MS3 Final, MSS: Emergency & Disaster Nursing

Which cultural issues should the nurse consider when caring for clients during a bioterrorism attack? Select all that apply. 1. Language difficulties. 2. Religious practices. 3. Prayer times for the people. 4. Rituals for handling the dead. 5. Keeping the family in the designated area.

1, 2, 3, 4 1. Language difficulties can increase fear and frustration on the part of the client. 2. Some religions have specific practices related to medical treatments, hygiene, and diet, and these should be honored if at all possible. 3. Prayers in time of grief and disaster are important to an individual and actually can have a calming affect on the situation. 4. Caring for the dead is as important as caring for the living based on religious beliefs. 5. For purposes of organization this may be needed, but it is not addressing cultural sensitivity and in some instances may violate cultural needs of the client and the family.

The occupational health nurse is called to the scene of a traumatic amputation of a finger. Which intervention should the nurse implement prior to sending the client to the ED? Select all that apply. 1. Rinse the amputated finger with sterile normal saline. 2. Place the amputated finger in a sealed and watertight plastic bag. 3. Place the amputated finger into iced saline solution. 4. Wrap the amputated finger in saline-moistened gauze dressings. 5. Replace the amputated finger on the hand and wrap with gauze.

1, 2, 4 1. The amputated finger and all tissue should be rinsed with sterile normal saline to remove dirt and sent to the ED with the client. 2. Place the finger and all tissue in a watertight, sealed plastic bag to prevent loss and contamination. 4. The finger should be wrapped in gauze moistened with sterile normal saline.

The nurse is teaching a class on disaster preparedness. Which are components of an emergency operations plan (EOP)? Select all that apply. 1. A plan for practice drills. 2. A deactivation response. 3. A plan for internal communication only. 4. A preincident response. 5. A security plan.

1, 2, 5 1. Practice drills allow for troubleshooting any issues before a real-life incident occurs. 2. A deactivation response is important so resources are not overused, and the facility can then get back to daily activities and routine care. 3. Communication between the facility and external resources and an internal communication plan are critical. 4. A postincident response is important to include a critique and debriefing for all parties involved; a preincident response is the plan itself. Be sure to read adjectives closely. 5. A coordinated security plan involving facility and community agencies is the key to controlling an otherwise chaotic situation.

A gastric lavage has been ordered for a client who is comatose and who ingested a full bottle of acetaminophen, a nonnarcotic analgesic. Which intervention should be included in the procedure? Select all that apply. 1. Place the client on the left side with the head 15 degrees lower than the body. 2. Insert a small-bore feeding tube into the naris. 3. Have standby suction available. 4. Withdraw stomach contents and then instill an irrigating solution. 5. Send samples of the stomach contents to the laboratory for analysis.

1, 3, 4, 5 1. The client should be placed on the left side, which allows the gastric contents to pool in the stomach and decreases passage of fluid into the duodenum during lavage. After the placement of the orogastric tube, the head is lowered to facilitate removal of the gastric contents. 2. A large-bore tube is placed through the mouth into the stomach of a client who is comatose and an endotracheal tube is inserted into the airway prior to beginning lavage to prevent aspiration. 3. Standby suction is an emergency measure to prevent aspiration in case the client vomits. 4. Removing stomach contents before beginning the lavage helps to prevent overdistention of the stomach and aspiration. 5. Samples of the first two (2) lavage washings should be sent to the laboratory to be analyzed for chemical compounds.

The ED nurse is working triage. Which client should be triaged first? 1. A client who has multiple injuries from a motor-vehicle accident. 2. A client complaining of epigastric pain and nausea after eating. 3. An elderly client who fell and fractured the left femoral neck. 4. The client suffering from a migraine headache and nausea.

1. A client who has multiple injuries from a motor-vehicle accident. Injuries from a motor-vehicle accident can be life threatening. This client should be assessed first to rule out respiratory difficulties and hemorrhage.

The nurse is caring for a client in the ED with abdominal trauma who has had peritoneal lavage. Which intervention should the nurse include in the plan of care? 1. Assess for the presence of blood, bile, or feces. 2. Palpate the client for bilateral femoral pulses. 3. Perform Leopold's maneuver every eight (8) hours. 4. Collect information on the client's dietary history.

1. Assess for the presence of blood, bile, or feces. A diagnostic peritoneal lavage is performed to assess the presence of blood, bile, and feces from internal bleeding induced by injury. If any of these are present, surgery should be considered to explore the extent of damage and repair of the injury.

Which situation requires the emergency department manager to schedule and conduct a Critical Incident Stress Management (CISM)? 1. Caring for a two (2)-year-old child who died from severe physical abuse. 2. Performing CPR on a middle-aged male executive who died. 3. Responding to a 22-victim bus accident with no apparent fatalities. 4. Being required to work 16 hours without taking a break.

1. Caring for a two (2)-year-old child who died from severe physical abuse. CISM is an approach to preventing and treating the emotional trauma affecting emergency responders as a consequence of their job. Performing CPR and treating a young child affects the emergency personnel psychologically, and the death increases the traumatic experience. Caring for this type of client is an expected part of the job. If the nurse finds this traumatic enough to require a CISM, then the nurse should probably leave the emergency department. This requires an intense time for triaging and caring for the victims, but without fatalities this should not be as traumatic for the staff. This is a dangerous practice because medication errors and other mistakes may occur as a result of fatigue, but this is not a traumatic situation.

The client diagnosed with a bee sting allergy is being discharged from the emergency department. Which priority discharge instruction should be taught to the client? 1. Demonstrate how to use an EpiPen, an adrenergic agonist. 2. Teach the client to never go outdoors in the spring and summer. 3. Have the client buy diphenhydramine over the counter to use when stung. 4. Discuss wearing a Medic Alert bracelet when going outside.

1. Demonstrate how to use an EpiPen, an adrenergic agonist. Clients who are allergic to bee sting venom should be taught to keep an EpiPen with them at all times and how to use the device. This could save their lives.

A vat of chemicals spilled onto the client. Which action should the occupational health nurse implement first? 1. Have the client stand under a shower while removing all clothes. 2. Check the material safety data sheets for the antidote. 3. Administer oxygen by nasal cannula. 4. Collect a sample of the chemicals in the vat for analysis.

