Chapter 72, Chapter 73, Chapter 69: Nursing Management: Emergency, Terrorism, and Disaster Nursing
The following four patients arrive in the emergency department (ED) after a motor vehicle collision. In which order should the nurse assess them? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. A 74-year-old with palpitations and chest pain b. A 43-year-old complaining of 7/10 abdominal pain c. A 21-year-old with multiple fractures of the face and jaw d. A 37-year-old with a misaligned left leg with intact pulses
ANS: C, A, B, D The highest priority is to assess the 21-year-old patient for airway obstruction, which is the most life-threatening injury. The 74-year-old patient may have chest pain from cardiac ischemia and should be assessed and have diagnostic testing for this pain. The 43-year-old patient may have abdominal trauma or bleeding and should be seen next to assess circulatory status. The 37-year-old appears to have a possible fracture of the left leg and should be seen soon, but this patient has the least life-threatening injury. DIF: Cognitive Level: Analyze (analysis) REF: 1676 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
23. The urgent care center protocol for tick bites includes the following actions. Which action will the nurse take first when caring for a patient with a tick bite? a. Use tweezers to remove any remaining ticks. b. Check the vital signs, including temperature. c. Give doxycycline (Vibramycin) 100 mg orally. d. Obtain information about recent outdoor activities.
ANS: A Because neurotoxic venom is released as long as the tick is attached to the patient, the initial action should be to remove any ticks using tweezers or forceps. The other actions are also appropriate, but the priority is to minimize venom release. DIF: Cognitive Level: Apply (application) REF: 1697 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
When preparing to cool a patient who is to begin therapeutic hypothermia, which intervention will the nurse plan to do (select all that apply)? a. Assist with endotracheal intubation. b. Insert an indwelling urinary catheter. c. Begin continuous cardiac monitoring. d. Obtain an order to restrain the patient. e. Prepare to give sympathomimetic drugs.
ANS: A, B, C Cooling can produce dysrhythmias, so the patient's heart rhythm should be continuously monitored and dysrhythmias treated if necessary. Bladder catheterization and endotracheal intubation are needed during cooling. Sympathomimetic drugs tend to stimulate the heart and increase the risk for fatal dysrhythmias such as ventricular fibrillation. Patients receiving therapeutic hypothermia are comatose or do not follow commands so restraints are not indicated. DIF: Cognitive Level: Apply (application) REF: 1681 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
21. Family members are in the patient's room when the patient has a cardiac arrest and the staff start resuscitation measures. Which action should the nurse take next? a. Keep the family in the room and assign a staff member to explain the care given and answer questions. b. Ask the family to wait outside the patient's room with a designated staff member to provide emotional support. c. Ask the family members about whether they would prefer to remain in the patient's room or wait outside the room. d. Tell the family members that patients are comforted by having family members present during resuscitation efforts.
ANS: C Although many family members and patients report benefits from family presence during resuscitation efforts, the nurse's initial action should be to determine the preference of these family members. The other actions may be appropriate, but this will depend on what is learned when assessing family preferences. DIF: Cognitive Level: Apply (application) REF: 1679 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
22. A 28-year-old patient who has deep human bite wounds on the left hand is being treated in the urgent care center. Which action will the nurse plan to take? a. Prepare to administer rabies immune globulin (BayRab). b. Assist the health care provider with suturing of the bite wounds. c. Teach the patient the reason for the use of prophylactic antibiotics. d. Keep the wounds dry until the health care provider can assess them.
ANS: C Because human bites of the hand frequently become infected, prophylactic antibiotics are usually prescribed to prevent infection. To minimize infection, deep bite wounds on the extremities are left open. Rabies immune globulin might be used after an animal bite. Initial treatment of bite wounds includes copious irrigation to help clean out contaminants and microorganisms. DIF: Cognitive Level: Apply (application) REF: 1688 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
2. The emergency department (ED) nurse is initiating therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/LVN) (select all that apply)? a. Continuously monitor heart rhythm. b. Check neurologic status every 2 hours. c. Place cooling blankets above and below patient. d. Give acetaminophen (Tylenol) 650 mg per nasogastric tube. e. Insert rectal temperature probe and attach to cooling blanket control panel.
ANS: C, D, E Experienced LPN/LVNs have the education and scope of practice to implement hypothermia measures (e.g., cooling blanket, temperature probe) and administer medications under the supervision of a registered nurse (RN). Assessment of neurologic status and monitoring the heart rhythm require RN-level education and scope of practice and should be done by the RN. DIF: Cognitive Level: Apply (application) REF: 15-16 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
34. The ED staff has been notified of the imminent arrival of a patient who has been exposed to chlorine. The nurse should anticipate the need to address what nursing diagnosis? A) Impaired gas exchange B) Decreased cardiac output C) Chronic pain D) Excess fluid volume
Ans: A
35. The nursing supervisor at the local hospital is advised that your hospital will be receiving multiple trauma victims from a blast that occurred at a local manufacturing plant. The paramedics call in a victim of the blast with injuries including a head injury and hemorrhage. What phase of blast injury should the nurse expect to treat in this patient? A) Primary phase B) Secondary phase C) Tertiary phase D) Quaternary phase
Ans: A
21. An industrial site has experienced a radiation leak and workers who have been potentially affected are en route to the hospital. To minimize the risks of contaminating the hospital, managers should perform what action? A) Place all potential victims on reverse isolation. B) Establish a triage outside the hospital. C) Have hospital staff put on personal protective equipment. D) Place hospital staff on abbreviated shifts of no more than 4 hours.
