NUR.213 NCLEX Questions - Triage & Emergency Preparedness

The nurse is the first responder at the scene of a 6-car crash on a highway. Which victim should the nurse attend to first? 1. A victim experiencing dyspnea 2. A victim experiencing confusion 3. A victim experiencing tachycardia 4. A victim experiencing intense pain

1. A victim experiencing dyspnea The client experiencing dyspnea is the priority. Needs related to maintaining a patent airway are always the priority. The victims experiencing confusion, tachycardia, and intense pain would be assessed following stabilization of the client with an airway problem.

The community health nurse is preparing to teach personnel and family preparedness for disasters to a group of parents of school-age children. Which items should the nurse plan to include in disaster preparedness? Select all that apply. 1. Flashlight 2. Supply of batteries 3. Battery-operated radio 4. Extra pair of eyeglasses 5. 4-week supply of water 6. 4-week supply of nonperishable food

1. Flashlight 2. Supply of batteries 3. Battery-operated radio 4. Extra pair of eyeglasses Options 1, 2, 3, and 4 should be identified as items to have on hand as part of disaster preparedness. A 3-day supply of water is recommended (1 gallon per client per day). Similarly, a 3-day supply of nonperishable food is recommended. A 4-week supply of water and food is unnecessary and not recommended.

The nurse in charge of a nursing unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply. 1. A client with chest pain 2. A client with a Holter monitor 3. A client receiving oral antibiotics 4. A client experiencing sinus rhythm 5. A client newly diagnosed with atrial fibrillation 6. A client experiencing third-degree heart block who requires a pacemaker

2. A client with a Holter monitor 3. A client receiving oral antibiotics 4. A client experiencing sinus rhythm Clients should be medically stable if discharged and should be able to manage their condition at home. A client experiencing chest pain could be having a myocardial infarction and needs frequent monitoring. A client newly diagnosed with atrial fibrillation requires medication and monitoring to stabilize the condition. A client in third-degree heart block is considered unstable, especially if the client needs a pacemaker.

The nurse is reviewing the manual of disaster preparedness and response for the annual hospital disaster drill. The nurse reads that which are functions of the American Red Cross (ARC) as opposed to the Federal Emergency Management Agency (FEMA) in the United States? Select all that apply. 1. Provide monetary relief. 2. Provide crisis counseling. 3. Identify and train personnel. 4. Issue presidential declarations. 5. Deploy National Guard troops. 6. Handle inquiries from families.

2. Provide crisis counseling. 3. Identify and train personnel. 6. Handle inquiries from families. In general, the ARC provides support to individuals involved in a disaster, whereas FEMA deals with regional responses to disasters, such as issuing presidential declarations, providing monetary relief, and deploying National Guard troops. The ARC has been given authority by the federal government to identify and train personnel for a disaster and provide disaster relief, including crisis counseling, operating shelters, and handling inquiries from families.

The nurse from a medical unit is called to assist with care for clients coming into the hospital emergency department during an external disaster. Using principles of triage during a disaster, the nurse should attend to the client with which problem first? 1. Fractured tibia 2. Penetrating abdominal injury 3. Bright red bleeding from a neck wound 4. Open massive head injury in deep coma

3. Bright red bleeding from a neck wound The client with arterial bleeding from a neck wound is in immediate need of treatment to save the client's life. This client is classified as such and would wear a color tag of red from the triage process. The client with a penetrating abdominal injury would be tagged yellow and classified as "delayed," requiring intervention within 30 to 60 minutes. A green or "minimal" designation would be given to the client with a fractured tibia, who requires intervention but who can provide self-care if needed. A designation of expectant is applied to the client with massive head or other injuries and minimal chance of survival; the corresponding color code is black in the triage process. Such clients receive supportive care and pain management but are given definitive treatment last.

Which client should the emergency department triage nurse classify as emergent? 1. A client with a displaced fracture who is crying 2. A client with a simple laceration and soft tissue injury 3. A client with crushing substernal pain who is short of breath 4. A client with a temperature of 101°F (38.3°C) with a productive cough

3. A client with crushing substernal pain who is short of breath A triage method commonly used in the emergency department consists of 3 categories: emergent, urgent, and nonurgent. The emergent category implies that a condition exists that poses an immediate threat to life or limb. An example of a client who fits into this category is the client experiencing crushing substernal pain who is short of breath. The urgent category indicates that the client should be treated quickly but that an immediate threat to life does not exist at the moment. The client with a displaced fracture who is crying and the client with a temperature of 101°F (38.3°C) and a productive cough would fit into this category. The nonurgent category indicates that the client can generally tolerate waiting several hours for health care services without a significant risk of clinical deterioration. The client with a simple laceration and soft tissue injury would fit into this category.

The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first? 1. A victim experiencing excruciating pain 2. A victim experiencing moderate anxiety 3. A victim experiencing airway obstruction 4. A victim experiencing altered level of consciousness

3. A victim experiencing airway obstruction Client needs related to maintaining a patent airway are always the priority. Therefore, the nurse would attend to the victim experiencing airway obstruction first. Care to the other victims follows.