1. Have the client stand under a shower while removing all clothes. The skin should be immediately drenched with water from a hose or shower. A constant stream of water is applied. Time should not be lost by removing the clothes first and then proceeding to rinsing with water. If a dry powder form of white phosphorus or lye spilled onto the client, it is brushed off and then the client is placed under the shower. The first action is to remove the poison from the client's skin and prevent further damage. If the client becomes dyspneic, the nurse administers oxygen while waiting for the paramedics. The vat should be labeled as to the chemical contents per Occupational Safety and Health Administration (OSHA) regulations, but if not, then the nurse must determine which chemicals are in the vat so the HCP can treat the client appropriately.

The client is highly allergic to insect venom and is prescribed venom immunotherapy. Which statement is the scientific rationale for this treatment? 1. Immunotherapy is effective in preventing anaphylaxis following a future sting. 2. Immunotherapy will prevent all future insect stings from harming the client. 3. This therapy will cure the client from having any allergic reactions in the future. 4. This therapy is experimental and should not be undertaken by the client.

1. Immunotherapy is effective in preventing anaphylaxis following a future sting. Immunotherapy does not cure the problem. However, if immunotherapy is done following a reaction, it provides passive immunity to the insect venom (similar to the way RhoGAM prevents a mother who is Rh negative from building antibodies to the blood of a baby who is Rh positive). This is the purpose for immunotherapy in clients who are allergic.

The ED nurse is caring for a client who had a severe allergic reaction to a bee sting. Which discharge instructions should the nurse discuss with the client? 1. Instruct the client to wear a medical identification bracelet. 2. Apply corticosteroid cream to the site to prevent anaphylaxis. 3. Administer epinephrine 1:10,000 intravenously every three (3) minutes. 4. Teach the client to avoid attracting insects by wearing bright colors.

1. Instruct the client to wear a medical identification bracelet. Clients who have severe reactions to insect stings should wear identifying bracelets to provide information. If the client is unconscious, the bracelet can alert the health-care provider so treatment can be started.

The health-care facility has been notified an alleged inhalation anthrax exposure has occurred at the local post office. Which category of personal protective equipment (PPE) should the response team wear? 1. Level A. 2. Level B. 3. Level C. 4. Level D.

1. Level A. Level A protection is worn when the highest level of respiratory, skin, eye, and mucous membrane protection is required. In this situation of possible inhalation of anthrax, such protection is required. Level B protection is similar to Level A protection, but it is used when a lesser level of skin and eye protection is needed. Level C protection requires an air-purified respirator (APR), which uses filters or absorbent materials to remove harmful substances. Level D is basically the work uniform.

Which is the primary goal of the ED nurse in caring for a client who has ingested poison? 1. Remove or inactivate the poison before it is absorbed. 2. Provide long-term supportive care to prevent organ damage. 3. Administer an antidote to increase the effects of the poison. 4. Implement treatment prolonging the elimination of the poison.

1. Remove or inactivate the poison before it is absorbed. The primary goal for the ED nurse is to stop the action of the poison and then maintain organ functioning. ED nurses do not provide long-term care. Antidotes are administered to neutralize the effects of poisons, not to increase the effects. Treatment is implemented to hasten the elimination of the poison.

The client is admitted into the emergency department with diaphoresis, pale clammy skin, and BP of 90/70. Which intervention should the nurse implement first? 1. Start an IV with an 18-gauge catheter. 2. Administer dopamine intravenous infusion. 3. Obtain arterial blood gases (ABGs). 4. Insert an indwelling urinary catheter

1. Start an IV with an 18-gauge catheter. There are many types of shock, but the one common intervention which should be done first in all types of shock is to establish an intravenous line with a large-bore catheter. The low blood pressure and cold, clammy skin indicate shock.

The father of a child brought to the emergency department is yelling at the staff and obviously intoxicated. Which approach should the nurse take with the father? 1. Talk to the father in a calm and low voice. 2. Tell the father to wait in the waiting room. 3. Notify the child's mother to come to the ED. 4. Call the police department to come and arrest him.

1. Talk to the father in a calm and low voice. This will help diffuse the escalating situation and attempt to keep the father calm. Sending the father to the waiting room does not help his behavior and could possibly make his behavior worse; loud and obnoxious behavior can become violent. This will not help the current situation and could make it worse because the nurse doesn't know the home situation. The nurse should notify hospital security before calling the police department.

The charge nurse is making assignments. Which client should be assigned to the most experienced nurse? 1. The client diagnosed with a snake bite who is receiving antivenin. 2. The client who swallowed a lye preparation and is being discharged. 3. The client who is angry the suicide attempt did not work. 4. The client who required skin grafting after a chemical spill.

1. The client diagnosed with a snake bite who is receiving antivenin. Before administering antivenin, the affected body part must be measured, and it is remeasured every 15 minutes during a four (4)- to six (6)-hour procedure. The infusion is begun slowly and increased after 10 minutes. The affected part is measured every 30 to 60 minutes after the infusion and for 48 hours to detect symptoms of compartment syndrome (edema, loss of pulse, increased pain, and paresthesias). Allergic reactions to the antivenin are not uncommon and are usually the result of a too-rapid infusion of the antivenin. The most experienced nurse should be assigned this client. This client is beyond critical danger and is being discharged, so a less experienced nurse could care for this client. This client has many needs, but anger is not a priority over a physiological need. A less experienced nurse could care for this client.

The client has expired secondary to smallpox. Which information about funeral arrangements is most important for the nurse to provide to the client's family? 1. The client should be cremated. 2. Suggest an open casket funeral. 3. Bury the client within 24 hours. 4. Notify the public health department.

1. The client should be cremated. Cremation is recommended because the virus can stay alive in the scabs of the body for 13 years. An open casket might allow for the spread of the virus to the general public; therefore, the nurse should not make this suggestion. The nurse should not tell the client's family how to make funeral arrangement for viewing. Burying the body quickly is the second best option for safety of the funeral home personnel and anyone who could come in contact with the body. The quicker the burial, the safer the situation (if the family refuses cremation). The hospital, not the client's family, must notify the public health department.

