HESI - Case Study - Natural Disaster in a Small Community

The new graduate nurse just started orientation 6 weeks ago in the Emergency Department (ED). After receiving disaster training, which statement indicates that the new nurse understands what a disaster could be? A. An internal disaster is anything that occurs outside the hospital. B.An external disaster is anything that endangers clients, staff, or requires evacuation or relocation with or without notice. C. An internal disaster is anything that doesn't impair the operations of the hospital but disrupts normal client care. D. A disaster could be internal or external in scope. An event occurring inside a healthcare facility or campus that could endanger the safety of patients or staff is considered an internal disaster. An event outside the healthcare facility or campus, somewhere in the community, which requires the activation of the facility's emergency management plan, is considered an external disaster.

D. A disaster could be internal or external in scope. An event occurring inside a healthcare facility or campus that could endanger the safety of patients or staff is considered an internal disaster. An event outside the healthcare facility or campus, somewhere in the community, which requires the activation of the facility's emergency management plan, is considered an external disaster. Based on the participation of emergency preparedness drills, a nurse should know that a hospital disaster plan is divided into two categories: internal and external. An internal disaster is any situation that creates an environment that disrupts normal client care like a power outage, fire, or flood, as opposed to an external disaster, which may yield a large influx of clients to the hospital in a short time period. Both internal and external disasters could occur at the same time.

The first survivor returns from decontamination and the graduate nurse has administered a tetanus injection per the healthcare provider's prescription. The graduate nurse notices erythema and raised wheals on the client's chest and upper and lower bilateral extremities. The graduate nurse anticipates and prepares to take action with which intervention? A. Administer acetaminophen prior to drawing labs. B. Provide a cool cloth for the client to apply to the areas affected. C. Apply calamine lotion liberally to the chest, arms, and legs. D. Anticipate administering diphenhydramine 50 mg intravenously stat.

D. Anticipate administering diphenhydramine 50 mg intravenously stat. The client is having a reaction to the tetanus injection, resulting in anaphylactic shock. The nurse anticipates the HCP prescribing an antihistamine such as diphenhydramine to treat the client's reaction and to prevent anaphylaxis.

After the need to collect physical evidence, which forensic nurse ability plays a key role in the investigation of a disaster? A. Documentation of interventions and identification of physical evidence and its collection. B. Competency education, chain of custody, confidentiality, and dignity. C. Collaborating with the law enforcement agencies and documentation. D. Discovery, identification, and collection of physical and non-physical evidence, and documentation.

D. Discovery, identification, and collection of physical and non-physical evidence, and documentation. It is imperative for a forensic nurse to discriminate between what could be evidence and the manner in which it should be collected. This is the key role of the forensic nurse in the investigation of a disaster.

Once the evidence is collected and the client is taken to the autopsy room for holding. The charge nurse tells the graduate that the disaster has been contained and that the incoming staff had arrived and the graduate nurse was going to be able to go home. Working well beyond the scheduled shift, the graduate gives report to the incoming nurse and prepares to leave the hospital. Which implication poses the greatest risk to client safety and to the graduate as the shift ends and while driving home? A. Sadness. B. Stress. C. Relief. D. Exhaustion.

D. Exhaustion. Exhaustion poses a risk not only to client safety but also to the nurse when driving home. Opting for the sleeping quarters at the hospital may be a consideration in this case.

The charge nurse explains to the hospital staff that they may be required decontaminate clients because it is the first step when responding to any chemical incident. Which statements accurately reflect the staff members' understanding of client decontamination? (Select all that apply. One, some, or all options may be correct.) Select all that apply A. Client decontamination is a process that leads to removal of something on a client that will affect the client or healthcare providers. B. Client decontamination means that the clients will be kept isolated at all times and so will the healthcare providers or first responders who come in contact with the client. C. Client decontamination is only done when healthcare providers are at risk. D. There are two types of client decontamination always performed by first responders to not affect the way the hospitals set up the triage.