Ans: B
28. A man survived a workplace accident that claimed the lives of many of his colleagues several months ago. The man has recently sought care for the treatment of depression. How should the nurse best understand the man's current mental health problem? A) The man is experiencing a common response following a disaster. B) The man fails to appreciate the fact that he survived the disaster. C) The man most likely feels guilty about his actions during the disaster. D) The man's depression most likely predated the disaster.
Ans: A
30. The nurse is caring for a patient admitted with a drug overdose. What is the nurse's priority responsibility in caring for this patient? A) Support the patient's respiratory and cardiovascular function. B) Provide for the safety of the patient. C) Enhance clearance of the offending agent. D) Ensure the safety of the staff.
Ans: A
24. A nurse is triaging patients after a chemical leak at a nearby fertilizer factory. The guiding principle of this activity is what? A) Assigning a high priority to the most critical injuries B) Doing the greatest good for the greatest number of people C) Allocating resources to the youngest and most critical D) Allocating resources on a first come, first served basis
Ans: B
20. A patient with a fractured femur presenting to the ED exhibits cool, moist skin, increased heart rate, and falling BP. The care team should consider the possibility of what complication of the patient's injuries? A) Myocardial infarction B) Hypoglycemia C) Hemorrhage D) Peritonitis
Ans: C
12. A 20-year-old patient arrives in the emergency department (ED) several hours after taking "25 to 30" acetaminophen (Tylenol) tablets. Which action will the nurse plan to take? a. Give N-acetylcysteine (Mucomyst). b. Discuss the use of chelation therapy. c. Start oxygen using a non-rebreather mask. d. Have the patient drink large amounts of water.
ANS: A N-acetylcysteine is the recommended treatment to prevent liver damage after acetaminophen overdose. The other actions might be used for other types of poisoning, but they will not be appropriate for a patient with acetaminophen poisoning. DIF: Cognitive Level: Understand (comprehension) REF: 1689 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
9. When planning the response to the potential use of smallpox as an agent of terrorism, the emergency department (ED) nurse manager will plan to obtain adequate quantities of a. vaccine. b. atropine. c. antibiotics. d. whole blood.
ANS: A Smallpox infection can be prevented or ameliorated by the administration of vaccine given rapidly after exposure. The other interventions would be helpful for other agents of terrorism but not for smallpox. DIF: Cognitive Level: Understand (comprehension) REF: 1690 TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
11. When assessing an older patient admitted to the emergency department (ED) with a broken arm and facial bruises, the nurse observes several additional bruises in various stages of healing. Which statement or question by the nurse is most appropriate? a. "Do you feel safe in your home?" b. "You should not return to your home." c. "Would you like to see a social worker?" d. "I need to report my concerns to the police."
ANS: A The nurse's initial response should be to further assess the patient's situation. Telling the patient not to return home may be an option once further assessment is done. A social worker may be appropriate once further assessment is completed. DIF: Cognitive Level: Apply (application) REF: 1682 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
22. After a radiation exposure, a patient has been assessed and determined to be a possible survivor. Following the resolution of the patient's initial symptoms, the care team should anticipate what event? A) A return to full health B) Internal bleeding C) A latent phase D) Massive tissue necrosis
Ans: C
13. A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10 abdominal pain and states, "I had a temperature of 103.9° F (39.9° C) at home." The nurse's first action should be to a. assess the patient's current vital signs. b. give acetaminophen (Tylenol) per agency protocol. c. ask the patient to provide a clean-catch urine for urinalysis. d. tell the patient that it will 1 to 2 hours before being seen by the doctor.
ANS: A The patient's pain and statement about an elevated temperature indicate that the nurse should obtain vital signs before deciding how rapidly the patient should be seen by the health care provider. A urinalysis may be appropriate, but this would be done after the vital signs are taken. The nurse will not give acetaminophen before confirming a current temperature elevation. DIF: Cognitive Level: Apply (application) REF: 1675-1676 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
15. The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first? a. Remove the patient's rings. b. Apply ice packs to both hands. c. Apply calamine lotion to any itching areas. d. Give diphenhydramine (Benadryl) 50 mg PO.
ANS: A The patient's rings should be removed first because it might not be possible to remove them if swelling develops. The other orders should also be implemented as rapidly as possible after the nurse has removed the jewelry. DIF: Cognitive Level: Apply (application) REF: 1687 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
18. An unresponsive 79-year-old is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 105.4° F (40.8° C), blood pressure (BP) 88/50, and pulse 112. The nurse initially will plan to a. apply wet sheets and a fan to the patient. b. provide O2 at 6 L/min with a nasal cannula. c. start lactated Ringer's solution at 1000 mL/hr. d. give acetaminophen (Tylenol) rectal suppository.
