practice ?s Exam 1

Which classification of emergency department triage will the nurse document when the patient presents with a skin rash? Urgent Emergent Nonurgent Priority

C Rationale Nonurgent conditions can wait several hours if needed, for example, a skin rash. Urgent conditions must be treated quickly, but they are not life-threatening. Emergent conditions are life-threatening and must be given priority. "Priority" is not a triage category. p. 196

How many hours after death can a dead or decapitated snake inflict venom? 1 hours 2 hours 3 hours 4 hours

A Rationale A dead or decapitated snake can inflict a bite for up to 1 hour after death. This is a result of the persistence of the bite reflex. After 1 hour the snake can no longer inflict a bite. p. 210

Which statement regarding the critical elements of a trauma system indicates a need for further teaching by the nurse? "A trauma center has no provisions for rehabilitation services." "There is access to care through communication technology." "Timely availability of prehospital emergency medical care is evident." "Efficient care is provided as rapid transport to the next qualified level of trauma center is ensured

A Rationale A good trauma center offers early provisions for rehabilitation services. The remaining statements indicate understanding. Trauma centers provide access to care through communication technology: for example, an enhanced 911 service. A trauma center also offers timely availability of prehospital emergency medical care and ensures rapid transport to the next qualified level of trauma center. p. 200

Which nursing action may cause an "after-drop" in a patient with moderate hypothermia? Applying a heating blanket Administering drugs at short intervals Having the patient consume warm coffee Having the patient drink warm, high-carbohydrate liquids

A Rationale An after-drop occurs when the core body temperature continues to drop even after the patient is shifted away from the cold environment. It is caused by the return of cold blood from the periphery to the central circulation. Heating blankets can promote core temperature after-drop by producing peripheral vasodilation. Warm, high-carbohydrate liquids help rewarm the patient with mild hypothermia; they do not cause an afterdrop. Metabolism is unpredictable in hypothermic conditions; therefore drugs are administered at longer intervals when treating patients with moderate or severe hypothermia. Caffeine is a diuretic and can worsen dehydration. p. 217

Which finding is associated with a scorpion sting? Hyperactivity Pulmonary edema Increased salivation Increased blood pressure

A Rationale Hyperactivity is typically associated with scorpion stings. Pulmonary edema is a common clinical sign with pit viper bites and brown recluse spider bites. Increased salivation and increased blood pressure are observed with black widow spider bites but are uncommon in patients stung by scorpions. p. 213

Which statement regarding disaster triage categories is accurate? Class I patients are given red tags. Class II patients are given black tags. Class III patients need immediate attention for a life-threatening injury. Class IV patients are referred to as the walking wounded.

A Rationale Class I patients are emergent patients and are given red tags, indicating that they need immediate treatment. Class II patients can wait a short time for care because they do not have life-threatening complications and so should be given a yellow tag, not a black tag. Class III patients are referred as the walking wounded because they are able to walk and do not need immediate treatment. Class IV patients are expected to die and are given a black tag. p 228

Which characteristic would the nurse expect to see in fourth-degree frostbite? The affected part is numb, cold, and bloodless. There is increased blood flow to the affected area. Large, fluid-filled blisters develop in the affected area. There is full-thickness and subcutaneous tissue necrosis

A Rationale Fourth-degree frostbite is the most severe form of frostbite in which the affected area is numb, cold, and bloodless, and the full-thickness necrosis extends into the muscle and bone. Amputation may be required if gangrene develops. First-degree frostbite involves increased blood flow in the affected area and edema formation. Large, fluid-filled blisters with partial-thickness necrosis develop in the affected area of seconddegree frostbite. In third-degree frostbite, full-thickness and subcutaneous necrosis appears as well as small blisters that contain dark fluid. The affected part is cool and numb, blue or red, and does not blanch. p. 217

Which rewarming method is used to treat severe hypothermia? Performing hemodialysis Incorporating convective air heaters Administrating warm IV fluids Administrating heated oxygen via the respiratory tract

A Rationale Hemodialysis is an extracorporeal rewarming method. It is the treatment of choice for severe hypothermia. Administration of warm IV fluids is a core rewarming method used to treat moderate hypothermia. Incorporation of convective air heaters helps in speed rewarming and is used to treat mild hypothermia. Administration of heated oxygen via the respiratory tract is used in the treatment of moderate hypothermia. p 217

Which responsibility would the general nurse be assigned to assist the emergency department (ED) nurse during a disaster? Provide care for stable patients in the emergency department. Assist the nurse in resuscitating and transporting critical patients. Identify patients who can be transferred out of the critical care unit. Direct ancillary departments to deliver supplies to meet service demands.

A Rationale In a disaster, the general nurse is designated to provide care for stable patients in the emergency department. This helps the ED nurses focus their efforts on aiding mass casualty victims. The critical care nurse identifies patients who can be transferred out of the critical care unit and assists the nurse in resuscitating and transporting critical patients. They may also direct ancillary departments to deliver supplies to meet service demands. p. 231

At which core body temperature would the nurse stop performing cooling interventions for a patient with heat stroke? 102°F (38.9°C) 101°F (38.3°C) 100°F (37.8°C) 99°F (37.2°C)

A Rationale Interventions to cool a patient with heat stroke continue until the core body temperature is 102°F (38.9°C). Core temperature is continuously monitored using a rectal or esophageal probe or a temperature-monitoring urinary catheter to prevent hypothermia. If aggressive cooling interventions continue beyond 102°F (38.9°C), hypothermia may set in. p. 208

Which belief will affect care of a Jehovah's Witness patient in the emergency department? Refusal of blood transfusions Tendency to be very family-oriented Dislike of their bodies being exposed Inability to converse in a language spoken by the staff

A Rationale Jehovah's Witness patients do not accept blood transfusions; this belief can affect delivery of care. Some Mexican-Americans tend to be very family-oriented; however, this may not be a barrier for health care. If a patient cannot converse in a language spoken by the staff, dedicated interpreters can help communicate with the patient either through telephone or in person. Patients from the Middle East and some Mexican-American patients may be modest and not like their bodies to be exposed; the nurse should take adequate care to maintain the privacy of these patients. p. 195

Which envenomation grade would the nurse assign when a patient presents with fang marks from a rattlesnake but no local or systemic reaction? None Minimal Moderate Severe

A Rationale None is the envenomation grade based on the presenting characteristics of fang marks without local or systemic reactions. A minimal envenomation grade is assigned when there are fang marks as well as local swelling and pain but no systemic reactions. A moderate envenomation grade is assigned when the swelling is progressing beyond the site of the bite and systemic symptoms occur, such as nausea, vomiting, or hypotension. A severe envenomation grade is assigned when an extremity is swollen, there are severe symptoms, and subcutaneous ecchymosis is present. p. 210

Which clinical manifestation is indicative of compartment syndrome after frostbite? Painful tingling Dark coloration Decreased edema Pain relieved by analgesics

A Rationale Paresthesia, or painful tingling and numbness, is a sign of compartment syndrome, which is a severe, limbthreatening complication caused by severe neurovascular impairment. Increased edema and pain that is not relieved by analgesics are other manifestations of the syndrome. When the affected extremity is compared with the unaffected one, pallor is observed if compartment syndrome has set in. p. 218

Which level of trauma center can provide appropriate medical intervention and support for a patient who sustained critical injuries in a multiple vehicle collision and needs advanced surgical care? I II III IV

A Rationale Patients who require advanced surgical care are treated at a Level I trauma center. A Level II trauma center provides care to the vast majority of injured patients but is not able to manage complex injuries. Level III trauma centers provide stabilization of initial injuries and then transfer the patient if the patient needs advanced medical care. A Level IV trauma center provides advanced medical care in rural or remote areas where Level I trauma center facilities are not available. They provide basic and advanced life support and then transfer the patient to a higher-level trauma center if necessary. pp. 199-200

For which duty would the chief in a Hospital Incident Command System (HICS) be responsible during a disaster? Select all that apply. One, some, or all responses may be correct. Control finances. Manage logistics. Oversee safety and security. Command public information. Delegate duties to unit leaders.