A. Client decontamination is a process that leads to removal of something on a client that will affect the client or healthcare providers. It facilitates the expeditious movement of clients into the health care system for treatment during a disaster. D. There are two types of client decontamination always performed by first responders to not affect the way the hospitals set up the triage. Decontamination triage should not be confused with medical triage. Decontamination triage is the process of determining which victims require decontamination and which do not.

When a nurse is advanced triaging clients during a disaster, which principle is the most important to remember? A. Do the greatest good for the greatest number of clients. B. Once a client is assessed according to S.T.A.R.T., reassessment is unnecessary. C. Preservation of all life takes precedence, regardless of the level of casualties. D. The nurse conducts the triage on a first-come basis and according to S.T.A.R.T.

A. Do the greatest good for the greatest number of clients. This principle is used to divert scarce resources away from clients with little chance of survival in order to increase the chances of others who are more likely to survive.

The charge nurse is aware that the hospital has a disaster preparedness plan for such incidents. Which key components should the nurse expect to be included in the plan? (Select all that apply. One, some, or all responses may be correct.) A. Effective triage strategy for clients. B. Reminding staff that they are not going home. C. Client care, communication, and safety. D. Security, documentation, and resource allocation. E.Placing an order for additional supplies.

A. Effective triage strategy for clients. The disaster plan includes a triage strategy plan based on assessment criteria to calculate the level of severity of injury. C. Client care, communication, and safety. Clinical protocols, staffing procedures, staff education are key components of a preparedness plan and should be developed and practiced beforehand. D. Security, documentation, and resource allocation. Security, documentation, and resource allocation are vital components to be included in any disaster plan.

What tactics are most efficient for the charge nurse to use when assigning roles to staff and additional volunteers? (Select all that apply. One, some, or all options may be correct.) Select all that apply A. Ensure that all tasks assigned are performed according to policy. B. Replace the need for an incident command center. C. Ensure that all tasks are completed as assigned. D. Identify and manage all those who should be sent home. E. Mitigate any differences between departments.

A. Ensure that all tasks assigned are performed according to policy. Staff and volunteers must be aware of and apply the hospital's emergency plan policies to all assigned tasks to ensure safety of clients, staff, volunteers, and responders. Proactive assignment of tasks to team members and volunteers maximizes following policies efficiently and minimizes the risks of losing lives. C. Ensure that all tasks are completed as assigned. Assigning roles to staff and volunteers is an orderly approach for delegating responsibility and accountability ensuring task completion during emergencies or disasters.

Fluid resuscitation is a critical intervention for burn management and the Parkland formula is one of the most widely used burn resuscitative fluid formulas. The charge nurse is instructing the graduate nurse about the application of the formula. Which intervention is accurate in describing fluid replacement based on the Parkland formula? A. Half the fluid is given over the first 8 hours after injury and the remaining half given over the next 16 hours. B. Half the fluid is given over the first 12 hours after injury and the remaining half given over the next 12 hours. C. Half the fluid is given over the first 16 hours after injury and the remaining half given over the next 8 hours. D. A rapid infusion is needed so the total fluid is given as a bolus over two hours.

A. Half the fluid is given over the first 8 hours after injury and the remaining half given over the next 16 hours. The Parkland formula provides an approximation of fluid replacement requirements by calculating the amount of fluid to infuse during the first 24 hours after injury based on Total Body Surface Area (TBSA).

The graduate nurse is notified that other ambulances are in route to the hospital. The nurse is instructed to prepare for the arrival of victims and don PPE to assist with the decontamination of the incoming clients. Which of the nurse's actions illustrate safe removal of PPE? A. Remove the gown by rolling downward from head to toe without touching outside of gown. B. Remove by grasping the front of the gown and quickly breaking the ties. C. Pull the gown over the head, carefully avoiding the nose and mouth. D. Take off the mask before removing other PPE.

A. Remove the gown by rolling downward from head to toe without touching outside of gown. Rolling and folding the gown in a downward direction prevents contamination by containment.