ANS: A The priority intervention is to cool the patient. Antipyretics are not effective in decreasing temperature in heat stroke, and 100% oxygen should be given, which requires a high flow rate through a non-rebreather mask. An older patient would be at risk for developing complications such as pulmonary edema if given fluids at 1000 mL/hr. DIF: Cognitive Level: Apply (application) REF: 1683 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
34. The ED nurse is planning the care of a patient who has been admitted following a sexual assault. The nurse knows that all of the nursing interventions are aimed at what goal? A) Encouraging the patient to gain a sense of control over his or her life B) Collecting sufficient evidence to secure a criminal conviction C) Helping the patient understand that this will not happen again D) Encouraging the patient to verbalize what happened during the assault
Ans: A
20. Following an earthquake, patients are triaged by emergency medical personnel and are transported to the emergency department (ED). Which patient will the nurse need to assess first? a. A patient with a red tag b. A patient with a blue tag c. A patient with a black tag d. A patient with a yellow tag
ANS: A The red tag indicates a patient with a life-threatening injury requiring rapid treatment. The other tags indicate patients with less urgent injuries or those who are likely to die. DIF: Cognitive Level: Remember (knowledge) REF: 1692 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
3. After the return of spontaneous circulation following the resuscitation of a patient who had a cardiac arrest, therapeutic hypothermia is ordered. Which action will the nurse include in the plan of care? a. Apply external cooling device. b. Check mental status every 15 minutes. c. Avoid the use of sedative medications. d. Rewarm if temperature is <91° F (32.8° C).
ANS: A When therapeutic hypothermia is used postresuscitation, external cooling devices or cold normal saline infusions are used to rapidly lower body temperature to 89.6° F to 93.2° F (32° C to 34° C). Because hypothermia will decrease brain activity, assessing mental status every 15 minutes is not needed at this stage. Sedative medications are administered during therapeutic hypothermia. DIF: Cognitive Level: Apply (application) REF: 1681 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
1. During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next? a. Palpate extremities for bilateral pulses. b. Observe the patient's respiratory effort. c. Check the patient's level of consciousness. d. Examine the patient for any external bleeding.
ANS: B Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient's breathing. The other actions are also part of the initial survey but assessment of breathing should be done immediately after assessing for airway patency. DIF: Cognitive Level: Apply (application) REF: 1676 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
6. A patient who has experienced blunt abdominal trauma during a motor vehicle collision is complaining of increasing abdominal pain. The nurse will plan to teach the patient about the purpose of a. peritoneal lavage. b. abdominal ultrasonography. c. nasogastric (NG) tube placement. d. magnetic resonance imaging (MRI).
ANS: B For patients who are at risk for intraabdominal bleeding, focused abdominal ultrasonography is the preferred method to assess for intraperitoneal bleeding. An MRI would not be used. Peritoneal lavage is an alternative, but it is more invasive. An NG tube would not be helpful in diagnosis of intraabdominal bleeding. DIF: Cognitive Level: Apply (application) REF: 1678 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
16. Gastric lavage and administration of activated charcoal are ordered for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which action should the nurse plan to do first? a. Insert a large-bore orogastric tube. b. Assist with intubation of the patient. c. Prepare a 60-mL syringe with saline. d. Give first dose of activated charcoal.
ANS: B In an unresponsive patient, intubation is done before gastric lavage and activated charcoal administration to prevent aspiration. The other actions will be implemented after intubation. DIF: Cognitive Level: Apply (application) REF: 1689 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
4. A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should a. obtain a complete set of vital signs. b. obtain a Glasgow Coma Scale score. c. ask about chronic medical conditions. d. attach a cardiac electrocardiogram monitor.
ANS: B The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the secondary survey. DIF: Cognitive Level: Apply (application) REF: 1676 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
19. A patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first? a. Heart rate b. Breath sounds c. Body temperature d. Level of consciousness
ANS: B The priority assessment relates to ABCs (airway, breathing, circulation) and how well the patient is oxygenating, so breath sounds should be assessed first. The other data will also be collected rapidly but are not as essential as the breath sounds. DIF: Cognitive Level: Apply (application) REF: 1685 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
8. A 22-year-old patient who experienced a near drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period? a. Auscultate heart sounds. b. Palpate peripheral pulses. c. Auscultate breath sounds. d.
ANS: C Because pulmonary edema is a common complication after near drowning, the nurse should assess the breath sounds frequently. The other information also will be obtained by the nurse, but it is not as pertinent to the patient's admission diagnosis. DIF: Cognitive Level: Apply (application) REF: 1686 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
7. A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). The nurse determines that discharge teaching has been effective when the patient makes which statement? a. "I will take salt tablets when I work outdoors in the summer." b. "I should take acetaminophen (Tylenol) if I start to feel too warm." c. "I should drink sports drinks when working outside in hot weather." d. "I will move to a cool environment if I notice that I am feeling confused."
ANS: C Electrolyte solutions such as sports drinks help replace fluid and electrolytes lost when exercising in hot weather. Salt tablets are not recommended because of the risks of gastric irritation and hypernatremia. Antipyretic medications are not effective in lowering body temperature elevations caused by excessive exposure to heat. A patient who is confused is likely to have more severe hyperthermia and will be unable to remember to take appropriate action. DIF: Cognitive Level: Apply (application) REF: 1682 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
10. When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87° F (30.6° C), which assessment indicates that the nurse should discontinue active rewarming? a. The patient begins to shiver. b. The BP decreases to 86/42 mm Hg. c. The patient develops atrial fibrillation. d. The core temperature is 94° F (34.4° C).