A, B, E Rationale The duties of the chief of the HICS include controlling finances, managing logistics, and delegating duties to unit leaders as appropriate to the type and scale of the event. A HICS officer oversees essential emergency preparedness functions such as safety and security, public information, and medical command. p. 230

A nurse is performing a mental health assessment for survivors of a terrorist attack. Which finding in the group indicates the risk for posttraumatic stress disorder (PTSD)? Experiencing flashbacks Assisting others to overcome their grief Managing to sleep for 4 to 5 hours each night Reporting feeling numb 2 to 4 days after the incident

A Rationale People who experience flashbacks of the disaster are at a high risk for PTSD. People who report feeling numb for 2 weeks or more after the incident are also at risk for PTSD. People assisting others to overcome their grief can find an outlet for their own unexpressed emotions. People who are unable to sleep are likely to have PTSD. ability to retain information, such as using index cards with essential data, which are easy to carry and review whenever you have a spare moment. p 233

Which clinical sign demonstrates the neurotoxic effects of a coral snakebite? Ptosis Muscle rigidity Hypertension Nausea

A Rationale Ptosis is seen after a coral snakebite. Hypotension is associated with a coral snakebite. Muscle rigidity and nausea are associated with a black widow spider bite, but these are not seen with a coral snakebite. p. 212

When assessing a patient who presents to the emergency department after sustaining a scorpion sting to the left foot, the nurse understands that which finding indicates a need to notify the Rapid Response Team? Seizure activity Dry mouth with thirst Diminished lung sounds Wheal-and-flare reaction

A Rationale Scorpion stings can cause severe systemic symptoms that can affect the nervous system. The nurse should notify the Rapid Response Team if the patient develops seizure activity. Other signs of systemic complications would be excessive drooling, not a dry mouth, as well as pulmonary edema, not diminished breath sounds. A wheal-and-flare reaction is present with bee and wasp stings. p 214

Which acronym represents the facility-level organizational model for disaster management? HICS NIMS FEMA DMAT

A Rationale The Hospital Incident Command System (HICS) is the disaster management organization at the facility level. The National Incident Management System (NIMS) and the Federal Emergency Management Agency (FEMA) are national organizations. A Disaster Medical Assisting Team (DMAT) is either federal or state run. p. 230

Which role of the International Medical Surgical Response Teams (IMSURTs) is accurate? Establish fully functional field surgical facilities. Set up acute care centers for people affected by a disaster. Establish first aid stations or special-needs shelters. Provide surgical staff for health care facilities and hospitals.

A Rationale The IMSURTs establish fully functional field surgical facilities wherever they are needed in the world. The Medical Reserve Corps (MRC) establishes first aid stations or special-needs shelters in disaster areas. They also set up acute care centers in the community for days to weeks to alleviate emergency department and hospital overcrowding. Disaster Medical Assistance Teams (DMATs) provide staff to assist health care facilities that have become overwhelmed with casualties. p. 230

Within 48 hours after arriving at a high altitude mountain resort, a hiker develops poor activity tolerance, tachycardia, tachypnea, and a dry cough. Which treatment would provide the most effective relief? Lower altitude Warm blankets Dexamethasone Acetazolamide sodium

A Rationale The most effective intervention to manage serious altitude-related illness is descent to a lower altitude. The patient should be kept warm, but that will not eliminate the manifestations. Acetazolamide sodium should be taken before and during the trip for prevention, but it will not help after symptoms of altitude-related illness have begun. Dexamethasone can be administered during descent to help with symptoms, but it is not the most effective treatment at this time. pp. 219-220

When the nurse is assessing a patient who sustained several hornet stings and denies any allergies, which localized effect would the nurse expect to identify? Select all that apply. tching Dyspnea Vomiting Hypotension Double vision

A Rationale The nurse should expect the patient to report itching where the hornets have stung the patient. Systemic manifestations would include dyspnea, vomiting, and hypotension if the patient has an anaphylactic reaction. Coral snakebites would cause diplopia or double vision. p. 214

After a bomb blast, injured patients were brought to the emergency department. Which health care team member will be responsible to assign order of priority to patients for providing care? Triage officer Public information officer Medical command physician Hospital incident commander

A Rationale The triage officer rapidly evaluates the patients and determines priority for treatment; this is the first step in emergency care of these patients. The public information officer serves as a liaison between the health care facility and the media; the triage officer does not treat patients. The medical command physician decides the number, acuity, and resource needs of the patients. The hospital incident commander assumes overall leadership for implementing the emergency plan at a higher level than treating these patients directly. pp. 230-231

Which intervention may lead to complications in a patient who is suspected of having heat exhaustion? Giving salt tablets Spraying water on skin Removing constrictive clothes Giving oral rehydrating solutions

A Rationale Salt tablets should be avoided in a patient who is suspected of having heat exhaustion because they cause stomach irritation, vomiting, and nausea. Spraying water on the skin may relieve heat exhaustion. Making the patient feel comfortable by removing constrictive clothing will reduce heat exhaustion. Giving oral rehydrating solutions will reduce heat exhaustion. p. 208

For which duty is the triage nurse responsible during a mass casualty event? Select all that apply. One, some, or all responses may be correct Quickly assessing each patient Determining the highest-priority patients Deciding the number, acuity, and resource needs of patients Serving as a liaison between the health care facility and the media Assuming overall leadership for implementing the emergency plan

A, B Rationale The role of the triage nurse is to assess each patient to determine treatment priorities. The role of the medical command physician is to decide the number, acuity, and resource needs of patients. The public information officer serves as a liaison between the health care facility and the media. The role of hospital incident commander is to assume the overall leadership for implementing the emergency plan. pp. 230-231

For which role would the Disaster Medical Assistance Team (DMAT) be responsible when deployed to a disaster area? Select all that apply. One, some, or all responses may be correct. Triage to evacuation. Provide primary health care. Establish special-needs shelters. Provide staff to assist health care facilities. Sustain operations in the area for 48 hours.

A, B, C Rationale A DMAT is a part of the National Disaster Medical System (NDMS). They provide relief services ranging from primary health care and triage to evacuation for the victims in the affected area. They also provide staff to assist health care facilities that have become overwhelmed with casualties. The Medical Reserve Corps (MRC) establishes special-needs shelters when deployed to disaster areas. DMATs usually have enough medical equipment and supplies to sustain operations for 72 hours. p. 230

Which symptom is typical of heat exhaustion? Select all that apply. One, some, or all responses may be correct. Headache Weakness Hallucinations Nausea and vomiting Body temperature greater than 104°F (40°C)

A, B, D Rationale A patient with heat exhaustion has flulike symptoms such as headache, nausea and vomiting, and weakness. Dehydration is the primary cause of heat exhaustion. Symptoms exhibited by a patient with heat stroke include a body temperature greater than 104°F (40°C) and hallucinations. p. 207

Which requirement would be expected of the staff members of an emergency department during a mass casualty situation? Select all that apply. One, some, or all responses may be correct The staff members should be flexible. The staff members should be creative. The staff members should not alter their routine tasks. The staff members should prevent family from visiting to limit chaos. The staff members should know whom to call during an emergency.

A, B, E Rationale The staff members of an emergency department should be flexible and creative to provide the staffing coverage necessary for a large-scale or extended incident. The staff members should also know whom to call during emergency conditions. During a disaster, family members are permitted to visit to obtain information about their family members' status or condition. During a mass casualty event, staff members should not necessarily stick to their routine tasks but should perform tasks according to the emergency conditions. p. 232

Which health care professional will the nurse refer a victim of domestic violence to for counselling and follow-up? Psychiatric crisis nurse Forensic nurse examiner Prehospital care provider Emergency medicine physician

B Forensic nurse examiner

Which statement made by an emergency medical technician regarding mobile army surgical hospital (MASH) units indicates a need for further training by the nurse? "They included skilled health care personnel." "They were deployed after the Korean and Vietnam Wars." "They became the original model for the development of civilian trauma centers." "They provided treatment to injured soldiers who were transported from the battlefield."

B Rationale MASH units were first deployed during, not after, the Korean and Vietnam Wars. The remaining statements are correct. Skilled health care personnel staffed MASH units. MASH units became the original model for the development of civilian trauma centers. Injured soldiers transported from the battlefield were able to receive treatment in MASH units. p. 199

Which nursing action will increase the effectiveness of discharge instructions? Provide large print materials for all patients. Assess the patient's visual acuity and reading level. Ensure that instructions are no higher than a 10th-grade reading level. Offer instructions in English for patients who speak English as a second language.