When setting up decontamination tents, it is imperative to set up a flow that includes which areas? (Select all that apply. One, some, or all options may be correct.) A. Set up an initial triage, a decontamination area, second triage, and treatment area. B. Set up an area for clients not requiring decontamination. C. Set up a separate lane for clients arriving by EMS transport that have been decontaminated but did not sustain life threatening injuries. D. Set up a fast track area for clients with life threatening injuries that would allow delivering basic life-saving treatment during decontamination. E. The order of the decontamination does not matter because at that point nurses just want to quickly assess any life-threatening injuries.

A. Set up an initial triage, a decontamination area, second triage, and treatment area. Decontamination is vital to client safety during a chemical disaster. Establishing a separate decontamination area for clients that require secondary and /or technical decontamination if primary decontamination is not adequate. D. Set up a fast track area for clients with life threatening injuries that would allow delivering basic life-saving treatment during decontamination. Establishing a fast track decontamination line for clients with severe or life-threatening symptoms is important for delivering basic lifesaving treatment during the decontamination process.

After explaining the triage system, the nurse clarifies the clinical parameters that are used to evaluate each client before deciding what color of tag to use. Assessments and observations are categorized in four words; observe, palpate, listen, and smell. Based on the S.T.A.R.T. adult triage system, which assessments demonstrate the appropriate triage assignment? (Select all that apply. One, some, or all options may be correct.) Select all that apply A. Those who are able to ambulate by themselves and who have superficial lacerations = Green. B. Extensive body injuries or burns that impact the client's ability to survive = Black. C. Walking wounded carrying contaminants from the explosion = Yellow. D. Shock, airway obstruction, third-degree burns over 75% of body = Red. E. Presence of spontaneous breathing and respiratory rate less than 30 breaths per minute with an open fracture = Yellow.

A. Those who are able to ambulate by themselves and who have superficial lacerations = Green. This assessment is categorized as observation of a client with minor injuries and is triaged as green. B. Extensive body injuries or burns that impact the client's ability to survive = Black. Black is the color used for clients who are unsalvageable or whose injuries are so severe they are not expected to survive. D. Shock, airway obstruction, third-degree burns over 75% of body = Red. Clients demonstrating this assessment who have immediate threats to life and who need immediate attention are triaged red. E.Presence of spontaneous breathing and respiratory rate less than 30 breaths per minute with an open fracture = Yellow. This assessment is categorized as observation of a client triaged yellow.

The volunteers have arrived to assist the nurse in assembling supplies. According to Maslow's needs, which supplies should the nurse ask the volunteers to assemble first? (Select all that apply. One, some, or all options may be correct.) Select all that apply A. Water and snacks. B. Admission paper work. C. Blankets. D. Allergy bands and name labels. E. Insurance information.

A. Water and snacks. According to Maslow, the first layer of needs to be met are physiological needs such as food and water. C. Blankets. The physiological need for warmth as provided by blankets is also indicated by Maslow's first layer of needs. D. Allergy bands and name labels. The second layer of Maslow's hierarchy is safety needs such as allergy bands and name labels.

Meanwhile, the charge nurse delegates to the environmental services (EVS) supervisor and the hospital's maintenance department employees a list of additional supplies needed immediately in the triage area. Which are the most important for the EVS supervisor to gather and take to the triage area? (Select all that apply. One, some, or all options may be correct.) Select all that apply A. Water containment collection system such as wading pools, barrels, pumps, and modesty screens. B. Containers, hoses with gentle flow, controlled nozzles with hot and cold water, ropes. C. Shower single with flex head and/or multiple heads, plastic pallets to prevent slippage, and barrier tape. D. Mild soap, sponges, sterile gauze, long handled soft bristle brushes, towels, and blankets. E. Gowns and suits for clients to don post decontamination, Self Decon "trash bag" kits, tarps. F. Emesis basins, open-lid clothes hamper, latex gloves, Clorox wipes for cleaning up spills, broom and dust pan.

