Natural Disaster in a Small Community - HESI RN Case Studies

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.) 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. d. There are two types of client decontamination always performed by first responders to not affect the way the hospitals set up the triage.

After explaining the signs and symptoms of an allergic reaction to the first client, the charge nurse tells the graduate nurse to give report to those helping and then go to the emergency room because there is an ambulance about to arrive. Since the graduate nurse is still in orientation, the charge nurse wants the graduate to observe the process and help when asked. The charge nurse explains that EMS called to give a trauma alert and report on a critical, unstable client. The third client is a 37-year-old who has a blunt and penetrating injury to the chest affecting the left lung. He has multiple lacerations and extensive full-thickness burns to the face, chest, and arms sustained during the explosion. The client is cricothyroid intubated due to facial injuries and burns. The client has a chest tube applied to decompress a tension pneumothorax, plus two IO IV's in place on each tibia and has had 3 boluses of LR. Despite the fluid resuscitation, the client's blood pressure is 60/40, HR 55, respirations 40 are rapid and shallow, SPO2 is 66%, pulse is thready, diaphoretic. The client is bleeding profusely from the chest wound. The client is not oriented to time and place. The healthcare provider approaches the trauma team ready to admit the client and assign the roles. As the ambulance arrives at the hospital's emergency room bay, the client is rushed into the trauma room, CPR is in progress. The client looks greyish in color. The graduate nurse is overwhelmed as she has never seen CPR in progress. There are many people working together to keep this client alive. The defibrillator is on and the graduate nurse suddenly hears someone shout, "clear"; as everyone steps away from the bed. The graduate nurse remembers that advanced triage systems are used to increase survival chances in clients who are most likely to survive, and this is not the case for this client. 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.

Due to the proximity to the chemical plant, the hospital has historically prepared for a potential disaster such as this. The disaster team is paged, anticipating multiple casualties resulting from this disaster. The proximity of the chemical plant leaves little time for the emergency department to prepare for what is arriving. 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. c. Client care, communication, and safety. d. Security, documentation, and resource allocation.

While the manager is on the phone, the charge nurse gathers the disaster preparedness manual and hands it to the manager. Realizing the severity of having both internal and external disasters occurring simultaneously, the manager assigns roles to the staff in the ED as outlined in the disaster preparedness policies and procedures. 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.) 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. c. Ensure that all tasks are completed as assigned.

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.

Clients begin arriving at the facility and are directed to the decontamination corridor for safe removal of toxic substances before going to surgery or other specified units. Decontamination includes using a soft brush with soap and water solution to remove all toxic substances from an individual. 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.

An Unlicensed Assistive Personnel (UAP), an Emergency Medical Technician (EMT), 2 Radiology Technicians, 1 Environmental Services employee, 2 nurses, 3 police officers, and 2 fire fighters arrive. They are members of the HAZMAT team and the team lead divides them into 3 teams. Team 1 goes to the parking lot to set up a fast track decontamination tent. To decrease the possibility of exposure to the staff and other clients in the hospital, the team sets up a triage tent in the hospital's parking lot. This triage tent is manned by staff and volunteers. The open-air environment allows social distancing and rapid evaluation, treatment, and discharge of low-acuity clients. 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. d. Set up a fast track area for clients with life threatening injuries that would allow delivering basic life-saving treatment during decontamination.

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.) 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. b. Extensive body injuries or burns that impact the client's ability to survive = Black. 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.

The manager begins to review the type of clients in the ED to assess if they could be either discharged or moved to another unit. A second nurse calls the critical care and medical-surgical units to find bed availability. In preparation for the influx of clients, a respiratory therapist and a hospital administrator bring available emergency equipment such as ventilators and oxygen tanks.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.) a. Water and snacks. b. Admission paper work. c. Blankets. d. Allergy bands and name labels. e. Insurance information.

a. Water and snacks. c. Blankets. d. 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.) 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. 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.

Clients arriving at the emergency department directly from the scene of potential mustard gas exposure rarely have symptoms. The onset of symptoms occur from 1 to 24 hours after exposure. After decontamination, clients with signs of airway involvement should be admitted directly to the critical care unit. There is no antidote for mustard gas. Treatment is supportive. The surgeon and additional surgical team members arrive in time to begin assessment of the first casualties resulting from this disaster. A 27-year-old client working at the chemical plant when the explosion erupts. The client arrives with traces of soot on his face, singed facial hair, coughing, and tachypnea suffering from burns, chemical burns, and smoke inhalation. Initial assessment indicates 50% of the client's body has 1st and 2nd degree burns to the upper anterior and posterior chest area and bilateral upper extremities. Auscultation of the lungs reveals stridor and rhonchi in all lung fields. Preparing for possible cardiac or respiratory arrest, the ER HCP begins high flow oxygen and instructs the nurse to prepare to assist with intubation. 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.) 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. c. Understand correct positioning of the client for the procedure. e. Know how to connect the laryngoscope blade to the handle.

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.) 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. c. Clients exposed to mustard gas will present with gritty, itchy eyes.

Meanwhile, the leader of the response team meets with the nurses assigned to triage the victims and quickly reviews the S.T.A.R.T. adult triage algorithm with them. The nurses know that this triage method will assist them to rapidly determine who will need immediate assistance and whose care is not imminent. 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.

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 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.) 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.

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.) 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. d. Use appropriate PPE to reduce exposures to chemicals as much as possible. e. Avoid direct contact with chemicals if possible.

The pharmacist is responsible for ensuring enough medications and supplies are available throughout the duration of the disaster event. The nurse confirms with the pharmacist that enough medication is available for chemical and explosive types of injuries. 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 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 new graduate nurse that just started orientation 6 weeks ago in the Emergency room. After receiving disaster training, which statement indicates that the new nurse needs additional disaster orientation? a. An internal disaster is anything that may cause an influx of clients disrupting the normal shift without notice. 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. Any situation that creates an environment that endangers healthcare workers.

d. Any situation that creates an environment that endangers healthcare workers.

The graduate nurse watches the client succumb to the wounds and hears the HCP say, "Time of death, 10:10 AM." The graduate feels numb, stating "I did not contribute to the care of this client." The charge nurse recognizes something is wrong with the graduate and the charge nurse asks the graduate to approach the client as everyone walks away. The charge nurse asks "Are you okay?" The graduate expresses feeling powerless, unable to contribute in the care of the client. The charge nurse explains that the client sustained fatal injuries and that it was important to learn what a code in a disaster is like. The charge nurse asks if the graduate would like to help prepare the body and take it to the autopsy room, as this may help you have closure. The forensic nurse arrives and begins to explain to both the charge nurse and to the graduate that physical evidence needs to be collected and documentation needs to be accurate. 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.

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.

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.