B Rationale When providing discharge instructions, the nurse should assess the patient's visual acuity and reading level to determine the print size suitable for the patient, then ensure that discharge instructions are customized to address the patient's needs. Instructions must be provided at no higher than a sixth-grade reading level. Educational materials are preferably provided in the patient's primary language; interpreters may be necessary to customize the information correctly if the material is not available in the patient's primary language. Large print materials are provided for older patients and patients with visual deficits. p. 198

Which component of the primary survey provides a rapid baseline assessment of neurologic status? Exposure Disability Breathing Circulation

B Rationale Disability examination during a primary survey provides a rapid baseline assessment of neurologic status. The last component of the primary survey is exposure. Breathing determines the respiratory rate, movements of the thoracic wall, and any evidence of chest wall trauma or physical abnormalities. In the primary survey, circulation becomes the priority after airway and breathing have been managed. pg 203

Which type of injury results in a penetrating trauma? High-speed crashes Metal or glass fragments Blast effects of an exploding bomb Assault with kicks and punches

B Rationale A penetrating trauma is caused by injury from sharp objects and projectiles. Wounds from fragments of metal or glass, ice picks, or knives are examples of penetrating trauma. Such wounds can have life-threatening consequences. Blunt trauma is caused by injuries from high-speed crashes, the blast effect of an exploding bomb, or an assault with kicks and punches. p. 201

Which action would a nurse take if designated as the triage officer in the hospital? Leads implementation of emergency plan. Evaluates each patient to determine priorities for treatment. Decides the number, acuity, and resource needs of patients. Serves as a liaison between the health care facility and media.

B Rationale An experienced nurse designated as a triage officer in the hospital evaluates each patient to determine priorities for treatment. The hospital incident commander assumes overall leadership for implementing the emergency plan. The medical command physician decides the number, acuity, and the resource needs of the patients. The community relations or public information officer serves as a liaison between the health care facility and media. pp. 230-231

Which situation is the cause of classic heat stroke? Heavy perspiration when exposed to heat Chronic exposure to a hot, humid environment Strenuous physical activity in hot, humid conditions Inadequate fluid and electrolyte intake during heat exposure

B Rationale Classic, or nonexertional, heat stroke occurs over a period of time after chronic exposure to a hot, humid environment. A home without air conditioning in the summer heat can cause classic heat stroke in older adults. Strenuous physical activity in hot, humid conditions causes exertional heat stroke. Inadequate fluid and electrolyte intake and heavy perspiration causes dehydration and depletion of essential salts in the body, which can cause heat exhaustion during heat exposure. p. 208

During a mass casualty, which information would the nurse use on the identification band of a patient brought to the triage area of the hospital? Date of birth Disaster number Name of the patient Social Security number

B Rationale In disaster situations, the patient receives a special bracelet with a disaster number. Preprinted labels with this number can be applied to patients' chart forms and personal belongings. Digital photos are also used as identifiers in some systems. The standard hospital registration process and identification band with date of birth, name, and Social Security number can be applied after the patient's identity is established. p. 229

Which passive external rewarming method is used to treat mild hypothermia? Warm pack Warm clothing Heating blanket Connective air heater

B Rationale Providing the hypothermic patient with warm clothing is a passive, external rewarming method. This allows the body temperature to slowly rise. Heating blankets, warm packs, and connective air heaters are active external rewarming methods, which raise the body temperature quickly. p. 216

Which nursing action is classified in the exposure aspect of the primary survey? Maintaining a vascular access using a large-bore catheter Removing all clothing for a complete physical assessment Preparing to assist with manual ventilation if necessary Re-evaluating the patient's level of consciousness (LOC) often

B Rationale Removing all clothes for a complete physical assessment during an injury is an intervention used in exposure. Re-evaluating the patient's LOC frequently is an intervention in disability. Maintaining vascular access using a large-bore catheter is an example of a circulation intervention. Preparing to assist with manual ventilation when required is an example of a breathing intervention. pp. 202-203

Which information would the nurse use in planning care for a patient with a scorpion sting? The sting site is always reddened. The sting has a neurotoxic effect. Tapping the site of the sting decreases pain. Symptoms from the sting can arise after 24 hours.

B Rationale Scorpion stings have neurotoxic effects. Tapping on the site of the sting increases, not decreases, pain. The sting site may not always be reddened. Symptoms from the sting occur immediately and peak within 12 hours, not 24. p. 213

Which degree of frostbite presents as large, clear-to-milky, fluid-filled blisters with partial thickness skin necrosis? First Second Third Fourth

B Rationale Second-degree frostbite presents with large, clear-to-milky, fluid-filled blisters with partial-thickness skin necrosis. First-degree frostbite is the least severe and involves hyperemia and edema of the involved area. Third-degree frostbite appears as small blisters that contain dark fluid and an affected body part that is cool, numb, and blue or red and does not blanch. Fourth-degree frostbite is the most severe form in which there are no blisters or edema, and the affected body part is numb, cold, and bloodless. p. 217

Which clinical sign is consistent with a bite from a pit viper? Ptosis Seizure Hypertension Tissue necrosis

B Rationale Seizures are one of the clinical manifestations of a pit viper bite. Ptosis is the manifestation of a black widow spider bite. Hypertension is seen in black widow spider bites and scorpion stings. Tissue necrosis is a result of a brown recluse spider bite. p. 212

Which organization published the Life Safety Code? The Joint Commission (TJC) National Fire Protection Association The American Association of Critical Care Occupational Safety and Health Administration (OSHA)

B Rationale The National Fire Protection Association published the Life Safety Code, which provides guidelines for building construction, design, maintenance, and evacuation. TJC published ways for health care facilities to create a welcoming and safe environment for lesbian, gay, bisexual, transgender, and questioning (LGBTQ) patients. The American Association of Critical Care published an approval for nurses to use chlorhexidine gluconate (CHG) solution to bathe patients in critical care settings to avoid multidrug-resistant organisms. OSHA published Occupational Exposure to Bloodborne Pathogens, Final Rule for nurses and health care providers. p. 225

Which arthropod has a stinger that becomes lodged after entering the skin? Wasp Hornet Honeybee Bumblebee

C Rationale The honeybee stings just once, leaving the stinger in the victim. When the honeybee stings a person, the stinger and the venom sac pull away from the bee, and the bee dies. Bumblebees, wasps, and hornets are capable of stinging repeatedly when disturbed; they have a smooth stinger that typically does not become lodged in the victim. p. 213

Which organization stockpiles critical equipment and supplies in case they are needed for a pandemic influenza outbreak? American Red Cross The U.S. government Medical Reserve Corps (MRC) The Federal Emergency Management Agency (FEMA)

B Rationale The U.S. government stockpiles critical equipment and supplies in case they are needed for a pandemic influenza outbreak. The MRC and the American Red Cross assist the community when catastrophic events such as earthquakes and tornadoes occur. FEMA sets standards to manage disaster operations. p. 228

Which information would the nurse provide a group of scouts regarding actions to take for pit viper snakebites when camping? Select all that apply. One, some, or all responses may be correct. Administer oxygen. Take photos of the snake. Apply a tourniquet tightly. Suck venom from wounds. Keep the extremity above the heart.

B Rationale The nurse should instruct the scouts to attempt to safely take a photo of the snake if they are able as this can help the health care provider decide appropriate treatment. Coral snakebites could cause respiratory paralysis, so this patient may require oxygen. The nurse should instruct the scouts to not apply a tourniquet or suck the venom from the wound. The nurse should instruct the scouts to keep the extremity at the level of the heart. pp. 210, 213

Which team member of the emergency department plays a leadership role in emergency situations after usual business hours until hospital leadership personnel arrive? Triage officer Nursing supervisor Public information officer Medical command physician

B Rationale The nursing supervisor helps fill in for the hospital incident commander in the emergency department if the hospital incident commander is not there during a crisis. The role of the triage officer is to evaluate each patient to determine priorities for treatment. The role of the public information officer is to serve as a liaison between the health care facility and the media. The role of medical command physician is to decide the number, acuity, and resource needs of patients. p. 230

The presence of a large number of media personnel is interfering with care to the victims of a mass casualty event. Whose responsibility is it to actively resolve this issue? Triage nurse Public information officer Trauma program manager Medical command physician

B Rationale The public information officer is the staff member tasked with drawing media away from the clinical areas so that essential hospital operations are not affected. The public information officer serves as the liaison between hospital administration and the media. The triage nurse assists the triage officer in determining priorities for the treatment of patients. The trauma program manager acts in collaboration with the medical command physician and triage officer to organize nursing and ancillary services to meet patient needs. The medical command physician decides the number, acuity, and resource needs of patients. p. 230

Which member of the health care team is identified as the gatekeeper in the emergency care system? Physician Triage nurse Nurse practitioner (NP) Physician assistant (PA)

B Rationale The triage nurse is a registered nurse (RN) and is said to be the gatekeeper in the emergency care system because the triage nurse is normally assigned to perform the triage function in the emergency department. The triage nurse ensures that patients with the highest-acuity needs are prioritized. The triage nurse may seek the input of an emergency physician, NP, or PA to help establish the acuity level if the patient's presentation is highly unusual. p. 196