A. Water containment collection system such as wading pools, barrels, pumps, and modesty screens. Run off water from the decontamination process is essential to prevent contamination of the environment. B. Containers, hoses with gentle flow, controlled nozzles with hot and cold water, ropes. Hoses with gentle flow prevent further contamination. Take care to contain all runoff water in containers to avoid burns to providers from the used contaminated water. C. Shower single with flex head and/or multiple heads, plastic pallets to prevent slippage, and barrier tape. These are all supplies necessary to the decontamination process. D. Mild soap, sponges, sterile gauze, long handled soft bristle brushes, towels, and blankets. These items are needed in order to decontaminate clients. E. Gowns and suits for clients to don post decontamination, Self Decon "trash bag" kits, tarps. All contaminated clothing will need to be removed prior to or during irrigation and should be placed in trash bags.

While burns can cause rapid swelling of the airway, chemical burns cause mucosal irritation that exacerbates edema in the airway. It is important for the nurse to be familiar with and able to quickly gather intubation supplies and equipment to assist the person performing the procedure. Which information is helpful for the nurse to know when assisting the HCP with airway intubation? (Select all that apply. One, some, or all options may be correct.) Select all that apply A. It is not necessary to remove dentures prior to intubation. B. Be familiar with where the intubation equipment is kept. C. Understand correct positioning of the client for the procedure. D. Ensure the client has had this procedure before. E. Know how to connect the laryngoscope blade to the handle.

B. Be familiar with where the intubation equipment is kept. It is important to be familiar with and able to gather intubation equipment quickly. C. Understand correct positioning of the client for the procedure. The client is positioned according to the preference of the person performing the intubation so the nurse follows direction given. E. Know how to connect the laryngoscope blade to the handle. This is important to know proactively because it is usually done in the context of a life or death emergency situation where every second counts. Also the nurse needs proactively to check to see that it illuminates properly, and change the bulb if indicated.

In situations where explosions occur in chemical plants, the high concentration of chemical exposure can cause adverse effects. The severity of the effects will depend on the length of exposure. During a chemical spill, which type of injuries can a nurse triaging clients expect? (Select all that apply. One, some, or all options may be correct.) Select all that apply A. If a victim is wearing appropriate PPE at work, there is no need to inspect for dermal injuries. B. Chemicals are toxic when inhaled, so exposure can cause respiratory problems. C. Clients exposed to mustard gas will present with gritty, itchy eyes. D. The nurse expects to see clients with dilated pupils caused by the chemical exposure. E. The nurse immediately expects to see blistering of the skin when the client arrives at the hospital.

B. Chemicals are toxic when inhaled, so exposure can cause respiratory problems. Inhalation of mustard gas causes shortness of breath, obstruction of the airway due to inflammation, and cholinergic effects like excessive saliva. C. Clients exposed to mustard gas will present with gritty, itchy eyes. Mustard gas affects the eyes. Clients describe gritty, itchy eyes that could result in corneal damage.

The S.T.A.R.T. adult triage is a system that contains four triage categories that are color-coded. The nurse explains that all clients are assessed, identified, and tagged according to 1 of 4 colors, each color representing the severity of injury. Which sequence indicates the nurses understand the triage process? (Select the appropriate order in each option from least to worst categories.) A. Black, yellow, green, red. B. Green, yellow, red, black. C. Yellow, black, green, red. D. Red, green, yellow, black.

B. Green, yellow, red, black. Green is assigned to clients who have minor injuries. Yellow is assigned to clients who are stable and whose transport can be delayed. Red is assigned to clients who have the highest priority because they are critically-injured and require immediate attention. Black is assigned to clients who are unsalvageable or who are not expected to survive their injuries.

Venous access is very important for critically ill clients and can be difficult in injured or burned clients. Due to the 27 year old client's extensive burns, the nurse has difficulty quickly obtaining an IV site. Which action by the nurse would expedite rapid infusion of fluid, blood products, and medication for this trauma victim? A. Prepare for bedside surgical insertion of a triple-lumen central line access. B. Locate the client's proximal tibia and prepare for access insertion. C. Notify the PICC team for access placement as soon as possible. D. Insert a 22-gauge angiocath in the left antecubital.