Which situation warrants the nurse obtaining information from a material safety data sheet (MSDS)? 1. The custodian spilled a chemical solvent in the hallway. 2. A visitor slipped and fell on the floor that had just been mopped. 3. A bottle of antineoplastic agent broke on the client's floor. 4. The nurse was stuck with a contaminated needle in the client's room.

1. The custodian spilled a chemical solvent in the hallway. The MSDS provides chemical information regarding specific agents, health information, and spill information for a variety of chemicals. It is required for every chemical found in the hospital. This situation requires an occurrence or accident report. Any facility administering antineoplastic agents (medications used to treat cancer) is required to have specific chemotherapy spill kits available and a policy and procedure included; in this situation the nurse already knows the chemical involved. This requires a hospital variance report and notifying the employee health or infection-control nurse.

The nurse is discharging a client from the ED with a sutured laceration on the right knee. Which information is most important for the nurse to obtain? 1. The date of the client's last tetanus injection. 2. The name of the client's regular health-care provider. 3. Explain the sutures must be removed in 10 to 14 days. 4. Determine if the client has any drug or food allergies.

1. The date of the client's last tetanus injection. Any client who has not had a tetanus injection within five (5) years will need to receive an injection as prophylaxis.

The nurse is assessing the client who suffered a near-drowning event. Which data require immediate intervention? 1. The onset of pink, frothy sputum. 2. An oral temperature of 97°F. 3. An alcohol level of 100 mg/dL. 4. A heart rate of 100 beats/min.

1. The onset of pink, frothy sputum. The onset of pinky, frothy sputum indicates the client is experiencing pulmonary edema. This needs to be treated to prevent further decline in this client. An oral temperature of 97°F is in the lower level of within normal limits. A blood alcohol of 100 mg/dL is an elevation but should not be considered priority over pulmonary edema. Treatments for elevations in toxicology levels can be considered after the client is stable. A heart rate of 100 beats/min is tachycardia but not at a critical level. The nurse needs to remember Maslow's hierarchy of priority, and airway and breathing are physiological needs that take priority.

The client has ingested the remaining amount of a bottle of analgesic medication. The medication comes 500 mg per capsule. Two (2) doses of two (2) capsules each have been used by another member of the family. The bottle originally had 250 capsules. How many mg of medication did the client take? _________

123,000 mg of analgesic medication were consumed. The container originally contained 250 capsules. Two (2) doses of two (2) capsules each were removed. 2 × 2 = 4250 capsules - 4 capsules = 246 capsules remainingEach capsule contains 500 mg.246 capsules × 500 mg = 123,000 mg of medication consumed

The nurse is discharging a client diagnosed with accidental carbon monoxide poisoning. Which statement made by the client indicates the need for further teaching? 1. "I should install carbon monoxide detectors in my home." 2. "Having a natural bright-red color to my lips is good." 3. "You cannot smell carbon monoxide, so it can be difficult to detect." 4. "I should have my furnace checked for leaks before turning it on."

2. "Having a natural bright-red color to my lips is good." The lips should be pink, not bright red or blue. This indicates a saturation of the hemoglobin with carbon monoxide. This client needs more instruction. Installing carbon monoxide detectors in the home is a recommended safety measure. Because carbon monoxide is colorless and odorless, it can be dangerous. It is detected with special detectors.One of the major causes of accidental carbon monoxide poisoning is a faulty furnace.

The nurse in the emergency department has admitted five (5) clients in the last two (2) hours with complaints of fever and gastrointestinal distress. Which question is most appropriate for the nurse to ask each client to determine if there is a bioterrorism threat? 1. "Do you work or live near any large power lines?" 2. "Where were you immediately before you got sick?" 3. "Can you write down everything you ate today?" 4. "What other health problems do you have?"

2. "Where were you immediately before you got sick?" The nurse should take note of any unusual illness for the time of year or clusters of clients coming from a single geographical location who all exhibit signs/symptoms of possible biological terrorism. Power lines are not typical sources of biological terrorism, which is what these symptoms represent. This might be appropriate for gastroenteritis secondary to food poisoning but is not the nurse's first thought to determine a biological threat. The nurse must determine if the clients have anything in common. This is important information to obtain for all clients but is not pertinent to determine a biological threat.

The male client was found in a parked car with the motor running. The paramedic brought the client to the ED with complaints of a headache, nausea, and dizziness and the client is unable to recall his name or address. On assessment, the nurse notes the buccal mucosa is a cherry-red color. Which intervention should the nurse implement first? 1. Check the client's oxygenation level with a pulse oximeter. 2. Apply oxygen via nasal cannula at 100%. 3. Obtain a psychiatric consult to determine if this was a suicide attempt. 4. Prepare the client for transfer to a facility with a hyperbaric chamber.

2. Apply oxygen via nasal cannula at 100%. These are signs and symptoms of carbon monoxide poisoning. Symptoms include skin color from a cherry red to cyanotic and pale, headache, muscular weakness, palpitations, dizziness, and confusion and can progress rapidly to coma and death. Oxygen should be administered 100% at hyperbaric or atmospheric pressures to reverse hypoxia and accelerate elimination of the carbon monoxide.. These are signs and symptoms of carbon monoxide poisoning. Pulse oximetry is not a valid test because the hemoglobin is saturated with the carbon monoxide and a false high reading is being obtained. This may be done, but it is not the first action. This may need to be done, but getting oxygen to the brain is first.

During a disaster, a local news reporter comes to the emergency department requesting information about the victims. Which action is most appropriate for the nurse to implement? 1. Have security escort the reporter off the premises. 2. Direct the reporter to the disaster command post. 3. Tell the reporter this is a violation of HIPAA. 4. Request the reporter to stay out of the way.

2. Direct the reporter to the disaster command post. Emergency operations plans will have a designated disaster plan coordinator. All public information should be routed through this person. The media have an obligation to report the news and can play a significant positive role in communication, but communication should come from only one source—the disaster command center. Client confidentiality must be maintained, but the best action is for the nurse to help the reporter get to the appropriate area for information. This allows the reporter to stay in the emergency department, which is inappropriate.