After a mass casualty event, the hospital administration seeks help from the crisis support team to provide sessions for small groups of staff. How will this debriefing provide psychosocial assistance to hospital workers? Reviews the system performance Promotes effective coping strategies Determines opportunities for improvement Improves the emergency management plan

B Rationale Two types of debriefing occur after a mass casualty incident or disaster. The crisis support team provides sessions for small groups to promote effective coping strategies, which reflects psychosocial assistance. The second type of debriefing involves reviewing staff and system performance, determining opportunities for improvement, and improving the emergency management plan, but the crisis support team does not handle this type of debriefing. p. 233

Which information is used on identification tags to identify a patient brought in from a disaster site? Name Digital photo Date of birth Social Security number

B Rationale When patients are brought to the triage area of the emergency department from a disaster area, digital photos may be used to identify them. A bracelet with a disaster number is also used to identify the patient. Printed labels of this number are applied to the patient's chart forms and belongings. Standard hospital registration procedure and identification bands with date of birth, name, or Social Security number can be applied after each patient's identity is established. p. 229

Which attribute is true of a Level I trauma center? Select all that apply. One, some, or all responses may be correct. Location in rural and remote areas Requirement to conduct medical research Remain in contact with preferred medical centers Provision of a full continuum of trauma services for all patients Transfer to higher-level trauma centers arranged as needed

B, D Rationale A Level I trauma center is required to do research and provides a full continuum of trauma services for all patients. Level III, not Level I, trauma centers are usually located in rural and remote areas and arrange transport to higher-level trauma centers as necessary. Level II and III trauma centers remain in contact with preferred medical centers; Level I trauma centers do not. Pg 200

Which type of injury would the nurse document when caring for a patient with a gunshot wound to the abdomen? Blast effect Blunt trauma Penetrating trauma Acceleration-deceleration forces

C Rationale A gunshot wound is considered a penetrating trauma, caused by injury from sharp objects or projectiles. An explosion causes a blast effect. Blunt trauma is caused by a motor vehicle accident. Acceleration-deceleration forces can occur when a person falls from a great height. p. 201

Which assessment finding is associated with severe hypothermia? Diuresis Dysarthria Bradycardia Muscle weakness

C Rationale Bradycardia is a clinical sign of severe hypothermia. Diuresis and dysarthria are clinical signs related to mild hypothermia. Muscle weakness is associated with moderate hypothermia. p. 216

Which statement is true regarding Level I trauma centers treating seriously injured victims of interpersonal violence? Care is performed in community hospitals. Level I trauma centers are located in rural and remote areas. These facilities often conduct research. Patients are transported to Level II and III facilities if needs exceed resource capabilities.

C Rationale Level I trauma centers are often located in research facilities. Levels II and III trauma centers are located in community hospitals. Level IV trauma centers are located in rural or remote areas. Levels II, III, and IV trauma centers transport patients to Level I centers if needs exceed their resource capabilities. p. 200

How does a hospital in the United States test its disaster preparedness according to mandates set by The Joint Commission in 2020? It conducts emergency drills at least three times per year. It involves actual or simulated patients in all emergency drills. It involves community-wide resources in at least two drills per year. It participates in the management of a real disaster three times per year.

C Rationale Per The Joint Commission (2020), the disaster preparedness of a hospital is tested on the basis of emergency drills. The hospital must involve community-wide resources in at least two drills per year. The hospital must include actual or simulated patients in at least one drill to assess the ability of collaborative efforts and command structures. Hospitals are expected to conduct emergency drills or participate in managing a real event at least twice a year. p. 224

Which clinical manifestation is an indication of high altitude pulmonary edema (HAPE)? Exertional dyspnea Throbbing headache Persistent dry cough Defective muscular coordination

C Rationale Persistent dry cough is an important finding in a patient with HAPE. Other findings include cyanosis of the lips and nail beds. Exertional dyspnea is expected as a person adjusts to high altitude. Dyspnea at rest is abnormal and may signal the onset of HAPE. A typical finding in the patient with acute mountain sickness (AMS) is throbbing headache. Ataxia or defective muscular coordination is observed in the patient with high altitude cerebral edema (HACE). HAPE often occurs in conjunction with HACE but may occur during the progression of AMS. p. 219

Which is the best team member to care for a patient admitted to the emergency department after reporting being raped? Police officer Psychiatric crisis nurse Forensic nurse examiner Physician or primary health care provider

C Rationale The forensic nurse examiner is trained to recognize evidence of abuse and to intervene on the patient's behalf. Although the physician or primary health care provider, the psychiatric crisis nurse, and the police officer may be involved at some point in the care of this particular patient, they are not the best individuals to collaborate with at this time. It is important to remember that not all rapes are required to be reported to the police. p. 190

Which health care personnel within the institution's emergency response plan decides the number, acuity, and resource needs of patients in a mass casualty event or disaster? Triage officer Community relations officer Medical command physician Hospital incident commander

C Rationale The medical command physician decides the number, acuity, and resource needs of patients in a mass casualty event or disaster. Responsibilities also include identifying the need for and calling in of specialtytrained providers, such as neurosurgeons or orthopedic surgeons. The hospital incident commander's role is to take a global view of the entire situation and facilitate patient movement through the system. The triage officer rapidly evaluates each person who arrives at the hospital, including those who come in with triage tags in place. The community relations officer serves as the liaison between hospital administration and the media to release only appropriate and accurate information. p. 230

Which person is responsible for determining the number of staff needed to care for the anticipated victims of a mass casualty situation? Triage officer Public information officer Medical command physician Hospital incident commander

C Rationale The medical command physician is the person who determines the number, acuity, and resource needs of patients who are brought in for emergency care. The triage officer is a physician who rapidly evaluates each patient to determine priorities for treatment. The public information officer serves as a liaison between the health care facility and the media. The hospital incident commander is a physician or administrator who assumes overall leadership for implementing the emergency plan. p. 230

After scheduling an appointment for a patient reporting a possible brown recluse spider bite to the left arm that is very painful, the nurse would instruct the patient to implement which intervention? Remove jewelry. Place the arm in a splint. Apply cold packs or ice. Wrap the arm with an elastic bandage

C Rationale The nurse should instruct the patient to apply cold packs or ice to the area as this can decrease the rate of venom spread. The nurse should instruct the patient to remove jewelry, apply an elastic bandage, and splint the arm for a coral snakebite. p. 213

Which clinical finding is characteristic of moderate hypothermia? Dysarthria Severe hypotension Decreased clotting Decreased pain response

C Rationale The patient with moderate hypothermia has decreased clotting caused by impaired platelet aggregation and thrombocytopenia. The patient with mild hypothermia has dysarthria or slurred speech. The patient with severe hypotension has very low blood pressure as well as decreased neurologic reflexes and a decreased response to pain. p. 216

Which patient would the nurse refer to as the "walking wounded" when assisting the triage team at an earthquake site? Conscious patient with a bleeding head injury Patient with third-degree burns on 80% of the body Patient with several bruises and a closed fracture of the elbow Patient with bleeding wounds from shrapnel and an open fracture

C Rationale The patient with several bruises and a closed fracture of the elbow is "green-tagged" or referred to as the "walking wounded." These patients can help evacuate themselves and go to the hospital in a private vehicle. The patient with third-degree burns on 80% of the body has a lesser chance of survival; this patient is "blacktagged" and given treatment last. The patient with bleeding wounds from shrapnel and an open fracture and the patient with a bleeding head injury are "yellow-tagged." These patients need treatment within at least 2 hours. p. 228

Which nursing action requires intervention when caring for an older adult with orthostatic hypotension? Reassesses mental status Keeps the call light near the patient Encourages the patient to ambulate Raises the side rails of the stretcher

C Rationale To prevent falls, older patients with orthostatic hypotension should not be allowed to ambulate. They should be encouraged to call the nurse rather than ambulate. Older patients may have difficulty adjusting to the noise and pace of the emergency department (ED), and they might have other problems that may lead to delirium. Hence, their mental status should be reassessed. The side rails of the stretcher should always be up to prevent older adults from falling. The call light should be kept near the patient so the nurse can be called easily and so the patient can use the light without having to ambulate. p 193

Which skin manifestation is typical of a black widow spider bite? Bullae Eschar Papule Vesicle

C Rationale Typically a tiny papule or small red punctate mark is observed in people affected bitten by a black widow spider. Bullae are seen in pit viper bites. An eschar is noticed in brown recluse spider bites. Vesicle are also associated with pit viper bites. p. 213

Which statement describes an internal disaster? Select all that apply. One, some, or all responses may be correct. It occurs outside the health care facility. It endangers the life of people within the community. It creates the need to evacuate the health care facility. It endangers the safety of patients and staff in a health care facility. It requires activation of the facility's emergency management plan.