The community health nurse is working with disaster relief after a tornado. The nurse assists in finding safe housing for survivors, providing support to families, organizing counseling, and securing physical care when needed. Which level of prevention does the nurse exercise? 1. Primary level of prevention 2. Secondary level of prevention 3. Tertiary level of prevention 4. Quaternary level of prevention

3. Tertiary level of prevention Tertiary prevention involves reduction of the amount and degree of disability, injury, and damage after a crisis. Primary prevention means keeping the crisis from occurring, and secondary prevention focuses on reducing the intensity and duration of a crisis. There is no known quaternary prevention level.

The nurse in the hospital emergency department is notified by emergency medical services that several victims who survived a plane crash will be transported to the hospital. Victims are suffering from cold exposure because the plane plummeted and was submerged in a local river. What is the initial action of the nurse? 1. Call the nursing supervisor to activate the agency disaster plan. 2. Supply the triage rooms with bottles of sterile water and normal saline. 3. Call the intensive care unit to request that nurses be sent to the emergency department. 4. Call the laundry department, and ask the department to send as many warm blankets as possible to the emergency department.

1. Call the nursing supervisor to activate the agency disaster plan. In an external disaster, many people may be brought to the emergency department for treatment. The initial nursing action must be to activate the disaster plan. Although options 2, 3, and 4 may be additional measures that the nurse would take, the initial action would be to activate the disaster plan.

The nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the nurse attend to first? 1. A pregnant woman who exclaims, "My baby is not moving." 2. A child who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!" 3. A young child standing next to an adult family member who is screaming, "I want my mommy!" 4. An older victim who is sitting next to her husband sobbing, "My husband is dead. My husband is dead."

2. A child who is complaining, "My leg is bleeding so bad, I am afraid it is going to fall off!" Priority nursing care in disaster situations needs to be delivered to the living and not the dead. The child who is bleeding badly is the priority. The bleeding could be from an arterial vessel; if the bleeding is not stopped, the child is at risk for shock and death. The pregnant client is the next priority, but the absence of fetal movement may or may not be indicative of fetal demise. The young child is with a family member and is safe at this time. The older victim will need comfort measures; there is no information indicating she is physically hurt.

The nurse in charge of a nursing unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Select the clients who can be safely discharged. Select all that apply. 1. A client with dyspnea 2. A client experiencing sinus rhythm 3. A client receiving oral anticoagulants 4. A client with chronic atrial fibrillation 5. A client experiencing third-degree heart block 6. A client who has not voided since before surgery

2. A client experiencing sinus rhythm 3. A client receiving oral anticoagulants 4. A client with chronic atrial fibrillation Clients should be medically stable if discharged and should be able to manage their condition at home independently, with family assistance, or with community services. The client in option 2 is stable because sinus rhythm is a normal finding. Oral anticoagulants can be taken at home as long as the client understands how to take the medication and is provided with education about the medication. The client in option 4 can be discharged because the client's condition is chronic, not acute. The client experiencing dyspnea is not considered stable. The client experiencing third-degree heart block is considered unstable and will most likely need a pacemaker insertion. Clients should not be discharged after surgery until they have voided.

The nurse in charge of a nursing unit is asked to select those hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply. 1. The client with heart failure (HF) who has bilateral rhonchi 2. The client who 24 hours earlier gave birth to her second child by caesarean delivery 3. The 48-hour postoperative client who has undergone an ileostomy because of ulcerative colitis 4. The client with peritonitis caused by a ruptured appendix who is febrile with a temperature of 102°F (38.9°C) 5. The 2-day postoperative client who has undergone total knee replacement and is ambulating with a walker 6. The 3-day postoperative client who has undergone coronary artery bypass grafting and is ready for rehabilitation

2. The client who 24 hours earlier gave birth to her second child by caesarean delivery 3. The 48-hour postoperative client who has undergone an ileostomy because of ulcerative colitis 5. The 2-day postoperative client who has undergone total knee replacement and is ambulating with a walker 6. The 3-day postoperative client who has undergone coronary artery bypass grafting and is ready for rehabilitation The client who remains febrile with peritonitis and the client who has continuing rhonchi with heart failure need to be monitored on an ongoing basis. The remaining clients could be cared for at home with the help of a home health care nurse.

The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first? 1. A middle-aged man with 1 foot trapped under the wreckage 2. A crying teenager who is holding pressure on an arm laceration 3. A young woman who appears dazed and confused and is shivering 4. A screaming middle-aged woman looking frantically for her husband

3. A young woman who appears dazed and confused and is shivering The young woman is demonstrating classic signs of shock, possibly from a closed head injury. Initial management of a client displaying signs of shock includes management of airway, breathing, and circulation. Initial treatment includes keeping the client warm. Oxygenation and intravenous fluids will be needed immediately to stabilize and maintain tissue perfusion. A first responder would be unlikely to be able to release a foot trapped under wreckage without help. The teenager is already applying pressure to the arm and is more likely to be able to maintain self-care until help arrives. Assisting a client with search and rescue would only be feasible once help arrives. Therefore, the nurse should attend to the client with the priority needs and the greatest potential of survival.