Which signs/symptoms should the nurse assess in the client who has been exposed to the anthrax bacillus via the skin? 1. A scabby, clear fluid-filled vesicle. 2. Edema, pruritus, and a 2-mm ulcerated vesicle. 3. Irregular brownish-pink spots around the hairline. 4. Tiny purple spots flush with the surface of the skin.

2. Edema, pruritus, and a 2-mm ulcerated vesicle. Exposure to anthrax bacilli via the skin results in skin lesions, which cause edema with pruritus and the formation of macules or papules, which ulcerate, forming a one (1)- to (3)-mm vesicle. Then a painless eschar develops, which falls off in one (1) to two (2) weeks. Scabby, clear fluid-filled vesicles are characteristic of chickenpox. Irregular brownish-pink spots around the hairline are characteristic of rubella. Tiny purple spots flush with the skin surface are petechiae.

The nurse working in an outpatient clinic is caring for a client who is experiencing epistaxis (nose bleed). Which intervention should the nurse implement first? 1. Take the client's blood pressure in both arms. 2. Hold the nose with thumb and finger for 15 minutes. 3. Have the client sit with the head tilted back and hold a tissue. 4. Prepare to administer silver nitrate, a cauterizing agent, with a packing applicator.

2. Hold the nose with thumb and finger for 15 minutes. Most nosebleeds will stop after applying pressure on the nose between thumb and index finger for 15 minutes.

The elderly female client with vertebral fractures who has been self-medicating with ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), presents to the ED complaining of abdominal pain, is pale and clammy, and has a P of 110 and a BP of 92/60. Which type of shock should the nurse suspect? 1. Cardiogenic shock. 2. Hypovolemic shock. 3. Neurogenic shock. 4. Septic shock.

2. Hypovolemic shock. These client's signs/symptoms make the nurse suspect the client is losing blood, which leads to hypovolemic shock, which is the most common type of shock and is characterized by decreased intravascular volume. The client's taking of NSAID medications puts her at risk for hemorrhage because NSAIDs inhibit prostaglandin production in the stomach, which increases the risk of developing ulcers, which can erode the stomach lining and lead to hemorrhaging.

Which problem is most appropriate for the nurse to identify for the client experiencing renal trauma? 1. Infection of the renal tract. 2. Ineffective tissue perfusion. 3. Alteration in skin integrity. 4. Alteration in temperature.

2. Ineffective tissue perfusion. Bleeding results in an impairment of tissue perfusion. Because of the large amount of blood flow through the renal system, bleeding is a major problem.

The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a medical unit. Which nursing task cannot be delegated to the UAP? 1. Obtaining the intake and output on a client diagnosed with food poisoning. 2. Performing a dressing change on the client with a chemical burn. 3. Assisting a client who overdosed on morphine to the bedside commode. 4. Help a client with carbon monoxide poisoning turn, cough, and deep breathe.

2. Performing a dressing change on the client with a chemical burn. This is a sterile dressing change and should not be delegated. UAPs can obtain intake and outputs, but evaluating the information is the nurse's responsibility. A UAP can assist clients to get up to the bedside commode as long as the UAP is knowledgeable about body mechanics. The UAP can assist a client to turn and ask the client to cough and deep breathe.

The client with a temperature of 94°F is being treated in the ED. Which intervention should the nurse implement to directly elevate the client's temperature? 1. Remove the client's clothing. 2. Place a warm air blanket over the client. 3. Have the client change into a hospital gown. 4. Raise the temperature in the room.

2. Place a warm air blanket over the client. The warm air blanket blows warm air over the client and is an active warming method.

The client presents to the ED with acute vomiting after eating at a fast-food restaurant. There has not been any diarrhea. The nurse suspects botulism poisoning. Which nursing problem is the highest priority for this client? 1. Fluid volume loss. 2. Risk for respiratory paralysis. 3. Abdominal pain. 4. Anxiety.

2. Risk for respiratory paralysis. Clients with botulism are at risk for respiratory paralysis, and this is the priority problem. Fluid volume loss is a concern because of the potential for the client to go into hypovolemic shock, but this is not priority over airway. The client will be in pain and pain is a priority, but it does not come before airway and fluid volume. The client may be anxious, but a psychosocial problem usually can be ranked after a physiological one in priority.

The ED nurse is caring for a client diagnosed with frostbite of the feet. Which intervention should the nurse implement? 1. Massage the feet vigorously. 2. Soak the feet in warm water. 3. Apply a heating pad to feet. 4. Apply petroleum jelly to feet.

2. Soak the feet in warm water. Soaking the feet in a warm bath of 107°F causes rapid continuous rewarming.

The elderly male client is admitted to the medical unit with a diagnosis of senile dementia. The client is 74 inches tall and weighs 54.5 kg. The client lives with his son and daughter-in-law, both of whom work outside the house. Which referral is most important for the nurse to implement? 1. Adult Protective Services. 2. Social worker. 3. Medicare ombudsman. 4. Dietitian.

2. Social worker. The nurse should arrange for the social worker to see the client and family to determine if some arrangements could be made to provide for the client's safety and for the client to be provided with nutritious meals while the adult children are at work. A long-term care facility or adult day care may be needed.

A chemical exposure has just occurred at an airport. An off-duty nurse, knowledgeable about biochemical agents, is giving directions to the travelers. Which direction should the nurse provide to the travelers? 1. Hold their breath as much as possible. 2. Stand up to avoid heavy exposure. 3. Lie down to stay under the exposure. 4. Attempt to breathe through their clothing.

2. Stand up to avoid heavy exposure. Standing up will avoid heavy exposure because the chemical will sink toward the floor or ground. The absence of breathing is death, and this is neither a viable option nor a sensible recommendation to terrified people. Staying below the level of the smoke is the instruction for a fire. Breathing through the clothing, which is probably contaminated with the chemical, will not provide protection from the chemical entering the lung.

The ED receives a client involved in a motor-vehicle accident. The nurse notes a large hematoma on the right flank. Which intervention should the nurse implement first? 1. Insert an indwelling urinary catheter. 2. Take the vital signs every 15 minutes. 3. Monitor the skin turgor every hour. 4. Mark the edges of the bruised area.