C, D, E Rationale An internal disaster endangers the safety of patients and staff. It is an event inside a health care facility or campus, so it creates the need to evacuate or relocate its people. The health care facility's emergency management plan is activated in response to an internal disaster. An external disaster may be natural or a biologic terror attack that endangers the life of people within the community. It occurs outside the health care facility but also requires activation of the facility's emergency management plan. p. 224

Which statement is true regarding the role of forensic nurse examiners (RN-FNEs)? Select all that apply. One, some, or all responses may be correct. Cares for patients with chronic mental health disorders Supervises overall patient care in the emergency department Provides care for rape, child abuse, and domestic violence victims Recognizes evidence of abuse and intervenes on the patient's behalf Documents injuries and collects physical and photographic evidence

C, D, E Rationale The RN-FNE obtains the patient's history, gathers forensic evidence, and provides counseling and follow-up care for victims of rape, child abuse, and domestic violence. The RN-FNE is taught to recognize evidence of abuse and intervene on the behalf of the patient. The RN-FNE is responsible for documenting injuries and collecting physical and photographic evidence from the patient. RN-FNEs treat emergency patients, not those with chronic disorders. They may practice in a hospital's emergency department, but they do not supervise patient care there. p. 190

Which is a duty of the nurse case manager in the emergency department (ED)? Provide discharge teaching. Obtain and record the patient health history. Arrange appropriate referrals for the patient. Coordinate the triage process with the triage nurse.

C. Rationale The nurse case manager in the ED arranges for appropriate referrals and follow-up for the patient. The emergency nurse obtains and records the patient history. The nurse provides discharge teaching to the patient and patient's family. The primary health care provider and assistant may coordinate the triage process with the triage nurse. p. 198

Which nursing action will treat hypothermia in a patient? Massage the extremities. Set the room temperature to 90°F (32°C). Infuse the patient with cold solutions. Use heat lamps and warming blankets.

D Rationale Interventions to prevent hypothermia include using heat lamps and warming blankets to keep the patient warm. The room temperature must be set to 75°F to 80°F (24°C to 27°C). The patient must be infused only with warm solutions and blood products. Massaging the extremities is not advisable if the patient is injured or has burns. p. 202

Which incident would result in penetrating trauma? Beaten with a baseball bat Kicked and beaten with fists Fell after being pushed from behind Sustained a gunshot wound to the arm during a mob attack

D Rationale A gunshot, which penetrates the skin and flesh, is an example of penetrating trauma. The remaining incidents, kicked and beaten with fists or a baseball bat and sustaining injury from a fall, exemplify blunt trauma. p. 201

Which clinical manifestation would indicate that the patient was bitten by a pit viper? Nausea Renal failure Pulmonary edema Metallic taste

D Rationale A metallic taste in the mouth is typical in victims of pit viper bites. Nausea is noticed in coral snakebites, bee stings, and spider bites. Renal failure is associated with brown recluse spider bites. Pulmonary edema is associated with spider bites and scorpion stings. p. 212

Which action will the nurse certified in basic life support (BLS) perform on a patient with a cardiopulmonary disorder admitted into the emergency department (ED)? Provide cardioversion. Administer appropriate cardiac medications. Initiate invasive airway management. Perform cardiopulmonary resuscitation.

D Rationale A nurse certified in BLS can perform cardiopulmonary resuscitation. Nurses who are certified in advanced cardiac life support can perform electrical therapies, invasive airway management, and administer drugs. p 196

Which tag will the triage nurse use for a patient who has an open fracture with large wound after an earthquake? Red Black Green Yellow

D Rationale A yellow tag indicates that a patient requires urgent care because of major injuries. A red tag indicates lifethreatening injuries requiring immediate care. A black tag indicates that a patient will likely die regardless of treatment. A green tag indicates that a patient has minor injuries and does not require immediate treatment. p. 228

Which is an appropriate question to ask when caring for a patient with traumatic injuries who identifies as a Jehovah's Witness? "Will you need an interpreter for discharge teaching?" "Would you like to receive the Sacrament of the Sick?" "Do you have an advance directive on file with our institution?" "Will you consent to a blood transfusion if it is a necessary part of your care?"

D Rationale Patients who are Jehovah's Witnesses may not consent to the transfusion of blood products or to receive medications made from blood products. Given the patient's faith and physical status, this is an appropriate question for the nurse to ask in this scenario. A patient of the Catholic, not Jehovah's Witness, faith may want to receive the Sacrament of the Sick. Although asking if an interpreter will be needed for discharge instruction might be applicable if the patient's primary language is not English, this can be asked at a later time. It is appropriate to determine if the patient has an advance directive on file, but it is not the highest priority. p. 195

Which change leads to polycythemia in people who remain at a high altitude? Decrease in respiratory rate Respiratory acidosis Decrease in cerebral blood flow Increase in hemoglobin

D Rationale People who remain in a high altitude environment may develop hypoxia resulting from reduced availability of oxygen. This stimulates the release of erythropoietin and induces red blood cell production. This causes an increase in red blood cells and hemoglobin concentration leading to the development of polycythemia. A decrease in oxygen at high altitudes leads to an increased (not decreased) respiratory rate to improve oxygen delivery; an increased respiratory rate causes decreased carbon dioxide and respiratory alkalosis (not acidosis), which limits a further increase in respiratory rate. Increased sympathetic nervous system activity increases the heart rate, blood pressure, and cardiac output. Cerebral blood flow increases (not decreases) to maintain cerebral oxygen delivery. p. 219

Which collaborative intervention would the nurse perform first for a patient with heat stroke? Remove the patient's clothes. Wet the patient's body with cold water. Apply a cooling blanket. Provide high-concentration oxygen therapy.

D Rationale Providing high-concentration oxygen therapy is the first intervention that should be implemented to avoid tissue hypoxia. Removing clothing and wetting the patient's body with cold water or applying a cooling blanket are done for rapid cooling after ensuring that the patient is breathing effectively and has proper circulation. pg 208

Which condition related to prolonged immobility in the emergency department (ED) does the nurse seek to prevent in a patient? Arthritis Syncope Kidney failure Pressure ulcers

D Rationale Some patients spend a lengthy time on stretchers while awaiting unit bed availability. Protecting skin integrity begins in the ED: interventions that promote clean and dry skin, mobility techniques, and routine turning help prevent skin breakdown. Syncope can result from medications for pre-existing medical conditions. The patient would not develop arthritis in the ED, but pain because of arthritis and back pain may increase as a result of a longer stay in the hospital. The patient would not develop kidney failure in the ED, but could develop a urinary tract infection. p. 194

Which organization offers training in disaster management to all levels of health care professionals? Disaster Medical Assistance Team (DMAT) National Fire Protection Association (NFPA) Federal Emergency Management Agency (FEMA) National Disaster Life Support Foundation (NDLSF)

D Rationale The NDLSF offers Basic Disaster Life Support and Advanced Disaster Life Support training courses to all levels of health care professionals. FEMA provides training to the Community Emergency Response Team (CERT) so that people are better prepared for disasters and can respond more self-sufficiently to incidents and hazard situations in their own communities. The NFPA provides guidelines for building construction, design, maintenance, and evacuation. DMAT is a medical relief team made up of civilian medical, paraprofessional, and support personnel that is deployed to a disaster area with enough medical equipment and supplies to sustain operations for 72 hours. p. 230

Which arthropod bite results in a dark and necrotic wound (eschar)? Bee Scorpion Black widow spider Brown recluse spider

D Rationale The brown recluse spider bite contains neurotoxins that cause cell damage. After a person is bitten by this spider, the wound becomes dark and necrotic in 1 to 3 days. Bees and scorpion bites give localized severe pain at the sting site. The bite of a black widow spider produces a tiny papule, a red punctate mark, with intense pain at the site. p 212

Which statement made by the nurse indicates a need for better understanding of the role of the emergency department (ED) case manager when working with victims of intimate partner violence? The case manager reviews the ED census on both a real-time and a retrospective basis." "The case manager offers basic life support interventions for patients before they get to the ED." "The case manager teaches patients to manage their conditions on a daily basis to prevent deterioration." "The case manager coordinates with team members to develop a discharge plan for victims of intimate partner violence."

