NUR.213 EVOLVE Test 1 - CH. 68 Triage and Emergency

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? A. A patient with a red tag B. A patient with a blue tag C. A patient with a green tag D. A patient with a yellow tag

A. A patient with a red tag Rationale 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. p. 1646

A patient fell through the ice on a pond near his farm and is admitted to the emergency department with somnolence. Vital signs are blood pressure (BP) 82 mm Hg systolic with Doppler, respirations 9 breaths/minute, and core temperature of 90 o F (32.2 o C). The nurse should anticipate which intervention? A. Active core rewarming B. Immersion in a hot bath C. Rehydration and massage D. Passive external rewarming

A. Active core rewarming Rationale Active internal or core rewarming is used for moderate to severe hypothermia and involves the application of heat directly to the core. Immersion in a hot bath, rehydration, and massage are not appropriate interventions in the treatment of severe hypothermia. Passive rewarming is used in mild hypothermia. p. 1639

Which part of the assessment will the nurse address during the secondary survey of a patient in triage? A. Assess patient allergies B. Patency of the patient's airway C. Neurologic status and level of consciousness D. Presence or absence of breath sound and quality of breathing

A. Assess patient allergies Rationale 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. p. 1633

After stabilization of a trauma victim's airway, breathing, and circulation, what is the nurse's next priority action? A. Assessing neurologic status B. Obtaining a complete history C. Examining the extremities for fractures D. Performing an abdominal assessment

A. Assessing neurologic status Rationale: Standard trauma care includes assessing and stabilizing the ABCs (airway, breathing, and circulation), followed by a neurologic assessment and care. This includes stabilizing the cervical spine. Obtaining a complete history, performing an abdominal assessment, and examining the extremities for fractures are done after assessment of the airway, breathing, circulation, and neurologic status. The abdominal assessment and examination of the extremities are part of the head-to-toe survey. p. 1632

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

A. Brisk capillary refill Rationale: 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. p. 1637

The nurse is examining the abdomen of the patient in the emergency unit of the hospital. What finding indicates excessive fluid in the abdomen? A. Dullness on percussion B. Tympany on percussion C. Decreased bowel sounds D. Bowel sounds in the chest

A. Dullness on percussion Rationale: Dullness on percussion of the abdomen indicates excessive fluid in the abdomen. Tympany on percussion indicates excessive air in the abdomen. Decreased bowel sounds may indicate a temporary paralytic ileus. Bowel sounds in the chest may indicate a diaphragmatic rupture. p. 1633

After assessing a patient with a neck injury, the nurse prepares to do the jaw-thrust maneuver. Which symptoms would prompt the nurse to perform this procedure? Select all that apply. A. Dyspnea B. Inability to speak C. Lower limb edema D. Abdominal distension E. Postural hypotension

A. Dyspnea B. Inability to speak Rationale: A patient with a neck injury may have dyspnea and may not be able to speak due to the presence of a compromised airway. The jaw-thrust maneuver helps to open and secure the airway in the patient with a spinal injury and can be used to alleviate respiratory distress. Lower limb edema is caused by the accumulation of fluid in the interstitial spaces. Therefore lower limb edema does not indicate that the patient has airway obstruction. Abdominal distension is a manifestation of gastrointestinal dysfunction, but not airway obstruction. Postural hypotension is caused by hypovolemia. It is not an indicative of airway obstruction. p. 1630

A patient is admitted to the emergency department with a traumatic head injury. What is an appropriate nursing action during the primary survey? A. Using the Glasgow Coma Scale B. Removing the patient's clothing C. Obtaining a portable chest x-ray exam D. Monitoring the electrocardiogram (ECG) for heart rate and rhythm

A. Using the Glasgow Coma Scale Rationale: During the primary survey, the Glasgow Coma Scale is used to assess the degree of disability. It determines the patient's response to verbal and/or painful stimuli to assess the level of consciousness. In the secondary survey, the nurse uses a portable x-ray to check for any displacement of endotracheal or gastric tubes if any are inserted into the patient. The patient's clothing is later removed for a thorough physical assessment. An electrocardiogram (ECG) monitors the heart rate and rhythm as part of the secondary survey when the patient requires life-saving interventions. p. 1632

During the primary survey the nurse observes a patient exhibit paradoxical movement of the chest wall during respiration. What actions does the nurse take? Select all that apply. A. Open the airway. B. Insert the endotracheal tube. C. Use the jaw-thrust maneuver. D. Give supplemental oxygen therapy. E. Ventilate with bag-valve-mask with 100% oxygen.