2. Take the vital signs every 15 minutes. Vital signs should be taken frequently to assess for covert bleeding. The hematoma in the flank area may indicate the presence of trauma to the kidney. Because of the large amount of blood flow through the kidney, hemorrhage is a high risk.

The triage nurse is working in the emergency department. Which client should be assessed first? 1. The 10-year-old child whose dad thinks the child's leg is broken. 2. The 45-year-old male who is diaphoretic and clutching his chest. 3. The 58-year-old female complaining of a headache and seeing spots. 4. The 25-year-old male who cut his hand with a hunting knife.

2. The 45-year-old male who is diaphoretic and clutching his chest. The triage nurse should see this client first because these are symptoms of a myocardial infarction, which is potentially life threatening. The child needs an x-ray to confirm the fracture, but the client is stable and does not have a life-threatening problem. These are symptoms of a migraine headache and are not life threatening. A laceration on the hand is priority, but not over a client having a myocardial infarction.

The nurse suspects the client admitted with a near-drowning is developing acute respiratory distress syndrome (ARDS). Which data support the nurse's suspicion? 1. The client's arterial blood gases are within normal limits. 2. The client appears anxious, has dyspnea, and is tachypneic. 3. The client has intercostal retractions and is using accessory muscles. 4. The client's bilateral lung sounds have crackles and rhonchi.

2. The client appears anxious, has dyspnea, and is tachypneic. Initial clinical manifestations of ARDS usually develop 24 to 48 hours after the initial insult leading to hypoxia and include anxiety, dyspnea, and tachypnea. The client would have low arterial oxygen when developing ARDS. As ARDS progresses, the client has more difficulty breathing, resulting in intercostal retractions and use of accessory muscles. Lungs are initially clear; crackles and rhonchi develop in later stages of ARDS.

The nurse in a disaster is triaging the following clients. Which client should be triaged as an Expectant Category, Priority 4, and color black? 1. The client with a sucking chest wound who is alert. 2. The client with a head injury who is unresponsive. 3. The client with an abdominal wound and stable vital signs. 4. The client with a sprained ankle which may be fractured.

2. The client with a head injury who is unresponsive. This client has a very poor prognosis, and even with treatment, survival is unlikely. This client should be classified as an Immediate Category, Priority 1, and color red. If not treated STAT, a tension pneumothorax will occur. This client should be classified as a Delayed Category, Priority 2, and color yellow. This client receives treatment after the casualties requiring immediate treatment are treated. This client is a Minimal Category, Priority 3, and color green. This client can wait days for treatment.

The client comes to the clinic complaining of sudden onset of high fever, chills, and a headache. The nurse assesses a patchy macular rash on the trunk and a circular type of rash that looks like an insect bite. Which question would be most appropriate for the nurse to ask during the interview? 1. "Do you live in an area where animals roam the street?" 2. "Have you been working in your garden lately?" 3. "Have you been deer hunting in the last week?" 4. "Do you use sunscreen when you are outside?"

3. "Have you been deer hunting in the last week?" Deer ticks (Ixodes scapularis) are responsible for the spread of Lyme disease, which is what this client is experiencing based on the signs/symptoms.

The client has ingested a corrosive solution containing lye. Which intervention should the nurse implement? 1. Administer syrup of ipecac to induce vomiting. 2. Insert a nasogastric tube and connect to wall suction. 3. Assess for airway compromise. 4. Immediately administer water or milk.

3. Assess for airway compromise. Airway edema or obstruction can occur as a result of the burning action of corrosive substances. Vomiting is never induced in clients who have ingested corrosive alkaline substances or petroleum distillates. More damage can occur to the esophagus and pharynx. A gastric lavage may be done but not by inserting an NGT and attaching it to wall suction. Water or milk may be administered to dilute the substance if the airway is not compromised.

The ED nurse is completing the initial assessment on a client who becomes unresponsive. Which intervention should the nurse implement first? 1. Assess the rate and site of the intravenous fluid. 2. Administer an ampule of sodium bicarbonate. 3. Assess the cardiac rhythm shown on the monitor. 4. Prepare to cardiovert the client into sinus rhythm.

3. Assess the cardiac rhythm shown on the monitor. The rhythm on the monitor should be assessed. Many clients who become unresponsive have a lethal rhythm requiring defibrillation immediately.

Which federal agency is a resource for the nurse volunteering at the American Red Cross who is on a committee to prepare the community for any type of disaster? 1. The Joint Commission (JC). 2. Office of Emergency Management (OEM). 3. Department of Health and Human Services (DHHS). 4. Metro Medical Response Systems (MMRS).

3. Department of Health and Human Services (DHHS). Federal resources include organizations such as DHHS and the Department of Justice. Each of these federal departments oversees hundreds of agencies, including the American Red Cross, which respond to disasters. This organization mandates all health-care facilities to have an emergency operations plan, but it is a national agency, not a federal agency. Most cities and all states have an OEM, which coordinates the disaster relief efforts at the state and local levels. MMRS teams are local teams located in cities deemed to be possible terrorist targets.

The school nurse is caring for a child with a deep laceration. Which intervention should the nurse implement first? 1. Clean with saline solution. 2. Apply direct pressure. 3. Don nonsterile gloves. 4. Notify the child's parents.

3. Don nonsterile gloves. The nurse must follow Standard Precautions in the school nurse setting by donning nonsterile gloves prior to caring for the client.

The nurse in the emergency department administered an intramuscular antibiotic in the left gluteal muscle to the client with pneumonia who is being discharged home. Which intervention should the nurse implement? 1. Ask the client about drug allergies. 2. Obtain a sterile sputum specimen. 3. Have the client wait for 30 minutes. 4. Place a warm washcloth on the client's left hip

3. Have the client wait for 30 minutes. Anytime a nurse administers a medication for the first time, the client should be observed for a possible anaphylactic reaction, especially with antibiotics.

A nurse is at the lake when a person nearly drowns. The nurse determines the client is breathing spontaneously. Which data should the nurse assess next? 1. Possibility of drug use. 2. Spinal cord injury. 3. Level of confusion. 4. Amount of alcohol.