D Rationale The emergency medical technician (EMT), not the ED case manager, is trained to provide basic life support (BLS) interventions such as oxygen, basic wound care, splinting, spinal immobilization, and vital signs monitoring before a patient arrives at the ED. ED case managers review the emergency department census on both a real-time and a retrospective basis to determine how many patients have visited the emergency department, and how often, in a certain period. They also provide patient education about managing conditions on a daily basis to prevent deterioration and coordinate with team members to develop discharge plans for victims of intimate partner violence to ensure their safety. pp. 197-198

During a natural disaster event, which member of the team will coordinate patients moving into a lounge to free bed space? Triage officer Public information officer Medical command physician Hospital incident commander

D Rationale The hospital incident commander is a physician who assumes overall leadership for implementing an emergency plan in a disaster situation. The incident commander can coordinate patients due for discharge moving into the lounge, freeing beds for new disaster victims. The triage officer is a physician or nurse who rapidly evaluates each patient to prioritize treatment. The public information officer is a person who serves as a liaison between the health care facility and the media. The medical command physician decides the number, acuity, and resource needs of the patients. p. 231

Which health care personnel can assume overall leadership for implementing the emergency plan during a disaster? Triage officer Public information officer Medical command physician Hospital incident commander

D Rationale The hospital incident commander is the health care employee who assumes overall leadership for implementing the emergency plan during a disaster. The triage officer rapidly evaluates each patient to determine priorities for treatment. The public information officer serves as a liaison between the health care facility and the media. The medical command physician decides the number, acuity, and resource needs of patients. p. 230

Which statement accurately portrays care of a family during a crisis that involves death? Crisis staff will support the family members during the funeral. Safety of the family is maintained by bereavement staff. Family will be restricted from viewing the patient until the forensic evaluation (if any) is completed. The nurse will provide concrete phrases such as "the patient died" while communicating with family.

D Rationale The nurse should use concrete and accurate words, such as died or death when speaking to family members after a patient's death; this can help prevent confusion. Crisis staff maintain the safety of the family during a death crisis. Bereavement staff support family members during the funeral. Family may be allowed to see the patient before the completion of any forensic evaluation; however, IV lines, equipment, and other evidence should be kept intact. p. 199

Which presenting symptom will be treated with the highest priority? Skin rash that appeared after taking an antibiotic for 4 days Sprained ankle secondary to a fall Flu-like symptoms and a fever of 101°F (38°C) A stab wound to the stomach

D Rationale The nurse treats the patient with a stab wound to the stomach with highest priority, because the patient may be bleeding and in pain. This patient needs urgent attention, because stab wounds can be immediately life threatening. Skin rash, flu-like symptoms, and a sprained ankle are not emergency situations requiring immediate attention; these patients can wait while critical patients are being attended to. p. 196

Which protective gear is most important when caring for patients with tuberculosis or other airborne pathogens? Surgical cap Eye protection Impervious cover gown Powered air-purifying respirator (PAPR)

D Rationale The nurse uses a PAPR or a specially fitted facemask when caring for a patient with airborne pathogens. These patients are preferably placed in a negative-pressure room if available. When there is a high risk of contamination from blood and body fluids, other safety precautions may be used. These include use of a surgical cap, an impervious cover gown, and eye protection. p. 193

Which nursing action will help ensure a patent airway in a patient with impaired consciousness? Administer oxygen via nasal cannula. Apply a nonrebreather mask. Provide bag-valve-mask (BVM) ventilation. Anticipate supplies needed by the provider to place an endotracheal tube for mechanical ventilation.

D Rationale The patient with significantly impaired consciousness is provided an endotracheal tube and mechanical ventilation. A nasal cannula and nonrebreather mask are used for a patient who is able to breathe spontaneously. Bag-valve-mask (BVM) ventilation with the appropriate airway adjunct and a 100% oxygen source is indicated for a patient who needs ventilatory assistance during resuscitation. p. 201

Which concern is the priority when patients with green tags evacuate themselves and go to a hospital for treatment on their own? The actual number of casualties cannot be determined. The health care system is unprepared to meet the influx of these patients. The emergency department may not anticipate the arrival of such patients. They may unknowingly carry contaminants from the disaster site to the hospital.

D Rationale The priority concern when patients with green tags evacuate themselves is that they may unknowingly carry contaminants from the disaster site to the hospital. These may be nuclear, biologic, or chemical in nature and may have potentially disastrous consequences. It is difficult to keep a record of the actual number of casualties that may have occurred in the disaster. Health care providers and the emergency department must anticipate the arrival of these patients. As part of their emergency preparedness, they are expected to plan appropriate decontamination measures. p 228

A new nurse is learning about the nurse's role in a disaster as part of orientation. Which statement about the nurse's role in a mass casualty incident is accurate? Learning about disasters is nice to know, but not essential. Applying advanced skills out in the field can be very helpful until help arrives. Nurses take a passive role in helping others save lives and fulfill an important obligation. Nurses may have to assume roles in making decisions for the most appropriate treatment of casualties

D Rationale Nurses play key roles that extend to all areas of the health care facility during a disaster. They may have to assume roles in triage, patient transfers, discharge, or providing care for stable patients. Learning about the nurse's role in a disaster is essential. The nurse will play an active role during a disaster. If the nurse is out in the field during a disaster, basic skills will be applied. p. 231

Which is the desired outcome of a disease management program for patients with chronic conditions? Provide health teaching related to the identified disease. Prevent clinical deterioration within the hospital setting. Help the patient manage the disease at home. Keep the patient out of the hospital for as long as possible.

D. Rationale Disease management programs are specific to chronic conditions, such as asthma or diabetes. The desired outcome of a disease management program is to keep the patient out of the hospital for as long as possible. Providing health teaching and preventing clinical deterioration by teaching patients how to manage their health conditions are key components to the program. However, neither of these is the desired outcome. p. 198

Which member of the emergency care team reports a patient's mechanism of injury (MOI)? Triage nurse Nurse practitioner Health care provider Prehospital care provider

D. Rationale The prehospital care providers report the MOI as a communication standard when handing off care to the emergency department (ED) and trauma personnel. Patients who are brought to the ED for medical care will often relate the MOI by describing the particular chain of events that caused their injuries. The triage nurse or emergency nurses communicate this information to the nurse practitioner, health care provider, and other staff members for continuity of care. p. 191

CH 10

EAQ

Ch 12

Emergency & Disaster

Ch 11

Environmental emergencies

True or False: A patient who experiences an alkali chemical burn is easier to treat because the skin will neutralize the chemical rather than with an acidic chemical burn.

False: Alkali burns are harder to treat than acidic chemical burns because the skin will neutralize the acidic burn.

Which service would a Medical Reserve Corps (MRC) team contribute to the health care for the people in an area affected by a tornado? Select all that apply. One, some, or all responses may be correct. Provide emergency animal care. Establish fully functional field surgical facilities. Establish first aid stations or special-needs shelters. Help staff community centers that face shortage of personnel. Set up an acute care center (ACC) to alleviate hospital overcrowding.

Rationale An MRC is made up of a group of volunteer medical and public health care professionals, including physicians and nurses. The MRC helps establish staff community centers or hospitals that face a shortage of personnel. They set up an ACC for patients who need acute but not intensive care to alleviate hospital overcrowding. They establish first aid stations or special-needs shelters. The National Veterinary Response Team (NVRT) provides emergency animal care. International Medical Surgical Response Teams (IMSuRTs) establish fully functional field surgical facilities wherever they are needed in the world. p. 229

What are some patient priorities during the emergent phase of burn management? A. Fluid volume B. Respiratory status C. Psychosocial D. Wound closure E. Nutrition

The answer is A and B. This phase starts from the onset of the burn and ends with the restoration of capillary permeability. Wound closure, and nutrition would be during the acute phase, and would continue into the rehabilitative phase. Psychosocial would be in the rehab phase.

You are about to provide care to a patient with severe burns. You will don: A. gloves B. goggles C. gown D. N-95 mask E. surgical mask F. shoe covers G. hair cover

The answer is A, C, E, F, and G. Before providing care to a patient with severe burns the nurse would want to wear protective isolation apparel like: gloves, gown, surgical mask, shoe covers, and hair cover. This protects the patient from potential infection.

A 58 year old female patient has superficial partial-thickness burns to the anterior head and neck, front and back of the left arm, front of the right arm, posterior trunk, front and back of the right leg, and back of the left leg. Using the Rule of Nines, calculate the total body surface area percentage that is burned? A. 63% B. 81% C. 72% D. 54%

The answer is A. Anterior head and neck (4.5%), front and back of the left arm (9%), front of the right arm (4.5%), posterior trunk (18%), front and back of the right leg (18%), back of the left leg (9%) which equals 63%.

