4 A patient with a blood pressure of 60/30 mmHg and a heart rate of 40 beats/minute

2 - A patient with a gaping head wound and no pulse The patient with a gaping head wound and no pulse is dead and should receive a black tag. The patient having chest pains after a crushing injury, the patient with a bleeding leg after a stabbing injury, and the patient with blood pressure of 60/60 mmHg and a heart rate of 40 beats/minute should receive red tags, as all of these conditions are life-threatening.

While caring for a patient with heatstroke, the nurse suspects that the patient is at risk for skeletal muscle breakdown. Which symptom supports the nurse's suspicion? 1 Weakness 2 Color of urine 3 Texture of skin 4 Core body temperature

2 - Color of urine The tea color or brown color of the urine is an indicator of kidney injury in a patient experiencing heatstroke. The breakdown of skeletal muscle leads to kidney injury. Weakness and fatigue in heatstroke is caused by extended exposure to heat. The texture of skin turns hot, dry, and ashen during heatstroke. Heat stress causes elevation in the core body temperature and is not an indicator of muscle breakdown.

Which description is accurate about secondary drowning? 1 Immersion in cold water 2 Delayed death from drowning 3 Death from a drowning accident 4 Survival from a potential drowning

2 - Delayed death from drowning When an individual experiences secondary drowning, it is referred to as delayed death from drowning due to pulmonary complications. Cold water immersion is referred to as immersion syndrome leading to fatal dysrhythmia. When the victim experiences submersion into water or any other fluid that leads to suffocation and imminent death, it is considered a drowning accident. Survival from a potential drowning is called a near-drowning incident.

A patient has an injury due to an explosive device. Which is an example of an explosive device? 1 A knife 2 Fireworks 3 Falling debris 4 Toxic chemical

2 - Fireworks Fireworks are explosive and can cause injury. Falling debris, a knife, and toxic chemicals on their own are not explosive.

Which risk factor predisposes an individual to submersion injury? 1 Hyperthermia 2 Inability to swim 3 Child pampering 4 Alcohol abstinence

2 - Inability to swim The primary condition that predisposes an individual to submersion injury is the inability to swim. Hyperthermia is a condition experienced due to elevated core body temperature, leading to heat stress. Neglect exposes a child to injuries, especially in instances when the child is left unattended near a swimming pool. Alcohol intoxication causes peripheral vasodilation leading to cold-related injuries.

Which effect does the nurse anticipate in a patient who has ingested contaminated freshwater during a submersion injury? 1 Extreme thirst 2 Pulmonary edema 3 Muscle contractions 4 Altered mental status

2 - Pulmonary edema In a submersion injury, the victim of near-drowning accident aspirates freshwater that is usually contaminated with chlorine, mud, or algae. The end result is acute respiratory distress causing pulmonary edema. Extreme thirst is experienced during heat exhaustion caused by hyperthermia. Strenuous activity in a hot and humid environment causes severe muscle contractions in the exerted muscles. Altered mental status is a result of cerebral edema caused by direct thermal injury to the brain in a heatstroke.

Which characteristics confirm deep frostbite? Select all that apply. 1 The skin feels tingly. 2 The skin appears white. 3 The skin is insensitive to touch. 4 The skin feels crunchy and frozen. 5 The skin shows signs of gangrene.

2 - The skin appears white. 3 - The skin is insensitive to touch. Deep frostbite affects the layers of the skin. The skin texture is white, hard, and does not respond to touch. The signs and symptoms of superficial frostbite include tingling, numbness, and burning sensation on the skin. With deep frostbite, the affected area will gradually become gangrenous, but does not appear so right away. The surface of the skin feels crunchy and frozen to the touch with superficial frostbite.