3. Level of confusion. The nurse should assess the victim for hypoxia. Signs and symptoms of hypoxia include confusion or irritability and alterations in level of consciousness, such as lethargy.

The elderly client is brought to the ED complaining of cramps, headache, and weakness after working outside in the sun. The telemetry shows sinus tachycardia. Which intervention should the nurse implement? 1. Determine if the client is experiencing any thirst. 2. Administer D5W intravenously at 250 mL/hr. 3. Maintain a cool environment to promote rest. 4. Withhold the client's oral intake.

3. Maintain a cool environment to promote rest. The nurse should encourage the client to rest and should maintain a cool environment to assist the client to recover from heat exhaustion. The elderly are more susceptible to this condition.

The nurse is caring for a client in the prodromal phase of radiation exposure. Which signs/symptoms should the nurse assess in the client? 1. Anemia, leukopenia, and thrombocytopenia. 2. Sudden fever, chills, and enlarged lymph nodes. 3. Nausea, vomiting, and diarrhea. 4. Flaccid paralysis, diplopia, and dysphagia.

3. Nausea, vomiting, and diarrhea. The prodromal phase (presenting symptoms) of radiation exposure occurs 48 to 72 hours after exposure and the signs/symptoms are nausea, vomiting, diarrhea, anorexia, and fatigue. Signs/symptoms of higher exposures of radiation include fever, respiratory distress, and excitability. Anemia, leukopenia, and thrombocytopenia, signs of bone marrow depression, are signs/symptoms the client experiences in the latent phase of radiation exposure, which occurs from 72 hours to years after exposure. The client is usually asymptomatic in the prodromal phase of radiation exposure. Sudden fever, chills, and enlarged lymph nodes are signs/symptoms of bubonic plague. These are signs/symptoms of inhalation botulism.

The nurse is teaching a class on bioterrorism and is discussing personal protective equipment (PPE). Which statement is the most important fact for the nurse to share with the participants? 1. Health-care facilities should keep masks at entry doors. 2. The respondent should be trained in the proper use of PPE. 3. No single combination of PPE protects against all hazards. 4. The EPA has divided PPE into four levels of protection.

3. No single combination of PPE protects against all hazards. The health-care providers are not guaranteed absolute protection, even with all the training and protective equipment. This is the most important information individuals wearing protective equipment should know because all other procedures should be followed at all times. Masks are kept at designated areas, not at every entry door. This is a true statement, but it is not the most important information; in an emergency situation, the respondent should use the equipment even if not trained. This is a true statement, but it is not the most important statement.

The ED nurse is caring for a client with fractured pelvis and bladder trauma secondary to a motor-vehicle accident. Which data are most important for the nurse to assess? 1. Monitor the creatinine and BUN. 2. Check urine output hourly. 3. Note the amount and color of the urine. 4. Assess for bladder distention.

3. Note the amount and color of the urine. The amount and color of urine assists with diagnosing the extent of injury. Color of the urine indicates the presence of blood. The amount indicates whether the urine is contained throughout the pathway from bladder to urinary meatus.

The ED nurse is caring for the client who has taken an overdose of cocaine. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Evaluate the airway and breathing. 2. Monitor the rate of intravenous fluids. 3. Place the cardiac monitor on the client. 4. Transfer the client to the intensive care unit.

3. Place the cardiac monitor on the client. The UAP can attach leads to the client for the cardiac monitor.

The client has been brought to the ED by ambulance following a motor-vehicle accident with a flail chest, an intravenous line, and a Heimlich valve. Which intervention should the nurse implement first? 1. Start a large-bore intravenous access. 2. Request a portable chest x-ray. 3. Prepare to insert chest tubes. 4. Assess the cardiac rhythm on the monitor.

3. Prepare to insert chest tubes. The client will require a chest tube because the Heimlich valve is only temporary; therefore, the nurse should prepare for this first.

The nurse is teaching the client home care instructions for a reimplanted finger after a traumatic amputation. Which information should the nurse include in the teaching? 1. Perform range-of-motion exercises weekly. 2. Smoking may be resumed if it does not cause nausea. 3. Protect the finger and be careful not to reinjure the finger. 4. An elevated temperature is the only reason to call the HCP.

3. Protect the finger and be careful not to reinjure the finger. The client should take extra care to protect the finger from injury. The peripheral nerves protecting the finger require months to regenerate.

The emergency department nurse writes the problem of "ineffective coping" for a client who has been raped. Which intervention should the nurse implement? 1. Encourage the client to take the "morning-after" pill. 2. Allow the client to admit guilt for causing the rape. 3. Provide a list of rape crisis counselors. 4. Discuss reporting the case to the police.

3. Provide a list of rape crisis counselors. The client should be provided the phone number of a rape crisis counseling center or counselor to help the client deal with the psychological feelings of being raped.

The triage nurse in a large trauma center has been notified of an explosion in a major chemical manufacturing plant. Which action should the nurse implement first when the clients arrive at the emergency department? 1. Triage the clients and send them to the appropriate areas. 2. Thoroughly wash the clients with soap and water and then rinse. 3. Remove the clients' clothing and have them shower. 4. Assume the clients have been decontaminated at the plant.

3. Remove the clients' clothing and have them shower. This is the first step. Depending on the type of exposure, this step alone can remove a large portion of exposure. In most situations this is the first step, but with a potential chemical or biological exposure, the first step must be the safety of the hospital; therefore, the client must be decontaminated. This is the second step in the decontamination process.. This assumption could cost many people in the hospital staff, as well as clients, their lives.

The ED nurse is caring for a client diagnosed with multiple rib fractures. Which data should the nurse include in the assessment? 1. Level of orientation to time and place. 2. Current use and last dose of medication. 3. Symmetrical movement of the chest. 4. Time of last meal the client ate.

3. Symmetrical movement of the chest. When a client suffers from multiple rib fractures, the client has an increased risk for flail chest. The nurse should assess the client for paradoxical chest wall movement and, if respiratory distress is present, for pallor and cyanosis.