B. Locate the client's proximal tibia and prepare for access insertion. If venous access is difficult in a critically injured client, an intraosseous (IO) access can be accomplished. The IO can accommodate the rapid infusion of fluid needed, provide quicker access, and avoids the areas of burn trauma. The intraosseous must be removed within 24 hours of insertion to avoid infection.

If many clients who sustained minor injuries arrive at once, there may be a delay with decontamination procedures. The volunteers should give the green clients washing instructions. Which explanation indicates to the nurse that the triage client understands the decontamination instructions? (Select all that apply. One, some, or all options may be correct.) Select all that apply A. There is no need to remove contact lenses once they have been irrigated with water or saline solution for at least 15 minutes. B. They explain that they must rinse off chemically exposed areas and remove all clothing which should then be placed in a labeled polyethylene bag. C. They explain that they must flush skin with plain water for 2 to 3 minutes, then flush skin with a solution of ¼ peroxide and ¾ water, rinsing twice between flushes. D. Although decontamination with a shower of water is necessary when exposed to liquid chemicals, removal of clothing is required only for vapor agents. E. The group of clients states they do not have to decontaminate because they came from the field site and the EMS personnel referred them directly to the ED.

B. They explain that they must rinse off chemically exposed areas and remove all clothing which should then be placed in a labeled polyethylene bag. This is a true statement and the appropriate process for decontamination.

Most of the HAZMAT team is aware of the principles of decontamination: decontaminate as soon as possible, decontaminate by priority, and decontaminate only what is necessary and as far forward as possible.The graduate nurse is asked to give a quick in-service to the nurses on the unit about how to protect themselves from chemical contamination. Which are the best descriptions of chemical safety to share with the other nurses during this in-service? (Select all that apply. One, some, or all options may be correct.) Select all that apply A. PPE gear is only necessary for clients who are actively bleeding. B. No need to worry about PPE; the clients are decontaminated at the field site. C. Follow established methods for decontaminating clients. D. Use appropriate PPE to reduce exposures to chemicals as much as possible. E. Avoid direct contact with chemicals if possible.

C. Follow established methods for decontaminating clients. Be familiar with the hospital's policies and procedures for decontaminating clients prior to a disaster occurring. D. Use appropriate PPE to reduce exposures to chemicals as much as possible. Practice donning and removing PPE in preparation for a multiple casualty event. E. Avoid direct contact with chemicals if possible. Avoiding direct contact with chemicals in a chemical disaster requires expertise in donning and removing personal protective equipment (PPE).

One of the survivors limps towards the admissions desk at the emergency unit. He tells the unit clerk that he stepped on a large chard of glass when he stopped to render aid to a burn victim at the plant. He states that he is unaware if he came in contact with the chemical that caused the explosion. Which action by the nurse is the most important safety intervention? A. Instruct the client to take a number and wait for his turn for treatment. B. Delegate transportation of the client to the practical nurse (PN) to fast track ED rooms. C. Have him immediately removed from the unit to the decontamination tent for removal of any potential chemical residue. D. Take care of the client's foot wound and administer a tetanus injection.

C. Have him immediately removed from the unit to the decontamination tent for removal of any potential chemical residue. The uncertainty of the client's chemical exposure warrants immediate removal from the emergency unit to prevent or minimize exposure and contamination to others.

Walking through the double doors of the hospital, the graduate nurse heads to her car and notices someone leaning up against the wall sobbing with face in hands. It is the charge nurse who startles as the graduate approaches. The graduate places a hand on the tearful charge nurse's shoulder in an effort to provide comfort. Which therapeutic approach should the graduate nurse implement that would most likely initiate a conversation with the charge nurse? A. Tell the charge nurse it has been a long day, the shift is over, and they both should go home and get some needed rest. B. Ask why the charge nurse is crying, since the charge nurse has been a nurse much longer than the graduate nurse. C. Alert the other nurses on the unit since they are closest to the charge nurse and have them ask why the nurse is crying. D. Offer the charge nurse silence and non-verbal communication while allowing the charge nurse to cry.

D. Offer the charge nurse silence and non-verbal communication while allowing the charge nurse to cry. Therapeutic listening encourages, initiate, and facilitates communication with the charge nurse.