As the nurse providing care to a patient who experienced a full-thickness electrical burn you know to monitor the patient's urine for: A. Hemoglobin and myoglobin B. Free iron and white blood cells C. Protein and red blood cells D. Potassium and Urea

The answer is A. Patients who've experienced a severe electrical burn or full-thickness burns are at risk for acute kidney injury. This is because the muscles can experience damage from the electrical current leading them to release myoglobin. In addition, the red blood cells will release hemoglobin. These substances will collect in the kidneys leading to acute tubular necrosis (hence leading to AKI). Therefore, the nurse should monitor the patient's urine for these substances.

A patient has a burn on the back of the torso that is extremely red and painful but no blisters are present. When you pressed on the skin it blanches. You document this as a: A. 1st degree (superficial) burn B. 2nd degree (partial-thickness) burn C. 3rd degree (full-thickness) burn D. 4th degree (deep full-thickness) burn

The answer is A. These are the classic characteristics of a 1st degree, superficial burn.

A patient has full-thickness burns on the front and back of both arm and hands. It is nursing priority to: A. Elevate and extend the extremities B. Elevate and flex the extremities C. Keep extremities below heart level and extended D. Keep extremities level with the heart level and flexed

The answer is A. This position will decrease edema, which will help prevent compartment syndrome.

Which statement below is INCORRECT about the yellow triage tag color in regards to a disaster situation? A. A survivor with this tag color is seen after patients with the green tag color. B. A survivor with this tag color can have treatment delayed for 30 minutes to 2 hours. C. A survivor with this tag color has serious injuries that could eventually lead to the compromise of breathing, circulation, or mental status, especially if treatment is delayed more than an hour or so. D. A survivor with this tag color has second priority for treatment of injuries.

The answer is A. This statement is INCORRECT. It should say: A survivor with this tag color is seen after patients with the RED (not green) tag color.

A 30 year old female patient has deep partial thickness burns on the front and back of the right and left leg, front of right arm, and anterior trunk. The patient weighs 63 kg. Use the Parkland Burn Formula: What is the flow rate during the FIRST 8 hours (mL/hr) based on the total you calculated? A. 921 mL/hr B. 938 mL/hr C. 158 mL/hr D. 789 mL/hr

The answer is A: 921 mL/hr....First calculate the total amount of fluid needed with the formula: Total Amount of LR = 4 mL x BSA % x pt's weight in kg. The pt's weight 63 kg. BSA percentage: 58.5%...Front and back of right and left leg (36%), front of right arm (4.5%), anterior trunk (18%) which equals 58.5%. ......4 x 58.5 x 63 = 14,742 mL......Remember during the FIRST 8 hours 1/2 of the solution is infused, which will be 14,742 divided by 2 = 7371 mL......Hourly Rate: 7371 divide by 8 equals 921 mL/hr

Your patient with severe burns is due to have a dressing change. You will pre-medicate the patient prior to the dressing change. The patient has standing orders for all the medications below. Which medication is best for this patient? A. IM morphine B. PO morphine C. IV morphine D. Subq morphine

The answer is C. The best route that is predictable and easily absorbed is via the IV route in burn victims.

The wounded victim is able to walk and obey commands. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black

The answer is A: Green.

The nurse notes a patient has full-thickness circumferential burns on the right leg. The nurse would: select all that apply A. Place cold compressions on the burn and elevate the right leg below the heart level B. Assess the distal pulses in the right extremity C. Elevate the right leg above the heart level D. Place gauze securely around the leg to prevent infection

The answer is B and C. The patient has burns that completely surround the front and back of the right leg. This can lead to compartment syndrome where the edema from the burn compromises circulation to the distal extremity. The nurse should elevate the extremity ABOVE heart level to decrease swelling and assess distal pulses in the extremity to confirm circulation is present.

A patient has an emergency escharotomy performed on the right leg. The patient has full-thickness circumferential burns on the leg. Which finding below demonstrates the procedure was successful? A. The patient can move the extremity. B. The right foot's capillary refill is less than 2 seconds. C. The patient reports a new sensation of extreme pain. D. The patient has a positive babinski reflex.

The answer is B. Escharotomy is performed when a full-thickness burn, due to eschar (which is burned tissue that is hard), is compromising blood flow to the distal extremity. The eschar is cut and this relieves pressure and allows blood to flow to the extremity.

You're assisting the nursing assistant with repositioning a patient with full-thickness burns on the neck. Which action by the nursing assistant requires you to intervene? A. The nursing assistant elevates the head of the bed above 30 degrees. B. The nursing assistant places a pillow under the patient's head. C. The nursing assistant places rolled towels under the patient's shoulders. D. The nursing assistant covers the patient with sterile linens.

The answer is B. If a patient has severe burns to the neck (head as well) a pillow should NOT be used under the head because this can cause wound contractions. Instead rolled towels should be placed under the shoulders.

While collecting a medical history on a patient who experienced a severe burn, which statement by the patient's family member requires nursing intervention? A. "He takes medication for glaucoma". B. "I think it has been 10 years or more since he had a tetanus shot." C. "He was told he had COPD last year." D. "He smokes 2 packs of cigarettes a day."

The answer is B. Patients who have had burns need a tetanus shot if they have not had a vaccine within the past 5 to 10 years.

You receive a patient who has experienced a burn on the right leg. You note the burn contains small blisters and is extremely pinkish red and shiny/moist. The patient reports severe pain. You document this burn as: A. 1st Degree (superficial) B. 2nd Degree (partial-thickness) C. 3rd Degree (full-thickness) D. 4th Degree (deep full-thickness)

The answer is B. These are the classic characteristics of a 2nd degree (partial-thickness) burn.

A patient who is being treated for partial thickness burns on 60% of the body is now in the acute phase of burn management. The nurse assesses the patient for a possible Curling's Ulcer. What signs and symptoms can present with this condition? A. Swelling and pain on the area distal to the burn B. Burning, gnawing sensation pain in the stomach and vomiting C. Dark red or gray sores on the soles of the feet D. Difficulty swallowing and gagging

The answer is B. This is a type of ulcer that occurs in the stomach, duodenum, due to a high amount of stress on the body from a burn. The blood supply to the factors that help protect the stomach lining from gastric erosion decreases and this allows for ulcers to form.

You're providing education to a group of local firefighters about carbon monoxide poisoning. Which statement is correct about the pathophysiology regarding this condition? A. "Patients are most likely to present with cyanosis around the lips and face." B. "In this condition, carbon monoxide binds to the hemoglobin of the red blood cell leading to a decrease in the ability of the hemoglobin to carry oxygen to the body." C. "Carbon monoxide poisoning leads to a hyperoxygenated state, which causes hypercapnia." D. "Carbon monoxide binds to the hemoglobin of the red blood cell and prevents the transport of carbon dioxide out of the blood, which leads to poisoning."

The answer is B. This is the only correct statement about carbon monoxide poisoning.

A patient is presenting with bright red lips, headache, and nausea. The physician suspects carbon monoxide poisoning. As the nurse, you know the patient needs: A. Oxygen nasal cannula 5-6 Liters B. 100% oxygen via non-rebreather mask C. Continuous Bipap D. Venturi mask 6 L oxygen

The answer is B. This is the treatment for carbon monoxide poisoning.

A patient experienced a full-thickness burn 72 hours ago. The patient's vital signs are within normal limits and urinary output is 50 mL/hr. This is known as what phase of burn management? A. Emergent B. Acute C. Rehabilitative

The answer is B. This phase starts when capillary permeability has returned to normal and the patient's vitals are within normal limits and ends with wound closure. The phase after this is rehabilitative.

During the acute phase of burn management, what is the best diet for a patient who has experienced severe burns? A. High fiber, low calories, and low protein B. High calorie, high protein and carbohydrate C. High potassium, high carbohydrate, and low protein D. Low sodium, high protein, and restrict fluids to 1 liter per day

The answer is B. This type of diet promotes wound healing and meets the caloric demands of the body.

Select the patient below who is at MOST risk for complications following a burn: A. A 42 year old male with partial-thickness burns on the front of the right and left arms and legs. B. A 25 year old female with partial-thickness burns on the front of the head and neck and front and back of the torso. C. A 36 year old male with full-thickness burns on the front of the left arm. D. A 10 year old with superficial burns on the right leg.

The answer is B. When thinking about which patient will have the MOST complications following a burn think about: percentage of the total body surface area that is burned (use the rule of nine to calculate), depth of the burn, age, location of the burn, and patient's medical history. The patient in option B has 40.5% TSBA burned (option A 27%, C: 4.5%, D: 9%). Remember that the higher the total of the body surface area that is burned the higher the risk of complications due to an increase in capillary permeability (swelling, hypovolemic shock etc.). In addition, the location of the burn is a major issue with the patient in option B. The burns are on the head and neck and front and back of the torso. Therefore, with head and neck burns always think about respiratory issues because the airway can become compromised due to swelling or an inhalation injury. And with torso burns that are on the front and back, the patient is at risk for circumferential burns that can lead to further respiratory compromise. The other options have burns that are isolated.