Which expected outcome is priority for the nurse who is caring for a client with chest trauma from a gunshot injury? 1. The client will have an absence of pain. 2. The client will maintain a BP of 90/60. 3. The client will have symmetrical chest expansion. 4. The client will maintain urine output of 30 mL/hr.

3. The client will have symmetrical chest expansion. Symmetrical chest expansion indicates the client's lungs have not collapsed and air is being exchanged. This is the client's priority outcome.

The triage nurse has placed a disaster tag on the client. Which action warrants immediate intervention by the nurse? 1. The nurse documents the tag number in the disaster log. 2. The unlicensed assistive personnel documents vital signs on the tag. 3. The health-care provider removes the tag to examine the limb. 4. The LPN securely attaches the tag to the client's foot.

3. The health-care provider removes the tag to examine the limb. The tag should never be removed from the client until the disaster is over or the client is admitted and the tag becomes a part of the client's record. The HCP needs to be informed immediately of the action. This is the correct procedure when tagging a client and does not warrant intervention. Vital signs should be documented on the tag. The tag takes the place of the client's chart, so this does not warrant intervention. The tag can be attached to any part of the client's body.

A student reports to the school nurse with complaints of stinging and burning from a wasp sting. Which intervention should the nurse implement? 1. Grasp the stinger and pull it out. 2. Apply a warm, moist soak to the area. 3. Cleanse the site with alcohol. 4. Apply an ice pack to the site.

4. Apply an ice pack to the site. The nurse should apply an ice pack to the site. The cold will decrease the blood flow and sensation. The ice should be applied intermittently.

The nurse is teaching a class on biological warfare. Which information should the nurse include in the presentation? 1. Contaminated water is the only source of transmission of biological agents. 2. Vaccines are available and being prepared to counteract biological agents. 3. Biological weapons are less of a threat than chemical agents. 4. Biological weapons are easily obtained and result in significant mortality.

4. Biological weapons are easily obtained and result in significant mortality. Because of the variety of agents, the means of transmission, and lethality of the agents, biological weapons, including anthrax, smallpox, and plague, are especially dangerous. Sources of biological agents include inhalation, insects, animals, and people. The only known vaccine against a possible bioterrorism agent is the smallpox vaccine, which is not available in quantities sufficient to inoculate the public. Because of the vast range of agents, biological weapons are more of a threat. A biological agent could be released in one city and affect people in other cities thousands of miles away.

The client has had an anaphylactic reaction to insect venom, a bee sting. Which discharge instruction should the nurse discuss with the client? 1. Take a corticosteroid dose pack when stung by a bee. 2. Take antihistamines prior to outdoor activities. 3. Use a cromolyn sodium (Intal) inhaler prophylactically. 4. Carry a bee sting kit, especially when going outside.

4. Carry a bee sting kit, especially when going outside. The kit usually includes a prefilled syringe of epinephrine and an epinephrine nebulizer, which allows prompt self-treatment for any future exposures to insect venom or other potential allergen exposure.

The client comes to the clinic for treatment of a dog bite. Which intervention should the clinic nurse implement first? 1. Prepare the client for a series of rabies injections. 2. Notify the local animal control shelter. 3. Administer a tetanus toxoid in the deltoid. 4. Determine if the animal has had its vaccinations.

4. Determine if the animal has had its vaccinations. This is a priority because if the dog has had its vaccinations, the client will not have to undergo a series of very painful injections. The nurse must obtain information about the dog, which is assessment of the situation.

The female client presents to the emergency department with facial lacerations and contusions. The spouse will not leave the room during the assessment interview. Which intervention should be the nurse's first action? 1. Call the security guard to escort the spouse away. 2. Discuss the injuries while the spouse is in the room. 3. Tell the spouse the police will want to talk to him. 4. Escort the client to the bathroom for a urine specimen.

4. Escort the client to the bathroom for a urine specimen. By escorting the client to a bathroom for any reason, the nurse can get the client to a safe area out of the hearing of the spouse. This is the most innocuous way to get the client alone.

The off-duty nurse hears on the television of a bioterrorism act in the community. Which action should the nurse take first? 1. Immediately report to the hospital emergency department. 2. Call the American Red Cross to find out where to go. 3. Pack a bag and prepare to stay at the hospital. 4. Follow the nurse's hospital policy for responding.

4. Follow the nurse's hospital policy for responding. The nurse should follow the hospital's policy. Many times nurses will stay at home until decisions are made as to where the employees should report. Many hospital procedures mandate off-duty nurses should not report immediately so relief can be provided for initial responders. The nurse's first responsibility is to the facility of employment, not the community. This is a good action to take when the nurse is notified of the next action. For example, if the hospital is quarantined, the nurse may not report for days.

A gang war has resulted in 12 young males being brought to the emergency department. Which action by the nurse is priority when a gang member points a gun at a rival gang member in the trauma room? 1. Attempt to talk to the person who has the gun. 2. Explain to the person the police are coming. 3. Stand between the client and the man with the gun. 4. Get out of the line of fire and protect self.

4. Get out of the line of fire and protect self. Self-protection is priority; the nurse is not required to be injured in the line of duty. This puts the nurse in a dangerous position and might cause the death of the nurse. This will escalate the situation. This is a dangerous position for the nurse to put himself or herself in.

The nurse is providing first aid to a victim of a poisonous snake bite. Which intervention should be the nurse's first action? 1. Apply a tourniquet to the affected limb. 2. Cut an "X" across the bite and suck out the venom. 3. Administer a corticosteroid medication. 4. Have the client lie still and remove constrictive items.

4. Have the client lie still and remove constrictive items. The client should lie down, all restrictive items such as rings should be removed, the wound should be cleansed and covered with a sterile dressing, the affected body part should be immobilized, and the client should be kept warm. Although this is seen as a first action in old television westerns, it is not a recommended action for clients who have been bitten by a snake. This action will cause further damage to the tissue by restricting blood flow to the tissue. This is an action seen in classic television programs and movies from the 1950s and 1960s, but this is not the current treatment for snakebite. If this is done, the rescuer will suck the venom into the rescuer's mouth and possibly be poisoned. Corticosteroid medications are contraindicated in the first six (6) to eight (8) hours after the bite because they might interfere with antibody production and hinder the action of the antivenin.