The nurse observes the graduate nurse caring for a patient who has multiple bee stings to the hands. Which action by the graduate nurse requires correction? 1 Removing rings and watches 2 Using tweezers to remove the stingers 3 Treating a mild reaction with a cool compress 4 Removing restrictive clothing around the sting sites

2 - Using tweezers to remove the stingers The stinger should always be removed with a fingernail, knife, or needle using a scraping motion. Tweezers should be avoided, because they may squeeze the stinger and release more venom. The nurse should remove rings and watches, because it might not be possible to remove them if swelling develops. Treatment depends on the severity of the reaction; cool compresses are appropriate for a mild reaction. Any restrictive clothing around the sting area should be removed.

A parent brings a child to the emergency department with a bee sting. The child has nausea, feels faint, and is having difficulty breathing. Which of the following health care provider's prescriptions should the nurse implement first? 1 Applying cool compresses to the upper right arm 2 Elevating the right arm above the level of the heart 3 Administering 0.4 mg epinephrine subcutaneously 4 Administering 25 mg diphenhydramine by mouth (PO)

3 - Administering 0.4 mg epinephrine subcutaneously Removing the stinger with tweezers may have caused additional venom to be released into the body. This would increase the severity of the reaction, as seen with the nausea, syncope, and breathing difficulties. Therefore the priority intervention would be to administer epinephrine to treat the reaction. Cool compresses, administering diphenhydramine, and elevating the arm are all appropriate treatments if the reaction is mild, that is, stinging, swelling, headache, and so forth.

A patient is brought to the emergency unit of the hospital with a compound fracture of the radius. How should the nurse rate the patient as per the Emergency Severity Index (ESI)? 1 ESI-1 2 ESI-2 3 ESI-3 4 ESI-4

3 - ESI-3 The nurse should rate the patient with a compound fracture of the radius with ESI-3. The patient is stable and can be attended by a health care provider within an hour. A patient rated as ESI-1 would be unstable and in need of immediate attention, as in the case of a patient with cardiac arrest. A patient rated as ESI-2 has a threat to the stability of vital functions and needs continuous monitoring, as in the case of a patient with chest pain. A patient rated as ESI-4 is stable and may need simple procedures or diagnostic study, as in the case of a patient with cystitis.

The nurse is triaging in a mass casualty incident. Which patient would likely be designated "red" during triage at the site of this occurrence? 1 An individual who is distraught at the violence of the incident. 2 An individual who has experienced an open arm fracture from falling debris. 3 An individual who is not expected to survive a crushing head and neck wound. 4 An individual whose femoral artery has been severed and is bleeding profusely.

4 - An individual whose femoral artery has been severed and is bleeding profusely. Red indicates a life-threatening injury requiring immediate intervention, such as severe bleeding. Emotional trauma would not warrant a "red" designation, whereas a fracture would likely be deemed "yellow," urgent, but not life-threatening. Those not expected to survive are categorized "blue."

An elderly patient is being discharged from the hospital after treatment for heat cramps sustained during a strenuous workout. What should the nurse emphasize during discharge teaching? 1 Stay outdoors 2 Do not use salt tablets 3 Drink caffeinated drinks 4 Avoid intense activity for at least 12 hours

4 - Avoid intense activity for at least 12 hours The nurse should instruct the patient not to exercise or do any strenuous or intense activity for at least 12 hours after discharge. The patient should stay indoors in a cool, low-humidity environment. Salt intake should be encouraged to increase the low sodium level. Caffeinated drinks should be avoided, because they cause dehydration.

A terrorist's dirty bomb scattered radioactive material in the city. What initial measure does the nurse take to limit radioactive contamination? 1 Assess vital signs. 2 Administer antibiotics. 3 Attend to the blast injuries. 4 Cover patients' noses and mouths.

4 - Cover patients' noses and mouths. In a "dirty bomb" blast, radioactive material is scattered into the surrounding environment, resulting in radioactive contamination. The radioactive dust and smoke can spread and cause illness if inhaled. Hence the nurse should initiate measures like covering patient's noses and mouths to limit contamination. Victims who have sustained blast injuries can be treated, but this does not limit radioactive contamination. The nurse assesses vital signs in emergency care during a primary survey when patients are presented in triage. Administration of antibiotics is relevant when patients are suffering from a disease that can be effectively treated with medicines, not to prevent radioactive contamination.