ANS: D A core temperature of 89.6° F to 93.2° F (32° C to 34° C) indicates that sufficient rewarming has occurred. Dysrhythmias, hypotension, and shivering may occur during rewarming and should be treated but are not an indication to stop rewarming the patient. DIF: Cognitive Level: Apply (application) REF: 1686 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
5. A 19-year-old is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the left hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. The nurse will anticipate giving a. tetanus immunoglobulin (TIG) only. b. TIG and tetanus-diphtheria toxoid (Td). c. tetanus-diphtheria toxoid and pertussis vaccine (Tdap) only. d. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap).
ANS: D For an adult with no previous tetanus immunizations, TIG and Tdap are recommended. The other immunizations are not sufficient for this patient. DIF: Cognitive Level: Apply (application) REF: 1681 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance
14. The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment? a. A patient with no pedal pulses. b. A patient with an open femur fracture. c. A patient with bleeding facial lacerations. d. A patient with paradoxic chest movements.
ANS: D Most immediate deaths from trauma occur because of problems with ventilation, so the patient with paradoxic chest movements should be treated first. Face and head fractures can obstruct the airway, but the patient with facial injuries only has lacerations. The other two patients also need rapid intervention but do not have airway or breathing problems. DIF: Cognitive Level: Apply (application) REF: 1676 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
2. During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal pulse is absent and the leg is swollen. Which action will the nurse take next? a. Send blood to the lab for a complete blood count. b. Assess further for a cause of the decreased circulation. c. Finish the airway, breathing, circulation, disability survey. d. Start normal saline fluid infusion with a large-bore IV line.
ANS: D The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a possibly life-threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey. Although a complete blood count is indicated, administration of IV fluids should be started first. Completion of the primary survey and further assessment should be completed after the IV fluids are initiated. DIF: Cognitive Level: Apply (application) REF: 1676 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
17. A 54-year-old patient arrives in the emergency department (ED) after exposure to powdered lime at work. Which action should the nurse take first? a. Obtain the patient's vital signs. b. Obtain a baseline complete blood count. c. Decontaminate the patient by showering with water. d. Brush off any visible powder on the skin and clothing.
ANS: D The initial action should be to protect staff members and decrease the patient's exposure to the toxin by decontamination. Patients exposed to powdered lime should not be showered; instead any/all visible powder should be brushed off. The other actions can be done after the decontamination is completed. DIF: Cognitive Level: Apply (application) REF: 1690 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
1. Which patient should the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined below? A) A patient with a blunt chest trauma with some difficulty breathing B) A patient with a sore neck who was immobilized in the field on a backboard with a cervical collar C) A patient with a possible fractured tibia with adequate pedal pulses D) A patient with an acute onset of confusion
Ans: A
12. Emergency department (ED) staff members have been trained to follow steps that will decrease the risk of secondary exposure to a chemical. When conducting decontamination, staff members should remove the patient's clothing and then perform what action? A) Rinse the patient with water. B) Wash the patient with a dilute bleach solution. C) Wash the patient chlorhexidine. D) Rinse the patient with hydrogen peroxide.
Ans: A
13. A nurse takes a shift report and finds he is caring for a patient who has been exposed to anthrax by inhalation. What precautions does the nurse know must be put in place when providing care for this patient? A) Standard precautions B) Airborne precautions C) Droplet precautions D) Contact precautions
Ans: A
15. A patient is being treated in the ED following a terrorist attack. The patient is experiencing visual disturbances, nausea, vomiting, and behavioral changes. The nurse suspects this patient has been exposed to what chemical agent? A) Nerve agent B) Pulmonary agent C) Vesicant D) Blood agent
Ans: A
19. A backcountry skier has been airlifted to the ED after becoming lost and developing hypothermia and frostbite. How should the nurse best manage the patient's frostbite? A) Immerse affected extremities in water slightly above normal body temperature. B) Immerse the patient's frostbitten extremities in the warmest water the patient can tolerate. C) Gently massage the patient's frozen extremities in between water baths. D) Perform passive range-of-motion exercises of the affected extremities to promote circulation.
Ans: A
23. A hospital's emergency operations plan has been enacted following an industrial accident. While one nurse performs the initial triage, what should other emergency medical services personnel do? A) Perform life-saving measures. B) Classify patients according to acuity. C) Provide health promotion education. D) Modify the emergency operations plan.
Ans: A
24. A patient is admitted to the ED after being involved in a motor vehicle accident. The patient has multiple injuries. After establishing an airway and adequate ventilation, the ED team should prioritize what aspect of care? A) Control the patient's hemorrhage. B) Assess for cognitive effects of the injury. C) Splint the patient's fractures. D) Assess the patient's neurologic status.
Ans: A
25. A nurse has been called for duty during a response to a natural disaster. In this context of care, the nurse should expect to do which of the following? A) Practice outside of her normal area of clinical expertise. B) Perform interventions that are not based on assessment data. C) Prioritize psychosocial needs over physiologic needs. D) Prioritize the interests of older adults over younger patients.
