10, 11, 12
A nurse assesses a client admitted with a brown recluse spider bite. Which assessment does the nurse perform to identify complications of this bite?
Monitor clients temp every 4 hours
A nurse is field-triaging clients after an industrial accident. Which client condition would the nurse triage with a red tag?
Multple fractured ribs and shortness of breathe
The complex care provided during an emergency requires interprofessional collaboration. Which team members are paired with the correct responsibilities? (Select all that apply.)
Psychiatric crisis nurse—interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis Paramedic—provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration
On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, and blood pressure 106/66 mm Hg. What action would the nurse take?
Start an intravenous line and infuse 0.9% saline solution.
After a hospital's emergency department (ED) has efficiently triaged, treated, and transferred clients from a community disaster to appropriate units, the hospital incident command officer wants to "stand down" from the emergency plan. Which question would the nursing supervisor ask at this time?
"Do all areas of the hospital have the supplies and personnel they need?"
After teaching a client how to prevent altitude-related illnesses, a nurse assesses the client's understanding. Which statement indicates that the client needs additional teaching?
"My partner and I will plan to sleep at a higher elevation to acclimate more quickly."
A nurse is constructing a personal preparedness plan in case of a disaster. What does the nurse consider in making this plan?
Store basic supplies to last for at least 3 days.
A hospital responds to a local mass casualty event. What action would the nurse supervisor take to prevent staff posttraumatic stress disorder during and after the event?
provide water and heathly snakcs throughtout the event
A hospital prepares for a mass casualty event. Which functions are correctly paired with the personnel role?
- Hospital incident commander—assumes overall leadership for implementing the emergency plan -Triage officer—rapidly evaluates each client to determine priorities for treatment
A new graduate nurse has started working on a medical-surgical unit. What actions would the nurse take to be prepared for a disaster?
- know the institutions emergency response plan -participate in the institutions diaster drill -develop a personal preparedness plan -understand that nurses play a role in every phase of a disaster -be willing to be flexible working during a crisis situation
An emergency department (ED) nurse is preparing to transfer a client to the trauma intensive care unit. Which information would the nurse include in the nurse-to-nurse hand-off report?
- mechanism of injury -diagnostic test results -isolation precautions -safety concerns
A nurse triages clients arriving at the hospital after a mass casualty. Which clients are correctly classified?
-A 35-year-old female with severe chest pain: red tag -A 60-year-old male with an open fracture with distal pulses: yellow tag
An emergency department nurse plans care for a client who is admitted with heat stroke. Which interventions does the nurse include in this patient's plan of care?
-Administer oxygen via mask or nasal cannula. -Infuse 0.9% sodium chloride via a large-bore intravenous cannula. -Obtain baseline serum electrolytes and cardiac enzymes.
A client resuscitated after drowning is admitted to the emergency department. What assessment findings does the nurse recognize as symptoms of a drowning? (Select all that apply.)
-bilateral crackles -bradycardia -cyanosis of the lips -hypotention
Which assessment findings would indicate to the nurse that a client has suffered from a heat stroke? (Select all that apply.)
-confusion and bizarre behavior -hypotension -tachycardia and tachypnea -body temp more then 104
An emergency department nurse is caring for a client who had been hiking in the mountains for the past 2 days. What are the most important indicators that a client is experiencing high-altitude pulmonary edema (HAPE)?
-crackles in both lung feilds -persistent dry cough
An emergency department nurse is caring for a trauma patient. Which interventions does the nurse perform during the primary survey? (Select all that apply.)
-needle decompression -initiating IV fluids -endotracheal intubation -removing wet clothes
Emergency medical services (EMS) brings a large number of clients to the emergency department following a mass casualty incident. The nurse identifies the clients with which injuries with yellow tags?
-partial thickness burns covering both legs -neck injury and numbness of both legs -small pieces of shrapnel embedded in both eyes -bruising and pain in the RLQ
A nurse is teaching a wilderness survival class. Which statements would the nurse include about the prevention of hypothermia and frostbite?
-wear synthetic clothing instead of cotton and keep skin dry -wear sunglasses to protect skin and eyes from harmful rays -know your physical limits -change your gloses and socks if they get wet
A nurse is triaging clients in the emergency department. Which client would the nurse classify as "nonurgent?"
62 y ear old with a simple fracture of the left arm
A nurse is triaging clients in the emergency department. Which client would be considered "urgent"?
75 year old female with cough and temp of 102
An emergency department nurse is triaging victims of a multi-casualty event. Which client would receive care first?
A 26-year-old male who has pale, cool, clammy skin
A nurse is triaging clients in the emergency department (ED). Which client would the nurse prioritize to receive care first?
A 45 year old reporting chest pain and diaphoresis
A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center?
Level II—located within community hospitals and provides care to most injured clients
A primary health care provider prescribes a rewarming bath for a client who presents with Grade 3 frostbite. What action would the nurse take prior to starting this treatment?
Administer IV morphine
An emergency department nurse cares for a middle-age mountain climber who is confused, ataxic, and exhibits impaired judgement. After administering oxygen, which intervention would the nurse implement next?
Administer dexamethasone.
A middle-age mountain hiker is admitted to the emergency department exhibiting a cough with pink, frothy sputum and cyanosis of lips and nail beds. What priority action would the nurse implement?
Administer oxygen via a nonrebreather mask.
A client presents to the emergency department after prolonged exposure to the cold. The client is difficult to arouse and speech is incoherent. What action would the nurse take first?
Administer warmed intravenous fluids to the client.
An emergency department manager wants to mitigate the possible acute and chronic stress after mass casualty events in the staff. What action would the manager take?
An emergency department manager wants to mitigate the possible acute and chronic stress after mass casualty events in the staff. What action would the manager take?
A nurse assesses a client recently bitten by a coral snake. Which assessment would the nurse complete first?
Cardiopulmonary status
A nurse is volunteering in a temporary shelter for survivors of a hurricane. Which client does the nurse anticipate has the highest need for further assessment and referral?
Client with a score of 48 on the Impact of Event Scale-Revised (IES-R)
While on a camping trip, a nurse cares for an adult client who had a drowning incident in a lake and is experiencing agonal breathing with a palpable pulse. What action would the nurse take first?
Deliver rescue breaths
What is the primary goal of a triage system used by the nurse with clients presenting to the emergency department?
Determine the acuity of the client's condition to determine priority of care.
An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event?
Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims.
A nurse wants to become involved in community disaster preparedness and is interested in helping setup and staff first-aid stations or community acute care centers in the event of a disaster. Which organization is the best fit for this nurse's interests?
The medical reserve corps
A nurse plans care for a client admitted with a snakebite to the right leg. With whom would the nurse collaborate?
The poison control center
While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action would the nurse take first?
Transfer the client to a negative-pressure room.