Which medication is useful in the treatment of a sting by an African honey bee? 1 Mannitol 2 Ceftriaxone 3 Chlorpromazine 4 Diphenhydramine

4 - Diphenhydramine Stings by African honey bees cause a severe reaction that requires intramuscular or intravenous antihistamines such as diphenhydramine. Mannitol is widely used in the treatment of cerebral edema in patients with submersion injuries. Ceftriaxone is a medication recommended for treatment of symptoms arising in the later stages of Lyme disease. Chlorpromazine is used to control shivering in a hypothermic patient.

The nurse notices bruise marks on the hands and forehead of a patient being treated for hip injury and suspects family violence. What is the appropriate nursing inquiry in this scenario? 1 How did you hurt yourself? 2 Did you hurt yourself playing basketball? 3 Are you taking medication for the bruises? 4 Do you feel safe at home? Is anyone hurting you?

4 - Do you feel safe at home? Is anyone hurting you? There are very few patients who would be wiling discuss the topic of physical abuse unless directly asked. Hence, the nurse should screen the patient for family violence or intimate partner violence and ask a direct questions, such as, "Do you feel safe at home? Is anyone hurting you?" Screening for family and intimate partner violence is required for any patient who is found or suspected to be a victim of abuse. Questions such as, "How did you hurt yourself?", "Did you hurt yourself playing basketball?", and "Are you taking medication for the bruises?" are indirect and the chances of the patient evading the topic of physical abuse are high.

During the primary survey of a trauma victim, it is determined that a patient has a patent airway. What is the priority nursing action? 1 Measure the blood pressure 2 Assess for external bleeding 3 Palpate the pulse for quality and rate 4 Examine the chest for signs of breathing

4 - Examine the chest for signs of breathing Even with a patent airway, patients can have other problems that compromise ventilation; the next action is to examine the chest to assess the patient's breathing. The nurse measures the blood pressure to check for any abnormalities; however, this check is not the top priority. The patient should be checked for any external bleeding and for any irregular pulses, but these actions are not the top priority.

A terrorist attack involving a nuclear bomb occurred in a nearby city, and the closest hospital is expected to receive a large volume of victims. The hospital has activated its emergency response plan and patients are beginning to arrive. To utilize resources effectively and efficiently, there are colored tags available for triaging patients in order to determine the seriousness of injury and the likelihood of survival. A nurse is triaging a patient who is able to walk, has no obvious deformities, is in no distress, and is complaining of wrist pain. What tag should the nurse give this patient? 1 Red tag 2 Blue tag 3 Black tag 4 Green tag

4 - Green tag Triaging for a mass casualty incident (MCI), such as a nuclear bombing, requires the use of colored tags to determine the seriousness of the injury and likelihood of survival. The nurse should apply a green tag, because it is used for minor injuries. Red tags designate life-threatening injuries that need immediate intervention. Blue tags designate those who are expected to die. Black tags are for those victims who are dead.

A patient comes into the emergency department complaining of extreme thirst and vomiting on a very hot day. The nurse assesses that the patient has profuse diaphoresis and is ashen in color. Vital signs are blood pressure 90/50, pulse 98, and temperature is 101 o Fahrenheit. Which of the following is the immediate priority for the nurse? 1 Administer salt tablets 2 Initiate oral fluid and electrolyte replacement 3 Start intravenous fluid bolus of lactated Ringer's 4 Place the patient in a cool area and remove any restrictive clothing

4 - Place the patient in a cool area and remove any restrictive clothing The patient is experiencing heat exhaustion, and the initial treatment step is to place the patient in a cool area and remove any restrictive clothing. The nurse would not administer salt tablets, because this could lead to complications such as gastric irritation or hypernatremia. The nurse would not administer oral fluid and electrolyte replacement for a patient experiencing nausea or vomiting. An intravenous bolus may be started, but it would consist of 0.9% normal saline, not lactated Ringers.