Ans: A
26. A nurse is participating in the planning of a hospital's emergency operations plan. The nurse is aware of the potential for ethical dilemmas during a disaster or other emergency. Ethical dilemmas in these contexts are best addressed by which of the following actions? A) Having an ethical framework in place prior to an emergency B) Allowing staff to provide care anonymously during an emergency C) Assuring staff that they are not legally accountable for care provided during an emergency D) Teaching staff that principles of ethics do not apply in an emergency situation
Ans: A
27. The triage nurse is working in the ED. A homeless person is admitted during a blizzard with complaints of being unable to feel his feet and lower legs. Core temperature is noted at 33.2∞C (91.8∫F). The patient is intoxicated with alcohol at the time of admission and is visibly malnourished. What is the triage nurse's priority in the care of this patient? A) Addressing the patient's hypothermia B) Addressing the patient's frostbite in his lower extremities C) Addressing the patient's alcohol intoxication D) Addressing the patient's malnutrition
Ans: A
37. A patient is brought to the ED by two police officers. The patient was found unconscious on the sidewalk, with his face and hands covered in blood. At present, the patient is verbally abusive and is fighting the staff in the ED, but appears medically stable. The decision is made to place the patient in restraints. What action should the nurse perform when the patient is restrained? A) Frequently assess the patient's skin integrity. B) Inform the patient that he is likely to be charged with assault. C) Avoid interacting with the patient until the restraints are removed. D) Take the opportunity to perform a full physical assessment.
Ans: A
38. A patient has been exposed to a nerve agent in a biochemical terrorist attack. This type of agent bonds with acetylcholinesterase, so that acetylcholine is not inactivated. What is the pathologic effect of this type of agent? A) Hyperstimulation of the nerve endings B) Temporary deactivation of the nerve endings C) Binding of the nerve endings D) Destruction of the nerve endings
Ans: A
38. An 83-year-old patient is brought in by ambulance from a long-term care facility. The patient's symptoms are weakness, lethargy, incontinence, and a change in mental status. The nurse knows that emergencies in older adults may be more difficult to manage. Why would this be true? A) Older adults may have an altered response to treatment. B) Older adults are often reluctant to adhere to prescribed treatment. C) Older adults have difficulty giving a health history. D) Older adults often stigmatize their peers who use the ED.
Ans: A
4. A patient has been brought to the ED with multiple trauma after a motor vehicle accident. After immediate threats to life have been addressed, the nurse and trauma team should take what action? A) Perform a rapid physical assessment. B) Initiate health education. C) Perform diagnostic imaging. D) Establish the circumstances of the accident.
Ans: A
7. A major earthquake has occurred within the vicinity of the local hospital. The nursing supervisor working the night shift at the hospital receives information that the hospital disaster plan will be activated. The supervisor will need to work with what organization responsible for coordinating interagency relief assistance? A) Office of Emergency Management B) Incident Command System C) Centers for Disease Control and Prevention (CDC) D) American Red Cross
Ans: A
7. A patient is admitted to the ED with suspected alcohol intoxication. The ED nurse is aware of the need to assess for conditions that can mimic acute alcohol intoxication. In light of this need, the nurse should perform what action? A) Check the patient's blood glucose level. B) Assess for a documented history of major depression. C) Determine whether the patient has ingested a corrosive substance. D) Arrange for assessment of serum potassium levels.
Ans: A
8. The paramedics bring a patient who has suffered a sexual assault to the ED. What is important for the sexual assault nurse examiner to do when assessing a sexual assault victim? A) Respect the patient's privacy during assessment. B) Shave all pubic hair for laboratory analysis. C) Place items for evidence in plastic bags. D) Bathe the patient before the examination.
Ans: A
9. The announcement is made that the facility may return to normal functioning after a local disaster. In the emergency operations plan, what is this referred to as? A) Demobilization response B) Post-incident response C) Crisis diffusion D) Reversion
Ans: A
29. A patient admitted to the ED with severe diarrhea and vomiting is subsequently diagnosed with food poisoning. The nurse caring for this patient assesses for signs and symptoms of fluid and electrolyte imbalances. For what signs and symptoms would this nurse assess? Select all that apply. A) Dysrhythmias B) Hypothermia C) Hypotension D) Hyperglycemia E) Delirium
Ans: A, C, E
1. The nurse manager in the ED receives information that a local chemical plant has had a chemical leak. This disaster is assigned a status of level II. What does this classification indicate? A) First responders can manage the situation. B) Regional efforts and aid from surrounding communities can manage the situation. C) Statewide or federal assistance is required. D) The area must be evacuated immediately.