D. Give supplemental oxygen therapy. E. Ventilate with bag-valve-mask with 100% oxygen. Rationale: When a patient exhibits paradoxical movement of the chest wall during respiration, supplemental oxygen should be given through an appropriate delivery system. If the respiration is inadequate or absent, the patient should be ventilated using a bag-valve mask with 100 percent oxygen. When airway patency is absent, the airway should be opened. An endotracheal tube is inserted when there is no airway patency. Intubation is performed if there is respiratory distress and the patient cannot breathe. The jaw-thrust maneuver is performed to prevent obstructing the airway. p. 1630

Decontamination is required after disasters involving toxins. Which personal protective equipment is required to prevent a nurse's secondary exposure to a toxin? A. Face mask B. Head cover C. Lead apron D. Nonsterile gloves

D. Nonsterile gloves Rationale: Nonsterile gloves are required to prevent secondary exposure during decontamination after a disaster involving toxins. Head covers are not required. Lead aprons are used to prevent exposure to radiation. Respirators, not face masks, are required for exposure to inhaled toxins. p. 1643

Which chemical causes a patient to experience eye irritation and skin burns? a. Sarin b. Phosgene c. Mustard gas d. Pralidoxime chloride

c. Mustard gas Rationale: Mustard gas is a toxic substance that causes eye irritation and skin burns. Sarin is a highly toxic gas that causes immediate death of an individual. Phosgene is a colorless gas that causes severe respiratory distress, pulmonary edema, and death. Pralidoxime chloride is an antidote that helps to antagonize the effects of sarin. p. 1645

Which factors predispose an individual to heat stress? Opioid Alcohol Inability to swim Adequate clothing

Alcohol Rationale Alcohol affects the body's ability to regulate temperature, and hence, should be avoided, because it increases the sensation of warmth. Opioids suppress shivering and hence body temperature is regulated and so they do not lead to heat stress. The inability to swim can cause a submersion injury and is not a heat-related injury. Wearing adequate clothing suitable for the weather as well as wearing clothes that do not interfere with perspiration reduce heat stress. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. p. 1636

The east coast of the United States is experiencing a hurricane, and the emergency departments in the area are informed that they will be receiving hundreds of patients in the next hour. What organizations will health care organizations contact in order to obtain more resources to manage the mass casualty incident (MCI)? Select all that apply. A. The Joint Commission B. National Disaster Medical System (NDMS) C. Federal Emergency Materials Agency (FEMA) D. National Incident Management System (NIMS) E. The local community emergency response team (CERT)

B,D & E Rationale: NDMS is a part of the U.S. Department of Health and Human Services, Office of Preparedness Response, which sends disaster medical assistance teams (DMATs) to disaster sites with supplies and equipment to provide medical care for 72 hours. NIMS is responsible for coordinating federal, state, and local government efforts to respond to and manage domestic MCIs. The local CERT is an extension of the first responder services. The Federal Emergency Materials Agency is not associated with disaster preparedness. The Federal Emergency Management Agency is the organization that provides resources to communities experiencing an MCI. The Joint Commission is not involved in providing emergency resources. Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers. pp. 1645-1646

A nurse obtains a medical history from a patient that is admitted to the emergency department, using the mnemonic AMPLE to gather what patient information? Select all that apply. A. Blood pressure B. Allergies to food C. Medication history D. Full set of vital signs E. Tetanus immunization

B. Allergies to food C. Medication history E. Tetanus immunization Rationale: During the secondary survey, the nurse obtains details of the illness, length of time since the incident has occurred, treatment provided, the patient's response, and level of consciousness. The mnemonic AMPLE is a mnemonic that prompts the nurse to ask about A, allergies to drugs, food, latex, environment; M, medication history; P, past health history, tetanus, immunization; L, last meal; and E, events or environmental factors leading to the illness. The nurse checks vital signs and blood pressure at the start of the secondary survey prior to the assessment of health history. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. p. 1633

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

B. Keeping the patient warm with blankets Rationale 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. p. 1632

The nurse assesses that a patient who sustained a severe trauma injury has asymmetric chest wall movement and no breath sounds on the left side of the chest. Which treatment strategy will help to alleviate the patient's symptoms? A. Administering mannitol B. Administering chlorpromazine C. Applying a bag valve mask (BVM) D. Infusing warmed intravenous fluids