A patient injured in a radioactive explosion requires immediate medical attention. What are the appropriate measures that should be taken in this scenario? 1 Assess vital signs. 2 Administer antibiotics. 3 Attend to the blast injuries. 4 Provide for decontamination.

4 - Provide for decontamination. An immediate intervention requires initiation of decontamination procedures because the radioactive material on the patient's clothes and body can spread and cause illness if inhaled. The nurse assesses vital signs in emergency care during primary survey when patients are presented in triage. Administration of antibiotics is relevant when the patient is suffering from a disease that can be effectively treated with these medicines. The victims who have sustained blast injuries can be treated subsequently.

The nurse is caring for a patient with severe hypothermia. What is the appropriate nursing intervention for this patient? 1 Use radiant lights. 2 Use air-filled warming blankets. 3 Assist with warm water immersion. 4 Provide heated, humidified oxygen.

4 - Provide heated, humidified oxygen. The patient with severe hypothermia needs active internal or core rewarming with heated, humidified oxygen. The patient with mild hypothermia needs warmth from radiant lights. The patient with moderate hypothermia is provided air-filled warming blankets or is immersed in warm water.

An elderly patient is brought to the hospital with puncture wounds caused by a cat bite. Which complication can arise? 1 Meningitis 2 Heart disease 3 Hepatitis virus 4 Septic arthritis

4 - Septic arthritis Older adults are at a higher risk of infection from animal bites. The puncture wounds from cat bites can cause infections from causative organisms found in the mouth of even the healthiest of cats. This infection leads to septic arthritis. Meningitis may occur in a patient with Lyme disease, within days or weeks after initial symptoms. Heart disease is manifested in the later stage of Lyme disease. Human bites can cause puncture wounds that are infected by hepatitis virus.

A nurse is conducting a primary survey in an emergency department. What is the purpose of the survey? 1 To assess whether the patient has any threat to life 2 To determine the priority for treatment for patients who are in the emergency department 3 To evaluate whether the resources in the emergency department are adequate to treat the patient 4 To evaluate the status of airway, breathing, circulation, disability and exposure and environmental control

4 - To evaluate the status of airway, breathing, circulation, disability and exposure and environmental control The primary survey in an emergency assessment focuses on airway, breathing, circulation (ABC), disability, and exposure or environmental control. It aims to identify life-threatening conditions so that appropriate interventions can be started. The initial focused assessment prior to a primary survey determines the presence of actual or potential threats to life. Determining the priority for treatment is triaging. Patients are evaluated to decide whether they meet the criteria for ESI (Emergency Severity Index), thereby determining the number of resources required for the treatment.

When treating a severely hypothermic patient, what is the clinical reason behind warming the patient's core first before the extremities? 1 To prevent pain and discomfort 2 To stimulate muscle coordination 3 To stop the patient from shivering 4 To prevent a further drop in temperature

4 - To prevent a further drop in temperature The patient is at risk of a further drop in temperature during the warming procedure when the cold blood flows back into the central circulation. Severely hypothermic patients should have the core rewarmed before the extremities. Analgesia is administered intravenously to tackle the pain associated with rewarming. Muscle coordination is stimulated by the nervous system. Neurologic symptoms are indicative of thermal injuries to the brain and, hence rewarming the core does not impact the nervous system. Severe hypothermic patients stop shivering when the core body temperature is below 86° F.

The nurse responds to a mass casualty incident (MCI). The nurse finds a patient whose condition is not life threatening but who has multiple traumas. What colored tag does the nurse use for the patient? 1 Red 2 Blue 3 Green 4 Yellow

4 - Yellow Yellow colored tags are used for patients who need urgent medical attention but whose condition is not life threatening. Red tags are used to indicate life-threatening conditions that need immediate intervention. Blue tags are used for patients who are expected to die. Green tags are used for patients with minor injuries.