Ans: B
13. A 6-year-old is admitted to the ED after being rescued from a pond after falling through the ice while ice skating. What action should the nurse perform while rewarming the patient? A) Assessing the patient's oral temperature frequently B) Ensuring continuous ECG monitoring C) Massaging the patient's skin surfaces to promote circulation D) Administering bronchodilators by nebulizer
Ans: B
14. A male patient with multiple injuries is brought to the ED by ambulance. He has had his airway stabilized and is breathing on his own. The ED nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding? A) Absence of bruising at contusion sites B) Rapid pulse and decreased capillary refill C) Increased BP with narrowed pulse pressure D) Sudden diaphoresis
Ans: B
15. A 13-year-old is being admitted to the ED after falling from a roof and sustaining blunt abdominal injuries. To assess for internal injury in the patient's peritoneum, the nurse should anticipate what diagnostic test? A) Radiograph B) Computed tomography (CT) scan C) Complete blood count (CBC) D) Barium swallow
Ans: B
19. A 44-year-old male patient has been exposed to severe amount of radiation after a leak in a reactor plant. When planning this patient's care, the nurse should implement what action? A) The patient should be scrubbed with alcohol and iodine. B) The patient should be carefully protected from infection. C) The patient's immunization status should be promptly assessed. D) The patient's body hair should be removed to prevent secondary contamination.
Ans: B
2. The nurse observes that the family members of a patient who was injured in an accident are blaming each other for the circumstances leading up to the accident. The nurse appropriately lets the family members express their feelings of responsibility, while explaining that there was probably little they could do to prevent the injury. In what stage of crisis is this family? A) Anxiety and denial B) Remorse and guilt C) Anger D) Grief
Ans: B
20. The nurse is coordinating the care of victims who arrive at the ED after a radiation leak at a nearby nuclear plant. What would be the first intervention initiated when victims arrive at the hospital? A) Administer prophylactic antibiotics. B) Survey the victims using a radiation survey meter. C) Irrigate victims' open wounds. D) Perform soap and water decontamination.
Ans: B
27. A nurse is undergoing debriefing with the critical incident stress management (CISM) team after participating in the response to a disaster. During this process, the nurse will do which of the following? A) Evaluate the care that he or she provided during the disaster. B) Discuss own emotional responses to the disaster. C) Explore the ethics of the care provided during the disaster. D) Provide suggestions for improving the emergency operations plan.
Ans: B
3. A patient is brought to the ED by ambulance with a gunshot wound to the abdomen. The nurse knows that the most common hollow organ injured in this type of injury is what? A) Liver B) Small bowel C) Stomach D) Large bowel
Ans: B
31. A nurse who is a member of the local disaster response team is learning about blast injuries. The nurse should plan for what event that occurs in the tertiary phase of the blast injury? A) Victims' pre-existing medical conditions are exacerbated. B) Victims are thrown by the pressure wave. C) Victims experience burns from the blast. D) Victims suffer injuries caused by debris or shrapnel from the blast.
Ans: B
31. A patient is admitted to the ED with an apparent overdose of IV heroin. After stabilizing the patient's cardiopulmonary status, the nurse should prepare to perform what intervention? A) Administer a bolus of lactated Ringer's. B) Administer naloxone hydrochloride (Narcan). C) Insert an indwelling urinary catheter. D) Perform a focused neurologic assessment.
Ans: B
32. A patient is being treated for bites that she suffered during an assault. After the bites have been examined and documented by a forensic examiner, the nurse should perform what action? A) Apply a dressing saturated with chlorhexidine. B) Wash the bites with soap and water. C) Arrange for the patient to receive a hepatitis B vaccination. D) Assess the patient's immunization history.
Ans: B
35. The ED nurse admitting a patient with a history of depression is screening the patient for suicide risk. What assessment question should the nurse ask when screening the patient? A) "How would you describe your mood over the past few days?" B) "Have you ever thought about taking your own life?" C) "How do you think that your life is most likely to end?" D) "How would you rate the severity of your depression right now on a 10-point scale?"
Ans: B
39. A group of military nurses are reviewing the care of victims of biochemical terrorist attacks. The nurses should identify what agents as having the shortest latency? A) Viral agents B) Nerve agents C) Pulmonary agents D) Blood agents
Ans: B
39. An ED nurse is triaging patients according to the Emergency Severity Index (ESI). When assigning patients to a triage level, the nurse will consider the patients' acuity as well as what other variable? A) The likelihood of a repeat visit to the ED in the next 7 days B) The resources that the patient is likely to require C) The patient's or insurer's ability to pay for care D) Whether the patient is known to ED staff from previous visits
Ans: B
4. A nurse is caring for patients exposed to a terrorist attack involving chemicals. The nurse has been advised that personal protective equipment must be worn in order to give the highest level of respiratory protection with a lesser level of skin and eye protection. What level protection is this considered? A) Level A B) Level B C) Level C D) Level D
Ans: B
5. The nursing educator is reviewing the signs and symptoms of heat stroke with a group of nurses who provide care in a desert region. The educator should describe what sign or symptom? A) Hypertension with a wide pulse pressure B) Anhidrosis C) Copious diuresis D) Cheyne-Stokes respirations
Ans: B
9. A patient with a history of major depression is brought to the ED by her parents. Which of the following nursing actions is most appropriate? A) Noting that symptoms of physical illness are not relevant to the current diagnosis B) Asking the patient if she has ever thought about taking her own life C) Conducting interviews in a brief and direct manner D) Arranging for the patient to spend time alone to consider her feelings
Ans: B
22. A patient is admitted to the ED complaining of abdominal pain. Further assessment of the abdomen reveals signs of peritoneal irritation. What assessment findings would corroborate this diagnosis? Select all that apply. A) Ascites B) Rebound tenderness C) Changes in bowel sounds D) Muscular rigidity E) Copious diarrhea
Ans: B, C, D
10. A group of disaster survivors is working with the critical incident stress management (CISM) team. Members of this team should be guided by what goal? A) Determining whether the incident was managed effectively B) Educating survivors on potential coping strategies for future disasters C) Providing individuals with education about recognizing stress reactions D) Determining if individuals responded appropriately during the incident
Ans: C
11. You are a floor nurse caring for a patient with alcohol withdrawal syndrome. What would be an appropriate nursing action to minimize the potential for hallucinations? A) Engage the patient in a process of health education. B) Administer opioid analgesics as ordered. C) Place the patient in a private, well-lit room. D) Provide television or a radio as therapeutic distraction
Ans: C
14. A group of medical nurses are being certified in their response to potential bioterrorism. The nurses learn that if a patient is exposed to the smallpox virus he or she becomes contagious at what time? A) 6 to 12 hours after exposure B) When pustules form C) After a rash appears D) When the patient becomes febrile
Ans: C
17. A patient is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the physician will perform which of the following actions? A) Insert an oropharyngeal airway. B) Perform the jaw thrust maneuver. C) Perform endotracheal intubation. D) Perform a cricothyroidotomy.