According to the North Atlantic Treaty Organization (NATO) triage system, which situation is considered a level red (Priority 1)? 1. Injuries are extensive and chances of survival are unlikely. 2. Injuries are minor and treatment can be delayed hours to days. 3. Injuries are significant but can wait hours without threat to life or limb. 4. Injuries are life threatening but survivable with minimal interventions.

4. Injuries are life threatening but survivable with minimal interventions. This is called the Immediate Category. Individuals in this group can progress rapidly to Expectant if treatment is delayed. This describes injuries color-coded black or Priority 4 and is called the Expectant Category. This is a description of injuries color-coded green or Priority 3 and is called the Minimal Category. These are injuries color-coded yellow or Priority 2 and is called the Delayed Category.

The nurse is teaching a class on bioterrorism. Which statement is the scientific rationale for designating a specific area for decontamination? 1. Showers and privacy can be provided to the client in this area. 2. This area isolates the clients who have been exposed to the agent. 3. It provides a centralized area for stocking the needed supplies. 4. It prevents secondary contamination to the health-care providers.

4. It prevents secondary contamination to the health-care providers. 1. This is not a rationale; this is a statement of what is done at the area. 2. This separates the clients until decontamination occurs, but the question is asking for the scientific rationale. 3. This is false statement—the supplies should not be kept in the decontamination area. 4. Avoiding cross-contamination is a priority for personnel and equipment—the fewer the number of people exposed, the safer the community and area.

The ED nurse is caring for a client who suffered a near-drowning. Which expected outcome should the nurse include in the plan of care for this client? 1. Maintain the client's cardiac function. 2. Promote a continued decrease in lung surfactant. 3. Warm rapidly to minimize the effects of hypothermia. 4. Keep the oxygen saturation level above 93%.

4. Keep the oxygen saturation level above 93%. The oxygen level needs to be maintained greater than 93%. The client needs as much support as necessary for this. Mechanical ventilation with peak end-expiratory pressure (PEEP) and high oxygen levels may be needed to achieve this goal. An expected outcome is a desired occurrence, not a common event. Tachycardia is a common manifestation of a near-drowning event, but it is not desired. A combination of physiological changes, hypothermia, and hypoxia put the client at risk for life-threatening cardiac rhythms. Any near-drowning causes a decrease in alveolar surfactant, which results in alveolar collapse. A decrease in surfactant is not the desired outcome. The client needs to be rewarmed slowly to reduce the influx of metabolites. These metabolites, including lactic acid, remain in the extremities.

The nurse is providing discharge teaching for the client with intermaxillary wiring to repair a fractured mandible. Which statement by the client indicates teaching has been effective? 1. Iced alcoholic drinks may be consumed by using a straw. 2. Only one (1) food item should be consumed at one (1) time. 3. Carbonated sodas should be limited to two (2) daily. 4. Teeth can be brushed after tenderness and edema subside.

4. Teeth can be brushed after tenderness and edema subside. Hygiene is helpful in healing. The mouth should be rinsed and an irrigation device should be used frequently. Gentle brushing and rinsing the mouth after each meal and at bedtime can begin after edema and tenderness subside.

The parents bring their toddler to the ED in a panic. The parents state the child had been playing in the kitchen and got into some cleaning agents and swallowed an unknown quantity of the agents. Which health-care agency should the nurse contact at this time? 1. Child Protective Services (CPS). 2. The local police department. 3. The Department of Health. 4. The Poison Control Center.

4. The Poison Control Center. The Poison Control Center can assist the nurse in identifying which chemical has been ingested by the child and the antidote. CPS should be contacted only if the nurse suspects an intentional administration of the poison, but at this time determining which poison the child has swallowed and the antidote is the priority. The local police department is only notified if the nurse suspects child abuse. The Department of Health does not need to be notified.

The ED nurse is caring for a male client admitted with carbon monoxide poisoning. Which intervention requires the nurse to notify the rapid response team? 1. The client has expectorated black sputum. 2. The client reports trying to kill himself. 3. The client's pulse oximeter reading is 94%. 4. The client has stridor and reports dizziness.

4. The client has stridor and reports dizziness. Stridor or dizziness indicates an occlusion of the airway, which is a medical emergency. The RRT is called when the client is experiencing a decline but is still breathing.

Which statement best describes the role of the medical-surgical nurse during a disaster? 1. The nurse may be assigned to ride in the ambulance. 2. The nurse may be assigned as a first assistant in the operating room. 3. The nurse may be assigned to crowd control. 4. The nurse may be assigned to the emergency department.

4. The nurse may be assigned to the emergency department. New settings and atypical roles for nurses may be required during disasters; medical-surgical nurses can provide first aid and may be required to work in unfamiliar settings. The nurse should not leave the hospital area; the nurse must wait for the casualties to come to the facility. This is a position requiring knowledge of instruments and procedures not common to the medical-surgical floor. The people in this area are usually chaplains or social workers, not direct client care personnel. In a disaster, direct care personnel cannot be spared for this duty.

The ED nurse is caring for a female client with a greenstick fracture of the left forearm and multiple contusions on the face, arms, trunk, and legs. The significant other is in the treatment area with the client. Which nursing interventions should the nurse implement? List in order of priority. 1. Determine if the client has a plan for safety. 2. Assess the pulse, temperature, and capillary refill of the left wrist and hand. 3. Ask the client if she feels safe in her own home. 4. Request the significant other wait in the waiting room during the examination. 5. Notify the social worker to consult on the case.

In order of priority: 4, 2, 3, 1, 5. 4. This is done first before any action is taken to decrease suspicions on the part of the significant other. The nurse needs to ask the client questions regarding the injuries and may not get truthful answers with the significant other in the room. 2. The nurse should assess the actual physical problems before assessing the potential abuse situation. 3. This is one of the first questions the nurse should ask to determine if abuse is occurring. 1. The nurse should determine if the client has a plan to escape the violence. The nurse should provide the client with hotline numbers for safe houses. 5. The nurse should refer the client to the social worker for further evaluation and referral needs.