C. Applying a bag valve mask (BVM) Rationale: When a patient has asymmetric chest wall movement and no breath sounds on one side of the chest, it indicates that the patient has a flail chest or a pneumothorax. This means the patient may have respiratory distress. Therefore the nurse should provide ventilation to the patient by using a bag valve mask for effective treatment. Mannitol is a diuretic, which helps to reduce cerebral edema but will not alleviate the symptoms of abnormal breathing. Warmed intravenous (IV) fluids will help treat hypothermia in a patient who has frostbite. This intervention does not help to provide adequate breathing to this patient. Chlorpromazine helps to reduce shivering in a patient who has heat stroke. It does not help to alleviate abnormal breath sounds and chest movements. Test-Taking Tip: If you are unable to answer a multiple-choice question immediately, eliminate the alternatives that you know are incorrect and proceed from that point. The same goes for a multiple-response question that requires you to choose two or more of the given alternatives. If a fill-in-the-blank question poses a problem, read the situation and essential information carefully and then formulate your response. p. 1630

The nurse is caring for patients in the emergency room. 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. Patient with severe respiratory distress Rationale: The Emergency Severity Index (ESI) is a five level triage system used to critically analyze the priority of patient care. ESI indicates that patients with severe respiratory distress, cardiac arrest, and intubated trauma patients are prioritized for treatment (ESI-1). Patients with abdominal pain are given third preference (ESI-3). Patients with minor burns such as first-degree burns are given the last preference (ESI-5). Patients with chest pain likely due to ischemia are given second preference (ESI-2). Test-Taking Tip: Look for answers that focus on the patient or are directed toward feelings. p. 1629

After completing a full set of vital signs on a patient who was injured severely in a motor-vehicle accident, the nurse begins to insert a Foley catheter per the health care provider's prescription. Which of the following would warrant the nurse to notify the health care provider? A. Priapism B. Rectal bleeding C. Perineal ecchymosis D. Abdominal distention

C. Perineal ecchymosis Rationale: The nurse would not want to insert a Foley catheter if the patient has blood at the urinary meatus, scrotal hematoma, or perineal ecchymosis, because these are signs of possible damage to the urinary tract, and the Foley catheter could possibly cause additional damage. A Foley catheter may still be inserted in a patient experiencing priapism. Abdominal distention and rectal bleeding do not affect the urinary tract. p. 1634

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

D. An individual whose femoral artery has been severed and is bleeding profusely. Rationale: 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." p. 1646

A large group of people were involved in a tractor trailer accident. Gasoline was spilled, and several people experienced skin contact with the substance. What is the recommended solution to rinse most toxins from the skin? A. Sterile water B. Soap and water C. Half-strength peroxide D. Copious amounts of water

D. Copious amounts of water Rationale: Rinsing the skin with copious amounts of water will remove most toxins. Peroxide is not recommended for rinsing toxins. Soap and water is recommended after the water rinse. Sterile water is not required. p. 1643

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

D. Examine the chest for signs of breathing Rationale: 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. p. 1631

A nurse is conducting a primary survey in an emergency department. What 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. To evaluate the status of airway, breathing, circulation, disability and exposure and environmental control Rationale: 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. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. p. 1630

While assessing an unresponsive apneic spinal cord injury patient, the nurse understands the need to open the airway with the jaw thrust maneuver and apply a cervical collar. What intervention would be the priority for the nurse to complete next? A. Inserting an intravenous line B. Assessing skin color, temperature, and moisture C. Determining the patient's level of consciousness D. Ventilating with a bag-valve mask at 100% oxygen

D. Ventilating with a bag-valve mask at 100% oxygen Rationale: Ventilating with the bag-valve mask at 100% oxygen would be the priority, because breathing is the priority after the airway has been stabilized. The nurse would not assess skin color, temperature, and moisture or insert an intravenous line until after the patient's airway and breathing have been assessed and treated, because this is part of the circulation assessment or treatment. The patient's level of consciousness has been determined already; he or she is unresponsive. p. 1630

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? A. Red B. Blue C. Green D. Yellow

D. Yellow Rationale: 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. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation. p. 1646

Which is the focus area in the treatment of submersion injuries? a. Correcting fluid imbalances b. Rewarming when hypothermia is present c. Freezing the injured tissues by submersion d. Prevention of a further drop in body temperature

a. Correcting fluid imbalances Rationale The primary focus area in the treatment of submersion injury is correction of fluid imbalances. Fluid imbalance is corrected when the gas exchange is improved by way of mechanical ventilation and positive airway pressure. Submersion injuries cause acute respiratory distress that requires ventilation and oxygenation for treatment, not rewarming. Frostbite causes the freezing of tissues, which doesn't occur in a submersion injury. There is no drop in body temperate during submersion injury; hence treatment focuses on physiologic function. p. 1640