Ans: C
18. A patient is brought by friends to the ED after being involved in a motor vehicle accident. The patient sustained blunt trauma to the abdomen. What nursing action would be most appropriate for this patient? A) Ambulate the patient to expel flatus. B) Place the patient in a high Fowler's position. C) Immobilize the patient on a backboard. D) Place the patient in a left lateral position.
Ans: C
18. There has been a radiation-based terrorist attack and a patient is experiencing vomiting, diarrhea, and shock after the attack. How will the patient's likelihood of survival be characterized? A) Probable B) Possible C) Improbable D) Extended
Ans: C
25. A patient with multiple trauma is brought to the ED by ambulance after a fall while rock climbing. What is a responsibility of the ED nurse in this patient's care? A) Intubating the patient B) Notifying family members C) Ensuring IV access D) Delivering specimens to the laboratory
Ans: C
28. A patient is brought to the ED by friends. The friends tell the nurse that the patient was using cocaine at a party. On arrival to the ED the patient is in visible distress with an axillary temperature of 40.1∫C (104.2∞F). What would be the priority nursing action for this patient? A) Monitor cardiovascular effects. B) Administer antipyretics. C) Ensure airway and ventilation. D) Prevent seizure activity.
Ans: C
32. A patient suffering from blast lung has been admitted to the hospital and is exhibiting signs and symptoms of an air embolus. What is the nurse's most appropriate action? A) Place the patient in the Trendelenberg position. B) Assess the patient's airway and begin chest compressions. C) Position the patient in the prone, left lateral position. D) Encourage the patient to perform deep breathing and coughing exercises.
Ans: C
33. A patient has been admitted to the medical unit with signs and symptoms that are suggestive of anthrax infection. The nurse should anticipate what intervention? A) Administration of acyclovir B) Hematopoietic stem cell transplantation (HSCT) C) Administration of penicillin D) Hemodialysis
Ans: C
36. A nurse has had contact with a patient who developed smallpox and became febrile after a terrorist attack. This nurse will require what treatment? A) Watchful waiting B) Treatment with colony-stimulating factors (CSFs) C) Vaccination D) Treatment with ceftriaxone
Ans: C
36. A patient is brought to the ED by family members who tell the nurse that the patient has been exhibiting paranoid, agitated behavior. What should the nurse do when interacting with this patient? A) Keep the patient in a confined space. B) Use therapeutic touch appropriately. C) Give the patient honest answers about likely treatment. D) Attempt to convince the patient that his or her fears are unfounded.
Ans: C
40. A 23-year-old woman is brought to the ED complaining of stomach cramps, nausea, vomiting, and diarrhea. The care team suspects food poisoning. What is the key to treatment in food poisoning? A) Administering IV antibiotics B) Assessing immunization status C) Determining the source and type of food poisoning D) Determining if anyone else in the family is ill
Ans: C
40. A nurse is giving an educational class to members of the local disaster team. What should the nurse instruct members of the disaster team to do in a chemical bioterrorist attack? A) Cover their eyes. B) Put on a personal protective equipment mask. C) Stand up. D) Crawl to an exit.
Ans: C
6. A patient is brought to the ED by ambulance after swallowing highly acidic toilet bowl cleaner 2 hours earlier. The patient is alert and oriented. What is the care team's most appropriate treatment? A) Administering syrup of ipecac B) Performing a gastric lavage C) Giving milk to drink D) Referring to psychiatry
Ans: C
8. While developing an emergency operations plan (EOP), the committee is discussing the components of the EOP. During the post-incident response of an emergency operations plan, what activity will take place? A) Deciding when the facility will go from disaster response to daily activities B) Conducting practice drills for the community and facility C) Conducting a critique and debriefing for all involved in the incident D) Replacing the resources in the facility
Ans: C
10. A triage nurse is talking to a patient when the patient begins choking on his lunch. The patient is coughing forcefully. What should the nurse do? A) Stand him up and perform the abdominal thrust maneuver from behind. B) Lay him down, straddle him, and perform the abdominal thrust maneuver. C) Leave him to get assistance. D) Stay with him and encourage him, but not intervene at this time.