The wounded victim is unable to walk, has respiratory rate of 12, capillary refill is 8 seconds, and is unresponsive. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black

The answer is B: Red.

The wounded victim is unable to walk, has respiratory rate of 40, capillary refill is 6 seconds, and can't follow simple commands. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black

The answer is B: Red.

The wounded victim is unable to walk, respiratory rate is absent but when airway is repositioned breathing is noted. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black

The answer is B: Red.

A patient has experienced full-thickness burns to the face and neck. As the nurse it is priority to: A. Prevent hypothermia B. Assess the blood pressure C. Assess the airway D. Prevent infection

The answer is C. Due to the location of the burns (face and neck), the patient is at major risk for respiratory issues due to damage to the upper airways and the risk of an inhalation injury.

After receiving report on a patient receiving treatment for severe burns, you perform your head-to-toe assessment. On arrival to the patient's room you note the room temperature to be 75'F. You will: A. Decrease the temperature by 5-10 degrees to prevent hyperthermia. B. Leave the temperature setting. C. Increase the temperature to a minimum of 85'F.

The answer is C. Patients with severe burns can NOT regulate their temperature and are at risk for hypothermia. The room temperature should be a minimum of 85'F.

A patient is in the acute phase of burn management. The patient experienced full-thickness burns to the perineum and sacral area of the body. In the patient's plan of care, which nursing diagnosis is priority at this time? A. Impaired skin integrity B. Risk for fluid volume overload C. Risk for infection D. Ineffective coping

The answer is C. The patient is now in the acute phase where fluid resuscitation was successful and ends with wound closure. Therefore, during this stage diuresis occurs (so fluid volume deficient could occur NOT overload) and INFECTION. The location of the burns increases the risk of infection because these areas naturally harbor bacteria. Therefore, this takes priority because during this phase wound healing is promoted.

Based on the depth of the burn in figure 1 (picture is above), you would expect to find: A. report of sensation to only pressure B. blanching C. anesthetization to feeling D. extreme pain

The answer is C. This is a 3rd degree to 4th degree burn (full-thickness) and the nerves that detect pain are destroyed. The patient would have no feeling or experiences an extreme decrease sensation to pain

The _____________ layer of the skin helps regulate our body temperature. A. Epidermis B. Dermis C. Hypodermis D. Fascia

The answer is C. This layer contains fatty tissue, veins, arteries, nerves and helps insulate the muscles, bones, organs and helps REGULATE our body temperature.

A catastrophic disaster has occurred 5 miles from the hospital you are working in. The hospital's disaster plan is activated and the wounded are brought to the hospital. You're helping triage the survivors. One of the wounded is able to walk around and has minor lacerations on the arms, hands, chest, and legs. You would place what color tag on this survivor? A. Red B. Yellow C. Green D. Black

The answer is C: Green tags are for patients who have MINOR injuries. If the patient can walk around they are tagged as green. Sometimes they are referred to as the "walking wounded".

You're working as a triage nurse during a disaster situation. Based on the triage color code tags placed on each of the wounded, which tag color represents the wounded who have the highest priority of being treated first? A. Green B. Yellow C. Red D. Black

The answer is C: Red. The red tag indicates the patient must be seen first because they have life-threatening injuries, but could survive if treated quickly. The patient is still alive but there is a severe alteration in their breathing, circulation, or mental status that requires immediate medical attention.

The wounded victim is unable to walk, has respiratory rate of 19, capillary refill of one second, and is able to obey your commands. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black

The answer is C: Yellow.

A patient is receiving IV Lactated Ringers 950 mL/hr post 18 hours after a receiving a severe burn. The patient urinary output is 20 mL/hr. As the nurse your next nursing action is to: A. Increase the IV fluids B. Continue to monitor the patient C. Decrease the IV fluids D. Notify the physician of this finding

The answer is D. The patient's urinary output is too low and needs more fluids. It should be at least 30 mL/hr. Therefore, the nurse must notify the physician for further orders. The nurse can NOT increase or decrease IV fluids without a physician's order.

During the emergent phase of burn management, you would expect the following lab values: A. Low sodium, low potassium, high glucose, low hematocrit B. High sodium, low potassium, low glucose, high hematocrit C. High sodium, high potassium, high glucose, low hematocrit D. Low sodium, high potassium, high glucose, high hematocrit

The answer is D. Think about the increase in the capillary permeability that happens with severe burns, which causes the plasma to leave the intravascular system and enter the interstitial tissue: Low sodium..why: sodium leaves with the plasma to the interstitial tissue and drops the levels in the blood; High potassium...why? damaged cells lysis and leak potassium which increases the leave in the blood; high glucose...why? stress response leads the liver to release glycogen and this increases levels; high hematocrit...why? when the plasma leaves the intravascular system (the fluid) it causes the blood to become more concentrated so hematocrit increases (this will decrease when the patient's fluid is replaced).

The wounded victim is unable to walk, respiratory rate is absent and when airway is repositioned breathing is still absent. The wounded victim is assigned what tag color? A. Green B. Red C. Yellow D. Black

The answer is D: Black.

While triaging the wounded from a disaster, you note that one of the wounded is not breathing, radial pulse is absent, capillary refill >2 seconds, and does not respond to your commands. What color tag is assigned? A. Green B. Red C. Yellow D. Black

The answer is D: Black. The black tag is placed on the wounded that are dying or have expired. The injuries are so severe that death is imminent. There is severe alteration or absence of breathing, circulation, and neuro status.

A 65 year old male patient has experienced full-thickness electrical burns on the legs and arms. As the nurse you know this patient is at risk for the following: Select all that apply: A. Acute kidney injury B. Dysrhythmia C. Iceberg effect D. Hypernatremia E. Bone fractures F. Fluid volume overload

The answers are A, B, C, and E. Electric burns are due to an electrical current passing through the body that leads to damage to the skin but also the muscles and bones that are underneath the skin. The patient is at risk for AKI (acute kidney injury) because when the muscles become affected they release myoglobin and the red blood cells release hemoglobin in the blood, which can collect in the kidneys leading to injury. In addition, the heart's electrical system can become damaged leading to dysrhythmia. The iceberg effect can present as well because the extent of damage is not clearly visible on the skin (there can be severe damage underneath). In addition, if the electrical current is strong enough it can lead to bone fractures (specifically cervical spine injuries) due to the severe contraction of the muscles involved.

A patient arrives to the ER due to experiencing burns while in an enclosed warehouse. Which assessment findings below demonstrate the patient may have experienced an inhalation injury? A. Carbonaceous sputum B. Hair singeing on the head and nose C. Lhermitte's Sign D. Bright red lips E. Hoarse voice F. Tachycardia

The answers are A, B, D, E, and F. These are all signs of a possible inhalation injury. Bright red lips and tachycardia are present in carbon monoxide poisoning as well.

A patient arrives to the ER with full-thickness burns on the front and back of the torso and neck. The patient has no spinal injuries but is disoriented and coughing up black sooty sputum. Vital signs are: oxygen saturation 63%, heart rate 145, blood pressure 80/56, and respiratory rate 39. As the nurse you will: (SELECT ALL) A. Place the patient in High Fowler's positon. B. Prep the patient for escharotomy. C. Prep the patient for fasciotomy. D. Prep the patient for intubation. E. Place a pillow under the patient's neck. F. Obtain IV access at two sites. G. Restrict fluids.

The answers are A, B, D, and F. After reading this scenario the location of the burns and the patient's presentation should be jumping out at you. The patient is at risk for circumferential burns due to the location of the burns and the depth (full-thickness....will have eschar present that will restrict circulation or here in this example the ability of the patient to breathe in and out). Based on the patient's VS, we see that the respiratory effort is compromised majorly AND that there is a risk of inhalation injury since the patient is coughing up black sooty sputum. Therefore, the nurse should place the patient in high Fowler's position to help with respiratory effort (unless contraindicated with spinal injuries), prep the patient for escharotomy (this will cut the eschar and help relieve pressure and allow for breathing) and prep for intubation to help with the respiratory distress. In addition, obtain IV access in at least two sites for fluid replacement....remember the first 24 hours after a burn a patient is at risk for hypovolemic shock.

Burns

registerednurseRN

Disaster Triage

registerednursern