Ans: D
11. Level C personal protective equipment has been deemed necessary in the response to an unknown substance. The nurse is aware that the equipment will include what? A) A self-contained breathing apparatus B) A vapor-tight, chemical-resistant suit C) A uniform only D) An air-purified respirator
Ans: D
12. An obtunded patient is admitted to the ED after ingesting bleach. The nurse should prepare to assist with what intervention? A) Prompt administration of an antidote B) Gastric lavage C) Administration of activated charcoal D) Helping the patient drink large amounts of water
Ans: D
16. A patient is admitted to the ED who has been exposed to a nerve agent. The nurse should anticipate the STAT administration of what drug? A) Amyl nitrate B) Dimercaprol C) Erythromycin D) Atropine
Ans: D
16. A patient is brought to the ER in an unconscious state. The physician notes that the patient is in need of emergency surgery. No family members are present, and the patient does not have identification. What action by the nurse is most important regarding consent for treatment? A) Ask the social worker to come and sign the consent. B) Contact the police to obtain the patient's identity. C) Obtain a court order to treat the patient. D) Clearly document LOC and health status on the patient's chart.
Ans: D
17. A patient was exposed to a dose of more than 5,000 rads of radiation during a terrorist attack. The patient's skin will eventually show what manifestation? A) Erythema B) Ecchymosis C) Desquamation D) Necrosis
Ans: D
2. A workplace explosion has left a 40-year-old man burned over 65% of his body. His burns are second- and third-degree burns, but he is conscious. How would this person be triaged? A) Green B) Yellow C) Red D) Black
Ans: D
21. A patient who has been diagnosed with cholecystitis is being discharged home from the ED to be scheduled for surgery later. The patient received morphine during the present ED admission and is visibly drowsy. When providing health education to the patient, what would be the most appropriate nursing action? A) Give written instructions to patient. B) Give verbal instructions to one of the patient's family members. C) Telephone the patient the next day with verbal instructions. D) Give verbal and written instructions to patient and a family member.
Ans: D
23. A patient who attempted suicide being treated in the ED is accompanied by his mother, father, and brother. When planning the nursing care of this family, the nurse should perform which of the following action? A) Refer the family to psychiatry in order to provide them with support. B) Explore the causes of the patient's suicide attempt with the family. C) Encourage the family to participate in the bedside care of the patient. D) Ensure that the family receives appropriate crisis intervention services.
Ans: D
26. A patient has been brought to the ED after suffering genitourinary trauma in an assault. Initial assessment reveals that the patient's bladder is distended. What is the nurse's most appropriate action? A) Withhold fluids from the patient. B) Perform intermittent urinary catheterization. C) Insert a narrow-gauge indwelling urinary catheter. D) Await orders following the urologist's assessment.
Ans: D
29. The nurse has been notified that the ED is expecting terrorist attack victims and that level D personal protective equipment is appropriate. What does level D PPE include? A) A chemical-resistant coverall with splash hood, chemical-resistant gloves, and boots B) A self-contained breathing apparatus (SCBA) and a fully encapsulating, vapor-tight, chemical-resistant suit with chemical-resistant gloves and boots. C) The SCBA and a chemical-resistant suit, but the suit is not vapor tight D) The nurse's typical work uniform
Ans: D
3. A patient has been witness to a disaster involving a large number of injuries. The patient appears upset, but states that he feels capable of dealing with his emotions. What is the nurse's most appropriate intervention? A) Educate the patient about the potential harm in denying his emotions. B) Refer the patient to social work or spiritual care. C) Encourage the patient to take a leave of absence from his job to facilitate emotional healing. D) Encourage the patient to return to normal social roles when appropriate.
Ans: D
30. The nurse is preparing to admit patients who have been the victim of a blast injury. The nurse should expect to treat a large number of patients who have experienced what type of injury? A) Chemical burns B) Spinal cord injury C) Meningeal tears D) Tympanic membrane rupture
Ans: D
33. A nurse is caring for a patient who has been the victim of sexual assault. The nurse documents that the patient appears to be in a state of shock, verbalizing fear, guilt, and humiliation. What phase of rape trauma syndrome is this patient most likely experiencing? A) Reorganization phase B) Denial phase C) Heightened anxiety phase D) Acute disorganization phase
Ans: D
37. The emergency response team is dealing with a radiation leak at the hospital. What action should be performed to prevent the spread of the contaminants? A) Floors must be scrubbed with undiluted bleach. B) Waste must be promptly incinerated. C) The ventilation system should be deactivated. D) Air ducts and vents should be sealed.
Ans: D
5. A patient who has been exposed to anthrax is being treated in the local hospital. The nurse should prioritize what health assessments? A) Integumentary assessment B) Assessment for signs of hemorrhage C) Neurologic assessment D) Assessment of respiratory status
Ans: D
6. When assessing patients who are victims of a chemical agent attack, the nurse is aware that assessment findings vary based on the type of chemical agent. The chemical sulfur mustard is an example of what type of chemical warfare agent? A) Nerve agent B) Blood agent C) Pulmonary agent D) Vesicant
Ans: D
